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FILE NAME: Norfolk & Southern (NS) DATE: 1936 Sept DOC#: NS037 DOCUMENT DESCRIPTION: Medical Journal Article - Asbestosis - A Roentgenologic Review of 71 Cases U/71 Asbcstosis: A Roentgenologic Review of 71 Cases B y J . R U S H SH U L L , M .D ., Charlotte, N. C. R eprinted from R A D IO L O G Y , Voi. 27, N o. 3, pages 279-292, S eptem ber, 193(5. [Reprinted from RADIOLOGY. Vol. 27, No. 3, Pages 279-292, September. 1936.] ASBESTOSIS: A ROENTGENOLOGIC REVIEW OF 71 CASES B y J. RUSH SH U LL, M .D ., Charlotte, N . C. SBESTOS has been used in industry for centuries. It would seem that the pathologic action of this dust in the lungs would have been recognized be fore 1900, when Murray, in England, per formed an autopsy on such a case. This autopsy was performed on a man, the last of 11 men who had begun work together in an asbestos plant in 1S90. Murray did not report his findings until 1906. Probably the first case in English medical literature to be definitely proved as asbestosis, was reported by Cooke in 1924. This patient had tuberculosis as a complication. Little attention has been paid to this form of pneumonoconiosis in the American literature until 1928, when the "Journal of the American Medical Association" com mented editorially on Cooke's report and suggested that this condition deserved more consideration than it has been given. The first cr.se reported in America was by Mills, in 1930. Since then many individual case reports, or small groups of cases, have been brought to our attention; but no large series from which a comprehensive study can be made has appeared. . Asbestosis may be defined as a disease of the lungs caused by the inhalation of asbes tos dust and fiber. It is classified as a pneumonoconiosis and is characterized roentgenologically by an early interstitial fibrosis with progression into a terminal diffuse fibrosis. This fibrosis begins pri marily in the bases of the lungs, involving the peribronchial structures. The paren chyma of the lungs is comparatively unin volved. As the disease progresses there de velops a filmy, hazy appearance of the lung-fields which has been aptly described as a ``ground-glass appearance.'' The right side of the heart is frequently enlarged in TABLE I.-- PULMONARY ASBESTOSIS 1 Percentage of Cases Having 16 35 20 Slightly Moderately- Markedly- Advanced Advanced Advanced Right-sided car diac hyper- trophv 3/ .5 62.8 95.0 ; Pericardial and pleural thick ening 0 High left dia 28.6 45.0 phragm 12.5 48.6 80.0 Emphysematous type of chest 6.3 65.7 95.0 CHART I.-- PULMONARY ASBESTOSIS: SLIGHTLY ADVANCED CASES Ui "7. Name Age Color Years' Exposure X -- *u. Ji 1 W. I. W. 28 W M 4 i _ 2 C. \\ \ * 34 W M 2Vs 3 S. E. T. 25 \V M 2 Vs -- 4 J. S.* 24 \V M i+ 5 B. B. R. 28 W M 4 -- 6 K. T.* 26 w M 2 + ** " L. B. H.* 26 w M 9 + 8 J.H .* 24 \Y M IV * -- 9 J. G. 44 \Y M 10 -- 10 J. L. E.* 49 W M 6 -- 11 \V. F. 3S \V F 13 -- 12 R. L. D. 46 W M 12 -- 13 T. J. C.* 36 W M 8 -- 14 L. E. B. 34 W M 2>/s -- lo L. M. 23 w F 4 -- 16 C. B. J. 30 w M o - * Re-examined 15 months later. ** Healed miliary. j? - ill U= ^ Slight _ -- -- -- -- _ Moderate Moderate Slight Slight -- Slight 1 1 3 2 s i -I 3 2 4 H V l- l 5 JJB -- Sr* Jz .2 3 vT 5 >. + -- -- -- -- -- -- -- -- -- -- _ -- -- + - _ -- -- -- -- -- -- -- -- -- --_ -- -- - -- -- - Yes _ -- -- --_ --_ -- -- _ _ _ -- -- - - - - 279 cn 3 3 No. 12, R. L. D.. died oPJ pneumonia 15 months after examination. Ill only three days. . 