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FILE NAME Monsanto MON DATE 1960 July DOC MON008 DOCUMENT DESCRIPTION Conference Proceedings - 13th International Congress on Occupational Health 1161 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 The Alcoa Foundation AMF Foundation Columbian Carbon Company Consolidated Edison Company of New York Inc. Addressograph Corporation Continental Can Company Inc. Allegheny Ludlum Steel Corporation Continental Oil Company Chalmers Manufacturing Company Corn Products Refining Company America Fore Loyalty Group Corning Glass Works American Brake Shoe Company Crouse Company American Can Company Crown Zellerbach Foundation American Cast Iron Pipe Company Cummins Engine Company earns American Cyanamid Company American Industrial Hygiene Association Curtis Publishing Company eh Northern California Section Deere and Company siter American Medical Association Detroit Edison Company American Metal Climax Foundation Inc. Dodge Manufacturing Corporation American Mutual Insurance Alliance Douglas Aircraft Company American President Lines Ltd. Dow Chemical Company American Telephone and Telegraph Company E. I. Dupont de Nemours and Company American Viscose Corporation Dupont Mr. Irenee Armco Steel Corporation Armour and Company East Ohio Gas Company Atlantic Refining Company Eastman Kodak Company Electric Storage Battery Company J. T. Baker Chemical Company Bausch and Lomb Optical Company Endicott Johnson Corporation Equitable Life Assurance Society of U.S. Baxter Laboratories Inc. Esso Standard Bayuk Cigars Inc. Bethlehem Steel Company Esso Research and Engineering Ethyl Corporation Boeing Airplane Company Bristol Company Budd Company Burlington Industries Inc. Burroughs Wellcome and Company California Texas Oil Corporation Campbell Soup Company The Carrier Foundation Inc. Fairchild Camera and Instrument Company Dearing Printing Company Federal Bearings Inc. Federal Paper Board Company Inc. Federated Department Stores Inc. Firestone Tire and Rubber Company Food & Drug Research Laboratories Inc. Ford Motor Company 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 Palmolive Company The Garret Corporation General American Transportation Company General Aniline and Film Corporation General General General General Dynamics Corporation Electric Company Foods Corporation Mills Inc. General Motors Corporation General Tire and Rubber Company Union Incorporated Goldman Sachs and Company nave VR DUNUKO 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 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 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 National National Biscuit Company Dairy Products Corporation Institutes of Health Public Health Service Department of Health Education and Welfare National Lead Company New Orleans Public Service Inc. Newport News Shipbuilding & 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 Corning Illinois Glass Company American World Airways Inc. Paramount Pictures Corporation Pennsylvania Railroad The Peoples Natural Gas Company Pepsi Company Pittsburgh Steel Company Procter and Gamble Company Provident Life & Accident Insurance Co. Kaiser Industries Corporation Kennecott Copper Corporation Kimberly Corporation Koppers Company Incorporated LaSalle Steel Company Legge R. T. M.D. 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 & 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 Standard Oil Company Indiana Dy LIDI vi DUNUKS 1005 WLIO Standard Oil Company New Jersey EM and affiliates LL Standard Oil Company Ohio PN Standard Railway Equipment Company ALL Foundation BL HR Standard Oil Company VL AEE Stauffer Corporation A aoc Studebaker Packard Corporation ERI 4 Sugar Beet Products Company nA Sun Oil Company MRD Sunstrand Corporation Lek th Swift and Company ed Sylvania Electric Products Inc. ots in The Fall Tampax Incorporated EvetF Tennessee Corporation Texas Company wie one Texas Instruments Inc. Tidewater Oil Company DONE 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 Camp Paper Company Zenith Radio Corporation POEM NSE WHE OH tam ot sti Wid THIRTEENTH WS A Saat ee Riga gee died asda RATE ce tee CONGRESS ON | dene emer veweeNE eran July 25-29 1960 Copyright '1961 by the U. S. Executive Committee of the Thirteenth International Congress on Occupational Health ALL RIGHTS RESERVED Library of Congress Catalog Card Number 58-32683 ge a A hetCelt Rep Public Health GIFT DESIGNED BY HARVEY SATENSTEIN MANUFACTURED IN THE UNITED STATES OF AMERICA BY BOOK CRAFTSMEN ASSOCIATES INC NEW YORK RC 963 A1I65 1960 1960 Public Health EXECUTIVE COMMITTEE Library Chairman .L WADE M.D. Chairmen L. GREENBURG M.D. S. E. MILLER M.D. Secretary R. E. ECKARDT M.D. Treasurer . H. E. TEBROCK M.D. Executive Secretary J. W. MUCKELL R. ASTON D.D.S. C. U. DERNEHL M.D. T. ELY M.D. B. S. Fox J. LAUER M.D. H. L. MAGNUSON M.D. H. B. NACHtigall M.D. N. NELSON PH.D. M. NEWQUIST M.D. L. T. ROBERTSON M.D. I. R. TABERSHAW M.D. S. P. WAGNER 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 REGISTRANTBSY COUNTRIES Country Total Afghanistan eee eee ..........0... Algeria 6... cece eee eens Argentina Australia 2.0... aeee 0... . ccc ccc cee ee eee Austria 000. c ccc ccc cece eee Bahrein . cece eee eee 0.2.2.0... Belgium Bolivia 2020 eee ...........-20.02 ...... 00.0.0 ccc cece ee eee Brazil 20... cc eee British Guiana ............2-.05. Canada ...... 0.0... c eee eee Chile 2.0 00. 0. 0.0 0 ce. ce 0 eee . eee Colombia eee ee ............00.00: Cuba 2.0 ce. ce e6 ee. ee. e e. ee Czechoslovakia 00.2 2.1. c . e . e Denmark ..... 2c. ccc eee Finland France 2.0. 0c0 ce0 ce c. enc. e e. ens oo. c ec ccc cee cece eens Germany Greece eee e eee eens .......... ee eee eee eee India ... 0... cece cece ccc ceeees Indonesia Iran oo 00000 .............2... ec ccc eee eee eees Ireland .. 0... cece ce eee eee Israel 2.. ee . ee eee Italy oc eec e eee eee 1 l 19 3 8 1 2 1 5 2 54 4 9 5 1 4 62 39 36 l 5 1 2 1 2 21 Country Total Japan ...- ee eee eee eee eee . Luxembourg .......-...-++-0000- Mexico 22. ce . eee. eee Morocco 1.) ee ee ee 20 3 6 l Netherlands ..............---+--- 16 Netherlands ........ .... 2 Northern Rhodesia ......... I Norway - eee eee ce eee . 13 Pakistan 00002 eee eee ............0 1 Peru eee eee 4 0006. hts Philippines ..............-- 5 Sp Portugal 002s ee eee ...-...-..0-2 5 Romania .............2.20.0+05- 1 Spain 2.2 2.2. ee0 e ee. e ee. eee e. ee 5 Sweden 0002 e eee .........-.-200- 29 Switzerland ...........22..00005- 6 Thailand see eee eee es .......-.. l Trinidad see eee eae ............ 2 Union of South Africa ........... 9 United United Kingdom ...............- 94 States .........2...-.-2.. 1040 Uruguay ....- eee eee eee eee eee 2 U.S.S.R. oe ec cece 1 Venezuela . eee ee eee 7 Yugoslavia Total ... cee. cec. e e. ee. eee 4 2.0... cece ce eee es 1568 m th th -- he ci ' 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 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 people friendly and hospitable We hope that new friendships were made new understand- ings reached and that the memories of the Thirteenth International Congress on Occupa- 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 KIVILUOTO 311 ml of the buffer described in Appendix 1 and continue as in Appendix 1. Normally for blood specimens the final washing must be performed four times instead of thrice as for urine specimens APPENDIX COPROPORPHYRIN ESTIMATION To 5 ml freshly voided urine in a stoppered test tube add 0.2 ml 3 per cent hydrogen peroxide solution 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 ultraviolet light and grade the specimen ++++ by degree of fluorescence APPENDIX HEMOGLOBIN DETERMINATION Take 0.05 ml blood and make up to 9 mls volume with 04 per cent ammonium hydroxide Measure absorption on a colorimeter using a standard filter EEL 404 and convert the reading to hemoglobin percentage to the nearest even number from a prepared calibration graph APPENDIX PUNCTATE BASOPHIL COUNTS Make a thin blood smear on a slide of 08-10 mm thickness fix for about one minute in methyl alcohol allow to dry and stain for 30 seconds in Sellars stain 1 g methylene blue 6 g sodium bicarbonate in 100 ml deionized water Wash in tap water until the slide is a sea green color Using a dark ground condenser and an Ehrlich eyepiece set to a mm square count the punctate cells in ten consecutive fields Although in counting the punctate cells are classified as large medium small very fine or polychrome according to the size of the intra- cellular structure this differentiation is for further reference on an individual case and normally only the total count is given Close the eyepiece to a mm square and count the R.B.C. in this square Repeat both counts five times on different parts of the slide to give a punctate count of 50 large fields and an R.B.C. count of five small ones Calculate punctate per 1000 R.B.C. NONOCCUPATIONAL ASBESTOSIS RAIMO KIVILUOTO Roentgen Department of the Central Hospital of Northern Karelia Introduction genologic point of view asbestos dust inhalation had Pleural reaction is very often observed in asbestosis we In the advanced cases of this pneumoconiosis pleural fibrosis has been almost always found and a clear Loma correlation between pleural changes and the severity of the pulmonary fibrosis has been observed by several investigators Observations on the occurrence of pleural calcification in asbestosis have also been made Reports of pleural calcification as a roentgenologic sign or complication of asbestosis have especially been made by the German authors 1 In addition to advanced cases of asbestosis special cases have been presented in which pleural calcification has been the chief finding been considered the most probable etiology Pleural calcification resulting from hemothorax tuberculosis or empyema usually occurs unilaterally and is situated on the visceral pleura In most cases marked pleural thickening and displacement of the intrathoracic organs is observed The calcification resulting from dust inhalation usually occurs bilaterally and is most often situated on the parietal pleura In advanced cases calcium deposits are found in the lateral parts of the chest basally and mediastinally The calcium deposits take various forms large_confluent plaques bizarre figures or roundish spots 2 Except in asbestosis pleural calcification has also been observed among workers exposed to talc and mica 4 or to various dusts including a short exposure to The Roentgenologic and Clinical Picture of Cases Observed in Northern Karelia asbestos 5 In the advanced cases calcium deposits are found The diagnosis of pneumoconiosis is primarily based bilaterally in the central parts of the diaphragm on on occupational exposure to dust Only very few re- chest walls especially anterolaterally but also dorsally ports of pneumoconioses without occupational exposure and on the mediastinal surfaces In the incipient cases may be found in the literature 6,7,8 6,7,8 In Northern the calcium deposit takes place either on the antero- Karelia Finland during few past years interest has lateral chest wall more often on the left or in the been attracted by the high incidence of cases of pleural central parts of the diaphragm apparently more often calcification showing a rather curious and characteristic on the right Pericardial calcification is sometimes roentgenologic picture very similar to that observed in pneumoconioses The cases have been mainly found among the residents of a certain area and in these cases no previous history of adequate pulmonary or pleural disease could be elicited The occupations of the patients showed no uniformity and the main part of the patients had no clinical symptoms of pneumoconiosis A study of the areal distribution of cases revealed that they were grouped round two anthophyl- asbestos mines Asbestos constituted the common present The calcium deposits are located on the parietal pleura In a series of 150 cases no interlobar calcium deposits were observed The parietal location has been demonstrated by diagnostic pneumothorax examinations and it has also been noted in some autopsied and surgical cases Using a tangential roentgen beam the parietal location of solitary plaques may be observed these plaques having their bases toward the inner chest wall or toward the diaphragm In advanced cases external factor sought Even from a solely roent- the lack of soft tissue mass between the calcium deposit wan = Vibe atin pans arnt elk nA aod dad ben ab das meronae are unt Gai natn 312 MEDICAL PRACTICES and inner chest wall due to the parietal location is apparent and diagnostical pneumothorax examination is seldom needed The majority of cases of pleural calcification described above have been clinically symptomless In a series of 150 cases the ordinary chest roentgen examination by A and lateral projections revealed pulmonary fibrosis corresponding to the anteprimary or primary stage of pulmonary asbestosis in only about 14 per cent Even the main part of these cases had no sub- jective respiratory symptoms The series mentioned above has been selected solely according to the roentgen diagnosis without reference to other factors The concentration of the cases around two asbestos mines in Kuusj^/rvi and its neighboring communes has as yet been the only way to confirm the roentgen diagnosis The majority of 25 cases living outside this area had previously lived there According to these facts any other etiology would be very dif- ficult to credit In very few cases a previous occupational exposure to asbestos dust has been observed which lends slight support to the roentgen diagnosis The diagnosis has