Document jgQKeNN0vJ5KwR46RZp1xxvnO

4- Jrf^**T~?*'~ "*'r ss&is DeuTSCHES^MRCnil/.:; f o^S.012-1 A> i^r 60: KuB>lS?fr --'Xj'>-. . 1 V 5f*^^4 . ty J9M .-- -v- [Aus der Ludolf Krehl-Klinik Heidelberg (Medizinische Universilatsklinik). ' Direktor: Professor Dr. R. Siebeek.J tJber don Lungonkrebs boi Asbestoso.' '' * '. - ' Von .. - - Dozent. Dr. H. W. Wcdler, r" -Obernrzt der Klinik. . (Einqeganqen am 20. Marz 1943.) y tzk: \jy^" / . v~*-* In den letzten 12--15 Jahren ist im deutschen und auslandischfn .-V5. V.JS-. Schrifttum eine so nnifangrviche Erfahrung fiber die Asbestoso nicder. gelegt uonlen, daB wir die Gefahrdung der Asbestarbeiter und das klinisi-hc Krankheitsbild ibrer Bomfskrankheit sowie dereri Yerlauf M'eitgeliend kennen. Immerhin stehen beziiglioh ihrer Pathogenese noeh eine Roiho von Fragon offen. die vor nllem von t ierexpcrimenteller und chemiseh-physikaliseher Bearbeitung her weitere Aufklarungen crwarten laasen. Atif uoniger broker und gesiehcrter Grundlage sind dagegon u usere Kenntnisse von ilm*n Koinplika-tionen und Begleit- krankheiten aufgebaut. Hior konnto in pingster Zeit voin Verfasser pin umfangreichor Beitrag zuin Wrhalteii der Lungontuberkulose bei dieser Koniose geliefert werden. Ebcnso aufschluBrcieh wie wichtig ist ' die Fnige uacli den Beziehungen zum Lungenkrebs, auf (lessen Haufung bei Asbestose in den letzten Jahren wiederholt aufmerksa'm gemacht wurde. Das Interesse hieran liegt niclit nur auf sozialmedizinischem und versiehemngsrochtlicheni Gobiot, sondem greift daruber writ ins Allgemoinmedizinische hinaus, weil dam it cin neues BeLspiel einer exo- genen Krebsentstehung beigebracht werden wurde. Die Zahl der hierher gehorenden Beobaehtungen ist zwar absolut geseben klein, aber doch im Verhaltnis zu der Seltenheit dieses Leidens so beaghtlich, daB eine zusammenfassende Darstellung erlaubt erscheinl. Sic ist auch deswegen enriinscht, weil bisher von klinischer Seite eine solche Arbeit im Sehrift- tum iiberhaupt noch nicht vorliegt. Wir schicken zunaebst eine Wiedergabe der-bisher bekannt gewor- denen Beobachtungen von Lungenkrobs bei Asbestose im Weltschrifttum voraus, schlieBen dann die neuesten Krfahrunsen hierzu an und be- leuchten die Besonderheiten dieses Rrankheitsbildes sowie dessen klini- schc Diagnostik. Die erste Erwahnung einer Krebsgeschwulst in der Asbeststaublunge treffen wir 1933 bei Glovne in einer Arbeit, die aich mit der pathologischen Anatomic und Histologic der Asbestose bcschaftigt. Er sprieht dort von Komplikationen der Asbestose. die in ursaehlichem Zusamnienhang mit ihr steben sollen (eitrige Bron chitis, Bronchopneumonie, Tuberkutose, Emphvsem, Bronchiektasen) und von Bcgleitkrankheiten, die nach dem damaligen Stande des Wissens niebts mit der St&ubcinwirkung zu tun hatten. Unter den U-tzteren erwabnt er eine Beobachtung. SCF-FA-1055 t&S&Si ^____ ;. J3& .-cuioma of ay related e bringen. loch nicbt Geeicbts- ie 8 Jahre lebte. Sie Gerinneel Basis des grofie GefceU- 1=5 von ine Frau, 3 Monate labteilung elschwere a, Ascites itologisch je Todee- eine MittCranken22 Jahre >estweber r 3 Jahre 3 letzten -Qonaten. irf soane eristisch. kS^che 5e=nirte t rechtstrlappen, :h eteilte Fur eine Lnotchea i Epithet onchien. rose von bsen dcr lerartige fur die AsbestLungenbebandwegen t sowie ge rOntnnischer Uber den Lungenkrebs bei'Asbestose. ' 191 .. Prozefl anmutete, aber als 'tumor erka.fi nt werden konnte, weil Metastasea im Becken and der Wirbelsaule vorhanden waren. Bei der Sektion wurde neben der . Asbestose ein 5 : 3 : 4 cm roessender acindeer Krebs ira linken Lungenunterlappen festgestellt. der in den Lungen, den liaksseitigen Hilus- und Aortendriisen, in der rechten Xebenniere. der Bauchinuskulatur, dem Becken, der Wirbelsaule und dem Srhadel MetasWeen gesetzt hatte. Den Ausgangspunkt der Geschwulst bildete ein groQer Nebenast des linken Unterlappenbronchus. Ein atiologiecher Zuaammen. hang, zwiVhen beiden Erkrankungen schien ibnen sehr nahehegend: ..That the . irritating effects of the inhaled asbestos particles may in this case have been a significant factor concerned in the developement of the primary lung.cancer seems . sufficiently plausible to be worthy of consideration." tiloyne konnte 1936 zu seinen 3 Beobachtungen eine weitere hinzufiigen. Er ianrl ein entdifferenziertes Carcinom des linken TJnterlappens bei einer Asbestose, dessen Trager 59 Jahre alt war und 21 Jahre im Asbestberuf gearbeitet hatte. . 193H machte Sparks ohne nahere Einzelheiten die Mitteilung, daB Gloyne bei seinen Sektionen G Falle von Lungenkrebs bei Asbestose angetroffen babe. Bander erfuhr brieflich von Gloyne, daB sich diese 6 Krebse auf 50 Autopsien liezogen. Xordmann erweiterte im gleicben Jahr unscre Kenntnisse um 2 neue Krebsfalle bei Asbestose, die cr kurz hintereinander in Hannover sezieren konnte. Die erste Patientin war 35 Jahre alt. Sie hatte von ihrem 17.--26. Lebensjahr, genau 7 Jahre, in der Krempt-lej, Spinnerei und Weberei einer Asbestfabrik gearbeitet. 4--5 Jahre vor dem Tode bekam sie Husten und Atemnot. */, Jahr vor dem Tode rrnt sie unter dem Verdaeht einer Tuberkulose in irztlicbe Behandlung. Hornig uelite die Wahrscheinlichkeitsdiagnose suf Krebs im linken Unterlappen bei ausgepragter Asbestose. weil klinisch die Zeichen einer Atelektase bestanden und tomographisch der Hauptbronehus verlegt war. Anatoniisch handelte ea sich um ein verhornendes Plattenepithelcarcinom mit w-alnuBgroBer ZerfallshGhle, die AnsebluB an den Unterlappenbronchus hatte, Pleuraverscbwielung und Aletastaaen in Leber und Xieren. . Die r.weite Beobaebtung betraf einen Sojahrigen Mann, der vom 36. bis . 43. Leltensjahr in der Vorbereitting einer Asbertfabrik 7 Jahre tatig gewesen war. 13 .Monate vor seinem Tode magerte er stark ab und bekam blutigen Auswurf. Er stand anfungs unter dem Verdaeht einer Tuberkulose. Cber der linden Lunge unten fand sich Dampfung und abgeschwachtea Atmen. R6ntgenologisch war das linke Unterield verachattet. Die behandelnden Ante diagnostizierten eine Asbestose mit Lungenkrebs. Die Sektion bestatigte dies. hDer Krebs war im linken UnterUppen in Zusammenhang mit dem Hauptbronehus auf WalnuBgrdBe zerfallen und hatte Bcziebungen zum Herzbeutel, der linken Karamerwand, dem Zwerchfell, dem Peritoneum dea linken Oberbaucies, dem retrdperitonealen Gewebe hinter der Milz, den dortigen Lymphknoten und der unteren Brust- und oberen Lenden"irWlsaule. Histologisch handelte es sich wieder um ein verhomendee Platten' cpithelcarcinmn. Auch im rechten Lungenunterlappen fand sieb ein beginnendes Bronchialcarcinom. Xordmann schloB an diese Beobachtungen eine eingehende Wurdigung der Gesichtspunkte an. die ihm einen Berufskrebs zu beweisen schienen. Er sprach als .erster klar von einem Berufskrebs der Asbestarbeiter. 1939 machte Wedler auf eine weitere Beobachtung in Deutschland aufmerksam, die von Bohne stammte, aber nicht mitgeteilt worden war. Der 56j&hrige Mann hatte von 1925--1835 10 Jahre zum Teil als Meister in einer Asbestfabrik gearbeitet. Wenige Jahre nach der Staubexposition bekam er ecbon Beechwerden von seiten dcr Atmungsorgane. 1928 war cr 2 Monate verechickt. fipiter machte er Otter Heilstattenkuren, ohne daB Tuberkelbacillen bei ihm gefunden wurden. Wegen tlber den Lungenkreba bei Asbeetoee. 193 Im Peritoneum bestand eine auagedehnte Tumorausaaat, mit Ascites. Der linke Pleuraraum enthielt einen ErguB von 50 ecm. Kompensatoriscbea Emphysem der linken Lunge. Die kacbektische Frau starb an Kreislauischw&che infolge der Lu ngenerkrankung. Die zweite Beobacbtung stamrot von Alwens. Die Sektion nahm Fiacher- \VAseU vor. Ich kam ala Gutacbter mit dem Fall in Berdhrung. Der 60jahrige Mann (13. 8. 81 bis 19. 9. 41) hatte bis '/> Jabr vor dem Tode 42 Jahre in einer Asbestkautacbukabteilung gearbeitet. Er erkrankte im Januar 1941 unter zu- nebmender Atemnot und Gewicbtsabn&hme mit den Zeicben eines linkaseitigen Pleursergusses. Absolute Dampfung, aufgehobenes Atemgerauach und Recbts- verdrSngung des Herzens. Der Auswurf enthielt reichlich AabestkOrpercben. In deni mehrfach durch Punktion abgelasaenen, gallertigen, rotlichen Ergull wurden reichlich Tumorzellen gefunden. tlber der recbten Lunge unten waren vereinzelt feinblasige Rasselgerausehe zu horen. Die Blutaenkung atieg schnell an. Im Aus wurf keine Tuberkelbacillen. Rbntgenologisch wurde eine. Asbestoae mittleren Grades featgestellt und im recbten Hilus evtl. der Prim&rtumor vemiutet. Die ' Sektion deckte eine leichte Asbestoae mit einem diffusen primaren schlcimbildenden Drilsenzellcarcinoin der linken Pleura von grdfltenteila adenomatbsem Cbarakter und Metastasen an der Baucbseite der linken Zwerchfellkuppe, der Seroea des klcinen Beckena und der Brustmuakulatur links auf. Da* Sektioheprotokoll der Brustkorborgane sei im einzelnen angefuhrt, da bisher daruber niebt beriebtet wurde. Brustsektion. Panniculua adiposua maGig entwickelt. Thorax iat maGig gewdlbt und elastisch. Rippenknorpel sind gut zu durehschneiden. Daa Zwercbfell steht rechta in H6hc <)<*s 5. Intcrcostalraumea; auf der linken Seite 1st es nach unU-n umgeklappt und ragt weit in die Bauchhdhle hinein. Scin untere.r Pol steht hier tiefer als Her Beckenkamm. Bei der Pneumothoraxprobe entweichen auB der linken Pleurahbhlc fast. 3000 ccm einer gelblich-braunen, fadenziehenden FlGaaig- keit. lias ganze Mediastinum ist nach rechta verdrangt. Das Hen hangt tropfen- fSrinig im Mediastinum; seine linke Kante liegt in der Mittellinie. Die reebte Lunge ist bia anf geringe strangformige Verwachaungen frei in der Pleurahohle. In der Pleura costalis finden sich bis handfl&cbengroGe. derbe, weiBe.'sehnige Platten mit einzelnen knollenfOrmigen ebenso derben, weiQen Knotcben. In der Pleura des rechten Lungenoberlappena sieht man eine groOe atrablige Xarbe.' Auf der Pleura der rechten Lunge erkennt man einen feinen, m&Qig feat baftenden grauen filzigen Belag. Die reebte Lunge selbst ist von gehfiriger firSCe und mittierem Luft- und Fliissigkeitsgehalt. Die Pleura und die Schnittflache zeigen eine maflig starke, schwarze, netzfflrmige Zeichnung. Im Sbrigen ist das Lungengewebe von roter Farbe. Herderkrankungen aind nicht nachzuweisen. Im Unterlappenaat der recbten Lungenarterie haftet auf der Intima ein kleiner braunroter Blutpfropf. Die Lungenarterien sind leer. -- Die linke Pleura iat in ganzer Ausdehnung achwartig verdickt. Auf der Innenflache findet man massenhaft dicht beieinander stehende, bis walnuGgroBe Knollen mit maulbeerartiger Oberflache, bestebend aua einem gallertigen -- auf der Schnittflacbe weiQen -- Geschwulatgewebe. Dieses eondert beim Durehschneiden eine fadenzicbende FliiBsigkeit ab. Xeben dem Tumor- gewebe sieht man ebenfalla einige aehnige Platten wie rechta. Daa Geschwulst- gewebe dringt an keiner Stelle tiefer in die Unterlage ein, vor allem niebt in das Lungengewebe. Xur im Bereich der eingangs erwahnten Hautknoten an der linken Bnistacite findet man Geschwulstknoten in der Zwischenrippenmuakulatur. Die linke Lunge ist stark atelcktatisch und nur mit einer strangformigen Verwachsung an der Brustwand adherent. Das Lungengewebe ist von zah-fester Konaistenz, grau- rStlicher Farbe und- zeigt auf Schnitt- und Oberflache eine schwarze, netzartige Zeichnung, die etwas dichter ist ala die der recbten Seite. Im Lungengewebe selbst nirgends Tumor. Trachea, Bronchien heider Lungen sind von geboriger Weite und Deutsche* Arehir f. kiln. Med. 191. H4. 13 . fiber deu Lungenkrebs bei Asbeatoee, 195 ubertreten. Aber aucb im Interstitium findet man fiber&U locker verstreut schleirobildende Geschwulstzellen. Xur an wenigen Stellen findet man Bolide Epithetformutioncn ohncScbleimbildung nach Art ei nes Carcinoma solidum. DieGeechwulst findet sieh iiberall in Her Pleura parietalis und visceralia links und ist stcllenweise gtwing in die subpleuralen Schichten des Lungengcwebes hineingewuchert. Hier findet man sie hesonders in den fjepten und vereinzelt aucb in Lympbbahnen. Diagnose: Primares aclileimbildendes Drusenzellencarcinom der Pleura, grdStenteils von adpnomatdsem Charakter. Dir fraglirhen glasigrn KnOtcben von der Bauehseite der linken Zwerchfell- kuppe und von tier SSttosa des kleinrn Bcekens erweisrn sieh mikroskopiscli als .Metastasen vom glcirhrn Bau tvie der Primftrtumor. . Damit sind <lie bisher l)eobachtetcn und in tier Weltliteratnr bekannt gewordenerv Valle von Lungen- und Bru&tfellkrebs bei Axbesttwe erscbdpft. AD einzige halien bishrr Xordmann und fjorge den Versuch nnternommeu, tierexperimnitell an wriBrn Mauaen die ZiiRammriibangafrage zwiseben Aabestslnnhinhahitioii mid Liingcnkiebs zu bcarlx-iren. .Sir srtzten 150 Mause zu jhren Versm-hen an und bestauhim sir entsprrchrnd tier durrhsehnittlichen Lebena- und Arlieitsdanrr drs Menwhen zwisrhen J1.1, und 3 Mouatcn. CDt die Halfte der Tirre starb vorln-r. Krinrs tibeileble dir Inlmlatimi lunger nls 9 Miniate. 20" der libcrlebvndeu Tiriv wirsen rill verliruiiendes inultizriitrisrbrs I'lattenepithel- , rareinoni und 42--.)*" epiiheliak* Neubiltlungrn slier Stsdicn auf. Damit soli die lirvarltlirbr Brdrulmig ties AsbitUstaidH-s fur tlas primare Lungrncarrinom des AslH-starbeitrrs e.\|iri'iiiiciilell gustutzt werilen. Die Zahl der endgiiltig durcb den Versuch gehraehlen 'L'irre. uus drnen die obigen Zablen crrerhnrt wurden, ist sehr~ klcin. Nur 2 -Tiere batten Xrubilduiigeii. die als Krebs migesproehen wurden. Die Autoren wiesen srlbst auf dir S'chwierigkeit der Abgrenzung von einfachen Mrtaplasien bin. Es muB einem erfabrenen Morphologcn und Sachkenner iibc-rlassen bleihen zu entsebeiden. wieweit die Scblusse der Experimentatoren berechtigt >ind und wieweit die erforderlichen VorsichtsmaDregrln beziiglich Einbeitlichkeit und Bruuchbarkeit des TiermateriaU lieobachtet wurden und wieweit in diesen Orenzen.Spontantumoren in den Bereich der Erwagungen gezogen werden raussen. .Nordmann und Sorge sind hierauf kurz eingegangen. Auffallig ist, dafl man const bishrr bei den Tierexperimenten mit Asbrststiub, die allerdings unter anderen Oesichtspunkten angrstellt wurden, offenbar ahuliche Beobacbtungcn niebt gemaebt hat. Auch ist man bei veraehiedenen Xiersektionen (Hunde, Ratten), die an Tieren vorgenommen wurden. die in Asbestfabriken lebten, auf solcbe Beobaebtungen nicht gestoBen. Wenn man von einem Berufskrebs in einer bestimmten Arbeitergmppe spreehen will, so wird man zun&chst den statistischen Beweis erbringen miissen, dafl dor betieffende Krebs in groBerer Haufigkeit als in anderen Benifs- und Bevolkmungsgruppen vorkommt, wobei die Forderung nach einer moglichst gleichartigen Alterszusammensetzung bei den Yergleichszahlen schwer zu erfiilJcn sein wird. Der statistische Weg hat auch /iir die Asbestose noth cine weitere unverkennbare Schwierigkeit. Es wird sieh bei dioser an sieh seltenen Krankheit immer nur um kleine absolute Zahlen handeln konnen. Eine einzige Beobachtung als Zufallsereignis kann dabei schon recht groBe prozentuale Versehiobwngen herbeifiihren. Weiter wird man mit Nordmann bevticksichtigen mnssen, daB besonders in den letzten Jahren der Arbeiterweehsel in den Asbestfabriken die Ergebnis.se iin negativen Sinno 13* t-s&iG&ii tJber den Lungenkreba bei Aabeatoee. 197 Tabelle 1. ai b UtK ' Alter, Nr. Geschlecht i Staubarbelt Jfibre <t 0 Freies Interval! Stadium der Jahre Asbeetose 1 Todeeurgache R Publlziert durch i 35 .1., $ 1 > 47 J., 3 ` 26 3 50 J.* o f - 4 i 6 0 35 .1., 3 6 1 31 .1., 0 7 54 J., 2 8 44 J-, ? 9 38 J,, $ 21 20 20 8 11 18 13 10 . 4o J. d JaLi 63 J.e 69 J., 0 2 1 J.,3 15 12 10 10 * in hi m hi in ii--hi hi in Fahr 1914 .Bureach/Loes^hcke 1Q01 Beintker/di Biaai 1931/37 Beintker/Path. Inst. Munster 1931 Stroebe/Beger 1933 Bobne .1936 Saupe/Le tterer 1938 Saupe/Baniecki hi Wedler/Walkholf 1939 in Wedler 1939 0m Wedler/Kocb 1939 iii Wedler 1939 - ii /^fagen-CaV Wedler/Walkhoff ~ 14 ! 35 J., 5 15 55 J., 3 16 38.1., 2 17 58 J., 3 18 60 J., 3 7 7 12 30 18 70 !.. 3 60 J., o 16 42 21 38 J., 2 22 54 J., 3 23 59 J., 2 24 25 CH> 42 J., 2 27 50 J.. 2 28 35 J. q 29 18 J., 2 40 J., 2 4 27 4 3,25 22 6 12 5,5 1,75 10 9 12 7* 2 I i v i 6 2 2 10 .2 6 a H1 ii Bronchial-Ca. Kordmann 1938 iii Bronrhial-Ca. Xordmann 1938 iii LungenabaceQ, Xordmann 1938 Empvem m Bronchial-Ca. Bohne/Wedler 1939 iii Bronchial-Ca. Wedler/ Li nzbacb 1940 hi COeaqib^Ca^ di Biaai u.a. A1 wens/FischerWaaels ill Bobne III Koopmann III Bohne III Holm u. a. HI , Prrm+.te C I < LungenabeceB," . Wedler/Poczka s Amvloidoae III j ^ffefeoinsuff. Wedler u.a. I! | Lungentbk. Wedler u. a* 0 i. lawagntbk. di'Biasi u. a. III ( [Pleuragewacha )Xeu tscblaender kleinen Zahlen erlauben allerdings hieraua zunacbst noch keine besonderen Schluase. Nach der Geschlechtsverteilung komraen auf 4 Manner 2 Frauen mit Lungengewachsen. Fur die Geschlechtsverteilung der Krebse der Lunge unter Mannem und Frauen werden sonst Zahlen von 3--4 : 1 angegeben. Die Quote der lungenkrebskranken Asbestarbeiter nach dem Geschlecht ist naturlich auch abhangig von der Zahl der in den Betrieben orbeitenden Frauen und Manner. In Deutschland uberwicgen die ersten bei weitem. Bei den beiden obengenannten Frauen " "yrimr mi iiji wji.i i * Alle : der e bei auf. alien belle 2mat freie das lang die), igate genwei* cht. sren .ten lgt: ler. ist. daC leiauf ten erch al.tz rt. et it. in < tlber den Lungenkreba bei A&bestose. " 199 In der "VVeltliteratur ubersehen wir also bisher 14 maligne LungenRippenfellgeuachse epithelialer Herkunft, die auf 92 Sektionen entfaUen. Da* sind rund 16% Kxebsfalle bei s'ezierten Asbestosen. Von die8en 14 sind zunacbst nur 11 soxveit in Einzelbeiten beschrieben woiden, daB aus ihnen noch weitere statistische Ergebnisse gewonnen wcrden konnen (s. Tabelle 2). i J.M. Alter. ' | Nr. iimchlecht Staub xp. * i KreUsw Inter rail Jahrv \ Jabre TabelJe 2. Stadium der A*bePio*c 1i . Arr dew | Lokali- 1 MeOewSvh'v* j wation j tastaaeo Auu>r 1 33 J., $' .2 71 J.. 5 8j9 ii ho ' 15 i-ii n ! verliomtes 1 rechter ' Platten- . Ober- epithel-Ca.' lappen ! keine verhorntes rechter | ' keine Platten- , Unter- i epithel-Ca. lappen \ Gloyne Gloyne 3 37 .1.. 5 21 HI ' Platten- rechter j keine epithol-Ca. Cuter- ' ' lappen Lynch und Smith 4 41 .1.. J IS m acinoses linker I aus- Egbert und Ca. Unter- Igedehnte Geiger lappen iMetasta- ! siernng *) 33.1.. S 7 II n vc-rhorntes , linker j Leber, Xordmann Platten- Unter- : X iere epithel-Ca. lappen \ /; Oi) (J * oH J,t q 10 12 n i 2: m verhorntes linker i, aus- A'ordmann. Platten- Unter- Igedehnte 'Kleiner Krebs, epithel-Ca. i lappen j MtjtasU- aucb im reeh- i aierung , ten Unter, , lappen 7 I reoJiter ja Bobne/Wed- | Mittel- ler ,lappen | s 60 J. t o IS III verbomtes | rechter keine Wedler, Platten- > Unter- : , Linzbaclt epithel-Ca. J lappen t si 40.)., $ 111 . 1 * III pseudo- I rechte | Peri- Teutach- alveolires j PleurR 1 toneum 1 laender Meso- theliom , | i )> 60 J., <J 42 . 'h J--11 i adenoma- Itnke j aus- Alwene- tfises 1 Pleura j gedehnte Fischer- i Pleura-Ca. 1 ; Metaata- | Wasels ; t j signing 1 IT 59 J., d 21 l* ' i entdilfe- 1 linker ; ? | Gloyne renziertes Unter- ' Ca. ` lappen : aus. > bis lung mbvall berose, arlen ?n;npc le t. >- mm Uber den Lungenkreba bei Aabestoee. 201 sind, so wirken aie doch dadurch viberzeugend, daB aie an ganz verschiedenen Orten mit ungefabr gleichmaBiger Haufigkeit gefunden \nirdon (Deutschland, England, XJSA.). j Diesen rein zahlenmaBigen Verhaltnisaen lassen sich nun aus obigen Ableitungen noch weitere positive Gesichtspunkte aniiigen, auf die Nordm8nn allerdings an kleineren Zahlen turn Teil scbon hirigewiesen hat. Wir nennen hier zunacbst das Lebensalter der Krebstrager. Allein 4 von ihnen befanden sich noch in dem relativ jugendlicben Alter von 35--41 Jahren. Wenn auch der Lnngenkrebs schon bei Jugendlichen vorkommt, so liegt seine gToBte Haufigkeit sonst doch erst zwiscben dem 50.--60. Lebensjahr. Dieser Stufe gehoren untcr unserem Material 6 Kranke an. l)ic Verteilung nach dem Geschlecht ist gegen die sonstigen Zalilenverbaltnisse hier zuungunsten der Frauen verseboben. Unter 11 Fallen treffen wir 4 Frauen an. Fiir den Lungenkreb* geben die jrroBen .Statistiken sonst cine Verteilung der Gesehlechter von 3--4 : 1 zwischen M&nncm und Frauen an. Immorhin wird man im Auge behaltcn' niiisxen, daB besondvrs in Deutschland und England im Ge.gensatz zu l*SA. in den Asbe-dfabriken die Frauen als Arboitnehmer zahlenmaBig die Manner hbertreffen. t Sehr beachtlieh erseheint die haufige Ubereinstimiunng des Sit zes der Geschvulst mit den schwersten Veranderungen der Asbestosa in den Untcrgesehossen iler Lunge, wit wir es oben ausfuhrten. Writer ist der histologische Charakter der Lungengewachse auffallig. Das moist verhornende Plattenepithelcarcinom steht zahlen- mallig ganz im Vordergrund. Wir zahlten unter 8 naher bezeichneten Bronchiulkrebscn allein 6 solche. Das bei den Lungcnkrebsen sonst iibliehe Zahlenverhaltnis unter den einzelnen Gewachsformcn ist hier ganz zugunsten des Plattenepithelkrebses durchbroehen und einseitig verschoben. Wenn man die Lungenkrebse histologisch in die 3 g'roflen Gruppen der undifferenzierten Zellen, der Plattcn- und Zylinderepithel- carcinome einteilt, so stellen die ersteren in den groBen Statistiken das Hanptkontingent mit fund */9 aller Falle, Da die Plattenepithelkrebse an wenigsten zu Metastasierung neigeh, mag cs verstandlich ersebeinen, daB bei den obigen Beobachtungen in 4' Fallen keine Metastasen gesehen wurden. Gerade die histologische Beschaffenheit der Lungenkrebse mit <lem eindeutigen Uberwiegen des Plattenepithelkrebses spricht fur seine selbstandige Stelhmg unter den Lungenkrebsen. . Der Krebs wurde immer erst nach einer relativ langen Einwirkungszeit des Staubes gesehen. Sei es, daB die Arbeitszeit im Asbeststaub sehr lange war, oder daB sich bei kurzer Arbeitszeit mit gewohnlich betraehtlicher Exposition ein l&ngeres Intervall einschob, in dem der Staubxchaden sich weiter auswirken konnte. Eine Reihe einwandfreier ! Otar don Lungcnkrobs bet Aabestose. 203 barkeit dieser Verhaltniase gefordert werden. Dieser Punkt kann fur die Asbestose bisber noch nicht ala gesichert angesehen werden. Das liegt aber nicht an negativ ausgefaltenen Versuchen, sondem einfach daran, daB diese Frage in grbBerem Umfange noch nicht in' Angriff genommen worden ist. Die' eraten Versuche haben Kordmann und Sorgo mit einem frappant erscheinenden t)bereinstimmungsergebnis untemommen. Wir kamen bereits oben darauf zu sprechen. Man wird allerdings vorsichtigerweise weitere Bestatigungen und Anerkennung dieser komplizierten Verhaltniase durch weitere Sachkenner abwarten miissen. Jedenfalla sprechen alio bisher bekamit gewordenen Tatsachen doch mit groBer Wahrscheinlichkeit daftir, daB die Nordmannsche Ansicht iiber den Benvfskrebs der Asbestarbeiter berechtigt ist. Avtch die anderen Autoren wie Gloyne, Lynch und Smith, Egbert und Geiger sowic Linzbach zeigen die Tendenz, hier engere ursac-hliche Beziehungen zu vermuten. Der Veranch ciner Widerlegung dieser Artnahme ist bisher von keiner Noite untemommen worden. . Wenn wir tins nun die Frage vorlegen, worin die cancerogene Wirkung des Asbeststaubes zu suchen ist, so miissen wir allgemeine und ortlichc disponiprende Faktoren trennen. DaB zmn Zustandekommen *ines Krebses eine allgemeine Krebsdisposition (Voranlagung) vorauszusetzen ist, wird allerorts .angenommon. Worin fiie zu suchen ist, laBt sich schwer sagen. Es ist aus tier allgemeinen menschlichen und experimentellen Pathologic bekannt, daB die Bercitschaft zu Krebs von anlagemaBigcu Faktoren abhangig ist. Das driickt- sich darin aus, daB unter gleichen Experimentbedingungen und einigerntaBen gleichntafliger Exposition fur cancerogcne Schaden bcim Menscheri die Quote Krebskrankcr immer nur einen -Toil der Gefahrdeten ausmacht. Das uns fiir die Asbestose vorliegende Beobachtungsmaterial laBt eine Analyse nach familiarer Krebsbelastung nicht ausreichend zu. Wieweit und in welcher Weise der Asbeststaubschaden eine solche allgemeine Krebsdisposition schafft, wissen wir nicht. Ihre Annahme bieibt eine Hvpothese. Dabei scheint es nicht so zu aein, daB sich diese allgemeine Disposition so stark auswirkt, daB sie etwa auch die Ent-'stehung von Kxcbsen an anderen Organon begunstigte. Dafur sprechen die vorgelegten Zahlen gar nicht. Won e.ntscheidender Wichtigkeit -cheint immer vor allem die oitlicbe Umstimmung zu sein. Ihren morphologischcn Ausdruck in den abgeanderten Gewebsreaktionen der Lunge haben wir oben naher aufgefiihrt. Als deren Ursache kommen in erster Linie chemische und mechanische Faktoren in Betracht. Da der Asbest cbemisch einfach definiert ist, liegen die Verhaltniase hier leidlich iibersichtlich. Man kann wohl von vomherein sagen, daB Stoffe aus der Gruppe der bekannten eancerogenen Agentien nicht in e vollaaden. a dem e eine jnschcbeinxsh sie .uagelicose 5 Ans biowird titzen rtige ;rofle .hien ^ Tell :iner -den -ung men ung der :ose des bei ebs :en or an. ue :n, b- jxx er re Uber den Lungenkrebs bei Asbestose. 205 betrug, sonst erstreckte sie sich auf 7 Jahre und roehr. Bei kurzer intensiver Bestaubung scheint dennoch sur Krebsentstehung jnuner ein Jangeres staubfreies Interval1 hinzukomxnen zu mussen. Es gibt bisher keinen Krankbeitsfall, bei dem der Zeitraum vom Beginn der Staub- arbeit bis zum Nachweisbarwerden des Krebses weniger als 12 Jahre betragen hatte. Man wird weiter gewobnlich erwarten durfen, daB der Krebs nur bei ausgesprocbenen, wenn aucb nicht immer schwersten Formen der Asbestose auftritt. Die obigen Beispiele belegen dies. Die ersten Symptome eines sich entwickelnden Lungenkrebses, die an sich ja schon meist nichts Charakteristisches oder gar Pathognomo- nisches bieten, warden nicht so auffallig sein wie bei einem vorher gesunden Menschen, weil Kurzatmigkeit, Hasten, Auswurf und gewisse MiBempfindungen im Brastrauni dem Asbestosekranken sowieso ge- laufige Bcschwerden sind. Auch ein gewisser \'erfall der allgemeinen Krafte, dcr einen Lungenkrebs sogar anfangs gar nicht zu begleiten braucht, Gewichtsabnahme und Appetitlosigkcit sind bei den schwercn Formcn der Asbestose recht haufigo Erscheuuingen. Auch akute Ver- sehJeohteningen im Allgemeinzu.stand, einschlicBlich der ortlichen Lungen- beschwerden, kommen oft als Ausdruck aufgcpfropfter Infekte, die schwerer bbenmnden werden, vor. Im ganzen wird man es sich fur die Yorgeschirhte der reinen Asbest-osc* aber doeh zur Regcl machemnussen. daB der KraukheitsprozeB eine nur ganz allmahliche uber Jahre, ja Jahrzehnte sich hinziehende Versehlechtening erfahrt. Wenn in dieser Entwiekhmg plotzlieh Einbriichc siehtlieher ortlicher und allgemeiner Yerschlechteningen vorkominen, wird unter anderem der Gedanke an eine Krebsrntwickhing auftanchen miissen. Nebendem Krebs kommen sonst hierfiir am haufigstcn unspezifische Infekte mit Bronchitis, Pneu- monie oder AbsreB in Frage. Die koinplizicrende Tuberkulose spielt nach unseren Erfahrungen nur eine untergeordnete Rolie. Sie wird dabei viel zu haufig diagnostiziert. DaB sie natiirlich im Bereich des Moglichen liegt, ist selbstverstandlich. Uber begleitende Lungenlues oder Pilz- erkrankungen ist bisher nichts bckannt gcworden. Von den Aligemeinsvmptornen ist schneller Gewichtsverlust beaeht- lich, aber nicht bcweisend. Das gleichc gilt -- wie gesagt -- von der Appetitlosigkeit, schlcchtcr Gesichtsfarbe und NachtschweiBen. Be- ruhen diese allein agf der Zunahme der Asbestose, so werden-sie gewohn- lich auch von einer verstarkten Atemnot, Cyanose, evtl. Trommel- M-hlegelfingem und sonstigen ortlichen Lungenbeschwerden begleitet sein, aber naturlich wird man sich vor Augen halten miissen, daB ein Lungentumor die Zunahme solcher Beschwerden auch bedingen kann. Im ganzen wird sich die Situation aus der Vorgeschichte allein nicht ausreichend klaren lassen. , Nicht viel anders ist es mit den meisten ortlichen Beschwerden bestellt. Da die schwerere Asbestose meist erheblichen Reizbusten setzt, Ober den Lungenkrcbs l>ei Asbestose. 207 i.-t. Nur grdbere Schwarten oder spezifischc imd unspezifische Kompli- kationen konnert. Ausnahmen bedingen. J)as Atcmgerausch pflegt untcn schwacher als oben zu aein. Sclten ist- es umgekehrt. Nebengeriiusche sind nnlen zahlreicherund haufiger als oben; Seitemmterschiede bcsagcn nieht viel. Findct man einseitig eindeutige Zeichen oinor At-elektnse, so ist dies jni hochsten Grade anf Tumor vordachtig. DnB dieses SyiUn ptom la-ini Lungoutunior aber nicht obligat zu sein braueht, ist ja sc lbst- verstiiudlich. ErgiisJe, besondors solclie hainorrhagischer Art, kommen bci ili-r gcvbhnliehea Asbestose praktiseh nieht vor. Einschmelzungs- zeichen kann dcr Tumor mit dom AbseeB un<l dcr Tuberkulose gemeinsam haben. Bronchicktasien in Gestalt von zylindrischen Luftrbhrencrweitc- rungon sind bei schwerer AsbestoNe nieht sclten. Sie werden gelegcntlich bei dcr klinisehen Untcnuiclnnijr in ihrer Abgrenzung gegen Einschmel- zungen Sohvvierigkoitcn mac-hen kbnncn. , C robere Asymmetrien des Brostkorbes, Verziehungen der Mittclfellorgane und Zwcrchfelle bediirfen immer einer gesonderten Erklarung. Der Rontgenbefund diirft-e stets die wiehtigste Untcrsuchungsmetliode zur Erkenrmng einer Geschwul.-tsein. Du bei niufl man beachten, daB die .