Document KRkd1gn5eKjOeV361MaLYqZMo

FILE NAME Insurance Industry INS DATE 1964 DOC INS083 DOCUMENT DESCRIPTION Medical Journal Article - Asbestos Exposure and Neoplasia JAMA April 6 1964 Asbestos Exposure and Neoplasia Irving J. Selikoff MD Jacob Churg MD and E. Cuyler Hammond DSc New York Building trades insulation workers have relatively light intermittent exposure to asbestos Of 632 insulation workers who exposure smoking habits and personal history on the size of series and on inadequate histological verification in some cases entered the trade before 1943 and were Within the last few years a number of additional traced through 1962 forty died of problems connected with asbestos exposure have cancer of the lung or pleura whereas only appeared making clarification and resolution of the 6.6 such deaths were expected Three of the pleural tumors were mesotheliomas there was also one peritoneal mesothelio- foregoing siderable increased statistical uncertainty a matter of con- concern First there has been greatly use of the various types of asbestos a ma Four niesotheliomas in a total of 255 fold increase in world utilization of this group deaths is an exceedingly high incidence for such a rare tumor In addition an unex- pectedly large number of men died of cancer of the stomach colon or rectum 29 compared with 9.4 expected Other cancers were not increased 20.5 were expected 21 occurred Twelve men died of asbestosis of minerals from 500,000 tons to 2,500,000 tons per year in the last 30 years as well as a greatly increased number and variety of industrial applications of asbestos over 3,000 such uses now recorded Second suspicion has been growing that malignancy associated with asbestos exposure may include neoplasms other than carcinoma of the LTHOUGH PULMONARY CARCINOMA had been observed in the earliest studies of asbes- lung Thus a significant relationship has been claimed between diffuse mesothelioma of the pleura and peritoneum and asbestos exposure tosis association between the two conditions was This communication is concerned with investi- first suggested by Lynch and Smith in 1935. Ad- ditional reports of such association followed Per- haps the most striking data was presented in the annual report of the Chief Inspector of Factories gations undertaken to study the following factors 1 the incidence of deaths due to pulmonary carcinoma among a group of workers exposed to as- bestos under United States industrial conditions of Great Britain for 1955. Every death with asbestosis in the files of the Factory Department in the past several decades 2 whether or not such individuals would also be found to have an from the first recognition of asbestosis as a disease increased risk of other neoplasms and 3 whether entity was studied Altogether 365 such deaths were recorded 1924-1955 Sixty or 17.8 were found to be accompanied by cancer of the lung or such risks would be present in an industry other than the producing or products industries with which most reports in the past pleura Doll after reviewing the problem and add- have been concerned but which would not nec- ing data of his own concluded that lung cancer was a specific industrial hazard of heavily exposed asbestos workers Nevertheless some investigators have held that while these observations might be suggestive they did not establish an increased incidence of carci- essarily represent the most important areas of asbestos exposure at this time Further it was hoped that study of an industry with asbestos exposure of limited extent and intensity would throw some light on the potential problems associated with minimal exposure to asbestos noma of the lung in pulmonary asbestosis and Paner further that the association The factor of selection was tial weakness in evaluating was unproved considered a potenreports of autopsy Materials and Methods Our investigations have been concerned with 1,522 members of the Asbestos Workers Union in series It was noted that complicated and unusual cases would be more likely to come to autopsy thus raising the apparent frequency of associated