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- r5v*i sufficient attention is becom?p';&.?:+)' g more apparent. The manufacture of asbestos products has increased -J -w- more than fourfold in the last 20 and hence, because of the effective types of suction apparatus now in use will remove a mfurirntmi of not over 90 per cent of the dust, but the remaining 10 per cent may be definitely injurious. In 1916 protec tive devices of the suction type were placed in a certain asbestos mill, and yet 15 years later cases of asbestosis with fatal termination were reported among workers from this plant. Since the most efficient type of protective machinery known apparently does not completely protect, although the num ber of workers affected is probably somewhat reduced, and the time re quired for the production of an ad vanced type of disease is probably lengthened, the problem becomes a matter for serious consideration. In the case of any industrial em ployee presumed to be physically handicapped by any condition or dis ease, supposedly caused or aggravated by conditions under which he has worked, there enters the question of compensability. Pulmonary asbesto sis has not as yet been widely recog nized as a compensable disease in states having laws governing the compensation of workers. If such cases are viewed as compensable un der the Industrial Compensation Laws, it will be necessary to decide the degree of disability in each individual in order that proper rating may be made. Irtrl M Si? 2*3 Ki w. r Jia m.M * * V * *h. >v*v* .w; ,,. >-y r-5' ?. /* ~Y< PULMONARY ASBESTOSIS 223 `i .: .'.-S'*&>*:Y:-:.3k.- . PPrraaccttieicfalillrl'yall wmriters on the sub- x-ray evidence of asbestosis who had . ject axe-'agreed. that' the principal worked less than 4 years in the indus symptom of the condition is a varying try. Of the 52 workers with evidence degree of dyspnea, and that the physi of asbestosis only four had worked cal signs -are those found in fibroid less than 5 years, forty-eight having tuberculosis. Hence a definite diag been employed for 5 years or more. nosis cannot be made by a physical There were eleven with an advanced examination-alone. The x-ray film, type, no one of whom had worked less ** apparatus uv,-*. tfT$m?TTr> 7&: Suf'diatj^ViliV- |Wy'be - <# ^? protec- . fpe. were tmQ, and , ^bestoeifl .^^ . * Reported' '.-SJ jfe. Sfiioe-^^'ry'- yfbpeetiTe idoea not / H~ itt- *, '5. r- J,.(V ^ .cably.' ^naere- V. ?J&aa ad- robihlf, however, is. distinctive, in that it shows a picture of pathological changes /in several -particulars different from those found-m the x-ray films of any other respiratory abnormality. The . presence of the condition can be dem- onstrated by'the x-ray film alone, but the degree* of. disability cannot be . estimated unless, the symptoms and physical, sign* are also considered. The dyspnea is usually out of proporturn to other symptomatic manifesta tions,. and- is the one symptom which, .. ia.the_moreadvanced cases, precludes any form of*muscular exertion. For ttat' Teaaoh*. as- asbestotic victim is * ;< anablafo-sell his* labor on the open .aariceV and must be rated as totally than 8 years. One of these advanced cases had been exposed to asbestos dust for $ years, two for 9, and one each for 10, 11, 12, 14,15, 1G, 17 and 20 years. Unfortunately I have no record of the length of service of these employees in the various departments of the mills, all of which are unquestionably dusty, but it is agreed that the carding room is the dustiest, and the weave room probably next. It is presumed that the dustier the work, the more likelihood there is that pathological changes in the lungs may result. It is noteworthy, however, that some employees work in asbestos plants for years without suffering any pathologi <2aabled..K?:f/-- ii. . . cal changes in the lungs, as far as can zM em-*i 1 iS&2 ' I,'have seen:no statistics in the literature. in-regard to the incidence of asbestdasamong the workers in the be detected in the x-ray films. . In this series of 151 employees, ninety-nine showed no positive evi *r gravsned-.