Document QJZ5nmBrp3KJjaDgJqQyjnmKo

FILE NAME: Hercules Chemical (HERC) DATE: 1948 DOC#: HERC009 DOCUMENT DESCRIPTION: Book Excerpt from Diseases of the Chest - AsbestosisVI. Analysis of Forty Necropsied Cases ^ 1 / 4. W VOLUME XIV li Va'; B Va s lfA e B E a s a 1 " FEB 9 13 V NUMBER 1 VH> * a i* & r I i ! JANUARY - FEBRUARY t 19 4 8 ; EXECUTIVE OFFICE. S00 NORTH DEARBORN STREET. CHICAGO 10, IIXINOIS " PUBLICATION OITICE. ALAMOGORDO ROAD, EL PASO, TEXAS B o u n d S o n d C lo u M alt A u ,u .l 1. 113, a .h . Po.lotUe. a t El Pa. T.*a Uodr Uw Acl ol ConqnM oi Auqurt U . 1 12, Coprriqht. H U . b r tbd American Cslloqo of Chil Phrrteiano * FOURTEENTH ANNUAL MEETING -- AMERICAN COLLEGE OF CHEST PHYSICIANS 5 ConqroJi Hotel, Chicago, Illinois -- Juno 17-20. 194 I ! r i ,v A sbestos is: VI. Analysis of Forty Necropsied Cases* KENNETH M. LYNCH. M.D. and W. M. CANNON. M.D.'* Charleston, South Carolina ^ During the past eighteen years the necropsy studies at the Medical College of South Carolina have included forty cases in which asbestosis of some degree has been encountered. In this period several reports1-* have been published. Since various previous writings give extensive presentations of the industrial relations, clinical manifestations, roentgenological diagnosis and pathology of the disease, the scope of this paper will be limited to such additional information as may be gained in relation particularly to uncleared questions. A division of these forty cases into three groups based upon the estimated grade of pulmonary fibrosis (Pigs. 1, 2 and 3) is given in Charts I, n and m . So far as possible the duration of exposure has been ascertained but that important information is missing in many of the histories. Where possible it was supplied ky the employer. All traced exposure was in an asbestos factory where prior to the time of recognition of asbestosis as an industrial hazard the working conditions were undoubtedly very dusty, but where dust control has been progressively improved in the last twenty years or so and where conditions for work are recently as good no doubt as technical circumstances will allow. In Chart I, covering cases of minor asbestosis, there is one conspicuous case (49037) of failure of history of exposure to fit the disease state. There is nothing to indicate that this man actually worked ten years in asbestos dust, and the history of ten years exposure must be doubted. In case 70964 a nodular fibrosis of the lungs was also - --present, in reality excluding the- case- from comparison. Case 15652 r is Included in the discussion of tuberculosis in the series. Other wise this group showed only incidentally the finding of asbestosis. Even the employment which caused it escaped the history of the case. In Chart H, listing cases of weH- developed but not advanced " asbestosis, Is encountered a conscious relation of the employment exposure in connection with the case, although really in most of Presented at the Thirteenth Annual Meeting, American College of Chest Physicians, Atlantic City, New Jersey, June 8, 1947. soutn CaroDlineap*artment of Pathology,. Medical College of the State of 874 Vo lume ."CIV these cases t the necropsy grade of lung three years. ' general the ac parallels the figoFigure 3: Grade 3 a located in termln. 5! Bjpiwjj.^ 'T>' --- ---- -s<?s 'N' M.D." studies at rlu- forty ca.>r.< in ''Ted. Tn thi* >resc-nta;ion.s ot roentgenological of this paper may be gained ps based i;po:. 1. 2 and 3) i> :he duration of .nt information if mas .-.applied -.ibestos factory as an industrial dusty, but ed in tile last are recently a.n.v. In C hart I. mspicuous case disease state worked r. : exposure must lungs was ..-or.. Case 15'.52 .- series. 0 `iirr Oi :'.:.-.`ury <j-. : ro t adv.v.o-d i.e e:npio> -re:.