Document oebND5LmDzR2z6kGbebwqbqD7

~rcf vW &Wv S4&&1 'N^ N-NOT COWt mi . -, -P> - 1 ' ?5gr J| ?**}' DID 15 C: &$&!&-i B&3 THE OCCURRENCE OF PULMONARY FIBROSIS AND OTHER PULMONARY AFFECTIONS IN ASBESTOS WORKERS* ix; o: ;-; E. R;'A.'MEKlifttHfeAy MD. f ` r"' II, M. Mtdical Inspector cf Facloriu .;>,7;->-'; , $dN*- Introduction- tRIOR to the commencement of this inquiry, in February, 192S, He was treated in the Charing Cross Hos pital for two months, and then returned to work. After a few months, however, he became ill again, and was re-admitted to the -- H fapfr.*.'- g; ;;; ^aegfev.-.-- 5: *.* #, ** i %'* -v * definite Knowledge existed of only ttvo deaths oi asbestos workers about whom there was expert opinion that the inhalation of asbestos dust had at least contributed to. if not, caused, the fatal outcome. ~ The first of these, in retrospect the Hospital in April, 1000, where he died. The. post-mortem examination confirmed the--/' clinical diagnoaia of extensive pulmonary ; fibrosis. There was no evidence of pulmo- ; nary tuberculosis, and examination of the ; sputum for B. tuberculosis was negative. The second case was reported by Dr.. ts most suggestive, only came to light W. E. Cooke in 1924, eighteen years .7. some years after the occurrence, when later (2): , :. `Vl#?5 * ' t XiCjai?^:: v..:' 'H.u/Hw.Vv- - , , full information was unobtainable. All that is known of this case, now referred to as "the Montague Murray Case," is contained in the evidence *...'.f-t*Ar*,,t. The deceased, a woman, aged 33, who : died in 1924, had worked in asbestos for IS / years, but intermittently for the last 5 . years, owing to periods of ill-health. The ` given by Dr. Montague Murray before post-mortem examination revealed, not _/T At ;5Kis *;.- ' X '.' r1r*(a3 *02 j -t t* .? V - 2f?4BaS ss sr '6 J J " the Departmental Committee on Com pensation for Industrial Diseases in 1906 (1). From this source, we learn that: The patient, a male aged 33, came under the care of Dr. Montague Murray at the Charing Cross Hospital in the beginning of 1899. He had worked with asbestos for "com* 14 years/* 10 years as a cnrdrootn hand, and the remainder in some other room . of the factory, "where there was much less dust." He volunteered that, of the 10 people working in the cardroom when he went into it, he was the only survivor, and only extensive fibrosis of the lungs, but also : much change due to pulmonary tuberculosis. * :* Although Cooke (3) and Stuart. ^4. McDonald (4) were conclusively of the opinion that in this case the lungs V*:, showed a progressive dust fibrosis, together with a chronic tuberculous in- .v# fcction, the etiologic relationship be- ."l.Vtween the inhalation of asbestos dust and fibrosis of the lungs would have \lV been strengthened by the absence of a c tuberculous infection. i! i.,v IWi: that all the others had died somewhere about 30 years of age. There is no note as to the nature of his work, previous to that in the asbestos factory. Cooke's case is, however, of outstanding importance, not only because of the discovery of "curious bodies" '* in the lungs--discussed later--but also, .;. * Received for publication Feb'. 17,1930.* and of more importance generally, be- V 1J k4 II -! 1 i < '.., ;: 5,.-;>>f/' >!.!: 23? * v* ii **- i 198 J. I. H. _l_BB 0007109" Jlay, 1U0 GG j V* :Vft*  . 7I . PULMONARY FIBROSIS IN ASBESTOS WORKERS 199 \ '* #, i i cause its publication again directed ./attention to the possibility that inor- ' ganie dusts containing little or no One silica may be productive of extensive This ease, at that time the third of which the Factory Department had knowledge, was, however, the first in which the four essential conditions, Q C/7 ~r li-J O ,.J f \^ * vigSkw? .-.hsacsr* a;i ****,, . i --.i tJrrkS^sae1-- -'.'pulmonary fibrosis. Of these dusts, necessary to establish a relationship -, ,the silicate^s form a'veiy large class, between the inhalat^ionpf.a*s}_b__er^rs,~tTors dustt- t-- - - ^ j . ... r, j-- -- - - -i * ^ . "' . :^of wh1cfi"as`i--estS-----i-s''b-u*t--o-n--e---e--x-a--m---p--le.1 --a--n--d---th--e---d--e--v-e--l-o--p-m---eintt of fibrosis, could ^ .r* > .;.*M#a_n.y. oth1.e_r,,,,m._emi_b_e_r_s_ _off ith1_e*1_cl_a_s_s, Ib_e1-d__e_m_o_n_sJt._raitned__, __T__h_e_s_e__c_o_n__d_it_io__n_s j1';' /r *r - /.such as the feldspars, kaolin, French '//.v chalk,, and pumice, are extensively '.vv-iused" in industry. The importance, /'/therefore, of delimiting the potcntiali- arc: 1. Work involvi&f exposure to asbestos dust. 2. Tbc exintciiee, dcmouctrablo clinically ` LA*:` .' h .*' 'V , 5^ : ' It.*; ties of the class as producers of pul^'emonary fibrosis is clear. .^.'r-';,:Cookc's case was the first to be ` generally reported in the medical * //'.'press;1 the facts of the Montague t-v/Murray. case, although contained in and radiologically, of a definite pulmonary O.-.s? *; V J fibrosis. 3. The absence of previous or present i.n- EtotoJV Ca0 ! '-.l -.*-(J]J fections known to cause pulmonary fibrosis --e.p., tuberculosisa, irnnfnluuenocea, or p&neu- ~v. V5' monia. 4. The absence of previous or present ' i't'.'i-.V/ ji;:";jjvlllsIffjSmi ;,j^,!7fthe-evidence presented before the work involving exeppoossuure to other dusts, . ;v, ^Departmental Committee in 190G, and which might cause pulmonary fibrosis. <> ` Y-;'Yj- .vY<.'4 published in 1907, were liable to be These eonditions being fulfilled, a rrSfe.+j;; '^ overlooked in tho mass of important relationship between the inhalation of '/jto^tcrial on industrial diseases elicited ,'v?V; by that. Committee, Sinee Cooke's case, Dr. I. M. D. V -'j Grieve has made a careful study of a asbestos dust and the development of the pulmonary fibrosis may be prosumed. The importance of establishing : ; . v. j 4i- **- ' -t, ,' i ; ."iti ; ';Erup of asbestos workers in his pr&o- whether the supervention of this dis-*' * ;':an^ has courteously allowed .............. 1 | mw^iaccess to his records^1' /' " i February, 1928, Dr. MacGregor, * * ` Officer of Health for Glasgow, ' attention to an asbestos | |'*^forlter, who was receiving treatment * one of the hospitals in that city. i - itr^l"..(cae the details of which have * *VVi(iribe(>B,'n>Tvii-f w.. it t:1 __ v \ * "Ciai.irT.V'V history, no presumptive cause, than the inhalation of asbestos was ^0UD{f to account for the of fibrosis. in relation to the evolution of dust, and the examination, both clinical and ra* diologic, of workers, was undertaken during the year 1928, commencing ip# GG I5II9?- :::1 *t  m200 THE JOURNAL OF INDUSTRIAL HYGIENE with the carding, spinning, and weav ing processes of the industry. In the meantime, in 'March, 102S, tin* d<stlh of an .'Lslmstiw worker (one of Dr. Grieve's cases) occurred in another part of the country, and, on post mortem examination, a condition of widespread fibrosis of the lungs, with out tuberculosis, was revealed. The microscopic examination also disclosed the presence of the curious bodies. In 1928, also, Dr. F. W. Simson (6) reported a fatal case of fibrosis of the lungs occurring in a native work ing in an asbestos mill in southern Rhodesia. In order that this brief survey of the events leading up to the present in quiry may be complete, it is necessary to review the investigation made in '1910 to 1911 by Dr. Collis and Miss Whitlock--the only previous inquiry into the subject. - In May, 1910, the Registrar-Gen eral drew attention to a death which had been certified as "acute pulmonary phthisis in an asbestos worker," and to a statement (for which he was un able to vouch) that seven other deaths from phthisis had occurred in the same factory. Following this, extensive inquiries were made, a medical report on all the employees in the factory concerned was obtained, and Dr. Collis and Miss Whitlock investigated generally the various processes in the industry with respect to the evolution of dust, methods of ventilation, lost time due to sickness, -etc. Also inquiries were tnadc of the Canadian government as to the conditions in the asbestos quarries and mills in that Dominion, evidence of increased sickness and mortality rates among the workers, and any methods of ventilation which had been found of especial value. ''jfijffi The result of tins investigation did not conclusively prove that asbestos *' possessed injurious properties, but it pointed to the probability that Buch ' jfU w:ts the case. It is interesting to consider why it was that no conclusive proof one way or the other could be.:r^ obtained, then, os to the injuriousness of asbestos dust. Some, if not all, of'^i^ the factors which affected the position. then are, in varying degree, continu-;$* ing factors, and have an important!-;*^ bearing on the present inquiry. Their2^' operation, while providing a solution-vi^f to this query, also affords an explana-T'C-^. tion to another pertinent questionr^j^ Why is it that this industry, founded in antiquity, has only recently excited^l^. attention, by reason of its raw material 'll^ becoming suspected as a cause of mdus^kjjyv trial disease? ' The answer appears to be that in the^ss post it was not practicably possible,totfi obtain proof of the injuriousness of/^V asbestos dust, considering the limita^'^'* tions imposed by the state of the indus^^l; try, and the point reached by research^j^ work into the relationship between^* dust inhalation and diseases lungs. The industry itself, not _ __ one today, was then (1910) consider^^' ably smaller. Certainly it had begun^^i to grow rapidly, but the number workers who could have been employc^^gi for a period of time long enough allow of the development of definite^-^ physical signs of pneumonokoniosis^fe? must liave been quite small, and persed over the country. Precise knowledge of the morbicfcy!& affections of the lungs produced by inhalation of dusts was more fragmen-^-*-. vi l THIS DOG1V/ * oi d mmi5 ES GC 15120 i bb ooo7ni"TM4if4> -r~-----------------ass! `KSS PULMONARY FIBROSIS IN ASBESTOS WORKERS 201 *:< * , f : " tuy than it is i4>J:iy. The position show au excess mortality from phthisis, %: was clearly staled two years later in and those which do not--as well as ^ ^, f'Jr ~' .'revidence placed before the Royal Com- being a comparative index of the in- Jv mission on Metalliferous Mines and dustries belonging to the former group, 3 iif * p ^ *M;;s {' ' ;r-' A* .1 ii.'Hfi ti .-i.-ii- \ . 1 fc* **s'.wa '- : I* 1 . - <* * . V , il-'ivt.i Quarries. Tin's Commission, when rc- not only is of little value as a means of J porting in 1914 (7), stated "we do not classification in the latter group* , but I i I] ^ 4 i!. know whetlier other dusts besides those also tends to distract attention from it, r- wmm V'~oontainingfree crystalline silica induce and to result in the associated dusts be- 23: V;;Y pathological condition in the lungs, ing dismissed as more or less innocuous. w r^ 'K*though the experiments of Professor Evolution of dust is only one factor, {*'% Beattie in animals suggest that this though an important one, which may ,':r f'may occur." It is only in the last year cause variations in the phthisis ;V':1 fortwo that research has produced some lality rate in different industries. jv-.-r*' "definite evidence as to the precise Wages, hours of work, aggregation ^.'-'-'effects of some of these dusts on the workers, amount of food, bousing, ;^clungs(8) (9) (10) (11) (12). other social and1 environmental conciK ., -.-.j - < * "*' In 1910, radiography of the lungs, in lions are, howevrecrr,, powerful influences V ii : both its technical and its interpretative in the same direeccttiioonn,, and arc not CD j: !;>.