Document QXpa0rkpm6mRyrVK1xwMRJe96

FILE NAME State of the Art Literature SAL DATE 0000 DOC SAL928 DOCUMENT DESCRIPTION Book Excerpt - Anonymous 44 machines is productive of con 2. Since material leaving picking such material should be ex- siderable dust storage rooms receiving while material is being hausted Workers who must enter such rooms of respirators No blown should be equipped with approved types while the picking material should be removed from storage rooms machine is in operation the laden air removed by exhaust Clean air should replace in event of recir- 3. This requires systems attachetdhatto dtuhset ecqounciepnmternattions entering any room be kept at culation of air that found in outdoor air levels comparable to of the working environment 4. Periodic studies of the condition control methods adopted determine whether the he appear necessary to that dust concentrations are constantly adequate This requires are equally determined for each opeorfatiinosnpecVteinotnilaantdiornevmieeawsusrheomueldntbse perfornied important The work trained for such studies by persons ined athetnther sk ame te STATISTICAL DESCRIPTION OF EMPLOYEES OCCUPATIONAL HISTORIES At the start of the medical examination the physicians questioned each worker to obtain a complete record of all the jobs at which he had worked This information was recorded on the portion of the physical examination form reproduced in figure 27. After the basic census data name age sex color and marital status had been recorded the worker was asked how old he was when he first began CASE RECORD Weme saccmncc--ceevee (Serena: aeeecses { } ee: Det MY peprro ier r eerrrt oe g btivem ...- AMR. cccoene ces Methe oe Putal crwenssecccere Calor... ~ Maral ......,........... ........ a wet tev eeeneee Dd bp a one Adabeoet, - -- co Your Agg Agg FOEr. eccc. mmmm. enee Gwe... .0000-v2.-cceceernreeee Pam dhle....0scsccccesso--- - OCCUPATIONAL HISTORY omit me inaadiee tears = we, gare M om a =< : -. 1 : J, | -. . 7 -. { 4 4 nee " eooee t , " A . oe . al . | : | _) : a i \ j stl Tow Ten \ ' i { i vee Sate FIGURE FORM USED FOR RECORDING OCCUPATIONAL HISTORY industrial work This figure was subtracted from his present age und line of questioning was begun to elicit information on the work done in the intervening years No occupational history was regarded as compl^teuntil all of this time could be accounted for by definite entries The job he held at the time of the study was entered on the top line of the vccupational history together with the number of years he had held it the mime of the department in which he worked and any other pertinent data th"tcould be obtained Next he was asked what he kuul done previously and again a complete entry was munde The name of the factory was entered for each period of enu- 1471 +6 ployment in the asbestos textile industry After each job had been accounted for the worker was asked what he had done before that If man had worked in an industry in which workers are known to exposed to pneumoconiosis dust entries were made in the last column to show what materials he handled and whether or not control measures were in use Information on previous employment in dusty trades is of paramount importance in a study such as this Any cases of prolonged exposure to pneumoconiosis- producing dust other than asbestos must be treated separately : After the field study had been completed an engineer assigned dust exposure values to each worker following a procedure illustrated in table 15. In assigning these values consideration was given to each joli a worker had held in an asbestos plant The importance of the occupational history in a study of this kind ese can scarcely be overemphasized It is the connecting link between the engineering and medical studies The correlations between medical findings and dust exposure that nilequnte occupational histories make possible provide means for estimating the dust concentra- tigns to which workers may be exposed safely tigns Only 23 persons reported previous employment in an industry in which workers are known to be exposed to pneumoroniosis dust Such periods of employment usually were so short that no deleterious effects would be expected Twenty persons had normal field markings Only one of these 23 persons had plants asbestosis at the time of this study a man who had worked 3 years years in a foundry and 10 years in asbestos textile COMPARISON WITH OTHER INDUSTRIAL WORKERS sixths of the employees were native Amierienns of AngloSaxon stock and the remainder were Negro males Before beginning work in asbestos textile factories more than 200 of the 541 persons had worked at similar occupations in cotton or wool textile plants A large proportion of the employees had worked on farms either before beginning industrial work or in intervals be tween periods of industriak employment these About 15 months before this study was begun approximately 150 workers in asbestos textile facturies were replaced by workers with little or no previous asbestos exposure Although an effort was made to examine us many as possible of these former workers lean than half could be examined Partly as result of these personnel changes the group of employees examined in this study had an uns usually low average age There was an abnormally large percentage of workers with less than 5 years employment in the asbestos textile industry and an abnormally amull perventinge of persons who hand worked 10 years or more in this industry we 47 Table 21 Age distribution of nebesins workers Number of work ARR White mas | hite ferns S Neves makes Total nce cece rece ewww cence erererrrs vee Under 20 yMUMS ccc e eee ec eee e Dr 0D TE oc PAPS cee eee eee creer neces ose to 29 at . to 34 years to 39 yeats we 41784 41784 Lear 10 VRATS VRATS eee ee reer rr rr rae er ett eer rt 74110 Sb Pars 10 SEATS SEATS Kalina Kalina Kalina 18379 once ccc cc cree tees cnc recent remem 2 (HF NOOSE ee - eee TUPAC AM age OL P cece r cece mere tenn eres Unko060 Unko060 age conc cce eee cee ee ee cee eee Seeley see es eees wees seee r ... ee ... 2139-189 2139-189 deviation p=) 1s rs) 3 si Me 2. 1a ? 10 . i 0 1 th 3. 114 487997 487997 487997 487997 487997 4879 7 4 Q 4 " e a 1 tu jy * < a Bay te ls 3 3 1 1 " " " de de fo ... os pet t vs ~* al st 10 ys 3 : : : . The low average age of this group of asbestos textile workers mist be kept in mind in making comparisons of health conditions in these factories with health conditions in American industry in general Table Average age of white male industrial warkova Industry 1 Publie - Averet : Averet i Heath | i | Asbestos textile . eee Iron sou steak Granit cultiDE | Anthracite mines Fur cuttig 2. .eoee soot Pottery ren Fouodsy....- HZRAKASH i HZRAKASH HZRAKSH HZRAKASH HZRAKASH HZRAKASH HZRAKASH HZRAKASH 6 HZRAKASH Industry ' a coresO age s peeen. Spflict Baswein HA : 3 11 Pas Pony + ie we ura bee ee : The average age of white male industrial workers is less in the asbestos textile factories studied than it is in 14 other industries in which the Public Health Service has made similar studies White males employed in asbestos textile factories average 32.1 years white females 30.4 years and Negro males 32.4 years of age TABLE Length of emplnument in the unla stos teztile industry Sex and colur OT White White in Whay Whay ten Net | Trans empanelik Ps Trans empanelik empanelik almskim jestik kishrest , . ' Teal. CS . ' ee Abend 11049 * : 341 606 wo WWta Tere wee ote ee meme 8 STE hi out Tt ade. ci 100 ae ray a ro 132 a me t: ~ te oo . ot be. ee ad ' : : eee : 1 " 48 Correspondingly the average length of employment in the asbestos textile industry is relatively short Only 18.8 percent of the employees in the asbestos textile industry more than 10 have been employed included in table 22 for which information years In the 13 industries industries have on length of employment is readily available only two of employees who have worked less than 10 years as large a percentage that the asbestos textile This is partly accounted for by the fact industry is of comparatively recent origin in this country Only o.ne of the plants studied had been in operation before 1920 MEDICAL STUDY PROCEDURE A medical examination was made of each worker employed in the textile factories of North Carolina during the winter of nsbestos also examined in 1935 36 A group of former asbestos workers was order to obtain a complete sample of asbestos workers Office workers and other employees not exposed to asbestos dust were included in these examinations They are classified as controls Included in this control group which numbered 76 persons were 27 in the asbestos industry for the first persons seeking employment time Before making any medical examinations the two physicians made an inspection tour of each factory in which this study was made in order to familiarize themselves with the various jobs or occupations involved in the manufacturing process This is a necessary pre- requisite for taking a usable occupational history Space for examination and fluoroscopic roonis and laboratory was obtained at a location as convenient as possible for all concerned An iniprovised darkrooni was used for fluoroscopy and for processing the ray films In an adjoining roora thie modical examinations were made by two physicians approximately according to the following schedule Four persona at 9 a ru four at fonrat 1 four at p m aixi four at 3 m In other words about 30 minutes were re examination The routine used in the study of pulinonary tuberculosis quired per of the cheil After the history and physical was followed in the examination findings had been recordod the group of four was finorosonpeil and client roentgenivis taken A few examinations were made in the evening and otin grains were were made in the schedule so as not to interfere tin weriously with the adjustnients work routine of the employees with particular attention to At plant A the urine of workers was examined of silies exeretion In addition to this metalwilie stisky zostlite arvatur arvatur Vi atimoonus nwtore fuade of the sputum of workers in pskat~ts minil C for presence of acu fast bacilli and salamlowin buchies Sections of the physical examination form used in this study have been reproduced in several places in this bulletibullnetin as a means of indicat- we ing the information information that was collected e Lo, { . ( ( . r) a 1 . 1 , i { : $ 49 PAST MEDICAL HISTORY Each person was questioned in order to find out whether he had previously had certain diseases which are of importance in the study of chest diseases FAMILY AND PAST MEDICAL HISTORY ( Gare we fer? Pend? humors of T. B. wen eee See & T. B. t . Pears by Va Sums.......... La an EN B 7. Pe = ... sa tape. t Dus Rent .... Avwags came af eats penris.....0.- . a Were eatin we comms PHEre.... .... & > Tone On pomee ae Bean meme coos Rapemees Foow....cccsccseccrees Sere Fever Sr deewes < C. ea) us & . Pm wan One are e - Cmyt Pw ore A Ber ony ee b PRESENT HEALTH HEALTH Tres n ^' Suwes. Tee eon Cte Pay _ sways af cave - Wages Den caw os ses ees emt cccuee oe Cott... bow. Bow tay Pare ooerers weeenwoeses . . . Abvateed tee cm vce Av Oe tem eraen cue. AarTS neg oo sone O0 ce a erawanees Re nn a eee ce rte n me pewter ecanesene FIGURE 28 FORM USED FOR Recording Past AND PRESENT MEDICAL HISTORY Tabulations of previous illness did not indicate that premioma pleurisy respiratory diseases other than the common cold sigestive 50 disturbances or prolonged contact with an active case of tuberculosis had made people more susceptible to asbestosis Frequent disabling colds were more common among persons with advanced pulmonary fibrosis than they were in persons with little or no fibrosis but this probably is a result of the fibrosis rather than a predisposing influence SYMPTOMS OF ASBESTOSIS progres- The chief symptoms usually associated with asbestosis are sive dyspnoea cough hemoptysis emaciation weakness poor chest expansion curved finger nails or clubbed finger tips chest pain and cyanosis In these respects asbestosis resembles silicosis Early cases of course would have relatively few of these symptoms and an advanced case would have almost every symptom listed The appearance of these symptonis can be explained on the basis of a more or less general fibrosis of the lungs and concomitant pathological changes such as emphysema bronchiectasis and fibrous pleurisy The cardinal symptoms of asbestosis are cough and dyspnoea These two symptonis occurred together and in combination with other symptoms far more frequently than one would expect on the basis of chance alone Table 24. Number of persons who had certain paire of disorders compared with the number who scould be expected to have them on the basis of chance ninne Where the differences are statistically significant the observed numbers apprat in jar~- Typc 11 rkland La od lilt lemopty | 15 Lam i Chil - - ! ... weight } PRID Weak 1 apperate Calculated OC harried alculaC't atrie sfald ei7k Calc13u4338l373aC't atrise faleikdGF Calculated l'skuksiel l'skuksiel | 134338373 134338373 Cakulatol Oilserved Oilserved C'atrisfaleik -> 2 C'atrisfaleik $ ; na ' | # ie] na . else. Tt cceetvwoves IIE scenes ser aegeccereg weesfesaens seaselen | : . i^' ope . we oes eo? oe : As table 24 shows 94 of the 122 people who complained of dyspnoea had a cough also On the basis of chance alone assuming there was no enusal connection between the two symptoms one would expert that 36 people would have both conditions Actually the two ronditions are found together far more frequently than that and it is safe to assume that there is some sort of causal relationship Similar considerations hold for most of the other pairs of impairments Typically the enugh of asbestosis dry and momprovinctase In El~na El~na valur valur kur teen rubukitel rubukitel na 19 veelttipid mid that it boid pojemen's pojemen's the bedd sbitats at 18.6 . | ve lt ipid Pulparintis semaid semaid despippdiespLipSpiLTSTUU despippiLSTU ZNEPerdiments despipiLSTU ZNEPerdiments ZNEPerdiments the p edvabalus p edvabalus kj^redessen kj^redessen Elvist Elvist sig hah in Hups at^' taken from from Plan syviniel lagtips lagtipps quidemt^vi^ lagtipps Pakih Pakih ee , ... ... ... ** 31 some cases there is scanty viscid expectoration Severe paroxysms of coughing occasionally occur in cases of asbestosis having serious disability At such times highly tenacious sputum is raised Usually a complaint of dyspnoen was entered on the records only when breathing was labored after an exercise test see p 65 carried on in the presence of the examining physicians The high percentage dyspnoen of persons with who were able to be at work is undoubtedly due to the sedentary nature of much of the work in asbestos textile factories streaked sputum occurred frequently among persons exposeil to asbestos dust although there were only two active enses of pul- monary tuberculosis in the group These two cases have not been included in tables 25 and 20 and figures 29 and 30. The absence of pulmonary tuberculosis makes hemoptysis a more significant finding in Its presence seems to indicate that bronchiectatic and emphysematous processes are going on in the lungs The presence of asbestosis bodies in the sputum which will be discussed in a later section also can be interpreted as a sign of disintegrative processes in pulmonary tissue Weakness and loss of weight are closely related symptoms Indie- pendently of age and other factors these symptoms increase in fres quency with increasing dust exposure They are accompanied by a general bodily appearance not unlike that of fibroid phthisis Nineteen of the 447 exposed people complained of a pain in their chests which is best described by the term substernal dis tress It was vaguely defined and not as rule very well localized and it seemed to be an ache or a feeling of oppression rather than a sharp pain It did not seem to be of cardiac origin Only one of the 24 persons with a past history of pleurisy complained of a chest pain of this kind It appears that substernal distress may be connected with the cough or the dyspnoen that accompany asbestosis table 24 The symptoms of asbestosis are listed in table 25 where their incidence is classified arenriling to the total dust exposure of the persons affected For purposes of comparison the employees of asbestos textile factories have been divided into five groups which differed in dust exposure one of them being a control group of employe ees who were not exposed to asbestos dust A number representing the total dust exposure was assigned to encl exposed employeempeloyee by multiplying the number of years he had worked in the asbestos industry by the average dust concentration to which he presumably had been exposed His total dust exposure is thus expressed in million particle years If worker had changed from one occupation to another dust exposure value in million partiele years was calens Inted for racli veripation and these values were mihilish together to obtain his total dust exposure a Au exauppiest exauppiest slide 150 d^>as leen given given in the sequin sequin entitiest entitiest ' Phurideration Phurideration of chest zruen 52 The percentage of workers who complain of cough dyspnoes streaked sputum and other symptoms increases rapidly with increasing asbestos exposure In all cases the percentage of workers who are affected by a particular symptom is larger than the percentage in the control group Two of the cases of dyspnoen found COUCH *y rl vex ** ! i | 4 | DYSPHO A 81 10 J STREAKED SPUTUM SPUTUM 7 STREAKED eo - WEARNESS oo i an : ao wu CHEST PAIN 0% MO DUST CIPOSUC 4833 Than as 88-41 at _ 0.00 8 OVER 60 $ DUST EXPOSURE MILLION PARTICLE YEARS FIGURE PERCENTAGE OF PERSONS CLASSIFIED by HAD CERTAIN DISORDERS Dust ExpOSURE WHO in the control group were accompanied by heart defects severe enough to have caused shortness of breath Table Classification of present complaints according to the dust exposure of the affected pITSJAJ Present comput | Mart~-n Mart~-n Mar3t mar~ s d- ialn sure Just to Just \Eowreaces! mrece | mote UL LIN mr. Voces cece wes eeee : 044ch [be cgermap 56. 