Conchiolinum

Langenbeck's Archiv f. Klin. Chirurgie, XVIII, pt. 4. Inflammation of the bones (ostitis) in the mother-of-pearl grinders, by Dr. Carl Gussenbaner. Prof. Billroth has observed in his clinic during the past four years several cases of a peculiar inflammation of the bones in the mother-of-pearl grinders, to which English (Wien. Med. Wochenschrift, 1870) first drew attention. The peculiar characteristics have been defined already, together with a description of the progress of the disease, in his publications on this subject, in such a manner that the classification of this disease as a new and special one is perfectly reliable. English thinks that the occupation of the mother-of-pearl grinders itself is the cause of the disease. We had, therefore, from cases coming under our observation, in two directions, to make use of the clinical experiences, carefully collected, stating the variations in the symptoms, and thus representing the general picture of the disease, with reference to the etiology, course, and results; to verify the previous observations or to add to them. The etiology, with reference to the intimate relation of this disease to the occupation of the mother-of-pearl grinders, was, if possible, to be affirmed or proven. In regard to this, inspection of the factory rooms and close watching of the fabrication of mother-of-pearl buttons, give us most reliable information; upon this information we base our thesis.

For this purpose I visited several such factories, and came to the conviction that in all these factories, only one and the same injurious agency affects the workmen, and produces the peculiar inflammation of the bones. This injurious matter is the dust of the mother-of-pearl, which was so densely suspended in the air in all the factories inspected, that in a few minutes the clothing was gray.

These so-called "mother-of-pearl" button factories are not at all what we imagine, or like other factories, with large rooms and sufficient ventilation, corresponding to the number of workmen employed, but, on the contrary, are small low rooms, in which four to six or more turning-lathes are placed, so that the workmen have scarcely room enough for free motion. There is nothing in the utensils that can give rise to this peculiar inflammation of the bones. The necessary manipulation are not different from those used generally by turners. The only existing difference is the crude material.

Metal and wood-turners furnish, no doubt, a large percentage of the diseases of the respiratory organs, produced by dust-inhalation, but they are never afflicted by the same diseases as the mother-of-pearl grinders.

English brought up the question as to which one of the constituents of mother-of-pearl the injurious effects are due, and stated that horn-turners also are affected with diseases, and more frequently than mother-of-pearl grinders; he thinks that the organic ingredients of these materials may be the injurious agents. English does not say positively whether the former are afflicted by similar diseases, and it seems as if such cases had never come under his own observation.

Hirt and Merkel in their able work on the diseases from dust inhalation do not mention a case of an analogous disease among the horn-turners. Now, if the idea were correct, that inhaling mother-of-pearl dust produces such a disease, the mode of its action is a mystery. In what manner de these injurious effects occur? Through the production of a general disturbance of nutrition, a dyscrasia, as English supposes, or in what other way?

To answer this question will be the theme of our present paper, in which the discussion on the etiology and pathogenesis of this disease will be the principal part.

The first question, whether inhaling the dust of the mother-or-pearl causes the disease, demands a close examination of the constituents chemically. It is almost exclusively the inner layers which are worked. After the mother-of-pearl is divided into small parts adapted to the purpose, the two layers are separated by splitting, and the inner layer of the shell is used for the grinders work. The dust produced therefore by the grinding consist exclusively of atoms of this inner layer. The minimal quantity of dust produced by the steel instruments used at this work, and the wood splinters from the turning-lathes settle by their gravity to the floor, and consequently need not be taken into account.

The grinding of the shell pieces produces only a slight amount of dust, or none at all, as the grinding is generally done on a wet grindstone. It is, therefore, clear enough that the dust suspended in the workroom consist mainly of particles from the inner layer of the mother-of-pearl. According to chemical analysis of bivalve shells in general, the mother-of-pearl consists of 90-95 per cent. CO2

CaO, 2-3 per cent. of organic matter, and about the same per cent. of other salts. A reliable and correct analysis of mother-of-pearl could not be found. A knowledge of its constituents was necessary for understanding the effects of the dust. Dr. Klansen, assistant at the Pathological Institute of Chemistry, made, at my special request, a very reliable and satisfactory quantitative and qualitative analysis of the mother-of-pearl, for which I am very much indebted.

The shell of the Avicula margaritifera , which gives us the precious mother-of-pearl, consist, like other bivalve shells, of threefold anatomical and chemical constituents or layers.

First, the external or scale layers , consisting of manifold brown, superimposed scales.

