Document KRwkdrnwwqpBDgdXG8wd54nDr

-- 1936 -- Cfjc Saranac Laboratory for ttjE fetubp of Cubtrculosis OF THE EDWARD L. TRUDEAU FOUNDATION REPORT OF THE DIRECTOR u AND FINANCIAL REPORT ,For the year zsdisc September 30 1936 ft REPRINTS OF SCIENTIFIC PAPERS c ^aranacllafec Scabcmp of jfEkbtriru Ito KirfKfiLrWr* TA^rA^ \ :> > r. 'p ^ A r>r.: \ THE SARANAC LABORATORY THE fact that the Saranac Laboratory has always been a separate insti tution from the Research and Clinical Laboratory of the Trudeau Sana torium is not generally understood. Both laboratories are sponsored and controlled by the Trudeau Foundation, but the Saranac Laboratory is located at 7 Church Street in the village of Saranac Lake and not at the Sanatorium. Thi properties of the Saranac Laboratory consist of the original budding, given to Dr. E L. Trudeau by Mr. George C. Cooper in 189-* as a private research laboratory, together with the John Black Wing, donated by Mr. and Mrs. Frank B. Black m memory of their son. The addition contains the library and lecture room, erected in 1927 and 1925, and private research rooms constructed in 1935. There are also two animat houses. While the Saranac Laboratory co-operates with the Sanatorium in every possible way, and serves as the headquarters of the Trudeau School of Tuber culosis, it provides diagnostic facilities to the physetans practicing m the village and carries on independent researches in the field of tuberculosis and assocated conditions. To avoid confusion, the Trudeau Foundation publishes separate reports of the Trudeau Sanatorium and the Saranac Laboratory. THE SARANAC LAKE ACADEMY OF MEDICINE IN the early pan of July. 1931, a group of physicians in Saranac Lake met m the John Black Room to discuss ways and means for supporting the diagnostic and research activities of the Saranac Laboratory during a period of diminishing income. They were of the unanimous opinion that this insurution is essential to the continued existence of the village as a center for the scientific treatment and srudy of tuberculosis. As a concrete expression of this feeling, they commuted themselves the nucleus of a body to be known as the Saranac Lake Academy of Medicine. Its object is "to foster interest m the pursuit of scientific mediane m Saranac Lake" through the agency of the Saranac Laboratory. Its members pledge themselves to support the aenvioes of this institution m every passible way and to seek assistance from others for us operation. Tne active members are physiaans practicing in Saranac Lake, but associate, sustaining, and life memberships are also open to interested laymen. In the financial report for the current year will be found a list of contributors The formation of the Academy created nothing new. Tne Laboratory, the Library*, the diagnostic service, the scientific lectures and research have always been an integral pan of the medical life of the village, but by many they have been freely accepted as a natural heritage from the great founder of this health community. By membership m the Academy of Mediane. or by con tributions throuc'n it, anyone can feel that he has a par. m keeping alive the Trudeau ideals for the furtherance of medical science. THE SARANAC LABORATORY FOR THE STUDY OF TUBERCULOSIS OF THE EDWARD L. TRUDEAU FOUNDATION LABORATORY STAFF Leroy U. Gardner. M D ------------ ---------------- Director end Pathologist Arthur J. Vorwjld. Ph D., M.D. -----------------------Assistant Pathologist Thomas M Durkan. M E---------- ---------------------------------------- Chemist s ta Richard V. Fletcher. M.D.-------- ------------------------- Clinical Pathologist Winfield O. Kelley, B.A.----------- ---------------------C Clinical Pathologist John R. Murphy. M.D.------------ -------------------------Clinical Pathologist Douglas S. McCrum, B.$.. (E.E.) Photographer and Assistant Chemist Morns Dworsk:. B.5.. C.P.H. -- Assistant m Experimental Pathology Catherine M. Cummings----------- ---------------- Librarian and Secretary Roy Dayton----------------------------- ------------------------- Financial Secretary James V. Luttrell______________ -- Purchasing Agent and Technician George C. Hulpntt------------------. Anthony B Delahant-------------- -------------------------_---... Technician ---------------------- Technician i Fran as T. Creedon------------------- ------------------------------------- Technician Eduard L. Gockeier___________ Andrew J. Redim------ ------------- ------------------------------------- Technician ------- --___ ___ ____ _____ Technician I J Cloyd Downs_______________ ------------------------- Voluntary Assistant John G. Schmid:----------------------- ----------------------------Voluntary Asiistsr.r Leo A Rabidou----------------------- ----------------------------Voluntary Afr.itant Stephen Wonher.-------------------- ------------------------ Voluntary Assistant Roy A Gnnncil--------------------William E. Labounty-------------- ------------------- ... Voluntary Assistant --------------------------------- Assistant Henry C. Stout________________ ----------------------------------------- Assistant FIELD AND CONSULTING STAFF Donald E. Cummtr.gs. B.S ____Assistant Director m Charge of Field Wor^ Homer L Sampson. D.Sc . _____ ._________.... Consulting Roentgenologist John W Karr. M D --. _____________________ Assistant Roentgenologist Darnel M Bmmfiel. M.D. _________ Clinical Consultant Robert N. Downs_______ ____________________ Roentgenological Supervisor Rjchard Libby _________ __________________ Roentgenological Technician Richard Waiters------------ ____________________Roentgenological Technician Melvin Berg____________ __________ Bacteriological Technician arid Cler\ William Ficldm_________ ____________________ Roentgenological Technician Hugo K Loustan_______ ______________________ Bacteriological Technician Hcicn R. Smith_________ _________________________________ Stenographer i 1 5 CONTENTS Report of the Director Financial Statement Reprints of Scientific Papers j '. Leroy U. Gardner The Diagnosis of Silicosis uitn Special Reference to Roentgenological Manifestations Pathology of the Pneumoconioses The Simiianti of the Lesions Produced b\ Silica cr.d by the Tubercle Bacillus Arthcr J. Voriaals Eipenmenta! Tuberculous injection in tr.e Guinea-Pig Foetus