11 pikamm ce eee eee ee Lams A pighi pigh straktu sjatum famed gouty Cermy ood ctteetel@ oll. Num Pre Num ee. iNume Pee Nu^-os Pers Num Per let cet: hee: cwnc | bev . cents LIFT MIL tee ... r es e we | et eee e ry @ 4 . a . i] . u ees ee ry = bs -- e ww, ^'! tae v, t v6 v nC JOB Ce ery eee eer oe ee ees te) tl cr ty ee a ee srs 13-8 an wy o. a al Jj tI .- y 2 i a tts 3 s ry s ries * ore . we se a v . : coe ee, ls rz) Je gee ae : = le dee oe 1. ve . + Lata Lata not availshoe availshoe fur icl workers workers Another indication that these symptomis ate an integral part of the symptom complex of asbestosis is to be found in the relation of 53 these symptoms to the fibrotic changes that occur in the lungs The degree of fibrosis can be estimated from the field markings seen on ray examination a subject which will be more fully discussed in a later section For the present it will be sufficient to say that as a result of continued exposure to asbestos dust the normal or degree exnggeration of linear pulmonic markings become coarser and more widespread second linear exaggeration Upon longer or more intensive exposure a fine interstitial fibrosis sets in which gives a hazy ground appearance to the lung field hrst- COUGH 22 Bae ee . ye Xre : Seise ay DYSPNDEA 4 |STS BLOOD STREAKED STREAKED SPUTUM o% WEAKNESS X had rh4 ee SANUOTAN CHEST PAIN s% ee LINEAR 2%, YY LINEAR LRA 4 2 LINEAR I GROUND 2"GROUND Pe GLASS GLA33 a LUNG FIELD MARKING FIGURE PERCENTAGE OF PERSONS CLASSIFIED BY Lung Field Mankings WHO HAD CERTAIN DISORDERS degree ground glass and eventually almost completely obscures the linear markings second ground glass Asbestos people have been classified into four groups ave cording to their lung markings and the percentage of persons huving certain symptoms has been calculated for each group Here again the incidence of these symptoms increases greatly with increass ing fibrotic change Such a relation is entirely to be expected for dyspnoea since the disease diminishes the volume of the lung available for the respiratory function The high incidence of the other symp- toms in the presence of librote changes that have progressed to the ground stuge is additional evidence of degenerative changes in the lungs 34 Table Classification of present complaints according to lung markings uj the affected persona Lung markings Present complaint complaint | : 1-6757M H Second jegreE beFirst gree | Second 1-6757M Dear : . i STUNDU SAMA TUUNU SIA'S i Tets Percent Nem- ' her Percent Nude bet Percent Numbef Num bet Perment ...... COUED... .cccccrecccveesesnes Dyspeom..... ese Lots Lots of ent . wee streaked sputum Chest paid .... ec cee wees Los of appetite ...... peewee 313 r) 43 15 a rs 1] | os ... ty owe naeaaes "Im - A gt; a zt ds ui a, wu M aa TY rs 4 vi oa an oo} . at 2 , 3 $ 4 uu 533 2 4 4 3s 533 o 2 3 i o 533 b nn ar f Fou W- oO. ws " 120 $ 411 41 : . RAY FINDINGS FIELD MARKINGS The classification of lung markings used in the preceding ser tion is part of a scheme that was used in a study of anthracosilicusis FLUOROSCOMC XA1 ATIONS Oeor . Ken Ken and Tree .......--... - Dupage (ame tantte Ser Perey toreresy . Pee ere oe -RAY INTERPRETATIONINTERPRETATION ... of On.. Sd t= ~ omens amg fates = . . ia . seseeeensseseemmnenencense cases neta sectensarecaeemeemmcesnsnaneseeees . 40 eee . . N \ ~ 1 J < tT Emeey Wy oo... 8... ee sesecerres deena aceessvesseess FIGURE FORM USED FOR RECORDING X RAY FINDINGS 51 It of course highly desirable to have a system of classic fication fication which which will help in deciding whether a ziven ziven type type of lung marking represents an early or a late stage of a pneumoconiosis and this scheme has been drawn up to illustrate the probable sinquieture of fung markings that vernis during enuttmund exposide ti pneumoconiosis dust During medical studies of anthracite miners for instance all of the stages represented in figure 32 were found Among exposed workers on the contrary no case was found which had progressed beyond the ground stage This constitutes a difference between asbestosis and silicosis that Merewether 25 Lanza 18 and Pancoust 29 among others have commented on Further investigation will be needed to decide whether this difference is due to a peculiarits of asbestos dust or SCHEME OF BAY INTERPRETATIONS INTERPRETATIONS INTERPRETATIONS FIGURE SCHEME USED IN CLASSIFYING RAY MARKINGS whether it is due to the rare occurrence in asbestos textile mills of the excessively high dust exposures 100 to 300 million particles per cubie foot and more found in certain other dusty trades In typical case of asbestosis the lower half of the chest ray film has a fine granular appearance which Merewether 25 aptly des scribes as ground glass Not infrequently there is inore fibrosis on the right side than on the left The presence of emphysema in the apices which results in increased nuliolucence tends to exaggeran the cloudiness of the buses of the lungs Emphysema preveries the ground uppearance of the buses Chest rays of individuals individuals with pneumoconioses induced by other silicates with the exception of mica do not regularly show the basal localization of librosis that is so characteristic of asbestosis FU rpneonndars oboe FU ow Sees fg 30 Occasionally in an asbestotic chest the heart has a shaggy outl when viewed roentgenographically a phenomenon discussed by ot investigators This seems to be of more frequent occurrence whi the worker has been exposed to dust containing a high proportion fibers the dust produced in twisting or broadcloth weaving for i stance than when he has been exposed to short asbestos partici partici NO DUST CXPOSURE SUE 10-31 10-31 of 60. t 18 370 30- 370 20-20 . UNDEN 20 Cd] 4 20 30 40 20 60 7@ @6 60 00 peac = AACLIN | 30-30 ( e0.ags. 3 30.38 a 10-20 UNDER 20 it -} fa 38 60g 30 60 10 63) PERCENT PERCENT te {_ ASBESTOS \ 10-39 FUVTTTSA0 NDrSe1ae0N 40-40 meee ObOGRL LDA . act act 30-31 30-31 eee act Toe 30-20 anaes wets tet ot @ 80 Me Ge 80 se re 66 8s - PERKENT PERKENT --- --- o ...ws? elas --- Gmm...emd 0459 Qitere as anes Se teen car meere FIGURE 33. PERCENTAGE OF at oe Field MALES CLASSIFIED BY AGE WHO HAD CERTA - Markings 229 MEN HAD NO PREVIOUS Industrial Dust POSURE BC HAD BEEN EXPOSED TO KAOLIN DUST Ex , TO ASBESTOS DUST AND 357 HAD BEEN EXPOSE such as those produced in carling in onier to establish this point Further study would be necessary necessary Unlike silicosis nodular and congloinerate shian re d notofw ous nd asbestotic workers in the absence of tuberculosis tuberculosis or other infections The principal difference discernible on mny film between an euris and an advanced stage of asbestosis lies in the density of the groundglass markings and the degree to which the linea pudowanie markings markings have been obliterated Although degree and seconded gres ground markings have been tabulated sepurately in sever tables published in this report it is often dilleult de cuje w further further , 57 particular film represents an early or an advanced stage of pulmonary fibrosis There is of course an increase in the prevalence of lung fibrosis with advancing age Because ground appearance of the lung fields which is indicative of fine interstitial pulmonary fibrosis is a most important diagnostic sign of asbestosis it is necessary to evaluate the relation of this condition to age and other relevant factors From un- published data collected by the Public Health Service tabulations ef lung markings in relation to nge were made on two groups of men One comprised 229 men who had never been employed in a dusty- dusty- group in mining and refining trade the other group included 50 men engaged kaolin by wet methods The percentage of men who have a second- degree exaggeration of the linear pulmonic markings increases with advancing age It is significant however that in the entire group of 309 men there were no cases of ground lung markings Other studies confirm this Dreessen 43a examined 50 mien exposed marble dust 15 percent had second linear markings but none to had ground or nodular markings Similar data are available miills who were exi 42 f^...r 201 men employed in portland cement amines G ardner and Sanipson No cases of granular markings or of discire nodular fibrosis were found In every age group the proportion of asbestos men who had advanced stages of pulmonary fibrosis is grenter than in the men unt to asbestos dust The percentage of men with ground exposed lung markings increases with advancing age In view of the data for the two occupational groups just discussed and of the relation between this condition and length of employment it appears that the reason why the incidence of this type of pulmonic markings is curtes lated with age is that the older people have been exposed to asbestos Table Relation of feld winekings ta nga Men seeking employment in a dusty trade for the first time kaulin workers and mon employed in az^"cslustertut tertut factories gs NNa a prvemus 2 1 prabure \ : . . Aventen 819bers AACCH H Tistat Tistat examined : : rent per. Br i ' SE Nume Met - 1 j Ane | PEM 1081 01416 wre ' : 3 rent ith Ane Stim of mu a4 Petes een: oHUa > Nome ET Literat FLAR ... ws: rent an fit arene lige 01416 : coat; ek ' Shy, Jsem Rot: 4 t I Num let of 91-41 wes PM 1916 th 11''VT VT wat Bith % % ,,,, ," Will fee s ," ; Tifoq eve tacae lifeti ... Lor La weorn KO Otte . vt . the 16 the 161 ee We 1776 woe ee we -~ - .. ws " a M si ... ve . a ts ray a Mo ee bf tus teetue as ane . at a7 oo TY a " - : ue oe = ie te tes . 4 . wt eee . . : Ww u . v 2 58 dust for the longest time It would be important to know whether susceptibility to asbestosis varies with age but these data do not seem to be extensive enough to test this point satisfactorily - The prevalence of ground lung markings increases greatly % with increasing length of en- | ployment as figure 34 shows The incidence of ground AFERD ast, munntNS muntNS e ?* ta lung markings also increases with increasing dust- exposure In figure 36. which is based on table 28 the heights of the Primnra Priminira Primnira = _ 1 _ vertical bars represent the percentages of asbestos workers in _ different exposure groups who 3 LENGTH OF 0-045 FIGURE 34 RELATION GROUND FIELD MARKINGS TO LENGTH OF EMPLOYMENT EMPLOYMENT had ground field markings either first secomi degree The 76 controls have been excinded from this tabula- tion and a number of - ckers whose dust exposure was not known have also been omitted Many of the percentage values must be viewed with caution because they are based on sinall numbers of workers This is particularly true in the groups with more than 10 years employment 20 - Considering the four dust exposure groups re* ve, one at time there is a consistent and regular increase in the percentage of persons with ad- vanced stages of lung fibrosis with increasing aot 0 BIOGACES APPECTER (Oe ... length of employment \ Age course of erenses with also inlength of employment but these fibrotic elinnges cannot ascribed be ascribed to advane- un _ . dary mee rt STO O /cea5 FioURE 35 BUST COME Patum k^ TICLES m TICLES PER EW FT RELATIONOF GROUND Lung- FIELD MARkings to Dust Exposure ing age because as tablu 27 shows fibrotic changes of this degree are not to be expected in workmen of comparable age who are not exposesi to siliceous dust Obviously there are grent differences between individuals in the time time that elapses from their first exposure to asbestos dust and that fibrotic changes are evident on ray examination the 11 some persons this was mineli less than 5 years and others ct a gpecis 59 to be more than 10. Although it is impossible to account for these lifferences entirely it is possible that one fuctor may be the difference in physical exertion that different occupations require sedentary occupation shallow breathing might be adequate to meet a person's respiratory needs such a person would inhale less air and conse- quently fewer asbestos particles than a person engaged in vigorous muscular work who was obliged to breathe deeply Some of the individual differences to be found in these data may be due to differences in the total amount of asbestos inhaled CONCENTRAT CONCENTRAT 8. ** a _ . - . te eo, ae. tags 3 - _ 19 THAN TM 1833 vy >, ee ~ e fi cr "te 3 OUSTRY 63663763 63663763 63663763 IN OUSTRY OUSTRY *% 1800 e FIGURE 36 % INCIDENCOEF GROUND FIELD MARKINGS IN RELATION TO LENGTH OF EMPLOYMENT AND DUST CONCENTRATION Table Proportion of asbestos textile workers with ground lung markings Dust rijemure million parties par etal~ Sagt s is aleman industry + 01441 | 99 | 1916 Overt: ' J Street. H secnceee| Hey 48.00... ... nee eee eee ee . one seen #i a qi ... wv. baa ad o~ ct te veeee 4 o, 11 at " " Stlewrent 11499 11499 Le. J bere Chimenie WwW i . al : G . we, ue oe 1 199 Nihertet, CP teed Vementage.s. oo... GIVEN GIVEN [terest .. bo Prores Prores make 1, a - ND chy : 6 ra | a weds as ? me = on o- It will be noted that the relation between dust exposure and the incidence of ground lung markings is not simple one Even if length of employment is disregarded as in figure 35 the incidence of ground markings is proportionately lower at 10 . 19.9 million particles per cubic foot that is at the next higher or . i - i | It i Fi t $ i b 60 next lower dust concentration Although it is probable that these differences represent sampling errors due to small numbers of expose persons it may be that asbestos fibers excite u different and possibly more severe reaction total particle count satisfactory measure asbestos dust than asbestos particles If this were true the tabulated above would not be a completely of the pneumoconiosis power of It is not unreason to suppose that the amount of pulmonary fibrosis might be more closely related to the weight of inhaled asbestos dust than to any other physical property of the dust The number of dust particles can be used as a rough estimate of the weight of most dus laboratory studies have shown that the two quantities are highly correlated This may not be as good a measure in the case Fon H 18+ _ PERCENT ao) PERCENT ete ada Oe L wo ot? Coron teres ye mees @rde eoore teense esene abeae LION P teaee eoecs Coons Obese tees Croce BEF reset : eeert arees: 7] a RELATION DIAPHRAGMATIC REPRESENTED FIGURE 37. OF PERCENTAGE OF PERSONS in Each DIAPHRAGMATIC FIXATION TO DUET EXPOSURE THE OR THIRD EXPOSURE GROUP WHO HAD FIRST FIRST SECOND Degret DiaPHRAGMATIC FIXATION HAS BEEN HEIGHT OF VERTICAL BARS REPRESENTED BY THE of asbestos because as table ^shows there are many long fibers in the dust suspended in workroon air The difficulties encountered in mizasuring fibers have already been discussed p 23 and only one additional point need be mentioned here A liber 50 microns in length is capable of reaching the lungs table 37 it would be counted as one particle in making dust counts and yet it would have approxie mately 30 times the weight of a fragment of the same liber univ i micron in length The 2 particles would have the same influence on the dust count but one would carry 30 times as much asbestos to the lung as the other if both were inhaled and retained Unfortu nately measurements of the weight of dust in the air were not made If they had been it is possible that the relation between ushestusis and dust exposure might have been altered =e oe 61 DIAPHRAGM During fluoroscopic examination of the chest the degree of movement of the diaphragm was observed and recorded The percentage of people with impaired diaphragmatic movement increased with increasing length of dust exposure and the proportion of workers with severe degrees of impairment likewise increased Table 29. Occurrence of diaphragmatic ^ zationin relation to million particle years of exposurei PERCENT Degreoef fixation Controls Millan Millan poeTILLO poeTILLO VEZES VEZES Lucht 251 17 Er NOM. occ eee cceo wee naa . eenee . ood wd as on 4 a 12 x ? 4 ' a Uy 1 a . e ' ' NUMBER OF CASES Derve of G81100 Million particle seats . Controls ' | Cewe Td. ide . . OW Nee te: | 1 24 2 e ii 190 a 162 11 i 3 o.-: wv 2 10 3 i 5 +1 12. 