the New York metropolitan area members of New York Local 12 and Newark NJ Local 32 of the International Association of Heat and Frost Insu- lung neoplasms Further it was argued that au- lators and Asbestos Workers As the full title im- topsy statistics which dealt with particular groups of those who died do not reflect total populations of asbestos workers Additional reservations were plies these men are insulation workers Although the union is considered one of the building unions its members do insulation work in a va- based on the frequent absence of data regarding riety of industries including shipbuilding Called From the Division of Thoracic Ducase Department of Medicine and the Department of Pathology Mount Sinai Hospital Read before a joint meeting of the sections on radiology and diseases laggers in Great Britain they are often designated pipe coverers insulators or asbestos of the chest and the American College of Chest Physicians at the 112th Annual Meeting of the American Medical Association Atlantic City NJ June 17 1963 workers in this country The union is one of the oldest in the country NOTICE Thik metarial may be protected by copyright ket TKR 17 U.B Code AAA COURT REPORTING 142 per DEPOSITION -, EXHIBIT SS #5! Vol 189 No 1 ASBESTOS EXPOSURE ET AL 23 ** The New York local as the Salamander Associa- tion of Boiler and Pipe Felters was the first union of insulation workers in the United States It amal- gamated with other locals as the current Asbestos Workers Union in 1912. The stability of this union has been reflected in the stability of its membership rolls Once a pipecoverer always a pipecoverer has been of epidemiological importance to us and has made this group of men particularly suitable for the study of term effects of asbestos inhalation Unlike unskilled workers exposed to asbestos inhalation in poorly paid industries there is little labor turnover among insulation workers Accurate employment records are main- tained by the union which has also been concerned with health problems in the industry The trade was badly hit during the depression some men had to drop out and very few were added during the 1930's By the end of 1942 the union rolls consisted mainly of men with considerable experience plus a few who joined in 1940 1941 and 1942. Between 1946 and 1962 union membership increased substantially Source of From union records a list was prepared of every individual who was a member of either of the metropolitan locals on Dec 31 1942 or who joined between that date and Dec 31 1962. No one was omitted whatever his subse- quent work history The 1942 list included 632 men 890 men joined after 1942 Personal data were obtained from union records and the work history of each man was detailed including withdrawal from employment war_ser- war_service other employment retirement illness These data gave the baseline for calculation of the onset and duration of exposure For members who had died records of the Health and Welfare Fund pro- vided date and place of death Copies of death certificates were obtained on all but one of them Autopsy protocols histological specimens and hos- pital records were obtained and reviewed in those deaths approximately one half in which the terminal illness had occurred in a hospital Statistical Previous studies have suggested that neoplasia associated with asbestosis sel- dom occurs until 20 years after first exposure to as- bestos dust Therefore we decided to limit the present analysis to men with such an exposure history Our complete records cover all members of the union including active and retired mem- bers both dead and alive during the year period from Jan 1 1943 through Dec 31 1962 However with few exceptions the only men with a history of 20 years or longer since first exposure to asbestos were the 632 men on the union rolls as of Jan 1 1943. The exceptions were a few men who joined the union after Jan 1 1943 but who had been employed previously as asbestos workers elsewhere , 1963 Of these 632 men 255 died before Jan Table Years of Experience of 632 Asbestos Workers Exposed to Asbestos Dust 20 Years or Longer - Age 35-39 40-44 2 oe. 45-445-499 ne 50-54 =... 