Document 2noDQbO1Ok0garVq6wv566Gg

MOT WV-1077 UCTUKE 0-1 OCCUPATIONAL DISEASES CSmiTIOS, UTCERPRSTATICN OF COHPEnSATIOB UftS IK THE VARIOUS STATES Henry 0. Saysr Introduction The fforktsen's Compensation law is o modern conception of the e^loyGr' s lia bility to hi3 injured workman. The earliest compensation law in this country was enacted in 1910 (the first 'tes York Act, which ms held vrcor.stituttorsi' in 1911) i and the present compensation law of the State of 3ew York wc.3 arneted in 1914. Eassachusetta, Hew Jersey and Wisconsin followed in 1911, and may states folicod later. The compensation lass confer may hone/its upon in jured workers and the dependants of deceased workers of a monetary choreetor. Unlike the system of employers* liability which it displaced, the com pensation system also confers upon the injured employee the right to medical treatment at the expense of hia employer, and it imposes upon the ph~:tcian certain duties and obligations. 7hile nodical treatment is a benefit inher ent in the system, the ascertainment of medical facta and the expression of medical opinions bosod upon such facts bacons essential parts of the admin istration of the law. It follows, therefore, that knowledge of the condensation Ians, theirStodaaontal principles and their characteristics! is a necessity for the physi cian who would undertake the care of cases cosing within the Jurisdiction of those laws. Medical knowledge and training are not the whole araaasatarim of the industrial doctor. There are certain lay and legal concepts of the oystea that must be the concern of the doctor oho would devote gome port of his practice to injured workmen cooing under the compensation law. It is to some of those lay and legal concepts that we are presently to ad dress ourselves. At the outset we my concede that generally diagnosis and therapeutic pro cedures are no different in coinpensation work than they are in strictly .pri vate practice. Perhaps in cornering surgical measures in cases where there is a surgical choice, consideration assy be given to the provisions of the compensation law and their effect under the circumstances of the case, and the vocational use of an iftjured center, but always the interest of the injured nan is paramount and his welfare cones first. But diagnosis and therapeutic measures, as well eo etiological considerations, rust all bs brought into complete barcony with the. compensation law and the somewhat complex system that is constituted thereunder. Accordingly, let us see what this compensation system is. ''Compensation* is a cos non tern that denotes the systea of extending medical treatment, together with Etonoy benefits on account of actual or potential wage loss, as the direct responsibility of industry to its injured and disabled workers, and the widows and children or other dependents of deceased workers. It may bo said that compensation is universal in the United States. The con** ponsation system prevails nos in all but one of the statesj namely, the State of tlicsissippi, and it likewise prevails in the District of Columbia end most of the territorial pcsseesions of the United States. Compensation is*Lso provided by Federal La* for all longshoremen end harbor workers who are employed under maritime contracts of employment, and for all civilian employees of the Federal Government. 01 501 1110 It is iaportant that the lodestrial physician be faniliar wiwh the require ments and prcrisif'r.s of the conpeasotion law of the state in tfhich he resides and practices. If he is is a sanitise state, he should also have sere knew- lodge of the 0. S. Longshorstaan's Compensation Act, end the principal variance 3 between that law and the local state compensation law. Char?at9?i^tics of Cosroensatloe differlag in na07 particulars, ouch so the schedule of bsnefi 'J.i poritfds during which benefits are payable, procedures for adjudlcc. sr.- tent of dales, aid the provisions for radical treatment, ifcoro &r-> ;erts.i. cocjron characteristics of the ecspecsatioa systems that prevail i*o \.X si& It ray bo well to note sore of these cobboo characteristic*. 1. Conpecsation is payable for all disabilities to enployess rssult,*;:r from accidents arising out of and in the course of their sEploycent, exoopt *'re tentional self-injury or injury due solely to intoxication.* 2. KegHgar.ce of the employee is no bar to the right of ccaponsation. Neither is the negligence of a fellow worker nor the aesusod risk of the b.s:csss any deferse. This is really the keystone of the whole cooper.aviicc sys tem. 3. The cctspenaation rate is based upon a percentage of the -worker's rages or his earning capacity, with certain autisua provisions. 4. Compensation is payable periodically during disability or during a definite period .stated .in the law for such disabilities, lur.p sum ^-yrier*to sre the exception to the rule In seme states under given clrcuftatans&s. 5. Medical treatment is afforded the injured worker at the expense of his employer for varying periods of tfcce, and 80iTties with Halts of aaowrts. Tork ia one of the few states whore nodical treatment is uoliaitse as to time and amount. 6. Security for the payment of co-npensatioa is required. This -vty b3 effected by * insurance in the ranner provided by lam, or by self**insurance '--/-z:? the conditions prescribed in state laws. 7. Enforcement of the law by boards or eonaaiasions rather than through the courts. * .* S. In a number of states condensation, is payable for disability or death cue to occupational disease, as well as disability due to accident. Nodical Cars The industrial physician Eiust be fanilisr with the medical provisions of the law in his state. State laws vary widely on this subject? in tbs ;.3nnor of hu selection of the physician to treat injured trorkars, as to charges for such troatceat, and as to the tine during which the employer is responsible for treatment, Unlike private practice, in cosponsation the relation-hip ie wot 0-2-2 01 DQ1 1111 solely that between doctor and patient. This cvrot t* too greatly emphasised. The employer eater*-that relationship, as do also *h* ;ublia author!ties administering the iae. BitAor directly hisself, or -.hrrecfc his insurance car rier, tiie employer sr^avpay the cost ot radical *y*ctamt. Similarly he, or his insurance carrier, euAt pay the cooper satic*. frr the entire period cf dis ability, which may bo cMrteeed < say b*r *r)!rrH ? a result of good or in different treatment, Another consideration. oMigatioa cf the o^ioycr to ?ay or the right of the claimant to rseein recusation in a disputed .asa. rny to a greet extent depend upon tho nodical oriniax of the attending rhysieijn, Here come in ques tions of etiology, petheloigr <u*d diagnosis, and fton t>o doctort3 early oh- aervatiens and the completeness of his records hecone 5:tar*dnative. The doc tor has only one obligation, namely, t servo tha truth. :* hruld not ho the employer's doctor nor ihe clsinant's doctor, but he chculd he witness to the truth as ha sees it. His pinion should not depend upon his interest in the payment of his bill for his amices nor the fee that ho is to receive for his testimony, Ho should bo definite in his opinion, not vague, sr4 he should state dearly hie facte and observations and not be afraid to say he docs co^ know, if they are the facta. And if he expresses an opinion and believes he la right, he should be billing to stand up to it and calntain it. In He* York, the period of tine during which treatment say be rendered at tho expense of the employer is not limited in the statute. The law provides that the employee is entitled to treatment ."for as long a time as the nature of the injury and the process of healing ray require.1* That, however, is not tho pre vailing rule outside of Hew York. In rsost states a definite period of tine during which treatment say be required is set forth in the law, or a maximum cost in dollars nay be prescribed. It is necessary that the industrial physi cian be familiar with those provisions of his local law. Generally speaking, compensation laws cast upon employers the duty of furnish ing and providing medical treatment for their injured employees, but the em ployer is relieved of that obligation wfcan his employee refuses, without good cause, to accept the services of the employer's doctor. Is some states the employee say transfer his treatment to a doctor other than the cr.e furnished by the employer if he obtains the consent of the administrative authority. That consent will generally be granted only for good cause. But here in New York, we have a unique system. The original law which placed on the employer the responsibility of designating {often upon the recommenda tion of his insurance carrier) the physician to treat his Injured employee, if he was to be held liable for payment of the doctor's charges, was amended in 1935 to accord to the injured employee the right to choose his own doctor, without interference from hia employer or insurance carrier, provided the doc tor had received fron the Industrial Commissioner authorization to treat cas3s under the Compensation Law, The authorization cf physicians was made by the Commissioner upon recommendation of the County Medical Society of the county in which the doctor resided. By an amendment of the Lew passed at the last ses sion of the Legislature, the duty of qualifying physicians under this law was imposed upon a newly created Medical Practice Committee of three physicians, appointed by the Coamiaaioner, in the four largest counties in the City of New York, Elsewhere ia the State, that duty still rests upon the Medical So cieties, Doctors qualified and authorized to treat compensation cases .-.re arranged upon the panel by the Medical Practice Committee or on recommendation of their respective County Medical Societies, according to their particular qualifications and their fields of practice. Each doctor, when authorised. D-2-3 01 501 1112 is assigned & serial runaber sfcieh zust fellow his signature ill reports in compensation cosea, .ad **o &* cericl nuaber i* prefixed * naee latter or let ters desiccating "fcstfcar 2i# isctor- Is sutboriwd a# a sat.;-eu ?raetition*r or a specialist la one .*.r ~?t *1)3. lo : xtcr Toy va . 3 *;, otherTfcan first Bid or emergency t3*t-.Ut calls ;'or ovtcide of his assigned field. Gtaaru . ul.Tiercea, '.'os :.* v*;e, ml* o*- ao operative sur- 3017-, cor cay a spec as.; . ,n or give a ceci- cal report cr.d cpiaicr. -* * ;o -.Haa re '*,s agrsed to lir.it hia rrvcv'-; The er^loyer rsy not .77 ...ccssend to b'o vices of a particular '*:stoi* uuissa doctor, end oven *>.cn `.he r-qv.jA s*u-t ba n', * v.at he uuo the scr* 7-70 . -`.r^.* h'r- to r.?C7j-0Bil a {>?icau:.: rgfc. Since contract sad T-*e do not enter Into t':c relatica-raip of the roctor a;yi the sploysr, it um cocoscary to provide for the cstccuisfcaert of 9. feo sche dule to *hiah doctors east conform in .jcrxeasntiaa vork, Th.ia schedule *302 es tablished by the Industrial Ccnaissioner after hearing all inWrested pertits. The schedule established Is a ndnirnun fee schedule, below which no doctor ney charge, but higher fees la a particular case of unusual difficulty zay he arranged by agreement between the doctor and the employer or his insurance carrier* To protect the doctor and to provide a speedy and impartial aeons of adjusting radical bills, as to the reasonableness of which dispute has arisen, two r.ethcds of procedure have been provided to pass upon the ratter of fairness and the ne cessity of treatment. Both of these procedures call for such detorrinations lo be cade by doctors. In the four largo counties of 1'ae York City, the determina tion* are cede by the newly created Medical Practice Concittoe, con-rosed cf thro doctors appointed by the Industrial Coranissioner, Elsewhere in the State, the determinations are nsde by an arbitration before five doctors, two of talcs are appointed by the President of the local County Sedicsl. Society, and two appointed on behalf of the eeployer or his insurance carrier by the Compensation Insurance Rating Board and a fifth doctor appointed by the Industrie! Ccnmis.sior :r O';r the years, arbitrated sedicel bills have numbered fewer than 1,CCC a ytar, as ccittr&stcd with the estiaated raisiber of sodical bills of core than a nillioa a year, chile the total anounfc in dispute has not exceeded *75>OdC z. year out of total medical expenditures in the State in excess of $l,Cr0,000 a year. The Sew York law provides in greet doteil for nsny of the procedures r.ecacsexy in connection with nodical treatment and the relations between doctor, petient, employer and insurance carrier. lino does not peraitef discussion cf these various details. Basis of CoppoasatioR Benefits Another characteristic of coepeaeetion laws, as distinguished fros. the old em ployers* liability lass, is the fact that all compensation is related directly to disability and loss of earning capacity.- A percentage of wages, with gener ally scse fixed rARinun, is payable as conpensation during .nctual or potential disability. For instance, in New York two-thirds of the average ssekiy wego is paid c3 coEpens&tion, with a rsaxinua rate of $23.00 a reek ~jic a zi~ir^n cf . $12.00. Ihese rasinuB end minissus rates were increased this past v*ar by or* D-I-4 01 501 1113 legislature, effective June 2, fro:* $25.00 end $S.OO respectively*. Toe ra*i- run rate is provided for a period of one year, as an emergency to root the in creased cost of living an account of the war, All disabilities cay be divided into four classes, disregarding death benefits in this consideration, vis: 1, Permanent total disability 2. ?ercnnsnt partial disability 5. Temporary total disability 4. Temporary partial disability A disability in one class cay progress fron one classification to another, as for instance, a temporary total disability any become oca of the perrrnuont disabilities, or & total disability rny beccae with improvement only a martial. It i3 important that the industrial physician keep in mind these classifica tions. P^magent total disability is that condition which completely incapacitates & person fron corking and the condition is not amenable to improvement. Ac cn illustration, the loss of two hands or two feet or two eyes, or any two of them, ia declared to be permanent total disability. Proa e less standpoint, this is usually the most coatly type of disability. In adjudging disabilities the loss of use of a member, as by paralysis or deformity, ia considered the sane as* the actual loss of the member by amputation. And the partial loss or loss of use of a scabs* is proportioned to the total loss. Porranert partial disability is that type of disability that, while permanent in director, is not wholly disabling. In this c&togory are found the ampu tations of single combers or parts of members, end the loss of use of such num bers or parts. Ifcese losses are camoaly referred to as 0schedule losses," since the evaluation of the disability is dependent upon & schedule of Auch Xoseoo rat out in the law. The determination of these cases does cot depend uoon actual loss of wages so much as It does upon potential loss. If a man loses two fingers of bis bond, his loss of time from work my be but a few weeks, perhaps throe or four, but his potential loss is measured by the statu tory schedule that sets up orbitwily a number of weeks of compensation to pay him for his present loss and any future loss of earnings that be might sus tain. These schedule losses run all the wey from 15 weeks for the loss of a little finger to 312 weeks for the loss of an arm. These schedule values very in different states, there being little uniformity of opinion as to the value of a thumb or eh eye or any other member. Permnent partial disability also includes cases in the so-called "non-schedule" class, in which a condition is permanently disabling to some extent. In this class of cases aay be included back injuries that are persanent, but only partly disabling, or head esnes following fractures or concussions. These esses are settled not on the basi3 of a schedule, but on a reduction of the compensation rate, on the theory that tbs worker has sse earning capacity. Temporary disability is by far the most numerous class of disabilities ar.d i3 that condition that prevents the injured person from working,, but the ecad:*- tioa can be regarded at the time merely as temporary. This is generally the case with any injury that compels a man to stop work while be is undergoing medical treataent. During the time that osdical treatment is indicated the condition is altmys classified as temporary, although it my later be classi fied as a permanent disability. S-I-5 01 501 1114 Temporary rartisl disability is that condition that, while not permanent, is cot even totally disabling. That is illustrated by the type of ease where the injured person is advised to return to light work, often receiving treatment outside of working hours. Of oocrse, the caspensation rate is properly ad justed to take account of the partial earning capacity. The determination of the extent of disability within these classifications is the function of the administrative officer, but be must at all tines be guided Id caking his findings by the infortaed and expert advice of the doctor. Death benefits. Coepeusaticn in case of death is known as "death benefits" and is payable for various periods and at various rates, depending upon the individual state law* In Hew York, for instance* compensation to a widow is payable during her Ufa, unless she resarriea, in which case it terminates with the payment of too years of compensation from the date of remarriage. The widow receives 30$ of the husband*g wages, taken at a maximum of $1950 a year* Compensation Is also payable for each child under the age of 13 years, until be becomes 18, at the rate of 102 of the wages. In the case of the death of the mother or her remarriage the compensation rate for the child ren is increased to lg&. The aggregate of compensation la a death case may not exceed 66-2/3 per cent of the wages. In case the total condensation payable to a widow and children is less than the 66-2/3 per cent, benefits asyhe paid up to the maximum to brothers, or elster, father, or mother, or grandparents, if dependent for support in whole or in pert upon the deceased workman. Depen dency is usually conclusively presumed in the case of a widow and children. A husband say be awarded compensation for the death of his wife by an industrial accident, provided he was dependent upon her for support* Medical Reports A word on the subject of reports. Under the compensation systems of ell states, the physician is aa essential and integral part of the administrative machinery. Bo cos^enaation case is adjudicated without a doctor somewhere 2s the picture. uith the attending or consulting physician, careful observation and record are of the utmost importance* Therefore, reports of physicians take os a high degree of probative force and importance* Particularly under any free choice less such as that 2a Rev York, preapt, full and periodic reports are necessary. A first report in considerable detail is essential not only to the administra tive official, but even more importantly, it seems to me, to the employer or his insurance carrier. Bheo an accident has occurred and is reported by the employer, both to his insurance carrier and to the administrative authority, end a prosit report by the attending physician is rendered indicating a disability related to the injury, prompt payment of compensation by the eaploysr or.his insurance carrier should, and usually does, follow* The doctor1 a report, , therefore, is In the interest of the workman, the employer, the insurance company, and the general public. In the interest of truth and effectiveness, reports should be foil, give the history as obtained from the injured person, a clear description of the injury, the diagnosis and where possible, the prog nosis* If observation has bees properly trade, note should be made of any pre existing abnormality or deformity and record and-report should be msde of that antecedent condition. Mention of it in the report may era tine end trouble later ox* when some question with regard to such condition arises; Doctors ore prone to complain of the paper work involved in oos^e&sstios cases* It must be evident that the paper work is utterly important and a necessary pert of the system* Careful reports frequently relieve the doctor of the necessity of attending hearings and testifying. D-I-6 01 501 1115 Continuing periodic reports, though such loss detailed, ere also accessary for the sceoth operation of the law. The doctor should prccptly report the dis charge of a patient and state whether he is able to do his regular work or only light work, and whether there is any percacent condition. In Sew York, by a law enacted at the 1944 session of the legislature, doctors are required to re port directly to the Industrial Ccnnissioner, and failure to do so say render the doctor subject to disciplinary procedure, even to the extent of revocation of his authorisation to treat cccpcreation cocoa, formerly it vss the practice of scay doctors to send their reports in duplicate to the insurance eeapany, which then filed one with the Coarsiesioner* :n, however, the doctor 32st send one copy to the Ccnaissloner and another to the employer or insurance carrier. It is utterly necessary for the insurance carrier to have copies cf all reports for upon them the coop&ny depecds to determine action to be taken relative to the injured person's aoapenaation. But it is also obligatory for the doctor to file one directly with the Coanissionsr, even though the doctor bo oaastolng on behalf of, or at the request of the insurance company or the employer. OccucatioRftl Dlpeasag In considering the coverage for occupational diseases, the extent of such cover age and the methods of coverage vary greatly in different states* For instance: (a) done state laws licit occupational diseases to certain specific industries or to certain specific diseases that predominate in the industries of the state. Illustrations of these are mining operations in certain states or the crushing, saelting and refining of metals and metal ores. These are limited laws enacted to aeet certain cell-known and recognized conditions. (b) Sene state laws provide coverage by lists of nosed diseases and by sched ules of conditions in which they are found in the industries. Such was. the law of Sew York for sany years, and such are the laws of nary states today, includ ing among others Hew Jersey, i&ryland, Minnesota and Rhode Island. Iks socalled schedule nethod of coverage has the great nerit of certainty... informative to the employee as to the conditions for which he cay makeclaim, and also to the employer as to those conditions for which he say be held liable. The schedule method *f coverage has also the merit of sinplicity. Objection is esada to that method, however, that in these days of changing industrial pro cesses and methods, the schedule ray not include soce diseases that are char acteristic of new substances that were not comonly used when the schedule ms written and that, therefore, eo&e person may he deprived of compensation for a condition that is truly occupational but not named in the law. This, of course, cay happen even though the law be amended and enlarged from time to tire to keep it abreast of changing industrial conditions. It is suggested that a schedule law could be kept up with current conditions by providing that soae adaiaistrativo board or body shall have authority, when the Legislature is not in session, to add diseases to the schedule after a hearing and proof that sons disease or condition not named in the law is actually a hazard cf workers in seme industry. Tfhen, therefore, eos new chemical or substance cones into industrial use and creates a disease hazard it could, by prompt notion of the authorities, be made as occupational disease. (c) fore states provide in their compensation laws for the inclusion of all occu pational disease, by /ague and uncertain language is the definitions in the statute. The evident purpose and intent of ouch definitions are to rake the Is?? all-inclusive, of occupational diseases, but without any attempt to be spe cific as to the conditions covered thereby. An illustration of this sort of un- 01 501 1U6 certain language is contained in the Massachusetts la* which is declared to cover all 3 injuries," sheroaa noat laws cover six 'accidental injuries." The emission of the word "accidental" baa teen interpreted by the courts to rate the las applicable both to injuries by accident end to injuries by disease, but the very broad possibilities of the definition have seemed to causa cha idnin- istretive authorities of that State to exercise extres* care Inst cespenaeticn be attended to diseases and conditions r.ot doflaSely and certainly the rscpos sibility of the employer. In such cases it ffould eosa desirable to have seze sort of Halting definition in the statute. Such a limitation ie found in the cozpersatien lacs .? states, xhicb declare that the tars "occupational disease" shall scan only a 5 -to.se that urisos cut of conditions that are characteristic of and peculiar to the ezaploycent or process in fihicfc the worker is employed." Ibis, while net a satisfactory definition, is at least an intelligent limitation upon any ten dency to nate awards for all garner of diseases that say not bo charseteristic in any ray of the employment, but that nay be assented to have arinen in the osmloyasat by reason of sees cerely incidental condition. The very difficulty of defining "occupational di&eaee" is perhaps best illus trated by the definition contained in tins statutes of Illinois and Indiana. Both statsa employ the same exact wording. That definition reac3 as follows: "Sec, 6. In this Act the tern "occupational disease" spans a diasane arising out of and in the course of the employment. Ordii^ry diseases of life to which the general public is exposed outside of the employment shall cot bo ccasensable, except where tbs said diseases folio* as an incident of an occupational disease as defined in this section. "A dissase shall be deesed to arise out of the employment, only if there is apparent to the rational mind upon consideration of all the circunstasces, a direct causal concoction between the conditions under which the work ie per formed end the occupational disease, and which can be seen to have followed as a natural incident of the work as a restilt of the exposure occasioned by the nature of the ecplcyawnt and which can be fairly traced to the erploy&ent as the prexiaate cause, and which does not came from a hazard to ^hioh workmen would have been equally closed outside of the employment. The disease must be incidental to the character of the business and not independent of the relation of employer and employee. The disease need net to have been forseen or expected but after it3 contraction it sust appear to have had its origin in a risk connected with the ocployaent and to have flowed from that source aa a rational eonsequence." You will note that hia definition appears to be all-inclusive in the first sen tence, but then it is qualified by language that makes an exception of "ordinary cissasss of life." It eight be pertinent to inquire, what are the ordinary discsees of life that ara excepted? Certainly no one, be ho doctor or lawyer, is so *?ise os to be able to say with certainty what the definition scans in certain cases, (d) Soae compensation laws, by explicit declaration, are intended to cover -any and all occupational diseases.n That is the rule in Hew York that has teen effective since 1935. Th* first Pew York laa including occupational diseases was enacted io 1920, such occupational diseases being listed by naze and descrip tion of industrial process. To the very extensive schedule of diseases in the law, the legislature add3d an additional itea ioicwn as Paragraph 22, that ros-ds "any and all occupational disaasoa.