Document 4vEBoekZQ0ZVE8g3oNX9K1baV

FILE NAME: Metropolitan Life (ML) DATE: 1931-1948 DOC#: ML205 DOCUMENT DESCRIPTION: Editing of 1935 Dr. Lanza Publication on Asbestosis in US Asbestos Plants and Citations in Downstream Literature .... - V ______ _ Metropolitan Lite Insurance Company C> r. M w l b u Cr t U A X U .IL I /N*dkW0iplf* Maroh 0, ISSI J [ r. iU M U r& m u J U lr i S tm t, Bm lark City* Mr. Ivdtm LLi C la r a r ith i i tha ra p a rt af tha mahoataa,,shady, is tha saaaary rapart a t tha Aaarlsaa pleats stadia* J tha Canadian wiawiary ra p a rt v lU ha farthaaadac s h o rtly . l a th is ra]M rt tha la s t a t tha J e k M - * s a llle Oaapusy * t f c r r l l l a , * J . I s daalfmatad u P lan t A. Z a s a ls o aa o iim a apy ta Mr. Boyar tad i f yao vlafa ad d itio n al aopiaa, plsasn 1 st as c m . laadlaao t 7 , Z 111 ha w r 7 (la d to lUwmat th is r apa rt or a ap llty u r rf i t U j m aa daolra. Zt i a r f ic a r w , a d s a to a d th a t th is rapart La aea fi-A w tla l u d i t t f l l ha ( l m aa pahU n ity ty a B M f i vtth tha iiw n r t of tha f i n a aaomarmad* A fter yaa ha and a n>amna ta { ar i t , Z ohaald l i t e tha apportamity o f iti cmao-lny v tth yaa y gtff BS*0*lAtSS tlM i f jnJhllOlUiflft eta tic 1 u, P ith hart ragardo u d an rirlay y to P ay Laoara cppra- c --A .'- - -- -*i # ~~7 Tan. A ssistasi ia ti cal BLraetor. J o * * C 4 . } PLAIN TIFF'S EXHIBIT 2011 teai sum.v eo. ( y  3s oi : 3 Oi 3 3 m7 8 J 1 PLANT A Ho, Dept. 3ainplea Taken Preparation 6 Card roon 2 Ring frono e i spinning room 1Uula apinning 2 Trialing 10 ULlllon .pteor cWu.fnt/ 0f dir i to n to 1 2/5 to ^ 2/3 to 2 1/5 to 1} Reaving 4 Fait Dept. a 3h6ut in a sulating Moldod braku bond and clutch o t-* IV) 1/20 to 2. 1/3 to 44$ 1/3 to 4 t >i*'P.U,H;T.!B,* PLANT 0 .'< \ ' nut n \j ***, PLANT E Ho. Ulliion flawplen Partiolea Taken por cu.ft. of air Ho. ULlllon Ho. ULlllon Ho, ULlllon Samples Partiolea Sanplea Partiolea Sanplea PartLolaa Takon per cu.ft. Taken per cu.ft. Taken por cu.ft. of air of air of air 0 to 8 0 to 43 -- -- 8 50 to 02 6 } to 4} 6 5 to lfi -- 8 28 to 78 ---- ---- -- -- -- 1 6 1/B to 1 B l to i -- -- 8 s to 10 Included ip spinning Q 1 to 5} . (Jnoludoa 8 8 1/3 to 7- j (Inaludea i brood loom broad loo , j weevlng) / weaving) J1 4 1/5 to 4/S . 6 1 to 10 15 1 to 7 8 loj to 19} ! -- -- -- -- -- ---- -- -- i --. . ~7 -- ---- _ . 2 to 5/6 _______ . I -- - --1i HWIK MUX. - 13 - t y mr Ba s a jo r d is a g ra e = e a t. A ll concerned wore guided by t h e i r ex p e rte a c e l a s i l i - c c a is rd o th e r types o f p c e u s o c c c io s is , hence th e f i l e s c la s s e d as n egative f o r a s b e e to s is wars f u r th e r su b d iv id ed L ito 'd o u b tfu l* and n e g a tiv e * . Only t<- car. t a l l w h eth er'th e in d iv id u a ls c la sse d os d o u b tfu l arc p ro g ressin g tow ard a d e f i n i t e a a b e s ta s is . P a r t i c u l a r a t t e n t i o n was fo cu ssed os. the prasonce o r absanc* o f L u ll s a t ic e s o f tu b e rc u lo s is and, i s t h i s r e s p e c t, a l l the r e - r i r a a n o i these filu s Tara is accord. V ith the unhappy experience oi s ilic o s is i s B ind, i t was f a i t th a t a g r e a t d a a l o i car sh o u ld ba devoted to a s c e r ta in in g , l i p o ssib le, irhathar or so t asbeetosis predisposes to tuberculous isia c tio s. Table I I e x h ib its th s d ia g n o s tic s l a a s i i i c a t i a s o i th a sa 125 in d iv id u als, T ith th a ir synptens and sp e c ific occupations. liv e o i these par sons ora c o t p h y s ic a lly exanined. *2** caaaa o i a a b e a ta a ia are d iv id e d in to tw.o c l a s s e s , f i r s t stag s t asd second s ta g , The f i r s t stage- seb raco s thoaa who show by a- ra y exam ination d a fis ita le s s pathology s u iiic ia a t i s extent to w arrant a diagnosis of pnauso- c o c io s ia , b u t who h are so d a f i s i t a sy u p tc u s . The a card s ta g s cases e x h ib it aors extensive- lung pathology asd also, d a f i s i t a symptoms. A ll thaaa in d iv id u a ls* Taro a c tiv e ly esgugsd i s fa c to ry worh, asd i t was co t p r a c tic a b le to maks sny d i a t i s s t i o c betw een them oc th a b a s is o f working a b i lit y o r d is a b ility . ?-fuL asy is d iv id u a ls bean found who e x h ib ite d e x te n siv e p u lsccu ry Involvement and narked p h y s ic a l - d is a b il ity o r t o t a l d i s a b i l i t y , they would have been c l a s s i f i e d as th ir d s ta g e , b u t no such wers fouxd. ` lea o sb o stas worhar (2nd degree s ta g s ) r e t i r e d o f h is owe acco rd acd because o f Id age te c years previous to th is stu d y , b u t is s t i l l a c tiv e about h is gardec. I ! C Li . *# # t 0 JL i I n D uring *-* p ro g re ss o f th e s tu d y , p h y s ic ia n s who wore p r a c tic in g in tho ccn n u n itics chare asbestos worksrs liv e d were questioned, and sta te d th a t they d id s o t fin d cm u n u su al amount o f tu b e r c u lo s is among th e se w orkers. Ths c o n tra st between, th is s ta te o f a f f a i r s and th a t found in communities irith a s ilic o s is hazard, is noteworthy. tha follow ing ta b les c la s s ify re s u lts of examinations by occupation in in d u stry and t j- years o f exposure. I t is to be remembered, however, th a t these in d iv id u a ls are e la a s if ia d according to th e departm ent in which they were working a t tha tin e of exam ination o r where they had sp en t most of th e ir tim e. 2iary had changed from one dep artm en t to a n o th e r and from one p la n t ta another during th e ir years o f employment in the asbestos in d u stry . Since only the amounts of" d u st c o lle c te d a t th e tin e o f th is s u rre y in th s v ario u s departm ents a re known, th e re i s no way o f knowing tha average amount o f d u st in .ths atm osphere in h aled by th e se people o v er th s years o f t h a i r employment. Consequently, i t is s o t p o ssib le to c o rre la te in d iv id u al cases w ith d e fin ite amounts o f d u st exposure. , TA3ZZ 7 By D e p a rtsa n ts P o sitiv e Doubtful Segativs Tea-ring Carding Spinning Parsing Spooling Tracking loom fin in g ' Packing Tlnding P ic k o r T w istin g I Othor T otal oxasined 22- 13 3 13 . 4 1 9 3 3 1 0 2 3 2 1 1 0 3 1 0 1 0 0 3 4 1 2 0 2 3 5 0 6 3 4 67 39 20 r a w * ** a lifts 'ass's'asscc w a n * r zz z .* a ** n * raz s t r* "I ( i j , -- -- e -- -- ... * 'j C.V ... ... -- ... HU*) * 1*4*Iff 1 ! 1 >41 #|W| f l If 411*) '^4 1 1 hSm in !* *i<* j* VII*) 4**it# ( |M(4l4 * i H ^M4J U* 1 Hi *) *|U| l(V |3 ||< | *WI1<| IHW| | | g 1 It,!! 3 |h4M j i 4 M*l 1 till* fM III 0 || I 1*M | l **!* ! 3nm 444t l(<4f) l|M) ||*>m4|IC 1 | | | |C||l|.fc 1,?!! UO 1U1*|1 |34* 1! g U*4 |P*1J |`1 I Vili**} Ui i, |" l 4 < c (ii|>) fTw* || * |M ( | i| | ; i t u |.1 Hk) 1`t 'll * (' ' i' 4,* .1. feil*) I( *"l*l ( ' J -- II n 1 *m o K -- >*1111 I I 1*IV**H1-** | i l l " l 11 4 t **(!l i J t i ( *>*h i i l f a-*in 1 ( C . |( l | i* *1 1 IV ttl i**5-*** , j i i n f l r 1 3*|*x *f 4*<f **1 * * |l l l T l I <|MTII1| " *J Jl S 'i l " f i -- <{ l | t % 3t|Itt4 |tittH l |l(| IMf tf a * if *4 | |M it !! l*3-j Ht*H p|HM4i|J<J 11*3 3/f a -- |M I H1**M 91 !! | 11*4 1 |ul> u< n 3 a |||T |r-> ) * II*" I it > i C*|*( :f l - J i .t " U S ls * |l * I) S a ||||a u | mmu* | | ; It t tf IMI ~ - im | l|> * | | | | | | | U | IM W N |I | i f it * t% >3aa| in* * | Si>|M|*|i|| |SM < II m 1 S*|*x u Sd*| | | * | p | | u i M l)l* * < |l U 9 V *111 i j* t> t ii< i x,uM m |k|i| im i4 4 +H*: t% n * <; ' *|Am| H|*H tll||444M f MM*. a K T Rfi*# - 16 - TA3I5 n Tears of Isu o su n p o sitiv e D oubtfal Peeutive Over 13 7 ears 1C to 13 7exs 5 tO 10 79CT3 Cedar 3 7ars ; to ta l axminad 13 - K p a rt tin a) 3 (1 sat 7 3 2 con- 30 ` 27 3 tin - 17 n 67 39 12 ttoua) 20 . Tia- io i lr e i n g tib ia a are a lso o f i n t e r e s t , b u t, lilcs t i e tvo p rev io u s, ara of l i f t e d valna and l i t t l e i s tia vay of d e fin ite ccaclualcea can ba based upon thax. SA3L3 711 Ajjo Groups P esitiT Doubtful negative 50 aed over 40 to 49 30 to 39 20 to 29 C edar 20 7 aars to t a l exaniuad IS' 3 2 13 6 4 17 12 6 24 13 S 1 2 0 67 39 20 TA3I3 T C I Sax P o sitiv e Doubtful negative C ala (T o tal exaaluad 108} 39 32. 17 Pecala ( * v .is) a . 7 3 SA3T2 H Chaat Z rranslcn ' 1 to 2 leches 2 to 3 leches 3 leches plea Sot ceeelecc. to tal P ositive 23 31 5 3 07 D o u b tfu l 13 21 3 2 39 negative 7 12 0 23 c n ~ ^ ' * mm t s 0 1 7 5 `- Death c la in s : 1. Proved to bo a t 7? i s t , so t xpocod to dust; died of puinonsry end in te s tin a l tu h e rc u lesis. 2 . Colored w ile age 27; worked in asbestos e u y ear and eight e o a th s ; d ie d o f p u ln onary tu b e ro u lc s ia fo llo w in g * . henerrhago; ra s i s s a ra to riu a t a so u th s. Also had a fo u r' p is s C a sse rso n . Ho rider.ee o f a s b e a to s is . 3. C olored sale- age 32; worked in a sb esto s p la n t one y e a r and se re u so u th s;' d ie d of pulmonary tu b e rc u lo a is a f ta r cue south * i s h c a p i t a l . C a v ita tio n b o th lu n g e ; no e rid e n ce o f asbea~ toads. 4 . C olored s a l e age 3d; worked in a s b e s to s p la n t two y e a rs , and s i s s o u th s . E ia p h y s ic ia n b e lie v e s t h i s was a case o f uneo sp lle a te d tu b e rs u ie s is . Tio not innate o f h o s p ita l or sacatoriun. So ro m a tio n could be o b ta in e d o f a o th s r tr o oases except iro n the d sa th c s r t i f i as rh ic h gs.ro pulnonary tu b e rc u lo sis as th s cause of death. to ta l and rem anent d is a b ility els 1. Zalo, espleyed in asbestos p lan t three years. Zis physician s ta te s ha f i r s t cane under h is observation w ith an old e s ta b lis h e d ease o f tu b e rc u lo a is about two y e a rs a f t a r asbestos, esployeent s ta rte d . Also had tu b erculosis of the kidney and c e rris a l glands. 2 . h a le , employed in asb esto s p la n t e ig h t so u th s. Z is phy sician sta te s old fib ro id tuberculosis with tubercle b a c illi in sp u tu n . So Z -ra y a v a ila b le , b u t according to p h y sic ia n eabestos bodies were found in sputun. 3 . H ale, te n y e a rs e c p lo ju e n t. Two p h y sic ia n s who tr e a te d bi-t a t d i f f e r e n t tin e s ore new in c lin e d to be l i a r a th i s nan , Is not tuberculous, but has asb esto sis. 4,1 S h ite m ale, ra n re-exam ined a t tim e o f L n re s tig a tic n . Zis p h y sician re p o rts w ell nourished, husky looking, good co lo r, no c y a n o s is ; no clu bbing o f f in g e r s , dim inished expansion, in c o sc a n t cough; 1 -ra y shews fin e n e t t l i n g d is a e n is a te d through b o th lu n g s . So erid en ce o f tu b e rc u lo s is . Probably a second stage asb esto sis. co DmwvV.OUI UUUI LULHJI i>t5lVtCtS*diti 0i ! 57 r" .