Document jmKNkDNg0pRnxpXzo5Kv8QDY2

REPORT OF THE COMMITTEE OH LEAD POISONING OF THE! SECTION ON INDUSTRIAL HYGIEHE OF THE AMERICAN PUBLIC HEALTH ASS 'If At the Annual Meeting, held September 50, 1929 Minneapolis, Minnesota; A. Standards B. . Bibliography Mimeographed copies of this Report are to be dis tributed free at the Minneapolis Meeting above referred to. Members of the Section may secure additional copies at the cost of mailing, 10^. - Others may obtain copies at 50jzf each. Suggestions and criticisms of the Report are freely solicited. Address: Dr. Carey P. McCord, Sec'y, Sect, on Ind. Hyg., A.P.H.A., 34 West 7th Street, Cincinnati, Ohio. M36961 DUP050315268 ''l A. Standards (Diagnosis - individual Treatment - Industrial Control) FOBFWRD TV>e Committee, in submitting the following report upon standards, has endeavored to emphasize those general principles which seem best to have met the test of practical experience. The omission of data that may be con sidered significant by many has been made to avoid confusion and to present the argument as briefly and elearly as possible. The Committee is mindful of j -':i limitations and has especially tried to avoid being arbitrary by an explanation and discussion of the proposed standards. It is assumed that to be of real value those standards must be practical enough to warrant their application (directIv or indirectly) by the general practitioner, the industrial physician, the safety engineer, and workmen's oompensation tribunals, according to their respective fields. The report is divided into throe parts: Diagnosis, Individual Treat ment and Industrial Control. Because of the medico-legal importance of the subject, attention has been given in the- medical sections to procedures and instruotions that may with profit be followed by the physician who is pre paring lead onses for compensation purposes. It is to bo understood that this is a progress report intended for presentation to the Section on Industrial Hygiene -of the American Public Health Association at its annual mooting for 1S29 (held September 3C to October 4, at Minneapolis) with the request that the Committee be continued for the purpose of considering and reporting at a later date upon such .com ments, suggestions and criticisms as may arise from this report. At the same time it is hoped that this report may form the basis of some action by the Section looking toward thD establishing of appropriate -standards for DUP050315269 guidance in the matter of load poisoning, subject to annual reconsideration until such a time as there is general agreement in the Section upon the subject and its component parts. For the present, a list of the industries and trades involving ex posure to lead is omitted but the reader is referred in this connection to U.S. Labor Bulletin No. 506. Likewise the technique of various laboratoryprocedures has been omitted, but with the intention of taking them up at a later date.. Committee, - Dr. G. H. Gehrmann, Medical Director, S.I. DuPont De Nemours & Co. Miss Ruth M. Hutton, Senior Investigator, Ontario Provincial Depart ment of 'Health.* '.....' Dr. Robert A. Kehoe, Medical Director, Ethyl Gasoline Corporation; "Associate Professor of Physiology, University of Cincinnati. Dr. Henry H. Kessler, Medical Director, New Jersey Rehabilitation Commission. Dr. Carey P. McCord, Director, Industrial Health Conservancy Labora tories (Cincinnati). -- Dr. May R. Mayers, Bureau of Industrial Hygiene, New York Department of Labor. Mrs. Dorothy K. Minster, Industrial Health Conservancy Laboratories ( C inc innat i). ** Dr. A. R. Riddell, Clinical Specialist, Division of Industrial Hygiene,' Ontario Provincial Department oF~Health. Hr. HIT, P. Yant, Supervising Chemist, Health Laboratory Section, U.S. Bureau of Mines. ^Dr. Emery R. Hayhurst, Professor of Hygiene, Ohio State University, Chairman. ^Deceased I DUPO 50315270 PART I STANDARDS OF DIAGNOSIS General Considerations General principles.-The same principles that apply to making a diagnosis in any other diseaie entity apply in the diagnosis of "lead poisoning". The principles recognize the necessity of taking a complete and accurate history with symptomatology, making a careful physical examination, and, finally, the making of special laboratory tests, such as those of the blood and urine, and in no other disease is more attention to be given to certain specific findings in the blood and urine than in lead poisoning. History taking.-Not only "lead poisoning" but other occupational diseases are frequently undiagnosed because in obtaining a history no adequate inquiry is made into the vocation or occupation of the patient. The Committee therefore urges that this question of occupation be stressed in every history. Further more every history sheet, chart or record containing a request for the nature of the patient's vocation should bold-face, underscore or otherwise call attention to this item. In order to gauge the extent of the exposure it is recommended that the exact operation engaged in by the patient be specified. It is not enough to know that a Worker was employed in a lead plant. It makes a great difference whether he works in a smelter charging a furnace with old battery plates, or whether he works in a wet color process. Therefore, there has been devised a socalled standard form for recording and reporting the essential features of an occupational disease case which has had some 16 years' usage in various States and is presented herewith. DUP050315271  - . W . w? . S3 >. S' ft -"* * ^ . Sftitll DUP050315272 fi* vjr, /w DUP05031 5273 m 2' - The inquiry: into the sywptomatology becomes also an important part of the history. ^Because'1 of the occaaional vagueness of the symptoms, and their varia- 1 ./ '''r- v 'j*'1-'. ' ; bility as wj^.12 as their idonti+y with the- symptoms of ipher diseases, resort hrequ<|ptly: he j&d to metifqds soodlficully directed to load poisoning to ^jlt'e the diagnosis; e.g., certain symptomsflihat are most frequent if not characteristic,'in toxic episodes of "load poisoning", Such as the ashen pallor, or palsy, andjbhoso laboratory tests ii$rch are recognized as characteristic of cases of "le|p poisoning", r If one ^consults the voluminous literature on the subject he is immediately ; < jfc / struck With the fact that authorities have apparently disagreed for generations f %: as to precisely wljat justifies a diagnosis of lead poisoning. There appear bo those on tho one hand who trill not make a liagnosis of lead poisoning m* *< colic is present; while there aro others who take tho position that the pr of "stippled cells" in the bipod in Itself constitutes a sufficient basis f* ^ iS. ' i.,i# positive diagnosis, even in the absence of all clinical manifestations of this disease. A large mrilbor of intermediate positions he been takrn by as many '. i |p ' practitioners and others. Therefore^ attempts are JSadc here to sd clarify the terms and classify the signs, symptoms, and laboratory findings of this disease as t<Fmuke .it possible for the average practitiSiicr t$ make a proper diagnosis by following the leads indicated. No less wc question the efforts of some to make tho diagnosis fool proof" by specifying, for example, just whit the hemoglobin content of the blood r must he depressed to, or precisely bw raafi5r "stippldd colls" should be found in a given field, and similar^dotails. It mast be remembered that it is always extremely difficult to make tho diagnosis of any disease dependent upon a system t ? >} of weights and measured, no matterJhow carefully they have been figured out. -u > DUP050315274 -3This would be a desirnblo accomplishment, indeed, in view of the unfortunate lack of familiarity of the arerago general practitioner with lead poisoning and tho fact that load workers, in the groat majority of cases, consult the general practitioner before any ono else, and because his findings necessarily play a primary rolo should the case subsequently come up for compensation. Certainly it docs not seem justifiable,--nor indeed would it seem possible to arrive at any satisfactory results--by attempting to lay down arbitrary rules for the diagnosis of load poisoning such as are never used in the diagnosis of any other disease. Standardization of Terminology Many of the differences of opinion as to diagnosis are, on analysis, found to bo due to differences of opinion as to tho definition of the various terms used, rather than to any fundamental difference in the medical interpretation of cases. "Poisoning" appears to be a rather unfortunate term, moreover, in that it tends to convoy--pnrfcicularly to tho lay mind--ideas of extreme distress and dramatic episodes. It is felt, therefore, that considerable progress might be made in the direction of clarifying the situation and standardizing the diag nosis, if the terms may be defined. Definitions Lead,- The element Pb (plumbum), its organic or inorganic compounds or forms, or admixtures thereof of therewith. Lead Exposure,- Any environmental condition or practice that permits of entry of lead into the body. Portals of Entry for Lead,- Refers to tho respiratory tract and the digest- DUP050315275 ivo tract. Lead may likewise be implanted in the body through direct physical means, by hypodermic injection, or by intravascular administration. With the exception of tetraethyl lead, and related organic compounds, its absorption through the skin or through abraded or lacerated surfaces may be considered neg ligible. Load Ingestion,- When lead enters tho body by way of the alimentary tract. Lead Inhalation,- When load in n- dust, spray, vapor or volatile form enters the respiratory passageways through breathing effort. Lead Absorption,- When lead enters the body through any portal and is taken into the tissues. Lead Poisoning or Lead Intoxication,- When absorbed lead causes subjoctivo symptoms with objective findings. incipient Lead Poisoning,- When absorbed load begins to produce clinical manifestations. Subacute Load Poisoning,- When absorbed lead causes a train of minor or moderate clinical manifestations. Acute Lead Poisoning,- When absorbed lead causes an episode of marked clin ical manifestations. Chronic Lead Poisoning,- when absorbed lead causes protracted manifestations with or without acute episodes. Lead Complications,- When absorbed lead inaugurates or aggravates any other disease condition. Lead Saquelfo,- When a pathologic condition remains as a residuum of ante cedent lead poisoning. Lead Mobilization,- When absorbed lead which had been normally distributed in the body is released and redistributed and (or) excreted. Load Socrotion,- When absorbed lead is subsequently eliminated in tho se cretions . DUP050315276 -5- Lead Excretion,- 'Then absorbed lead is subsequently eliminated in the ex cretions . Lead Reabsorption,- When excreted lead is again absorbed into the body ......... I fluids. Lead Elimination,- When ingested or absorbed lead is subsequently extruded or discharged from the body. Belayed or Latent Lead Poisoning,- When, during lead exposure, lead absorp tion occurs with or without lead poisoning, but is followed by lead poisoning after the cessation of lead exposure. Discussion of Definitions Lead.