Document mO2JQZ9bp1gQy531NMbMD9nQ

%*:: Vr.?'' SOI THE 'MEDICAL JOURNAL OF. AUSTRALIA .Mir 21. 1940 OCCUPATIONAL DISEASES OF THE CHEST. EXCLUDING SILICOSIS.* _:sbarp margins of the ravtllac silhouette (Figure I'). ^Occasionally there are scattered, granular and punctate . mottled shadows, but these have not the well-defined : margins' :of the coarser silicotic noduiation. liy M.\u*k-e Joseph, **i.It.C.P., F.R.A.C.F., , Hislologfeally. asbestosis produces . diffuse . fibrosis, Honorary physician. Thoracic Unit, Royal Prince 1 starting mainly around the terminal bronchioles and. Alfred Hospital, Sydney. atria as collar-Ilke ebeaths and extending peripherally as tbc disease progresses; It produces profound thickening `r-Vt* ` ' ' .of the alveolar walla, the interlobar septa and the pleura, Eves if one excludes silicosis, industrial lung disease is and throughout the lung/tissue are seen fibres of asbestos still a tremendous subject and far .too large even to . 'either singly or-In clumps, as well as the characteristic attempt to cover in one short lecture. *1 propose, therefore*' asbestos bodies. ' Those parts of the lung not Involved In to limit my remarks to two conditions which have come within my personal experience more frequently than other industrial lung diseases--.namely, asbestosis and coal* -*workers' pneumonoconiosie. Also I shall deal with these from the point of view of the thoracic physician, and not tc*;.. i that of the industrial hygienist the fibrotic process oaturally become emphysematous. Dyspnea is the outstanding symptom, and.reduction of respiratory capacity will be progressive unless the patient Is removed from dust exposure at a very early stage of the disease. This Is readily understood; because the primary ccoonnddiittiioonn iiss ppuullmmoonnaarryy ffiibbrroossisis - which becomes mors !j The uses of asbestos have been known for over two ; marked with tbe passage of time even'if the subject is ^.. thousand years, one of the earliest references to it being-' re_m__oved _fr_o_m_ __c_o_n_t_a_c_t__w_i_t_h t--he duust .Pleural thickening v- Herodotus in 150B.C.; he described how the Romans :.**nd emphysema are. natural sequels and add 'to the 8#'1** u ,n tbe ?uliD AlP* *d Ur*l *nd It forpatient's increasing respiratory disability. ..He becomes 7^?^>, en8brouding their corpses before cremation. - The name.Tillable, to chronic, or recurrent bronchitis; and ultimately asbestos" is derived from the Greek meaning "inconsum-'r;. to the development of. coy pulmonale... , able", and Plutarch referred to the wicks .of the lamps of &the Vestal Virgins as "asbests". The dust aseoclited with the handling of asbestos created difficulties in those days -^'.^v-j^as at present, and Pliny is a.n. SO referred to the -use of. 'jU.'V; respirators to avoid the inhalation of dust . Frdrn a study of 5 patients with asbestoslsr Hugh Jones, John-Read and'Roger Williams'(to be published) con* eluded that the primary disability wad a diffusion defect, 'as -would be expected from the thickening of the alveolar walls. They also found that those patients who had much The Australian production of asbestos is not Urge: It''fibrosis had'diminished vital eapacitJes.but noapprecTable amounted to 2500 tons in 1054, of which all but 460 tons . 'reduction.-ln maximum breathing capacity unless bronchitis came from Western Australia. This by no means satisfies was.present. . 3 tbe requirements of industry, and large quantities are.'-J' ' -'*'**'*. ` imported, mainly from South as the crushed rock, and men Ajufrriiecas,. Iitt aarrrriivveess Imn employed in emptying saaacckasa* these > x PaUsnt-recentiy studied was a man. aged 47-years, with.. history'^ exposure to asbestos dust from 1927 untU 1954.