Document 9mk1MK2yYnDpEQ8ojeqbbK1e

S- t* * The occupation-related Cancer of the Asbestos Workers by Martin Noaj^mann with 6 illustrations in tie text (received Qin March 18* 1938) The asbestosis, the occupation-related diesease of the asbestos workers, is naturally tied to countries and cities which have erected asbestos processing plants. The knowledge about Ms strange disease is somewhat older and more extensive in England and in the US from what it is here. But even in 19o6 Marchand demonstrated an asbestos Jning to the German Pathological Association, without, however, recognizing it as such. Eight years Hater Fahr showed a second case and explained it correctly in th'^ most important characteristics. In the past ten years the disease has been studied especially in Eng land, the US, and Germany, and we are familiar, here and abroad, wit-, extensive routine mass examinations of asbestos workers. In Germany, one case especially, whicvwas observed by Beger and Strobe, brought important progress, because Beger examined the asbestosis from the miners logical angle in great detail, and with that triggered corresponding studies in other places. (Koppenhoefe , Sundius). After long years of asbestos dust asthmatic symptoms develop and pain ful death occurs, since the right side of the heart is paralyzed. A ' considerable number of cases is found, similarly to the silicosis, in association with pulmonary tuberculosis (Egbert, Wood), and there are everywhere reports abo't cases, where the asbestosis was combined with a carcinoma of the lungs (Wood, Gloyne, 1933). The number of necropsies is small evrywhere, but they have been very much on the riBe lately. In Germany, there are, up to now, as far as 1 know, 9 cases that were dissected or published respectively ( Mar chand, Pahr, Loeschke, Strobe - Beger, die Biasi, Wedler, Boehme, 2 of the author). Although thcjliterature now and then mentions cases of carcinoma, there are only three publications from the US and England that deal in some detail with the problem of cancer in the asbestosis lung, and who ' express with care, which should always be exercised in the beginning, the suspicion of a causal link of the two diseases. The far-reaching consequences for our insurance system make it necessary to discuss those papers in a few words, before we report two observations of our own. The collection of the 6 ca'ses and^the other mentioned cancers in SCF-FA-0525 8003 1452 PRODUCED BY FORD 2 in association with asbestosi^hall prove the statement that there is an occupation-related cancer for asbestos workers. Case .1. lynch and Smith (American Journal of Cancer ?4, 56 (1935). lynch.reports about a 57 year old worker who had been employed as a weaver for 22 years in a cotton mill and had then worked for 21 years in an asbestos plant. The x-ray picture that was taken of him, shortly before he died, coincides in detail with the illustration for our case 5 - which was bjfeugh^ by Hornig - with the deviation that the shadow of the tumor is located in the right lung. The dissection dis closed a fibrosis of the lung with numerous asbestos needles and as bestos particles and a hardening squamous epithelial carcinoma in the right lower lobe. The tumor is compared by the authors to the Schneeberg lung cancer or to a cancer after a coal dust lung and other pneumoconioses, and is finally compared to all cancers in workers that are exposed to ore con taining arsenic, for all of which there can be hardly any doubt as to a causal link between the occupation-related disease and the cancer. Thus much can be said with certainty, thal. that the fibrosis of the lung.* preceded the carcinoma for a long time, and that it agrees with our knowledge about cancer in general, to deduct the cancer from chronic irritations, in this case of the bronchi. Case 2. Gloyne (tubercle 1935,5) Gloyne reports about a thirtyfive year old woman, whose occupation wi^t ^ithe aBbes^tos began 17 years before her death and lasted for eight years. Therefore, there were nine years before her death in which she was not connected with asbestos work. The asbestosis of the lung was of moderate degree. He found a small walnut-sized node in herupper lobe, microscopically he found a squamous epithelial carcinoma, which could be traced in branches to the tip of the lung and to the pleura. The new formations could very obviously be seen to follow-the branches of the bronchi. The edges of the new formations showed gigantic cells. Case 3. Gloyne ( Tubercle, 1935, 5). The other case in the same paper deals with a sevety-one year old woman with an asbestosis of a medium degree, ascites, and a thrombosis of the leg - in the vein of the left 8001 1453 vv PRODUCED BY FORD 3 Bide. In the right lower lobe a new formation with numerous necroses and caverns which are supposed to have looked very similar to the case Bhovn.by Lynch (case l). Microscopically, it waB another squamous epithelium carcinoma. In the Bumraary, Gloyne does not hold an actual primary location of origin for certain, as for example a bronchus, despite the growth at the bronchial trunk, the tumor could also have originated at many locations at the same time. In thejojfher^case (case 3) the tumor had obviously developped at the place of heaviest asbestosis. In both cases the author was of the opinion that the tumor was not large enough to be accepted as the cause for death, but the asbestosis was also not pronounced enough to be res ponsible on its own, but rather the two together snuffed out the life. The author raises the question as to the causal link, but does not make any attempt in his publication to answer it. Case 4. Egbert and Geiger (Amer. Rev. Tbc. 34 143 (1936). A 41 year old native Hungarian worked, without interruption, for 18 years as a weaver in an asbestos plant. Nine years before his death he contracted pneumonia for 8 days, he retained from this coughing and shortness of breath. Only two years before his death the plant was somewhat treated. He died within eight* months with the symptoms of a pulmonary cancer in the left upper lobe. In addition to the asbestosis, a bronchial carcinoma was found, which was metastising into many organs, microsco pically it was an adenocarcinoma. The authors conceive of it as possible that asbestos causes a pulmonary carcinoma. Within a short time period , their were two cases at our institute of as^bestsos workers with asbestosis and pulmonary carcinoma. Case 5. Own Observation.