Document NEY2G0xk8xLV68ZoBNnYgEow

FILE NAME State of the Art Literature SAL DATE 1931 DOC SAL014 DOCUMENT DESCRIPTION Pulmonary Asbestosis PULMONARY ASBESTOSIS By J. V. SPARKS M.R.C.S. Eng D.M.R.E Cambs Londin England ainse T T HE fact that the inhalation of asbestos dust produces an effect upon ago ae the lungs was observed many years but the serious results which follow : have only more recently been recognized : ThTehe pathologic lesions which it produces Jy and its symptomatology have been studied 4 aus in more detail just recently at the City "BYR ee of London Chest Hospital by Dr. W. ex& Burton Jper Wood and Dr. S. R. Gloyne you in the United States are dealing with a different type of asbestos different from that em- ployed in England It seems reasonable to suppose therefore that an effect should be produced on the lungs similar to that pro- duced in England providing that the manufacturing processes are carried out in the same way Unfortunately I have no knowledge of the America It may processes employed in be that we are more : ie As the result of the study of the radiHog ologic appearances in a series of patients - sd suffering from this disease we have been ae a able to gain some idea of the changes it produces in the lung which may I hope in future be of some value in the further _ study of this condition and its earlier recog- Tar nition This disease was described by H. economical in our country in that we make use of the short asbestos fibers which would otherwise be qyasted and they are used for dry cloth weaving In its natural state asbestos differs from other minerals in that it is fibrous occurring in long silky strands which are highly resistant to heat strong acids and alkalis ei ek K. Pancoast Philadelphia and Philadelphia E. P. Pendergrass 12 During the manufacturing processes the 3% of Philadelphia as long ago as 1925 since since 1 which time practically no literature on the workers may be exposed to dust containing containing varying amounts of asbestos In some of Jens:ubject has been published in America so te these processes the asbestos content is : a far as I am able to learn apart recent high in high and in others much very higher : tee editorial in the Journal of the American asbestos lower the higher content being present in the air of Po Medical Association 1 describing the the rooms devoted to the textile branch of is, death of a patient from pulmonary ashes- the industry I have no knowledge of the fide tosis This patient apparently commenced effect on the workers mining the crude wy the 2 to be exposed to dust as long as 32 years material as there are no mines in England d before would Pee death This not suggest that It has been estimated by Dr. E. Merry- cha the disease was a very serious one from the point of view of shortening the duration of wether 2 one of His Majesty's Inspec- aea 7s! life tors of Factories that at the present time something over two thousand workers in ihe Asbestos which was known to the ancient } i world is a silicate occurring in minerals in England are exposed to the inhalation of pure asbestos dust as distinct from a j.- combination with iron magnesium calcium much larger number of workers who very (* or aluminum and is quarried or mined in may be exposed to asbestos admixed with other 3 vSaoruitohus ti Afprairtcsa oafndthCeawnoardlad OinfcltuhdeinagsbIetsatloys products In his report however it is very { imported into England 80 striking to notice the preponderance of per cent comes Ne om Canada so that it seems unlikely that workers who have been employed in the asbestos factories for a period of four years before Radiological Society Presented Sixteenth California Dec. 1-5 1930 Annual , of Angeles North or less It seems reasonable to suppose that after