Document KGN0Lj2ygpOQxJgj24nRpaX4K

1142 LETTERS TO THE JOURNAL 2. Brown. C.A., and.KenA.: PortonUkto ot Right VoBtricte by FolyottaWobo Cathatar, South ern Med JU;46&467 1906. 3. Johnaob. C.E.: Ptelontioa o! Right Atrium by a PofyathyUo* Cgtboter, JAMA lMt84-686 - (Fab 14) 1968. \X 4. Dooriag, Rj(: Stetamar. EA; and Con- aiofly, J.JL: CaapUcMhai ol lodwoOteg Vanoua Cathataca: With Pirtiaihr Rtem to Catho- tar Rmhohia, Amer / Surg''U4i2fi9-266 (Aug) 1967. / 5. DruaktecM.Si, and SUgte. P.D.: Bacterial Contaminatxm of Iodwotling Intravaooua Polyathytao* Gathaters, JAMA 186:968-968 (Sapt 21) 1963. 1. Tract through mural thiombua and right atrium (arrows) produced by potyatftytana cathatar. eter, which remained in place through* out the course, waa as great as 10 liters per 24 hours. The central venous pressure remained leas than 6 cm HiO during this period but the excursion of the column in response to/the heart beat was greater than usual. The car* - disc silhouette waa nornyti two days poetoperatively, Early in the morning'of the eighth postoperative day the .patient became confused and tire lllood pressure dropped from 125/8h/o 100/75 mm Hg. He subsequently bebeme tachypneic and dyspneic but did nqt complain of cheet pain. Shortly thereafter, the central pulse was 120 beats per minute with a waak femoral pulse of^O beats per minute, obtainable central pressure HiO. The/patient died shortly after ward. Np intracardiac injections were attempt At ndcropsy the . sac was distended by 600 cc of fluid. There was a si hole on the ventral epicardial of the right atrium. A friable'' mral thrombus, measuring 2 cm eter, was at* tached to the endc surface im- mediately beneath bole. A well- defined oblique caliber of l to 2 'coursed thr ;h the thrombus and atrial wall. The central 2. Oblique section of tract through right strium with' nscrosis of myocanUum and ftbrin deposition. EpicsnUum shown st bot tom (hemstoxyfln and sosln, x200). V- venous catheter had been removed be fore the necropsy. Microscopic exami nation disclosed-necrosis of the atrial myocardium around the tract. A bwll pulmonary vein contained a recent thrombo-embolus. The head of thb pancreas was re placed/bysadenooaTcinonia, which in vaded theNiuodwnmn. lymph nodes, and liver. Peath was ascribed to Comment/--'A polyethylene cath- used/to iponitOr the central can be inserted into\tbe right atrium. Hie accurate radiologic localiza tion ot a radiopaque catheter tip in the superior vena cava would avoid this complication, ha this patient, the beveled catheter tip lodged in the right atrium and injured the myocardium, causing a mural thrombus. The beveled catheter tip was probably held dope to the atrial wall by the thronftius, and ulti mately perforated/The well-defined tract through the thrombus and myocardium, and the necroeia of the myocardium at the puncture site, suppo view. The effect of contini of liquid from the esthete, die atrial wall is not ie abrupt onset of signs of iponade on die eighth day heralded t_h_e__a_t___ perforate____A__p__a_t_e_n_t_c_a_t_h- eter conducting liquid undes^psoa sure into the pericardial sac. made hydropericardium unavoidable. Hie presence of a radiopaque'tip on polyethylene catheters used to monitor central venous pressure would facilitate their proper place ment. Calibration of these cathe ters by etching them at appropriate intervals would also be of value. Prolonged (greater than 48 hours*) and indiscriminate use of central venous catheters must be avoided. BruCS A. FtnsatAN, MD H. CuxctNT Jvnam, MD Au Alter, Mich 1. lNuBrr DJ)., *nd Sobbdwr, 3-D.: AcciPu-H of a Potyatbyiaoa Cathatar From i Vote to Right Atrium. New Eng J Med 281i744-746 (Oct 28) 1964. Asbestos Bodies And Their Bioeffects To the Editor:--'Has letter outlines the history of the asbestos body from its discovery through a period of little clinical significance to the present day when it holds the posi tion of being possibly one of the greatest industrial medical prob lems of theagew- - ' Asbestos:--Asbestos is a general term that covers a number of min erals of which four are of commer cial importance: crbridolite from the Republic of South Africa, amo- site also mined chiefly in the Re public of South Africa, chrysolite which occurs in many countries of the world, and anthophyllite- which is mined mainly in Europe. Asbestosis:--This