*aspects, was still in ils infancy mid, necessarily compara'bl.e...a..s...I.t.c.L..w...e.c..n...t.h..e....... ~ 7 so far from having attained its present workers in auy two industries. . 2.' ; V-'. status of bciug an indispensable aid to In thus reviewing some of the influ 5i j: the diagnosis of the dust diseases of the ences which have retarded recognition *S lungs, was on unused ally. of the baneful effects of some dusts In addition, the existence of ameas- upon the lungs, the singular attributes tjp'-/-. - :.':'ure of exhaust ventilation in the most of pulmonary fibrosis, the most impor jridusty processes of the industry, incoin- tant of the diseases caused by the in trpltte as it was, bad important results halation of dust, must not be over modifying the onset, course, and looked. ^gTduration of any pathologic lung condi- This disease, insidious in its onset, ^y^f. tions rcsultiug from the inlialation of stealthily advances with but faint the: dust. This influence has been 'y|w;;':xauch: more pronounced in the period t'^w.'^'intervening between 1912 and the warnings of its progress; inexorably it. cripples the essential tissues of the lungs, yet for a considerable period' present, inquiry, and will be referred causes almost no inconvenience to the !l ;?>-?< again.. worker. As time goes on, however, 'Another factor which has tended and still tends to obscure the possible Jj ^'.^deleterious effects of the non-silica *j;Vdusts, is the general use of the phthisis h "'Mortality rate as a comparative index f. of the degree of injuriousness of the ( . .. ' dust encountered in the various dusty * '^..' occupations. This rate, while of great value in separating dusty industries t. .! . into ttwo great groups--those which l 'VJ4.V the lungs find more and more difficulty in rc-aerating the blood; and breathing is quickened on slight exertion. Still the worker is able to remain at work, but is aware of his undue shortness of breath on extra effort. Usually, how ever, lie ascribes it to causes other than the dust be is inhaling. As the disease progresses, if no acute illness has caused a fatal termination, f *: \ ><: * -i----B---B-----0---0--0---7---1--1---2-----1- r ; > f ,4 v * . ..l.Wi' NOTETHISP'; ;''^TDID:af !V f ` . 2u2 THIS JOUltNA rh *3v- fVi .y.v,,JL.. ... Jikl.J-'..A 'n S*f^fV*V* i#J* ' ` *k ' `s`/lsl.j'riif, l.-l*i1J} U!,.: . . .*!T >? -ft ,, --.. i a-V* , . ahm L;*j frsXO *r :. . * **?*;:*. / i *>*,.*.:: \ 1 i-i ssijl t** ;V3a1 '..- ' * g.. V- ;*' sj "I ,, 4 &9& ft tfv'l l*V`V * v* *4 v:* -* - y- ^r3*3rv'3',Y > i <, : i ,:a-;i5;,-t\:*'* .* . i'll >.< a stage is reached when the lungs can asbestos dust bos a totally different r%' do little more than maintain life; and physicochemical constitutionfrom that < the shortness of breath is extreme. of dusts containing much free silica and * ;v Even in its terminal stages, the disease, causing Silicosis.. It was felt that - :"C; deceitful to the lost, may masquerade although much valuable guidance '' r. as chronic bronchitis, pulmonary tu could be obtained from tbe methods berculosis, bronchopneumonia, or the of investigation of silicious dusts, care :.v - like. had to be taken to keep an open mind,, ,'S. While more or less acute cases of so as not to be unconsciously biased 'yj, fibrosis closely simulating miliary in the direction of nssuming that the. ;; tuberculosis have occurred, even in this effects of the dust, if any, must be com- -v. *;.! ' country (13), they have all been asso parable in some degree t those of r"^~ ciated with the inhalation of dense concentrations of free silica dust, and are, fortunately, the exception rather than the rule. . The difficulty of diagnosing pulmo crystalline silica. Asbestos and the Asbestos Industry ; 4 t/r*~ ' Aibeslo* :%V nary fibrosis, especially in its early The term asbestos is a collective.^: v ' stages, or if complicated by tubercu name, of no definite mineralogic sig-V..^-' losis, has been stressed by a number of nificaoce, which has been applied to a authorities, and has, undoubtedly, con variety of silicate minerals, which differ;!, - - tributed to impede the attainment of from one another in chemical compo-c precise knowledge of the extent to sition and physical properties, but ! which the various industrial dusts which resemble one another in their affect the lungs. finely fibrous feature and flexibility :-!. Difficulties and obscurities still im (14). Their value depends on the iv. pede, though to a less degree than in facility with which they are capable of the past, any investigation into the being split up into long aod flexible^^N'. effects of an industrial dust upon the fibers, which can be spun like cottoa'i V^,'':: lungs of those exposed to it; but prior and woven into cloth; on their resist- V^-- . to the .W...a..r..,.a...lt..h..o..u..g..h there were certain ance to heat and acids; and on their! slight indications that asbestos, in insulating properties with respect to'i>|5;'; common with some other dusts, heat and electricity. might produce permanent pathologic Varieties of asbestos possess these changes in the lungs, it was not possible qualities in differing degree. Com-! to obtain evidence sufficient to prove mercially, therefore, selection is made jirp;.;'V or disprove this hypothesis. by the manufacturer of that variety At tbe outset of the present inquiry and grade which is most suitable for into what, if any, pulmonary diseases the purpose in view, regard being paid workers exposed to the inhalation of to ordinary economic factors, such as /. .. asbestos dost are more prone to con the cost of the raw material, and theyiv' . tract than the general population, it price which the finished article may be /;!;!"!.. was considered essential to view the expected to command. '`TaJ* it, problem afresh, aod with complete Consignments of asbestos of the.';;: detachment, because of the fact that same general variety, but with differ-,*;'; - '" av^irA j. t H.v'r-fit-- ;.ry. NOTE: THIS DOCUMENT DiD (lay, 1SU I;--,'/.' NOT COME FROM PPG FILES '-^sOsnno^7yT--urm - GG 151^7 . if ' PULMONARY FIBROSIS IN ASBESTOS WORKERS 203 ' ent countries of origin, are frequently ' miscd in the preliminary processes of "/ manufacture. Thus Canadian chryso- tile may be mixed with Russian, or Rhodesian chrysotile, and so on. Less .`.`frequently, totally different varieties, such as amosite and chrysotile, may be 7 mixed. ' ''Practically speaking, all that goes -.under the name of asbestos, in com. : merce, is cither fibrous serpentine or a . fibrous mineral of the amphibole, or 7 hornblende, group. The former is the .-.most important commercially; but *; strictly, the mineralogists confine the bined water, and usually more cal cium, aluminium, and iron. Members of this group arc resistant to acids, but arcmore difficult to spin, some being quite unsuitable forthis purpose. The most important members of this group are crocidolitc, amosite, and tremolite. Crocidolitc and amosite are mainly silicates of iron, the former having a beautiful lavender-blue color, thelatter being brownisb-gray. Both are spun and the yarn is woven into doth for various purposes, such as acid filter ing, and for making into insulating 'VIABLE l.^-COMPOSITION OF SERPENTINE AND AMPHIBOLE VARIETIES OF ASBESTOS - -4`-'MoINaEoRcAr.L VARICTT SiOt AI,0, fERCTNTi.CE OP Com MgO CsO No0 K.0 bined Water ' z? 1 90 1 Serpentine TAmphibole .*, (boro. >" blende) - Chrysotile Crocidolite Aiuosito Tremolite 39-42.5 0-3.7 0.7-4.4 39-43 0-0.35 O00 SO.5-52.1 0-1 35.5-37.4 0-3 0.75 C.2-9 O a * 4S-53 1.2-9.4 34-44 0.7-6.4 .0.0 0-2.5 ... 57.2 0.9 3.2 22.S 13.4 0.6 0.3 13.3-18.5 1.6-4.5 2-3.8` 2.4 om '"-.'7" !-id .' . , 1*.'. , ~ i- T,'" 7 * *.1 r.*- -- 1- . A*. . .J:>*;.*-'vv p.- *' OE-s'S. H-S oo u***^jc el - ,{.**,.* 4 i-.-- -I W- ? ! l* ' i * \7 'J',"'. i : i , ;*? *1 v j; 471 r \'**m " r > term asbestos to fibrous forms of liorn- blende. These two types are sharply ! "."7 . distinguishable, chemically and miner: y- V! alogically. | V^sVrScrpcntine asliestos, or chrysotile, is y ".a-hydrated magnesium silicate, con: . % taining practically no calcium, a high ; percentage of combined water, and & _/71ow percentage of iron. This variety ...7is,very suitable for spinning, but is ;y:; attacked by acids. Nearly 80 per cent. ; the world's production of asbestos is . ;S ^crived from Canada, and is of this "variety; the remainder comes mainly . from South Africa and Russia. The amphibole, or hornblende, vari eties contain less magnesium and com- mattresses, as well as for other pur poses. Both are produced extensively in South Africa, from which quarter all required commercially is obtained. Amosite, a comparatively recent dis covery, is found there in very large deposits; its use is steadily increasing, the initial difficulties associated with the manufacture of textiles from this variety having been overcome. Tremolite, found in various quarters of tbe world, has been mined in north ern Italy since the time of the Romans. Its chief use is in the manufacture of asbestos millboard and for filtering purposes. Table 1, compiled from various : . ' * .%rfi . 7**5V*:-: '.'.. It'7; ' ! -*,5 t f -l:TS i BB 0007 ' " ;VL 1] *./** #*# ' 's V ; / ** * CC f 512; . -; ? NOTE SHIS DOCb vrern* vn\'D w 204 THE JOURN HLES -|* sources, shows the main differences in the composition of these four varieties. Only a very small proportion of the world's production of asbestos, which is between 300,000 and 400,000 short tons, per annum, is suitable for spin ning, and the most desirable grades of spinning fiber, consequently, command a high price--now over 100 a ton. The shortage of this grade has led to improvements in manufacturing proc esses which have enabled less expen sive grades of fiber to be utilized for spinning, some of which give rise to an increased amount of dust. About four-fifths of the world's pro duction of asbestos is fiber unsuitable for spinning, and this is used in the manufacture of asbestos millboard, tiles, sheeting, paper, and many other articles. It is the discovery of indus trial uses for these very short fibers, and the dust-like waste, which has been responsible for the phenomenal expan sion of the industry as a whole. ` The spinning and textile section has also shared, because of the extensive use of the yarn and cloth in the manufacture of steam packings, insulating mat tresses, brake linings for motor cars, fireproof curtains, and the like. In 1880, three years after the dis covery of the large Canadian deposits, the world production of asbestos was little over 500 short tons; by 1900 it had risen to about 35,000 short tons, by 1920 to over 230,000 short tons, and by 1925 to over 330,000 short tons (15). The imports of asbestos (all grades) into the United Kingdom rose from 18,591 tons in 1922 to 33,520 tons in 1927 (16). The figures for 1927 refer to Great Britain and northern Ireland only. Of these quantities 8,844 tons and 3,794 tons, respectively, were reexported. Thus the consumption of asbestos in this country trebled within ; v five years. . The Industry V On considering the uses of asbestos one is astonished, not only at the wide range of articles manufactured from. ' this mineral, in greater or less propertion, but also at the diversity of Indus- v*. tries which nowadays find its usei-'Tr necessary, either in the form of the ra^im material, or as manufactured articles:;.^1"! Evidently, therefore, with the multi-,>*-. - plicity of processes and dusts encoun-- teml in the ramifications of the indus-vl'-V * try, discrimination would have to be =..! exercised, and some limit set to tbe -i;;'/ processes included in the inquiry. ' The processes selected may.. divided, roughly, into `. 