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JOHN G. WELLS. M. O. 41 JEFFERSON STRECT NtWNAN, GEORGIA TCLOMONC 233*0811 6 December 19 5 7 Stats Board of V'orkmen1 s Compensation **34 Labor Building 254 '.-'ashington Street, S Atlanta, Georgia Re: Mr. Larkin Houston This 5^? tear old utility nan in the weaving division of the Asbeston Mill at UniP.oval was first hired in May op 1949. It has been seventeen 3/ears and three months since his original exnosure. He has a total dust exnosure of 48.3 MPPCFY. Mr. Houston was first seen in 1957 and stated at that time that he was entirely well. His oast history was remarkable only in that he had sustained a fracture of his nose in 1935, and had been left with a deviation of the nasal septum, which, he stated, created no difficulty. Physical examination in 1957 revealed a blood pressure of 110/70 and completely normal heart and lungs. There was no clubbing. ' He has been seen annually since that tine; and in April of 1959, stated that he had had a good 3/ear but noted that his wind seemed a little shorter on heavy exertion and that he nave out a little more easily than in orevious years. Phvsical examination was normal. There have been no dramatic and sudden changes since that time. However, he has noted a steadilv progressing shortness of breath on exertion and during the past year has observed that his breathing re serve has been steadily diminishing, and particularly when attempting to push heav3/ objects or exert himself. * During the nast year, this sense of dyspnea has worsened and patient has found himself losing increasing amounts of work-time because of a sense of steadilv diminishing strength, energy and stamina and increasing dvsnnea. Since July of 1967, he has found himself becoming short of breath ouite easily and in the course of his dailv job which has required con siderable lifting and pushing of heavy objects. He notes that if walks on even a straight and level surface for any period of time, his breathing becomes trogressivelv fhorter. He has been coughing in the morning for the past several vears and has observed that the morning cough has become more severe in the nast year or two and has become productive of small to moderate amounts of dark, sometimes yellowish, snutum which has never contained blood. 4 r-t r1 5C1403a8 " M ,.ar.<i custon -2- . has begun to cough more duri ; produced scutum in signifies: .ts on rattling within the chas tha dav but during this tine degree. He. has bean unaware of There h.avs been occasional marastamal aching nains which ' avs been related to hard breathing but not specifically to exertion and there has been no radiation of pain. He has become aware of his heartbeat followin'? exertion in the last few months and notes that it tends to round in a regular fashio: He has had no dependent swelling but observes that his lac-s tire more easily than they formerly did. They do not ache on exertion. Since July of 1967 , he has begun havin'? bilateral uorer reras terra! aching discomfort which seems cccasionallv to radiate into the right sub scapular repion. This ache has been relieved bv rest. because of increasing fear of coronary arterv disease he received an Exercise Tolerance Test on 2 Hover.ber 1967. At this time he walked on a treadmill for three minutes at a rate of two miles oar hour. During tha third minute he became moderately increasing dvsonaic, but experienced no chest pain and was not observed to cough. ' Immediate cost-exercise, two and five minute electrocardiograms were obtained and showed no significant ST-T wave changes. Exercise cardiogram was interpreted as negative and this information was given to the patient. Annual physical"examinations since 1957 have revealed the nasal seoturn to be deviated to the right and partial obstruction to breathing through the left nostril. There has been no evidence of sinus disease manifested b^ suura-sinus tenderness. Respiratory excursion and descent of bases to percussion- has been adequate and remains so. The lungs have been consistently clear except in August of 1957 when some diminution of breath sounds over the bases anteriorly and posterioriv was noted. There have been no rales. The cardiac examination has been consistently normal and the second aortic sound has always been normally louder than the second pulmonic sound. However, again in 1967, A.2 was noted to be only slightly greater than ?2. There have been no murmurs or evidence of peripheral arterio sclerosis * Urinalyses have been consistently normal over the past tan years. So, also, have 'white counts and differential examinations of the stained blood. acked corpuscular volumes have varied from 49 in 1957 to 50 in 1957. The hemoglobin has generally staved in the neighborhood of 14.7 grams per cent. 5CI^0Jo<? H-?. has te.r.de.d to have slightl'' nor?, than usual riUnb?" of red calls . His F.HT was 6. 