Document zdp40GnkG882k7Z8oBz5j8kEB

MT-001691 UO I AFFIDAVIT STATE OF COLORADO COUNTY OF JEFFERSON ) ) ss. ) I, Margaret J. Baumgardner, being of full age and first duly sworn do hereby state: 1. Iam the Research Coordinator for the Claims Resolution Management Corporation ("CRMC"), a wholly owned subsidiary of the Manville Personal Injury Settlement Trust ("Trust"). The CRMC was created in December 1998 and is staffed by former Trust employees. On January 1, 1999, CRMC began providing claims resolution facility services to the Trust. 2. In this position, I manage the Asbestos Claims Research Facility ("Facility"), a document and records repository, located at 4755 East 46th Avenue, Denver, Colorado. The Facility contains the business records including but not limited to correspondence, memoranda, reports, records and data compilations ("records") ofManville Corporation or related entities ("Manville"), generally, as well as Manville records relevant to litigation of asbestos liability. The Trust has managed and operated the Facility from November 28, 1988, the date on which the Manville bankruptcy plan was consummated. 3. My experience and familiarity with the documents at the Facilitybegan in 1983 while working for Manville. In my work as a paralegal for Manville, I assisted in locating, indexing and packing many ofthe records which became the foundation documents for the Facility. I continued to work for Manville until September 1987. From March 1988 to September 1988,1 was hired to supervise and assist in the indexing of the first 20,000 boxes which were turned over to the Trust in November 1988. From September 1988 to January 1989, I assisted in the privilege review of documents to be given to the Trust. From November 1988 to April 1994,1 worked for Freeborn & Peters and was put in charge of the Facility, managing all productions and "new" acquisitions. In September 1995,1 was hired by the Trust to manage the Facility. In December 1998,1 was hired by the CRMC to manage the Facility for the Trust. Accordingly, I am personally familiar with many of the records stored at the Facility, as well as how the records have been gathered. 4. To the best of my present knowledge, information and belief, I certify that these records were made at or near the time by, or from information transmitted by, a p erson with knowledge, were kept in the course of the regularly conducted business activity of Manville, and it was the regular practice and the business activity of Manville to make the records. Margaret J. Baumgardner Affidavit Page 2 5. Documents from this Facility were copied for Trine & Metcalf. The documents copied have come from microfilm and medical article files at the Facility and are bates labeled MT001691 through MT-001729, and these documents are true and correct copies ofdocuments found at the Facility. Subscribed and sworn to before me this 8th day of March, 2004. JENNIFER EMMERICH notary public STATE OF COLORADO MAHKE1 ANALYSIS SICHON SALKS EHOMOrtON Dl.PA* ' " Nr .'OHN*.MANVILLS COWATIO FOREWORD A lei/ scattered article.'? appeared in medical journals in recent year; concerning occu pational disease of asbestos v.orkerr. noticed of late, k thorough study and diagnosis apparently has not yot been made ns Lho disease has not pre viously boon rjonerol.ly recogni "' d. Face orpin of articles on inis disease v:ero trihen from medical journals in the Medic:'], [.ibrary nt Fifth Avenue and lUord litre- t and are prorn-n tea in this report. ' MARKET ANAUY8IS SUCTION 9AUCS PKOMOTION OCF*AR f "f NT JOHNS MT-001693 EXCEIIPTB M VARIOUS MK1) l.bAL JOUKHALS UN ^PllAXCA^i'1: *> Canadian iLedieu.1. Arnoci. ' : on Journal fob. lOkU - .Pnr,' i VZ Pcdloy, Frank G. - Puirn i .cj /.;-,bc: to i.r. Mortality and n.obility records of asbestos workers are not availa bio. Information nr. to tiv- fleet of such work on the worker in extremely .Limited. ' Doat.'ii of r.n asbestos. worker '..hi^- > occurred in 1900 was reported by Dr. llurroy in iMurinna to ' o. bop-.r Uont of Indus trial biroM'-o:; Nnd the.* evidence 1:033. ' ou j.ha tuo aonth "nr, duo to f 11 occnpation.'i 1 disease. (iitni' study) Asbestos is or non Lially a irxncf'i:;i LI..Lorre, Trie Caned ism ir.bcstos ;tr: raid to contain out `U.% silica unit C.b'f .iron ox :i.d n. I,1. i.n i.ea I. I.y, asbestos a iToc Ls two '.issues. first, it may 11sodum :..'iiiiil. warty r'i'ov/ths in tho si's - the su-euLied "ur.bor.i-or corn!'.", 'foii'.ll.y, It may gjvt* rise le a fibrosis of the liitvyt, somoifne L }.imi.ln to that produced by L.L.Lcn. Inventiry.tion of "asbestos corns" indicator. Hint they e tyarm Ioms Lone in nature and have. for their core a tiny spluir of ....w.;: to:. More. It i:. bn 1 loved tint ; L Lien is n of uuLn.onsiy L i hror in. At proper t 1: tbn occurrence of ;>u Li.umnry a::.be;-, to: i:, .'i si Lien to. iio niuily.aiu bar bnon for nil Lea in ermes of naboatorin. to the Ior:.:s tion carciot :>r c. i ..roved by , since a oca to;, itself mo of pulmonary tissue II, ii.Lr<nt bn thought that ifsIon i.n thin condition win otwuntia.lly tiic sane or that of ordinary i Li coni a, if it were not for the fact that certain very chime ! aria tic oociics are report ed unlike those seen in any other pa' jloyioai picture. i,c refer to tho ao-c, LLed "curious l/ouies". .eroscoyie nootiom. of lunyr, of nr,bur ton '..orkorc show iiaa^c elonrs eu eodion varying in l.o.iyth MAHKLT ANALYWIb ftFCTION SALES PHOMOTiON DCPARi U NT JOHN^-MANVILLI corporation MT-001694 from 10 to 100 micron::. They may have a Ingle clubbed ends or may appear ns elongated dumb holla, are sometimes single coccal or streptococcal forma aro seen. The; "o not a Lain v/ith ordi nary Aniline dye::, bub am themsolvos . Le yellow or yellowish brown. Apparently they aro composed m a contraL core, which .in probably an ssueotos rp.i ru I o, upon i.el) colled lal nggreg:: bos of blood proteins hove boon absorbed. .Since tno rojiorled enneu; of thin ;.or:: o lrvo occurred largo.ly fmonq spinner:: and weaver;:, 1!. possible thot_/Mi'* mining and crushing of whoa tor. doc:; not pro; -at a hn/.nra. The f.rlluro to rocognlse ttio aisngso in Canada, h>... vor, i.s no evidence of this, for in other occupation:: experi " - lv\i: suown that .largo groups of men oiITer serious occupation-1 efl\:cbr. wnich go unroeo'i)inn for yearn. Bulletin of Hygiene - !. `on - Lee. J.9LU V. 4, glL Pa U78 Abstract - Qioyn . o. iiootllionuc (food, ,,B,, Pulmonary /.abe M'ris. R.adiogrr>p!iic Apponmncon in Bkiagrarns of 1 he Chest oi' Porkers in Asher.lor.. Tubeclc. VjZ '. V. 10. LIk--Gb; lb. figures on G p-ls.: lb rof.) 'file <: iri.iiii". L symptom of puinonar gsbnr.tosls, like that -of other To cm:: of :: 11 l.eosir, is dyspnoea. Milch progresses until in the advanced stages of the disease, il .ccomcs ov:tror.v3. The dyspnoea may bo .accompanied by eyanos: and the complexion of nos t pat.ien Is has a slightly leaden hr-. Chest expo nr ion may be reduced bo one inch or less. Cough 1 :';lcj.o:n .re; rive ana ex pos luivilion is .iiodcvuto in asoiml. or .n nunent. The jnyaicnl signs are those of a :.Lliitorsi pulmonary fibro sis chiefly .fleeting the .Lung bases. Pulmonary tuberculosis may uuporvoiui or modify llm clinical, `owuro. i.ii'.m blio dioouso is well os bru.ili'jheii the prognosis apy cs bo lie grave. Post 'lortem, the dLagnostic foul u e which rei ver to Uistin<gu.irh the condition J'vo.n otiior Lor of pncmunoconiunis is the presence is the lungs of golden y Mo.; foreign bodies with MARK FT ANA1Y4I9 SLCTION IAUI ^HOMOTION OCPAHIMi.NT .'OHNJl.MAdVIUU COItrOHATION MT-001695 r.figmuntooi outline and clubbed extremities bearing a superficial resemblance to minute crustacean forms. n British Med Leal Journal - !'.ept. Jib, l'Jk'J (P. 57U) Cooko,17.F. - i.I.D.j F.R.G.P.Gd.; .U.0.1'. I.oridon. jD.P.H. Asbestos l>ur51 anu the Gin eus bodies Pound in Pulmonary As tor in A scientific. treatment of the ' lys 1 h of the sodics found, dii,?L some oil Islandin'* braetr. token. I h",vo mentioned that the greater portion of asbestos dust con.'ifctn of slender translucent fibres. In section.- end extract;: of lung!' l-horo is a remarkable pnucit of those fine spicules. Iho end-reru.Hr.' of dir'estiou : hov; the ;na r/rnnel.-.-.v dust, and Inc largo black, blue, uni hro'.m par c.Lcle- . i i ;!r:l. .appears to bo piecos of quarts'.. Re la lively lew firs a plains -arc found, but curious bodies of all descriptions are erosent in enormous numbers. Ail. these .facts inml us to imsipi.r. the bodies to consist of central nuclei of asncslos, spicules U|;on which colloaial aggregates of blood proteins, plus, possioLy, solar do faction.'-; of asbestos, and in the cnr.fi- of chrysolite workers .dn iron so 1.1, hove been .absorbed and moulded by current:) in t!"- bronchi ana alveoli. OccasionalLy blollto fragments into fine black spicules, and if our rea"otii.ng be correct, some at b ast of the pillions of curious bodies si toil Id show a central i.-e of this mineral. British i.iociical. Journal liept. ko, l`JLd Hacldow, A.G. - Ivi.)1.; Gh.B. GLlnicn I. Aspects of Pul <mory Ashes tosifi A clinical anti scientific study m specific cases of this disease. h'xnmir.ul.ion of some fifteen asbe..ios workers. MAHKH ANALYSIS BICTION SA LES PROMOTION DLPAR * *,rNT JOHN&.MANVILLE CORPORATION ^T -0 0 1 6 9 6 Significant extracts token. Of thoao four fatal casco, the average at death was 41, and the overage yearn actually spent in the factory were under tiO, all In asbestos-mattress making for moot of the time. The .male patient had worked until two days re fore death (on n .light job) Inti, the other l.luvo had boon incu -cits Led for an .uvorngo of two and olio-half yearn (byrs ., l> nv k yrn., G moo.; 1 yr., 10 moo.). Only in one of them had tu1 sclo bacilli been found .in the sputum. Advanced Pasoa In pvnetlcc, those workurr. uo not all for much '.intention until they reach the stage of total iua-pacity. Until then they are naturally more prone to chert tro 1 on during the winter mouths and oomo timer am fit for week:; at a tia .. Olinlcn l.ly Four women Average - 35 year:; of age 11 14 years spent .is factory " 3 children upicr. (PhiIdrc-n all healthy) tuffer from shortness of lr th ' Have cough without cxpectc tion . Iieai,, although not Losing .i u weignt Pain is variable, and occur from time to time with localised pleurisy bight sweats absent Has been no haemoptysis no tubercle bacilli have b"'m found heart noirnial - Pulse rate UP at rest Average full range of chest expansion is only one inch in the upper thorax and even term around lower rib". On.roI. of symptoms It is very difficult to ascertain the date of onset of symptom", but the patient:; generally ' 'Lievu it was. after five years of work. Conclusions M T-001697 The foblowing conclusions have ! ' u vntablir.hod. 1. That the inhalation of asbnsto' dust will in the long run produce a state of fibrosis, the distribution being peripheral and basal, the rlcdit base becoming int-?-..- advanced and the upper lobes tending to develop compunsnLory emphysema as first the din- phrugmatic and gradually tho on tiro ; I ural surf:.cor. becoming obliterated. MARKS! ANALYSIS SPCTION SAUI PNOMOTION DLPAH I v1.*rt ^OHN$-M ANVILLK COMMON AT ION 2. That the disease is not its u rule complicated by tuberculosis. 3. That the disease is usually fir.* t recognised after more than five years exposure, although sy' i-'-mntic examination might reveal it ccusLier. 4. That the condition is usuall; - outid first during an nblack of iiiJ'luoiwi or winter col.tl, v/i1' exacerbations oi' the disoano occur. 3. That even in advanced cases ta-ce is a marked abatement during the summer months, 0. That the onset of anorexia si ;n <Lisos to the worker that v.'ork is no Longer possible. 7. That the patient way then iiv : lor several years and con tinue to bear children, but become pro essivoly v/eakor and more emaciated, more hopeless, sleepless, x- I exhausted, until un attack of broncho-pneumonia or bronchitis bv11 > ;g death at last. 0. Further, that imboutosis Ijou can be found in the sputum, if any, In n.ll odvnncod casos, as well ' s in most early cases. 0. That they, can be demonstratea o. lung puncture in advanced cases, but since no patient is likely to permit more than one punc ture to bo made, a negative finding i". inconclusive. 10. That radiography is of great v i.uc in diagnosis and in observing progross. 11. That the trontment of Lheso c ' os, being purely pallia tive so far, calls for great patience aid vigilance over several years, and much relief can be afforded. 12. Finally, that the disclosure of the danger arising from asbestos dust has brought home to the workers the need for observ ing the measures provided for their p1 , lection, and is bound to ho salutary, although the mortality s luistics v;ill probably be swelled by the wider recognition of l"' ; disease. MT-001698 MAHKtT ANAIV&I9 ftLCT'ON British i.ledicnl Journal - Dec. 5, 1927. (P. 1024) Cooke, w.K. - "pulmonary Ashes Louis" McDonald, btuort - "Ilisk logy of Pulmonary Asiiest.osis" SAlJfl PROMOTION DF.PARI'M.NT JOHNJ2MA^VILUt CORPORATION Oliver, Sir Thomas - "Clinical Aspect ; of Pulmonary Asbes L.v. '.3" The above ar Helen oro scientific ! >'oa treats of this same disease. The material covered is proci: ".ally the some. In fact, much of the material of the later art.i'-los from ./hlch the abstracts are based appear to be based on the sir. experiment:-. The illus trations of the microscopic photograph'- are enlightening* MAHKLT ANALYSIS SUCTION SAUCS PHOMOT'ON DCHAM >*'NT MT-001699 ,'OHNS-M AN VILLK COl*ORATION (-11 Ct -'i } ' ly'fy . ch rr^c (-i- (>'11">' > J ou '/uc-'. '?.-<r Kmtoki u. : AsiiksTosis y a tcKi 003073 posterior lnln:, Ur; reaction was negative. Furlliermore, the injection of 0.2 c.c. of tin1 hormone of the anterior lube of the pituitary body, when injected into the akin of a pregnant woman, produced no reaction, whereua, when injected in the .same way in the non-pregnant, woman a distinct rial circle ia produced in a few hours, which persists from twenty-four to thirty-six hours. The accumulated evidence, therefore, goes to show that tin; hormone responsible for the Zondek-Ascheim reaction is derived from the anterior lobe of the pituitary body; that the reaction is positive tpiite early in pregnancy, at a time when such positive evidence is most needed; anti that the re liability of the test is very high. Jt, is regrettable that from its nature the test cannot be made generally available. It requires tin; assistance of a laboratory where a large stock' of young female mice is con stantly at hand, and where then; a re trained observers. The test., as a consequence, is expensive. It, may prove, however, that the skin test, referred to may overcome the dilliculty. Recently, 1 >rs. Otto l'ollalsrhek and R. Forges, of Vienna, have made some valuable; observations on Ibis phase of the subject,, and report that in their hands the skin test, has proved to be reliable, except in one patient who had a hypophyseal tumour. .Should these observations be continued we shall have at, last a simple and reliable method of determining the existence of early pregnancy. A.U.N. ASBESTOSIS ASBESTOS is a mineral of interest to Canadian physicians, particularly to physicians practising in the Province Quebec, for a very considerable part of the world's supply of asbestos is mined in the Black Lake District between Quebec City and .Sherbrooke. If work with asbestos presented a hazard to the worker it w ould be reasonable to suppose that cases of disease would be reported from time to time, but so far as can be determined no cases of specific disease have been reported among asbestos workers in the Province of Quebec. This does not mean, however, that a hazard docs not exist; it merely means that no hazard has been recognized. Mortality and morbidity records of asbestos workers are not available. In fact, information as to the effect of such work on the worker is extremely limited. The death of an asbestos worker which occurred in 11)00 was reported by l)r. Murray in England to the Department on Industrial Die eases, and the evidence suggested that the death was due to an occupational disease. This case was not reported in the medical literature. No further reports appeared until 192J, when Dr. W. hi. Dooke, of the Wigan Infirmary, published the history of a case of pulmonary asbestosis. Since then a number of isolated cases have; been reported, mostly in the manufacture of asbestos, and mostly in England, but four cases in .Southern Rhodesia were reported by R. W. Simson in o1f928. The latest publication on the subject is by W. JO. Cooke, in the Iiritinh Medical Journal for September 28th, 1921). This article is in the nature of a review. Asbestos occurs in nature as a fibrous form of serpentine. Its analysis varies somewhat in different parts of the world, but it is essentially a magnesium silicate. There may or may not be iron present, anil some forms contain aluminum. The Canadian asbestos is said to contain about 41 per cent of silica and 2.5 per cent of iron oxide. Clinically, asbestos affects two tissues. First, it may produce small warty growths in the skin,--the so-called ``asbestos corns." .Secondly, it may give rise to a fibrosis of the lungs, somewhat similar to that produced by silica. Investigation of the "asbestos corns" indicates that they are granulomatous in nature and have for their con; a tiny spicule of asbestos libre. Evidently asbestos is mildly irritating to the body tissues. The manner of the formation of the pulmonary lesion is of great interest to students of pneumoconiosis, for there is a widespread impression that, silica is necessary to the formation of pulmonary fibrosis. Nor can it be said at present, that, this view is definitely disproved by the occurrence of pulmonary asbestosis, since asbestos in it,self MT-001700 25-1 Tiik Canadian Mkdioai. Association .Journaj, 3ZEVT2 is u silicate. To our knowledge uo analyses of pulmonary tissue for silica have been made in cases of asbestosis. It might be thought that the lesion in this condition was essentially the same as that of ordinary silicosis, if it were not for the fact that certain very characteristic bodies are reported unlike those seen in any other pathological picture. We refer to the socalled ``curious bodies." Microscopic sections of lungs of asbestos workers show large elongated bodies varying in length from 10 to 101) microns. They may have single clubbed ends or may appear as elon gated dumb-bells, and sometimes single coccal or streptococcal forms are seen. These bodies do not stain with the ordinary aniline dyes, but are themselves pale yellow or yellowish blown. 