1. Processes involving the manipulstion of asbestos, either pure, or admixed with a**w-': small proportion of eottoa, or other vege*'?2v^ table fiber. * *rjT ~ it* 2. Processes involving the munipulution-:*j&y-' of uashbes(tAoas ttoAgneftlhwer. with other dusty .m..a.^--' terials. 3. Processes involving the making up of asbestos cloth into other articles. Group 1 entails exposure to asbestos-?.^!v dust mainly, and to cotton, or other^V* vegetable dust, very slightly; group 2 entails exposure to asbestos dust inlrT-^Tp very varying amounts, and also expos^i^'*.ure to divers other dusts, such as brickfM-,^ dust, magnesia, kieselguhr, fossil meal if and cement; in group 3 the exposure'to^/V-,? asbestos dust--provided no other as-^v* bestos processes are being carried on-S^ in the vicinity1--is, in the majority cases, negligible. Processes belongins^v^" to all three groups may be carried on in ' the same factory, and workers mayif^- transfer from one department to> another (30). . b m .*`F*<. .* V. '1 ` J J, I.Ei r.v;:;. 1 BB 0007115 C-G 15124 i. v-i.-mi. tw.w"nww<.imawjmij-i|umj'cjw * fc|* *! ' 4___ ^7 ^`5 PULMONARY FIBROSIS IN ASBESTOS WORKERS 205 / .Investigation into the intricate ques tion of the effects of mixed dusts, while possibly productive of some general corollary, would lose much of its value . jn the absence of knowledge of the . effects of the several component dusts, and moreover would introduce an in' calculable variable into the final results. For these reasons, and also because the Montague Murray case, Cooke's, Grieve'a, and Seiler's cases ; all occurred in processes included in .group 1, it was considered advisable to exclude, as far as possible, from the - inquiry all workers exposed to the in fluence of mixed dusts, and. all those ..not employed in processes included in ^groups 1 and 3. : -The processes included, therefore, 'are the crushing, preparing, sieving, opening, mixing, carding, spinning, ^doubling, plaiting, braiding, and weav ing of. asbestos, together with the operations incidental thereto. Also ' included is mattress making, where the filling is asbestos, and the manufacture f some insulating materials, where the .dust produced is asbestos. ' .The carding and spinning processes have many points of resemblance to the corresponding processes in the cotton industry, but with essential modifications and restrictions caused by the different physical characters of the-asbestos "fiber. These processes are aided by an admixture of cotton, or-other vegetable fiber, and usually from 2 to 10 per cent, by weight of cotton is added. More rarely, and for pedal purposes, long-fibercd asbestos is carded and spun with no admixture of vegetable fiber, but usually asbestos ysras contain a core of either cotton or metal wire. Asbestos yams are not only used for the weaving of .fabrics, which them selves are used for a multitude of pur poses, but, braided together, are made into ropes for use as steam packings and other purposes. The interstices and center of the rope may be filled with other materials such as tale, oil, or graphite, depending on the precise use to which the rope is to be put. Asbestos mattresses, used for blan keting steam engines, and for other insulating purposes, are made of asbes tos cloth stuffed with-asbestos fiber. Tire stuffing material may be, however, sing wool, magnesia (containing ap proximately 15 per cent, of asbestos fiber), or kieselguhr with a small per centage of asbestos fiber. The man ufacture of mattresses filled with mixtures of asbestos fiber and other materials has not been included in this portion of the inquiry. The shortness, slippcrincss, and lack of strength of the individual asbestos fiber, as compared with cotton, flax, wool, silk, and other textile fibers, have . been the cause of much technical diffi- . culty in manufacture. The efforts of manufacturers to cope with these culties, together with those due to wide variations in the physical properties of the raw material, are reflected in the methods employed by each. For these reasons, and because of the great num ber of patented and special products manufactured, one finds considerable differences in detail in the processes in use. The majority of the processes men tioned result in the evolution of dust, although by no means to the same extent. Differences in plant, quality of asbestos used, methods of manufacture, type of finished article, and extent of application of exhaust ventilation, ;" >.' :1 -, % wo* i..I ., . '.X-"VJ Ui ! CL, J- -.jit-ft IT Ctml * c5v> UJ s-*---, i .. i. .* * * Jt lH.*L'r.`:^<VWa r'!V.*r>- 1 'y -si :)i ,f: - t . VAs-;% jjv,' ___ _ I'flB'nrt --------------- --- _______ [ A; -. --v'--:->i >: v*. ?;W.?-y>fr; N0IE:THir 'V'Kd.0 V' !> !} K ' ' i ::! i i -.v i + /t; ste^iwr & -Kua* - mwbWsIS'f.VeiJ?v-r - : m *v m w#f vtAJ iLiiiffs - JttllF-VVJL ;!i .4 J M-V't . WQJJ21X3 THE JOURNAL 4 * V . `_*.J 6, :&u_ ttC/ nil result in variations in the evolution and roost probably an overestimate, V\- of dust in similar processes in different is 600. Thus, about 2,200 appears to-^-k factories. be the total population at risk in thia-'v^ Variations in the evolution of dust in country, for the purposes of this in- different processes being of outstanding quiry. This figure, however, does not:)'?\ importance, a series of samples of dust include the large number of workers /fr- from the air of workrooms urns col engaged iu the processes in group 2 ' \ lected, by means of the Owens jet which involved exposure to the influ----r *'; apparatus. ence of mixed dusts, of which asbestos Population at Risk.--A. calculation of is but one, and commonly not more/:.; ; the total number of workers employed than 20 per cent, of the mixture. in the processes already enumerated as This estimate of the population.- at risk, although it may be excessive/is TABLE 2.--DISTRIBUTION, ACCORD ING TO LENGTH Of EMPLOYMENT, OF (A) 775 WORKERS ENGAGED IN ASBESTOS PROCESSES AND (B) SELECTED SAMPLE OF 363 WORKERS useful, since it enables us to judge-ofi^j?* the adequacy of the sample of workers examined, and to apply more correctly/ u. v the incidence rates of any pulmonary''.; fr- affections disclosed by the examination ;/ % ' of the sample (30). .< (A) CB) The sample examined (after eleven^v^ tas. cicrxoTxo HXuV HZVu d z *cu#s ze St s 0^4 **#******* 4S3 62.3 80 24.5 S"9 it*t*f*f**i**tf 200 25.8 141 33.8 10"14a **<** 51 6.6 84 23.2 1H9. ****, 21 3.1 28 7.7 20 and over.................. 17 2.2 21 5.8 cases are excluded of fibrosis and pre/$viC fibrotic conditions due to causes otherV-vj? than the inhalation of asbestos dust)3j$v:; numbered 363, representing 16.5.per&H*r cent, of the population at risk,, esti-$'ir mmaatteedd aans aabbnovvee.. TTVhiep manner.- otr?$4 selection of the sample must be referred to, since just interpretation of fthe$/f^ results depends upon , a due appretia^^v; Total............... 775 100.0 363 100.0 tion of the relationship of the sample to.frjj;'., the whole population at risk. rV/.V^uS^- The principle of selecting primarily^ Included in this inquiry, but excluding those longest employed was adopted those engaged in processes included in but regard was also paid to the 6thei,^>> . group 3 in which the exposure to as, . bestos dust is negligible, gives a figure of approximately 1,600; if we could ' add to this the number of workers end of the scale, so as to obtain infor*^??^* matron as to the length of exposure dust necessary before effects are mamritiM fested, and also as to ihe parUculai-/?T- engaged in handling pure asbestos fiber process in which the worker-yisifipyh only, in the preliminary stages of the engaged. It was felt that, in this wayj;;v^>` processes included in group 2, we the maximum information would, should obtain the total population at obtained in the shortest time. risk from the effects of asbestos dust it Table 2 shows the distribution,-;^^' self. Unfortunately, this latter figure according to length of employment.c'-yr is unobtainable; but a rough estimate, (not necessarily in one factory)/;of ^^ i`.h- :c;. \\*m- It! isf-v"Xy,' C-G -rMvS'vr . . . . PULMONARY FIBROSIS IN ASBESTOS WORKERS 775 workers engag'*) tlic pr*H*-?vi`s a center which is cquipitcd witli the under review, nod of flic sample of 3(i.`J necessary X-my plant, tint] where tho i ; -W ' C .T :i\.j ; 555 workers, distributed in Mu* name u;iy. M'rviut'H of u consul(.nil versed in tho f'\.C The enormous preponderance numcri- science of radiography of the lungs ore [ dlly of workers employed under five years in these processes is striking, as it also the very low percentage of ** ' * *. workers employed ten years or longer. *J Comparison of the two parts o: the available. Furthermore, it must not be overlooked that such examinations are voluntary, and not, os in South Africa, compulsory. Moreover, re peated and protracted examinations ;!g%iS > ; ) *" 5 t- -- table shows that the effect of this 9I * '*-*.- method of selection is that the number *r:V examined in each succeeding five-year employment group is a progressively .. greater proportion of the total number 4., , which could have been examined in 1- each particular group. With a soli % -r, ' tary exception, all those examined were vat work on the day of examination. only result in the exhaustion of all concerned, and much depends on the willing co-operation of employers and employees, since the only incentive is a desire to further the common welfare. Radiography, therefore, has a differ ent function in these inquiries, than when it is applied to individual cases for compensation or other legal pur LJJ a; j 3 K ; v y? . -- i; r? *,4, 151/ ,. ^ V ~~t mJ.! 4 a*** r* -\ ' *,*^1 enVv. i:. ^,;* (i *.s". .r"{ , * W'l < I < *' -I f tr> '"I'.t - 4 * Not only the value, but the neces- poses. This function is not that of - -t t I 1 'Li*1.- sity,; of radiographic examinations of replacing careful clinical examinations, H `..the chest in investigations into the as has been recently foreshadowed (18, .. - effects of dust uponthe lungs, has been p. 40), but primarily that of being emphasized repeatedly by Watirins- an indispensable aid in diagnosis, -- Pitchford, and reaffirmed by the especially of doubtful cases, in tbe -Departmental Committee on Compen- determination of complicating lesions, ^ration for Silicosis (17). A high . .;;;.^JstaDdard of radiography is essential; '>! ;i*,, as Watkins-Pitchford phrases it. the t. -;,v "/ radiograms must be "technically satis* * Indifferent films are useless, in measuring the extent and progress of the disease, in locating the point at which tbe earliest radiographic signs appear, and finally as. a check upon the human factor presented by the .. i iu* C ,. . . V r ,< i examiner himself. The examinations (except one) were IV*/*. v . .------------ 1TM 'evolves the examination of i"L.,'*7Vv'workers in factories, large and small, ^5. ; rattered over the country, it is not f v P^^icable, nor is it necessary, oon *lering the special purposes of the \ ,Vx'^uiry. fr radiograms to be taken of f .vvv..- workers examined. The dislo- i * I?4*00 wor^ 4 factory, caused by *ff absence of a number of hands for . *"* ^Pose, cannot be viewed with . v;. - V !".C0nccra especially when, as is not -- .requent, the factory is remote from carried out at each factory, in a room set apart for the purpose, suitably wanned, and with the necessary appointments. On occasions the noise of traffic or from the adjoining factory was a hindrance, but in one way or another these difficulties were over come or minimized. All the selected workers were exam ined by the writer. At three factories, however, a number of workers were examined jointly with Dr. E. L. Middleton. His far-reaching experience of tbe , , . JvU ; .5 it iifassa ?