->chwere Asbestose nicht immer -- wie man naeh dem Sehrifttum glauben konnte -- nur zu fei)ien symmetrischen Verdichtungen des Lungengewobes fiihrt. Neben gewissen Asynunetrien kommen nuch flachenhafte Triibungen umsebriebener Art in den Unterfeldern, besomlers medial vor. Diese dicht-eren Schatten sijid aber doch gewohnlich nieht so kompakt und tumorurtig, sondern nu-hr atreifig gezeichnet und unseharf abgesetzt. Harte oder tomogniphische Aufnahmen werden das BronchiaIsystem often, evil, sogar erweitert erkennen jassen. Duu-h Entzundungen bedingte Bronchusstcnoson sind hisher bei der Asbestose nicht bekannt geworden. Koinpuktc, einseitige,: umschriebene Verschattungon in der Lunge, womoglich mit BronehuaverschluB, Bind pmktisch fur cinca Tumor beweisend. Dahiu gehbren aucb standige oder mit-der Atmung wechaelnde Verachiebungen des Mediastinums und Lahmungen des Zwerchfells, des ftecurrcns oder bei Oberlappenprozessen meist auch ein Hornerscher Symptomenkomplex. Umschriebene Ver dichtungen in den Obergeschossen eignen menials der Asbestose. Hier liegen die Verhaltnisse viel klarer und cinfacher ala bei der Silico'c. Grobc Schattenbildungen entstehen sonst bei der Asbestose vornelvudi<'h (lurch un.sjx-zifisehe Entzundungen. Die 'Tuberkulose ist lang3t nieht so haufig w ie gemeinhin angenommen -wird. Ihr crates Auftreten < den Unterfeldern ist nach den bisherigen Beobachtungen bei A8b<','<,,',' sehr sclten. DaB im Rahmen der ubli.-hen diagnostischen Verwertbarkeit die Tnmo- und Bronchographie fur die Tumorerkennung in der 1/unge von entseheidendem Wert sein kann und dafl fur sie die Oblichen Regelu der Deutung gelten, sei der Vollstandigkeit halber angefuhrt. Ali"li<'b te Lungenwchen, bei :i primaren chweis im *r Fail bei assen. ist fur die n konnen. )ten Biut: gehoren: 1 Ko--uenhrru /oriQ anderer tild ist ein utsenkung Dennoch Asbestoseht, vahrnden sind. er zu be n. 'rkennung ?utung ist kritischen imenhang nd an die so haufig 1 scbHnt. ilos bei '.aublunge tige gute *n bciden nentcllen ite daran -so Komnen Kntrund einmenhang Jcten hat inkt ein- Ober den Lungenkrebs bei Asbestose. 209 Zusammenfassung. Es wird fiber die bisher bekannt gewordene und erweiterte Kasuistik von bdsartigen Lungen- und Pleuragewachsen bei Asbestose aus dem Weltschrifttum berichtet. Die Grfinde, welche einen ursachlichen Zusamtnenhang ' zwischen beiden Erkrankungen nahclegen, tverden aufgezeigt. Das klinische Biid des Lungentumors bei Asbestose wird besprochen und die Ausdehnung des Yersicherungsschutzes auf diese Komplikation fiir angcbracht gehalten. Schrifttum. . Baader, E. W.: Dtsch. roed. Wscbr. 1989 I, 407. -- Egbert, D. S. and A. J. Geiger: Araer. Rev. Tbc. 34, 143 (1938). -- Gloyne, S. R.: Tubercle 14, 550 (1933); 17, 5 (1935); 18. 100 (1938)-- Hornig. F.: Z. Krebsforsch. 47, 281 (1938). -- Linibach, A. J. u. H. W. Wedler: Virchows Arch. 307, 387 (1941). -- Lynch, K. M. and \V. A. Smith: Amer. J. Cane. 24, 56 (1935). -- Nordinann, M.: Z. Krebaforech. 47, 288 (1938). -- Ber. 8. internet. Kongr. Unf&llmed. u. Berufakrkh. Frankfurt a. M., Bd. 2, S. 983. Leipzig: Georg Thieme 1939. -- Nordmann, M. u. A. Sorge: Z. Krebsforsch. 31. 188 (1941). -- Sparks, J. V.: Brit. Radiol. 11, 371 (1938). -- Wedler, H. \V\: Klinikder Lungcnasbcstose. Leipzig: Georg Thieme 1939. 1 Die Originalarbeit lag dem Verfasscr nicht- vor. - Deutsches Archiv 1. Idle. Med. 191. Bd. 14 PRODUCED BY FORD *88 (7. DiWm'cf nd V, (Jlivn: Sidenlmtseke VYcrto *k-I den IMmvpntkien, Wir stellcn also bctiAcktlich nirtlrigerc ids dte Normtverto dcr Fe/I5. Indexc test, ja sugar (He jncdrigsten, bis jetgt nvfgcfvndenen; uml c* echrint vns die Anni-kme nicht r.v gett-ngf, r,v scin, dn(J, tvenn der Befvnd tcilvcise wit die Kiscnnrmvt dc* mt.cn Orgnnismvs vnd dcsimlb nnch lies girkidirrwntcn Ufwtcs r.nrSekr.vtnkrcn M, nndcrcreeits nvtb nut die Xcigwur des Orgnmsmus, soviet trie tnSeltch (las .Mctnll nvfrv. spnren vnd es sotnrt ftir die AYicdcrkendcllung des Fnrbstoffcs, mit den Endcrgpbnts seiner msehen Entfcrnirog nits dem Krcislavf, r.ti bcnvtr.ru. Wir knben vrrsvekt die Bcdevtvng vnd die Nntibnrkcit dcr .An. trendvng des YerkSllnisses Fe/B T?ci dcr pkysiopnlkogcnctfsckcn Avs. tvcrtvng nlmormrr sidcrniniscbcr Eckwlc vnd im nl'ccmeinen des Ycr- Invfes dps Bk'tslvffw'cckse's mi* ("nktiseken Beispio'cn dn rr.vslel'c'. Im foigenden Vingmmm trird d"s Vrrknlfen des Veibnilni<ven Fe/JJ lei einigeo H&mepalhicn dnrgcslellt; vj voter den nnurmschcn Formcn cr- hi geVn sich dvrcli ein hOhetc* /rr ! i; VedmHnis nls dio Norm clinmk- <?#? 111 lerisicrt iin trcsentlickcn die npbt- 0.*V 11 ii i! stiseken dnd hypoplnstfsclien e,x ii Amtmicn vnd in ntlgcmcincn I! Kronkkeitw.vsUVndcn, dio dmrb a. 6 c d. .AMi. t s--|. no VrtWVnlv Kr, n: hr'm Vmiit'm: l> In S t'S'lm ton W* >' yr. Iivrfsj r In 4 ntV't wit imiWrrr .lndmV (nniehnttWH: .1 In I KMIm tn ..rxtml'r'H-r Hr [m.-Ii*-nrTiiT .Miflmtc". fvnkt ionclle Tragbeit der Ervtlvvpotato cltnmklerlsiert siml. Wir kOnttcn r.nsnmincnfassrn, dnB, wie "iclt ans vnaerr F.rfnhrung crgibt -- vnd die Eingriffs- mOglicbkcit vmslfindlickcr. die Avfspcirkcrvngs- vnd Avssckeidtings- vorgiinge brrintivssendcr Fnklorcn nvsgcscklosson -- die VcrgrOBc- rnng des Verlmltnlsscs Fe/B in dcr Mckrkeit der FMle dio Folio cine* fcMendcn odrr vvccnflgen'lcn Eisrnverbrnvckc* dnrstellt, vnd dnfl diese CB letr.te Tatsnebc attf cine tvnklionrHc InsvffWcnr. dor hSmopoietischrn O CJ O'evclw biwlevtct; trfthtpnd die Vcrnitmlcrvng dcsjclben VerJiiltnisscs dcr Ansdrnek elites sebr leblmflen Hilinoglobinnitfbones end cincr Net tling des Orgnnisnms r.utn ,,Spnren" des' JCiscns dnrstollcn kann (diese ** -o sweite Mpgliciikcil ist bet Karcnmistamtcn des Mrt/ills in, Bctmebl r.v r.ieiirn, vie lyvisrli bet ,,byj<eehroinen essenlioilen AnSmicn"J. r.Ilernftir. FOr die Wtrmtnr sVhe msn nncln OHrs. C-: J1 rlrsmtj'o del ferro ti H CTmjiOtt'nr<t!o drils I'Uirmin In evn<lii>!..i,| iinnnnli - pnt0log!cho (Im Urorit). "NOTICE: Ttiis Moteriot moy W* proct*o >.7 topyrighf l<iw.(TH|<j J 7 US. Code) r.\"s drr Lndolt KrcW-KHnJk HcltJcP>crg (Nrdilnlscli- Vnlrersitatsillniki. JJitrVlor: Professor Dr. E. Slebcck.J . t'fjcr drn Lungrnkrcbs bri Asbcslosp. Von Dosent Dr. It. AY. WctUrr, Otterorst tier jri'nts, (Rbjlyingrn tim 20. tTHrx 1213.) ' Tn den letr.tcn 12--15 Jabren ist ini devtseben vrtd nvslondischcn .''Vl'plttnm cine so vmftngreiche Erfabning O'jcr die Asbestos? niederI'flent norden, dstJ trir die Crf'Vmhtng der Asbestnrbc/tcr vnd d/rs klinisehe Ktnnklieitbild iltrcr Bcntfskninklieit sovie doren Vcrlnvf tvcitgcltcnd kennen. Immcrhin stelten ber.vglicb Hirer Pathogcnese nocli cine Reibe von Fmgen often, die vor allem von ticrcrpcrimcnteller imd e-ltemisch-pliysikalweber Benrbeitvng her tveifere Avfkianingen mmrtcn Inwen. Avf tveniger broiler vnd gcstcJicrier Gnindisgc siml ditgegcn vmcre Keuntnissc von ibren Koinplikntionen vnd Hcgk-it kmnkhciten aufgelraut. Hicr konnte in jOngster Zcit vom Verfnsser ein vmtnngrcicber Beitrng r.um Verhollon dcr Lvngcntuberkvlosc bri dieser Koriioso gelietert tverden. Ebcnso nufschlvBrcich wie tvichtig ist lie Frege nark den Bczichvngcn *m Lnngenkrcbs, svf dessen HAufttng bri Asbestose in den letzten Jahren tviederbolt oufmerksam geroneht wnnie. Dns Intcressc hinmn iicgt niclit nvr nvt sosiidmc(I7.misckcrii tnd versieberungsreclitliebcm Gebiet, sondem graft dorflbcr writ Ins .Allgeineinmedir.iiiiseho hinnvj, tveil dnmit ein neves Bclspiel cincr exogenen Krebsentstckung bcigobrockt tverden wUrde. pie ZaM der kierher gekprenden Brobachtvngcn ist r.var absolut geseken klcin, nber dock im VerbAltnis ad der Scllenhcit dieses Leideits so bcnchtliek, daB cine r.iisnmntenfnssende Dnrstelfttng crlsnbt crsckcinl. Sic ist sock desvegen crwQnscht, veil bisker von kliniseker Scile cine solche Arbeit im Sckrifl. lm flberhnnpt noch nicht vortiegt. Wir seklcken r.mnlel'tt eino VViedcrgsbc der bisker brknnnt getror. <Vncn Beobachlnngen von Ltingcnkrrb.t bei Askestoso im U'cItscbrifUmn towns, scklieOen dnnn dio nevesten Erfnlinmgen k feral nn vnd bcfevcklen die JSeFonderheiten dieses Krnnkkeilsbildcs soiv/e (lessen kliniscl'e Dingnostik. Die rate Brwibnnng dner Krebsgrehwolt tn der Asbestsliitiblvpge trrffrn wir 19-73 bet Oloyno In einer Arbeit, die stch mlt der pstholeglseben Anatomic ami IHttologle der Asbestme bescbdftlgt. Er sprlekt dort von Kempfilcntlonen drr As'iestosr. die In urstelilirbeni Zotnmmenknng mit Ibr stebrn otien (ritrige Drtmrbitts, Bronehopnevmonie, TtikerVulosr, Emphyoem, BronrkieVfescnl vm! von Heglrilkninkheitm, die naeh dem dnmaVgm Stands des W1sens nlehfs mlt drr J>'.an(iein<nrtttmg r.n Inn batten. Untcr drn letr.trrrn enrilhnt or i-lne !(eobsebt("ip. PRODUCED BY FORD m' IX. \V. Wn'.'rr- die rr n k* MV. Vunnbtvt: ..Tlx-re has "'so brcli pap ease pf a'loamooa carcinoma nf (lip plrttm. Ht la eriderifc a*. (h Minint-ni. (lm* *M wns In nny wit related tn t In "ItTSi'et"*'. |TC J(onn!r ** 1 p v " r * (vriifre |V-!'rA^n van T.niEfithTpbs VI An*rf"toe Vliicn. IVibei elai'Me rr. ri'ir filinbef'sri'e Vrrknilprms! If'drr Kmnkbriten noeli nteht Vfintip'fM r.n T:vnm-ri. Inunrr'iin T'MvMfi Shm rrn ire bistp'pgiarbe UrsirM*. piinkte sic nlirr dprh iinhrr.ulrEPn. Die crsfc dicsrr '.pi'If Hprit,"pM.n"ET'" Frfrnf pine 35|4hrige Frau. d'Y 5 Ja?up Asl>ctpinneriti war wnt dnunrh iwh 9 Jsbre obnc Sin'diexpoaition Irb'-e. SY stnrb__ xvic die Srktion r.cigle -- an finer nSlJijtn Adiestore. rincm flcrinnspl ' lm rfflt'pn Herzen. Miln.lri'^nrU*. "hd finer tMemnceIfrt DV.ong. Jn !rr Bnsis dta trclifcn Dunerne'trtn ppens wwdo ri"P k'inl*c*i nifbl erkamtle wnlmingreBe y. schwuht pfnmlrii. 'lie Ms in d<e Spi'.w nm* verdirk'e FYcm iilnanfrcYMe. J'rtn. fnrn nrm niflt', ror*in"'Y*i. Dns vrrliprupude rin'.!cep'!lirlcnrcinem ging ran . ' ritipm k'ctnrn Jlmnrlitu "US. JJ!f zwritr Jlrc,'"r,itting mit ScWi <-rtrrrVr slch elrir.Va'ls 8Ur fine I'mn, (lie "I Jahre nl* xiwde. .Sir lintte 15 Jahre Ter iltretn Tode in .'mil 5 uni* 13 JfonMr in tier erfalmmC'ermflO rebr atanbreir'irn Jlatrnlzrn. liml Aitfbfreillingsnypjltinj rinpf Asbcstrahiik Efnrbfi'rt. <.!'oyn fnnil bei ihr nnnlomlnch fine mitteNchivrre A*wlose mil r.um Tpil r.nfalimm Tumor im mehten J/mj:cmmteT!"ppcn, Ascitet nntl Tliroin'xm- (lrr linltrn J?cinrcne. Mvlastaspn feMten gtrieMntls. Histo'ogYtli hnndrlte rs ail-h nncli nm pin vrrhornmdrs I'Mtcnfpl'.belrnreinom. Der Kn-'n wnr in bridrn Fs'irn nipht- *u nnsgedchnt, dnlj er ollcln*cp Todcs- nrnfhp jtti xin irliVn, JJm glripbp Knit fBr 'lie As*re"lp"P. In demrelbru JnSrp (IP3'.j knm nnx USA. von Lyneh nntl Smith fine Mil- (filling Ober pinen LnnEfnUrv'.n *.fi Anlifjtosf, drr fine mulQlirliehc Kmnkrn. gprpMclitp iieigpgv'irii wir. Dvr ileirt 'ipwlirlplipnf r.TjAhrizf Krnnke. der 22 Jnhrt linumirnll- uml Milctrt Ms wr Kmnkriilinu*f(ifnnhm* 21 Jehre As'ifstwehrr gpMTStn wnr. hnlte *vlt 5 .Jnhren 0*)tr Kurr.lnf'igkpfl Beklngt. Jischdon er 3 dnhf vor stinpm Todr srhon vorlilmnsflieml Srhtnprr.pn lm Rdi-kpii uml Ober den 3 Ictr.lpn llipppn rechls irlmbt Imlle. crnpitprlcn sip!' (Hpe In den Ipltlrn Ilennionsten. W f> Tprfkd. huslelf, tvimlp nrpr'.H!"'. Wumi Tempern'iirpn, Blolnostnirl TOsir Q llpJntnBl,vs|uipp. l>pr h!tin>f'if Jtpfunrl unr fllr pine Asbpslo^ chnmktrristwrl'. M I'.pplit.i urilrn O'icr ilpr Un'se mtr tin* A'.pmgrrRiwli n'lj^sphwlielit. Dio klinisehp Dincnosp Iniilctc "*>l Alftore unit rhmnispii imlnrieremlf IVieumonle mil Scliimrlc rcfliln untrn. rnll)loj;lrli-nii'(lonil.rli fnml inmi npl>pn drr Anbcstoee mlt rccltll- <0 rpiliger l'lpuritis tmd ilnnirhicki.nnni pine ZrrfnlMiPMr lm ipchlpn Untprlnjijicn, tn (){(, nmkrtnkof'ivrh fflr pine T'lr'trkukrcf Kp'wltrn wnnlp. Krt mlkrofkoplfrh nlplllt nltli fin 1'lnltpuppltlirlltirl'S lirmns. ,Mftn*?n.pn wm-n niph'. rorhnndpn. Fllr pint Anlmlose nncpwOlinlipIt 1st die BfxchrciM'nE von glrirlirtilium hvslinpn KnOlehtn In drr Unnpr. JJfl.tCnrtiimin E'"U von pinpni Brr.ne*i|ts mil niplnplnrtiop.lirin Kpillwl nipt. Als Urutrbe dnrli'pn dip A'doren nn dro rlnpnistltpn Heit auf die Bronchiti'. Sip |np)irn in-xr<e'ipli dps Zo.tnntmfnhnngps iwisplipn Kip'js nnd Asl*c*loo von rinrr ..prwiMr n-lnlimisslii|i" nntl rwn J'nmllp'pn r.n ni.drtpn DrmWtrplnpn drr Lvncr. limn 'ifrlr'ilr'm KE*'pr`. end Cplgfr (USA.) H'fr pint wpittrp drrnrUgr Bfolinplilting, ilir sio -- Uloynps Hinwris von IP33 ntisgotommen -- [Or (Ik rreto dicscr Art Cdierlinuiit Itit'.ipn. l>r Jljohricr Mnnn wnr IS Jnhre long Asbtsl* ne'-wr cpursen. Xnrh I'Jiihrijrr bpMp*t pr lm AnscMtffl nn fine Longrn- entiiilntinnc Hnlpn nnd Atpmnut. 3 >*nnn!p vordpr knrr.pn Kmnkodienn'iehnn'J. Inns lifknm pr Mticc nnfnl'jwrtnr fWrkpnsphmrrrpn. Kr wnr nbg'msgrr*. ufgm dpr Splimprr.pn 'Inver Vtvrg'ieb, lintte lloslm. Ujnnom nntl A'.pnmyt sntHf Wii'ig'filrijen Au'wmf. .Wir"der Avhrstore nnnlf links imlrn in drrl.onge rdn!cenoloei-p'i fin Her.! erfnndcn, drr wip tine AtrfeUtoje oder ein pnrnmpnisfVr U'icr dpn' l.nngenkre'js W A's'jpstose. 191 l'p7r(J niimnteV, nher nls Tumor eriovnnt srerden konnte, writ Mrto*n.spn lm Hrpfef,i nnd drr WirbeisSide rorlinmlrn wuren. Hei drr Sektion tmrde nr'ien drr .Vips'.o*' fin 5 :.3 : 4 cni messpridpt ncinOser Krebs im Ilnkrn Liii'qrnnnlfrlnpie'i I's'rvdfl't. dpr in dpn Lttngm, dm linksseitigm it!Vs- unit AnrlpndrOspn, in drr i.etitm Xrljrnniere. drr BnucJimnskninlur, dem Bpckrn. drr Wirltpljil'.dp und dim Si-fcadrl .Vptnstnsrn rrsp'-et lintte. Dpn Ao^gnncspttnkt drr (>pse)>irtiM Mldptc in EmOpT Xp'jpnwt dm linktn UntprlnppenbroneJius. Etn ftlWogisplicr Eiiwimnipn*i.vng ztrisrlien Mden Srfemnkungpn irMrn fhnen tphr nnlifliegpnd: ,,TIinl tho iniinling p'fpp** of llio inhnlpd nljpstos pnrttelrs may In this pa** hnre ijeon -ijiiiricmit fnefor concrrnrd In the dcvclopemcnt oC tho primary lung ennerr srpins rtdrieim'.iy plausible to bo worthy of consideration." ' Ufoyne Jtonnfe 1930 in scinen 3 Ceoljncbtungen dim wpltero Mnaufngtn. Er fund pin pntdiifprcnzlertea,Oircinom d*s linkpn Unterlnppcns bei einer Abps*.osf. IrrTCi Tr.1grr 09 Jnlne nti wnr und 21 Jnlire Im Abo*.l>eruf gearbritrl bst'e. I**3S mnc'.'f Sparks ohno nShpro Einrp'bpilen die Mltlpllunc. d0 Cloynp *ei spinen Srkfionen 0 Flifle von Dungmkre*s bei Asbesteso nngptpoffpn Im*je. Hander frfnbr briefllch von Oloyne, d0.ieli diese 9 Krpbse nnf 00 Autepsipn Vffipcti. ' / .f Nordmann ftweltert? Im gMeben Jahr unsero Kcnnln!s um 2 rttitp Krfl. fn'V *xi A*>fstom, dip er kurr. hin'ereinandcr In Hannover setierpn konnte. Die io>e rntientin wnr 35 Jahre nit. S'C batto von llitem 17.--20. lyibpnajnhr. grnmi 7 Jnhrc, In der Krempplcl, Splnncrel und IVeberef finer Aabestfatirik gpnrbeftet. r--0 Jahre vor dem Tode bekam Ilusten nnd Atemnot. '/, Jnhr vor dpm To>t mi th 'inter dem Vprdneht dner Tnberkotosp In Itrrtliebe lihnndlung. Jlornlg trllte die Wnhraeheinlicbkfltsdlagnom nuf Krebs Im tlnken Unterlnppcn bei ana. erpriigter Asbestoap, well kllnlsch dio Eeielren piflrr Atelektase beitnndfn und ("mogmphisch dpr Hauptbronrhus vprlegt war. Anatomlseh handetto sleh um in verbpmrndes Pinttcnppilhfleapcinom mit walnuDgreOer Zerfalb'iOMp, die An- p*b|nB nn den Unterlnppcnbronchus hatte, 1'lcuraversehwlflnng und Mrtnjtaren in teller mid Xierpn. ' Die zwrite Beobaehlung belmf elncn OOjUbrlgfn Mnnn, der torn 30. Vs <3. Icbrnsjnlii' In der Vorbeireltung einrr AsbrstfabrJk 7 Jabro tAtlg gewtm war. 3 Monate vor srinem Todo magprte er stark nb nnd bekam blutigrn Auswurf. Er nand aniangs unlor dem Verdacbt einer Toberkuiop. L'*rer der Unkeo l,imge uiitrn land sirh IMmplung und shgenchwOcliten Atmen, ItOntgcnoieciseh war das linkp Vnterfeld verschattct. Dio bebnndelnden Arzte dlagnostizlprten e*ne Aabrstoau wit Luncpnkrcbs. Dio Sektion bestAtigto dies. Der Krel>a war im llnkcn, Uoter. lapjipn in Euannimenbang mit dem HnujitbTrincbas nnf IVnlnuOgrOBo trrfnlfpM und balte Jlezlfhiiiigcn zum ItcTzbeutel, der llnken Knmmerwnnd, dem Zwerebfell, 'nn Pcriteiiarmi dr* linkpn Oberbauche*. dem retrojieriteitenien Oewrbo Muter der >'i*z; den dortigen Lymphknotrn und der untrren Jtrut. end obeten tenden- nli*ifIAulf. Hiatologiseh handflte os 'ieii wiedef um pin verliomendea Plntten. rjatbrlfapfinom. Aurb }m rceiitcn Dungcnuntcrlappcn fnnd sicli ein bfginnendrs Ititniel'ialrarvinom, Xprilmann scMpO an diese Bcobnehtungen elne eMgebprldo IVOrd'gnng der Ufslvbt'pankte an, die Ibm ftnen Betuf*kreljo tu bewpicn sebienen. Kr aprarh l> ersler klae von elnem Berufskrebs der Abestrbrlter. 1939 marlite tVpdIer auf fine wpitcro /leobncbtong Jn Deutschland aufmprksani,' die von Bohne etammtp, nher nieht mltgetpilt worden wnr. Dpr OSjUbrige jrnnn ba'te von 1925--1935 10 Jahre xum Teil als Mei*ter In einer Asbestfabrik grutbeitet. "'nige Jahre naeh der Rtanbesposltion bekam er aebon Be*ehwpnlpn von sritcu dpr Atmungaorgane. 1928 war er 2 J.'onntp vererblrkt. SpStcr ntaehte er Otter )!ei!st*ttenknren, ohne dnD Tu'jerkrHiaci.'Irn bti ibm gn/unden warden. Wrgen PRODUCED BY FORD 1IT2 It. W. IVedlcr; . . ^ O O W _* * 'O f.mrlitix-mlrf Vro*rtiln*.l|lrr*fng trlfi--* /fftrimidvM gab cr Y, Jnlir ror *ciirm T..'.. ffir nt<f. lit KmiiWmm Imi* rr ZptVk (W nllcrmeinrn AbM'-igi'Miri^ Uvttnmc imd riiie* tannm-lvr* iintm Ober dm l.iingrii Mri'.Hil'Tnii'.nrr'n Kntnrdi-. Jm Anatrnrf tnhlirirlic .IvVw'kiirfirreVn. nV-r. kmie Trda-rkcIViriiV". Mbit, arnknng Murk tiewblmnist (!m/9"i). I.ink* illirr drr 9. Hipnr fund rich In dev Vim. drrrn Axillnrlinir rim mil tier limit rrnnr1irm* kaalnnicngroBc Oc*cbtrut*t, ' cntfcrnt mml? unit rich nl* Kre'ieineVia'nre liemmet-el't^j ROntgrnelogieti U-. rtnndm die Zriebcn rtnrr A*br*to*e *mric rinr JWcbnnngavemieJmmg tn dm rcchten 0!jetgr*rhe**en, Offenbar tvnrde nneb dm mir vorliegrnden Vntcrl*|vii dir J)ingmi*r nitf rinr'i I,nnzcukiT'>* in*,m vitnm nirbl errtellt. LVr Kmnkc *'*tV bald nnrti der E*ri*ion i'it Mr'.nVnjr nn Iterrsebinlrbe. Per ScV.lon*'ie,and nerdc fi>,,'rmlcniin<j',n i*r*irSi^''1Tn: ..Die l.nngct' Immi ?r*t mil tier Brusttnmf renraebwn. Da* Herr, war nicht vnrgr(ilJert, dir .Vttdiiilnli'r vnn brnvnrr>\cr JVV iind elwn* eldidfrr Kon**lenr.. Dir '''die i.T'i*cr im.r Vet- and vni'.rricb, |1|T Vntr*i-i]'|iit von (W*irt finmii^n nn! erbiefrlgiT frxrV. Pie tecMf Lunge i*0 brim Jlcrananebmrn Im Bereicb dr* MilirHnpncn* rin. Srin OctvcV *nh gelbriltlieb unit vOlHg irrbdlrn nit* end T.rtste nu'geiMm'.r JlOblcu- ""'1 Knetetdiildnng. }b.T Cbrrlnppi-n tmr b!et- and nfltrirb. run fe*ter I<o"*i."*cnr. and lolticcr. Per Vinter, fnppen trnr tom rtiirfrizrr. crnnrdtlicber J'nrTj? und fc*ter Koml-eleas. Aacb rr rrirtm irli nl* luftlree. Mir niikmkrpi.r*ir Vnlcmiebeng der Lengcn ergnb lm irrli'm Milirllnpp'n tVT'l*ebr* Krel>*grwolie. irft'nrnt im Unirrlniiprn nlle *r A*besto*e efeirnktenVlsebrn Vrrdnrfrrtingr-n rerluindrn ttnren. I'or nOrm fnndrn slch In nt|rn Bcbnillrn As,jr"'kor|'rrcSrn.M . JCneh Bander (tpttn) milrt 9 Antnrn In dm JnSrcn IP39--193S In*grmmt )4 Krrbsfnlir 'iri pr'irn Im'irn. Br srhi an* dimer Mtttrilunp nit'it* JfBtirrm hrrrrr. n dnIJ nnr'i nHrn tiirtirrlgm Un'.crtnBcn# nde ie cbm xngrto'irt trnrdcn. dirsr Anp'ren nirht In *ollrm Umftme 'imyulzt wrrdrn kCnnet*. MHl fnijttr rin xurfntirlirW ktlnirkrr nnd pnttintnairch-annirmlrelirr BrrirM rrn Wrdlrr nnd Mnr.bncti Wn-r rinr nriirrr tlnrrliW^gr Kmnkm^meMcMn. dir dm cnnr.rn Vrrlnuf dm Jicidrnn t*mrti*r. Drr COjiliirlec Mnnn tinttr vnn l?it bln 1939, Jm cnnrrn 18 Jntire. In rlnrr Axticntfntirik gmrWtrt. Kr nnr nnr dir 3 rt*trn .tnlirr rinrr tnrkrn .Slnti'irliin'IrknnK (Vor'irrrlinngJ nn*se*et*l. !>'" rn'.rn IVjrhwrrttrn tmlm Imld nncli AriirtL<nufnahnic rin, 193? tioi rr Wit* dn* IBM riwr >mkijmptir.irttrn rliwrrrn Aidr-rtmr, dir irh rrliWchrnd rntwfrkrlt Imttr. Jm Javte dm trtetrn I^>irn*j/i'iir ntrillr lrh O'fr dem rrcfitrn ZTrr1iMI |m irrhtrn J.tu'Crtiliiitrrlnj'prn rinr r.nnrtimrnde Vcmctmlloiijf mit dm kllnl<t-Vn Zriclirn rinrr Atrlrktn*e nnd |rtteirn Zrrfnll* *owir *tnrkm ncnmtgitonnm Schmnrrn In drm cnzrliOn'crn ln*rrmlittiirrrrii'>rfrlrli rin. .Her An*tmrf wnnlr Mn*ig. AHc Aniirlclirn pmrhm fitr rlir-n Krrli*. drr nction kllniscli dingnortWrrl trnnlc. Itri drr fjcklinn limtStlgtr nidi dir JJtinnmr rinr* rrrfnltrncn Trrhommdrn I'lnllmc|>i!lwlmrcinijiii*, dn* Torn rreltli-n Un*rrlTin|iridimnv?ni mijglng. Mrtn. xtnxrn irnrrn nirht vorhnndrn. In Orntwldmid lirzm lnr.ivi.<rlirn nurli 2 nritrrr Brn'iaeMongm w. dir Mdirr niclil in dn* ScliriP.lnm cingrgnngrn lmt. Dcr rmlr Foil 'minlr von Trijl*rMnrnder nmclicn, dcr dnrd'irr 'rerrll* 2ntnl kor* mtlndlirli tirTlc'itrlr. Klnrr jirraOntlrtirn rtiri(tlic!im MRtrifttng cnlnifimr leh dnr.n foiemde*! In3S rr.lmlr Trnt*rhtnei*drr rinr 40j9hrlge Fmn, dir ndt Inngrn Vnlrrlnrrlinngm 19 .I.-dnr in rinrr A'V-nifnlirik llllg n*r. IHr k'initrlir rjingno*r lnfr!r 'ml i!ir; ,.l.on;r'l`,n"i')r nvlit*? CirrSotic!mr I^ingriipfrw'J rrrtil* ? Viknriirimdr* Kni|iliv*rni link*. A*citr*. Mwtigmdtgr Knr!ir*lr.'` Itri drr Srktlon fund *lrti kHne 'TuWkn'mr, dngrgrn n'irr rlne clr nn*Krtlrlmtr A*'w**ii*c m't nin**rn!wflm A'bmlkPrjn^rlirn nnd rin rrrkts*rl*lgr* l'irnmWn*tom, dr* rich hivtotostwti "f* ..jnrtnlonlrco'air* Jfrwllirliom" JrrmiimWIfr. . Ober dm I.nngrnkirb* l>ri As'-mlmr. 1W I mi t'lTiinnr'im tirrlnnd rinr rurn^Tr'm'r TnmornnKoin* mil A*rt'r*. Drr finkt- l',M(.*nn'tiii rnMdelt rtnm KrgnB vnn nPrrm. KmnirtinInriMrlw^ t{m|i'ir<rnt .Imt liiikm r,""cr. Mir Itnr'irkli*rtir lfmn Hindi nn l\rvi*tnnf*rtmili.tir In'ntgr drr !,,,.if-T-Ti(ninVime. I.V r.nrilr Itmirartilnng lnmnl rm Alirrn*. Ole Brkllon fw*im Klrher. Wn*rl* vnr. IcH knm nlf GolncMer mil drm Kn'I In TUrriilirong. Dvr nojAhrlgn .Vann (13. 8.81 M* 19. 9.4tJ Iialtc Id* '/t Jnhr vor dem Tode 42 Jnhrr In rinrr .W,e*ikxnl*rtitikniiicflong gnirbrltct. Er rrkmnktr Im Jnnoar 1941 nnlrr ra- m-hmrndrr Almmot and (JmlrMunlinnkme mil dm Zelelien rlnrs Jlnk**cf!tgrn l*i*imrrgti**r. A'*oloto DSmpfong. notgeliolimr* Alrmgcrtn*rk oml licrlil*. nn,riiijinng dr* IfcTTrn*. per Awnvnrf rnlhirit rrlcMIek Av^irvlkarprrr'im. In Inn mriirfack derrh Ponktlon idige?n**jnen. gnlfrrligm. rOttlehm E*gti9 irerdm iritldiek Tvmorret'm gefundm, Cl*er drr reeklm L'n'cr wntm wntrn vrtr*.nT.rlt Mn'itqjige Ilnme'Krrattnriil* tit hdrrn. Mir Mln'.arnknng *lirc eimrlt nn. Im Ati*. nrf krino To'ierkri^eltlm. Ii9nlgmolocl*rli trvrde rinr A*br*lo*e millirrrn flindr* fmlgcslrtlt und im reclilrn Hilo* evil, drr PrimXrltnnor vermntrl. Pie S'k*irn derklr rinc Wchlc Abelr*e mlt rtnein diffn*m jirlmilrcn *eltlri'iibitdrndrn IMmntrllrarcInom der Ilnken rictim von giMienlcHs ndrnomalfttem CItnmkirr nd JIct"*tnrn nn der Jtaoch*eile drr linkm J^nrreWctlkoppe, der Brrom dr* Vrinm Broken* nnd der BmrtmTfrkoUtnr link* nnf. Dn* SeklioinpretokoM der l!rti*'.kor,Jonpine *el Im rintrlnen engelnlirt, dn bi**ier dnrO'ier nichl berichtet Jtrn*t*ekllnn. Tannlmlu* ndipora* mS3ig enliriekelt. Tberax 1*1 m83ig tmfflbt and elajlhrb. P.IpprttVnorprI *ind gat r.u datehnchnrtden. D"S Etrerrlifell etil reelits In H9be de 6. Inlereonla'mume*: atif der linken Sello l*t e* n*c't nn>m amgekhppt and mgt well In die BaaeWiOMo Wneln. Jein ontrrrr Pol *!rltl t*kr liefer al* der Jteekenknmm, Bel drr Pneamolbomxpm,ie enltrrlelim aa* der linken PlemahOWo fx.l 3009 eem einer gelbllcli-braaneji, fadentlelienden Fltlnsig. tn*. Da* gartr.e Jfedia*linnm 1st naeh reeht* verdrtnRl. Das Herr, b&ngl ttapfm. i.Vinin |m Medlnnllntmt; Dcinellnko Knnlellegtln der Mllteltlnle. Die reclile I^mge M !!* ant grringe stmnglOnnlge Venvacbstingen frel In der I'leambO'de. In drr Ilium toslnll* finden rich bl* lmndflaebengteBc, drrtie, weiOr, "eknigr Ptalten mit efnrrinm knoUrtifOnnigen eben*a derbm, trriUen KnOlcbm. In der P/mra de* ireltirn Lttngenoberlappcn* slebt man eine greUe rtrabligo Ifarlje. Aat der PIcam 'rr teehlen fringe erkennt man elnen felncn, mlCig feat haftenden gmntn filtigen B-ing. Mie rreliic Lnnge sellwt 1st von gehOriger CrOOe nnd mitllrrmi Lnft- und Mfi**igkeit*gekrtlt. Mia rieorn and die Schniltflilelie te'een cine tnUBIg utarke, .tr'irnirte, nettfOmiice Edclimmg. Im Obrlgen lt dos Lungengcwrlw von enter Knrbe. Hi*rdrrkranknngrn *lnd' lilclit nacktwweiacn. Im Unterln|ijena*t der nvliten Longcnnrtrrfo liaflet nnf der Intima eln kleiner bmimroter Illnfpfropr. Die Lnngcnarlerlen sind leer. -- Die link* rtevm 1*1 Inganzer Ansdehnangjehmirtig tmlirkl. Aid der InnenfMelie flndel man niamenbaft diebt beieinnnder lelwnde. I"* tralnaBgroBe Knollen mit mauHJremrttger OberOSche, bcatriiend no* einem wDiv'.lgen -- auf tier Scbniltflkcbo weiUen -- Ceebtrol*lgetrebe, Diees *ondert Mm Mnreb*chnelden elne fodentlehende FlD*lgke!l n.b. Nebrn dem Tumorr-n'elie niehl man cbenfnlh elnigo *ebnige' J'latten trie reeht*. Dn* Geachtrulrl. teirrlx" ddngt nn kdner Stelic tiefer in dio Untcrfnge eln, vor allent nieht In dn* l.oiigeiigrivebe. Pforlm Jleteloh der elngangn ernDhnten Hantfcnolen nn der linken ttriintrrite findrt man Ge*ehtrnl*tknofen In der Etil*chemippenmn*kaiatiir. Die iikn Dmge 1*1 *tnrk atetektatfseh and nar mlt einer tnmgfOmiigeii Vcmaeliating an der limstmiml ndhtrent. Das Ijongengewcbr l*t von vAh-fiwter knit*l*lmtt grain tut'lelier Fnrbe nnd teigt aof Schnlit- nnd (JIvrfMche eine *cimnrr.r, nrlr.arlice JWrlinimg, die etwa* dieliter i*t nN die der reebten Belle. Im Longrngetrrlie eel'nl nirgeml* Tumor. Tnchen, DmneMen beider J.imgoTi tint! ton geltCHgcr Write nnd /tentwhe* Arehlv f. kiln. Ned. HI. TM. 13 PRODUCED BY FORD lot ' H. W. Wr.IIrr:- Tm inr*er Wnnpi. tfosebprpvlstjfeircbe i*t nirgenpl* nrtcbwrFsbnr. in?ip*l_vTPtp\. iprwi-n Hn<t V-ci<t'*r*rH* you *c*vwnn!rr Fnrbe mipl TrricSp-r Kpmsm'.cv'r.J -- IM* Mr*t fat tsmim *-> jroB wie 1>c brirlpcninpvsl. Itenbcpt'clblltller glnlt nml spi-prin.1. KrUcrttrV W milij-c voriiinplpwi. f)cr h'nlte VmfriW fat. VWn, pfor rpvblc elwns rnrri'/v*. IVnwp! dr* liiiken l> mm, pirn recli'cn 2--3 , tln-k. Wni'.tir'ir HtT/.klntevn r.*r. m>pl wMnBtnMc. Km*t7.nrrrirn mi'.lrlwtii un<] rv iiirtn Wont!. !)a.< MvobM !t Mil ftllpn ScWltpn aJ^hmilDii; liramms. Anrfn in cnnr.'T ApwMnnmg irt pvvipl rbistfap-b. .Mtkrp>*lpnpi*ebi-r Ite(npi. , l'.rrbtr Longe. Hie bpingp-rwlMtlpt'ir wlgl*tpdImpra *?rrrfogccmphrTr'im'&v Vrnlml'pmiyir, V'pwIiWiitMIrlt limlp-t mnn ii jrrilwtrtth'rn ICrmijr- AMpigervmgrn p-lnr* tcinbavidgcn Ttthwnprrn Pignimlc*. In p!lp**em IVwir1! ttip;*, dn* pfiVjnchtsk (Irtrp'n* din p'odlic!'? hyn'inc Vmwnndbing onp! Jm'-p.--*. Xpipu (trn Ablng-mu'ipon i!pp nn'AtnVi'Wipn figmcnte* pipS'. nmt nbcr npicb trih fri*p-Sp\ tedivp-fae mpyb fan A'dino Ipcrriffcm typfaprbe Ad>cr*-c>*'*kOn'cT. Hir*o Ifagm In grpijen-n Jtpngrn strl* mit dem Antbm how-pigment nwimmni. .'Inn IbipJpP lie nlfpr'iuirti nnnMiflngij vnn plk-rr-n in Lrnigp-itnlvpioTcn onp! Itn inlmiHip^ii IVtrp'ie (Or *ielt nllp-fap |icjp-tpd. Itt-ic'dic!i AMpijTrnngcn vnn Kobb-stnob toi! AvijcvtV>]vnrIirn vWil mnn nuplt ptntrr pier Plcom. Pie groOen-Uronehtcn pnp* fmltrn Iriiwpkr ScMcim unit nitPV!o9pnP* Epitbcf. Bfp nmnci'Wpn'piiKi rklfarh mwilerl. O'l-mll n'n-r *!npl ic mit einscbicbtlgcm Fllmmrrcpilbcl ntngckletito. Epillicbm-t p!nipm iiwn inch nirgp'mJ* nnebwefaen. Dn* Longcngewchc tintnilWfor nn'p-r drr IMcum tcigt rinpn lelebten Kollnp* ilpr Alvpolpn. Dn* Aivwkrvi^tW nrigt birr rWfocb firffaiirn. nbcr nlrgrnd* nlvpivchrn Cbnmkler. Im Obilgpn nirgprmls pnvnninnMift Vprjtntipnmgpn Im Longcnjpnvtjei Llnke fringe. Am Oewebe dcr linken Longc findet rich iter Bclond dvr Kollnp*lndomHon mit dr*ipmm>pUvp*m Aivroinrkatnrrh Pinpl Fibrose pies Inter, pfitiunip. Im pp-ribrpmehintp-n (IpnplfO gennil wle rccht* flnplcn sieh mcbiicb Anllin* kpvsenbfagenmgcn mit einvr ItyoTInpwe dee omKebcntlen Ocwebcs. Jtcicldichcr sir vrehts (inpict mnn III dipsrr Longa typf*rhc A*brsto*f*k0rpcrchen, "nil r.iror kjVIip In Anf- onpi A'l'mil. ErlK'illdi mitmiT n! plipmen liegegnct nmn freien A'Sist. nmlcln. Pic yclhOile ilic^r KOrpcrcbcn g'bl In trpinchcr Wclso cine pwiliw Kmcnrcnklinn. In dcr llnkcn l/ineo fimlct mnn nciter nmfnngrrlcbe Blolongm imtl on Jilnlnngcn itwrrlmptr.le (!cvrc,'*ncVroscn. Uiese tind mcfvt nils JOngcrcn iMtiimv. pin /Vninrknlipinowbrlniingcn ro!l.t8npllf[ feMen. Pie Anbcstosifki^J'cr' chon .ninpl in p!i<r<cn nckrctlschc" I'nrl(cn Olicmll crhnUcn nnd treten plnrch ilic A'cVrmpn pips nbriEcn Up'ttv'.nnv vp-hr chnrl herror. Aueh In clicner Lnngc findenjirb mn IimneliUlnppnpnt pile gMcbcn Vcramlcmngcn wic reehl". EpHbclmctnplnwn werpien micli In pllescr pingo vcrmilJl. ' Pingno'C. Znhltvicbe As'icvtmvijWrpcrclicn In bcldcn Pungcn mit gcrlngcr Iinmchriclicnrr Fibrrme (ecriifgc l,pingennsbc*lo*e). Komprrsslonsnlclckl"* (lint Kollnpdnplpimlhin (ipr linltpn Lunge. Blotongrn, NeHrown nmJ gcnngr Iirp.'ncbopi'cnnipjnie in pier linitcn Lnngc. rlenrnloinor link*. Per Tumor weehjclt In *elncr StniHnr. An clnlgcn Stp-llrn finpict mnn uliple Znplrn unit Strtnge iimgcben run EOgcn cinev mj.nomntOrn r/irtfibrlllamn Blm1cgecijpi. Fn*t idle Urvc!npi!trcllcn bcnltr.cn RtoOc Scblcinivnknolcn: mnn <Mit ninuvnlmfl f?lrgctrlngrurn>cn. Vpnelntelt flndct man Zcllcn mil Rcpln'r.lcn Vok'io'cn. wo pier Scblclni jn pin* umllcgcmie Blnilcecnr'pc nimgctrvten !!. -- An nnplrrpn Rfclfcii blelct flcr Tumor pin* Blit! dicht nclmn. rlnnmtcrtirgnnlpT HoWnVjnm. plic von Hncin glnt'.rn cinvcMeV.lgcn Epl'lid >u.L-hlcipIrt ximl. Awc'i P<i<-m !:Tnl!icl>..-l!cn cnllinl'cn vir'Inrli ScMcIm nnpl ICecn ieh In Kirin-!ringform mi* plp-rn K|p".'iclmbnnpl nb. rni'ici 're In tin* Lumen dcr Iloblruimic j . J 1 Cbrr den Limgnnkreb* bcl AVicstono. *55 cVrirrtcn. Aber noeh Im Intcmtitlnm flndct mnn il'iemll locker vcralrent scMeim. i^lpjrnplc ClescbirtileticIIen. Nor nn wrnfgm Etellcn f'ndct mnn njlhtc Epitlid.' i.vumticncn ohne SciilrimbiMnng nneb Art ctrmnUorcInonm notWorn. Die C'mchwtii**. (imfct ,*irh O'jcmlt in pier rimm [nrielnli* pmpl vt*ccmii* fink* nm! I*t ftrllcnn-tmo owing in die wbpleomlcn ScMchlm tics Lnngcngcwebm Iiincingpnmchctt. Itirr (i~!cl man le bcsonplers In den Septm oml Ttrethtrll imcli In Lvmpiibnhnpm. IMngnoe: PrimJre* o!ileimbilplemlos PrileenaeUencnrelnom pier Plrnrn. grOOtontell* rpvn ndp>nomn'.0*cm Chornktor, Hie ftngliclien glnjigcn KnOtciicn von dcr BnneVcito tier Ilnkcn Enerrlilcil- lap}** pmpl von pier Scrosn pies klclnrm Iforkm* cnicimn *lch mlkro*Vop(*rb !