Document Gmw26JK14bn6XYbxO1ekk4dKN

FILE NAME: ALCOA (ALC) DATE: 1942 Jan DOC#: ALC076 DOCUMENT DESCRIPTION: VA Medical Bulletin Volume 18 Number 3 't g h e M EDICAL BU LLETIN of (he Veterans' Administration FRANK T. HINEIS, Administrator of Veterans* Affairs CHARLES M. GRIFFITH, M. D.. Medical Director JANUARY 1942 '.'x a* . iiO 'MSM il! UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON : 1941 k F or u l t by tb* Superintendent of Document. Wajhinfton. D. C. * - 8 Subscription price 50 cent a year Price IS co t PNEUMOCONIOSIS: A STUDY OF 379 CASES H ahrv B. W n x iA M S , 31. P., Veteran*' A d m in istra tio n , O lern , ft. C. A survey was recently concluded (while tlie author was on duty at Veterans" Administration Facility. Surmount, X. V.) to determine the relative incidence of pneumoconiosis in beneficiaries of the Vet erans' Administration. Tlie data for the study consisted of question naires, formulated by the chief, division of postgraduate instruction and medical research, which had been sent to and executed at Held stations, in relation to beneficiaries who had been exposed to occupa tional dust hazards; radiograms of chests of affected beneficiaries; and, in a few instances, tissues from affected beneficiaries who had died. A-total ol cases so collected from the field stations of the Veterans' Administration was 370. The beneficiaries in this series bad been variously occupied : As miners of metal ores (lead, copper, gold, silver, iron, quartz), coal (anthracite and bituminous) miners, brick yard laborers, tunnel laboreis, rock drillers, street cleaners, laborers on various types of construction work, automobile factory employees, blacksmiths, grinders, stonecutters, cement workers, railroad switch men, machinists,sandblnsters, pottery workers, qnarrymon (limestone, sandstone, granite, marble, slate, etc.), laborers on stone crusher, tobacco-factory emplojees, bricklayers, silk-mill employees, steamengine firemen, asbestos workers, Holders, grain-elevator employees, textile workers, steel-mill employees, stone masons, grocery dealers, fanners, aluminum inciter, clerk, tile presser, iron workers, foundrymen, cnriiciitrrs, metal polishers, glass workers, smelter workers, and powder-factory eriiployees. In a few cases no occupational history was given. Modem study of dusty occupations has led to the rather definite conclusion that there are only two forms of dust which really cause pulmonary disease, namely free silica (SiOa) or silicon dioxide and nsitestos (magnesium silicate). Talc, also a silicate of magnesium, is closely allied chemically to asbestos and is under suspicion. As yet, however, it lias not been definitely proven to be a factor in the pro duction of lung disense. Coal-dust causes pigmentation (anthracosis) and occasionally slight fibrosis, hut this lias been proven to be rela tively harmless from a pathological standpoint. Dust, from the var ious minerals commonly mined is not considered a factor in the pro duction of the disease. The silien-bearing rock encountered in min ing is the source from which tlie disease is contracted. Workers in tho cement industry, although exposed to dust, are not affected, because the materials which they handle contain little or no silica. Most of the various clays used in the pottery industry are innocuous, and there is some reason to believe that some of them modify or even inhibit the development of silicosis. Coal dust, is also believed by some observers to modify or inhibit the progress of the disease. It MEDICAL BULLETIN' OF THE VETERANS' ADM INISTRATION 251 should not be understood from this that there is no dust hazard .in the pottery industry, because certain employees in this industry are subjected to high concentrations of silica-bearing dust, espe cially the grinders, polishers, and furnace men. Dusts from hay, grain, flour, etc., encountered on farms, in grain elevators, mills, and bakeries constitute no real hazard so far ns the production of chronic lung tliscase is concerned, although they may set up an acute bronchitis. They would also probably aggravate an existing tuberculosis. The same may be said of the dusts encountered in jute and textile mills. Road and street dust ennnot be regarded ns hazardous, ns the amount of silica in such dust is very small and in low concentration. After study of the data submitted, 171 cases of this group were classified (cither definitely or probably) as having lung disease due to