Second, the calcareous layer (Schlossberger's terminology for the oyster-shells), consisting of a lustreless, chalk-white triturable mass, which is accumulated especially between the external and inner layers, enough also between the single sheets of the former, and minimal quantities also in the latter.

Third, the mother-of-pearl layer , the innermost of all the layers, possessing besides the known brilliancy of , the greatest firmness, and it is like the external layer, stratified. A calcareous substance is found between the single laminæ in minute quantities. These different layers consist, according to Dr. Klausen's analysis, of the following compositions:

I

The external scale layer : 10.22 organic substance; 0.55 HO; 89.23 CO2

CaO, traces of MgO and alkaline salts.

II

The calcareous layer : 10.15 organic substance; 0.32 HO; 89.49 CO2

CaO, traces of MgO and alkaline salts.

III

The mother-of-pearl layer : 5.57 HO, insoluble organic substance; 0.11 HO, soluble organic substance; 0.47 HO; 93.555 CO2

CaO; 0.295 alkaline salts (chlorides and sulphates).

PO3 could not be detected in this.

The organic substance consist of 16.7 per cent. (results two analyses) nitrogen. The organic substance insoluble in HO is also insoluble in diluted alkalies and acids. Concentrated boiling alkalies and acids dissolve the same, but decompose it.

Phosphorus and sulphur could not be detected in the organic substance.

The organic substance of mother-of-pearl is according to the results of analysis composed of the same constituents as all the other shells, and shows like them a great percentage of nitrogen.

It seems probable, on the simple observation of the circumstances under which the mother-of-pearl grinders work, that they constantly respire the dust, which enters freely with the act of inspiration into the bronchi, and eventually into the lungs, and that the dust enters the blood. I had nevertheless to prove by all means the truth of my hypothesis, the more as I base my conclusions upon this fact, such a doctrine must therefore be proved by the most reliable and simplest experiment.

To accomplish this I put a dog into a hermetically-closed tin box, into which by means of a ventilator the dust of the mother-of-pearl was blown; in this way the air was constantly more or less saturated with the dust. This dust I obtained from a mother-of-pearl button factory, in quantity about 60 pounds, and after being purified from the wood and steel splinters by means of a sieve, I used it for said purpose. With this quantity I continued the experiment for four months and a half, so that the animal had to inhale the concentrated dust in this apparatus four to five hours every day; the rest of the day he was kept in the dog-kennel. I thought of producing ostitis in young dogs, but could not see any results, but in regard to the entrance and accumulation of the mother-of-pearl dust into the respiratory organs, I had the best and most striking results. The dog were entirely covered with the dust, and the openings of their nostrils densely overlaid by the dust, after a stay of only half an hour in the apparatus, when full at work.

After two weeks the dogs began slightly to cough. At first I had a female dog with two pups, six weeks old, in the apparatus for the experiment; but as the pups on the 5th and 12th of August died, in consequence of a lobular pneumonia, I had to take another young dog to continue my experiments until the end of September. On these dead animals I could detect the mother-of-pearl dust in the mucous membrane of the respiratory organs, and in the parenchyma of the lungs, in the nasal, laryngeal, tracheal, and bronchial mucous membrane. I could only detect the calcareous dust on the epithelia of the mucus, and here and there in the uppermost layer of the epithelia of the mucous membrane by the microscope, and by treatment with HCl. I the lungs of all four dogs (two of them were killed) the mother-of-pearl dust could be found, not only in the epithelia of the smallest bronchia and alveoli, but also, and more prominently imbedded in the parenchyma, disseminated in particles of the size of a pin's head, and as large, too, as hemp-seed. These accumulations were discernible even to the touch as calcareous matter; they effervesced on addition of HCl. These accumulations of calcareous dust were, as the microscopical examination of specimens preserved in alcohol proves, present in the parenchyma of the lung-tissue. On the contrary, in specimens which were kept for a longer time in "Müller's fluid," and which have lost the CO2

CaO, I could by considerable magnifying, detect most minute particles of a homogeneous light-refracting substance, partly free in the tissue, partly in round cells, which was not at all changed in form or condition by adding a solution of potash dilute, HCl or HNO3 , and therefore can be taken as the organic substance of the decalcified mother-of-pearl dust, "Conchiolin." The mother-of-pearl dust must have therefore entered in the smallest bronchi and alveoli through the epithelium, or after the destruction of this into the parenchyma.

Accumulations of mother-of-pearl dust in the bronchial glands of the dogs could not be detected. These experiments have doubtless proved that the mother-of-pearl dust inhaled by the mother-of-pearl grinders penetrates the lung parenchyma under perfectly analogous conditions as those under which the dogs were placed, only that the men breathe the same saturated injurious atmosphere for a longer time each day. This conclusion is borne out by the character of the diseases prevalent among the mother-of-pearl grinders.

