Marxian Octopus

CHAIRMAN BOWDITCH: Our first speaker this afternoon, as compared with some of those whom we heard this morning, is a relative newcomer to industrial medicine. Following periods of private practice and general medicine in the Army, he had his first industrial work in the Plastics Division of the duPont Company at Arlington, New Jersey, and is now medical director of the Electric Storage Battery Company in Philadelphia.

Dr. Francis B. Lanahan will speak on Preventive Medical Armor for the Lead Industry.

Preventive Medical Armor for the Lead Industry

By Francis B. Lanahan, M.D.

Medical Director, Electric Storage Battery, Co., Philadelphia, Pa.
November 1948

I should like to preface my prepared presentation by a few remarks which I am stimulated to make in light of the tone of the discussions which preceded the luncheon period. My relative youth and brevity of experience in industrial medicine prompts me to make the obvious remark, that my position here at this microphone draws heavily on the courage of my convictions. At Philadelphia, the Electric Storage Battery Company has two plants. We have, to our conviction, over 2,000 people

With that preface to describe the environment that my presence here represents, I should like to present this for your consideration.

Purges are known chiefly within the walls of Communistic domination. Ulcerations on the body of nations inflicted by extended arms of the Marxian Octopus as excised by healing Christian action. Curative or destructive are today's searching forces.

Curative and constructive are the aims of The Electric Storage Battery Medical Division in Philadelphia. Preventive medical principles form the foundation of the Division's reorganization instituted one year ago. Assessment of all established procedures was instituted. On the body of the Preventive Medical Program, lead control methods hung like a withered aim, helpless to prevent illness.

Though harsh is our criticism of established methods, sincere is our admiration for investigators who applied these methods in the light of past knowledge. It is believed these same investigators with their proven abilities will, with the stronger light of present knowledge, lead the industry forward into the arena of preventive medicine.

As our present control methods are known to be common to the lead industry in general, our convictions and corrective measures are presented here for general consideration.

Entering the field of lead toxicology, we carried deep rooted convictions concerning the soundness of preventive medical principles and the wealth of benefit they hold for industry. We looked for methods of control indicative of levels of lead absorption within limits compatible with health. Methods in use were found to be non-specific of lead absorption and demonstrative of existing tissue damage. Invariably, the horse was out of the barn. Nor did we know which horse to look for. When analytical methods were resorted to, it was for specific diagnostic purposes; indeed, too late with too little for preventive medical aims. We found the use of hemoglobin determinations, stippled cell counts and physical examinations established as the medical methods of choice, and we followed them, lacking knowledge of better means. These revealed established disorders of structure and function.

Lead in air determinations were in use. These necessarily were brief and infrequent when related to the individual's total work exposure. They could not reflect negligent working habits. Hygiene instructions fell on torpid health attitudes as on the well known duck's back. The knowledge that these methods and working habits were widely existent in the lead industry gave small and unwanted consolation. To establish preventive medical principles a wide chasm appeared before us. It was the void between lead exposure and toxic lead absorption, between results of spot air samples and actual lead absorption during the total work period, influenced by negligent working habits.

It was the darkness obscuring failing tissue defenses of the worker whose prolonged exposure to generally safe environment could be causing insidious damage. A bridge was needed to span the chasm and give firm footing for the preservation of health. Nature is found to give the bridge. An instrument of the Divine Scientist, human metabolism, spans the chasm. The man on the job is the best impinger and precipitator of the lead to which he is exposed. His period of collective samples represents his total working period. His faulty working habits are reflected. These facts are recorded in analytical studies of his excretions.

The direct relationship between atmospheric and oral lead contamination and lead excretion in blood, urine and feces has been revealed by the meticulous studies of Dr. Robert Kehoe and his associates at the Kettering Laboratory. Ranges of excretions related to casual and to occupational exposures and compatible with health have been indicated by them.

