Document mm769eEbD6ZgoBp8GagDRwN24

FILE NAME: Crane Company (CRC) DATE: 1936 May DOC#: CRC104 DOCUMENT DESCRIPTION: Journal Article - Clinical Aspects of Silicosis [Industrial Medicine] Page 224 INDUSTRIAL MEDICINE May, 193Sl 2: 00--"Common Injuries of the Chest," by E dgar W. Davis,_Department of Chest Surgery, Univer sity Hospital, Ann Arbor, Mich, (illustrated with slides). 2:30--"Industry Turns to the Physician," Dr. Carey P . McCord, Director', Health Conservancy Laboratories, Cincinnati, (slides, gross specimens, autopsy material and special measuring instru ments) . 3:30--"Fractures of the Neck of the Femur, Acute and Ununited; Methods of Treatment for the Acute Fractures and Various Types of Treatment Available for the Ununited Fractures," Dr. Carl E. B adgley. Professor of Orthopedic Surgery, Univer sity of Michigan Medical School, Ann Arbor. 4:30--Business Meeting. 5:00--"Vascular Dilatation and Cerebral Stimu lation," general discussion. 6:30--Annual Banquet. 8:00--"Clinical Aspects of Silicosis," by Dr. Ross K. Childerhose, of Allenwood, Penna., (slides and exhibit). D R. HORACE W. PORTER summarizes the pro gram as follows: "It was the aim of the Program Committee to get away from the usual symposium on fractures as much as possible, and deal more with the medi cal side of our specialty of industrial medicine and surgery. "The address of Dr. McCord was of unusual in terest; the various occupational diseases had never been discussed so completely before at any meet ing of this organization. Dr. McCord had just re turned from Yucatan where he was sent to investi gate an occupational disease which suddenly be came prevalent among the natives who gather chicle for the chewing gum manufacturers. The disease consisted of an necrosis of the left ear and chin, with the right side of the face uninvolved. "In addition to discussing occupational diseases in general, Dr. McCord demonstrated, by autopsy of three guinea pigs, one of which was normal, the results of injecting dust containing silica into the peritoneal cavity of these animals. "Dr. McCord also demonstrated various instru ments for the proper and accurate measuring of dust and carbon monoxide. "The movie on `Burns' was a clinical master piece; the result of considerable work on the part of Dr. Grover Penberthy and his Assistant, Dr. C. N. Weller, of the Children's Hospital, Detroit. "Another outstanding feature of the day's pro gram was the evening address by Dr. Childerhose, who is associated with Devitt's Camp for Tubercu losis at Allenwood, Penna. "Situated as he is in the anthracite district, Dr. Childerhose has made the study of silicosis a hobby, and is well able to discuss the subject authoritatively. "At the business meeting the following officers were elected for 1936-1937: President--A. H. W hittaker, M.D., F.A.C.S., Detroit; Vice-President -- L eon Sevey, M.D., Grand Rapids: ' Secretary-Treasurer -- D on F. K udner, M.D. F.A.C.S., Jackson; Directors -- L. H. Childs, M.D., Flint; Carl E. Badgely, M.D., F.A.C.S., Ann Arbor; and H enry J . P yle, M.D., Grand Rapids." . . 'f Clinical Aspects of Silicosisf . . By Ross K. Childerhose, M.D., Allenwood, Penna. SILICOSIS is essentially an industrial disea^ and as such it has a vital interest for usl Within the past decade especially, the ijll terest in this particular industrial hazard has begi come so widespread, and the knowledge of tha disease so increased, that it has become necessary for us as physicians to have a thorough undeijf standing of the condition. Text books of 10 yeaifl ago contain little or no information on the subject,! and we must concede that most of our knowledge! is but recently acquired. Not only has interetfj become widespread amongst the medical profesjl sion, but legislators also, aided by representative?! of labor, are enacting or propose to enact laws of| compensation for the disability caused by this dis-j ease. - Considerable confusion exists regarding thi" various names that have been applied to lung d struction caused by dust. For example, the ter pneumonoconiosis is the one usually applied toj dust diseases in general, and because of this, J the preferable term because most cases are no] due to one particular dust alone, but are a mi|| ture of two or more dusts. For instance, the thracite miner of Pennsylvania is subjected to twj dusts, i.e., silica from the rock and coal dust. Thu he has pneumonoconiosis rather than silicosis. TKf