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FILE NAME Colonial Sugar Refinery CSR DATE 1960 Apr DOC CSR225 DOCUMENT DESCRIPTION Journal Article - Complications of Asbestosis 1344 APRIL 30 1960 CENTRAL CYANOSIS APRIL 30 1960 Clincopatholgical COMPLICATIONS OF ASBESTOSIS has been made that while the tongue is probably the most sensitive site for the observation of central cyanosis intelligent guessing does not replace thorough of arterial oxygen saturation or oximetry estimations no may be that lymphatic as well as vascular invasion and metastasis are hindered though James found difference in the incidence of metastasis to different 24 i organs in the miner and miner except for the brain in which secondary deposits were found in only % of miners and 27 of miners ~ ge Clinicopathological Conference Clinicopathological Conference COMPLICATIONS OF ASBESTOSIS DEMONSTRATED AT THE POSTGRADUATE MEDICAL SCHOOL OF LONDON CANCER IN FIBROTIC FIBROTIC LUNG ditoday of diagnosing pulmonary shadows in of miners has recently been R Abbey Smith.,, Je notes in single fibrotic nodule unaccompanied by radiographic evidence of simple pneumoconiosis and slowness in growth of certain lung cancers in miners In a review of 320 cases operated on for lung cater one hospital and drawn from the of town and country he records that general population This survived two years or more after operation compares with 34 reported by A. B. Taylor and 1954 in relation to 512 resections and exitin 1 R Bignali and I. Moon in 1955 in to agricultural relation 205 appears that the industrial group of workers fired better than the and rual evidently because because of the inclusion in the former of a number of einers miner being defined who has witked five years or more as person underground at The cost face no account of sitaation of the mines Was laken the same period with he found that of the same criteria of 21 miners who had resection only thre died in the first two years which tsa survival rate of -a after : statistically significant difference from the whole He oders two possible explanations first that the specific zer develops op growing tumout which he finds the more of tumour is retarded by the zhalation of coal dust on the lung lymphatics Against the first he ws This paper shows that experience is better distilled to : ; statistics than to obiter dicta It is a reminder of the > is the case of a man with asbestosis with a fatal This No. 215526 P.M. No. 8556 He theory that previous damage may mitigate later disease : complication Case with haemoptysis and exemplified the as has been suggested in times past by clinicians who presented of the cause of haemoptysis and said that healed tuberculosis by the blocking of ; problems of diagnosis associated with the lymphatics reduced the spread of cancer and the toxic- the nature of the lung changes effect of empyema More information on this asbestosis : problem would be welcome and the higher survival Clinical History rate among group miners together with the Dr. PHILIP JONES This man was aged 50 years this lower incidence of lung cancer among miners at death His medical history starts in 1922 when at the s reported by Kennaway and Kennaway certainly points 4 of 14 years he got rheumatic fever He apparently age from this However he was to the usefulness of further inquiry into the factor made a good recovery medical examination in which may be responsible g1r9a4d0ed*inthgeraoguep oIfV 3at2 atnhoAurgmhyhe himself felt perfectly well In 1943 he had a gradual onset of swelling KING GEORGE'S JUBILEE TRUST APPEAL aching and stiffness of the metacarpophalangeal joints both hands and of the wrists shoulders knees and In 1935 a grateful people subscribed lm as a national of continued for five years there was little offering for the twenty years reign of King ankles This constitutional upset but the illness icft him with a and wrists and with George V. and the offering was dedicated to the cause residual stiffness of his shoulders arthritis always dear to the king's heart of advancing the 43 Mey: deformity of the hands typical of rheumatoid physical mental and spiritual welfare of the younger aed From 1938 to 1949 he worked in an asbestos factory generation in his kingdom The fund inaugurated for There he felt well but on routine radiological this purpose George's Jubilee Trust now 8 celebrating its own silver jubilee and it has just 3 asbestosis was certified and subsequently became a launched its first national appeal for funds since its storeman From that time onward be noticed foundation Over the past twenty years the Trust increasing shortness of breath on exertion In May Be. haemoptysis and was | has given more than im in grants for the welfare of 1958 had brisk he got worse a investigation HM admilled Hamersmith Hamersmith Hospital for investigation + the young but the income at the council's disposal to even with the help of legacies and other gifts barely exceeds 40,000 a year The funds are chiefly used to help those who leave school at the age of 15 