55-59 we 60-64 65-69 70.74 ss . i ae 75-79 84 Lo. 85- sae 19431947 85.0 | 230 339 391.5 382.0 221.0 1390 830 315 5 35 Years 1948- 1952 ~ ~ 1953 1957 185.0 70 486.5 2915 324.0 530 364.0 390.0 308.C 316 341.5 344 181.0 2860 115.5 1370 70 705 185 38 2.0 ---- sy 19581962 11.0 700 314.5 502 5 268.5 255.0 280.0 1975 75.0 23.5 135 Totals 16 |. 1,912.0 2,478.0 2,336.5 2,011.0 Of these 632 men 339 had been exposed to asbestos dust prior to 1924. In other words as of Jan 1 1943 20 years or longer had elapsed since these 339 men were first exposed The remaining 293 men reached the exposure point at some time after Jan 1 1943 and before the end of 1962. The 339 men who were first exposed prior to 1924 were counted in each of the 20 years or up to the time of death of those who died The 293 who were first exposed in 1924 or later were counted only after they reached the sinceexposure point those who died being dropped at the time of death When the statistics were completed we found that we had records covering a total of 8,737.5 years of experience of men with a history of 20 years or longer since first exposure to asbestos dust Of the 8,737.5 years 1912.0 were in the five- year period 1943-1947 2,478.0 were in the period 1948-1952 2,336.5 were in the period 1953-1957 and 2,011.0 were in the period 1958-1962 Table 1 shows the age distribution of the years in each of these year periods Table 2 shows 1 the average specific death rates of all US white males during each of these periods and 2 the average specific death rates from cancer of the lung pleura mediastinum and trachea among US white males during each period as reported by the US National Office of Vital Statistics The years were then multiplied by the corresponding reported US death rates to ascertain the expected number of deaths under the null hypothesis that the death rates of asbestos workers do not differ from death rates of all US white males both age and date being taken into consid- eration The results are summarized in Table 3 Results Total During the first five years 19431947 only 28 deaths occurred among the asbestos workers whereas 39.7 deaths would have occurred had their specific death rates been the same as for all US white males during those years Ta- ble 3 In other words at the start of the study the asbestos workers had below average death rates This is by no means surprising Indeed such 143 24 ASBESTOS EXPOSURE ET AL JAMA April 6 1964 Table Total Deaths and Deaths From Cancer of the Lung Bronchus Pleura Mediastinum and Trachea per.10,000 White Males per Year 1943-1947 Total Lung Cancert 36 oe 55 1 1948-1952 Total 30 Lung Cancert 48 1 1953-1957 1958-1962 Total 26 Lung Cancert *~~ Total 25 Lung Cancert 1 43 I 42 } 133 196 295 435 634 977 1,453 2,422 4 124 5 189 7 281 7 417 166 605 166 915 166 1,353 3 2.162 5 115 6 116 7 8 178 10 178 1 10 276 272 11 416 17 418 21 11 586 16 607 21 878 ne B 1,346 12 7 2,017 9 866 ce 1.363 2.148 Ca 35 11 Death rates as reported annually by the US National Office of Vital Statistics A year average is given here for each period Average for 1958-1962 is a projection of 1958-1960 since 1961-1962 rates are not yet available Death rates include cancer of the fung bronchus pleura mediastinum and trachea assigned to international list code No. 47b prior to 1949 and to No. 160-164 thereafter &. rides r Peed . SS ena) en SNe . is almost always found in the first few years of a prospective epidemiological study of this type The explanation is almost certainly as follows The 632 men in this analysis were actively employed as asbestos workers in 1942. Since disability from illness or other causes precludes employment in a trade of this type these men were presumably well or at least not disabled at the start of the study pe- riod Almost any group so selected as to exclude the ill and disabled has a lower death rate during the ensuing few years than does the general population since ill and disabled persons have extremely high death rates A selective effect