is a type of lung fibrosis in workers exposed to large amounts' of asbestos dust. It may or may not be associated with recognizable clinical disease during life and is produced by all types of asbestos. Asbestosis was recognized as an industrial disease at the turn of the century, but at the time, the bodies were not noticed. Gloyne rites Fahr and Feigel who, in 1914, discovered "strange crystals" in lung sections from a patient with asbestosis.' Later Cooke, in 1924, reported "curious bodies" from asbestosis cases, but because of their beaded structure, he thought they might be fungi.' Stewart and Haddow (1929) believed that the bodies' were as sociated with the disease qnd coined "asbestosis bodies."1 This term was used until it became noticed that large numbers of bodies could be found in the lungs of asbestos work ers in'the absence of much patho logical change, with subsequent substitution of the term "asbestos body." Gloyne in 1932 demonstrated that each body consisted of an as bestos fiber as a core with some coat ing material around it, which might protect the tissues from the harm ful effects of the mineral.* Wagner In 1960 reported that the rare pleural mesothelioma in the JAMA, March 25. 1968 Voi 203, No 13 4 :?93b UCC 007821 PLAINTIFF'S EXHIBIT UC-3567 LETTERS TO THE JOURNAL 1143 Republic of South Africa was asso ciated with exposure to crocidolite in the mining areas.5 The associa tion of ordinary bronchial carci nomas with exposure to asbestos dust had long been recognized, but it has recently been shown that this is related to high dust dosages in asbestos workers and that care ful environmental control has al most eliminated this tumor as a problem in factories. Wagner re ported that many of his cases of mesothelioma occurred in patients who had never worked in the mines but had lived in mining areas per haps only for a year or two as children. He also showed that the time lag between last exposure and tumor formation was always long, averaging 40 to 50 years. Ashestosis and bronchial carci noma obviously connected with se vere dust exposure were problems solely for the asbestos industry. But, if a very small amount of dust could cause a mesothelioma, might not asbestos products be hazardous to the whole population? It was logical to examine the lungs of normal members of the population for the presence of these bodies. Thompson in 1963 found 26% of autopsy cases in Capetown contained what appeared to be as bestos bodies.* Other studies indude one by Cauna et al in 1965 which reported that 46% of autopsies in the Pittsburgh area contained bod ies.' Although fewer than 600 cases of mesotheliomas have so far been reported in the medical literature, the increase in asbestos consump tion in recent years might produce a great epidemic of these tumors in the future. These reports have received great publicity and led to the suggestion that the use of asbestos should be banned altogether. One artide (Pre vention Magazine [July] 1967) suggested that it might be unsafe to visit Expo '67 because of the risk of asbestos in the air.* This asbestos scare has ignored some of the facts on mesotheliomas, not all of which can be taken at face value. First, asbestos is not a single mineral. Wagner's mesothe lioma cases were associated with the croddolite areas and not with amosite or chrysolite. In other countries attempts to demonstrate that exposure to dusts other than croddolite could produce mesothe liomas have so far been almost com pletely unsuccessful. The mesothe lioma problem is, therefore, not one that involves the whole asbestos in dustry, but only users of crocido lite, and this mineral represents a relatively small proportion of total consumption. _ . In the South African mining areas from which Wagner obtained his cases, it is common practice to surr face roads with the waste asbestos rock, the rest of which is deposited in dumps. Wagner states that some of his patients had played among these dumps as children and others no doubt drove along the roods with car windows open. Although they may have had a low exposure by industrial standards, these indi viduals probably inhaled far more dust than- members of a normal urban population. For many years asbestos bodies were believed to be formed only around asbestos fibers, but recent evidence, from an endeavor to dis cover how many materials will pro duce asbestos-like bodies and the chemical processes involved, has shown that the deposition of a sim ilar . coating can occur around a number of materials.