* Urln!nsrn vem gtclcfien Ban wic pier tVloilttlomor, _ IMmit sinpl pile bijber bcobnclitctcn pmpl in pier Wcltlltemlur beknnnt gevrordenen IVV ven I.nngcn-mnp! Bro^tfrllWl*? *>el Arbestme crscbOpIt. Al* cinr.ige hnben bisber Norplmnnn nnpl Sorge pJcn V-rsnch nnternommen. ikrc.vrrrimentell nn vreifjen Mltpisen d-c Zpp*nmmcl',,nng*fmgc iwijcben A*bcst- .!obinbnlnlion onpl Lnngenkrcb* til Ijcnrbcitcn. Sic *ctrtcn 169 Milnec in Ibrcn VpTvpn-hcn nn nnd bcstAobtcn *io enl*prcolicnpl pier dnrebsclinittliclicn Jyripcn*- oml At'icifodnccr dp* JIcncben iwiecbm -'I'/, onpl 3 Monntcn. (Jber dm HAlfic rlp-r Ticie tnrb vorber. Kdncs Jljcrlcbtc die Inimlntion iAngcr nl V Monntr. 2U% pkr tilicrle'rcnplcn Tlcrc wicjen ein vcrborncmlcs multlwnvtrisclic* Plnttcncpil'id- pvrviwn pind <2--67% opithclinic NeobiipJovvgrji nllcr Slndicn aot. Dnmil oll plic nwap-lillrhe Bcpicotung dee Asbcctetnobc* filr pine priinAre Lpingcncnrcinom pics .\l-eatnrbeiter* cnpcdmentdl gcstfltit werdem. Die Znhl pier cndgOilig plapch den Vpprsoch grbmchtcn Here, no* plrnen dto oblgen Znhlen erreclinet minlcn, i*t cbr kWn. Nor 2 Ticro batten Neobildongcn, plie nl* Krcb* angesproeben woolen. I6e Aotori-n wlesen *db*t not die Sebwfcrlgkelt pier Abgrrnr.nng von elnfachen JlpHnplnden bin. E* moO einpnn erfnbicncn Mpwpbologen pint Sncbkmnpr 0!n-r- l*?sn blc|!>en to entecheWen, wfopvdt die Scbliltce der E*|>erimenlatpjTrn berccbtigt bnl onpl wfeweit die erfpirderllchen Vom'ebtemnOrrgrfo bezOgtieli Knbeitliclikcit onpl Bmuebbnrkrlt pic* Tlormnterinla bcolmchtet warden nnd wieireit in die*cn l-'icnten Bpontnntpnncren In den Berelch dcr ErwAgiingen getogen nerden mileccn. Norplmann nnd 8ergs-*lnd Iiiemof korr. eingp-gongen. . _ AoB*IJig lit, daO man *pm*t W*bor be! den Tieroiperimenten mit Abe>tt*ob. lr nllpnllng* onter nnderen Uesiebtsponkten nngeelellt worden, offenbnr Sbnllebe l!rpi>melitongen niebt gomaeht lint. Auch it mnn bei versehirdenen Tiemektionen (llunde, Ilnltcn), dfo nn Tieien vpngenommen worden, dio In Asbestfabrikcn lebten, of o!die Beobachtangen nicht geetoBen. Wcnn man von elnom Bcrttfskrebs In clner bentimmlen Arbclterimppo aprcchen will, eo wlrtl mnn r.undrbst tlcn statiatiaclion Bowcia erbriiigen md*scn, plnB dor bctrelferulo ICrcb* in groBcrer Hiofigkeit nl.* in nntlcren Bends- nnd' Bcvblkcrnngngnippen rorkommt, wobet plie Jvrderung nnch einer rndglicliet gleichnrtigon Altcnmtinnmmensetziing b'i plcn Verglcich**nhlcn sekwer stt erfflllcn soin w/rd. Her slntfstincJio Mp^r hnl atieh- fOr plfo Asbe*tose noch cine pveitcro nnccrkrnnbnre Spliwlcrigkcit. E wird *!oh be! dieecr nn !ch seJlcncn ICrankbeit Immcr irnr 11m klcine absolute Eoblcn hnndcln kOnnen. Kino cinr.ige llcobni-iitiing nls Zofnltscrcignia knnn dobei *ebp>n recli* groOe protentu!c l emcliicbungen he'rbeifOhrcn. Wciter win! man mit Norplrnnnn be- . npp-ksichtigcn mOssen, daO bosenders in tlen Ictr.tcn Jnbrrn pier Arbcitcrsrebscl in den Asbestfabrikcn die Ergcbnisso Im' nogntiven Sinno . 13* H. W.IVwWpts ' bcein'-rilcM igmi wirtl* da gvwONnl'cb I(It dir TCtvlwilstrbmii; chtc bmje StnubrxTmsifion mid evtt. ci'i liUigcre stnirbfrric* Interval! vergek~rn hnben tm*0. J>ie wenigstrn Arljri'.cr biriben brute TO Jang? 5u den gr. ffUmletcn Jletrieben. Attch svirkt die Staubbekfimpfung trQnscbcm. vrcrteni'risedetn Stnubscbnden nn der Lunge entgegrn. Immerhiu hidx-n xrir brute bei den nebwcrrn Asbestosen memt noch Arbeitcr vor un>. die ibren Stnubspbnden mis frittirrer ^cit mit sicli tmgen, wo die Arbeit*. becJingnngen wesenltich ungitus'.iger Ingen. . At* r.weiter Grsicbtspnnkt. tier fitr flie Zusnmincnhnngsfmgc r.wiseVn Krcb* tml Asbe*!nsc wfrbfig ist, wine r.n erdetern. welcbe bcTOnderpi. VerbiUt nisse beim St:tbsebndcn end den Befunden nm Ortder Krnnkbci* rneetn>ffen werdrn, d'eden Krebs Terstiim.llir.b tnne'wn void eon nndemi Ltutnenkn-bswi unlersebeide**. AN SeblulWein den Bcwcises inttUtrn expcrimentellc Erfnh. rungen belcprn, dnB die K*vbsenscugung nuch nm Tifi gelingt. { I * I j J j { j j j Cbrr den /singenkrebs bef Adiestose. pj? TnltcMe 1. i# ! f> - ! it ; n ; f.w. Nr. ! Alter, iPcfdileeW j j StfWtonrbett j Ktrfr* ! SUotHom 1 1 InterroJl A-wU,' j i t ! 33 J., 9 2 I 47 J., d 3 |1 50 J.., d i1 1 ! d I1 a ; 35 j., d a 1 31 J., 7 7 M 1.. 7 H 41 >.. 7 T 20 j T 21 |t 20 t 20 i 8" n 15 m HI in . m i m j 11--Ul m in * 0 3S J., 2 13 m/ e' itnrvh iFnbr 1014 * j Bnresch/Leeaebeke 1931 Beintker/dt Bli! 1931/37 1 Beinlkr/P*tb, Inst. HOnster 1931 jStroe.be/Becer 1933 S Bovine 103 Snnpr/Letlerer 193-9 Snu pc/llnniocki 1935 Wedle-r/WalkboH Wenden svir mis r.unAchst dem stntNUecben AVeg tit. liter kOmv.-n wir nN virklicb r.nvrrftssig nnr dip Sektionen mit genatier nnntomiseber Untersuchung der Lttngcn verwerlen, well bei den rein ktiniseben Dingnosen gewisse IrrtnmsimigliebkeiU'n gegeben stnd. AeOerdctn rtcbew rein klinincite Arbeiten r.ti dieser Fmgc niebt r.ttr VcrtOgung. In Dentscblnnd stnd bislier 30 Asbcstnrbefter sezieit sverde**. Die nngcsrblrwsene Ttibelle 1 gibt die Fillle nneb Alter, Gcscbtccbt. Arbeitsr.eit, Stadium dor Asbestosc itnd Todcsnnmche -- soweil n- anflcrbnfb dev Asbestose oiler tier dutch sic bedingten Ilereschwiltbi- odcr ngowler Pneumonic Ng -- irjptlcr. Die ersten 18 Todcrfalle siml bereits vcrvffcntl relit- worden. Die nnderen 12 babe ich gesuntmeb. IMm enter Nr. 20 initgrtrittn Junge MSdcbcn knnn ltier vcmncblnwipt scerdrri. dn sic mtr efne kumr Rtnnbc.tpositlon batte nnd aiuitomiseb noeb keine Adwtew bot. Von den verbleibetiden 29 Sericrtcn bntten 09 o 4 efnen UronehNlkrebs ttnd 2 uei'eve ein ttndignrn Plcumgow&chs. K> o erreebnet sieb hieraus eine ProrenttnM von rttnd 20% fur innligiie Gescbwfllstc der Lunge bei *cr.irrten Asbestosen In Dentscblnnd. Atidere wnligne Neubildungen des KOrpers tviml'-n insgesmut nur 3mnl gefunden, und r.wnr Je eine des Mngens, der tSjtcitu-09 Toitre uttd der Prostntn. AVenn nticl* der Lttngettktcbs stntistNch in den 3 b'tr.trn Jnbrr.ebnten betnvcbtlieb zngcnommcn bot, so stebt er nn groBcu fJektionfntist5Jccn doch imnter nocb bitter den Krcbscn des Venlnimngsknnnls deu'lielt r.nrilrk. Er nimmt nn Hduffgkcit in der KrebsstnlNtik der Orgnnbrrbse je nneb den ver*cbiedenen Anforcn sonst den 4.--2. Pints n'n. ijei iler Asbestose liegtdrr Lungcnkreb* in Deutsd*. In ml n ett im A'onlergninil, u-ie die obigen EnhJen lebren. Aueh ist do* .IJoretwcbnittssterljenUrr drr I>mieenjen-iAcbtritger erlicbiieh niedrigrr nls dns ft-r Tmg'T nmlerer Cnreinome (mnil 51 Jobro r.n 00 Jnbre). Jib- It* 45 J.. d tl C3 J., d 12 69 J., 2 13 9! J.. d 10 12 10 10 0 14 35 J.. 2 15 55 j; d 10 3* J., V 7 7 12 0 12 7 17 58 J., d IS 00 J., d 10 18 .2 1 to 70 J.. d . 10 20 00 J., d 42 1 % 21 35 J.. 2 22 54 J..d 23 09 J., 2 21 52 J., d 25 60 J., d 20 '42 J., ? 4 27 4 3.20 ' 22 0 1 0 2 2 10 27 50 J., 2 2S 35 J., d 29 18 J., 2 JO 40 J.. 2 12 5.0 1.70 10 2 0 T. IU ,m m li ii hi hi hi HI hi i-n hiHI hi hi HI i HI IT 0 -HI Wedler 1930 Wedler/Koeh 1930 Wedler 1939 Magcn-Ca. Wedler/WnlkboII 1939 Bronclilnl-O. Nordmnnn 1938 Bmnrhinl-Cn. Nordmnnn 1938 lAingenubsccD. Xordmann 1938 KmpTrm Broncnist.Cn. BobneAVedlor 1939 Bronekial-Cn. Wedler/I,l*beeh 1940 Orsopb.-C*. dl Bias! v. a. '* pleum-Ca. Alwens/Ftsobor. Wssel, Bohno Koopmann BoHnc Holm u.. Prostata-Cn. Ivunpnb*crf), WedI?r/Poc*Vft Amvlehtose Nfercntnimff. Wedler o. *. Lungcnlbk. Wedler u. a. Lnnj^ntbk. dl Blast n. a. Pleumgewflcl*. Teutseblaender kleinen Znhlcn erloubcn sllcrding* bleraus zunScbst noch keine be* senderen Scblflsso. Nach der Geseblecbtscertcilung kontmen old 4 MSnner 2 Fmuen mit Isingengeurftchscn. FOr die GcscWechtiverteHung der Krcbse der Lnngo nntcr MSnncm und IVmicn iverden son9t ZiMcn von 3--4 :1 angegeben. Die Qoeto der lungenkrebskmnken Asbentnrbeitcr imeh dem Gcschlecht Ist nalilrlieh nnch nbhSngig ron drr Zabl dcr in den Betrieben nrbeitemlen Pmuen und- ?Wnner. In Deut*eWnnd flberwiegen die ersten bei weitem. Bet den l>eidcn obengenonnfen Fmuen PRODUCED BY FORD PRODUCED BY FORD 198 " H. W..\Vedcrt ** * * fa'lt das rclaiiv ntedrigo Stcrbenttcr von 35 birr. 40 Jnhrcn avf. AUr ' Krcbstrfiger lmtV-n cine nusgrprilgfc bis achwerc. Asbcstosc. Nur der Mnnn mit ln Pleurnwrcinom (Nr. 20) wien rinc mMSigc.Asbcsfose U-! nfferdings pcfir fringer, nber ivofif nur gerfnger Slnubexposiifon nnf. Nordinnnn hat schon damuf nufmerksam gcmacht, dnB in alien Fftllrn cine Inngcrc Stnubnrbcit im Spiclc ist. Dns Irifft nnch obiger Tabcil<* (Or alie Krebstruger ohne Avsiinhmc r.n. D'o Expositionswit tiegt 2>nnT bci 7, 2turd bci 10 umi jc Intnl bet 18 bsw. 42 Jnhtcn. Das sfiutbhvie Interndl vor der grcifbnren Krkrnnkutig nn Krebs, rellHrcnd dem tl.n. A.bets!nnbf!rpnt in tier Lit'igr svpiirr irirken .Vimi. irnr versehieden 1? ' _ (V,--12 Jnlnv). Ininl war < nicht ncn.'" Ireknunt (Sr. 30 der Tnbc'V). Dicse Balden xrigen c!nil?n,tg, dnlj >lcr Lungctikrcbs die htttdlgv.tKomplikotion bci der Asbcsfwe ist. wenn man von ngonden Pnetimom'cn nnd Ilcreschwftclic nbatrlit. Sclbst die Tuberkutose, dcren. Hiufigkch ji eonst die dcs Krebses veil ftbertrffft, ntcht bier Mnter dem Lungrn. krebs gnnr. urcscntlich r.uriick. Dnmil ist cin entachoidendcr Bcwvis fOr den cngcrcn Zunimnonhnng ron Asbcstc*e and Lungcnkrcb* erbrncht. ' B ist cretmmlich, dnO die houligen Pror.enfr.nMcn mis dem grOGcrrn Ausgongsinntrrint gcuau wit den von Nordm a nn frOher nngeUlhrtcn Zablen aos cinem kleinercn Beobnehttmgsgut Qbereinstimmen. ' Im Ausland Hegen die dicfbev.flglichen VerMltnisse bis hettte reie Wet: Die grCBten Krfnhningcn besitwn in dieser Fnigo die Englftndcr. Es besteht nnch dem engUschen Schrifttuin, dns xu unObemiehtlich ist. well die Klnr.elfnlle r.imi Tri! mebrfncb verOffentlieht irtmlcn, ohne dnO man sic noeh trennen knnn, leidcr nicht die Mbgllchkeit, die Einr.clbeobnehtungrn gennn vrio oben nufr.wfOiiren. Man tnuB sich bis nnf wcitcrc* tnit den Znhlcn ron (lloync bcgnflgcn, der aut 00 Sektiown von Asbesfosen (naet Bonder) 0 Lungrnkrcbsfftlle (ivohtgcheinlfcli cm* o cltlkOlich ernes P/eomgem'iefw*) gwekort hut. Ft ergibt kh hkrnvf W fine Ltmgcnkrcbshllufigkcit von 12% be! Abestose. ^' Gnnr, ahnlichc Znlilen licgen iws TJSA. vor. Ich habe dort bos der < Literntnr bis 10.19 13 SektionsfaHc gesnmmelt. Dio Zald it mOglichcr. neise nicht ^nt* voilstHnilig. dn mir cinigo Arbeiten nicht r.ngftnglicli wtreu. Untcr dlcscn scr.iritcn Aslrcstosen tmf fch mil 2 Bronchisl- krrb.se, dir oben nrigc/iihrt mmlcn. JJns cnMprftche eJncm Hnndcrl*nlt von mwl l!5%. Bin nmterrr Orgnnkrcbs vnmie dort nicht rc.ifgcfflhrt, ' J'.claliv hA'tftg ist liber die rnennionic n!s To<ism?*cho (4mnt) beiichtd Worden. . Au Frnnkrelch llegcn tnenortigcrn-ei'c t nnserem Thcmn fiber. . Imnpt keine cigcnen r.weckdienliclieii Angnben vor. i Iibensowen'g wvnle in nndcren Lilndern dnr.u etwns ver6(fentlicM. In Itnlien, wo man die Asbrstose schr gut krnnt, ist bishrr kein Lungcnkrebsfnil geehen wenten (Vfglfnni u, o.)., Ober den Lnngonkrebs be! Asbestos*. 199 Jn der AVelttiteratur (Ibcrsehen wir also bishcr 14 moltgnc Lungen.. t:i|(|;nfeHgewfteli9e epithelialer Herknnft, die anf 02 Sektionen entfallcn. t*a.< sind ntnd 10% Krcbsfalte be! sesierten Asbesfosen. . ' Von dicscn 14 find tnnftchst nur 11 soweit In Einselbeiien beschrieben I wwrter*. dnO bus ihnen noch meitere statistwclte Ergebnisse gcirormrn i wcnlen kOnnen (s. Tnbellc 2). ! | Tsbelle 2. ;* 1 .Utcr. V. esn. Jnhv Frrte* Irr*rfs mft J*br* 1 Stail(nm ifpr . j Art l(" ! I 1- Mcen .A nine I 1 98 ' j0 i--ir verbornte* techier kelnc Oforn Plsttcn- Ober- epHliel-Ca. fsppen 1. * 4 \71J.. 2 r 1.0 10 n verhemtta reehter keine | CMorne Pfatten- Pnter- efltbef-Ca. fnppcn ;) j- <j 2t m. Ptatten- reehter epiUie!-Ca. Untcr- tappen keine Lvneb und' ! 'Smith 1 :*t i.. d i i 1 IS m aeinOse* linker - aos. Egbert und Ca. Unter- rfcdcbnte Oelger lappen Stetasta- aiming 24 MJ., 7 1 i 1 sod., d ; i i1 t t [wj.. d 1. . i |WJ- d !i ? ; <0? I 7 10 . 18 10 ph 1* . ii 2m . in T m" verliemtes linker Pfatten. Unter- epitbei-C*. lappen verbomtea linker Platten- Untcr. epilhei-Ca. lappen f reehter Mittellappen Lc'ier. j. Nordmann Nicre '. |ao- Nordmann. gedehnto jKlelner Krolie, Mcta*ta- 'atich Im rerh- sicrwng I ten Unter. | lappen J" Boltnf/IVfMl. hr verliemtes reehter Waltcn. Untcr. rjritbrl-Cn. lap]>cn pwodo- rechte tilrro^flrr* l'lcnra Mrw- keine Tcrl. totrrtim Wedlor. blntbaeh Teulaeh. Inrnder i" 00 J.. d 42 V, M oo d., d 21 f i--ir adenoma- tOsrs Pieora-Ca. Ilnkc Pleura abs. . gedehnie Mcln*ta. aierung jentdlffe- linker renekrtes i Unfer-1 Ca: | fappen | f 1 Aiwena. Placber. Waaels Clovno # PRODUCED BY FORD 200 M. IV. U>ncr: Die Verteilnuff twch Jem Gce!deebl mariit nn{ 7 Mnmivr 4 Frauen mt. Dna .Alter Jiegt rwiseben 3.0--7| Jabren. 4 airbed Javo" nllein in dem rrlnfiv iugendfiehen Alter von 3i !>; 4! .JnJirrn. Jrumrr ist dir Zeit voro Arbeit sbrginn bi xur Krebsehtwieklunp rerbSltnismAIJig Inng (rirjscben 12--42 Jnhtvn). Bel kursor Stan),, expositionwil erhirbt sicb gcuOb'dfrh cm JAngcm* etnobfrcics Intern!! tin, avns tn beweisen echcinl. tint? !;o Stmibeimvfrkung--wean flbtt. Irnupt -- erst wlir nlbnftldirfi r. finer Krebseulwiekluug {flint. Dir Melirwdd drr brfnllewn Kmnkrn Imtte cine sellwere Asbestos'. . ohne dB sjc in dirser Form nPertliogs oWrgn* cin joiUJte. 1 i Omni Jngen J.imgen. tint! 2nd I'leuragcvAelise vor. Die Lungen. krcbsc srlieinrn alfc -- soweit tins uacMTnglteb nocb sicbcr r.u entscheidm ist--vom Bronrbfolejnthcl ausgegnngcn r.n sein. Kino fflr cincn Alveolar, krebs typisebo Bcolmehtung limlot sicb niebt dnruntcr-. Dem bito!ogi*r)ie Cbnmktcr n.nrb Oberwiegen die vvrhomcndcn < Flotlencpithrlkrcbse. Von 8 Itist/dogiscb nalier beiseichncten Imogen,} krebsen smren 5 verbomendo Plnttcncpitbelkiebse; ein' weilcrer Flatten, } epithelkrcbs war niebt verhornt. Ein nndcrer Krebs gehSrto dor Groppe t $ dor undiffemmderten GewAebse nn nnd dan Ictete n-uchs acinSs. I Die 3 Ptenmgenflchsc warden nts ..pseudonlvcolArcs Mcsotbcliom", i nls ndrnomnliiscs Plcnmrnrcinom" nnd nls ,,s<pmnioua enreinomn" \ \ brwbricbcn, 4 der Lengengew&cbse im engrren Some batten kelno Mctastnscn gesetrt. f Die Lokalisation der primiren Lungenkrebse f5!!t allein 7mal av( die 4 0 ! oo Unferlnppen, wo die Asbcstose linmer am stArksten entwiekelt bt. 4m1 *itrt (Inn Gtvhchn im Imken, 3mn! im reeMrn Untwlappen, Deni. w ' gegonflber sind der reebte Mittal- nnd Obrrlappcn nt*r Jo Irrtnl mil riner Ocschmibt vertreten. . . Dicee Crtliebe tJbcreinsUinirmng der GescWidstlokalisation mil den ' stArksten asbcstotischen Gevebsrcrtlndeningcn in den TJntergeachossen der Lunge ist- aufflUIig, Dio r.nhlcmmOige IlAnfung des Lungcnbrebses beleer.ierten Asbestosr- trfigem ist der rrste cndewrbtende Bcwcis fflr eine- nRhero tirsfleh- Hebe Vcrknflpftmg tliescr beiden Kmnkbci'tcn. Der Fror.entants von 10% Lungen- und Flcurnkrcbsen iicgt writ flber der sonst stnltstfscb iu crwnrtenden HAnfigkeit bei anderen Scktionen. IVenn die Lungen- IcrebshAufigkcit nuch in den letrten Jnbrr.ehntcn sieher erheblieb * | genommen hnt. so mnrbt sio rrnch grofim Stat-istiken bei Sektionen Im . Durchschnitt doeh niebt mriu als 2--0% nus. AVcnn {Or dio Asbcstose die obsoluten /5aMcn -- sric wir r.eigen konnten --soeb nocb rcchtklein i Dlnr den Ltnigeukrcb* W Al^sto*e. 20t dud, so wirken sic dock dminreb nbcrreugeml, dnfl sio mi gmtr. vrr- -cliiedeneii Ortcn. mil nngrfnbr gleiebmiVIiiger HAuFigkeit gehmden iriio'rn (DcutecblnmL Bnglnnd, VSA.}. Diesen rein mMernnafligen VerhJltnisscn inasen rich niin nus obigm AWeittingennocb weilere positive Gesiclitspunkte antQgen, uf die Nordmitnn ntierdinge en kloincren JJaidcn r.um Toil rchon hingewiesen Jwt. tVirnenncn bier sunSchstdaa Lebensfl)ter dor KrebsWgcr. Ailerrt I roll ibticn bcfnnden sicb noch Jn dem reJntir jugendliebon Aitrr on 33--41 Jnbrcn. tVenn nuch der Lnngenkrebs sclion bei JiigcmJficbrn wkonnnt, so Jiegt seine grSAto IWub'gkeft onst doeh emt rwisehrn dem A--00. Lrbrnsjnhr. Die"er 8tfc geftOren iintcr unserent Matemt i Kmnke nn. ' , Die Verteiiung rvach dem Gcsebiecbt ist gegen dio wwtigen /blifenverbattnisse birr xuungonsten. der Fmuen verseboben. Unter II Fallen treffen wir 4 Fruuert nn. Fur den Lvngonkreba geben die rroflen Statbtiken nonst cine Verteiiung der Geseblcchter von 3--4 :1 r.wiscbcn Mftnnvm nnd Frauen an. 'ImrocrMn winl man im Auge bebalten mflssen, dnB bceomlem in DeutscWmifl tmd England im Gegensn.tr r.u USA. in dn Asbestfabriken die Frauen als Arbeitnehmer taldrnniABig die Jlftnricr Obcrtreflen. . Sebr bcacbtlieb erscbclnt die bAufige I'bcrelnatimmung .des SitJ!CilcTOcchmltm>tden nchwemtcn Verilndenmgcn der Asbentoso in den Untcigtc?iowcn <!er Lnnge, wfe wir cs oben niisfflhrten. Weiter ist der Mstologlsche Charnkter der Lungengesdlrbsp nnffSllig. Dm mcist verhomendo Plattcnepithelcnrcmom stebt toblcn- m&dig gan* ira Vordergrund. Wir tAbltcn unter 8 nAher bereiebnetm BroncbialJuebsen allcin 0 aolcbe. Dm bei den Longoakrcbsen gorvt iibliebe ZnMenverhAltnis unter den e$rminen Getrichsformon lat hltr guns eugunsten dcs Plattenepltbclkrebses durrhbtecbon unit einsritig remeboben. IVenn rnan dio Lungcnferebse histotogisdb in die 3 groCen Gmppen der undifferensierten Kclfcn, der Pfottdn- end Zylinderepftfiel- torcinwno eintciit, eo stellen die eisleten in den grdUen Stntistiken da* Knuptkontingcnt mlt nmd % niler FAlle. Da dio Plattenepilbelkrcbse an wonigsten eu Metnotasiening neigen, mag es verstSndlieli ercbeinen, tlafJ bei den obigen Bcobachtungen in 4 FSJfcn keino Metastoaen gesehen mirdcn. Geradc dfo Wstologischc Bcocbnffenhelt der Lungenkrrbso mil dem eindoutigen Ubcrwfegon do* PlatlenepitbcJkrebscs spriebt /Ar scino r/bstfindige Stelliing unter deri Lnngenkrebsrn. ' Der Krebs vrurdn immer erst nacli einer relntiv Inngon Einwfrkungsseit des Staubcs gesehen, Sel es, dnO die Arbeitsreft im Asbeat* staub aobr lnnge war, oder daO sicb bef kurr.cr Arbcitsreit mit gewdlinHch bctrfichtlieher Exposition cln Iftngercs Interval! einsehob, in dem dvr Stanbsclmdeit rich weiter nusn-lrken konnle. Eine Rcibe cinunmUrcier PRODUCED BY FORD 202 H. W. Wrr; BeobarMn":!*'n. die rum Tcil vom Verr. selbst genmcbt wrrden konntrn, Mrrt on*. deR lw*i drr Asbestose der Stnobsrhnden *ieh ort rrst in dicscm Intern I) viustcfJt und r.it pfnrr ntnehmenden Fibrose ffilirt. Uiiter alien Lnngenkrebstallcii l*ei Asbrstose findet sich nirlit ein eiiixigrr. bei drm nieht diese lunge Kbiwirkiingswit- de Asbestslnnbe* gegebru ware. Kicim bosteht- cine whr gnte {.'brrcinstimmnng mit den iirfn'i.- nwgen bei nndcrr'i Bervfafcrrbscn. Die soostigen histologfschen Befunde in der A*bo*l!nge eroioglirhcn un* ein weiteres VcrstAndnis fOr die oblgcn Zvmmmi'n. hAnge. Mnn trifft in den Asbcststniibiungen nn den kleineren Bronehien moist ausgedcbnte EpillieimcVipInsirn, die sis prneanerrtise Slndien angesproeben werden kwnncii. irOcfislwntiischrinlicb geben an* Omen fm wesrnttiehen die enrrinomatosen Ncnbifdnngen hrrror'. Nordniann hat in einem Fnile sugar die Beobnchtung gemneht, datJ bei einem groBcn Oireineni des iinken Unterlnppons anf der nmVrrn Suite ein eben br. ginnender Weiner Kicb* vorknm, der nieht nl* Mctnntnse, sondem 1* ein nu* dein metaplnstischen Bronehiatrpithc! autochthon entstnndcnrr Kreb* angesprochen werdrn mntJte. Er hfilt deswegrn'die niuKilecwInrr Krebscntetclmng bei der Asbestosc filr besondet* bcxcichncnd. Hirr linden wir Paf-aFelen iti dent J?chnecbcrgcr Lungcnkrcbs. Es hnt den Anschrin, ids ob neben diesen Metaplasien auch die sonstigen histologisehcn Verftndcrengcn in der Lunge bei der Krcbsent.atchnng mitsprechen. Ihnen alien Ist in nr*ter Linie die stark gr- steigerte Wachstumstendcns der Gewtbe eigen. Hier siml wi nennen die reicWiebcn EpithrldcsquAnmUonen mit Formvcrilndeningen der Deckzellcn, die Bildung von whlrc'rbcn Makropbngen end FVrmdJtorpctnrsfiwllril sowic die Bindegewebswuchenmg, Dabci rerfen, womuf Linnbach Benig nnhm, die elnwlnen Gcwebc atm Ihren nor. nrnleii Ber.irtinngen grlCet. ohm- daO indr* der Gewelisschadcn so erbrb. lich ist, dal) Zeilontcrgang cmtrilt. In dimer gestcigcrten Wachslum*. tendenr. uikI Stoning tier nonnnfen geireblieiien Berfrimngrn siml HiTfn- krRfte filr die Ktcbscntsfchtmg webl mit groOer Wsbrschclnllehkeit tn lichen. Anch fflr die I'lciimgcwSeii*" gelten diese Gcsichtspunkte. Dns Lnngeiifell ist in die Umbrntprozcssc cinber.cgen. .Mnn findet dort Epitheldc*qiintnntionen. Fibrinmiflagening. Bindcgcwcbscntivicklung. Wr. cbirichtng timl Einliig'-ning von AsbcstkrystoIIcn nmf Anbi-etkOrpercben (CJIoyne n.n.J. Aite dime nnfgofOhr'en Oe*lrlil*punkte fttgen trh den Emdchtcn, die mis den stniistischen ZnWen enmclwn. got ein end Widen stntr.emh- Animientc fOr den inm-ren Z<'*.vnmentmng r.irlsrheii Abe*to*e nnd Lnpgenkrchs. Nrben tW erbobtrn JIn'r nn Krrbs'.rRgem bei Asbmtose mu 13 nis wit-trr flberr.eucv'id. r IVurisdb- ticrrsp'-rimentrlfc P.eprodur.irr- 8003 1501 Ober den LengontsrebB bef A^bestrsr. 205 bsrkeit dieser Verh5!tnise gcfonlert tverden. Dieser Punkt knnn for die Afbeslose bisher nncli nieht nl* gesichert nngeoei'en n-en'rn. I,`n Vfgl <tber nirii! nn negntir nnsgefnlirnen Yenwcben, wondern einfnrlt inran, dnO dime F'ntge in gtvHerem Umfonge noeli nieht in Angriff ernommen irordrn )*t. Die ewten Vcr*uehe hnben Nordnmnn uml Serge mit einem frappnnt ersebeinenden ObereinstiiiinHingsergebiiis imtpmommen. Wir kamen bereit* oben dnrnof ru spreeben. Mnn nird nHerding* ror*iehtfgcrweie iveitere Be*ti%tigringen uml Anerkenmmg diescr kompliiicrten .Verhnltnisse dnrcfi uritcre Sncftkroner nbn-nrtm mflsjen. Je'lenfaU* npreeben affe brsher beknnnt geivordenen Tntnnefien doth nil yreSer Wabreeheinliciikcit dnfdr. dnO die Jiordmnnnscfie Ansicbt filter den Benifskreb* der A*be.qtnrbeitrr irereehtlgt ist. Attch die no* deren Autoren trie Uloyne, Lynch nnd Smith. Egbert uml Geiger ,*otre Linxbnch zelgen die Tendenx, hier engere vrriichUchc JJezieiwn- grn ea Termuten. Der Vermich einer Widerlegung dieser Amwhme ist b'shcr Ton keiner Seite untemommen irorden. '' IVcnn wir tins nun die Fmgc Torfegen, worm die caneerogrne Wir. king dcs Anbeststanbe* nn stichen ist, so mflssen wir nligemeine und Grtliehe disjtonierende Faktoren trennen. DnB .snm Zastandekommen rinc* Krebses eine nligemeine Krebsdisposition" (Vcranlngung) vormisf.ti*et*en ist, wird alferorts angenommen. Worin sie r.u snehen ist, faOt deb sebwer sagen. Es ft aus der allgemcinen mensebfichen utid expert, mentellcn Pntbologie beknnnt, dalJ die Bercitschaft r.u Krebs von an-. ` MgemVIigen Fnktoren nbhSngig ist. Da* drflekt sieii dnrin mis, dnO enter gloichcn Exfieriincntbedingnngen und cmigcnnnfJen gleiehmAOieer Exposition fQr carcerogene Schaflen beim Menschen die Quote Krebs- , kmnker immer nur cincn Teil der GcfShrdeten nnnmoebt. Dns nils ffir die Asbestose vorliegendc BeoWlittingsmatertnl J4fJt eine Analyse psch fnmilisrer Krebsbeitvstang nieht nusreichend in. Wcweit und in weieher Weise der Asireststnubselmden eine *o!ebe sllgemcine Krebsdisposition eehaftt, wissen Vlr nieht. Ibre Annolime blcibt eine Ilypothesc. Dabei schrint es nieht o tit sein, dn!J sieii diese Mfgrmeine Disposition so stark auswirkt,. <IaO sie etiva nucii dir Unt. rtchiing von Krebsen nn nnderen Oignnen begunstigte. Dnfur spreeben die vorgeiegten ZnWen gar nieht. Von entseficidender - Wirbfigkrit vbeint immer vor ni/ein die brt/iehe Umstmummg r.u sein., Ihren inorphoiogischcn Ausdmck in den nbgcSnderteii Gewebstenktloncn der i.ongc hnben wir oben nSher nufgeftihrt. Ah deren Umache konnnen in ernter Linie cbemisehe und mechnnische Fektoren in Betrnrht. Dn 'hr Asbest chemisch emfwcli definirrt ist. Jirgen tlie VrrliRItni.ise hier Mdiieh Obemicbtlieh. Man knnn wohl von vornl>erein *ngen, dnO S'toffe rus der Gruppe der brkennfrn enneerogenen Agenlleii nieht in 204 H. tV. Wetter: Cbrr den bungrnktel'S bei Asbestosc. 205 J'ntge kommen. Die Eimvfrkttng dcs Asbcstslnttbcs ntif die I/jjipe votf. V-tnig, ?ont efstreekte vie sicli.nnf 7 Jnbre end mebr. Bei ktirrer rich! Rich tvnbrscltcinlidi fiber chrtnischc nnd mechnnischc Scbndcn. inlrnsiver BestAobung scheint denttocb stir Krebsentstebung immer rin Dm cltctmsrhe Wirknng Rvehcn rrir in <Icr Kicsclsfiiirv. die sich nm J i.'nigrres ntnubfm'es Intervnil hinikommcn r.tt ntwssen. Ks gibt btslter fotel'Icr nnnrrifbnrrn .SerjientinnsbeRt hrmtislcscn dfirfte. ])nC !p Hit,, kciiien KmnklieilpfnII, bei item dcr Jlcitraom vom Beginn der Stnub- cnnccrejr.mr Wirknng ist nnch doit Erfnbrtmgon der mensrb. nrljcit bis ram Jfachireisbnnrerden dc* Krebses senigrr p!s 12 dnbre lichen PnUiologic nnd rcichliehcn Ticrcspcrimcnten gnnz unwohrscbrin. V'tfngen hilte. Man vrird sreiter gcsrohnlieh ersmrtrn diirfen, dnO drr Belt nml pnthttsrh nnsidchcml wMerlegt. Dnll nllcnJings in den (lurch nip Kn-bs mtr bei augesproebcnen, wonn nuch niebt immer scbn-erstr'i gesclztcn, fQr die Asbestosc drilich ondem ntigcordneten vnd nutr. I'onncn der Asbestosc nuftritt. Die obigen Be'spiclc beiegen die*. prfigten GewrbsvcrAndeningen nndcre VerbAll-nisse *1 bei dcr Silirosr Die ersten Symptome cines ich entwickelnden Lnngenkrcbse", die gegeben sind, mnO im Attge bchsltcn nerden. Dicsc nntlcrsnrtige Am. .in sich ;n schon moist niebts Chnmkteristisches oder gar Fothegnomo. ordmwj; mid Form dcr Gevebsncnbihlung knmi jmmerbin nrvlrrc b;o. nise'ies bieten, nerden niebt so at'ffJHig sein trio bei einem vorher logtscbc Renktionswriseil dc Ocwcbes nuIOscn. Dnrftber hinnns wird c-s'jtiden Menscheti. trril K'Jrentmigke't, Huston. Ausmirf nnd getris.se m.in nber gemde dir utcchenisebcn Rfichwirkungcn dcr viclcn ppi'jm MiCeinpfindungcn im Brutnwm dem Asbestosekrnnkcn nowicRO ge- Asbcslnndctn uml KOrperchcn, dfe w-nhrc.lieinitch besonders dem Horn- Innfige Bcsehwiden sind. Auch cin gewisser VerfnTI der nllgcmetnen blendcnsbest- mit Reiner s'nircn. sebwcrloslicben Besclwffcnbcit eigen KnVtc, der einen Lungenkrsbs sognr.artfangs gnr niebt ru begieiten .*ind, benchten mfissrn. Ilmen konuiit- wohl !chcr fflr die cigcnartipe bmtiebt, Getriebtsabnnhmc and Ajipetitloslgkeit sind bet den sebweren Oewebsrcklion dnrfh die slAndigo ntrchnnischc Iiriticrong cmc grate Komten der Asbestosc rrcht ItAitfigc Etselieimtngen. Attcli nkute Vrr- Bctieiitnng r.u. s-bhvbtcnmgenim AHgemefnr.untnml,einse!t)icBlicbder6rtlichenLungrn. SchliclJlich sri nocb (Inrun erinnert, dnfj besonders an den Brondticn Is-srbwertlen, kommen oft nls Atisdruek nufgcprropfter Infekte, d'e bei drr Kcbivcrcren Asbestosc sich cntifindlicho Rcaktfonen, mm Toil si-Iitrercr Oberwundcn tverden, vor. I.tn gnneen wird mon e sieit fflr die mit Bronchieklnsrnbildungen, nbspicler, die ibrcrscit* gelcgcntlich cinvr Vorgcscbirhtc der reinen Asbestosc nber doch mr Kegel ntccltcn mflssen, Krebsentslchung Voiscbub tcisten kArmen. ' ilitd der KrnnkbeitspnmeB cin mtr gsns nltmAblicbc fiber Jnhre. jn In diesen nllgemeincn nnd vor nllcm OrtJichen Gegebenbeiten werdm .Inbirebnle sicb binciehende VcmchieeJitening erfilJirt. Wcnn in diesrr wir ffir die Asbestosc bei nnscren heutigen Kennlnissen die ErkJAnmj: Knttvicklttng plotzlicli Einbrflehe siehtlicher drtlieber and ollgemeiner Mr die Krrbsrntstolnme nrhen mflsrn. Vide dcr Schildcn kommen Wrsrhteebteningen vorkontmen. wird nntcr itndercm der Gednnke ntt Hirer Definition nnch nield. ttbrr den Bcgriff der chronischen Rciswirkitng inp Krebscntvrickinng nuftnttchen mil*scn. Jfebon dem Krcbs-kommcn hinnns. BnB wir !nmit nocii writ von einem volien VcrstAndni* drr sonst bicrfOr am h&tifigsten unnpcsifische Infekte mit Bronciiitis, Pneu CO o o w feinerm Bcmcbnngcn enffernt sind, Jmt dieses Problem bei dcr Asbestosc mit dem der Krrbscntstchting fiberhnupt gemcinwm. tVenden vvir tins mm noeh der klinlschen DbignosentcHong drs monic oder AbsceO in Frage. Die komplirirrende Tobcrktdose spiclt. imeh nnseren Erfnhrungen nor cine dntergeordneto Kolle. Sic wird dnbet viol r.n bAufig dingnostisiert. DnC sie nntflrlich ln\ Bereieh dcs MAgliebrn Is-gt. 1st seibstverstAndtich. _ Ub?r beglcitcnde Lttngenlucs oder Pilz- Wol Krebses in tier Abcslsfiitibhnigc r.n: Gmndsfttr.tich vvrrden iiier nlbr tlingnosliseben Bnt'Sgttngen An- rkmnkttngen 1st bisher niebts brknnnt gntvorden. Von den AUgeinrlnsymptomcn It- sehncller Gcwlchtsverltist benebt. N wcMdnng nml GilJtiRkrit findwi nitWnrn, lereit "ir iin nuch oust bei lirb, nber niebt betveisend. Dns gleiehe gilt -- ilc gesngt -- von der dcr Krcbserkertnimg drr I/tmge vnd Pleum bedienen. Dn sieb der Krebs Apix'tiHosigkeit, schlecbter' Gesichtsfnrbe tmd NaehtnchweiBcn. Be- nber hier nnf cine Gmndkmnkbeil ntifpfropf*. tvertlrn tvfr mit bcstimmlen mben diese ollcin nuf dcr Zumtlinie der Asbestosc, so trerden sie getrChn. BigcnMinlichkeiten drs'Ktitnkbeilsbildcs rrrhncn tmd bestimmte Vor. licit nuch von einer verstsrkten Atenmot, Cyanoso. evtf. Trommel. kenntnisse nns der .Syiiij>tonm*oleg5e tier Asbestosc initbringcn nttbscn. scblegrlfingem ml sonstigen ortliehen Lttngenbeclitenlctt Ijecleitct F'ir tlie Vorgrsrbichf.c tvirtl es rtniSelist wieht'g rein, cine genm.iv vin. nber nnttlriieh vrird mnn sich vor Arigcu halten mflssrn, dnU ein Bcrtifsnnnmnese niifr-'Mif.linteii tmd die Kifn*>rting r.ti bcrileksicbtigen, f.tingrnlumor die Zttnabme soldier Besebtrcrtlen nttcb bedingen k.