Document ykQD0ZpMRBdQv75k5e1dBeKxE

a" 6) 0.5 SookBqf] m LIBRARY v>2 Sciiooi f MdktM university of okuhoma OfcliJtomt Cty OkUfeom* t.2. ffi jg| S6 gs -- d 'assitadc. The physical signs in her ciicst were those ot appearances m uic two mugs omy umci- ;a si', -is of ilia right lung. In July, 1922, signs of cavitatiou were may bo summarized as follows: .......... .. aw" ar<\, the spinurn became more profuse, wish sweats ana " jj-cguiar temperature, and site died on llarcb 1-tb, 192*. . . . An ^-ray plate showed extensive fibrosis, more marked in hc right lung, two calcareous glands at the root of the left lung, and 1. Thero is well marked diffuse interstitial pneumonia with chronic bronchitis and some emphysema. 2. There is well marked anthrncosis. :;-iwo small calcareous particles in the base of the left lower lobe. 3. There is an extensive tuberculous coudition with y'. Mucroteopiecil Appearances. ` RbjUt Lung---The picura is thiekened over cite entire surface of r.tbc lung, and showt the remains of dense adhesions to the chest chronic phthisis. 4. In the alveoli, bronchi, and brouchiolc*, and uLso in the interstitial fibrotic areas,''are certain foreign bodies rwzll aud pericardium. Tlic lung is firm and small. The glands -Afci.the'root.of the lung are large, and on seetiou are black, show thickened capsule, and some calcareous particles. On section, lung is seen to be fibrosed and to a large extent airless, the lung tissue being replaced by fibrous tissue. Dense atrsnds of >.-cbrous tissue from the pleura intersect the lung. In the apex there is a large cavity, the size of a peeled tangerine orange. The r middle and lower lobes show numerous small areas--varying in ^ size from a hazel-nut to a pin s head--of caseation, some of which -have proceeded to cavitation. The bronchi are dilated. Left Luii!/.--'The picura is thickened and shows the remains of * 'adhesions to the chest wall. The thickening and adhesions era * not so marked as in the right lung. The lung is firmer than normal. At the root of the lung are two large calcareous mafias, which will be described in detail later (Fig. 7). As this communication denis specially with the nature of the foreign bodies, tho general histological features will bo dealt witli very briefly. - Tho interstitial fibrosis is such as might lie expected as a result of- a combination of a pneumonoconiotic condition and a chronic tuberculous infection. Tlie typical whorled formations seen, in a more purely silicotic condition are not present. There is a marked endarteritis in the smaller branches of the pulmonary arteries; some are throm bosed and organized. Many of the smaller bronchi are .one the size of a Urge hazel-nut, the other about half that size-- ' .calcified tuberculous glands. The other gUads are black and show . periadenitis. In the left apex there is an area of old scar tissue -,T about the size of a sixpenny piece, and a cavity the size of a waisut. Scattered tlirougbouc the lung are small areas of - deuser consistence than the vest of the lung, some of which *how definite calcareous panicles, others small areas of caseation. C.-T4liere is a considerable increase in the fibrous tissue. obliterated; some have still caseous-looking centres. Somo of the alveoli show tho usual metaplasia of their lining cells into cuboidal form. The fibrosed and thickened'wails of the bronchi in many places gradually merge into the areas of diffuse fibrous' overgrowth. There aro numerous foci of lymphocytic cells among the fibroblasts. Some of these seem obviously derived from lymphoid tissue in the $j> i Three outstanding fontures are presented by sections bronchial walls. The interstitial fibrosis is progressive. ~r, Crota this case.' The first is tbc enormous amount of fine The tuberculous condition is obvious histologically. r; granular pigment in the peribronchial fibrous tissue, walls of alveoli, .and in phagocytes scattered through, the sections. . - The particles of this dust are similar iu size aud shape to the black granules seen in the asbestos fibre. Tubercle bacilli were not detected, but the histology is characteristic. Tho lesions aro chronic in character, and there is no special indication of an aente exacerbation. There is well marked caseous bronchitis with lymphatic " The second unusual feature is the presence of large solid spread and numerous fibro-caseous deposits with giant angular particles (Fig. 2). These arc situated in areas of cell systems (see Fig. 8). The