Document O1QYMJZ4vypEb9eGEXZ5mJGZp

FILE NAME: Metropolitan Life (ML) DATE: 1951-1992 DOC#: ML319 DOCUM ENT DESCRIPTION: Dr. Abram s Intimidation Over Diatomaceous Earth Hazards at J-M by M-L & Dr. Lanza \ M e t r o p o l i t a n L i i E^Ln s u r a x c e C o m p a n y H e n r y F,. N o r t h ViCK -I 'li (SIDEM H e a l t h a m i W i^ - a k i ; D i v i s r o x Wir.LiAM P. S h e p a r d , M. I). Tmtill VlCE-PliESUJEX'T :'Ar pAfiF-nr Goaht Head Oi-tht. ooo Stockton StKELT S a x F r a n c i s c o -<> ClA1.1II )IAX1A F ebruary 7 , 1952 V N $ jb ^ A .J. Lanza, M. D. y Chairman I n s titu te o f In d u s tria l Medicine y/. New York U n iv e rs ity -B e lle v u e M edical C enter 477 F i r s t Avenue New York 16, N.Y. Dear Tonyi \ U n fo rtu n a te ly , we s h a ll have to do w ith o u t H a lv e rso n 's s k ille d guidance u n t i l a f t e r th e February 26th m eeting. However, Malcolm M e rrill i s s t i l l Acting D irecto r nd he i& topt only able but perhaps even more d iscern in g than Hal in a s i tu a tio n o f t h i s KinS. I am ding o v er to see him t h i s a fte rn o o n to be su re he i s f u l l y aware o f th e nuances o f th e s i t u a t i o n so t h a t he can keep Abrams in l i n e . I a p p re c ia te your two l e t t e r s o f Fe b ru a ry 5 F o rtu n a te ly , I have one from Carey McCord oh th e o v e rt "crim es" being committed by o f f i c i a l s t a t e h e a lth d ep artm en ts, such as Abrams tr y in g to swallow up th e whole i n d u s t r i a l hygiene f i e l d . W ithout q u o tin g anybody, I* w ill make su re t h a t M e r r ill i s aware o f th e se m a tte rs . ' !* ">' f ' Abrams j u s t tele p h o n ed to say t h a t i f th e in d u s try i n s i s t s , he would be w illin g to do th e survey j o i n t l y w ith th e I n d u s t r i a l Hygiene I n s t i t u t e . I ran a c ^ s S him a t lu n ch a t S ta n fo rd y e ste rd a y and s u b tly p u t a bug in h is e a r t h a t he m ight n o t be a b le to g e t th e f u l l end w illin g c o o p eratio n o f th e in d u s try on h is own. He b lu s te re d a b i t and m aintained th a t i t was h is le g a l p re ro g a tiv e , but ap p aren tly a f t e r th in k in g i t over and ta lk in g w ith MgrjtLll, he changed h is mind. I fe e l ra th e r stro n g ly , a f te r th inking i t over, th a t you w ill have to have Anderson and Smart a t th e February 26th m eeting. T ellefsen o f G reat Lakes Carbon i s l i k e l y to n n v ite them b oth, i f you d o n 't , s in c e th e y a ls o u se t h e i r s e r v ic e s . Abrams has a very c o rd ia l l e t t e r from Mr. Westmont saying th a t th e y w ill be represented a t the meeting. . V By th e tim e I g e t back from n e x t w eek 's t r i p to W ashington, I w ill have fo r you a complete agenda of the proposed m eeting and a complete l i s t o f ju s t what Abrams proposes to do in h is su rv ey . I w ill be a t y o u r com plete d is p o s a l on th e 7 2 5 th . L et us know i f you need h o te l r e s e r v a tio n s . . V S tran g ely enough, th e second and even more damaging a r t i c l e prepared by Goe o f th e "Search" magazine and Nate Hale o f th e C h ro n ic le , has n o t y e t appeared in th e C h ro n ic le . They may be doing i t f o r some n a tio n a l m agazine. / Best regards. Sincerely yours, A 3 W.P. Shepard, M.D. Third V ice-President I 1 I >*7 15, 1951 0 J . La*, K. D. 477 T ir o i At u u s He v Iork 16, N. I . /I Bear Tony: 4^ ^ d t a x * * t ^ " t 0^ ,r s oi * t h * tf* * * . , ' la ad d ition , there\v*o thm p it s r e s e r v a tio n s v h ich VS th tr ip ; eking toaL ^ P'ff * $ 3 4 5 .0 0 f o r or yon i s td-moct $ 1 6 0 7 .0 0 . :. . O r* a t third o f th is fc' Tellefaea rec *.70 v i l l c o te f. * iT 1 1 - . tr .acco cm t 'at4*sa agreed to are on eth ird , and on th i* baai* toair cheek fo r $535.00, as 'copy o f hi* le t t e r o f check and s e t t l i n g th A ** / * S in cerity Tear, J . ? Voodard01 001 i * * 1* ** TiU eJf` l a a ' t S e o 'r Lake Carbon Corporation M Seat la th Street . *':U w fo rk 1 7 , I . T. l^ a p X H ip iT ^ I I ~ *rrv __ rouM a rniHico im u.t.A. RE9UEJT FOR ^' SH PA Y t o A * J. Unr.(i, M. D. 477 F 1r L Avn. New I o i k 1 6 , fi. Y. CHECK Q , LOCATION qiiq ^ DAT* 5-15-51 C H E C K No. 00012104 IN PAYM ENT r o i l ri o r c .' i p i u i m l ndv!..0 ]y o e r / i e c - o f A. J . Urn z, M. D . , i n c on nr c M on ,vi th lnvotii. i, ml i o n o f nlumJnura i n h a l a t i o n progi'W r, t Loroooc, 6 f u l l day.-i Mard 2'j to March 31, 1951, i n c l u t . i v e , p lu o h o t e l or.pan.sen, an t n n l z H on /it L at he d b i l l , d n l c d A p r i l 17, 3 3 f . l ..................................... AMOUNT 1262.00 HOTij: Cic.-.t Lnkr n Carbon C o r p o r a t i o n ' s ein ok No. > 0 3 3 /, to J-H, da tod 5-11-51 und amounting to fc5.75.00, n-p-eVento U v l r * n r r r . ? d - u p o n nlwn? o f Dr. Lanz/ '.s "xj>en-v.i. C O N rlD C N T IA L P L A N K T O N . I r AM V--H O T I O I.C IIO W M IN V O U C M tn P A C O r C H I C K IVOUCMIH^^O, 550? . m . 3/, c o n I ii AC r o n rttHAi.* in v o ic e h o . AMOUNT connccr $1262.10 Arrnoveo C A O H IC n TOTAL $1262.00 MCAcIInIv pr ap ymint. Cl wrk i . lii.vt te*l I t f t i t t . l( till. il) V i. |,, K, m l I. r . , , . n j iilJ tr .) . ||J .In i I tt to t. ' S'/nd io J . P . Uoodard, 7 th f l o o r , ' to be enclosed ti^h l e t t e r of ' trnnomittnl. ' Swsk.._^! lilZ'Kfil ENVIRONMENTAL RESEARCH 59, 23-35 (1992) Some Hidden History of Occupational Medicine H e r b e r t K. A bra m s Department o f Family and Community Medicine, University o f Arizona, Tucson, Arizona 85724 Received May 15, 1992 INTRODUCTION Irving J. Selikoffs research and publications on asbestos-related disease con stitute a landmark in recent medical history. Many investigators contributed to the asbestos story, starting at the turn of the century,, and the. salient features of asbestos diseases were in the literature by the 1940s. But it remained for SelikofFs work, some of it done in collaboration with the trade unions representing the affected workers--a sponsorship not common in occupational medicine--and its prompt and effective publication, to stimulate widespread public interest and the consequent lawsuits which contributed in part to the control of these diseases. Some of the people, and one of the insurance companies involved in the episodes described, made constructive contributions to occupational health in the early part of the century. A. J. Lanza, for example, conducted studies on asbestosis and silicosis and,their relationship to tuberculosis among hard rock miners. In 1949, he became director of the Institute of Industrial Medicine at New York University. Louis Dublin, statistician for the Metropolitan Life Insurance Com pany, contributed substantially to the understanding of silicosis and tuberculosis and the impact of work conditions on health. These facts make the following story all the more poignant. Both asbestos and diatomaceous earth diseases' came to industry's attention in the late 1920s and early 1930s. In the Johns-Manville facilities in Canada and the United States, and in the Raybestos-Manhattan textile manufacturing plants and in other asbestos fabrication industries, damage claims for asbestosis had been increasing. During the same period a study in Lompoc, California, at the Johns- Manville plant, the largest producer of diatomaceous earth (diatomite, or DE) uncovered an epidemic of silicosis and silico-tuberculosis (Legge and Rosen crantz, 1932). Labor complaints (L'Amiantose, 1950) as well as lawsuits com bined to alert the industries to the problems. < So serious were these problems that several of the companies were impelled to subsidize scientific investigations. Johns-Manville, Raybestos-Manhattan, and several other companies joined together to sponsor research on asbestos, and Johns-Manville supported studies on diatomite. In both instances, they called on the Trudeau Foundation Laboratory at Saranac Lake, New York, headed by Dr. Leroy U. Gardner. 1Any statements regarding the diatomaceous earth story which are not referenced are documented in the files of the Bureau of Adult Health, California State Department of Health, copies of which are held by the author. 0013-9351/92 $5.00 Copyright 1992 by Academic Press, Inc. All rights of reproduction in any form reserved. 24 HERBERT K. ABRAMS ASBESTOS Although asbestos had been recognized as a health hazard since the turn of the century, the lung disease had been named asbestosis in 1927 by the English physician W. E. Cooke, and silicosis had been known since antiquity, industry in both cases (i.e., asbestos and diatomite) continued to resist their recognition as compensable occupational diseases long after their own sponsored studies con firmed these diseases both in animal experiments and in human studies. In 1929, Johns-Manville requested the Metropolitan Life Insurance Company (Metlife) to study the asbestos problem and Dr. Anthony J. Lanza, then assistant medical director of Metlife, was assigned the job (Lanza, 1935). What followed was a curious pattern of confirmation of these diseases as workconnected, and " editing" of the findings of their own paid investigators. Dr. Lanza, the principal medical authority for these companies, was aided by the willingness of various scientists to accommadate their findings in favor of indus try. . While the direct economic stake of the asbestos and diatomaceous earth indus tries was obvious, it was at first not clear why Metlife and its leading doctors, Lanza and W. P. Shepard, were so deeply involved in managing the disposition of the research findings and in the interpretation of these health hazards to the industry, the workers, the medical profession, and the general public. Metropolitan Life for some time had carried group life insurance for the em ployees of Johns-Manville and the company also had been granting funds to the Saranac Laboratories. However, it was not until the expos of the diatomaceous earth situation in early 1952 that it was revealed that Metropolitan Life was also a substantial investor in the Johns-Manville Corporation (Moody, 1951). Diato mite had been used by Nobel to make dynamite at the end of the 19th century. Ironically, it proved to be the spark that set off a chain of events leading to the expos of some questionable behavior on the part of certain corporations. Much of the evidence for the above did not come to light until lawsuits resulted in the revelation of hither to confidential records. Let us consider a sample of the evidence in chronological sequence. From October 1929 to January 1931, the Metropolitan Life Insurance Company Industrial Health Service, under Dr. A. J. Lanza, studied asbestos dust condi tions and workers in several plants in the United States. Although completed in January 1931, the study was not published until 4 years later in 1935 (Lanza, 1935). During the interim the Johns-Manville and Raybestos-Manhattan people had the opportunity to persuade Lanza to insert phraseology favorable to the industry. For example, George S. Hobart, an attorney for Johns-Manville, wrote on December 15, 1934, to Vandiver Brown, the top attorney of Johns-Manville, that he did not want Lanza's report to suggest that asbestosis might be assumed to be " similar to silicosis." Brown sent on December 21, 1934, Hobart s editorial suggestions to Lanza with the following comment. I am sure that you understand fully that no one in our organization is suggesting for a moment that you alter by one jot or tittle any scientific facts or inevitable conclusions revealed or justified by your preliminary survey . . . all we ask is that all of the favorable aspects of the SOME HISTORY OF