-when he-lSft the industry because oi increasing dyspnas. have been exposed to a high concentration of th"e: dust., ' He h_ad forked m_a_in_l_y__a_s__a__iagger _a_nd-a_sbestos-m_attr_ess Asbestos fibres of extreme fineness can be obtained, spun; -.maker wfth` various firms, with a'break of four'yeirs during fs'^toto yarn and woven Into cloth which has a great variety:' which he served with the Royal Australian-Air Force. He . of uses. In addition to "being woven, it can be ground and :was dyapacelc -on mUd, exertion, and had a plethoric tacit* j ' mixed with other materials to make insulating slabs," 'and definite dubbing of the fingers. Medium crepitations boarding, brake and clutch linings, electrodes for welding,' '-were heard over the lower lobes of both lungs, and an X-ray - acid-resisting filtering elotbs, packings, jointings and wrap* IjVyt pings for steam pipes. The dust given off In the process is mostly less than 5a In diameter and 10a in length. As1 other dust diseases of tbe lungs, the occurrence of examination of bis chest,showed the appearance seen in Figure II. It is interesting that the 'film token three yean ago (1957) was passed as normal, and it was seen from a cdoemveploapriesdon,sfinto[c, fethheesleefst ktihaegraabmsessttohsaItndthuestfriyb.roTshise has mainly respiratory ' (if: ..asbestosis depends upon the concentration of dust to which . functioiTtestsVere carried out by Dr. John Golebatch, with &b`it.-?ii.',-;t'Tvahuhueceejrrwwevaowraakermeeca,.ri inwAseacvwceve&xenpryvrtouuhthsaeiauevlleuadMsPfsali;nudhiIunritdvo<t9(ai(Vvw4iMdtuuhu*uuea1liuduvTraMartMuiiaouUtnuiQoteontBsfif,m;e*axsp^voswvuuuriiteuch..!.'::. ^.,.mt\(h1ev0v07%xfoo)lu,loo*t#wwhhieainngfmaarwex<ssiwmuulatsl ..'breTahteh.invgitacla,pcaacpitayciwtyasw' a12s - 3*8 litres litres per <;:jailicosis, among workers apparently, expoaed .to'similar-- minute (72%), and the diffusion capaciry'for -carbon xnon* ^`conditions. - v' ...v'^oiide was 10 (66% .of normal). ' $$ - Clinically the mode of presentation Is with dyspnoea ofr* ' ! tt*t ttoogh there is slight.'airway impair* grad- ua-lly increas.i.n..g....l.o..t.e...n..s..i.ty, often w--ith a cough w.h.ic.h.. ment, the main detect is In the matter of diffusion .across is generally non-productive. There are usually no physical the alveold-caplUary membrane. - \: ' ''signs In the early stages of the disease, but later rdles .s?cdevelop, with evidence of impaired respiratory.function and cyanosis and dabbing of the fingers In advanced casea. 'As was mentioned previously, the cough.is mostly non* &&-.*.* eroduetive. but examination of the scanty soutum produced Last October a group of six men suffering from, asbestosis was examined. They-bad all worked for a period of approxi mately ten years in-what was known as the "asbestos gang": whose work involved emptying 'bags of Imported asbestos Into a crushing machine. All'complained of dyspnoea. sod central asbestos fibre bare. Asbestos bodies obtained/. appearances'was not.close. * ' 'in a pure state b.y .try.ptic dig_estion of the lung-s ha,ve been: Asbestos!s*ls not only a crippling disease in Itself, bet found to consist of approximately 70% organic matter nd 30% inorgani^jnatter^ They may bp found In sputum before there' is any'^adiblogkaj evidence of asbestosis, and must be regarded as an indication of Inhalation of asbestos dust, but not necessarily of clinical asbestosis. renders the -subject more susceptible to two serioos diseases. The studies of Wood and Gloyne and of Middle- ton and McLoughlln indicate that there is ah Increased susceptibility to tuberculosis in patients with asbestosis. although this has been questioned by other' workera ` \RsdioIogicalJy tbe appearances are fairly characteristic.- .. Studies by Doll, and by Lyqch et olii, both in 1955, indicate ..Usually there is a diffuse haxiness throughout the lower;!. q^u--ite-d--e--fi-n--i-t-e--ly--,--t-h--a-t--c--a--r-cinom--a o- f t--he- lnn.--g has a-.hig-her 'lung fields generally with obliteration of.the^aonnsilyv: lqddnce*to asbestosis sufferers than in the general pops-- This high Incidence of bronchial, carcinoma bat^JJ at a meeting of the New South Walee Branch of-lhev'-*-.---- CSR-540 it *ir . ; *5-* ,>! n*sl5 vw-x- - THE MEDICAL JOURNAL'. OP 'AUSTRALIA *;iKp 806 '*.'