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FILE NAME State of the Art Literature SAL DATE 1942 Jan DOC SAL032 DOCUMENT DESCRIPTION Medical Bulletin of the VA - Pneumoconiosis- A Study of 379 Cases fs Ng SeSie ATeast Roe ee ESFEone : Re 3) CREDE oc Fk % a * Seae - Pi yi : VolumeVolume 18 v a Number Number Number TheThe The MEDICALBULETIN MEDICALMEDICAMLEDICALMEDICALMEDICAL BULETIBNULBETUILNLETIBNULETINBULETIN BULETIN the ' Administration AdminstraAdimonstraAidomnstraionAdmistrAadimonstraAdimoinnstraion Administration CHARLES Adminstrao : HINES Administratorof Veterans Affairs CHARLESCHARLESCHARLCESHARLES M.HINESGRIFITH AdminstraorAdminstraorAdminstratorAdminstrao D., Veterans DirectorDiector Director JANUARY JANUARY JANUARY JANJUAARYNUARYJANUARY 1942 1942 1942 1942 MARTINMARTINMARTIMNARTIN COOLECYOOLECYOOLEY M.M. D., EditorEditor GOVERNMENT WASHINGTONPRINTPGRINTINGPRINTGINTINGOFERE OFEREOFERE For sale by SuperintendentSuperintendentSuperintendentSuperintendent of DocumentsDocumentsSubscription |: WashingtonpriceC.centecente yearyear : ; . Price Price PNEUMOCONIOSIS A STUDY OF 379 CASES HARRY B. WILLIAMS M. l'eferans Administration Oteen N. A survey was recently conducted while the author was on duty at Veterans Administration Facility Sunmount N. Y. to determine the relative incidence of pneumoconiosis in beneficiaries of the Vet- erans Administration The data for the study consisted of questionnaires formulated by the chief division of postgraduate instruction and niedical research which had been sent to and executed at field stations in relation to beneficiaries who had been exposed to ocenpational dust hazards radiograms of chests of affected beneficiaries and in a few instances tissues from affected beneficiaries who had died A total of cases so collected from the field stations of the Veterans Administration was 379. The beneficiaries in this series had been variously occupied As miners of metal ores lead copper gold silver iron quartz coal anthracite and bituminous miners brick- yard laborers tunnel laborers rock drillers street cleaners laborers on various types of construction work automobile factory employees blacksmiths grinders stonecutters cement workers railroad switch- slate men machinists sandblasters pottery workers quarrymen limestone sandstone granite marble etc. laborers on stone crusher tobacco factory employees bricklayers mill employees steam- engine firemen asbestos workers molders elevator employees textile workers steel employees stone masons grocery dealers farmers aluminum melter clerk tile presser iron workers foundry- men carpenters metal polishers glass workers smelter workers and powder factory employees In a few cases no occupational history was given Modern 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 SiO2 or silicon dioxide and asbestos magnesium silicate Tale also a silicate of magnesium is closely allied chemically to asbestos and is under suspicion As yet however it has not been definitely proven to be a factor in the pro- duction of lung disease Coal causes pigmentation anthracosis and occasionally slight fibrosis but this has 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 bearing rock encountered in min- ing is the source from which the disease is contracted Workers in the cement industry although exposed to dust are not affected Teenuse 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 250 \ AION MEDICAL BULLETIN OF THE VETERANS ADMINE 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 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 as the production of chronic lung disease 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 cannot be regarded as hazardous as the amount of silien in such dust is very small and in low concentration After study of the data submitted 171 cases of this group were classified either definitely or probably as having lung disease due to dust inhalation either uncomplicated or complicated by infectious disease The hist^riesin 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 producing dust A history of this type of case should show not only where he worked but what he did in detail how long he did it and to what form of dust he 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 Some 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 are discrete ^fin the early cases tending to become confluent in the advanced cases In the extremely advanced cases these nodules tend to lose their individual identity in denso 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 S1 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. tuberculosis S TB advanced cases in which the individual nodules bad lost their identity in dense fibrous masses of infiltration These are considered the resultant of sili- cosis combined with tuberculous infection but it is impossible to determine a separate background for either process 8. Cases without definito evidence of silicotic involvement but with definite evidence of lung disease the appearance of which indicates a background of infection only BAS Pes ^ ICAL BULLETIN OF THE VETERANS ADMINISTRATION \ 10. Fibrosis Cases showing no nodular deposits with slight or marked accentuation of the lung markings This condition cannot be regarded as characteristic