Criteria for dealing with workmen on the planes of their lead absorption and excretion have been established by them on the basis of long experience. The use of these analytical studies are known to all of us. Essentially, our application of them has been for diagnostic purposes. When we have been alarmed by anemia, high stipple count or clinical evidences of disorders which could mean lead intoxication, we have resorted to them.

Few of us have applied the analytical measures as preventive controls. Known outstanding exceptions have been the programs developed by Dr. Hamlin in the American Brake Shoe Corp. and in the Ethyl Corp., but to a lesser degree in certain other industries, by Dr. Kehoe. The majority of us have placed the burden of our negligence on the complexity of analytical procedures. We can no longer afford to retain our present methods in the guise of lead control. We must recognize them for their inadequacy as preventive measures and resort to them in their true function as secondary diagnostic tools. This change is forced upon us by the present availability of a simplified, rapid analytical method to determine lead in urine spot samples.

This is the procedure described by Dr. Jacob Cholak and his associates at the Kettering Laboratory in the January, 1948 number of the Journal of Industrial Hygiene and Toxicology. Though rapid, the method demands studied care to avoid contamination and technical errors. Yet, it is practical within the abilities of all of us who are determined to strive for the highest plane of medicine and hygiene.

It is our purpose to use this method for the regular observation of our workmen. Relying generally on spot urine samples, we will study larger volumes or frequent spot samples of urine in the event a single spot result suggests an increasing range of excretion.

When high range of excretion is indicated by the additional studies, samples of blood and urine will be obtained for more precise analysis.

As the rapid method is known to confuse bismuth with lead, it will be routine to inquire of any medication being taken by the workers. The incidence of bismuth in the routine studies is expected to be small. When high values are obtained, the longer method of analysis will be employed, thus excluding bismuth or any other metal than lead.

To minimize contamination of the samples by work clothing it is planned to collect the samples before work clothes are worn or after showers. Collection of samples at the beginning of a shift is likely to exclude high concentrations or dilutions of the samples. Equipment necessary to apply the use of the rapid method is approximated to cost $3,000. As the analyses must be made in an atmosphere free of lead, the cost of air conditioning a room in the production area would have to be accounted. A 500 sq. ft. area is considered adequate for the analytical laboratory. A technician working under the supervision of a chemist can make 30 to 40 determinations daily. To avoid phosphate precipitation, the samples must be analyzed as soon as possible after they are voided and always within 24 hours. A general survey of the plant by this method will establish the mean excretory levels of the men working in specific areas. On this basis a schedule of interval studies can be established. Attending to necessary precision, the ease with which the analyses can be made will allow for a flexibility of the scheduled studies to check variations in production methods and environmental factors.

This routine applicable to group studies will be applied to individual workmen whose excretory levels fail to conform to mean group values. Air analyses will be used to accomplish its present purpose but it will gain a firmer footing of usefulness in distinguishing the atmospheric factor of contamination in suspected environments.

The suspicion will have been cast by high mean values among the workmen of the particular area. Should our facilities and the personnel permit us to develop our own analyses by the longer methods, as has been shown to be practical by Dr. Hamlin and Mr. Weber of the American Brake Shoe Corp., the combined equipment is judged to cost about $10,000.

As in the general field of industrial medicine, small plants with limited budgets can share the benefit of this quality of medicine and hygiene by pooling their needs and spreading their expenses through the use of centrally located industrial clinics.

The qualification of such existing clinics for our particular need or the stimulus to develop them is a fertile field of activity for the Lead Industries Association.

As we progress toward the accomplishment of our program we do so with the stimulating conviction that our efforts will establish a regimen of preventive medical control which will — Keep men fit for their jobs and jobs fit for men.

CHAIRMAN BOWDITCH: The principal discussion of Dr. Lanahan's paper will be by a man from whom you heard this morning. He is a specialist in industrial medicine and toxicology of many years' standing, a member of the Committee on Lead Poisoning of the American Public Health Association, associate professor of medicine at Marquette University and consultant to Globe-Union. Inc. and to a number of other industries and insurance companies. Dr. Elston L. Belknap.

