Document B18bbnKzJ00kDQ331o10mr2o

FILE NAME Colonial Sugar Refinery CSR DATE 1960 DOC CSR037 DOCUMENT DESCRIPTION Journal Article Excerpt - Complications of Asbestosis with Cover Letter to General Superintendent A.B.A. Ltd. from Wittenoom Manager Mr. Allan ASBESTOS 86 AUSTRALIAN BLUE ASBESTOS LIMITED_ TELEGRAPHIC ADDRESS BLUEASBESTOS WITTENOOM WITTENCOM GORGE C PRIVATE General Superintendent Australian Blue Asbestos PERTH W.A. Limited " P.999 24th June 1960 Dear Sir ASBESTOSIS We are enclosing an extract taken from the British Medical Journal recently It is the report of a discussion on the result of a post mortem on a man with asbestosis with fatal` complications We have not included the first part but only the of the Journal if summing up You could no doubt procure a copy I have underlined several passages which have been necessary stressed by Dr.Oxer Dr.Oxer It is quite interesting and gives some information previously not known to me Yours faithfully okAllan okAllan . Manager OAA CENTRAL CYANOSIS 1341 APRIL 30 1960 ae oximetry while the tongue is probably the has been made tshitaet for the observation of central most sensitive does not replace thorough cyanosis intelligent guessing saturation or estimations of arterial oxygen of be that lymphatic as well as vascular invasion 3229 manady metastasis are hindered though James found o 4 difference in the incidence of metastasis to different in the miner and miner except for the brain organs in which secondary deposits were found in only % . pn1".eumocotumorniosisderfeisnshortpeedct ; dsuirOsv8uei5vuta2anwsl.ntsataeie05ohnrae0lndo0se practical miners and 27 of minces to3 FIBROTIC LUNG This paper shows that experience is better distilled to CANCER pulmonary shadows in statistics than to obiter dicta It is a reminder of the . mitigate later The diculty diculty of odfiagmnoisnineg rs has recently been theory that previous damage may the radiographs Smith He notes in has been suggested in times past by clinicians who aga emphasized by R. Abbey as unaccompanied by healed tuberculosis by the blocking of the single fibrotic nodule particular of simple and lymphatics reduced the spread of cancer and the toxic 19% radiographic evidence cancers in information on this the slowness in growth of certain lung for of empyema and the higher review of 320 cases operated on problem would be welcome miners In a and drawn from the among this group of miners together with the lung cancer at one hospital rate records that of lung cancer among miners of town and country he lower incidence general population more after operation This reported by Kennaway and Kennaway certainly points survived two years or A. B. Taylor and the usefulness of further inquiry into the factors 36 with 34 reported by to figure compares relation to 512 resections and which may be responsible J. Lexi in 1954 in Moon in 1955 in with by 1. R. Bignall and A. " APPEAL 205. that the industrial group appears KING GEORGE'S JUBILEE TRUST relation to than the agricultural and subscribed lm as a national workers fured better In 1935 a grateful people of the inclusion in the former evidently because offering for the twenty years reign of King rural miner being of miners V and the offering was dedicated to the cause & of number George worked five years or more the king's heart of advancing the who has as 2 person al the coat face no account of laken always dear to mental and spiritual welfare of the younger physical fund inaugurated for of the mines was in his kingdom The georaphical situation with the same criteria of generation George's Jubilee Trust is now During the same period who had this purpose and it has just he found that of 21 miners celebrating its own silver jubilee operability three died in the first two its first national appeal for funds since its undergone resection only which is a survival rate of -a launched foundation Over the past twenty years the Trust for the welfare of years after from the whole statistically significant difference the has given more than lm in grants council's disposal two possible explanations first that He offers tumour specific the young but the income at the even with the help of legacies and other gifts barely miner develops growgroiwing ng the more The funds are chiefly used to to him and secondly which whic he finds is retarded by the exceeds 40.000 a year of 15 there 33 help those who leave school at the age probable that growth of tumooufrcoal dust on the lung 610,000 of these in 1948 and there will be effects of prolonged inhalation and lymphatics Against the first he in the in 1961 and 917.000 in 1962. With the increasing calls needs an additional income of parenchWy.maR. James as finding no difference upon it the Trust :. quotes histological types of carcinoma frequency of different But it may 110,000 a year well known it gives Many of the Trust's grants are who between miners and miners in this for example to enable young people f the histological type is not important factor which operates bursaries could not otherwise afford to do so to join thsechools to that in fact there may be somtehe rate of growth of all Bound Trust courses at sea and mountain in coal coal miners to slow down their the factor which improves Schools Exploring Society or to the courses the British moored in Ports tumours If this is so that which explains why on the old sailing ship Foudroyant prognosis could be akin to pre- mouth harbour It also gives a great deal of with longer duration of symptoms work of the national voluntary patients fare better than those with L short operatively favours the second support to the day Trust's council says the youth organizations As the history ' But Abbey Smith G. national appeal in support of a national referred 0 by F. appeal is a the nation 38 expisnation the blocking and it is described as a call to Kergin of the lymphatics by carbon cause it did in 1935 its responsibility for F the choking of the glands by heavy accept again as will depend Those macrophages on whom the future of the country ateion carbon deposits and fibrosis making lymphatic interested in the work of this very metastasis dillicult Kergin has drawn atteation also who are should send their inquiries to the secretary fibrous tissue binding glands to blood vessels organization Jubilee Trust 166. Piccadilly London to the miners 11 King George's Be so often found in the lungs of W.I. Tane Smith Der & er Med 1939 leri A. A. 127 127 T AB AB and M. Annual Cast Puls 1954 M9 oon Puas 1985 D. 18.5 Puls R..And Meh 127 Air And TOT Dis Chest thor 152 And Photos 105 11 112 J. Clace T. tad McDonald ) , R. Bir 26 Kenway