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i __r ' 'Hr*- 6c\-V>5\M^^c^V Vi?,? V0U\Ul, K ppg/ND0CUM^t Was not MAT s6, 19*8] PULMONARY ASBESTOSI3 IN SOTITH AFRIOA^S^S m liV PULMONARY ASBE5T0SIS IN SOUTH Fig. 7). Phagocytosis was not confined to flie^tS&dl^ffljicles, rat even large rods were seen completely* enclosed and often ^JC/ bent in order to allow them to occupy the space within the '9 AFRICA. cells (Fig. 7). It was thought that these foreign bodies, together with the crystalline matter, may have been the cause 1 . ! I (TFifh Special Plate.) ' T F. TV. BIMSON, M.B., Ch.B.Ed., rATXOLOCKT AT TEX SOUTH ATS1CtX ISSTITCH TOE UZD1CA1 RESEARCH, JOHAXVESSUM. of the fibrosis, as the connective tissue, both in distribution'' and formation, was very suggestive of changes resulting from a dost occupation of the lungs. At the same time the history of pneumonia and protracted recovery must be taken into consideration; since an unresolved pneumonia with subsequent fibrosis is not an uncommon occurrence amongst natives working on the mines in South Africa. It Itas been known for some time that workers exposed i- ,, i to the dusty atmosphere arising from some processes in volved in the preparation of asbestos materials suffer from pulmonary disability. The mining of the mineral -itself - is probably not a source of danger, as asbestos is mined mostly in open quarries. After sorting, there remains waste" rock which still contains fibre in payable quantity. Crushing of this rock causes a considerable degree of dust exposure, and exposure to the dusty atmosphere - is still more exaggerated in the carding and spianing of asbestos in the mills. . Very little concerning the pathological changes in the lungs of persons working with asbestos lias been found in the literature, and it was thought that a record of the following cases might be of interest. On September 2nd, 1926, the medical officer of an asbestos mine in Southern Rhodesia forwarded to the South African Institute for Medical Research three small specimens of lung from a iiott-mortctTL case for histological examination. - Cases m ax rv (Nos. 6419 and 6731). Consultation of the records and previous histological sections of material from the same mine has revealed two additional cases, both of which showed lobar pneumonia. There was very little -connective tissue increase, nut the unusual structures (Fig. 8) and refractile crystalline particles were present. Nir*") history of length of service in the mill was obtained with either-..i- of these cases. t* - .Further study of the golden yellow bodies showed a variety of shapes, but the most common forms had rounded"",' or club-shaped ends and a segmented body tapering to-. a finely pointed tail. They were non-rcfractilc to polarized light, soluble in strong acids, and, on raising to a red heat, turned black and tended to lose their outliuc. In sections treated with hot dilute hydrochloric acid and potassium, ferrocyanide they gave a well-marked Prussian blue,' reaction-. No'pigment except these structures giving tho iron reaction could bo detected in tho section's examined. Strong hydrochloric acid, having been tested for the ( j J. j -- "A-- ,-.ey . r;~ r r-; , -1 j ^< . . Case i (No. 9026). ` The snbject was a male adult .native, who had worked for twelve months in the asbestos mill, and, except for a short presence of iron and found negative, was used to dissolve out iron from fresh sections. After treating the sections the hydrochloric acid gave a very distinct red-pink colour. '! ---s' wriod before his death,. had had a good record of health. with potassium thiocyanate, and the red-pink colour dis*. For nine weeks before death he suffered from acute tuber* appeared on the addition of a solution of mercuric chloride.- ' -. culosis, and the post-mortrm findings showed miliary tuber- The sections were re-examined and showed that the majority - culosis involving the lungs, liver, spleen, and pericardium. The object of the histological examination was to ascertain if there was any evidence of fibrosis in the lungs which might be - directly ascribed to the nstnre of his employment, since workers of the golden yellow bodies had been dissolved out. From these tests it was concluded that the structures contained^ , '- a large percentage of iron. in the mill are exposed to a very dnsty atmosphere. - As controls, sections of lungs from a large number *. Apart from the tuberculosis and associated fibrosis, sections miners on the Rand who had died from silicosis and tuber of the lungs showed a certain amount of connective tissue change which bad no obvious connexion with the tuberculous process. It was also found that curious golden yellow seg mented structures, with rounded or club-shaped encls (Fig. 1), were'embedded in this fibrous tissue, together with very minute, doubly retractile particles, the latter presumably silica. . Although the curious segmented bodies were remarked Upon, no further investigation was carried out at the time, and the culosis were examined. Bodies such as have been described above were found in none of these, nor was the Prussian blue reaction or other test for iron positive except in those cases where the pigment was obviously of haeinatogenous origin. A single case of a' miner was also investigated; he had worked for twenty-eight years in the haematite mines in tho North of England, and subsequently for seven and , * 1 . new-formed fibrous tissue was attributed to the presence of a quarter years in the gold mines of the Rand, South silica. Africa. The cause of death was carcinoma of the gall- Case n (No. 11016). bladder.' Macroscopically the pulmonary root glands wero t It was not until September 29th, 1927, when a portion of lung from a second case was sent by the medical officer from the same mill, that the foreign bodies and fibrosis were more fully investigated. This niece of lung was from a male adult - native who had been employed in the mill for a period of two enlarged, pigmented, and fibrosed. The pigment was dark rust-coloured and gave a marked Prussian blue reaction with dilute hydrochloric ncid and potassium ferrocyanidc. 'Occasional rust-coloured subplcural islets were visible. On years. About September, 1926, he was admitted to hospital section the lungs showed a slight diffuse fibrosis and a j j , ; '/ * , - suffering from pneumonia, and had a long illness. He was dis- few largo areas of fibrosis. . Tho whole lung gave a marked - ' ' * ' charged, and later (September 19th, 1927) readmitted in a dying condition. He was very emaciated, and had the physical signs - of pulmonary tuberculosis with fibrosis. At autopsy tile lungs . were firmly bound down by adhesions, the root glands enlarged and hard, and the lungs on section hard and fibrous with an almost leather-like consistence. The mesenteric glands were also considerably enlarged. iron' reaction. - Histological sections' of the large areas _ showed moderately well defined, bnt irregularly shaped, ' masses of well-formed acellular fibrous tissue (Fig. 9). The alveolar walls were slightly thickened, and there was a moderate degree of connective tissue increase round the blood vessels and bronchi. A large quantity of pigment * ; r i: 1 |[ Histological sections showed a generalized bnt moderate degree of a reddish-brown colour was contained in phagocytic cells }1 of fibrous thickening of the pleura, trabeculae, and alveolar and lying free in alveoli, alveolar walls, and between the !1 walls. In addjtion, there uras a much more marked fibrosis arranged in irregular-shaped nodoles, chiefly related to the blood vascular system and bronchi. This fibrous tissue was cellular, the elements arranged in an irregular manner, and included some small lymphocytic accumulations (Fig, 2). There was no resemblance to the orderly, whorled arrangement and sharp definition of the silicotic nodule (Fig. 3). The bronchi were the seat of slight catarrhal changes, and many of the fibres of the newly formed fibrous tissue. The greater part ' ; of this pigment gave the iron reaction. In addition, there 1 was another variety of pigment^ in much smaller quantity, J in the form of crystalline refractile particles. The latter ( q j was intimately mixed with the iron-containing dust. This 1 rr> < lung was especially examined to determine, if possible, J| : whether the same peculiar bodies were being formed from / q J alveoli contained.*' dust cells *' filled with phagocyled particles. a deposit of ferric iron dust as in the case of an asbestos 0 | There was no evidence of tuberculosis or acute pneumonic con dust which contained both ferrous and ferric iron. A |o j - solidation.. Embedded in the fibrous tissues, lying free in careful and thorough search was made, hut no particles I t alveoli (Fig. 4), and contained in phagocytic cells, there were with a similar appearance were detected (Fig. 10). At the j fQ j - 1 ` ; numerous golden yellow segmented bodies (Figs. 5 and 6), a few large angular black bodies, and very minute doubly refracting . particles. Phagocytosis was a very striking feature. Large ' . * numbers of the bodies UUclcat ealln and were contained within ordinary Aj -- amo-n-oft-- time of tho patient's death this cose of .ironstone phthisis j j wns complicated by underground work in the gold mines j ^ j on tho Rand, but in 1919 it simulated, hv x-ray photo- j mmliT nml nlivcir-nl evnniinntinn. an earlv ease of silicosis. 1 H86 Mat 6, 1928] PULMONARY ASBESTOSI8 IN SOUTH AFRICA. fllii.wTcuafijimimiiiM nd confirms the findings of Sir Kenneth Goadby* and Ur. Cronin.* In addition to the human lungs showing asbcstosis, Dr. Mavrogordato of the South African Institute for Medical Research has supplied me with the lungs of a guinea-pig which died in December, 1627, from causes other than asbestosis. This animal was exposed to an asbestos dust atmosphere experimentally. The length of exposure was two hours a day on each of fifty days. The first exposure took place on February 4th, 1925, and the last on April 1st of the same year. The asbestifomi compound used for the experiments wns a chrysotile* obtained from the mine in Southern Rhodesia. Histological sections showed a slight generalized fibrosis and an increase in pigment, but the interesting feature was the presence of the golden yellow bodies (Fig. 11), similar to those seen in the lungs of human pulmonary asbeatoais. A comparison between the human cases and the experi mental animal showed that the fibrosis was more rapid and ixtensive in the human cases than in the experimental animal. This is readily explained by tbe difficulty in reducing tbe tough asbestos fibre to a uniformly fine powder, and to the presence of a comparatively Bmall proportion of the rock dust which is usually associated with asbestifomi compounds. For " dusting " animals a limited amount of dust is available, and of this only a small proportion contains particles of sufficiently small dimen sions to permit of their reaching the lung alveoli. In silicosis4 the size of the majority of the particles* which reach the alveoli is between lp and Z/i; in the haematite lung, mentioned above, tlie particles appear larger, but even here are much smaller than the greater number of those prepared from asbestos for " dusting " experiments. In the working mill the conditions are very different from an asbestos dust atmosphere produced experimentally. Fiue dust is continuously reaching the atmosphere, and only the very fine particles remaiu suspended for any length of time. These gradually increase in numbers until a maximum concentration is reached, then remaiu more or less con stant during working hours. Thus it will be seen that, in order to produce changes in experimental animals show ing the same degree of fibrosis in the same length of time, on atmosphere approximating that of the workiug mill will have to be obtained. The amount of fibrosis in two of the human cases (Cases i and 11) was quite definite, and, if duo to the presence of asbestos dust, the initial rate of production was rapid a lien compared with present-day non-infective silicosis on the Rand. It is difficult to state a definite time for the production of an appreciable degree of fibrosis in pure non-infective silicosis, but modern observation tends to show that it is in the neighbourhood of ten years. In Case 1 a moderately marked fibrosis had taken place after one year of work in the mill, but this was complicated by tuber culosis. It is known that the rate of fibrous tissue pro duction is very much greater in. dust diseases complicated by infections, but even allowing for this the connective tissue increase in Case 1 was' rapid. In Case 11 there was a still more definite fibrosis after two years of work in the mill with no evidence of tuberculosis. Before' this work was completed Drs. Cooke,* Stuart McDonald, and Oliver' published their papers dealing with pulmonary asbestosis, and previous to that a.short article on the same subject appeared in the Lancet.. The similarity between the case described and ours was suspected when the first article appeared, and our work goes fur to confirm the findings. As iu those recorded here, the asbestos dust responsible for the changes iu the lungs in their case was a chrysotile. Whether other asbestiform compounds are capable of producing these changes it is impossible to say, as there appears to be no record of any such eases in the literature. In the Union of South Africa* and Rhodesia there are many asbestos mines, from some of which chrysotile is obtained, but two other interesting varieties are found__ namely, crocidolitc and amosite, Amosite is a compara tively recent discovery, the chemistry of which has1 not been completely worked out, but it appears to be somewhat similar to crocidolite in composition. Both these com pounds contain a large percentage of ferrous iron. Analysis of four samples of amosite* showed between 32 and 44 per cent, of FeO, and eight sample of crocidolite* between 16.5 and 40.5 per cent. Up to the present there has been no examination of post-tnortem material from cases of death among those working in mills where these minerals arc treated. No such material has been made available. Chrysotile or serpentine asbestos usually contains 2 to 3 per cent, of FeO isomorphously replacing magnesia. The analysis of Dr. Cooke's case showed 3 per cent, of FeO, and the Rhodesian mineral, according to Mr. A. L. Hall,* 2.44 per cent. Dr. McCrae of the Government Chemical Laboratory, Johannesburg, analysed the FeO content of the asbestos used by Dr. Mavrogordato in his animal experi ments, and found a much lower percentage--namely, 0.45. Apparently, even with very email