DR. ELSTON L. BELKNAP [Globe-Union, Inc., Milwaukee, Wis.]: Mr. Bowditch, members of the Lead Industries Association, friends and co-workers: I believe that Dr. Lanahan is to be congratulated for his convictions and his determination to approach this in a very basic way. I wonder, and perhaps he can answer me shortly, whether his method of urine examination, spot samples and group samples, will replace the time-honored method of physical examinations for lead lines, blood studies for hemoglobin, types of red cells, stipple cells and history, or whether it is used to supplement it. I am interested to know how soon, also, he thought he could recheck his workers with this method.

For instance, if he has 2,000 workers and 40 can be done a day, it would take about fifty days before he could get back and re-check a worker. Perhaps he will supplement that with the other usual forms of treatment in the meantime. My experience with lead in the urine has been to get it, if possible, about twice a year on a lead worker, preferably a twenty-four hour urine that has been collected at home, away from the plant. It is then studied by the Fairhall modification of the chromate method, which, though it takes three or four days, we have felt from experience has been the most fundamentally safe procedure because it is primarily an analytical chemical method. I understand that Dr. Fairhall has modified this so that the analysis can be done in a matter of hours. This, I believe, will answer the objections to this method.

It seems to me the question comes back to this. When you have done an examination of lead in the urine, what do you have? Do you have a diagnosis of lead poisoning or do you have a diagnosis of lead absorption? Certainly, the Public Health Committee, of which Dr. Kehoe is chairman, specifically said that no one laboratory finding made the diagnosis of lead poisoning and, as already has been brought out here by a number of speakers, including Dr. Mayers, whom I have always admired primarily for her ability as a clinician, that one must view the patient as a whole. No one should attempt to make a diagnosis of lead poisoning by any one laboratory finding. I have seen workmen who have become ill with relatively low urine leads.

The man that I mentioned this morning, for instance, I believe had about — 0.25 mg. of lead with no symptoms, and the day he got in the hospital, he had 0.14 mg. of lead per litre of urine. I do not believe that that was the result of any magical treatment that he received in that interval. I think that is simply the variation in urine findings that one must expect in these cases.

On the other hand, I have seen men working for thirty years in the storage battery industry with urine values as high as 0.5, 0.6 and 1.0 mg. of lead per litre of urine, who have never been disabled, ill, lost any time and have shown no anemia, who have had no wristdrop, no lead encephalopathy.

They have normal blood pressure and a normal routine urine. One such man is still turning out a good day's work at the age of sixty-five, and he dates back to the time when conditions were not as we would desire them, when 25 years ago, 75 percent of the men had evidence of heavy lead absorption. We know also that our lead in the air at times is much more than it should be, 3, 10, 12, 15, 18 mg. per 10 cu. feet. Of course, we have corrected that now with air line respirators using as much suction at the source of the dust as possible. In modern production methods, even when you are improving a situation, often the worker has to use the respirator.

Of course, no one can deny if the respirator is used continuously and no effort is made to correct conditions of lead exposure, it is a confession of engineering weakness. If you wish, however, to keep men from being sick, I am afraid you are going to use respirators occasionally in the storage battery industry while protective suction equipment is being fitted into production. In fact, if that man I was talking about this morning, could have a job found for him, and I think it can be found, where he is using not an ordinary respirator which he is likely to discard, perhaps, because he does not get enough air through it, and is given an air-line respirator, that would be just the same to me as if he were moved out from the lead exposure. I have done that again and again, and the man is still making good money and he is satisfied; the company is satisfied, because he goes on and continues his convalescence even while working. We covered this morning, I think, what constitutes lead poisoning or true lead intoxication. Lead absorption is one thing; disabling lead intoxication is another. We are not using those terms to escape any responsibility. We are simply wanting to be precise, as we like to be in any field of medicine.