-^. -v industry..-' ifc\ would seem to be a dence of asbestosis in the films. Five l ; ..:matter.(rf'some importance to- deter had worked in asbestos for 6 years, . name the average somber of employees three for 7, three for 8, four for 9, |$eeto`.. <*** J-ftcogf ''/j"T;i' ' who mayVbe now, or who are likely six for 10, one for 11, and one for 15 ' to'become^ disabled by the condition. years. All the others had worked for ' Thaye latelyhad occasion to review the periods varying from a few months .. x-ray films of 151 workers in asbestos to 5 years. Since the percentage of & auok.--v.^ | .mills. ,/Of> these, fifty-two showed those in the series who were affected definite.-evidence of asbestosis in was so high, it seems remarkable that Y varying degrees. Of the 151, eighty- so many could be entirely free from ' , six had*worked in asbestos for periods the condition even after years of expo dividual l'I -V varying: from 4 to-20 years, and in sure. Since this process is non-infec. - Y/ this group were found fifty-one of the tious, the term "physical resistance to *- - TT'C'-i -fO* * fifty positive .cases, a percentage of 59.3. disease" is not applicable. It is true . ."There was-jonly one case with definite that muscular development avails vm a S4H tsf.w#** JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY [Ajrr., ISM nothing as a protection against the disease, since well developed men are as frequently affected as those not so well developed. It is also possible that some individuals may be sus ceptible even though exposed to low concentrations of dust. It is the opinion of some writers that the inhalation of asbestos dust and the consequent production of asbestosis has a tendency to exacerbate old tuberculous lesions. This opinion is apparently not universal. Merewether (1) says "from a review of 42 fatal cases of confirmed asbestosis it appears that asbestosis ... is less fre quently accompanied by tuberculosis than is silicosis." Gardner and Cum mings (2) state that "primary tubercu lous infection is influenced only to a limited degree by inhaled asbestos." Egbert (3), in as analysis of 23 cases of pulmonary asbestosis with fatal termination as reported in the litera ture, found that tuberculosis was present in only 6 cases of the 28, and in only 3 instances was death due primarily to tuberculosis. It is universally agreed that silicosis does tend to exacerbate old tubercu lous lesions. In fact more or less rapidly progressive tuberculosis is considered the most frequent and most serious complication of silicosis. Boisliniere (4) says that silica is the only phthisis-producing dust. In ob servations for several years I have been unable to find evidence that the inhalation of asbestos dust, or the condition asbestosis itself, has any tendency to render active old, appar ently healed tuberculous lesions. In this series of 151 workers there were three who had a definite asbestosis in addition to an apparently healed tuber- Vi culosis. One had' been* working in * asbestos for 10 years, another for 4 years, and the third for 2 years. There was no evidence in the films that the presence of asbestosis had yet had any tendency to activate the' tuberculous lesion. The films' of- 23 workers showed evidence of tubercu lous infection without any pathological changes indicating asbestosis. .Of these, eleven showed healed childhood type tuberculosis, but none of. these' had worked longer than IS-months in asbestos. Two workers showed healed childhood type tuberculosis. with no asbestosis, one of 'whom' had spent 8 years in the work and the other 6 years. There were 5 filwiq showing apparently arrested adult type disease with no asbestosis. 