> * C 1 f"4 bj r ( \ S') \ : .... i ; ,-r^ x . - '^ m k ^ D ocsaber 10, 1931 Dr*i* T La f la tropo L itan Lif Ineu rnaca C o ., 1 3sd lecn Arums* Sew l o r x C ity . Ear P re lim in a ry S tudy o f 1 Dear Dr. Lsnxat I haro srandncd th e g a lle y p ro o f o f your a and D r. X cC ocn ell1a p ra lisd n a ry study e n t it le d tffa c ta o f tba, 3 In h a la tio n o f A sb estos Ctaat cal tha L ings o f Labonto a T ork srr*, which you a ero good cough, to send a w ith your la t t e r o f Decern-- bear 7thy end tu.ro compared i t w ith th e ndmoograp h s! pamphlet o f which i t purpor t to bo * ccndsas& tlca Confirm ing cy telep h o n e coc reir ca tio n o f thi s a ftern o o n , X an p lam in g to tr s a s a lt th e p ro o f sh eets to 2 r . Hobart so th a t he w ill r a c r ir e then toaorro-* and a h u ll r e c u sa l th a t h e retu rn then to as not. la t e r than 'E nrsdsy w ith h i a c o - a a n ts , a f t e r which I .hH sea th a t th ey aro proa p tly tran sm itbod 7 to j-ctu 1 s h a ll a lso in q u ire o f th e E syb eetag Ccacpeny whether o r n o t th ey d a a ire to iragHne tha p roof o f th e a r t ic le b efo re i t s f in a l p r in tin g nd *K_ilT endaa-ror to persuade th ea n o t to i n s i s t upon such an aTa-al m ^ 1 h a te th a fo llo w in g to aakas (1) C ra c ln ric n S o. 1 (g a lle y H ) has e m itte d a se nte nce appearing- in th e o r ig in a l w h ic h , as a o d ifio d by y e n , re a d as fo llo w s- 'C L in i c o lly fru s i t h is stu d y i t appeared to bo o f a. ty p e a ll d o r tha n s ilic o s is * . (2) Thera is a ls o c a itte d th a f i r s t paragraph on page 15 o f th e o r ig in a l r e p o r t w hich reads as folio* ntering the progrees o f tha study, phyaic.aa who t e r o p r s c t i c i n g in th e e c m n i t i a a wara asb o o tn s worier-s Li-red, *nore g u c s tic n e d , and s ta t a d t h a t they d id n o t fin d n un-- u s u a l a u c u n t o f tu b r r e u lo a is icrcr.g th e e e e r k e r s . l i a c o u t r e s t between. th i s s ta ta o f a f f a l r s and th a t fruud in ennuam itioa th ' C. *r v. Cr C ? a flU ico cia h a ra rd , i a noteworthy** Both th e forego lag o b a e rra tic n a Included in tout o r i g i n a l r e p o r t p re e e n te d an a s p e c t o f tout zuttot- t h a t wma X ^ f a t o r a b l o to th a i ndu s t r y and we should I l k a to sou th c a ro ta *6 O ) Csa g a lle y 11 th o r a r d *death* h a a boca ocsittod oftacr th a phraea o f 36* (-0 Ccnclutrica fo. 3 (g n lle y 1 ) Tha ro rd * p r* U rin ary * i a n a e rte d -- to =y c ia d unnocar s a r i l y -- lin c e th a e n tire a r tic la is d o fln ita ly Lzbellod a t tha ccnn c a c o a e a t aa a * rra1 .in in aT7 * shudy* (5) E a a r r ia g to th a l a a i en tese* o f th a th i r d pATSJJXIpil o a pago 13 ( e h ic h La n o t changad i a th a g e lls y p r o o f ) , c i t cocaa to ae th a t soaa uo rt o f a d d itic n a l phraee c r d an ce la reqoired ia crd ar to re la ta i t properly to , T h a t haa gana b e f a r e . As i t atonda n cey i t La n o t a tire ly d a a r ju a t That ons ia expecied to educa thsrom a* 7ery tnly yct 73sT CCj 3ocEre-C ocrg S . S o b a rt Zm'Am V ozrheea F-i. miZLizssa 7endTwr Brera Attorney C Ju X. \ - - -- * OCi ? )' ej "t ::T*?' I I t ** MN %q o Z < > y pi O M ) 7) ci U 5 O n 1 o t- a XU a Y. H :> o o X s* a o >. < !.. W > Pi J A O > Uo < t ; * WW l'u e O 4t - [A . V r* A* h * 3 r> -t r-I O & fl g i ^ -& f lo n hS s^ Cl . H B n.'i r: t 4 T n t: n rl rl *. t* *r 1 n <J k M 4* m I I n O c> r\ ii * n H .lt io: *7 iN t *I .4 n r* xi tt 44 t:c N u . `: n b -r {* /. n i: < i l I . 1 O ? ti i l 'r* * tb; 8 f \ *O H ;iM Vi no ri n i : U * n M M ) 'i o \ f lT fIM a I o *i XJ T VJ o t i f i l i ri 4i M J5 y ^ N SS fr o -o ti BB-o J M tj 4* O V5 3fl Oa (RV n 4 rl H f a f H J t t ti <* n lui i -rt hB O e j : o t: H T " K T | t* V i b jj o V. r fi n U hfJ Vo rf H x n fcr c: ti 4 4J II t 1e iTje nt Jt ti h a --4 M I P o 1 ' . ,1 n I Jtl . t> d *4 ct o 8 d 1 n *. *\ . p n *r* ~ i K p d e i cH rl \ 4 r i t f A` n* r 4 ) O M <rt 4 i Cl 5- g n H t Mj V. O j ~ r, >. jv, o ti H r* P. * U ft P I ni n i i' I' d N* i 4 w p * a h t*jti r> t :. o*aeit Voi /4i* U q *> ri V t> I rf c ri < o jq n ,-. -< H . c r. t" 4* p . p M 'o R l! . lI)| w' tOi o o r* t' ff\ ' no x: a4: wi--nrrl: n * 1. -v H * ^ ; i t i * o t- n d Al } ti ti t:. t 4* H [1 tx i \ r * l Vi Vi IX O K *t o ' >1 P r \ O I tu p n n r n u M - vi i; n to 6 V i r p * *i w O *-*H r t 4 * Ir p ti .p b fEt k fi OV,"O a j41: ja>i C oi: * jA < i ri* n . ri u k e i b t u i t:s t i l i r i B C f* *' 'l l ` *- p *j H C p_4 i: a n p t c V i i " rf rf f nV xi V o f) n O o nr l n pt": * 1 r-i / i f-i< Py> , I !| il -* p -- <1 I d * t ai > n *t h r< 1 * v( d (i r i r-i XI m ti o f t f t H c> t: ; kl (I r-j t! o l. e Vli rtti n rf<i I[>: *i / *; p11 tpi fdi fni ot P I- 4' .4. n n li ' cl o -* I-* i. fniix ' o t: Vo rl f lit 4 o * ' * *> A*} t> t ti v A'. r, a: m{n ji v r Vt At *i rt` ri -f n t o *' V. I V f c ( Ur^ V V n d ir a r D rc * n , o t i n a - r l t b i n - r h i c b i t u i . - ' s t d o n r o l o p , i r a a t o C h a d c a a r a r c c s 7 o d \rj t h a l u s c o , o r a j t o t h a t y . i . i n t i *.j o d u u t , e t c * (2 ) C al 12. \t tho h o tto p o th ia n a l le y I o ta e rta th n t t h e r lo s oh fe r t h in a n o to ( i n e t c a d o ln th o hocy o th a o r t i o l a ) ib a a t a t o n o n t t h a t a s n e a r a in Cha P .cpcrt o 1231 ro L a tir u r to tho- oslar.-;-no r t o th o p a r t i d ord t h o -jao o l o .y a r i t h T r . (:cd p . 7 c .lu p o r t o 1 9 3 1 ) ;,a a r a t t n r o c u r i o a i t y I f o n d o r r h y t h a o tat-rn u m t ( a h ic h oeaeca to na m i t a l n r s o r t a a t ) l a p u t i n a n o t a i s a t o a d o l n t h a `e o d y o t h o a r t i c l o . I tha a n tb e ra p r a o r to h ato i t in tho f o n o a n o to , o ecu rao , t h o i r u d r r e a n t a h o u l d c o n t r o l . a a i t b a r n o p a r t i c u l a r h o a r i s ; ; i n a r.7 < r r o n t opoo th c p e l o t a in b ic h tho co cp an y i a i n t a r s e t o d . {3) 9,n i . 1 2 . Tha l a n t pareurraoh en t h i a p o l i c y i a a a o u m e y >< `.ha 1! u j t c o n s t a - r i c h r a o o o c t to tria o c r o r - a l p l a n t a . wh <^ * w^ >a3 i t l a a t a t o d t h . i t p l a n t '3 '''rua u e s n c c a a a a r i l y d u o t y 4 . I u srt-cra t.md t h i a d e m r o t ln a n 7 na*/ r s f a r t o ony p l a n t o i J o h s r - H u r r i l l e , h u t I a n 'TcndTrir.i' - r h o th o r t h o p r o p r i e t c r o f s l . c s t 3 h i n had an o p p o r tu n ! t y to T 'n '.r tho c o m o n t . I t a tr ilr n a no th a t the r o s c r e -xould s e r r a rrcry purp eso l i "to lm .7a o u t in thu f i r o t l i n a o i tho ooraucrauh cs t h d t v o lle y t h a T c r d a t j a a u s n a c o c o a r i l y d u s t y - . How<rrr Chat i a a r o a t t a r *-rith n r . i c h a r a i s d i r o c t l y c o n c o m a c a e d I r o r e l y u r y e s t i t Tor c e s a i d c r a t i o i I t i a t h a a a a o r p r e a s l e n h i e b a p p c - a r a i n t h o h c - p o r r e i 1331 3 ". p-ifjo 1 1 . C a l l o y 1 2 . Po c tre n n et. ( - 0 C a l . 1 4 . Th a w ord ";! s o t h 4 cfcould ho i n s e r t e d a f t e r t h a T a r d a ' i t i KJ* in t h o t h i r d p a r a r r u p h o i c u h t i i l a - Z s r s r a n c a C l a i r s " . Tcu ha7o a lre a d y c o llid a t t e n t i o n to th ia in y c u r l a t t e r o i I s c m h o r 10 to *** T *i ( 3 ) C d . 14 o r d e r u h t i t l o Or: c l u s i o s o - . T7o. 1 . I i t p r a e -r hth y c u r m ^ r r s t i c s i n l a t t e r t o O r . o i T e c e i t o r 1 0 th t h a t t h o r s cSa*ald ho adc;d t o t h i a c r s c l u c i e n a 3 h r 11o r t o t h a t o r . i s h a p p e a r e d ( a t p . 2 0 ) i n t h o ."u p e r t o i 1 X 1 . 'C l i n i c a l l y , i t in o i a typo s l i d o r than o i l ! c c a i o 4 -- or i i tho la.era : to,tomerrrt nacroly, doctors do s o t ~mst to n k o tha s t a t e m e n t in t h a t p o c i t i T e p o m , i t tU r h t ho fnllc^a (an aurrpentorf in your letter)? clinically, ires: th.a study it appeared to ho of a typo slider- than siliscaia- ? er, ii Chat .0 too serene, it ri.-ht hn sot forth as iollrtrs? * 1 0 for as isdleain hy tha study, aiheotcaia ia of a typo (or arpcars to ha oi a typo) slider than a lliceaia*. Tho tract ecrdi.cr 1j sot insortast, creop: tl.-.t Z think it uould he dsa lrah la (if tho do'-tora are satieiio-i that sash i.* tho Tact), to -.a-re sera crprsrai.on ce-rparis,p as hosts si* eith aiiicooi* and indieatiaij that thore 1* a real liiTorenca hoteosrr tho tero i i*eoj s, oo far ao aci im ti n - Vnrelrd.7Q net inriieatsi. hi cotir-=o, Coro surain Z hats Is nlsd *-q ~~ahnhllit7 that eh Pern J0 rcep Cerraisoion till lneroduce a hill in --3 1c"iala turo e h o-ir.j in Jv'-ar/ :i IP 13 : ard IT it l3 tha policy 7 i Jch.ro--*f.rt :1 1 a eo op-e 39 ary hill that a tears-,cod to inoluda aoha-j *.?3i3 , j ecrearyahla, It t --j ! I ha tery halpf-Jl t: "ate es eiiici.cl ~ r r n r i to :hc~ that th a ra 13 a oohet or:*,lal dii is reset hctnas a oheo*.;c1a ^ trd eiliceslsr and hy ths nxsa to' cr. it ecu 1-1 ha troublesetto li cr. c 7o a d lta r 3r w n c 4- o ' f i c t a l . r o - c r t aheuld a " ~ c : i r f m ih', eh t h a s ere l e s i l o ha Man t ha t thoro la 7077 1 1 1 1 Lj li* ar.y d i f f o ranca la tr o or. t.c j tre di acaooo. aa onlamcent la T e . 2. I and e re ta n ti tb a t tho .a ta tn r.c n t/ * 0 =aJr^ - at7 r r r a a a c i o n t i f i a o ta n d p o in t, and I do a a t seo hrw to ras o e n o ia te n tly o tjo c t to it< Te. 3 . t a ^ r e o t h a t th a v ord p r e l i r d n a r y * la j c ; t r r T . M a a . II o * 4* 0 * r e . 3 . Tho retida tha sana a a en r a r a 21 of tha licuar* o f 1*531 a n d , h o r c o , l t r a 7 h e a l l t t l a l a t a t e a f c , j c t . I e e - r e r , I - o i n o u t h a t a a :,*3 . 3 n c~r r o n d o t h a l n f n r o n c o s i . ; h t ce d rrr.m t h a t aohcfltoalo dooa MA ta tho nortaJLlt7 r f t r ho rea Ic e la c a re a . h - t th a t in fo c e n co soga n ot sean to he J u o t i f i o d 2r e a t h l s a t a d / . I a s T o r d a r l r ? i 2 i C r r o c ld Ve a a c r e a c c e r n i a c i a n f i t i c a t a t c n a n t IT t h e r e T e r o c s i t t o d f r e n 7o 3 t h o L a a t t h r e o e r r e * , t o - f r i t ' c h h a r than tu h c rc a l' io*. H e* fi . T h i a l a t h o s t e a o o a t f e r t h o a parpo 21 c f U n c o r t o f 1 r o l . ii* .h th o flx c a c tle n t h a t tn a Tvoport o 1331 a t tho end o t h o S O T t e n c u be. t h o n o r d 8 * t h a n f r e o 3i l i c a (3 1 C2 )* and t h o g a l l e y p r o c i h a s t h o o r d o "t h a n g r a n i t o d n o t * . S e r e i ^ s - i n i t r e y h o % 1 i t i l o l a t e i a c r i i i c i za th nta i m e n i , Vnt T do n e t I H th o r u r r e a tlc a th a t thoro ia a p o s o ih ilit y tirai a e V sa tee is m y cau so prsroroccciasia m r e a d i l 7 than g r a n i t o i c a t . Tha resacar I ohj e-et la th a t anny c u s s o s i ' s i l i c o s i s a r e m pnooed tc c r ip in a ta In g r a n it e d e e t and t h i a s V a t r s e a i aa i t m r ra u d o ou-rpotrio tr u n a p o s s i b i l i - : - t h a t a pncm ncccs l e s t o S3 7 a r i 3o s e r e ren d i 17 f r e n a a i rateo....