Document 70Kx5dem0Q228NgDjpk981B2V

pE g^l'lg II I'ln'inmujiwi,,,, ,..,. ,M V f Is I I '.! ,1 | > 1:1 , ; ; i tr . I?.. 51 HI m ,M O H A T A SBESTO SIS ' A fe p rt o f Cm. n d a Bmlm* . WILLARDS SOPER T his case is presented because apparently it is definitely one of puhioaw y asbestosis, condition th at would appear to be mud more wide spread than a t presentsuspected tmd regarding which b a t little haa as yet appeared in American medical literature. Only very recently has inter est howl am used, stim ulated particularly by a number o! articles and studies in the m edical p u ss or England. Ju st as certain other dusts took their toll over along period before the medical profession awoke to Cast Report Mr. K . a man of 30 years, was admitted to the WHSara Wirt Winchester H ospital on May 26,1929, on account of symptoms suggesting pulmonary tuberculosis. The family history was completely negative for tuberculosis. The patient had been weB and strong as a boy; he had the usual childhood diseases and tft&er frequent head colds. A t the age of ten years he suffered for a short time from a s ailment diagnosed malaria, and recovered completely. He had an attack of tenting micturition associated with haematuria about five years btdore admission. For the Jailer trouble he wascystoscoped withouta diagne k**hg mate* The urinary symptoms then ceased ctrtirdy, never to recur H e began w orkm an asbestos Jaeto.y a t the age of 17 and continued In the industry with mere orlessconslftntexposureto the dustfrom then on. The raset ofthe presentillness wasin the faflof 1923with dyspnoea. Some aals^te was also noted. 5 c continued a t work until Frbruary, 1929, having l t seven pounds In the interim. In Februaty, following exposure to smoke In a factory fire, the sputum became blood-streaked and continued so off and 00 aP to adorisston, although there was never any frank haemoptysis. On account of these symptoms the patient gave up his work in February and continued under his physician's care, with the dyspnoea rather increasing, to a a s e s S & a la the chest. < Oo admission to the hospital ih symptoms were a Ile whitish morning iraKnm atiHni mm A. tK . .m _j u _j _ i,, .i_a __i._... .... . paia over th M e cheei, qidte a cxcrtioBi nervotieaeo; IreitahBity ano coneupauon ot .arte m onti' standing. H b b t mghl wasstated to bave been 150 pana*, a n si a 142 to 14$; toe admiaetott wcfeht was 142 pounds. 11 sputum had been examined for tubercleto talion vera!oceaslonebetween February 1 peiieat was fairly well nourished, a little pale peeeoare. He did not took psrticuUrly B. Tlie ------------- --- ~ v . left pupB was slightly larger than On right but reactions were nonaal. Several M b acre missing and too that remained tonsils were a H a luge and a vety fear small cervical lymph nodes were la st palpatila along the margin of toe left trapalila. The thorax was welt to n ed The measured exparwion a tti* nipple Bee was 5 em. The heart was in i ` no abnormalities were noted except a a% ht arrhythmia. a Buie todness ataeo both chwddcs and*a practically normtdnotc otoerwim over the anterior chest. Ihraferhiily there was a Bttledulness over both tope down to the ito dotsslspine and more merited on toe right. The notea t the bases n bypem sonant Brcatofag was broncbovesicukr o c a toe i p t Oilid on boto side. There wet a few dry crackling superficial riles a t both bases about toe wholectoanfercace of the chest. There were alto occasbaal idles of toe same sort acaueted o*et toe whoto ol bo longs, bat definitely The abdomen was normal. Ihcre we no lymph-node enlargements except as noted above. The genitaBa were normal. Reilcxa were normal. H ie fingers allowed no dabbing. The bonds, however, were interesting In that toeee was on toe tig h thand between too thumb and the S a t finger s fibrous most