. en confirmed by others sod is widely accepted. Doll's of the terminal bronchioles, but dlstally extends for a alysis-has shown that the average risk amoag meu variable distance np to the division ot tbe final order ot \ sployed In asbestos tor 20 years or more has been tea respiratory^ bronchiole, ot which there may be three,., aes that, experienced by the general population.; depending upon the degree of dust accumulation. In the : ^ The second, topic I wish to present is coal-workers' course of time tbe ensheatbed bronchioles dilate, producing . icumonoconiosis, and again In the time available only what is known as focal emphysema. Until Heppleston's ' rtain^ aspects can be dealt with. The coal deposits of work (t was generally considered that focal emphysema... 2W: South -Wales are the most Important and'extenslvely was the result .of obstruction ot air passages by dust.'-'it orked in Australia, and are situated in the vicinity ot fibrosis.'-This* histological condition ot focal emphysema A`- eweaafle; Bulll and Llthgow, being referred to respeerely as the northern, southern and western-coalfields, .forms the basis on which It is possible to understand tits '; dyspnoea /of simple pneumonoconiosis. As respiratory-;^ pproximately! 13.250 men;are employed in these^ines; :d-the extent of the pneumonoconlosls problem chn.be luged by the fact that at present 870 men are receiving xnpensation for this condition (420 total and 450 partial), great deal of work has been done on this subject1 by the -'.-bronchioles'dilate, their cross-sectional area, and therefore;:-' .their-'volnme, increases In proportion to the squares of..-' their radii. This is equivalent to an Increase in the volume -.- o'functional'dead space, and leads to deficient aeration of .the'dually placed segments ot tbe airway. /AJ 'elr' National, School of Medicine at Cardiff, and our A -To . 'add ' -to * the ' coal-miners* dUsbility, generalized io\ ft of the pathology of the disease is largely based vesicular emphysema not Infrequently develops. ThU is i the'observations ot Professor J. Gough. In oar own -'distinct from focal emphysema, and is characterized byr^.ljjg ate, pioneering work was done in this field by the late' dilatation ot alveolar ducts, atria and alveolar sacs. The ;; ZQ* tarles Badham and-carried on by Dr. W.-E. George and -'.cause of tbU condition in coal-miners is the same as that-vAf hers. -iS> V .... ,;la the majority .of non-miners who develop emphysema--o; It was'onee thought that miners who developed paeumono- A namely,, chronic bronchitis. Pemberton bas shown by a >nlosis did.so Ith coal -dust, because of the inhalation ot.-sillca and that the coal dust Itself "was mixed inert. .. careful:. comparative study that chronic bronchitis approximately, three, times as common In coal-workers is as " R. James bss shown that the dust to which the miners ^ In other Industrial groups.' .In case it could be considered: *-^ ' South Wales are exposed rarely contains more than 1% ''that smoking was a factor, be investigated this possibility ea silica; moreover. In 100U cases ot coal-workers' and -found that a greater proportion ot tbe coal-workers veumonoconlosls studied by Jsmes, 19 subjects bad were lifelong non-smokers or had given .np smoking, than orked aa trimmers loading coal into the holds ot ships -d hsd/never been underground; seven ot these bsd jnfluent massive fibrosis. This aecords with Gough's in the non-mining groups studied. There was also a con siderably lower proportion ot heavy cigarette smokers among the coal-workera. It would he surprising It the 1940) findings, and disposes ot the theory that the con- inhalation- ot dust-laden atmosphere over a long period ition is dne to highly siliceous dust from rock strata ' Jjacent to the coal seams. Moreover, the pathology la did not cause such mechanical irriution as would, in thelong run, lead to the development ot chronic bronchitis; iffarent from-that ot silicosis. ` i.