* This has raised many nice legal D-I- 01 501 1117 problems and the status of diseases under the New Tcrk la* is far from ortain or settled. In the leading ease on the subject cf* occupational disease, the He* fork Court of Appeals declared in the language of Judge Finchs "The contention is made that his paragraph 2S extends the Forfcmon's Cocpensation lac so as to sake it applicable to any disease arising cut of end in the course of the employment, just as it is applicable to any accident arising out of and in the course of eaploytjent, This in substance would make rorkmen's compensation the equivalent of life and health insurance. *** "Manifestly, it was not the intention of the Legislature to change the Sorbcon's Compensation La? from a statute affording protection to employees against the hasards of their occt^atioa to a law insuring against diseases which eight happen to be contracted while the employee was engaged in his occupation, ** "Thus an occupational disease is one which results from the nature of the em ployment, and by nature is meant, not those coeditions brought about by the failure of the employer to furnish a safe place to work, but coalitions to which all employees of a class are subject, and which produce the disease as a natural incident of a particular occupation, and attach to that occupation a hazard which distinguishes it from the usual run of occupations and is in excess of the hazard attending employment in general* Thus compensation is restricted to disease resulting from the ordinary and generally recognised risks incident to a particular employment, and'usually from working therein over a somewhat extended period. Such disease is not the equivalent of a disease resulting from the general risks and hazards common to every in`ividual regardless of the employment in which he is engaged." (Goldberg vs. 954 Mercy Corporation, 276 H.T. 313) It is clear, l think, from this declaration of the court that not all diseases occurring to workmen are occupational diseases within the meaning of the law, cad the court has explicitly stated that the occupational disease provisions of the Compensation lew are not to be construed as providing life and health insurance for the workers at the expense of their employer. Tine docs not permit of extensive discussion of court decisions on occupa tional diseases nor of the various ratifications of the administrationcf that law. It is Important, however, that the industrial doctor familiarise himself with the laws of his state on the subject of occupational diseases. As we have indicated, there may be vide variances in the laws of the different states. It, this field perhaps is demonstrated the greatest difference between the private practitioner and the industrial doctor. Upon correct diagnosis much depends. Etiology plays in this field a most important part. Differentiation between conditions produced by industrial processes or by toxic substances used in or produced by the industry and those conditions wholly unrelated to the industry, is essential. This requires a knowledge of the industrial processes surround ing the worker and the substances with which he comes in contact. Upon the doctor's knowledge and skill may depend the right of a disabled worker In obtain the compensation Intended by the law or the obligation of his employer to pay the benefits called for under the law. This is indeed a heavy responsibility. So complex are the medical questions that arise from time to time in occupa tional disease cases that it has long been urged by many that a fair and in telligent administration of the law requires en expert medical board to pae3 D~2~9 ' 01 SOI ms upon ties. It is interesting to note that the la? of Maryland rales orchis ion for such a board of Lores jhysiei&r.s, appelated by the Oommor frox :.S53 recommended by the Council of the State i'edical Society and by the deans cf the two nedical colleges in that State, That board has no? been functionary for several years and it 1 raking an eav table record, narked by nicest fair ness, intelligence and courage. Such boards say troll point the vpy to the administration of such laws in the future. Stifegflla Another phase of occupational diseases has to do with silicosis and asbsstosis, or other lung disease due to the inhalation of* harmful dust. This is a subject for the complete understanding of which an entire course would scarcely suffice. Silicosis and asbostosis are the recognised and demonstrable conditions of fibrosis in the lungs, resulting from long years of exposure to the dust of free silica or asbestos la very finely divided particles. 5bile disabling caeca cf silicosis resulting frea a relatively short exposure - say two or three years - have been known, they are the rare exceptions, and it is the rule that silicosis does not result in disability without exposure of ten years to tseaty-five years, unless complicated with tubercular infection. These long exposures are rarely in employment by the same employer. They coamonly result from exposures in several different employments. When dis ability occurs, however, the liability for compensation is placed os the lest employer by shorn the worker was employed in such exposure. This was is the beginning felt to be very unfair, since the employer made liable for compen sation benefits might have been the employer in whose employment the man was the least exposed. Moreover, at the time of the enactment of any lav bringing silicosis under the act, a tremendous amount of exposure with its resultant offsets has already taken place before the effective date of the new lav, end. to place that already accrued burden on the employers on that date would be more than many of them could carry financially, to meet the situation of the already accrued liability and permit industry to "catch up," so to speak, Hen fork and several other states enacted lave limiting the recovery for sili cosis or other dust disease to an absolute minimum, as of the date cf the statute, and then increasing the maximum benefits on a sliding scale as tine passes and the workers continue in dusty occupations. In New York, for in stance, a nt::isua limit of $5,CC0 in any silicosis case was sot. That maxi ms was reached a few months ago, and thereupon the Legislature amended the . law fixing a nestman cf 6,500 on all cnees arising after April 1944% The progression from an original noxious benefit of $500 to the present lir.it has been accomplished without too great a disruption of industry end without driving onployers in the dusty trades out of business, which et one tine seeced likely to happen and which would have resulted in widespread uneaploycent. Tata relief benefits in silicosis are not the greatest part of the lav. Mwfetwg the dusty trades subject to compensation has had a very narked effect upon preventive measures, and has greatly stimulated the engineering and safety programs of this branch of industry. Already the effect of dust control is having a most beneficial effect on the health of the corkers in dust. In He? York, because of the peculiar medical problems involved in dust disease determinations, a special medical board was set up of throe experts is this field, and to this expert medical board are referred all medical questions involved in particular cases. D-I-X0 01 501 1119 Security for --ageenta Another characteristics of compensation laws ia the fact that they all require security for the payment of compensation. As we have seen, sor^easation is payable periodically as it beecaes doe. Hany cases of long-term disabilities or death bsnefita call for periodic payments spread out over years. It is not sufficient to leave the claimant or beneficiary at the risk of the con tinued business life or solvency of the employer. His security sust be supple mented by the assets of e recognised insurance carrier. Through the medium of insurance, the claimant is assured that the coney to pay his claim to ma turity is set aside and reserved, and rill alraya be available to him rfcsn dus. Tiis employer in affect really pays for hie accidents in advance, and, tfcarafcre, is net so immediately concerned with the ultimate cost. Also, he is relieved of the devastating impact of a serious less or catastrophe. JSoreover, through this medium, the cost of accidents ia spread out over the whole of industry and can be accurately measured. Hvary dollar paid in com pensation acd every dollar paid in cedical and hospital charges enters into the statistics of the cost of couponsation and has, therefore, a very direct bearing upon insurance rates, and the cost to industry. Insurance, in a very real sense, ia the agent of industry aad the trustee of its moneys paid for compensation* Whatever losses are incurred and paid by insurance must even tually be made good by industry through the medium of premium rates. It is not cy purpose to discuss the problem of insurance or the principles underlying it at any length, but it is so completely identified with the compensation system that some understanding of its function is necessary for the physician practicing in the industrial field. The method of securing the compensation obligation varies in different states. lnsurar.ee carriers are of three general types, namely, state funds, stock in surance companies and mutual insurance associations'or companies. In addition, in most states onployers who are able to prove their financial ability, say bo permitted to assume their own compensation obligations under a system known as "self-insurance." Generally, self-insurance is conditioned upon the em ployer copying with certain rules and requirements es, for instance, in Sen aork, whore in addition to his egreeaent to pay the compensation benefits and medical cost, the employer must deposit securities with the Industrial Com missioner in an amount sufficient to guarantee the payment of all dales should the employer default in any payments. State funds are of two typos--one the competitive Send end the other, the ex clusive or monopolistic type, Ihe competitive fund, as in Hew York, exists along with stock and mutual insurance, and the employer haa the right to choose whether he will insure in the State Fund or with a private carrier. The ex clusive or monopolistic state fund exists in seven states. In those states stock and niatial insurance is excluded and employers have no choice but to insure is the state fund. In such cases the State Fund makes its own premium rates, and may act arbitrarily in many matters, because of the lack of any competition. Administration Another feature of the compensation system ia the fact that the law is adminis tered and claims adjudicated by administrative officials rather than by the courts. In two or three states the law is enforced through courts, but the overwhelming rule, is administration by boards ar4 commissions. Faycent of unccntrovortod claims is sade the immediate concern of the onployef or hie in surance carrier, while controverted claims ox's heard before and decided by tho p-i-n 01 501 1120 administrative authority. This sake* for speedy hearing and detercinstioa, for inforsaliiy of procedure with the very ortninrsa of technicality. From the administrative decision, an appeal is usually allowed to the court*. Orly serious cases are likely to coca before the courts on appeal, and generally the courts have jurisdiction to review decisions only on questions of law, the findings of fact by the administrative officers being final and conclusive. Conclusion la conclusion, it should be evident froe the foregoing that the role of the physiei&a in compensation is coat important, and hia rec ords >ind reports highly significant. "hilo it is evident tbatan injury will be treated the came and heal the saae, whether the injury occurred in the enploytient or out of it, and the 3ao& procedures and skill will he required in either case, still there is a wide difference in the manner in ohich the case nill be observed and recorded,. Any physician who would seek to do industrial rerk, oust learn and observe much that he will not learn in the curriculum of his medieal school, fhe subjects that X have here sketched in outline should be given intensive study by the doctor, and will greatly aid hi aa he goes forward in this most inpertant, useful, and interesting field. P-I-12 01 501 112 lecture a-n C&HERIA FOR SSSUIZKia> TH2 FRESEUCE <F AN CCCSPATICaUL DISEASE Irving firwy, H. 2., F.A.C.P. Tho historical background of industrial aed occupational diseases (1) can he traced beck to the time of Hippocrates. However, It was not until the yea? 1700 shea Raaazslni (2) published his oeaorabls treatise on the affects of occupation in relation to the health of the worker that the medical profes sion bed vividly called to their attention the inportence of industrial hazards in relation to health .and disease. Since then* there has beonm interesting literature on the subject of occupational diseases, Tarns such as "disease arising out of esplcyiwnt,8 "peculiar to the occupation" and ndue to the nature of the work," have all been used to define the tern occupational disease. The scat pcapcnly encountered occupational disease is dermatitis. It has been satin*ted that the proportion of densetitle to all other occupational disease is 69 0). The criteria f&r establishing a diagnosis of occupational dermatitis ie excluded frog consideration i& vies of the feet that this subject will be discussed by another speaker in this symposia*. As physicians, we recognise the fact that certain criteria cost be present be fore a diagnosis of occupational disease can be established. These criteria nay be listed as follows: I. History of exposure (usually prolonged) to a substance that has been proven to .be Injurious. II. The presence of distinctive clinical symptoms and objective findings. * III. Corroborative laboratory data. I. History of exposure (usually prolonged} to a substance that has been proven to be injurious: The s-peptons of occupational disease say be insidious in onset. It is gener ally recognised that exposure over weeks, ooathe, and years, is necessary be fore there ere either clinical aynptoaa, physical findings or corroborative laboratory data to justify a diagnosis of occupational disease. Experimental t?ork aztong animals usually forms the basis as to whether or not a substance is injurious. Clinical experience baa bees, and is, however, the important guide in determining whether or not any chemical is injurious to the health of the worker. Poisoning by the absorption of lead is probably the Heat example of an occupational disease and can be illustrated by this case reports A male adult, 42 years of age who had been an iron worker and "buroernfor about fifteen years, was eaplcyed in the construction of a bridge. The steel girders used ih the bridge were painted with red lead. While driving the rivets thro the girders, the red lead was salted and the fuses escaped. In the construction of the, tower, a situation was created comparable to an enclosed chamber. In pre vious years of employment as a riveter and burner, this individual was not ex posed, to the absorption of lead in any enclosed areas. Approximately one sor.tb after the onset of work in his present occupation, the patient began to conplain of a metallic teste in the south, nausea, vomiting and increasing abdomi nal colic and constipation. The essential findings on physical examination D-XI-1 ' 01 501 1122 were tee paxier ana ^'i3cr.-:2,cies or taw goes. *ms *ssent:&i rmaings on isooratory examination were an abnormal ascent of lead in the urine (0.22 s^t.per liter of urine) and tea presence of 4D to 50 stippled cells per fifty microscop ic fields. ApprcxiimteTar one hundred sees were splayed in tee sane occupa tion end doing the esse job uatfer like eircusstaacee, end thirty-five (4; devel oped signs end symptooa of lead intoxication, corroborated by laboratory findings. The diagnosis of occ^etlofial disease in this group is relatively simple. The criteria as stated above rare present. All of the patients bad 1. A history of exposure to a substance that has beea proven to be injurious. 2. There Tver* characteristic clinical sycptosa and objective findings. 3. Corroborative laboratory data (abnormal lead sotaoolisa) w&a present. The symptoms of acute load poisesleg &re distinctive. In acute lead poisoning, there ia always evidence of an abnormal lead absorption and lead setabollso white can be verified by quantitative sxaslcation of the urine and of tee hole blood. There nay or say cot be a varying degree of aaeaia, but there is usually an abnormal amount of stippling of the red hlocd cells. Individuals exposed to tee absorption of toxic materials ray develop signs and eyzptocs suggestive of an occupational disease and nevertheless have an illness, white is entirely unrelated to the occupational hazard. The following case citation a111 illustrate such an instance: A sale adult, 40 years of age, me employed as a garage worker for a period of ten years then he developed unilateral convulsive seizures affecting the right upper and lover extremity. SbEanioatlcn of the spinal fluid aid of the oeull fundi revealed so abnormalities. A diagnosis of tuner of the bras was sus pected. There cere no syaptoas referable to any other organa or aySterne other than the central nervous system. Because of the fact that the patient worked in a garage end handled gasoline containing lead (tetra ethyl), a diagnosis of lead poisoning wee suspected* Quantitative studios of the whole blood urine for lead core reported as containing erronts of lead that nerd distinctly atnoraai. A diagnosis of lead encephalopathy was oede, based upon the LUtory of occupational exposure tad on tee finding of abnormal amounts of lead in biological materials. There investigation and subsequent studies revealed tee fact that the laboratory reports of abnormal amounts of lead In the urine and blood were incorrect. The normal enount of lead in a liter of urine nay vary fron sero to 0.1 cgn. of lead. The normal amount of lead in the whole blood nay vary free aero to 0.0f or 0.1 rgm. per 100 grans of whole blood. Inasmuch as we are dealing with infirtitisisal amounts of lead in the biological materials, tee greatest care cust be exercised in the choaical determinetiecs* The chemicals used in estimating the amount of ,. lead in &uy given specimen say contain sore lead than was present in the ori ginal specimen to be examined. In the case under discussion, it was conclu sively proves after numerous control studies and other investigations, that the lead in the urine end whole blood mss well within normal limits. The diagnosis of lead poisoning aa a cause of the convulsive seizures was challenged. He ere cognizant of the fact that there say be pathological lesions in the brain causing numerous symptoms including convulsive seizures that cannot be recognized or proven to be present even after tbs cost meticulous and scientific study. In the case under discussion, subsequent events indicated the necessity for surgery. The patient was operated on and a brain tumor removed white was followed by conpieto recovery. The lesson to be learned from this ease is quite obvious. Although lead nay 01 01 ii2:i iffeat tbs nervous oystea, it dees not necessarily fellow that necrolcgical syeptoss that cannot be explained on say other basis are necessarily cue to the occupational hasard, At 00 time in this case in question was there a history of abdoainal colic, nausea, veeiting, arthralgia, etc* The clinical syeptoss sera not characteristic of the occupational disease in question* The patient had a history of prolonged exposure to the absorption and there r 00 abnormal aaeunts of lead but as proven subsequently, there was no anoaift, no stippling of the red colls, and there were no abnormal findings of lead in the biological sateriale. Even if wo assume that this patient had had ftbnonral le?;d absorption, certainly, neither the lead absorption nor any leading poisoning played a part in the origin of the brain tusor,its development or subsequent clinical course which caused tho patient to stop corking and seek asdics! care. She inportar.ee of obtaining a complete and detailed faaily csd past history, especially of previous occupations, cannot be overerphasised. The sycptccs of occupational disease nay bs insidious in their onset and run a chronic course. The need for a differential diagnosis especially in any bissare case nay require all laboratory aids and special studies. fre knot? there is co parallelisa between synptoise and disease. There are instances where psychoscnatic or functional disorders nay produce synptoca and after complete physi cal examination and laboratory eaaoinatior., patients are found to be entirely free of disease* It is well recognised that organic disease say exist with out clinical symptoms. Hypertension, nephritis, diabetes, gastro-ducdenal ulcer, disorders of the hemopoietic system, broncho-pulncaary system, skeletal system, etc., may exist without producing clinical ayrptoms. In the course of a routine preenployncnt.or pre-placement or health examination, disease may be discovered of uhioh the individual is entirely ignorant. It becomes clearly manifest that since there is no parallelism between disease and sygptocs, that before arriving at a diagnosis of occupational disease, thorough and careful medical examination is necessary la every instance. These "silent" diseases enumerated above may. exist for itany months or years until seme in cident brings that patient to the office of his physician, An industrial accident or the question of an occupational disease causes the patient to sook medical care and then for the first tine, some constitutional or under lying disease unrelated to occupation, is discovered. The necessity of an adequate pre'placement examination becomes evident and its importance can be readily appreciated rhea se are dealing with individuals who my in the course of their cork be exposed to the absorption of injurious substances that my produce disease* The examining physician has the responsibility to determine whether the patient1 s illness is due solely to the occupation or only partially to the occupation or whether the illness is entirely unrelated. If an occupational hasard is known to exist, the synptocs and abnormal find ings is any given case can be properly evaluated when the physical condition of the patient prior to employment is known* Thorough physical examination, 1-ray examination of the chest end a blood tfaeeenoann should be a routine pro cedure. *?kere indicated, blood studies or other laboratory examinations may be essential both prior to employment and during the regular employment. In dividuals exposed to the absorption of inorganic dust containing silica or asbestos require periodic X-ray exaairation of the lungs* The fcse&rd of a specific occupation is the determining factor as to the type of medical survey necessary in order to recognise the earliest manifestations of industrial ill ness* Tho incidence and severity of Ulaesa in any type of industry depends r.ot only upon, the control and prevention of disease but also upon its early recognition. ... In reviewing the special bulletins of ,U?e Ben York State Department of labor of the years 1932 to. 1939 (5), that section which deala with occupational disease rev$al3 the fact tisat host eoraon occupational diseases are Dermatitis and tho3 duo to the absorption of metals (lead, arsenic, mercury,*etc*) and the absorp tion of solvents (derivatives of tens! and petroleum). To these substances, in recent years, may be sdc'ed the absorption of the.non-organic dusts such as silic:. JM Oi 501 1124 and arkestos* ;t io clearly evident that cr.iy sfter prolonged arposurs to the absorption of tease substances that sirr-s sr.c sycptocs cf occupational '-score evident* In tless esses -hero ccrpcnsctit?n has boen paid for lesr. pels* xiing, tbs absorption of this heavy setal has occurred 0V3r a period cf yssra hsfozc* the specific occupational disease knifestod itself, However. tie lr.Vr.Iati.an of lea3 lust end lord fures ray cause lead poisonin' within sv*'*=-*'Z .ev.-ts to L'o-'erai neniks. .ixperio^ce tes a* can that ss with load Oast aid ?.ud fv.v.8, sc tco, with tho solve ate, e poisoning my occur "\5.".hin a period c.T -xrcTo.l week* cr nentub* The nod3 of absorption is frequently the detiiixiairg factor as to th appesr&ns* of toxic ayrsptcr-a. ahon tker is absorption af injuricus substances ihn_ 'h9 lungs or thru the akin, :aanifestattens of t:icity my hocone apparent within several reeks after contact. The ce-rce of concentration cl ih injurious substance ia the working atmosphere is >,$.e dezestsiniag feeter ae to the tine interval betnsen the onset of work and ths vcroorvonco oS tbs o-cr;pati-nai disease. In eilicoals and asbestosis, It is sell recognised the period of exposure 'to xhs inhalation of the dust ray take several years before clinical syzrptoES arise, The coraon denominator in all occupational diseases aside fren the Question of the specific hasard is the period of zice or employment. XI. The presence of distinctive clinical sygptoroe and objective finding! 2t is reasonable to expect that when an occupational diseas is under consixratios that certain clinical sytiptoes and objective finding sill tsr present. 3y virtu of accumulated eedical experience the physician today is cognisant jf tho clinical symptoms that are usually associated with occupational iisccae, vihile there nay rot be all of the signs end syiBptotr,s preserAin any given case, it is reasonable to expect that a patient having an occupational disease rill have the syoptona and signs that are usual to the disease to a varying degree. By reason of the fact that occupational disease is associated with distinctive clinical synptoss and objective findings, most definitions of occupational disease include the tern, "peculiar to" or "characteristic of" tha caploy^eftt* As an illustration of distinctive syeptosse and findings in an occupational disease, the following instance ofbenzol poisoning is citods 1 rale adult, 43 yearscfsge, had worked as a pressmen on black and white srossoe for s perled of 25 years, that eas no hazard in this type of ecsplcyusat. Son t) roe to four cumtha after he b.gan working on nulticolored presses rrasro !:a oas exposed to a variety of colored inks and the inhalation of fumes of benzene teasel), the patient began to complain of increasing weakness, black and bio spots of the skin in various parts of the body, loss of '--eight sad strength, with bleeding froa the nose and gums; Tha concentration of bengone vapors in the oork-rooa air ranged froa 50 to TO parts per Billion tarts of air. The patient was admitted to the hospital with a diagnosis of l^rszol poisoning. Blood studies revealed a pronounced anemia with a narked leukopenia and a thrombocytopenia. tfi white blood cells shen the patient ?3 first esatsined were 1,600 per cu. ca with a pronounced lyrcphocytosis (?3)* There vms progressive leukopenia end increasing anemia with dininutica of the plntclate. Beepite nuaerous blood transfusions, the patient expirod. Post cortaa examination revealed a complete aplasia of the bene narrow, 2a this case cited, there was a histojy of proven exposure to.a substance . that is injurious. T/o also note here the characteristic clinical syigjtoixs and objective findings as a result of the jSpl&aia of the bor.e narrow due to benzol. D-2I-4 01 SOI 1125 There is i* us,'Suasion of -he r .