* th -c r r e n it o d n o t . t thinV: -r s f c r u l d , i f r o s o l i l o , e l i m i n a t o i l i cr.. . p a r i ' o f c e - c l e a i m h e . fi f r l l r o i r e r t h o c e s i - c o l e r : i f t e r t h a r e n a *ef i r -* In l i r a 2 o f t h a c o n c l u s i n 3o 7 . T h ia l a t h o = aff in t h o P.auort o f 1331. Ho c e r n i i ( f i ) Cala 14 s e d 13 s n b t i t l o T l a c o n a e c d a t i a r . - . Ih s y c o r y o f t h o Ho p e r i o f 1721 X ha-? a r e n c i l a e a s , ia t o r e c o m - r d a t ! cn P o . 4 t o I n c o r i t h a vp-rd *7 0 0 2 1 1 1 3 * h o f e r o t h o 7 7 rd * o f f 3e t s * *0 a t o h a r o *.t rra d aa e o l i i s e t n d i a o c a t h o r o e s l h l a o f f s e t * c f a a t - r t a e l a on t h o ha _ r t and c i .- c a l a t i c n * . I do net thinV tho p o in t la c f sa eh i s p c r t i s c o , hut I ce.ll a t t o n t ic a to i t s o t h a t i t 1 * n o t c e - r i c c i o d .. I * rreo t i th tho ? i b * r c u r q e r t i c n o In 73 s r l a t t a r to I r . Linea of focm Vor l f t h . c1--"e /r.*-i 7- - - - ___ y/ re-- - v o a Tv Hdbdrt & Minard Lefcourt Building 1180 Raymond Boulevard Newark, New Jersey Dec. 15, 1934. Re preliminary study of Metropolitan Life Insurance Company Mr. Vandiver Brown, Attorney, Johns-Manville 22 E. 40th Street, New York City. Corporation, Dear Mr. Brown: I received your letter of December 10th with enclosures, including proof of the preliminary study entited, "Effects of the Inhalation of Asbestos Dust on the Lungs of Asbestos Workers". I have carefully examined the proof and return same. In reading this proof I have compared it with the paper of the same title which was prepared by the Industrial Health Service of the Metropolitan about three years ago. I submit the following suggestion (for convenience of reference I have numbered my comments in red pencil in the margin of the several pages of the galley proofs): (1) Gal. II. At the end of the paragraph which discusses the "variables" upon which the progress of the disease is influenced, the following sentence appears:- "It might well be assumed that similar variables would influence the occurrence of asbestosis." You will recall that in dealing with the New Jersey Legislative Commission which has had charge of the proposed new legislation in New Jersey whereby silicosis is to be added to the list of occupational diseases for which compensation is required under the terms of the compensation statute, we have consistently agreed that there is a substantial difference between silicosis and asbestosis -- both as to the clinical nature of the disease and as to the reasonable probability of its incidence, and you will also recall that in particular we have urged that asbestosis should not at the present time be included in the list of compensation diseases, for the reason that it is only within a comparatively recent time that asbestosis has been recognized by the medical and scientific professions as a disease -- in fact one of'our principal defenses in actions against the company on the common law theory of negligence has been that the scientific and medical knowledge has been insufficient until a very recent period to place upon the owners of plants or factories the burden or duty of taking special precautions against the possible onset of the disease to their employees. I, therefore, dislike to have this report suggest that asbestosis Mr. Vandiver Brown, 2 might be assumed to be similar to silicosis, either as to the period of time within which it might develop, or as to the dosage received by the lungs, or as to the quantity of dust, etc. (2) Gal. 11. At the bottom of this galley I observe that there is set forth in a note (instead of in the body of the article) the statement that appears in the Report of 1931 relating to the enlargement of the particles and the use of logarithum (See p. 7 of Report of 1931) As a matter of curiosity I wonder why this statement (which seems to be quite important) is put in a note instead of in the body of the article. If the authors prepfer to have it in the form of a note, of course, their judgment should control, as it has no particular bearing in any event upon the points in which the company is interested. (3) Gal. 12. The last paragraph on this galley has a summary of the dust counts with respect to the several plants. I notice that it is stated that plant E "was unnecessarily dusty". I understand this does not in any way refer to any plant of Johns-Manville, but I am wondering whether the proprietor of plant E has had an opportunity to review the comment. It strikes me that the report would serve every purpose if we leave out in the first line of the paragraph on that galley the words "was unnecessarily dusty". Galley 13. No comment. (4) Gal. 14. The word "death" should be inserted after the words "6 of 36" in the third paragraph of subtitle "Insurance Claims". You have already called attention to this in your letter of December 10 to Dr. Lanza. (5) Gal. 14 under subtitle "Conclusions". No. 1. I agree with your suggestions in letter to Dr. Lanza of December 10th that there should be added to this conclusion a statement similar to that which appeared (at p.30) in the Report of 1931, namely, "Clinically, it is of a type milder than silicosis" -- or, if the doctors do not want to make the statement in that positive form, it might be as follows (an suggested in your letter): "Clinically, from this study it appeared to be of a type milder than silicosis"; or, if that is too strong, it might be set forth as follows: "So far as indicated by the study, asbestosis is of a type (or appears to be of a type) milder than silicosis". The exact wording is not important, except that I think it would be desirable (if the doctors are satisfied that such is the fact) except that I think it would be very helpful to have an official ^report to show that there is a substantial difference between asbestosis and silicosis; and by the same token it would be troublesome if an official report should appear from which the conclusion might be drawn that there is very little if any difference between the two diseases. Mr. Vandiver Brown 11311 official report should appear from which the conclusion might be drawn there is very little if any difference between the two diseases. as No. 2. I understand that the statement/to the cardiac enlargement is correct from a scientific standpoint, and I do not see how we can consistently object to it. that No. 3. I agree that the word "preliminary" is superfluous. No. 4. O. I. No. 5. This reads the same as on page 21 of the Report of 1931 and, hence, it may be a little late to object. However, I point out that as No. 3 now reads the inference might be drawn that asbestosis does add to the mortality of tuberculosis cases. But that inference does not seem to be justified from this study. I am wondering if it would be a more accurate scientific statement if there were omitted from No. 5 the last three words, to-wit "other than tuberculosis". No. 6. This is the same as set forth on page 21 of Report of 1931, with the exception that the Report of 1931 at the end of the sentence has the words "than free silica (3102)" and the galley proof has the words "than granite dust" . Hear again it may be a little late to criticize the statement, but I do not like the suggestion that there is a possiblility that asbestosis may cause pneumoconiosis more readily than granite dust. The reason I object is that many cases of silicosis are supposed to originate in granite dust and this statement as it now reads suggests that a possibility that a pneumoconiosis may arise more readily from asbhestos, than granite dust. I think we should, if possible, eliminate all that part of corelosion No. 6 following the semi-colon after the words "of air" in line 3 of the conclusion. No. 7. This is the same as in the Report of 1931. To comment. (6) Gal. 14 and 15 subtitle "Recommendations". In my copy of the Report of 1931 I have a pencil memo, as to recommendation No. 4 to insert the word "possible" before the word "effects" so as to have it read "as well as studies on the possible effects of asbestosis on the heart and circulation". I do not think the point is of much importance, but I call attention to it so that it is not overlooked. I agree with the other suggestions in your letter to Dr. Lanza of December 10th. very truly yours, GMH/HF Re-typed 2/14/95 B rid g ep o rt, Cana Jan. 2, 1935. Ur. Vandiver Bronn, A ttorney, Johna-Uanv ilie Corporation, New Xork C ity . Dear Mr. Brom i Thank you f o r your l e t t e r o f Dec. 24. Both Ur. Sirapaon end o y s e lf f e e l q u ite ' < safe In leaving the approval o f the report in your hands. I do th in k t h a t Hr. Uobart made soae e x c e lle n t suggestiona in h is l e t t e r of Dec. 15, and hope th a t Dr. Lanca v i l i give a l o t of consideration to the cocaents. I ta k e i t f o r granted th a t when t h i s a rtic le coaes o ff the p ress, the M etropolitan Insurance Coapsny '171 see t h a t you g e t copies o f i t , i n which event, we c e r ta in ly would l ik e one f o r our f i l e s . lo u rs veiy tru ly , UFJ-0 Secretary. r ^p=l . PUBLIC HEALTH REPORTS * JA2H7ASX 4, 1323 0.1 EFFECTS OP THE INHALATION OF ASBESTOS DUST ON THE LUNGS OP ASBESTOS W0BKE2S A Trwdmlssr7 Stady By Al J. Latia, A tndaai tid ie d Director, VTtttUM J. ilc C u rm a . A uietaU M eiiad D inner, tad J. WLUjlai Fcxarxu, C u m ;!, Xetrepeiila* Life ' tneamuM Co. ......... Efraqojjdiocc la 1929thobretropolitanLifoInsur4ance Co. vas approachedby n&rinU representingtheasbestosindustryintheUnitedSlates, who vara desirous of ascertaining whether asbestea dust was an oecupa- tional hazard ia their establishments and, if so, what eras tha natura of this hazard and what should ba 'done to present or control it. About this time sortirai articles had appeared in English medical journalsdescribing&pneumoconiosisduetoasbestosdust. Ululain oneortwoisolatedmsterxes the'occur:cneeof this typeofpneumo coniosishadbeendescribedin'Americanjournals, thoindustryitself appeared to be quite uninformed of tH5 easteses of any such occupational disease. ' Tlia hazard of silica drat, with special reference to tha lungs, has long been appreciated, end a great deal of study and research has been applied to the problem(in tha metal mining and certain other industries) in Great Britain, the United States, tha British Do minions, and in other countries. Tha- natura of the efeemof silica dust espreased in tho term ''siliec3is,,, with tha resultant entraor- dinary predispcsirioc to puimonsry tuberculosis, is veil known. Theso ejects hare seen associated with the inhalation of dust con taining free silica is Tarring amounts. The enects upon the pul- -raonorT tissue of dusts containing combined silica--sukates--era stiH&ferrilafieldforinrestigiiica, but evidenceisaccumulatingthat certain of thesedusts produce pathological results quite cisunot from true silicosis. namp "ssbestosis" has been applied to the pneumoconiosis caused by asbestos dus and it will be so used in this report. Chem ically, the asbestos of commerce is a hydrated magnesium silicate consisting primarily of silica (combined silica) 44.1 percent, mag nesia 43 percent, and water 12.9 percent, while ferrous iron and aidkel are present in small quantities. This commercial variety of 10133V-a --i Cl) . 