Document 5DRrZ97MVO80bqjo2q1xMdMyD

FILE NAME: CERAMICS (CER) DATE: 1945 DOC#: CER036 DOCUMENT DESCRIPTION: Published Conference Proceedings - Discussion on Modern Conceptions of Industrial Lung Diseases PROCEEDINGS OF THE ROYAL SOCIETY OF MEDICINE i Ed mo U nder the D irection of the EDITORIAL COMMITTEE . Honorary Editors : MAURICE DAVIDSON, M.D., and ERIC A. CROOK, M.Ch., '. AiniTANT Editoi : J. M. BROWNE KUTSCHBACH, M.B, DJ.H. PAGE I VOLUME THE THIRTY-EIGHTH. SESSION 1944-45 rgoing Physical Treatment in Mental p Y AND PSYCHIATRY Mr R. BENrscii , Dr. J. H. QuAvrri. (p. 21). Mr. ,, or American Psychiatrists labilitation crapcutic Process " * * SECTION OF RADIOLOGY OFFICERS : President--. L. A. G rout, M.C., F.R.C.S.Ed., F.F.R. Immediate Past-President--N. S. Finzi, M.B. Vice-Presidents--A. E. Barclay, O.B.E., M.D. ; F. Campbell G olding, M.B. ; E. Durr G ray, M .D. ; W. M. Levitt, M.D. ; B. W. W indeyer, F.R.C.S.Ed. Hon. Secretaries--}. V. Sparks ; Frank Elus, M.B. Other. Members o f Council--Group Capt. J. F. Bromley ; G. T. Calthrop, M.D. ; S. Whately D avidson, M.D. ; Major H ugh D avies, R.A.M.C. ; H. K. G raham Hodgson, C.V.O., F.R.C.P. ; A. S. Johnstone, F.R.C.S. ; Peter Kerley, M.D. ; Jo h n B. K ing, M.D. ; J. W. M cLaren; E E. T allent N uthall. M.D. : J. Ralston Paterson, M.C., F.R.C.S., Ed. ; Lt.-Col. Eric Samuel, R.AM.C. ; E. Rohan Williams, M.D. ; Representative on Library Committee--F. C ampbell G olding, M.B. Representative on Editorial Committee--F. Campbell G olding, M.B. .ponsible for the statements made or the vie*l Tilchficld S.r., ' c,orv> LONDON LONGMANS, GREEN & CO., LTD., OF PATERNOSTER ROW 43, ALBERT DRIVE, S.W.19 1945 'y of Medicine 28 u \ x wc h a \ c f o u n d i ncl usi ons in , d as nckcusliC by Coles a n d by their rickettsial nature. We have h e al t hy adul t cattle, but we have present, tried c a h c s which have Hence of a pre-existing infection, h> not t h i n k t he di sease is, strictly 'umbers of infected ani mal s were ks in t he local cat t l e h a v e been h onl \ d u r i n g cal f hood, a n d lies tl t u n d i h o n In calves t he di sease ; ral Tox, described the following u n o . ( f immumtv conferred b\ n u i d c n c e <>f t he di sease a mo n g s t '.\;e!\ W h e n in j .i mi arv 1929, w.iv Mi ggcHrd to tli. M a n a g e r of iii\ mi n e r s a, p o s a b l e wh o ha d :cfoic. m t he 28 pr u n er s selected, t he di sease d u r i n g 1927 to 1928, d ur in g the illness T h e fortunes Tv. b\ which date this particular f o l l o w i rig t a b l e ''l t r a c t c d c r u b - .pbus beiuern 1 ebrurs 1 n d April Jo Kcmins ]0 1st cjsc b 2 29 , i H h csc lb l 29 * us uru'Tecte J , whereas it the " s h a d beco-Tie infected ;e poiject was an economic one. deugned to demonstrate residual scriouslv ra c ed SC. (he results the rule 'f en a rase of a second attach in of cases Yet second attacks are 'most i nvar i abl e wi t h t he qual i fvnlder than the initial attacks i. t he Pr esi dent , D r Lcwt hwai t e m m u n i ? c d a liorse over a pcricxi u r u s by the intravenous route h o r a t o r v ani mal s , and h a d given m a n cases it h a d failed to modifv mid ati opportunity to treat cases well ha ve been, as D r Fel i x had antibudv content, m ad e in the control of rickettsial y i should be taken of the excepand allied infection, Rickettsia f vet er i nar y as well a, medi cal Sectional page 17 Proceedings of the Royal Society of Medicine xx9x '>in Section o f Radiology P re sid en t-- J. L A. G r o u t , M.C., F.R .C .S.E d., F . F . R . [January 19, 1945] DISCUSSION O N M O D E R N C O N C E PT IO N S OF INDUSTRIAL LU N G DISEASES Dr, Charl es L. S u t he r la n d . In 1931, Professor E L Colhs read a p aper to the Section of Epi de mi ol ogy of this Society ent i t l ed " R e c e n t V i e w s on P n e u m o n o c o m c x e s " (Proc R Soc M e d , 2 4 , 531) I do n ot 'p r op os e to bring this general review up to date, but this meet i ng of t he Section of Radiol ogy offers a sui t abl e oppor t uni t y to discus- the role of radiography in the diseases due to dust inhalation, in industry. As long ago as 1907 S u m m e r s of Bendigo, Austral i a, first poi nt ed out th'- value cf X-rav exami nat ion of the lungs in the diagnosis of pulmonary dust disease Soon after wards at the Ra n d gold mines in South Africa its extensive application to the diagnosis of mi ner s ' pht hi s i s for t he pur poses of W o r k m e n ' s C o m p e n s a t i o n est abl i shed it on a vers Strong f o u n d a t i o n Rut this Sout h A f r i c a n exper i ence, whi l e it is verv ext ensi ve, is, ,i! t he sa me t i me, verv rest ri ct ed in t h a t it relates to one par t i cul ar occupat i on a n d t he pecul i ar wor ki ng condi t i ons i nci dent al t her et o, \17 t he u n d e r g r o u n d dr i l l i ng in t he g o l d bearing q uar t7 In this countrv, on the oilier hand, there are numerous occupations in which the