Document 067kw2epg7Y61GNdEYn25Z3J

THE JOURNAL OF INDUSTRIAL HYGIENE Volume XV MAY, 1933 Number 3 `'the ROENTGENOLOGICAL ASPECTS OF PNEUMOCONIOSIS AND ' ITS MEDICO-LEGAL IMPORTANCE* Henry K. Pancoast, M.D. and Eugene P. Pendergrass, M.D. From the Department of Radiology, University of Pennsylvania, Philadelphia, Pa* E HAVE been intensely in cation (1), we were further stimulated Wterested in the roentgenologi- hy the reports on silicosis among the cal aspect of pneumoconiosis.Rand miners in South Africa (2)._ . It since 1916- This interest' originbaetceadme a most fascinating study as in a desire to learn something of the added experience brought out new and ; changes produced in the roentgeno- interesting features, It became quite 'grams of presumably healthy adult evident to us later that the physical, ' chests by certain factors which were histological, and pathological processes not definitely pathological but more involved in pneumoconiosis made the or less generally operative in modem teaching of the roentgenological aspect ..life among city dwellers and workers of pulmonary tuberculosis to students in certain occupations in which indi a much easier problem. viduals were exposed to varying quan Naturally a deep interest in one as tities of various kinds of dusts. This pect of the subject of pneumoconiosis "aturally led to investigations of work- became conducive to a desire to delve :*9b exposed to harmful quantities and into all of its various phases. It should jiualities of dusts, as a result of which be borne in mind that roentgenological definite and striking pathological piil- appearances are always demonstra unonary changes were induced. At tions of pathological processes of dis |the time of our preliminary communi- ease in the living subject and as they Tleceived for publication, February 27, *33,....................... 'Presented in abstract before the Section n Industrial Medicine, College of Physi cians of Philadelphia, December 9,1932. may be modified by the physiological functions of life. . It has seemed quite evident that the two most important ways of study- 117 0 "d [Sjoe.efiBd uios'xejajP'Aq pajaMOj 9:T T00-iE-a3d 0Z669Q27 :L J9puesuMou>|un may ift|dt?0:SI lO qsd'ZS pefteoey ROENTGENOLOGICAL ASPECTS OF PNEUMOCONIOSIS 119 since roentgenology is such a powerful means of attack and defense in medico legal questions. We stress these facts for the reason that we have heard so pouch inexpert testimony of the inex perienced offered as expert testimony and even accepted as such. Our interest in all of these phases of the subject does not belittle the impor tance of the clinical examination, which m has indispensable values, especially in relation to the various aspects or de grees of incapacity, particularly in the late stages of the disease; and in the ' detection of complicating tuberculosis , and in differential diagnoses. But ; when roentgen examinations are made | with the proper care and by the correct technic, and interpretations are based [; upon the factors mentioned, what in formation is there to be determined |. clinically which can compare in im- iport&nce with the roentgen findings? Nevertheless, the clinical study is es- teemiai in, every case in rounding out _l complete status as a pathological ; problem. There are but few clinicians country as yet who have had iffieient, experience to qualify them expression of authoritative opin- 10' upon cases of silicosis, or poeu- COniosis of- origins other than silica, lough their opinion may be of very ite value in differentiating other iditions if present in the individuals |uestion. Moreover, even clinicians ferienced in examining cases from industry may not be qualified to |SS opinions Upon cases in other occupations. Even the clinical |tion of pulmonary fibrosis in its degrees does not give a comlowledge of the pathological. |0:which may be present. . f: technic of. roentgenological ex animations is of the utmost impor tance in all cases in which the exact status of the pathological condition is of unusual importance, should any exist. First a word in regard to rou tine fluoroscopic studies alone: These may be ample in the examination of a. large givup of individuals under cer tain circumstances and in follow-up studies after roentgenographic studies have been made primarily. They must be made with care, however, and with the eyes fully accommodated. Fluoroscopic observations' alone have no value whatever as medico-legal records, nor are they likely to give much information in certain industries, especially when the silica intake is un usually rapid, as in high percentage silica dusts. When an exact knowl edge of the lung condition, and as to whether any exists, is highly desirable, the technic of examination must be of the most exacting precision possible, and at least equal to that employed in the detection of early tuberculosis. Unfortunately, it is carried out in this manner with comparative infrequency. Stereoscopic roentgenograms, made in the postero-anterior direction if pos sible, are of- the utmost importance, especially when unusual questions are to be settled. Aside from their gen-, eral diagnostic superiority over flat films, the latter are apt grossly to exag gerate minor apparent abnormalities which may become actually insignifi cant when viewed stereoscopically. In advanced silicosis the lungs are practically