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- ; "|f ,,, * -I>i^Tf&*i r*/ri|1/Ir?1 w *, (>,;( A REVIEW OF PNEUMOCONIOSIS FURTHER ROENTGENOLOGICAL AND PATHOLOGICAL STUDIES' By HENRY K. PANCOAST, MO, e*d EUGENE P. PENDERGRASS, M.D. PHU-tOClPMA, PtXKSYLVASU Sfe K 1925, at the request of the Editor of the American Journal of Roentgenology ri* * and Radium Therapy, we reviewed the roentgenological and pathological aspects of pneumoconiosis in a paper presented before the American Roentgen Ray Society . and published in the Journal*4 of that year. feiFit iV- 5 tr * t A more complete presentation of the sub ject was made in a monograph*1 published in 1926. The condition has aroused a sur 1 prising amount of interest throughout the civilized world in the short time that has elapsed since then, and especially in -his ^11 t t < country. Papers have appeared in great numbers, further experimental work has been done and numerous investigations "**&*&' * , iiJH s' . s/is# v - ; -, have been carried out, especially here, by federal and.state health bodies in connec tion with many industries. For these rea sons it has seemed pertinent to present a further and up-to-date review of the sub ject to the body of roentgenologists. This increasing interest in the subject is a recognition of the great importance of the condition of pneumoconiosis as a more or * less necessary risk of commercial develop- merit in the progress of civilization during recent years. This has led to the enactment '"i- ' of adequate compensation laws and reguladons governing the adoption of safety .-Tv.'*. V measures intended eo eradicate or modify the essential dangers of occupations by countries, notably the South African Australia, New Zealand, Great Britain, Germany and one of the Canadian T ;rv - ^yi. 1.Provinces. In this counoy we have no ~ti.-i --': J> fate*! laws directly applicable to the en- ' L \ fqrcamdit-bf controlling measures or com *, -4 pensacon. In only a few states is pneumo- ljmr W^co^osis a compensable disease. Some states quate oversight, but largely because of the geographical extent of this country and the scattering of the more or less dangerous dusty industries, there is a lack of knowl edge of that prevalence and its seriousness. As the roentgenological examination is the most accurate and satisfactory method of detecting the condition from its earliest to its most advanced stages and of study, ing its progress and its incapacitating ef fects, it behooves us as roentgenologists to be familiar with all of the phases of the disease, and not soleiv with the reentgenographic appearances with which all of us are more or less familiar. We must play a large part in the education and the public ity which are so much needed to overcome the ignorance still existing, even on the part of employers and employees. We will be called upon for our part in the program leading to the enactment of satisfactory compensation laws which are sure to follow in time. In the meanwhile, civil suits are increasing in number and we must train ourselves in order that we may be able to testify, when called upon, honestly and justly for the benefit of all concerned. It Has been our endeavor in this presen tation to avoid as far as possible any repe titions from our previous publications, and references to them will be made only w!*en it may be necessary to better explain he newer phases of the subject. NOMENCLATURE While it still seems probable that :-:iica (SiOt) is usually the active fibrosing agent in the condition which we recognb'- ** essentially a pulmonary hbrosis, adherence to the general term of pneumoconiosis sciu seems advisable just as much now as at the time of our previous presentations of the subject. Some other dusts undoubtedly w? ; t* g: / . . .v #neu un aionq^bi ' iiimi i uwvsuj os rnvvivavs (Mtifuitiaoi Scfconi aad Heapitai, PMUJalpfcta, Pa. R4 at tk4 TWr** . vl ,'T*--'.Av;i -i'i*;. Intiintl 'y*.*Bn%, Aam i'nn flowrun RafSoetcrr', Wr 8'4r, IwL, Spl JJ-S*, ifcjOw * 'irr Y-tfr) 586 Henry K. Pancoast and Eugene P. Pendergrass Ocrwcia, ./.