Document 71p4vmkNDQRmw5E0NdRb9dQZa

FILE NAME: Welding (WELD) DATE: 1936 DOC#: WELD029 DOCUMENT DESCRIPTION: Presentation from Conference - A Case of Acute Pulmonary Asbestosis ACTA MEDI CA SCAN DI NAVICA RAPPORTS ET COMPTES RENDUS DU DIX-SEPTIME CONGRS DE MDECINE DES PAYS DU NORD TENU COPENHAGUE DU 27 AU 29 JUIN 1935 PUBLIES PAR LE I) O CT K U R A . N OR GA A RI) SCRTAI RE GNRAI. DO CONGRS I M P R I M E M E R O Y A L E BAG GE - C O P E N H A G U E - 1936 Id. Carl Johan Jacobson, Copenhagen. A case of acute Pulmonary Asbestosis. Casr licconl: ('. II., mechanic, 25 years old, a d m i t te d for bronchial a s t h m a to this depart ment on J a n u a r y 18, 19J5. Apart from scarlet lever in childhood and herniotom y in adolescence (ur tra u m a t i c hernia), I he p a tie nt pave a past history of pood health. In particular, no disposition to p u lm o n a ry tuberculosis, no hay fever, no previous attacks of asthma. . During the last year the p a tie n t has worked in a shop at electrowelding of rails and boilers. The welding is done with asbestos-covered electrodes, and d gives rise to a great deal of sm oking w ith production of asbestos dust which is hurled out in the air. On welding inside the boilers, he says, there is formed a great deal of such dust. I le thinks, t h a t such electro-welding of boilers from the inside is an exceptional specialty of the factory in which he works; this is not the ease, however, according to the chief physician of the factory inspection. The illness, on aceomiL of which he now enters the hospital, began about h n e ck s ago with violent spells of coughing and copious e xpectorate. The coughing spefls were followed by m arked shortness of breath. He gradually became so dsspnoeie th at he had to sit up in bed all night for the past 10 days, and the cough would set in at once as soon as he tried to lie down. lie would also get very dyspnneie on the slightest exertio n, l ie q u i t work K da y s before admission, but it did not seem as if rest at home m ade his a tta c k s of a sth m a less severe. He says there lias been no palpitation of the heart or other functional distur bances. He has never worked with lead. On admission, the pa tie nt was found lo he in a fair sta te of nutrition. The respiratory excursions of the chest were small; the he art was lung-covered; posteriorly, the 12th rib marked the inferior border of the lungs. The percussion sound was resonant. Whistling and sonorous ronchi were heard everywhere, hut there were no areas of dullness or o th er signs of infiltration. The heart sounds were elear. and the action regular. The physical exam ination revealed no other p artieular abnormalities. 'Hie tem perature was norm al on admission, and kept normal throughout his slay in the hospital. D u rin g the first days he produced a good deal of expectorate (about 50 c.e.. daily), hut this subsided rapidly, l he most striking feature was his marked dyspnoea. L aboratory tests: W asscrmaim negative. S e d im e ntation test (1 hour): 2 mm. I'irqucl negative. Vital annually of tha aiu-st, e stim a te d oil the day after admission, 2100 e.e. (00",, of the normal for his weight and sitting height). X-ray c definite si;, density or (slight deg Xo tube perfectly : Under ; lied, t h e pi hi; he was gi\ result. Af! continued atory exei When . gain ing 5 I, itis, Kmpl Comnv osis, the tried, tin 200 c.e.}. be appro asbestos 483 X-ray examination showed conspicuous details of lung structure, but no definite signs of beginning silicosis in (lie form of infiltration, small areas of density or similar abnormalities. X-ray diagnosis; lironchitis? Emphysema (slight degree). No tubercle bacilli were found in the expectorate; and the blood picture was perfectly normal. Under trea tm e nt with nicordaniin. potassium iodide, inugnyl, and rest in bed, the p a ti e n t im proved rapidly, a n d got up after ti days. After oilier ti days t]iis dcpart- Icscence (for n particular, mis a t t a c k s rowclding of odes, and it lust which is is form ed a in s from the -: lliis is not inspection, uim a b o u t 6 he coughing became so vs. and the tiid also get e admission, less severe. inai d i s t u r b'd ion. The ng-covered; percussion verywherc. 