percentages of FeO the golden yellow bodies are formed in the lungs. . With regard to the unusual structure and chemical nature of the golden yellow bodiea found in the lungs in pulmonary asbestosis, until many more cases have been examined and more experimental work has been done very little can be stated. There is no doubt that they are in some way associated with the asbestos, or, probably, more particularly with the FeO content, either of the asbestos itself or of the dust of the mill. This dust contains a much higher percentage of iron, which may be derived partly from the lode from which the asbestos is rained. Three possibilities regarding the formation of the golden ?r yellow bodies are worthy of mention: --" (" (1) In the form of a gel, as suggested by Dr. Stuart McDonald. (2) As particles of ferruginous quartz formed in the lungs ' under conditions similar to weathering, or ferruginous quartz changed in composition as a result of combination r - with constituents of the body fluids. In support of this it may be mentioned that crocidolite, which is an alkali " silicate with ferrous iron, is especially liable to decomposi- tion when exposed to weathering. Sodium is removed, the iron oxidized and hydrated to form limonite, and silica , set free; there then results a ferruginous quartz which possesses the finely fibrous structure of tlic original mineral. ' It is extremely hard, and coloured a rich golden yellow. It ,, U possible that a change such ns this occurs with the small quantity of ferrous iron associated with chrysotile, and the ' colour of the bodies in the lungs is very suggestive. (3) Phagocytosis of these structures is a very prominent" feature in the lungs, and it was thought that the action of r those cells may have been responsible, first, for some change in chemical composition, then a building up and moulding L into the various shapes seen. The fibrous tissue change in the lungs of the above- mentioned coses of workers in asbestos mills is probably the result of a reaction on the parts of the tissues to both the golden yellnw bodies and a small quantity of silica. Sufficient cases of pulmonary asbestosis have not been recorded to base an opinion npou tbe liability to secondary infection by specific inflammatory processes such as tuber culosis, but it is very suggestive that two. of those now. recorded, which have been examined histologically, have shown tuberculosis complicating the changes produced by an asbestos dust occupation of the lungs. Besides these cases there is still further evidence in favour of tuberculosis being a complicating factor. Dr. H. M. Murray reported a fatal cose iu the Charing Cron Hospital Gazette iu 1900; and in the United States of America, from one source,* during the period 1607 to 1914 there were 13 deaths, 3 of which were from tuber culosis. I11 1910 Dr.. Collis1* reported on the. relationship of asbestos dust to pulmonary tuberculosis, and found that 5 deaths from phthisis had occurred in five years amongst a staff of less than forty workers employed at a factory where asbestos is woven. Id conclusion, I wish to record my thanks to Dr. Mavrogordato for data and material from an experimental animal; to Dr. Irvine, chairman of the Miners' Phthisis Medical Bureau, Johannesburg, for material from silicotic cases and from the lungs of a haematite miner; to Dr. McCrae for his analysis of the FeO content of a sample of asbestos; and to Mr. P. Longmore for his valuable assistance in preparing the mirrnnWooranhs. J BB 000703TM! May 16, 1928] F. W. SIM SON : PULMONAHY ASBESTOSIS IN SOUTH AFRICA, fI UftTsittGsABi Jootcimaxaii Fig, 1,--Pulmonary a^be^tcu-i* (Case 1). Golden \ bodies lying in the centre of a nodule of young n. :m* tissue. ( x 850.) Fig. Pulmonary atbestosis (Cate 11). Irregular flbrotic nodule showing a moderate degree of cellularitr. ' , Fig. 4 --Pulmonary asbestos!* (Case 11). Small phago cytes containing granular dust and golden \*llow Imdiea. One large body is lying free in the alveolus. (x 850.) t * `a Kits, 5.--Pulmonary adn^t^is (Cane n), Larg* g*Men yellow structures wjili globular ends and segmented body tapering toward* one end. (x 650.) Fig. 6.--Pulmonary asbe^tosis (Ca*e ill. Large golden ellow atructuns with globular nub and wgimnird indy tapering towards one end. (x 850.) WWfeWiis Hat *6, 1928] ABDOMINAL P.WlilffttfMfr Kanona. Very imperfectly localized. The pain it often descrit * Goadbr, sir K.: A Cana of 1roastno^ Ptuhilit- Aanrrt, 1921, |1, TS2. * Cronin, A. J.: Dust Initiation by UicnutiU Uinen. Juuru. InilHit. llM., IMS, rill, 231, ' the patient at " like an ordinary bellyache, but more severe.*' It is frequently griping in character and varies 1 Bali, A. L: Further b'oin on (be Atbetfo* Otrumnwi near Kaaiwhe lloop, in the Barberton District, Trane. Uevl. bur. A, Africa, 1321, tarvi, 47. in intensity; the more severe spasms usually occur at more or less regular intervals, and last for a few'seconds, during 4 McCrae, J.: Tho Alh *f Silicotic Lunge. Johnnnwbun-: rubllcaUoBi of the South Alnean institute tor Metliral Beeearrli, 1911, Xo. 111. 4 lValtms-ritchford. \V., and Uoir, J.: On the A aturt nf the Doublprtfractino Particlrt ifen in llicriiieoi'ie Seetient of Silicotic Lungt. Johannesburg * Publication* of the South African Institute lor Hedical Aeeearch, 1910, No. VII. which the patient moons and writhes restlessly in bed. This early pain is entirely unassociated with auv tender ness on palpation, and the patient may rub or pros on his abdomen in a vain attempt to secure relief--a thing tliut * Cooke, W. E.: Fibrosis of the Lunn due to the Inhalation of Asbestos Dust. British Medical Journal, 1324, 11, 147, 1 Cooke. W. E-. Stuart McDonald, and Sir T. Oliver: rubuonnry Albertosia. Britlih ifedit:al Journal, 1927, ti, 1024. 4 Ball, A. L.: idntn in the Cnion of South Attica. Gcol. Surrey, Union of South Africa. Memoir No, 12, pp. 17,18, 22. * Boltman, F. L.: Mortality from Respiratory Diseases In Dusty Trades. Sufi. VS. Bur. Labor Statistic/, 1318, June, Whole Kumber 231, * Collie, E. L. i Annual Report of the Chief Inspector of Factories and he never does, when the second pain lias appeared. This initial pain in appendicitis is, I believe, a true splanchnic pain, and, like all true splanchnic pain, is due to increased tension on the muscular wall of the viscus concerned. Borne degree of obstruction to the lumen of the appendix', causing retention of inflammatory exudate Workshops for England and Wales, 1810. distal to the obstruction, is an essential factor in its pro duction. Sometimes--in fact, it is almost the rule in tlie most fulminating cases--we find a hard, laminated faecal. ABDOMINAL PAIN AS EXEMPLIFIED IN concretion engaged in the relatively narrow base of the appendix, while distal to it a collection of foul pus under ACUTE APPENDICITIS: great tension rams -the concretion home into tbe base. In A Clinical and Biological Consideration.* .... gT this condition, so well described by "Wilkie* as acute appendicular obstruction, the central pain in the umbilical region continues until general gangrene or localized per ' JOHN MORLEY, Ch.M., F.R.C.S., foration of the appendix relieves the tension within it and BCWOSAEV ASSISTANT StfllGtOS, 1LIVCHESTLX (OVAL 1ATIR11ARY; tho pain disappears. In other cases a stricture at the base, EOXOZARY COXSCLTIRU SURGEOZ, AXCOATS HOSMtll; LECTURES ur api-lied ajiatomy, maxcuzstez uiciveksity. tho result of some former ulceration, gives rise to the same sequence of events. In others a kinking at the base com Thb Evolution" of otnt Knowledge of Abdominal PAIX.f Almost the first considerable contribution to our know, ledge of the mechanism of abdominal pain was mado by J. Ross of Manchester* in 1687. Ross held that there were two kinds of pain in visceral disease--true splanchnic pain, felt in the affected organ; and associated somatic bines with inflammatory swelling of the mucosa to occlude tho outlet into the caecum. In yet rarer instances a foreign body is the occluding agent. A critical examina tion of the specimens removed in a large number of cases of early appendicitis has convinced me that wherever this splanchnic pain is present some degree of obstruction to the lumen, with retention of inflammatory exudate under tension beyond it, will be found. It is possible that the pain, referred to the cerebro-spiwnl nerves of tho body wall. inflamed condition of the appendix lowers tho threshold of Lennandcr* established the insensibility of the exposed painful stimulation and allows a relatively slight disten gastrointestinal tract to tho ordinary painful stimuli, and attributed all abdominal pain to stimulation of nerves in the sensitive parietal peritoneum. Mackenzie, whose views form the orthodox teaching of the current textbooks, accepted Ross's views on somatic pain, but rejected splanchnic pain as non-existent. He believed that painful stimuli passed from the viscera through, the afferent splanchnic nerres to the spinal cord, but were only appreciated by {the brain as arising from the sensory nerves of the parietes. j Mackenzie's theories of is viseero-sensory and viscero-motor [reflex have been widely accepted, and will be discussed jlater. Hurst* in 1911 published observations which have ;restored our belief in true splanchnic pain; he proved that this type of pain is produced by a single adequate stimulus-- namely, increased tension in the muscular wall of the viscus concerned. Yet Hurst does not'reject Mackenzie's views on the viseero-sensory and viscero-motor reflex mechanism. My purpose in this paper is to discuss the light which a study of acute appendicitis throws on the mechanism of abdominal pain; and since Mackenzie's theories were based very largely on his observations in cases of appendicitis, thin disease may reasonably be used to test those theories. sion to cause pain; but without increased tension visceral pain is impossible. Under certain conditions recurrent attacks of appendicitis may occur in which this splanchnic central pain is the only evidence of the disease, and great difficulty in diagnosis results. A striking instance of thiB difficulty was afforded by a man, aged 21, who gave a history of four severe attacks of epigastric pain, each lasting for a few hours, during the course of four months. There had been neither tenderness * nor muscular rigidity during the attacks. Exploration a week after, the last attack showed that the only viscus affected was the appendix, which was swollen and oongested in its distal portion, There was a narrow stricture at the base, and, distal to this, a collection of thick yellow pus. In tbe ten months that have passed since the operation there have been no more attacks. It is evident that this patient was suffering from recur rent attacks of acute obstructive appendicitis of too mild a type to cause perforation, and that his pain was of the pure splanchnic appendicular type. Tho reason for the entire, absence of local pain and rigidity I shall discuss later, when dealing with the second pain. The brief inter The Two Pains in Appendicitis. mittent colicky attacks of central - abdominal pain so common in children, .and described - by physicians os The conventional teaching on the pain in acute " umbilical colic,** are very commonly due to spasmodio appendicitis is that the attack is ushered in by pain efforts to expel a concretion or a nest of threadworms referred to the. region of tlie umbilicus or a little above from the appendix, and form another example of pure it, and that after a few hours the pain becomes localized splanchnic pain. in the right iliac fossa or moves down into that region. Although the splanchnic pain in acute appendicitis is felt in the umbilical or lower epigastric region, and not in The Initial or Central Fain, the region of the appendix, it should not be described as a The first point that X wish to emphasize is that the referred or reflected pain, as no radiation of pain or reflex initial pain is entirely different in character and in its process is involved. The appendix is developmental^ a mode of origin from the pain which appears in the right part of the mid-gut loop. The brain can only appreciate iliac fossa a few hours later. The initial pain is felt in painful stimuli arising from any portion of the mid-gut ns the centre of the abdomen, and though the patient may vaguely situated in the centre of the abdomen, and stimuli refer it to the mid-line at or above tbe umbilicus, he often of appendicular origin are no exception to the rule. It is describes it as all across,*' sweeping his hand evenly characteristic of tins splanchnic pain that it i* dull and across tbe 'central region of the abdomen. It is, in short,4 aching in character--as patients express it, " like nn ordinary bellyache "--and vaguely localized ; m other 4A poll-graduate lecture delivered at the llanchritcr Royal Infirmary, f For turnout ol apaca Out introductory atcuoa lisa buen abridged. words, it is form of Head's protopathic pam. 882 PCC' __ PNE JOCOX10S1S. fl XlTl'Hi*tl ^NMl In t):j Mwiit caso no invoN-ii Ajiotonmt of tlio utJulli . iis idlM *': - : r .iu'i u ha:f v.'.irt 1, w..st.-i J: . -u.ci:.; |i mi.i!. l.xieiixiv.** lihrmts meni'isitii resembling piintu:* >m msilur meoingilia has also liocil described by Afckniii. 11 iUnm-iierg,** ami other*. A* far nv u U;i'.wtt, niai-biur, wt...!! I- * nn-l- r*' -'*-- *-1 K'-tf. f-veii an.i , i...at* at tii-i *** a.inu ! u, **J";7r f:ti rflii.rlir-TV I a'lli*' maTtiifariui-** ui tIt-- itulUsui Till1 t.u in1. i lau.1..!., iliiT-r i.-ii-f*!. i ..|.|i in 11.< u `.l. ycer-W** tin* cyst* oro vary littio toxic, although it appear* licit uccurml at tho onaet nf iniVidion or early in thu *'in>o of a cast of disseniiuatud eysticcrtosi* described )>y duiiiiicf', si. I ben-tor*; in lie* otiumiil nt rvImM". itriisM liv ilie van. i- t VJM-. ef workers. A*, l*f**-\>T. r.iiMivp it lilfiyrent pi-v'-i-i, revolving a varying aiumnit ui iTU-V, mjj Id caTTtWuU !- iv- touiui -tie dust l.loduptM r all* wo** Major It, Priest*1 in 1626. procc** way unTgr-vreTta-ls at an'm*r pruviw n~ Jho case we record proved fatal after nearly six year* if symptoms; bus tbo parasites cs|ki inlly when lni;ili/.e<i in t!to eyo or brain, may live for long period*, very taro a*K being noted up to twenty years (Kuchcumciktor, Itoili-IvanolT, Pfeifer, and others). that this u.iP.~Tn*i-r~ i;.iv7r'*Kt'i".i m * = " ti!^!:Ll`!ii-;'^-Uli:i.'ii.-is,ss-iui|-or,.an.vii.w>oiiUii tu lin inirvatnt OI_dul than at liv |HMiit liuv. ' ----------- ITi'l-.ry cl /V."7"/'.** V*.--T1v pat hut has !i;,.t a ynngh irma viihin a fir.