Document 82X1xwroQqzbx2vz7Vd79R36a

K-1782 /, ./.... / HCOiNALC) M. SMART. M.O. JOSCPH P. 60YLE. M. O. JOHN K. SNtflEY. M.D. afinrtAt *!>*neir iwim>yo i*i4 <<* iniv iKa* Uf* A-ww <h ; 1.C 17 A ijX ;/$A Ffsi:- Vsf>t = ntc:;tv;o t Angles ^I A Deri. / f II ' "* ' . IT. A. >t u MWvwr.pA Tht traveler! Insurance Company $10 We*t Sixth stvaee Log Aagele* 14, California Attention: Jojcph Btldufc, Boptoaencaelv* Ed: B 8269502 Araxtrong Cork Coapany to; E. 0. HcCarrell 36 U 276-634 Gentlemen: Hr. KcCarrell V*a referred to oar office By Cr. Jkmaltott fat cnmlcxtlija on Biccibir 7, 2936. So obtained the following history tzca th patiaoc: gaatdeaee hlataxv: The patient, egad S3, Vrai bom Ktreh 3. 1903, In Bouton, Ton*, uhre ho lived fox 1$ year*. Then he noved to lot Angela* end b* remained hero over tine* with the rxmpclon of two olght* ipent in Poxtetvlll*, California, in 1943. Occupational hl*torvc Hr. HcCarrell worked * O cook end manager In hotel* end rearenrant* end elan in hie own piece* of baeine** cmtll 1940. \ Troa 1940 to 1943 he we* employed by the Blent ttnbber end Ajbeato* Sork* In | In* Angelo* where he did ateea pipe end boiler Inanlatioo work In the *hlp y^4i Ith k vtfk4 1m n|iaa4 uck u 4**jgt*+ which were not ventilated end chut he was crpojlod to cotuidctahle dnxt end fiaaea, parcientarly aabeaco* and megniile. Ba did not wear a ts**h ox raapiri- tox on tht* Job. Since 1943 the patient hn* been employed by the ArmeCrang Cork Coepeny \ la la* Angela*. &* hen worked in vnrlcv* building*, hotel*, raitaarautj, \ tteo pleata, etc., throughoot Loa Angeles County, doing attaa pipe laatal- } latlon In holler rood*. Ee alao worked with "dlatrlck block11 (fiber glaaa) end did refrigerator taiulatlou work Ceewfcjy^B luotallaLiou), 8 he worked with eebeatos (25-051 Bugneala). cogh.|K*yIa\{*lllc) and iota glial, bat does not believe be ever need dlet:ooiccida earth, tie patient atated thera waa alvaya considerable dnot and ftjcnca frcat the above sat*ctili, the degree varying In the different arte* he worked, Ko oeale et replr*tar v* wore at thl* Job and the patient had been off work alsce Beceahex 4, 1955. > 1 ,C **'K A : v. `b j '; ff=> - 3 / t/ ' 2 -. >. - TL TLavaiaua tiuuuuce Cuopeuy yebvoaey 211 1957 Ri: E. 0. MeCartell t pnaet nd_eaurli! of present IHhki: While at work on Hoveobtr 14, 1956, the patltae etsrtcd Co &augh and ^ehoitod" on adwti* ''dletrlck block" date efeer Caking * deep breath. This via fallowed by an attaele of coughing. Be (Cored this tad occurred three or four tinea withIn the past year hut that following tb( last expoure the cough *cd to he worse and he consulted bla fanlly physician, pr. Econlcott, for tsaalaaSleq and advice. Cheat x-ray* were taken at The Hospital of the Coed SKwrtcaa and imported a sbevisg "iur clasua on the lunge, or flbtoala." The patient vu studied by or. Hatley on Hovtwber 29, 1956, and a copy of hla finding* la enclosed. Hr. KcCarroll was advlaad by Df. Knmtcstt to avoid dust exposure and strenuous work. The potlent stated that he rarely had cold although two months previously he bod * head Cold with Increased cough but no fever. Ea was given lost eoegh *7rop which didjtwc help. Chief floavljilnts: (1) fatigability for the previous atx notch** (2) shortness of breath which cone on gradually about tlx ton tin ago. The dyspuaa ins noticed especially on exertion such as cllublng itatri bet did not bothar bin whoa ha waliid or drove hts ear and did not occur after nails' or at night, Par the same length of tin* ha has no dead difficulty In taking a deep breath. (3J Cough which had been present for six or eight months bee was more noticeable during the past meneb. The cough occurred at any else and vaa agiravacad e*p*cj.ally by axarctee et* d*p hroathlng. It