1lie heart revealed admission, sst days lie is subsided (1 ho u r): ' day after 'ft height). log. 1. Hoentgenograin of th e chest on admission to hospital. he was given incandescent-light t r e a tm e n t and respiratory exercises, with good result. After 20 da y s in the hospital, he was discharged, as feeling well, for continued am bulant tre a tm e n t with 12 iueaudesecnl-light bulbs ami 12 respir atory exercises. When admitted, he had been rather exhausted, but lie improved rapidly, ginning 5 kg. in weigh l in 12 days, ('.lhiical diagnosis: lim n eh ini a si lima. Iin me h itis, Emphysema, a n d A cm e pulm onary silicosis (Asbestosis), Comments. To make an unquestionably sure diagnosis of asbest osis, the presence of "asbestos bodies" must be demonstrated.- 1 tried, therefore, to find such bodies in the expectorate (altogether *200 c.c.). Hut before I mention this examination in detail, if mav tie appropriate, I think, to give a brief review of the history of asbestos and pulmonary asbestosis. :S1* Asbestos was known even in ancient times, and the Romans mined it from the Alps and the Ural Mountains. It has been men tioned by Herodotus, Pi.inv and Marco Polo; the last author reports that it was used by the Tartars. Although its valuable fire-resisting properties have been known for thousands of years, asbestos has not been employed for indu strial purposes to any particular extent before the last part of the past century. In the asbestos factories the various processes of manufacture generated a very considerable amount of dust, and in the working classes the manufacture of asbestos has long been considered unsafe work. It is rather strange, therefore, that prior to 1921 there had been reported only 1 case of disease due to inhalation of asbestos dust. This was a faLai case of pulmonary asbestosis in a dd-years old man who died in 11)00 in the Charing Cross Hospital, London. The case was described by Murray who made the diagnosis of pulmonary fibrosis, '['he diagnosis was confirmed on autopsy, and microphotos of lung sections showed "spicules of asbestos". This was the first and, down to 1921, the only record of death due to asbestos. In 1921, Cooke described a fatal case of pulmonary asbestosis in which the post-mortem examination revealed the presence of peculiar, so-called asbestos bodies in the lungs. These bodies were elongated and measured from 20 to 70 x in length; many were clubbed at the ends or swollen on the middle; they were brownish-yellow in colour and gave a positive Prussian blue reaction on account of their iron content. Subsequently these bodies have been described by several authors (Strokbk, Stewart), and their nature has been investigated very thoroughly by Hf.ckr. Asbestos is a magnesium silicate, of which there are numerous varieties, most of them containing some iron. It has now been found that the organism is able to transform and in part destroy this silicate. I!i;c.i:h has demonstrated what Cookk had already found it reasonable to assume: that carbon dioxide and the moist heat of the organism can hydrolyse the silicate. The course of this process is probably as follows: After the asbestos dust has entered the lung tissue, it is acted upon bv the acid body fluids, and the metallic atom is liberated from the crystallic lattice. The particles are now surrounded by protein whi deteriorates now and the ridding i: As month lungs in pal demonstrate sputum, but through a n these bodies during an eAs it did no such a room sputum fron antiformin, of minerals 1 evapora butter-like it was treat microscope demons trat< edly refrael asbestos fib same manir Mr. R. J; the mineral None of the to the asbt these partii bodies. One of lb examined, is more rest asbestotic 1 The dim Oliver as i and differ!i phasizes in exertion, d 485 0 Romans protein which envelops them like a coat of gel, and the silicate been men- deteriorates while the iron remains. Asbestos bodies are excreted ast author now and then with the expectorate. The organism has thus a chance W ,`Cii known 1 for indupart of the rocesses of dust, and long been of ridding itself of the absorbed asbestos. As mentioned, asbestos bodies were demonstrated first in the lungs in patients who died of pulmonary