Cornpared u-ith that in the Aduh r.M' ; 7-17.0: * \ REPORT OF THE DIRECTOR OF THE SARANAC LABORATORY FOR THE STUDY OF TUBERCULOSIS -- 1936 -- Leroy U. Gardner. M.D., Director THE policy and genera] nature of the wort in progress at the Saranac . Laboratory has remained unchanged during the past year. Problems dis- covered m field investigations of pneumoconiosis and associated tuberculosis are being studied and elucidated in the laboratory. A close co-ordination berueen field units, the roentgenological laboratory at Trudeau and the pathological division has insured a very practical trend to much of the research. But other problems of a more theoretical nature are also being attacked, their solutions may ultimately find application in the field of diag nosis and prevention of disease due to dust. Soil other quesaons have been referred to the laboratory by industrial groups who have doubts as to hacards involved in the manufacture and use of their products. The year has been a very busy one owing to the illness of the field director which has thrown additional responsibilities upon other members of the sun Their willing co-operation has made it possible to fulfill our obligations, carry on an extensive program of investigation and secure the income necessary to maintain the laboratory. LABORATORY RESEARCH Important unsolved problems which are being investigated by experimental methods induce: (1) An attempt to determine whether crysuiiine silica actually dissolves in the body. (2) A comparison of the biological activity of cineren: forms of free silica. (3) A similar comparison of the erects of cineren: forms of combined silica or silicates, `(a) The modifying action of other substances inhaled or injected at the same tint with silica (t) The erect of panicle site on the rate of ossue reaction. (6) A determination of the decree of retention of inhaled shea pamdes less than one micron in diameter m the luncs (") The erects of mouth breathing on the accu mulation of dust in the lungs (S) Assays of the biological aeavuy of various industrial dusts (9) A study of immunity in the silicotic host. These experiments, most of which were mentioned in last year's report, are no: completed but some have progressed suEciently to indicate their trend and probable outcome. The eec: o/ other dui:s inhdrd with r.iicu. Gypsum, iron oxide, calcium fluoride, and perhaps some of the silicates appear to inhibit the action of silica and cause a delayed and oiten typical cellular response. 6 30RAT0RY the Saranac Problem} disi tuberculosis co-ordination leau and the much of the ire also being field of diagons have been as to hazards r field director :s of the stan jr obligation}, income neces- y experimental ystalline silica ogicah activity of the effects xiifying amor. Iica. (5) The determination .n one micron l on the accu ral activity o:' tic host. These eport. are not heir trend and oxide, calcium the action of (1) Gypsum end Siiicc A group of guinea pigs exposed to an atmosphere of nearly 172 million particles of pure caisned gypsum cus: per cubic loot of ai: developed no significant chances in 2 years. At the present tunc. 16 months afier concluding the exposure, the survivors still show no ill effects. So it has been concluded that the inhalation of gypsum cus: m high con centrations is harmless. This conclusion is substantiated by negative results after the injection of an excessive dose into the peritoneal cav-.ry of guinea pigs It is also m accord with clinical observation. Gypsum mixed with equal pans of pure quart; causes a dumping of the dust particles m the atmosphere. Many of the aggregates are too heavy to remain in suspension and too large to be inhaled As a consequence relatively little of the quart; can enter the lungs and the development of fibrosis is very slow. Observations on animals exposed to men a mixture have now been extended over a penod of 2 years and 7 months They show less fibrosis than guinea pigs inhaling pure quart; for 12 to 15 months The lesions that develop are modified in character as well as extent; very- few of them exhibit the hyahmcaoon that typifies mature tiiicouc fibrous That the protective action of gypsum dust Lakes place tn the atmosphere rather than in the body is indicated by another experiment in which animals have been exposed on alternate weeks to atmospheres containing pure quart; and pure gypsum. In these guinea pigs rlicotic fibrosis developed in typical form and at a rate comparable to amount of exposure to quart;. A new- experiment in which animals inhale a mixture of 1 part quart: and 3 parts gypsum-, is now m its 12th month; it is too soon to surmise the result as no specific reaction to silica ha: yet developed. Tuberculous infection in association with inhaled gvpum manifests a temporary tendency to progress but this is followed by healing with forces (2) Jirn end Silica For this study there have been three inhalation ex periments and rwo m which the materials w-ere injected into the veins of rabbits Wc have worked with iron ere (hematitr) containing 6 per cen: tree silica and with ferruginous chert, the rock m which the ore is lour.;, which averages about *5 per cent cf silica. An 6 hour daily inhalation o: approximately 500 million hematite ranicics i per cubic foot of air produced no pulmonary fibrosis in years Injeccon expcr.ments are not ye: complete. Guinea pigs infected w:tn attenuated t tubercle baciili and kept m this atmosphere showed a temporary progression o: the infection followed by healing with considerable fiorcsis a > A similar exposure to inhaled chert with *S per cent siiica caused only $ < slightly mere reaction m 2`/; years than the hematite with 6 per cent silica In animals kept in a normal atmosphere for 13 months aiter stopping the exposure, the reaction already initiated has manifested littie teneency to progress Chemical examination of their lung! revealed that oniv 6 or 7 J'cr cent of the ash was composed of silica The figure is low; m human silicosis i: generally exceeds 16 per cent. A check-up reveaied that while most of the dust panicles used for experiment were of inhalabic dimensions those c: the siiica. component were in the upper sice limits while those m the iron were m the smaller range This caused the siiica particles to settle out of the air more rapidly than the iron Accordingly a new lot of chen. ^ . -..."