- n.nnihi of nlining work a: aia-im, hua L<i timr that this was *' fioin th-; llirnat." and appi'arisi n, haw hn purely tho js-idi, nf du*t irritatkm. Will.in rs'-nt vvars IW Hires* *wra, 1 Riimler: Ob. Kit, lili. 13 (piutel by Fanttiam, sail TliectnM, rt Animal taranitn f Man, LwiIm, 1916). ''tile*: QuoitJ l*y IV, Otlcr. Wwijin anil Ptmr.Uct ml yitdiriur. t'unibiui. W-nl'tsi, aaj TbooWtu: 7b* Animal Painutci if Man. Ij b-Ish, 1516, p. JJ1 * t v*Etta: Quo-.v.l by Oruir.pt, PiCcii da f'aintilelajit, Tacit. 1937. 1 Tit.i t'aillu : Quoted by Bfuo.pt. * Mi Arthur, Lic-Jt.-Colonel tv. P.: Fcmnal ciMnRinnieattau. * Moth, J. IL t Briii.h Medical Jmurnat, iS, ii, 470. * Al'ki... C. 3. Uill: JUhL. 193, i, S-U. > IhnmtM, T.: QneitJ by Oppcaliciui, Ttil-bael f Xertaut hiicaiel, Kdiu.. mi, it, m > IT' tinrluf*; Chante-AnnmUn, voL fti. " Astana*? : Zirnlrt't fltlir,, ret, riL * tI"rnS!iUi: Zrltirht. f. .Yruro.*., vol. *xjj, ** rum, Slater 6-; iltitJW/i'li*fH" enu-ii has iivi.-at. >| in verity, and there ha* l*n a liuh sputum lir*l thing in tlio Illuming. The tii.i symt'iiun 10 raws anxiety was h|..atu|,.^ns*s, w hirli d"n lnjv d Ini* v* als ayo. and this hat bernuh' *'ss,n(iialid hi** tli.-n. lln. g-in-ral csiuditMa iia C'itv*iii..| -ati.lacmry, am) id* piMi. :ii.ir *yni|iiii,i. w-vre an Minicvatly to iui"rfcr with 1:h vinplnvmri.i until a fe nuiiiilis ago. .At lln* tun** It** tsuiipMimst nf la-Mtr.f.-. |m*.oi w; isht, Iii'i|U* n: night swratinc*, and an niVasnuial .light a.'hmy of the left rhotililcr. On no oista.tou ha* thcic t* n luvttioptyui. . .Vofev on f.'mmintfioa.--Ilf* i* a span-lmilt mm; *.-tgU 7 .1. II Hi.; i"tti|.*ratnr*,1 pul\ ami n-piralmn*. wrhin ucruui limits. No i,l*viV;,, iiy.pn.f.*a niii**d on .1:111.111 < 1 > 1. t,vano*wsf lip* anT rlicik*. l.ip nut a murk-d lealur.*. W.-IJ-ni.rkt,| aagr, cluldnng t.oti'--'l hv th**. yaiusu for at lva*-t tv., v.-ar*. npuiuqi canly, and of a u.uvoid nature. Tuhvrvlo Laciilu* ah*u.t a fnsjucnt examination. Kjuminatio* uf Chrit.--In.peclion shows'.! cxpaiMtnn in In* psSr generally tone inch by nieasiir>*iu'*ni|; there v* hvtvrtrupUs tl Vhu cxtranrdinarr muscles of respiration; the aupraelava-ular (** MIL1 PPG mm5* FILE \Werc markedly le.llnve*!: the heart apes heat wa in the bilk Vitrrc^iiil spa.-.- suliin tl.,; nipjite, tin.*. Th*- p'*r.*';*.in,i nw. ,s i4latteiirij throuchnut; fin.-re >< relative dulln--t ov.-r the right upper lohe, ho*, h lit front and liebind. On atisrullalton th* respiratory sninn'ir war dnnmnb*d fin**ralh. and of a bank Rescli ok the Lvualaijo.v or Asbestos Bust. quality^ over th.* right- upper lol*** antcriprlv and po-teriorlr; expiration w-as piolng.t'. all over th** chest; rhonviii wvre gcacrrl, it with uno pleural frirnoit at both hac*. II. E. SEILER, M.B., rii.il., D.P.n.C.vB., ASStSTAST SltairAS OirtCES, rrsuc UiatTIf BCfitTMEST, CLASCOW. Sytciol I'idle.) Other Sijitin>.--Examination of oilier systems so mga'iirt. .V*f?_'y Lstim'>m/radiogram of th** vlu.i -hows a ii**' mnftltiig **f a *iii''*.li*: l>trt* thistugt,uut Ivih lung*, 1111.1.* nurh.4 * on the righi Md** and nt U'lli litm. wtth initicat;..n nf a dcbuua fihriMii., o|etia.'iy on tie: rigid rid'*, tri e [>crial plate.) Titr. aslicsto* industry lias been in exiitcncc for over two thousand years, and it is retnurknVilo that the possibility nf daniago to the lungs, arising from tho inlmJatiou of dust during its manufacturing process, has not been in vestigated until within comparatively recent years. Very fmv eases of pneurooeonio*i duo to asbestos dust bavo Iicon recorded in medical literature, and for thia reason the notes on tho following caso may lio of soma interest. ( Prnyreu.--Tie* patknt was a'liiiitl.'d to ho*piial fur nlvervatha, aud uas now l--*n an in*pa'it*nl- f.-r six ntenili*. Iturtng tin period hk pen* 1 at mtidiii'tn liiui iniiirovisl con*id. val'ly, and Is lias gain'll uV'-r 1 rl, in Weight. Tin: vyanot* wlii.'h had levs noted on fir*t evatuiuali'iu hi* to a great rat* nt di.aiipvaml, hat there ;i* *.1 if! wnini rid.-im* on In** cheek* and li|e. Tas cough, which is new nismf'-sily is* truuMrmmie, j* still pn wwt. and there is a H-atuy muv'iid Sputum. )`hyiral rsan.iuaiina si tlio eluwt reveal* im m.-w fealiirc apart from lie- *le.n.e j bronchitic sound.. Tlv. temperatine and puls" remained aitkia normal limits during Ihu pvriod of cdwi-vatioii and uvaitcral iu hoapitol. Tho first recorded caso was that reported by the late !>r. Montaguo Murray of Charing Cross Hospital in 1600. No other caso was reported, and tho inference that asbestos dust might be the enn*c of an extensive pulmonary fibrosis was lost sight of fur some time. In 1624* and 1627* Dr. W. E. Cooko published bin exhaustive reports on another case, and described in detail tho pathological changes aed his " curious bodies," which are apparently a unique feature of the microwxipienl picture. This stimulated other investigations, and Simeon* has reported similar findings in workers employed "i tho crushing nf ~~'irrnt Mfk. as nnnrt from tlio nianulf taring uroentscs. In most. -oL the cases hiinorto repnrii\i tho extensivd fibrosis has Ih-cii asvitinieil uttner with ^mliiiuiiary ttilicrculosts or an ' was tnc primary' cause oi the1 liln'uMlC The patient, s man sccfl *d year*, vn sent, for n opinion of his chest condition to the tubfiviilui* iiLptii>3ry. TJio iiucstion uf InU-reulo'i* warn raivod U a coii'oquinee of his roniplain; of <s.:ip!i soil hrovlhlrs-npsa, combined villi loss of weight, and lassitude, cst.'iidinj over a period of several months. Prrtiottt Hittuet.--'There war no history of I nil. reuloris in tho f mily. _No l.i.iory could lie clivilnj of arv iJIn^*s in rarlv life * hi, h uiicht haw led to a pii!n..niarv Cl.rhsU. and, apart from Ih- syiiipiun* vlir-h he con-i.|.r.-.| '|0 l*. a--ociati.l with his vcrupatioii at an aIm-*IwS woriur, he has had no other iiiu^mis. Oirui-itiun,--Whin a bos hi* had worked for a very sh..rt |it i h*d iu a glass work*. Thrr. al'u r. for a period of Uimv-tvo > i-'. iv ha. Ivin *-**'jatcd with thy aslr.if^ indtiMry, l>uiiii Uus period ho tut* hero euiph/jcd ia tho various procui.r of Conclusion. There seem* little il'iuht (lint this i< n tleiiuitc ca*s* af pulmonary (iline-is, tin* re*i;lt of the itthithttiou of ashcat< dust. The r.'fi't dcv' liij.nu'iit of syniptoiiia uf toxaemia, assocSated with luiix-Mmuling piilnioimry eymptatu*, wit at first sugge-tite nf a elirnuie pulmonary ttilicrcttloMi with an ncutu I*xnr.*rh.*itinn. However, the physical sipti, tho persistent nlwncc of the tulien-h* li.n-iilu* in tU spilttllll, niuJ the tn;iiiit'*n:iiiCi' nf t'*tn|*rauite and pula* within noniml limit*: iletnaiifhsl further invrstigatiou. Tho typiral rniliugrni'hm fentun*. (Ktgttv uxirc markctl is tlio basal, port inns nf the lung*) and Iits lung period W employinciit with nslawtiw point dufiitiicly in the directiex of a lihroMS f occnpatii'ii.Tl origin, c*p**-i.*dly as tlw^ is neither a history af other tllnc***** in childhot"! or adolescence t nijiptirt n tnuri* muinmn rntt-c of pulrninarj fibrosis, nur d<x**t litis currchtlintt nf history, snnii'.ouu, and pliysici.l sig;n o*e:ir in there httt**r c*ns. Toxacmit symptoms itt the alr-onro nf n ttt's'ri*ulnu* air.'ftion arc of special interi**t; wlu*th ;r they are the rrettli of the aleofp* tion of smite i..n.ti*,tHi:t r.f tlio nshestns rw.h or net h a point which rwjuirci further iiivesiigatiou. nrrre'x.Tt. 1 CvAe. If. T.. f t f'* * t It.* l.ti*igs iln* t 11. tclutciica cl Altai* D'Ct, .V.'*'...? J-uirual. 1734. 11. 117. iCof.Hr. W, K. v.;4it M fioiial I, amt titr T. <>ditr*. rwhacaitj /..,*..*. V.'K *' Jr*?r. Ii. VI. : t.iii*.h, V. tv . rt.im.aiiyd.4pe6** ib keitk Al' Liuuk Medial :.7. .. KS. ---- --------------- T'bB 0007034 l ------------------------------ -- a w.. to Ins Volvnc 90 NUM4U 2 EDITORIALS HE THIS DdWlIM sunshine there each day for three years, recorded by the month, ranged from 15 for December, the lowest figure, to 9.5 in July, the highest. -The average per centage of maximum sunshine from 11 a. m. to 1 p. m. --the period during which infants can be most con veniently exposed--showed a similar increase from December to July. The sun's -rays during December, January and February in the M&ude of Toronto pro duce a slight but definite antirachitic effect on rats fed on a rachitogenic diet A sharp increase occurs in the antirachitic .effect of sunshine about the first of March, The antirachitic effect of sunshine in April and May is approximately eight times as great as in December, January and February. It would appear that the increase in the antirachitic effect of sunshine in March, April and May is due not so much to an increase in the amount of the ultraviolet rays of the length present in the sunshine in winter as to the presence of rays 11 i.-i t are shorter than those found during the winter. The antirachitic effect of skyshine (reflected rays from the sky and clouds) is approximately from one half to two thirds as great as that produced by what is ordi narily termed sunshine (rays from the sun plus the reflected rays from the sky).* Ordinary window glass is impervious to the anti rachitic rays of sunshine. Consequently much effort has been devoted of late by glass manufacturers to the production of glasses that will transmit some of the rays in the region of the ultraviolet. Reports on some of the available products have already been published in The Journal.* Those now marketed are bnly jxirtly pervious. The studies of Tisdall-and-Brown * on rachitic animals show anew that no antirachitic rfleet, or at the most a negligible effect, is produced by the sun's rays through ordinary glass. The anti rachitic effect of skyshine through the special glasses is slight--in fact, almost negligible--except immediately adjacent to the window. Similar results were obtained wr.li rays through an open window covered with ordi nary fly screen. In order to obtain much benefit from rays through an open window or a window glazed with jiecial glass it is necessary to receive the direct rays of the sun. Tisdall and Brown believe that the use of Kjtccial glass during the winter months is probably of little value. Its use in the latitude of Toronto & justified from about the first of March on, as the inclement spring weather prohibits the exposure of fsaiienis to the sun's rays, which at that time have a Krc.it antirachitic effect. By means of this glass, these unt i rachitic rays can be utilized. Aim nd Brown, Alan: Antirachitic Effect of Skytbine, 1 V. .th,ld- 84: 737 (No*.) 1927. <M., r Window Glaa. Subititute*. J. A. M. A. 88:1563 "i-.ii i.v \>' . Sheard, Charlea; Ultraviolet Radiation and Ita Trant- M-i-.Irw.,, i| ,,`rioTu* Subatancea, ibid. 88: 1315 (April 33) 1927. M*i Loon, H. B.; Falk, I. S., and Coadc, E. N.: Ultra* Jul, |fl) ***m Sunlight and Incandcacent lamp*, ibid. S9i 187 t*r. ,n<t Brown, Alan; Antirachitic Value of the Sun'a 4|7f.: (N.'vj 1^70u* Special Window Glaaaea, Am. J. DU. Child. fttlmo! Apparently the first case of pulmonary asbestosis reported was in 1924. W. E. Cooke * has just made available the record of a woman who began to cough soon after she started work in an asbestos factory at the age of 13 years. Her general health did not suffer until she was 26. Five years later she was totally incapacitated and she died at 33. Her complaints had been cough, dyspnea, expectoration and lassitude, and the physical signs those of fibrosis and cavitation of the hmgt^>.,Postmortem examination of the patient's lungs*1 revealed diffuse interstitial pneumonia, chronic bronchitis, some empyema, anthracosis and extensive tuberculosis. Certain foreign bodies were unique. They were found in the alveoli, bronchi, bronchioles and interstitial fibrotic areas and apparently were neither of , vegetable ' nor of animal origin. The hypothesis advanced is that these bodies are portions of asbestos fibers in the process of alteration "fcsa absorption by hydrolysis, either by direct chemical^ < action or by enzymes. The qu<^tion remains as teg w 2 whether the fibrosis was the result more of tuberculouO 3* g infection or of the presence of asbestos. Considerable: 3 x fibrosis, however, has been found in one case without* fc ^ apparent tuberculosis. z< Industrial dusts have been the objects of widespread Q W t research. In view of the fact that asbestos has beeeo , q ^ in use since five centuries or more before the time Christ, it seems strange that it has not attracted atte^ 5 tion. Asbestos is a silicate and is associated wijth othg| uj ^ substances in the proportions given by Cooke 2g fluoililuowwwaas** 50ia................................... ItlgDClU . a . . 4 *4 . .4 ... Form oxide..................... Allriwlw| M.............. ....... Water ................................. iI4ta.liiLa.n. Fiber . RJ --j c*/*5 Z Oryotilt 40.27 41.50 3* 2.81 m0.90 13J5 >CO Microscopically, asbestos consists of translucent glis tening fibers, on the one band; opaque angular particles and minute black granules, on the other. In the process of manufacture, much dust is generated, particularly in carding, and this dust is made up of the angular particles and black granules mentioned. Few of them appear in the finished product Analysis shows: ___ PcrCent Finished article: Iran (as firmas aside)........ .. 0.1 Grade rmw material: Ime (at ferraoe stride)................ 2.81 Dad from cardiac room: Ima (ai ferroua oxide)........ 18.4 '`From these results it appears conclusive that the I-- I I to j inI i blackened brittle parts of the asbestos fiber are the iron-containing portions--the bugbear of the manufac turer, the cause of `dust' and a danger to the health of workers in the process of manufacture." loj IQI li I 03 I I 03 , Although Cooke's case is only the second reported, * -- / many other cases seem to have occurred. One patient, for instance, who had worked in a carding room for ten years bef re his admission to a hospital said that - _____ ___ 1. Cooke, W. E-: Pulmonary A*be*to*i, Brit. U. ]. It 1024 (Dec. 3) 1927. 