ashostosis. Stewart has demonstrated them in the blood from punctures of the lung and in sputum, but only in patients who had been suffering from ashostosis through a number of years. He states, that it is difficult to find these bodies in the expectorate, and that they are to be looked for e had been estos dust, i s old man !. The case pulmonary iicrophotos is the first sbestos. In is in which if peculiar, elongated ibed at the \v in colour 1 their iron during an exacerbation of the bronchitis of the respective patient. As it did not seem advisable to perform a puncture of the lung in such a recent case as the one here reported, 1 collected 21)0 c.c. of sputum from our patient. Stewart had destroyed the sputum with antiformin, but 1 employed Bi-rkks's method for demonstration of minerals in silicotic expectorate. I evaporated the 200 c.c. of sputum till it formed a very thick butter-like mass, from which I made smears on slides; a part of it was treated with hydrochloric acid. By means of the polarization microscope and by incineration of the mass, it was possible- to demonstrate several large refractive aggregates and smaller mark edly refractive particles. But by comparison of these bodies with asbestos fibres that had been treated with hydrochloric acid in the same manner as the expectorate, nothing definite could he derived. Mr. R. B o g v a d , M. S., who has been kind enough to carry out by several nvestigated the mineralogical examination arrived at the following conclusion: None of the scarce filliform particles have the slightest resemblance to the asbestos bodies mentioned in the literature; most likely, numerous been found estroy this eady found moist heat this process these particles have nothing to do with asbestos or with asbestos bodies. One of the electrodes which the patient used in his work has been examined. In the packing was found asbestos (actum lile) which is more resistant to acids than is the ehrysotile asbestos found in asbestotic lungs by other investigators (Bkgkb, Cooke). The clinical picture of pulmonary ashostosis is described by it is acted is liberated ounded by Oliver as resembling in the early stage any oilier form of silicosis and differing but slightly from pulmonary tuberculosis, lie em phasizes in particular the marked shortness of breath on slight exertion, deficient respiratory capacity and physical debility; as m 18b differentiating signs lie points out the absence of fever, a degree of dyspnoea in excess of the physical signs, a greater amount of general disability, and comparative absence of night sweat. 1.1 '1/ holds that pulmonary asbestosis can be classified by itself as a special characteristic occupational disease. It is associated with coughing, expectoration and shortness of breath, in particular on exertion and in foggy weather. The salient's physician has told me--on Mav 8, Ifldo--that the patient is now feeling fairly well, the expectoration is minimal arid he has regained his capacity for work to a fair degree. Reexamination of the patient, here in the hospital on Mav 13, 103.), shows the vital capacity of the chest to be 4000 e.c. (i.e., lllo of the normal capacity for his weight and sitting height). X-ray examination of the chest shows a mild degree of bronchitis and emphysema. Auscultation of the lungs: There are still signs of emphysema, hut no signs of bronchitis. The diagnosis of pulmonary asbestosis is made on the anamnestic data, the sudden onset of dyspnoea, the finding of emphysema, bronchitis and asthma, and the prominent lung structures in the X-ray picture'. Hut the diagnosis cannot he said to he established with certainty unless the presence of asbestos is demonstrated in the expectorate. Yet, theoretically there can hardly be any doubt that the greater part of the asbestos will be deposited in the connective tissue, so that it is not very likely to be found in the expectorate in fairly mild or recent cases. There is, besides, the possibility that this might perhaps be a case of poisoning through a production of noxious substances from the electrodes or from the welded material. The first possibility comprises the production of mtro-conipounds which are markedly irritating to the respiratory