always emphysematous, and the thicker lower portions contain much more than the normal amount of air and sometimes comparatively less interstitial pulmonary tissue, hence these portions are likely to be over- 170 `d IZ10 t? :e6ed woa-xejgpAq paj9MO<j <L9:ZT T00E-i2-a3d 01669921? :1 jepuesuMoiftiun :woy i/\|dt?o:21 lO COd lS peceoey ixxjt, juujcumaj-i UJt1 11NLHJSTK1AL HYGIENE ing pneumoconiosis are, first, through pathology,--a natural process of in vestigation in the dead or an experi mental process in living animals, and, secondly,,by roentgenological examina tions on living subjects. A correla tion of investigative observations along these lines together 'with a study of the physical and ,chemical factors involved in the inhalation and subsequent dis position of the dust has been the means of a thorough understanding of the condition of pneumoconiosis. By the physical and chemical factors is meant the physical quality of the dust, its chehiical compositibn, determined es pecially by petrographic estimations in the case of silica, the dust count (by light or dark field whichever may be recognizedas standard in the future) at the individual locality during general working Conditions, the time, at work and duration of occupation, the pro tective devices employed, and theii approximate protective value. To these should always be added an inves tigation into previous occupations and dust exposure. : It has been1 most fortunate for gen eral information of all of us interested in the subject that' ample opportunities have been afforded to various inves tigators for autopsies on individuals presenting all the various degrees of progress of silicosis in many different industries. In the si i t.njwy check-up of roentgen appearances in early sind all Stages of pulmonary tuberculosis it has been necessary, with very few ex ceptions, to await death from the ter minal stages of the disease in the hu man. subject, and few opportunities have been afforded for comparison of early roentgen appearances with the pathological process' as: it existed at that particular period. Since the workers in many dusty industries have been exposed frequently to other haz-i ards such as industrial aooidcntg whivhf have resulted in death, it has been pog- f sible to compare the roentgenological | appearance with the pathologies.! pic-1 turn at the time in practically all stages,1 of the condition! ! ): It has been our endeavor to learitl the interpretation of roentgenographic! and fluoroscopic appearances as nearly ! as possible On the basis of pathological ! studies and we believe that anyone | qualified.to interpret roentgenological! findings must be familiar with the ap pearances of the healthy chest and j lungs, with those produced by pneu-1 mbconiosis in all'stages of progress ! in all dusty occupations, -with the pathology of the disease under all of | these conditions, and with the physical factors involved in its production. Otherwise one is not qualified to sender accurate interpretations, especially, when they are of vital or medico-legal importance. A knowledge of patholr ogy is just as important as differential diagnosis; moreover, anyone familiar | with the roentgenographic appearances of the various stages of the condition characteristic of but one industryy such as mining, pottery, or granite cutting, is not necessarily qualified by that ex perience to make accurate interpreta tions in connection with the disease acquired in certain other industries such as sand pulverizing or asbestos worldng Appearances which might' be interpreted as of comparatively trivial importance in workers in one industry may be of very great impor tance in another. Such knowledge is^j of the utmost importance in both di- " agnosis and prognosis, particularly 0'd IZ10 s :e6Bd uiorxejgpAq paj9MO<j Z.S : 3 T T 003-Z3-33d EE0Z669Q2V :1 JepuesuMou>|un :wo.y \H6WZ\- l-OWZS peoraoey exposed especially as to penetration, shadow in the sagittal view. The! if the routine technic adapted to the localization of large, dense areas normal individual of the same physi consolidation by the lateral view ig cal development is employed. It is often. very important for differential^ often advisable, therefore, to make a diagnosis. If these areas are found | set of roentgenograms by the usual be in the apex of the lower lobe they! technic for the build of the individual are not apt to be tuberculous, as lower,J which will show the upper chest, ade lobe apical tuberculous lesions are not ' quately but which may blot out much likely to take on this appearance. of the pathological change in the lower Supplementary fluoroscopic obseisl portion by over-penetration, and then vations should be made of every case : to supplement these roentgenograms examined. The special advantage, in: by another set of lesser penetration to addition to those of every chest study, show to better advantage changes in IS the determination of diaphragmatic . the lower lung fields, (Figs. 1 and 2). excursion and costal expansion, which Often in advanced cases there are is a most important factor in estimat dense fibrotic consolidations, in the ing incapacity. In the cases of rapidly ' mid or subapical lung fields which may progressive interstitial fibrosis, this ob be tuberculous in addition to being servation may be the deciding factor silicotic. Another single roentgeno in diagnosis