2. McDonald, Stuart: Hittology of Pulmonary Afbcstosia, Brit. Id. J. pi 1025 (Dec. 3) 1927. Qp j V. f120 CURRENT COMMENT JVJ**x. i!,'iIv;v; he was the only survivor of ten men who had started ried by the blood stream toward the heart. Tin* * work with him. Conditions are better now, for modem migration may take hours or days, but eventually tl*^. factories are equipped with devices for removing the wandering bodies reach the heart. It was surprising dust. Nevertheless, asbestosis, because f its dangers t fearn further, however, that the majority of thc^ and it unique pathologic features, deserves more objects do not remain in the heart but are pumped into attention than it has had. the pulmonary artery and lodge in the lungs, where FOBE1GB OBJECTS IB TBS CIRCULATIO* The protective devices at the command of the body are remarkable and varied. They help to avert disaster and sometime* death under conditions that-would tax they produce infarcts with apparently Httle disturbance, to the pulmonary circulation. The presence of these foreign bodies within the lungs appears to cause little discomfort. Abscess of the lungs rarely occurred. Apparently sterilized foreign objects in the venous cir.rnlation do little barm to the heart or longs, and j ' * the resources of the most ingenious physician to the unsteriHzed objects which are smooth and symmetrical utmoat if his assistance alone were depended on to rarely muse infection. UneteriKzcd, irregularly shaped devise relief. Some of tire mechanisms on which the bodies, as nails or fragments of nails, are must organism depends involve chemical reactions. Thus, dangerous- and give rise to abscesses. acids and alkalis tend to become neutralized and conse It will come as a surprise to learn from Warthen quently less harmful. Toxic organic products, whether that it is possible for objects to pass from the venom introduced from without or produced endogenously, to the arterial circulation, this transition, probably may be oxidized, conjugated or otherwise altered occurring m the lungs, without leaving any macroscopic chemically so that the resulting compounds are more evidence of-pulmonary injury. He notes, as others readily tolerated and eliminated. Some substances. have observed, that the smaller, more symmetrical and Eke certain 6f the heavy elements, may become innoc lighter objects in the venous circulation, tend to remain uous through deposition in tissues. The outcome In in the heart, while the larger, more irregular and all these typical instances tends to result in diverting heavier-bodies-are carried into the lungs. Foreign danger.^ . [ bodies that remain in the heart appear tCf~lodge near There are other protective reactions that depend almost entirely on mechanical effects. This applies tp the disposal' of foreign materials, particularly such as are chemically inert and insoluble in the body fluids. Metallic pieces somehow manage for the most part to the apex of the right ventricle at die hase of the chor dae tendineae. As this is the most accessible region of the heart in man, die newly developed possibilities of intracardiac surgery may be requisitioned whenever foreign objects thus 1< *' traverse the alimentary canal without serious injury to it The swallowed open, safety pin has given many MOTWMBWftlWaiffFI LES a mother well justified worries until it emerged with out detriment to the unsuspecting infant that ingested it. Accidents, occasionally introduce metallic particles THE DANGERS OF ULTRA.VIOLET BAYS not only into the soft tissues but even into the blood The tendency of therapeutic methods to be adopted stream. More than one bullet or projectile fragment has entered a large vein and gradually proceeded along the path of the vessels. Where does k go? A review of the literature by Wartben.1 has left him .with the impression that wandering foreign bodies in the venous circulation are carried by the blood stream to the hart, where they\ are kept in motion by the. churning action of die heart or become entangled in and discarded in great waves of popularity and forget fulness has never been so completely manifested as in the current attention given to the use of physical thera peutic methods, particularly the ultraviolet ray. Not only do barber shops swindle prospective victims of baldness with incandescent lamps colored purple, not only do electrisal corporations sefi, as ultraviolet ray dtiicuy contraptions deftveiing hardly y ultraviolet radiation at all,.but some manufacturers of apparatus the chordae tendineae of the right ventricle and actually delivering ultraviolet rays of potency endeavor gradually. widieddad in the endocardium. No is made of foreign bodies reaching the lungs- in bk tnrer studies at St, Elizabeth's Hospital, Richmond, Vnj to determine the course by foreign in the venous circulation and their ultimate lodging ptacr, objects of various sizes yni-t shapes were inaertel in the veins of a series of animals. These investigations showed clearly that the foreign objects within the lumen of a normal vein of a dog are car to place these devices wherever a sale can possibly be made. Regardless of the fact that practically every method in medicine that may do good cm also do harm, t&ae madnore are being sold to bath institutes, swim ming pools, massage parlor?, beauty parlor?, dubs, barber shops and innumerable other businesses in which medical supervision is certainly not probable, indeed, hardly possible. Th sales are made notwith standing the fact that scientific literature has already revealed that the ray* may in some instances depig* t WrtW, H. lik f Frtigs thriin ia Von Circulation, mentize or bleach the skis, that they possess dangerous Arch. Surf. IS 1712 (Nor.) 1927. . effects for the eyes, that some people who do not tan I BB 0007036* 1 t he. Lancet; ih<50 v<>V \ S70 the LANCET,) VV'JOMlNARV AsUKsTOSIS. 1 ACRU. 10, 103ft This is but an example of the matters which remain was 363, or 16-5 per cent., of the estimated total to be dealt with. They are details, and only details tvorkers in the irtflUKir.V.* T)f these, 93 (or 26-2 by comparison with the arrival of a. great central scheme, but there will be room in their adjustment for the display of adequate leadership, and it is not' of the disease, lu 15-3 eases radiograms were made ; too soon to give them consideration. "ox oi these showed definite diffuse fibrosis, 23 were only suggestive. Dr. Merewether is careful to oyp 0*2 PULMONARY ASBESTOSIS. emphasise the fact that only a proportion of the workers have ltecn examined and that it would b The introduction of that extremely useful substance unfair to assume that roughly 1 in 4 asbestos workers <6 asbestos into industry has unfortunately given rise to hOr 5_C u<t a new occupational risk and to yet another form of . chronic pulmonary fibrosis. The material lias in one zSu form or another been known since the days of Greek have fibrosis; the group examined was loaded with a high proportion of men who had been five years or more in the industry. The actual figures were these. There were no cases of fibrosis among fmQ>-? and Romau civilisation--the ancient writers refer > Z yr to it as " unquenchable stone "--and Charlemac.se is said to have had a table-cloth made of it, which was cleansed by throwing it in the fire. In earlier ot op days the hornblende variety of asbestos was ofieu referred to as amianthus. -Sir Thomas Browne, ihe author of Religio Medici, in one of his poems sighs that he might have amiantine toes which would not Miffer from the gout. The indestructibility of ~tn X *-- CJ 0. u. 00 r_ >- asbestos has no doubt been the primary reason for its introduction into trade processes; asbestos will resist great heat, strong acids, and alkalis, whilst a. C QB owing to its fibrous structure certain varieties of it can be carded and spun like a textile. A report1 just published by the Home Office deals with the effects of asbestos dust on the lungs and on the dust suppres sion in the asbestos industry, and is written by Dr. E. R. A. Merewether and Mr.C.W. Price, respectively medical and engineering inspector of factories. Dr. Merewether's report is based upon data obtained in an extensive investigation made during 1928 and 1929, initiated by the Home Office, following the discovery of non-tuberculous fibrosis in the lungs of an asbestos worker, of sufficient severity to necessitate treatment in hospital. Prior to this the Home Office IMS% had knowledge of only two deaths ifl Ulilt'll -the initiation oi asbestos gust was a coprp>,ntn'T ; * a survey of the industry in 1910-11 had not revealed any serious hazard. The well-known triad--exposure to dust, fibrosis of the lungs, and high mortality-rate from pulmonary tuberculosis--has long been recognised in industrial processes involving the use of free crystalline silica, but,,as Dr. Mekewetiier remarks, the fact that a serious, even fatal, degree of fibrosis can be produced by other dusts has not been generally appreciated. A peculiar feature of the fibrosis produced by asbestos dust is the occurrence in the sputum or lung-juice of bodies, described by Prof. Matthew Stewart, which have a curious resemblance to a minute crustacean.* These consist, as Birton Wood and Glotne have shown, of a series of discs around a central spicule of asbestos. those who had been employed less than 4 years, 36 cases in those employed from 5-9 years, 27 eases in those employed 10-14 years, 15 eases in those employed 15-19 years, and 17 cases in those employed over 20 years. Considering the relation of fibrosis to ago the largest number of cases were found in tbo age-groups 30-39 and 40-49 ; Dr. MerewetiieR deduces that the important factor is the length of exposure, and that the age factor is negligible. The difficulties in ascertaining the incidence of fibrosis amongst workers in particular processes seem insur mountable as many processes are housed in one room and workers are transferred from one process to another. But there is clearly a lower incidence and probably a later onset among the spinners as a group than among those who crush, card, or weave asbestos. No evidence was found to indicate that one variety of asbestos is more potent than another in producing fibrosis. Concentration of dust and length of exposure are interdependent factors. For a numl>er of years disablement, it seems, is curiously slight, even more si than in the case of silicosis. This may be due iu part t< the character of the disease, and in part to the fact tha the work is not as a rule strenuous. The affeetei worker often continues at work until occasions breakdowns from bronchitis until he his aware c shortness of breath upon exertion. A termini: hroncho-pueumonia or other acute infection ma supervene while the man is still at work ; with othei there may be a period of invalidism. Particulars ar given of ten cases up to the end of 1929 iu which a advanced degree of abestosis without tuberculos was the primary cause of death, nine being verific l>oKt mortem. The length of exposure in these cas varied from 9 to 24 years. The rate of progre seems to vary within wide limits. With conrinut exposure to high concentrations of dust the fibro; may be fully developed in from seven to nine year: with a lesser the fibrosis may take 15 to 25 years mature. So far as the available data go there is j S]tecial liability to pulmonary tuberculosis among asbestos workers. The manufacturing processes fall into one of two groups according as they employ (more or less) pure asbestos and asbestos along with other dusty substances. The former group has been the subject of this inquiry on the ground that the effect of asbestos dust alone must be worked out before the complicated factors can be assessed. The popula tion at risk in thiR group of the industry is not exactly known, but is estimated at 2200. A certain amount of selection was used in the examination, new-comers and long-time workers being chosen. The men examined were with one exception at work on tinday of examination ; their number (excluding 11 cases who had previously worked in other dusty occu]mtions) Preventive measures are dealt with by Mr. x Price in the second part of the report. The factor and workshops concerned number at least 160, which 18 are textile factories. Small premises : the rule. The majority are well-housed and w< ventilated, but there are some open-sided sin which are difficult to keep clean, and some which . congested with material. The arrangement' ventilation vary much. Dust removal sysu where used effect a measure of general ventilatii over-head extracting fans are unsuitable and li need. Extraction by downward displacement has h considered for weaving rooms and Hr. Price co*i> it might, with suitable safeguards, replace loealised exhaust ventilation, although it could n<> , _ ' H.M. Star inner? Office. T*p, 34. 1. 3d. Till; Laxi kt, M.ijrb ]-t. ji, 145, and March itMli, 701. successful without efficient heating. While \ dusty processes are already recognised, lie point' NOTE: THIS DOCUMENT DID 1 BB 0007037 J NOT COME FROM PPG FILES -------------- - --MBMUIBgi iJvSTAt'l A mo THIS DOCUMENT WAS NOT A RECORD OF PPG INDUSTRIES, INC. DID NOT COME FROM Voic>** 9S XciuXfc 19 CURRENT COMMENT rrs FILES AND CANNOT BE AUTHENTICATED BY PPG INDUSTRIES. INC. js represented by the effort to find a nonvolatile agent little tuberculosis. Metal grinders and polishers display (ft for complete narcosis or, failing that, a nonvolatile agent the black type of iron lung; induration is less evident ---- I ) I to serve for so-called basal anesthesia, supplemented by and tuberculosis is unrestrained. That siderosis and --i the use of a volatile anesthetic. Lendle's paper seems to show that neither Avertin nor the barbital derivative "Pemocton" is a satisfactory solution of the problem. asbestosis are allied seems likely in dew of the evidence I---- 11._ that the iron-containing1 portions of asbestos constitute the danger to health in the asbestos industry. LLi r> Safe and efficacious new methods of anesthesia may Concerning the relation of physicians of the United r\ result from the modern work in this field; but all the States to this industry, Mills pointed out that asbestos , evidence indicates that the products thus far proposed is mined and manufactured in many parts of this coun- C.O *2^ for so-called basal anesthesia are hypnotics or sedatives try and that pulmonary asbestosis surely - will be and should be used as such. They cannot be safely used encountered. In England the workmen's compensation Cli P-- for complete anesthesia and can be safely used in com act lias recently been extended to include tills condition.