Document bBwQXkvz3Z8w1408MMDwgO420

SSAMERICAN JOURNAL OF ROENTGENOLOGY" AND RADIUM THERAPT`lA U A~>:^ ',.^*.<r ' * .. *,r- j*, ; 't *o*.r*.*w- vou X1V NOVEMBER, tw No. s\ $ i REVIEW OF OL'R PRESENT KNOWLEDGE OF PNEU MOCONIOSIS, BASED UPON ROENTGENOLOGIC' ' 1*:'. r - V* . -.* -V i STUDIES. WITH NOTES ON THE PATH-. A A. OLOGY OF THE CONDITION* ./ . BY HENRY K. PANCOAST, M.D., ~ AND . ' EUGENE P. PENOERCRASS, M.O. .' W v TX'K- D*parontt of Ro*ntstaolr, Gatvtroxrr of ?enfl*y(vnia ... 1 WXIUVA.NU iv. HE word "pneumoconiosis" is of ever since.: The United States Public Greek orrgm, and implies a condition Health SenriceandtheBureaaofMines have Tof the iungs arising from the inhalation ofbeen carrying out a routine study of dusty I excessive quantities of dust. The fact occupations, especially mining, for' even that damage to the^ lungs may be wrought a longer period. Their iirst report `mchiding . ;l * ; /, - -y the inhalation of certain dusts has been roentgen-ray observations was nude by .tcogniaed for many centuries, but the '. w* * rsct type of dust or dusts responsible for the pulmonary* changes and the nature U A of the pathological processes induced are Al of comparatively recent knowledge. Sys tematic roentgen-ray studies, painstaking Lanza and* Childs4 in 1917. Jarvis and his coworkershave contributed much valuable data from their studies of the granite carters of 3orre, Vermont. The experimental work of Gardner, ss-s* Permar" and others has added much to our * . *'? > . ': j ` - - utnological investigations following autop knowledge of the pathological processes -. < i ; -i . * sies mb abundant animal esserunentanon throughout the world during the us ten or twelve years have led' to a try exact understanding of this most involved in pneumoconiosis. We can be justly proud of Miller^*4* for the won derfully dear knowledge he has imparted to us of lung histology, and pardcuiariy ..:.V : . "Ln--*V ' / u! . \ ,r ~* -1-t >ru J1f auresting condition. Amend is far behind many other cwntries in the methodical study of tawctoconiosis and the practice ofpre'tn-s measures. Comparatively few sys- 'tiaa*. investigations have been carried . , rouN one of us, in conjunction nth 1 er and Landis instituted clinical aid : rjenoloiricaf investigations of the of the lymphatic system, upon which to base our conception of pulmonary path ology. Notwithstanding all these and many other American contributions, the amount of work accomoiished in the study of pneumoconiosis in thus countrv cannot compare with the extent to which the condi tion has been studied abroad, especially in South Africa, Australia and Great * *' <h . ' . , ' . t , ' --v. - * ^ * , ^ workers in a large number of Britain. Naturailv, in the latter country, fj\- duscries. and our preliminary especially, the concentration of dusrv e t L`. *. <v>t*'- . i * < V. '' < punished in 1918.1 These industries nos been 1 definite aid to all ituc:- c been carried on intermittentiv observations. In those countries not oniy v..-. .naw Man. .uivatcu* Rsuruct JUv Soc:*7y. 0. C Itn jj-ij. ;>. iStiiiW' 4S'*4kl <Sit9 aM A Review of Our Present Knowledge of Pneumoconiosis 4J0. *- * * - 4 k . *."* luphragnu*. There were no symptoms such occupation. The dust-wan* always.' Arable rile appearance. On fnvestiga,,v,, .th:.e..y. rfo--unad -sh-e- hLa. dj --work! e-dJ *to--r rears handling and helping in print- ^ oi cigarette packages on waich there 4va* considerable bronze work. The was used in liquid form and was very dense and* herlud: worked longer at* ,S -: -l ttbhheeecajuoostbeheotrhfsalunhcn&agavOntriynot^guorbathlbweeesoer.Rnmxaoznbiisli-hg;ee>drbi.terw.'./s,*f_abv*ip.*l*,,"'' .,y.>: .! ... ~ * * ..1VW li' 'll r Ak. ye * r- ; -< t Vr -t -- a . i^n^tiy spiiled and dried, leaving a fine .juar. After a day's work she could taste and her sputum was said to be inrush. We are familiar with this case _.u<i x..n vouch for the above statements. Anyone who has seen a cement factory in operation knows that ic is ope of'the- *" . -- - ; ??