-f. - Radiologicaliy, simple pneumonoconiosis is characterized The development-of. pneumonoconlosls depends'**on two ; r::hgoeaurrpdsto-otofthfeapcaitnortdrisciv,leidonueealsle;reglaaivntiednngaidttomenothtsipceahdel urdiscutsIcttosfanecclfetonartnsradwtitoihtnhe,.'- idlviduals vary In the degree and extent of the pneumo- oconiosis that develops. These factors are difficult to sse**' but It appears that the efficiency ot the nasal filter nd presence ot other pulmonary disease, such as roniwitls, are enetlc factors, important The claims of metabolic physiological peculiarities of the lung and and . is .lymphatic system and physiological - response to' limatic factors 'and others have been Invoked, but none ppeara to have.been substantiated. .by fine opacities described and classified in the Inter-. national System as category I, 2 and 3. In some cases a conditioh la superimposed which has been termed "eon-. fluent massive fibrosis". This eonsUU of well-marked-' collagenous fibrosis forming masses varying in size from 0-5 to'15 cm. In diameter. They occur most commonly in the apices ot the upper and lower lobes--that U, In positions most favoured by tuberculosis. Although tbe etiology of this condition has been disputed for some years, there Is now airly general agreement that It resulu . from superimposed tnberculous Infection. James in 1954. . 'was able td nnd histological and bacteriological evidence .'of tuberculosis in 40% of the massive lesions present in 245 South Wales coal-workers. Since it *is difficult to ' '"W m Dust particles"greater than 10m In diameter seldom reach* believe that the bacilli penetrate into existing massive ie long alveoli, either settling oat ot the atmosphere or lesions, one must postulate that the organisms reached cing filtered off by the respiratory tract; however^ their situations by being inhaled before or wltb tbe dust. articles less than 3m can reach the alveolar spaces In These lesions sometimes cavlate, causing tbe production , irge numbers. Here they are taken up by phagocytes of Intensely black sputum which bas been likened to `hlch apparently originate In the alveolar walls, and then printers' Ink. Confluent massive fibrosis bas been divided ither are watted upwards -gpd goally expectorated, or into categories A, B and C on the radiological appearances *.** ater the lymphatic vessels and are transported to the of Increasing severity. .mpboid tissue ot the lungs and thence to the hilar *In 1953 Caplan described another form of massive mph nodes, from where they may travel to the scalene ' fibrosis, in which tbe round opacities were multiple and odes which are accessible to biopsy. Still other pbago- well defined.'and distributed throughout both lung fields, ytes .with their carbon load gather in foci aronnd the but particularly at'tbe periphery. These lesions occurred esplratory bronchioles, where they constitute the eharac* In coal-minera with a mild degree of simple pneumono eristic lesion of coal-workers* pneumonoconiosis.- -These coniosis who also had rheumatoid arthritis, and wera melons are stellate and intensely / black, are scattered shown to be histologically distinguishable from confluent arougbout the lung,.and vary in diameter from miero- ~ massive fibrosis. The condition has been given the name eopic dimensions to about S mm.; but they contain com- . of **CapIan's syndrome". arativeiy little fibrous tissue. Gough, by tbe use of whole- jog sections, has demonstrated these lesions beautifully, howing all gradations of simple cosl-dust pneumonooniosls. In reeent years It has become increasingly recognized that severe'respiratory disability can exist without radio logical evidence of pneumonoconiosis. There is a category 0 in coal-workera* pneumonoconlosls; that is, significant _-*>- 3m it I Gough pointed - out the essential difference between' and even disabling d^ease can exist with an X-ray picture illcosta and coal-workers* pneumonoconiosis. and described In which recognisable dust opacities are either absent or he characteristic focal emphysema of the latter. 