280 RADIOLOGY the moderately advanced cases, and it is a common finding in the markedly advanced cases. The fibrosis is a result of chemical irritation caused by silica in the dust and of mechanical irritation instigated by the as bestos fibers. Another finding characteristic of this dis ease is the presence of peculiar golden col ored, crustation-like bodies in the lungs of these patients. Stewart and Stewart and Haddow have suggested the name "asbes tos bodies" for them. Gloyne described a technic whereby the central core of these bodies was found to be a minute asbestos fiber. He also pointed out that it is im portant to demonstrate tubercle bacilli be fore one can assume that tuberculosis is a complicating factor. Clinically, the most striking symptom is undoubtedly dyspnea. This is progressive, slow, and insidious in development and is due to inelasticity of the lungs and inter ference with blood supply. Cough and ex pectoration, especially the latter, may be nearly or quite absent except during bron chitic attacks. Anorexia, cyanosis, loss of .weight, and emaciation are rather late manifestations, and are usually out of pro portion to the physical signs, differing therebv from tuberculosis alone. During the latter part of 1934 it was my privilege to examine the chests of 71 of 100 workers who had been dismissed from local asbestos plants. All had undergone physi cal examination before they were referred for roentgenologic study and were found to be physically disabled. Stereoroentgenograms were made of each CHART II.-- PULMONARY ASBESTOSIS: MODERATELY ADVANCED CASES Name Color Tl>crculosis Present Cardiac Hypertrophy Right-sided Comments . 23 a X urt *SO. tc jy x < A >2 (A l 3 a ~bn d tc 6 '= 3 j 3 9 1? >% a 'ug-rs 1g *|5 *3 U La. tiT 3 >* is ? 1 R .A .W .* 26 \V M 5 - -- 2 L. E. W. 25 W M 7 + + -- 3 J. C. S. 36 w M 8 -- Slight 4 W .L .B . 30 w M la -- Moderate 5 C. A. S.* 53 w M 8 -- Slight 6 R. H. S. 57 w M 5 -- -- i T. R. 40 c M 5 -- -- 8 C. D. 33 w M 9 -- Moderate 9 J. M. 39 w M 12 -- Moderate 10 L. M. 41 w F 7 -- Moderate 11 C. M. 42 w F h -- -- 12 O. B. L. 43 w M 7 -- Slight 13 R. K.* 39 w M 10 -- -- 14 E. C. L. 23 w M 3 -- Slight 15 S. J. 31 c M 7 -- Moderate 16 M. I.* 37 w M 9 + -- 17 R. G. J. 38 w M 12 + + Slight 18 W. H. 24 \v M 4 -- Slight 19 H. H. 20 w M V i -- M oderate 20 U. L. J. 38 w M 10 -- -- 21 0 . G.* 39 w M 7 -- Moderate 22 R. G. 27 c M 77* -- -- 23 P. F. 38 w F 11 -- Slight 24 L. F. 53 w F 12 -- Moderate 25 W. \V. F. 40 w M 10 -- Slight 26 A. W. 40 c M 17* -- Advanced 27 S. D. 29 c M 6 -- -- 28 J- D. 30 w M 6 -- Moderate 29 F. C. C.* 39 w M 8 + ' -- 30 W. L. C. 42 w M 6 -- Advanced 31 V. 0 . B. 3 w M S -- Slight 32 A. R. B. 54 w M 12 -- Slight 33 G. L. B. 57 w F lo -- Moderate 34 F. A. C. 28 w M s -- -- 35 C. G.* 31 w M s -- -- -- -- -- Yes -- -- R Yes No. 2, L. E. W., died one ---- - year after examination. -- + - Yes Tuberculosis. Yes + -- Yes Yes -- -- Yes -- + -- Yes -- -- Yes Yes + -- -- -- -- Yes -- + -- Yes Yes -- -- Yes --, -- -- -- -- ---- -- -- -- -- Yes Yes -- -- -- Yes + L -- No. 17, R. G. J., is in -- + ---- term inal stages of -- + -- Yes tuberculosis. Death -- + -- Yes imminent. -- + -- Yes -- -- Yes -- ---- -- Yes -- R -- -- ---- -- Yes + R Yes -- + -- Yes -- + -- Yes Yes + -- -- -- -- -- Yes Yes -- -- Yes -- ---- -- -- + -- Yes -- + -- Yes - +. - Yes * Re-examined 15 months later. SHULL: ASBESTOSIS 281 patient, using a skin-target distance of 72 inches. The same technic was m eticu lously observed in each case, so that films of good contrast and equal exposure could be obtained for comparison. A number were also examined roentgenoscopically. Fifty-six were white males, six were white females, and nine were negro males. The average age was 34.4 years and the time of exposure varied from 16 m onths to 21 years. In eight recognized cases of tuberculosis Fig. l. Fig. 2. Fig. 1. Case 3756. E xam ined on Dec. 3, 1934; w hite m ale, aged 49 years. years: no complaints. Early type of asbestosis. Fig. 2. R e-exam ination m ade on Feb. 15, 1936; th ere is slight im provem ent. P a tie n t was exposed six CHART III.-- PULMONARY ASBESTOSIS: MARKEDLY ADVANCED CASES 2 5 7 a a ^N am e Age | Color Sex Y ears' Exposure Tuberculosis Present Pericardial and Pleural Thickening High Left D iaphragm Trachea Displaced 11 .2 _L !