OCCUPATIONAL MEDICINE 25 survey be included and that none of the unfavorable be unintentionally pictured in darker tones than the circumstances justify. I feel confident we can depend upon you . . . to give us this `break' and mine and Mr. Hobart's suggestions are presented in this spirit. Dr. Lanza was obliging, for his conclusions emphasized that " . . . asbestos dust caused a pulmonary fibrosis . . . different from silicosis . . . and of a type milder than silicosis" (Brodeur, 1985). (Some years later, Dr. Hutchinson, a British physician, reported what many already had observed, that " asbestos is the most vicious of the pneumoconioses" (Hutchinson, 1965).) Despite Lanza's care to report as favorably as possible, he reported, of 121 men currently working, 64 or 53% had definite asbestosis and all but 8 had symptoms of dyspnea and cough. Although the willingness to alter his report was significant, the delay of 4 years in publishing his findings added to the unconscionable delay of almost half a century in the general recognition and control of asbestos as a major health hazard. In 1936 several major asbestos companies contracted with Dr. Leroy U. Gard ner of the Saranac Laboratory to conduct studies on asbestos. In his letter of November 10, 1936, to M. F. H. Schluter of Thermoid Rubber, Sumner Simpson, President of Raybestos-Manhattan, writes of a conference with Vandiver Brown, attorney for Johns-Manville, Dr. Gardner, and Drs. Lanza and McConnell of Metropolitan Life. They offer to pay Gardner $5000 per year for a 3-year period. Simpson writes, " the idea of Mr. Brown and myself would be to have four or five . . . asbestos manufacturers take over this study . . . and then we could determine from time to time after the findings are made, whether we wish any publication or not. My own idea is that it would be a good thing to distribute the information among the medical fraternity providing it is of the right type and would not injure our companies" (Metlife, 1991). On November 23, 1936, Dr. Gardner writes to Mr. Brown of Johns-Manville agreeing with the proposal " to proceed with the proposed asbestos experiments" . . . for a sum of $5000 annually for a period of three years. " The Saranac Lab oratory agrees that the results of these studies shall become the property of the contributors and that the manuscripts of any reports shall be submitted for ap proval of the contributors before publication" (Metlife, 1991). On March 23, 1939, the editor of the trade paper Asbestos writes to Simpson " . . . of course we understand that all this information on asbestos is to be kept confidential and that nothing should be published about asbestos in Asbestos at present" (Metlife, 1991). . On May 4, 1939, Simpson writes to Brown his concern that Gardner is " . . . giving some results of the experiments with the asbestos dust to various professional organizations. He (Gardner) is certainly not living up to his agree ment of November 1936. The reports may be so favorable to us that they would cause us no trouble, but they might be just the opposite, which could be very embarrassing." And, on May 10,1940, Brown writes to Simpson about the same concern (Metlife, 1991). ..... * On October 24, 1946, Gardner suddenly died, leaving unpublished manuscripts on his asbestos studies. At this point, Dr. Lanza, then Associate Medical Director for Metropolitan Life, took over the handling of Gardner's findings. In the manu 26 HERBERT K. ABRAMS script " Asbestosis, Reports of Studies by the Saranac Laboratory to the JohnsManville Corporation," dated September 30, 1948, there is a section entitled " Neoplasm" in which appears the statement . . certain observations on this subject were recorded in the outline of the proposed manuscript on Asbestosis submitted by the late Dr. L. U. Gardner in February 1943. In it he called attention to the high incidence of lung cancer among mice inhaling long-fiber asbes tos. . . ." This section has been marked with a large scrawl " OUT" (Metlife, 1991). In the " Outline of Proposed Monograph on Asbestosis-Saranac Laboratory Study Under Grant From Asbestos Association, 1943," Gardner notes under " Part I Human Asbestosis" the caption " Complication of Asbestosis, Cancer of the Lung." Here, Gardner refers to 23 human autopsies and makes this comment on cancer of the lung: " . . . there are now on record 10 cases of lung cancer in asbestos workers. Compared to the total number of autopsies on asbestosis, this incidence is excessive. . . . The evidence is suggestive, but not conclusive that asbestosis may precipitate the development of cancer in susceptible individuals." With respect to his animal experiments, Gardner summarizes, " Thus the inci dence of lung cancer in the long-fiber asbestos mice was over 16 times the average for mice inhaling other dusts for comparable periods. . . ." In addition, the Gardner outline has a " Recommendation for a new standard of safe atmospheric concentration of asbestos dust" in which he states, While there is no official standard, the tentative one of four or five mppcf of air is frequently quoted. . . . This is probably unreliable" (Gardner, 1943). This statement is par ticularly significant in light of the many arguments over the standard which oc curred in later years. . Lanza sent these manuscripts to Dr. Kenneth Lynch of South Carolina with the request that Lynch edit the documents for publication. Lynch was then Dean of the Medical College of South Carolina and was also an authority on asbestosis, having published the first U.S. report on a case of lung cancer with asbestosis in 1935 (Lynch, 1935). Lynch reviewed the material and recommended that it be published as is. Lynch wrote Lanza on June 30, 1947, " . . . the partially com pleted manuscript which Gardner left could properly be published as a final report upon the experimental program which . . . had been completed. Lynch said the manuscript " . . . is worthy as it stands." Lynch repeated his advice to Lanza in a letter, August 7, 1947: " I still believe Gardner's material is publishable as it stands . . ." (Metlife, 1991). When A. J. Vorwald succeeded Gardner as head of the Saranac Laboratory, he then took up the matter of editing with Lynch. Lynch repeated his recommenda tion that the material be published as written; however, Vorwald, apparently with Lanza's concurrence (or possibly his direction, since Lanza is copied in all this correspondence), insisted that the material had to be edited before publication. On October 12,1948, Thomas Durkan, Assistant Director of Saranac, sent J. P. Woodard of Johns-Manville " copies of our experimental studies with asbes tos____The report is . . . fairly complete . . . with the exception of a minor section devoted to lung cancer. . . . " ... ..... Vandiver Brown, General Attorney of Johns-Manville, is quite explicit in his SOME HISTORY OF OCCUPATIONAL MEDICINE 27 memo of October 22,1948, saying, . I suggest eliminating reference to tumors and also to pneumonia" (Gardner had also reported excessive incidence of pneu monia in his experimental animals). On October 27, 1948, Brown transmitted Gardner's report to eight companies, American Brake Block, Gatke, Keasby and Mattison, Raybestos-Manhattan, Russel Manufacturing, Thermoid, Union Asbestos, and U.S. Gypsum, " with the request that you treat it with the utmost confidence. . . . It is obviously undesir able that the report in its present form receive any distribution or publicity outside a limited number of people in our respective organizations" (Metlife, 1991). And, on November 30, 1948, J. P. Woodward of Johns-Manville in his letter to Thomas L. Gatke, President of the Gatke Corporation writes, " . . . I have dis cussed with Dr. Lanza his taking up with Saranac the matter of revising the report and putting it in the shape we agreed upon. Dr. Lanza has agreed to do this for us." Lanza, on December 14, 1948, writes these instructions to Vorwald " . . .I t was the feeling of the group (the underwriting companies--HKA) that all references to cancer or tumors should be omitted. . . .'' And to make the report even more favorable, Lanza says, " The group felt that there might be included under Con clusions a reference to the non-progressive character of the fibrosis. . . ." Fur ther, instructs Lanza, " Where experimental results indicate that asbestos fibre produces a different action than that caused by free silica, emphasize these points. . . ." As a final order to Vorwald, Lanza says, " Any report on human asbestosis should be separate and not a part of this report." The report entitled " Experimental Studies of Asbestosis" by Vorwald, Durkan, and Pratt was finally published in the AMA Archives o f Industrial Hygiene and Occupational Medicine, January 1951 (Vorwald, 1951). This was 15 years after Gardner agreed to do the studies and 5 years after his death when he left the manuscripts which Dr. Lynch had said should be published without change. It reflected faithfully the changes dictated by the industry via Dr. Lanza. How many lives would have been saved if Gardner's observations including those on lung cancer and asbestos had been reported without censorship? DIATOMACEOUS EARTH Evidently Dr. Vorwald rankled over his experience in having to alter the Gard ner findings at the behest of industry, as evidenced by the following exchange in 1948 between him and J. P. Woodard, Executive of Johns-Manville, concerning the diatomaceous earth studies. On December 22, 1948, Woodard wrote to Vor wald, with a copy to Lanza . . . we assume that the results of the studies will be considered the property of JohnsManville who is advancing the funds, and that we will determine whether, to what extent and in what manner the results should be made public, and that nothing will be published that does not have our approval as a contributor. This is in keeping with the arrangement made in the case of the asbestos study and is, I understand, usual, and for the protection of both Saranac and ourselves. 