* bestosis is ample reason for the presenta over vibrating machines. The heavier rock tion of a general resume of the entire in particles are separated by gravity and rhe dustry, as well as the pathological, clinical asbestos fibers are aspirated out by vacuum and roentgenological aspects of the condi fans into special chambers. The crude *- tion. bestos is then shipped to the various fac The dust evolved at the asbestos mines tories. All of these procedures are carried contains a moderate amount of silica. The out at the mine bases because of the econ harmful products of the asbestos factories omy in shipment of the lesser bulk of the are almost entirely silicates. Heffernan4* be crude asbestos- lieves that silicates such as asbestos under The mining part of the industry is at go changes in the lungs quite like silica, tended by the elimination of a large quant only slower, and that asbestosis is a true ity of dust, which contains silica as well as silicosis. This is, ofcourse, not proved. silicates. Pneumoconiosis is found among The product was mined and the asbestos the workers. Very liede has been written fibers were separated from the mineral and about the condition of these men. Recently employed in the making of indestructable we have bad the opportunity of examining fabrics several centuries b.c. Attention is the roentgenograms of 58 men from one of called by Cooke*' to a cremation doth de the Canadian mines, some of which showed scribed by Herodotus 450 b.c. Materials pneumoconiosis. As the mineral rock con made of it have been used ever since then, tains as high as 60 per cent silica, the mine but the most rapid development of the worker's condition is due largely to this commercial industry has been during the directly, although probably not entirely. past two or three decades. The raw product which goes to the factories Nature. Asbestos is a peculiar fibrous and contains very little free silica. crystalline mineral composed almost en The most dusty occupations in the indus tirely of silicates, mainly of hydrate mag try are to be found in the factories, in nesium silicate, with varying admixtures of which the work is done in inclosures where those of aluminum and iron. The general the asbestos is refined and is finally spun term is applied to ail silicate minerals and woven into the various materials with which have a fine fibrous structure that can which we are familiar. During all of the be split up into long, flexible fibers for the factory processes, a large quantity of fine purposes of spinning and weaving. The dust is set free, but in varying amounts in fibers will split up in a longitudinal direc the different ones. Most factories, at least tion almost indefinitely. The minerals differ in Great Britain, have devices for removing in their exact constituency, especially as much of the dust. ` to the amount of iron and aluminum, in Early Case Reports. 'l*he first report of1 different countries in which they are found * death resulting from asbestos dust inhala and mined. Much of the asbestos used in tion was presented by Murray,1* in *9CO. Great Britain and the United States is The man worked in a factory for ten years, `mined in Canada. CooJce*' gives the follow- mostly as a carder, and was the sole sur 4 ing chemical composition of asbestos: vivor, before his death, of to other m?.i wh sqfa.................................. per cast started work with him. The autopsy on this case revealed pulmonary' fibrosis* Photomicrographs of sections of the iS* i. Iran oxide........................... .... 4.81 * Ahunflffuft 0.70 - r* War:............................... .... 13.55 showed large spicules of asbestos, ar least they were so regarded at that time. . The second case reported in medical TheIndustry. At the mines, the mineral is literature was presented by Cooke.1* 111 blasted, crushed and finely ground in ma 1914. It was again reported by him in Jf chines*. The crushed dust is then passed tail in 1917,*' This individual stopped, hi* tfc. XXVI. Na* Review of Pneumoconiosis work in a factory after eighteen years of intermittent occupation. The cause of death was probably asbestosis and super imposed tuberculosis. We referred to this c35e in our previous contribution," in 1916, is largely a tuberculous one, especially as lC the first available autopsy report in the literature. In view of the many deaths which hare been reported since then, we mu; now concede that this death was probably the result of both conditions. Naturally, Cooke was the first to describe the unusual and characteristic asbestos bodies in the lungs, and the authoritative description of them was made in his second report of this case in 1927. These bodies will be described in detail later on. The second paper and third public re port was presented by Oliver," in 1927. He reported the cases of two women who had died as a result of asbestosis after working thirty and eighteen years respectively. Neither individual had evidence of tuber culosis. It is interesting to note that the sec ond of these cases stopped work after eighteen years' occupation, and did not de velop definite symptoms until four years later. The next report was by McDonald," in 1927. He referred more fully to Cooke's case, and reported an additional one which died. He thought it reasonable to believe that in the former one the tuberculosis was a superadded infection. His own case did not have tuberculosis. In addition to the two types of asbestos bodies first described by Cooke, he added a third, all three of which are now recognized. Seiler,m in 1928, reported another case who had worked twenty-two years in vari ous capacities in asbestos factories, and preserved the typical symptoms of the advar.