> uxx 1 S B -5 oB -- H O 1 P. S. 36 W M 10 _ M oderate _ + ! -- Yes No. 3, S. G., died three 2 C. H . S.* 33 w M l lA -- Slight + -- Yes m onths after exami- 3 S. G. 30 c M 8 -- M oderate -- -- Yes nation, of an acute 4 R. W. 40 w M 8 -- Slight + + -- Yes fulminating tubercu- 5 P. J. V. oo w M 20 -- Advanced + + -- Yes losis. Autopsy re- 6 G. \V. C. 38 w M 13 -- Slight + R Yes ported in text. 7 G. H.* 36 w M 9 -- M oderate + + -- Yes No. 5, P. J. V., died one 8 S. P. 36 w M 6 -- M oderate + + -- Yes month after examina- 9 E. A. 26 c M 8 -- M oderate + + -- Yes tion. A utopsy re- 10 C. G.* 34 c M 9 -- M oderate + -- Yes ported. 11 F. B. 31 w M 6 -- M oderate -- + -- Yes No. 6, G. W . C., is in 12 L. B. J.* 35 w M 8 -- M oderate -- + -- Yes sanatorium with tu- 13 C. M e. N. 47 w M 10 + Slight + + R Yes berculosis. 14 T . F. E. 50 w M 6 -- M oderate + --' Yes 15 A. J. H .* 37 w M 10 -- M oderate + + -- Yes 16 W . E. G.* 38 \v M 8 -- Slight + -- Yes N o. 16, W. E . G ,, had 17 R. H .* 41 c M 12 -- Advancet -- + -- Yes p n e u m o n ia fo u r IS G. M . C. 32 w M 6 -- -- + -- Yes m onths after examina- 19 F. D. B. 31 \v M 7 ~ Slight + -- Yes tion. Recovery. 20 G. C. 36 w M 9 -- M oderate -- ---- * R e-exam ined 15 m onths later. 282 RADIOLOGY Fig. 3. Fig. 4. F ig. 3. C ase 3744. E xam ined on D ec. 1, 1934; w h ite m ale, aged 24 years. P a tie n t w as exposed tw o years. Only com plaint was a slight cough for few m onths. E arly type of asbestosis. N ote slight prom inence of right auricle. Fig. 4. R e-exam ination m ade on F eb. 13, 1936. N o com plaints. T h ere is definite increased aeratio n of the lung-fields. Fig. 5. " Fig. 6. Fig. 5. Case 3699. E xam ined on N ov. 22, 1934; w hite m ale, aged 31 years. P a tie n t w as exposed five years. Early type of asbestosis with slight cough and dyspnea. N ote characteristic basal involvement. Fig. 6. R e-exam ination m ade on F eb. 13, 1936. N o sym ptom s. N o te decided roentgenologic im prove m ent. (11.3 per cent) in the entire series, the de gree of infiltration was only slight to mod erately advanced and one or both upper lobes were involved.. Only two cases ap peared active. Since these examinations were made, five patients have died. Autopsy was per formed on two, a detailed report of which will follow. Of the remaining 66 patients, 21 have been re-examined recently. In studying the orignal and follow-up roentgenograms of the series and contrast- sh u l l : asbestosis 283 Fig. 7. Fig. 8. Fig. 7. Case 3839. Exam ined on Jan. 7, 1935; w hite male, aged 37 years. P atient was exposed nine years. Slightly advanced type of asbestosis. Slight cough and some dyspnea, b u t no tim e loss from work. N o te th a t in addition to the findings of asbestosis there is an activ e tuberculous lesion in th e upper rig h t lobe. Fig. 8. R e-exam ination m ade on Feb. 15, 1936. N ote im provem ent in lung-fields. N o com plaints. D e cided gain in weight. H as worked steadily in a textile plant since discharge from asbestos mill in N ovem ber, 1934. Fig. 9. Fig. 10. Fig. 9. Case 3738. E xam ined on D ec. 1, 1934; w h ite m ale, aged 2G years. P a tie n t w as exposed ten years. Slight cough for one year. E arly type of asbestosis. N ote co-existing tuberculosis. Fig. 10. R e-exam ination m ade on Feb. 10, 1930. T h is p a tie n t has g ain ed eig h t p o u n d s in w eight a n d has worked as a radio technician since his discharge from the asbestos mill in N ovem ber, 1934. N ote fibrosing of tuberculous lesion and increased aeration of lung-fields. ing them with a number of plates of other types of pneumonoconiosis, it has been pos sible to make certain observations which seem to be peculiar to this group of asbes- tosis cases as a whole. These are tabulated under Table I. Furthermore, it