28 HERBERT K. ABRAMS To which Vorwald replied in January 1949,2 " It is unwise for us to jeopardize our research position which we would do should we acquiesce in having no respon sibility for publication of our findings. Medical research is not conducted on that basis. Rather, it must remain free and in a position to serve in the best interest of human welfare. . . . " Despite this principled stand by Vorwald, it was to be several more years before the Johns-Manville experience with diatomaceous earth was to see the light of day in an American publication, and some two decades late if the science and industry people had handled it responsibly. Following are some of the main events in this episode. The Johns-Manville Corporation acquired the diatomaceous earth (diatomite) mines and mills in California in 1928. They occupy a huge area near Lompoc, Santa Barbara County, and constitute the largest diatomite industry in the world. Diatomite is almost pure silicon dioxide (Si02), usually termed free silica, which is the cause of silicosis. .............................. The earliest contact of public authorities in California with this industry oc curred in 1930 when Drs. R. T. Legge and Esther Rosencrantz, both from the University of California College of Medicine, made a medical study of 118 labor ers at the plant. They did the investigation under the auspices of the Bureau of Tuberculosis of the California State Department of Public Health in response to reports of a high rate of pulmonary tuberculosis in this area. In summary, of 118 men given physical examinations and chest X rays, 81 or 68.5% were found to have silicosis. This study was published in the American Journal o f Public Health (Legge and Rosencrantz, 1932). . For 20 years following this event, nothing further appeared m the American medical literature. During this period, several reports of silicosis in this industry appeared in European journals (Podwyssozki, 1910; Nordman, 1943; Duvoir and Durobert, 1947; Vigliani and Mottura, 1948). Yet there was silence from the world's largest producer and its eminent medical consultants (Abrams, 1954). The first recorded contact of the newly established Bureau of Adult (Industrial) Health of the California State Department of Public Health occurred in October 1940 when Dr. J. P. Russell visited the Lompoc plant and, according to his state ment, was " unable to obtain access to physical examination or x-ray records or to inspect the Lompoc quarries and mill because of the company's blanket require ment that permission to enter the plant must first be obtained from the head offices in New York City." . Dr. Russell wrote this to Dr. Elmer BiAgham, the health officer of San Luis Obispo, in response to an inquiry from Bingham about a patient with silicosis who gave a history of having worked at the Lompoc plant. In addition, Russell stated " both Mr. Westmont (plant superintendent) and Dr. Truax (plant physician) in formed me that to the best of their knowledge, no one employed in this plant has ever developed silicosis." Occasional contact by the California Bureau of Adult Health with Johns- Manville in Lompoc began again in 1944. None of these involved medical studies 2 The exact date was illegible. SOME HISTORY OF OCCUPATIONAL MEDICINE 29 but, in February 1957, dust studies were done. At that time the maximum allow able concentration (MAC) was 5 mppcf. On this study of 16 areas sampled, 4 were within the " safe" limit. The other areas showed counts between 5 and 270 mppcf. In August 1947, a combined medical-engineering study of the industry was proposed to be done by the Bureau of Adult Health with the California Division of Industrial Safety and the U.S. Bureau of Mines. This was never done because according to certain members of the Bureau staff based upon a statement-by Dr. A. J. Lanza, then Associate Medical Director of Metropolitan Life Insurance Company, the company had the problem under control, and Dr. Reginald Smart, a medical consultant to the company, and Dr. W. M. Anderson, the plant physi cian, would soon publish the medical data they had been accumulating for some years (Abrams, 1954). I became Chief of the Bureau of Adult Health in.the summer of 1947. Following this, until my departure in the summer of 1952, I visited with Drs. Smart and Anderson many times and met with Dr. Lanza several times and they repeatedly assured me that they had the problems under control; that Dr. Leroy Gardner, who had died in 1946 and had been head of the Saranac Laboratory in New York, had been investigating the problem under subsidy from the company since 1936, that they (Anderson and Smart) had furnished Gardner with 22 lung specimens taken by autopsy or surgery from Johns-Manville workers; and that they had a file of many more cases. At the very same time, company representatives and Dr. Lanza were telling me that essentially no problem existed. At a meeting I attended in 1947 at the Mark Hopkins Hotel in San Francisco on the occasion of a visit by Dr. Lanza, a Johns-Manville management representative stated flatly that no workmen s com pensation award for diatomaceous earth pneumoconiosis had ever been made by his company. Several months later after the public expos of conditions at the Johns-Manville plant in Lompoc, I found in the California Industrial Accident Commission files 32 workmen's compensation claims against the industry, filed between 1932 and 1950, almost all against Johns-Manville, a few against Great Lakes Carbon Com pany. Of this number, 7 had been given awards and 10 had been settled by " compromise and release." The remainder were in various stages of litigation or inaction (Abrams, 1954). . ... In 1948, Dr. William H. Carnes, a pathologist at Stanford University who had worked on diatomaceous earth cases as a consultant to the industry, gave me carbon copies of two papers prepared for presentation at the AMA Convention in June of 1948. One was entitled " Diatomaceous Earth Pneumoconiosis" by W. H. Carnes, W. Anderson, and R. Smart (1948). The other was " Diatomite Pneumo coniosis Pathologic Aspects" by Carnes (1948). They are scholarly papers de scribing the disease in detail including discussion of 10 lung specimens sent to the Saranac Laboratory for examination by Gardner and, later, Vorwald, after O w ner's death in 1946. These papers were actually listed in the AMA program of that year and abstracts were printed. But the papers were never published. In 1950, Dr Carnes gave me a copy of a letter from Professor Philip Drinker of Harvard, who was then the editor of the Journal o f Industrial Hygiene and Occupational 30 HERBERT K. ABRAMS Medicine, requesting publication of the manuscript by Carnes, Anderson, and Smart. Smart wrote a curt letter of refusal. Carnes, in 1952, after the expos had broken, told Nathan Hale, reporter for the San Francisco Chronicle, that publi cation of the papers had been suppressed by the company. At a meeting in about 1950, in San Francisco with Dr. Lanza and others, we discussed diatomaceous earth. At one point I referred to the condition it causes as silicosis. Dr. Lanza became angry, pounded the table and corrected me, " It is not silicosis, it is diatomaceous earth pneumoconiosis!" (Abrams, 1990). In September 1951, I had a visit from Robert Goe, assistant editor of Search magazine. Search was the monthly publication of the California Tuberculosis and Health Association, the Christmas Seal organization, and the leading voluntary health organization in the state. Goe was interested in writing features about occupational health problems of the lung. My staff and I described many problems in California: silicosis in hard rock miners, asbestosis, and others. He had never before heard of diatomaceous earth and this aroused his interest. We suggested he might visit the Johns-Manville plant in Lompoc and the Great Lakes Carbon Company plant in Southern California. He left our office with the idea of writing a feature about how interesting is the diatom, the one-celled water creature whose skeletal remains make up diatomaceous earth, and about what good work the industry is doing in protecting their workers. Two weeks later Goe phoned me to say he had been to Lompoc and Santa Barbara. At Johns-Manville he was denied access to the plant and told there was no problem. Dr. Busby, Director of Tuberculosis Control for the Santa Barbara Health Department, refused to talk about it in his office. Dr. Caldwell at the Santa Barbara Tuberculosis Sanitorium told him there were five cases of silico-tuberculosis in the sanitorium at that time. A local attorney showed him records of eight claims in which the company had made a settlement. Goe wrote a rather interesting and innocuous article about the diatom and diato maceous earth and quoted mainly from Italian scientists who had published about the disease in European journals. Upon returning to San Francisco, he called Dr. William Shepard, Vice Presi dent of Metropolitan Life Insurance Company and Medical Director for the com pany in the West. Shepard was on the Board of Editors of Search and was a prominent physician in occupational medicine and Goe had heard that Metropol itan Life Insurance Company had once studied the problem. Over the telephone Goe read the draft of his article for Search which he wished to publish in the November 1951 issue. Shepard advised him not to publish it as " it is an unim portant problem . . . there are few people involved . . . why not write about lead poisoning in the storage battery industry?" A few days later during the time of the APHA Convention in San Francisco, Shepard contacted Goe with the admoni tion, " You're not going to publish that, are you?" . . On November 4, 1951, a meeting was held at the offices of the California State Health Department in San Francisco to discuss the article which Goe had written. Attending were Charles E. Smith, Dean, University of California School of Pub lic Health, Berkeley; Drs. Robert Dyar and Frederic Knete tfae State Department; Byron Hubbard, Industrial Hygienist of the Bureau of Adult Health, SOME HISTORY OF OCCUPATIONAL MEDICINE >* and Dr. Abrams, Chief of the Bureau. We all read the article. All agreed it was innocuous and all wondered why Dr. Shepard, who had no obvious connection with Johns-Manville was so concerned that it not be published. Because of his experience in Lompoc and, added to this, the effort of Shepard to persuade him not to publish the article, Goe and his editor, Mary White, became intrigued with the subject. They put aside the first article and investigated further. They probed into the California Industrial Accident Commission (1AC) worker's compensation files in the state building in Los Angeles and dug up evidence of 102 cases of diatomaceous earth pneumoconiosis since the early 1930s; they were impressed with evidence of company suppression of information about the disease and of company efforts to avoid paying compensation. The result was the article which Goe published in the January 1952 issue of Search magazine entitled, " Death by Dust, Pneumoconiosis from Diatomaceous Earth" (Goe, 1952). j . On the day the Search article appeared, Dr. Shepard telephoned me. His voice was angry and excited and he accused Search of " yellow journalism." He spoke of writing a letter of protest and of firing Mr. Kirk, the Executive Director of the California Tuberculosis and Health Association. He stated that the California Tuberculosis and Health Association had no business concerning itself with such subjects and should confine itself to tuberculosis. (Note Shepard's previous sug gestion to Goe that he write about lead poisoning.) Goe later phoned me to say that he learned that Shepard had called the Association and that he and White expected to be fired. Following the Search article, the San Francisco Chronicle, ( The Story ot a Strange and Dangerous Dust" ), Lompoc Record, and other newspapers published stories. The International Chemical Workers Union, the union at Johns-Manville Lompoc, went out on strike and made health protection a major issue. The East Bay Labor Journal, July 4, 1952, headlined its story, " Chemical Workers Face Death by Dust" and said, " The strike . . . now in its 15th week . . . is literally a strike for their lives" (Abrams, 1954). . In a conversation with Dr. Shepard shortly after the story broke, I mentioned to him that Time magazine had called me and was doing a story. Shepard asked me the name of the Time writer. I told him " Ed Rees." The Time article never appeared. Nathan Hale, the San Francisco Chronicle reporter, went to Lompoc. Among other things, he learned: Dr. J. M. Bertero, former director of the Santa Maria Hospital, told him that between 1935 and 1950 there were eight deaths there from diatomaceous earth pneumoconiosis but they were not listed as pneumoconiosis because " . . . we didn't want to be bothered by lawyers." George C. Lockard, Director of Lompoc's Community Hospital, told Hale, " We have never to my knowledge, had such a case. I had not even heard of the disease until the Chronicle's story on Sunday. Furthermore, if I had any infor mation, I would not make it available to you for this reason today: I could not get my family out of town tomorrow." .... In the aftermath of the expos, I had recommended that the Bureau of Adult Health along with management do a thorough study of