., i.\f ! I wu secured in which both *he siiica and the iron pamclei had been ground to the desired cce. On suspending this dust m the atmosphere a dust doud was produced that averaged over 600 million particles per cubic foot of air, 95 per cent of which were less than 3 microns in diameter. On analysing the atmospheric dust inside the animal cages only 33 per cent of the material * was found to be silica. In other words, there was still some selective sealing of the quart: parncles in the air before it floated into the cages. But even so. the animals would be subjected to over 360 million pamcies of free silica m every cubic foot of air, which is far m excess of that necessary to produce silicotic reaction in a period of 13 months The new experiment is now m the 15th month but no nodular fibrosis has yet developed One is therefore compelled to seek some other explanation for the failure of the silica to produce us usual ecect. There is a definite tendency for pamcies of iron to adhere to the surface of niica particles suspended in the atmosphere. Theoreocally the protective coating night interfere with the interaction between the silica and ossue: if the coating is applied chemically there is definite experimental proof that it does. If the suspension is made in water instead of air no evidence of protection u detected. The injection of an aqueous suspension of the same chert into the ear veins of rabbits causes silicotic fibrosis within a year: After the two dusts enter the body there is nothing to indicate that the; iron is attracted to the silira and neutralises its action although it does modify the character of the tissue response Guinea pigs exposed on alternate weeks to pure quart: and to hematite dusts develop silicotic fibrosis of the lung; whose seventy is directly proportional to the amount and duration of the silica exposure. The final solution of this problem wail require time and extended observation involving animal experimentation and a study of the physical relationship of air suspensions of silica and non-uitceous panicles Infection of guinea pigs exposed to ferruginous chert -with attenuated tubercle bacilli produced a result like that in the hematite senes but there was a tendency for the spread of the infection to occur more frequently and the scar ossue that followed healing involved larger areas of the lungs. (3) Granite dust is recognized as one of the common causes of silicosis but ns behavior is peculiar. The rock consists of a natural mixture containing about one-third quart: and rwo-thjrds silicates in the form of feldspar and mica. Only the quartz component is thought to be harmful. Early inhalation experiments with granite dust in this laboratory failed to produce silicosis in guinea pigs although the unit material causes numerous cases of the disease in the workmen at Barre. Vermont. At the erne, the failure of the laboratory experiment w-as attributed to insumcie.it exposure. However the lungs of the animals contained quantities of dust which should have initiated at leas: the eariy stages of a clicotic response. Furthermore, guinea pics exposed to granite inhalation and infected with attenuated tubercle bacilli developed a fibrosis which had some of the charactensacs of silicosis although typical nocules did no: form. In the human cases the reaction to granite dust has also beer, unusual. The roentgenograms of many of the Barre cutters show a linear type oi reaction instead o: the usual nodulauon Others have a noduiaaon but it is frequently associ.ted with definite evidence ^JJ T. o-: \n` 7?v*T rr.r-: irry-'r. 7*'Tx-*-.-crn--.tc.... - * t. 5K*.:.yh-f:; .., ...> i b . *v,l ' i"r' - " . * - * . . "bi.r c--- -__ I -icles had been ground nosphere a dun cloud per cubic foot of air, imeier. On analysing :r cent of the material me selective settling of cages But even so, the .cles of free silica m necessary to produce experiment is now in ied. One is therefore jlure of the silica to adhere to the surface eocally the protective ie silica and tissue; if penmemal proof that of air no evidence of uspension of the same brosis within a year. ; to indicate that the 'though it does modify *d on alternate week; : fibrous of the lunc; and duranon of the will require nme and i and a study of the n-siliccous panicles then with attenuated ;atite senes but there ccur more frequently areas of the lungs ion causes of silicosis ral mixture containing form of feldspar and ifuL Early inhalation 1 to produce silicons imerous uses of the ne. the failure of the exposure. However t which should have Furthermore, guinea attenuated tubereic actenscics of silicosis cases the reaction to am of many of the the usual nodulanon. with definite evidence > l : * I ; \ r j ' k - * r r. u r r uf infection A few autopsies on granite cutters with histories of long rxpwurcs have revealed no nodules, the lungs ot other men whose ca ptures were similar but m which there was evidence of tuberculosis showed typical silicotic nodulanon The number of such cases has been too small warrant any conclusions but the findings cannot be disregarced. The various observations have suggested the following hypothesis: The situates in granite dust prevent the free silica component from exerting its usual enect m the normal ossues: in the presence of a complicating tuKrcuious infection the inhibition is released and the silica is free to act. To test this hypothesis a number of experiments have been devised and some of them arc already finished. Firs: it is necessary to be certain that an excessive dose of granite dust will not produce alicosis in the body o: a .normal arunal. Previous experience has adequately demonstrated the reliability of the intravenous method of inaction to produce a characteristic tissue response in the case of pure slica. Such response is elicited within a year after the injection of 1 gram and even 0.1 gram of quart: particles all less than 3 microns m diameter. The results have been verified too many times to question the method. Granite dust was ground to the same degree of fineness and four senes of rabbits were injected with the following dose;: 3.33, 1.67, 1.0 and 0.5 grams. The largest