*. **H most dusty of ail puces, and yet the x V :****& industry cannot be regarded as a hazardous, v ` *V one from the standpoint of pneumoco k -*rlSSfcf " In connection with metal industries niosis. There are several distinct, nccupa-* .ve 'v.ive examined a few stove plate tions in this industry especially those' .of' gutu-Jb-rs and foundry men whose lungs coal * handling, rock grinding* esaest showed well-marked second stage grinding and the packing and handling of/ fuiiiue# after a number of years' occupa- the finished product. With Miller and* ion. W* have regarded the appearances Landis1 we examined 20 cement workers. a likely due to >.md. seven! years ago. Five of these* showed BRICK WOUKSUS possible dm stage changes* and the ocher is definite second stage appesnacs* Tite constituents of brick arc suitable The earliest second stage changes were, for the production of pneumoconiosis. found in a packer after seven yeais-occnpa-" Gavs contain hydrated aluminum silicate tion and were slight only/Of the. men xith more or less sand or free silica and longest at work, a cement'grinder showed, x few other ingredients. Sand is a necessary slight second stage aoduiadon after eigh*. constituent of brick days and may con teen years and a kiln room m*n presented stitute quite a high percentage. Fire very definite nodules after nineteen years* brick mixtures usuallv contain more sand All occupations showed some gfrawyT ;* !T? jun the clay for building bricks, and the One would exoect the greatest' etfecr ' *- constituents are often mixed dry. among the rock grinders, although . the' *+ Middleton4* reported silicosis in rS rock contains but a comparadv^y gwJf silica brick makers. Purdy41 quotes CoiHs* percentage of free siiica. \Ve cannot, of as staring that almost pure siiica occupa course, tell what changes have ... \r` - U*" '-< tions like silica brick making have a been found had any of the mess been high mortality from tuberculosis, while working thirty or forty years.* `Toe j .< rith workers in mixrures of siiica and day as used in ordinary bricks, the mor second stage appearances were variable, some of the nodular shadows being small . 'a. *--*. tality is very low. We have had no personal and discrete and othersy*soft'* and'com*, ^J*..'* esperience with pneumoconiosis in brick pararively large. * workers. One man who had worked con tinuously as a brick maker for forty years ASSXSTOS WORXZRS * *. T-r* N '' *W''1 i tr vas recently examined by us and* no This is another very dusty industry. chances of a silicotic nature were found Asbestos is a magnesium silicate; and the . 'fc ' in the lungs. On the other hand, we have rock that is crushed contains more or less been told by other brick workers that many free silica, to which the workers say be af their companions who had worked in exposed ail the way through the process j %a e the industry for a long rime were obliged of manufacture to the finished product*'. to v^p because of lung troubles. We have Cook4* describes asbestos as a oleum ,.. ** . ,, .1 oet- informed of one individual whose and magnesium silicate, with 40 per cent oerv^ition was the replacement of fire of free silica among other constituents. :nw. in & steel mill iumace and who This percentage no aoubt varies is differ-' tar*'' :d clinical evidence of advanced ent localities. 'Cook reported one asbestos ouuK..nary fibrosis after many years of worker who died of a pulmonary condition ?V^:- v .11. . . ^ j A Review of Our Present Knowledge of Pneumoconiosis after twenty veais' occupation. The roent genograms snowed extensive puinjonary obrosis. Macroscopicaliy the lungs were denseiy fibrosed and showed caseation and cavities, and microscopically tubercle ' f, . but if extensive inhalation was deseiootng. u decided pu. fibrosis resulted. He concluded :-u*c undum dust was harmless to the lung. -osii ;.ar : bormu. v + r'-' v^; -S -'. bacilli were found in caseat*ed_ areas. From our own experience we would regard this as largely a tuberculous case. Whh Miller and Landis1 we examined 17 asbestos workers, 2 01 whom showed hist.' stage changes and the other r 5 definite second stage appearances. Of die men longest at work, one after seventeen years' occupation showed very definite dhfiWr -soft'* spots throughout both hags,- and another showed*' about the same appearance after fourteen years' occupation. Very slight .nodular shadows found,in one man after only two . occupation. Most of these second * _ stage'cases showed also well-marked first :" stage appearances still present, indicating In the manufacture of caroorurdma, a mixture of sand and coke ;s 'ised .n in electric furnace. The resulting product is a crystalline and umorjhous -iiicoa carbide (SIC. which is said to be siiim free. After leaving the rurnacc Me rruae product.is crushed and ground. In maiung abrasive wheels and atones the particles are held together by some substance like porcelain, then shaved or cut down and fired in a kiln. The substance holding the carborundum particles together a likely to contain silica, whivh may be set free when the wheels or stones ire used for.abrasive purposes. U.MS PtTST \ < ' 41 , % v a persistence of free drainage hiiumward. Nicholson1- states that the inhalation -> . v" n--.