or in the interpretation of gram or stereoscopic pair of very much roentgenographic appearances. More oyer-penetrated exposures, and espe over, a preliminary fluoroscopic ob ciallyif made withthe use of the Potter- servation is likely to be the means of Bucky diaphragm, may throw addi determining just what additional ro tional light on these areas. Sometimes entgenograms may be required in any we have in this way shown cavities, in' given case. them which could not ordinarily be Much has been written upon the found. Lateral views are often very roentgenological aspect of pneumo important in the location of lesions, coniosis, and we are loathe to add to in showing the posterior costophrenic that which, vre have already presented spaces, in the determination of the (3, 4, 5, 6) except to emphasize what exact degree of. emphysema, in the appear to us to be very important estimation of cardiac size, and the points in the present-day chaotic state condition of the heart and aorta, and into which the subject of this condition sometimes in differential diagnosis. It has fallen, or, perhaps, it would be is a well recognized fact that the sagit better to say arisen. The most im tal view does not give the correct portant of these would seem to be the information as to heart size and con necessity for exact correlation of roentfiguration of its shadow in the ad genographie findings with pathological vanced silicotic individual, and the processes. It becomes necessary, lateral view is imperative for this de therefore, to review briefly the known termination. The marked emphysema pathological changes in order to'show of the advanced silicotic is likely to how we have attempted to make the cause rotation of the heart and to roentgenographic appearances con diminish the width of the cardiac form, with them. Most dusts which 90'd VZ10 9 :e6ed wo>*xej| Aq psj3MOd 8S :3T T00E-iS-a3d 0Z66993V '-I JspussuMouW mojj |/\|d tC\'ZV iO'QOd'ZZ peAieasy Received: 27.Feb.01 12:04 PM From: UnknownSender To: 4256997033 FEB-27-2001 12:58 ROENTGENOLOGICAL ASPECTS OF PNEUMOCONIOSIS 121 Powered b y# F a x.co m Page: 7 of 21 p 0 7 Fw. i. froentgenograni of thechoat of an anthracite coal miner aged. years, who spent llyearsinthemine dcinEvarioiLs-keodscf work,.-iucEudiiig the u^tof the jack' bamcter (dcilt). Ho symptoms, Chestesarrinixl becauee of HKCupatbri doriog a routine i&ndy,and can. ooxogaBdedasriBgatu'eaiccejjtfar the calcified primary in the right- lucg. On might eipeeft some slight e-yile-acca-ttf pceufliocotil+isis in this case because of hia work as a driller. Iso. 4. Bjo^TLfjiiogvani of the cheat of aate el rooulder, aged fii ye^ra, 15 year? crau-paiign. Tb* de^, JWmogeiwMJS hilista shadows aoc increased p-'ornioeiiije- at ibo trunk sbadewa indicate thti peri^a^uiaf-garibcniichiai-ljiaph node type oi sdlueisTheincreased density of t-he right lower raid lung field indicates anin.tciBtifial i>*pe of feroaiSj wbicl. is f urther suggested by restriction aid Blight peak! ng of the right dome of the diaphragm. In the roentgeoDgram where b a fine mxutar mottling in the mid lung fields indicative of an. early nodular type of th-e condjiion. Tha is ^oo Sue to bo reproduced ta a reduction. Three types of silicosis art inaoif-eaL intlia to 03 Axii joujftNAL OF INDUSTRIAL HYGIENE It is erroneous to refer to all of these ditions are positively ruled out and thfj changes in appearance as the result of appearance has become. present q| fibrosis ^lone. more marked over a period during Now this appearance of prominent, which serial examinations have bed hilum shadows and increased promi made. Moreover, even if due to pneiil nence of trunk shadows and linear moconiosis, the appearance does ok markings, with or without the faint represent an incapacitating degree of haze, has in this country at feast been the condition in any way, or most cetjj designated as the first stage, of silicosis tainly not unless it has developed or pneumoconiosis. There may he mtfier rapidly f lei suiting in a dusty some excuse for continuing to call this occupation capable of producing itf the first stage, but continued experi With very rapid development of pneu| ence with cases of pneumoconiosis de moconioais one is more apt to find evi-i veloping in various. industries has fed den'ces of the interstitial type of fibro us to question the wisdom of designat sis. We may seem to be unnecessarily!! ing any appearance of pneumoconiosis verbose in connection' with such by any term denoting numerical stages minor aspect of the condition, but our of progress. In this particular in experiences with so many cases of what | stance under discussion the individual have seemed unwarranted claims fori may develop the appearance in a com total disability based largely on no paratively short period of from 1 to 5 more roentgenological evidences than' years, or not pass beyond it, on the those just mentioned, have forced us| other hand, in fifty years. Moreover, into this detailed expression of facte. it is not apt to be distinguishable as a ^ In cases with silicosis which ismou- stage of the past in more progressive periods of the condition, and in some croseopic nodular ! lymphoid deposit industries it may be insignificant or in proliferations tend to lxcome conglom distinguishable as a stage at all. We erate and to produce a macroscopic prefer to designate the'appearance by nodular process which appears on the a term which implies its pathological royregenograflii as the typical rounded nature and to call it not a stage but the perivQsculur-piribrQ'niihitifi-tym'ph node diameter, or even larger, apd which type or preponderance of the condition. ate so, characteristic of the condition The appearance of this type or pre- in many industries. As this appear-;: ance was . found as . a more advanced eharxctprfetie of pnenmocr/riosis bur, stage of silicosis in tie earlfer cases ex amined, ami especially among miner!