intertwined with the pathology of many other forms of phthisis
pulmonalis, so the symptoms must be common to those obtaining in other
forms of pulmonary disease. They are insidious and gradual in their
development, and may be classified as the subjective, the physical
signs, and the objective phenomena. The subjective symptoms may be
present without noticeable departure from an appearance of health.
There may be difficult respiration with more or less dyspnoea,
especially in the mornings and evenings, besides a sense of heaviness
and oppression in the chest, with a feeling of inability to inflate the
lungs. These symptoms may be increased on exertion, respiration
becoming wheezing, with imperfectly-developed asthmatic attacks.
Hoarseness, with varying degrees of aphonia, more or less dysphagia or
unequal pupils, may be present. Nearly all of these symptoms may be
accounted for as indicative of mediastinal pressure or irritation of
the pneumogastric nerve by the enlargement of the bronchial glands. The
catalogue of phenomena may be present in whole or in part, and the
intensity of their manifestations may vary from time to time in the
history of a single case. If the bronchial glands are much enlarged, a
sense of discomfort, oppression, and uneasiness {452} at the root of
the neck may be experienced, which increases until actual pain is felt,
located in the back between the scapulæ, but sometimes radiating
through the intercostal nerves around the chest. Cough, as a rule, is
an early symptom, usually dry, paroxysmal, and associated with
dyspnoea, or there may be bronchial catarrh, with a relative amount of
expectoration. Syphilitic disease of the larynx may occur coequal with
the pulmonary trouble, and some of the above symptoms may be thus
explained and many others added. Rheumatic and nervous symptoms,
including sleeplessness and deterioration of the blood-crasis, may
testify to the syphilitic infection of the blood.
When a physical examination of the chest is instituted, thickening of
the head of the periosteum of one or both clavicles, substernal
tenderness, thickening of the tibial periosteum, are usually detected.
Prominent among the physical signs are the evidences of enlargement of
the bronchial glands. According to Guéneau de Mussey, percussion over
the spinous processes of the cervical vertebræ in the course of the
trachea reveals in a healthy subject a distinct tubular sound down to
the point of bifurcation of the trachea at the level of the fourth
dorsal vertebra. Opposite the fifth and downward we get the
lower-pitched pulmonary resonance. When the tracheal and bronchial
glands are enlarged, the tubular sound over the upper dorsal vertebra
is replaced by dulness, which may contrast sharply above with the
tracheal and below with the vesicular resonance.
The respiratory murmur will be feeble in volume and limited to
inspiration, especially over the interscapular region. Over one or the
other bronchus the respiratory murmur may be more high pitched than in
health, and slightly exaggerated on one side or at the base of the
chest. The rhythm is often jerky and paroxysmal; the paroxysms are more
or less constant, but are liable at times to increase.
The additional physical signs in syphilitic phthisis, unassociated with
gummata, are those shared by other forms of fibroid phthisis, and do
not require particular description here, as increasing dulness, varying
degrees of bronchial breathing, and bronchophony. A peculiar alveolar
rustle, resembling the sound produced by the rumpling of wall-paper,
has been alluded to as characteristic.
Inspection or palpation sometimes reveals changes in the contour of the
chest, with displacement of the movable thoracic viscera, as in fibroid
phthisis. When cavities occur, the physical signs necessarily
correspond to those of other varieties of phthisis at this stage.
When a gumma is large enough to be recognized by physical examination,
one finds dulness or flatness on percussion, confined to a section of
the chest, and not occupying its semi-circumference, as in pleural
effusions. The vocal fremitus is suppressed in proportion to the size
of the gumma. The respiratory murmur is abruptly cut off over the area
of flatness, but it may be only distant bronchial breathing. The vocal
resonance is absent or is distant bronchophony. Around the gumma the
respiratory murmur is usually very feeble or scarcely audible,
generally without râles unless they are due to neighboring congestion.
The percussion resonance is good or exaggerated. Proportionate
vicarious functional activity prevails in the opposite lung. If the
gumma be large, the heart's impulse may be displaced to the left or
right, and dyspnoea may occur as in case of pleural effusions. In this
stage, owing to irritation of the bronchial mucous membrane, there may
be expectoration of a tough, glairy mucus, or as a gumma softens the
expectoration may become purulent.
The objective phenomena vary: the chest is often well developed, the
body fairly nourished, and constitutional symptoms of a severe
character may be wanting. The patient may be capable of hard physical
labor, even though a {453} considerable part of the lung be affected.
Moxon relates a case of a man "employed in carrying sacks of grain who
was suddenly killed, and who had fibroid infiltration of a great part
of the left lung and part of the right, and besides scars in his liver
and testes." But in some cases the complexion is pallid and waxy,
indicative of cachexia associated with digestive disorders, with
night-sweats, and a variable but low thermometrical record. Usually,
the progress of the disease is slower in syphilitic than in tubercular
phthisis, but when the systemic poisoning is grave and many other
organs are coincidently involved, the progress is more rapid; but the
process peculiar to syphilis is often past, and the patient suffers
from simple catarrhal phthisis with formation of cavities and softening
gummata. Diarrhoea and night-sweats are said to be less frequent than
in ordinary phthisis, and the pulse is slower. Hæmoptysis occurs
infrequently, because the process in the lungs is chiefly fibroid; but
it is possible through the rupture of newly-developed blood-vessels in
the new formation in the lung or hemorrhagic infarction through the
rupture of atheromatous vessels.
DIAGNOSIS.--This depends mainly on the history of the cases, the prior
or coexisting syphilitic lesions, especially laryngeal processes,
cutaneous syphilides, exostoses, perforation of the palate, substernal
tenderness, and the thickening of the tibial periosteum or that of the
head of one or both clavicles. Family immunity from phthisical
tendency, recovery from lesions usually incurable if they have any
other than a specific origin, are suggestive of pulmonary syphilis. If
a patient retains flesh and strength beyond the natural expectation
considering the serious lesions of the lungs, the fact is of relative
importance when considered in connection with the other diagnostic
features. The distribution of specific lesions is variously located by
different authors. Grandidier found induration affecting the middle
lobe of the right lung in 27 out of 30 cases believed by him to be
specific phthisis; the surrounding lung contained large areas free from
disease. This tendency to localization in portions of the lungs,
leaving large areas free from disease, is of value in diagnosis.
PROGNOSIS.--The prognosis is involved in the discovery of syphilis as
the cause of the disease and on the subsequent appropriate treatment.
Grave and important specific lesions, according to some authors, have
yielded to the resources of art. Fournier has recorded a case where
"dulness at the summit of the left lung was extensive and signs of a
cavity distinct. After six weeks of antisyphilitic treatment recovery
was almost complete. In this case the presence of a phagedenic ulcer of
the foot was the only sign that suggested syphilis, the symptoms of the
pulmonary affection being identical with those of tubercular phthisis."
The principles presiding over the prognosis of the various stages of
pulmonary diseases in general are applicable to syphilitic pulmonary
processes.
TREATMENT.--When a case of pulmonary lesion presents itself, unless the
existence of tuberculosis be demonstrated, we must ascertain if the
symptoms can possibly be due to syphilis, and the line of treatment
indicated in any single case must be based upon an estimate of the
prominence of the specific process. The ravages of syphilis, however,
often produce such loss of substance in the lung that the lesions are
irreparable, and therefore we cannot always accomplish the brilliant
results which usually attend an antisyphilitic treatment. If there is
evidence of enlarged bronchial glands, in addition to other measures
local counter-irritation is useful by means of the biniodide of mercury
ointment, 16 grains to the ounce, and applied for a continued period,
or a preparation of iodine with croton oil may be tried. In the main,
the general principles of treatment correspond with those recognized in
similar forms of pulmonary disease of a non-specific etiology.
{454}
PNEUMONOKONIOSIS.
BY EDWARD T. BRUEN, M.D.
DEFINITION.--A generic term applied to pulmonary diseases due to the
inhalation of particles of irritating dust.
SYNONYMS AND CLASSIFICATION.--The synonyms and classification of
pneumonokoniosis have been based upon the character of the dust
inhaled, using such terms as anthracosis ([Greek: anthrax], coal),
disease due to coal-dust; siderosis ([Greek: sidêros], iron), due to
metallic dust; chalicosis ([Greek: chalix], gravel or pebbles), due to
mineral dust; tabacosis, due to tobacco-dust; and byssinosis ([Greek:
byssos], cotton), due to cotton fibre and dust. A more imperfect
classification has been derived from the avocations of the sufferers;
for example, miners' phthisis, Sheffield grinders' rot, potters'
consumption and asthma, freestone-hewers', masons', or millers' lung.
HISTORY.--From the early experiments of Cruveilhier, who injected
mercury into the system and subsequently noted the pulmonary changes,
down to the experiments of the present day, evidence has accumulated to
show that inorganic irritant materials are capable of exciting
inflammatory new formation in the lungs. The difference between the
changes produced in the lungs by experimental processes and those
occurring after the inhalation by artisans of inorganic materials
consists in degree rather than in essential character. In
pneumonokoniosis the pulmonary processes are gradually developed, and
consequently the ensuing changes in the tissues represent those usually
associated with the more chronic forms of pulmonary lesions, and may
not only occasion phthisis, but during years of life may cripple the
sufferer by engendering chronic catarrhal processes in the mucous
membranes, complicated by emphysema or asthma.