'These ' filma were of employees who had spent the following periods in this: work: One each for 4, 6, 7,- and 9 years; and one, no term.. of~ service given. There was 1. case -with an apparently healed and calcified miliary tuberculosis with a history of only 8 months' service in the industry. In the 151 films there were only' four which, from an x-ray standpoint, were diagnosed as probably active tuberculosis of the adult type. One of these had been in service for 5 months, and one each for 15 months, for 6 years, and for 10 years. Since 1 case had worked only 5 months and another 15 months, it would seem im probable that this type of work could be the cause of their active disease, particularly as the films of both cases indicated a chronic type- of disease and apparently not an acute exacerba tion. There remain for consideration 2 active cases with 6 and 10 years' service respectively. Agreeing that 6ccupatian ba* %' * *' - -----rj -1 p: r r: qcuufraiuoD* i \r ) . T3iy'-first , film,. - *, snows some fine f . / v ^roifi'v^hd Ofclr-t ' " *! * . h*_ 3* . ,.-5ri*sdj!q?..mYolypin " :.y gmVindicat \ . I # ^tfirwbch`'Wn sj; io ^'^'svefibwa' a^tube? " .ijn^a qmlecewist ; taM^Vfay-.;3^i .^bercnlqus leei L .' ' '_dve^.>ithough; Ef/vU elapeeff--^unoe t V^i'^.fcaken,: Thjrcij * . .industry for a/5? - * but- returned to ;<T`\\ Oneof the me * - in .the .ccmsidgEs ^ . bestows is>5wKgs *w ; V ispK^ssrvef'n ,/handicapped.bj [.V. 4 the iadns^: j-qtiestioii iaujtjCt jyrtr: HR is-'V <* the work in asbestos may* have aggra vated their pulmonary condition, 2 cases of active tuberculosis in 151 workers seems a decidedly low per centage, if this type of industrial occupation has any tendency per to exacerbate old tuberculous lesions. Tuberculosa of an active type may be found quite as frequently in the routine examination of workers in any industry, regardless of whether or not the occupation be dusty. Case I. The x-ray dims of one man who has worked approximately 10 years in asbestos illustrates the fact that employment in this industry even for a long time does not tend always to re-setivate old tuberculous lesions. The first film, taken April 2, 1930, shows some fine fibrosis on both sides from the 6th to the 9th posterior ribs, thickened interlobular pleura with some involvement of the diaphrag matic pleura, and a slightly "shaggy" heart outline, these pathological changes indicating a probable asbestosis which is not very far advanced. In addition to this condition the film shows a tuberculous infiltration in the right apex, which appears to be in a quiescent state. The second film, taken May 3, 1935, indicates that the tuberculous lesion still remains inac tive, although a period of 5 years has elapsed since the previous film was taken. This man left the asbestos industry for a while during this period, but returned to it about 2 years ago. One of the most important problems in the consideration of pulmonary asbestosis is whether or not the disease is progressive, even after an individual handicapped by it ceases to work in the industry. Information on this question is of considerable moment in rating the eventual degree of disability^ of a worker, either in the assessment damages in civil suits or under State Compensation Sparks (J apparently cessation checking its spread. ________ . Gloyne (6) state that once asbestosia bodies are found in the sputum the * course of the disease appears pro-. gressively downward, and cessation of ' Akiyh itA .. . _ }; Jtf spread. Many writers consider is & progressive disease, whether or not there has been cessa- \ tion of exposure. However, Sayew' (7) says that "a man suffering simple silicosis "' ' when removed phere and placed mgs/' Boisliaiere (4) says: "Silicosis- by no means always progresses. after.* the hazard has ceased, nor doea ^ always produce tuberculosis." /. r -; It is reasonable to mshwb that the - ^ eventual effect of the inhalation of a dust whichi sometimes contains ,,as much as 99} per cent silica might be . somewhat more severe than thafc-"^' . caused by a dust which contains. maximum of only 2.6 per cent. It seems to be true, however, that the Vi.