5 million units ir. 195 7 end has staadil'' but slowl--- decreased sine?. then to 5.59 ir. 1962 and 4,33 ^iilicr. calls ran cubic m-'. ir. 1997, Sa^ial chest x--ravs obtained du^ir.c' nh-- dac^d*? Hava been consistent!*.* normal excant oarhans ~or a y?n? sli^bT decrease in the vertical diameter of his chast ir. the oasd three ^esrs Slight irregularit** of the left cardiac outline has smeared as has a v?.r'? snail far.dir.-, adh.asior. ir. dh.a r.id portion of dh.a lafd diaohrac-.. The vascular r. ark inns remain disdir.cd although a vary minimal r.odularidy is making ids appearance. in the lowar radial right lung field. These x-rav changes are r.od yad diagnostic of oulm.or.arv asbesdosis as we have learned to recognise it in this r.ill, bud ar?. cuite suspicious and combined with cdhar findings (r.odad below) render such a diagnosis Vital capacities hava changed vary little since 1962 although he has rair.ad tan rounds ir. weight ar.d have decreased from 3.1 liters do 3 liners. Toth values are equivalent do 75 par cent of predicted normal. Forced vital caoacity ad 0.5 seconds has decreased from 2.57 do 1.92 liters cr from 83 do 63 per cent of predicted nomal. The forced exoiratory volume at 1.0 seconds has r.ot changed as creatl" and has decreased from 2.94 to 2.47 liters or from 92 to 82 par cent of predicted normal. He continues to hava satisfactory maximal excitatory flow rates and maximal mid excitatory flow rates, although there is again a decreased from. 6.3 to 5.0 and from 3.5 to 3.3 liters ear second. His maximal ventilator^ free has decreased from 1.70 to 1.15 liters or from 119 p=r cent of predicted nomal to 8 5 per cent. His alveolar ventilation indices has shown a steady decrease from 1.5 to 1.1, although the latter figure is not in and of itself pathogno monic by any means of obstructive disease. The. significant observation from these values is that he continues to have nomal ventilatory ability without evidence of significant expiratorv obstructive disease. There is, however, an increasing decrement in vital capacitv ar.d maximal volur.tarv ventilation values. His residual volumes -calculated as percent of total lung capacity (October 1967) are 25.1 and 25.8 per cent. For a man of his age and body surface area, the credicted value is 30.8 per cent. Again, it car. be seen that there, is no evidence at this time of significant emphysema or ob structive difficulty. The defect is more that of a restrictive, defect and this also demon- S'tl'cLt-r.ci ?T2.T)fld.C5.Hv 071 Vif-S . 1* 5CI403J0 Mr. Larkin Houston . --u_ In October of 1057, he. received numerous other blood pas studies. A sever, minute pulmonary r.itrcgar. emptying rate '.-.'as performed and shoved 1*2 r' c?nc n.*,r'C?,=r. sir ssvsn ninutr^s* Trii. s itsst s'jc-cr?. r.ctt's*' rii.xi.r*^ cf i.nsni.^Bd His sTirsr'isl Dst'^isl or*sssuts ot oxr*irsn 5cllc^N?in=r ? i.5hbsn nir^-tTss breathing of 100% oxygen was 600 ml. of mercury. Steadv state--restiny carbon monoxide diffusion studies were nerfcr^ed and yielded values of 11.38 and 11.7 ml. of carbon monoxide oar minute per mm. of mercurv. Minute volumes of ventilation on these tests were 8550 and 8120; and minute alveolar ventilation was 5120 and 4800 ml. per minute. The. ratio of dead space volume to tital volume was 0.31 and 0.3 2 - values a? a in suggesting an absence of significant obstructive ventilator*.' defect. Physiological dead snace on these twc examinations was 135 and 1^5 ml. There was some evidence of alveolar hyperventilation manifested by partial pressures of oxygen in the alveoli" of114.2 and 115.8. The Aa pressure differences were. 46.9 and 43.5 mm. of mercurv and his arterial oxygen saturation was 92.2 and 92.2 per cent on the two diffusion studies. These studies are. interpreted as indicating an alveolar-capillary diffusion defect resulting in less than normal arterial oxygen saturation. VJith exercise at one mile per hour (1.5 ft. oer sec.), he is able to increase his arterial oxygen saturation to 94.9, but as noted above, became, increasingly fatigued and dvspr.eic - obviously being able to mair.ta this increase or.lv at the expense of increasing work expenditure and fati<* Mr. Houston has shown a moderatel'* accelerated downhill course during the last twentv-four months, as noted subjectively in his history. Although there, are a few physical findings and only early roentge.nolo findings to validate his symptomatic complaints, the. physiological fur.ctic tests do provide a concrete basis for his complaint. C!i.ni.C2.2. I^.^r^bSion ? 1. Pulmor.arv asbestosis, due to occupational exposure, to asbestos ^i.2}|5T*3 a) restrictive, ventilatory defect, secondary to one b) Alveolo-canillarv diffusing defect, secondary to one, with 7*0 d -- arterial cxvgen ur.saturation. * r\ -5Ci^03ol P nl I <1<u ,-t >v* m 5CI40Jo2