Document 15KQrkz8dmvm10M1ve54e911X

FILE NAME State of the Art Literature SAL DATE 1931 DOC SAL013 DOCUMENT DESCRIPTION Journal Article - Asbestosis . Pacem eee Te tee r NR yk dave NN ee . pe ee a ele oe ana P*, Sed: Dat AKadn - co iol yes SAFES 927 MENT . TR Ss a . ' BSD \ Mo . os tenes . Rete SL fe. eo ret a se we a gees _ pera WGP Aan are Ner INo S OTS geneWw, ere we ee ou TP ee ae te er pmaraeay = 4 7 E ARCHIVES OF PATHOLOGY = : - 7 = = ~<] BALTIMORE 5773_EXEDBIT 5773_EXEDBIT __ fone. eee ee ee Ne a A. EMTORIAL EMTORIAL BOARD LUDVIG JAMES EWING New York S. B. WOLBACH Borlek Borlek ALFRED STENGEL Philadelphia HEKTOEN CHinage WILLIAM OPH^ LSSan Francisco W. G. MAC CALLUM Baltimore OSCAR T. SCHULTZ Evanston } $ ~ . VOLUME 12 1931 MEDICAL COLLEGE COLLEGE OF VIRGINIA VIRGINIA _ PUBLISHERS : AMERICAN MEDICAL ASSOCIATION CHICAGO ILI AeAe; eaepascRaTE WA St NAS ne wwe" 3 MGs RLY katte oye . 4 SO : ' the plasma the pro- increase in the blood ' 77 in the hepatectomized animals with simple er than a quantitative ---- - 1 liver do not appear . = In the destructive ,,regeneration prod- circulation If it is traces esent in the ~--- | _~ tissue by extirpation of this specific nutri- The formative stimuli retions or hormones --: feeding suggest that { = be kept in mind that ~=> : that cell regeneration the supply of nutritive stion of this supply hepatic homologous of hepatic cells : liver leads to some liver into grown of the liver contains a type oe : * ae ASBESTOSIS REPORT OF TWO * CASES Po . HAROLD L. STEWART M.D. _ CARL ERNEST J. BUCHER M.D. AND H. COLEMAN M.D. PHILADELPHIA pulmonary Asbestos as such was known to Pliny Charlemagne is said to have passing through table cloth made of it which was cleansed by possessed a found in Canada Italy hie. The mineral deposits of asbestos are and Rhodesia It is a silicate occurring in minerais il combina- Africa It occurs in the form of tion with iron copper calcium oradmdaigtnioensifuinmer particles are used in the fibers which can be woven In millboard and paper The manufacture of sheeting tiles asbestos for motor cars fireproof curtains increasing nemaetdtrfeosrsesbraakned lsitneianmgs packings has expanded the spinning for insulations The use of the dust in cement and plaster industry considerably increased the danger of inhalation the erection of fireproof buildings has from 500 hazardous form of the industry Its expansion in the most in 1925 and the fact that methods of manu- tons in 1880 to 330.000 tons the fine dust for new purposes facture have been introduced for utilizing of a pneumokoniosis due have contributed to the beginning appearance known as asbestosis to mitaiation of asbestosMduurrsaty * presented evidence before the Departthat he In 1906. Montague for Industrial Diseases mental Committee on Compensation in an asbestos had had under his care in 1900 a worker employed and died At the autopsy factory who developed respiratory sfyomupntodmswhich Murray attributed to extensive pulmonary fibrosis was inhalation of asbestos dust * In 1924 eighteen years later Caoke plicated by pulmonary tuberculosis He reported was the a similar case comfirst to describe the _ Submitted for publication July 17 1931 Medical College and Hospital * From the Departmem al Patlu bay Jefferson from the Martin Research Fund aided by a grant Hyg 198 1930 1. Merewether E. R. .: J. Indust Committee on Compensation for Indus- 2. Murray Montague Departmental and Index 1907. Cd 3496 p 127 trial Diseases Minutes of Evidence Appendices Report 1907 Cd 3495 p 14 1924 1024 1927 3. Cooke W. .: Brit M. J. 147 ! : . pe of te wosepe wo { te toper troent PR Piaget . ie jive trae + ee ABN 910 ARCHIVES OF PATHOLOGY an - curious bodies in the lung now known as asbestosis bodies while McDonald worked out the histologic features The latter believed that the bodies were portions of asbestos in process of alteration and absorption by hydrolysis with the passing of silica into a colloidal state and --- ~-- | ~ tsi*S later a gel Stewart and Stewart and * Haridow showed that these bodies could be found in the juices expressed from affected lungs and could be found in the sputum by digesting it with equal quantities of - - - antiformin Lynch and Smith working without knowledge of this - ~~ of demonstrated these bodies by digesting sputum with 10 per cent sodium hydroxide Gloyne proved by means of ground illumination that when the golden asbestosis body was dissolved in concentrated sulphuric acid it had a central core consisting of a minute asbestos fiber The asbestos fiber itself under ground illumination has the appear- * ance of a sharp piece of wire Fibers measuring 200 microns can pass the protective mechanism of the upper respiratory tract and enter the lung REPORT OF CASES CASE 1.