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    "ocrText": "Drinker folder\nREPORT or AN INVESTIGATION OF THE CAUSE OF NECROSIS OF THE JAW\nOCCURRING IN CERTAIN WORKERS EMPLOYED BY OR FORMERLY IN THE\nEMPLOY or THE UNITED STATES RADIUM CORPORATION.\nThis investigation was begun following the receipt of a letter from\nMr. Rodder, dated March 12,1924, giving an account of two cases of necrosis of\nthe 3am occurting in employees of the United States Radium Corporation -\none fatal case and one existing case, supposedly on the mend.\nCareful inquiries and investigations made during two visits to the plant\nin Orange have enabled us to trace the following instances of chronic disease\nprocesses occurring in the Jaw bones of employees engaged in the application of\nluminous paint.\nCase 1. -- Miss M. Maggin, employed from October 1,1917, to January\n25th,1922, developed a necrosis of the your and later died.\nCase 11. Miss Virginia Budolph, employed from September 23,1918, to\nApril 13,1921, developed, following the extraction of a tooth by Dr. W.F.Barry\nof Newark, a rapidly progressing necrosis of the Jaw, not improved by curetting\neight or nine times. Miss Rudolph finally died as 8 result of this disease\nprocess.\nCase 111. - Miss Vincent (NOW Mrs. Kuser) employed from 1917 to 1920\ninclusive, developed, following the extraction of a tooth five months ago,\nprogressive necrosis of the Brow, necessitating the removal of much of her left\nupper Jaw and tro blood transfusions. Dr. Theodore Blum the dental surgeon\nin charge of this woman, reports that a necrotic process has now begun in the\nright side of the lower Jam and that the patient is in a very serious condition.\nCase 1V. - Miss Margaret Carlough, employed, by her own and her\nsister's account, for a period of six and one-half years ending last December,\nbegan to fail in health three years ago. Her symptoms were extreme fatigue and\nweskness with pallor. She continued Her work in spite of increasing 111 health\nand in October 1924, developed a toothache with local swelling of the face.\nOn December 24,1923, she had on upper and lower right molar pulled, a piece of\ndecayed bone coming out with one of these teeth. She then stopped work. Normal\nhealing of the Jaw d1d not ensue; instead, a discharge of pus began and persisted.\nLater two other teeth at some distance became affected and were extracted.\nShe has, at present, in addition to the process in the lower jaw, a new simus\nin the upper Jaw communicating with the antrum, as shown by X-rays. Her\nappearance is very bad. She has lost much weight and is very pale. Her blood,\non microscopical emmination, shows a profound anemia. She complains of pain\nin the bones of her face, has considerable inconvenience from the discharge of\nfoul pus in her mouth and is forced to spend much of her time in bed. She says,\nhowever, that lately she has felt a little better -- a statement not in accord\nwith her appearance and with the new septic process. We believe this girl to\nbe in an extremely serious condition.\nThe accompanying X-rays show the condition of Miss Carlough's Jow on\nMay 7,1924. These films show necrosis of the right upper maxilla with a great\ndeal of clouding of the antrum and an apparent tendency to extend into the nose.\nThe necrosis is not not great enough to cause loss of all the teeth, but the\ncondition of the antrum gd the tendency of the process to extend upwards toward\nthe skull makes one\npossible onset of meningitis.\nCase V. - Miss Grace Fryer, employed four and one half years ago,\nhad a left lower molar extracted one year ago. The wound apparently healed\nnormally. Six months later a sinus appeared at the site of the extracted molar\nand drained pus profusely for some months. X-rays taken at the Reconstruction\nHospital, New York City, on March 3,1924, showed evidence of a chronic infectious\nprocess in the Jaw in the region of the extracted tooth. This patient left the\nhospital five days Inter unrelieved and with a diagnosis of chronic osteomyelitis\n0 £ the jaw, possibly due to phosphoros poisoning. She is, however, now reported\nby Dr. McCaffrey, Dr. Harry Dunning's assistanct, to have recovered satisfactorily.\n(Dr. Harry Dunning 33 East 68th Street, New York City.)\nIn addition to these five cames, we have the opinion of Dr. V.F. Barry\nof Newark, a competent dental surgeon, in regard to the condition of the jerre of\nseveral other present or former employees of the Radium oration. In r.Barry's\nopinion, Miss Katherine Schaub, employed from March 22,1917, to March 19,1920,\nMiss J. M. Smith, employed for seven years, Miss 0. Smith, and Miss Vera Eldridge\nall show Jaw changes similar to those shown by Miss Rudolph when he first saw her.