-ily iii m.u. t <>: Collude of ciu-. f the .suite . : 44 2 4 a 7 Volume XXV 3. . ASBEST.O...S.I.S.................. 375 these cases the history of the. employment was traced out after I n r i T 'f T 57 djHgn0sis- The shortest known exposure to cause this grade of lung fibrosis was twenty-eight months during an elapsed three years. The fibrosis was naturally of recent formation. In general the advance of the disease and the age of the lung fibrosis parallels the duration of exposure and the length of time since FIGURE 1 FIGURE 2 Ffgare i : G rad e I asb esto s . H u m an lung. X 75. Figure- 2: G rade 2 asbestasls. H u m an lung, X 75. i FIGURE 3 4 ti " S H SiSiSSiSK S t? * ':'JI FIGURE 4 Sf l.VNCll AND CANNON No. 10672 8rx U Arc M 32 11726 12892 15052 M 50 F 29 M 32 20532 F 80 30514 M 35 30078 F 35 3C007 M 45 48619 F 36 49037 M 28 70904 M 50 ; 50454 M ? Exposure No Data No Data No Data No Data N Data No Data N Data No Data No Data 10 yr$. ? N Data No Data c h a r t i -- Min o r g r a d e --12 c a s e s Asbestos Bodies FIB R O SIS Old Recent Hodolnt 4-4- + 4- 4- 4- 4-4 4- 4- 4- Pleum + + 4 + + 4- 4-4 4* 4 -L + 4- 4-4- 4- -I4" 4-4- 4-4- Mnjor Dlsense Encephalitis, Acute Aortlc Insufficiency, Cor. Sclerosis Pulmonary Tuberculosis Typhoid Artcrloscl. Gangrene of Feet Artcrloscl. , Cerebral Hemorrhage Sarcoma of Uterus Drowned Carcinoma of Groin Endocarditis Arterloscl.. Pneumonia Injury chart i l --mdium grade --14 cases Jll < MWWIWI-- - *' -.'vw>im. -a* Volume XIV CHART I I - MEDIUM GRADE--14 CASES No. A*:** m i M 40 10044 F 40 11511 F 55 11613 11837 11067 17726 18062 20186 22047 25237 46916 47715 66100 M 62 M 40 F 45 M 44 F 65 F 36 M 30 M 45 M 37 M 37 M 50 KxiuiMiru 28 mas ,In 3 yrs. No Data No Data AxbCfclu* liiiUli'* _ 4-4+ No Data No Data , No Data No Data No Data 4 yrs. 14 yrs. before 4 yrs. 3 yrs. before 13 yrs. 3 yrs. before No Data 10 yrs. 1 yr. before 22 yrs. 1 yr. before 4+ + + 4 + jtt. t + + ++ T 4-4+ + 4-4- ++ + F I P ROS*8 ota Itucvul floduluf I'ltu ru M" )" f I ....... .......... : Gunshot ++_ __ + + + .1 Pelvic Abscess, +_ _ - + 4- + + -jT- _-.por. Sclerosis Arterloscl. Cerebral Hemorrhage ASBESTOSIS .. Carcinoma of Neck 4-4- 4* 4" '' ___ .. . . - Arterioscl. 4- + ._ + _t tt- ? Mesenteric Thrombosis 4*4* + + 4-+ + ` Aortic Aneurysm 4*4* + + AQrtic Aneursym______ 4-4- 4~4~4~ Pulmonary Tuberculosis J"JL 4-4- + 4-4- Pulmonary Carcinoma 4- A n e u r y s m ________ ++ 4-4- + + Gunshot _____ Pulmonary Carcinoma 03 3 I >r.M< ' * * . <-T No. 9676 10392 11599 12192 17620 Sex fe Arc M 30 M ? F 25 F 30 M 38 19094 M 45 20514 M 57 22G74 M 55 24693 M 45 25145 M 35 27030 83512 109-111 IVi'i'.ij M 55 F 35 to 3 V *' CHART I I I - Exposure 4</, yrs. tU'ayrs. Data Ho Data No Data 10yrs. 4yrs. before 20 yrs. 1yr. before 22 yrs. cotlonmlll 4 yrs.41 yrs. before No Data */2 yr. 1o yrs. before I! . 13 yrs. 3 yrs. before No Data 3 yrs. 13yrs. before 7 print- <u 1920 Asbestos Bodies 4-4- + 4-4- + + + + + + + *4- 4- 4-4- + 4 i I- + + + + + + + + + -f + !. .1. -ADVANCED GRADE-- 14 CASES Old 44-4-44-4-44- 4- 44-4-4- 4-4-4- I- 1 4- 4-444-4- 44 444 4 -i -t- FIBROSIS Rreenl M odular 4- + + 4 4-44-4-4......... , 4- 4--1-444- I- I 4-4-4- 4- 4-4-4- ......... ....... 444 .......... 444 ......... ....... Plcurn 44-4-4- 44-4-4- 4--1-41-44 4 4 ......... 4' 4-4- Miijor Dl*rn*r Pneumonia Pulmonary Fibrosis Pellegra Pulmonary Tuberculosis Hypertensive Disease Pulmonary Fibrosis Tuberculosis Pulmonary Carcinoma Fibrosis Syphilitic Aortitis Pneumonia Glomerulonephi It Is. Chronic ' Hypertensive Disease Cor. Sclerosis: Lipoid Pneumonia*4 Lung Abscess Pyelonephritis ' Pulmonary Fibrosis  :;iv ASBESTOSIS R7D beginning. Also the prominence of asbestosis bodies in the lungs generally consistent with the duration of exposure. In this group .ppears two of the three cases of cancer of the lung which are specially presented in another place. There is no other indication .n this chart that asbestosis of this degree is directly or indii'ectly responsible for death of the subject. In Chart III, showing data oh the fourteen advanced cases of t.re scries, is seen the first positive evidence of the direct killing <*ffeet of the disease. At least four of the cases show a major part played by pulmonary fibrosis in the death of the individual. In the few cases where other factors responsible for the appearance of recent cellular fibrosis of the lungs could be ruled out, there is evidence to support Gardner's experience with experimental asbestosis in guinea pigs that the fibrous disease does not progress indefinitely after cessation of exposure. There arc five cases of mown but not recent exposure, for instance cases 147595 and 25145, Chart m , showing advanced old fibrosis but none recent. There are twelve cases all told showing old but not fresh fibrosis. On the other hand, recent exposure, no matter of how long the duration, characteristically shows fresh fibrosis (see cases 9676 and 10392, Chart m ). The "A sbestosis