-J. M. a white man entered the Jefferson Medical College Hospital on June 8 1931 in the service of Dr. Edward Klopp He complained of headache abdominal distention and eructation of acid and gas A diagnosis of chronic cholecystitis was made A cholecystectomy was performed and the patient died The history disclosed certain facts The patient had worked as a spinner in an asbestos mill ior Peritonitis relative to nine years developed asbestosis Although the atmosphere was not very dusty he wore silver dust protectors in his nostrils For five years following such employment he worked as a laborer During the t past five years he had morning cough with moderate expectoration There was no history of hemoptysis or paiinn the chest He had some dyspnea and cardiac palpitation Physical examination was unimportant with the exception that he had an emphysematous type of chest The important roentgen observations were slightly increased peribronchial markings throughout both lungs and sume calcific deposits in both root areas The cardiac shadow appeared to be normal The sputum was not examined At the postniortem examination the heart appeared normal The left lung weighed 270 Gm and the right 320 Gni They were bluish gray practically free from adhesions and crepitant throughout On section no gross pathologic lesion was demonstravie Microscopically Microscopically Microscopically Microscopically there was ao eae aie Kraar tn kamay NOTA 4. McDonald .: Brit M. J. 1025 1927 5. Stewart M. .: and Haddow A. J. Brit M. 509 1928 581 Path & Bact 172 1929 1929 Stewart 6. Lynch K. M. and Smith W. A J. A. M. A. 659 1930 7. Gloyne S. R Tubercle 404 1929 8. Wood W. B. and Gloyne S. .: Lancet 445 1930 M. ] Te van: oz co #38eetpars ae A Z 2 Bevim ARoT 2 seb -tusis bodies while e latter believed that teration and absorp- . colloidal state and showed that these : affected lungs and equal quantities of knowledge of this 10 per cent sodium id illumination that ved in concentrated ate bain Sater veiw. tion has the appearmicrons * can pass tract and enter the o- ... cps Hospital mplained of headache diagnosis of chronic Peritonitis developed relative to asbestosis mine years Although tectur in in tectur tectur in Uk mmuuttrirlil mutril . laborer During the storation There was dyspnea and cardiac exception that he had en observations were mgs and some calcific 1 to be normal The ormal The left lung gray practically free Jorwteses : grade of emphysema 429. Stewart M. J 659 1930 cS STEWART ET ASBESTOSIS 911 Some of the alveolar walls were slightly thickened A few typical asbestosis bodies were seen in the alveolar walls There were scattered small collections of brown and blackish dust free and within phagocytic cells in fibrosed areas Much of this dust and all of the asbestosis bodies stained positively for iron The liver and the spleen were not pigmented The question of the relation of pulmonary asbestosis to tuberculosis is an interesting one The fact that they are frequently associated is settled Whether tuberculosis becomes implanted on pulmonary ashestosis or whether the occupational disease lights up a quiescent lesion is a mooted question It is true that when tuberculosis occurs it is liable to be of an anomalous type Gardner and fi Cummings exposed series of guinea to attenuated tubercle bacilli anu to an atmosphere laden with asbestos dust and attenuated tubercle bacilli They found the first instance that normal guinea receiving the strain of attenuated tubercle bacilli showed tubercles in the lung and in the tracheobronchial lymph nodes comparable to the primary complex in man The lesions caseated and healed by resolution Spread of the infection with macroscopic disease in other viscera was rare On exposing guinea to attenuated tubercle bacilli and to asbestos dust 32.2 per cent of one group of animals showed some evidence of spreading tuberculosis New disease began as a local extension from primary tubercles and metastasized to areas where dust reaction had occurred The tendency to healing by fibrosis was marked Macroscopic disease in the spleen was common and occurred occasionally in the liver In another group receivhunter hunter and attenuntul ruchu pole kweilli the Ineslization af tulireles was atypical Many bacilli were seen trapped in foci of dust reaction Some produced local tubercles ; others immediately entered dilated lymph vessels and were carried to the tracheobronchial lymph nodes Tuber- culosis of these nodes sometimes occurred without involvement of the lung Early disease of the spleen and of hepatic lymph nodes occurred in the majority of cases The combined action of tubercle bacilli and asbestosis in the lung produced more fibrosis than did either agent acting independently Case 2. J. aged 52. entered a hospital in December 1928 Tu 1921 he workte it all astiestos factory for a period of about ime montis in thus lactidy lactidy no precautions were taken against inhalation of asbestos dust Exactly what his duties were was impossible to determine On admission he complained of fatigue loss of weight and a slightly productive cough Tubercle bacilli were demonstrabic in his sputum at that time On roentgen examination a cavity in the right upper portion of the chest and a fine stipping in the lower portions of the lower lung 9. Gardner L. W. and Cummings D. .: ] Indust Hyg 13:65 1931 2 oe ek rate, f ) I peas ee vee os bef oT || || || | meaty a. a en) . Loe a, 912 ARCHIVES OF PATHOLOGY fields suggesting pneumokoniosis were found There was improvement; the patient was discharged and continued under observation as an ambulatory patient In September 1930 he was