'The ``curious bodies" may be isolated from lung tissue by digesting portions of the lung with trypsin. They may then be teased out, and in this way some idea of their structure may be obtained. Apparently they are composed of a central core, which is probably an asbestos spicule, upon which colloidal aggre gates of blood proteins have been adsorbed. These ``curious bodies" have been reported in different places in England and South Africa; in fact every published report of pulmonary asbestosis has described them. `It, is the opinion of Dr. Cooke that the ` curious bodies" are diagnostic of pulmonary asbestosis. Wince the reported cases of this disease have occurred largely among weavers and spinners it is possible that the mining and crushing of asbestos does not present a hazard. The failure to recognize the disease in Canada, however, is no evidence of this, for in other occupations experience has shown that large groups of men may suffer serious occupational effects, which go un recognized for years. shank a. hihilev. iMtonaI Comments I,i: iMai, ni;.s ('iu-a.-iiks The problem of I In; creche or foundling hos pital is how to lessen Ihe relatively high rale of mortality that so often exists among the chil dren cared for in these institutions. The death rate, formerly nothing less than appalling, has been of late much improved through a fuller appreciation of tin- value of pasteurization of milk and of tin- decisive part played by vitamins, but. it is still loo high. The outstanding fea tures of tin- affection that, carries off so many infants, as is well known, are nth repaid and diarrhoea, `fids affection can hardly be termed a disease, as it is not. a single entity and the causes are multiple. Vet many names have been applied to it -- le mal des creches, summer diarrhu-n, infantile cholera, milk injury fUzerny), disturbance of equilibrium (Finkelstein), and some others. Actually, what, is called by these various names is a symptomatic condi tion with a varied etiology. Drs. lamgpre and J'nnneton, in a helpful article that, appears in the present, issue of the Journal, have done good service in emphasizing nne important eause at least, namely, iufeetioli in the nose, throat, and ear, an infeetion, more over, whirl) may he diphtherial and, as such, unsuspected. These authors point out, that the problem involved, in many cases at least, is one of infeetion rather than alimentation. dareful examination, of tlie nose, throat, and ears, both clinical and bacteriological, should he carried mil in all infants that are not thriving, for lesions of these- organs may he overlooked or, on account of their relative benignity, may be passed over as of little account. J)rs. bongpre and I'anneton give some strik ing figures as a result of their investigations in a ereclie with which they are, connected, though they do not claim that, their findings arc neces sarily applicable to other similar institutions. Ji) sixty autopsies conducted on children dying with Ihe "mal des creches" only two infants were found to have intestinal lesions. The nut standing conditions found were otitis and mas toiditis, which were present in fifty cases. With out eliminating completely frank gastro-enlcritis, Iheir experience leads Ihom to lliink llmt Ihe signs manifested in the digestive tract in cases of athrepsia are not primary hut, secondary to a, septicaemia, usually due to infeetion in the ear. Furthermore, the authors have examined, in 151 eases, the secretions from the nose and throat in patients manifesting no local symptoms, and the pus in eases of otitis, and were surprised to obtain b. diphtheria; in 85, or 5fi.fl per cent.. Of course, the discovery of b. diphtheria; in noses and throats that, do not manifest the typical signs of diphtheria, or, indeed, any signs at. all, is not new, hut Drs. Longprc and Fanneton have performed a useful service in pointing out an important, cause of trouble in hospitals for children, where the diets prescribed arc proper, and the care is otherwise beyond reproach. ' A.ft.N. MT-001701 003106 i'ULMONAltY ASBESTOSIS. ]?AUioGJiArjnc Appkauancks in Skiaghams OK TIIK ClIKSTS OF ` WoKKBKS in Asbestos. By W. Buhton Wood, Af.A., M.D., D.P.H.(Cantab.), M.K.C.P.(Lond.) Physician to Out-patients, Cilp ofLondon Hospital for Diseases of the Henri and Lungs, Victoria Park, J5., Consuliitiy Tuberculosis Officer to the Essex County Council. <. . . . my first task skull bo to consider such DiseaEC* as arise from the offensive Quality o( tlm matter which tradesmen handle in the Way of their Business. Under this Head I reckon tho Diseases which affect Mine-diggers and all Workmen who work upon Minerals."--Kamakxixi ok Padua. (17iC.) Last year Dr. Leonard Williams, Medical Officer of 3Tealtli nnd Tuber culosis Officer of Burking, asked me to see several patients who had been attending a local dispensary. He had noted that though they were suffering from pulmonary fibrosis the condition differed in some respects from that usually associated with chronic phthisis. There was in each case a history of exposure to asbestos dust. In only two instances had tubercle bacilli been demonstrated in the sputum and neither signs nor symptoms were typical of tuberculosis in the fibroid form. Despite the absence of the final proof that only post-mortem examination can supply, a diagnosis of pulmonary asbestosis seemed to be justified in most of the cases. While the present investigation was proceeding two asbestos workers were admitted to the Victoria Park Chest Hospital, while the out patient department of the sumo institution supplied four more eases. Fifteen skiagrams of the chests of asbestos workers wore thus obtained. It is indeed strange that so little attention has been paid to the ill-effects of silicosis among workers in asbestos, a substance well known in com merce since the days of Hippocrates. I have failed to find any mention asbestosis in standard works on pulmonary diseases and few references to the condition are to be found in recent medical literature. Asbestos fo-/Jcv7o? -- unquenchable) lias been described by W. J3. Cooke [I] as "a physical paradox--a mineralogical vegetable, both fibrous and crystalline, elastic and brittle." it is one of the silicates, but as will be seen later, other minerals enter into its composition. It occurs in veins associated with quartz and similar rocks and is widely distributed. The best known varieties are found in Canada, Italy, Corsica and South Africa, but it is also found in tho older rock formations of bfc-rlh Wales and Ireland. Thu Asbestos Mountains iu what was formerly Cape Colony contain a fibrous mineral of rich blue colour and beautiful texture re sembling strands of finely spun glass. The veins of asbestos run through slaty rocks mingled with jaspers and quartzites rich in magnetite and brown iron ore [2]. The variety imported from Canada is known as white asbestos and lias a silky texture. The fibres are obtained by blasting in open quarries, the fragments of rock being then crushed, screened and pulverised [3], The crushed product is passed over a vibrating machine and the asbestos is withdrawn by vacuum fans into special chambers. To aave the expense of carriage these preliminary stages are usually carried .'ubeoaLt, !0'-3$5-3b3 V%>. \qzy J' S ' L S -T !d r w ! c ! ' f T ) 7 Vf f c o p y * ip * '* le w p ro te c te d b y >7 U .S . C o d e '* MT-001702 354 TUJiKKCLJJ [May, t',)29 out before importation. Carding and spinning of asbestos form an important industry in tins country. In these processes silica-laden dust is generated in large quantities. The heat-resisting properties of asbestos, its low thermal conductivity and partial resistance to the action of acids account for its extensive use in modern engineering processes. It is much used for jacketing boilers and steam pipes and in the packing of joints. Fire-proof sheeting and curtains, feltings for roofs and floors, even firemen's clothes have been manu factured, and its employment in industry is likely to expand with further developments of the machine age. I)r. "W. IS. Cooke states that the composition of Italian and Canadian asbestos fibres is as follows:-- Silica .. Magnesia .Ferrous oxide Alumina Water.. Italian litre 40 30 43 3V 0 67 2-27 33-72 Canadian rluysolil? 4067 41-50 2-81 0-90 3355 The high percentage of silica will be noted. In the process of manufacture, iron is as far as possible eliminated, but Ur. T. H. Pyroin's analysis of asbestos dust from carding rooms shows that this may be heavily impregnated with it:-- Finished nrtic-le : Iron (ns ferrous oxide) Crude raw material.. .. .. llust from carding room .. .. .. 01 percent.. 281 ,, .. 18-4 ,, The effects of inhaled silica dust upon tlm lungs arc well known. A concise account of these is given by U. J{. Sayers in the slhiciiaut foimml of I'tili.c Health {/!]. Shorter references to the subject will also he found in the well-known textbooks of Norris and Landis [5], and Powell and Hartley [GJ. It is doubtful whether the action of silica is purely mechanical, as precipitated silica has been found to produce a similar effect to that of the crystalline forms. Three deaths occurred among patients of the present series within the last few months. One autopsy was obtained. This provided material for pathological examinations by Dr. S. Koodhouse Gloync. The results of this aucl of an investigation of the sputum of asbestos workers will form the subject of a further communication. Pathology of Pulmonary Ashestosis. The macro- and microscopical appearances of the lungs of an asbestos worker have been described by AY. l-l. Cooke and Stuart McDonald [ 7] [8 |. The lungs, and particularly the right lung, were the seat of a massive fibrosis with thickened pleura. A large cavity was present on the right side and numerous small areas of caseation, though tubercle bacilli were not demonstrated. The interstitial fibrosis was such as might be expected as a result of a combination of a pneumoconiotic condition and a chronic tuberculous infection. An account of the histological appearances is given in Dr. McDonald's paper which is illustrated by a series of excellent photo-micrographs. Particular attention is directed to the appearance of certain foreign bodies lying free in the alveoli or within the large mononuclear cells. Of a yellowish-brown colour with narrow segmented bodies and clubbed MT-001703 May, 1920] l'ULMONARV AS1H2STOSIS 855 extremities, their resemblance to minute crustacean forms was.striking. Dr. McDonald thought they were probably " portions of asbestos fibres in the process of alteration and absorption by hydrolysis either by direct chemical action or by enzymes." On treatment with potassium ferrocyanide and hydrochloric acid the prnssiau-blne reaction was obtained. Jn specimens from the lungs of the same patient Dr. Cooke also found particles apparently identical with heavy brittle iron-containing fragments of fibre previously found by him in asbestos dust. lie states that the curious bodies referred to above are not found in asbestos itself. Dr. M. J. Stewart ['.)], however, found enormous numbers of similar golden yellow bodies in the expressed juice from the lungs of a patient who had worked in asbestos. Their presence in catarrhal alveoli and in fibrotic patches in sections from the same lungs was also demonstrated. Dr. Gloyne's sections from the lungs of a patient in the present series (Case 7) showed numerous similar bodies. Careful search failed to reveal any similar forms either in samples of raw asbestos or in the sputum of workers. Symptoms of Pulmonary Asrkstosis. The cardinal symptom of pulmonary asbestosis, like that of other forms of silicosis, is dyspnusa. The dyspmea is progressive and in advanced stages of the disease may become extreme. Chest expansion may be reduced to one inch or even less, as in Cases V and VI and also in the case described by IT. 15. Seiler [10]. The vital capacity of a patient in the present series (Case I) was approximately J ,000 c.c. The dyspmea may be accompanied by cyanosis and the complexion of most patients lias a slightly leaden Imp. "Wasting is a notable feature and may proceed to emaciation. As patients .suffering from fibroid phthisis are often well nourished, the degree of wasting in pneumoconiosis is a point of some diagnostic value. Cough is a variable symptom, hut is seldom excessive and may he slight. Expectoration is usually moderate and may he altogether absent over long periods. Particles of asbestos arc apt to penetrate the superficial layers of the skin of the arms and legs of workers. The irritation of these causes keratinisation and "asbestos corns" arc produced around a central core of fibre. Physical Signs. If pulmonary tuberculosis supervenes the signs and symptoms of this condition will obviously modify the clinical picture. Jn the absence of such a complication the physical signs are those of a bilateral pulmonary fibrosis chiefly affecting the lung bases. The adventitious sounds have a dry crackling quality and in the axillary regions are often superficial. The latter probably have a pleural origin. A friction nib may he heard over the same area. As the disease affects both lungs, cardiac displacement, if present, is usually slight. Early clubbing of the fingers may occur but is seldom well marked, and when seen is usually represented by slight swelling of the skin surrounding the proximal ends of the nails. D1FFKIO NT1AL DIAGNOSIS. Pealures which serve to distinguish asbestosis from pulmonary tuber culosis, though a combination of flic two conditions may be often suspected and sometimes proved, are the leaden or dusky complexion, extreme 35G TUJJKIlCJiU lMuylwli)2D dyspncua, wasting or emaciation out of all proportion to physical signs and the dry quality of the adventitious sounds. These, with an absence of tubercle bacilli from the sputum and a history of prolonged exposure to nsbestos dust, indicate the probable diagnosis. In one-instance (Case Vl) the result of sputum examination suggests that tuberculosis may have supervened some time after the onset of a non-tuberculous fibrosis. PROGNOSIS. When the disease is established the prognosis appears to he grave. As noted above, three of the patients of the present scries died during the present winter. Autopsy proved that broncho-pneumonia was the terminal event in one case, bronchitis" was given as the cause of death in another, while in the third it is probable that broncho-pneumonia was the proximate cause. . PiutATioN of Dxi'o.sum; to As in-: sms Dust. In the gold mines of South Africa the average time of exposure to silica dust before the development of pulmonary disease can he recognised is given h}' It. It. Sayers as seven and a half years [4]. A shorter period, even one of a few months, has resulted in pneumoconiosis where conditions are unfavourable. In the present scries of cases the shortest period of working v.as one year (Case IX) and the longest fourteen years (Case II). One patient (Case XII) was exposed to dust for a period of eight years before the onset of the cough. Another (Case VII) remained in fair health for five years after commencing work, although frequent colds and a tendency to winter cough were apparent. It is significant that a patient may only complain of symptoms of pulmonary distress some lime after ceasing