Document aByBbxzMJjdgJD9NoOOgXXDDY

FILE NAME: Owens Illinois Library (OWL) DATE: 1955 DOC#: OWL043 DOCUMENT DESCRIPTION: Archives of Industrial Health - Asbestosis as Differentiated from Other Pneumoconiosis /.y / / fr* '- - -4^---r*fs 6^_ /-^' / 5^ ^ S c+3 ^^ ied to d id a6 ^ d iffe r e n tia te d f ro tn neum ocom oded A. Soodtr, M.O., Milwmkee .TS jS s a s * - ! -- aneaea ~-rrj j s^r.zrzcurmmm The preceding discussion has shown that the roentgenological appearance ot* a well* defined asbestosis is quite distinctive and that it differs materially from any of the other pneumoconioses. For that reason. I shall not limit my part of the discussion to the differ* ences between this disease entity and the other dust diseases but shall include other conditions of the lungs which may be mis* diagnosed as asbestosis. The first and commonest cause of ml diagnosis is poor film technique. A perfectly normal chest can be made to look like one with definite iirst*stage asbestosis by slight underexposure, by lack of contrast, and by blurred vascular markings due to too long exposure time. Such films are especially common in overweight persons, the heart shadow usually being horizontal and often presenting a shaggy appearance due to com* pression of the vascular shadows in the lower lobes. Films lacking proper penetration, sharply defined detail, and lack of contrast should be rejected for the diagnosis of any occupational disease of the lungs but par* ticulariv of asbestosis. Another condition which causes diagnostic trouble at times is emphysema due to any cause, when there are one o r more adhesions of the diaphragm due to past pleurisy. The "ground-glass appearance" is very easily read Read in the Symposium on Occupational Diseases ot the Lungs. sponsored by the Massachusetts Medi cal Society in cooperation with the Institute of industrial Medicine ot the New York University-- Pott-Graduate Medical School, Boston, Oct. 28. 195J. into such a film. W hen to this are added some retained secretions in the lower lobes, which often are bronchiectatic in emphysema, the misdiagnosis is established. A pneumoconiosis ot which we have be* come increasingly aware in recent years is that due to excessive deposition ot coal dust. I t appears quite certain now that free silica is not needed as an essential component of the dust to develop the characteristic changes. T he fine lacy character of the shadows plus some emphysema gives a pattern which looks very much like "ground glass" aAd is easily mistaken for early asbestosis. All these examples I assume represent pa r e n t s who present themselves to their physi* i symptoms of dyspnea, with a hissome exposure to asbestos dust, and with cBh*l films of the character I have men tioned. How easy it :s to fall into `the trap of a gunshot misdiagnosis'. Unless other pos sible causes for the x*ray changes are con sidered first and a detailed past occupational history is evaluated, along with the char acter and extent of the most recent dust ex posure, another worker who actually needed reassurance will be told that his lungs are full of asbestos dust and that he should quit his trade! From that point on. his symptoms usually increase to a marked degree, and he has developed what to him is a real disability. In my experience, such doctor-induced dis ability is commoner ir. some areas than is the disability from the disease itself. Because of the complete lack of unanimity of opinion aliout this disease among phvsi.cians and because c: the need for more clearly defined criteria for diagnosis and adrice cn continued tm.p'.oym.er.t :r. the trade, the medical and industrial hygiene advisers of members of the As'estos Textile Institute T D T "' ' 3 j added -! lobes. y>cma, ve be- * <ars is l '\ I dust. \ - silica ? !rnt of anges. vs f cut pa* - physi* i a Itis* *t. and v men* e trap cr pos* .re conational char:'.ust ex- needed 'is are M quit ptoms and he -ability, vil dis* !' is the nimity physi* THiae. ivisers mute ASBESTOSIS A.\'D OTHER PXEUitOCONIOSES have set up a so-called A ir Hygiene Committee. This committee has met on several occasions to determine whether those who are most intimately associated with this dis ease can agree on the various medical and hygiene phases of the problem. At the last meeting, each medical member of this committee brought with him sample films of the various stages of asbestosis, in cluding some he had classified as essentially negative. All films were reviewed by the eight physicians who were present. W e found fairly good agreement on the more advanced stages of asbestosis but practically none on the borderline degrees. A number of my tilms from the textile mill in North Carolina for which I am consultant, representing cases which I had classified as "early or first-stage asbestosis," were called " essentially negative" by a number of physicians present who had had long experience with this disease. The reverse also was tru e ; some films I had called negative which others thought represented tirst-stage asbestosis. The same disagreement was found with the other films which were presented. I t was our final conclusion that it is impossible to clearly define a first-stage case and that it can be called "essentially negative" one day and "first stage" the next by the same reader. This was not new. It has been emphasized repeatedly by Pender grass. beginning in 1938. O ur group finally agreed that little atten tion should be paid to the first-stage diag nosis. that little, if any. disability has been shown to exist with the borderline stages, that no one should be advised to stop work with these questionable degrees of change, and that workers should be kept at their reg ular jobs but the dust control should be so improved that their cases will not progress to the stage where everyone agrees that they have asbestosis. Regarding recommendations of transfer to !