-' chronic bronchial catarrh, Im.nchiectasis. passive congestion from cardiac ; deebinphii^ibii,bthe i'dfi ma|igiaficy,'h^ should not be accented as nq evidence 6Tpneumoconiosis, especially in medi co-legal Cases, unless all of these con- the s,Jcoxil stage of the condition. (bee iihgbfiiffblfe; isimasPicuanAbWi^ saner or itisfenlfioanyn however, in many indusmes. notably the granite ii cutter, sand blaster, sand stone.and a3-t || bestos workers.. (See Fig. 6.) It U os- " pecjally likely to be sbsent^or ineo^- 0T -d morxBi^AqpamMOd 1210 01 :sBea 00 ; T T00S-i?--ft3d Se0i669S2k :oi J3puaSuM0u>|un ^ Wd WZI lo qad LZ p3AIS08M Page: 11 of 21 P. 11 P m FS ^ ^ E g` aSC3 O^o ft, e a so --sMt> 2" 3 PW @ <i2-Hj s jr i ^ *q Ft-*S3.s. R it) I--Sr1 O O' 00 47 p * mfl> S' e &O oh fCtf gft tJ ^ +- *+ Is S El o os "" -g if *ft JH Jo OR <! ^ ^ S C tC*L q Cb n. jr-tj>i *dCfc 93. FH pto p . c+- T *p; eSO " US |& S" O P3 5F <s p0c+1-- ET "oy &^ fa to' ^ ^*45 E| 2 ** SP ' I3 p5 ^St " -- S. I TM ^ BE S ^ft a^.lLg-SJg. 8. w o * 5 S' rs. o s S ^ 0c(OP=rqf1 SE}T TJ O" ss <*' , *i-a3 t(3-' Eo' M SO sr & 15 si 3 o, i Ptr p. OiO S' t3 (Ote 3 ^ tJ giH K` to (* BE* O Sg? (0 ft <$ a H o. c= s OVB-L-I. -cft- a ftr---1 T*J 3 ft o tr1 tr Powered by <glFax.com Received: 27.Feb.01 12:04 PM From: UnknownSender To: 4256997033 FEB-27-2001 13=00 Pro. S. RoantieDO*raiti of tie cbujt of a malt ajed Si yeaaa. vrtio bad worked os an autJiracLtecoal miaer J:r 40 years. FSSs cfa-ieJ eoanpSftint was shortness ot breotti sad rathmatin attack* for J y&Bis. TtLB <aac sa us&d as an iLkieUat4i>ni oE tkfc popular type or predcDiinanoc of pneurocxsoiucsaB becau&c tbe nodu.l(M- -ora sanj-Cifliitiy iarfie to show in a reduction- Ae. h naattor of fact th.e cas* represcata tte earner stages 01 a <liffTP termiaaL fibroafe LndLeatcd by Lbe nodulea tending to become cODgfinerau and tho bejieimis- of HSOnKtldatod. areas in the embapLcal reawms. Tbe apparauoc& <.f tbesa srtaaanigek. t-liat the origin of the consolidations is to be that- <tf an intesfautisL typeoffibiosis, whichisintoresiLcit. The Eacttiiat fch&y nrenotat the penpiiety indicates ttal tfcey firtprisbably Dot tobercuLoufi-in origin. Fiq f. HoeDtsenograni oftlchesrtoEaEejnaloaged37yfiarar^p|laiiaabeat05worker [or ytars. Tho appeatance iodicatea a fairly '.veil ndyanced atage of aebeatosia. Motetheiacrreaaijd prorainenceof hilnm and E-ranh ahadcmHand the linear and nt-eretjjjal fibrosis of tie Lower lung fields- The c-osiopHrenii; aogl and leit BfaNac border cbaractevigtLenity iudittoiiot. Note the ab&BQC&ef nodular -appearancea. ' Rejwodictipn furnished through tbe eonrtesi. of Dr. J. V. Sparks, Landau. C v ^ ^ A AAJ-j ^ \ spicuous in those who are developing examinations until after 20, 30, or'j silicosis rapidly, such as in those more years of occupation. working with pulverized sand without There is another type of silicotic ap- \ adequate protection, (See Figs. 1 pearance which was very puzzling to! and 2.) us at first because of its exact identity^ If this appearance is absent or near and our inability to find the proper | ly so as a stage of progress in so many place for it in a numerical classifica industrial 3ilicoses, why designate it as tion of progressive stages, . Our at a numerical stage of progress at all? tention was first called to it by Drs. We have ceased to do so, and have Riddell and Brink (S), and later by - called this appearance the nodular type Dr. Smith (0), Further investiga or preponderance of silicotic fibrosis, tions and experiences with it in con-'| or, more correctly, silicosis. nection with some sand pulverizer?! A coincident tuberculous process of seemed to place it as a sort of missing'! the typical adult type usually can be link in many of the cases in which there? distinguished readily in silicotic indi was an omission of the old second stage viduals with this preponderance or or nodular type of silicosis. Fortu-1 type, provided the nodules are not nately a definite pathological placed large or too widespread beyond the seems to have been found for the con central lung fields. When the nodules dition and a roentgenological classifi-1 are large and more widely dissemi cation for the appearance. nated the diagnosis of superimposed One can imagine the hilumward! tuberculosis becomes far more difficult progress of dust and its effects being. and may be impossible. Gardner (7) rather rapidly checked by an unusually-; has called out attention to the fact profuse intake of silica, resulting; in a-i that such nodules may become the seat quick or abrupt blockage of lymphs of tuberculous infection in some in channels. Then only the plcuraTward ; stances and with some dusts, such as pathways would be open for the lym- ; granite. We have seen cases in which phatic travel of dust cells. Soon these; the nodular type of silicosis haa been