th o A eo l the rod of one's litrlc finger, an outgrowto o l toe skin. This was faltfy sea in consistence, shout that ol a fibroma; It was non-tender and was said to have resulted tram a sliver of asbestos penetrating toe skin. Also two of toe agi towed what were called asbestos eonts, namely, a n a l hard areaseatoaboutam fflim ctrc in diameter and said also to have been d long standing and toe result of esbmlos slivers. Aotondery: 11 blood count showed 4,000,000 red cells with 75 per cent haemoglobin, white cefls 6,250, with a differential of polymorphonuclcars 08 per cent, lymphocytes 22 per cent, huge monomictears E per cent, codnophltes 2 per cent, Ih c urfoe was normal and the Wasscrmenn negative. Ten ^ r^ewwy#* i Viii.^ w if! ^ " `e ^ ' Z ASBESTOS ^ * ' m antiformin . - ' , 7 V 5lri,!i"* fra|W ' of the toms was a rather .Ufiusc fine t v n of shadowing ,hal * rattw *w toed over toe lower t W M * J Z f , ;! p r :*5' 3 & & sh : j '? rs m t'r tbi.. 1. X-Ray of i.esT.,. PwunmxY AsnermwiH, May 26, 1020 tong. The trachea was drawn a Mule l,, the right opposite the elaviHe- , f, *. diaphragm aj|>carotJ aimvwlwu hq^ver limn the left tol 1 a -> sta to.w blending b ,, ,, the h Z cl I above, ewtttauous a t toe lateral margin with a s h a d o w ^ * filled tto u '" V m - : f-':''-* 'a v i.-`'r i' V '? H "S ts;,, : l m m ft1 tf j W M ifiM li * .j * ; ^ * CMttSlfen ta r i o r e r ta toft draptoegm but r i m r e ta r g n a ri ita to * m cl r^ g g rito * ttW p leu risy . ^ to w H ^ o a U ^ ^ h B a m u riw th toward ita b u a and itong ih rid ttosegfo ofilio heart where. to quote Burton Wood { ft prato! ft cobweb appearance. T he urarktogswere Bestially 0! same to both tangs. The right long m ridilton stato ri definite linear thickening t>! Ita fissure between t a upper and middle lotos to tta outer ha ol tta hto*. T ta tonererto of ihtefisw rc toted tarato a group ol two qultcdcfinite deisesb rit aa oi calcified tracheobronchial node*. T ta(lientM & ehatgtdim J'il>-2,W 2lh Duringhiay to the hospital No cough ever developed. The aputum rem atori sH^ft to MOOOM,thto to characterand was ratted without ritto to the morning. It was ocrestoaafiy Mood-streaked. There were no genitourinary symptom, T ta chief com print was the heretog seosatton to the chest experienced before Mm&fcn. ` The temperature was nomiai with an occa sional 99*, the poise 80 to 90, ami n itratio n s were usually normal, with an occasional 20 to 22 1`ofiowiag igsefsttge the patient rated at home with ras regular work bai up ami about the house more or tea. He presented himself far examination again on April% W ,a W nine rramtbsftcr hi discharge. He staled then a t tta dyspnoea tod tacerne definitely more marked, and that the tie m orta to tp o taw itt ta d persisted onchangcd wHh a liuto morniog cough added. He sus|Jected that his eondilron was due to a sinus trouble for which he stated to f | Stato* treated a t the lime. The sputum ta ti heett Wood- streaked on stp M I C ta lw ta t still there had been no frank haemoptysis. The burning peto tad ceased atout December and ta d been superseded to * dull, drawing jttdte-IdJ p ta l breast. A cenato omoont of malaise a r i definite weakness on ertim i cotHtoocd. Weight had increased from the 1+2 on discharge to lta pomato TtrecmUl for this gaia t t a patient gare to tta codllvcr oil a r i tomato juke which he look consislenllj- during the whole - period, lie was under treatment for his pyorrhoea. __ The striking feature of tta wteramtoation was tta dyspnoea. Respiration were 25 and even onitoaiy speech produced shortness of breath. T ta com pierm i woe slightly leaden and there was a very noiiceabto cyanosis ol tta oars, tatuls and thin on (tecssure. There were ito other changes ftom the original esnmliulfon eacopt to the thorax; this was symmetrica! ami gare the ric c i