\nDr. Barry refuses to pull a tooth from any one of these girls, believing that\nif he does so an intractable necrosis, which he compares to that of phosphorus\npoisoning, will be initiated.\nCompetent dental surgeons in Boston, who have examined the films upon which\nDr. Barry bases his opinion, disagree with him, and state that, in their opinions\nMiss Schaub is the only patient who shows definite hone changes.\nOne of your employees reports that a Mrs. Madlinger (formerly Miss\nNettie Lozier), employed by the Radium Corporation for five years and up to three\nmonths ago, had a tooth extracted two months ago and that pus is still draining\nfrom the cavity.\nHere, then, is a series of five cases of necrosis of the Jaw - necrosis\nnot al all like the ordinary infections of the Jam which do occasionally follow\nthe extraction of a tooth. Instead of a localized process which heals either of\nitself or after the establishment of drainage, we have a chronic progressive\nrotting away of the bone, which, in the opinion of Dr. Barry and of dental surgenns\nwhom we have consulted in Boston, is essentially different from an ordinary infec-\ntious process or from tuberculosis of the bone, but resembles practically exactly\nthe necrosis of the jaw resulting from phosphorus poisoning. In our opinion, so\ngreat an incidence among your employees of this unusual disease process in the\nJan cannot be coincidence but must be dependent upon some type of bone damage\noccasioned by the employment.\nANALYSIS OF POSSIBLE TOXIC AGRINTS.\nIn view of the excellent general hygione of the work as conducted in\nyour factory, it seems at once advisable to study the special ingredients used\nin the luminous material.\nThe base, \"Undark\", of the luminous paint contains no phosphorus but\nconsists of a luminous sinc sulphide containing minute traces of copper combined\nwith small amounts of radium bromide, probably changed later into radium sulphate.\nThe amount of radium bromide per gram of dry luminous powder base averages,\naccording to Mr. Viedt, 0.007 mg., intimately mixed with the zinc sulphide. The\nvehicle is varied and the paint is applied with fine brushes.\nAs we learned from the dial painters that until six months ago it was\n-3-\ntheir universal practice to point their brushes in their mouths, we have con-\nsidered the possibility of brushes or of vehicle as a source of difficulty.\nBacteriological studies of the twelve brushes have been negative for anthrax, the\ndangerous bacterium sometimes occurring in hair and bristles. The bacteria\ncultured from the brushes were Bacillus subtilis, Staphylocoocus albus a\ngram-negative, non-sugar fermenting bacillus -- harmless sir-borne organisms which\nmay be found normally in the mouth. Oun scacia, the usual vehicle for the lumin-\nour material, is entirely non-toxic, being frequently administered by mouth and\neven intravenously in pharmacological preparations. We may now consider the\nconstituents of the \"Undark\" itself.\nZinc.-- Zinc, in the opinion of practically all recent authorities, is in itself\nnon- poisonous (1). So-called \"poisonous\" actions are due to the local irritant\neffects of soluble salts. Zine sulphide is on insoluble salt and has never\nbeen the cause of any kind of poisoning. It is not reasonable to suppose that\nthis salt would be readily absorbed or, if 80, that it would be toxic in the\nrelatively small quantities involved. We are, fortunately, able to instance\nadditional proof of this in the operations of the New Jersey Zinc Co., In a\npart of the works in which zine sulphide is made the employees are exposed to it\nin large quantities in a finely divided form. They must inhale and swallow it,\nas well as have a liberal contact with it through the skin. Dr. C. K. Drinker\nhas observed these workers over some years and finds them in good health with no\nunusual pulmonary, skin, or digestive disturbances which might be due to local\neffects; and certainly with no necrosis of the Jan as a result of their very ample\nexposure to sine sulphide.\nThe zinc sulphide which your company employs is, to be sure, not identical\nwith that just mentioned. Its molecular state has been changed by roasting 80\nthat it is photosensitive. It is also, we find, more insolute than the non-\nluminous sulphide in common inorganis reagents. This would tend to diminish any\npossible local effects - of which we found none in your plant - and make it\nmore difficultly soluble for the organism. Lastly, if it were dissolved and\nabsorbed by the organism it would change its chemical form, becoming probably a\nchloride or eventually a phosphate, and in this form would be identical with the\nsoluble product from ordinary zinc sulphide that had been absorbed. If such a\nsolubility does take place, the presence of soluble zinc in the organism, even\nwhere the exposure is many times greater than at your plant, is harmless, as is\nemply proved by the good health of the employees of the zine sulphide department\nof the New Jersey Zine Company and by a large general experience with the problems\nof zinc poisoning.