could bo closed in much the same man closely simulated by an ordinary or ner as the hilum ones. Gardner (10), even hemorrhagic bronchopneumonic then came to the rescue of our theory '.; spread from a primary apical tubercu by stating that under such circum losis to the raid lung fields, either ipso- stances dust cells could and did pene lateral or contralateral or both. The trate the lymph channel walls direct ; appearance of nodular silicosis is often into the interalveolar connective tissue i closely simulated by miliary tubercu to set up changes productive of an in losis and we have experienced difficulty terstitial cell proliferation and subse-; in differentiating it from actinomyco quent fibrosis. Gardner further sug-; sis, sporotrichosis, and leptothric in gested that the previous condition of 1 vasion of the lungs. the pulmonary lymph nodes induced This type of silicosis may not be by childhood tuberculosis and other ': definitely incapacitating unless it has agencies might have some influence on- developed rather rapidly. It may not the rapidity of onset and progression o| j be found except by chance in routine silicosis. We have had reason to sus-; ST 'd \-Z 10 Zl sBed uioa-xejag? Aq paisMOj T0:T T00S-iS-:33d 0166992*:oi JapuosuMou^un :woj-| mtO Zl loqod LZ psAeoay roentgenological aspects of PNEUMOCONIOSIS 127 |et thl3 possibility m some cases exained and 'showing marked bilateral Ication of these nodes as a result [ childhood tuberculosis. $SThe interstitial cell proliferation and Ibrosis so produced presents a typical dentgCTiographic appearance and to Ich we have just alluded. (Figs. j-2,4,6.) It is a fine and rather homoeneous haze usually fust- seen in the sight lung in the middle third and just elow, and later in the left lung. It ads to spread rather evenly into rger areas. It may or may not have perivascular-peribroachial-Iymph ode type of the condition associated 1th it, depending upon the rapidity- progress of the process. (Fig. 4.} is likely to appear in very rapidly ogreasing cases, but IS also found jjOUgh less frequently in those of jwer progress. We have designated its as the interstitial type o> yi aivmimee, and have subdivided it into pid and slow, which subclasaifica- must depend largely upon the ysieal factors and time of exposure, detection of this type requires tgenograms of the best quality and stereoscopic set in order to identify i appearance as that of an intrapul- condition. Fluoroscopic obei vatlona are necessary to determine fether or not the underlying, cause of 1 hazy appearance is responsible for !|Mcted diaphragmatic excursion. type of fibrosis will almost insbly progress to the terminal stage little or no appreciable nodular fince. (Fig. 6.) Care must be Incised in differentiating it from a 1C interstitial lung change result- |from pneumonia or continued up- t. respiratory infection as in the cb. A tuberculous spread from another lesion must, also be ruled out. If the appearance is limited to an upper lobe it most certainly is not due to in terstitial silicotic fibrosis but is quite likely to be due to a rapidly progressive tuberculous process. We have had occasion to make this differentiation. Thickened pleura may closely simu late the appearance in the fiat roent genogram. The condition responsible for this appearance in advanced form and of rapid development has been termed "acute silicosis'' by Chapman (11) and some others. We have seen several cases similar to those to which Chap man alludes. These individuals worked in sand pulverizing plants and most of them eventually died of pneumonia or tuberculosis. It seems to us question able whether such a term as "acute silicosis" ia advisable. Silicosis is a condition which is extremely variable in its progress and yet the actual onset of fibrosis to some extent is probably largely simultaneous no matter how rapid the ultimate progress. This un usually rapid fibrosis differs from the better known forms of the disease only because of variations in the physical factors involved and the greater and earlier predisposition to pneumonia, tuberculosis, and other respiratory in fections, It has seemed more logical to speak of a rapidly developing than an acute silicosis. Moreover, one can not be certain in these eases that the acute factor is not largely a rapid tu berculous process or a pneumonia. There are few if any arguments to be recorded in connection- with the terminal stages of silicotic fibrosis. In stead of the third stage, we have pre ferred to call this aspect of the disease the terminal diffusefibresis. It is more T 'd iStoei. :eBed uiorxedff Aq pajamoj I0:T T00S-iZ-a3J E0i669S2V :1 japuesuMou^up :woJd IfldWSI- iO'Q^'AS psAraoay ROENTGENOLOGICAL aspects OF PNEUMOCONIOSIS 129 jpoentgenological appearances have change in silicosis. It is a theory of S^ieen somewhat variously described by ours that the absence of marked evi ^different authors (12, 13, 14, 15), and dences of emphysema and all of these Kperfiaps easiest for roentgenologists to other differences might be explained piancfersiand by Sparks (16), and ac on the basis of a lack of aeration due to cording to our own observations as the very peculiar characteristic patho iotfell, they may be briefly summarised logical features of asbestosis to be cs!