as yet not been confirmed by other methods In the sputum of 20 cases no asbestos bodies were found and asbestos fiber in one case Small amount of anthophyllite asbestos was lung of an autopsied case and in the from the vicinity of the asbestos mine found in lung of a the cow pulmonary fibrosis among residents around the two asbestos mines Some investigators have pointed out the difficulty of attributing the calcification to inhalation damage in view of its parietal location few if any changes being observed in the lung or the visceral pleura 2,5 It seems possible that the asbestos fibers move with the lung and visceral pleura in relation to the parietal pleura thus causing capillary hemorrhages on this only as previously presented by the author The hemorrhage coagulates and organizes forming a collagenous plaque which slowly calcifies This theory could explain the course of the process resulting from inhalation of small quantities of fibrous mineral dust The clinical significance of the pleural calcification seems to be slight the majority of cases showing no clinical respiratory symptoms Further investigations on this point are needed From roentgenologic point of view this endemic pleural calcification is of some significance The roentgen diagnosis is in typical cases easy but in some cases difficult Early pleural changes on the anterolateral chest wall may simulate infiltrations and large calcified plaques may cause difficulty in interpretation of pulmonary changes by hiding infiltrations The high kilovoltage technique can hereby be especially recom- mended In chest roentgen examinations of workers of asbestos mines in Northern Karelia and of Outokumpu Copper mines located in the same area attention must Discussion The total number of cases of pleural calcification around the two asbestos mines amounts to over 800 be paid to the fact that even extensive bilateral pleural calcification does not have to be a sign of severe pulmonary changes resulting from occupational dust exposure as previously reported by the author This number of cases was found in a mass survey of about 10,000 adult REFERENCES inhabitants and may include cases with previous occu- 1. Jacob G. and Bohlig H Die r^ntgenologischen pational exposure to asbestos dust In the history of the main part of cases examined at the Central Hos- Komplikationen der Lungenasbestose Fortschr Rontgenstr 515 1955 pital of Northern Karelia the lack of occupational ex- FFT posure has however been apparent Some of the patients have not had any idea how the dust inhalation RATE could have happened the same cases have presumed that the dust rising on the roads might be responsible 2. Muller H Uber schwere Formen der Asbestose Die Staublungenerkrankungen Band 3 Wissenschaftl Forschungsberichte 66. Dietrich Steinkopff Verlag Darmstadt 1958 3. Siegal W Smith A. R and Greenburg L Study of talc miners and millers Indust Bull 434 Migacvhed In Northern Karelia the roads highways do not have pavement Without mineralogic examinations it is of 1943 4. Smith A. R Pleural calcification resulting from course impossible to decide whether these calcifications exposure to certain dusts Am J. Roentgenol are resulting from inhalation of anthophyllite 375 1952 dust originating from the asbestos mines or from sur- 5. Fehre W Uber doppelseitige Pleuraverkalkungen ee = face deposits of other fibrous dusts such as tremolite- infolge beruflicher Staubeinwirkungen Fortschr asbestos which is a very common mineral in Northern R^ntgenstr85:16 1956 Karelia The first alternative seems to be more prob- 6. Eisenbud M Wanta R. C Dustan C Stead- able man L. T Harris W. B and Wolf B. .: Non- 2 occupational berylliosis Am J. Indust Hyg a In occupational pneumoconiosis some authors have 282 1949 called attention to the absence of pulmonary fibrosis 7. Goyal R. K Pneumoconiosis in the industrial besides the prominent appearance of the pleural calci- population of Rajasthan J. Indian Med Ass ER FritesARE fication 2,5 on the other hand a clear correlation 30:79 1958 has been observed between the severity of pulmonary 8. Kiviluoto .: Pleural calcification as a roent- ht re r fibrosis and pleural calcification 9 In nenoccupational genologic sign of occupational endemic antho- asbestosis it is apparent that extensive calcification may asbestosis Acta radiol suppl 194 1960 Se me occur without any roentgenologically detectable pul- 9. Bohlig H Jacob G and Muller H Die Asbes- monary fibrosis It seems possible that even very small tose der Lungen Georg Thieme Verlag Stuttgart amounts of asbestos fibers may cause pleural calcifica- tions 1960 10. Vorwald A. J Durkan T. M and Pratt P. C Anthophyllite is more stiff than serpentine asbestos In animal tests brittle mineral fibers have not caused pulmonary fibrosis 10 but fibrosis has been observed Experimental studies of asbestosis Arch Indust Hyg 3 1951 11. Noro .: On the histology of asbestosis Acta Pathol et microbiol Scand 23:53 1946 in workers exposed to anthophyllite dust 11 12 Further studies are needed to reveal the part 12 Wegelius C Changes in the lungs in 126 cases of asbestosis observed in Finland Acta radiol 139 possibly played by asbestos as an etiologic factor in 1947 , & leben tena ee SPan sothanMaaiteoe seeen yy at gma SAE wa ailng Weer ti yale sushaod eis 326 MEDICAL PRACTICES A REVIEW OF RECENT DEVELOPMENTS IN OCCUPATIONAL PULMONARY DISEASES OTHER THAN SILICOSIS LEO NORO M.D. Finland At the Twelfth International Congress on Occupa- tional Health held in Helsinki three years ago the French Professor Marchand presented a review of the subject mentioned in the title a large and comprehensive bibliography being attached to his presentation The Organizing Committee has at this time asked me to present a review of the same subject from the last several years It must at once be said that the compil- ing of such a bibliographic review has not been an easy task More than ever before research work has been focused on occupational pulmonary diseases The problem has been discussed at national and international meetings the last time being only two months ago in Milan From the literature which has been at my disposal I have found almost 316 articles from the recent years dealing with this subject and yet I cannot have had access to all the articles from this field pub- lished in the world I shall follow with some excep- tions Marchand's classification There is reason to state at the onset that the con- stant industrializing is causing the air we breathe to become more and more polluted Great masses of people even the peoples of the so called developed countries are changing their breathing air through their movement from agricultural to industrial centers I am here thinking specifically about the huge industrialization process right now taking place in India and China But man's breathing organs and especially his lungs do not come in contact with hazardous influences only in the working environment The most common pollutant of our breathing tobacco smoke -is rapidly triumphing all over the world with the rising standard of living in spite of the efforts we doctors take to warn mankind of its danger The automobile industry is producing cars in a rapid tempo to pollute the air of the traffic roads With the growing population centers and their increased use of fuel for power and heating more pollutants enter the air Bacterias viruses sponges and other small organisms have not disappeared either Thus the environment of man with reference to lungs is changing continuously While the great enemy of the lungs tuberculosis is gradually disappearing new diseases are arising giving new importance to the air impurities Chronic bronchitis asthma emphysema and lung cancer are already much more important diseases than tuberculosis in countries with highly developed industry and a high living standard Man himself and the changing of his reaction to the environment also require attention Allergies are one problem for example The danger of allergens affecting organisms through the respiratory and digestive organs and the skin is continuously increasing new medicines foods cosmetics etc. are common allergens Allergic reactions are important when we consider the breathing organs and their obvious connection with the air impurities Many of the chronic occupational diseases of the lungs occur only after a long exposure time We are gradually however observing the signs of these diseases among those occupational groups which have been exposed for some length of time Our knowledge of many factors influencing the lungs is already fairly complete I am thinking only of asbestosis those many chemicals causing acute lung injuries such as chlor or nitrous fumes and the diseases caused by bacteria sponges or viruses Often our knowledge is still very restricted and the interpre- tations in many individual cases are difficult to make this is true of allergic diseases and chronic bronchitis lung cancer emphysema and fibrosis on the whole and especially of the role of nonprofessional and pro- fessional environments in their occurrence Yet we have with special appreciation to Great Britain's ex- cellent vital statistics important evidence at our dis- posal of the relationship between occupation and certain pulmonary diseases such as chronic bronchitis After this general survey now let us study the details Since silicosis will be discussed in another connection I shall begin with asbestosis Asbestosis The major part of our present knowledge concerning asbestosis is contained in the excellent German book that appeared some months ago Die Asbestose der Lungen by Muller This book contains in addition to 700 of their own cases references to practically the entire world literature in this field some 650 references There is nothing basically new about the pathogenesis clinic prognosis and prevention of this disease Further information is however obtained about the frequency of clinical symptoms as well as roentgenologic and bronchographic observations from the authors careful examination on their material of 700 cases The relationship between asbestosis and lung cancer is still statistically indetermined In spite of this asbestos cancer exists and the authors give their own specification to it Does asbestos dust have similar nonoccupational affect as for example beryllium This is a problem that has been exposed through the observations of 126 nonoccupational pleural calcification cases called neighborhood cases that had been found in the population living around two open asbestos quarries published by the Finnish Dr. Kiviluoto According to this study the details of which the author will present himself at this Congress more than 800 pleural calcification cases were found in the minute ray investigation of farmers workmen and their wives who never had any occupational exposure Calcification was usually located in parietal pleura as it is also most often in occupational asbestosis In most instances it occurred bilaterally on the inner chest wall Basal and mediastinal calcification was also often observed a pulmonary fibrosis being found only on a few cases The calcification was noticed to appear slowly These roentgenologically noticeable changes gave insignificant clin- ical symptoms These observations make it evident that measures must be taken to prevent the air pollution of the environments surrounding the factories and asbestos quarries The results of Dr. Kiviluoto's work are motivation for similar investigations in other countries to certify these observations NORO 327 Other fibrotic lung diseases and benign pneumo- several cases What factors effect in different conditions coniosis caused by silicates mixed or silica dusts Glass wool sericite sillimanite talc anthracol acutseubacute chronic proteins alcaloids irritating mechanic factors toxic allergic bacteria the silica carborundum cement Fuller's earth china and ball included questions that are still waiting to be clays graphite gypsum kaolin limestone marble answered In addition for example the experience mica Thomas basic slag etc. with byssinosis is still contradictory in different coun- I shall pass this group with a brief mention of tries The interesting research results of Dr. Schilling talcosis and graphite lung which are still objects of of England make one think that this disease has not continuous research With great enough exposure un- yet disappeared as has been contemporary thought in doubtedly the dusts of this group have their affect in my own country the occurrence of fibrosis However it is evident that with improved hygiene these types of changes will become more and more rare pulmonary Infectious and parasital pneumopathies Amebiasis anchylostomosis anthrax bilharziosis brucellosis hydatitosis leptospirosis ornithosis tuberculosis tularaemia Pneumopathies due to toxic chemicals and metals GASES FUMES AND VAPORS CI NO SO desmodur hydrocarbons oils kerosene etc. borans METALS Aluminium antimon barium beryllium cadmium chrom cobalt fluor gold iron manganese nickel osmium platinum selenium sulfur tungsten titanium vanadium wolfram zirconium etc. etc. With 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 The question is very important for example with tuberculosis Of course the relationship between tuberculosis and pneumoconioses is under constant study The amount of toxic chemicals and metals influenc- Lung cancer due to occupation Arsen asbestos ing the lungs is continuously growing Vanadium chromates isopropyl alcohol manufacturing nickel chrom and beryllium have been subjects of research radioactive substances etc. especially in Sweden and in our host country