workers arc exposed to dust i nhalation Not only do them occupations differ from each other in the quality and quantity of the dust cloud, but in the same process or occupation [her- arc cquallv wide variations at different working place, and different working times T h e phvsi quc of the individual w o r km a n is also a variable factor I: is ther efor e not advi sabl e f i om t he r a d i og r a p h i c evi dence alone to draw concl usi ons as to diagnosis and prognosis of t he p n e u moc oni os e s, all t he ot her cvid-ncc, cspcci al k the duration and intensity of the dust exposure, must have due consideration T h i s is m a d e verv clear m t he A n n u a l Re por t for 1943 of t he Seme. Me di cal Inspect or cf Fact or i es ( Dr M e r c w c t h c i ; ' E s s e n t i a ! for t he correct i nt cr prct at i >n of m a n s X rav .ijijKarauces whi ch mav be ascri bed to t he i n h a l a t i o n of i ndust r i al dust s (or fu.mcsi is a vers detailed knowledge of the processes which mav be causative of the character and amou nt s of the dust evolved, together with a most careful investigation of the work of each indi vi dual concer ned since first he ent ered industrv This often requires a knowledge of ihc progress of and c h a n g e in a part i cul ar process, since present disease mav be due to antecedent conditions of work, long since remedied "Still mor e is this essential for d et er m i ni ng the weight which sho ild be attached to such a bnor mal appearances both as regards the outlook for m e individual and the advice which should be given to him and in assessing the need for and nature of am preventive measures in the process Admi tt edl y, with the exception of silicosis and asbestosis, vve ar c onl v t o u c h i n g t h e fri nges of k n owl e dge of t he pn e u mo c o n i o s e s T h e r e is, however , al ready sufficient evi dence t h a t a b n o r m a l X- ray appe a r a nc e s whi ch mav be di scovered in wor ker s exposed to d us t or f u m e s but whi ch arc r o t caus ed bv n o n occupational diseases, do not always signify any present or i mp e n d ng di st ur ba nc e 1of health, still less should they be r egarded as necessarily signifying 'he existence of a definite occupational disease. T hey may, and often do, indicate exposure to an industrial dust, but that doe< not necessarily imply the existence of a pneumoconiosis, or disease, or present or future disablement, any mo re t han the discovery of asbestosis bodies in the sputum bv itself determines anything but exposure to asbestos dust, and that not necessarily to a significant degree." Dr Mcrewet her mentions two conditions, asbestosis and silicosis Whilst asbestosis occurs amongst workers in a limited n u m b er of occupations mar. pulating asbestos, silicosis on the ot her h a n d is widespread because of the n u me r ou s occupations involv ng t he h a n d l i n g or b r e a k i n g of q u a r t z , flint or st one wh i c h cont ai n free -J11ca SiO. in l ar ge proportion. T h e characteristic action of free silica in the lungs has been closely studied bv workers in all parts of t he world and definite conclusions reached as to its effects, if not as to its mode of action. T h e r e arc, however, many industries which involve the risk of inhalation of mixed dusts cont ai ni ng silicates and small p-nportior.s of free sdica These mi xed dusts produce effects which differ from those of free silica T h e r e J i l y -- R ad 1 of Medicine 18 d dusts as merely silica effects i constituents. Certainly this 'ungs to come within the scope 11 v. in which silicosis is defined mt most dusts which have prouiic percentage of silica so that .mdemn any other substance as ical silicosis" and it is found in ioder. Free silica produces a n, the silicotic nodule, scattered the nodules stand out from the a larger mass by the fusion of is connective tissue. It contains egated on the periphery of the non to the amount of dust; as idant fibrosis. Throughout the there may be some emphvsenra .me inflammatory thickening of n or "snowstorm" effect on the ubrotic nodule. Occasionally in ith a corresponding increase in . c so contracted as to throw a pace between the nodules there i. but no striation is ordinarily .c extent a final result; it marks iar morphology is explained by nrst instance tends to collect in f nodulation gives us the first classical silicosis in this country licsc years the worker has been vals. The defensive mechanisms .st of the inhaled dust so that lis, and even pneumonia, it takes ge or numerous or mature to be . (1935) recognizes radiographic narked linear striation " or " in!ic general opinion is that linear pccifically diagnostic of silicosis, ten show tvpical nodular fibrosis ;.iv be found without such radioi is followed bv definite silicotic g on a single X-ray examination me, there is a risk, as one Amerising a "stage of imagination." v not be nodulation, particularly knowledge of the processes is of .t cf dust reaching the tissues of of time required to produce the resulting fibrosis. In the sandthc disease developed in two to .1 event was the development of ut. the lung may be " effectively mity of silica to produce silicosis, [ost-mortem examination. This >g and Belt (1938) in Northern hie findings. Watkins-Pitchford .. specific signs and cannot there in say; " It is probably associated 19 Section of Radiology 521 radiographically with some increase of the shadows--both dendritic and reticular nor mally cast by the connective tissue of the lungs." ., , . .. . Significance of classical nodular silicosis.