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FILE NAME: John Crane (JC) DATE: 1936 May DOC#: JC009 DOCUMENT DESCRIPTION: Journal Article - Clinical Aspects of Silicosis Page 224 INDUSTRIAL MEDICINE May, 193^ 2 :00--"Common Injuries of the Chest," by E dgar W. D avis, Department of Chest Surgery, Univer sity Hospital, Ann Arbor, Mich, (illustrated with slides). 2:30--"Industry Turns to the Physician," Dr. Carey P. M cCord, 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," D r. 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., D etroit; Vice-President -- L eon S evey, 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. B adgely, M.D., F.A.C.S., Ann Arbor; and H enry J. P yle, M.D., Grand Rapids." Clinical Aspects of Silicosis! By Ross K. Childerhose, M.D., Allentuood, Penna. SILICOSIS is essentially an industrial diseasj and as such it has a vital interest for ui$ Within the past decade especially, the jj terest in this particular industrial hazard has be come so widespread, and the knowledge of disease so increased, that it has become necessary! for us as physicians to have a thorough undei^ standing of the condition. Text books of 10 ago contain little or no information on the subjects and we must concede that most of our knowledge! is but recently acquired. Not only has interest] become widespread amongst the medical profes*| sion, but legislators also, aided by representatives! of labor, are enacting or propose to enact laws i' compensation for the disability caused by this di ease. - , Considerable confusion exists regarding various names that have been applied to lung i struction caused by dust. For example, the ten pneumonoconiosis is the one usually applied dust diseases in general, and because of this, ^ the preferable term because most cases are noj 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 tot dusts, i.e., silica from the rock and coal dust. Thu he has pneumonoconiosis rather than silicosis. r~ term anthracosis applies to the pigmentation"' the lung caused by the carbon. Siderosis is con 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 wife shall see, the actual destruction is caused by ca, and the term silicosis is now generally applie for all these conditions although, properly speak| ing, pneumonoconiosis is correct. Dusts are classified into two groups, i.e., organjg ic and inorganic. We find the first type of dusti many industries, more especially in the textil trades. Carpet and rug weaving factories are! ed for their heavy dusts. Tobacco factories have some degree of dust of this type. These dif may cause harm to the workers by: (1) carry inorganic dust particles along the lung, (2) by < ing as a vehicle for the entrance of bacteria to 1 lung and thus causing an inflammatory readies or (3) by setting up a protein hypersensitive^ in the body to this particular dust. This latl condition appears in the form of bronchitis, rh tis, and headache. In the textile industry known as "Shoddy Fever," and generally affei 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 pq! monary tissue destruction, and for our discuss}^ may be dismissed. ' We must, therefore, look to the inorganic du as the cause of pneumonoconiosis. Any inorga dust to do this must contain silica, either alone] in combination. It is amazing the number dustries in which silica may be the main constih ent of the dust arising in the process of work, i I mention some of them? Nearly all forms of mining render a siliq * Presented at the Spring M eeting of the M ichigan Association of Inra Physicians and Surgeons, Jackson, M ich., M ay 6, 1936. ihazari fzinc, < degrei igranit gpartic fing ai |high f Itery i fing fo |hazar< premin fnost p.scouri SPaper (and e bonta: (rece peludee fHn c Jdiseas twhich tthe si; |tive ir gjainin |and tb eans ?artic ai retioi itra i'the ithe cu idrphe el. fsafety Ithat a rtic; ^conter ; saff ad gi aay b sed. phe de ftme 1 le d; isv ady epenr s.wii frhich idu sen iby aar KlcV' p . 5,,No. 5 INDUSTRIAL MEDICINE Page 225 Jazard to the workmen, such as gold, silver, lead, pic, copper, iron and anthracite. There is a high legree of hazard in the quarrying and dressing of Sranite, sandstone and flint. In iron foundries, |barticuiarly in the preparation of moulds for cast- jig and the shaking out of these casts, we find a silica content in the dust. Sand blasting, pot tery .manufacture, glass making, sand rock drill ing for excavating work, all contribute a silicosis latard at some stage in the work. I have only to remind you that silica is the chief ingredient in fast of our abrasives, and this brings to mind luring and polishing soaps and powders, sand paper, sandstone and whetstones, sand blasting, [fad even some forms of tooth pastes and powder Hntain silica in a very finely ground state. In' recent years the asbestos industry has been inHuded, but this will be discussed later, lln older to have a clear understanding of the Jjsease, we should remember several factors upon l^ich its development depends. The first concerns (Hesize of the dust particle inhaled. To be effeciifa in its destructive action, all dust particles con taining silica must be less than 10 u. in diameter, fad the vast majority are certainly under 4 u. This fceans that the dust which is harmful is invisible, particles larger than 10 u. cannot be phagocyted "Bid are therefore carried off in the bronchial se ctions, The second factor is the density or con centration of dust. Most authorities report this mthe number of dust particles less than 10 u. in ` cubic foot. Usually the number runs in the undreds of thousands or millions depending on clarity of the atmosphere. The standards of Mfety set up by various official bodies consider " at a concentration of dust less than 10 million `rticles per cubic foot in which the free silica "ntent is 35% or less to be the maximum limits !safety. Later, I shall discuss several industries 1give the comparative dust concentrations that y be found when no prophylactic equipment is 1. A'-third factor that is equally important in development of the disease is. the length of e to which the workman has been exposed. ^ duration of time necessary to produce silico sis naturally affected by the other factors alady mentioned, and will therefore vary greatly 'pending on the industry. Approximate time limwill also be mentioned later for some of the Ige industries. ' some industries the silica dust is contaminby the presence of other inorganic dusts 'hich seems to have either a stimulating or a re ading effect on the corrosive action of silica on e pulmonary tissues. Typical of these is that of *il dust which has apparently the effect of re ading silica, and that of alkaline soap in the rasive soap industry where silicosis frequently ties the acute form. Thus the problem of sili**is is different in different industries. The in dividual resistance of the laborer must also be Len into account. Many times I have been puzzedby the apparently small decree of fibrosis in a se 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 pulOnary tissues. ae action of silica on the pulmonary tissue is "t of a foreign body having a corrosive action. 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 Va is drained through the subpleural 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 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 by the alkaline body fluids and slowly dissolves to form a complex colloidal silica hydroxide, which in turn has a highly corrosive action on the nearby cells. Thus we have a minute area of necrosis surrounding the dust particle. Because the- con version of the silica into the hydroxide is very slow we have, for practical purposes, a continuous irritant, and this explains why the simple removal of the worker from the dust exposure does not pre vents a continued advance of the disease in the formation of scar tissue. This irritating and cor 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./t, With the continued formation of scar tissue, a marked degree of emphysema develops and, especially n x i U 1 w U N May, 1936 along thfi mediastinal margins, the alveoli enlarges chronic form with very few symptoms. This has fit dust ii so greatly that emphysematous blebs are often been attributed to the "protective" action of the, miners a: found at autopsy. In the later stage of the disease coal dust, but the exact explanation is still forth:,' /high as 2 there is a partial obliteration of the vascular bed coming. Where an alkaline dust is found in com*: tunately, and increased pressure results on the right heart. bination with the silica, as in the abrasive soap'/ However The whole picture is one of excessive proliferation industry, not only is the action of silica enhanced/ [get an av of fibrous tissue with nature making valiant efforts but also, the susceptibility of the worker to tuber ""Tcuhbisicisfoeo> to compensate by emphysema. Naturally the vital culosis is increased. lung capacity is lowered and the extra burden put region co on the heart, bringing the final picture to one of Diagnosis takes abc _ cardiac decompensation. - Clinically, the disease is divided into three /T 'H E diagnosis of silicosis, like all other diseases]! JL depends upon a well taken history. It is nti idrillera, os:* , stages, but this classification depends more on the sufficient merely to inquire whether the man was] in as shoi or other x-ray picture than on the actual clinical findings. working in a dusty occupation. One should know] ..Several classifications have been advanced, some the particular type of work, how long he has been] extent ar of which are very complicated. None of them is at it, what precautions the company has taken toi the anthr entirely satisfactory but the one in general use is prevent dust, and what his former occupations Mr mTMinnee.rrs^ i1rJ as follows. Stage 1: Physical signs and clinical symptoms have been. Frequently, with a well taken history,' a diagnosis can be made with a fair degree of ac-/ ' aTnhaeinat are absent, but the x-ray shows a slight increase curacy, and the diagnosis can then be clinched by. attention ; in the hilum shadows and perhaps there is a slight an x-ray. The roentgenological picture is no doubt' on the lu : restriction of the right half of the diaphragm familiar to you. A combination of the history arid- [[position . ' under fluoroscopic examination. Some claim that the film is in most cases, sufficient for the diag ''ate, with a slight haze in the mid-zone of the right lung nosis. Unfortunately, the physical examination of [not as sei /asbestos is indicative, but I doubt whether this is entirely \ reliable. The x-ray diagnosis at this stage is most the chest is not of much value. The fibrosis, even when in large masses, gives very few signs because] those of s " difficult. , ,,of the overlying areas of emphysema. It is this is called, bestos oc , . Stage 2:, Physical signs and clinical symptoms emphysema that acts as an effectual blanket, and J are usually absent although there may be a slight hides the underlying pathology. especiall; ; bronchitis and the vital lung capacity is moder- About the only problem in differential diagni?; `ally wav which w . ately lowered. The x-ray appearance is, however, sis is that of tuberculosis, and usually it is.:$[ /'.quite characteristic--nodular shadows distributed question of whether tuberculosis is a complica-] .Vances tc f equally on both sides in the inner % of each lung tion or not. Generally, one can say that the dis- of its pa .``asbestoi ' field. ,tributions of the shadows on the film are those of, Stage 3: Physical signs are those of emphysema silicosis because they have an equal and bilateral] bodies at and moderate bronchitis. There may be a low distribution, and are found chiefly in the mid-zone ish-brow shape th< . grade fever but the most prominent sign is that of of the lung. In distinction, the shadows of tuber-] - dyspnea on mild exertion, and some cyanosis. The culosis have a predilection for the apex and are, Prussian x-ray picture discloses large patches of fibrous often unequally distributed. The presence of a lieved th is found tissue in both lungs, distortion of the diaphragm cavity is a definite sign of tuberculosis, since we by numerous pleural adhesions and areas of em never get excavation in a pure case of silicosis'. of these physema, particularly in the apex and at the base. Just a word of caution in the interpretation of confirms same fre In acute silicosis, the first and second stages are cavities in advanced stages of silicosis:--I have Silicosis. not often seen because the process is so rapid that often been misled by the presence of areas of large masses of fibrous tissue form directly. emphysema which are surrounded by patches of One oi Complications fibrosis. The appearance is most deceptive, Because ]well fo r; frequently the only means of definitely determi HE only complication of importance is pul ing the presence of the suspected cavity is b; ;the sand T monary tuberculosis. It is a recognized fact autopsy. However, nearly all patients with formed . 'dust is a that if there has been a pre-existing latent tuberformation will show tubercle bacilli in the sputum] culous lesion the inhalation of silica dust will un In all suspected cases of tuberculosis it is necess, "grinders doubtedly re-activate it. If, however, the silicosis to examine the sputum thoroughly. Just to r( of as hig " ome gr has been well established, then the secondary in- on one or two negative sputum examinations is ^ _fter fiv< 1 fection of tuberculosis will be somewhat limited have a .false sense of security. I have seen maim [water or and tends to be chronic. There is a certain similar cases of. silicosis with cough and expectoration, little val ity between the two diseases in that both have a fever, and normal weight and working, who [had wor predilection for the lymphatic system. If the open cases of tuberculosis, and who were, then [were 73' lymphatics 'are obliterated or badly disrupted by fore, continually infecting their families. It ` . [that the areas of fibrous tissue, then the tuberculous lesion been my practice to require at least 10 negativi [stone wl tends to be hemmed in, so to speak, and we have sputum examinations-and two 24-hour collection] .this, bee; a fibroid type of tuberculosis. Just to emphasize specimens which were examined either by very the importance of this complication let me quote centration methods or by culture or guinea `6Silica the figures of the Massachusetts Special Industrial inoculation. Every case of silicosis should be Needless Commission. Their findings among industrial sidered as a probable tuberculosis patient unti iilicosis workers were that the tuberculosis death rate proven otherwise,'and even then he is a candida' [sand in among granite workers was 33%, and among tool for an acid fast infection. silica sharpeners was 15%, while the proportionate mor tality of males over 20 in the general population Individual Industries