SECTION THREE

YEARS OF OCCUPATIONAL MEDICINE IN CANADA

CHAPTER TEN

YEARS IN AJAX AND WHITBY, ONTARIO

Before the end of January, 1942, I found myself and all of our belongings moved into a fine brick house in Whitby which I had bought, with a mortgage on it.

At the first of February, I began my job at Defence Industries Limited, Ajax, Ontario, which was sometimes described as Pickering Plant because it was near the small community of Pickering. The plant had been built to produce artillery shells for the Second World War which was still going on. The plant was a significant part of Canada's war effort and employed about 9,000 people. The plant was spread out over many acres because of the constant danger of explosions when dealing with explosive materials. There were three TNT lines placed widely apart, which became my chief concern later, where molten TNT was poured into large artillery shells.

At first, I joined the regular medical staff in the examination of new employees and attending patients in the outpatient clinic or hospitalized on the premises. Soon, however, without my seeking it, I was asked to set up and take full control of a project to control TNT poisoning among the plant's workers. How they came to choose me I do not know, but in looking back on my life, it seems that this was only the beginning of a series of events which pushed me in directions which I had not planned or sought.

I soon learned of how distressing the problem was. It was the biggest health problem that the plant had to face. So many workmen were suffering from what was called TNT poisoning that it was a tremendous financial burden and made staffing of the TNT lines very difficult. Not only that, but the talk and apprehension current among employees was nearing panic.

I first approached the problem by going to the University of Toronto and consulting with professors and department heads to learn what was known about TNT poisoning and to get suggestions as to how to diagnose the condition and what laboratory procedures might be used to give early warning of its onset.

I found that so little was known about it that nobody could tell me what to look for, except that it caused jaundice. Likewise, the only laboratory tests suggested were those which were measurements of bile in the blood and urine. I obtained many suggestions of tests which should be explored, and was offered full cooperation of the Department of Pharmacology. With this limited information, I returned to the plant at Ajax to plan my approach, and to determine the staff, space and laboratory facilities I would require.

With the full cooperation of management I had the necessary rooms assigned to me at the plant hospital and set up the laboratory procedures I would carry out. I also planned the various forms I needed for keeping track of patient records and recording all laboratory results in organized detail, so that I would not only have records of findings for diagnosis and treatment, but also which could be easily analyzed for research purposes. The records also were designed to keep track of

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patients, where they were working, where they were moved to, if transferred, with dates, and with an active method of keeping track of them at all times. This also included a follow-up method, even after they quit working for the plant for a couple of months or so.

I had a private office with my own private secretary and a nurse, Miss Stone, assigned to me full time. With this hospital staff and the laboratory technicians at my disposal, and with all personnel in all of the line first aid stations on all three shifts, with their nurses, placed under my control, I was in a position to set up an elaborate program and activate it. Originally I was given the title of Assistant Medical Director. This was later changed, at my suggestion, to Superintendent of Toxicology and Medical Research which was more descriptive of my real functions.

The first document I wrote I placed in the hands of the plant management and superintendents, and also in the hands of all of the plant physicians and nurses, both at the plant hospital and at the line first aid stations. It was entitled, "Organization for Management and Control of TNT Contacts and Sickness". It was also sent to Dr. F. M. Jones, Chief Medical Officer for Defence Industries, at company head quarters in Montreal, and to Dr. F. M. R. Bulmer of the Ontario Health Department, who during the war worked with Dr. Jones in looking after health interests on behalf of Canadian Public Health authorities in munition industries. These two physicians, throughout my service at Defence Industries at Ajax, Ontario, were kept informed of my activities and visited me at intervals. They also received copies of all forms and medical papers which I produced there.

The document, "Organization for Management and Control of TNT Contacts and Sickness," has over eight closely typed pages and is too long to include in this description of my life, but a copy is preserved in my filing cabinet. In the document it was made clear that all workmen complaining of sickness believed to be caused by TNT must be seen by me and their treatment placed directly under my control.

I soon recognized that moving a workman away from TNT exposure was a vital part of treatment. I obtained the wholehearted support of management in this maneuver, and in order to get the cooperation of the workmen I insisted that management continue to pay the higher TNT worker's salary schedule while the workman was employed in another area. When a man had to be moved, I issued the order in writing, and when he was well enough to return, I put that also in writing. Most employees gained so much confidence in me that they never questioned my judgement. However, if a man preferred not to return to work in TNT, he was permitted to continue where he was, with his salary reduced to the level current for that department.

The following principles, which I proposed, were accepted and enforced by management:

1. No worker may be employed to work in TNT whom the examining doctor considers unfit for such work.

2. No worker may be transferred from another department into TNT without first obtaining the approval of the TNT line nurse.

3. Workers ordered out of TNT by Dr. Park must be moved out of contact promptly.

4. No worker ordered out of TNT by Dr. Park may be returned to TNT without the approval of Dr. Park.

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5. TNT workers must have a separate area for lockers in the change house.

