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FILE NAME Brakes BRK DATE 1937 Jan DOC BRK005 DOCUMENT DESCRIPTION Article - New England Journal of Medicine - The Value of Sympathectomy in the Treatment of Vascular Disease - The New England Journal of Medicine Howe's VOLUME 216 0-7 JANUARY 28 1937 NUMBER 4 VERMONT STATE MEDICAL SOCIETY | o THE VALUE OF SYMPATHECTOMY IN THE TREATMENT OF VASCULAR DISEASE a _ BY R. H. SMITHWICK M.D. NONSIDERABLE progress has been made in the understanding of vascular disease as a re- sult of a better understanding of the relation between the vascular and the sympathetic nerv- ous systems Our knowledge of this subject is by no means complete but is increasing rapidly from year to year In the brief time at my disposal I shall discuss the results of sympa pulses result in vasoconstriction although vasodilators are also pathways visceral first clari- find the efferent pathways of the visceral nerves from the central nervous system The neurons of the vasoconstrictors arise in the lateral col- leave umn of the gray matter in the entire dorsal and upper two or three lumbar segments of the spinal cord fig 1 Their axons the cord ORIGIN OF EFFERENT MOTOR SYMPATHETIC PATHWAY POST ROOT PERIPHERAL N. Poet 90cectbooes, le? : me SYMPATHETIC SYMPATHETIC f GANGLION TRUNK- TRUNK- BREY RAMUS WHITE RAMUS GANGLIONIC ARTERY fff PORTION ( aan PATHWAY : ANT : ROOT => of FIG 1. Diagrammatic representation an efferent vaso- from its origin in the lateral horn to its : constrictor pathway arterial wall The devious pathway makes - ' termination in the different places from an ana- interruption possible in many -- - its of view Note the pre- and postganglionic portions .. tomic point This is of great physiologic importance as of the pathway described in the text thectomy in Raynaud's disease obliterans angina pectoris and thromboangiitis essential hyper by way of the anterior roots reaching the out- lying sympathetic trunk by way of the white rami communicantes which run from each tension Anatomy Before turning to the clinical as- of the subject I wish to mention certain pects anatomic and physiologic facts which must be in order to understand the effect appreciated on blood vessels of sympathectomy We are concerned primarily with the motor impulses to arteries their origin pathways and the most accessible points at which they can be inter rupted The most important of the motor im- From the Surgical Services and Circulatory Clinic ofAnual ththe e Massachusetts General Hospital Presented before the One Hundred and Meeting of the Vermont State Medical Twenty Annual Society October 16 1936 R. Assistant Surgeon Massachusetts Smithwick and address of author see This Hospital For record Issue page 190 General Week's peripheral nerve to the corresponding ganglion of the sympathetic trunk These white rami arise close to the intervertebral foramen | This portion of the pathway will be referred to as preganglionic The axons terminate in some ganglion of the sympathetic chain where they form synapses and then continue on to the blood vessel wall as postganglionic fibers The postganglionic axons leave the ganglion of the sympathetic trunk by way of gray rami and ther join the peripheral nerves leaving them at va- rious levels along their course to supply the arteries in question It therefore becomes ob- vious that the efferent vasoconstrictor pathway , 162 DANGEROUS HAWES N. E. J. OF M. + JAN 28 1937 J DANGEROUS DUSTS BJOHN B. HAWES 2ND M.D. HE subject on which I am to speak is im- Another case was that of a man who had de- portant for two reasons In the first place veloped tuberculosis He had worked as a cutter this question of dust dangerous or otherwise of cotton cloth with scissors and with a machine constitutes the most important problem in the in one of the most grade private charitable whole field of industrial medicine and second enterprises for the handicapped that I know of ly dust is the source of one of the most vicious in Boston He was under the care of a well- ' rackets inflicted on this country This latter known and competent physician In going over I will describe briefly coe the files of this case I read a letter from this The basis of this racket is founded on 1 ig- physician to the effect that his patient's exposure norance on the part of the workingman 2 ig- to this cotton dust inhaled in the course of his norance on the part of doctors as to what dusts work might well have led to pneumoconiosis and are dangerous and 3 unscrupulous and mer- should therefore be considered a possible cause cenary lawyers The average workman is well of his tuberculosis Naturally I had inspected aware that the granite cutter who has been ex- the premises where this man worked and knew posed to granite dust and has been disabled that the dust was conspicuous by its absence and thereby quite properly