Document bOLE8QOB6k7o8NMOe698Q2VpD

PCLMOXAKT ASBESTOSIS Ot emaciated. His chief complaints were pains in the right side of the "stomach/5 right side of the hack and shoulder, and shortness of breath. History: Trior to 1931 the patient's health was good and practically no time was lost from work as a result of illness, although for five years lie had noticed some shortness of breath. He had had influenza in 1918, hut except for that had always been well. In 1931 he lost three days from work on account of sharp pains in his back, extending down over the three lower ribs. Xine months later intermittent sharp shooting pains occurred involving his right shoulder. These lasted about ten days. Except for the shortness of breath, there were no further symp toms until Xov. 7,1933. when there were renewed attacks of pain involv ing the right shoulder, axilla, and the three lower ribs on the same side. The pain occurred about every hour and lasted about thirty minutes. It seemed to be more severe during the night. The patient also became quite weak and denied to lo-e weight. Ho was now compelled to quit work and seek medical aid. Turing Xovember and December, under medical care, he grew weaker and lost more weight, his dyspnea was aggravated, and a cough, productive of wiry, white mucoid sputum de veloped. On Jan. S, during a spell of coughing, he expectorated fresh blood mixed with mucoid material. The family history was not significant. Oi.t-.uyat to mil History: The first exposure to a dusty atmosphere occurred when the patient was about sixteen, when he began to work in a cotton mill as a weaver. Ho first worked in a place wilh open doors and window';, and later a humidifying system was installed; he did not consider the atmosphere excessively dust laden, lie continued work as a weaver in various cotton mills until 1913, when he obtained a job as n weaver at an ashe-tos factory, which he held until just prior to hospital admission. During times when his work there was sus pended he did odd jobs, with apparently no occupational hazards. Be ginning in 1913, he worked in an extremely dusty atmosphere, in spite of the fact that windows and doors were kept open as much as possible. About J9:23 a humidifying system was installed, but this lie considered rery inefficient, though it improved the atmosphere somewhat. In winter the heating system kept the air in the plant too dry to allow settling of dusty particle'. In summer, when all doors were kept open, nir from the forced draft from the " preparation room/' emptying out side the plant, entered the room in which the patient worked. The last five or dx months of hi- employment he was at " wet work " insn-rid of dry vent ing, reducing the exposure to du>t. He was accus tomed to work overlime. since he was paid by the yard. Tliis man, tlion, worked as a cotton mill weaver for approximately twenty-two years and ns an asbestos mill weaver for some twenty-one years, which may account for certain features of silicosis in the lungs, addition to those of adwstosis. #Coarse.- Throughout his stay in the hospital the patient continued complain of persistent pain along the right costal border and right -o y <ox. f o< oo w zp min oO xlu < t- hr H 2o! 2 O _ UJ . z9DO co Q. nh --2 >>9Z 22 W</T St bmd Do <s> 5: r- 2 a o co ~ Sgyg -^ t- & t <T> <rj CD 'tl te* ' fr 2 9;r-_ ^ #: & m? jS * *sj oo S' * r/> i ^ BB 0005402 J I 58 KEXXETH M. LTXCH AXD W. ATMAB SMITH side of the abdomen. The cough, with c-xiiectoration of a large quantitv of mucopurulent sputum, continued and became more aggravated. There was anorexia, with progressive loss of weight and strength. For the first three weeks after admission there was an irregular afternoon elevation of temperature. In the latter weeks of the illness fever of remittent type was constantly present (99:-L01')t rising on the day of ' death to 104\ The pulse rate ranged between 90 and 100. The res- piratory rate was constantly above normal and on the- slightest exertion there was dyspnea. Examination: In general appearance the patient looked much older *than fifty-seven. He appeared exhausted and was extremely weak and V I cm ' previ X who a gci Thor l.y p area- riehi <ornc Fig. 1. Roentgenogram Showing Pi-laionaiw Asbesto-silicosis and CXSti^cbra. or Lower Right Lone emaciated. The finger nails and toe nails were clubbed and somewhat cyanotic. The bony tliorax was of the emphysematous