\nCopper. It is hardly conceivable that the minute traces of copper present\nin \"Undark\" are significant as a toxic agent.\nRadium. There is a great deal of material in the literature on the effects\nof radium on animals and on men. In individuals working in the manufacture of\nradium apparatus and in clinical workers with this substance, the important\nsymptoms of over-exposure to radium are disturbances of the male and female sex\norgans, skin changes, and changes in the blood. These changes occur in persons\nwho are exposed to radium externally but not in such a way as to be able to absorb\nany of the element itself. Disturbances of menstruation in the female and sterility\nin the male are clearly recognised. The sidn changes, which vary in severity,\nare essentially those demonstrated by Dr. Lehman and Mr. Roth. And in the work\nof Nottram (2), Gudzent and Halbersteadter (3), Williams (4), Pfahler (5), and\nothers there is ample evidence of a disturbance of the blood functions following\nover-exposure to radium. This désturbance of the blood functions following over-\nexposure to redium. This disturbance consists in a change in the white cells of\nthe blood: a diminution in number and an alteration in the proportions of two of\nthe component types of cell, the lymphocyte and the polymorphonuclear cell. The\nred cells of the blood may also be affected, and there is evidence in some cases\nof a change in the ability of the bone marrow to manufacture these cells. At\nleast five deaths due to failure of the blood-forming organs have been reported\nas associated with over-exposure to radium or X-rays (6). The presence of\nchanges in the white cells may be uncombined with other damage, and dn individual\nshowing these changes may be in good health, but the weight of opinion at present\nis in favor of regarding the occurrence of even minor deviations from the normal\namong radium workers as evidence of over-exposure to radium. This index has\nalready found a basis in practice in the London Radium Institute, where the blood\nfilm is used as a means of determining the need of vacations or of increased\nprotection.\nIn regard to the distribution and time during which radium in various\nforms will stay in the body, there is a mass of evidence which is often contradic-\ntory. From it emerges the fact, however, that reliable workers have shown that,\nexcept for emanation, both soluble and insoluble salts of radium once in the\nsystem may remain a considerable period, even longer than a year in the case of\ninsoluble salts intravenously injected (7).\nPertinent facts in regard to the effect of radium on bone have been\ndemonstrated. We have found in the literature no reports of cases of necrosis\nof the bone occurring among radium workers as the result of over-exposure to radium\nduring the course of their work. It has been demonstrated exporimentally, however,\nthat X-rays, which are similar to but less penetrating than gamma rays, will delay\nor prevent the union of a fracture by delaying the normal production of callus\n(8). Exposure to X-rays will also disturb the growth of bone (9). Gamma rays\nthemselves, in a local application of radims in the course of treatment of cancer\nof the tongue, have produced in & sound Jaw a necrosis (10) similar to those with\nwhich we are concerned,- similar even to the extent that in one of the four Jaw\nbones so radiated, and to all intents normal, necrosis followed the extraction\nof a tooth. That radium, if absorbed, might have a preference for bone as a final\npoint of fixation is to be anticipated from the similar chemical nature of radium,\ncalcium, barium, and strontium. Strontium has been shown to be deposited by\nreplacement of calcium in bone (11), which has for its basic substance a calcified\nmatrix. So it is not surprising to find that a considerable fraction of radium\nremaining in the body following the intravenous or intramuscular injection of\nboth soluble and insoluble radium shats becomes fixed in the skeleton (12).