term anthracosis applies to the pigmentation" "" the lung caused by the carbon. Siderosis is con|l sidered as the damage to the lung by the inhala . tion of iron dust, but I doubt whether any actual! damage to the pulmonary tissues is done. As we( shall see, the actual destruction is caused by sili|| ca, and the term silicosis is now generally applie* for all these conditions although, properly spea|| ing, pneumonoconiosis is correct. jiff Dusts are classified into two groups, i.e., orgari|| ic and inorganic. We find the first type of dustr many industries, more especially in the textiH trades. Carpet and rug weaving factories are no| ed for their heavy dusts. Tobacco factories " have some degree of dust of this type. These du may cause harm to the workers by: (1) carry^ inorganic dust particles along the lung, (2) by acj ing as a vehicle for the entrance of bacteria to f lung and thus causing an inflammatory reactiotj or (3) by setting up a protein hypersensitivenq' in the body to this particular dust. This latf condition appears in the form of bronchitis, rh tis, and headache. In the textile industry itJB known as "Shoddy Fever," and generally affe>' the new, worker only. While these various d turbances by organic dusts may be serious orj vial, yet at no time do they cause a definite pd monary tissue destruction, and for our discussyj may be dismissed. We must, therefore, look to the inorganic did as the cause of pneumonoconiosis. Any inorga dust to do this must contain silica, either alonel in combination. It is amazing the number ofj_ dustries in which silica may be the main constit) ent of the dust arising in the process of work. V' I mention some of them? Nearly all forms of mining render a silic ----------------- ' f: * Presented at the Spring M eeting of the M ichigan Association of India Physicians and Surgeons, Jackson, M ich., M ay 6, 1936. "3 IV O L .C '2 , ^ rasr hi. 5.,No. 5 INDUSTRIAL MEDICINE Page 225 rd to the workmen, such as gold, silver, lead, "c, copper, iron and anthracite. There is a high '.gree of hazard in the'quarrying and dressing of ite, sandstone and flint. In iron foundries, ,,irticularly in the preparation of moulds for cast-g and the shaking out of these casts, we find a 'gh silica content in the dust. Sand blasting, pot;7 .manufacture, glass making, sand rock drillg for excavating work, all contribute a silicosis 'ard at some stage in the work. I have only to femind you that silica is the chief ingredient in ' qst of our abrasives, and this brings to mind hiring and polishing soaps and powders, sandper, sandstone and whetstones, sand blasting, 'd even some forms of tooth pastes and powder `-ntain silica in a very finely ground state. In cent years the asbestos industry has been in- uded, but this will be discussed later. In oi-der to have a clear understanding of the ease, we should remember several factors upon !ch its development depends. The first concerns e size of the dust particle inhaled. To be effec tive in its destructive action, all dust particles con The sequence of changes that occur in the lung following the inhalation of silica dust is readily understood by realizing that silica essentially causes an over-production of fibrous tissue and this in turn causes an entire derangement of the lymphatic drainage of the lung. Silicosis is there fore a disease or disorder of the lymphatic system of the lung. The pulmonary lymphatic drainage is slightly different from the venous drainage. Roughly speaking, we may say that the inner % of the lung drainage is toward the hilum through the peri-vascular and peri-bronchial lymphatics, while the outer 14 is drained through the sub pleural cistern which in turn empties into the larger lymphatics along the inter lobar septa and from thence to the hilum. We shall see the im portance of this in a few moments. At the bifurca tion of each blood vessel lies a minute patch of lymphoid tissue through which pass these peri vascular and peri-bronchial lymphtics. These lymphoid deposits act as an important filter to the inward passage of the dust particle. Pathology of Silicosis ing silica must be less than 10 u. in diameter, ind the vast majority are certainly under 4 u. This v eans that the dust which is harmful is invisible. Particles larger than 10 u. cannot be phagocyted ind are therefore carried off in the bronchial se cretions. The second factor is the density or con centration of dust. Most authorities report