Document aNV2erqG6EB7o04baao1aGGe

FILE NAME: Owens Illinois Library (OWL) DATE: 1955 DOC#: OWL041 DOCUMENT DESCRIPTION: Archives of Industrial Health - Some Clinical Observations of Asbestosis in Mine and Mill Workers l ; 'j& fs y ' M /0& & C y ('/'7 9 /? 5 S -S an ie d i n i c a i O beruatton o^~^!letoi in W in e a r i l W i K W o Aherd PAUL CARTIER, M.D., Thtford Min*, Qutbtc, Cnodo; . 1 cases have Ijcen diagnosed by roentgenology, and 33 of these 121 cases have been on- srw. v vrW XK -. Insttad of giving the usual clinical description of asbeStosis as mentioned in the pro- firmed by the pathdlogiatl study of the lungs; so we can say that 33 cases have been diagnoscd by x-ray and histological interpreta tion. The remaining seven eases have been gram, which description may seem to many diagnosed by pathological study only, having a matter of personal impression and there- been missed on the reading of the standard fore controversial, I prefer to bring to your chest films; but it is important to add that attention a series of remarks and comments these seven cases are cases of minimal asbes- collccted during my nine years of medical tosis. Without going into a too long discus I supervision of some 4000 asbestos mining-^s io n of the effectiveness or the superiority / workers. "^ty^-oent genology' over histupathology or From 1945 to 1953 the annual medical and .Vrny examination of the asbestos work er*, alng with the histnlogieal study of 58 viceVtasa for' making a diagnosis of asbesto sis, I sNnikt like to add the following re marks. \ , autopsy.cases, permitted the detection of 128. Wc have to admit that the roentgenologi cases of asbestosis; 40 of the patients are cal interpretation might fail to detect cases airead)- dead--and autopsies have been pert fnrnu:d j -ind SS arc still living. 'Table 1/gives the .age-group distribution and the classification by degree of asbestosis in the 128 \:asc$. Youm ay see that there are 72 cases of minimal, 35 cases of moderate, and 21 cases of advanced asbestosis. The age distribution indicates that 16 wurkers are 70 years and over--one worker with far advanced asbestosis is 84 years of age and still living--and 66 workers are 60 years and over. . First, i t seems indicated to explain how the diagnosis of asbestosis has been made in these 128 cases. One hundred twenty-one of minima! asbestosis, but from personal ex perience and from repeated contacts with Gardner, Sampson, Robert, Bristol, Votw ald, and Pratt, I can say that no cases of asbesto sis of clinical importance have been diagnosed by the pathologist without having been de tected anteriorly by the. rucntgenologist. I do not know whether a similar statement is true for employees of the asbestos textile industry, where apparently the x-rav pat tern of asbestosis is fainter than the one found in the asbestos mining industry. A second comment, is about the wide discrepancy in the appreciation of the degree of asbestosis by different pathologists. Tu a few instances, cases which looked like mini Ttutforit Industrial Clinic. Ri'.ifl in tin.' Symposium on Occupational 0!vast-i of the r.mtfat, |iriorel by the Maiarlm.eHs Medical Society in "xiKrtion with the Institute o ' . liiilu-trial Medicine **f the Xcw York University-- Pot-liraduatc Medical,School, Boston, Oct. 28, m.i. mal asbestosis to one jeithologist have been classified ns advanced Asliestoris by another pathologist. With the increasing number of autopsies for ukl employees and with the recent use of the lung biopsy and the lung resection in aslwstos workers, we may assume 204 cubical onsnnr.iTioxs o f . i s m ,s t o s is T-Wile i.--Thelford Mines Survey, 1945-1953 D is trib u tio n O f l l s C a t o o f AtHv<taU h y A e* C i mips, anil by Intensity literature. Xevertlieless, briefly, I. want to review these causes of death, trying to investi Minim! rii*toil* M'.-Irmt* Kil.'l'ittUli A'lvnDMil #b*iloiti* Tout Aye Croup*, Tr. ' ' '."A"1--- ......... . a 5u*50 6M4 6.V70 TOO ar*mri Total 20 24 I a 9 ' 72 * M s 4 35 6 1 --JO ' --3 --1 21 22 40 Si 10 JO. J23 gate -the part played by asbestosis in the death. It is true that 12 cases, or 30% of the deaths, were caused by an evolutive tuber culosis; this incidence may seem too high, but knowing that a more complete statistical analysis of all the employees ih the asbestos industry made in 1950 did not reveal a higher incidence of tuberculosis than in ft control that there will be more instances in which group or a severer evblution of the tuber pathologists will differ in opinion among culosis, this rate' of 30% is not ill itself suf themselves and will not