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Diagnostic Features of Silicosis and Silico-Tuberculosis
DISEASES OF THE CHEST
Ja**a*j
Diagnostic Features of Silicosis and
Silico-Tuberculosis Ferdinand Chenik, M.D. Detroit, Michigan
T IS generally recognized today that silicosis is the most common and, from the tandpoint of medical interest, the most impneuortant of the hazardous forms of that the known also well loconiosis. It is the upon in its effect azards of silicosis very is pulmonary tuberculosis eath rate in igh. Silicosis has the tendency to produce icreased susceptibility to pulmonary infec10ns and particularly to tuberculosis. Latent überculous foci or childhood type of tuberulosis may become reactivated by silicotic hanges or a preexistingsilicotic process may ecome complicated by a superimposed tuerculous condition through external infecion with tubercle bacilli. Pathological Changes in Silicosis. Silicosis evelops by breathing air which contains cry fine particles of silicon dioxide dust, also nown as free silica or quartz. The microcopic silica dust which is capable of producig pathological changes in the parenchyma f the lungs is only two to five microns in iameter; the dust particles which are more han ten microns in size are usually harm3ss. The inhaled dust, when lodged in the lveoli of the lungs, is first carried into the emphatic circulation by the phagocytes, 'hus, the dust becomes depositedin the traheobronchial lymph glands producing there athologicalchanges first. But when the inflation of dust continues, supersaturating he lymphatic system, then as the next step, tie phagocytes deposit their dust particles i the cells of the lungs. The presence of Dreign particles in the lung tissue stimuites a protective reaction resulting in the )rmation of thick fibrous tissue walls around ie dust particles. In this manner silicotic odules are formed. They are from one to x mm. in diameter. The nodules progresvely increase in size. When there is a coniomeration of nodules localized in a certain ortion of the lungs, there occurs a coalJcence of the nodules into larger silicotic reas. Thus, silicosis is a progressive disease.
Nodulation and formation of new fit, tissue continues in the victim even aft exposure to dust has ceased. The r d
it*** pathologic
86 produced in the lungs is permanent formerly believed that the changes in the parenchyma of the * lime.* vu_o was due to the mechanical action of the sh dust particles. At present most
authoriti^
agree that the chemical action of silicon d' oxide stimulates fibrotic changes. Silico dioxide,whichis slightly soluble in the alkaline body fluids, produces toxins which are supposed to initiate fibrosis and nodular formation. The process is always bilateral, occuring simultaneously in both lungs. The
length of the process varies from several months to twenty years. Where silicosis and tuberculosis coexist, the pathology in the lungs corresponds to the changes producedby both diseases. Nodulations and connective tissue fibrosis are scattered within and about tuberculous infiltrations, forming massive areas of chronic disease. Chronic adhesive pleurisy is a frequent complication. The occurrence of cavities and caseation is infrequent. Again, some other types may present a somewhat different
characterized mainly by perinodular tuberculous processes. The silicotic nodules
picture,
may become caseous, being surrounded by exudative tuberculous infiltrations. In silicosis, complicated by tuberculosis, it may be said generally, that the pathological changes precorrespond to the type of tuberculosis sent. General Diagnostic Considerations. There are no specific signs or symptoms in silico a or silico-tuberculosis that are not foun bre other pulmonary diseases.Shortness of mptomS y and disability are the main s 1 iines diagnostic purposes the disease is some divided into three stages. In the first c the symptoms are not very marked, possibly for some shortness of breathis no disability at first. As the iy r ual gresses, the respiration becomes g
,
s^
diseaS^
DISEASES OF THE CHEST
t938
, more affected. Then the most piore an gtic symptom is marked dyspnea. ctel c tiara hing ig lat,ored and disability also t> later, a chronic cough Tnc rea g dnaiiy. But sets in eiop the iiUng capacity for breathing ' weakness progresses and finally deCreas In this final stage, d sability occurs. c°mpe develop tuberculosis to nkely im is tne fatal. Deaths from uncomare infrequent. The silicosis d single Plica j signs are of no help in differentiatdisease from other pulmonary condimg present. But a physical which might be
.
J
.
.
becomes
*t
lamiem nation first
is of greatest importance beplace it leads to the deterthe C presence of some pathology ination of the it aids in deterthe lungs, and then type of infection mining the presence of some complicating silicosis. In difficult borderline cases, the physical examination proves especially valuable. Again, a physical examination alone is absolutely insufficient for establishing the diagnosis. For this purpose, a most carefully obtained history and an x-ray examination become absolutely indispensable.For the diagnosis of tuberculosis superimposing silicosis, sputum examinations are '
inate the chances of acquiring silicosis. Working close to a place from which fine silica dust may be blown in many directions for a distance of many feet, creates a potential environment of exposure. Besides mining and quarrying there are many other industries where silica hazards exist, such as: foundries, potteries, glass factories, paint factories using silica, and occupations such as grinding, sand-blasting, etc. The concentration of silica dust varies in different in-
dustries. The concentration of silica dust determines the extent of pathology and the length of time necessary to produce silicotic
changes in the lungs. The higher the concentration of the silica dust the less time will be required to produce bad effects, and the extent of pathological changes will be greater. The length of exposure required varies, therefore, with the different occupations in various industries. Among foundry workers the risk of acquiring silicosis is comparatively lower than in many other industries and the time of exposure, therefore, would be longer. But occupations which involve a high concentration of fine silica dust cause a rapid progress of the disease, and silicosis may ocrequired. cur in as short a time as a fewmonths.Therefore, the details of the type of occupation in History. In determining the presence of silicosis, a good history is the most essential a certain industry and the length of time of factor. The history must be very complete, exposure must be necessarily included in the covering not only the type of work done, but history. also the length of time spent in a certain X-ray diagnosis. Equally important as the occupation. In taking the history it is of history is the x-ray examination.It is supergreat importance to ask the individualabout fluous to say that the x-ray plates must be all occupations in a chronologicalorder, from taken by an expert and read by an experthe day the victim has left school andbecome ienced radiologist. For the purpose of diaginvolved in gainful work until the onset of nosing silicosis or silico-tuberculosis, the best he present disease in question. The purpose possible films are .required, showing the of this procedure is to discover whether an minutest structural changes in the lungs. dividual who recently had a dustless oc- Improper exposures may not reveal the most cupation might not features, have been exposed to desirable and most characteristic alation of silica dust sometime during his thus increasing the difficulties in obtaining " ilicosis is a progressive disease and it a definite diagnosis. The silicotic nodulations 6 traced to a dusty occupation many on the x-ray plate appear as well-defined yea baCk in the past The fact that some_ shadows about 6 mm. or less in size of unilscontinued many years ago a dusty form density. They are distributed bilateralOCCUD n> does not eliminate silicosis. The ly, with somewhat lesser distribution in the dj Seas iS perm anent and the progress of the lower portions of the lungs. When there is nodules, localized in certain siijCa Con tiriiies even when exposure to coalescence of ri St conglomerhaS many areas of the lungs, there appear years o the been discontinued for other nand, not being directly ate shadows on the x-ray film. Silicosis may lung conditions such ln a dusty occupation does not elim- simulate many other
JJ
bod?
dise^
-
DISEASES OF THE CHEST
Jan^v
Conclusion infections, etc. as miliary tuberculosis, fungi is usually a permanent and 1. Silicosis exposures By taking a series of x-ray disease, In order sive characterized by nodul greS~~ other diseases may be eliminated. fr distribution of mations and fibrosis in the lungs. to obtain a better idea of the plates are 2. Silicosis has the tendency to i n silicotic nodulations, stereoscopic susceptibility to pulmonary that recommended. Some authorities believe 3. Shortness _ , of breath on exertion Conph stereoscopic plates and a series of x-ray exand lowered lung capacity are the diagcom 0n posures are essential requirements for with tu- symptoms in silicosis. nosis. When silicosis is complicated 4. The physical examination is berculosis, the reading of x-ray films becomes extrem may valuable but alone is insufficient for est complicated. Cavities essentially more lishing the diagnosis. be seen only in far-advanced cases. 5. The history is of primary importance able Sputum examinations. In order to be it must be complete and exhaustive but with to determine whether silicosis is complicated special reference to the type of occupation parin and lung infection with some type of the silica dust environment and the length repeated sputum in tuberculosis, with ticular of time of exposure. examinations are of primary importance. 6. Perfect x-ray plates are indispensable Routine sputum examinations should be done They must be interpretedby an expert radioin every case. When the sputum is negative logist. The distribution of silicotic nodules is for tuberculosis, animal inoculations of the bilateral. 7. Routine sputum examinations are rematerial will sometimes prove of great help
°
tuberculosis^^ vi«j.i )
/
quired.
in establishing the diagnosis. »
ipiodol Bronchography* Frank Walton Burge, M.D., F.A.C.P. and
Joseph
W. Post, M.D., F.A.C.P. Philadelphia, Pa.
ay has has well as others. CROM the time that the roentgen ray agent studyin diagnostic Roentgenologic contrast been used as a
study of pathoing physiological action and pathological logical changes in the lungs and bronchial changes, physicians and research workers tree was advocated as early as 1918, when
have increasingly sought suitable contrast media. At the present time, we have our contrast meals for the gastro-intestinal tract, enhanced in recent years by the added ability to visualize the actual mucosal pattern of the tract; likewise, in the urinary tract, retrograde pyelography and intravenous urography and cystography; cholecystography for studying function andlesions of the gall bladder; lipiodol installation of the paranasal sinuses; air as a contrast medium in ventriculographyandencephalography,pneumoperitoneum, double contrast enemata study of the colon; arteriography; myelography visualization of fistulous tracts, as
Chevalier Jackson* attempted bronchoscopic insufflation of bismuth and barium powders, while H. L. Lynah*, in 1920, employed a lomixture of bismuth and pure oil for the cavity. calization of an abscess a The first experiments with lipiodol, as ' Aby J. diagnostic agent, were made 19 and papers published on the subject in r J. Forestie assistant, Subsequent to this, his dd llpl ol in conjunction with Leroux, injected ot c in the human trachea.Since that time, have come to use it, although we feel only the surface of its diagnostic possibui in pulmonary lesions, has been touche Lipiodol application to the bronchia has a two-fold purpose: diagnostic
*Delivered before the meeting of the American College of Chest Physicians at Atlantic City, June 7th, 1937.
therapeutic. Diagnostic
sica^ °
.
indications are:
■
Ja**a*j
Diagnostic Features of Silicosis and
Silico-Tuberculosis Ferdinand Chenik, M.D. Detroit, Michigan
T IS generally recognized today that silicosis is the most common and, from the tandpoint of medical interest, the most impneuortant of the hazardous forms of that the known also well loconiosis. It is the upon in its effect azards of silicosis very is pulmonary tuberculosis eath rate in igh. Silicosis has the tendency to produce icreased susceptibility to pulmonary infec10ns and particularly to tuberculosis. Latent überculous foci or childhood type of tuberulosis may become reactivated by silicotic hanges or a preexistingsilicotic process may ecome complicated by a superimposed tuerculous condition through external infecion with tubercle bacilli. Pathological Changes in Silicosis. Silicosis evelops by breathing air which contains cry fine particles of silicon dioxide dust, also nown as free silica or quartz. The microcopic silica dust which is capable of producig pathological changes in the parenchyma f the lungs is only two to five microns in iameter; the dust particles which are more han ten microns in size are usually harm3ss. The inhaled dust, when lodged in the lveoli of the lungs, is first carried into the emphatic circulation by the phagocytes, 'hus, the dust becomes depositedin the traheobronchial lymph glands producing there athologicalchanges first. But when the inflation of dust continues, supersaturating he lymphatic system, then as the next step, tie phagocytes deposit their dust particles i the cells of the lungs. The presence of Dreign particles in the lung tissue stimuites a protective reaction resulting in the )rmation of thick fibrous tissue walls around ie dust particles. In this manner silicotic odules are formed. They are from one to x mm. in diameter. The nodules progresvely increase in size. When there is a coniomeration of nodules localized in a certain ortion of the lungs, there occurs a coalJcence of the nodules into larger silicotic reas. Thus, silicosis is a progressive disease.