- A woman of 33 had worked between her 17 th and 26 th year, with a break in between of 1 i years, which means , for precicaely 7 years in an asbestos plant as a worker, 2 years tjpt of theBe she was in the asbestos turning department, the rest in the winding and weaving department. After this time, that means for 9 years, she did not set foot into the plant, and lived far away from the factory. The father-.died of cancer of the esophagus, the mother died of a mis carriage. The siblings are healthy with one exception, that sister suffers 8003 1454 " ' PRODUCED BY FORD 4 from tuberculosis. Five brothers were killed in the war, two siblings died when they were small. She herself had had only the children's diseases. Her own marriage remained childless, after she had experienced 3 miscarriages. The VaR of her blood was negative. I>uring her employ ment in the plant she had had a bronchial caffoarit once, but she had never taken sick leave from her work. 4-3 years before her death she started to cough, later she experienced shortness of breath, es pecially bad in spring and autumn. 3/4 year before her death she started medical treatment, at first with subfebrile temperatures, pleural friction and dragging, left-sided breathing. The x-ray picture from this time shows a strange shadow in the lower left division, which extended in wedge-shape from the hilus to the back. When she entered a sanatorium the diagnosis, which had been up to then for turculosis, was corrected into pulmonary asbestosis oand, instead of the very dense and large > shadow in the area of the lower lobe, there was now a tumor, and at that .in causal link with the asbestosis. Th^'body was very thin and pale. The lungs were intergrown in the sur faces, the same the organs of the upper abdominal cavity. The lungs were bloated, and the cutting surfaces were reddish-brown, Bmooth, and full of foaming fluid, in which asbestos particles were found in great quantity. The cutting surface of the lung divided by a network of slaty strands. The left lower lobe was very hard, slsty or white. In the ex tension of the main bronchus, and connected to it openly, was a cavity, limited by spikes of walnut-size, through which skeleton vessels and bronchi ran like a scaffold. The further environment of the cavern was callous, the pleura above it full of nodules and thickened up to 10 mm, its cutting surface was dry, subdivided and white (cf. ill 1). Liver and kidney contained metastases, partly in the form of fully developped nodes, partly a callous whiter gridwork. In the segments of the lung that were free from cancer, the familiar picture of asbestosis could be found microscopically. It should be noted here that the callouses were in part quite considerable, and Bur passed by far the pictue of diffuse lung fibrosis, a6 is known from dust lungs. Especially striking was the great number of gigantic cells around the asbestos particles, also compared to to which 8003 1455 PRODUCED BY FORD 5 I had access, that is to -the cases of Bahr, di Biasi, Loeschke, and Stroehe -Beger. The tumor itself was a calcifying squamous epithelium car cinoma, in whose epithelium cone and stroma whole packages of asbestos needles ana asbestos particles were found (ill. ?). The metastases were of identical structure, but without asbestos. Case 6. Own observation.- A 55 year old man had worked between the 36 th and 43 rd, that is seven years, in the asbestos hall of an asbestos plant in the preparation for the spinning, then he was without employ ment for 3/4 year, during which time he contracted pneumonia, and then he was, till 4 months before hie death, employed in a wool - laundry. Be had not been irJ^the sVvice in peace time, but he was a soldier for three years during the war, he had had diphteria, scarlet fever and malaria. His weight was never above 65 kg. He probably started to com plain about dryness in his throat in 1919. Later, he was treated for bronchial cat^arrh and excessive stomach acid. 13 months before his death he lost a good deal of weight and developped bloody sputum. Tu berculosis was suspected. Four months prior to his death he stopped working. He was coughing and had shortness of breath. The breathing was dragging on the left side,and there was a damping and wekened breath ing. Th sputum contained great quantities of asbestos particles. The x-ray picture showed ..a *eep shadow in the area of the left lower lobe (ill.3). His doctors , Schulte and Reichelt (Hannover), diagnosed from these Byuptoms an asbeBtosls of the lungs, a carcinoma of the left lower lobe with spreading in the peritoneum, based on the narrowing of the esophagus which showed up in the x-ray picture. The body showed intergrown lusgs with bloating of the lobules and a finely structured steelgrey and coarse gridwork. The colour of the cutting surface was otherwise reddish-brown. In the segment of the lower lobe there was black and white speckled tumor, which had spread to the neighbouring organs of the pericardium,. the left chamber septum of the heart, the diaphragm, the peritoneum of the left upper abdominal cavity, retro peritoneal tissue behind the spleen, the group of lymphnodes at -this lo cation, and tie lower thoracal and lumbar vertebrae (ill. 4). In the middle of the tumor, in extension of the main bronchus, there was walnut-sized cavern of decay with tindery edgeB. 8003 1456 PRODUCED BY FORD 6 8003 1457 The microcospic examination of the cancerfree segments of the Hung showed an astyestosis which cuold well "be compared, where degree and extent are concerned, with the> uncomplicated death cases. In the left lower lobe a strongly decaying calcifying squamous epithelium carcinoma, which contained asbestos needles and asbestos particles. In the lower left lobe there was another^segment which attracted attention because of its hardness (ill.5). Th^microscopic examination showed here a pronounced wild growth of the broncial epithelium, which was spreading in limited areas as a true carcinoma. The lungs were, in the areas of callouses and alveolar caverns, as rich in macrophagi and giant cells as was case 5. We summarise the quoted cases and those of our own observation of asbestosis and carcinoma in a chart: Chart 1. The Occupation-related Cancer of the Asbestos Workers nr. author aee/se* fcgf|Bt8 work ifBtinsl,eBtos Sgjft; fin. 1 1935 Lynch Smith US 57 yeras, 21 years male ago 21 years squamous epith. ca. right lower lobe 2 1935 Gloyne England 35 years, 17 ys. ago female 8 years Bin. squamou epi. ca. right u. 1. 