this in the number of dust particles less than 10 u. in jQie cubic foot. Usually the number runs in the WHEN the dust particle reaches the alveolus it is phagocytosed by large mono-nuclear cells of endothelial origin, which for want of a better name have been called "Dust Cells". These cells are able at first to transport the particle to the neighboring tracheo-bronchial lymph nodes where their further progress is arrested, and the first destructive effect of the dust is noted. The present conception of its action is that silica is acted upon 'undreds of thousands or millions depending on by the alkaline body fluids and slowly dissolves to *-c clarity of the atmosphere. The standards of form a complex colloidal silica hydroxide, which safety set up by various official bodies consider in turn has a highly corrosive action on the nearby ' at a concentration of dust less than 10 million cells. Thus we have a minute area of necrosis rticles per cubic foot in which the free silica surrounding the dust particle. Because the- con ntent is 35% or less to be the maximum limits version of the silica into the hydroxide is very f safety. Later, I shall discuss several industries slow we have, for practical purposes, a continuous *"dgive the comparative dust concentrations that irritant, and this explains why the simple removal ay be found when no prophylactic equipment is of the worker from the dust exposure does not pre ed. A'third factor that is equally important in vents a continued advance of the disease in the the development of the disease is. the length of formation of scar tissue. This irritating and cor e to which the workman has been exposed, e duration of time necessary to produce silico sis naturally affected by the other factors al- `ady mentioned, and will therefore vary greatly "-pending on the industry. Approximate time lim- Swill also be mentioned later for some of the ge industries. . . some industries the silica dust is contamin- d by the presence of other inorganic dusts 'ich seems to have either a stimulating or a re ding effect on the corrosive action of silica on e pulmonary tissues. Typical of these is that of al dust which has apparently the effect of re ading silica, and that of alkaline soap in the rasive soap industry where silicosis frequently mmes the acute form. Thus the problem of sili- :is is different in different industries. The in dividual resistance of the laborer must also be ' en into account. Many times I have been puzz- edby the apparently small degree of fibrosis in a " e where I would normally expect an advanced ge. These occasional cases have been ex ' ' ed by an extraordinary ability on the part of -ture to excrete the silica before it can be in- '\ed by the phagocytes and carried into the pul- dnary tissues. ... l i e action of silica on the pulmonary tissue is t of a foreign body having a corrosive action. rosive action of silica stimulates the formation of scar tissue in its neighborhood to an over abund ance. Naturally, this distribution of scar.tissue will depend on the lymphatic drainage. ..:Thus, early in the disease we will see an intensification of the trunk markings and a nodular appearance on the x-ray film from fibrous tissue formation along these vascular channels. These small areas of fibrosis will be seen particularly in those minute, areas of lymphoid tissue. With continued dusting these nodules become larger and give a "snow storm" effect on the x-ray film. Should, however, the exposure to silica be so intense or carried out for a long time the lymphatic drainage becomes so disorganized that dust accumulates in the inter stitial tissue and massive areas of fibrosis-are formed. That portion of the lymphatic drainage that runs peripherally also carries dust particles, and in the course of time a pleuritis results and dense pleural adhesions are formed. The density of these adhesions is often astounding, and at autopsy they make the removal of the lung very difficult. These adhesions, especially at the. dia phragm, interfere with respiration and a char acteristic finding of the third stage is the marked irregularity and fixity of the diaphragm. With the continued formation of scar tissue, a marked degree of emphysema develops and, especially 4UJ j May, 1936 . v u l,, a, in 1 mediastinal margins, the alveoli enlarges 1 ! ^ y +that en?Physematous blebs are often t w f -at autoP?y; *n the later stage of the disease anrM 1S 3 paJtial