oe Kenway Kenway 201951 257 the Order of Merit an Sir The Queen has conferred and President of the Royal Society Cyril Hinshelwood in the University Dr. Lee's Professor of Chemistry Oxford APRIL 30 1960 Clinicopathological COMPLICATIONS OF ASBESTOSIS BRITISH 1345 MEDICAL JOURNAL COMPLICATIONS OF ASBESTOSIS DEMONSTRATED AT THE POSTGRADUATE MEDICAL SCHOOL OF LONDON complication with asbestosis with a fatal > This is the case of man P.M. No. 8556 He K Case No. 215526 and exemplified the with haemoopfttyhseiscause of haemoptysis and problems of odfiagtnhoesilsung changes associated with the Be the nature asbestosis Clinical History This man was aged 50 years JONES Dr. PHILIP starts in 1922 when at the Be at death His medical history fever He apparently of 14 years he got rheumatic he was age recovery from this However made a good medical examination in group IV at an Army he himself felt perfectly age of 32 though onset of swelling well 1943 he had a gmreatdaucaalrpophalangeal joints aching and stiffness of the wrists shoulders knees and of boil hands and + there was little ankles This continued but the illness left him with a and with constitutional upsoeft his shoulders and wrists residual stiffness of rheumatoid arthritis deformity of the hands typical factory 1938 to 1949 he worked in an asbestos From on routine radiological felt well but told he had There he in 1949 he was examination of his chest a certified and subsequently became was time onward be noticed storeman From exertion In May investigation increasing brisk haemoptysis and was + 1958 he got worse had a admilled to Hammersmith Hospital for e EXAMINATION AND INVESTIGATIONS INVESTIGATIONS INVESTIGATIONS small He had marked clubbing hios f the Angereslbaonwds toaensd rheumatoid changes in hands glands and two shoulders enlarged axillary the medial side of the mobile cutaneous nodulepsersoinstent scattered rates over right arm There were was 120/65 his pulse both lungs His pressure 3 aortic systolic was regular and he hapdulma ongarraydesecond sound with murmur an accentuated at the heart and diastolic murmur an opening snap of the chest Fig ) showed a apex A radiograph the right large pulmonary fracture of the sixth rib on the vascular shadows and a reticular mottling over " vascular of both lung fields with a shaggy out lower zones barium swallow there was slight line the heart On at the of the left atrium The changes enlargement could be those of an enlarged pulmonary right hilum with a right hilar neoplasm artery or those associated hilar mass Tomography Fig 2 confirmed the right examined an numerous occasions His sputum was cells and asbestos bodies for tubercle bacilli malignant found Bronchoscopy but nothing abnormal tree to be showed showed the hand side of the bronchial lobe was normal but there normal The right upper in the region of the right was stained mucopus of the right middle lobe with a granular appearance However a biopsy descending and lower lobe bronchi of from the granular areas showed no evidence of lymph glands and of the malignant change Biopsy with showed only changes compatible nodules m./hour rheumatoid arthritis for the The electrocardiogram gave little support clinical diagnosis of mitral stenosis despite the slight of the left auricle seen on barium swallow enlargement was normal except that the haemo- The blood cou11n.t5 100 ml Blood cultures were globin was The E.S.R. was 125 mm./hour mm./hour persistently negative test was positive for The differenatritahlritaigsgluatnidnaetlieocntrophoresis of the serum cheumatoid proteins showed high a and fi peaks urst Po view on ChestChest radirograaphdiograph posterior is not visible of the The fracture sixth is A COMPLICATIONS OF ASBESTOSIS BRIMAL an changes typical of again discharged After that he deteriorated steadily 3.12 His the to capillary with increasing hacimoptyses though he was in no pain an monoxide diffusing He was finally admitted again in September 1958cheswthaennd ai with arterial oxygen he showed signs of consolidation of the right inspiratory capacity a swelling over the left clavicle He died 00 te ..I 3 laces September 29 alpacity alpacity and a Clinical Diagnosis ! BOFY 101 1. Carcinonsa of lower lobe bronchos with S eat quetastases to spine brain and elsewhere oplysis ha L It oplysis steadily Has assessed as heart disease asbestosis asbestosis abidopsi Howaraplysis could be he had i came sis In any dished dished for it , the suspected i Te It was per globum was Swed markedly 2. Asbestosis 3. Rheumatic heart disease disease quiescent aortic incom- petence and mitral stenosis 4. Rheumatoid arthritis mortem Findings Dr. B. E. HEARD The body was wasted weight 6 st 10 lb. 42.6 kg height ft 7 in 1.68 m Both hands showed ulnar deviation and the fingers and toes were clubbed There were two small nodules 1 cm in diameter over the right elbow and there was one 4 cm in diameter over the left They contained caseous material and histologically showed looking fibrous walls lined by macrophages and enclosing amorphous material with many cholesterol clefts here no certain evidence of active rheumatoid disease here The chest measurements were antero- 25 diameter 20.5 cm lateral cm circum- poserior ference 72 cm This is within the normal range and excludes a shaped chest Both pleural sars were completely obliterated hy dense fibrous adhesions The was also obliterated and showed a plaque pericardium of calcification over the pulmonary conus The peritoncion was normal STATE OF THE LUNGS The trachea and main bronchi contained a large quantity of stained mucus and both lungs were oedematous There was bronchiectasis in the fibrosed areas to be described The right lung weighed 1.370 g normally 400-450 g There was a carcinoma 7 cm in diameter in the posterior basal segment of the lower lobe adherent to the diaphragm and invading it The cut surface was pale and granular and there was central necrosis The lower lobe also showed some subpleural fibrosis There were secondary deposits in the hilar lymph nodes The middle lobe was heavily infected all bronchi being filled with mucopus and the tenth thoracic vertebrae eath rilapse of the Sprituata examination examination During this time in the involuntary jerking of the ragi he bad attacks of leg she de were thought Lacksonian lit associated with HE.G. examination gave parative radiological sim ashe ste sis SPECIAL PLATE lingular The left leng the showing honeycombing of the and anterios segments of of thick subpleural zone commencing way down the back of the lower labe comencig involving the coophrenic angle and the whole of the diaphragmatic surface F. A higher