THE CONCEPT OF A NEW DISEASE CAUSED BY SILICONE
IS BIOLOGICALLY PLAUSIBLE AS SILICONE IS NOT INERT.
1. Investigation at Dow Corning into use of silicones as pesticides: in
1968, found that Dow Corning 360 fluid both attracted and killed
cockroaches; also repelled mites and mealy bugs; killed and repelled aphids.
(Plaintiffs' Exhibit 705)
2. Dow Corning Report, 'Histopathological Findings In Animals of Various
Species from Experiments Conducted by Thomas D. Rees", 4/22/68.
(Plaintiffs' Exhibit 548)
Silicone injected into various animals produced organ damage including
chronic inflammation of liver, kidneys and occasional pancreas and gonad
abnormalities seen in mice; similar but less prevalent organ damage in rats;
and liver abnormalities and chronic kidney inflammation in guinea pigs.
Additionally, holes in cytoplasm of cells commonly observed in all species.
3. Dow Corning Research: Immunological Enhancing Activities of
Organosilicon Compounds and non-functional fluids, 10/2/74. (Plaintiffs'
Study carried out to determine if certain silicone oils could act as
adjuvants in experimental animals. An adjuvant is a chemical that will
enhance or prolong the immune response when given mixed with a foreign
protein (antigen). Study concluded that nine of the forty-nine adjuvants
tested showe6 adjuvant activity similar to that of known adjuvant (CFA).
CONCLUSION: Silicone oils can act as adjuvants to enhance the antibody
response to a standard antigen in experimental animals.
ANIMAL STUDIES SHOW SILICONE INDUCES BIOLOGICAL AND CHEMICAL
CHANGES AND IS SYSTEMICALLY DISTRIBUTED
4. "Summary of Histopathological Findings in Primates", 3/21/67 Dow
Corning Document. (Plaintiffs' Exhibit 774)
T'welve monkeys injected with silicone fluids in both breasts and left
cheek. Animals sacrificed at two years after first injection; findings
included holes in cells (vacyated cells) in lungs, cheeks and breasts;
abnormal adrenal glands and chronic kidney inflammation.
These tests signal potential immunological impact of long term presence of
polysiloxane in primate fluids in primates.
5. Structure-Activity Relationships of Oral Organosiloxanes on the Male
Reproductive System. by D.R. Bennett, S.J. Gorzinsid, and J.E. LeBeau.
Toxicology and Applied Pharmacology. 21, 55-67 (1972). (Plaintiffs' Exhibit
Oral organosiloxanes depressed male reproductive function in the mouse, rat
6. Local & Systemic Effects of Dimethylpolysiloxane Fluid In Mice. by
N.Ben-Hur, M.D., Donald BaBantyne, Jr., Ph.D., Thomas Rees, M.D. and @g
Seidman, M.D. Plastic & Reconstructive Surgery. Aprfl 1967. pp.423-426.
(Plaintiffs' Exhibit 544)
Mice and rats injected subcutaneously with silicone fluid; on autopsy,
silicone found in the vital organs and lymph nodes. Phagocytes ingested
silicone fluid and caused granuloma-like lesions; silicone also engulfed by
wandering histiocytes and transported to lymph nodes and throughout the
reticuloendothelial system to liver, spleen and other organs.
7. Changes In the Lung Following Injections of Silicone Gel. by Marcus
Castro Ferreira, M.D., Victor Spina, M.D. and Kyoshi Iriya, M.D. British
Journal of Plastic & Reconstructive Surgery. pp.173-176. 1975. (Plaintiffs'
Injections of silicone gel in 38 MI. rats produced findings of silicone gels
in lungs on autopsy, the result of phagocytosis of the silicone by
macrophages, carried to the lungs in blood stream or through lymphatics.
Authors conclude that silicone gel behaves like silicone fluid and is not so
inert as solid silicone as was previously supposed.
8. Dow Corning Corp Research Dept Report# 3977. Authors: Joseph LeBeau &
Stanley J. Gorzinski DMPS fluid (Dow Corning 360 Medical Fluid) distribution
and disposition in rats following subcutaneous injection. (Plaintiffs'
Dow Corning 360 medical grade silicone administered to rats. With
assistance from radioactive labeling, silicone fluid found in expired air,
urine and feces as well as in times and organs. Migration of silicone
through lymphatic system confirmed.
9. Dow Corning Report # 3323 Project # 464 by Ruth M. Lacefield, et al.
Biological Distributions of DMPS. (Plaintiffs' Exhibit 688)
Radioactive labeled medical grade 360 fluid traced to determine biological
distribution in test animal; silicone found in brain, blood, bile, internal
10. 2, 6-cis-Diphenylhexamethyl - cyclotetrasiloxane Chemistry Analytical
Chemistry, Biological Effects and Excretion. By Bennett, Don R. Aborg,
Bertfl. Editors ACTA, Pharmacological et To;dcologir-al. Vol. 36, Supp-
III, 1975. (Plaintiffs' Exlubit 553)
2, 6-cis being evaluated as an estrogen by Dow, noted to produce changes in
male genital organs of rabbits and dogs.
11. Structure Activity Relationships of Organosiloxanes and the Female
Reproductive System. by James F. Hayden & Sue A. Barlow. To7dcology and
Applied Pharmacology. Vol.21, 1972 pp.68-79.
(Plaintiffs' Exhibit 689)
2, 6-cis is biologically active in the female rat and produced estrogen-like
12. Investigation of the Toxicologic Properties of a
Phenylmethylcyclosiloxane by R.J. Palazzolo et al. Toxicology and Applied
1972. pp.15-28. (Plaintiffs' Exhibit 691)
Experiments by oral ingestion and by skin applications on various species
showed silicone material to be biologically active by mouth in monkeys
leading to testicular atrophy and decrease or absence of seminal fluid.
13. Peritoneal Response To Silicone Fluid. A Histologic Study. Brody,
Gerald L., M.D. and Frey, Charles F., M.D. Arch Surg. Vol. 96, February
1968, PP 237-241. (Plaintiffs' Exhibit 586)
Injection of silicone fluid into rats produced histiocytic granulomas. Fact
that granulomas exist and that silicone is transported to draining lymph
nodes indicates that silicone is not inert.
14. Biocompatibility of Silicone Implants. by Heggers, John P. Ph.D., et
al., Reprinted Annals of Plastic Surgery. Vol. 11, No. 1, July 1983, PP 37.