<?'.'Jt*> , : : *I ' * . * '.,,x ___ ^5, M; ^ /. -- J VI' l_BB 00071187^ M GG 15127 :1 - -1** MfTTP ' - 20S THIS JOURNAL OF iVi i Di liesp a rhb i* * pathologic changes in the lungs, pro these, it diminishes in intensity, but duced by the inhalation of various still persists. In other words, we find dusts, was of great value, and Itis tacked on to the paravertebral dulness i-* assistance was much appreciated. an area, above and below, of impaired S-, Every effort was made to complete resonance, which is much more exten- * (.lie clinical examination of the workers sivc Mum that usually a^ociated with before the onset of winter introduced old inactive hilar tuberculosis. difficulties due to ephemeral bronchitis, Iui|urincnt of the percussion note i colds, and influenza, which would tend was found to be constantly more to obscure the wain issues. Thus the marked in the right side; in fact, at first -'J:. clinical, and two-thirds of the radio* it was thought that in the earliest graphic examinations were completed degrees of fibresi3 it was confined to by the middle of November, 192S, prior that side, but later, and more extended -t to the commencement of the influenza observations lead to the conclusion epidemic early in 1929. that the earliest detectable cases are'?/* bilateral, although the signs on the left ``jf Clinical Examination side are tenuous. '/&. Percussion This change is so constant that it has -L< been adopted os the most reliable single The inhalation of asbestos dust clinical sign presented by this type of }.'> originates changes in the lungs, which pulmonary fibrosis, and no case has '*{* may be looked upon as a measure of been classified as fibrotic in its ab-'-yJ the efforts of the living tissues to repel, scnce. or incarcerate, the irritant particles of Considering the frequency with'ifc.' dust. These changes modify the per which signs indicating what may be cussion note. It is true that the note termed "enlarged roots" were found in elicited may be similar on both sides, asbestos workers, it may be that para- but the note is not normal. It is vertebral dulness is one of the earliest thinner and higher pitched than nor signs produced by the inhalation of mal, and there is a sense of resistance asbestos dust, indicating congestive:^* imparted to the plexor finger. In changes in the root areas and a choking ' other words there is a diffuse, but of the lymphatics with dust. Reflex* slight, impairment of resonance. impairment of note, due to irritation of.jfSf?. This alteration in the percussion the lung tissue by dust, is, however, an-.Viy. note, however, is more difficult to attractive explanation. It does n t.^ ' recognize because it is bilateral, and follow, of course, that workers present- -yj*. extends over a wide area; consequently ing these signs will ever develop a defi- the aid of contrast percussion is denied. nite asbestos fibrosis.' ;. It is best elicited by rapidly, and. Clearly, the physical signs presented & verylightly, percussing the back of the by any case of diffuse pulmonary fibre- chest from apex to base on each side. sis not only may be modified by-**!,- It will be found that the extreme changes produced by some intercurrent ; apexes remain clear, but below the lung disease, but, ab initio, will vnry.^ apexes the impairment is general. It according to the state of the lungs he- increases over the root areas; below fore the onset of the fibrosis. Thus,.*? - May, 1(30 <*!-. !_BB 0007119~7 '1^ 1 tXf \*r PULMONARY FIBROSIS IN ASBESTOS WORKERS 208 . . V*i ,*47A*< * 'the fibrosis may be implanted upon a . perfixtl}* noniml cheat, ju which case (o healed tuberculosis. That there is an extensive fibrosis is clear enough, Y tho problem of diagnosis is straight* und (hut most of it is not due to ukIics* .i'4* -forward. In other cases, however, tos is strongly suggested when examin - preexisting root changes, so common in ation of the lower portions of the lungs *'>V- -.1 ah industrial community, niny be pres- shows that they are comparatively or tlic lungs may be ulrcady (he slightly affected. Further help in these cases, of course, may be obtained from the history and symptoms. I: . , . * *1 j ^ t *, V* ".`'. pleural thickening, the result of an old ^;,T.?pleural effusion. All these examples have been noted in the prewuit invesli`.^^pition, and others will readily conic to 3^5tod* 3^: '^'.Although in most of these coses the ,, 7< ~:;dust fibrosis, if moderate in degree, can 'be confidently diagnosed, especially Vj^^.vith the aid of radiography, it must be j ilC.'-admitted that the problem becomes (i'Y'i.' .yery difficult when the dust fibrosis is ^comparatively Blight, and the changes M^pioduced by other conditions are pro: vp ^Bounced and diffuse- Three types of ii these cases have caused most difficulty f#^among'those examined; fortunately, t v . ^-numerically they were few. i The first of these is where the dust V.Y^brosis has been implanted upon lungs T ^ .. ^(41feady emphysematous. It seems . |-.'r'..^,'that, at any rate in the case of the -- A.:.asbestos fibrosis, until the fibrotic ^^^L.^i.ehanges get the upper hand, clinical ^j&jJ^diagnosis of the fibrosis in these cases fjp 'rf.\ I* "`Possible. Nevertheless, although problem of the diagnosis of a i-._i._i-j ______ _____ ________i__ * ;y ' >*bat it can arise only under exceptional Yv-^?'fcumstaiiccs. |v . The second type of case which has 4*``V ; t;.; ten a source of difficulty in clinical :r V:>5iagnosis is that in which there are j-.'# ^tenve bilateral fibrotic changes due as to render that side useless clinically f . \ 1 for diagnostic purposes. If the side r ' ' ^-= " "`i !" .* > affected by the pleurisy happens to be the right, the radiographic picture is also curtailed by the normal partial obscuration of the left lung base by the heart shadow. -........ * These three types were, with the possible exception of the first, uncom mon, and are mentioned merely to call to mind some of the ways in which an asbestos fibrosis may be masked, in greater or less degree, by changes due to other disease. Only passing reference need be made T; ! ' Ui$-3.X>'sS && to the other physical signs found in the asbestos fibrosis, since they do not v,.( differ materially from those presented by silicosis. Chest expansion is dimin ished and may be reduced to one-half inch or even less in advanced cases. Retraction of the apexes is common, and sometimes shows a peculiar feature differentiating it from that found in fibroid phthisis. Instead of the im mobile and sunken apexes seen in the latter disease, the ajjcxes arc seen to descend during inspiration, and to rise again during expiration. This seems to indicate the anchoring of normal apexes by fibrous tissue in the lower portions of tlic lungs. Some confir- ^BB_007J20 J g: it.i29 ' ;miV<4twT**0*-;-..*"5`.4/ `"* .. J III .! - ife 'f. ? ` fji 1i! hri: ! *TT- TMJc ^ISS h; ^ t- j'> ^ - r .,,.. . " ` -"7^0^??:' 210 THE JOURNAL OF INBUSflUAL HYGIENE: '.<' ' 1 ' J mntion of this was obtained radio* logically. Auscultation ' In the majority of the coses of fibrosis, the respiratory murmur is weakened, much or little, generally, more on the right side, and often still more at the base; the expiratory sound is weaker than the inspiratory, and often becomes less and less audible as one approaches the bases. Transitional phases between this and harsbened breath sounds and pro longed expiration are not uncommon, even in the same chest. The latter may be noticeable in the upper por tions of the lungs, but progressively diminish toward the bases. Other combinations were also noted, how ever.- The dry character of this type of fibrosis during most of its course is rather striking. Scattered fine rides and clicks in the root areas, axillae, and bases were not infrequent; slight edema of the lower halves of the lungs was noted in one of the more advanced cases; but in a number, no adventitious sounds at all were heard. Pleural crepitations, and rarely a slight pleural rub, were noted--these attacks seem to cause little pain--and in one case a little fluid at the right base. * No doubt this variability in the sounds heard on auscultation reflects underlying changes,, temporary or permanent, in the lung, and is depend ent, inter alia, on the extent of the fibrosis with its associated pleural thickening--changes due to past disease, catarrh, or other intercurrent affection, and to the degree of compensatory emphysema present. Symptoms V:^^ The symptoms exhibited by these>*v^ cases of fibrosis, as might be expected,*^!--;' closely resemble those of siffoosas.*?;?..^ The distribution of the main symp-^f*^ toms, and of one sign, cyanosis, whids*J is included with the symptoms for con-vi;'; venience, is given in Table 3. A lew<;g-._'cases have been excluded on they-T`grounds that one or other of the symp-$:l-i. toms complained of might be assigned to causes other than the fibrosis, suc1a?;>V' TABLE 3.--DISTRIBUTION OP FOUR&jj? COMMON SYMPTOMS, AND OF-^^ r; OCYVAS NlLTOASOTISel, A1MMOAXNtGrt CMAk ShWEStfi w;,-t -' .-'*r*'. v* OF FIBROSIS SYMPTOM CASES in WHICH V SYMPTOM - .***\ V'. was paasENTAVi'-'v. -'V.l'v : No. Couch......................... Cyanosis..................... Dyspnaa........................ sire '$* Expectoration............... Pain............................... "YCK* * Excluding thoe is which the presence ^ : of the symptom is referred to other csuaee. ^'^ . as a complaint of shortness of breath in>~* ,> a case with a past history of thyroid intoxication, or of dyspnea*^?; associated with obesity. -mm Between 50 and 60 per cent, of the^h .r v_____ t -v.j showed some degree of cyanosis, whereas only about one-third comr-j,,^j, , plained of expectoration, and one-^.771 tenth of pain, or discomfort, in the^h^T chest. Also, while 14.6 per cent. of.i;. >.; the cases had no complaints and --iaa showed no cyanosis, and only 3.4 per',.\7 :l GG 15130->n suy.uMJ'-i :; __ I BB 0007l2l~T ' * '*4 ** .,*/ PULMONARY FIBROSIS IN ASBESTOS WORKERS ' t v., )';-1).+7>.* >*>* ' presented all four complaints and 0 -j . irere eyanosed, 60.6 per cent, presented Vv: . two, three, or four of the five items. Clearly, none of the four complaints, :,\V - or the presence of cyanosis, can be an T?r infallible indication of the existence *_y ` - of fibrosis; but the presence of two of V^' ; -thcm, shortness of breath on slight -rV'f 'ercrtion, and cyanosis in some degree, /::-> 'j in an asbestos worker, is highly sugges'. '.rv '-tivc.'in-the absence of other evident ; cause. `.'V'"*' Nevertheless an advanced degree of ' fibrosis may be present, and little com: plaint made. Symptoms, unless dis- dressing, are so often a function of > <& . the -introspectivenes8 of the patient. Slight degrees of fibrosis, too, give rise :\to no symptoms, in the absence of '-'tji'}.an intercurrent bronchitis, since the remaining sound lung tissue is still V/r,, amply sufficient for all purposes. Cough was the most frequent symp' : tom, and was of two types. For a few yi..':;/. weeks after commencing work in a dusty process, asbestos workers often ^4-. dust irritating, and cough *$rY' while 'in the dusty atmosphere; this | lasts for a few weeks, and then usually disappears. The writer has noticed *ffect on himself, but only while in K;/:* very heavy cloud of asbestos dust. dust seems to be only slightly " this way. One or two men j1'^0 had previously worked in cotton or blow rooms, and were by that dust, stated that they were unaffected by asbestos dust. \' ^rt^inly asbestos dust does Dot cause asthmatic attacks like those seen in t v.:. otton card room workers. One man, migrated from a cotton card room waste") nine years ago to an c;.