higher magnification x 1.4 of the left lower lobe showing the subpleural zone of honeycombing and adhesions ddensense overlying adhesions segmntA higher magnification x1,41 x1,41 of the posteroof the upper lobe to show a lile apical marked by an arrow and numerous emphysema separated from veins by zones of pigmented long at rite each inhule The at white lines mark lobules and the black foci nark sceandary approximately approximately Between septasepta and foci are of unpigmented lung Two deposits the top of the picture are indicated NES Jaijaniahaheeteenate bil _ honey- lang yellow and consolidated There was some combing of the anterior part of this lobe The upper lobe showed slight apical fibrosis associated with two bullae 1.5 cm in diameter but no calcification In all of the lung unaffected by fibrosis there was mild parts The centrilobular emphysema . in the left lung is shown in Figs 4 and 6. Respiratory bronchioles well away from the interlobular septa were heavily dust- pigmented and moderately dilated Histologically these emphysematous foci were shown to be pigmented by black dust in macrophages lying mostly within the walls of the dilated respiratory bronchioles and in the same situation were numerous small asbestos bodies There was no notable increuse of reticulin in these areus The tumouE was a moderately differentiated columnar carcinoma with tubular and papillary patterns Most reports stress the frequency of squamous carcinoma with asbestos so the present case is somewhat unusual There is no question of this being a mesothelioma The left lung weighed 885 g and was prepared by pressure fixation and barium sulphate impregnation Fig 4 to demonstrate emphysema The volume of the lung 2.2 litres was at the lower limit of normal There was honeycombing Fig 5 in a thick comencig subpleural zone of lung half down the stained intensely for iron by Peris's reaction Some of the bodies were smooth and rounded Others were sausage with a variable amount of segmentation Some ended crystals accompanied the bodies and may have been asbestos fibres Elsewhere in the lung there was centrilobular emphysema of a mild grade The low volume of the lung and the encasing effect of the honeycombing correlate well with the lungfunction studies which showed a small inspiratory capacity This may be what has been referred to as a tight Jung The adhesions were moderately dense over the lung but were not cartilage There was no evidence of Caplan's change despite the coincidence of rheumatoid arthritis and asbestosis as described by Rickards and Barrett HEART AND OTHER ORGANS The heart weighed 370 g normally 281-361 g for man of 5 ft 7 1.68 m The increase in weight was partly due to dense adhesions described above and trace of hypertrophy of the left auricle and possibly the right ventricle L.V. 1,5 en thick R.V. 0.4 cm thick The pulmonary and tricuspid valves were normal but the mitral valve was 70 mm in circumference normally 90-110 mm The chordas back of the lower lobe including the costophrenic tendineae were fibrous but not shortened The edge of angle and the whole of the diaphragmatic surface the valve was straight The valve cusps were fused and Also honeycombed were the anterior parts of the thickened by brosisand the valve admitted one and a lingula and a little of the anterior part of the anterior half finger Histologically there were no signs of segment of the upper lobe Honeycombing was accom active rheumatic fever but at one point there was a _ panied by bronchiectasis Histologically the detail of the respiratory tissue was considerably simplified Most of the airways consisted of small bronchi or bronchioles which were dilated Fig 7. There were no alveolated passages Between the holes were thick walls of moderately dense collagen small mural thrombus as described by Magarey.who attributes the fibrosis to the organization of successive layers of fibrin on the surface The aortic valve was normal in circumference but showed adhesion of the commissures for distances up to 7 mm The cusps themselves were slightly fibrosed There were no lightly infiltrated in places by lymphocytes but as a rule having an inactive appearance Stains for clastic tissue showed no alveolar shadows most of the clastic being vegetations The coronary arteries showed moderate atherosclerosis and the aorta a mild degree The heart changes were consistent with an old history of rheumatic confined to the walls of blood vessels Fig 8 The fever There was no sign histologically of rheumatic in larger arteries the fibrous areas of lung showed considerable intimal elastosis but elsewhere in the lung intimal thickening was only slight Most of the dilated bronchi were lined by cubical or flattened epithelium but in some areas macrophages were present in moderate numbers sometimes accompanied by amorphous debris Some of the macrophages were in the form of multinucleate giant cells Fig ) well- known in recognized asbestosis Asbestos bodies Fig 10 were lying free They had the characteristic in the lumen often in clumps colour and Heard B. 1959 14 58 activity The oesophagus and the rest of the alimentary tract were normal but the liver was slightly increased in weight 1,630 .; normally 1,400-1,600 g and con- tained some scattered secondary deposits of growth up to cm in diameter It showed centrilobular conges- tion throughout confirmed The goll- bladder biliary ducts and pancreas were normal The spleen was normal but the marrow of the sternum ribs and vertebrae contained numerous large secondary deposits There was a fracture of the middle of the sternum and collapse of the tenth thoracic vertebra The adrenals right 15 g left 20 .; normally 6-7 g each were enlarged by metastases but the other LEGENDS TO SPECIAL PLATE focus of centrifabular emphysema showing asbestos bodies with other pigment in the walls of dilated respiratory respiratory bronchioles ^ 245. juxtaplenral zone stained of left is a thin layer lying outside the elastic famina border of the lung Within the tissue The minnminanall elastic blood vessels endocrine glands were normal The rinary system was normal The brain showed secondary deposits Fig 11 up to 1 cn in diameter in the left occipital lobe and in both cerebellar hemispheres Pathologist's Diagnosis 1. Carcinoma of the lung with metastases in the hilar lymph nodes adrenals liver brain and bones 2. Honeycomb lung due to asbestosis Fig A multinucleate giant cell containing containing fragments of asbestos bodies ^ 1,012 3. Old rheumatic heart disease 4. Old rheumatoid arthritis wrinkled FIG encrustations A clunip of asbestos hodies showing encrustations over the asbestos fibres ^ 1,02 S. Tubercle 1933 34 445 CloyneRickards A. and Barrett Binted G. Magarcy T. Binted J. M. Thorax 1958 13 185 . 