Document RLjakLO0XbKvMRbyYbyzddya

FILE NAME: Welding (WELD) DATE: 1948 May 22 DOC#: WELD032 DOCUMENT DESCRIPTION: Journal Article - Clearing of X-Ray Shadows in Welders' Siderosis V .2 5 4 V .l y. 2SH THE rjLKCErj-i ;( ifc*I^to>^k'^(ai<y0&M^X'^'7 |gU^W8''-nil'*pB!^BRSf SampaB': pjti.ir.22,'1048 'viatnful' mdnuwldgheuta are irire to Miro I, M. Tonkin, B.BO., an(l Mr, R. Hunt for the entomological w o r k t o .Miro R. J . Beron;''Miro-' P .D a v e y , Miro V. ,D .. Markham.&nd Mr. iE. GL-.England, for, techuioal arC'-ata*:---,); to , Mr..' F; : Higginaonfor th e histological preparations ; tq S r., F. GhH. Gellifor th e d ra w in g s m id to Mr. F. Welsh, f.h.m.s., and Mr. 0. Sutton for the photographs.. ` t REFERENCES r ' . ..... Bavey, D .G . (1846)-7Vdrui. R.<Soc. trap. Meet,- llyg. 40,171. . . Fairley, N. H., et al. (1947) Ibid, 40, 621.. Garnh&m, P. C. O. (1948) /6&I, 44, 601'. X Hawking, F. (1948) Nature, Load. 164, 175. . Hull, O. 0. (1942) J . infect, DU. 71, .18. -- Conlston, F, (1944)/6W,f75, 231. James, S. P. (1931) JProc.H. Acad. Set. Amsl. 34, 1424. . a--< Tate, P. (1938) PartuiMogu, 30, 128. Klkuth, W., MUOrow, I... (1937) Klin, tyschr. 16, 1690. Lancet (1948) Jan. 31, p. 182. ; r Mer. G. Cl., Goldblum,'N. (1947) Nature, Loud. 159, 414. . Ranaolo, Q. (1936) fi(n. Malarial. 18, 318; " ` Rclohonow, E. (lB39)`Jiip.' 3rd ini. Congr. Microbiology, New York, .. . p. 139. ... ; ,. . . . '-- Mudrow.Ti. (1943) DUch. tromnmed. Z. 47. 289. < ouuattiuu, r . (iinuj . i j . a . acmiiiati/imi:, sen, 9,169. ftbortt, H,,E., Garuham, P. C. C. (1948) Nature, Land. 101, 126. --- CoveU, q.1,1Simto, P. G. (1948) 1IHI, mcd.J. I,'517i --- -- ' Matamos,'B. (1048) Ibid, p. 192. CLEARING OF X-RAY SHADOWS IN WELDERS' SIDEROSIS 'T > ' A. T: D oig A. I: G. McL aughlin Mib.'st. And.j D.P.H. , ,'M.B. Sydnoy, M.R.C.P. K .M . M EDIOAP INSPECTORS p F F A O T O B IE S ... iS . " -. With iUutfrations on plaie . In 1936 we described -the abnormal X-ray shadows in the ch e st' films ' f :some.' electric-afe wefdeis and emphasised. that they were found 'in- mein Who wore Apparently, in good health' (Doig and McLaughlin' 1930), Wo wore unable a t that time to ;como t a conclusion 'about the cnse f tlie condition, but suggested that the iron-oxide particles 'in the wldiig fume,';whn 'inhaled; might be opaque t,q` X rays and produc the pictur w ithout'tlio associated presoneb `of fibrosis and `congestion'."' Or original'observation, lias been amply confirmed'by' many investigators, including Enzer and 'S an d er''(1938), 'B ritton; and Walsh - (1940),' Koelscb :(1941), Cramer (1942); ' Humperdinck (1942), troh ?(1944),'and Jones and Looldirt (1944); -'. . ' E nzrand Sander's article,' illustrated with excellent 'photomicrographs, contains the only published account of the'pathological investigation of the lungs of a welder ;who had died after an accident a'nd who during life had shown the characteristic radiographic changes. A part from lobar pneumonia in the left lung,' both'lungs showed a finely distributed' black pigmentation throughout and thore' w as'no tuberculosis.' On histological examination the lymph-glands showed irregularly distributed pigmont (almost all of: which ivas within large macrophages. In the lungs thero was much amorphous pigment, mainly ieppari..rtoriid b u t also in peribronchial lympltatio,.channels and alveolar septa. o fibrosis was. found eith er`in the glands or in tlie lung'tissue;' tho blood-vessels were riot obliterated, even where th e pigment was innsii dense, rind the walls were A ct tliiokeried. Chemical'analyses of two samples of the lungs showed 0'096 and 0-089 mg. of silica per 100 g.