bronchi, which are not fibrosis and in caseating areas. They vary in size from specially the seat of tuberculous change, show catarrh with 3 to 360 microns in length. The particles are so large-- peribronchial thickening. There are numerous emphysema ./.masses of them are seen iu certain areas--that they must tous areas. Tim alveoli show, in the majority of cases, some bare occluded small bronchi. Fibrosis ol the *airoli thickcuiug of their wails, and contain many catarrhal cells, .'supplied has taken place and later necrosis, as seen in apparently derived from the lining cells; a similar catarrhal Fig. 3. . change is seen in the terminal bronchioles, some of which : TVe hare never seen anything parallel to this in pneumono- aro dilated. ; coniosis duo to other dusts, nor have we been able to find . The Foreign Bodies. * -/;sucli occurrence in literature. On comparing these large The larger black and irregularly fragmented bodies which --* particles with asbestos dust there is a striking resemblance have been described by Dr. Cooke were not very obvious in 1& in sizes, shapes, and colour. In fact, it is very easy to the material I examined, but were clearly seen in some-' }' take each single particle found in the lung sections aud microscopical preparations of his which I had the opj>or- ?* immediately find its brother in a slide made from the dust. tunity of examining. X shall not refer to them specially, Jt- Wc cannot think there is any reasonable doubt that the but confine my attention to certain highly characteristic aud tr particles in the lungs aro the heavy, brittle, iron-containing much smaller bodies which are abundant in .all the sections fragments of asbestos fibre. The more extensive involre- examined. Some of these are free, but many are phage- sF* meat of the right lung is thus explained. The heavy par* evtosed by the large mononuclear cells in the alveoli (Fig. fi). tides would pass more easily down the more vertical right Some are easily included in comparatively small phagocytic ^.bronchus than the horizontal left bronchus. colls, but the majority ore huger, varying in size from 20 p to 70 /L, or even more in the case of certain elongated forms. Tlie smaller bodies are rounded and homogeneous, HISTOLOGY OF PULMONARY ASBESTOSIS. and all have a distinct yellowish-brown colour suggesting ST stuart McDonald, m.d,, f.r.c.p., Professor of Pathology, University of Durham. fJFiih Special Plate.) blood pigment. The longer forms have a highly character istic appearance, strongly suggestive of some organic struc ture. Most have an auauiar appearance, which on closer examination can be resolved into a closely set' scries of rounded discoid bodies (Figs. 4, 5, 10, and 11). In some cases tho globular forms aro arranged along tin* Vilv remarks are confined to the histological appearances more filamentous forms and occasionally are clustered ''in the Inngs in this condition, with special reference to at tho ends of the* rods, simulating sporangia of a b certain foreign bodies of most unusual appearance which Uyphoaiycetes (Figs. 5, 6, 10, aud 11). Some have f:- are present botli iu the alveoli and interstitial substance ciub-like extremities at one or both ends of the'filaments. -- of-the lungs. The observations are based almost entirely Others, again, suggest the appearance of minute crustacean bn. material supplied from the case described by Dr. Cooke, forms (Fig. 10), but closer examination does not support c- The investigation lias been conducted iu the pathological . the idea of either vegetable or animal origin. These ^`"department of the University of Durham College of i bodies do not stain with the ordinary aniline stains, *' Medicine. , but preserve their original yellow-brown colour. They a re I may state, however, that the appearances are practically seen welt in unstained sections. They give a characteristic identical with those observed in a second case of this con- prussiiui-blae reaction with potassium ferrocyaaide and j/r-dition, sections of which I have had an opportunity* cf dilute hvdrodiloric acid. The reaction is not so obvious examining through the courtesy of Dr. I. IX. D. Grieve of unless the solutions are slightly warmed. 