Body" The so-called asbestosis body has become a characteristic elem- nt in human asbestosis and is also found in the lungs of some animals which have been the subjects of experimental asbestos dust exposure* but not in others. It consists of a central asbestos fibre with a shiny yellow-brown coating appearing in a variety of architectural forms. Similarly coated bodies of smaller size may be found in silicosis and in miscellaneous occurance of no apparent relation to asbestos dust exposure.4 The location of asbestosis bodies (Fig. 4) in the terminal bronch ioles and in the vestibular area of the lobule is significant in the pathogenesis of the disease. Those of smaller size appear In the peribronchial lymph nodes, where there Is foreign body reaction but usually little if any fibrosis. " _ " Time will not here permit full discussion of all matters of interest about these bodies. From previous publications it may be said that their formation Is not an essential in the pathogenesis of f-'iperimental asbestosis in some animals although it is a charac- ' ristic microscopic feature in the naturally occurring human disease. Injury to the lung by the asbestos fibre occurs experi mentally before the coating deposits in some animals7 and without altogether in others. It appears that the coating may be a defensive occurrence, segregating the fibers from direct tissue oSO LYNCH AND CANNON fiov.-Pcc., una contact. From study of the history of these cases it is apparent that these bodies remain deposited in the lungs more or less permanently, at least for as long as twenty-seven years (Fig. 5, case 147595, Chart HI). That they undergo slow but definite change is also apparent.1 Findings of these bodies in the sputum is indicative of nothing more than the fact of previous inhalation of asbestos, not of the condition of the lungs. They are usually more numerous in cases of current or recent long exposure. They may be found for years after the cessation of such exposure, but in even advanced asbestosis of long duration they may not be found at ail or only in sparse numbers. Since nothing valuable is to be gained from lung puncture for examination of pulmonary material for these bodies that cannot be obtained by simpler measures, there seems to be no justification for that procedure as a measure to be used in diagnosis. Pleural Fibrosis One of the outstanding features of disease encountered in advanced asbestosis is pleural thickening and more or less adhesive obliteration of the pleural space. Since the deposit of asbestos dust does not reach into the pleura, the reason for pleural fibrosis is not clear. That it is not an essential of the disease state is shown by some of our cases. That it may be a secondary condition, possibly of I . -t _ \ * * *** FIGURE 5 FIGURE 6 Figure S: Asbestosis bodies within old fibrous and almost obliterated air spaces, from exposure 27 years previous (147.595). Human lung, X 525.-- Figure S: Grade 3 asbestosis (147.595). No pleural fibrosis. Volume XIV basis in intercurrent cases. In case 147595 heavy asbestos dope fibrosis from exposu years before death, i area was quite r.ormz was no pleural ::bro; was none. In ten of t: other lung disease ur In one of our previ fibrosis of the lungs f exposure. Associated was the occurrence < resembling silicosis. F observation of this m: was uncovered. Later3 we reported ; asbestosis which also ; within which were si used the term "asbesto in an asbestos factory cotton mill for twenty All told, our series cc occurs, five In the adv: one among those of it: trates the occurrence c whorl." Although the reason fibrosis in our cases is an unknown silica dus However, the questio in asbestosis is again r that nodular fibrosis, intratracheal injection or more microns in le similar, injection of fit accord with Gardner'sfibrosis of the lungs ir dust consisting of long of asbestos ground to el. tosis of rabbits and gui: that similar, although the lungs of the latter ! .... .lu'M.'ir! :.c?.* rm .... s.' ..-V . _ ' .4. "V ;-' - . .',. 'Vl.'..'." '-I`' . * ` v-. ' __, _ V - . "r;. . 7 "...ir ~*-<~>. : V; *. v;v`. '*4 .,V"" hiMM .'