A sign of lead absorption, certainly, is lead line, a finding which can be easily determined by spot illumination, even a flashlight, or better still, a head mirror and a small hand lens which costs about ninety-five cents, incidentally. One can then definitely say there is or there is not a deposit of linear or round row of dots in the gum tissue next to the teeth.

Of course, one should know that the individual has not been taking bismuth for the treatment of syphilis. Otherwise, the physician cannot rule out the fact that the apparent lead line may be a bismuth line. I believe I have seen some perfectly marvelous lead lines that excited me then I found out when the Wasserman report came back and after a little private conference with the individual, that he was getting bismuth as treatment for syphilis. In fact, some of the men doing syphilology insist that a patient is not receiving sufficient bismuth unless he shows a bismuth line.

One does not always see a lead line if a man has good teeth. A case that I had had perfect teeth and showed no lead line until after he was disabled. The pyorrhea, decay and detrius around teeth seem to be a precipitate of what is apparently lead sulfide in the gum. However, that is merely an evidence of lead absorption. Certainly, if there is no bismuth to be confused with, and if one sees a lead line, one knows that the worker has had too much lead absorption and the physician should be on his guard regarding a possible disabling lead intoxication. That is fully as important to me as the determination of the lead value in the urine. It is certainly a good deal less expensive.

In doing medical work in industry, one has to learn to fit in with production schedules. The men are not always anxious to come in for periodic re-examinations even though it may be on company time, and the company is not too anxious to have them. However, I want to see the men as often as necessary. That may be every day in some cases, though usually every two weeks and in some cases every month or three months, depending on the concentration of exposure. But to make an examination of the man for a lead line, to talk to him, really to get that patient-doctor relationship that Dr. Johns spoke about this morning, to take his blood pressure and to make a note and record the facts is usually a matter of only a very few minutes.

Then, if one's technician is working at the same time on another group of men and gets the hemoglobin and the stippled cells, one can fit, as you see, right into production. Nobody warms the chair very long. But we have our information, and we see the man as often as we need to in our best judgment. We have men who have been having their ears stuck for blood every two weeks, for twenty years, and, if we miss them, we hear from them. If we forget to call them in, they come in complaining, "Why don't you call me in?" That is something you would not expect, but those old-timers know the conditions that were there before we started this system, and they know that it pays to have this medical observation. So much for lead line, which is a simple procedure and which I should like to illustrate presently. Like a lead line, a few stippled cells, say, 5 to 10 per 50 fields, are also an indication of lead absorption but are not likely to mean lead intoxication. They are much simpler to study than lead in the urine. Lead in the urine is extremely valuable in mass group studies. It is valuable for research purposes and, certainly for medico-legal cases for doubtful cases.

I hope I have intimated that I have no quarrel with people who are interested in doing lead in the urine. I think that it is a valuable and helpful adjunct, but as Dr. Fairhall has said, urinary lead excretion is one of six cardinal factors in the diagnosis of lead poisoning and, standing by itself, a urinary lead indicates nothing but lead absorption. I should like to emphasize the symptoms of lead intoxication. As I said this morning, if a man is sick, if he is really ill, if he is weak, if he is nauseated and vomiting, and if he has a real constipation or occasionally if he has diarrhea, and even more rarely, if he has a fleeting arthralgia, or joint pains, with all the other factors, if we know that he has been exposed to lead, if he shows evidence of lead absorption in some one of those ways, with those symptoms, plus a rising stippled cell curve, then we know that he probably has true lead poisoning. Then it is just and wise to admit it to the patient promptly and tell him what he has and see that he gets immediate relief. Fortunately, relief can be given to the most severe type of violent lead colic in 20 to 30 minutes after the injection of calcium gluconate.

I am especially interested in trying to make this clear to you today because this is what I try to make clear to my medical students and what we also try to make clear to the doctors in our county and state medical societies. The doctors are the harder problem, incidentally.