2 Qo tee 5 . 3 mtd 3 of labeled + The pertesisat values is the appre half of the take were solained by dividing the values total tested by the fronding values in Lha serwer half the labu This is shown in figure 37 where asbestos workers have been divided into five groups one of them a control group according to the tota amounts of asbestos dust to which they have been exposed during their working life Only two of the 76 controls had any impairinent of diaphragmatic movement For each group the percentage with normal diaphrag~-naticmovement and slight + moderate or severe +++ diaphragmatic fixation has been calculated These percentages liave been represented by the heights of vertical bars Severe forms of diaphragmatic fixation accompanied advanced stages of hung fibrosis Among 295 persons with degree linear lung markings 9,5 percent had impaired diaphragmatic moves moves nient Of the 2 persons with degree ground lung markings 68 percent had impaired diaphragmatic excursion This is a reasonable finding since lung fibrosis and diaphragmatic limitations appear to be part of the same process 62 Diaphragmatic abnormalities such as peaking did not occur to any significant extent in asbestos workers although they are common among persons with silicosis In a study of granite workers carried on by the Public Health Service 46. 87 Irregularities of the diaphragm were rather constant Forty percent of cases had evidence of it and as the condition advanced there was an increase in changes of the diaphrag matic shadows There were instances in which angulation of the diaphragm was in evidence and others which showed indications of extensive adhesions In a study anthracite miners carried on by the Public Health Service 51 p 58 Decrease in the motibility of the diaphragm as demonstrated by fluoroscopy was frequently observed ' This malfunction varying from slight to practical fixation increased with the severity of the pulmonary pathology Not in- frequently adhesions between the visceral and diaphragmatic pleura could be seen On the contrary in asbestosis with the exception of one man lig 45 there was no roentgenographie evidence of dia- phragmatic peaking It appears that the limitation of movement which is a definite part of the symptom complex of asbestosis may be due to inelasticity of the lungs and binding of the lungs to the parietes and the mediastinal structures by fibrous pleuritis See pathological section PHYSICAL FINDINGS The objective symptoms that are most frequently observed and most useful in establishing a diagnosis of asbestosis are general appearance of ill health particularly any signs of loss of weight the condition of the finger nails and diminished chest expansion These symptoms obviously appear late in the course of the disease The usciul chest signs seem to be limited to adventitious sounds Diminished breath sounds prolonged expiration and crackling rules over the bases of the lungs and interscapular regions seem to accompany asbestosis Various miles and adventitious sounds were heard in the chests of 5 percent of the persons in the control group R^leswere noted in 14 percent of the asbestos persons who haid nonual lung field markings or who had only degree linear exaggeration However in the gmup of persons with ground lung markings persons who had asbestosis 49 percent had r^les or other adventis tious sounds In about fifths of the cases r^les persisted after cougli Changes in the percussion note are hard to evaluate probably because the condition tending to give a dull note is unterbalanced by generalized emphysema which produces rsonatice The absence of loculized areas of runglomerate fibrosis and localizoil areas findings in which there is marked compensatory counts for the lack of more definite emphysema ol^>viously ol^>viously aes a we ewe me 63 CHEST EXPANSION Chest expansion decreases with increasing dust exposure and with increasing pulmonary fibrosis Asbestos men were divided into four groups according to dust exposure and the average chest expansion and the average chest girth at expiration were calculate each group The same men were classified into four groups on the vomer PHYSICAL EXAMINATION Rast. Spt ..crcewnee Bl.------- Wr .epeeee US L. . Jus and B ------- COPD WEE ceecerese> < sonesee --- Mad ker = Pepe peqeiel ....000--.-lewnpelas ...--assoceree MM wo ges B. 4. Gina... ares FAM nnnes ab. > Terent cn eene cen PUBFYR eroE ee------ . tom Gleads Gama. Parent.mai Carvel scasesercns Sem fom Gee oom oulrnee .. --- Pum weve weege@sg Sep ners 2 emcmmenne eee - erecane Pre amuerr. suave After & expen ... mm arr cemecenoctmmns Eee ow Tye Baeenns -. 2. oon oe core- san ererene be i Creumt.: " 4 > io oe re awes a Eee Guten ...-.6 ees - cnese eptees me ces eene eo eee a tn edd Geom! ents nn Searai waree of decors eoneee eos Bowes .---+-- ~_- Figure 36 FORUMSED FOR Recording Physical FinDINGS basis of lung markings and similar calculations were made The decrease in average chest expansion cannot be attributed in any luck of chested men in the groups with high dust exposure or mil- vanced pulmonary fibrosis On the contrary the averige chest girth increases slightly with increasing dust exposure and with mereasing pulmonary fibrosis Several factors may have contributed to the LN J A a . ( : - ~ 7 . i 7 ' t ; ] i _! | , fe 64 latter phenomenon and the availabl^' data provide no nieans for discriminating between them Since the trend is slight it may be disregarded The ratio of chest expansion to chest girth decreases with increasing dust exposure and with increasing pulmonary fibrosis Relation Table 30. of average chest expansion to dust exposure exposure in male ashe WCOFKETS test engeanenn. imenee rob at expiration expiration inches do elavaid vegre^-aronti c.rth y.. | Dust esposure Misthos particle vejrs e , . , ,to 45 to 99 Gree tee , au LTA 20 Ag. I 203 wie .009 ots 44 op Table 31. lution un anrinne chest ezpansion lu lung workings in male asbestos iraskers Lune In malices ChesterpagMJOB ChesterpagMJOB turhat turhat Difalion Difalion Inches Ratio of expansion to dinh 4 gree Pinteene 40518 fimilit fre vocue fej Fipcresecrpe Sec oytey fey Pee ececcneescs teeee our wr a od Fhe uO +6 S se wy 210 J. we Chest expansion tends to decrense somewhat with but the average chest expansion is less in advancing nge it is in men of exposed men than comparable age who have not been so exposed Table Average chest expansion of males sat liven Age Fap to taste ; : Number ktualn 1 HN Bee, ktualn ' | Avernee Chee oe i | brging Lampinred in brging Llib Theme i ee etter Theme Mul | PAPO 96h 18 Jual ater : | Kemi 11 | mre tS age | greup | ATTTHET Number of Meet... pe ...stuup Aurie steer. a 1110-400 | fects een facher el facher A - . 5) ferme 3 ned i we das, oot te as 44 oe ul he he I ony & 2 oe we ...... a. Jue BY ote 14 ^' <o Dae. 2 respiratory Externally the thornx shows evidence of limited diameter movement the supra- and lavicular lavicular fissae are the posterior diameter of the chest is increased conspicuous the angle may be more obtuse substernal fat be obtuse evidence of wasting or loss of subcutaneous may present certain of the accessory muscles of respiration respiration ow be 63 may appear to be hypertrophied In other words the general appearance of the chest is that of fibroid phthisis plus emphysema Among the conditions that may reduce chest expansion are pleural adhesions and the relative inelasticity of fibrotic lung tissue RESPIRATORY RATE The direct effect of pulmonary fibrosis on respiratory rate may be seen in table 33. Before the exercise the respiratory rate of males with ground lung markings was higher but not significantly so than the respiratory rate of males with first degree linear exaggeration of pulmonic markings The exercise test consisted of having the subject stand with one foot on a box 14 inches high and to raise his other foot to the level of the top of the box 25 times in 30 secomis The respiratory movements were counted during a second period preceding the test during a second period inmediately after exercise and during a second period 2 minutes after the test Exercise raised the respiratory rate of all four groups of men but the rise u respiratory rate was dependent upon the degree of pulmonary fibrosis the men with ground lung markings being affected most After 2 minutes rest the fall in respiratory rate was again dependent on pulinonary fibrosis The respiratory rate returned most closely to the preexercise rate in men with normal pulinonic markings or with degree linear exaggeration of lung markings The return to the preexercise rate was slower in men with asbestosis groundglass lung markings Table Relation of respiratory rate to lung markings in male asbestos Workers Average resurslary reta : Lune -fem) martiors Pere <treree beer fecwed cave sams | ria Avery le om : Secon.s deyne ***** *** **** Kins Number of H^ESAINur exCTURE Ilature exCTURE cece ee @ryPrese eo a teadntes altet exerting : QQ: 21 1 ] ; 265... eet eo we -1 30 411 ot 411 265 10 A BD itaeias 265 ...edOPtr . Stet we, sboee os came me Table 34 Influence of authracu on the wrsmesy | respiratory rute si authracit Averecy 1 Exista Exista Exista Exista Art. men. caddy Qmarenes oes ... ... ... ... ...... ... Ncserdame of teen 08 caeteet Stee It th to te expe we | 1. de altif edi 1. e diet fest 18 yee Pao he Jd lig to - --- a. -- eee The slats slats s'e enok sterftacje sterftacje dak Pakku Heth Heth Hucienu No N on PO a gto ts al - 4 ee ee ewe 66 Similar relations were found in a study of anthracite miners In men with anthraco the respiratory rate was definitely higher than in essentially normal men before exercise after exercise and after rest CLUBBING OF FINGERS AXD CURVING OF MAILS Many asbestos workers particularly those with long dust exposures had a deformity of the finger nails The terminal phalanges may become so bulbous that the finger resembles the end of a drum stick a condition conveniently described by the term clubbed fingers Usually it is accompanied by a downward curving of the end of the nail The affection is almost always bilaterally symmetrical and often involves the toes as well as the fingers It is conumon in pulmonary tuberculosis In bronchiectasis emprema and congenital heart disease it may be seen in its most exaggerated form Such exaggeration however was comparatively rare in this study In a study of 2.711 31 anthracite workers the deformity regardless of degree was observed in about a third of the workers having anthraco but was present in only 4 percent of the controls The real signit cance of the affection has not been determined Norris and Landis 62 state that in all probability it is a manifestation of standing toxemia associated with phthisis or bronchiectasis The bronchiec tatic and emphysematous changes noted in the asbestotic lung at autopsy probably account to a great extent for the occurrence of the change in the workers with asbestosis Table Number and percent of asbestos asbestos exposed workers who had clubbed fingera or curved finger nails classified by lung marking Lung markings 1 Degree of clu~bing BDU CURLI88 | Firu-seerws | | | ! bom i 89-9811 ; cd leers Berredsierray | Seung clas. Mod glu Tota t om. | | | t | Nun | i Per- cent Nuro | Nuro Nuro Pee sent NUTO- bet | Pee , : | Sume , t,or | | Per. wus p Twit se wetenece A ee niin PETE TTT TT POH eee + er Teen eee | atx 100 PTs ew a) i om de <vi om! i os sol 73 1 cree i) " ts se me: sy 4; 10 eo: ': 3! ad 1421 14 te 3. a. ue Pod wv. as on oa <l Five controls 6 percent had curving of the nails This percentage was much lugher 19.2 in the exposed group percent of the workers with first or degree field markings had this condition Thurty ground MEART DEFECTS Taking age into consideration blood pressure values conformest closely to the values found on examination of 10,143 10,143 male industrialindustrial workers 7 a 67 Heart defects were no more numerous than in industrinh groups in general They were tabulated in relation to dust exposure and pulmonary fibrosis in the same way as the impairments just dis Leo. % .Pe!wate opayo's =< - ue ot &, > 8 * tb. & J {.metd. | @ a eon bad Gasca 9 fam we Figure 34 PHOTOMICROGRAPHS OF ASBESTOSIS BODICE FOUND IN SputoSpn uton ENLARGED 530 TIMES Except E RULED IN UNITE OF 30 MICRONS WHICH IS MAS BEEN Enlarged 310 Drawn Drawn Beside Times A SCALE Each aseESTOS BODY enssed but no simple relationships could be found & careful caniza study including usbestos workers electrocardiograms was made Many workers with advance on one rases of grup ashistus ashistus fe had normal hearts and no evidence was fuimil which would reka heart imparments imparments imparments to asbestos dust exposure GS ASBESTOS CORN Asbestos corns are wartlike callosities 1 mm to 3 mm in size usually located on the palmar surfaces of hands or fingers and occas sionally on soles of feet or on the legs see fig 394 Their presence on the palmar surfaces of the hands is explained by the fact that workers on breaking threads of asbestos force tiny slivers of asbestos under the skin where it initiates a foreign body response This response is characterized by hyperplasia and hyperkeratization Table 36 shows that the occupations in which asbestos corns are most common are ones in which workers test the tension of moving threads with their fingers or in which they are obliged to break threads with their hands or to knot threads together Tible 36 Percentage of asbestos workers who had asbestos corns classifed | occupation Occupation Le Number mjinyel Numter Numter I. ateeng Min P oreo | BIER O Fe. Tye Tye and trLLE DS 1918M JOS Mieders Mieders and flashers 20... elec ceeeeeee te Cloth wifi .. cccce ese sce cence Crushers .. de eecevee winners winners Virn spiers and winners o.oo cece cee ceceeconeeeoebeee Mure and ring slugnen eee eees seteees . en eeene . cece a . . Carsete ce eee Present Stennersphers and clerki Pickers Pickers and pi Stennersl phers Stenersphers ae ndccws weee Wiline sau suadkermen.. and Cotte ole trindentrinden cecewee Fnemers and trinden watchmea Carpenters yarumen night Managers and supertalanoesta cece and watchmea seeeee- Preenipiosu ste teeees Total... cn ccrccccvecccoccsceeecseceanescc tebe smeees asceses Does bot include 47 recally harred work 33 15 e A 7) ty x . : ws ai e . : 182 182 ? 182 : e CY) ... v s ; ) ; 9 ang a . ay a -- e. * , : - . . U n Ty Ws Microscopically Dewirtz 10 states that the corns present a picture of slow chronic local irritation The horny and Malpighian strata of the skin nre increased Round infiltrationis noted particularly in the pupillary layer of the dermis Asbestos fibers or crystals are alsu seen and they are regarded by Dewirtz us the agent responsible responsible for the thickening of the rete mucosum busal layers and the giant cell formation Gloyne 16 has also found asbestos fiberin the corns but noter that asbestosis bodies of the type ^...bserved in asbestatio lungs and sputum were absent The workers liave themselves called these little tumors asbestos curns or usbestos warts Not in- frequently the corns become very tender particularly when pressure is applied to them in the course of handling tools or mai biners Cen account of the pain the workers will attempatttempt to remove remove the spicule of nineral with a pen knife or some other sharp instrument fl the fiber be meompletely removed it recurs with greater li per yy 69 because of the added trauma Most of the workers so afflicted insist that every bit of fiber must be removed before the corn is cured Only occasionally however is medical relief sought and in such cases Dewirtz 10 advises complete surgical removal LABORATORY FINDINGS ASBESTOSIS BODIES Unusual structures have been observed by several investigators on histological study of the lung tissue of men who had died from asbestosis but no detailed description appeared until 1927 when Cooke- Cooke9 and McDonald 22 published photomicrographs and discussen the conditions under which asbestosis bodies are formed Their papers apparently awakened interest in the subject and several papers on asbestosis bodies appeared soon afterward The following review of the literature on asbestosis bodies is fur from complete but it will serve to indicate the kind of information that has been put on record thus far There is good evidence to show that these bodies originate as a cellular response to an inhaled asbestos fiber The core of the body is an asbestos fiber which is surrounded by protein de its Apparently asbestosis hadies are formed only in the lungs pass ner have been recovered from the feces 36 suggesting that they pass unchanged through the gastrointestinal gastrointestinal tract They have not been demonstrated in the asbestos corns which form on the hands of asbestos workers 10 57a nor in the peritoneum of experimental animals 57 into which the dust has been injected Gardner 57 found the bodies in the lungs of dusted guinea pigs but for some unaccountable reason found them to be sparse in simi- larly exposed rabbits The bodies can usually be demonstrated in the sputum of