(eh the basis of the probable pathology plained later. Certainly there is much fjj$ asbestosis somewhat as follows: to learn about this condition, and es -There is an appearance suggesting pecially by serial study. . Increased prominence of hilum and Space will not permit our entering fstrunk shadows, especially in early into all of the details of the subject Stages, but this is overshadowed later of pulmonary asbestosis. . These are ||m by other features. It is somewhat many of the essential pathological ferent from the perivascular-peri changes found in silicosis, such as those bronchial-lymph node predominance suggested and consisting of a moderate ||&f Silicosis. Sooner or later, there ap- cell proliferation and fibrosis. The ears a rather homogeneous density in predominant pathological feature; is |&e;lower lung fields, evidently due to the presence of the asbestosis bodies ^interstitial type of cell proliferation which numerous authors have; de Snd'fibrosis. Later on there is a fur- scribed and to whom we have referred tier increase in this density in a wider in a previous presentation on the sub &Mf with, a fine network of fibrosis, ject (&), These bodies are of various IjteMch may be a transition of inter&ti- sizes and arc found in various stages of stlintoamild terminal fibrosis. There development1 in' many localities, but fsb very little nodular predominance particularly imbedded in fibrous tissue^ id it is always inconspicuous. With most of them in large clumps in the 'appearance diaphragmatic excur- alveoli and very, large ones .in the.terion ig limited and the outline may be min&l air passages. Whether, any fi even. Then there are some appear bres are sufficiently small to1 be phago- ed which differ very materially from cyted is uncertain. Certainly they do of silicosis: The dipph-rn.^'m.i.t' n not reach the pulmonary lymph ntides |jftline is. indistinct, the costophrenic (16), The bodies increase in size from pcs are clouded, there is the ab- ' the original fibres probably by colloidal ce of the typical emphysematous aggregates of blood protein and con arance of advanced silicosis, with, taining an iron salt (17). Possibly, as Ismail shadow of the rotated heart, Sparks (16) suggests, this reaction to Sfc'thc left cardiac border is often the inhaled asbestos fibre is, after all, a f indistinct. Now the first two of safeguard against even more serious last appearances cannot be laid pulmonary changes. Gardner .(18) kened pleura alone, because this has admirably described the relations ociated with silicosis also. The of the largest of these bodies to the ict left cardiac border cannot be terminal air passages in. which they olely to lung changes, because are found. He states that they are apt ^sti's as much or more pulmonary to be surrounded by a fibrous collar in. ST'd IZ JO gi. :o6ed ujoa-xiystfJ Aq pajaMOj 0:I I00S-ZZ-a3d 01669921? :1 japuesuMou>(un :woj-| lAld tzO-S t l-OWZZ psAjaoay THE JOURNAL OF INDUSTRIAL HYGIENE the air passage wall, and it has seemed to us as quite likely that this collar surrounding what is really a foreign body of increasing sine, together with the presence of large clumps of the smaller bodies in the alveoli* must be conducive to a condition of multiple minute areas of atelectasis or drowned lung. Such a state of affairs might well explain the lack of roentgenologi cal evidences of emphysema and the other peculiarities of asbestosis as com pared with silicosis, and also the in tense dyspnoea and cyanosis of the late clinical stages of pulmonary asbestosis. This is a comparatively new aspect of pneumoconiosis. Intensive studies of the condition have been made in Great Britain, especially by Merewether (19), and Merewether and Price (20), and in South Africa by iSimsori (21). Comparatively little has been written on the subject in this country except by Lynch and Smith, (22), and Gardner. The conditions in the industry in this country should be judged with a fair degree of accuracy by comparison with those in Great Britain, The report by Merewether and- Price states that approximately 2200 individuals were exposed to prac tically pure asbestos dust in factories in England. Now Great Britain and the United States both use the Cana dian asbestos product alrnusl exclu sively and conditions in the two countries are probably very similar. Merewether (23), in a personal com munication, has stated that there were 319 recorded deaths from silicosis in Great Britain in 1931 and 9 from, asbes tosis or asbestosis with tuberculosis. Full particulars were available to date of 35 'deaths from asbestosis or asbes- tosifl with tuberculosis. In 11 case; tuberculosis was either a comphcatL or terminal factor and in 24 no tube; culoaia was present, '`The averaj age at death in the oases of asbestos: with tuberculosis was 45.7 years, an, the average length of employment ii asbestos, 13.5 years; In the cases with! out tuberculosis, the average age & death was 40-6 years, and the average length of employment in asbestos wi 15.1 years." Their asbestos risk hi been controlled since March 1, 19; by a very stringent Code of Regul tions (24, 25, 26) applying to the in? dustry. . . We must all realize that pneumi coniosis, while a dangerous' and i: capacitating condition under cert; circumstances, is a- inure ur less necei saiy risk of commercial development i the progress of civilization. We cai not get along without ooal, and yi coal mining entails certain hazards; one of which