Vaa usually raoproductive but occailonally after hard eooghlng, the patient raised approxlsately Goa taaspoonful of clear, white sputum, Thera had baan no hemoptysis or btmEh-'ii frh.' Kf- JlcCarrelX added that he first noticed this eoagh whan ha "choked'1 on iduefEtyloj<tuc over one year ago. Then ha had no farther trouble until fix or eight WBEhe ago. (4) Dull pain la tba mid chase for the past alx souths which vaa aggravated by deep breathing and exertion. Bavietf of (vateas failed to rev**i any other aytaptocur. The patient * S vaight had bcae stationary around 195 pound* for the past two yara and ba dented having fewr, *u**ta, or chills. fcaviaw of the ay**, ears, oo and tk.fl.fc, s.fc.fl-Lflfciflbiil and g.fl(ei flriufliry fl^flCflal vaa aafcifl.ly kfl*kiv. Psat medical history: Hvaalaa and chicken pooc at th ag* of 39, both of average severity. The patient dcuiod having othur illncssaa in tha past except for a head onld about once a yonc with occasional "pleurisy1 i>iius in che shoulders, Surgery; Repair of lofr hare.la in 1946; hemorrhoidocccwy to 1954 or 19SS, bath operations performed at Tha Eonpirai of tha Coed Scoarltan. f!.. ' t, 1= . & * / >. <1 -3 - The Traveler! Insursnco Coopcny ft.! ft. O. HtCa.r.U r.bruary 21, 1937 1 Pmllv history; The patleuc'e fathdff was living and well at 81 year,. El. tiocbdr died of unknown causa c 41. Ooa brother and f<mr sisters vtra living and veil. One brother died la Infancy of pneumOTie. The p.eitnt va, `carried and bad as children. Thera wa, no family history of cubsrtuloslj, cancer, diabetes, or heart trouble. Habits! The patient eleaps vll eight honra at night. Bo doci oac rroke or drlnlc and vu taking no meditations; Hbrsleal emsntuetlaa; Height 6 feet, Weight 20S 1/2 pounds. RIood pressure 100/68. The patient vne veil developed and Bonrisbed, tot acutely Hi, but bo b*d a dry cough vhcoavn; be cook a deep breath, Head tad gcalp - negative. Bara - negative. Eyes - negative except Sot iliebc areas fee'll,. Ho* - alight discharge promt, Teeth tad gum* * Psgstlve. Teneila . three plus enlarged and cryptic, not Injected., Pharyhl negative. tTecfc - nodes negative, questionable distention of Jngnlar veins. Thyroid - negative. Eaaxt tones distant, regular sloes rbytha, not enlarged or displaced, fi aquall.d 4-2* p0 "'. Cheat; Than vu alight fcyphoeii (1+), lnertased -p diameter, and slight lag. Breath sound* sure ditrlnithsd viti barah inspiration and prolonged expiration. Theta ua moderately Impaired resonance and a f.v rise raiaa present throughout both baaai anteriorly and poeCtrlosly. Abdomen - oe tenitruui, masses, rigidity, or acara. Spleen * negative, liver - palpable at the coated margin. Estrenltlea no clubbing, eyaaesla or edma, " Chest fluoroscopy; the diaphragms moved 3 ens. ' thara w< dlffnjo linear fibrosis throughout both lower lung fields. laboratory work perfoined In bar office fs as follows! 12-7-SS. Shin tecs; Intermediate coSerculla - one plea positive. Coeeidioidin - negative. RistopUsaln - one plaa positive. lt-14~3d. spuema spacicura: Wat mount for ssbeatof bodies; One group of structure! characteristic of asbestos bodies ware iaea In the tantrlfugcd sediment, Flucsclou-concetucxacion for acid-fast bacilli! &ot*clvo. Culture far U. tuberculosis; Hcgative. 12-28-36. Sputa ipecifsen: Exsodnatlott for dsbestosla bodies: The spucias vm divided and a portico digeatad With (0dlH9 hydroxide, a portion with aodlua hypochlorite following by eentrlitigation. Thera is a scattering of long, (lender refractory fibres 4 - ID meg. in nd varying in length from 1/2 to 2 cfcae* the law pwtr nierascople field, k number of small fflbcr fiaarphou! bodloa are aoea. Ko struefcnra* characteristic of asbestosls bodia* ware seta in say of the preparations. U-17-3S F" - e> 5 *4- Th Travelers Tojvreoce Company SAi E. 0. KeCarcell February Zl, WJ7 A copy oi aj Intorpcotattoo of the chest film l* enclosed. ciagiaoels: (ij Pulmonary fibrost* due chiefly to the UihaUclaa at asbestos du*t. Hwflvoc, the cffocct of Idnltcloa of fitor glade and ecbtr materials vsob a* rugae*!