of being rath fiqllcnri over tta upper lutti front. On [uitinspira S f tion, espinomi to tta anteroposteriordiameter appeared to be nit, ttare being no viride motion of tta sternum. Ttic eldgaslrium moved forward strikingly with inspiration. There wassome lag in the lateral espansion of Lhcrightbase A t the ripple fine t a chest, measured 045 cm. on extreme e dratfoo,m ifoareeofonlyU cm . T ta tongs A o n ri an dtgree oftfiaerenoetatw ien tta notes on lightand tansy perensdoo. WUh tta latter t a tininesstow noted,buton fightpercussion there s f tta r v ` definite oaten to orerttaw hdfe to both h ^ e ta ^ p r o i m n n S o n ta A iht to ttaS th d o rrispinebehtodand from t a f i t a i h t o t a t a i b S t o l t a tu ria and antcriMfy, liv e r flatness began a t t a fitb rib and did not change in either phase of respiration. On auscultation the breathi was i S T ta _ todefiWtfc With cottglqhowever, a striking type rfifih m s h e a r i t a a t a top to (to bottom on ta sides ta t to u t markedly to tta -rt# a rito a ri beiow ta6thribtofront;itw assuperficial, fine, dry and cracklfag to charac ter. The quality o f rite was esscBthily the sand overall. Blood-pressure was 13ftover90,pracriwtiy the sameas dtnfog the hospital sinyt T ta general impression was that t a rites were considerably more definite and more wide spread than nine months before.* The increasing dyspnoea and cyanosis seemed in accord w ith the increase m the rib s. The vital capacity -was 1350 CO., 29 per cent. Unfortunately this bad not been determined a t the time of the original admission. The new X-ray films were a Stile has exposed than thosepreviouslytaken and brought.out the markingsstfflbelter. Discounting t&* fact, it was impossible to determine a definite X-ray charge. Beforeentering upon a discussion,something should be said ofasbestos. Tfcisword is from the same in Greek, meaning unquenchable. A sbestos was known to th e ancients for Its fire-resisting qualities. Greek and Roman w riters refer to its use for lam p wicks. ABsstan Is m ade to it by M arco Prfo, and Charlemagne is said to have a rem arkable tobfo-efoth of this m aterial which was purified by being throw n in to a fire. Only sdatlvtSy recently, however, has i t ccnm into extensive use In industry. A & estos Is a Heatc o f numerous varieties. I t is always found associated w ith other raiaeeais,especially w ith chrome,iron andu ite . Cooke (2) gives th e composition of th e < s foBowsi . . 40.87 *i1..S30l . 0.9B 13.53 43M 0.S7 rV. p S | .* i ; '> ` t i'i ilp l A j' ff? f I t--; ! ' '1 '/ 'J j j |||{ ` . . 'l % if : ? . ' * -1 - i lllferf , , , k i t m t s m , . . . . __________________ iUllKCSES-OE 5.TI I.0Y.OR R C S C a^ y in 1 i r t i o f l EN. OIN F irm tire standpoint of pathobgy, however, the m ineralogicsl com position of asbestos lavery im portant. T he lonwing analysis b gener ally acceptai: ` quarts................ ............................................... Red**...................... ....... ................................. laaMn, .s o a . 0.25 0;45 XMlifca 98.85 .TO <M0 0.35 F an a the foregoing dtao icn l n i m ineraiogjcal an aly sa it becomes M th s t ssb a tw is made upm alnly of a magnsium silicate con taining b u t traces of free silica (quart). Fotm erly asbestos was obtained ahnost exclusiveiy {m a Ita ly and C otsica and the Italien workinga atUl yield large quantifies. South A frica also suppBes large am ounta B ut the Canadian asbestos,a'nce th e rcognition o l Us commercial value m 1*77, haa bccome th t m ost widciy used induatrially. t is fourni in a Email belt of serpentine in the Province of Quebec, dnefly near Black Lake and Thctford. Elsewhcrc it is w iddy distribulcd, b u t in quantities too sm all to be worked to Cooke states th a t tt e b re raicroscopicaBy is sew to constat of two btoijk^ n o ito