Document 3JKwJB0j3yeqrB3Yn48KZ5Yy0

FILE NAME Brakes BRK DATE 1940 DOC BRK007 DOCUMENT DESCRIPTION Journal Article - Clinical Studies in Asbestosis American Review of Tuberculosis _ TUBERCULOSIS OFFICIAL JOURNAL THE AMERICAN TRUDEAUOFSOCIETY pa ;a i EDITOR vee MAX PINNER New York City EDITOR EMERITUS ALLEN ALLEN KRAUSE Baltimore Maryland 7s . zs Oklahoma JOHN ALEXANDER ALEXANDER EDITORIAL BOARD J. JOHN Arbor Mich BRUCE J. ALEXANDER AMBERSON New York City BURNS AMBERSON Lake N. L. H. GARDNER Lake Y. U. GOLDEN York City N.Y. H. E. BALDWIN Denver Denver ROSS GOLDEN LONG Philadelphia F. H. CORPER DOLLEY Angeles Calif - ~ ESMOND MOORMAN MOORMAN Philadelphia ; > D. RICHARDS RICHARDS JR Nae eNwew YJo. C rkiCit ty y Oklahoma City Pa. ; VOLUME XLI JANUARY 1940 ~ PUBLISHED AVENUES AT AT THE NATIONAL NATIONAL " Auto BY BY NATIONAL TUBERCULOSIS ASSOCIATION ASSOCIATION CLINICAL STUDIES IN ASBESTOSISI MOSES J. STONE Among the newer diseases which are a byproduct of our industrial age asbestosis has come to occupy a fairly prominent position The diagnosis of this form of pneumonoconiosis its clinical course the effect it produces on organs other than the lungs as well as its various complications and sequelae are still very much in thecontroversial stage The marked development in the industrial use of asbestos has resulted in an increase in the number of people exposed to this occupational hazard This together with the greater interest developed by medical men and legislature boardsin industrial disease has produced a great impetus in the study of this subject The literature on this subject is still rather exposure meagre only recently has the hazardous nature of to * asbestos dust been recognized and studied Asbestosis a hydrated magnesium silicate the composition of which varies with the sections from which it is mined Most of the asbestos used in the United States is Canadian crysotile containing approximately - 43 per cent magnesium 13 per cent water and traces of iron and nickel To be sure asbestos is not a new mineral Known to the Romans who mined it from the Alps and from the more remote Urals the mineral Pliny was mentionedin the writing of Herodotus and the second Polo spoke of its use by the Tartars Marco - Only within the last decade has the subject of asbestosis really re- ceived the attention of the medical world Prior to 1924 there is but one recorded case of disease due to the inhalation of asbestos dust . - This was recorded in 1900 by Montague Murray in the Charing Cross + Hospital Gazette The first complete description of this disease entity - appeared in 1927 when Cooke 1 and McDonald 2 reported 2 cases of asbestosis and discussed the histological changes found in the lung Hoffman 3 was the first American to focus attention on the magnitude of the asbestosis problem in the United States In 1930 Mills 4 Presented at a session of the Clinical Section at the 35th annual meeting of the National Tuberculosis Association Boston Massachusetts June 28 1939 * 520 Beacon Street Boston Massachusetts Es ~ - 12 offered the sai bodies bodies the as taining ordinar with p mented pears h asbesto to be p the pre thicken and pe oblitera pulmon . thromb thicken - others I cytes ar tubercu lumina amorph scattere the fibr bronchi events fibres in sarily of tissue re Since and pub the actio to infect stains bodies interesting ature of asbestosis is finding finding interesting interesting feature feature of asbestosis asbestosis bodies interesting lung well as asbestosis finding bodies asbestosis in the sputum Gloyne as a core asbestos fibre fibre taining deposits golden yellow ordinary histological yellow brilliant brilliant with potassium becomes ferrocyanide ferrocyanide becomes slender slender elongated | mented structures bodies The substance the body seg- pears homogeneous with bulbous ends centre linear ap- the homogeneous thickening which except features centre the the the to asbestos fibre The essential features with pathological changes appear a to pleurisy pleurisy fibrosis contraction the lungs lungs and ~._ ., presence and the asbestosis bodies pleura is found with Uniform visceral The fibrosis varying degrees pleural pleural pericardial