6. TNT workers must wash before eating and going to the toilet.

7. Each TNT worker must take a shower bath at the end of each shift.

8. TNT workers must have clean uniforms and clean gloves at the beginning of each shift.

9. TNT laundry must be washed separately from all others and by a special process.

10. TNT laundry must be kept separate from all other laundry and returned for TNT use only.

11. Used TNT shoes must be kept separate from all others and reissued for TNT use only.

12. Workers ordered out of TNT permanently must, at once, change their uniforms and shoes.

The above principles were well enforced and had a great deal to do with the control of TNT sickness. Because showering at the end of the shift was so important in freeing the workman of skin contamination and preventing him from carrying TNT home with him and thus extending the length of his exposure, I was able to secure thoroughness in this showering by having men take showers within their work hours, where supervision could enforce it.

In trying to control TNT absorption and TNT poisoning, I worked on the premise that TNT could enter the body in four ways:

1. By inhalation in the rooms where it was melted and poured while in a liquid state because it got into the air in a vapor form in much the same way as steam from boiling water. However, unlike steam, the mist from TNT when cooling recrystallized and settled on everything as a dust. In this dust-like form it could be stirred up into the air and inhaled.

2. By the workmen eating it in the form of dust when handling the food with dirty fingers. Also, when a workman handled a cigarette with fingers dirty with TNT dust, he inhaled TNT with the smoke.

3. TNT could also be absorbed through the workman's skin when in contact with it. This absorption was slower but could be largely eliminated by careful washing.

4. TNT could be easily absorbed into the blood stream through an open wound.

The one person whose life I was unable to save died of TNT poisoning because he had been allowed to continue working in TNT with an open wound on his wrist. He was already in hospital and dying before I had anything to do with TNT.

Under my instructions, the nurses saw to it that no one ever worked in TNT who had an unhealed wound. This even included men who had teeth extracted. They were kept out until the gums were well healed.

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I must say that I had the very best support from all of the nurses who worked under my direction. To them goes much of the credit for what was attained in control of TNT sickness at Ajax. They not only carried out my orders exactly, but they were on the look-out for early symptoms of TNT poisoning and brought them to my attention promptly.

In order to reach TNT workers referred to me by nurses or doctors, I arranged my time as follows:

At 8:30 a.m. I was on duty in the hospital clinic to serve those who had just come off the night shift.

Again at 3:30 p.m. I was on duty there to serve those going in to start work at 4:00 p.m.

To serve the day shift, working from 8 a.m. to 4 p.m., I was at a clinic conducted at 1 p.m. in one of the TNT line's first aid stations. With the three TNT lines handled in this way, I was able, by cycling them in order, to provide each line with two clinics a week within my six days a week at the plant.

After each 1 p.m. clinic was over on the particular TNT line I was on at that time, I always, before leaving that line, made a complete inspection tour of that line. This was a vital part of my control which enabled me to see for myself how well the working place was being kept clean. It took a long time, but by reporting to top management after each inspection, I was able to point out failures and to make further recommendations. In this way, I finally got all lines to maintain excel lent housekeeping and the very best of ventilation. The superintendents of lines one and two were cooperative to the best of their ability, right from the start, but the superintendent of line three dragged his feet for months. He was an older man and apparently resented my telling him what he had to do. However, each of my inspection findings was written out carefully and specifically and addressed to each line superintendent himself, always with a copy to top management. Top management eventually compelled him to clean up properly, because I was always able to show that more TNT illness was coming from his line.

The plant hospital was required to follow through on the standing orders which I had supplied for any patients admitted to the hospital with TNT sickness symptoms. These began with thorough clean-up instructions detailed in nine specific items, which had to be carried out daily for four days. Then there were specific orders for a low fat diet, medication, and laboratory work. Routine urinalysis, urine color, Webster test and blood pressure were to be done daily. The following were done the first day and every third day thereafter: haemoglobin, blood smear, red cell count, haematocrit reading, icterus index, Van den Bergh, cephalin cholesterol flocculation test and other procedures as ordered.

During the years when clinical cases of TNT poisoning were encountered, several tests were carried out and data on many cases evaluated to determine their significance in identifying the effects of the disease. These were written up by me whether or not they were of value.

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On September 7, 1942, a paper was written by me on the subject "Serum Chloride in TNT Sickness." The data did not show that the test had any significant value so it was never published and the test did not become routine.

On September 29, 1942, I wrote a paper on the subject "Report on Webster Test and Urine Color Test in TNT Absorption." This showed that bile was appearing in the blood and urine of cases with jaundice which was merely confirmatory of the clinical signs but of no particular value apart from clinical jaundice. This report, as were all others, was forwarded to Dr. Jones and Dr. Bulmer, but never published.

On October 26, 1942, I wrote a paper entitled "Report on Study of Sedimentation Rates in TNT Absorption." This report too failed to show any significant changes which could be related to TNT absorption by workers. This did not show any need to carry out this determination in TNT cases. This report was sent for their information to Drs. Jones and Bulmer, but never published.