*=' : & . ASfiESTOSlS 881 . "7 ~:.'jn:c XIV J , a.n in intercunent or secondary inlecUon Is ^ \ , es In case 147595, Chart EH, for instance, although there was a.bto deposit and associated advanced grade f old -it - a'rosls from exposure known to hare terminated twenty-seven -a r s before death, apparently from asbestosis itself, the pleural " Z Z quite normal (Fig. 6). In sixteen of the forty cases there * -a* no pleural fibrosis; even in six of the advanced cases tdiere $ none In ten of those showing pleural fibrosis, there was some - S J : h e r lung disease upon which the pleural state may be blamed. ' Nodular Fibrosis 1 't in one of our previous reports* is cited a case (10392) of fatal % fibrosis of the lungs from eleven ^ I t exposure Associated with general pulmonary fibrosis in this case "fc ,^6 occurrence of localized hyaline nodules of scar tissue 3*- hH smcosis From the exhaustive history obtained in long |; ~ -- to dust I ' te " w.'S'portcd a. case ot carcinoma o( the lung In advanced I -. Mstosls which also showed silicosis type hyaline tlbmM nodulm W . vithin which were shown ashestosls Oodles. In that reportw e gr? used the term "asbestosillcosis." The subject concerned had worked m i n i b e ^ s factory for twenty-one years and previously In a "cotton mill tor twenty-two years. ,,,,riniar fibrosis l b All told our series contains eight cases m which nodular fibrosis il occurs, five In the advanced group, two In the medium group, and j i one among those of minor grade. Gloyne also records and dlus- ^ t r a t e s the occurrence of nodular fibrosis `'resembling the silicotic ^ A lthough the reason for this prominent appearance of ^ u l a r : {i b ^ s in our cases is not clear, we have previously a^umed that an unknown silica dust exposure probably w u FTnwever the question of possible occurrence of nodular fibrosis h i ^ U raised by King. ^ at nodular fibrosis of the lungs occurred from expenmentel intratracheal Injection of rabbits with asbestos fibre o fJ teen " microni in length. while diffuse similar injection of fibre of 2.5 microns length. TWs_ is not m accord with Gardner's- findings of wholly non-nodular diffuse fibrosis of the lungs in guinea pigs from inhalation of ^bestos dust consisting of long fibre and practically no eIc^ frm of asbestos ground to eliminate long f i b r o in ` tosls of rabbits and guinea pigs there is the additional dlf^ n<T that similar, although smaller, asbestosis ^ J * * * TM ^ the lun-s of the latter but not in the former. King and his asso LYNCH AND CANNON Nov.-Oc., 10-\H ci thought that certain black pigment associated with the . j.stos fibre in rabbit's lungs might represent a comparable j. 'nation. Since there arc other indications of difference in ' spouse of different species to asbestos dust in Gardner's exeriments, this question will have to be subjected to further examination before it can be proven that nodular fibrosis of the lungs may not occur in natural asbestosis of human beings. Carcinoma of the Lung in Asbestosis In 1935, we-1 made a report of the occurrence of carcinoma of she lung in a case of asbestosis; Prior to that time there had been no particular reference to that disease in relation to dust exposure except, as there recalled, among the workers in the mines of the Erz mountains in Bohemia and Saxony. Published papers were cited laying suspicion upon radium examination and upon arsenic in the ore concerned. By 1939, when we reported a second, a total of eight cases of carcinoma of the lung in asbestosis had been recorded. In various published papers in the meantime, additional cases have been reported and discussions made (see Gloyne,10 Egbert and Geiger,11 Nordman,12 Anderson and Dibble,13 Vorwald and Karr,14 Klotz,13 Halleb and Angrist18 and Homburger17) some of which indicate a relationship of carcinoma of the lung to asbes tosis and to silicosis, and some of which argue to the contrary. In our necropsy service has been encountered an additional case, making a total of three In forty cases of asbestosis during a period of eighteen years. This incidence of 7.5 per cent is to be compared with a general incidence of 1 per cent of carcinoma of the lung in 2,683 necropsies in the last ten years. Of further interest in the question is the fact that each of our three cases had medium to advanced grades of asbestosis. In addition to these necropsies we have recently had a case proven to be carcinoma of the lung by bronchoscopic biopsy in a. rrmn who had been exposed to asbestos dust irregularly for twenty years and who showed asbestosis bodies in his sputum. It may be interesting to compare this record with that of the experience of Klotz,15 who reported four cases of carcinoma of the lung in fifty subjects of silicosis during eleven years, an incidence of 8 per cent, while In a total of 4,500 autopsies during the same period the incidence of lung carcinoma was only 1.18 per cent. Apparently to the present there are at least sixteen necropsies cases of carcinoma of the lungs in asbestosis, which, considering the comparatively small necropsy experience in the disease, seems excessive. From reports of the natural occurrence and from the question raised by experimental evidence, it seems that continued Volume a IV effort, especially ex; important problem. The question of v. progress of tuberculc ative here. Certain rate among asbesto: proof of the content comparing tutaercuir similar condition to the other hand, Gar no influence upon ti surveys of asbestos has been found. In our ov:n serie. that tuberculosis hs forty showed some 15 per cent, while th in 2,683 necropsies < A careful analysis only four of the eis of these (12192) hs showing the nodula: condition is well aci culcsis. Another (12 asbestosis. Of the otl of asbestosis and or fibrosis. Forty necropsied c and certain finding: sented. In this series occi: beyond a limited ti: though the fibrosis i In minor grades oi recognizable Influez condition caused ti: the state of asbestos This was likewise : damage. Only in ad-< and in only a part or the sole factor i Volume XIV ASBKSTOSIS 833 effort, especially experimental, should be made to elucidate this important problem. Tuberculosis in Asbestosis The question of whether asbestosis favors the development or progress of tuberculosis gains little evidence to support tire affirm ative here. Certain British reports indicate a high tuberculosis rate among asbestos workers and others do not. No acceptable proof of the contention in the form of properly -controlled studies comparing tuberculosis in other groups of people living under a similar condition to the asbestos workers has been offered. On the other hand, Gardner reports from his experimental work that no influence upon tuberculosis occurred from asbestosis, and from surveys of asbestos workers no unusual incidence of tuberculosis has been found. In our own series, from superficial analysis it might appear that tuberculosis had been favored by the condition. Six of the forty showed some form of active tuberculosis, an incidence of 15 per cent, while the incidence of occurrence of active tuberculosis in 2,683 necropsies during the same period was but 5 per cent. A. careful analysis of the individual cases, however, reveals that only four of the eight had active tuberculosis of the lungs. One of these (12192) had an advanced grade of pulmonary fibrosis showing the nodular localization characteristic of silicosis, which condition is well accepted as favoring the development of tuber culosis. Another (12892) had only a minimal and early grade of asbestosis. Of the other two, one (22047) exhibited a radium grade of asbestosis and one (19094) an advanced degree al old diffuse fibrosis. . SUMMARY Forty necropsied cases of human asbestosis have been analyzed and certain findings related to uncleared questions are here pre sented. In this series occurs evidence that the disease does not progress beyond a limited time after exposure to asbestos dust ceases, al though the fibrosis caused persists and ages into dense scar tissue. In minor grades of the disease, there is little to indicate any recognizable influence. Characteristically some other unrelated condition caused the fatal disease. In practically all such cases the state of asbestosis was undiagnosed until disclosed at necropsy. This was likewise true in most of those of medium grade lung damage. Only in advanced form was asbestosis a conspicuous state and in only a part of those of that grade was it a major event or the sole factor in the fatal disability. LYNCH AND CANNON Nov. -D ec., IDH# Asbestosis bodies remain deposited in the lung indefinitely at " as lons as twenty-seven years. In old deposits they show lymph"* nodes 6 Sm3ller i0rms d0 occur ln Peribronchial " VOlVement 13 a Part of the disease is not constant nor essential. It is indicated as of secondary occurrence. Local fibrous nodular lesions comparable to those characteristic o