there 852000 610,000 of these in 1948 and there will be .Oiiieg in 1961 and 927,000 in 1962. With the increasing calls EXAMINATION AND INVESTIGATIONS He had marked clubbing of the fingers and toes rheumatoid changes in his hands elbows and shoulders enlarged axillary glands and two small mobile cutaneous nodules on the medial side of the persistent right arm There were scattered rales over both lungs His pressure was 120/65 his pulse was regular and he had a grade 3 aortic systolic murmur an accentuated pulmonary second sound with murmur an opening snap and diastolic murmur at the heart apex A radiograph of the chest Fig ) showed a fracture of the sixth rib on the right large pulmonary vascular shadows and a reticular mottling over the lower zones of both lung fields with a " shaggy Out- line to the heart On barium swallow there was slight enlargement of the left atrium The changes at the right hilum could be those of an enlarged pulmonary artery or those associated with a right hilar neoplasm Tomography Fig 2 confirmed the right hilar mass occasions His sputum was examined on numerous bodies for tubercle bacilli malignant cells and asbestos but nothing abnormal was found Bronchoscopy showed the hand side of the bronchial tree lo be normal The right upper lobe was normal but there was stained mucopus in the region of the right middle lobe with a granular appearance of the right descending and lower lobe bronchi However a biopsy from the granular arcas showed no evidence of malignant change Biopsy of lymph glands and of the skin nodules showed only changes compatible with cheumatoid arthritis The electrocardiogram gave little support for the clinical diagnosis of mitral stenosis despite the slight enlargement of the left auricle seen on barium swallow The blood count was normal except that the haemo- quotes WR frequency of differe at between miners and as finding histological reneminers no difference in the types of carcinoma Bat it may be that the Sicological type is not important in this respect that in there may be same factor which operates to slow down the rate of growth of all If reis is so the faciar which improves their could akin to that which explains why of upon it the Trust needs an additional income of 110.000 2 year Many of the Trust's grants are well known it gives bursaries for example to enable young people who Outward could not otherwise afford to do so to join the t Bound Trust courses at sea and mountain schools : the British Schools Exploring Society or to the courses ; on the old sailing ship Fondroyant moored in Ports globin was 11.5 g./100 ml Blood cultures were persistently negative The E.S.R. was 125 mm./hour The differential agglutination test was positive for rheumatoid arthritis and electrophoresis of the serum proteins showed high a and "peaks sy longer danation of symptomssymptoms pre- mouth harbour It also gives a great deal of unseen operatively fue Better Thien those with A short 0 But Smith favours the second Bistory explanation the Kergin of Flocking referred to by F. lymphatics by carbon laden macrophages and the choking of the glands by heavy carbon deposits and fibrosis making lymphatic metastasis difficult Kergin has drawn attention also to the fibrous tissue binding glands to bland vessels and so often found in the lungs of coal miners It national support to the day work of the national voluntary the youth organizations As the Trust's council says 4 appeal is a national appeal in support of a cause and it is described as a call to the nation to accept again as i did in 1935 its responsibility for those on whom the future of the country will depend Those who are interested in the work of this very practical organization should send their inquiries to the secretary King George's Jubilee Trust 166 Piccadilly London 4 W.I. feited Bingham Bingham ee. 1782 Fith Fith ch 24,215 1951 25 Sit The Queen has conferred the Order of Merit on Cyril Hinshelwood President of the Royal Society : and Dr. Lee's Professor of Chemistry in the University of : 1.Chest radiograph The fracture of views on first admission posienor the anth rib is not visible oo an Fig Tomograph confirming right hilar mass IN IN 1957 1 1954 18 Oxford Ais ceg hfs nok on . . COMPLICATIONS OF BRITISH MEDICAL JOURNAL lunpes 15 pical of an abscolarscaplary aquaxide diffusing antenal oxygen oxygen capacity angla by ypu again dischanged After that he deteriorated steadily with increasing haemoptyses though he was in no pain He was finally admitted again in September 1958. when he showed signs of consolidation of the right chest and swelling over ihe left clavicle He died on Septender 29 Clinicad Diagnosis 1 aremana el lower Jobe bronchus with inchestres inchestres to spone and and elsewher elsewher 2. Asbestosis 3. Rheumatic heart disease quiescent aortic incompylence and mitral stenosis 4. Rheumatoid arthritis -IST toes cond be hd bad a a mortem Findings Dr. F HEARD The body was wasted weight 6 51. 