admitted to the Jefferson Hospital for Diseases of the Chest in the service of Dr. B. Gordon He complained of the same symptoms as before Physical examinations revealed the following salient facts He was mark- edly emaciated The chest was emphysematous in type Expansion was much limited particularly in the right upper portion where there was lagging Over the apex of the right lung physical signs indicative of a cavity were present Over the remainder of both lungs expansion was limited tactile fremitus was increased breath sounds were roughened and somewhat exaggerated and there were numerous scattered r^les The area of cardiac dulness was within normal limits the heart sounds were distant there was a mitral murmur at the apex The abdomen appeared to be normal There were clubbing of the fingers and curving of the nails the skin was slightly cyanotic The patient left the hospital in March 1931 against medical advice somewhat improved but he returned a month later with exacerbation of all his symptoms and an acute respiratory injection His course was progressively downward bronchopneumonia developed and he died April 2 1931. At no time during his stay in Jefferson Hospital were tubercle bacilli found in his sputum There were a moderate secondary anemia a slight elevation of nonprotein nitrogen and negative results from Kahn and Wassermann tests On roentgen examination Sept. 20. 1931 there was multiple small cavitation in the right upper lobe and the interlobar pleura below it was much thickened In the lower lobe right and in the middle and lower lobes leit there was an increase in the markings that resembled a dust change normal The heart appeared At the postmortem examination the heart weighed 280 Gm and measured 13 by 8 by cm The myocardium was mottled red and yellow and appeared soit and dull There were many firm gray translucent nodules on the free margins of the mitral valve leaflets The coronaries were thickened and tortuous and con- tained atheromatous plaques The parietal pleura on both sides was thickly studded with small discrete gray pinhead nodule- firm in consisteure Simi- lar ones were present but much less frequently on the visceral pleura Over the bases of both lungs firm fibrous adhesions completely obliterated the picural cayities Between the bases of the lungs and the diaphragm these adhesions were converted into a thick tough yellow homogeneous substance having the appearance of hyaline cartilage The right lung weighed 961 Gm and the left 830 Gm The consistency of both lungs was much increased over the normal The bases were particularly firm and tough and dark brown The upper half of the right upper lobe was excavated by a large multilocular cavity The wall of this did not differ in density from that of the adjacent lung tissue giving the impression that the cavity had formed so rapidly that a limiting fibrous wall was not thrown out * The cavity measured 6 cm across and through it coursed many thrombossed blood vessels It had a foul fetid odor as of gangrene Throughout the remainder of this red f^,,ng there were patchy areas elevated muist and measuring about 1 cm in slightly above diameter In the the cut surtace gray and left lung in addition to what has already been described for it were two round nodules simul^/r in appearance one in the upper portion of the lower lobe and one in the lower portion of the upper lobe on the outer aspect near the pleura The one in the lower lobe was slightly larger measuring cm in diameter It cut with increased resistance and on section was with gray cheesy composed material of thick dense The regional strands of fibrous tissue intermingled lymph node draining this area Wai similar to this nodule There were no cavities in this lung In many tresh smears examined from these caseous areas no tubercle bacilii were found aay 9 en ray a improvement the patient ambulatory patient In ital for Diseases of the 6 the same symptoms as nt facts He was mark- Expansion was much ore was lagging Over vity were present Over fremitus was increased and there were numerous normal limits the heart the apex The abdomen ' de fingers and curving ent left the hospital in but he returned a month espiratory infection His developed and he died Soe geewe S (ee BSP condary anemia teljwoaba TOM a slight - Kahn and Wassermann multiple small cavitation . it was much thickened lobes left there was an stp The heart appeared My id measured 13 ellow and appeared soft ales un the free margins ed and tortuous and con- both sides was thickly firm in consistency Simivisceral pleura Over the site atefl site atefl die jicurai we em these adhesions were stance having the appeartim and the left 830 Gm : the normal The bases e upper half of the right The wall of this did not aving the impression that wall was not thrown out d many thrombosed blood ughout the remainder of the cut surface gray and round nodules similar in one in the lower portion The one in the lower lobe : with increased resistance Ebrous tissue intermingled e draining this area was sf. In many fresh smears ere found STEWAKI ET AL ASBESTOSIS ASBESTOSIS 913 Microscopically the parietal pleura was studded with tubercles These were composed