patients with asbestosis although according to Lyneli and Smith 36 the sputum may be negative on repeated examinations even in established cases For cases of this type lung puncture 40 has been suggested as a dingnostic procedure Asbestosis bodies are variable in form fig 394 and in size table 371 Characteristically they are slender elongated segmented structures with bulbous emits which give them a dumbbell or drumstick shape Ocensionully a forked or Ymhaped body such as the one marked 11 in figure 39 is encountered A rosette such as the one illustrated in the center of figure 39 was observed only once in the examination of sputum samples from 281 persons Rosettes however are conquest in sections of lung tissue Stewart Tutersall and Haddow 41 SHY We suggest sputumn as feat keres the fohngs of large eluunp of clumps of gakoistunes gakoistunes bumbio Ph" desertslund desertslund is a clear militatem of disunti gration of bined lass an whether whether by a process of situ ile suppurative suppurative suppurative suppurative b^,vurdusjenjebm^,vuridusjetnjemists ES 15 Kit Aufst race race a residt somandnessomandnes tubs tubs romanas romanas infection6 infection6 tease alie te cum buile th">tHliere is also a defunt~ defunt~ 9sider9sidierivivng i9sidenrivingg askarslysis Cuote: Figure 194 YEARS IN THE EMPLOYED EMPLOYED 14 OF MOULAGE ASBESTOC SORN ON Thune oF OLD MAN CARD ROOM OF AN ASBESTOS TEXTILE FACTORY YEARS IN COTTON AND WOOLEN TEXTILE Milla 2x EMPLOYED t PREVIOUSLY PREVIOUSLY PHOTOGRaph PHOTOGRaph PHOTOGRaph PHOTOGRaph 7 71 The asbestosis bodies illustrated in figure 39 show some of the variations in size and shape seen in sputum smears Five of these asbestosis bodies A C D E K were found on the same slide This sample of sputum was obtained from a year mule spinner who had been employed in the asbestos industry for 7 years exposed to an average dust concentration of 8 million particles per cubic foot wonarve Because he made no complaint of any of the major symptoms of asbestosis and because his lung fields were second linenr no diagnosis of asbestosis was made The bodies labeled G and H came from another mule spinner a year man employed 2years in an average dust concentration of 7.9 million particles per cubic foot Except for a cough he had none of the symptoms of asbestosis and his lung fields were essentially normal In several photomicrographs of the asbestosis body the asbestos fiber may he seen clearly The bodies are somewhut fragile and frag- ments such as L in fig 39 often occur Unstained specimens are golden yellow or golden brown They do not stain with the iniline dyes ordinarily used in histology but they stain blue prussian reuction when treated with potassium ferrocyanide ve ' Asbestosis bodies can be demonstrated on sectioning z tissue Since they arise as a tissue reaction to an inhaled asbestos ..er their size is important because it indicates the length of the asbestos fibers that may reach the lungs The greatest length of the first ius asbestosis bodies found during the study of prepared sputum speci- mens was measured on camera drawings Every asbestosis body was measured and the frequency distribution of these measure- ments appears below Table Frequency distribution of the lengths of the first 165 gabestosis bodies found in spulum amzara 1s oma neOo + ve Laneth in MATTUALE it | Numbeorf Mion Isalam uf The bencih ' spention} os Lep in mNTORS Number of Ri wriee Pewter st ; Ile kenestkeeneste : measuresk . Takal measuresk oe cree ee sveees KA 117181 117181 70 Ly. ll. reer .. Mena VU ' Terre sett .., ..- winy ee : ee ey fee gee HO Loge AP eet, woe Yee 114 121 SS 121 12 ww ee _ . * _ : - -- ! cee - = Ocsbuy nee itd Cet Pen) 'we teat ER ee LOO SHIT MM eletiese tovlen in cpasiete. LAMJUE uitsputiit uitsputiit requami requami cunrestrated cunrestrated antikernija WILDESHENI WILDESHENI turented with with an equal vidu^-ieal antikernija antikernija ventrifuged as impart de nimed the antilumin a diguted uit and with the balkis the Riisturt Lereemg Beren Sa^-ade Saa^-ade U part jenent je sklaami sklaami time 5 drehbar drehbar ind FO Dirie The rules rules thaken thaken uri in safi b^' 89 U. 417 It is timin ult historisk itrinti an tilimgram lusel sad the historisk bruintet s^set itrintitian itrintitian With than ten tilimgram IN rifum rifum fwotas ... festment peastrum Junie gulured brilliant brilliant Nue It mainid 'Hail festment with peastrum terror Junie vn^"lakettia liberar sonil cuble the lalim are cuble yellow is colur 43102 18 72 The asbestos bodies ranged in length from 10 to 125 microns their average length was 35.1 microns After completing this series routine measurements were discontinued since this seemed to be i large enough sample to indicate the sizes of asbestosis bodies most frequently found The largest body found in subsequent study of sputum specimens measured 184 microns in length There seems be no completely satisfactory explanation for the absence of to bodies measuring less than 10 microns in length asbestosis Asbestos appears to differ from other pneumoconiosis dusts with respect to the size of the largest particle that may rench the lungs The largest reported upper limit of size for rock dust in the gold mines of South Africa and in the granite 48 and anthracite 51 industries in this country is 14 microns The data of table 37 are in harmony with concept that has been gaining support in recent years namely that particles beyond 10 microns in size reach - the alveoli Measurements indicate that the diameter of air snes may be from 150 to 300 microns in adults or in other words of such a size that asbestos fiber or resulting asbestosis bodies may be readily accommodated dyspnoea asbestos Asbestosis bodies were found more frequently in the sputum of persons who complained of a persistent cough than in the sputum of persons without a cough Thus is a reasonable finding since the of coughing tends to raise materials from the lungs act Half of the 56 people who complained of dyspnoea had asbestosis bodies in their sputum Less than a fifth of the 225 people who did not make a complaint of had asbestosis bodies in their sputum Almost the same relationship holds for a complaint of cough exposed Asbestosis bodies were found in the sputum of persons whose condition was diagnosed as asbestosis proportion 24.3 percent of essentially normal 46.9 percent of A much smaller persons liud asbestosis bodies in their the presence of asbestosis b^"ilies is evsipduentcuemof Tehxpuossuirteaptpoeaasrbsestthoast dust but it is not necessarily a diagnostic sign of asbestosis tosis bodies were found in the of Asbes to asbestos dust for sputum persons who had been exposed exposed as short a time n^3 months Of the workers employed less than 1 year 22.5 percent had usbestosis bodies in their sputum A larger percentage 38 percent of workers than 5 years had these bodies in their sputum employed mote In evaluating these percentages it must be remembered that they are based on the exami- nation of a single sputum specimen from each individual sperimens could live been collected and If severai examined the percentage of persons with asbestosis bodies bodies would almost certainly be much higher No asbestosis hodies hodies were found in sputum sumples from any of the 76 persons tested who were not exposed exposed to asbestos dsi | a, -_ om 73 The incidence of asbestosis bodies increased with increasing dust exposure Table 38 Relatioonf dust concentration to occurrence of asbestosis bod~-r~- . Number _ Number Percent Weighted dust exposure Number with esr with sates tasis bad as badia Total siposed 0104 0104 eer errrers Slave Slave rcserreeree o emer t l y cc eeeeees over .... .. wm a bead ve on 4 cl Pa! > ro ' 21 , . RESULTS OF TESTS ON URINE Each person employed in the three asbestos plants studied was asked to bring a hour sample of urine in a metal container provided for that purpose In addition to the standard clinical tests the silica content was determined by the method of King and Dolan 59 of the 416 persous exposed to asbestos dust at the time of the study unne analyses are available for 403 and these results have been kept separate from the results of urine tests made on 07 persons whose work did not them to usbestos dust expAolsbeumin was found in the urine of 10 of the 248 white males tested in the urine of 10 of the 98 white females and the urine of of the 17 minles tested Only one sample of urine from a white males negro contained sugar Benedict's test These rates of incidence are no than in the controls and insofar as published data are available higher than the rates generally for comparison they seem to be no higher found in industrial populations Tault Relation of urinary urinary silica to dust espraute espraute ees Unitary silice Control | - - Dun rca, meetiege GostFon ch reer - - atest Stetv =: jets eee _ sae _ oe ae : 4 3 heIeN ieee * ed . Millierms sili^nner K oe! swev Blase ot mn hint . worn: Millier Millier uns vad~t~ j~ isi . ae - Nunder tist ..e ees ee ek ee hydrated in concentrationsconcentrations concentrations ranging ranging from # 1 11 1 Silica was present urinary silica concentratiestas concentratiestas concentratiestas tie after tee ay: per 100 ec Average varied widely takie an ny 0 whose dust exposure Tes persons there was any simple relation between the exynos exynos he velo etic. that selasate ted the afte dust which consists of magnesiumit it ajjminto thee TS ee tea centration of urmary selima Rather centration The fund limiti " vinky Nine anal limiti jf buff ti. jodugu . alee FR ul oot t ieeet attendit om mwe ee .t ae .e ce ee o oe it exposed persons fluctuate above and below the value for the controls The total daily silica output was calculated by multiplying silica concentration by the volume of urine excreted in 24 hours these values table 39 also show no simple relation to dust exposure Urinary silica analyses are available for two other of whose diet groups people of resembled that of asbestos workers in consisting largely vegetables The urine of seven male college students living in the same city averaged 2.6 mg per 100 cc based on single specimens not hour samples An earlier survey of an industrial plant in Ten- industrial nessee made by the Public Health Service showed that the daily asbestos silica output averaged 29.80.9 20 mg a value very close to the mean silica output of nonexposed asbestos workers Diet plays an important part in influencing urinary silica concentration as King and Dolan 39 have demonstrated on experimental animals A predominantly vegetable diet with its high silica content leads to high urinary silica output It may be that the dietary intake of silica was so great as to totally mask any possible efect of silicate absorption through the lungs In any case the phenomenon differences reported by King and Dolan for gold miners 50 and by the Public Health Service 51 for anthracite miners nnniely a higher silica excretion in men exposed to silica dust than in nonexposed controls does not appear The urinary silica concentration of the asbestos workers is higher than that reported for the two occupational just mentioned and this appears to be largely due dietary groups Silica concentration increased with increasing specific The silica content is of course too low to influence gravity the specific gravity directly Instead it appears that the two values may vary concomitantly and that the drinking of large quantities of water for instance would lower both the specific gravity of the urine sub- sequently excreted and its silica content as well Tan~-rKelation of silica content of urine ^finspecific gravity cperie ; eravay I Aterly [ Number of Aterly Cerret Number xseey : Nah Item 819 | [ te | trr by 11.4 11.4 oo... 3 port porportt| 14 rr a 2 om 2 10 ~ tet . ......... 31 THE DIAGNOSIS OF AMNESTOGIN In preceding sections of this bulletin the signs and asbestosis have been treated one at a time or two at to show their relationship to dust exposure in this following sertions the symptom complex complex of asbestosis asbestosis and dust exposure will be discussed syniptains of time in order and the two its relatio^t relatio^t fes OU myaels dead tad a D D FIRST DEGREE -LINEAR SECOND DEGREE LINEAR FIRST DEGREE GROUND SECOND DEGREE GROUND GLASS FIGURE 40 PORTIONOSF CHEST X FILMS WHICH WHICH ILLUSTRate ILLUSTRate the Succes Sive CHANGES BROUGHT ABOUT Or CONTINUED INMALATion INMALATion or ASBESTOS DUST ad In order to show these markings on ^ larger scale than would he possible if the entire film were reproduced and to illustrate this system of classification Egure 40 has been prepared oO Symptoms cough tinged sputum pain in the chest weakness decreased chest expansion curving of the finger nails and adventitious chest sounds are symptoms which also occur in uw silicosis It is possible to differentiate pulmonary asbestosis from ome silicosis by lustory of exposure to asbestos the presence of asbestosis bodies in the sputum or lungs and by the type and distribution of the ray markings With reference to asbestosis bodies in the sputum the data show that they may appear after 3 months exposure They show evidence of exposure to dust but not established disease Lynch and Smith 35 reported difficulty in demonstrating the bodies in an ad- vanced case The presence of rosettes as ^...lustratedin figure 39 has been reported to be of greater diagnostic significance No advanced cases of asbestosis of the ridden typetype were observed in the present study Reports 13. 20. 26 32 of fatal American asbestosis cases which were relatively uncomplicated by the presence of other disease processes are essentially similar to reports of incomplicated British enses 9 14 34 35 Patients in the terminal stage are usually reported to be emaciated markedly dyspnocic cyanotie and usually have a severe cough with wiry mucoid sputum REPRESENTATIVE CASE HISTORIES Plates made from representative ray filins appear as figures 41 to 31. Roentgenograms of a normal chest figure 41 and of a chest showing advanced silicosis figure 42 have been included for purposes of comparison In figures 43 to 51 which represent asbestotic patients wre an abstract from the case history and physical examination accom- panies the ray In viewing these roentgenograins it should be remembered that the ground lung markings that are characteristic of asbestosis are exceedingly difficult to photograph and reproduce It will be noted that the distribution of the shadow-shadow- is not quite as general as in silicosis not quitPE EeVIE sathracite zike ich PE EVIESUNEs hat s~-k~-tlahrorlier in the sputum af sathracite miners but they seeni tudjarfet tudjarfet muffi akumuffi aku nally from aleshimik aleshimik kolies 2 ee we cae TS TS FIGURE 1. NOPNAL PULMONIC MARKINGS WHITE MALE AGE 23 decorating Note the linear type of pulmonio markings usually usually seen in the clust grain of an average industrial worker not exjament tu a dust bazstrel had worked d years in the decorating decorating department department of a pottery and general outilour lalur roalgenos roalgenos The man 2 years at oe mi FIGURE Silicotic PULMONIC MARKINGS WHITE MALE AGE $ Note enarse nodular appearance with beginning evalescence of these shadow in the upper half of the left Musicrate Musicrate engslivsenia engslivsenia fwith ligses and shight shight men ... tinal distortion Nodular quarkings of the type bere shush were hit hotel in @ tiplov^'es FIGURE 43. EARLY ASBESTOSIS WHITE MALE AGE 29 Occupationni Occupationni k~-story Carter mainstem 4 vrare nondusty tezdes 31 Estimated ilmat r^/posure35.3 million jurticks jet eubic fout veare thy Multime particle year 1.19 No significant past nirilical findings or complaints interin~ dinte 120 Physical zasmination slender white white male Begin 171 weight 112 pounds Rather look chest expansiun 2 in~ lies inches Nu change in fremitas breath wounds or pereissamm note Skummi jiremsure 16 11 the rate 96 and 20 before immediately after mod 2 minutes after funetus.l 74.3 Urinary vilica 5.2 mg per likhre likhre li^ urmitjut 34 mig SPLTLEIS nirmalysia nirmalysia negative specibe cravity 1.020 glass N ingdegree proumi apkarame not quite obliterating the Sinear markings markings Note the Me elusesset reticular routen markings markings just oil cach luksuzn and the apices fentining qiate clear turquiniis Jaunt clisease kariastestosis astestosis without without symptoms symptoms complicats 1 key disquirtotdiisqauikretotisake disquirtotisake . oy FIGURE 46. EARLAYSBESTOSIS WHITE MALE AGE 39 history Occupational Occupational asbestos 1 year exposure Estimated dust first b Million Mule spinner asbestos last 15 years roving attendant nundiusty trades N'i years . Weighted average 10.5 million partieles per enlac partirle years .2 Pasi Shrapnel wound right parietal region of head October 1915 Bilateral pupumunta sa a child Componen Shitgls it weakness later~-neliste f'hysicul cammination neles weight 144 juuniks build fairly well sourished Neight 66 expansion 32 inclus Whoool girematite 136 22 Pulse rate N3 121 and 54 and respiratory rate H6 24 and 18 