silicosis occurred in such prominence as to question whether they may not also be produced by asbestos. . Carcinoma of the lung was also of such prominence as to require continued consideration as possibly inducible in a susceptible sub ject by severe asbestosis until disproven by further investigation. Although tuberculosis of the lungs occurred with more frequency than m the general necropsy series, careful analysis of pertinent e\.deuce does not add much weight to the idea of relationship whe some evidence occurred that improvement of tuberculosis may proceed in the face of advancing asbestosis in at least one case. RESUMEN Se han analizado cuarenta casos autopsiados de asbestosis hu mana y se presentan aqu algunos hallazgos relativos a ciertas cuestiones an no aclaradas. Ocurren pruebas en esta serie de que la enfermedad no progresa sino por un tiempo limitado despus de haber cesado la exposicin al polvo de asbesto, aunque la ibrosis producida persiste y se convierte en cicatrices espesas. En grados menores de la enferme dad, hay poco que indique alguna influencia reconocible. General mente alguna otra, condicin distinta caus la enfermedad fatal. En casi todos esos casos la asbestosis pas desapercibida hasta que se descubri en la autopsia. Fue esto cierto tambin en la mayor parte de los casos en los que el dao ai pulmn fue de grado mediano. Solamente en la forma avanzada fue las asbestosis un estado conspicuo, y slo en parte de los casos de ese grado fue el suceso principal o ei nico factor n la incapacidad fatal. - Los cuerpos de asbestosis quedan depositados indefinidamente en el pulmn, por lo menos por veinte y siete aos. En depsitos viejos se notan algunos signos de alteracin. Pequeas formas si ocurren en los ganglios linfticos peribronquiales. La invasin de la pleura como parte de la enfermedad no es ni . constante ni esencial y cuando ocurre es un hallazgo secundario. Lesiones nodulares fibrosas locales, comparables a las que son caractersticas de la sicosis, ocurrieron con tal prominencia que despertaron sospechas de que quizs puedan ser producidas tam bin por el asbesto. Volume XIV Ei carcinoma del p Que no .se debe abane un sujeto sensible pr refutado esto por invi t0 Aunque lu tubercul '*! que en la serie gener: ^ datos pertinentes no ; r entre estas dos er.ferr caso, hubo dates q le ) r mejorando an cuand. f /-umionary A Wae. Am. Rcv. Tuber rnmV `PuJmonarv I *4 oholv PulmonJa-rCtranAc. Objects in the Lun 5 Idem: "Puim ona^A s 26 Gr^aLrdEnpeUr.hLe.Jiua.lr"eEtatipoilcl 7 ; , ,,Chrysote.b 8 TLsues," Am. . 8 J" CIea?- J. V. " d Aliuni 9 Gloyne. S. R.: "T -e \ 1n Tubercle, 14:493 '933 10 "Oase of bat Cel n11 EZguPbeerrtc,leD-.1S8.:1a0n0d, 1G9e3isseel 1930Ort f Case ^1):b > 12 ip^m ann. M.: "Beruf 1133 AndeArs'o4n7,:2c8.8'sW. 3asnTd d . . Lung," J. Hyq 38'135 i A. j. and Karr cinoma," Am. j . pa*it 15 Klotz, M. O.: "Associatir l16 HHonlulifbh,r'tHT3.5B'3.8'and 1117 fHionmmbu^rthasrP.uFJm o`tna-*rvr^' : Pulmonary Asbest* D i leopoli N-f Prior to 1930 there was literature of any specific and French literature, au \ / // 94 Volume XTV A S B E S T O SIS 885 at El carcinoma del pulmn tambin ocurri con tal prominencia >\V que no se debe abandonar la posibilidad de que sea producible en al un sujeto sensible por la asbestosis grave, a menos de que sea refutado esto por Investigaciones ulteriores. or Aunque la tuberculosis pulmonar ocurri con ms frecuencia que en la serie general de autopsias, el anlisis cuidadoso de los lc datos pertinentes no apoya la idea de que exista alguna relacin er entre estas dos enfermedades, mientras que, por lo menos en un caso, hubo datos que indicaron que la tuberculosis puede seguir re mejorando an cuando la asbestosis contina avanzando. > a. REFERENCES 'y 1 t S ? ' J Ci.U fi)tf5r3!raoW' A': "AsS" t" is S" 1" Sputum una .it "> " w < * p. as 5 & c" ctama ot *" in e *^ 8 ! ? ^ 5 3 ^ S jfc JS r * * " d 31muar 5 Idem. Pulmonary Asbestosis; V. A Report o Bronchial Carcinoma 6 7 r^rrtnprhTCU?T ^ TM plaSlao,",,4Pwne-uJm-oCnainoccocrs'is3,6":5J6A7M, 1.9A3.9,. 111:1925, 1938. l- 7 Aan5imm*al, TCinsrsyuseost.i"leAmAs.bResetvo.sTausbearnc.,In4d5:i7c6a2to. r19o4f2Subtile Duififeerreenncceess iinn is 8 cleR -,J- w- and Rae, V. M.: "The Effect of Asbestos and 1946^b t0S and ^ ummutn n the Lungs of Rabbits,'* Thorax, 1:188, a 9 r0be^/eS4Y4b3,.T9323M0rbld Anatomy 4X1(1 otology of Asbestosis," n 10 r1ferc/ai8e:100^193FCUCarcinoma of Lun&Occurring in Asbestosis," e 11 Egbert. D. S.and Geiger. A. J.: "Pulmonary Asbestosis and Carcinoma- F936rt f CaSe WUh Necropsy Findings," Am. Rev. Tuberc., 34-142, 1. 