the The Secretary General of our Congress Dr. Eckardt US.A. The importance of vanadium is especially in- handles the role of working conditions in the occur- creasing It is necessary however to bear in mind rence of cancer in his book Industrial Carcinogenesis that with the expanding use of oil heating the crude most variedly and with good criticism Yet it is to be oil coming from various parts of the world contains suspected that in industry many other substances also vanadium in very different amounts The role of the have a cancerogenetic effect Our knowledge in this acic sulfur compounds in the ashes is also to be field however is still very limited and although ex remembered For a detailed study of beryllium I perimental cancer research has gone far we still lack * bane would refer you to the proceedings of the conference in practice necessary facts It is hoped that the well- held at Health the M.I.T. in 1958 a comprehensive list A M.A. Arch Indust of references on beryl- endowed cancer will more than organizations and research before concern themselves institutes with the lium is contained in a publication on these proceed- ings We in Europe to my knowledge do not have the big problems with beryllium which seem to exist in occupational aspects in the etiology of cancer The results from the investigation by U.S. Public Health Service concerning the hazards of radiations to the US.A. It is impossible in this short presentation to name all the new chemicals with irritant effect on the lungs We industrial physicians have special difficulties attempting to evaluate the aftereffects of acute irritants miners are expected with great interest cases of Schneeberg and Joachimstal will in the very widespread uranium mining that will presently be answered Whether the get successors is a question to the lungs nitrous fumes Cl SO etc. especially with reference to etiologic differential diagnostics in chronic bronchitis and emphysema Pneumopathies caused by radiation The influence of radiation as the cause of cancer has already been referred to above Our knowledge about Pneumopathies due to organic dusts allergens and pneumomycoses Actinomycosis aspergillosis coccidioidomycosis cork suberosis cotton byssinosis drugs dyes feathers flour grain gum acacia hair hay farmer's lung histoplasmosis jute leather canna- bosis linen moniliasis nocardiosis sporotrichosis sugar cane bagassosis tobacco tabaccosis tropical woods etc. The agricultural population has received increased attention during the last few years in the investigation of the relationship between work and health Farmer's lung and other pulmonary diseases found in agricul- the other effects of radiation on the lungs are very small In connection with therapy large doses 10002000 r have been found to cause changes in the lungs in the form of pneumonitis and fibrosis From East Germany there comes the report of a chronic pneu monia case of a chemist which led to death the cause of death being considered the breathing of radioactive dust over a period of 20 years Conclusion To our present knowledge we already have a foundation for the technical prevention of these diseases ture have proved surprisingly common upon closer investigations Unfortunately so far there have not been powers to investigate these conditions in the countries where the agricultural population works under the We 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 This question requires much research worst hygienic conditions We have not enough knowl- We have already reached far in the roentgenologic edge about the pulmonary diseases of the workers in diagnostics of the pulmonary diseases and there we are the old Asian rice mills for example making constant progress We are also aware however The effect mechanism of most organic dusts is still unclear and we are also in a difficult field where of the difficulties therein as to several of the disease groups referred to above Together with the roent- bacteriology and allergology will be of much help in genologic examination we must develop other clinical NRA re i. OO Ape AERA, core) 328 MEDICAL PRACTICES examination methods especially the physiologic lung function diagnostics In its most advanced form we have to apply it not only in laboratories but above all in the field examinations to the examination of 20. D^"nnerL Pneumoconiosen oder Staublungenerkrankungen der Lunge Kritische Betrachtungen und Vorschl^/gezu ihrer Entsch^/digungZbl Arb med 9:12 1959 population groups exposed to different exposures Above all we need also in this field keen interna- tional collaboration to solve our common problems and to exchange information so that each of us in his own country could apply in practice the knowledge we already possess to the betterment of our working population BIBLIOGRAPHY 21. Ferin J. and Ulehlov^ V Ceber die Selbstreinigung der Lunge von Staub und ihre Bestimmung in Tierversuch Arch Gewerbepath 630 1959 22. Fletcher C. M Disability and mortality from chronic bronchitis in relation to dust exposure A.M.A. Indust Health 368 1958 23. Fletcher C. M Radiological diagnosis of pneumoconiosis In the Symposium on Industrial Pul- General monary Diseases ed by King and Fletcher Lon- Pneumoconiosis Abstracts Vol III London 1959 S^'ance sp^'ciale consacr^'l ^ l'^'tude des pneumopathies professionelles Silicose except^'e Arch mal prof 253-354 1957 don 1960 p 72 24. Gernez C Balgairies .; Fournier P. and Voisin C An often unrecognized manifestation of pneumoconiosis in miners aseptic liquefaction of pseudotumoral formations Semaine Albahary C Les asthmes professionelles probl^mes pos^'s pour leur r^'paration Arch mal prof 18.41,633 1957 4. Altshuler B Yarmus L Palmes E. D and Nelson N Aerosol deposition in the human hop Paris 1081-1089 1958 in French J.A.M.A. 2140 1958 25. Gersing R Die fruhen Reaktionen der Lunge auf verschiedene Staubarten im vergleichenden Tierversuch Beitr Silikoseforsch 42 1956 respiratory tract A.M.A. Arch Indust Health 15.293 1957 26. 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H Some pharmacological effects of diborane A.M.A. Arch Indust Health 346 1956 60. Kutschera W Ein eigenartiger Fall einer Vergiftung durch Dissousgas Mitt osterr San verw 57.228 1956 61 Lachnit V. Zur Therapie der Reizgasvergiftung Zbl Arb med 177 1958 62. Leicher .: Zur Differentialdiagnose zwischen Aluminiumlunge und Morbus Boeck Fortschr Rontgenstr, 84.571 1956 63. Levinskas G. J Pollis A and Novick W. J. Jr Distribution and excretion of poranes A M.A. Arch Indust Health 14.346 1956 64 Lewis C. E The biological effects of vanadium A.MAA.MA Arch Indust Health 497 1959 Lindgren S A. and Swensson A Yrkesmedicinska synpunkter pa framst^llning och bearbetning av plaster Sv Lakartidningen 55.2227 1958 66. Lingen Louise and Sundell C C Lungforandringar iakttagna efter inandning av oljehaltig luft Nordisk Medicin 58.1974 1957 67. Lowe H. J and Freeman G Boron hydride borane intoxication in man A.M A. Arch Indust Health 523 1957 68. Machabeli M E Gdzeldze E. G and Mgeladze T. G. 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Meiklejohn A. and Posner E The effect of the use of calcined alumina in china biscuit placing on the health of the workman Brit J. Indust Med 229 1957 77. Melnikova E. A Angaben zur Bestimmung des zulassigen Kadmium- und Vanadiumgehaltes der Luft in Industrieraumen Gig ^> san 21:25 1957 Mozentseva N. V Hygienic characteristic of industrial aerosols of wolfram Gig 1 San 25 1957 79. Minden H Bruckner Ch and Simon .: Bei- trag zur Cadmiumvergiftung Arch Gewerbepath Gewerbehyg 531 1959 80. Mitchell .: Pulmonary fibrosis in an aluminium worker Brit J. Indust Safety 123 1959 81. Mittler .; King M and Burkhardt B Toxicity of ozone AM Arch Indust Health 191 1957 82. Mogilevskaya O. Ya An experimental study of the effect of rare metals ore dust on the respiratory organs Gig 1 san 25:30 1960 83. Moschinski G Jurisch A. and Reinl W Die Lungenveranderungen bei Sinterhartmetall- Arbeitern Arch Gewerbepath, 697 1959 84. Molitor L Mosinger M Barthel .; Heyart H and Perinet : Recherches sur les poussi^res de laminoir et leur capacit^' pathog^ne Les sid^'roses pulmonaires Luxembourg 1957 127 pages Moschinski G Jurisch A and Reinl W. Die Lungenveranderungen bei Sinterhartmetallarbei- tern Arch Gewerbepath, 697 1958 Nakanisk~-S. and Namiki S Symptoms in workers exposed to isocyanates R^d^kagaku34.980 1958 87. Nebelung W Akute Vergiftung mit Dimethylsulfat Arch Gewerbepath 581 1957 88. Oyanguren H Haddad R and Maass H.Stannosis Benign pneumoconiosis owing to in- halation of tin dust and fume I. environmental and experimental studies Indust Med 27.427 1958 89 Pe^-^lverR Diagnosis and treatment of manganese intoxication Report of a case A.M.A. Arch Indust Health 16:64 1957 90 Portela F La reaction de l'alv^'ole pulmonaire ^ quelques produits industriels Proc XII Int Congr Occup Health Helsinki 3.311 1957 91. von Lingen Louise Lungskador efter inhalation av olja eller oljehaltig luft Nordisk Medicin 59.290 1958 Poteryaeva G. E The toxic properties on antimony pentachloride Gig Truda 2:22 1958 93. Quilligan J .; Boche R. D Falk L. H and Klotin P : The toxicity of ozone for young chicks A.M.A. Arch Indust Health 18:16 1958 94. Oettel H Gesundheitsgef^/hrdungdurch Kunst- stoffe Arch exper Path Pharmak 232 1958 95. Reinl W Ueber die Erkrankungen durch Tho- masschlacke Vanadinschlacke und Vanadinver- bindungen und ihre Ursachen Staub 143 177 1958 96 Robertson A. .: Pneumoconiosis due to tin oxide In the Symposium on Industrial Pulmonary Diseases ed by King and Fletcher London 1960 p 168 97. Rogers W. N Chronic beryllium poisoning treated with corticotrophin Lancet 267 1957 98. Rohrs L. C Metal fever from inhaling zinc oxide A.M.A. Arch Indust Health 16:42 1957 99. Roschtschin I. V Das Vanadium als industrielles Gift J. Hyg Epid Microbiol Immunol Prague 492 1958 100. 101. 102 103. 104. Roschina T. A An experimental investigation of the action of the chromomagnesite and magnesitochromite refractories dust on the body Hig Truda 3:28 1959 Rosmanith .; Volf J and Knopfelmacher E Respiratory disease in workers producing sulphuric acid Pracovni l^'karstvi9.411 1957 Rosmanith J. and Knopfelmacher E A case of BaSO pneumoconiosis Prac l^'k140 1957 Roush G. Jr The toxicology of the boranes J. Occup Med 1:46 1959 Rowe V. K. et al Toxicity of propylene oxide determined on experimental animals A.M.A. Arch Indust Health 228 1956 . atg 3 eth VO aA 5 Vi oe < UR 1 ENA, i alatehe Ah AR TE eSaaY: ae ARR OMY? . a yt 4 a ea 4  cot sag H& iphand 5ay eS halkha NORO 333 105. 106. Ruiz R. F. and Iribarren R. R Neumopat^>as por queros^'n The Medical Bulletin Standard Oil Co. N.J. 20:35 1960 Rumyantsev G. T On the question of barytosis Gig i San 17 1958 107. Sarai S. and Ueno .: Electron microscopic views of dust produced in electric steel melting Proc XII Int Congr Occup Health Helsinki 325 1957 108. Schepers G. W. H Durkan T. M Delahant A. B Redlin A. J Schmidt J. G Creedon F. T Jacobson J. W and Bailey D. A The biological action of fiberglas dust A.M.A. Arch Indust Health 18:34 1958 109. Schneider H 7.142 1957 Ueber Siderose Zbl Arb med 110. 111. Schechter W. H How toxic are high fuels Nat Safety News 77:28 1958 energy Sch^...ler P. et al Stannosis II clinical study Indust Med 432 1958 Schuler P. et al Manganese poisoning Environmental and medical study at a chilean mine Indust Med 167 1957 113. Serenko A. .; Stanislavsky Y. M Khazan G. L. et al Sanitary conditions of work and peculiarities of pneumoconiosis in workers at the Iron ore Aglomerating plants Gig Truda 2.17 1958 114. Soriano M Asthme exp^'rimentalpar l'acrol^'ine Sem h 3p213 1958 115. Sim V M. and Pattle R. E Effect of possible smog irritants on human subjects JAM.A. 1908 1957 116. Sj^bergS. G Vanadium dust chronic bronchitis and possible risk of emphysema Acta med Scand 154 1956 117. 118. Sj^berg S. G. and Rign^'r K. G Besvar fran luftvagar m.m. hos sotare i oljeeldningsanl^/ggningar Nordisk Medicin 1973 1957 Smith J. S. and Kench J E Observations on urinary cadmium and protein excretion in men exposed to cadmium oxide dust and fume Brit J. Indust Med 240 1957 119. Smith J. C Kench J. E and Smith J. P Chemical and historical mortem studies on a workman exposed for many years to cadmium oxide fume Brit J. Indust Med 246 1957 120. 121. Tebrock H. E. and Machle W Advances in the management of chronic berylliosis Proc XII Int Congr Occup Health Helsinki 167 1957 Thomas D. L. G and Stiebris K VanadiumVergiftung in der Industrie Med J. Australia 607 1956 122. Thomas M. D. Hendricks R. H Gunn F. D and Critchlow J Prolonged exposure of guinea pigs to sulfuric acid aerosol A.MA. A.MA. Arch ^ ndust Health 17:70 1958 123. 