oblderation of the vascular bed mCr?aSe.dpressure results on the right heart. " n m TM *Picture is one of excessive proliferation , of fibrous tissue with nature making valiant efforts ' 3mpenste.bY emphysema. Naturally the vital ' Is bwered and the extra burden put A? Jp16 ".ear^' hringmg the final picture to one of 2- cardiac decompensation. ^ i- Clinically .the disease is divided into three ,, stages, but this classification depends more on the - x-ray picture than on the actual clinical findings ...Several classifications have been advanced, some of which are very complicated. None of them is . entirely satisfactory but the one in general use is as follows. nr^TAv?E H signs and clinical symptoms r ab? ^ > bUu Jhe x`ray shows a slight increase m \ he hnnm shadows and perhaps there is a slight restriction of the right half of the diaphragm ^nd- l ? Uuroscpi<l 1examination- Some claim that a . haze m the mid-zone of the right lung 1SvnuiCatlm?' but 1 doubt whether this is entirely ' difficult X"rayr diaSnsis at this stage is most I' Stage 2:, Physical signs and clinical symptoms are usually absent although there may be a slight bronchitis and the vital lung capacity is moderately lowered. The x-ray appearance is, however, quite characteristic--nodular shadows distributed field*ly n b th SideS in the inner % 0f each lung Stage 3: Physical signs are those of emphysema and moderate bronchitis. There may be a low grade fever but the most prominent sign is that of dyspnea on mild exertion, and some cyanosis. The x-ray picture discloses large patches of fibrous tissue m both lungs, distortion of the diaphragm by numerous pleural adhesions and areas of em physema particularly in the apex and at the base. n acute silicosis, the first and second stages are not often seen because the process is so rapid that large masses of fibrous tissue form directly. Complications T r HE only complication of importance is pul * tuberculosis. It is a recognized fact that if there has been a pre-existing latent tuber culous lesion the inhalation of silica dust will un doubtedly re-activate it. If, however, the silicosis has been well established, then the secondary in fection of tuberculosis will be somewhat limited and tends to be chronic. There is a certain similar ity between the two diseases in that both have a predilection for the lymphatic system. If the lymphatics are obliterated or badly disrupted bv areas of fibrous tissue, then the tuberculous lesion tends to be hemmed in, so to speak, and we have a fibroid type of tuberculosis. Just to emphasize the importance of this complication let me quote the figures of the Massachusetts Special Industrial Commission. Their findings among industrial workers were that the tuberculosis death rate among granite workers was 33%, and among tool sharpeners was 15%, while the proportionate mor tality of males over 20 in the general population was only 7%. These figures apply, of course, to cases of pure silicosis, but sometimes the tuber culosis is modified by a contaminating dust. In the anthracite industry tuberculosis assumes a very chronic form \vith very few symptoms. This has rof dust n TM to tbe "protective" action of the J|m iners a: coal dust, but the exact explanation is still forth;1 [high as 2 ' f?mi+ng- Where an alkaline dust is found in com tunately, bination with the silica, as in the abrasive soapi ^.-However '+?0t only ia. fbe action of silica enhanced,''] f get an av but also, the susceptibility of the worker to tuber-i f cubic foo culosis is increased. '-Hi | This is e: . ' Diagnosis . . .-'?s4i<f -|l I!.'traekgeiosnabcoc /T ' HE diagnosis of silicosis, like all other diseases^? -. depends upon a well taken history. It is not! sufficient merely to inquire whether the man was! working in a dusty occupation. One should know! the particular type of work, how long he has been! at it, what precautions the company has taken to! have beend.USF re^quenYtlbya, twihtihs afowremllertakoecncuhpaisttioonrsy'!! a diagnosis can be made with a fair degree of ac;i curacy, and the diagnosis can then be clinched by! an x-ray. The roentgenological picture is no doubt; i F 1mar t0 you' A combination of the history and-'i the film is in most cases, sufficient for the diag! F f F Unfortunately, the physical examination ofJ the chest is not of much value. The fibrosis, even! when m large masses, gives very few signs because! of the overlying areas of emphysema It is