some years of such employment the > 1249 [7 Na eee , aye ; ne ty Jen eyy! I, a} ve hy fee? t Sve yy o4 i aREES wg NE ' fo ae, . a he NG LY ~oos At. - i 7 i ae . " i 7 ik a ms, ty ~ SS aay iD | a . _^' mi edt ht rNoErNGSfFt vu tye : a ay \ -* _ asi 7 vy YN Sy rh . tee9! ry 1 ta Ee as 5 me Fad <3). ee a rit BeAS0; 30, Sar: bh % 2b t sae at x3 a ' Sarg Segre Sata ~ Sak oo : =. eigee ws mer oe te Swetsoe onc ry woes . - rs Sete - an & gestas Ee (pm STE. Sey qf 1250 RADIOLOGY workers may become affected by the inhala- for hardening into sheets tiles building and tion of asbestos dust and other indus- insulating materials or brake linings Some- tries The fact that they cease to be ex- times it is carded spun or woven into vari- et ALN Kat TE ST Le tfSa ee se ahora tate fei Ri ar tse ry fa . #, ne Voor Te at age bas a Ww L az x ms: & wpe: oe =e ye we held ee ad RAS Pet Por te Ba +ms A.a 1;a 3 : Le is a) v re } M5 $ t FS: It i Wee i ieI % 44 posed to the dust vent the disease from progressing does not however prewhen once established Asbestos is usually broken up into short lengthis before importation importation importation into into England England where it is crushed and disintegrated and sometimes mixed with various substances ous products like mats mattresses curtains or used as an inert filling of a licat- resisting character That the asbestos in dustry is a growing one that the importation importation importation importation of of is shown by the fact asbestos has trebled within the last five years and it seems likciy that the study of the dangers which accom egies l'! < ~ eae Fa ET OE ght et Bier. Ee Tad 4 a pee LIENS eration sae ARSE OD gas ie!mee : Sel Lite tere ghee RIN Ey, Ol pier sate pes fngriae ty Ah fom wsagh opie:uaAoaiMgotet h rate? PRES p . Prete : eae vee! ea ad e ACT. SPARKS PULMONARY ASBESTOSIS Sores pany it will become of increasing impor: tance . When examined microscopically by dark- x: ground illumination the fiber gives the im- :. pression of a sharp brittle metallic wire * sr broken off at various angles and in different lengths and being highly refractile it has the appearance of the glowing filament of an electric bulb ciede Hi- +gs, it? The fibers can be found in the nose and mouth and in the skin lesions of the work- ers When inhaled into the lung the fibers up a pneumonoconiosis of a characteris- tic variety 1251 ETIOLOGY AND PATHOLOGY 3, re ay \ XK The first fatal case of pulmonary asbestosis recorded was that by H. Montague Murray 3 who made a postmortem ex- amination of a case at Charing Cross Hospital in 1900. The next case recorded was by W. E. Cooke 4 and Stuart McDonald 5 In the lungs of this patient they noted the presence of certain curious golden yellow bodies having the appearance of minute crustacean forms In 1929 Stewart 6 and Haddow 7 showed that these curious bodies could be found in the juice expressed postmortem from the lungs in cases of pulmonary ashestosis and that they also could be detected in the sputum It was these writers who first suggested the name of asbestosis bodies for these structures ( Fig ) Later in 1929 S. R. Gloyne 8 showed by means of ground illumination that when an asbestos body was dissolved in con- centrated sulphuric acid it had a central core consisting of a minute asbestos fiber He has also demonstrated the presence of for- eign body giant cells in the lung sections from a guinea pig and states that it is im- portant to demonstrate tubercle the human lung in the presence of before assuming that tuberculosis as a complicating factor bacilli in asbestosis is present Roentgenogram Fig 2. worker exposed for of chest nine years symptoms three years of asbestos duration of / Up to the present we have examined some fifty cases at the City of London Chest