dust inhalation, cither uncomplicated or complicated by infectious disease. The histories in many of these cases were rather inadequate, and, without a detailed history, it is difficult to form a definite opinion in the individual case. For instance, a man may have worked in a mine for many years and still have had little or no exposure to disease-producing dust. A history of this type of case should show not only where he Ivorked, but what he did in detail, how long lie did it, and to wliat form of dust lie was exposed. In other words, the production of disease by dust depends upon the form of dust, plus its concentration, plus the time of exposure to it. Sonic of the films submitted were of poor quality and the lesions were not as sharply outlined as they should have been. However, the general average of the films was quite good. The characteristic lesions in the lungs in silicosis are fibroid nodules varying in size from 2 to 5 mm. in diameter. These nre discrete-in (lie early cases, (ending to become confluent in the. far-advanced cases. In the extremely far-advanced cases these nodules tend to lose their individual identity in dense masses of fibrous deposit. These cases are almost invariably associated with infectious disease, usually tuberculosis. The cases studied were classified as: 1. Silicosis, first stage ( S i ) : Showing accentuation of the lung markings with fine discrete generalized nodulation. 2. Silicosis, second stage (S2): Showing marked extensivo nodulation, still discrete, the individual nodules being generally larger than in the first stage. 3. Silicosis, third stage (S3) : Showing very extensive nodula tion with large nodules tending to become confluent. 4. 5, and 6. Silicosis, first, second, and third stages, plus infec tion These cases were of the same types as 1, 2, and 3, with definite evidence of accompanying infectious disease. 7. Silico-tuberculosis (S TB) : Far-advanced cases in which the individual nodules had lost their identity in dense fibrous masses of infiltration. These are considered tile resultant of sili- ' cosis combined with tuberculous infection, but it is impossible to determine a separate background for either process. 8. Cases without definite evidence of silicotic involvement, blit with definite evidence of lung disease, the appearance of which indicates a background of infection only. . '252 MEDICAL BULLETIN OF T H E VETERANS ADM INISTRATION 9,10. Fibrosis: Cases showing no nodular deposits, with slight or well-marked accentuation of the lung markings. This con dition cannot be regarded as characteristic of silicosis; it is often present in cases of respiratory infection, acute or chronic,, in psissive congestion due to cardio-renal disease, or in other con ditions. These linear shadows are also subject to normal . variations in the adult chest. 11. Asbestosis: This condition has been termed "silicatosis" in contradistinction to silicosis. Early cases of asbestosis arc diffi cult to recognize as such. The radiographs usually show only minor changes indicating an interstitial fibrosis, sim ilar in apjiearance to those cases in classifications 9 and 10. The more advanced cases show what has been described as a "ground glass" appearance; that is, a diffuse haze over the lower lung fields, together with a marked accentuation of the lung m arkings, hut \ with little or no nodular deposit. This haze may I ks so dense \ as to obscure the cardiac borders and the domes of the diaphragm. ' 12. Negative: Cases in which there was no evidence of lung disease. The following table shows the incidence of industrial lung disease according to the occupations represented: SI 82 63 81-Inf. 82-Inf. S3-Inf. S T B Asb. Total 11 7 1 22 3 1 1 1 - 1 1 2 1 T o ta l............................................. 38 12 3 11 20 7 13 7. 4 3 1 1 2 T 2 1 1 2 1 i 1 3 1 1 32 38 20 15 72 7 87 2 0 8 1 4 1 3 3 2 2 i 1 1 1 2 1 4 1 1 1 l 27 3 171 t I t will tv notiti th a t them Is a preponderance of m iners shown in this tahlo. H ard-rock m iners consti tu te the largest group of workers in nusty occupations. These could be subdivided in to sm aller occupa tio n al croups if more information were available. * Although there w as do Industrial history given in these cases, the radiographic appearance w as quite typical of silicosis an d they were ao classified. * T h e industrial history of theae cases is open to question. I t is believed th a t m ore detailed histories w ould have furnished moro appropriate Information. * Alu mlnum melters wear large asbestos apron* and gloves while working over the crucibles. T h e 'm olten m etal spatters on theae. thus releasing considerable q uantities of asbestos d ust. In the rooms where n n u m b e r o f these men are a t work there la probably a considerable concentration of this d u st. I t also seems likely th a t the friction of these garments incidental to th e work would be an added factor in th e release of asbestos particles. Diagnosta.