1350 APRIL 30 1960 COMPLICATIONS OF ASBESTOSIS RADIOLOGICAL APPEARANCES These are typically those of fine like reticular pattern pa ticularly affecting the lower for fields and causing " shegg border to the heart as in patient Besides this Cyst changes may be seen and ver often the thickenin Although the ray picture typical and almost pathognomon in a few advanced cases there many patients who have undoubi asbestosis as judged by a histo of exposure and the clinic features of clubbing rales in lungs and typical changes in lu function who do not have speci changes in their chest radiograp That is extremely important relation to the diagnosis as * shat see later because in gene Asbestosis Reviewed Professor I. MCMICHAEL Dr. Jones would you sum it up Dr. JONES The case is of great interest as it demonstrates so many of the problems associated with asbestosis which we should review Asbestos itself is chiefly a double silicate of magnesium and iron It occurs in a number of mineralogical forms one of the most valuable being chrysolite Asbestosis is al pneumoconiosis arising from the inhalation of asbestos dust during the manufacture of asbestos goods such as asbestos sheeting fireproof clothing linings lagging for boilers and pipes etc. One way of thinking of the pneumoconioses is in relation to the chemical toxicity of the different dusts At one extreme are those such iron which are as entirely toxic and simply produce a characteristic radiologicnt appearance of the Ings with no change in bodily function Then came atliers such as coal which which do this but also have pathogenic action by altering the a reaction of the lungs to tubercle Next there are dusts such as silica which produce a local reaction and pulmonary fibrosis Finally there beryllium of such Toxicity that they can general tissue paisons which produce regardewidespread elfects in the body as well as local fibrosis in the lungs Asbestos is very toxic and produces not only pulmonary fibrosis but reactions the pleura and in even in other organs Dr. Heard has excellently demonstrated the pathology of asbestosis in our patient but by way of summary here is a picture Fig 12 of whole section of another patient who died from asbestosis There is an interstitial fibrosis as in the gross pleural thickening and some patchy bronchiectasis Besides these three features which are conimon in asbestosis there may be associated tuberculosis as there was in this second case or even more important associated lung cancer as in our patient Sometimes the interstitial fibrosis gives rise to the formation of bullae or occasionally even to a widespread honeycomb lung Le that which occurs with other rare forms of pulmonary interstitial fibrosis such as the xanthomatoses buttrial history andand a characteristic ray appearanc There is a characteristic ray appearance in asbestosi medico legal standpointstandpoint n from the all patients with asbestosis have the characterist radiological . radiograph FiFinalynally, the asbestosis cannot be classified in the same categori as thosethose accepted internationally for the oth pneumoconioses CLINICAL FEATURES AND COURSE Gross clubbing of the fingers and persistent rales are the characteristic clinical signs of 1 the chest is the main sympto condition condition Exertional dyspnoea in ather pneumoconioses Patients suffering fro Large lung section prewpiatrhedasbbyestPorsoifsesssohrowGionuggh from another parent ar thickening patchy fibrosis and bronchiectasis accompanying tuberculosis at the lung apex APRIL 30. 1960 COMPLICATIONS OF ASBESTOSIS die either from the complication of asbestosis may or more tuberculosis more common in past years from that of carcinoma of the lung Those phaorttikciulllaerdlyby chest infection or cancer may finally get cor pulmonale The disease usually makes its appearance rather the course of few months often long suddenly over inhalation It after the initial exposure to the asbestos has been suggested that the nsbestos ties dormant as an body which has to ripen over many years ssbestos break down and liberate its toxic contents before il can which In this respect asbestos is again like beryllium also lie dormant in the body and then suddenly may effects concurrently with some other produce its : infectionCarcinoma of the lung is serious and well- recognized complication in asbestosis Its frequency is difficult to determine for it is now in asbestosis More- condition in the general population common to asbestos may have occurred many the over exposure before the cancer develops Nevertheless years has a risk about 10 times that of the general asbestosis of getting carcinoma of the lung Another rather rare phoapzualradtiisonmesothelioma of the pleura This draw attention to the fact that a patient has wtuomourr kedmay in asbestos dust Finally in women who work with asbestos there is a high incidence of cancer of the ovary FUNCTIONAL EFFECTS ASBESTOS DUST the The asbestos bodies simply prove exposure to asbestos do not mean asbestosis dust and of themselves bodies who has inhaled Anyone may cough up asbestos of without necessarily having changes dust Vice versa a patient may have asbestosis in the lungs without asbestos bodics definite and gross asbestosis during life necessarily being found in the sputum Since medico the diagnosis depends on a history of dust exposure together with with the appropriate vray of and other changes the finding of asbestos asbestos bodies is importance in proving exposure that asbestos libres once inhaled It seems probable of seats the course colagen colagen are coated ripens by forming transverse cracks collagen cover break down liberating and then the asbestos body can the toxin and causing the reactive fibrosis in the lungs The nature of the toxin is uncertain It is however presumably the same substance which is carcinogenic was first described in this country by M. Asbestosis Mereweather and Murray in 1907. After that in 1930 dust in the lungs Price reported the dangers of asbestos sup res ion recomendations for dust and made Thereafter there was a great improvement In the where our patient worked The utmost asbetoi factory asbestosis are now taken to prevent precautions disease Nevertheless occurring It is a disappearing and the amount needed to asbestos dust is most toxic and cause asbestosis is not known so constant vigilance new preventive methods are needed if this disease is to be abolished is a diminution of the inspiratory capacity There with the " shrunken lung demonstrated which