Hos- pital and have six records of postmortem findings The Symptoms and Physical Signs are described by W. Burton Wood 9 as fol- lows : . The cardinal symptoms dyspnea and cough the foriner is in many cases the earliest symptom noted by the patient who com- plainosf slight breathlessness on hurrying or going upstairs or that his chest feels stuffy He therefore discards the res- pirator worn hitherto under protest In the late stage of the disease dyspnea may be extreme and slight exertion may give rise to labored breathing Cough is a variable symptom and though usually present it may be absent for long periods It either dry or accompanied by the expectoration of a little viscid phlegm The sputum in this as in other chronic pulmonary diseases may on occasions be streaked with blood this -_ 224 eee te sewn<s@ on vt Uewee: . Ff ari 4 jne.:oe ated wate27 Oe eyeet x satel aAm Set heyGP gon- + ne e 8 ^' _ e nd . ap em quensfo fzt. aa) wt yeu ~ mo s } we Pesa A = + Omrewca prewa a. UP) * + L ord abs gre.be y Atate oe 7< ae Om oe, Oo : oy. 4; be Pee saaA: ee ee e ~ be ad nwt wree de 7 mi ee tet he gis ee wow adtsee me 4 fF atresweBop ae . : 7-7} ey ~ ee . | mei e - = em of dager et ST~o _ herd w-A2Th.e ROS" i aot e vos! a Pad veryaw + fe ge e, oe ae 4 . ' pat] ae ~ Stake fet f 4! aan i , 4 ae and a on =e LR =. Pak *Y: oa 1252 RADIOLOGY is however is exceptional only exceptional The only frank : only in hemorrhage ; of noted series in in our series cases oc- When curred in an worker worker asbestos worker established was who unhealthy also has leaden hue was has an the PHYSICAL discase is discase is SIGNS unhealthy unhealthy the Cyanosis skin Cyanosis may ; 74 oie wl eke i! so: | TA oY ae te. Fouasere S eso: aaxbels ba wt woatt.| Ue aj ae) ee bine oS j i, M ops at yg! pees Ti - ct x| sh tpt Sa ee | vont a raBnal oe ai Pes Sr? 6 96R:ag Al > | " y: ee Bes y, + vi | PT age.rs) | hy a! ASS oad oY are 2? RAea br eee Se an . Th fe *% hie ja atl bai [es Mar]) * p tt ir "i +d, Spa eke eB EST Sp. VoRB YE Oe ve ~. FER 95 bern: a oon arenye + = tee ns wedwd eo =o a = ee } e1. de ne F wee . . , < va|s an 7 j 8 + weg eth as Yar a . ' {es * -@ Tere os obp 5 f ai! Fide ye} Say if ett ya2q. Sey o\e x! Be 4 q Fat 74 9 7 6 eS t, Yr ed s- . . 2g *! es 3% an ny we . f - me wiry . an oe oe: ayyeys. 7 : - er . ae yy Ge a 4 ~~ wt. a . wr & we 4 & alt . S, f .. fou r us e L 4. * > 3 vat oh s & y care is es - Fig 3. Photomicrograph of section of lung of case shown in Figure 2 NES suffering from adolescent phthisis with cavitation g Many patients complain of anorexia lassitude pains in the chest and loss of weight this latter is a noteworthy feature for the wasting may be progressive and in the late stages is sometimes extreme be absent slight or sufficiently sufficiently evident to cause a dusky complexion The chest is poorly covered and expansion expansion is defective - may be reduced to ate one inch or less The vital capacity of one of our male patients was only 1,000 cubic centimeters Cluix bing is seldom marked feature but a slight eet Reals ve Dy tomcat : f wed . _~ ial of ens SPARKS PULMONARY ASBESTOSIS ASBESTOSIS 1253 wi:;" "3 , "ys. . .. '. swelling of the skin above the proximal ends of the nails is often apparent Corns due to the irritation caused by the asbestos fibers in the superficial layers of the skin of the hands are occasionally seen The skin in other exposed positions c.g. the legs of girl workers may be similarly affected The physical signs in the lungs are those of pulmonary fibrosis limited to or pre++: dominant at the lung bases The coarse cessation of exposure to the dust avail to check its spread Symptomatic treatment is disappointing as we have no means of re- asbestos lieving the dyspnea which is the patient's chief complaint