In the beginning of their employment in these factories the men are frequently attacked by catarrhal bronchitis. The owners of these factories will not admit that these diseases are consequent upon their work in the factory.

It seems that the men after awhile get accustomed to the irritation which the dust exerts upon the respiratory organs, and consequently cough less frequently.

Observations and experience prove that when the inhalation of any dust is constant respiratory organs become less sensitive to its irritating action, and if we remember that the quality of the mother-of-pearl dust is such that it irritates the tissues scarcely more than in a mechanical way, this will not seem strange.

Hirt and Merkel do not agree in their writings upon the diseases of the mother-of-pearl grinders. Merkel classes the mother-of-pearl grinding among employments injurious to health. Hirt does not pay much attention to it. Merkel mentions a discovery by Greenhow; in the lungs of a mother-of-pearl grinder, accumulations of the dust from the size of a millet-seed to that of a hazelnut were found, which corroborates the truth of our experiments. It would be of great interest to collect morbility and mortality statistics from this profession. Vienna would be the best place for this purpose; there are the most flourishing factories of this kind. There are about two hundred to three hundred men employed in the factories known to me.

It struck me as a remarkable fact that in each factory which I visited the employed were from the ages of twelve to twenty. On inquiry upon this subject I could get only evasive and unsatisfactory answers.

Let us now consider the etiology and pathogenesis of these diseases.

We find first, that the diseases has been observed in young people, who were not yet matured, before and after puberty. There is no case known to us where an individual fully grown has been attacked by it. After working in these factories a longer or shorter time, that is from several months to one or two years, a part of these men contract the disease. (I cannot give exactly the percentage.) Workmen attacked once by the disease are always subject to it again when they renew their work. The disease first shows itself by a more or less intense pain in the bone which afterwards becomes the seat of the disease. The pain generally comes on suddenly; in the early stages of the malady it is continuous, but after several days is slightly remittent, and is generally described by the patient as a rheumatic pain. It is strictly localized in that part of the bone in which the further development of the disease takes place. Individuals who have been previously attacked recognize the beginning of the malady at once by the peculiar sensation of pain belonging to the disease. In the beginning the pain is not increases by pressure on the bone nor by muscular exertion.

Soon after the appearance of the pain, the general health is affected, and slight fever occurs. Sick person whom I frequently attended, and upon whom I had good opportunity of making observations, had always a slight fever without chill. Increased thirst, diminished appetite, partial or total sleeplessness, general sensation of heat, alternating with slight chill (sometimes chill), secretion of a dark-colored urine, with sediment; these are the general symptoms. An elevated temperature, in patients at the clinic, condition for a couple of days, until the increase of the pain and the exacerbation of the fever make work impossible. Then swelling of the diseased bone occurs as a second symptom.

The swelling always develops first on one or the other end of a diaphysis, never in the middle of it, nor on the epiphysis . If the disease is in a long bone, the swelling develops on a strictly circumscribed spot, whence it spreads.

Externally perceptible swelling is in the beginning purely periosteal, and towards the corresponding epiphysis, as well as on the border of the diaphysis, marked with a sharp, clear, distinct margin. The surrounding soft parts may afterwards participate more or less in the swelling, and then cause considerable swelling of the affected extremities. The swelling is extremely painful to the slightest touch, like every other swelling is extremely painful to the slightest touch, like every other swelling of the periosteum. Its consistence may vary. It is at first soft, elastic, more or less distinct, fluctuating. After a longer period it becomes solid, and may become as hard as a bone. We have seen no case in our clinic where an abscess had formed, but still, in two cases under our observation, we could positively diagnosticate an accumulation of fluid by the distinct fluctuation, which had been again reabsorbed.

English mentions a case in which formation of an abscess took place. I several times saw an ossification-like swelling, which, after a shorter or longer time, disappeared.

The swelling progresses with the disease from the end of the diaphysis towards the middle of the bone; it may then spread over the whole length of it, and also over the epiphysis and inflammation of the joints takes place, which may end in suppuration.

English associates this constant occurrence of the swelling in one end of the diaphysis with the course of the nutrient arteries, and expresses himself as follows: "The disease always begins on that end of the diaphysis towards which the arteria nutriens is running; it is the point where the blood-pressure is greatest, and progresses towards the opposite end."