this? a? pbyaeTM ^hai acts as an effectual blanket, and! b a6u the underlymg pathology. .yffl s iAb0UA Jbe onjy problem in differential diagnoj sis is that of tuberculosis, and usually it is. a! question of whether tuberculosis is a complicaJ tributions of theeneshuraaldi oyw' sonoen ctahne sfailymtharaet tthhoesedios-ill becaus tbey have an equal and bilateral! of ' and arf .fou.nd chiefly in the mid-zone? o i g' In dls] 1ilctln, the shadows of tubenl culosis have a predilection for the apex and are! often unequally distributed. The presence of a? cavity is a definite sign of tuberculosis, since we] never get excavation in a pure case of silicosis: Just a word of caution in the interpretation oil cavities in advanced stages of silicosis:--I have! emnh be6n by the Presence of areas off which are surrounded by patches off hbrosis. The appearance is most deceptive, and! fntq^ ntIy the ^ y m e a n s of definitely determid ing the presence of the suspected cavity is bH foUrmP5 ' HoiTer r>nearly aU patients with cavil Tn ru3tl0n w !n ,show tubercle bacilli in the sputum! In all suspected cases of tuberculosis it is necessary! to examine the sputum thoroughly. Just to rely! F ne or two negative sputum examinations is to! F F a/alf.e sense of security. I have seen many] ffee vv eerr , and normS aTl twhecigFhgt hanadndweoxrpkeicntgor, awtihoon,anreo?l ?pen cas<r? of tuberculosis, and who were, there^ fore continually infecting their families. It h i been my practice to require at least 10 negativ'd sputum examinations' and two 24-hour collection P ? n w enS Wh!ub .were examined either by con-4 centration methods or by culture dr guinea pig! t??culatlon' Every case of silicosis should be con? sidered as a probable tuberculosis patient until proven otherwise, and even then he is a candidate for an acid fast infection. , |velop a si |driller, o: "in as sho: '-or other ;extent ar | the anthr 'miners ir | stand tha The as attention i on the lu ^position . I ate, with snot as se: |:asbestos those of s fis called. Jbestos oc l^especiall; ^ally woi [`.which w Stances tc sof its pa Ihasbestoi ^bodies ab Jish-brow | shape thi ^Prussian |lieved th ;is found fof these confirms [same fre silicosis. ,, One oi [Because twell fo r: |the sand formed . |dust is a grinders of as hig ,,3ome gr Rafter fivi ffwater or llittle val |had wor [were 73' [that the [stone wl [this, bee; [has very _?<' Silica Needless [silicosis pand in Individual Industries Tof silica [[.shaking T HE hazard of silicosis naturally varies in del gree among the different industries in whic* sinca is used. Some industries have more dui than others. Probably the greatest concentrate ' Mass; i/ealed a id chi lass ms \ j'No. 5 INDUSTRIAL MEDICINE Page 227 n,:" is to be' found in hard coal mining where high and also in certain parts of the pottery works. "and miners helpers may be exposed to as ,Js 232. million particles per cubic foot. For`tely, this dust has only V-h% of silica in it>,, 'ever, the-rock drillers in the anthracite mines an average exposure of 82 million particles per $ foot, and the silica percentage is up to 31. Each industry is a study in itself. The more one studies the subject of silicosis the more one,is amazed at the innumerable uses that modern science has developed for this seemingly inert substance. All the way from astronomical telescopes to tombstones do we find silica. I ':"'nisceoxnptlaaiinnsedabboyutth3e1%facftrethe astiltichae. roUcksuianllyth, aitt Treatment '"'about 20 years for the regular mirier to de THINK we all realize the seriousness of silic p a second or third stage silicosis, but the rock osis, and naturally our problem is how to pre er, on the other hand, will show a third stage vent it. This can be done in one way only. That *short a time as three years. For some reason is to remove the dust at its source. Vacuum dust ther silicosis is not seen to nearly the' same removal equipment is the only way to insure t .among the soft coal workers as we see1it in against this danger. Standards of safety require thracite region. There are probably 100,000 that dust counts be kept under 10 million per cubic ;s in the anthracite area, and you can under foot. The use of face masks, except where a de 'that silicosis is quite a problem with us. finite supply of fresh air is given continually, is of V 'asbestos industry has come in for much' no use. Those small face masks that cover the nose ' tion in recent years. The