* bination with other agents for the production of com ____ ' r.; UJ plete anesthesia only by those thoroughly experienced in the administration of anesthetics and closely familiar with the studies of the use of nonvolatile agents for anesthesia. Thus far their intravenous use must be considered unsafe. ^PULMONARY asbestosis In 1928 The Journal,1 commenting on an article by VT. E. Cooke,* suggested that pulmonary asbestosis, btcause of its dangers and its unique pathologic fea tures, deserved more attention than had been accorded it. Two and a half years later Mills * reported the first case from the United States. His patient had worked INSENSIBLE PERSPIRATION AND BASAL METABOLISM The estimation of basal metabolism has proved to be O r-> o ounexpectedly valuable as a diagnostic aid. The mea surements of the respiratory exchange, which are now -"i* -5**v depended on to furnish the requisite information, have been greatly simplified in recent years, so that the procedure can be made applicable even in the office of Cz t Cx ; the individual practitioner. There are, however, refine ments of technic that ought to be applied more widely than they usually are. This refers particularly to the proper preparation of the patient and to the maintenance of strictly "basal" conditions. In the case of infants "s ~ ur W7 . cz in an asbestos mine in South America prior to 1898, and children, obvious difficulties present themselves in had returned to the United States, and again had been the measurement of respiratory exchange as well as C~ employed in South America, this time in an unstated occupation, between 1911 and 1913. He died in Min nesota in 1929. The history of the case indicates that the asbestos which was found in the subject's lungs in direct estimations of heat output. Fortunately an alternative procedure has been proposed in the relatively simple method of ascertaining the insensible losses rep resented by perspiration. The determination of loss !c !C at necropsy was inhaled prior to 1898. If so, the pro by insensible perspiration as an index of metabolism found pulmonary changes which evidently were induced was discussed in detail in 1926 by Benedict and Root0 by the asbestos, and which seemingly contributed to the in its application to adults. Its use in relation to chil jatient's death, were present thirty-two years after dren has been championed by S. Z. Levine and his the agent that caused them was introduced. Even if the co-workers 7 in the Department of Pediatrics of the exposure to the asbestos occurred at the time of the Cornell University Medical College, New York. Basal patient's later visit to South America, the pulmonary standards of insensible perspiration were proposed by injury endured at least seventeen years. Accordingly, these workers in reference to the normal infant. The Mills has concluded that pulmonary asbestosis is an latest researches of Levine and Marples * have been con incurable disease, from which the patient may or may cerned with the validity of the proposed methods and not die. The cause of death, if tuberculosis is avoided, their basis of reference to predictions. A statistical seems to be pulmonary fibrosis with its indirect effect study was made of the published data responsible for on the heart. At necropsy of Cook's patient, pulmonary the standards at present available for the basal metab fibrosis and evidence of extensive tuberculosis were olism and basal insensible perspiration of normal found; it was not certain whether the fibrosis was due infants. The investigation included consideration of more to the tuberculosis or to the asbestosis. In Mills's the correlation between the two variables in simul case, evidence of tuberculosis was not found but the taneous calorimetric measurements as well as in inde fibrosis was severe. The conjecture seems warranted, pendent measurements with the respiration chamber therefore, that asbestos is" capable'of producing two and the balance. The evidence secured points to a types of injury, somewhat as iron dust is capable of high positive correlation between the physiologic mech producing two types of pulmonary siderosis. Accord anisms of heat production and insensible perspiration ing to Bohrod,4 who cited the work of Hart, the red in the human subject. | f J <^ f type of iron lung is. found in persons who work in iron nnnes and in factories using certain iron pigments; pneumonoconiotic induration predominates and there is Pulmonary Aibcrtotii, editorial, J. A. 1L A. 90: 119 (Jan. 14) 1S2J tiooke, W. E-: Pulmonary Asbestosis, Brit. M. J. 90: 1024 (Dee. 3) , y Hills, R. fi.: Pulmonary Asbestosis: Report of a Case, Minnesota 13: 495 (July) 1930. Bohrod, M, G.: Pulmonary Siderosis, Arch. Path- 10: 179 (Aug.) 5. London Letter, J. A. M. A. 94:2078 (June 28) 1930. 6. Benedict, F. G., and Root, H. F.: Insensible Perspiration: Its Relation to Human Physiology and Pathology, Arch. Int. Med. 3Sj 1 (July) 1926. Insensible Perspiration and Metabolism, editorial, J. A. M. A. 80; 1629 (May 19) 1928. 7. Levine, S* Z.; Wilton, J. R., and Kelly, Margaret: The Insensible Perspiration in Infancy and Childhood: L Its Constancy in Infants Under Standard Conditions and the Effects of Various Physiologic Far* tors, Am. J. Dis. Child. 37:791 (April) 1929; II, Proposed Basal Standards for Infants, ibid. 39:917 (May) 1930, 8. Levine. S. Z,, and Marples, Eleanor: HI, Basal Metabolism and Insensible Pcrsniration of the Normal Infant: A Statistical Study of Reliability and of Correlation, Am. J. Dis, Child. 40: 268 (Aug.) 1930. i29, 1939 the estabtesirability Infirmary Tommittee ham one, rely to the jordinated assuredly ;h confer* FOR 1929. population have been S:-- Persons, r3 1437 live biiths puerperal . 1-80 id . 2-53 1 have done one charatred cells in ?mic states secondary ycythjemlA, all all those ; a reeponee lore tissue* *een the ry arterio* jin types ef "--notably i monoxide e to poison* mechanism s they would ifiift. Tbflfr owardi the i in' Tte, Lancet ycL l THE LANCET,] AXAT.YSI* OP PsYCHOTK'S.--PULMONARY' ASBl and Bode would group under the separate heading of and paranoid conditions as frequently the result of erythroleuksemia, but there seems little necessity for habit-deterioration, the psychotic development being this further group. All cases of ervthnemia may traceable in the life-histoiy. where t raits of pcrsonalit v be regarded as potentially leuksemic. Frequent and emerge of a type that leads to increasing maladjust copious bleeding and phenylhydrazine are regarded ment and finally to the rupture of compensation that as the best means of treatment ` and a special warning we call the psychosis. Looked at in this way the is given against splenectomy. therapeutic problem of the psychoses, as Dr. Gillespie It is doubtful if the third'group of Parkes Weber pointed out, seems more hopeful, principally fiom the and Bode--polycythaemia hypertonica--needs to be preventive aspect. This would involve working with differentiated from the first. Polycythaemia asso children and adolescents in the pre-psychotic stages. ciated with high blood pressure was first described as Some confirmation is forthcoming both from rccer.t an entity by Gaisbock, and on the continent rejoices psychiatric experience with children and also, it i*4__ GO in an eponym. High blood pressure is found in many interesting to find, from some instances of the psyche---" LL1 >. cases of polycythfemia, both secondary and essential, analysis of children such as those quoted by Dr. O _l and renal disturbances are not uncommon. All cases Melanie Klein. ___ -- _ of polycythaemia might perhaps be brought together What the discussion principally brought out is theT "** LL^ ` under the firsthand second of the authors' groups. need for much closer rapport between the different ^ ' investigators, psychiatrists and psycho-analysts. It * is unfortunate that there should be such a division of O--; ANALYSIS OF PSYCHOTICS. Thu discussion at the Royal Society of Medicine on psychotherapy in mental disorder, which we reported last week (p. 825), revealed a divergence of view which may be explained in part by differences in scientific method and in part by differences of training and experience. On the one hand are psychi atrists whose woik has been concerned principally with institutional material: on the other hand am jiycho-analysts who for the most pait have not had much to do wilh the type of psychotic found in mental hospitals and whose training in psycho-pathology has Iiet'ii predominantly on Freudian lines. Dr. Devine lioni vide experience of confirmed psychoses again advocated the view, so ably expounded in a recent book, that the basic cause of psychotic manifestations U primarily * organic." He uses the term " organic " in a special sense as pertaining to the vegetative aspects of the organism, not necessarily the same as the usual clinical sense of "structural." With such a point of departure it is clear that the modifications which psychotherapy tends to produce--primarily i` the psychological level of the integrated activities f the organism--cannot be considered as cardinal 'lit must be regarded as symptomatic palliatives, i `-echo-analysts. however, feel capable of explaining di the characteristic psychotic symptoms in psyebo- opinion as springs from impetfi ct collaboration. It - is clear also that there is much room for research * into the predisposition to psychosis and into tin- --' possibilities of modifying the various factors while C.,3 = they are in the making. It would be most useful if a /=';, C_3 number of people, apparent candidates for psycho- \ pathy, could be followed and studied from childhood into adult life. Fuithermoie. an attempt should be made to disentangle the congenital or inherited and O'j .JU UJ presumably less modifiable predispositions from those which are acquired and presumably more modifiable. Our county asylums, drawing upon a defined area of population, should be peculiarly well situated for the study not only of mental disease in families but of the inheritance of individual traits and tendencies. In Lf the psyclio-pathology of the developed psychoses themselves there remains a wide field for study. The relative dearth of ai-licles on this topic published from mental hospitals in this country is in striking contrast with the number of researches on the physico chemical condition of mentally sick patients. The problem of accessibility has not been sufficiently studied ; a continuous search should be made for a technique of access. When these questions have been better explored it- will become possible to discuss treatment, psychotherapeutic and otherwise, more effectively. ______ : IP*" lo^ii-al terms alone, deduced from psycho-analytical ini'-rpretation of the mental processes involved. PULMONARY ASBESTOS'S, Tie- fact that these interpretations have not received i>> any means a universal acceptance, and that even i hose psychiatrists who are sympathetic towards iiiii'h that is psycho-analytic are st ill sceptical of some >f flu- most fundamental of the assumptions involved, nat uglily does not deter psycho-analyst sfrom pursuing Ib.'ii working hypotheses. Dr. Glover refrained from h'liic much more than defining the ways in which tin- special psycho-analytic methods of approach I Imt ics may become accessible to psychotherapy. II i-sjilained that the cases so far dealt with were ' b w and the time that has elapsed too short to i1' dv final claims. We might add that a perusal of 'i i-ili.Tiii'e pioneer psycho-analytic work on some `l, i '-Hive psychoses, mentioned by Dr. Sylvia Payne "> ' r contribution, does not compel conviction of the ' `'iMn y of liis interpretations. ''ui there is a viewpoint whieh in the discussion ' <1n organicists and psycho-analysts hardly ' 14 ''d sufficient attention, although it is widely held '" 'ii- continental psychiatrists. For example, a dis- 1 i"itliHslongbeen made bet ween the "fundamental 'b process" and the "accessory symptoms" ''* " bi/Jiphrenia. The fundamental process would ^"-t'oiid to Devine's organic substratum, while ' ' "t-Hory symptoms are presumably accessible to ' `Mierapy. Similar interpretations would make i' "'. s of manie-depressive type and also many l idiopathic epilepsy explicable on the basis of l ' 'onietimes inherited, responses to psvebo- 1 bietors. Here also psychotherapy should have a It is now recognised that the inhalation of dust generated in the manufacture of asbestos often gives rise to an insidious and progressive puhnonar> fibrosis which is distressing in its effects and disastrous in its consequences'. The value of asbestos depends upon its well-known resistance to heat and to the action of strong acids and alkalis. Its importance in the mnnnfaetnre of fire-resisting articles, whether designed to protect against risk or for use in connexion with machinery, and the absence of any efficient substitute is the cause of ever-increasing demands upon the factories where the fibre-containing rock is crushed and the fibres spun and carded. The number of persons employed in t he fact ories is already large and. as Sir Thomas Oliver 1 points out, many of the workers are young. In the past too little attention has been paid to their welfare, and the need for rigid standards of protection is mgent if fuitlier suffering and loss of life are to be pievented. T,lgeffects of flic inhalation of asbestos aif dr" y--*-)-- Bitira which it contains, but tiie resulting fibrosis tliffei s liiMulUglllllH Muhi'the nodular foim seen in other types of silicotic lung--e.g.. in gold mineis' phthisis. The wborled formations seen in the lattei are absent and arc replaced by a diffuse fine interstitial pneumonia. The difference is also reflected in radiograms of the two conditions, the gold miner's lung showing scattered dense rounded opacities which contrasl with the fine basal mottling and linear stria' whieh arc eharnrteristic of the aslvstos worker's lung. " 1 (application in the resolution of the precipitating 'Oliver. T..Arrli. S. (irwerliepnlh. Inal Ocmi'l'diyc., lir.'fl, I.. ' 'not her view regards schizophrenia, paranoia. Heft I'. | BB 0007039 | * 702 tbs IAXCST,] THE SCIENTIFIC EXAMINATION of FICTCBBS.--A FRIPP KEVORIA1-. [MARCH 20. 