Document 06M9M79MGYEb8Y8L0YkV29DJm

FILE NAME State of the Art Literature SAL DATE 1955 DOC SAL059 DOCUMENT DESCRIPTION Journal Article - Asbestosis as Differentiated from Other Pneumoconioses C Asbestosis as DifferentiateDd ifferentiated from Other 35 Pneumoconioses A. SanderM.D. Milwauken A. Q. wiTat We SRA ST ey tae DLoS The preceding discussion has shown that No.the roentgenological of a well- < - appearance defined asbestosisis quite distinctive and that it differs materially from any of the other into such a film When to this are added some retained secretions in the lower lobes which often are bronchiectatic in emphysema the misdiagnosis is established A pneumoconiosis of which we have become increasingly aware in recent years is that due to excessive deposition of coal dust It appears quite certain now that free silica is not needed as an essential component of pneumoconioses For that reason I shall not the dust to develop the characteristic changes limit my part of the discussion to the differ- The fine lacy character of the shadows plus ences between this disease entity and the some emphysema gives a pattern which looks other dust diseases but shall include other very much like ground glass and is easily conditions of the lungs which may be mis- mistaken for early asbestosis diagnosed as asbestosis The first and commonest cause of mans diagnosis is poor film technique A perfectly All these examples I assume represent patients who present themselves to their physi- normal chest can be made to look like one with definite stage asbestosis by slight underexposure by lack of contrast and by blurred vascular markings due to too long exposure time Such films are especially common in overweight persons the heart shadow usually being horizontal and often presenting a shaggy appearance due to compression of the vascular shadows in the lower lobes Films lacking proper penetration sharply defined detail and lack of contrast should be rejected for the diagnosis of any occupational disease of the lungs but particularly of asbestosis Another condition which causes diagnostic trouble at times is emphysema due to any cause when there are one or more adhesions of the diaphragm due to past pleurisy The ground appearance is very easily read Read in the Symposium on Occupational Diseases of the Lungs sponsored by the Massachusetts Medical Society in cooperation with the Institute of industrial Medicine of the New York UniversityGraduate Medical School Buston Oct. 28 1953 tioned How easy it is to fall into the trap of a gunshot misdiagnosis Unless other possible causes for the ray changes are considered first and a detailed past occupational history is evaluated along with the char- acter and extent of the most recent dust ex- posure another worker who actually needed reassurance will be told that his lungs are full of asbestos dust and that he should quit his trade From that point on his symptoms usually increase to a marked degree and he has developed what to him is a real disability In my experience such induced disability is commoner in some areas than is the disability from the disease itself Because of the complete lack of unanimity of opinion about this disease among physicians and because : the need for more clearly defined criteria for diagnosis and ad- vice o onn continuceontindued emplemoployymmentent in thetrade the medical and industrial hygiene advisers of members of the Asbestos Asbestos Textile Institute 208 mE lamba pete te bor ae added ws lobes we ve be des pars is ae + dust + silica ~ ent of anges vs plus -ent pa- physi na hisest and -- --- e trap er pos- ce con- pational char- Lust ex- needed ngs are Id quit ptoms and he sability vil disis the usimity physi- ^'. Avisers ~ titute ASBESTOSIS AND OTHER PNEUMOCONIOSES have set up a called Air Hygiene Com- mittee This committee has met on several occasions to determine whether those who are most intimately associated with this dis- ease can agree on the various medical and hygiene phases of the problem At the last meeting each medical member of this committee brought with him sample films of the various stages of asbestosis in- cluding some he had classified as essentially negative All films were reviewed by the eight physicians who were present We found fairly good agreement on the more advanced stages of asbestosis but practically none on the borderline degrees A number of my films from the textile mill in North Carolina for which I am consultant representing cases which I had classified as early or stage asbestosis were called essentially negative hy a number of physicians present who had had long experience with this disease The reverse also was true some films I had called negative which others thought represented stage asbestosis The same disagreement was found with the other films which were presented It was our final conclusion that it is impossible to clearly define a stage case and that it can be called essentially negative one day and first stage the next by the same reader This was not new It has been emphasized repeatedly by Pendergrass beginning in 1938 Our group finally agreed that little attention should be paid to the stage diagnosis that little if any disability has been shown to exist with the borderline stages that no one should be advised to stop work with these questionable degrees of change and that workers should be kept at their regular jobs but the dust control should be so improved that their cases will not progress to the stage where everyone agrees that they have asbestosis Regarding recommendations of transfer to less dusty or nondusty work we agreed to the following ; 1. Persons under 40. when the diagnosis is clear cut beyond first stage should be moved to a nondusty joh if possible 2. Where progression is seen on serial films regardless of age less dust exposure is clearly indicated 3. Exceptions should be made if there will be material improvement in dust control on the present job within a very short time I have deviated from my assignment of differential diagnosis because the diagnostic criteria are so intimately associated with it Until we have some agreement on ray in- terpretation the present chaotic state of af- fairs will continue In the differential diagnosis it is my belief that a new approach is essential not only with asbestosis but also with nonoccupational diseases as well Because textbooks in medicine are written by diseases each followed by a listing of other diseases which must be differentiated from it the disease itself becomes fixed first in the diagnostician's mind He says to himself This is it and he pays only cursory attention to the diag nostic criteria of the disease and to the dis- eases from which it must be differentiated A more scientific approach would be to list all the conditions and diseases which are compatible with the ray pattern which the patient presents and then after a complete and detailed medical and occupational history physical examination and laboratory studies to see which of the positive findings more closely fit the listed diseases I should like to cite a case which undoubt- edly would not have been misdiagnosed had this approach been used A railroad shop repairman aged 57 had to stop work because of increasing shortness of breath several years ago Cyanosis and dyspnea became progressively worse and he died of anoxia and right heart failure several months ago His work- in the railroad shop included welding unpacking and repacking asbestos insulation around locomotive boilers and doing some fitting and grinding The chest ray film showed a diffuse mottled and micronodular pattern in both lungs and compressed lower lobes due to high position of the diaphragm with numerous annular shadows of less density scattered throughout both lungs Asbestosis was diagnosed by the man's physician because there had been some ashestos exposure because he had always heard that the ray pattern of asbestosis was rather bizarre and this certainly was and 209 3 aK terdey RS 4 veAg 7. ry Sle) te tath Str Pea =o INDUSTRIAL HEALTH because it did not look like the siderosis of welders about which he had read something recently The degree of asbestos exposure was not inquired about it was spasmodic and minimal Other diseases and conditions of the lungs were not con- sidered The annular shadows should have brought emphysematous blebs or air cysts into the differential diagnosis as well as the granulomatous diseases Miliary tuberculosis had to be ruled out as well as berylliosis with emphysema Sarcoidosis also had to be considered although the annular shadows were against it After definitive study the diagnostic possibilities should have been reduced to emphysematous blebs plus pneumonitis or polycystic disease plus pneumonitis Also there were none of the characteristics of asbestosis and no pleural involve- ment When the most detailed analysis and study will not reveal the true diagnosis which happens in occasional cases taking a biopsy spe- cimen of the lung should be considered This has become a rather simple procedure with little danger of complications It must be remembered however that because of the relatively small piece of lung usually ob- tained for biopsy there always is some danger that the diagnostic pathological change will not be revealed In conclusion as with all chronic chest diseases so especially with asbestosis all possible causes of the pathology revealed by the chest film must be considered - Poorly After postmortem study the diagnosis was clarified widespread congenital cystic lung with interstitial fibrosis due to long- standing infection The cuboidal and columnar epithelium lining of the cysts is note- worthy Also there was complete absence of anything resembling asbestosis bodies an absence of pleural thickening and no evidence of any hyaline fibrosis Even with this studied cases result in misdiagnoses which not only are embarrassing to the physician but which may also cause irreversible harm to the patient We owe it to our patients and to the medical profession to so thoroughly investigate every obscure case that such un- fortunate situations do not arise DISCUSSION Dr. Karl T. Benedict West Boylston Mass It is a privilege to substitute for Dr. Harriet Hardy she has helped me many times but a sub- lieves that this was a case of asbestosis and is sending the tissue slides to various pathologists He should be convinced soon that he most likely was wrong which will be most stitute is always a second The assignment is the differential diagnosis I have had no experi- ence with asbestosis and furthermore I believe that experience with most pneumoconioses as seen today is gained only after 20 to 30 years study embarrassing to him This case along with many others which could be cited clearly points up the need to consider all possibilities in cases presenting hizarre ray patterns Each case must have painstaking study including not only the immediately preceding occupational history but also a history of every job from the first one on An example is a foundry worker because it often takes that long to produce such disease In spite of the foregoing I believe I am qualified to make certain remarks because I have been practicing industrial medicine for 15 years in one of the world's largest artificial abrasive plants Since 1940 we have taken more than 25,000 chest rays on some 5.000 abrasives workers From 1911 to 1940 except in rare instances we simply did socalled routine physical examinations I agree with Dr. Sosman that the physical exami- with a chest film which was characteristic of a moderately developed asbestosis Careful study of the occupational environment revealed no possibility of asbestos exposure in this shop More detailed early occupational history revealed that the man had been a plumber's helper during the late teens and early twenties doing all the sawing of asbestos pipe coverings usually in con- nation is not worth very much in these circumstances Thanks to Phil Drinker and others dust control is much better in our plants today In one large plant our dust counts run consistently 3,000,000 to 2006,000 particles per cubic foot We handle a great variety of dusts for that is our business and safe handling is essential Recently at the Seventh Saranac Symposium several renowned authorities on pulmonary diseases attemated to define pneumoconiosis I shall not There was ni definition there either Instead fined basement rooms there were minority and majority reports One 210 1.TH -tudy i hap y spe . This with ust be of the hy ob- ir dan- change chest sis all aled by Poorly which vsician : harm nts_and ( ~ . Mass Harriet it subtuent is experii believe . 35 seen ro study ce such '. qualified . ave been is one of * Since st_X rays : 1911 to " lid so- al exami- circum- ers dust + in one asistently POL Wy | our . URI ilmunary .. I shall Instead .. Corte ASBESTOSIS AND OTHER PNEUMOCONIOSES group insisted that pneumoconiosis simply means dust in the lung The other group restricts it to those conditions producing demonstrable The hitch is Who demonstrates the disability disability The roentgenologist film sees nodular fibrosis in the ray that is pneumoconiosis to him At once or sometimes much later the industrial physician and hygienist set about to correct conditions to prevent progress of the pneumoconiosis or development of new cases Later though the worker still know of his trouble the family physician hmaasydinffoit- culty clearing an ordinary chest cold or the is faced with surgeon anesthesia worries The occupational disease or the health department specialists in our state government want reports when injury has resulted Compensation and insurance authorities talk about the number of pneumoconiosis cases based upon those workers whose earnings have suffered The compensation lawyer appears later in the picture and alas sometimes the last the pathologist may be of tuberculosis or coniosis the first in cancer is proving that a case in reality pneumo- I believe we all know when the man is suffering from pneumoconiosis whether we be laymen or physicians What he wants to know is What is wrong What can be done about it Is he perma- nently disabled Is his life shortened but There nosis or can be only one answer differential diagnosis or not better diagfunction studies but adequate dust control Since different dusts require different degrees of dust control witness the different effects from inhaling small amounts aluminum therapeutically and beryllium or radioactive dusts There is therefore good reason for you and me to continue to study pneumoconioses > and their differential diagnosis We in the abrasive industry are continuing this research Specifically we believe that under reasonable control alumina dust is no problem You have heard of the carbo- rundum lung no doubt this is an unjust label as my good friend Dr. Eddy of the Carborundum Company well knows for Carborundum is just a trade name for the fusion product silicon carbide Furthermore just what disease disability or pathology silicon carbide per se will produce in man has never been proved conclusively I believe It is entirely possible that this lung condition is caused by significant free silica contaminations Further study is needed and we intend that it shall be made Shaver's disease has been mentioned before In spite of several years research tending to prove that alumina fume is the cause there are those who believe that silica fume is to blame Industry is somewhat discouraged by the inconclusive nature of these and similar medical studies We all know about the problems related by beryl- lium and radioactive dusts On the other h^nd our concepts of clay and talc pneumoconioses have changed in recent years And what do we know about zirconia or titania or magnesia or boron carbide or graphite dust inhalation In our industry organic substances have caused only two minor cases of asthma And we have seen no cases of can- cer of the lung among our abrasives In conclusion our goal is not a specifeimcpM loy. eesC. figure but maximum dust control to pneumoconioses This eliminate all goal is not easily attainable Adequate differential diagnostic knowledge will help us to achieve it ee :e3* Maximum allowable concentration Ee OE Re oe pe ew ai Sore ee ve me ee ee ae ae se. re te