Document OzMzZmNgjZ0Nj4zZb0MVv9Me1

FILE NAME: Ford (FD) DATE: 1960 DOC#: FD251 DOCUMENT DESCRIPTION: Conference Proceedings - International Congress on Occupational Health - Funders, Attendees & Presentations I Proceedings THIRTEENTH INTERNATIONAL CONGRESS ON OCCUPATIONAL HEALTH The following corporations, governmental agencies, labor unions, professional societies, and individuals contributed to the financial support of the Congress: AFL/CIO The Alcoa Foundation AMF Foundation Addressograph-Multigraph Corporation Allegheny Ludlum Steel Corporation Allis-Chalmers Manufacturing Company America Fore Loyalty Group American Brake Shoe Company American Can Company American Cast Iron Pipe Company American Cyanamid Company American Industrial Hygiene Association (Northern California Section) American Medical Association American Metal Climax Foundation, Inc. American Mutual Insurance Alliance American President Lines Ltd. American Telephone and Telegraph Company American Viscose Corporation Armco Steel Corporation Armour and Company Atlantic Refining Company J. T. Baker Chemical Company Bausch and Lomb Optical Company Baxter Laboratories, Inc. Bayuk Cigars, Inc. Bethlehem Steel Company Boeing Airplane Company Bristol-Myers Company Budd Company Burlington Industries, Inc. Burroughs Wellcome and Company California Texas Oil Corporation Campbell Soup Company The Carrier Foundation, Inc. Carson, Pirie, Scott and Company Caterpillar Tractor Company Celanese Corporation of America Champion Paper and Fibre Company Chance Vought Aircraft, Inc. Chase Manhattan Bank The Chemstrand Corporation Chesapeake Corporation of Virginia Chrysler Corporation Cities Service Company Clevite Corporation C olgate-P alm olive C o m p an y Columbian Carbon Company Consolidated Edison Company of New York, Inc. Continental Can Company, Inc. Continental Oil Company Corn Products Refining Company Corning Glass Works Crouse-Hinds Company Crown Zellerbach Foundation Cummins Engine Company Curtis Publishing Company Deere and Company Detroit Edison Company Dodge Manufacturing Corporation Douglas Aircraft Company Dow Chemical Company E. I. Dupont de Nemours and Company Dupont, Mr. Irenee East Ohio Gas Company Eastman Kodak Company Electric Storage Battery Company Endicott Johnson Corporation Equitable Life Assurance Society of U.S. Esso Standard Esso Research and Engineering Ethyl Corporation Fairchild Camera and Instrument Company Fawcett-Dearing Printing Company Federal-Mogul-Bower Bearings, Inc. Federal Paper Board Company, Inc. Federated Department Stores, Inc. Firestone Tire and Rubber Company Food & Drug Research Laboratories, Inc. Ford Motor Company The Garret Corporation General American Transportation Company General Aniline and Film Corporation General Dynamics Corporation General Electric Company General Foods Corporation General Mills, Inc. General Motors Corporation General Tire and Rubber Company Globe-Union, Incorporated G oldm an, Sachs a n d C om pany The B. F. Goodrich Company The Goodyear Tire and Rubber Company Gulf Oil Corporation Gulf Research and Development Company Harnischfeger Corporation Hazleton Laboratories, Inc. Helm, Mr. Harold D. H. Hercules Powder Company, Inc. Heyden Newport Chemical Corporation Hine, C. H., M.D. Hinman, Mr. John H. The Hoover Company Hoffman-La Roche, Incorporated Hope Natural Gas Company Geo. A. Hormel and Company Hughes Aircraft Company Humble Oil and Refining Company Industrial Medical Association Inland Steel Company International Business Machines Corporation International Harvester Company International Minerals and Chemicals Corporation International Resistance Company International Telephone and Telegraph Corporation Iranian Oil Consortium Johns-Manville Corporation Johnson and Johnson S. C. Johnson & Son, Inc. Jones & Laughlin Steel Corporation Miles Laboratories, Inc. Mine Safety Appliances Company Monsanto Chemical Company National Biscuit Company National Dairy Products Corporation National Institutes of Health, Public Health Service, Department of Health, Education and Welfare National Lead Company New Orleans Public Service, Inc. Newport News Shipbuilding fc Drydock Co. New York Life Insurance Company New York State Natural Gas Corporation New York State Society of Industrial Medicine The New York Times The News, New York North American Aviation, Inc. Norton Company Ohio Oil Company Olin Mathieson Chemical Corporation Otis Elevator Company Owens-Corning Owens-Illinois Glass Company Pan-American World Airways, Inc. Paramount Pictures Corporation Pennsylvania Railroad The Peoples Natural Gas Company Pepsi-Cola Company Pittsburgh Steel Company Procter and Gamble Company Provident Life Sc Accident Insurance Co. Kaiser Industries Corporation Kennecott Copper Corporation Kimberly-Clark Corporation Koppers Company, Incorporated LaSalle Steel Company Legge, R. T., M.D. LeTourneau-Westinghouse Company Lever Bros. Company Liberty Mutual Insurance Company Life Extension Examiners Eli Lilly and Company Thomas J. Lipton, Incorporated The Magnavox Company The Mead Corporation Medical Society of the State of New York Meigs, J. W., M.D. Metropolitan Life Insurance Company Radio Corporation of America Raytheon Company Republic Steel Corporation Revlon Foundation, Incorporated Reynolds Metals Company R. J. Reynolds Tobacco Company Richfield Oil Corporation John A. Roeblings & Sons Corporation Joseph E. Seagram 8c Sons, Inc. Shell Oil Company Simplex Wire and Cable Company Sinclair Refining Company A. O. Smith Corporation Socony Mobil Oil Company Sonoco Products Company Sperry Gyroscope Company Standard Oil Company (California) S ta n d ard O il C om pany (In d ian a) i - i i a -i v y i ' A J w i N i s K a iUUO Standard Oil Company (New Jersey) and affiliates Standard Oil Company (Ohio) Standard Railway Equipment Company Foundation Standard-Vacuum Oil Company Stauffer Corporation Studebaker Packard Corporation Sugar Beet Products Company Sun Oil Company Sunstrand Corporation Swift and Company Sylvania Electric Products, Inc. Tampax, Incorporated Tennessee Corporation Texas Company Texas Instruments, Inc. Tidewater Oil Company The Michael Todd Estate Trans World Airways The Travelers Union Carbide Corporation Union Oil Company of California United Artists Corporation United States Atomic Energy Commission United States Rubber Company United States Steel Corporation United Steel Workers of America Universal Oil Products Company Upjohn Company VAW--International Executive Board Washington Steel Corporation Weirton Steel Company Western Electric Company, Inc. Westinghouse Electric Corporation Wilson, Mr. Charles E. Wilson & Toomer Fertilizer Company Wiremold Company Woodard Research Corporation Wm. Wrigley, Jr. Company Union Bag-Camp Paper Company Zenith Radio Corporation THIRTEENTH CONGRESS ON July 25-29, i 9 6 0 C opyright 1961 by th e U . S. E xecutive C om m ittee of the T h irte en th International Congress on O ccupational H ealth ALL RIGHTS RESERVED Library o f Congress Catalog C aid N u m b e i: 58-32683 I Public Health GIFT DESIGNED BY HARVEY SATENSTEIN MANUFACTURED IN THE UNITED STATES OF AMERICA BY BOOK CRAFTSMEN ASSOCIATES, INC., NEW YORK R C ^^3 A I Z< o5T /<? 3 V 3 u b ! ir irlecv / Hts L b ra.ry EXECUTIVE COMMITTEE Chairman . L. W a d e , M.D. Vice-Chairmen L. G r e e n b u r g , M.D. S. E. M i l l e r , M.D. Secretary-General R. E. E c k a r d t , M.D. Treasurer H . E. T e b r o c k , M.D. Executive Secretary J. W . M u c k e l l E . R . A sto n , D .D .S . C. U. D e r n e h l , M .D. T . E l y , M.D. B. S. Fox J. L a u e r , M.D. H. L. M a g n u s o n , M.D. H . B. N a c h t i g a l l , M.D. N . N e l s o n , P h .D . M. N . N e w q u is t , M.D. L. T . R o b e r t s o n , M.D. I. R. T a b e r s h a w , M.D. S. P. W a g n e r , R .N . 940 10 REPORTS OF ORGANIZING COMMITTEES In addition, many others visited points of interest to them either before or after the Congress. When the debris had been cleared away and the hubbub had subsided by Saturday, July 30, the paid registrations figures for the Congress were as shown in the following tabulation. NUMBER OF REGISTRANTS -- BY COUNTRIES Country Afghanistan .. Algeria .......... Argentina . . . Australia . . . . Austria .......... Bahrein ........ Belgium ........ Bolivia .......... Brazil ............ British Guiana Canada .......... C h ile .............. Colombia . . . . Cuba .............. Czechoslovakia Denmark . . . . Finland ........ France .......... Germany . . . . Greece .......... I n d ia .............. Indonesia . . . . Iran .............. Ireland .......... Israel ............ Italy .............. Total 1 1 19 3 8 1 2 1 5 2 54 4 9 5 1 4 62 39 36 1 5 1 2 1 2 21 in Country Total m th th Japan .................................................. 20 th Luxembourg ...................................... 3 Mexico ............................................... 6 pi Morocco ............................................. 1 lit Netherlands ........................................ 16 ci Netherlands-Antilles ........................ 2 to Northern Rhodesia .......................... 1 at Norway .............................................. 13 P1 Pakistan .............................................. 1 ac Peru .................................................... 4 Philippines ........................................ 5 w Portugal .............................................. 5 Romania ........................................... 1 I p Spain .................................................. 5 I oi ol Sweden ............................................... 29 sc Switzerland ....................................... 6 w Thailand ............................................ 1 b Trinidad ........................................... 2 d Union of South Africa .................... 9 ic United Kingdom .............................. 94 United States .................................... 1040 Uruguay ........................................... 2 tl U.S.S.R.................................................. 1 b Venezuela .......................................... 7 a ii Yugoslavia .......................................... 4 tl Total ...........................................1568 b o One hundred and ten people paid and registered but were unable, for one reason or another, to attend. Thus the total actually present, exclusive of wives or guests, was 1458. It is the impression of the Organizing Committee that the Congress was an overwhelming success. Certainly the number and quality of the scientific papers delivered was outstanding. Dr. Irving Tabershaw and his whole Program Committee deserve a special note of thanks for iV the hard work entailed in bringing such an excellent program to the Congress. It is the hope of the Organizing Committee that all those who attended, especially those from foreign lands, not only learned much from their attendance at the Congress but found our land and our I people friendly an d hospitable. W e hope th a t new friendships w ere m ade, new un d erstan d ings reached, and that the memories of the Thirteenth International Congress on Occupa 7 tional Health will linger long. Speaking for all members of the Organizing Committee, it was a pleasure and privilege for us to plan the Congress and welcome all who attended. J KIV ILU OTO 311 m l of the buffer described in A ppendix 1, a n d con tin u e as in A p p en d ix 1. N orm ally for blood specim ens th e final w ashing m ust be perform ed four times, instead of thrice as for u rine specimens. APPENDIX 3-- COPROPORPHYRIN ESTIM A TIO N T o 5 ml freshly voided urine in a stoppered test tube add 0.2 m l 3 p er cent hydrogen peroxide solu tion, 1 ml glacial acetic acid and 3 ml ether. Shake gently, release pressure, and place in a lightproof box overnight. Observe the red fluorescence under u ltra violet lig h t, a n d g ra d e th e specim en 0 --|--(--|--p by degree of fluorescence. APPENDIX 4-- HEMOGLOBIN DETERM INATION T ake 0.05 ml blood, a n d m ake u p to 9 m is volum e with 0 4 p er cent am m onium hydroxide. Measure absorption on a colorimeter, using a standard filter (EEL 404), a n d convert th e reading to hem oglobin percentage to the nearest even num ber from a pre pared calibration graph. A PPEN DIX 5-- PUNCTATE BASOPHIL COUNTS M ake a th in blood sm ear on a slide of 0 8-1 0 m m thickness, fix for about one m in u te in m ethyl alcohol, allow to dry and stain for 30 seconds in Sellars stain (1 g m eth y len e b lu e, 6 g sodium bicarb o n ate in 100 ml deionized w ater). W ash in ta p w ater u n til the slide is a sea green color. Using a dark ground condenser and an Ehrlich eyepiece set to a 6-mm square, count t h e (p u n c ta te cells in ten consecutive fields. (Although in counting, the punctate cells are classified as large, m edium , small, very fine, or polychrom e, according to the size of th e in tra cellular stru ctu re, this differentiation is for further reference on an individual case, and norm ally only the total count is given.) Close the eyepiece to a 2-mm square, and count the R.B.C. in this square. Repeat both counts five tim es on different parts of th e slide, to give a p u n c ta te co u n t of 50 large fields and an R.B.C. count of five sm all ones. C alculate p unctate p e r 1000 R.B.C. NONOCCUPATIONAL ASBESTOSIS R aimo K iy ilu o to R oentgen D epartm ent of the Central H ospital of N orthern Karelia Introduction Pleural reaction is very often observed in asbestosis. In the advanced cases of this pneumoconiosis pleural fibrosis has been alm ost always found, and a clear correlation between pleural changes and the severity of the pulm onary fibrosis has been observed by several investigators. Observations on the occurrence of pleural calcification in asbestosis have also been made. R eports of pleural calcification as a roentgenologic sign or complication of asbestosis have especially been m ade by the G erm an a u th o rs (1). In a d d itio n to advanced cases of asbestosis, special cases have been presented in which pleural calcification has been the chief finding (2). E xcept in asbestosis, p le u ra l calcification has also been observed am ong workers exposed to talc and mica (S, 4) o r to various dusts in clu d in g a short exposure to asbestos (5). T h e diagnosis of pneum oconiosis is prim arily based on occupational exposure to dust. Only very few re ports of pneumoconioses w ithout occupational exposure may be found in the literature (6,7,8). In N orthern Karelia, Finland, during few past years interest has been attracted by th e high incidence of cases of p leural calcification showing a rath er curious and characteristic roentgenologic picture, very sim ilar to that observed in pneumoconioses. T h e cases have been m ainly found among the residents of a certain area, and in these cases no previous history of adequate pulm onary or pleural disease could be elicited. T h e occupations of the patients showed no uniform ity, and the m ain part of the patients h ad no clinical symptoms of pneu moconiosis. A study of th e areal distribution of cases revealed that they w ere grouped round two anthophyllite-asbestos mines. Asbestos constituted the common external factor sought. Even from a solely roent- genologic p o in t of view, asbestos dust inhalation had been considered the most probable etiology. Pleural calcification resulting from hem othorax, tuberculosis, or empyema usually occurs unilaterally a n d is situ ate d on th e visceral p leu ra . In m ost cases m arked pleural thickening and displacement of the intrathoracic organs is observed. T h e calcification re sulting from dust inhalation usually occurs bilaterally and is m ost often situated on the parietal pleura. In advanced cases calcium deposits are found in the lateral p arts of the chest, basally and mediastinally. T h e calcium deposits take various forms--large con fluent plaques, bizarre figures, or roundish spots. T he R oentgenologic and Clinical Picture of Cases Observed in N orthern K arelia In the advanced cases calcium deposits are found bilaterally in the central parts of the diaphragm ; on chest walls, especially anterolaterally b u t also dorsally, a n d on th e m ed iastin al surfaces. In th e in cip ien t cases the calcium deposit takes place either on the antero lateral chest wall, more often on the left, or in the central parts of the diaphragm , apparently more often on th e rig h t. Pericardial calcification is sometimes present. T h e calcium deposits are located on the parietal p leu ra . In a series of 150 cases n o in te rlo b a r calcium deposits were observed. T he parietal location has been dem onstrated by diagnostic pneum othorax examina tions, and it has