(Plaintiffs' Exhibit 592)
Silicone is capable of eliciting a cellular immune response. This may
indicate that silicone acts like an incomplete antigen.
THE IMMUNE RESPONSE TO SILICONE:
FROM THE ANIMAL MODEL TO THE HUMAN
15. The Adjuvant Effect Of Silicone-Gel On Antibody Formation In Rats. by
Naim, John 0. Lanzafame, Raymond J. Oss, Carl J. The University of Rochester
School of Medicine and Dentistry, Rochester, New York. (Plainiffs' Exhibit
Silicone gel is a potent, immunological adjuvant and may also be able
to mediate an auto- immune reaction.
16. The Effect of Silicone Gel on the Immune Response. by Naim, John 0.
Lanzafame, Raymond J. Oss, Car] J. Journal of Biomaterials Science accepted
Silicone gel is capable of eliciting auto-antibodies in the series of animal
experiments; silicone gel from McGhan commercial breast implant behaves both
as a potent humoral adjuvant and relatively weak cellular-mediated immunity
adjuvant. Silicone gel also capable of inducing auto-antibodies in the rat.
THE IMMUNE RESPONSE IN HUMANS FROM SILICONE
17. Antibodies To Silicone Elastomers and Reactions To
Ventriculoperitoneal Shunts. Goldblum, Randall M. Ronald P., et al., The
Lancet, Vol. 340: August 29, 1992. PP 510-513. (Plantiffs' Exhibit 595)
Severe immune reactions seen in patients with silicone elastomer (shunts).
18. "Antinuclear Autoantibodies In Women with Silicone Breast Implants".
11/28/92, Press RI et al. Lancet 340: pp.1304-1307.
Antinuclear Autoantibodies (ANAS) found in women with silicone breast
implants; some of the ANAs similar to those found in idiopathic auto-immune
disorders but some other putative antigens could not be identified and may
represent novel auto-antibody/autoantigen systems.
19. "A Clinical and Immunologic Evaluation of Women with SBI and Symptoms
of Rheumatic Disease". 6/15/1993 Bridges A.B et al. Annals Int. Med. 118
Physical exams and lab work conducted on 156 women with silicone breast
implants and rheumatic disease complaints; controls for lab studies were 12
women with silicone implants and no rheumatic symptoms and 174 with
fibromyalgia without silicone implants.
Findings suggest that most women with SBI and rheumatic disease symptoms do
not have classical connective tissue diseases; however possibility that
atypical auto-immune illness, may be associated with silicone exposure in
small number of women exists.
20. Immunopathologic Effects of Silicone Breast Implants. Suzanne S.
Teuber, M.D., Steven H. Yoshida, Ph.D. and Eric Gershwin, M.D. Western
Journal of Medicine, Vol.162, No.5, May 1995. pp.418-425. (Plaintiffs'
This review of studies on silicone and immunity concluded that silicones are
neither biologically nor chemically inert and that there is clinical and
theoretical reason for concern.
AUTHORS COMMENT ON IACK OF POWER SUFFICIENT FOR STUDIES TO BE CONSIDERED
DEFINITIVE OF ENGLERT SCLERODERMA STUDY FROM AUSTRALIA AND MAYO CLINIC
21. Immunological Reactions to Silicone Implants: Risk and Management.
Robert F. Spiera, et al. Clinic Immunother 1 (6) 1994, pp.406-411.
(Plaintiffs' Exhibit 517)
Scleroderma-like illnesses are markedly over-represented in women with
silicone implants and identifiable connective tissue disease, mimicking the
earlier reported Japanese experience with injectable silicones. Although
authors clinically recommend to their patients removal of implants if
symptomatic, some patients with scleroderma-like illness may have a
progression of disease and even death despite explantation perhaps due to
migration of silicone distantly in the host and the consequent inability to
remove the substance entirely. Exposure may thus initiate a self-
perpetuating disease process no longer requiring the presence of the initial
22. "Surface Dependent Antigens Identified by High Binding Affinity of
Serum Antibodies in a Subpopulation of Patients with Breast Prosthesis".
12/93 Kossovsky, Nir et al. Journal of Applied Biomaterials 4 (33): pp.1-8.
(Plaintiffs' Exhibit 538)
Silicones found to function as human adjuvants by denaturing native
macromolecules. Hypothesis tested by two assays of sera from three groups:
249 with SBI, 47 non-implanted age-matched healthy women; 39 non-implanted
women with various known rheumatological diseases. Conclusion is that
silicone may function as an adjuvant by inducing changes in the confirmation
of native molecules.
23. Silicon and Silicones Theoretical and Clinical Implications of Breast
Implants. by Steven H. Yoshida et al. in Regulatory Toxicology and
Pharmacology. Vol.17, 1993, pp.3-18.
Authors review the element silicon, the chemistry of silicone, the
immunogenicity of silicone, and the know biological functions of silicone to
demonstrate how silicone might promote auto-immune disease in pre-disposed
individuals. Review of case reports of 27 people with immunological
reactions as well as literature on silicone exposures in animal studies
leads authors to conclude that silicone can generate inflammatory and immune
responses despite its long standing and incorrect representation as a
chemically and biologically inert substance.
SOLID, SCIENTIFICALLY VALID LABORATORY DATA
DEMONSTRATE THE DISEASE
24. Autoantibodies In Patients with Silicone Breast Implants. by Alan J.
Bridges. Seminars in Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug.
1994, pp.54-60. (Plaintiffs' Exhibit 488)
Review of literature as well as 1992 American College of Rheumatology
abstracts from annual meeting show differences in the clinical and
serological features of patients with connective tissue disease associated
with silicone implants compared with patients with idiopathic connective
A DEFINITIVE EPIDEMIOLOGICAL STUDY TO DETECT REIATIONSHIP BETWEEN SILICONE
IMPLANTS AND CONNECTIVE TISSUE DISEASE MAY NEVER BE ABLE TO BE PERFORMED
BECAUSE OF THE LONG LATENCY PERIOD AND THE RARUY OF CONNECTIVE TISSUE
DISEASES. THUS, A STUDY OF CLINICAL AND SEROLOGICAL FEATURES OF PATIENTS
WITH IMPLANTS WHO DEVELOPED DISEASE BECOMES PARTICULARLY IMPORTANT.