was obvious that a classification could be effected. Since the 284 RADIOLOGY Fig. 11. Fig. 12. Fig. 11. Case 3771. E xam ined on Dec. 5, 1934; w hite m ale, aged 37 years. P atien t w as exposed eight years. M oderately advanced type of asbestosis. N ote pericardial and pleural adhesions. Fig. 12. R e-exam ination m ade on F eb. 28, 1936. N o change in the appearance of the lung-fields. Fig. 13. F ig. 14. Fig. 13. Case 3755. E xam ined on D ec. 3, 1934; w hite m ale, aged 26 years. P a tie n t was exposed tw o years. H e had previously worked on a farm . Past medical history was entirely negative. M oderately advanced type of asbestosis. N o subjective com plaints. N ote miliary-like deposits suggestive of a healed tuberculosis. Fig. 14. R e-exam ination m ade on F eb. 22, 1936. P a tie n t now regularly em ployed in a textile p lan t. N o com plaints. N ote slight b u t definite increased aeration. one constant feature of all these cases is un questionably the diffuse fibrosis, this sign was taken as the "yard stick" in compiling such a classification. After the groupings were arranged, the other roentgenologic findings were tabulated under each group. The following seems to be a satisfactory and working classification: (1) Slightly advanced cases. (2) Moderately advanced cases. (3) Markedly advanced cases. SHULL ! ASBESTOSIS 2S5 Fig. 15. Fig. 16. Fig. 15. Case 3708. E xam ined on N ov. 24. 1934; w hite m ale, aged 35 years. P a tie n t was exposed seven years. Chief com plaint was dyspnea. M oderately advanced type of asbestosis. Fig. 16. R e-exam ination m ade on F eb. 17, 1936. T here is a slight increase in aeratio n of th e lung-fields. Fig. 17. Fig. IS. Fig. 17. C ase 3743. E xam ined on D ec. 1, 1934; w hite m ale, aged 38 years. P a tie n t w as exposed eig h t years. Cough and dyspnea were the chief com plaints. M arkedly advanced type of asbestosis. Fig. 18. R e -exam ination m ad e on M a rch 15. 1935. P a tie n t h ad an a tta c k of lo b ar p n eu m o n ia in J a n u a ry , 1935. N ote changes in lung-fields and in cardiac outline. -k 1. Slightly Advanced Cases (Chart 1).--sary to aid in arriving at a diagnosis. There In this group are 16 cases. In all, there is a are no cases of pericardial and pleural beginning interstitial fibrosis in both lung thickening, in none is the trachea displaced, bases producing a filmy, hazy appearance. rarely is there an emphysematous type of The roentgen film cannot be considered chest, and less than half showed right-sided diagnostic; a history of exposure is neces cardial hypertrophy. In this group there 28G RADIOLOGY .... tv . 5 . sC- Z<et>s Fig. 19. Fig. 20. Fig. 19. Case 3751. Examined on Dec. 3,1934; white male, aged 33 years. P atient was exposed one and one-half years. He had cough for two m onths with m oderate dyspnea. M arkedly advanced type of pul monary asbestosis. Fig. 20. Re-examination made on Feb. 10, 1936; no im provement. N ote slight increase in cardiac base. (This patien t's father had worked in the same plant for five years prior to dismissal in September, 1934. His lungs showed only an early or slightly advanced type.) Fig. 21. Case 3735. Examined on Nov. 11, 1934; white male, aged 39 years. P atient was exposed seven years. Markedly advanced type of asbestosis. Dyspnea was marked. Note left dia phragm and characteristic basal involvement. This film is typical of markedly advanced asbestosis as evidenced by basal involvement, fuzzy cardiac outline, high left diaphragm, and the characteristic ground-glass appearance of the lung-fields. are two females and 14 males, all white. The average age is 32.2 years and the aver age time of exposure is 5.4 years. 2. Moderately Advanced Cases (Chart 2).