'How- sparser than in tbe sundard category 1 film. I have seen . ver; It remained .for A. G. Heppleston, by painstaking a .number'of such patients from tbe Cessnock mines, and crlal section technique, to demonstrate that the proximal . the deUlls of one patient who had a lobe removed because .mlt of this sheath of dust cells Is regularly in the region :ot a suspicious apical lesion will illustrate tbe point. THE MEDICAL JOURNAL : OF AUSTRALIA Mat'21. 19*0 ^ The patient was a man. aged 64 yean, who h*d been a a worker with severe disability due to bis occupation may t vainer for 40 year*, lie hnd first noticed dyspnoea three years before he was referred to me on June 19.-1958. This .have no radiological evidence of poeumonocontosls. had reached the stage at which he said he found it difficult . 4. Tests of expiratory functlou such as that of-the' to walk out of the pit. and even the exertion of bathing and maximal .breathing capacity and timed vital capacity, in - ' dressing caused breathlessness. He had only a slight cough, conjunction with-clinical evidence of respiratory disability; and the sputum he produced was white and frothy. Hie chest skiagram in 1936 hnd been passed at clear, but a current one showed an opacity At the apex of the right lung (Figure V). Tulierculosis was considered the most likely diagnosis: but repeated sputum tests gave negative /'results, and because of the possibility of carcinoma provide a better Indication of the state of the worker's' pulmonary health tbsn an X-ray examination, and should supplement tbe iatter in tbe regular assessraent/of the miner. x Acknowledgements. thoracotomy wa* advised. Clinically and radiological!/ the patient appeared to have marked emphysema, and this was confirmed by respiratory function test carried out by .Dr. . Colebatch. His vital capacity was normal (3-41 litres), but *" the maximum breathing capacity was considerably reduced. My thanks are due to Dr. R. Hughes,-of the Manufac-tT ` turers' Mutual Insurance Company, for the X-ray films'- l* - of tbe patients with asbestoais, and to Dr. K: 0. Outhred i. and Dr. J. Colebatch, of tbe Joint Coal Board, for certain being 36*3 litres per minute (36% of the predicted value). figures.and X-ray .films relating to patients with coal- : '* - The total lung capacity was 136% of predicted level and . miners' pneumonoeoniosis. I am also grateful to Mr. : * ' tbe residual volume 161%, giving a residual volume to total Woodward Smith, of the Department of Medical Ulu8tra-.: A lung capacity ratio of 63. He was subjected to surgery, and .tlon, University of. .Sydney, for tbe photographic rspro- . !? ,v. *.* although a less extensive operation would have been -.'preferred, a right upper and middle lobectomy had to be performed because of technical difficulties. The lesion proved to be tuberculous; but the Interest in the case is the fact that examination of the lung sections showed a marked /.degree of pneumonoconiosls, despite tbe absence of dust opacities in the skiagram (Figure VI). , . ductlons. 4 .?& ;'y Bibliography. , V, "'U - ' CaTuX, A.. (1963), "Certain Unusual Radiological Appearances in the Cheat of Coal Miners Suffering from Rheumatoid Arthritis", There.r, S: 39. Caajtbktxr, R. -O., CoamuKB.'A. X*, GutaoN, J. C-, and *.' . Htooms, 1. T. T. (1966). "The Relationship Between . j -y` > The lack of correlation between tbe radiographic appear* ,,-;:-aheea of pneumonoconiosls and tbe degree of respiratory disability is also exemplified by studying tbe respiratory function testa of tbe patients whose - skiagrams I . nsed -.`.to demonstrate tbe radiological categories of simple . * Ventilatory Capacity and Simple PneumoconloaU in Coal-- ' workers", Brit. 2. i*du*tr. MuL, 13: 166. . ,;V.-j- 7 DotA, R.*(1956), '."Mortality from laing Cancer ia'.Aabaatoa /-V| - Workers", Brit. J. sduetr. Med., 13: 3L - * *. -t;-: Goook, J. (1940), "The Pathology of Pneumoooalosla", Pm(groo med. J., 36: 611. - pneumonoconiosls and confluent massive fibrosis. Reference Couoh, 2. (1947.)