Growing worse, she was admitted to a hospital on February 23, but pneumonia developed, and death resulted on March 3, apparently from that cause and poor resistance. The death certificate gives the primary cause as lobar pneumonia, with acute myocarditis as contributory.

The physician who attended this case stated that when he first saw the patient she was in an extremely run-down condition, seemingly from the influenza. He gave the cause of death as it appeared, without thorough examination, because he had no idea of other complications. He did not know her history, so did not connect it with radium poisoning, but during the first few days she did not appear to have an ordinary case of pneumonia.

Case No. 17.-L. K. D., a 24-year-old female, had been employed as a dial painter in the studio for about three years during the war. In the latter part of February, 1926, she noticed a marked swelling of her face, which was worse in the early morning. Her ankles and legs began swelling at a later period. A pain appeared in the right lumbar regions of the back. She was hospitalized on March 27. The hospital records show edema of face, hands, ankles, and legs, and evidence of fluid in the abdomen. Diagnosis was: "Chronic nephritis-nephrosis." A week later the edema of the face had grown worse, but it was reduced in another week. Ten days later she was able to be up, and was discharged as improved on May 3. After being brought home she was alternately better and worse. Convulsions appeared on December 31. A near-by physician was summoned, who attended her until her death on January 8, 1927. The death certificate states the cause to be chronic nephritis and chronic myocarditis, and the contributory to be hypostatic pneumonia. The physician stated that when he was called in her heart and kidneys appeared badly affected. He treated her for the apparent conditions, as he knew nothing of her past history or employment in the studio. When he learned that, three months later, he revised his diagnosis, especially as she had suffered from progressive anemia as well as from the acute conditions described, but no change was made in the official records.

The next four cases are among those mentioned by Hoffman.12 He also mentions another case which he had not seen, but whose dental record shows necrosis. The patient, V. E., had left the locality, and could not be traced. It was, however, rumored that she had died since leaving there.

Case No. 18.-J. F. (J. S.), a 29-year-old woman, was employed in the studio for about eight and one-half years. She had been mentioned in the report of the examination of the establishment in 1924. Her blood condition was not up to standard. One tooth was found to be abscessed, and it was claimed that she was subjected to an undue amount of exposure. One dental firm refused to pull the tooth, as X rays showed indications of necrosis. It was extracted later by another dentist, and it is claimed that no trouble resulted. The former findings indicate a possibility of affection, so the case remains among those regarded as suspicious.

Case No. 19.-G. M. S., 23 years old, was employed as a dial painter in the studio for six and one-half years, but left in September,

12 Journal of the American Medical Association, Sept. 26 1926.

1923, on account of the cases which had developed there. X rays of her teeth before 1925 indicated necrosis, though she claims she had no dental trouble until 1927, when seven teeth were extracted. Although the dentist who performed the work stated there was no necrosis present, the case is still open to suspicion.

Case No. 20.-A. B., a 28-year-old female, was employed as a dial painter in the studio for six years, but left there in June, 1922, when trouble with her teeth developed. The first dentist consulted refused to make any extractions, but these were finally made by a firm of exodontists. All her upper teeth were extracted, and 23 in all have been removed. Aside from the pain and loosening of the teeth, she developed a pain in the chest and an intermittent swelling in the left breast, which appeared to be a tumor but which disappeared at times. Although many physicians have been consulted, the origin of the swelling has not been determined. Rheumatic pains appeared later in her body, mainly in the hips. Blood tests showed an anemic condition and X rays indicated a mild necrosis.

Case No. 21.-N. M., a woman 29 years of age, was employed as 8 dial painter in the studio for about six and one-half years, but left because she became afraid of the work. After the extraction of a tooth in January, 1924, the jaw did not heal, and the X ray showed slight necrosis, which the dentist declared was caused by the work. The socket finally healed three years later, but the lower teeth have recently become loose, and her throat feels dry. She has had no medical attention, principally because she has a small growth on the neck, and is very sensitive about it. It is claimed by some to be a benign tumor and by others to be a goitre condition. It has been evident for about six years, but she states there is no pain, and consequently she does not want to bother about it.

Case No. 22.-M. K., 38 years old, worked in the studio as a weigher for four and one-half years. In November, 1921, she suffered a bad attack of influenza and was advised by her physician to stop working. Pain developed later in the face, exhaustion, and rapid loss of weight, and finally marked anemia. Two teeth were pulled, showing definite necrosis.