- For the sake of brevity it is well to use the term "lead" in a com prehensive sense covering all the various chemical and physical conditions in which the metal is used in industry, hence the definition proposed. Later, the Committee proposes to draw up a list of the lead compounds that are considered the most dangerous in industry with perhaps a supplemental list of those which exhibit less dangerous effects upon the body. Lead Exposure . For the purpose of securing some definiteness for* procedure, it is proposed that any industrial condition wherein a worker may ingest or inhale a total of 2 mg. of Lead or more per day, for 30 or more days, should bo considered a condi tion of Load Exposure, under the definition; or, any workplace breathing atmos phere containing more than 5 mg. of Lead per 10 cubic meters shall bo considered prima facio a condition of Load Exposure, provided workers are em.nloycd 8 or more hours per day for a working period of 30 or more days, DUP050315277 -6- "By using Duckering's figures and the record of plumbism among the employees of the given establishments, the length of exposure and the character of the plumbism that appeared among them, Legge was able to make a fairly exact statement of the quantity of lead which is to be regarded as dangerous. He con cluded that 2 mg. per day is the lowest dose which, when in haled as dust or fumes may, in the course of years, set up load poisoning. If the working day is 8 hours - as it almost always is in British industry - this would mean about 5 mg. of lead to 10 cubic meters of air. If there is no more load in the air than this, encephalopathies and palsies will not occur, and colics rarely", -Experimental Studies on The Effoct of Ethyl Gasoline and Its Combustion 'Produces, R.S"Sayers, et-al., Report of ttie U.S. Bureau of Minos, 1927, pp.6-7. "Teloky is of the opinion that if 1 mg. or a little more of lead is taken daily for several months, it will cause plumbism. A daily dose of 10 mg. would, in the course of a few weeks, bo followed by serious symptoms", -Sir Thomas Oliver, in Kober & Hayhursts Industrial Health, >p.428. Obviously, the nature of the lead substance will often determine whether an amount as little as those above mentioned may prove hazardous. Lead Exposure may be assumed in certain industries and trade processes as now pursued, and the Committee proposes to compile a list of those in a future re port . Lead Exposure may be suspectod when a dark deposit is found on the gums, and perhaps teeth and other oral structures, or follows the application to the parts of a weak sulfide solution, and when the discoloration disappears quite entirely by the use of a tooth-brush or adequate mouth cleansing, and providing the black deposits of other substances may be ruled out. When this deposit is due to Lead it may be assumed that the exposure has gone no farther than suchj this is in con trast to the finding of the definite lead line in the gum margins, as described be low, under Lead Absorption. Whether or not the sodium sulfide skin tost for evidence of exposure to lead (in any forms by which it might get onto the skin and become enmeshed in the imbri cations of the horny layer) is trustworthy and feasible, and the conditions neces sary for the technique of the test, are matters which the Committee would be pleased DUP050315278 - 7- to hear more about before definitely recommending this test. It is claimed that Lead exposure may bo considered verified in the case of a given worker if, and whenever, a 5 por cent solution of a sol uble sulfide, e.g., NaOH, or KOH, when applied to tho skin turns dafk (due to the formation of load sulfide), provided, of course, that other rarely present dark metallic sulfides are absent (bismuth, cobalt, copper, mercury, and nickel). In painters and others who have been constantly exposed to load dust or solution this test is said to be often present for sev eral days following the last exposuro and even despite ablutions in the meantime i It is suggested that the test be made by dip ping a swab in tho solution and applying it to the skin from the end of the middle finger, over the back of the hand, up tho arm, and down tho chest to the level of the umbilicus. If lead is contained in the imbrications of the outer layer of the skin, the moistened mark so traced will turn dark and perhaps black in the course of three to five minutos. -E.R. Hayhurst - See Am. Jour. Med. Sciences, 147:795 (Juno) 1914. ~ Lead Exposuro in itself is not compensable since there is no recognized dis ability from thiB condition alone. Portals of Entry for Lead The respiratory tract, and lead in dust, spray or vapor forms are considered the chief items of danger in Lead Poisoning. Second only in importance is the matter of taking lead into the mouth, as through mouth-breathing, licking the dust covered lips, licking lead coated objects, straining liquids or foods through a lead coated mustache, and transferring lead to the mouth either directly or indi rectly by the fingers and hands, or upon things put into the mouth (food, eating and drinking utensils, gum, tobacco, oipes, pencils, etc.). Occasionally workers have been known to chew metallic lead, solder, and the softer alloys containing lead, as a habit. It is possible that the tear-ducts (draining into the nose as they do from the eyes) may prove a more important portal of entry than now supposed. It seems quite clear that the skin, with or without cuts and abrasions, is practically im- DUP050315279 pervious to the entrance of Lead into the body, except in the case of tetraethyl lead. Lead Ingestion By definition, "ingestion" implies swallowing, so that lead ingestion refers to lead which has passed the throat and is in the alimentary tract. It can be seen that lead in the mouth may be either spit out or swallowed; also, that much of the lead in the upper respiratory'passageways will find its way into the throat, to un dergo the same routing as that in the mouth, while part of that in the windpipe and larger bronchi may have a similar terminal. Lead ingestion is usually established by the finding of lead in the fcccs, although it may bo a content of any portion of the alimentary tract. It is quite impossible in the present 3tato of knowledge to determine oxactly the previous routing of load found in an alimentary excretion: it may have been (1) ingested, (2) inhaled and then ingested, (3) ingested, absorbed and excreted in the feces, (4) inhaled, absorbed and excreted-in the feces, or (5) combinations of these. It is doubtful whether any form of ingested lead passes through the alimentary tract without some absorption. The more insoluble compounds, such as lead sulfide or lead silicate, are known to be only slightly absorbed, but a considerable portion (through small akoiints) of the soluble forms are absorbed. Lead Ingestion in itself is not compensable since thero is no recognized dis ability from this condition alone. DUP050315280 -9 Lead Inhalation When lead is in the breathing atmosphere it is in its most dangerous form, for there follows inhalation with ingestion, and possible consequent absorption and poisoning. Experimental evidence has shown that inhaled lead may be absorbed from the nasal mucous membrane, although undoubtedly its principal points of absorption lie in the lungs and the alimentary tract. "Conclusions: 1. Particulate matter in the form of pul verized lead carbonate is readily absorbed from the upper air passages of cats and dogs, 2. The absorption is rapid and of a magnitude far in excess of the minimi toxic dose, 3. Ab sorption in industry of lead salts by the upper respiratory passages would therefore seem to be a definite possibility." -- Hermann L. Blumgart, Jour. Ind. Hyg., V:157-8 (Sept.) 1923. It is usually assumed on experimental evidence that only a portion of the lead which is inhaled actually passos through the glottis into the lower respiratory tract: "Two of Lehmann's assistants, Saito and Gfrori, breathed in pondered white lead, inhaling through the nose and exhaling through the mouth. Saito found that he exhaled 10 per cent of the quantity inhaled, that 51 per cent was caught in the nose, and 3 per cent in the mouth, and the remaining 36 per cent he assumed had passed to the lungs. Gfrori exhaled only 2.8 per cent, and the amount calculated to have reached his lungs was 43 per cent* When they breathed through the mouth they found 15 per eent was caught in the mouth and they believed that the lead in mouth and nose was eventually swallowed with the mucus and saliva", Alice Hamilton, Industrial Poisons in the United States, 1928, pp.44. ' Lead Inhalation in itself is not compensable since there is no recognised disability from this condition alone. Lead Absorption When lead has once been inhaled and (or) ingested, a considerable part of it is commonly absorbed into the tissues of the body, evidently depending upon a num- DUP050315281  -.... - 10 ber of factors, of which ase of solubility is a major one. Load Absorption my be said to be analogous to the incubation stage of dis ease-conditions that arc characterized by developmental periods without symptoms. It is a condition, therefore, due to lead, with objective but without subjective manifestations. It is probably true that during this period various abnormal vents are transpiring which the future may disclose, and therefore permit of an earlier diagnosis of Lead poisoning than is now possible. Among the phenomena of Load Absorption are to be considered the following, the positiveness of a diagnosis being directly related to the degree in which these are found to occur: 1. Lead Line (Burtonian Line).- That the presence of the lead line _in the gums is difeot evidence of lead absorption is generally accepted--lead has been ab sorbed and some of it subsequently deposited in the gums. The typical lead line is frequently very difficult to demonstrate and must be carefully differentiated from venous congestion of tho gums or that due to cyanosis, to bismuth and to certain other metallic deposits. Likewise the accidental local deposition of lead sulfide on the gums (see Lead Exposure) should be guarded against by the preliminary use of a tooth-brush. Such deposit is usually blacker and more diffuse than the true lead line. Absorption may, however, have taken place some time in the near past and an interpretation of the symptoms of which the individual complains, must not be in fluenced too largely by the fact that he exhibits a lead line at the time of the examination. Unfortunately this definite and characteristic sign of lead absorp tion is often absent, apparently due to good mouth hygiene, absence of teeth (al though it may occur in the absence of teeth), or a bad condition of the gums. A decided aid in differentiating the venous conditions mentioned is a hand DUP050315282 - 11 lenswhich will reveal the fact that the true load line is most prominent at the gum margins and consists of discrete spots which are, in fact, the sub-lying papil lae of the mucous membrane Which have taken on the pigment. A careful history should determine the possibility of the presence or absence of other metallic de posits . It is a common experience, that stomachache in a lead worker is only too fre quently diagnosed as lead colic, without further investigation. When a lead worker with a lead lino in his gums, however, comes to h physician and complains of stom achache, the diagnosis is almost a foregone conclusion. And yet a load worker either with or without a lead line in his gums may have a stomachache for any of the reasons that any one else may. Careful laboratory examinations both of blood and of urine are required for a proper interpretation of the significance of the lead line in any given case, as well as consideration of a history of Lead Exposure. Since a qualitative examina tion of the urine for lead is of little value, and since accurate quantitative analysis requires the use of intricate methods and considerable time in the hands of a skilled chemist, the practitioner will have to depend for the present upon a careful history of Load Exposure and blood findings for the proper interpretation of the blue line in the gums. 2. Laboratory Findings.