English comes to this conclusion by comparing the occurrence and progress of the swelling with the course of the arteria nutriens on the bones, which in the cases observed by him were diseased. English seems to think that a great blood-pressure causes the disease, or, at least, that it is one of the principal factors. It is very difficult to understand what the direction of an artery or a greater blood-pressure has to do with the origin of an inflammatory process. I must contradict his conclusions, try to define my own, and explain in brief my views upon the etiology and pathogenesis of the ostitis among the mother-of-pearl grinders.

I take the dust of the mother-of-pearl, which, as proved, enters by the act of respiration (with the respiratory air) into the lung-tissues, as the injurious agent which produces the ostitis.

The Conchiolin must be the irritant producing the inflammation of the bones. The retarding of the blood stream in capillaries of the marrow must be consequent upon the accumulation of Conchiolin in the vessels, causing obliteration of the smallest vessels, and consequently embolism. In every respect, I think the Conchiolin, the insoluble organic substance of the mother-of-pearl, the irritant agent.

The multiplicity of the ostitis in mother-of-pearl grinders has some similarity with the periostitis consequent upon syphilis, pyæmia, or septicæmia.

The etiology and pathogenesis of said disease may be as follows: The mother-of-pearl grinders inhale the mother-of-pearl dust, which partly enters into the lung-tissue, and partly is again expectorated. The dust accumulates in the lungs in small disseminate particles, and produces a local inflammation of the lung-tissues, which rarely ever shows any perceptible symptoms. It may although, in course of time, by long-lasting inhalation, occasion such changes in the lung-tissues, as follow the inhalation of any other kind of dust. The mother-of-pearl dust, consisting of CO2

CaO and Conchiolin becomes changed by degrees in the lung-tissue. The CO2

CaO becomes dissolved, and the Conchiolin remains as an insoluble substance in the fluids of the body; this gets like other kinds of dust into the circulation, accumulates in the capillaries in the ends of the diaphyses, and eventually occludes the smallest arteries and causes an infarctus. The primary osteomyelitis leads only by contiguity to ostitis, periostitis, and articular inflammation. As an osteomyelitis caused by a certain substance of the mother-of-pearl, we may call it a "Conchiolin osteomyelitis."

The ostitis and periostitis which always accompany the osteomyelitis, according to the above explanation, have to be regarded only as progressive inflammations of the respective tissues, and have no specificity for it. But if, as experience teaches, the inhalation of horn-dust produces a similar or the same bone disease, which I think very probable, then there may be also, besides the Conchiolin osteomyelitis, a horn-substance osteomyelitis.

Here are a few clinical observation:

I

Ostitis maxillæ inferioris . B. T., age fifteen years employed in a mother-of-pearl factory; also ostitis of forearm.

II

Ostitis radii et ulnæ utriusque . N. F., age seventeen years, employed two years.

III

Ostitis fibulæ sin . J. J., age sixteen years, three years employed in the factory.

IV

Ostitis ulnæ dext . D. T., age fifteen years, in factory one and a half years.

V

Ostitis ossium metatarsi pedis sin. T. G., age fourteen years, in factory two years. First time in our clinic May 20th, 1872. Second time, Ostitis ulnæ sin ., December, 1873. Third time, Ostitis scapulæ sin ., October, 1874. Fourth time, Ostitis humeri sin., ossis cuboidei sin., et ossis tali dext ., December 19th, 1874.

VI

Ostitis femoris sin . K. Sch., age eighteen years, worked three and a half years in mother-of-pearl factory.

All these cases show that the bone inflammation of the mother-of-pearl grinders always commences as an osteomyelitis , and that the ostitis and periostitis follow as a consequence.

According to our familiarity with the character of the ostitis of the long bones, must the etiology and pathogeney of the primary osteomyelitis in the short and flat bones, be traced back to the same process; that is, the accumulation of

Conchiolin in the spongy substance, and embolism of the smallest bloodvessels.

I have only to remark one fact more, that the periosteal swelling appears under analogous symptoms of a periosteal abscess, but after all we never had an opportunity to see a spontaneous perforation, but always reabsorption.

The result of the disease is, according to present experience, as a rule, resolution; that is to say, favorable. Suppuration is less frequent.

The question why person attacked once are again subject to this disease, is not yet settled, as the inflammation in general does not occur the second time in the same place, but, on the contrary, in a new place, so it may be called every time a new special disease. Strange to say, persons quitting the factories are free from the disease, but as soon as they return to work they get the disease again.

Prognosis is favorable. Nutrition is not disturbed, and, after the inflammatory process subsides, perfect health may follow.