Case No. 23.-M. C. C., 38 years of age, worked in the studio as a dial painter and instructress for 15 months. About two years ago, eight years after leaving the employment, her jaw commenced to ache. A year later one tooth in her lower jaw fell out, and others became loose. In February, 1928, severe pain was experienced, and a dentist was consulted. He said the teeth had been neglected, but, learning that she had been a dial painter, he refused to extract any unless X rayed and found free from necrosis. Another dentist did likewise. X rays were taken, showing that part of the jawbone was necrosed. Her teeth are very painful, but she is advised against extractions. Pains have developed in her back and her right side seems paralyzed intermittently.

Case No. 24.-H. T., a 30-year-old female, worked in the studio as dial painter for over four years. Trouble with her teeth developed in February, 1928, six and one-half years after leaving the studio. Two teeth were pulled, and necrosis followed. Further information was refused.

Case No. 25.-E. M., a woman, age unknown, was employed in the studio as a dial painter for about two and one-half years. It was

stated that her right arm is paralyzed, but further information was refused.

Case No. 26.-A. R., 37 years old, worked in the studio for six years, then in another studio for six years, up to May 1, 1928, She began to feel somewhat ill about 1920, but did not associate it with her work with the radioactive materials. It was mainly acidosis, and was thought to be caused through spraying with lacquer, without sufficient ventilation in the room. Her teeth began to get loose about 1917; some were extracted at that time and in 1921, so that only three remained. Two of these fell out recently and the jaw is now very painful. She has lost considerable weight since losing the teeth. Case No. 27.-R. R., a woman 39 years old, worked as inspector in a studio for six years, up to 1922. Her teeth started to become loose in 1918, and 16 loose teeth were extracted. Two teeth were left, to hold the plate, but these have since dropped out. Apparently no other troubles have resulted so far.

Several fatal cases among dial painters were investigated, which had been attributed to the occupation, but it was found that they could not in any manner be connected with it. There must necessarily have been a certain number of deaths among employees in the establishment, which were due to other causes. However, it was found there have been other cases similar to that of the one chemist recorded. The most startling of these, that of Doctor von Sochocky, a former official of the firm, occurred during the investigation.

Case No. 28.-The history of the death of Dr. S. A. von Sochocky on November 14, 1928, is well described by Martland in his recent article. It might be added that Doctor von Sochocky was a physician as well as a chemist, and knew he was dealing with dangerous materials, but according to all reports ignored the dangers. He was fascinated by the qualities of radium, and is said to have played with it, taking the tubes of radium salts out of the safe and holding them in his bare hands while watching the scintillations in the dark. He is also said to have immersed his arm up to the elbow in solutions of radium or mesothorium. His death certificate gives the primary cause of death "Aplastic anemia, due to inhalation, ingestion, and penetrative radiation from radioactive substances-occupational," and the contributory cause as "Terminal sepsis, hematuria, and broncho-pneumonia.'

Case No. 29. Another death had occurred among the laboratory workers a year earlier. V. H. R., a man 44 years of age, had been employed in the establishment for nearly 13 years. His occupation is stated on the death certificate as clerk, but at least part of his duties consisted in carrying radium salts about the place and wrapping them for delivery. Before his death he told one of the nurses in the hospital that he personally handled all the radium extracted in the establishment. During the early years there was a lack of proper screening and his fingers were badly scarred, according to the report of Doctor Drinker in 1924.9 The findings of his condition at that time were: "Decayed teeth. Slight pyorrhea. Marked changes in blood. Recommend vacation, protection against gamma radiation, and blood studies." It was stated further: "It is also interesting

* See footnote 2 on p. 24.

Journal of the American Medical Association, Dec. 5, 1925, pp. 1769-1776.

that Mr. R's blood shows significant changes-a condition which, if continued, might have disastrous results. The presence of a safe for strong radium in this office is the probable explanation of the exposure. Certainly insufficient protection is clearly indicated." On October 21, 1927, he suffered from a chill. Examination by physician next day showed influenza and acute bronchitis, with secondary anemia.