'Where the bodies ;s.5 Armlcy, Leeds. are too large to bo phagocytosed by individual ceils timr '* Histology. tend to become surrounded by plasaodinl masses. Many of Numerous sections have been made from both lungs. tho phagocytes contain much carbon pigment in addition. Jt^Tlie changes are more marked on the right side, but the Though these bodies are mainly found in the alveoli and PLAIN IIH-'b EXHIBIT fssssfs^s. A" i\ l! i iiii V* / l .h?t'*idibular passages, they are also present in the caseous tuberculous infection in this case, in relation to tho fibre; - ideas', m the neighbourhood of the phthisical cavities,. and chango, it is difficult to say, but it is a reasonable assun.;!l some can be demonstrated in the fibrotic areas surrounded tion that tho tuberculosis was a superadded infection, by definite fibroblasts. One in particular (see Fig. 12) in Or. Grieves's case referred to above there was in in measured about 7S /*. It is clear aud segmented in its jections examined a considerable degree of fibrosis withou; middle part, but tbe extremities are nodular and clubbed. apparent tuberculosis. The immediate cause of death ;J It is difficult to imagine that a foreign body of such length could bo transported by phagocytes, but they may represent larger' bodies left in a bronchus which has become obliterated. The bodies hare been examined with the micro-spectroscope, but so far no duo as to their nature has been obtained by this means. They are not refvactile that case was a terminal bronchopneumonia. Till soro* experimental work is completed the exact nature of this* foreign bodies must remain in doubt, but their highly characteristic appearance may well prove to be an impor. tant diagnostic point in the recognition of the lung gf 4 worker in asbestos. by polarized light. I am ouch indebted to Dr. Cooke for material from hit cu te Dr. Grieve for aa opportunity of examining his tnicrosoopu'ai Nature of the Bodies. ' sections, to P. L. Robinson. D.&., of the Chemical Department. Armstrong College, for his advice and suggestions on the chemmrr We hare shown these preparations to several patho logists, but the appearances are new to them. To confirm our own opinion we have submitted them to experts in of the siBcates, and to Professor W. H. Lane, F-iLS., of Man. Chester, for a reasoned opinion as to the aen-botanical naturt* v* the foreign bodies. ' zoology, who are unanimous that they are not of animal nature. We have also submitted them to botanical and chemical authorities, and though there haa been a consider able difference of opinion, some regarding them as hypho- mycetes,. the general opinion has been that, they are not vegetable forms. - ... . ' .. . The fact that exactly similar bodies have been found in CLERICAL ASPECTS OP PULMONARY ASBESTOSIS. ' ' _ : - ' . XT: . . Sa THOMAS OLIVER,' 1LD., F.R.C.P., Consulting Physician, Royal Victoria Infirmary, Ifeweaatle-oa. : Tyae;. Emeritoft'PVefessoriof the Principles sad Practice . . ' of tr-'K-i--t University.of Durham. . the lungs of another asbestos worker, and, so far as I can ascertain, have not been found elsewhere, would seem to Du. W. E. Coon has given a short account of .the history indicate that they are* essentially derived from or associated of asbestos, also of the processes of its-manufacture imo in some way with the asbestos itself. It is also certain that cloth-like structures much in the same manner as raw they do not in any way resemble concretions, largely com cotton Sbro is woven. He. has told us that in the carding posed of calcium and other salts, containing iron department a considerable quantity of dust is evolved. TL derived from blood, such as have been described as strepto- crushing of the. rock is not carried on to any extent ia tlirix forms in the spleen, and which may closely simulate tills country; fchi> is usually done ia the countries where mycelial filaments. The hypothesis advanced is that these the mineral is quarried. Canadian rock is crushed bodies are portions of asbestos fibres in the process of altera in Canada so as to reduce the expense of transport io tion and absorption by hydrolysis, either by direct chemical Great Britain. Our workers are therefore lea exposed :o action or by enzymes. The particular variety of asbestos the harmful influence or the dust--e fortunate circuit- with which this patient worked was a Canadian serpentine stance, since the rock frequently contains as much as from (chrysotilo). It would probably contain silica and a SO to 60 per cent, or more of silica. magnesium salt in about equal proportions (40 per cent.) With the exception of Dr. Cooke's paper on pulmonary with up to 3 per cent, ferrous oxide, 1 per cent, of alumina, asbestosis published in 1324, and tbe details of a fatal and water. From its high resistance to beat we are apt to published by Dr. Montague Murray ia the Chorintj C/t-.