- The question as to whether lead is being actively ab sorbed into the body in a given individual at a given time can best be determined by laboratory examination of the blood and urine. It must be remembered, however, in this connection that laboratory tests must be 'jegun at the earliest possible mo* ment if they are to be of the greatest value and repeated tests may be necossary in any given case. DUP050315283 12 a. Blood. - Examination of the blood is a very valuable laboratory means for the diagnosis of lead absorption, for when lead is being absorbed into the body it tends to produce some changes in the blood picture* There should be a hemoglobin determination, a red and white cell count, and preferably more than one smear ex amined for morphological changes in the cells. All of the individual elements in the blood picture must be considered together. Briefly, the blood picture in Lead Absorption has the following features, which, taken together, may be considered diagnostic: (a) Changes occur in the morphology of the erythrocytes such as are usually found in severe oases of anemia (see Stippling below). Like wise, the blood picture often undergoes rapid and great changes. These points are extremely important in differential diagnosis. (b) Stippling (punctate basophilia) of the erythrocytes This con dition is more prevalent in Lead Absorption than in any other blood picture of equal severity otherwise, -and is therefore the most charac teristic finding of this condition; yet it must be considered in con junction with the rest of the blood picture, if its true significance is to bo appreciated, for stippling is by no means the whole picture of the effect of lead upon the rod corpuscles. There precedes it and is invariably associated with it, a marked increase in the appearance of reticulocytes (regarded as young erythrocytes prematurely appearing in the blood stream), and polychromatophilia. At times in Lead Absorp tion, reticulocytes and polychromatophilia arc more pronounced than stippling. These are of course present in practically all of the ane mias, but rarely so much so as in Lead Absorption. Thefe likewise may occur in Lead Absorption an undue amount of poikilocytosis and anisocytosis in proportion to the degree of other blood changes, while nucle ated red corpuscles are not infrequent. DUP050315284 13 Stippling or basophilia of the rod corpuscles, however, is shared with other conditions affecting tho blood and hence in itself is not pathognomonic of lead absorption. "The number of basophilic red cells i3 increased above normal numbers in the following pathologic states; Lead intoxication, benzol poisoning, arsenic poisoning, in all types of anemia in which there is regeneration, hemolytic icterus, following hemorrhage, leukemias, at times in acute infections, in neoplasms involving the bone marrow, and in polycythemia." (Carey P. McCord, U.S.Labor Bull., 460:32, 1928.) In fact sensitive methods will show some basophilic material in normal blood. Stippling in Load Absorption may be detected in the blood intermittently and be present in variable amounts from day to day, and yet the rest of the blood picture be quite definitely diag nostic of this condition. Undue emphasis, therefore, must not be plaoed upon the degree or amount of stippling in tho presence of other positive findings. On the other hand, the increasing presence of stippled cells appears to be of considerable importance in follow ing the progress of a case of Load Absorption, and in prognosis as preceding acute phenomena, and may thorofore be of great practical im portance in the industrial control and treatment of such cases. It is perhaps well to emphasize again tho fact that tho diag nosis of Lead Absorption cannot properly be dependent upon the pres ence of an arbitrary number of stippled or other cells in the blood pioture, but must bo dependent upon a very careful appraisal of all of its elements. (c) The erythrocyte count and hemoglobin are only slightly reduced in all but severe cases, whether these be acute or chronic, giving the DUP050315285 - 14 * appearance of a very low grad secondary anemia. In many, cases there may be no reduction whatever* - in fact there may be a polycythemia with hemoglobin over 100^5, but accompanied by distinct morphologic changes in the cells. "Lead anemid', then, my be said to exist when, in Lead Absorption, the count is about 4,000,000 or below, and the hemoglobin decreased to some 80?? or below. (d) The color index is, in the average case, only a little less than 1, although it becomes lower where the erythrocyte count and the hemoglobin aro reduced. (e) The total leucocyte count is normal (5,000 - 10,000), but there is a slight relative lymphocytosis at the expense of the poly morphonuclear leucocytes. Recent evidence appears to show that white cell counts may vary 100?? in normal persons, and should be made with the patient in the same posture each time and after the same relative amount of exercise or rest. (See Walter E. Garrey, ref. in Scientific Monthly, Sept. 1929, p.287.) The presenoe of leucocytosis usually implies a secondary in fection or some influence other than Load Absorption, with which, of course, the latter may co*-exist. A leucopenia is not a finding of Lead Absorption. It may be a very temporary normal condition; but usually indicates some other intoxication; such as benzol poisoning or one of the more virulent infections producing severe degrees of anemia, perhaps without temperature (Stroptococcus hemolyticus, Bac illus pyocyaneus, etc.). DUP050315286 - 15 (f) Tho mononuclear coll count may to found to be somewhat in creased, - a relative increase in large lymphocytes pointing to a more severe intoxication, and of small lymphocytes, to a more sub acute or chronic' intoxication. (g) Other laboratory blood findings, such as the reaction of the cells to hypertonic salt solution (Liebormann^ Test), or the hematoporphyrin tost in the blood, fragility of the red cells, clotting time, and the attempts to detect lead in the blood plasma (see Other Evidences of Lead Absorption, below), etc., are all of value in that they give still further evidence that the blood cells are being ad versely affected by lead, but these findings., except the test for load (in expert hands), are not pathognomonic, nor are they necessary to a diagnosis. b. Urine. - Sevoral laboratory workers have reported lead to be excroted in the urine of normal persons, under the usual conditions of civilization, and in amounts commonly falling between 0.04 and 0.08 mg. in the 24-hour specimen. The term "normal lead" may bo applied to this exoretion for the present. When, however, lead is being actively absorbed by tho body it will usually be found to be excreted in the urine in amounts exceeding 0.1 mg. although varying in quantity day by day. Since it appears in these very small amounts, it requires the use of delicate tests to detect its presence. There are now several "method^' in use which arc sufficiently sensitive for this quantitative determination. Such tests can be made only in laboratories equipped for tho purpose. Qualitative determination of lead in the urine would appear to have little value. At present, an absolute diagnosis of Lead Absorption at least re DUP050315287 quires the finding of lead in the urine in abnormal amounts . Homatoporphyrln (iron-free hematin) may occur in increased amounts in tho urine of more marked oasos of load absorption, but occurs also in many other conditions. It may impart a dark color to the urino. o. Feoes . - Lead is found in small amounts in the feces of most normal persons, and more constantly and in larger amounts than in the urine, as a rule. During Lead Absorption, likewise, much more lead will usually be found in the feces than in the urine, but these findings are occasionally reversed for a day orso at a time. Ingested Lead (i.o., that which has not been absorbed), makes upsome portion of that found in the feces and there is at present no practical method extant for differentiating Ingested Lead from Excretod Load in the fecos. Hence, oven tho quantitative estimation of lead in the foces is of only relative value in diagnos ing between these two conditions. However, the quantity of lead in the feces is often a cluo to the intensity of Lead Exposure if samples are obtained within some 48 hours of the ces sation of exposure. d. Other Laboratory Findings. - The presence of lead in the nose, mouth or gastric secretions, cannot^ at present, be regarded as of any significance from the standpoint of clinical diagnosis because such is merely indicative of the fact that lead has been inhaled, mouthed or ingested, as the case may be. It is no indication that it has been actively absorbed through the nasal or gastro-intestinal mucosa and so no indication that it has at any time become part of the body economy. The possible value of tho X-ray in diagnosing Lead Absorption or DUP050315288 17 related conditions is now avmiting report. 3. Other Evidences of Lead Absorption. - Teste for load in the tissues of the living subject are not feasible at present cxcent in the ease of the blood where sensitive methods of analysis often show the presence of lead in cases of active absorption. Post-mortem analyses yield information as to the quantity and distribution of lead in the tissues and, when properly evaluated, are of considerable diagnostic value. Here, again, it must be pointed out that more qualitative tests are of lit tle value, for small quantities of lead are commonly found in human tissues (bones and liver especially) without any apparent relationship to the illness and death of the subject. Lead Absorption in itself is not compensable since there is apparently no disability in this condition alone. The future, however, may change this opinion should it be shown that Lead Absorption does result in impairment. Lead Poisoning or Lead Intoxication Used in the sense of the definitions proposed, all cases of Lead Poisoning are special conditions of Lead Absorption which present evidences of intoxication. The term "load absorption" has unfortunately been used rather loosely in the past by some, to refer to cases which they vaguely regarded as "mild" cases of lead poi- DUPO 50315289 18 soning. There has been very proper objection to its use in this way. Lead Absorption used in the sense proposed would, by definition, not readily lend itself to varying interpretations; indeed, it is an expressive term because it definitely refers to a physiologic and etiologic process and not to any sympto matic manifestations. Surprisingly variable amounts of evidences of Lead Absorption may accompany definite evidences of Lead Poisoning. In short, susceptibility to actual poisoning varies enormously with different individuals, and even at times with the same in dividual. Thus, individuals may be found with rather marked evidences of Lead Ab sorption, but without complaints or any of the objective findings of Lead Poisoning, while other individuals may be found with limited evidences of Lead Absorption, but with rather pronounced evidences of Lead Poisoning. Perhaps one explanation of the occurrence of acute symptoms without concomitant signs of marked absorption are due to the possibility of the sudden disappearance of the major portion of lead from the blood stream by its absorption into the liver or storage in the bones. In such instances, however, the symptoms should rapidly subside. Diagnosis. - The diagnosis of Lead Poisoning is made upon: (1) The case his tory, (2) the symptoms, (3) the physical signs, and (4) the laboratory findings. 