01119 i prrreat tha solutioa of soma al the dusts, psrrictilariy any silica whichmight ba present. Tha rmsix^^r was actuated by an electri callydrivenrotarypumpandlb*rats ofairsamplediu measured, by*****ol sresistancetypeoUlowmetertritiianinclinedmonome-' ter for rsecscring thepressure difference. Eachsamplerepresents tbs dust collectediron atohime0/ 100 cubicfeet 0/ air. Tbe electric precipitator is designedupon tba Cottrell precipitator prly-riple used for recovering dusts and fumes commercially, This principle depends on electrifying the dust particles bymaking them pass through an electrostatic field and thus causing then to settle out upon a sheet of celluloid. The electrostatic field is set up by ' meansofatransformeroperatingfromthelightingfineson120rolls, current. Air is drawn through the apparatus by a small rotaryfan, runby&motor, thequantitybeingmeasuredbyaflow meter. Semples of dust brushed from beams and pipe fines sear the ceiling alsowere securedfor rheroml analysis. All samples wereshipped to "the industrial hygiene laboratory of the Metropolitan Co., and the duat counts were coda according to the methods accepted, by ilia UnitedStates Bureauof Mines and the UnitedStates PublicHealth Sendee (1). Particles in siza up to 380 microas in the greatest diameter were counted. " -- Chemical analyses were mods for total (fres and combined) silica according to the acceptedstandard method of Hidebrand (3). Inthefirst plant studied(A) ouiypardries 10micronsandunder insicswerecounted. It hesbeendemonairatedrepeatedlythat no silicapardries esteeding10microns (&micronequrdsone-millionth pert of &materorone-thousandthpart of amafimeter) ingreatest diameter enter the lung dssu ; for this reason, tha larger particles usually ere cot considered when determining dust counts. Inter, as it appeared fromsoma of tha pubiiiLed ardcics (4) (English) that csbestos pardriasmuenlargerinsizewerefoundinlungtissue, it was deeded tocount ail pardries andmake differential counts of all those 10 microns and under.1 Total pardries par cubic foot and tha correspond;a? weight of tha dust in milligrams were obtained. Since no relationship between tha dust couna and tha correspcuding weigiia was found, die weights ora sot includedin the tabulations in this report. Table 1 shows by plants and by departments the auhnun end minimum dust counts in million pardries per cubic AlthoughthecountsinplantAareofprendre 10micronsandunder, "fOf1rrUioagpatrnaanttaafmetaa-ri.drMUtmM0d1u1iSiSsm&rtSdCss?aSirtt!faaiairt*ttaitpmetasr^tawsnt^.1ta3a4iintrSd&at*i<tibttasrrSireaaUetrrrt.snrvawinetaorttovvaatInsJaoCiarrMaml.*laturinssaa.rirmduiAitS(-Ssrasr-, bumqiilu-awitnsneaaaSsOlI.iT3s-auw.tsaiar1lscoaiatbisiaatttSt*eawKtcieansiianpalratfd!a1siimaaUc)M. 3(t!aUIdiasaonhtiaiulrzomra')t m(i) I lia proaaiaCrr tt1 ri 1. > V A J. I S- z ip t i'c ? :' "s^,.1i,v>.?r!`- r~*~' ?'----U--'*'*-.'*%*,'AWW tad ia the other planta an for oil particles, direct comparison la possible, as ia ao sample taken were the number of particles 10 microns andunderless than94 percent of the whale. * , * an'def/frcnImt* ia/diiwaid eaun^USMinWawStexiZiiiwi parti*cU* par a K* foal nm M IM S nm 0 n a to K ntZ JipMlgMrt iTHtri y*m* U ri tU4 a*ar W t( au> 10(Mr 1IPBMM M* ft** ** Ukm tm 3XBC*a urti* 2fs> tM>at lflrr*pant* e a pm COM tara sta *&* wHk Som** *t IXJBM too* ir Kob inai* Ur* MIQfe U r* ttA> MOM MefMT Pi* 93Ttt* O il* P Cadua mdM to** to** ir. to** *r __ _ Si* Ina f f r t r t T tk < m m n t-.... .. )UwK Unit* Mart 1 M-Ul U4H Jm )+- M a 4 1 Jft 2 tM 1UcMai taipmsfc 1 1 i b- i 1 1 1 41 m-uw 4 1 t\U4]4)t;i ^ -hj 1 U i -r s * * ! 39 ai *3 M >MvwU>.< TVnereasthedust inthepreparationroomispracticallyallduoto asbestos, the contrarr is tko ease in the other departments. In the cardie?, spinning1, and wears? rooms asbestos comprises about 25 percent of -the material used. On special jobs the perec3ta?o of 'asbestosmar bohigher, but ingeneral thefiguraquotedUapproxi mately correct, tha other material consisting prisdpaEy of cotton. In theinsulatin?departmentsof plant A, asbestosisbut 5percent of the total material used. In the molded broke-lining and clutch 'dirisioa of plant D, asbestos ecspVisJa about 25 percent of the total material. The aetual exposure to asbestos sa, therefore, is consid erablylessthanUindicatedinthedust countsintable1. cotrarmoms uf thx 7Ujrrs The processes in these pianta were rery cmdar to those In cotton mdlainjsuemL Forillustration, theprocessinthepreparationroom of plans 3 is here detailed as length: Asbestos3receivedinbags. Theseeraemptieduponthefloorand the asbestos is shoveled into pc? mills and run for about 5 minutes morder to crush and open tho fibers. From there die asbestos is shoveled-into tracks anil wheeled tohoppers vidi cither kuriacaui orverticalopeners,similartothesousedintentilemills. Afterpassing through tha opener, the material is discharged iuta trucia. TTkste >"manufacturingmaterial is first run through a garnet mad:inn and A 1 . 5 Je**T< 1S3 dischargedinto trucks, whichore wheeled to tho openan, and tha is fedinto thesein thesamemoaner os is the nowmaterial. After being discharged fromtha opener, tha material is pat onto a vibratingor shakingscreen, where tlialongfibera pickedoff07 a modern hood and blown into a bin to be iued again in textiles. Thashort fibers/ailing;throaghthascreenire eithersoldonsuchor nsed in -'"t-ing an aabeatoa cement. Tha cotton is received in bales, opened, and also ran through Terticr.lopeners. ItIsdischargedintotracks. Thofilledtracksfrom tha vertical and horizontal openers containing eithor tho asbestos fiber, tha cotton, or tho waste material ora taken to separate storage bins. As needed, these rrrr.trrir.ls are weighed and dumped onto the fioor in proportion to the minium desired, and tho resulting mixed materials are then passed through a mining picker. As this nurture isdischargedfromthapicker, it issprayedwithalight mineral oiL Tha material is then taken by a mechanical conveyor to tho sioroga bin in tho card room. Two of these mining pickers discharge onto this conveyor system, while a third machiso is equipped with a suction device whichconveys the material to &storage binin tho cardroom. Thaobjectofthatwosystemsistofacilitatethahandling of two grades of material at the seme time. The third machine is not equipped with an oil spray. Tho object of the oil spray is pri marily to entrap the snail asbestos .fibers and hold themenmeshed in the cotton fiber throughout the processes of carding, spinning, and weaving. Incidentally, it is apparent that it also diminishes the amount of dust. Tha material is saturated with about 4 percent of ad it this point; but by the dme it readies tha looms, tlia oil had diminished to less than 1 percent. 'Whilemineral oil wasusedinthepreparationroomofplant C, it apparentlywasnot asErecous osinplant 5. In plant EToil was not used, nor was there any attempt at humidification or aay system ofdustexhausting. Cordingmachineswerefedbyhand. InplantA there was a humidifying, ventilating, and heating system, whuo plant B depended on natural httmidiiy. In plant Z the carding machines were equipped with a dust-exhaust system, but it was cot escieatiy used. In plant C carding was dona in 2 buildings, 1 of which was equipped with on eir-condidotting system, and in both buildings tho machines had exhaust equipment. Two plants, 3 and C, had arrificai humidity installations in their spinning rooms. In the former the temperature was 76* F.t relative humidity To percent. Onu plant, C, had a humidification systemin tho twisting department and also in the weaving department, where the relariva humidity was 75 percent with a dry-ouib temperature of 6i* F.f as compared with a rciativa humidity of -Wpercent in the weavingroomof plant A. fi--rri.tSB 6 AsidofromplantE, Itwouldappearthat thedosthasardvs sot esessstre exceptintha preparationrooms of plants3 ami C. The dust countsorainteresting, too, whenconsideredinth*light of tbs permissible standard for granito dust, established by tho United States PublicEealthSorrica (7), namely, about 10 millionparticles (10 micronsandunder)percubicfoot. ITowarer,weorenotjustified in assuredegthat becauseavailableinformation,sugrsts that asbes- .tosxs is a milder diseesa clinically than silicosis, tbs threshold of permissible dust counts is higher. Asbestosis appears to be patho logicallydiffermi fromsSicoais, and the experiencewfar does aot warrant an attempt to denea a standard of dustiness for asbestos dust. . bust corrraot. Variousmeasures, suchosoiling, humidification, andlocal exhausts, tended to reduce the dust. Nevertheless, it wns evident Lliat they were only partly successful. If It is expected to control dustiness in these plants, Enel reliance must rrst upon properly constructed evhitiwe equipment. InplantCinonodepartment anexperimentalInstalla tionoresset Up. Inspiteofsomoobviousfaults, tbs equipment,on thebasis ofcomparativedust counts, reduced thedust by30percent cad with further alterations will probably be 73 percent effective. Inthiscasesuchareductionseemedquitesatisfactory. It kneitherpracticable nor economically desirable to install such equipment as willmaimtheairentirelydustfree. Thenormaldefensivemechanism ofthebodytakesesseofafairamount ofatmosphericpollution. It iswhenthabody,isexposedtoonexcessiveamountofdust that this defense mechanism breaks down. Theapplicationofexhaust equipment totextilemachineryinvolves considerable dimculty, especially where the construction of tho plant is such that it is not possible to apply dowu-draft suction to the looms. It is desirable to install exhaust apparatus in any plant on an ex perimental basis Erst, and th check its efficiency by dust counts. This practice wul result in saving a needless expenditure of money. . n r n ic jj. xnAmsamoxs X-rayfilmsweremad*of125persons(103men, ISwomen)wcririr.g in asbestos plants in the United States. All but five of these worn given physical examination. The coses were selected more or less at randomfromamongthosehavingmomthan 