Document npRnny1EyBxG9RKjaprK8QXY2

PLAINTIFF'S EXHIBIT SL-189 -- 1939 -- Cfjc Saranac Haboratorp for tfjr fetu&p of ubcrrulosis OF THE EDWARD L. TRUDEAU FOUNDATION . REPORT OF. THE DIRECTOR AND FINANCIAL REPORT ,For the year ending September 30 1939 1 REPRINTS OF SCIENTIFIC PAPERS tEfje Saranac ILafer Scabrmp of ^cbicfnc THE SARANAC LABORATORY The fact that the Saranac Laboratory hu always been a separate institution from the Research' and Clinical Laboratory of_ibe .Trudeau- Sanatorium is not generally vindemood._Bqt)) laboratories are sponsored by the Trudeau Foundation, but the Saranac Laboratory u located at 7 Church Street in the village of Saranac Lake and not at the Sanatorium. The properties of the Saranac Laboratory consist of the original buildinc. given to Dr. E. L. Trudeau by Mr. George C. Cooper in 189a aa a private research laboratory, together with the John Black wing, donated by Mr and Mrs. Frank B. Black in memory of their son. The addioon contains the library and lecture-room,'erected in 1927 and 1928. and private research room; constructed in 1935. There are also two animal houses To avoid confusion, the Trudeau Foundation publishes separate reports of the Trudeau Sanatorium and Saranac Laboratory. THE SARANAC LAKE ACADEMY - OF MEDICINE Ik July. 1931. a group of physicians in Saranac Lake met in the John Black Room to discuss wavs and means for supporting the diagnostic and research activities m the 5arar.ac Laboratory dunng a period of diminishing income. They were of the unanimous opinion that this mstituoon is essentia! to the continued existence of the village as a center for the scientific treatment ar.d study of tuberculosis. As a concrete expression of this feeling, they connrated themselves the nucleus of a body to be known as the Saranac Lake Academy of Medicine Its object is "to foster interest in the pursuit of scientific medicine in Saranac Lakr" through the agency of the Saranac Lab oratory. Its members pledge themselves to support the activities of this institution in every possible way and to seek assistance from others for tu operation The active members are physicians practicing in Saranac Laic, but associate, sustaining, and life memberships are also open to interested laymen. The formation of the Academy created nothing new. The Laboratory, the Library*, the diagnostic service, the scientific lectures and research have always been an integral part of the medical life of Saranac Lake, but by many they have been freely accepted as a natural heritage from the great founder of this health community By membership :n the Academy of Medicine, or by contributions through it. anyone can feel that he has a pan m keep ing alive the Trudeau ideals for the furtherance of medical science. . a - *--- . THE SARANAC LABORATORY TRUSTEES LEROY U. Gardner. M D.. D-.re::;r Epwmo R Bremen. M.D William ? Thompson. M D. OLfViR B James. Treciuitr Roy Daytcn. Secrecy , Donald E. Cl'mmincs. BS Assis:zr.: Director in Charge of Fit'<d Wol, *r t >%r rT-;* y: *.. +J'<: THE SARANAC LABORATORY FOR THE STUDY OF TUBERCULOSIS OF THE EDWARD L TRUDEAU FOUNDATION laboratory staff Leroy U. Gardner, M D. _________ _____ ____ _____________Director Arthur J. Vorwald, PhD., M.D._____ ______ _Pathologist Thomas M. Durkan. M E.Chrmirt end Engineer Louis Berkelhamer, B.S., M.S. ........_____ ....__........ Petrographer Douglas S. McCrxim, B S., (E.E.) ____Photographer and Assistant Eng.neer Morns Dworski. B.S.. C.PJi. ...... Clinical Bacteriologist and Assistannn Experimental Pathology Catherine M. Cummings ...__...______ ____ ____ Librarian and Secretary Roy Dayton ____ ______ --____ -Financial Secretary James V. LurtreU ________ ____________ __Purchasing Agent and Technician George C. Hulpntt .......________ ______________ Technician Anthony B. DeiahantTechnician John G. SchmidtClinical. Laboratonan Andrew J. Redlin________________ ___________________________ Technician Francis T. Creedon___ ...-------- Technician Edward Goclder ...._____________ ____ _____ _____ _____ .... Technician Roy A Gnnnell ----- Technician Robert E Liddy _Voluntary Asnstant Robert Banker------------------------------------------------------------------------- Assistant Henry C. Stout--------------------------------------------------------------------------- Assistant FIELD AND CONSULTING STAFF Donald E. Cummings, B S.____Assistant Director m Charge of Field Work. Homer L Sampson, DSc.------------------------------ Consulting Roentgenologist Daniel hi. Brumoel, hi D. ......................... Clinical Consultant Robert N. Downs------------------------------------------ Roentgenolog cal Supervisor Richard Libby-------------------------------------------------Roentgenological Technician Richard Walters--------------------------------------------- Roentgenological Technician Joseph Goldstein--------------------------------------------- Rocntgrnolog.cal Technician Melvin Berg-------------------------------------Bacteriological Technician and Clcr^ Helen R. Smith ...........---- ................-----------------Stenographer ..... Lhrectpy ... Pathologist st and Engincc* _Petrographer aslant Engineer and Assistant in ental Pathology n and Secretary anrial Secretary and Technician ... Technician ... Technician cal Laboratortan -- Technician ___Technician ... Technician ..... Technician luntary Assistant --__ Aiiiitar.: .. Ajjman! of Field U'oit Roentgenologist mica! Consultant og ca! Supervisor jtcal Technician g-cal Technician .cal Technician tear, and Cler'r Stenographer i I i I i t } l Reron o:' the Director CONTENTS Finanr.it Statement Repnnti of Scientific Papert Leroy U. Ga)o Ait Hygiene in the Mining industry The Medical Control of Silicosis and Tubercuio-Suicosu Arthur ) .Vorwalp. A B Delahant and M Dm-ORSKI Silicosis and Type 111 Pneumococcus Pneumonia: An Experimental" Study ......................... Donald E. Cummincs. R N'. Doucns and M. Biro Tuberculous Lesion; in Mate Jnaussnai Workers Leroy U Gardner. T M Durr an. D V. BRL'wr:iL end H. L. Sampson