<1 c;lls, i'?.e white cells ^ b 'ho ca^karyocytes or plttt`>lT*fcs, As a resul ,V 'r.j j,>r $sion of all of *hestj fc-reo '.X r.sots cf the blood, thorn is anemia with weakness end loss of strength and weight, and es a resuit of the deoroaso to absence of platelets, there is bleeding into the skin end all of the cavities of the body* At this point, it seem* advisable to stress the importance of the fact that the Industrie! physician should be cognisant of the hazards of any materials used in a soeoific Industry* Jt seems wiso that a program of education rela tive to the nasards in specific Industrie* be instituted eo that the employer group may realise iks dangers inherent in occupation* The speaker has. had the opportunity of examining a dosen or more aenwho for many years has l>een en gaged in the rubberising of cloth* Various solvents were used including such chemicals as ethyl ketone, toluol, gasoline, and othjsleno dichloride. iTith the speeding up of activities during the war, the conoontrsticn of these materials In rubberising ballon cloth was increased with the result that signs and symptoms of intoxication oveloped among the */orkers, ffhen attention was called to the employer that possible substitutes could be used that were harmless, tries substitutes sera interduoad and ventilation other safety aeas-rr^a .Tore Im proved ith the result that there was no further illness* The speaker further had the opportunity of seeing half a dozen cases of methyl broaid ppisening sous two years ago* The employees were filling ampules vith methyl bromide (which was to be used aa a delousing agent among the soldiers) The amnloyer had no knowledge whatsoever of the extreme toxicity of this solution .vhich rea dily vaporises and beeernes a gas and nay have irreversible aotion en the central nervous system, One of the workers died aa a result of methyl bromide intox ication* There were approximately twelve people engaged in the York and the eraplayer knew absolutely nothing about the toxicity of the chemicals *Moh the workers handled* 2t would certainly seem advisable for the chemical concerns that manufacture and distribute these various products, who are undoubtedly fami Her ith tho hazards, should have the employer groups or the workmen ed ucated as to the possible potential dangers when forking with au'*tacce that may prove injurbua. The solvents that are derivatives wither of potroleurn or coal tar when absorbed may produce toxic symptoms by virtue of their affinity for certain organs in the body* Benzol, a derivative of coal tar, when a sorbed, produces irrit ative phenoeena of the bone marrow to the end that aipasia with death may occur as avideseed by the case presented above. Carbon tetrachloride, the most frequently used solvent, is a derivative of petroleum* When absorbed, carbon tetrachloride causes gastrointestinal disturbances and aay produce injury to the li7er and to the kidneys, la most of the cases observed, uncomplicated recovery has been the rule after carbon tetrachloride absorption. In two in stances, death occurred as a result of acute hepatitis an neute renal in sufficiency following; irritative phenomena in tho kidneys with suppre sion of urination. Both of these patients were known alcoholics. Because of the changes in the liver parenchyma that may be present in chronio alcoholics, it is ad visable to exolud these individuals from working with any of the solvents. The clinical symptoms and objective findings that oenur la the patients #ith silicosis and asbestosis and asbestosis will tQ discussed in another leoture at grater leaS^h. The speaker, however, desires to call attention to the tact that pulmoaa-y tuberculosis in its X-ray appearance may mimic any and all types of duet diseases, as may be illustrated by the CoUoair.s aae cite, tion, -' 1 patiJit y**-rs f ago, was ployed for a period of tro yr-irs as * D-1J-5 01 501 1126 r^chinivt ' a r.%1':'? , Hi* *'v!% 'Vutti-- err,:-. r .o-.ir ; .-r. . r.d ;.ftrr rhi.* ..n o *-3od, 'he ^. ti:rt 'r.plHir.; i >f 'ir.x.-a-.si orortnocs of fcrua'h, Vi-ar* . ?s rA a ins in t ' -rwots*. "r.ur-jj s- 5'-ntiaJly .\*;;ati-a e.'.cept f?r ;.o ion of 'ho '-onch'-sic '.sr K-*ia`.: sounds end a slight degree c? hycerresonance thru out both or.osta, "-ay ex amination revo&lcd findings soso^nly present in silicosis, ' `catterud thru- out bobh lung I'ioldSj there *ero uisiiret miliary a^dulati^ru- * ay.?- vtricol in distribution# I.i the ri.ht infra-? Uvleular region, -.here wa3 .in area af conloseoneo of th?3S nodules. t.ha secor.d and third interspaces if t>.a la: ch^st, vhsr -7!'.s cor.QIona ration of these neJylos ur^h ao.a> honeye ruing, but r.o definite cavitation *&s acted. The patient *a markedly -tyspneio utd ot- f.paste *lth a pronounced doersaae in the Vital Capacity, via i* :o the plan*. .yh?i*w the patient was orbing rove*led the fact that them -ran r.d elite a hazard either iarmediete or Sr. t.ho vicinity .Thera the patient ms .verting* -- J*37ic of the pt history excluded any poo.sibla content ,/ifch -ilica,' 'tesaito the fact that the X-E*.y had all mho charset urittio s -pcaranees of ailteosis, it was reasonable to conduce after bhoro iuveatiRation that the 'Rtioat bed & hedod, miliary tuberculoute. this cuso citation id fur ihsr proof of the necessity of tftoro atudtes in the differential diagnosis ev.cn the sweatier. of occupational disease arias*. III. Corroborative laboratory data. In many instances where occupations! dteoase is nuapectod, lab oratory aids are of importance raid value in arriving at a diagnosis, The lu'-oz-atory investigations that con bo of ovine sraj- a, Studies of the working environment (diet sampling, air analysis, ato.) b, Sxardn&tion of the hilogical mte rials (urine, whole blood, etc.) c, Conlete blood count and vlood cheatatry studies {for liver end renal injury, etc,) d, X-Say examination. X cot*s.lied di?c-alien cC the rvaluation of any or all of *heoe variou* pro se.-unos as laboratory aids doss not seem essential to this presentation# It it apparent, that abnerra! coneentrations of silica d;ist, beacol, etc* in the atmosphere 3an bo considered as proof of the prosshoe of -orking conditions b'-st are harmful. The examination of biological materials ia of i7aius in datenaioins the presence or absence of abnormal amounts of ratals such as "'her solvents are suspected of having cauesd injury to the liver, special bleed chemistry studios as the Icteric Index and the Van den *argh are c-f intostance, X-Say examination of the lungs is of course e foetid dotomining 'sfcethtT or not there have been parsaehyrjal changes as a re sult of the inha latics of ijjy duet that may be considered ftamful. 7n diocutsin.*; the criteria for dotsraining the praser.ee of occupational divas-cv* oe&sidVTttica has been given to disease htat stay develop after sx- pisiu'o to ccntoct with an injurious suba+ance over a period of many months or yvart^ There can be no disagreement as to the oiassifioation of lead P*.5<-r:.:*.S, silicosis, bsntol coioor.ing, mercury poisoning, etc, as oecupa- diseases* Th medical acpocts of eooupttional dise^so if V-sced upon of fir it? tl.s fta-.o c-i^tee1^r,vifaY, olrika*o^?eaaigimrapploh r to .define and int-srprot iino# ic*c4 has. been added' to the 'UCcu-'itios-Al in c-n-6 01 501 1127 disease list to instate .'aop'jMftilon for "*ny ana *11 occupational diioMM** Clarity *rd Ais'inetnes* has cot os-ilted from this type of all-inc 1usive la*. As a result of the failure of specifio definition, clAla for compensation ob the basis of occupational disease has arisen la instances of rheusatio fever bronchitis, prtewo&le, asthma, pulmonary tuberculosis, arthritis and' actlnoaycesis, eta, these diseases are ocnaca to the general population and are not apooific to any one industry. Disease may occasionally he contracted as a result of occupation, as any be illustrated by the following cases A nurse 26 yaare of a^e, was employed in a tuberculosis hospital. Physical examination and X-Ray examination of the lungs revealed normal findings. Tuberculin skin test m negative prior to employment, Sight months after the o:i*at of the patient's work is this tuberculosis hospital, she developed cougha fever In the afternoon and X-ray evidence of pulmonary tuberculosis Contact with an active oaso of pulmonary tuberculosis may have ooourred out side of routine hospital duties, However, one cannot deny that the disease say have been contracted as a result of occupation* One should not classify the rare instance of pulmonary tuberculosis which develops is an individual working In a tuberculosis hospital as an occupational disease. The necessity for formulating criteria to determine when tuberculosis is the result of an occupational contact has been stressed by 3rahday, (6) From the medical point of slew, Infectious diseases such as pulmonary tuber- ouiosls and constitutional diseases ouch as asthma, should not be classified M as occupational diseases, AsthaA, like many other forms ofyaiergy is due to underlying constitutional factors and is inherent in th^fndividual. The occupational factor nay act in the nature of preoipitatiag, eliaioal symp toms as may be illustrated by the following case citation* The patient 31 ysar* of age, had a pre-existing history of hay fever, and a fastliar history of various types of allergy, 3 set employed in dyeing and blending furs. After eighteen months, he developed attacks of sheeting relieved by adrenalin. In this instance, an individual with a known pre existing allergy ns employed in an Industry known to produce sesltlsatioa. The industry was responsible for the attack of asthma, but certainly not for the underlying allergy. Bronchial asthm is a hereditary disease which occurs only in predisposed individuals* These potentially sensitive Indiv iduals may become apooifically sensitised to various proteins or aofc-pro tein substances with which they may ooae in contact in the course of their occupation* The period of exposure required before sensitisation takes place may vary from a few days to several years and differs with the individual {?) In another individual, 30 years of age, olinioal signs end syap toms of bronohial asthma developed after sin month's work with an Insecticide containing derris root and pyrethrum. A diagnosis was made shortly after the onset of symptoms, following a change of occupation, the symptoms of asthma im mediately subsided and there has bees no recurrence sinaa* pre-asthmatic symptoms suoh as Basesing and rhiaerrhea are usually present before the attack of asthma occurs and it is advisable to res&ve the patient from his environ ment contact when these early systems of sensitivity ere evident, i In the State of Sew York, "accidental injuries due to harmful subetanoee" are properly differentiated from "occupational dieeases from exposure to harm ful substances and occupational activity". Acute poisoning suoh as may follow exposure to c&rVon monoxide, esrbon dioxide, and olinioal symptoms arising 01 501 1128 out of a single exposure Is considered an aecidentul injury duo'to harmful sub stances. Those acute Hints* >8 tiiat on*ide-od occupational uccidenta should not Vo classified uncer rue heudin' of occupational diseases. Tho con- .cept of disease In general as a physiological adjustment or occupation has been stressed by Garrison (8). Disease that can occur amongst all groups of people irrespective of station and occupation and deem not occur in excess in any one occupation should not be classified as an occupational disease* Xa this discussion of the criteria of occupational disease, it seems apparent that 'the diagnosis of an occupational disease can be established in any given case* If nodical opinion were to prerail, there should be very little dif ficulty in the classification of what is and what is not an occupational dieease* For the sake of clarity* It seeaa advisable to have clearly stated those diseases which are to be considered occupational* Tho criteria for determining when such 1 Unease* as asthma, infectious diseases, etc* may be occupational, can likewise b defined0 frith clear definitions and criteria established and accepted, th* problem* that arise in any discussion of occu pational disease are nearer eolation* 01 501 1129 2IBLIC02APKT Sigoriet, Eonry 2,t Historical Seekeround of Industrial Disease, Wesley X, Carpenter Lecture, Bulletin .'oi cino, v&l. XIX, 1936, p, 597.609* Cccuos.tior.al of* ITedi- ter*zsini, Bernardinoj D Korols Artifleus, District :.fcdi-.a, 17C0. Schwarts, L. and Xulipas, L,: Occupational Diqcsssn 'if :S> rsi*, z.ra < ?obigor Philadelphia, 1939. vrsy, Irving and Greenfield, Irvinss Acute Lead Pc'.aonir.S: Ir.i-atrial Industrial Lsdiciaa, Iky 1933. tf.vr York State Dspartasont of Littor. Division of Statistics ar.d InCessation; Cost of Cojpanaatica, Spooial Bulletin $ 196, **232 and 208, 3.952 to 1939* Brahdy, Leopoldt Occupational tuberculosis and Coaper.sation Less, Aaor, /lev, of Tuberculosis, 7olP XU7, 8o 5 tfov8afcer I9UI, Gray, Irving ar.d Albert, hurrays Aoths*-Prevention in Industry, Industrial Jfedioins, Deccaber --.Tiiou, p, HP 1 Life as an Occupational Disease, Bull* IVY, Aoadesy Of Hodicin, Y1* 10, He, 12, I>oa 19& 01 SOI 1130 tfJCTtJRS D-1II toxic oases, n?ga anp tapors Leonard Oreenburg, U.D. It is a rather difficult task for a speaker to present the subject of toxic gases, faross and vapors in a course sxh as the present one in the thirty minutes which have been allocated to this lecture. The speaker suet decide in his cars mind how he can present the subject so as to ive the students a maxima of valu able information* Because of this limitation, it has been decided to resent the basic underlying principles of the subject fith very little detail onceru ing the toxie properties of any single material, in the hope that these basic principles will serve as a framework on which the student &ay, in the future, add hie scowsulated knowledge. In order to seintain life, the animal body obtains oxygen from the inspired air and in turn exhales carbon dioxide resulting from the metabollisa of fats, proteins and carbohydrates within the body. This exchange of gase* takes place In the lungs, between the air in the terminal alveoli and the blood, in the smallest of the blood Vessels, namely the capillaries. The surface area of the alveoli la extremely large, approximately 90 square metera, which is approximately the area of a standard siso tennis court. The amount of air which a person breathes in order to satisfy these setebollio requirements varies with, the degree of physical work. Obviously, the heavier the physical work the acre air and oxygen is required. The following is the amount of air in approximate figures required for vadooi degrees of activity. Resting bed Walking Running slowly Heavy Exertion Heaviest exertion 6 liters per minute ll* - 26 liter# per minute h} liters per minute 65 - 100 liters per minute $p t* 150 liter# per minute If there are contaminants in the atmosphere being breathed, a large amount way ba taken la in a relatively short tine because of the large gaseous exchange and it is obvious that if a man is engaged in hard labor, his gaseous exchange will inorease and for this reason he takes in more noxious gas. Therefore, the total, amount of noxious material taken into the lungs is greater than that In the esse of a man engaged in sedentary work, this simple fact explains why heaey exertion produces susceptibility to poisoning; In practice, we sometimes find that a can compelled to enter a olosed tank, say for example for the purpose of cleansing, may sueoumb to the gases, fiates or vapors in the tank and fall unconscious to it# floor. Subsequently, when- rescue is attested by a second worker without adequate protection, the seoond worker will also suooiab to the effects of the toxic material. Frequently on rescue of both men from the tank by proper and suitable means and with the inauguration of resuscitation techniques, the first mn will be brought back to consciousness whereas the second man. the attempted rescuer of the first, will often succuab and fail to be revived. The second man clearly has, by virtue of hi* exertion in attempting to lift the first man, absorbed a larger amount of the noxious material which brings about his death. The large'Surface of the capillaries, the large surfaoe of the alveoli, and the large amount of inhaled air which takes place particularly with phy*ical effort, make it obvious that even small percentages of contaminating substances in 1 The blood carries ases by virtue of *wo mechanisms* (1) the hemoglobin ewchanism which plays 'm -olo in the transport of oxygen and carbon dioxide- and (2) the solution aeofaaniaa by virtue of which a gas is absorbed by liquid such as the blood, depend!*).*, ca the partial pressure of the gas and its soljbilit; in the blood, this is usually referred to es the law of partial pressures or the law of Henry and Dalton, In passing, it ay be pointed out that the solubility xoohagisa is of greet importance when sen ere exposed to ataospherss under J.v.reased pressure, such as compressed air work, in the oase of divers, or caisson ">rkers or whoa con are exposed to low atmospheric pressures as In the case of aviators ascending to great heigrtd in a very short period of time. Just for illustrative purposes, j have made two computations with reference to two important substances 5 namely beozol and methanol. These computations are very approximate and do act take account of certain iL*jortaat factors which we need.not discuss in the short time available but they w.'ll servo to indicate very approximately the amount of absorption which may take 4>lac In the case of a man engaged at ordinary labor in the usual type of workshop* let us assume that a ran breathing 25 li;er* of air per admitv is working ia an atmosphere of benzol vapor of approximately 75 parts per s.lUioa for one hour, a concentration of bensol vapor not unocsoionly encountered in industrial es tablishments. The man would absorb 0.5 ' grass of bensol and i.u an eight-hour working day he would absorb 2,9 grams 0. this material. The fatal dose by month is usually given as 15 grass. In the case of methanol, a worker in one hour would absorb 0,35 grass and in eight hours, 2.05 grans when the atmosphere breathed contained IOC' parts per aillien. A dose of approximately If. grams taken by mouth at one foe is con sidered dangerous. Please bear in mind that these two examples are not to be coneide*td accurate but merely indicative of the amount of toxic material which say ts absorbed, tu a given working period. It is important to bear in air.d that absorption by the pulmonary rou^e ia more important that absorption throng* the gastro-iateatinal traot because of ae other basic reason, flhen a ioxio aaterial is abeerbed through the ges ro-in testinal tract, the blood v.iich carries this material must first pass through the liver before going to body tissues. In the liver, the material a.\y be detoxified* Cn the other hand, the blood which absorbs toxic saterial fron the lungs does not pass through the liver first but passes directly to the body tissues by means of the axterial circulation. This fact is of great inportaao in the case of toxid dusts. Tears ago it was a general belief that lead, poison ing was chiefly produced ty the ingestion of lead and many industrial establish ments expended considerable effort ia compelling workers to cleanse thsir hands, teeth and mouth prior to eating lunch. *c* we know that moat of the lead which is ingested is excreted rather directly through the intestinal traofc, whereas the load dust which is breathed into the lungs must remain there in situ.un til it is dissolved and carried away by the Hood etrean. Only snail por tion of Such lead dust is expectorated or removed from the lung* by the natural cleansing nochonism of this organ. D-XIX-2 01 501 113 The classification of atmospheric contaminants is a somewhat arbitrary proced ure but is nevertheless a valuable on ; o.' sviaouta of this sub3001 since it makes it possible to readily keep in mind 'he ^ooral scope of :he problem with which we are dealing. The following olaaeifieatien If suggested os a useful one for this purposes a) Dust - Solid p&rtlQies mechanically generated} in Ttses from say 1 micron to 10 Riorone and larger. b) Kitts are gases in which liquids In the fora of droplets or bubbles ere dispersed, 9) Fumes are gases in which aeorphu* or crystalline particles are dispersed, and usually resulting from the sublimation or condensation of vapors of various actsIs. fhe partiole site here is usually from .001 to 1 micron In cite. d) Vapors and geaes, particles below .001 microns in site haring vigorous Brownian movement of the single partioles. ffe must no* pass on to a consideration of the nature of toxic gases, fumes and vapors. For your purposes. 2 should like to present these in four groups, as f0liarss (1) Irritants (2) Asphyxiants (>) Volatile drug and drug-lifcrr substances (U) Inorganic and crgano-aeteliie substances let.us now consider the nature of each of these gnaupe of substances. Irritants The-bost important characteristic of the group of irritant gases is the in flammation of the tissues vbioh they produce, The members of this group naturally vary to some extent in the relative degree of irritation they produce as compared with the systemic toxic effects result ing from their inhalation, this group may be divided into two sub-groups; the first kacern primry irritant# which possess little of no systemic toxic effects} and the second group, the secondary irritants which produce systemic effects of some importance. The primary irritants vary among themselves in that some have their most im portant effects on the upper portion# of the respiratory traot whereas others exert their most profound effeot on the bronchi end still others on the deeoer pulmonary tissues. For example, amenla. hydrochloric acid, formaldehyde and sulphuric said, in general, affect the upper portions of the respiratrey tract. Sulphur dioxide and chlorine affect the upper respiratory tract and also the hro&ohi whereas phosgene and nitrous oxide chiefly affect the lung tissues? For example, in the case of nitrous oxide, it not infrequently happens that a worker, after exposure to this gas which may be slightly irritating so that he is conscious of the irritating effects to the upper respiratory tract, may some six or twelve hours later develop acute ede&a of the lungs to which he succumbs* The most important of the secondary irritants is hydrogen sulphide which is really a systemic poise but has nevertheless marked irritant action on the cornea and conjunctivas and certain volatile hydrocarbons which possess irritant action for the upper respiratory tract and bronchi but whose most important effects are systemic in nature. '* It not infrequently happens that with exposure to low concentration* of hydro gen sulphide, say for example in building excavations, that the workers may D-in-3 - 01 SOI 1133 eospi&ia only o? Ctt^vmcVivial irritation for which they 3*0k medical relief. Several yvu-s .;;o, in the construction of a large sewer projoct in `Km vicinity of Buffalo, 'he sx.'avri*.ica pass-d 'hrough a >rea in shioh hydrogen sulfide was liberated la small amounts. Here anay sen developed conflumctivial irrita tion but no systemic effects, laphyxl8.uta The general characteristic of thi# group of substenocs is that for reasons which we will discuss later, the body tissues are deprived of oaygen and raturally, when this occurs, asphyxiation results. This group la composed of tiro sub-groups; (1) Simple asphyxiants (2) Chemical asphyxiants Simple Asphyxiants The staple asphyxiants are inert or physiologic illy neutral gases which exclude oxygen from the atmosphere vtiioh the worker is compelled to respire, the gases being present la concentration* so high that t ie necessary amount of oxygen to support a&inai life is not present. In this group we say place such gases as nitrogen, hydrogen, helix, aethane and carton dioxide. As you know, fermenting silage kept ia ailoe on farms and used for cattle fodder produces carton dioxide is large amounts. It Act infrequently happens that a farmer is cocpelled to descend into such a silo for the purpose of repair or some other reason and there becosw# asphyxiated. Methane similarly affects workers in mines and other places underground where this gas accumulates in high concentrations. Chemical Asphyxiants The chemical asphyxiants are different than the group of simple asphyxiants in that the exposed person breathes an atmosphere sufficiently high in oxygen to support life but the chemical asphyxiants prevent the utilisation of this oxygen by the tissues. Two examples of this group may ba cited; namely, oar bon monoxide and the cyanides, for example, hydrogen cyanide (HCn), Carbon monoxide readily combines with the hemoglobin of the blood and in effect ing this union, prevents the oxygen of the respired air from entering its nar co! combination with the hemoglobin* In other words, the carbon monoxide deor` oases the capacity of the hemoglobin for carrying oxygen, Naturally, with small concentrations of carbon monoxide, the decrease is oxygen carrying capacity ay only be relatively slightly decreased but with higher concentra tions of carl on monoxide in the atmosphere breathed and over a longer period of tiao, the body may actually be deprived of the necessary quota of oxygen for the support of life and asphyxiation will result. Hydrogen cyanide la somewhat different is its actlost. It combines with the ox idative ferment in the tissues and In this way deprives the tissuos of their capacity to utilise the oxygen for the maintenance of the vital processes. The end result, however, is essentially the same and if continued for a sufficient period of time, asphyxiation will result. Volatile Drug and Drug-like Substances The third group of materials which must be considered is a wide variety of chemicals which are extensively used in industry, partioularly since the advent of the war. This group includes the organic solvents and certain petroleum der ivatives, D-m4* - 01 501 1134 The chief chasactoristics of thirf jroup t..fcen as a wholo la thu fact ^hat all of these substances h *, to sono oxr.mt, 'he property of inducing anasthesia rfhon inhaled in sufficient quet.titiea o-or a suffioijnt period of time. Sqb# haT* little or no other physiological aotion on the tody than the production of anesthesia while in the ease of others, the anesthetic aotion is rather mild, whereas the systemic effects are extensive, a* Primary Anesthetic* The nost narked effect of the inhalation of these substances is the production of an anesthesia. As examples of the substances in this group, we sight site nitrous oxide, hydrocarbons of the paraffin series, ouoh as sthane, ethane, propane, butane} various fractions of oetroleua, such ae petroleua ether, petroleua bensene, gasoline, ete.j certain of the ketones, such as aothyl ethyl ketone> and certain hydrocarbons of the olefin series, euoh as ethylene, propylene and butylane. b. Anesthetics whioh may cause changes in vietraj organs This group of substances produces organic changes in the body even in the ab sence of &arked anesthesia although the anesthetic changes are present If the exposure is sufficient and these substances nay also produce viseral change# from prolonged and repeated exposures to concentration# which do not produce anesthesia. In other words, in this second group, while the substances are anesthetic in nature, the anesthe tic aotion is overshadowed, particularly in industrial exposures, by the changes produced in the body organs. In this group of substancea, we nay include toethy1 chloride, methyl bromide, carbon tetrachloride, trichlorethylone, vinyl ohieride, 0. Anesthetic gases and vapors whioh injure the heaatapoetlo eyeten These substacoes also produce anesthetic effect# but as in the previous group, the anesthetic effect is usually overshadowed by the injury whioh these substances produce is the hes&tspoetio system, particularly is industrial exposures. There are two outstanding example# is this group} namely, bensone and toluene. d Anesthetic ga#es and vapors whioh chiefly Injure the nervous eyeten This group of substances Is characterised by its high degree of solubility and is low concentration in the respired atmosphere the concentration of these anterials say mount up is the blood stream to rather high levels. They appear to have a particular predilection for the nervous system oa which marked changes may be seen as a result of exposure, in this group we may include such sub stances as methyl alcohol, propyl, butyl, a^l and ethyl alcohol, carton dis ulphide and methyl bromide, * Volatile drugs setting mainly on the circulation In this group there are but two or three important substances} namely nitroten- sene and aniline and the organic nitro compounds. Nitrobenzene firms am isomer of oxyhemoglobin when it ooaee in contact with whole blood. This isomer is oalled aetheaoglobin* Kethemoglobin has a property of binding oxygen aore firmly than does hemoglobin. It is thus relatively diffioult to dissociate the oxygen from methemcglobio, la this way the normal function of the hemo globin of the body is altered. Poisoning from these substances U now rela tively uncommon In industry since industrial processes which use nltrobensens and aniline must often use those materiel# in olosed pipe lines, in this way preventing exposure of workers to the absorption of this material. y D-m-5 _ oi 501 1135 inorganic and Organe-Metaliio Tolwtile Substances and Miscellaneous Compounds Ttia group of substances, son-.