receives compensation as that the quarters were light airy clean and well does the sandblaster and in many instances the ventilated by no conceivable chance could the foundry worker Naturally the laborer is in no dust have been in any way a cause of his illness position to make a distinction between the vari- These are examples of what I believe to be ous varieties of dust innocuous or dangerous ignorance on the part of physicians desiring to All dusts look alike to him Therefore if in the help out their patients The following case is course of his work in a line kiln a textile fac- rather different A man in a certain very large tory or flour mill or elsewhere he comes down with bronchitis bronchiectasis asthma tubercu- industry in this country may be exposed in the course of his work to minimal amounts of rust or losis or something similar he very naturally iron dust which is beneficial rather than harm- argues that it was the dust that caused it and ful equally minimal amounts of lime which claims damages This brings us to the second contains a microscopic amount of a harmless reason for this racket which is likewise based on silicate lime in fact is often advocated in treat- ignorance on the part of the medi ment and some powdered soap one of the in- cal profession as constitutes a dangerous+ gredientosf which silicate perfectly harni- -dust and to the difference between general less in such minimal quantities The powdered term pneumoconiosis and the specific sili- soap used for lubricating iron or steel wire - | cosis Of the many physicians whose testimony as it is drawn through a die It should be borne | I have listened to in such cases I know of only jin mind that this soap was lubricant and in no one that I feel is actuated by mercenary mo way an abrasive as an abrasive soap would have tives for testifying as he does In the vast majority of instances of this kind doctors are testifying for their clients with honest and sincere motives A few examples of this might well be given here A physician whom I have known for 30 years as an intimate friend and a grade general ruined the wire The physician I have in mind testified in fivoef these cases in which I like- wise appeared In one case the autopsy showed that the man had died of cardiorenal disease with no trace of silicosis in his lungs but it was claimed that the man had silicosis that this was responsible for his death His testi- practitioner testified in my presence that a certain man who had been working in a woolen mony in the other cases was along similar lines Of this nothing further need be said mill had acquired a chronic asthmatic bronchitis because of the dust to which he was exposed in the course of his work He had never inspected the mill itself Aside from the fact that wool dust is perfectly innocuous and never has caused any serious disease I personally had inspected this mill which was situated in one of the sub- The third factor and the most important one in the development of this racket is the crooked and mercenary attorney One of the very large industries in this country that of cementmaking where workers may be exposed to one of the harmless silicate dusts has been subjected to attacks on this basis with the result that ver- urbs of Boston and had found the conditions there to be the most hygienic that one could ex- pect There was practically no dust Read before the meeting of the American Clinical and Climatological Climatological Association at Richmond Virginia October 27 Hawes John B. President Boston Tuberculosis Asso- clation For record and address of author see This Week's Issue page 180 diets of 15,000 20,000 and 25,000 have been awarded to the plaintiffs with cases said to amount to over 12,000,000 now pending Clever lawyers with able assistants a hired group of witnesses and unscrupulous physicians were able to carry on this remunerative occupation for a very long time before the manufacturers con- ae estaetee sre cas oa > ere VOL 216 NO 4 DANGEROUS HAWES 163 bined resources to defeat them aspect of this question So much for one Now I return to my subject dangerous dusts The title is a bit of a misnomer as there found an eighth to a quarter of an inch of brown desert sand on the floor some of which in the breathed course of the work was of necessity hence this man's silicosis is only one dust that may be dangerous and that is the dus which contains silicon in some form All the organic dusts and those inorganic dusts Another marked case of silicosis occurred in a man who had worked for many years in the| Walter Baker Chocolate Factory in Milton and which do not contain silicon are harmless Lest yet chocolate and cocoa dust are certainly in- there be a storm of dissent from those who wish to contradict me when I make this statement nocuous enough This man's sole job I found on investigation was to resurface the granite