10 lb. 42.6 kg height 5 ft 7 in 1.68 m.1 Both hands showed ulnar deviation and the lingers and toes were clubbed There were two small nodules 1 cm in diameter over the right elbow and there was one 4 cm diameter over the left They contained caseous material and histologically showed looking fibrous walls lined by merophages and enclosing amorphous material with many cholesterol clefts There was no certain evidence of active rheumatoid disease here The chest measurements were antero- paserian diameter 20.5 cm lateral 25 cm Terence 22 em This is within the normal excludes a barrel shaped cliest Both pleieral sacs were completely obliterated by dense fibrous adhesions The pericardum was also obliterated and showed a plaque of calcification over the pulmonary conus The peritoneum 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 a The surface was pale and granular and there was cennial necrosis subpleural The lower lobe also showed some There were secondary deposits in the hilar lymph nodes The middle lobe was heavily infected all bronchi being filled with mucopus and the stars more cell Sot! LEGENDS TO SPECIAL PLATE 4. 1 The loft bung showing honeycombing of the interes puts of the lingubre and anterior segments of the upper lobe and also of a thick subpleural zone combining half down the back and unvolving the costoprenie angle and the diaphragmatic surface of the lower lobe the whole of Te. a A higher magnification ^ 1,4 of the left lower ohe showing the subpleural zone of honeycombing and dense overlying ndhesivas IH A higher magnification magnification ^ LA of the postero- ar owl upper lobe show a line apical arrowl and minerous emphysema separated from unpigmented lung at the Eee white focilines mark centres approximately septs periplieral unpigmented fung zones of by aeeeeea a near top of the picture the are ACW pale indicated APRIL 30 1960 COMPLICATIONS OF ASBESTOSIS MISICAL JOURNAL F10 4 Nee ee bette ee Ne Aree bee 7% MEDICAL JOURNAL lung yellow and consolidated There was some honeycombing of the anterior part of this lobe The upper stained intensely for iron by Perls's reaction Some of the bodies were smooth and rounded Others were lobe showed slight apical fibrosis associated with two bullae 1.5 cm in diameter , but no calcification In all parts of the lung unaffected by fibrosis there was mild sausage with a variable amount of segmentation Some ended crystals accompanied the bodies and may have been asbestos fibres Elsewhere in the lung centrilobular emphysema The appearance 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 increase of reticulin in these areas The tumour WAIS " moderately differentiated columnar carcinoma with tubular and papillary 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 lung 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 patterns Most reports stress the frequency of HEART AND OTHER ORGANS squamous carcinoma with asbestos so the present case is somewhat unusual There is no question of this being The heart weighed 370 g normally 281-361 g for a mesothelioma The left lung weighed 885 g and was man of 5 ft 7 1.68 m The increase in weight prepared by pressure fixation and barium sulphate was partly due to dense adhesions described above and impregnation Fig 4 to demonstrate emphysema The partly to a trace of hypertrophy of the left auricle and volume of the lung 2.2 litres was at the lower limit of possibly the right ventricle L.V. 1.5 cm thick R.V. normal There was honeycombing Fig 5 in a thick 0.4 cm thick The pulmonary and tricuspid valves were normal but the mitral valve was 70 mm in subpleural zone of lung commencing half down the back of the lower lobe including the costophrenic circumference normally 90-110 mm The chordas angle and the whole of the diaphragmatic surface tendineae were fibrous but not shortened The edge of Also honeycombed were the anterior parts of the the valve was straight The valve cusps were fused and lingula and a little of the anterior part of the anterior thickened by Ebrosis and the valve admitted one and a segment of the upper lobe Honeycombing was accom- half finger Histologically there were no signs of panied by bronchiectasis . active rheumatic fever but at one point there was a small mural thrombus as described by Magarey.who Histologically the detail of the respiratory tissue was attributes the fibrosis to the organization of successive considerably simplified Most of the airways consisted of small bronchi or bronchioles which were dilated Fig ) There were no alveolated passages Between the holes were thick walls of moderately dense collagen lightly infiltrated in places by lymphocytes but as a rule having an inactive appearance Stains for elastic tissue showed no alveolar shadows most of the elastic being confined to the walls of blood vessels Fig 8 The larger arteries in the fibrous areas of lung showed 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 vegetations The coronary arteries showed moderate atherosclerosis and the aorta a mild degree The heart changes were consistent with an old history of rheumatic fever There was no sign histologically of rheumatic activity 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 9 well- known in recognized asbestosis Asbestos bodies Fig 10 were lying free in the lumen often in clumps They had the characteristic and Thorax brown colour Heard B. E. 1958 13. 