-j regard asbestos as indestructible, but, given time, it is Hospital Gazette in 1900, there has not-been, to my know possible for hydrolysis of such silicates to occur, even in ledge, anything written in this country upon the subjv* :. ~ pure water. Such hydrolysis would be hastened and intensi I have had, however, the opportunity of visiting asU.*s;us fied by the presence of CO, in the pulmonary alveoli, and factories in America, and of seeing cases of pulmonary the warm moist atmosphere there would, no doubt, accelerate asbestosis through the kindness of Dis. Haddow anil the process. Even under these conditions the process would Grieve of Armley, Leeds. It may, I think, be safely said necessarily be a slow one. The magnesium could be that there must have been several deaths of workers i:> separated out as relatively insoluble carbonate, or more British factories from the malady, bat as no autopsy aud soluble bicarbonate, which in turn would be converted into microscopical of the lungs were made tho any other salt for which there happened to be the appro were probably certified as pulmonary tuberculosis. priate acid available. .. Asbestos manufacture is largely a familial occupation. The iron existing in* a ferrous condition in the presence It has been carried on in this country only for a little of an oxidiring agent' might be converted into the feme over thirty years. Carding aud spinning of the fibre are state, and subsequently precipitated as hydroxide.' The important processes in the manufacture of asbestos good.*. silica might pass into a colloidal state, at first in sol form .In these departments many women are employed, motin-rs (orthosilicic acid), later passing into a gel (metasilicio acid). being succeeded by their daughters. Where ventilation f If this were so in sol form, it would tend to remain the and spinning rooms is properly attended to associated with the surfaco of the asbestos fibre by the atmosphere is fairly dear of dost and floating fibre, adsorption, and'might be held there till it became a gel. otherwise in these. operations considerable quantities vl Iu time the gel might adsorb the solution, and so gradual dust become suspended in the atmosphere. In a British conversion of the fibre into a mass of gel would occur. factory the dustiest process is " hand beating " of the Tkero might be in the tissues sufficient albuminoid material finished mattreeses rood for covering and protecting the to effect rapid gdatinization of the sol, particularly if, as internal machinery of automobiles. This work should nu.v would be the case here, the sol was being slowly produced. bo undertaken in a room separated from the main parts The fact that the eel is of high surface tension, and of the factory, with open windows at one end and strut::; formed at an irregular rate, would give it a spheroidal down-draughts at the other, bnt even with this precaution structure and account for some of the appearances seen men working therein should wear masks. here. Whether this be the exact explanation or no, it is Recently, with Dr. Grieve of Armley, I examined two at least an hypothesis which should be capable of experi women who are the subjects of pulmonary asbestosis, os>* mental verification. As has been held by Gye and others, aged 48 and the other ZB. The older patient was one <-: in cases of silicosis there may be a direct chemical action the first to commence work thirty years ago iu of silica on the tissues apart from the merely mechanical particular factory I visited. At that date ao danger fr- irritation of the particles, with the prodaction of fibrosis. dust was anticipated, so that no effective ventilation Orthosilicic acid is, as bos been shown, an active poison, the workrooms was attempted, such as prevails * but rapid conversion into metasilicio acid would Although only 48 the first patient mentioned looks its action. '- by soveral yean, aud is extremely emaciated. She -.av* Aa to the relative part played by the asbestos and the up work a year ago on account of increasing physiol * I i Aty ^ '~fa fat \^,~W7SS>i*jB^^SajaAS^i^ 10.51 a"' S 8"kBnTm I3Z1 LIBRARY v.2 t.2. School of Medlcint I UNIVERSITY OF OKUHOMA Oklahoma City, Oklahoma i! Mi *4?. rwy.s *V*&fr}.*'J*Jr!. && V5<<*t*?T-s *?| SB m VrM c,io.s //357 83Lp> -&&* sh Lledical Journal ** V. 2 - rt. 2 //9*7~` /)f>it>i<-iv'