25. Multiple Autoantibodies In Patients with Silicone Breast Implants, E.
Bar-Meir, S.S. Teuber, et al. Journal of Autoimmunity, 8, 1995, pp.267-277.
(Plaintiffs' Exhibit 509)
Sera from 250 patients tested blindly (116 women with SBI and 134 controls)
to analyze twenty auto-antibodies. Chief complaints of implanted patient
group included polyarthralgias, fatigue, myalgias, morning stiffness and
Statistically significant greater frequency of auto-antibodies in women with
implants for fifteen of the twenty auto-antigens. The association of auto-
antibodies in implants suggests an adjuvant action of silicon/silicone by-
26. Detection of Lymphocyte Simulation by Silicon Dioxide, by David L.
Smalley, Douglas R. Shanklin, Mary F. Hall and Michael V. Stevens in
International Journal of Occupational Medicine and Toxicology Vol. 4, No.1,
pp.63-70. (Plaintiffs' Exhibit 594)
In the continuing work investigating the immune response to silicone, the
authors adapted standard mitogen testing which demonstrated cell-mediated
immune responses of T-lymphocytes to purified silicon dioxide or silica in
the implanted patients.
These test were run on 50 symptomatic patients with SBI and 50 normal age
matched female controls without implants or symptoms. T-lymphocytes were
harvested from each group. This test method distinguishes the immune
disorders found in mammary implant patients due to sensitization to silicon
dioxide (silica) from other altered immune disorders unrelated to implants.
27. Quantitative Aspects of Cellular Responses to Silicone by Douglas R.
Shanklin and David L. Smalley, International Journal of Occupational
Medicine and Toxicology Vol. 4, No.1, 1995 pp.99-111. (Plaintiffs' Exhibit
A study of pathology slides from 100 consecutive but random patient
consultations and mammary capsular tissue surrounding which had surrounded
SBI. Cellular responses occur in women with mammary, as seen in
histopathological examination. Lymphocytic response with resulting
formation of granulomas and macrophages.
28. Immunologic Markers In Silicone Breast Implant Recipients, by David
Smalley, Mary F. Hall, Douglas R. Shanklin and NCchael Stevens in
International Journal of Occupational Medicine and Toxicology Vol. 4, No. 1,
1995 pp.147-153. (Plaintiffs' Exhibit 763)
The presence of various autoantibodies and the significant number of
symptomatic implantation is taken as evidence for a range Atypical Immune
responsiveness consistent with a primary cellular immune response. The name
- silicone associated disease - is understood as an inclusive term fota new
form of autoimmunity caused by an alien material (silicones and related
substances) which mimic known and better defined autoimmune diseases.
29. Immunologic Stimulation of T-lymphocytes by Silica After Use of
Silicone Implants. by David L. Smalley, Douglas R. Shanklin, Mazy F. Hall,
Michael V. Stevens and Aram Hanissian. The FASEB Journal, Vol. 9, Mar.
1995, pp.424-427. (Plaintiffs' Exhibit 504)
Standard lymphocyte stimulation test performed on 70 implant patients, 76
normal controls without implants or symptoms, and 18 patients with classic
rheumatic disorders without a history of SBI. Lymphocytes harvested from
all groups. Results show implant patients with increased stimulation index
compared to controls in those with rheumatic disorders. Follow-up study
with 220 normal controls, no SBI, 942 implants with symptoms, and 34 implant
patients without symptoms.
CONCLUSION: Silicone Implant patients respond immunologically to the
silicone dioxide (silica) contained in mammary prostheses.
30. Affidavit of Douglas R. Shanklin, M.D. (Plaintiffs' Exhibit 764)
Dr. Shanklin, a Board Certified pathologist, discusses the six independent
reports by six independent labs, each documenting silcone/silica memory T-
31. Curriculum Vitae of Douglas R. Shanklin, M.D. (Plaintiffs' Exhibit
32. Affidavit of Donard S. Dwyer, Ph.D. (Plaintiffs' Exhibit 766)
Dr. Dwyer, former Director of Immunology at Procept (owned by Bristol-Myers
Squibb), managed the research program on T-cell receptors funded by Bristol-
Myers Squibb, a former manufacturer of silicone breast implants. The
Smalley/Shanklin laboratory data was evaluated by Dr. Dwyer and found to be
based on the standard and acceptable method for measuring T-cell
proliferation which has been reproduced and is consistent in the Procept
Thus, the conclusions that patients with SBI have a T-cell mediated Immune
response to silicon dioxide (silica) is justified.
33. Curriculum Vitae Donard S. Dwyer, Ph.d. ((Plaintiffs' Exhibit 767)
34. Antinuclear Antibodies in Breast Implant Patients are Exposure-
Duration Dependent But Not Age Dependent. Robert Ira Lewy, M.D., FACP;
Edward Ezraffson, Ph.D. Departments of Medicine, Baylor College of Medicine
and University of Texas Health Science Center of Houston, Houston, TX.
Immunology of Silicones Workshop. March 13-14, 1995. National Institute of
Health, M.D. (Plaintiffs' Exhibit 495)
35. Autoantibodies In Sera from Patients with L-Tryptophan-Associated
Eosinophilia-Myalgia Syndrome. by Leed D. Kaufman, John Varga, Juan J.
Gomez-Reino, Sergio Jimenez, and Iran N. Targoff, Clinical Immunology and
Immunopathology, Vol.76, No.2, August, pp.115-119,
1995. (Plaintiffs' Exhibit 508)
Study found unique auto-antibodies in sera from patients with EMS
(Eosinophilia-Myalgia Syndrome) associated with exposure of L-Tryptophan.
These auto-antibodies were clearly distinct from the aut-antibodies commonly
recognized in systemic auto-immune conditions.
36. Silicone Breast Implants: Immunotoxic and Epidemiologic Issues. by
Steven H. Yoshida, Shanna Swan, Suzanne Teuber and M. Eric Gershwin, Life
Sciences Vol. 56, No. 16, pp.1299-1310, 1995. (Plaintiffs' Exhibit 695)
Discussion of adverse immune effects from silicone from literature analysis
including local responses in animals, systemic responses in animals,
inflammatory responses in humans and autoimmune disease in humans.
Discussion of limitations of epidemiological studies of silicone related
diseases to date, including Mayo Clinic Study, Wells and Englert.