is pneumoconiosis. So: miners will work their entire lifetime at their mining occupations and develop any incapacitating form of tla condition; a few others may not be si fortunate. We cannot adjust oiEfi mode of living to be deprived of got iron, and other metals, of pottery, as1 bestos products, the foundry, abrasivi work, and innumerable other indusi tries and their products. We must a] admit that certain hazards must to accepted by the worker after he been made fully acquaintedLwith thi provided they are known by those li dividuals who are in a position to gi the information. This is one point view of the subject. Another side to the question is thi it is incumbent upon the employer protect his employees to the best 9T 'd IZ10 91. :e6ed Aq pajaMOd 0:I T00E-i2-a3d 0i66992t :oi j9puesuMou>iun mojj |Ald peAjeosy ROENTGENOLOGICAL ASPECTS OF PNEUMOCONIOSIS 131 ^his ability by all known and proven ' gfc.fet.y precautionary measures. rrThirdly, an extremely important asjfpect of the situation, and one to whieh |;tof little attention has been paid in ' the past, is a means of acquainting S employers of possible dangers to their |i'workers and of the best precautionary iliheasures to be used in order to miniEnaise the hazards or entirely remove | them. Industrial medicine has known ? the hazards and has developed the pre^ 'yentive measures, but employers are |5: not students of industrial medicine. State Health Boards have been active ft in spreading propaganda in connection i with preventive medicine and com| municable diseases and in enforcing |: certain regulations for the control of the latter, but how much attention | have they given in past years to regu lation of the dust hazards of industry? y Morally, the worker disabled as a faesult of |he dust hazard would seem be entitled to compensation, just ;.aa much as though liis incapacity |,:.were the result of bodily injury. His ^realization of this fact has suddenly ^'developed a medioo-leg&l Aspect of : pneumoconiosis in this country which |i|!&.t the present time more or less in a .ftate of chaps. How simple it. would if there had been enacted in every jstate uniform and adequate eompensa|tibn;: laws and regulations governing adoption of safety measures to tdicate or greatly modify the essen1-dangers of dusty industries, such i been done in Great Britain, o, Australia, New Zealand, the j&th African Union, and Germany, ^ly k-few of our States enforce wny Jpeatiye regulations or have any pupensation laws which make silico- i `Compensable industrial disease. One of the great misfortunes to the medical profession of the legal situa tion in this country is the fact that decisions by Compensation Boards and in Civil Courts must be based to a considemble extent upon conflicting medi cal testimony. As the roentgenologi cal examination is of so much impor tance in establishing the status of the claimant as to disability from, pneu moconiosis, the roentgenologist plays an important part in the conflicting ex pert testimony. It seems to be a diffi cult matter for Boards or juries to decide upon the relative merits of op posing medical testimony, whereas it would seem that the basis of these merits should be the qualifications of the opposing witnesses. We have ob served instances in which this might be a very difficult decision even for medical men,, because medical opin ions must often differ.' On the other hand, there have been very many more instances in whieh it would seem that it should have been a. very easy matter to have, decided upon the relative merits of the character of testimony1 and of qualifications. We have pre sented the foregoing facts'with a view of attempting to prescribe what the qualifications and knowledge of a ro entgenological expert should be in con nection with silicosis. The tardiness which we Americans have shown in the adoption of adequate measures to adjust all difficulties in connection with dust hazards probably is best explained by the wide scattering of the industries in which dangerous dusts are evolved over such a large country as oura. In England and on the Rand, for example, where hazard ous dusty industries are far more con centrated than here, attention was L\'d IZ ion :o6ed morxejg? Aq paiaMOd V0:T T00S-iE-a3d 0Z669Q3t' :01 J9pu3SUM0U>|Un :wojd l/MdWSl- l-O'qsd'ZS poAieoay ldZ Tins JOURNAL OF INDUSTRIAL HYGIENE . centred upon silicosis at an earlier pe riod and received much more serious attention. In our own country pneu moconiosis, and especially its hazard ous aspect, receives very scant atten tion. in the curriculum in most of the medical schools, and particularly in those in which there is no course in in dustrial medicine. Then, too, our form of government is not conducive to an easy control of the situation. The Federal Public Health Service has performed yeoman service along investigative lines in most aspects of silicosis, but the Federal Government does not make regulations and pre scribe compensation laws. These du ties must' be left to each of the States individually. . * There can be but one satisfactory outcome to the situation. Compensa tion laws must be passed by each State ae nearly uniform in easeotial dtjLslls as .possible in order to avoid any ef fects leading to unjust competition. Medical Boards must be created hav ing, among their many other duties, full authority to decide upon the merits of