pericardial thickening fibrous tissue extends into the apices The obliterating bronchioles layers are surrounding the show pulmonary endarteries surrounded by fibrous tissue and interlobar and tissue show ~ thrombosis thrombosis thickened thickened others others may Essentially bronchopneumonia bronchopneumonia lobar events events Lynch 6 Gloyne Gloyne 7 indicative that fibres fibres fibres the mouth indicative exposure sarily sarily disease and nose indicative of asbestosis bodies Essentially bodies indicates tissue tissue response to presence presence asbestosis bodies indicates ~ tissue Since 1930 much has and and public written view Many controversial controversial points points the the action health points of lung relationship such asbestos asbestos dust tuberculosis tuberculosis the relationship asbestosis asbestosis to infections especially remain demand demand effect on circula- tory tory system etc. based remain study the attention attention of investigators investigators This This report report patients patients were examined Me In collaboration with the late Dr. John Hawes collaboration collaboration 2nd The with the Dr. John B. patients Hawes, 2nd. The patients ASBESTOSIS the carding had been employed for three years or more in a factory manufacturing asbestos brake lining for automobiles and worked in or weaving rooms spinning Many of them were engaged in the moremore dangerous work of crushing the crude asbestos The great majority of them had been employed from five to fifteen years years and many had worked for more than twenty years The cases came to our attention through disability claims and were given complete physical examinations the years of 1936 and 1937. during None were employed in asbestos factories at the time or since their medical examinations CLASSIFICATION Of the 180 patients 32 were diagnosed as negative although they claimed disability ray film as well as physical signs failed to show any abnormalities that could be ascribed to asbestosis The 148 patients were classified as follows remaining > Stage 78 patients Stage 54 patients Stage III patients A patient was classified as stage I when there was definite limitation chest expansion less than 2 inches in addition of dence of increased to roentgenological evi- this lung markings It must be admitted that frequently interpretation must be somewhat arbitrary as it is often difficult to draw the line between normal and quite Unlike silicosis the exaggerated lung markings after early fibrotic changes are very indefinite and only considerable experience careful standardized ray technique and proper history can a diagnosis of early asbestosis be made and even then not with any degree of certainty In stage II were included those FIG 1. Stage I. Patient worked for four asbestos lining Two years prior to strength also some cough and expectoration There was only . FIG 2. Stage II Patient worked for thirteen turing asbestos lining years as an inspector in a plant manufacHe has had dry cough for seven years which has continued on about the same also dyspnoea on the slightest exertion FIG 3. Stage III Patient has been exposed to asbestos dust for a has marked dyspnoea and has to sit twenty years He up on a stool at side of bed and sleeps in that position Unable to lie down Chest expansion one inch FIG 4. Asbestosis bodies found in the lungs of patientpatient who died of Note the various sizes and shapes of these bodies as seen with the lopwup lmo onw are y r tuberculosis : FIG 5. Asbestosis body HighHigh power magnification . FIG 6. Another view of the asbestosis bodies high power 4 16 MOSES J. STONE ~ patients who had definite symptoms and whose ray films revealed definite evidence of pulmonary fibrosis In stage III were included those patients who had both definite symptoms as well as pulmonary roentgenologi- _ cal evidence of marked : involvement : LENGTH OF EXPOSURE Number of Cases - 7597 Expoof s Exu por sue re .,,& orless 25 14 years and over RELATIONSHIP OF LENGTH OF EXPOSURE TO PATHOLOGICAL CHANGESIN less Of the 47 patients who were exposed four years or 25 showed no a | definite pathological changes 14 were classified as stage I and 8 as ' stage II Fifty