124. Timokhin D. I Problems of industrial hygiene in employment of magnesium catalyzer Hig Truda 2.42 1958 Tur J Liderosis pulmonum Med Pracy 10:33 1959 125. Vallee B. L Zinc and its biological significance A.M.A. Arch Indust Health 16 147 1957 126. Vorobjeva R. S The question of the cadmium oxide J. Hyg Epidemiol Immunol Prague 2 244 1958 toxicity of Microbiol 127 Zapp J. A Hazards of isocyanates in polyurethane foam plastic production A M.A. Arch Indust Health 324 1957 Pneumopathies due to organic dusts allergens and pneumomycoses 1. Bringhurst L. .; Byrne R. N. and GershonCohen J. Respiratory disease of mushroom workers farmer's lung J.A.M.A. 171 1959 2. Bugyi B. and Moln^r.: Lungensch^/dendurch Reisstrohstaub Beitr Silikoseforsch 51:37 1958 Bugyi B On Conionmycoses Prac l^'karstvi 200 1958 Chinachoti N. and Tangchai .: Pulmonary alveolar microlithiasis associated with the inhala- tion of snuff in Thailand Dis Chest 687 1957 5. DaSilva Horta J. and De Carvalho Cancella L * Experimentelle Korkstaubkoniose Experimentelle Suberose . Arch Gewerbepath 319 1937 D^"nner L Pneumokoniosen durch Staub von Getreide und Saaten In Staublungenerkrankungen Band 3 ed by Jotten and Klosterk^tter Darmstadt 1958 p 541 Dickie H. A. and Rankin .: Farmer's lung an acute granulomatous interstitial pneumonitis occurring in agricultural workers J.A.M.A. 167 1069 1958 Frank R. C Farmer's lung coniosis due to organic dusts 79.189 1958 form of pneumo- A.J. Roentgenol Frost J. and Georg .: Taerskerlunge Ugeskr Laeg, 1383 1956 10. Groetschel H and Trense E Tod eines Druck- ers an Asthma bronciale nach Umgang mit Nasszerst^/ubemitteln Arch Gewerbepath 16 375 1958 11. Gupta A. .; Ferris B. G and Rao M. N Oxygen consumption of male Indian jute workers A.M A. Arch Indust Health 20:96 1959 Klunker W Zur Frage der Atiologie und Path- ogenese des sogenannten Bacher- und Mullerasthmas Schweiz med Wschr 714 1957 Kyung V. A Dust of the kukkersite shale as an etiological factor of occupational pneumoconiosis Gig Truda 3:44 1959 Lowry T. and Schuman L. M filler's disease syndrome caused by nitrogen dioxide JAMA 153 1956 Murray R Dingwall .; and Lane R. E. An outbreak of weaver's cough associated with tamarind seed powder Brit J. Indust Med 14 105 1957 Pestalozzi C Febrile Gruppenerkrankungen in einer Modellschreinerei durch Inhalation von mit Schimmelpilzen kontaminiertem Befeuchter- wasser Befeuchterfieber Schweiz Med Wschr, 710 1959 17 Pollak K Guthert H and Schanzenbach H Experimentelle Untersuchungen zur Frage der Getreidestaublunge Arch Gewerbepath Gewer- behyg, 519 1959 18. Roach S. A and Schilling R S. .: A clinical and environmental study of byssinosis in the Lancashire cotton industry Brit J. Indust Med 17.1 1960 19. Schilling R. S. .: The epidemiology of byssinosis In the Symposium on Industrial Pulmonary Diseases ed by King and Fletcher London 1960 P. 185 20. Schilling R. S. F. The epidemiology of byssinoadventure and misadventure J. Occup Med 1.33 1959 21 Stott H Pulmonary disease amongst sisal workers Brit J. Indust Med 15:23 1958 : : : 5 (4 aa * 334 MEDICAL PRACTICES 22. Smetanin N. .: The maximal permissible con- centration of the loess dust in the air of cotton spinning plants Gig Truda 3:53 1959 23. Tiller J. R An investigation of byssinosis in a rayon mill Trans Ass Indust Med Off 157 1958 24. Totten R. S Reid D. H. .; Davis H. D and Moran T. J Farmer's lung report of two cases in which lung biopsies were performed Amer J. Med 803 1958 25 Tuffnell P. G. and Dingwall .: An investigation into the acute respiratory reaction to the inhalation of tamarind seed preparations Brit J. Indust Med 250 1957 26. Wassermann M Bugeag G and Iosubas S Recherches experimentales concernant la maladie des fileurs et des tisseurs de chauvre Proc XII Int Congr Occup Health Helsinki 3 374 1957 27. Wegmann T Galletti P and Amrein H. P Baumwollstaublunge Schweiz Med Wschr 88.437 1958 28 Zannini D and Wassermann M. Discussion: A prporpoospos de la Fi^vre des cereales des travsilos alleurs des silos Proc XII Int Congr Occup Health Helsinki 386 1957 Infectious and parasital pneumopathies Drankin pneumopathies Infectious 1. Drankin parasital parasital pneumopathies .: Brucello- sis and and and occupation Gerasimova Gig TrTuruddaa 8 195819B5r8ucello- 2 2. Gross P Westrick M. L McNerney J. M and Pittsburgh M. P. H Experimental Tuberculopneumoconiosis A.M.A. Arch Indust Health pneumoconiosis pneumoconiosis .: 320 Harris 3 H. TreatmentTreatment Treatment of Brucellosis BruceBlrulcelolossisis J.JA..AM..MA..A. Harris 1960 709 . 4. Junak G. Leptospireninfektionen bei Kanalarbeitern Arch Gewerbepath 565 1957 5. Kathe .: Die Leptospirose als Berufskrankheit Arch Gewerbepath, 316, 1959 6. King E. .: Recent Research in Infective Pneumoconiosis Proc XII Int Congr Occup Health Helsinki Helsinki 283 1957 7. King E. .; Yoganathan M Harrison C. .; and Mitchison D. A Experimental infective Pneumoconiosis A.M.A. Arch Indust Health 380 1957 8. Ramsay J. H. and Pines A Results of treat- ment of pneumoconiosis complicated by tuber- culosis Brit Med J. 2.345 1959 Schuppert 9. Schuppert R.: Lungetubrklose Lungentuberkulose als Beruf- Beruf- skrankheit bei Metzgern und bei in Landwirt- schaft besch^/ftigten Personen Z. ^rztl Fortbild Baetjer A. M Damron C and Budacz V The distribution and retention of chromium in men and animals A.M.A. Arch Indust Health 136 1959 6. Baetjer A. M Lowney J. F Steffee M.D and Budacz B. A Effect of chromium on incidence of lung tumors in mice and rats A.M.A. Arch Indust Med 124 1959 7. Bidstrup P. L Occupational causes of lung cancer Trans Ass Indust Med Off 2 1959 8. Bohlig H. and Jacob .: Die H^/ufigkeit des Lungenkrebses bei deutschen Asbestarbeitern Proc 308 Int XII 1957 Congr Occup Health Helsinki 9. Braun W Krebs an Haut und inneren Organen hervorgerufen durch Arsen Dtsch Med Wschr 870 1958 10. Browning Ethel Harmful effects of ionising radiations Elsevier Monographs Industrial Toxic Agents Amsterdam 1959 11. Cember H Bronchogenic carcinoma from radioactive particulates Second United Nations Conference on the Peaceful Uses of Atomic Energy Geneva 1958. PapPapeer r Conf 900 12. Chiurco G. A. Lavoro e tumori Archivo di Medicina Mutualistica Vol 14 1959 372 pages Vide also Proc XII Int Congr Occup Health Helsinki 147 Fr. 139 Engl 1957 13. Davies D. F A review of the evidence on the relationship between smoking and lung cancer J. Chron Dis 579 1960 14. 14. Doll , R.: OccupatOicocnuaplational lung cancer In the Symposium on Industrial Pulmonary Diseases ed by King and Fletcher London 1960 p 208 15. Doll R. Occupational lung cancer a review Brit J. Indust Med 181 1959 1960 16. 16. Dvizkov P. P OccupOcupaational tional cancer . Gig. Truda, 3 Eckardt Eckardt 17. EcEk ckarda t rdt R. R. E Industrial CarcCianrocgiennosgens NeNew w YorYorkk Industrial and London 1959 Ellinger Medical Radiation Biology Medical 18. .: Elfileildnger 1957 p , , Radiation Biology SpriSnprgi-ng. Espin^s 19. Espin^s P^'rez Ctraabajno cer pulmonar 20. D.: niosis Med y seg Finkel Miriam P trabajo Internal 5 1957 emitters emitters y neumocoand tumor Proc induction Geneva Conf Peaceful Geneva Uses of , Vol New York Atom,ip c Energy . lesions in 21. Gallego J. D Pulmonary lesions in pneumo- pathies due to dust Proc XII Int Congr Occup Health, Helsinki 378 1957 Occupational Occupational Ocupational 2222.. Goldblatt M. W Carcinogenesis Carcinogenesis Carcinogenesis 10. Spink W. W Current status of therapy of brucellosis in human beings J.A.M.A. 697 . 1960 23. Grosse lymphknoten 220 H . Mischstaubinduration der Hilus- und Lungenkrebs Frankf Z. Path Causation Brit 11. Terzin A. L ornathosis 24. Haddow A. ed Causation of cancer Brit Med malian pneumonitis POMP viruses in man Bull 14 1958 Breslin mammals and birds J. Hyg Epid Microbiol 25. Harris W. B Breslin A. .; Glauberman B Immunol Prague 129 1958 and Weinstein associated with M. .: Environmental hazards the milling of uranium ore Lung cancer due to occupation and radiation A.M.A. Arch Indust Health 365 1959 Gsm 1. Causation of Cancer British Med Bull 14 26. Hueper W. .: Experimental studies in metal cancerigensi agit) 1958 2. Upmark E Bronchial carcinoma in printing workers Dis Chest 27 1955 cancerigenesis X. cancerigenic cancerigenic effects of chromite deposited tissue ore roast deposited in muscle tissue and pleural cavity of rats A.M.A. Arch Indust Health ale 3. Azhbel S. .: On cancer diagnosis in patients suf- 284 1958 einen fering from toxic pneumoscleroses Hig Truda 27. Irmscher G Ueber einen Todesfall an chro- GON rund 3:11 1959 nischer Pneumonie nach Inhalation von alpha- ET 4. Barborik N. et al Carcinoma of the lungs in und betastrahlenaktivem Industriestaub vor electrolytic chromium plating Prac L^'karstvi rund 20 Jahren Das Deutsche Gesundheitswesen et 413 1958 1732 1958 we at NORWOOD 335 28. James W. R. L Primary lung cancer in South Wales workers with pneumoconiosis Brit J. Indust Med 12:87 1955 29. Kennaway E. and Lindsey A. .: Some possible exogenous factors in the causation of lung cancer Brit Med Bull 124 1958 30. Koelsch .: Der Arsenkrebs Zbl Arbeitsmed 129 161 1958 31. McLaughlin A. I. G Iron as a Carcinogen In the Symposium on Industrial Pulmonary Diseases ed by King and Fletcher London 1960 p 162 32. Puccini .: Le problema della cancro Med Lavoro 51:18 1960 % Rinck H Der Chromatkrebs der Lunge als Berufserkrankung Medizinische 342 1956 34. Sepke G Zum Schneeberger Lungenkrebs Zbl Arb Med 114 1957 35. Smith R. A Lung Cancer in Miners Brit J. Indust Med 318 1959 36. Sunderman F. W Donnelly A. .; West Bob and Kincaid J. .: Nickel poisoning A.M.A. Arch Indust Health 20:36 1959 37. Sunderman F. W Kincaid J. F Donnelly A. .; and West Bob Nickel poisoning A.M.A. Arch Indust Health 480 1957 TREATMENT OF PLUTONIUM DEPOSITION IN HUMANS WITH DTPA - EFFECTIVENESS OF TERM ADMINISTRATION AND ORAL ADMINISTRATION W. DAGGETT NORWOOD M.D. Manager Health Operation Hanford Atomic Products Operation operated by General Electric Company for the Atomic Energy Commission Richland Washington The recommended maximum permissible amount of soluble plutonium Pu 239 in the human body is 0.04 microcur-0.6i-0e.6 g ) Rigid control methods are necessary to limit body deposition to this extent For instance allowable concentrations in air are lower would serve the dual purpose of eliminating a fair amount of Pu 239 and indicating whether or not there was a change in effectiveness of this agent when used over an extended period by a factor of millions than the comparable allowable concentrations of many of our most toxic chemicals There will be increasing potential for exposure to such isotopes with the expanding use of such materials in industry defence and medicine Hence it becomes most important to have the safest best and most convenient method possible for treating the individual who has accidentally acquired a deposition of Pu 239 which exceeds the maximum permissible limit Treatment here of five employees who had _ har- bored small quantities of Pu 239 for some years indicated that intravenously administered diethylenetriaminepentaacetic acid DTPA was much the most effective agent discovered to date for increasing the urinary elimination of Pu 239 2 The present study was made to improve knowledge of the effectiveness of DTPA in eliminating Pu 239 via the urine when treatment is extended over a period of many months It was also directed toward determining the effectiveness of DTPA in increasing elimination of Pu 239 via the urine and feces when administered orally TABLE I EFFECTIVENESS OF INTRAVENOUSLY ADMINISTERED DTPA IN INCREASING URINARY EXCRETION OF PU 239 WHEN GIVEN FOR MANY MONTHS Week of Treatment DTPA in Grams Per Week Average Daily Urinary Excretion of Pu 239 Expressed as Disintegrations Per Minute Effectiveness Expressed as % of Initial Effectiveness 1 2 2 1.6 No treatment for period of 5 weeks 11-12 1.6 13-14 2 No treatment for period of 5 weeks 665 610 12 481 495 15 100 92 72 74 178529 Term Administration of DTPA An employee who had accidentally received a depo- sition of about 4 microcurie of Pu 239 some 30 months previously was treated with DTPA intraven- ously Initially the daily urinary output of Pu 239 was about 665 disintegrations per minute per hour specimen of urine Table I It was considered advis- able to cautiously continue treatment over an extended period unless evidence of kidney irritation or other untoward effect appeared during the treatment This 26 2 496 178529 LAWN 22222 436 178529 LAWN 22222 246 178529 LAWN 22222 190 178529 LAWN 2 125 178529 Average daily elimination of Pu 239 for periods preceding and following the above treatment was 12 disintegrations per minute in 24 hours The DTPA for this study was kindly supplied_by supplied_by Dr. Murray Weiner Geigy Pharmaceuticals P.O. Box 430 Yonkers New York R. H. Wilson was most helpful in coordinating sample collection and assisting in the interpretation of results G. D. Brown and staff Except for minor changes as shown in Table I the employee was given 1 g of DTPA intravenously in the Manufacturing Area Medical Center on Monday and 1 g on Thursday of each week for three successive weeks Such periods of treatment were alternated with performed the bioassays of the many samples periods of three weeks of no treatment This was con- otede sate ew Cete 610 SOCIAL AND LEGAL ASPECTS tlement above the loss of wages the longer he was off patient had taken his vacation in the interim for work which he had received vacation pay He offered no This case illustrates how an individual deliberately complaints and the examination was again negative perpetrates his disability on a subjective basis in order to increase the size of his monetary settlement The man finally returned to work 30 days after this injury and remained at work thereafter He instituted CASF No. -A year trainman was injured while standing too close to a slowly moving train litigation against the company because he demanded compensation about seven times his actual loss of when his arm was struck by a grab iron causing him to spin around and strike his head against the side of a car He received a cm vertical laceration across the earnings and the company refused Each time this patient was seen period it seemed that he really to grant the claim during the day believed he could middle of his forehead The man was stunned but re- work and that he actually wanted to He was phys- mained on his feet The laceration was repaired at the ically able and was not considered as having post- plant dispensary rays of the skull were negative traumatic neurosis Why then did he not work There There were