also been noted in some autopsied and surgical cases. U sing a tangential roentgen beam, the parietal location of solitary plaques may be observed, these plaques having their bases toward the inner chest w all o r to w ard th e d iap h rag m . In advanced cases the lack of soft tissue mass between the calcium deposit 312 MEDICAL PRACTICES and in n e r chest wall d u e to the parietal location is p ulm onary fibrosis am ong residents a ro u n d th e two apparent, and diagnostical pneum othorax exam ination asbestos mines. is seldom needed. Some investigators have pointed out the difficulty of T h e m ajority of cases of pleural calcification de a ttrib u tin g th e calcification to in h alatio n dam age in scribed above have been clinically symptomless. In a view of its parietal location, few, if any, changes being series of 150 cases th e o rd in ary chest ro entgen e x am in a observed in th e lung or the visceral p le u ra (2,5). It tion by P-A and lateral projections revealed p u lm onary seems possible th at the asbestos fibers move w ith the fibrosis, corresponding to the anteprim ary o r prim ary lung and visceral pleura in relation to th e parietal stage of pu lm o n ary asbestosis in only a b o u t 14 p e r p leu ra , th u s causing capillary h em o rrh ag es o n this cent. Even th e m ain p a rt of these cases h ad no sub only, as previously presented by th e author. T h e jective respiratory symptoms. hem orrhage coagulates and organizes, form ing a col T h e series m entioned above has been selected solely lagenous plaque which slowly calcifies. T h is theory according to the roentgen diagnosis w ithout reference could explain the course of the process resulting from to other factors. T h e concentration of the cases around inhalation of small quantities of fibrous m ineral dust. two asbestos mines in Kuusjrvi and its neighboring T h e clinical significance of the pleural calcification communes has as yet been the only way to confirm the seems to be slight, the m ajority of cases showing no roentgen diagnosis. T h e m ajority of 25 cases living clinical respiratory symptoms. F u rth e r investigations outside this area had previously lived there. According on this point are needed. to these facts, any o th er etiology w ould be very d if From roentgenologic point of view, this endemic ficult to credit In very few cases a previous occupa p le u ra l calcification is of some significance. T h e ro e n t tional exposure to asbestos dust has been observed, gen diagnosis is in typical cases easy b u t in some cases which lends slight support to th e roentgen diagnosis. difficult. Early pleural changes on the anterolateral T h e diagnosis has as yet not been confirm ed by o th er chest w'all may sim ulate infiltrations, a n d large calcified methods. In the sputum of 20 cases no asbestos bodies plaques may cause difficulty in in te rp reta tio n of p u l were found, and asbestos fiber in one case. Small m onary changes by hiding infiltrations. T h e high kilo- am ount of anthophyllite asbestos was found in the voltage technique can hereby be especially recom lung of an autopsied case and in the lung of a cow m ended. In chest roentgen exam inations of workers of from the vicinity of the asbestos mine. asbestos mines in N orthern Karelia and of O utokum pu D iscu ssio n Copper mines located in the same area attention must be paid to the fact that even extensive bilateral va1 pleural calcification does not have to be a sign of T h e total n u m b er of cases of p leural calcification severe pulm onary changes resulting from occupational around the two asbestos mines am ounts to over 800, dust exposure. <4$ as previously rep o rted by the au th o r. T h is n u m b er of REFERENCES cases was found in a mass survey of ab o u t 10,000 ad u lt in h a b ita n ts and m ay include cases w ith previous occu 1. Jacob, G., and Bohlig, H .: D ie rntgenologischen pational exposure to asbestos dust. In the history of the m ain p art of cases exam ined at th e C entral H os pital of N orthern K arelia the lack of occupational ex posure has, however, been apparent. Some of the patients have not had any idea how the dust inhalation could have happened; th e same cases have presum ed that the dust rising on the roads m ight be responsible In N orthern Karelia the roads (highways) do not have pavem ent. W ith o u t m inralogie e x am in atio n s it is, of course, impossible to decide w hether these calcifications are resulting from inhalation of anthophyllite-asbestos Kom plikationen der Lungenasbestose. Fortschr. R ntgenstr., 83:515, 1955. 2. M uller, H .: U ber schwere F orm en d e r Asbestose. D ie S ta u b lungenerkrankungen, B and 3, W issen schaft!. Forschungsberichte 66. D ietrich Steinkopfl Verlag, D arm stadt, 1958. 3. Siegal, W .; Sm ith, A. R.; a n d G reen b u rg , L.: Study of talc m iners and m illers. In d u st. B ull., 22:434, 1943. 4. Sm ith, A. R.: P leu ral calcification re su ltin g from exposure to certain dusts. A m . J. Roentgenol, 67:375, 1952. du st o rig in a tin g from th e asbestos m ines o r from s u r 5. Fehre, W .: ber doppelseitige Pleuraverkalkungen face deposits of other fibrous dusts, such as trem oliteasbestos, w hich is a very comm on m ineral in N o rth ern Karelia. T h e first alternative seems to be m ore p ro b able. In occupational pneumoconiosis some authors have called attention to the absence of pulm onary fibrosis besides the prom inent appearance of the pleural calci fication (2,5); on the other hand, a clear correlation has been observed between the severity of pulm onary fibrosis a n d p le u ra l calcification (9). In n cn o cc u p atio n al infolge beruflicher Staubeinw irkungen. Fortschr. R ntgenstr., 83:16, 1956. 6. E isenbud, M.; W an ta, R . C.; D u stan , C.; Stead m an, L. T .; H arris, W . B.; a n d W olf, B. S.: Nonoccupational berylliosis. A m . J. Indust. Hyg., 77:282, 1949. 7. Goyal, R . K.: Pneum oconiosis in th e n o n -in d u strial p opulation of R ajasthan. J. Indian M ed. Ass., 30:79, 1958. 8. K iviluoto, R.: P leural calcification as a ro e n t genologic sign of non-occupational endem ic antho- asbestosis it is ap p are n t th at extensive calcification may phyllite-asbestosis. A cta radiol., su p p l. 194, 1960. occur w ith o u t any roentgenologically detectab le p u l 9. B ohlig, H .; Jacob, G.; a n d M uller, H .: D ie A sbes m onary fibrosis. It seems possible th at even very small tose der Lungen. Georg T hiem e Verlag, Stuttgart, am ounts of asbestos fibers may cause pleural calcifica 1960. tions. A nthophyllite is m ore stiff th an serpentine asbestos. In anim al tests brittle m ineral fibers have not caused p u lm o n a ry fibrosis (10), b u t fibrosis has been observed 10. V orw ald, A. J.; D urkan, T . M .; a n d P ra tt, P. C,: Experim ental studies of asbestosis. Arch. Indust. H yg., 3:1, 1951. 11. N oro, L.: O n th e histology of asbestosis. A cta P athol, et m icrobiol. Scand., 23:53, 1946. in w orkers exposed to anthophyllite-asbestos du st (11, 12. W egelius, C.: C hanges in th e lu n g s in 126 cases of 12). F u rth e r studies a re needed to reveal th e p a rt asbestosis observed in F inland. A cta radtol., 28:139, & possibly played by asbestos as a n tiologie factor in 1947. ?. 326 MEDICAL PRACTICES A REVIEW OF RECENT DEVELOPMENTS IN OCCUPATIONAL PULMONARY DISEASES OTHER THAN SILICOSIS L e o N o r o , M.D. F in la n d At the Tw elfth International Congress on Occupa O ur knowledge of many factors influencing the lungs tional H ealth held in Helsinki three years ago, the is already fairly complete: I am thinking only of French Professor M archand presented a review of the asbestosis; those many chemicals causing acute lung subject m entioned in the title, a large and com prehen injuries, such as chlor or nitrous fumes; and the sive bibliography being attached to his presentation. diseases caused by bacteria, sponges, or viruses Often T h e O rganizing Com m ittee has at this tim e asked me o u r knowledge is still very restricted, and the in te rp re to present a review of the same subject from the last tations in m any individual cases are difficult to make, several years. It m ust at once be said th a t the com pil this is tru e of allergic diseases and chronic bronchitis, ing of such a bibliographic review has not been an lung cancer, emphysema, and fibrosis on the whole, easy task. M ore th an ever before, research work has and especially of the role of nonprofessional and pro been focused on occupational pulm onary diseases. T h e fessional environm ents in th eir occurrence. Yet we problem has been discussed at national and in tern a have, with special appreciation to Great B ritain's ex tional meetings, the last tim e being only two m onths cellent vital statistics, im portant evidence at our dis ago in M ilan. From the literature which has been at posal of the relationship between occupation and m y disposal, I have fo und alm ost 316 articles from the certain p u lm o n a ry diseases, such as chronic bronchitis. recent years dealing with this subject, and yet I cannot A fter this general survey, now let us study the have h a d access to all the articles from this field p u b details. Since silicosis will be discussed in an o th er lish ed in th e world. I shall follow, w ith some excep connection, I shall begin writh asbestosis. tions, M arch an d 's classification. T h e re is reason to state a t th e onset th a t th e con Asbestosis sta n t in dustrializing is causing th e a ir we b re a th e to T h e m ajor part of our present knowledge concerning become more and m ore polluted. G reat masses of asbestosis is contained in the excellent Germ an book people, even the peoples of the so called less-developed th at appeared some m onths ago, Die Asbestose der countries, are changing their breathing air through Lungen by Bohlig-Jacob-M uller T h is book contains, th e ir m ovem ent from ag ricultural to in d u strial centers. in addition to 700 of their own cases, references to I am here thinking specifically about the huge indus practically the en tire w orld literatu re in this field trialization process rig h t now taking place in India (some 650 references). T h e re is no th in g basically new a n d C hina. B u t m a n 's b re a th in g organs, a n d especially a b o u t th e pathogenesis, clinic, prognosis, a n d prev en his lungs, do not come in contact w ith hazardous in tion of this disease. F u rth e r inform ation is, however, fluences only in the working environm ent. T h e most obtained about the frequency of clinical symptoms as common pollutant of our breathing air--tobacco smoke well as roentgenologic and bronchographic observations -- is rapidly triu m p h in g all over the w orld w ith the from the au th o rs' careful exam ination on th e ir m aterial rising standard of living, in spite of the efforts we of 700 cases. T h e relationship between asbestosis and doctors take to w arn m ankind of its danger. T h e au to lung cancer is still statistically indeterm ined. In spite m obile industry is producing cars in a rap id tem po to of this, "asbestos cancer" exists, and the authors give p o llute the air of the traffic roads. W ith th e growing th eir own specification to it. population centers, and their increased use of fuel for Does asbestos dust have sim ilar nonoccupational pow er and heating, m ore pollutants enter the air. affect as, for exam ple, beryllium? T h is is a problem Bacterias, viruses, sponges, a n d o th e r sm all organism s th a t has been exposed th ro u g h the observations of 126 11 ? have not disappeared either. T h u s, the environm ent of nonoccupational p leural calcification cases (so-called m an, w ith reference to lungs, is changing continuously. neighborhood cases) th at had been fou n d in th e p o p u W h ile the great enem y of the lungs, tuberculosis, is latio n living a ro u n d two open asbestos quarries, p u b gradually disappearing, new diseases are arising, giving lished by the Finnish Dr. Kiviluoto. According to this new im portance to the air im purities. Chronic bron study, the details of which the au th o r will present him chitis, asthm a, emphysema, an d lung cancer are already self at this Congress, m ore than 800 pleural calcifica m uch m ore im portant diseases th an tuberculosis in tion cases were found in the m inute x-ray investigation countries w ith highly developed industry and a high of farm ers, workm en, and th eir wives, w ho never had living standard, any occupational exposure. Calcification was usually M an him self and the changing of his reaction to the located in p arietal pleura, as it is also most often in environm ent also require attention. Allergies are one occupational asbestosis. In most instances it occurred^ problem , for example. T h e danger of allergens affect bilaterally on the inner chest wall. Basal and m edi ing organisms through the respiratory and digestive astinal calcification was also often observed, a p u l organs and the skin is continuously increasing; new m onary fibrosis being found only on a few cases. T h e m edicines, foods, cosmetics, etc., are common allergens. calcification was noticed to appear slowly. T hese roent- Allergic reactions are im portant when we consider the genologically noticeable changes gave insignificant clin breathing organs and their obvious connection w ith ical symptoms. These observations m ake it evident the air im purities. Many of the chronic occupational that measures m ust be taken to prevent the air pollu diseases of the lungs occur only after a long exposure tion of the environm ents surrounding the factories and tim e. W e a re g radually, how ever, observing th e signs asbestos qu a rrie s. T h e results of D r. K iviluoto's work of these diseases among those occupational groups are m otivation for sim ilar investigations in other coun which have been exposed for some length of tim e. tries to certify these observations. k NORO 327 Other fibrotic lung diseases and "benign pneumo coniosis'' caused by silicates, mixed or non-silica d u sts (Glass wool, sericite, sillim anite, talc, anthracol, carborundum , cement, Fuller's earth, china and ball clays, g rap h ite, gypsum , kaolin, lim estone, m arble, mica, T h o m as (basic) slag, etc.) I shall pass this group with a brief m ention of talcosis and graphite lung, which are still objects of continuous research. W ith great enough exposure, u n doubtedly, the dusts of this group have their affect in the occurrence of fibrosis. However, it is evident that w ith im proved hygiene these types of pulm onary changes will become m ore and more rare. P n eu m o p ath ies due to toxic chem icals an d m etals G ases, F um es and V apors (C l, N O a, S 0 2, borans, desm odur, hydrocarbons, oils, kerosene, etc.) Metals (A lum inium , antim on, barium , beryllium, cadmium, chrom, cobalt, fluor, gold, iron, manganese, nickel, osmium, platinum , selenium, sulfur, tungsten, titanium , vanadium , w olfram , zirconium , etc.) T h e am ount of toxic chemicals and m etals influenc ing the lungs is continuously growing. V anadium , chrom, and beryllium have been subjects of research, especially in Sweden and in our host country, the U S.A. T h e im p o rtan ce of v anadium is especially in creasing. I t is necessary, however, to b ear in m ind that w ith the expanding use of oil heating, the crude oil coming from various parts of the world contains vanadium in very different amounts. T h e role of the acic sulfur com pounds in the ashes is also to be remembered. For a detailed study of beryllium , I would refer you to the proceedings of the conference h e ld a t th e M .I.T . in 1958 (A M .A . A rch . In d u st. Health); a comprehensive list of references on beryl lium is contained in a publication on these proceed ings. W e in E urope, to my knowledge, do not have the big problem s w ith beryllium which seem to exist in the U S.A. It is impossible, in this short presentation, to name all th e new chem icals w ith irrita n t effect on th e lungs. W e industrial physicians have special difficulties a t tem pting to evaluate the aftereffects of acute irritants to th e lu n g s (n itro u s fum es, C l, SOz, etc.), especially w ith reference to etiologic differential diagnostics in chronic bronchitis and emphysema. P n eum opathies due to organic dusts, allergens and p n e u m o m y c o se s (Actinomycosis, aspergillosis, cocci dioidom ycosis, cork (suberosis), cotton (byssinosis), drugs, dyes, feathers, flour, grain, gum acacia, hair, hay (farm er's lung), histoplasm osis, ju te , le a th e r (cannabosis), linen, moniliasis, nocardiosis, sporotrichosis, sugar cane (bagassosis),-tobacco (tabaccosis), tropical woods, etc.) T h e agricultural population has received increased attention during th e last few years in the investigation of th e re la tio n s h ip betw een work a n d h e alth . "F a rm e r's lung" and o th er pulm onary diseases found in agricul tu re have proved surprisingly common upon closer investigations. U nfortunately, so far there have not been powers to investigate these conditions in the countries where the agricultural population works under the worst hygienic conditions. We have not enough knowl edge about the pulm onary diseases of the workers in the old Asian rice mills, for example. T h e effect m echanism of most organic dusts is still unclear, and we are also in a difficult field, w here bacteriology and allergology will be of m uch help in several cases. W hat factors effect in different conditions --acute, subacute, chronic; proteins, alcaloids, irritating m echanic factors, toxic, allergic, bacteria, th e silica included--are questions that are still w aiting to be answered. In addition, for example, the experience w ith byssinosis is still contradictory in different coun tries. T h e interesting research results of Dr. Schilling of England m ake one think th at this disease has not yet disappeared as has been contem porary thought in my own country. In fe c tio u s a n d p a ra s ita i p n e u m o p a th ie s (Amebiasis, anchylostomosis, anthrax, bilharziosis, brucellosis, hydatitosis, leptospirosis, ornithosis, tuberculosis, tularaem ia, etc.) W ith the diseases of this group there are continuous difficulties in etiologic diagnostics: when is the infec tion to be considered due to work and when not? T he question is very im portant, for exam ple, w ith tu b er culosis. Of course, the relationship betw een tuberculosis and pneumoconioses is under constant study. L ung cancer due to occupation (A rsen, asbestos, chromates, isopropyl alcohol m anufacturing, nickel, radioactive substances, etc.) T h e Secretary General of our Congress, Dr. Eckardt, handles the role of working conditions in the occur rence of cancer in his book Industrial Carcinogenesis most variedly and with good criticism. Yet it is to be suspected th a t in industry m any o th er substances also have a cancerogenetic effect. O u r knowledge in this field, how ever, is still very lim ited , a n d a lth o u g h ex perim ental cancer research has gone far, we still lack in practice necessary facts. It is hoped th a t the wellendowed cancel organizations and research institutes will more than before concern themselves w ith the occupational aspects in the etiology of cancer. T h e results from the investigation by U.S. Publit H ealth Service concerning the hazards of radiations to m iners are expected with great interest. W hether the cases of Schneeberg and Joachim stal will get successors in the very widespread uranium m ining is a question th at will presently be answered. Pneumopathies caused by radiation T h e influence of radiation as the cause of cancer has already been referred to above. O ur knowledge about th e o th er effects of radiation on th e lungs are very sm all. In c onnection w ith th erap y , large doses (10002000 r.) have been found to cause changes in the lungs in the form of pneum onitis and fibrosis. From East Germany there comes the report of a chronic pneu m onia case of a chemist, w hich led to death; the cause of death being considered the breathing of radioactive dust over a period of 20 years. C onclusion T o o u r present knowledge, we already have a foun dation for the technical prevention of these diseases W e are as yet in a weaker position as to their medical prevention: we know too little about why one person gets them and one does not. T his question requires m uch research. W e have already reached far in the roentgenologic diagnostics of the pulm onary diseases, and there we are m aking constant progress. W e are also aware, however, of the difficulties therein as to several of the disease groups referred to above. Together with the roent genologic exam ination we m ust develop other clinical 328 MEDICAL PRACTICES exam ination m ethods, especially the physiologic lung function diagnostics. In its most advanced form , we h a te to apply it not only in laboratories but, above all, in the field exam inations to the exam ination of population groups exposed to different exposures. Above all, we need also in this field keen in tern a tional collaboration to solve ou r common problem s and to exchange inform ation so th at each of us in his own country could apply in practice the knowledge we already possess to the betterm ent of our working population. B IB L IO G R A P H Y G eneral 1. P neum oconiosis A bstracts, Vol. I l l, L ondon, 1959. 2. Sance spciale consacrl l'tu d e des p n e u m o pathies professionelles (Silicose excepte). Arch, mal. prof., 18:253-354, 1957. 3. A lbahary, C.: Les asthm es professionelles: p ro b lmes poss p o u r leur rparation. Arch. mal. prof., 75.41,633, 1957. 4. A ltshuler, B ; Y arm us, L.; Palmes, E. D.; and Nelson, N.: Aerosol deposition in the hum an respiratory tract. A.M .A. Arch. Indust. H ealth, 77.293, 1957. 5. Anders, W .: Soziale Problem e bei allergischen Erkrankungen am Beispiel der Asthma bronchiale, Off. Gesd. d ienst, 79:488, 1958. 6. A nderson, W . H ., a n d Schm idt, W . F.: E valuation of disability in coal m iners with chronic pul- ' m onary disease. J A .M .A ., 777:145, 1959. 7. A ntw eiler, H.: M astzellen u n d H ista m in nach Injection von Staubsuspensionen. Arch. Gewerbepath., 16:601, 1959. 8 Baader, E. W .: Einige neue Problem e der Gewer bepathologie (Lungenemphysem , Kadm ium , Des m odur). B eih . z. Zbl. A rb eitsm ed ., H eft 3. D arm stad t, 1956, p. 172. 9. Berkson, J.: T h e statistical investigation of smok ing and cancer of the lung. Proc. Staff M eet., M ayo Clin., 54:206, 1959. 10. B erlin, R a g n ar: Y rkespneum okonioser. Svenska L k a rtid n in g e n , 55:3157-31-71, 1956. 11. B ernard-G riffiths, M m . C.; C ham peix, J., and B aldini, A.: A sthm e professionel p a r contact avec des m oisissures (a propos de 24 observations). A rch. m al. prof., 75:272, 1957. 12. Bugyi, B.: B eitrge zur Frage d e r S ta u b reten tio n s fhigkeit d e r L unge. M u n k a v d ele m , 5:49, 1957. 13. C ancella, L. D e C.; B aader, E. W .; C houx, J. De; Frouchtm an, R.; Lffler, W .; W orth, G.; and Zorn, O.: In d u strial diseases of th e chest: a com m entary on cu rren t problem s. Dis. Chest, 32:683, 1957. 14. Carstens, M.: D ie asthm atischen R eak tio n en der B ergleute. A rch. G ew erbepath., 75:45, 1956. 15. Carstens, M.: Z u r F rage d e r K au salitt von Emphysem und B ronchitis der Bergleute. Arch. G ew erbepath., 75:285, 1957. 16. D a u treb a n d e, L.; B eckm ann, H .; a n d W alken horst, W .: L ung deposition of fine dust particles. A .M .A . A rch. In d u st. H e a lth , 16:119, 1957. 17. Davies, C. N .: D eposition of du st in th e lungs: a physical process. In the Symposium on Industrial Pulm onary Diseases, ed. by King and Fletcher. L ondon, 1960, p. 44. 18. D n n e r, L.: K linisch-rontgenologische D iffere ntialdiagnose der Lungenkrankheiten. Stuttgart, 1958, p . 362. 19. D n n e r, L .: E m physem bei S ta u b lu n g en erk ran kungen -- Emphysem als selbstndige Berufs -- k ra n k h eit. Zbl. A rb . m ed ., 7:137, 1957. 20. D nner, L.: Pneum oconiosen oder S taublungener krankungen der Lunge? Kritische Betrachtungen u n d Vorschlge zu ih rer E ntschdigung. Zbl. Arb. m ed., 9 :12, 1959. 21. F erin, J., a n d U lehlov, V.: L e b e r d ie Selbst reinigung der Lunge von Staub und ihre Bestim m ung in T ierversuch. A rch. G ew erbepath., 76:630, 1959. 22. F letcher, C. M.: D isability a n d m o rta lity from chronic bronchitis in relation to dust exposure A .M .A . In d u st. H ea lth ., 78:368, 1958. 23. Fletcher, C. M.: R adiological diagnosis of p n e u moconiosis. In the Sym posium on Industrial P ul monary Diseases, ed. by King and Fletcher. Lon don, 1960, p. 72. 24. G ernez-Rieux, C ; Balgaines, E.; Fournier, P., and Voisin, C.: An often unrecognized m anifesta tion of pneumoconiosis in miners: aseptic lique faction of pseudotum oral form ations. Semame hop. Paris, 54:1081-1089, 1958 (in French). J.A .M .A ., 767:2140, 1958. 25. Gersing, R.: Die frhen R eaktionen der Lunge auf verschiedene Staubarten im vergleichenden T ierv ersu ch . B eitr. Silikoseforsch., 42:1, 1956. 26. Glm me, J., and Swensson, : Om andra pneum okonioser a n silikos. N ord. M ed ., 58:1973, 1957; Non-silicotic pneumoconiosis. Proc. X II Congr. In d u st. H e a lth , 3 :165, 1957. 27. Goetz, A., and T suneishi, N.: A Bacteriological Irritatio n Analogue for Aerosols. A .M .A . Arch. In d u st. H e a lth , 20:161, 1959. 28. G rau b n er, E.: Classification System of the P neu m oconiosis. P racooni lekarstvi, 78:109, 1958. 29. Gronem eyer, W .: Das gewerbliche Asthm a. Dtsch. m ed. W schr., 85:30, 1958. 30. Gross, P au l: C u rre n t concepts of pneum oconiosis. P athological aspects. J.A .M .A . 772:546, 1960. 31. Gross, P au l: A n im m unologic a p p ro ac h to the pneumoconioses. A .M A . Arch. Indust. H ealth, 27:228, 1959. 32. Gross, P au l, a n d Sm ith, K. W .: T h e topographic distribution of m ineral dusts in some pneumoconiotic lungs. Dis. Chest, 55:140, 1959. 33. H iggins, I. T . T ; C ochrane, A. L.; G ilson, J. C.; and W ood, C. H.: P opulation studies of chronic respiratory disease. A com parison of m iners, foundryworkers, and others in Stavely, Derbyshire. B rit. J. In d u st. M ed., 76:255-268, 1959. 34. H olstein, E. (H erausgeber): H aublungenerkran k u n g e n . L eipzig 1958 (T a g u n g in E rfu rt, 1956). 35. H o lt, P. F.: Pneum oconiosis. In d u stria l Diseases o f th e L u n g Caused by D ust. L o ndon, 1957. 36. Hyde, Leroy: Diffuse pulm onary fibrosis. Post grad. M ed., 26:208, 1959. 37. J tte n , K. W ., a n d K losterktter, W .: D ie Stau blung en erkra n ku n g en , B and 3. D arm stad t, 1958. 38. K hvapil, M.: B iochem ical m eth o d s in assessing the effect of industrial dust on th e organism. H igiena T ruda, 4(4):28, I960. 39. K hukhrina, E. V.: M ethods used in th e study of the pneumoconiosis incidence-rate. Higiena Truda 4(4):7, 1960. 40. King, E. J., an d Fletcher, C. M. (eds.): A Sym posium on Industrial Pulm onary Diseases. T h e P o stg rad u ate M edical School of L on d o n , 1957 and 1958. C hurchill L td., L ondon, 1960, (273 pages). 41. King, E. J., and H arrison, C. V.: R eaction of the lung to dust. In the Symposium on Industrial Pulm onary Diseases, ed. by King & Fletcher, Lon don, 1960, p . 37. 42. Kleinfeld, M., and Giel, C. P.: Pneumoconiosis. J. C hronic Dis., 9:111, 1959. NORO 329 43. K losterktter, W .: T ierexp'erim entelle U ntersu chungen ber das Reinigungsvermgen der Lunge. A rch. H yg ., 141:258, 1957. 44. K ovnatsky, M . A.: Silicatoses. M oskva, 1957 (179 pages). R eview ed: H igiena T ru d a , 2(3):60, 1958. 45. LaBelle, C., and Brieger, H.: Synergistic effects of aerosols. II. effects on rate of clearance from the lung. A M .A . A rch . In d u st. H e a lth , 20:100, 1959. 46. Lagze, M . P.: La m alad ie a sth m a tiq u e et ses lim ites sur le plan mdicale. Arch. mal. prof., 18:255, 1957. 47. L ane, R. E.: C hronic bronchitis and occupation. B rit. J. T u b e rc ., 52:11, 1958. 48. L aw ther, P. J., a n d W aller, R . E.: A tm ospheric pollution and lung cancer. Trans. Ass. Indust. M ed. Off., 9:5, 1959. 49. L u p u , N. G h.; Velican, C.; a n d O linescu, V.: T h e action exerted by certain pneumoconiotic factors upon the a d d mucopolysaccharide contents of pulm onary macrophages. Brit. J. Indust. M e d , 16:244, 1959. 50. L blich, H .-J.; Koch, W .; Sffge, K. H .; a n d N ordm ann, M.: Die R esorption einverleibten Staubes. Feinkrnige Staube (Kalkspat, Spateisen stein, T alk, R util). Beitr. Silikoseforsch., 50:1, 1957. 51. L blich, H .-J.; Koch, W .; a n d N o rd m a n n , M : Die Resorption einverleibten Staubes. Die A u fnahm e von Kieselgur. Beitr. Sthkoseforsch., 50:11, 1957. 52. M arch an d , M.: P neum opathies professionelles non selrogenes. Essai de classification. Proc. X l l I n ternational Congress on Occupational H ealth, H elsinki, 1957, 1:157 (Bibliography post 1950, pp. 170-191). Vide: M archand, M.: Les p n eu m o p a th ie s professionelles. Arch. m al. prof., 18:260, 1957; Les pneum oconioses non selrogenes. Arch. Hig. Rada 4:402, 1953; H ygine et securit d u T ra va il, Fase. IV. L ille, 1955 (Bibliography pp. 28-54). 53. M arks, J., a n d N agelschm idt, G.: Study of th e toxicity of dust with use of the in vitro de hydrogenase technique. A M .A. Arch. Indust. H e a lth , 20:383, 1959. 54 M ayer, E., and R a p p a p o rt, I.: B ronchitis and E m physem a. J.A .M .A ., 165:1227, 1957. 55. M orrow, P. E.; M ehrhof, E.; Casaret, L. J.; and M orken, D. A.: An Experim ental Study of Aerosol Deposition in H um an Subjects. A.M .A. Arch. In d u st. H e a lth , 18:292, 1958. 56. M otley, H . L.: P ulm onary fun ctio n im p a irm e n t in pneum oconioses. J.A .M .A ., 772:1591, 1960. 57. N agelschm idt, G.; N elson, E. S ; K ing, E. J.; A ttygalle, D.; and Y oganathan, M.: T h e recovery of quartz and other m inerals from the lungs of rats. A M A . A rch. In d u st. H ea lth , 76:188, 1957. 58. Nesis, A. J.: M ethods of x-ray e x am in atio n in pneum oconiosis. G ig. T ru d a , 7:22, 1959. 59. N o rd m a n n , M.; Koch, W .; a n d M der, E.: Die R esorption einverleibten Staubes. Sptstadien rein e r gem ischter Stube: Kieselgur und Quarz. B eitr. Silikoseforsch., 65:21, 1959. 60. O renstein, A. J.: U ltim as Investigaciones sobre N eum oconiosis. M edicina del T rabajo, 24:190, 1959. 61. P em b erto n , J.: C hronic bronchitis, em physem a and bronchial spasm in bitum inous coal workers. An epidem iologic study. A .M A . Arch. Indust. H e a lth , 75:529, 1956. 62. Pendergrass, E. P.: T h e Pneum oconiosis P roblem w ith Emphasis on the Role of the Radiologist. Springfield, 111., 1958. 63. P rin ci, F rank: Status of th e pneum oconioses. I n troduction. A .M .A . Arch. Indust. H ealth, 78:361, 1958. 64. R e in , H ., a n d B rin k m a n n , O: B ekom m en H o h l glasblser ein Lungenemphysem? Berufskrank h e ite n in der keram ischen In d u strie, H eft 6. W rzb u rg , 1959. 65. Sander, O. A.: C u rrent concepts of pneum oco nioses-- clinical aspects. J .A .M A ., 772:1587, 1960. 66. Sander, O. A.: N ew er concepts of th e pathogenesis o f th e pneum oconioses (T h e 1958 Ram azzini O ra tion). ]. O ccup. M ed., 7:7, 1959. 67. Sano, T ., a n d O sanai, H .: T ypes of p n e u m o coniosis and their pathogenesis. R eports of the Inst, fo r Science o f L a b o u r (Tokyo), 55:27, 1959. 68. Sartorelli, E., and Scotti, P.: Studio sperim entale e statistico sull' incidenza della bronchite cronica e dell' enfisema polm onare nella popolazione operai di una m iniera di pirite. Med. Lavoto (M ilano), 48:704, 1957. 69. Schneider, H.: U ntersuchungen zur Frage des berufsbedingten Emphysems und der berufsbedi ngten Em physem bronchitis der Glasblser. Berufskr. in d. keram . u. G las-Ind., H eft 2. W urzburg, 1958. 70. Schneider, H .: D ie berufliche E rk rankung der A tm ungsorgane, in F. Koelsch: H andbuch der B e ru fskra n kh e ite n , 2. Aufl., Jen a, 1959. S. 620 (L iteraturverzeichnis S. 1109). 71. Schneider, H : D ie S taublungenerkrankungen in Bayern in den letzten 50 Jahren. Staub, 20.1, 1960. 72- Schrenk, H . H .: S tatus of th e pneum oconioses, environm ental factors. A.M .A. Arch. Indust. H e a lth , 78:365, 1958. 73. Srm ek, J. a n d S rtek, J.: C hronic in d u stria l in flammations of the respiratory tract and p u l m onary em physem a. Prac. leii., 70:156, 1958. 74. Strecker, F. J.: D ie in tra p e rito n e a le Gewebstreaktion au f SiCb-freien L ungenkohlestaub un d ihre A bw andlung durch geringe Quarzbeimengungen. B eitr. Silikoseforsch., 43:21, 1956. 75. T arg am ad ze, K. S.: O n th e in trach eal m ethod of intro d u ctio n of dust to anim als. Gig. Truda, 2:56, 1958 76 W o rth , G ; D urben, H . H.; Ellersick, W .; Gast haus, L.; an d N erreter, W .: Z ur Frage von Bronchialspasm en bei Kohlenbergarbeitern im U n te rta g eb e trie b . B eitr. Silikoseforsch., 43:1, 1956. Asbestosis, fibrotic lung diseases, and " benign pneum oconiosis" caused by silicates, m ixed or non-silica dusts 1. Coal W o rk ers Pneum oconiosis. A M A . A rch. I n dust. H ea lth , 15(6), 1957. 2. A delbahr, G.: Lungenvernderungen bei einem K orundschm elzer (B erufskrankheit oder Suicid). M schr. U nfallhk., 60:65, 1957. 3. A h lm ark , A.; B ruce, T .; a n d Nystrm , A.: Pneumokonios (talkos) vid bearbetning av taljsten N o rd isk M edicin, 59:287, 1958. 