trespectiveTS fare inuwihiately after and 2 minutes after functiuni exereine fest Torta P mediate chest type with slighit mervase in P chajeter of clust How many sistent crackling r^les at right hase ^ slastoscorn on palmar surtaev ul left disky wrist Sight evamisis of lips and nails A disky reil cast be mate Spot fulmientoure negative for 11. fulmientoure and blushes bodies Umary silica 3.4 mg per 10KELA 124 hours 21.5 mes Fluornscupu Muslerate 2 l1imitation uf diaphragmintie excursion mumderately me^-esselin size and density Mhda Neran Nate the legre gramy or granituleglass apparzanov apparzanov mot odhalito ro ating the linear markings giving giving evneral evneral retientar apparaitaiva apparaitaiva la lang thiels thiels Generalized Alihisis Diagnosis Askaristuses 2 FIGURE 45. MODERATELY ADVANCED ASBESTOSIS WHITE MALE AGE 46 Occupational history Unisicloth vionsly in nondusty trades owe dual Friimated exposure exposure .rear finit b Million partiele weaver asbestow 7 year ^ months k^year including 10 years as farmer Pre- Weighted exposure 15 million partieles per enbie 109.2 Dry Thimml mediak Tonsillretutay Complaints 1919. Pleurisy right March 1926 lacking inormning euugh for 3 years prudtetive thick muevid aputurn Slight dyspnoea 2 to years tinged sputum Pleurital - Zamsuntian Heiglit TO'~fl TO'~fl inches Weight Hi^- passoseks Thimml sure 150 kg Pulse rate 72. SS and % respiratory rate 24 % anul 23 tipus imuushiately after and 2 Bunites after functional define define pleted only about half of finemeritust exercise listi Clust Patient room somewhat somewhat rounded expansion meli Crackling r^les livard over both lungs Shoulders and these parxist aftir quigli 2+ curved fingve nai 3.1 mign sqin liecat pberrea1t0h0invge See Fluoroscopy bowel. Fluoroscopy Taft side of diaph~-rar~-ni~-noves mure freely than right 2 = h~-mita- tion of rzeUP Xerally on right pinponderance ran Sinowa second ground opwaraure ediliterating usual buvar pulinomie markings also shows pinponderance of fibarusas in the tunes of uni chaggy appestaden af heart shadow bung bung Dinguusia Astrostosi3s tauosterately adv~ nessly ot Ges cone FIGURE MODERATELY ADVANCED ASBESTOSIS WHITE MALE AGE 40 Ey history !,Ocyceuaprastioindalle 4 years Mule spinner asbestus last 13 years nondusty trades exposure -. Fatimated dust Weighted average 13.5 million particles culie foot medical b Million 173.7 per m~ particle year Past Intivenza and pineumonis 1919. Complaints ComplaiNnotnse disabling Froquent disabling colds Physical examination Intermediate Physical 156 ponnils examination white male Height 20 inclus weight Intermediate elist pliaji expansion 2 inches Dry musical r^les over haven of lungs Urinary silien 5.6 mg per 100 et buur Spuitum not examinst output B j"ugi Fluorscopy Fluoroscopy Starwokslight limitation of diaphragmatic exenf left with degree diffuse ground right right and Sliuw's firstalerne granular appearance of the lung fickle markings it illustrates the line appearance int odsliterating the duvar reticular fibr~-man gamiciated with tiim conditum Burl the tendency tu l^r most delise at the bams of the lines Hiugnosis Aalm~-st~-~-s~-s Aalm~-st~-~-3s~-s * _ I. -_ FIGURE MODE~ATELYADVANCED ^ SBESTOSIS WHITE MALE AGE 49 Occupational history Mule spinner sabastos 25 years working 10 to 11 louTS a day nondusty trades 9 years. exposure Weighted Estimated dust average 7.9 million foot cubic b Million particle year 221.2 Past Typhoid fever at age of 11. Influenza 1918. particles per Dry pleuriss right in 1931 second attack in 1935 on left More than average nuruber of chest culis each year Kidney colie 1931 Complaints dyspines empecially in elimbing stairs Might morning emieli jast to years jirvuluctive of small amount of white frothy sputumu Physieni examinatiToalnl fairly developed man Height 70 miebss and weight 172 points Blood pressure 140 80. Pulse rate 80 1131 and hit respurs atory rate 24. 32 and 24 respectively hefure immediately after aint 2 minutes after functional exercise testi Chest is loug and well develujast with mine flaring of the cintul inargins Chest expausmin ?; inches Numerous ~ tarklingr^les at liases on deep firestlung and after enuigh Sputum ^>single speenumit was negative for send barille and aslastosis inalies Urmary silica 31.2 mg per 100 ve 124 linie unitjurt 23.th much Flurnenpy Fluurnenpy Daphragm almost fixed and lung Bells interpreted as showing a legreo_gromel legreo_gromel appearance Neray Nottehe line gramy or ground appearance fairly tu the lower thirds of each lung held well limited Hinguunis.Hingunis.AAdl^stusindHilng^uuniss.Atdl^usstuisinn] ae 8 seg . FIGURE MODERATELY ADVANCED ASBESTOSIS WHITE MALE AGE 39 Occupational Broadclotli loom room arberton 14 years nondusty trades 7 yean Estimated dust exposure Weighted average 40.7 million particle- euhie Sentical Past particle thy Millum years 439.7 Sentical Hilatern^>pueuinemia an a child Binus disease for the years Typhoid fever 1911 years . Complaints hacking morning eauch productive of 7 ounces of viseid sputuu past 2 years Shortiums of breathi 2 year per pa 2 white Physical 'zeminationFairly developril sieinker white man Ilright 72 inches weight 163 juanels Ilani premure 104 70. Pulse rate tib Th and us Hespiratory rate 21 2009 and 30 Oxfore immaniateir after and 2 minutes after Fluoropy Peaking functional exercise tests thest as hung sletuber type Expansion 12 inoties fleart sounds are distant with a pillimine sevmich tuathsound somewhat somewhat accenactcentuuatedaacentuaed tac enetuatedd of the diaphragm tuath sides 3 em excursion upwar forced respiration ray. Nute the deformity of iliap~-l~-rak~-nThis ense is the only one showing showing Pringnutis adsaneni definite deformity in the gr~-m~-n The hunt Gelds were interjintisk as claw ang degree diffuse grauy or gmumul glass atquearance with emphysema emphysema Manderately adsaneni zaliestimin zaliestimin galant~-m~-3 n 86 FIGURE ADVANCED ADVANCED ASBESTOSIS WHITE MALE AGE 48 history Occupational Mule spinner usbestos 17'1 years 1 years in same rouin with carding machines 11 years he worked 11 hours a day nondusty trades 17 years 3 Estimated dust exposure exposure particle enbie fout 6 Million particle Weighted average 10.0 n^"llion partieles per years 103.8 Pas Frap FrapeuteFru apet ut chist colds about 1926. Influenza 1929 and 1932 Aerophagia for several years Malaria Complainta Complainta 6 years duration puumibly somewhat improved since quitting work in astuston Bevere proxysmus of cough in morning rausing hum ta vanuit frespicitis anil productive of sn^/llatmoulit n^tens~ ionisfiuend Moderate rly spationa sanien 1925 unchanged Lumi 15 to 20 sputam associated weakness builure quilting work its gekunsten pounds in weight and of Physical ezumination Skuter fairly developed and nourishest white male Height 68 mielies wright 131 pasients Iather long narrow rhest ^ hest expansioli ' J^'lies Tactile ant your fremutus spiparviitle normal Slucht tripsurist resnice luner half of each Int Numerous persistent stry crackles mostly over half right and left lower portions of lungs curving finger nails Faint breath kilonul animis lawer unes primaire 135 50. Pulse and respiratory rate respectively 72 100 and 88 at 24 32 anel 28 thefore immediately after and 2 minutes after the functional dysjuomia dysjuomia fusilawing this exertise exercise fist Urinary silica tuule Moderate rc Sputini incative for acidfast barilli and Belushimin queimen kuskus 2 mx jar luu Fluginaenjoy Fluginaenjoy 2 2 lag of rhaphiracuatie expursuit right and left radiulurenev lower lung fields Hathor just Sheis Nazare lation of lunar funguases Sheis sseeinil grains apwarate apwarate markings Cinta Pathizel Klitosis estabilistiest Well Well estabilistiest estabilistiest astmistasis i with almostalmost congiurconegiure abiliturs + FIGURE ADVANCED ASBESTOSIS WHITE MALE AGE $$ Occupational historyhistory PrepPraepraarattiioon n department fazlastimi 14 years tenebisty tenbisty partirken 27 Wischted average 38.9 mimilllluumm partirken per tradies years ass dust exposure Estimated Estimated ~ d~ Typ^>nach partieleiyvars cubic fuut 6 Millun draujant in 19630 Typ^>nach feverava feverava et .1 Maxillary sitinisem of 2 mmuters of smite 11 medicalDry Past 11 Complaints euch 10 years pevainctive unere dvaputoam of vege smite reek over a period of 24 units Rather O Chessnnial isteina oil a 8 o w F ren aputuin to dis spisma prevent walk very slowly lai years vzemination ilright Phusion Muterste artufmalt~-m~-n 112 70. Muterste artufumalatar~tufu-malmat~~-m~--n n sit a SUITO % 54. ami 31 lebury Tidurskateis rate of -tique test Patient exercise but expressat a mete exercise is kalninni s^>st shatova twin Breathing half of twin b^>m^'ssiter + sa over the lower srut wun ^t with the the morti~ utunk spud a oe ate First sound at the ajut secund curving of the finger snla^ilsbemse da itateis a peed Fluoroscopy Aurtie yy inest markings Fluoroscopy on size kap~-dag~-m 1+ inere exentsioni exentsioni em on furent ehatfsawe ef inest markings buayan finetly inest markinAgdsvamncaerd kAidvnagncsed Advanced asta Lingmuaja. Lingmuaja. ee ew Toe eoe tt, < o ee . ; arte an . wee ae anes T ee ee re eo FIGURE ^ SBESTOSISwith FibrOID TUBERCULOSIS WHITE MALE AGE 38 fecupational history pinner sabestum 11 years & msomitlis nondusty trades 12 years nondusty Fajunnied dust exposure Weighted average .9 million partieles jur envie foot nd b Million article veam MA.M5A.5 nd Bervived sanatorium treatment for tulierenkim^s 8 months in 1930. Had pemmuma Ars child Appretidectomy in 1916 ezamination Very Compensata. Dry einigli past years worse at night Flight dyspnoea S vears kusioni thin man Wright 131 pounds liberi ^ i^-ssuh 100 701 Pube rate 72 NO and GS Nespiratore rate 101 166 and 21 talore immediately after and 2 minutes after fivetimal exercise testi Asthenie FATA of chest Some defurunts of rhest dise to scrlieman Clust expansion 21 mebes Breath saminids are slightly increased over the extreme right upyn~ Very few dry r^lesright scapula fissa Heart The pulmonie serumid sentnich ia min~ t grenter than the aortic mtuml Flu enerupu. Fluenerupu. Fluuenerupu. Diaphragm muoves freely and expially expially in both sales On respiration fureed respiratriespoiratnion exPutsuu exPutsuu is raion right andil d'emiackett d'emiackett d'emiackett d'emiackett astentam~-z astentam~-z with fibratie Dungunars Minderately aidsatieval aidsatieval with artistest fibratie tube Perdisip i INCIDENCE OF ASBESTOSIS ay Preceding sections of this bulletin have stressed the importance of the ray findings in establishing a diagnosis of asbestosis The reason of course is that ray examination is the most direct means now available for detecting the primary effect of inhaled asbestos dust on the body namely initiation of interstitial fibrosis of lung tissue Classification of asbestosis into a series of stages which follow one another in their development is a difficult matter because it depends to a great degree on the interpretation of relatively minor changes in the lung markings Other investigators have encountered the same difficulty Lanza McConnell and Felinel 17 and Fulton Dooley Matthews and Houtz 13 set up a - category of doubtful cases of usbestosis Stage 1 in the accompanying tabulation i ^,revir less corresponds to their category of doubtful cases It comprises coses in which diagnosis rests largely on ray evidence Stage 2 presents early cases of asbestosis and stage 3 designates moderately vanced cases More advanced cases stage 4 are relatively infrequent Stage 5 was reserved for ridden cases ne markings Table Relation of asbestosis to lung se re indiag t AtherAtohnesrtons . Bug of LOR ; a 'f[a!oa Tall Total I 372 | | * t a 1s 44 ooo... : begrav Wma? ete ee scene mm. tues... Paewccasecceses cae Gemmrn ureree | |-seeee- Fores ctomrwe wowed fi o on cc e. ccass gine... Recend<searer E7OUR .cs.cceece! Vssecssese- a 31 i 6 u '[ovecconene 2 | sees eseeeee bbeee sees l rere a: : ot y a Table 41 illustrates the relationship of stages of asbestosis to the ray findings Although diagnoses of early stages of asbestosis were occasionally made in the absence of definite ground lung field markings when rough dyspnoen and objective findings were present in sufficiently advanced degree diagnoses of the later stages of ashes tosis were not made unless unmistakable ground markings were present in the lung fields The incidence of asbestosis increnses rapidly with increasing dust fifth exposure fifth of the workers with nu exposure of 30 to 991 million particle years and half of the workers having an exposure of more FOR than 100 million particle years had asbestosis In comparisonstali - anthrarissiliensis these are exceedingly low dust- xposure values 50 90 The relation of asbestosis to dust concentration and length of employment in table 43 is of great practical importance because it shows what working conditions are most likely to cause asbestosis and how long a period of exposure may elapse before the disease becomes evident Table 12. Relation of asbestosin to total dual exposure Diarbasis Million part riyears e . | Iban Iban 10 19 Over 100 Trial Essentially . normal ATL A eree e ees Retesicere Jo. Avewene 0, babmi 4 t acetcw cm cesar rececenees 191 r 3] $ : L) \ v LJ v 9 ...| Sn steers iw, M a 4 1 v & a: 13 a F | : 10 pod Pad rag 5hed : 441 reznsure r^,ksngfick se reznsurezrnsuere could but be estimates estimates and persons with active pulmatary breg esciugeg from t~ utalant . na tuberculous + Table Occurrence of asbestosit in relation to dust concentration and length of employment PERCENTAGE WITH ASBESTOSIS Dust exposure million particias pet euhi~ last Years 18 asiwmos lustry 10 99 1 Oter in 10 eer 9.9 Over 10. enn Ey een RMU, se scosneen ee! EOPOTOPOTS 52 1... EES Emm (Peramtage......cccccce ' Aflerted .....i Cig Purweaniagt............. a TT AENWUMS, ccncsessscceee senterseeveesi 2: . fom a b .] om, a im Cay 5555- 55- | 39. 39. 39. 30 aH 300 300 | 300 i ry 3 oy 13 19 or: +3) y oe The percentage of persons with aasbestosis increases greatly with increasing length of employment Lanza McConnell and Fehnel 17 reported a similar trend their percentage values are higher than these There There are two explanations for the sinall number of persons employed 15 years or more This group of asbestos textile factories has been in operation from 6 to Hi years and because of the relatively short life of the industry in this section of the country comparatively few persons have been exposed to asbestos dust for long time Another explanation is suggested by the fact that almost fourths of the workers employed more than 15 years have the early stages at least of a disabling disease asbestosis Since there is no satisfactory way of locating and examining persons who drop out of an industry becuuse of disability incurred therein the percentage values of the foregoing tables are necessarily minimal estimates of the prevalence of asbestosis . J ee 91 Pennsylvania The incidence of asbestosis increases with increasing dust concen- tration In their report of a similar study carried on in asbestos textile factories Fulton Dooley Matthews and Houtz 15 found that 8 percent of the workers exposed to an average dust con- centration of 5 million particles per cubic foot had asbestosis 22 per- cent of the particle group and 37 percent of the million- particle group had asbestosis THEESHOLD CONCENTRATION OF ASBESTOS DUST From a practical standpoint one of the most important results of a medical and engineering study such as this is the definition of safe working conditions in the industry under study deaily a threshold concentration of dust should be the highest dust concentration that | life The would not produce pneumoconiosis in originally healthy workmen during their entire working chief difficulty in this study as in most of the earlier studies of the Public Health Service is that very few workmen are exposed a long period of time to low con- Because centrations of asbestos dust of the importance of the problem it seems to be desirable to use such data as are at hand to define tentative safe working conditions conditions that may serve as standards for the guidance of factory manage data are available 4 and engineers until more complete In an analysis of this kind the cases that occur at relatively low dust exposures are of especial significance because they indicate what the zafe limits of exposure may be These cases must be examined indi- vidually as well as statistically in order to be sure that there are no unusual features that would complicate statistical analysis Below 2.5 million particles per cubic foot the interpretation of table 43 offers no difficulties None of the 39 persons exposed to dust concentrations below 2.5 million particles per cubic foot had a case of asbestosis although as a matter of fact only 6 persons had been particles employed more than 5 years Three doubtful cases of asbestosis fell in the range 2.5 to 4.9 million Because clean cases of asbestosis were found only in dust con- centrations exceeding 5 million particles per cubic foot and because they were not found at lower dust concentrations 5 million particles per cubic foot may be regarded tentatively as the threshold value for asbestos exposure until better data are available In order to find out the levels to which asbestos concentrations have been reduced in practice an engineering study 7 was made in an asbestos textile factory in which dust control equipment has been recently installed This shows that means are already available for reducing the dust exposure of a majority of asbestos textile woric~ ts to less than 5 million particles per cubic foot 92 The data of table 43 provide a simple means of comparing asbestosis with other pneumoconioses In a previously reported study of the Public Health Service 51 it was found that workmen in anthracite mines could be divided into three groups which differed with respect to the nature of the dust to which they were exposed The percent- Percentages Table 44. of workers raposed to certain concentrations of asbestos dust nsbestos in lextile jactories where dust control measures are ward to a itimited extent and in jactories where effectire dust control is practiced F Ditzimn Ditzimn particles per cubic inot Limited - Exten od of dus dut st control lus lut st conte measures eponsures ? Over 10 * eeeeee . $ ,. ** bo secae 45 17 17 Dhteae 45 BY Unde2r4 2 oo... Date from sahip 43 * Data iton 2. ages of men having any stage of anthraco 1 2 or 3 have been tabulated separately for each group in relation to average dust con- centration and length of employment In pas g it may be of in- terest to call attention to the difference betweer the pneumoconiosisproducing power of the three kinds of dust encountered in anthracite mines If one compares groups of men with the same dust exposure and the same length of employment in general the percentage of men with anthraco increases with the free silica content Table Percentage of men having autkruen & 1,425 rete mince espond to dust enne faining by than enne parent free Salage Dus maint in million quar 1 digles jet bie kant t J Ya Ibistry * men t Oo Prised who 131 1131 Mek Sprettfe oy. Bad Bad te rust ... Pram ... ...ton obened Spret fe Ad Qeree. Containing show i Pevwees Gee tists ... Sve tine ... ... ...... . Y'esm is inplustry | Yram in Hindustry than { t i] i than 13 t (tseazes + OY s Jom cian 1310 >! 5 . | Tome + ... 406 ... ter ... ... 2 cs . Steorme , fe@e tes a8 cee ee . wet Jum ** FILLYW FILLYW Sees OE tea. x is OS 16 ft Ce 7) 1 ca weloogeh wo: * as fo] rn Ch a 33 w. " oon ey amas se tes nee Tha wwe sta O broth Lak">pLak">p Lak">p th Post Hemitle Bulk No. * Lane titan IMEN CLABjurst 21 As in asbestosis the incidence of pneumoconiosis among anthracite miners increases with increasing length of employment There is al fe much more definite increase in the incidence of anthraco with increasing dust concentration than there is in asbestosis probably 93 because men were exposed to a much greater range of dust concen- trations in anthracite mines than in asbestos textile factories In comparison with the three kinds of dust encountered in anthracite mines relatively low concentrations of asbestos dust and relatively short lengths of employment in the asbestos textile industry result in pneumoconiosis There was no free silica quartz in the dust encountered in the asbestos textile factories According to table 43 16.3 percent of 69 former asbestos workers and 378 men and women employed at the time of the study in three asbestos textile factories had asbestosis Persons who were not exposed to appreciable quantities of asbestos dust have not been - included Eight percent of the 375 workers employed at the time of study had asbestosis This does not completely represent the incidence of asbestosis because about 150 employees were discharged from these factories 13 months before the present study was made Many of the discharged asbestos workers had asbestosis us the reports of Shull 31 Donnelly 12 and McPheeters 23 show Although an attempt was made to examine as many as possible of these discharged cases only 69 could be examined 43 persons of whom had asbensis asbensis according to the diagnostic standards employed in this study Que assumes that the number of persons employed in these factone was the same before these 150 persons were discharged as it was when the study was made and if one assumes that 62 percent of all the dis charged cases land asbestosis then 50 cases of asbestosis escaped observation Adding these to the 73 that were found dividing the sum by 447 and multiplying by 100 gives an estimated percentage of 27.5 This is not an unusual percentage value In numerous studies of the dusty trades the percentage of workers with pneumoconiosis has been found to be between 20 and 25 percent Two such studies may be mentioned Of 7,722 miners and men seeking employment in lead and zine mines at Picher Okla who were examined in 1927 28 49 21.3 percent had silicosis In a study of anthracite miners 51 The prevalence of anthraco among the entire group of em- ployees was found to be about 23 percent Other investigators have reported the incidence asbestos textile factories Lanza McConnell and of asbestosis in Felinel 17 re- ported Of the total of 126 ray examinations 4 were diagnosed as second asbestositsi^ as first degree 39 as doubtful and 20 n negative The persons he studied were selected more or less at those madom from among having more than 3 years of employment in the industry Since Lanza did not examine all the employees in the factories he studies perrentage values calculated from his data are directly comparabcolmpareable with ratoef incidence for the present study 94 Fulton Dooley Matthews and Houtz 15 noted that Asbestosis was found in 14 persons 12 men 2 women or 25 percent of the : exposed group INCIDENCE OF ASBESTOSIS IN DIFFERENT OCCUPATIONS The percentage of persons affected by asbestosis varies in different occupations The numbers of persons employed in many of the occupational groups are so small that caution must be exercised in making comparisons but the data seem to be of sufficient interest to warrant publication Classified by departments the preparation department has the highest percentage of asbestotic persons Card- ing is the principal occupation in this department Although only s of the 72 carders had been employed more than 10 years 29.2 per- cent had asbestosis Eleven carders had advanced asbestosis No other occupational group had so large a proportion of advanced cases Table 46 Numbearnd percentage of workers haring asbestosis classified classified accord- ing to department and occupation Department sad occupation . i . Number Percent o Numbgered. pdalOynes . : Number Number with safe lace deres. AAtverttvert i ,> , Willower end sis ker me: Povcers aR [HUrh...ccccccercocee- seeeee Caron... . | -| wooeee 0 a Q: i) e. a- " Spinning Lyytint Lyytint and windi" seeee- . Mole and ring puaaer .... cn een eee e ne eewcc ones case tencenee Tmurnsers and tinders mrs Corvers... TATIAE *; 8 2- z :. s fi aa) ween pacers ave h Woecert,.. Tatehand brake Cremer, 2, nc swcvccsconcce: eee ereseneses using wMYFTI wMYFTI 4 4 e n Frasher eee peters miremierers and Bhistor Feats AAS e... REM cewevI ereccccs oonng . Kurerinvepenes smel wnilery,... ccc ssc ecccecessesees Liepeprere stich om rtawte bd. cece ce eee w ese wc ew sence Ull-ow aseed CR I@TR. vee ee coe cove revevece eeveees ~ se seceveees i Bo : eee. A) a 17 o " 312 11 @' Oo, LW = 1 Cy ss " rn " ry - In the spinning twisting und winding department the mule and ring spinners huve a higher proportion of asbestotie persons than the average 24.6 percent Twenty of the sixty mule and ring spinners had been employed more than 10 years Ce third occupation with an excessive prevalence rate for asbestosis is cloth weaving in which 25.6 percent of the workers are affected Only of the 43 workers hand been employed more than vents 95 ABRESTOGUS IN GREAT BRITAIN AND IN THE UNITED STATES Lanza 16 has called attention to a point of interest namely that British investigators have found asbestosis more severe and menacing rd than it was in the United States He adds that this difference is ce probably more apparent than real Lynch and Smith 20 have reported 3 fatal cases whose duration of employment in asbestos textile mills was 11 17 and 21 years in occupations having dust exposures of the order of dry weaving Stock 32 reported a fatal case in a man 27 years of age who worked 8 years as a carder in an asbestos plant Egbert 13 has also given complete findings of similar case in a man 30 years of age who hod worked 13 years as carder and who died 4 years after onset of symptoms and 3 years after discon ; tinuing work These examples of American fatalities some in young individuals suggest that the period of dust exposure before disability or death ensues is as short as is the case in silicusis Bridges 63 in the factory inspector's reports of Great Britain has shown from year to year table 47 that the duration of employment of fatal cases with asbestosis is only half that of cases with silicosis Table Silicosis and asbestosis in Great Brain Brain Number Number AUPPINE JE 01 JTALD | : 'ination femijenit femijenit femijenit 10 M .: + mum + , 31.M muin QYPTQAYRPOTARO Through 1933- 1 Through toe. occ cc cece cress saeeeee. cccceereeececees Guawie Oh tahercusmasd. { BPI Asbestoia coc cce ee fulareuine cece Asbestoia with fulareuine oe asak asak ' Qt: mw aR. a, i 2386 2386 2386 2386 t & Pd Py 2 on us ... ant 12 8 More than 90 percent of the raw mineral used in the manufacture of asbestos textiles in this country and Great Britain is Canadian chrysotile indienting that very little difference is to be expected trona the standpoint of biological reaction in the two countries As mear as dust concentrations in the various operations of asbestos mamulaetme mamulaetme of British practice can be compared with results adatained in this commis try no greater differences are toumil than exist in the inherent limita- _ tions of the samphez desiers desiers [ would seent therette th">t negligible differences exist quite pointthe here and abroad with this in the manifestations ich time disease disease exception exception of associateek or complicate complicate ing tuberculosis _, PATHOLOGICAL FINDINGS IN ASBESTOSIS Specimens for pathological study were furnished through the courtesy of Dr. J. Rush Shull Charlotte N. C. and Dr. H. F. Easom director of the Division of Industrial Hygiene of the North Carolina State Board of Health The pathology of asbestosis is characterized by diffuse interstitial pulmonary fibrosis and by the presence of asbestosis bodies in the lungs GROSS APPEARANCE In gross appearance the lungs vary in color from brownishi to pale gray Usually they are not distorted like silicoric or anthraco silicotie lungs unless an extensive amount of standing fibrosis is present Often the lungs are firm and heavy but softer areas can sometimes be felt on palpation Crepitus depends on the amount of fibrosis The pleura may be thickened and fibrous tags may be scattered over the surface In the cases described in this report thickening of the pleura and the presence of fibrous adhesions are more frequently found on the right lung than on the left Adhesions to the diaphragm are sometimes present On section small dark gray irregularly shaped areas are seen on the cut lung surface They are rather evenly distributed and they ewm are of approximately the same size Visible strands of connective tissue of varying size run through the lung parenchyma forming a ee more or less regular fibrous network and enclosing the dark gray nodular areas and lung tissue which show alveoli Areas of well- marked emphysema are noted in the apices and outer portions of the o lower lobes a feature that was referred to in the discussion of the ray findings The bronchi and bronchioles appear to be distended and their walls are often thickened In one ense this bronchiectasis is most marked in the upper lole particularly in the apex Congested arens are oerasionally seen on gross inspection of some of the lung sections They are probably terminal The hilar lymph nodes are not markedly increased in size They are pinkish gray and contain about the usual atuoint of anthracotic pigment found in city dweller MICROMEOPIC APPEARANCE The pleura when thickened is made up of adult fibrous commeetive tissue cells The collagen fibers are usually well developed and may show hyalinization In some serions the thickened pleura is vascular 1964  97 the blood vessels generally being small capillaries Areas of variable size containing anthracotie pigment are occasionally found in the subpleural connective tissue Throughout the parenchyma of the lung a diffuse interstitial fibrosis is present which varies with the asbestos exposure of the indi- vidual The areas of fibrous tissue are irregular or stellate in shape and may contain small blood vessels The cellular elements consist of adult fibrous tissue cells fibroblasts some collagen and often numerous macrophages The strands of fibrous tissue represen an increase in the interlobular connective tissue The fibrosis is usually rather uniformly distributed throughout the entire lung In areas of considerable fibrosis atelectasis is noted due to the contraction of the fibrous tissue The alveoli occurring between areas of fibrosis are generally distended and show a moderate to marked emphysema The alveolar walls are thickened by fibrous tissue and in some sections hyalinization and the loss of nuclei occur The alveoli are lined by single layer of epithelial cells The bronchial walls and the walls of the bronchioles may be thickened and a slight to moderate lymphoeytie infiltration is present occasionally The smaller bronchi and bronchioles are frequently quite distended The walls of the small blood vessels are thickened particularly the adventitia which contains an increased amount of fibrous tissue Sections through emphy sematous blebs show a fairly thick fibrous connective wall lined by a single layer of fint or low cuboidal epithelial cells The in blebs measuring as much as 7 mm in diameter the specimens studied are apparently of bronchial origin om Asbestosis bodies are found in almost all parts of the pulmonary tissue They occur most frequently in the areas of fibrosis and are accompanied by a greenish black pigment They are also noted in the connective tissue about the small bronchi in the alveolar walls and in the alveoli Macrophages and giant cells are usually present when the asbestosis bodies are found in the alveoli and often surround or engulf the bodies These cells also contain a considerable amount of anthracotic pigment and the dark greenish black pigment com monly found in asbestosis A brownish yellow pigment in lesser amountsis also present The asbestosis bodies occur in the lungs in variety of shapes The most frequent is a bended rod with large rounded ends Spindle shapes with bended centers are niso noted Rosette formation is relatively frequent There appears to be no relation between the number of asbestosis boilies and the amount of pulmonary fibrosis In one case in which there is exceedingly little fibrosis the asbestosis bodies are particularly numerous while in fe another ease showing extensive fibrosis they are quite infrequent These bodies are golden yellow in color and are stained blue with potas sium ferrocyanide showing the presence of ferric iron With this SILICOSIS o 4, . ABESTOSIS FIGURE 52 PHOTOMICROGRAPHOSF OF NODULAR FIBROSIS FIBROSIS AND YSEM^ IN AN ASBESTOTIC 99 stain some fine blue strands bave been noted which are apparently asbestos fibers in the process of becoming asbestosis bodies By the use of polarized light fine fibers are often demonstrated in the tissue which are identified as asbestos These may be seen in the peri- bronchial connective tissue the interstitial connective tissue the ore 2 .be ' FIGURE 53 -ASBESTOSIS BODY IN ALVEOLAR CONNECtive Tissul TICALLY NO Fibrosis in This angA CASE 21 MAGNIFICATION 1 ARMY MEDICAL MUSEUM NO S2255 PRAC DOOX alveolar walls and in the alveolar spares The blue staining fibers and the asbestosis bodies are not visible when viewed with crossed Nicol prisms Other fine erystalline material is sometimes noted The presence of complienting tuberculosis is often difficult to demonstrate Unless ensextion is well defined the tubercles may Ft q ie 102 .- +6, = areca oan eA ane,SN kce INTERLOBAR FIGURE 55 Cas2 e 1 FUSION OF INTERLOBAR RIGHT LUNG MARKEDLY THICKENED PLEURA WITH PLEURA DENSE DENSE FIBROUS TAGS OVER ENTIRE SURFACE cece 104 f Figure 57 -Case H. SECTION OF RIGHT LUNG ADVANCED ASBESTOSIS DISTENDED BRONCHI AND AIR SPACES AT BOTH APEX AND BASE O.FFUSE fo FIBROSIS THROUGHOUT Lung Substance and THICKENED PLEURA FIGURE 58 -CARE H 21 SECTION OF LEFT Lung DISTENDED DistribuTED DistribuTED 27 AEE MATHE /USIFABULY AIR SPACES REST OF LUNG AREAS THROUGHOUT THROUGHOUT EMPHYSEMATOUS BRONCHI FIBRULS 450 Aro 106 Case 23 Fits 59 to 6 Main Neuro aged 33 vears Owari no douth Pneumonia terujatianul terujatianul history Worked as cleaner and sweeper in the cartroons of ani bestris plant for 13 years prior to deatli Previously roofer asphalt ; year Estimated dust exposure 35.3 suillion particles per cubic fout b mundaun particle years 438.9 Flauroscopy Moderate 2- la ground appearance of diaphram~-n righ and left first degree Note obliteration of costophrenic angle on right Moderate pranular appearance right base Interpreted as commencing generalized fibrosis ing 59 Note the defimte evidence of fibrosis at the right base and obliteration of the right entophrenicangle This evidence of increased fibrosis and fibrous pleurisy is also shown in the necropsy material ifigs 62 and 63 Vertical Influenza 1918 duration 2 weeks Frequent colds Medical history negative until 2 weeks before death when he developed pneu- monia Physical examination colored male Height 151 pounds Long ebat right side slightly smaller inches Moderate dullness over bases on percussion 70...inches Weight Expansion poor 11 Persistent eraekling r^les over baaes of lungs Palpation and fremitus urgative Faint breath sounds over haven Bloud pressure 140/90 Pulse rate 76 80 and 65. Rc spiratory rate 28 25 and 24 before Immediately after and 2 minutes after exereiset Blight transient dyspnoes luumediately after exercise Asbestosis bodies in sputum Urinary s^>lica3.3 mig per 100 ee 23 ing per 24 hour Dingunars Minderately advanceri sahesto stage 3 15 montlis Ixfure death Puthidagieni esaminasing showed muckerately advanced asisestusis A nyelerate degree of diffuse pulmonary fibrosis and emphyseins was notor seninpanied by many axlestamis Iuulien Aente diffuse pinetitonitis W">intement Chemical esamination of lung Sample from right lutig 2.69 percent s^>lica0.14 pereunt silica in ash 16.1 percent @e 107 . FIGURE 59 CHEST CHESTR of CaSE 15 MONTHS MONTHS BEFORE BEFORE DEATH DEATH eo 109 FIGURE 60 CASE23 RIGHT LUNG ENTIRE PLEUNAL BY DENSE Fibrous Tags SURpace CoverED . 110 " *s. FIGUNE 62 -CASE 23 SECTION OF RICHT LUNG ASBESTOSIS FIBROUS ANEAS AND EMPHYSEMA THROUGHOUT THE LUNG SUBstance SUBstance MODERATELY AdvaNCED UNIFORMLY DISTRIBUTED 111 ioan te FIGURE CASE 23 SECTION OF LEFT LUNG OWS LESS INVOLVement Than Right LUNG IFIG_62 IFIG_62 112 Case 25 17 64 and 63 Male white aged 27 years Cause of death Lobaprneumonia Decupational history work at age of 10 years Broadcloth weaver asbestus } year Truck driver 3 months Broadcloth weaver asbest0 years Truck driver 3 years Broadcloth weaver asbestosi 4 years W'eighted average dust exposure 49.7 million particles per cubic foot or 347.9 million particle years ae Medical history Past history negative developed into pneumonia Had influenza prior to death which ray examinations made 15 months and 1 month fig 641 hefore death showed degree ground iasswhich was interpreted as commencing generalized Abrosis Medical examination The principal abnormalities found on physical physical examina- tion 15 months before the death of the patient were second curved nails second cyanosis and decreased fremitus on both the right and left side The heart size and heart sounds were normal blood pressure 120 74. On esercise the pulse rate rose from 88 to 116 and 2 minutes later had fallen to St. The respiratory rate rose on exercise from 18 to 30 and returned to 22. The patient had a chest girth at expiration of 37 inches and a chest expansion of 2 inchies He was a chesteil man 68 inches tall weighing 195 pounds Fifteen months before death this case was diagnosed as early asbostosis stage 21 Pathological examination showed early asbestosis A diffuse interstitial fibrosia with little emphysema and bronchioletasia and numerous asbestosis bodies was noted Lobar pneumonia was shown to be the cause of death Chemical ezamination of lung Bampie froin right lung 2.44 percent silica 0.21 percent silica in asl~- 8.42 percent Rainple from left lung 2.44 perrent silica 1.27 pereunt silica in ashi 11.17 percent oe 4 . FIGURE 64 --CASE BEFORE DEATH M.25 PART CHEST OF THE Rays Taken 15 MONTHS AND I MONTH DIFFERENCE BETWEEN THE TWO ROENTGENO GRAMS IS DUE TO A DIFFERENCE DIFFERENCE IN RAY TECHNIQUE 114 O eos Figure 65 CAB2 E 5 SECTION OF Right LUNG EARLY ASBESTOSIS UNI FORM DISTRIBUTION DISTRIBUTION OF FIBROUs Areas THROUGHOUT LUNG SUBSTANCE ACKNOWLEDGMENTS Grateful acknowledgments are due the employers and employers of the asbestos textile plants in which this study was made for their interest and cooperation . Howard F. Brubach laboratory assistant prepared ray chest films conducted clinical and chemical tests on urine and sputur samples collected the atmospheric dust samples used for chemie analysis made the photomicrographs reproduced in this bulletm and materially contributed to the progress of this study in these and in other ways Junior Statistical Clerk Marjorie W. Hertford coded and tabulated the medical findings and prepared the graphs and tables included in this report Associate Chemist F. H. Goldman made chemical analyses on sainples of asbestos dust and samples of lung tissue 115 wu) wre SUMMARY OF MEDICAL FINDINGS A medical examination was made of each employee in three asbestos textile plants employing 423 men and 118 women These persons were much younger than the average industrial employee and they had been employed in this industry for relatively short lengths of time Almost half of these workers hail been previously employed in cotton or woolen textile mills Only 23 persons had been employed a trade in which workers are known to be exposed to inorganie dust and only 1 of these 23 persons had pneumoconiosis For this reason it is believed asbestos exposure can be held respon- sible for the cases of pneumoconiosis that were found in these three factories Asbestosis is a form of pneumoconiosis caused by continue.l inhalation of asbestos dust The primary effect of asbestos dust on the body is to set up an interstitial pulmonary fibrosis This may be seen at autopsy and reports on three cases appear in the pathological section of this bulletin This type of fibrosis may also be " detected by ray examination of the chest On the ray filin the shadows cast by this type of fibrosis resemble ground glass in appearance and usually extend over the lower portions of the lung fields frequently being heavier on the right side Unlike silicosis nodular , fibrosis has not been detected in asbestos workers As in silicosis the chief symptoms of asbestosis are progressive dyspnoea variable cougli substernal chest pain decreased chest expansion emaciation weakness clubbed finger tips and curved finger nails Most of these symptoms seem to be the result of the pulmonary fibrosis set up by inhaled asbestos dust and the concomitant pathologic changes suelt as emphysema bronchiectasis and bronchiolectasis which can be demonstrated at autopsy The percentage of persons affected by asbestosis or by any one of these symptoms depends upon the dust exposure In all cases the percentage of persons affected by any given sign or symptom of asbes- tosis is greater th^n^fincontrol grumps of industrial workers who were not exposed to inorganic dust A characteristic of asbestomis is the finding of asbestimis bodies in the lungs and the sputum Although it does not appear from these data that a finding of asbestosis bodies ean be used to establish a dingnosis of asbestosis nevertheless it is evidence of asbestos exposure exposure 136 > @ ete 117 Only three cases of asbestosis all of them diagnosed as doubtful or borderline vases were found to be exposed to dust concentrations of less than 5 million particles per cubic foot These three individuais had dust exposures of about 4 million particles per cubic foot Above 5 million particles per cubic foot numerous cases of marked asbestosis were found It would seem that if the dust concentration in asbestos factories could be kept below 5 million particles the engineering section of this report has shown how this may be ac- complished new cases of asbestosis probably would not appear ANNOTATED BIBLIOGRAPHY To facilitate reference to the papers listed in this bibliography a brief note has been appended to each citation which indicates the kind of information that may be sought for profitably So far as possible no information that can be gained from the title has been repented in the annotation and consequently the length of the note is no measure of the merit of the article In the interests of completeness a number of papers have been listed here which were not referred to in the text The papers on lung cancer as a possible complication of asbestosis are an example No cases of lung cancer were found in this study but it appears that it would be a profitable thing to look for whenever autopsy material is available for study For that reason papers dealing with the subject have been included ENGINEERING REPORTS 1. Annual report of the chief inspector of factories and workshops for England and Wales M. Stationery Office Lundon England 1910 Contains a section on observations made by Dr. Collis on the effects of exposure to asbestos dust on 40 workers in an asbestos textile factory 2. Bloomfield J. J. and J. M. Dalla The determination and control of * industrial dust Public Health Bulletin No. 217. 1935 Discusses generally methods of dust quantification and methods in use for controlling industrial dust 3. Hatch Theodore and 8. P. Choate Statistical description of the size properties of nonuniform particulate substanews Jour Franklin Inst 207 309-387 1939 Gives statistical parameters for the calculation of total surface area volume and mass of a given distribution of nonuniform dust particles 4. 4. Fulton W B. R. L. Houts A. Dooley and J. L. Matthews Asbestosis Part 1. The collection and exuuting of dust encountervi in nahest.om fabricating plants 1934 Pennsylvanis Dept. Labor and Industry Bull 37 Discusses the measurement of sulieston clust and its physical properties Engineering sturig of four plants 3. Natch Thendore and C. B. Moke The mineralogical con eisitionof air- borne fumuiry dust Jour Ind Hyg 18 91-97 1936 A petrographie study of dmi~ nefoundry dust nervesting in particle sue Compamation of ilust rvjuurted to vary with size 6. Hurlibut C. S. and C. R. Williams The mimeaingy of asbestim dust Juur Find Hyg 17. 299-211 19:35 Discusses the commjamition of settlesh settlesh dust samples obtament in manufamcanufatcturinug rmaniufacnturging aslustus aslustus textiles and other asbestin prudin~ ts facturies facturies 118 r 1 1 1 f - . ' ! t "a, . 119 7. Pase R. T. and J. J. Bloomfield A study of dust control methods in an asbestos fabricating plant Public Health Reports 52 1713 17271937 This investigation included a study of atmosplierie dist concentrations in the factory workrooms and a study of the exhaust systemis used to rounAVO asbestos dust APSESTOSIS Alwens W. leher Asbestore der Lungen $ 1707-1800 1935 Munchener n.ed. Wochense^-iz ray and medical study of 35 employees of factory 22 cases of asbestosis were found flocculent markings but no nodulation a German asbestos textile ray examination showed Sa. di Biasi W. Zur pathologischen Anatomie der Lungenasbestore fur Gewerbepath und Gewerbebyg 8 139 155 1937 Archiv A year man employedi 21 years in an arlentus fartury died of eirenlas tory insufficiency after seeking treatment for shortness of breath Oh autojmy the right side of the heart was enlarged There were phara phara sillusions The filrusia seen on gruss inspection and euuhruuvel on jakna tological exsinitiation was most extrusive in the lung hawn5 Samiuus abel Byrden 41 have reported on the asbestimin brochies found in this ease 1Bureschi Annemane Pneumunokoniose Berufskr^/nkiseit und Entschulis gungspflicht 1931 Deutsche Med Wochenschr 27 1100-1102 1247 ; 124 A year man employed 26 years in an tos factory sought treatment for disabling dyspnoea cardiac insufficiency and cough Clinical and ray findings characteristic of asbestosis are desetilmed in det Died as a result of right ventricular insufficiency mortem exams ination revealed pulmonary fibrosis marked hypertrophy and dilatation of the right ventricle and little hypertrophy of the left ventricle 0. Cooke R. E. Pulinonary usucatoria 1024 1025 1927 Brit Med Juur 1977 Vol 2 A year woman employed in an sabestus factory over an 18uar perud evniplained of cough drapnues expectoration and lassitude An ray plate showed extensive fibrosis niure marked in the right hung two calearevus glands at the root of the left lung and two niali calearisuus particles in the have of the left lower lobe On autogmy dense pleural allusions were found On section the right lung is men to la fikirimanch and to a large extent airkw the lung timmte being replaced by fibrous tim Cairamous names and areas of cascation ami eavitatum wate fosint 10. Dewirtz A. P. Aslustwarzen Arch f Dermat u Byph 161 1 5 1980 Description of the localization and the g~maand histulagiral appearances of azizslus cuPLIA Domwelly J. Pulmumary Asbestosis 1281. 1933 Amer Juur Pub Health 23a oer Partial review of piros j^^'osbservations on the dimrose Includes case rejsets un ihre totally illmabilul illmabilul patients patients taken fruiu a mtus of 13enses 14 ligunesi chest plates All but of the 15 kai at some time been diagiosarak preko monary rrulusja Donnelly J. Pulmonary Aslastosi invidienre and Hyr 18 222 228. 1934 Description of ray flues of t^l astustus astustus wurkers wurkers jipogeniusts Jace Lit Ph] tod thteed me mt 120 am 13. Egbert D. S. Pulmonary asbestosis Report of a case with necropsy Andings Amer Rev. Tubere 31 23 341935 Autopsy report on case described by W. B. Soper Amer Rev. Tubere 22 571 364 1930 White year male employed as an asbestos carder 13 years complained of dyspnoes and streaked sputum No cough Examined and rayed on two occasions before death whichi resulted from cardiac failure On autopsy diffuse fibrosis of lung il- volving particularis upper lobe of right and portion of upper lobe of left arrested tuberculosis asbestosis bodies throughout lungs few in tracheo- bronchial lymph nodes 14. Ellman P. Pulmonary asbestosis Its elinical radiological and patholes- ical features and associated risk of tuberculous infection Jour Ind Hyg 13 163 183 1933 A year man employed in the cardroom of an ashestos factory 9 years became disabled on account of dyspnoea acevinpanied by dry irritating cough and progressive anorexia loss of weight and clubbing of finger ray and clinical examination At autopsy this case was diagnosed as advanced pukinonary asbestosis complicated by tuberentions pleurisy A year woman employed 2 years making asbestos mattresses lweame dyspnneie wasted and e,, anutic Died of tuberculosis ings are presented +s Autopsy fin~-t- 15. Fulton W. B. A. Dooley J. L. Matthews and R. L. Houtz Aplustoant^' Part 11. The nature and amount of dust encountered in asbestos fabri- cating plants Part III The effects of exposure to dust encountered m asbestos fabriesting plants on the health of a group of workers vania Dept. Labur and Industry Bull 42. 1935 Pennsyle Report of a medical examination of 66 workers papers Bibliography of 125 16. Gl^,yneS. R. The morbid anatomy and histology of asbestimis Tulsrele 14 443 454193 493750 5351933 . Detailed description of pathological findings and review of literature e 17. Lanza A. J. W. J. McConnell and J. W. Felinel Effects of the inhalation of asbestos dust on the lungs of salestos workers Public Health Rejaorts ee 30 1-12 1935. Reprint No. 1665 we Brief description of the findings of an engineering and medical study made in an adhustos textile plant ray iumwere made of 126 persons 18. Lanza A. J. Audientais Jour Amer Mei Assue 106 MAS 19:16 Brief description of some of the early obarvations on the disease partiens larly as men in United States Man nutes un eliniral picture and rowuit genology : Lovisetto Dumeniru Pulmonary sal~-r~-l~-misHeronis of the Internas tional Confervur un Niliesmas bell at Johannesburg Aug. 13-27 1981 Studies and Reports Series bid Hyra No. 13 pp 2066 209 209 Author's nisservations on workers handlling pury audumiem ani aslustos mixed with cullon or other vegetabile dusia Conclubs that at kust 5 years of exqumuty proqui^-oal to pruiner POOLETTAPOLionis dirvet rat~-n~-bers tween quantity of dust inhakul mul purinewo~ N~ LAR~ |Nstarbhaluss tarbhkalusk ease may develope in 7 to 9 years and the chimease ran rause death after 13 years lwavylwavy expusat ore ware 121 20. Lynch K. and W. A. Smith Pulmonary asbestosis ] Including the Prpooet ol we gare came, Annet Hev Tuberc 23 643 660 1931 White merle 16 years ukl employed as an asbestos carrier 11 years sought mestical t~ vatmentfor chest pain loss of weight 23 lb. and shortners of berath ray examination on ^ occasions during a year period showerl mutthing in both lungs Died so a result of slow cardine failure On autopsy extensive hrosis emphysema and bronelicetasis were found Tutwrrulusis was absent oe. McDonald Stuart Histology of pulmonary asbestosis 1027 vol 21 1023 1026 1927 * Brit Med Jour 23. The interstitial Abrosis is such as might be expected as a result of a conibination of a pneunioconiiotie condition and a chronic tuberculous infec tion The possibility that asbestosis bodies may have been of plant or animal orig~-n~-may be excluded The hypothesis aitvanced is that these bodies are portions of asbestos fihres in the process of alteration and absorption by hydrolysis either by direct chemical action or by enzynie McPheeters S. B. survey of a group of employees exposed in gebestes dust Jour Ind Hyg 18 229 2391936. Reports the results of a survey of 210 persons exposer to ashestos dust 24. Martz L. Asbestosis and 72 11-15 1930 Tuberkulose *. tuberculosis der Lungen Zeitschr L. Tuberk Asbestosis cuimplicated by tuberculosis was found in a year woman employed in an asbestos factory during a year periet 23. Merewether E. R. A memorandum on aslustosis Tuberele 13 68 81 109 111832 139 1933 ^ comprehensive review of British studies of ashustosis including economie mineralogical and medical historical facts main features of the disease asbestosis bodies correlations with dust exposure risk of tuberculosis preventive measures and compensation 26. Mills R. G. Pulmonary sabestosis report of a case 495 499 1930 Minnesota Med 13 A year man exposed to asbestos dust in a mine 17 years previously was admitted to a hospital where he died of heart block Markel huig fibrosis was found on autopsy Asbestos fibers and asbestosis bufies were found on microscopie examination 27. Muma Giovanni Clinical and radiological notes on pneumoconinis dime to ashraton Biliermia of International Conference Iwid at Julianiwatnirg Aug. 13-27 1930. Hyg No. 13 p 209 Muries and Reports Series 1 tlnd The ray al~-ownartm~-rizationdistribuuteri bilaterally in the hilar and puitse hilar sones which in mout advanced cases outsiderably reluces transpar chey Punetinen There is infiltration of the Inurs 28. Oliver Thomas Clinical aspets of pulmonary Bele~-st~-mmin Jirit Jour 1927 Vol 21 1026 1027 1927 Med palmuntary Cami kiintorum of two warmen who are the mahjorts of one agvil IN and the other 39. as astasis 20. 