of this type gradually wears off with time and largely disap pears within five to ten years from the time of in- itial selection During the second year period 1948-1952 the death rate of the asbestos workers was slightly higher than the death rate of all US white males ie 54 observed deaths compared with 50.8 expected deaths In later periods the death rate of the asbestos workers was proportionately higher For the period 1953-1957 there were 85 observed deaths compared with 56.6 expected deaths and for the period 1958-1962 there were 88 observed deaths compared with only 54.4 expected deaths Table Observed and Expected Number of Deaths Among 632 Asbestos Workers Exposed to Asbestos Dust 20 Years or Longer Cause of Death 1943 1943 1947 Total all causes . asbestos Observed asbestos workers Expected US white males 28 39.7 Total cancer all sites 2... Observed asbestos workers Expected US white males 13 5.7 Cancer of lung and pleura . Observed asbestos workers Expected US white males 568 0.8 Cancer of stomach rectum colon workers and ) Observed asbestos workers Expected US white males . 2.0 Cancer of all other sites com- bined : workers Observed asbestos workers Expected US white males AsbestosIS ' ie crane Observed asbestos workers 3 2.9 Years 1948- 1948- 1953 1952 1957 54 85 50 17 56 26 8.1 8 14 13.0 13 2.0 4 2.5 7 26 5 4.28.45.0 4.28.45.0 6 4.28.45.0 4.28.45.0 1958 Total 1958 19431962 1962 88 255 54 39 203.5 95 9.7 18 36.5 45 24 66 14 2.3 29 94 7 4.28.45.0 4.28.45.0 21 20.5 12 Cancer of the Lung Pleura and Trachea each of the four year periods far more deaths from cancer of the lung and pleura occurred among the asbestos workers than would have oc- curred had their death rates from these diseases been the same as for all US white males Table 3 Altogether 45 of the 632 asbestos workers died of cancer of these sites whereas only 6.6 such deaths would be expected from general US experience Of these 45 deaths 42 were recorded as due to bronchogenic carcinoma and 3 to neoplasms of the pleura The pleural neoplasms were all recorded as mesotheliomas Thus it was found that the death rate from can- cer of the bronchus and pleura was 6.8 times as high among these asbestos workers as in the general US white male population both age and date being taken into consideration It may be asked whether the high rate of lung cancer among these asbestos workers could pos- sibly be attributed to an unusually large proportion of cigarette smokers among them We cannot answer this question directly since we have not yet been able to ascertain the smoking habits of the men who died However the following pieces of evidence indicate that unusual smoking habits cannot account for the high death rate from lung can- cer among these workers We have interviewed 320 of the 377 surviving members of the 1942 group Table 4 gives a summary of the smoking habits in this group compared with a sample of men drawn from the general population of 1,121 counties in 25 states The un- ion sample is somewhat inadequate since it does not include the men who died and does not in- clude all of the present living members of the union Nevertheless it shows that a substantial proportion of asbestos workers never smoked ciga- rettes regularly Certainly the 632 men in our analysis of death rates were not all heavy cigarette smokers In the general male population cancer death rates are about ten times as high among cigarette smokers as among nonsmokers and the ead Nene 144 thes ". Vol188No I ASBESTOS EXPOSURE ET AL 25 FE -| Table Smoking Habits of 320 Abestos Workers Exposed to Asbestos Dust 20 Years or Longer Compared With Sample of Men From the General Population ee Smoked . Never Smoked Pipe Cigar Regularly Asbestos Regularly Never Cigarettes ee ee ne a History of Cigarette Smoking oars Asbestos Workers General Population Asbestos Workers ce ce Bc Age 9.3 Ro 1049 50-59 % 4.6 6.1 General Population Population 7.5 __ 9.9 : Asbestos Workers 85.1 79.6 General Population 737 - 70.2 ____ 60-69 70+ __ 20.3 25.5 23.6 37.1 30.1 11.8 16.2 23.9 69.7 62.7 60.2 390 Sample of men from general