l M inute p&rt of the fibre. The dust w b to ^ tfrfs t ffpgHfoT showed th a tf te dust containing the greater quantity of die biack p artid es contained the largest am ount of iron. Those particles were found in very sm all number fit th e {brisked article. W hereas the dust showed 18.4 p er oebt of iron as ferrous oxide, th e finished article showed only 8.1 p er cent, Cooke concludes th a t the blackened b rittle p arts o i the fibre are the iroB-eontabdng portions, {he bugbear o i the m anufacturer, dust, and a danger to the health of th e workers. form it is often bipeds A t the m anufactory I t is mixed w ith other fibres, espeefefiy cotton. Then there are th e processes o i carding, roving and spinning which may he c a rn a l o u t ju st as w ith cotton, wool o r silk. -V o l the processes produce asbestos dost* som om ore than others. Oar warn tmk{<nttWHUitlmpul ItsttuunMiy H SStStfd th a t the bands werecomposed of 30 per cent of asbestos fibre and 70 per cent uf cotton fibres woven together. > FUUCQKAS? ASBS5TOSIS S77 - DISCUSSION Prior to the appearanceof the above-described case, pulmonary ashestosrs was practically unknown to m ost of us in New Haven. However, on account of the history of prolonged exposure to asbestos dust and the several respects in which the patient's symptoms, sign,and X -ray A m , tMflcrou from those of tuberculosis, the condition was im mediately suspected as possibly due to the inhalation o t asbestos dust. During T u h m ll " " ritiu * MaJr' titere appeared in th c cu tren t number of woerefeanartlclc on Pnltnm ary A tialoH s, w ith special reference to the radiographic appemance, by W . Burton Wood (1), H e description of tn composite X -ray findings m JS of pulm onary trtmttoqfa des> erfbed by Wood as so nearly identical with the X -ray picture of our case and the symptomatology so sim itar th at weim m ediately concluded th at we were dealing w ith such a case, w ith possibly a minimal tubetcu- lo" f superimposed. To Uds study by Wood, later studies by the same author, and thelm tited literature on the subject 1 am indebted for most of the m aterial of th is presentation. Wood In th e above cited artid c in I n im k g& ts a clinical d istra c t of 16 cases w ith reproductions of the n . A description of Sic composite skiagram of ail of these cases is repeated veibatim . .. ia,(lire ot ahjagram in the w oken exposed iongest to ashes- uw a a sta the |geseHC<ofshadowssi^gtathig ft. arfatfnr a.s-fly the tower two thinb of the lungs. The fine quality of the shadows is worthy n o te S r ^ o f toe caaaexhtoftagroundgW appearance,Ihoogbondoae inspection a fine emttlifig to evident. Bronchial striations towaM toe hu i s am f*wntoet and w an to spreado at to term a fine network giving an appearance use that of cobweb. As the stnations radiate outward from the hug roots, they cuttoc edge of toe cardiac shadow, especially on the left ride, givingtaggy appearanceas it toe heart were encased toccatas felt. When mo deforte mottling is present it lacks the coarse quality described to toe skiagrams of Chests bowing pneumoconiosis, for example to Sooth African coalmine. ^Another feature fs evidence of basal pleurisy, and toe frequency wfth whito toe coKopbrraic angle on one or both sides is obSterated wffl be J l&1` ti,e **" *&> b it a thickening of the apical pleural cap. Annularshadowssuggesting a possTbifiiyof cavitation were seen to threecases; ^ U,C8eWCFCt,Acrc?e found sputum. Tbe region of " d "" Bra " >"**TM lo* <dhe n K ? **ala<Ml"olod in large p a ri as to symptom s, physical signa, 'l ! L . ! '! L ;lr #1** m 'M l H v n u u m b. s u m - SmPTOBB .