no other injuries except for a slight contusion of the right upper arm Neurologic examination was entirely negative and remained so thereafter No treatment was indicated other than analgesic medication for pain The patient did not work his next turn and was seen again the following day The previous night he had a mild headache but was now asymptomatic Examination was again n^'gative The patient was seen again four days after the accident The sutures were removed and adhesive bridges were appeared to be several reasons While the patient was being treated in the dispensary shortly after the accident a company representative remarked that it would be good if he did not miss work since his work group had gone for an unusual length of time without a time accident This was interpreted by the pa- tient and his fellow workers as company interest in avoiding lost time rather than the employe's welfare Resentment was incited and led to deliberate lost time The patient was also encouraged to miss work applied His only complaint was occasional frontal headache which was relieved by aspirin He had not returned to work and when questioned as to why he gave some vague complaints of soreness in his right arm and upper back Examination was again negative because he had a head injury which required suturing Another factor which played a part was encouragement by certain parties to deliberately perpetrate unnecessary lost time for the purpose of establishing a claim against the company for income greater than for objective findings It seemed to the physician that his regular earnings the man believed he could and should be working but This case illustrates how management action work i for some reason had not done so He was formally group standards for lost time and litigation practices approved returned for work to work and was six days so advised The patient after the accident and in work ment of groups interfere with the medical manage- the injured employe and create unnecessary worked for several hours but then reported off because disability leading to excessive monetary gain of headache He was seen again the following day complaining of headache dizziness and soreness of Summary the upper back and right arm The laceration was In summary I have outlined certain economic healing well Examination results were negative once factors that have a negative influence on the disabled again He apparently did not intend to work he was employee The discussion has dealt with why and how pes treated symptomatically and seen again one week such factors interfere with the individual's recovery later at which time his condition was unchanged Following this visit he was not seen again for another RMEOSMT two weeks It was then 24 days since the injury The from an occupational injury with the thought that a clearer understanding must precede any effort to do anything about them RAGE BASIC PRINCIPLES FOR PRECAUTIONARY LABELING EDWARD J. HOGAN Chairman Labels and Precautionary Information Committee Manufacturing Chemists Association Inc.; Packaging Coordinator Allied Chemical Corporation New York N. Y. It is an honor and a privilege to speak to you as a representative of the Manufacturing Chemists Association regarding one if its activities The Manufacturing Chemists Association is an incorporated national trade organization composed of more than 180 companies engaged in the manufacture and sale of chemicals These companies account for more than 90 per cent of the chemical production capacity of the United States From its founding in 1872 the MCA has been concerned with the many problems accompanying the growth of the chemical industry Prominent among these has been the promotion of safety and the Association is proud of its contributions to the record of chemical manufacturers in this regard which is among the best in all industry This achievement is the more notable in view of the inherent hazards in many of the industry's processes and products The Association's interest in safety goes far beyond that of its members employees to include those transporting handling and using its products The objectives are promoted in a number of ways but I shall discuss at this time only that phase concerned with 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 limited in number and each had been long established Cus- tomers were so accustomed to the use of the existing compounds essary and that specific instructions such warning labels as seemed unnec were used on industrial chemicals were limited to the stronger HOGAN 611 acids and alkalies and extreme poisons There were of course the 1927 Federal Caustic Poison Act and a number of state poison and pharmacy acts but these were chiefly directed to the labeling of household packages In most cases they were pointed toward the hazard of ingestion and relied solely on the word POISON to warn the user The expansion of the industry and the broadened use of its products brought recognition of the need for more comprehensive labeling One of the early steps in this direction came in 1934 and covered the uniform precautionary labeling of six products or product groups under a series of voluntary agreements between the manufacturers of these products and the Surgeon General of the United States These agreements served a very useful purpose until they were discontinued by the United States Public Health Service in 1952 because specific labels for these pro- ducts which had in the meantime been developed under the Manufacturing Chemists Association's program were considered more appropriate 1936 As chemical products especially in the organic group mulitiplied and grew more complex the need for further steps became evident This was emphasized by a survey conducted by the Association in which resulted in distribution to its member executives of a printed book titled A Confidential Report on Labeling Importance to the Chemical Adequate com- Manufacturer This report persuaded many panies to embark upon their own warning label programs or to expand those already begun World War II greatly accelerated the growth of companies our industry Not only did established ex- pand their production of known chemicals but they developed innumerable new ones Many cor- of as well industry porations from other segments as completely new concerns began chemical manu- facture most important of all from the point of view of precautionary thousands of inof dividual companies large and small and millions workers began to operate processes using chemicals entirely foreign to any of their previous experiences The need for a comprehensive program of education in the safe handling of chemicals was obvious Early meeting in 1944 MCA considered the problem at a the of its member executives It was decided that best method to reach the man in the shop using labels authorized chemical products was by means of instruction and the formation of a Labels and Precautionary Information Committee was accordingly The called insure LAPI Committee as it has since been met for the first time on May 17 a broad view of the problem the popularly 1944. To members selected included those with chemical medical legal Since research administrative and sales backgrounds that date this has been a continuing and active committee The work of LAPI is well known to industry and administrators of health and safety programs through its publication Warning Labels Guide For the Preparation of Warning Labels for Hazardous Chemicals This manual frequently re- ferred to as the LAPI Manual is now in the review stage with a Fifth Revision scheduled for publica- tion this year It might be assumed that having agreed upon the need for precautionary labeling the writing of labels would be simple All one need do you would say is to mark a hazardous product POISON and add the do's and don'ts Unfortunately the problem is more involved than that What are the meanings of the terms used Chemicals may be harmful 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 the skin Of course there is also the matter of degree How shall we distinguish between the vapor or gas which asphyxiates and one which causes cyanosis What really is a poison There is the difficulty of language Statements must be brief but accurate They must be expressed in terms that ordinary workmen understand Not only must the statements help avoid accidents but if such occur first aid should not be delayed while someone hunts an interpreter In the case of named chemicals or proprietary compounds what is our responsibility to the doctor who may be asked to treat persons injured by them As a result of these and many similar questions the following principles were adopted These principles are set forth in detail in and comprise Part I of the LAPI Manual 1. Each chemical product presents a distinct problem and must 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 materials from which it is formed or by analogies based upon chemical struc- ture Mixtures of two or more chemicals may have properties that the individual vary in kind components or degree from those of any warning label for mixtures should be based on the properties of the finished product Impurities may contribute hazardous properties and should not be overlooked 2. All statements on warning labels should be brief accurate and expressed in simple easily under- stood terms 3. Precautionary labeling should be used only when and to the extent necessary The language should be practical not based upon the inherent properties of a product alone but directed toward the avoidance of hazards resulting from such use handling and storage as may reasonably be anticipated The use of warning labels for relatively harmless products or the use of unnecessary words will develop a disregard for labels and defeat their purpose as surely as will failure to give adequate notice of hazards 4. On labels of different products uniformity in lanto indicate the same hazards and same degrees of guage hazard is most desirable in order to gain greater understanding through standardization 5. The following subject matter should be con- sidered for inclusion on a warning label a name of product b signal word designating degree of DANGER WARNING or CAUTION c Affirmative statement of hazards d precautionary measures covering actions to be followed or avoided e Instructions in case of contact or exposure where advisable NOTE under some laws antidotes are required when the word POISON is used Instructions for the handling and storage of containers should also be considered for inclusion on the label This is information relating to characteristics of the con- tainer as well as those of its contents 6. The inclusion of the word POISON and the skull and crossbones on a label should be limited to those cases where the product is a poison according ARR SS, yt SY OR OO gma ay a Pet we dete atest Ft & B: My Hs HY 2M nln et dMtARIAM LOLN GG APHO A . GT PSEPA ee ae Bee NRENR 1 ST A SE UNE x PET eyRONE OVARINAA onARNT sgt oe eR e TAI va Fa HN IE OT HR EPRIATRANRE TNE Map Vico OrRETOCREDA fSa E 612 SOCIAL AND LEGAL ASPECTS to a definite toxicity standard or where such use is Parts II and III of the LAPI Manual contain several prescribed by law When used this legend should be hundred illustrative labels such as the one shown in addition to the other label warnings and should Those in Part are for industrial chemicals Ex- not take the place of the words DANGERI WARN- amples included are generally for those products most ING and CAUTION which are designed to show important commercially and as a whole they take in the relative degree of hazard a broad range of hazards The labels in Part III cover 7. A nondescriptive code designation or trade name the majority of pesticides sold in large volume This should not be used as the only identification of a section was added following the passage of the Federal hazardous chemical If the complete name is not Insecticide Fungicide and Rodenticide Act in 1947 shown the label should clearly state the type of The latter requires adequate warning labels for this chemical, Corrosive Acid Lead Compound 8. Warning statements should be grouped together important group of chemicals and the MCA labels have the informal approval of the United States De- in a prominent location on the label and should be - partment of Agriculture and are consistent with its printed in easily legible type which is in contrast by Interpretation 18 Revision . typography layout or color with other printed mat- How successful is the LAPI Program As may be ter on the label The label should be affixed firmly to expected the LAPI principles have the broad support and in a conspicuous place on the container In accordance with the principles just stated the of MCA members who as stated earlier represent 90 per cent of the US production of industrial usual warning label includes a a signal word- chemicals In fact chemical manufacturers both in DANGER WARNING or CAUTION give and out of the Association fully supported these a general indication of the severity of hazard b a statement of hazard or hazards as Vapor principles The very fact that such a program exists and is supported exerts a persuasive force upon the Extremely Hazardous Causes Burns or Rapidly Absorbed Through Skin c precautionary measures -such as Do not breathe vapor Keep away from heat and open flame or Avoid contact with skin and eyes and d where appropriate instructions in case of accident as In case of contact immediately flush skin or eyes for 15 minutes for eyes get medical manufacturer who might otherwise neglect proper labeling The latter knows that should he be called to court