37. Repeated Exposure to Silicone Gel Can Induce Delayed Hypersensitivity.
Phillip P. Narini, M.D., et al. Plastic & Reconstructive Surgery, Vol.96,
No.2. August 1995. pp.371-380. (Plaintiffs' Exhibit 519)
Study performed to investigate a possible cell-mediated immune response to
silicone gel. Authors demonstrated an antigen-specific lymphocyte-mediated
response in the animals primed only with silicone gel. A delayed type
hypersensitivity to silicone gel was induced.
38. Antinuclear Antibodies and Breast Implants. Henry Claman, M.D. and
Alastair D. Robertson, Ph.D. The Western Journal of Medicine. Vol. 160,
No.3. March 1994. pp.225-228. (Plaintiffs' Exhibit 513)
Antinuclear antibodies tested in the sera of four groups of women. Four
Group 0 = 19 women without SBI, healthy;
Group I = 38 women with SBI, healthy and pleased with implants;
Group II = 82 women with SBI with various symptoms but no definite
diagnosis of autoimmune connective tissue disease;
Group III= 11 women with SBI with overt connective tissue diseases.
Results: no positive ANA tests in Group 0.
Significant positive ANA tests in higher than expected
frequency (18%) of Group I women, healthy women with SBI.
Many women have a variety of complaints and also have positive ANA tests
In women with breast implants with later connective tissue disease,
scleroderma was far more prevalent than rheumatoid arthritis or SLE.
39. Self-Reported Signs & Symptoms In Breast Implant Patients with Novel
Antibodies to Silicone Surface Associated Antigens [anti-SSAA(x)]. Nir
Kossovsky, Journal of Applied Biomaterials, Vol.6, 1995, pp.153-160.
(Plaintiffs' Exhibit 520)
Previous sera studies that had shown statistically significant levels of
antibodies to Silicone Surface Association Antigens were correlated to
symptoms by clinical survey sent to sera positive SBI women. Results showed
statistically significant differences in 3 symptoms of anti-SSAA positive
40. Immune Functional Abnormalities In Patients With Chemical
Abnormalities and Silicone Breast Implants. by Campbell, Andrew W., M.D.
Vojdani, Aristo, Ph.D., Brautbar, Nachman, M.D. (Plaintiffs' Exhibit 587)
Forty patients with SBI and forty healthy sex and age-matched controls
selected for study including physical examination, history and laboratory
Many immunological abnormalities are found in individuals with SBI;
conclusion is mechanism of fime injury causing auto-immune diseases or
41. A Pathophysiological Examination of the Biophysics and Bioreactivity
of Silicone Breast Implants. by Nir Kossovsky and John Stassi. Seminars in
Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp.18-21.
(Plaintiffs' Exhibit 573)
Biological responses to implanted silicone are initiated by surface
adsorption of native proteins to the implant. Proteins then undergo
conformational changes and denature on complexing silicone. Bioreactivity
is thus surface dependant and affected by characteristics such as surface
area, shape, charge in chemistry. Biological response occurs with possible
42. Silicone Toxicology, by Harris Busch. Seminars in Arthritis &
Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp.11-17. (Plaintiffs' Exhibit
Silicone is not inert; silicone and/or the multiple chemical contaminants
within elicit foreign body reactions associated with granulomatous
inflammation and fibrosis and have potential for significant toxicity in the
43. Abstracts and Presentations from the Workshop on Immunologies of
Silicones Sponsored by National Institute for Health, NCI and DCBDC held
March 13, 1995. (Plaintiffs' Exhibit 772)
44. Silicone-Specific Blood Lymphocyte Response in Women with Silicone
Breast Implants, by Emmanuel A. Ojo-Amaize, Victor Conte, Hun-Chi Lin,
Robert Brocker, Milcon Agopian and James Peter. COIN. Giagn Lab.
Immunol. Nov. 1994, pp. 689-695. Vol. 1, No.6. (Plaintiffs' Exhibit 621)
Blinded cross-sectional study with 99 women, 44 with SBI. SBI group divided
into asymptomatic, symptomatic and implanted women and symptomatic explanted
women. Control was 55 healthy volunteer women without SBI.
Conclusion: Silicon specific T-cell responses observed in twice as many
symptomatic as asymptomatic women exposed to SBI, sugggesting cell mediated
immunogenicity plays a role In the development of abnormal immune reactions
associated with silicone. This provides a new apparently specific screening
45. Human Immune Response to Polydimethylsilaxe (silicone): Screening
Studies in a Breast Implant Population. Wolf, Lappe, Peterson and
Ezrailson. Vol. 7, Oct. 1993, FASBE Journal, pp. 1265-1268. (Plaintiffs'
THE BIOLOGICAL PIAUSIBILITY OF A SILICONE ASSOCIATED DISORDER:
SILICA EXPOSURE AND AUTO-IMMUNE DISEASES
46. Portions of Lot History from 3M Implants - Lot # S04-19747 implanted
in Mildred Merlin showing silica as component material.
47. Report from the Instructional Course of the Int'l Society of Aesthetic
Plastic Surgery, Uppsala, Sweden, March 16-18, 1993. in Memorandum from Curt
Sahlgren, 3M Sweden to: Bruno Lowinger, 3M Europe. March 18, 1983.
(Plaintiffs' Exhibit 483)
3M acknowledges that recent investigations have shown that gel bleed from an
intact implant leaves "...particles of elemental silica and organic silicone
within the systemic organism of the body with not yet known adverse
48. Adjuvant Effects of Amorphous Silica on the Immune Response to Various
Antigens in Guinea Pigs., by D. Mancino and N. Bevilacqua Int. ARchs.
Allergy appl. Immun. S31 97-103 (1977). (Plaintiffs' Exhibit 480)
Amorphous silica is able to enhance the humoral immune response to various
antigens, widely differing in molecular weight.
Silica has been shown to influence the immune response with either
depressive or stimulators effects depending on the type and amount of
49. Pathological Effects of Inhaledled Amorphous Silicas in Animals, by
H. Groth, M.D., Choudari Kommieni, D.V.M., Ph.D., William J. Moorman, Lloyd
E. Stettler, Ph.D., William D. Wagner. Presented at ASTM International
Symposium on Health Effects of Synthetic Silica Particulates, Torremolinos,
Spain 6 November 1979. (Plaintiffs' Exhibit 479)
Exposure by inhalation to monkeys of amorphous, fumed silica produced
findings of large quantities of silica in macrophages in lungs and tracheal
lymph nodes of monkeys and early nodular fibrosis in the lungs of monkeys.