3 /illegible/ 71 yrs. female 15 yrs ago 1 year, 7ms. squamous epi. ca. right 1.1. like case 1 4 1936 Egbert Geiger US 41 yrs, male 18 yrs ago 18 yrs adenoca. bronchus left lower lobe with num roetas. 5 1938 Nordmann 35 yrs (Hornig) female 18 yrs ago 7 years squam.epi. ca. left, 1 lobe, like case 1, met in liver, k 6 1938 Nordmann 55 yrs male 18 yrs ago 7 years squam. epi. ca. like ca 1, spreadin to heart m Germany: 12 dissections, of which 2 ca. ........ about 17% England Wood) 12 cases of death, of which 2 (5?) ca. about 20% ' PRODUCED BY FORD 003 1458 7 The data show, that asbestosis of the lung goes in a number of cases hand in hand with pulmonary cancer. This occurrence could be a coinci dence (Gloyne, Wood). But in 1h ese 6 cases that were observed in de tail, there were so many characteristics that were repeated, that fte cancer in the asbestosis lung seems to be of a causal relation. Pirst of all, the email number of the case should be explained. The number of the workers that are at risk in the asbestos plants is by far smaller thatri the overall number of employees in the factories. Por example, the^umber people that might be concerned in Germany is estimated only to be a few thousand. Only a fraction of those really work in the asbestos dust. Furthermore, many of the employees are women, and they are often only for short periods of time, as are the men. According to English, American, and German authors, it takes several) years for noticeable symptoms or objective signs to appear that Bhov the inhaled dust. Thus, we can not operate vith large numbers , where our problem is concerned. Furthermore, the attention about the occupation-related asbestosis has not been been at"Cacted for long. The great majority of the papers of the medical field in England dates back to the years 1927 - 29 (cf. lit.) In Germany the asbestosis of the lungs has only been dis cussed in detail since 1931 / 32 - with the exceptions of the two forerunners Marchand (1906) and Fahr(l914). The same is true for the United States. Our chart shows very clearly that the studies which are especially dedicated to our problem, were published within the last three years, nothing is more natural than having the detailed study of a disease only when the disease itself is known in its main symptoms. If we can only expect small numbers, we can only use the dead patients for the deliberation of the occupation-related cancer of the asbestos workers. In Germany 12 dissections are known, including my own, two of those had cancer, ca. 17#. In Hannover 3 cases wer dissected, two of which were canorous, another, 4. case, with unfavourable prognosis, is under medical care, and is, probefty, wilhout complications of can cer, that means then ca. 50# carcinoma. The number of the actually dissec ted cases in Germany is probably not much larger, due to the scant pub lications. In England there is a survey of 100 cases, which were ob served by Vood. JO# of these are combined with tuberrculosis, 17# not PRODUCED BY FORD 8 yet certain, the other 55 are certain asbestosis lungs. IP have died, two out of those from pulmonary cancer and one with "a few deposits of growth in the pleura*. 2f we disregard the last ambiguous case, 2 out of 12 asbestosis patients would amount to M% cancer victims. The small number of cancer cases can thus not be used as an argument against the causal link, it corresponds to the status of the scienti fic study of this problem. The percentages that J quoted, and which are calculated from such small numbers, cannot claim to be the actual percentages, but they will help to study the problem. We are, in fact, hopeful that the efforts of the plants and and their doctors to improve the conditions in the factories will prevent a fast rise in the observation material and will take care of the danger as it is discussed here. The most obvious argument against the causal link between lung cancer and asbestosis is the large number of lung carcinoma overall, and especially its prevalencejin the age group of 50 - 70 years old. Concerning the age group, the chart shows that half of the cancer patients were younger, two of them 55, one 41. The increase in youth ful cancer patients is even surpassed in importance by the fact that it is such an even time span which passes between the beginning of their work with asbestos up to 1h e death: 15-21 years, an average of 18 years thUB, which time period is met exactly h^ half the patfients. The ahortest time of 15 years till the death was for the oldest in the group. The older patients amongst the victims have thus started their exposure to asbestos much, later. The achieved age, then, does not seem to be then bo mucfwVi^a^dispoeition of the cancer for a special age group, but seems rathe^r a function of the develoment of cancer in association with asbestosis. Again, 4 out of 6 patients have /ent only part of the time an in the asbestos dust, but then it is always the firs* part. After the asbestos was deposited in the lungs, and the people refrained from further inhalation, the development of a cancer could still not be prevented. The times of employment amounted to at least 7-8 years, only for the 71 years old woman it was 1i years. But her asbestosis- was very considerable. Therfore, as was proven already by the microscopic study of the sputum already while living, and just 8003 U59 ; PRODUCED BY FORD 9 just as surely by the anatomic examination of the lung, thre removal from the factory does by no means cause the removal of the asbestos from the lungs, nor does it prevent the development of lung fibrosis and heart muscle hyper plasia with the corresponding, if maybe bearable symptoms. This development, then, reminds of the experimental tar can cer in most impressive manner, when, as is well known, after a certain t#me span, the development of the carcinoma cannot be stopjftcd anymore, even if the brushing with tar is stopped. Thus, the ema11 number of observations is balanced out, in our opinion, through the patterns they seem to follow. Independent from tire age, the cancer occurs in association with asbestosis, also in young people, after approximately 18 years, after there were