^estos card room, on account of the s-'.., effect of the dust, does not find asbestos dust irritating, but to this day cannot work with a cotton ffy scutcher (as he occasionally does) with- --out precipitating a coughing attack ^ within an hour or two. Although he suffers from winter cough and some shortness of breath, he stated that his health has been much better siincceethe change. Asbestos dust, therefore, very mild powers as a reflex the upper respiratory tract, this respect, comparable This is an unfortunate attribute, since 11' it leads to the assumption that the dust is more or less innocuous. The second type of cough is more J-- intimately associated with the develop- CD meat of fibrosis, and occurs, or perhaps . is noticed, after a varying number of years' work. Usually it is present only Li* Ai.,. , ?, in the morning on getting up, when after rather a sharp attack of coughing, a little viscid sputum "like an oyster" is brought up. A similar bout may occur at night after ceasing work; at times it is sufficiently sharp to cause retching. It is generally rather worse in winter, and may be noticed only' then. Although it dosely resembles smokers' cough, its features are pre cisely the same in nonsmokers. - Persons giving a history of cough dating from an attack of pneumonia or other illness in childhood, almost in variably state that the cough has not become worse since working with asbestos. One worker succinctly de scribed the cough as "first in the throat; later catches the chest." Generally, this cough causes very little inconvenience and may pass un noticed until the development of some other symptom directs attention to the general state of health. Thus, out of 'V V' i ,:-i!i z.'a.sK'JUH ! SK'l.'WAdillJ .-.vu. a r! v-rltyv/ ; ! v. GC 15131'.-. .. . r'/fc,? te!' mmm- Y' '*) if ' !':* -: tt^* JX!*,t*sf;.5. 7/-VVf'sv fi !?/- 1!$: ' iplf!i' rf$Wr- `; fjite,-'- , ,.J!S ~.T* *;f fj/j *s*i * gw-tj* i* :.t*--*X*t7*'*A.ii;%4.^,.1AMi)*2..<v.vw!<./sT-'!r.- :*--.. I .-'I*! J f NOTE: THIS DCa;^NT35W M :ipn .*($ rltfojj Jsad'Kpilri,nlYMVcMhii-rJpr'! 'go'ftx 212 THE jouio: ....: V<V.*r 'form sixty-six cumm of lilinisis, in tlurty- ami in the remainder of the cases'^ threo (50 por cent.) lint cough was stated to have preceded the onset of shortness of breath, in twelve (1S.2 per cent.) to have developed contempo Kd- . *a** Radiography " Radiograms of the chest wer^frlti^- raneously, and in twenty-one (31 .S per tained of 133 workers, or 35.5 percent?'?:'-- cent.) was either not noticed until nfter or tire number examined cimirn^z: the onset of shortness of breath, or, TOf these, over 100 were taken by Dr~^^ although the latter was complained E. W. Twining of Manchester, and of, cough was not admitted. Dr. N. Tattersall of Leeds, and the*??/ Complaints such as "colds go to the - - -- "1 vi1 v . chest," and "frequent colds on the chest," were not uncommon. Com Twining:^; plaint of spitting of blood was excep and Dr. Tattersall have devoted manyj^jT tional; and in all cases in which this hours to the joint study with the wiitir^p- complaint was mentioned, the exciting of the radiograms, and have dmWr-viy/ cause was, primarily, some disease freely on their wide experience of. radi-^t other than the fibrosis--e.g., in one, it ographyof the chest in furthering'the v/t' was due to pulmonary tuberculosis; purpose of the investigation. in another, it occurred only during a Dr. R. S. Paterson of Manchester/-?^* prolonged attack of pleurisy; and in a too, added his experience to a' finsl|/v/ third, the hemorrhage was gastric in review of the films, and Dr. E. Barclay;*'A, origin. Cyanosis, a valuable sign now of Cambridge, lent his assistance**^ when present, rarely amounts to more in interpreting some difficult' films, than a duskiness, or slight blueness, of to both, grateful acknowledgment- the lips; it contrasts, however, with the made. general pallor of the face with which The standard of radiography waalj^b} it is often associated in these cases. very high; indeed, a high standard is),^ Cyanosis in some degree was noted in indispensable, if it is desired to .tr&c&j3i; 56 per cent, of the cases. It may be the cause of such a fine and diffuseCti;^ absent even when there is a consider fibrosis as that produced by ashes-1-?-*." able degree of fibrosis, or it may come tos. and go. The films are superficially, but on])?'W' Pain in the chest is rarely com superficially, comparable to silicosis^*;* plained of, and then it is usually de In the earliest negatives studied .'witirjj? scribed as "tightness of the chest," Dr. Tattersall, a characteristic slight^#* "soreness," or "aching." It was noted obscuration of the lung fields, a general* si-J in 10.6 per cent, of the cases. lack of translucency, was noted. Th Well-marked clubbing of the fingers appearance, for want of a better tena'gsQ;' was noted in a few cases. The general was denominated os "veiling." nutrition is hardly affected, except in Burton Wood has independently noted f-2?* the latest stages. Only ten (10.5 per (19) and confirmed this, referring to cent.) were noted as being thin. In as the "ground glass appearance.'('^\ one, the nutrition was very poor; in Dr. Tattersall also drew attention, to' twenty-one (22.1 per cent.), fair; the more or less rounded "whorls'.* . j ' V.' 000 7l2rjTMW or, , r -- GG - - - -j-2 ' / -j ,?*>-! 1;.-I I 1.*! * jt 1$ ; t t i * ( -**. *^ f * Jir-j.i :,.J i >! ') ^ '> I i*%** * * *.* - * i ' .* 'f * f -V ' t fj.i f *1- ' ftite-... V'M:f 3,Vfl\ '`'* '*-.*rarsta r" tYtJ-W'i*.*vf 1 .*!t i}. -.'**i i]* -*'.* y^.yM Mja >r/ )> '-4 ; * j ; * * *< ,J i i *, H ;;* NOTE: THIS DOCUMffi!! l.'WQ^'lGOME^f?0M PPQl*' l.'WMift/lMf(ifomaa ddA'Mz 212 TliK JOURNAL OF sixty-six cism of fibrosis, in lliirtv- ami in tin; remainder of tho coses llirw* (oO per coni.) the cough was ROOil Stated to have preceded the onset of shortness of breath, in twelve (1S.2 per Radiography . '^V/iXxrv cent.) to have developed coiitempo* Radiograms of the r.hest wery.&* ' ranoously, and in twenty-one (31.S per tained of 133 workers, or 35.5 per cent.r^'. cent.) was either not noticed until after ot the number examined clininnUy^ the onset of shortness of breath, or, Of these, over 100 were taken by although the latter was complained E. W. Twining of Manchester, andVi^ij of, cough was not admitted. Dr. N. Tattersall of Leeds, and the Complaints such as "colds go to the remainder (except one) by Dr. F.' L.&r* chest," and "frequent colds on the Henderson of Glasgow. To all three,' chest," were not uncommon. Com I am much indebted. Dr. Twining$5 plaint of spitting of blood was excep tional; and in all coses in which this complaint was mentioned, the exciting cause was, primarily, some disease freely on their wide experience of. radi-y^r other than the fibrosis--e.g., in one, it ographyof the chest in furthering'the'lVt' was due to pulmonary tuberculosis; purpose of the investigation. in another, it occurred only during a Dr. R. S. Paterson of Manchester, prolonged attack of pleurisy; and in a too, added his experience to a finali$.' third, the hemorrhage was gastric in review of the films, and Dr. E. Barclay;';^, origin. Cyanosis, a valuable sign now of Cambridge, lent his assistance**^ when present, rarely amounts to more in interpreting some difficult - films,'^5 than a duskiness, or slight blueness, of to both, grateful acknowledgmaeenntt']-isfty^ the lips; it contrasts, however, with the made. 'Vr^kk general pallor of the face with which * IhvVSTT* The standard of radiographIVy wwEo*ajVfj.p-!T?n it is often associated in these cases. very high; indeed, a high standard: a}*<y. ' Cyanosis in some degree was noted in indispensable, if it is desired to trace'pi& 56 per cent, of the cases. It may be the cause ot such a fine and diffuse^*--' absent even when there is a consider able degree of fibrosis, or it may come tf,oibsr.osis as that produced b*y as..b..es.-rV-''.Tfi-t' and go. The films are superficially, but only-^^i Pain in the chest is rarely com superficially, comparable to silicosisi^': plained of, and then it is usually de In the earliest negatives studied.with'5^ scribed os "tightness of the chest," Dr. Tattersall, a characteristic slight'^0 "soreness," or "aching." It was noted obscuration of the lung fields, a general* in 10.6 per cent, of the cases. lack of translucency, was noted. Thisp& Well-marked clubbing of the fingers appearance, for want of a better term^f; was noted in a few cases. The general was denominated os "veiling." Drj^y nutrition is hardly affected, except in Burton Wood has independently noted the latest stages. Only ten (10.5 per (19) and confirmed this, referring to cent.) were noted as being thin. In as the "ground glass appe&rance.'^j^-. one, the nutrition was very poor; in Dr. Tattersall also drew attention, totT'Vf twenty-one (22.1 per cent.), fair; the more or less rouuded "whorls" iof-'-'tr i-*----B--B-----0-----0----0----7---1--2--4-- i MGC 15133 v.-m;L'.'Jt1: / > i-iS V II t: c ( / t 0 c V t c l a r a t a a a t I e l *] V I I r a 1( e I PULMONARY FIBROSIS IN ASBESTOS WORKERS 213 *r ^vtiyiTiz si seen in the striation in the Awjoid-xones in some of the films. ^ -There was general agreement as to V^lhe fine and delicate nature of the ^'characteristic mottling. Dr. Tanning t(ip. s personal communication dated .yAug.2, 1929)--while lamenting that there has been, as yet, neither time nor ^ opportunity to study the changes from every aspect, and therefore his present views may be modified on considera tion of all the evidence--states; .. $ ^ la general my opinion is that the earlim t*t ttagei are not ebaraeteriatie radio- ^t^-locically, but that the stage of fine duaty f-w5>tfpplinc is almost certain to be eveotually improvable a* an early asbe*to* lesion. We &aaw it constantly in a large series of films, K?- sad after a little experience it ia quite easy r?^?'to detect it. |^;^.V'.'6ome of the other eases showed a few grouped lesions, like rosettes or leopard markings, each component being about the si*e of a primary lobule. ` These are similar V5',to lesions sometimes seen in tuberculosis, il ^i.'ln tbs asbestos cases 1 regard them as being groups of primary lobules making up a ; lobule, the walls of which are infiltrated. ^'.JTbey certainly teem to correspond in sire w^Sjwitb the macroscopic lesions seen in the lr.?!'T.pethologic*l specimen. The advanced cases show heavy basal and iyyrrwid-field mottlings, common in pneumonol^^^coniosis, with a tendency to avoid the #jjapieea . tv'.*--;On the whole the leaions are distinctly SjL E?|U** dense than those of silicosis, and arc less 10 C10*1? >nto well-defined etages, but think we can recognise: 1. A very doubtful stage of increased ^ic'^liaetr striation*. `IriiT- fairly definito fine dusty stippled ^^.^.ppesrsnec. a;V ` Coarser mottling with increased linear It% iliY. ttrietions. _ t. Gross lesions with pleural changes snd ,*;V' * displscements due to the pull of the fibros- .' : ^iog lesions. r/jr*c*`i The few tuberculous lesions we have come A5u'V terow have been easily distinguisliablc. The radiographic appearances in the earlier stages arc most marked on the right side at the base or in the central zone. This corresponds with the clin ical findings. This preference for the right side has been noted also in silicosis, by the South African ob servers. The cases showing radio- graphic signs of a dust fibrosis have been classified in three broad groups, This grouping, although unscientific, is convenient practically, considering the main purpose of this investigation. Indeed more precise classification based on the particular radiographic changes noted might well be mislead ing at the present time. Much combined clinical, radiologic, and pathologic study is required into the whole subject of these fine types of dust fibrosis, which have been noted in workers exposed not only to silicate dusts other than asbestos, but also to other inorganic dusts containing no silica, before it will be possible to classify the radiologic changes as has been done so successfully by the South African workers in respect to silicotic fibrosis. The hypothesis that, because asbes tos dust produces a pulmonary fibrosis with consequent deviations from the normal in the lung skiagram, the de gree and potentialities of this fibrosis can be assessed by comparison of its radiologic picture with those of stand ard silicotic films, is untenable. At least two general types of pul monary fibrosis caused by inorganic dusts can bo recognized. A third, representing the purely peribronchial variety of fibrosis, might be added; or it may be that all dust fibrosis will be found to approximate more or lass closely one or the other of these two tn 3 i-U .sv:r:ir- s ir-v/.&as ,i i'!; *.v f . . . 'I< V..T S it;'r . !I -i .'a,-/*; #;vV?T: ()jv. f :1 :* , }6 a.* win t, ,/< ,. ti il?i.:ic &'-r&i? i n ...i** \ t v v. "w-.wi* < I* / ; r,- Jf. r V ' - hyx: JV:: *:. * 0007125 NOT COME m Jiij S?J8j 214 THIS JOURNAL OP INDUSTRIAL HYGIENE types. These types are (l) that pro On studying the development: f.$bduce] by combined silica, dust, an asbestos fibrosis as displayed in a serics'.^V*: example of which is seen in asbestos of radiograms, and especially in the fewv^v^ fibrosis, and (2) that produced by free available taken a year or more before silica' dust, represented by silicotic fatal termination, one cannot helpt^C fibrosis. asking the question, "What is theretf^i These two types, while resembling here which could have this effect?''.^ one another in clinical signs and symp The answer is that the damage to the-'^v toms, differ materially both in the lung is much greater than it appears nature of the lesion produced in the be when judged by the silicotic stand-'v^v lung, and in the character of the asso ard. ciated radiographic picture. Thus, diffuse attempts to weigh, consciously or were, wsiwviwwtJ muwMguvuv VUC Aimg.Vrr^Hw unconsciously, asbestos fibrosis, or any enveloping and eventually strangling^vrV^ dust fibrosis other than silicosis, by the ultimate lobular structure, rather means of the standard radiographic than depositing itself in numerous^Tr changes found in silicosis, is unsound more or less isolated foci, as in silicosis.* and is likely to lead to a misconception Thus, at any rate in the less advanced^-;*;; of the potentialities of the dust in ques stages, the radiologic picture of-the^ri. tion. lesions does not impress the eye, uacoa-r^-t^ Badham (8) gives an example of this sciously viewing it from the standpoints^; source of error in reporting the unex of silicosis. - ' pectedly early death of a man affected The radiographic picture may sbow^.i&y with a fine fibrosis caused by an ortho- soft and fairly coarse nodulation, but it^b close basalt containing no free silica. is neverso impressive as the nodulationP^Jp: Referring to some of the radiologic in a silicotic film. `V differences between the fine fibrosis of Paradoxically, the distinctive "fes^tj^vg dusts other than silica and the nodular turc, both clinically and radiologically,^^^ fibrosis of quartz dust (i.e., true sili of the asbestos fibrosis is its unfformity^^S cosis), he states: ,, The modesty of the symptoms,'/thftj^^ unobtrusive, but diffuse, impairthenn^' Moreover, the coarse fibrosis of silica gave of the percussion note; the homo-^r; clear interspaces of normal lung, while the fine fibrosis presented a uniform granular mottling leading to the conclusion which is prolmbly orronoous that the actual develop ment of fibrous tissue was greater in a nodular fibrosis as silicosis than in a general geneous stippling of the skiagram;' are fragments of an entity, unmistak^^* ablo when assembled, but enigmatic|p)jg when divorced. a.: * Only two references to the' radio^'^V ised fine fibrosis caused by eilicates. To me it appears that tba mechanical damage to tba lung is greater in a fine fibrosis than in a coarse fibrosis when both are well developed. .graphic appearances of the chest'.i asbestos workers have been tracedi^Vg' one in a report by Pancoast ' and?$jg Pendergrass (10), and the other in-.an.jf/^article by Burton Wood (19). '. The evidence obtained in the present Pancoast and Pendergrass togetber^w inquiry amply confirms this general with Miller and Landis examined "17^?^ statement. asbestos workers, 2 of whom 8howed..%'"5v- -------------- ---- 1 BBL2222BL1 ;*5ip \ .".4m GC 151351 :. TWMU'im.n1 1> w- war v,.. PULMONARY FIBROSIS IN ASBESTOS WORKERS 215 - * * ***,. -I-:'- stag6 changes and the other and by the time the stage is reached j5 definite second stage appearances, when the features discussed above arc, .t'pi <)f the men longest at work, one after in varying degree, positive, and the . .. . m -i r.i~ 4 * ^-Fi** . i *4 * * *< . ***$$?& yenteen yean* occupation showed radiologic picture is recognizable, the fr.-very, definite diffuse, 'soft' spots fibrosis is not in its inception, nor even . 'tV-Hr/pro -throughput both lungs, and another in its earliest stages, but is developed 4?Y-.ahowed about the same appearance and fairly widespread.' jjjg^afterV, fourteen years' occupation. TVe must, therefore, recognize an JSf*c-vVery- slight nodular shadows were earlier state when the fibrosis is present 'ffifefound in one man after only two years' in slight degree, and also when there is . . I *1 A ^inoccupation. . Most of these second evidence of choking of the lymphatics, " fr Wastage' cases showed also well-marked -J-r--------------- '------------------- *--' first stage appearances still present, ^ indicating a persistence offree drainage HumwonL '/Tn all instances the nodu- "shadows were characteristically indefinite, ^aoft' and varied considerably in size." specific. ^,Their first stage appears to correspond determined and 8 ^with. stage and their second stage moderate degree t/with stages 2 and 3 mentioned above, tion of practical value will be available. \ I It "appears from the context that Efforts have ! ; these observers regard asbestos fibrosis distinguish workers in this stage t' original rock--a view difficult to sub^^g^rrtanUate^ 2/' ?. ? ; in ed .i>^.a8 (5.8 per being really a silicosis due ceonft^.f)reweeresisliocacladsesrifiiveedd: to adim' ix',-; - :Th*:;vev * fvo*:' ,ll.otw* i*n<g* il7t-a*buil?tation sho from the.t,w. e .n. ty-o -nti.eii-wf'\o;rk/e*>rswo._u_t of 363 - Burton Wood (19) in a series of fif- Clinical Examination* ' Per v "i c.^V^tGen skiagrams of asbestos workers (363): No. Cent. Fibrosis.................................95 20.2 Y' .. ; ) zr` notes: '.`The most noticeable feature of Prefibrotie conditions....... 21 5.8 Radiologic Examination* (133): Fibrosis................................ 52 39.1 -i /iiiisvffi :. v. Stating chiefly the lower two-thirds SuRgestive ch&oges not .the Jungs. ' The fine quality of the definitely diffuse fibroeie22 16.5 *V worthy *>oite. Some of . ' +*,,*r,4 * * ` uI *1iff'Ss*4'*(? '< 1 " ' * eases exhibit a 'ground glass* Many of these cases present a slight --'VU :i+. m. ** :ji,: appearance, though on close inspection diffuse impairment of percussion note '* * -.I'tf-. I 11 " ..w `tTJ aottling is evident. . . . when --perhaps better described as a slightly s -; ,, * definite mottling is present it increased sense of resistance felt on 008186 9U8Jfty described in percussion, mostly of the right lung, * skiagrams of chests showing pneu- at least as contrasted with the left, . i' \+i w. W*3 ' Ofcon^os"i e.g. South African gold and associated with some weakening . " of the respiratory murmur. Prob- \ could be detected , but only by means of r-`* >*>.* * j y /tse 1 BB 0007127 1 V 4* ! 1 1. JJ f 1 .v\ i r I. * *. ; l&f.rCJ AiJ3 JVI'kjilJ* -''j' / - pi-P-JVn ; S3:3S3i;;j. .!I ivSus-lSivf-*i.' -i. . im m&r iff al^fc'-.V'Tv. K.Vf; h *. <i { ??! t ' 1 21V Tliii JOl/itNAL OF INDUSTRIAL HYGIENE *. caV,. . . -*.,.VrfM tf : :.-;vsgn /y/Lupurison with :i radiogram taken prior to commencing work with asbesi/jx. by such means the earliest stages of silicosis have been worked tint by the South African observers. TJ^re, the radiograms taken at peri- six-monthly medical examinations can always be compared with initial /a/iiograms taken before the employees ore permitted to work underground, group is dismissed from any furthep'f*y>s consideration. ' 5fy' A general summary of the findings inS^ the 374 workers who were examined]^ clinically, classified under the most portant lesion, is presented in Table Illustrative Cases - The salient points of a few cases are-'^E-T set out below to illustrate clinical aad*7;'-3, TABLE 4.--GENERAL SUMMARY OF FINDINGS CLASSIFIED UNDER THEtt^1 MOST IMPORTANT LESION CASES or mitosis rssri8KOTic| CONDI TIONS FULMOXABY TOBERCVfcOBIS OTHZB muoSAXT LESIONS U SQ v. `w *isfA>; -;i5gK i '2 E'/V-'r'i <M............ 5-4............ 10-14............. 15-19......... 20 nod over. 92 0 Total. Percentage.. 95 10 21 25.4i 2.71 5.6| 0.3 21 5.6 i One case of thickened pleura due to old gunshot wound. * One case of emphysema due to goosing. 13 10 3.5 2.7 X. ------ * 'm: . ijpfUSrj; In other cases included in this group, dilTuso weakening of the respiratory murmur was noted, with fine sticky rillcs in the root areas. At present no stress can be laid upon this group. The clinical changes are so slightly marked that until comparative radio grams are available it would be unsafe to draw any deductions. ForthepurI>omcm of this inquiry, therefore, this other features. Five radiograms: arc reproduced to illustrate the radiological^ appearances of some of the casS"i| There are insuperable difficulti^^^ however, in reproducing the fin^f^&V changes depicted in the original nega^th, tires. ;; Case 1.--This worker, a female, aged 24,3^^; has been employed in asbestos for ten arid feer one-half years--as a card tenter one year,'^.,^ NOTE:v v * --- T. H. IS DOC! SENT DID ___ NOT "OME FROM PPG FILES j&i \#v PULMONARY l'JJIROSIS IN ASBESTOS WORKERS 217 and n( a doubler nine mid our-lmlf years. old Lultereidosi* of I In; lung root* nml Ken* JIpT fntnily. am) |terminal m'dicnl; liistiiry end increased slrmtinii, especiiilly in the tonlain nothing f note, Nlnvh;in no ciini- tower Imlf of the right lime, Ktiggesling early plaint* and feels ipjilo well. - JJcr nutrition fibroins. b pond. She in puli*, Itu l show* nn eyn noaia. Cask 4.--This worker, a male, need 23, C/5 .........ChetL--Sin: link il client expansion nf 1J ! ' fmH Inti) empliiyiiil ill nkliistiM for iiiim *"* *JLl ' r incites.' ` No impairment nf the fierctission years, mostly mnltress mak iiig. II is family CTS ---j . note i* detected. The breath sounds. in the ; suit personal medical history contain noth- ;i_ f^cvJjv vv;,1;.friiioggthhhtteJruolenofgtt.;,atriJeidSwxaepdnidrkaeedtri^osneoeuisnnedprsraoallloyren^Ugliejeadiinradtht.othsAee ^ing, ojf.no.tf!. He complains of occasional pain in both sides of the chest, and perhaps a little undue sliortness of breath on cxer- co skiagram showed some Very" slight and y ib. doubtful changes in the direction of in- (teased striation. fir. " : Casc 2.