Prophylaxis is impor tant and the only hope for the worker lies the adoption of the proper means of protection against the risk atten- dant on the inhalation of the fibers " . y creakings and crepitations usually associated ~ with fibroid change are however replaced POSTMORTEM FINDINGS by fine dry crackles These may arise in i+ the pulmonary parenchyma or be due to the a movement of slightly roughened pleural sur- i faces A definite friction rub may be heard '! over one or other axillary base As the F. fibrosis is bilateral there is seldom any appreciable cardiac displacement CLINICAL DIAGNOSIS we When the patient's occupation is known | diagnosis should seldom be difficult except in the early stage of the disease The his- .* tory of cough and dyspnea the signs of pul- monary fibrosis and the situation and qual- ity of the adventitious sounds the radi ologic appearances and the presence of asbestos bodies in the sputum combine to form a distinctive clinical picture The presence of asbestos bodies in the sputum does not necessarily mean that the patient is suffering from pulmonary asbestosis but merely that he has been subjected to the inhalation of asbestos dust The previous occupation of the patient may be of impor- tance in excluding the possibility of fibrosis from other causes PROGNOSIS The findings in one case N. C. female aged 34 Fig 2 are described by Dr. Page 10 The body was emaciated The pleurae were uniformly thickened to a slight extent on both sides some recent plastic pleurisy was present The lungs showed a diffuse fibrosis and were contracted left lung more than the right On section the trabecul^stood out rather prominently forming a fibrous network especially in the right upper lobe The bronchi were only slightly dilated The lungs were congested and in patches were bronchopneumonic Microscopically the fibrosis became more readily apparent in less affected areas it was more prominent around the blood vessels and less so in the alveolar walls while in some sections little was seen but scar tissue with blood vessels and numerous elastic fibers Some lymphocytic nodules were present in the fibrous tissue and giant cells of the type associated with foreign bodies No typical tuberculous giant cells were found and no tubercle bacilli In addition to a large quantity of amorphous dark brown pigment numerous golden asbestosis bodies were seen the majority of them em- bedded in fibrous tissue If the fibrosis was less advanced many were seen to be in { 1 7 XK * It is too early in the study of this discase to say very inuch on this subject but once the asbestos bodies appear in the sputum the ourse of the disease would appear to be progressively downwards nor does the clumps in the alveoli Fig 3 Varying in size and shape the majority showed a large clubbed head a segmented body and a tapering tail The hilum glands were pigmented but were only slightly enlarged and no asbestosis bodies were found in sections ~ . os YY a solp ] p a *4 ont 4id -. i l woeeaiy!oeat Ae: yTp ewe RTO RI CTFtery nem: et apt PL COLI 3 ~ ~} al Pn F om f~ hye ee Cres~y wae _~os =4.Faae eae eo Tee ~~LPT | fo : L, ., a8 ih , 4 ~ a t * 7 iat, wove 4? " os STAT STAT } 3 ii ~~ ANToiEE, E V PT [0 a Ned ay DY ave wn wee. S oy at 2 ened ie Ee es2.