work (Cases I and X). A reference to the radiograms will show that in general the density aud extent of the lung shadows is proportional to the duration of the exposure to the dust. ltADIOI.OGICAn Aitkaiiaxoes. Deductions from a small series of films must obviously be made with caution. Most of the cases described below have only been under my observation for short periods, and though the presence of complicating tuberculosis has been noted in all cases in which the tubercle bacillus was demonstrated, negative sputum or absence of sputum on one or two occa sions obviously does not rule out infection of this type. All that is possible at this stage is to draw attention to what appear to me to be the salient featu res of the films. It is further obvious that reduction in si/.e, absence of illumination and difficulties of reproduction must prevent a. convincing demonstration of some details which arc present in the original films, as seen in the viewing box. The most noticeable feature of skiagrams of workers exposed longest to asbestos dust is the presence of shadows suggesting a diffuse fibrosis affecting chiefly the lower two-thirds of the lungs. The fine quality of the shadows is worthy of note. Some of the cases exhibit a "ground glass" appearance, though on close inspection fine mottling is evident. Thebronchial striations towards the lung bases arc prominent and seem to spread out to form a fine network, giving an appearance like that of a cob web. As the striations radiate outwards from the lung roots they cut the MT-001705 May, 1929] PULMONARY ASRliSTOSlS 357 %r edge of the cavdiiic shadow, especially on the left side, giving a shaggy appearance as if the heart were encased in coarse felt. When more definite mottling is present it lacks the coarse quality described in the skiagrams of chests showing pneumoconiosis, e.g., in South African coal miners. I have been able to include a typical skiagram of the latter con dition kindly lent to me by Dr. I*1. G. Chandler. Deference may also be made to articles by Kir Thomas Oliver [II] and W. Ktenart [1*2]. Another feature is evidence of basal pleurisy, and the frequency with which the costo-phrenic angle on one or both sides is obliterated will be noted. Many of the cases also exhibit thickening of the apical pleural cap. Annular shadows suggesting possibility of cavitation are only seen in three cases (William H., Barbara L., Violet S.) and in only one of these (Violet 8.) tubercle bacilli had been found .in sputum. The region of the lungs most apt to show marked changes in pulmonary tuberculosis of the fibroid typo is usually spared. I am indebted to Drs. V. 8. Hodson and A. J. Kc.ott Pinehin, for allowing me to see eases under their charge; to Dr. F. G- Chandler for the loan of a skiagram of miner's phthisis; to Dr. J. V. Sparks, under whose supervision the skiagrams were taken ; to Dr. Hood house Gloyne for helpful suggestions; and particularly to Dr. Leonard Williams, Medical Oflicer of Health for Barking, without whose cordial co-operation the present series of cases could not have been brought together. CASE NOTES AND SKIAGRAM REPORTS. CASK I. Frederick K., nged --Admitted to Victoria Park Chest Hospital, January 1929, complaining of severe shortness of breath on slight exertion. Juiuiiti/ llixtiiry.--Two brothers died of phthisis. One brother, a stone mason, died of malignant disease of the chest. HUloiy.--Seven years ago the patient startl'd a. factory for (-"rinding up crude asbestos into fibre. Ifr wore a respirator ul work, hut dust used to cause severe coughing and cxjiectoration. He abandoned work about Die end of 1927 for business reasons. After giving up work lie remained free from cough till August, 1928, when it letnrned and " his breath failed him," even walking' causing dyspn<ea. In Novemlicr, 1028, he coughed lip quite a pint " of dark blood mixed with phlegm. He had been losing weight since leaving the factory. Pliysicnl --The patient is a fairly healthy-lookingman. Finger nails are curved, but thorn is no definite clubbing. The faee slightly cyanoseil. The chest is emphysema tous. There is impairment of percussion note at base of right lung and line, fibrotio crepitations are heard at both bases. Xo T.H. found in sputum. KK1AUHAM. 7 he skiagram shows a " ground glass " appearance of both lungs, more noticeable on the right and most marked at the right base. There is some contraction of the, right apex where the pleura) cap appears to be thickened. The original skiagram shows line diffuse granular mottling of tin; right lung. The costophrenic angle is obliterated and there is a marginal shadow due lo thickened pleura at the right base. The periphery of the cardiac shadow is blurred. CASK II. Milium 11., aged -Hi.--Admitted to Victoria Park Chest Hospital, May 1928, complaining of severe shortness of breath and cough. Ifmli.i-The patient had worked at an asbestos factory for fimt'U&n years Dip to tune of admission). JIc remained under observation in hospital for a period of seven weeks. Expectoration very slight. There had been cough, worse during the winter, for the last three years. .Morning cough had occasionally caused vomiting. He attended the MT-001706 358 TUDKItCLIi [May, Vm tuberculosis dispensary at tlio end of November, 102V, at which time lie was suiTering from bronchitis, the sputum la in" negative for T.B. Hi; bail suffered from " pleiirisv " as jL boy. '- Family Hislury.--Nothin;; abnormal. Physical Signs.--The patient is emaciated. Taee cyniioscd. Fingers clubb>-d. cussion note is poor generally. There is harsh breathing and prolonged aspiration at ;he base of right Inns. l''ibrotie erepitations uru heard all o\er tlie hin;;s und are especially marked at the bases., SKl.YGKAM. > TiiOle is thickening of tlie right apical pleural cap. Alrove and behind right- clavicle them is a circular area, probably caused by small cavity. An annular shadow is seen over the anterior end of third rib on the right. There is a "ground glass" haze over the middle third of cm;h lung field. Fine granular mottling is disseminated over both lungs. Towards the right base there is an aggregation of these shadows leading to fairly dense opacity. Tlie trachea is slightly displaced towards the right. The mediastinal shadow is wide. The edge of cardiac shadow indistinct, and on left side lias a " felted " appearance. The costoplnenic angles arc obliterated. CASH III. Kilim B,, aged 20.--First attended tuberculosis dispensary in September, 192b, i-onipluining of cough accompanied by much frotby sputum and shortness of breath. History.--Asbestos worlicr, 1010-102;!. The patient remained on tlio hooks r,f (lit, dispensary np till November, 102H. The case was diagnosed as pulmonary fibrosis involving both lungs. No definite evidence of T.]!. was found, hut in 1027 the pats-nt, was admitted to sanatorium where she remained for two months. Temperature norma! during this period, and she was able to take short walks, but complained of dyspinen. 1'rrvinnn History.--Tnlhicnza, 1010. No history of plain isy or pneumonia. l'hyiirnl Siyns.--Extremely thin (weight C st., I!lb.) Slight cyanosis. No clubbing. There is some retraction at l>oth lung apices. J'ereussiou note is impaired at both apiees and a'so at left axillary region where breath sounds are weak. Fihrotic crackling crepitations are heard in both inframamiiiary regions and at Imlli luces po-t<-riorlv. Sputum negative for TJi., 102-1, 102b, 102.S (.'{). SKIAGRAM. There appears to be slight thickening of the apical pleural caps. Tiie upper portion of mediastinal shadow is somewhat widened. Edge of cardiac shadow shows " felted " appearance, most marked along the left margin. CASK IV. Barbara K.. aged 40.--Firs* uttended dispensary in September, 102G, complaining of cough with a little sputum and occasional shortness of breath. Diagnosis of pulmonary tuberculosis was made, but sputum was negative for T.ll. History.--The patient had originally been a worker on the land, at which time she developed "tissichy" cough. She worked as u sweeper in nn asbestos factory for about ten years, 1017-1927. Cough during this time was never severe but was worse when she was at work. During the last year nt the factory she had pain at front of chest, cough und dyspini a. Increase of these symptoms caused her to give up work. Slight cough without expectoration has persisted. J'rcuions Hislnry.--Nothing abnormal. Physical Signs.--Patient poorly nourished (weight C st., 11 lb.) Not cyanosed. Fingers slightly clubbed. Chest is emphysematous. There is marked retraction of the right apex. Percussion note impaired over left upper lobe. There is also impairment of right base. Bronchial breathing, whispering poctorilorpiy over a small area below right clavicle, suggesting cavity in this region. SKIAGRAM. This shows some slight scoliosis, with displacement of I lie trachea to the rigid. Bight apex is retracted and covered by thickened pleura. Over the second intercostal space on l ight side there is an annular shadow, pi sihly due to a cavity. Internal nnd external to this is n slight haze. Way, 1929J lMJLMONAUT ASHKSTOS1S 359 At the right base there arc some fine linear shadows ami line granular mottling. Tin; right coslophrenic angle is obscure, a ml there appears to be some thickening Si Die pleura toward* right base. ' CASE V. " Mary Ik, aged 40.--Attended tuberculosis dispensary Match, 1027, complaining of cough and shortness of breath of four years' duration. l'amity //odor//.--One brother said to have died of pulmonary tuberculosis. History.--Patient worked in an nslxistos factory, 1017-3020. About 1024 she began to have a cough. Ifliis was associated with expectoration in 192a and has continued ever since. 1`fiysinil Kitjns.--The patient is extremely thin and in a very debilitated condition. Fingers slightly clubbed. Chest emphysematous. Some impairment of the percussion note at light apex. Fihrntie rides arc heard all over both lungs. Expiration prolonged at right apex. Sputum T.lt. negative four times, 1927-1928. SKMGKAM. The cardiac shadow is enlarged transversely and the left auricular region is prominent. The trachea is slightly displaced to the right. There is some relative clouding of right apex. In the right mid an 1 lower zones there are numerous rounded opacities of moderate density. Some of these have a diameter of 4 mm. There are numerous small granular opacities. Some of these towards base of tin; lung arc very dense and probably represent calcifications. Similar changes, but to a less degree, me found on left side. The haziness of the mid-zones is partly accounted for by breast shadows. . CASE VI. lferlM il llddcr If., age 42.--Complaining of spasmodic cough with cxpectoraDon. I'limily History.--Nothing abnormal. History. --Vni\onl first attended tuberculosis dispensary in 192). At that time sputum was negative. Sputum again negative in 192a. T.lh positive 1927. 'J'.ii. positive 1928. Patient worked in asbestos factory at intervals from Ucoembev, 1918, to November, 1028. (Total period in factory about seven years.) J'liysirnl fiiyns.-- Patient is a moderately well-nourished man. Weight 9 st. 12`J lbs. l'aee slightly cyunosed. Fingers clubbed. Chest expansion barely one inch. Percussion note impaired over both upper Jobes, specially on right side. There is also marked impair ment of percussion at tin; base of left axilla. Crepitations are heard all over right lung listeriovly. lircalh sounds at base are harsh. Crepitations also heard in left axillary region. SKI A fill AM. Trachea markedly displaced towards right. Cardiac shadow slightly enlarged. Eight border merges with mediastinal shadows which are very dense. J.cfl. border of heart has a " felted " appearance. The outer zone, of each lung shows a fairly uniform " ground glass" opacity. In Die original film this is seen to he partly due. to numerous granular opacities. Upper surface of diaphragm is obscure on both sides and right costopbrenic angle is obliterated, ajipoaraneos suggesting thickened pleura in this area. At the bases some clearer areas are seen which are probably bronchial. There is clouding of right apex. CASK VII. Nora C., age 34.-- Patient first attended tuberculosis dispensary in -Tuly, 1928, complaining of dry cough of three years duration, and marked shortness of breath. Homily History.--Nothing abnormal. History.--Patient began to work in asbestos factory at the age of 21. During the first five years she remained in fair health except for frcijucnt colds and some winter cough. No respirators were worn at the factory, and as far as she knows, no precautions were taken against dust. After the lirst live years "her chest began In he stuffy " and she lost up/Hitite for food. She remained at the factory for eight or nine years. The breathlessness was first noticed three years ago about one year after leaving the factory. At tile same lime she also began to lose weight. At the end of 1928 admitted to Victoria Park ( best 111>spita) whi le she remained till death, which occurred on March 1 of this Near ns the vosull of an attack of hroueho-piiciinionia of one week's duration. - Whilst in MT-001708 300 TUUKltCLK [Msiy^l20. _r hospital cough very ulij'lit. There wns no sputum nnd temperature normal. The1 {.i c. a Were examined for T.li. eight time.; with negative results. J'hyxirul Niytix. --J'utient is emaciated. Knee lias slightly violet tinge. Fingers verv slightly clubbed. Cliest expansion I>:ter-ly one incli. Tln-re is marked ret i act ion at litilu |hx. i'ercussioii m>te impaired at rijjlit apex anil is poor all over left limp. Fihrotic crepitations are heard all over limps, behind anil in front at light base, also all over left front, l'leural frielion sounds are board below angle of left scapula, beard over upper third of elicst on right side, front and back. Harsh breathing and prolonged expiration at right apex. Few crepitations also heard ut left apex near unglu of scapula and under left axilla. 6KIAGV.AM. The trachea is central. Tlio eardiae shallow is apparently somewhat displaced to the left. There is marked thickenin;,' of right apieul cap. The lower half of right loop is hazy, and mimerous small discrete opacities are seen. At the base numerous fine linear opacities radiate outwards from lower end of liilnm. Upper edpe of diaphragmatic shadow is obscured, and costoplironic; angle is obliterated, lamp pent-rally hazy and in middle third mimerous small granular opacities arc seen. Left edge of eardiae shadow obscure and merges into dense haze which occupies whole of lower third of limp. There is abnormal projection from -upper part of left liilnm with convex, sharp outer margin. CASK VJ1I. Violet S.. aped 20.--Admitted to sanatorium in January, 15)20, complaining of couph. 1'amilii lfixlory.--Nothing abnormal. JVrrmus J/is/mp.-- l'neunioiiia at the ape of six months. JIi^h'ii/.-- Had had couph "oil and on'' since leaving school in 1022 This had become, worse during the last six months. In May, 102M, ha-mopL sis of J pint, followed tw o or Ihri e d.t\s later by second attack lalnait 1 pint). Shortly after lids laid eonvalesi-i-nt holiday at Koiiruemoulh. No sputum was available for examination till l>cceiiibcr, 102s, v.bejj, tubercle bacilli were found, i'revinus to this, faces had been negative for 'J'.)!. thivi. times. At the age of JO, wont to work in an asbestos factory as spinner, remaining eight luonths. After a years interval, worked for a further year in asbestos factory. l'hijsiral fiiynx.--J'utient a fairly well-nourished girl am] looks well. Temperature norma! alter admission to sanatorium. No clubbing, hilt finger nails slightly curved. J'ercessit.n note impaired over right upper lobe. Numerous crepitations. skiagkam. Trachea central. Heart outline well defined. Mottled line granular opacities me seen over whole of light lung, producing general hazy appearance. Ihdow right i laviele hand of inti-rlolinl thickening is seen. Lchind right elaxivle annular shadow- suggests possible cavity in this region, ilight costophrenic angle obscured. CASK IX. Chris'.y M., aged 1H. --Attended tuberculosis dispensary, June, 102-S, complaining of couph and slight expectoration. I'lmiilii Hixlnry.--Father suffered from phthisis. l'l ' i itnix llixtnry.- .Had u di lii-ale c hildhood. First attended Larking dispensary, ag'-d *!: years, und was sent to blast Anglian Children's Sanatorium, where she reiiMiin d for nine months on account of enlarged cervical glands. Discharged in apparently gond health. She continued to attend dispensary on account of bronchial calai i h. cerv ieal glands, Ac. I.-itei sent to open-air school. In l!)2n, domestic work at M'eslrliff. 15)26, pneumonia. February, 1027, cough and expectoration, which was sometimes stained, hut no abnormal signs found in lungs. October, 15)27, commenced wank in disintegration department of nsbestus factory. About two months after skilling work lecurreiiee of cough with slight expectoration. Cough became progicssivcly worse during tile year, and she stopped work October, l'J2H. ' 1'lti/xirut Siynx.