Survey m Seventeen Cement Plants of Atmosphere Dusts and Their Efezts Upon the Lungs of Twentytu-o Ffunarea . Employees Leroy L\ Gardner Recent Developments in Relation to S>*'icosis REPORT OF THE DIRECTOR. ' of the Saranac Laboratory for the Study of Tuberculosis 1939 LEROY U. GARDNER. M.D. Activities in the Laboratory the put year have followed their usual trend No startling discoveries have been made but these rare occurrences in the study of chronic diseases are the good fortune of few investigators. Most of us mus: be satisfied to observe the successive manifestations of such diseases as they evolve in human beings and experimental animals. Our attempts to simplify nature's processes by creaung highly artificial conditions sometimes lead us astray but at others they provide the means of forging a link in a chain of evidence. . The reprints of published papers bound with this report in no sense re flect the extent of experimental work in progress. Possibly our policy of publication is unsound. "Point papers.** based upon individual tens, are raTelv issued because we ourselves are not always certain of their significance and reports on industrial diseases are often misinterpreted or given unwar ranted importance by non-medical readers. It has, therefore, been custom ary to defer publication until the compleuon of collateral experiments bearing on the same topic. This method permits evidence to be weighed and rvaluateo in the light of experience, but it may defeat itself by necessitating papers to long that few but specialists are interested in reading them. The annual report of the Director is nis vehicle to indicate the nature of the work of the Laboratory and to speculate upon its significance. The pur pose is not to draw final conclusions, but to inform the sponsors of the work and others of its trends and of any apparent progress. Experience with the action of asbestos dust still confirms the impresson reported a year ago that grinding the fibres of this mineral to an extremely fine state of subdivision destroys or at leas: mimmices th*<- wipsory to irnca:r the lungs Nothing has been discovered th>' wcompascle with tneerv that the irritating properties ** *h* ronrer erres is o: a rtecharjcaJ narurc * beyond our control. On the premise of 2 report by another observer to the effect that dogs would develop asbestosis. we experimented upon this species of animal but found that no reaction had developed after a year's contact . with asbestos fibre. The test for which such high hopes were entertained consisted in the introduction of large doses of asbestos fibre into both lungs by means of a bronchoscope, followed by collapse of one of them induced by denoting the stem bronchus with diver nitrate According to our theory of mechanical imuson the collapsed lung should move very little with respira tion and hence the fibres within it would exert Little infiuence. The reasons for the failure of the dog to respond to this dust are unknown, but the sairie is true of all other speaes tested with the exception of man and guinea pies. The probable dgruficance of the results has made it seem profitable to repeat the expenment on guinea pigs If the technical diEculty of bronchoscopy in this small animal can be overcome we should be able to substantiate our belief in this theory. A senes of expenments by Messrs Dworski and Delahant upon the nature of the injury produced by chca parades has yielded most interesting, though m some respects perplexing results. It will be recalled that the majonry of oheserven believe that slow solution of silica particles in the tissues results in chemical injury of the cssues This solubility hypothecs, at least in the simple form thus stated, is not consistent with all the expenmental observa tions. Chief among the latter are. first, the lack of rcacuons sugeesave of silicosis to repeated injections of soluble dlica of any known form and. second, the fact that the tissues respond to injections of fine silica so raptdly that it is hard to conceive of solucon having occurred. The expenments to be ated deal with the second objection to the solu bility hypothesis. In the living arumal a specific response to very fine quart; parades, under 3 microns in diameter, occurs within a few minutes, the rate depending upon the etc and manner of injection. Similar introduction of other minerals of the same parade site produces no such effects. On inject ing enough quart; of this sue into the blood stream, the animal almost imme diately suffers profound shock and dies within a few minutes to one hour. Intxapentoneal injections of too much silica cause acute illness for several hours and even subcutaneous injections produce infiammatory reactions of character istic appearance within as short a period u H minutes. Such responses appear too rapidly for any solution to have occurred after contact with the tissues. In the test tube traces of soluble clica can only be discovered after H hours of contact between fine quart; particles and blood serum at the temperature of the body. Tests that have been performed seem \. r 6 i. 5^ ' It. has been indicated that the toxic action of quart; u 1touted to parocles '3'microns or-less in diameter. The tame is apparently true in the production of the'more -chronic tissue ructions. While parades more than three times this cite may be breathed into the lungs, it would appear that only those less than the critical ate are biologically significant. This edect has always been attributed to the. greater amount of surface presented by a given number of `small than large bodies. To learn more of the influence of this factor of surface aru Mr. Dworski and Mr: Delaham prepared a senes of suspensions of graded card quart: parades. In making suspensions they varied the concentrations to that unit quanmies of each would present equivalent amounts of quart; surface. When groups of animals were injected with each of these suspensons. it was found that no silicosis developed if the necessary surface area of quart: was supplied by particles greater than 3 microns in diameter. Microscopic examination of the tissues disclosed that in the case of par ticles exceeding the 3 micron limit not more than 3 or * fragments had been ingested by any phagocyte and more often there would be only 1 per cdl Below the cnocal *i-r the number increased inversely with parade at. This evidence indicates quite dearly that surface area of the irritant only becomes important in relation to the intenor of the cells. The quart: surface m con tact tvuh extra-cellular fluids apparently has little to do with the development of clicoac nodulanon. This observation suggests that the immediate reactions to intravenous injections of quart: may be a non-reveiani index of toxiaty exened upon tissues not concerned with the disease, silicosis . The intracellular injury, however, becomes important when it is recalled that these changes are essentially the same as those produced by tuberdc baalli resulting in the pathological forms commonly desgnated as "epithelioid cells." Among other charactensacs such cells exhibit droplets of visible fat. The presence of this product of degeneration in the phagocytic cells of both tuberculoss and silicosis led Fallon to hypothesise that it was these non-spebfic fartv or lipoid suhsunces, liberated in large amounts, that led to the formation of the nodules characteristic of each disease. For years it has been known that lipoids from the tubercle bacillus would produce nodules, but no one had thought of testing the action of lipoids from injured cells. Fallon injected the fa try substances extracted from silicotic tissue and produced nodules, but he had diSculry in freeing his material of all particulate silica. We are rtpeanng his work, hoping to surmount this obstacle and demonstrate the validity of his hypothesis. A word of caution should be added, no one should infer from these ex- 10 % I 'I .1 II I! t rwrv-.v*; i 2 to parades e production i three times nly those leas always been m number of Mr. Dworski , med quart: a ao that unit irface. When , it was found : was supplied >e case of parnenu had been *ily 1 per cell ade o:e. Thu it only becomes surface in con ic development lediate reactions idea of toxiaty icn it is recalled iced by tubercle :d as "epithelioid ets of visible fat. yn'c cells of both these non-spednr i to the formation s been known that , but no one had l Fallon injected produced nodules, ite silica. We arc d demonstrate the ifer from these ex- penmenu that silica dissolves in the cells and is liberated in the blood stream where ltunay poison other tissues Apparently its eecct is exerted only upon tissues jn*im7ned*aterentan with the quaru parades. Phagocytes are injured or die and connective tissues "undergo'a peculiar hyaline transformation that Mr. Baisden. working m this laboratory, showed to be analagous to that in tanned leather. In these processes practically all of the dissolved silica is. absorbed. Analysis of the blood of all human beings reveals minute quan tities of soluble silica, but m silicones there is no excess. Likewise in the urine'there are even larger amounts but it is probable that most of it is derived from vegetable'foods and-water. .Other experiments by Mr. Steenken, in which fine quaru was injected into the brains of guinea pigs to Rudy its effect upon local suscepnbihry to tubercle bacilli, suggest an interesting contribution to cytology. The silica first produced small abscesses whose walls were composed of large phago cytic cells. After five months the. nodules located m the meninges bad been partially replaced by hyaline fibrous ussue but deep in the substance of the brain itself the lesions remained unchanged. In the latter locaoon the ordinary' connective tissue cell or fibroblast is lacking; in the meninges and in the walls of blood vessels such cells occur as in all other parts of the body. Since the silicotic reaction only became fibrous m parts of the brain normally containing fibroblasts it would appear that this cell is cwntial to fibrosis. This conclusion would not be acceptable to cytologms of the Maximow school, who .hold that the phagocytes are themselves transformed into fibroblasts. New impetus to the Rudy of the proteenve effects of calcined gypsum against quaru has been given by an observation that on intrapentoneal injec tion of a mixture of these two minerals, no silicosis developed in eight month's time. Control animals given the tame quantity of quart: alone showed sili con: nodules on all the peritoneal ossues. We are now attacking the problem in other ways to verify the original observation and to discover whether the mechanism u the same as that in the case of aluminum hydroxide. In all previous experiments, limited to the inhalation method, it had been inferred that the protection from gypsum was due to atmospheric Cocculaoon with the quaru and reduction in the amount of dust inhaled. The only point to be mennoned on the experiments with aluminum as a protenor substance is the apparent discovery of the cause of our previous failures with this mineral that proved so successful in the hands of the Cana dian investigators. They used it in dry state and completely neutraliced the anion of inhaled quart;. We used it m saline suspension with quart; to per form injection tests and observed no evidence of protemon. It has recently 11 Ii i to rule out the possibility that the reaction is due to soluble silica already present; m the saline solution used to suspend the parades. If they are completely removed by centrifugation, delicate oolonmetnc tests reveal the presence of soluble silica, but injection of this fluid has no edect upon animals. In other words, the particles of quarm themselves induce the symptoms. The only explanation now tenable is suggested by the observation that similar reactions are produced by injecting small doses (larger ones have different effects) of colloidal silicic add. It is possible that during the pro* longed immersion in water necessary to separate the quaru partides of the proper size there has been chemical reaction and that a thin film of colloidal silica covers the surface of each grain. Certainly it is hard to conceive that formation of such a film during the few minutes preceding the onset of symptoms that follow injection. further evidence that the injurious pnnaple resides on the surface of the particle and not in the suspending fluid is indicated by the lack of toxioty of the blood of a guinea pig dying m silica shock. Transfusion of such blood, into another animal causes no symptoms. And finally it has been shown that the injection of quart: grains whose surface has been coated with other sub stances like the hydroxides of aluminum or iron is likewise followed by no symptoms. The nature of the injury resulting from the introduction of large numbers of fine quart: panicles directly into the blood stream is unknown but it pre sumably affects some pan of the circulatory system or iu nervous control. The symptoms and pathological changes simulate those of surgical shock, practically all of the blood m the body being rapidly concentrated in the dilated vessels of the abdominal cavity and spleen. The blood no longer clots on removal from the vessels In contradistinction to surgical shock this condition does not respond favorably to injections of adrenalin. A feature that is most difficult to understand is the development of tolerance in animals that survive sublethal injections. After several such treatments they may be given three to four omes the original dose with impunity. The mechanisms responsible for these acute reactions to fine quart: and their possible significance in the chronic phases of silicosis are still a mystery They may be merely indicative of a capacity to react to silica, for these acute effect! are only observed m the species that readily develop fibrosis. The dog, for example, is an animal with an apparently high tolerance to silica although prolonged contacts with excessive quantities of fine quart: will ultimately produce nodulation Very larce amount! of the same suspensions that promptly killed rabbits and guinea pigs may be injected into a dog's veins without apparent effect 9 been noted that. if the suspensions ire not heated for seenlication, ax we had been dome, the associated aluminum'cbmpietely protects animals against acute silica shock. We hue now tuned to repeat our previously unsuccessful expennents. using unheated aluminum to set whether we can prevent the development of chroruc tissue changes Numerous other tests with the hydroxide of aluminum continue to demonstrate the value of this substance as an inhibitor of nlica. Aside from problems dealing with mineral dusts, a study is in progress upon the therapeutic value of a special compound of sulphamlamide. This powerful bacteriostatic agent had been combined with an oil on the theory' that u would then be capable of solution in the wax-coated tubercle bacillus and destroy the organism. Mr. Stephen Phillips. Jr generously offered fiances to study the effects of the new compound (dodecanoyl-sulpharulamide) upon acute tuberculosis m silicotic guinea pigs and also upon very chronic infec tions of the urn nature in guinea pigs previously inmuniced with Calmette's low virulent strain. BCG. We regret to state that the results thus far obtained offer little cause for encouragement; although some of the animals are Rill alive it now seems improbable that the drug has had any benencial erect Our experience contras that of most other investigators who have used it to treat primary' tuberculous infection in animals Diagnostic Work The table which follows indicates the number and variety of diagnostic examinations made upon panents in Saranac Lake and us vicinity. In spite of a decrease in the total number of patients there were 9a i more tests this year than last, tndicanng a greater tendency to use this service of the Labora tory The fact that 76 sputa were submitted for pneumococcus typing. *7 more than in I9-S. calls attention to the effectiveness of the publicity- given this subject. The 2a referred autopsy specimens represent cases of suspected pneumoconiosis, submitted for cor.drmaoon of diagnosis. On most of them there was not only a histological but chemical and petrographic examination of the minerals recovered from the lungs. Summary of Diagnostic Examinations . January 1, 1939 to December 31, 1939 ooU V* Diphtheria Cultures .......... 32 Vincent's Angina ______ ...... 20 Pneumonia Typing ........... 76 Undulant Fever ............. 19 Enteric Diseases ............. 11 Gonorrhea, smears ............. 11 Blood White and Differential ..... 640 Red and Hemoglobin_______ J14 Matching and Typing__ ____..309 Cultures ......___....... 32 Chemistry _________...... 307 Sedimentation . 149 Spinal Fluid. Urine and other material for tubercle bacilli__ 101 Sputum for tubercle bacilli .... 1136 Feces: Smear. Culture and Parasites .....________ ___ 40 ` Milk. Bacterial Counts ______ __ 27 Water; Bacteriology___....... 61 Water. Ortho-tolidine 36* . Unne, routine and speaal tests .11144 Autogenous Vaccines_________ 26 Surgical Pathological Specimens Autopsies. Human ........___ 46 Referred Autopsy Tissue 24 Animals Inoculated'for diagnosis 62 Ascheim-Zondek Pregnancy Test 20' Miscellaneous Examinations ___ 276 Supplementary Tests _________ 777 Total Examinations1642' The only radical administrative change to be reported has occurred in the Field Division. Mr. Cummings, who has to successfully directed this activity for the past seven years, accepted an appointment as Associate Professor of Medicine in the University of Colorado in September. However, we con sider ourselves fortunate that this new arrangement will stall permit him to spend one-third of his time in the Laboratory Field Division. While we can not hut regret the change, preventive medicine will be the gainer for he now has the facilities of a university hospital located near large mining communi ties m which to expand his activibes. It v.1! be necessary to employ an assistant engineer to help Mr Cummines maintain hu contacts in the field. A man with considerable experience has already been approached and it is anticipated that he may join the nan in the near future. In June the Fourth Symposium on Silicosis was attended by about one hundred enthusiastic participants. This year the character of the program was vaned by presentations of the experience in a wide variety of dusty 13  ii lI I I 'Tin -4 industries with and without silica hacards The interchange of ideas served `'to emphasise the fact that while' the essentials of the dust problem are the tame everywhere there axe minor variation* that are real and that may be the cause of misunderstandings. It is a pleasure to express publicly our appreciation to the twenty-one guest speakers who presented the topics for discussion and whose presence made this five-day meeting such a success. Mr. Kuechle, Vice-President and Claims Manager of the Employers Mutuals, has. again undertaken the edieng and publication of the report of the Symposium. His company has defrayed all expenses and has turned over the proceeds to the Laboratory as their contnbuoon to research in industrial disease. In view of the fact that the pan donations from the tale of previous symposia have amounted to $4,395. we have reason to be doubly grateful to both Mr. Kuechle and the Employers Mutuals r Without the financial support of those whose names appear on other pages of this report none of these activities would have been possible. For their i contributions, which amounted to $<4,575 during the past year. the-Director and his co-workers are deeply indebted. Of this total approximately $12,000 represents unrestricted'donanons which could be used for any research pur pose. Industry contributed approximately $35,000 for the solunon of its special problems. Income on endowment in trust of the Trudeau Foundation of $<.951 and unexpended appropriations of $17,134 received during the previous year brought the total amount available to $77,661.51. The apparent balance of $7.23* shown on September 30. 1939. the end of the fiscal year, represents overlapping contributions. This report would be incomplete without an expression of the director's appreeianon of the sympathetic support of his board of trustees and the loyal co-operation of his fellow workers All have worked together har moniously in the various activities of the inssrution. It may no: be amiss to review the development of the laboratory's program of industrial research and to explore the possibilities for future usefulness Twenty-two years have passed since Dr. Baldwin asked why the granite cutters in Barrc were dying of tuberculosis when the marble cutters, working with the sane tools, under similar conditions in Proctor, only a few miles away, had less tuberculosis than the general male population of the state of Vermont. To answer this question and others developing out of it has been our major objective since 191S. Physical facilities have been developed for this special kind of research and to the original staff of pathologists and bacteriologists w-e have added enpneers, chemists and a physicist-petrographer s Tne scope of the work has gradually expanded from an academic interest in a 14 \ \ _i ii i m ii i i--------------- -- inge of ideas served e dust problem are : real and that may eapres: publicly our -emed the topics for -tuch a ruecess r of the Employers :ion of the report of i and has turned over research in industrial a the sale of previous be doubly grateful to posable cause of altered susceptibility to tuberculosis to include the direct application of knowledge m preventive mediane. A consulunon service has been offered industry to solve us problems of .dust prevention and m collaboranon-wuh tfie Koentgen Laboratory at Trudeau, medical control of employee health' has been fostered. The Field Division of the Laboratory has even organized and paruapated in a community campaign for the eradication of tuberculosis. Through us individual efforts and through contacts with other agencies, the Laboratory' has attempted to disseminate information on these subjects to medical and lay groups that could apply this knowledge The cost of these efforts has been supported by industry, insurance, and private philanthropy, whose contributions have amounted to thousands of dollars ` It is not my purpose to attempt an evaluation of these senvino but to explore the future possibilitio of this organization, built with such a considerable appear on other paces :n possible. For their pan year, the Director approximately Si".02? for any research pur'or the solunon of us ie Trudeau Foundation 4 received during the ',661.SI. The apparent - end of the scal year. expenditure of effort and money. I am naturally concerned to discover whether this private institution can continue to cany on aenvioo that in so many places arc functions of universities and governmental agenoo. The first and, most practical question is whether such a program will conbnue to be valuable enough to attract the necessary financial support. Are there still enough unsolved problems in the field of industrial diseases of the chest to justify the cost of this expensive plant and ruff? Is there nowenough information about the diseases due to inhaled dust and their effect upon tuberculosis so that further research is unnecessary? If so, are there other irnunts used in industry- that increase susceptibility to tuberruloss and thus constitute a proper subject for our investigation? If work in this field ression of the director's jd of trustees and the : -worked together har- is to continue would it be more profiublc to narrow the range of our activines and devote more time to the solution of the fascinaong research problems that have already been uncovered? Before trying to answer these questions, let us look at the industrial he Laboratory's program is for future usefulness i I utuaoon. As far as the two known major dust diseases, silicons and asbestosis. are concerned there probably is enough information today so that they asked why the granite | could be either eradicated or at least reduced to negligible frequency. But to . marble cutters. working roctor. only a few miles i * put this knowledge into practice requires constant expert supervision and considerable expenditure of money. This is now being done with eminent population of the state f success m a number of our large industries because they can afford the developing out of it has ices have been developed 1 tuff of pathologists and i a physicist-petrographer - an academic interest in a g ri ft 2* trained personnel and the necessary' protective equipment. The small manu facturer with limited capital, on the other hand, still needs help. If he thinks of medical advice at all. he must discover some physiaan who cither knows or is willing to become acquainted with the hazards in the local plant and who will deal fairly with both employee and employer. For his engineering advice 15 I t  the dust-conscious mull manufacturer often turns to the rulers of protective ' equipment, or, if he can offord it, he may engage an outside engineer to design apparatus to meet his special requirements. But the essence of the control of a dust hazard is constant supervision: the.reason it works in the large plant is the presence of physicians and engi neers whose main duties are to keep both men and machines functioning properly. For success in the small plants, there must be other experts who, either as private pracnnoners or employees of the state, will spend their tune in going from shop to shop, checking the health of the employees and the operation of the machinery. Today there are not enough experts to meet this demand. Those who are qualified are either employed by the, large industries that can pay attractive salaries, or they are in the service of state or federal governments where, as inspectors, they guard apains infractions of industrial codes and. as investigators, they discover new dust hazards In some nates the departments of industrial hygiene are doing much to mini mize these hazards but with limited personnel they cannot supervssi routine activities in individual plants The conclusion u inevitable that more experts must be trained. Most modern dust control codes seek to prevent the formaoon of dust of all kinds with especially stringent restnroons for those that contain dangerous proportions of free silica or asbestos. This philosophy indicates that we shall always need expensive ventilanon. exhaust systems and engineers to insure their proper operation. Antidotes against the action of the toxic quaru dust, whose effect* are being studied in the Banting Institute and the Saranac Laboratory, must necessarily play a minor role m prrvenoon. Perfection of pracnzal methods for their use may somewhat reduce the cost of dust elimina tion because it may be possible to permit somewhat higher atmospheric concentrations However, regardless of health hazards, industry is coming to realize that men do not work as effectively in atmospheres polluted with visible dust. Fully as profitable as discovering agents to neutralize the action of silica would be the discovery of the factors that govern individual susceptibility. In the case of benign dusts, like those in the cement plants, there are certain men who seem to suffer no inconveniences and have spent their whole lives in an industry which in the past was notonously dusty. Others apparently found it so disagreeable that they sought employment elsewhere ifter a few months. Where there is a shea hazard the fan that only about one-fourth of any exposed group develops silicosis leads to the suspicion that some individual? are immune or at least highly resistant. If only such individuals were selected 16 makers of protective ie engineer to design tjnsunt supervision: physiaans and engilachine* functioning : other experts who, vill spend their time : employees and the ugh experts to meet ployed by the large i the service of state rd agains infractions r KB' diui hazards doing much soxunnot supervise routine ile that more expens j f> Is formation of dust of hat contain dangerous indicates that we shall id engineers to insure the toxic quartz dust, tute and the Saranac renoon. Perfection of ac cost of dust chminaat higher atmospheric ds. industry is cominc '(spheres polluted with r lize the action of silica idual susceptibility. In s. there are certain men their whole lives in an Xhers apparently found lere after a feu- months bout one-fourth of any ro that some individuals individuals were selected for employment in the silica industries the advantage would be obvious. An experimental study of this diScull problem is now m progress and if the results are at all encouraging it is hoped to extend the investigation to human subjects . ............. Much more needs to be known of the subtle relationships between dust diseases and the superimposed tuberculosis that u responsible for roost of the disability in silicotic subjects. Some new method of treatment is indicated for the very chronic forms of tuberculosis that commonly complicate silicosis because they do.not jespond favorably to ordinary sanatorium regimen. While uncompleted studies are helping to define the conditions under which asbestos* develops, there is need for more information on the influence nf this diesasz upon susceptibility to tuberculosis. Although such infection teems to be less frequent in employed workmen with asbestosis than in ihw with silicosis, tuberculosis is a common complication in those who die. Thrrr is still some question whether the association is a specific result of the dui reaction, as in the case of silicosis, or whether otheT factors are dominant New forms of dust disease are constantly being reported now that x-ray examinations of the chest have become rounne procedure in industry'. Invrsticanon of some of these has disclosed a silicosis masquerading under the name nf another causative agent. In other cava the peculiar shadows m the films arc apparently due to harmless collections of inhaled particles in the lunc* that have no significant effects upon the function of these organs In order to combat unjustified compensanon claims based upon mere shadows in a film with no actual disability, every industry is forced to become familiar with the effects of its materials upon the lungs. The widespread use of chest roentgenograms in industry has led to other abuses that can only be corrected by education. Many employers, faced with the possibility of furure claims for compensation, refuse to hire individuals \vho*c films show evidence of disease interpreted as .tuberculosis. They need to be taught that this infection may heal completely and that in mature adults the scars of old disease in the top of the lungs are not likely to be the source of new disease. To refuse employment to such persons, who consti tute about * percent of the population, will create a serious social problem. Or. the other hand, employees have learned to use x-ray films as the basis fur compensation claims that often have no jusnfication. They may feign disability after learning that their lungs show evidence of old scars, or when th.-v actually suffer from active pulmonary tuberculosis they claim that in haled dusts or fumes were responsible. While it has been quite well estab lished that of the dusts, only free silica and possibly asbestos have any influence ; 17 3 p ii :* i i i I I - c.4* :t9 __ upon a waited tuberculosis. there is a real need for authoritative information on ihe effects of other industrial byproducts. In spite of the experience with \ war gases and other irritating substances some physiaans hold to their opinions that there must be pulmonary inflammation which in turn must influence co-existent Tuberculous foa. There also is a wide scope for research upon the effects of various fumes and gases upon the normal lungs. Many of them produce unpleasant re* . acoons in the eyes, nose and throat but whether they cause chronic changes ' in the lungs and are responsible for all of the symptoms that have been ; alleged is questionable. If they actually do. every effort should be made to control them, but. on the other hand, industry ahould not be penalized for * injuries that do not exist. The subject of non-tuberculous pneumonia in industry u another that needs clarification. Opinion is changing on the role of dun in altering suscepti- bility to this disease; it is now believed that ocher factors axe responsible . for the high incidence of pneumonia in at least tome of the dusty trades. An appended paper by Vorwald. Delahant and Dworsb. reports the firn of a senes of expenments on this subject. Here it is shown that nlicosis has had no influence upon susceptibility to one of the non virulent types of pneumococcus nor upon the character of the resultant disease Prom this summary of the situation in industry it would apjxar that there are soil important problems to be solved. In scope they vary from those of general education and administration to detailed investigations of particular hazards and disease. Since these must be studied in plants or mines, in hospital wards and m experimental laboratories it would appear that there soil need for the specialized facilities of the Saranac Laboratory and associated departments at the Sanatorium. The study of silicons has now reached the stage where certain observations must be made on human subjects. The important problems of therapy foi associated tuberculosis, of individual susceptibility and objective measurement of disability cannot be investigated on experimental animals alone. A program of clinical research is now receiving detailed consideration. Trudeau Sana torium has already provided funds to establish a department of pulmonary physiology with the understanding that in subsequent years one half of the . cost will be born by the University of Rochester as an aenve partner in this endeavor. Dr Wnght. the physiologist, started his work in September. A group of clinicians ipccialicmg in pulmonary and cardiac diseases has been interested in the program and the necessary laboratory faalmes will of course be available. 18 t \ ! *\ t nontative information ){ the expenenee with ooans hold to their which in turn must 'ecu of various fumes reduce unpleasant re cause chronic chances ptoms that have been on should be made to d noc be penalised for tdustry is another that dust m altering susceptifanors are responsible ne of the dusty trades wonki. reports the first shown that sHiasa has most virulent type* c: it disease. y it would appear that ope they vary from those ivesagations of pamcular i in plants or mines, lr. would appear that there Saranac Laboratory and where certain observations . problems of therapy foi .nd objective measurement animals alone. A program deration. Trudeau Sanadepanment of pulmonary sent years one half of the is an active partner in this us work in September. A i cardiac diseases ha* been iboratory facilities will of The primary objective would be the discovery of some saesfactory method of treaong tubcrculo-nltcosis. This extremely chronic combination of occult tuberculosis and silicosis, which is being discovered all too frequently in m- duretal surveys, does not respond favorably to the ordinary sanatorium methods of- treatment -- at least the results have been unfavorable in cases trcaied'afttr symptom*'of the infection have appeared. We would'hope to experiment upon a carefully selected group whose disease was discovered in its recipiency. While these men were under observacon it should be possible to obtain uvful data bearing on the evaluation of disability and perhaps something cnuld he learned about susceptibility by intensive study with aJl the available mean* For the latter objective there would also have to be supplementary work on men with silicosis and no tuberculosis, and on others who had had long exposures to dust without