- 'i :ase. No tubercle bacilli were found in ri.. iputum. The roentgenographic ap pear:' <.ces seemed not to have been unusual. SiiYv-.n,1** in 1928, reported two deaths arn'-.r asbestos mill workers in South Africa, with autopsy findings. The first man worked only one year and died of miliar.* tuberculosis. The lungs showed slight fibrosis in addition to'the evidences 1 of the tuberculosis. The second case worked jb " two years in the mill and died;.The phfr*ii*~ cal signs suggested tuberculosis with fibre1; sis. Autopsy showed a moderatedegreeof fibrosis widi nodules, but quite cellular, J and not like the usual silicotic oodnksf', There was no evidence of tuberculosis.The various asbestos bodies were found in both ~ cases. These cases are of interest, cause both presented definite evidences o v ' asbestosis after one and two years' work*'* respectively, and also the various ` bodies. characteristic of the disease, and, secondly, for the reason that the second case pre- * seated the terminal symptoms and died of the condition after only two years' occupa- - don. .; Wood and Page,119 in 1929, reported- autopsy findings in the case of a woman' who died of bronchopneumonia after nine years' work in a factory. There were no . evidences oftuberculosis. The lungs showed, diffuse fibrosis and thickened pleura. Nu merous asbestos bodies were found in. the lungs, but not elsewhere in the bodyt Wood : Y' and Gloyne,u* in 1930, reported the asxtop4 4 sied cases up to four. Tuberculosis was' found in three of these cases, and in two, bacilli had been found in the sputum before death. Haddow,** in 1929, reported on the- . deaths of Oliver's two cases, and on two others. He stated that the certificate of the Vi last one, March, 1928, brought about the publicity and official recognition of the' condition. Since then, the workmen's com pensation act of Great Britain has been ex tended to include asbestosis.9* Haddow scams that one of Oliver's patients had tubercle bacilli in the sputum. Simson1** quotes Hoffman" as reporting 13 deaths in 19x8 and Collis,** 5 in 1910. These were in health reports, and will be referred to again under predisposition to tuberculosis. Mereweather and Price,7* in their recent comprehensive report on the asbestos in dustry state that approximately 2,200 in dividuals are exposed to practically pure asbestos dust in the factories of Great 538 Henry K. Pancoast and Eugene P. Pendergrass 'XtMkt, 'ijj, Britain. These authors examined 363 in dividuals among the workers. Of this num ber, 230 had been employed less than ten years, and only 2: over twenty years. All but one of the 363 individuals had been working at the time of the examinations. Ninety-five, or 26.2 per cent; showed defi nite evidences offibrosis, due apparently to asbestos dust solely. Their table of the rime incidence of the condition is of interest: Tears at Cases Showing Work xaraiaed Fibrosis . 0 4 S 9 IO CD 14 15 to 19 30 sad over 89 I4X 34 38' 31 0 36 17 IS Per Cent 0.0 *S-5 3a.1 53.6 80.9 This table does not apply to any one group of workers in the factories. The authors have collected also, outside of these sta tistical cases, records of ro deaths resulting from asbestosis, 9 of which were verified by * autopsy and the tenth by repeated clinical and roencgenographic examinations. Nine . of these deaths occurred from 1927 to 1929. The exposure of the 10 cases varied from nine to twenty-four years. At the rime of this writing. Lynch and Smith47 (1930) are among the latest eaten? rive contributors to the subject, and their ' report has been the first one in this coun try, at least in medical literature, to deal specifically with the subject. One of their . cases, a negro, died as a result of a gunshot injury after working twenty-right months ' in a mill during a period of three yean. His lungs showed definite interlobular, peri vascular and peribronchial fibrosis, and w also the various asbestos bodies. The secV'.ond ease, also a negro, died of lobar pneujpoooiri after four and a half yean of con tinuous work in a mill, His lungs showed .