--(January 15)251).- Some impairment of percussion note at riylf| apex, where breath sounds are slightly blowing. No adventitious sounds heard. MT-001709 Tuiikkci.b. Pf.ATK 1. Mav, 192!). To illustrate article Cask IT. Pulmonary Aslit-losis," Ijy W. Ui.rnoN Woon >T A Ain JT.IMI.(C.ii)talj.), .M.1T.U.P.(l,onci.). ........................... . MT-001710 TmiKnr.i.i: ri.An: n. >Iay, 1U2'i Cask IV. MT-001711 TlMIP.llCl.K, i'I.atk ju. May, ]3 >n. Cash V. MT-001712 Tuiikut. rum: iv, May, JOUU. Cask YJ1. MT-001713 TunKItCLK. May, Cask JX. Cask X. MT-001714 Tlll'.KlKl.K. vi-.vn; vi. May, Cask XVI. MT-001715 May, V.V2V] PUKMONAKY AS11KSTOSIS 361 SKIAGJtAM. Bronchial sliiutions unusually thick mid emphasised for a patient of 18 years. Numerous calcified foci around right liilum and ninny sunill opacities in tlic lowcn half of right (ic)tl, some of which appear 1o represent calcification. ' About the middle of right liilum a small triangular shadow projects towards the right, and probably rcpicscgts pleural adhesion. . CASK X. Citherinc 0., aged 27.--First attended tuberculosis dispensary, December, 392.9, com plaining of shortness of breath and occasional cough and expectoration. F.imihj Hix/ory.--Nothing abnormal. Hixtunj.--Patient bad wniked at an nsbestos factory for six and a half years continuing till 192 1. She was rpiite well all the lime she w as at the asbestos works. 11 was only during the last six months that she had hud dyspno-a, slight cough and expectoration. She had, however, been losing weight for the last two years. Weight: 1927, 7 st. ; 1929, ,*> st. 12 lb. P/n/sicul Siijiix.--January 10, 1929: Patient is extremely thin and dyspnn ic. Not cyanosed. There is no clubbing. ]* .-traction of chest below both clavicles and some lhiltoning at the right base. Krcslh sounds over the l ight upper lobe ill front are blowing, vocal resonance is increased. There is some impairment of percussion note at right base. Fibrotie crepitations with a dryish ipialilv and sijiic-aky sihili are heard in l>th lungs, especially towards the bases. T.ll. negative Jive times, 192.8-1029. RKIAGHAM. Thickening of pleura at both apices. There is haziness of middle /one of right lung, with marked thickening of interlobar septum.- There is line discrete mottling and some very fine linear shadows at the base. The hilar glands appear to be enlarged. Bower half of left lung is cloudy. Fine linear shadows Siam similar to these on the rigid side. The left edge of cardiac, shadow shows very marked "felting." l.'piicr surface of diaphragm obscure on right, invisible on left. Bight costoplnonie angle obliterated. CASK XI. Bo-etta N., aged (50.-- Seen at dispensary cm .lannavy 10,1929, complaining of tightness across chest, severe cough without expectoration and marked shortness 0f breath. lii^lm;/.-- First attended dispensary 3 911 for t ough with expectoration. In 1916 diagnosis of emphysema with pulmonary fibrosis was made. There is no record of the finding of T.li. in the sputum, and patient has apparently remained in the same condition for many years. About 3912 conunenrod work as spinner at asbestos works. Cough commenced towards end of first year of working, after which she bad recurrent coughs every two or three months. These increased in severity and her doctor advised her that her w ork was " not doing her any good." Vhijxical SitjiiH.--Putic.nl is poorly nourished, {.'best emphysematous. No clubbing. Sharp post-lassie crackles are heard in both axillary regions and a few at the bases posteriorly. SKIAOItAM. Heart is slightly displaced tow ards the left and there appear to lie some adhesions in the region of the cardiac opex. 'The right lower lobe is apparently contracted. The interlobar septum occupies a iower position than usual. 'The strialions at the right base arc denser than normal. Towards lower end of right hilmn there are some rounded opacities about 4 nun. in diameter. CASK Nil. F.tsie X., aged 555.--Attended Victoria Park Chest Hospital in November, 3928, complaining of cough, expectoration, shortness of breath, wasting, fever and debility. l'liniihj Jlnlnii/.--Sister died of phthisis when patient was H years old. --Commenced work as spinner in asbestos factory, aged 28. Worked con- 3fi'2 TUJIKHCr.K [JMf, 1029 tinuously for lliiiit-i'ii years. Cough commenced live years before erasing work and gradually gut worse. ()ii entering factory, weight It) si., now 7 st. J'ln/iinil Xigui.-- Valient extremely thin. Not cyanosed. Slight clubbing of lingers. Slight impairment of permission imte over upper half of right lung... Dry fibrutie cracklings Jive hoard nil over right lung. Harsh breath sounds ami prolonged expiration below right clavicle. Sputum T.D., negative four times 10JS. HMAUKA.M. Cervical rih on left. 'J'rachea displaced towards right. Delow centre of right clavicle in first intercostal space there is a dense, rounded shadow alsmt 4 mm. in diameter, apparently due to cnlcilieat'un, A few other smaller calcified areas in same legion, There are dense calcifications at upper end of light hiluoi. llight interlobar septum very thick, immediately below- inner end of septum is a large oval shadow about 1?, in. by J in. Outside left liilmii urc u few small ealcilirations. There is a rounded opacity above left clavicle and a few small dense s|ils. Deft edge of cardiac shadow clear-cnl except at apex, where it is striated. CASK XIII. May II.. aged 20.-- Attended Victoria I'.ul; Chest Hospital. February, 1920, complaining of congl), pains in right side of cla st and " terrible shortness of breath." limtonj.-- August, J02a. commenced work as spinie r at asbestos factory where she continued till the present tine-. Cough commenced l-Vbruary. )92S. There had been no spit. 1'ams in right side of chest. Dyspnua of eight wcckV duralion. J'liy-icot Sif/itx.-- Tmpaitcd percussion note al right base, with dry friction, ml. also heard in right axillary legion. Chest expansion, 1 in. t>KI \GltAM. Dr.mchial strialions slightly more obvious than usual. Otherwise no abnormality seen. CASK NJV. Alice M-, aged IS.--Attended Victoria 1'ark Chest Hospital February, 1929, cuiiiplainjng of Cough and pains round lower part of chest. J'mnitii 1/isfnri/.--Nothing abnormal. Itflory.--Valient leas been working at an asbestos factory for one and a half years. Has bad no shortness of breath, and is not losing weight. There is no expectoration, but she complains of feeling of phlegm in the throat. Cough worse when she is at work. .As far as she knows no precautions against dust taken in Die factory. Sii/ns.--No abnormality detected, but linger tips arc. slightly shining above nail-base suggesting earliest stage of clubbing. There are asbestos " coins" on the hands. Nothing abnormal detected. SKIAOUAM. CASK XV. llaymo'id ft., aged hi).--Attended Victoria Vnrk Chest Hospital February, 1929, complaining of shortness of breath, lassitude, cough and expectoration, sometime!-, streaked with blood. l'rinihj History.-- Drother died in 1P29 from pulmonary tuberculosis. History.--192(1 worked at nsla-tos factory us store-keeper. His work necessitated constant visits in the spinning rooms. 1929 patient had attack of "pneumonia," said to be tuberculous, and kept in bed four months. Then attended tuberculosis dispensary. About this tune he coughed up a tcaspoonTii) of bright led blood on two or three occasions. Cough has persisted ever since. During the last two years there lias been increasing lassitude, and iie lias boon very short of breath since 1929. J'htfsirnl NiyttH.....l'atieiit slightly cyanosed. llound shoulders. No elnhhjug. Slight impnii ment of percussion note over both apices. Creaking sounds, hn^ sibili and crepitations nro heard all over both lungs. ' KKIAU1CAM. There is indefinite mottling above both apiees. A few- small calcifications in region of both Inin. Kdgu of cardiac shadow is distinct. MT-001717 May, 192'.)J i'U/.MO.NAU V A S1JKSTOS IS 303 . 11.0. (limb:), ngei!'&t. CASK XV). ' Ghiagnim shows posterior view of lungs of )>.ttifiit wlio hail worked for eleven yciMFin 11ic South African f{nl<l mines. TM Kpntnni nef'ivtive for T.R. At (lie light apex, clear area apparently due to cavity. All over remain lev of holh limn (adds there are. numinous disc rete dense opacities. The edge of the cardiac shallow is distinct on the left, lint at the light hast: it is puiily ohscnretl hy interlacing lincnr1 slriations which extend hum hilimi to upper surface of diaphragm. 1 REFERENCES. [1] Cookk, W. E. "Pulmonary Ashestosis,'' Bril. Med. Journ., 19ti7, 2, 1021. [2] " Ashestosis," Encylopadin Britannica. [3] Oiavmt, Sir Thomas. " Pulmonary Ashestosis in its Clinical Aspects,'' Joiirn. Induxt. llyg., 1027, 9, 183. [4] Savi:j:s, R. R. "The Effects of Silica Dust upon the Lungs," Aiuer. Journ. of Public Health, 1027, 17, 203. [5] Nonius, G. W., and Lamms, JL R. M. " Diseases of the Chest," Tbird Ed., p. 521. [G] Power.!,, Sir It. Doiau,as, and IIautci-.y, Sir PKitciVAr.. " Diseases of the Lungs," Sixth Ed., p. 330. [7J Cookk, W. E. " Fibrosis of the Lungs due to the Inhalation of Asbestos Dust," Brit. Med. Journ., 1021, 2, 147. [8] McDonald, Stuakt. "Histology of Pulmonary Ashestosis," Brit. Med. Journ., 1027, 2, 1025. [9] Stkwakt, M. .J. "The Immediate Diagnosis of Pulmonary AshesiosU at Necropsy," Brit. Med. Journ., 1023, 2, 500. [10] Sinnuu, Jl, E. "A Case of Pneunionoeonions. Result of Inhalation of Asbestos Dust," Brit. Med. Journ., 1028, 2, 0S2. [11] 1U(;I'aui,axi), Wh. " Silicosis and Tuberculosis seen in Granite'Workers," Journ. lndustr. llyg., 1027, 9, 315. [12] Stkkaht, W. " Radiography in its Relation to Miners' Phthisis on the Witwalcrstrand," Arch, oj Jiudio. and Elect, 'l'her., 1023, 27, 277. A STUDY OF THE SEDIMENTATION DATES IN 252 CASE OF PULMONARY TUBERCULOSIS By It. H. Tn.m,, M.D., M.K.C.P. Medical Sufcrintaidciil, h'intf Edward VII Sanalorinni, Miitlmrst. In a review of 300 T.B.-f cases under observation in the Sanatorium between October J92G and July .1928 it was possible to show by a correlation of the Sedimentation Hates on admission and discharge with the end result of treatment the value of this test ns an indication to prognosis and the response to treatment[1]. A study of 200 T.B.-F cases and 52 T.B.-- cases discharged to dale seems worth recording, as it strengthens the basis of conclusions then reached and is suggestive of others then hinted at. The technique employed is that described in the former paper :-- To two volumes of a sterile solution of 3'R per cent, sodium citrate eight volumes of blood are added. The unit of volume is one drop of blood from a broad-ended glass pipette; the blood is drawn from an ear nr finger and mixed in a watch-glass. A column of the diluted blood, 4 in. ( = 100 mm.) long, is drawn by capjjkuy MT-001718 678 Sept. 28, 1929) ASBESTOS QUST AND rUDMOffAJir ASBESTOSIS. 003099 The result was more remarkable when an attempt was made to classify tin; cases into " exudative " and `` fibroid " groups, according to the a-ray picture. x KxucTativo. Filiroifl. Alive. Dead. Alive. Dead. No cavity ............................................... Cavity ar ray evidence, only ... ... 14 IS 3 7- 5n 1 Cavity clinically .................................. 7 . 7 10 -- Totals ,,................................. 29 15 23 1 ease sanocrysin should be withheld until sanatorium treat ment has had a trial. . "When tluro is disease of long duration, combined with an exudative cc-ray picture, sanocrysin treatment is not fiee from danger, but in such cases ft may be possible to combine it successfully with artificial pneumothorax-. In judging the results, it should be remembered that the type of pulmonary tuberculosis seen in hospital patients in Ireland is commonly seven;. I ha-re been encouraged to persevere with sanocrysin treatment by the opinions expressed by my colleagues in Bejfast and elsewhere. Certainly it is not a cure-for tuberculosis of the lungs, hut it is a valuable aid to treatment, if used with caution and discrimination. There has thus been a heavy mortality in the exudative group, although many' of them did well while under treatment. But I believe that the results in exudative cases could be improved on, if treatment were prolonged over a period of several months, frequent a>ray examina tions are necessary in such cases, and the patient should be kept at rest as long as any exudative foci can be seen on tbe x-ray film. Possibly it may prove to be best to give several courses at short intervals. In any case, if active disease is present after sanocrysin treatment, artificial pneumothorax or phrenic avulsion should- be considered, even if the temperature and pulse rate are normal. I think also that some exudative cases with cavitation should have a period of rest and tonic treatment before trying sano crysin, which might be employed when tbe limit of improve ment has been reached. In tbe fibroid group, however, the lesults have been more satisfactory, as there has been only one death among 29 patients. It might be suspected that these patients would have done equally well without sanocrysin-, but must of them bad the treatment because they had failed to respond to routine measures. Of this group, 55 per cent, were discharged without tubercle bacilli in the sputum, as compared with 43 per cent, in the exuda tive group. Excluding 10 " cavity " cases, 72 per cent, of the fibroid cases were without tubercle bacilli on discharge. - Tuberculosis of the larynx was present in 8 cases of my series, and 1 do not think it contraindicates sanocrysin treatment, as the laryngeal condition usually improved, and 6 of the 8 cases are alive. Cachexia, intestinal tuberculosis, and disease of the kidneys are contraindications. It is often advantageous to combine sanocrysin and collapse therapy, especially in cases where there is wide spread disease of one lung, with some active trouble in the better lung. If the case is acute, and the lung tissue is breaking down rapidly on one side, it will probably he necessary to collapse the worse lung immediately and try sanocrysin afterwards. In another kind of case, when the patient has passed Through the acute stage and show's some resistance, I have found it more satisfactory to give a long course of small doses of sanocrysin first, and to try artificial pneumothorax later. When the disease is almost entirely unilateral, and collapse therapy is clearly indicated, I think sanocrysin should not be employed; later, if fresh foci of disease develop in the functioning lung, it may he of service. In my .series 19 patients had artificial pneumothorax treat ment, and satisfactory collapse was attained in 7, all of whom are alive at the time of writing. The collapse was only partial in 11 patients, and 5 of these are alive. There are two types of pulmonary tubercle in which I d : sanocrysin may he of value. One is the earlv exudative east in which the disease in the lungs is severe or widely spread, bm in which there is some evidence of rc-istame. The other is the predominantly fibroid type of disease, when symptoms and tubercle in the sputum persist after several mouths of sanatorium treatment. Id the exudative ease I think it is important to begin suuoery.sil] t tea 1 incut as soon as possible, in the fibroid ASBESTOS DUST AND THE CURIOUS BODIES BOUND IN BULMCtNARY ASBESTOSIS.-1 BY IV. E. COOKE, M.D., F.R.O.P.Ed., M.R.C.P.Lond., D.P.H. (From the Pathological Department, W igan Infirmary.) Asbestos was woven into cloth before the time of Herodotus 450 b.c., but the history of the industrial disease pulmonary asbestosis dates only from a.n. 1800. In 1899 a mail wras admitted to Charing Cross Hospital under the care of the late Dr. H. Montague Murray. The patient was suffering from pulmonary fibrosis of obscure origin. He had worked- for ten years in an asbestos factory, and his occupation was suspected as being the cause of deatii, which occurred in 1900. The case was not published, but Dr. Murray, in his evidence before the Departmental Committee on Industrial Diseases in 1906, referred to the presence of spicules of asbestos in sections of the lungs. The next case, and the first published, was recorded in 1924. The clinical history and histological - appearances have been the subjects of papers in tbe British Medical Journal (1924-27), and in the Journal of the Itoyal Micro scopical Society (1927). The findings upon which the dia gnosis of pulmonary asbestosis was made in that case, and the results of further work on tho curious bodies that have been found in the lungs hi all necropsies in the disease are the subjects of this paper. Asbestos and Asbestos Bust. . Asbestos belongs to the pyroxene or hornblende group of minerals, and i.s classed with syenite, granite, and porphyry. I scarcely need remind you that the igneous rocks were originally silicate solutions--compounds of silicic acid with earthy bases. Under certain physico chemical conditions hornblende and serpentine pass into fibrous varieties and are then giver, the technical naino asbestos.n The infinite varieties of asbestos differ in their chemical constitution and physical characters, but I propose to deal with one type only--chrysotile--the average, composition of which is: Silica ... ilagaesia Ferrous oxide Ahuuimc Water ... 