several years of exposure to asbestos dust. The comparison of the cases yields still further similarities. It is, first of all, understood, that the cancer is located in the lung itself, and thus apears as a clear primary cancer. Furthermore, 5/6 of the cases are a callous squamous epithelium carcinoma, and again 5/6 of the cases the carcinoma is located in the area of the lower lobe. As is well known, the cancer of the lung is usually mostly located in the bronchial mucuous membrane, an ad^no carcinoma or a small-celled, rather indifferent tumor. The squamous epithelium carcinoma ranks only in third place In many cases, the actual cause for lung carcinoma are not known. But it is supposed that often scars and bronchiectasis formations precede a lung carcinoma. In those cases the development of the cancer is sup posed to have been caused by the new growth around the lung tissue, because a large number of cancers develops-in areas of long--peroid growths around tissue. Gloyne described the^ cancers that he observed as small, in no place had they excessively attacked life-necessary tissue. But atill he was not succesful in totally ruling out the mul tiple point of origin of the tumors in the lungs. Vhere this is con cerned, only Egbert and Geiger's case seemed to be non-ambiguous as a primary adenocarcinoma, it is located, according to the illustra tions, as a round knot arouna its primary location in the bronchus. Lynch ana Smith, on the other hand, had first thought of their case as a hardening tuberculosis! e think that we ourselves have observed the 8003 1460 PRODUCED BY FORD 10 smallest tumor: in the lower right lobe of our second case. The growth of the bronchial epithelium that can be recognized as cancer here in non-callous layers of flat cells (ill. 5) was equally developped over a larger area, and was connected to the also otherwise known branchings of the bronchial epithelium in callous lungs. Therefore, we think the multiple, roetaplastic squamous epihthelium carcinoma of the.'.bronchial tr^unk to be typical for the asbestosis, with the other known form of the adenocarcinoma being the exception that confims the rule. The observation and interpretation are the same as for the can cer on the basis of .a cirrhosiB of the liver, of which existence nobody is in doubt. In this connection, the argument will be made thta a gr^oth around the lung tissue is not sufficient for the etiology off the cancer..: It should r- be expected then that the occurence of the lung cancer voul&be much more frequent in association with silicosis or tuberculosis. It would amount then to giving the asbestosis of the lung a special role. According to our opinion this is the case. Tuberculosis and silicosis show certain similarities in the growth, that the lung experiences. Afterall, both diseases of the lung are characterir.ed by the rplacement of tVvxlung tissue with cell-rich and finally connectivetissue-rich callouses. These changes correspond to the tubercle bacilli at certain places or particles of atone dust. In this, it shall be assumed as correct that the particles are carried together through the lymph stream. Therefore, in tuberculosis and silicosis there are, side by side segments that are doomed to decay and practically untouched tissue. In asbestosis, howver, the changes in the lung have been right from the beginning, been name d diffuse fibrosis. Our own experience with as bestosis confirm this. V/e do agree with di Biasi, when he calls large callouses as nothing extraordinary for asbestosis, in our cases, too, there were these larger callouses. Therefore, the diffuse fibrosis of the. lung with asbestosis can also not be compared with the truly even fibrosis of a obstruction lung. Still, the name of diffuse fibrosis should be retained, for the asbestosis does not have the nodules and nodes of the common silicoisi These nodules have a fibrous, concentrical ly layered nucleus and frequently concentrically layered fresh granula- 8003 14 61 PRODUCED BY FORD 11 ted tissue. Contrary to that, the callouses in asbestosis are triangular, and they are even in fibers and cells where their composition is con cerned . Due to shape and size of the needles they are not being floated to^gether in ^the case of asbestosis. Only very small quantities arrive in the*Smiddle peritoneum through the lymj^ vessel s. Despite very careful examinations of all groups of lymph nodes we, too, did not find any asbestos needles or particles to a larger extent in the lymph nodes. The asbestos needles remain then, after being inhaled into the lung, distributed all over the organ. This is even more obvious if not only th/ asbestosis ^articles themselves, but the amount of the bare asbestos needles e&e considered. Therefore, due to the diffuse spreading of the asbestos needles a ju6t as diffuse chronic irritation has to be assumed which triggers the diffuse proliferation of the lung tissue. According to the studies o^ Beger in Hannover thiB is supposed to be a silicate which is freed at the dissol ving of the asbestos needles, di Biasi, the morphologist, thinks it just as obvious that the manypointed needles affect the tissue in ^me chanical manner. Morphologically the proliferation appears as a fib rous connective tissue, which is however accomanied by a number of cellous elements, among which is the formation of the foreign body gi gantic cell., which is cell grwwth that can be directly linked to the asbestosineed3emiandra6bestos particles. This formation of tfrs foreign body gigantic cell was, according to the histological samples in our two caseB especially high, and it could be observed all over the lungs. Gloyne observed similar facts. Hand in hand with this formation of gigan- Stj tic cells there were groups of macrophagi and other granulations in the area of the formation of callouses. There were also lymphocytes and and plasma cell infiltrates. Ve have then, in association with asbestosis processes of restructuring and growth evenly distributed all over the lung. This growth irritation persists - as was to b e seen from our staistical obsevations above evn when the inhaling of new asbestos dust is halted by changing the place of occupation. If a cancer develops under such conditions, it could be effected that this new kind of growth would also be in a diffuse form. In our cases and in the case 1 (Lynch and Smith) and case 3 of Gloyne's, which are PQ8003.. 