\nRadium once deposited in bone would be in a position to produce peculiarly effective\ndamage. In the first place, all of the weakly penetrating radiation would be\nabsorbed with intense local damage. And, secondly, the more penetrating game\nrays would be, to a large extent, changed into easily absorbed secondary radiations\ncharacteristic of the calcium atom. The effectiveness of a unit of radium inside\na bone would be many thousand times greater than the same amount outside of the\nbone and the soft tissues as well, because of the enormously greater proportion\nof radiations absorbed in the bone. The alpha particles and many of the bota\nand gamma rays from an external source would never take effect in the bone at all,\nher by reason of their being becrbed too easily or with too great difficulty.\nwhich\n-5-\ncan do harm must be the radium. The profound effect of radium even in minute\nquantities on living cells is too well-known to require more than mere mention.\nIn addition, experimental evidence is not wanting to show that there may be\nselective deposit of radium in bone, and that the effects of radiations of the\nsort emitted by radium may provent both bone growth and the repair of fractures.\nA necrotic process in the jew bone itself, strikingly like that occurring in\nemployees of the Radium Corporation, has been reported in four instances following\nthe use of radium in the mouth for therapeutic effect on cancer of the tongue.\nWith this evidence for radium as the probable toxic factor, we endeavored\nto determine the extent and made of exposure to radium experienced by the Bradium\nCorporation employees.\nCONDITIONS OBSERVED AT THE PLANT\nWe found the girls employed in painting dials in a large well-lighted\nroom. The fact that the \"Undark\" to be used in mixing the luminous paint is\nissued to the workers in very small amounts (1 to 2 gra) in small containers as\nrequired, made it seem, at first glance, as if the possibility of dissemination\nof the material was very slight. Yet the clothes and the persons of many of the\nworkers were said to be luminous in the dark following exposure to light.\nBy means of this \"flash\" test and examination in the darkroom, we were\nable to show that the air of the workroom must contain sine sulphide. Dust samples\ncollected in the workroom from various locations (tables,chandeliers.mil beams,\netc.), and from chairs not used by the workers were all luminous in the dark-room.\nThe the dresses, the underclothes, even the corsets,\nof the dial painters are luminous. One of the girls examined with her dress off\nby Mrs. Drinker showed luminous spots on her legs and thighs. The back of another\nwas luminous almost to her waist. Dust from the machine shop below was luminous,\nand the same property was exhibited by office girls and by others about the plant\nnot employed in thepainting room. This, we think, is evidence that \"Undark\" is\nbeing carried in suspension about the paint-room and even beyond its confines.\nSome quantitative notion of the rate of deposition is gained from the fact that\ndresses worn in the painting room for only a few hours begin to exhibit a general\nluminosity in the dark following exposure to light. The conclusion seems to us\ninevitable that, if \"Undark\" is the source of this luminous dust, the dust must\nnecessarily contain radium.\nDust samples collected from various places recently oiled - and this dust\nmust have settled long since the one-time process of spraying with a pure zine\nsulphide base was discontinued -- is equally luminous. The fact that the luminosity\nfades away in the dark is merely an expression of the fact that the temporary re-\nsponse of the sulphide to light is far greater than the permanent luminosity\nproduced in the sulphide by the radium. In our opinion, the luminosity, for\nexample, in the sicins of the workers, is due to \"Undark\" which is present in such\nsmall quantities as not be be seen unless flashed. There can be no comparison\nbetween the amount of \"Undark\" persisting in the skin after vigouous washing and\nthe rather thick streak of the paint on the dial of a watch. The transiency of\nthe luminosity is not a proof that the skins do not contain radium, but morely\nthat they do not contain enough radium to confer spontaneous visible luminosity.\nThe same reasoning is applicable to the dust samples.\nWe are at present engaged in analysing for radium the dust samples which\nwe collected. The results are, so far, negative, - a fact which is not surpris-\ning in view of the extremely small quantity of radium combined with the zinc\n-6-\nsulphide. It is, however, impossible to assert because no radium has been\ndetected in the dust (the dust being demonstrably derived from \"Undark\") that it\ntherefore contains no radium. We believe that \"Undark\", and therefore radium,\nis dissominated about the painting room and adjacent offices as a suspension of\nvery minute quantities in the air.