--When one has to deal with the individual workman who presents the radiographic picture just described two aspects have to be considered: in the first place, his ability to work, and, secondly, the prognosis. The radioeraph, whilst it reveals to us that damage has been done to the respiratory capacity, does not tell us what reserve power the lungs possess. The clinical condition therefore is the chief factor in assessing the physical capacity of the worker. Very often the man is fit to carry on his present occupation but would find it difficult to take up a new one, yet he may be advised by his medical adviser to leave his occupation. This may be sound advice on the principle that the first object in treatment is to remove the cause of the disease In this connexion Dr. Mercwether's point that present disease may be due to antecedent conditions of work, long since remedied, should be carefully noted. . . Dominating the prognosis is the possibility of the presence of tuberculosis or its inter vention later on. Every case of silicosis is potentially a case of tuberculosis; the him m ust therefore be carefully scrutinized for any indication of infection. Here too tne clinical condition and history may be of profound importance. But while we know that 60 to .0*, of those who die of silicosis have also tuberculosis, a great number of the sufferers lrom silico.-is live on for years and carry on their work, to die ultimately of the ordinary illnesses of mankind. This is especially so in industries such as the potteries, where silicosis affects the advanced age-groups. Pneumoconiosis of coal miners.--In the coal mining industry there are a great many occupations where the workers are exposed to the inhalation of dust There is a great variety of dust and mixtures of dusts in the different coal-fields, and the indiv idual collier may be exposed to a different tvpe of dust according to his place of work. Moreover the actual intensity of exposure has increased of late years owing to the more intensive methods of mining. The collier has become dust-disease conscious so that the radio FIG. I.--Dutt reticulation in coal miner's tuna. logist in a coal-mining district is being asked to examine an increasing number of chests. The law has made the condition a compensatable one. A Special Scheme under the Workmen's Compensation A a s has been made providing compensation for coal miners in respect of disablement and death by pneumoconiosis and pneumoconiosis accompanied by tuberculosis. Pneumoconiosis in the Scheme (1943) is defined as " fibrosis due to mca dust or*other dust and includes the condition of the lungs known as dust reticulation . The lung conditions found in coal miners may be divided into three types: dust reticula tion, nodulation, and massive fibrosis. , , , *' Reticulation is probably the effect of simple overwhelming of the defences of the lung* bv dust of respirable size. The lymphatics become packed with dust cells and localized accumulations of 3ust and dust cells appear which have been called 'coal nodules by 522 Proceeding of the Royal Society oj Medicine 20 Radh.'nn (1936 ai.d 1939) Focal e m p h y s e ma gives a h o r .esco mb ed ap pear ance to the cut r u r face . licit (1942), b\ using a special silver stain, sh ooe d that the dust-laden phagocytes in the localized a ccumul at i ons were hel d t oget her by fine r e t i c u l um fibres. T h e s e fibres are produced in just sufficient n u m be r s to do this; there is no r edundance as in classical sili cosis H e claims t h a t t he c ondi t i on is a fibrosis a l t h o u g h t hat t e r m is usually reserved for col l agenous fibrosis. It is also c l a i me d , since t he d u s t is c o mp o s e d of s ome q u a r t z as well as silicates a n d coal, t h a t the fibrosis is a silicotic one But r eticulation can be p r oduced in eight scars or less, a short er peri od t h a n t h a t in whi ch we expect to find classical silicosis But wh e t h e r we call it a fibrosis or not, it is unl i kel y t h a t t he r et i cul ar fibres pl ay m u c h part in producing the X-ray picture of reticulation; certainly not the part the collagenous fibres plav in producing the appearances of silicosis Accordi ng to C ou g h (1944) the X-ray picture is