the problem. I suggested 32 HERBERT K. ABRAMS this also to Shepard since he was officially a Bureau consultant. On February 6, 1952, Shepard told me the company would rather have the Industrial Hygiene Foundation (1HF) of Pittsburgh, Pennsylvania, do the study, as an " impartial agency." It should be noted that the IHF was 100% management supported. Dr. M. Merrill, then Deputy Director of the California State Health Department, objected to this. The 32 workmen's compensation claims for DEP which 1found in the 1AC tiles are a fascinating source of information on how some of the companies fought the claims and how on the one hand company-employed physicians accommodated their professional integrity to the needs of the company but how some personal physicians fought heartbreaking battles to win compensation for their patients. An example taken from the stenographic records of the Referee's Summary follows (in the case of M. Gonzales vs Great Lakes Carbon and Johns-Manville Company Dr. Reginald Smart, for the defendants, testified he first saw the patient's chest x-ray in 1940 and made a diagnosis of diatomaceous earth pneumoconiosis with superimposed tuberculo sis. Dr. Smart stated he had never told patient about his condition. " There was care used not to excite fear or hysteria of the men regarding any danger." Dr. Smart does not discuss condition of employees with them, unless authorized by the company who retains him. The patient was never told his chest disease was due to his work, nor was he advised to get out of dust. . . .3 At a hearing on September 25, 1950, Dr. Smart stated that in 1941 he told representatives of management that the applicant's pneumoconiosis was due to his work. On the basis of his testimony, the lawyer representing Pacific Employ ees Insurance Company raised a protest against the Dicalite Company* for fraud ulent concealment of facts relative to this patient. He stated Dicalite knew of the applicant's condition in 1940, but did not report it to the insurance carrier until 1949. The lawyer representing the National Automobile and Casualty Insurance Company joined in the protest (CA IAC, 1949). . . In another case, Dr. A. B. Steele of Santa Barbara, California, in the claim of his patient E. J. Williams, states in part, These conclusions by Dr. Gardner (of Saranac) established the fact that silicosis . . . could not be acquired in the Johns-Manville plant. . . . From the beginning there has been some thing odd about these conclusions . . . as cases have multiplied . . . 1 came to regard these 3 Dr. Kenneth W. Smith, former medical director of Johns-Manville, had made a study^of"708 men who then worked in the asbestos mills of Johns-Manville in Quebec, Canada, during 1948. All of the X rays except four showed signs of asbestosis. Smith made the following statement: It must be remembered that although these men have the x-ray evidence of asbestosis, they are working today and definitely are not disabled . . . they have not been told of this diagnosis for it is felt that as long as the man feels well, is happy at home and at work, and his physical condition remains good, nothing should be said. When he becomes disabled and sick, then . . . the claim should be ma fibrosis . . . is irreversible and permanent. . . Should the man be told of his condition today. there is a . . . possibility that he would become mentally and physically ill, simply through the knowledge that he has asbestosis (Brodeur, 1985, p. 102). * Dicalite was a product of Great Lakes Carbon Co. SOME HISTORY OF OCCUPATIONAL MEDICINE 33 mistaken conclusions as the Gardner myth. . . . I have become more than ever convinced that silicosis can be acquired from the dust in the Johns-Manville plant at Lompoc. . . . (Mr. Williams was given a compromise and release settlement of $1000 (CA, IAC, 1944).) . The aggressive intervention of Shepard on behalf of the Johns-Manville Cor poration was a source of puzzlement for us at the California State Health Depart ment. Many local authorities came to the defense of the Search magazine article, among them Dr. Charles E. Smith, Dean of the University of California School of Public Health, and Dr. Harold G. Trimble, a prominent chest physician who was on the California Tuberculosis and Health Association Board. On April 1, 1952, shortly after the expos, Robert Goe called me on the phone to read the following item from Moody's " Manual of Investments, Industries, 1951" (Moody, 1951). Term loan outstanding December 31, 1950, five million dollars at 2.7% interest payable 5% annually from July 16, 1952, balance July 16, 1967 issued under twenty-five million dollars credit from Metropolitan Life Insurance Company and Mutual Life Insurance Company of New York to the Johns-Manville Corporation. Remaining twenty million dollars available through December 31, 1951 for borrowing in units of not less than two and one-half million dollars, subject to commitment fee of not less than one-half of one percent of unused portion. In 1953, after I had moved to Chicago and while I was preparing my paper on diatomaceous earth pneumoconiosis for presentation at the annual meeting of the American Public Health Association in New York City on November 10, I re ceived a telephone call from a colleague working at the California State Health Department to say that Dr. Shepard requested me not to present the paper (Abrams, 1954). . Some time later, Harriet Hardy, one of our pioneers in occupational medicine, commented on the basis of similar experiences, . . Knowledge of such behav ior by U.S. industry was a shock to me, who, although exposed to a variety of human weaknesses as a medical student and physician, had not realized the possible evils of the free enterprise system. I learned much at Saranac, confirmed by earlier and later experience with industry and insurance companies and espe cially with legal advisers" (Hardy, 1983). ETHICS Medical ethics has been a focus of concern since antiquity. The Oath of Hip pocrates attributed to the " Father of Medicine" (460-370 bc), in some form, is sworn by medical students as they are given their diplomas. As Pellegrino (1987) points out, " The central and most admirable feature of the oath is the respect it inculcates for the patient. In the oath, the doctor is pledged always to help patients and keep them from harm." This central thought persists in the many modern modifications of the oath. In recent years, certainly in the United States, medical, and more broadly, scientific, ethics have become a major concern to the professions and to the public, so much so that a new career has developed: the medical ethicist. The subject is presented with vigor, if not always with clarity, in the newspapers and 34 HERBERT K. ABRAMS the television shows. Most of the issues which have been publicized revolve around the physician-patient relationship, such as confidentiality, life mainte nance in terminal illnesses, and special problems resulting from AIDS. Possible bias in research because of conflict of interest has led some medical journals to request authors for financial disclosures which may indicate conflict of interest. The stories detailed in this report illustrate the pressure from the sources of money to control the disposition of research discoveries, and the ability, in these instances, of industry to find physicians and other scientists amenable to this pressure. Occupational and environmental medicine probably experiences more of such pressures than do other specialties. Examples of other similar episodes are the osteogenic cancers in radium watch dial workers (Martland, 1929), coal work ers pneumoconiosis (Smith, 1981), and beryllium disease (Hardy, 1965). Henrik Ibsen made the issue the central theme of his famous play " An Enemy of the People" (Ibsen, 1882). ... , The stories also point out another intriguing and growing issue in present-day society: the role of the law and the judicial process in medicine and in science. Although we in medicine are prone to be critical of lawyers and fearful of the entry of the judicial processes into the work of doctors--and in many cases this appre hension is justified--one needs to appreciate another aspect: many of the hitherto concealed facts about the knowledge of asbestos-related disease were uncovered on the initiative of lawyers. Similarly, in communities throughout the country, lawsuits are bringing to light individual and public health hazards that should have been researched and publicized by the scientists (Lilienfeld, 1991). _ The relationships between medicine and the scientific professions, the people in our neighborhoods, the workers in our factories, and the public media are all interdependent. Technicians discover chemicals in our water supply; physicians diagnose diseases. Whether there is a connection or not depends on scientific investigation, but often the impetus for this scientific study remains to be gener ated by the concerns of individuals and communities of people, whether ex pressed in the media, in lawsuits, or in political action. In all of this, questions are raised about the role of the physician, especially the physician or scientists employed or subsidized by industry. To whom does he owe his loyalty? Whose agent is he? What are his responsibilities to his individual patient and to the public health? Two and one-half millenia ago, Hippocrates gave us the guideline primum non nocere, and by extension to the modern context, Pellegrino says, " Ethically responsive doctors will thus find themselves more and more at the intersection of social and individual ethical values, impelled to act responsibly in both spheres" (Pellegrino, 1987). REFERENCES Abrams, H. K. (1954). Diatomaceous earth pneumoconiosis. Am. J. Public Health 44, 592-599. Abrams, H. K. (1990). Historical perspectives in occupational medicine--Diatomaceous earth silico sis. Am. J. Ind. Med. 18, 591-597. ^ Brodeur, P. (1985). " Outrageous Misconduct, the Asbestos Industry on Trial," pp. 113-115. Pan theon, NY. [Correspondence Brown and Lanza; p. 102 re. Smith] SOME HISTORY OF OCCUPATIONAL MEDICINE 35 California Industrial Accident Commission (1944). Claim SF85723, E. J. Williams vs Johns-Manville, California Industrial Accident Commission (1949). Claim LA-107-170. Manuel Gonzales vs Great Lakes Carbon Corporation and Johns-Manville Products Corporation, et al. Carnes, W. H., Smart R., and Anderson R. (1948). " Diatomaceous Earth Pneumoconiosis," prepared for AMA convention, not published. Carnes, W. H. (1948). " Diatomite Pneumoconiosis. II. Pathologic Aspects," prepared for AMA con vention, not published. Duvoir, M., and Derobert, L. (1947). La Pneumoconiose par terre de diatomes etude experimentale et clinique. Ann. Med. Leg. 27, 48-58. . Gardner, L. (1943). Outline of proposed monograph on asbestosis, unpublished; copy obtained from Attorney R. Motley, Charleston, SC. Goe, R. (1952). Death by dust. Search, January, pp. 109-111. Hardy, H. L. (1965). Beryllium poisoning--Lessons in control of man-made disease. N. Engl. J. Med. 273,1188-1199. Hardy, H. L. (1983). " Challenging Man-Made Disease," p. 46. Praeger, New York. Hutchinson, J. E. M., (1965). Introductory lecture, symposium on Asbestosis, Newcastle Med. J. 29(12), 12-16. K, v . Ibsen, H. K. (1882). Enemy of the People, in " 6 Plays by Ibsen. Random, New York. L'Amiantose et Les Mdecins, Le Travail, Montreal, 3 Aot, 1950. Lanza, A. J., et al. (1935). Effects of the inhalation of asbestos dust on the lungs of asbestos workers. Public Health Reports 50, 1. Legge, R. I., and Rosencrantz, E. (1932). Observations and studies on silicosis by diatomaceous silica. Am. J. Public Health, 22(10), 1055-1060. Lilienfeld, D. E. (1991). The