1. The Case: History. - This refers to events, which have transpired in the patient's past working life and those involved in his present circumstances. The items to be considered in the case history of a possible caso of Load Poisoning are as follows: DUP050315290 19 - A definite history of Load Exposure. Direct inquiry into tho trade process, showing Lead Exposure. (This may bo omitted whore the trade process, such as painting, en ameling, otc., is already accepted as an exposuro to Lead. As before stated, tho Committoe plans to draw up a list of such industrial exposures.) A physioian*s diagnosis of load poisoning in the past. A dispensary, clinic or hospital diagnosis of load poisoning in the past. The nature-of abdominal operations performed (ulcer, gall stones, other biliary tract afflictions, appendicitis), and whether or not such operations relieved the symptoms, and especially whether symptoms returned upon return to the some employment. Past illnesses, keeping in mind clinical manifestations which might have been due to lead poisoning. Detention for mental up-sets, delirium or aeuto mania. Number of children (strong experimental and some clinical evidence of limitation of offspring). In women, history of miscarriages and early death of offspring. 2. The Symptoms, - Since Load, which has been absorbed into the systemic cir culation, bathes all of the tissues of the body, its toxic effects may be very wide spread indeed. Its symptoms are therefore very numerous, depending upon tho organs involved and may resemble those resulting from other diseases of these same organs. Occasionally, a worker who is obviously "leaded" denies symptoms for one reason or another. The differential diagnosis on the basis of symptoms alono, therefore, may DUP050315291 be very difficult, especially in Sub-acute or Incipient cases. Indeed, there is no symptomatic manifestation of Lead Poisoning which is in itself pathognomonic of this condition, although the so-called "lead triad" of abdominal colic, obstinate consti pation and severe headache (without fever) is very suggestive. For convenience, the symptoms to be looked for in Lead Poisoning are grouped systcmically: A. Gastro-Intestinal Loss of appetite, especially for breakfast. Coated tongue. Sweetish or metallic taste in the mouth. Nausea. Vomiting. General gastric discomfort (dyspepsia). Colic--perhaps very severe, difficultly relieved by opiates, board-like hardening of the abdominal muscles which are apt to be depressed (scaphoid abdomen), and generally relieved by pressure (in contra distinction to most of the other acute abdominal conditions). Constipation, which may be very obstinate. B. Neuro-Muscular Headache--frontal, often very severe. Weakness--of the hand grips, wrist extension, general weak ness, falls. Dizziness. Nervous tremor of the hands, tongue, eyelids, etc. Backache. "Rheumatism", Wakefulness or disturbed sleep and nightmare. Mental depression. DUP050315292 21 - Nervous excitement. "Neurasthenia". vrrist drop or load palsy--bilateral, and especially if with escape of the supernator longus muscle, by which the pa tient is unable to lift an object with his hands, but is quite capable of raising an object placed across his forearms. Ocular disturbances (diplopia)--duo to optic neuritis, etc. Blind spoils. Mental symptoms, such as delirium, hallucination, loss of memory, stupor, etc. (load encephalopathy). Aural disturbances--doafness, tinnitis. Loss of weight. C. Cardio-Yascular Fainting. Nose bleed. Palpitation. D Respiratory Chronic bronchitis. Asthmatic attacks. E. Reproductive Organs Menstrual disturbances (See History above). 3. Physical SignB. - There is likewise no physical sign, as this term is used in medicine, which is pathognomonic of Lead Poisoning. The ashen pallor, or double wrist drop, or the writhing colic are however very suggestive. Occasionally DUP050315293 a worker with physical signs o.f lead poisoning denies all symptoms thereof, Here, history and laboratory findings must be depended upon. *Pallor--"ashen pallor" which is often marked around the mouth and nose (circumoral). The ashen pallor in lead poisoning deserves special mention in that it differs very markedly from the greenish pallor of secondary anemia and the lemon yellow pallor of pernicious anemia. It differs not merely in appearance, but in the curious fact that it appears to have no definite rela tion to the reduction either in hemoglobin or in the rod cell count. This relationship is rather striking in the other anemias. In lead poisoning a marked pallor of the face and lips has been regarded as characteristic of the disease, but authorities agree that it may be narked in very mild cases. Koelsch believos that it is probably due to the action of lead on the skin capillaries--a vaso-constriction duo to faulty norve mechanism. Profound anemia may however follow a length ened period to the influence of lead, Lead line in the gums (See Lead Absorption). Foul breath. lyrist drop. Tremor (tongue, lips, chin, hands). (See Present Symptoms, above.) Incoordination (fingers, arms). Grip strength weak (dynamometer or spring-balance test), bilateral. Strength of wrist extension weak (dynamometer or spring-balance test), bilateral. Reflexes usually decreased (knee jerks, wrist, elbow, cremasteric). Ataxia. Ocular palsies. DUP050315294 23 Deafness Anxious facial expression State of nutrition (some cases show a wasting of hands, arms, and perhaps general emaciation). Acne, dermatitis. Abnormal blood pressure, but subject to wide variations: Hypotension in early stages. Hypertension in longer standing cases. Arteriosclerosis (radial, brachial, temporal). Signs of nephritis--chronic interstitial: nocturnal urination, edema of ankles, hands and face (small granular kidney). Gouty signs (great toe joints, palms, fingerst other joints). Premature aging. Evidence of mental disturbances; Hysteria - especially in young women. Neurasthenia. Unconsciousness, corn, convulsions leading perhaps to death. Delirium or acute mania ending perhaps in death. Blindness. Brain tumor complex. Pseudo-general paralysis. Dementia with tendency to end in the asylum. The commonplaceness of the clinical picture (symptoms and physical signs) as above described for purposes of diagnosis is self-evident. Aside from acute oolic, lead palsy, encephalopathy, or other quite obvious manifestations of "lead poison- DUP05031 5295 - 24 ing" (as that term ia used in the present diBoussion) any or all of the other signs and symptoms may be due to any of a number of conditions and cannot be regarded per ss as diagnostic of Lead Poisoning* A significant history with prominence of the above list of symptoms and signs may, however, be considered good presumptive evi dence of Lead Poisoning, particularly is this true where a lead line is associated. 4. Laboratory Findings. (See also under Lead Absorption.) Blood Urine Feces Skin test (sodium sulfide &/0). Other tests. An absolute diagnosis of Lead Poisoning cannot be made without positively finding a pathological amount of lead in the urine (or blood, tissues, secretions) accompanied by a proven history of exposure, usually, if industrial, of some days* time or more; a syndrome of several or more of the symptoms listed above; and one or more of the starred (*) items under Physical Signs listed above. The diagnosis of Lead poisoning is, however, seldom absolute at the present time, but is made up on strong presumptive evidence in which the chief item missing from the above pic ture is the failure to examine the urine for pathological amounts of lead. DUP050315296 Sear DISCUSSION Cases for diagnosis appear to fall naturally into three classes: (1) Those with positive disability, (2) those with doubtful disability, and (3) those without disability. 1. CASES WITH POSITIVE DISABILITY Procedure. - The suggested procedure is as follows: (1) It must be established that the worker was exposed to lead to a degree generally considered to be significant, because there are all manner of ap parently insignificant exposures to lead which exporiencc has taught may be disre garded, except the assumption that the individual has proven to be unusually sus ceptible. (2) It must be definitely established that some of the symptoms evi dencing themselves in his disability are such as are commonly associated with lead poisoning. (3) The presonco of other diseases or accidents causing similar dis ability must bo carefully weighed as provocative of all the symptoms and objective findings present, or as causal of only part or certain ones of them, if any. (4) The physical examination must in evory instance be thorough, and the objective findings for lead carefully searched for and labelled as either posi tive or negative. (5) Several appropriate laboratory examinations of the blood must be made, having in mind lead poisoning. (6) Two or more examinations of 24-hour collections of urine should be made for the presence and quantity of lead. The usual routine urine examinations for other findings must be made. (The Committee is debating the matter of attempt ing to state the amount of lead in normal urine. See p.15. Urine). (7) The importance of making these laboratory tests at the earliest possible date following the onset of symptoms is re-emphasized. DUP050315297 Diagnostic Possibilities If the disability is such as to be definitely associated with Lead Poisoning, and this is further confirmed by the laboratory, there can be no doubt as to the diagnosis. The sole point left is to establish industrial Lead Exposure. (2) If the disability is such that its relation to Lead Poisoning is in doubt, the presence of laboratory evidences of Lead Absorption should, generally speaking, be strong presumptive evidence in .favor of lead as a cause for the dis ability--other possibilities, of course, being weighed in the usual manner. Again industrial Lead Exposure must be shown. (3) Cases of disability which are presented without laboratory find ings of Lead Absorption are problematical at the best, and only strong evidence of Lead Exposure with symptoms and signs pointing to Lead Poisoning may be expected to receive a favorable hearing in a plea for compensation. (4) Lead Poisoning may exist due to Lead Exposure unassociated with the present employment: (a) Exposure in another employment; (b) use of lead con taining cosmetics or hair dyes; (c) use of load containing medicines as therapeutic measures; (d) use of leaded foods, and (e) other accidental or intentional inges tion or inhalation of lead. 2. CASES WITH DOUBTFUL DISABILITY Discussion. - In this group are included all cases where the existence of disability cannot be established beyond a doubt by noting the physical signs, since the claim for disability is made upon the basis of subjective symptoms only. For example, the worker may complain of such symptoms as headache, dizziness, dyspepsia, general lassitude, etc., and maintain that, as a result, he is unable to work. Are these symptoms, if they exist, due to Lead Poisoning? Is the worker pretending or DUP050315298 27 are the symptoms due to causes other than Lead Poisoning? It is obviously impos sible to prove or disprove the existence of most subjective symptoms. Much must de pend therefore upon the impression of the physician with reference to the reliabil ity of the patient's statement. Procedure. - Every effort must again be made to determine the existence or absence of Lead Exposure, while the Physical Signs and Laboratory Findings require the closest attention. Diagnostic possibilities. (1) If the symptoms of which the worker complains, though ever so vague, are those definitely associated with Lead Poisoning, and the laboratory find ings show Lead Absorption, the presumption is in favor of lead as a cause for the symptoms and such disability as is present. All other possible causes for the symp toms and disability must of course be taken into consideration as indicated above. (2) If the symptom complex, though vague, is doubtfully one associ ated with Lead Poisoning, but the laboratory findings show Lead Absorption, the pre sumption of evidence is still in favor of lead as the cause of the symptoms and the disability. (3) If the clinical picture is doubtful and the laboratory findings for Lead Absorption are negative, the presumption of evidence is definitely against the possibility of Lead poisoning. 