* _ -----y asbestnsis,lBte th a tofother term s S o dyspnoea is progressive and is advanced stages ot the disease m ay become extrem e. Chest expulsion may he reduced to one h u h or even less. Dyspnoea m ay be accompanied by cyanosis and the arap tad b n of m ost patients h is a slightly leaden ime. t . . --d joey proceed to em aciation. Cough is wHgHK ey tv sad may be altogether absent over a long - a ir e a p tto penetrate the superficial layers lags oi workers. Irritatio n by these causes ............. ....... an coma" are produced around th e central owe If puhnonarytabercuiosls supervenes, the signsand symptoms o l this condidoo would oW oodyrnodiiy the clinical picture. In the absence la iA ' - - - - * #**y have a o ry c racu ro g q u ia ty , an n in rue axmary regrons areo u en super ficial. T ^ la ttr a probably have a pleural origin. A friction rub may be heard oiser th e asm s a m . As the disease affects both lungs, cardiac displacem ent if p reseo tis usually sEght. E arly dubbing of the fingers m ay nark ed . When seen i t la trsualiy repre sented bv dinht ew dhse of the skin surrounding the praam s! rad s of Features whhdt serve to distingaisb asbestosia end pulm onary tuber culosis, though a com bination of tbc two conditions m ay be oiten sus pected dad soaetbnee proved, are the le a d o r dudty complexion, rattem e dyspnoea, w asting o r em aciation o ut o t ail proportion to physiamt etraw1 eawthl oTuud KHaBtiu ret r*tninc asralvmenmliilnlnotetes HsoAoHntwaIse. a ja w ww iitah an absence of ttdieidehectlB from the sputum ,and ab isto ry ofprolonged exposure to asbestos dust Indicate the probabie diagnoaa m toettosis When the disease tBestablished the prognosisappeare to be grave. . t;- .-.i..i........t...... -n- ....^... -C; ' S I lira-I*I'.-'*..*. .VVp-.nii...' - b. rsuttm xK V askestqsb 579 m ntAtitnr m s x pw a a tt to assestos oust h t Wood's series of cases tbc shortest period of working w as one year ana helongestperiod fourteen years. One patient was exposed to dust for * period of eight year before th e onset of cough. Another tM e w m ^ned m la ir heaMi for five year* after commencing w ork, although cop* s d a teadeacy to w inter cough were ap p aren t I t { tress only some time slte r ceasing work. Wood states thaT a rSrem m th e rndfcgtaiw w at show th a t in general tire deadly and extent of the am g shadoware proportfoa^ to the duration o f exposure to the d o st ' PATHOLOGY - ^ ^'00^e ^ imbiished in England a brief antopsy report which he then thought wasof the first case. Tbc patient bad worked in a*ea- tos tw enty years. Adhesions were extensive. Thu lungs were Son and sm ul and c u tw idt abnorm al resistance. The extensive ffbrotic process appeared distinct from tbaaCM tered tuberculous fed. Cooke speaks of particles ofmineral m atter in (ho fibrous tissue and in the caseous tuber culous areas, The bronchi were dilated, the being epithelium gone and & tensive porihrG&elHaJ fibrosis was presents This report by Cooke brought to Jam word of the first autopsy on a cas* of asbestos* by M urrey in J9QD, the essential features of which were the pulmonary fibrosis and "spicules of asbestos." In 1927 Cooke w w te a second we comprehensive article deserfeing the histology of the tangsof the case originally reported in 1924. H e described for the fiB t tim e and showed ancrophotogniphs of deposits of large angular P%itt!d partkfea which he judged to be the heavy b rittle iron-coat^ning fragm ents o f asbesto# fibre. H e explained the greater fnvolve c a t of the righU uag o a tfee theory th a t the fragm ents would mere earily travel down th e m ore vertical right bronchus. McDonald (4)'about the sam e tim e published a study upon w hat he term ed /'th e foreign bodies," the m aterial being from Cooke's case mid Di 1W8 Slmson (5) wrote an article entitled Ptdmtmmy A tb a h sis im A frk t. In it Sc described the findings lit sections of lungs of four asbestos workers. Two suffered death from tuberculosis and two from pneumonia. The first tw o coses showed considerable fibrosis end the la tte r two only a moderate am ount. AH, however, showed "curious 1111181 V t' W K B m ^^r 7- ... ... . r' . T -- Zi V 7 Cf ,TW- v '%3rl ' & '* . . . - : l / % -- f..