40.87 per cent. 41.50 ,, 2.81 ,, 0.90 ., 13.55 The iron content, may be important.. It will he interest ing to see whether the effects of the iron-free dusts of some Italian, Arizona, Finland, and Chinese asbestos arc the same Us in chrysotile workers. Microscopically,, chrvsotilc fibre consists of colourless retractile translucent strands, hut intermingled with the fibre are masses of black angular particles, brown particles of all shades from, light Yellowish-brown to deep golden blown, and particles tho colour of sapphire blue. The dint generated during the process of manufacture consist-: of Irnements of fibre and translucent spicules split off from it. 1 A jjpir r-.iil in ;i tli'-rui.-ion in the Sot-lion of Oocop ii ionti I Hi- s ,ii ih- Annual M.r-jiiiii' of the British iledicul Association, IJtiuche-Ur, 1929. b ^ b llZ Z ' V d K0SS 0\ r- rH o o E--1 SPT, 28, 1929] ASBESTOS OUST AND PULMONAIIY ASBESTOSIS. ^ 'Jliese spicules are of varying lengths and thicknesses, some of them being-beyond the-limits of-resolution and ultra-riticroscopio. The dost contains also the black,- brown, find blue fragments seen in the nnv asbestos. The colour less translucent particles and the brown and blue particles of tho dust are refractile In- polarised light. The black particles arc biotito and magnetite, and do not transmit light. These iron-containing-minerals are responsible for tlio varying- percentages of iron in different specimens of aslxtstos, and, as would he expected, tho dust containing the greater number of these.black particles has tho greater iron content. .Microscopically, the finished woven article contains very few black particles, whereas the dust from tho carding room is. grey in appearance and contains them in abundance. . The iron content of chrvsotile, the finished article, and tho dust is as follows: - Chrysotilc : iron (as tenons oxide) ... Finished article: iron (as l'eiroii.x oxide; Dust from -carding- room : iron (as ferrous oxide) ... ... ... 2.81 ]>'-r rent. 0.1 ,, 18.4 ,, In addition to the angular pieces a .fine black granular dust is generated during tlm process of manufacture. process it was found that if the specific gravity wa3 kept about 1070 the-black dust and larger fragments of asbestos, as well as the partially digested lung tissue,sank to the bottom of the tube. By" decanting the apparently clear . supernatant liquid, centrifugolizing, neutralizing, and washing the deposit, the curious bodies could he obtained in a pure state. This was done, and .sufficient- material for ar-rav examination obtained. The bodies were attached to a hair with gum and subjected to a seven hours' exposure by Professor Bragg's -method.' If tho bodies were mineral the a'-ray film would have .shown a definite translatable atomic pattern. The films, however, did not do so, and we were then able to exclude the suggestion that the bodies wore altered asbestos fibre. The result definitely pointed to the greater proportion of their composition being of non-mineral origin. The hulk of the curious bodies is .soluble in si mug acids and alkalis, and if solution he observed under dark-ground .1 sbesfo,? Dn.it in the. Linnjs. Sections of lung and the results of digestion of the lung with trypsin show an- enormous amount of lino black granular dust, much of which is carbonaceous. In addi tion .there are two striking features. The first is the almost complete 'absence of the vorv fine translucent spicules of fibre which' make up the great proportion of asbestos dust in factories. This point will lie referred to later. Tho second feature is the presence of largo frag ments varying' in length from 10 to 360 microns. They are found in fibrotic and necrotic areas, singly ami in groups. Tho particles arc so large--masses of them are seen in some sections--that they must have occluded small bronchi and resulted in fibrosis of the surrounding area with, later, necrosis. Comparing theso largo particles in the lung with those found in asbestos dust tho close resemblance in sizes, shapes, and colours is apparent. There arc the same black, blue, brown, and translucent fragments. In fact, it is easy to take each single particle from the lung and imme diately find its brother in a slide made from the dust. The question I had to answer with regard to tho -1924 ease was, " Did the dcc-eascd's occupation cause or con tribute to Iter death ? " Upon the foregoing evidence one answer only was possible. Thr. Curious hollies fnuud in I'iiIiiiuiki 11/ .1 shrstosis. In addition to the fine granular dust and larger frag ments of asbestos, sections of the lungs show curious bodies, some of which are illustrated in Figs.-1-5. Thev are found ill alveoli, bronchioles, fibrous mid necrotic areas, and ill phagocytes, in sections of both lungs. If a portion of lung be teased and extracted with water, or digested with trypsin, or, as Professor Stewart pointed out (1928), a smear is made from tho cut surface of the fresh lung, theso bodies are seen in myriads. The larger bodies measure from 20 to 100 microns or more in length, are'of a gohlon brown colour, and sumo are shaped as seen in tho illustrations. They may have single clubbed ends or appear as elongated dumb-bells, some as filaments, while others suggest a series of discs. Single cocoa] and spore like forms, ami aggregations of these, and streptococcal forms are not uncommon, and the. colour varies in tho smaller types from a very pale yellow' to a yellowish-brown. 'Hie bodies do not stain with any of the aniline dyes, but, in chrysotile workers, give the Prussian blue reaction for iron in varying degrees of intensity. These curious bodies have been found in every necropsy in pulmonary nsbestosis, and tho problems W'e have to decide are, first, what the Imillcs are, and secondly, whether they am diagnostic of nsbestosis. It would be unprofitable to retrace all the steps which led down the many by-Janes during the course of the work, hut I might mention a few pertinent details of interest. Professor Stewart suggested to me that a belter method than simple extraction of the lungs with water or saline would be to digest portions with trypsin. During this Fjo.~. 1 -.xr> 2.~" Curious Sorties " mowin': 1 te- 'nlmnl.il os-reynlps --jei 101eft, nirehtoiinilly, from 1 lie yirtoli-r tilainpnls of ;i,lr,,lr-' floe on ivhirh lll'-y u IT itil.'O, )jcil. ( .. sOO.) Fli.s. 3. 4, INI) 5.---'Curious tuuIie' llu: nu.-lci ot" wliir-li con..Ft of .-picnics of biolite. ( cSOO.) (Pliotomicro^i ajile 1,,' C. F Hill anil W. F. Cooke.) illumination their bases are seen as extremely line spicules, some of which, by transmitted light, would probably be invisible. Under a dissecting microscope it is po-dhle partially to fracture the /arger bodies and to .show a central fine core, as in Figs. 1 and 2. - I have mentioned that the greater portion of asbestos dust consists of slender translucent fibres, tn sections and extracts of the lungs there is a remarkable paucity of these line spicules. The end-results of digestion show the fine granular dust and the large black, blue, and brown particles, and what appear to ho pieces of quartz. Bclntively few fine spicules are found, hut curious bodies of all descriptions are present in enormous numbers. All theso facts lead us to imagine the bodies to consist" of central nuclei of asbestos spicules upon which colloidal aggregates of blood proteins, jdus, possibly, soluble fiuftious of asbestos, and in the case of chrv.sotile workers an iron salt, have been adsorbed and moulded by cm 1 cuts in the bronchi and alveoli. Occasionally biotite fragments into fine black spicules, and if oni- reasoning he coriect, some at least of tho millions of curious bodies should show' a central core of this mineral. Figs. 3, 4, and 5 illustrate this condition, ami are, 1 think, tho final proof of our theory. MT-001720 t>80 Sept. a8, io?9] CLINICAL ASPECTS OB PULMONARY ABBESTOSIS. [ Tub Bam iliDJOAE JOS The method of formation would appear to be as follows. The fine spicules- of asbestos cause, by mechanical action on the bronchioles and alveoli, either minute- extravasations of whole blood, or serous exudates, which envelop them. Solution of any soluble fraction of asbestos takes place. The total amount of asbestos that is soluble must bo extremely small', a proved by the x-ray pattern of the curious bodies, hut in the case of chrvsotilo workers some solution is suggested hv the free iron reaction. We must remember, however, that the Prussian blue reaction may he due to the iron of haemoglobin. Any surface in contact witli a colloidal solution may act as an adsorbent, and in the present case the fine spicules must be considered to do so. Interaction between the soluble fraction of chrysotile and plasma proteins takes place, syneurcsis occurs, and, with the loss of water, the adsorption is rendered irreversible. The adsorbent is permanently unsheathed with stable colloidal aggregates which become moulded into the familiar shapes by alveolar and bronchial currents. .Some support of thi3 is adduced hv the fact that micro organisms adsorb colloidal material in the presence of blood scrum and colloidal asbestos. Staphylococci so- treated appear as large round yellowish-brown discs, and in the process their property of staining with aniline dyes has been lost. Tlie organisms coalesce and form masses, and I think it probable that some of the coccal and spore forms of tlie curious bodies are similar organisms. Finally, the answer to our second question must he found. Are the curious bodies diagnostic of pulmonary asbestosis? Asbestos is unique among the minerals in being fibrous, and the .dust generated during the manufacturing process is also unique. As can he imagined from the formation of the curious bodies, there is no reason why any fine spicule of mineral should not liave colloidal matter deposited around it and become moulded into a curious body. But, as no other mineral dust is fibrous, this occurrence must he so rare as to be negligible from a diagnostic point of view. The conditions which, apparently, must obtain for the formation of tlie curious bodies are the presence of plasma proteins and fine spicules of difficultly soluble material. These conditions are ideally found in asbestos workers, aud for this reason I believe the curious bodies, if -found in any numbers, are patho gnomonic of pulmonary asbestosis. I must express my gratitude to Dr. S. A. Henry and Dr. K. R. A. Merewether of tlie Home Office for their stimulating interest in the work, and for providing me with many specimens of asbestos, and to Mr. T. H. Byrom, F.I.C,, and Mr. J. A. Derbyshire, if.Sc., for tlieir invaluable assistance in the chemical and physical side of the work. I.nrn.m.'RE. Cooke, W. E. : British Mrdieul hmniat, 1924, ii, 147. Cooke, W. E., and Hilt, C. l-\ : Jiuir/i. Buyut Minos. Soe., 1927, 232. Cooke, IV. E., McDonald, S., and Oliver. T. : Biltii. Medical Journal, 1927, ii, 487. Stewart, Mi J. : British Medical Juar/ud, 1928, ii, 585. CLINICAL ASPECTS OF PULHOAAItV ASBESTOSIS.* BV A. C. ft AD DOW, M.B., Ch.B., LKE1TS. ' History. Bcnixci 1926 Dr. Ian M. B. Grieve, who was then with me in. general practice at Leeds, drew my attention to the fact that several patients under our care of late with chest troubles were asbestos workers, and we agreed that they exhibited, features sufficiently in common to justify investi gation of what seemed an uncommon type of pneumonoloniosis. We accordingly examined every asbestos worker who came our way, some fifteen in ah', and bad most oli these radiographed. Then, in March, 1927, a female patient with long-standing disease died in hospital, and Dr. Gryeve attended the post-mortem examination. With Dr. A. L. Taylor he examined the sections of fibrosed Lung, and found a remarkable condition which Professor Stewart recognized as similar to the case described by Dr. Cooke in 1924. o'-cIe Section oi Occupational fiivctiaca at the Annual Met .#1. the teUisli Ueiiical Arsociminn, Manchester, 1929. Sir Thomas Oliver cqjne to sea our cases, and he described the clinical findings before this Section of the British Medical Association at Edinburgh in 1927. The _ two patients he reported on (both women) have since died, one in March, 1928, and the other in February of this year. One male patient died in March, 1928, and it was the certification of this case as death from " broncho pneumonia, secondary to chronic asbestos poisoning, caus ing pulmonary fibrosis," which brought about tlie publicity ,, of a coroner's inquest and official recognition of this disease. Fatal Cases. . Of these four fatal cases the average age at death was 41, and the average years actually spent in the. factory were under twenty, all in asbestos mattress-making for most of tlie time-. The male patient had worked until two days before death (on a light job), but the three others had been incapacitated for an average of two and a half years (three years and five months, two years and five months, and one year and ten months). Only in one of them had tubercle bacilli been found in the sputum. She was one of those reported by Sir Thomas Oliver, and at her own request no necropsy was held. I cannot personally trace any other death of an asbestos worker in my practice except that of a woman who died of perforated gastric ulcer in Leeds Infirmary, and whose lungs were examined by Dr. A. L. Taylor, with positive findings, two years ago. No death had ever been traced to asbestos dust in Leeds until the present series, and the only asbestos workers recorded by the medical officer of health for Leeds as having died of phthisis were found to have worked at a gas-mantle factory where asbestos is not employed in any department. I know that many workers had drifted away from the asbestos factory because they believed it was unhealthy, whilst many women had ceased work to attend to their, homes, and any fibrosis present would readily he overlooked in later years when death overtook them. Ailranced Cases. In practice these workers do not call for much attendance until they reach the stage of total incapacity. Until then they are naturally more prone to chest troubles during the winter months, and are sometimes unfit for weeks at a time, but at the present moment I have only four cases under treatment. These are all permanently incapaci tated. They are alt women, and are fairly well at present, though they were very ill in February and March. Three of them have been away from work for eighteen months and the fourth for four and a half years. They were all in the mattress department. Their average age is 35, and tlieir average of years spent in the factory is fourteen, dating hack to their teens. They average three children apiece, which accounts for most of the1 time lost from work. The children are healthy enough. Clinically, they all suffer from shortness of breath on exer tion, have cough without expectoration, are lean, although not losing weight at present, and complain of anorexia with resulting weakness (for in Yorkshire one is only as strong as one's appetite). Pain is variable, and occurs from time to time with signs of localized pleurisy. Night sweats are absent, and there has been no haemoptysis. No tubercle bacilli have been found. Tlieir hearts are normal, with a pulse rate approaching 90 at rest. The average full range of chest expansion is only one inch in the upper thorax aud even less around the lower ribs. On percussion there is always some dullness at both bases, and usually over the lower lobes generally. The breath sounds are diminished over the same area, and the voice sounds are usually well conducted. The respiratory murmur in the upper lobes is broncho-vesicular. Friction sounds can be heard at the bases and sometimes in the flanks. Moist rales and crepitations are for tlie most part absent now, but were abundant at the bases during the winter. These exacerbations liave a serious bearing on tlie cases, and it will be noted lliat all the deaths have occurred at the end of winter. Onset of Symptoms.--It is very difficult; to ascertain the . date of onset of symptoms, but the patients generally believe it was after file years of work. Depending as it does on so many factors, it must be extremely variable. M T-001721 680 Bbkp. a8, 19*9] CLINICAL ASPECTS OP PULMONARY ASBESTOSIS. 