ETIOLOGY.--Predisposing Influences.--Atmospheric dust is composed of
organic and inorganic matter, and both have been demonstrated by many
admirable experiments to be very widely diffused in the air we breathe.
In most instances the injurious action of inorganic dust is augmented
by the conditions of imperfect ventilation under which it is inhaled,
because the amount of dust deposited in the lungs is thereby increased.
Illustrations of this fact can be found in various avocations,
particularly among miners. The injurious action of dust inhaled when
there is imperfect ventilation is increased in proportion as there is
deprivation of sunlight, both conditions tending to lower the vitality
of the artisan. Again, the rigor of confinement of parents engenders a
sickly or scrofulous constitution which is transmitted to their
offspring, causing great mortality among the children of artisans,
especially where they, in turn, are subjected to unfavorable
environment.
When work is performed in constrained or stooping positions, or when
proper inflation of the chest is not secured, the liability to
pulmonary disease is increased.
The foregoing conditions having been considered, the injurious action
of dust upon the lungs is in proportion to the quantity deposited in
them. The {455} entrance of dust is, however, physiologically opposed
by the action of the pulmonary cilia, although the resistance is
frequently ineffectual. This inefficiency may be owing to the quantity
of dust inspired or to deficient tissue-integrity in general upon which
the ciliary action depends in inverse ratio.
Exciting Causes.--These vary materially in different avocations. The
most injurious industries are those in which the various forms of
grindstones are used, or those trades which necessitate labor in an
atmosphere loaded with particles of steel, iron, or flint. In London,
where millstones are made from French burr, a peculiarly hard flint
quarried on the Marne to the east of Paris, and more liable to chip
from its hardness and dryness than flint quarried in other places, the
mortality among the artisans is said to be very much increased.
Peacock, who has investigated this subject, asserts that in certain
manufactories of this class the average age of those engaged is very
low: of 23 apprentices the average age was twenty-four, and the longest
period during which the occupation could be followed was thirteen
years. The same author has also demonstrated the presence of silicious
particles in the lung-tissues. In the pottery districts of England the
death-rate from pulmonary diseases is greater among those who work at
that avocation than among the other inhabitants.
The study of the effect upon the lungs of the inhalation of coal-dust
is very important. In the coal-mining region of Cornwall the deaths
from chest diseases among miners is double that of males in the
community at large; the mortality of those working in lead-mines is
also very great.
The black spit of pitmen, examined under the microscope, is seen to
consist of mucus enclosing finely-divided particles of coal, frequently
presenting the special bands of the particular coal in which the
subject of the disease may have worked. The fact that coal-dust may
enter the lungs in the act of breathing is corroborated by Rindfleisch,
who, reporting for Traube a post-mortem made in 1860, found in the
fluid expressed from the parenchyma of the lung "one of the dotted
cells of coniferous wood entirely carbonized, in which he was able to
count seven pores close together. This particle of charcoal-dust
equalled half the diameter of an alveolus." Inhaled particles of dust
first penetrate the bronchial tubes and infundibula, and, entering the
alveolar parenchyma, mix with the general current of extravascular
fluid, together with which they ultimately tend to reach the lymphatic
vessels. On their way they must occasionally meet with corpuscular
elements which have the power of permanently adopting small solid
particles into their protoplasm: foremost among such elements are the
stellate corpuscles of the connective tissue, next the migratory
amoeboid cells, which are found in the connective tissue of the lungs
as well as elsewhere, and which carry the black pigment with them
wherever they go. The residual portion which escapes, being arrested by
cells on its way through the lymphatic system, is carried to the root
of the lung and enters the lymphatic glands of the mediastinum; here
the granules meet an obstacle to their further progress, for the
countless lymph-corpuscles with which the glands are stored are ready
to take up as many of the charcoal particles as can by any possibility
be accommodated in their protoplasm. We may conclude that the influence
of inhalations of coal-dust varies in different cases, but may be
considered as prominent among the exciting causes of pneumonokoniosis.
The charcoal-grinders and carriers, chimney-sweeps, moulders, iron and
glass polishers, and the workers in mother-of-pearl, all suffer more or
less from destruction of lung-function. Deposits of oxide of iron have
been found in the lungs of operators who have for years used this
substance as a polishing pigment. Merkel reports the case of a man who
was employed to clean the surface of oxidized iron by scrubbing it with
sand: his expectoration was grayish-black, and was found to contain
small grains of magnetic {456} oxide of iron; the lungs were found to
be indurated with cavities at the apices.