<r?i dusty or nondusty work, we agreed to the following: 1. Persons under 40. when the diagnosis ;> clear cut (beyond"first stag?!." should be moved to a nondusty joh if pnsihle. 2. Where progression is seen on serial films, regardless ot age, less dust exposure is clearly indicated. 3. Exceptions should be made if there will be material improvement in dust control on the present job within a very short time. I have deviated from my assignment of differential diagnosis, because the diagnostic criteria are so intimately associated with it. Until we have some agreement on x-ray in terpretation, the present chaotic state of af fairs will continue. In the differential diagnosis, it is my be lief that a new approach is essential, not only with asbestosis but also with nonoccupational diseases as well. Because textbooks in medicine are written by diseases, each fol lowed by a listing of other diseases which must be differentiated from it, the disease itself becomes fixed first in the diagnostician's mind. H e says to himself. "This is it," and he pays only cursory attention to the diag nostic criteria of the disease add to the dis eases from which it must be differentiated. A more scientific approach would be to list all th e . conditions and diseases which are compatible with the x-ray pattern which the patient presents and then, after a complete and detailed medical and occupational his tory, physical examination, and laboratory studies, to see which oi the positive findings more closely fit the listed diseases. I should like to cite a case which undoubt edly would not have been misdiagnosed had tins approach been used. A railroad shop repairman, aged 57. had to stop: work because of increasing shortness of breath several years ago. Cyanosis and dyspnea became progressively worse, and he died of anoxia and right heart failure several months ago. His work in the railroad shop included welding, unpacking, and repacking asbestos insulation around locomo tive boilers and doing some fitting and grinding. The chest x-ray film showed a diffuse mottled ami micronodular pattern in both lungs, and compressed lower lobes due to high position of the diaphragm.with numerous annular shadows of less density scattered throughout both lungs. Asbestosis was diagnosed by the man's physician, because there had been some ashestos-dust exposure, because he had always heard that the x-ray pattern of asbestosis was rather bizarre land this certainly was), and 209 IXDL'STRtAL HEALTH because it did not look like the sidcrosis of welder about which he had read something recently. The degree ot asbestos-dust exposure was not inquired about tit was spasmodic and minimal). Other diseases and conditions o( the lungs were not con* sidered. The annular shadows should have brought emphysematous blebs or air cysts into the differen tial diagnosis, as well as the granulomatous diseases. Miliary tuberculosis had to be ruled out as well as berylliosis with emphysema. Sarcoidosis also had to be considered, although-the annular shadows were against i t After definitive study, the diagnostic possibilities should have been reduced to emphy sematous blebs plus pneumonitis or polycystic dis ease plus pneumonitis. Also, there were none of the characteristics of asbestosis and no pleural involve ment When the most detailed analysis and study will not reveal the true diagnosis, which hap pens in occasional cases, taking a biopsy spe cimen of the lung should be considered. This has become a rather simple procedure with little danger of complications. It m ust be remembered, however, that because of the relatively small piece of lung usually ob tained for biopsy, there always is some d an -, ger that the diagnostic pathological change will not be revealed. In conclusion, as with all chronic chest diseases, so especially w ith asbestosis, all possible causes of the pathology revealed by the chest film m ust be considered. Poorly After postmortem study the diagnosis was studied cases result in misdiagnoses which clarified--a widespread congenital cystic not only are embarrassing to the physician lung, with interstitial fibrosis due to long but which may also cause irreversible harm standing infection. The cuboidal and col to the patient. W e owe it to o u r patients and umnar epithelium lining of the cysts is note worthy. Also, there was complete absence of anything resembling asbestosis bodies, an to the medical profession to so thoroughly investigate every obscure case that such un fortunate situations do not arise. absettce of pleural thickening, and no evi dence of any hyaline fibrosis. Even with this clear-cut postmortem evidence, ti&Hbvsiriap who originally made the diagnosis 9#Jie- DISCUSSION* Da. Kasl'T. Benedict. West BoyUton. Mass.: It is a privilege to substitute for Dr. Harriet Hardy: she has helped me many times, but a svb- lieves that this was a case of asbestosis ahd stitute is always a "second.'