136 ibid, 1959 14 58 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 contained some scattered secondary deposits of growth up to 1 cm in diameter It showed centrilobular conges- tion throughout confirmed histologically The gallbladder biliary duets 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 g normally 6-7 g LEGENDS TO SPECIAL PLATE each were enlarged by metastases but the other endocrine glands were normal The urinary -A focus of centrilobular emphysema showing asbestos bodies with other pigment in walls of dilated the respiratory bronchioles ^ 245. section of a fibrosed pleural zone stained clastic fibres On the left is a thin layer Pleural of tissue lying outside the elastic famina which marks the original border of the lung Within the lung finer air have been replaced by dense fibrous tissue The minal elastic content is related to small system was normal The brain showed secondary deposits Fig 11 up to 1 cm 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 blood vessels 95 Feb. 9. multinucleate giant cell containing fragments of asbestos bodies ^ 1,012 FIG 10. clump of encrustations over the asbestos bodies showing wrinkled asbestos fibres ( 1,012 ) 2. Honeycomb lung due to asbestosis 3. Old rheumatic heart disease 4. Old rheumatoid arthritis Gloyne S. R Tubercle 1933 14 445 Rickards G. and Barrett G. M. Thorax 1958 13 185 185 Magarey F. Brit med J. 1951 E. 56 1350 APRIL 30 1960 RADIOLOGICAL APPEARANCES Asbestosis Reviewed Professor J MCMICHAEL Dr. Jones would you sum up D JUNTS 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 double silicate of magnesium and iron It in number of mineralegical forms one of the valuable being chrysolite chrysolite Asbestosis is " " pueumoconiosis arising from the inhalation of asbestos Just daring the manufacture of asbestos goods such as asbestos sheeting fireproof clothing linings lagging for boilers and pipes etc. One way of thinking relation relation to of the pneumoconioses in chemial toxicity of the different dusts At one extreme are those such as iron which are entirely toxic and smply produce a characteristic radiological appearance of the frings with no change in Mobily function her roche athers such as coel which this but also have pathogene action by altering the local Traction the ungs to tubercle Next there are desis as silica which produce a local reaction in the pulmonary fibrosis Finaly Finally place others as brillmm of such toxicity that they can be regarded as general tissue poisons which produce widespread elects in as well as local fibrosis in the lenes Asbestos is very lasic and produces not cale pulmonary fibrosis hat reactions in the pleura and even in other organs Dr. Heard has excellculty demonstrated the pathology of asbestosis in our patient bat by way of seats seats here is a picture Fig nother patient who died fibrosis as of from in the These are typically those of fine lacz reticular pattern p^ ticularly affecting the lo"wer ! fields and causing a shagg border to the heart as in may patient Besides this cyst changes may be seen and ve often ~ the pizurat thickenin Although the Tay picture typical and almost pathognomon in a few advanced cases there a many patients who have undoubt asbestosis as judged by a histo of exposure and the clinic features of clubbing tales in : uns and typical changes in lu function who do not have speci changes in their chest radiograp That is extremely importan~- relation to the diagnosis as + shall see later because in gene the diagnosis of pneumoconio depends an appropriate indu history and a characteristic ray appearanc There is a characteristic ray appearance in asbestos but unfortunately from the medico standpoint r all patients with asbestosis have the characterist radiograph Finally the radiological appearances , asbestosis cannot be classified in the same categori IS Those accepted internationally for the oth pneumoconioses CLINICAL FEATURES FEATURES AND COURSE Gross clubbing of the fingers and persistent rales the chest are the characteristic clinical signs of : condition Exertional dyspnoea is the main sympto as in other pneumoconioses Patients suffering fro and some patchy Besides these three which are asbestosis there may be associated taber- culesis as there was in this second case or even more important associated lung cancer as in our patient the interstitial fibrosis gives rise to the of bullae or necasionally even to a wide- hung de that which occurs with other care of pubronary pubronary interstitial interstitial fibrosis such xanthomatosesxanthomase techniqu 11. 12. Large long section prepared by Professor Gough technique from another patient with asbestosis showing it grows pleurat thickening mitchy fibrosis and bronchiectasis or accompanying tuberculosis at the long open APRIL 30. 