50. The Biological Action of Degussa Submicron Amorphous Silica Dust (Dow
Corning Silica). Inhalation Studies on Rats. by Gerrit Schepers, M.D.,
D.Sc., Thomas M. Durkan, M.E., Anthony B. Delahant; Francis T. Creedon AMA
ARCH. of IND. Health. Vol.16. Aug. 1957. pp.125-146. (Plaintiffs' Exhibit
Inhalation studies on rats exposed to amorphous silica dust from Dow Corning
silica died from pulmonary vascular obstruction coupled with pulmonary
insufficiency and emphysema.
51. Myoflbroblasts and Free Silicon Around Breast Implants. by Ross
Rudolph, MD Jerrold Abraham, M.D., Thomas Vecchione, M.D., Steven Guber,
M.D. and Marilyn Woodward. Plastic And Reconstructive Surgery. Vol.62.
No.2. Aug. 1978. pp.185-196. (Plaintiffs' Exhibit 485)
Breast tissue and capsules (scar tissue) explanted from women during
explantation surgery revealed presence of the element silicon via scanning
electron microscopic technique. Such a technique cannot identify silica.
Such a technique must be developed because silica in tissue can cause
silicosis, a fibrotic disease.
52. The Association of Progressive Systemic Sclerosis (Scleroderma) with
Coal Miner's Pneumoconiosis & other Forms of Silicosis. Gerald Rodnan, M.D.
et al. Annals of Internal Medicine. Vol. 66, No.2 February 1967, pp.323-
334. (Plaintiffs' Exhibit 602)
Silica exposure is a hazard of coal mining; the authors describe an
association of progressive systemic sclerosis (scleroderma) within coal
miners or in other occupations marked by heavy exposure to silica dust
53. Health Effects of Synthetic Silica Particulates. A Symposium
sponsored by ASTM Committee E-34 on Occupational Health and Safety and the
Industrial Health Foundation Benalmadena-Costa (Torremolinos), Spain 5-6 No.
1979. ASTM STP 732. D.D. DUNNOM, Ed., American Society for Testing and
Materials, 1981, pp.82-93. (Plaintiffs' Exhibit 478)
Chapter by Robert Burrell "Immunological Aspects of Silica".
54. Effects of a Crystalline Silica on Antibody Production to T-Dependent
and T-Independent Antigens In Balb/c mice. by D. Mancino, M.L. Viotte, M.
Minucci. Int. ARchs Allergy appl. Immun. 73:10-13 (1984). (Plaintiffs'
55. Adjuvant Effects of Silica (Tridymite) on Antibody Production, by
Benvenuto Pernis and Florenzo Paronetto (Introduced by Hans Popper). Dept
of Experimental Pathology, Institute of Industrial Medicine, University of
Milan, Italy. Received 12 April, 1962. PSEBM, 1962, v.110. (Plaintiffs'
56. Endothelial Metaplasia of the Alveolar Capillaries In Experimental
Silicosis of Rats. by Mochimura H., Kawanami O., Kudoh S., Niitani H.
Japanese Journal of Thoracic Diseases. 33(3):268-74, 1995 Mar. (Plaintiffs'
Silicosis induced in rats by administration of silica particles.
57. Mortality Study of Gold Miners Exposed to Silica and Nonasbestiform
Amphibole Minerals: An Update with 14 More Years of Follow-up. by Steenland
K, and Brown D. American Journal of Industrial Medicine. 27(2): 217-29,
1995 Feb. (Plaintiffs' Exhibit 673)
Follow-up study of over 3,000 gold miners reveals significant excesses of
arthritis, muscular skeletal diseases including systemic lupus and sclerosis
and skin conditions including scleroderma and lupus, all diseases of auto-
immune origin which have been associated with silica exposure.
58. Silicosis in Brazilian pit diggers: relationship between dust exposure
and radiologic findings. by Holanda NM, Holanda NM, Martins MP., Felismino
PH., and Pinheiro VG. American Journal of Industrial Medicine. 27(3):367-
78, 1995 Mar. (Plaintiffs' Exhibit 674)
59. Detection of anti-topoisomerase I antibodies using a full length human
topoisomerase I recombinant protein purified from baculovirus expression
system. by Whyte J., Earnshaw WC., Champoux JJ., Parker LH., Stewart L.,
Hall ND., and McHugh NJ. Clinical & Experimental Immunology. 100(2):214-8,
1995 May. (Plaintiffs' Exhibit 675)
60. Occupational silicosis-Ohio, 1989-1994 [published erratum appears in
MMWR Morb Mortal Wkly Rept 1995 Apr 28;44(16):325]. by Anonymous.
Morbidity & Mortality Weekly Report. 44(4):61-4, 1995 Feb.3. (Plaintiffs'
61. Shedding of Silicone Particulates From Inflated Breast Implants. by
Alex Vargas, M.D. Plastic & Reconstructive Surgery. Vol.34, No.2. pp.252-
253. Aug. 1979. (Plaintiffs' Exhibit 486)
Explantation of a saline implant showed collections of "sand" on the
surface; on infrared spectroscopy, demonstrated the silicon-carbon bond.
62. Silica Exposure In Auto-Immune Disease. by Steenland, Kyle, Ph.d. and
Goldsmith, David, MSPH, Ph.d. American Journal of Industrial Medicine
28:603-608 (1995). (Plainfiffi' Exhibit 489)
Authors summarize the evidence of association of silica exposure to a
variety of auto-immune diseases including systemic sclerosis, rheumatoid
arthritis, lupus and chronic renal disease. Authors posit the link between
silicone exposure and auto-immune disease, and whether silicone breast
implants have same causal relationship with auto-immune disease.
63. Silica-Induced Scleroderma, Haustein, Ziegler, Hurrmann. Panel of the
American Academy of Dermatology., 1990; 22:444-8
(Plaintiffs' Exhibit 507).
CLINICAL EVIDENCE OF A SILICONE RELATED SYSTEMIC DISEASE:
CASE REPORTS AND CASE SERIES PUBLISHED IN MEDICAL
AND PEER-REVIEWED JOURNALS
64. Silicone in the Liver. Possible Late Effects. By J. Hunt, M.J.G.
Farthing, L.R.I. Baker, P.R. Crocker, D.A. Levison. Gut. 1989, 30, 239-242.