fits in with other by Dr. Heard in this case In contrast air there is often little disturbance to Dneumoconioses of the lungs there is is flow so that all the movement breathing used to good advantage and the maxiwemlul mmaintained capacity M.B.C. is often surprisingly is assessed by suffering from asbestosis Thus if a patient volume F.E.V. test the M.B.C. or forced expiratory with he is unfairly assessed for compensation compared a man suffering from silicosis or workbreearthslespsnneeussmoi-n coniosis The essential cause of the of transference of oxygen asbestosis is the dificulty than the herass the altered alveolar membrane more so reduced maximum breathing capacity which is the cause Carbon dioxide being in say coal pneumoconiosis and is soluble stiffuses 20 times us rapidly as oxygen transfer is usually adequate at rest unuffceted Oxygen but when they so that the patients are rarely cyanosedfail in oxygen start to exercise there x rapid is saturation and gross hyperpnoes The diagnosis is made on a history of exposure the and rales and usually by means presence of clubbing evidence that the of a radiograph There is however evidence do the radiograph may not show changes as early as specific Although the latter are not function tests in other uncommon to asbestosis they are only seen block and capillary interstitial such as sarcoid scleroderma fibrosis and other rare conditions Thus king- microlithiasis making the pathological tests are useful for for if it can be shown that the patiebnltochkashaans interstial fibrosis causing alveolar capillary gross clubbing and rales and a history of exposure to that he has asbestosis asbestos dust it seems reasonable whether the radiograph is specific or pal . Bell R. Brit J. user Med 1955 12 81 Discussion Professor McMICHAEL There are many other facets to this patient but before we go on to them are there any other points or queries which could be raised on ? the pathogenesis of asbestosis Dr. R. WILLIAMS I think there is one point in of the mechanical theory that is worth raising support give asbestos ground up into a If experimentally you and it seems that fine dust fibrosis does not occur asbestos fibres between 20 and 50 microns in length are necessary to produce the typical peribronchiolar fibrosis DISTIGIUDION OF FUROSI FUROSIS the Professor E. L. BYWATERS What is the explana- tion of the distribution of fibrosis Does it correspond to the distribution of asbestos in the lung or is there sunie other explanation ? Dr. HEARD As a matter of fact it doesn't seem to correspond Although some of the best asbestos bodies in this case were in fibrosed areas there were surrounded by perfectly normal lung in other plenty Dr. Nagelschmidt from Sheffield was here two parts and he was saying that they have recently deaxyasmiangeod chemically number of lungs from cases of asbestosis In some there was lot of fibrosis and no asbestos However he did point out that practically because the asbestos content there was a possible error was estimated as the percentage of the dried weight and the dried weight of fibrosed lung is not altogether comparable to the dried weight of the normal lung It is quite a problem and so far as 1 know the peripheral distribution of the fibrosis has not been explained It is not restricted to asbestosis being seen in other forms of honeycomb lung C. an Report Mereweather R. A and Price W. Effects of Asbestas Dust on the Lungs 1930. H.M.5.0 Londes [ * 1352 APRIL 30 1960 COMPLICATIONS OF ASBESTOSIS BRITISH MEDICAL JOURNAL ASBESTOS IN THE PERICARDIUM Professor McMICHAEL Dr. Plotz you have a question Dr. PLOTZ New York I've got a couple of questions In reading the case history I was surprised pleasantly surprised and greatly relieved find that no mention was made of this man's smoking habits Some of our surgical friends are putting asbestos rather than tale into the pericardial cavity to produce adhesions on the grounds that chemically they are both silicates and the adhesions grow much more quickly with asbestos This does not meet with my approval on other grounds but am wandering what Dr. Hugh and Dr. Heard would have to say about that One other minor point that bothered me a little in the case perhaps I am getting a little touchy at the age of and a little over you said that his age was a factor in determining whether or not to operate on him and you decided not to operate on him because of his age 1 am wondering if he was too old or loo young Dr. JONES I couldn't agree with you more about age But the thing we debuted in his particular case was the patient's general condition including his age He was a man of 50 who had gross rheumatoid arthritis and was considerably disabied and deformed by il He had severe breathlessness from his asbestosis and his general condition was such that we didn't think it was justifiable to do an exploratory thoracotomy on a very small chance of being able to eradicate the carcinoma permanently I am afraid am not all that optimistic about the effects of surgery in carcinoma of He did smoke but incidentally he had on adeno- carcinoma which is not a kind particularly related to . We believe from the work that is being done both in this country and in the United States in relation to smoking that it is the squamous and the cell carcinomas which arisea since the 1900s and could be correlated with smoking Way back in the 1900s carcinoma of the Jung was equally common in men and women and it was predominantly an adenocarcinoma then It is the recent emergence of the squamous and cell types which gives the male preponderance and which various people have related to smoking Professor MCMICHAEL What about the dangers of asbestos in the pericardium ? Dr. HGH I think that's a very interesting point because asbestos and tale are similar chemically On general principles | would be a lule worried about the possible ultimate effects of asbestos in the pericardial pericardial cavity Tale is used in the pleural cavity to produce adhesions after many h I don't know if anyone has put asbestos in the pleural envity I would be a little worried about asbestos but reason I've got no for saying that it's a bad thing Dr. C. COPE Is there any fung trouble in tale manufacturers ? Dr. JONES Oh yes RHEUMATIC FEVER AND RHEUMATOID RHEUMATOID ARTHRITIS Professor McMICHAEL Professor Bewaters would you like to comment on the recurring sequence of alleged acute rheumatic fever followed by progressive rheumatoid arthritis This is the second example we have seen day . Professor BYWATERS I think they are both fairly common diseases And when you get a difference here of say 21 years between