1969 COMPLICATIONS OF ASBESTOSIS JOH 1351 MEDICAL JOH asbestosis may die either from the complication of Tuberculosis more common in past years or more particularly from that of carcinoma of the lung Those not killed by chest infection or cancer may finally get cor pulmonale The disease usually makes its appearance rather suddenly over the course of a few months often long after the india exposure to the usheslos inhalation || has been suggested that the asbestos lies dormant as an asbestos body which has to ripen over many years before it can break down and liberate its toxic contents In this respect asbestos is again like beryBium which also lie dormant in the body and then suddenly may produce its effects concurrently with some other infection Carcinoma of the lung is a serious and well- recognized complication in asbestosis Its frequency in asbestosis is difficult to determine for it is now a common condition in the general population More over exposure to asbestos may have occurred many before the cancer develops Nevertheless the years paper by Doll makes it fairly clear that a palient with asbestosis has a risk about 10 times that of the general population of getting carcinoma of the lung Another hazard is mesothelioma of the pleura This rather rare tumour may draw attention to the fact that a patient has worked in asbestos dust Finally in wemen who work with asbestos there is a high incidence of cancer . of the ovary FUNCTIONAL EFFECTS EFFECTS ASBESTOS DUST The asbestos bodies simply prove exposure to asbestos dust and of themselves do 031 mean asbestosis Anyone may cough up asbestos bodies who has inhaled of dust without necessarily having the changes asbestosis in the lungs Vice versa patient may have a and gross asbestosis without asbestos bodies definitenecessarily being found in the sputum during life Since legally the diagnosis depends on a history of dust exposure together with the appropriate - ray and other changes the finding of asbestos bodies is of importance in proving exposure It seems probable that asbestos fibres once inhaled are coated with collagen Over the course of years the " collagen cover ripens by forming transverse cracks and then the asbestos body can break down liberating 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 Asbestosis was first described in this country by M. Murray in 1907. After that in 1930 Mereweather and Price reported the dangers of asbestos dust in the lungs and made recommendations for dust suppression Thereafter there was a great improvement in the Nevertheless factory where out patient worked the utmost precautions are now taken 10 prevent asbestosis occurring It is a disappearing disease asbestos dust is most toxic and the amount needed to cause asbestosis is not known so constant vigilance and new preventive methods are needed if this disease is to be abolished There is a diminution of the inspiratory capacity which fits in with the " shrunken lung demonstrated by Dr. Heard in this case In contrast with other nneumoconioses there is often little disturbance to air Now so that all the movement of the lungs there is is compensation advantage used to good and the advantage capacity M.B.C. is often surprisingly well maintained Thus if a patient suffering from asbestosis is assessed by the M.B.C. or forced expiratory volume F.E.V. test he is unfairly assessed for compared with man sullering from silicosis or workers pneumo coniosis The essential cause of the breathlessness in asbestosis is the dimeulty of transference of oxygen neross the altered alveolar membrane more so than the reduced maximum breathing capacity which is the cause in say coal pneumoconiosis Carbon dioxide being Sulle diffuses 20 times as rapidly as oxygen and is Affected Oxygen transfer is usuntly aslespunte nt rest so that the patients are rarely cyanosed but when they start to exercise there is a rapid fall in oxygen Discussion Professor McMICHAEL There are many other lacets to this patient but before we go on to them are there any other points or queries which could be raised on pathogensi the pathogenesis of asbestosis is Dr. R. S. WILLIAMS I think there one point in support of the mechanical theory that is worth raising If experimentally you give asbestos ground up into a fine dust fibrosis does not occur and it seems that asbestos fibres between 20 and 50 microns in length are necessary 10 produce the typical peribronchiolar fibrosis DISTRIBUTION DISTRIBUTION it FIBROSIS Professor E. G. L. BYWATERS What is the explana- tion of the distribution of fibrosis ? Does it correspond 10 the distribution of asbestos in the lung or is there some other expinmation 7 Although Dr. HEARD As matter of fact correspond Although some of it doesn't seem to the best asbestos Saturation and gross hyperpnoen The diagnosis is made on a history of exposure the presence of clubbing and rales and usually by means of a radiograph There is however evidence that the radiograph may not show changes as early as do the function tests Although the latter are not specific 