population as reported by Hammond and Garfinkel death rate from lung cancer increases greatly with posure to asbestos by insulation workers as stud- the amount of cigarette smoking However a large ied here results in a marked increase in the inci- proportion of all men in the United States have a history of regular cigarette smoking From data in dence of cancer of the lung approximately six to seven times the expected incidence Altogether a prospective study on smoking it may be esti- 45 17.6 of 255 men with more than 20 years mated that if all men smoked a pack or more of elapsed since the onset of exposure died of cancer cigarettes a day ie if all the nonsmokers cigar of the lung or pleura smokers pipe smokers and light cigarette smokers had instead been heavy cigarette smokers the cancer death rate would be approximately These data do not give the incidence of cancer of the lung in asbestosis They relate to the specific conditions of our investigation to a group of 3.4 times as high as it is at this time men with only intermittent exposure to materials From this we may conclude that even if all our containing limited amounts often % to 20 of e asbestos workers had smoked a pack or more of asbestos under working conditions varying from cigarettes a day and indeed from our sample we very dusty as in extracting old insulation in closed ww know they did not and if exposure to asbestos quarters to those with little dust exposure as in were of no significance then their lung cancer building construction in open air Moreover they death rate would have been about 3.4 times as relate to the relatively recent past in a trade with high as the rate in the general US male popula- the shorter work week of the strong building trades tion Clearly the smoking habits of the asbestos unions in an era when industry has been aware workers cannot account for the fact that their lung- of potential asbestos hazard and the working popu- cancer death rate was 6.8 times as high as that of lation has had some consciousness of potential white males in the general population risk associated with dust exposure These data Gastrointestinal Cancer to our surprise would not necessarily apply to asbestos exposure the death rate from cancer of the stomach and the in other industries such as the factory production death rate from cancer of the colon and rectum of asbestos products the asbestos textile industry were higher among the asbestos workers than etc where conditions of employment might be would be expected from the rates reported for the quite different Our results do not contradict the US white male population calculated in the same even higher incidence of lung cancer suggested in way as for lung cancer Twelve deaths from gastric other studies ; they are merely a shade less strik- cancer occurred among the asbestos workers as compared with only 4.3 expected Seventeen deaths from cancer of the colon and rectum occurred among the asbestos workers as compared with 5.2 expected Cancer of All Other Sites combined death rate from cancer of all sites other than lung and pleura and stomach colon and rectum was not increased Twenty such deaths occurred among asbestos workers as compared with 20.5 expected AsbestosOifs the 255 deaths 12 were due to asbestosis pulmonary insufficiency cor pulmonale The lapsed time from first asbestos exposure to death from asbestosis averaged 45.8 years with ing Diffuse Pleural and Peritoneal Malignancy Mesothelioma the incidence of diffuse pleural mesothelioma is complicated by the insecurity of its histological verification While some pathologists will so categorize a high proportion of diffuse pleural tumors in the experience of others it is a very rare tumor and may be mimicked by anaplastic peripheral carcinoma of the lung and diffuse fibrosarcoma of the pleura It is difficult to evaluate completely the published reports of diffuse pleural mesothelioma in asbestosis in the absence of complete details of each case a range of 32 to 59 years To the present time there has been no informa- Comment tion concerning the incidence of