of silicosis it is often present in eases of respiratory infection acute or chronic in passive congestion due to cardio disease or in other conditions These linear shadows are also subject to normal variations in the adult chest ee 11. Asbestosis This condition has been termed silicatosis in contradistinction to silicosis Early cases of asbestosis are difficult to recognize as such The radiographs usually show only minor changes indicating an interstitial fibrosis similar in appearance to those cases in classifications 9 and 10. The more ne 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 markings but with little or no nodular deposit This haze may be 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 following The table shows the incidence of industrial lung disease according to the occupations represented: 81 S2 83 | Inf | Inf | Inf STN | Asb | Total ore Miners metal | Miners con Granite workers Rack drillers San Blasters Stanecutters 2, Pottery workers . Stone crushers Molders see Bricklayer furnace Smelter Stone mason eee bee Asbestos murder No Industrisi hisbury 1 1 Carpenter . Aluminum melter oo) Sheet worker 00... : . 11 7 8712 7 15 OD fal Ka DS we e 1 Total oo ee 38 12 2 32 38 20 27 a 371 It will be noted that there is preponderance of miners shown in this table Hard miners consti tale the furgest group of workers in dusty occupations tional groups if mate Information were available These could be subdivided into smaller occups- * Although there was no Industrial history given in these cases the radiographic appearance was quite typleal of sikteosh and they were so classified typleal The fartustrial history of these cases is open to question It is belleved that more detalled histories would have furnished more appropriate Information Aluminum melters wear farge asbestos aprons and gloves while working over the crucibles The molten metal spatters on these thus releasing considerable quantities of asbestos dust In the roorns where a numher of these men are at work there is probably a considerable concentration of this dust It also seems likely that the friction of these garments Incidental to the work would be an added factor in the release of asbestos particles Diagnosis 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 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 clicited in the more- F ; F MEDICAL BULLETIN OF THE VETERANS ADMIN~ i Aton 253 advanced cases together with signs of emphysema The dearth of ovidence of disease shown by symptoms and physical signs is striking study when compared with the extent of disease shown by the radiograph ray is the most definite and satisfactory method of diagnosis This together with a carefully taken history is absolutely necessary in making the diagnosis and in following up the individual cases The great hazard in these cases is an intercurrent acute respiratory infection such as pneumonia or influenza In the cases complicated by tuberculosis it is often difficult to differentiate the shadows of the two diseases Often cases of tuberculosis will show nodular deposits very similar to those of silicosis the appearance of the shadows of each disease may also be modified by the other In these cases detailed histories are even more important and the cooperation of the clinician and the roentgenologist is indispensable Of course in these cases the symptoms physical signs and laboratory findings of tuberculosis are present Of the 171 cases shown in the table 52 or about 30 percent were classified as uncomplicated silicosis or asbestosis 38 of these were in the first stage 12 in the second stage and only 2 were classified in the third stage A mortem examination of one of the last cases showed a advanced silicosis without evidence of infection Nevertheless the pathologist who was one of the reviewers of this series of cases felt that there was probably a background of infec- tion If this case had not come to autopsy it would have been classi- fied as tuberculosis The remaining 119 cases all showed evidence of complicating infectious disease more or less extensive and in most cases probably tuberculosis While this is not an extensive series of cases and no definite con- clusions can be drawn from it it is believed that it agrees with most observers in that it supports the belief that disease of the lungs due to dust inhalation increases the susceptibility of those organs to tuberculosis and that this susceptibility is increased in direct ratio to the extent of the industrial disease The reviewers aro of the opinion that the number of cases of industrial disease in this series is very small considering the number of cases of 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 from different facilities This review has shown that there is a need for more careful and detailed histories in cases of this type Medical officers should familiarizo themselves with this disease they should inform themselves of the various sources of 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 Lako Laboratory for the Study of Tuberculosis and Dr. Homer L. Sampson roentgenologist Trudeau Sanitarium both of Saranac Lake 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 medical officers of the various facilities who cooperated in furnishing the lata