* - ' ' In 'ail instances the nodular shadows were characteristically 14sort" and varied eon- of lime dust in the Derbyshire region does not produce anv esrensive lung fibrosis. * ' .<Vt > siderably insize. y v- : - caaaonwDuai It is soluble in the body iluids. Roentgeno grams showed a diffuse mild fibrosa probably due to a small amount of free : * ... We have been .unable to obtain any silica present. Purdy*1 in his review of <.* definite mforaarion in.regard to the condf- the literature on silicosis found that dusts ** ticai of tha lungs of carborundum workers. like plaster of Paris and lime stone were " ** T " ' investigated the industry regarded ns devoid of ail harmful actioa ' * Y.. regarded the dust oh the lungs. We have had no experience lungs, and the reason in the examination of lime stone workers- *j*MMi .? -i why workers were not aifeeted to any grekt' extent was because of the labor " '' ` * work damage, exceed- showed ere _ rooms 'where71ha abrasive wheels were cut down going to the. baking kilns showed greatest hazards. Gardner4* described the carborundum ^ #. .very dusty; and -j per cent of .^n?'th--g- p^arades were r.a micronsforor cieeisisuiainr experimentation . dust reached aodes and did as unable to parenchyma. MtSCXU-tNKUCS iNORGwCVlC OVSTS We found second >r.ige appearance* :n one charcoal burner of many vear>' >.cu* pation. but tlua exciting factor l- this individual is unknown. . One dint grinder in a sand paper 'orks showed advanced third stage Jt.tage* after ten years' occupation (Fig. ^ . , One worker in a plaster work# v'wwea third stage ubrosis. .. One man who had worked In . waur paper factory running a waiiyapd machine for six years showed second stag* appearances. _ VVe have been informed that pneumo* coniosis has been observed among juts workers, and also in cotton mill workers, especially those who open the bald* No doubt there is a certain amount of ire* AND RADIUM THERAPY r* *. 1 , - ` - <.. .a " Wj* V-A VOL. Mv NOVEMBER, ipa* = -.v-*- -.^U'LrrSS review of our present knowledge of pneu* UOCONIOSIS. BASED UPON ROENTGENOLOGIC' ' *' i: r* *: STUDIES. WITH NOTES ON THE PATH-. A OLOGY OF THE CONDITION* .; BY HENRY K. PANCOAST, M.D., AND EUGENE P. PENDERGRASS, M.D. \* .- Department of Roentfefioiofy, University of Pennsylvania v' A FHILAOtt/MIA, ?*.NNrrt.v*.\ ca .* ` ' THE word " pneumoconiosis " is of ever since.* The United States Public Greek origin, and implies a condition Health Servtceand the Bureau of .\ lines have of the lungs arising from the inhalation ofbeen carrying out a routine study- of dusty excessive quantities of dust. The fact occupations, especially mining, for even + sat damage to the lungs may be wrought a longer period. Their first report including V . 1 by the inhalation of certain dusts has been roentgen-ray observations was nude by ; ' ' 4 recognized for many centuries, but the Lanza and'Childs1 in 1917. Jarvis and t,act *>*? ^ust or ^uats responsible his coworkers4-14 have contributed much * ' ] for me pulmonary changes and the nature valuable data from their studies of the IA 4 of the pathological processes induced are granite cutters of Barre, Vermont. The f( of comparatively recent knowledge. Sys- experimental work of Gardner,5*-** Per- 1' . - -4 teraaac roentgen-ray studies, painstaking mar45 and others has added much to our ;; ' A pathological investigations followingautop- knowledge of the pathological processes < .] ires and abundant animal experimental involved in pneumoconiosis. We can be , 'f .< r.on throughout the world during the justly proud of Miller1*-4* for the won r . j cast ten or twelve years have led' to a derfully clear knowledge he has imparted * .