3. CASES WITHOUT DISABILITY Discussion. - A group of cases occurs among exposed or possibly exposed lead workers where no disability or impairment is claimed. This may be due to the fact that the worker has not sensed disability or impairment, or to the fact that he wishes to oonceal same for one reason or another. DUP050315299 28 - Procedure, - Here every effort should be made to determine whether or not there ie a (hidden) disability or impairment which could be associated with Lead Poisoning for the object of preventing Lead Poisoning in any of its stages or phases. Diagnostic Possibilities (1) Positive blood and urinary findings of Lead Absorption in these cases would simply establish Lead Absorption and not Lead Poisoning. All oases of Lead Poisoning in any of its stages should be compensated. This compensation should be in proportion to the disability present, and cover the entire period or periods of disability. Incipient Lead poisoning By definition, those symptoms which begin to appear when Absorbed Lead j.s* - creases beyond the threshold of physiological adjustment, and evidences of intoxi cation appear, are called, as a group Incipient Lead Poisoning. The symptoms are variable in this stage, but usually consist of some of tho following*. 1. Symptoms A. Loss of appetite Headache Coated tongue General weakness Sweetish or metallic taste Slight Dizziness Ha-usea Dyspepsia Constipation B. Mental Depression "neurasthenia" Poor sleep C. palpitation D. Bronchitis E. Menstrual disturbances DUP050315300 - 29 - 2. physical Signs Pallor Lead line Slight tremor Blood pressure--hypotention 3. Laboratory findings Blood positive Urine positive (i.e., pathological amounts of lead) Feces positive (for increased quantities) Skin test positive (if there has been skin exposure) Sub-acute Lead Poisoning By definition, this condition exists when Absorbed Lead causes a train of minor or moderate clinical manifestations. In addition to the evidences cited un der Incipient Lead Poisoning, which may be all more marked, one would expect to find the following: 1. Symptoms A. Vomiting Colic "Rheumatism" Uervous excitement B. Weakness of the wrists Hervous tremor Baokache Loss of weight C. Fainting D. Asthmatic attacks 2. Physical Findings Tremor Incoordination Strength of wrist extension weak Reflexes decreased Acne, dermatitis DUP050315301 - 30 3. Laboratory Findings (See Incipient Lead Poisoning). Acute Laad Poisoning By definition, this condition exists when absorbed lead causes an episode of marked clinical manifestations. Hence, to the findings of Subacute Lead Poisoning (many more pronounced) there may be expected to occur some or more the following: 1. Symptoms A* Obstipation B. Wrist drop Aural disturbances Loss of weight? Ocular disturbances C. Nose bleed? Mental disturbances (perhaps mania) D. Bronchitis? 2. Physical Findings Wrist drop Ataxia Ooular palsies Anxious facial expression State of nutritiondecreased? Blood pressure--Bypertensicn Deafness Signs of nephritis? 3. Laboratory Findings (See Incipient Lead Poisoning). Chronic Lead Poisoning By definition, this condition exists when absorbed lead causes protracted manifestations with or without acute episodes. Therefore, any or all of the symp toms delineated under Acute Lead Poisoning may exist with an acceptance of those that arc marked questionable there, and, in addition the following: DUP050315302 1. Symptoms A. Obstipation with occasional attacks of diarrhea B. Arthritis C. Chronic bronchitis 2. Physical Findings A. Gums and teeth likely to be in very poor condition rendering a lead line undeterminable Blood pressure,-usually hypertension Arteriosclerosis Interstitial nephritis Gouty signs Arthritis signs Premature aging Atrophy Cachexia 3. Laboratory Findings (See Incipient Lead Poisoning), Chronic Lead Poisoning may exist for years with only occasional exacerbations, of varying severity. Tetraethyl Lead Poisoning Since the order of appearance and the character of some of the symptoms of Tetraethyl Lead Poisoning are different from Lead Poisoning due to other known causes, attention is called to special literature upon the subject. (Experimental Studies on the Effects of Ethyl Gasoline. R.R. Sayers, et. al., U.S.Bureau of Mines, 447 pp., 1927). Lead Complications By definition, complications may be said to exist when the presence of lead in the body inaugurates or aggravates any other disease condition. The commonest complications of lead poisoning aro those of the gastro-intestinal tract, such as gastric ulcer, duodenal ulcer, gall tract afflictions, appendicitis and occasional- DUP050315303 - 32 Xy parotitis and orchitis. Lead workers are at least as subject as any individuals to the ordinary ail ments such as ordinary stomachache, gastric ulcer, appendicitis, etc. It is quite obvious, therefore, that all other causes be estimated in considering the health of a lead worker quite as much as in making a differential diagnosis in any other individual. Compensation for Lead Complications should be allowed in full whenever the complication has been inaugurated by Lead FoiBoning. In those circumstances Where Lead Poisoning has aggravated another disease condition, a basis for compensation should be reached covering the probable added damage due to Lead Poisoning. Lead Sequelae By definition, lead sequelae are pathologic conditions remaining as a residu um of antecedent Lead Poisoning. Aside from the various nerve changes which result in paralyses of one form or another, arterioscelerosis, hypertension, and nephri tis are the sequelae which most often come to the attention of the Compensation courts. While there has been and still is some doubt as to the relation of Lead Poisoning to these oardio-vascular conditions, the relationship has not been defi nitely disproved as yet and it would seem proper to continue to consider these con ditions as possible sequelae of Lead Poisoning until such time as the matter has been more definitely settled. It would seem proper to put the burden of proof on the other side and not withhold compensation from workmen who have contracted those conditions during a long period of exposure to lead until the question as to whether or not such a relationship exists has been established beyond any doubt. Lead Sequelae should be compensated provided provision is made for same in the compensation statutes or regulations, and for the reason above stated. DUP050315304 - 33 Latent or Delayed Lead Poisoning Cases of Lead poisoning are reported to occur in persons who have not been recently subjected to Lead Exposure. Such cases are defined as Latent or Delayed Lead Poisoning. There is a deposition on the part of the Committee to limit the tern "Latent Lead Poisoning" to those cases arising, within a short time after the cessation of exposure, for example, within a few months, and to use the tern "Delayed Lead Poisoning" for those cases arising more remotely after the cessation of exposure (see discussion under Part II, Industrial Treatment). When a worker who is suffering from Lead Poisoning ha<J been subjected to Lead Exposure in one or more occupations previous to the one in which he was last en gaged, and in which he was also subjected to Lead Exposure, the Committee feels that the occurrence of Lead Poisoning should probably be charged wholly to the place of last exposure provided twelve or more days of Lead Exposure have been suffered in the place of last employment. The question of Super-added Load Poisoning, i.e., a circumstance where a worker has been subjected to Lead Exposure in two or more consecutive or concurrent employments, is considered entirely possible. In such cases it would appear that a compromise finding might be reached by which responsibility for Lead Poisoning could be charged to the respective exposures in a fair and equitable manner and compensations adjusted accordingly. NOTIFICATION Every case of Lead Poisoning should be notified to the proper official agency, usually the department of health and (or) the department of labor (or equivalent bodies). To avoid duplicating statistics, the Committee recommends that but one notification of Lead Poisoning for the same case be so entered within the space of a twelve months' interval, and that renotifications within this period of time be entered as relapses, or Delayed, or Latent Lead poisoning. DUP05031 5305 Part II STANDARDS OP TREATMENT The treatment referred to hereunder is curatiTe treatment. The discussion of preventive treatment properly falls under Industrial Control. It is felt, however, that a word might here be said regarding the so-called preventive treatment such as the taking daily of milk, lime water, sul phuric acid-in-lemonade, magnesium Sulphate, calcium sulphide, etc., which is frequently advised for workers exposed to the dangers of lead absorption. Controversy has arisen cbncernihg the advisability of such measures and the Committee has decided to defer recommending them until it has opportunity to make further investigations of the matter. Curative treatment may be : .considered under the heads ofs--(A) That directed to the abatement of symptoms of Lead Poisoning, and (B) That towards the removal, if possible, of lead accumulated in the subject's tissues, i.e., t promote Lead Mobilization, Excretion and Elimination. Without this latter treatment the cure cannot be considered complete. It should not be forgotten by those called on to deal with the problem of Lead Poisoning-that'certain individuals, although leaded, do not show immediate toxic manifestations but may be poisoned with the result that they may develop degenerative changes in the arteries, heart, kidneys, liver, etc., and perhaps become prematurely aged. A. The treatment of immediate toxic manifestations. This