-tmi. tlnB Lnngi'iiktfbtc liri AsbMttosc sich erst nnch jnlirelnngcr S'.ioib- Im gnmscn wird sich die Situation nos dcr Yergesrbicbtr nllrin niclit 'xpo'i'.io't einr.n.t'.clir" )>fb'i*it, tvel*! dir JJnner der Gcf&lirdting r.'nn nusreiebcnd klaren lessen. Teil dtin h ihre In*eii*i'At nnfK'-vt-oBeii tvenlen kn.ttn. tVir kennen bivhrr Niebt vie! nndem ist.es mit den meiten drtl'eben Besrbttrnle'i itnr eiite inr.igc Ileolmnliitinu, tvo die ,\' '"ii sr.cil im S'nub nnr V/t Jnhre bvtrllt. Dn die scbtrercre Asbestosc ineist erlieblieben Kr'r.btisten setr.i. PRODUCED BY FORD r' i i i t l I i 4 1i 4 I CO o o w {w o iu I 2? If. W. WVIer: 1st mit d"*spp> Kruiithif.sr.ciehcn nicht Wei nnwifnngen. JXi gleiehp gilt ftlr dip Ateninot, Btwns wipbtiger sehpint mir dir Bcachtung dps Answurfrs r.u ?in. Jvr ist bei der unkomptir.ierton Asbcstose mpi* sj'ilrlieh und r.5b .sphlpimig, bei groberpr Bronchitis nnd Bronch ipklnspn obcr nveh Toiebliphev und eilrig. Him i*t nur AyBcml sclten Bint bei. grmcngt. IfStifigcrp nupb sparlirbe Bhitcntfrrnmgen bedfirfen enter tsesonOprrn Krkblmng, leb selbst babe Bint im Auswurf in Gestalt dps Himbeergelppsputuins nnr bpi pincm kowplir.tprrmlcn Lnngcn'umor . Ecschen. Ini Srbrifttnm sind nur otnjirtnp sjsVlichp Angnbrn tfipscr Art nurh fflr die cinfiiehe Asbestos? vorlmmlcn. Tumorxcilen im Ausivurf diirftcn nnr spbr seltcn spin. Horn!* will in mcn Fnjlp too Tumor ts'i Asbcstose rciehJich Kpitbpliwllpn im Sputum gpsphen hobpn. VVpnn Zerfnll dr* 'Lungpngpwebps einsetrt, wird sich dips unchver an der Andening dps Ausrvnrfps erkenuen Inescn. Bpi mpinpr Beoboehtung vmr dips sclir pindrurksroll. Drr Kinnke nrf plOWich groSe Mengen kdmfg cebnliter nckrolischcr Mnespn nns. VielirirM gclrngt r' dnbeioucb einmnl d.w Symptom dpr ..nsbeMosie bodies in plumps" der Englander r.u linden. hanriclt sirli dnbri m rmrltenformigc Hnufcn ron AsbcstVdrperpbcn, die inimrr dunn fm Auswnrf mdtretcii Jconnen, wenn Lungcrgewpbe xcr. fafit (AbseeB, Tuberkt'!oc, Tmnor). Sip sind den ctnstischcn Fnsem fin Ausmirf dingnostisch gleichwertig. t?ber dip Bedcutang der Atrmnot warde obpn srlion gpsproelicn. Sk> wird erst bei grtWercr AuSdchnang dps Tumor* odrr Broncbialversrhhil) new. mtf Jhn idlcin r.n bmieben scin. jMgPKPU splirint mir dm Srhmrrr.rn in der Bnst cine grSBcro Bcdcutung xnMikommp.n. Kip sind led drr Asbcstose "Hem grwOhnlieb mtcrfipblich nnd unbest burnt. Bci .uosprem Tnmorfnil tmtpn sip mit Forlnebrciten der Gpscbwulst ennr. in dpn Venlprgnfnd; sie nnhmcn pinpn typiseben ncnmrgifomipn C'hnmkfcr an. Im Scbritttxwx Unden tick ibnlhtc Wn. nrisr. Die Ursnpbp Iiierftlr 1st wplit In einpm t)bprgteiipn dcs Gewicbsps nn{ die pnrietnip Plentn nnd ptU. die Intpreostalnerren -- wenn niebt gnr nu( Jlp.tsstnspn -- zurtlckwifQhrrn. Dipsp fliimpiso aid db eJIgpntelncn nnd Orllbficn Bpsphwenlpn, dip grOOtpntpils dip Vergpsrliiplitr nn dip Hnm! gibt, megen genOgpn. FOrdpn sonstigpn objektirpn Brfnnd mng folgp'ulpn bemerkt werden: Die Asbcstosp bpfftHt d'e Lunge bpiderscits. Slreng efnspitige Pnw.essp, uni die cs siph beini Tm'ior mpist hnmlplt, kemmen niebt vor. Gcwbhn. lich fiprrspbt nurh pine npifgpbpndc 5rnmcfr/e der VprSndror)grn vor. Mnn fnnl) nber nisspn, dnO dip rppbtc Lnugcnspite von der Fibrose uitch imnnnlpnvpisr slilrfcpr bptroffpn spin knnn. Ulfpr den Obprgccho9pn <Irr Lunge fimlpn wir nip grbbcrp IMmp^iingpn. Dns AtcmgprSnsch ist bipr mpist mull, nnr spltm nbpspliuarbt. I)ip nbbnegigcn Lungen. iv>rfipn bietpn mpist pin** nmBigp b mittp/stnrlcp Scballnbfchn-ndnmg, dir, svrnn nirb nirbt gp.nr. symrurtriscb, sn dopb Inst imincr doppelspitig Ctwr den Cunemkrebs be! Ashcs'-ese.' 207 is*. Nnr grobpre Schirnrten odpr eper.ifisehe end ynsppzifischp Komp'l. Jtn'.ionpn konnpn Aesnnlimen bedingpn. 17ns Atemgpr5u*cb pflpgt unten srbwfteher als ebon i sein. Scltpn ist es nmgckebrt. NpbcngprSnsrbp sind untpn r.nMrpipbpr wnd b&uIigPT nls oben; Seitpnunterscbiwip bemjern nirbt vipl. Fnulel mnn einscit-ig pindpulige Zpicbpti pincr Atricktnsp, so ist dips jm bOchften Grade sol Tamer rvrdilcMig. J)aB dipso* Xinnptmn beini Lungentomor nbpr nipbt eblignt tu spin bmuebt, Ist jn elbst vpfstandlich. ErgOnsc, besomJcrs eolrlip h&morrlmgischpr Art, Voinmcn bei der gcsvObnlichen A/bes>tose pmktisch niebt vor. Einschmcitungs. r.eicbpn kann der Tumor mit dem Absppl) und der Tuberjuilose gcmeinsniu bnben. Bronebiektnsipn in Gcstnlt von eyfindriseben Luftrobrenerweit^. rungpn sind bei chwerpr Asbcstesp niebt eplten. Sie mpulpn gelpgpnttich bei der Winisehcn Untersncbung in ihrer Abgrpnrjng gegen Einsehmclwmgen Seh'vierigkpiten mnclipn kdnnen. , GrSbcre Asymmetricn den Brantkorbesv V'prr-ich'jngen der Jlittclfpllergnue imd ZwprpJifelle bedOrfcn immpr pincr gesonderten ErkUnmg. Der P.bntgpnbpfond dOHte stets dip wiebtigste Untcrsucbangs. fnetbode sur Brkcnnang ciner Geschwaht sein. 17abe* muB mnn bonebten. dnS die scbwpre Aebcstose niebt immer -- wie mnn nch dem SchrifUmn glnuben kdnnte -- nur *u feinen symmetneeben VcrJicIitnngpn drs Lnngcngesrpbes fohrt. .Neben gewisspn Asymmptripn kommen nueb flipbenSnltc Trftbungen amRchriebener Art in den Untcrfeidem, besemtprs medial vor. Diese diebteren Sehntten sind nber doch gpwdbnlieb nipbt so kompokt und tumornrtig. sondem mchr atreffig gcicielmct und unspltnrf nbgcctr.t. Jlnrte odpr toinpgmpbiscbp Aufnnhmpn wpnfpn ibis Bronclimlsystem offen, evil, sugar cnvcitcrl erkennen lasspn. Dmrb Knttttndungen bedingte Bronphasstcnasen sind bisher bei dpr Asbcstosc niebt befennnt geworden, Kempakte, einseitigp, omsebtirbene Vprsphnttongen in der Lunge, womoglieb mit BronchorrerscMuO, sind prnktbth I0r einen Tumor beweisend. JTshln gehdren aoch stimlige oiler mit dpr Atmang wpehselnde Vprncbicbungen drs Medinstinums und Ldbmangen dm Zwercbfeils, dcs Reeonrns oder bei Obcrlnjfpcnprospsspn incist ouch em Hornorspher Symptomenkomplex. Umscbricbcnc Vprdkhtungen in den Obergeschosscn eignen niemnls der Asbrstose. Hipr Jipgen die VerbAftnisse Wei klnnr and cinfaeher nfs be! der Sifieosp. Grobc Sebattpnbildungen entstehen spnst bei der Asbestwe Vomphmlipb ibtrch unspctifische EntsQndungen. Die Tabcrkulose ist Mngjt nirbt so baufig vie gemeinbirt nngcnommen ivird. 1hr erstes Au/tretcn In dpn Vntcrfeldcm ist nach den bisherigen Beobacbtungcn bei Asbmtosp pbr setten. Dof) fm Rabmen der tlbfichen diagnostisphen Ypr-prtb*ir. kpitdie Tome- and Bronehogmpbic fOr dip Tymorerkcnrung in der I/ingu von entselicidcndem Wert spin kann and dnl) IQr sip dip Oblicbcn Begfin drr Doatyng getten, sei der Voltstonitigkpit balbrr nngrltibrt. AbnVu-b PRODUCED BY FORD PRODUCED BY FORD I 4 < . 1 { 1 t oo o ) o w Ul CJ 20.3 If. W. UWtpr: . vrrfifilt cx *Hi mit- dcr Bronchoxkopic. Cbcr dingnoxtvirlie J.mttv-n. pnitkltuni >\ K-Mrhrn Jcrim* I'Mnlirungcn nuOer cinigen VenmcVn, 1*. I drnen Ader!kijrprn-Keit im Duigensnlt gcfundrn vunirn. Bet pritniiv'i Pleumlumoren odcr j'trtnxlnsrn vrnung dcr TmoT7.cllnnchwrM ii Funktnt die Situation PcMngnrtig r.u erhelfcn. Die* vmr der f'nfl Im A1wcii Beobnrhtung. Metnxtnscn warden die Dingnoe imnicr xchncH lJtn I.vmch. DnO iHngrr bcdcltende Tuniorcn Fiebrr bedingcn kOnncn, it fur d. Dingnore imwexentiicb, dn Infrkte die glrichc J'olgen Imbrn kbrnn-n. Z'im Btntbild nnd r.itr Seukungxl>roelilr!intcvng dcr rotcn Wm. kCrprrchen *ri brmerkl. dnD AnSmien nicht r.tir A'bexloxe griiyrr": rlirr kmnnirn xehon cinmnl hohe Fnrlixtoff- und Zellwortc nix Komjnn. mtioiwerxrliciniiHg vor. JJrgicilendp lnfekte dfirften Au'nalniH.'ti vcr. nntiuwtn kunncn. Ziineimicnde AnSmien siml enter AmscMuB andtrrr vielfSIiiger Uranchen tumorrerdSchtig. Vom DiftcrcntinibiulbiM ixf. eix dingnwtixchrr Anhalt ff\r Tumor niclit r.n crwnrtrn. Die Blutscnkunr hfc be! unkomplirfcrtcf AxbrMoxc nn sich niclit bcscMeunigt.- Denno-A lindct rann xie bei Sericnuntcrxuchongen on snblreichen Axbcxto*-. krnnkrn vcrlinltnismSOig eft in bexchcidencm Gmde erhSht. wniir. xcheinlicli writ Infrkte im JJronchlnlbmvn dobci hfiufiger vorhnnden *W. StArkerc nml mmchinr.nde Srnkungxbcechlcunigung let immer mi be- nr)iten nnd nnch den Ublichcn klirdschen Regain r.w verwrrtcn. * Dnmifc wilren die Winiseli wichligxtcn Gexirhtspunkte inr Erkennitnj rinex Lungcnliimotx bci Axbrxtosc imfgeftlhrt. Die richt-lgc Dcutung bt immer Snche finer gedtegenen klinixrlicn Atlgrmeinxcbnu nml kritixclnn Vcmrbrit ling der Einnclr.rirhcn. Wcht lg iit e..o. in dicxeni Zuxntmnrnhitnp do* Kmnkhritsbihl iler Axbctoxc im nltgcmeincn mi kcimcn nnd nn dir KomnlikntienxiiiOglicltkcit mit Turner r.n denken, dcr bcinahe re lionfir wic die nktiTe Tnberkoloxe in der A*brttunge voraukommen *cbei"I. 3inl doch in l>utrhin.nd .bixiier nwr 10 nktive Tuberkuloren M Axbrstwe grgeniiber 0 Tiimorcn beknnnt geworden. tVrnn dn Krcignix dex Anftretenx Ton Kerbs in dcr Axbrxtstn'ibfuncr ro hAnfig ixl. vie obrn gewigt wurde, nml venn ouch onstige gulr GrQndc (ftr rinrn rngrren tiwacMichrn Zvnnmmenhnng r.visrhrn beidrn I`irkr:\pkun"rn sprrehen, xo wird innn, xrenn nuch die liercx]>criincntelltit (.'ftt'-rl-igcM noeh .nixgrxchnllet verden mrixxen, doch xchen heute doom denkrn irnwn. den gcxrtr.lichcn VcrniclicntngxxriHitR nut dirxc Kemjdiknlion mixr.udchncn. In <Ien vrnigrn bihrr vorgrkommenen K"trel'hdigunExvrri'nliren Imhen dir Urmfxgrnosxrmichoften out Grvnd cmlicitlirli'T Slrllnngnnhinr ilrr brfiagtrn Gutnrhtrr den Ennommcnhonp nncrknnnt. In drn von mir ditrriigrxehrnen dhrxbrr.iigiirltrn Aktrn hat in DrxitxrWnnd kefn Guforhirr rinen oblrhnendcn Stnndpwnkt ringenommrn. Ubor don I.mtgenVrah< W Abe*lom. 200 Eunommeiifnasung. K< ninl fiber die bixher beknnnt gevofrirno uivl erveiterte Kni*lik i.<> bO^utigwi Lungen. nnd PIcvmgevAchxen brl Asbextosc nus dem V.'rliwlirifllum berichtet. Die Grdndr, velchc einen utxSeldiciien Ztt. ..immenhong swjgchen berden Erkmnkongcn nohclegen, verden oufer/rigt. Ihvx kliniodic Bild des Lungentnmow bel Abestoe wird bel.rorhe'i end die AnnJehming dex.Vcrxichenuigenclnitres not dicse Kornj.,ik"lwn tdr ongebroebt geholten. . . Sehrifltom. llnn-ltr. K. W,; Dtvb>m-d. Whr. WS I, <07. _ Kgbert. D. S. ond A. J. rler: Amer. Bar. The. 34. 143 (1038). -- Olovne, 8. R.! Tubercle 14, COT f(TO): 1?. 5 {iroc)t 18. IOC (IP30) _ Hornlg, F.: Z. Krrbefowch. 47. 2! (IW). -- Llnibaeh, A. J. u. H. W. Wedler? Vlrchov* Areh. 307.387 (1041). -- Ijnrb, K.M. *nd \V, A. 8mitb: Amer. ). Ckne..'24, M (1030). -- Nordmann, II.: 5k Krebrforwh. <7, 288 (1038). -- Bcr. 8. biternnt.' Kongr. Unfsllmed. u. Beiilcrkh. Fmnkfort . M.. Bd. 2, 8. 793. Leipilg: Georg Thieme 1930. -- Nord- mttm, M. o. A Sorge: Z. Krobrtorseh. SI, 188 (1041). -- 8pnrki. J. V.: Brit. ). Rmtiol. 11,371 (1038). -r Wedler, H. W.; KRnik der Lungenn*be*tec. Leiprig: *irg Thieme 1030. 1 Die OHginalarbeit leg dem Verfosser nleht or. OcutvXc* AreMr r. kno. Med. Id. IM. , 14 7 Translation H Date crt material: Language: n/d Translated by: L> Carpenti Dele: Forwarded to: 6/17/80 Writer: Addreaeee: I.UNG CANCER IN ASSOCIATION WITH ASBEST0S1S In the last 12-15 years, extensive experience with asbestosis has been presented in the German and foreign literatures so that we have now acquired far-reaching knowledge about the risk for asbestos workers arid the picture of clinical illness of their job-related disease, as well as its course. Still a number of questions remain unanswered relative to its pathogenesis, which should be further explained from a standpoint of animal-experimental and chemical-physical studies. On the other hand, our knowledge of their complications and associated diseases rest on narrower and less certain foundations. In recent times, an extensive contribution to the pattern of lung tuberculosis in this koniosis was made by the author. Informative and important, alike, is the question concerning the relation with lung cancer, which has received a large amount of attention in the last years due to the frequency with which it was found in association with asbestosis. Interest in this is not limited only to the sociological-medical and insurance-related field, but rather it extends further into the field of general medicine, because with this, a new example of an exogeneous cancer formation could be cited. The number of related observations so far is,to be sure, small, but so predominant in relation to the rarity of this disease, that a comprehensive representation seems permitted. It is also desirable because, so far, such a study from a clinical viewpoint is not yet available in literature. First we would like to give a summary of the observations which have become known so far of lung cancer in association with asbestosis in world literature, we will add the new findings and illustrate the . peculiarities of the picture of this disease as well as its clinical diagnosis. We find the first mention of a cancerous tumor in an asbestos dust lung in 1933 by Gloyne, in a study concerning the pathological anatomy and histiology of asbestosis. He speaks there of asbestosis complications, which are connected with it originally (purulent bronchitis, bronchopcnumonia, tuberculosis, emphysema, bronchiectasis) and of accompanying diseases, which, based on the status of the knowledge of the time, supposedly had nothing to do with the influence of the dust. Among the latter, he mentions an observation, which he quickly dismisses with the following: "There has also been one case of squamous carcinoma of the pleura. There is no evidence at the moment that this was in any way related-to the asbestosis." Vi 156-705 6003 1473 PRODUCED BY FORD SCF-FA-1055 2. In 1935, Gloyne published two further contributions of lung cancer in association with asbestosis. He though he still could not prove an etiological link of the two diseases. Still, certain histiological criteria seemed to suggest this to him. The first of these two observations concerned a 35 year old woman, who had been an asbestos spinner for eight years Bnd then lived nine years more without any exposure to the dust. She died -- as the dissection indicated -- of moderate asbestosis, a clot in the right part of the heart, spleen infarct, and meningeal bleeding. At the bBse of the right Upper lung lobe, a clinically unrecognised walnut-sised tumor was discovered, which reached into the top and thickened pleura. Metastases were not present. The callous 6quamous epithelium carcinoma originated from a samll bronchus. ' The second observation with dissection also involved a woman who lived to 71 years. Fifteen years before her death, she had worked one each for 6ix months and then for 13 months in the matress and preparation department of an asbestos factory which was known to be very heavy in dust. Anatomically, Goyne found asbestosis of medium extent with a partly decayed tumor in the right lower lobe of the lung, ascites and thrombosis in the left leg vein. Again, metastases were not present. Histiologically, it was a callous squamous epithelium carcinoma. In both cases, the cancer was not spread widely enough to appear as the only cause of death. The same was ture for the asbestosis. In the same year, (1935), a report came from the U.S.A. by Lynch and Smith concerning lung cancer in association with asbestosis; it was accompanied by a detailed disease history. The 57-ycar-old patient described here, who had been a cotton worker for 22 years and then for 21 years (till he was admitted into the hospital) an asbestos worker, complained for years about short breath. The years before his death, he suffered temporary pains in the back and above the last three right side ribs; these pains flared up again in the last months of his life. He deteriorated, coughed, lo6t his appetite, developed fever, and experienced blood sputum, as well as stress dyspnea. The clinical findings were characteristic of asbestosis. Low on the right above the lung, the breathing noise had weakened. The clinical diagnosis was asbestosis with chronic pneumonia with callous slab low to the right. Pathologically-anatoroically, along with the asbestosis with pleuritis and bronchiectasis on the right side of the right lower lobe, was found, which macroscopically was thought to be a tuberculosis, decay (?). Only the microscope showed a squamous epithelium cancer. There were no metastases present. The description of simultaneous hyaline nodules in the lung is unusual for an asbestosis, the carcinoma started from a bronchus with metaplastic epithelium. The authors attributed the cause to chronic irritation of the bronchi. In regard to a connection between cancer and asbestosis, they spoke of a "possible relationship" and drew comparisons with other occupational lung cancers. 8003 1474 PRODUCED BY FORD 3. In 2936, Egbert and Geiger (U.S.A) reported a further observation of this type, which they considered except for Gloyne's ]933 study -- the absolute first of this type. The 4D-yeai--old-man had been an asbestos weaver for IB years. After nine years of work, he retained cough and shortness of breath after he had had pneumonia. Eight months before the short . hospital treatment, he suffered severe intermittent attacks of back pain. He Dost weight, had difficulty moving because of the pain, suffered from coughing spells, shortness of breath, cyanosis (?) bloody sputum and (?) metastases into the left hilus and aorta glands to the right adrenal gland, into the stomach muscles, the pelvis, the spine and the skull. Along with the asbestosis, a focus was found by x-ray on the left side of the lower lung, which looked like an atelectasis or a pneumonic process, which however, was recognized as a tumor because metastases were present in the pelvis and spine. In the dissection along with the asbestosis, a 5:4:5 cm ascinsoe cancer was determined in the left lung underlap, which had sporca. Origin of the tumor was a side branch of the left lower bronchus lobe. An etiological connection between the two diseases seemed plausible to them: "That the irritating effect of the inhaled asbestos particles may in this case been'a significant factor concerned in the development of the primary lung cancer seems sufficiently plausible to be worthy of consideration." In 1936, Gloync added another observation to his three. He found a differentiated carcinoma of the left lower lobe in association with asbestosis. The carrier was 59 years old and had worked with asbestos for 21 years. In 1938, Sparks revealed, without any further details, that in his dissections, Gloync encountered six cases of lung cancer in association with asbestosis. Baader learned by letter from Gloync that these six cancers were referred from 50 autopsies. In the same year, Nordmann expanded our knowledge by two new cases of cancer in association with asbestosis, which he dissected in Hannover within a short time from one another. The first patient was 35-yearsold. Of the 17-26 year of employment, she had worked for exactly seven years in (?), spinning and weaving of an asbestos plant. Four to five years before her death, she contracted shortness of breath and cough. 3/4 year before her death, she came under doctor's care for a suspected tuberculosis. Horning made the probable diagnosis of cancer in the left lower lobe in association with asbestosis, because clinically, the signs were present of atelectasis and the main bronchus was displaced tomographically. Anatomically, this was a callous squamous epithelium carcinoma with a walnut-size decay cancer, which was connected with the lower lobe bronchus, pleura callousity and metastases in the liver and kidneys. 800? 1475 * - * PRODUCED BY FORD 4 4. The second observation concerned a 55-year-old man who between the ages of 36 to 43 had worked seven years in an asbestos plant. Thirteen months before his death he lost a lot of weight and had bloody sputum. In the beginning, tuberculosis was suspected. Above the lower left lung, suppression and weaker breathing were found. The x-ray showed a shadow on the left lower segment. The doctors handling the case diagnosed it as asbestosis in association with lung'cancer. The dissection confirmed this. The cancer in the left lower lobe and con nected with the main bronchus was decayed to the size of a walnut and had spread off into the pericardium, the left chamber septum, the diaphragm, the peritoneum of the left upper stomach, the retroperitone tissue behind the spleen, the lymph nodes located there, and the lower (?) and upper lumbar spine. Again, histiologically, it was a callous squamous epithelium carcinoma. In the right lung lower lobe, a beginning of bronchial carcinoma was found, as well. Nordmann followed up these observations with an exhaustive evaluation of the arguments which seemed to prove to him the existence of an occupation-related cancer. He was the first to clearly speak of occupational cancer of asbestos workers. In Germany, 1939, Wedler directed the attention to a further observation which originated from Bohne, but which had not been published. A 58-year-old man worked for ten years, from 1925 to 3935, as foreman in an asbestos factory. A few years after the exposure to dust, he became afflicted with problems to the breathing organs. In 192B, he was sent to a sanatorium for two months. Later he often underwent sanatorium cures, without any tubercule.bacilli having been found in him. Due to the steady deterioration of his condition, he left his job 1/4 year before his death. In the hospital he showed signs of general weight loss, cyanosis, and especially noticeable catarrh. In the sputum, numerous asbestos particles, but no tubercule bacilli showed. Hypostasis highly accelerated (57/95). On the left lung,' above the 9th rib, in the front auxiliary line a chestnut-sized tumor intergrown with the skin was found, tt was removed and turned out to be a cancer metastases. The x-rays revealed symptoms of an asbestosis as well as an increase in the pattern of the upper part on the right side. Obviously, the diagnosis of lung cancer was not established - according to the acces sible reports - in vivo. The patient died soon after the removal of the metastis from heart failure. The dissection findings were described as follows: "The lungs were firmly intergrown with the chest wall. The heart was not enlarged, the muscles were of brownish color and somewhat faccid consistency. The left lung was rich in blood and fluid, the lower lobe was coarse consistency and slatey color. The right lung tore when in the process of being removed, in the area of the middle lobe. The tissue looked yellowish and totally decayed, and presented extensive formation of caverns and nodules. The upper lobe was full of blood and fluid, of firm 8003 1476 PRODUCED BY FORD 5. 8003 U 7 7 consistency. It also proved to be without air. The microscopic examination of the Jungs showed a typical cancerous growth tissue in the right middle lobe, whereas the lower lobe showed all changes which are characteristic for asbestosis. Above all, the sections contained asbestos particles. According to Baader (1939) six authors supposedly observed, in 1935 to 1938, 14 cases of cancer in association with asbestosis. This report does not disclose any details, so that according to all reports up to now, as they were given above, these statements cannot be confirmed to the full extent. In 1941, a detailed clinical and pathological-anatomical report by Wcdlcr and Linzbach followed about a further clear history of the disease, which contained the full course of the suffering. The 60-year- old man had worked from 1921 to 1939, all in all, 18 years, in an asbestos factory. Only for the first three years was he exposed to a high level of dust (preparation). The first symptoms occurred not long after he began the employment. In 1938, he already presented an image of an uncomplicated asbestosis of a high degree, which had developed insiduously. In the course of his last year of life, there was, above the right diaphragm and in the lower lobe of the right lung an increasing shadow with the clinical signs of an atelectasis and later decay as well as very strong neuralgiform pain in the sur rounding areas of the intercostal nerves. The sputum became bloody. All signs pointed to cancer, which was clinically diagnosed. The dissection confirmed the diagnosis of a decayed callous squamous epithelium carcinoma, which originated from the bronchus of the right lower lobe. There were no metastases. In the meantime, there are two more observations in Germany which are not yet part of literature. The first case was observed by Teutschlender, who reported about it twice orally. Pertaining to this, the following can be seen from a personal written communication: Jn 1938, Teutschlaender dissected a woman of 40 years, who had been employed with long interruptions for ten years in an asbestos plant. The clinical diagnosis for her was;: "lung tumor on the right (?), cirrhotic lung process on the right (?) vicarying emphysema on the left, ascites, cachexia to a high degree." The dissection did not reveal any tuberculosis, but rather a very extensive asbestosis, with a large number of asbestos particles, and a pleural blastoma on the right side, which was determined by the histiological examination-as a: "Pseudo alveolar mesothelium." The peritoneum contained a large number of metastases in association with ascites. The left pleural cavity contained a hematoma of 50 cms. Compensatory emphysema of the left lung. The cachectic woman died of circulatory weakness'due to the lung disease. The second observation is by Alwens. The dissection was performed by Fischer-Wascls. 1 came in contact with the case in my role as a medical expert. The 60-ycar-old man (August 31, 81 till September 19, 41) had been employed up to half a year before his death for a total of 42 years in an asbestos caoutchouc department. He fell ill in January of 1941 with increasing shortness of breath and weight loss with the symptoms of pleural hematoma on the left side. Absolut'1 Jumping, ................... ................................... ........................ PRODUCED BY FORD 6. abnormal breathing noise, and displacement of the heart to the right. The sputum contained a great number of asbestos particles. The fluid that was tapped on several occasions contained a considerable amount of tumor cells and was reddish in color and gel-like in consistency. At times, small bubbly rattling noises could be hear above the right lung. The hapostasis rose fast. There were no tubcrcule bacilli in the sputum. With the help of x-rays, an asbestosis of medium degree was diagnosed, and a tumor was suspected in the right hilus. The dissection revealed a slight asbestosis with a diffuse primary, mucus producing glandular cell carcinoma of the left pleura which was for the most part of adenomatose character, and it revealed metastases on the stomach side of the left diaphragm peak, the serosa of the small pelvis and the chest muscles on the left side. The dissection protocol of the chest organs shall be mentioned here in detail, since it has not been published so far. Dissection of the chest: Pannicuius adiposus developed moderately. Thorax is moderately arched and clastic. The rib cartilegc can be cut easily. The diaphragm is located on the right side at the level of the intercostal cavity, on the left side it is turned down and reaches far into the abdominal cavity. It lower pole here is lower than the pelvic comb. When applying the pneumo-thorax probe, almost 3000 cm of a yellowi s-brown sticky fluid oozes out of the left pleural cavity. All of the mediastinum has been displaced to the right. The heart is suspended in drop-form in the mediastinum, its left edge is located in the middle line. The right lung is, except for a few strand-like growths, free in the pleural CBvity. In the pleura costal is there are callous slabs the size of a palm, of white color, and coarse and sinewy with individual bulb-shaped, just as coarse with nodules. In the pleura of the right upper lobe, there is a large radiating scar. On the pleura of the right lung a moderately sticking, fine, grey and fclty coating can be observed. The right lung itself is of appropriate size with medium air and fluid contents. The pleura and the cutting surface show moderately strong black netty patterning. Otherwise, the lung tissue is red in color. There are no diseased foci. The lower lobe branch of the right lung artery, there is on the intima, a brown-reddish blood clot. The lung arteries are empty. The left pleura is thickened slab-like over its full extent. On the inner surface there are numerous, located closely to each other, up to walnut-size nodes, with a cauliflower type surface, which consists of gel-type tumor tissue which is white on the cutting surfaces. This exudes a sticky fluid when cut. Beside the tumor tissue there are severs! sinewy slabs as on the right side. At no place docs the tumor tissue penetrate more deeply into the foundation, above all not into the lung tissue. Only in the area of the skin nodes mentioned in the beginning at the left side of the chest, there arc tumor knots in the muscles between the ribs. 8003 147k PRODUCED BY FORD 7. The left lung is highly atelectatic and adheres to the chest wall only in strand shaped growth. The lung tissue is of tough-coarse consistency, of greyish-red color, and shows on the surface and cuts a black, netty patterning, .which is somewhat denser than the one on the right side. Nowhere can there be tumor tissue found. The lymph nodes of the hylus are on both sides of the black coloring and soft. The heart is barely as large as the first of the dead body. The sides of the pericardium are smooth and shiny. The fatty tissue beneath the pericardium is moderately sufficient. The left ventricle is small, the right one somewhat distended. The wall of the left one 5 mm, of the right on, 2-3 mm. Both cardiac valves are delicate and closable. The coronary arteries are of medium width and have a delicate wall. The myocardium is evenly brownish-red at all cutting surfaces. The aorta is all over delicate and elastic. Microscopic Findings: Right lung The structure of the lung shows at places emphysematose changes. At several places there are in the peribronchial tissue nodular deposits, a finely grained black pigment. In this area, the per- bronchial tissue shows a clear hyaline change and fibrosis. Beside the deposits of the anthracotic pigment there are also fresh and also decaying asbestos corpuscles. These are always located in great quantities close to the anthracotic pigment. But they arc also found independent from these in lung alveoli, and located by themselves, in interstitial tissue. There were also under the pleura, considerable deposits of coal dust and asbestos particles. The large bronchi contained in part mucus and discarded epithelium. The bronchioli were widened in many places. But all over they are lined with one-layered flickering epithelium. There are no epithelium metastases anywhere. The lung tissue just underneath the pleura shows a slight collapse of the alveoli. The alveolar epithelium here presents often glandular, but nowhere atypical characteristics. For the rest, there arc no lung tissue pneumonic changes. Left lung The tissue of the left lung presents the finding of the collapse induration with desquamative alveolar catarrh and fibrosis of the interstitium. In the peribronchial tissue there is, just like on the right side, a considerable number of deposits of anthracosis with ophylanosis of the surrounding tissue. In this ling, there are more asbestosis corpuscles than on the right side, some fresh, some decaying. The free asbestos needles are to be found consider ably less frequent than the asbestos corpuscles. The gel coBting of these corpuscles gives, in a typical way, a positive reaction to iron. In the left lung there are many more hemorrhages and tissue necroses that are veined with hemorrhages. Most of these are of more recent origin, since there is no sign of demarcation. 