003102 The method of formation would appeal' to be as follows. Tile fine spicule* of asbestos cause, by mechanical action on the bronchioles and alveoli, either minute-extravasations of whole blood, or serous exudates, which envelop them. Solution of :wy soluble fraction of asbestos tabes place. The total amount of asbestos that is soluble must bo extremely small, a proved by the x-ray pattern of the curious bodies, but in the case of chrysotile workers some solution is suggested by the free iron reaction. We must remember, however, that the Prussian bine reaction may be dne to the iron of haemoglobin. Any surface in contact with a colloidal solution may act as an ad'sovbent, anrl in the present case the fine spicules must be considered to do so. Interaction between the soluble fraction of chrysotile and plasma proteins takes place, syneurcsis occurs, and, with tlie loss of water, the adsorption is rendered irreversible. The adsorbent is permanently unsheathed with stable colloidal aggregates which become moulded into the familiar shapes by alveolar and bronchial currents. Some support of this is adduced by the fact that micro organisms adsorb colloidal material in tho presence of blood serum and colloidal asbestos. Staphylococci so- treated appear as large round yellowish-brown discs, and in the process their property of staining with aniline dyes lias been lost. The organisms coalesce and form masses, and I think it probable that some of the coccal and spore forms of the curious bodies are similar organisms. Finally, the answer to our second question must he found. Are the curious bodies diagnostic of pulmonary ashestosis? Asbestos is unique among the minerals in being fibrous, and the ,,dust generated during the manufacturing process is also unique. As can be imagined from the formation of the curious bodies, there is no reason whv any fine spicule of mineral should not have colloidal matter deposited around it and become moulded into a curious body. But, as no other mineral dust is fibrous, this occurrence must he so rare as to he negligible from a diagnostic point of view. The conditions which, apparently, must obtain for the formation of tlie curious bodies are the presence of plasma proteins and fine spicules of difficultly soluble material. These conditions are ideallv found in asbestos workers, and for this reason I believe the curious bodies, if -found in any' numbers, are patho gnomonic of pulmonary ashestosis. I must express my gratitude to Dr. S. A. Henry anil Dr. E. R. A. Mereweiher of the Home Office for their stimulating interest in the work, and for providing ine with many specimens of asbestos, and to Mr. T. H. Byrom, P.I.C,, and Mr. J. A. Darhyshire, M.Sc., for their invaluable assistance in the chemical and physical side of the work. LITERATURE. I'liiiki.., W. E. : British Medical Joiinial, 1924, ii, 147. Cooke, W. E., and Hill, C. lo : Jotirti. Royal Micro*. Soc., 1927, 232. Couke. W. E., McDonald, S., and Oliver, T. : British Meilicai Jottntul, 1927, ii, 437. Stewart, M. T. : British Meilicai Journal, 1928, ii, 585. CLINICAL ASPECTS OF PULMONARY ASBESTOSIS.* IY A O. HAD DOW, M.B., Ch.B., LEEDS. History. Deluxe, 1926 Dr. Ian M. D. Grieve, who was then with me in: general practice at Leeds, drew my attention to the fact that several patients under our care of late with chest troubles were asbestos workers, and we agreed that thev exhibited features sufficiently in common to justify investi gation of what seemed an -uncommon type of pneumonoconiosis. We accordingly examined every asbestos worker who came our way, some fifteen in all1, and had most of these radiographed. Then, in March, 1927, a female patient with long-standing disease died in hospital, and Dr. Grj.cve attended the post-mortem examination. AVith Dr. A. L_ Taylor lie examined the sections of fibrosed lung, ami found a remarkable condition which. Professor Stewart r< i-ognized as similar to tlie ease described by Dr. Cooke iji 1924. 'Rea,! in tlie Section ol.fhe British lledicul Occupational Diseases at the Annual Meeting oociaimn, Manchester, 1929, Sir Thomas Oliver came .to sea our cases, and Ije described tho clinical findings before this Section of the British Medical Association at Edinburgh in 1927. The two patients he reported on (both women)' have since died, one in March-, 1928, and the other ill February of this year. One mule patient died in March, 1928, and it was - the certification of this case as death from " broncho pneumonia, secondary to chronic asbestos poisoning, caus- big pulmonary fibrosis," which brought about tlie publicity of a coroner's inquest and official recognition of this disease. Fatal Oases. Of these four fatal cases the average age at death was 41, and tlie average years actually speift in the . factory were under twenty, all in asbestos mattress-making for most of tlie time: The male patient had worked until two days before death (bn a light job), but the three others had been incapacitated for an average of two and a half years (three years and five months, two years and five months, and one year and ten months). Only in one of them had tubercle bacilli been found in- the sputum. She was one of those reported by Sir Thomas Oliver, and at her own request no necropsy was held. 1 cannot personally trace any- other death of an asbestos worker in my practice except that of a woman who died of perforated gastric ulcer in Leeds Infirmary, and whose lungs were examined by Dr. A. L. Taylor,, with positive findings, two- years ago. No death had ever been traced to asbestos dust in Leeds until the present series, and the only asbestos workers recorded by the medical officer of health for Leeds as having died of phthisis were found to have worked at a gas-mantle factory where asbestos is not employed in any department. I know that many workers had drifted away from tho asbestos factory because they believed it was unhealthy, whilst many women had ceased work to attend to their, homes, and any fibrosis present would readily be overlooked in later years when death overtook them. . Ad canted Coses. In practice these workers do not c-all for much attendance untit they reach the stage of total incapacity. Until then they are naturally more prone to chest troubles during the winter months, and are sometimes unfit for weeks at a time, but at the present moment I have only four cases under treatment. These- are all permanently incapaci tated. They are all women, and are fairly well at present, though they were very ill in February and March. Three of them have been away from work for eighteen months and the fourth for four and a half years, They were all in the mattress department. Their average age is 35, and their average of years spent in the factory is fourteen, dating hack to their teens. They average three children apiece, which accounts for most of the-time lost from work. Tlie children are healthy enough. Clinically, they all suffer from shortness of breath on exer tion, have cough without expectoration, are lean, although not losing weight at present, and complain of anorexia with resulting weakness (for in Yorkshire one is only as strong as one's appetite). Pain is variable, and occurs from time to time with signs of localized pleurisy. Night sweats are absent, and there lias been no- haemoptysis. No tubercle bacilli have been found. Their hearts are normal, with a pulse rate approaching 90 at rest. The average full range of chest expansion is only one inch in the upper thorax and even less around the lower ribs. On percussion there is always some dullness at both bases, and usually over tlie loner lobes generally. The breath sounds are diminished over the same area, and the voice sounds are usually well conducted. The respiratory murmur in the upper lobes is broncho-vesicular. Friction sounds can he heard at the bases and sometimes in the flanks. Moist rales and crepitations are for the most part absent now, but were abundant at the bases during the winter. These exacerbations bate a serious hearing on the cases, and it will he noted that all the deaths have occurred at tlie end of winter. Onset of Symptoms.--It is very difficult to ascertain the date uf onset of symptoms, hut the patients generally believe it wa.s after five years of work. Depending as it does on so many factors, it must be extremely variable. Oi O i Ul op Pi --0 <N <N Di--i O O  ^ SiiPT. 28, 1929] MEMORANDA. Ir MainwSciiuDfl fvitQ,Al Our earliest clinical diagnosis is also in the neighbourhood of five years'of work.' X-ray Findinga.--Excellent radiographs of these four advanced cases were taken for me by Dr. Bowden recently. Exposure was for two-fifths of a second. All the chests shoved abnormal radiolucency and marked limitation of .diaphragmatic morement. The radiographs show this trans- luQency above the level of the ninth rib posteriorly and the fourth rib in front. Below that level, roughly, in all of them there is definite infiltration, particularly on the right side. The outline of the diaphragm tends to be irregular anti flattened, and the root shadows to he enlarged in a downward direction. Without going into further detail, the picture is that of asbestosis. But the shadow of the fibrosed zone is in itself characteristic. It is devoid of radiations from the root shadow and presents an amor phous, ftocculeut appearance, in which small cavities are indicated in some of the cases. In estimating the respira tory handicap we must not forget that the bases extend bcloiv the shadow of the dome of the diaphragm. Lung Puncture.--Another line of investigation, sug gested by Dr. Henry, has been carried out--namely, lung puncture. Asbestosis bodies can he extracted from the patients' lungs during life by means of a hollow needle and syringe. I punctured all these four cases, and Pro fessor Stewart has found " bodies " in two of them. We do not recommend it as a routine method of diagnosis. No tubercle bacilli were found in any of them. ' Sputum.--Much preferable is the examination of sputum by tiie antiformin method, which Professor Stewart has applied with striking success, and the only difficulty is to u;et the sputum. This is often available in winter, and if the patient has a receptacle in readiness the sputum will turn up some time. Three of these cases yielded the " bodies " in sputum, and the fourth had no sputum but was positive on lung puncture. JRmorantm: MEDICAL, SURGICAL, OBSTETRICAL. ^ A METHOD OP EXAMINING THE SPUTUM FOR ASBESTOSIS BODIES. Hals an ounce of so of sputum is added to an equal quan tity of undiluted antiformiu. This is gently agitated until the sputum is completely dissolved, after which it is diluted down with two or three ounces of,water and allowed to stand in a large test tube for three or four hours. The bulk of the supernatant fluid having then been decanted, the remainder is centrifuged at a moderate speed for ten to fifteen minutes. The whole of the supernatant is now poured off, and tho deposit transferred to an albuminized slide by means of a pipetfe. After thorough drying on a hot plate and final fixation over a bnnsen, the film is very gently washed in water, dried, and mounted in Canada balsam. After a little experience the asbestosis bodies are readily picked up with the low power, and their true nature is then confirmed with the 1/6 inch or oil immer sion lens. As a rule they are present in very small numbers, perhaps only one or two in a whole film. In the cas9 of some of the older workers, however, numerous bodies, up to one or two per field in certain portions of the film, have been found. It is obviously necessary to cleanse thoroughly all glassware, etc., used in making these examinations, other wise there is a risk of contamination of subsequent specimens. The films can he treated with hydrochloric acid ami potassium ferrocyanide to demonstrate the Prussian blue reaction given by the bodies. Pathology Department, School of Medicine, University ol Leeds. M. J. Stxwahi. Conclusions. The following conclusions have been established : 1. That the inhalation of asbestos dust will " in the long run " produce a state of fibrosis, the distribution being'peripheral and mainly basal, the right base becoming most advanced and the upper lobes tending to develop compensatory emphysema as first the diaphragmatic and gradually the entire pleural surfaces become obliterated. 2. That the disease is not as a rule complicated by tuberculosis. " 3. That the disease is usually first recognized after more than five years' exposure, although systematic examina tions might reveal it earlier. 4. That the condition is usually found first during an attack of influenza or winter cold, when exacerbations of the disease occur. 5. That even in the advanced cases there is marked abatement during the summer months. 6. That tho onset of anorexia signalizes to the worker that work is no longer possible. 7. That the patient may then live for several years and continue to hear children, hut becomes progressively weaker and more emaciated, more hopeless, sleepless, and ex hausted, until an attack of bronchq-pneiinioiiia or bronch itis brings death at last. 8. Further, that asbestosis bodies can be found iu the sputum, if auy, in all advanced cases,' as well as in most early cases. ' 9. That they can be demonstrated by lung puncture iu advanced cases; but since no patient is likely to permit more than one puncture to he made a negative finding is inconclusive. ------ _ 10. That radiography is of great value in diagnosis and iu observing progress. 11. That the treatment of these cases, being purely palliative so far, culls for great patience and vigilance over several years, and much relief can be afforded. 12. Finally, that the disclosure of the danger arising from asbestos dust lias brought home to tho workers the need for observing the measures provided for their protection, and is bound to bo Salutary, although tho mortality statistics will probably be swelled by the wider recognition of this disease. FOREIGN BODY IN THE LARYNX. The following case illustrates some of the difficulties of diagnosing the presence of a foreign body ip tho larynx, and the need, whatever the history may be, for making the most complete examination when this condition is suspected. The patient, a waitress at a country hotel, consuhed Dr.. Fiend of Hurstpierpoint on January 24tb, stating that on the previous evening, a3 she' got up from her chair, where she had been engaged in sewing, she felt a sudden pricking in the throat. After repeated questioning she admitted that she was in the habit of holding pins in her mouth, but stoutly denied that site had done so on this occasion. The meal which she had taken two hours previously contained noticing that could be impacted as a foreign body in the throat. Dr. Frend could see no abnormality in the larynx or pharynx, but with great difficulty lie persuaded the patient to go to the Sussex Throat Hospital for further examination. . My examination by indirect laryngoscopy yielded negative findings, but as the patient stilt complained of the pricking sensa tion I asked Dr. Prowse to make an x-ray examination. I confess that I was surprised to see in the radiogram that a pin was lying, horizontally and in an antcro-posterior plane, opposite the sixth cervical vertebra--that is, on a level with iho entrance to the larynx. The laryngeal mirror had failed to reveal the presence of this pin, although the patient's larynx had presented no difficulty m examination. I decided to examine with the endoscope, and did so the same evening with the patient under general anaesthesia. I used Lynah's oesophageal spatula, and at once discovered a longitudinal tear about one inch in length on the posterior oesophageal wall. This discovery was soon followed by the sight of a pin-point abrasion on the posterior aspect of the right arytenoid. By making the necessary adjustment in the patient's position I brought the larynx into view, and was able to see the pin transfixed through the right arytenoid, with most of it lying free in the middle of the larynx. I grasped the pin with forceps and inserted the tube a little deeper; by this maiiceuvre I was able to draw the pin forward wholly into the tube and, thus eliminate any possibility of damage to the tissues. The patient wrote on February 17th that she had suffered no soreness or hoarseness, and that she had not felt tho least discomfort. The following features of this case are of special interest; (1) The absence of symptoms, even of the wheezing respira tion described bv Chevalier Jackson. (2) The unusual posi tion of the pin---foreign bodies in the larynx usually lie with tlm long axis in the sagittal plane. (3) The failure to see the pin by indirect laryngoscopy. One concludes that it must have been tucked under the aryteno- epiglottidean fold and brought into view as a result of MT-001723 jlKO. '___:v MB/] pum oy au y asm;stows. 003116 PUL jIONAUY AS1 iESTOB'lhi. other mii c'j.d,, mor-' ! -p. hilly with cffvfi.io iron c j 11 i magnetite. The cumpuuitii-n uf the V. till km\ Italian and 1>V Canadian fihi cs i.s as follows; W. E. COOKE, M.l)., M.li.O.P., J~hvtfw of the Tathol"gical 1)<:j/uiiM.iil, Wijm Infirmary. (H'iH Special Plate.) I.s 011; Bnirisn Mvidicai, Jouu.vu, of July 26;b, 1024 (p. 147), 1 published a short note on ilio woman who is the subject of this paper. The only similar ca,e cn record Silica ...................................... ill agnosia ... ... ... Ft i i ou.s ... . . Alumina ............... ... Water ........................... Jrifi.m Fih *c. .. 