-'htat ral.collaner :sly related, incites these material# which are characterised chiefly by their effects on organs of the body and hare relatively little other effect# of importaaee. In this group we stay include such substances as mercury, phosgene, lead, nickel and iron carbonyl and arsine. la general, most of the hear/ metals which are toxi should be placed in this latte-r group* protection against Toxic gaees, Panes and 7apore l believe it is important for the industrial physician *;o kao* a great deal about protection against toxic gases, vapors and fumes. Unfortunately, many Industrial physiciaas do not have an (appreciation of the basic principles involved ia the protection of the worker against these toxic materials# The first approach to protection consists in the substitution of non-toxic or relatively aon-toxio for toxio aatarials* for example, ia the use of pet roleum. fraotions as solvents instead of beaaolj or, for example, in the use of toluol in place of heruol under controlled conditions. The second approach consists in the use of setarial which may be toxic but utilising the material in closed vessels and cfased pipe line systems only. This technique is by no means possible In all cases but where it may be used, it is a great aid in the conduct of industry on a safe wasis. Shore these first two techniques cannot be used, the third technique stay be utilised* namely an enclosure surrounding the processes insofar as possible and the provision cf an exhaust ventilation system so that there may be no degrees of toxic muterial from the enclosure into the ;;rkroo air, tffcere thsse approaches fail or oanaot be used, it is necessary to resort to the use of respiratory protection devices* Such devices are of many different kinds, depending upon the nature of the material against which the worker is to be protected, In the case of dust* of relatively large partial* sise, mech anical filters consisting of paper or cloth may be used, Shore the material is colloidal in sire, then it is necessary to us a finer type of mechanical filter which my consist of a cloth or pper impregnated with substances which rneder the pores of the filtering material sail enough to retain celloids. In the case of gases, it is neoassary to use material or chemicals in the gas aak absorbing chamber which is capable of absorbing the toxic gas and pre"eat ing its passage through the filter. Such mats-iais as pumice or diathenaetious sarth or activated charcoal or eilioa jell may be used. It awat be borne in miod that respiratory equipment is reslly a last resort in the protection of the worker. All filters afcd respirators have a certain resistance to the passage of air. This resistance increases with the increased rate of air flow and therefore where a man is engaged in heavy laborious *rk, the resistance sy become a serious impairment to hi# offort, increasing fatigue and decreasing working efficiency. Bear in mind that respiratory equipment my only be used if sufficient oxygen is present in the atmosphere or if sufficimt oxygen is supplied from a self- contained ocygen bottle carried with the respiratory equipment, st should also be borne in mind that gas aaics my be used only for low concentrations of toxio gases, in most cases in th# neighborhood of 2 or $ per cent, and that they only provide protection for that g* or group of gases for which they are designed. Their working Hfe is relatively short, usually no longer than two or three hours, and finally that the use of a gaa mask in a toxic atmosphere, particul arly at moderate or hard labor, can only be ca-ried out by health and trained work#re. o-m-6 01 SOI UXTOffi D-U INDUSTRIAL SOLVES Ifey R. Hayers, Jf.D. The tforid's fair Introduced nany of us for the first time to an a*tin* array of new material* made possible by the ingenuity of our industrial res<mrob ohexists, since that time the war has greatly aceeierated industrial chemi cal research! and in this phenomena1 growth and developaant industrial sol vents have played an indispensable role* indeed, our material world would look entirely different without them. lie could never have developed our great synthetic rubber plants, so important to the war effort, without the use of a variety of special solvent#* Sol vents are revolutionising the shoe industry where adhesives are largely taking place of machine or hand-sewing* This change is inteoduQisg boa*cl, one of our moat toxic advents, into an industry where solvents were little used beofre* as a preliminary step to electroplating and anodysing operations, or the spray-painting of metal parts, it is now the practice to remove the film of grease which tends to adhere to the surface of the metal in order to get a more perfect finish* for this, various solvents are used as degreasing agents - tee most popular being tri and perchlorethylane* In tee manufacture of waterproof materials - such as are used in making army raincoats - plastics have replaced rubber, and large quantities of solvents have been required; these are only a few examples. Sew chemical* with special solvent properties and new combinations of solvents are eonstantly being developed to meet tee production needs of special industries* la view of this, it is interesting to note that despite tele competition, a few of our old tine solvents con tinue to hold their own, ?irst among these, perhaps, are bensol and toluol, both aromatic hydrocarbons, which are now being produced in unprecedented amounts because of sew chemical processesi which have been developed* Bensol, as you know, injures hm- topoetio system, causing the blood disease Isown as "Aplaetio Anemia"* It is very insidious in its action and its use in industry is very difficult* to ooctroi* Since the war, toluol which has always been a good substitute for hansel in many industrial situations and is far less toxic, has been difficult to obtain for use as a solvent becuese of its priority for the man ufacture of T,K*T* for explosives, The chlorlated hydrocarbons constitute another very large group of su'stances of primary importance to industry. Vany of these substances are highly toxic; not all of thea, however, are solvents* Host familiar In this group are car bon tetrachloride and trichlorethylene*. Physiolacs are more familiar with oarbon tetrachloride as a therapeutic agent for the treatment of intestinal parasites thaa aa an industrial solvent* Sold as "Carbons* in drug stores, it is popularly regarded as an effective and harmless non-infloanable cleaning fluid* This it a serious error. Dermatologists have even prescribed it to young people suffering from odoleseset acne to remove excess grease from the skin* On suoh advice, one 'irl washed her faoe .*ith it every night before going to bed for a year - and nothing happened to her* Also, nothing happened to tee acne* Nevertheless, inhalation of carbon tetraohloride vapors, may result in toxic hepatitis, renal insufficiency or a hepatic-renal syndrome. These appear to be enormous difference in individual susceptibility to this substance. Fatalities fres* acuta yellar atrophy of the liver have occurred in individuals who did not appear to have had any great exposure* 01 501 1137 A oan , orkin, in * plunt .rbore rtfrih*Tutors -vore .*ai.a4, re-cor.ditiortod, said* it a practice to cleanse *he small ;t*l part* by dipping them in a saail pan of carbon tetrachloride which ho kept on a bench beside him, B develop** Intense Jaundice and almost died* A whole series >f girls using am11 am ounta of carbon tetrachloride to remove samll stains from parachutes they were searing, all developed serious illness, though the exposure did not look ispressiva. Exposure to really high e^neentrations may result in serious lung irritation with edema of the lungs9 paeupeal*> convulsions and death .Ye will discdee this substance later on la greater detail* Triohlorethylene, as eosncaly used in industry, had been regarded as a rel atively hannless solvent with simple narcotic properties* Under war con ditions, however, it recently proved fatal to two workers who tried to clean out the sludge froa the inside of degreasing tasks without using proper respiratory protection* Similarly acetone and ethyl methyl ketone, are sol ants which had been looked upon as relatively innocuous* Since the war, however, they too began to be used in unprecedented amounts and we began to discover toxic potentialities never before suspected. One girl subjected to an intense exposure, developed convulsions and another became unconscious. Both were proa^tly removed to a hospital where they fortunately recovered* In one plant, wnere amy raise oats were being mnufaetured and these solvents were used to glue together the seams, total solvent vapors in the air were found to bo so high as to reach explosive proportions, In this case, control of the toxic heeard automatically reduced the concentration below the explosive limit* You probably remember the deaths which occurred through the country when ethylene glycol was tried a# a vehicle for the sulpha drugs* in industry "methyl cUqq1v*" the aone-methyl ether of ethylene glyool was found to be ext;eaaly toxic both to the blood and the central nervous systems when used in ooonection with the manufacture of so-called "fused* collars -- col lars which cose back stiff from the laundry without having to be starched. Careen disulphide is another of the solvents which is toxic to the central sorvQus system. It is used in the manufacture of rayort. Unless adequate control measures are instituted it is capable of producing very disturbing personality changes; psycho-neuroses and even true psychoses which may be indistinguishable, medically from similar conditions of son-occupational origin with Which the psychiatrist is familiar. The petroleum distillates; gsnllna end pet roleus naphtha, though highly inflammable, continue to beour safest solvents, toxicologically speaking. Leaving systemic effects, for the moment, it i important to remember that since all of these substances are fat solvents they necessarily tend to de fat the ekin and dermatoses commonly result from skin contact. Shat is far mare interesting in this connection, however, is that derma toses may develop in workers who never touch the solvents; dermatoses in volving *.he face and neck, for example, of workers who merely, stand aroung is the room where the solvent it used, or frequently pass through it, in the course of the.day's work*. This was something of a puxsle to us at first. Repeated air tests, however, in typical situations brought to our attettlon the fact that, when sufficient, solvent vapors are present in the air of a xorfcsooB, deposition .of* dropiate from the air upon exposed parts of the skin is capable of cuaeing a dermatitis,, D-ll-2 01 501 1138 In suoh case#the*dors*title oan b prevented not by or other protect ive clothing/ but by the installs* ion of a proper ventilating system to remove these air contaminate at their source and so prevent their dissemin ation into the atmosphere of the workroom* Simultaneously* such *a approach will prevent systemic disease. It will be readily seen from the above that the olinieel entitle* which arice in connection with exposure to industrial solvent# are very diverse -- illus trating the broad scope of industrial intcxioology* this is a relatively see field to the medioal practitioner who necessarily see* few of these case* in hla practice, or even at the hospital* the sooner, however, that he coass to appreciate the problem* Involved -- and also the extent to which he will inevitably become personally involved -- the better prepared he will be to meet the new opportunities and responsibilities whioh are awaiting him* The nedioal practitioner is yet to experitnoe the full impact of industrial chemical research upon the' praotioe of medicine* It is the purpose of what follows to discuss toso of the baaio medical pro blems with which the medioal practitioner is confronted in handling a pat ient who has been exposed to an industrial solvent. This would seem to be more profitable than taking each solvent in turn and giving a resume of its toxicological properties, sine# these aan be readily obtained fro the literature* Since exposure to beasol in toxic concentrations produces a blood picture with which most physicians are familiar -- the blood disease knows as "aplastio anemia'1 -- title condition would seem to provide a particularly good medium for the present discussion. That is there about industrial blood dyseraslas which makes them different from those of non-ocoupational origin? fffcat are the similarities? is there anything special that a phy sician would be expeoted to do about them other than what he does in hie regular praotioe? These are a few of the pertinenrt questions* The answers are interesting* Industrial blood dyeoresias do not differ in any fundamental way fr-Ti corresponding blood diseases whioh are non-ocoupatlonal in origin* The diagnostic procedures and laboratory technics* are essentially the same* aplastic anemia is aplastio anemia whether it is due to bensol or it is of unknown etiology* Gut the important thing is that when it is due to beejol, the etiologies1 factor is known) the cause can be removed* and the patient*# life can often be saved* Furthermore, "aplastio anemia* of industrial origin can he prevented -- which is manifestly impossible where the etiology Is obeoure or unknown* And so, It behooves the practicing physician not only to know how to reoog- nise and make a correct diagnosis of blood dyscreels which comes to his attention but to asks careful Inquiry into the possibility of an occupational etiology in that particular case* Furthermore, veooiltle& of early evldenoe* of injury to the hematopoetie system in oases of industrial origin provide the bs&ss for preventing the development of fatal blood disease* It provides the means for removal of the patient from injurious exposure while there is still tn opportunity to save his life* Furthermore, such a person should never again be permitted to work with bensol or any other heaatetexio substance* Cases ere reported where years after exposure to bensol had ceased, and there had been an apparently complete recovery* a worker will for tone unknown reason develop a recurrence of the aplastio anemia and die* Beasol is a cost insidious substance* "arioua blood changes my .be present in the sence of a suggestive clinical picture. Veafcneaa, fatigue, lose of *e\L; ` epia ia, dryness of throat, lots of appetite, nausea, distines#, insomnia may all be absent even when blood studies *ee demonstrate injury to the nomatopoatie system* D-n-5 01 501 1139 0rw occasionally finds a worksr nplaining only o'* he fact th-t "black and blue spots" appear on his skin from tjjw ho tine. He usually alieeea ho has "bumped hinsolf", thou^t h-* ioes not rurv'tal -r exactly ;/hea. Or, a worker may* have no complaints whatever. And yet an examination of hie blood may shew a critical blood dyacrasia j and the case aay go rapidly down hill to a fatal conclusion, before adequate steps can be taken even to obtain hospitalisation. Incidentally, the frequent lack of purpura and bleeding from mucous surface in industrial bent cl poisoning has in son instances made it impossible to get the release of emergency hospital beds eves for cases which terminated fatally, because the critical condition of the patient was not properly appreciated. Bleeding and coagulation time are not always increased even in eases with greatly reduced blood platelets. As in all cases of "aplastic anemia", & marked leukopenia and reduction ia the blood platelets are the characteristic blood findings. The relative lymphyoytoeis, much discussed is not usually present, An early reduction in red cells, which is extremely important has received insuffiolent attention, A characteristic increase in mean corpuscular voltae, which also occurs early, will .be overlooked unless the Sintrobe oonstants are studied. Contrary to popular belief, the bone narrow, on sternal puncture is not always apl&stie. It may be hyperplastic. Prevention is always more satisfying them treatment. And in industry, the plant physician has unique opportunities along these lines. They are: (1) coopera tion with management in seeing to it that the chemical exposure is kept with in safe limits, by ventilation or other safe praotlee procedures* and (2) periodic physical examinations of workers to detect early indications of blood abnormalities. Aha re sueh abnormalities begin to stake their appearance in workers in a particular department, it is a sure sign that the exposure is excessive nd something should be done to reduce it. Indeed, the extent of the exposure and aatuai absorption of benzol in spec ifio departments may be further evaluated by examination of the urine for changes in the sulphate partition. There seems to be a correlation between banco1 absorptio" and the ratio of organic to iaofgOAio sulphates in the urine. Snob changes provide interesting data as to absorption. They do not, however, give evidence of intoxication. In plant medical surveys, "hat are the earliest blood changes to be looked for? Experience has shesm that by and large, too great reliance should not be placed upon a leukopenia alone when one is attempting to spot early cases cf teasel poisoning in such a survey. Any white cell count below 5,00(1 should be looked upon as having possible significance and the patient kept under careful medical observation. Harked leukopenia is more frequently found in severe than in early case#; and assy oooasiosally be absent even in the former. Reduction in the rad cell and platelet counts when associated with an increase in mens corpuscular volume appear to be the earllost signs of intoxication. Indeed, a macrocytes is in a benzol worker should, per s9 be looked upon with suspicion even in the absence of all othor blood abnormalities. The a bsenoe of purpura and bleeding from mucous surfaces should not lull the physician into a false sense of security, tferfc to benzol, carbon tetrachloride is perhaps ono of the greatest offenders of the industrial solvnete. Its use during the war has increased enormously. This is partly due to the fact that its toxicity is not adequately apprecia ted! pertly to the fact that it is sold under a great variety of trade names so that the user has not knowledge of its chemical cosmosit ion* partly because it is peculiarly suitable, beous.se it is non-inflasmable, for use in cleaning large sachinery, motors, dyamoa and the like which cannot be dipped into the decreasing tanks used for small metal parts, Q-U4* 01 501 1140 Thor appears to hi an enormous -if prance in individual susceptibility to this s ibstat**. r.icohol seems to greatly dispose -,o acute poisoning. I like to tell the story of a physicist la our office who, on leaving coIIb^b, got a research job in the physics department there. He was studying certain of the physical properties of bensel, carbon tetraohlroide and carbon diaulphide ft 11 three apparently having a molecular structure of special interest to him. In order to do his work, whioh required the greatest degree of precision, it was necessary to keep all the windows and doors dosed so a to prevent air movement. Occasionally, when he arrived is the noruing, he found that despite all precautions, a fly had gotten into the rocs* In those cases he promptly killed the fly by spraying him with carbon tetrachloride from an steadier he had ready for the purpose. He had no idea that he wad dealing with poisonous substances. Ho one at the oeliege warned him. Se is perfectly well today. One day when he waa telling us this story -- not realising how hair-raising it sounded to industrial toxicologists -- I asked bin whether he ever drank any alcohol in those days* He replied that he dids*t becu&ae he couldn't afford it, z believe his laok of funds saved his life. To the nedieal practitioner, carbon tetrachloride poisoning presents sobs very difficult problems in differential diagnosis. Excepting is extremely acuta cases, one is dealing with a toxic hepatitisj a nephrosis, or a combination of both. There Is nothing in the clinical picture whioh is pathognomonic of car bon tetrachloride. The patient is usually jaundiced when he first consults his physician. Is it obstructive jaundice; catarrhal or epidemic jaundice; or is it a toxic hepatitis? Only a careful work-up of the case will produce a correct diagnosis; and In such a work-up, the occupational history is indispensable. That does not seen that a person who has been exposed to carbon tetrachloride nay not also develop and obstruction of the biliary tract In no way related to his occupation. In a toxic hepatitis, however, one gats very suggestive changos in the blood chesiietrys a phosphatase above 10; increase in serum cholesterol; a hli serum bilirubin; low total proteins,* with the serum albumin especially low, and the euglobulln womewhat elevated. The ioterio index is elevated; one gets an indirect Van den Derg reaction and increased bilirubin in the urine. There oay be an increase in blood guanidine to whioh some work ers attribute the liver damage. The blood sugar and oalolum are low. The blood nitrogen is high where there is an associated nephrosis, as there often is. To the physician who sees the ease early in the plant medical office, the patient may present a very different picture. He may come in ccc^laining of gastro-intestinal disturhaases only. There will be no jaundice at this stage nd many of these easea are consequently unrecognised as potential liver cases. They are frequently ^iven a pill, by the physician os the nurse and sent about their work. By the time jaundice develops, it EBay be impossible to save his life. This is not as uncommon experience, a plant physician should acquaint himself with the substances to which the workers, for whom he has assumed responsibility in the plant, are exposed. 