because of claimed injury by one of his inadequately labeled products the opposing counsel would surely cite the warning statement used on similar competitive products Within months after the organization of the LAPI attention Committee in 1944 its chairman was asked to serve Using these or similar statements a typical label as advisor to the State of California which sub- may read sequently became the first of several states to regulate ANILINE the precautionary labeling of hazardous chemicals DANGER HAZARDOUS LIQUID AND VAPOR RAPIDLY ABSORBED THROUGH SKIN Besides California the ensuing years have seen similar regulations or laws adopted by Connecticut Oregon Hawaii Illinois Texas New Jersey New Do not get in eyes on skin on clothing Avoid breathing vapor Use only with adequate ventilation In case of contact immediately remove all contaminated clothing including shoes and flush skin or eyes with plenty of water for at least 15 minutes get medical attention Wash clothing before use POISON York State and New York City All have been based upon the MCA principles Reference has already been made to the Federal Insecticide Fungicide and Rodenticide Act and to the fact that LAPI labels comply with the regula- tions issued pursuant to it At meetings of the International Labor Organization held in Geneva Switzerland the MCA's precaution- ary labeling system was endorsed and much of its content adopted for ultimate use by ILO on a world- Author's Note The Manufacturing Chemists Associa- wide basis WSL emt tion has available at its office 1825 Connecticut A committee of the International Association of Avenue N.W. Washington 9 D.C. at nominal cost a Governmental Labor Officials which consists of U.S. Ahn series of individual Chemical Safety Data Sheets on and Canadian state provincial and federal admin- NC the properties and essential information for safe hand- istrators has developed a Suggested Draft for Uni- ling and use of 79 chemicals Manuals on Standards form Rules and Regulations relating to the Labeling and Recommended Practices on the use and handling mE of specific containers and an outline of recommended SCRE general precautions for handling and storage of cer- for Use Handling and ing Substances Harmful Employees This draft Storage of Containers Holdto the Safety and Health of adheres to LAPI principles tain classes of containers in the MCA LAPI Manual and was the foundation for the current regulations These data will serve as excellent guides in the devel- in New Jersey and New York State and City opment of applicable phrases for container handling In this highly regulated when all of us and and storage statements industry particularly are subjected to many restrictive laws and regulations is to the credit of the chem- Author's Note The word POISON has been used indiscriminately in the past and its meaning has been ill defined For labeling purposes the MCA Manual recognizes poisonings by three modes of entry ingestion inhalation and absorption through skin- but limits use of the word to those cases where the ical industry that its adequate labeling practices began as a voluntary program and that the labeling legis- lation of recent years has been in support of the industry's principles rather than controverting them Further evidence of the LAPI Committee's influence is the fact that definitions for POISON sub- toxicity has been demonstrated either by human experience or laboratory animals tests to exceed certain defined limits stantially identical with that of its manual were written into the regulations under the Federal In- secticide Act and have also been substituted in the ne ante KLEIN 613 Aveda Interstate Commerce Commission Regulations for the The common aim of all these groups is the adequate former definition of Class B. Poisons Again LAPI and uniform labeling of the hazardous substances has been instrumental in obtaining the acceptance which they produce Uniformity is essential for the of the word flammable by ICC and other public free flow of commerce and important in educating agencies as less likely to be misunderstood than people to understand the significance of label warn- inflammable Its reputation has extended so far ings The public must be led to recognize that chemi- that in 1953 the Association of British Chemical cal products may on occasion be hazardous and re- Manufacturers which is MCA's British counterpart quire care in handling just as experience teaches sent representatives to this country solely to study us that care in handling is necessary with edged the LAPI program and subsequently adopted one par- tools and with electrical and mechanical devices alleling it Unlike the latter which seldom carry warning labels This program is receiving additional impetus from chemicals will always require some precautionary other trade associations which have been most gener- labeling because their properties can seldom be deter- ous in their cooperation As already indicated the mined by visual inspection LAPI objective is principally aimed at industrial In conclusion I should like to emphasize that any chemicals While the principles are generally accept- precautionary labeling program based upon the prin able to all groups their application may vary in ciples set forth by the Manufacturing Chemist's Asso- detail for different segments A committee of the ciation could not be considered experimental The Chemical Specialties Manufacturers Association has concept on which such a program was based has been prepared a model law for the labeling of household proven and accepted in similar programs inter- aE products Directions for use are usually an important nationally With such a program you have not only WH addition to small household packages and may convey taken out insurance on the future of your products He information for proper use which supplements the but you have provided a necessary adjunct in the Un tn-& precautionary statements Similarly the American Pe- fundamental obligation to warn of the health hazard troleum Institute recently published a manual of pre- involved in the use of either new or established BT cautionary labels for petroleum products as distinct dad products from petrochemicals Both associations support LAPI GHAR MRO principles I thank you aDHONI a THE CARDIAC CASE IN WORKMEN'S COMPENSATION IRVIN KLEIN M.D. Medical Director Workmen's Compensation Board State of New York It is my great pleasure to be able to address this thirteenth International Congress on Occupational Health It is significant that common problems know no national boundaries and together we have sought remedies in different countries of the world for over 30 years It is apparent that this is the only sound method by which we can solve these problems It is of additional significance that we are thus able to set a good example of the way in which other matters may be disposed of This afternoon we are to consider the cardiac case in workmen's compensation To merely dismiss it with the wave of the hand is unworthy of the talent and intention of this organization A search into the causes and results in this area is necessary and important There is a continuing and growing interest in the cardiovascular episodes during and in the course of employment Recently great attention has been paid to the increasing number of these cases which have come before the workmen's compen- sation boards for evaluation and adjudication In New York State for the years 1947 to 1957 the figures have risen from 167 compensated cases to 545. For the first six months of 1960 up to 150 cases were closed without award for many reasons failure to prosecute withdrawal of claim and failure to make out a proper case after trial The most frequent involvement has been the coronary arteries resulting in postocclusive angina failure pulse irregularities and infarction It is not necessary at this time to review the var- ious skills involved in the diagnostic procedures nor is it necessary to review the need for proper history and record keeping We can safely assume that the trained physician is fully aware of the need for these There 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 that the exact mechanics involved in the closure of a coronary vessel and the resultant myocardial infarction are not fully understood It must be further conceded that the sclerotic proces 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 with all of his dis- abilities whether manifest or hidden It is therefore incumbent upon the physician to be the first to recognize this in industry Others should be cognizant of this as well It appears to me that no defenses can be set up on the thought that in a given case with any degree of sclerosis the clinical end result would have occurred in any event We must 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 reasonable to ordinary analysis and be ready to review each case on its own merits Recognition that we do not have a full explanation at this time should not preclude us from drawing a conclusion It is important to keep in mind that the legal process is the dominant factor when the cardiac case in industry is discussed Too 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 without intervals which are not considered in stating MAC either performing physical work which requires average minute lung volume of 12 or 10 lower volume could be considered only for entirely sedentary work From this calculation it was evident that a workman absorbs 3.4 g or 2.8 g of trichlorethylene in eight hours modifies it into 850 mg 700 mg of trichloracetic acid and into 1897 mg 1412 mg of trichlorethanol It is difficult to say how great is the pharmacologic effect of daily administration 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 admin- istered per case in cases of angina pectoris or neuralgia n.trigemini four times a day maximum Beforehand however we can suppose a hypnotic effect especially if we take into consideration that the inter- mediary product in the metabolism of trichlorethylene is chloralhydrate The ascertained daily dose of tri- chlorethylene corresponds according to the American MAC to 43 the current known that g of choralhydrate It is well known hypnotic dose is 1-2 g and it is chronic intoxication with chloral is that also not very rare and is similar to chronic intoxication with trichlorethylene It is also possible to see to the effect of trichlor- ethanol which is the principal metabolite of trichlorethylene and in our opinion it is primarily responsible for the symptoms of intoxication Owing to the fact that pharmacologic literature does not often mention this substance we can compare it with tribromethanol Narcosis is attained by this substance after a dose of 3.5-5.6 g in a man weighing 70 kg In our case there forms 19 19 g of trichlorethanol daily I think that these considerations result in the fact that the American MAC is rather too high If it was created from experiments with animals it is necessary to declare that animals are not suitable in trichlor- ethylene cases because they have great desaturations by lungs and have entirely different ways of metabolizing trichlorethylene The dose required by Swedish authors 50 mg of trichloracetic acid in urine corresponds theoretically only to the Soviet MAC is 9 ppm about 50 From our previous experiments where we considered only trichloracetic acid in smaller percentage 16 per cent was found that in lower concentrations of trichlorethylene in air up to about 400 ...g per liter is 75 ppm the ratio of trichloracetic acid in mg to trichlorethylene in ...gin II II of air is about 2 This ratio was decreasing with the increas- ing concentration of trichlorethylene Several obser- vations from practice bear witness to this fact From our recent experiments results that the ratio is the- oretically 1.1 Vlachov^Barton^>~ ekI think that it is not possible to give more accurate directions for practice due to the great difficulties occurring in practical work and thus we can conclude that this ratio On lies the within the mentioned values 11 or 1212 basis of literature data that a great part of working people have health disturbances after a time work at 50 mg or 100 mg of trichloracetic acid in urine per liter we see that it would corre- spond with 100 200 g of trichlorethylene in air This concentration in air corresponds with 100-200 g of trichlorethanol in urine For the purpose of solving the question of MAC values in the most important industrial poisons there ought to be available a great number of carefully made observations in practice It is also necessary to investigate in laboratory experiments the absorption metabolism and elimination of these substances For medical thinking it is acceptable to consider the actually absorbed dose Experiments 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 CHARLES R. WILLIAMS PH.D. Assistant Vice President Liberty Mutual Insurance Company Boston Massachusetts In the United States hygienic standards tolerable limits for inhalation are developed for the purpose of providing guides to be used for controlling exposures to toxic materials in industry These guides are dependent on the basic philosophy that for most such materials there are levels of exposure which can be tolerated without adverse effect The principal exceptions to this philosophy are those which are applied to carcinogenic and sensitizing materials So little is known of the processes of carcinogenicity and sensitization that the tendency is to consider that levels of known carcinogenic and sensitizing materials should be kept as close to zero as possible The problem then is to