3years of employ ment in the industry. It was soon obvious that the early diagnosis I of asbestosis must rest to a largo extent on X-ray pictures of the chest. As in the sariy stages of silicosis, the clinical symptoms of \ !t the asbestos workers were usually Indefinite and inconclusive. The interpretations of these Cos are based on tha readings of ouc com petent roentgenologist, but they have been reviewed by sovcral f' ' r T lM aa>T<.C3 oUica experienced in this field. Tlic dUTereneca of opinion were of &minornature, indthenwnsgeneralagreementastointerpretation. .The films were read conservatively, talcinginto account the physical examination and the age of tho individual, and were classed as powitrre onlywhen there was so major disagreement. - All examiners were guided by their experience in sillcede and other types of pneuXBcconicses. Thefilms.ciassedasnegativeforashestesiawerefurther subdivided into doubtful and negative. Only time can tcil whether the individuals classed as doubtful are progressing toward a definite osbestosis. Particular attention mu focussedon the presence or absence of indications of tuberculosis, and in this respect all the reviewers of the films were in accord. Tilth the unhappyexperience of silicosis in mind, it wss felt that a great deal of ears should ba devoted to ascertaining, if possible, whether or not asbestesis pre disposes to tuberculousinfection. The esses of osbestosis were divided into two rinaves, first stage and second stage. Tin first stage embraces, those who show by X-ray examination, definite lung pathology scSeient in extent to warrant &diagnosis of pneumoconiosis, but who bars no dcunita symptoms. The second-stage eases exhibit xnora extensive lung pathology end also definite symptoms. AHtheseindividuals*wereactivelyengagedinfactorywork, and it wasnotpracticabletomakeanydistinctiononthebasisofworking ability or disability. Had any individuals been found who exhibited extensive pulmonary involvement and Hiarked physical disability or total disability, they would have been classified as third stage, but so such eases were found. Cf the total of 128 X-ray examinations, 4 wero diagnosed os second-degreeosbestosis,83ssfirst degree, 39osdoubtful, and20es negative. There is a definite incrcaaoin the percentage diagnosed as positive in reincon to the years of exposure, os shown in tabic 2. Small numbers makeit impossible todeterminehowfar thofactor ofage enters into this increase. TajIX2.--CiMi/faiwnofcena ij jrarjoferpetico Yac (o p o n a ffW SSSli TQKlU* fiaiUv XUSUMT Dwa^al fetllM Oh u i--it&t iro rftr fctu m l m a l resSrr-J at Stt m la taU M uar. s e t i eli a s n tsoux ais tanita. 1? 3 ft St T } a a 4 17 Jfl ' 1 a 1Blimilrwin acoard. V ihmh at eM tee. a m a 4 3 12 jttt-m i c^affi^dLg-tirS'sa.. *^*-~.~- ^.T i^r^r^.?r..v-v;*rXuo^i-K^-'. r4 ,E 3 8 Of the 64 persona given physical examination and diagnosed aa haringpositiveasbestosis, onlySwarsentirelyfreefromsymptoms, while10out of37withdoubtfal and7out of20with,ergativediag noses were free from symptoms. Dyspnoea and cough were 'the symptoms most complained of, but none of these cases exhibited the urgentorevidenttypeof"shortwind"seenintruesElicosia. Several of those classed as negative stated that they were "short winded" and were so recorded, but too much emphasis should not be placed an statements of subjective symptoms. During the progress of the study, physicians who were practicing in the communities where asbestos workers lived were questioned and stated that they did not -find an unusual amount of tuberculosis runny these workers. The contrast between this state of affairs and that foundin a community with a silicosis hanard is noteworthy. The incidence of tuberculosis (based upou X-ray urns) is givenin .table 3; 40 of the 67examined had less than 13yearsof employ ment in the industry. XjLfltJ Incident* 9/ tusenrdont Ta&n SeubCat Xfptln 7 J M 1 1l - -- a s a T il l we v k dtecfU 3# prelf eulTw a l i e 2<iy tiK!n<L *Table-1 givesinformationostophysical sigmaofchest trouble. Tabu ij-- CXuladirti* fMSn O-MStAti X-x33t- rar&L. n a rrisi *s* *t(Bnt tracM. ' XSatao ss rsnusMijit r.s i -- ---- *T n! ao c *4<c&tMao<toMtoBdvttluiOiXrti /^Htsiu. i At ttsrt 4i i t o r t i to crld tq q lu essto d f i t s -bmwiff. 11 Stott SOCU*4SH4 *<nCAOfStim i ttQ&d HSI JJtoKOfU. 6 TThat sigciucauce, if any, can be attached to die presence of "asbestos- corns" on die hands of workers appears doubtful, as 13 percent of the positives (12 out of 64) end 13 peresat of the others (doubtful, 7out of 37, negative, 2 out of 20) showedsuch cams. Eachroentgenologist whorenewedtheX-raySimscalledattention to the fact that thus aims indicated a very unusual incidence of enlargement of tho.heart. It is probable that this is a comovusatory enlargement due to the additional work put upon die heart in efforts v i i * 9 to pomp blood through tbs fihrosed lungs. It. is possible that not suSdant attentionhasbeta paidto theaffects of thepneumoconioses upon tho heart.. ' ... Manyworkarehodchangedfromona department toanother and fromoneplant toanother dcriagtheir jean 0/ employment in the asbestosindustry. Sinceonlythe amounts 0f dust collectedat the time 0f this surrey in the various departments ora known, then is so tray 01 knotting the average amount 0f dust in the atmosphere inhaled by these people orar the yean of their employment. Conse quently, it isnot possible-tocorrelate individual eases withdnSnita amounts of dpst exposure. catnuncs ctarm Tothrowlight ontherelationshipbetweenoabesiaxhandpulmo nary tuberculosis, an analysis of death claims and total and per manent disability claims was made in regard to companies carrying group insurance and having available figures- There were 2,039Urea involved, with a total exposure of 7,019liicyean. The death claims an so small in number that reliable con clusionscannotbereachedfromanysubdivisionofthefigures. The same is true of the sickness claims under health insurance. The number of claims for respiratorydiseases is highin twoof tha plants studied, but lowfor the others, as compared with the Metropolitan experience of 1927. However, during the latter part ci 1923and the first part of 1929therewasanepidemiccidr.fiucnza. Tho records of one establishment (plant 33) showed that 0 of 3S death claims and 3 of 10 permanent and total disability claims wera Bated a due to pulmonary tuberculosis. This appeared to be an in ordinateamount oi tuberculosisfromthisplant. However, manyof the employe were Negroes, and also tuberculosis claims are gener ally high in this section of the country. Realizing tho difficulty in diagnosing pneumoconiosis and the tendency to confuse it with tuberculosis, these were studied individually. The physicians who had treated the individuals ware Later-dewed, and the hospital and sanatorium records, including availsbio X-ray films, wore cvtfgated, wirathefollowingresults: Dtath1.dAeitrt.yi:p_ist, nos exposed to dust; died of pulmonary and Int2e.stCtnoallorteudbemrcaulleo,siasg.e' 27; wonted in asbestos 1 year and S wmaosntihns;sadnieadtoorfiupmulm10onmaroyntthusb.ercAullososishafodlloawfionguraphleums oWrruhsasgeer-; ma3u.nC.olNoroedevmidaelen,ceagoef3a2s;bwesotorkstesd. inasbestosplant 1 year and 7 months;Cdaiveidtatoiofnpbuolmthonluanrygs;tunboerecvuidloesnicseaohfearsb1esmtoosinst.h 01-U S -T_.-.;-iJ-j?rSer&ga'gtSgSgSgiSSS^!ipsBC3sfgSS*d^ Tg^jggbg>a^&&S^ 10 6 4m.oCnothlos.redHmisalep,haygseic3ia4n;wbeoHrkcevdrssinthaissbewsatossaplcaanste2oyfeaurnscoamnd plicatedtuberculosis. 'Was,notizunatoofhospitalorsanatorium. No Information could bo obtained on the other tuna cases. T o ta l 1 . a nMd apleer,menaonltorJydedisaibniliatsybdesatwosn sp: lant 3 yeas. Hw physician lsitsahteedstchaasethocf`ftiurbsterccaumloesiusndaberohuits2obyseeacrsraatifotnerwaistbheastnosoledmepstlaoby mglaenndtss.tarted. Also-had tuberculosis of tba kidney and cervical (ta2l.esMfoinled,inegmopflooyleddfiinbraosibdestutobserpclualnotsi8smwoitnhthtsu.beHrcilsepbhaycsililciiainn sbpeusttousmb.odNiesowXe-rreayfouanvdaiilnabslpeu;tbuumt.according tophysician, as him3.aMt dailfaf,e1re0nytetiamrse'seamreplnooywmeinnct.linTedwotopbheyfiseivcaiantisnswmhoantrleaasteodt tub4e.rcWulhoiutes,mbaulet,hwasasasrebeessatomsiisn.edat time ofmvcstignriou. His pcyhaynsoicsiiasn;sroepcolurtbsbwinegllonfofiunrgisehrse;dd,ihmuisnkisyhelodokexinpga,ngsiooond;icnocleosrs,annot lcuonuggsh.; XN-oraeyvisdheonwcesofifnetubmeorcttulilnogsa.disPserombianbaltyedathserocoungdhsbtaogths asb5e.sWtoshisit.emale, 13yearsinasbestosplant. Is nowtnsanato rtieunmd.reAansbinestetorseisstinangdcapsue.lmHonisarpyhytsuibeearacnuslotasties;scdaivnittyheinharsigehnt lbuenlige;vesspututubmercluolaodseisdlownigthantutbederactleedbaascbiellsitoasnids. asTbheisstopsatbioenditesis; progressing in a satisfactory manner. It was not possible to locals the other, three cases of total and permanent ciaabflity who had been diagnosed as having pulmonary tuberculosis. On the basis of the information obtained, the deaths in death-claims cases appear to bo due to uncomplicated tuberculosis; three of themware Negroes, who were probably tuberculous at the time their employment in the asbestos plant commenced. Of theS disabilityebiimcases, V-ras uncomplicated tuberculosis and 2 ware uncomplicated asbestosis who were put on disability because of a mistaken diagnosis of tuberculosis. In this same com munity weknowof one deathdue to uncomplicatedasbestosis in an individual withmanyyears' employmentintheindustry.1 coscncstoss 1. Prolongedexposuretoasbestosdustcausedapulmonaryfibrasis of a type dinsrar.t fromsilicosis and demonstrable on X-rayIT.ns: Clinically, from this study, it appears to bo of a typo milder than silicosis. 2. Coses of definite cardiac enlargement were frequently found to be associated with asbestosis. I > < m g) r> - WHS1-1 m 0 L 119 11 3. A predisposition to iuberculosis no to asbestos tat woa cot indicated in this study. 4. As'oestosisoaobservedinthissens ofeaseshod notresultedin meriteddisabilityin007 case.' 3. It ianot knownhowsuch aabestosias& j add tothemortality of pneumonia and sente contcbereuioea pulmonary infections. . 6. Itisnotpracdoableasja t toestablish,standardsfortheasbestos dost content of air. 7..Thaamount ofdust intheair intheasbestosplantsstudiedcan be substantially reduced. xzcouurmnunoKa It is recommended--- LThat theindustryseriouslyface theproblemofsat corural in asbestos plans. 2. That newemployees be examined physically, including2-ray examination of the cheat, and rejected for employment if they show tuberculosis or pneumoconiosis. 3. That employees be examined physically, preferably everyyear, but at least every 2 yearn, tiiia examination to inclsao an X-ray examination`of thecheat. 