1462 ....... PRODUCED BY FORD 8003 1463 12 very similar as per illustrations and description, the growth of the squamous epithelium carcinoma is also roakroscopically much more even ly spread in all directions, especially also in the pleura, as a knotty bronchial carcinoma, of which there is a representative in our chart, too. If then there is, in association with asbestosis, a diffuse growth irritation all over the lungs, there is a corresonding diffuse s reading of the later carcinoma. According to different opinions the squamous epithelium carcinoma of the lung is directly derived from the alveolar epithel\um. It shall not be discussed here, how far the covering epitheli of the bronchi approached the growing potential of the alveolar epithe lium when spreading into other organs. But if this idea is adopted, the connection of the carcinoma to tiie proliferated alveolar epithelium in the shape of macrophagi and gigantic cells is direct. At this^oint, thev methods of morphology cannot interpret more from the findings, which would speak for the causal link between asbestosis and cancer. It is too much to ask to have the first rePort on an occupational cancer simultaneously sovve fully the cancer problem stemming f^rom this new exaille. It can only be demanded that there be no contradictions to the patterns that are known so far for the formations of tumors, and that observations with similar occupational cancers coincide with the findings. The closest is the comparison viih the Schneeberg lung cancer as Recognized occupational cancer of the miners there. Here, too, we frequently find a squamou6 epithelium carcinoma of the lung. This occu pational disease surpasses statistically all the other conioses in the number of death victims from lung cancer^, bo that one is almost pushed to the opinion that the chemical quality of the ores is the de cisive cause for the development of the lung cancer. In these cases, the thought came up about the co-affectation of the arsenic and radioactiveV^of \he Btone in connection with the coal dust. Thus, the asbestos could have contained carcinogenic substances, too. In repeating the results from our statistic statements, we summarize our observations: Indepent from age, that means for young people, too, the cancer in asso ciation with lung asbestosis occurs after approximately 18 years, if employment was several years in the asbestos dust. In the overwhwelming majority of the casees of the published cases (5/6 of all cases) the cancer was located^n the lower lobe and was 8 squamous epithelium PRODUCED BY FORD 15 carcinoma with callousity. In the lungs, that were for years exposed to the irritation of the asbestos needles, there can be morphologically seen the signs of a diffusely spreading growth irritation in the shape of a diffuse fibrosis, desquamed alveolar epithelia and foreign body gigantic cells around the asbestos particles. This growth around the lung tissue is pathogenetically a well-known basis for the cancers. What quality of the asbet^o finally is the final cause of the develop ment of the tumor, is so far not known. Therefore, in order to gain recognition of this cancer as an occupation al disease, it does not take bo much the proof that a cancer is possible at all according to our status of knowledge, but more the proof that it practically repeated in typical form in sufficient numbers. Even had 1 been the only observer, I would have been convinced that there has to be a causal link, in connection with Hie older observations, I arrive at the absolute certainty that we are indeed dealing with an occupations cancer of the asbestos workers. 8003 1A64 PRODUCED BY FORD PRODUCED BY FORD i ;> 1 o09 o o* o ^ir* fAt** firm f*t**A*i*^n W M*p*^a*!! \ M. Mmttia Ofr Hrroftkrrln irr Aibe*trbtl(tr'. Vo* XirHi KHium. Utf iT*ifiMWn. n ft. 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DW RtVitfenaufnaSme, dla rean W ISm maehta, kwrt iNnnr er atrV# attmait feta mR dee mn /foraif ^elirachten ,\UAInta an (wwerem M ft Qforein, wit tier ASefbbimf, tU9 dee ttf? T mw*wSattm In dee eeehten Un|f nltxt. Kan iteflta dvreh <fla SA(e .t rinr HIetIa dee tang* mK uMretcWn AW*tnaaleln end >lwv<w4`kiVprnhei and eln eerhornendea FlatlenapMSetcareliiom h neStm InteHapfan W. flee Tmr aln! row den Veeff. an dW Sefte 5e* Schneebetget f^trnbrefMr oiler anck eine* KreWe* narh RnMenetaablanga nnd amlreen fnenmokonkiNen gefeflt, and aSW9lteS eerglkhen mil KeV> Irl Artieltem In araenhattlgm SIrtm, lel denen *n*i an tinea rwIrStfc-hen ^naammeeiSnng >*kVw tVr Bemfwehrtnkaf^ and ifem Kn-W k*m gmaelfeh veed*. ftetlrl We kOrnie mil 8*eherWH W. k*fart aenlrn, iU0 die Flhrtad* <frr Lunger* dem Cttvlnom tang* 7si vftmtHgrlaafen e1 *rf d*6 h mil der Kenntnla vm KveW Ibee- k^itfg In Klnklang atehe. den Kteha eon eSronWhen Rntn, III dlenem 1`alW iW RnmrSlm, SenaleMert. Fall 2. ftfojae (ToWreW IMl, 5). fflofmr Wrirhfet AW aim i^JiS* *k* Kim. ilrren TktlgrkrlC In Adnt 17 Jahea eor dem Tmf* Segam% awl a ' Mr andanerte. AW tagen roe tletn Tiale JeHre, In denen ala nil ih? IdratarMt nkSt In IWAhrnng t*mf. Die A*W**mk* fief taw* nr mi Bigen tlrarlea. fm reehtm OSrd*f*fien find er etnen Vk4nrnaalnn0(tru6en Knoten.faikroHSrppWSeinHattenefilHeWrflmrro/ ' ii li in A'Hhirtfem Id* tap Langenp*tv rmd Pfenm eerfnlgen lie! Iwta f<der tfie Netihlkfnng gan* oMenWr dm Veftarlganaen flee Penn. SS-n. Ata Karate der NetfldSIting warm rirahte Zeftrn in Waditen. Faff 3. fttfUfmt (TtilerrW 1933. ft). Utr imfrre Kail tfar glrltheti YfeidfenllirStiitg hamlett met einre 7))iSrtg*A Krao mil Aebeatfftda fffrl<n`hveret t Irate*, A*tRea m*l fleinvmenlhn*mhfaieder tlnken Sell*, tai rerStert t'ntrrhftfen efna Nealdktmtg mil uMreleton Xckmaea aval Saternen. die deal von tpfk (Kelt I) itgebildHeri Kail* ihtttleh ge- *krn Satan anft. KUtroakupiarS vledef eia Ptalfenefdfhefcafvlnufa. fa drr ZfMmmtafuanf eracSelni fftoynt rht elgentlicSef pehniror AajNffatAk(, *. 9. eln Broncho*, nAeSt gam drW, tmU dea Waeka- *- ` i rn r jg fpn V. ,\Wmm * far tknfitrrS St .WmirMn. 