4. A hlm ark, A.; Bruce, T .; and Nystrm, A.: Pneu moconiosis in iron foundries. Proc. X II In t Congr. O ccup. H e a lth , H elsinki, 7:365, 1957. 5. A hlm ark, A.; Bruce, T .; and Nystrm , A.: Pneumokonios hos kiselgurarbetare. Nordisk M edicin, 59:289, 1958. 6. A lvisatos, G. P ; P ontiakis, A. E.; a n d Terzis, B.Talcosis of unusually rap id developm ent. Brit. J. In d u st. M ed., 72:43, 1955. 7. B o b ile v a , A. X. e t al.: X h e A m o u n t of D u st in R esidential Districts of Asbest and its Effect on th e C h ild ren s H e alth . Gig. i L an., 23(9), 1958. 8. Bohlig, H .; Jacob, G.; and M uller, H.: Die Asbestose d e r L ungen. S tu ttg a rt (Thiem e), 1960 (166 pages). s!:I;f s$- t ;sf 330 MEDICAL PRACTICES 9. B ohlig, H .: Schwere M ischstaubsilikose bei einem Schwerspatmuller. Proc. X II In t. Congr. Occup. 31. Prosperi, G., a n d Barsi, C.: Sulle pneum oconiosi dei lavoratori del cemento. Rass. med. indust., H e a lth , H elsinki, .3:310, 1957. (T orino), 26:16, 1957. 10. B ridge-D avis, S.; a n d N agelschm idt, G.: A re p o rt on the absence of pneumoconiosis among workers in p u re lim estone, B rit. ]. Indust. M ed., 13:6, 32. R aiklin, N . T .: M aterials characterizing the n a ture of pneumoconiosis in the coal m iners of the K araganda Basin. Gig. T ru d a , 3(4):48, 1959. 1956. 11. D juricic, I , and Savic, V.: L a m ic ro h em a tu rie des ouvriers dans u n e m in e et u n e usine d 'asbeste. Proc. X II Int. Congr. Occup. H ealth, Helsinki, 3.324, 1957. 12. E h rh a rd t, W ., a n d H eid em an n , W .: Z u r K linier und Pathologie der O ckerstaublunge. Arch. Gewerbepath. G ewerbehyg., 37:504, 1959. 13. I ehre, W .: lie b e r doppelseitige P leu rav erk al kungen infolge beruflicher Staubeinwirkungen. 33. Sadkovskaya, N. 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J A M .A ., 165:1908, 1957. 116. Sjoberg, S. G.: V an ad iu m dust, chronic b ronchitis and possible risk of emphysema, Acta med. Scand., 757:381, 1956. 117. Sjoberg, S. G., a n d R ignr, K. G : Besvr fran luftvagar m.m. hos sotare i oljeeldningsanlaggningar. N o rd isk M e d ia n , 58:1973, 1957. 118. S m ith, J. S., a n d K ench, J E.: O bservations on urinary cadm ium and protein excretion in men exposed to cadm ium oxide dust and fume. Brit. J. In d u st. M e d , 74:240, 1957. 119. S m ith, J . C.; K ench, J. E.; a n d Sm ith, J. P : Chemical and historical post-mortem studies on a workm an exposed for many years to cadm ium o xide fum e. B rit. J. In d u st. M ed., 74:246, 1957. 120. T eb ro c k , H . E., a n d M achle, W .: -Advances in the m anagem ent of chronic berylliosis. Proc. X II l n t. Congr. O ccup. H e a lth , H elsinki, 3:167, 1957. 121. T h o m a s, D. L. G , a n d Stiebris, K.: V anadium Vergiftung in der Industrie. Med. J. Australia, 43:607, 1956. 122. T h o m a s, M. D ,, H endricks, R . H .; G u n n , F. D.; and Critchlow, J : Prolonged exposure of guinea pigs to sulfuric acid aerosol. A .M A . Arch. Indust. H e a lth , 17:10, 1958. 123. T im o k h in , D . I : Problem s of in d u stria l hygiene in em ploym ent of m agnesium -torium -cobait catalyzer, H ig . T r u d a , 2.42, 1958. 124. T u r , J : L iderosis p u lm o n u m . M ed. Pracy., 70:33, 1959. 125. V allee, B. L.: Z inc a n d its biological significance A .M .A . A rch . In d u st. H e a lth , 16 147, 1957. 126. V orobjeva, R . S : T h e questio n of th e toxicity of cadm ium oxide J. Hyg. Epidem iol. M icrobiol. Im m u n o l. (P ra g u e ), 2 244, 1958. 127 Z app, J. A.: H azards of isocyanates in p o ly u re thane foam plastic production. A M .A. Arch. In d u st. H e a lth , 75:324, 1957. Pneum opathies due to organic dusts, allergens and pneumomycoses 1. B rin g h u rst, L. S.; Byrne, R . N., a n d G ershonCohen, J.: Respiratory disease of mushroom workers, fa rm e r's lung. J.A .M .A ., 777:15, 1959. 2. Bugyi, B,, and M olnar, L.: Lungenschden durch R eisstrohstaub. B eitr. Silikoseforsch., 51:31, 1958. 3. Bugyi, B.: O n Conionmycoses. Prac. lekarstvi, 70:200, 1958. 4. C hinachoti, N ,, a n d T an g c h ai, P.: P ulm onary alveolar m icrolithiasis associated with th e in h ala tion of snuff in T hailand. Dis. Chest, 32:687, 1957. 5. DaSilva H o rta, J., and De C arvalho C ancella, L.: Experim entelle Korkstaubkoniose (Experimen telle S u b e ro se ). A rch. G ew erbepath., 75:319, 1957. 6. D n n e r, L.: Pneum okoniosen d u rc h S taub von Getreide und Saaten. In Staublungenerkrankun gen, B and 3, ed. by Jo tte n a n d K losterktter. D arm stadt, 1958, p. 541. 7. Dickie, H. A., and R ankin, J.: F a rm e rs lu n g an acute granulom atous interstitial pneum onitis occurring in ag ric u ltu ra l workers. J.A .M .A ., 167: 1069, 1958. 8 F rank, R. C.: F a rm er's lung--a form of p n e u m o coniosis due to organic dusts A.}. Roentgenol., 72.189, 1958. 9. Frost, J., a n d Georg. J.: T aerskerlunge. Ugeskr. L a e g , 778:1383, 1956. 10. G roetschel, H , and T rense, E.: T o d eines D ruck ers an Asthm a bronciale nach Umgang m it N asszerstubem itteln. A rch. G ew erbepath., 16: 375, 1958. 11. G u p ta, A. S.; Ferris, B. G.; a n d R ao, M. N.: Oxygen consum ption of m ale Indian jute workers. A .M A . A rch. In d u st. H e a lth , 20:96, 1959. 12 K lunker, W .: Z ur Frage d e r tiologie u n d P a th ogenese des sogenannten Bacher- und M ullerasthmas. Schweiz, m ed. W schr., 87:714, 1957. 13. Kyung, V. A : Dust of the kukkersite shale as an etiological factor of occupational pneumoconiosis. Gig. T ru d a , 3:44, 1959 14. Lowry, T ., and Schum an, L. M.: "Silo-filler's disease"--a svndrom e caused by n itrogen dioxide. J A M A , 762:153, 1956. 15. M urray, R ; Dingwall-Fordyce, I.; a n d L ane, R . E.- An outbreak of w eaver's cough associated with tam arind seed powder. Brit. J. Indust. M ed., 11 105, 1957. 16. Pestalozzi, C.: F ebrile G ru p p en erk ra n k u n g en in einer Modellschreinerei durch Inhalation von m it Schimmelpilzen kontam iniertem Befeuchter wasser (Befeuchterfieber). Schweiz. M ed. W schr, 89:710, 1959. 17 Poliak, K ; G u th e rt, H , and Schanzenbach, H.: Experim entelle Untersuchungen zur Frage der G etreidestaublunge. Arch. Gewerbepath. Gewerb e h y g , 77:519, 1959 18. R oach, S. A , a n d Schilling, R S. F.: A clinical and environm ental study of byssinosis in the Lancashire cotton industry. B iit. J. Indust. M ed., 77 1, 1960. 19. Schilling, R. S. F.: T h e epidem iology of byssino sis. In the Sym posium on Industrial P ulm onary Diseases, ed. by K ing a n d Fletcher. L ondon, 1960, p. 185. 20. Schilling, R. S. F ' T h e epidem iology of byssino sis-- a d v en tu re and m isadventure. J. Occup. M e d , 7-33, 1959. 21 Stott, H .: P ulm onary disease am ongst sisal w ork ers. B rit. J. In d u st. M ed., 75:23, 1958. 334 MEDICAL PRACTICES 22. Sm etanin, N. I.: T h e m axim al perm issible con centration of the loess dust in th e a ir of cotton sp in n in g plants. Gig. T ru d a , 3:53, 1959. 23. T iller, J. R.: An investigation of byssinosis in a rayon m ill. Trans. Ass. Indust. M ed. O ff., 7:157, 1958. 24. T o tte n , R. S.; R eid , D. H . S.; Davis, H . D.; and M oran, T . J.: Farm er's lung, report of two cases in which lung biopsies were perform ed. Amer. J. M ed ., 25:803, 1958. 25 T u ffn e ll, P. G., a n d D ingw all-Fordyce, I.: An investigation into th e acute respiratory reaction to the inhalation of tam arind seed preparations. B ril. J. In d u st. M ed., 14:250, 1957. 26. W asserm ann, M.; Bugeag-M ihail, G.; an d Iosubas, S : Recherches experim entales concernant "la m aladie des fileurs et des tisseurs de chauvre". Proc. X II In t. Congr. Occup. H ealth, Helsinki, 3 374, 1957. 27. W egm ann, T .; G alletti, P.; and A m rein, H . P.: Baumw ollstaublunge. Schweiz. M ed. Wschr., 88.431, 1958. 28 Z an n in i, D (and W asserm ann, M ,, Discussion) : \ propos de la "Fivre des cereales" des travalleurs des silos. Proc. X I I Int. Congr. Occup. H e a lth , H elsinki, 7:386, 1957. Infectious and parasitai pneum opathies 1. D rankin, D. I., a n d Gerasim ova, M. M .: B rucello sis and occupation. Gig. T ru d a , 2:8, 1958. 2. Gross, P.; W estrick, M. L.; McNerney, J. M.; and Pittsburgh, M. P. H.: Experim ental T uberculopneumoconiosis. .M .A. Arch. Indust. H ealth, 79:320, 1959. 3 H arris, H. J.: T reatm ent of Brucellosis. J.A.M .A., 173:109, 1960. 4. Ju n a k , G.: L epto sp iren in fek tio n en bei K a n ala r beitern. A rch. G ew erbepath., 75:565, 1957. 5. K the, J.: D ie Leptospirose als B erufskrankheit. A rch. G ew erbepath., 77:316, 1959. 6. King, E. J.: R ecent R esearch in Infective P n e u moconiosis. Proc. X II In t. Congr. Occup. H ealth, H elsinki, 7:283, 1957. 7. King, E. J.; Y oganathan, M.; H arriso n , C. V.; an d M itchison, D. A.: E xperim ental infective Pneumoconiosis. A.M .A. Arch. Indust. H ealth, 16:380, 1957. 8. R am say, J. H ., a n d Pines, A.: R esu lts of tre a t m ent of pneum oconiosis com plicated by tu b er culosis. B rit. M ed. J., 2 .345, 1959. 9. S ch p p ert, R.: L u n gentuberkulose als B eruf skrankheit bei M etzgern und bei in Landw irt schaft beschftigten Personen. Z. drztl. F ortbild., 52:417, 1958. 10. Spink, W . W .: C u rre n t status of th era p y of brucellosis in h u m an beings. J.A .M .A., 172:091, 1960. 11. T erz in , A. L.: Psittacosis--ornathosis--m am m alian pneum onitis (POMP) viruses in m an, m am m als and birds. J. Hyg. Epid. M icrobiol. Im m u n o l. (P ra g u e ), 2:129, 1958. Lung cancer due to occupation and radiation 1. C ausation of Cancer. B ritish M ed. B u ll. 14(2), 1958. 2. A sk-U pm ark, E.: B ronchial carcinom a in p rin tin g workers. Dis. Chest, 27:4, 1955. 3. A zhbel, S. I.: O n cancer diagnosis in p a tie n ts su f fering from toxic pneumoscleroses. H ig. Truda, 5:11, 1959. 4. B arborik, N . et al.: C arcinom a of th e lungs in electrolytic chrom ium plating. Prac. Lkarstvi, 70:413, 1958. 5. B aetjer, A. M.; D am ron, C.; a n d Budacz, V.: T h e distribution and retention of chromium in men a n d anim als. A .M .A . A rch. In d u st. H e a lth , 20:136, 1959. 6. B aetjer, A. M.; Lowney, J. F.; Steffee, M.D.; and Budacz, B. A.: Effect of chrom ium on incidence of lung tum ors in mice and rats. A.M .A. Arch. In d u st. M ed ., 20:124, 1959. 7. B id stru p , P. L.: O ccupational causes of lung cancer. T rans. Ass. In d u st. M ed. Off., 9:2, 1959. 8. B ohlig, H ., a n d Jacob, C.: D ie H ufigkeit des Lungenkrebses bei deutschen Asbestarbeitern. Proc. X II In t. Congr. Occup. H ealth, Helsinki, 5:308, 1957. 9. B rau n , W .: Krebs an H a u t u n d in n eren Organen, hervorgerufen durch Arsen. Dtsch. Med. W schr, 83:810, 1958. 10. B row ning, E thel: H a rm fu l effects of ionising ra diations. Elsevier M onographs: Industrial Toxic A gents. A m sterdam , 1959. 11. C em ber, H .: B ronchogenic carcinom a from rad io active particulates. Second United Nations Con ference on the Peaceful Uses of A to m ic Energy. Geneva, 1958. Paper A /C onf. 15/P/900. 12. C hiurco, G. A.- L avoro e tum ori. A rchivo di M edicina M utualistica, 4:Vol. 14, 1959 (372 pages). Vide also: Proc. X II Int. Congr. Occup. Health, H elsinki, 147, (Fr.), 139, (Engl.), 1957. 13. Davies, D. F.: A review of the evidence on the relationship between smoking and lung cancer. J. C hron. Dis., 11:519, 1960. 14. D oll, R .: O ccupational lu n g cancer. In th e Sym p o siu m on Ind u stria l P ulm onary Diseases, ed. by K ing a n d Fletcher. L ondon, 1960, p. 208. 15. D oll, R .: O ccupational lu n g cancer: a review. B rit. J. In d u st. M ed., 76:181, 1959. 16. Dvizkov, P. P.: O ccupational cancer. Gig. Truda, 4(3):3, 1960. 17. E ckardt, R . E.: In d u stria l Carcinogens. New York a n d L ondon, 1959. 18. E llinger, F.: M edical R adia tio n B iology. Springfield, 111., 1957, p. 224 ff. 19. E spinos-Prez, D.: C ancer p u lm o n a r y neumoconiosis. M ed . y seg. trabajo, 5:5, 1957. 20. Finkel, M iriam P.: In te rn a l em itters a n d tum or in d u ctio n . Proc. In t. Conf. Peaceful Uses of A to m ic E nergy, Geneva, 1955, Vol. 11. New York, 1956, p. 160. 21. Gallego, J. D.: Pulm onary lesions in pneum o pathies due to dust. Proc. X II Int. Congr. Occup. H e a lth , H elsinki, 5:378, 1957. 22. G oldblatt, M. W .: Occupational Carcinogenesis. B rit. M ed. B u ll., 74:136, 1958. 23. Grosse, H .: M ischstaubinduration der Hiluslym phknoten und Lungenkrebs. Frankf. Z. Path., 67:220, 1956. 24. H addow , A. (ed.): Causation of cancer. B rit. Med. B u ll., 14(2), 1958. 25. H a rris, W . B.; Breslin, A. J.; G lauberm an, B.; a n d W einstein, M. S.: E n vironm ental hazards associated w ith the m illing of uranium ore. A .M .A . A rc h . In d u st. H e a lth , 20:365, 1959. 26. H ueper, W . C.: E xperim ental studies in m etal cancerigenesis. X. cancerigenic effects of chrom ite ore roast deposited in muscle tissue and pleural cavity of rats. A.M .A. Arch. Indust. H ealth, 18:284, 1958. 27. Irm scher, G.: lie b e r einen Todesfall an chro nischer Pneum onie nach Inhalation von alphaund betastrahlenaktivem "Industriestaub" vor ru n d 20 Jahren. Das Deutsche Gesundheitswesen, 52:1732, 1958. NORWOOD 335 28. Jam es, W . R . L.: P rim ary lu n g cancer in South W ales coal-workers w ith pneumoconiosis. B rit. ]. In d u st. M ed ., 12:87, 1955. 29. K ennaw ay, E., a n d L indsey, A. J.: Some possible exogenous factors in the causation of lung cancer. B rit. M ed . B u ll., 14:124, 1958. 30. Koelsch, F.: D e r A rsenkrebs. Z bl. A rb e itsm ed ., 5:129, 161, 1958. 31. M cL aughlin, A. 1. G.: Iro n as a C arcinogen. In the Sym posium on Industrial Pulm onary Diseases, ed. by K ing a n d Fletcher. L ondon, 1960, p . 162. 32. Puccini, C.: L e pro b lem a della cancro-silicosi. M ed. L avoro, 51:18, 1960. 33. R inck, H .: D er C hrom atkrebs d e r L unge als B e rufserkrankung. M edizinische, 342, 1956. 34. Sepke, G.: Z um Schneeberger L ungenkrebs. Zbl. A rb . M ed., 7:114, 1957. 35. Sm ith, R . A.: L u n g C ancer in Coal-M iners. B rit. J. In d u st. M ed ., 16:318, 1959. 36. S u n d erm an , F. W .; D onnelly, A. J.; W est, Bob; and Kincaid, J. F.: Nickel poisoning. A.M .A. A rch. In d u st. H e a lth , 20:26, 1959. 37. S underm an, F. W .; K incaid, J. F.; D onnelly, A. J.; and W est, Bob: Nickel poisoning. A.M .A. A rch . In d u st. H e a lth , 76:480, 1957. TREATMENT OF PLUTONIUM DEPOSITION IN HUMANS WITH DTPA -- EFFECTIVENESS OF LONG-TERM ADMINISTRATION AND ORAL ADMINISTRATION* W . D a g g e t t N o r w o o d , M .D . M anager, H ealth O peration, H anford Atomic Products O peration, operated by G eneral Electric C om pany fo r the Atomic Energy Commission R ichland, W ashington T h e recom mended m axim um permissible am ount of soluble p lu to n iu m (Pu 239) in th e h u m a n body is 0.04 m icrocurie -- 0.6 pg (1). R ig id control m ethods are necessary to lim it body deposition to this extent. For instance, allowable concentrations in air are lower by a factor of m illions than the comparable allowable concentrations of m any of o u r most toxic chemicals. T here w ill be increasing potential for exposure to such isotopes w ith the expanding use of such m aterials in industry, defence, and medicine. Hence it becomes most im portant to have the safest, best, and m ost con venient m ethod possible for treating the individual who has accidentally acquired a deposition of P u 239 which exceeds the m axim um permissible lim it. T reatm en t, here, of five employees w ho h ad h a r bored small quantities of Pu 239 for some years in d i cated that intravenously adm inistered diethylenetriam inepentaacetic acid (DTPA) was m uch the most effective agent discovered to date for increasing the u rin ary e lim in a tio n o f P u 239 (2). T h e present study was m ade to improve knowledge of th e effectiveness of D T PA in elim inating P u 239 via th e u rine w hen treatm ent is extended over a p e riod of m any m onths. I t was also directed tow ard determ ining the effectiveness of D T PA in increasing elim ination of Pu 239 via the urine and feces when adm inistered orally. Long-Term A dm inistration of DTPA An employee who had accidentally received a depo sition of a b o u t .4 m icrocurie of Pu 239 som e 30 m onths previously was treated with D TPA intraven ously. Initially the daily urinary o u tp u t of P u 239 was a b o u t 665 d isintegrations p e r m in u te p e r 24 -h o u r specim en of u rin e (T able I). It was considered advis able to cautiously continue treatm ent over an extended period unless evidence of kidney irritation or other untow ard effect appeared during the treatm ent. T h is * T h e D T P A fo r this study was kindly supplied by Dr. M urray W einer, Ceigy Pharmaceuticals, P.O. B ox 430, Yonkers, N ew York. R . H . W ilson was most h elp fu l in coordinating sam ple collection and assisting in the interpretation of results. G. D. Brown and staff perform ed the bioassays of the m any samples. would serve the dual purpose of elim inating a fair am ount of Pu 239 and indicating w hether or not there was .a change in effectiveness of this agent w hen used over an extended period. T able I EFFECTIVENESS O F INTRAVENOUSLY AD M INISTERED DTPA IN INCREASING U R IN A R Y EX CRETIO N O F PU 239 W H E N GIVEN FOR M ANY MONTHS W eek of Treatm ent D ose-- D T P A in Grams Per Week Average D aily U rinary Excretion of Pu 239 Expressed as D isin teg ratio n s Per M inute Effectiveness Expressed as % of Initial Effectiveness 1 2 665 100 2 1.6 610 92 N o treatm ent for period of 5 weeks 12 11-12 1.6 481 72 13-14 2 495 74 N o treatm ent for period of 5 weeks 15 26 2 496 74 27 2 436 66 33 2 246 37 46 2 190 29 50 2 125 19 A verage daily elim ination of Pu 239 for periods preceding and follow ing the above treatment was 12 d isin te g ra tio n s p e r m inute in 24 hours. Except for m inor changes as shown in T able 1, the employee was given 1 g of DTPA intravenously, in the M anufacturing Area Medical Center, on Monday and 1 g on T h u rsd ay of each week for three successive weeks. Such periods of treatm ent were alternated with periods of three weeks of no treatm ent. T h is was con- 610 SOCIAL AND LEGAL ASPECTS dem ent above the loss of wages the longer he was off work. T his case illustrates how an individual deliberately perpetrates his disability on a subjective basis in order to increase the size of his m onetary settlem ent. C asf N o . 