*./; 1 try exact understanding of this most to us of lung histology, and particularly 1 :aterestinu condition. of the lymphatic system, upon which to : Vj Amenca is far behind many ocher base our conception of pulmonary path sentries in the methodical studv of ology. Notwithstanding' ail these and many other American contributions, the amount of work accomplished in rkestudy of pneumoconiosis in this country cannot j -at. vita iqiiS. one of us, in coniunction compare with the extent to which the condi er and Landis instituted clinical tion has been studied abroad, especially aw : trenolocicai investigations of the in South Africa, Australia and Great LtC' workers in a large number of Britain. Naturailv, in the latter country, : . . A . ' ' /* . * twv >tyc:- custries. .ind our preliminary especially, the concentration of dustv * published in 1913.1 These industries has been a definite aid to all w been curried on intermittently observation*. In those countries not only % , * , .T maw Met-jn*. RoaxTuas Kit SoeiXTV. 0. C,, kn. ih ** i i* *>%: v;__- f rn*' s: . -- - '* W* * * V. t* C`.4 \ % \ V* A Review of Our Present Knowledge of Pneumoconiosis 41$;.;. juphnigm*- # There were no symptoms ^,/ntbie w the appearance. On i'nvestiga- %a they found she had worked Tor -. ears handling and helping in print- ^ oi cigarette packages on which there ,vii considerable bronze work. The jjjjtfH.ii was used in liquid form and was - '`-Ai ifeqtu'-i?iy spilled and dried, leaving a fine jU5c. Alter a day's work she could taste and her sputum was said to be punish. We are familiar with this case ;uu ' a vouch for the above statements. 3 " in connection with metal industries ,vc :>:r\*e examined a few stove plate nnV-ocrs and foundry men whose lungs showed well-marked second stage cfw-iwrf ^fter a number of years* occupa- jon. V'e have regarded the appearances a likelv due to >and. .1 -i X ! i > i -* > . ,i BRICK WOUKEKS The constituents of brick axe statable for the production of pneumoconiosis. Ciavs contain hydrated aluminum silicate M-irh more or less sand or free silica and a few other ingredients. Sand is a necessary constituent of brick days and may con stitute quite a High percentage. Fire brick mixtures usuailv contain more sand than the clay for building bricks, and the constituents are often mixed dry. Middleton13 reported silicosis in 18 silica brick makers. Purdy*1 quotes Colfis* os staring that almost pure silica occupa tions like silica brick making have a high mortality from tuberculosis, while rith workers in mixtures of silica and day as used in ordinary' bricks, the mor tality is very low. We have had no personal experience with pneumoconiosis tn brick xoVkers. One man who had worked con tinuously as a brick maker for forty years vis recently examined by us ana no changes of a silicotic nature were found in the lungs. On the other hand, we have been told by other brick workers that many of their companions who had worked in the industry for a long rime were obliged to because of lung troubles. We have bee- informed of one individual whose occupation was the replacement of fire briwA in a steel mill furnace and who tho - :i clinical evidence of advanced ouur-.nary fibrosis after manv years of such occupation. The dust* very dense and ber'had: worked' the job than any other man the others having been obliged because of lung troubles. ^CXMENT. WORXERS Anyone who has seen in operation knows that most dusty of ail places, and yet the .. industry cannot be regarded as a hazardous-IT one from the standpoint of pneumoco- : niosis. There are several distinct- occupa-- tions in this industry, especially those of - - : coal * handling, rock grinding, cement grinding and the packing and handling of* the finished product. With Miller and' * ] ?' Z~-. *** Landis1 we examined 26 cement workers., several years ago. Five of these'showed * 2* possible first stage changes'and the other ` ; < is definite second stage appearances." ' " The earliest second stage changes were ^ found in a packer after seven yearsLoccupa-*. * tion and were slight only.* Of the men longest at work, a cement grinder showed.- ' slight second stage nodulation after eigb-. teen yean and aldln room man presented . very definite nodules after nineteen years- ` Ail occupations showed some One would eroect the greatest' effect -. among the rock grinders, although . the' r rock contains but a comparatively ma|I . percentage of free silica. We cannot, of"' course, tell what changes might have been found had any of the m*n been * ' & ... * - working thirty or* forty years.' 