silence; The asbestos industry and early occupational cancer re search--A case study. Am. J. Public Health 81(6), 791-800. Lynch, K. M., and Smith, W. A. (1935). Pulmonary asbestosis. iii. Carcinoma of lung in asbesto- silicosis. Am. J. Cancer 24, 56. Martland, H. S. (1929). Occupational poisoning in manufacture of luminous watch dials. J. Am. Med. Assoc. Feb. 9, p. 16. . _ .. Metlife (1991). Plaintiffs exhibit in Scordino v. Metlife, et al. Circuit Court, Jackson County, MS. Note that several of these citations have been used in other litigation and have been referenced in Lilienfeld (1991), Brodeur (1985), and elsewhere. Moody (1951). " Manual of Investments" (1951) Industrials, New York. Nordman, M. (1943). Die Staublunge der Kieselguhr Arbeiter, Virchow Archiv F. Path. Anal. 311, 116-148. Pellegrino, E. D. (1987). In " In Search of the Modern Hippocrates,'1(R. J. Bulger, Ed.), pp. 48-53. Univ. of Iowa Press, Iowa City. Podwyssozki, W. (1910). Beitr. Z. Path. Anat. Allg. Path. 47, 270. Smith, B. E. (1981). Black Lung: The social production of disease. Int. J. Health Serv. 2 (3 ), 343 siy. Vigliani, E. C., and Mottura, G. (1948). Diatomaceous earth silicosis. Br. J. lnd. Med. 5, 148. Vorwald, A. J., et al. (1951). Experimental studies of asbestosis. Arch. lnd. Hyg. Occup. Med. 3, 1. Novss>*r *>> .1 < h\ CONFIDENTIAL Search togaxine A rticle on Dlafwnace j u s Earth * PLAINTIFFS i EXHIBIT About ono month ago the Bureau of Adult Health was v isited by Hr Robert Goe, tho managing editor of Search Magazine. Several am bers of the Bureau s ta ff met with him. Bb was interested in writing sto ries concerning occupational health hazards invoking the lungs, and in exploring the various fie ld s of in te re st in 'C alifom ia Be bocarae Interested in the diAtomaceous earth problem. Our Bureau pointed out th a t we could not release to him any sp ecific information concerning our plant studies, but suggested that he obtain inforoatio n on the subject from the Jotos Manville Company and it s medical people* About two weeks a f te r tide, the w riter received a telephone c a ll from Mr. Goo, who reported the fallowing t He had done a good deal of research into the problem and among other things had read a l l of the available sc ie n tific lite r a tu r e on the subjoct and visited Lompoc, the plant, and various people in the community as w ell as the Santo Barbara County Health Department and Santa Barbara County Tuberculosis Sanitarium. In the course of his reading he discovered - :th a t th e only s c ie n tific a rtic le s available on tho subject were those of the I ta lia n worker s .' He came to. the p lan t a t .Lompoc with the intention of w riting an informational a r tic le ooncernfag diatomaceous lung disease and complimenting the company on i t s e ffo rts to control the dust basard. However, he was n et with h o s tility on the p a rt -of the coqpauy and th e ir advice th a t he not publish the a r t i c l e . He subsstptntly n et wiA a sim ilar reception on the p a rt of various other people, including Dr. ,-lfilltom Shepard, whom he consulted on returning to San Francisco. Dr. Shepard advised him not to w rite the a r tic le , tthlle in Santa Barbara County he v isite d the County Tuberculosis Sanitoriun and was to ld by Dr. Caldwell, the supervisor, th a t there were a t th a t time four cases in the sanitoriun of combined tuberculosis-i l i c osis fron diatoaccaous' ~ earth . He also conferred with a Hr. Grosasaaa, an attorney in Lompoc who handles cases fo r claimants,who showed hin records of 8 cases of pneumoconiosis fron diatoraaceous earth in which Grossnann had effected some type of settlement. Various physicians in the conraunity were uncommunicative on the subject although they apparently knew about i t . Dr. Busby, tho toad of the Tuberculosis Soction of the Santa Barbara County Health Department, would not discuss the subject in h is o ffic e , but la te r v isite d the C alifornia Tuberculosis Association and was generally uncommunicative on the su b ject. At th is tin e Hr. Goe wrote a Btory on the disease, which was e sse n tia lly a stra ig h t description as culled from the I ta lia n lit e r a tu r e . I t was read over the phone to the w riter and appeared to be a stra ig h t factu al statement in agm oent with the known facts about the disease. Dr. Carnes, pathologist a t Stanford H ospital, had done several autopsies of dlatantoceoos earth eases while he was a t Saranac. When f i r s t contacted by Goe be was in terested in a canfsrenos on the subject*. About a week la te r , he seemed no longer in te re ste d . On Sunday, Novecfcer 1; toe w riter received a telephone c a ll from Dr. Dyar saying th a t Dr. C. E. Smith of OJS. School of Public Health was desirous of having a conference w ith'us on the natter of a possible "newspaper scandal" or "newspaper stink" about the diatomaceous earth situ atio n a t Johns Uanville. Dr. Dyar knew nothing else about the situatiom. November 6 , 1 9 5 1 . In the morning I spake crrer the telephone irith Vary Ttfhite, the editor of Search Magaaine, a superior to Mr. Goe. Kiss White sta te d th a t she was with Ur. Ooe on the tr ip to Lccpoc and confirmed tho s ta ry described above. She also stated th a t subsequent to his f i r s t contactw ith Dr. Shspard, Dr. Shepard again contacted Ur. Ooe and suggested to him th a t i t would be b e tte r for him not to publish the a r tic le , apparently the sens a r tic le which had been reed to me over the telephone. She also explained th a t Ur. Goe had mentioned th is n a tte r to Ur. Vilton Silverasua, a science w riter for th e San Francisco Chronicle, and Silverman expressed great in tero st in the subject, saying th a t be had thought of doing a sto ry on i t some tine ago and was now quite in te re ste d . He telephoned Dr. C. E. Smith of U. C. School of Public Health, apparently to v erify some of the facts in th e case and i t was apparently fo r th is reason th a t Dr. Smith knew about i t and called the meeting for la te r th is day. . . On the afternoon of Noverber 6 a conference was held a t Dr. Smith* s o ffic e with Dr. Smith, Drs. Dyar, K riete, Byron Hubbard and the w riter. The a r t i c l e , ih ich was the same one read to me by Ur. Goe over the phone about two weeks before, wan on Dr. Smith's desk with a note attached from Mary 'Shite, on which was w ritten her opinion th at there were some aspects of th is situ atio n which were "odious," implying th a t facta about the situation were being sup- pres sod by certain people and also th a t there was apparently some question . ra ise d as to whether cases of diatooaceous earth pneumoconiosis en title d to workman'8 compensation were being denied th e ir ju s t compensation. This note and th e a r tic le i t s e l f wore read by a l l present and a n agreed th a t the a r tic le was q u ite unobjectionable. Dr. Abrams reviewed the situ atio n , including work of the Bureau w ith the Johns UairwUle p la n t. Dr. X riets raised th e question as to whether the Bureau had done a l l th a t i t Hhould be doing in connection with get tin g improvements a t th e Johns Hanvills p la n t. He si wo wanted to know whether we had informed Division of In d u strial Safety and what th e ir resp o n sib ilities wore. Dr. Abrams pointed out th a t Division of In d u strial Safety had p articipated in much of our past contacts with th e company and had actually requested of our previous studies and wero generally aware of the situation. I t was f e l t th a t i t would be well to inform Division of In d u stria l Safety a t th is tin e of the e n tire situ atio n and prompt then to get in to th e p ictu re. With regard to the question of compensation, i t was pointed out th a t th is n atter is purely the con cern of the In d u strial Accident Commission and th a t we in the Health Department had nothing to do with i t . I t was suggested, a-nri Dr. Smith made a note to inform lies r h ite and Ur Goe, th a t they should take th is matter up with the In d u strial Accident Cocmission. Dr. Smith, in answer to a question from Dr. K riete, disclaimed any p o s s ib ility of coercion on the p a rt of ce rtain people in suppressing tM n a rtic le . Subsequent to th is meeting another telephone conversation was bad with Robert Ooe. He said th a t he thought th a t ha would the a rtic le evar u n til th e ir January issue to give him an opportunity to get more facte in the case, p a rtic u la rly with regard to the In d u stria l Accident Cooniseion aspects. HKA:mr cct Dr. }yur Dr. Kriete Herbert K. Abrams, l!.D W .--.--. *_ ; ' Z. <..' i --^FHB-DIATOM--SEARCITT"' ............. ...... n... . ' ' 1 -- , *i .** ,* .... \ * ... ' zo spontaneous lung collapse, owing to the presence of numerous air bub bles between the connective tissues beneath the pleura in the apex of the lung; (4) absence of a typical nodu.. lar stage as seen in classical simple , ....'S ev eral million years ago in the -... silicosis. Xhe formation of fibrous ^ > ' - tissue set up by inhalation of dia- - Miocene age', the San Rafael Moun- a i ; tain* .emerged from the. Pacific and .* . t ^ tomaceous earth seems more diffuse ... vast bodies of diatomite ooze--made v *- -. . than nodular. This area of diffusion continues to grow after the irritant '"'up of microscopic shell.fish--drained , r *. **. * *1*. ' r* starting it has ceased to act. . . * . f ' r from the slopes .and was 'caught in " '.'.V V. .**. A '' ' The reason for the, difference be the low foothills east *of Point Con-; . tw een the mild silicosis observed ; ception 'in Santa. Barbara"JCounty..- ' Vy* '' s m i l i i i , ! " among workers in the chide diatomite ,These*, deposits to ' set ..the stage, o f'.diatomite..were countless centuries "-: ' i**r.*,r .-and the malignant silicosis observed . later,'-for. great. efforts by men of;,-] among, the workers In refined dia- .'V.'}.v in d u s try -^ a n d fo ra period of disease '*' 7 \ v. '.'<> v.. y death'to m en of Jabor. : ' . * V^ V - the' somewhat harmless crude mate- ' ;-5..v-*''.Technically known, as diatomaceous ; 'Vv..'. earth, SiO--from .80 to 90 per cent ** .Vi ' ' ,*' * ' ^ *' '.'rial ;into microscopic particles'which \\- silica,..the'diatom ite ooze solidified . ; -r V . .***. ; . can: be-inhaled in large quantities ' within a much shorter period of ex 0 / huge grey deposits of unbeliev- - .* . , ' * posure. "' - * ` '. , . ably light material that man one day w ` The problem of-making a diagnosis ' 'found suitable for insulation, dyna' : ' mite*' furnace brick, glass wax, pol - * of silicosis or pneumoconiosis from ishes, filter agents and concrete. ....... "dnieaatrolmy aecveoeruys veiasribthle isstatghereeitfohldas. aIlnl ' Then the diatom demonstrated - the - ' ' the appearances of tuberculosis in the .. price it would exact from the men X-ray. While tuberculosis seems to . . who dug it from the earth. . enjoy the company of diatomaceous v..' -Sim ple classical free silica.dust is : dust, routine laboratory examinations a- "well-known , hazard of most every will determine whether or not it is type of mining, and the varieties of present. -resultant 'silicosis have been vener- . In the early stages it is extremely have'been largely brought under con- V.i: > trol by industry and medicine...' \ . 'i .... pneumoconiosis d e v e lo p in g from . diatomaceous earth',* while clearly not .i~ , `affecting the vast numbers of workers *;V represented in other mining indus- .' .. J-.