p r oduced by the supe r i mpos i t i on in d e p t h of t he coal nodul es on a flat film T h i s of itself mi ght not be sufficient, but there is a contrast effect due to the accompany in g focal emphysema T h e question of radio-opacity of some of the dust must not be forgotten T h e di sabi l i t y caus ed by r e t i cul at i on is usual l y of t he very sl ightest, m m a n y cases it is difficult to make out any disability at all Reticulation has been rather slightingly referred to as " old colliers' l ung " b u t c \ c n in old colliers t he possibility of it bei ng p r o d u c e d in a rclotiveh short period in rcient scars must not be ovcrhxiked C u n i m n s (1936) and mans oihcrs since ba s e pointed out the i mport ance of e mp hy s em a in causing d s s p n t c j in coal miners T h e r adi ograph docs not give us m uc h assistance m assessing this except perhaps that serial films ma y show its de v e l o p me n t at the bases In some of the yo u n g e r coal mi ner s there is a distinct t a c hyc a r di a ( Keat i ng a n d T h o m a s , 1939) but tins appear s to be f unct i onal since so far it has not been r el at ed to a ny car d ac c h a n g e or to t he de gr e e of retie illation X o d u l a t i o n -- T h e pathological condition, winch gise rise to the nodulation arc three in tiumher First one meets with classical silicosis in pit sinkers, h a r d headers, emitters, br ancher s an d st onc me n, all of w h o m m a y h a s c to drill in silica rock Such workers, howescr, mas drill In ot her strata so t ha t we cannot say t hat all fall sictims toclassical silicosis Secondly ther e is a mi xe d f o r m of silicosis, the m e d u s a - h e a d type, wher e t he r e is a collagenous fibrosis accompani ed by dust deposition A third form mas be due to coal nodules of larger size than in reticulation T he radiographic appearance seen caries from the classical c.i, s'orrn to the doubtful nodulation seen in reticulation An interesting variation 's that of cere tine ncxiuhtion almost a suppling N o d u l a t i o n ma y pr ogress to mas s i ng the t ype f o u n d m st one wo: hers r u n s t he ordinary course of classical silicosis A/ussr.e f ibroin in its advanced form presents usually one or two masses placed centrally in each lung, with large emphysematous bulbe at the bases and sometimes also at the apices On cutting these cricket-ball or sausage masses, cither a glossy black surface is f o u n d or a ragged black surface similar to t hat f ound on a br oken ' ' b r i q u e t t e " S o m e times the whole interior has broken down into an oily black fluid Massive fibrosis mas be less in degree a n d be present in different parts of the lung It ma s be a c c o mpani ed ns n o dul at i on Mi croscopi cal l y it is difficult to m a k e out t he s t r uct ur e owi ng to the a mo u nt of dust T h e cause of t he f o r m a t i o n of these masses h a s been ' ' mousIs ascri bed to- (1) Bl ockage of l ymphat i cs by silicosis f ol lowed by excessive depos i t i on of d us t in one ar ea (2 ) Coalescence of no d u l e s , this is rare, wc do not often find a m a r b l in g of the cut surface of t he mass. (3) I nfect i on, p a r t i c u l a r l y t uber cul osi s c i t h e r pr e- e xi s t i ng or s u p e r i mp o s e d on d u s t fibrosis i' he liquef act i on of the cont ent s of t he inter ior of t he mas s is often considered a ma n i f e s t a t i o n of tuberculosis but it is difficult to find t he o r g a n i s m in these cases (4) I rr i t at i on, ei t h e r caus ed by t he dust or by the dust along with some infection, the mass ssould thus arise dr noio without a definite preceding stage A h ho ug h one frequently finds colliers working regularly who show these masses, the prognosis on t he whole is not good Mos t of [h_ d e a t hs d u e to pneumoconi os i s certified by the Siucosis Medical Board are in this stage Tuberculosis may of course be found with reticulation, n o d ul a t i on or massive fib;osis, but it is often difficult to pr ose T h e cause of t he coal m i n e r s ' pneu mo c o n i o s i s h a s still to be as cer t ai ned, bu t t he r e is al most gener al acce pt a nce of t he view t h a t silica pl ays a large part , a l t h o u g h its act i on is modified by t he ot her dusts T h e silicates pr esent arc not yet a c qui t t e d entirely and the coal has been held responsible by some because t rimmer s who work only in coal suffer from the disease But as Belt points o . ', coal contains silica and silicates, and trimmers lungs contain no more coal than some colliers' lungs In the past the peculiari 21 ties of coal mi ner s m e . , -: c hemi cal an.a'.y sis of I m p s . < L U G a r d n e r s p m i c , ; 1 1 ; . ends to cont ai n mor e tut d over which most of the 1 tissue is of no di agn i sm n silica cont ent of t he s n . u ' -- t silica in l ung tissue is wu susceptibility to tuberv,. n di agnos i s mu s t rcniawi or, r a c hemi cal analysis. A c..: g r e a t e r value. Giovi.c i 1f , give conclus.se esidu.ee Im React i on lo ot her i!.,> -s p r od u c i n g effects some'- Mu m m e r s In cases rcyx-'i reticulation and lo that <' t mal l oral t he cc t ; >, ' u about 3' , iron A ten c. 1940) show a r e ; -< u!a'i r t ' One case of death i n m p ei ght sears has been, r t y f o u n d Vas a s, f| p oc n f ' was less ,1 ,'kcd A a , ' ' ' In cuT-ras; to the m u f o u n d US a rc' i,!' of t a U. til. r.,-1 In. an, i r . c -' . 