should aim at the abatement ofacute symptoms*' for the immediate relief of the patient. It can be accomplished by bringing about immediate cessation of Lead Exposure, and emptying the alimentary tract of its unabsorbed lead by means of saline cathartics. In many oases this is all that is necessary to give relief. Alternating rest and moderate activity, and a full diet usually corrects the symptoms in a few days. Alkaline salts including calcium DUP050315306 carbonate or lactate, given to the point of a maintained neutrality, are beneficial. In severe colic, or for the headache of encephalopathy, small doses intravenously of calcium chloride, or Fischer*s Solution (given very slowly) usually relieve the pain, also other acute Symptoms such as vomiting. For the purpose of administering CaCl2, 15 c.c. of a 5$ solution is recommended. In practice 5-10 c.c. will usually be found quite sufficient, but 2-5 c.c. of a 10$ solution may be used. Sot applications to the abdomen may help to relieve the colic. Anti-spasmodics have been advised. They may be used in cases which are not relieved promptly by the administration of calcium. Experience would seem to indicate that these will be very few. If the patient is suffering severelyand no calcium chloride is im mediately available for intravenous injection, as indicated above, l/lOO of a grain of atropine, repeated if naeessary, or 15 drops of F. E. Belladonna in repeated doses, may be used for this purpose. Amyl nitrite or nitroglycerine have been suggested as alternatives for this purpose. More experience with their employment is wanted before the Committee can definitely recommend them. The use of opiates, or morphine (gr.1/8 to gr.l/4) should be limited and restricted to the relief of unbearable pain or unmanageability, and given preferably with atropine (gr.l/l50 t$ l/l20). Enemas have been found useful in stopping the pain of an attack. They may be difficult to administer because of spasm. They should be slightly warm. Magnesium sulphate (Epsom salts) 1 o*. should be administered per mouth to clean out the intestinal tract. Castor oil may be given in severe cases of constipation. Where it is found necessary to continue the use of aperients one of the milder salines should be employed. Sir Thomas Oliver states that the abdominal pain can be relieved by the administration of DUP050315307 *36* sodium mono-sulphite in i/2- or 1-grain doses thrice daily and states that D*4. Stevens of Cardiff has found tile internal administration of 1/4grain dose of calcium permanganate helpful. Likewise, for eolio and consti pation, he recommends a mixture of potassium iodide and magnesium, sulphate to which 5 drops of tir.cfc. .mu x vomica with a carminative may he added. He cautions against the ure of potassium iodide in I sad i-cisoain? in repeated doses. In sever-., ci.seo oi -'.or.ttipation accompanying oel..c, 1 drop of croton oil on a piece of sugar may be added by the mouth. Immediately following the abatement of severe symptoms the patient should be put on a diet rich in cadclum. This should consist of: Juicy fruits, green vegetables, carrots, turnips, etc.; milk, foods cooked with milk, and milk products such as cheese, butter and ice-cream; molassesj eggs. h quart of milk should be taken daily. With this should be given 2 grams of calcium lactate a day in four or more doses. If no milk is used, the calcium lactate should be increased. Calcium chloride may be used, but it is unpleasant and should not be taken by mouth in large quantities. One drachm of a 1 in 8 solution by mouth may be tried three times a day. This treatment should be considered the preliminary to *daladingtt and should be continued for a week in ordinary oases or until the patient Is in good physical condition. In those showing nervous manifestations it should be continued until the signs are stationary. Somfetftmes it may hare to be protracted, running into months. When nephritis is present, treatment with calcium and high calcium diet should be prescribed and other efforts made to clear up the nephritis before "deleading". During epileptiform seizures the bowel should be washed out with mustard and warm water, a tablespoonful of mustard to a pint of water, and after ward a small enema containing 30 or 40 grains of bromide should be ad ministered per rectum (Oliver). DUP050315308 -37Wrist drop cases should be put up in hyperextension splints. Cases of paralysis which are slowly recovering should be given passive massage and electricity. B. "Deleading" following treatment for relief of symptoms. After acute manifestations have been cleared up or are stationary and when the patient is in at least fair general condition, efforts may be made to remove stored lead from the body. Experimental evidence has ahovm that only a portion of this stored lead can be eliminated in this procedure, but presumably it is thnt<which is the more readily mobilised and, judging by the improvement shown by a number of longstanding cases, after this had been carried out, the results dppaar to be of value. The Committee feels that more experiences should be reported, however, before it can recommend "deleading", but the following may be tried as an empirical measure, based upon the reports of Aub and his co-workers (In Lead Poisoning, Med. Monographs Vol. VII, Williams $ Wilkins Co., Baltimore, 1926). During the "deleading process" the patient is placed on a diet poor in calcium and the acid-base equilibrium of the body is altered by the adminis tration of suitable drugs. In this way, the calcium reserve is experimentally found to be drawn upon and, with the removal of calcium from the bones and elsewhere,lead is also freed to the circulation and excretion promoted. It is of value to check the excretion of lead during this process by lead determinations in the urine. The diet should not include milk or foods cooked with milk. Likewise, calcium-rich foods such as green vegetables, fruits, ordinary vegetables, cheese, butter, molasses, eggs, etc., should be prohibited. The diet should be made up from the following: Meat,-liver, potatoes; rice, tomatoes and canned corn (without milk); corn meal, bread (cooked and used without milk), soda biscuits; bananas, apples (peeled); tea or coffee without milk or cream, but with sugar; butter fat (prepared by melting butter DUP050315309 -38in hot water and skimming off the butter fat), salt and pepper. During the administration of this diet the patient may be given eitherj (A) 15 minims of the dilute phosphoric acid (U.S.P.) every hour for about 10 times daily for several weeks. (Each dose should be followed by a mouth wash of Sodium bicarbonate). It is quite distasteful to many. Or: {B) Ammonium chloride, 1 gram in a glass of water, ten or twelve times a day;--some prefer the tablet form but in either case nausea and stomach disturbances may follow. Nephritic cases should not given either of these drugs since they are acidic in action. In such oases, sodium bicarbonate 26-40 grams a day may be given to upset the acid-base equilibrium, and may be found effective in favoring the excretion of lead. Potassium iodide, if used, should be limited to small amounts. It appears to have no advantages over ammonium chloride or phosphoric acid and many disadvantages. One of these disadvantages is that it is not so effective. Likewise, this drug is contra-indicated in nephritis. During this treatment the patient should be in bed, preferably in an institution or where he oan be very closely watched throughout the course. The first signs of the return of toxic manifestations should be treated by increasing his calcium and curtailing the deleading treatment until symptoms abate. yjhen acid "deleading" is being applied, symptoms of acidosis such as loss of appetite, headache, malaise, dyspepsia, bronchitis, rheumatic pains, should be indication for reducing the dosage. During alkaline administration, symptoms of alkalosis, i.e. hypersensitivity or tetany, should be treated in a similar way, --dosage should be restricted and, where necessary, calcium administered. It has been found advisable to carry out "deleading" in the form of courses. Intensive treatment is applied for five or six days and then a discontinued for/week or ten days during which time the patient is permitted DUP050315310 to partake of a more liberal diet. This break is followed by another course of intensive treatment, and so on. AS previously stated it is advisable to cheek the course of "delead ing" by laboratory estimations. By this means the number of courses required to render the patient "deleaded" can be better defined. It must be remembered that the term "deleaded" is only relative, since only a portion of the stored lead may be eliminated in this way. Where it is not possible to follow the course of "deleading" by labora tory examinations, two courses of five or six days each, with a break, are recommended for ordinary' oases. Those with signs of nerve damage should preferably be brought back for a second double course within a period of six months. When the deleading process is complete the patient's calcium balance should be restored and he should be able to return to work at the end of a week or ten days. He should be advised not to undertake work which exposes him further to Lead. DUP050315311 40. PART III STANDARDS OF INDUSTRIAL CONTROL A.The Problem The increase in lead poisoning on the American Continent is an indication that industrial control is either inefficient or not practiced. In practioally all forms, lead may be toxic to the human organism,--highly toxic as a molten vapor or a soluble, dusty or volatile form; slightly toxic as a sulphide or silicate. Its widespread distribution, therefore, in industry and manufacture warrants the taking of further steps to reduce the morbidity resulting from its use. The exposure. The exposure to industrial leading in its various forms starts at the mine where it is ored, and from whence the hazard cortinues to the smelter and refinery where it is transformed into pig lead. From here it is shipped to other plants where it is changed by various methods into certain physical forms such as piping, or into compounds of lead. It may be oxidized by simple exposure to the air, and especially by a moderate degree of heat, into lead oxide, and by further oxidation into litharge or, by still further heating, into red lead. Again the pig lead may be changed into a carbonate by the Old Dutch or Carter process. Still other compounds such as lead sulphate, nitrate or tetraethyl lead may be formed by suitable processesA From the actual mining of the ore, smelting and refining and changing it into one of its many compounds, the lead worker is in constant exposure either through the actual handling of materials, or its accumula tion on his clothing, skin and mucous membranes, or through the inhalation and swallowing of it in a dusty spray or vaporous state. After the compounds are made they are usually ground, sieved and packed in suitable containers. These operations create a special exposure in themselves. Use in. indastry. In addition to the actual manufacture of these compounds. DUP050315312 4i. the use of pig lead and its compounds in industry add a further exposure. For example, the pig lead may be melted and used as coating for pipes or telegraph cables. The pig lead itself oxidizes to a slight extent. The handling of the lead causes some of this oxide to become loosened