*, ilUu, and Com glaji* do not b coapletely discounted. nevertheless, tic x-ray fllaj are Boro Cbaraceorlatid of ajbettodl* than lay other iXagX* disease, The cu-arse, grotad-gJUae appearance and the localisation of Cbt fibroil* In the lover portion of each lung are quite i f characteristic of asbestos is. tli iscowry of aibaitoi bodlei in the specimen dated lf-14-f$ 1* also ecafirawCory of asbtscosts, (2) Cor pulmonale with right ventricular hypertrophy. (3) Primary tuberculous Infection. Disability: PlcxBo refer to Dr. H, L. ttoeloy'e palnotuiry function report diced Hovenber 2B, ISjd. Tou will uocn that this* aCudiea indicated nry llttla abnormality lo wnc i lot ion bat shoved A xlgnifiesat reluct ton la the arterial oxygen saturation after olid axarelse. There Vu aim evidence of pulmonary flbroel* preventing A Bomal oxygen uptalta during mild exercise. This indteacoj that Ur. KtCixreU bn difficulty lccraasiug bla cardiac output and pulmonary blood flow at the else of aaerclia. This* two abnormal W*sar. tent., i,e.t hyptmla during exercise and decreased oxercLee oxygen uptake. Indicate chat Kt, HcCarrtll should not b* compelled to climb atapa. ladder*, or engage In physical exertion of a ccnpirabls nature, because aa Dr. hotley point* ouc, pUd axetslne btlags ott scuta hypoxia and Increase* cb* load on the right heart. Therefor*, Hr. HrP-anfell l* dlM4 for the type of rk h* ba* been doing lot the path sever*! yean. It Lt our belief that if be l* forced EO COOClAut doing cbls type of VOtfc, b* Will evootoally develop right heart failure and become a cardlo^paLtiosuty cripple. Therefore, t beve advised bla to side treatment of hi* pulmonary coodleloo. xf tbi* la success ful, h* night eventually be able to do light sedentary rarfc for which he would haw E0 ba trained. Ac the prtsnnt tlo* Hr. HcCsrroll 1* totally disabled for Che work that he ha* been doleg. There 1* very little chance that this disability will Jrrprove usics* tha patient receive* any usussally favorable raapemae to the therapy to be reccostcnded later. Without Creataunt the probabilities.are that hi* disability vill boeomo note savqre. ! Prognosis: la Etneral the ontlooV for pulmonary flbroais of this type If not gOOd, The disease timds to be paeaveoslv* aa he* loan ub*acvud gs thi* cx*. Hovtvor, tha use of positive pressure breathing and * taroid therapy are Coo tav CO *Ay thoe Hr, HcCarrall'a pulmonary ccndlcioa can not ba Improved, Recomendatlon* ` Hr, HeCamall should be tlveu a trial of intaruitCeuv positive pressure breaching la ea effort to overcome the contractive fibrosis vhlcb on* net* in hi* i-ray*. You will note that tbt* mo's total lung capacity ha* alrtady beau taduced and tbo tendency la til type* ef pulmonary fibrosl* 1* fat cbe contractive process to lncroasa to that eventually the bellows aeefeu of the lvage l* greatly restricted. The one of steroid therapy he* achieved soma .yi-fXiy.v . 1 o'!/ != . 0 <S i." V.'