1 excessive r et i cul at i on as ' to a l u m n a a nd s\ as the: d u rain nu n \s orbs P J,*C ` A l t h o u g h t he ani. n, v . m i n i n g , t her e is ::o he t ' R e r a n , , a to eii, s;s l a 1 AS.t h h GO' 3' AC ss r k t : t. hit ion h a s t been xl'. ' animal c\p; :s ! 1j ' r ed. o o p e .'(.* d 1'! c I : ahi ement Boiler u alt r- iron dust in mar.v t o o * dressers and i cnl trs arc c t i me th.cv devel op a sev c n of the arc welder- Th'-r- . m a s merely m.d.catc tr c the moment a -nod deG ! of steel a n d . .. 1 ' so ' shadows found rad, grip' - find these even althougo React i on to d i n t of f `--c asbestosis H e r e o i a r ; tr ' leading to dilatation, the [ a an interstitial fibiovs ac,; ; as a ground-glass a ppei r an c h a n g e s usually occur v- i--. this s u p p l i n g t her e is a n ei t her f r o m t he fibre- t r ::c ; Asbest osis is not pro-.:,, effect, since verv finch . injected in an.mala The , of the characteristic c'" m In the preparation, of u Silicosis and Asbcstisis M o Factors D ep ar t ment of t' Dr S R C l o s n e , Dr 11 ; Grout, and this ass.star.ee i c2i Proceeding* of the Royal Society of Medxcinp 22 ' REFERENCES ] ' C / r ! A V ,, C .'1936, ] ICO) Rep / V pubi H i m ,V 5 IT B IL 'I.T H [`ath B a a , 4 9 . 3 0 ------ M1142; S p t c Hep. S r r med H a Cc u r , No 243 C A M P B E L L , A H , and C L O Y N E , S R (1942) 7 r a t h Baa , 54, Cx-al .Mining I nd uu ry (Pneumoconiosis) Compensation Scheme (1J4J, S R & O No b-j C U M M I N S , S L (1936) J. H yg , 16, 517. L E A N E R , S (1041) Lancet (in, 417 D O I G . A 1 , m d M c L A U G H L I N , A I G (1936) Lancet ( 1), 771 Dus: m Steel Fo un dn c i ( 1044) H M. Stationery Office. G A R D N E R , L. U , i n d R E D L 1 N , A. J. (1942) 7. tnuttr. H y g , 2 4 , 125. G L O Y N E , S R. (1930) Fcr*on*l co mmunie* ' on. G O U G H , J. (1 944) R e p o n of the Advisory Committee on the Tretment *r.d Rehab ditino n of M.r.ers in the u V e Region suffering from Pneumokoniosis. H M St*uonery Office H A R D I N G , H. E (1W45) A m . 7 mdustr. M e d , in press , w , . H U N T E R . D , M I L T O N , R , PER RY , K. M A , and T H O M P S O N , D R ( 194 4) B a i J induttr M e d , 1, lo9 K E A T I N G , N , *nd T H O M A S , R. W. (1919) Personal communicauon K I N G , E J , and B E L T , T . H. (10,M) P h y n o l R ev , IS, 329. M A Y F O G O R D A T O , A (1926) Pub! S A j r In ti med R ts , J, N o 19 M I D D L E T O N , E. L ( 1910) Proc. Internat Comp S .-sis, London Report of the M i n e n ' Phthisis Medical Bureau (1935) Govt Printer, Pretoria S A M P S O N , H (1937) Third Symposium on Silicosis, Saranac Lake, N Y S U T H E R L A N 'p LC _ L , M EIK LEJO H N , A , and PRICE, F. N. R (1937) 7 VT AT KI N' 5- IT TC HF O RD , w . (1927) 7. xnduur Hy. g. 9> 199. U'crkmcn's Compensation Act (193U) n M. Stationery Office du vr H j g , 19, 312 D r Ri c h a r d Fawci t t Radiological aspect [A b r i d g e d j -- It is impossible to arrive at a t r ue i n t e r p r e t a t i o n of t he mmo i m sh a d o ws e n v i s a g e d m t he X ruv pi m 2 r -` P h w 1 h o u t (omplctc cooperation between clinician and i.cb'dugist, and an cxbai: tiv c r,cc u p a t i o n n l historv of the patient Di Sut he r l a nd ha already stressed t l m po n t . SO, t o o , h a v e Pendergrass and others including myself Loc h radi ol ogi st views t he subj ect f r o m t he t \ p e , or u p ttv >f t i ' t s u h c h o < c u r s ; n his own neighbourhocKi. and whilst \arious lndu-une give i nc to a ch 1 r a c t c n v 1 1c r , k ! : o - M ph pne ui noconi ouo p.asms f r om initial infect i on, or m o w i o n , to oh:: rr-iii;h w h i c h th e d c ;ia n u rc f r o m d m earthlv sphere, be he tuncmaon, coal or iron-ore miner, or boder-sealer, Ac , but wi t h subt l e ciifTeience*. 