10.30 ... 43.57 ... 0.3/ ... 2.27 ... 13.72 ....... ....... ....... ....... ....... Firt.- ti m Cur>. --m ile. 40.87 41.50 2.81 0.90 13.55 Tim pure.-, t mdiesfo.9, having fibres of extraordinary length',, was that of a rnan admitted to the Charing Cross Hospital in 3899, where ho died in 1900. l)r. lh I.. Middleton of the Home Offif.o kindly lent the notes of the case, and of the evidence given before tlm Departmental Committee on Industrial Diseases in 1906 by the late Dr. II. Montague Murray, under ivho.se cave the man had been. This patient, occurs in Northern Italy. Asbestos may contain fro 14 0.5 to 15 per cent, of iron oxide, but asbestos yarn is prepared from mineral as free as possible from iron. To get rid of the difficultly soluble iron, asbestos i.s soaked in orthophosphoric acid .solution and washed in '.rate;' liefor-s manufacture. The percentage of iron, than, is of recog a man aged S3 years, had worked in the carding room of nized importance, ' an asbestos factory for ten years prior to his admission to hospital. He informed Dr. Murray that he was the solo survivor of ten men who started work with him in the Hanufeaturing Process. The process of manufacture resembles that of cotton. carding room; the others had died, presumably as the The crude mineral is subject to mechanical treatment, in a result of their occupation. A y>st-morl c m examination v. as grinding machine. Tho heavier rock is separated by held and the diagnosis of pulmon iry fibrosi- was confirmed. gravity, and the remaining asbestos passed through card Dr. Murray in hi.s evidence refers to photomicrographs of ing, roving, and spinning machines, and from the.,o to the lung sections which show "spicules of asbesias." These weaving sheds. cro the salient facts of the first ami, down to 1924, the Daring the carding process, and to a less extent in -,.11 only record of a death duo tho processes, a very con t > Osh w-tos. siderable' amount, of dust 13 That these tu 0 eases .stand ni'Uia is very surprising. Tho asbestos industry is r. ere than 2,000 years old, DESCRIPTION OF PLATES. FjO. 1.--A^bcAto? fibre, tbe b ilk cf vhi-.-h fs (ranMm.-cnf and in which are Mack .mgubir iron-cootainin'r frujiinent.-, Thes-e consiituiy a largo X' roA)iyrtf>ri of the dust gi-neruted in uumufacf me. (x 150.) generated. In up-to-date factories all machines are fitted with extractor covers and the dud removed. In rev: T.ve know that asbestos Fm. 2.~--J.iiga p'.fichi o/ fobtdoo in fihnAic area ol lung. (> 353.) the first factory' where factories, up to rpiite lecent yOAJS, hove been devoid of any appliances for the r,revec lion and extract it r. of ve:, 71 ieiiark of I)i. Fid. 5.--F: r.i of njh*.^*os 350 imc-runs in lergiii in nccreiio nun of iuug. (x 160.) >jus. 1, 9, a:-'d 16.--Curious T'dies. (x 400.) Fft:.'. 5. 6, 10, .'M.' H.--Cuiiouc boilit.-s SiK-v/iug discoid a rrargenn'nt and globular ex Jig. 6 show? pruticlei of ttieie bodi< and grunul.iv lb.St in tv r;y t.-- b. (X VJkh).) the patient the subjeet. oc tin's paper was employed e.r met hud of dust lemovat was used, and the atmo spheric conditions wco Mm rev's patient is s rtrgestivc, and med'cal ni-.r. have i.aig suspected asbestos dust Fm. 7.--Fihio vi iur.g with c1u?Lup of the curious bodies lyir.j fteo in aivf.li. rid. 8.--Fib/0-c.ve'''Us ar-.-; with g'hrd cells. or. usioiially so bad that workers in her particular roam could not seo each to ho tho cause of lung eruiditiot.s in work tj. in badly Fig*. 1 tu 6 n-.j xn rod Ada d ty kind permission <f the Ed'tvr of the ; anal of L\j H-yii Mi t'< y.-jcuj teal Society. other. vsr.tilaf ed fa :*ories. A.v'r-sros is . C, Asbestos ril.i'- ami Pint. Microscopically asbestos iirencal vegetable, both r.brotis and | fibre is seen to consist of two very dilferent elements. , and brittle; as capable of being The hulk of the fibre is translucent and glistening, curded, spu and vwoven as woo), flax, or si . A single with here ami there black op: rpm angular pavticl -a strand can l-e sunn t gh less than an ounce to 100 yards, (Fig. 1). Minnie black gram ks also are present. mid a : loth menufe,,. red which weighs less than 8 ounces Tlieso black particles are actually part of the fibre, : id; Siiif.ro re id. It occurs in every country, but is but their appearance ;,ngg. sts a different chemical com i.svi'' found in any ; i countries alike, nor, indeed, in any position and different physical charm tem from the t'Oeutiy. translucent pol l ion. Tho dust generated during manu Uiitcn'ireil. As be it at p.*. iuth-st; n.etihle, ami its fire-misting 'ere lin.v-. ;j the aniients. The lionmns ruined f. vr tho I-. ::a.'. Alps and tho Ural Mountains. Herod it us (circa 7:0 E.c.) ties'rihed a cn axition dotti r. sue from st 0- - is. Pliny (circa A.n. SO) minions the 1 nixit idt v in ; ay 1, g it. tsvahu (circa 20 me.) and Plutarch (area A.i>. 70) both speak of the wicks of the lamps of the '. vital Virgins being made from asbe.-ta, so called Imcause l'.-'y la'intained r. perpetu'd fiaino without Wing cousin led. P <v (ci/ot A.D. 175) rcfaix to a gold lamp mado by C ; lk;.:a. lai; of Athens for Jliaerva. the wick or which r:.i mad,., of C:.i pa.iian linen, " tho only linen which is not ccurumod by fie." Later (a.d. 1250) Marco 1`i.Jo writes that ho had situ Tartars Using clnlh that v. iihstc,.d fire .. huh was made cl a " Certain,.' Mineral! of l.ariii lound i: a Mai.ntayn facture is seen to consist of these sharp angular parti. Dj and minute granules, fugc-osting, of com,", that thyy aro more brittle than the translucent part of the fibre. These pai tides are found in very stud! numbers in the finished article. Mr. T. H. Dyrom, F.!.(!., analysed several samples of dust, and found IbM tin? dusts contain ing the greater numbers of these black particles contained tilo largest amount of iron. The iron content of tho finished article, raw material, and dint, is u, follows: Finished arti. In: Iron (as ferrous oxide) .............0. \ V, Crmk' raw ia:.l r i isl : Iron (as ferrous oi it:).. .. 2tfc(, Dust from caxlinp; room : Iron (as ferrous t.xi.l.'i ... 13.1% From tbme resells it appears (Oitrlusne th.t (fit- II lik ened brittle parts of the asbestos fibre are tie- iron-f-mt:)i;iiner portj-.iis--il'.n hughe.,r of the innnufnetr,:a-r, the '-.n-o amt," a;ia a tl;ui*:k-i Ij the hc.iltli of u.njv-Mv -1 pruro>s of nir nufai i tM O. Although its a ah: ihlc j,ro]>crHe.s have hei it known for tli.ni :.::ids. of years tho n.adorn adaptation of ajustos to tile i; dm,triai ail, dates from oid, a few e .rars ami. Clinical flist 'i'i/ of tli Case. Th-' d'ii n-t- (?, a wuihan ic/t .l 33 yc-ars, <:! wtuk .jl ih:`> age of 13 yoims in an r. T-M "'a f.iciory in vw)iitjli no }'rr-\ i -ion maOo lor flit i\1 raciion of iln?t. Frum mi c.iMy 3;t-, soon -.iff. i- Composition-. Mb- dos is one of the silicate., and it , varieties are m, me Com. V/herevei' it occurs it is found a -Svcirdc;; with `J ,i. .ini tie.- tv. O {`/I I-'/. ill ' {/ - j" hi, S "iin of i> j-.. ^Hih .-w 1,|: lit in . <-7t l/.i.A & ? i h j . - v. at. fhr> A.l.l .tPl yL.. ilu li, ill lh .)!, ilc.ll / Cl iioft, T.-'.u I tu.; :) 131?, couijii ;m ing' v..nk, : i:V* v-mI from cough, vhich iii.1 n-ii int-Titiv \vilh J)i`r gctioua in allh until Slid w.is 11 * - n 63 years of ag'\ am? iioiJ h-pn v/-nkir<" t t'ii'lc on Tf<hu ij.ij time until 5 )t.-is i,iL-r (1932) V.ei- alirmhiucks r.t woil; v-mo inluini! leu: O'.ing to ill li'iltii. Site occAM-irai a l. i \a.;;I one or tv.> pr:rif. }-: rf bo.vc: until sli t j'nal!.- o-a A vti-V in .'.tiy, 1622. " U| to i\ c:-.i pt.ii'm (I of rturli. cIvsumow.t. cat, lti j. ut i^eiouiai. .JpMLk/ic.iji!. iO iM -1 ol/i DecimiuiLb -y iq z i MT-001724 I927] PULMONARY ASHESTOSIS. (llhiilititinij the ixipers by Una. W. E. Cooke and Stuart McDonald.) [Tkk Ba!t;hm MxiWCiL Joufl-IAI. Pig- I- Fig. 2. I'm;. 5. Fig. 6. MT-001725 DKC. j, l'32 7] IM'IAlUXAliY ASJiKSTOSJS (llhiitnitinij thv. iAiprr.1 hy i)jts. W. J- Cooke and Stuart Mi-J)oxai.j.) p ThbBritiss V->*. iV <fi$sk*> o.i*A .F' .** ' C-* Fig. II Fig. 10 MT-001726 D20. 3, 19*73 PULMONARY ASBESTOS1S, UjdicalJou 0U3118 j lu^ilude. The physical signs in her chest were those of Ithresu of the right lung. In July, 1922, signs of cavitation wero noticed, the sputum became more profuse, with sweats and frr,.?ular temperature, and she died on March 14th, 1924. jto x-ray plate showed extensive fibrosis, more marked in the risht lung, two calcareous glands at the root of the left lung, and pro small calcareous particles in the base of the left lower lobe. AJncroscopifal Appearances. flight Lung.--The pleura is thickened over the entire surface of llic lung, and shows the remains of dense adhesions to the chest ^all and pericardium. The lung is firm and small. The glands ihe root of the .lung are large, and on section are black, show a thickened capsule, and some calcareous particles. On section, jbe lung is seen to be fibrosed and to a large extent airless, the jung tissue being replaced by fibrous tissue. Dense strands of fibrous tissue from the pleura intersect the lung. In the apex there is a large cavity, the size of a peeled tangerine orange. The middle and lower lobes show numerous small areas--varying in size from a hazel-nut to a pin's head--of caseation, some of which have proceeded to cavitation. The bronchi are dilated. Uit Lung.--The pleura is thickened and shows the remains of adhesions to the chest wall. The thickening and adhesions ere uol so marked as in the right lung. The lung is firmer than normal. At the root of the lung are two large calcareous masses, oue Ihe size of a large hazel-nut, the other about half that'size-- calcified tuberculous glands. The other glands are black and show periadenitis. In the left apex there is an area of old scar tissue about the size of a sixpenny piece, and a cavity the size of a walnut. Scattered throughout the lung are small areas of denser consistence than the rest of the lung, some of which show definite calcareous particles, others small areas of caseation. There is a considerable increase in the fibrous tissue. Three outstanding features are presented by sections from this case. The first is the enormous amount of fine granular pigment in the peribronchial fibrous tissue, walls of alveoli, and in phagocytes scattered through the sections. The particles of this dust are similar in size and shape to the black granules seen in the asbestos fibre. The second unusual feature is the presence of large solid angular particles (Fig. 2). These are situated in areas of fibrosis and in caseating areas. They vary in size from 3 to 360 microns in length. The particles are so large-- masses of them are seen in certain areas--that they must have occluded small bronchi. Fibrosis of the alveoli supjilied has taken place and later necrosis, as seen in Pig. 3. We have never seen anything parallel to this in pneumono- coniosis due to other dusts, nor have we been able to find such occurrence in literature. On comparing these large particles with asbestos dust there is a striking resemblance in sizes, shapes, and colour. In fact, it is very easy to take each single particle found in the lung sections and immediately find its brother in a slide made from the dust. We cannot think there is any reasonable doubt that the particles in the lungs are the heavy, brittle, iron-containing fragments of asbestos fibre. The more extensive involve ment of the right lung is thus explained. The heavy par ticles would pass more easily down the more vertical right bronchus than the horizontal left bronchus. HISTOLOGY OF PULMONARY ASBESTOSI8. BY stuart McDonald, m.d., f.r.c.p., Professor of Pathology, University of Durham. (With Special Plate.) My remarks are confined to the histological appearances in the lungs in this condition, with special referenoe to certain foreign bodies of most unusual appearance which are present both in the alveoli and interstitial substance of the lungs. The observations are based almost entirely on material supplied from the case described by Dr. Cooke. The investigation has been conducted in the pathological department of the University of Durham College of Medicine. _ I may state, however, that the appearances are practically identical with those observed in a second case of this con dition, sections 'of which I have had an opportunity of examining through the courtesy of Dr. I. M. D. Grieve of Arinlev, Leeds. lr Histology. ' ~ Numerous sections have been made from both lungs. The changes are more marked on the right side, hut the appearances in the two lungs only differ in degree. They may be summarized as follows: 1. There is well marked diffuse interstitial pneumonia with chronic bronchitis and some emphysema. 2. There is well marked antluacosis. 3. There is an extensive tuberculous condition with chronic phthisis. 4. In the alveoli, bronchi, and bronchioles, and also in the interstitial fibrotic areas, are certain foreign bodies which will be described in detail later (Fig. 7). As this communication deals specially with the nature of-the foreign bodies, the general histological features will he dealt with very briefly. The interstitial fibrosis is such as might he expected as a result of a combination of a pneumoiioconiotic condition and a chronic tuberculous infection. The typical wliorled formations seen in a more purely silicotic condition are not present. There is a marked endarteritis in the smaller branches of the pulmonary arteries; some are throm bosed and organized. Many of the smaller bronchi are obliterated; some have still caseous-looking centres. Some of the alveoli show the usual metaplasia of their lining cells into cuboidal form. The fibrosed and thickened walls of the bronchi in many places gradually merge into the areas of diffuse fibrous overgrowth. There are numerous foci of lymphocytic cells among the fibroblasts. Some of these seem obviously derived from lymphoid tissue in tho bronchial walls. The interstitial fibrosis is progressive.. The tuberculous condition is obvious histologically. Tubercle bacilli were not detected, hut the histology is characteristic. The lesions are chronic in character, and there is no special indication of an acute exacerbation. There is well marked caseous bronchitis with lymphatic spread and numerous fibro-caseous deposits with giant cell systems (sec Fig. 8). The bronchi, which are not specially the seat of tuberculous change, show catarrh with peribronchial thickening. There are numerous emphysema tous areas. The alveoli show, in the majority of cases, some thickening of their walls, ancl contain many catarrhal cells, apparently derived from the lining cells; a similar catarrhal change is seen in the terminal bronchioles, some of which are dilated. The Foreign Bodies. The larger black aud irregularly fragmented bodies which have been described by Dr. Cooke were not very obvious in the material I examined, hut were clearly seen in some microscopical preparations of his which I had the oppor tunity of examining. I shall not refer to them sjiecially, but confine my attention to certain highly characteristic and much smaller bodies which are abundant in all the sections examined. Some of these are free, hut many are pliagocytosed by the large mononuclear cells in the alveoli (Fig. 5). Some are easily included in comparatively small phagocytic cells, but the majority are larger, varying in size from 20 p to 70 p, or even more in the case of certain elongated forms. The smaller bodies are rounded and homogeneous, and all have a distinct yellowish-brown colour suggesting blood pigment. The longer forms have a highly character istic appearance, strongly suggestive of some organic struc ture. Most have an annular ajipearance, which oil closer examination can be resolved into a closely set series of rounded discoid bodies (Figs. 4, 5, 10, and 11). In some cases the globular forms are arranged along the more filamentous forms and occasionally are clustered at the ends of the rods, simulating sporangia of a hyphomyeetes (Figs. 5, 6, 10, and 11). Some have club-like extremities at one or both ends of the filaments. Others, again, suggest the appearance of minute crustacean forms )Fig. 10), hut closer examination does not support the idea of either vegetable or animal origin. These bodies do not stain with the ordinary aniline stains, hut preserve their original yellow-biymn colour. They are seen well in unstained sections. They give a characteristic prussian-blue reaction with potassium ferrocyanide and dilute hydrochloric acid. The reaction is not so obvious unless the solutions are slightly warmed. Where the bodies are too large to be pliagocytosed by individual cells they tend to become surrounded by plasmodial masses. Many of the phagocytes contain much carbon pigment in addition. Though these bodies are mainly found in the alveoli and L z b l 'C -w vp vT O o g S z-O l -S520/ . 