2f they are working with a hepatotcxic substance such aa carbon tetrachloride, he must regard any oase coming In with g&stro-intestinal ooaplaints as a potential liver death and investigate ihe case thoroughly and without lesa of time. He should see exactly where in the plant, the person has been working, and assure himself that the operation is conducted with proper safeguards so that he will not have a series of liver deaths cn his hands In the imediate future. This has happened more than cnee in our experience. The plant physician should sake careful pre-placement as well as periodic exam inations of workers who are to exposed to toxic solvents of any kind. In the Dtu-5 - 01 501 1141 case of oarboo tetrachloride, persons frith diseases of the liver, kidneys or heart particularly should not bo exposed. Chronic alcoholics are definit ely out. Is periodic p hysloal examinations suggestive changes in blood chemistry say give earlier indications of intoxication than will the liver function tests. If he looks for it, the plant physician may discover a cone outrio constriotion of the visual fields in early carbon tetraohlride poisoning. Prevention is possible In the early stages. Ones a true toxic hepatitis develops, it may be tmpoesiblo to prevent a fatal termination. Without going into detail as to therapy in industrial liver cases. It night be worth mentioning the faot that although a high carbohydrate diet, which is also high in calcium, Is known to protect the liver, during acute ill ness, a hi gh protein diet is indicated partioularly in the presence of the lew serum protein which is usually assooiated with this condition. Recent anisal experiments hate demonstrated that certain of the sulphurcontaining asdao-aoids appear to have the property of protecting the livers of animals exposed to known liver poisons, such as chloroform or carbon tetrachloride. Administration of these amino-acids before and sometimes even after gibing a knows fatal dose of these liver poisons have prevented the development of the toxic hepartitis and saved the animal1a livea. Recently, one of these amino-acids, known as methionine, was reported to have saved the life of a nan who accidentally drank a fatal dose of carbon tetrachloride. Experiments suoh as these are still in their infancy. But the results are very stimulating and full of promise, ferhaps some chemical substance will be available to us in the neer future which would enable us to provide adequate protection to workers who, in the course of their work, are unavoidably exposed to s*4bstances potentially injurious to the liver. There are soma other anInal experiments whioh, 1 believe, will be of inter est to you. Animals exposed first to one and then to a second hopatotoxio substance, eill develop aoute yellow atrophy of the liver end die even when the doses in both instances were so low as to cause no demonstrable injury Then given singly. Though analogies with animals do not always carry over to human beings, these experiments have mdo us feel that it is unwise to expose workers stiffsring from liver disease or those who are receiving treatment for syphilis with a hepatotoxio substance such as a rephenamine, to a second hepatotoxio subataaoe such as carbon tetrachloride, in the oourse of their work. That a combination of toxic substances is apt to be more toxio than is the sum of its single components is a general principle which we hear reiter ated from time to time. It apparently has a substantial baels in experience, both in the experimental laboratory and in industry. For this reason I wuld like to tell you briefly about an interesting oase which cams to our attention, where there was exposure to a combination of several of the oh loricated hydrocarbon solvents. A man, 26 years of age, was engaged in applying a paint remover in redondiioaliig elevators in buildings, Recuaee of the nature of the work, no ven tilation was provided. The paint remover contained carbon tetrachloride, chloroform and a considerable number of the higher chlorination# of ethane, propane, butane and pentanej the exact chemical components being unknown even to the producers, as is often the ease where chlorination processos are carried out on complex organic substances. The aaa in question, worked with the paint remover for about a year and lost some 40 lbs. in weight during this period, ffe have insufficient knowledge of other elements in the clinical picture during this time because we learned D-ll-6 01 501 1142 of the ease only after his death* About fire days tefiore aemission to the hos pital, however, he complained of severe abdominal pain with vomiting, and pre sented a general picture of surgical abdomen* Examinations of hie blood In the hospital prior to operation showed that he had a white coll count somewhat below 2,000 and a rod cell count slightly above 3 Billion* There was a marked increase in bleeding and dotting tine and platelets were greatly reduced* A laparatonosy revealed necrotic ulcerations of the colon. The bleeding was auoh that nothing could be done* At autopsy he was found to have an aplastic anemia with a granulocytopenia, generalised parpura, tozio nephrosis r hepatitis and necrotic ulcerations of the colon. The combined Senjury to the heaatopoetle system, the liver, and kidneys pre- sneted by this case is of the greatest interest in view of the nature of the exposure. Even more interesting, however, are the neorotio ulcerations be cause ulcers of the gastro-intestinal tract are reported from time to time in persons exposed to Urge amounts of carbon tetrashlorids. Two such oases have recently come to our attestioni one, a man with a perforated peptic ulcer which was operated upon} the other, a nan who developed severe heaateaesis and was hospitalised, where X-ray pictures taken later revealed definite evidences of a duodenal ulcer. Both men had had unusually heavy exposures to caroba tetrachloride immediately proceeding the onset of these scute surgical conditions. Another subject for speculation in the case of the smn using the paint reoover was the relation of the ulcerated colon to his agranulocytosis. *e all know that ulooration of the mouth and throat is conoon with this blood dyeerasia. However, that my be; and regardless of whether, in this particular case, the disease actually was eaused by the paint remover, the clinical pic ture is so suggestive of what might be expected to occur under the circumstances, it is very impressive indeed, 7fe cannot leave the industrial solvents without a few words on the subject of narcosis. Lowgrade narcosis such as one sees In workers exposed to trichiorathyler.e, for example, tends to make them drowsy, irritable, restless and they are apt to complain of vague subjective gastro-intestinal dlsturtanc e which are not easy to verify on physical examination. Actually, we would like to know a lot sore than we do about the long range effeota of continued or frequently repeated narcosis of this general degree of Intensity, over a long period of time. A word of caution, however, is particularly necessary at this time when every one is so psychiatricslly-minded There is sn increasing tendency, new-a-daysc to look upon these people as eases presenting personality changes and to refer them for study to a nearby psychiatric olinlo, without stopping to consider a toxic etiology and investigate the ocoupationai history. It has already bean pointed out this evening that grave mental and aeurological otenges may result from exposure to certdn industrial chemicals} iaolading some of the solvents? and that these personality changes may be indistinguishable clinically ffcea non-occupational psyohoneuroses or even psychoses. I wish, therefore, to warn against a diagnosis of sental disease being nade without first carefully loves tigating the occupational exposure of the patient. Before leaving trichlorethylene, I would like to say a word about an explosion which recently occurred in the use of this supposedly non-explosive substance r This was believed to have been due to its use in a degreasing tank located in close proximity to soae welding operations, where unusually high temperattares were being generated. Particularly new when welding operations ere rapidly multiplying in industry, tho possibility of such a contingency should at all times be borne in mind. C-U-7 Oi SOI 1143 Jo coneInsion, it migjvt be well to stress once more the great variopy of clinical disease entities which stay be produced by exposure to indus trial solvents in toxic concentration; and the fact that the*e syndromes do not necessarily hoar any of the ear-narks of an occupational disease0 Jaundica, aplastic anemia, ftaphrcsis, psyohoneuroSis -- all of these con ditions look essentially alike whether they are of occupational or non* occupational etiology, the sam general diagnostic procedures and labora tory tests are required in either case in order to make a diagnosis. Regardless, however, of how carefully and intelligently the case has been worked up; or howaceuratoly the diagnosis, if the possibility of an occupa tional etiology has been overlooked the only means available for saving the patient's life say have been lost. For, if the condition is occupation al in origin, no amount of treatoent will be effective unless the patient is ironediatsly removed fress further exposure. Furthermore, recognition of an occupational etiology, where it exists, will provide invaluable In formation as to the type of work the patient suet avoid in the future j it will provide a basis for prognosis; and it will sake possible seeistaco to `che patient and his family under our compensation laws - providing them with financial assistance during a period of disability. It even helps the doctor get his bills paid. Recognition of the occupational etiology where it exists, contributes to proper reporting of occupational diseases, thereby making more accurate the occupational disease statistics available. Very few people realise that we have no reliable information at the present time as to the statistical Incidence of occupational diseases, principally because physicians fail to recognise them. With the beet intentions in the world, a p hysiciaa will not report a case of aplastic anemia, if it does not occur to hia that it is occupational in origin. The plant physician has an unusual opportunity to protect the health of workera, exposed to Industrial solvents In the plant under his oharge. He should acquaint himself with the nature of the chemical substances involved and the ways in which they aro processed. The Department of labor whose legal responsibility it is to provide worker# with safe and hsfithful working conditions is always ready to work with hia and with sanagenent in ensuring safety in the use of these Baterials. The plant physician is-thus in .a, strategic position not only to recognise cases early before irreparable damage has been done; but to prevent andy d&mtge whatever from being dons in th4 first plaoe. Industrial solvents can, in general, be used with perfect safety if ade quate control steasures are instituted. D-ll- 01 SOI 1144 LECTUH2 D.7 industrial gsHKATosta "Louis Schwarts,Al.D, HISTORY Industrial disease* have occurred ever since the world, was civilised enough to here industry, It is highly probable that the builders of the pyramids #effared from silicosis, Paracelsus; however, is the beginning of the Sixteenth Century was the first to write about occupational diseasee0 He refer# in hi# book, "Itorbi# Metallious", to certain changes in the skin caused by salt ooapounds0 The first book which really give# us a compilation of occupational die ease# of his day was written by Bernardino Rernestnai in about the year l?00o In this book he mention# painful and swollen hand# noted in baker# and also that the slevers of com developed an lteh froa the dust which he stated was due to an invisible parasite present in the cereal. This was a re markable observation in those days before the invention of the mierose ope and resains true to this day, beouase grain itch, straw itch, lirureed itch, etc,, due to such parasites, occur even now among the handlers of these substances. Besides theeo, he also described fissures on the hands of wash women which he said were due to lye and the infalaxnaatloa of the hands of mldwites due to contact with the seerations of the genital tract during childbirth. The first Englishman to write on occupational diseasea wae Percival Pott, who in 1775, called attention to chimney sweeps* caxser of the sorotum. Among French writers, Alibert in the first quarter of the Nineteenth Century wrote extensively on occupational skis diseases. About the same time, C, Turner Thackrah, an Engileha^a, wrote a book oalled n The Effects of Arts, Trades, and professions and of Fads and Habits of Living on Health and on Longevity"9 In this book he points out many occupational skin disease# and eapHases the value of oleanlineas La their preventions Among Frenoh writers in the nineteenth Century, the works of Chevalier and BeaIn stand out. In Germany, works on occupational dermatoses began to appear about the beginning of the nineteenth Century and many German writers continued to work on the subject, Blaeohko, Jadasoha, Bloch, Mayer, OppenheLm, HIloan, and Rills are some of the names associated with this subject, Xn England such writers as JU Preeser ffhite, peroival, Sequira, i&Cloud and Little have studied and written extensively on the subject. In the United States, scattered contribution# were sade by various writers since the year 1900 on the subject. Occupational skin disease laws have been passed by a number of our States and stay more of the States are about to pass such laws, Xn fact, industrial dermatoses have become of such importance in the United States that the U.S, Publio Health Service in 1926 detailed an officer to sake a. study of this subject and opened a Section devoted solely to its study. The prime `importance in the control of industrial skin disease is the knowledge of the frequency of their occurrence. The gathering of statistics of the occurrence'of occupational diseases, including derma* titis, is cos?*ratively recast In the United States The statistics in Great Britain in regard to dermatitis, are more complete because in I9I8, dermatitis due to dusts and liquids was legally made an industrial 01 501 1145 disease, However, authorities Tea in Great Britain differ as to the orevalence of Industrial dermatoses, S, Graham Little states that over f?c of occupational diseases in England are industrial dermatoses# R, Barth- olemsy states that among 8122 cases of occupational diseases reported in England from 1926 to 1931, 7011 cases, or Qi.#, were industrial derma toses, 3, Orerton saya that out of 139k compensated cases of industrial d is ;iasos_occurring in 1927 ia English factories, 879 cases were dematos a with a further 100 cases of ohrose and epitheliratous uloorations. The rYorkmen's Cozensation statistios for 1928, 1929, and 1930 show that there was an increase la the number of cases of dmatitis during those years. In 1923 there ware 1170 oases; in 1929 there were 1405 cases and in I930 there were 1499 *a*e* It is admitted by these English writers that the figures do not rspresent the actual occurrence of i&dustrial deratosee beeusee only those cases are reported who are inoapaoitated from work for one week or more and R a grosser flhlte estimate* that at least 16 to 19 thousand cases of industrial dermatitis occur yearly in England, INDUSTRIAL DERMATITIS IB OKRMABY The number of cases of industrial dermatitis in Germany is not directly available, but according to official German statistics for 1930, the number of occuaptlocal diseases that year was 3920 in industry and 937 in public institutions and ? in agriculture. These occupational dis eases represent l,Q8g of the total number of occupational accidents and illnesses. The figures do not include occupational dermatoses but judging from the proportion ofoooupational dermatoses to occupational diseases in other countries, it is safe to say, that in Gersany there were at least ?000 cases of 00cupationai dermatoses in 1930, That there are many cases of occupational dermatoses in Austria, France, and the Scandinavian countries is evidenced by the many reports of dermatologists of these countries, but official statistios are not available. INDUSTRIAL DET1MAT0SES I TEE UNITED STATES ffi th the advent of compensation legislation in the United States, more attention was given to oooupational diseases and with them to occu pational dermatoses. Shea the United States public Health Service, In 1928, decided to make studies is occupational dermatoses, soma of the States had already gathered statistics concerning their frequency of occurrence and had made compensation laws concerning them. At the present time in the United States, 23 States still do not com pensate for, nor record,, the occurrence of industrial dermatoses. The following States now have laws which compensate to a more or less de gree for occupational dermatoses and also gather statistics, more or less ooaplete, concerning the occurrence of these diseases $ Washington Oregon California Minnesota Connecticut Sew York Pennsylvania Maryland North Dakota New Jersey Rhode Island Mississippi Illinois Ohio. North Carolina South Carolina ft'est Virginia New Mexico Wyoming ^ Missouri Tennessee Wisconsin Indiana Massachusetts Nebraska 01 501 1146 The law# in these State# vary cons iderably* Fifteen of them take in all occupational dermatoses, or at leaat these occurring io the principal industries in those States* The other# have laws which limit the derma toses to those caaaa dye to oertain substances. The gathering of statistlot as to the occurrence of occupational skin dis eases also varies a great deal in thee# States* Some of them oaks it oocpulscry that oases of occupational dermatitis losing a week or sore from their work should be reported. Others, that dermatitis cases losing any time from their work should be reported, and some of the states require no reporting at all* Ohio has excellent records. From 1933 to 1955 about 2$00 oases of occupa tional d eraatitls occurred in Ohio among a total of about 1*000 occupational disease oases, or 6c of all the occupational disease oases in Ohio sere occupational dermatitis. Between the years of 1926 to 1931. there were about 1*600 oases of industrial dermatitis reported in Ohio. This was more than ?(# of all occupational disease oases reported. In New York State it is only within the last few years that anywhere near aco urate statistics have been available of the ooourresoe of occupational dermatoses. The New York State Departmeat of labor oases from June. 1930 to February, 1932, show only 185 cases of occupational dermatitis, whereas the report in 192+ showed 626 cases of occupational dermatitis or 6# of 1012 oases of scheduled diseases, reported that year* The first six months of this year show over 1000 oases in Sew York. The figures do not inolude such traumatic skin affections as blisters due to friotion, etc* The reoords in Connecticut show that in 1931 there were 181* oases of occupa tional dermatitis reported* In 1932, 2C9 oases of dermatitis out of a total of 358 occupational diseases were reported; in 1933. 362+ oases of derma titis out of a total of 597 ooouAptienal diseases; in 192*, 2*12+ cases of dermatitis out of a total of 2*85 occupational diseases, la these years, about 7C5$ of all the oases of occupational diseases in Connecticut were dermatoses. The laet available records in New Jersey show that ?3 of all occupational diseases were dermatoses. In i&sg&chusetts, about 6% were dermatoses. In Oregon, a compensation la only paid for poison oak* spruce or hemlock dermatitis, yet there were 250 claims for oo^ensation in the past year. In Oregon there are nany cases of fruit poisoning contracted la canneries where employees working in fruit juices develop an infection around the finger sails, but the lav dees not oover these cases, nor are they reported. In California, out of 1528 cases of occupational diseases reported, 1156 were occupational dsraatitis, or about 73#*. A great amfly of these oases were fruit poisonings* In Missouri, 59 of all occupational disease* were dermatitis. In isonsin, is ten years there were 1909 oases of dermatitis out of 3019 oases of occupational diseases, or 63S* Altogether, it is estimated that industrial ders&tltis constitutes more than 65? of all occupational disease oases reported In the TTnited States and from available reoords it is estimated that there are about 20,000 eases of industrial dermatitis with sufficient severity to lose time froa work occurring in the United States* Actually there are many times this number Note* pg. k omitted on original smnusoript, - 01 SOI 1147 a compensation of about $200,00, and that th average cost of radical car par oaaa is also about >ICO00, so that an estimate of Ji*,000,00000 as the annual cost of occupational dvraatoste in ths Unitod States is a conservative one* The free olinie# of hospitals see but few of these cases, because they are not charity patients* They.are cared for by the ?Ua$ physiciaa, the insurance soapsay physioian, or the pa'lent'* cam private doctor. In our investigations, we found that among over 25*000 near oases in the deraft* tological clinics of New York,, only 58 were diagnosed as occupational, or about one-fourth of 1 per eeat ,e found in the records of the clinic# investigated that the histories of cases resembling contact dermatitis were not accurately taken and that patch tests were rarely'performed. It seems that many of the oases of occupational dermateaas were lost in the large number of ease* diagnosed as eocene and de rmatophytese# and "tide* This may aooount for the relatively small pcroastage of occupational dermatoses reported in the New Tor* dermatological clinics However, it is not to be expected that, outside of housewives* ada wash woman's hands caused by soap and cleaning fluids, there would be many cases of industrial dermatoses applying to the free clinics for treatment, beoauae those case# are not charity oases Their treatments are paid for either by the employers or by the insurance companies In our investigations as to the number ** oases of industrial dermatoses treated is industrial clinice, we examined the records of the largest industrial clinic in New York City and found 105 eases of industrial dermatoses out of about thirty thousand industrial accidents treated This clinic, however, did not draw from the basis industries where the majority of the eases of industrial dermatitis occur Dermatologists who are intereeted in occupational dermatitis and look for it in their clinics find a large percentage of them among their patients. for instance, Pordycc, in the Journal of American Medical Assoo, 1922, page 2U5 states that skin troubles from occupations fora of all skin diseases j Lane, in the Archives of Denaatology and Syphilology, November 1* 1922, pages * 5o5-575, states that occupational dorjaatose* cos^riae four to five per cent of all oases of dermatitis $ R. pros eer ffhite states Gardner, in the British Journal of Dermatology andSyphilclogy, October,'!SJ087 P* 297*520, state* 7gS And Knowles, in the Journal of the Aaer Ksdioal Assoc,, 19*7* p 79 states iw, and Oooenheia in the Transaotione of the London Dermatological Society, 192^, pp* '51-71*, states 2C* CAUSES OP INDUSTRIAL DERMATITIS There are wvy etiological factors in Great Britain and Germany which are not present in the United States* For instance, the scrotal cancers of chimney sweeps and mule spinners due to eoot and oils the skin cnaoer* due to arsenic, which are reported in England* and the frequent occurrence of ectem among bakers both in England and Gammy are sot present in the United States* G. R* Lancashire, is 1930, made an analysis of causes of deimtose* re* ported to Insurance Societies in Great Britain and found that 1% were due to aniline dyes* 12 occurred in painters and was due to turpen tine or similar solvents* 1# occurred in rubber workers and was due to solvents *ad accelerators and 7% coeurred among takers. These figures are somewhat different from the available statistic# in the United States / The chief oause* of industrial dermatitis differ in the various states 01 501 1148 of the U&itod States, according to the prevailing type of industry present, In 1951*8 in New York State, about 25f* f all the cases of Industrial derma toses were due to aikalis# about l6 were due to petroleum derivations, 9J5 were due to plant products, were due to dyes and l& to acids In Chio, the rubber induetry formerly furnished nearly Z% of all the cases of industrial denaatoses and the oil ahd cutting compounds about X8, but in the last few years, the number cf eases of dermatitis caused by rubber compounds has taken second place to the number caused by oils* Alkali* are responsible for about 1C of the industrial dermatitis in Ohio; solvents for about IQ?* and poisonous plants for about 2?$. In Connecticut, the reports of industrial dermatitis in the last few years she* that poisonous plants'are responsible for about 5<# of all the reported cases Mercury is responsible for about 1S of industrial dermatitis cases in this State This is because of the many hat asking factories in Conn ecticut where merely is ueed in converting rabbit hides into felt, la Missouri, over 6C# of the oases of industrial dermatitis reported were due to lime and cement, 1% were due to poisonous plants, due to caustics and sulphuric sold and were due to lye It can be stated in general that the majority of the occupational skin disease reported in the United States are caused by alkalis, oils, sol vents, dyes and poisonous plants and acids. All individuals are not susceptible to the same degree to skin irritants. The anatomical structure and the physiologic secretions of the skin are factors in susceptibility to external irritants The defense mechanism of the skin against external irritants consists of the cornified cells of the outermost layer of the akin and the secretions of the glands of the skin The eomifisd cell* are tug& and >re insoluble in water and alcohol and will withstand the setion of even fairly strong acids but sre vulnerable to alkalis and sulphides. The perspiration acts as a dil uent of irritants which are water soluble and the sebaceous secretions consisting of chorestere! and liquid waxes, fora a protective coating against water soluble irritant*. The pigment of the akin also acts as a protective factor against certain skin irritants, especially against light. The perspiration and the sebaceous matter may, however, under certain conditions act as aids to irritants on the skin. <7e will speak of this lator. The vulnerable portions of the skin are the ipeaiags of duct* end hair follicles through which certain chemical compounds, especially those which are fat soluble, may easily ^ntvr. ? binning or breaks in the ooroified layer of the epithelium also act as portals of entry for external irritants.' RASS In co fnr as the characteristic texture of the skin and the connexion affect the d ;fenj mechanism of the skin, it may be said that race plays a part in predisposition to sensitivity to external irritants. Blondes and thin-skinned individuals are more susceptible to certain , irritants than those with darker, thicker and more oily skins. For this reason, many chemical factorise will employ oily negro labor for certain Jobs in vhieh irritants are handled- a* for instance, workers on filter presses, driers and grinders in synthetic dye manufacture, Workers having greasy, oily, thick skins, withstand the action of such solvents as ecaps, turpentine, naphtha, etc., better than do those with dry skins. On the other hand, in occupations where oils, greases or waxes are apt * ' 01 501 1149 to soil the olothlng, as for instance in oil refineries, sachine shops and gSaS* those persons who hare much hair on the arms and legs ana who hare excessive sebaceous aeoratloos are sore likely to develop acnelike 1os ions and folliculitis* Then again, la occupations whero the worker comes in contact with water soluble irritant dusts, such as soda ash and lisa, those 'tho have an excessive parspirutioa arc more likely to be irri* tated because these substances coaly irritate the skin when they are dis solved in water or perspiration* In a study of akin hazards among workers in waxes, we found that tho most severe cases of cosedonee and eons, <3ue to those su*'9tanoes, occurred among thed worker* who have dark, swarthy, oily skins and sbo were in the acne ego. The various protions of the skin of the same individual differ Ln sus ceptibility to external irritants* J9 havo fiound the inner surface of tho forearm and tho upper am and tho anterior portions of the body ore more often affected by industrial dermatitis than ore the other portions* HIST The diet of a worker influences hia susceptibility to external irritants* A JIur.ber of investigators have proven that when animals have been rendered acidotio or alfcilinio, they have been rendered more susceptible to the action cf external skin irritants* ,.'o can readily see that in human beings the diet jeay influence the pH* of a perspiration and the pH* of a per spiration certainly influences its ability to act aa a solvent on external irritants* The pH* of a perspiration also influences its action as a neutraliser of external irritants. ?or ex*:Aple, if a man i% deposed to an alkali,, such as soda ash* and he has a markedly acid perspiration* the acid of his parspiratioa is likely to neutralise the alkalinity of the soda ash, whereas if he has an alkaline porepiration, it may augment the action of the soda ash* ffe have partially verified this in industry* MAtGveSie Ago also seems to exert an influence on sensitivity to external irritants* Kost of the workers affected with acute industrial dermatitis ere young and new workers. On the other hand, the chronic ecsematoid types of industrial dermatitis usually oeur io workers of middle a(;e or beyond* SEX Soman are very often irritated by su'-atanoee in l&d istry with which oen usually ork with Immunity* SBASCfiJ OP TiTi YEAH Occupational dmatitis is more prevalent in warm weather* This may be due to the fact that little clothing is worn in warmer weather and contact with skin irritants is more likely to occur* Although in those industrial diseases in which lack of cleanliness plays a role, the fact that men are less inclined to bathe after work in the winter than in the summer, may equalise or even exceed in the winter the rate of the susaor incidence. ?rsconce of Other Diseases The presence of other skin diseases, Specially of the itching type whore 30niching tends to rub in any irritant which may be deposited on the akin, also predisposes to industrial dermatitis* It has also boon notad that those D*W7 01 501 1150 workers soffering .vith 3*brrh& end vita rye otic iafetiora are sera oror,a 'to devlot industrial dcraatitia theft ethers. Claar.llassa The most ijoportsat predisposing cause of industrial dermatitis is, to cr/ nind, the lack of cleanliness* Cleanliness of the environ isat-that ie to 3e*', clean rooms, clean floors, clean walla, clean sichinea and iha *ir k3pt fres from irritating fuses, supers, *ad d.