4. That the industry sponsor studies on known eases of aabestosia, aswell osstudiesoneffectsof asbest&iaonthaheart andcirculation. xcsrom.s3cusrT3 The authors wish to express their smsere thmt-* to ail those who aided in makirg this study possible, especially the omci-ais and em ployees of tha asbestos companies who operated to-the fullest extent; andjnv*everyfacilityforsecuringdata; alsotoDr.Pancaost,oftha UniTeisity of Pennsylvania, for his interest and valuable advice ia interpreting2-ray Sims, and to Dr. F. w. Meriwether, of tha Uuited StatesPublicHealth-Service, surgeoninchargeofthaUnitedStates Bureau of Mines Cooperative Clinic in Picher, Ckhu, whose inter pretation of ail tha 2-ray Sims listed in this report is followed. Ap preciationis alsoexpressedtoDr. W. AimarSmith, andDr. Kenneth Lynch, of Charleston, S. C., for iniormadon and advice, particularly astothepathologyoftabestosis;` toDr.W.W.Wild,0/ Charleston, S. C.; to Dr. Joseph E. Wyatt, of Newark, N. J., and Dr. E. E. Fellows, of New"Font, for assisting in interpreting 2-my dims; to Dr. Paul 0. Saoka, of Lancaster, Pa.; to Dr. IL H. Stevenson, of Danville, Quebec, Canada; end to Dr. L. U. Gardner andMr. Dotuild H. Cummings, of the Saranac Laboratory, who have undertaken the study of a pathological effects of the inhibition of asbestos dust -v.**-"~\~C,t7n<jr~Sr>S?*:r^i.4.wp~11. :"--li.-iite-ia*sr c r ' ;I i \ JoorrVtSS 12 through miniai esperimaatation, with tha aid of a groat rote the Metropolitan Lifa loaurimca Co. nxrmrscss Greeaburr, Lxormrd, sad 21oomi*lii, J. X: T ie Im pA& t duai m p lh i ap paratus u tm d by the Usulad Slates pablic Health Serries. -*ib. Health O lUfL, taL <7, eo. 12, Mat. IS, 1032. Reprint no. 1323. Drialcar, Philip, sad Thnmson,'Rol>rt IL ; DoUrminatlea of n a p e ids by aUet=atla<-e=meat yraepitatow. Jour. lad . E y j^ raL VH, eo. S, Zaza 1923. (3) Tlillrhnndi TT. ? - T ia ansiysi of Heat and earhonata raelo. BulL 123, Coltad States Geological Surrey, Waxhinctoo, D. C. WCook, V7. H r PnlciORBry^sbestows. Brit. Mod. Jour.. Dee. 2, 1927. WGreen. H r A. phofaanlgioga tplde seethed far tha deiersnitatlea of jortlda sfm of paint and lubber plgaanta. Jour. r n o kiln laad tats, 1921, pp. 192, (07. () irhlppU . G. C t Vital rtaHstiea. John Wiley and Sons, Iferw Y ork,'1323, P--UL (7) Husad , Ju IL, BritU a, R. IL, Thorsproa, L. EL, sad BloonfirM, J . Xr Tha health of nrerkers tn dcsty trades. IL Hsposurn ta riUcnoua dost (c~mit Industry). Pah. H aslth BulL Ho. 137. 1323. EN D EM IC T7PH TJ3 D i ALABAM A 3y X H. Bsxoa, M. D,, J u n G. U cA arcrx, ?h. D-, and D. G. "Cun, IL C., D. ? . XL, diooeaio Slats DtpcrcrunX 0/ HtxdLK, iiom ^om tr;, Ala. LETTHOOCCnOh* In&preliminaryreport madsinJenaofthisrear beforethaCon ference 0/ State and Protindal Health Authorities, bud In Wash ington, ths authors iserased tho epidemiological aspects of endemic typhus os It occurs in southern United States. In that report it was noted that there had been a rapid increase in this disease in certain Southern States, as is shown in taLle 1. That other countries Ha-re experienced a similar rise in inddencsTs evidenced by tho figures in table 2. The disrincrioa feotween epidemic typhus and the endemic typhus of this country-arts fast recognisedin IS9SbyBrilL He (1) found in the United Static a type of fever which, resembling typhoid, pire anegativeWidalreaction. Infurtherstudieshe(2,3)demonstrated its similarity to typhus, Hat showed that it was milder in character andlesseentagious,onlyonecaseis arulebeingfoundinahousehold. Alsohereportedthatitres mostprevalentduringthafalloftheyear instead of lots winter or spring. In 1912 Anderson and Goidbergcr (4) proved that 3riiTs diwaso was bnmunologiccily identical with Mexican typhus, or taharrHilo. Naturally this led to die belief diet it was louse boms. t*pHtxauflr*. is* `oSmsatT wcCna t* is i s u m a rebiia U*ltS xuaeuiao. Cilii. 0ii2i ASBESTOSIS--LANZA M't-EnA,.1,M; A19J6 tumy tir still in its infancy. Postoperative observations may be cibnged as the survival period increases, which, if it does, will aster the surgical indications and the selection of cases. Close cooperation between laboratory investigators, clinicians and meieosurgcons is imperative in order to make the best selection of cases for surgery and to evaluate accurately the results; obtained, whether they arc failures or successes. ASBESTOSIS A. J. LANZA, M.D. Assistant Medical Director, Metropolitan Life Insurance Company NEW YORK Astestosis is a pneumoconiosis caused by the inhala tion roll asbestos dust. It is distinct from silicosis in its patteaftogy and clinically. Whether asbcslosis will remain a cfistiiarct form of pulmonary dust disease or will prove to t e of a type common to a number of dusts remains t o t e seen. So far, it is the only pneumoconiosis, other thasn silicosis, that has received any considerable amount of sSatdy from pathologists, clinicians and industrial hygwrrists. Whereas silicosis has been recognized for many centssrfer, asbestosis is a newcomer. Asbestos (Canadian) i s se hydrated magnesium silicate containing no free sSESct but about 44 per cent of combined silica, 43 per ceniS magnesium, nearly 13 per cent of water, and traces nf iron and nickel. While asbestos was known to the. araefents, the fabricating of asbestos on a large scale is comparatively new ; it received a tremendous impetus fmorani its use in connection with automobiles and as an insulating material and a heat resistant for a great variety of mechanical purposes. While Hoffman*12 called attention to the possible hatrmfulness of asbestos dust in 1918, it was not until February 1927 that asbestosis was, so to speak, officially recognized in this country by the filing of a disability claim for workmen's compensation in Massachusetts. The claimant was a foreman in the weaving department of an asbestos plant, and the claim was upheld by the Massachusetts Industrial Accident Board. This was twenty-seven years after the first fatal case was reported in England by Dr. Montague Murray. In 1910 and again in 1934 a fatal case was reported in England, and in 1928 the British Factory Department conducted an investigation and enacted laws for the protection and compensation of the worker against this hazard. The whole subject in England has been summarized by Merewether.* At the present time, as nearly as can be estimated, there are about 12,000 individuals employed in the chief asbestos plants in the United States, of whom 10,000 might be exposed to asbestos dust. In 1927 a fatal case of uncomplicated asbestosis was reported to the Medical Society of South Carolina.3 md since then, including this case, there have been deven fatal cases reported in the United States, eight mcomplicated and three complicated by tuberculosis. These reports, together with the fact that asbestosis igured in the extraordinary occupational disease litiga;on that has spread over this country, resulted in both iboratory and field studies of this new hazard. Gard Read before the Section on Preventive and Industrial Medicine and tblic Health at the Eighty-Sixth Annual Session of the American edteal Association, Atlantic City, N, J., June 13, 1935. 1. Hoffman, F. L..* Mortality from Respiratory Diseases in Dusty ades, Hull. 23!, U. S. Department of Labor, June 1918. 2. Merewether, E. R. A.: A Memorandum on Asbestosis, Tubercle j 69 (Nov.), 109 (Dec.) 1933; 15* 152 (Jan.) 1934. 3. Lynch, K. M,, and Smith, \V. A .: Pulmonary Asbestosis, Am. Rev. here. 2 3 : 643 (June) 1931. ner and Cummings * at Saranac Lake, N. Y., cotu_ menced animal experimentation with asbestos in 1928 and reported their observations in 1931. These two authorities in the United States and Gloync in England have described the pathology. While silicosis is prcdominantly parenchymatous, asbestosis is mainly inter- stitial; nor is asbestosis characterized by the nodular formation so distinctive of silicosis. A search of all the death records on file in the Metro politan Life Insurance Company revealed that asbestosis had been given as a cause or contributing cause of death in only nineteen cases. The first case noted was in 1924, there were two iirl927, one occurred in 193]> and the rest have occurred since 1933. The diagnosis was supported by autopsy in only six. In one of the six the primary cause of death was carcinoma, in another glioma of the brain, and in another pulintmarv tuberculosis. In the other three asbestosis was given as the primary cause, with cardiac failure as the contribut ing cause. Some of these cases were reported in the literature. Asbestosis complicated by heart disease was given as the cause of death in seven cases. There were no autopsies in these seven and pulmonary tuhcreulosL was diagnosed in several by the attending physician, so perhaps too much weight cannot he given to tin certificates. Diabetes and pulmonary tuberculosis were also nun. tioned in the remaining six cases, in which there wen no autopsies. All nineteen patients were males and v.itii one exception all were white. In our studies of asbestos mines and fnbricatiiw plants," the clinical picture of asbestosis was mi: than that of silicosis. To be sure, the individual pa'.a; i with marked asbestosis will greatly resemble the T- vitlual with silicosis. There is the same dyspnv:. :i exertion, the same dry cough, and the more m i- indefinite physical signs elicited by the stethoscope. I V patient with asbestosis is apt to have clubbed line; not usually seen in silicosis--and he is apt to H i faced and even show a slight cyanosis, while the -ii;- w patient is apt to he fairly robust looking. Of com "in each instance I refer to patients whose disease i- complicated by infection. We did not find in communities in which a-L was mined or fabricated the familiar picture of ' i bility aud tuberculous infection so characteristic of i ! rock mining communities. Our observations wen- r e ported by the statements of physicians practicim ..i these communities. All the patients with asbestosis ' .t we detected were, with one exception, working ste.: ':o at their trades. In only one case did we find cvi<i< of active tuberculosis aud that diagnosis was based <y on the roentgen appearance. Several showed ho iL1 tuberculosis. Gardner and Cummings in their veicalled attention to the difference between the actin' >;' asbestos dust and silica dust in relation to tulx-c-'. Infection in experimental animals, and their nhsc" tiotis tend to hear out our clinical study. In all, our clinical data are based on 126 phy-iml examinations of asbestos workers, all of whom had mote than three years' exposure and who were seleeied at random. Sixty-three of these presented a roentuen appearance which we thought indicated a pneumoc*- 4. Gardner, L. U ,, and Cummings, D. E.; Studies on Pneumonokoniosis: VI. Inhalation of Asbestos Dust: Its EttVct 1'rimnry Tuberculous Infection, J. Imlust. Ilyg. 1 3 :6 5 (Feb.) 5. Gloytie, S. R.: The Morbid Anatomy and Histology of Tubercle 1 4 : 445 (July), 493 (Aug.), 550 (Sept.) 1933. 6. Lnuxn, A. J.; McConnell, W. J., and Feline!. J. \V.: * * the Inhalation of Asbestos Dust on the Lungs of Asbest UVri.''-- Pub. Health Rep. 5 0 : 1 (Jan. 4) 1935. ^Volume 3 jf'osis, br.i |.W e calldent pul grams. T;panadtietnhtisr. | tinuing [addition [Ynent an One i Cjnvestig; Jnenacin Apparei r. ffactoric: mot ava |impressi juade to h the ihe Bril be extre hart in i Slave be< plants. s- bling aAs in Pgram. ! ynterpre- eviti ^studies. of pner lability ; [such as Xto find Etask in Testimatc easier, p in g , w( aJ-*.?.R?rcpde!r.-, Disability : 1934. * 5 ASBESTOSIS--LANZA 369 but the .symptoms were indefinite and inconclusive. \\ e allied these cases first stage. Four presenting evi dent pulmonary symptoms and corroborative roentgeno grams. wc termed second stage. Of these sixty-seven patients, twenty had been exposed more than ten years and thirteen more than fifteen years. We are still con- timiiug mtr asbestos studies and hope to secure additional information on the time clement in develop ment and the tendency and rate of progress, t >ne feature that has impressed us is that the British .-iini -tiuators found asbestosis more severe and more menacing than wc did. This difference may be more apparent than real, but it is possible that the English tarn l ies may be more dusty than ours. There were not available any comparative dust counts, but this imp'.Vi-Mon is based on their reports and on statements made :n myself and mv colleagues by persons familiar with the English conditions. One process, described in the Dritish reports as ``mattress making" and stated to he extremely dusty, does not appear to have a counter part m this country. In both countries, energetic steps have been taken to control the dust hazard in asbestos plain-, so that it is probable that further cases of dis- ahlin; asbestosis will be rare. - in silicosis, the diagnosis centers on the roentgeno gram. However, the whole matter of attempting to intvi |M'et these films and correlate them with the clin ical -deuce, if any. is difficult and elusive. If, in our -tu i we had found a more clear-cut and severe type >>f nimocomosis with marked symptoms and dis- 'ibih:v as well as a distinctive roentgen appearance, 'ltd my colleagues and myself had been accustomed to i'i o in our previous investigations of silicosis, our ta-l ::i attempting to make a positive diagnosis and rsiii 'i'c the extent of the disease would have been ea-u-r. There is no doubt that, especially in the begin ning. \ e were handicapped by endeavoring to evaluate ashe-tosis with a silicosis foot rule. Tiie x-ray appearances are not clear cut or distinctive as in -ilicosis and do not lend themselves to ready grouping into progressive stages.There are less evident pathologic changes in these films and the shadows arc liner, more granular and softer than in silicosis. The asbestosis film gives the impression of ground glass, . and there is no nodulation with the consequent ten dency of the nodules to coalesce and give dense opaque areas in the films. The distribution of the shadows is somewhat different, occupying tho lower third of the 1'ing. except in far advanced cases, when the shadows may occupy the major portion of the lung. Wc noticed frequently the well marked outline of the interlobar septum on the right side. We also noticed that a num ber ot films in cases of asbestosis showed enlarged hearts, and this might be expected when one considers lhat the pathologic process tends to constrict the pul monary blood vessels as they ramify along with the bronchioles.7 ft is possible that the x-ray appearance of asbestosis may not be distinctive of this disease alone but uniform m appearance with pneumoconiosis due to other silicate dusts. Much more investigation and study of roentgen- "granis ,.f industrial workers exposed to all sorts of silicate and other dusts are needed before it will be imssiblc to speak definitely on this, the most important ti* phase of the diagnosis of pneumoconiosis. One thing is certain. The utmost care and patience needed to elicit the occupational history of the ? ' pubrow, J. L., in dtscuscion on McCann, \V. S.; Hurtado, Alberto: v.:. Iv Kolan, and Fray, W. W ,: The Estimation of Functional $- Pulmonary Fibroses, J. A. M. A .*103tB 10 (Sept. IS) patient and to correlate this and the clinical picture with the roentgenogram before a diagnosis of asbes tosis is justified. As noted in relation to other occupa tional health hazards, there is an all too frequent tendency to make a diagnosis of a specific occupational disease because of presumptive or actual exposure with out the corroboration of other essential factors to a correct diagnosis. One is not justified in making a diagnosis of asbestosis any more than of silicosis in the presence of a roentgenogram showing no distinctive pulmonary pathologic changes. Associated with exposure to asbestos dust is the occurrence in the sputum and pulmonary tissues of a peculiar formation known as asbestos bodies. These asbestos bodies have been described by a number of observers and are due apparently to the action of the tissues on the asbestos fiber. Their exact significance is doubtful, but it is commonly agreed at the present time that they are not diagnostic of pulmonary fibrosis and indicate merely that the individual has been exposed to asbestos dust.89 Some observers believe that, when these asbestos bodies appear in the sputum in clumps, they indicate actual disintegration of lung tissue. Dr. M iller0 of the United States Public Health Ser vice describes the technic that he employs in the intraperiloneal injection of finely divided dusts in a state of suspension. Miller defined three types of reaction: absorptive, inert and proliferative. The first is pro duced by relatively harmless or inactive dusts, the sec ond by dusts that might cause pulmonary fibrosis, and the third as the typical reaction of silicosis. Recently Miller 10 described the effects of the injection of three varieties of asbestos; namely, chrysotile, crocidolite and amosite. Chrysotile is Canadian asbestos and, as pre viously stated, is largely magnesium silicate. Crocido lite and amosite contain only a small quantity of magnesium, containing instead iron silicate in approxi mately the same quantity. The three types of asbestos produced the same type of reaction; namely, the one described by this investi gator as inert. He states: We have been assuming that the dusts producing this inert reaction cause pneumoconiosis of the diffuse fibrosis type as distinct from the proliferative reacting dusts which cause nodular fibrosis. This assumption, as you know, lias not been proven by corresponding animal experiments vvitli the same dusts, but results from observation of pathologic material from autopsies. . . . 1 believe that the gross behavior of asbestos in the tissues lias further strengthened the value of our classification of dusts and the intraperitoncal test as a means of determining the harmful dusts by its clinical correlation. Much work remains to be done before asbestosis is spoken of as authoritatively as is silicosis. In the mean time, asbestos plants are being cleaned up and the dust is being controlled. This, together with tiie smaller number of persons employed, implies that there will probably never be the wealth of clinical material that has been available in silicosis. It is by no means certain that asbestosis progresses as does silicosis after with draw al from dust exposure, nor does infection seem to lie as closely and intimately associated with asbestosis as with silicosis. The answer to these and other prob lems resulting from exposure to silicate dusts demands further study both in the field and in the laboratory. Metropolitan Life Insurance Company. 8, Merewcther,* Woml. W, B., and Gloyne, S. tt.i Pulmonary Asbestosis, I-ancet 2 t i3$3 (Dec. 22) !9J4. 9. Miller, J. \V., nml Sayers, U. K.s The Physiological Response of the Peritoneal Tissue to Dusts Introduced as Foreign Bodies, Pub. Health Wrp. 4 0 t BO (Jan. 19) 19.W. 10. Miller, J, W .: Personal communication t * > * Silicosis and Asbestosis BY V A R IO U S A U T H O R S E D IT E D BY A. J . L a n z a , M .D. W SISTANT M KDICAL IMKECTOR, M ETR O PO LITA N LI F t INSURANCE C O M PA N Y ; C H A IRM A N , INDUSTRIAL HY GIEN E CO M M U TEF. O F T H E NEW YORK TUBERCULOSIS AND HEA LTH ASSOCIATION O X FO RD U N IV ER SITY PRESS LONDON* N EW YORK. TO R O N TO ,J2<) SILICOSIS AND ASBESTOSIS esses in which dust control m easures can be readily instituted. As soon as the hazard was realized, in d u stria l firms fabricating asbestos took energetic steps to control the di^st so that it is probable that cases ol: asbestosis will becom e uncom m on. A recent report from the U nited States Public H ealth Service details dust control methods instituted in an asbestos textile plant which illustrates in a striking m anner w hat can be done to alleviate du st.2-5 Asbestosis has not appeared to be as serious a disease in the U nited States as it has in F.ngland, ju d g in g from the various reports from the latter country. Asbestos "mattress making," m entioned in the British reports as a serious hazard, is a process not found in this country. T h e role of infection in asbestosis is not as clearly defined as in silicosis a n d the clinical evidence available indicates that tuberculosis does not have the in tim ate reliTtionship w ith asbestosis th a t is so-conspicuous in silicosis.24 2S E ffects of Silicosis upon t h e Fam ilies o f S ilicotics From the earliest times, w hen silicosis was first described as a disease of miners, the fact that the wife did not contract tuberculosis from the husband was m entioned and the many recent investigations have not upset this general conclusion. Hoirm an 26 staled in 1922, " T h e frequency of pulm onary tu berculosis among imm ediate relatives of granite cutters, but particularly wives, daughters, and m others, is m uch less than, as a m ere m atter of probability, w ould be assum ed to be the case." T h is was borne o u t by th e late r studies of M cFarland 27 and Russell.3* Cummings of the Saranac Laboratory, who investigated this subject in connection with the Pichcr Clinic, com m ented on the fact that, despite the wretched living conditions, and the lack of cleanliness and sanitation in m any hom es of advanced silicotics whose sputum was loaded w ith tu b ercle bacilli, no PUBLIC HEALTH AM ) ECONOMIC ASPECTS 421 adult type tuberculosis was found am ong exposed children up to the age of sixteen. Nevertheless, these various testimonies do not exclude the necessity of treating tubrculo-silicosis as a communicable disease and of m aking follow-up investigations of members of families of advanced or disabled silicotics, to determine the presence of tubercle infection or the desirability of segregat ing contacts from the diseased m em ber of the family. Sound public health procedure should be the rule and reliance should not be placed upon the supposed immunity of the family because the tuberculosis is com plicated by or conse quent upon silicosis. C o n t r o l and P revention of Silicosis T h e control of silicosis is both an engineering and a medical problem , as are so m any other situations that concern the public health. Both the engineer and the physician, with their technicians, have their parts to play. In some instances, the medical phase may predom inate ; in others, the engineering, b u t it is seldom th at they can be separated or be independent of each o ther if a thorough job of prevention is to be done. E ngineering Control T h e developm ent of silicosis is d e p e n d en t upon the dosage of silica and the m atter of avoiding a dangerous quantity m ight be thought simple. T h e lay m ind, familiar with the definiteness of the hazard of carbon m onoxide, and other toxic substances producing acute effects, usually fails to appreciate the inherent difficulties of establishing a threshold limit for a substance pro d u cin g a chronic disease whose development is measured in term s of years rather than hours. fro m tim e to tim e, critical com m ent is directed toward the industrial hygienist by the engineer because the former has failed to inform the latter of the sale or threshold lim it of ill Industrial numi; AND TOXICOLOGY ' u.iir.