dose contains approxi mately 1 gram of fret silica in the form of quartz which theoretically is ten times the amount necessary, to cause reaction During the 1* months which have elapsed since complenng the injections most of the animals have been killed /it autopsy none has shown even microscopic evidence of a silicotic type of reaction, the response is of the type produced by inactive silicates This result has been encouraging bu: the animals that are r.iii alive might possibly develop chances later so they will be kept as Icr.g as possible. To be absolutely certain that there has been no error the observation is King repeated with a duplicate senes of injections using a dust that has beer, checked Kith chemically and petregraphicaliy before, and after grinding (In the first senes oniy chemical checxs were made on the composition' c: the dust ) To test the action o: the other components o: cramte individually, the same method is being employed. One gram of feldspar particles has caused no significant reaction m one year's cne The micas have no: yet Ken investigated as there nave been technical difitcuities in gnnding them ti the required nee. There still remains the testing of granite and its individual components in tuK-reulous ammais These experiments arc now in progress. Granite is being injected into r a frits with systemic tuberculosis, into others with * localized ir.icction m the liver and into a third group whose livers are sensitized by me lmectioti of heat-killed tubercle bacilli. This should demonstrate whether the tubercle bacillus, its products or their interaction with the tissues will iree the quartz in granite from the inhibitory action of the siiieate; {*) Calcium liuo-lie end rnca. The inhalation of fluorspar dust which contained 1` per cent o: quart: produced oniy a very early siiicotic reaction in the lymph node; but r.o: the lung; of rats exposed for a period of 10 9 rs i ' months. After 15 months there w-as still nothing in the lungs lnjecoon of 1 gTim of this dust, ground so that all particles were less than J nucrons in diameter, caused an early silicotic cirrhosis of the liver alter 15/2 months "although almost no change was seen at 12 months It is probable that ini this instance the spar was merely diluang the siiica as the dose of the litter was relatively small. In the inhalation experiments it averaged only 6S million parades per cubic foot of air and m the injection expenmenis the gram of dust contained only 0.1 gram of silica. As this study was undertaken merely to test the activity of a particular type of rock the possibilities were not so thoroughly explored. The data of this first group of eapenments form the basis for our belief that other types of dust inhaled at the same tune with silica modify its aenon. Thus far only retarding influences have been investigated. There may be substances, possbly the alkalies, which accelerate the action of silica. \XTien opportunity permits they will be investigated although this problem presents many technical difbrulnes. (5) The diferent form of free silica. Free silica exists in crystalline * and amorphous forms. As pointed out a year ago. there is evidence to ' indicate that one of the common types of crystalline silica known as chalce dony may be more arrive than normal quart;. In chalcedony the crystals are exceedingly minute and are cemented together with^amorphous silica whereas normal quart; occurs in the familiar large crystal. The tests on these rwo substances have not progressed suEnently to permit dednite conclusions as to their relasve irritating properties There are also other forms of crystalline silica produced by heating normal quart; to diaerent temperatures These former arc known as chrystobalite. tndymitc and vitreous silica. For some unexplained reason tndymite seems to be more active in the tissues than the others, but all are capable of causing brosis Of the amorphous forms of silica it was Rated last year that opal was aenve and this observation has been vended It has now been demonstrated that another cineralocical form of opal known as diatomite or diatomaceous earth is also capable of producing oncosis in animals (The mineral, diatomite, is composed of masses of microscopic plants known as diatomes which have "skeletons" of silica. It is thus becoming apparent that silica in the free state, whether crystalline or amorphous, is capable of setring up progressive fibrosis m the body. Whether all forms are equally capable of penetrating the lungs from the air remains to be demonstrated. When this phase of the work is com pleted it may become possible to correlate the degree of biological acovity with the physical properties which are somewhat dinerent in the various forms of ciica Trus should be helpful in determining the mode of action of ebea upon the tissues. The niicctei or combmotions of nliea with venous bests Clinically the only nbmte which is generally accepted as a cause of disease in the lungs u isber.os. Technically asbestos is no: a single spenes of mineral, the term includes a variety of more or less complicated hydrated silicates of mag nesium which have the common property of a porous structure. Among 10 ui^s Injecaon than 5 microns ver after 1 V/i It is probable as the dose of nu it averaged ion experiments this study wi x of rock tnc s for our belief Jica modify iu ugated There the action of i although this is in crystalline it evidence to iown as chalcemy the cry!s morphous silica The tens on permit detinue are also other ru to different tndymite and ms to be more using fibrosis. that opal was n demonstrated ar diatomaceous lcral. diatotnite. nes'which have sate, whether : fibrosis m the the lungs from ie work is comological 'activity tn the various mode of acoon Clinically the :se in the lungs ineral. the term ilicates of mac leturc. Among the other sbeates that have been reported to cause nodular fibrosis are talc and slate However, the possible pan played by cc-existunt latent or active inferaon has not yet been given due consideration in these A systematic examination of representative silicates is now m procress, making use of the intravenous and mtrapentoneal mjeccon methods to deter- mine whether excessive dosages are capable of producing reaction in living tis sues iThc behavior of most of them has been followed for at leas: a year and it seems quite obvious that they will prove to be pracacallv men in uninfected animals Tne reaction m all cases is one of phagocytosis at the see where the uncord parades happen to be earned by the blood stream Most of the . phagocytes are immobile and they do not tend to collect into locaiiced , masses as is the case with uncombined obca. It is of course possible that more reacnon will develop later but nnce there has been no change m a i year in the animals injected intravenously it is improbable that any will ; ever occur The following silicates have already been studied senate (from ' mo sources), feldspar, garnet. dlimaniie. talc and ceoiite (both synthetic and natural.) The injection of asbestos minerals has just been tuned, but they present technical difficulties which will have to be overcome before . 5 they can be injected into the blood vessels of animals The final step wiii be the tesur.g of the same substances upon animal* with healed and active tuberculous It is quite conceivable that in such hosts some of the dilates may produce a different response. i Alterations e/ immunity in tie silicotic subject. The eapiananen for the high frequency of infection, and par.icuiarly tuberculous intecson. in the clicouc individual'has not yet been discovered This subject is cull under investigation and is bemg atucked from several aspects. It is known that tubercle bacilli grow very rapidly m a young ciicour focus produced artificially m expenmer.ul amnais. in the old Jesses of human leucosis the organisms are usually very few and hard to find. The question arises as to whether the rubercle bacillus is cumulated by the dies itself or by some of the products forr.icd from the interaction between u and the tissues (1) JEfecti upon baric ns in vitro. Previous experience in the laboratory had shown that the addition of silica particles to artificial culture media accelerated the rate of growth of rubercle baclh but the amount of culture obtained after a given period of erne was no greater than without the dica Recently some exceedingly fine crystalline ciica. was sent to the laboratory' that has had a very marked accelerating influence on cultured basili. The old experiment is being repeated on a quantitative bis* (I) Eftrts upon bsrtrnu m mo. An attempt is being made to deter mine on a quantitative basis the number of tubercle bacilli m dico-rubercuious lesion* of various ages. The erect* of siicosis upon the host are manifested by the development of the obvious fibrous nocuies in the lungs but there may also be more subtle changes in the body fluids that explain the peculiar susceptibility to % tuberculosis Tne immunity mechanisms of the body fluids are now tnc 4 subject of intensive scusy. 11 s i *>> * !, v-V ft.-? Nt Xkm >\ *-> ^ ^%V ^ V ^ ^ --- . v/.'v! *;*. fTz 4 , . J\u *K. Vv . **V. V % Natural immunity. Among certain other species the white rat manifest* a* natural immuniry to infection with the tubercle bacilius. If the organisms arc injected into the animal's veins real tubercles do not develop; the bacteria merely circulate m the blood for an indefinite period of time. It has now been shown that tubercles will form m a silicotic rat. Whether this means an increase or a lowering of resistance in debatable, but at least it has been demonstrated that there is an alteration of natural immunity A similar experience was demonstrated some years ago in rabbits, which are naturally resistant to human type tubercle bacilli. Thus it appears that it is possible to alter natural immunity with shea. Acquired immunity. It is well recogmced that a certain degree of artificial immunity can be induced in animals by vacanattng them with tubercle baalli of low virulence. This procedure is very simple and the effects of the primary infection, which remains locahced. can easily be differentiated from those of the reinfecting test inoculation with virulent tubercle bacilli. In the silicotic host this is not so simple as the silica causes the vaccinating infecaon to spread. It is possible, however, to induce immunity with heatkilled baalli.' This method is under investigation and although the results are not yet complete it teems probable that the usual protective action will not be destroyed. It may prove to be somewhat impaired. The sensitivity to tuberculin of animals m the acute and subacute stages of silico-tuberculosis is comparable to that m animals with simple tuberculosis Unfortunately the extremely chronic forms of siiico-tubcrculosis found in man are not reproduced m animals. As soon as silicosis has developed in a group of rabbits now bemc dusted their immune responses to pneumococcus infection will be tested. This experiment has a practical as w-eil as theoretical bearing for it has never been proven whether the nhcotic individual is actually more susceptible to pneumonia than the normal. There is considerable evidence for believing that he is not. The work on the po&sibie alteration of immunity is not suf ficiently advanced to draw inferences as to its outcome The efert 0/ mouth brecthmg is being investigated by exposing animals whose nasal passages have been more or less completely stenosed with caustics to the inhalation of dusts in the same room with normal controls The weight of inhaled dust will be the criterion of the effect of this procedure. The soiub-.lity of niicc in the body is heme approached from the angle of excretion m the urine as suggestet: by King. The unnary output of silica m groups cf norma!, tuberculous, and silicotic subjects is being followed over a long period of ume Whiie u is not possible to analyse ali of their food for its stiica content, an attempt is in progress to discover how much of the excreted siiica may be cenved from food and how much from in halation. Retention of extremely fine mica in the lungs. A request was received to test the biological acr.vuy of a siiica powcer composed of particles not greater than 20 Angstrom units tn diameter. This material seemsd to oner the opportunity of proving whether, as some observers claim, the lung treats very fine particles bke a gas and eliminates them with the expired air or tc rat manifest* f the organisms a develop; the ad of time. It . Whether this it at least u has inity. A similar :h are naturally -at it it pouible gree of artificial i with tubercle d the eifrets of x differentiated tubercle bacilli the vaccinating mity with heataugh the results enve action will The sensimatv ilico-ruberculoss Unfortunatelv' n man are not ow banc dusted x tested. This for it has never more ruweptiblc .ice for believnc unit)* is not sui tsposing animals >\ ittenased--with normal controls x effect of this ! from the angle inary output of is being followed alyse all of their cover how much much from in- lest was received of particles not .1 seemsd to oner .1. the lung treats it expired air or ) 5 I l i whether they are retained and cause disease. Unfortunately there is no wav to prevent parades of this magnitude from dumping and it is impossible . determine the sice of minute dumps by ordinary methods of measurements Nevertheless an inhalation experiment w-uh an imperceptible auspension tit atmospheric dust is being started to learn whether any reaction wiii occur. Testing oI induitnal dusts suspected of disease-producing capacities. A ssudv has been completed on the action of glass wool and it has been dem onstrated that this substance is incapable of causing fibrosis in the amar.al KjJ\ Injected intravenously it has no more eriec: than the men ciicates Jc.-s.Tfvd above Larce quantities can be ingested either with food or by the laninp stomach without producing demonstrable reacaon in any pan of . the alimentary tract. Tests upon the action of dolomite, silica jell and several other substances have been staned mm studies The third annual survey of the iron ore miners in the Lake Supenor Jistnct has now been completed. The results of examinations mace by the wnouf company physicians and of the roentgenograms of the chest totalling well over SOI-1- have not ye: beer, tabulated but new cases of cdero-oiicoss nr profession to more advanced stages of this cor.diaon have been rare. Likewise the production rate of new- tuberculosis has not been as great as was anticipated Particular interest attaches to the group of cases, rather rare in this industry, which exhibit massive conglomerate shadows in the rocrtcenocrsm A few of them have apparently been observed in the process of evolution Sometimes they develop rapidly in men nail at work who have nr symptom.? of infection Most of these shadows persist but a lew have disappeared as rapidly as they come. Their ultimate outcome is st:i! a matter c: cor.-teture but with the opportunity to follow their .course year after year it .should be pcssiole to establish their clinical significance The Cust concentrations m all the mines have been maintained at levels which can hardly produce new cases of uliccsi:. In ail rock work involving ex|>>suros even to low concentrations of tdica dust the wearing of respirators is enforced Future observations on the men wii] therefore be largely con cerned with the evolution of such disease as may have already r-arted. A medical clinic was established tn a plant of the Inland Steel Company at the hcp.nnmg of the year. Physical examinations are bang made by a phvsician in their employ, stereoscopic films of every chest are taken by a member o: Dr Sampson's technical scan and a complete laboratory ex amination including blood count. Kahn test. unr.e examination and anything civ indicated is made m the clinical laboratory. An engineering survey i Kmc carried on m the plant to discover and correct any nacard that may exist The procram in:iud:s both pre-emr'oynen: and periodic examinations of all crop!"wees Out o: mere than 102 examinations this year only 2 or 3 of tuberculosis have been civovered These men were informed of their conditions and agreements were made i<_-r their treatment. Other cunJnii'Uf were likewise crouch: to tr.c attention oi the men and after a 13 ) i thorough explanation they were referred to their own physicians for treat ment. The plan is working well as the employees base confidence in the -clinic physician and they appremate the company's interest in their hralth. From the scientific standpoint the opportunity to re-examine lrom umc to ume a very large industrial group that is exposed to no particular hazard is unique. The material accumulated will furnish a basis of comparison for mining and other groups constantly exposed to high concentranons of silica. A third study is bang made m the cement industry. Although there is no theoretical hazard from sliza an the manufacture of this product, agood deal of dust is produced In spue of the negauive chest findings in'; the survey made by the United States Public Health Service, the Cement; Association, which has high ideals for the health and safety of men employed by its member companies, asked the Saranac Laboratory to survey more of its* plants. Three of them, located in Pennsylvania. .Alabama and Kansas, have now been studied. The men were examined either by local physicians or by the clinical consultant to the Laboratory. Stereoscopic roentgenograms ^ of the chest were made and interpreted by the department at Trudeau, i Laboratory enguieers made surveys of the concentration and character of , the du in the plants. The data from the las: plant have not yet been * compiled; the positive endings at the others were surprisingly meager. No pulmonary* changes are visible after prolonged inhalation of finished cement dust. A few- of the men show an increase in the linear markings of the lungs but the incidence of this change cannot be correlated with the intensity or duration of the exposure. With one exception, where a man had run a drill in sandstone, the same can be said of the inhalation of the raw materials. limestone and clay, of which cement is. made. Tuber culosis is not ir.tuenced by the inhalation of cement dust; the frequence of healed lesions has been the same as that in the general population. Com plaints referable to infection of the upper respiratory tract have been relatively uncommon in the men thus far examined. Final conclusons as to the influence of cement dust will only be drawn after analysng the findings from widely scattered plants; at the present ome it hardly appears that evidence of serious injury will be discovered. A similar r.udy was made of the men and the possible industrial hazards in another gypsum plant. Tne findings confirmed the conclusions previously reached, that the long-continued inhalation of gypsum dust is no: dangerous. teachinc. addresses, and publications Various members of the run gave their usual courses in the Trudeau School of Tuberculosis. Tne Silicosis Symposun. which had been held during the two preceding years, was emitted because it was felt that not enough new material was available for discussion. Dr. Vorwald, the assistant pathologist, his g:\en a senes of lectures on the anatomy, physiology and pathology of the lungs to the nurses at Trudeau. Clinical-pathological conferences were held frem time to cme as pan of the program of the Saranac Like Medical Society. Pipers were presented by the director, the assistant pathologist, and the chemist, before the American College of Physcians. the Amencan Society of Safety Er.pneers. the New York State Medical Society, the American Association o: Pathologists and Bacten- H ologists. the Komcidc Club. the National Tuberculosis Association. the Fourth District Branch of the New Vo:* State Medical Somcty. and the FrarJdm County Medical Society. Membership on fearra!. state. industrial and insurance corr.mtttecs dealing with silicons has also reouired considerable tine ;and thought. Five papers have beer, either published or are ir. presa. Reprints of three are bound as pan ot this report CLIS'ICM. LSB3R.VTORY WORK The diagnostic service to the clinicians and hospitals of the community has been maintained with a physician and three part-time technicians avaiiaoic to perform any tests that may be required The work is tnanced by fees from patients, contributions to the Saranac Lake Acaoeny of Medione. an appropnation from the Trudeau Foundation and tnc proceeds of contract* with the Genera] Hospita! and N'orthwoods Sanatorium. The maintenance of this department is always dtmcuh because many of the physicans eject to have only the more elaborate tests performed by the laboratory Routine examinations, which constitute the buik of the work and which would bring m more income are done elsewhere Nevertheless it has been felt that the .insntution has an obligation to the community and every eccn is being made to maintain the service The remuneration is no: sumaentiv attractive to hold a qualioed diagnosncian veiy- long and hence tne personnel is constantly changing However it has been possible to bnd competent physicians to pertem this service during the period while thev arr onix-un; their cures Dr. Vorwald. the assistant pathologist, has assumed the respon sibility for this department and ha* not oniv improved the general cuanrv of the service rendered but has personally given pjtr.ological Ciarr.ow.on over Z'jl- surgical specimens without charge to tnc panenis Durir.c the year a total of 5u35 examinations have been mace in trus department. The unfortunate illness of Mr. Cummings, the held director, has kept him away since February, but the other members ot the star have loya.iy assumed extra respesr.sibiiities. Dr. Vorwald. assistant pat.nolocist. has cameo mo*: of the load of supervising the experimental work in the laboratory, thereby relieving the director. Mr Downs, teic supervise: ot roentgenology, has taker, over the administrative details for the study m the iron ore moustry ar.d the supervision o: the clinic in the Inland Steel Company Mr. Durian, the chief chemist, and Mr. MrCrum have made the engineering surveys m the cement ar.d gypsum studies Miss Cummings, the secretary, has spent many extra hours with the extra correspondence and voluminous reports that would orcinaniy have emanated from the ceid curctor s cmce. The director take* this opportunity to express to tr.em and to a:i tne other members c: the star his appreciation for their supper: A: the roentgen laboratory at Truseau the laboratory buoget provides the salary for an assistant to Dr. Sampson. Dr. Jor.r. V*'. Karr, a graduate ot tr.-e University cf Rochester, joined the itan m this capacity in August. It is hoped that he will be able to relieve Dr. Sampson, wr.o is now hard pushed to review the many thousar.es 01 ;ms irom our own and other industrial surveys IS V Mr. J. Cloyd Downs, voluntary assistant chemical engineer, has not been able to spend much tune in the laboratory but he snli serves us as a valuable consultant. Mr. Edward Goeelder, who was a volunteer histological technician last year, has made his services so valuable that he is being taken on to the regular staff. Four more volunteers have served more or less time m the laboratory this year. Mr. L. A. Rabidou, Mr. John Schmidt and Mr. R. A Gnnnell have been assisting in the preparation of dust suspensions for animal injections and in various other ways. Mr. Stephen Worthen spent the summer in the chemical department, analyzing lung tissues. Our appreciation of their services is gratefully acknowledged. In the diagnostic department the change m personnel has been unusually rapid. Dr. Robert Major left for his home in February and Dr. Richard V. Fletcher relieved him for three or four months until Mr. W. O. Kelley, who was formerly in charge of this work, returned for the summer. On October first Dr. John R. Murphy took over the responsibilities. All of them deserve the gratitude of the institution and the community for their able services. FINANCES \ The statement which follows indicates a balance of $15,031.06 at the end of the fiscal year. This sum is not surplus earnings but is made up of advance appropriations for research already in progress. Receipts dunng the year amounted to $62,608.43, which with the balance of $11,385.82 earned over from last year makes a total of $73,994.25. Of the current receipts $42,037.28 was in payment for consulting field and laboratory services and $10,000 was an appropriation by two associations of nock and mutual insurance companies for basic research. The balance consisted of earnings from income and miscellaneous gifts. The anonymous gift of $1,000 for equipping the new John Black Wing was acknowledged m last year's report, but was not credited to income as it was received after the expiration of the fiscal year. The sum of $1,278.15 was received from the sale of copies of the "Silicosis Symposium" published by the Employers Mutuals Insurance Company under the direction of Mr. B. E. Keuchie. The director expresses his grateful appreciation for the support received from all who have contributed to the work in the laboratory. Speaal mention is made of the large contributions from the National Bureau of Casualty and Surety Underwriters, the American Mutual Alliance, the Employers Mutuals, and Mr. Samuel Eckert. The director acknowledges his debt to all the members of the staff who have rendered such faithful service and to Dr. Baldwin, the director of the Trudeau Foundation, for his unfailing sympathy and advice. 16 jI engineer. has nor been he trill serves ui n i _i a volunteer histological ie that he is being taken served more or less cmc Mr. John Schmidt and ation of dust suspension? Mr. Stephen V*'or.hen ycing lung tissues. Ou: ged. pnnel hat been unusually bruary and Dr Ricrurd unul Mr. W. O. Kelley, d for the tummer. On sensibilities. All of then ommumty for their able cc of 515,031.06 at the nings but is made ur c: ogrets. Receipts dun.-.c e balance of S11.I-S5 SI .994.35. Of the current :ng field and laboratory atsooaoons of stock and The balance consisted o: anonymous gift of SI.O'.'v .nowiedged in las: year s eived after the expiration tceived from the sale o: the Employers Mutuals E. Keuchie. for the tuppon received the laboratory- Special the National Bureau o: n Mutual Alliance, the he director ackncwiedcis e rendered such faithful Trudeau Foundation, ic: SLXIX1MU cr DI'CNCITlC EXAMJN \710N S Januaiy 1. 1936 -- Decemrcr 31. 1936 t*j-.r.en eultuftt 1K-i Vincent's Angina_______ Sto=ch content* --------------------------------- * 15 Vdi. fcsr.inoiojicx'. count*__________ 51 H.^";er, barter*! euruniuc.-. ______ *1 Agglutination lot typnoib_______ I 'i'iiff. c-'.eeuc*! nizjr.mon363 Lhener.u*! count* .... 131 S.-r.cirs (cr gonococcus ---------------------- 9 RfC *-.d *.nc count* 355 L'r..nt lit! Hrri~giob.r. deterounauen*______ ITS Autegersou* weere* anc C.ira:ti Cirjlincr tine _________________ * prrpite; ---------------------------------------- 3 1 Mat;* irc ire typ:-;_____________ IT' ?a:.-.ologi:al ;cc;c;cr.t------------------------ ITT Cuitute* It Rcietred *. t; p i v * p r c~ r r. >__________ 54 Cneru'try ________ 1I< Autopsies, hur.ir.____ _________________ at SC.r^ruik-a _____ ill >pra! r.u.d. unr.t i*.; ctr.et --.ittr.xl Ar.nr.iii inoculates lor e;agno*i*___ S3 Mis:e.Iar.tcu* eia--ur tior.*___________US i. r tubercle fcacuii_________________ '.<1 ------------ I"," .lur lur tuocrcie rarilii515 Ten; SC35 SARANAC LABORATORY FOR THE STUDY OF TUBERCULOSIS RECEIPTS AND EXPENDITURES Year ending September 30, 1936 Balance on hand October 1, 1935 __________________ 5 1 1.385.82 Receipts: From endowment: Interest ____________-___ _______ Dividends 1.S75.00 1,COO.00 Gita and other receipts for maintenance of ' plant and work_____ Gita for building and equipment --------------------Transferred from Ehcabcth Miibar.k Fund--------- Sale of old equipment Repayment of advance to worker--------------------- :,s?s.oo 55.633.43 1.000.00 2.500.00 350.00 250.00 I Total receipts for year------- 62,608.4 3 Total of balance and receipts 73,994.25 Expenditures: Salaries, for research and aeid survey*---------------- 47.704 95 Travel and other expenses of workers---------------- 2,421.90 Fuel, light, supplies, animals, feed and other running expenses 7,964 5 4 Fermanent improvements of plant________________ 871.80 Total expenditures for year 58,963.1V Science on hand September 30, 1936 _____________ Cash on hand: Bankers Trust Company (Saranac Laboratory Fund) _____________ Saranac Lake National Bank (Trudeau Foundation account) 15,031.06 1 4.5 35.42 495.64 15,031.06 See following pages for list of contributors IS OF TUBERCULOSIS URES' 936 _ _ sius'.s: 00 00 -- 2,875.00 -- 55.633.43 -- 1.000.00 -- 2.500.00 350.00 250.00 ----------------------- 62.60S.4? ------- 1------------ 73.954.35 ... 47.704.95 _ . 2.421.90 ___ 7.964 5 4 871.SO 14.5?'.43 495.64 15.031.06 CONTRIBUTIONS TO TME SARANAC LABORATORY 3 From October 1, 1935, to September 30, 1936 (S'oir Ittm tr;ti*td ittcr Octobtr 1. 1936. in **cond column, to be credited in 1937 report) Adirondack Fund for the Tuberculous 999.96 249.99 American Mutual Alliance (Casualty Companies) . 5,000.0-0 Mrs. Bigelow Crocker 5.00 5.00 Mrs. Charles L. Crocker . 50.00 50.00 Mrs. Francke G. Dane . 50.00 oo Agnes Musser Eckert Fellowship 1,000.00 Dr. Leroy U. Gardner 407.00 50.00 Dr. Albert H. Garvin. 7.00 Gulf Rock Oil Corporation 50.00 Hillside Fluorspar Mining Company 1,250.00 Inland Steel Company : 2,599.95 4.299.99 Johns-ManviUe Corporation Lake Superior Iron Ore Associatio 1.250.00 10,262.34 3,607.4 5 Mr. Lawrence MacFarlane 100.00 National Bureau of Casualty and Surety Underwriters . 5,000.00 New Jersey Manufacturers Casualty Insurance Company . 200.00 Owens-Illinois Glass Company . 600.00 Pennsylvania Glass Sand Corporation 5.00 Portland Cement Association 2.400.0-0 2,400.00 Mr. Arihur B. Purvis .... 250.00 Rosiclaire Lead cf Fluorspar Mining Company . 1,250.00 Sales of 5ock "Silicosis Symposium" (thru Mr. B. E. Kuechle and Associates) .... . 1,278.15 163.00 Curried joTWurd . 53,052.43 1 3,087.46 19 < J % 5 -- 1. V V*- Brought forward-.............................. 53,052.43 13,087.46 Saranac Lake Academy of Medicine: Mrs. John F.'Archbold .. .. R.Dr. Edward Baldwin . Boyce ef Roberson.............................. A.Mr. W. Currier .... Dr. Joseph T. Eaean .... 50.00 25.00 10.00 50.00 ' 50.00 Xirs. A. C. Erkander .... General Hospital of Saranac Lake L.Xliss Anna Gilbert .... Mrs. Henry Hudson .... Dr. David T. Smith .... R.Mr. B. Smith.............................. 50.00 51.00 25.00 10.00 100.00* i lo.po 4 Dr. George E. Wilson .... . 15.00 Mr. Frank J. Tone.............................. United States Gypsum Company . 2,125.00 In Memory of Sydney Lunt Wood: C.Xliss Sarah Armistead . * 5.00 Xlrs. S. L. Wood and Xir. John Wood 15.00 100.00 625.001 15.00 Xliss Susan Wood.............................. 50.00 55 ,633.43 1 3,857.46 For New Building and Equ IPMENT Anonymous, thru Dr. Henry B. Dous: . 1,000.00 For Endowment (Held in trust by Trudeau Foundation) Milbank Memorial Fund, completing pledge .... 50,000.00 Mr. Frank J. Tone.............................. 5,000.00 * 20 i