--There are 35 patients in this group. There is definite interstitial fibrosis radiat ing to the periphery and producing a ground-glass appearance to the lung-fields. Bronchiovascular markings are increased and pericardial and pleural thickening are noted. Right-sided cardiac enlargement is more frequent and emphysematous types of chests are common. The series contains five white females and 30 males, five of whom are colored. The average age is 37.1 years and the average time of exposure is 8 years. 3. Markedly Advanced Cases (Chart 3). --There are 20 patients in this group. In only one is there no roentgenologic evi dence of right-sided cardiac' hypertrophy and in only one other is evidence of an em physematous type of chest lacking. Nearly half.have,pericardial and pleural thickening and the majority"^how a high left dia phragm (Table I). The average age in this group is 37.1 years and the average time of exposure 8.7 years. All are males, 16 white and four colored. In the entire series only six showed evi dence of slight displacement of the trachea, SHULL: ASBESTOSIS 287 Fig- 22. Fig. 23. Fig. 22. Case 3700. Examined on Nov. 22, 1934; white male, aged 36 years. P atient was exposed ten years. He had an unproductive cough with a negative sputum. Note the shaggy heart. Markedly ad vanced type of pulmonary asbestosis. Fig. 23. Re-examination made on Feb. 18, 1936. Chief com plaint veas dyspnea. N ote spread of fibrosis. and of these three had x-ray evidence of tuberculosis. As would be expected, the degree of cardiac hypertrophy is largely de pendent on the length of exposure. Other findings do not seem to depend on this fac tor to the same extent. Just what influence the degree of exposure, i.e., the type and amount of dust inhaled, exerts on the roent genologic picture is difficult to say, as it was not possible to determine this factor. One would expect more serious and exten sive pathologic changes in cases in which there has been a greater degree of exposure. Undoubtedly there are other factors which play an important role in the amount of damage done to lung tissue: the patient's constitutional make-up, his intelligence, previous disease of the lungs, and other causes may exert an influence in the rapid ity with which the disease progresses. I do not believe tuberculosis plays a significant part in the development or prognosis of as bestosis. Roentgenologic evidence tends to uphold this statement. Two of the pa tients with definite evidence of tuberculosis showed unquestionable improvement on re-examination 15 months subsequently. Both are employed in other industries. L- ----- -- J^i ] t .' f ' i : i . _ . .jfeilJi Fig. 24. See caption under Figures 25 and 26. The series of re-examined patients is too small, and perhaps insufficient time has elapsed', to draw definite conclusions on the progress of the disease from a roentgeno logic standpoint. When more patients have been re-examined over a longer period of time, such a report will appear. How ever, the observations made on the 21 re examined patients are worthy of note. ---I l-U . IJJM UIUI jiM U l 28S RADIOLOGY Fig. 25. Fig. 26. Figs. 24, 25, and 26. Case 3792. E xam ined Dec. 12, 1934; w hile m ale, aged 55 years. P a tie n t w as exposed 25 years. He had been totally disabled for the past two years. M arked dyspnea, troublesome cough, emaciation, and peculiar palor of the skin. M arkedly advanced type of asbestosis. N ote the shaggy heart and very little air space remaining. This patient died one m onth after this examination. Photographs of lungs and sum m ary of pathologic findings after autopsy are found in the text. Fig. 27. Case 3746. Examined on Dec. 3, 1934; negro male, aged 30 years. P atient was exposed seven years. Chief com plaint was cough of five years' duration and recent continued hem optysis. T here is some cardiac enlargem ent b u t no roentgenologic evidence of tuberculosis. He died three m onths later and at autopsy tuber culosis was found. (See report.) In the Markedly Advanced Group there were five re-examinations: three gained some weight, one lost, and the other re mained the same. One showed no change in the roentgen picture and in three there was an increase in the amount of fibrosis. There was no improvement in the heart shadow in two, and in two it had en larged. Clinically four showed no improve ment. The fifth (See Figs. 29 and 30) showed definite improvement. In the Moderately Advanced Group, seven were re-examined. Three had gained a substantial amount of weight, two re mained the same, and two had lost. Three showed improvement in the lung picture and two a definite spread of the disease. One showed an increase in the size of the heart and another showed definite improve ment. In the Slightly Advanced Group, nine were re-examined. Three had gained con siderable weight and_pnly one had lost. Five showed improvement in the lung pic ture and only one any increased fibrosis. In none was there any alteration in the size of the heart. Three of these cases had roentgen evidence of tuberculosis. Clini cally these patients were much improved. Generally speaking, it would seem that improvement can be expected in the early cases when they are removed from asbestos SHULL: ASBESTOSIS 289 plants. As the disease progresses, improve ment is less likely, and when the condition becomes markedly advanced the patient usually becomes a permanent invalid and the prognosis must be considered entirely unfavorable. Lanza states: "It is by no means certain that asbestosis progresses as does silicosis after withdrawal from dust exposure, nor does infection seem to be as closely and intimately associated with asbestosis as with silicosis.'' AUTOPSY FINDINGS IN ASBESTOSIS Autopsy was performed on two patients in the Markedly Advanced Group. One (S. G.) died of an acute fulminating tuber culosis process, with continued hemaphysis, three months after examination. There was no roentgenologic evidence of this con dition. The other (P. J. V.) died one month after examination, of asbestosis. Pathologic examinations of the lungs were made by Dr. J. B. Bullitt, Professor of Pathology in the School of Medicine at the University of North Carolina. Case 1 (S. G.). "Gross: The lungs are somewhat distorted by being molded in the container. The conditions in the two lungs are essentially the same. The pleura over practically the whole surface is rough and apparently had been adherent to the pa etes ; in some areas it is as much as two millimeters thick. The interlobular divi sions are obliterated by adhesions except as below described. The cut surfaces show nearly uniform character from base to apex, though the degree of damage is greater in the central and base portions. Narrow grayish lines block the tissue into irregular small areas. A few small gray spots, resembling tubercles, are scattered here and there from base to apex. Near the central portion of each lung is an irregular shaped area of solidification, about two by three centimeters, which is apparently caseous pneumonia. Similar areas of smaller size are found in the apical and in the basal portions. In this area are small cavities, about three or four millimeters in diameter. Except in these areas, the tissue Fig. 28. Case 3746. Roentgenogram of lungs following autopsy. Lung m apping was attem pted but was unsatisfactory. Synopsis of autopsy findings reported in text. has an elastic feel, similar to but somewhat less than that of normal lung. I find noth ing to justify the massive hemorrhage that he is said to have had shortly before death. The heart showed nothing of import. The hilal lymph nodes are enlarged and mottled with caseous areas. ".Microscopical: In all parts of both lungs there is considerable fibrosis. In great part, -this consists of small irregular shaped nodules with lobular distribution, but also there is much fine