- m w n u n ii r u < i golden-yeBow bsdief,<*,.&Ui lb author states ho never found in antopaca of m m en riving f u n sU traa and tabriudosis In the Sand Cona ld a n h la q O R b |im to n d faciurfonof the "yellow bodies." Simaon thhtka th a n in au u d d en tle red d en s in favor of tubestods eondnefog to tuhnreiloaia as n ja n p lh a c b a . H a u tu Ccdiia who found th a t five deaths bom phthisis acetified In S w yean among a staff of le a than 40 workers employed s ta 'is e tb ry w here asbestos w as woven. T he n u t tulopsy reported n s m July ,92 by Page and Wood (6). This case was shtdfedbrioredettfo and m especially interesting In th at them was no am gdfcatfag fabeneutoss A woman had worked o h yean as a weaver pf asbeatorand sa w up the occupation on acoount off ai h es'tli ihout four yean before death. D yapnw a, loss of w eight and strength eonfoutediucreashigly nnttl h a demise, A description of this autopsy is w orth repeating in p art- . .. Body a n em aciated. U rn pleurae were uniform ly thickened to o slight extent. In O n upper third of th e cheat th e layers w etn bound together by m oderately fine adhesions; on both sides some recentplastic pleurisy was present. The lungs showed a diffuse fibrosis and were contracted, the left lung more than the tight On section,the trabeculae stood oel rather prom inently, form ing a fibrous netw ork, especially in the right upper lobe, and denser fibrous strands appeared aairregtdariy shaped nodules particularly in the right lower lobe. The bronchi were only slightly dilated. The lungs were congested and in ] ' bronchopncumotuc. M icroscopically the fibrosis became t apparent; in less-affected areas it waam ost prom inent aroond th e b vessels and less so hi th e alveolar w alls, w ifie in som e sections HtUe waa seen but aeawhasuo w ith blood vessels and num erous elastic fibres. 1 Some lyngdioeytlc nodules went present in the fibrous tissue and ^ a n t cells of the type associated w ith foreign bodies; no typical tuberculous giant cclla were found and no tubercle badsu. I n addition to a lu g e quantity of amorphous dark brown pigm ent numerous golden-yellow described by M cDonald and Simson were seen, in sections taken from various parts o f foe lungs The m ajority of them were imbedded in fibrous tissue; where the to be in dum ps in the alveoli, usually radiating from the centre w ith their (dubbed ends outw ard; is isolato) specimens were aeon in foe fibrous tissue and risevarying fn aim and shape theiruijority showed a huge d o tte d " 'M fo ^d ren iarb w feav rifo ' Tdmrnm m ^ m S m Ifred flood eotpusde were riso present T hebotSeaw ereofagdden. 4 * ? * * - '* * '* + ^ ,, * Qrm&rcri . Am w M fey Stewart (j) the fluid expressed from the lung was C M M t^ aial foiwd to c o a tti gpldcn-yfjftpw bodies. With the aid of The autopsy of a fin d ease was reported by Wood and Page (&) in January, 1M0. in foesinnm aryof their case they slate th a t the three features & spedsi interest ate ( i) rapid evolution of foe tubttculous procoss io a patient who bad been exposed to asbestos d ust; (2) foe presence in th e lu n p of alarg e num b o t asbestosia bodies within two years of the first exposure to fie d ust; and (3) the presence in the lungs stages o i foe form ation of typical , The eBrentjal fratures thcn of foe pathological changes appear to he the presenceofa ,, Regarding tho'p . . * end srbcstosis bodies. fco..f.f..S..e...a_s_b_e_s_to_s_f_i_b_re_in_ foe lesions of asbestos workers. Gloyne )in 1929published an illum inating paper. Summaris ing the description of raw asbestos, he stated th a t it may