6003 1479 PRODUCED BY FORD B. In these necrotic segments the asbestosis corpuscles are preserved everywhere and "they stand out considerably due to the necrosis in the rest of the tissue; In this lung, too, there arc the changes in the bronchial structures as on the right. This lung also does not show any epithelial metaplasmas. Diagnosis: Numerous asbestosis corpuscles in both lungs with light, detnarked fibrosis (slight lung asbestosis). Compression atelectasis and collapse induration of the left lung. Hemorrhages, necroses and slight bronchiopneumonia in the left lung. Pleural tumor to the left. The tumor changes in its structure. In some places there are solid cones and strands surrounded by areas of myxomatous delicately-fibred connective tissue. Almost all tumor cells have large mucuous vacuoles; there are many ring shaped. In individual' cases there arc cells with burst vacuoles with the mucus having oozed out into the surrounding connective tissue. At different locations the tumor present the image caverns that are located close to each other and which are lined by a smooth one layered epithelium. These epithelium cells contain frequently mucus, and they separate from the epithelium group in ring-shape and enter the lumen of the cavities. In the interstjtium there arc also all over, loosely distributed mucuous tumor cells. Only in few places are there solid epithelium formations without the formation of mucus in the kind of the carcinoma solidum. The tumor is located all over the pleura parietalis and visceralis to the left and has, in some places grown into the subpleural layers of the lung tissue. There, they are mainly found in the septa and occasionally in the lymph vessels. Diagnosis: Primary, mucus-forming glandular cell carcinoma of the pleura, mostly of adenomatous character. In question are the glassy knots of the stomach side of the left diaphragm peak and of the serosa of the small pelvis (?) , under the mi6croscope, to be metastases of the same structure as the primary tumor. This concludes that all cases observed so far and published in the world literature where pulmonary or pleural cancer occurred in association with asbestosis. Up to now, Nordmann and Sorge were the only ones to attempt a solution to the question of a link between the inhalation of asbestos and pulmonary cancer with the help of animal experiments with white mice. They used 150 mice for their experiments, and they exposed them to dust from 1H to 3 months, corresponding to the average life and employment span of humans. More than half of the animals died before the end of the experiment. None of them survived the inhalation more than 9 months. 20% of the surviving animals showed a callous, multiple squamous epithelium carcinoma; 42% to 57% showed epithelial new formations of all stages. 8003 1480 * * ' PRODUCED BY FORD 9. This is to confirm the causal meaning of the asbestos dust for the primary pulmonary carcinoma in the asbestos worker with the help of the animal experiments. The number of the animals that finally made it through the test, and from which the numbers above were calculated, is very small. Only two of the animals had growths, that were determined to be cancers. The authors them selves pointed out the difficulty of demarcation of simple metaplasias. An experienced morphologist and expert will utlimately have to determine whether the oonolusions of the experiroentors arc justified, and in how far the necessary care had been taken regarding the unity and usability of the animal material and how far, within these limits, spontaneous tumors have to be included in the deliberations. Nordmann and Sorge discussed this briefly. It is striking that 60 far, the animal -experiments with asbestos dust, that were admittedly conducted under different angles - did ' not show comparable observations. Dissections of animals (dogs, rats) that lived in asbcstbs'pXahti', did not reveal such obser-^ .... vations either. If there is to~be a* statement about an' 'occupational ....... cancer in a certain group of employees, first there will have to be the statistic proof that the cancer in question with increased frequency as compared to other groups of employees or populations. It will be difficult to fulfill the demand for the comparative numbers as matching in ages. The statistic method has also a . further obvious difficulty for the asbestosis. It is a very rare disease in itself and there will always be small absolute numbers involved. One single, coincidental observation could bring about a large shift in percentages. Furthermore, one would have to consider with Nordmann.that, especially in the last years, the turnover of workers in the asbestos plants will affect the results in a negative way, since usually the development of cancer is preceded by a long lasting exposure to dust, and possibly, a dust-free interval. Only few of.ythe^eaployees remain in -the shops long enough that present a risk. Also, the attempt at '' cleaning up the dust contributes in a desirable way to the reduction of dust damage to the lungs. We have workers that are still carrying the dust damage from past times when the working conditions were far more unfavorable. > The second point that should be discussed for the question of the link between cancer and asbestosis, is which special conditions are found at the dust damage and the findings of the location of the disease which would render the cancer understandable and which would distinguish it from other forms of lung cancers. The final step of the proof would have to be experimental observations which would prove that cancer can also be induced in animals. , .. "' 8003 1481 ` * PRODUCED BY FORD 10. Let us first discuss the statistical method. Here, we can use as dependable only the dissections with precise anatomic examination of the lungs, because the purely clinical diagnoses always leave certain room for error. Furthermore, there are no purely clinical studies concerning this question. So far in Germany, there have been 30 dissections of asbestos workers. The following chart 1, lists the cases according to age, sex, time span of employment, stage of the asbestosis and cause of death - as long as they lay outside the asbestosi or heart insufficiency or fatal pneumonia that were caused by the asbestosis. The first 18 fatal cases have already been published. The other 12 were collected by me. The young girl that is listed under no. 29 can be neglected in our context since she had only a short exposure to dust, and anatomically did not yet show an asbestosis. Of the remaining 29 dissected patients, four had bronchial cancer, two more had a pleura] malignant growth. From this, a percentage figure of around 20% was established for malignant tumors of the lungs for dissected asbestosis in Germany. Other malignant new growths of the body were found only three times: one of stomach, one of the esophagus, and one of the porstate. Even if pulmonary cancer has increased considerably in the statistics of the last three decades, it is still, in the large dissection statistics clearly behind the cancers of the digestive tract. With its frequency in the cancer statistics of the carcinoma of the organs, lung cancer occupies 4-2 rank, depending on different authors. As the numbers above show, lung cancer is by far the most important in association with asbestosis in Germany. The average age of death is considerably lower for the carriers of lung tumors than for the carriers of other carcinoma (approximately 51 to 66 years). Hut. for now, the small numbers do not yet allow for special con clusions to be drawn from this. In the distribution according to sex we have four men and two women with pulmonary growths. For the distribution of sex for lung cancer, usually there are numbers of 3/4 to 1. Of course, the quota of the asbestos workers with lung cancer is also dependent on the number of the women and men working in the plants. In Germany, there are far more women. For the two men mentioned above, the relatively low age of death is striking; 35 and 40 respectively. All cancer carriers had a clear to bad asbestosis. Only the man with the . pleural carcinoma (no. 20) had a moderate asbestosis with a very long, but only light exposure to dust. Nordmann already pointed out that in all cases a long time of employment in the is involved. This is true, without exception, according to the chart above, for all cancer carriers. The ;time span of exposure is twice 7, twice 10, and once each 18 and 42 years respectively. The dustfree interval, before the diagnosis of cancer could be made and during which the deposit of asbestos dust in the lung can be effective, varied in length (H to 12 years). In one esse we do not have precise information, (no. 30 of the chart). 8003 1482 PRODUCED BY FORD 11. These numbers clearly show that lung cancer is the most frequent complication with asbestosis, if heart insufficiencies and fatal pneumonias arc disregarded. Even tuberculosis, which usually surpasses cancer in frequency, in this case clearly falls behind . lung cancer. This provides an important proof for the close link behind lung cancer. It is striking that the percentage of today, gained from the more extensive material, coincides exactly with the numbers that Nordmann had gained earlier from a much smaller amounf of observation material. Abroad, the conditions pertaining to this, arc up to now, as follows: In this area, the British have most experience. But according to the Enlgish literature, which is diverse, because some of the individual cases have been published several times, unfortunately it is not possible to list the individual cases as we did above. Till further developments take place, the num bers provided by Gloyne have to suffice. He observed six cases of lung cancer (one probably a pleural tumor) in 50 dissections. This shows a frequency of lung cancer in association with asbestosis at 12%. The numbers from the OS.are very similar. 1 have found in the literature up to 1939, 13 cases of dissection. This number is probably not quite complete, since some studies were not accessible to me. Among these dissected asbestoses 1 found two bronchial cancers, which were listed above. This would correspond to a percentage of approximately 15%. There was not any mention of a different organ cancers. Relatively frequent (four times) is the pneumonia as given cause of death. Strangely enough, there is no report pertaining to this matter from France. And just as little was published about this problem in other counti'ies. In Italy, where asbestosis is a very well known disease, no case of pulmonary cancer has been observed (vigliani and others). Therefore, in the world literature, we see so far 14 malignant pulmonary-pleural tumors of epithelial origin, which came from 92 sections. This means approximately 16% cases of cancers in dissected asbestosis. ' Of these 14, only eleven have so far been described in detail so that statistical results could be gained from them, (cf. chart 2). The distribution according to sex shows seven men and four women. The ages are between 35-71 years. Four are in the relatively young age group of 35 to 4). In all cases the time between the beginning of the employment to the occurrence of the cancer is relatively long (between 12 and 42 years). If the exposure to the dust was short, usually a longer dust-free interval will follow, which seems to prove that the ef fect of the dust will if at all, lead only gradually to an occur rence of cancer. The majority of the affected patients had a bad asbestosis without it having to be obligatory in this form. 8005 1488 PRODUCED BY FORD 12. In nine cases there were lung tumors, in two cases pleural tumors. of the lung tumors, as far as this can be determined, seemed to originate from the bronchial epithelium. There is no observations among them that would be typical for an alveolar cancer. All ' According to histological character the callous squamous epithelium cancers were in the majority. Among the eight histologically closer defined lung cancers five were callous squamous epithelium cancers. One further cancer of the squamous epithelium was not callous. One further cancer belonged to the group of non-differentiated growths and the last one was acinous. The three pleural growths were described as "pseudo-alveolar meso- thelium", as "adenomatous pleural carcinoma" and as "squamous car cinoma." ' Four of the lung tumors in the limited 6ense had not spread into mctastascs. The localisation of the primary lung cancers is seven times alone in the lower lobes, where, at all times the asbestosis is developed most of all. Four times the tumor is located in the left , three times in the right lower lobes.' Compared to this, the right side middle and upper lobes are represented only once each with a tumor. The matching localization of the tumors with the strongest changes in the tissue as triggered by the asbestosis in the lower parts of the lung is striking. The numcrological frequency of lung cancer in dissected asbestosis patients is the first convincing proof for a close causal link of these two diseases. Sixteen percent of pulmonary and pleural cancers surpasses, by far, the otherwise statistically expected frequency of other dissections. , Even if the frequency of the occurrence of lung cancer has risen considerably in the last decades, it still docs not show up in the over all statistics of dissections more than 2%~6% on the average. And even if for asbestosis the absolute numbers - as we have shownare still relatively small, they still are convincing through the fact that they were established with even frequency at totally different places (Germany, England, U.S.A.). To these numerological conditions further positive points can be added from the above deductions, which were already presented by Nordmann, in small numbers. 8003 1484 PRODUCED BY FORD 13. First, we shall present the age of the cancer carriers. Four of the men were still young, 35-41 years. Even if lung cancer does occur in adolescents, its greatest frequency is not before the ages of 50-60. Six patients from our study belonged to this age group. The dist ribution according to sex shifted here towards women, contrary to the number ratios which are usually valid. There are four women a mong 11 cases. The large statistics list, otherwise a distribution ratio for the distribution according to sex as 3-4 to 1 between men and women. Still, one hBB to remember that in Germany and England, in contrast to the U.S., women surpass men as employees in asbestos plants. Especially striking seems to be the frequent coincidence of the location of the tumor with the location of the worst changes of the asbestosis in the lower segments of the lung, as we reported above. Further, the histological character of the lung tumors is striking. Where numbers are concerned, mostly the callous, squamous epithelium carcinoma is of importance. Among eight bronchial cancers that were described in detail, six alone were such. The number ratio which is common in lung cancers among the individual growth forms is totally changed and shifted in favor of the squamous epithelium carcinoma. If the histological distinction is made into the three groups of undifferentiated cells, squamous and cylinder epithelium cancers, the first group contains by far the cases according to the larger statistics with approximately 2/3 of all cases. Since the squamous epithelial cancers have the least inclination to form metastases, it may be understandable why the observations of four of the cases did not show any metastases. The histological character of the lung cancers speaks, for its independent position among the lung cancers. The cancer was always observed after a relatively long effect of the dust. It may be that the time of employment in the asbestosis dust was very long or that, at a short time of work there with a considerable exposure there was a longer interval, in which the dust damage could be further effective. A series of clear observations, which were made in part by the author himself, show us that the dust damage in asbestosis will often only occur after this interval, and will lead to an increasing fibrosis. Among all the cases of lung cancer in association with asbestosis there is not a single one that would not show this long span of the effect of the asbestos dust. This is in agreement with observations of other occupational cancers. The other histological findings of the asbestos lung give us a further understanding of the links discussed above. There Brc, in the asbestos dust lungs, at the small bronchi mostly extensive epithelial metaplasias, which can be viewed as pre-cancerous stages. Most likely they are generally the origin of the carcinomatous new formations. Nordmann has even made the observation, in one case, that at a large carcinoma of the left lower lobe there was on the other side a small, just beginning cancer, that could not be a metastasis, but a bronchial cancer originated epithelium in an authochthonous fashion. Therefore, he believes the origin of the . cancer in association with asbestosis in several places to be especially characteristic. Here, we find parallels to the Schnecberg lung cancer. ______ ________________ _____________ ________ ___ '` ... . 8003 1485 PRODUCED BY FORD 14. It seems thBt beside these metaplasias, the other histological changes in the lung also play a role in the development of cancer. The most characteristic one is the highly increased tendency of the tissue to grow. Here are the numerous epithelium despamations with changes in shape of the covering ` cells, the formation of numerous macrophagi and foreign body giant cells as well as wild growth in the connective tissues. As Linsbach pointed out, this triggers the individual tissues' removal from their normal relationship, without however, the damage to the tissue being bad enough to cause death of the cells. In this heightened growth tendency and the interrup tion of the normal inter-relations of the tissues, in all probability the triggering forces of the occurrence of cancer have to be seen. These points hold also true for the pleura] growths. The pleura is included in these processes of restructuring. Epithelial desquamations, deposits of fibrin, growth of connective tissue are to be found there, the same as callousities and deposits of asbestos crystals and asbestos particles (Gloync and others). These points fit well into the results that come from the statistic numbers, and they form confirming arguments for the inner link between esbestosis and lung cancer. Besides the increased rate of cancer carriers with asbestosis there has to be, to be further convincing, the possibility to reproduce these conditions in animal experiments. This point can not yet be seen as fulfilled for the asbestosis. But this is not the consequence of negative results in experiments, but rather in the fact that this question has not been tackled yet in a larger scope. Nordmann and Sorge conducted the first experiments with & result that seemed striking in its agreement. We discussed this earlier. But, to be careful, one will have to wait for further confirmations and acceptance of these complicated conditions by other experts. In any case, all facts gained so far speak with high probability for the fact that Nordmann*s theory about the occupational cancer of the asbestos workers is justified. The other authors, too, like Gloyne, Lynch, and Smith, Egbert and Geiger and Lin2bach show the tendency to suspect closer causal links. No side has so far tried to disprove this assumption. If wc now ask ourselves the question of where to look for the carcinogenic effect of the asbestos dust, we have to separate general and local effective factors. It is assumed everywhere that the development of a cancer is based on a general disposition for cancer. But it is hard to 6ay of which it consists. It is known from the generally human and the experimental pathology that the disposition for cancer is dependent on genetic factors. This is expressed in the fact that under equal conditions for the experiment and roughly even exposure to carcinogenic damage for people, the 8003 '486 PRODUCED BY FORD 15. quota of cancer carriers is always only a part of the ones at risk. The observation material that is accessible to us for asbestosis did not allow an analysis of cancer occurrence in the family in a satisfactory manner. We do not know how far and in what way the asbestos dust damage creates such a genera] disposition for cancer. The assumption remains a hypothesis. It does not seem to be the case that this general disposition has such a strong effect that it would also trigger the occurrence of cancer in other organs. The given numbers do not speak for that at all. It always seems to be of greatest importance how the surrounding area is affected. We have discussed above in detail their morphological expression in the changed tissue reactions of the lung. As their cause, primarily chemical and mechanical factors have to be considered. Since asbestos is chemically simply defined, the conditions here are tolerably clear. It can probably be stated right in the beginning that substances from the group of the familiar carcinogenic agents are not in question. The affect of the asbestos dust on the lung takes place probably through chemical and mechanical damage. For the chemical damage we look to the silicic acid, which proably dissolves from the more easily affected serpentine asbestos. It is hight unlikely and prac tically unproven that it has a carcinogenic effect, as was ?/ shown from observations of human pathology and animal experi ments. But it must be kept in mind that the conditions are different for silicosis and that the tissue changes are at different locations and of different character for the asbestosis. This different arrangement and type of new tissue formation could indeed trigger different bilogical reactions of the tissue. Beyond that, one will have to give special attention to the effect of the many pointed asbestos needles and particles, which are probably especially characteristic to the hornblende asbestos with its rigid, hard to dissolve quality. They have great importance for the continuous mechanical irritation which trigger the reaction of the tissue. . Finally, it should be recalled, thBt in bad cases of asbestosis inflammatory reactions take place at the bronchi in part with formation of bronchiectasis, which in turn, could favor the development of cancer. In general, and above all, local conditions, we will probably have to look at the present status of our knowledge for the explanation of the occurrence of cancer in association with asbestosis. A great deal of the damage does not exceed in its definition as the term of chronic irritation. The problems of the association with asbestosis and the origin of cancer have in common that wc are still far away from a full understanding of the finer inter-relations. 8003 1*87 PRODUCED BY FORD 16. Let us now discuss the clinical diagnosis of cancer in the asbestos dust Jung: In general, all diagnostic deliberations will have to be applied and are valid, which we also use in general cases of pulmonary or pleural cancer determination. But since the cancer here builds on a foun dation disease, we will have to expect certain characteristics of the way the disease presents itself, and we will have to be in pos session of certain knowledge from the symptology of the asbestosis. For the history if will first of all be important to take down a complete occupational anamnesis, and to keep in mind that lung ex posure to the dist,with the duration of the risk sometimes being compensated for by the intensity. So far, we arc only familiar with a single observation for which the employment in the asbestos dust lasted only lli years, in all the other cases it was seven year or longer. If the exposure to the dust is short but intense, there seems to be a longer, dust-free interval necessary for the occurrence of cancer. So far, we do not have case of the disease, for which the time period from the beginning of the work in the dust to the diagnosis of the cancer would have been less than 12 years. One should expect in general that the cancer would occur only in association with clear, if not always worst, cases of asbestosis. The examples above show this. The first symptoms of a developing lung cancer, which in themselves don't have anything characteristic or pathognomonic, will not be as striking as they would be in a person who was previously healthy, since shortness of breath, coughing, sputum and a certain discomfort in the chest area arc complaints that are very familiar to the asbestosis patient. E'.ven a certain deterioration of the general strength, which docs not even have to go hand in hand with a lung cancer in the beginning, weight loss, loss of appetite are often symptoms in cases of bad asbestosis. And acute deterioration in the general condition, including the local lung pain, are often an expression of secondary infections which are difficult to overcome. But overall, one would have to observe the rule for the previous history of asbestosis, that the process of the disease is a deterioration which is very gradual, drawn out over years and even decades. If this development shows sudden instances of obvious local and general deterioration, then the thought of a development of cancer will hove to appear. Responsible for this condition arc, beside the cancer, unspecific infections with bronchitis, penumonia or abscesses. The complicating tuberculosis is, according to our observations, of minor importance, but it is much too often diagnosed. Of course, it will always be within the realm of the possible. So far, there has been no information regarding an association with lung lues or fungal disease. Among the general symptoms, fast weight lose is important, but does not prove it. The same is true, as has been said, of the loss of appetite, bad coloring of the face and perspiration at night. If these symptoms are based alone on the increasing asbestosis, they are usually accompanied by an increased shortness of breath, cyanosis, possibly drummer's fingers and other local complaints of the lung, but one has to keep in mind that a lung tumor can also trigger the increase in such complaints. Overall, the situation will not be clarified from the previous history alone. 8003 148? PRODUCED BY FORD 17. It is not very different where the local complaints are concerned. Since asbcstosis mostly causes bad irritation cough, this symptom cannot be used for determination. The same is true for the shortness of breath, of somewhat greater importance seems to be the observing of the sputum. In a case of uncomplicated asbcstosis it is of small quantity, sticky and mucuous, in case of bronchitis and bronchiectases it can be more copious and purulent. Only in rare occasions does it contain blood. Frequent even if sparse bloody sputum requries an explanation. 