'I he progress as s hown in t he r a d i o g r a p h s is g ove r ne d and varied by occupation and incidence of extraneous influences and infections I propose to show and describe a series of illustrations in one particular industrv to exemplify a tvpc and point out individual variations and sonic of the pitfalls in differentia! diagnosis These are legion T h e first pitfall must assuredU be traced to faulty r adi o graphic technique, the ordinary standard P A chest radiograph should he taken in the first place a n d followed, wh e n i ndi cat ed, bv films of var vi ng K V a n d position, to d e m o n st rat e cavi t at i on, 01 t he t e x t u r e at t he bases of ernphv s e ma t o u s l u n g ' , for e x a m p l e T h e chest m e a s u r e m e n t a n d gener al bui l d of t he pat i ent mus t be u m - i d e r e d a nd al l owed for T h e r e is no s t a n d a r d e x p o s u r e -- but t her e is a * a n d u r d r a d . " g r a p h T h e expos ur e is indicated bv intelligent observation of (lie pattern T h e upper and lower portions of the thorax mav need a different radiological technique T h e presence of the female breast shadows does not exclude the existence of " dust" disease T h e onus of errors n diagnosis must not be cntirels laid at the door of the radi ol ogist T h e request " X-rav chest, p l e a s e ' ' ' is not good e n o u g h G o u g h lias rightlv said t hat " it is under st ood t hat the X-rav picture of r eticulation can be pr o d u c e d m the n o r m a l way bv c h a n g e in t e c h n i q u e " M u c h i n f o r ma t i o n is ga i ne d bv careful r adi oscopy T h e greatest n u m b e r of the pneumoconioses would apnear to fall nun certain clas'ifica- t.ons, t he one usually cventuallv m e r g i n g into its successor m t he d o w n w a r d progress of the patient T h e classification of H a r t and Aslet t (1942) b gcncral l v accepted, namel v fed N o r ma l , (b) ret i cul at i on, (c) no d u l a t i o n , {d) coal ement no d u l a t i o n , (e) massi ve s ha dows (/) mul t i pl e fluffy s hadows, (g/) local gross fibrosis of u n c e r t a i n cause; (h) l un g fields eq u i v o c a l -- t he l at t er two bei ng classified as i ndef i ni t e-- a verv cons i de r a bl e g r o u p in m y opi ni on T h e categories (c to f) have been gi ou p e d together un d e r the hea d in g consolidation, categories (d to /) being termed major consolidation This classification differs little from that used In the South African authorities for silicosis a m o n g gold miner s on the Ra n d (Simson. Strachan, S under land and Irving, 1930, Miner' Phthisis Medical Bureau, 1939), from that of an A m e r i c a n C o m m i t t e e ( Pancoast e l a l , 1935), f r o m T w m i n g 's c o m p r e h e n s i o n of the condi t i on (193S), and, in its earlier stages, f rom the app e a r a n c e seen in the p u l mo n a r y m v e w e s cf agri cul t ural workers (Fawcitt, 1940) an d a m o n g s t haematite i ron-cre workers (Stewart and Faulds, 1934, Fawcut, 1943) or from that seen in occupational disease of the lungs in boiler scalers ( Dunner , 1943, D u n n e r a nd H e r m o n , 1944) a nd manv ether Once a g a m let it be stressed t hat t he progress f r om one stage to a n o t h e r is a gr adual one in some cases, and in some of mv illustrations t he occupational history and C'.mca! course cf the case belie the radiological appear ances Ea c h par ticular stage has 23 ,ts p tfa'X in the mated, to me ext ent a u r ( h a m of pr ogress is gemm. r adi oi ng. cal pi ct ure woh uh. dust expos ur e is an a!! m p of the radio-opaque dusts, di s e as e-- m a y occur verv n or ga ni c " d us t i nf ect i cr , m. logical evidence n u ) he a 1 | l ) 4 i hs*A -v> V FIG 2 Wl ! [The author showed a to illustrate the chain <f t H x m a t i t e iron ore exim bv Thurston Holland Sunder, Stewart and Fa d be found m u previous p experienced workers in 1. lung Ma ny of ihe f-dk F ig 1 demcnslra'es D' received severe crus'".-,. Stage of re!ict-(c:mo - lace-nke pattern, smnetm rr.av occupy cnly par t cf api ces being c e m p a r a t . '. e as close to the k 1ia I is to be d.fferer.tia'ed fm of t he pa t t e r n ci t we v m s t r u c t u r e s cf t we a r ' e r . - s effect. r .VJ G Proceedings of the Royal Society of Medicine 24 '-'rt.-ved l ung mar ki ngs, or l i near mar ki ngs , tend to s p r e a d out or rad:n*e iron*, the h h a a nd are riuamly venous shadows. Tr.is has been d e mo n s t r a t e d by H e r mh e a s e r a nd m an u n p o b h s h e d wor k bv Lodge Co mme n c i n g ret i cul at i on is s hown in. F ig 2 --T. W . aged 51. F o u r t e e n ye a r s f a r m s e r v a n t Ni net een y e a r s in haematite i r cn- or e mines, t he ore bei ng oily a n d of low silica c o n t e n t No p u l mo n a r y disability. F ig 3 -- J. W., aged 62. A gunpowder worker, worked 40 years making black powder In the process, charcoal, brimstone and saltpetre are employed and ground up to a powder in the mills--the powder is polished with blackload The reticulation seen in t he r a d i og r a p h is ver y pr onounced and one wonde r s whi ch of the four ingr edients empl oyed ma y be r adi o- opaque . He di ed at t h e age of 70 f r om p u l m o n a r y t uber cul osi s No P M. examination. I IG. t> FIG. 6 FIG 8 Fic 4 (J verging on B , aaged 53) snow is illustrative of the per manency of the appear ance a: r et i cul at i on five wiiake mottling Worked in iron-ore mines for months--since County r oa dm an for over thirty years seven >ears On machines Very well ' Chest expan- s;on 3} In F i c 5 J. R , aged 56 Shot finer. I r on- or e l a b o u r e r ei ght y e a r s Shot firer t hi r t y- t wo >ear5 in coal mines (reticulation) No machines. Some dvspnoea The radio opaque dust (iron) tends to monopol.ze the picture. ir.e ra aio opaque Si cqe 0 / n o d u l c l i o n .