- . No quantitative analysis for iron was modo, but both .in sections of tho lungs and glands and. in the rosiduo left aftor micro incineration the Prussian-blue reaction for iron was obtained. . Enzor' and Sander conoludo that the radiographic -appearances were caused by the deposition of iron oxide in the lungs resulting from-'inhalation of the welding fume, and point out the apparently' inert natrnvi of the pigment and the absence of functional impairment. i The condition can -be called siderosis, not in' tho sonso in which Zonkor originally used the term as implying the presence of fibrosis, hut simply meaning the presence of iron dust in the lungs. Subsequent investigations have shown conclusively th at iron oxide in its pure fonri does not set- up fibrosis in the lungs. -McLaughlin-et al. (1946}' described siderosis in 4 silver finishers w ho h ad irihaled iro n ''oxide/(rouge)- a t -work for m any years, pno of th ese meir diod after a'gastrie^oporafcion.'and no fijbroBur of(;the lunge w as'" found, xiiroe confirm atory necropsies(Wore desoribOd h y B arrie a n d H arding (1947).' I t was also show n b y experim ents w ith sponges.:th a t irun-oxid.6' d u st is (Opaque ,-tu X iayrt. : IIurdiug (19-49) an d H arding e t a l; (I947) mtrodU(5ed'U dh'6xidedutO ctbe: lu n g s'o f- ra ts both b y intratracheal injection1and-riy. inhalation' and obtained 'radiographs comparable with those obtained in hum an'siderosis.^ HistologicaLstudies' showed th a t fibrosis did riot develop in . relation to,;;.the deposits of iron-oxide d u st in th e lringsi ' > '' ' ' Sinco 1936 wo have continued o u t' exam inations of , some hundreds of welders (olectric-arc,. .carbon-arc, 'arid oxyaectyleno) and have found siderosis in-each group, b p t we have .'delayed .publication, in tho hop.e of;'an opportunity,. which has so far not" presented itself, for necropsies an d histological studies,, m e faeu tuuL hly one necropsy in a case of w elder's sidorosis .has been reported (death wag M o to an accident) is ovidencc th at th e condition is not morbid. ,(We have been constantly on t i e look-out for necropsy m aterial. . FOLLOW-UP. OF ORIGINAL CASES' :In .October, 1945, wo re-.exanunecl,;.;16 ,:of the, cases desoribed .by us in 1936, and in some respects the results aro instructive,., All except 2 pf; th em j)ad continued to work:full tim e as weldors, and all had rcmameiV in.gopd health. ' Qne ,jnan. has given .up .ivelding entirely, -and'' ,the pth er;h a8 become a .welding {instructor. 'Those 2 eases: are described. in 'greater- detail below. O f-7, men w ho'show ed no specific radiographic changes due to dusb in 1936, 5 (average a g e ; 33*3 years, average Jyvolding exp'osure'' 14-8 years) still showl n o : abnorm al changes;) T (aged 35, sixteen years rieldmg) was riow , classed as suspioious; an d ! (aged 30, .fifteen years Avoiding) showed a definite h u t slight degree ,qf radiographic ret;,cu-, lation. Classed as suspicious in 1036,. .weJdors .Bhqiyed in , 1945 a -definite p ictu re o f `.welders'.- siderosis ;.their ages w ere 2 9 -and 31 y ears a n d 'th e ir welding experience fifteen and seventeen years. -Of 6 men who previously; showed dofinite inhalation ohanges 5 continued, to do So. in' 194G."'Xil-''4: - 6f theso; (average: ago 55-25, average; welding pxpericrice 32-25 .years) there ,was; no , change in the intensity of tho abnormal'_X-'r,ay shadows;'. In , one caso (case 2 below) there was, a considerable cloaririg .Of th e shadows. The other m a n ' (case<1) h ad a, normal" cheat- film- where, previously ho h a d shown pronounced radiographic ohangos 'due.to' inhalation of d u s t.' COMPLETE CLEAUING OF X-HAV SKABOWS . This m an (w as1case ,2 in oiir. 1936. puhUehed Series. H e w as first seen in 1934, w hen he was. 35 years old 'an d ' h a d -boon .an.jelootric-arc w elder for eleven years,. He' .had n o t been previously exposed to dust. . Ilia- welding experience had included, ab o u t half his tim e iu various- ty p es of storage ta n k s w ith ail average capacity of- '600,gallons. " N e a rly all h is'w o rk wtis on uheoated mild steel, and. he' h a d n o t used b a re w ire electrodes o r the carbon-arc m ethod. E x c e p t for a slight corigh- arid 'occasional m orning sp u tu m h e had no sym ptom s of ill health. Clinical examination rovealed a chest expansion equal on both sides but rather less than normal. Tho percussion note was riot'impaired ; the breath sounds were harsh, with prolongation of tho expiratory murmur over both lower zoue3, especially, in the mid-axillary area ; and post-tussio crepita tions wore heard a t tho bases. Examination of the sputum disclosed large numbors of macrophagos packed with fine granules of iron oxide giving the Prussian-blue