Document 9J8evemb23GkorvymqRL46dQ6

PULMONARY ASBESTOSISJ- X By J. V. SPARKS, M.R.CS. (Eng.), D.M.R2L (Cambs.), Lqxoqn, Exclaxo 'T^HE fact that the inhalation of j asbestos dust produces an effect upon ' tiie lungs was oiwerved many years ago, but the serious results which follow -^haye only more recently been recognized. |fe|JTlie pathologic lesions which it produces i^Ppjjfand its symptomatology hatfe been studied in more detail just recently at the City SpJ of London Chest Hospital, by Dr. W. ^ Burton Wood and Dr. S. R. Gloyne. S) As the result of the study of the radi- otogic appearances in a series of patients suffering from this disease we have been `JMTable to gain some idea of the changes it produces in the lung, which may, I hope, in future be of some value in the further y**. study of this condition and its earlier recoga sition. This disease was described by H. K. Pancoast and E. P. Pendergrass (12), $ of Philadelphia, as long ago as 1925, since which time practically no literature on the subject has been punished in America, so 3 fz? far as I am aide to learn, apart from a recent editorial in the Journal of the American Medical Association (1) describing the ariSJ'dssth of a patient from pulmonary asbes- `3 tosis. This patient apparently commenced a ,<> to be exposed to the dust as long as 32 years before death. This would not suggest that. j.V tiie disease was a very serious one from the Jr-i, point of view of shortening the duration of 1# life. ik-.i Asbestos, which was known to the ancient JiC;* world, is a silicate occurring in minerals in i combination with iron, magnesium, calcium, ; ' or aluminum and is quarried or mined in various parts of the world, including Italy, ' South Africa, and Canada. Of the asbestos 1' / imported into England, SO per cent comes l ' ' om Canada, so tliat it seems unlikely that ^ ` 'Prnmtrtl Utf{are ilt UattiolMiwl Seeiely ( Korth America, at the SixU-tiiili Animal Meeting. at Im Amities, California, liec. t-J. lyjQ. you in tiie United States are dealing with a type of asbestos different from that em ployed in England. It seems reasonable to suppose, therefore, tliat an effect should be produced on die lungs similar to tliat pro duced in England, providing that the manu facturing processes are carried oat in the same way. Unfortunately, I have no knowledge of tiie processes employed in America. It may be that we are more economical in our country in that we make use of the short asbestos fibers which would otherwise be pasted and they are used for dry doth weaving. In its natural state asbestos differs from other minerals in that it is fibrous, occurring in long silky strands which are highly resistant to heat, strong acids, and alkalis. * During the manufacturing processes the workers may be exposed to dust containing varying amounts of asbestos. In some of these processes die asbestos content is very high and in others much lower, the higher asbestos content being present in the air of tiie rooms devoted to the textile branch of die industry. I have no knowledge of the effect .on die workers mining the crude material as there are no mines in England. It has been estimated by Dr. E. Merry- wether (2), one of His Majesty's Inspec tors of Factories, diat at the present time something over two thousand workers r* England are exposed to the inhalation of pure asbestos dust, as distinct from a very much larger numlxsr of workers who may be exposed to aslxsstos admixed with other products. In his report, however, it is very striking to notice the preponderance of workers who have been employed in tiie asiicstos factories for a period of four years or less. It seems reasonable to suppose that after some years of such employment the i 250 RADIOLOGY workers may become affected by the inhalation of asbestos dust and seek other Industries. The fact that they cease to be ex- for hardening- into sheets, tiles, building and insulating materials, or brake linings. Sometimes it is carded, spun, or woven into van- *' ; - \i I*'J4 X *.! Pie. L Photomicrograph of tissue from lung showing asbestosis bodies (X 760). posed to the dust docs not, however, pre vent the disease, when once established, from progressing. Asbestos is usually broken up into short lengths before tmjsortation into Kngland. where it is crushed and disintegrated and sometimes mixed with various substances ous products like mats, mattresses, fim-curtains, or used as an inert filling of a heatresisting diameter. That the asbestos in* dustry is a growing one is shown bv the fact that the importation of aslxstos lias trebled witliin tiie last five years, and it seems likely that the study of the dangers which accom- SPARKS: PULMONARY ASBESTOS1S 1251 pany it will become of increasing iriiportance. When examined microscopically l>y darkground illumination the filler gives the im pression of a sharp, brittle metallic wire1 Jpsiijj?'