patients worked four to nine years Of these 36 cases were classified as stage I 12 were considered as stage II or fairly marked asbestosis and 8 were found to be suffering from advanced or .... stage III asbestosis Of the 40 patients who were exposed to fifteen _ years 14 were classified as stage I 20 stage II and 6 stage III Twenty patients were exposed for over fifteen years Of these 9 showed the early pulmonary changes of stage I 14 were classified as - stage II and 2 stage III The average length of exposure of the stage.. I patients was eight years stage II ten years stage III eleven years to While thereis but slight evidence that the degree of fibrosisis apt - increase with the length of exposure there are other factors such as intercurrent infections and other constitutional factors that play apart in the development of fibrotic changesin the lung structures Loe Since all patients were seeking compensation on account of disability many of the complaints were undoubtedly exaggerated On careful questioning however one could evaluate the symptoms fairly accurately The outstanding symptom in all the patients was dyspnoea Many also complained of tightness in the chest Of the 54 patients in stage II 32 complained of dyspnoea on slight exertion tightness in the chest cela cough and general fatigue In addition to the above symptoms 10 pa- hithaded det tients also complained of marked loss of weight All of the 16 patients in stage III complained of dyspnoea inability for any sustained effort dit cough expectoration tightness in the chest anorexia and loss of weight ini be rausdveited i we. le ide caled uded ES IN ed no 8 as se 36 ed or ifteen e III ese 9 ed as stage years apt to ich as a part bility careful cately y also .ge II chest 10 paatients effort veight aL a seamsr myaie e ga ASBESTOSIS - PHYSICAL EXAMINATION Bo a ingThe chest findings were mainly those of basal fibrosis with accompany- emphysema at the apices On the whole physical findings were quite meagre and were not in proportion to the symptoms given by ~ patients The outstanding physical sign was diminution of chest ex- pansion Many cases showed evidence of dulness at the bases with hyperresonance near apices In the majority of cases auscultation disclosed prolongation of the expiratory phase with some pitched edvriydcernaccekolfinagsrso^cilaetsedMobriosntchri^tilessw or erberofnocuhnidecotnalsyiwshen there was definite - RAY EXAMINATION ray examination constitutes the most important single procedure in the diagnosis of asbestosis Those who have examined many cases of -._ silicosis will find the ray interpretation of asbestosis extremely diffi- cult Early ray diagnosis of asbestosis is still in the realm of conjec- ture and should be undertaken only those who have had the tunity to examine many such cases oppor- oo ot In the early stages there is only a slight relative increase in density in ~~ " the lower zones producing a filmy hazy appearance of the bases The | shadows are much finer lighter and have a granular appearance rather than the nodular or patchy type of infiltration found in silicosis apparently small amount of lung involvementinvolvement in the early stages maTkhees the ray evaluation rather difficult As the disease progresses signs in- in dicative of stage II are seen There is an increase in density the lower . lung zones the diaphragm becomes indistinct in outline and shows on ; roentgenoscopic examination limitation of motion The costophrenic angle is obliterated by thickened pleura _ fine lace network of ~~ A fibrosis of interstitial or perivascular form rather than a definitely parenchymatous seen The characteristic chest ray film shows granular or ground appearance with more or less obliteration of - the usual linear pulmonic markings This is localized in most cases in the midlung region and bases The bronchovascular markings are in- creased and often pericardial and pleural thickenings are noted Many cases in our series showed elevation of the diaphragm In stage III because of the frequently associated bronchitis and bronchiectasis the parenchymatous changes become more marked ae an _ a . mos * oe sha Kent MOSES J. STONE TUBERCULOSIS IN ASBESTOS WORKERS