develop information which can provide a valid basis for establishing levels of toxic materials which can be tolerated in the industrial environment TERMINOLOGY In order to avoid confusion it must be pointed out that there are differences in terminology with refer- ence to acceptable values for exposures to potential toxic materials Thus we find such terms as Maxi- mum Allowable Concentration which certainly has the broadest usage Maximal Acceptable Concentration which has been utilized by the American Standards Association Z37 Committee 1 and Threshold Limit_Values Limit_Values which is used by the American Conference of Governmental Industrial Hygienists 2 All of these terms have the same basic implication that these values are allowable or acceptable or that there is a limit which denotes a fine line between toxic and nontoxic As a matter of fact the users of these terms rarely accept the implied connotations The problem is one of semantics In 1949 the Committee on Chemical Agents at the 9th Annual Congress on Occupational Health United States recommended that the term Hygienic Guide was much more descriptive of the actual utilization of the numbers In September 1955 the American Industrial Hygiene Association began publishing its 6e71 6e71 il 34 ssr # zh % ! ia praegeys ene aN Ly TER ar Varta rie ae ge IT HS A REY ae WILLIAMS 989 Hygienic Guide Series using the term Recommended Maximum Atmospheric Concentration 8 hours In 1956 Smyth 3 proposed the use of Hygienic Standards for Daily Inhalation For some time the writer 4 has been urging the general acceptance of the concept of Hygienic Standard or Hygienic Guide since these terms express much more accurately the actual purpose of the application of such criteria in the occupational health field excess of the acceptable concentration probably would produce injury When the level has been established on the basis of a func- tional change or discomfort it is logical to assume that exposure to concentrations not greatly exceeding the acceptable concentration would not produce materially injurious effects Hence it is important to understand the criteria upon which any such maximal accept- able concentration has been established ORGANIZATIONS Though the purpose of the acceptable concentration is to minimize health hazards its immediate use is for guidance in establishing In the United States the establishment of hygienic guides is carried on by groups of competent individuals operating within existing organizations and utilizing available technical information The American Standards Association a private organization representing American industry has been sponsoring engineering procedures to prevent objection- able concentrations of toxic or noxious ma- terials from being present in the air of work places Comparison of the results of air analyses with those concentrations indicates acceptable conditions or otherwise the need extent and urgency of control measures development of standards in the occupational health Sampling and analysis should be carried out field since 1941 chiefly through its Z37 Committee These American Standards include the scope and purpose as well as general chemical and toxic properties Maximal Acceptable Concentration and sampling and analytical methods and references Since their start 19 such standards have been published and the Committee is continuing to be extremely active in the field The basis on which this by competent personnel using an acceptable method which will provide a reliable measure of exposure Air analyses in conjunction with acceptable concentrations of such atmospheric contam- inants as are encountered in industrial operations serve as a measure of exposure as a means of diagnosis of occupational disease Diagnoses should be based on a consideration Committee operates statement provided follows is set forth with all of in the introductory their standards as The Meaning of Maximal Acceptable Concentration 1 of all factors including results of clinical and physical examination as well as of air analyses means of assessing amounts of materials in the body and a knowledge of toxicologic effects of the materials in question In the application of the standards it should be kept in mind that It is generally recognized that there are levels of concentration of atmospheric contaminants to which a person may be exposed without known ill effects or discomfort In 1 The acceptable concentrations serve as standards of good practice 2 They serve as engineering guides Design and operation should aim at main- view of the impracticability of maintaining uncontaminated air in most industrial envir- onments it is necessary to establish acceptable concentrations of atmospheric contaminants encountered in industrial operations These concentrations in themselves do not taining all concentrations below the acceptable maximum 3 They should be applied and interpreted by competent individuals with a full understanding of the basis and limita- tions of the information from which the represent a scale of relative toxicity they represent the concentrations of contaminants below which ill effects are unlikely to be standard has been developed 4 It is advised that these standards are considered to be guides toward good experienced by any but hypersusceptible indi- industrial hygiene and are not intended viduals as legal requirements These concentrations are usually based 5 The levels are applicable only to ex- Se s upon data obtained by one or more of the following procedures e 1 Laboratory tests on animals 2 Laboratory tests using human subjects 3 Environmental and medical investiga- posure to a single substance In the case of exposure to mixtures the effect may be increased or decreased and controls should be based on the specific situation tions in plants A common feature of these procedures is that the experimental exposure shall correspond the normal work pattern This should be taken into consideration also in the The American Conference of Governmental Indus- trial Hygienists began its work in the standards field in 1947. They publish annually a list of the materials with values which they call threshold limits The application of maximal acceptable concentra- values which are given represent the concensus of a tion values Three criteria have governed the establish- ment of these concentrations (1) Organic or other tissue changes (2) Functional reactions which have no discernible untoward effects on health committee of qualified experts in the occupational health field They are reviewed and brought up to date each year The most recent published list dated 1959 2 contains values for 169 gases and vapors 71 toxic dusts fumes and mists 11 mineral dusts and but cause impairments such as coordinations and increased proneness to list of 21 philosophy of called tentative values this group is set forth in The basic paragraphs accidents 3 Discomfort or adverse sensory effects In those cases in which the concentrations have been established on the basis of organic changes it is logical to assume that repeated exposure to concentrations significantly in preceding its listing of values Threshold Limit Values for 1959 2 Threshold limits should be used as guides 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 without adverse effect The values listed refer to time weighted average concentrations for a normal work The amount by which these figures may be exceeded for short periods without injury to health depends upon a number of factors such as the nature of the contaminant whether very high concentrations even for short periods produce acute poisoning whether the effects are cumulative the fre- quency with which high concentrations occur and the duration of such periods All must be taken into consideration in arriving at a decision as to whether 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 limits are based on the best avail- able information from industrial from experimental studies and sible from a combination of the experience when pos- two These values are based on various criteria of toxic effects or on marked discomfort thus they should not be used as a common denominator of toxicity nor should they be considered as the sole criterion in proving or disproving diagnosis of suspected occupational diseases These limits 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 modi- fication for use in the evaluation or control of community air pollution or pollution nuisances These values are reviewed annually by the Committee on Threshold Limits for changes revisions or additions as further information becomes available The Committee welcomes the suggestion of substances to be added to the list and also comments references or reports of experience with these materials In addition to these two groups the American Industrial Hygiene Association has since 1955 been publishing the Hygienic Guide Series To date guides have been published for 97 substances In many respects this series is similar to the recommendations of Smyth in his report to the A.I.H.A. in April 1956 Information is provided for each material relative to the recommended maximum atmospheric concentrations severity of the hazards both health and fire the exposure tolerance atmospheric concentrations immediately 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 under the heading Specific Procedures brief descriptions are given of first aid prophylactic measures and special medical procedures Finally a list of references is given It is also significant that in each case under the heading of Recommended Maximum Atmospheric Concentration a statement is made as to the basis of the recommendation This approach represents by far the most desirable way of dealing with the problem of establishing hygienic standards Mere lists of numbers leave much to be desired It is extremely important that all available information relative to the establishment of the standard be included with it BASES FOR THE ESTABLISHMENT OF HYGIENIC GUIDES The establishment of numbers for tolerable limits in the United States is based primarily on two kinds of information animal experiments and human experience The scientific research which produces the basic data is carried on by private industry universities research laboratories and governmental agencies The results of such investigations are published in many United States technical and scientific journals In some cases particularly new chemicals the technique of applying analogy with other known chemically similar materials has sometimes been used until valid data have been accumulated The committees or organizations utilize all available published and in arriving at their judgments as levels which will provide a basis employee health referred to above unpublished data to the kinds of for safeguarding Animal Experiments The technique of evaluating toxicologic and physiologic responses in animals as a means of pre- dicting possible effects of toxic materials physical agents or other environmental conditions on man has long been a routine tool in the occupational health field In spite of this however there has been little attempt made to provide a standardized approach to investigative techniques in industrial toxicology In many respects this is fortunate for in dealing with the effects of a toxic material on a biologic system considerable flexibility is required in applying established criteria Usually early tests will indicate the course of further study The lethal doses and the effects on magnitude of acute different organs will indicate the severity of the acute hazard and the importance of various routes of absorption Corollary information relative to species variability sex age and possible synergistic effects can be obtained at this time All of this information will then provide a basis for future more extensive term studies In the case of new substances the first step which is generally adopted by toxicologists or industrial laboratories in the determination of toxicity is the utilization of screening tests on experimental animals These are usually followed by detailed studies of acute effects resulting from single injection ingestion or inhalation experiments In addition irritating effects on skin and eyes are evaluated In 1956 a complete compilation of acute toxicities for an extensive series of materials was published under the auspices of the Aero Medical Laboratory 5 The purpose of this volume was to bring together available data on acute toxicity of various substances for several species of commonly used laboratory animals as determined by oral or parenteral admin- istration or inhalation of fatal doses In the intro- duction to this volume the various significant con- ditions influencing the acute toxicity for any given dose compound were discussed These include the the rate of absorption route of administration site of injection and other influences including disease environment temperature habit and tolerance etc In addition it was pointed out that the toxicity of chemicals will vary with species of animals and some- times even with different strains of the same species Within the same strain the toxicity may differ with age weight sex and general condition of the animals must ty wade LF Sethe tet KRY lets SMAORAL ics MDE. NS EE WA He hd) ea NOU Tbe sat heal Shaw i Eh ede a 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 Following accumulation of data on acute effects time chronic effects are then studied through inhalation feeding injection and absorption experiments The nature of these is determined by the results of earlier screening tests At a conference on The Toxicological