(Plaintiffs' Exhibit 540)
Silicone identified in liver of two patients that had abnormal liver
function and liver scarring. 'nese patients had been on dialysis prior to
renal transplant and siliconized blood pump insert had liberated silicone
65. Migration and Chemical Modification of Silicone In Women w/Breast
Prostheses. by Lencio Garrido, MRM Vol.31, 1994, pp.328-330.
(Plaintiffs' Exhibit 692)
NMR (Nuclearmacnetic resonance) spectroscopy performed on women with SBI and
3 without implants revealed silicone and other silicon compounds in both
blood and liver of implanted women, whether or not implants were clinically
ruptured; however total concentration was lower when implants appear to be
66. Migration and Accumulation of Silicone In the Liver of Women with
Silicone Gel-Filled Breast Implants. Bettina Pfleiderer & Leonicio Garrido.
Magnetic Resonance in Medicine Jan. 1995 33(l): pp.8-17 (Plainfiffi' Exhibit
Authors formed NMR spectroscopy in liver of human volunteers with implants
and results clearly reveal presence of silicone in the liver. Prior work by
same authors on rat model demonstrated a considerable amount of free
silicone migrates from gel-filled implants and that silicone is not
chemically inert but undergoes chemical degradation.
CONCLUSION: Migration of free material from silicone implants to local and
distant sites occurs through lymphatic or hematogenous pathway.
67, Rheumatic Disease Among 1167 Women Reporting Local Implant and
Systemic Problems After Breast Implant Surgery. Elizabeth Ann Coleman,
R.N.P., Ph.D., et al. Journal of Women's Health, Vol.3, No.3, 1994. pp.165-
177. (Plaintiffs' Exhibit 518)
National Cancer Institute (NCI) investigators contacted 1,167 women who had
had breast implant surgery and who had reported local implant or systemic
problems to the FDA. Out of the 820 women interviewed, statistically
significant associations that were found included breast implant type with
scleroderma, breast implant manufacturer with systemic lupus.
68. Siliconosis: A Spectrum of Illness, by David Borenstein. Seminars in
Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp.1-7.
(Plaintiffs' Exhibit 632)
This, and ensuing papers published in Seminars in Arthritis and Rheumatism,
emanated from a symposium held in 1992 at George Washington University
Medical Center. Information reported at the symposium presented initial
data supporting the notion that patients with exposure to silicone gel are
experiencing a new illness, previously described as "human adjuvant disease"
or chronic silicone arthropathy. Symposium presenters used terms such as
siliconosis or silicone implant syndrome.
Conclusion: Siliconosis is a musculoskeletal pain syndrome characterized by
overwhelming fatigue, arthraigias and myalgias. Additionally, alopecia,
fever, sleep disturbances, Sjogren's-like Syndrome, lymphadenopathy and
arthritis have also been identified.
69. Clinical Findings In Symptomatic Women with Silicone Breast Implants.
by Frank B. Vasey, Deborah L. Havice, Thomas S. Boranegra, Mitchel J.
Seleznick, Paul H. Bridgeford, Pindaro Martinex-Osuna, and Luis R. Espinoza.
Seminars in Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp.22-
28. (Plaintiffs' Exhibit 633)
Fifty women seen in clinic between 1977 and 1991 with SBI were followed.
The most common clinical findings included chronic fatigue, muscle pain,
joint pain, joint swelling and lymphadenopathy. 33 women underwent
explantation: 24 of them improved clinically, 8 did not change and one
worsened. Authors believe that this case series supports the relationship
between SBI and rheumatic disease signs and symptoms.
70. A Clinical and Laboratory Profile of Symptomatic Women with Silicone
Breast Implants. by Gary Solomon. Seminars in Arthritis & Rheumatism,
Vol.24, No.1, Supp.1, Aug. 1994, pp. 29-37. (Plaintiffs' Exhibit 634)
276 patients with SBI evaluated to describe frequency of various symptoms in
Conclusion: siliconosis Is a novel systemic disease with symptoms of chronic
fatigue, cognitive disfunction, sicca syndrome and arthralgia occurring in
women with longstanding implants who have antecedent local pathology in the
form of capsular contracture and/or implant ruptue.
71. Epidemiology of Silicone Related Disease. by Shanna Swan. Seminars in
Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp.38-43.
(Plaintiffs' Exhibit 635)
Author discusses problems inherent in epidemiology of silicone related
diseases, especially due to atypical nature of the disease, which
complicates disease definition and renders study of classic disease unlikely
to check risks of silicone exposure. The report addresses the most
important study design issues -- disease and exposure definitions, bias,
confounding and power -- in the context of studies of silicone related
72. A Profile of Symptomatic Patients with Silicone Breast Implants; A
Sjogren's-like Syndr-ome. by Bruce Freundlich, Charles Atman, et al.
Seminars in Arthritis & Rheumatism, Vol.24, No.1, Supp.1, Aug. 1994, pp. 44-
53. (Plaintiffs' Exhibit 636)
Prospective non-controlled study on first fifty consecutive women with SBI
at the Graduate Hospital of Rheumatology revealed the most prominent
complaints to be fatigue, generalized stiffness, poor sleep and arthalgias.
Other problems included Raynaud's phenomenon, alopecia, adenopathy, night
sweats and frequent soar throats. Fifty percent of the women complained of
dry eyes and dry mouth. Positive ANA or rheumatoid factors in 38% of
Conclusion: Findings indicate the presence of a unique syndrome associated
with silicone breast implants characterized by musculoskeletal pain and aut-
73. Scleroderma After Silicone Augmentation Mammoplasty, by Spiera, H.,
JAMA 260: 236-238, 198838 (Plaintiffs' Exhibit 773)
Case-control study showed a much higher incidence of prior silicone
implantation in scleroderma patients when compared with patients with
74. Case Report- Scleroderma, Primary Bilary Cirrhosis and Sjogren's
Syndrome After Cosmetic Breast Augmentation with Silicone Injections: A Case
Report of Possible Human Adjuvant Disease. Y. Okano et al. Annal of the
Rheumatic Diseases, 43, pp.520-522, 1984 (Plaintiffs' Exhibit 599)
A 52 year old women developed scleroderma, liver disease and sjogren's
syndrome after cosmetic injections with silicone.
75. Silicone Implants and Rheumatic Diseases. by John S. Sergent, et al.
Textbook of Rheumatology, Update 4. 1993 pp.1-12.