3 -- A 37-year-old trainm an was injured w hile standing too close to a slowly m oving train when his arm was struck by a grab iron, causing him to spin around and strike his head against the side of a car H e received a 5-cm vertical laceration across the m iddle of his forehead. T h e m an was stunned but re m ained on his feet T h e laceration was repaired at the plant dispensary. X-rays of the skull were negative. T here were no other injuries except for a slight con tusion of the right upper arm Neurologic exam ina tion was entirely negative and rem ained so thereafter. No tieatm ent was indicated other than analgesic m edi cation for pain T h e patient did not work his next tu rn and was seen again the follow ing day. T h e previ ous night he had a m ild headache b u t was now asymptomatic. Exam ination was again negative T he patient was seen again four days after the accident. T h e sutures were removed, and adhesive bridges were applied. His only com plaint was occasional frontal headache which was relieved by aspirin. H e had not returned to work; and when questioned as to why, he gave some vague com plaints of soreness in his right arm and upper back Exam ination was again negative for objective findings. It seemed to the physician that the m an believed he could and should be working but fo r som e reason h a d n o t done so. H e was form ally approved for work and was so advised. T h e p atien t returned to work six days after the accident and worked fo r several hours b u t th en reported off because of headache. H e was seen again the following day, com plaining of headache, dizziness, and soreness of the u p p e r back and right arm . T h e laceration was healing well. Exam ination results were negative once again. H e apparently did not intend to work; he was treated sym ptomatically and seen again one week later, at which tim e his condition was unchanged. Fol lowing this visit he was not seen again for another two weeks. It was then 24 days since the injury. T h e patient had taken his vacation in the interim , for which he had received vacation pay. H e offered no complaints, and the exam ination was again negative. T h e m an finally returned to work 30 days after this injury and rem ained at work thereafter. He instituted litigation against the company, because he demanded com pensation ab o u t seven tim es his actu al loss of earnings, and the company refused to grant the claim. Each tim e this patient was seen durin g the 30-day period it seemed that he really believed he could work and that he actually wanted to. He was phys ically able and was not considered as having posttraum atic neurosis. W hy then did he not work? T here appeared to be several reasons. W hile the patient was being treated in the dispensary shortly after the acci dent, a company representative rem arked that it w ould be good if he did not miss w ork, since his work group had gone for an unusual length of time w ithout a lost-time accident. T his was interpreted by the pa tient and his fellow workers as com pany interest in avoiding lost tim e ra th e r th a n th e em ploye's welfare. R esentm ent was incited and led to deliberate lost tim e. T h e p atient was also encouraged to miss work because he had a head injury which required suturing A nother factor which played a part was encourage m ent by certain parties to deliberately perpetrate u n necessary lost time for the purpose of establishing a claim against the company for income greater than his regular earnings T his case illustrates how m anagem ent action, work group standards for lost time, and litigation practices in work groups interfere with the medical manage m ent of the injured employe and create unnecessary disability leading to excessive m onetary gain. Sum m ary In sum m ary, I have outlined certain socio-economic factors that have a negative influence on the disabled employee. T h e discussion has dealt w ith why and how such factors in te rfere w ith the in d iv id u a l's recovery from an occupational injury, w ith the thought that a clearer understanding m ust precede any effort to do anything about them. BASIC PRINCIPLES FOR PRECAUTIONARY LABELING E dward J. H ogan V ice-Chairm an, Labels and P recautionary Inform ation Comm ittee, M anufacturing Chem ists' Association, Inc; ; P a c k a g in g C o o rd in a to r, A llied C hem ical C o rp o ra tio n , New Y ork, N. Y. It is a n hon o r an d a privilege to speak to you, as a representative of the M anufacturing Chemists' Association, regarding one if its activities. T h e M an ufacturing Chem ists' Association is an incorporated national trade organization composed of more than 180 com panies engaged in th e m an u fa ctu re a n d sale of chemicals. These companies account for m ore th an 90 per cent of the chem ical production capacity of the U nited States. From its founding in 1872, th e MCA has been concerned with the many problem s accompanying the growth of the chemical industry. Prom inent among these has been the p rom otion o f safety, an d the A sso ciation is p ro u d of its contributions to the record of chem ical m an u fa ctu re rs in th is regard, w hich is am ong the best in all industry. T his achievem ent is the m ore notable in view of the inherent hazards in many of the industry's processes and products. T h e A ssociation's interest in safety goes fa r beyond th at of its m em bers' employees to include those transporting, handling, and using its products. T he objectives are prom oted in a num ber of ways, but I shall discuss at this tim e only that phase concerned w ith the labeling of chemicals to instruct those hand ling or using them how to do so safely. In the early days of the industry both the chemicals distributed and the trades using them were lim ited in num ber and each had been long established. Cus tom ers w ere so accustomed to the use of the existing com pounds th at specific instructions seemed unnec essary, and such w arning labels as were used on industrial chemicals were lim ited to the stronger HOGAN 611 adds and alkalies, and extrem e poisons. T here were, o f course, th e 1927 Federal Caustic Poison Act and a num ber of state poison and pharm acy acts, but these were chiefly directed to the labeling of house hold packages. In most cases they were pointed toward the hazard of ingestion and relied solely on the word "PO ISO N " to w arn the user. T he expansion of the industry and the broadened use of its products brought recognition of the need fo r m ore comprehensive labeling. One of the early steps in this d irec tio n cam e in 1934 a n d covered the uniform precautionary labeling of six products or product groups under a series of voluntary agree m ents between the m anufacturers of these products and the Surgeon G eneral of th e U nited States. T hese agreements served a very useful purpose u n til they were discontinued by the U nited States Public H ealth Service in 1952 because specific labels for these p ro ducts which had, in the m eantim e, been developed u n d e r th e M a n u fa c tu rin g C hem ists' A ssociation's program were considered m ore appropriate. As chemical products, especially in the organic group, m ulitiplied and grew m ore complex, the need for further steps became evident. T his was emphasized by a survey cond u cted by th e A ssociation in 1936 which resulted in distribution to its m em ber executives of a printed book titled "A Confidential R eport on A dequate Labeling--Its Im portance to the Chemical M anufacturer." T his report persuaded many com panies to em bark upon their own warning label program s or to expand those already begun. W orld W ar II greatly accelerated the growth of our industry. N ot only did established companies ex pand th eir production of well-known chemicals, bu t they developed innum erable new ones. Many cor porations from other segments of industry, as well as completely new concerns, began chemical m anu facture. And--most im portant of all, from the point of view of precautionary labeling--thousands of in dividual companies, large and small, and m illions of workers began to operate processes using chemicals entirely foreign to any of their previous experiences. T he need for a comprehensive program of education in the safe handling of chemicals was obvious. Early in 1944 MCA considered th e pro b lem at a m eeting of its m em ber executives. It was decided th at the best m ethod to reach the m an in the shop using chemical products was by means of instruction labels, and the form ation of a "Labels and Precautionary Inform ation Com m ittee" was accordingly authorized. T h e LAPI Com mittee, as it has since been popularly called, m et fo r th e first tim e on May 17, 1944. T o insure a broad view of the problem , the members selected included those w ith chemical, m edical, legal, research, adm inistrative, and sales backgrounds. Since that date, this has been a continuing and active comm ittee. T h e work of L A PI is well know n to industry and adm inistrators of health and safety pro grams through its publication "W arning Labels A Guide For the Preparation of W arning Labels for Hazardous Chemicals." T his m anual, frequently re ferred to as th e "LA PI M anual," is now in the review stage, with a Fifth Revision scheduled for publica tion this year. It m ight be assumed that, having agreed upon the need for precautionary labeling, the writing of labels would be sim ple. A ll one need do, you w ould say, is to m ark a hazardous product POISON and add the d o 's a n d d o n 'ts. U n fo rtu n ate ly , th e problem is m ore involved than that. W hat are the m eanings of the term s used? C hem i cals may be h arm ful in a variety of ways. A product which may threaten your life solely by ingestion should not be labeled the same as one that may kill by absorption through th e skin. O f course, there is also the m atter of degree. H ow shall we distinguish between the vapor or gas which asphyxiates and one which causes cyanosis? W hat really is a "poison"? T here is the difficulty of language. Statem ents must be brief but accurate. They m ust be expressed in terms that ordinary workmen understand. N ot only must the statem ents help avoid accidents, but if such occur, first aid should not be delayed w hile someone hum s an interpreter. In the case of trade-nam ed chemicals or proprietary com pounds, w hat is our responsibility to the doctor who may be asked to treat persons injured by them? As a result of these and m any sim ilar questions, the following principles were adopted. These principles are set forth in detail in and comprise Part I of the LAPI M anual. 1. Each chem ical p ro d u c t presents a distinct p ro b lem and m ust be treated individually in the light of its own characteristics. Conclusions regarding the hazards of a product cannot safely be drawn either from the properties of the m aterials from which it is form ed o r by analogies based upon chemical struc ture. M ixtures of two or m ore chemicals may have properties th at vary in kind or degree from those of the individual components; any warning label for m ixtures should be based on the properties of the finished product. Im purities may contribute hazardous properties an d should not be overlooked. 2. All statem ents on w arning labels should be brief, accurate, and expressed in sim ple, easily u n d e r stood terms. 3. P recau tio n ary lab elin g should be used only w hen and to the extent necessary. T h e language should be practical, not based upon the inherent properties of a product alone, bu t directed toward the avoidance of hazards resulting from such use, handling, and storage as may reasonably be anticipated. T he use of w arning labels for relatively harmless products or the use ot unnecessary words will develop a disregard for labels and defeat th eir purpose as surely as will failure to give adequate notice of hazards. 4. On labels of different products uniform ity in lan guage to indicate the same hazards and same degrees of hazard is m ost desirable in order to gain greater understanding through standardization. 5. T h e following subject m atter should be con sidered for inclusion on a w arning label: (a) nam e of product; (b) signal word designating degree of hazard--DANGER!, W ARNING!, or CAUTION! (c) A ffirm ative sta te m en t of hazards; (d) precautionary measures covering actions to be followed or avoided; (e) In stru c tio n s in case of contact o r exposure w here advisable. (N O T E : un d er some laws antidotes are re q u ired w hen th e w ord "PO ISO N " is used.) Instruc tions for the handling and storage of containers should also be considered fo r inclusion on the label. T his is inform ation relating to characteristics of the con tain er as well as those of its contents.