and form a dust which may find the Portals of Entry of the body. Hence in many industries and trades workers are constantly exposed to lead in one of three forms; a wet, pasty or spray form; a dry state; and in the form of a dust or vapor in the breathing atmosphere. Mode of entrance. A brief summary of certain points made in Part I are in order here. It is an accepted fact that lead enters the system through the air passages and gastro-intestinal tract. With the exception of tetraethyl lead, the skin is not significant as a point of entrance. While ingestion through the mouth (gastro-intestinal tract) is of importance, the most important industrial mode of entrance is through the air passages. Animal experiments have demonstrated that lead dust and vapors may be absorbed through the nasal mucous membranes as well as in the lungs. This indicates the necessity of stressing those methods that are concerned with the prevention of lead dust or vapor from getting into the breathing atmosphere. The futility of the ordinary respirator in accomplishing this purpose has been repeatedly demonstrated by the high incidence of lead poison ing even where it has been used consistently. It is an easy matter to determine by chemical analysis whether or not a given atmosphere contains Lead, and the quantity present, and a great extension of this practice is advocated in industrial plants using lead. Nothing less than a complete, lead-free atmosphere for the operator to breathe should be aimed at. In the end, this can be accomplished for each worker by the use of a special respirator or helmet receiving a fresh supply of air from an outside or uncontaminated source. ''WWJS5I DUP050315313 48. B. gSBSjUfl, QOllSIDBB&TIOKS The industrial control of lead poisoning depends on two factors 1. A properly conceived plan that is comprehensive yet practical. 2. The adequate execution of that plan. Discussion. The history of progress in industrial hygiene, accident pre vention, and social and labor legislation is replete with examples of plans that have failed because of noneompliance with one or both of these factors. Either the fundamental plan has. not been well conceived or the execution of it has been faulty. Legislation as a whip has accomplished less than education in promoting the welfare of the industrial worker. Large scale industry has co-operated better than small scale industry in executing plans for the improvement of healthful and safe conditions for workers. The lay ing down of arbitrary rules by governmental agencies frequently defeats its purpose. The word of the law may be obeyed but not its spirit. The general improvement of the health of the worker through shorter hours, increased wages, and greater leisure as well as specific improvements In factory hygiene, are evidence that industry is alive to the economic value of humani tar ianism. Workmens' Compensation. The recognition of occupational diseases is gradually being extended into the Workmens' Compensation Laws of the various states, provinces, and countries. Since lead poisoning is one of the most frequent forms of occupational diseases, and since its symptoms, complications and sequellae are so often serious, industry must become aware of the heavy burden it carries not only through large turnover, curtailed production or through compensation'payments, but through the humane aspects of the case. DUP050315314 43, C. THE PLAN Goal. The ideal to be rimed "t in elimin-tirg lead poisoning should be to prevent Lead Ingestion and Lead Absorption through the control of Lead Exposure. Principally, the idea is to remove lead from actual or atmos pheric contact by the adoption ofA. Various industrial means, such as 1. The supply of a lead-free atmosphere from outside sources. 2. Automatic processes. 5. Confining cabinets or isolated spaces. 4. Air conveyances for lead in dry, vapor or spray forms. 5. Hoist or oily processes. 0. Substitutes for lead. 7. High-class factory or 'workplace hygiene. B. Various personal means, such as 1. Personal hygiene, observing particularly instruction to employes on how to prevent lead poisoning. 2. Medical supervision with frequent examina tions specifically for Lend Exposure, Lead Absorption and Lead Poisoning. 3. Regulation of hours of labor involving Lead Exposure. 4. Limitation of the employment of youths, 'women, the delicate or sickly, ^nd those who have previously suffered Lead Poisoning. DUP05031 5315 44. 5. Prohibition of the employment of those showing increasing or marked evidence of Lead Absorption, any stage of Lead Poison ing, or a history of increased susceptibility* of marked symptoms ift previous attacks. The more eliisive of the above items are next discussed under the two following headings * Standards for Workplace Hygiene* Standards for Personal Hygiene* The words "shall" and "should" are advisedly used in these standards to denote compulsion or admonition respectively. STANDARDS FOR WORKPLACE HYGIENE 1. Age. No Worker iess than 21 years of age shall be permitted to engage in any occupation where Lead is used, i.e., subjected to Lead Exposure. "The general clinical conclusions of appointed surgeons- in the various lead factories would be, we believe, that the susceptibility of young persons is at least twice that of adults, and there is some ground for supposing that the tissues of an adult, when growth has ceased, more readily adapt themselves to deal with the absorption and elimination of poison ous doses than do the tissues of a young person."- Legge and Goadby's "Lead Poisoning and Lead Absorption",1917, pp.SS. 2. Sex. No female under 45 years of age should be permitted to handle any dry substance or dry compound containing lead in any form where the Lead content is in excess of 2%. "Figures showed females to be attacked about twice as frequently as males" -Thomas M. Legge, Jour.of the Royal Society of Arts, No.4007, Sept.S, 1929, p.1028. DUP050315316 45; 3. Workplace, Every employer shall without cost to his employes provide and maintain for the protection of his employes who are engaged in a work or process involving Lead Exposure, workrooms or workplaces which comply with the followingj (a) So illuminated that there are at least 4 foot candles of light Oh all working planes where the air is breathed. (b) So ventilated and arranged that there is at least three complete exchanges of air per hour, using normal outside air. (c) All workrooms shall be provided with a smooth floor permitting easy removal of dust by vacuum cleaning, flushing, the use of oiled mops, or sweepi; g with wet saw-dust or other wet material, or other means to lay dust. Dry sweeping of floors is prohibited. (d) The walls of workrooms shall be smooth and shall be painted, varnished, whitewashed, cleaned or otherwise freed of dust or smurge at least once annually. Dust may bn prevented from accumulating upon walls by vacuum cleaning, flushing, oil mopping, or adequately ventilating outside of workhours. Dry sweeping of the walls is prohibited. (e) Windows and lighting fixtures shall be kept clean. (f) Machinery, benches, hoods, ovens, etc., shall be frequently freed of dust accumulation. (g) Ho scrap, tailings or materials containing lead in dry form shall be allowed to accumulate on the work room floor. DUP050315317 46. 4. Materials, (a) All dusty materials creating a condition of Lead Exposure should be kept moist where possible. (b) All dusty materials, creating a condition of Lead Exposure, should be kept cornered and, where it can be done without adtual interference with the work process, they should be connected with adequate exhaust systems and ventilation* Special regulations for Tetraethyl Lead, its compounds, mixtures and dilutions shall be taken as recommended by the IJ. S, Public Health Service (Pub. Hlth. Reports, Vol. 43,0147-5149, Sfov. 30, 1928). 5. Processes. The wide variety of processes makes it impractical to specify the precautions to be taken for each, but certain general rules (indicated by the word ''shall") and principles (indicated by "should11) are layed down for the handling of Lead so as to pre vent Lead Exposure. (a) All work shall be conducted and such adequate devices provided and maintained by the employer as to protect the employe from Lead Exposure. (b)Wherever possible, automatic processes should be sub stituted for hand processes. (c) Wherever Lead is melted, the melting pot should be provided with a hood connected with an effectixre vent to the exterior. (d) All receptacles such as crane buckets, boxes, barrels, cars, conveyors, chutes, hoppers, dumps, or other containers when creating a condition of Lead Exposure shall be equipped DUP050315318 47* with hood or other close-fitting cover connected with .n air exhaust of sufficient oh-r cter to pre vent the esc pe of heed in dust form to the surround ing atmospher-. (s) Jill crushing mills} grinding mills and sieving machines operating on lend containing material in a dry state shall he connected with an efficient air exhaust and dust collecting system,oh he completely confined. (f) AH vats containing solutions of soluble lead salts for boiling should be protected by suitable hoods. (g) All shaking, mixing, dusting, spraying or other wise frequent manipulating of dry materials containing lead shall be performed either in cabinet, or under an exhaust equipment, or in a special room with mechan ical exhaust ventil:.tion, and, in case it is necessary that the worker be located in, or is required to fre quently enter, such cabinet, equipment, or room, he shall be provided with a form of helmet or respirator which draws air from an outside source. (h) /ill packing of dry material containing lead shall either be carried on by a type of packing machine that retains or removes all'lead dust, or the worker shall be equipped ns specified in (g) above. (i) All workers when required to be employed tempor- nrily in or near lead duet ,spray or fumes shall be equipped as specified in (g) above. (ti) all operations which through speedirg up increase- DUP050315319 48. the exposure to lead dust spray and fume should be slowed down or discontinued at periodic intervals. (h) 411 workers not eng-aged in work involving a Lead Exposure should be completely separated therefrom. (l) Lead-containing dusts, sprays, fumes, or vapors should not be permitted to escape to neighboring premises. (m) .t least daily inspections should be made of all work conditions and apparatus that pertain to the pre vention of Lead Exposure. (n) The lead exposure associated with the various processes of an industry should be accurately measured from time to time, so as to give an indication of the importance of the hazards, and so as to evaluate the measures taken for the reduction of such hazards. 