* tvV rf-5 Tl* Travelors XniunaCH Company &: r. 0, HcCarrtU rebruat7 21. l7 Oi Csrtain types of pulmonary fibrosis, particularly berylliosis, This type of therapy it too lsew and hu beta used in so few cajea of ssbtacosls that X know of so reported earls* In ehi medical licAtecura. Scvcrthtlesn, the results la berylliosis e..d otbsr types of fibrosis ere very sacoursgtag. If Steroid therapy It Co he used,'it should be used cautiously end under Tcdtcal Supervision, recognizing that this wa bag * poettlvfl cobcrculia Celt sad that steroid thorepy sons clues causes sa exactrbatloTj of tuberculosis, especially if ancl-fcuhsr""lei drug* ere uve cures *1033 Vtth the steroid , eedlcaSloa. Other aide affects of steroid therapy ttttst also ba counteracted such as the tendency eov*xd retention of sudlua sad tfca excxccioa of potassium. Fevtrthaless, steroid therapy and Intamlcteat positive pressure breathing therapy offer the only real hope of as-renting this nan's pulmonary disease and perhaps bringing about some improvement. tflictouship of ldsored'a condition Co hjj occupation: This BUUO has had Bd significant Indus trial duee exposure arreaps is the course of bis work In Various type* of Insolation work sine* 1940, Be ha* nevar done mining, <jutrrylng, or worked is ceramics or 1b the processing of Silica, dUCOnacaouj > earth, ate. There is no known exposure to beryllium, E* has had significant exposure Co several varieties of insulation, particularly sjbestas. Silica, > and foam and fiber glass- the s-ray films es'e tuite characteristic of pulmonary flbcosl* das to asbascosis, They are twe ebarsetsristis of beryl liosis. dietosaceouo earth pueemotoaiosis, or silicosis, T5a clinical findings or* net those of branchiaecari* pur Of chronic passive congestion due to left -> hurt failure. In y optoloa, Hr, HcCamtll has palsujury fibrosis of occupa f tional origin. This flinrosls con best ho attributed to asbestos although owe can tut say. chat othr Inhaled JubjCSDCCS such Ss silica or fiber glass have not been significant factors- T bollavo his pulmonary disease is occupational la origin. /' BE3:fv face. c t *3 / \ rcginalo H smart, m d JOSEPH r, .M o JOHN K. SHiarr. pa, o *<&*<** *j-a0~4 |ij* <*f *< ir** L01 *H4C Kt 1 > *# p'40 _ Mr. V/iiliam T, Kays Attorney it Li* 6331 Hollywood Boulevard 1*05 Angele$ 28, California, It-Ek ^me<i U/hireemb Riley t1 Dear Mr. Kays: The'following report la sent to you it the request of Mr, James W. Pile'/ whom we first examined on June 27,- 1957 with regard to his pulmonary condition. The following history and finding* were obtained: Residence history: Mr. Riley was born In Joplin, Missouri on October 23, 1899, He has lived In the Las Angeles area since 1903 with the following ext :Ioni: In 1918 He was briefly in Quanlieo, Virginia. From 1936 to 19 -1 he lived In San 7raseisco. In 1997 he was la Fresno, California fos two months. In 1952 he worked In Datnn, Indiana lor si-t months, la 1953 he was in Santa Marti, CaUlivuia for four mortha aod in Las Vegas, Nevada for four months, In 1956 hi* work required a seven month stay la San Diego, Caiifutoia. Occupational History! Since 1919 Mr. itiley Ha* been employed in 1 the Heat insulstigp industry, Hs work requiring the application of insulatlaj materials to boilers, steam pipes aid other structures requiring insulation.. The i:isulatiaj asAtd^iaLs which he has worked with Include asbestos, block, iSctrieh block, fkalcj_ rockwool, fiber glass, cork and Mono block, hie believes he may Also hive worked with diatomaeeou* earth occ: sior.aliy as a loose powder to be applied agalr.se boilers to pro.'ld? a porous material which will allow for expansion and contraction of the boiler due to tem perature changes. The ocher materials mentioned shove are supplied in verlouj for--.3 such as blocks, ect-ed cyl.Jido. 3. elicets, <i.-.d bla.-ito'.j, Vj-y ctien it was nennssn?