be ground into foie powder, calcined in a crucible and m ounted on a slide aa a wet preparation w ith concentrated sulphuric add w ithout showing any signs ofdbstrucfiojt, ffftwnhmffrm wMhfvfwjfh i a fifpQ shows fettndte&otfih n s and indi* vidual fibres of varyfog lengths. The fibres are highly retractile; they ......... * ig e f f o d fee and have often a very fore saw-fike iS ffC S S fi edge, wlEc the a d s m brokeM ttfiureut anglesta d ocaaicmaBy fflt W ith he i n n a u In f in d Gfoyue d aa o astrate d th at asbestos fib re he m ill) rm ta v ti Im ra l Ire w> railed asbestos ram s w ith fine needle and, when examined by dek-greutnl B usriaation, show the characteristic appesnm res of dm asbestos B m a. S e then d ennat tented asbeatreun the m onth and note o t tw o o p eretta by m ethod conHSltng oi d ig est! o{ th e m stenal w ith aatiionm ii, rantriiuga& m of the digested m ateriel, rald filsg o t the depositin u d b le to destrey aH ; edluLu firim * and m allv the m oling a w et praparatiou of tire ra lcined deposit in coneentm ted ndphnne acid and exsm biatloii by darkground m urnlnatlon. B y the w a r m ethod ho found asbestos fihras in the tputum of three of six came examined. Furtherm ore, typical athestos fibres were found in the luogtaul w exepresent in the expressed juice of th e ta * o f ease aVaSaid*. F inallyhem adew etpeeparatlonsoithe gatan-ycU o boffics lit expressed h isg juice for exam ination by darkground ffluawtatiou. Concentrated nBphtnfc ad d waa very gently run under die cova-sBp, Thc.yeBow bodies began to dissolve and in the m iddle of their structure were a num ber of typical asbestos fibres. A t th e end of half an b o u tpractically all the m aterial of which the bodice were composed had dkUMfeared, leaving only a faint ghostlike outline of the bodies w ith highly refracdle asbestos fibres w ithin them . The asbestos fibres Jay a t different angles. Gloyne concluded O at, in any event, w hatever other m aterial enters into the com position of th e bodies the banc factor is the asbestos fibre, and he suggested the term "ashestosis bodies'1as being the m ost descriptive. Stew art (7J in 1928 stated th a t in one autopsy of his own of a case of pulm onary asbestosis and in three by a colleague asbestosis bodies were readily dem onstrated in large number by simple microscopic examination of lung juice expressed upon a dido and covered w ith a cover-glass. Stew art and Haddow (10) in 1929 wrote a prelim inary report on th eir efforts to obtain far diagnostic purposes asbeston's bodies by lung punc tu re and front sputum . From tw o cases clinically of pulm onary asbestosis they withdrew from the base of th e lung through a needle a m inute am ount of blood-stained m aterial. U nm istakable golden-yellow aabestosis bodieswere {bund in considerable num ber in th e m aterial from one. In the second case negative results were obtained, Sputum is usually lacking or is in but small am ount except during attacks of bronchitis. gm II From twaM<h4pevw> afoot * half-wraceof mucopurulent $ u tm ii waicbSft&ttd. <fe*lved in a a eqw dquantity o f m - dStttpd ast^tennitt, n jb f to ta d , and th e deposit w ished laid exeadaed rotcro9CQpt9% A fU t professed arch ttrough numerous fields two typical fisbeftta& boiSei Were found t&one of tie specimens examined. la ioi artfcfe p o lish ed to January 1930 Gloyne (11) gave th e icm tta of aoinud experiment* to bow whether the asbestos fibre is definitely ttodc o r w h e t h e r o o a n l&ort foreign body o r &raSd sterfl* irrita n t J|& co8eft& faitt we& os follows: (1) b ests f t w when In erted iotoanfeaal {feme*acted a* benign irritant* producing granu lation tissue; 0 0 tissue contained m any bestow s p a n t edits,presum ably ttattem ptto destroy the asbestosfibres by phagocyto sis; (3) connective tissuew as formed in due course, but th e giant cell persisted; j$ theBsbestods giant cellw as readily <fistlnguishcd from the tru e tuberculosis giant ceH; (?) asbestosis bodies wen n ot found; (6) asbestos injected repeatedly intravenously appeared to have no toxic S ection (fiatanttissues. CONCLUSIONS 1. A comIs reported whichseems to be typicalo fpulm onary asbestosis. 