ge The still debatable question of the relationship between asbestosis and tuberculosis has been discussed by numerous authors This study was di dis ; mainly undertaken to determine the incidence of tuberculosis 7sbestosis workers Since among a many patients do develop pulmonary fibrosis their resistance to pulmonary infections is greatly decreased Most of the English investigators among them Stewart 9 found marked in- "_ crease of tuberculosis infection among asbestos workers He states that in there can be no question that pulmonary asbestosis predisposes to tuberculous infection of the lungs His opinion is also held by Ellman 10 who found an increasing incidence of tuberculosis persons exposed to asbestos dust Donnelly 11 refutes these above statements and finds no definite relationship between asbestosis and tuberculosis In fact Merewether and Price 12 finding only 3 cases of tuberculosis among 374 cases of asbestosis indicated that a lessened susceptibility to tuberculosis existed in such cases - ye, Out of 180 films taken in our series of cases 9 showed evidence of parenchymatous tuberculous infection two of this group had active tuberculosis and 7 showed inactive or healed lesions In our series of asbestosis stage 16 cases of advanced asbestosis only one had active tuberculosis . other active case of tuberculosis had only moderate " One II - Of those patients who had inactive disease 5 had moderately advanced ~ -- _ asbestosis stage II and all had been exposed to asbestos dust for more than ten years Thus we are not impressed with tuberculosis as being / serious complication of asbestosis We find that bronchitis bronchiec- _ tasis and bronchopneumonia are more frequently associated with asbes- . tosis than is tuberculosis _ Indeed we feel that because of the frequency of tuberculosis in silicosis many patients with bronchitis or low grade bronchopneumonia were erroneously diagnosed as being tuberculous => ~ Only one person in our total series has subsequently developed active pulmonary tuberculosis OT = oe HEART STUDIES -- One hundred and fifty patients were studied to ascertain the cardiac involvement if any in cases of asbestosis Heart measurements were - done by Dr. George Levene of the Massachusetts Memorial Hospitals Ninety of the 150 patients studied or 60 per cent showed prominent pulmonary vessels This prominence was apparently either due to en* ethen Ran Ai sis and dy was among ibrosis .lost of ked ines that oses to Ellman xposed ts and is In culosis ility to ace of active ries of . One ge II vanced r more - being chiecasbesuency grade ulous active ardiac ; were pitals inent to en- alt sey aa gN. Ron 3 wears: ASBESTOSIS 19 gorgement or perivascular fibrosis The transverse diameter was increased in 50 cases or 33 per cent after cases or 8 per cent of our total series had sided hypertrophy A study was then carried out to determine the heart findings classified as moderately advanced stage II and asbestosis Of these 56 advanced stage III the pulmonary vessels 2ca5seosr 3454 oprer62cepnetr cent showed prominence of transverse diameter 7 cases of the latter of associated heart group were excluded because cent the disease In the remaining 18 patients or 32 enlargement of the transverse diameter per asbestosis was associated with , cardium the pleura of the lower The pleuroperi- om lung fields and the diaphragmatic domes hypertension mended to clarify the diagnosis The diagnosis any stage of asbestosis roentgenographic appearance of " accentuated by passive associated with heart disease may be greatly congestion As a result of our geroscopic examination is studies roent- the heart shadow recommended recommended to determine enlargement of and alterations in the cardiac silhouette special importance in cases of asbestosis associated with This is of . mitral stenosis and cor pulmonale It is cardiac embarrassment is of importance our belief therefore that utmost early symptoms It is evident that the disease is of cardiac dyspnoea noted early in this or circulatory rather than of pulmonary origin FOLLOW STUDIES 4 ~ We had an two to three yeoaprpsoarfttuenritthyeitrofirrest^xamine13 patients of this group from examination Two