< oy 18 ol ~se Cras tas Sir =F vo me R s =. = < =SE Feaniaad ; ms Sat a &: eeeasu: enesee wae o eeOe ot 19 a ci RADIOLOGY -- -- ---- HOSPITAL HOSPITAL vy, . e. y Sweet vey od a J e HOSPITALaygem mn " EY, es rr BAe era 7. ery Pep Hse) Rs We. AS PES ire a el pier wk a Bins eke ca St led ie Cte seers a apatites AO rm Toegery eaeT mno ee ead Fig. Fig upper upper Roentgenogram twelvetwelve twelve years after twelve twelve years after lower Roentgenogram asbestos lower faosubretesetnosfourteen RoReonetgnetngocgnroarirnan years who Roentgenogram of chest patient leaving factory Roentgenogram of chest of Cxtsced far Roentgenogram individual who has worked Roentgenograin of chest individual individual who has an of chest of vulividti ab who fas heen an and half and half years SPrateee asbesing a hale year ia Whesing workee ip > Ppp petty - ue tay, Soh) S53 Peeps gfe ot ile tne Bias Ris as MeapSrEa ODCeRas eS e edey ma + Wy 6 (> x ae ae ae Pat y ee ro hal t ^' t Se aa vo, Om = ke aae ETS ih gs re WI mm Xs = ( . rae BYeee ae 4 * fy g3yt) PS ee R FUJMAL FUJMAL PUI a . / Jagr eof. Latei mes . jee ret o t pi. ' . ve. osbysmerpvtatoimosn worker developed Fig. 8 years years and sand years Fig upper upper right Fig. 9 years Roentgenogram Roentgenogram Roentgenogram of chest of patient Years. He years He developed developed tuberculosis Fig. Fig Fig lower left Roentgenogram Roentgenogram Roentgenogram years was asbestos * Worker, (0. worker Tuberculosis + Fig 10-1 Was an Fig, 10.4 (lower lower patient Figure right Tuberculous TubTeurbecruculloouuss Tuberculous lesion patient shown Ffoir gure worker fo, scien righs ), chINtCOoMon yyeeagrs WAS an Asbestos, * 4 * Pad uw? te bale e caw. x. +. ig Te, ny . er ts, oo ~ ary lt / Ts eae ~~ o il awd om, Se sea - ~ iol deme 4 . a. ed Ol Roos oy a7 i ars = . . 3 hy eo : it q aa Hr, t ei, + . Pa | if. rita: Sea: k e ee ~ gh egg ope ohn . EM _ onget Fhe TPSgh . TPT <% e. ae (_ee e ! [ i} fj Wye ti ie & | " | 1. if |TS { i a ie > es es (Fs ys < f *, ware 1256 RADIOLOGY prepared found in from them the sections neither neither prepared were from any the liver spleen and kidney The fluid ex- pressed from the lung was found to con- tain asbestosis bodies and also free asbestos fibers . It is seen that these asbestosis bodies are found mainly in the alveoli of the lungs They consist of a central asbestos spicule surrounded by a colloidal aggregate of blood protein and possibly an iron salt and one wonders whether their formation may not be a protective action on the part of the body One can easily imagine that these fibers which are inhaled right into the alveoli can set up an inflammatory reaction in the pleura One of the first radiologic signs is often a dry diaphragmatic pleurisy has in has often been noted in the left auricular or pulmonary area No appreciable displace- ment of the mediastinal contents is usually usually apparent The lung fields at first show a slight relative increase in density in the lower zones due to a lack of air entry without any appreciable accentuation of the bronchial striations Fig ) Sometimes some small calcareous deposits are seen scattered in the lower zones of approximately the same size as the calcifying tu bercle but they have a slightly lesser den- sity and are irregular in outline Later there appears a patchy increase in density in the lower zones which may also involve the zones producing a fine network of 9 fibrosis Figs 6 and 7 which does not ap pear to be of a bronchial type but rather = . alveolar or perivascular ;2 me, 2. RADIOLOGIC APPEARANCES These appearances are described in con- The radiologic appearances of pulmonary asbestosis are usually quite typical in the radiogram when the condition is well advanced In the early cases they may easily be overlooked especially when one observes the radiogram without any knowledge of the clinical history This latter method of observation is always practised in our hospital so as to give the physician an unbiased opinion of the radiologic ap- pearances A advanced case shows some of the appearances enumerated in the next paragraph its The diaphragmatic movement is limited its outline tends to be indistinct and is sometimes uneven There is clouding in the costoplirenic angle due to thickening of the pleura a thickening often seen