the two with the rheumatic fever occurring in childhood I think a coincidence is possible We have seen a number of people with both dsenses and one disease doesn't seem to confer Immunity from the other I think we are always happler that the first diagnosis is correct when there are no intervening symptoms Here there is no doubt about the rheumatoid arthritis I didn't see the patient during life nor I think did Dr. Dixon so I am not quite happy about the nodules which Dr. Jones described It's a very unusual place he pointed to on his own atm Dr. JONES That was where they were on this patient's arm Professor BYWATERS I would think it's quite likely that they weren't rheumatoid nodules Dr. Heard didn't seem any too happy either on the pathological side but I haven't seen the sections I think this is of some importance from the point of view of the lung becatise the Caplan type of lesion seems to occur mainly in rheumatoid patients with nodules elsewhere In faci the Caplan lesion is a modified rheumatoid nodule occurring in the lung substance or the pleural fissures perhaps as a result of the abnormal stresses from fibrosis You can trace in early specimens the pallisade layer round the necrotic fibre which is the hallmark of the rheumatoid nodule I am not saying that these are not nodules I haven't seen them | but it might be the reason why he didn't develop further changes in his lungs Professor SHEILA SHERLOCK When I first came to this School in 1942 I used to sit back admiringly while Professor Bywaters thought of another good reason why rheumatoid arthritis and rheumatic fever were unrelated liseases Is there really no relation between these diseases RHEUMATOID ARTHRITIS AND DIS EMINATED DISSEMINATED LUPUS Dr. COPE I've commented at a previous conference on the relative frequency with which we've seen acute rheumatism followed by rheumatoid arthritis and then followed by disseminated Jupus When somebody wrote to me about this and inquired for details I quoted the about two cases knew of and the same day whilst was doing the letter the Records Records Department turned up cheumatoid " * live others were diagnosed diagnosed cheumatoid arthritis and then subsequently disseminated lapus Professor BYWATERS We [eel there is no real relation but often close clinical and sometimes even Unless you have got bona- tide heart lesions it is sometimes extraordinarily difficult to differentiate the early stage of rheumatic fever from the very early episodes of lupus ankylosing spondylitis or rheumatoid arthritis If you get adequate heart lesions you can he fairly certain about it sometimes ! Professor McMICHAEL It's very interesting to see McMICHAEL these arrested valvular lesions The minimal adhesion of the mitral valve and nortic valve cusps indicates that even although the valves may be damaged progression is not inevitable There are some who think that progression of rheumatic valvulitis is inevitable but this man presumably with valve damage at 14. got through to 50 APRIL 30 1960 A ac me COMPLICATIONS FRACTURED Rt evidence Was Professor BYWATERS Was there any evidence at of any metastasis in the fractured rib that necropsymight have given us an earlier clue to the diagnosis metas e Dr. HEARD There were very widespread metastases I didn't examine that particular rib but I expect it was niTected intimal thickening Dr. Core What about this heavy intimal thickening is i characteristic of asbestosis Does it lead to hapens ? pulmonary hypertension or what happens OF ASBESTOSIS MEDICAL JOURNAL 1353 Dr. HEARD The gross intimal thickening of the pulmonary arteries I in arteries that showedshowed was the fibrous thickenig thickening a areas Elsewhere there was only little thickening With this and the normal right ventricle pulmonary much in the way pulmonary pulmonary hypertension there of was hypertension . the We are grateful to Dr. J. P. Shillingford and Dr. B. E. Heard for assistance In preparing this report and to photographic department of the Postgraduate Medical School for the illustrations Drug Treatment of Disease DD rugDrug ruDisg ease Disease INFECTIONS OF THE EYE BY ARNOLD SORSBY M.D. F.R.C.S. Research Professor in Ophthalmology Royal College of Surgeons of England and the Royal Hospital London Infections of the interior of the eye are grave emer gencies and call for immediate and expert treatment Relatively uncommon they are seen after intraocular operations perforating injuries or in severe infections of the cornea In contrast infections of the outer eye occurrence are daily When the infection is bacterial in origin treatment by antibiotics is generally ellicacious but virus infections still present a consider- able problem The poor penetration into the interior of the eye of of the antibiotics greatly limits the value of many systemic administration of these drugs in the treatment of intraocular infections Fortunately subconjunctival subconjuctival injection of some of the antibiotics is a feasible procedure in expert hands and gives excellent results For external infections of the eye focal application is so eminently satisfactory and so readily given that neither systemic administration nor subconjunctival injections often need to be considered The newer agents thus carry forward an older tradition of both ophthalmology and dermatology in which local appli- cations have always had a greater vogue than systemic therapy AVAILABLE DRUGS are allied to that of trachoma is responsible for another substantial group in which inclusion bodies can be found in epitheliat scrapings taken from the conjunc- tiva the gonococcus accounts for a relatively small proportion of the possibly as little as 20 or tess in present series the pneumococcus accounts for further substantial proportion All these organisms are fairly readily susceptible to the modern sulphonamides in adequate so that most cases of ophthalmia neonatorum respond quickly to systemic administration Apart from ophthalmia nconal and the somewhat similar purulent ophthalmia of adults the penetration sulphonamides systemically are useful in the after- treatment of septic affections in the lid and orbit dealt with surgically In the treatment of intraocular infections the sulphonamides systemically are of little use owing to their poor Sulphonamides administered locally are of value in only one disease trachoma free from secondary infection It is however likely that this isolated indication for the use of sulphacetamide has already been superseded by the greater efficacy of sonte of the antibiotics Sulphonamides The classical sulphonamides are all highly insoluble When sulphacetamide as