--Th e so- cal l ed st a g e c l n o d u ! a ` i on--or in some t r ades oi a vaar ent r . e d u l a t i o n - i s in my opi ni on t he vi l l ai n o! the pi ece as f a - as -'confus ^ " 7 n i - "e r o r e t r tm.n of t he r a d i o g r a p h s Is concer ned The a p p e a r a r - e represem an apparently innocuous condition signify C ' h o 'o T , o} & J pa. no. ogy o. oo.' Lnoodauulieesl CC?t oo dqauI of e. el e T wi n i n g --dt hfeyofa, mr ei ons'ai d t1o0 atphpe e aSrKe5(1)o! "trhoeu nidmt tihale dreovoet l oopfmei snt : h e Kl L g b b o C ( ^ n U n <PK b C^ SV C P f " d ^rp a s s ) ; (h> ",n t he u p p e r lung fields bet ween e .ung roo.s (tuitin, Kleicmet. Kast'.e, cit As s ma n) : (3) "in t he l a t e r a 1 mm'-fields" o b k e i S)C EIr!,,d " l n .the l at eral middle regions"; (5) " m the l ower lobe' " (St aub exr)erlt: rlcV mostly amo n g s t stonecutters, nodules ar e seen e l r l y a V x o f C i e fewer l o l 4 ,Sea5e 3 ` (1) l he ^ ' ^ l e r a l r egi on cf t he u p p e r lobe ,2) V e 00 F r o m rr.\ c a n " il c - `. r e r i ght lung is t ^ e a ' e a w t u t whe r e coalescence m ->s , 1 sematite is universal ver> * T h e typical radicgrup.n cj effect--a nd ls seen m m a n , dust infections, 1 * is seen sa lable (mycotic) invasion The s ha dows pr oduced c> are discrete from one ar.of It is the next st ep be;, one (true nodulation) is an ins c accept this theory The typt; s ome t i mes of var yi ng deruvG It is only possible to don di f fer ent i at i on, but t her e i> a : organic and organic dusts ;r n o d ul a t i on to c o a l e s c e s r.f-d ( f d a n g e r is r emoved, l>cco n the organs dust appears _ [ ' Ogr ess to br ooch ectaws i th.c a p p e a r a n c e cf r . oduhoi o As mor name dust ' dmea * ma r k i n g s or so called 1u:ag < i ilar shadows become less lis to a ` \ c r v m j m e d degr <een. ruptured capalo mm..o heart is frequenti) narrow a this <n m asbest oos I' madows v :h an j'ci : however, develop the changes mas be observed me F' u rt h c r m o re , if t he p a n e : r ma t r ach cal gl and or gland* . i to view 7hn> gl a nd cor t* T h e org.imc dust d.^as'*carl v stage*, n . v i d y at t he h F ig 6 --A G He re .5 : s he ns. 5 fcu* to C e parc c es Fi c 7 is a section fro-- G'e wor ke r --*he part i cl es c f . F ig 8 --Bv wa> cf c c n f a s a!so in a haematite 1ren ere w It is of note how ve.m c' i Sander, 1938 and 1944 L o g } e r mc o 1544) s . r d a ' e Af Fic 9 --J L F a --, wo*/, e .h 1b . Ps a sof er tv pe of r general affected T r e me", particular case made a s'cw : In mi har v t uber cl e t w,e n: t) r oughout both lu'-gs A e a, rr i sl eadmg Fic 10--Second ar> c ^ c c s.derably mere discrete 7~en- F ig II 13 a case cf s e c c n : inspect ion reveal s t h a t mom. k dney). The changes seen in Eoeoxk wi t h e r> th e m a n 0 d c s u m <K e It is not unusual to fhui r. who has worked in several r which the commones t is t u l c Vi.lue in such cases, a r .so : m di cat mg the existence a su F ig 12 -- W J W . Fmrew. d( nse bar d m 0 11!1 n g c f Sii c t: e Ra n d ; and1 t he coo jscen' McW . s `eel d ress e r su cw a* ahr e s t 1 d e r'.heal rad - g "-G Dr S u t v:e r1a n d has > r. 11 d :rc n cc r.'er. SjSg Medicine 24 id out or radiate from the ibhshed work by Lodge. ' meteen years in haematite u) pulmonary disability, cars making black powder, oved and ground up to a l The reticulation seen In c four ingredients employed nary tuberculosis. No P.M. I FIG. H . appearance of reticulation seven years. On machines Very well. Chest expan ears Shot firer thirty-two spneea. The radio-opaque some trades of apparent "confusion" in interpretaiay signify pathology or of the initial development i "round the root of the v upper lung fields between >n the lateral mid-fields" "in the lower lobe" (Staub 's. nodules are seen early of the upper lobe; (21 the 25 Section of Radiology 527 From my own'personal observation, the postero-medial region of the upper zone of the right lung is the area where not only nodulation is first seen in haematite workers, but where coalescence most generally first occurs; but the "staining" (so-called) of haematite is universal very early on in the occupational history of the workman. The typical radiograph can be best described as snowflake mottling or snowstorm effect--and is seen in many dust infeciions--it is also seen in other than inorganic dust infections; it is seen associated with organic dust, as the result of bacterial or vege table (mycotic) invasion. The shadows produced by nodulation have an Irregular and ill-defined margin and are discrete from one another--they are