291 (nm< m IUvitrMHNiitM. tW T*w* kiiiiw torh an rWIn Or^, m \J**<i*** ilfr Lnncrn ml ttaSm an RtfHe dm nwnntfSr aeSr tfSMeti jWrfiftHif wMrnutfn #i, foi wWtm fall (Vlt 5) *aTtlf (WV^ ofUmtS-SflirH an frr Slfflr tUr tirk"t mtalrkirttrn A*bf*toiii jftjSn ?S4i*ttr**f Im BfMeS dm flntan Vti>f'apywtia Wn Tamer, ^ **af I" wmirlMrSeai ZnaartmwnSanr mfl Sr AaSfdcada, an. futirVii. fn Wlf riflpuHtttfilw \W. rffft Qarfnrk,ff>9<Jl(fT^t ^ frSS* mar arSr mafrr nmf SUB. ttt* Langert arm PleSm* nirSt k*iB gem* mar, nm ala Tn1wrn<eHt r gelten, a*mr ivk arMan IStn n*cS H*rr RrSwrtn !fn Tl nkrSf a!Ul ufi TrrrarS^r*, aSenao rih <>nt*na tf* oSrvm Batn-St*. DU l>nyra ** ffW*S, *tf Art BeSnlttffitS* rrAt'tann, *latt nnd nlt *rSi*m*a> mrSt tn bafmn. Vlelwflir Sit Ian ticbla iMammni U* Lrhm TemleSu^ Dee Vwf. atrTft *Mr Kragr nacS Hem wraleMirHen famawmefiba#^ rW *Vr I* m4**t fSiWtatlon rfaecAaw latnen Vrraoch vntama&a^ da tn l<nn(nrtm, Fall 4. A>Vrf nm! ^irr {Amrr, Htr, TV. l J4J fMWjJ. Itjlfuipr ifMHitrr fUgar arVftrta tnantwfrcSn !l JaVr* aS W'r (n rltirr A*Mf(irik. Von rUer Jtfiglgtn Lm|fnnrttflnif^ 9 We tnr (Inn TnS, MiWlt ft Mwrfen twa! Atrmnot tarSk, 9 JaHre *nr Tta *tmte mine FabHk efnlgermaBen aanirvt Er *P*rh Inner*utlh tot 9 Vmvttff wlff dm &rWn(K^fi f^HnttnkrrlMfi Im llnkm UlfrWpfWi. Hln faml man itltr det ASort*. #S eSt In anklrrS-twn Organm matactaaffmalm BwHeMikanln^ wlkr<kn(n<r!i ,Wen**rrtno. IU Aatoren Saftm e* rfarckiai RH^firh, fn0 der A*!ie*t rln Dingencareivvnn ertrugt. *. fa knrtmi AVfataf warden In awnffa thrift at S PtOm SoWlli an ArSilnn nl( AdaifmS nrwf ('irrbwm iVt Uinr, VmW A. 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A*emw4 fin, lawawlnt rMlmm Im FrtlS)nSr wnd HtrM. '/ ^ PS!VSnHlflieSadrr Lami* vardareS aeMafrStrtUrSrgtrtngr nfUTOrmlg tnr IKrftn Talf kam da Si IrtfUrl** PeSarwIInng, tnnAeSat mtt wV rmndeH. Drr Bnla UnterUppm var.aeSr kart, acMafrlg ndr veil. la (rhritfn Tfmpftafnrfn, fJrttHtUcSmn Kefton omf vSSppandtr, Bala. \ MingMangdea HanpiSfeneSua and nK DimSeffnwr VarSInrfangataiaf *lti](rr Atman*. f>u RAtfjfrnWVI to* dW 2<H arVtt tWn dpa riaxarty bnmmttar HoAfraaoi ron WUUaOgrdfta; fnre* den alfbtfavt* art Stan fV*hatfn Im Mhi I'atrrWd, riot krilfOrml| vem MHoa aac% tWlBe *i*l Rnmeklaa W da Wnbaank HidttftltKgta DU tdtm frn> Rflrkrn v%. fn finer HrlbtltS (ffl. *lla ArWl von No***f Ikr t'mgfImng drr Kimm mar ilerk, dU Finn dariSrr tnotlf Sla ta 10 m dSmen Fa>!) atflRr man die IUnri| Dia^nma a*f Tfcberkvloaa iSAHk mdUkt, aaf dUr SekmlttfUeSa (neba, (afaV&art and d6 (vKl ASS. 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M fcefclm mtlitnr .Tahie In rutWft! whtf. iVt Vft|lrlrK tier KtV frpl^ tVr wV rWrv(nrilmfmm|n ^kftnkmipn tl Unpiyefbi terck Hne ifCrntbf tnrl cMIrOfirb l^ftr^er-WeVHe Sr>i*irW eractet. Dim# Vfrlndnumw antapm hen M rt neM^mllniHirlt, tfB lift Kreln l dw t*mjte |akffn Ut nnd Met tU *ff*Vpitfijtrr f, lMwIrVrata ereeVmt. Avl^, ,lre nn bWlmntffn BteTItn mtwueriet* Tnhefkeflamtefl erfer 8fr4n. attfnltfrtVhm. Et (l 4a() dU AfimSim ik ikbll^ nrtWm te, tWm tamlt-lt ft W-S Wl */# ter KWf m fin \hIhwwwIm VUttcWfiHM. t*8 tfleo* Tellekm lank ten LjrfnpMroiB cnrrmmn wtef wMtrnm In % der W*e Nf*t flat (Vretnom fcn <lf !Vr Krfla tier Lanxr W hekatmfHcS In <Vn mefetaa fllba |winlf In W HmnrKItWKIrhnlitnt ?Wef% rm AilwwnMi^ orW rm slrmHrh Itelifferenfer Trim*if. (>m llttlfivpitlid errlm>m tin It'ntf Hfhl m Ifiwfirkelt eM an 9. .Sltllr, Brim (^nunenffimm #!*? In rVIrn KilVnlif rigrtitttrhfn I'rm^ nnWkntmt. JehrH dnrflft) S*fl*n, UnntMrkU*mtMMtn^n tlim l^wymth-lwMHt vft rumwtewfeft. 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Mfb In wiarnn FHVn veren aulrbf ptllWn 'Hrbtlflfti vorbanilm. fkalitr Il0( brh (fir rfiffua* IKfate tier nKtfhlunit nml IVnlttUR flelchen tenm Mm Krfbi inf (feet Bate Itwffo l#l tfer Arkrettaf* mh nfc-M rrrxlelrfim mil tier lrkllrk |Wrb. fitter 1/WrfitrbiMf. an rfmen HealHlt nWituml ttflfcll. In ((Win 7wwfnwtnhn^ tin! man d*n Klntraml erbeten, te eln (ifftfltnnmSnn iter !eng* Mr die Adotit* dn Krtlet mrh kip tlliem VlWnte elner StaminKnlonfr. lAmwcN dOrfla *frr Avmfnark Vr ttiffai*ti KlWtim bfkqbrbdtm tefn, dettn r frSIm brf Afteafite te KniVtrHen and Kmfen te gemHnrn ftflroafe. i>le*e XnWrkm nlrM Man dflrflf alnlann rmartm, tfatt ibr Uopnlnk Whm f+nen fISrOtn. kontmtrWS jwMrMrten Kfrfl nrf t. B, W dfr BiHrmla mite dw TnbevknVx* tW blnlipf vln. El IlM pn*K kmttenfteeli nnf(affte fakVm Onndutomtuti. 0* PRODUCED BY FORD ft l- 00 o o rOo :*0> M* ftyfM rio.1 .(>r S, tan trim M Hrr Aabartiri* iltr"kk( Hint In Ihrtr Tm. matitimirtr.iitiir hhi h fWm wbI Xrth,n jlr^1in,'i0V Wrgrn Hit Wan mat ISaiiBa liar X.Wn knnaant a* awk VI Aar lit plivr Znaaiaainnnntliwaiatmiiitg. Anf 1V1 LvanfJtoap galattgan "In nnr lit lam .Vmifrtt In *V Lvanitfiktiotaii ^ SlillalfalV. Anrlt nit Vim 1ml* n**Ut!i*rT Vatarrmrkmig alfc* f.t mfiMlniitrfntnipf^n alarttbar Matait* katiao A"lmtO"l"klV[wrtVn gjn .IVurnMn rlnt1m. IV AaValitaafrbi MalVn abm narb IVn Kattalmmig In ilif f.nttg* Rlt |I* gtntf V*n rlrlHIl. fin* I4IH nock vial ntaltr In* Am*. nw wan 4*M taiir alia A*V*ftwHak6rrnfrbtn at||^ awalnn ilia ffllk tin mark lata .lakarfmilaln naif barllrhalflitlgt. Fjr nla* ah ilurrli all* allffaw Varloalloaig tlar Aalntlianieh ah rVir*. illltattor aKa.mhW 1W* in ttrtamrtrnaii, tlar HI* Hilfmn Ft*, lifaralittn ala* l.mtaaairgmatrr* linklat. Satll alaat VnlaanaeMiaUBai an Hayaa laa llnattmvtf "ilia a* *lala Hnbal aaan aln Wllail bnttaltln, af*n U lira AnfV.ii..* Hi" Ahr*l noHabt fwf nbal. IWt Mna|ahnliaan ii Bmi ll**t alaa Ilanlanka mitai!r.t"ra* alwaaat anaV, il*B alls vtalan *pit*** Nattain attf naaahaiilarlta WtW Him Mirkntt* auaflfm. Slurphologodk trill alia rrtalifaaalliin ala faaanrlclta* lUanltgtnaW In Kmthrtmtng, ta .Ian Ala alar alaaa llaHaa taW**a KVmania ir-alVat. Halo grWt 4b Franaalka'aaparriaaaniatllnlilaifni ah alia tannaltlallaar aaal alia A.tr*ln*H*h anal A.lr*1tri.ki>|.Trti*n to InalaVnala Zallnurbarttn*. Ilia* Hhana- tatllallalniait oar aanalt alam Bnalniak alar WatAajVlaan I'ripnrata la anaatamn tralan Kalian Vantalaaa grnB oral Olar alb gaatta Longa Mnotf |a*tr.nfallan. AMlrha* l*(Vrl f.Topar. Hnatal ha llanal anil alitor RlaamtrllblMmig glngra V.knt(>K*aia*rai|a|am on.1 at*lata llmnnlatlonao la HrraiaV alaa hit* ManUkl*^. Aikla Lrmplncyten onaf Plaaaual. laaflllaala waran irwlaanalait. Wlr Wat *1*1 lot alaa .