^everywhere a definite increase of young ?; ififctbus,tissue, in addition to the various as^ bentos bodies. Reference will be made to other* cases examined by these authon in ** die. description of asbestos bodies. It is in- teresring to compare the findings in these cases and those of Simson with the dinual table of Merewether and Price. It is quite possible that protective measures pi*, sd an important part in the incidence ot die condition, as shown in the report ot die last named authors. Appearance of Asbestos Dust. Cookc; :>u has described the microscopic appearance of the components of asbestos dust in some what the following manner: (1) Small fragments of asbestos fiber. The bulk of the fiber is translucent and glistening, with here and there within it opaque particles and minute black gran ules. These appear to be actually parts of the fiber, but their appearance suggests dif ferent chemical composition and physical characteristics. (2) Translucent spicules split otf from the fiben. (3) Black, brown and blue particulate matter. The Black particles are iron. They are few in the finished asbestos product but are numerous in the dusts of the carding rooms. The iron in the finished product was only 0.1 per cent, whereas in the dust of the carding rooms it was 18.4 per cent. Asbestos Bodies. This is, perhaps, the most interesting feature of pulmonary asbestrv sis. The various bodies found in the lunp of asbestos workers have been described in detail by numerous authors, notably by Cooke,*447-" McDonald," Simson,`"Gleyne,1* Merewether and Price" and Lynch and Smith.*7 The description given by of the various asbestos bodies is as compf** hensive as thae of any other author and is abstracted as follows: (1) Enormous amounts of fine granular1 pigment like that seen in the asbestos dust fiber. Much of this may be carbonaceous. (2) Large or moderate sized angular par ades, io to 360 microns in size, correspond ing to the black, brown and blue particulate matter found in the dust. These particles are found in fibrous and necrotic areas, singly or in dumps. Because of their sue, they might occlude small bronchi. (3) Almost complete absence of the very Henry K. Pancoast and Eugene P. Pendergrass Drmu, : 6M&ra.-*!ag -.2-\ orf course, as k any fairjy well advanced 1* *i. - case of opnnecmrisoiosis. The most unusual feature of die Edition seemed to us to be the fact chat 5s both sets of roentgeno grams die appearance seemed to begin more often on the left side than the right I W.j and progressed rrtnre on that side. This is the reverse of vhat is the rule in all other occupations wehzve studied. Merewether71 states ehat it iBgias on the right side, as !ii v~a one would cjliis--, and the cases we ob served mar base been examples of the ex ceptions whichare occasionally observed in cases on careful analysis resolves itself rto a fine mottling and linear shadows w! 'cfc, toward the base, may look like cobweiv*. It is evident that the nature of these changes in the lungs requires the best type of roentgenograms for their portra>ah Also, the seriousness of what may seem to be minor changes to the uninitiated re quires a roentgenoscopic study of diaphrag matic movements to make one realize the actual state of disability present. It is evi dent also, as Merewether states,71 that aa opinion as to the degree and intensity of an asbestosis fibrosis based upon a comparison $ts5r3-5E3CBsi If* ft . !> fe3ST8.!f-^ *> of roeatgenographic changes with chose shown in standard silicosis films will be aa underestimate. Of the 363 cases examined by Mere wether and Price, 133 had roentgeno- graphic studies. Of these, 52 were said to have presented appearances of diffuse fibrosis and :: were suspicious. r^a $ We have had the opportunity recently of examining in consultation the roentgeno grams of 53 men employed at the mines in many occupations and daring periods vary ~,Vi. % ing from eight months to forty years. Of this number, 15 showed definite evidence * "" . %r * of pneumoconiosis, one was doubtful and 42 showed no lung changes. The longest worker showed a moderate nodular stage " ~to. 9.2jseamaoanammia aa uouta worker. Male, * agm forTr-mree. employed for wgateea yean of the condition. The shortest times in * and a uti't/iu as tb' e d' a* of* enmin' adon. which definite changes were indicated were Than are am ves&miaaat types of Sheens in four years for one first stage case, five years for another and five years for one and mriy advene aterstittaL The Utter is indi early second or nodular stage case. The cated by the fusxi haae toward the bases, and awce on the Note the psrtUi oblitenson worst case showed a diffuse third _ ^ oftae left bean boresr. The size of the ^Hi*c fibrosis after thirty-one years' occupation ^ >f. - ^**hwfow 'zs dae tnae oid technique of many yean Asbestos mine dust is not comparable * n5w ** diaphragm asardon J lack each side, ordi- to that of the factories for many reasons. ?