contracting silicosis. Since it has been estimated that there are several thousand of tubcreulo-silicosis in the United States whose treatment is either inadequate or delayed until too late to expect favorable results, it behooves someone to attack this problem of therapy. Saranac Lake has adequate facilities for such an investigation, the background of expenenee in tuberculosis and silicons and many contacts with industnes where this disease is prevalent. With funds. in provide full maintenance for a group of ten or twelve silicone subjects for a period of perhaps two years, much could be learned It rs earnestly hoped that the money can be found to suhsidne this project. In the educational field a proposal has been made to establish a "registry" for case* of pulmonary disease due to dust, similar to those now functioning for the review of diagnoses of tumors. Under this plan pathological mcerial together with thr occupational history' and. where possible, x-ray films of thr deceased persons lung* would be sent to a committee for review. The Saranac Laboratory, which already renders such service on a limited scale, might hope to participate in return for the information that would be gained Such a registry should be helpful to pathologists whose expenenee re this field is limned 10 an occasional case. Fr financial support the institution now looks largely to industry', but u* or.lv guarantee of income from this source is the successful solution of problems that arc troublesome and expensive in particular trades To realise its fullest possibilities the Laboratory should have a backlog of unrestneted income. It could then explore new fields by attacking abstract problems that might appear to have no immediate application. It could experi c ment with therapy for diseases already contracted. It could play a much larger s 19 I I i pan in'thv training <5f the personnel needed to supervise preventive programs iri the smaller plants With the uiuversity'aEIiation. "which may some day matenalire, it could asust in undergraduate teaching Industry can hardly be expected to supply all the funds for such general purposes, other groups who might also benest could share the cost In the past the insurance com panies have been liberal contnbutors. in fan the annual grant of the Metro politan Life Insurance Company and that of the Mtlbanl Memorial Fund largely maintained the Laboratory for years before industrial conuns were established. More recently the respective associations of both the stock and the mutual companies have been subsuntiaJ contnbutors. An intimaoon that their support cannot connnue is cause for concern and we must seek nre sources of unrestnned income. There is work to be done and industnal development is constantly creating new problems. The 5aranac Laboratory may reasonably hope to uke pan m their solutidn. Like mos: educational institutions it needs greater financial security. r *i 20 I Tidrn * preventive program* vhich may tome day Industry can hardly jrposes; other group; a the insurance com{ grant 0/ the Metrosank Memorial Fund luithal contacts were >f both the nock and 1. An intimation that >d we must seek new t is constantly creaong y hope to take part tn iced* greater financial SARANAC LABORATORY FOR THE STUDY OF TUBERCULOSIS RECEIPTS AND EXPENDITURES Year ending September JO, 19J9 Balance on hand October 1, 1938 ------ .....------------------- ----SI7,134 n Receipts: . From Trudeau Foundation .............._____ Gifts and other receipts for maintenance of plani and work --_...___ ....______________ S5.951.8S 54,575.67 Tot.I receipts for the year 60.507 TmaJ of balance and receipt; ---------- ------------------------------------ 77,661 '" Expenditures: For research and field rurveys ___ -- Tra\el and other expenses of workers ...___ --- Permanent equipment________________ -------------- Fuel, light, insurance, animals, feed, supplies and other running expenses______ __________ 58.464 74 1.460.99 1.651.53 8,840.5 Total div^urscd flcLr..-, cn hsr-.d September 30. 1939 ........................................ 70,418.0: 7 -,4- Src following pages for hst of contnhutors. 21 I W I I 1 ! CONTRIBUTIONS TO THE . SARANAC LABORATORY < From October 1, 1938 to September 30, 1939 ' NOTE. -- litmft ta tccood eolucaa received liter October lot. ? JS39. to be credited to the 190 fiaaociit report. # Adirondack Fund for the Tuberculous . 1,000.00 249.99 Air Hygiene Foundation of America 6,275.00 500.00: Ass'n of Casualty cf Surer)* Executives 2,500.00 i Dr. Edward R. Baldwin .... 50.00 Colorado Fuel of Iren Company 2,000.00 1,000.00 Mrs. Bigelow Crocker . 10.00 Mrs. Charles L. Crocker .... 50.00 Mr. Thomas M. Durban .... 50.00 Employers Mutuals Insurance Co., thru - Mr. B. E. Kuechle, Proceeds from Sale of "Silicosis Symposium" 198.52 57.00 Dr. Leroy U. Gardner . . . . 155.00 375.00 General Hospital of Saranac Lake . 916.74 250.02 Xliss A. Louise Gilbert . . . . 10.00 Inland Steel Company . . . . 3,854.16 875.03 Johns'ManviUe Corporation 5,000.00 1,250.00 Edna Perrin Labarrere: Bequest in Mem or)* of Dr. Jacques Louis LabarTere . 1,000.00 Mr. Lawrence Macfariane 100.00 Miscellaneous Contributions . 339.00 90.00 National Carbon Company 1,375.00 1,375.00 Owens-Coming Fiberglas Corporation . 625.00 36.00 Penn-Dixie Cement Corporation . 750.00 Pickands, Mather cf Company, for Lake Superior Iron Ore Association 15,000.00 2,916.00 Carried forward............................ 2: 41,258.42 8,974.04 -THWiMiarB Brought forward............................ 41,258.42. 8,974.04 Mr. Stephen Phillips............................ 6,500.00 Ponland Cement Association . 2,747.00 Mr. Arthur B. Purvis . 250.00 Republic Steel Corporation 3,250.00 St. Joseph Lead Company . 250.00 United States Gypsum Company . 247.50 In Memory of Sydney Lunt Wood: 750.00 125.00 32.50 Miss Sarah C. Annistead . Mss Susan Wood............................ Mrs. S. L. Wood Mr. John Wood 5.00 50.00 20.00 20.00 54,577.92 Less exchange on two Canadian cheques .2.25 54,575.67 9,901.54 9 f ft