Document 8z3QXmYvR0G6BNk0dDYMw6BZ

JLj Chemistry,1 Pharmacology, Public Health, and News. F 26 35 Iff TWO Y0LU2CES ANNUALLY Yol. CCXXVTL Yol. IL fob1 1934. /fjv' O.V^ R U N'lfRR D AtfD TWELFTH TEAR. UBRARY OF THE LOS ANGELES COUNTY MEDICAL ASSOCIATION S34 SOUTH WESTLAKE AYS. . . EDITED BY Sis SQTJIPE SPEIGGE, MJ>. Cantab., P.B.C.P. Lond., F.E.C.S. Eng.,- ` 1d EGBEBT HOELAffl), B.Sc., M.B. Lond., ILD. Beene. U8RARY QF THE . " L A CO. MEDICAL ASSN. 634 SOUTH WESTLAKE LONDON .. I'UBLISaSD 3Y T2Z PROPRIETORS. TSB LANCET LUUTSO. NO. T, ADAll STREET. ADEL?HI. TY.OL, Of TSE COUNTY OP LONDON. AND PRINTED BY **** WATSON * 7INET. LTD- 52, LONG ACRE. \7.03. ildix rr.  e. 5^ fR BAt7'^7 , n> 1934 eaaeer and Tea 2 that-the advantage, i unhappy r a proper :ontinuoa* dreamless, lly happy lour time* >nly wak da. txx ucfcrr] (( drs.` w' b. wood abd B.'bL oi mTC: PUUOXA*T ASBESTOSIS [0X0.22/192 _v --HUT____ iyere asthma contmnes unmtemmted^for daj ths others pulmonary tuberculosis. Tea'hMsr'fl male, weeks and may end XKfatal exh^ttion, cansfjirays 9 females) are still alive. All have tubercle bacilli and be Rested by the metate^af^cflptiaiioagS^regalme asbestosis bodies ia the sputum. icjectiop which 1 first used abotfl Ml yearp'ago. The needle is^tept in position with a full syiipge, and after nx.--rtJUtowAxr asbxsxosxs wxss obsolxscxxt TOBSXOCFLOSZS - in initial direction of a dose which is known to cause Nine eases (4 males, 5 females), nut group emphanes no unpleasant symptoms, one or jnore minims are injected every^j, 30, or 60 second* according to the patient's reactionXthe rate being varied until it is found how frequently the injection can be made without tachycardia olsotbef symptom arising. The injections are continuedSa necessary, for even half an hour or more; relief'atfvays follows and generally manifests itself by the patant falling into a deep the fact that obsolescent tuberculous is not necessarily reactivated by asbestosis. Three cases have been fatal (1 male, 2 females); of those still under observation 2 (females) have radiograms exhibiting typical asbeatotis and healed apical tuberculosis, with asbestosis bodies in tbs sputum; and 4 cases (3 males, 1 female) have asbea totis bodies present in the sputum sad radiograms showing obsolescent tuberculosis but indeterminate or negative at to asbestosis. ' sleep, which may be the first he has had for several -> both too bitaal tue days.- ,' ^ Anaphylaxu/oan also be most efficiently treated for om m by this method of injecting adrenalins, which ia far -ticTia. In H more eflprare than occasional injections of larger of asthma doses. Ai adrenaline is always at hanos^when a riven such pstiejn is given serum or other treatmenbswhich ar attack. cause anaphylactic reaction, the lattes npuld 7 ease to i4 fever prove fatal. paroxysm . IV.--DOUBTTTJ- ritnm Seventeen cases (6 males, 11 females) under observa tion. All but one have suggestive symptoms end signs but the radiograms are indeterminate, and with two exceptions the sputum, where available, no asbestosis bodies. Of these exceptions one has symptoms, signs of emphysema, and a negative radio gram, but asbestosis bodies are present; the other has no physical signs or symptoms and a negative radiogram,. but has asbestosis bodies in the sputum. . TBS CUBICAL PICTUBS ixysm tho ae sympsovercome PULMONARY ASBESTOSIS asm* or OKS hdvdsxd casds The picture of pulmonary asbestosis is that of % paeumonoconiosis occurring in a factory in which few precautions had been taken to protect the workers a paralyse Bt W. Busxon Wood, BUD. Camb., H.R.CJP. Lond., dates tho "ioiohaia* DP.H. ramoniom coxsexRxo rsmcxur roa Tcsncczcsa to rm MKT cooacnt cooKcn.; rsmetAX to ocreamRe, errr or aoxsox universal ?A sosktax* vxcxosxa pox ; am antage of bronchial S. Roodhousx Glotxz, MJ). Leeds, D.P.H. ild never ramoMOiST to m xoemaa ' ^balance ivantage onstantly to inject t the fiat j aborted, it, though he had to ion at the ea rise to anted by nt prefer does not danger of cases the cieney ia prepan* Ddbzko the last few years we have from time to : tune reported the result of our observations of the ! effects of the inhalation of asbestos dust as seen in I patients attending a chest hospital or revealed at ; ratopsy. Our studies commenced in the year 1928, `and a preliminary paper dealing principally with radiographic appearance! was published by one of ts in the following year. In 1930 we reported our findings in s series of 37 asbestos workers who had been examined at Victoria Park. As we now have bad the opportunity of studying 100 cases, the time ftems opportune for a brief survey of the whole ptmp. AtfAXTSXS 0* CASUS Our cases may be divided into four chief groups, Uo rtprooccas'one x.