\*ba*l..il* Obtr alia gnnit Lnngt ulrlrktoHlj aarlaalla MWlitni". aalar VniVtlvnr*iiga. flh-arr kVaaVlomartla Mil an. aria an* tttt*rrrn nfifbtW-btn IVtrartonngaal obtn karrtaf*. gangrai wt. anrk naatn alia Znlnlir vial netiain A"V"l"laaili thircb 4aa M'r*-W alaa ,Arlaaal*|tl*a*a* aintarlaaaaaalm V. lira alaa V.itMa-laiait* altar* Krrl-aa lantar aalalirii Vor'otlingttngm kimtilt man aranaalrii. alaO ataak allaaa- nttt*rti*t Wnatiaftin* In tliffarr Wala aitialagrl win!. Ill ttnnarati Filh-n aanal In alam Kail I <tjraa* ,,nt| Nmiltt aanal Kail .1 Vint Wajar. alia naalt AMalbliing nnal lltwbtb. imng rtn.it.lir gtrVlirn. art ala* WnaMnnt alia MaHaaia|illli*V*relnoK aatalt aaaakat*ikaa|tln'lt "alar vial gtrlrtimiBtgtT i**tb abm Sallrn rrrbaalIrrl. ItHlaaaaawIpra *ab In alar llanra, ala aln kaiaitllgc* BronrlitaVanf. Ikl BamWkaaha Ira Aahrafarbalttt. Jy| (k~ .jrtt-ta-n l**ralanaana. Narb aanfarrn Atm-ltatamtam alrtl tlaa t*1alfan> rfjtla-kan-iaattan alaa laaitoa allarkt vnaat Alravlarafaltkal alKaWfa*. MV <rjl kb *laa IVfkrvHllta! liar HnanrMan M tlaa K|ntmmng In arlrrVI- flai*aaan alam AltmolaraftltM In nalltaa MWaanntfatlratl niSarf. naa lat Wr rrOrtarl armlrn. Mark! man aVIl alar allaaa Vsratallaay an a la,n. h alar AnnrVltfO aln Carcltaana an alia paiJiVriarlrta Afraaalar. r^ilaVn In l>*l*li alaa Maknafafiagan nnal Kbamrllm aln mtmKM. laaar. Mrlaf lot mil aim Mrtkaatm alaa Mtaapkofncla lata Zall nla*tl atM Va flafaiiailan Vaaaarrtalaaan. oar lagonalan ala* ttrafeliHrlifn Zaaaaawatkanfaa a Wn Aabcatnalr taaal Kmba rprAaV. Van knant nlcM vartaiagrn. ala9 W tlaa f. I)anlaltttti| titan Brnafkaala* (krlaNtatllg afaa K""V|*ttMam an* atlraran naoan Btbfabl iraikaa -laVart *lnl. Sian kaaan VtHgHtft aarlangan, al*B kain Wklta"faatrla -at aVn bWtar Vkattnlan RmrliinlB)(krKtn tlaa CtarNatabtWklttai; taarltanilan IK. ttml alaS Rrfakntngan an llmllrlirn flrralakaaftavt atall Ulomhiatlninttn. Am ntrMtn fhfl ifea VtrgVIch mil lima MlattmVrfta UmKtnkraV ala anrtktnntm BaraiUralia alaa Awltai-n IVmarVllaa, Aaeh talar flaalaat o|r arlta hinflf tin Italian, rpilVkarrlnnnl alaa fjnnm. Diraf fVmfatrkraitknnj nVrragl atafhfkrk alb- at*Wan Conlnatn tfnrab ilia Zakl aafntr Ttaltnafafar an Larattan, karln. m it*B man fibntlirfi alatn gfrlrlngl hi, In afar rlrtraVAaa R,. ahallmtiril alar Kna Air otrbllgatr ami alia tnlacbaklrmfa fraatV Ida Hr k>lirhnat ala* Laotgankraliar* in anrltan. In allamn Kalian bat tnan an alia Vitirkt!tl Hat Aram natal Ah RaafluaktlTlIlt rlat Oralalaaa In I'aaUaalimit artIt KnhhnataiManb gt-farbl. Ro mAgan ntarli Ira AaVaA aoraannla rarclnaantnt Rabwantm tnlhallm arfn. fniar MVlariatalnno rtaa Krgafnthaa* ana n*rran atalbtWhtn An. tafan f"*trn air atnaart flroWtitiangra tnmmmrn: fa 'iilataio tom IrWtnaltrr, alaaa nnrb Vf Janagtn Ltiilan, lalll aba Ka. - M AaVatmla afar Lnrtgtn narb rtaa In.labran anf, ma laarbaraa' Jolara Im A*Vtlinb grarlrllal naanlr. In aim lUrr aoa. UlatllaN Vkaiitntnmabrnrn KtlWt Vfatttl airb *lar Krtba In aha (Srr. *lilt".lm Mrbrtahl [., alW F*Ha) Ini Tnlrrlappan nrI nnr aln n.llmaptiWarrlnatm mil Vrrlta*non. Dir alam tangjibrlicrn flth rbr Arlr.aant.lrln anagamlilan t.mrn laaaaat ntrr^abontrla Hit An. aafc-ltan rlna* alaffat* varlarrllrtan Warb1arwt*aalgaw In ftawfall alattr iftf. fannt I'llattar. rlan|naantartar AlrttafaraitlHtallpn ttawl FmanlkOrivr. tWrntrlWi nm Hla AHr*l..l.k.>lrrr)tm arkanatan. DWrr Vanlaaa aim Lnttaa lurnalr* Mrfrt pallnomrllrarli alaaa aiAalVkannl* RruanKaga Ur alia KrrW. 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JTona, <"t fltord SiUt to HrWWtoto and (rflndtlrXar ArWt dUaa IjfcfMkrr^ tor itoa aarfc lomantitotofUsX and aaraU^WX to vaft o* SmXf, dal ran afton VrtXtoUrs, dU noeX Xm rick (( to Stop* rpfXm toX4fft(tn. vlfmittoX Itonaf naf dU ErfaXmnfm dinar MwdtoahrXm Fran.tor Xntltlft nwtot, Ki Ut ran dUarn fattorn toatMfdt nordpo, M to lUX lot drr toH/ntm lWn^ dUr KraoXtoQ nas dU Wtonf atom feUfeta* and v--toairfiXlff Vm toialrto Ml, wm Mm Vlma, rtletoa darrX aatoa Flfaoaelaft--, UtoajaiXn aatoa ndMXafcaauta tdUaaptl* ft rXwilTrtdart U. VOL. XI, No. 126 Asbestosis ASBESTOSIS By J. V. Sparks, B.A., M.R.C.S., L.R.C.P., D.M.R.E. 371 (Read at the Annual Congress, December 9, 1937--Received January 11, 1938) ULMONARY Asbestosis differs from the other pneumoconioses under Pdiscussion by reason of the nature of the particles inhaled, and by reason of their different chemical composition. Further, the shape of the particles causes them to be arrested more often in the bronchioles than in the alveoli, and their size and shape render them incapable of being readily transported into the lymphatic system. One is, therefore, not surprised to find that Pulmonary Asbestosis gives quite a different pathological, and therefore radiological, appearance to most other forms of pneumoconiosis. Fic. i. Asbestos bodies in lung multiplied by 1,200. Specimen by Dr. Gloyne. Nature oj the Particles Inhaled Asbestos is composed of long, silky fibres, like fine strands of glass, held together by a fine fibrous network. In the manufacturing process these fibres are broken up into short lengths, and in some cases they are ground down into fine dust. The asbestos content of the air varies considerably in the different processes utilised, but is highest in the textile branch of the industry. When examined SCF-FA-0530 June 1938 372 /. V. Sparks ' microscopically by dark ground illumination, the fibre gives the impression of a sharp, brittle, metallic wire, broken off at different angles and in different lengths; and, being highly refractile, it has the appearance of the glowing filament of an electric bulb. Chemically it is a silicate of iron and magnesium, and does not contain a free silica. The Shape of the Particles Inhaled The shape of the asbestos particles inhaled causes them to be arrested in the terminal bronchioles, and a deposit of iron-containing material forms over Fic. 2. Female, aged 27. Asbestos Worker 6 years; symptoms developed 3^ years after leaving factory. them. These are now known as the "Asbestos Bodies," first recognised by Fahr in 1914, and called "crystals." They were subsequently described in 1927 by Cooke and Hill, and Stuart McDonald as "curious bodies,'' found in the lungs of asbestos workers. Later in 1929, Stuart and Haddow made the suggestion that the bodies should be called "Asbestosis Bodies"; and it was Gloyne, in 1929, who showed that the central core of the body consisted of an asbestos fibre coated with a substance soluble in strong acid. They are of a golden-yellow colour, and vary considerably in size and shape. These bodies are produced as a tissue reaction to the inhalation of the asbestos fibre; the covering is thought to be protective. VOL. XI, No. 126 Asbestosis 373 Gardner and Cummings showed that the golden-yellow material