of this a group were = ea 3 a , 20 MOSES J. STONE originally classified as stage III 8 as stage II and 3 stage These patients were carefully studied in The Clinic for Cardiac Research of the Massachusetts Memorial Hospitals by Drs George Levene William Duncan Reid and Maurice A. Lesser The vital capacity was affected in all cases being from 50 to 75 per cent below the normal calculated on the basis of height and weight ray examination revealed definite progression of fibrosis in the two cases that were originally classified as . stage III Two patients had evidence of old coronary disease This was corroborated both by the ray as well as electrocardiographic examination The electrocardiograms of the remaining patients were exception entirely normal Sedimentation rates were normal with the of the two with coronary disease which showed an increased rate Ourimpressiongained from the study of this small group is that in _ advanced fibrosis due to asbestosis the disease will progress after exposure ceases This howeveris not the case in the earlier stages We also feel that the heartis not affected unless pulmonary fibrosisis marked In the light of the blood studies fibrosis is the result of irrita- tion due to asbestos fibres and is not the result of infection Since the entire group was first examined 18 patients have died cause of death was given as follows The Bronchopneumonia ... 0.0... cece cee ce cw ence ee eee me cceeneecce aces cases _ Lobar pneumonia ene ~, Carcinoma eee c ccc eee sence eee cnet encceecsccncecmnccee + Cerebral shock weet eee e cece cee ce een cree ceeeremesetemmncene 0s... ween cece cee e eee es seer ewwens ce cc cues see Fete e ele ed ee essere ener ence ceteecwernm seen eceececeeeeee cases cases 2 cases I case 2 cases case Most of the patients are still able to pursue againful occupation although ws unable to perform duties that demand much physical exertion Seven- ' teen patients are invalids most of them complaining cough dyspnoea . oe, marked fo = co CONCLUSIONS of Le and Asbestosis hazard 1. like silicosis constitutes an occupational : arising from exposure to asbestos dust pulmonary and thickened 2. Pathological findings are those of pleura most marked at both bases fibrosis early 3. Dyspnoea isis an early symptom the andis chief cause of | disability ASBESTOSIS 5 4. ray findings are not characteristic in early stages In advanced asbestosis ray reveals lace interstitial fibrosis and thickened pleura at the bases giving the ground appearance 5. Bronchial and bronchopulmonary infections are common comm- plications 6. Tuberculosis is not a frequent concomitant of asbestosis leads ventricular 7. Advanced asbestosis not infrequently hypertrophy and failure to right 8. degree of foricnedvolvement rigidly em- 9. When exposure ceases fibrosis does not progress unless the is already marked All health laws relating to dusty occupations should be in in all asbestos factories ; em- compensation exposure 10. Workers developing pulmonary fibrosisin the course of to asbestos dust should be entitled to William Reid A. am deeply indebted to Drs George Levene D. Maurice Lesser of the Clinic for Cardiac Research of the Massachusetts Memorial Hospitals and to Dr. Lois C. co^peration Miller of the Department of Radiology for their me in preparation of this paper and valuable assistance given REFERENCES 1 COOKE W. Pulmonary asbestosis Brit M. J. 1927 2 1024 2 MCDONALD .: Histology of pulmonary asbestosis Ibid 1927 2 1025 dusty 3 HOFFMAN F. Mortality from respiratory diseases in Dusts U. Bur Lab Stat Bull 231 1918 trades Inorganic Minnesota Med 4 MILLS R. Pulmonary asbestosis Report of a case J. 1930 13 4995 5 LYNCH K. M. AND SMITH W. A Asbestosis bodiesin sputum and lung J. A M. A 1930 95 659 fibre workers 6 LYNCHK. M Pulmonary asbestosis Ibid 1936 109 1974 7 GLOYNE S. R The presence of asbestos cle 1929 10 404 in the lesions ofasbestos T Tuber- with pulmonary 8 GLOYNE S. .: Reaction of tissues to asbestos fibre asbestosis Ibid 1930 11 151 reference to 9 STEWART M. .: Liverpool Med J. 1933 41 par2t 142 10 ELLMAN P J. Indust Hyg 1933 15 165 11 DONNELLY .: Ibid 1936 18 222 12 MEREWETHER AND PRICE H. M. Stationery Office London 1930