On April 15, 1943, I wrote a report for Dr. Jones and Dr. Bulmer entitled "Vitamin Tablet Experiment." For this experiment I had tablets prepared by a drug supplier containing 1000 international units of vitamin Bi and 100 mg of vitamin C. I also had a placebo made which was identical in size and color.

From July, 1942, through March, 1943, the line nurses, under my instructions, went about once a day and placed one tablet in the mouth of each TNT worker, at his place of work. They kept careful records and gave their records to me.

At the end of the time the nurses tabulated the answers of the TNT workers to the question, "Do you feel better from taking the tablets, no change, or worse?" My analysis of this data failed to show any value except that which might be a psychological effect which was the same with placebo as with vitamin tablet.

There was one benefit which came out of it, and that was the necessity for the nurse to see each worker every day for observation. This gave the workers a daily opportunity to complain, if any of them were sick, without their having to stop work to go to the first aid station. This report was never published but a copy is in my filing cabinet.

On June 2, 1943, I prepared a paper entitled "Effect of TNT on Reticulocyte Counts in a Shell Filling Plant." This study was undertaken because earlier efforts at the University of Toronto to help find a way to detect the onset of TNT poisoning had shown some promise. Dr. A. W. Ham of the Department of Anatomy, and Dr. G. H. W. Lucas of the Department of Pharmacology, in their experiments on dogs, found that injections of TNT caused a drop in the haemoglobin and a rise in reticulocyte count. So, in collaboration with Dr. Ham, a study was undertaken at Defence Industries, Ajax, to determine whether the exposed workers, in our plant, showed the same changes in their blood smears.

This study was set up so that all of the technical work was done by Dr. Ham 5 technician, Mr. G. A. L. Ross of the Department of Anatomy, and all of the readings of smears and counts were done by Dr. Ham. Although some reticulocyte counts and other laboratory blood records were in our files, none of these were included

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Evidence of cyanosis
Evidence of jaundice
Blood pressure
Haemoglobin
White blood cell count
Van den Bergh test
Cephalin-cholesterol flocculation test
Foulger scores

Table I: Workers who had not been in contact with TNT for four weeks or more.

Table II: Regular TNT workers in contact with TNT.

Table III: Workers who were studied before going into work with TNT and then again later after considerable exposure.

1) None of the items recorded in this study showed levels indicative of abnormalities which could be attributed to TNT absorption.
2) In the few cases where elevated reticulocyte counts were found, no evidence of clinical TNT sickness could be found.
3) The higher reticulocyte counts, when found, did not bear any relation to changes in the haemoglobin.
4) The study did not indicate that it had any significant value as a forewarning of TNT sickness.

a) Probably the dosage given to dogs was too high and therefore not com parable.
b) At the time the study was made at Ajax, Ontario, on TNT workmen, our program of good housekeeping and strictly enforced preventive measures was so effective that no doubt our workmen were then receiving much less TNT into their systems than they were in the previous year.

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On June 3, 1943, I wrote a paper entitled "Study of Methaemoglobin Levels in TNT Workers." This paper was based on the findings of Mr. J. H. Johnston, of the Division of Industrial Hygiene, of the Ontario Department of Health, and Dr. G. H. W. Lucas of the Department of Pharmacology of the University of Toronto, done on the workers at our plant in Ajax, Ontario.

The data was collected in three tables. Table I listed three controls with no methaemoglobin, all of whom had no exposure to TNT. Table II listed TNT workers, all of whom were well and without cyanosis. Table III were TNT workers with some symptoms of illness.

Conclusions

1. Methaemoglobin in the blood is, on the whole, a little elevated in TNT workers.
2. Cyanosis, as observed in TNT workers, is not due to Methaemoglobin.

This study was never published but a copy of this paper is in my filing cabinet.

On June 4, 1943, 1 wrote a paper entitled "Oxygen Capacity in TNT Workers." This study was carried out as a supplement to that recorded above. It seemed indicated as a further search for the cause of cyanosis in TNT workers. Dr. G. H. W. Lucas of the Department of Pharmacology of the University of Toronto carried it out at my request. A Van Slyke gas analysis apparatus was used to make the analyses.

This study showed that the blood of TNT workers was normal in oxygen carrying power. The study also failed to suggest the presence of any haemoglobin compound which would account for cyanosis in TNT workers. This report was never published but a copy of this paper is in my filing cabinet.

On June 5, 1943, I wrote a paper entitled "Carbon Dioxide Combining Power and PH of Plasma in TNT Workers." At my request, Dr. G. H. W. Lucas of the Department of Pharmacology carried out these analyses with the Van Slyke gas apparatus and the Evelyn instrument on March 26, 1943.

Seven TNT workers were studied, all of them feeling well. All of them had normal blood pressure, normal pulse rates, and normal haemoglobin. Only one was cyanosed. In every workman of this series the carbon dioxide combining power and the PH of the blood fell within the normal limits. This paper was never published but a copy is in my filing cabinet.

On June 9, 1943, I wrote a paper entitled, "Oxygen and Carbon Dioxide Content of Venous Blood in TNT Workers." This also was based on studies carried out by Dr. G. H. W. Lucas, at my request, in a further effort to discover the cause of cyanosis in TNT workers.