We make the distinction between lead absorption and lead intoxication, because, in a perfectly sincere manner, the average doctor who, perhaps, has seen one or two cases of lead absorption and intoxication in his life, if any, even in medical school, often relies primarily on the statement of his patient, "Yes, I work with lead." "What do you mean you work with lead?" "I work with paint." "What kind of paint?" "I don't know. All paint has lead, hasn't it?" Unfortunately, the doctor does not always pursue that type of questioning until he is forced to on the witness stand, and then it is somewhat embarrassing to him as a physician to admit his error in being led astray by his patient.

In our State our Industrial Commission examiners are often called on to act as attorney for an applicant, and I have heard them go through that questioning before a hearing comes to pass. If the applicant cannot answer intelligently, they say, "You have no case. Go find out what kind of paint you are working with." If the doctor has the facts he should speak with authority but the average doctor does not realize that he is regarded by a layman as an authority. One of our problems is to make the average physician realize the weight that is put upon his words. A patient often comes to him and says, "Doctor, I have been working with lead, and I have a bellyache. Don't you think I have lead poisoning?" The physician often replies, "Well, I don't know; perhaps you have," and then passes it off. He does not even think of the possibility of this going to court. He finds a little anemia, with or without stippled cells: he may not even look for lead line and probably forgets to have a urine lead. Then suddenly he finds himself called up to a court hearing and he has to make good the mistaken idea the patient had, that his physician thought he had lead poisoning. Such a physician is in for a bad half-hour on the stand, with a competent cross-examination by an experienced attorney.

The physician, if he wishes to speak with authority, must make his diagnosis one that will stand up not only in court but that he could get up and argue for before his county medical society. There is the jury of his true peers, and every word he says to them has to stand the severest kind of scrutiny.

Even though he knows that he cannot make a diagnosis on one laboratory finding alone, he must depend on exposure, plus the following facts: There must be evidence of lead absorption shown in the urine and gums or a few stippled cells. There must be actual signs of intoxication, usually a disabling colic and usually terrific constipation, obstipation, we call it, which does not respond to any cathartic. That makes up the ordinary kind of lead intoxication. Ninety per cent of the cases are lead colic. Hunter, of England, has said that there are ten times as many lead colic cases as lead palsy cases. Most of us see very few lead palsy cases, fortunately. I have seen, perhaps, half a dozen in twenty-five years.

When we have looked at this thing from the point of view of industrial exposure, then we have to go at it from the standpoint of differential diagnosis.

Does this man have a gallbladder colic? Does he even have a coronary occlusion referred pain to the abdomen? Does he have a pancreatitis? Does he have kidney colic? And, in the case of a palsy case, are we dealing with, perhaps, an alcoholic, or infectious neuritis? It is a helpful sign that with most cases of lead palsy, there is no pain, and the palsy is primarily extensor rather than flexor.

I have gone into some detail on this because the usual physician has not had experience with this type of industrial exposure. By and large, by his own admission, the average doctor knows very little about it except what he reads in the textbooks. These, in many cases, are perhaps twenty years behind the times.

The problem, then is one of education of our young physicians as well as education of the laymen, of management and of the worker to distinguish the points I have been making.

In regard to residuals, in my experience, the 90 percent of the cases which go to make up lead colic come through without any permanent residual. True, they may have temporary anemia. The lead palsy cases may have a residual, but not always, if treated properly.

Lead encephalopathies, the third and rarest of the three types of lead intoxication, may have a serious residual, if they recover at all,

such as mental involvement, but, again, they may come through, as did some of the ethyl-fluid cases, without any residuals at all. I would not like to leave anybody with the impression that we do not meet lead poisoning anymore in modern industry. I agree with Dr. Johnstone, that in the small industry we are likely to have it all the time. It frequently appears in unusual places in many small plants.

The accompanying photographs show how we go in what we think is a 1, 2, 3 manner.