\nBy means of dental films, we endeavored to determine the amount of general\nradiation in the plant. Pfahler (5) has established the fact that any fogging of\na sealed dental film within two weeks is evidence of an over-exposure to radium or\nX-rays. Films placed in various spots in the plant - store-room, telephone\noperator's room, office, etc. -- all showed slight but definite fogging within one\nto two weeks. Films placed in Mr. Viedt's and in Mr. Roth's desks showed marked\nfogging at the end of a week, Films in the painting room showed distinct foreing\nat the end of two and three days, those at the weighing room end being\nthe darkest. We have more films yet to be heard from. Some are being carried\nby Miss Smith and by Dr. Lehman and others are in place in the painting room, but\nthe fogging of all films which have already been returned to us constitutes,\nin our opinion, definite evidence of an excessive exposure to gamma radiation.\nIn an attempt to determine whether or not radium has shown any effects on\nthe personnel, we investigated the generá health of the employees and their\npersonal hygiene in the plant; we also examined the teeth and the blood of a\nrepresentative group of workers. In all, twenty-two individuals from various\nparts of the plant were examined, fourteen of whom we considered to have had a\nlong or an extensive exposure to radium or to \"Undark\" and eight of whom we con-\nsidered to have had a slight exposure. Thirteen of these individuals were employ-\ned in dial painting or were working in the room with the dial painters. Nearly\nall of the workers reported themselves to be in good health. The general con-\nditions of work were good and did not seem to produce fatigue, eye-strain, or\nother cause of complaint except a persistent luminosity of the persons of the\nworkers.\nTable 1, included at the end of the report, gives a summary of our find-\nings upon the dental condition of the employees examined.\nTable 2 gives a sumary of our findings in the bloods of the twenty-tiro\nindividuals examined as compared with normal findings. The significance of these\nfindings is that no blood was entirely normal, and that the findings characteris-\ntic of exposure to radium or to X-rays in excessive amount appear in many cases\non examination of the blood films (2) (3) (4). The chief features are a reduction\nin the white cell count, a decrease in the percentage of polymorphonuclear cells\nand an increase in the percentage of lymphocytes. These some findings are noted\nin some instances in the reports of the Life Extension Institute upon the health\nof your employees, but the institute does not appear to have been aware of their\nmeaning. If we consider only the fourteen cases with the greater exposure,\ninstead of the mixed group of twanty-two, the percentage of blood abnormalities\namong your employees is markedly increased. The demonstration by us and by the\nLife Extension Institute of this peculiar type of blood damage among your\nemployees - a blood picture that has been so well-recognized in the literature -\nconstitutes beyond contention a proof of excessive exposure to radium in your\nfactory.\nCONCLUSIONS.\nWhat then are our conclusions as to the causation of the necrosis of the\njaw which has occurred in your plant? In the absence of any demonstration of\n-7-\nthe toxic properties of brushes, solvents, or zinc sulphide, the well-recognized\nMological activity of radium leads us inevitably to regard it with suspicion.\nWe have not been able to find accounts of necrotic processes in the bones of\npersons similarly employed elsewhere. We have, however, undoubted proof of ex-\ncessive exposure to radiation in your workers, as evidenced by the abnormal con-\ndition of their bloods, and by the fogged dental films. There is, in addition,\nevidence of an air-borne route by which redium itself may be absorbed. How it is\nexactly that these two processes -- external radiation or a slow, long continued\nabsorption of minute quantities of radium - alone or in combination, have produced\nthe bone destruction we are unable at present to demonstrate. In view, however,\nof the effects of radium on bone already in the literature, in view of the\nover-exposure to radiation which we have demonstrated in your plant, and finally,\nin view of the possibility of on actual absorption of radi III through inhalation,\nwe believe that the burden of proof rests with the person who would maintain that\nradium has not in some way caused these necroses of the jaw, as an effect hitherto\nnot observed under these conditions of exposure."
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