- fibrosis in asbestosis is produced by much shorter exposure than is the-' 7 , rule in silicosis. Gardner and Cum- -- mings (2) say: "The particles and- v'7 elongated fibers of asbestos, dust da ,^' not, during this period (2 years and 5 ~; months), penetrate so deeply into ^ Vv air passages of the lung as do-the, other dusts previously studied. The major portion is held up and pha^ v -:w gocytosed in the lumina * ESC `" WiS. 4&. *3Wr r>. m r ,v>? mm iiS 7? Sw^S'V-iri - A-rfi bronchioles and the alveoli given off from their walls." Since the condi tion is not an infectious process, it should not continue to progress on re moval of the causative factor. Gard ner and Cummings (2) state that the asbestosis body and the production of fibrous tissue in the lung is caused by hydrolysis of asbestos fibers in the tissues. Theoretically, then, extension of the pathological process should continue until all asbestos fibers re maining in the lung are hydrolyzed, which may require a considerable time. Several of my cases seem to indicate that the rapidity of progress of the fibrotic change in the lungs after cessation of exposure is dependent to some extent on the amount of involve ment which occurred before the indi vidual ceased work. To illustrate this point, consideration of additional x-ray films of 3 cases reported in 1933 may be of interest. Case II. D. S. W., white male. Ceased work in card room of asbestos plant in January, 1929, after working only 18 months. The first film was taken June 13, 1931, and shows a fairly extensive fine fibrosis, a "shaggy" heart outline and some involvement of the pleura. The sec ond film was taken on March 8,1935, approximately 4 years later. Com parison of the two films indicates that in the 4 year interval the densi ties at the hila have increased notice ably, the pulmonary fibrosis has ex tended toward the apices, and the hypertrophy of both the right and left heart has increased. Symptomat ically, the dyspnea has noticeably increased within the last year. The man has not been exposed to asbestos dust since January, 1929. Case III. Quit his work in the asbestos 'plant, in June, - ____ __________________,__j _____ _*___________ \____ the lungs, the usual "shaggy? .hearts outlinc and adhesive pleurisy.This : >/Srj^fTb**aeof`pr case was diagnosed well-advanced aa, bestosis. The last .film shows-.an/: -V'in'.waae AS Ana- extensive progression of`the-condition, the fibrosis having extended, into, the apices, and also become more, dense. In spite of the fact th&t.this-i&aa has had no exposure, for 8 period; of>$ i *.-v1' years, the condition has ^teadfly be* come more extensive.. At'the time this is written he has begun to show symptoms of progressive heart failure, and a fatal termination seems in evitable.. ' - ' ; \ ` Case IV.. R. p.. J.,. white "male. ';:.f^waa.'`aSfint;^ aretes Quit his work in.the card.room<&' asbestos plant in - April, 1930; The first film -was taken April * 23,; 1930, and shows fine fibrosis and-motiling, over the lower lung fields wife-some'* r^tunp^jf1 ca$ea % ' .movement -fit ' "'fails'to exhihii^ "shagginess" of tha-heart entimd and ' pleural adhesions: The. : next* film, taken September 2, 1931, ' 1 months after the first film, shows some in crease in the pulmonary fibrosis. Thi^ man, under rest treatment,, improved - P'V.v^nptectibn: qk*e jaH&S Suflai i-^J^fptoduced' tojtft his general physical condition'map. i v of asBestosmisx-; terially. He was advised not to return.> {.* ['%: Saapaatnesit ;gr; to work in an asbestos plant^but he rf did not heed this advice because he . I- '. v iiiQtixxs of asbes) becomes--^ felt that he must make an .