typo. Kxpansion was equal but poor. Dullness was present over the bases of both lungs, be- ing more marked on the right. The upper levels were resonant. % Breath sounds were suppre'-ed over the right base. Kfdes of all varieties were present in the lowor posterior and axillary aspect of the chest. ^ though less numerous over the right base than the left. They were in- creased by cough. There were numerous coarse, dry, "squeaking" sounds over the upper lobes a- well. ^ Fhe heart wn? normal in ~ize and position; the sounds were good. * Ihere Mere no murmurs. The pulmonic second sound was accentuated. *:l The systolic blood pressure was 100, diastolic 00. The superficial ves-~ sels were thickened and tortuous. Tlie abdomen, muscles, bumjoints, extremities and nervous sys- -*>, 1 Xo t A>b. piH. nial. cent nuui ( Da neul olVil puei olive fT I !r- n: 1 BB 0005403 | PULMOXAKY ASUESTOSIS 59 irm presented no abnormalities except for the clubbing of the fingers previously noted. X-ray examination of the chest was made by Dr. Hillver Rudisill, who rej)orted as follows: " First examination, Jan. 12, 1934: There is n generalized fibrosis throughout both lungs, particularly in the bases. There is generalized increased density in the right base probably caused bv pleural thickening. In addition I believe there are bronchiectatie nrers through the lower halves of both lungs. Impression: Pulmonary fibrosis, pleural thickening (particularly richt base), and bronchiectasis, probably the results of inhalation of sonic irritant material." Fig. AsBEsTO-iOi.ji'osas with Carcinoma or Lower Lobb I Ik- tuberculin (Mantoux), and AVassermann tests were negative. No tubercle bacilli were found in the sputum on numerous examinations. Asbe>ii>is bodies were present in nnconcentrated viscid, tough mucopus. To'ts lor fungi wore negative. The miliary findings were nor ma!. I'.lood counts were as follows: Jan. 11, 1934: hemoglobin 80 per > < !i; (Daie), leukocytes 13,325, small and large lymphocytes 11, large uioii.iiiurlcars 3^ neutrophil.-, 8b; Feb. 20, 1934: hemoglobin 72 per cent 1 l'aie). leukocytes 13.250, small lymphocytes 18, large mononuclears 4, neutrophil-, <0. eosinophils 2. 1 !u- admission diagnosis was pulmonary fibrosis and pleurisy with t!ii-ion. 1 he linal diagnosis was asbestosis and chronic indurative pneumonia. Jnlnp.s,/ (B.G.) .Vo. 2nr,U-;n~r,s, March IT, 1234: Summary of patli"b'gieal diagnoses: Filirosis of lungs; pulmonary asbestosis; epider- 60 KENNETH M. LYNCH AND W. ATAIAB SMITH moid carcinoma of right lung; bronchiectasis; purulent bronchitis;] acute pleurisy; chronic myocarditis. The body is extremely wasted as to adipose tissue aud musculature,! all muscles, including the interosseous, are quite shrunken. The distall phalanges of the fingers and toes are broad and rounded. The chest i is quite prominent anteriorly. The right lung is densely adherent over its whole surface, but par-, ticularly over the lower lobe and at the base, over the diaphragm andi toward the spine. The left is adherent'rather lightly at the apex and' very densely over the lower lobe, particularly over the base and dia-3 phragm. The left pleural cavity over the middle three-fourths.con-] The vh ,,ml in tin ' |- 111 ,.\\ er a-p ,\ bris. rn lie' spi Oitl the 'l . i h11-' ii J iciekiuv. ' Tile U ;mnbwaP ro A Fir,. 3. Silicotic Hyaline and Calcareous Nodvle^in Lung, to " Asbestosis" Bodies. X 210 S/i.. . <\ tains about 300 c.c. of turbid fluid and there are no attachments here to the outer pleura. The pleura of the right lung is thickened as a whole and is of car tilaginous and even partly calcareous quality over the base. That of the left lung is likewise thickened, but over the free portion it is rough, congested and " furred," with small nodules in the surface. The apex ot the left lung is composed of a globular mass of light balloon-like emphysematous bullae with intervening fibrous trabeculae, and sub-apicallv there is a group of small caseous and calcareous hard nodules. The midportiun of this lung is light, spongy, dry, and of a mottled dark slaty bluish-gray color, beginning at the apposition of the interlobar pleura, the mwer part of the lung is deimciv tough, with gross fibrous trnbeculation fusing with the thickened pleura, and at the base honeycombed by rounded cavities about the size o0f b- ird\s*h>oV:; 1o The iihinutoi The 1 pale ami (>1 h> t appearai I'") In hcreulos bromide ilh > nilular -mall m. pllied ai: eardilis. 