2. J iu v m t'ju y y m y v ip e ty I""<N r- oo H 2 1026 Dec. 3, 1927] PULMONARY ASBESTOSIS. 003121 Y Y bzthbaJL ^ \& U A n a J ^ ' 1Q-ZU i o ^ v S y iC A tn h ^ u S , H Z -7> infundibular passages, they are also present in the caseous areas, in the neighbourhood of the phthisical cavities, and some can be demonstrated in the fibrotjc areas surrounded by definite fibroblasts. One in particular (see Fig. 12) measured about 75 p. - It is clear and Segmented in its middle part, but the extremities are nodular and clubbed. It is difficult to imagine that a foreign body of such length could be transported by phagocytes, but they may represent larger bodies left in a bronchus which has become obliterated. The bodies have been examined with the micro-spectroscope, but so far no clue as to their nature has been obtained by this means. They are not refractile by polarized light. Nature of the Bodies. We have shown these preparations to several patho logists, but the appearances are new to them. To confirm our own opinion we have submitted them to experts in zoology, who are unanimous that they, are not of animal nature. We have also submitted them to botanical and chemical authorities, and- though there has been a consider able difference of opinion, some regarding them as hyphomycetes,. the general opinion has been that they are not vegetable forms. . The fact that exactly similar bodies have been found in the lungs of another asbestos worker, and, so far as I can ascertain, have not been found elsewhere, would seem to indicate that they are essentially derived from or associated in some way with the asbestos itself. It is also certain that they do not in any way resemble concretions, largely com posed of calcium and other salts, and also containing iron derived from blood, such as have been described as streptotlirix forms in the spleen, and which may closely simulate mycelial filaments. The hypothesis advanced is that these bodies are portions of asbestos fibres in the process of altera tion and absorption by hydrolysis, either by direct chemical action or by enzymes. The particular variety of asbestos with which this patient worked was a Canadian serpentine (ehrysotile). It would probably contain silica and a magnesium salt in about equal proportions (40 per cent.) with up to 3 per cent, ferrous oxide, 1 per cent, of alumina, and water. From its high resistance to heat we are apt to regard asbestos as indestructible, but, given time, it is possible for hydrolysis of such silicates to occur, even in pure water. Such hydrolysis would be hastened and intensi fied by the presence of COs in the pulmonary alveoli, and the warm moist atmosphere there would, no doubt, accelerate the process. Even under these conditions the process would necessarily be a slow one. The magnesium could be separated out as relatively insoluble carbonate, or more soluble bicarbonate, which in turn would be converted into auy other salt for which there happened to be the appro priate acid available. The iron existing in a ferrous condition in the presence of an oxidizing agent might be converted into the ferrio state, and subsequently precipitated as hydroxide. The silica might pass into a colloidal state, at first in sol form (orthosilicic acid), later passing into a gel (metasilicic acid). If this were so in sol form, it would tend to remain associated with the surface of the asbestos fibre by adsorption, and might be held there till it became a gel. In time the get might adsorb the solution, and so gradual conversion of the fibre into a mass of gel would occur. There might be in the tissues sufficient albuminoid material to effect rapid gelatinization of the sol, particularly if, as would be the case here, the sol was being slowly produced. The fact that the gel is of high surface tension, and formed at an irregular rate, would give it a spheroidal structure and account for some of the appearances seen here. Whether this be the exact explanation or no, it is at least an hypothesis which should be capable of experi mental verification. As has been held by Gye and others m cases of silicosis there may be a direct chemical action of silica on the tissues apart from the merely mechanical u-rttatmn of the particles, with the production of fibrosis. rthosilicic acid 13, as has been shown, an active poison, its actfon converslon iuto metasilicio acid would minimize As to the relative part played by the asbestos and the tuberculous infection in this case, in relation to the change, it iB difficult to say, but it is a reasonable assump tion that the tuberculosis was a superadded infection, and in 'Dr. Grieves's case referred to above there was in the sections examined a considerable degree of fibrosis without apparent tuberculosis. The immediate cause of death iu that case was a terminal broncho-pneumonia. Till some experimental work is completed the exact nature of these foreign bodies must remain in doubt, hut their highly characteristic appearance may well prove to be an impor tant diagnostic point in the recognition of the lung of a worker in asbestos. I am much indebted to Dr. Cooke for material from his case, to Dr. Grieve for an opportunity of examining his microscopical sections, to P. L. Robinson, D.Sc., of the Chemical Department, Armstrong College, for his advice and suggestions on the chemistry of the silicates, and to Professor W. H. Lang, F.R.S., of Man Chester, for a reasoned opinion as to the non-botanical nature of the foreign bodies. CLINICAL ASPECTS OF PULMONARY ASBESTOSIS. ' SY . . Sib THOMAS OLIVER, M.D., F.R.C.P., . Consulting/Physician, Royal Victoria Infirmary, Newcastle-on- Tyne; Emeritus Professor of the Principles and Practice , , of Medicine, University , of Durham. . . Er.-W._E.. Cooke has given a short account of the history of asbestos, also of the processes of its manufacture into cloth-.like structures much in the same manner as raw cotton fibre is woven. He has told us that in the carding department a considerable quantity of dust is evolved. The crushing of the rock is not carried on to any extent in this country; this is usually done in the countries where the mineral is quarried. Canadian rock. is crushed in Canada so as to reduce the expense of transport to Great Britain. Our workers are therefore less exposed to the harmful influence of the dust--a fortunate circum stance, since the rock frequently contains as much as from 50 to 60 per cent, or more of silica. With the exception of Dr. Cooke's paper on pulmonary asbestosis published in 1924, and the details of a fatal case published by Dr. Montague Murray in the Charing Cross Hospital Gazette in 1900, there has not been, to my know ledge, anything written in this country upon the subject. I have bad, however, the opportunity of visiting asbestos factories in America, and of seeing cases of pulmonary asbestosis through the kindness of Drs. Haddow and Grieve of Armley, Leeds. It may, I think, he safely said that there must have' been several deaths of workers in British factories from' the malady, but as no autopsy and microscopical examinations of the lungs were made the deaths were probably certified as pulmonary tuberculosis. Asbestos manufacture is largely a familial occupation. It has been carried on in this country only for a little over thirty years. Carding and spinning of the fibre are important processes in the manufacture of asbestos goods. In these departments many women are employed, mothers being succeeded by their daughters. Where ventilation of the carding and spinning rooms is properly attended to the atmosphere is fairly clear of dust and floating fibre, otherwise in these operations considerable quantities of dust become suspended in the atmosphere. In a British factory the dustiest process is "hand beating" of the finished mattresses used for covering and protecting the internal machinery of automobiles. This work should only bo undertaken in a room separated from the main parts of the factory, with open windows at one end and strong down-draughts at the other, but even with this precaution men working therein should wear masks. Recently, with Dr. Grieve of Armley, I examined two women who are the subjects of pulmonary asbestosis, one aged 48 and the other 39. The older patient was one of the first to commence work thirty years ago in the particular factory I visited. At that date no danger from dust was anticipated, so that no effective ventilation of the workrooms was attempted, such as prevails to-day. Although only 48 the first patient mentioned lookp older by soveral years, and is extremely emaciated. SlVe gave up work a year ago on ac''~""+ increasing physical 3^ MT-001728 Deo. J, 1027] AN ACTI7B''CONSTITUENT OP " GLUEHOBMENT." fTitesaflBicaur.nJsoacami* 1A*Q7 1 lability, shortness of breath, and cough. At present she las no expectoration; her respiratory capacity is one inch. Although the apices of both lungs in front are resonant, .here is distinct flattening of the percussion note at the lases. The respiratory murmur at the apices and midung is coarser than usual, and the expiratory murmur is irolouged. At the right base the respiratory murmur is eeble, and small dry friction sound is heard. Towards the iase of the left lung and extending into the axilla are lenrd small moist tinkling sounds, suggestive of cavitation laving taken place; here also small friction sounds can be leard. Similar physical signs prevail posteriorly. The apex jeat of the heart is displaced upwards and outwards; it is 'elt external to the nipple, a circumstance which, combined vitli marked accentuation of the second sound of the leart heard over the pulmonary artery, suggests that lbrotic changes have already occurred in this lung. 'Uthough the patient states that she has no expectoration, :his was present six weeks ago, and when examined was round to be free of tubercle bacilli. There is no enlarge ment of the,exteriial glands. The other patient, aged 39, has been an asbestos workor For eighteen years. She had no illness until four years igo, when she developed cough and attacks resembling ironchial asthma. After remaining away froin^ the factory 'or three months she returned to her employment, and Followed the occupation for three years, when she married, ind as in the early months of her pregnancy she pst considerably in weight she retired from the factory. Although reduced considerably in weight, and the subject if cough all through her pregnancy, her infant daughter, gho is 14 months old, is healthy and well developed. The patient complains of a dragging in the chest without actual pain. There is noticeable shortness of breath on slight exertion, and she complains of morning cough with expectoration. The sputum has been examined and is negative as regards tubercle bacilli. Her appetite is poor. She weighs 8 st., a drop of 3 st. having occurred within the last two years. Her heart is healthy; the apes beat is not displaced, but the second sound over the pulmonary artery is distinctly accentuated. The apices of her lungs are resonant. Here the respiratory murmur is coarser than usual and the expiratory is prolonged, so that the inspira tory and expiratory murmurs approach each other in equality. Moist rales are heard in mid-axillae and small friction with crepitation is heard at the bases. This woman's mother, who i3 aged 60, is still working in the factory. From what I have seen clinically of pulmonary asbqstosis it resembles silicosis of the lungs in the marked shortness of breath on slight exertion, deficient respiratory capacity, physical debility, and, in examination of the sputa of not too far advanced cases, absence, of tubercle bacilli, but since fibrotic changes are developing in both of the patients to whom I have alluded, there is almost sure to develop, if such has not already taken place, pulmonary tuberculosis. The clinical picture of pulmonary asbestosis differs slightly from that presented by a patient the subject of ordinary tuberculosis of the lungs, in so far as there is a pronounced deadening of the skin varying from mild bronzing to slight blueness, a degree of shortness of breath in excess of the physical signs, a greater amount of general disability, little expectoration, and comparative absence of night sweats. AN ACTIVE CONSTITUENT OF THE PREPARATION CALLED " GLUKHORMENT." BY H. H, DALE, C.B.E., M.D., F.R.C.P., Sec. R.S., AND H. W. DUDLEY, O.B.E., M.So., Ph.D. (From the Department of Bicebemiitry and Pharmacology, "National ' Institute for Medical Research, Hampstead, Loudon.) Is May of this year Professor vou Noorden published in the Klvnisdie Wochenschrijt an account of a new pancreatic preparation which had a controlling effect on carbohydrate metabolism, but, unlike insulin, was effective when adminis tered by the mouth.1 To this preparation the name " glukhorment " had been given, and the title of the paper made it clear that the substance was regarded by the author as containing a new anti-glycosm ic principle, naturally pre formed in the body. On information, evidently supplied to him by the chemist responsible for devising " gluk horment," Professor von Noorden stated explicitly that, in spite of indications in the patent specification, which might suggest some connexion of the active principle with a guanidine derivative, no such derivative, and in particular no syntliaiin,* had been added; and, further, that the finished preparation contained no guanidine derivative of any kind in recognizable amount. Professor von Noorden drew the cautious conclusion that, if the activity were due to a guanidine derivative, it would have to be one of extremely high activity. In July of this year one of us (H. H. D.) received a communication from the Horment Company, who were manufacturing glukhorment, stating that the)- were sending material in the hope that clinical trials of it could be arranged. In due course this and several subsequent consignments of glukhorment were sent by the Horment Company, with a request for their trial. A consideration of preliminary reports, on the mode of action of this preparation on the human being and on laboratory animals, suggested a strong similarity between its effects and those with which we had become familiar, through experiments then for some time in progress, on the action of syntliaiin. Some of the glukhorment * " Syntliaiin " la the aynllietic compound, decamctliyleiiediguanidine, introdwied by Frank, Nottminnn, and Wagner, as an antidiabetic remedy lor oral administration, and already the aubject ol numerous reporta. was immediately placed in the hands of one physician, who will presumably report his experience with it in due course. The physiological resemblance to syntliaiin was so pro nounced, however, that, before the question of wider clinical trials was considered, it was thought desirable to make a simple chemical examination, in order to confirm the fact that the preparation was free from syntliaiin and similar guanidine derivatives, as stated in the paper by Professor von Noorden, of which copies had been submitted by the Horment Company in support of their request. The result of this first test showed clearly that a guanidine derivative strongly resembling synthalin was present in substantial amount in the glukhorment tablets as submitted for trial. The evidence thus early obtained was at once so clear and so surprising that it was considered desirable to use a further quantity of the material submitted, in order to obtain precise information as to the nature of the substance in question. The isolation of the substance was made easy by the fact that the nitrate of syntliaiin is a remarkably insoluble salt. Chemical Isolation from Glukhorment of a Guanidine Derivative closely resembling Syntliaiin. Two hundred glukhorment tablets were powdered; the powder, weighing 60 grains, was thrown into 1 litre of boiling water and the mixture was kept gently boiling for fifteen minutes. The liquid was then filtered, while still hot, from a largo mass of insoluble protein. The filtrate was evaporated in vacuo, with the addition of octvl alcohol to prevent frothing, ' to a volume of 120 c.cm. O11 standing, it set to a jelly; this was wanned to 40, when it became fluid, and concentrated nitric acid was added until the reaction of the liquid was strongly acid to Congo red. A white crystalline nitrate separated from the solution on standing, and the liquid no longer set to a jelly when cold. The crystalline material was collected by centrifuging, washed in the centrifuge with a small quantity of dilute nitric acid, and dissolved in about 25 c.cm. of hot water. This solution was boiled with charcoal and filtered. To the hot filtrate 0.5 c.cm. of 6 per cent, nitric acid was added, and the nitrate crystallized on cooling. This was filtered off and dried; it weighed 1.135 grams. It was then converted into the picrate by dissolving it in water and adding a saturated solution of sodium picrate until 110 further precipitate was produced. The picrato was filtered MT-001729