diffuse pleural mesothelioma in asbestosis since the published Carcinoma of the Lung results with regard cases are reported without reference to a total pop- to carcinoma of the lung are clear Industrial ex- ulation in which they occur Nevertheless the 145 " 26 ASBESTOS EXPOSURE ET AL JAMA April 6 1964 growing number of reports of individual cases suggests that these tumors are perhaps becoming relatively frequent complications of asbestos ex- posure Our observations in this series are similarly suggestive In three of the 255 deaths among the men who had worked for 20 years or more the exam- ining pathologist considered the death due to diffuse pleural mesothelioma and in the two cases in which we have been able to review the histological material the histological appearance was that often so categorized and asbestos bodies were pres- ent This incidence of more than % of deaths from pleural mesothelioma is strikingly high for a tumor which is generally considered to be extremely rare In one case in our series pathological examination suggested diffuse peritoneal mesothelioma This single experience is too fragmentary for evaluation Gastrointestinal Carcinoma instances of gastrointestinal carcinoma in the presence of asbestosis have been known but there have been no data to indicate that these were more than coincidental findings Among the asbestos workers studied here cancer of the stomach colon and rectum was three times as frequent as expected These data suggest that there may perhaps be an etiological relationship between industrial asbestos exposure and carcinoma of the gastrointestinal tract Environmental Asbestos Exposure recent demonstration by South African * and British British in- vestigators of pleural and peritoneal neoplasms among individuals who had chance environmental exposure to asbestos many years before raises the very important question of possible widespread carcinogenic air pollution The possibility of environmental exposure has long been known Soon after the initial clarification of asbestosis as a clinic " entity Haddow demonstrated asbestos bodies in a man not employed in the industry but living next door to an asbestos factory This finding was later mirrored in the finding of chronic beryllium dis- ease among residents of a community near a beryllium factory What is new however is an appre- ciation of the potential Thomson and associates extent of the problem * have reported the fre- quent findings of asbestos bodies in the lungs of urban dwellers Among 6,312 individuals rayed in an area about an asbestos mine in Finland 13 Kiviluoto found 499 cases of pleural calcification of the type characteristically seen among asbestos workers without obvious cause In a comparable area without any asbestos mine no cases were found among 7,101 persons rayed It should be noted that these were not people who worked in the none but rather were farmers housewives and others who lived in the general location In one subject who came to autopsy polarized microscopy demonstrated asbestos fibers in the lung Similarly the lung of a cow graz- ing near the mine also showed the presence of asbestos A particular variety of environmental exposure may be of even greater concern Asbestos exposure in industry will not be limited to the particular craft that utilizes the material The floating fibers do not respect job classifications Thus for example insulation workers undoubtedly share their exposure with their workmates in other trades intimate contact with asbestos is possible for electricians plumbers metal workers steamfit- ters laborers carpenters boiler makers and foremen perhaps even the supervising architect should be included 1E 100th St New York 10029 Dr. Selikoff This study was supported by the Health Research Councal of the City of New York Cooperating in this investigation were the executive officers of the International Association of Heat and Frost Insulators and Asbestos Workers Washington DC and the officers and membership of the New York and Newark NJ locals of this Union References 1. Lynch K.M. and Smith W