1 A peculiar feature of pulmonary asbestosis In the presence of the so-called asls-st.min bodies. These Wens discovered by Prof. Matthew Ktewart In the sputum of workers suffering from t lie disease, and they have been demonstrated by a mmils-r of investigators in sections from the lungs, and in lung juice removed during life by exploratory puncture or expressed at autopsy. The asbestosis body, which bears a curious resemblance to a minute crustacean, consists of a central core of asbestos fibre which appears to bn embedded in a series of discs. One cud of the fibre is often buried in a bulbous extremity, and this with the succeeding discs produces the appearance of a minute screw. The nature of the aggri'gat ion around the central spicule is unknown, but Gloyne* has been able to demonstrate the central fibre by exposing the containing body to the action of sulphuric acid. shadows are obtained sif I lie whole urinary If, however, the renal function is dcprv*ncshadow may appear for six hours or more, iin* rapidity with which a pyelogmm in obtaintherefore a rough guide to the efficiency of t lie in The method may be regarded as a definite mb in urology. Where it Is sufficient for dingr purposes it is obviously a great gain to tile its who is spared ureteral catheterisation. ami II *) also he useful in those cases in which the catlirb tion is attended by special ditliculties, * advanced tuberculosis of the bladder. I'roselt has already been tried by a numlter of surged Germany and France, and is being tested in Knp Mr, Frank Kidd records some observations h current number of the Joumal of Urology. A FRIPP MEMORIAL. THE SCIENTIFIC EXAMINATION OF PICTURES. A proposai. has been made in the public ; The famous Italian pictures, which returned to that a memorial to the late Sir Alfred Fripp s)i their various homes last week, after being on crowded be instituted to perpetuate his memory.and we view in Burlington House for the past two months, received from the popular novelist. Major evoked enormous general enthusiasm and, as was Beith, an outline of the scheme which has beer inevitable, certain discussions on the attributions. in hand. It is proposed to invite public subscript For more than ever is the authenticity of old masters to a fund to be devoted to the development becoming a serious financial matter, while the prices extension of the Children's Department of G for genuine canvasses soar upwards under American Hospital, the endowing of cots, the building of a desire of possession. It is significant of much tiiat is ward, or in such other manner as the governoi happening in clinical medicine that recourse should the hospital and Sir Alfred's own relatives i be had to exact scientific methods in diagnosing the decide. The trustees of the fund will he 1 period of a painting and possibly the actual painter-- Lonsdale, Mr. Wilfred Godfrey, and Major Bay Bi critical acumen is taking its place wit h lortun erudiiu* Subscriptions may be sent to, and will be gratef as something personal whose value can be added to by acknowledged by the Hon. Secretary, the " employing the methods of laboratory technique. Alfred Fripp" Memorial Fund, lie. Cheap* Ilr. A. 1*. 1-aurie, professor of chemistry to the ltoyal Imndon, J0.C.2. Major Beith writes: " Two cha Academy of Arts, has contributed to this month's teristic donations have already been received by i issue of The A ttaiyitf. an article--a record of a recent a cheque for 1000 from those truly pract lecture delivered before his Society--upon the philanthropists, the Froth Blowcis, mid a surr identification of pigments used in painting at different 10s. raised by farthings among the children o periods, in the course of which he gives a brief account a County Council school in one of the poorest disti of other methods of examining pictures. The of London." The total sum subscribed will technique employed closely resembles that of the handed intact to the Governors of Guy's llospi pathological laboratory, and it is not suggested that An institution, as our renders know, with which the verdicts of these investigations are to take the Alfred was closely associated as a student, surge place of t he judgments of t hr instructed. Knowledge of and governor for over 40 years. the art of painting, its history, and the manners of the various sehools.of brushwork.and of idiosyncrasies of well-known executants will remain the medium of VITAMIN DEFICIENCY AND ANAEMIA OF identification, but the chemist and t lie radiologist can be drawn upon for assistance. 1 >r. A. Martin de PREGNANCY IN INDIA, Wild (see The Lancet, Nov. 2nd, I!2n. p. Ii:i2) lias An antemia of pregnancy is common in India arm gone over the ground, when invest igat ing 1 lie pigments all communities except the Kuropenn. The hi, used by the Butch and Flemish masters from the picture closely resembles that of pernicious mi."err fifteenth century onwards, and such a system of and treatment with liver extract is often success) inquiry may give art critics a feeling, shared by many If untreated the disease is frequently fatal or there it medical practitioners, that.,with a disputed diagnosis as be recovery after delivery. The amentia is diffi-n a possibility, the calling in of the chemist and radio tinted from true pernicious antemia by this oeeurrei logist is a measure of ordinary prudence. of spontaneous recovery and by the rarity of nchl. hydria. regarded as an invariable concomitant of <i pernicious antemia. The condition has received a gn PYELOGRAPHY WITHOUT CATHETERISATION. Goon results are claimed* for a new method of examining the urinary tract by means of a preparat ion called nroselect an. Since the advent of cholecysto graphy urologists have been stimulated to search for a'similar method applicable to their specialty, Aftertrying varioussubstances Liclitcnhergand wick have hit upon an iodide compound which they call urosclectan, and it promises to be very useful for the purpose. As it is badly tolerated by the stomach it has been given by intravenous injection. Two injections are made at three minutes' interval, the first 40 r.rm. and the second 00 c.cm. nf a 40 per cent, solution of the drug. Films may be taken a quarter, threequarters, and one and n quarter hours after the final injection, and it is said that as a rule good deal of attention without any light Iwing thrown up its (etiology so far. A new study, however, lias Ire made by L. W'ills and M. M. Melit a. working under t auspices of the Indian ltesearcl) Fund Assisiaf ion f the Maternal Mortality Inquiry, and they offer sm interesting suggestions in the course of apn-limina report-.1 Their first important contribution is t recognition that the disease is not. essentially ; amentia of pregnancy, but widely affect s worm throughout the population. It is only exacerbated 1 the exigency of pregnancy. II camay evidence quoted that, it is even common also among men. T1 wide prevalence of the condition mid the equally wii prevalence of poor nourishment, deficient both ; quantity and quality, readily suggest the likeiilim that an association between the two is of fundament, importance in (etiology. The rcporl is only ;i po *\VooO, \V. burtaii, nml (lloyne. S. Hnoillmiisc : Tun T.avckt, liminary one, chiefly occupied with (he accurate dr-fin March 1st. n. 41.). Valler-Riulot, I',,llnl-nee,J., Noiiionra-Amni-lr. ami fiernl.M.i Wills, x,.. ami Mchtn, M. M.: Ii d. .lour. Med. flo., 199 Prose Me,),. March I'.llli, |i. .ms. xvll.. 777. .APKI> *$, 1930} \ - 1 1 ! Vi PULMONARY ASBESTOSIS. 1f Thk tlRfH*4 789 of London. Although tlic surgeons of tlie time usually different dust concentrations. Correlating dust counts - - iar.ii; of a humbler social class and received a less lilieral with the history ami the medical aud radiological features NOT COMEfiiQM.PPG FILES ^ education than the physicians, they based their practice of each case, they found that the two factors of greatest on sound anatomical lines and were rapidly improving important* in the development of fibrosis were length of o their position in the medical world; they not unnaturally exjur-ure and dust comentration. Age and sex played nted the action of the physicians, some of wliora also no part. While no definite case of fibrosis clearly due o i<d surgery, in prohibiting them from giving internal to asbestos dust was found among workers with less than ^^Su:cdics. Ambroise Pare, who wrote treatises on medicine five yean,' ex|>osiire, the antlmrs are not prepared to rule t uml miJwifcry, is regarded by Dr. Herlicrt Spencer as out the jwssibility that such cases might occur on exposure l.U i * the reformer of surgery and midwifery." of workers to high concentrations of dust. They lav stress on the fact tlmt fur the production of generalised fibrosis! * PULMONARY ASBESTOSIS. c,;-a definite minimal quantity of dust must <ie inhaled, "and that tlie lower the~ concentration the lower will be Dr. E. R. A. Merewether and Mr. C. W. Price have the time tlia-t elapses before fibrosis develops. If, as seems c: '-'carried out with commendable success'an official inquiry probable, this view is correct,'tlie practical inferences are v into the effects of asbestos dust in inducing fibrosis of the very important, for it follows that the application of : lung. Their results are embodied in a report submitted measures resulting in a reduction of the concentration of by the Chief Inspector of Factories to the Home Secretary dust in the neiglibouvliood of asbestos processes will bring on March 17th, and laid before Parliament- on March about, first, a great increase in the latent period preceding . 4th, Before February, 1628, when a case of non-tuberculous the development- of disabling fibrosis, and secondly, as h" fibrosis of the lungs was discovered in an asbestos worker measures for the prevention of dust are perfected, the - (Seiler's ease), the Factory Department of the Home almost total disappearance of the disease. Tlie increased UJ Office had knowledge of only two deaths about which liability of silicoties to pulmonary tuberculosis does not.. t!>ere was an expert opinion that the inhalation of asbestos appear to be shared by asbestos workers ns a class, or o " d*t had contributed to, if not caused, the fatal outcome. even by those of them who hove developed pulmonary In the first of these, described by Dr. Montague Murray fibrosis. In this respect, and in the mode of distribution m 1906 before the Departmental Committee on Compensa of the fibrous tissue in the lungs aud in tlie radiological tion for Industrial Diseases, the post-mortem examination findings, pulmonary fibrosis among asbestos workers differs ' confirmed tlie clinical diagnosis of extensive non-tuberculous pulmonary fibrosis; in the second, which was described by Dr. W. E. Cooke, director of the Pathological Depart- from silicosis. At the same time as tlie report by Dr. Merewether and Mr. Price was issued Earl Russell introduced a bill in the House of Lords to extend S .nient of the "Wigan Infirmary, in the British Medical Section 47 of the Workmen's Compensation Act, 1925 Journal of July 26th, 1924 (p. 147), the illness showed (relating to silicosis scliemes), to industries involving ex 5 'a progressive dust fibrosis together with chronic tuberculous posure to asbestos dust, and to amend the provision con infection, but the evidence for an etiological relation cerned with medical arrangements and examinations. In between inhalation of asbestos -dust and fibrosis of the our issue of March 23rd, 1929 (p. 562), we drew attention -a vould have been stronger if tuberculosis had been to inconsistencies in tlie four existing schemes applicable to #.. Tlie inquiry by Dr. Merewether and Mr. Price groups of dusty "occupations; this bill aims at making initiated when, investigation of Seiler's case having a general scheme to cover all industries and processes to definitely excluded other industrial and infective causwehsich compensation schemes apply. . of fibrosis, it became necessary to decide whether the c| * 3 ' Cr"5* 'supervention of this disease in an asbestos worker was :n exceptional occurrence or evidence of a grave industrial "risk. Dr. Cooke's observation that microscopical examina tion of sections made from the Inng of his case revealed the presence of curious annular and club-shaped bodies,' and clinical and pathological observations that have since then been published from Leeds, London, and South Africa, have shown that free silica cannot be regarded as the only dust capable of producing pulmonary fibrosis,' and that the inhalation of silicate of magnesium, the con stituent ef asbestos dust, is, if anything, more effective in producing a like condition. Dr.' Merewether and Mr. Price at the beginning of their investigation tried to discover how many persons in the country are constantly exposed in the course of their daily work to the influence of pure or almost pure asbestos dust. Such information ttas necessary in order that they might check the adequacy of the sample of workers examined, and envisage in proper perspective the problem confronting the industry. The numbemof exposed workers they believe to be about 2,200, and of these they examined 363, In 133 the examination including radiology of tlie chest. Diffuse pulmonary fibrosis attributable To flie inhalation of dust was found lb be present in 65 of the workers examined, representing 26.2 per cent, of the series. By distributing the workers ace- "og to the process in which each had been longest 2, and grouping similar processes together, the of the report were able to make certain broad generalizations about the relative effects of work in DELAYED LETHAL EFFECT OF RADIUM ON TISSUE ` CULTURES. A further step in the investigation of the destructive influence of radium on certain types of new growth is reported by Dr. F. G. Spear.1 In the Journal of September 14th last (p. 508) we referred to the discovery by Drs. Canti and Spear that after a short exposure ef a tissue culture to gamma irradiation there was a marked fall in the number of cells in mitosis (40 per cent, that of controls), and that this was followed by an increase (160 per cent.' that of controls), which compensated almost exactly forthe diminution seen during the first period and subsequent to irradiation. Dr. Spear now reports experiments showing that the gamma rays have a delayed lethal effect on tissue cultures in vitro. While the resistance of individual cultures to irradiation was found to vary considerably, it seemed to be established that the greater the intensity of irradiation the sooner the lethal effect could be observed. When 300 mg. of radium was used at a distance of 0.S cm. the probable life of a culture was approximately -doubled if the duration of exposure was halved; with 100 mg. of radium, however, halving the exposure had a less pro nounced tendency to double the life of the culture. Com parison of the action of the two doses of radium showed that the exposure of a culture to 300 mg. of radium for six hours produced a lethal effect six days (three subcultures) earlier than did exposure to 100 mg. radium for eighteen hours, though in each case the dosage was tlie same, '; ! * .- 'JU-port an Efl-vU "f TWil on (hr and Pun Snnpms. *'n in tin* Imlinirv. iU F,, R. A. Ur- -. 1 li. r. U,r>., mill C. W. ruco. H.jr. St.lion.tv ii!Rw. 1SC0. (1*. 'il. ik 1.) amounting to 1,800 milligram hours. It was also foiu'A _________ 1t'rorreriiutje *./ the Huifel Surfeit, B, TOl, 106, 1330, p, -4A. j gQ QQ 0 ~7 0^ 1 wQI alt* Wrfe*l fafe*^** Jte xArtiMO of .***-. imirepurtohflte^^^^ hT.JH.ll.' The'.'. '.IT, *1 -- Ook CMfWranat fetartti UMrakwy irwmV*x .Apay sutborilir* iniheinMcd M.-dTs'a*a tSSirne- in P,, tv4 PWQhWitAi if ^faywyuvt ^ jnht 'lit-iAt lil '*' ' ^ ttkniiM of aw -fcr wtutt nd frJntt wronrttb' rciudif obtained, whether *qr ore 4a* or ^acvd+es. *.- - -.-. . ^ .; T . -.-< >w.- - ; . . ---- _ ik .