*'" Gloyne* had demonstrated that the body coating contained iron, and Beger1* had shown that pro tein material was also involved. As bestos bodies, in the electron microscope, show a coating com posed of small dense granules about 60 Angstroms in diameter. Similar granules in a number of tissues had been assumed to represent either ferritin or hemosiderin. Since this tied in well with the iron-protein nature of the capsule, it was sug gested that the asbestos body coat ing was made up of one of these chemicals, and occasionally 'of fine filaments about 60 A in diameter which we now believe to represent calcium deposits. Experimentally produced bodies with nonasbestoe materials ap peared very similar to asbestos bod ies. TTiey were golden brown in .un stained sections and were often segmented and the coating con tained iron. For this reason Gross suggested the term "ferruginous" body, which, should be used for all bodies found in human lungs at least until the mineral involved was positively identified.1011 Whatever the foreign material that stimulates the production of a ferruginous body, the coating con sists of the small dense granules described above. The situation at present is then that we must not assume that fer ruginous bodies seen in the lungs of normal persona are asbestos bod ies until their mineral core has been definitely identified by electron diffraction, which involves isolat ing, concentrating, and manipulat ing the small bodies onto an elec tron microscope grid. In addition to our analytical investigation of these structures which we hope Will reveal which human ferruginous bodies are caused by asbestos,, other Btudies now being conducted'are exploring their epidemiology. A re port on such a study recently pub lished by Enterline and Kendrick1* was the basis of an editorial in Thb Journal, (201:966, 1967). In the field as well as the laboratory, therefore, there is justification for awaiting further evidence which may be expected to provide a sound basis, in fact, for solving the gen uine health problems related to as bestos. Interested readers are referred to a paper, "Asbestos Bodies and Bio effects, A Detective Story" given by J.M.G. Davis at the 32nd. an nual meeting of the Industrial Hy giene Foundation in October 1967.M Robot T. P. dxThyilul, MD Paul Ghm, MD Pittsburgh * JJd.G. Davit. MD Cambridge, Eo| 1. Fftfeur and Feigel* cited by Giojnw, S.R.. AitettM. International Uter Office Occupational and Health Supplement, (Jib) 1968. 2. Cooke, W.E.: Fibroats of Longa Due to In halation of Admtw Dual, Brit Afd J 2:147 (July 26> 1924. 3. Kaddovr, A.C.: Clinical Aspects of Pulmo nary Aabaatoaia, Brit Mrd J 2:680-681 (Sept 28) 1929. 4. Gloyno, 8.R.: Abeatoeie Body, Loner*. 1:1351-1366 (June 26) 1932. 5. Wegner, J.C.: Proceeding* of the Pnrumoconiome Confer**e, Johannooburg, AJ. Ownstein (ad.), London: J. & A. Churchill Ltd., 1966. 6. Thompson, J.G., Kiarhula, HO-C; and MacDonald. R-K.: Aabaatne Ag a Modern Urban Haaant, 3 Afr Mrd J 37:77-81 (Jan 19) 1963. - 7. Cauna. D. Trotten, RS.. and Grets, P-: Ashtotes Bodies in Human Lungs at Autopsy, JAMA 199*371-373 (May 3) 1965. 8. AnjOvd, L.. and Thurfbeck, WJ4.: The Incidence of Aabaatee Bodies in the Longa at Random Necropsies in Montreal, - Conod Mod Arm* J 96*1179-1188 (Dee 3) 1968. 9. Gross, P.; Crattey, l~J.; and deTwvflle, R. T.P.; "AAeatos" Bodice: Their Nmupsetfictty, Amor Jnduetr ffyg Armor J 26*641-642 (Kov-Dvc) 1967. 10. Grom, P., et al: "Pulmonary Farraginous Bodies: L Their Development in Raepooee In Filamentous Dusts; U. A Method of Isolating and Concentrating Them, Arch Path, to be pob- liabad. IL Davis, liLC.: Etectroo-Mierasoops Stud ies of Atbeefnato in Man and Animate, Ann NY Acad Sd 132*96-111 (Dec 31) 1966. 12. Beger- in Virdtovt's Arthwrr 296:280*353. 1933. 13. Enterttoe, PJB.. and Kendrick. M.A.: Aibeelru Duet F.apnniiaa at Various Levels and Mortality, ArcA CitMroa fieailh 15:181-188 (Aug) 1907 14. Davis. J.M.G., et al: "Asbestos Bodiea and Bioeflecta, A Detective Story," m-Troaeoctiono of Induotncl Hygiene Foundation'* 32nd Annual Storting, to be published. JAMA March 25. 1968 Vol 203. No 13 UCC 007822