--The importance .of a detailed occupational history cannot be emphasized too strongly. The symptoms exhibited by cases of uncomplicated silicosis are few and often absent. Cough and expectoration are not troublesome. In the far-advanced cases there may be dyspnea, anorexia, loss of weight, and cyanosis as a terminal manifestation. The same may be said of physical signs. De creased resonance of various degrees may be elicited in the more- MEDICAL, 1IUI.LETI.V O F T H E 'V E T E R A N S ' A D M IN IS T R A T IO N 2 advanced cases, together with signs of emphysema. The dearth evidence of disease shown by symptoms and physical signs is strikii when compared with the extent of disease shown by the radiograp X-ray study is the most definite and satisfactory method o f diagnos This, together with a carefully taken history, is absolutely necessai in making the diagnosis and in following up the individual cast The great hazard in these cases is an intercurrent acute respiratoi infection, such ns pneumonia or influenza. In the cases complicati by tuberculosis it is often difficult to differentiate the shadows o f tl two diseases. Often, cases o f tuberculosis will show nodular deposi very similar to those of silicosis; the appearance of the shadows < each disease may also he modified by the other. In these cast detailed histories are even more important, and the coojieration < the clinician and tlie roentgenologist is indispensable. O f conn in these cases the symptoms, physical signs nnd lnlxiratory finding of tuberculosis arc present. Of the 171 cases shown in the table, 52 or about 30 percent wci classified.as uncomplicated silicosis or asbestosis; 38 of these wei in the first stage, 12 in the second stage, and only 2 were classifie in the third stage. A post-mortem examination o f one of the lai cases showed a far-advanced silicosis without evidence o f infectioi Nevertheless, the pathologist, who was one of the reviewers of thi series o f cases, felt that there was probably a background of infec tion. I f this case had not come to autopsy, it would have been classi fled as silico-tuberculosis. The remaining 119 cases all showed evi deuce of complicating infectious disease, more nr less extensive am in most cases probably* tuberculosis. While this is not an extensive series of cases and no definite con elusions can be drawn from it, it is believed th a t it agrees wit! most observers in that it supports the belief that disease of th lungs due to dust inhalation increases the susceptibility of tlios organs to tuberculosis, and that this susceptibility is increased ii direct ratio to the extent of the industrial disease. The reviewer are of the opinion that the number of cases of industrial disease in this series is very small, considering the number o f cases ol pulmonary disease coming under the observation of medical officers of the Veterans' Administration. Only 379 cases were considered as potential cases, and nine of these were submitted in duplicate fronr different facilities. This review has shown that there is a need foi more careful and detailed histories in cases of this type. Medical officers should familiarize themselves with this disease; they should inform themselves of the various sources of disease-producing dust, and should know what types of occupations are hazardous from this standpoint. In the study of this series of cases, the writer was associated with Dr. LeRoy U. Gardner, pathologist and director of the Saranac Lake Laboratory for the Study of Tuberculosis, and Dr. Homer L. Sam p son, roentgenologist, Trudeau Sanitarium, both of Saranac Lake, N. Y. A composite opinion of the three reviewers was appended to each questionnaire, after careful study of the available data. These reviewers were much interested in this .study, and wish to express their thanks to the officials of central office, and to the, med ical officers of the various facilities, who cooperated in furnishing the data.