-attempt ` . . j _,engagmg-ur an; to care for his family. ..He started to * .S* '.most pwwmwwni work again in May, 1933, and con-'/ g. ' ;:j irthft diseps tinued until October; 1934, when he- k ` t -ifl.out;of''akjFa was forced again to leave- his job. -c/ithe physical sta The final film, taken August 30, 1934, .dir/**' *' but>alsb te^tiu tL'.t -JtAtt? * Ti-: v. ` *: # ^ H> *- *1 PULMONARY ASBESTOSIS . icdicates extensive progression o! the fibrosis well up into the apices, and a definitely hopeless outlook. In fact ' dtis r*" is beginning to manifest the physical signs and symptoms of pro? passive cardiac failure, which, in my opinion, is the terminal result most feW: frequently met with in pulmonary Jgs^y* ' asbestosis. , The rate of progress of the condition in Case II, and the extensive progress in Case III, even though there was cessation of exposure in both cases, qualifies the statement of Wood and Gloyne (6) that "once asbestosis bodies are found in the sputum the course of the disease appears progres 55r;- '. &fefc sively downward." Asbestosis bodies ^ere not found in the sputum of Case II, but were found in that of Case EL The sputum of Case IV was at first negative for the bodies, but they are present since the condition has become far advanced. Inciden tally careful examination of the spu tum of cases with definite asbestotic W involvement in the lungs frequently fails to exhibit asbestosis bodies. The high percentage of pulmonary asbestosis (34.4) found in this series of 151 workers, indicates unquestion ably the need for more complete protection of employees in asbestos mills. Sufficient evidence has been iv1 E produced to prove that the inhalfttfon of asbestos dust is productive of serious *% impairment of health. In fact, the victim of asbestosis, as a rule, eventu w# i; * *i*fc. *'t.4>'/ ally becomes totally disabled from engaging in any form of labor. The most prominent and lasting symptom of this disease is dj'spnea, and is out of all proportion not only to the physical signs found in the lungs, but also to the pathological changes depicted in the symptom which m for several years. The prognosis for''. extension of life after cessation.; m *j men* is not rar aavancea is encomag- ,^v mg, but the hope for amelioration the dyspnea is not encouraging. An industrial worker is entitled &)' -Tv every protection that may'safeguard m 7 *-<. his health, so that he may earn a livelihood for himself at least a reasonable in the work in which he is;''most-"^'lV:^^: skilled. If he is prevented from tinuing in such work because painnent of health through no' of his own, he is entitled; to some remuneration for his power. That protection workers has been woefully the past has been It is imperative that such'protection; as nearly complete as possible; provided by mill owners. '.: Efficient r.ii m the aggregate of numerous claims for.- `*i. compensation and frequent damage;-. suits. That complete protection can*; tar AMs s&j.-li: U- 63 I'd*!*! &Pr:-Vi*.` 'W.U^ *-t l4 fMife !& hm mm Wsi !*' / i: 228 JOURNAL OF INDUSTRIAL HYGIENE AND TOXICOLOGY (Apr, m - BIBLIOGRAPHY 1. Mssewxtbxb, E. R. A.: A memorandum . on asbestoais. Tubercle, IS, 69, 109, ' .152(1933,1934). 2. Gasdkzs, L. U, amd CTnooKos, D. E.: Studies on experimental pnerxmokonio- . ' sis. Vli Inhalation of asbestos dust; its-effect upon primary tuberculous L infection. Tms.Jotnu, IS, 65 (1931). *3. Egbbbt, D. S.: Pulmonary asbestosis: . . . Report of a case with necropsy find* ings. Am. Rev. Tuberc., 31,25 (1935). 4. BouuKzznx, L. C.: Silicosis and tuberculosis. J. Missouri State Assoc, SO, 309 (1933). 5. Srxnu, J. V.: Pulmonary asbestosa. Radiology, 17, 1249 (1931). 6. Wood, W. B, and Glotnx, S. R: Pul monary asbestosis. Lancet, SIS, Hi (1930). 7. SarzBS, R. R.: SDieosis--Review of history, pathology, and prevention. U. S. Pub. Health Repts, 43, 5S6 (1934). ; Mfi AS* W.*LT*i as Mi \>v m Lift v.r 'jTri--'. ; :;'s KjC*. m m CS:J [ ?G ji j;.- * Tom Foley Page Two ROBERT MANNING AND JOSEPHINE MANNING KENNETH MILLER AND ROSEMARIE MILLER WILLIAM PARKER AND LOUISE PARKER (FINAL JUDGMENT ONLY) WINFRED PETTY AND MAZIE PETTY CORNELIUS PRINCE AND OLIVIA PRINCE GLADYS SOLOMON, REPRESENTATIVE FOR LEON SOLOMON PAUL STAGNER AND MARGARET STAGNER KENNETH D. STEWART AND MARY STEWART (FINAL JUDGMENT ONLY) STANLEY VARDAS AND JO ANN VARDAS (FINAL JUDGMENT ONLY) JOHN A. WALL JAMES T. WRIGHT AND HOLLEY WRIGHT GEORGE YARBER Sincerely LISA FLYNN Administrative Assistant LF/teh Enel. LTR70/OOK 3)