covering the fibre contains iron and often shows segmentation. Gloyne suggests that this iron may be derived from the tissues, probably from blood pigment, and that the golden-yellow substance is the product of a colloidal reaction between the fibre and blood protein. These asbestosis bodies are readily demonstrated in the sputum in cases suffering from Pulmonary Asbestosis; but they can also be demonstrated in any patient who has been exposed to the inhalation of asbestos dust, and their presence does not mean that Pulmonary Fibrosis is present. The asbestos fibre is thus surrounded by a protective coating, as it is unable to be removed by phagocytosis. Further tissue reactions occur simultaneously and include an accumulation of large phagocytic dust cells and asbestosis giant cells; these accumulate in the terminal bronchioles and alveoli, and prevent aeration of the involved portion of the lung. These groups of cells and bodies become encapsulated in fibrous tissue, blockage of the lymphatics occurs at a late stage and affects the terminal lymphatics around the bronchioles. The symptoms of the disease are very much more pronounced than the physical signs, or the radiological appearance, and have been well described by Dr. Burton Wood. The cardinal symptom is dyspnoea, which in the.late stages of the disease may be extreme. Cough is a variable symptom, and though usually present, it may be absent for long periods; it is either dry, or accompanied by the expectoration of a little viscid phlegm. Many patients complain of anorexia, lassitude, pains in the chest and loss of weight. The last is a noteworthy feature, for the wasting may be progressive, and in the late stages is sometimes extreme. The disease now comes under the Workmen's Compensation Act, and it is now illegal to employ young persons in the Industry. Unfortunately it is impossible to recognise the disease radiologically in its early stages, and when the radiological evidence of fibrosis is present it means that the lesion is ad vanced, but even at this time the radiograph does not show changes relative to the patient's condition. Great help has been provided in the recognition of the lesion at an earlier stage by the willing co-operation of the employers in allowing radiographs of their employees to be taken when symptom free. These films play an important part in the subsequent examination of these patients. Preventive measures have been designed to diminish the asbestos content of the air in the factories, and it would appear already to have diminished the incidence and severity of the disease, and to have prolonged the period before symptoms arise. But in the patients with evidence of fibrosis it would appear that the disease in most cases continues to progress slowly in spite of the fact that the patient has ceased to be exposed to the dust. The X-ray appearances, first described by Pancoast, are only typical when the lesion is advanced, and the pleural involvement is a prominent feature. An advanced case shows some of the following appearances:-- The diaphragm movement is limited; its outline tends to be indistinct, and sometimes uneven. There is clouding in the costo-phrenic angle; this thickening may extend along the costal margin towards the apices. June 1938 Figs. 3A and 3B. Female, aged 35, Carding Department, 13 years, showing progress of Fibrosis at an interval of 4 years. <Or' X J--t 2 Asbestosis Fig. 4. Male, aged 50, Packing Department, 25 years Fig. 5. Female, aged 43, Asbestos Worker 5 years; symptoms developed 1 year after leaving factory. Asbestos bodies found in the sputum 12 years after leaving the factory. 375 J une 1938 Figs. 6a and 6b. Female, aged 35, Spinning Department, 13 years; symptoms for 5 years, showing develop ment of a tuberculous lesion. Interval between the radiographs 9 months. Vol. XI. No. 126 As&esiosts 377 The heart outline is often poorly defined, showing a ragged edge due to pleuro-pericardial adhesions. In late cases there is sometimes a prominence of the pulmonary artery. The lung fields show a slight relative increase in density towards the lower zone, due to a lack of alveolar aeration, often alluded to as a "ground-glass opacity." . Later there appears a patchy increase in density, in which fibrotic strands can be distinguished; no modulation is seen. The fact that there are comparatively few visible changes in the radiograms of Asbestosis when compared with Silicosis, does not mean that the changes are of a less serious nature or less advanced. Corn-plications The chief complications of Pulmonary Asbestosis are as follows:-- (1) Purulent Bronchitis. (2) Broncho-Pneumonia. According to Gloyne this occurs in the parts of the lung least affected by the asbestosis, and may explain why it is such a fatal complication in this condition. (3) Pulmonary Tuberculosis. In a series of 100 cases, sufficiently ill to seek advice, published by Gloyne and Burton Wood, active tuberculosis was found in 21. A number of cases of healed tuberculosis have also been found at autopsy^ these are probably not more numerous than in post-mortem work in general,, but indicate that the supervention of asbestosis does not necessarily mean the lighting up of a quiescent focus. (4) Carcinoma has been found in 6 cases, by Gloyne, at autopsy. I am indebted to Dr. Wood of the London Chest Hospital for permission to exhibit the prints of many of the radiograms; and to Dr. Gloyne for the pathological details and specimens which he has prepared for the exhibit. BIBLIOGRAPHY 1 Cooke, W. E., Brit. Med. Joum., ii, 1024, 1927. 2 Cooke, W, E., and Hiu, C. F., Journ. Roy. Microsc. Sor., 47 (Series iii), 232, 1927. 3 Faiir, Munch Med. Woch, 1914. 4 Gardner, L. U., and Cummings, D. E., Journ. Indusi., Hyg., 13, 65 and 97, 1931. 5 Gloyne, S. R., Tubercle, 10, 404, 1929. 6 Gloyne, S. R., Tubercle, 12, 54, 1930. 7 McDonald, Stuart, Brit. Med. Journ., ii, 1025, 1927. 8 McDonald, Stuart, Lancet, ii, 346, 1932. 9 Wood, W., Burton, and Gloyne, S. R., Lancet, ii, 1383, 1934. 10 Gloyne, S. R., Tubercle, July, August, and.September, 1933. 11 Sparks, J. V., Radiology, Vol. XVII, p. 1249, December 1931. 12 Pancoast, H. IC., and Pendergrass, E. P., "Review of our Present Knowledge of Pneu- monoconiosis, Based upon Roentgenologic Studies, with Notes on Pathology of Condition." Am. Joum. Roentgenol, and Rad. Ther., xiv, 381-423, November 1925.