[caption] Fig. 1--The old and new method of inserting separators between storage battery plates.

Fig. 1 — I show this photograph of inserting separators between storage battery plates because I think any layman who has never done anything with lead — and the average doctor has to be regarded as a layman in this area — can tell, by looking at the left-hand picture, that conditions in that picture are not nearly as good as they are in the right-hand picture. You can see in the picture on the left-hand side that a plank has been thrown on the floor; lead dust can fall on the plank and be kicked up and inhaled. In the right-hand picture there is a slotted rack so the dust falls through to the floor where it will not be kicked up as dust and then can be washed down at the end of the working day. In the right-hand picture again we have slotted down-draft suction tables. I think you can see for yourself that that man on the right has a much safer job. In spite of that, we insist that they wear respirators, whenever possible, though, practically, the engineering precautions there have cut the lead exposure remarkably.

[caption] Fig. 2--The definite, punctate deposit of lead sulphide appearing as small black dots, in the mucous membrane next to the teeth.

Fig. 2 — Often we have the problem as to diagnosis of a lead line. "Doctor, have you ever seen one?" Some doctors admit that they have not, but I think this picture proves that there is such a thing. You see here the definite, punctate deposit of lead sulphide in the mucous membrane next to the teeth. The dirt and detritus stippled cells which is quite enough often to be associated with disabling lead colic.

Figs. 4 and 5 — This periodic re-examination chart gives you an idea of the value of recheck studies. These examinations are made about every two weeks with the date at the top; then at the side the particular symptoms that we are looking for, either weakness, headache, drowsiness, if there was a brain involvement and the usual gastrointestinal symptoms, such as constipation or colic.

We do watch the weight though the weight does not give any specific information, only to indicate something as to the general physical condition of the man. Then we test each man for extensor weakness of the wrist at the same time we are taking his blood pressure and looking at his teeth. Teleky, I think, was the one who brought out most clearly the importance of testing the extensors prophylactically. We make a note as to the pallor, the number of teeth opposite which there is a gum lead line, and the strength of the wrist extension. We observe the blood pressure finding also because we are interested in finding whether these cases are going to go on and develop an increased amount of hypertension and arteriosclerosis as some have alleged in the older literature. To date we have not seen that in our experience.

At the bottom of the chart we have a place to record stippled cell count and the hemoglobin. In one particular case, early in the.

[caption] Fig. 3 — Photomicrograph showing stippled blood cells.

[Missing Page 51-52, probably mostly figures, with a small amount of text leading up to page 53 here:]

and the hemoglobin. In one particular case, early in the game, when we did not take warning quick enough, he was running 10, 21, 30, 110, 217 stippled cells and we still let him stay on the same job. He began with diarrhea, which was an intestinal influenza, and at first he had no lead line. Then he suddenly blew up with constipation and afterwards he had his lead line.

The anemia was a late development here. That is the most important thing. I think, in the blood picture regarding lead. We all agree that lead stippling, or stippling of red cells is not a specific indicator for lead absorption or intoxication. You may find it with Hodgkin's disease. Benzol poisoning, tumor, malignancy, any type of severe anemia, will eventually show nucleated red and stippled cells, but with the lead intoxication, you get your stippled cell rise early, long before the hemoglobin drops.

In this case he did not have his drop to 65 and 60 hemoglobin until after he was disabled. If we had been relying on the hemoglobin, we would have allowed him to go a lot further than we did, absorbing even greater amounts of of lead.

Following calcium gluconate intravenously, the patient went back to work and worked for two or three years. He was in excellent physical condition before he left our employ. He went back to the same type of work, incidentally, but with a respirator. The particular man had been working at a job where nobody thought he had a lead exposure. He was working in the forming room, normally a wet room, but he was the one man in the department who was dropping dry plates into a battery case. He did not show up for examination until he got sick. We did not like that; we like to be able to put our finger on these cases of impending intoxication three or four months ahead of time.