--This man, aged 24, has been 1 employed in asbestos for five years, carding ,'.\snd mixing. Previously he worked for four ;.v .years in the cotton trade, yarn weighing, vl . Hi* family and personal medical history T- ,f * contain nothing of note. He has had a J ;V'.V` 7 alight morning cough and expectoration i..l;->- (or a year. His nutrition is good. His o o c,- ,7' '*' / rolnr is fresh, and there is no cyanosis. 'if. . '' Chest--There is some impairment of the i ' "'* fr'; - iiettuision note aver the middle third of the - "right lung, behindhand slightly at the right j? '\bssc. The breath sounds are harsh, and - ^expiration is prolonged in the upper half of :"*V'...I, the right lung, tieliind; expiration is also V" `-prolonged over the left upper lobe, behind. Vi" - , ^c respiratory murmur is weskened at the base, and the breath sounds arc of a : -^i :' "'`whiffing" character. There arc no added wuda. A skiagram showed enlargement tho right root, and alight haxineas and V.Js -.f1*triation in the central rones in both lungs, * :-,,*utKeting early fibrosis. C**1 3.---This man, aged 32, Las liecn 7`~vV.vemployed in aabestos for six years in the t r00, and as a stripper and grinder, Fia. 1.--Cased: Moderate fibrosis. Un due degree of striation and fine mottling in central tones of both lungs; calcified glands in roots, with rather coarse striation in upper lolies; T interlobar pleurisy on right side, between the lower and middle lobes; emphysema at bases. fcrPrevious!y he was employed in a cotton card /If lr nine years. He had army service tion. His color is normal. His muscula fiv years, but wasi ni ot gassed. He gives Vk .i;.'v..''5.- V.' *I* family .__it history ^ of; asthma; otherwise there i >i'* [ ** of note in his family or personal medics! history. He has no complaints and ture and nutrition are good. Chut.--There is no retraction of the a |>excs, but there is a slight flattening hclow the right clavicle. The percussion note is .. quite well. Ilia musculature ia very slightly impaired generally, behind, partic -fe Hi* color is pale, but he shows no ularly on the right side. The breath sounds .'.vy.'fV.Q'anosii. arc weak, generally, and expiration is pro . CAcf,---There is slight impairment of the longed. No added sounds are detected. Percussion note generally, particularly at The skiagram (Fig. 1) shows an undue r`cht base. The rcsjiiratory murmur is degree of striation and fino mottling in the '* weakened geiierHily. No added central rones of both lungs; calcified glands IV..: *. *UDds are detected. A skiagram showed in the roots, with rather coarse striation in > i... ` !' V ^ . m f a . * <*S# if .i . - * , '' i - Ji _^ v. _ " ! ; laV4*:.' |. i 1 IitA>f TM 1. 1iw^i J "Ja'#fhV* ..' ^i;*F4r 'V* j1 t J i; \w f ; a ; .*> * * * v% i'.i; v; v-N,* : .i J ' .V # 'Ar,* n * \ '-tfirxm.IW1 V-- ; ; .i S' -sir.^rr. =.T_ . 1 c`--crxl i;'i-vOl1 v..r *.,* V - if * t; . *...*.........- rtt"i/4. ra,;S.-;*c*^ "'fjf *v. * ** [;>/V N*. I rx_j^_nR^ I BB 0007129* M**' t mK 41 i;c:a m i Y4 fL'SisS*fc-4* . - , irM,; r? S.i'lj:. /* jy-trsW-* r*T'."- 7Jkdkpfii i?*.*::,*e? * 1 -w5 . * * V 1 ' rf. *** - InS'--*-1! -*r - r^ , >.>Va-,` w . fiR >* --j*S ^ I tmi'f . . * r&i :* dJS'ii -'-V - - f! sJ? s?s 218 T1IK JOURNAL OF INDUSTRIAL HYGIKNK th* upper lolies; 7 interloliar pleurisy on the right side, between the lower tint! middle lobes; and emphysema at the buses. The com was diagnosed ns moderate fibrosis.' Cask 5.--This woman, aged 40, bus liecn employed for eleven yean in asbestos, for moot of the period mattress making. Pie* viously she was employed in a laundry. She has recently been ill for three months with pleurisy (no history of tapping); other* wise her family and personal medical history moderate fibrosis, most marked toward tha$5 bases. Cash 6.--This worker, a female, aged 31^r&\>' has been employed in asbestos for sevenijK^f years, owning, and bos been exposed to<5js& much dust. Her previous em]doymeui&&U was non-dusty. Her family and personaljj**^ history disclose nothing of note. She cornel plains of having had a cough for five years'^ and of shortness of breath on hurryingS'S'S She is thin and undernourished, and polaa*"'' *; -.-t* , V*ij r'*? MS &fV2, fci rKfe __ Fio. 2.--Case 6; Moderate, but fully developed, fibrosis. Enlarged glands in both roots;, diffuse fine mottling in both lungs, especially the right. are negative. She complains of having had a winter cough for three or fonr yean, and of shortness of breath on exertion since her attack of pleurisy. Her nutrition is good; her weight is stationary. She has normal oolor, and no eyanoeis. Chest.--There is some general impairment of the percussion note over both lungs, be* bind, more noticeable at the bases. The respiratory murmur is weakened generally. Persistent crepitations and medium r&les are noted low down in the right axilla. A skiagram showed diffuse fine striation and fine nodular mottling, with light opacity at the bases. The case was diagnosed as Fin. 3.--Case 7: General fibrosis, mostly!; linear, but with little mottling of right fuhg& _ Old puerile tuberculous scant at apexra.iCjfej^itfV yf Dust is present on her hair and mV nostrils. Chest.--She has a chest expansion of oneffigtSp fourth inch. There is slight general impsiri^ ment of the percussion note, definite at tbei&JS apexes and the bases. The breath ound||^J^_ are weak; expiration is slightly proloagCdl^^l No added sounds are heard. Her heartdr&jji not enlarged, and no murmurs are dctectwB&gff The skiagram (Fig. 2) shows a numberT^fs&T enlarged glands in both roots, and a difiuse^f^ fine mottling in both lungs, especially ttesfej?;, right. This is a cose of moderate, but lull^gjiv developed, fibrosis. Case 7.--This woman, aged 46, has bceng**^*; NOT Co 5 ViL, i iO i '/: > ? DS! rmploj-et nluiut th Attainder utiier fac history d a persona yrurs age lli-r comr lulls, and Iter nutri Chest.-- half inch, noted. T of the p< sounds ar lunged. > cross cnlar the second over the ac shows a ge with a lit There are i sears at t! nosed as ge This cns (i. In Case dust extent ent casa th. less eonccn in the first nmuyycan. Case S.- Ii.-is been er years as a eutton and IK'rsonat mr note, except eab* child. *f breath on fur three ye: xpeetoratio lb' is thin an Chest.--Cl is retraction "He is imps front, and ov right lung, hingi-U at the ? tunt rales nr h'w rides at `bowed a defi ution. Til is "dvimccd sta; Case 9.--1 '"I, it X'u.S N* I i /X** <^; T,* *.*. *#4 v, :. .*#- /. . .; . IF ': . .: _";^*'V> - - - PULMONARY FIBROSIS IN ASBESTOS WORKERS / ' employed in asliestos for thirty-two years-- employed for twenty years in axlirstns in y_; gbout three year# on cards, and the re- many capacities. There is nothing of note CS 'VO F. f ..t".-,'wainder-a# a spinner. She ha# done no in his family history. He gives a history of -- UJ *ri V.* other factory work. Her family medical pneumonia a nuinlier of years ago. Hi# r.* ; \ ~ - history discloses nothing of unto. She has complaints arc: a little shortness of breath t |g penonal history of nei>hritis seven or eight on exertion for the lost two or three years; if 1 v'.'.' Trtr* ago, causing three months' illness. otherwise none. His nutrition is fair only. eF'v-jler complaints arc: shortness of breath on His color is fresh, but there is slight cyano ijJUs, and winter rough for nbout six years, sis of the lips, at times. t' " Her nutrition is fair. She is rat her pale. Cheat.--The skin is poorly elastic; there 1 ' .y -,,Qha,i,--She basa chest expansion of oneJ v.v half inch. No retraction of the apexes is is Borne retraction of the apexes. There is an impaired, rather "boxy," note on percus- O > - ` -vv acted.' .There is general alight impairment aion, generally,-especially over the upper * ' of'the percussion note, In-hind. Breath half of the left lung, and over the upper two- : sounds sre harsh and expiration is pro thirds of the right lung, behind, and in F; longed. No added sounds are heard. No l1- *J. '.Ja ,*. gross enlargement of the heart is noted, but V ,V *`:(hasecond sound is found to In- aerentuated front. Respiratory murmur ia generally weak. Expiration is slightly prolonged, but diminishing toward the bases. Pleural I aver the aorLic area. The skiagram (Fig. 3) show* a general fibrosis, mostly linear, but i-j^Vaith-a little mottling of the right lung. crepitations are noted low down in the right axilla. `A skiagram showed a definite fine diffuse fibrosis. Neither lung lights up very | There are also very old puerile tulierculous well, and throughout both there is a very j seats at tho a|iexea. The case was diag- fine diffuse rciiculul ion and mottling-- \ f'.V nosed as general fibrosis, modemtc, but fully develo|ied, fibrosis. ; V'This ease should bo comiiared with Case The fine diffuse character of the radiologic -- 0. .'.In Case fi there whs u heavy exposure to apix'iiranccs in particularly noticeable Imre. - . dust extending over a few veurs; in the pres- Cask 10.--This man, aged 40, lias been | -ent case there was ex|>o#ure to a very much employed for twenty-five years in aslwstos, . Ires concentration of dust, except possibly during nine years of which he was not ex ;.':.'iii4nthe'firet three years, but extending over posed to dust. For eleven years of the | many years. remainder lie was employed in the card j .4;-: " .i' Cass 8.--This Worker, a male, aged 02, room, and mattress making. His family . v ".'has been-employed in mthextoo for twenty and personal medical history disclose noth * Vy/J**11 as a weaver. He was previously a | cotton and ailk weaver. His family and f rj^^'i^jwsonal medical history show nothiug of -'nfWotlte*, aewxcuefHptt tthka.it bLe*_w_a__s_r_e_g__a_r_df e_ Jd _a_s__a_ld_le* li- tf-'i.f &' <ala. child. Hit complaints are: shortness ing of note. His complaints are: shortness of breath on exertion for three months; cough after a few hours' work in duRt during the last two or three yesrs, with little or no expectoration; and pain in the left side of *!*sth on exertion, and on going uj>st airs, the chest for the last three months. His ^lTe years; morning cooxugh and a little nutrition is good. He is pale, with slight S eaxPpefcctornattiiooan for the last tuhnrene wxuinnters. duskiness of the lips. ** and pale, with eome cyanosis. Chat.--There is some retraction of the Chest expansion is 1 inch; there apexes. The percussion note generally |^t**'*treetion of the a;>cxcs. The )>ercussion is impaired, and of a "boxy" character. ** impaired over both upjier lobes, in Breath sounds are harsh and expiration is a-WT^^TV' Sront,- and over the upper two-thirds of the prolonged over the right upper lobe; else -"Vf*unEi behind. Expiration is pro- where the respiratory murmur is a little . :*DCed at the bases. Pleural rub and incon- weakened and expiration is not materially V'-; rfUcs are noted at the left base, and a prolonged. No added sound# arc heard. . J* * the right base. A skiagram {j;.- . v.- "^ed a definite diffuse fibrosis with nodu- : bon. This is a ease of fibrosis in the earlv LV^.;;.MvaocedsUge. The heart is normal. The skiagram (Fig. 4) shows diffuse striation and fine speckled mottling throughout both lungs--fibrosis, fully developed. *** 9---This man, aged 41, has been +i*. i\ + Case 11.--This worker, a male, aged 40, : >J Fa . ? --. ' -r. a . av-'i* r -. .f.\f . .v .th&n'HK-.- * ~ * .,U"'.".W.| JUJ.W I, k'jnujui) ,1'1 -3j; ;,;!v i hliifl ?S'i * jI **W 4 i fejSj N3 ill ... , " &8S2I0 : rati '3 gaffes' r^ 3 *$jf k'J ???!