The records of the hospital to which he was sent give the following results of the blood examination: "Hemoglobin 60 per cent, erythrocytes 2,500,000, and leukocytes 2,500; examination of sputum: Tuberculosis-negative, streptococcus positive; anemia and leukopenia. Ulcer on finger; violent odor. Upper lips swollen. Eyes sore. No other abnormal signs. Wassermann test, negative." His temperature was normal on entrance, and below normal later. His hemoglobin went up to 70 per cent, but by November 4 had dropped to 35 per cent, with erythrocytes 3,180,000, leukocytes 4,200, polymorphonuclears 52 per cent, and lymphocytes 48 per cent. He improved and was discharged on December 1, but the anemic condition grew worse, so he was readmitted two weeks later, for a blood transfusion. The blood count on admission was: Hemoglobin 28 per cent; erythrocytes 1,900,000, leukocytes 15,000, with polymorphonuclears 40 per cent, large lymphocytes 56 per cent, and small lymphocytes 4 per cent; color index 7. The transfusion gave only temporary relief and he died on December 20, 1927.

The death certificate was signed by a physician who attended him the last three days during the temporary absence of his regular physician. The cause was given as chronic progressive anemia, with a contributory cause of hypostatic pneumonia, as the origin of the disease was not known to the physician. The regular physician admitted freely that the disease was of occupational origin and that the deceased was aware of it.

On the day of death an electroscopic test for gamma radiation was made by physicists from the establishment at which he had been employed. The result is said to have been negative.

Case No. 30.-During the investigation it was discovered that the death of another worker six years previously looked very suspicious. M. W., a man 54 years old, had been employed in the extraction division for about five years. According to the firm, his duties were confined to the storeroom for carboys of acids and machinery, but it was admitted that he might occasionally have handled some tailings from the extraction rooms. It was claimed by others that this was part of his regular duties, bringing him into contact with material to which he possibly was peculiarly susceptible. His previous health had been good. He was strong and healthy, but was said to have been a heavy drinker.

In June, 1922, he suffered from sore throat and weakness. His physician thought the trouble was occupational, and advised a vacation. The vacation did not improve his condition, which subsequently was diagnosed as anemia by two other physicians. Injections were administered, but by July 10 he had lost 30 pounds in weight. He was extremely pale and weak, and suffered from shortness of breath and swelling of legs. The condition grew worse and resulted in death on November 18, 1922. The death certificate gives the cause as pernicious anemia.

Connection with exposure to radioactive substances was thought possible by the physician who attended him at death. He said the severe anemia resembled those of the later poisoning cases, and was accompanied by edema. One of the other physicians did not agree with this opinion. He thought that drinking was partly responsible, and he stated that a high blood pressure existed and that chronic nephritis had developed. The relatives of the deceased felt that it was caused through his work, and expressed a willingness to have the body exhumed and tested for radioactivity, but no action had been taken.

Cases in Other States

While all known cases of poisoning from radioactive substances were for a long time confined to the single New Jersey studio, the first one to start dial painting and probably the largest in the country until the appearance of the disease, similar cases finally came to light in other localities. This showed that the poisoning was not due to some condition peculiar to this one studio, and it also created apprehension among the various firms who were engaged in the work.

Some of these firms had, however, known that outbreaks might be expected at any time, because the investigation conducted by different firms had disclosed radioactivity among the dial painters in some of the studios. The knowledge of these discoveries had, however, been carefully concealed by the firms, who feared disruption of their business if the facts became known. Even the victims had not been informed of their condition, nor the cause, through fear of panic among the workers.

Case No. 31.-On October 27, 1926, a paper was read before the laryngology and rhinology section of the New York Academy of Medicine by Frederick B. Flinn. This mentioned that two cases had appeared among the dial painters in a Connecticut studio. One of them, which he stated had been brought to his attention in June previous, was described in detail. Description of subsequent progress of the case and death on January 26, 1927, was added when the paper was published later, 13 giving a fairly complete history of it from the development of the jaw condition.

It is, however, a question whether the poisoning was not indirectly responsible for a previous disability, the fracture of a femur as early as April, 1925, four years after beginning dial painting or one year and nine months after leaving it. A suspicion that the poisoning was the cause, prompted investigation of hospital records for her past history, which is given here to afford a complete picture of this case. The deceased, E. D., was born November 17, 1902. She had the usual children's diseases. In August, 1918, when nearly 16 years old, she started to work in a watch factory, presumably on clerical work. She suffered an attack of influenza during the first year, and was ill for about one week. In the latter part of February, 1921, she had cerebrospinal meningitis, and was in the hospital for two weeks, receiving intraspinal injections of serum. After discharge from the hospital she remained at home for about two months, then went back to the watch factory, where she was employed in the dial-painting division. The factory discontinued operation seven and one-half months

13 The Laryngoscope, St. Louis, May, 1927: A Case of Antral Sinusitis Complicated by Radium Poisoning, by Dr. Frederick B. Flinn, New York.