-t ili I FRANKA. PATTY, Editor Contributors i J. BROZEK L. F. CURTISS E. E. DART W. B. DEICHMANN D. 0 . HAMBLIN I. HARTMANN F. F. HEYROTH F. R. HOLDEN G. W. JONES R. A. KEHOE J. B. LITTLEFIELD C. P. MC CORD F. A. PATTY L. SCHWARTZ " H. SPECHTJ.-.. i. H. STERNER J. F. TREON W. N. W1THERIDGE VOLUME I IN TERSCIEN CE PUBLISHERS,' INC., NEW YORK INTERSCIENCE PUBLISHERS LTD., LONDON DUST IN THE CAUSATION OF OCCUPATIONAL DISEASE 511 of aluminum by physicians for therapeutic or prophylactic purposes, m akes onlym etallic aluminum available. Some investigators, notably Hannon," have reported marked success in the treatment of patients with severe disability. How ever, when purely objective criteria have been used to measure disability the results have been somewhat less striking. Gardner, Dw orski, and Delahant" have suggested that variations in response to aluminum therapy may be due in part to the nature of the dust that has caused the silicosis. They suggest that dust which, is p rim arily free silica m ay react with aluminum more readily than dust which contains high per* centages of iron. The use of aluminum generally in industry for the therapy or prophylaxis of silicosis should be contemplated only with the utmost caution. I. ASBESTOSIS Asbestos is a hydrated magnesium silicate. More than 90 per cent of the raw mineral used in this country and Great B ritia n is produced in the C anad ian chrysotile mines. Asbestos is used in two general types of m anufacturing processes. I t m ay be used either by itself or mixed with other insulating materials Buch as diatom aceous earth for fireproofing, packing, or insulating; or it m ay be com bined w ith cotton and woven as a textile for fireproof and heat-resistant clothing and other substances. Lanza" estimates that there are about 10,000 persons exposed to asbes tos in the United States. Most observers feel that the incidence of asbestosis in. Am erican asbestos workers is quite low. Asbestosis has, however, been reported more / frequently in England and Canada. Lanza, M cConnell, and Fehnel" concluded from their study of asbestosis th at: Prolonged exposure to asbestos dust causes pulmonary fibrosis different from. _ that produced in silicosis and demonstrable by roentgenogram. C lin icatty it appears to be milder than silicosis. Definite cardiac enlargement frequently was found to be associated w ith asbestosis. A predisposition to tuberculosis, due to asbestos dust, was not indicated al though it was not known to what extent asbestosis may add to the m ortality from pneumonia and acute nontubercuious pulmonary infections. S y m p to m s . The onset of asbestosis, as of silicosis, is slow although Bym pton . are apt to be somewhat more marked than in silicosis. In silicosis there m ay be m arked x-ray findings with little com plaint of symptoms, whereas the opposite is likely to be the case in asbestosis. A s in silicosis, dyspnea is the cardinal sym ptom . Anorexia occurs frequently in advanced stages, and cyanosis and d u b b in g of the fingers are apt to appear with greater constancy in asbestosis. P athology. The fibrosis in asbestosis is diffuse and tends to predominate in the basal portions of the lungs in contrast to the generalized nodular fibrosis of silico sis " J. W. G. Hannon, Tram. Can. Im t. Mining Mel^.48, 180 (1944). " L . U. Gardner, M. Dworski, and A. B. Delahant, J. Ind. Hyg. Toxicol^ 26, 211 (1944). " A. J . Lanza, J. Am . Me<L Aajoc., 109,388 (1938). " A. J. Lanza, W. J. McConnell, and J. W. Fehnel, L'-S. Pub. Health ilept^ 30,1 (1933) 512 tim V .U U ) t . UAIt't' with u predominance in tlic upper portions oi the lung, Hrutichiectusis uiid broiiehiolectasis are frequont, especially in the more librous portions. Whereas the prolifera tion of fibrous tissue is caused by chemical action in silica exposure, it is induced by mechanical action in asbestos exposures. Gardner" found that the tiluosis-producing character of asbestos could be almost eliminated lijr grinding the libers so that no particles more than 2 a in length were present. As previously mentioned, asbestos is classified among the inert dusts. Microscopic A natom y. Johnstone'' described the microscopic upponrunce of the lungs somewhat as follows: in the early phases of the disease there is thickening of the alvcolnr septa which results from fibroblastic proliferation. The alveolar spaces contain numerous phagocytes. With progression of the disease fibrosis becdtnes moru marked; the nlvcolnr structure gradually disappears, and in its place there is now dense librous tissue, The few alveoli that remain in the area of fibrosis are lined with low cuhoidal epithelium giving them an almost.glandular appearance. Scattered throughout the lung in both the diseased and healthy parts are spindle-shaped structures described first by McDonald." These bodies nro 20 to 100 n in length and arc bulbous on one or both ends so that they appear dub- or % dumbbell-shaped. They arc brownish in color, do not stum, and give u Prussian-blue reaction for iron. Simson801ms produced, these bodies in guinea pigs by experimental exposure to atmosphere containing asbestos. Lynch" concludes that these "curious bodies" signify exposure to asbestos dust but do not necessarily indicate nsbestosis. X -R a y Exam ination, Tor mi excellent review of roentgcnographic findings in both silicosis and nsbestosis the reader might well refer to Pendergrass.82Character istic differences in the roentgcnographic findings in silicosis and nslicstosia are tubulated below: Aibislosit Silicoiij meni). fibrosis diffuse (film may have ground glass appearance from pleural mvotvu- findings may bo either bilateral or unilateral. Lesions largely in the lower one half or two thirds oi die lung fields. Emphysema in upper portion of lung fields. fibrosis nodular. findings eliar.ieterislieally bilateral. Lesions'predominately in the upper twothirds of (he lung holds. Emphysema in lower portion of lung fields. Control. Prevention (if nsbestosis depends entirely upon preventing exposure to concentrations of dust sufficiently high to produce the characteristic reaction. " L. U. Gardner, 1ml. Med., S, 45 (1940). 11R. T . Johnstone, Occupational Diseases. Saunders, Philadelphia, 1912 " S. McDonald, Bril. Med. J., 2, 1025 (1927). " F. W. Simson, Bril. Med. J., 1,835 (1928). . *' K. M. Lynch, J. Ain. Med. Assoc., 09, 1947 (1930). " E. V. Pendergrass, "Roentgen-Ray Diagnosis in Silicuris urn! A.-I>i-Un.->L," in A. J. Lanza, Silicosis and Asbcslosis. Oxford Univ.' Press, \Vw York, lt'.'iS. L . p vi.';-'' DUST IN THE CAUSATION OK OCCUPATIONAL DISEASE 513 Drccsscn, DulluVulle, EilwiucJs, Millur, and Sayers" have found evidence to indicate th at 5,000,000 particles per cubic foot of air is a satisfactory figure for tho maximum permissible atmospheric concentration of asbestos to which workers may be exposed. Definite permissible standards, however, have not been established. VI; Dust Causing M luhuul Fibrosis or No Fibrosis Gardner" hns pointed out that any known inorganic dust other than free silica and the asbestos silicates may produeo nonspecific dust reactions, as described on page 480. X-ray markings may be found in other conditions such as chronic infection and heart disease. No interference with pulmonary function or disability is produced by dust of.this type and there is no influence on susceptibility to tuberculosis. * ' A. SILICATES M cC ord," from u num ber of Bournes, bun compiled a list of tho commonly used silicates, which is presented hero: " 0/iVin--a magnesium silicate widely present In nil bnslc rocks.. Many VHilctics of lids si one nro known. Calcium silicate--nonexistent In nature, but n common product of industry; may bo found al blast furnaces and in production of cement and hydrated limes. Other 9ilh'ntes of culclum nro known. ' - H'i/fruiiff--a zinc silicate (rare). Sodium ilicale (mein)--tho well-known water-solublo silicate, commonly called water glass. This is widely used in industry, notably as a fdler in soaps. This is the only crystalline silieato of sodium, the others boing amorphous glass, ` ' TnmolHe--a magnesium-calcium silicate. Ael/csloa--tremolite, arlinolite, chrysolite, or amianthus, all of which are essentially mag nesium silicates. , . Jm/er-anotlier form of muguesium:euluium silicate. Crocidolile--"blue usbestos." It is,a sodium Iron silicate. Talc--a hydrated mugnesium silicate with extensivo industrial application. Soapelone--a form of talc. . . Affalile--a variety of talc resembling asbestos, l l is used in the coaling of paper, and as a paper filler. , , Meerechaum---also called sepiolile. It is closely akin to title. , Serpentine--hydrated silicate of magnesium. It is a common building Mono. Si7/iMnifc-^alumiinim-conlaining silicate. The source of many stone tools of the stone ago Topat--t semiprecious.stono of silicuto origin. Chemically ll is an aluminum (luosillcalo. Fuller't earth--a hydrated silica-aluminum compound, associated with furrio oxldo. Kaolin (kaolinilc)--many related silicates of mixed constituency. Clay--hydrated aluminum silicates containing Iron. Titanium, quartz and mica, are likely to be presont in clays. 'MV. C. Drccsscn, J. M, DalldVallc, T. I. Edwards, .1. IV.. Mill, r, amt ll. R. S a y o . U.S. Pub. Health Dull. No. U1 (1933). VC. P. McCord, /inf. Med.. 2, 4 (UM ). til 1 i %