*.3ts, will diminish iho occurrence of industrial dorratitis* Personal c Ir.&aHnesa i3 of sq;sl importance, The daily chang.ng to clean underclethos ash wrfc clot1 as, cleansing nh^ar bathe Immediatelv after xork i# flniehed# eo aa to remove potential irritants fro.v the skin* are all important factors in preventing industrial cr:natitis Atxracr By tills .re -lean a hypersensitivity in which an intibody is produced in the system in response to an external irritant which acts as an anti^on* TMs antibody cannot be demonstrated An all oases. uost easts of industrial dorss.tltis are act due to allergy, They can be explained hy changes in th defense bischanisa cf th skin o" the worker or by increase in the vulnerability of the akin, or by an exes9siva count or concentration of the external irritant. Rowover, the faot that th-jr is a specific hype-sersitlvtty of certain indi.viiuale to the action r.a^ substances in industry cannot be denied, 1 have seen eases where the mere present a in the same room with certain nitre oonpounds has produced pruritus in the hyperaenaitiTe individual. Allergy, can be acquired by exposure to certain substances. This ex posure L'.ay be through the skin or through the rorpisfcery or ^pstr intestinal tracts. Allergy to mercury, chroma, ^nd formaldehyde has * eefct experimentally produced by investigators, Bss^caitizs-J.on has also h.-.en experimentft 1 ly pr-dueed to these sub stances, Zn factories, we have noted workers w o first developed a consist itis after a few days* exposure to a substance and later on, after thsy continued the work for a period of t:me, th dermatitis diaAppeared and Icauaity developed and they catcm "hardened", as they chcm3l7oa call it* Among th users of substances processed withchericala, allergy is the principal causa of den&titis because cals .neea distributed to tne public are harmless to by far the larger percentage of people. As i or instance, furs, dyes, cosmetics, etc,, while used by millIons cans s dermatitis in coc^aratively few* The chief active causes of industrial dermatitis differ in various localities according to th prevailing typo of industry. In rural eoasdiiitias, plant poisonings ar prevalent, whereas in large .mn ufacturing conmunitics th chemical irritants are th chief ceuees. A simple classification of th actual causes of industrial dorrmtoses is Ks followss la jscnanical end Physical; vr.dcr this heading wa have such ocrSTtiona ascuts, abrfisioC3 end pi-esauro. Th latter two aay cause painful callouses aa ooour on the heads of ths glass blowers from handling heavy blowing irai, Heat, which S.Y* S 01 501 1151 may cause scalda in th* wet form and `burnt in the dry fora. Cold which causes such creditions a; chilblains and frost bitea is workers exposed to the weather. Radiation, both artificial and natural, aa from the X-Rays end Radius which causes severs burns and cancers aeons technicians and radiation from the tun which causos characteristic changes in the sicins of such workers as sailors and farmers. 2. Chemical Irritants s These aay be divided into general irri tants and specific irritants, T he general irritants are those which will irritate the skins of all individuals. The specific irri tants are those which will irritate the skins of certain hy persensitive individuals, The general irritants nay be divided into inorganic end organic. The iuorganio irritants can be subdivided into acids and their salts, alkalis, and the salts of irritant setala. The principal inorganic irritant acids and their salts are sulphuric, nitrio, hydrochloric, hydro fluoric, chromic and arsenioua. The priacijel irritant alka lis are sodium and potassium hydrate and carbonate end calcium oxide and calcium hydrate. Hie principal setaIs which have irritant salts are mercury, chromium, nickel silver, sine, arsenic, antimony end phosphorous* The principal organic general irritants can be divided into or ganic acids and their salts and organic solvents. The princi pal organic so ids which may cause dermatitis are oxalic, car bolic, oresylio, formic, lfcic, acetic, ualleio, hydrocyanic, phthalic, and abiotic. The principal organic solvents which may cause dermatitis are thft various alcohols, turpentine, bonsol, carbon bisulphide, carbon tetrachloride, triohloreihylene, aryl acetate, butyl,acetate, toluol, gasoline and solvent naphtha, 3. Specific Irritants? These cause dermatitis only among certain hypersensitive individuals. Many dyes and their inter mediates are skin irritants. Aniline oil, nitro compounds, compounds of naphthalene, beruidino berueathrone and many of the suiphonic acids. Certain of the dyes cause derjen- titis -fur dyes among which are paraphenylenedisaine, paramido phenol, aniline black. Leather dyes among which are amido aso toluene, astido asp bensone, Bismarch Brown and Uegrcsine. Photo developers often cause domat it it. The principal one is natal, others ere paraphonyleaedlamias and pyrogallol. Soaps often cause dermatitis bsouase they contain free al kali, especially when mixed with water and also because sene of them contain certain substances, such as phenol or cresol, on order to make them disinfectants, and they also sometimes contain perfumes which may irritate hyper sensitive individuals. r&ny fabric dyes have been reported to have caused derma titis. ; cannot give a full list of them, but some of the principal ones are Crystal Violet, Malachite Green, Methyl Violet, Victoria Blue, Victoria Green, Metanil Yellow, Chrysoidine, Aursmine and X great many of the dyes which require chrome mordants, Tho rubber compounds and their Impurities .often cause derma- D.v. 9 -01 501 1152 iitis. r*bv&r, is, richer obtaicad frcn '.Tils r i 1**-vs ir--oe* la che fo"33*- ana ^atnsrsd by r..-.':iva later and rucked cr c irsd over firs3 usirg certain nuts, ?.u'.:er so curso contains m-uiy if the products of ooobwiion, such as phanoia, oocfcic acid s-.r.d iho tarry matters .*11 of rhizh aro potential skin irritants. Planta tion r*>'*bcr is also cured '* -mrtinr, Vat :r.ly the jurfacs of it contains the products of ocrai'.. Ion and this is ***3il/ cashes off before the rubber is used for *f..tyfaaturin^ purpose3 lc..'y c" tr > compounds .*sod in rubber a.:-> akin Irritants. The sccelcrj.fccr jt s-instances which :.ra asad to h-.sto-i `ha v-u2o?.r.ii&tiort of rubber, are often the onuses of sxrir. irrigation cacng ry" b >r ./orsors* Tho ariaoipal accelerators vrhich have caused darruRtitis in the rubber industry are hesamethylnnsiotraBitta, commonly railed :*'Cru.' th guanedinoe, totrecwthylthinr*m disulphide, <5 ttsonly called "t*.*dsn, moroapta fcenso fchiasole, commonly c&llod l?Cnotes und thiethyl fcrisslhyl trianino, commonly called n?:*iaer*en Fare and Ortho toluifiina hvo also caused damvtit its, Anti oxidants are also used as compounds of rubber in order to prevent the rottioj or oxidation of rubber. Phenyl Seta naphthylaaine is one of the cc-raon rubber an* i-oxidanta which ecaotines cause dam`.title, especially if it should "bloon? out of the rubber. *&ny of the insecticides and fungicides are skin irritants. The compounds of mercury, arsenic, fluorine, nicotine, andpyrethrua are the principal itritants in this class of chemicals. f.xplosives are also irritants to a considerable number of .Yorker*. Curing the tforld ;Yar, when explosive manufacturing plants had to be rapidly built and safety precautions ,vere at a ainiiaisa8 derma titis among munitions workers .'as very prevalent. Some of the principal offenders among the explosives are trinttro toluene, tatra aitro methyl anailine, trinitso res orein, fulminate of mer cury, picric aoid and its confounds and styphnic acid and its com pounds. Dermatitis cay also arise in the manufacture and use of eosswtic*. I:wy coemetios contain irritant dyos and the essential oils used in cocrsetics and perfume are nearly all irritants if used in suf ficient strength. The vegetable ord the minora1 oils ore also frequent causee of derma titis. In r&ehins shops and among mechanics the cutting oils and th* cutting compounds y.ro the chief offenders, Petroleum distillates, euoh as gasoline and 2ubrtouting oils also cause dermatitis among garag man, automobile mechanics and otr.eraeople using them, Plants? Iteny plants are irritating to the skins of certain indivi duals 'and gardeners and florists may suffer from dermatitis from them. Among the most common plant irritants aro Poison Ivy, Sua^o, Poison Oak, Pyrethrun, Cooobola, Brasilian tfalaut, and Primrose. Biologic Agentst Those are often the cause of industrial dermatitis and 2y--basubdivided into three classes* U Parasitic Inseots, such as will cause grain itch, 3traw itch ani linseed itch, 2, Bacterial Infections, such as erysipeloid reused bv the bacillus of swine erysipelas and occurring among butchers and carcass handlers? anthres occurring among hide and wool DoV* 10 01 201 1153 handln uad pyogenic infeetions. jr Fungus InfsotIons, such as meailia infsetions, occurring ou the heads of' rrulS packer7 Rignwora occurring among berbora, wool sorters , fur handlers, animal handlers and hath attendants, The actions on the skin of these various causative factors any he classi fied as follows* Some eot as 1, Keratin and fat Solvents, such as mild alkalis and soaps. 2. Desslectors, or Hygroscopic Agents, which take the water out of the skin, such as sulphuric acid a&4 powerful alkalis, 5, Some ars Protein Precipitant*, such as heavy natal salts, which form albuminates in combining with the skin. k. Spaa are Oxiditers, and by their strong affinity for the hy drogen in water, will liberate osygen, Such oxidisers are chlo rine gas, peroxide of hydrogen, ohraado asid and its salts* 5* Then, there are substances whioh tend to hydroliso when gorging in contact with the stoleture of the skin and fora irritating cos* poustdi* An example of this class is Sexaaothylenetetranino, which on hydroUsing first forme formaIdehyder, and then later goes on to formic acid. 6, There are certain substances which act as timulant# to the ker- atin-forming cells of the skin and are apt to cause new"growth* arsenic, petroleum products and aniline compounds are example# of this olase* * i 7, There is still another group whioh is known as Sensltlaers. exposure to then for varying lengths of tint*, the akin booease sensitised to their aotion* These substances any be called Anaphylactoid in their action* The nitre and the nitrose com pounds and certain vegetable* and ftagi belong to this elass* * " Hypersensitive orier* nay not insediately upon oooing is contact with an irritant, develop a dermatitis* A period of time usually elapses. This period rosy vary from a far hours to a few ejaye. 3om workers develop only a mild dermatitis and are able to oatinue working and finally they become immune, Others develop-so severe a derartitie that it necessitates their discontinuing work. These usually do net develop an iaananity. The immunity, if developed, in most instances lasts only a short timefrom a week to a month after discontinuing Work. Thore is one class of worker <>ad fertiaately this type is rare, who after working without any . trouble for many years, audderly beeernes sansiticed to the arterial* which he formerly handled with safety and develop# a severe dermatitis* '"hes# worker# never become Irome* They may even develop a polyseositivity to many of the ordinary material# of daily Ufa uz* ** a result suffer from chronic, iaourable eesemes* DUQ50S1S t Workers may have inflasnations of the skin due to causes other than the hazard# of their occupation. Therefore, it ie important to determine whether a dermatitis from whioh a worker is suffering is or industrial origin-first, beeuaae it has a direct bearing on the treatment of the case and on the prevention of its recurrence. .Second, beeuse* of the eompen- setion Involved, nad third* in order to det*raise who pays the physi cian** fee* - If it can be dotsmined that the dermatitis is due to exposure to cer tain occupational skin hasards, then the major portion of the treat ment consist* in preventing further contact with these hasards* Thtet is* removing the patient from his working ssrviTonment, or providing him with suitable protective elathing. Is these cases* the prevention of the recurrence of the disease consists in preventing contact with the offending material either by methods stated above or by installing proper safety measures* such M totally enclosed processes* adequate vnetlistioa, clean work rooms* clean clothing* etc* The compensation lews in aaty of the States are so worded that if a physician undertakes to treat a worker and he make* a diagnosis that the disease is of industrial origin* then his fee is practically taken c art of cither by the Compensation Cosmdasion or ty the Insurance carrier* But* if after treating the patient the physician should determine that the dermatitis is not of Industrial origin* the e^iioyer or Insurance carrier will not pay for the treatment and the physioiaa must look to the *patient for his compensation* You can readily see that this has a tendency to make the physioian. lean towards*** diagnosis of industrial deaatitU because very often his chances of being paid a fee by the poor, worker-ia.uncertain* .It is to the advantage of Insurance carriers and Compensation. Boards to devise mans to remedy this condition, ,,. .j . -- - . There is no one factor upon.which-a .diagnosis of industrial dermtitis^ o&n bs made* . Is most instance* the appearance of the letion* gives no. clue to the irritant*. Especially is this so in the aetite and' chronic ecsematold types of occupation! dermatoses* All of the following factors must be- considered and each one form pniy a link in the ahain of evidence on which a diagnosis of industrial-dermatitis shoul4 be aad#g 1* History* The hitoi9>o the denstiti* is moat. important* In order for ther dermatitis to ba. considered as of possible coeujeiticB* origin* it must be brought out that such * ..dermatitis was not>*preent'bef6re the patient entered on the occupation* It must also be shews that the deraatitis developed during the period.of industrial exposure*;or aftec.*; lapse , of a reasonable incubation period since the cessation of exposure* This- . incubation period should not be. over * week* If thw history shew* that-,. - the other workers .similarly.employed are similarly effected,..or .that.-new.. :: workers at the process are usually* similarly affected* then the possibility* of a diagnosis of Industrial dermatitis- is strengthened* If: the history^, should disolooe thefact'that- thal patient- has had similan attack*?.of. derma titis previouagc the p^sent^ expoa'ura* then, the possibility ofc the: present: attack beiniynittn hi*occupation* is weakened* but noh necessarlly; doners * my with, besauea it may* be. ppiaibel-ttat in his: previous esploynsat h*;n - say have aet' wltfr the same irritanlr or. conditioner which^are now causing;^ i hi* danatitis*' Knowledgej^ysioiaa. of thaworkiag processes which the patient iaengagpd and-tha substance* with which he eas*st> la*-1 * ' contact is Important* because this enables him to. know;whether the:worker^ - is exposed to known irritants or to oadditions which tend to cause dermatitis for instanoe, if a worker appears witte a dermatitis of the hands and fore- anas and states that he works on a rubber' mixing mill, then wo know that he is exposed to.all dermatitis,,then* is* a rubber-,worker.,who handle#5only*" > cold vulcanised rubber objects,* If ttehistory shows-that.the. dermtitis*-' develops whenever the* worker-Is'at work, gets well or improves^ when' heels'' * sway from work and again incurs when he returns to work, then the historyitself establishes a definite cause and relation factor between the occu-- pation and the dermatitis* 0; 7. 12 01 501 1155 - . ** '*--.** 2* Site of Eruptions The sit of th *niption is also important. In xaaing patients* they should be caapletaly divestod of clothing, this say in sacy eases reveal areas of ders&tttla on portions of the body not cosplalned of by the patient and nay give the clue to a proper diagnosis* Occupational der&atitis usually begins on the exposed parte-the hands* the fingers* and the forearms, if the offending satrial la a solid or a liquid and also on the face and neck if it 5s a vapor * the covered parts of the body may also be affected, if fum* or vapors penetrate the clothing* or if the clothing is not frequently washed and. becomea saturated with irrtant chemicals. Thus* dermatitis my occur on the body of the worker hand ling irritant dusts whioh penetrate the olothing* such as finely powdered rubber aexpounde. Or dermatitis nay occur on the covered parts of the body when the clothing becomes saturated with petrclous oils and waxes* especially If the worker does not taks dally cleansing baths and if he does not change his work clothas daily* Occupational bacillary infections such as erysipeloid of butchers and ver ruca necrogeniea of cadaver handlers also usually occur on the hands* Th* malignant postule of anthrax among hide and leather handlers usually occurs on the head* face* and arms* . Occupational deimtitis is also found at dolets of friction on the body* The wrist, where thenda of the gloves or sleeves rubj the belt line* where the belt or the top of the trousers cause friction} th ankle at th shoe tops; and the neck at the collar line, are all sites where friotion aids the action of industrial irritants* Sometimes a dermatitis of undoubted occupational.: origin nay hocone generalised* This oaours when the irritant is one to which the worker has developed a high degree of activity, ttmy substances Ire known to be see itisera* Sitro, aitroso and the chloro compounds are nctor ious sensitisers* In such instances a priaaiy localised dercatitis or burs assy .also sensitise the patient and a few days later a generalised densetitle say develop* 3# Charasteristio Appearance of lasleast An industrial dermatitis of the aoute ecte&atoii type begins as an~eiyiKnm followed' by papules and ves icles and when the vesicles break, by an ooting and orusting, no natter what irritant is the.cause* Occupational ayeotic infectlens* such as riagwona among bath attendants; barbers, beauty parlor operators and yeast infections among cannery workers* usually ooour on the hands* but the appearance Is no different than that of ringeem or yeast infsotions of non-industrial origin. There are* however* a few olasses of industrial irritants which produce more or less characteristic lesions on oertaia portions of the body* Paronychia and onycholysis are cocoon lesions among fruit and vegetable earners* The chlorinated naphthalenes and diphenyls produce acne-like lesions on the face end on th parts of the body whioh cobs in contact with the work clothes if the work clothes are not frequently washed and ohaaged* certain tar coupunde also cause aone-like lesions on the exposed parts* Oils cause fdllioulltis and boils* especially on the hairy portions of the body* petroletss andun refined paraffin* grease and tar cause keratosis to develop on the hands and forearms, -free And soreturn and these keratoses occasionally becotce malignant. However* tile scrotal cancers repwted in England as occurring among mule spinners and chifi&sy sweeps have net been noted in this eountry* Certain hydrosoopio oheaicals* euoh as sugar, salt and lime which remove the water from the skin* and solvents* such as the petrolew distillate* whioh rejDova thc.fat'_froa the skin* my over a long period of time cause dry fissured eesenair.1 "Exposure to certain aniline derivatives* such as alpha, naphthylaalhe and hensedine* are known to have caused miignaat growths* E* . 01 SOI 1156 / Gehraam has reported pftpilloaata of the bladder among the worker ex-- >psoed over long period* of time to such tail in* derivative*,; Arsenic,, especially if taken internally, ha9 also caused new growth* la the fora of keratoses and epitheliojmt, particularly oa the pala* of the hands and solas of the feet, geratotie lesions excessive pigmentation around the face end the nack say be occupational among workers exposed to the sttn* such as farmers end sailors* Occupational, dermatitis oust be differentiated from such diseasos es se- borrhoaio demat itis, fungus, infections, liehn planus-, impetigo centa^ giosa, pityriasis rosea, erythema aultiferae, drug eruptions, neuro derma-- titis snd ;am titis due to contact with irritants met with outside of the., place of occupation, the industrial physician or the 'onerul practitioner may at times be in doubt about the diagnosis of these conditions in * worker exposed to an occupational skin hasard, especially if he does not strip the patient and examine the entire surfaoo of the skis, but to the dermatologist the characteristic location and appearance of seborrhooic dermatitis. Lichen planus, lap.tig eoatagios and neuro dermatitis and the generalised eruptions of pityriasis rosea, erythema, multiforae and drugs offer no great problem in differential diagnosis from ooeuaptionsZ dermtitis. It' is true that the presence of base ecoditlona does not bar out the fact that *a industrial dermatitis say also be present. In foot, the presence of oertaln.of theseskirt diseas<s often predisposes a. worker to an industrial dermatitis* . . The greatest difficulty in differential diagnosis Li presented.by deraa-- title due to contact with substances net outside of the place of eeoupa-- . . tion* In these oases the. lesions are similar in. appearecce snd location*: and only the most careful'consideration of all. the foots earn lead; to a eorreat etiology. It is here that .the p&toh teeVis, of greatest .value^., The patch test is based on the .theory that if a dermatitis is caused by^T. hypersensitivity to a certain substance, then ,if that substance !ir-\st , ~ applied to an area of unaffected akin of the susceptible individual end i; left on for a period of time, it will cause an inflammation at the spot where it touches the skin.. In doing, patoh tests,, it la. is^ortant to know what concentration* Certain chemicals cam:coma la: contact. ^ with the normal skin fo?~a stated period of time without causing, an \9 inflammation or reaction* If'ls'alto important that'so general.,irr*-* tants, such as strcog acids or alkalis are used In the patch'test, be* cause obviously they wiH bum. ax^ skin. The portioajof the.body on..,___ which a patch test is to be performed is also of importanoe because it-1- has been found that the different portions say vary.,'in. sensitivity, tar c certain chemicals. for instance* the tough, hojv$r portiem# of the skin,^ such as the pals of* the hand* are less susceptible to irritants than is the acre tender skin on^-he lane? surface of >he forearm*, "hearagain it has been found that.the portibp of.the akin which is Inflamed, is, more sensitive than other 'portion* of the skin* Pot this /reason* patch^ tests perfomed/on uninflamed skin adjacent, ot the eruption are! more ... ` . likely to giber positive reactions than *ha performed on more distant'., areas. It may even be necessary, to wait until the eruption heali^Vo^' . that p*toh .tests may be peroftfoed on the portion of,the skin wfaiph. woo, actually affected, ,v '` ____ _ .. If the orker is handling knew* irritant* and hi# fellow. workenuar,.'Lo' also affected* the cause is' obtlous and the patch test la unnecessary,^ - but if he is the only one" or th`group who Is offeated',.thcnk he. should'S' be patch tested with the* materials with which h oomee ; in. etaofc the course of hia occupation'. If he is patched with only, one substance^.. T then a control patch should be* placed on his* If he is patched'with more than one su'stance* then any.negative reaction from one of these substance* serves as a control* " It is also desirable to use as a control ................. D.V* li* 01 SOI 1157 r /- one of the softer* who ha* aa dermatitis. In patching with solids, boat resulta are obtained by moistening them, preferably with perspiration from the patient which can to obtained Pros the axilla. Sonatina*, it my be necessary in order to obtain a reaction fro a patch test, to use perspirations of different hydrogen ion concent rations. (Hof. Schwarts, boatss "Soasitivity to External Irritants la Industry", flaw York State Journal of tfedleine, Docember 15. 