agree with the roent*. ficient to establish a causal relationship be genologist in the estimation of the amount tween asbestos-dust inhalation and tuber of nsbestotic fibrosis present. This lack of culosis. agreement is very'confusing in any medical Considering the second cause of death, study, but it is still more confusing before coronary thrombosis, it is difficult to explain a compensation board. how a minimal or a moderate asbestosis For practical purposes, it is of great ini-' could contribute to the formation of a throm portance that a solid roentgenological classi bus in the coronary circulation, and, conse fication of the cases of asbestosis, correlated quently,*! am inclined to estimate these five with the histopathologicnl findings, he recog deaths as not related to the factor asbestosis. nized and accepted by all those concerned The third cause was cardiovascular dis with this problem of asbestosis, because the eases. It is not so simple to say how many chest film must be considered as an essential ot those employees have died from their i criterion in making a diagnosis of asbestosis cardiovascular disease and how many have I and, notwithstanding the limitations of the died from their asbestosis. chest films in some exceptional minimal cases, The fact that most of the employees who this tool remains more objective and more have died from cardiovascular diseases were adequate than atiy other presumptive criteria. 0 and over and the fact that statistics men Table 2 shows the seven main causes of tion that 65 to 70% of the population of the death in the 40 cases of asbestosis that have same age are also dying from cardiovascular been autopsied ; 12 patients have died from diseases should be taken into consideration evolutivi tuberculosis, 5 from coronary before arriving at a conclusion.. . thrombosis. 10 from cardiovascular diseases, 4 from cor pulmonale, 6 from bronchogenic carcinmi, 2 from bronchopneumonia and. bronchiectasis, and the last one from cancer T a b l e t.--Thetfont Mines Survey, 1945-1953 Cam.* o f tteath In a Srl*s of F o rty Cane* o f A*b*ttnils *>i the brain. In reading this Table, the first question which comes to mind is: To what extent is E. ululiv mltf. viilosll , Minima! Moil-rat* Aih-uitml AI>M* Art ri Ah**. toil* to*!* tosi* 5 ? 0 T otal 15 ibis enumeration of causes of death different Comnnry thrum* l*o,*l 1 4 0 3 in mi a similar enumeration for a comparable- (.'uf'llovtiaoliar 3 4 3 10 Sjriiup of employees from another industry? L'oIrto|*tiit'|)*r.nnle 0 1 3 4 Ibn'orttinately, I do not know whether there Itp.nchwnml* rtm liium i 3 t 3 0 is a marked difference, and I did not have U t<>tbho|>niMiiiinnl * 0 6 3 the opportunity to discuss this Table with ami l-ronrhl* tori* "ibcr physicians or to -compare it with a 1 0 0 1 Miuibr one which may exist in the medical Total tl IT * u tynrsTRMt.tiE.tt.ru fir a few borderline tMses in which it was employees in the industry does not seem to difficult to appreciate clearly the role played indicate any statistical evidence of a' causal by thc asliestosis and the- role played by the relationship. Therefore, the part played by cardiovascular pathology, the different car the asbcstotic fibrosis in ( roup 5 remains diologists consulted were of the opinion that,, questionable. unless the. ashcstotic fibrosis- is extensive The two patients who died from broncho enough to produce pathological or clinical pneumonia and bronchiectasis most likely signs of right heart failure, it is impossible died from this pathological process rather to tell with some certainty that the fibrosis than from their minimal asbestosis. The last lias contributed' appreciably to the death,, patient died from cancer of the brain. especially if there are evident signs of ad lit summary, in inv {ersonal opinion, six vanced degenerative diseases. patients quite obviously died, front asbestosis. In practice;, this group of employees with and the other 34 developed a lesion which cardiovascular diseases and a minimal or a could very well he considered as the cause of moderate degree of asbestosis is liecoming, a serious problem as far as the compensation aspect is concerned. Without too much im agination'and front the findings of an in Table 3.--Thclfvrd Mines Survey, 1945-1953 Clinical Statu* ot Klitltt.v>Kticlit Mtlii* patient* with Axbtstnsls creasing number of autopsies on old em ployees, we can-assume that there is a large unknown number of employees who have a minimal amount of asbestosis and who, most likely, will later on. al.