(Plaintiffs' Exhibit 623)
This chapter in Kelly's Rheumatology discusses silicon, silica and silicones
as well as the diseases associated with these materials. That silicone is
toxic in both animals and man is well proven, according to author. Author
discusses local reactions to silicone implants, lymphadenopathy and
granuloma formation and silicone implant related synovitis, the immune
reaction in humans to silicone, and the musculoskeletal and rheumatic
diseases associated with silicone.
76. Causal Inference In Syndromes Associated with Silicone Breast
Implants: Psychogenic and Environmental Factors, by Marc Lappe,
International Journal of Occupational Medicine and Toxicology, Vol 4, No.1
1995. pp.165-175. (Plaintiffs' Exhibit 768)
Author discusses three hypotheses that could explain the occurrence of
illness in silicone gel implanted women and rules out all but the causal
hypothesis that silicone is responsible for bonafide systemic, immunological
illnesses in some breast implant patients.
77. Silicone-Reactive Disorder, a New Auto-immune Disease Caused by
Immunostimulation and Supemntigens, by M.A. Lappe, Medical Hypotheses (1993)
41, 348-352. (Plaintiffs' Exhibit 769)
Silicone related illness is a unique disease complex best described as
"silicone-reactive disorder. The author supports his theory with five lines
of evidence: 1) silicone breast implant components include immunostimulating
substances including amorphous fumed silica; 2) silica-stimulated
macrophages can induce auto-immune disease; 3) silicone has been shown to
provoke antibody production in concert with certain antigens; 4) autoimmune
reactions following exposure to superantigens have been associated with a
wide range of bacteria; 5) some of these bacteria are found in the silent
infections that have been reported in breast implant recipients.
CLINICAL METHODOLOGY OF DIAGNOSING A DISEASE AND ITS CAUSE
78. Cecil Textbook of Medicine, 18th Edition, Edited by James Wyngarrden
and Lloyd Smith, 1988 W.B. Saunders Co. (Plaintiffs' Exhibit 770)
Clinical tests to reach a diagnosis include medical history, chronological
events and symptoms to test diagnostic hypotheses, physical examination and
laboratory studies. Physician must gather data and interpret data in order
to reach diagnosis.
79. Preliminary Criteria for Silicone Related Disease (SSRD), Berkeley
Delphic Panel 10/22/95, Consensus Statement on Systemic Silicone Related
Disease. (Plaintiffs' Exhibit 771)
PRIOR TESTIMONY REGARDING METHODOLOGY IN DIAGNOSIS OF
NEW SILICONE RELATED DISORDER AND ITS CAUSE.
81. Testimony of Eric N. Gershwin, M.D., Thiess v. 3M. (Circuit Court
State of Oregon, No. 9401-00139), June 8, 1995
page 789/14 - 790/3
page 790/10 - 795/17
page 796/5 - 811/20
page 813/25 - 830/2
Dr. Gershwin, Board Certified in Internal Medicine, Rheumatology and
Immunology, a Professor at U.C. Davis for the past twenty years, formerly of
NIH, Editor in Chief of Clinic Reviews in Allergy and Immunology, has six to
eight articles relating to silicone exposure and disease in peer-reviewed
journals, testified in this case against 3M that there is a new, unique
disease in which women have a constellation of symptoms that are not
ordinarily seen in other circumstances, but which experience has occurred in
the past from other exposures such as drugs or environmental agents such as
Dr. Gershwin has assembled a bibliography listing over 600 articles about
silicone gel and autoimmune disease.
82. CV of Dr. Eric N. Gershwin
83. Excerpts from Trial Testimony of Luis Espinoza, M.D. from case of
Brenda Toole v. Baxter Healthcare, Tried before the Honorable Sam C.
Pointer, U.S. District Court Northern District of Alabama, January 1995
pp. 1891 - 1922
Dr. Espinoza, a Board Certified Rheumatologist and Professor of Medicine,
Chief of Rheumatology, LSU School of Medicine at New Orleans, Board
Certified in Internal Medicine, Rheumatology, and Diagnostic Immunology and
Laboratory Rheumatology, with 8 published Peer-Reviewed articles relating to
the effects of silicone breast implants on women, testified that in the
Department of Rheumatology at the LSU Medical School, Dr. Espinoza
supervises 5 faculty members, 6 research fellows, 1 clinical fellow in
rheumatology, as well as other technicians. There, approximately 3,000
women with silicone breast implants have been seen and evaluated and
treated, since 1984.
At LSU College of Medicine, the rheumatology department has confirmed that
anti-nuclear antibodies system (ANA) is positive in over 50% of women with
silicone breast implants, as compared with less that 20% of women in the
general population who will show a positive ANA.
The conclusion of Dr. Espinoza is that the typical symptom complex that
women with silicone breast implants consists of painful muscles, painful
joints, debilitating fatigue. In symptomatic women, these symptoms are
present in approximately 80-85% of the symptomatic patient population.
Other symptoms that are common to women with SBI are skin rashes,
telangiectasias which are dilatations of the capillary vessels, commonly
seen in patients with connective tissue disease, atypical synovitis, nerve
entrapment, and Raynaud's phenomenon.
84. Excerpts of testimony from 2 doctors in the case of Toole v. Baxter
before Judge Pointer. (USDC Northern District of Alabama, Southern Div.
Cv94-P-13, 5595 - Dr. Gloria Gastone, Dr. Robert Kirwin Schneider.
page 1702/14 - 1702/21
page 1707/6 - 170917
page 1714/18 - 1714/25
page 1722/16 - 1724/21
Robert Kerwin Schneider
page 1386/9 - 1388/3
page 1390/9 - 1391/10
page 1395/1 - 1399/24
page 1412/18 - 1422/15
page 1451/7 - 1453/3
85. Affidavits From Physicians Attesting to Silicone Related Disease
identified, Diagnosed and Treated in Their Patient Population
William Bethea, M.D.
Lenore Brancato, M.D.
Nachman Brautbar, M.D.
David E. Burns, M.D.
J.D. Doll, M.D.
Bruce Freundlich, M.D.
Joseph Markenson, M.D.
Lige Rushing, M.D.
Andrew Solomon, M.D.
Gary Solomon, M.D.
Phillip Sumner, M.D.
Affidavits from other physicians have been promised but have not yet been
forwarded to this office for inclusion in this Exhibit List.