6. Sanitary provlsions. (a) The employer Shall provide a separate washroom equipped with(1) One lavatory basin for every five employes fitted -with waste pipes and two spigots conveying hot and cold water or the equivalent. (2) One nail brush, soap and a clean towel for each employe(or a sufficient number of paper towels). (5) Ten minutes' time allowance at the employer's expensefor each employe for the use of the washroom DUP05031 5320 49. before lunch and at close of the day's work. The washing should be supervised and records of the same kept. (4) One shower bath for every five employes. The baths should be approached by wooden runways, be provided with wooden fibor gratings, be supplied 'with hot and cold water, and kept clean. (b) The employer shall provide toilets,urinals and water closets in strict accordance with the official sanitary regula tions governing factories or other workplaces in the community. (c) The employer shall provide a dressing room adequately heated, separate from the workrooms, equipped for each employe with a double sanitary locker or two sanitary lockers, or two individual ceiling hangers with cord-pulls, in either case the one for his street clothing and the oth-r for his work clothing. (d) The employer should provide an eatirg room separate from the workroom with sufficient tables and seats and keep same clean. (e) The employer shall provide food lookers in the eat ing room which shall be kept under lock and kep held by the foreman or other supervisor who shall surrender key at lunch time and quitting time only, and only when satisfied that the given employe has complied with the following sanitary regula tions Each employe in a process presenting possible Lead Exposure shall, before eating -- DUP050315321 50. (a) Thoroughly dust or exchange the outer cloth ing, or place clothing not subjected to workroom Lead Exposure ovep same. (b) Wash the hands and face thoroughly. (c) Clean the finger nails Each employe in a process presenting possible Lend Exposure shall, before quitting the workplace, carry out (a),(b), and (c) and also (d) Dust and leave his work clothing in the locker or hanger provided therefor. (e) Take a complete shower, sponge or scrub bath. (f) Don street or other wearing apparel which has not been subjected to Lead Exposure. (f) The employer should supply one pair of overalls and one jumper for each employe andshould repair and renew such clothing when necessary and wash the same at least once each week. (g) The employer shall supply a sanitary and potable drinking water, regular ard copious use of which should be encouraged. English) (h) The employer shall post in a conspicuous place, Rules(in/ ) for Personal Hygiene (see below), and in the several languages to correspond to the comprehension of the various employes, provided 5 or more of a given language are employed. Each appli cant upon hiring for work in a process subjecting him to Lead Exposure shall be supplied with a copy of Rules for Personal Hygiene. DUP05031 5322 51. RULES FOR PERSONAL HYGIENE 1. Do not go to work on an empty stomach. Do not put fingers in the mouth. Do not take food into the workroom. Do not eat food in the workroom Before eating and before leaving work, thoro\ighly wash the face, arms and hands with soap and water, blow out the nose and rinse out the mouth, 2. Take a bath daily. Cleanliness is one of the best preventatives of sickness. 3. Do not chew tobacco while --.t work, for in the handl ing of the tobacco with dirty hands the dust may be carried by your fingers into your mouth. 4. Do not drink alcoholic liquors. ,vlcohol favors lead poisoning. 5. Keep your finger nails clean and cut short so that the dust cannot collect under and around them. 6. It is better not to wear mustache or a beard as they collect dust. If worn it is better to keep them cut short ad to wash them thoroughly every day. 7. Keep your bowels open. Take a dose of Epsom salts once a week. 8. Dry sweeping and dusting about the workplace is pro hibited (See Foreman for methods of cleaning up). 9. Wear a respirator or helmet where Foreman instructs you. 10. If ill consult a physician at once. DUP050315323 52* III. MEDICAL StfPEfiVlStON ---------- - ---Ilnur-ft -n I II 1*11 ifi l 1. Medical supervision should be obtained for all workers sub,iacted to Lead Exposure. 2. Efforts toward organising medical services to this end should be made. Small groups of workers subject to Lead Exposure should make arrange ments with clinics or hospitals having adequate laboratories, or with other industrial units, so as to command adequate medical and laboratory supervision. 5. Only competent medical men who are directly interested in promoting industrial and public health should be engaged to control the medical supervision of Lead Exposed workers. 4. All workers should be examined nt the time of hiring. The examination should include at that time findings of possible Lead Absorption or Lead Poisoning from previous exposure since workers tend to follow the pursuits with which they are most familiar. No applicant should be employed who shows any evidence of Lead Absorption or Lead Poisoning or any definite heart, kidney, lung or arterial disease, anemia, neurological conditions, marked oral sepsis, or gastro-intestiral disorder. 5. Each worker engaged on a lead operation of any kind should be medically ex-aained weekly: (a) The examination should be conducted in a room separated from the workroom and especially provided for this purpose. (b) The examination should consist of: (1) An inquiry into incidental illnesses includ ing accidental mishaps that may have arisen during the preceding week. DUP050315324 55. (2^ A careful inquiry into any present health complaints. (3) A physical examination with particular reference to Lead Poisoning in any of its stages or phases. (4) A laboratory examination which should consist of a red cell count, white cell count, a hemoglobin estima tion "nd a differential blood examination with particular reference to the detection of stippled or other abnormal cells (see below). 6. A monthly dental examination is recommended. 7. Three criteria for changing the employment of a worker are suggested: A. Upon blood findings (a) The presence of reticulosis, stippled cells (basophilia), or basophilic aggregation in increased amounts. (The Committee plans to inquire into the technique of various methods of establishing these findings, and '-.rtth a view of placing one or more of the toohrlques upon a quantitative basis). (b) ft red cell count well below normal, (c) A hemaglobln estimation well below normal. (d) a gradually changing condition of the red blood cells when followed through four blood examinations, made at intervals of one to seven days based upon the probable intensity of exposure, as evidenced by (1) an increasing stippled (basophilic) cell count. (2) An increasing presence of other abnormal cells. (3) A progressive reduction in the red cell count. (4) A progressive reduction in the homaglobin. DUP050315325 E. Upon physical findings 54 (a) Gradual lo;=s of wei ,ht, appearance of pallor, tremor or hypotension. (b) a reduction ir. the hand and vrist strength tests after four consecutive (weekly) examinations as sho..'n by a progressive change in a record charted for such strength tests. C. Upon syr.ptom tology,- obviously, upor any arr^y of symptoms indicative cf Lead Poisoning in any of its stages; but note that some workers m.y deny symptoms in order to hold their jobs. 8. all oas.'s of Lead Poisoning in any stage shall be reported to the proper city, state, provincial or other governmental authority according to respective laws or regulations covering this matter. IV. REGULaTlO. 0? HOURS OF UtfiOR A shorter work day or shorter work week would diminish the time of exposure and thus reduce the possibility of lead poisoning. It is therefore recommended as a standard that all men exposed to any of the leading hazardous lead operations* be permitted to adopt one of the following plans: 1, iOrk five days a week (40 hours) 2. -York seven hours a day,os'e-ha If day on Saturday (38 hours) Z. Change at monthly intervals from a Lead Exposed to a Ton-Lead Exroc-ed operation. * iS stated above, ti e Committee1 expects to prepare a list of the industries and trade processes involved in significant Lead Exposures. DUP050315326 "pr 55. B. Bibliography Foreword The Bibliography prepared by the Committee consists of an alpha betical list of approximately all articles published during the period January 1, 1928, to December 31, 1928, on the subject of Lead and its effects on human beings, the titles of which have been found in the following publications; (1) Bibliography of Industrial Hygiene, Inter national Labour Office; (2) Journal of Industrial Hygiene; (3) Quarterly Cumulative Index Madicus; (4) Chemical Abstracts; (5) Journal of American Medical Association; (6) Public Affairs Information Service; (7) American Journal of Public Health; (8) Miscellaneous. The emphasis is largely on the industrial aspects, but there are other articles which have been included because it was felt they might throw some light on the subject at hand. Roughly, it may be said that the articles included encompass the subjects of Chemistry, Toxicology, Clinical Aspects, Analytical Material, Industrial Processes, and General Topics. The Bibliography has been prepared primarily for the Committee in relation to its work, particularly in regard to the devising of Standards such as those presented in the preceding Section (A). The entire Biblio graphy can, however, be made available to anyone interested under certain conditions* The Bibliography includes 265 articles as it now stands to which * *The Bibliography comprises approximately 27 pages with ten items to the page, four lines each, giving the author, title, journal or place, page(s), epH date of publication, whether or not abstracts are available and, if so, where. There are not sufficient typed copies of the Bibliography even td supply all the members of the Committee and it is considered unfeasible to re-type the manuscript for a few copies. If requests for 20 copies.however. DUP050315327 / ! i / 56. / some more for 1928 may yet be added. These are divided roughly into the following countries of origins 70 American, 36 British(this includes British Empire), 80 German and Austrian, 18 French, 12 Italian, 20 Russian, I Polish, 1 Hungarian, 8 Japanese, 3 Belgian, 3 Swiss, 2 Miscellaneous, and II Uncertain. Abstracts are obtainable at the time of this writing (Sept. 28,1929) for 112 of the listed titles for 1928. These abstracts have been secured in two ways s (l)From printed abstracts already published, as in the following Journalsj Chemical Abstracts; Physiological Abstracts; Biological Abstracts; Jour, pf Indust. Hygiene; Jour. Amer. PubiHlth Ass'n; Jour. Amer. Med. Ass'n, (2) Original Abstracts made by the Committee. Apparently abstracting Journals are considerably in arrears even for many of the major articles which appeared in the literature for the year 1928. In some instanoes the original journals have also proved unobtain able by the Committee in the time at hand. However, the Committee hopes to secure abstracts for most., .if not all, of the articles cited in the Bibliography.* * All requests for bibliographic material or suggestions concerning it should be addressed to Dr, Carey P. McCord, Secretary Industrial Hygiene Section; A. P. H. A.,34 West Seventh Street, Cincinnati, Ohio. are received the Bibliography can be mimeographed and mailed out at a cost of about 75/ per copy. Those interested should communicate with the Secretary of the Section at once, and it seems necessary to set the final time for receiving such requests at a period not exceeding 60 days from the publication notice hereof in the American Journal of Public Health. The Committee can supply copies of abstracts at a cost of 5/ each for those not exceeding 1/2 page, double Space,(the majority) and 10/ for those longer than this. Citations to printed abstracts not exceeding five in number can be furnished free and more than this, at the actual cost of typing. DUP050315328