1936, Vol. $6, ho. 2ti). the results of patch test* oust be correlated with the *erkor*s particular oooupation, the history of the dermatitis, the site and morphology of the lesion in ofdor to arrive at a corrert etiology. Patch test# are only a link in the ohala of evidence on which a diagnosis of industrial dermatitis Is nade. a positive reaction only show* that the portion of the skin on which the patch was applied was at that tine sensitive to the subst ance with which patched. In order to state that this substance was the cause of the occupational dermatitis, e must be sure that the patient was exposed to the substance in the course of his work and presuppose that the patient's skid was also seas ittea st the tine of industrial exposure, .Vhen negative results are obtained from patch tests with the materials root with in the course of the patient's occupation, w# must not hastily conclude that the dermatitis is not of industrial origin, because the skin area ever which the c&toh was placed may not he hypersensitive. Or, if. the eruption has disappeared, the patient may no longer be sensitive when the patch tost Is performed but soy have been sensitive at the time he had the eruption and when he was industrially exposed. Or, a negative patch teat reaction may be due to the fact that the natch test never accurately reproduces aotual working conditions, suoh as friction, masooration, heat, cold and sunlight, which may be additional factors adding to the irritating effect of the substance to which the patient is exposed. Or, it may be that the concent ration of the chemicals applied as % patch test my not be as great aa they actually war# during industrial exposure. Or, finally, the actual industrial Irritant may not have been discovered and applied as a patch test, ffhen negative reactions a^e obtained from patch tests with su*"stane# encountered in the work room and the dermatitis which the worker Has resembles a content dermatitis, an effort must be made to perform patch tests with saterials not vith in the patient's boas which say be the causes of dermatitis, for instance, certain plants, or perhaps paints or svan new furniture. T*ts of thle kind will in some cases show that the patient is sensitive to materials met with outside of industry and not sensitive to the materials which he meets In his place of employment. The technic of performing patch tests is Important in obtaining and evalu ating results. Shen patch tasting for hypersensitivity to general irritants such dilutions must be used in the tests aa are known sot to levitate the normal skin. (Ref. Schwarts, Louis* "Sensitivity to External Irritant* in Industry", Hew York State Journal of Medicine, December 15, 1936, ?ol. 36* Ko. SU). The Insulating materials inserted between the chemical and the adhesive plaster should be a non-irritant substance, sueh as unvarnished cellulose, or better still, a thin sheet of mica may be ,aed. The resin on waterproof cellophane itkelf may be an irritant, as say he sea* of the compounds is dental rubber. The adhesive plaster used to hold the patch in place often itself causes an erythema of the akin, (Ref. Schwarts, Louis and Peck, 'amuel tf.* "The Irritants in Adhesive Planter*, Publio Eos1th Reports, Juno li*, 1955, y0l; 50, Ko.. 2*), At the time the patches are removed ther? my bo no reaction orgeat, but soma time later (a few hour* to a few days) a delayed reaction my develop . 01 501 1158  *5= .*- ' . at the aits of the patch Thora is 3me dispute as to tha significance of delayed reaotions. Sana hold that tho skia mu sensitised by tha patch test, but X think that in cur present state of knowledge a should re gard delayed resetions aa denoting hypersensitivity just as uadelayed reactions do. Patch tests properly performed and evaluated can be of great help in the diagnosis of industrial demeritis, but if in* properly performed sad evaluated, they may lead to confusing and unjust conclusions. Punsus infections also offer a problem In differential diagnosis from industrial dermatitis. A large percentage of workers are affected with mycotic infections in sobs fora or another. Epidermophytosis, trichophytosis, tinea cruris and tinea versicolor are comoa skin diseasos. Allergic reactions in tho fora of dermatosis on distant parte of the body resulting frost these fungus infections are recognised ly allergists and dermatologists. These allergic reactions or phytids may be confused with Industrial <3 tra&titis. If the phytids or the sycotic infections appear on portions of the body ot exposed to industrial irritants, they are not so apt to oause doubts in diegnosis, but they often appear on the hands and here they are apt to cause trouble in diagnosis. The various testa, with fungus estreats, such as trieophytla, are of little value in making a differential diagnosis because nearly every one has .. or has had a fungus infcotton and positive reactions are the rule. They ere of more value when the testa a-e negative; because then-- they tend to shew that the present eruption is not of fungus origin,, although even here it is not absolute proof, beoause among other .. reasons the causative fungus may not he the one from which the testing extract is made. Then again, the fact-that, a Yorker has a fungus infeet ion does sot preolude the fact that he may also --. have an industrial dermatitis. In fact, it is held by some - dermatologists that the presence of a fungus infection predispose*., to hypersensitivity to other external irritants. Patch testing may el- so offer some help but here ajjain the industrial exposure., the history of the eruption, he site of the lesion* and their morp hology must all be carefully cons Idared before a diagnosis is mde Chronic ecEases, sore or less guaeralited and of long standing offer very difficult problems in etiology, especially when they are complicated by secondary infections, patch tssts are of lit tle value in-most of these oases, because polysensitivlty is usual-- ly present. It iaimpossibla to determine whether the demetitis.. ar.d polysens itlvity was caused by industrial exposure or whether the dormQtitis and sonsitivity was caused by exposure to substances eaoountered;'duteida of the work* room*. 'M Cases sometimes appear before Compensation Hoards claiming compensa tion for disability due. to a dermatitis which the worker claims to have suffered as a result of his occupation, but which at the. tfaa* the case is eing head, has disappeared. In these cases it is ales / difficult to determine the causative factor, if patch, tests, done.. at this time are positive, they are of great help, but if negative* , they are not, because the patient may have devaloped.au immunity by... his recovery.- From these facts it can be seen, that there is no on characteristic symptom on which a diagnosis of an industrial 1 armtitis can be made, Tho worker s ocaupstion, the history of his skin eruption, its site sad morphology sad evaluation of *he patch ^ests must all be taken into consideration by a dermatologist familiar with the substances sad the D.T. 16 01 501 1159 r processes of the worker's occupation 'before * can hope to rake a true diag nosis as to the etiology or a dermatitis in * worker exposed to as occupa tional akin hatard However, thoae two cardinal rule# are usually true. Road Chart 13. CANCER IH TK&USfHT Cancerous changes in the skin nay ooour 1a rounds or sears caused by indust rial accidents, such as bums and wound*. Cancerous degeneration also occurs in so-called sailors' and farmers' skiaa, supposedly due to overexposure to the ultra violet rays of the sun* Radium and X-Ray cancers among tech nicians and physio Ians we are familiar with* Certain chemicals are also said to cause cancers of the skis* The soot cancer of chimney sweeps described in England has not been described in America* Coal tar, certain oils, and petroleus products predispose to the development of canoer* In our studies In oil refineries we have verified this faot. Workers in arsenic also tend to develop karatotic lesions on the exposed parts* Such lesions have been reported by European observers, but in our studies in factories where arsenical insecticides are manufacture, we have failed to note their occurrence* Ye have, however, s en such lesions occurring as a result of the internal administration of arsenio over long periods of tine* An usual number of .papillomata and carcinomala of the bladder has been found to occur among synthetic dye workers both in Europe and in America* Workers exposed to sueh dye bases as. Anthracene, Bensedin and Alpha- ,l( Naphtylamine, are said to have cancers of the bladder occurring amongst .< then thirty times more frequently than the average population. Aniline and its derivatives are also said to cause the occurence of eaaeer. Cancers of the liver have been experimentally produced in rate by feeding then certain aniline dyes* aside aaotoluene and also by rubbing.certain of these aniline dyes into wounds of the skis* Other substances said to cause earner are Toluidin, Xylol, Xyloidin, Gundin, Anieidin, Dyphenyla&ia, Eaphthol, Kong-Red, Safranin, Hensoepurpuria and BJtue-Roaardlin, TREATHKHT OP IKDrSTRlA! 75E&ATOSE8 A person who is so sensitive to the material with which he works that he can not develop en immunity, should seek soaa other occupation* Host of the cases of Industrial dermatitis develop on new employees and are usually mild in character* Sech workers should be ^iven a protective ointment to put over the exposed parts, proper protective clothing, such as rubber gloves, aprons, etc*, and kept on the job* Host of them will develop immunity* Those h do not, should be given other work to do where they will not come In contact with the irritant* This usually effoots a cure. In applying medication to the lesions, only the mildest fora ofolataente or lotions should be used, such as boric acid or calamine, Steong ointments are apt to Irritate the skin and cause mere da matitis. Desensitize!ion has not met with any encouraging rest)its. PR'rVESHQB The ideal prevention is to so safeguard the operations that injuriaus chemicals do not come in eontaot with the skin* This can be done installing totally enclosed processes Modern factories are being built so that the worker need not corns in contact with any of the hemical# used from the begging of the B-v"17 ' W 501 1160 smaufscturlng process to t&e very end* Raw chemicals are brought, to the* factory in sidcsed railroad car*, emptied by suction-hose into enclosed storage containers from wfaioii they are. seat tqr turning calves to the> various retorts and kettle* through a closed system* pram these kettles the finished produot is prosessed in totally enclosed machinery, such as filters, grinders, etc#, and placed Into closed shipping containers by means of hose or pipes. la sose industrial processes, where this is not possible, or shore there is old equipment, the workers must be protested by being ooapellod to wear suitable protectire clothing, such as rubber glares, aprons, Backs, and goggles. This protective, clothing should be frequently cleaned and laundered* Over processes from which are given off irritating dusts or fumM, a special suction ventilating, apparatus should be installed eo that these irritant can sot eons in contact with the worker* The work rocos themselves should have proper : nd adequate ventilating equipment so that dusts and fumes have no obanco to accumulate In any concentration. Eule# for the use of protective clothing shouldbe enforced. when respirators or gu masks are furnished, the men, should be compelled to sear them* Cleanliness is of prime bqpdrtance. The floors and walla, of the work rooms should kept scrupulously clean as should all machinery*! Convenient shower baths should be installed and the sorter should be oos^elled to take baths after work. In factories where there are special skis hazards, a ooutl* set of locker rooms should te provided, that is* one,for'street) clothes and ope for depositing the soiled work clothes^ la thi* way,'...' the worker cosing to work will enter the first locker where he will strip and leave his olothes in. the looker*. From there he proceed*..through hall to the second looker where olean work clothes are waiting, for'h* From this looker room he proceeds to his work. At the ead of: the work shift, be enters the looker room is whioh he had put on his olean work elethaa. Here he deposits hie soiled work olothes? and goea- to the shoves bathe* From the shower bathe he proceeds to the looker, room-where he had. left his street clothes and then goes home*. . ... . There are may protective ointment*, on the market-designed fort ther pro- - ventIon of industrial dermatoses* Thee* ointments are supposed.to aot by forming a protective film over the skin and tjaue to pre sent the irritant from o offline in contact with the skin. Soma, of them are seeful, other# only imperfectly perform their functions. They may be easily rubbed off during work or say be washed off by the perspiration. Sc# of them any offer pro tection against a particular chemical. There, 4.re veiy few of them however, which oon protect against strong alkalis. There are instance*-where < protective ointment may be of value, especially if used during'the tia*<. pending installation of the more permanent protective measure which X have described, protective ointments are usually washed off by the-*crfcnea: ' before leaviafcth* factory* This aot also removes the irritant' cheaioalw . . from the skier and is no small part of the protection supposed to be-given by the ointaentY Ointments should never be rolled upcm as permanent pre ventive measures, hot only as temporary expedients pending installation of proper safety appliances* Kew applicants forwork should be carefully examined and those having such predisposing skin conditions as previously stated, should. nob\i- . .' be employed in occupations where there is a si in hazard. In occupations which present serious skin hasards, all applicants for jobs should be stripped during the medical oxaainatiou endshould be patch tested with the;materials with whioh they are to work and.it found to be hyper*-, ssnsitivs, they should he rejected*.- The workers should be eooourag#dj to report to frfto medical.'department, all irrigations of the skin,; nor. . matter hew trivial. There ehould ?* frequent medical examinations of the woike re to discover the presence of skin diseases which have aot been^^ 501t D* V* ia - UA 116 reported* The physiolas In hare should have a .verking knowledge of derma tology tad give porper treatsunt for these oasos, or if he dojs act have such knowledge, d erontological cases should he gjat to & consultlag dermtologist. It is not always necessary to remove the worker from hia Job in order that ho ?say got well. Indeed, it is sometimes better to allow hint to work, if he has a slid dermatitis, and treat him while working in the hope that he will develop an immunity or become "hardened", as the workers themselves call it. A groat many workers will become hardened and the immunity thue acquired usually lasts while working and sometimes will continue for a considerable period aftor contest with the chemical has ceased so that the worker may stay away from his Job for two or three weeks and cone back and still be immune. If, however, he stays away for a few months, he will in most cases lose his iswunity and will again have to go through the process of becoming "hardened". Those workers who develop such a severe dermatitis that they can not get well while working, should bs removed from the Job and when they have become well, they should be placed in sons other part of the plant where they will not come in contact with that irritant, Uuaioipal and State laws should be formulated to compel factories to report all cases of occupational dermatitis to either the Departrant of Labor or Health and those Departments in turn should report their cases to the United States ?uv`lie R a1th Service, xt is onyl by knowing where iadostiraldarms- titis occurs that we can hop to be successfully cope .vith it, iruaicipal and State Departments of Labor or health should have devislone of industrial hygiene within their departments, the inspector of whioh should be required to make periodic inspections of factories in order that they my note the occurrence of occupational dermatitis and the safety precautions adopted for its prevention. Special studies should be made by the Bureau of Industrial Hygiene of unusal outbreaks of dermatitis in order to determine the cause and to institute preventive measures* Bureaus of IndustIra1 Hygiene should strive for the passage og law* compelling factories to in stall proper safety devices against occupational dermatitis. Insurance carriers should also have trained Inspectors to inspect the fact** cries of proposed risks before accepting them* If preventable hasards are found, the risk should not be accepted until proper safety devices are in stalled. Insurance carriers should also have trained sanitary and safety engineers could bo used for the safety of the worker and the financial ben efit of the insurance carrier* The inspectors of insurance carriers can acquaint the superintendents and foremen of factories concerning the hasards presant in the factory and how to guard against them and the foremen oan in turn acquaint the workers. The manufacturer of cheoioals should have laboratories to study the health hasards of their products and how to guard against them and they should im part this knowledge to their rusto&ers* Plant physio iaas should take every opportunity teeoh safely and cleanli ness to* the workers, Thoy should also carefully investigote the causes of any unusual oocurrenoe of dermatitis and, if necessary, call in consulting dermatologists and safety engineers to help discover the cause and to in stitute proper measures to prevent recurrences. Plant physicians should also advocate pre-amployaunt examinations end the regular periodic examinations of workers. ` / .v. 19 - Oi 501 1162 `r j V.'. .**' l' ' r y, I,;-. .*iiU -x* o a y t u > t LECTUH3 D-VI DUSTS ISJ RSXATXOK TO tfZSSASSSCP THB LUKGS Leroy tu Gardner, feS. (Outline of lecture) I. pneusMCOBioais - a condition of the lung* Induced by prolonged inhalation of dust* . The tissue resetion varies from simple phagocytosis to fibrosis depending uj?a the coopositioa of the inhaled particles, . II. POUR KAJOR TYPES OP PNEUMOCONIOSISt 1. Steal# teaith-reactlen to &oat kinds of inorganic dust. 2. Siloco#is-reaction to free silica. 5. Modified silioetis-reaction to froa siHo* mixed with large amounts or other minerals. U. Asbeatos is-reaction to any one of a group of silicates hating fibrous structure. 5. Other forms not yet differentiated *7 basic anatomical study to sup plement impressions obtained from rcetgeaograas alone. Some of these1 suggestod forma may actually be modified silicosis, others may be largely the rosdlt of infeetion} some may actually be specific types of dust reaction. It is also possible that accumulation* of radio-opaque particles may them selves cast shadows on an X-ray fils. Essential features of the four types* 1. Simple benirt*. A. Anatomic characteristics - minor ohronio inflaamsatory changes around the major lymphatic trunks with no significant affect upon functional tissuee. Distribution largely perivascular and In extreme oases invol ving interlobular septa. fi. X-ray pattern - generaUsed exasreration of the norsal vascular tree shadows. Superimposed retioulatioa when septa are heavily involved, C. Specificity - linear exaggeration in X-rav nav result from anv cause which widens blood vessels, more blood in ltmexi. thickening of wall, deposits of dust about vessel. Dust of any kind, including free silica, may have latter effect. Linear exaggeration may be a precursor of specifio silicotic modulation but this outcome cannot be inferred even with exposure to free silica. D. Clinical si^ificanoe - usually pons., Kith certain types of duet, particularly tUHsVd that* is associated reticulation, there may be com plaints of dyspnoea. 2. Susceptibility to pulaonarv infection - cenerallv unaltered. / P-7*-1 . 01 501 1183 r s 2. Silicosis A* Anatomic characteristic* a. in a lung fra of infection - discrete, 2 to li m nodule* of hyalin fibrous tissue, uniformly distributed throughout all part* of both lung?* b. ?n association with healed or latent chronic infection of lung* - tendency for excess of nodules to from about infection* lesion, developing large area of fibrosis. Compensatory emphy sema and chronic adhesive pleurisy* B X-ray pattern a. Without infeation - generalised aodO&tioa involving all parts of both lungs*. In advanced cases the ooetophrenio regions oay be clear due to subsequently developing emphysema* -' * b, frith associated infeotlon - massive cangles*rate shadows on a background of generalited nodulation, In advanced oases contrac tion of massive fibrosis and o^hysena any disturb the pattern of generalised modulation. . ;- C Specificity- produced only by dust high in free silica, typ fled by-quarts. Silica 0022btoed as silicates has no such effect D. Clinical aigilfIcaaoa. % a. Without infection most cases have no systems or at most dyspnoea on exertion only. Disability non*- 'the pulmonary reserve is sufficient to meet all ordinary demands*, b, frith infeotion, .dyspnoea is almaya more marked. If in fection is healed but fibrosis massige and es^hysesa sarked there may be dyspnoea at rest and real disability*.... If infection is tilll active symptoms of intoxication my not bo manifest for years and marked disability may be deferred till a short time before death. .................- ' ; g* Susceptibility to pulmonary infection^.. Specific increase in sueceptiity~to tufeerc10: bacillusTiit nctr to pneumococcus or other organisms* '*'/ *.>. a. If latent tuberculosis antedates silicosis the infeotlon may be reaotivated producing, the very chroaio combined lession kneam as tuberculoellioosis This it a apacific, kind, of disease differing from either ailioosl# or tuberculosis in pure form with a bad ultimate prognosis. b. If tuberculosis is superimposed upon, a pre-exletihg active Silicosis the infection is apt to run as acute course and term inate fatally la a few month*. c-vn-a 01 501 1164 3* Modified 3iliooair A. Anatomic characteristics. th* silicotic modules are surrounded ty"senes or ceilular aonactive tissue containing large umounts of aoa-silieeou* dost* Similar dapositif occur about major lymphatic trunks t-nd often connect adjacent diUootie nodules. Beaction to noa-ailioeoua duets nay re sult in small oonglcserat1on* of nodules. Infection probably essen tial for the larger ones. B. X-ray pattern - usually very similar to that of silicosis. The periiyapnatio linear reaction* my cause com reticulation and occas ionally the shadows of the nodules are lees elear out. Ca Specificity. The basic irritant is free silica; the extent and severity or the modification is dependent upon the concentration and character of other minerals. D. Clinical signlfleanoe - as in less eoeplioatsd lUioosis. , Susoeptlblllty to infeotioa - ditto. Certain associated minerals ^te iron or ooei may favor keeling of the infnotion but massive fib rosis nevertheless ensues. Asbestosis A. Anatomic characteristics a diffuse, aoa-nodular fibrosis of the parenchyma Uie lung storting as alcavea about the terminal b roa chidea. Croup* of patent air apaces persist throughout the sear tissue. Peripheral bronchioles are dilated producing this-**lied blebs. Chronic adhesive fibrous pleurisy. AsbestosU bodies"iron-staining protein deposits about inhaled fibres. Diagnostic when mineral associated with characteristic fibres is. 8. X-ray pattern. Liit diffuse has* to an obliterating "ground appearance'' most marked In the lower thirds of both lungs* In ad vanced eases pleuropericardial adhesion may produce the "porcupine heazrfc* shadow. Ca Specificity. Prodused only by fibrous eilioatee known as as bestos . 6ooascna1 asbestosis bodies found in routine histologic examination of lungs due to aooidentally inhaled asbestos* pm Clinical significance. Dytpneoea more marked in proportion to apparent severity o? reaction s^en in roentgenogram. Disability my be total. R. Susceptibility to Infection, i&ny die of bronoho-pneumonia j severax reported autopsies of death due to tuberculosis; surveys of employed asbestos workers show no excess TB. SsperiseataUy no alter ation of native susoaptibility to tubercle bacillus. Ill, ETIOLOGY. Prolonged exposure to excessive concentration# of very fine duet. fKesTeoaJSHtffl* obtain only in industry. Defense wchanisra* of body adequate to protect any dusts in state of nature. Hence pneumoconiosis ie strictly an in dustrial condition. 1. Duration r exposure bears reciprocal relationship to concentration and D-n-3 01 501 1165 1' - ft,'' particle flee* Measured in year* and cot aoaths or weeks* Except under very unusual conditions exposures of 10 to 12 years-essential to pro duce silicosisj for asbestosis ? to 8 ywn. Silicosis never less than l to 2 years. g Concentration. Usually expressed In Billions of particles per ou* ft* of air. jjay te la mgs/cm# ft. Determined by aioroooopic counts of snaples collected'in impiagers or other apparatus* 3. Particle Siss. Particles must he snail enough to stay in atmos pheric suspension and still smaller to be iaahled into lung* Kot many larger than 10 nloroBs found within teralml air spaces, fibres of asbestos an exception - some inside Imags-measure 100 to 200 microns. Experiment aho that quarts particles larger than 3 microns havs ho pseoifio irritating action# h> Kiaeralologlcal Ccegosittan - best dstomined by Z-ray diffroction analysis* Nature of particle detenines its capacity to irritate. A. Pres silica is a ohemieal poison whose setion Is proportional to amount of stirface in ccmtact with living. ooli* . Cover the survfsos oheaieally with alumina or mechanically by grinding with soft iron and quarts beecaaes inert. Therefore, it s notion is not mechanical. B. Asbestos - my be a mechanical irritant although experimental proof i# not etssplete. . .. i: C. Other minerals* exert minor degress of injury and resultant --' reaction us`2ly short of true fibrosis.-*"' . : XT* DlKGtiCSZS. - fiaeod upon three essential**' * 1. History of adequate exposure to industrial dust. 2. Demonstration of x-ray pattern of the particular pneumoconiosis. 3* Physical examination. (1*) History of exposures- * *- *._v A. Occupational history must cover e tire industrial*'lifetime, last occupation may be sals leading because partially .disabled mn often employed*Xa* jobe- like-watchman and elermtogt operators.... 3. Should include both industry and particular job with^appreximate cates of each employment. e.g. All foundrymen aet exposed to quarts. dust.,but: shippers and sand blastars are. Soft coal miner* frequently exposed to so quarts but moat metal miners are. * " *' C. Determine nature of Material* used. Qriadsrs by have used, sandstone wheels- (9Cfi plus free silioa) in the past* today-they use emery, carborundum or a2taint oxide wheel* that causa no silicosis* Bat grinder, in foundrle. mjr grind .nicoua .wrf from cMfcin^. and so be exposed to a hazard*. 01 501 1166 (g) Characteristic X-ray patterns A. Exaggerated liaear Barking and perhaps reticulation of simple bertign pnetwoconiosos. 7*.v -V ' < ."V y'/^?r>&, '. ' I?/Generalised discrete nodulation of sisple silicosis. , C. tfpdulation . localized conglomerate shadows of ellieaIs plus **14 ,usually tuberculosis ia hsaled or latent stages. Tuber- eulo-eilicosis. C. Koduiatl.cn plus superimposed patt m* of typical tuberculosis. The lest eoaaonly associated conditions running an acute course. 8* * Piffuse,haziness of both Xotfer lung fields of asbestos ia. <51 Physical T.tfcftinntioa. V.v,- -A?,' & Lt-' ir'' S\- S>V V. >^ > ' v": "?> tT^ * X i*-.r , -#/r..>,/'' .' A:< , - * :h# A. la the 'uaoooplloated ease characterised by paucity of signs in coopsrisen with extent of x-ray findings. S^in* present those of enphysem^and perhaps chronio bronchitis. v 5? Is eases ooaplibated by >infaction, physical examination say be ab helpful# v - <1 a.., '.'r ^;.r.^te^ntio:vfi disability if present. D. Sputffla/exatolnatloaJ ' :;s. Mineral particles of little significance. X-ray diffrac tion necessary for identification of snail sices. b.'^Tubercle bacilli. In tuberoulo-silieesi* absent for years ^ ;until shrotly aati-aorten. la silicosis with typical tuber- 'v.'f'oulosiS'occur early. ' .. / ? COWPLICATIOMS OF SILICOSIS. .i 1. Lungs. -v- V. ,:V Ejnphyset* **- in advanced cases, Cfcrpnio pleurisy 4a .4angl^rmt/$ypec - / * Tuberculosis!