--l.,l.,^i C ' * -- ~ 1--; -. ,,-.-^ ,,->. furtuatmii a* distinctive : sJddiss, ' "-'' ' i A search of nil tltr death a>>frI> *tt file in Ui> \|. , ASBESTOS1S . politan Life Insurance Oi|i|m' rcvenhxl tlua a-l- i,.,,i^C.- t. A. J. LANZA. MIX AmuUM Uokil Uindir. Ilcuvoiliisa lit* lunm Cenww? - Vctv tntii - i.- : liad 1>ccn riven ns n cattle *r coiirnluiim;; cause* m *1* i*n o- nly .n.!i.n__e_te*_e__n c_ases. *Tf*h(.e firs: cav n< .ted. u.. "ltSv-^^' . 1924. there were two in 1*07, n:iv occurm] u I' 11* i a*<l the rest have occurred sincr 1933. Tlu- di.c,,.,.;v~-. -- Aslicstosis i* a pneumoconiosis cruised liv iIh* nihab- wa supported In* ant>>)sy in only six. In m.i- ..i .i..J*^~! tion of asbestos dust. It i* distinct from silicosis in its six the jirininry ^ausc ofdealh was cnrci:..iu,1 ,,, !C pathology and climcafly. Whether adicj-tosis will remain another glkiiua of tlac brain, and tn another pub. ,rv|~- C. a distinct forth of pulmonary fltist disease or will prove : tulxTctilosis. lit the other three a-k stosi-. wa* vn.., -- i to he of a type common to a number of dusts remains . the jirininry cau-v. with cardiac -failure as the f"un.i,i|;.f~> i to be seen. So far. it is the only jmeumneoniorfis. miter inff cause. Static of these cases were rejsrte>l it. liw'rzf'' ^ than silicosis, that has received anv coiisideralile atmwmt . literature. of study from pathologists, clinicians and imlustria! f A>hc>to>is comjilicate.l by lutirt diseaw wa ^ hvgicnists. - ^\as the cause jof <leaih in wvm crises. There wn. B * Whereas sIHcosi* has lieen rccogniTed for ntanv cCP- *utP*jei in tltese seven ami pulmonary iuImti turics. asbestosis is a tK-wcomrr. A>lcstos (Canadian) was diagiaosol in several by the attending jihvi. . is a hydrated magnesium sHicatc eraniaiuing o free silica but alxmt 44 per cent of cmuhinetl silica. 43 |r cent magnesium, ncarlv 13 jier cent of water, and traces of iron and aided. While adiestos was known to the ancients, the falirtcating of asbestos on a large scale is comparatively new; it received a tremendous imjxtus from its use in connection with automobiles and as an insulating material and a heat resistant for a great so periiais t*m much weight cantuK 1 given it. i Certificates. l^ialtetcs nisi ;u!m*mary tulKTC.il>**i< were ak*> >,. tkmed in the remaining six cases, in which there , rr no autopsies. All nineteen patients were males ninl * m, onr exorjition all won.* white. In our studies of asbestos mines and tnhrii-.iij,,., plants.* the clinical jweture of a*liesto'!>i was u,,i.|,.p tlian tint of silicosis. To l*c sure, the individual p.d,, ,(l variety of mechanical purposes. . with nnrketl nsliestosi- will anittly reseinMe the n,,|j. While Hoffman1 called attention to tin* possiMe vkltad with silicisi*. There is the same dyspin . ,,tI liannfulness of aslwslos dust in IVlti. it was not imtil exenion. the same dry c<i::;:li. and the nvVv >>i I. February 1927 tliat asbestosis was. to sjx-ak, othciallv imhTinite i>iiy>ical signs elicited hv ;!te stv:lvisc>*|ir 11,,. recognized m this country by the filing of a disability jntiem with asliest'tsis is apt to fiavc c'.uhlied i__ cbiim for workmen's cnmiwnsntion in DJa^tchusrtts. nut tLsnally seen in silicosis--anil he N a]: t*> lx- The daintant was a foreman m the wx-avin^ department .faced ami even sh>w a slight cyanosis, wliile tin1 >ih..h a. of au asliestox pbnt. attd the claim was ujhehl by .tlx- jiatient t ajit to U* fairly robust 1>>king. (`if i.t, 3Iassachusctts fachtstrial .\ccidem Jt-ord. Tliis' wws * in-each instance I refer ;p jwilients whose ilisea*e i twenty-seven years after the first fatal case was reponwl complicatcrl by infection. in England by Dr. Montague Murray. - In 1910 and . We did n<4 find in tsmniuuiiti>s in which ns| again in 1934 a fatal case was rcfxmcd in KiighnU. and was niinvd >r fabricated iliv familiar ja'eture <*i in 1928 the British Factory Dv|iartmvm Dmductcd an liHity ami tulwraiious ituVetion s duiractvristic **i i. .,,j investigation and enacted laws for the pnm-ction and Tick mining cnnummit>e. *hir ohstTvatious wen ,,(l. comjwmation of the worker againM this hazard. The 'ported Ire .the statements of iJiysirians j.nuaiem) wh*ic subject in ICngland Ins lieni siinmiarized ,by . these cininiiimitics. All theiKitieiits with asU-t.r.i. ,tii| ilereuxtlicr.*' At flic present-time, as nearly as can he J- wv sletixntsl wen*. wtiirtc evcvption. working 'ti .i.i,|v estimated, tlicre ate alsiut 12.0U<) imlivhln:tl enijdoywl' at tlwir trades. In only one rase iliil we find end. in,, tint c_hi *ieff a__slx__t_s.l.os ,,fdt.a__u*ts. fn stiin..*. jt'n,,i!l.cd Sta*t'in. ,* o_ tf ojhi'amn!i.i.v.. itul*ercu1**.s.::.s .a.n..dt itilou.-sit dilli.tig.*n..o-i?s --was Ict-ed whom 10.000 migln lie rxjsisi-d to asU*sto> hi>t. on the roentgen ain-eanuKv. Several showisl h. In 1927 a fatal case of into implicated nslx-stosts was rrjsirtcd to the Medical Swiety of S>mth Caroh'na.* and since then, including this can-. .flkTe have hem Hcveit fatal cases -ecyeirtcit ill ilw Vnitrd States, eight uncinnjilican'd ami three cont]>Hcats| lw tulxTcnloSis. Ttwsc rej^jms. togeilKT with the fact ilwu aslmstosis figured in the extraordinary oceupation:d disease litiga tion that has spread sn\r this country, resnlurtl in Uxh laboratory and Jkdd stmlus of jhjs.ztciv 4iazar>l. fiard- tulxTculosis. tiirdikT and Cummings in iheir rep.,,, called attention to tw diiTenuja* liewvveiMlu- aeti..., aslicstos dst and silica. *hiij'4n^rt,*ai>*Hi to ink,,!,. iufiTtion in cxiKTinK'mal anr^adN `Amf'/heir ol. ( lions tend to Ivar iitt our eltnVaJ stmlv. In all. our riinietd da*.:i arc Iciseii on 12o pin ,.;i| examinations of a-k,*; i- v.otkers. all of whom (...) wore than liiree \xar-' e.\;^ur <iinl who were l.. <, ,| at random. Sixty-tUrw nt these presented a m ,, W|*eat,aihv which we thotn-hi iiidiiate*! a |>:.e::in<. tnd WUr Ik M >n ^ |,TfirfWHt W rarfk llralUi U |S>I iWCtU ` ^J%a*atcU ' * '** * ^ .1. Jl> TTMks. aH Awtn^ii 4. UfcfilM*. I., r,, M<f l`rt^ ;!* ***. VI. * O > Tmtrtv. S3i4i O** Wt. fwl*. Ilrftiiii Sr^. A i I - ! Wc called rixse.ca^rlbw -------- -- ---------- --;------ -------- 4-.............jit^'y^Kthy -wi- OTii triw Jr^mecu*-gram Ixrinv a sliggntsds of arfice- dcnt 'justified. v\*nroiviri ryhcitatto <abcr tvcu;a- K**TM* ** trriicd M&t*rf *re-uam * '*al *W jazard<.<1hcre 'jfjtf iftff frcmcRt jonaus. itmuv lexl bcrn r-x|rol\el*r tni vcur* tcwlrtKT to Utttc ai.-acmtso. of;* fleyittc *tcciipauial and thirteen 0*0* a*e adfifcnh- .%.s8ty**c Wgium* of 4*nntw^`t>'^icie?H>>Mrr witli- ' tinuing nr M***tu*^kdit^'*ml lntjc to awn*;'."XWf ibe vxwn^cwwiC^^1 adtluiuiial Kifi^:ti< Wi;K-4hr^ VUttann <n tbAx4<^. ;<^nm . mem and the tendency nr.d rate of progress.' 1 . diagnosis of esIxsSmms any tn-fe titan oi silicosis in tin* One feature tliat luis impressed r.-js that the Uritidi presence of a mciugent grain showing no distinctive investigators found a>4<es!os:s m. .re severe and more. fwlntnaiy.]Cuho:.gic climtgH^ , menacing than mv-dnl. iThi* dinemice rnavbc more , Associated with cxj>o*urc to adwstn* dust- > die apparent than -rval. int h is jus-fiikr that tJtc English vunvocc 3n tile spsr.Hmaud pnlnneir.n- tissue* of a factories nay lr more diwr thau-onx*. There were -ficWiEar imbU'n^iMwsm* Indies. Tlx>e not available any ci>nijral'ivi- dust counts, but ibis aslxi*n** jmdiv> Imvr been desrrilx-d liy a numlx-r of tmpreerii is loscd v their rrj*firtsd on statcmeuU tdirervcr* and are hic tqiparruth- to tbesetum of the .made io<uyH-)f and my wnBrague* lw person* familiar ' tissue* on tlx* aslwto* iiher.-Tticir exact significance ' with tin- KugiiJi omdiiums. One .priecss. described in i> doubtful. but; it V-atunwmly agreed at the present tite Hritish rejiorts as "maitrc.-s making*" and stated to time tltat they arc imt diagnostic of pulmonary fibrosis be nurenvlr ihi>:y. do n<4 ap|<nr to have a counter and indicate merely 4liat the individual lias l<ccn part in this country. in Usli cmmtrics. energetic steps cxjxiscd to asbestos dust-* Souk* edtservers lx-lieve tliat. have been taken to tmitnJ die dust hazard in asliestos when these aslwstns Iiodies aptwar in the sputum in plants, so tliat it is probable that further cases of dis dumps, they indicate actual disintegration of lung abling aslieslrwis will lie tare. * tissue. As in silicosis, the diagnosis centers on the roentgeno Or. Miller* of the United States Public Health Ser gram. However, the- whole natter of atumj>ting to vice dcscrilics the technic that lie employs in the intra- interpret these films and correlate them with the clin jwrit*meal injection of finely divideil dusts in a state ical evidence, if any. is difficult and elusive. If. in our outi smussjjiiccnasiun. .MMiullteer cdeifminedtl ti.rce tvyjiixcs oi reaetinn: studies, we Had found a more clear-cut and severe type. tdisorptivc. inert and proliferative, llic first is pro- of pneumoconiosis with marked sympu<ms and dis- ducetl by relatively harmless or inactive dusts, tlie sec Z' \ aiulity as well as a distinctive roentgen appearance. ond In* dusts tlat might cause pulmonary fibrosis, and )such as niv colleagues and myself had been accustomed tlie tliird as ilx* tv*]>;cal reaction'of silicosis. Reccnth* to find in our previous investigation* of silicosis, our Miller described tlie vfivets of the injection of three task in attempting to make a poritivc diagnosis and varieties of asliestos: namely. c!iryst>tilc. cr<<eido!uc and estimate the extent of the disease would have hem ainositc. Cbrysotile is Lanadian asl>csti> and. as preeasier. There is no doubt dint. e*]ccial]y in the begin vbmsly statcil. is largely magiWsium silicate. Crocidiv ning. we were handicapped by endeavoring to evaluate ine ami "kinosiu* contain only a small ipiautity of asliestosis with a silicosis lux' rttlc. magnesium, containing instead inn silicate in ajjiro.\i- The x-ray apjicarancci arc not clear cut or distinctive ' matdy iIk* same <|iiamitv. as in silicosis and do not' laid themselves to ready The three t>ies <f asbestos jireduccd the same tyj*e grouping into progressive stages. There are less evident jf reaction^ iiamcly. tlie .onc'described by ibis mvestipathologic changes' in these films and the shadows arc ^fatoras nicrt. He states: finer, more gnundar and softer tlian in rilktwis. The ' We W-e bin ownttif: that the <lu>is proihx-ing Hit* inert ashestosis fibii gi\TS tlie imjircssion of grmtnd glass, react< unw {Sk-ttm><ni>fit of llte diffuse li!e<ik lyin' as and titcre is no nndulatkm with tlie coimijuent ten-, ibstinct fn*n tlie pridiftrudve reacting dast, wbidt cause mwlubr dencj* of the nodule* to coalesce and gi\x ilensv opaque fibnah. Thb assumrsinn. a >iki kiti-w. 'has im beet! pr\vii . areas in the films. .The distribution of the slradow* is ncwhat difTcrcnt, occupying the ..lower third of the lung, except in far advanced cases, when the sltadows * by eurrrsgxnding animal -experiment* sail the same dusts. Uu results Iras sdncnatnin ni paOMdngk material foan autopsies. . - 1 believe that ibe jetoss.'Vthavwr t asUMns in tin: tissues has further strengthened the value of <nr dassifiratsm 'may occujty die major portion of the lung.. \Vc noticed f dusts' and 4be jntraporitnncal Scd maai of determining frequently the well marked outline of tlie intcrlolor tic lanutul dusts bj' its<Tinical ourthtini septum oh tlie right aide. \W also noticed that a num ber-xif films in cases of aslwstosis showed enlarged Much tvutk mitnius pi be done lwfore aslx*sto*i* is 1warts, and this might bc cx|>ccted wlicn one consiclcrs sjxtken of as authoritatively as is talicosi*. {jj the uteon- tliat tlie jstthologic procoif temls to constrict the pul- ttHK. adantos idant* are* bang cleaned tin and the dn<t msury blood ve??cU ns tlwy ranu/y akstg with tlie is Iwntg yumroliivl. -fTtiK togetheT ,*rilh rite smaller kfondriiic*.* ; ^ v". riumiwr u inTs<ms e*nfd"ycd. inqiHcs J^at tlwre will It is 4Jossihle that-the x-ray^ ajipvatntice of aslicstosi* lirtihaldy ;nt*ver bc.ibe. tweghb - mucrinl tliat may not lie disiiiwiitx* *4 thi 4ta* iiccn ftvmhddr hi inJ<ri*a. Iffis W-noetwans certain iwkruriw"'il"irin he ?'f*.*M*>pww* TUr m'*Tr ia lijFan,<1 -p^-IntittimraosviiwUevoes-f ls*iattlv-iespdeiaagknstaoktsuf*iivsnnuit-uhi*t^|*Mwti^mc_usi2_^xJn_hn_xicsc_,.uthe mod iuijx>nant H- Jw* tvMthmg ir.nn Mlxvrte Un<s tlnnan.!* innher Mwiv lsdh iti the held ami m tlx* laUiratuwr "EG-One dung is Certain,'^fbc amxo 4uV4' .!mS,.pti*-k'; are mvtled .to <4kri ihe sccuicuioiKtl hi>|(ri7 sd lhc -Sf MirrmwLrr.- n'wL If; Tg itiif lil?r, A' IL: tVImwr .aUW.M.,-|^nr,t l |K tiO. ja jyt. ;. imm, ). i~. a*: Unitirr, X.as Od tened IssMu) a the |*>1a-- O C/3 wall w f|g o3 Iw---*r Li- f*, :4 n .* I --| !I rn Ii IOI !,'| Io| to I ' oI PI ^*1 'V GTAf^A fljO THIS DOCUMENT WAS NOt A RECORD' OF W3 INDUSTRIES, INC, DID NOT COMC FROM Voir** 95 ASBESTOS1S--L1 'XCH AND SMITH !7'SMFJ!:ES AND CANNOT BE<5$0THNTfCATE0 BY PPG INDUSTRIES, INC. ASBESTOSIS BODIES IX SPUTUM AXD LUXG* KENNETH M. LYNCH. M.D. AXD \V. ATMAR SMITH, M.D. CHARLESTON*, S. C. Asbestosis has, of comparatively recent time, assumed a position f prominent and perhaps peculiar inter est in the field of pneumonoconiosis and occupa tional disease. While the asbestos industry is more than two thousand years-old, it is "only within the past few years that it has assumed two cases are apparently the only records of autopsies in cases of asbestosis up to that time. In a companion article, McDonald * recorded a histologic study of the lung tissue in Cooke's case and Cg w stated that the appearances were practically the same " as in another case the sections of which were in the .ATI possession of Dr. I. M. D. Grieve of Aimlay, Leeds. '-U. McDonald found, in addition to well marked diffuse -v! ^ t- interstitial pneumonia, chronic bronchitis and emphy- ' < ^ sema, anthracosis and extensive tuberculosis, certain ' -C Tv" peculiar foreign bodies in the alveoli, bronchioles and -'-`T the prominent place which it now occupies in the industrial arts. Until recently asbestosis. has been assumed to be essentially ciKw;^ ?nA The free smea has been thought to constitute the UJllgdrtms factor m pneumonoconiosis as i^ptragtiori mltVi Vw* orlnrii... h.--,1. ..ii.hl i tf~ f,'vV l. * 'T.v-/ ' r:*. .V ; ... - .:; A, otheraustsr - it has come to attention within the last three or four years that there is a peculiar character istic in the state of asbestosis, not found in sili cosis, and it is our purpose in this report to record some data that have come to hand, since t t, ^4-.y-*J*i.r -jt, i,, .v/V^ . m r.