Nodulation and formation of new fit, tissue continues in the victim even aft exposure to dust has ceased. The r d
it*** pathologic
86 produced in the lungs is permanent formerly believed that the changes in the parenchyma of the * lime.* vu_o was due to the mechanical action of the sh dust particles. At present most
authoriti^
agree that the chemical action of silicon d' oxide stimulates fibrotic changes. Silico dioxide,whichis slightly soluble in the alkaline body fluids, produces toxins which are supposed to initiate fibrosis and nodular formation. The process is always bilateral, occuring simultaneously in both lungs. The
length of the process varies from several months to twenty years. Where silicosis and tuberculosis coexist, the pathology in the lungs corresponds to the changes producedby both diseases. Nodulations and connective tissue fibrosis are scattered within and about tuberculous infiltrations, forming massive areas of chronic disease. Chronic adhesive pleurisy is a frequent complication. The occurrence of cavities and caseation is infrequent. Again, some other types may present a somewhat different
characterized mainly by perinodular tuberculous processes. The silicotic nodules
picture,
may become caseous, being surrounded by exudative tuberculous infiltrations. In silicosis, complicated by tuberculosis, it may be said generally, that the pathological changes precorrespond to the type of tuberculosis sent. General Diagnostic Considerations. There are no specific signs or symptoms in silico a or silico-tuberculosis that are not foun bre other pulmonary diseases.Shortness of mptomS y and disability are the main s 1 iines diagnostic purposes the disease is some divided into three stages. In the first c the symptoms are not very marked, possibly for some shortness of breathis no disability at first. As the iy r ual gresses, the respiration becomes g
,
s^
diseaS^
DISEASES OF THE CHEST
t938
, more affected. Then the most piore an gtic symptom is marked dyspnea. ctel c tiara hing ig lat,ored and disability also t> later, a chronic cough Tnc rea g dnaiiy. But sets in eiop the iiUng capacity for breathing ' weakness progresses and finally deCreas In this final stage, d sability occurs. c°mpe develop tuberculosis to nkely im is tne fatal. Deaths from uncomare infrequent. The silicosis d single Plica j signs are of no help in differentiatdisease from other pulmonary condimg present. But a physical which might be
.
J
.
.
becomes
*t
lamiem nation first
is of greatest importance beplace it leads to the deterthe C presence of some pathology ination of the it aids in deterthe lungs, and then type of infection mining the presence of some complicating silicosis. In difficult borderline cases, the physical examination proves especially valuable. Again, a physical examination alone is absolutely insufficient for establishing the diagnosis. For this purpose, a most carefully obtained history and an x-ray examination become absolutely indispensable.For the diagnosis of tuberculosis superimposing silicosis, sputum examinations are '
inate the chances of acquiring silicosis. Working close to a place from which fine silica dust may be blown in many directions for a distance of many feet, creates a potential environment of exposure. Besides mining and quarrying there are many other industries where silica hazards exist, such as: foundries, potteries, glass factories, paint factories using silica, and occupations such as grinding, sand-blasting, etc. The concentration of silica dust varies in different in-
dustries. The concentration of silica dust determines the extent of pathology and the length of time necessary to produce silicotic
changes in the lungs. The higher the concentration of the silica dust the less time will be required to produce bad effects, and the extent of pathological changes will be greater. The length of exposure required varies, therefore, with the different occupations in various industries. Among foundry workers the risk of acquiring silicosis is comparatively lower than in many other industries and the time of exposure, therefore, would be longer. But occupations which involve a high concentration of fine silica dust cause a rapid progress of the disease, and silicosis may ocrequired. cur in as short a time as a fewmonths.Therefore, the details of the type of occupation in History. In determining the presence of silicosis, a good history is the most essential a certain industry and the length of time of factor. The history must be very complete, exposure must be necessarily included in the covering not only the type of work done, but history. also the length of time spent in a certain X-ray diagnosis. Equally important as the occupation. In taking the history it is of history is the x-ray examination.It is supergreat importance to ask the individualabout fluous to say that the x-ray plates must be all occupations in a chronologicalorder, from taken by an expert and read by an experthe day the victim has left school andbecome ienced radiologist. For the purpose of diaginvolved in gainful work until the onset of nosing silicosis or silico-tuberculosis, the best he present disease in question. The purpose possible films are .required, showing the of this procedure is to discover whether an minutest structural changes in the lungs. dividual who recently had a dustless oc- Improper exposures may not reveal the most cupation might not features, have been exposed to desirable and most characteristic alation of silica dust sometime during his thus increasing the difficulties in obtaining " ilicosis is a progressive disease and it a definite diagnosis. The silicotic nodulations 6 traced to a dusty occupation many on the x-ray plate appear as well-defined yea baCk in the past The fact that some_ shadows about 6 mm. or less in size of unilscontinued many years ago a dusty form density. They are distributed bilateralOCCUD n> does not eliminate silicosis. The ly, with somewhat lesser distribution in the dj Seas iS perm anent and the progress of the lower portions of the lungs. When there is nodules, localized in certain siijCa Con tiriiies even when exposure to coalescence of ri St conglomerhaS many areas of the lungs, there appear years o the been discontinued for other nand, not being directly ate shadows on the x-ray film. Silicosis may lung conditions such ln a dusty occupation does not elim- simulate many other
JJ
bod?