'The second stage appearances were variable, some of the nodular shadows being ->.4? - and discrete and otherssoft'* ana com- _ pararively large. * \ASBESTOS WORKERS * This is another very dusty industry. Asbestos is a magnesium silicate^ and the rock that is crushed contains more or less free silica, to which the workers may be exposed ail the way through the process of manufacture to'the finished product-'. . Cook4* describes asbestos as a calcium, and magnesium silicate, with 40 per cent of free silica among ocher constituents. This percentage no doubt varies in differ-' . ent localities. Cook reported one asbestos ' worker who died of a pulmonary condition ;>*: -r.*. -- :'U 420 A Review of Our Present Knowledge of Pneumoconiosis *v? -r. . .. 1 A* j*i of i\ -v-C-a-d k- > *'...#*<* after twenty years' occupation. The roent genograms showed extensive pulmonary fibrosis. Microscopically die lungs were densely fibrosed and showed caseation and cavities, and microscopically tuberde baciili were found in caseat'ed areas. From our own experience we wouid regard this as largely a tuberculous case. ~ Witi Miller and Landis1 we examined 17 asbestos workers, 2 of whom snowed first.; stage changes and the other 15 . definite second stage appearances. Of the men longest at work, one after seventeen years' occupation showed very definite -diffuse,, -soft" spots throughout both lungs,' and another showed' about the . .'soacmcuepaatipopne. aVraenrcye after slight fourteen yean' nodular shadows were, found,in one man after only two years' occupation. Most of ehese second - ,. + . but if exteni\e inhalation tub. was developing, decided pu. fibrosis resulted. He tonciuded triac undum dust was harmless to the. lung. osis -or,* bormai In the manufacture of curboru.-cuo. a mixture of sand and <.oke is fjied in in electric furnace. Thu resulting product is a crystalline and amorphous i-:;icaa carbide i.SiO '-\hich is said to be siiica free. After leaving the turnacc the crude product is crushed and ground, in maLag abrasive wheels and atones the particia are held together by some substance like porcelain, then shaved ur cut down and fired in a kiln. The substance holding the carborundum particles together is likely to contain silica, which may be set free when the wheels or stones ire used for.abrasive purposes. .c .:.T _v ' d`*V* - stage'cases'showed also well-marked first stage appearances still present, indicating a persistence of free drainage hiiumward. ^ all instances the nodular shadows were characteristically "soft" and varied con* UM2 3VST Nicholson* states that the inhalattaa of lime dust in the Derbyshire repion does not produce anv extensive lung fibrosis. ,, -TT-V .t*. siiddeerarafcbly in size. s * X* *5 r*S . * *. ' - GfcJUOJWNDWt ... We have been unable to obtain any %*.* definite information in regard to the condl- It is soluble in the body fluids. Roentgeno grams showed a diffuse mild fibrosis probably due to a small amount of free silica present. Purdy*1 in his review or the literature on silicosis found that dust* like plaster of Paris and lime stone were regarded ns devoid of ail harmful action on the lungs. We have had no experience in the examination of lime stoau workers- ' ... * why workers1 were not attected to any : great' extent was because of the labor MJSCSLL.4.VEOCS INORCAXIC OUSTS .turnover- Few laborers remained at work We found second >?age appeuraiae? one charcoal burner of axanv war/ ecu* patron, but the exciting factor * **rus individual is unknown. , One ilinc grinder iu 4 sand paper'urxs . 'a .,''where the abrasive wheels were cut down V... *' /V* - Before going to the. baking kiins showed - ` *.! " ; thegreatest hazards. , .................................carborundum per cent of , _ or iess in ,. V.**, s sfte/and therefore suitable for cellular .disposition/ By., animal experimentation . .Lhe found that carborundum' dust reached T. k."t. '<_4 ; .the tracheobronchial.lymph aodes and did .. prbduca. fibrosis there. He was unable to find a true fibrosis in the lung parenchyma. showed advanced third stage .u.'.nges after ten vears* occupation iF\<z. a . . One worker in a piaster work* 'w*\>eu third stage fibrosis. v: .. One man who had worked in . pacer factory running a waiiuapcr machine for six years showed second stag appearances. ^ We have been informed that pneuflio* coniosis has been observed among juttt workers, and also in cotton mill worc* especially those who open the !>*!* No doubt there is a certain amount ofirS*