to extend along the costal margin on both sides to the apices The heart outline is often poorly defined showing a ragged outline due to changes in the lung around the pericardium Fig 4 It is not displaced in position unless the degree of fibrosis is greater ou one side than on the other A prominence trast to the coarse fibrosis seen in silicosis combined with the occurrence of fairly large nodules of varying density in the lung fields se and around the hila The fact that there are comparatively few visible changes in the radiogram in asbestosis when compared with silicosis does not in any way mean _ that they are of a less serious nature or less advanced as the density of the silicotic lesion would appear to be greater and the fibrosis of a coarser character involving localized areas of the lung whereas in as- bestosis the fibrosis would appear to leave very little intermediate undamaged lung 10 Figs 9 10 and The study of this subject has emphasized to me the importance of comparative radiography of the chest 10 One hopes in the future that it will be made possible for us to examine the workers before they commence their employment in factories where ; an iy q Pe -Sy Be ah SY. if ee CEES ace Ee rh 1%: asbestos is used so that a comparative study can be made of the lung condition at yearly intervals When making this examination it will be essential to employ the method of comparative radiography which we have at- Lae!. Ome i-alSages. AE 08 sf 6> ta Made,es we hede Ree aLIAaah 4 re at 3 oe eotsdes Os ON maT Pil in Tieaone wait tS wSeiee at 7 A eet hare me met a i See ; oe 9. " ya 8 ee hy ne hg 5: mt ena fel ROG At aie an renh RL Aaya Ge REN ange? an ok ea a tay Pewe e E te . ot . mn oda mine yet i ROD ev Nf Lae Ly, Se TON Roepe aooe k n err] MSeccorraesc He lang eee PVT ome hee ee ree poetoies OTe=~ VE = % a iF SSeS Cire RTaeons A Pee = Fo ~ ge n: f Set, SPARKS PULMONARY ASBESTOSIS 1257 . RR ~ e032, assta"ord dies! Eh 03S hay a oe iy ed: tempted with considerable success during the past three years at the City of London Chest Hospital All these patients having symptoms came voluntarily to the hospital so it must not be expected that such gross changes will be discovered by a routine examination of a group of workers from an asbestos factory REFERENCES 6 7 8 9 10 STEWART M. .: Immediate Diagnosis of Pulmonary Asbestosis at Necropsy British Med Jour Sept. 15 1928 II 509 STEWART Path M. J. and HADDOW A. C Jour and Bacteriol 1929 XXXI 172 Glovne S. Rooustouse The Presence of the Asbestos Fiber in the Lesions of Workers Tubercle June Asbestos 1929 X 404 407 Wood W. BURTON Pulmonary Asbestosis Radiographic Appearances in Skiagrams of the Chests of Workers in Asbestos Tuber- cle May 1929 X 353-363 Woon W. BURTON and PACE D. .: Case of Pulmonary Asbestosis X 457-460 Tubercle July 1929 1 PuNlomvo.na8ry1A9s3b0esXtoCsiVs J14o3u1r A|m Med Assn 2 MERRYWETHER E The Effects of Dust on the Lungs Home Office Asbestos Publication of the 3 MUWR.RAY sHe.e bMeOlNoTwAGUE Quoted by Cooke Asbestosis Asbestosis 4 COOKE W. E Pulmonary Asbestosis British Med Jour Dec. 3 1927 II 1024 5 McDonald STUART Histology of Pulmonary British Med Jour Dec. 3 1927 11 12 Idem from Case of Pulmonary Asbestosis Death Tuberculosis Two Years after First Exposure to the Dust 1930 XI 157 158 Tubercle January SPARKS J. V tive The Difficulties of Compara- Radiography of the Cliest British Jour Radiol July 1929 II 325-330 PANCOAST H. K. and Pendergrass E .: Review of Our Present Knowledge of Pneumonoconiosis Based upon Roentgen- ologic Studies with Notes on Pathology of TCohnedritiNoonveAmibnerJou19r25RoXenItVgen3o8l1-a4n2d3 Rad wr | a ee ae wee a te Mehdtalkwe e mw \ FN e, 188 , aan cecal a 7? ps mache tf setts? ay rie . ; n " .. . * -. ~~ ate. me c Cr ~ Se asl 5 N t