2. W hen there 1ms been exposure to asbestos dust the presence of pulm onary asbestosis Should always be suspected. 3. T tem o stcaramonsingfexym ptom bdy^m oea. This and theother Symptomaare essentially those of a progressive generalised long fibrosis. 4. T he physical signs of uncomplicated pulm onary asbestosis are substantially those of generalised fibrosis of both lungs and basalpleurisy. 5. X -ray exam ination is o f p e a t value in establishing the diagnosis. 6. Asbestoscontains b u ta vw y small am ounto f free silica but probably conduces to a m ore h asty evolution of any accompanying tuberculosis, as in th e better understood forms of silicons. 7 An im m ediate diagnosis a t autopsy is said to be made possible by simply squeezing out upon a dido a drop of lung juice from the fibrosed tissue and covering w ith a cover-glass. The asbestosis bodies in large num ber w e readily visible undo'the microscope. sbbuography CD-Wot, W. K i Tabardc, 1929, s, (2) CMR*W.E.T3rfL iL 1927,81021 b. ;-S i - - E-SI'-lOY -DP RESFARCH 1 U F U OF LEN&mG II 584 vnuABD b. so n s (J) Cooke,W . & : ttM * 1 0 ^ % 147. , (4) McDonald, &.: Ib id , 1OT, &, 1M L '* (5) (A) PM >,D.& ,AiiD W tt,~& . T ita fe U B ,!, ? . k C7>SnvfT, R J : &CLM.J, 1028,11,SO., ', (8) C w i h , 8.R . 9 ) WeaB,W.&f i n u an iS .` M d.l m i . l S . ^ 00) Sew jir,ie.y1AiHieowi A iE liJE w k$tikeB K t,i9S% edU a. (ID GuN8lS .f e in te k l tm 4 lA . V ; , l |l ! $/ft*,;. *<*'*%" t o b b r c o l o s is o f t h e U V BR ' ' ,, V ; ' ; ..w m m p tiim x m , >> '. ? A ltio n ^ jaB teiy tuberculosis o f the B veris found in from 50 to 80 p er cent of 8 cases etyfcgfium pdm oBary tuberculosis,m assiveabscess ,fo n ito b ad u eth B & rilBwmls ttr e . Ihtthologistshavedesstted hepatic tubercuhadi into m iliaty mad local tuberculosis. T he U tter i t farther divided into tubercttloaia Involving th e bile-ducts and massive tubercu- a* m nseA L a n m n Brislowe (1) m ade t i e fa st attem pt to describe lo ad tuberculosis of the liver in 1858, W etheted ft) reported's prim ary case of tuberculosis of theliver, w ithiresh m Bary tubercles in both lungs A easeof second ary nodular tuberculosis of th e liver, w ith walled-off cavities containing chyltform fluid was seen by Thayer (3). Maximowitsch (4) discovered a prim ary case of m ultiple tuberculous liver abscesses, complicated by hard nodules resembling carcinom ata. A case of prim ary m ultiple tu berculoma of th e liver, w ith a degenerated hydatid cyst, is reported by dcCrespigny and O dand (5). In the Untied Stales Nary Medical Bullc- ri, Robinson (6) w rites of a case of large "solitary" tuberculous abscess of the liver. MacfClnxic (7) reported a case w ith m ultiple abscesses. A case o f diffused nodular hepatitis w ith th e nodular development having to centre in th e portal system is recorded by M acaigne and Finet (8). Frank (9) also reported a case sim ilar to the last one mentioned. F let cher (10) saw au interesting case w ith tuberculous cavities o i the liver in a boy six years eiag e. Tfcefindingsatnecropsyrevcaled also a general ised tuberculosis. Foucsr (1 0 says tuberculosis of the liver occurs only in those races not having an hereditary or acquired im munity against tuberculosis. F o r example^ cold abscesses of th e liv e r are found among the Igorrotcs o ff A ftersummarizing 30 articles and abstracts on this subject, it wss dis covered th a t only three esses had been reported by Americas authors.