^tries. has for .thirty or more years ' V ' puzzled the experts. To bring some V... light.in the subject, Search reporters " ; talked to doctors, lawyers, hospitalized / v workers, representatives of public ' health agencies, and borrowed freely from the works of-Vigliani and Mot- tura, two Italian doctors who have : prepared the-m ost complete analysis s available, on their findings in the di atomaceous earth industry in their country. .j* . Crude amorphous diatomite (silicon .. . dioxide) is dug from open pits and *. . carried to cyclones and grinders in ' ' the mill, where it is reduced to pow- * . der. It is then subjected to tempera-' ' 'tures up to 1;250 degrees centigrade, V ' t r a n s f o r m i n g the crude diatomite earth into microcrystalline cristobalite ' ' ---each grain visible only by micro- .. scope.- The refined diatomite is then. ' I-' v V.*-.. t\ */*; , **#< * i ., a l. / ' difficult (without autopsy) to dis tinguish between silicosis .from dia- tomaceous earth and that caused by other dusts. And thirdly there is not enough clinical and autopsy experi-. . ence on record to give the general practitioner or the hospital diagnos tician a source for information as to ' the stage of the disease or the course . it may take. ' . - In the tuberculosis sanatorium at Santa Barbara there are at present - four patients who have silicatuber ... culosis. Their length of exposure to diatomaceous earth dust ranges from one to ten years before silicosis be came evident. They were hospitalized only when tuberculosis became evi d e n t The record does not show that *they had previously been diagnosed ' as silicotic. Another case on record.. ... was exposed for a period of one year and did not show evidence of silicosis ... from diatomaceous earth until diag nosed by Navy doctors .nearly te n ' 'years later. : Since there are not sufficient rec ords available to determine the degree ' to which this type of silicosis is re- sponsible for or contributes to death, i. the .immediate problem' centers on '(1) the-disability the patient inherits J!.\ \ W A 'V* I .- v -.v -'r:.'v l- a s.a result of the disease, and (2) *. securing accelerated public and pri., vate laboratory and medical invcsti- ; gation among the multitudinous in . dustries who use diatomaceous earth ;... .products, i ,.t i Where disability is concerned the. -- J , .. Industrial Accident Commission has heard numerous cases in recent years .. . has-granted a settlement. They '* i',';1*001" *. that injury from silicosis is permanent and without cure, and that ^V -''M ;the disabled.worker'is in for a life- I k GovernoX W arren--I am convinced we .will eMer upon a new- era o f progress in \h e cause of health when /w e make it Ppo\ssible f_o_r__ev_e_r,y one of ' our people toXprotect himself and :his family frdoum economi'c disaster/ ` :..hills: . ` ' I believe it is the responsibility of ..- / t h e states to undertake to heW doc- .! is-.tors,-- hospital and Vhe public they serve in the lutiorX of what up to . i. the present has Veen an insolu- backbreaking medical ."ble problem. " HwSr 0n.v dO S e ibMaUon has been added to the othr thraeutic techniques, being earned on at B eW ii State Hospital ; / * , hope that eyaluation of the results ; w ill add to existing knowledge about this ,acJ 0r?inn the S t\te Department Mi* r specific treatments left -;io r .th e hospitayon an instmltional level i s " " ` the carbon diA ide treatment. Mixed with v 'Cv ' oxy8en carbon dioxide isTinnaled through " In?Jsk- not/for the eff/ct df the carbon ' ' ^u/ to cut down onl the oxygen V * f ; .:-j?take an<y produce a jnild oitygen starva--' " -Don. tvT*he/m os_t__oaft--en-;Vht dva. ncerti theor'y. of*:.*, why thisytreatment works is that some phy- c . uological alteration m the functioning o t i i * ' brj * n takes placef so as to. produce an '**' . ... -- -- treatment used for SeriMsly affected Jjfcychdneuroti :s. In most ` case/ neuroses--th most; comm >n form of ' a 7 ? eU1 disor.t!<p--cari be tr :ated priv-. ' ateiy by psychiatrists or at out-patient clinics by individual psyebothe apy. How- '. iVer,.a few cass require-;hospitalization if ordinary methods of dealing with neurosis ' fUa1ilftifIenrpsfuf ch severe vca.wse.dl*the ind..uc. ing o f. ! either made into bricks or bagged in -. powder form for shipment. Accord-''2 to workers in the mills, the dusty areas are mainly in the bagging proc- css and aide the railroad cars, and, ., o f course, 3n the same car when it is . unloaded at its destination. . The Italian experts agTee that.the . crude diatomite causes at most only : " fid silicosis. Ordinary precautions,- . respirator masks, local exhaust sys- terns, and wetting methods control the dust Adequately. There is, how-, ever, definite indications that the re fin e d raicrocrystalline cristobalite (produced by the heating, or ignition process) creates a hazard not as yet adequately measured in this country. Doctors Vigliani and Mottura of Italy* have observed cases of ad- J.A -M .X . Ja n . 15. j j . . vanced. silicosis caused by inhalation kof diatomite dust among workers "employed in the-manufacture of filter candles. Twenty workers in two fac tories making these candles for more than one year were examined in the two factories, 13 were silicotic; of these, 7 were in an advanced stage and one bad open tuberculosis.* . ^ * r f. ls *<>* divergence of opinion as to whether silica dusts play an active part In the development of tuberculosis. Re - arch projects along Uila line a re b e ln r conducted at the iru d eau Sanatorium Laboratories a t Lake Seraaac. New York. from 1944 to date, 2 workers have died, one^ of silicotuberculosis and ' the other of silicosis; several became incapacitated and were obliged to . leave work; 6 were pensioned. . - According to the Italian doctors, the .most important feature of the 1 .-1.1 4/ignited diatomitae daiult msti asi.lIiIcaoasJist -* a_p_p_e_a__r'A.i;-' V.e' -:;-: .-'.to be:- (1) rapid development and V Notes on V isit to Santa Barbara, December 5, 1951 --Diat^^^ceoii^ Earth L"' ' " r V is it made by: H. K. Abrams, M.D. and V. D. David, H.D. N arrator: H. K. Abrams, H.D. Perspngseen: Dr. Joseph T. Nardo, Health Officer, Santa Barbara County; . Dr. Lauren F. Busby, Director of Tuberculosis Control fo r Santa Barbara City and County Health Departments; Mr. Frank Harader, Executive Secretary, Santa Barbara Countv ^ Tuberculosis Association; ' Dr. David H. Caldwell, Director of Tuberculosis Hospital, Santa Barbara County. Purpose oi v i s i t : To fu rth e r explore the problem of diatomaceous earth pneumo coniosis . Prs ^Nardo and Busby: Ve conferred b rie fly with Dr. Nardo, who was friendly to v ' theiadea of. a .fu rth er.stu d y o f .th is problem to properly, evaluate i t s importance. re ->-err6d us to Dr. "Busby "to work out d e ta ils. I told Dr. Busby th a t recent re-examination of th is problem led us to believe th at i t was more important than we had h ith e rto thought. Ve were thinking'seriously of doing a state-wide, i f not nation-wide, study of i t . Dr. Busby's f i r s t comment was, "I t is about time you realized th a t." Dr. Busby sees only the diatomaceous earth cases th a t haouen to come in to h is X-ray c lin ic s . He keeps a card f i l e and X-ray film f i l e arranged ^7" alphabet according to name of p atien t. Therefore i t i s not possible easily to pick out the cases of pneumoconiosis from the others. However, he has started segregating these cases in h is card f ile but has not progressed very fa r since he has several thousand cards. Moreover, he is working only on the records as f a r back as about 194-6, when he took th is job. His records also contain very l i t t l e or no c lin ic a l or occupational h isto ry . They contain merely the name, age, and other identifying data and the c lin ic a l and X-ray diagnosis. He states th at he keeps the h isto rie s "in h is head." He has no s ta tis tic a l help in arranging k ls i i l e3 and he would welcome assistance. I offered him the p o ssib ility of assigning fo r a lim ited period of time one or two of the Bureau personnel to se t up a proper f ilin g system which would permit cross f ilin g and easier access to th e wealth of information which the records in th is department have accumulated over the years. He would welcome such help and awaits a fu rth e r contact from us. DunJiS the time we spent with him, approximately an hour, he was able to re c a ll the following cases of pneumoconiosis from diatomaceous earth, e n tire ly by memory. A ll of these people were exposed a t the Johns-Manville Plant in Lompoc. 4 \v. V:4 T Max Romero - combined with tuberculosis. Now a t the Santa Barbara jr County Sanatorium. Age 48 in 1946 when diagnosed. r $ Ju lio Becerra - Combined with tuberculosis. Vas a p atien t a t the sanitorium. Toung woman. V. A. Snyder. \j\z Mrs. Mary J Vatkinsr- Combined with tuberculosis. New a t the sanitorium. 1 . PLAINTIFF'S Her exposure was in connection with sewing of bags a t the iohns-Manville Company, Lompoc. Age 43. I / v . EXHIBIT - 2- 'fB Vincent G rossinni.- Combined v ith tuberculosis, Nw a t the sanitorium. ~Tl3 Joe Delira - Combined v ith tuberculosis. Now said to be a tra c to r driver. Present location unknown. Age 37. Howard Downing. ' John Fagaragon. t Donald Ashe \- Worked as a chemist for one year a t Johns-Manville. Is now working with the Sea Bees, U.S. Navy, Port Hueneme, C alifornia. He was diagnosed as an uncomplicated pneumo-- coniosis v ith lin e a r fibrosis and emphysema, but no ' d is a b ility . H us occurred a year or more ago. Young man. V ictor S trad io tto - Now probably living in Lompoc. John C. S ells - Now said to be living in San Diego. Age 81. Frank Winters - Age 54.. An electrician a t the plant fo r 20 years. Now has diatomaceous earth pneumoconiosis. Dr. Anderson told ^ him "to leave" but Hr. Winters sta te s, "This is the only . \> : : s k il l I have. Where'can I go now?" Kelvin McCollum - Now a p atien t a t the Tuberculosis Sanatorium with combined tuberculosis, pneumoconiosis. Was d ia g n o se d i n ' . 194-7 a t the age of 36. He was a foreman a t the Johns- Ffenville Plant in Lompoc. 'T'S Howard Winn.- Combined w ith tuberculosis. Now a t the sanitorium. Charles Batkin --Has been a t the sanitorium. He has a pneumoconiosis . and possibly tuberculosis. .Kenneth l^.m --Age 35 in 1947, when be was diagnosed as rti early case of pneumoconiosis. He may be s t i l l liv in g a t Lompoc. Leland Steffansen - Age 51 in 1950, when diagnosis was made of pneumo coniosis . John Tonelli --Age 35 in 1950, when diagnosed as pneumoconiosis. A. G. Eohlfsen - Age 59 in 1951, when diagnosed as pneumoconiosis. ------------------- - - Name of man not remembered by Dr. Busty. He was la s t living in San Diego and recently died. Dr. Busby understands h is lungs were sent to Saranac recently. The following information was also given by Dr. Busty. The Great Lakes Carbon Corporation, which i s the second la rg e st producer of diatomaceous earth, operates a quarrying p lan t about fiv e miles vest of Loupoc and they are also b uilding a processing plant ju s t outside of Lompoc, which may have already started operations. He sta ted th a t he i s desirous of v isitin g these p lan ts with us and would be glad to drive us out in h is car any time we could come o u t. (In the county, a lso , i s another mining company, the p ro d u c t of -which D r. Busty is not fa m ilia r with, called the Airox Company, located in Casmalia, Santa Barbara County. He a ls o stated th a t he ju s t recen tly picked up a case of s ilic o s is in a man working a t th e water reclamation p ro ject tunnel a t Goleta. The contractors are the HrIverson Company. He sta tes t ha t the man also had a history of hard--rock mining.} 4*. %i - 3- There are riv e doctors practicing in Lompoc. The older ones are: Anderson, Heidges, and Duncan; and the never ones"are Hollovay and Foley.' Dr. T m r the former Johns-Manville Company physician, is s t i l l living in Lonrooc, but not * practicing. * 3 . J)r' ^ash^ stated th a t he has talked with both Dr. Caldwell and Dr. Kunka concerning doing a mass X-ray survey in Santa Barbara County. He is in favor of i t and s ta te s th a t Dr. Caldwell i s very enthusiastic about i t . There are now 30 beds vacant a t the Tuberculosis Sanitorium. Dr. Caldwell feels th a t there is more tuberculosis in the county needing care. Mr. Harader, of the Santa Barbara County Tuberculosis Association, is also very anxious to do such a survey. Haradert Executive Secretary, Santa Barbara County Tubercu lo s is Association. Mr. Harader also believes that the diatomaceous earth situation ?olL d;nt ? r nxious to do a mass X-ray survey of the entire county IP f 1?? ^ ^ y <^ses of tuberculosis but also cases of pneumoconiosis. He states Tub! r ulos5f Association does not own i t s own X-ray equipment but can re n t the,equipment from the Ventura County Association a t the rate of about $50 a day He w ill cooperate with us in any in d u stria l study which we may desire. Ca^dv^~L: Director of the Santa Barbara County Tuberculosis H ospital. Ve had lunch and about three hours with Dr. Caldwell in discussion i f blea\ Caldven to the sanitorium in about 1946. f ^ be had ne7er heard of diatomaceous earth he would most lik e ly th a t cases of t+uVbehreculosis whi h-ihc^hSoScc6uenrre"d itnubpearctiuelnot5sish-av1in1gvpans ehumisocfoi nr siotsiismdpirdession b e tte r with th e ir tuberculosis than uncomplicated cases. However, he has since revised his f i r s t impression and feels that while the tuberculosis lesion o ^ r a y f ilm seems to be modified by the presence of diatomaceous earth pneumoconiosis the T a ?uf se.l s nob aJ proved ^ t i s actually worsened. He proceeded to give us e ta ile d h is to n e s and show us film s of several cases now in the sanitorium. In general., tnese cases nave been characterized by improvement while in the sanitorium but have a ll sooner or la te r returned to the sanitorium with hemoptysis, loss of weight and other symptoms. He now feels th a t the prognosis i s poor. , . ^ in cfe Busby, the records of the Tuberculosis Sanitorium are a lso not in a sta te by which th e pneumoconiosis cases can be nicked out very easily However, he told m o f several cases th a t he has seen since 1946 and the c S r t of th e hosgLtal vas able to .ra d the names of several others th at she could remember since about 1943 However, the h o sp ital was established in about 1930 and there fn d ^ d ^ l help ve " "" " .J * ^ digging out the cases of pSumoconiosis " d vould help any person we could assign. He gave us the folloving neies of patient, SncV aboS^A ^*5 ^ a^ ^ CP P^ : ^^.B neum9C0niosis which could be remembered Joe D elira, James O livera, Juan Valdivia, Floyd r,in sn n Antonio Orso George Hello, Julio Becerra, Melvin McColLunr*, Ed V i l l I L ^ S a r l e ^ ^ i n ' Max Remer*, Howard Vinn*, . Norberto Migdaleno*, Mary J . VatkLns. * * Now a t sanitorium. Williams i s employed as maintenance man. Of th is number, five are a t the present time patients in the sanitorium. Hr. Ed Williams vas diagnosed as uncomplicated pneumoconiosis about four years ago on a pre-employment examination when he applied fo r a job a t the sanitorium as a ja n ito r ia l worker. Because he needed money, he made a compromise and release settlem ent with the Johns-Manville Company fo r $1,000 several years ago. The following four have combined tuberculosis and pneumoconiosis, and th e ir course can be described as one of in te rm itte n t improvement and remission with a gradual down--hi l l course. They are Magdaleno, McCollum, Romero and Vim. Eliminating the duplications in names given by Busty and Caldwell, there are a to ta l of 26 people with diatomaceous earth pneumoconiosis, with or without tuberculosis th a t were given to us by Caldwell and Busby. These cases date only from 1943 or l a t e r . A complete l i s t of these names is attached. This l i s t should be checked with the records of the In d u strial Accident Commission. I t vas Dr. Caldwell's b e lie f th a t Mr. Melvin McCollum had not made a claim and that his expenses a t the h o sp ital were being paid fo r by the Johns-Manville Company. `He did not know d e fin ite ly whether the others had made claims fo r condensation. ' , Mr. Howard. Vinn f i r s t entered the sanitorium in 194.6. He had worked a t the 'Johns-Manville Company i n Lompoc fo r eight years u n til May 1942. He has been to ld nothing by the company concerning h is physical condition, even though they had done 2-rays on him. He has both tuberculosis and pneumoconiosis. Dr. Caldwell showed me the minutes of the meeting of the Santa Barbara County General H osd ial on December 14, 1950. They contained a report of a ta lk Dr. Anderson, the medical d irec to r of Johns-lfenville Company in Lompoc, gave before the society on th e subject of diatomaceous earth pneumoconiosis. The following auotes were taken from these minutes. ` 1. "All powders in th e ir various steps can cause lin e a r lesions. The progressive conglomerate lesions are probably due to cry sta b o lite .and trydim ite, which do not nodulate as in s ilic o s is ." 2 . "Diatomaceous earth pneumoconiosis symptoms are the same as the symptoms of s ilic o s is , the difference being th a t diatomaceous earth pneumoconiosis causes d is a b ility and death, while s ilic o s is causes d isab ility only." 4" 3 . "These p atients (diatomaceous earth) probably are more susceptible to tuberculosis (than those .with ordinary s ilic o s is )." Action: 1 . S ta tis tic a l help to Busby and Caldwell to search out n cases of pneumoconiosis (both ordinary s ilic o s is and diatomaceous earth s ilic o s is ) and s e t up a b e tte r f ilin g system. 2 . Cheek a l l names given by above with I n d u s t r i a l A c c id e n t Comm ission compensation records. 3 . Medical-engineering study of p lan ts of Johns-Manville Company and Great Lakes Carbon Corporation in Lompoc area. 3 MEMORANDUM STATE OF CAUFORNIA DE P A R T M E N T OF PUBLIC H E A L T H * E C j j{ V "& jjj ' U ' r u t H U i r To: . Dr. Herbert I . Abrams ' through Mr. Fred B. Ingres . . From: H r. P a u l E . C aplan Date: December 19, 1950 S3K Subject: Monthly meeting of the Santa Barbara County Hospital Medical Staff On December l^f, 1950, Dr. Pardo, new Health Officer of Santa Barbara County, in v ite d me to the dinner meeting of the above organization. Main sneaker of the meeting was Dr. Valter Anderson, who spoke on Pneumoconiosis produced by diatomaceous earth. After h is talk he showed chest x-ray slid e s of many of the employees of Johns-M anville. * ; 'Im portant`points that he brought u-p were ( l ) lOfl disabling rag p-r co n lo si s have been recorded at Xonrooc within the past 20 years, w^h tR Heaths Many cases o f progressive conglomerate le s io n s have been observed with exposures of 1 to 2 years to the dust. One case was observed after a 7 sontn exposure. (2) The conglomerate lesio n s which are disabling are caused by the processed powders, which change the amorphous s i l i c a to cristo b a lite (6o) and trid yaite (2$ ). The r e la tiv e to x ic ity of these two crystals compared to quartz isJ ciartz 5, tridym ite 8, and c risto b a lite 9. * * ( 3) Intravenous .innoculation o f animals by Gardner with the untreated diatomaceous earth caused fib r o sis and death to the animals. (h) The ty p ica l x-ray pictures of th is pneumoconosis are very d ifferen t from ty p ic a l s i l i c o s i s p ictu res. There i s not the typical nodulation but sometimes a pseudo modulation i s observed. Instead of the a rteria l systems being involved, as in the case o f s i l i c o s i s , pneumoconiosis due to diatomaceous earth involves the venous vascular system. ( 5) Lanza says that the incidence o f T.B. .at Lompoc i s no higher than at Santa Maria (supposedly a comparable community) but Anderson thinks that the r e sid e n ts at Lompoc are more su scep tib le. . I vas unable to ta lk with Dr. Anderson after the meeting, but on the previous day, I had made arrangements with Mr. Legge and Mr. Wilson, of Johns-Kanvill*e to do a sizea b le engineering study there th is February. . PEC/ld 'aul E. Caplan 477 FIRST AVENUE NEW YORK 16, N. Y. Reprinted from A m er ic a n J o u r n a l o f P u b l ic H e a l t h , Voi. 44. No. 5, May, 1954 Copyright by the American Public Health Association, Inc., 1790 Broadway, New York, N. Y. Diatomaceous Earth Pneumoconiosis Some Sociomedical Observations HERBERT K. ABRAMS, M.D., F.A.P.H.A. An occupational disease hasard be came the focus of publicity in the lay press and a strike issue. Sub sequent investigation of workmen's compensation records and other as pects revealed valuable information concerning the disease, the ad ministration o f workmen's compen sation, medical testimony, and re lated factors. Accelerated steps to abate the hasard followed the events mentioned. Suggestions are made to avoid such difficulties in the future. Workers' Union. However, the an nouncement culminates an episode which has deep implications for the public generally and for industry and the medical profession particularly. The story of this little known disease with the formidable name is an interest ing incident in the history of American industrial medicine. The occasion is not appropriate, nor is there adequate space, to attempt to relate it here in any detail. Rather, this report is an inquiry into + In a recent issue of the Chemical Worker,1 official publication of the In ternational Chemical Workers' Union (A F L ), the following news item ap peared: The seven-month long strike of 1CWU, Local -- . . . has finally ended . . . Many gains were won . . . Most significant of all, however, was the union's achievement in gaining recognition of the presence of a health hazard in the plant, in which the product diatomaceous earth is mined, and the final agreement by the com pany to take steps to eliminate the condition. While many workers in the -- plant had contracted pneumoconiosis and while many workers have already died from this dread disease, the company, had, for years, con sistently refused to recognize the existence of this work-connected disease. The main issue in the long dispute between the union and the company was the union's demand for the elimination of this health hazard. They were fighting for a principle and, in fact, for their very lives. . . * This news item probably has been seen by no more than a few thousand members and families of the Chemical * Io this and subsequent quotations tbs author has deleted all identifying names. some of the factors operative in the progress, or lack of progress, of in dustrial health. For example, in this disease, there was a long time lag be tween the first medical publication on the subject and its general recognition as an occupational disease. To be sure, the history of industrial medicine re veals other examples of this: beryllium lung disease has only recently emerged from a somewhat similar evolution and coal workers' pneumoconiosis is at this very moment awaiting general recogni tion, although the facts have been avail able for some time. Downing,2 as recently as 1952, wrote: It is apparent in the study, control, and pre vention of occupational health hazards . . . that the United States is not on a par with other countries. Lack of recognition of the importance of industrial skin cancer stands out in sharp contrast to the unrestricted and wide publicity given this important matter in England, Germany, and Switzerland, where these cancers are notifiable and