Although the numbers studied is small there did not seem to be any indication that the blood of these TNT workers contained any unknown haemoglobin combination that was interfering with the capacity of their haemoglobin to carry and give up oxygen or to carry carbon dioxide. This study was never published but a copy of this paper is still in my filing cabinet.

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On August 10, 1943, I wrote a paper on the subject "The Van den Bergh Test in TNT Absorption." This paper was based on a study of our records of people who had had the test done on their blood and the results recorded.

Table I contains the Van den Bergh readings on 22 TNT workers who were perfectly well at the time the test was done. No reading was over 0.50.

Table II contains the names of 30 employees who were ill but whose illness was not due to TNT. In six of these the Van den Bergh was over 0.50 which indicates that an elevated Van den Bergh is not specifically caused by TNT. There were only two patients listed in Table II whose Van den Bergh was above 1.00. In both cases the diagnosis was acute prostatisis.

Table III contains the Van den Bergh readings on 32 patients whose illness, by clinical diagnosis, was attributed to TNT absorption. 14 of these had visible jaundice. The two most jaundiced had readings of 40.00 and 16.00 respectively. A third has a reading of 2.30. All the other 11 had readings ranging from .60 to 1.80.

From this Table III it can be deducted that an elevated Van den Bergh is not vital to a diagnosis of TNT absorption because the diagnosis can better be made clinically in the presence of a sufficient exposure to TNT. However, it is certain to be high in the presence of obvious jaundice. In Table III there were 10 cases of undoubted illness due to TNT absorption in which the Van den Bergh was normal. This paper was not published but a copy is in my filing cabinet.

Early in September, 1943, changes in the responsibilities of the medical staff were made and my work load increased. In addition to my continuing to carry full responsibilities for all patients having any TNT-related medical problems, I was assigned all of the plant's occupational medical problems. That is, it became my responsibility to see, deal with, record and treat any illness in the large plant which could be caused by exposure to poisonous industrial substances. This meant that I had to make tours of the whole plant to study the nature of all chemical exposures, and to become familiar with the signs and symptoms of a much-expanded variety of occupational medical problems.

I was not, of course, expected to handle plant accidents, but I had to, for my own safety, become familiar with all of the explosive hazards of this huge ammunition industry. In addition, at the same time, I was made Medical Officer of Health for the whole Ajax community. This included the public health problems of the huge plant itself and also the public health responsibilities for all the residents living on the company's property, and inspections of toilet facilities and cafeterias.

In keeping with my expanded responsibilities, I prepared and sent to all line nurses, and my personal staff, a memo explaining the extent of my responsibilities and what they would have to do in cooperation, so that I could fulfill my obligations. At this time I revised my timetable for work so that everyone would know where to find me and where to send workers to me for consultations and medical services. The schedule for me, as drawn up at that time, was as follows:

Forenoons:

Mondays -- Limited to general plant inspections.

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Tuesdays -- Clinics at nurses stations on "cap and detonator" (C & D), "pellet and tracer" (P & T) and line 1.
Wednesdays -- Inspection tours of C & D, P & T and line 1.
Thursdays -- Clinics on lines 2, 3 and 4.
Fridays -- Inspections of lines 2, 3, and 4.
Saturdays -- At my clinic at the plant hospital.

Afternoons:

Every afternoon, Monday through Friday, I was engaged in office work, but available for consultations in my hospital clinic suite in the plant hospital.

This schedule enabled me to handle my clinic responsibilities on the lines, so that there was a minimum of interruption of workmen's work, and the Saturday clinic, at the hospital suite, made me accessible to workmen who were off duty, or working on shifts other than the day shift, if the condition was urgent.

With three forenoons every week set aside for tours of inspection, I was able to keep on top of housekeeping, ventilation, medical accident hazards, control of toxic hazards, methods of handling poisonous substances, and general working conditions throughout the plant. If I found anything that needed correction, I always put it in a written memo addressed to the superintendent responsible, with a copy to top management. In a similar manner all public health memos were sent to the foreman responsible with a copy to top management.

In October, 1943, I wrote a report entitled, "Menstrual Survey in a Shell Filling Plant." This was never published but there is a copy in my filing cabinet. The study was carried out by the company's trained nurses with all following the directions I laid out. The numbers of women surveyed are large enough so that the conclusions may have some significance. The women surveyed were strictly limited to those from eighteen to thirty-nine years.

Seven groups were set up as follows:

Group One -- Consisted of 75 office workers as controls. These had 4% disturbances in menstruation.

Group Two -- Consisted of 392 line workers who differed from office workers only to the extent that they were doing factory work which they were not accustomed to, which involved change of shifts, sometimes heavier work, often standing for long hours and changes in eating and sleeping routines. However, none of Group One or Group Two had any exposure to harmful industrial powders or chemicals.

In Group Two, 18% had menstrual disturbance which was 14% more than those in Group One. This might be reasonably attributed to work in the assembly line environments, but had nothing to do with chemical exposures. So in evaluating the effects of exposure to powders and toxic chemicals, it seems reasonable that only percentages of menstrual disturbances over 18% can attributed to specific chemicals.