% r-Vd * ( * .11 ft i >* -: { -- K..4J "/l-S . * if- *m- ii . ^j$atfse: ada-t el K$U 'v! aS*;V^j :% J ' ' NOTE: THIS GCOU^ NOT COME FROiVl Pi 220 TJfK JOURNAL OF INDU8TMAL IIVOfKNK linx Imtii luiipliiyiHl fur Iwriity-twii )i*ni in asliesto*--during tlie first eleven years on canto nnd ns n weaver, during which he was CX|>osed to a considerable concentration of (lust. During the remainder of the time he was employed on a (ion-dusty pruress, hut was c.t|Kied to a less concentration of dust derived from other processes. Ilis family And {N-rsiiual .medical history give nothing of noth. His complaints are: shortness of breath on climbing stairs for the last five years; slight morning cough and expectora- Fio. 4.--Case 10: Fully developed fibro sis. Diffuse striatioa and fine speckled mottling throughout both lungs. tion.for about the aame time; and alight aching of the chest in front, below the left clavicle. His nutrition is good. There is light cyanosis of the face. Chest.--Chest expansion is 1 inch; there is retraction of the apexes. There is im pairment of the percussion note generally, most evident over the whole of the right lung, behind, and over the right upper lobe in front. The nnte is "boxy*' over the remainder of the chest. The breath sounds are slightly weakened generally, except at the right apex, but there is no gross change. Expiration is prolonged generally. Fine crepitations are heard in both axillae, and over the right iipimr loin*, in front. The' heart is normal. .Sputum is mucoid, butia'S negative for Ilacillus tuberculosis. Clul&S: Ling of the fingers lias been nolm| for aboutef?^ two years. A skiagram showed an exteaCfife.* give diffuse fibrosis--fibrosis in a faid^Sj^ advanced stage. Cask 12.--This worker, a male, aged 60,:HE? has beyn einployed in nxhestu.<i for twenty-SSiS six years in the card room. Previously-heMj&i was a sawyer's laborer. Therme iias nothin of note in his family and imrsonal medics^'''^. history, lie complains of slight shortness*^? of breath on exertion of recent years,? of winter cough lor the laat three or*f< years; expectoration is stated to be -nil ji His musculature and nutrition are? There is slight cyanosis of the face. Chest.--He has a chest expansion of three fourths inch. The percussion note is iau^p-r paired generally, especially over the upper lobe in front. The respiratory.mur-J^V, mur is weakened over the whole of the ehert^v'.'. except the left upper lobe, where there sre^&j whistling breath sounds, and medium rdleL&i^ The heart is normal. A skiagram showedi#ft very extensive changes throughout the chei'i$jj3f- of a coarse type without fine stippling. '`.Th<rw^i roots showed a choked appearance. Then#3j& was heavy mottling at the base. One'cld^f tuberculosis focus was noted at the left bssc,^^-; and some calcified glands in the left hilunU&^v The diagnosis was fibrosis in the advanecd3?&7. stage. i Case 13.--This man, aged 66, hos.1^-'^'-" employed in asbestos for twenty-one J as a weaver. For about sixteen yean viously he was a cotton and silk wtijjtti' His father died of "chest trouble" at theagt of 45; his sister died aged 15 of pulmonary tuberculosis. lie has only been away sick week or two in twenty-one yean, andifias never had any serioua illness. His? plaints are: undue shortness of breatlaa*i exertion during the last two years;.# for the last two or three winters. Expector^ ation is creamy, and occurs a fair amountofcft times. He has lost weight, and ia thin.fiSS'&jJj; Is pale, but with some cyanosis of theifAM^rc^ and with a malar flush. . .. CAesf.--Chest expansion is 1J iseHtfnf^i there is retraction of both apexes. Duloes*ii; is detected on percussion over the upp*?**' two-thirds of the right lung and over ------------------ - &&2r up|n*r lolms weak, ti-frd >vrr t iiplx'r Tim n librostit* gall as dn (lllHTTl Ca* riininr in IU10 until j (am, i nnd nil. !. for niT of of Work Ai-avin; .liparli; \ ember `--OK, It in a tinConSoll \ lo-is di' Eavo a I luring t -inn*; c riclit sb, -ix tmm: f graj 'tab-* tli " *T>ysi atkiniw lb- bad ('rartin u*bt; In. i.| I hf btralli sii 'lx crop! mid a pbx A KV'|i,||, l*,rii`arilf: "I >-\; *'1 wnS ton- J,,. |, *ad tin'*! f|.|,,; `Hally, *'f" Umr K. Jii ``tl'ilv, :r WENT DID -i v>;jife.. iSiOT COME FROM PPG Fi njliMiMsAttV VIHROsks ire Aouixmw wonurmfs 221 in front, `i t* iniinwt, i_ Club. ""l*'d fiirnlxtiit vl MI " in a faiily male, aged lia. for twnly. J'lX'ViiiUMly i,.. 're is nmiiii.i* "onal tncilji'al cht shortittWw "t .VMM, atl'l three nr four ''I to lie till, ion arc fair, ice. sion cif three- i note is im>vcr the lift irulory nuu of the rln.i re >' > nr.* IC'1' Jcs. 1 R^Pc rlnv.1 'PliUR. The lien. There e. One i.l.l IlC ll'fl Iiiiv, left hiliiiu. o ailvanrril I) ha* Imvh -OIK* Vi'Iirx yearn priIk weaver. `at Ihragr pulmonary way wick a r, anil has His cinnbreath isi r; conch ICx|iector* iimnint of Iiin. lb* the face. iurhe*; Du!m> ic upjwr r the left ,, M7"'- " . *W*r Inis', In liin.l, noil over Uilli upl"T '.* W>es in front. }ln*ath sounds arc rather Cv.atwk, witlt prolonged espirution. ScatJ ; . '' '(lTcd variable r,hunchi mill rules arc heard f ooter the right lung, Miind, over the left r ' lobe iu front, mol over the left root. "'-The' l-icram ahowetl a definite diffuse 5 ' '* P,u* tuberculosis. Sputum was f .v'nfrrcati (one examination). The diagnosis fK'i >".** dust fibro6i in the advanced stage, with | - %?tnlreulosi*, probably active. th<` Kpiitinn Imii) ri'iimiiMil snmU in anmunt, and its apiH-arance did not suggest tubercle. "Afy diugniiKis from the. Iwgiuiijng was unc of pulinohiiry aslaistoxm with )msaibly -added tubcrclu. - "l look two X-rays of him, neilhcr of which showed ap;iearanccs suggestive of tubercle, everything pointing to a very extreme degree of fibrosis." He died on Oct. 13,192$. No postmortem examination was obtained. V.Ctss 14.--This worker, a male, aged 30, -^ eimnenccd work in an asbestos plant .7 Vj^laTBlO, but was employed on other work i ` I '^aatU January, 1914. During the next five I until early in 1010, about three years y sad nine months were spent in army serv - jcc) for nine montlis of which he was a pris- 'f- VM'eoer of war, but he had two short periods i' ;./>..of.work in asbestos--eleven month* in. the >.-weaving, and six tnoutlis in the mattress, ` '.`.`..departments. From cnrly in 1019 to So- VTtnlicr, 193/, lie wnrki'd in asbestos pro::'_ i ',esses, but for only six years and ten niotitlis f .) in a dusty one (mattress making). He then j. leased work. He was referred to a tubercu- J. ' lusia dispensary on Oct. 10, 1927, when lie j ; gave a-histoo'of bronchitis in 1916 and 1917 v -^- daring thc)Var,aud of never being very well ?j'y.Y.-'siocc; complaining of dyspnea, pain in the ^'-yright aide, and a slight cough of only about i.^.ijtti* months' duration, with a small amount , ..'..s.i^of' grayish sputum. Dr. K. Tattersall f f-Vij.^rtates that at that time: V'. ^'V.^-^Drspnoea waa very marked, even on _ talking, and there wn* definite cyanosis. I I**1* marked hollowing and respiratory V !/r'Ji.'li*atraction at both apices, especially the Fio. 5.--Case 14: Massive fibrosis, with pleural thickening, retracted a|iexes, and pneumothorax on left aide with incomplete collapse ol lung. * l" l note over most of the right lung ' upper half of the left; bronchial '/ sound* at both apices; fairly numer- crepitations, mostly on the right side, . r 4 pleural rub at the right base. He had bruit at the apex and pleuror. ifX.b;BErieardial friction. examined him a numlier of times, the . OCC4lion bring April 20, 1928. In that I Av.^ume he had lost V pounds, felt very weak, I H,e dyspnoea was increasing. The remained much the same, though occaY a*bi'i if he got a cold, the moist sounds 1-5.4*?$*^** ore numerous, esjiecinlly at the Seven sputum examinations were It will be noted that the length of expo sure to asbestos dust is unlikely to have lieen more than about ten years and two months, and of this lime he waa employed only shout eight and one-half years in a dusty process. War service, of course, may lmvc reduced his resistance. The skiagram (Fig. 5) shows a massive fibrosis with pleural thickening, retracted apexes, and pneumo thorax on the left side with incomplete col lapse of the lung. No doubt fibrosis of the type pro duced by asbestos dust can of itself a '1 y*V. *nd up to the time I last saw him lead to complete disablement, and ,A , ..15 .Ui it; f, II*. f, t1#*#44'*' V'W;, [j7~BB~0007*133~7 ,7 NOTE: THIS DOCUMENT DIQ..,,. NOT COME FROM PPG FILE$|$ 222 TIIlS JOURNAL OF INDUSTRIAL HYGIENE finally to a fatal termination, even in the absence of a supemdded tubercu lous infection. 'The primary effect of the fibrosis would appear to be that of causing defective aeration of the blood, result ing in an added strain on the heart. For many years, and even with an advanced degree of fibrosis this may be of little inconvenience, provided physical exertion is limited, and acute illnesses are avoided. U11imate)y,-'Tr3T however, the margin of safety, alrreeaaddyy/.!^^- diminished, is lost ami the circulatioalv%- slowly fails, with the usual signs of$:f? edema of the lungs. More often?*^?; however, an attack of bronchopneu-; v monia, influenza, or other acute infec-;^^ tion adds too much to the strain, iin^&pl pairs the cardiac musculature, results in a fatal termination. . /.AAV. (To in concliol&l) BOOK REVIEWS BLEtvERaimjNR. By Prof. Dr. Paul Schmidt, Dirrktor des HvRienischeo Intituts dcr Universitiit Halle a. d. S.; Priv.-Doi. Dr. Adolf Sciier, Oberassistent am Hycieniachen Institut Halle a. d. S.; uoil Priv.-Do*. Dr. Slillfried LiUner, Aasistent an der Medixinischen Klinik Halle a. d. S. Paper. Pp. 70 with index, illustration*, and bibliogra phy. Berlin and Vienna: Urban <k Schwanenberg, 1030. This monograph is divided into a short introductory or general section and a special section. The first part is devoted principally to a discussion of the outstanding diagnostic symp toms of lead poisoning and of the work done by Dr. Schmidt and his collabora tors in the microchemical determina tion of lead in blood, urine, and feces. The second part discusses in detail the usual sources of lead poisoning; the absorption, distribution, and excretion of lead; tbc pathology and clinical find ings associated with lead poisoning; and, finally, the diagnosis, prophylaxis, and therapeutic treatment of lead poi soning. Dr. Schmidt's monograph is particu- larly apposite. It brings the literature^;* of the subject down to the present and represents the mature thought an investigator who has long made thb'V'-.*." field particularly his own. Tin: discus-^;' sion of the diagnostic features of Icadj^f.' poisoning is especially clear and to point. In this connection it is of-'ut-TTrn terest to note that emphasis is place3|*v on the importance of the determin*^-* tion of lead in the blood. No attempt is made to discuss details of technic. The mon,ogra"wpmih. t-*V'f ' presents instead a critical review of'thc^-T? more recent experimental work' relat^^ ing to lead poisoning and will,.in co^^r sequence, doubtless have a wide;'^^^|;, peal to all investigators in this'fiel^^ The bibliography, which contains `TSfygZ. references to the recent woriclana&j.' brings the literature of thc-'suljj down to 1930, is particularly valuables^ "Bleivergiftung" may well be rccoinjjy^: mended as a valuable additionttottlw^ library of students of public bealth^' L. T. Fairhall. l,r cylti* t:<: {H-t acm 'U'tii. erewii/,; ^-e, i,, Vyub,`,K a Hringt., w&jti. ^l `f'.rt 'A '> ^,7. I*/", ? `j-vj '':Vn ,. rr Ir i I 'lTJ