reaction: No asbestos bodies wore seen. - Radiography allowed' a well-marked reticulation witli a tendency to early nodule formation-(fig. 1). On being informed 'tliat'his radiograph'was not normal ho gave up his. work'as i, , , ' 7 9 0 18X XKOBT] nB .. DOIO, DR. MCLAUaHHlN : X-HAY SHADOWS IN .WELDERS 8IDEEOSI8 [may 22, 1948 a weider to beoomo a storekeeper.and thus. Kadt no. further exposure t<\ w elding, f\ime. Radiography sixteen montha Iatershow ed th a t th e shadows were stillpreent, but th a t the reticular, strands :had become blurred, suggesting congestion ih.flj ata f dust deposition. Subsquent films until 1938 showed th a t' ifce!blurring had persisted,'but th a t' there1was'a definite decrease in the intensity of the shadows. ' FoUotv-tip.--The man was not seen again until 1946, when h looked healthy and said th a t ho felt very nell.1 K eh aii no . showing /adiographio reticulation of,the lungs in contrast. with'.those ehdwihgrnodulacion, and. there seems to be little./,-justification. for this. - practice. The difference between the medical and logeleoacepts of pneumoconiosis should be'kept ciearlyr'in m in d ly 1' ;[ So1far as we are aware, no previous reports h'avo appeared in which the disappearance o r 'even 'retro gression of the lesious ui pneumoconiosis re described. regular, morning cough or sputum, chest'movements-were of Bntzen (1033)' records a.case of " acute siderosis" in moderate degree, and percussion and auscultation revealed no abnormal sighs. A radiograph, of the cheat showed the com, piote disappearance of tho blurring, reticulation, and mottling! the film being normal except for a slight rcaidual accentuatinn of the normal linear markings (fig. 2). ' whioh a man worked fo r,two month's at a machine for crushing stool sponge and was exposed to a very ,light spongy dust wliioh oxidised quiokly, The radiographic changes consiated'of irregular finemottling which resolved to some extent later andwere,interpreted as a muiary ' PAKTIAI, CLEABINO OF X-BAY SHADOWS . pneumonia. In view; of the short! exposure it seisins to Tho man in whom tho X-ra ' shadows bacamo less intenso was catt 1 of ur 1936 series. He was first seen in 1933 when he was 44 years of age. Because f slight staining of the Bputum he was sent to. a tuberculosis ainio ,,A there, scon ,, one o f us (A. T. D.). His father and grandfatlierliad both died f silicosis. He himself-had worked as.a blacksmith for eighteen years, occasionally doing a little aro welding, and after that for eleven years he had boen a full-time aro welder doing half his, work with covered electrodes in'enclosed spaces. When seen he had ho pronounced'symptoms' except a slight occasional cough and hiv had, the appearance of perfectly fit man, with excellent build, musculature, colour, and nutrition. ' "" Physical examination revealed few abnormal physical signs except somewhat harsh breath' sounds and a few fine ptst-tussio crepitations a t the bases, i He continued to work as a welder in the same factory b u t under improved conditions of^ventilation. - . Fpllow-up.--We made periodical .examinations until 1938, us that this term is more applicable than acute siderosis. O u r'2 cases provide clinical and radiographi evidence to support the view th at some dusts, though producing abnormal X-ray shadows when enough !n.h"!e4;-merely lie inertly m the .tissues and cause Ho' proliferation of fibrous tissue or other permanent reaction. The normal scavenging mechanism of the lungs doss not appear to be impaired.' Some, of the dust is drained.away-in tho lymphatics to, .the, lymph-glands, .and it is conceivable that some might1pass' through' `the' lymph,glands after being;.extruded from the phagocytes .in1, which they arrived in the glands, and be finally discharged'into the blood-stream through the thoracic' iliict. I t is likely, however, that much ol the dust is removed from the lungs in the sputum. We showed in 1936 that elimination of the dust by the sputum was aotively going-on in one case eighteen months after the man had. given up welding. This is the man whose radiograph now, shows no abuqrmal shadows,. Barrie and Harding ((947), as result of .their, necropsies of silver.finishers, have also concluded pad' thoso, continued to reveal a satisfactory state of general health, with no change in the degree o f .siderosis, H e wee ' loet sight of in 1936 h u t was traced in 1946. I t was found th a t since'1940 ho had given Up full-time welding and had become a welding instructor a t a technical college. This meant th at his exposure to ' welding fume was a great deal less than when he- was working a t tho factory. He estimated th a t only.a quarter of his time was spent in- actual welding, and - that- most of the inhaled iron dust is eliminated in the sputum. It appears/therefore that in cases.o f,benign pneumoconiosis, when no more dust, is inhaled or when the amount inhaled is less than the amount eliminated, th accumulated dust .tends gradually, to clear away, with, a corresponding improvement .in th radiograph., Though neoropsies in cases of siderosis are few,, there th at only, ( h -short breaks, in,dem onstrating th e . technique of the work or in correcting faults. Ho work in confined spaces was done a t ,th technical college.'- We could not examine him ourselves, and are indebted to Group-Captain J. XG. Somerville, No. 3 R.A.F. Rehabilitation Unit, who made' a clinical examination in June,''1945, and reported ; " The man says he feels-very Well and has no complaints. There'is no cyanosis and no dyspnoea-on. exertion,, and no abnormal clinical signs can .be found in. Ids qheBt," The is,,a constantlygrowing body-<o f , evidence that .it does not seriously affeot the worker's health.. Clinical examinations (Enzer and Sander 938, Sander- 1647, Britton and Walsh,. 1940, .Humperdinck 1942,, Groh -1944,. Doig unpublished), show no,,signs of fibrosis or of <diminished pulmonary ventilation. ' Enzer et al, (1946) found . no.;.statistically, significant ..difference 'between 16 welders with siderosis and a group- of radiograph taken a t the tim e was sent to us. I t still showed definite degree of. siderosis, b u t compared with those taken before 1938 there was, considerable resolution as shown by diminution in the intensity and concentration of the lsions. ' The film now shows no nodulation, b'ut.meroly a rather coarse reticulation with some blurred " beading " of the bronchi (figs. 3'and 4). discussion'; ` . Siderosis is one of. the benign pneumoconioses, a term applied by Pendergrass and Leopold (1946) to those eases in vrhioh inert dusts are deposited, in tlie lungs causing characteristic radiographic changes, but n fibrosis or disability. Etymologically, the word pneumo coniosis moroly means " dust in the lungs " and does not oarry with it tho concept iof fibrosis, but textbooks usually define it as fibrosis 'of the lungs duo to dust. In the Workmen's Compensation Act, 1943, and in tho normal, men in a .comparable age-group as regards vital capacity, pulmonary ventilation, and endurance in statio and dynamio work. Further evidence of the inert* nature' of- iron;in--the respiratory tract'is-found in descriptions of behign pneumoconiosis in occupations, other than wolding,' involving exposure to fine iron' or iron-oxide dust. ' Otto (1939) mentions a caso of siderosis in' a man employed in an ochre mine and mill. There were few subjective .symptoms. Bukell et al. (1946) found 16'out of 171 persons exposed to iron dust in iron turneries showing radiographio reticulation, but symptoms . were few. - Pendergrass and Leopold. (1945) record 4 cases of benign pneumoconiosis among 60 stool grinders ; Sander .(1947) describes 3 cases in oxyacetylone cutters ; and Hamlin (1947). 4 cases in foundry grinders and burners. In all three series the men worked in rooms where there was also exposure to silica dust ,as well as National Insurance (Industrial Injuries) Aot, 1946, iron, but the amount of silica dust was considered too pneumoconiosis is defined as " fibrosis of the lung due low to oauso silicosis. - On the other hand, we know of to' silica dust, asbestos dust and includes the condition an oleotrio-arc welder who worked in a steel-fettling shop of the lungs known as dust reticulation." Pol; com pensation purposes the term must necessarily bo restricted to a disabling condition. Recently, however,., there bos been a tendenoy to restrict it still further to those cases exposed to free silica dust as well as. to tho iron oxide of the welding fume and -who died from silicosis (H. E. Harding, pergonal communication). But when the exposure to the dust of iron or its oxides is uncomplicated TBB AANCarr]'. DR. KRDEI ! F0kOH<YTBKhULOSlsraBTBD'WTHp-ASnS4LTOYXIO AULL/ [.L by other factors it does not set up a disabling condition. As supplied to u s ,. p .a .s .