20. Pancoast K. G. Miller and H. M. Lamlis A study of thus efforts of clust inclemkation upsis the bungs powutgenologie Trans Asuk Amer Physirian Physirian 32 97 10897 108 1917 122 The ray aspects of 137 individuals exposed to organic and inorganie dust are presented Of the group exposed to inorganie dust 15 were asbestos workers Shadows almost invariably first appeared in the right lung on a level with the hilus shadow The appearance of the shadows is reporter softer and less sharply defined in asbestos workers A gund description la given of the three stages which the authors recognize in the progress of pufilmu~ uniosis 30. 30a Schuster Norah H. Pulmonary asbestosis in a dog 34 731 757 1931 e Jour Path and Baet A dog kept in an asbestos factory 10 years had suffered for two years from cough and dyspnues and for six months from progressive wasting The dyspnoea becaine so distressing that he was destroyed On examination of the lungs diffuse fibrosis bronchiectasis phagocytosis and askiestos fibers were found Asbestosis ixalies were not found Seiler H. E. and M. GilmouT A ease of pulmonary asbestosis Med Juur 1931 1 1112 1114 1931 Brit A year man employed 23 years in an asl^stmfactory as a varder cloth weaver and in the manufacture of milliard sought treatment for rong breathlessness loss of weight and lasitude Radiographie examination revealed a diffuse fine mottling of a silicotie nature spireait throughout both lungs The patient who is the subject of these notes has died and the fact that pathological examination allowed that death was dissolely dissolely to cardiac failure secundary to back pressure resulting from the thassive generalized fibrosis and irrespective of any addest infection is un adustiimal point of interest in this case 31. Shull J. R. 27 279 Asbestosis a roentgenologic review of 71 cases 292 1938 Radiology Results of medical examination of asbestos textile workers reports Two autopey 32. Stock G. A. Pulizonary asbestosis 126-129 1933 Med Bull Veterans Adn~- 10 A year man employed 8 years as an ashestos carrier was admitted to wwe a hospital beesium of shortness of breath and chest pain He was under cme weight and had poor chest expansion No julmonary tuberenkais present The inortem diagikmen were Preunumia Bevite olarpneume4 me niosis sil kul~-rsof both lungs pleurisy chronic Abritania right and chromie Kheinous with ad amionakft interkl^rleft kyjevtrophy and dilatation + of the heart ammuntieitia eltronic goluutisia iuatiew and Al~-r~-min Histological examination revealed tog 33. 3. Strebe II Bericht ^...ber deur Fall von nalastosis welelier der Arbeit des Herrn Prof. Heger zugrunde liegt Vireisow's Arrhiv 1. pathulogische Anatomie u Physiologie 200 334-157 TIES year man eruploved in German aslast~-mfactory M vears complainedl sif dyspnea dyspnea heimchitis and hea of weight ray examinatiexaominantion slowest Kue Boreulent markings in twiddle much lower quortquortiionquoortinon of ding freichs Devel of heart failure Ou autojmy femarsel Starvanin manipolis mentia and aslastomis Imacies Na sigus of rrislimin White T. Putionary Canilina 1933-259-262 1933-259-262 1933-259-262 asl^,shisis 1938 Trans Mish Saue State of North- A Fevrarsild miui ertaplacard 9. vines in an asiaratus mill snacht merdient treatment an acromit of shortness shortness of herath nonprendurtivas enough and slight loss of weight All simptomis simptomis ingreawid ingreawid in Severity SeveritSeyverity de Bun Weich vie ' 11 i ' a i TH TH ' On Nitas esamumation years later The lung fulls are negative fur tuiwrenkostu The examination shows a marked widespread fibrosis tl~-n~-iclountleiths clunts which reaches the periphery The heart outline i in entirely admcurul by dense fibrosis and the phrenie angles are oddliteratesi The exact heart measurements cannot be determined he- cause of the shagginess of the beart outline but the heart is definitely ; endarged 34. Wonut W. B. and D. Pane A case of pulmonary asbestosis Death from tulwreulusis two years after first exposure to the dust Tubercle 11 137-135 1930 A year woman employed 15 months as a spinner in an asl^mtosfactory sought treatment for anorexia weakness wasting siri pain in the minist side of the ebest of three months duration She denied having cough ur expectoration There was no radiographic evidence of premiuuenniusis On histological examination of the lungs in the few sections examined in which tuberentuus lesions were not present the asiustos together with a large quantity of black pigment was generally surrumded by a little fibrous tissue hit there was no gross Bbrosis Aslustus Kilure and ass 0 hestusis bodies were found 35. 35. Wood R. D. and S. R. Gleyne Pulmonary asbestosis a review of one i hundred cases Lancet 227 2 1383-1383 1934 Of 100 asbestos work ng who sought medical treatment 33 had imeomisqalis estel asbestymis Had asbestosis with active tuberculosis I had as bestosis with uborescent tuberculosis and 17 were diauursed as doubtful doubtful cases of sixstosis Septie bronchitis purumonia and puke monary tuberculosis are the cominonest terminal complications of the | discase ASBESTOSIS BODIES Gloyne S. R. The presence of asbestosis bodies in the facees in a case of 1 pulmonary Abrosis Tubercle 12 138 159 1931 | The faeces were emulsified with four or five times their volume of 3 per cent 1 furmalin in saline The emulsion of the facevs when centrifugal was found to contain a seanty number of asbestosis bodies 37. Cloyne 8. R. A method of staining the a instosis laulieu found its the sputum of salestos workers Jour Ind Hyr 13 83-86 83-86 1031 Deneribus techniques employing Prumian blue and anuminium sulfide 38. Lynch K. M. and W. A. Smith Anlustrimis Indica ^finsputum amt hing Jour Amer Mist Anmic 05 139 6Al 1930 Aalmostosin bewbies fillustrated were recoverve from the lungs of two risbustion workers and from the sputium of four mainstem workers workers 39. Pagr C. A study of the sputnu in pulummary asbestimis Mest Sei 189 44-45 1937 Miner Jout Clumps of ashuntenia funtien were found in the sputuru 10 astastes workers with avanevi asl~-n ymin Aslantunis Ination were found in all lost od the 31 enara atuwinal 40. Stewart M. noch C. Haddow Demonstration of the qurular tuntun of pulmonary astumtimin padarotomin kuulio in material ulitauust by lung puncture anul in the sputuu Juur Path and Haet 32 172 HER Aulumtemis bumbios were found in material abtamust be punetiring punetiring the Soft ling with a lovelbow nooseller Patient was a Jinversemihil Jinversemihil Jinversemihil mutato mutato e tupikavesh tupikavesh an Bli asbestos factory 15 years who had congti ils spuses mini koost koost weight ee em come 12+ 41. Stewart M. J. N. Tattersall and A. Haddow On the nemurrence of elumps of asbestosis bodies in the sputum of ashestos workers Jour Path Bact 33 737 7411932 densely A clump of asbestosis bodies was found in the soman sputum of a year employed 11 years in an ashestuns factory the complained of cough dyspnoes and anorexia The radiograph showed difuse fiiir striation throughout the lower third of both pneumonia On lungs Died of bronchia- basal portion autoper There of was notable diffuse Sbrosis of the greater both lower lobes The Abrosed tissue was emphysematous Asbestosis bodies were somewhat somewhat fibrosed areas most niuuervus in the No evidence of tuberculosis 41a Sundius N. and A. Bygr^'n Der Staubinhalt einer die Beschaffenheit der Asbestosislunge und Gewerbepath und Gewersboegehnyagnn8ten26Asbe7s0t1um9i3s7k^rperetien Archiv fur coniposition Quantitative microchemical analysis of ashestonis bodies isolated human lung showed that the gel from a largely of ferrie oxide phosphatesuarnroourngdainnige tshuebasstbaensetroswhfoiesre ecnhneamiisctaeld coniposition suggests that it is protein and water Chemical ray examination of cores of asbestosis hodies indiested that tahnealcyhseimsiacnadl composition of the subxestos fiber remained uneban .ed OTHER PNEUMOCONIOAES 42. 42. Curtis A. R. 1937 The health of cement we ern Indust Meel 6 195 200 res plants Results of a medical survey of 201 men Morbidity data for 21 exposed to dust in a cement anil 2 ee 43. Dreessen W. Hyg 15 66 Effects of certain silicate dusts on the lungs 78 1933 Jour Ind ce ray 43a The silicate diuts of tremolite tale and slate induce fibrosis of the lungs which is definitely demonstrablea ifnintehediffuse bilateral Dreemen W. C. Effeet of inhaled martile dust as observed in Vermont marble finishers Public Health Reports 49 724-732 1934 wes Although marble dust when inhaled in the nes lous than 26 million particles cubic concentrations here ulmerved per foot produces a mild bilateral wesw lwienreearnfoitl edronainaidn 15 jureent of the 80 men verl no seriemas lng changes there was no disability due to the dust even after years of expomiare many 44. 44. Drumwen W. and J. M. Dalla The efferta twa Georgia tale mills and of expumure to dust in 1035. Reprint 1869 mine Publie Health Requirts 30 131-143 . . Anthranmiliremin Enginevring and medical study of the relation litween dust decurrence of junenurunimman in Gili workers exjumure and 43. Drawwn W. C. and It Jones Assuc 1117 1179 1191179 119 IQMI Junt Amer Most Results of a nucilical examination of 2,711 anthracite miln~tu employed and 195 disabilest g~ ne 46. Hofkamani F. Mortality from respiratory disenses in dusty tracks umore ganie dustsi Bull 8. H^,rFab sitat No. 231 176 Gives brief pp 184 PHIS summarus of the efforts of from exinmury li g~ g~nnee dusts europosleek c^voprational mortality data variable variable in 1901 4 e ate 125 47. Middleton F. L. Industrial dust pulmonary disease due to the inhalation of Lancet 231 1-9 59 64 1930 Part i rivals with silicosis Part II with siliestosis 48. Russell A. E. H. Britten L. including asbestosis bealth of R. Thompson and J. J. Bloomfield workers in dusty trades II Exposure to siliceous dust The industry Public Health Bulletin No. 187. 1929 grawle Au engineering medical and statistical study of the effects of exposure to granite dust on workers 49. Sasyuedrs tR ube. rculV osi.s Meriwether A. J. Lauza and W. W. Adams Silicous Kanaar and among miners of the state district of Oklanum Mussouri Mines Technical I. For the year ended June 30 1929. Bureau of Paper 545. 1933 Results of medical and in lead and zine roentgenographie mines roentgenographie examinations of 7,722 men emploved 30. Sayers R. R. print 1626 ilieusis Public Health Reports 49 305-602 1934. Re- Discussion of the historical medical and 51. Sayers R. R. J. Bloom^-eidJ. engineering aspects of silicosis _ sen D. K. M. Valle R. R. Jones W. Drys coal Brundage and R. H. Britten Anthraco hard miners Public Health Bulletin No. 221. 1933 ani ng Medical and engineering study of incidence uf dust expomire among 2,700 anthracite minempneumoconiosis in relation ^fin : 2 Thumpson L. R. D. K. Brundage A. E. Russell health of workers in and J. 3 Sinonifield The rement dusty trades I. Health of workers in a Portlam plant Public Health Bulletin No. 176. 1925 Includes sa engineering study of dust conditions in of respiratory ailments and physical a cement plant records . workers examinations of a large group of 52a CANCER AND ABRESTOUIS Exbert D. S. and A. J. Geiger Pulmonary Amer Rev. Tuberc 34 143 150 1938 sabestosis and carcinonia made Eksicion the characteristie putlulogical and histological signs of kohe of the left lung 53. Gloyine 8. IL Squamona carrinoma of comm, Tul^rele17 5 101 LIKES lung occurring in bolastimis Tun Description of malignant lesions noter in two sini mil retegized in life ramm lesions were squall Thay mimowol prickle rolls cvil mumis The emintha pilvanevel pilvanevel aking the keratinization art tinuous fingretike prilongations The bruichial muvuma h cun lung where the grustlu were in a quistion is the galaxiosis was quite silvaueril 34. Glovne S. R. that rell Tularele 18 100 1936 enreinoma of lung verurring in astratosis 101 easi putijioral Typical Typical extensive galastomis employest 221 was found un autojmy of a Mhyvarold Mhyvarold man years in the storage de partrivit of an astast~-mfactors .1 misqilastu n anit the size of cod Bloor doomoor kostue cuif hall was funtuk in the putijioral jailtusu jailtusu jailtusu of the left hng Pontinimais with the pleura The gruth Bt oem mw eee eee Oe r ewe 126 ee 2 was soft pinkish white and fairly well demarcated It grew outward from a center in a compset mazs destroying lung tissue as it progressed 35. Lynch K. M. and W. A. Smith Carcinoma of lung in silicosis Amer Jour Cancer 24 34 641935 weaver mill about As of he had Case report of white male age 57 who had been cotton wearer 22 years and in asbestos 21 years expos exu por sue re ex- tenaire ^ brosisof lungs and pleurs with emph,, sembaronchiectasis and cardiac embarrassment In addition to the diffuse fibrosis the authors noted formation of hyalin Abrous nodules characteristic of silicosis The pulmonary cancer appeared to originale from one of the branches of the bronchus to the right lower lobe where squamous metaplasia of the living epithelium was observed The duration of the cancer could not be speciBed but it did not antedate the fibrosis o MISCELLANEOUS 36. Britten Rollo H. and L. R. Thompson A health study of ten thousand male industrial workers Statistical analysis of surveys in ten industries Public Health Bulletin No. 162. 1926 Summary of anthropometric and physiological data obtained in physical examinations together with incidence of certain physical defects 57. Gardner L. U. and D. E. Cummings Studies on experimental pneumonokonimis VI Inhalation of asbestos dust Its effect upon primary tuberculous infection Jour Ind Hyg 13 05-66 97 112 1931 Guinea have been exposed for eight hours daily for perioda as long as two and third years to an atmosphere containing approximately thirty million particles per cubic foot of asbestus dust Canadian ehrysotile 1.5 microns and less in diameter Rabbits and albino rats have likewise been exposed for aborter perioda 390 days 88. Gloyne 8. R. The presence of the asbestos ^bre^bre in the lesions of asbestos workers Tubercle 10 404 4071929 Asbestus fibers but not sabertosia bodies were found in asbestos corns 59. King E. J. and M. Dolan Bilicosis and the metabolism of silics Can Med Assoc J~-x~-3r 1 21 26 1934 Urinary s^>lies enntent of 36 miners was 2.2 mg per 100 re of 40 students 3 mg per 100 re single apweimens Analytical procedure is described described Miller J. W. and R. R. Hayers The pliyziological rea i^oef peritunes timue to certain isulustrial and pury mineral dusts Public Health Re m rt3a 1 1677-1688 1936. Reprint No. 1787 32 dusts were classified according to the reaction prelievi on intraperitoneal injection into CMS PR^ 61 Miller W. S. Tim lung 1937. pp 59 Clurken C. Thunan Springbeid M. Baltimore Baltimore 62. Norris W. and R. M. Landin Dimenon of the chest and the tiples of physical chaguoman edition = 1033 W. H. Hannders Cu kriptis pris Stl 63. Extracts from the annual requirt of the Chief Junjaetor of Facturim ant Worksliga 1986 Dept. Lamban Chapter Health His Majesty'sMajesty's Stationery 0 cme wer wwe fe