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Group Three -- Consisted of 87 women who were working in TNT for the last two months or more. 32.2% had menstrual disturbances. Approximately 14% of these could be attributed to TNT. About 64% of the changes were in the direction of in creased menstruation.

Group Four -- Consisted of 38 women who had been working in tetryl for the last two months or more. 36.8% complained of menstrual disturbances. This would be about 18.8% more than those of Group Two which could be attributed to tetryl. About 76% of these were in the direction of increased menstruation.

Group Five -- Consisted of 86 women who had been exposed to condite for the last two months or more. In this group 29.1% had disturbances in menstruation of which about 11% could be attributed to the condite. The changes in the group were about 88% in the direction of increased menstruation.

Group Six -- Consisted of 64 women who were exposed to smokeless powder for the last two months or more. In this group 19.4% had menstrual disturbances of which only about 1.5% could be attributed to the powder which seems statistically of doubtful value.

Group Seven -- Consisted of 92 women who had been exposed to mercury fulminate for the last two months or more. Of this group 20.6% had menstrual disturbances of which only 2% could be attributed to mercury fulminate which is probably statistic ally of doubtful value.

In the summary this survey brought out that women working in TNT, tetryl and condite tend to have menstrual changes which can be attributed to those chemical exposures. This study was never published but there is a copy in my files.

On January 7, 1944, I completed a paper entitled "TNT Sickness and Its Control in Industry." This document was never published but it probably would have been, if the war were not still going on at this time. A copy of this paper is on file in my filing cabinet. Copies were circulated among proper authorities when it was completed and, of course, forwarded to Dr. F. M. Jones and Dr. F. M. R. Bulmer.

This paper draws on my experience in examining and dealing with some 2,500 employees who, over the preceding year and a half, came to me complaining of illness which was attributed to TNT; but not all of the complaints were genuine. I had kept careful records of signs and symptoms which I drew upon to write this paper on TNT sickness.

From these records I tabulated the frequency of symptoms complained of by the group of TNT workers involved. I also tabulated the frequency of observed jaundice and cyanosis and the frequency of low blood pressure and low haemoglobin. These frequencies are all given in percentage of the whole group.

These frequencies of symptoms are shown in the table below with the most prominent ones appearing first and others in their decreasing order of frequency.

Frequency of Symptoms

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From this data it is evident that loss of appetite was the most frequent complaint. Nausea was frequent enough that, when accompanied by loss of appetite, it might well have led to under-nourishment and contributed to the undue fatigue and headache.

Cough, tightness in the chest and breathlessness commonly appeared together which made me consider the possibility of a lung condition. In true TNT sickness the cough was always unproductive. When a thorough examination of the lungs and heart failed to turn up any evidence of lung or heart disease, I was left with the conclusion that these symptoms were indicators of TNT sickness. The other symptoms, dizziness, abnormal drowsiness, abdominal cramps and muscle pains, may have had some significance among the symptoms of TNT sickness, but it is more likely that they were secondary manifestations associated with the first mentioned symptoms which would result in under-nourishment and poor circulation. The impairment in circulation was certainly a factor because in 80% of the cases of TNT sickness, the blood pressure was low.

Cyanosis, although detectable in only 20% of cases, was often associated with low blood pressure. Much research failed to uncover any other condition in the blood itself which would explain the cyanosis. It seems plausible that the low blood pressure was in some way associated with dilatation of the capillaries, resulting in slowing of peripheral circulation with consequent cyanosis.

The high frequency of low haemoglobin indicated that TNT tends to cause anemia, which might accentuate the feeling of breathlessness in the absence of lung or heart disease. Jaundice was seen less frequently than cyanosis, but when present seemed to indicate more liver involvement.

I became, through practice, so skillful in detecting jaundice in the sclera that I almost invariably recognized its early development before a positive Van den Bergh test could be obtained.

This paper points out that the treatment of TNT sickness is prompt interruption of exposure and maintaining it until the patient recovers. This also emphasizes the great importance of minimal exposure in prevention of the disease.

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The paper was written at a time when TNT sickness at Ajax was already quite well controlled, so in order to document how this was accomplished I am reproducing here the last page of the paper in toto.

Excerpt from the paper "T.N.T. Sickness and its Control in Industry."

The reason for the remarkable decrease in T.N.T. Sickness in our plant cannot be attributed to any one factor. I am listing below the factors which I think are responsible. I am listing them in order of importance beginning with the most important factor.

1) Early recognition of symptoms by line nurses and myself, so that patients are moved out of contact early, before serious symptoms develop, and kept out until recovery is complete.

2) Close supervision and daily contact with each T.N.T. worker, on the part of line nurses, under the present system of organized control.

3) Improvement in cleanliness in the T.N.T. rooms and more care on the part of the workmen.

4) Daily change of uniforms and daily showering with a general improvement in personal cleanliness.