a soluble sodium salt became available it was used widely as a local application in all forms of ocular infection including infected corneal ulcers Some of the claims put forward for sulpha- cetamide were untenable the experimental and clinical results claimed for corneal infections due to Pseudomonas pyocyanea organisms insensitive to uncritical sulphonamides reflect the early enthusiasm for the may be taken that the limited of action of the tulphonamides together the fact that the Sulphonamides locally are inactivated by pus and breakdown products of tissue make sulphacetamide of little value in ocular therapeutics sulphonamides given systemically treating There is however an unquestioned place for the some of the external infections of the eye in ophthalmia neonatorum it is possibly still the agent of choice The causative organism in ophthalmia neonatorum is commonly Staphylococcus aureus virus closely Administration Systentic Antibiotics Administration Antibiotics Systentic for Peniclin Penicillin streptomycin chloramphenicol and the detracyclines are widely used systemically and are all valuable as local applications in ophthalmology The extensive use of penicillin ointment as a prophylactic measure after removal of corneal foreign bodies and reduced after other minor injuries of the eye has greatly the incidence of infected corneal ulcers and mucopurulent conjunctivitis Ointments of penicillin and of as also of used comonly in the treatment of subacute and acule subconjunctival subconjuctival injections infected corneal and , blepharitis replacing almost entirely all the + older remedies Penicillin and streptomycin being very soluble can also be used as for ulcers and intraocular infections generally so that there is a broad field for the use of these agents in ophthalmology Recently it has been questioned whether it is justifiable to give any of these antibiotics for relatively minor infections It is held that some patients may become sensitized making the systemic administration neem EXHIBIT EXHIBIT 164 SIMPSON . 44.3644.36 164 AUSTRALIAN LIMITED BLUE ASBESTOS AUSTRALIAN < ASBESTOAS SBESTOS ~, LIMITED LIMITED a ay ae TELEGRAPHIC TELEGRAPHIC ADDRESS WITTENOOM GORGE : ULURASCES FOL WITTENJOM WESTERN AUSTRALIA brown brown . brown oo In bbrroowwn n In brown 7 , , sy} PRIVATE PRIVATE f bo fy oe ay A wo i 3 leer Z^' , . AAssbestbos estos Limited June 1960 P.826 24th June - ASRESTOSTS We encloso for your information two copies article of en extracttaken from the British Medical Journal It is quite an interesting and reveals several fants not known to us before There issun is of quite a lengthy the Journal clinical description of the caso else in thie . Yours faithfully Homagor HomaHg omagoroHomr agor Homagor Homagor ' DAVIS DAVIS . . oe EXTRACT taken from the British Modical Journal of 30th April 1960 headed ASBESTOSISREVIEWED Professor J.McMichaol Dr.Hugh Jones would you sum it up The case is of great interest as it demonstrates so many of the Dr. Jones associated with asbestosis which we should review Asbestos itself is problems double silicate of magnesium and iron It occurs in a number of chiefly a of most valuable being chrysolite Asbestosis is a mineralogical forms one the the inhalation of asbestos dust during the manufacmanuftacture ure ponfeuamsobneosntioossigsooadrsisisnugchfrasomasbestos sheetsheetiing ng fireproof clothing linings lagging for boilers and pipes etc. and One way of thinking of the pneumoconioses is in relation to the chemical toxicity of the different dusts At one extreme are those such as iron which are entirely toxic and simply produce a characteristic rediological appearance of the lungs with no change in bodily function action by Then come others such altering the reaction reaction as coal which do this but also have a pathogenic of the lungs to tubercle Next there are dusts such as silica which produce a local reaction in the lungs and pulmonary fibrosis Finally there are others others such as beryllium of such toxicity that they can be regarded as general issue poisons which produce widespread effects in the body as well as local fibrosis in the lungs Asbestos is toxic and prodices not only pallonery fibrosis but reactions in the pleura even in other organs Dr.Hoard has excellently summary demonstrated the pathology of asbestosis in our patient but way of here is a picture Fig.12 of a whole lung section of another patient who is from asbestosis There an interstitial fibrosis as in the present gross pleural thickening and some patchy bronchiectasis Besides these features which are common in asbestosis there may be associasociatedaassociatedted fuberculosis there was in this second case or even more inmortant asasociated sociated lung cancer as .. as in our patient Sometimes the interstitial fibrosis gives rise to the formation of bullae or occasionally oven to a widespread honeycorb that which occurs with other rere forms of pulmonary interstitial as the xanthomatoes . RADIOLOGICAL AFFEARANCES These are typically those of a fine like reticular pattern particularly affecting the lower lung fields and causing a shaggy border to the heart as in Desidos this cystic change may be seen and very often the our patient Although the ray picture is typical and almost pleural thickening who have undoubted pathognomonic in a few advanced cases there are many patients of asbestosis as judged by a history of exposure and the clinical features clubbing reles in the lungs and typical changes in lung function extremely That is who do not important have specific changes in their chest radiograph in relation to the diagnosis as we shall ace lator because in general the diagnosis of pneumoconiosis depends on on appropriate industrial history and n characteristic ray appearance There is a characteristic ray appearence in asbestosis but unfortunately from the medico standpoint not the all patients radiological radiological with asbestosic have the characteristic radiograph radiograph Finally FinallyFinally Finally the radiological radiological radiological appearances of asbestosis cannot bo dhssified in the same categories as those accepted internationally for the other pneumoconioses . 