of epithelioid cells a few lymphocytes giant cells and fibrous tissue in considerable amounts Many were hyalinized to a considerable extent Caseation necrosis was practically absent They were of the productive type with a few well formed tubercles The nodules in the by strands of fibrous pleura were examined from the large cavity left lung were large caseous areas divided up into lobules tissue Sections from them and from the tubercles in the for tubercle bacilli but none were found In sections taken in the upper lobe of the right lung there were fresh lique- ON ne a Fig 1 case 2 . small bronchiole completely filled with cellular exudate and asbestosis bodies The fine segmentation and the clubbed end in some can be ; distinctly seen X 406 faction necrosis very little polymorphonuclear and lymphocytic cell infiltration little hyperenna and a thin newly formed layer composed chiefly of young fibre- blasts The principal lesion or the Jungs was a difuss fuasis fuasis particularly markerl in the lower lobes In many places the alveolar walls were markedly thickened in others the alveoli had been completely replaced by fibrous tissue Many bronchi were inflamed and there were many areas of pneumonia present A high per- of the arteries were the seat of an obliterative endarteritis The most centage feature in the lungs was the asbestosis bodies They were present in striking walls and spaces and in the great numbers in the fibrosed areas in some alveolar rey 4 11. t4 4.3 Pe se poy teat a. h . rs PT Blecher in 3 p PETEO gti 4 Sa to = luke ae ; : 914 ARCHIVES OF PATHOLOGY smaller bronchial branches Particles of them were tragitented and were seen m phagocytic cells Mainly they lay loose in small clusters with collections of polymorphonuclear leukocytes and polyblasts about them viten completely occluding a small bronchiole or an alveolar duct They measured roughly from 10 to 200 _ microns and were golden brown They had a variety of appearances but a characteristic morphology They were seen often as a series of regular disks very much as are red blood cells in rouleaux formation Frequently a series of disks ended in a club form on one or on both ends Sometimes they were seen as long * delicate filaments ending in clubbed ends or again as short chilled forms singloer ~- double suggesting a dumbbell Occasionally single paired or coccal forms in chains were found or even sporelike aggregations They were present in the juice squeezed from the lungs They did not stain with hematoxylin or Gram's stain They did however give the prussian blue reaction for iron in varying degrees of intensity in the main rather pronounced In the areas in the left lung these asbestosis bodies were fewer in aujacent aujacent aujacent jung jung tisue tis ue tissue a ot en ... ' .... cam meeee soma caseous tuberculous number than in the sale with indictinet > co - a EN Fennell = oe ge ELIE SOD Fig 2 case Spleen An asbestosis body is lying in the center of the field One end is clubbed the other pointed X. 4 outline When these caseous areas had been stained for pressian ble reaction following the staining of them for acid bacteria carb^,l fuchsin saturated solu- tion 95 per cent alcohol deculorization with 25 per cent nitric acid Loeffler's methylene blue the asbestosis bodies stained a pale green instead of a distinct blue and their morphology was less regular but they could still be recognized In addition to the asbestosis bodies there was considerable golden and black present granular pigment in phagocytic cells Much of this gave the iron reaction the spleen the endothelial cells were funded with a fine aniorphous golden A few large and sometimes blackish dust typical asbestosis bodies were Some found of this dust Practically was extracellular every hepatic cel contained a few granules of a golden pigment Many of the Kupfer cells contained considerable quantities of light golden and blackish granules of pigment About the portal radicles it was common to see a pigment In the mucosa of the stomach there were many with fine golden pigment granules In the kidney in the capillaries of the glomeruli which were filled with few cells loaded phaeocytic cells many cells were coarse granules with filled seen of a golden and blackish pigment The lymph node draining the caseous area in . TE " rr i . ented and were seen in with collections of polycompletely occluding a sughly from 10 to 200 ppearances but a charof regular disks very uently a series of disks they were seen as long clubbed forms single or red or coccal forms in ere present in the juice toxylin or Gram's on for iron in varying the caseous tuberculous in number than in the ere pale with indistinct .1 contur of the field ar pressian blue reaction - l fuchsin saturated soluent nitric acid Loeffler's reen instead of a distinct could still be recognized e golden and black his gave the iron reaction ed with a fine amorphous is dust was extracellular Many of the Kupffer cells and blackish granules of se few cells loaded with any phagocytic cells filled ey many cells were seen with coarse granules of a aining the caseous area in Pr se mee STEWART ET AL ASBESTOSIS 915 the left lung contained a caseous