/ tn rut thr blocks of sheet* uaL.j a baud *.v. It was stay necessary :p harr.rnsf r.ills through this material to secure i: ;ta proper loer.ilor., 5tr.ee this wo:',: was oi'tc.i tMr.t; in corvtir.Ld spiers oueh is boiler rooms, a high dust coneer.triiipn wo; irequertly aualrsd in poorly R - S r] ]i F ]i r -i- Mr. Vrilliam T. Hays Re! James Vi'hStcomb Riley September 19, 1957 ventilated areas, Occasionally Mr. Riley wore & mask when the dust concen tration became uneomiortible. Onset and course of nreseat Ulncsa: Mr. Riley considered himself to be I.i good health until i 1/2 years ago when he line became aware of short ness of breath upon exertion which has slowly progressed. At prosedt hs feels short of breath when walking rapidly on the level or when walking up &A incline. Approximately three years ago, he became aware of cough which has persisted to the present and is productive of 2 to J teaspoons of naucoid sputum dally, There has not been hemoptysis, edema, orthopnea or paroxysmal nocturnal dyspnea. Ho has not been aware of fever. ?or the past several months, he has noticed minimal Intermittent left lower anterior chest pain which Is not related to exercise, rest, meals or position. It usually disappears spontaneously l to Z hour* after oaist, V/ightloes of approximately 20 pounds has occurred during the past 12 months. - Mr, Riley first became aware of a definite pulmonary abnormality ween he was recalled by the Los Angcl'ca City- Health Department after having had a routine chest film in May, 1957, Further examination* wore made including x-ray and sputUm tests, A letter from Dr, Morris J, Schiif dated July IS, 1957 indicates that sputum examinations on 6-10-57 and 6-21-57 revealed acid-fist bacilli la tbs smear of tha concentrated rpseimen, The tuberculin skis test reaction was positive. The diagnosis was indicated to be far advanced, pulmonary tuberculosis, active. It was thought that pulmonary nehestosia might be present. Mr. Riley aj next examined by Dr. Dean S. Seofield of Los Angeles whoso conclusion on hie re port of July 17, 1957 was that Mr. Riley had pulmonary tuberculosis, right, moderate, with cavitation. Clitcf complaints: 1) Shortness of breath with exertion, progressiva since ousel 3 1/2 years ago, l) Persistent cough for 3 years, productive of Z to J teaspoons of mucoid sputum daily. 3) V/elghI los* of approximately 20 pounds during the past year. Inventory of systems; No other symptoms were elicited by systematic cucstioning, Past medical hlstotv: during childhood Mr, Riley had had measles, mumps, chicken pax, wnocpisv cough and scarlet fever. None of these were nvirt and there were no eair.plicatluus, A ,crlc;ooclc was removed S3 191?. h, i*,?t r R . 0 3> I. .3 .3 |3 -3- Mr. William T, Hays . Rei James Whitcomb Riley fispteaibor 19, 1957 Family history; Mr. Riley's mother died at age 74 of urdCr-Cwa cause. Kis father died at age 73 of a heart attack. He has oa brother and two sisters who are living aad well. His wife and three children are living and la good health. There Is no familial history of tuberculosis, diabeto, cancer or hypertension. Habit a; Mr. Riley smokes one package of Cigarettes daily and uses Hlroholic beveragos to a moderate etetent but take# no regular msdieationj, Physical examlnatiofli Mr. Riley was seen to be a thin, well-developed white male who appeared chronically 111. His height was 69 1/4 inches; weight, H9 pounds; temperature, 93.6 degrees; pulse, 80 per minute; , respirations, zo per miau.cc; and blood pressure, 122/70, EtciminAtioo of the chest revealed moderate increase in the antero-posterior diameter of the Chest. Both pulmonary bases lagged with deep inspiration. There wag in creased lyluscle tension`over the right upper posterior ehent, The lunge were hyperreiocant to percussion ever the upper lobes and thara was diminished resonance at both bases. Breath sounds wera bronehovesicul.U' over the upper two.thirds and bronchial over the bases. Fine crepitant and crackling rales were present at sJLlhaae.3, s-aScclurlyt posteriorly and laterally. The point of maximum cardiac impulse