dise^
-
DISEASES OF THE CHEST
Jan^v
Conclusion infections, etc. as miliary tuberculosis, fungi is usually a permanent and 1. Silicosis exposures By taking a series of x-ray disease, In order sive characterized by nodul greS~~ other diseases may be eliminated. fr distribution of mations and fibrosis in the lungs. to obtain a better idea of the plates are 2. Silicosis has the tendency to i n silicotic nodulations, stereoscopic susceptibility to pulmonary that recommended. Some authorities believe 3. Shortness _ , of breath on exertion Conph stereoscopic plates and a series of x-ray exand lowered lung capacity are the diagcom 0n posures are essential requirements for with tu- symptoms in silicosis. nosis. When silicosis is complicated 4. The physical examination is berculosis, the reading of x-ray films becomes extrem may valuable but alone is insufficient for est complicated. Cavities essentially more lishing the diagnosis. be seen only in far-advanced cases. 5. The history is of primary importance able Sputum examinations. In order to be it must be complete and exhaustive but with to determine whether silicosis is complicated special reference to the type of occupation parin and lung infection with some type of the silica dust environment and the length repeated sputum in tuberculosis, with ticular of time of exposure. examinations are of primary importance. 6. Perfect x-ray plates are indispensable Routine sputum examinations should be done They must be interpretedby an expert radioin every case. When the sputum is negative logist. The distribution of silicotic nodules is for tuberculosis, animal inoculations of the bilateral. 7. Routine sputum examinations are rematerial will sometimes prove of great help
°
tuberculosis^^ vi«j.i )
/
quired.
in establishing the diagnosis. »
ipiodol Bronchography* Frank Walton Burge, M.D., F.A.C.P. and
Joseph
W. Post, M.D., F.A.C.P. Philadelphia, Pa.
ay has has well as others. CROM the time that the roentgen ray agent studyin diagnostic Roentgenologic contrast been used as a
study of pathoing physiological action and pathological logical changes in the lungs and bronchial changes, physicians and research workers tree was advocated as early as 1918, when
have increasingly sought suitable contrast media. At the present time, we have our contrast meals for the gastro-intestinal tract, enhanced in recent years by the added ability to visualize the actual mucosal pattern of the tract; likewise, in the urinary tract, retrograde pyelography and intravenous urography and cystography; cholecystography for studying function andlesions of the gall bladder; lipiodol installation of the paranasal sinuses; air as a contrast medium in ventriculographyandencephalography,pneumoperitoneum, double contrast enemata study of the colon; arteriography; myelography visualization of fistulous tracts, as
Chevalier Jackson* attempted bronchoscopic insufflation of bismuth and barium powders, while H. L. Lynah*, in 1920, employed a lomixture of bismuth and pure oil for the cavity. calization of an abscess a The first experiments with lipiodol, as ' Aby J. diagnostic agent, were made 19 and papers published on the subject in r J. Forestie assistant, Subsequent to this, his dd llpl ol in conjunction with Leroux, injected ot c in the human trachea.Since that time, have come to use it, although we feel only the surface of its diagnostic possibui in pulmonary lesions, has been touche Lipiodol application to the bronchia has a two-fold purpose: diagnostic
*Delivered before the meeting of the American College of Chest Physicians at Atlantic City, June 7th, 1937.
therapeutic. Diagnostic
sica^ °
.
indications are:
■