%*' .3>&*> 5fo*iy tespiiaaon.Bis 1 {inch on forced respiration. Some silica is present, but there is tuy rhe great concentration of asbestos dust i*1- the ^irty'dsdiistrtai assuaoconiosis. We noted mine as compared to the factory. Fromour '** TKft same tessdmcy to obliteration of the own experience so far, we would not regard ` jS` _ ** ` ` mentioned by Wood, ise fibrosis and the shadows. Wood states .. .. _ or may not show ribae. Wood and Gloyne^* state gruttg. put appearance in late the hazard at the mine as very great. Prognosis. It seems to be the rather general opinion that the prognosis in pul monary asbestosis among factory workers is to be regarded as grave without adequate protection, in a large number of cases Vm. ^n* N"- * Review of Pneumoconiosis mrjpg^ong chose who work where there " Concentration of dust. The * Apparently progressive even after !of occupation. Merewether and ^chat with continued exposure w ,, Vcentration dust fibrosis may be fidiy de-^.1 produced by silica. Asbestos*is a siHcattv,\ Vdooed in from seven to nine yean and^iand if we are to regard asbestosis as 'jeach may result in about thirteen years;; ^silicosis, as has been suggested \Mt! less concentration, fibrosis may not be>* ^proved,* the latter condition is ^ ^ \jyiv developed for fifteen, twenty orrdirectly caused by the asbestos. Certainly*, .twcicv-five yean. Inhalation of du^ im-; the legal status of asbestosis as sflicosis ha* ' "** Ciai> concentration results in a mores'pot been established. In some instances jpActi degree of fibrosis in a shorter time asbestosis has had to be made a compeasa- thrn when the concentration is lower., .^fi?ble disease. ' * , disposition to Tuberculosis. The con Hajud Rocjc Mining. This group of' dition of pulmonary asbestosis being a new workers comprises the largest engaged>inr chiia in the pneumoconiosis family, a great any single hazardous industry through amount of interest centers around the in out the world, provided the rock is of a.si- * cidence of tuberculosis. Among the early liceous nature. The large amount' of dust case reports referred to in the beginning evolved In the various processes of mining- of this occupational section, pulmonary Is always dangerous unless adequate pro* tuberculosis was reported as an accom tective measures are adopted. The drillers panying condition in a few instances. and those working with diem or near that - Cookes case had advanced tuberculosis. are prone to be the most exposed. If the Simson reported one case which died with fine dust is allowed to escape, it remains ' r tr tuberculosis and one without evidences of the infection. He thought that we could not as yet formulate any definite opinion as to the frequency or the predisposition. suspended in the air for hours* Blasting ak ways stirs it up. Without protection, the usual typical symptom-complex and the roentgenographic appearances develop ear- . Simson quoted Hoffman4* as reporting 13 ly and progress rapidly, and.the workers deaths among asbestos workers, 3 of whom are predisposed to tuberculosis. More has had tuberculosis. He also quoted Collis" been written upon the hazards of this in as reporting 5 deaths from tuberculosis dustry dun those of any ocher. Numerous among less than 40 workers at a factory. writers have been extensively quoted else Wood and Gloynem referred to 3 cases where. Many more or less similar Indus* showing evidences of tuberculosis at au tries and their hazards have been described topsy. Haddow" observed many asbestosis in detail, such as the drilling in coal mines,;, cases and among them 4 died. He did not granite cutting and sandstone quarrying. believe that the condition predisposed to The most detailed descriptions of hard the infection, ae least not as a rule. Mere* rock mining have emanated from South wether and Price stated that asbestosis Africa through individuals associated in differs from silicosis in the distribution of medical work or other ways with the Rand the fibrous tissue, in more rapid develop gold mines. These mines are so often re ment, in roentgenographic features and ferred to in the literature that a short ab pcssiMy in a lessened susceptibility to tuber- stract of the description of the region and atl'- ii. Merewether" states that out of of the character of the rock, may be of in j'. ,rises examined, evidence of active terest. Cluver4* scans that the first gold nfi :.*. iiosis was found in three. He thinks mining in South Africa started in the the .vhile there is no outstanding sus- Transvaal in the 70's, and the first gold ccr :!ity proved, he does not agree that was taken from the Witwatersrand in 1885. ^ '' r. iJ'-.-h-; ..*>lfK. -I-ii ***.?