* "pneumoconiosis la Coal Workers in Wales",.. Vj to Table 2 will show that a man in category 3 can bare Ocesp. Med^ 4; 66. _ k . .; . Timx I. HonanoH, A:\fi. (1963)." *The Pathological Anatomy of . Simple Pneumbconiosis In Cosl Workers'.'. J. Path. Boot, , 66: 336. . 1*1 r of Pujriretonr Ftmfion TrtU m Patfrrt* teki CmMVrin* HbKTWi. D. (1966). "The' Diseases of Occupation", English J`ar*mmceenic*it. Universities Press, London. . - Jamm, W. R. L. (1956). ."Primary Lung Cancer in South Vital Cipedty. Xulnui BrenUUnc ChpMUy. Wales Coal Workers with pneumoconiosis" Brit J. fnrfittfr. Med., 13: 37. .. ". Jambs, W; R. L. (1967), "Pneumoconiosis", Brit J, glim. Prat, .;jj JMtWVTS' . Ate. (Teut.) YoInu* Rise. Dim Mftfta. Ter- ee&tage Utres KOToTfTUi. per Waste. r*R-V.: Per- TL-C-* outage HomaL ' 4.* ' ' * .. \ 11: 164. . / .* .- ;;ejf ``Jakss, W.'JL 1a '(1964), rThe Relationship ot Tubercolosis to :4i . ` the 'Development' *of Massive Pneumokoniosls la Coal - tf .Workers",-Brit J. Teberc., <6: 69. ** = 74V -'KtLVAnucat -O. &, fivnjmx, A.and Purcicn. C.^ - -.. <1960, "Cavitation in.the.Massive Fibrosis of CoalworkanV.j Pneumoconiosis", rhoreo, 9: 360. , ... X 1 1 .*6630 69 39 33 33 ' 4*0 34*-e3 -A S3 45 B C . 7SO0 . 33 30 3-8 1*8 4*1 ioe S3 ns 130 so m 86 49 86- 7637. ' 81 * 'x . -80 86.:- Moaiow, C. aad-CoaaK, A. C (1969), "Pneumoconiosis",j . - Med. Cite, S.' iwin-y 43: 17L :*. *PsMarrOM, J. (1966), "Chronic Bronchitis, Emphysema and.-'f -Bronchial- Spasm in Bituminous Coat Workers", d.M.A. ,vL . 94 ioe * 88 .* 30 74 84 73 8S63 ' ; : Art*. Uduetr. HUH, 13: 639. . * ` l .* . *' ..;Vj /;* Baho ef niidual volume to total Jni cspsdty. - ", (YDATID DISEASE iN A CHILDREN'S HOSPITA^^: ` 'Considerably less- respiratory disability., thin-^-one -in' ..* . * ' iV^- ' tCrllo Category 2; that virtually'no" respiratory disability may j .exist with category A, confluent massive fibrosis, and a jfv:',fcategory c man may have appreciably better, respiratory i function than one in category B. As long ago *as 1948 Vv'iV-/Fletcher described tbe case of a coal-worker wbo was tbe raj:*..:'f.; local champion for tbe 76 yards sprint and whose chest- skiagram showed progressive massive fibrosis.**: Sixes 1938V72. 'patients with bydatid/diseass have been admitted to the 'Royal- Children'* .Hospital, Melbourne. ! ^.Eleven of tbese^ere teen for theJrst time in 1967.-The *- continued prevalebce ot hydatla disease provided-'the' ....... j' stimulus for a.-review of the/pcdiatric aspects ot ths.) ' Conclusions* ,- condition. IntormatioK. obtained from other centres Sa w %' From tbe foregoing, as well as from other published Australia indicates tbaVjfie problem is by no means; E*;*: /_ work which time prevents me from Including -in. this ` purely * local, because oj**s 1009 patients with hydatid si paper, the following conclusions must be drawn, * ..disease have .been.>d^fitteokto public hospitals ln>the *&.$'`*';i -*.> i. The respiratory disability of coal-workers is primarily jrJ/`-."an airway diseass^-and ls-due to . fo).. focalempbysema 3^- * :and' (ft) chronic bronchitis and- generalised vesicular , emphysema. - Capital-cities ot Australia during tbe past, twenty years.- A* further 86 patients with ptftoonary bydstid disease; have been-treater by Dr. S. C. FXxpatrlck of .Hamilton,; Victoria; .Since>2320.. . - *. i '-'Mr1 * i. There Is no correlation between respiratory disability ' and tbe X-ray appearances in tbe chest ` A In tbe mstter of determining compensation, tbe . X-ray findings in tbe chest may be misleading and unjust in two directions: (o) a worker with radiologlcaliy evident pneumonoconiosls may have no respiratory disability; (b) ^.pilhlcal Material. x *~ '1 Sixty-seVea of tbe patients were VictorObL three werei referrejK from Tasmania .and two came, frobs southern New>south Wales. Thirty-five ot the Victorians, patients- living in Melbourne at tbe time of their adtolsstoa 'teThospital. Some ba6 previously lived, or spent holiday: tike:-: