Document 0gzrO4VKZMrLq55LQbpK3YzRJ

94 Fulton. Dooley. Matthews,, and Houtz (15) noted that 'Asbestosis was found in 14 persons (12 men. 2 women), or 25 percent of the exposed group." INCIDENCE OF ASBESTOSIS IX DIFFERENT OCCUPATIONS The percentage of persons affected by asbestosis varies in different occupations. The number- of persons employed in many of the occupational croups uv so small that caution must be exercised in malting comparisons, but the data seem to be of sufficient interest to warrant publication. Classified by departments, the preparation department 1ms the highest percentage of asbestotic persons. Cat#ino- is the principal occupation in tins department. Although only S of the 72 carders had been employed more than 10 years, 29.2 percent had e.-be-to.-is. Eleven carders had advanced asbestosis. X o other occupational group had so large a proportion of advanced eases. T able -10.__,V . >/te r and a* Tea Ve. <' y n rb r * i-.ar.nQ , I g ill ... a i ! I-C C U x ltiu it classified atcord- IV! nrand/vftui Ntiir.lifTwith \jj7- *-r vlT\"-**t1uS'bv* r A te l * W I { i ! , j I ' ( t ; ASBE? Lanza (IS') British invest i than it was i probably nunported 3 fatal mill- wa- 11', of the order < man 27 years plant. Kgbei in a man 30 y< died 4 years tinning work. These exan suggest that ensues is as si Bridges 11'.:i shown from y of fatal cases 1 t'r \\ -' fl ..ro>'*>........ ................ * Spinnr..'. M'iV-.n1t iz z .` c. r. Wt-uv! wL'r.2_ ..... "" T ......... i, __ , ._ j .. f4 r;. c'rv*-.* __............. ... y ** ?*- .. -' TI*. y.r:.. r.' .1. Sc.up.e..r..c.v..E..'.ie..c..-. ..:. .:. . . ....... <>! -I" - . - --- T o ta l.................................................................... ' " n-' H lt 11 ' ` u ti 1ti 0! 24 (ni nX ............... ........ 3 31 * 22< -0sti 311 4DI f4 ....... 1 fit (fi <11 a1 " .<* 35 35 , In the spinning, tu i-m g . and winding department, the mule and ring spinners have a higher proportion of asbestotic persons than the average, 24.0 percent. Twenty of tbe sixty-five mule and ring Spinners had been employed more than lu year.-. A third occupation with an excessive prevalence rate for asbestosis is cloth weaving, in wliicli 25.6 percent of the workers are affected. Only 3 of the 43 workers had been employed more than 10 years. Throu.'i ,-'i- wit.h. m .* Aslfstoi wiiL. t More than of asbestos t chrysotile. in< the staiulpoin d i i s t conecnti o Briti-h pea try. no irreal tions of the fpfite nesrligib lieiv alul abro ing tubrculo? i MABfeHm u m I ^ ifii<fl~i lilillfcliawir PATHOLOGICAL FINDINGS INASBESTOSIS ; Specimens fur patlioh>gical study were furnished through the co u rtesy of Dr. J. Kush Shull, Charlotte, X. C., and Dr. H. F. Easom, director of the Division of Industrial Hygiene of the Xorth Carolina State Board of Health. The pathology of asbestosis is characterized by diffuse, interstitial, pulmonary fibrosis and by the presence of asbestosis bodies in the lungs. GROSS APPEARANCE In gr-* appearance the lungs vary in color from brownish to pale "fay. Csually. they are not distorted like silicotic or anthraco- silicotic lungs unle>s an extensive amount of long-standing fibrosis ir present. Often the limits are firm and heavy, but softer areas can Monetino-' be felt on palpation. Crepiti' depends on the amount of fibrosi'.The pleura may be thickened and fibroustags may be scattered over the surface. In the casts described in this report, thickening of the pleura and the presence of fibrous adhesions are limn- frequently found on the right lung than on the left. Adhesions to the diaphragm arc sometime? prenoit. On section. ?mall. dark gray, irregularly >haped areas are seen on the cut lung 'iirface. They arc rather evenly distributed and they aiv of approximately the same size. Visible strands of connective ti"ue of varying size run through the lung parenchyma, forming a more or le-s regular. fibrous network, and enclosing the dark gray, nodular areas and lung tissue which show alveoli. Areas of well* marked emphysema are noted in the apices and outer portions of the lower 1"!>C'. a teatuie that u a' referred to in the discussion of the X-ray finding'. The bronchi and bronchioles appear to be distended and their w.-di- aie ..;i.-n ilm-keiied In one ea~e. this hroncliiectasis is most marked in the upper lobe, particularly in the apex. Coiige'ted area' are occasionally seen on gross inspection of some of the lung section'. They are probably terminal. The hilar lymph nudes arc not markedly increased in 4ze. They are pinki'h gray and contain about the ii'ind ,m of anthracotic pigment found in a city dweller. ! ^ j ; ; r J * ! 1 | l ; ' | . MICROSCOPIC A P I-tU R lM E The pleura, when thickened, is made up of adult fibrous connective tissue cells. The collagen fibers are usually well developed and may show hyalinization. In some sections the thickened pleura is vascular, (96) . j the blood vessels g size, containing an subpieural connect i Throughout th e| is present, which v vidua). The areas and may contain s of adult ilbiov.' numerous maeroph increase in the inte rather uniformly < of considerable fibi the fibrous tissue, generally distende. The alveolar wall' hyalinization and t single layer of epit the bronchiole' nn cytic infiltration i bronchioles arc fit blood vessel' are ti ati increa'ed aim sematoiis blebs 'h linetl by a single 1 blebs, measuring studied, are appar Asbestosis bod it tissue. They occ' accompanied by a the connective tis and in the alveoli when theasln-'to'i or engulf the hotii of anthraeotic pii monly found in amount'isal?o pi. variety of shape' rounded ends. K'.'ftte formatioi n-iaii.-ii between pulmonary iibio?i fibrosis, the asbe another case, sho These bodies are sium ferroeyanid. I >SIS leil through the Dr. H. F. Easom, e Xorth Carolina ffuse, interstitial, sis bodies in the brownish to pale tie or anthraco-standing fibrosis t softer areas can >n the amount of us fairs may be <1 in this report, mis adhesions are left. Adhesions areas are seen on ributed and they ids of eonnertive hyma, forming a g the dark gray, . Areas of welier portions of the discussion of the ir to be distended bis bronchiectasis e apex. portion of some ed in size. They int of anthracotie Ibrous connective veloped anti may pleura is vascular, the blood vessels generally being small capillaries. Areas of variable size, containing anthracotie pigment, are occasionally found in the subpleural connective tissue. Throughout the parenchyma of the lung a diffuse interstitial fibrosis is present, which varies with the asbestos-dust exposure of the indi viduai. The areas of fibrous ti--ue are irregular or stellate in shape | and may contain small blood vessels. The cellular elements consist of adult fibrous tissue cells, fibroblasts, some collagen, and often numerous macrophages. The strands of fibrous tis-ue reprc-efi! an increase in the interlobular connective tissue. The fibrosis is usually rather uniformly distributed throughout the entire lung. In areas I of considerable fibrosis, atelectasis is noted due to the contraction of the fibrous tissue. The alveoli occurring between ureas of fibrosis are generally distended and show a moderate to marked emphysema. The alveolar walls are thickened by fibrous tissue, and in some sections hyalinization and the loss of nuclei occur. The alveoli are lined by a single layer of epithelial ceils. The bronchial walls and the walls of the bronchioles may be thickened, and a slight to moderate lympho cytic infiltration is present occasionally. The smaller bronchi and bronchioles are fre<|uctitiy quite distended. The walls of the small blood vessels are thickened, particularly the adventitia, which contains an increased amount of fibrous tissue. Sections through emphy sematous blebs show a fairly thick, fibrous, connective-tissue wall, lined by a single layer of flat or low cuboidal, epithelial cells. The blebs, measuring as much as 7 mm in diameter in tin* specimens studied, are apparently of bronchial origin. * Ashestosis bodies arc found in almost all parts of the pulmonary I tissue. They occur most frequently in the areas of fibrosis and are i accompanied by a greenish black pigment. They are also noted in [ the connective tissue about the small bronchi, in the alveolar walls, and in the alveoli. Macrophages and giant cells are usually present when the ashestosis bodies are found in the alveoli and often surround i or engulf the bodies. These cells also contain a considerable amount [ of anthracotie pigment, ami the dark greenish black pigment comj manly found in ashestosis. A brownish yellow pigment in lesser amounts is also present. The ashestosis bodies occur in the lungs in a [ variety of shapes. The most frequent is a headed rod with large rounded ends. Spindle shapes with beaded centers are also noted. I Rosette formation is relatively frequent. There appears to be no relation between the number of ashestosis bodies ami the amount of pulmonary fibrosis. In one case in which there is exceedingly little fibrosis, the ashestosis bodies are particularly numerous, while in j another case, showing extensive fibrosis, they are quitesinfrequent. These bodies are golden yellow in color and are stained blmlwith potnssimn ferrocyanide, showing the presence of ferric iron. With this m u gj^pr-- FIB & " _-.^ r a r " - .Afct ' Z ***' f M-`- . - ' L T- T'** sitan some fine h > asbestos fibers in * ase of polarized li which are identif bronchial connect V / 1 V- "*.- ^ *I ti . A '-I.- ,-* \ * '` A '>*. ' **^ i ,s t ! I ^ ' - ,*S r - ; ' .'4 , V SfLIC O SIS r*-\ mr* % y f, -5-^-rrv NORMAL \ %< 1 itb .X if'iiA fr aVbmTk* *.i- .*-<*.`0*. J .j.ijm A B ESTO SI5 *l.ifcrrir.li.l'-ii FIGURE 52,-PHOTOM ICROGHSiHi c c..'.G SEC--GNS s o -'.a g t h e p r e se n c e o r n o d u l a r F ib r o s i s a n d e m p h y s e m a in a S il ic o t ic Lu n g a n d D if f u s e Fib r o sis and Em ph ysem a in an a sbesto tic l u n g , a sectio n o f a Normal lu n g i s S h o w n fo r c o m p a r is o n . Ma g n ific a tio n 16X. I 1 F ig u r e 53.--a s b e s t o ; TICALLY NO Ft BROS (Ar m y m e d ic a l Mu alveolar walls, and and the asbestosis Xicol prisms. Otli The presence of demonstrate. Unit 99 stain some fine blue strands have been noted which are apparently asbestos fibers in the process of becoming asbestosis bodies. By the use of polarized light, fine fibers are often demonstrated in the tissue which are identified as asbestos. These may be seen in the peri bronchial connective tissue, the interstitial connective tissue, the 1f t ' " " - ---- - - ... ^ s- * .rw>^--;vjKr. ;*,;%,'*v*.-'t *->'iC-'i''' ''>-. *, -ri-* *' l v '^ "`/-V* 2 ,,% ' ' I ' . ' * Kt i -. - y - y v t \ , f . - ->> K*%_. ._.. . J 2E,:ts-s3'aj r j no the presence ung and Diffuse riO N OF A NORMAL Fig u r e 5 3 .--a s b e s t o s is b o d y in in t r a-alveo lar c o n n e c t iv e T i s s u e , p r a c t ic a l l y n o F ib r o s is in T h is a r e a , c a s e h -21. Ma g n if ic a t io n i .ooox. (a r m y Me d ic a l m u s e u m No . 52255.) alveolar walls, and in the alveolar spaces. The blue staining fibers ' and the asbestosis bodies are not visible when vievved with crossed Xicol prisms. Other fine crystalline material is sometimes noted, j The presence of complicating tuberculosis is often difficult to demonstrate. Unless caseation is well defined, the tubercles may mmMMM 100 resemble the developing iihrous areas of asbestosis to a marked degree. It i- not easy in many ca-os to differentiate caseation from old hyaliuized connective tissue in the stained specimens. In one of the c a - e s -tuuied. tiie pre-cnee of aeidlnst bacilli in the alveoli and connective ti--ue of the alveolar walls without the presence of easea- w m *-ri ` 9s ' A p\ ,* * * * ') 41 *4 - 1 t *! i / J t t s * f > Sr | .A. . * '- , * % *- r-# r . *' ' m - ** ,, .V -- * - %1 ' ' af it 'i % > Ik " . * .i i*-i - . J '*' F ig u r e 54 --a s b e s t o s i s b o d ie s a c c o v ; f i b r o s e d Lu n g T i s s u e . Ca s e H -2 i *. Museum n o 52255., * = A \ area oe - S M / MEDIC At. tion was observed. This could possibly he an early tuberculous infection in the preinvasive stage, or it could well be a contaminating nonpnthogenie acid-fast bacillus. Sample- of three varieties of asbesto- iehrrsotile, crocidolite, and amosite) were injected into the peritoneal cavities of guinea pigs, ttmia&bBuk using a ted mi uig the physj described else' dueed an iner basis of this re dally harmful Asbestos dust, tion. causes a clinical and p< dusts. M ale, white. :n Cattze of i/o i/A.(tCCiip-ttioonl A, plant. 1'rinr to i Ml'liflll I I'/'d hetau-e uf weaki. Pntholoqicol fl nin th ilitfn-e ir11< tniphy.-tm a. hr<>i C Of ful f i l l t f>I ft, t silica 0.1) percent percent. .-ilitn 0.7 iak rfn^ff'nui 101 dosis to a marked using a technique developed by the Public Health Service for study- tiate caseation from in i the physiiilo-.dcal behavior of dust. Tin- method has ecimens. In one of i in the alveoli and ! described eWev.here bOj. All three sample- >: a-be'to- uu-t : -- duced an inert type of reaction in the peritoneal tissue. On the e presence of oasea- s i ha-is of tins response, asbestos dust has been considered to be poten tially harmful, especially when inhaled over long periods of time. Asbestos dust, like talc (43, 44), which also produces an inert reac tion. causes a diffuse, pulmonary fibrosis as has been observed on clinical and post-mortem examination of persons exposed to these dust?. SELECTED AUTOPSY CASE REPORTS Case H-21 F iji. to > ` * *i t Male, white, aged 3S year-. 4< ` ,I .---M yocarditis, Ore ip 't! -- \ \ i i r ked for 12 years in the e a \ . : t r n an .f an a ? l -tos plant. l 'rh.r tu t .i- he l a d worked in a cotton tuilh , M f l 'cnl f i - ' i - r --Confined to lied for the an.-t part f ids last 6 m onths of life becau-e of w*'uki.i dy-pnoea. am i u n p ro d u c th e emu:.. ( Vo' o(o:i. -imwod well-defined advanced a-be-to-i.-. evidenfi ! by much dirfu-e inter-'..tial pulmonary fibrosis accompanied by a-be-to-is bodies, emphy-ema. nronchirctu-i'. and broticliiolecta-i-. ? I, ,;,n il ,,/i i ' / , 1,(1 t,\<s,n.-- Sample from riant hunt--ah 3.3 percent, .-iiica o.tj peroint. -diea in a-h IS.32 percent. Sample from left lung--a-h 3.8 percent, -lira it.70 percent, -lira in ash 20.13 percent. *% :* 1 , t 1 1V r c e l l s in an a r ea o p 705X. (ARMY MEOICAU i early tuberculous be a contaminating tile, crocidolite, and ties of guinea pigs, l|1l l P ) j i ^ 'nwwjM "mwgwHWPlWW 102 : ,, nlilWW F ig u r e 55.--Ca s e h -2 1 . Rig h t l u n g . Ma r k e d l y T h ic k e n e d p l e u r a W ith f u s io n o f in t e r l o b a r P l e u r a . De n s e F ib r o u s t a g s o v e r En t ir e Su r f a c e . Figure 56.F ib ^miiBwpiiMwitfi- , . ........ ......................................... 11i.iiwi | | p p ^ f t i \ 103 mm :n e d P leura w ith :r En t ir e S u r f a c e . i [ Fig ure 5 6 .--Ca se H -2 '. left i__sc. Pleu ra Much t h ic k e n e d F e .ver F ib r o u s a d h e s io n s t h a n .'. e r e n o t e d on t h e Rig h t l u n g . 43182- 'W it lO i \ ^er 4 i 1* i a F igure 57 - C a se h -21 S ection o p R ight Lu n g , a d v a n c e d a s b e s t o s is . D s-E -.:.?r. e s o n c h a-.d a . s = a .'e s a- Bo t h Ap e x a n d B a se D i f f u s e F IB R O S S ' H R C -..C --' L... --C. S .. ii-' A-.C E a -. 3 T H IC K E N E D PLEU RA \ Figure 5 Air S p Em p h y : M m m w ' m m m 1 1 4-iipW W i , ASBESTOS'S, j .SE. DIFFUSE ' BA. FIGURE SS.--CASE H - 2 i. SECTION OF ,1-EFT LUNG. D:5TENDEO 3 RQ \Cm AND a m SPACES AT APEX. Ra t h e r ^ fo rm cy D is t r ib u t e d F i m o u * AND Empm y s e m a t o u s Ar e a s T h r o u g h o u t Re s t o f Lu n g . | li|W W "i.ill" <411 * f. 106 Case H -23 trip.. 5 to m Mate, N egro, aged 33 years. Com o f ilutth.-- Pneum onia. Occupational history.-- Worked as cleaner and sweeper in th e card room of an asbestos p lan t for 13 years p rio r to d ea th . P reviously, roofer (asphalt*, y ea r, Esti,natal exp* arc -- hi , 35.3 million particles p e r cubic fo o t; (b.i million p article w a rs, 43S.il. FI'Hiro-rup t -- M o derate '2 --.' lag of d iaphragm right a n d le ft; first degree gri m 111t-gta-s a ppca ra iice. X-riru.-- X>Ue eliiiteratio ti of costophrenic angle on rig h t. M oderate g ra n u la r ap p earan ce right b a s e . In terp ret! d as com m encing generalized fibrosis <fig. 39). Note the definite e\ idenee of fibrosis at the right ba-e and obliteration of the right eo-tophrenie ang'e Tin- ei idenee of increased fibrosis and fibrous pleurisy i ' a l'ii shown in th e neerop~\ m aleriai fig'. 02 and 63 . .1fi licnl history.-- Influenza. P a ls d u ra tio n . 2 w eeksl. F re q u e n t colds. M edical history negative until 2 weeks before death when he developed pneu* monia. Physical txmniuntiai, -- (slender, eol,.rcd male. H eight, "OH inches. W eight, 151 p o u n d '. Long chtM ; right side slightly sm aller. E xpansion p o o r (1H inches'. M oderate dullness o w r bases on percussion. Persistent crackling rales over bases of lungs. Palpation and frem itn-, negative. Faint breath sounds o v e r bases. Blood pressure, 140 U0. Pulse ra te , 7li, SO, a n d 68. Re spiratory rate. 28, 28. and 24 (before, im m ediately after, an d 2 m inutes after exercisei. Slight transient dyspnoea im m ediately after exercise). Asbestoses liodies in sputum . U rinary 'lira . 3.3 mg per 100 ee 33 mg p er 24 hours). iiinatKist*.-- M o d erateh ad v an ced u~bestu'is stage 3 15 m o n th ' before d eath . Patl otoyisol <sunn nothin showed m oderately advanced asbestosis. A m o d erate degree "f ddl i-e puluionarv fibro-i- and em physem a was noted accom panied by many a'besto-is bodies. Acute diffuse pneum onitis wa- present. ( i . . . .m l i,-: .I t.'it ,o o< luoy tissu i.-- Sam ple from right lung-- ash 2.69 p ercen t, silica 0.44 percent, silica in ash 16.3 percent.. ' lI i r fig u r i t 1- w w p i u ^ i n | p i '!|!iyuj w i p i p w j w i i u i i y i i 'W P w i j i j i H i j i i i piA '. i w i w M g p j 't te carilroom o f a ia.-phalt >, * year, c foot; (6t million left; first degree Moderate granular i fibrosis 'fig. 59). bliteration of the id fibrous pleurisy F req u en t colds, developed pneu inches. Weight, a n d o n ix>or (1 ststent crackling e. Faint breath SO. an d fis. Rel 2 minutes after r is e 1. Asbestosis 2-1 hoursi. iths before death, sis. A m oderate accom panied by -ash 2.69 percent, F ig u r e 5 9 . - C h e s t x -R ay o f Ca se H -23 1S Mo n t h s b e f o r e Dea th i fiftVnrnhniinlir-'ii'i-' ili1ftlM*lllttill(ai 108 aiWM -A * V A4 */ V V \ . % <* * Fig u r e 6 0 .--c a s e m-2 3 . r ig h t l u n g , e n t ir e p l e u r a l S u r f a c e Co v e r e d by d ense Fibrous t a g s. figure 6t.~ Kr -- ?.,, E liuuwmim W M A `P P i s^pupip - L .jm um ' 1,i.w w r V A 109 / 1 i \ SURFACE COVERED FIGURE 6 1 .--CASE H-23. LEFT LUNG. NOTED ON very Few THE PLEURA. f in e fib r o u s tags are ""I AfMUJW MJW JJ. JiHflH,** ww . mi Ily'-w u'wwmway /` . . i{ \ f ig u r e 6 2 .--C A se m-2 3 . s e c t io n o f Rig h t l u n g , m o d e r a t e l y a d v a n c e d a sb e st o sis Fibro us area s and em physem a Uniform ly D istributed t h r o u g h o u t t h e Lu n g S u b s t a n c e j * Fig u r e 63 --c< t* .ip igp p M . > f f* , s' % 1 9 It .r a t e l y a d v a n c e d imuy Distributed f ig u r e 63.--Ca s e H-23. SECTION O_F L. EFT LUNG cS.hHoOwWs l e s s T h an Rig h t Lu n g (Fig . 6 2 i. in v o lv em en t wm wmrnmmm I|JP"|P'P .... . r* * * . i * TM ----- . ,-- 112 , f C ase H -25 IFlz? At and 65 Male, white, seed 27 years. Caiese o f d e a t h . -- Lobar pneum onia. Occupational f n'm-ij.-- Begun work at age of 16 years. B roadcloth w eaver asbestos . 1 y ear. T ruck driver. 3 m o u th -. Br<>adcinth w eaver asb esto s), 2 years. T ruck driver. 3 year.-. B roadcloth w eaver a-!>e-tos . 4 years. Weighted a ti ;u ;;. duM j /kwhii .-- 4',1.7 million particles ]-er cubic foot, o r 347.9 million particle vcar-. iftdica! h u to r, -- Pa-t history negative. Hud n.duenza. prior to death, which developed into p: eumonia. X -ra y ir a m i tar .<,>.-- Film - m ade 15 m o n th - an d 1 m o n th fie. 64' before d e a th show ed first-degree ground g la-- vvhicii w a- in terp re te d a- com m encing generalized tibro-is. Medical tram a.-- T h e principal a b n o rm a k tie . f i m d on phv-icai ex am in a tio n 15 m onths before th e d e a th of th e p a tie n t were second-degree curved nails, second-degree cvu:io-is. and decrca-ed fremitu on both the right and left side. T h e h ea rt size am ! heart -m ind- were n orm al: ido*.: pres-ure. 13d 74. On exercise tiie pnl-e ra te r - . from xx to 116 an d 2 m in u te- !at>-r had fallen to S4. T h e resp irato ry ra te n - e on exerei-e from 1 ' to 3*1 am i re tu rn ed to 22. T h e p a tie n t had a che-t girth at expiration of 37'. inche- an i a che-t expansion of 2 inches. He was a ih ick -eh e-ted m an tjx-_ mci.e- ta il w .ig n u g 1!*5 po u n d -. Fifteen month.- before d u A i thi- ca-e via- diug'.o-ed a- early a-be-to-i- stage 2 . Pathological examination -bowed early a-'oe-to-l-, A diffuse interstitial fibrosis with little em pi.y-em a and broijchmiecta-:- and n pnerou- a-bc-tosis bodies was noted. L obar ! m- : .i u.i- - ,>- *o be t: - ea of d eath Chemical txao. a of long ..* -- ir-Uii r.g n t lui.g-- a -h 2.44 percent, silica 0.21 p e rc e n t, silica in a-h 8.42 percent Sam ple from left lung-- a-h 2.44 percent, -idea 0 27 percent, -ihea in a-h 1 i . 7 percent. I fig u r e 64.- Be fo r e D G RAM S IS HMJ 113 PWWWIMIM-Wj f H 25 l roadcioth weaver iver iasbestos), 2 years. hie foot, or 347.9 >r to d e ath , which :. 64 i before death ?ncing generalized physical examinagree curved nail.-, el it and left -ide. 174, On exercise alien to S4. The 22, The patient nsion of 2 inches, pounds. Fifteen stage 2!. .nterstitial fibrosis estosis bodies was -a s h 2.44 percent, ft lung--ash 2.44 i 15 MONTHS BEFORE DEATH l MgrT g r-wav.-.......-- --***= > ~ ~' ' I !i t | ONE MONTH BEFORE DEATH '" * SURE 6 4 .-C A SE H -2 5 . CHEST X-RAYS TAKEN 15 MONTHS A befo re Death pa r t o p th e Difference betw een t h e T wo g r a m s is Due to a differ enc e in X-R ay tec h n iq ue. i t MONTH lOENTGENO- ' HWltil* 114 yigMatetf ! |V ' Grateful acknow the asbestos textile est and cooperatiot Howard F. Bru films, conducted < samples, collecte! analysis, made the materially contrib other ways. Junii tabulated the me included in this r chemical analyses tissue. i Fig u r e 6 5 .--c a s e h -2 5 . S e c t io n o f r ig h t l u n g e a r l y a s b e s t o s is U n i form Distributio n o f fibr o u s area s through out lung S ubstance. t - p i p ip jiii ui ij hii pj i,i.ii i n . p jil I \ & A ACKNOWLEDGMENTS Grateful acknowledgments are due the employers and employees of the asbestos textile plants in which this study was made for their inter est and cooperation. Howard F. Bruhach, laboratory assistant, prepared X-ray chest Sims, conducted clinical and chemical tests on urine and sputum samples, collected the atmospheric dust samples used for chemical analysis, made the photomicrographs reproduced in this bulletin, and materially contributed to the progress of this study in these and in other ways. .Junior Statistical Clerk Marjorie W. Hertford coded and tabulated the medical findings and prepared the graphs and tables included in this report. Associate Chemist F. H. Goldman made chemical analyses on samples of asbestos dust and samples of lung tissue. 115' ASBESTOSIS UN|jn g S ubstance. t Bt 1 m p mar* ------ --*fl^jln'l .Mittlirtiilii-it SUMMARY OF MEDICAL FINDINGS j A medical examination was made of eaeli employee in three asbestos textile plants employing 423 men and 118 women. These persons were much younger than the average industrial employee and they had been employed in this industry for relatively short lengths of time. Almost half of these workers had been previously employed in cotton or woolen textile mills. Only 23 persons had been em ployed in a trade in which workers are known to be exposed to inor ganic dust, and only 1 of these 23 persons had pneumoconiosis. For this reason, it is believed, asbestos-dust exposure can be held respon sible for the cases of pneumoconiosis that were found in these three factories. Asbesto-is is a form of pneumoconiosis oauseri by long-continued inhalation of asbestos dust. The primary effect of asbestos dust on the body is to set tip an interstitial, pulmonary fibrosis. This niay be seen at autopsy, anti reports on three cases appear in the patho logical section of this bulletin. This type of fibrosis may also be detected by X-ray examination of the chest. On the X-rav film the shadows cast hv this type of fibrosis resemble ground glass in appear ance and n-ually extend over the lower portions of the lung fields, frequently being heavier on the right side. I like silicosis, nodular fibrosis has not been detected in asbestos workers. As in silicosis, the chief symptoms of asbestosis are progressive dyspnoea, variable cough, substernul chest pain, decreased chest expansion, emaciation, weakness, clubbed finger tips, and curved finger nail-. Most of these symptoms seem to he tfie result of the pulmonary fib r o sis set up by inhaled ashestos dust, and the con comitant pathologic changes, such as emphysema, bronchiectasis, and hrmtchioleetasir*. which can f>e demonstrated at autopsy. The percentage of per-ons affected by asbestosis or by any one of the-e symptom- depends upon the dust exposure. In all cases the percentage of persons affected by any given sign or symptom of ashes- to s is is greater than in control groups of industrial workers who were not exposed to inorganic dust. 1 * A characteristic of asbestosis is the finding of asbestosis bodies in the lungs and in the sputum. Although it doe* not appear from these data that a finding of asbestosis bodies can he u-cd to establish a tliairno-is of asbestosis. nevertheless it is evidence of asbestos exposure. fJlfi) j I i I jt I | * | t f j J f Only three borderline ea less than 5 n bad dust exp< J million jnt in asbestos 1 engineering t complisbed t. .i.IMWPUP *PP iiiiBWiliii nm dU m ree asbestos tese persons ee and they t lengths of y employed id been emosed to inormiosis. For held responi these three | I : 1 i j ' j ng-continued istos dust on *. This may in the patliomay also be 1-ray film the ass in appearle lung fields, oosis. nodular . ! re progressive creased chest % and curved e result of the and the conichiectasis, and isy. by any one of n all cases the aptom of asbesrkers who were stosis bodies in pear from these d to establish a bestos exposure. j ' J i ? | ;i i | f 1 117 Only three eases of asbestosis, all of them diagnosed as doubtful or borderline cases, were found to be exposed to dust concentrations of less than 5 million particles per cubic foot. (These three individuals had dust exposures of about 4 million particles per cubic foot.) Above 5 million particles per cubic foot, numerous cases of well-marked asbestosis were found. It would seem that if the dust concentration in asbestos factories could be kept below 5 million particles (the engineering section of this report has shown how this may be ac complished), new cases of asbestosis probably would not appear. i a m iim m mt k Wife M j a k a n n o t a t e d b ib l io g r a p h y To facilitate reference to the papers listed in this bibliography. brief note has been appended to each citation which indicates the kind of information that may be sought for profitably. So far as possible, no information that can be gained from the title has been repeated in the annotation and consequently the length of the note is no measure of the merit of the article. In the interests of completeness, a number of papers hare been listed here which were not referred to in the text. The papers on lung cancer as a possible complication of arbet<><fe are an example. Xo cases of lung cancer were found.in this study, but it appears that it would be a profitable thing to look for whenever autopsy material is available for study. For that reason papers dealing with the subject have been included. EXC.IXEERIVG REPORTS # ' i * % > * , ' 1. A nnual r-;*->rt <>f th e chief iu-peoti.r <>f facti.ru-> a n d workshop fr E ngland a n d W a > '. H . M. S tatio n erv ():h` >\ L.:.d<.n. E n g lan d . KUO. C o n tain ' a -ection on observation* made by Dr. Collis on th e effects of expo-un- to a-be-to* d u -t on 40 w orker- in a n a.*l>estos te x tile facto ry . 2. Bloom field. .T. -f . an d .1. M. Italia Valle. T he d eterm in atio n a n d control of in d u -tria l d u st. Public H ealth B ulletin No. 217. lt*35. D iscu--e- cenerally-acccpted m ethod of d u -t q u an tificatio n a n d m eth o d s in use for controlling industrial du-t. 3. H atch. T n.'odore. and > P. C hoate. S tatistical description of th e sire prop erties of noimniform particulate substances. Jour. Franklin Inst. 207: 369-3S7. 1929. C ite s -u .-.-tira l ])aram*-tcr- f..r the calculation of to tal surface area, volume, a n d nia.-s of a given d istrib u tio n o f n ouuniform d u st particles. 4. F u lto n . W. B . P,. L H..-itz. A. Dooh-y. and ,1. L. M atth ew s. Asbe*tosfe. I'a rt I T he collection a i d com .) ms: of d u -t encountered in asbestos fabricating plants. Pennsylvania D ept. Labor and Industry Bull. 3 i. 1934. Discusses th e m easurem ent of asbestos dust and its physical properties. Engineering study of four plants. 5. H atch . Theodore, and C . B. Moke. T he m ineralogieal com position of airborne foundry dust. Jour. Ind. Hvg. IS; 91-97. 1936. A petrographic study of air-borne foundry dust according to particle size. Composition of d u st reported to vary w ith size. 6. H u rlib u t. C . S.. an d C . R . W illiams. T he m ineralogy of asbestos dust. J o u r. In d . H y g . 17: 2S9-293. 1933. Discusses the composition of settled dust sam ples obtained in factories m anufacturing asbestos textiles and other asbestos products. (118) 1 ! j } j , j 7. Page, R . T., asbestos fa " This invest the factor? abe** j.. o S. Alwens, W. 82: 1797-1 N-ray and t factory. : ffoeculent Sa. <11 Bia-i, W. fur Gewerl ' A 50-yea r-ol< tory iii>u If autopsy ti adhesion, tological e Bygdcu >4 8b. Buresch, An gungsptliel 1931. A 47-yoar-oh ment for f ami X-raj Died a- a nation rev th e ritrlit \ 9. Cooke. W. 1024 H)2.'i A 33-yea r-ol period (( An X-ray two caleari particle- ii adhesions and to a i tissue." < found. 10. D ew irtz. A. 1 Description < asfiestos c< 11- D onnelly, J. 1281. ` | ; Partial re vie on three to ehe-t plat) monary tu 12. D onnelly, J. H yg. 18: : Description i 43102--:is-- j bibliography, a cli indicates the ably. So far as :ie title has been ngth of the note s have been listed ?rs on lung cancer pie. Xo cases of that it would be terial is available the subject have rkshops for England d. 1910. Its on th e effects of .tos textile factory, mtion and control of 1935. itio n and m ethods in ition of the sizepropF ran k lin In st. 207: surface area, volume, ;t particles, it thews. Asbestosis. loitered in aaliestos 2 T ,,d i is tr v B ull. 37. physical properties, al composition of air1936. ding to particle size. jgy of asbestos dust. obtained in factories products. oft> a., iaiiMmar ,v~i . n a v iir 119 7. Pas*-. R T . a - I Bloomfield. A study of dust control m ethods in an o - - - : - .: a i P iid ie H ealth R eport* 52: 1713-1727. 1937. "T h is iiive-t.tjit.o:, included a study of atm ospheric dust concentrations in th e factory workrooms, and a study of the exhaust systems used to remove asbestos dust." a sbesto sis S. Alw ens, VY. C eber Asbestos d e r Lungeii. M tinchener m ed. TVochensehr. $2, 17*.7-1'<'<>. 1'.'35. X -ray and medical study of 35 employees of a Germ an asbestos textile factory. 22 ca-e- of a-be-tosis were found. X -ray exam ination -low ed floeculent markings but no nodulation. ga, : Biasi. W. Z ir pathuiogi-chen A natom ic d e r r.ungenushestose. Arehiv fitr G ew erliciiath. und G ew erbehyg. S: 139-155. 1937. A od-y ear-old m an em ployed 21 year- in an a - b e - t o - facto ry died of c.reulato rv insufficiency afte r -eeking treatm ent for shortne-s of breath On au to p -y ti e rie lt -ide of the heart was enlarged. There were pleural adhesion. T i e fibrosi- -een on gro~ inspection a n d confirmed >:. hi, tologicnl ex am in atio n a - m ost exten-ive in t i e lung oases, rjtindi an d B ygden 41a have rep o rted on th e asbestos!- inn lies found in t l . - ea-e. Sb. B ure-ch. A .urem arie Pncum onokonioe, B ern f-k ran k h eit und E nt-chu ligong-ptiii-i.t. D eutsche M ed. TVochensehr. 57: 1lrtu 1^1)2; 1247-1249. 1931. A 47-year-old m an, em ployed 29 years in an asbestos facto ry , sought tr e a t m ent for disabling dyspnoea, cardiac insufficiency, and cough. Clinical a n d X -ray fin d in g ' ch aracteristic of a-bctoi a re described in detail. Died a ' a r e ' ;|t of right ventricular insufficiency, Po-t-nortem exam in atio n rev ,-aled p u lm onary fibrosis, m arked h y p e rtro p h y an d d ila ta tio n of th e right ventrle';,- and little hypertrophy of t i e left ventricle. 9. C ooke. TV. E. P u lm o n ary asU stosi. Brit. M ed. .lour. 1927 , Vol. 2 : 11124-1921 1927. A 33-year-old woman em ployed in an asbestos factory over an lv y v a r period "com plained of cough, dyspnoea, ex p ecto ratio n , an d la--itude. An X -ray p late -lo w e d ex ten -iv e fibrosis, m ore m arked in t i e rigi.T lung, tw o caicareou- glands at the root of th e left lung, and two small calcareous particle.- in th e b a-e of th e left low er lobe." On a u to p sy , den-e pleural adhesions were found. "O n section the [right] lung is seen to be fibroed a n d to a large e x te n t airless, th e lung tissue being replaced by fibrous tissue." Calcareous m a-ses am i areas of caseation an d cavitation were found. 10. D ew irtz, A. P. A sbcstw arzen. Arch. f. D erm at. it. Svph. 161: 1-3. 1930. Description of the localization and the gross and histological appearances of asbestos corns. U . D onnelly, J. P u lm o n ary asbestosis. Amer. Jo u r. P u b , H ealth 23: 1275 1231. 1933. P artial review of previous observations on the disease. Includes ease reports on th ree to ta lly disabled p a tie n ts ta k e n from a series of 15 eases (4 figures-- chest p la te s i. All bu t 1 of th e 15 had a t one tim e been diagnosed p u l monary tuberculosis. 12. D onnelly. J. P u lm o n ary asbestosis: incidence a n d prognosis. Jo u r. la d . H yg. IS: 222-22,S. 19S6. D escrip tio n o f X -ray films of 131 a sb tsto s w orkers. 431*2--3------ il wUtt*CMfilHl 120 S3. E g b e rt, D . 5. P u lm o n ary asbestos!*. R ep o rt of a ease w ith necropsy 20. L ynch, K. M. findings. Anter. Rev. T uberc. 31: 23-34. 1935. i report of a ; A uto p sy rep o rt o n case described b y W. R. ?o|ier (Amor. R ev. T u b erc. 22: W hite male, 4 57I-5S4. 1930*. W hite, 30-year-old m ale em ployed as an asbestos c a rd er 13 y ears com plained o f d yspnoea a n d b lood-streaked sp u tu m . No cough. Exam ined and X -rayed on tw o occasions before d eath which i medical tree breath. Xm ottling in resu lted from cardiac failure. On a u to p sy ``diffuse fibrosis o f lungs in autopsy ext volving particularly upper lobe of right and portion of upper lobe of left; arrested tuberculosis; asbestosis bodies throughout lungs; few in tracheo bronchial lym ph nodes." 14. E lim an, P. P u lm o n ary asbesto*!,*: Its clinical, radiological, a n d patholog ical features, and associated risk of tuberculous infection. Jour. Itld. H yg. 13: 105-183. 1933. A 43-year-old m an em ployed in th e cardroom of an asbestos factory 9 years became disabled on account of dyspnoea, accom panied by dry, irritating cough an d progressive anorexia, lo*s of w eight, a n d clubbing of fingers. X -ray and clinical exam ination A t autnp-v tin* case wa* diagnosed a " ad v an ced pu lm o n ary ahc*tui. com plicated by tu b ercu lo u s pleurisy. A 31-year-old woman employed 2 vear* making asbesto* mattre*sc* became dvspnoeic, w a-ted, and cyanotic. Da d of tuberculosis. A utopsy find ings are presented. 13. F u lto n . W. B., A. Dooley. J. I.. M atth ew s, a n d R. I- H outz. A-bestOsis. P a rt 11. T h e n a tu re an d am ount ,,f d u -t en co u n tered in a-b e -to s fab ri cating plants. P art III. The effects ,.f exp. -ure to d u -t encountered in asbesto- fat'rieatii.g plant* on the health of a group of workers. Pennsyl vania D ept. Labor and Iu d u - m Bull. 42. 1935. R ep o rt of a m edical ex am ination of 69 w orker-. B ibliography of 12. 1 : I f * i | I 1 Tubercolosi 22. M cDonald. St 1927 (voi. 2 " The interstit bination of tim i." The animat origi bodies are absolution I 23. M ePlieeter*. s dust. Jour survey of 2 24. M artz. L. A 72: U -15. A*be.ti*i* cm e m p lo v e d ii 25. M erew ether. 1 1 0 9 -1 IS ; 15 A com preht iis m ineralogici papers. asbesto*!* b l(i. G lovne. S R T he m orbid anatom } a i d iii-tol,.i\ of asbe*tosi*. T ul tercie 14: 445-451; 493-497; 5r.0-.Ves. 19,33. D etailed description of pathological findings and review of literature. 17, L anza. A. J.. W. J. M cC onnell, an d J. W. Fennel. Effect* of th e inhalation of asbestos du~t on the lung* of a-besto* worker*. Public H ealth R eports 50: 1-12. 1933. R ep rin t X o. 1095. B rief d escription of th e finding* <4 an engineering a n d m edical stu d y m ade in a n a*be*to* textile p lan t. " X -ray film* were m ad e of 126 |*er.*ons."` 15. L anza. A. J . Asbesto*is. Jo u r. Amer. M ed. Assoc. 100: 305-309. 1939. Brief d escrip tio n of some of th e e a r.' o t i - * r \ a t i o n < on th e di*ea~e p a rtic u larly as seen in U nited states. Also notes on clinical picture an d roent genology. 19. L ovisetto, Domenico. P u lm o n a ry a-besto-i*. Record* of the In te rn a tio n al C onference on SilicoM* held at Jo h an n esb u rg . Aug. 13-27, 1930. Studies an d R eports, Series F T n d . H yg.., Xo. 13, pp- 509-309. A uthor's observations on worker* handling pure asbestos and asbestos mixed w ith cotton or other vegetable dust*. Conclude* th a t a t least 3 y ears of exposure required to produce pnoiimociuuosi*: direct ra tio l>etxveen q u a n tity of d u st inhaled an d pneum oconiosis. W ell-established case m ay develop in 7 to 9 years and th e disease can cause d eath after 13 years' heavy exposure. J i I i 1 , I , j . preventive i 26. M ill*. R . G. 49.5-499. 1 A 5S*year-old was adm itn fibrosis was found on mi 27. M ussa. Giova to ,sM*stOS Johaim esbui Hygri, Xo. 1 T h e X -ray sh< hilar zoiu * ency. .Som. 2x. Oliver. Tliouu Jour. 1927 Case histories one aged 48 29. Pancoast, H. study of th Amer. Phys m titiw iim w iifinNit a case w ith necrop-y Vmer. Rev. T uberc. 22: Joyed a s an asbesto-, fiood-streaked sputum, mils before d e a th which ise fibrosis of lungs m an of upper lobe of left; t lungs; few in traeheo- f | ' liological, and pa tin,logs infection. Jour. Ind. t asbestos factory 9 years panied by dry. irritating and clubbing of fingers. is case w as diagnosed as y tu b ercu lo id pleurisy." *-stos m attresses ijecatne creulosis. A utopsy fitid- t i. L. Houtz. Asbe'tosis. uitered in a.-be-tos fabrire to d u st encountered in mp of workers. Pennsyl- | rs. B ibliography of 12?. y of asliesto-i-. Tubercle re\ lew of literature. Effects of the inhalation rs. Public H ealth Rep*>rts j * g and medical study made re m ade of 12>i persons." ssoc. 1CMA; 3nS 309. 19311ons on th e disease particu clinical picture and roent- Records of the Internanesburg, Aug. 13-27. 1930. o. 13, pp- 500-309. jure asbestos and asbestos . C oncludes th a t at least "> moconiosis; d irect ra tio betoconiosis. II ell-estahlislied isease can cause death after , I ' t ; | ! i , 121 20. I.yneh, K . M., an d W . A. S m ith. P u lm o n ary asbestosis II. In clu d in g th e report of a pure case. Aiucr. Rev. T ubere. 23: 043-000. 1931. W hite m ale, 40 y ears old. em ployed a an asb esto s card er 11 years, so u g h t m edical tre a tm e n t for chest pain, ins? of w eight `23 lb.) a n d shortness of breath. X -ray exam ination on 3 occasions during a .j-year period showed m ottling in both lungs. Pied as a result of slow, cardiac failure. On autopsy extensive fibrosis, em phvsem a, an d bronchiectasis were found. T ubereulo'is was absent. ' 22. M cD onald, S tu a rt. H istology of pulm onary asbestosis. B rit, M ed. Jo u r. 1927 ivol. 2 : 102 V 102b ' 1927. ``T he in te rstitia l fibrosis i- such as m ight be expected as a re su lt.o f a com bination of a pneumoconiotic condition a n d a chronic tuberculous infec tion." The possibility th at asbestosis holies may have been of plant or anim al origin m ay 'b e e\e'. i ted. "T he hvpothe-is advanced is th a t these bodies are portions of a.-fiestos fibres in th e prose-- of alteration and absorption by hydrolysis, either by direct chemical action or by enzymes.'.' 23. M cP heeters, 8. B. A survey of a group of em piovees exposed to a-liestos dust. Jour, Ind. Hvg. is- 229-239. 193b. R eports " the re-nlts of a su rv ey of 219 >ersoiis exposed to asb esto s d u st."- 24. M artz. L. A -be-tosi- an d T u b erk u lo -e d er L ungem Z eitschr. f. T u b erk . 72: 11-13. 1933. Ashe-sheds com plicated by tuberculosis was found in a 30-\ear-old woman em ployed in an a-be.-to- factory during a 12-year period. 25. M erew other. E. R. A. A m em orandum " h asbestosis. T ubercle 13: 09-81; 109-1 [ v, 132-139. 1933. A com prehensive review- ..f B ritish studies of asbestosis. inel'idiug econom ic, minerah.glcal, atid tnedn'.il historical facts, m ain features of the disease, asiwsto-is bodies, correlations with ;st exposure, risk of tuberculosis, preventive measure-, at. 1 com pensation. ` 26. Mills. R. G, Puhnonarv ;w>--u>si> rep ..rt of a ca-e. M innesota M ed. 13: 493-499. 1930. A 3-S-year-old nuiti expose.! to a-besfos .lu st in a m ine 17 re a rs previously was a d m itte d to a Ini'p tal w here lie died of h eart block. M aik ed lung fibrosi~ was found on ant..pv. Asbe-ios fibers and asbestosis bodies were found on microscopic exam ination. 27. Mussa. Giovanni. Clinical and radiological notes on pneumoconiosis due to asbestos. Silicosis-- records of In te rn a tio n a l C onference held a t Jo h an n esb u rg , Aug. 13-27, 1930. S tudies a n d R eports, Series F iln d . H y g .', No. 13. p. -309. The X -ray shows ``a rb o rizatio n d istrib u te d b ila te ra lly in th e h ila r a n d perih ilar zones w hich in m o-t ad v an ced cases considerably reduces tra n sp a r ency. Som etim es th e re is in filtratio n o f th e bases," 2S. Oliver, T hom as. Clinical asp ects of pu lm o n ary asbestosis. B rit. M ed. Jo u r. 1927 iVol. 2*: 1029 1027. 1927. * Case histories of " two women who are the subjects of pulm onary asbestosis, one aged 48 a n d th e o th e r 39." 29. Pancoast, H. K., T. G. M iller, an d H. R. M. Landis. A roentgenologic study of th e effects of d u st inhalation upon the lungs. T rans. Assoc. Amer. Physicians 32: 97-108. 1917. s 9 wmt JWHPW MUMP -------------------- ..iiftfllffTr1*1*'* ' 122 T h e X -ra y asp ects of 137 indiv id u als exposed to organic a n d inorganic d u st a rc presented. Of th e group exposed to inorganic d u st 13 were asb esto s worker-. Shadows altuo-t invariably first appeared in the right lung ou a level w ith th e lulu- shadow. T he appearattee f th e shadow s is reported "so fte r a n d less sh arp ly defined" in asbestos w orkers. A good description is given of the three stages which the authors recognize in th e progress of pneumoconiosis. ? t On X-ray .. tuberculosi throughout is entirely obliterated cause of tl enlarged." 30. Schuster. X orah H. Pulm onary asbestosis in a dog. Jour. P ath , a n d B aet. 34. W ood, W. B. 34: 731-737- 1931. A dog kept in an asbestos factory 10 years " had suffered for tw o years from couch and dy-puoea. and for six m onths from progressive wasting. The l tuliereulosi 157-13S. .4 r . : - dyspnoea lx*eame so distressing th a t he was destro y ed ." On exandtiari**:. of th e lungs diffuse fibrosis, bronchiectasis, phagocytosis, and asliestos fibers were found, Asbestosis bodies were not found. 3rta. Seiler, H. F . an d M. II. G ilm our. A case of pu lm o n ary asbestosis. Brit. Med. Jo u r. 1931 i l : 1112-1114. 1931. A 42-year-old m an em ployed 23 y ears in an a.-l*e-t**s factory as a carder. dr>-cloth w eaver, and in the m anufacture of m illboard, sought treatm en t f.c "cough, breathlessness, loss of weight, am i lassitude. Radiographic exam ination re 'e a ie d a diffuse fine m ottling of a silicotic n atu re spread throughout both lu n g s . The patient who is th e subject of these notes ha- died, and the fact th at pathological exam ination showed th at death was .pie oleh to cardiac failure secondary to back pre-sitre resulting from th e tu a - iv e general!/* *1 fib ro sis am i irrespective of an y ad d ed infection is an additional point of inn-rest in this case." 31. Sh .'.h .1. R. Asbestosis- a roentgenologic review *>f 71 cases. Radiology 27. 279 292. I93ii. i I sought trea side of the expectorati On histolov which tul . a large qu. fibrous ti-he-toMs l*<> 33. Wood, XV. B hundred ea Of 100 a-becated a-bo liestosi,, m ca-es of a limnary m disease," Re- fits of medical exam ination of asbestos textile workers. Two autopsy n-norts. 32. S to c k . G . A. P ulm onary a s b e s to s is . Moil. Bull. V eterans' Adrn. 10: 39. G loyne. S. R pulm onary 129-129. 1933. "T he facce- v A 27-year-old man. employed 8 years as an a sU -to s carder, was adm itted to a hospital tiecause of shortness of breath and chest pain. He was under weight ami had poor chest expansion. Xo pulm onary tuberculosis present. I Ir form alin ii found to c< 37. G loyne. S. E "T lic post-m ortem diagnoses were: Pneum onia, acute lobar; ptieumocon.nsis, ail loin1 of both lungs; pleurisy, chronic, fibrinou, right, a n d chronic sputum of Describe- tec fibrinou with udhe-ions, left; interlobar, left; hypertrophy an d dilatation 38. L ynch, K. M <*f the h e a rt; appendicitis, chronic." H istological exam in atio n revealed Jour. Amei a 'l'c stn sis bo*lie- am i fibrosis. - Asla'stosis bo 33. Str.iebc. H. Bcricht ulx-r den Fall von Lungcn-asbestosis, w elcher der ? workers an Arbeit ties H err.i Prof. Roger zugrtiude liegt. X irchow 's Archiv. f. p ath - I'logische A natom ic u. Physiologic 290: 334-337. 1933. 39. Page. R. C. ! 33-year-old m an em ployed in a G erm an asbestos factory 20 years com plained <*f d y -p u o ea. bronchitis, a n d lo.-s of; weight. X -ray ex am in atio n showed Med. Sci. ; Clum ps of as! fine, ftoccuient m arkings in m iddle and lower portions of lung fields,' Died f with ad vat of heart failure, (hi autopsy, found fibrosis, em physem a, and asbestosis th e 31 case bodies. Xo signs of tuberculosis. 40. S tew art. M. J 33a, W hite, T. P. P u lm o n ary asbestosis. Trans. Med. Soc. State of Xorth C aro lin a. 1933- 239-292. 1933. pulm onary puncture ai A 43-year-old roan employed 9 years in an asbestos mill sought medical treatm ent ou account of shortness of breath, nonproductive cough, and slight loss of w eight. All sym ptom s increased in severity as tim e w ent on. t I Asliestosis b< lung with a an asbestos I HuiyjP'-jjjiPJi.'i. P fJP IJ 123 am i inorganic du-t it 15 e re asbestos 1 th e rig h t lung 01l shadows is reported A good tio-eri)<ti<,t. e in th e progress of ir. P ath, and Bart. for tw o years from isive wasting. The " On examination tosis, am i asbestos d. y asitestosis. Brit. aetory as a carder, d. sought treatm ent inJe. Radiographic icotin nature spread njeet of these note* showed that death sstire suiting from (> a d d e d infection is T cases. Radiology kors. Two autopsy V eteran s' Adiu. 10: der. was adm itted to Jain. He was utnlestulw-reulosis pre-ent. ite loi>ar; pneumoco>us, riglit, and chronic rophy and dilatation .examination revealed liestosis, weleher der j o w 's A rchiv. f. path 933. > a i years complained exam ination showed is of lung fields. Died ysetna, and asbestosis See. S tate of North s mill sought medical reductive cough, and erity as tim e went on. O n X -ray exam ination 9 years later " The lung fields are negative for 1 . tuberculosis. T he exam ination shows a m arked, widespread fibrosis / throughout both chests which reaches the periphery. The heart outline I is entirely obscured by dense fibrosis and the cardio-phrenic angles are . o b lite ra te d ." T h e exact h e a rt m easurem ents eantiot be d eterm in ed foe- i cause of th e shagginess of the h eart o utline b u t th e h eart is definitely' f enlarged." , f 34. W ood, W. B., and D. S, Page. A case of p ulm onary asbestosis: D eath from > tu berculosis tw o years a fte r first exposure to th e d u st. T ubercle 11; 1 157-158. 1930. ` A 2 t-y ear-o ld woman em ployed 15 m ouths a s a spinner in an asbestos fa c to ry sought treatm en t for "anorexia, weakness, w asting, and pain in the right side of the chest of three m onths' duration. She denied having cough or expectoration. There was no radiographic evidence of pneumoconiosis." j On histological exam ination of th e lungs, " in th e few sections exam ined in , which tubercufoits lesions were not present, the asbestos together w ith a large q u an tity of black pigm ent was generally surrounded by a little , fibrous tissue, but there was no gross fibrosis." Asbestos fibers and as bestosis bodies were found. I 35. W ood, W. B., am i S. R. Cdovue. P ulm onary a sb e sto 'is; a review of one ! h u n d re d cases. Lancet 227 <2 13x3-13x5. 1934. Of 1th) asbestos w orkers who sought m edical tre a tm e n t. 53 had uncom pli c a te d asbestosi, 21 had a -h o s to -i' with activ e tuberculosis, 9 h a d a s bestosis w ith obsolescent tuljerculosis, an d 17 were diagnosed a* d o u b tfu l cases of a'bestosis ".'septic bronchitis, broncho-pneum onia, and pul m onary tuberculosis are the commonest term inal com plications.of the disease." ASBESTOSIS B oD lE x 36. G !o \n c , S. R. T he presence of a s b e -to s is b o d ie s ip th e faeces in a case of p u lm onary fib ro sis T ubercle 12: 15x-t59, 1931. "T h e faeces were emulsified w ith four or five times their \olum e of 5 per cent j form alin in saline. The emulsion of the faeces, when centrifuged, was l found to contain a scanty num ber of asliestosi' bodies." 37. G loyne. S. R. A m ethod of stain in g th e a 'b e sto sis bodies found in the sp u tu m of asbestos w orkers. Jo u r. Ind. Hyg. 13: x5-x6. 1931. Describes techniques em ploying Prussian blue and am m onium sulfide. 38. L ynch, K . M .. a n d W. A. (Smith. Asbestosis bodies in sp u tu m a n d lung. Jo u r. Anier. Med. Assoc. 95: 659-661. 1939. Asbestosis bodies (illustrated, were recovered from the lungs of two asbestos I workers and from the sputum of four asbestos workers. : 39. Page, R. C. A stu d y of th e sp u tu m in p u lm onary asbestosis. Amer. Jo u r. ! M ed. Sei. 189: 44-55. 1935. i I C lum ps of asbestosis bodies were found in the sp u tu m of 10 asb esto s w orkers J w ith advanced asbestosis. Asbestosis bodies were found in all bu t 1 of th e 31 eases studied. { 40. S tew art, XI. J., an d A. C. H addow . D em o n stratio n of th e pecu liar bodies of pulm onary asbestosis ("asbestosis bodies"i in m aterial o b tain ed by lung j* p u n c tu re a n d in th e sp u tu m . Jo u r. P ath , an d Baet. 32. 172. ,1929. I Asbestosis bodies were found in m aterial obtained by p uncturing Ate left lung w ith a hollow needle. P atient was a 3S-year-oid woman, em ployed in | a n asb esto s facto ry 15 years, w ho h ad cough, dyspnoea, a n d loss of w eight. { fj '..... -egy . iftwmiii - i - -ffifMtthimr-ri ni i iffiiiiMHlfcM I .iii|-fTiirf~f,*MS,,aiaiai* *mek 124 41. S tew art. M . J., X . T a tte rsa ll, a n d A. C. H addow . O n th e occurrence of d u m p s of asbestosis bodies in th e sputum of asbestos workers. Jo u r. 47. M iddleton. K. I. dust. Lancet . P a th ! B act..3 5 : 737-741. 1032. Part I deals with A elum tt of a s b e - r .,- - r.,.d ,s h - f.m ud i.'. th- sp u tu m of a 31-year-oIcl ;. 31, U 'l'b`- Taet"r V. ShO Cnll|plailiel f .. ..'a. ;i; ,i :t'..,re\ta. 'Tlie rad io g rap h show ed diffuse fine trial..m through**ut the lower th ird of both lungs. Died of broncho pneum onia. On autopsy. " There was notable diffuse fibrosis of th e greater `basal portion of both lower lobes. T he non-fibrosed tissue was som ew hat em phv-einatous." A-ltestosi# bodies w ere m ost num erous in th e densely fib ro 'td area. X'o evidence of tuberculosis. 41a. Sundin*. X'., aucl A. B ygdem D er S ta u b in h a lt eiu er Aslw sfosislunge u n d die IVschaffenheit d er sogenam iten A sbe-tosiskorperebem Arehiv fiir tie.r;*epath. und Gewerbehyg. 8: 26-70. 1937, tp ia n t.ta tiv e mlcrocliemlcal analysis of aSbestO'is bodies isolated front a hum:-.: lung show ed th a t th e gel su rro u n d in g th e asbestos filler co n sisted larcX of ferric o\ide. plm -phafe, an organic substance whose ebem ieal com: . -it;..n s u g g * 't' th a t it i- a pro tein , a n d w ater. Chem ical analysis a n d i\-riiv exam ination of cores oi nsbestosis bodies in d icated th a t th e chem ical com: -it.o n of the a -U -t,,- fiber rem ained imeliauged. OIHKH PXKt'Mol ONlo-E- >> I 1 48- Russell, A. E., R health of worke in d u stry . Pul An engineering, l granite d u st on 4.' i t . I , . . 1 and tubrculos Kansas, and M Mines, Technic Results of medical in lead and d m 50. Saver.-. R. R. 8: print 1620, Di-ciission of the 51. 8ayers. R. R.. J. sen. D. k . Rru coal mi tier-. 1 Medical and engi- 42. C urtis. A. .1. H. Th> health of cem ent w orker-. In d u st. M ed. 6: 195-200. 1937 lb - h.i' f a m edical -u r w y of 201 men e.\po-ed to d u -t in a cem ent m ill. M. ' ,t:t> d a ta f.-r 31 plants. 43 [tre e * - : . IV. C. Ilffect- of certain silicate d u sts on th e lungs. Jo u r. la d . H yg 15. t,0-7,V 1933. * Tin - . cate d u -t- of treiuolite tale a n d slate induce a fine, diffuse, b ilateral du-t c\|)o -u re a 52. Thoiiip-,m . L. R.. healUi *f work cement plant. Includes an engin of respiratory : workers. film i ! the lui g- u n .c h :- definitely d em onstrable m the X -ray ." 43a. D r e e '- : . . \V. C. Effect of inhaled m arble d u -t as ob-erved in V erm ont m ;i" fi: i-her- Public H ealth Roi*ort> 49: 724-732. 1934. 52a. E gbert, D. 8.. a: Amer. Rev. Tip "A lt:." .h m arble d ;i't when inhaled in the concentrations here observed It-- m an 20 million particles per cubic foot) produces a mild bilateral, h: . ar tihr,,-i- in 15 percent of th e SO m en X -rayed] n>* -erious lu n g changes noted a n d there wa~ no d isability due to th e tlu -t, even a fte r m any year- of expo-ure." 44. D rr.......... IV. ('., an d J. M. D allaV alle. T h e effects of expo-ure to d u st in tw- i.to rg .a ta .c lnili- a i d mint's. Publ.-c H ealth R eports 50: 131-143. 1935. R eprint lt,o*t ' E m ir .. ru.g and medical -nitty of the relation between dust exposure and ncc.rrenee of pneimuiconio-i- in 66 worker. 45. D ree-- W. C., an d If. R. Jones. A nthraco-ilico-i- lo u r A m er, Me*l. I Assoc. 107: 1179-1 lj>5. 1936. . Res:;',:- of a m edical exam ination of 2,711 em ployed and 135 disabled anthracite miners. 40. H offm an, F. L- M o rtality from resp irato ry d i-ea-e- in dusty tra d e s a n o r ganic d u stsi. Bull. C. 8. Bur. Lab. S ta t. X'o: 231, p p . 170-180. 