all claims for disability from pneu moconiosis, without recourse to con flicting medical testimony. This would require that all members of such Boards should be thoroughly familiar with all aspects of the condition. The physical problem such as dust counts and analyses of dusts would have to be taken care of by experts in these lines. The Board could have the advantage of investigative work by such bodies as the United States Public Health Service. Experimental work would probably have to be earned out as it is at present by well recognized'private individuals or institutions. This, seems like a Utopian Bcheme for this country. but it is only because we are a nat| of individual states, each one of whri must adopt procedures which in oti countries are carried out . with faction by central governments. Such Medical Boards, in order"' be fully efficient, should have auth ity and be able to pass reliable jud ment upon the health and the e tion of the lungs of all applicants ] positions under new employers and ' provide means for the periodic exaii inations of all employees in hasardd dusty occupations! In the first ii stance, they should give due consider`d tion to all possible effects from pi vious occupations, bearing in mind th| progressive nature of silicosis of con paratively rapid development, after years of cessation fronra hazard ous dusty environment. The last en ployer is not always responsible the development of an incapacitate silicosis, as is well, demonstrated in 1 case illustrated in Figures 7, 8, and ( The reader is first referred to the i tration legends, after reading which the following comment is in order:. This patient first came to us 1924, with a history of previous pheu monia and left pleural effusion (Fig, TjJ At that time his occupations, past anil present, were unknown. A diagnosis* of pulmonary tuberculosis was entirely justifiable. He was nest seen and ex amined in 1929 because of gradually progressing dyspnoea. At that time the roentgenographie appearances at once demanded an insight into oceu<3 pations. It was found that he been a-machinist for IS years, but be fore that had been a miner for TS months and a firebrick worker -for 5 j 6 year?. The inferences' to be drav from the two laet examinations in-19292 ST 'd jo 81 eBBd ujorxBdig? Aq pajaMOj b0:T I00E-Z5-S3d EE0Z669QEV :1 J3puesuM0U>iun :woJd lAld t [O'C|0d'Z3 PSA!S30d ROENTGENOLOGICAL ASPECTS OF PNEUMOCONIOSIS 133 ROENTGENOLOGICAL ASPECTS QF PNEUMOCONIOSIS 135 jjl; PjlNOOAST, M. X.; AND FEND*H<SRAa, 117, Cooke, W. if.; Asbestos Dust and the 5!, P.: A Review of our Present Curious Bodies found in Pulmonary Knowledge of Pneumoconiosis based Asbestosis. Brit. Med. Jour., 1929, upon Roentgenological Studies, with Notes on the Pathology of the Con dition, Am. jour. Roentgenol,, 1925, S, 578. 18. Gardner, L, U,; Address before the Section on Industrial Medicine, Col f ^3811 ' -j % PawcoaSt, H. K,, aUrn PnirUBsOKAse, lege of Physicians of Philadelphia, December 9, 1932. E. P.: Pneumoconiosis (Silicosis). 19. Meeewetheb, E. R, A.: The Occur A Roentgenological Study with Notes rence of Pulmonary Fibrosis and other on Pathology. New York: P. B. Pulmonary Affections in Asbestos Hoeber, 1926. . _ . Pancoast. H. K., and Penderorass, Workers. This Jour., 1930, IS, 198, 239. E, P.: Review of Pneumoconiosis: Merewethes, E, R, A,, and. Price, Further Roentgenological and Patho logical Studies. Am. Join. Rosal ia gehol.', 1931, 55, 556. C. W.: Report on Effects of Asbestos Dust on the Buuga and I:[1I 0uppi'tsB-- sion in the Asbestos Industry.' Lon fe Gardner, L. U,: Personal Communica don, H. M. Stationery Office, 1930. tion.: 21. Simson, F. W.: Pulmonary Asbestosis t:,.Riddell, a. R., and Brine, G, C.: in South Africa. Brit. Med; Jour., Personal Communication. 1928, 1, 885. Smith, A. R.: Personal Communica- 22. Lynch, K. M., and Smith, W. A,: As ticn. i Gardner, L, U,: Appendix on PathoSi'i; logical Studies. U. S. Pub. Health bestos Bodies in Sputum and Lung! jour. Am. Med. Assoc,, 1930, SB, 659. 23. Merewether, E. R. A.: Personal Com ^ J3ul. no. 187,1929. munication: An Extract from the An ^Chapman, E, M,; Acute Silicosis. Jour, Am. Med., Assoc., 1932, S3, 1439. nual Report of the Chief Inepector of Factories and Workshops for the Year IWobi], W. B.: Pulmonary Asbestosis: 1931, ~ te Radiographic Appearances in the 24. Statutory Rules and Orders, 1931, no. [A: Skiagrams of Workers in Asbestos. - 1140. Factory and Workshop. The Tubercle, 1929, 10f.353. Asbestos Industry Regulations, 1931, jjSjdPEit, W. B.; Pulmonary Asbestosis: London, H. M. Stationery Office, 1932. " A Report of a Case and a Review. 25. Statutory Rules and Orders, no. 341, "h"'. Rev, Tubcro., 1030, flff, 571! Master and Servant. The Silioooio i>LlvEn, T.: Pulmonary Asbestosis: A ' and Asbestosis (Medical' Arrange :$Ocio-Mfidieal Study. Arch. f. Gewer- ment) Scheme, 1931. London, H. 1'path. u. Gswerbehyg,, 1930, 1, 67. ^Voon. W. B.,-a.\u Gluijne, S. R.: Pul- V ihonary Asbestosis. Lancet, 1930, M, Stationery Office, 1931. 28, Statutory Rules and Orders, 1931, no. 344. Master and Servant. The As *'445- ' ||Sfark:8, J. V.: Pulmonary Asbestosis. (^Radiology, 1931, 17, 1249. , bestos Industry (Asbestos) Scheme, 1931. London, H. M. Stationery Office, 1931. 1.210 iz 96Bd uiorxiyagfAq pajaMOj 90 :I I00E-A2-33d EE0Z669927 :1 JopuesuMou>iun :wo.y [Aid VO'-Zl WapiLZ :p3A|0O0y