shaking was only 7%. These figures apply, of course, to HE hazard of silicosis naturally varies in de Mass; baled a T ' cases of pure silicosis, but sometimes the tuber- gree among the different industries in whfd .d chi - culosis is modified by a contaminating dust. In the silica is used. Some industries have more dii] ma anthracite industry tuberculosis assumes a very than others. Probably the greatest concentrate 3*. ' No. 5 INDUSTRIAL MEDICINE Page 227 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 Each industry is a study in itself. :232.million particles per cubic foot. For- The more one studies the subject of silicosis the `tely, this dust has only lVz% of silica in it,,, more one,is amazed at the innumerable uses that " irer, the-rock drillers in the anthracite mines modern science has developed for this seemingly an average exposure of 82 million particles per inert substance. All the way from astronomical j foot, and the silica percentage is up to 31. telescopes to tombstones do we find silica. ;is explained by the fact that the rock in that ja contains about 31% free silica. Usually, it Treatment about 20 years for the regular mirier to de- THINK we all realize the seriousness of silic I *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 her silicosis is not seen to nearly the' same removal equipment is the only way to insure '.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 iin 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 e>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 elungs 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 ioccupations 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. woven, into the numerous materials with The seriousness of silicosis as an industrial hazard xh 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 Traumatic Derangements f,'esabout 20 u. to 100 u. long. They are yellow- irown in color and do not take any stain. In About, the Ankle Joint pe the bodies may be clubbed, and they give a Sian Blue reaction for iron. In fact, it is be- lthat they are partly caused by the iron that und with the asbestos mineral. The finding ese bodies either in the sputum or at autopsy, is the diagnosis of asbestosis. There is the .frequency of tuberculosis in asbestosis as in `"is.. . U ';e of the great uses of silica is as an abrasive, M use of its hardness, it lends itself particularly for this purpose. One of the chief offenders is sandstone wheel, and under its use there is ed a constant stream of silica dust. Metal is also formed, but it does no damage. Tool `ders may be subjected to a dust concentration as high as 20-30 million particles per cubic foot, e grinders have shown a third stage silicosis .five to eight years' occupation. The use of .on the stone in tool sharpening is of very e,value. In a British study of 500 grinders who ^worked at this occupation for 21 years there e',.73% who had silicosis. It is now advised t the carborundum be substituted for the sandy wheel because it is not nearly so dangerous, 7because it does not wear away so quickly and 'very much less free silica, ilica is also used in the form of sand blasting, dess to say, this exposes the worker to a real posis hazard. In the iron foundry, the use of d in casting causes quite a high concentration "ilica in the atmosphere, particularly in the - g out of the casting and cleaning the casting, assachusetts, a study of these conditions re ed a dust count as high as 200 million for the dichippers and 84 for the sand slingers. In ^manufacture, the hazard of silicosis may be By M. T. K oven, M.D., F.A.C.S., and H. E. Beller, M.D. 1 Brooklyn, N. Y. ANY traumatic mechanisms about the an kle joint are incompletely understood and often are inadequately treated. We shall attempt to classify the most important de-: rangements while integrating where possible the manner of their causation and the lesions produc ed and methods of treatment. 1 '^ The three chief factors which determine the type of injury in and about the ankle joint are the force of tne impact, the obstacle, and the position of the foot when striking the obstacle. Thus, run ning or jumping proportionately increases the force, while the relation of the position of the foot impacting against an obstacle to a large measure determines whether the foot inverts or everts. In the discussion to follow, one notes that the astragalus appears to play the most important role in the anatomic consideration. From, its position it is the pivoting bone buttressed between the an kle joint and the foot. Hence, it is essential to re view some features of the astragalus. Superiorly, its articulating surface narrows from the anterior to the posterior portion and articulates with the tibia. In complete dorsiflexion the -wider sides are wedged firmly against both malleolir In plan tar flexion this mortice is insecure.because of the space between its posterior lateral, walls and the malleoli.- Read before the Awodation of Traumatic Surgeon,.New York City.