12 ?ofsTM?v.2M.'i 938erUSlCrebS der A5bestarbeiter," Ztschr. /. Krebs- e 13 LuS'?T'N?o.f38:?8l9b38.' J' H" "SillCSl3 and Carclnoma of the r H dnorna/' &nd Pulmonary Car* 0 15 *i939Clatl0n 0i Slllc3ts and Carcinoma of Lung," Am. J. 1 18 ^'i'and ^n?PSu' A.: "Bronchlogenic Carcinoma in Associa 1 ,, tton with Pulmonary Asbestosis." Am. JKPath.. 18:123, 1942. 17 Homburger, F.: `The Coincidence of Primary Carcinoma of the Lung n and Pulmonary Asbestosis," Am. J. Path., }9:797, 1943. 8 S i Discussion LEOPOLD BRAHDY, M.D., F.C.C.P. New York, New York Prior to 1930 there was almost no mention in American medical literature of any specific disease due to asbestos. In the British and French literature, authors recorded high frequency of chest 88a LYNCH AND CANNON N o.-D e.. 194* symptoms among asbestos workers and speculated on the relation of symptoms to the inhalation of asbestos or of silica or of iron or to other conditions associated with asbestos work. There were reports of a high tuberculosis morbidity among those exposed, and general high mortality. Some authors gave fair descriptions of the pathology or of the clinical picture of what we now call asbestosis but correlation of the pathology, roentgen appearance and the essential factor In etiology was lacking. There was con sensus, however, that somehow asbestos work was harmful. The international encyclopedia on industrial diseases, entitled "Health and Occupation," published in 1930, deplores the lack of more accurate and detailed data on the asbestos hazard, and goes on to say that the increasing' utilization of asbestos urgently calls for study of the condition. In 1930, Lynch and Smith published the first necropsy protocol j together with the detailed occupational history which left no , ` doubt that the disease is a lung fibrosis and is directly due to the j inhalation of the asbestos in the dust. R. S. Mills, in the same year. : and later, Lanza, Gardner, McConnell, Pendergrass, Shull, Sparks, Stone and others made Important contributions. In the seventeen : years since that confession of confusion in the encyclopedia and : Dr. Lynch's pioneer publication, American medicine has progressed ; with speed in the knowledge of this condition. ' ' Today, we have had the privilege of hearing the latest repon, of the continuing observations by Dr. Lynch. Some problems, he : tells us, need further elucidation, among them, the relation to ; carcinoma. Although we must keep an open mind, the evidence i : warrants the tentative conclusion that asbestos workers do have I ; a higher incidence of lung cancer. Now that early lung cancer J ; often is amenable to surgery, this gives added value to the periodic I chest x-ray survey among these workers and calls for more meti- ! culous film interpretation than is essential in most survey work. From the viewpoint of public health, of diagnosis, and of work men's compensation adjudication, observation is needed to establish the tiologie relation or the absence of any relationship between tuberculosis and asbestosis. Many of the older clinical observations j (though not ail) favored the conclusion that there is a relationship j similar to that between silicosis and tuberculosis. The report we 1 have heard today does not confirm this view. One statement, or rather the implication of one statement, of Dr. Lynch must be ! interpreted in the light of other clinical experience. Dr. Lynch .reported one case in which tuberculosis improved in the face of : advancing asbestosis. However, we occasionally find tuberculosis ' improving in spite of the presence of silicosis and we do know : that silicosis adversely affects tuberculosis. Tuberculosis sometimes 1 i! j ' fjrww*sv it, :t.w. Volume XIV A S B E S T O S IS 887 heals under the most unfavorable conditions of the infected organ. S i u b e m u l o s t s may he* in the (ace of asbestosis. there or, should not add any weight to either side in evaluating the effec of asbestosis on tuberculosis. . ,ftn ' Dr. Lynch may not be conscious of a sermon to the clinician contained in his post-mortem reports. He said that in m^ of well-developed, though not in advanced