1918. Gives brief sum m aries of the effects of exposure to inorganic dusts, compiled from occupational m ortality d a ta available in 1918. j t t A 41-year-old mat treatm ent for , pain of aching witnin a few n m ade. Ri'-id-a-b e-to -i-, ther* lobe of the left 53. Cloyne, 8. R. S cases. Tufcrcl Description of ma and not recogm Cell n t- 'ts . Th, tinuous fingerlil lung where the `4. Gloyne, 8. R. < Tubercle 18: 10 Typical, cxterisivi em ployed 22R, t neoplasm about **f th e lower lob* iMw^i'wriWBW^iSaHpii MM* ittdto me O n th e occurrence .-,f bestO'* workers, putitm o f a 3 t-yCar-Mi.! >'. .She complaint-! .,f pii sh ow ed diffuse tn:.g>.' I)ied of hroiic!;.,ise fibrosis of tfie great.-r Mid tissu e w as somewLar mmerotis in the dcnM v icr A.-besto>islnnge usu! orperclien. Arciiit jvir b>.dies isi ilated fr*m a a-ftestus filter consisted fistm ice w hose chemical . Chemical analysis ami iicated tiia t the fli.-niicai nged. d u st. Med. 9: I 95-200, 1 d i|- t in a cem ent mill, n th e lunas. .h,nt. In!. J- e a fine. diifu'e, bilateral ble in tlie X -ray." as o b -er\ed m Vermont -732. 1934. ..itratnm- here ob sen ed reduces a nuid bilateral, Ij no serious bin s changes ic d u st, even a fter many ts of exposure to dust in th R eports 30: 131-143. tween dust exposure and' osis. Jo u r. Amer. Med. Jo y e d an d 133 disabled 'ses in d u sty trad es (inord, pp. irtc iso . i9is. inorganic dusts, compiled 91S. ' | 12.3 47. M iddleton, E. L. In d u strial pulm onary disease d u e to th e in h alatio n of d u st. L ancet 231: 1-9: 59-94. 1939. P a rt I d e a l' w ith lie.'-. P a rt II w ith -iltcato-is dncluding asbestosis). 4*i. Russell, A. t... K. H. B rrte n . L. L. lu o iu p - u . an : L -b P.ooiiihetd. T he h ealth of w orkers in d '.-ty trales. ft. E xpo-ure t> siliceous d u st (g ran ite industry}. Public H ealth B ulletin Xo. 1ST. 1929, An enginecra.a. mc<licui. am i statistical stu d y of th e effects of exposure to granite d u-t on workers. 49. Sayers, R. R.. F. V. M er.w ether. A. J . L anza, a n d 5V. 55 . A dam s. Silicosis a n d tuiierculosis aim ing m iners o f th e tri--ta te d istric t of O klahom a, K ansas. ani M is'otir:. I. F or th e car ended Ju n e 3b. 192s. B ureau of Mines, T echnical Pan- r .343. 1933. R esults of m edical am i r. -entgenograpiuc ex am inations of 7.722 men em ployed in lead an d zinc mine-. 50. Sayers. R. R . Siiie. print 1929. Public H ealth R ep o rts 49: 593-902. 1934. R e Discussion of th e historical, medical, and engineering aspects of silicosis. 51. Sayers, R. E ., .1. J . Bio .infield, J . M. DaHaVaile. R. R. Jones. 55'. C. Dreesen. D. k . Brundage. am i R. H. B ritten . A nthruc-- ikeosi.- am ong harl ci.ial m iners. Public H ealth B ulletin Xo 221. 1933. M edical and engineering tudy of incidence of piteuinooe.njsis in relation to d u st exposure am ..; g 2.790 a n th ra c ite min r-. 52. T hom pson. L. R.. D. K. B rundage, A. E. R u-sell. a n d J. J. Bloomfield. T h e h ealth of w orker- n. d :-tv trati*-s. I. H ealth of w orkers in a P o rtlan d cem ent p la n t. Put.;., H e a lth Bulletin No. 17t>. 19 2 '. Inclitdes an *-:mini'-rr g -tm lv of d u -t 'onri'.':"i.- in a cem ent p lan t, recordo f respiratory aihinu.t-, am i phy~:eal exam inations o! a large group of worker-. CAX'CEK AM x-tlK-T " - I - 32a. E g b ert. D . and A. I. fit iger. P ulm onary a-besto-:* a n d earcinom a. Alucr. Rev. Tuberc. 54 143-130. 1939. A 4l-year-o'id man e u .p in e d 1 ' year-a.- an a-be-to- w easer sn'.g'.t medical treatm ent for dx-pno. a, cough, and "an msidiou-. gradually increasing pain of aching character throughout the back." P atien t lo-t 40 poundwithin a few inont:.-. Before death, X -ray am i iai.ratory tests were made. Be-ide- tie characteristic pathn'ngicai am i i.i-tologicai signs of asbestosi-. there wa- a large prim ary carcinom a iH a-trated- in the lower lobe of th e left iiir.g. 33. Gloyne, S. R. Sipiam ous carcinom a of lung occurring in asbestosis: two eases. T u b ercle 17: 3-10. 1933. D escription o f m alignant lesion.-- n oted in tw o cases. T he lesions were small a n d n o t recognized in life. T hey showed prickle cel's, k eratin izatio n , and cell nests. The growths advanced along the bronchial mucosa by con tinuous fiogerlike prolongations. The grow ths were in a portion of the lung w here the a-be-tosis was quite advanced. 54. Glovr.e, ik R. O at cell carcinom a of lung occurring in asbestosis: case. T ubercle IS: 105-191. 1939. T ypical, extensive asbestosis w as found cm a u to p sy of a 59-vear-oid m an em p lo y ed 221 >y ears in th e sto rag e d e p a rtm e n t of an asbestos facto ry . A neoplasm about the size of a golf bail was found in th e peripheral portion of the lower lobe of the left lung, continuous w ith the pleura. The growth I mm W 'lW m B r* **-'' 'i w w jwwhii,W 1J iVtifoffWi fniWi Vf i r i.ijfa 12fi w ai soft. pinkish' white, and fairly ell dem arcated. It grew outw ard from a center hi a compact mass, destroying lung tissue as it progressed. 55. L ynch, K. M ,, a n d \V. A. .Smith, C arcinom a o f lu n g in asbesto-silicosls. Alt ter. Jo u r. C a n c e r 24: 5(5-64. 1935. Case report of w hite tuale, age 57, who had been cotton w eaver 22 years an d w eaver in asbestos mill a b o u t 21 years. As resu lt o f exposure, he h ad ex tensive fibrosis of mugs and pleura with em physem a, bronchiectasis, and cardiac em barrassm ent. In addition to th e diffuse fibrosis, th e authors noted form ation of hyalin fibrous nodules characteristic of silicosis. T he pulm onary cancer appeared to originate from one of the branches of the bronchus to th e rigid lower lobe, where squanum* m etaplasia of th e living epithelium wa> n t-e rv fd . T h e d u ra tio n of th e cancer could not b e speci fied. but it did tint antedate th e fibrosis, MISCELLANEOUS 56. B ritten. Hollo H.. and I,, R. Thom pson. A health study of ten thousand m ale in d u strial w. rxer. S tatistical analy*:. of surveys in ten industries. F.ibhc H ealth Huh. tm X. 162. 1626. B im m ari o f ant h r ; xunetrie a n d physiological d ata obtained in physical exam ination-, to g -lia r w ith incidence of certain physical defects. 57. tia rd n e r. I.. ( ai d I ' {.. C um m ings. S tu d *-- on experim ental pnoum onononio-i-. VI. I; .aiution of asb e-to s rlu -t: I t- effect upon p rim ary tuberculous infect.on. Jo u r. Ind. Hyg, 13: li`i xti. 97-112. 1931. `G uinea-pigs have exposed for eight hour daily for [K'rioJs a - long as two and oia-ti. - 1 years to an atmo-ph.-ro containing approxim ately th irty -fiv e mil! o-, particles per cubic fm a of a-b esto s dust (C an ad ian ctirj sot lie 1 5 tn.iTon. an d less in dium H er. R ab b its an d alb in o ra ts have likewise bee*, i-xpo-ed for shorter p e rio d - 330 days?." 5s. U iovne. S. R. T i.e pre-t nee of th e a-b esto - fibre in th e lesions of a.'!<e-tos w orkers. T ubercle 1(1: 404-407. 1929. Asbetos fibet*'. bi.t :.ot a 'b e 'to .'i' bodies, were found in asbestos Corns. 59 K ing, K. J ., a n d M Dolan. Silicosis a n d th e m etabolism of silica. C an. M ed. Assoc, Jo u r. 31: 21-26. 1934. 1'rinary silica eont>*;.t of 50 m iners a s 2.2 mg per 100 cc: of 40 stu d e n ts 1 mg p< r HU) cc - i.gie'ia> eim ens'. A nalytical procedure is described, 60. Miller. J. \V.. and R. R. Bayers. The phy siological response of peritoneal ti-siie to eerta.*. industrial and pure m ineral du~ts. Public H ealth R eports 51: 1 6 7 7 - lo s . 1936. R eprint No. 17B7. 32 ih i'ts wen ola*'.f,cd according to the reaction produced on intraperitoneal injection into gu.nea pigs. 61. M iller. W. S T he lung. C harles C. T hom as. Springfield. 111. B altim ore. 1937. pp. 55. 62. X orri-. G. W,. a n d H. H. M. Landis. Pt'-a-e> of th e chest a n d th e p rin ciples of physical diagnosis. \V, M. Baum lers C o,, P hilad elp h ia. 5th edition. 1933 63. E xtracts from th e annual report of th e Chief Inspector of Factories and Workshop. 1935. C h ap ter I I I -- H ealth. H is M ajesty 's S tationery Dept. London. o