5) Improvement in worker morale. Workers now show more confidence in the line nurses, myself and the company in our efforts to improve their health. The workers themselves are reporting symptoms earlier and not trying to hide symptoms be cause of suspicion of unfair treatment. Foremen are cooperating much better because they are convinced of the value of medical control, which has been reflected in a marked decrease in the number of man-hours lost through sickness.

6) Enlargement of the T.N.T. rooms so that there is more air space in proportion to T.N.T. handled.

7) Establishment of a fairly satisfactory technique for washing T.N.T. garments at our laundry and the present system of segregating and handling of T.N.T. garments.

8) The extensive use of ferrous sulphate tablets among T.N.T. workers.

9) The routine monthly check-up on all T.N.T. workers by the line nurses.

10) The elimination of dry sweeping of T.N.T. rooms.

11) The treatment of non T.N.T. ailments and thus reducing susceptibility to T.N.T.

12) The segregation of T.N.T. workers in the change rooms.

13) The judicious use of masks, guards and gloves.

14) The segregation of used T.N.T. shoes.

15) Better hospital and laboratory facilities for treatment and diagnosis of T.N.T. cases.

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On January 31, 1944, I wrote a paper entitled "Case Report, Toxic Jaundice Due to T.N.T." This paper was never published but it probably would have been published if the Second World War were not still going on. I have a copy in my files.

The patient was a young man who had a heavy exposure to TNT dust followed by a heavy exposure to hot TNT fumes. The length of his exposure was exactly two months.

He first reported to me on November 4, 1943. On this date he complained of loss of appetite, nausea, undue fatigue, tight feeling in the chest, shortness of breath and abdominal cramps. At that time there was no cyanosis and no jaundice. His blood pressure then was 116/60 and his haemoglobin 92%. 1 took him off exposure to TNT immediately.

I saw him again on November 7th and found his condition unchanged.

I saw him again on November 13th. By this date his feeling of tightness in the chest had disappeared and did not return. He still had no cyanosis and never did develop any. However, he still had his other symptoms and was becoming jaundiced.

On November 17th he was admitted to our plant hospital. In a couple of days all symptoms had disappeared except poor appetite, nausea and weakness. However, his jaundice was becoming worse. Then the diagnosis of toxic jaundice was made and his Van den Bergh test was going up rapidly.

His liver and spleen were just palpable on November 24th and on that date he was transferred to the Toronto General Hospital under the care of Dr. Raymond Farquharson. I kept in close touch with Dr. Farquharson. He continued the general routine I was following, and essentially the same laboratory tests were followed at the Toronto General Hospital.

The Van Den Bergh readings continued to go up and eventually reached 40 units before starting to go down on November 30th. The changes in the urine color and the Webster test paralleled those of the Van den Bergh.

No other laboratory tests, except liver tests, showed anything of significance. The Webster test in this patient showed traces of T.N.T. in the urine for 18 days after his last contact. Usually when a workman's exposure is broken the Webster test becomes normal in four or five days. Liver function tests showed abnormalities until jaundice was gone. The cephalin cholesterol flocculation test was the last to return to normal.

The patient eventually recovered completely with a slight setback near the middle of December when he broke out with chicken pox while in the Toronto General Hospital.

In April, 1944, I prepared a 24-page document wherein I listed by name and described briefly 92 cases of undoubted TNT sickness encountered at the Defence Industries Pickering Plant at Ajax, Ontario, between May, 1942, and the end of March, 1944. This document was entitled "Case Reports of TNT Sickness." This paper was not published but a copy of it is in my file cabinet.

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In this series of cases there were 64 males with an average age of 36 years and 28 females with an average age of 28. In this series all of the common symptoms were higher than the series of January 7, 1944. They are being listed below in their descending order by frequency. This may be because the January 7, 1944 report may have been moderated by the inclusion of some which might not actually have been TNT sickness.

Symptoms by Percentages

On May 26, 1944, I wrote a paper entitled "Report of a Fatal Case of Toxic Jaundice Due to TNT." I was not involved in this case in any way. In fact, it started before I was even working at Defence Industries at Ajax, Ontario, and the young man had died long before I heard about it. But after I was assigned to TNT I heard about it and looked up the records on it.

It is a depressing account of gross mismanagement all around, largely because the patient denied that he had worked in TNT and continued to lie about it until his record was discovered two days before he died. This was too late to save his life no matter what was done.

His record showed that he had suffered a burn on his wrist from molten TNT and that he had had previous contact with TNT in several ways. Because his burn was alleged not to be due to TNT, the treatment used was worse than nothing. He was not given the clean-up necessary for TNT exposure. He became progressively worse, was hospitalized and eventually transferred to Toronto General Hospital on March 21, 1942, where he died on March 23rd. An autopsy was done by Dr. I. H. Erb on March 25, 1942, after he had been embalmed, so evidence was difficult to find, but Dr. Erb certified that he had died of liver atrophy from TNT poisoning. This paper was never published, but a copy is preserved in my filing cabinet.