86. Curriculum Vitae Shanna Helen Swan, Ph.D.
87. Curriculum Vitae of Arthur Brawer, M.D.
88. CV Mark Lappe, Ph.D.
89. CV David F. Goldsmith, M.S.Ph., Ph.D.
90. Affidavit of Gary Solomon, M.D.
91. Affidavit and Curriculum Vitae of Daniel Wallis, M.D.
THE EPIDEMIOLOGY TO DATE.
92. Letters to the Editor, Arthritis and Rheumatism, Vol.38, No.5, May
1995, pp. 719-726., by Robert Spiera in respect to the Sanchez-Gueffeo
study. (Plainfiffi' Exhibit 600)
93. Letters to the Editor, Vol. 333, No. 21, England Journal of Medicine,
pp. 1423-1424. Nov. 23, 1995.
These letters and correspondence concern some of the limitations and
problems perceived by other physicians practicing in the field of medicine,
rheumatology and internal medicine, concerning the Harvard Study.
94. Affidavit of James R. Jenkins, General Counsel to Dow Corning, sworn
to on July 10, 1995 in support of Dow Corning Motion for Summary Judgment
against Insurance Carrier to pay, as defense costs, the Dow Corning funding
of Medical Research and Epidemiology.
95. Portions of the proceedings on the record before Honorable Robert J.
Columbo, Jr., August 11, 1995, State of Michigan, Circuit Court for the
County of Wayne. Case No. 93-325-788CK. Dow Corning Corporation v.
Hartford Accident Indemny Co., granting Dow Corning's Motion for Summary
Judgment on Transamerica's duty to pay all Dow Corning's costs for medical
research as defense cost in defense of claims for systemic illness and
autoimmune disease caused by silicone breast implants.
96. Letter, Plastic Surgery Educational Foundation (PFES) 8/5/92 to Dr.
Sherine Gabriel - PSEF wiU fund 90% of costs of Mayo Clinic Study.
97. Portions of Testimony of R. Barrett Noone, M.D., Vol. 2, Sept. 1994.
Re: All PSEF Funding for Epidemiology came from SBI Manufacturers.
98. Letter to the Editor, New England Journal of Medicine, July 8, 1994
from Plaintiffs Steering Committee for MDL-926 concerning and enclosing 1994
research funding to PSEF by manufacturers for "epidemiology research".
99. Dow Corning Bankruptcy Schedule dated 6/30/95 showing all funding for
external mammary research studies by Dow Corning.
100. Excerpts from Deposition of Graham Colditz, Ph.D. 1/21/95 In Re:
Silicone Breast Implant Product Liability Litigation concerning regarding
receipt of Dow Corning money for Harvard Study.
Page 11115 - 11/25
Page 13/24 - 14/3
Page 17/10 - 17/18
Page 19/23 - 26/21
Page 49/8 - 50/14
Page 70/18 - 85/12
101. Excerpts of Deposition of Matthew H. Liang, M.D. 1/21/95 In Re:
Silicone Breast Implants MDL-926
Page 15/6 - 15/20
23/9 - 24/1
36/23 - 38/4
41/20 - 56/13
64/15 - 69/4
81/12 - 86/21
126/16 - 132/3
141/24 - 142/13
153/19 - 158/10
181/8 - 188/7
102. Excerpts of Deposition Testimony of Pierre Blais, Ph.D. 11/14/95 from
case of Merlin v. 3K Vol.2, pps. 243-252.
Dr. Blais is of the opinion that the presence of silica in the McGhan/Merlin
implants was a defect (silica is hydrophilic and absorbs lipids to some
degree as well as water) and there is no distinction in fact between
amorphous silica and the crystalline silica, as amorphous is simply silica
that is reduced through a fine state of division although the crystalline
structure is the same as crystalline silica.
Cite pages 261/19 - 268/8
In addition to platinum, used as a catalyst there are other impurities and
additives to the silicone gel. The gel consists of only 80-909'o PUTE
silicone and the balance are additives, impurities and such things as D4.
103. Excerpts from Deposition Testimony of Noel Richard Rose, M.D., Ph.d.
September 16, 1995 and September 17, 1995 - designated as defense expert
immunoligist in case of Merlin v. 3M.
page 37/21 - 40/11
page 43/9 - 43/21
page 45/6 - 55/2
page 71/2 - 72/14
page 75/4 - 75/16
page 84/18 - 85/1
page 95/14 - 96/21
page 115/19 - 116/1
page 122/12 - 123/1
page 127/21 - 128/11
page 129/18 - 130/18
page 170/8 - 171/6
page 185/17 - 186/5
page 208/14 - 209/14
page 219/4 - 219/8
page 227/7 - 227/17
page 234/14 - 238/8
page 241/3 - 241/13
page 245/2 - 249/2
page 254/18 - 255/2
page 261/14 - 262/1
page 266/11 - 267/18
page 268/19 - 269/1
page 283/13 - 284/7
104. A Rheumatologist's View of Silicone, by Frank B. Vasey, International
Journal of Occupational Medicine and Toxicology, Vol.4, No.1 1995, p.203-
105. The Epidemiology of Scleroderma: A Population-based Case-Control
Study, Principal Investigator - David Schottenfeld, M.D., University of
Michigan, School of Public Health
106. T-Cell Modified Immune Response... by Shanklin & Stevens
107. Connective Tissue Effects..., Abstract by Martin, Edworthy &_______
108. Immunological Aspects of Silica, by Robert Burrell, Health Effects of
Synthetic Silica Particulates, ASTM STP 732, American Society for Testing of
Materials, 1981, pp.82-93.
109. Mortality Study of Gold Miners Exposed to Silica, by Steenland & Brown
(See Exhibit 57.)
110. Silica-Associated Connective Tlssue A Study of 24 Cases, By Anne-
Claude Koeger, M.D., Thierry Lang, M.D., Didier Alcaix, M.D., Bernard
Milleron, M.D., Sylvie Rozenberg, M.D., Pascal Chaibi, M.D., Josiane Arnaud,
D.Pharm, Charles Mayaud, M.D., Jean-Paul Camus, M.D. and Pierre Bourgeois,
M.D., Medicine, Vol.74, No.5, September 1995.
111. Photos made from slide presentation testimony of Dr. Arthur Brawer at
Merlin v. 3M Daubert Hearing USDC District of Nevada CV N-95-696HDM on
December 11, 1995.