cases J * ' f ^ m e asbestos exposure was traced alter necropsy diagnosis that means that the clinicians neglected the occupational histori of their patients, probably because there was another serious dis ease present. That the diagnosis was made post-mortem suggests there were not enough routine chest films made of these workers when e y were well and certainly not sufficient chest e*am- InaUon when they became 1U. We should take to heart us failure to recognize the occupational disease during life. Many new substances were introduced in Industry in the last decade new compounds known only to the chemist today will be used in industry tomorrow. Some of these substances may P ches^symptoms. The clinician, practising in the locality of the industry and not the pathologist should be the first to clearly " t a"" industrial^process is a health hazard chnician must be the first to know, what is equally important from health viewpoint, that some suspected industrial Procei* * a health hazard. Let us reflect on the significance of the fact that twenty years ago hardly one of us would have s^sPect ^ h the lung symptoms presented by one of our patients working on refrigerator insulation were directly due to asbestos. Perhapstod^ay some of us are missing the etiologic factor in cases history under our observation because we neglect ^ ^ occupational r Dr Lynch's studies on the pathology would interest if he had not combined them with investigations into th occupational hiatory In each Individual caae. It la the correlation .nv.ir.vi makits them a major contribution to medicine. There are other conclualona of Dr. Lynch's applicable to problems o f TM clinician Dr. Lynch finds indications that when exposure I f t h e disease develops but lit . *% > is definite and that must be a comfort to rk 'e s It e 2 i r to get him readlusted to a new occupation and makes Workmen's appU^d^to^hef Mcomdaiy cardia^embarrassment once that % " o rZ c h T c o S o n Hr" tte w t emphatically correct b cr r ru r. 888 LYNCH AND CANNON No*.-Df.. 19-ii limitation of chest expansion and also means.that no recession of symptoms or signs directly related to the fibrosis is to be expected. Another finding is that length of exposure and severity of the disease are correlated. This sounds self-evident but in silicosis we cannot make that statement. This characteristic should enable us to concentrate and strengthen asbestosis case-finding among those workers who need It most, i.e., those with long exposure, and to be alert when examining a patient who declares: "Oh no, that dust does not bother me, I'm used to it, worked there without trouble for twenty years." Furthermore, this correlation of exposure-time with severity enables a workmen's compensation board to equitably allocate liability when two or more employees with asbestos hazards are Involved in the same case. Then, too, Dr. Lynch's conclusions mean that when we have negative medical findings on a patient exposed for only a few months we can reassure him with confidence on the absence of dust disease. As if to balance these conclusions which make our jobs easier the newer observations indicating that nodular fibrosis may occur in asbestosis makes matters more complicated. Now, knowing that nodulation occurs in asbestosis not only the pathologic but also the roentgenologic distinction from silicosis becomes more blurred. We must be- more cautious or perhaps, give up trying to reason .from a film or a pathologic finding as to the type of dust exposure. This has been an informative presentation. It necessarily is an unusual privilege to be first to hear repots of pioneer Investigation from men whose publications have their place in the history of diseases of the chest. I want to express my thanks to Dr Lynch for that privilege today. ` Discussion W. BERNARD YEGGE, M.D., F.C.C.P. Denver, Colorado I wish to compliment Dr. Lynch on the contribution he has made to our knowledge of asbestosis. Pulmonary asbestosis differs from silicosis by size, etc., of the particles inhaled and by chemical composition. Asbestosis is caused by an alkali which is magnesium silicate, along with calcium and iron. In silicosis the offending dust particle is silicon dioxide. In asbestosis the shape of the particle causes them to be arrested more often in the bronchioles and the alveoli anl they are not so