* 6. T h e inclusion of th e w ord " PO ISO N " a n d the skull and crossbones on a label should be lim ited to those cases w here the product is a poison according 612 SOCIAL AND LEGAL ASPECTS to a definite toxicity sta n d ard o r w here such use is Parts II and III of the LAPI M anual contain several prescribed by law. W hen used, this legend should be hundred illustrative labels such as th e one shown. in a d d itio n to the o th e r label w arnings a n d should T h o se in P a rt 11 are for in d u stria l chem icals. E x not take the place ot the words DANGERI, W A RN amples included are generally for those products most ING!, and CAU TIO N!, which are designed to show im portant commercially, and, as a whole, they take in the relative degree of hazard.f a broad range of hazards. T he labels in Part III cover 7, A nondescriptive code designation o r trad e nam e th e m ajority of pesticides sold in large volum e. T h is should not be used as the only identification of a section was added following the passage of the Federal hazardous chemical. If the complete nam e is not shown, the label should clearly state the type of Insecticide, Fungicide, a n d R o d e n tic id e A ct in 1947. T h e latter requires adequate w arning labels for this chemical--e g , "Corrosive Acid", "Lead C om pound" . im portant group of chemicals, and the MCA labels 8. W arning statem ents should be g rouped together have th e inform al approval of th e U n ited States D e in a prom inent location on the label and should be partm ent of A griculture and are consistent with its p rin te d in easily legible type w hich is in contrast by In te rp re ta tio n 18, Revision 1. typography, layout, or color with other printed m at How successful is the LAPI Program ? As may be ter on the label. T h e label should be affixed firmly to expected, th e LAPI principles have th e broad support and in a conspicuous place on the container. of MCA members, who, as stated earlier, represent In accordance w ith the principles just stated the 90 per cent of the U S production of industrial usual w arning label includes: (a) a "signal" w ord-- chemicals. In fact, chem ical m anufacturers, both in "D A N G E R !", " W A R N IN G " , or "C A U T IO N "-- to give a n d o u t of the Association, fully su p p o rte d these a general indication of the severity of hazard; (b) principles. T h e very fact that such a program exists a statem ent of hazard o r hazards--such as "V apor and is supported exerts a persuasive force upon the Extremely H azardous", "Causes Burns," or "R apidly m anufacturer who m ight otherwise neglect proper A bsorbed T h ro u g h Skin"; (c) p re ca u tio n a ry m easures labeling T h e latter knows th a t, sh o u ld h e b e called p * --such as "Do not breathe vapor," "Keep away from to court because of claimed injury by one of his heat and open flame," or "Avoid contact with skin inadequately labeled products, the opposing counsel and eyes"; and (d), w here appropriate, instructions w ould surely cue the w arning statem ent used on in case of accident, as "In case of contact im m ediately sim ilar competitive products. flush skin or eyes for 15 m inutes; for eyes get m edical W ithin m onths after the organization of the LAPI attention." C om m ittee in 1944, its chairm an was asked to serve U sing these o r sim ilar statem en ts, a ty p ical lab el as advisor to the State of California, w hich sub may read: sequently became the first of several states to regulate A N IL IN E DANGER! HAZARDOUS LIQUID AND VAPOR RAPIDLY ABSORBED T H R O U G H SKIN the precautionary labeling of hazardous chemicals. Besides California, the ensuing years have seen sim ilar regulations or laws adopted by Connecticut, O regon, H aw aii, Illinois, T exas, N ew Jersey, New' Do not get in eyes, on skin, on clothing. York State and New York City. All have been based Avoid breathing vapor. upon the MCA principles. Use only with adequate ventilation. Reference has already been m ade to the Federal In case of contact, im m ediately remove all Insecticide, Fungicide, and R odenticide Act, and to contam inated clothing, including shoes, and the lact th at LAPI labels comply w ith the regula flush skin or eyes w ith plenty of w ater for at tions issued pursuant to it. least 15 m inutes; get m edical a tte n tio n . W ash At meetings of the International Labor Organization, clothing before re-use. h e ld in Geneva, Sw itzerland, th e M CA's p re c a u tio n POISON ary labeling system was endorsed and m uch of its content adopted for ultim ate use by ILO on a world \ * A u lh o r's N o te: T h e M a n u fa ctu rin g C hem ists' Associa w ide basis. tio n has available at its office, 1825 C onnecticut A committee of the International Association of A ven u e, N .W ., W ashington 9, D.C., at n o m in a l cost, a G overnm ental L abor Officials, w hich consists of U.S. ! series of individual Chemical Safety Data Sheets on and Canadian state, provincial, and federal adm in the properties and essential inform ation for safe hand istrators, has developed a "Suggested D raft for U ni ling and use of 79 chemicals, M anuals on Standards form Rules and Regulations relating to the Labeling and R ecom m ended Practices on the use and handling for Use, H andling, and Storage of C ontainers H old of specific containers, and an outline of recom m ended ing Substances H arm ful to the Safety a n d H ealth of general precautions for handling and storage of cer Employees." T his draft adheres to LAPI principles tain classes of containers in the M C A L A P I M anual. an d was th e foundation for th e cu rre n t regulations T h e se data w ill serve as excellent g uides in th e devel in New Jersey a n d New York State a n d City. opm ent of applicable phrases for container handling In this highly regulated era--when all of us, and and storage statem ents. industry particularly, are subjected to m any restrictive laws and regulations--it is to th e credit of the chem {Author's N ote: T h e w ord "P O IS O N " has been used ical in d u stry th a t its a dequate lab elin g practices began indiscrim inately in the past, and its m eaning has been as a voluntary program and th at the labeling legis ill defined. For labeling purposes the M CA M anual lation of recent years has been in support of the recognizes poisonings by three modes of entry--viz., industry's principles rath er th an controverting them . ingestion, inhalation, and absorption through skin-- F u rth e r evidence of the L A PI C o m m itte e 's in b u t lim its use of the w ord to those cases w here th e fluence is th e fact th at definitions for " PO ISO N " sub toxicity has been demonstrated, either by hum an ex stantially identical with that of its m anual were perience or laboratory anim als tests, to exceed certain w ritten into the regulations under the Federal In defined limits. secticide Act and have also been substituted in the KLEIN 613 Interstate Com m erce Commission Regulations for the forme.r definition of "Class B. Poisons." Again, LAPI has been instrum ental in obtaining the acceptance of th e word "flam m able" by ICC and other public agencies as less likely to be m isunderstood than "inflam m able." Its rep u tatio n has extended so far th a t in 1953 th e Association of B ritish Chemical M an u factu rers, w hich is M CA's B ritish c o u n te rp art, sent representatives to this country solely to study th e LAPI program and subsequently adopted one p ar alleling it. T h is program is receiving additional im petus from other trade associations, which have been most gener ous in their cooperation. As already indicated, the LA PI objective is principally aim ed at industrial chemicals. W hile the principles are generally accept able to all groups, their application may vary in detail for different segments. A committee of the Chemical Specialties M anufacturers Association has prepared a m odel law for the labeling of household products. Directions for use are usually an im portant addition to sm all household packages and may convey inform ation for proper use which supplem ents the precautionary statem ents. Similarly, the American Pe troleum In stitu te recently published a m anual of pre cautionary labels for petroleum products as distinct from petrochem icals. Both associations support I-API principles. T h e common aim of all these groups is the adequate and uniform labeling of the hazardous substances which they produce. U niform ity is essential for the free flow of com m erce and im p o rtan t in educating people to understand the significance of label w arn ings. T h e public m ust be led to recognize that chem i cal products may, on occasion, be hazardous and re quire care in handling, just as experience teaches us th at care in handling is necessary w ith edged tools and w ith electrical and m echanical devices. U nlike the latter, which seldom carry w arning labels, chemicals will always require some precautionary labeling, because their properties can seldom be deter m ined by visual inspection. In conclusion, I should like to emphasize th at any precautionary labeling program based upon the p rin ciples set forth by the M anufacturing Chemist's Asso ciation could not be considered experim ental. T he concept on which such a program was based has been tim e-proven and accepted in sim ilar program s in te r nationally. W ith such a program you have not only taken out insurance on the future of your products, but you have provided a necessary adjunct in the fundam ental obligation to w arn of the health hazards involved in the use of either new or established products. I thank you! THE CARDIAC CASE IN WORKMEN'S COMPENSATION I r v in K l e i n , M.D. M edical D irecto r, W o rk m e n 's C o m p en satio n B o a rd , S tate o f New Y ork It is my great pleasure to be able to address this th irteen th Intern atio n al Congress on O ccupational H ealth. It is significant that common problem s know no national boundaries, and together we have sought remedies in different countries of the world for over 30 years. I t is ap p are n t th at this is the only sound m ethod by w hich we can solve these problem s. It is of additional significance that we are thus able to set a good exam ple of the way in which other m atters m ay be disposed of. T his afternoon we are to consider the cardiac case in w o rk m e n 's com pensation. T o m erely dism iss it w ith th e wave of the hand is unw orthy of the talent and intention of this organization. A search into the causes and results in this area is necessary and im portant. T h ere is a continuing and growing interest in th e cardiovascular episodes during and in the course of em ploym ent. Recently great attention has been paid to the increasing num ber of these cases w hich have come before th e w orkm en's com pen sation boards for evaluation and adjudication. In New York S tate for th e years 1947 to 1957 th e figures have risen from 167 com pensated cases to 545. F o r the first six m o n th s of 1960 u p to 150 cases w ere closed w ithout aw ard for many reasons (failure to prosecute, w ithdraw al of claim, and failure to make out a proper case after trial). T h e most frequent involvem ent has been the coronary arteries resulting in postocclusive angina, failure, pulse irregularities, and infarction. I t is n o t necessary at this time to review the var ious skills involved in the diagnostic procedures, nor is it necessary to review the need for p roper history and record keeping. W e can safely assume th at the train ed physician is fully aw are of the need for these. T here remains, therefore, only the consideration of the relationship of the pathologic process to the work load and the proper rehabilitation of the pa tient. It is suggested th at the exact m echanics involved in the closure of a coronary vessel and the resultant m yocardial infarction are not fully understood It m ust be fu rther conceded th at the sclerotic process begins fairly early in adult life and this, undoubtedly, plays a large part in the occurrence in industry. It has been the philosophy that the working man is hired for his abilities along w ith all of his dis abilities, w hether m anifest or hidden. It is therefore incum bent upon the physician to be the first to rec ognize this in industry. O thers should be cognizant of this as well. It appears to me th at no defenses can be set up on the thought th at in a given case with any degree of sclerosis the clinical end result would have occurred in any event. W e m ust recognize that this type of reasoning leads nowheres, since general izations have little value in this area. It is best to be prepared to take an attitude which appears rea sonable to ordinary analysis and be ready to review each case on its own m erits. Recognition that we do not have a full explanation at this time should not preclude us from draw ing a conclusion. It is im portant to keep in m ind th at the legal process is the dom inant factor when the cardiac case in industry is discussed. T oo often the physician becomes involved in a case to a point beyond his medical sphere. At that point he attains the status of an advocate in the proceedings for which he is not trained, for which he is obviously ill prepared and 988 MAXIMUM ALLOWABLE CONCENTRATIONS daily work w ithout intervals (which are not considered in stating MAC either) perform ing physical work w hich req u ires average m in u te lu n g volum e of 12:1 (or 10:1; low er volum e could be considered only for entirely sedentary work). From this calculation it tvas evident th a t a w orkm an absorbs 3.4 g (or 2.8 g) of trichlorethylene in eight hours, modifies it into 850 m g (700 mg) of trich lo racetic acid a n d in to 1897 m g (1412 mg) of tric h lo reth an o l. It is difficult to say how g re at is the pharm acologic effect of daily adm inistration of 3 g of trichlorethylene, due to the fact that it does not occur in such doses in medical practice. In the past years 1 ml was adm in istered per case in cases of angina pectoris or neuralgia n.trigem ini, four times a day m axim um. Beforehand, however, we can suppose a hypnotic effect especially if we take into consideration th at th e in te r mediary product in the m etabolism of trichlorethylene is chloralhydrate T he ascertained daily dose of tri chlorethylene corresponds, according to the American MAC, to 4 3 g of choralhydrate It is well know n th at th e c u rre n t hypnotic dose is 1-2 g, a n d it is also known that chronic intoxication with chloral is not very rare and is sim ilar to chronic in to x ic atio n w ith trichlorethylene It is also possible to see to the effect of tric h lo r ethanol, w hich is the p rin cip al m etabolite of tric h lo r ethylene and, in our opinion, it is prim arily responsible for the symptoms of intoxication. Owing to the fact that pharmacologic literature does not often m ention this substance, we can com pare it with tribrom ethanol. Narcosis is attain ed by this substance after a dose of 3.5-5.6 g in a m an w eighing 70 kg. In o u r case th ere forms 1 9 g of trichlorethanol daily I think that these considerations result in the fact th at the Am erican MAC is rath er too high. If it was created from experim ents w ith animals, it is necessary to declare that anim als are not suitable in trichlor ethylene cases because they have great desaturations by lungs and have entirely different ways of m etabolizing trichlorethylene. T h e dose required by Swedish authors, 50 mg of trichloracetic acid in urine, corresponds theoretically only to the Soviet MAC-- th a t is, 9 ppm a bout 50 From our previous experiments, where we consid ered only trichloracetic acid in smaller percentage, 16 p e r cent was fo und th a t in lower concentrations of trich lo reth y len e in a ir (up to about 400 ig per liter-- th a t is, 75 ppm ) th e ra tio of trichloracetic acid in m g to trichlorethylene in fig in I I of a ir is ab o u t 1:2. T h is ratio was decreasing w ith the increas ing concentration of trichlorethylene. Several obser vations from practice bear witness to this fact. From our recent experim ents results th at the ratio is th e oretically 1.1 (Souek-Vlachov4, B artoniiek). I think th a t it is not possible to give m ore accurate directions for practice, due to th e great difficulties occurring in practical work and thus we can conclude that this ratio lies w ithin the m entioned values IT or 12. On the basis of literature data that a great part of working people have health disturbances after a long-tim e w ork at 50 m g o r 100 m g of trichloracetic acid in urine p e r lite r we see th at it would corre sp ond w ith 100 to-`200 f ig of trichlorethylene in air T h is co n centration in a ir corresponds w ith 100-200 fig of trichlorethanol in urine For the purpose of solving the question of MAC values in the most im portant industrial poisons there ought to be available a great num ber of carefully m ade observations in practice. It is also necessary to investigate, in laboratory experiments, the absorption, m etabolism , and elim ination of these substances. For m edical thinking it is acceptable to consider the actually absorbed dose. Experim ents with animals are suitable only for the orientation of newly intro duced chemical substances. SCIENTIFIC BASIS FOR THE ESTABLISHMENT OF TOLERABLE LIMITS ADOPTED IN THE UNITED STATES FOR THE PRINCIPAL INDUSTRIAL TOXINS C h a r l e s R. W il l ia m s , P h .D. A ssistant Vice P resid en t, L iberty M utual In su ran ce C om pany, Boston, M assachusetts In the U nited States, hygienic standards (tolerable limits) for inhalation are developed for the purpose of providing guides to be used for controlling expo sures to toxic m aterials in industry. T hese guides are dependent on the basic philosophy that for most such m aterials there are levels of exposure which can be tolerated w ithout adverse effect. T h e principal excep tions to this philosophy are those w hich are applied to carcinogenic an d sensitizing m aterials. So little is known of the processes of carcinogenicity and sensitiza tion that the tendency is to consider th at levels of known carcinogenic and sensitizing m aterials should be kept as close to zero as possible. T h e problem , then, is to develop inform ation which can provide a valid basis for establishing levels of toxic m aterials which can be tolerated in the industrial environm ent. T ER M IN O L O G Y In order to avoid confusion it m ust be poin ted out that there are differences in terminology w ith refer ence to acceptable values for exposures to potential toxic materials. T hus we find such terms as "M axi m um Allowable C oncentration," which certainly has the broadest usage; "Maximal Acceptable Concentra tion," which has been utilized by the American S ta n d ard s A ssociation Z37 C om m ittee (1); and "T hreshold L im it Values," which is used by the American Conference of Governmental