- was ,a_,white crystalline Perhaps this statement should be-qn&lided by saying that over a 12-year period of observation siderosis in welders nas not been' found'1to cause disability. powder, and "from this the sodium salt was prepared, giving, even at a concentration of 30%, a clear solution as described by O'Connor (1948). Preparation of the sodium salt requires patience and (accuracy ; if the ;; ? SUMMARY final'pH is taken tp 7, or if tho solution; remains; exposed <1 A_U. .% - iL_J_ -The jiSlihfkl j * "work;. relating . to the ..benign, p.n. euino-..' to ,air,, it' biyiomes darkor but remains translucent. The oomoBi8 ';'or '.siderosis of; welders is briefly , reviewed;v solution has! bitter but not unpleasant tpste, which Inhere ia evidence that the condition ia not accompanied .'can' be readily disguised with flavouring agents. by fibrotic"changs in the lungs or by obviousdisbilifcy. ' All the pationts wore, given- 12 g. of pi.s. daily i n , In a ru-oiamination of 15 ivelers examined nine years divided doses three-hourly, one night dose being omitted. or more previously 5 of 7 men with no abnormal radio .1 gave a sixty-day course in cases T, 2, ahd 3,; ,Dr. graphic .changes at tlio first examination were still normal ' Jannette Owen gave a sixty-day course in eases 4 and "5 ; the sixth man of this group showed suspicious and the and Dr. .Grace" "O'Malley gave a four-week course in seventh early but definite inhalation changes (reticula- .case .0. All the patients were men. The results are tion) ; 2 men who previously bad suspicious changes summarised in the accompanying table. As regards tho had definite, radiographic reticulation ; and 4 of 6 jnen patients not treated by myself I have interpreted the who had originally shown well-marked radiograph' of d a ta siinplind'to me 11 . welders' siderosis still, had tho same condition. All C ase 1.--A man, aged 19, was adm itted on Aug. 6, 1947, these men had continued to, work ;as welders apd jiad. remained m good h e a l t h . . ;. i.. , ,(i, , The cases of 2 .men are outlined, of whom., one liad given up yielding and ,the other had spent less, time at the job. ^In .th .^rst ca^eithe abnormal shadows, com pletely disappeared, and , in the second ,the shadows became less i nte r., ' V, ; . ` ...' . . " ,[ ..These 2 cases provide evidence.that],the radiographic with an exaoerbation of pulmonary tuborculosis, which had originally, been diagnosodin 1941. Ho! went rapidly downhill and was severely toxic. . By December his weight had fallen from 119',to 1U7 lb. A- large cavity in the left apex" had increased from 3 X 3*/, in. to 3ljz x ' 4 i n . and showed a fluid level. Ponicillih 9 mega units, in six days,"had no effoOt on his general condition or temperature, and on Jon. 27,1948, a course of p.Ala. was started. , . . "' " There was. dramatic improvement after the first few days' reticulation and, nodulation'of .welders,, siderosis is not necessarily permanent,, and that the iron-oxide dust can be eliminated from tlio lung,parenchyma after some years. --the toxicity disappeared, appetite returned, and li became, interested in his surroundings and asked to be taken back to the general ward from' the. side ward where he .had been kept for two months. He-gained 27 lb. in eight-weeks.- ............. . , REFERENCES, * Barte, H. J., Harding, H.B. (1847) Brit.J. induatr, filed. 4, 226. Hi'ntzcn, T. E. (1933) Acta radial., Stckli. 14, 344. Britton, J. A., Walah, E..L. (1940) JMnduetr.'.Hv.`23, 125.' Buokell, M., Garrat J., Jupe, M. H., MoLaugnlin.-A. I. Gh; Perry, . X. M. A. (1046) Brit. J.induetr. Med. 3, 78. ,r , Oralner, J. (1942).ArcA; Ocwerbopdh: Ge/wrbhilg. 2,1644ii ' Dolg, A. T., McLaughlin, A. j.:G,,(1936) Lancet, i)-,771.; : Enzer, V., Sander, O. A'. (1938) J. indkstr. Hyg. 20, 333. Enzer, N-, Slmonaon, E.,Evahs;'A.