was Just to the left cf the xiphoid process. No thrill was palpable, A aiuus mechanism prevailed and the heart tone# were distinct at the apex and distant at the base. No murmurs were beard and the pulmonic second sound was slightly louder thih the aortic second sound. There was erythema and induration of approximately 2 cm. diameter on the right forearm which Mr. Riley stated was the residual of a recently administered skin test. The remainder of physical findings were all within the range of normal, Fluoroscopic examination of the cheat: An infiltration wish possible ea-sitation wn Aotfi in she right &pcx u.d suuu-pe-r, Linear fibrosis was pre sent in the lower half of both lungs. The diaphragms moved approximately 3 to 4 cm. and equally, In the lateral projection they were noted to be flit. Although the heart was net totally oalargrd, the right ventricle appeared ororainsat in the left anterior oblique projoetida. Laboratory evaluation? 6-27`i* - Blood count: Hob, 92 V or 13. i W3C S. SCO. Platelets average. D-fiercr.tial Za, 4. Frr.n. 5d. Sej. SO, Lymph. 09. Mor.c. 7. -iorphology normal. Hnmatoorlt do rr.m. hi one hour. li.:eimcnti;io:i rate * *.V:nt-i,Ll 31 mm. In enu hour. Cs,;ss:ul a? I'.iin, In ona hour. J 7, #* l. t v l 3 V 1 3 rl 3 1 i r3 i r3 -4- Mr. William T, Hays Rei James Whitcomb Riley* September Hi 1957 6-27-57 - Urinalysis! Morning, straw, clear, specific gravity, l.ou, Negative lor albumin and sugar. Microscopic - 0 to 1 white blood cell pec high power Held., Small amount mucus, Rare epithelial. Few bacteria. 6-27-57 - tstraderraal skir, tests: C'nucidioidlu - negative. Kistoplasmin - negative, 7,,2-57 - (Clinical Liberatory oCC, FUchard Smith, M. W. i - Sputum specimen, 3 cc. mucoid material: V/ctrnount lor asbestos bodies: Negative, There Is one large mass of elastic tissue showing alveolar formation. There are hyaline - glassy - straight fibres 3-3 microns in diameter and 1/8 i/s ot an ell Immersion field U length. They resist the action of acid. Flotation-concentration for acid-fast bacilli: Negative. ORAM STAIN shows large numbers of gram positive cocci In clusters and in chains; gbam positive diplacocci and largo gram potitive rods. There are de generated pus eells and a few epithelial cells, Acid-fast stain on the elastic tissue revealed ca acid-fast bacilli although gome of the material was lost In transfer, 7- 2-57 - Sputum specimen 3 cc, mucoid material (Clinical Laboratory ' of C. Richard Smith, M. D.): Supplementary rapott ea studies for asbesto- sis bodies. The remaining sodium hydroxide sediment was treated with eMeroe arid ooa.trUugcd at high speed. The resultant sediment and wettr.ount revealed three completely characteristic asbestosls bodies. These bodies give the Prussian blue stain reaction. 7-2-57 - 3 day sputum and gastric contents 40 cc. cloudy fluid eostaialrj approximately 20 ec. mucopurulent (Clinical Laboratory of C. \Richard Smith, M.O.): Culture for M. tuberculosis - several hundred VJhctoehromojaaie eelnriat cl aeis Mot httiUU (*./- Uu not believe these are M. tuberculosis, They are similar to a myce-bactcilum. capable of causing himsan disease. The guinea pig results will hslo to elarif1/ tbs identification. Meanwhile other tests wiil be carried cut. Guinea Mr inoculation in: M, tub ergulosia: Negative, (See attached latter! 7-2-57 - Culture from gastric-sputum jpauttr.es: *er ocr.ing Sensitivity teit: Straptsmycin - 77 H/10, cf thj ur;ani5ni3 ire (7/10" .-.re resittsr.e) ;o 10 meg, ol sc. ep'o.nyein net* m'.. b'ara-arr.ir.esalicyllc aoidi 103 per cent Of the organisms are rcsistco: ta 13 tr.cj. c: para-em.ir.osiUeyiie acid per ml. Iro/v.oairi: "i pz: cant ot the organisms ire sensitive (} per cent are resistant] te .1 r.'