fibrosis thicken ing the walls of alveoli that are still func tional. Most of this fibrosis looks like old healed scars, but much of it shows some in filtration with mononuclear cells, sugges tive of a slowly progressive process. In practically all these scars there Is some pig ment deposit--in some places a consider able amount, and also there are numbers of fine asbestos shreds. I am confident that much of this fibrosis is due to the asbestos, though part of it might be healed tubercu losis. In addition to this asbestos, the mi- 290 RADIOLOGY Fig. 29. Fig. 30. Fig. 29. Case 3778. Exam ined on Xov. 4, 1934; negro m ale, aged 40 years. P atien t was exposed 12 years. He had had cough and dyspnea for two years. M arkedly advanced type of asbestosis with typical cardiac enlargem ent. M easurem ents: M R 5.5; M L 10.2, and Base 12.0. Fig. 30. Re-exam ination m ade on Feb. 14, 1936. X ote dim inished cardiac outline and increased aeration of the lung-fields. Dyspnea now chief com plaint, b u t not as m arked as a year ago. M easurem ents: M R 4.5, M L 10.0, and Base 10.5. This is the only case in the m arkedly advanced group th a t has shown any improvement clinically or roent- genologically. croscope shows many very small typical tubercles in various parts of the lungs: moreover, the caseous areas mentioned above are characteristically tuberculous." Case 2 (P. J. V.). "Gross: Both lungs are essentially alike. The interlobar clefts are obliterated by dense adhesions. The greater part of the pleural surfaces are roughened and appear to have been ad herent to the parietes, though some areas are smooth and glistening and resemble the normal. From apex to base, on the cut sur faces. the tissue is blocked off into small polygonal areas by narrow white lines. In occasional places these lines broaden to as much as one to three millimeters; also at several places, just beneath the pleura, the pulmonary tissue is solidified into about five or six millimeters in thickness and twenty to thirty millimeters in breadth. Except for the fibrosis above described, the pulmonary tissue appears essentially nor mal to the naked eye, but when pinched between the fingers it has a distinctly in creased density, especially in the lower lobes. ``The hilal lymph nodes are much en larged and their cut surfaces are slightly mottled with gray. "The heart is distinctly larger than the average normal. The right ventricle is di lated, probably sufficiently to prevent per fect competence of the valves. The muscle is pale and slightly streaked. It is appar ently not quite as firm in texture as normal. The aorta and the heart valves show a mod erate amount of atheroma. "Microscopical: The microscope demon strates an amount of fibrosis greatly in ex cess of what the naked eye would lead one to expect. This is more marked in the lower lobes but is present in all parts of both lungs. It consists of nodules and bands of connective tissue which have clearly resulted in the obliteration of much pulmonary tissue. Much of it consists of old, hard scars with no present inflamma tion, but in much of it the process seems SHULL: ASBESTOSIS 291 progressive, as indicated by a low grade exudate (mononuclear cells). The rubbery plaques on the pleural surfaces are partly made up of thickened pleura, but mostly of actual lung tissue obliterated by fibrous tissue. A good deal of pigment is present in most areas. In all areas there are num erous spicules of asbestos. Some of the scars in this lung might well pass for healed tubercles, but I find no present tubercles, and careful search fails to demonstrate any acid-fast bacilli in any area. The lymph nodes at the hilum show hyperplasia, some little fibrosis, a moderate amount of pig ment, and a few spicules (very small) of asbestos, but no evidence of tuberculosis. "Except for moderate atheroma, the aorta and heart show