Pulmonary Asbestosis Carcinoma of Lung in Silicosis Amer J Cancer 56-64 May 1935 2. Annual Report of Chief Inspector of Factories for Year 1955 London Her Majesty's Stationery Office 1956 cmnd 8 P 206 3. Doll R Mortality From Lung Cancer in Asbestos Workers Brit J Industr Med 81-86 1955 4. Bohlig H. and Jacob C Neue Gesichtspunkte ^...ber den Lungenkrebs der Asbestarbeiter Deutsch Med Wschr 231-233 Feb 17 1956 5. Braun D.C. and Truan T.D Epidemiological Study of Lung Cancer in Asbestos Miners AMA Arch Industr Health 634-653 June 1958 6. Wagner J.C Sleggs C.A. and Marchand P Diffuse Pleural Mesothelioma and Asbestos Exposure in North Western Cape Province Brit J Industr Med 260-271 1960 7. Hammond E C. and Garfinkel .: Smoking Habits of Men and Women J Nat Cancer Inst 419 44A2ug 1961 8. Hammond E.C. and Horn D Smoking and Death Rates Report on Forty Months of Follow of 187 783 Men I. Total Mortality II Death Rates by Cause JAMA 1159-1172 March 8 1294-1308 March 15 1958 9. McCaughey WT.E. Wade O.L and Elmes P.C Exposure to Asbestos Dust and Diffuse Pleural Mesothelio mas Brit Med J 1397 Nov 24 1962 10. Haddow A.C. in Report of Annual Meeting of British Medical Association Manchester 1929 Lancet 230-231 Aug 3 1929 11. Chesner C Chronic Pulmonary Granulomatosis in Residents of Community Near Berylium Plant Threc Autopsied Cases Ann Intern Med 1028-1048 June 1950 12. Thomson J.G. Kaschula R.O.C and MacDonald R.R Asbestos as Modern Urban Hazard S Afr Med J 77-81 Jan 19 1963 13. Kiviluoto R Pleural Calcification as Roentgenologic Sign of Occupational Endemic Anthophyllite tosis Acta Radiol Suppl 194 pp 1-67 1960 146 VOL 188 NO 1 Annual Convention WEDK BRARY San Francisco Calif # WEDK APR APR BRARY BRARY June 21-25 1964 | Advance Registrations and Housing Form p 283 ORIGINAL CONTRIBUTIONS DIAGNOSIS OF BONE METASTASIS BY PHOTOSCANNING M. Sklarua MD and D. Charkes MD Plutadelphia RETURN OF RENAL FUNCTION AFTER URETERAL Alexander Brunschwig MD H. R. K. Barber MD and Steart Roberts MD New York OCCLUSION EVALUATION OF PATIENTS WITH BASE J 5. McDonal~-kD. Laughin 45 and G. Bedell MD Jowa City luma IMBALANCE CIGARETTE SMOKING CHRONIC BRONCHITIS IS Mirebell MD T. Vincem MD F. MD an Gd . F. FilFlilleey y MD DenDevnveerr VEIN SURGERY K. Lofgren MD Rochester Mian AND EMPHYSEMA ASBESTOS EXPOSURE AND NEOPLASIA 1. J. Solikoff MD Jacufa i burg MD and 2. Hammond Ps New York , WORK PHYSIOLOGY IN HEALTH E. aongaoanga UD , Los AngAngelees les AND DISEASE NORTH AMERICAN LOXOSCELISM C. J. Dillaka MD G. 3. Jansen 3D M and C. R. Hayden MD L^/rdeRock Ark Honeycu11 MD . SYMPOSIUM ON STEATORRHEA LABORATORY AIDS IN DIAGNOSIS OF STEATORRHEA M. Et Kalser MD PhD Coral Cablen Fla METHODS OF SMALL BOWEL H. J. Balt MD Ann Arbor Mich BIOPSY GLUTEN DIET FOR NONTROPICAL SPRUE Kurtz J. MD 1. M. Ruffin MD 5. M. { W Bath MD and W. M. MD L. Borland Jr. Roofsil MD Durham NC INTERPRETATION OF INTESTINAL MUCOSAL BIOPSIES Margot Shiner MRCS LRCP DCH London SPECIAL COMMUNICATION THE ANESTHETIST AS A PHYSICIAN K. Brecher MD H. H. Bendizen MD Phillips Hallowell MD Henning Pontoppidan MD and D. P. Todd MD Boston CLINICAL SCIENCE EPSILON AMINOCAPROIC COAGULATION AND FIBRINOLYSIS 3. H. Lewis MD and A. Dovle MD Pitisburgh SPECIAL CONTRIBUTION A TALE OF TWO LANTERNS F Ebaugh MD Denver NEGATIVE RESULTS 1 INTRAVENOUS METHO^ ARBAMOL 69 W. Shaftan MD and 5 Horace Herbsman MD Brooklyn NY EDITORIALS 9 APRIL 4 IS MISSING 2 THE MOST POTENT DIURETIC R 12 pH and CO2 IN RESPIRATORY FAILURE 70 LORD LISTER 1827-1912 72 17 CLINICAL NOTES 22 PHEOCHROMOCYTOMA WITHOUT HYPERTENSION 74 27 M. Kahn MD and D. ^ Mullon MD Tucson Ariz 33 SERUM POTASSIUM AND ' URETERAL PERISTALSIS 76 William Samuellas MD and H. H. LeVeen MD Brooklyn NY CONGENITAL PERICARDIAL DEFECT 78 37 F. D. Fisher MD and J. .. Ehrenhaft MD Towa City Iowa 40 FLUORESCEIN STAINING OF THE CORNEA 81 \ C. Holland MD Greenville SC 42 LABIAL MUCOUS SALIVARY GLANDS IN CYSTIC FIBROSIS 83 L. H. Meskin DDS Belly Bernard MD 45 and W. J. Warwick MD Miancapolis CONTENTS CONTINUED Adv Page 5 49 56 Sg. Als 64 Als ABV3317 Als Poth iss. ABV3317 ABV3317 as jaar