1 myself have seen sputum in the form of raspberry sputum only in the case of a complicated lung tumor. The literature has only few mentions of this kind for the simple asbcstosis. Tumor cells in the 6putum are probably rare. Hornig claims to have seen a large number of epithelium cells in the sputum of his case of a tumor in association with asbestosis. When the decay of the lung tissue begins, this will be easily detected from the change in the sputum. This was very impressive in my observation. The patient suddenly delivered great quantities of granular necrotic substances. Maybe we will be successful at some point to find the symptom of the Rritish ''asbcstosis bodies in clumps." These are rosette-shaped piles of asbestos particles, which con only be found in the sputum, if there is decaying lung tissue (abscess, tuberculosis, tumor). Diagnostically speaking, they are the same as the elastic fibers in the sputum. The importance of the shortness of breath was discussed above. Only when the tumor reaches b larger extent or if there is a bronchial blockage will it have to be related to it only. On the other hand, 1 find pains in the chest to be a more significant sign. In the case of asbcstosis they are usually insignificant and undefined. In our tumor case they became more and more prevalent with the growth of the tumor; they assumed a typical neuralgiform character. There are similar hints in the literature. The CBU6e is probably to be seen in the spreading of the tumor to the pleura parietalis and possibly the intercostal nerves. These hints for the general and local complaints, which are in most cases suggested by the previous history, may be sufficient. ' The following shall be remarked for the rest of the objective finding; asbcstosis attacks the lung on both sides. There are no strictly one sided process, which is typically the case for tumors. Usually, there is also b symmetry regarding the changes. One has to know, though, that the right side of the lung can be attacked more strongly by the fibrosis in normal cases also. We never find dampings above the upper segments of the lungs. In most cases, the breathing noise is rough, only rarely weakened. The dependent lung segments offer mostly a moderate to medium damping of the noise, which, even if it is not quite symmetrical, is almost always on both sides. Only coarse callouses or specific or unspecific complications can be responsible for excep tions. The breathing noise is usually weaker in the lower part than above. Only in rare cases is it reversed. Foreign noises are more prevalent in the lower part than above; differences in the side do not mean much. If there are clear signs of an atelectasis on one side, there is high suspicion concerning a tumor. But it is a matter of course that this symptom docs not have to obligatory be a lung tumor. 8003 1489 PRODUCED BY FORD 18. Hematoma, especially of hemorrhaging nature, are practically non-existent in the common asbestosis. Signs of melting can be a sign for either a tumor, an asccss and tuberculosis. Bronchi ectasia in the form of a cylindrical widening of the windpipe arc not rare in cases of bad asbestosis. They will, on occasion, create difficulties in the definition of against caverns in the clinical examination. There will always have to be an explanation given for strong asymmetries of the rib cage, displacement of the pleura in the middle area and of the diaphragm. The x-ray method will always be the most important method for examining and determing a tumor. There it has to be kept in mind that the bad asbestosis not always, as could be believed in the literature, leads only to delicate, symmetrical densing of the lung tissue. Beside cer tain asymmetries there are also flat cloudy blotches of circumscribed type in the lower segments,especially in the middle. But the dense shadows arc not as compact and like a tumor, but more of stripe patterning and not clearly defined. Hard or tomographic exposures will show the bronchia system as open, possibly even enlarged. So far there have been no reports about bronchus stenosis in association with asbestosis. Compact, onc-sidcd, defined shadows in the lung, possibly with a bronchial blockage, arc practically proof for a tumor. In this area belongs shifting of the mediastinum, cither continuously or changing with breathing, as well as paralysis of the diaphragm, the recurrent or in processes of the upper lobes also often a Horner's symptom complex. Defined densities of the upper segments are never characteristic of asbestosis. Here, the conditions are much clearer and simpler than they arc for silicosis. Rough formations of shadows occur in asbestosis mainly through unspecific inflammation. Thubcrculosis is by far less frequent than has been suspected. Its first occurrence in the lower segments is rare for asbestosis. For completeness sake, it may be mentioned here that the tomo and bronchiography may be of value for the recognition of a tumor of the lung within the framework of general customary diagnostic evaluation, with the usual rules of evaluation applicable. The bronchioscopy is of similar value. There are no observations about the diagnostic value of lung tappings except for a few experiments, when asbestos particles were found in the lung fluid. In the case of a primary pleural tumor or metastases the proof of tumor cells in the tapping fluid can '-.explain the situation very suddenly. This was the case in Alwen's case. Metastases will always allow fro their diagnosis to be established very fast. Since infections can have the same consequence it is irrelevant for the diagnosis that long-lasting tumors can cause fever. Concerning the. blood situation and the increase in the hyposatasis of the red corpuscles it should be noted that anemia is not a sign of asbestosis, it would be more likely to find high pigment and cell values as compen satory symptoms. Accompanying infections may be able to cause the exceptions. Increasing anemias are, when other multiple causes have been ruled out, suspicious of tumors. No diagnostic hint for a tumor is given with the differential blood analysis. The hypostasis is not accelerated for uncomplicated asbestosis. It is, however, found to be slightly increased for a great number of asbestos workers as is 9003 1<V0 PRODUCED BY FORD 19. established in routine examinations, probably because infections in the bronchial trunk are more frequent. Stronger and increasing acceleration of the hypostasis must always be checked, and they have to be evaluated according to the customary clinical rules. This concludes the most important clinical points for the recognition of a lung tumor in association with asbestosis. The correct interpret . ation is always dependent on a careful clinical general examination and the critical understanding of the individual signs. It is important in this context to be familiar with the image of the disease of asbestosis and to keep the possiblity of a complicating tumor in mind, which seems to be as frequent in the asbestos lung as tuberculosis. In Germany, so far, there were only reports of about 10 active tuberculosis in association with asbestosis as compared to six tumors. If then the occurrence of the development of cancer in the asbestos dust lung is as frequent as was shown above, and if still other good reasons speak for a close causal link between the two diseases - even if the results from the animal experiments cannot be included - there should be, even today, some thought given to include this complication in the insurance coverage. In the few cases that have come up so far in pompensatory procedures, the insurance associations have accepted the link due to the agreement in all statements of the experts that were questioned. Jn the files pertaining to this subject matter Bnd which 1 examined there was no expert in Germany that would have denied the request. SUMMARY The report is about the only so far known cases of malignant lung and pleural growths in the world literature. The reasons which suggest a causal link between both diseases, arc given. The clinical picture of the lung tumor is discussed and the inclusion of this complication into the insurance coverage is believed to be appropriate. 800? mi PRODUCED BY FORD Chart i dustfree in stage of asbestos!s cause of publish nr. years of . . . exposure to oust terval in yrs death ed by stomach ca 13 M bronchial ca bronchial ca 15 lung abscess 16 empyema 17 bronchial ca 18 bronchial ca 19 esophagus ca 20 pleural ca 25 prostate ca 26 lung abscess amyloidosis 27 kidney failure 28 lung tubercu losis 29 lung tubercu losis 30 pleural tumor PRODUCED BY FORD 8003 1492 PRODUCED BY FORD nr. age sex 1 2 3 t 5 6 7 8 o 10 11 Chart 2 \ dust dustfree stage of exp. yrs interval asbestosis type of tumor localization metastases author . 8003 1493 callous squamous upper right epithelium ca lobe callous squamous epithelium ca right lower lobe squamous epithelium right loca we lobe acinous tumor left lower lobe callous squamous epithelium ca left lower lobe callous squamous epithelium ca ? left lower lobe right middle lobe callous squamous epithelium ca right lower lobe pseudo-alveolar mesothelium right pleura adenomatous pleural ca left pleura non-differenciated left lower ca lobe none none none wide spreading liver kidney wide sprea ding yes none peritoneum wide sprea ding o/ REC'O FEB t ? ZOOi rP-fVeJ '6 7 7/ i VeifUr. H.U. ljng cancer in jpbtstoeii pnclciiu Dench. Arch. Kiln. M*J. 19). 190. r pp. 189*209 S' r A r PLAINTIFF'S 1 EXHIBIT I 13 I P-EXHIBIT-343 -- .*w 3f&$S$r- *. r j+eft ip; '>. . . ;:i iii. I-. - iti'p-.' ' . I'.m , wi, cekhany r c LliNC CANCER IN ASBESTOS IS PATIENTS [Article by Dr. U. W. Ned.ler; German; Dtsch. Arch. Klin. Med. 191. 1993, Pl>. 189-209 i ' Published by Heidelberg Open Clinic (University Medical. Clinic), Director: Dr. R. Siebeck, Professor In the last 12-15 years, such extensive experience in the field of ashectosis has been reported by both German and foreign literature that we arc now quite familiar with the dangers to which asbestos workers are subjected, and Che clinical picture as well as the development of this occupational disease. i."avercheless, there are still many unanswered path ogenesis-related questions which will eventually be answered through animal c:<re . i'u.ututlon anJ uitemical-physleal processing. However, our knowledge of accompanying diseases and complications is based on a much narrower and uncertain basi. At this time, the editor could publish an extensive re port on the behavior of lung tuberculosis patients suffering from this type of pneumoconiosis. One question which is as important as it is conclusive is i li.it concerning the correlation to lung cancer, whose incidence in as bestos is patients lias been repeatedly observed over the last few years. - The interest that this creates is not limited to the fields of social medi cine and legal insurance regulations, blit extends far into the field of general medicine, since this would produce a new example of the exogonet ic appearance of cancer. The number of such observations reported in itself ir. vi vv_siiui) 1 . hut is noverthclcss_ so significant in relation to the rare occurrence of this disease that""v feel It warrants the_publicarioiY~oT~3------ del oi I od report. This is also justificd'by The'fact "that, ns yec , from' a clinical side, no such work has ever been published. l-.'e shall, first mention observations previously published in worldwill'' Iit oralucc concerning Jung cancer in asbeslosis patients, and cimcl"d" villi- the lat est experience In that, field, as well as the chnractcrir.iics oi the respective clinical imago and its diagnosis. -1- i , . :<;* -if ,i i . i' : * .i' luwor in f lit ,1 in;;'- d /in vr-- ' : : ip. If: j i !'v ' -y nv, v.liilo wcT*k in;'. : : h (In* ; ' . and li i sic) i,; / : nics tos i s p/ituuls. Ik- mcni:iinn c . U:.- i - .`.vscrsis pat ii.-r.cs vli i<:U were thought' to bo related to l v >:r*gin c. f cK-, d i suusc (purulent bronchitis, bronchopneumi.-:u .1, tuber- c. i,i s , amphysi-v and hronciiicrtnsls) and nrrompnnytug dvsf.ir. os; which, \' ... d o'i 'staiM.: rT medical knowledge at chat time, were tinujglii tu be t:-' r-.-1 .it'd 11 . the effects of the dust. Under the latter, he makes Uir (ol- ! inf. observation: "Tiwri: has also been one ease of squamous cnrcinormi <:' the pK-mn. There is no evidence at the moment time this was in any way related to the Asbestos is". In 1935, Cloyne was able to provide two additional reports on lung earner decoded in asbestosis patients. At that time, lie still was not aM- lo moke a definite statement* as to the possible etiological correla tion of belli diseases. Nevertheless, certain histological aspects did appear to indicate this. ' The first of these two observations concerned a 35-year-old female who had worked for a period of 8 years as an asbestos spinner, and had then lived 0 years for 0 years without any exposure to the dust. She died, as shown by the autopsy, of moderate asbestosis with a coapulum ip. the right secL.ton of the heart, spleen infarct and a meningeal. hemor rhage. On Che basis of the. right lung upper lobe, a clinically non-identifinblc tumor was found, which was approximately the site of a walnut and which extended into the tip of the enlarged pleura. There were no inctaslascs to be observed. The cornified pavement epithelium carcinoma orig inated from a small bronchus. The second observation and autopsy also concerned a female who was just turning 71 years of age. Fifteen years prior to her death, she had once worked for a period of 6 months, and another time for a period of 13 months, in a hazardous dusty mattress and processing department of an j.'.h.star. p.l. tnt. In this patient, Cloyne found a moderate case of ashes- tosis, with a partly-collapsing tumor in the right lung upper lobe, ascites and thrombosis of the left leg vein. Here too there were no metastases to bo observed. .Histologically, this was also a cornified carcinoma of the pavement epithelium. In both cases, the cancer did not appear to be spread to the extent thai it could promote death by itself. The same applied to ashestnsis. In ihe same year (1935) a .report was issued by Lynch and Smith of tin Pnitod States e.uneerning Jung cancer in asbestosis patients, in which a detailed history of the disease was given. The 57-year-old patient whose ease Is described had worked Cor 22 years in a cotton weaving plant, and for 21 years in an .vshestos plant, until, his hospitalization; he had been comp la i.ning of shortness of breath for about 5 years. Throe years prior to his death, he started having occasional pains in the back .snd over the throe last files on the right, and again complained of shortness of breath in the last few months of his life. He became weak, coughed, lost his appetite, his temperature rose, he had blood In Ills sputum and suffered -2- -2rj r r ; Ps ; i,.v ! .'. ' T11 ` clinicil I i.iul i ngs hit'.: chiract' r i n i ' of : . '.-i:-1' - j ii- .it ii i.o < i i right 'li'-'ve tin- lungs, tlm respiratory t ). : i I. Tito clinical diagnosis was nsbcsios.is and 'hrmiie j : i . j. i: i " > : i. with ritul (skin) to the bottom righi. In add i t i nn :o a ,||. SI os i s with right lateral pleurUis ami hrunchi.t'clns i s . a duc-.oin- ,-d ia 'as found ill the right lower loho I hrmigli pa tho 1 o;; i m I - annt < a:, i oa I o::ai ii iiat Lnu . which was macroscop real 1 y taken ns tuberculosis. I'u'.y through the m ic roscopj c examination was it possiblp to detect cancer f i In- p,iv-.-iiiciiL of the epithelium. There were nu metastar.es to he observed. It is unusual I o speak of s i i::ul t ancons liya 1 ine nodes in the limps of asheel is patients. The carcinnma originated from a bronchus with a nirtap ' as i ia cp i i he l Luin. The authors felt that this had been caused by chronic irritation of tlic bronchi t. They spoke of tlic correlation between cancer and asbestos is as a "nnssi.hle relationshin" and tried to find parallels to other occupational diseases of the lungs. In W3ft, Egbert and Ccigor (USA) reported on an additional observa tion which they fall was tlic first one of this type (with the exception of (Uoyuc's 1.933 report). The 41-year-oid male had worked for .18 years as an asbestos weaver. After 9 years in this job. he had a case of pneu monia, followed by coughing and shortness of breath. Eight months prior to a short treatment i.n the hospital, he began to have occasional hack pains. He was emaciated and had trouble moving because of the pain; lie coughed, had cyanosis and shortness of breath, as well as bloody and puru lent expectoration. In addition to ashestosis, x-rays showed a cluster in the left bottom part of the lung, which had the appearance of an ate lectasis or a pneumonic process, but which was recognized as a rumor, due to the fact that meunstascs were present in the pelvis and in the spinal column. In addition to asbestosis, autopsy revealed a 5:5:4 cm acinose cancer in the left lower lobe of the lung, which had caused the appearance of mccascnses in the lungs, in Che loft lateral hilus and aortic glands, in tlic right suprarenal gland, in the abdominal musculature, the pelvis, the spinal column and the skull. The origin of the tuner was formed by a large secondary branch of the left bronchial lower lobe. He felt that Lhere was very likely an etiological correlation between the two diseases: "Thai the irritating effects of the inhaled asbestos particles may in this case have been a significant factor concerned in the development of the primary lung cancer seems sufficiently plausible to be worthy of consider ation." In 193ft, Gloyne was able to add an additional observation three initial ones. He found a non-differentlatcd carcinoma of lower loin: in a 59-year-old male suffering from asbestosis, who for 21 years in the asbestos industry. to his the left had worked in 1938, Sparks, without specific data, stated that in bin autops i or., Cloym- had encountered ft cases of lung cancer in patients suffering from mb' st os is. Header learned from Gloyne: himself that these 6 cases of can cel were based on 50 autopsies. In i Ik: same year, Nordmann provided us with two new observations of cancer cases in asbestosis patients that he had previously and cuusecut ivelv -3-  t.jr r r r . 1 -i the f i i sr .< 15-yi u r 1 d f <I <:. Between lur ' . . .vr . f life, sh- iir: ..ir.rkcd for exactly 7 yc;,rs in I Ik: . . ini' .n 111 weaving <!-( -i i* I m of on asbestos paint. rum' i-. ; ii' in In.-c death, sin' began In r.inigh ;i i<I hove shortness n.r i-r. ,.:"Ollis Ik: fore ;;1i<: (lied, she '-'OR created fur suspected I ii!.-'rri: I >': I ,. Il.iin.ii'. |;,iwe a probable diagnosis of cancer in the left lever lob'. . dm.' i o extensive ashestnsis, since there were clinical synp- t : s of atel.ecs.ns is and the inn In bronchus was tomograph ten lly found to !' d I-::i I "d. Analem ion 1 I y , this was a cornified cart*, inuniij nf tin: pave- me nt in' i I In.-1 i uni, with o wn I mil.-s i c.cd decomposed cavity, which also affected i.lie lower l.uhe hrnncIniR, with (ilnura callosities and meljstnses in the liver and Kidney::. The second observation concerned a 53-year-old male who, between II i 16::h and 43rd years of his life, had been involved the preparation I'nicw;scs of on asbestos plant, for a total of 7 years- Thirteen months prior to his death, there was sudden loss of weight accompanied by bloody r:-:*'cctorntioii. He. was first suspected of suffering from tuberculosis. Above che left long underneath, respiration was suppressed and weak. X-rays showed a shadow around the left lower field. His treating physi cian gave a diagnosis of asbestosts with lung cancer. This was confirmed by the autopsy. The cancer, which was in the left lower lobe, had also caused a walnut-sized decomposition of the main bronchus, and also affect ing che pericardium, the left chamber wall, the diaphragm, the peritoneum of the left upper part of the abdomen, the retropcritoncaL tissues behind the spleen, the lymph node and the lower breast and upper lumbar spinal column. Histologically, this was again a cornified carcinoma of tin: pave ment epithelium. Bronchial carcinoma had also begun to appear in the right lung lower lotio. In this observation, Nordmann included an evaluation of the various aspects which could possibly lead to occupational cancer. For the first time, there was a definite mention of occupational cancer in asbestos cci'.lctj. In 1939, Wedler reported on one additional observation made in Ger many, which hpd originally been made by Bohne. but which had not born re- . ported at chat time. The 58-ycar-old male had, between 1925 and 1935, worked as a part-time, craftsman in an asbestos plant. A few years follow ing his exposure to the particles, he began to have respiratory troubles. In 192F. he was transferred for a period of two months, l.eter, he often nn::c'-wc ut cures at cure centers, without; tubercle bacillus ever being detected. Because of a worsening of his condition, he stopped working 3 inis: In; prior to his death. In the hospital, he showed symptoms of general emaciation, cyanosis, and a probable catarrh, particularly under the upper part of the lung. Ills sputum contained numerous asbestos particles, but ii" tubercle bacilli. Ills bl.notl sedimentation rate sharply accelerated (r>7D'.i). To i In- left above, the ninth rib, there'was a tumor the size of a chest nut. which had grown together with the skin in the anterior axillary line, which was removed and found to be n carcinoge.nlc metastasis. X-rays showed .'.yii'i'tums of .lidiesi os i s as well as multiple indications in the right upper field. Judging from the documents in my possession, there was no iutra vltnn -A- . . , . ' I :i[1- I t i - 11I I i, t 'i I i -I l'() i ,)f i U f I i ' t . n( y i' : the ' i:-( ` . Hu.' 0<11., p --f i ! n;> were m ,1 f> I i :! i ! i. i J i' -11 i! i r with l hi; dies I v.i 1.1 . . ,ri v , i!..; vn' i i ho musculature hrownish-red In color .iik! . iMvwli.iflaccid. T!i.- left lung was filled with bl.ood and fluid, the l". .i lobe '..ms firm anil ci 11o-grny colored. Tin- right lung ru|iLnred in the ,v - I I'f the 'ii i dil t r- 1 .-it..- wh.-n i.einoved . Its t i - i*- Has a rntUI ish-ye ). I ok . .i M ..is decomposed anil sin",v.;l widespread format i.011 of cavities and nodes. .;:.|ier I uo wan filled th blood and fluid, its cons istenry was firm nod air-free. The lower iobe was slate-gray .and reddish-gray in color, and firm tu the touch. It was also found to be air-free. The m.icros ii 11 i c examination oT the longs showed typical cancerous tissue in the right middle lobe, and all the alterations which arc characteristic in the case of nshnstosis were present in the lower lohes. More particularly, there were asbestos particles in all the parts examined." According to Haarler (1939), six authors saw a total of 14 cases of ashestosis cancer between the years 1935 and 1938. However, this report did not Include any details and, judging from the available documents which ace listed above, this cannot be completely confirmed at this time. ln__194.l, a detailed clinical and pathological-anatomical report was published bv Wcdlcr and Linzbach on an additional patient history which described the complete course of the disease. The 60-year-old male had, between 1921 and 1939, worked a total of 18 years in an asbestos plant. Ho was only exposed to the strong effects of the particles (preparation) (or the first three years. His first problems were experienced shortly after his employment. In 1933. he already presented the picture of an uncomplicated and severe case of asbestosis, which hod developed chronically. Oaring the course of his last year of life, an increasing shadow developed over his diaphragm In the right lung lower lobe, with clinical symp toms of atelectasis and \ater decomposition, as well as severe neuralgic pains in the respective intercostal nerve area. Hlood appeared in his sputum. All symptoms seemed co indicate cancer which had alreaoy been diagnosed clinically. The autopsy confirmed the diagnosis of a collapsed minified carcinoma of the pavement epithelium, originating from the right lower lobe bronchus. There were no metastases to be found. In the meantime, two additional observations have been reported in Conanuy, but no documentation is as yet available. The first case was observed by Teutschlaender, who reported twice verbally on the subject. Following is a quotation from a personal comiii'i'i i rat ion on l lie subject: "In 1938, Tcutschlauiulcr performed an autopsy on n AO-ycar-old female, who had been employed in an asbestos plant for a I".-rind of 1.0 years with long interruptions. In.her case, a clinical diagnosis was as followed: 'l.ung tumor on the right? Lung process on the right? Secondary emphysema on the left, ascites, severe cachexia'. The aiilupsy revealed no tuberculosis, hut rather a widespread asbestosis with tussive ur.cumulat ion of asbestos particles and a right-sided plcurc blastema which wus histologically found to be pstudo-alvcolnc mesothelium. Tumors .. 1 ; ; : " '.eng ' '.i' per i l on- cm !;n ascites. llu: I.'.:, p!.:ur:il ','ivity Ih-'r.- ...r; compensacory icapiivscma in the* ... '.i he l i c fcin.i I' il.i <.' '! cardiac insuf lit icm y following 1 Tii- u. - ..I.'. .livu-rvac inn was node by Alwens. Tin.' autopsy was performed : ribcii-aAs a consultant, T become involved with tills case. The 1 vear-o ' <! naif: (fi/ .'/SI to 9/19/41) load been working in an asbestos rubber I ' ut for yours, until 6 months prior Co his death. lie bacame ill "In '.-'.Kiev r'9TJ with iucreas ing shortness of breath and loss of weight, u I ii syripto's of left pleural secretion. The respiratory sounds wore totally suppressed. and sustained, and there was right cardiac repression. Ills sputum coni.lined considerable, amounts of asbestos particles. In the jelly like red secretion, mostly obtained through puncture, numerous tumorous tolls eouid he found. Above and under the right lung, individual fine h V-h i c-1 ike rattling sounds could be heard. The sedimentation rate quickly increased. There were no tubercle bacilli to be found in the sputum. Eased on the x-rays, a moderate asbestosis was diagnosed, with l iic primary tumor thought to be in the right hilus. The autopsy revealed a mild case of asbrstosis, with a diffuse primary mucus-forming glandular cell carcinoma in the left pjeura of mostly adennlous character, and irjtastascs on the abdominal side of the left diaphragm cupola, the serosa and the snail pelvis, and the left side of the chesc musculaeurc. The autopsy report on the thoracic organs is quoted here, since no report has yet been r.aile on ' the subject. . Autopsy of the chest. Moderately developed panniculour. adiposes. The thorax is moderately expanded and flexible. The rib cartilage ran easily he cut. `The diaphragm is on the right, at the level of the fifth intercostal space; on the left side it is folded under, and penetrates far into tiie abdominal cavity. Its bottom pole here is lower than the neck of the pelvis. In the pneumothoracic test, almost 3,000 ccra of yellowish-brown fibrous fluid is released by the. left pleural cavity. The entire mediastinum is displaced to the right. The heart bangs in the shape of a drop in the mediastinum; its left edge lies along the median line. The right lung floats freely in the pleural cavity up to small sc ring-type growths. In the pleura costalls, there are gray and white tendon-like scales about the sire of the palm of the hand, with isolated tubular nodes which are also gray and white. In the pleura of the right In up, upper lobe, there is a large radiating scar. On the pleura of the right lung, there is a fine moderately firm adhering gray felt-lihe layer. Vnv right lung it.se'r is normal in size and filled with a modernlamom . o' air am! finiil. The pleura and the surface of the cut show moti. rate/ S 'Vi ro hi.-urn niesh-lypa markings. Generally, thelung tissues an- vd iu color. 1'Ik-m: are no clusters to bn observed. In the lower lobe branching nl rhe right pulmonary artery, a small brovnish-rdd blood thrombus ad heres to the intlnn. The pulmonary arteries are empty. The left pleura i:- inti rely covered with rind-like skin. On the inner surface, there are massive, tightly-packed tuberosities rearing the sire of n walnut, fi n :\ mulberry-type surface consisting of blister-like (white on the surfn.-c of the cut) tumorous tissues. When cut, the latter secretes a I - ; . : W/ll' I-'U to I'lrt 'I'OM., | i , We :;in ill'*.' < 'i' *e- f V* : : .. . T!!c' mm* fMii.-i I i-t.-ti: dees nnl pellet r:ll e .my ;'o" it". I-.. particularly not tin.* lung tissue. Only in r';;. of i..".- t'Jt^nwus nodes on the left side of the c.hcst, ns. men- t i" ' .d in tli..1 introduction, c;in tumorous nodes he found in the inl oncost a l i : i- . : I urr. The It-f r lung ir. highly atelectatic, am) only adheres m th chest t.v! ! throawk a series of growths. The lung tissue is tenacious nud grayish-ved to. wvler, and shows a black mesh-type marking tut I he sur f i. of the cv:t and ea the surface itself; which is somewhat thicker than O". '.I'.-, rip,':; side. Kc* tumors were detected in the lung tissue. The trachea and bronchi rf h.