tuberculous area similar to the one described in well healed tubercles All bronchial nodes were ihat lung and in addition many in the form of fine brown and deeply pigmented and fibrotic The pigment was for black granules mainly within phagocytic cells and a great deal of it stamira iron A few asbestosis bodies were present COMMENT COMMENT The two cases cited illustrate nicely the extremes and some of the features of the disease In the first case as far as the patient's health and life were concerned the presence of pulmonary asbestosis in the lung was relatively unimportant He had symptoms doubtfully attrib- utable to it It was only through the history which was confirmed by examination that the possibility of such a condition was postmortem out two considerations in suggested It is however important to point the asbestosis had anything to this case First it is a question whether do with his emphysema and cough As an etiologic factor the asbestosis cannot be ignored The other point is that one has to do with preventiv preventiv medicine The exposure was for nine year in a comparatively well ventilated factory in which precautionary appliances were used and yet the patient developed a minor grade of the dinistehaisseoccItupwaotuiolnd tsoeeom bvithaatte further precautionary means are necessary pneumokoniosis a disease in itself so preventable asbestos factory for In the second case the patient worked in an short time but without a mask This was long enough t^ permit his lungs to become densely filled with the dust Obviously the symptoms due to the marked did not result from the asbestos per se but were from the deposition of the pigment This demon- fibrosis resulting on after of a may come years strates that the symptoms the absolute necessity for wear- & short exposure and emphasizes again ing masks in even the less dusty atmospheres The marked fibrosis of the pleura particularly of that interposed base of the lung and the diaphragm is characteristic The between the unusual either but finding of rapidly liquefying areas in the lung is not of such an extensive freshly excavated area is the presence large tuberculous lesions in We have been able to demonstrate two beneath the pleura tuberculosis of the regional lymph the midlung just The analogy between parietal nodes and tuberculosis of the pleura this form of lesion and that of the tuberculosis of childhood is to say the least striking Gardner and Cummings have shown the course of inoculati 1 asbestos inhalation with comcident tubercuions ner in a personal communication to us replied in the negative to our work had been done experimental question as to whether or not any a healed primary focus It on the influence of asbestos inhalation on on the subject for it does not appear seems to us this would throw light that the asbestosis and the tuberculosis were coincidental lesions trad ee 4 a4 ens ? o* tt ar . et] Feds ang. pega ihe STE yee eRTE pe ce ce 916 ARCHIVES OF PATHOLOGY Our second case confirms previous observations that the asbestosis bodies have a tendency to disappear in a caseous area We have also shown that in such an area following an acid stain 25 per cent nitric acid the bodies do not stain so well for definite morphology but are still recognizable as iron and have a less such so that if these are present in the sputum in any case they should be recognized on a routine smear even after it has been treated with acid The finding of tubercle bacilli in the sputum in the second case on two different occasions plus the gross and microscopic features charac- teristic of tuberculosis is sufficient to establish such a diagnosis It is significant however that many more specimens of sputums were exam- ined for fast bacilli in which none were found and that no one note the solestasis hodies in the sputum although these were not being looked for specifically An important additional finding in case 2 was that of asbestosis bodies in the spleen Although we have diligently searched the literature mention of such a finding to our knowledge never previously has been made Whether these bodies get there by the blood stream as emboli or whether they are carried there by phagocytic cells we are not prepared to say and have no evidence on which to base a conclusion The fact that they are in that organ irrespective of how they got there seems to be significant It is interesting that neither in case 1 nor in case 2 despite the marked pulmonary fibrosis and the thickening of the smaller pulmonary arteries was there any dilatation or hypertrophy of the heart on either siden SUMMARY Two cases of pulmonary asbestosis are reported In the first case the symptoms were relatively unimportant In the second case the dis- case was concomitant with tuberculosis and with it was the cause of death The similarity between some of the features of tuberculosis in childhood and tuberculosis complicated by asbestosis is suggested In asbestosis the lung is not the only organ invaded by asbestosis bodies As we have shown the spleen and the lymph nodes niay harbor large asbestosis bodies From the historine dioen annears to be further need for study alring the lines of prevention of this disease