nothing of impor tance under the microscope." ASBESTOSIS AND SILICOSIS The roentgenographic picture of silicosis does not resemble asbestosis. In the for mer, the upper third of the lungs is in volved and the fibrosis is parenchymal and not interstitial. The lung-fields show char acteristic nodulation, and, in advanced cases, a coalescence producing dense opaque areas in contrast with the typical, hazy, ground-glass appearance of the asbestosis lung-fields. Silicosis is definitely a pro gressive disease, even when the patient has been removed from dust exposure. This is not the case in asbestosis, certainly in the slightly and moderately advanced groups. In asbestosis, there is a definite tendency to pleural and pericardial involvement which is strikingly absent in silicosis. MEDICO-LEGAL STATUS OF ASBESTOSIS IN NORTH CAROLINA Just a word about the status of asbesto sis in North Carolina from a medico-legal standpoint. In the case of McNeely vs. Asbestos Co., 200 N. C., page 5GS, the State Supreme Court held the plaintiff suffered an "injury by accident." The Court said: "He alleged in his complaint and offered evidence tending to show that his injury was produced and proximately caused by negligence of the defendant in that it maintains no dusting or suction system such as is approved and in general use in other asbestos plants. Consequently his allegation and proof both established the fact that his injury was caused by the negligence of the employer and hence was not the usual incident or result of the par ticular employment in which the workman is engaged. That is to say, the in iry was not produced by the inherent nature of the work itself and classifiable as an occupa tional disease, but was produced by the active negligence of the employer and his failure to exercise reasonable care." The Court held in effect that the injury itself was an accident in that it was an unlooked for and untoward event which was not ex pected or designed by the plaintiff, and therefore was compensable under the Com pensation Act. As a consequence of this decision, the State Legislature of 1935 amended the Compensation Act to include twenty-five occupational diseases, includ ing asQestosis. CONCLUSIONS 1. Asbestosis is a definite disease en tity. 2. Inhalation of air laden with asbestos dust and fibers produces characteristic changes in the lung. 3. The time required for the develop ment of the disease is variable. The earli est patient in my series had worked in an asbestos mill only 10 months. 4. The disease asbestosis differs from the disease silicosis, clinically, pathologically, and roentgenologically. 5. While the roentgenogram is the most reliable diagnostic aid, the interpretation and correlation with "clinical signs and symptoms is often difficult. Without the history of exposure a certain number of slightly advanced cases will not be recog nized. 0. A fair percentage of the slightly ad vanced and the moderately advanced cases do tend to improve and the attendant disa- 292 RADIOLOGY bilities to become lessened when removed from asbestos dust. 7. Asbestosis does not predispose to tuberculosis. 8. From m y observations asbestosis is not primarily a progressive disease. 323 Professional Bldg. RADIOGRAPHIC FINDINGS IN PULMONARY ASBESTOSIS 1. E m physem atous T ype of C hest. 2. Flaring of Lower Ribs. 3. Trachea not Displaced. 4. Diffuse Fine to C oarsj Fibrosis Reaching the Periphery, Interstitial in C haracter, Differen tiating it from the Roentgenologic Appearance of Silicosis. 3. H azy G round-glass A ppearance of Lung-fields. 0. Increased D ensity of All Pleural M arkings. 7. Shaggy Appearance of the Cardiac Outline. 8. Tendency Tow ard Right-sided Cardiac Enlarge m ent. 9. D isproportionate Rise of Left D iaphragm . 10. D egree of C ardiac In volvem ent is n o t C onsistent with th at of Pulm onary Involvement.