I think I should like to close with the statement that there is no short cut to clinical medicine. As Dr. Mayers has said, every single case has to be viewed as a whole, from the viewpoint of general differential diagnosis, and one must study the whole picture, not any one laboratory finding, not even stippled cells alone. Knowing these things to be frets, we can, with good conscience, go about our job of keeping the worker healthy and at work.

CHAIRMAN BOWDITCH: We are so behind schedule that I think we had better confine our further discussion to a brief reply by Dr. Lanahan, if he so wishes. Anything more can be at the end of the afternoon, if we have time.

DR. LANAHAN: Dr. Belknap posed several questions in relation to my presentation. The one that strikes me as most important is whether or not we plan to use urine lead determinations to make our diagnoses of intoxication, or resort to other measures. He has touched on the heart of what I feel is our presentation. The problem of which we are intolerant in our present program is that it is a diagnostic program. When we apply our proposed analytical studies as we are determined to apply them and are faced with a diagnostic problem, we will admit to ourselves that we have failed somewhere along the line, foiled in prevention.

Our persuasion to head in this direction is based on the studies that have been made by Dr. Kehoe and others who have established the ranges of blood and urine lead levels that are compatible with health, that are seen in people with known occupational exposure, accepting these ranges as our starting point. We hope to keep our people within a range of lead excretion compatible with such standards. As we see them working their way above such standards, we hope to make more extensive studies to catch the bugs in our rapid method. At this stage we feel that we will be ahead of clinical symptoms and stipple cell changes. We will be before the stage of diagnostic procedures, using preventive methods. Dr. Belknap has asked, if urine determinations will replace physical examinations. As I mentioned in the preface to my presentation, in spite of, let's say, the abundance of our medical personnel, we feel that we are not able to watch our people as intimately as necessary to prevent diagnostic problems.

We are looking for something which will give us a signpost by which we can have our fingers on everyone before they become diagnostic problems, and we hope that our proposed method is the measure by which we may accomplish this.

When we find groups, and the individuals within the groups, having excretory ranges above those which have been declared as compatible with health, we will resort to our present program of physical examinations and complete blood studies, repeating them as frequently as we wish. Again, let me say, when we have a diagnostic problem, we will admit that our preventive medical program has a hole in it.

Dr. Belknap asked how soon we can plan to review these people, if it requires one technician for 30 or 40 determinations daily?

Our present program, which I have described as involving study of stippled cells, hemoglobin determinations and personal communications with these people, entails the entire activity of two laboratory technicians. We estimate that it takes them 20 minutes for each technician lo do each laboratory study, which results in the determination of the hemoglobin and the stippled cell count. We believe urine studies will involve no greater lime and will require no additional technical personnel.

Our chemist, who at present does our lead in air determinations, can oversee the precision of our laboratory analytical studies, for I do not presume to be so qualified. I might add this. In Fig. 1, Dr. Belknap presented to you the picture of an assembly line, with grating in the floor and the down-draft in the table. Men were wearing respirators.

It is my routine to accompany the general safety committee which, incidentally, is a management-labor coordinated committee, in visiting every procedure throughout both plants once a month. I would love to find that each time we passed the assembly line and any other process we had, we would see our men actually wearing respirators, where they have been issued.

The respirator is either, obviously, down on his chest or it is in a position where he can quickly duck his nose under it as we are going by.

We have down-draft; we have water under the grates, and we have respirators. Our air levels worry us. We have people getting sick. We are doing what all of you are doing, and we are not satisfied with it.

CHAIRMAN BOWDITCH: This seems an appropriate moment to repeat Mr. H. J. Weber's very excellent definition of the industrial respirator. He has aptly described this device as "A muzzle type ornament worn loosely pendant from the neck, used in dirty industries to distinguish the laborers from the office employees."

I am sorry that we cannot continue this discussion further at this time, for I know that there are one or two others who could contribute valuably to it, but we must get on ...