--ruxacoxAnr asxxsxosxs Fifty-three cases (19 males, 34 females); 12 deaths ndiriv. ual mder the emotious sccretioa ases, the f adreoame when uamatioit (4 males, 6 females), including 2 with carcinoma of the hag and 1 with a few deposits of growth in the pleura, h the cases still alive end under-observation diagnosis nst* upon (a) typical appearances of the radiogram, (^symptoms and physical signs of fibrosis, and (e) pretence d asbestosis bodies ia the sputum. Them three diagnostic points ere arranged in order of merit. Twenty-four cases males, 15 females) were positive on all three counts; 1 (all females) had positive radiograms and clinical symp dren aline :d make* moderate 1 with a ircnaliae. age with aims cau of seven tom* and signs, but no sputum was available--or if iiailable no asbestosis bodies were found; 9 (5 males, 4 females) gave positive clinical signs and asbestosis bodies were present ia the sputum, but radiograms were abet not available or failed to show definite evidence of saeas* ; 1 (male) had a positive radiogram and asbestosis ^dies in the sputum but no clinical signs or symptoms. `-mi:OJ.*aT asssstosis win acixvx tubdcoxosu le. in which Twenty-one cases (4 males, 17 females); of these 11 1 males, 8 females) were fetal. One had a tuberculous 'tpyeme, one a pyopneumothorax sad lardtceoua disease. from a danger, the gravity of which was not realised. Sappily these conditions are now a thing of the past and elaborate precautions have been taken to protect the workers. There is thus good reason to believe that the disease is now under control, though it seems probable that workers exposed to ths dust under the old conditions will continue to present themselves for examination for some time to come. There is no need to amplify the descriptions of pulmonary asbestosis already given elsewhere. The symptoms.are indeed those common to all forms of pulmonary fibrosis uncomplicated by bronchial dila tation or pulmonary excavation---stubborn cough with little expectoration, discomfort or dull pain in the chest, occasionally perhaps a streak of blood in the phlegm, and dyspnoea. It is this last symptom of which the patient complains. The distress occa sioned by constant breathlessness is so great that the disease might almost be described as monosymptomatic. It is the patient's first and last com plaint. In the earlier stages dyspnoea is only apparent during exertion--" I found I could not hurry to work in the morning 1 "--in the later stages the act of undressing or even the effort required for speech may cause the patient to pant for breath. When asbestosis is complicated by tuberculosis, broncho pneumonia, or other thoracic disease, the.symptoms of these will be added, but the dyspnoea of pneumonoconiosis can still as a rule be recognised. MaL nutrition is very evident in the terminal months whenthe patient may pass into a condition of extreme cachexia. D1AGSOSB When a new disease is under consideration the salient features are first observed, and diagnosis depends on the recognition of gross symptoms. Thus phthisis was formerly only diagnosed when symptoms and signs of advanced disease were evident. We now diagnose incipient phthisis with confidence at a stage when the patient is healthy in appearance, well nourished, and little troubled by symptoms. In the diagnosis of asbestosis we have still to depend upon the symptoms and signs of more or less gross We have no means adequate to discover during life the existence of the finer degrees of i'll 'f: t 1 i it i i 2384 THS LAKCET] DBS. W. B. WOOD AXD S. &. OLOTK8: PUUXOXABT ASBESTOSIS [dec. 22, 1934 pulmonaryfibrosiswhich must precede graverdevelopmeats, and it is not surprising that the pathologist sometimes discovers post-mortem evidence of fibrosis not recognised during life. In diagnosis at the present time we have to rely on a history of exposure to asbestos dust as our starting point. The symptoms described by the patient may supply a due, for the malingerer doe* not as a rule emphasise dyspnea as his chief die* ability. In the physical examination the patient's appearance should receive special attention. In advanced cases the " earthy " character of the complexion and a slight violet tinge in cheeks or lips are noteworthy. The physical signs supply suggestive but never conclusive evidence. They are those of a basal fibrosis, and the fine nature of the pulmonary scarring is indicated by fine dry crackles not to those often heard over the bases of emphysematous lunge. More superficial crackles produced by the movements of a damaged pleura are often mingled with the fibrotic riles. The radiographic picture is that of a fibrosis of fine type affecting the lower two-thirds of the lung field*; the scarring is a* it were etched in. Attention may be drawn to a difficulty constantly encountered when a delineation of the basal portions of the lungs is required. The diaphragmatic shadow censors the bases of the longs, and in a radiogram taken with the ordinary antero-posterior technique as much as two inches of the lung may be blotted out. The extent of this " silent " area can be demonstrated in the normal lung by a lipiodol injection, the result of which will surprise those accustomed to regard the supradiaphragmatic area aa the lung base. Again, a lateral view of the lung, if the interlobar septum is thickened or if the middle lobe is opaque as the result of, for example, an epxtubereulous exudate, shows that the lower margin of the middle--Le^ of the lower portion of the right upper--lobe corre sponds approximately with the shadow of the cupola of the diaphragm. At a recent meeting of the Bfintgen Society Dr. L. A. Rowden pointed out that a more extended view of the lung bases can be obtained by the simple expedient of placing the patient in the dorsal position and centring the tube over the brow. We have tried this method and verified its efficacy. The exact diagnostic significance of asbestosis bodies in the sputum is doubtful. A* pointed out by one of us (S. R. G.) the formation of an asbestosis body is evidence of tissue ehange. We cannot assume, however, that .the ,expectoratibn of a few asbestosis bodies implies that' pulmonary fibrosis has already occurred. If we could make this assumption the problems of diagnosis and claims for compensa tion would be simple. Nevertheless the microscope will sometimes reveal commencing fibrosis in lung sections where ante-mortem radiograms failed to reveal evidence of disease. The clinical methods at present available do not enable us to determine incipient disease. The asbestosis body is simply evidence of exposure to asbestos dust and of tissue reaction thereto. 'This tissue reaction may be accompanied by fibrosis, but it does not necessarily follow that this is sufficiently extensive to produce symptoms or clinical signs or abnormal shadows in a radiogram--or we might add to justify compensation. ' FBOGXOSXS As the disease has only been recently recognised as a clinical entity our present ideas on prognosis may require modification. In a previous article we stated that the cessation of exposure.. to asbestos dust did not avail to check the spread of iitrrtio. This is certainly.often true, but we have now patients whose condition appears to have remained stationary since stopping work in the factory. Thu even serious damage to the lunge is not incompatible with many years of tolerably comfortable existence is proved by such an example aa that of a patient who was stfil able to cany out administrative duties at' a factory when nearly 40 years' exposure to the dust had caused a fibrosis involving all except the' apical regions of the lungs. We recently a female patient, at the request of Dr. C. who after a period of two and a half years' employ, ment as a spinner had retired to get Twenty years later symptoms, signs, and X ray picture* supplied convincing proof of pulmonar* asbestosis of a moderate degree of severity, and asbestosis bodies were readily demonstrated in the sputum. But despite some disability the patient, whose period of service did not entitle her to compensation, described herself as fairly comfortable, and she was still able to perform her household duties. It is none the lea obvious that any patient who betrays symptoms of fibrosis or in whom any evidence of fibrosis is die. covered, whether by physical or radiological tftwwt. tion, should at once cease working in any dusty occupation. A quiet life, preferably in the country, and avoidance of the risk not only of dust but of catarrhal infection, provides the best safe, guards against an aggravation of incipient Septic bronchitis, broncho-pneumonia, and pul monary tuberculosis are the commonest terminal complications of the disease. COVHXXT3 Oecupciion.--An elaborate analysis of occupational factors is not possible in this short article. AB the 6? women in oux series had been exposed, to asbestos dust in the same factory. They were employed in the following departments: spinning, 24; weaving, 5; mattress making, 9; carding and opening, 11; and miscellaneous or unstated, .18. Twenty-two of them began their employment before the age of 18, which is now no longer permitted under Home Office regula tions. The shortest exposure was six months (two cases) and the longest 15 years. ' The 33 men came under several categories. About two-thirds of them were employed in the same factory as the women and had performed a variety of jobs. The others included an elderly sun who was hiwwlf the owner of a small factory, a van boy, aged 18, whose spare time during two and a half years' employment had been spent in powdered asbestos in an open yard, a middle-aged boiler riveter who had served hia apprenticeship as a youth in s shop where asbestos was used for lagging pipes, and a man who had been employed asbestos mattresses in the open air at an aerodrome. Among the men the shortest exposure was 11 mouths (dis integrating department), and the longest about 40 years (clerical and administrative work). Four of the group began their employment under the age of 18. Pathology.--In addition to the autopsies mentioned, above, 10 post-mortem examinations have been made by one of us (S. B. G.) of cases we had not sees during life (3 males, 7 females), but these are not included in our 100 cases. Macroscopically the fibrosis is best seen in the lower lobes, and adherent pleura is very common, but silicotic nodules have not been encountered. Histologically the disease begins in the respiratory bronchioles and alveolar ducts, and is characterised by a cellular reaction rf +sJ laxctt} aot. 4- L. D'ABSEU : 8XmOIC4t ASPECTS OF 1HE SPASTIC COLON [DEC. 22, 1934 1385 34 ' -* . , u .nonuclear phagocytes and asbestosis giant cells ierest, an attempt will be made to * fc owed by the formation of a reticular fibrosis.1 i as an important atiological factor seen Tuberculosis and AsbestoHs.--In a previous article * ion of diverticula in the colon. The iad dealing 'with tuberculosis and asbestoais we recorded ught that surgery, apart from dealing Hut tibl* 10 cases of active tuberculosis in 67 cases of pul* flonary aabestosis (17-5 per cent.;. The figures lure ions such as obstruction, perforation, on, and fistulous ffammmiiwaifoms, enee jjow reached 21 cases of active tuberculosis out of :ieat uti the the iaed -aae. Dloy. eaty :ure* is of 100 (21 per cent.). It must be borne in mind, how* *rer, that these figures do not indicate the per* ventage of cases of asbestosis with tuberculosis in the industry. We have been dealing with a group, costly from one factory, who were sufficiently ul to seek advice at hospital. In discussing this ques* oon at length, Merewetber * considers, after a review J. af the whole industry, that the data axe too frag* {tnentary to be dogmatic at the moment, but that \ whatever " the added, risk of tuberculosis may be ^die* Bat 'd of ribed able j is asbestosis, it is leu than that associated with 1 aiicosis." We hope to publish our material on this 3 abject at a later date. it Complications.--Apart from pneumonia and pul* conary sepsis and complications arising from tuber* 14 of dife oiaa. -usty atiy, itioo '7 colosis, there have been none definitely attributable 1 to the asbestosis with the exception of two instancee 1 d spontaneous pneumothorax diagnosed by X ray, J ad apparently unassociated with tuberculosis, which 3 nay have been dne to the rupture of emphysematous 2 bullae. dangerous operation for the cure of i litis, makes investigation of the earlvr state of tremendous importance the knowledge of the etiology mai b medical treatment to be employed, i important factor, the administration in suspect prediverticolar states ne as a prophylactic measure. SPASTIC COLON Spastic colok is a well-recognised entity/ Dr. Stacey Wilson first drew attention to it in his book Iu Tonic Hardening of the Colon " 1; a tendea hard, contracted colon may be palpated in patients/vhom I have grouped into, three classes. (a) The commonest sufferer is described by Dr. Hardy * as being `vthe emotionally unstable type of individual whose colon is unstable also."