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In October, 1944, I wrote a further report entitled "Case Reports of TNT Sickness, April 1, 1944 to September 30, 1944." This was written to put on record the cases I encountered during this period, making it supplemental to the report written in April, 1944, detailing those cases up to March 31, 1944. It is significant that the number of cases per month was much reduced because of the control measures then in force. I saw only one case of TNT sickness during the last three months of 1944. This report was not published, but I have a copy in my filing cabinet.

On April 15, 1945; I wrote a further report on cases of TNT sickness occurring early in 1945. It was entitled "Case Reports of TNT Sickness, January 1, 1945 to March 31, 1945." A copy is in my files. This report for the above three month period contains only three cases of TNT sickness. This small number of TNT sickness cases again demonstrated the remarkable success of the preventive program which I had instituted at the plant. This plant was still working at about its usual capacity.

Sometime during my later years of working with TNT health problems, I was asked to visit the Bouchard Munitions Plant in Quebec which also had similar problems. I visited the plant and talked to the plant physicians there. I explained how the problem had been approached at Ajax and I think they benefitted by adopting similar measures.

On May 3, 1945, I wrote a study which I had conducted on all of the workers exposed to R.D.X. at Defence Industries in Ajax, Ontario. Since R.D.X. was a new explosive and little was known about it, it seemed appropriate that I should undertake a detailed study of workers in the substance, using the laboratory investigations which had been applied to TNT workers. The reason for this approach was to find, if possible, early indicators of harmful effects.

Sixty-two workers were covered thoroughly in this survey. Forty of them were men and twenty-two were women. The results are detailed in three tables. Each of these tables takes up seven pages of findings. A copy is available in my files.

Table I is devoted to symptoms and has a column for each of the following items: visual disturbances, diplopia, cough, sneezing, tightness in chest, burning of eyes, dryness of nose and throat, loss of appetite, nausea, vomiting, abdominal cramps, diarrhea, constipation, abdominal distension, rash, dizziness, headache, undue fatigue, breathlessness, drowsiness, muscle pains, swelling of hands and feet, hearing disturbances, urinary frequency, menstrual disturbances, sleeplessness and nervousness.

Table II lists examination results and has a column for each of the following items: cyanosis, jaundice, blood pressure, Chvostek's sign, reflexes, optic discs, Rhomberg's sign, bleeding time, coagulation time in seconds, capillary resistance, retraction time in minutes, reticulocytes in %, red cell count, urinalysis for color, urinalysis for specific gravity, urinalysis for albumen, urinalysis for sugar, urinalysis for bile and other signs.

In Table II urine color is tabulated according to the scale reading. Specific reading figures are recorded for blood pressure, bleeding time, coagulation time, reaction time, reticulocyte percentage, red cell count and specific gravity of the urine.

In Table III are tabulated the following examination results: sedimentation rate in minutes in one hour, haemoglobin in percentage, appearance of blood smear, white cell count, basophils, easinophils, monocytes (by numbers found), neutrophils, lymphocytes,

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Van den Bergh, serum calcium (9-11 mg is normal), serum phosphates (3-10 is normal), serum albumen (3.7-5.25 is normal), serum globulin (1.5-3.0 is normal), blood chloride (570-625 mgs. is normal) and cephalin cholesterol flocculation test.

The conclusion of the report states: "This study, although somewhat incomplete in some respects, failed to show any signs or symptoms of toxicity of R.D.X."

Further comment. I think this study was valuable for the very reason that no evidence of R.D.X. toxicity was found. It was carefully done and very convincing. I think, in any case against the company for damages in which R.D.X. poisoning was claimed, this study, when produced as evidence, would be a convincing defense. This report, entitled "A Study of Workers Exposed to R.D.X." was never published because at the time it was written the war was still on and publication of such things was still restricted. I have a copy in my files.

One time, when I was driving away from the plant at Ajax, for some reason I was looking at some papers I had in the car with me and I had an accident. The large parking lot was empty, and there was no other traffic in any direction, so I was moving slowly, without paying attention to where I was heading. Suddenly the car rammed into a large concrete block which was supporting one of the parking lot electric lights. The sudden stop threw me forward violently enough for my chest to break off the plastic steering wheel. My head was also thrown forward so that I received a cut on my lower lip. Otherwise no damage was done. However, with the steering wheel broken I had no way to control the car. So my car, with me in it, was towed to Oshawa where I obtained a new steering wheel without difficulty.

Although most of my time was taken up at the shell filling plant, I did manage to carry on a little private medical practice, using a small room in the front of my residence. I remember I took care of a confinement or two.

I also remember having a patient come to my office with a large piece of meat stuck in his throat. I could not see anything and had no instruments to explore lower down, so I sent him to the hospital in Oshawa to get service.

One time I was called in consultation to see a woman in the Oshawa Hospital who was suffering from a generalized and distressing rash, which her doctor could do nothing for. After studying her case and not discovering any environmental cause for it, I suggested that the doctor stop the newly popular drug he was giving her. When the medicine was stopped she soon recovered completely.

In Whitby the soil was good, and I had a healthy garden where I grew vegetables of many kinds. There was already a large productive plot of asparagus. I also grew a lot of gladioli flowers of many colors.