-o .present a cardio JIIM S''tom*........... .. Tuyrv ...... Minimal to-l* 11 S i Mtlrr(t A>lv<mit>l Al<*s* ASms toil* toil* 4 3 3 9 9 a 1 s vascular disease. Then, unless definite cri- IS u teria are developed to estimate "bjectively the harm produced hv the asbest. -i* and the death, although we do not know tlfe role harm'produced by the cardiovascular process.,, obviously- those cases will remain embar rassing to appreciate correctly both by the clinician and by the compensation Iwards. I have purposely separated from the cardiovascular group the four cases of cor pulmonale, because these four deaths seem pure evidently related to the presence of asbestos!. There are also the cases of two other workers who although they died from bronchogenic carcinoma and asljestosis >howcd evident signs of right heart failure. Therefore, we can say that in six cases ot asbestosis cor pulmonale developed and the patients died from their asbestosis. The billowing group of six cases of bron chogenic carcinoma present a special interest. Without going into any discussion of this problem of jiossihle relationship lietween asbestosis and pulmonary carcinoma. I just want to say that there are also seven other patients with-bronchogenic carcinoma among played by the ashcstotic fibrosis. Table 3 gives the clinica.l status of the 8i? living patients with asbestosis. In analyzing this Table, I have to admit that we cannot be too certain of the classification of the cases of asbestosis into minimal, moderate.' and advanced, because there is a significant dis crepancy between the roentgenological and the pathological classification. Here tlie classi fication is based on a roentgenological appre ciation. and likely the histopathological classi fication would lie different. A second inqiortnnt reason why this Table may look highly questionable is that it is quite impossible to evaluate clinically the respiratory function of a group of employees when a large proportion of those employees are 60 years of age and over ami when they present at the suite time other diseases that may impair the respiratory function to the same extent that asbestosis might do. the employees who did not have asbestosis. . Obviously at that age there are many Moreover, a general statistical survey of ail factors other than asU-stwsis which could 3* i iu!: tlrpa. ing wit ?V \ t'; staf adv 5i , wit iir -; r re!:.: the flu d:. da*. Ht ;t .  , tu msal vil hy .wiilli :chlikely ther ic b it !. six 'SIS. Iiicli -C or .'S3 my>l H' il rule S* ./.!ng Mlt iitfi :UUl 'lis ant! i-sipre* wsi- aille It i the tv ce? ;!iey Oiat llic any n]f: ' : :.v/c.il ORKHi\ ir/o::s or .ispnsrosis hrhwiKe tlie* enrdioropirntory function. ami factors. could explain very well why 10 patients with minimal ashe.-tosis are pre.-ent- !:`g modernt* mid severe #ymptom* while 5 with advanced nshestosis have no clinical y::1.;'toms. With, all its limitations, this Table seems to rove at least one thing, that the clinical tatv.s of 36 minimal, 4 moderate, and 3 advanced cases is good and that a total ot v a.shestbtic employees are able to work without any discomfort--I mean those in the `:rt two groups. ` Tor the remaining 29 cases, no good corr-Tation between the degree of asbestosis and the clinical status has been found. There is a better correlation between the age of the etnp.oyeei and the clinical status, showing the role played by the age. This Table may also demonstrate indirectly thru tuo many similar tables giving clinical lata. ;-itch as cough, expectoration, and weight, cannot prove too much. To >nMilitarize, I believe that aslie.-tosis is r. -eriotts disease in some instances, lint more freijncntly it remains a disease which can be tolerated rjtittc well for many years, even without appreciable symptoms, as long as another serious disease 'incj not supervene to cause death. On the other hand. :n practice, this dis ease may look more serkus and cause impor tant medicolegal problems if a too scientific medical concept or a too liberal social inter pretation is accepted by the medicolegal pro fessions, labor and compensation bodies. As a matter of fact, if the least amount or a minimal amount of aibestotic fibrosis is interpreted as asliestosi?. ``occupational dis ease,M and, more so. :: the compensation boards decide to apply the aggravating factor clause, notwithstanding any effective dustcontrol program, the problem will remain unnecessarily serious for many years to come. The combined effort of pathologists, physiopathologists. roentgenologists, cardi ologists, and clinicians is needed to orientate any research program fcr.d to.bring answers to the many unknown aspects of asbestosis. : i t II i!r ;i 207