Basis of Threshold Limit Values in 1959 6 V. K. Rowe and his coworkers presented an extensive summary of the kinds of observations which had been made over a period of more than 20 years by several industrial groups This discussion summarized and tabulated observations on mortality food intake body weight organ weights gross pathology micropathology hematology blood urea nitrogen clinical urine analyses central nervous system and cholinesterase Tables IV summarizing the frequency with which particular effects were observed under various circumstances give an indication of the significance of several biologic and biochemical determinations The significance of growth studies and cholinesterase in Tables I and II and the significance of the liver and kidney in all of these studies are well demonstrated in Tables III and IV The authors 6 point out that there is increasing pressure for more and more precise kinds of measurements in the biochemical and toxi- cologic fields as a means of establishing valid threshold limits They point out however that while this is an excellent objective and one toward which all should strive it is essential that one make the most practical use of available manpower and funds to obtain the most meaningful information The criteria which are set forth in this paper are those which are most widely used and certainly accepted by all workers in the field The best hope for increasing our fund of knowledge derived from animal experiments must . come from the development of new techniques and new criteria In summary 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 This does not mean that only those criteria showing a high degree of efficiency in the series of investigations reported herein should be used but certainly it suggests that they should be basic to any toxicological study designed to determine a threshold limit for repeated exposure One other set of criteria which is attracting more and more attention are those physiologic studies which can be made on animals as well as on humans In the symposium mentioned above Dr. John A. Zapp Jr. 7 discussed the importance of utilizing physiologic observations such as systolic and diastolic TABLE I FREQUENCY WITH WHICH A PARTICULAR EFFECT WAS OBSERVED AT THE LOWEST DOSAGE LEVEL AT WHICH ANY EFFECT WAS OBSERVED 6 Criteria of effect Wage Wydis Growth Hematology Clinical urines CNS Cholinesterase Oral a 64 172 1 79 17 4 109 8 10 Data from 1952-1959 . % 37 1.3 14 3.7 80 Vapor be % 16 38 1 21 07 1 32 42 5 3.1 _ Data from last 22-25 years All routes a % 152 410 5 170 2 43 5 141 8 10 37 2.9 4.6 3.5 80 Number of positive findings number of observations TABLE II FREQUENCY WITH WHICH A PARTICULAR EFFECT WAS THE Sole effect AT THE DOSAGE LEVEL AT WHICH ANY EFFECT WAS OBSERVED 6 LOWEST of Criteria Growth Hematology Clinical urine CNS Cholinesterase Oral a 25 172 0 79 07 4 109 4 10 Data from 1952-1959 Vapor % a % 15 0 0 3.7 40 2 38 1 21 07 1 32 _ 5 5 0 3.1 _ Data from last 22-25 years All routes a % 44 410 1 170 0 43 5 141 4 10 11 0.6 Swoo 3.5 Swoo Number of positive findings number of observations WILLIAMS 993 terms of the significance of such information in In such an extensive list as this there are many application to humans materials which are so little used that there is Human Experience While animal data provide some basis for judgment about the possible levels of toxic materials which may be used safely in industry they cannot be extrapolated to humans with complete confidence The ultimate criteria must come from human experience The validity of such criteria is based on the amount of experience in terms of both numbers of exposed people and time of exposure on the methods of evaluation of the effects of the toxic material on people and on the completeness of the evaluation of exposure levels in the environment and correlation of these levels with human exposure Data with reference to human effects are obtained from both controlled experiments and industrial environment exposures In the case of irritants for example such factors as odor detection sensory response and levels of negligible industrial experience available to assist our standards people For such materials reliance is placed primarily on animal experiments and the use of analogy as guides in setting limits For the more common industrial chemicals many years of experience in using them has provided the necessary background to verify existing standards Such experience is generally of a negative nature Where it is supported by clinical or physiological data correlated with levels of exposure as in the case of the year study of butyl alcohol by Sterner and his colleagues 10 the information is most significant Such medical programs are designed to evaluate the general physical condition of employees and to include specific physiologic tests which may be expected to provide early evidence of injury Studies of this type are by far the most valuable for establishing valid hygienic standards exposure which are irritating to eyes skin and upper SUMMARY AND CONCLUSIONS gent respiratory tract have been studied quantitatively in humans under controlled conditions In general such In summary it can be stated that hygienic standards studies combined with experience gained with actual for inhalation in the occupational health field in the ar plant use provide an adequate basis for establishing United States are based on the application of the or confirming hygienic standards for such substances best known biochemical toxicologic physiologic and LO PRN It is much more difficult to provide a sound basis of pathologic techniques to animals and to human Aa) human experience for substances which require rela- experience Investigations are carried on by private SSAYRT tively long periods of time before producing evidence industry universities research laboratories and gov- of injury Whereas the acute effects can be evaluated ernmental agencies The analysis of such data and relatively rapidly and by simple procedures time interpretation in terms of hygienic standards is done sme, detailed studies of controlled groups of industrial by standards groups composed of competent scientists workers are required to provide adequate evidence in representing every facet of the occupational health the case of those substances which may produce field The validity of these standards is demonstrated chronic injury The kinds of information which are available from by the United low occupational disease attack rate in States Verified cases of such injury are the the industrial experience with various chemicals fall into three basic categories One of these is limited tcom- result of exposures far above the established limits Many approaches are being made to the problem AP plaints associated generally with the sensory response of establishing hygienic standards in the occupational or with more severe forms of acute irritation reactions health field It became obvious some time ago that APRN affecting skin eyes or upper respiratory tract The research people in various parts of the world were vlad second kind of data result from clinical examination in some cases utilizing varying techniques As a result of exposed workmen The third is the result of human values for some substances differ by as much as an set BUEN toxicologic or physiologic studies To be of value in order of magnitude In an attempt to get some uni- 1 establishing hygienic standards such medical informa- fication in the basic approach to the problem and to Hs tion must be correlated with adequate data relating to the concentrations to which workers have been provide a mechanism to permit a much broader exchange of information and data among occupational CetoRdTie exposed health workers the Permanent International Com- In his paper Improved Communication Hygienic mission on Industrial Medicine set up a Subcommittee a Mate Standards for Daily Inhalation Smyth 3 reviewed to study this problem This Subcommittee held a 238 values from the 1956 American Conference of symposium on Maximum Allowable Concentrations s sa Governmental Industrial Hygienists list together with of Toxic Substances in Industry in Prague Czechoslo- his interpretation of these values He has also eval- vakia on April 14-17 1959 The Transactions of the uated the nature of the supporting animal and Symposium which appeared in four sections deal human An analysis of the four kinds of sources of with general areas of agreement among the delegates human data indicates the role of such experience in This statement of principles is an important first step establishing hygienic standards in the United States Of a total of 238 values which were analyzed human in establishing international cooperation in this important field On the basis of this work it is hoped data were utilized in 108 distributed as follows not only that we can look forward to the development Clinical Examination of Workmen Was of a series of internationally acceptable hygienic Correlated With Their Exposure 34 Industrial Complaints or Observations Less Quantitative Than Clinical Observations 33 Human Sensory Data 42 Human Toxicologic or Physiologic Data 10 Of the 119 values distributed in the above tabulation there were 11 duplicates wherein the same material appeared under two or more headings thus there were actually 108 separate substances analyzed standard values but that agreement can be obtained with regard to general principles and to methods and procedures which will be utilized in the establishment of such standards The present Symposium which is the second under the auspices of the Subcommittee will I hope crystallize even further the thinking of those in the occupational health field concerned with establishing sound standards to be used in assuring safe industrial environments 998 Eckardt Robert E. 7-10 64-65 Eckhardt W. 850-857 Elkins Hervey B. 981-983 Erhardt J. Th G. 850-857 1 Estadella 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 Form^nekJ. 714-721 872-876 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 Frant^>kov^D. 872-876 Friberg Lars 201-203 977-980 Friedland I. G. 692-694 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 122-126 Holstein Ernst 278-281 Holtz John 783-785 Horiuchi Kazuya 288-289 Horv^thM. 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 G^'rard942-947 Jullien Georges 724-726 ERE 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 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 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 Klein Irvin 613-615 Klutas Edna May 428-431 Kopp John 783-785 Kruger Daniel H. 615-621 Kr^...gerP. D. 971-973 Kubota Juko 313-314 Guymer R. F. 270-275 Guyotjeannin Ch 694-698 Gwozdz B. 795-798 LaBelle Charles W. 730-735 Lachnit V. 947-950 Laham Souheil 686-692 735-738 Lammers B. 876-878 Hamilton Gilbert L. 656-661 Hargreaves Margaret S. 275-278 Harris E. S. 281-283 Harris William B. 466-472 Landry A. S. 512-519 Lavergne Rafael 214-217 Lehmann Gunther 878-879 Leoca Mina 349-351 Hatch T. F. 839-845 Hayes Wayland J. Jr. 120-122 Hertig B. A. 839-845 Hinchcliffe R. 712-714 Letavet A. A. 431-433 891-892 983-987 Liber Amour Fiscus 738-740 Lieben Jan 316-319 Lienhard Wendell F. 879-882 Hine C. H. 281-283 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. I. 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 Maxfield 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. 486-500 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 Nale Thomas W. 625-628 Namba Tatsuji 757-758 Nestorescu B. 679-681 dy Newnham C. T. 324-325 Akeinth Niebroj I. 795-798 TH Nixon James 699-700 ea 8 AN Noro Leo 326-335 Ses Norviit Lembit 952-957 an Norwood W. Daggett 335-338 sent Nystr^mA. 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 Pesc^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 Pilat 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 Brossa S. 663-668 Quigley J. A. 65 Radcliffe J. C. 65-66 R^dulescuI. 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 Rieg^'rtA. L. 819-825 Rigner K. G. 257-258 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 Sawyer William A. 438-441 Scansetti G. 348-349 Udel Melvin M. 397-401 Ursoniu C. 676-678 Scheel Lester D. 783-785 1 Schepers G. W. H. 786-795 Schermerhorn W. 850-858 Schiller Hans 961-962 Schindl Karl 364-365 Schmidt G^...nther365-367 Schmidt Marjorie D. 367-368 Schmidtke H. 921-923 Schulte H. F. 486-503 Schunck 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 Shoib M. O. 85 162-166 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 datiobae Viles Frederick J. Jr. 556-563 Villarroel Sergio 227-230 Viola P. Luigi 818 bens Voelz George L. 564-569 pall Vosburgh B. L. 931-933 eae Vee Sick Absence Statistics Committee of the Perma- nent Committee and International Association Eas on Occupational Health 40-55 Silverman Leslie 441-448 Wade Leo 7 61 88 Wald Neil 569-572 Simpson H. Marjorie 448-452 Walker Mildred I. 167-169 lle 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 Weaver Neill K. 381-387 Sar Spett K. 795-798 Wechselberger F. 191-194 Oas PR Spiers F. W. 535-540 Wells R. Lomax 170 Spioch F. M. 795-798 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 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 Yingling Doris B. 457-459 Yoder John D. 590-592 Yoshimi S. 827-828 Yount Hubert W. 649-650 Thoma George E. 569-572 Thompson A. R. 301-311 ae Thorpe John J. 381-387 so, Tompkins Paul C. 551-553 Zahorski Witold 828-832 Tripsa Rodica 806-810 Zanetti Ennio 767-768 Troisi Fortunato Maria 387-397 Zannini D. 971 Truhaut Ren^'33-34 39 209-214 686-692 Zielinski John F. 592-600 Tucker F. E. 553 556 Zorn O. 971-973 we swe est