may I first define the word dangerous as mill wheels used to grind the cocoa bean An- eventually used here By dangerous I mean a dust that other very marked and fatal case of either by itself or in combination with some- bronchiectasis occurred in worker in a large exposed ~ thing elseiinjuresnjures or irritates the lungs or leads lumber mill where every workman was reduces to a fibrous tissue reaction which the to varying amounts of wood dust In this case individual's resistance to tuberculosis and other however the man fell down a chute into which bacterial diseases of the respiratory tract Na sawdust was poured and was taken out uncon- urally I do not include chemical poisons scious an hour later from the mass of sawdust Let us first consider the organic dusts Street which had buried him Here again there is 4 ' dust although it may contain small amounts of nothing to prove that wood dust is harmful silica in itself is harmless The only danger in- And so I so go on organic might through all the curred in breathing street dust comes from the dusts ; word about the germs that may be present especially in winter Now a non containing There has been a great deal of loose writing inorganic dusts The worker in the soft coal about the danger of organic dusts For many mine develops anthracosis which shows up strik- ray years the high mortality among the workers in ingly on an x but it is not a disabling dis- tobacco factories was notorious and was blamed ease nor does it predispose him to tuberculosis on the dust The truth of the matter is that If he gets silicosis as some of the workers in tobacco dust is not dangerous but that the work the hard coal mines occasionally do it is be- containing involved in this industry called for little or no cause of the granite or silicon rock physical exertion and therefore invited weak in which the coalis imbedded I have nodoubt lings while in addition the hygiene of the work- but that the slate and marble workers will pre- this ers was notoriously low Consider the textiles sent changes in their lungs after years of ex- cotton and wool Anyone going into the sort posure to dust but such exposure certain- ing room of either a cotton or woolen mill ly does no will harm Exposure t to usually find the air full of Here the thenI bales of raw material opened and con- do good ' Granted - to lime even seems feel surethat of ea tents fluffed up were Armfuls ofeet- only ton or wool are then put down an immense chute by the workmen where it is carried on to the - many you will not grant the dangerous dustis the one that contains siliconin some form what are the factors that determine the department degree _ next In the majority of instancesofof danger in the exposure to such silicon- anyone entering this room for the first time un containing dusts These may be given as fol- absolutely less heis nonallergic will soon notice lows a tickling of his nose and a strong tendency to rub or scratch that organ and sooner or later will experience some sneezing Strongly allergic persons will have this to a marked degree Cer- tain individuals of this type often come down with a severe acute rhinitis or a bronchitis dur- ing the first 10 days or so of their work in the leaving sorting room which soon passes off however no ill effects All this does not mean that 1 The amount or proportion of silica present in the dust Silicon is such a com- mon element that it might be said to be ubiquitous Itis present in small amounts in practically all street dust The stiff- ness of the fibersin hay straw and cere- als and that of the feathers of birds is due to silicon It is a normal constituent wool or cotton dustis dangerousin the slightest And yet one of the most marked cases of silicosis that I ever saw was in a workman whose job for of lung ash up to 1 per cent It is only when it is present in excessive amounts such as in granite dust and sand which many years had been in the sorting room of a large large factory where woolen carpets were made A part of the raw material in this room came from Egypt or some other foreign sandy district Amazed at finding silicosis in a wool worker when I knew that wool could not be the cause I investigated the plant and in this room are nearly pure silicon that it constitutes a menace 2 The form of silicon present in the dust Free silicon SiO2 as found in granite infinitely and sand is more dangerous than combined silicon as found in the silicates with one exception amcani DANGEROUS DUSTS HAWES HAWES N. OF M JAN 28 1937 3 3 4 Except for asbestos the silicates may be described as comparatively harmless Consider tale for instance Tale a mag nesium silicate is the basis of almost all toilet pow eders and is used extensively in the rubber industry It rarely if ever has been known to cause a disabling fibro- sis in the lungs The size of the dust particles Particles of less