compensable diseases and information regarding them, therefore, is relatively reliable. The history of industrial medicine here is full of failures to prevent the unnecessary deaths in industry that have occurred, for example, from 592 594 MAY 1954 AMERICAN JOURNAL OF PUBLIC HEALTH For 20 years following this publica was made. Legge 8 reported at that time tion nothing further appeared in the that, United States medical press as recorded in the Cumulative Medical Index. How ever, several European reports on human disease were published * 10' 11 . . a great deal of dust is disseminated in the atmosphere in certain working zones and constantly surrounds the habitations of the workers, as the plant operates night and day and before and after this date some ex perimental work with animals has been reported.1- 14 Since 1933 physicians for the in . . The menace is due to vast clouds of dust which escape and endanger the immediate workers and are disseminated bv `he pre vailing winds the district w; -e the -mployces reside. . . dustry had been collecting and examin ing clinical and pathological material At about the same time, it is reported (at least 22 lung specimens and 100 the T . S. Bureau of Mines made a dust cases;." This material provided con study, but no official information about vincing evidence of the existence of a this investigation could be obtained. disabling occupational lung disease. Mate Health Department records indi \e t , according to Johnstone 15: cate that certain ventilation measures in ifHo. Gardner came to California to study the dia:oi>ic.o""U earth industry, to re view collective X-ray films of the workers, and were recommended to the industry, but no information could be found as to what action was taken. to consult with physic,ans encased in carins for these men. In viewing the films of men wno had worked for years in this material. Gardner wrote later to one of us that "sili. cosis is conspicuous by its absence.". . . In 1940 a county health officer in California inquired of the Industrial Hygiene Service (now the Bureau of Adult Health ! of the State Health De partment concerning a case of suspected It was not until about 1946 that pneumoconiosis in a former employee physicians connected with the industry of the diatomaceous earth industry. began to acknowledge that diatomite The chief of the Industrial Hygiene could cause a disabling and sometimes Service visited the industry in question. fatal disease. In his reply to the health officer, he Reporting writes that he was informed by the plant superintendent and the plant physician that: Under California law employers and physicians are required to report to the State Department of Industrial Re lations cases of occupational injury and disease that cause absence beyond the day of occurrence or require more than first aid medical service. Until Janu ary, 1952, three physicians' reports and no employers' reports had been made (employers' reports were checked back to 1948). To the best of their knowledge no employee in this plant has ever developed silicosis. Dr. -- (then plant physician) stated that preempioyment and annual physical examina tions. including chest roentgenograms are: made on all employees and that none of these men ever showed evidence of pneumoconiosis even after periods of continuous employment as long as twenty year: I was unable to ODtain access to physical examination or X-ray records, or to inspect the -- quarries and mill on October 4, because of the company's blanket requirement that per Governmental Agencies Contact of governmental public health mission to enter the plant must first be ob tained from the head offices in New York City.16 and safety agencies with the industry in California began in about 1930 when the Legge study, previously referred to, Active contacts of the Bureau of Adult Health with the industry began in 1944. These were chiefly for dust studies I II 596 MAY 1954 AMERICAN JOURNAL OF PUBLIC HEALTH The company has also agreed to the forma tion of a joint union-management Health and Safety Committee, thereby giving the union recognition which they have never had be fore.1 Workmen's Compensation The newspaper reporters had, among other things, called attention to the fact that there was information to be found in the workmen's compensation records of the state. The author set out to dig into the records of the California In dustrial Accident Commission and was able to find 32 claims for compensation for alleged diatomite pneumoconiosis which came before the commission be tween 1930 and 1951 inclusive. In the course of this search 26 additional cases not in workmen's compensation files came to light. The work was laborious and the period of the studv covered only a few weeks. Further cases would probably have been found had there been more time available for the work. The study of workmen's compensa tion records was an absorbing ex perience. Space does not permit pre sentation of more than fragments of the material. However, where work men's compensation records are as complete as they are in California-- often containing the exact stenographic reports of hearings, as well as corres pondence and other documents-- these can be a valuable source of information for the guidance of public health pro grams. For example, I quote a few ex cerpts from the letter of a private physician presenting medical testimony for a claimant in the year 1944, who closes his statement with a series of recommendations for the prevention of the pneumoconiosis hazard in the diatomaceous earth industry: 1. That the Bureau of Industrial Hygiene in the State Department of Public Health in vestigate this plant and the dust hazard pre sented therein. -. That the dust hazard of the employees' homes also be simiiariy investigated. (At that tune many of the employees and families lived in company owned houses on the plant premises--HKA). 3. That other cases now available be evaluated with respect to the pulmonary fibrosis of their lungs present. 4. That follow-up of employees who drift away with symptoms of respiratory embarrass ment be made. 5. That authorities stop regarding this matter as a closed issue: namely, '`Silicosis cannot be acquired in this plant." 6. That the nature of the advice given em ployees in whose films fibrosis is demonstrated as in this man's case in the years 1938-39, might reasonably be asked from a preventive medicine point of view.18 So far as I am aware, these recom mendations were buried in the archives of the Industrial Accident Commission until their exhumation following the events in 1952 just described. In the files of another compensation case,20 there is a copy of a letter in the year 1946 from a medical consultant ad dressed to a top official of the industry. The letter contains a statement summar izing findings in the lungs of "six per sons who have been employed in diatomaceous plants in southern Cali fornia for significant periods." The statement declares that ". . . from the practical standpoint of control, it is ap parent that serious dust hazards exist in this industry which demand immediate and vigorous action." It has been contended by some that the "amorphous" or crude form of diatomaceous earth causes no disable ment in contradistinction to the "proc essed" forms. Therefore, it was of in terest to find in the above mentioned document the following comments: One man -- had worked only in the quarry and mines and as a consequence has been exposed to nothing but uncalcined earth. All of the others had mixed exposures to crude and calcined products . . . But if the -- case can be taken as a criterion, prolonged and heavy exposure to crude diatomite results in further extension of such reaction . . . 598 MAY 1954 AMERICAN JOURNAL OF PUBLIC HEALTH which must always be given some considera tion. It is rather gratifying to know that this man can have an exposure over a period of years and the condition is not related to dust inhalation. In this particular instance, we are dealing with a condition which has all the earmarks of tuberculosis. . . . I think we can with certitude rule out the presence of a silicosis. . . Since we have eliminated in our own mind the presence of silicosis, and since the dust, if it were a factor, would cast an X-ray pat tern which would antedate the tuberculosis, we can readily assume that the dust is not responsible for his present incapacity. I have held to the belief for a long period of time that in silico-tuberculosis, the silicosis ante dates the tuberculosis and in the absence of any of these factors, we must assume that the dust did not aggravate or predispose to his condition. Later in the same year, 1951, the same doctor presented testimony for a claimant (employee) for compensation for this pneumoconiosis. At this time his statement was as follows 24: Here is a man who has had a two year ex posure to dust that was in fairly high con centration. As you know, the dust to which he was subjected is diatomaceous earth, and the usual silica content is from 90-92 per cent. This silica is an amorphous form in contradistinction to the crystalline form which is the ordinary offender in producing the disease silicosis. Approximately 12 years ago I stated that this was a cause of death in these cases, and it did produce silicosis. . . . It is very possible that his tuberculosis ex isted for a good many years and may have antedated the exposure to the amorphous silica. . . . Administration of Workmen's Compensation The workmen's compensation study threw light on the administration of workmen's compensation at least in so far as certain types of occupational dis ease are concerned. It will be remem bered that workmen's compensation is the earliest form of social legislation in this country. Its objectives are gen erally agreed to be to provide equitable compensation for workers injured in the course of their work; to take injury suits out of the courts and thereby lighten the burden of litigation upon the employee; to reduce the burden of occupational injury on the general com munity; and indirectly to stimulate pre ventive measures. The findings of this study would in dicate that in all of these respects work men's compensation did not measure up well to its objectives. For example, of the 32 claim records analyzed, at least 26 in the light of our present knowledge were for definite cases of diatomite pneumoconiosis. Yet, only eight of these claimants received full awards according to the record at the time this study was concluded. The average length of litigation until a set tlement was reached was 16 months for the total group, with the shortest two months and the longest 56 months. From the fragmentary data available, it is not possible to assess the entire financial burden on the taxpayer of this industrial disease. The few cases cited in a letter from a county hospital to this author cost the public at least $20,000.25 This figure does not include expendi tures by the Bureau of Vocational Re habilitation and the welfare agencies. One can only guess how much the com munity has paid for the forgotten men of the Legge study in 1930 and the nameless victims, many of them il literate Mexican immigrants, who suc cumbed to the wasting disease in former years. Possibly this limited experience with workmen's compensation is not atypical. In a recent appraisal of the subject, Kossoris concludes with the statement: There is need today for stronger public concern with the inadequacies of workmen's compensation legislation and its administra tion. In spite of the tremendous forward strides in other social and economic areas, our compensation legislation and administra tion, on the whole, lag far behind.26