-;'* luup.s are normal in site, anil the. wall is Lender. No In .:-'t ;**.:s tissue* .as observed here. The hilary lymph nodes are bilateral ly hi ark in color, end soft in consistency. The heart is barely the size of tin dead patient's fist. The pericardium is smooth and shiny. There is so: suh-t-pi card i a! fatty tissue. The left ventricle is small; the right fin' romewha: expanded. The wall of the left ventricle is 5 mm third:; liter ef the- right ventricle 2-3 mm. The entire cardiac valve is soft and conclusive. The coronary artery is moderately enlarged, and its wall is soft. Cardiac musculature is of the same brownish-red in all cuts. The complete aorta is soft and flexible. MICROSCOPIC FINDINGS Right lung. The lung structure shows small isolated emphysema I changes. Occasional modular deposit's with a fine granular black pigment ation can he found in the peribronchial tissue. In this area, the perili'ouchiel tissue shews a definite hyaline alteration and fibrosis. In addition to the. antl;rn.cotic pigmentation deposits, typical asbestosis par ticles can re seen which are partly fresh and partly disintegrating. For che most part, these are parallel to the anthracotic pigmentation. How ever, independent from, tl^e latter, these can also he found by themselves in the pulmonary alveoli, as well as in the interstitial tissues. Massive at wci ir.c lows of real dust acd asbestos particles can also oe seen under neath the pleura. The large bronchi contain some amounts of mucus as well as epithelial, discharge. The bronchioli are greatly expanded. However, they are covered with one layer of glittering epithelium. No epithelial metaplasia ear. be found. The lung tissue directly underneath the pleura show:: a mild collapse of the alveoli. The alveolar epithelium shows a cou:: idr-rnhlc glandular, hut never non-typical', character. Generally, there are nn pneumonic changes in the lung tissue. _hcft_lev;. Ir the tissue of the loft lung, we find a collapsed in duration with dusijuar-itcius alveolar catarrh and fibrosis of the intcrslitiui-. in tin: ;*cr i bronchi nl tissue, as nn the right side, we find consider able anthracotic deposits with liyallnosis of the surrounding tissue. In this lung, we find a larger amount of typical ashestosis particles, both . in tin* development singe and in the decomposition stage. Asbestos needles are considerably more rare. The jelly-like envelope of the particles gives a * h.rae.l eiist ica) I y positive reaction to iron. In the left lung, moreover, uw rind several liemrrhaging arcns. as well as areas of tissue necrosis sMur-'lcd with the hemorrhaging b)ciod. These mostly occurred recently, since there arc abrolutely no signs of'dcmarcation. In these necrotic -7- . t- / ; .: j. . 1 : I :v I i .11 : i |.. 'll irl. :m'"s SI . .'Illd |' t 111 t I'. (' ' llh.'llply through . ! i,|ic ren.-'i n: ng ri'-^'ie. In this lung, l lm tamo h i'om h i.a 1 system .-.re found as in the tight lung. No I i1 can be found in lb i S luu;', oilher. Mi. gnusis. vinm'rout; nshcsl.osis p;i r t1 c 1 ns in bol.il 1 unt;s with miniic. I i il-rosi-; (n.ild (ni I iruin.'i ry at'-hcs( ns is ) . Cnnipi'i-ssion a t o 1 or l as i s and i-.': : .i|'red imlo rat i uu of Cbc loft lung. Hemorrhage , necrosis and minimal ti: ''.nl:c|in-.:unnn i a in tlu- left lung. P Icin'a I uijiic on tbe loft. The t urour grows in its own structure. In a few areas, there arc firm cones and strings surrounded by tbe strnmne of a myxomatous, slightly filirillar, connective tissue. Alninst all tumorcus areas have largo mucus vacuoles; several signet-ring shapes can be seen. Suiae cells with ruptured vacuoles can be seen where the mucus has penetrated to the surrounding tissue. In another area, the tumor lias the appparance of a collection of tightly-packed hollow cavities, which are covered with a smooLli, s iuglu-layer epithelium. These epithelial cells also contain large amounts of. mucus, and arc released from the. epithelial, accumulations in the form of signet-rings, and thus end up in the lumen of the hollow cavities. Tn the interst itium, however, loose, stringy min.us-f ormi ng tumorous cells can be found. Firm epithelial formatiuns without mucus formation of a solid careonoma type can only be found in isolated areas. Tumors can be found all over the pleura parietalis and visceral pleura on the left, and, in some areas, there is minimal, growth in the suhplcurnl layers of the pulmonary tissue. Here they arc parti cularly in the septum and some isolated ones can be found in the lymph atic tract. Uiaguos is Primary mucus-f orming glandular cell, care inoma of the pleura of mostly adenomatous character. The glassy nodes in question on the abdominal side of the left di.phragm tip and on the serosa of the small pelvis arc moeroscopic.ally found to be metastascs with a struccurc similar to that of the primary tumor. _ This completes the observations found in world-wide literature on published cases of lung and pleural cancer in asbestosis patients. Mordmann and Sorgo were the first to undertake a study of the cor relation between asbestos particle inhalation and lung cancer through animal experiments on white mice. For these experiments, they used ISO mine, which they sprayed with amounts corresponding to the average amounts received hy humans (taking into consideration average age and duration of employment) for a period of 1 _l/2 and 3 months. . More than half of the .inimals died nrjor to tliiv-ejmeciment Hone of tin: animals survived for longer than 9 months following inhalation. Twenty per cent of the remain ing animals were found to have a cornifiod multi-ccntrlc carcinoma of the p.ivemunt epithelium, and 42-572 epithelial regeneration in all stages, liiivri mental I y, this is in support'of the importance of asbestos dust in promoting primary pulmonary carcinomas in asbestos workers. The number -8- , ' r ' ii 1 I i' i n I i : i ' l . '* ml ( * > , i' * i ii t 1m, ,i|mvr ,i :r- : i;>- . is v*. r*y i ' . Cw-i J ^niuul**. Iwi'J im . ,u; ..i-i i.* Tli*- '.'.iHii'i's ; -:isf I vc:; r*:fcrivil t<* lln* i r i i i t v f* 11' i, i j t; i;; from smp U* w\-.rp I 'i n. W*.* must J*.-s v * it l , ;k t ic nccfl nm ipho l i: { and specialist lu rivcidc Co vh.il extent t . I ic i of tl'O csjXT invnic.rs arc valid ::ml to what extent, (Jv* . n . .-ry i - .isnccs u'ii!t rc.;o:;d to uniformity am* usu of the ncun.ii mater ial sre ol'scrvcd, and. v/iiMn Uiv.se limits, w!i ictt spontaneous i uumrs an.- to lie i f i vd under Clio type which is the subject of this work. 'ii*'er-aun .uul Surp.c r.avc a short report on chis. ' It is evident that no similar observations have ever boon made* l.*n- f-'i'c in animal experiments with asbestos dust; these experiments in fact vo:icovncd other aspects of the disease. Moreover, various dissections of an; ;,i.i I >: (Jo|-.j, rntr.) living in asbestos plants also did not lead to these ivh-crvations. . ' . i r' In discussing occupational cance.c in a specific industry, it is firs: necessary to produce statistical data in support of the fact that there is a Higher incidence of cancer in that industry than in other in dustrial or social groups, in which case comparative figures of age groups which are similar (as much as possible) arc difficult to produce. K.-n in the case of ashustosis, the statistical method also presents one additional obvious problem. This rather rare disease can only produce_______ sc'.-.n a_bsolutjc nunltcrs. One single random incident can create considerable per :rnt;igc differences. Moreover, in the case of Nordmann, we must take into consideration the fact that, particularly over the last few years, the high turnover of personnel in asbestos plants can give a negative value tc the results, since a long period of exposure to the dust and a lung dust-free interval usually must be present for the development of cancer. Now the number of workers who remain in hazardous plants fur lunger periods of time io very small. Dust prevention methods against dust injuries to the lungs also work against us. Nevertheless, our severe ca.-:; ef asbestosis arc mostly workers who are carrying the effects of dust absorbed In earlier years, when the working conditions were consider ably less proper. A second aspect of importance in the correlation between cancer and asbestosis should be mentioned here, which concerns particular conditions under which the injuries occurred and the findings made on location, con- dit ions wlii-h describe the type of cancer and differentiate from cither Ly;-- s of pulmonary cancer. . . As keystone*, fur (he evidence, there would have to he expor imeiital experience which would uiaku It possible to provoke, this type of cancer i ii an ini.sls . . Ill us now turn lo the statistical method. As reliable material, `..a .-an only evaluate here sections.with specific anatomical examinations "I the lungs, since certain errors can be made in the purely clinical diagnosis. Iloorover, purely clinical works on this subject are not avail able. r ' -9- r tl M i r. nslu- d11; i [fee ii;'! . t--S i: cjusr *rr c-::posuit- intv-rv;it SUl/.f dcnLli Author *; .1 I J 1 vn ] . : *; , :u .. / i j.. /. : s (J| :'o ,u II IS ;i ! j.. ' . U* * i:. 1 1- i: i..- J . I.; r.i .1 ' ! 1 : i_ ; )- is .1, :* J.! : | Kl I'. |o 10 T U` i: ;< .1 _ js i-< 1i 1 ! :n .1., v.' Jl# so .1., o* .1 Jl :is j.. V ' r.i J . j ' Jt ;,*i .1., \ Jl ;VJ .1.] V` *.' SS .1 , ' L'lJ k! I., U 1 1 : :-0 -1.. V1 -;>'( 1: i . . .1.. `; l/ :k . lo .1.. ' 1*5 IS .IS - 4 J" 1 j.:.; j. <; m i l.'M Jit . r.:;. . I. I.- m i J .1 >ii J-j.. u-:u i in 1 ij : III ; . H - 111 i llriilll r r.sk 1.1 . M,n- 1.1 r.'. i 'Sir... 1 r> IV : 1i 111 Hi i;1 I.!St.m.:',,,- I-* : \ i-: i i IV !: :*i* v i. i . no.-c ! i m ! ' III s i1 1m11 I i W..II- l V.*al;!u.(f I If :. nr.-.ii,. i::!. i .> i i\-.-i. tv::: : -.n. : i it ;stoniacii ca|,."'S1'.,S:.Ml' i ; ii I / ' i!i . :: n 1! I .Lunv;, .nlicusK',"'"1' Is.:-; emi.'hvscma : '.it . i....`. r .i 1 ... . r: i ; III r.i............ i \v. > 1h /).:< Ii l! 1 ivto- i i/ 1 III ! (1-l.ii r.i.: i et 1. ! J-H ! rU'Mt.t-Cu. IAIv.v*. > V lie In- r- i |; i ! ni !. 1 11 M ll i: in ; :> ;-> t:i i. t. ; III 1 l.i. in i Ml ! 1 1 > .,1 e al III ' i )u ; 1 iunc abQuss }V> 'll.- V i':.. ' ..imyloidosis : in reiial ins. v.v ct al. * 1 : : t.b. i v. . .11- c t .1 1 . ii i t.b. l.i. r.i:. i ct al. : HI Pitur.nl T...!-. Il.i (. ilc r t umo v -10- '. I ii ! - I'.IVv I i .I'll tips i |`<I ill I!' ri'a I . .! ... . ii.it uf lluv.i: v.i'v" accord i n/, rn alp.'. sex, .................. 1 ^ I . ' is .iikI ragse of ilo.iih if mlp.M- chan ashos- . v i L" ear.line. ' i:: u f f ic i Oficy or ni'.iml pneumonia as a result v ' ( i >.o.iTiio : i i'r.1, ! ;i fatal casts have already been reported. I . ; ---.c'! li"- additional I? eases. The cast of a young. ('.irl reported. 29 tan he ignored litre, since, she had a very short period (if ;tsur,, to the dust and did rot anatomically present a case of asbes- :t-. Of the ren.iini.ifi 29 autopsies. 4 bad bronchial cancer and 2 others ii-e.i a nn ii eiiant pU ora1 growth. liy performing t.lte ncessary ca I tuj.at inns . ;.ii, a 'iHiud percent ap.e number of 20?. for malignant tumors. in the lungs of c-ir-es of nf.her.tor. is autopsied in Germany. Other malignant growths of tie., iiudv i.vie found in a total of 3 occasions, namely in the stomach, :i." csophair.is and the prostate.. Although the number ol Jung cancecs "has statistically increased considerably over the past three decades, it nevertheless remains far lower than the number of cases of cancer of the esophagus, as shown hy numerous autopsy statistics. Depending on the various authors, its rate of incidence takes tlu: second to fourLh place among the cancer statistics concerning organic cancers. As shown by the above-mentioned figures, lung cancer in patients suffering from asbes tos is is a primary one in Germany. The average age at death for lung cum.nr carriers is considerably lower than for carriers of other types cf carcinoma (around 31 to 66 years of age). These small figures do not allow us to come to any conclusions, in a breakdown by sex, there are 4 males and 2 females with lung tumors. Fir the sex breakdown of lung cancer in males and females, the figures, r otherwise , arc: 3-4:1. The number of asbestos workers suffering from lung concur, based on sox, is of course dependent on the number of females and riles working in that industry. In Germany, the females exceed by far the miles enployed in that industry. For the two aforementioned females, the ape at death was relatively low, being 35 and 40 years. All cancer patients were suffering from chronic to severe asbestosis. Only one man with pleural ccrri.-.o.-.u (No. 20) suffered from moderace asbestosis; the latter had had a very long, but minimal, exposure to Che dust. Nordmann has already pointed out chat all these cases involved prolonged employment under dust conditions. According to the above table, this applies to all cancer patients without exception. The duration of exposure was 7 years in 2 easts, 10 y-.-ars in two cases, and 18 and 42 years In the last two cases, respectively. The dusc-free interval prior to the development of the cancer, during which the asbestos particle deposits in the lungs was still effective, varied (A months to 12 years).. In one case, this was not exactly known (lin. 30). These f ip,vires clear ly show that lune cancer is the most^rommon com plication encountered in cases of .asbgstosis , with the exception of agonal pneumonia and cardiac insufficiency. Even tuberculosis, whoso rate of in cidence. ts generalIy far higher than that of cancer, is considerably'lower than for l mu; ranrer in these rases. Tills constitutes conclusive evidence of tin. close carte tat Inn between asbestosis and lung cancer. It is supvisiiy. note that the current percentage values, based on large amounts of r mater ini , ar>- in complete agreement with those of Nordmann performed -.11- . ` . , ; . . 1 i! I .v.iMimi" rf -1' ; np. mat >c iI . /, a r. -a status of this (| u. - :a is .as follows: 'III. luglisli arc the most experienced in this field. However, .1 r.ling to Fuglish dueunient.it ion, this experience unfortunate! v does 1. ml itself t" tin- study of iiulividu.il observ.it Urns. This is due to' i i:, i.u:t Unit it is eery complex, since some individu.il crises hive hecn i sued irur-: than on.:e , and cannot he triced i nd i vidun I, I y . Fur the i i being. i,e shill hive to accept the figures produced hy Cloyno. based on VI ,-iutops i es oT ishestos i s carriers (according Co Bander), during ..I: i f 11 he observed fi eases of .lung concur (probably with pleural growth). This gives us a lung cancer incidence of 1211 in ashestosis patients. Very similar figures were, obtained from the United States. I as able to collect 13 autopsy cases in U S. literature up to .l`J39. This figure is probably not totally accurate, since there were a feu works which [ was unabl e to obt ain. Among these autopsy cases of asbestosi.:;, I en countered 2 cases of bronchial, cancer, which we hove already mentioned. This corresponds to a percentage figure of about 15%. There was no mention of any other types of organic cancer. Pneumonia was quite often reported (4 times) as the cause of death. suhj cc t . Absolutely no relevant data is available from France on this Other countries also reported little on the subject. In Italy, where ashestosis is well-known, no cases of lung cancer have vet been reported (Vlgliani et al.). . In world-wide literature, we therefore find 14 cases of malignant lung and pleural growths of epithelial origin out of 92 autopsies per formed. The incidence of lung cancer in autopslea cases of ashestosis is therefore around 16%. Of these' 14 cases, only 11 have ns yet been described in detail, so th-'f: additional statistical data still remains to be obtained (see Tabic 2). A breakdown by sex gives us 7 males and 4 females. Tlie ages lie between 35 and 71 years of age. Only 4 are between the relatively young ages of 35 and 41. The period between employment and the development of cancer is always relatively !nng (between 12-42 years). Short term exposure to the dust is lym-rally followed by a long dust-free Interval, which would tend Co indi cia e that the action of the dust. If there be such, gradually leads to the development of cancer. ' ' -.12- r c. o H- 00 c o>. u OJ o Vu0M) Xto* ta_>l w coI *wvna iJ c rj eo c u u n c at u <N rI 14 r r .. . !', ; I- III-, v.lif dud -I'-! red I lum severe .iwhus; iy havt- t" bv i'. tuis Conn. n-i\ v-t`i |J , ,r:-.s i- f ;-c 1 nuna ry crowc.li n-vi 3 cases ol pleural grevi.h, ,-s uf 1 mi;; o.nicvc (as much as ran bo dih raincd at this rime) origin at...1 ; vi.m'.i tin hrcni'h i a i tp i i lio l iuic. . No specific observ.i r.ion of nlvcelar , : could lio. observed hove. From a h i s i n 1 ng i tn 1 point of view, there was a definite majority of i nsi i f eel oa rr. inuiaas uf the pavement epithel i nn. Out of 8 li isto.lugi cai 3y .1 i. i;;m'Seal eases of 111113 cancer, there were 5 cases of cornlflcd carcinoma uf the pavement epithelium; one additional case of cancer of the pavement cpichcliutu was nit cornified. One additional cancer case belonged to the group of nen-differentiated growths, and the last case grew acinose. The throe pleural growths were described as "pseudo-alveolar mesotheliuit", "adenomatous pleural carcinoma" and "squamous carcinoma". In 4 of the plumcmary growth cases, in a strict sense of the word, there were 110 metastases to be found- la 7 cases, die localization of die primary lung cancer was in the luvei- lobes, where the asbestosis is always most severe. In 4 cases, Che growth is localized in the left lower lobe; in 3 cases in the right lower Inie. In contrast, there was only 1 case of growth in the right center lobe, and another in the right upper lobe. The concordance between the localization of the. growth and i lie most severe ashes tos i s-re), a t ed tissue changes in the lower lung is evident. The statistical incidence of lung cancer in asbestosis carrier autop sies is the first c.onr. 1 .'sive evidence obtained in our efforts to determine the correlation of these two diseases at their origin. The percentage figure cf 16X for lung and pleural cnacer exceeds by far the incidence raie to he expected in other autopsies based on statistical data. Aldituigh the incidence of lung cancer has certainly Increased considerably over the last, decades, on the average, it has not increased by more than 2-4'!, based mi statistics of autopsies performed. Although, as we were able to show, the absolute asbestosis figures are still relatively low, they arc nevertheless convincing, since approximately similar values were obtained from totally different countries (Germany, England, U.S.). based on the aforc-mentioncd conclusions, the purely statist iml figures present an even more positive aspect, since such data had already been mentioned hy Nordmann, although in smaller numbers. Uc shall now mention the age groups of the cancer patients. Only funr tif the latter were between the ages of 35-41. Although younger liv'pli: are sometimes afflicted by lung cancer, the highest Incidence is found primarily in the age group 50-60. Within our study, 6 patients lu. l iiuged to that age group. -J 5- r r r 1 h I'oald:"., c i .'CcrnC'!, t lie .(v;'.'., 1 Ir'i-'- ai'v ul i . II case;. : :ml U unji"ii. Fur ivi;- aucii . largo ;; , * n no i sc efli-r .1 hi'eakdnwu of V-h..! ior me I i'S -mil . |, .. : . we must, keep iv. mind that i.u ronipurison re I lie U.S., li,. number < ( er,i|il eyed in asbestos plants far exceed* the number of r > :. cep 1 need . bvh iii Germany and in Gotland*. us we have already mentioned, one important cans i der a t inn is the i i e-;i- n; i i-i n i d.-n, ef vrnt'I li l.oen I. i.t.a t i on with i lie most severe changes e n: a- .1 by a-lustnr.is in the lower part of l lie lung. Moreover, the li iylological nature of pulmonary growth is evident. S:is t ica I ly, the incidence of mostly cornified carcinoma of the pave ment epithelium is by far the highest. Out of 8 diagnosed cases of bronchial cancer, wo found 6 such cases. The general lung cancer statis tics for various types of growths thus become one-sided to the advantage of cancer of the pavement epithelium. If we perform a histological break down of lung cancer into three large groups, namely non-difcreutintod colls, carcinoma of the pavement epithelium and carcinoma of the columnar epithe lium, the first will have the highest statistics with a total allotment of about 2/3 of all cases.' Since cancer of the pavement epithelium has the i-we't tendency towards metastasizing, it would be understandable that, of tie above observations, four were found to be without metastases. The histological nature of lung cancer itself, as well as the above-mentioned highest incidence of cancer of the pavement epithelium, explains its classification under lung cancer. Cancer was only observed following a relatively long period of latency folic ins exposure to the dust. Could this he due to the fact that the period of employment under asbestos dust conditions was very Jong, or that a short period of employment with considerable exposure resulted in a longer interval during which the effect of the dust continued to progress? A scries of thorough observations, which were partly performed by the anther himself, showed that, particularly in the case of asbestosis patients, dust intoxication often appeared during this first interval, and often led to progressive fibrosis. Among all the lung cancer cases observed in asbestosis patients, there is not one single case in which a long period of action cf asbestos particles was hot reported. This agrees very well wich odor observations made of other types of occupational cancer. Other histological findings in the lungs of asbestosis carriers allow us tn hotter understand the ahove-raentitmed correlations. In the small bronchi of lungs affected by asbestos particles, we mostly find gcncrali.-.vd epithelial me cap Lasta, considered as a per-cancerous stage. It is very prebahlc chat the carcinomatous regeneration originates here. In one ase, Nordmnnn even made the observation that, in a severe case of carcinoma in the left lower lobe, a smaller cancer was beginning to develop on the oilier side, which was not to be considered as metastasis, but rather as a etIi-dcvelopiny cancer originating from the metnplastlc bronchial epithelium, for that reason, he considers the multilocuLar development, of cancer in os h siusi;. patients to he particularly significant. Here we find parallels to l hi Sclmcr-herger lung cancer. -16- ;; . . :- ; 1,1 1 'r- i ,1 , j L . 11 j r*'' . ' !u 'U^ll " r II* ! ; -1' -11 p i r.- i : i: > :.. j i-, i 'I <: mi i r i lotr > i . 11> d--1. I vpm.-u ; n f r mi r . One : 11 * i .:* i (, i ! i " i ; I lie Mnr-.isi.-d [- n-li-iu'v Mv.-ord si--..id in r 11 t , .. . T" ii.-.vic i few. i-;t ran speak of extensive epithelial drs.|u imnc ion -..-i- i a It;-rat ion nf the shapes of epithelial ci-JI?, formation of numerous -;--,a ,-.cs and pi-in-' foreign hotly colls, as well as pro I i f oral inn of lie- ; ,-r t ivu tissue- Thereupon. as mentioned by binzbaeh, the various ri ji:i.'s ore released from their normal, condition without the injury re id- i.rsnt- ht inj; r'-:tenr.ive enough for the ceil to collapse. This in . :.--a d trnil'.su-v i .-u.-.utl regencral: i on anti the disorder of normal tissue ojw-.I 11 ions can probably he considered as promoting factors in the develop* ir.ent of cancer. These theories also apply CO pleural grouch. The pleura is involved in the decomposition process. Here we. find epithelial dc-.squam.it Lon, fibrin deposits, regeneration of the connective tissue, corntficat Ion and accumu lation of asbestos crystals and asbestos particles (Gloyne, et ai.). Ml these theories are based on statistical figures and constitute valid arguments in support of the Inner correlation between asbestosis and lung cancer. In addition to the increased incidence of cancer In asbestosis nati on'.;., ve also require proof of the reproducibility of the conditions through experiment at i on. i\s yet, this point could nor be proven in the case of asbestosis. This, however, is not based on negative results of experi ments performed, but rather simply due to the fact that this question has not as vet been addressed to any significant degree. The first experiments wore performed by Tordmann and Sorge, who obtained astoundinply similar results. These were already mentioned in the previous paragraphs. For more certainty, however, it will be necessary to obtain forcher confirma tion and recognition of \hls complex correlation from other specialists. nevertheless, all the observations made up to now tend to indicate with oJl probability that Nordmann's theory on occupational cancer in asbestos workers is a valid one. Other authors such as Cloyno, Lynch and Smith, Egbert- nod Geiger, as well as Linzbach, also tend to take a correlartun of the cause into consideration. No attempt has yet been made from any side to deny this assumption. If we now attempt to determine the origin of the carcinogenic effect cr - hestos particles, we must differentiate between general and local pro mating factors. We can generally assume that the occurrence of cancer in u'lially due to an inclination (predisposition) coward rhis disease. .lust where we shun Id look fur the answer for this is difficult to say. Wc. know (uci r.enoral human experimental pathology that predisposition toward cancer i fi dependent upon uysVcraic factors. This is particularly evident by the l.iet that wider identical experimental conditions and fairly similar ex- pi.'-ure to carcinogenic hazards, only a numher of the endangered persons dr .irmallv suffer from cancer. The available nsbcstnsis-relatcd ohsc.rvaLi,-;-. material' is not sufficient to allow us to perform on analysis of f.tmi- 1 I.: carcinogenic conditions. -17- . .:' i,:! Ill' :r. iii .. i. i Hi a- l, . I ' |i. i i i ! i it | ii l i i. .m < : -i'll j 11 < il i '1(1" . i I i f in 1 ' i;:iihii' is in it. k iimu'ii . Our t I n r ry : i . . i ; ill only :i hvp.'isis. tiii'.'i.-vri'. it would seen i.liut ii,1 r.i I in' isssitinn is not s;ruu: enough tn promote cancer in ... r lu's.iir.. i:.`:i of the aCorc-moiu iwnwd figures would tend to indicate i iri . Tin1 v"'fvini' I in.'i I i z.i I i nn von 1<I seem Co hr of primary iinpni'l .mo; i'.'i.'. its i'v ' rjilii l i.'i; i n-i I effects cm the oiocl i i eel tissue: tenet ions nf the J h.'ivu a I wady lieu'n mentioned. Since the e:111.*inL<:;> 1 definition of as- *i- ns is fairly simple, the conditions in this case ore easily understood, r.ir.'it from die start, we can state that one of the- elements from the- group of wel l-linnwn carcinogenic agents can lie taken into consideration hero. 'fin effects of ashosi.ns particles on the lungs arc- probably the result of chemical ami net nan i.eul in juries. The chemical effects can probably b'- traced to silicic, acid released from the somewhat vulnerable serpen tine asbestos. Based on experience in the field of human pathology and numerous animal experiments, it is very impractical and unlikely that the latter would have any carcinogenic effects. Vie must keep in mind that, tin.' tissue changes which it causes, and which are different in their local ization and extent in the case of asbestosis, would therefore present different conditions than silicosis. This different type and form of tissue regeneration can thus cause different biological reactions in the tissue. In addition Co this, however, the mechanical repercussions of the many tips of asbestos needles and particles, most likely are character istic of hornblende asbestos with its solid and hardly soluble properties. These probably play a significant role in the typical tissue reactions resulting from constant mechanical irritation. Ke must finally rcmenbec that, particularly in the bronchi, there can he inflammatory reactions in severe cases of asbestosis. These arc partly accompanied by the formation of bronchiectases, which can also be proiuuting factors for the development of cancer. Eased jn aur current knowledge of die subject, it is in these general, and, mare particularly, regional, factors that we shall have to look fur an explanation of cancer development in asbestosis patients. By defini tion, many of the injuries do not come under the group of chronic irrita tions. The fact that we are still far from completely understanding the finer factors involved here also applies to cancer development in asbes tos i.s patients. Let us now turn to the clinical diagnosing of cancer in lungs affected by asbestos particles: basically, all diagnostic aspects taken into r.onsideratimi in the case of cancer detection in the lungs and the pleura can he mud and are valid hero. However, since this type of cancer originates from anollier primary disease, we. shall have to take special cliaiarter i ::t ics of the clinical image as well as known elements with regard to the. symptomsLology of ashestos is into consideration. For elm past history, it is Important to first do an occupational .-inninuns i r., and keep in uiliul the fact that lung cancer in asbestos in patients generally appears only following year-long exposure to the particles, luit -18- r r r : ......... : * ;.} i i i 11 : i < -. . v ; i s omI" !": ' n'rPliv in -.h i < J t I he <!u r.-d l n r 1 i. "i of 1 r r >.! m i:iii:li| ion** v/n . -i:' y I I / '* vr.irs; iii .'ill < *1 ' i- i' r ;i:.e' -, . . .i' 1- 7 v- i;-.. (-I- riot-.:. In liu'' of s I to r l C o nn . imotsivc t" chr jiartidvs, i appears that theta is always a longer duni- - ,crv;il I* * i' o r tin.- app--.nance of i';iin:or. yet (here lino no : n. r h e period of line fcor.i the date of employment in dus K - f i 1.1 'd ,.|S-. i fj. up to the ronf i morion of the preserve of cancer was 1 <<:$ than I J irs. ('.'ni'nllv, wo con expect t!