* The assignment is is sending the tissue slides to various pathol y "the differential diagnosis." I have had no experi ence with asbestosis and. furthermore. I believe ogists. H e should be convinced soon that he that experience with most pneumoconioses, as seen most likely was wrong, which will be most today, is gained only after 20 to 30 years* study, embarrassing to him. because it often takes that long to produce such This case, along with many others which could be cited, clearly points up the need to consider all possibilities in cases presenting disease. In spite of the foregoing. I believe I am qualified to make certain remarks, because I have been practicing industrial medicine for 15 years in one of r bizarre x-ray patterns. Each case m ust have the world's largest artificial abrasive plants. Since painstaking study, including not only the im mediately preceding occupational history but also a history of every job from the first one on. A n example is a foundry w orker 1940. we have taken more than 25.000 chest x-rays on some S.OO) abrasives workers. From 1911* to 1940. except :a rare instances, we simply did socalled routine physical examinations. I agree with Dr. Sosman that the physical exami , with a chest film which was characteristic nation is not worth very much in these circum of a moderately well-developed asbestosis. Careful study of the occupational environ ment revealed no possibility of asbestos ex stances. Thanks to Phil Drinker and others, dust control is much better in our plants today. Iu one large plant our lust counts run consistently J.OOO.OOO < ajpttuOOO particles per cubic toot We posure in this shop. More detailed early liandle a great variety of dusts, for that is our occupational history revealed that the man had been a plumber's hel|>er during the late teens and early twenties, doing ail the sawing ot aaliestos pi|>e covering. uuaiiv in con fined basement rooms. business, anc safe handling is essential. Recently i: the Seventh Saranac Symposium, several wori-renowued autliorities on pulmonary disease* atte.--ited < define pneumoconiosis. I shall not. There . n>> dennitiun there either. Instead tlierc were -nty and majority rt|iorts. One . 21 B :/.TH -indy ;,IOV^ Thi* - with .t.-t be iti the Ty obe dancliange . chest .5. M :d<d hy l"oorly . which yician y harm ut and : ) . Mu*.: Harriet a a sub- .::turtu b . expert* S believe .. a i ten r' study, ce iuch irt DM OI ?. Since x-rays v 1911 to > did so- ASBESTOSIS AXD OTHER PS'EUilOCOXWSES group insisted that pneumoconiosis simply means dust in the lung. The other group restricts it to thoie conditions producing demonstrable disability. The hitch is, Who demonstrates the disability? The roentgenologist s e a nodular fibrosis in the x-ray lilm: that b pneumoconiosis to him. At once, or sometimes much later, the industrial physician and hygienist set about to correct conditions to prevent progress oi the pneumoconiosis or development of new cases. Later, though the worker still may not know oi his trouble, the family physician has diffi culty* clearing an ordinary chest cold or the surgeon b faced with anesthesia worries. The occupational disease or the health department specialists in our state government want reports when "injury" has resulted. Compensation and insurance authorities talk about the number of pneumoconiosis cases, based upon those workers whose earnings have suffered. The compensation lawyer appears later in the picture, and alas sometimes the last, the pathologist, may be the first in proving that a case of tuberculosis or cancer is in reality pneumo coniosis. I believe we all know when the man b suffering from pneumoconiosis, whether we be laymen or physicians. W hat he wants to know is. W hat is wrong; W hat can be done about it; Is he permar.ently disabled? Is his life shortened? There can be only one answer: not better diag- (nosis or differential diagnosis or function studies, but adequate dust control. Since different dusts require different degrees of dust control, witness the different effects from inhaling small amounts if aluminum (therapeutically) and beryllium or radioactive dusts. There b , therefore, good reason iut you aud me to continue to study pneumoconioses and their differential diagnosis. We in che abrasive industry are continuing this research. Specifically, we believe that under reasonable control alumina dust is no problem. You have heard of the "carbo rundum lung" no doubt; this is an unjust label, aa my good friend Dr. Eddy, of the Carborundum Company, well knows, for Carborundum b ju st a trade name for the fusion product, silicon carbide. Furthermore, just what disease, disability, or path ology silicon carbide per se will produce in man has never been proved conclusively, I believe. It b entirely possible that this lung condition is caused by significant free silica contaminations. Further study b needed, and we intend that it shall be made. Shaver's disease has been mentioned before In spite of several years' research tending to prove that alumina fume is the cause, there are those who believe that silica fume is to blame Industry b somewhat dbcouraged by the inconclusive nature of these and similar medical studies. We all know about the problems related by beryl lium and radioactive dusts. On the other hand, our concepts of clay and talc pneumoconioses have changed in recent years. And what do we know about zirconia or titania o r magnesia or boron carbide o r graphite dust inhalation? In our industry. organic substances have caused only two minor cases o i asthma. And we have seen no cases of can cer of the lung among our abrasives employees. - In conclusion, our goal b not a specific M. A- C " figure but maximum dust control to eliminate all pneumoconioses. This goal is not easily attainable. Adequate differential diagnostic knowledge will help us to achieve it. Ziii 1Maximum allowable concentration. r*. 9