..;j. cf isar.:isiti pur mi. -s- hlr. William T, Kays P.at James Whitcomb Riley September 19, 1957 7-10-57 - (Clinical Laboratory of C. Rickard Smith, W, D,) 1Z hr. sputum specimen Zt cc. aero-mucopurulent: f lotarion-coccentration for icld-izst bacilli: 2 plus positive (20 to slide),. Culture (or M. Mbe retilosisi Several hundred eolonies of photaehromogeaie icid-faat br.ci.Ui. These are not M, tuberculosis but they are characteristic of a myeo-baeterium capable of causing human disease, Piaeaosisi 1) Pulmonary fibrosis exhibiting %b<s principal features of ssbestasis although contributing effect] from the'inhalation of silica, mjr.eslum, fiberglass, foamglass, rockwool, and possibly diatomaeeous -irtb must be considered. 2) Pulmonary emphysema of mild to moderate severity and secondary to pulmonary ttbrejU, J) Pulmonary intlajiimatoey disease involving the apex and aubapex of the right lung, Preliminary studies indicate that this proeess is due to a non-tuberculous phatochroinojeiic acid-fast bacillus which may produce a disease quite similar to tuber culosis in Its clinical manifestations and chroniclty. Decree rf disability; Mr, Riley is permanently and totally disabled for the type of work which he hi] done sine* 1919. Ac pteaent bo is totally disabled for any type of physical activity feeding control of the pulmonary Inflammatory disease. Prognosis: Pulmonary fibrosis ol tht] type tends tu be progressive while dust exposure continues, is the serial cheat x-rays htvo demons tested in this ease. Progression is also apt to occur in the presence of super imposed chronic pulmonary inflammatory dfsea.ee. Adequate treatment of the infectious process with modern drugs may modify the fibrqtic reidtjon, cut the nature and degree of this influence is not.predictable owing to the relatively short period that this form of treatment baa been used in the presence of combined pulmonary diae.i.i,-. Recommendations for trcatr.-.er.t; .Sir, Riley rciuircs sahatoriunt care with bedrest anti appropriate ciicrr.utherapy. Preliminary studies by Er, C. Richard Smith's laboratory ladle.ice thM Streptomycin J = i isonistid are the most effective of che drugs tested fer tha treamer.: of ilic In flammatory disease. Rh'/alcal excmir.alioa aid x-r.iy study of the chest It periodic interval] will be necessary to evaluate the resper.as af the i;iftarn,;t,atery diseas: and to detect any progression of fibrosis. Complete P iltttanary itir-ction SRidic: sh.nitri be rej.-arr- m. apprasuRtttely one year. Jr. !* over.t prujrcjliSR Of fibrar.lt Is denser n-.it.vl. <v.,)jiecratior. c: more 1= - 1 2 V ) / Mr, V/Llllam T, Xays Ai J3.tr.vj Whitcomb Biley September i9, 195" ;rcS5lvt theraoy sues as inter milter: positive pressure breaths.::; ar.d 4:esroLet midieatisa may be accessary provided the Lsflammatory dicease Is under sufficient control la permit such therapy, Aelationshio of patient's condition to employment: Mr, Riley's occupation lor to: las; 35 yean has beco cooiiaed to (he application of beat insulation materials. There has bees oo othar source of industrial dust exposure. The x-ny films show pulmonary fibrosis of a pattern which Is more suggestive f asbestosia than any other single entity, Asbestos bodies have been recovered from the sputum. There La do clinical evider.es of bronchiectasis nor of chronic passive congestion of the lungs due to lsit ' ve.-.triCUUr failure. JLc my opinlso, Mr, Alley had pulmonary fibrosis of ereupational origin. The pveser.se of pulmonary fibrosis may have been a slgnnfie&at factor in the development at pulmonary inflammatory disease and its subsee.uc.-,t course, If I may amplify or clarify any of the preceding statements, it will be my privilege to do so. Yours very truly. JKjtarlt . Hlue i, M, C1, ,_