10 asbestosis they are only seen other uncommon diseases which cause alveolar block and interstitial fibrosis such as sarcoid seleroderma pathological microlithiasis and other rare conditions Thus lung- function tests are useful for making the diagnosis for if it can be shown that the patient has an interstitial fibrosis causing alveolar block has gross clubbing and rales and a history of exposure asbestos dust it seems reasonable that he has asbestosis bodies in this case were in fibrosed areas There were plenty surrounded by perfectly normal lung in other paris Dr. Nagelschmidt from Sheffield was here two days ago and he was saying that they have recently examined chemically a number of lungs from cases of asbestosis In some there was a lot of fibrosis and practically no asbestos However he did point out that There was a possible error because the asbestos content 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 I 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 whether he radiograph is specific or not 7 Os R. Brit 1. industr Mrd. 1955. 12. 81 Mereweather R. A. and Price C. of Asbestos Dust on the Lungs 1930. |ae 1352 APRIL 30 1960 COMPLICATIONS OF ASBESTOSIS AUITION MEDICAL JOURNAL ASHESIOS IN THE PERICARDIUM Dipfessor MCMICHSET MCMICHSET Dr. Plotz you have a ? D Plotz New York I've got a couple of questions In reading the case history I was surprised -pleasantly surprised and greatly relieved to find that no mention was made of this man's smoking habits Some of out surgical friends are putting asbestos rather than taie 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 wondering what Dr. Jones and Dr. Heard would have to say about that One other minor point bothered me a little in the case History --perhaps am getting a little touchy at the age a little over but you said that his age was determining whether or not to operate on bim and you decided not to operate on him because of 1 wondering if he was too old or too Hegudives I couldn't agree with you more But thing we debated in his particular was patiral's general condition including his age He was man of 30 who had gross rheumatoid authside and was considerably disabled and deformed by chance of being able to eradicate the permaneally am afraid am not all that about the effects of surgery in carcinoma of rheumatoid arthritis This is the second example we have seen day . Professor BYWATERS 1 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 diseases and one disense doesn't seem to confer Immunity from the other I think we are always happier 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. Hugh described It's a very unusual place he pointed to on his own arm 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 view side but I haven't seen the sections 1 think this is of some importance from the point of view of the lung because the Caplan type of lesion seems to occur mainly in rheumatoid patients with nodules elsewhere In fact the Caplan lesion is a modified rheumatoid nodule occurring in the lung substance or the pleural tissures 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 am not saying that these are not nodules 1 haven't seen them but it might be the reason why he didn't develop further changes in his lungs which is not kind particularly related to so fur as one kinases 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 and the cell carcinomas carcinomas which have arisea since the 1900s and could be correlated with sit 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 diseases Is there really no relation between these diseases ? Way back in the 1900s carcinoma of the lung equally common in men and women and it was predeunantly an adenocarcinoma then It is the acent emergence of the squamous and cell types which gives the male preponderance and which various have related to smoking Pretessor McMichalt McMichalt What pericardium about the dangers of Haudoses think that's very interesting because asbestos and sale are similar chemically principles would be a little worried abou ultimate effects of ashestas in the pericardial used in the pleural cavity to produce many spontaneous prenmatharocies but know if Aaye ic Itas pill asbestos in the pleural would be a litk varried about asbestos no reason for say that it's a bad thing Dr. C. there any lung trouble mi tale manufacturers manufacturers Dr. Jox's Oh yes Rotunistic Rotunistic FLYDU AND Rirustaom RiirustaRitiruostamtom ABTRIES Professor Mc Micinar Profes Professor Bywaters would to comment on the recurring sequence of acute sheumatic fever followed by progresive progressive RHEUMATOID ARTHRITIS AND 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 lupus When somebody wrote to me about this and inquired for details I quoted the two cases ) knew of and the same day whilst I was doing the letter the Records Department turned up " " live others which were diagnosed rheumatoid arthritis and then subsequently disseminated lupus Professor BYWATERS We feel there is no real relation but often close clinical and sometimes