/ Often the patient is a nervous female, thin asm unhappy, perennially dyspepticL ailing and constipated, through whose thru abdomenV the racing aorta and a hard tender colon can be palpated with ease/ Radiological safe* 3 We are indebted to our colleagues at Victoria Park and biochemical examination discover an active se. jf for permission to qnote certain cases seen by them, tonic stomachwithpylomspasm and hyperchlorhydria. pal* a For a full account of pulmonary asbestosis in all I have no evidence, nor clo I think, that these patients aiaal 2 is bearings the reader is referred to Dr. Merewether's proceed to diverticular formation. They are a exhaustive paper.* | BBXmCES 1 Oloyae. 3. Roodhouse: Tabesck, 1933, xiv., 445,493, and 650. ft Wood. W. B,, and QIorae.8.B.:Tee Lajcctt. 1931,iL. 934, t Jtewwethsr, B. ZL 4.: Tubercle, 1933-34, xr,, 69, 109, 1s sad152. -------------------- - frequently met with in th\ surgicayout-patient room; it is no place for them they Prepay surgery with groans and a constantly in\ dag list of symptoms, More than one has und< ronw pyloroplasty, many appendicectomy, without 'least relief of their dyspepsia. It it important to remexnter this class of patient LGICAL aspects op the spastic rhea investigating cases o/\pylorospasm. Cannon and Murphy * have produced pylorospasm by COtON AND THE PREDIVERTICULAR, traumatising intestines /nd\ have declared its STATE* occurrence in these circumstances to be due to a viscero.visceral reflex. GQinically, suitable general '1<.d_r_BatrjjcAr.et d'Abeeu, SLB. Binm, F.R.C.S. comical vJfrr. tux wen xatzox^l school 1 OF VEDXC ;, the mtal dcthooxt, cajotft^ lat SOTOICAl ittoisnujt, m osxsbal sc treatment combined Wth the administration of medicine containing belladonna, the tincture of hyotcyamus, the perch/oride of iron and of mercury, often leads to great improvement.) (0) Occasionally spastic colon ocVurs in the young athletic man who suffers from constipation; pain _ Hant patients Vaifering from & dysfunction* ipart from proved ^examples of oma, divertic* &ia, and ulcetative^colitia, axe , ed to surgical a well as medical wards for r estigation. Of this soup the majority us di barg_ed with intact Womens and uneasy minus t/othexi undergo fruitless jparotomy under generslwisesthecia; a minority, 3*ever, operated upon/under spinal anaesthesia, iiiplay a fascinating and/important living pathology. may be a prominent feature an? may `lead~ to operation for supposed acute abdox ' conditions, No abnormality /is seen other tl generalised enterospasm. (e) Far different is the last group represented by the rather fat middle-aged man, muscularWd athletic in his younger/days, sane and sanguine Mn outlook, but worried br an alteration in his bowefthabit and because bis ample meals, formerly enjoyed with ur fS as** Neoplastic, ulceratiu^, and fully developed divertic* 'Ions diseases of the colon hare no place in this '^per, which concerns a group Of cases suffering ?o abdominal >pain* mainly left^ided, but with relish, cause indigestion and discomfort ; frequently defecation is unsatisfactory and irregnlaA Small internal hemorrhoids often develop and the descending colon is t/nder and hard. Rectal examination is sportant references to other area* >and sometimes more painful than usual, but once the spancter *xiated wifn blood and mucus' ik the stools; has been/passed the rectum itself is normalA We atative diarrhoea and constipation occur in equal will consider later that the important pathological ^portions; Dyspepsia is often an important and change in these cases lies in the muscle layer aadAot ^eadjag symptom. Concentrating mamW on those in the mucous membrane; mucus and blood ate *dipmicular conditions, until recently mainly of therefore not always present. The test-meal (i all the [cases so far investigated) shows byperchlor-) `B&sed od a abort paper mad before tbe Ascodabtoa of hydria. t}utline in the radiological picture of the ?teoaa of Great Britain and Ireland at BisnJngbazn on ** 3rd. 1934. . barium enema, as in the clinical picture, is indecisive