2_BB_00540 5~7 pulmonary asbestosis 61 The light lung lias a similar group of balloon-like bullae at the apex and in the midportiou is similar to its fellow. The lower third of the v lung is of nodular, hard, solidified consistence. Occupying the inner ~ lower aspect, at the spine, is a honeycombed cavity containing caseous \ debris, ruptured in removing the lung because of its dense adherence . io the spine. The inner aspect of the cavity is quite rough, nodular, a and the surrounding substance lumpy and caseous. This merges more -or less into heavy trabeculated fibrous induration and small cavity - "pocking," as in the opposite lung. The lymph nodes at the root of the lungs are not conspicuous, a few * moderately enlarged black nodes being found. Fig. 4. Chronic Bronchitis and Bronchiectasis: "Asbestosis" Bodies in Bronchiole. X 130 The entire hilar and mediastinal tissue is quite fibrous and edematous. The heart is not enlarged, but is of rather small size, the muscle pale and flabby, the right cavity moderately dilated. Other organs and tissues are apparently normal in relations and appearances. Vuthologieul Diagnoses at Autopsy: Fibrosis of lung; chronic tu berculosis of right lung; chronic fibrous pleurisy; tuberculous pleurisy; bronchiectasis. Mir> i,sc(/pic Fin/linys: Examination of the heart shows quite marked cellular fibrosis of the myocardium, accompanied by some large and small mononuclear cell infiltration. The muscle fibers are hypertro phied and also degenerated. The histologic diagnosis is chronic myo carditis. I 62 KENNETH M. LYNCH AND W. ATMAR SMITH In the spleen young fibrous elements and large mononuclear cell&|| increase the thickness of the sinus walls. Polymorphonuclear leuko-^ cytes are conspicuous. Here and there are small groups of larged " foam " cells, the cytoplasm full of rather large, clear cut vacuoles, y In these and other mononuclear cells is a brown granular pigment. A club-shaped asbestosis-like body is seen, whetlier embedded in the tissue or merely upon it, from transfer from'Other tissue in cutting, it is dif--;ficult to say. The histological diagnosis is chronic splenitis, ashes-*, tosis (?). The kidney is approximately normal, save for congestion. The liver shows fibrous thickening of the capsule; fibrosis anc lymphocytosis of moderate grade in the interlobular framework; patchy a* O * U>tieVA5>* Fig. 5. Epidekiioid Carcixoma of Bkoxchcs and Luxo. X 1S5 fatty vacuolization of liver cells. Many nuclei of the liver cells are large and eavitated, with a bluish fluid substance within. There are 4 congestion and brown pigmentation of the central venous area. The histological diagnosis is passive congestion, fatty degeneration, portal cirrhosis. There is chronic fibrous thickening of the pleura, with lymphoid col lections, involving both visceral and parietal layers, with an internal covering of leukocytes and fibrin. The histologic diagnosis is chronic fibrous and acute fibrinous pleurisy. In the peribronchial lymph nodes are heavy deposits of large mononuclear cells containing a black and brownish granular substance in the pulp, with moderate associated fibrosis and deposit of asbestosis bodies, generally of shorter clubbed, rod, and dumb-bell forms. There is engorge ,-lear leut lymphade In the along the generally im-matioi alveoli. (Here is alveoli a jointed, < large me iu the fit occur in nuclear mucus a The collectic are seei udatior. leukoc> oral fit Int and en empty. Iu structi with c puruh of the At munh space and c S> culoi norm extei theli a hr The n 4r { BB 0005407 PCLAIOXABY ASBESTOSIS 63 is engorgement of f lie sinuses wiih serous material and polymorphonu clear leukocytes. The histologic diagnosis is nsbestosis and acute lymphadenitis. In the lung there is comparatively heavy, old interlobular fibrosis, along the bronchi and blood vessels. Broad bands of fibrous tissue, generally old and hyaline, with considerable hyaline laminated nodule formation, are disposed generally in this area, including some adjacent alveoli. Bronchioles here are irregularly and considerably dilated, and there is much deformity of alveoli involved in the fibrosis. In these alveoli are large numbers of asbestosis bodies, generally large, brown, jointed, clubbed, and long dumb-bell shapes, in groups associated with large mononuclear phagocytes. These bodies are also seen