-M. (1945) Jiiid, 27,'147. Grok. J. Hamlin, A,-(1944) Industr. Med. n. E. (1947) Occiip.'Med. 13, 4, 151918.. Harding, H. E. (1945)'Brit. J.induetr. Med. 2, 32. * , < r r Grout, J.L . A., Lloyd Davies, T. A. (1947) Ibid, 4, 223. Humperdinck, K. (1942) Dtsc/i. mes. IFscr." 68, 16. Jones, T. Ii,, Lockhart, J. A. (1944)'-Tex. St. Ji Med. 40,'532. ' Koelsch. F. (1941) Arch. Gewerbepath. Gcwerbehvg. 10, 519........... McLaughlin, A. I. G.. Grout, J. L. A., Barrio, H. J,, Harding, H. E. -345) /.one. I. 337. . -i ' Radiography. (April 19,, 1948) showed that-, the cavity had lost .its: fluid level and had shrunk from 31/, x 4 in. to 2*/4 x 21/, >,in. There.; was:..considerable contraction and hardening of the apioallesions and clearing of the soft mottling in the other zones. . ! ' ' His general condition remained Very good three weeks'after the completion of the "course ; ' b u t `his evening temperature rose" above 99*F, his erythrocyte-sedimentation rate (e .b.r.) romainod Unchanged, the number of baoilli per field increased, t0 `6,'and ho lost 2 lb. in weight." ' ' ' 1 C ase 2 .--A boy, god '16,.with,rapidly, advancing tubercu-lous pneumonia involving1the wholo loft lung. By. the end of December,, .1947, he was severely toxio and rapidly ,going downhill, with a'hectio pyrexia (see figure). ; After a course of 9 mega units of penicillin, P .A .S . was smarted on Jn. 27, 1948. Tho chngoiin th clinical picture, was even more remarkable than in case 1. Toxicity disappeared on- the fourth day, and the patient asked to resum the embroidery work ho had given up two months previously. H e gained PULMONARY TUBERCULOSIS TREATED W ITH p-AM INOSALICYLIC ACID 6 lb. during the seventh and eighth weeks of the course. Radiography showod th a t the rapid progress of the tubercu losis, was arrested .after tho first fortnight, and films mode EARLY RESULTS IN 6 OASES on April 30, 1948, showed hardening and-retraction of the lesions, which were then restricted to the left upper lobe, ' `A . E r d e i 1' the "other fields having almoBt completely 1cleared; 'The M.D. Vienna, M.R.C.F. S U P E R N U h Is R A S Y R E G IST R A R honeycombing in the loft upper lobe, noted in January, had given plac to clearly defined cavities. Thrco weeks after tho completion of the course the patient's With a comment by condition was still very good, with no sign of returning Wi E. Sr e u , M.A., M.D. Cainb., F.R.C.P., D.P.H. toxibity ; and major surgery of the left upper lobe (thoraco plasty or pneumonectomy) could reasonably be considered. B ut his pyrexia is now gradually increasing, although it is FHY8I0IAN-BOTERINTKNDENT not so high as it was before tho course o f p . a .s . ; there is a COLINDARE HOSPITAL R eports on the systemic treatment of pulmonary slight increase in the number of bacilli per field, j tbe E.3.R. bs risen from 8 to 15 mm. in an hour ; and the patient lias lost. 6 lb. in weight. tuberculosis with p-aminosalicylic acid (p .a.S.) have been published by Lehmann (1946, .1947) and Vallentin (1947), while Dempsey and Logg (1947), in the course C ase 3.--A man, aged 31, with tuberculous pneumonia and poor resistance, reached o hopeless condition by Decom ber; 1947, being very toxio and apathetic, with severe anorexia. of their work on the looal administration of this drug in tuberculous empyema, treated a few pariente systemically but for short spells only, because of limited supplies (personal communication). At Colindle Hospital we gave p .a.s. by mouth to 5 patients for sixty days and. 1 patient for four weeks, after which the supply of tho drug allocated for this trial was exhausted. He was given penicillin, 6 mega units, after which a sixty-day course of p .a .s . was started on Fob. 29, 1948. Again tho improvement in liia clinical condition was the first and most strlldng fleet. Cough becamo much easier, tho feeling of tiredness disappeared within a few days, and his appetite rapidly improved. '(Fivo consecutive specimens of sputum were negativo for tubercle bacilli. Radiography (April 30, 1948) showed much fibrosi, of the right apox, with displacement of the trachea, woU-morked