-..v t-r , ' r ^ G- American medicine thus far has no report ort_ -thia pemliai lundiiiutt and to the end that" fpunlcnlar interest may be stimulated in'itf study in the extensive asbestos industry. It islected that a further report of our studies be made at a later time. ->l _Fln 1924, Cooke1 recorded an autopsy on an asbestos worker who had been exposed for twenty years, the last five years intermittently, showing extensive fibrosis of the lungs and chronic tuberculosis. At this time' there was Fig. 2.--Asbestosis bodies in sputum; magnification about 950 diameters, seen in the lungs only black panicles, from 3 to 393 interstitial fibrotic areas. This is the first recorded microns in length, of various shapes. observation of these objects, which have since been called "asbestosis bodies," There was considerable ' " ~V . -------- disagreement among zoologists, botanists and others as - to their nature; McDonald advanced the hypothesis that they are portions of asbestos in process of alteration and absorption by hydrolysis, with the passing of the silica into a colloidal state and later into a gel. . In 1928, Simson34 followed with a report of four autopsies on asbestos mill workers in South Africa, the first being done in 1926 without discovery of the asbestosis bodies at the time. One of these subjects worked for twelve months in the mill, developed tuber culosis and died; the second worked for two years in the same mill and had a prolonged pneumonia during this time. This patient had neither tuberculosis nor pneu monia at autopsy but fibrosis of the lungs. The length of exposure of the third and fourth patients is not given, but both died of lobar pneumonia and both showed very little fibrosis. In the lung tissues of all of Fig. 1-Aibeetooif bodies in sputum concentrate; reduced from a photo* the four were found "golden yellow" segmented struc nuers^aph with a magnification of 705 diameters. tures with rounded ends. The descriptions and illustrations by McDonald and i 1927, Cooke * again recorded this case and cited Simson make it clear that they were dealing with the sher in which a patient who had worked in an same object and that it is the same as we have found estos mill for ten years showed at autopsy pulmonary in the lungs and sputum of asbestos workers. fibrosis and spicules of asbestos in the lungs. These In October, 1929, there occurred in the service f~ I s5t: I _ * Trent tbe Department! of Pathology and Internal Medicine, Medical of **>e State of South Carolina. n. ' VDO'<e, W. E.: Fibrosis of Lungs Due to the Inhalation of Asbestos ""* Bril. U. J. 2| 147 (July 26) 1924. I917 ^-o0'lt* W. E.: Pulmonary Asbestosis, Brit M. J. 2: 1024 (Dee. 3) one of us (K. M. L.) an autopsy on a patient dead ol; J 3. McDonild. S.: Histology of Pulmoottry Aibcttoeis. Brit. M. J. 8: 1025 (Dec. 3) 1927. . Snimr oioont, F. /tr. W,: Pulmonory Aibeetoeu in South Afno, Bnt a^ sbes/tosis--lyxch and smith AL0- . m a gunshot wound. This was a Negro man who, at the time of his death, was a worker in an asbestos mill, having done such work for a total of twenty-eight months during a period of about three years. At the autopsy there was nothing of significance beyond the gunshot wounds of the chest and abdomen. In micro scopic examination of the tissues, however, the peculiar bodies under consideration here were found in the sec- Fig. *AbestosU bodies m lung with phagocytes and black granular pigment within alveoli in pneumonia; reduced iron a photomicrograph with a magnification of 473 diameters. tions from both lungs, in alveoli, associated with fine black granular pigment and mononuclear cells, some being intimately associated with large mononuclear phagocytes, in the bronchioles, where there was also the black granular material and some mononuclears, in the alveolar walls, which were thickened, and within the connective tissues of the interlobular areas along the course of vessels and bronchi. Here there was a definite increase of fibrous tissue and much accumulation of black granular pigment. At about the same time occurred another autopsyon a Negro man who was working in an asbestos mill at the time of development of lobar pneumonia from which he died. He had been in this occupation almost continuously for a period of four and one-half years. In this case, also, it was in the microscopic study of the tissues from the autopsy that the asbestosis was dis covered, gross examination revealing only massive pneumonia of the whole right lung and upper left lobe. Sections of all parts of the lungs from this case revealed the "asbestosis" bodies. There were great numbers of them in the alveoli, the walls of the alveoli, the deeper pleural tissues, the bronchi and the inter lobular framework tissues, and they even occurred in thrombi of veins and in the peribronchial lymph hodes. Associated with them was much black granular pig ment, in the alveoli, interstitial tissues and lymph nodes, and in these nodes was also a heavy deposit of yellowbrown granular substance of the same color as the asbestosis bodies. Mononuclear and polynuclear giant cell phagocytes, were prominent in intimate connection with the asbestosis bodies in the alveoli, bronchi and veins. They contained much of the black granular material in the alveoli and bronchi, also. In the walls of the alveoli and bronchi and in the framework struc tures where these bodies lay- was a cellular increase in fibrous tissue. The peculiar bodies in the lungs of these two patiu* were first suspected of being mycelia and spores oi j fungus, possibly Aspergillus, On investigation of the subjects and after we had learned of their occupation the reports of McDonald and Simson were encomutrri and identification with the objects observed by thrs was established. It then occurred to mind that these bodies should found in the sputum of such patients, since thrr occurred in considerable numbers in the alveoli a-d bronchi, and that sputum examination might prove :0 an important measure in the diagnosis of asliestod. Consequently search was made for them in sputum .{ asbestos workers from the clientele of one of t:, (W. A. S.) Specimens of sputum were examined !. direct wet smear preparation and by examining tl* concentrated sediment of sputum after digesting it 10 per cent sodium hydroxide solution, kept warmed > about 80 C. until the mucus was well digested and i'.* mixture watery. The first sputum examined came from a man who U clinical and roentgen examination had active film*, caseous tuberculosis and also a moderate grade - f pneumonoconiosis. He had not worked in asbestos s'.* approximately a year but had been previously m occupied for about ten years. The sputum contain great numbers of tubercle bacilli. Asbestosis bodVi were readily found in direct wet slide preparations a.-d in large numbers in the sodium hydroxide digest cc-,centrate. It was at this point that it came to attention !*v; such sputum tests had already been made. In I'C* Stewart and Haddow,* and in 1930 Wood and Glow*.* showed that they could be found by digesting ;he sputum with equal parts of concentrated antifonr.-n and examining the centrifugated deposit. Subsequent y we have found the asbestosis bodies in the sputum * two other asbestos workers and have failed to find thrs Fie. 4.--Asbestosia bodies with phagocytes and black franulir ,t ^ in fibrous lung; reduced from a photomicrograph urith a 2SQ diameter*. The second patient was a Negro woman who * worked in an asbestos factory from 1918 to 1921 since. She had no evidence of pulmonary' clisea*\^ was under treatment for syphilis. None of the a.'l<-5 6 5. Sten-art. M, J., and Haddow. A. C-: Demonstration t Tlodie* ("Asbestosis Bodies'*) in Material Obtained hr ,, n tnd in the Sputum. J. Path. & Bact. 02-1172 (Jan.) I9- - 6. Wood. \\\ H.f and Cloyne, S. R.: Pulmonary Ashes* Is 443 (March l) 1930* . j BB 0007045__1 Voirwr S XckSZx 9 HYDROCYANIC ACID GAS--HAMER Obi bodies were found in direct unconcentrated wet prepara of deposit along the crystal filament may be pressed tion. In the sodium hydroxide digest concentrate they closely together or they may be separated by an interval were sparse and were not as long as those found in the at which the needle-like central crystal may be seen. first case. The sputum was mucopurulent. Sometimes the shaft is covered by a homogeneous non- The third patient had not worked in asbestos for . segmented deposit. approximately two years. He was employed in an In the lungs they are of the same forms, but their asbestos factory for seven months in 1924 and for full length may not be seen and they usually appear about two years from 1926 to 1928. He had active shorter. The size of the body varies widely in length fibrocaseous tuberculosis of the lungs, with tubercle and thickness, with the length of the filament and the bacilli in the sputum but no condition distinguishable as amount and uniformity of the deposit. No extensive pneumonoconiosis. The first sputum was mucoid in measurements have been made in this study, but in the character and insufficient for concentration. No asbes- lungs they have been, measured from 12 to 100 microns tosis bodies were found in direct wet unconcentrated long and from 1 to 12 thick, the shaft being narrower preparations. In this specimen were large numbers of than the ends. In sputum they have been measured dust cells, with fine black particles and numerous fine from 1 to 12 microns thick and up to 140 microns long. ntedle-like crystals. The second sputum was muco Asbestosis bodies do not take the ordinary tissue and purulent. A few asbestosis bodies were found in the sputum dyes and they have been found in their natural sodium hydroxide digest concentrate but none in the form in one of these cases in slide preparations of unconcentrated preparations. These sparse bodies were sputum stained by the ordinary carbolfuchsin method usually small, but some were long and thick. for tubercle bacilli. The fourth sputum examination was done in the case They may be stained on the slide by the prussian blue of a white man who had worked in an asbestos factory reaction for iron, the heavier and darker brown bodies for about fourteen years but not since 1926. He had taking a deep indigo blue, this shading to a lighter advanced fibrosis of the lungs, thought to be a late stage color in proportion to the heaviness and darkness of the of pneumonoconiosis, without any evidence of tuber yellow-brown substance. This reaction indicates a con culosis, and was in a state of advancing cardiac failure. siderable iron content to the deposit. This iron has been Examination of sputum on three separate occasions by thought to signify that the asbestosis body comes from both direct and concentrated preparation failed to reveal the iron content of asbestos. Since the material is any asbestosis bodies. evidently a deposit within the lung on an asbestos It was anticipated that this case, on account of the crystal, this does not appear to be a satisfactory explana length of exposure and the extent of pulmonary disease, tion. It is suggested that the iron content, if not the should have the best opportunity of exhibiting these whole substance of the deposit, is of tissue origin, bodies, but this expectation has not been realized. The probably iron, the ; jT M first patient had been exposed within about a year, and it showed by far the greatest number of asbestosis bodies in the sputum, but the other two patients had not been more recently exposed, one had not worked in asbestos for about five years, and neither of these two Clinical New Instruments gave any distinguishable evidence of pneumonoconiosis. It remains a subject for further .study as to the rela tion of the occurrence and time of duration of these bodies in the sputum to the extent of exposure to asbestos dust, and as to the state or stage of asbestosis or other associated conditions in relation to their expul sion in the sputum. The asbestosis bodies are quite variable in size, color and form but generally are of a characteristic structure. In the sputum, from which they may be better studied alone, they have a central filament of a transparent, slightly greenish tinged needle-like crystal. This is taken to be an asbestos ciystal. On this filament is deposited, in varying quantity, nodules, blobs and segments of a homogeneous refractive substance, vary . THE EXECUTION OF ROBERT H. WHITE BY HYDROCYANIC ACID GAS EetvA*a E. Ham is. U.D, Canaan Cm, Ntv. State Health Officer Robert H. White was executed by hydrocyanic arid gas at the Nevada State Prison, June 2, 1930. A study of the heart and respiratory action was made at the time of the execution, a Bowles stethoscope being applied on the bare chest wall over the apex of the heart The tube leading to the ear pieces on the outside of the prison wall was connected to the stethoscope while the prisoner was being strapped to the chair. This was at 4:36 a. m. The heart action at that time was 108, strong and regular. The gas was started generating at 4:37$. At 4:38 the pulse rate was 120, regular and strong. ing from a shining light yellow or greenish-yellow to a A small inspiration was taken at 4.-37J4, at which time the deep mahogonv brown, depending on the thickness of prisoner indicated that he smelled the gas. At 4:38 he took the deposit. In general this deposit occurs more on the a very deep inspiration, turning his head toward the gas. He extremities, usually in a spherical blob here, tapering toward the middle of the filament, which may be bare, giving the appearance of two clubs or baseball bats placed small end to small end. Again there may be a ball of the deposit on the extremities and the shaft have cylindric deposit of segments or disks of uniform i: irregular size, giving the whole body the appearance jf a dumb-bell. The clubbed form may break in the middle. 1earing two irtdian-dub forms. Again, the shaft and extremities may be the seat of more or less symmetrical deposits of globules, piled up, to give a variety of architectural figures. The segments or disks gave a spasmodic cough, his head fell forward, and he became unconscious. Following this first deep inspiration there was a complete stopping of the heart action for fifteen seconds. After that short period of time, or at 4:38}4, the heart again began to beat in an irregular manner, continuing thus for fifteen seconds, when it became regular and strong. There was no apparent loss of power in the heart action. After this time, for two minutes the heart became slower, beating 100 times a minute at 4:41J/S and eighty times a minute at 4:44.p At 4:46Ya the heart beats were distinctly regular but becorf-, |j ing very weak. The last heart beat was noted at 4:47. Respirations during this time after the first deep inspiration were convulsive and irregular.