-m cancer only occurs in p.wt irulnrly ii i!i-".iiucd, if not a I a y s the most sewre, forms of asbestosis. The nbovc? o...!mpl ci ort: support of this. Thr first symptoms of developing lung cancer, which are mostly not characteristic or pnthopnnumonic. will not be as evident as they might be in a prcvLour.Jy healthy person, since shortness of breath, coughing, e:;- perforation and certain discomforts in the thoracic area are already ex perienced by persons suffering from asbestosis. A certain loss of general strength, which is sometimes not present at all. in the early stages of cancer, loss of weight and loss of appetite, are also frequent symptoms of severe forms of asbestosis. Acute worsening of the general condition, including local lung disorders, often indicates accompanying infections which arc more'difficult to overcome. In general, the rule in the case of ca:-?s of pure asbestosis is that the development of the disease occurs very gradually over the years, sometimes over decades. Xf there is evident iocaJ and general worsening of the condition during Che course of such development, die possible occurrence of cancer must then be taken into 1 mi*idcrat ion. In addition to cancer, infections which are most frequently r-.-n-specific arc also encountered with bronchitis, pneumonia or nhccssws. /.wording to our experience, complex tuberculosis only played a minor role here. It is also much too often diagnosed. Of course, it is normal that it should be considered ^/ithin the realm of possibilities. Nothing has yet been published on possible accompanying pulmonary lues or fungus diseases. Of the general symptoms, quick Loss of weight can be an indication, bur it is not, a conclusive factor. This, as we previously said, also applies to the lack of appetite, unhealthy appearance of the skin, and nip.hl sweats. If a.IJ of those are related to the progress of asbestor.ln, tiny will generally be accompanied by increased shortness of breath, cyan osis, possibly drumstick fingers and ether local lung discomforts: how ever, we must, keep in mind that a lung tumor would also promot e an inci.ase of such disorders. Generally, however, the status of the. disease :'< 1; 11111L be dcterminod based on the cose history alone. There* is little additional information that can be obtained rrmn In-al disorders. Since severe asbestosis generally causes considerable in itaLiun through t:"ghing, little can be achieved from this symptom uf lot* disease. This also applies Co shortness of breach. Sputum observa tions would appear to be more important, as far as I am concerned. In the rase of non-complienteri asbestosis, the latter is mostly sparse and ;:! mi iiKHif-; iu the rase of more acute bronchitis and bronchiectasis, it ts '\*rv com.idcrabJ.c and purulent. it rarely contains blood. More frequent -1.V- r ' r . . ,: ltl. 1 - I WI i : : ; ' . I f .! i r i . . . . I*' .......... 1 in -.ir. nf i < |*!* f ry * r "> "in- ' ' . . .i:,I il` . i i . 'i tiin ul a1 i i ui , l e- . " > t . t i w i > - . - ; ' . Vt - ii for i. . i'' :.: : i '.up I < :r h< l ( '. i u - roie ! I " ii :\n\. 1 ......... .-.-.lit in f11 .j u' lloruii; incut i"ir- ' 'in;; sa.i ti'n- s i n.i .cb U' "f epithelial colly in dip sputum nf 'Jin nsiiestinis n-nL K i III iih--:. T l" tlu-re Is roll ipse of l;hn lunp, t i.':si:e. this ran c < -11 y Up ii'.vr.i M'iud through the n 11 ".v.i l ion nf dm sputum. Til In was a p if n i f i I'.nii fart it in my nkrervacion. The paLienC suddenly began u> I i 11 i . -ip I :i i i qiiiiii ii ies nf rnre-shaped lU'i'i'i'L ii; masse;-.. I'crlmpe we in finii In.-:-.- dip ".i.'.in'Sios is bodies in clumps" symptom as mention'd by t!i. . English. Those a re rose.CLc-shaped .iccumu lot ions of asbestos particles which always ;ip|ip.:if in the sputum whenever lun/; tissues collapse (abcc.se, tuberculosis. tumor). Their diagnostic value is similar to that of flex- i i i!.- fibers observed in the sputum. He have already mentioned the signi ficance of sliorlnn.'is of hre.atli. In widespread tumors or bronchial ob structions, this is directly related to the latter. On the other hand, l find chose pains to he highly significant. For patients suffering from ashestosis alone, these arc generally minimal and non-specific. In our tur.nr rase, these progressed parallel to the development of the tumor; they were elmractet irat.leal]y neuralgic. The documentation contains simi lar observations. These ate due to an attack by the growth on the parie tal pleura and possibly the intercostal nerves, if not actually on motas- tascs. These indications of the general and local disorders which can mostly lie obtained from the case history should be sufficient. As far is other objective findings are concerned, please note the following; asbestosis affects the lungs bilaterally. Exclusive uni lateral processes, whjch generally indicate a tumor, do not occur here. Tiic alterations which occur are generally very symmetrical. However, it must he noted that fibrosis cao normally affect che right lung to a higher degree. General suppressions are never found above che. upper part of the lungs- The respiratory sounds here are mostly hoarse, but rarely weak. The sounds of related pulmonary parts are mostly slightly to moderately weakened, and if not totally symmetrical, at least always bi lateral. Onlyindurat ion or specific as well as non-specific complica tions can cause exceptions here. The respiratory sounds are weaker in the lower part than in the upper part. The opposite is rarely the case. Aci-.nn.pnnying sounds arc more considerable and frequent in the bottom part than in the upper part: lateral differences are not significant. If definite symptoms of atelectasis are observed unilaterally, this could indicate the highest degree of tumor. Of course, this symptom is not always present in the rase of lung tumor. Effusions, particularly hemor rhagic effusions, are hardly ever observed in normal casus of asbestos is. The Ii..... .. can show sip.ns of fusion with the aheess: and l.ubc.reulos i s. I'.I-I. Ill'll i err an i in (he form of eylindrir.nl tracheal, expansion Is Croi|iieiil: in sev.rc cases of asbestosis. Their differentiation with fusions can some time- cause problems during the clinical examination. An uneven asymmetry of the thorax, as well as distortion of thciuodiastiual organs ami diaphragm, requires special analysis. -20- ' ?yv,i p ----'* T**w r r r ', . . , i; 1 d i*' i'' l'-' : P imp* >r c.:n ( e:-:;,: lua'.ii-n '. Lr.- pr-.'-'tii'c of ." rumor. St muff he romi-i'dM-ri'd r. of .1 -it.--i>ido n:. 1 .iK'.'iy- r- nil in a purely symmetri- . . ; it f tin I ue;; ; issues (.is claim in the documentation). In , i i i .i i n nsyi:-:. t r ir: , there ran ;il ?: superficial ilt'i t i pl` i ve . ; : 111 ih. l"-..-r finl`1.", p a r I. .i e n I a r 1. y in : I; medial area. 'lie:;::: era:.. slHcjeve. Iinwover . arc usually not so compart anti tumnnius . hut i-.-: ;)rc ia rlie ferni of somcwhnc hazy stripes. Solid or tomographic : r ' t.. -1 -.iiev tin' hioiiclii.il system as being open and comet imes even r:. eSt i!. I; r r ue'h i a I stenosis, wli i i:h sn.net imes follows i nf eel' i on , has not e.v-.l h.-ei: observ'd in cases of asbestosis- Compact, uni .1 a l. era I and s'c'evf icial 0|tacities in the lungs, possibly with bronchial obstruction, are practical ly almost indicative of a tumor. This also include:; media set;-.:) displacements which are either constant or vary with the respira tion. with paralysis of the diaphragm and recurrence with upper lobe pro- rrr~;y, mostly accompanied by a Horner syndrome. Circumscribing opacities in the upper field-.; never indicate asbestosis- These conditions, in. this rase, are much clearer and simpler than in the case of silicosis. In the case af asbestosis, coarse shadow formations primarily indicate non specific infections. Tuberculosis is far from being as frequent as is : ally assumed. based on previous observations, its appearance rarely crtcinatos in the lower fields of patients suffering from asbestosis. For p;-v s of completeness, ue must add here that, within the scope of use ful -iag.ntsric methods, tomography and bronchography can give different re;-.:-:s os far as tumor detection is concerned, and are to be interpreted according to the standard rules chat apply. The same applies to broncho- sr;;-; . Cif.er than for a few experiments, there is little knowledge av.-iil- a;-'. 1 r diagnostic lung punctures performed to detect asbestos particles ir. t1 .lung fluids. With primary pleural tumors or metastases, the detec- ti:< 'f tumorotis cells In the punctate greatly elucidates the situation. This was aLso observed t Alwen. Ir the. case of metastases, the diagnosis can always be made quickly. The fact that persistent tumors can create fever is diagnostically iion-rignif icant, since infections also cause this symptom. As far as blood count and the erythrocytic sedimentation rate art: r'".: rued. please note that anemia is not a symptom of asbestosis. On tin. 'ntrery. high color and cellular values arc signs of compensation. ~ anyii-.g infect ions could cause exceptions to this rule. Increasing .iii r.-c. with chv exclusion of complicating causes, could be indicative of a in; r. ,\ d i f f ore u< i a I blood count should also not be considered a:; diog- iiu: ; i - evidence of the presence of a tumor. In cases of uncomplicated as bestos Is, the blood sodimentation rate does not Increase in itself. Never theless, it is often found to he significantly higher in group examinations of a large number of asbestosis patients. This is probably duo to the fact Ih.i-. infections of thw bronchial system are more often encountered iu these par: i';;ts. higher and increasing sedimentation rate must always he nb- sci".o.i and evaluated according to the standard clinical standards. -21- i. . ' . '`c Li;f` rios* iv.pt.M* t nui t: I i a i. r. 11 aspect:* "f 1 * * *:; *, lurv'.w . :i.-` -is pat.i*MUs. 'H -fimti' iurrrprrtat ion of rlu* l.uicr j' ; . purely clinical .,,ncrn I 'iHpl mii.i I * \ oy.\ .ml * in* i'i-i i-lt .ii:.. 1>i in. I :ivuhinj symptoms. The important citing, ns f.ir ;j*< rhis is .n.vnial. is be able to recognize the clinical picture of asbvsto- i a I v l.'0( in ml ml that there can hi* eir.p 1 tent i mis wif.lt tus-urs, are dcre^icd in the Juries of asbestoses patients almost as f t'`jueni. J y :*r- active i al r r 111. -si s . tn Germany . only 10 cases of active tuberculosis Ii.-,.- iuen j*.-j i, > ri < ! (* * i* asbestos is patients as compared to 6 rases nf tumor. . ff Lite nc Ulcaice of cancer in Ilia lungs of nsbestusis patients is as I rr-queni os we have just stated* and if other conclusive evidence exists to support i he theory that there is a close correlation between the two diseases at th<. ir origin, we must, even excluding animal experiments, al ready consider extending legal insurance protection to iucLurie this ail ment. Tn previous compensation cases, trade associations have recognized Lliis correlation, based on the uniform attitude of specialists on this natter. In the files which 1 personally studied on this subject, no specialist in Germany has ever adopted a different stand on the matter. SUMMARY The present document contains a report on case histories which have been reported and discussed concerning malignant lung' and pleural tumors j.n patients suffering from asbestosis, based on worldwide literature. The reasons behind the original correlation between die two diseases arc given. The report contains a description of the clinical picture of lung tumors in asbestos is patients and a recommendation that insurance coverage be extended to include this ailment. REFERENCES 1. P-aader, E.W. : Utsch. med. Wsch^. 1.939 I, 407. 2. Egbert, D.S. and Ceiger, A.J.: Amer. Rev. The. 34, 143 (1936) 3. Gloyne, S.R.: Tubercle 14, 550 (1933); 17, 5, (1935); 18, 100 (1936)* 4. llornig, F. : 2. Krebsforsch. 47 , 281 (1938) 5. Linzb.ich, A.J. and l/edler, H.W.: Virchows Arch. 307, 387 (1941) 6. l.ynch, K.M. and Smith, W.A.: Amer. J. Cane. 24, 56 (1935). 7. NorUmnnn, H. : 2. Krebsforsch. 47, 288 (1938) 8. Proc. 8th Ini ernnt. Congr. Accident Medicine and Occupational Frankfurt o.M., vol. 2, p. 983. 9. Nordmaon. M. and Sorge. A.: Z. Krebsforsch. 51. 168 (1941) Original, (iceument not available from the publisher. -22- r :. V . : ' i i . .r. Hnc: ioi . I I . V | (I < i?i) II.W.: Klini'.; .ler l-unpiMi.isbostr^r. , Ci'org i'l i l cin* ; V! a ' -23- 91' ' . ' < ' ,ir-.te* - " ' - 'Jsfc - X , ^ w^.:--|r tilhBrwF^'^mf^lke:sisJ^.-n''''1^93'3'^':fttirreea` ftiirss-t8m:;ednetaiolirrii^go:f^t iath- c.paractinhoomloatgoiucs^^atunmaotyr-rian n;thae:.^vasst^t ?SiV ;eSI-La^v v,a +>! ('nnmUMtinnc.nf^o.^^ S^ious^iseaWs^ichJvaocoraing to .tie knowledge of ,'tnat^toer.ihaa-nothini VS?F^--UBUUa X'3 do; ' ' , :-' J ' J- ` "" ww j .. _4. - A ,,^V,~ 4-K lnftow Vi cf woTi'f n /-M-. c " ^V ,, ,, .1 Wllicll.-r ,.carc |>|g--.any;:,wj . .. ....... ... ... ..... *^%ln'-V*35 iGLOTNE '.could'-''contribute 2 further cases - of .lung,:.cancer. with' ashes; sis'^^huf iie-hlieved-that an etiological-, connection or both.diseases, could * no?'bl"lsr?ed yot. Certain histological.points, of view, howeyen, see; to.make .-it.viui'te obyious.^ * "- WS^v -e^Tlhteov;^sirsJtpfioSfn";e1^rh'efsoer^/S2h-oeSaarse,r%Taataido>nws hcoo; n:aceftrenerdthaa-rwt,o^m.caonn-,t/i-n^u-wehdor-thoadlx:;.vbeee/rsiiatialllay; ^othef'* 9^yeats-'without'.tbeing.exposedt o-asbest.os . dust .;^s. the - aut opsy -sho; m-i aSe^ied': oL Piaodafate-; asbeltosis, axlot. in Ihe-right.heart ,v:spleen .Infa: - i i jt.-. 1 . ewhenoV" A_ nl 1 n 1 c.fi 1 ot..-Tftf>nffn 1 !T fiWfl 1 H .* stas^lre^ntr.&e:>^37 piati.-egltt.eilx-. oarolncna..had?f|^.st.artJ:nco?oi f-nwrrr at. a" small'.bronchus.i. --.i .. .. --. > :'-V <. - ; f_ . a.-cough." and/shprtness' of;breath;""Eight'-,ydnths: pribr_-t6.jjtlie;vshort^hbspitalv; j3? /treatment, lie."got sever.e,/rseizure'-like;"backaches.-.'Ete';haci-grown-.thlii^ was T~gy hardly' mo bile-.oh account-.-of "his pains/i-had a. cough,.;.cyanosis-and-: shortness of bTeath-as-well- as-hl'oody^purulent sputum./^side from/the -ashestd.sis',' a\ SM-.;-.-focus was roentgenologically detected :h -the-lower;part/ofrthe/left/lung i-r-v. which resembled an atelectasis or a pneumonic processj-but;> could->e;-recog-SvV.'. nized. as -a-tumor, be c ausev-of.-me t a s t a s e s j? re s en t ,vin/the/pe lyis a nd^ 1n the~s xgi?? na1colUEajCiuri^g,'the.'Tautopsy. ript/ealy-tbf> -asbestosis/./but/aiso^a^':5-;4-c /^^//me asurlug\hcinpuS^cancer.f-in /the reft_ lowen^-loEd; we r e f ound which'had;; -e star . blishe'd - met astase s -in'ithe -* lungs','the'iLdTt-sided--'glands'-.of hilus\ and -aorta; Kw:-" the, right radrenal gland (suprarenal body) ,, the musculature, of the "abdomen-, the1 pelvis,;the/spinal-Oolumn and-the skullo The .'level' of- the::tumor.-consis ^ \.:t ed - of; a .big" 'branch-bf the'--brbnchus..'.ofvth.e left flower: lobe .j Thus .an/et idle '//conhec tioiribetween:\the.yfcwo.-illne'sses seemed very; obvious tbSthem,^namely ---: ; Vtha t''t he^ irrit at'ihg;}effe c^s^of ?:t he~inhaled"'usbe sto`s}parti?cl e s;;tmay-=-in'' ti ^PLrj?ase .'hayeibeen'a'-Tsignificaht^-factor-;..cbncerned;'"in: the- "deveiopmeht^of:sthevpr i.^^^'marFjrlung~-cancef-'"aeems:'-sufficiently plausible It o' be "worthy.- of/ considerat ic >- , U-iV <- .-y^- . ,- . f.- .- -j,.... Lg-^*/^vr/.:T-TrPrv' 1936'GlOYHE/'was -; fal-bblea'ttoo~' adddd,;, a - furtheenr:--'one t-too. Trreyious/ 3~'Ob'sexvatibr He';;found~~a'`-dedifferen11 ated ~carcirrcSiaTof,,the -.l|ft^/lower >e- with -an- asbes ,WEDLEB_idr e-w -'-'nttent ion i.n 1939t 6 .another; observat ion'jinlGermany which, -origi- ^.jiatet .~ iha d w .from, orke d.:J- iltum^yBut.lad'.not" -been communicated-(made rpublic),.-51he/nan,c:3Q:: uye ;s'r-1'*(/ 1925'.-v.r`' 119rt37f5*3^ .; as. .m..Kaster'."- ^-wor1kman ' in ..-1an--*' a_s*be`"sjt. os*_-p 1lanttl`_'. -:..0rsn.. :^l.y>a:;few'-.year.s'after.'having- been exposed;to dust, he -already:had.- tr.pubiewit ^his-respiratory 'organs;s^n 1928 he-was'-tent for;2.months .to aheaith resort; ^Several" times.-thereafter he. took .other rests at sanitariums,-although no"my- .^^cobacteria-;'.tuberculosis -were''found. Due -to an increasingly,;-wor.sening.\conditi <:^^he ' quit. his ;J ob 3 months 'prior ' t q his death. In the- hospitai'he^-showed'.signc ^d^of'-a general-emaciation, ^cyanosis and a catarrh which.was.-especially,noti- ;~4cible-over,ithe ...lower'part, of'the . lungs. There were numerous asbestos-'cor- '-5 ^p.uscles\in:Jthe;. sputum-but ho mycobacteria-tuberculosis.;;-The .erythrocyte, sedi ,'^.ment'ation was -strongly- accelerated .-.(57/95). . On the.deft/ above . the 9th rib e > behestnut-si zed; swelling; which was. grown together, with .the...skin, - was found .'ir T/^he'" enterior~raxillar-line. It'was removed and turned., out to .be. a .cancer'mete ..JL"stasis. '-ftoentgenologically,/there were, signs of an^asbest'osis as well;.as; an increase in-markings in the right upper stories (regions). According-to the/. Evidence-at-^my disposal, there obviously was no diagnosis -of; a.'lung cancer r^Jintra-' vitam.dThe- patient -expired- of heart failure soon after-'the, excision lot '^tthe ..metastasis ;rThe:.rfindings of -.the postmortem examination . were.de scribed-'as ^^ff ollows'nbT-i'TheVlungs .were tightly grown'together with ;.the^chest wall;-;Thet'- S' T^.heart*was not \enlarged,Ithe./musculature of a brown-redd 1 sh.-co.lbr-^and-fof -a^ dsomewhat :f1 a c c id"'c ons i stency... The left lung was-.full '-of "b1 ood;and 5fluid/~the ;;v:'./lower;:lobe - of solid';.(compact).- consistency- and of .slate'colorUpon "removal,-: V.the right lungft ofeyin.the area ;of-the middle lobe. Its tis.sue;. looked.yellow :freddish:'and;;completely^ deteriorated (decayed-)'and .was showing extended cavit --j^and. node format ion.'. The upper^. lobe-was-rich in blood'.'and fluid,, of firm:con '^\'histency; and/free of.-air.-.The lower, lobe was of a s_lgtiah, -greyy^^rreedddish. cole ^n.;and-firm./consi'Stency;dIt'was' also free of .'air.-.Thefmmiiccrr..oossccooppiiccalN^examinatio; I'/ of athe ' lSihg_s.l_s_h_pwe__Md_^typica lr c.ancer.-.'. t-is sue in t he(-r ig.ghhtt .middle . lobbes^',y. rwhheerree aass, "/the..: lower. lobe/^resented..''.all:"change s.^which. are cHhg.a fct er lafcL^fogasbe st osl* i:tumorraodes-;EL"the;.jiTD ^musculature ^;Tlie.. ' le^itliiimg-is^?:s't^op^ly4^electatic;andftaahers~o'nly/wlth}a^ ^'r-' - rT<rfc1-on'-H:fti:rkh'','5ft'hes'tiSWftTlr^3?he-*"liinflr-s,;tis rare^Ti s o-f-*a-ri::nnff:h -flTin'-fft on s i-fcpn mr cKia/rjofs-botii^imgs ' afe^dtipr oper/width);and-' ofv dellcat e;'^air.i:.Jumor,. tissue . ' n owhercpiroTable v Lyraplm'odes.- 'of;i.hi'lus'':on ''bothisidesijare* of/black ;"color - anc. soft^cbnsistency^TheCjtieart.-,1s..hardly;.-e's -big. as-. theTcorpse'-s; flst.^Pericai v-p. .diumiJteare s. Vsmooth'^and/shinyiv Subepi card ia 1 fatty..';t IssueTf.i's>pre sent^in/mo- jjgL'-.. aerala: abundancerv;;inhe.M:el*ti'Tentricle';l's' small/: tJle--';xight'*-t)ne^aibi1j;-fenla2:ge-. : "-/r;.. ?he2 wall, of '5the-vHef-t.--.'ohejS;-is. 5_mm/:that' of-'the ...right; 9ne/2:to -3; mnctJiick 'Vf-hr M,,' allrheartcTaiTesdelicate and/capable-Cf. ..closing-; -Crown>-(wreath?J - arteries' ..... on-f.medfliluiim wwiidfltt'hh'/.'aJanndd ..ddeelliicate wwaalll'..--'Thhee.myvocardium iiSs'--eeTvee-nnllvy- brroowwnn-.r-rreadri. oh-ai _ cuts.vAorta.-'iisfull; expansion is./delicate-and elastic. 1 'C^. :HicroseopicaIiiindingSj^ '.c-v;'. _ >t~ 1 lingir-'lh^laceslthe "lung,"structure is showing-minor .-emphysematous "i ... , changes. iNodule-shaped/deposits\of. a fine-grained black pigment-are .found ,-..i ' several places f^in the/peribronchial- tissue, -In.,this;.region,.-the peribron- ' .chial'. tissue.^sBows a-';distinct .-.hyalin; transformation- and 'fibrosis."let besld deposit'si'-of.' the'-'anthracotic-pigmentJ one' alsovsees partly ,fresh,.. and;^al_:V- ' so- partly degrading atypical asbestosis/corpuscles. !These'.are ' always -lying r. I/.: - together - in vlarger;. quantities /with the' anthracosis pigment.; But~they.;.are-al so .found;- independent \o~.that /-lying alone in. the' lung ^alveoli" andinrt he:- in .terstitiaritis.s.ue,;;>ILlkewise,rJbhere -are 'plenty, of; coal.dust, deposits;and .as- 4/&i-n./ _ merX'-'epithelium/iEpithelial- metaplasia', are.' nowhere. provable/;TheTlhng tissu iimmediaI't*e*ly--J^'un_d-er'the_^_.pleura* *".i`s i showin. g a_ .-s ligh ti co^ll^apse of'the; a^lveon li/.Z:Ui . Tiere/.the alveolar 'epithelium.'.shows often a glandular, but.'nowhere.-atypical -^''i/character;-.rOther: thahStlia.t ,Tnowhere -pneumonic' changes in: the-lung/tissue.^ !r$i? foffl' 1 V^sUyj^^lli^ueytof;' the'left .lungr.re veals/the finding of -the ..collapse Thir17' asbestos workersjhave-hitherto''.been dissected in Germany .-?The'~ added tble.;Noi:'^l^("pgi-;-:1.97)`:is rendering -the-.cases according/to i/age, sex.; > time-'o work.,-..-.stage --of^sbest os is -;or.r:the hearts weakness' conditioned-by -itv;or- ah-., e g on al~ n heumohia'.' The .-first-, 18 -death s. have,- a Ire adyv' been" published-.?'!' havei- collected - the remaTning~l2^~ih^under -Uo.29" listed-young.-gir 1 can;, here be.i%^ft.T:'`n'eglecte3i..-since she. had only-a'short exposure^o.'dust ;and., enatbmicaliy','5 iS7-^:'^adn^ t^deTeloped' an-asbestosis"' as yet.- Of the remaining-29 dissected?, ;-4;--ha . a bronchial cancer..and pothers a malignant'.pleura tumor; -From .this^a-'perr centagerofvexactly 20# can-ibe-balculaltra tof^ma-licno-gt tumors of ;ihe /lung'7;with-.dissected.-asbestolers-rln:Germany.--Other malignant .-new-rformations pf ith rS^^body-^ere -f odnd^a'lt bgeth'ertbnly^3: .t imes,. oneeach^of^the." sfomachp'h;he^reso^ pjiagus'.'and 'the?"pros-tate'viiEven.v if. -'the ?lung-'cancer. 'has-' statTsTlradQ-y^ihcfeas ^^T^cpnsidei-ably ih vthe:p a s t-3 -decades so*is- it still?distinctively. outstripjpe cancers^-of-1he^'tli'gestive"'tract',. .accordinghtonnajorr-autopsy^statisti otherwise',? depending-/-bn/.the.-/different authorsj^'its frequency -puts?itf>in th 4th to 2nd' place 'in the. cancer'statistic of . organ cancers. -In GermariyV-'the'J; V^:?-lung cancer;with:eLsbe'stosis' is far, in the'/f oregroundV?as-ithe above?figures ^~?7?are. showing"/ The average age of -the lung -tumor.vec t or-atvthe ?- time- of?death ^9'#'!:is"'-- al so ?' cons id erabiy. lower., than.; that of: ve ct or st-of other/care inomat a/f(roun 2j^^/ly/-51"4d?-66^e.krs)'`.^rs>Y^tb7.be^:'Sure^.''^he ' small;numbers: are ', not allowing^as >to-;bom^^o^_special^{p.articul^r} .'conclusions^/Accordingtrto the;-:repa3>-?n ^^^iCti^tloa^fSthei'sexea^aCdr: every-^bnen: there '-are- ^Iwomen^ with ,-lungi.tumors/k '^^Jlies^yriguxes^shGW^une^ui^oca^y^hat'^unj^ycancer^is^tli^^sir^frequentlwBonP^ 'j&&.I> licati ontwit;h=hst>e si6ss~;Clt^onerXLfsrigaris^agona r^'^umo^^SndrH'eafi^eak %*&. n (=> ss .-j5 vprrVtTi' ';'tihipt* <rnVn r 1 R'-'OTVirS^R^^'f T'(=t'niip-n f'-o-'-hiRiinli the.-lndlvidual ^cases^dn^the csame jmaimer^as" aboyei ^ecadse^t^i's^pooEiyL-arraa- eran -- and -'cnmo ' i <"-tH '/* o a a 'inn VTH cV> ofl :>ri rt+r- V\n/0''*>\ii+',!!'ootTQT* qT ". WU y^ Y'The -.figures .reported-Jfrom: the 'USA are - 'quite 'simular;:/Promtttiiereill fcollected! (jr.\13 autopsy, cases from medical literature.:up -to 1939*-Possibly, 'Ithis-figure:- -- p: may.not--be quite 'Complete.; since '.-some dissertations ; (medical^Teports )- were not "accessible tome. .Amongr^bese dissected asbestoses:.I>encounter.ed-.-'2':.bron- '0:[- chial cancers. which were mentioned aboye. -This would correspond cttf-a percea- tags' of roundly,15 ft -knother. organ cancer- was not specif ied there.'l-.The 'pneu !monia. has been reported ^relatively' often (4 times) as -cause of. death'.' ~Z ':-} - *--- ------------ a .a.,-: *--* -* ------ '-rejn'o exp^dient'-Ctini^rnmentaX) r^TJust' as-'little on-it-was-published' in '/Other countries, ;. In Italy,, where the asbestosis is very'well known,-no case'of-lung-cancer .'ha \ybeen' seen'".to':d'ate (yiGilANI,; 'etc-. )'; r. '/_;>*lirl'T-.-C-J! lAThus-ji:-in-theT-medicai.:Wor'ld ^literature -^e:'hitherto''survey ^::confro^^^ S a nt ...lung-pi eura -_t umor s ' of - ep ithe 1 ia 1 or ig in wliic h. d e rived!fr om J)2>;aut ops ie s Jhis'^ar.e -exactly :16;:'/& cancer-.case s,.with.'d.isse qted '/asbestoses cOut ..of these - only'lT'have. been;; described: ..in -detaiiv;so'^f^^at';''fir3.t*vthat^stil further .statistical:results lean be ` * " " "' " =- :jsV'.;_-is tb1 the'sex proportion,:' the iresult ris.7 (men)- -^Y^he - age. lie s^between- -3^ to'. .7.1. years'l;,: ^^ls^ie^Ji`.si^;c^eaT,;:ev-idence^for: a'-closer., causal-.'conriecti'on;:ol".rtliese'.Ttwoisai-l ri - '' -V . mi. .'-il ^ , -i ___________ ____ -o -.-- -o> tr?amouat';,to =cruoa u*xhya-unus2 .t.loiiuiS.'u*astbeai-'.tceoeusSmaeYrae01r7a"lien^ tclie^-t't-nea^ ^.Vto.majo^,autoj,sr.;statAs.tics;^f.-th;e-.a^soluteVflguxes;jror-,the:asbestosisSfs 5'fv*6inwcienreg-ianbsleof.a'tor-ir-tshhaowt --th-aerey -wsetriell-fo-quunidte-i-ns.meanllt'i-r"tehelyy adpifpfeearre,n""nt^elvaecrtehesle^<w;i?th'ap-" ^^:prox^artely^equal -frequency.^(Germany,-'England; USA) -/i*-: -nimo-nloo'Viti.A^nT.+ i at.' nne 4 i '^VAt^irst;^:weVmenti<>nvireTe.:.-the;''aga'rof - the' cancer vectors J'-Eoux '"of.--them-were A stm^-Bt-^tiie^e l'at iVe lyyoung -age, of - 35 -to- 41 i^rears. Alt hough-lung cancer.:!: X: occurring already-in juveniles, it can-be found most:.'frequently-.between the -i^^ages^of^O bo "6O. years.--According - to our-.material,. 6 patfent9_. belong to -.this ^^agerigroiip-J-v ^wf^/!^ j ' ,u'> - ^ '\>Z ^yi** v' 'H^V* A ~A V-4*4 aV* ` -*->> A *A-r '*" n A ^ ' ' ' .... .. --' , a. *< A w i + V*. + A a+>ia^ "IllAdO I* ....... " JTTCW ' cases we^en-- ____ __ r' 'lung cancer- of~3--4--1 rT^beljwqen'.-meln^and womenV Yet,, one must; keep:..!n- mind-Tthat womea^am-s. bc'^/ployees out number.. the- 'hie n - in>. asbestos- plants especially in - Go rmany "and -Ung- .-.vi Afi vaa manf 4 aw "" a Vawa -r-. +Vid^ ^ ta Anc w FOTtiernorV/rsh^'-iist^gioaiCcha'rictor of the lur.S'excrescences. ls; striki: -.'-V-.Tie nbotlviornT^plateSopitHolimn ooroinora is aanorieaiay.;ia tea foregrou.- . ^observation .thatjiWitli; a- Xarge,' carci'nomaTof tbelieft 'Just'S'be-I'^ J^.".^'ginning' .smatll:-cancex,,;bccurr0d:':bn'^he,-: other *.side^hich;^ad|Atplberregarde4'rrip* -\j A**ia s;_ a' me t ast asi s^^b'ut a sT/ail c an c er^autocht honousiyii-spr-inging-Sfrbin." ""the `met ip la \ .tic, br onchia 1. epitheliumVrlHe",X-tlier e f ore ;;->Te gards^the hiuXtib c.ular?cancer;.. ori '\ here find ing~ parallel's ;/t'' .M. -..--ifiTlt^e-'a-ooears asH'iafve1b'kespidaerst"'Itnhe. tshee' *m. ectaanpclaesifiesorthigein-i.oiltnhnehr hei.sftiorslot-gpilceacls changes, fi. ^-iave tnlstrongly increased growth-tendency of :the tissuee^oommon. Here,: V': toe abundantepltheliumdesquamations-are to :be mentioned withachanges in. of the .cover, 'cells,' the formation of. numerous aacrophagla end fo;lilsh bbdy-giant'cells s;s sell as the connective ,tissue-ercrescencei;,;ThereB; 'rt'-hs rdferred lo byliNZBACH,'- the'Individual tissues are.freedst.dlsengaged) ;:j d'N-lsHothlnecinrr-.n-ao'rmcealllredleasttirouncstiwonit.hoInutt,hsuisch Inac-rceoansseiddegrarobwlet-hd-teemndaegen,ctoy .tahned>.d;tiis?tsuu: ' nance of-* the normal tissular .relations one canmmost. prohably..see contribu ting forces.for-the^ cancer.t.origin. ' . -v-t" These viewpoints 'also apply to'the. pleura excrescences. .JThe-plenr a.-.is .inthe se'" re -building'nr oc esse s-Xinc lud edThere 'one .finds.epithelium desanama-r ^r;>Vi6ns 'fibrin.- lovers (strata'), 'development.- of' co nne c t iyet issiiei.-.c alios it ie ?a nd. t he < ~s t oring" ofihs be s t o sjcrys t a Is -and. asbestos is .porpusclesv'CGhgra^et c AT1 these viewpoints listed:.-are "adapting, well'-ito j.the;insights-jjhich: springy tha-stflti sfl fl1..-ri-ffWTes-:~nd ' thus hRnnms.-snmnt^ ntr * '- ivii. Aside from' the' i.ncreased rate ofcanc er...vectofs .^ith osbestpsisi'. theanimal ;;C.r-experimental reproductibil'ity (reproductiveness), must be.;.d.emanded.:.'asva-f\jr fcer :.c onvine inga- pr oof-.of \ t he^se,,;ra t i os-. (c onditions). i .R e gardingi-the i-a sbe st osi ?S?r*ffhia point.-' cannot be..consid,ep6d(hscer.tainedVas 'y''et`i>'/Tet ount 'of.,.experiments'Hhat', turned';!out ,.uiegatively-Tbub ^implyt-becauseTthis`'mat _ ^o-:' "" : ^ i:0yaTej-iRo^^ d sra^elycf^T^v^a>3^i^nec^i^jf^i.de ei^^&y\`_^^Ha.'rthei^irs tjC^hajK^alDs t anc~e^3^d *v'5^r'*- *''* . 'oi'* r\min.Z-f% o'tj r%'a'v*r\rr a n/MiV-o n^TTif* e Nona:' *nii+ .-rt^'*+>i /sV t- JiaT&^C c^aceTcjgerit)us5eTf^ct.-"ls', i .p atlio1 ogy': andV'tlie-.^abund ant J.adlma ^ _ ..... ................ _ a;prac_t'jTcaJ^rs^^ ^one^iist^e^p^i^lndv-tha.t^-in^ie Ttljs she* change s , 'tcaiise d^-est ahiieiie d") v-'Vnr"" + >10 rrf r-` a~nfl'{JW>H + nW't.K P rflfihfifitrifi 1 s\ 1 nr>3 1 lv'.-fl 1 ffflrAn+i-ir. 'nr*-r>B'Tirrc>fl '" onn -jk^g'etlierfwi$fe&b'he^dTapclng*of-^ r+ V, a-r* a f*+" o"p*'^5,TiIn o7*o> ot oV-`c 1'tti^T o'p^-T'b 'PeiV-dn r> o -o--`-f- r\' ' ^ -i-- - ^ ~n'J`"+ Vi a 1/^1 ^ ^ ECfciX^^^- ft'hei^ttuiiorjSto ^':\':alwaysxd'oublesidecL;:~Only. .gros ser.;t( stronger '/-tMcker) `rinds' iorispeclfic^^and ^^SnnspeclficVicompiloat ions ; cari;taqc6uht;,f.or.. exej)t-ipns.'.^Qie'i'.*spundriof trespiratio: |^;liSy,wenker^'t/^tlTe-r^ot^t.oiir^tan.'^atktiie .`tdp< Thi s jin" very"dr^ely>^e versed?Tlier< ^^^e%m'orefn^^o^s?and^pre'rffegiuent^additlonai;%6ises^6imd;f.at',-t;lie.rbott-diH c t hanjfaiV tie''-rStfop; ide d Ima tiex-^Tltt le one sided'( uniia't era 1;) ^iinequivocal4* signs;-(symptms)';-.of.iran?:at:electasis' areV-f ound, ;.so.~is :tiiis V;-..t6/.,tiie 'highest i'-vit S-ir:-'deffrflflV1' susirlei 6ns;'nf 'vtumoT. VIY'e'h'-'o'f conrsp. . -. t1* J ~ ----------J-------' ------' - One^ust ^consider*threrel3y^vttia1r-TtJb.e grave: as be st os i s 'doe sn H - always >de ad'^.diL ** ^concretionskof -- ------ - --