embedded in the fibrosed areas, and in some of the bronchioles, while large groups occur in lymph spaces near bronchi. There is only minor small mono nuclear or lymphocyte infiltration of the fibrosed tissue, with some mucus and leukocytes in some bronchioles. The pleura is very thick, composed of old fibrous tissue, and while collections of asbestosis bodies appear in alveoli near the pleura, none are seen within the pleural fibrosed thickening. There is an acute ex udation of fibrin upon the pleura, willi seine hyperemia, edema, and leukocytosis. There is some black granular material in the same gen eral fibrous area. In the intervening lobules the alveoli are quite deformed by pressure and emphysema, many large air sacs being seen. Generally these are mpty. In the lower left lobe the fibrosis is very heavy, most of the alveolar structure being obliterated, and here there is a marked bronchiectasis, with chronic inflammatory infiltration of the walls of the bronchi, some purulent exudate in these bronchi, and active pyogenic inflammation ~of the overlying thickened pleura. At the apices there is a remarkable grade of old fibrosis with large numbers of long asbestosis bodies in large giant cells in thick-walled spaces and in fibrosed areas, with hyaline nodule formation, necrosis and calcification, emphysema and bronchiectasis. Sections from the base of the right lung, thought grossly to he tuber culous, show the caseous cavitation and infiltration there to be carci nomatous. On a background of heavy fibrosis and bronchiectasis is extensive infiltration by masses and cords of stratified squamous epi thelium, maturing in considerable degree. This is shown to come from a bronchus, where there is squamous metaplasia of epithelial lining. There are considerable necrosis and purulent leukocytosis of the cavity un-a. 'Within and about the carcinoma area there is more active fibro- than in other portions of the lung, and heavy lymphocytic infiltra tion. Tim histologic diagnosis is asbcsto-silicosis, witli fibrosis, cmpliyVvnia. bronchiectasis, chronic fibrous and acute pleurisy; epidermoid bronchial carcinoma. ; *. 64 KENNETH M. LYNCH AND W. ATMAB SMITH . SUMMARY * This man had suffered long occupational exposure to dust, some forty-three years all told, about twenty-two in a cotton mill, about k twenty-one in an asbestos factory, with resulting fibrosis of extensive ^ LYAI grade in the lungs and pleura, the apparent consequences being pul- ai monary circulatory and respiratory disability, with emphysema, bron- ? chiectasis, and cardiac embarrassment. ** As has been observed by us in other cases of asbestosis, one of. which has been previously reported (C), the fibrosis of the lungs liere:J (Fro bears the accepted characteristic mark of silicosis, that is, in additionto diffused fibrosis, there occurred the formation of hyaline fibrous nodules. The pulmonary carcinoma appeared to originate from one of the-; Lye dition, lo repc -branches of the bronchus to the right lower lobe, where squamous meta-.> plasia of lining epithelium was observed. The duration of the carcinoma cannot be specified. It was appar-i ently of considerable time but certainly did not antedate fibrosis of the lung. A conception of its origin by reason of chronic bronchial irrita The her adm in the ri.if bveat tion is compatible with the current view of the etiology of such tumors. ,-i|ipetite nothin" References 1. Pirchan, A., and Sike, H.: Cancer of the lung in the miners of .Tiichymov (Joaehim^tal): Report of cases observed in 1929-30, Am. .J. Cancer 1G:' G81, 1932. 2. Rostoski, Salts, and Schmokl: Die Bergkrankheit der Erzbergleute in Schnecberg in Sachsen (" Schneeberger Lunsrenkreb> ''), Ztsclir. f. Krebsforsch. 23 : 360, 1926. jj 3. Simpson, S. L.: Primary carcinoma of the lung, Quart. J. Med. 22: 413, 1929. 4. Schulte, G.: Pneimiokonioaen dcr Ruhrbergleute mid Lungenkarzhiom, Fortsehr. a. d. Geb. d. Roentgenstrahlen 41: 444, 1930. 5. Sal*pe, E.: Carcinoma of the lung in arsenic miners: two eases, Arch. f. Gewerbeputh. u. Gewerbehyg. 1: 5S2, 1930. fi. Ltnch, K. II., and Smith, IV. A.: Pulmonary e-bestosis IX, including tbe report of a pure ease, Am. Rev. Tuberc. 23: 643, 1931. The wore cry i.i-ular i were nc fhc ton. were no hard. I ornwiiisi Yu othe e iiat en Tin ..-ms of I ((" livt Ai 1 :m inn /"A - n-.t . .. r*' iif the '1'iadrai ass wl movable Tin n G H535 I BB 0005409 |