2- a particulfarrolmythe complication tua bercg ulosis ae 3clik CLINICAL CLINICAL FRATURES AND COURSE 7 4 at CLINICAL CLINICAL rales in the chest aro the Grozs clubbing of the fingers and persistent Exertional dyspnoea is the main characteristic clinical signs of the coPnadtiiteinotns suffering from asbestosis may die more symptom us in other pneumoconioses common in pant years or more either of Those not killed by chest from that of carcinoma of the lung infection or cancer may finally get cor pulmonale 3c rather suddenly over the course of The disease usually makes its appearence the asbestos inhalation a few months often long after the initial exposure to that the asbestos lie dormant as an asbestos body which toxic It has been suggested before it can break down and librate its has to rinen over many years is like beryllium which may also lie contents In this respect asbestos again with come dormant in the body and then suddenly produce its effects concurrently other infection by rt wee ot : serious and well recognised complication in Carcinoma of the lung is a is difficult to determine for it is n w esbostosis Itsfrequency in asbestosin Moreover exposure to asbestos a common condition in the general population Nevertheless tha may have occurred many years before the cancer develops with asbestosichasa risk paper holl makes it fairly clear that a patient of getting carcinomoaf the lung about10times that of the general population This ratherrera tumour may draw Another hard is mesothelioma of the pleura dust Finally in attention to the fact that a patient has worked in asbestos of thto ehe voavrayry woman who work with asbestos thore is a high incidence of cancer the eee emcee FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL FUNCTIONAL EFFECTS EFFECTS EFFECTS EFFEFEFCETCSTS EFFECTS EFFECTS diminution of the inspiratory capacity which fits in with the There is a demonstrated by Dr.Heard Dr.Heard in this case In contrast with other shrunken lung there is often little disturbance to air flow so that all the pneumoconioues lungs movement of there is is used to good advantage and the dwa well maintained Thus if 3 breathing capacity M.B.C. is ofteins sausrspersisseidngblyythe M.B.C. or foread expiratory with a nan patient suffering fromheasbiessutnofsiasirly assessed for compensation compared volume F.5.V. test The essential cance piumoroniosis suffering from silicosia or torkersthe difficulty of transferencetransference transference of azien of the breathlessness in asbestosic is than the reduced maxion broag the altered alveolar membranes or so pneumoconiosis Carbon didoixoixiddee across in say coal pneumoconiosis pneumoconiosis pneumoconiosis pneumoconiosis pneumoconiosis pneumoconiosis pneumoconiosis Carbon Carbon capacity capacity capacity which is which is tthehe Gause Gause in say coal pneumoconiosis and is unaffected Oxpyen being soluble diffuses 20 times as repidly as oxyson at rest so that the patients bab are rarely cyanocod saturation and gross transfer is usually adequate when they start to exercise there is a rapid fall in oxygen hyperonea hyperonea The diagnosis rales and usually the rediograph may is made on a history of exposure the presence of clubbie and avidones that Theva is however by means of a radiograph thethe lung furstion furstion togts not show changea uc carly sarcoid scleroderma microlithis microlithis microlithis and other pure conditions vris vris teh. tests patient pillay be shown that the has an interstitial interstitinterstitial ial fibrosis pillay causing pillay causing -3 clubbing and rules rules and a history of whether the block has gross that he has asbestosis it seems ruasonable to asbestos dust exposure radiograph is specific or no themselves ASBESTOS DUST to asbestos dust and of The asbestos bodies simply prive exposure asbestos bodies who has inhaled asbestosis Anyone may cough up in the lungs Vice do not mean without necessarily having the changes of asbestosis without asbestos bodies dust versa may have definite definite and gross asbestosis legally tho a patient in the sputum during life Since with the appropriate necessarily being foundhistory of dust exposure together in diagnosis dopends on a the finding of asbestos bodies is of importance ray end other changes proving exposure inhaled are coated with collage It seems probable that asbestos asbestos fibres once by forming transverse cracks the collagen collagen cover ripens toxin and causing the Over the coursaesboefstyoesarbsody can breakbreak down ddoownwn liberating the uncertain It is and then the The nature of the toxin is reactive fibrosis in the lungssubstancesubstance which is carcinogenic however presumably the same described in this country byM.liurray in 1907 After the Asbestosis was first described the dangers of asbestos dust that in 1930 Hereweather and PricePrice reported dust suppression Thereafter there was a lungs and made recommendations for where patient our patient worked worked utmost- worked . utmost- the utmost- disappearing great improvement In the factory asbestosis occurring It is a disappearing precautions precautioprencaustions are nou taken to prevent and the amount needed to diseasc Nevertheless asbestos vigilance and now preventive methods bees a eerie ome. cause asbestosis not constant known so abolished be cause needed if this diseasies to be abolished pathogenesis DISCUSSION DISCUSSION DISCUSSION DISCUSSION There are Professor NicMichael Pgroofesso orn to the are there any other of asbestosis many other facets points or queries to this patient butbefore va which could be raised raised on the of the mechaniccal theory point in support into a fia is one you gis asbestos ground up and that is worth raising If experimentally asbestos fibres between 20 dust fibrosis does not occur and it so that typical peribronchiolar fibrosi microns in length ere necessary to produce the DISTRIBUTION OF FIBROSIS of of the distribution Professor Professor E.GE..G.L.ByLwaters.BywaterE.Gs.L.BywaterEs .G.L.Bywaters What is the explanation the lung or distribution of asbestoisn fibrosis Does fibrosifibrossis Does it correspond to to the fact is there some other explanation to correspond Although some matter of it it doesn't seen there vore Dr.Hesrl Dr.Hesrl As a were in fibrosed areas the best of the best asbestos bodies in this case in other parts Dr.Nagelse Dr.Nagelse , surrounded by perfectly normal normal lung that they have reconily plenty ago and he was saying Sheffield was here two days oago afgo lungs from cases of asbestosis In cone examined chemically a number -4- he asbestos However did point out th and practically no content was estimated as the Was a lot in Fibrosis the asbestos possible error because of fibrosed lung is not there was the dried weight and the dried weight It is quite a percentage percentage ocfomparable to wteihghet dried weight of thedinsotrrmiablutliounngof the fibrosis has the forms altogether peripheral problem d go far as I know to asbestosis being seen in other It is not restricted 4 boon explained of honeycomb Lung ce