tract. The welded material may also give off some noxious substances, especially if it is oiled--e.y., acrolein. The rapid improvement of the symptoms in this patient, 1 think, is chiefly attributable to his stay in the hospital by keeping him away from his dangerous job; in addition, bis lungs were given a chance and time to break down and eliminate the asbestos. This breaking-down of the asbestos, which has been demon- strated indispu tiates asbostos is correct, that srieite--and conclusion th; Fig. 2. H<n-. slowly. In his lysis of ashest scheinlich cin vorgang in d* Asbestosis i silicosis (or ch ably is fairly spontaneous > In recent ve ver, a degree it amount of sweat. died by itself sociated with particular on 487 strated indisputably also in experimental studies (Hkc-kr), differen tiates asbestosis from the other forms of silicosis. If .Jones' view is correct, that ordinary silicosis is due in part to silicates, especially sericite--and many things suggest it is correct---it is an obvious conclusion that the silicates break down too, even though more <35--that the minimal and May 13, 1935, i'.c,, 111% of t). of bronchitis emphysema, e anamnestic emphysema, etures in the .ith certainty a expectorate, t the greater f ive tissue, so ij rate in fairly lerhaps be a stances from st possibility ue markedly i slowly. In his work on silicosis, Boiimk (1934) mentions the hydro ial may also , lysis of asbestos and concludes: "hair Quarz und Silicate ist wahr s oiled--e.g,t scheinlich ein hnlicher, wenn auch sehr langsamer Auflsungs vorgang in der Lungen anzunehmen''. is patient, I I by keeping ~s were given . asbestos, iieen demon- Asbestosis is therefore to be designated as a special form of silicosis (or chalicosis), to which the individual resistance presum ably is fairly great, and in which there is a marked tendency to spontaneous recovery, at any rale in the initial and early stages. i In recent years, investigation into occupational diseases and their diagnosis have gained headway rapidly in this country, and I thought therefore it might be of interest to present before this congress an early ease of pulmonary asbestosis. For earlv clinical demonslralion of this condition, before the patient shows definite roentgenographic lesions and demonstrable asbestos bodies in the sputum, will give him the best chance of recovery. In analogy with tuberculosis and the demonstrable presence of tubercle bacilli in the sputum--once asbestos bodies are demonstrated in the sputum, the diagnosis of pulmonary asbestosis is established, but tire prog nosis is often to he regarded as less favourable. I wish to thank my chief, Dr. N. It. Christoffkrsfn, for inviting me to present this paper. 1 am also obliged to Mr. R. Bogvad for his kind assistance in the mineralogical part of this study. References. 1) Ijecgkh, I*. ( 'her die Asbestosis-Krperehen. Virchows Archiv V 290: p. 280 (1031). 2) liuiiKi:, II. F . : The IJet eel ion of mineral P a rti kies in Ilie sp u tu m in Silicosis. J o u r , in d u str. Ilyg. 1985, 17, p. 27. 3) HOiimh, A.: Die Silicose. Frgebn. ges. Med. 1934, 19. 4) C o o k k , \V. 1'..: P u lm o n ary Asbestosis. B rit. Med. J o u r . 1927, 2, p. 1024. 5) J o n k s , W. B.: Silicotic Lungs: T h e Minerals th ey contain. Jo u r, of Hyg. 1933. 33, p. 307. (>) L t z : Gewcrbehyg, Stuttgart 1932. 7) Me D onai.d. S.: Histology of p u lm o n a ry Asbestosis. Brit. Med. Jo u r . 1927. 2, p. 1025. 8) O i t v k i :, T n .: Clinical Aspects of p u lm o n ary Asbestosis. Brit. Med. Jour. 1927, 2, p. 1020. 9) S t h o k iu -:: Bericht ber ein Fall von l.ungenashestosis. Virchows Archiv V 290, p. 355 (1934). 10) Stkwaiit, X. .).: D em o n stratio n of Asbestosisbodies in m aterial. . . . Jour. P a th , and B a d . 1929, p. 172. From the Department of Medicine, Frederiksberg Hospital, Co penhagen. (Chief Physician: Dr. med. N. R. Ciiristofffhskn). 50. J. Tillgre Affect Even if the dependent of t importance to and increased disease. Furth thyreotoxicosiconstancy and. them into eon We have goin regard to the plicating hear erated upon, : b With rfr in these 200 c;r in m onths (m) resp 1 Medically treatei Surgically in ye;tr' Medically trenteSurgically in per cert Medically trente Surgically