Many other instances of dusty avocations may be mentioned as exciting
causes. The polishing of brass is sometimes effected by rollers made of
canton flannel which revolve with great velocity, filling the air with
fibres of cotton which are capable of acting as mechanical irritants.
In the sizing process in some cotton manufactories the material is
often adulterated with clays or some sort of salt to lessen the
glutinous qualities of the flour or tallow, and although the process is
carried on in damp rooms to lessen the brittleness of the size, dust
prevails, causing irritation of the nose, eyes, and throat. Some
interesting observations have been made on this subject by James Y.
Simpson, who has especially investigated the hygiene of woollen
manufactories. He suggests that these artisans are comparatively
healthy because of the oil absorbed while running the machines. In the
manufacture of cotton it has been found that in mills where cotton
containing dust and dirt is used, as the East India varieties employed
in England during the American War, the respiration was affected, and
the expectoration of numbers of operatives contained slaty-colored
matters, found, on microscopic examination, to contain cotton fibres.
Bakers who have to deal with highly-dried biscuit flour suffer more
than those using ordinary brands of flour. But when all has been said,
when we consider how many persons live permanently in an atmosphere
specially surcharged with dust without showing a symptom of a morbid
state of the respiratory organs, and since the epithelial cells of the
lungs can contain particles of coal, it demonstrates that foreign
bodies may penetrate the lungs without always inducing serious changes.
Mineral matter has been found by Riegel in the form of silica in the
lungs of a boy aged four, constituting 2 per cent. of the ash left
after incineration. In those of a day-laborer aged forty-seven it
amounted to 13 per cent., and in those of a woman cook sixty-nine years
old it reached 16 per cent. Accepting these figures as accurate, they
show a progressive accumulation in proportion to age among individuals
breathing dusty atmosphere. Traube thinks that the changes in the lungs
of coal-miners may not be produced by the accumulated particles of
coal, but by the chemicals contained in coal, and not found in
charcoal. In a discussion of this question in London in 1869, Wilson
Fox thought it remarkable that in proportion to the number of persons
exposed to the inhalation of irritating substances the cases of
phthisis were comparatively few, and suggested that a diathetic
condition might underlie the entire pathology.
In summing up the evidence bearing on the predisposing and exciting
causes of pneumonokoniosis we cannot overlook the recent discoveries of
Koch and his collaborators, but may conclude that although there is
increasing evidence tending to show that the bacillus tuberculosis is
always present in tuberculous pulmonary processes, yet its exact
etiological relation cannot be considered as established. We may still
hold that when large amounts of inorganic materials are taken into the
lungs, particularly if the ventilation or hygienic conditions under
which the dust is inhaled are imperfect, certain diverse pulmonary
processes are apt to ensue. That phthisis can be thus produced is
undoubted, but the nature of the irritant has less to do with the type
of the resulting disease than has an inferior or scrofulous
constitution, inherited or acquired, or the indulgence in habits
directly damaging to the health; since an unvarying specific cause
would be more destructive than has been proven, large numbers of
individuals escaping any serious effects when equally exposed.
PATHOLOGY AND MORBID ANATOMY.--Whatever be the dust inhaled, the
pathological processes set up by it partake of the same essential
character, though differing in intensity and in the division of
pulmonary tissue {457} principally involved, while the combined
inhalation of organic particles may essentially modify the results
produced. Examination of the lungs has revealed deposits of various
inorganic materials which have been inhaled, such as oxide of iron,
indigo, snuff, silica, coal, carbon, etc. A black discoloration of the
pulmonary tissue, with or without induration, enlargement, and
blackening of the bronchial glands, may, however, have its origin in
morbid changes independent of inhaled matter, such as defective
elimination of carbon and carbonic acid, with a sort of precipitation
of carbon within the tissues.
The black coloration of the lungs, especially in miners, is also partly
due to the deposition of a true hæmatoidin pigment in granular form,
caused by the irritating particles inhaled setting up changes in the
bronchial or pulmonary tissues, resulting in the escape of the coloring
matter of the blood either by rupture of capillaries or from
transudation of serum. Similar discoloration is often found in cases of
chronic bronchial processes independent of a dusty etiology. The most
penetrating form of dust is the silicious, on account of its hard,
vitreous character. German authors comment on the difference in the
power of penetration of mineral coal-dust as compared with
charcoal-dust, because the spiculæ of the former are elongated,
sharpened splinters. The coloration of the lung from clay-dust does not
diffuse itself so readily as coal-dust, yet it possesses more
irritating properties and creates more damage.