-'- ths aijjn. ooBfeoa iriid the fitjor cause of disability. V. Gther infectiooil,'d not unduly comeon. lv PrW^carci*Ba;of lung:^ probably no specifie relationship. 3ili ce*** BBaat oomraoa in.:canner age and reputed x-ray examination* - '/.of %ilSeotfta' .reveal .wreWrXy lung oanoer. *S. Heart*; tvC -7 ; /t tRaooplicited discrete uoduletien. no affection hart. ft-:}..'",.hf' Conglomerate fibrosis ^ubdieulo-eiHoosis has bad effeotupon pre- . eiMting heart, disease dosoen .1^ the age period (over h5) ehan r; 7:77 7 oilidoffis ;ao?t prevalent;. .r<S. V4s> ' :. .4; * Dtbat*ble W|^af>tub^3uio-^ilioosio abfcualiy initiatee diaeaee in a ;**3r nenttl*heater--' . A- ,S ,, .:>y.x ^ .. :-v 7>&&**S*.ftv * ^*''*&>:.** ; - ''' % \r: '* proofvei'-eny: S^sct ^npon 'other viesa ra. Large s iHootic abdooica1 v v^: lymph nod?s STOotinee c^use syaptoms fora proseure, $7 7s?^.T* * ^. "C> 01 501 1167 The Baturg of Industrial gxpoesre to the Wetal* The Boat important route for tho absorption of octal# under the condition* of induetrio2 exposure is ty say of inhalation of vapor, fuoe, dust end spray, and subsequent penetration of the pulmonary membranes, flowover, ex cept in the ease of true vapors and of partidea so am11 as to behave like vapors, there is always aapl opportunity for alimentary absorption of in haled setaIlia compounds. ffithia various ranges of parttele else, twenty- five to eighty per cent of the particulate setter entering the upper res piratory traot Is removed without reaching the pulmonary' alveolae, sene being exhaled, the remainder being deposited on route and eventually being swallowed, (Some, of course, is absorbed in the upper respiratory tract.) By reason of the greater ease of absorption of most metallic ehnpounds in the lung as contrasted with the alimentarytract, the smaller quantity of material in the alveolae of the lung represents the greater toxie hasard# Nevertheless the present tendency among industrial hygienist*-to disregard the aliasntary absorption of the natal* is an eversifegt *hiab is of greatest practical importance when It results in disregard of the opportunities for the ingestioa of these oea^ouda by industrial workers.- - This brings us to another type of exposure - that which xesttita-frt* t afc* lag into the mouth and swallowing certain quantities of potentially toxic* sweats, it is quite unnecessary that the food and flrink;of workmen'be - contaminated with the substance* with which they work, but it is-not-un-^ usual to find that they are* facilities for adequafr-personal' hygiene-are' A not uniformly available la industrial plant*, and spotless- and; duetles* || lockers and lunch rooms are act always found, ill tee often the am have % lunch boxes and bottles of milk in work rooms or in contaminated adjacent 1 rooms, and all too Frequently they handle tobaeoe, and eat or drink asack*- * or even regular meals without properly washing* They even put-tool* and " other contaminated artic le* into theri mouths* fhe eeeas^leof' brushes of the worker# with luminous paints Is well known. Other examples dould also be cited, These are matter* of ordinary sanitation and housekeeping which,- per haps ware eraph&eUed beyond their relative Importance in an earlier period, but which sometimes are neglected in the aids* of the modem entasis on air contamination alone. > In general the percutaneous absorption of metallic eospouada is of little ' importance among industrial workmen*. There are notable exception*, however; the alkyl lead and aeroury ooBpotmde are readily absorbable through the skin, ae are also the carbonyls, including ires peotaoarhonyl. fhe generalisation is justified thatwhea a metallic or organo-netallio- or organo-metallic com-' pound is a liquid at ordinary temperature or at body temperature*. case may' suspect that it will penetrate the unbroken skis with' dangerous* speed;7 Solutions of metallic compounds ia water ware* not appreciably, absorbed through the intact sJcih as a general things and there are few if* any demonstrated' instances of percutaneous absorption ofinorganic-metallic compound^ out of-*' organic or oil solvents, but it should be remembered that, new organic vehi~' cles for netsHie compounds need to be investigated lathis regard if they"; are to be employed under conditions in which cutaneous contact will'occur. . General and specific Clinical gftars^tertstiae* of Industrial` ^ ` Intoxication Induced h the Absorgtiop?of Betals^c - . 11 I, Lead Poisoning. 1, General - Involvement of museel both smooth and striate, voluntary and involuntary seuro-musoulsr apparatus, centra^nervous system and hematopoie tic tissues. D-VII-2 or:50i H69 iflrms d-vxi JNTC&.IDATIOK BY US7ALS Robert A Sehoe, k.D Hunan absorption of metallic compounds lathe eourea of industrial employment, and as the consequence of industrial processes, i* 4 setter of frequent, almost regular, occurrence* Moreover as new technological procedures develop and i&in widespread application a greater zumber of pre 'ioualy unused nntal* and neta 111c ooapouads &oa under consideration from the viewpoint of their physiological effect* upon out* It is a tcaptation, therefore, to examine these material* as a group and to consider what ace their common characteris tics, and what general physiological or clinical principle* ar* involved in the prevention* recognition and medical treatment of intoxications that may arise from their absorption, tie shall make sob* attempt in that direction from tine to time is the diacues ion that ensue*, but any comprehensive coo* Id*ration of the subject In this vein would iakouus far from the practical matter* that must be dealt with# Moreover the conclusion* that would result from such a discussion would be far from satisfying except as an intelleotual exercise, since we should find that most of the facts needed to demonstrate both the similaritie* and differences in the physiological behavior of the netaIs and their compquads are yet to be obtained by the patient and elabor ate research. Accordingly we shall try briefly to summarise the more useful facts on several of the metal* that -ive rise to Industrial poisoning at present, while illustrating the type of information that should be-obtained generally, through example* of data that are now available on only a few.* ?he ratals that '-re responsible for swat of the ease* of systemic intoxication that oocur In connection with present day industrial operation*, (as differ entiated from oontact dermatoses), may bo listed Is the approximately deoreas ing order of their frequency of occurrenoe a* follow*; lead, sine, asroury, eadmitaa* radium, nickel, irea and thallium* The exact position of several of these metal* in the list is somewhat uncertain in view of th* present status of statistic* on morbidity, but that of lead is in no doubt since it heads the list by a very Urge margin. Zina must be included because of its Importance, in common with certain other mstala such a* beryllium, magnesium and perhaps copper, in the production of metal fume fever* However, the latter is hardly to be considered a manifestation of metal poisoning, and no further referenoe will be made to it or to sino* Copper is sot listed for the reason that Industrial copper poisoning doe* not appear to have occurred. This is a strange and interesting fact in view of the high toxicity of copper salts for simple organism* and the serious character of oopper poisoning seen in sheep as the consequence of the ingestion of copper suffate introduced into the rock salt supplied on the range* (Bull. Ho* i*99 Texas, A^ric, 2xper. Station, Deo* 1924} It seems probable that both the dosage and the mode of absorption are important factors of safety under the donditiens of industrial xposurs to copper, but we shall not be in position to understand this pecul iarity of copper nor the apparent vagaries in the behavior of other metal# in the complex human organism, until we have learned how they are transported and distributed in the tissues and how and in what form a they are eliminated* n,tr knowledge of* these matter# i* quite fragmentary for most metals. s 1; for present purpose* one might be lod to include in this disoussion certain elements the poisonous effeote of which resemble these induced by toxic doses of the natal*, as arsenic, antimony, seleniwi, teilurlua, ehrmiwa, manganese and certain lose ccasaoa elements. However, in addition to the fact that time will not permit more than this passing reference, non of these elements is regarded as a cetal* in the strict soaae of the word* Therefore, only one of t*#m, manganese, will be added to the list given above, because of its practical importance as. the cause of a systemic type of industrial intoxication. 01 501 1168 of ekin and appendages (also conjunctival and upper respiratory irritation) 4, Reference* P, A, Heal et al; tr.S#- Pub Health Bull., 234* (1937) end 263 (194l} D, A, Hunter et *1; $uart. j, fed; 9*1$3 (l$4o) r 1, General - Involvement of respiratory treat in acute toxic and inflamm atory process, with similar inwelwe&aat of alimentary tract under suite* 1* conditions and especially following repeated low-grade exposures, 2, Clinical types. (1} Acute (mortality high at severe levels of exposure, with no permanent sequelae in survivers) Respiratory manifestation* - naso-pharyngitie , tracheitis, oonatrietisg pain, eough, pulmonary irritation, dyspnoea, pul monary edeaa, cyanosis and aephyxiel syndrom, dastro-enterio aanifestatiana. - mtallio taste, laryngitis- (swelling and pain on twallesring), nausea, vomiting, diarrhoea. Other manifestations - headache, ditslaAss.'Waknees, chills innreaainQ- acfBatlma^to. great severity,' fever (terminally), . (2)' Chronic - headache, nausea, vomiting and diarrhoea, with respira tory znenifeatationa of minor* importance. 3, References .. 1. prodan, J.Ind. Syg,..and Toxicol,. li, *132. (195?) Division of Hygiene; Rational Institute of Health, V. S, Pub. Health Report*, 5?*60M1Wh .'-'t . ' "- a, T. Johnstone, occupational Disease, Saunders .Philadelphia, 19UI ; '':? 'vo*?*-* ' v * IV, * Radlm-and feacthorluar Poisoning** 1, General A chronic disease involving long-continued effects upon osseous tissue ia which the metal 1# retained and upon the boas narrow contiguous*- - voreto, . -> . -- "-= ; 2, Clinical characteristics - (law morbidity with high incidence of-pro gressively increasing disability and eventual fatality) Skeletal manifestation* - radiation osteitis characterised in stage (!) by bone narrow changee firritative hyperplaeia with basophilic stippling followed, by, destructive action causing*aplaatio anemia); in stage (2) fy. replacement* C& Hone narrow with-Cellular fibrom * tiasoe;. in.$tagj^(3) by appearance of non-cellular fibrous'tissue with deoalottSeatiot^.if (emjhnr. eseMinted with spontaneous fracture*), " Osteitifiofc'Ja* associated with secondary infection results la. . necrosis of audible* Giugla-or. multiple osteoearaomta-- *-* - ' Hemato^^ieal aaaifestatlone - changes in-peripheral bloodVepre- sented taeophiiia stipplingand. varying feim of~*juhk!*; sometime regenerative and sometime aplastic apparently.* determined ty-stage and or spued of development ? of- process Upper respiratory cnnifeetatione Careiaoaa involving pen nasal sinusv.* .. J, Refereimes . H. S. Martland^ J,Am, fed, Aaaoo., 92*fe6; 522, (1929^--' - R. D. Evans et al-_ Saris*. of papers, latest of which; wilds reference to others found in J. led. Syg* *t* Toxicol, 2t*jll6 (191*2)- ` V-: / XMTIX<4 01 501 1171 2. Clinical ty*t* . !-< (1) Gaatro-enterie - (mild fora, with highest morbidity, ins ignlfleast mortality and negligible permanent disability) Anorexia, fool taste ia south, constipation (occasionally diarrhoea) abdominal distress, colic, general weakness and leas of weight. (2) Heuro-tusoular (voluntary) - (severe fora wi'b low iaoidanee, loir mortality, and high relative incidence of permanent sequelae). Extensor poreses and paralyses, especially wrist-drop (5) Cerebral - (Boat severe fora, with very low incidence, hifih aortallty, and noderate incidence of permanent disability) Encephalopathy (U) Mixed types Combining various characteristic* of above types. (5) Generally associated evidences of intoxication in all types Vascular (cutaneous pallor, lowered vascular tone, bradycardia. Heamtepoletio (hyperplasia, toxic changes,,aplasia (?), i.c. f basophilic stippling, anisooytesis, anemia) .?eatoees, inanition, loss of weight, arthralgia, low body toperator*. ` (6) __. Special type - (lew incidence, high mortality, negligible Incidence of permanent sequelae) Tetraethyl lead poisoning always acute cerebral excitation without hematological a*feetebioas, and with little evidence of asscolas ted visceral intoxication. 3 Reference Report of Committee on Lead Poisoning, Am. Public Health Assn., Hew Tort i<&. II.' Mercury Poisoning 1. General - An essentially chronic disease involving the central eystes, and to lessor extent mucous membrane* and excretory* tissues. 2. Clinical characteristic# - (low morbidity at present and low mortality, with slow recovery and high incidence of permanent sequelae in well-established cnees) CHS 5*nifefltations - fine tremors of fingers, lip# and tongue, manta1 aberration and deterioration Gastro-enterio nifstations - nausea, vomiting, diarrhoea, gingival irritation, bleeding end inflammation, stomatitis, sailvatic, foul taste and breath, anorexia with weakness and loss of weight, fcenal manifestations-edera and irritation (albuminuria and hematuria, excretory dysfuaotioa (retention of mercury, etc.) 3. Special types (1) Intoxication from alkyl mercury compounds - focal cerebral lesions characterised by ataxia, disarthria; lateral <J oiuaa end occular lesions. (2) Local effect's (mercury fulminate) - irritation, erosion and ulceration D-m>-5 01 501 1170 Diagnosis of gotaUlo Poisoning in. Industrial Xorkayn The diagnosis of poisoning resulting froa Industrial exposure to toxic nttc.lt it node by nothode corresponding to thoto eaplcqred in other tyyee of illness. One aspect of the problem is /oaeahat different in that such diagnoses often require substantial proof of their eorrvwtnese; not' only for the purpose of Instituting adequate seasurea for the elimination of further hasardecai exposure but also to substantiate the validity of a olaia for eostentation. It la necessary, therefore, to do a thorou^i olinieal job, to obtain the evidence neoeaaary to establish the fact*, and to felloe up the case or oases ee as to determine the extent and the duration of disability. The 8taps in the diagnostic procedure stay be defined'briefly* l. Sstabltahaent cf the Character^ Severity* and Duration*, of the Occupational akpoburw'.f ( It say be possible to accomplish this prupose ty Interviewing the patient* Often and In fast usxally* this is Inadequate* Generally it is necessary to investigate plant proeeeses and conditions' in order to- evaluate the potential hasard of the exposure, to any taUto, fue. dust*, or.vapor The- value of the "history of caeupatlonal exposure*? so frequently,referred to as one essential in the triad* of'diagnostic proceduret is,.eesBioniy.overeflphas^ iced* It is valuable or ada leading, to the extent that it is'factual on the* . one hand or suppostltioue on the other* It is rarely-'aors.than a working - ' diagnostic load*- Htyelolaas who deal with industrial'iatorteatiecw are , not justified in drawing inferences and in asking:snap judgments, but ua- 'orfcuootely they do so eoom&y 2* Elicitation of Symptcwntlo Information end physical^- Signs of Illness of Disease'" Little need be said to the careful .cliniciaa concerning,the importance of obtaining a detailed history of the. onset and.ocurse "of an. illness. There are certain points, however*, that any be emphasis**. The relation.-ship of occupation to nines* net be examined in terse of the entire occupational history of an individualsince the occupation at the onset of the illnss8 nay be quite different frost that-responsible for the illness* another feature of importance is the history of previous-illnessas-and their relation to a present* or previous occupation* Inquiry concerning time, lost from work la often- fruitful of information* Of still gfeater(is^jortance, la the establishment- of the date* of'the last workday"- ie. the last day of expos ure'* In relation to th* onset* of illness, the severity of present, syaptome, and the interpretation ef laboratory data* ., ,c, The value of a comprehensive physical examination a Wise referred.to gen erally in speech, but the actual performance and recording, of. the obaerva- tiona ooneonly- leave muoh to be desired* Detailed olinieal observation* are recessary to arrive at a sound diagnosis and even the, beat, of skill nay be inadequate*. Clearly, therefore, nothing but canfuaiah can.result from a cursory and inocnplate examination* .The neurological findings..are. often of the greatest importance and therefore a thorough neurological examination Bust be nade* It ie not always easy or even, possible, for. the general? clin ic ian to nftko the nicely balanced interpretation of neurological data re quired for differential diagnosis, but there is little excuse for hta-neg lect of systeaatic. tests .of the function of cranial, and segmctal serves and 9ndor6-* ., n D-7II-6 T. Msaginesc Poisoning,,.,. 1, General - a chronic disease ehemeteri4NKl ty nervous manifestation* md focel degenerative lesions of the brain and spinal cord. 2. Clinical characteristic! (relatively high incidence of permanent dis* ability, with negligible mortality) Cerebral nanifestatioo* - eetra pyramidal, and basal ganglion Involvepot, with stuttering, monotonous and economical speech, miked facies (inconstant), and lingml tremor, without mental impairment. Cord maifeststicc*> - coarse tracer of hand# increased by volition, apastio gait on broad base, iiwordination,, tendency to fall, motor atajcia, muscular spasm, and impairment of motor power. gasmtQla^tcftl manifestations - apparently inconstant lAucopeaia, and* anemia. 5* aeferenoe*. - - !*. S. FUna, t al, D. S.. Public Health **11. 2J*7 {I9i*0) t. H. pairhall and P* A Seal, Hatiemmi Institute' of Health gull* <* VI, Slokcl Carbonyl and Iron Carbonyl Politoning,.. 1* General - tout* Intoxications, dealt with together because of thoir clini* cal similarity, characterised essentially by effect* of. finely'divided tad. diffusa metallic deposit* i& ptfsemry tissues . . 2. Clinical characteristic* (duration 8 to.lh days- in- turnwore, mortality varies with severity of exposure, with no permanent disability in survivors) Stage 1 - frontal headache, disstae**, reduced body;te^srature e&d eshtus- tion, after variable latent'period. . * - -} Stage 2 > Ccugh dyspnoea, chest constriction, pneumonitis, and pulsoa* ary edema with cyanosis and asphyxia! Bycdros*. - . - Associated inconstant aahlfestatlono' dellritfr^-'edRvulsio&e, cerebral hemorrhage, hepatic involvement, .3* Reference* A s. /. An**, 3 Ryg., rii907i 8,1900:**.::* ^. ?liy and Xeralfc, BanflSil Oases, Berlin, 1931................ K. rotting, Arch. F; eew#rbepath,,.lw5<*> 1933T- - ::;. > m. Thallium Poisoning^ l* General - Involves nervous tissue* in genera1," including, the autonomim-- apparatus, with both irritative and degenerative effects... General toxio- ohanges in vlsoera are relatively jfroainenfc- following,,large dosage in. short time, the nervous effects being predominant In sure prolonged exposure to small do#ew5;>: ;* .j, 2, Clinical characteristic! Gastrc-eaterio manifestations - snorkle, nausea,, vomiting, gingivitis, stomatitis, and fetid breath ..... Nervous manifestations - irritability, senselenoe, exaggerated deep reflexes, generalised tremor, convulsions, pareses and.paralysis of muscles of extremities, taunlc, eyee, face* throat, and larynx,, iritis, retorbulbar neuritis . Cutaneous manifestations - keratitis*, (corneal) vasomotor changes and alopecia Renal manifestations - albuminuria 3 ffefereaoes Jwaee C. Hunch st al, JJUH*A. IQU131& (1953) and 102*1929 (V)3U) (numerous then raferences given in'these articlee) D-V1I-5 oi 501 1172 Table mammmmmtm 2* Nean Concentrations of Certain ratals In ttorml Urine National Grouos Number of Milligrams of Metel par liter of Grille Sancles. & Pb Sn Al Cu Prenchmea Uexleeas N. Americans Gormans Hk 0.050 0.001 0.1% 0.056 30 0.012 0.022 0.009 0.054 0.059 3Q 0.010 0.029 0.018 0.052 0.026 15 0.027 the occurrence of these metals la the urine presupposes their carriage in the blood, and for various reasons their concentration in the blood is of considerable practical interest ae Is also their distribution In the blood components. ?ahlee 5 cad 4 give tone of the pertinent facta in this regard. Table 5 Mean Concentration of Metals in Korral Blood National Groups Niaber of Milligrams of metal per 100 grams whole blood Samples Mn Pb Sn Al Cu Mexicans N. Americans 50 0.018 0.025 ' 6.010 0.012 0.126 50 0.012 0.027 0,0% 0.0% 0.105 Table 4 Distribution of Metals in the Cosoonents of the Blood of North American Adults Thole Blood Plasm Cells Milligrams of lietal is plasma and Celle of 100 Grams of Blood lb Fb Sa il Cu o.oia 0.02? O.OOir * 0.0015 0.006: 0.0% Q.G% 0.002 Q.0I1 . %0.0% 00 0.005 0.105 0.Q45 0.059 The limits of safe absorption of. the netsIs There is no valid reason for the assumption that tits absorption of small quantities of the metal* *o which man has been unavoidably exposed through out his existence lc in any way harmful. On the contrary rany of these netsIs have been found to be necessary in carrying out certain ooapiex physiological processes in various form of animal life. Therefore, three obvious questions arise in relation to the concentration of these elements in the tissues or excreta of animal* end m& (1) #hnb licit* of oenoentTWt- ion, if aqy, are required for physiological reasons? (2) ffhat are the upper liaits of the concentration* that are compatible with norm! healthy existence? (3) Shat are the range# of concentration associated with injurious effeeta? As corollaries of these questions, what are the relationships between rates, of absorption, rates of exoratios, and the resultant rates of retention is those instances is whioh excretion falls to keep pace with absorption? Also, In what tissues, if anf* do these motels accumulate? In taros of such questions the industrial- toxicology of those^aetals becomes merely a seriea of problems in minere1 metabolism, essentially Indistinguishable in principle fi-vn-fi 01 501 1175 5. Collection and Interpretation of Laboratory pat* The utwl laboratory testa cat the arias, and the ocsaaoa henatologioal observa tion# require neither elaborate knowledge or training to perfors or Interpret tut these should be attended to with cere end prevision. Additional laboratory procedure# should be selected Tor performance oa the Vesta of their relevancy. It is here that a background of ownprvhsnsiva iaforsntion la required, stnoe the ohoioe of oethods sust he based oa a sotfid saideratendlag of the genesis and character of the texts phencas&a that are to he identified or aeasured* Only eonplete uafaailiarity with the prohlo* at issue will pernit the physician to trust the chelae end perfcnftoce of e wh procedures to ordinary laboretofy technicians or even to otherwise well trained technical personnel who leak physiological and nodical background. Beth the technique and the interpretat ion of speoifie procedures require special training and experience, and the late protation can only he sound If based on eosgtrshensive physiologies1 knowledge. The need for such knowledge will appear as our discussion enters its next phase. The Signifloanee of Specifla Laboratory Procedures in the Recognition of lasardous gxpoeure tg lietals and in UKo Diagnosis oT"Keteiuc Poisoning The Behavior of BetaIlls Coapouads in the Huata Organism Bonsai absorption of actaIs < . The oendltieos of life on this planet are such that norwl individuals, with out reference to occupational exposure, absorb into their tissues neaeurable quantities of actaIs. Table 1 below gives s few representative data on the distribution and concentratIon of certain metals in the tissues of persons with no-occupational or otherwise unusual exposure to. thee*, metal*. -?** - - ' Cocoestration Levels of Certain jfettl* in Boros1 Human Tissues Tissues Uilligraa* of Hatal oer.lOO Grans of Presh Tissue Kidney Heart Brain Liver Spleen Lung Busole - ' ' Long 8oner flat bone m 0.060 0.0J2 O.OJQ 0,2GB 0,022 0,082* 0,050 0,300 0.1T0 Fb\ mCrnutrn 5 0,02f 0.166 0,000 0.03$ 0.190 0,000 0.02> . - 0.1*00^ - 0,003-- 0.130 o.rio 0.005 . 0.030 . 0.0Q5* 0,020 * 0,110 o.ooo: . o.ooia-. 0,010* 0.125'" 0.000- 1.860 * . 1,190 0.000 0*1*70 0.240 0.010' Tfcate oatali are taken in food and drink* and to a lesser degree are inhaled, in the form of dust that ooourw in low concentration in the air,. Generally speaking the great proportion of ingested set*llle aGrounds traverse the alimentary tract uaabsorbed and appear, little diaiaUhad, in the fetes. Seme of that ingested or inhaled is absorbed* however, this appearing in the tissues and also the urine. The order of amplitude of the urinary excretion is shown by the naan values is Table 2, D-vn-T Of 501 1174 - S*- . -->* from those arising in eosBeetica- 4th the mor*. e<MN*L mineral element*. Available iaforsmtioa dees not^establish the liait* of safe concentration In the tissues, blood, or urine of expoeed huasn beings for the metals under consideration, except in the ease of lead* In this case only has the bade information on human metabolism been sorked out to such an extent as to Justify practical industrial standards based on physiological considerations, it has been shown that when the seen concentration of lead in the urine of representa tive goups of workmen exposed to lead oompounde, does not exceed 9*10 mg. per liter, cases of lead intoxication do not occur* the range of values and their frequencies, that are compatible with safety, are shorn in fable 5 Similar data on blood concentrations are available but are not so reliable, for reason* that will appear in later discussion. Table 5 Lead Concentration In Urine of persens with Occupational Lead Exposure ialnt*lne<fTror YearTfoar tftfssHottTok Toxic ity, but dithoufc Ocetirrenee or illness Lead in Mg,/liter ______ ____ Frequencies of Occurrence Results Obtained on Slagle Samples of Urine of Exposed Men 0.000 - 0.019 0.020 o.oU> 0.C6O 0.050 0.100 0.120_ O.lU 0.260 0*200 0.220 3 1h 17 -10 9 6 l l l Total Mean and P. 5. of Mean Standard Deviation 7k 0,097 - o.ooU 0.045 Other pragmatic standards based bn the concentration* of fume, dust, vapor or spray in the air breathed by vortawm have been set up, however, in lieu of physiological standards. These are given is Table 6 bole*. table'6 Oenerally Accepted Upper Limit of Safe Concentration of Certain Metallto Ousts and Fuses in Atmosphere or Workrooms for Sours per Day over Prolongs(fparieda Metal Cadmium Mercury Load Zinc Manganese * - Concentration In ms. Per 10 Cu. H. O-VTI-9 1.00 1.00 1.50 15.00 30.00 01 SOI 1176 / (The reminder of the dtw**iesi *tlt he pTWsrsted *t%Tbm\\y *n& can be t*kn dcara in net*#. It win concern itelf *ith the pfayaiology of load absorption, retention, and excretion, in iHurtratios of dispioetic, hygienic* therapeu tic and physiologic concept* that ehould be extended by experimental mans to include other ratals.} D-7II-I0 01 501 1177