action of asbestos and mouth and contain a wet sponge are dangerous e lungs is similar to that of silica and in com1, because they do not prevent the dust from enter on asbestos is a magnesium aluminum silic- ing the lung, and give a false sense of security. With traces of iron. The destructive effect is ' Once the disease has gained a foothold, the man as serious as pure silica, but it is supposed that ' should change his occupation, but even this will 'os undergoes changes in the lung quite like not stop the gradual formation of fibrosis in the - of silica, only slower and that asbestosis, as it future. In the advanced stage, the patient should Sailed, is a true silicosis. The most dusty as be put to bed, and if possible, given sanatorium s occupations are to be found in the factories, care. In this way the cardiac reserve can be im -ally where the mineral is broken up and fin- proved, and the patient made more comfortable. f woven, into the numerous materials with The seriousness of silicosis as an industrial hazard ch we"`are familiar. The disease rarely ad- requires our careful consideration and study just ces to the third stage." The one unique feature as much as any other major problem. its pathology is the presence of the so-called bestos bodies". These are highly refractive *es about 20 u. to 100 u. long. They are yellow Traumatic Derangements -brown in color and do not take any stain. In fe the bodies may be clubbed, and they give a About the Ankle Joint -Sian Blue reaction for iron. In fact, it is beJ that they are partly caused by the iron that ftiund with the asbestos mineral. The finding ese bodies either in the sputum or at autopsy, rms the diagnosis of asbestosis. There is the By M. T. K o v e n , M.D., F.A.C.S., . and . ' H. E. Beller, M.D. 1 Brooklyn, N. Y. ; M e.frequency of tuberculosis in asbestosis as iri ANY traumatic mechanisms about the an fesis.'. . kle joint are incompletely understood e of the great uses of silica is as an abrasive, use of its hardness, it lends itself particularly and often are inadequately treated. We shall attempt to classify the most important de for this purpose. One of the chief offenders is rangements while integrating where possible the -sandstone wheel, and under its use there is manner of their causation and the .lesions produc ed a constant stream of silica dust. Metal is also formed, but it does no damage. Tool ed and methods of treatment. -1' ' `ders may be subjected to a dust concentration typTeheof tihnrjeuerycihnieafndfaacbtoorust twhhe icahnkldeejtoeirnmt ianree tthhee asehgigrhinadser2s0-h3a0vme isllhioonwnpaarttihcliersd psetragceubsiiclicfoosoits, force of the impact, the obstacle, and the position ,five to eight years' occupation. The use of onfintgheofroojtuwmhpeinngstrpirkoipnogrtthioenaotbesltyaclien.crTehausse,s ruthne e-'r,Voanluet.heInstaonBeriitnishtosotludshyaorfp5e0n0inggrinisdeorfs vwehryo force, while the relation of the position of the foot worked at this occupation for 21 years there idmetpearcmtiinngesawgahientshtearnthoebsftoaoctleintoveartslarogreevmeertass.ure e',.73% who had silicosis. It is now advised t the carborundum be substituted for the sand- In the discussion to follow, one notes that the "e wheel because it is not nearly so dangerous, astragalus appears to play the most important role "because it does not wear away so quickly and in the anatomic consideration. From, its position "very much less free silica. " . it is the pivoting bone buttressed between the an ' ilica is also used in the form of sand blasting. kle joint and the foot. Hence, it is essential to re less to say, this exposes the worker to a real view some features of the astragalus. Superiorly, cosis hazard. In the iron foundry, the use of ittos tahreticpuolsatteirnigorsuprofratcieonnaarnrdowasrtfircoumlattehsewainthtertihoer d in casting causes quite a high concentration 'ilica in the atmosphere, particularly in the tibia. In complete dorsiflexion the wider sides ' g out of the casting and cleaning the casting, are wedged firmly against both malleolir In plan assachusetts, a study of these conditions re tar flexion this mortice is insecure.because of the ed a dust count as high as 200 million for the space between its posterior lateral, walls and the d'i'chifjpers and 84 for the sand slingers. In malleoli. . -.P*: ; '"manufacture, the hazard of silicosis may be * Read before the Association of Traumatic Surgeon*,New York City.