In Whitby I was a member of the Kiwanis Club and we put on a street fair once a year to raise funds. It was interesting but exhausting because it ran into late evening on Saturdays. Just before I left Whitby they wanted me to be president, but I had to turn it down.

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One time in the winter I thought I would see what it was like to perform on skis. I had never had them on before so I didn't know when or how to use them. I walked out on the road, which at that time was icy and rutted. I soon found my feet sliding sideways on the ice and I fell down. I was not badly hurt but I quickly lost my interest in skiing.

In Whitby I belonged to the United Church of Canada and was active in the Men's Club in the Sunday School. I taught the adult class sometimes and for part of a year I served as superintendent of the Sunday School.

Toward the end of my service of Defence Industries at Ajax, I was sent a patient from the Toronto General Hospital who came and returned to the hospital by ambulance. I was not expected to attend the patient, but because I was then considered something of an expert on TNT sickness, he was sent to me to verify the diagnosis of the internist and top professors of the University of Toronto, who had already made the diagnosis of TNT poisoning. I was expected to fill out the report to the Workman's Compensation Board to ensure that his heirs would get the compensation coming to them because it was obvious to them, and to me, that the man was near death.

I found the man greatly jaundiced and much emaciated. I learned from him that he had worked at Defence Industries at Ajax only in the stockroom where TNT was received off the freight train. I knew what it was like in the storeroom, and that the TNT came in closed boxes which were kept in a large open shed with a roof over it. I knew that the only possible exposure there would be to a little dust that would spill out, if a box were broken in handling. I also knew that this tiny exposure could never cause TNT sickness. So I filled out my report for the Workman's Compensation Board, that the patient did not have TNT poisoning, and that, in my opinion, he was suffering from a malignancy which was obstructing his bile duct and causing his jaundice, even though I could not find anything on palpation.

A week or two later the man died, and a prominent story came out in the Toronto morning paper, that he had died of TNT poisoning. The source giving the information to the newspaper was the County Coroner. But he would never have such information if the death certificate were not sent to him signed by one of the illustrious physicians attending the patient. TNT poisoning was such a new thing that no doubt the doctors involved wanted to get the credit for their diagnosis.

A couple of days later I learned by some private enquiries that when the autopsy was done the following day, it was found that the man had died of cancer in the head of the pancreas, through which the bile from the liver has to reach the digestive tract. So my diagnosis on seeing the patient for about a half hour was entirely correct, and the doctors at the Toronto General Hospital were wrong.

Of course the report which had gone to the public through the newspaper was never corrected and I received no publicity whatsoever about it. I don t mean to imply that I was smarter than the hospital and university doctors, but I had the advantage that I knew the workman's exposure to TNT was so small that he could not possibly be harmed by it.

This principle of Occupational Medicine, not known at that time, even by the

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professors at the University of Toronto, states that "the degree of exposure to any noxious chemical must be great enough to cause the disease."

In May, 1945, a communication came through top management at Defence Industries at Ajax that another branch of Defence Industries wanted to hire me at a higher salary. No information was available as to what or where, but they were prepared to pay my way to Montreal for an interview with the manager of the project. So I went to Montreal and saw him in his office. In the interview he said he could not tell me what the project was about until I had consented to work for him, and was prepared to keep the secret. Since it is no longer a secret, I can tell you that I was surprised when he calmly said they were building a plant to split the atom.

So I was hired to be Works Chief Medical Officer of the N.R.X. Project. The company was prepared to pay my moving expenses and provide me with a house at the townsite which was being built for employees, several miles away from the project itself.

Since the house was not yet completed and the company wanted me to get further medical experience in some phases of medicine, arrangements were made for me to get two months private tutoring at the University of Toronto at the company 's expense.

I terminated my activities at Defence Industries at Ajax, Ontario, on May 3, 1945, and went to Toronto where I got some intensive instruction in laboratory work in haematology and biochemistry and in electrocardiography, and familiarity with what was needed in such laboratories.

I made arrangements to sell my house in Whitby and prepared to move. I had no trouble in selling the house back to the man I bought it from, who also held the mortgage on it. This transaction was carried through so easily because the buyer wanted the house for his son and family to move into.

Again, I was amazed at a change which took place in my life which was not in any way anticipated by me, nor planned by me.

As I look back over my years at the shell filling plant at Ajax, I don't want to minimize the hazards there. Although safety was not my responsibility, I did have plant-wide responsibilities in other areas, so I had access to and did visit all areas. Fortunately I was not involved in any plant accidents but I did routinely take the prescribed precautions wherever I went. In some areas the explosives dealt with were very sensitive. In these areas the mixing room was constructed so that one wall was very flimsy. If and when there was an explosion this wall would be blown out and the rest of the building spared.

One time four or five men were brought into the plant hospital after just such an explosion. I saw them in the hospital, but did not attend them. They all were burned and blackened all over, their clothes burned off and the skin stiff and charred. Although some survived long enough to be transferred to Oshawa Hospital first, they all died.

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