* broken off at various angles and in different lengths, and, licing highly rcfractile. it has rajjS* ^ie aPPeanlncc of.tlie glowing filament of an electric bulb. The fibers can be found in the nose and mouth and in the skin lesions of the work ers. When inhaled into the lung the fibers set up a pneumonoconiosis of a characteris *w tic variety. ETIOLOGY AND PATHOLOGY }*% . The first fatal case of pulmonary asbes- tosis recorded was that by H. Montague r *uv< Murray (3), who made a postmortem ex fnV: .r. it- &:v amination of a case at Glaring Cross Hos pital in 1900. The next case recorded was by W. E. Cooke (4) and Stuart McDonald (5). In die lungs of diis patient dioy noted the presence of certain curious golden yel low bodies haring die appearance of minute crustacean forms. [%;. In 1929 Stewart (6) and Kaddovr (7) f. i\\>: t ;3r it Si i: ` *if< showed that these curious bodies could be found in die juice expressed postmortem *from die lungs in cases of pulmonary ashestosis, and diat they also could lie detected in die sputum. It was diese writers who \* first suggested the name of "asliestosis i - i\- r. bodies" for these structures (Fig. 1). *Uk Later in 1929, S. R. Gloyne (8) showed </ by means of dark-ground illumination that *17: when an asbestos ixxly was dissolved in con centrated sulphuric acid it had a central core consisting of a minute asbestos fiber. He has also demonstrated tire presence of for eign body giant cells in the lung sections from a guinea pig, and states that it is im portant to demonstrate tubercle bacilli in the human lung in die presence of asbestosis before assuming that tuberculosis is present as a complicating factor. Fig. Z Roentgenogram of chest of 'asbettos worker: exposed for nine years: duration oi symptoms, three years. /' Up to the present we hare examined some I fifty cases at the Gty of London Giest Hos- j pita! and have six records of postmortemfindings. The Srinptoms and Physical Signs are described by W. Burton Wood (9) as fol lows: . The cardinal symptoms are-dyspnea and cough; the former is in many cases die ear liest symptom noted by die patient, who com plains of slight breathlessness on hurrying or going upstairs, or that his diest "feels stuffy." He, therefore, discards die res pirator warn hitherto under protest. In the late stage of the disease dyspnea may lie ex treme, and slight exertion may give rise to tailored breathing. Cough is a variable symptom and, though usually present, it may !>e absent for long periods. It is either dry or accompanied by the expectoration of a little viscid phlegm. The sputum in this, as in other chronic pulmonary diseases, may on occasions lx* streaked with blood; this 1252 RADIOLOGY is,-however, exceptional. The only frank hemorrhage noted in our series of cases oc curred in an asixatos worker who was also HIVSICAL SIGNS When the disease is established the skin has an unhealthy leaden hue. Cyanosis may j Kg. 3. Photomicrograph of section of lung of case shewn in Figaro 2. suffering from adolescent phthisis, with cavitation. ' Many patients complain of anorexia, lassitude, pains in the chest, and loss of weight; this latter is a noteworthy feature, for tile wasting may be progressive and in the late stages is sometimes extreme. I>c absent, slight, or sufficiently evideht to cause a dusky complexion. The chest is poorly covered and expansion is defective-- it may !>e reduced to one inch or less. Tim vital capacity of one of our male patients was only 1,600 cubic centimeters. Club bing is seldom a marked feature, but a slight sv.v . sT:? r .; SPARKS: PULMONARY ASBESTOSIS 1253 swelling of the skin above the proximal ends cessation of exposure to die dust avail to' .vf'" of tiie nails is often apparent Corns due check its spread. Symptomatic trertmfht isj to the irritation caused by the asbestos disappointing..as we have no means of re T-. fibers in the-superficial layers of the skin of lieving tlie"'dyspnea which is die patient's . .. die hands arc occasionally seen, 'llie skin chief complaint Prophylaxis is ail-impor-j . in otiicr exposed positions, c.g., the legs of tant and the only iiopc for the aslicstosi giri workers, may be similarly affected. Tiie physical signs in the lungs are those of pulmouary fibrosis, limited to, or pre- worker lies'in die adoption of the proper, means of protection against the risk atten-1 dant on the inhalation of die fillers. j < dominant at, the lung bases. The coarse ersakings and crepitations usually associated POSTMORTEM FINDINGS t with fibroid change are, however, replaced by fine dry crackles. These may arise in ': - the pulmonary parenchyma or be due to the . "> movement of slightly roughened pleural sur : faces. A definite friction rub may be heard ' over one or die other axillary base. As the ' fibrosis is bilateral there is seldom any ap- preciabie cardiac displacement Tiie findings in one case (N. G, female, aged 34, Fig. 2) are described by Dr. Page (10). The body was emaciated. The pleune were uniformly thickened to a slight extent on both sides; some recent plastic pleurisy was present The lungs showed a diffuse fibrosis and were contracted--the left lung more than the right On section, CLINICAL DIAGNOSIS- die trabeculae stood out rather prominently, forming a fibrous network, especially in the When the patients occupation is known right upper lobe. The bronchi were only diagnosis should seldom be difficult except slightly dilated. The lungs were congested ' in die early stage of the disease. The liis- and in patches were bronchopneumonia . - tory of cough and dyspnea^ the signs of pul Microscopically die fibrosis became more monary fibrosis and the situation and quai- readily apparent in less affected areas; it ity of die adventitious sounds, the radi was more prominent around the Wood ves ologic appearances, and die presence of sels and less so in the alveolar walls, while asbestos bodies in the sputum combine to in some sections little was seen but scar tis form a distinctive clinical picture. The sue, with blood vessels and numerous elastic presence of asbestos bodies in the sputum fibers. Some lymphocytic nodules were does not necessarily mean that die patient present in die fibrous tissue, and giant cells is suffering from pulmonary asbestosis, but of the type associated with foreign bodies. merely diat he has been subjected to die in No typical tuberculous giant cells were halation of asbestos dust. The previous found and no tubercle bacilli. In addition occupation of die patient may be of impor to a large quantity of amorphous dark tance in excluding the possibility of fibrosis brown pigment, numerous golden asbestosis from other causes. bodies were seen, the majority of them em bedded in fibrous tissue. If die fibrosis was PROGNOSIS less advanced, many were seen to be in. dumps in the alveoli '(Fig. 3). Varying in i ' It is too early in the study of this disease size and shape, die majority showed a large i to say very much on this subject, but once dubbed head, a segmented body, and a tap A die asixstos Ixxltes appear in the sputum the ering tail. The hiium glands were pig Q Durse of the disease would appear to lie mented, but were only slighdy enlarged and ^progressively downwards, nor does die no asbestosis bodies were found in sections m I'ii trS If h,t i? * HL i i^i fipSL ifr p h- ,1fl h?*:j *'T: jlj'S i 1254 i.v*oa** *** MosmAi. >&* RADIOLOGY 3,; I* Dtvtru. :n2 (}Vfw-Ta! A 3*! efcii 4'S U-ti-sv <Vi mw*.**%i***t{! `.j .A-b*- -w'' JtV- S* XfM. ?*ev .--5: P'S. 4 fitter left). Roentgenogram of chest of asi>csios worker, exposed for f<mr years. Mg, 5 (tipper right). Roentgenogram of chest of patient who showed asbestos bodies in the sputum twelve year* after leaving the factory. Mg. Q (lower left). Roentgenogram of chest of individual who has worked six and a half yean in asbestos. .. Fig. 7 (latecr right). Roentgenogram of cheat of individual who has been an asbestos worker for 1 fourteen years. * iiiZzlt-ii't* Z2&t*$r VS W J' KV vH' i. ill:- Fig. S (upper left). Roentgenogram ot cheat ot patient who was an asbestos spinner for twelve years and had symptoms for three years. Fig. 9 (upper right). Roentgenogram of chest of pattern who was an asbestos worker for seven years. He was under observation for two years, when he developed tuberculosis. Fig. 10-// (lower left). Roentgenogram of chest of patient who tor thirteen years was an asbestos worker. Tuberculosis developed. (Cf. Fig. 10-//.) . Fig. 10-// (tower right). Tuberculous lesion in patient shown in Figure l0-/f. . 1256 RADIOLOGY prepared from them, neither were any has often been noted in the left auricular or found in the sections prepared from the pulmonary area. No appreciable displace liver, spleen, and kidney. The fluid ex ment of die mediastinal contents is usually pressed from die lung was found to con apparent. The lung fields at first show a tain asbestosis bodies and also free asbestos slight relative inawase in density in the fibers. lower zones, due to a lack of air entry, with It is seen that these asbestosis bodies' are out any appreciable accentuation of the found mainly in the alveoli of the lungs. bronchial striations (Fig. 5). Sometimes They consist of a central asbestos spicule some smalt calcareous deposits are seen surrounded by a colloidal aggregate of scattered in the lower zones of approxi blood protein and possibly an iron salt, and mately the same size as die calcifying tu one wonders whether their formation may bercle, but they have a slightly lesser den not be a protective action on the part of the., sity and are irregular in outline. Later, body. One can easily imagine that these there appears a patchy increase in density fibers which are inhaled right into the in die lower zones, which may also involve alveoli can set up an inflammatory reaction the mid-zones* producing a fine network of in the pleura.