than 5 mierous are most dangerous Particles over that do not enter into the finer tissues of the lungs and arc therefore practically innocuous The rate of the fibrous reaction in the lungs is proportional to the fineness of the dust The density of the dust If the number of particles of containing dust per cubic foot of air exceeds twenty million such a dust may be said to be dangerous do not take the statement of the patient or that of his friends or indeed of his family physi- eian entirely for granted but that wherever possible you go through the plant and see for yourself the exact work that the man or woman did and how much actual dust he or she was exposed to in the course of said work This of course does not mean that you must take a dust count or make a chemical analysis which should be obtained from experts but it does mean using one's common sense in sizing up the situation The second point to be considered in making a diagnosis concerns the symptoms The most striking of these is shortness of breath cough may be but often is not present while loss of weight and strength spitting and general weakness are often conspicuous by their absence Shortness of breath by itself with- out any other condition to explain it is an im- ra portant point =. 7 = 5 6 men . disabling silicosis nosis been exposed . Intensity of the exposure The granite eutter working with a surfacing machine is exposed to infinitely more dust than the foundry worker who is only occasionally in certain types of work exposed to much dust A survey in Massachusetts showed a silicosis incidence of 15 per cent in gran ite cutters and only 8 per cent in foundry workers Length of the exposure It naturally follows that the longer the exposure the greater the inhalation of dust An ex posure 12 to 15 years is the average time required to give a granite cutter a while one of 2 to years can cause among asbestos work- ers = Third to be considered are the physical signs in the lungs These again may be conspicuously +. absent but in advanced cases generalized dulness most marked at the bases and extend ing upwards front and back harsh prolonged and often diminished expiration and occasional fine pitched rales as if two pieces of fine sandpaper were being rubbed together are important to bear in mind In addition to these signs there is one on which I am coming to place much importance namely a marked re- striction of chest expansion on taking a deep breath This is especially true in asbestos work- ers have nearly 75 and women have asbestos dust and . found that the one striking sign present in those whom have male positive diag . been greatly diminished chest expan- |: | and I 7 Finally might this the most sion rarely over one inch One mau of nearly important factor of all we come to that 70 years came in to see me who had worked factory indeterminable question the individual for many years in this particular as a resistance to dust Just as certain persons night watchman who by the very nature are extraordinarily resistant to tubercu- of his work had been exposed to little or no losis so are others for no known reason dust He had marked arteriosclerosis and con- able to breathe in large amounts of a siderable emphysema and complained of short- dangerous dust over a long period of ness of breath but nevertheless he was able to time without damage to their lungs expand his lungs nearly three inches ray showed normal lungs except for a moderate be ] Each one of the above points must taken into account Bearing them in mind let us now emphysema of silicosis This has Finally we come to the ray This in ad- consider the diagnosis in the hands vanced cases of granite cutter's silicosis or that been left far too long entirely in court of the sandblaster or indeed in marked as- of the roentgenologist If the ray man for itself The borderline cases er or at the clinic says that the plate shows a dif- bestosis speaks so ee nodular fibrosis and makes a diagnosis of however are very difficult to decide upon fuse poe silicosis no other factor pro or con up to the much so that I know of no two ray men who Of course the presence of a me!3 present time is apt to be tgoivtehnisserious consid- wcoomuplldicaatgirnege tuberculosis with a history of ex- eration I object strongly ee dust and even slight signs lnee The diagnosis of silicosis just as vtahreioduisagfaneo- pinostuhree ltuonagsdapnhgyesircoaulsly or by ray would tend we aT sis of tuberculosis depends upon the history of ex- to justify a positive diagnosis which without ae tors the first of these being these would be impossible fod posure Whenever you are called to give an Asbestosis is a relatively new disease con- PA opinion upon such a case I would beg that you Sf RS TIRE VOL 216 NO 4 EVALUATION OF ULTRAVIOLET THER THERAPY BA UNP KE Y R AND HARRI - .. 165 ' pees cerning which we know remarkably little except that it does not seem to correspond to the laws governing silicosis in general There is not the slightest doubt however in my mind at least that asbestos dust is the most dangerous of all dusts Asbestosis is able to produce total and permanent disability in a remarkably short length of time even after only 2 or 3 years exposure and occasionally less as compared with the much slower and more gradual action of pure silicon and the great majority of silicates Asbestos is an aluminum or magnesium silicate or a combination of these or others and in its chemical analysis agrees closely with that of tale cement and certain other silicates The fact remains however that asbestos is extreme- ly dangerous and fatal while tale cement and other silicates are comparatively innocuous ex- cept under prolonged intense exposure along with a very greatly lowered individual resist- : ance The points emphasized in this brief talk on a very big subject are the following 1 That there is only one dangerous dust- _ that containing silicon in some form 2 That the diagnosis should be based not purely on ray but on a history of exposure on the clinical symptoms and on the signs in the lungs along with the ray and That whenever possible a personal inspection of the claimant's work should be made in order to see for one's self just how much dust exposure there is thus insuring a correct and fair decision ie oe RAR ne ENCA PRECISE EVALUATION OF ULTRAVIOLET THERAPY Rene IN EXPERIMENTAL RICKETS : 7 aes BY JOHN W. M. BUNKER PII.D. AND ROBERT S. HARRIS PH.D. On e ane rMMNe eR 7 ernt ee ee bia Sa 5 eres wrt F a previous communication Bunker and Har- handicap of the filter method is the difficulty of ris recorded the opinion that light radia- eliminating longer wave lengths while retain- tions of wave lengths other than those in the region 2800-3100 Angstroms which at that time were generally regarded as constituting a vital band of light may assist in the biochemical processes of rickets therapy This opinion based on preliminary qualitative studies was strengthened by the findings of Sonne and Rekling who ing shorter since increasing absorption is generally first obtained at shorter wave lengths Another difficulty lies in the fact that such filters do not cut off sharply but generally allow definite increments of longer or shorter wave lengths to be present in selected band which increments must always be unknown importance if in fact there be a differ- various suggested 3025 an antirachitic region ence in the effectiveness , wave Since 1930 but few reports bearing upon this lengths . filter subject have appeared - Knudson.reporteKnuddson.reported Knudson.reported band By the method it was determined a ~' - of light eure and prevention of rickets in rats by radia- band made up principally from two tions from either a quartz mercury vapor are lines of the mercury are spectrum namely 3025 .: or from a GE S bulb and defined the gram and 3130 angstroms showed some therapeutic calories of these heterogeneous radiations neces value in experimental rickets in rats Subset sary to cure rat whose skin had been depilated quently by the use of a water monochrom- No attempt was made to evaluate different parts ator described by Harrison we were able to of the spectrum Gorter reported that only 2950 to 3100 Angstroms are active Knudson and Benford reported in abstract form that the antirachitic effectiveness of monochromatic eliminate from further consideration the line 3130 which was completely ineffective at an ap plied energy of approximately 1.75 grain calories per rat ultraviolet light does not correspond to that producing erythema but details are lacking Our own study continuing with optical filters of special glasses quartz and solutions of nickel sulfate and copper sulfate enabled us to investigate spectral zones of decreasing width One All the subsequent work was done with a Bausch & Lomb quartz monochromator type No. 33-86-05 with prisms 8 em by 8 cm which transmits sufficient energy from a 6 inch 220 volt Uviare to permit treatment of rachitic rats with single lines of light From the Biological Institute of Technology Research Laboratories Massachusetts Contribution Public Health bridge Mass No. 75 from the Department of Biology and Massachusetts Institute of Technology Cam Bunker John W. Director of Biological Research Labo ratories and Professor of Physiology and Biochemistry Massachusetts Institute of Technology Harris Robert Research Associate in Biology Massachusetts For records and addresses of authors Institute see This of Technologs Week's Issue page 150 - Experimental The arrangement of the equipment used in the phase of the investigation dealing with nochromatic radiations is shown in figure 1 In a white transite housing D open at top and bottom and raised from the bench on legs a vertical 6 inch Uviare A was placed in the