even pathological similarities Unless you have got bonalide heart lesions it is sometimes extraordinarily difficult in 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 be fairly certain about it sometimes ! Professor McMICHAEL It's very interesting to se^ * these arrested valvular lesions The minimal adhesion of the mitral valve and aortic 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 dantage al 14. got through to 50 APRIL 30 1960 . COMPLICATIONS OF ASBESTOSIS BEATION MEDICAL JOURNAL 1353 FRACTURED Ran Professor BYWATERS Was there any evidence at necropsy of any metastasis in the fractured rib that might have given us an earlier clue to the diagnosis ? Dr. HEARD There were very widespread metastases I didn't examine that particular rib but I expect it was affected Dr. Cops What about this heavy intimal thickening is it characteristic of asbestosis Does it lead to pulmonary hypertension or what happens? Dr. HEARD The grass intimal thickening of the pulmonary arteries that I showed was in the fibrous arcas Elsewhere there was only a little thickening With this and the normal right ventricle I doubt whether there was much in the way of pulmonary hypertension here We are grateful to Dr. J. P. Shillingford and Dr. B. E. Heard for assistance in preparing this report and to the photographic department of the Postgraduate Medical School for the illustrations Drug Treatment of 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- treatment gencies and call for immediate and expert Relatively they uncommon are seen after infections infections operations perforating injuries or in severe infections of the cornea In contrast infections of the outer eye are of daily occurrence When the infection is bacterial in origin treatment by antibiotics is generally elficacious but virus infections still present a consider- able problem The poor penetration into the interior of the eye of many of the antibiotics greatly limits the value of in systemic administration of these drugs the treatment of intraocular infections Fortunately subconjunctival injection of some of the antibioties is a feasible results procedure in expert hands and gives excellent For the external infections of the eye local application is so eminently satisfactory and so readily given that neither systemic administration nor subconjtival injections often need to be considered The newer kgents thus curry 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 allied to that of trachoma is responsible for another substantial group in which inclusion bodies can be found in epithelial scrapings taken from the conjunc ; tiva the gonococcus accounts for a relatively small proportion of the possibly as little as 20 or less in present series the pneumococcus accounts for further substantial proportion All these organisms are fairly readily susceptible to the modern sulphonamides in adequate concentration so that most cases of ophthalmia neonatorum respond quickly to systemic administration Apart from ophthalmia neonatorum and the somewhat similar purulent ophthalmia of adults the sulphonamides systemically are useful in the alter- treatment of septic affections in the lid and orbit denit with surgically the infections In the treatment of intraocular sulphonamides systemical y systemically are of little use owing to their poor penetration 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 some of the antibiotics Sulphianamides sulphonamides The classical insoluble sulphonamides are all highly When 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 sulphacelumide were untenable the experimental and clinical results claimed for corneal infections due to - rather Pacaronionas pyocyanca insensitive to tulphonamides reflect the early and rather uncritical enthusiasm for the sulphonamides It may be taken that the limited range of action of the sulphonamides together with the fact that The Sulphonamides locally are inactivated by pus and breakdown products of tissue make sulphacetamide of little value in ocular therapeutics There is however an unquestioned place for the sulphonamides given systemically in treating some of the external infections of the eye in ophthalmia hconatorum it is possibly still the agent of choice The Cansutive organism in ophthalmia neonatorum is commonly Staphylococcus aureus a virus closely Antibiotics Antibiotics for Administration Penicillin streptomycin chloramphenicol and the tetracyclines 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 corncal foreign bodies and after other minor injuries of the eye has greatly reduced the incidence of infected corneal ulcers and muco- purulent conjunctivitis Ointments of penicillin and of chloramphenicol as also of letracyclines are used commonly in the treatment of subacute and acute conjunctivitis and of blepharitis replacing almost entirely all the older solube remedies . Penicillin and streptomycin being very soluble can also be used as subconjunctival injections for infected corneal 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 Seen