Industrial H ygienists (2). All of these term s have th e same basic im plication--namely, that these values are allowable or acceptable or th at there is a lim it which denotes a fine line between toxic and nontoxic. As a m atter of fact, the users of these terms rarely accept the im plied connotations. T h e problem is one of semantics. In 1949 th e C om m ittee on C hem ical Agents at the 9th A nnual Congress on Occupational H ealth (United States) recom m ended that the term "Hygienic G uide" was m uch m ore descriptive of the actual utilization of th e num bers. In Septem ber, 1955, th e Am erican In d u strial Hygiene Association began publishing its WILLIAMS 989 "Hygienic G uide Series" using the term "Recom excess of the acceptable concentration p ro b m en d e d M axim um A tm ospheric C oncentration (8 ably would produce injury. W hen the level h o u rs)." In 1956 Sm yth (3) proposed th e use of has been established on the basis of a func "Hygienic Standards for Daily Inhalation." For some tim e th e w riter (4) has been urg in g th e general accept ance of the concept of "Hygienic Standard" or "H ygienic Guide," since these terms express much m ore accurately the actual purpose of the application tional change or discomfort, it is logical to assume that exposure to concentrations not greatly exceeding the acceptable concentration w ould not p roduce m aterially injurious effects. H ence it is im p o rta n t to understand the cri teria upon which any such maximal accept of such criteria in the occupational health field. able concentration has been established. T hough the purpose of the acceptable con ORGANIZATIONS centration is to m inim ize h ealth hazards, its im m ediate use is for guidance in establishing In the U nited States the establishm ent of hygienic engineering procedures to prevent objection guides is carried on by groups of com petent in d i viduals operating w ithin existing organizations and utilizing available technical inform ation. T h e Am er ican Standards Association, a private organization representing Am erican industry, has been sponsoring able concentrations of toxic or noxious m a terials from being present in the air of work places. Com parison of the results ot air analyses with those concentrations indicates acceptable conditions or otherwise the need, extent, and urgency of control measures. developm ent of standards in the occupational health Sam pling and analysis should be carried out field since 1941, chiefly th ro u g h its 7.37 Com m ittee. by competent personnel using an acceptable These "Am erican Standards" include th e scope and m ethod which will provide a reliable measure purpose as well as general physical-chemical and toxic properties, "Maxima] Acceptable Concentration," and sam pling and analytical m ethods and references Since th e ir sta rt 19 such sta n d ard s have been p u b lished, an d th e C om m ittee is continuing to be ex of exposure. A ir analyses in conjunction with acceptable concentrations of such atmospheric contam inants as are encountered in industrial opera tions serve as a m easure of exposure--not as a m eans of diagnosis of occupational disease. trem ely active in the field. T h e basis on which this Diagnoses should be based on a consideration C om m ittee operates is set forth in the introductory of all factors including results of clinical and statem ent provided w ith all of th eir standards, as physical exam ination as well as of air analyses, follows: means of assessing am ounts of m aterials in the body, and a knowledge of toxicologic "T he M eaning o f M axim al Acceptable Concentration" (1 ) effects of the m aterials in question. In the application of the standards, it should be kept in mind that: It is generally recognized th at there are (1) T h e acceptable concentrations serve as levels of concentration of atm ospheric con standards of good practice. tam inants to which a person may be exposed (2) T h ey serve as engineering guides. D e w ith o u t know n ill effects or discom fort. In sign and operation should aim at m ain I view of the im practicability of m aintaining taining all concentrations below the uncontam inated air in most industrial envir acceptable m axim um. onm ents, it is necessary to establish accept (3) T h ey should be a p p lie d a n d in te rp re te d able concentrations of atm ospheric contam by com petent individuals w ith a full inants encountered in industrial operations. understanding of the basis and lim ita T hese concentrations in themselves do not tions of the inform ation from which the represent a scale of relative toxicity: they standard has been developed. represent the concentrations of contam inants (4) It is advised th a t these standards are below w hich 11 effects are unlikely to be considered to be guides toward good experienced by any bu t hypersusceptible indi industrial hygiene and are not intended viduals. T hese concentrations are usually based as legal requirem ents. (5) T h e levels a re applicable only to ex upon data obtained by one or m ore of the posure to a single substance. In the following procedures: case of exposure to m ixtures, the effect (1) L aboratory tests on anim als may be increased o r decreased, and con (2) L aboratory tests using h u m an subjects (3) E n v iro n m en tal a n d m edical investiga trols should be based on th e specific situation. tions in plants A common feature of these procedures is that the experim ental exposure shall cor T h e American Conference of Governmental Indus trial Hygienists began its work in the standards field respond . to the norm al work p attern . T his in 1947. T hey publish annually a list of the m aterials, should be taken in to consideration also in the w ith values, which they call "threshold lim its." T he application of m axim al acceptable concentra values which are given represent the concensus of a tion values. T hree criteria have governed the establish m ent of these concentrations: (1) O rganic o r o th e r tissue changes (2) F u n c tio n a l reactio n s w hich h ave no discernible u n tow ard effects on health committee of qualified experts in the occupational health field. T hey are reviewed and brought up to date each year T h e most recent published list dated 1959 (2) contains values fo r 169 gases and vapors: 71 toxic dusts, fum es, a n d m ists; 11 m ineral dusts; a n d b ut cause im pairm ents, such as in-co- a list of 21 so-called tentative values. T h e basic ordinations and increased proneness to philosophy of th is g ro u p is set forth in paragraphs accidents (3) D iscom fort o r adverse sensory effects preceding its listing of values: In those cases in which the concentrations have been established on the basis of organic "T hreshold L im it V alues fo r 1959" (2 ) changes, it is logical to assume th at repeated T h resh o ld lim its should be used as guides exposure to concentrations significantly in in the control of health hazards and should 990 MAXIMUM ALLOWABLE CONCENTRATIONS not be regarded as fine lines between safe and dangerous concentrations. They represent conditions under which it is believed that nearly all workers may be repeatedly exposed, day after day, w ithout adverse effect. T h e values listed refer to tim e weighted average concentrations for a norm al work-day. T he am o u n t by which these figures m ay be ex ceeded for short periods w ithout injury to health depends upon a num ber of factors such as the n ature of the contam inant, w hether very high concentrations even for short periods produce acute poisoning, w hether th e effects a re cu m ulative, th e fre quency with which high concentrations occur, and the duration of such periods. All m ust be taken into consideration in arriving at a decision as to w hether a hazardous situation exists. Special consideration should be given to the application of these values in the evaluation of the health hazards which may be associated with exposure to combinations of two or more substances. Threshold lim its are based on the best avail able inform ation from industrial experience, from experim ental studies, and, when pos sible, from a com bination of the two. These values are based on various criteria of toxic effects or on m arked discom fort; thus, they should not be used as a common denom inator of toxicity, nor should they be considered as the sole criterion in proving or disproving diagnosis of suspected occupational diseases. These lim its are intended for use in the field of industrial hygiene and should be employed by persons trained in this field. They are not intended for use, or for m odi fication for use, in the evaluation o r control of community air pollution or air-pollution nuisances. These values are reviewed annually by the Committee on Threshold Lim its for changes, revisions, o r additions as fu rth er inform ation becomes available. T h e Com m ittee welcomes the suggestion of substances to be added to the list and also comm ents, references, or reports of experience w ith these materials. In addition to these two groups, the American Ind u strial H ygiene A ssociation has, since 1955, been publishing the Hygienic G uide Series. T o date guides have been p ublished for 97 substances. In m any respects this series is sim ilar to the recom mendations of Sm yth in his re p o rt to th e A.I.H .A . in A p ril 1956. Inform ation is provided for each m aterial relative to the recommended m aximum atm ospheric concentra tions; severity of the hazards (both health and fire); the short-exposure tolerance; atm ospheric concentra tions imm ediately hazardous to life; physical and chemical properties. In addition, under the heading of "Industrial Hygiene Practice," brief statements are given as to recognition, evaluation of exposures and recommended control procedures. Also, un d er the heading "Specific Procedures," brief descriptions are given of first aid, prophylactic measures, and special m edical procedures. Finally, a list of references is given. It is also significant th a t in each case, under the heading of "Recom m ended M axim um Atmospheric C oncentration," a statem ent is m ade as to the basis of the recommendation. T his approach represents by far the most desirable way of dealing w ith the problem of establishing hygienic standards. M ere lists of num bers leave m uch to be desired. I t is extremely im portant that all available inform ation relative to the establishment of the standard be included w ith it. BASES FOR TH E ESTABLISHMENT OF HYGIENIC GUIDES T h e establishm ent of num bers for "tolerable limits" in th e U nited States is based prim arily on two kinds of inform ation; anim al experiments and hum an ex perience. T h e scientific research which produces the basic d a ta is carried on by private industry, univer sities, research laboratories, and governm ental agencies. T h e results of such investigations are published in m any U nited States technical and scientific journals In some cases, particularly new chemicals, the tech nique of applying analogy with other well-known chem ically sim ilar m aterials has sometimes been used until valid data have been accumulated T h e committees or organizations referred to above utilize all available published and unpublished data in arriving at their judgm ents as to the kinds of levels w hich will provide a basis for safeguarding employee health. A nim al Experim ents T h e technique of evaluating toxicologic and physiologic responses in animals as a means of pre d ictin g possible effects of toxic m aterials, physical agents, or other environm ental conditions on m an has long been a routine tool in the occupational health field. InJ spite of this, however, there has been little attem pt m ade to provide a standardized approach to investigative techniques in industrial toxicology. In m any respects this is fortunate, for in dealing with the effects of a toxic m aterial on a biologic system considerable flexibility is required in applying estab fished criteria. Usually early tests will indicate the course of further study. T he m agnitude of acute lethal doses a n d th e effects on different organs will indicate the severity of the acute hazard and the im portance of various routes of absorption. Corollary inform ation relative to species variability, sex, age, and possible synergistic effects can be obtained at this time. All of this inform ation will then provide a basis for future, m ore extensive long-term studies In the case of new substances, the first step which is generally adopted by toxicologists or industrial laboratories in the determ ination of toxicity is the utilization of screening tests on experim ental animals T hese are usually followed by detailed studies of acute effects resulting from single injection, ingestion, or inhalation experiments. In addition, irritating effects on skin an d eyes are evaluated. In 1956 a com plete com pilation of acute toxicities for an extensive series of m aterials was published under the auspices of the Aero Medical Laboratory (5). T h e p u rp o se of this volum e was to b rin g together available data on "acute toxicity of various substances for several species of commonly used laboratory anim als as determ ined by oral or parenteral adm in istration, or inhalation, of fatal doses." In the in tro duction to this volume the various significant con ditions influencing the acute toxicity for any given com pound were discussed. T hese include the dose, the rate of absorption, route of adm inistration, site of injection, and other influences, including disease, environm ent, tem perature, hab it and tolerance, etc In addition, it was pointed out that the toxicity of chemicals w ill vary w ith species of anim als and some tim es even w ith different strains of th e sam e species. W ithin the same strain the toxicity may differ with age, w eight, sex, and general condition of the animals. WILLIAMS 991 Because of all these variables it is virtually impossible to be certain that all experiments are conducted in precisely the same way. In fact, only rarely does one find detailed discussion of all such factors involved in an experiment. F ollow ing accum ulation of d a ta on acu te effects, long-tim e chronic effects are th en studied through inhalation, feeding, injection, and skin-absorption ex perim ents. T h e n a tu re of these is determ ined by the results of earlier screening tests. A t a conference on T h e Toxicological Basis of T hreshold L im it Values in 1959 (6) V. K. R ow e a n d his cow orkers presented an extensive summary of the kinds of observations which had been m ade over a period of m ore th an 20 years by several industrial groups. T h is discussion summarized and tabulated observations on mortality, food intake, body weight, organ weights, gross pathol ogy, m icropathology, hematology, blood urea nitrogen, clinical urine analyses, central nervous system, and cholinesterase. Tables I-IV sum m arizing the frequency with which p a rtic u la r effects w ere observed u n d e r various circum stances give an indication of the significance of sev eral biologic and biochemical determ inations. T he significance of grow th studies and cholinesterase in T ables I and II and the significance of the liver and kidney in all of these studies are well dem onstrated in T a b le s II I a n d IV. T h e a u th o rs (6) p o in t o u t th a t there is increasing pressure for m ore and m ore precise kinds of measurements in the biochemical and toxi cologic fields as a m eans of establishing valid threshold limits. T hey point out, however, that while this is an excellent objective and one toward which all should strive, it is essential th a t one m ake the most practical use of available m anpow er and funds to obtain the most m eaningful inform ation. T he criteria which are set forth in this paper are those which are most widely used and certainly accepted by all workers in the field. T h e best hope for increasing our fund of knowledge derived from anim al experiments must come from the development of new techniques and new criteria. In sum m ary, the authors of this paper state: In spite of the fact that there are many new criteria being developed and tested today, the data presented herein emphasize the high value of certain of the older criteria. It would seem only prudent to make use of those studies which experience has shown to be most productive. T his does not mean that only those criteria showing a high degree of efficiency in the series of investigations re ported herein should be used, but certainly it suggests th at they should be basic to any toxicological study designed to determ ine a threshold lim it for repeated exposure. One o th er set of criteria which is attracting m ore and m ore attention are those physiologic studies which can be m ade on anim als as well as on hum ans. In th e sym posium m entioned above, Dr. Jo h n A. Z app, Jr. (7) discussed th e im p ortance of utilizing physiologic observations such as systolic and diastolic T able I FREQUENCY W IT H W H IC H A PARTICULAR EFFECT W AS OBSERVED A T THE LOW EST DOSAGE LEVEL A T W H ICH ANY EFFECT WAS OBSERVED (6) Criteria of effect Grow th Hematology Clinical urines CNS Cholinesterase Oral a 64 (172) 1 (79) 1 (7) 4 (109) 8 (10) D ata from 1952-1959 - Vapor % a % 37 16 (3 8 ) 42 1.3 1 (21) 5 14 0 (7) 0 3.7 1 (32) 3.1 80 D ata from last 22-25 years All routes a % 152 (410) 37 5 (170) 2.9 2 (43) 4.6 5 (141) 3.5 8 (10) 80 Number of positive findings (num ber of observations) T able II FREQUENCY W IT H W H IC H A PARTICULAR EFFECT W AS THE SOLE EFFECT AT THE LOW EST DOSAGE LEVEL AT W H ICH ANY EFFECT WAS OBSERVED (6) Criteria of effect O ral a D ata from 1952-1959 Vapor % a % Data from last 22-25 years AH routes a % G row th Hematology Clinical urine CNS Cholinesterase 25 (172) 15 0 (79) 0 0 (7) 0 4 (109) 3.7 4 (10) 40 2 (38) 1 (21) 0 (7) 1 (32) 5 44 (410) 11 5 1 (170) 0.6 0 0 (43) 0 3.1 5 (141) 3.5 4 (10) 40 'N um ber of positive findings (num ber of observations) WILLIAMS 99B term s of the significance of such inform ation in In such an extensive list as this there are many application to humans. m aterials which are so little used th at there is Human Experience negligible industrial experience available to assist our standards people. For such m aterials reliance is placed W hile anim al data provide some basis for judgm ent prim arily on anim al experiments and the use of about the possible levels of toxic m aterials which may analogy as guides in setting lim its be used safely in industry, they cannot be extrapolated For the m ore common industrial chemicals many to hum ans w ith complete confidence. T h e ultim ate years of experience in using them has provided the criteria m ust come from hum an experience T h e necessary background to verify existing standards validity of such criteria is based on the am ount of Such experience is generally of a negative nature. experience in term s of both num bers of exposed W here it is supported by clinical or physiological data people and tim e of exposure, on the m ethods of correlated with levels of exposure, as in the case of evaluation of the effects of the toxic m aterial on the ten-year study of butyl alcohol by Sternei and his p e o p le , a n d on th e com pleteness of th e evaluation of colleagues (10), th e info rm atio n is m ost significant. exposure levels in the environm ent and correlation Such medical program s are designed to evaluate the j of these levels w ith hum an exposure Data with general physical condition of employees and to include | reference to h u m an effects are obtained from both specific physiologic tests which may be expected to j controlled experim ents and industrial environm ent provide early evidence ot injury Studies of this type I exposures. are by far the most valuable for establishing valid jI as I no d othr e dceatseectioofn,irrsietannsotsry, forerspeoxnasme,plea,ndsuclheveflasctoorfs hygienic standards exposure w hich are irritatin g to eyes, skin, and upper respiratory tract have been studied quantitatively in SUMMARY AND CONCLUSIONS hum ans under controlled conditions In general, such In summary, it can be stated that hygienic standards studies, com bined w ith experience gained with actual for inhalation in the occupational health field in the p la n t use, provide an adequate basis for establishing U nited States are based on the application of the o r confirm ing hygienic standards for such substances. best known biochemical, toxicologic, physiologic, and It is m uch m ore difficult to provide a sound basis of pathologic techniques to anim als and to hum an h u m an experience for substances which require rela experience. Investigations are carried on by private tively long periods of tim e before producing evidence industry, universities, research laboratories, and gov of inju ry . W hereas the acute effects can be evaluated ernm ental agencies. T h e analysis of such data and relatively rapidly and by sim ple procedures, long-time interpretation in term s of hygienic standards is done detailed studies of controlled groups of industrial by standards groups composed of competent scientists w orkers are required to provide adequate evidence in representing every facet of the occupational health th e case of those substances w hich may produce field T h e validity of these standards is dem onstrated chronic injury. by the low occupational disease attack rate in the T h e kinds of inform ation w hich are available from U nited States. Verified cases of such injury are the in d u strial experience w ith various chemicals fall into result of exposures far above the established limits. th re e basic categories. O ne of these is lim ited to- com Many approaches are being made to the problem plaints associated generally with the sensory response of establishing hygienic standards in the occupational . or w ith m ore severe forms of acute irritatio n reactions health field It became obvious some tim e ago that I affecting skin, eyes, o r up p er respiratory tract T h e research people in various parts of the world were | second k in d o f d a ta resu lt from clinical exam ination in som e cases u tilizin g varying techniques As a result, J of exposed workm en. T h e th ird is the result of hum an values for some substances differ by as m uch as an s' toxicologic or physiologic studies. T o be of value in order of m agnitude In an attem pt to get some uni - establishing hygienic standards such m edical inform a fication in the basic approach to the problem and to tio n m ust be co rrelated w ith a d eq u a te d ata relating provide a m echanism 10 p e rm it a m uch b roader % to the concentrations to which workers have been exchange of inform ation and data among occupational | exposed. health workers, the Perm anent International Com I In his paper "Im proved Com munication. Hygienic mission on Industrial Medicine set up a Subcommittee j S tan d ard s fo r D aily In h a la tio n " Sm yth (3) reviewed to study this problem . T h is Subcom m ittee held a 238 values from th e 1956 A m erican Conference of sym posium on M axim um Allowable C oncentrations ! ; Government-! Indu strial Hygienists list, together w ith of T oxic Substances in Industry in Prague, Czechoslo- j his in te rp re ta tio n of these values. H e has also eval vakia, on April 14-17, 1959 T h e T ransactions of the uated th e n a tu re of the supporting data--anim al and Symposium, which appeared in four sections, deal hum an. An analysis of the four kinds of sources of with general areas of agreem ent among the delegates. hum an data indicates the role of such experience in T h is statem ent of principles is an im portant first step establishing hygienic standards in the U nited States. in establishing international cooperation in this im Of a to tal of 238 values w hich were analyzed hum an p o rtan t field O n th e basis of this work it is hoped d a ta w ere utilized in 108*, d istrib u ted as follows: not only th at we can look forward to the developm ent Clinical Exam ination of W orkmen W as of a series of internationally acceptable hygienic Correlated W ith T h eir Exposure 34 sta n d ard values b u t th a t agreem ent can be obtained Industrial Com plaints or Observations with regard to general principles and to methods and Less Q u a n tita tiv e T h a n C linical O bservations 33 procedures w hich w ill be utilized in th e establishm ent H um an Sensory D ata 42 of such standards. T h e present Symposium, which is H um an Toxicologic or Physiologic D ata 10 the second u n d e r th e auspices of the Subcom m ittee * 0 / the 119 values distributed in the above tabulation th ere were 11 duplicates w herein the sam e m aterial appeared under tw o or more headings; thus there were actually 108 separate substances analyzed. will, I hope, crystallize even fu rth er the thinking of those in the occupational health field concerned with establishing sound standards to be used in assuring safe industrial environm ents. 998 Eckardt, Robert E., 7-10, 64-65 Eckhardt, W., 850-857 Elkins, Hervey B., 981-983 Erhardt, J, Th. G., 850-857 Estadella-Botha, S., 663-668 ' Fabre, Ren, 686-692 Felton, J. S., 413-426 Ference, Anne M., 12-14 Ferran, G. H,, 486-503 Fiandaca, S., 353-359 Finulli, M., 770-772 Fischer, R., 872-876 Fisher, R. E. W., 250-256 Folsom, Marion B., 72-82 Formnek, J., 714-721, 872-876 Fornells-Martinez, E., 663-668 Forssman, Sven, 68-72, 257-258 Fortuin, G. J,, 258-259 Fournier, Et., 694-698 Frad, G., 259-260 Frantik, E., 714-721 Frantikov, D., 872-876 Friberg, Lars, 201-203, 977-980 Friedland, I. G., 692-694 Gabor, Sylvia, 465-466 Gasque, Mac Roy, 260-263 Gaultier, M., 694-698 Georgescu, A. M., 343-345 Ghosh, P. K., 426-427 Gillquist, B., 257-258 Glorig, Aram, 699-700 Goldman, Rose, 314-316 Goldstein, Bernard, 263-266 Goldstein, David H., 266-270 Gorospe, Alfredo A., 636-639 Gradina, C., 700-702 Grant, Ellsworth S., 118-120 Greene, Katrine R. C., 314-316 Grimaldi, John V., 607-608 Grimlund, K., 703-707 Gross, Paul, 707-712 Gucciardi, G., 259-260 Guymer, R. F., 270-275 Guyotjeannin, Ch., 694-698 Gwozdz, B., 795-798 Hamilton, Gilbert L., 656-661 Hargreaves, Margaret S., 275-278 Harris, E. S., 281-283 Harris, William B., 466-472 Hatch, T. F., 839-845 Hayes, Wayland J., Jr., 120-122 Hertig, B. A., 839-845 Hinchcliffe, R., 712-714 Hine, C. H,, 281-283 INDEX OF AUTHORS Hinkle, Lawrence E., Jr., 283-288 Hipps, John G., 608-610 Hogan, Edward J., 610-613 Holden, F. R., 281-283 Holm, A., 257-258 Holmquist, Carl-Eric, 122-126 Holstein, Ernst, 278-281 Holtz, John, 783-785 Horiuchi, Kazuya, 288-289 Horvath, M., 714-721, 872-876 Hueper, W. C., 473-486 Hughes, James P., 879-882 Hyatt, E. C., 486-503 Inoue, Toshi, 289-290 International Labour Office, 721-724 International Symposium on Maximum Allowable Concentrations of Toxic Substances in Industry, 33-39 Iorga, M., 341-343 Jensen, C. R,, 486-503 Juin, Grard, 942-947 Jullien, Georges, 724-726 Kammer, A. G,, 427-428 Kantor, M., 753-755 Kazantzis, G., 290-298 Keatinge, Gerald F., 298-301 Keenan, Robert G., 503-506, 783-785 Kehoe, Robert A., 126-129, 433-436 Kesy, Irena, 726-730 Killens, Richard, 783-785 King, E., 301-311 Kingston, James R., 911-917 Kitagawa, Tetsuzo, 506-512 Kiviluoto, Raimo, 311-312 Klein, Irvin, 613-615 Klutas, Edna May, 428-431 Kopp, John, 783-785 Kruger, Daniel H., 615-621 Krger, P. D., 971-973 Kubota, Juko, 313-314 LaBelle, Charles W,, 730-735 Lachnit, V., 947-950 Laham, Souheil, 686-692, 735-738 Lammers, B., 876-878 Landry, A. S., 512-519 Lavergne, Rafael, 214-217 Lehmann, Gunther, 878-879 Leoca-Radu, Mina, 349-351 Letavet, A. A., 431-433, 891-892, 983-987 Liber, Amour Fiscus, 738-740 Lieben, Jan, 316-319 Lienhard, Wendell F., 879-882 Lillis, R., 679-681 INDEX OF AUTHORS 999 Linch, A. L., 580-585 Lind, A. R., 882-887 Liniecki, J., 800-801 Littler, T. S,, 712-714 Lubin, Isador, 621-622 Lund, O.-E., 740-741 Lundervold, Arne, 887-891 Lutier, J., 401-402 Lutz, Earl F., 184-186 McCallum, R. L, 741-745 McClintock, R. S,, 879-882 McKerrow, C. B,, 745-749 McNerney, James M., 707-712 Magnuson, Harold J., 129-131 Malysheva, A. E., 891-892 Manheimer, Robert H., 314-316 Matthews, James, 131-134 Matuoka, Syukiti, 893-902 Maxlield, Mary E., 857-862 Meiklejohn, A., 134-138 Meila, I., 677-678 Metzner, Franz N., 316-319 Michon, R., 902-904 Mihaila, I., 904-908 Mikaelian, Michel, 320-322 Mikisha, A., 714-721 Milijic, Bosko, 950-951 Miller, S. E,, 937-939 Milox, M., 908-911 Minard, David, 911-917 Miskolczy, Wilhelm, 322-324 Mitchell, R. N., 486-503 Moise, Gh,, 676-678 Molfino, F., 952 Monaco, Alfred, 749-753 Morris, George E., 324 Morrow, C. S., 753-755 Moscovici, B., 341-343 Moss, N. Henry, 182-184 Motley, Arthur W., 623-624 Mountain, John T., 783-785 Moyer, Burton J., 519-522 Muica, N., 679-681 Murray, Robert, 139-145 Nadudvary, George, 465-466, 755-757 Naie, Thomas W., 625-628 Namba, Tatsuji, 757-758 Nestorescu, B., 679-681 Newnham, C. T., 324-325 Niebroj, I., 795-798 Nixon, James, 699-700 Noro, Leo, 326-335 Norviit, Lembit, 952-957 Norwood, W. Daggett, 335-338 Nystrom, A., 257-258, 653-656 Olloqui, Fernando Flores, 628-631 Oyanguren, Hernan, 227-230 Pafnote, Maria, 845-847 Paggi, Edoardo, 758-767 Pancheri, Giovanni, 145-146, 767-768 Parker, H. G., 147-150 Patrascu, M., 465-466 Payne, William W., 473-486 Pendergrass, Eugene P., 768-769 Pendergrass, Henry P., 768-769 Perales y Herrero, Narciso, 631-632 Pernis, B,, 770-772, 817-818 Pesce, Giuseppe, 958-959 Petrescu, Leonid, 661-663 Pettinati, L., 348-349 Petrovic, Lj,, 338-341, 368-371 Phillips, A. M., 553-556 Pietschmann, H., 947-950 Pilt, L,, 341-343, 679-681 Piotrowski, J., 780-782 Piscator, M., 201-203 Plumb, Carl S,, 260-263 Plummer, Norman, 283-288 Poleti, D., 338-341, 368-371 Potter, A. Lloyd, 150-155 Powles, William E., 351-353 Pradel, J., 522-531 Preda, N,, 343-345 Princi, Frank, 433-436 Puertas, Benito Nogales, 633-634 Quer-Brossa, S., 663-668 Quigley, J. A., 65 Radcliffe, J. C., 65-66 Rdulescu, I. C., 343-345, 679-681 Rae, Stewart, 772-776 Rainsford, S. G., 345-348 Rasetti, L., 348-349, 359-361 Raucher, Karl, 349-351 Reeve, A. Louise, 634-635 Renker, K., 917-921 Riedesel, M. L., 839-845 Riegrt, A. L., 819-825 Rgner, K. G,, 257-258 Risquez-Iribarren, Rafael, 155-158 Rogan, John, 772-776 Ross, W. Donald, 351-353 Rossi, Mario, 960-961 Rossier, P. H., 776-780 Rotta, C., 353-359 Rubino, G. F., 359-361 Rye, W. A., 361-364 Sakai, Yoshimichi, 158-162 Salmowa, J.,^780-782 Sands, Frederick W., 531-532 Santillan, Jose S., 636-639 Sarfeh, R., 436-438 Saruta, Namio, 532-535 1000 INDEX OF AUTHORS Savicevic, M., 338-341 Udel, Melvin M., 397-401 Sawyer, William A., 438-441 Ursoniu, C., 676-678 Scansetti, G., 348-349 Scheel, Lester D., 783-785 ' Schepers, G. W. H., 786-795 Schermerhorn, W., 850-858 Schiller, Hans, 961-962 Schindl, Karl, 364-365 Schmidt, Heinz-Gnther, 365-367 Schmidt, Marjorie D., 367-368 Schmidtke, H., 921-923 Schulte, H. F., 486-503 Schunck, Karl-Hans, 377-378 Schwartz, Louis, 639-642 Seles, L., 237-238 Serati, A., 963-965 Sherrill, S. S., 281-283 Shipman, Thomas L., 642-645 Vacher, J., 401-402 Valentin, H., 810-817 Van der Velden, W., 850-857 Van Liew, Hugh D., 911-917 Van Valzah, H. J., 678-679 Vigan, C., 965-971 Vigliani, Enrico C., 87, 452-457, 770-772, 817-818 3 Viles, Frederick J., Jr., 556-563 i Villarroel, Sergio, 227-230 1 Viola, P. Luigi, 818 Voelz, George L., 564-569 Vosburgh, B. L., 931-933 Shoib, M. O., 85, 162-166 Sick Absence Statistics Committee of the Perma nent Committee and International Association on Occupational Health, 40-55 Wade, Leo, 7, 61, 88 Silverman, Leslie, 441-448 Wald, Neil, 569-572 Simpson, H. Marjorie, 448-452 Walker, Mildred I., 167-169 Simu, George, 755-757 Walsh, Richard F., 645-648 Smith, Paul E., Jr., 857-862 Warnock, Dorothy M., 402-404 Sodergren, David, 122-126 Wassermann, M., 572-580 Sox, Ellis D., 281-283 Spett, K., 795-798 Spiers, F. W., 535-540 Spioch, F. M., 795-798 Weaver, Neill K,, 381-387 Wechselberger, F., 191-194 Wells, R. Lomax, 170 Westrick, Marian L., 707-712 Stankovic, M., 338-341, 368-371 Wetherhold, J. M., 580-585 Staskiel, L. J., 753-755 Wheatley, B. M., 585-587 Steele, Earl C., 371-373 Whipple, G. Hoyt, 171-178 Steele, Margaret L., 66-68 Whitney, L. Holland, 283-288 Steiner, S. D., 373-377 Wiecek, E., 801-805 Stokinger, Herbert E., 540-544 Wieland, H., 740-741 Stopps, Gordon J., 857-862 Williams, Charles R., 988-994 Stowell, Thomas E. A., 186-191 Williams, Katherine, 587-590 Strange, John P., 544-551 Williams, May M., 194-197 Sumner, Philip, 314-316 Williams, N., 819-825 Symanski, H.-J., 798-800 Willman, Helvi, 404-405 Szpakowa, T., 800-801 Winter, Kurt, 405-410 Szymczykiewicz, K., 801-805 Worth, G., 826-827 Wyndham, C., 924-931 1 Tabershaw, Irving R., 11-12 Taylor, Edmund W., Jr., 182-184 Teisinger, J., 987-988 Teso, G. A., 359-361 Thaxter, M. D., 147-150 Thom, W. F. J. M,, 379-381 Thoma, George E., 569-572 Thompson, A. R., 301-311 Thorpe, John J., 381-387 Tompkins, Paul C., 551-553 Tripsa, Rodica, 806-810 Troisi, Fortunato Maria, 387-397 Truhaut, Ren, 33-34, 39, 209-214, Tucker, F. E., 553-556 686-692 Yingling, Doris B., 457-459 Yoder, John D., 590-592 Yoshimi, S., 827-828 Yount, Hubert W., 649-650 Zahorski, Witold, 828-832 Zanetti, Ennio, 767-768 Z annini, D., 971 Zielinski, John F., 592-600 Zorn, O., 971-973 i--