- One of the first radiologic1 fibrosis (Figs. 6 and 7), which does not ao- signs is often a dry diaphragmatic pleurisy. pear to be of a bronchial type but, rather.,* alveolar or perivascular. , RADIOLOGIC APPEARANCES, These appearances are* described in con The radiologic appearances of pulmo nary asbestosis are usually quite typical in the radiogram when die condition is well advanced. In the early cases they may trast to the coarse fibrosis seen in silicosis, combined with the occurrence of fairly large nodules of varying density in the lung fields and around the tiilsu The fact that there are comparatively few risible changes In the easily be overlooked, especially when one observes the radiograin without any knowl edge of the clinical history. This latter method of otaervation is always practised in our hospital, so as to give dig physician an unbiased opinion of die radiologic ap pearances. A well-advanced case show's some of the appearances enumerated in die next paragraph. The diaphragmatic movement Is limited; its oudine tends to be indistinct and is sometimes uneven. There is clouding in the costophrenic angle due to thickening of the pleura, a thickening often seen to extend along the costal margin on both sides to the apices. The heart outline is often poorly defined, showing a ragged oudine due to changes in the lung around the pericardium (Fig. 4). It is not displaced in position unless the degree of fibrosis is greater on one side tlian on die odier. A prominence radiogram in asbestosis when compared with* silicosis does not in any way mean. that they are of a less serious nature or less advanced, as the density of the silicotic lesion would appear to be greater and the fibrosis of a coarser character, involving localized areas of the lung, whereas in as bestosis the fibrosis would appear to leave very little intermediate undamaged lung 4(Figs. 9, iO*f, and 10-3). The study of this subject has emphasized to me die importance of comparative radi ography of the chest (10). One hopes in the future that it will be made possible for us to examine the workers before they com mence their employment in factories where asbestos is used, so that a comparative study & can be made of the lung condition at yearly 'yt, intervals. When making this examination it will l>e essential to employ the method of comparative radiography which we have at-- SPARKS: PULMONARY ASBESTOS 12ST tempted with considerable success during () Stress*; U. ^ .. 9* JSfrTaantiate Diacnotie of the past three years at the Gty o Londoir Chest Hospital. All these patients; liaving- symptoms, Fuiwdoary Adsmosis at Necropsy. British MfaL Jour, Sept: IS. 1828. II, 509. (7) SirwABT, M. J, and Hasoow, A. C: Joun Path, and Bacterial, 1929. XXXZ 172. (8) Qoma; S. Rgoowooie; The Presence of the came voluntarily' to the hospital, so it must aot be expected, that such gross changes wilt Asbestos Fiber in the I idnni of Asbestos Worker*., Tubercle Jwe. 1929, X, 40MQ7. (9) Woos, W. Bunas Pshuoaary- Asbescosu: be discovered by a. routine examination of.a. groupof workers front an. asbestos factory. Radwpiophtc Appearances is SUi(bm of the Qiosth of Workers hr Asbestos- Taberde; May., 1929^ 353-063. (W) Woo* W* Boetwr, sad Pack. D. S.: Case of . REFERENCES' Potaaonry Asbestosis. Toseodn July. 1929, XL437*4d0u (1) Palmonary Asbestosis. Jour. Am. Med. Assa, Idem: Caseof PolondarrAsbeatosis:. Death fronr Tuberculosis Two Yesrs after First Nor. % 1930, XCV, 1431. Exposure to the Dust. Tabtrdn. Js (2) Uanvenat EL: Tbe Effects oI Asbestos 1930. XLi 157, 13Bf Dost as the Lancs. PuUicatioB a! the (U) StABsa, J. V.: The DUkakfcs of Homo Officer ' live Radiography of the- Chest (3) Mtnuur, H. Uotrncus: Quoted by Cooke. Joan. RadiolJuiy_1929, H, 32S-330L \V. E_ see below. (4) Coon, W. 2L: Pnlnononr A ibreotii British Med. Joan, Dee X 1927. II. KBL (12) Pamgoasx, H. K, and Pawun. . P.: Rargr^eMOwr Reseat KhooA^^^r' (3) McDoxau, SruAsrt Histology of Pafaoeosry Aibestosit. British Med. Jour, Doe. 3,1927, IL 1025. ij?1 oiogk Studies, with Note* an Pathology of Condition. Am. Joan RosnwssoL sndRad. Thee. November. 19B3, xiV, 381-03. i ^ .'S' -i v**<ei.i' "3 % '-Civ Ot'l ?t Vi -V: ;uS;J # .? l f: * V* r ? - tr. K > i v Y