described as being 2 to 5 mm. in diameter. It is the next step beyond reticulation and accordingly is associated with it--its onset (true nodulation) is an insidiously progressive process. Some other observers do not accept this theory. The typical silicotic nodule Is more opaque and of sharper definition, sometimes of varying density. The distribution is generalized as a rule. It is only possible to demonstrate a few of these cases and illustrate some points of differentiation; but there is a marked difference in the behaviour and picture of the in organic and organic dusts at this stage. Whereas the inorganic tends to progress from nodulation to coalesccnt nodulation, or, as in the (doubtfully) inert dusis when the source of danger is removed, become stable in appearance in the absence of superadded infection, the organic dust appears frequentlv to miss (he stage of mottling of this t)pe and progress to bronchiectasis of a massne variety, or, if the source of infection is remoied, the appearance of nodulation may disappear. As _ inor_ganic dust "disease" p--rogres-s-e--s, e- m p h y s e m a t e nds to increase, t h e sascul ar mar ki ngs or so-called l un g definition being lost in m a n y cases in the loner zones, the hilar s ha do u s become less ei l den t and the excursion of the d i a p hr a gm diminishes, e' entu- ally to a scry mar ked degree. Adhesi ons in the region of d i a ph r ag m arc c ommo nU seen; r u p t u r e d e m p h y s e m a t o u s bulLa: m a y g i \ e rise to s p o n t a n e o u s p n e u m o t h o r a x . T h e heart is frequently narrow a n d displaced or rotated, and the borders blurred, particularly is this so in asbestosis. It h as Dccn o b s e n e d by A m o r t h a t an i ncrease in the hi i ar shadows with an associated tachycardia may indicate a mixed infection. Manv men, however, d o clop the hypertrophic type of heart and eicntitaliv cardiac failure. ` These changes may be obsened radioscopically. ' Furthermore, if the patient be rotated into the oblique position, an enlarged tell-tale paratrachal gland or glands, likened in appearance to a short sausage, mav be brought i nto view. T h i s g l a n d c ont a i ns silica ear l y in dust inf ect i ons ' T h e organic dust diseases, such as the p ul mona r y mvcoscs, show r m p h v s c m a in the early stages, mainly at the bases, but frequentlv generalized. ' Fm. 6.--A G. Here is the typical mottling of haematite iron-ore This is not due to silicosis, but to the particles oi iron in the walls of blood-vessels and the interstices oi the lung alveoli. This man died from mabgnant disease of the stomach. Fic. 7 is a section from his lung--unstained--the typical red lung of the haematite ironore worker--the particles of iron are seen (see Craw, p. 30). Fic. 8.--.By way of contrast, the denser, more sharply defined nodulation of silicosis, also in a haematite iron-ore worker. F.arm w?rker..i"fected (rSqaitnndaoerr0, ^1ia913->08o^a0n?dSWto9a4'4/..r^Dr-\oCi*gOSaelnvdj `MfcLraauthgohlloing,ica1l936a)ppaenadranbcoeislerinscealleecrtsric(-Daurcnnwereldaenrds Fiermon, 1944) simulate the haematite iron-ore workers. Pnicillium s p . occurring in mouldy grain, gennierrLaVl affected. VTTh*e m01o.tIt?li.0n1g111?is nwo,tthsoemwpehllysdemefianteodus tolwunagrdsbatshees, pmen.dp-hfieerldys. mTohries particular case made a slow but ultimately complete recovery. bFrc,e tbe nodular appearance is more discrete and evenly distributed misleading bo*b lungs, the apices being equally affected. An atypical case may be very .T 10-. ,10- Secondary carcinomatosis--the nodulation is usually much larger and con siderably more discrete. There are other types, of course, where the nodulation is smaller. is 8 c,as<L oi. " conda/y,adenocarcinoma of fine type of mottling, but careful kidney1)00 revea s most f that mottling is in bone (secondary to primary in left The changes seen in Boeck's sarcoid (Longscope and Pierson, 1937) and those associated with erythema nodosum (Kerley, 1943) should not be confused with this type of case. It is not unusual to find mixed types of snowflake mottling in the same chest in a man u u wor*ed in several mines or types of mines-- or has a superadded infection, of which the commonest is tubercle. Serological tests as described by Craw are of particular 'alue in such cases, a rise in the sedimentation rate and other changes in the blood i ndicating the existence of superadded infection. This is exemplified in the case of: rfenlo' Fumss miner, with little evidence of haematite, but evidence of the ,, i f " tnottl:ing of silicosis of the South African miner (he spent mrny years on the Rand) end the coalescent mottling and cavitation of tubercle an almost ldenudoraeslserra,dioshgorawpinhg. silicotic mottling, reticulation and tubercle, presented o M r o t f c o r n e n t ^ ^ 3S *K>' ni ed ou t that ' h e markings may be more e x a g g e r a t e d because w* Mb m sm iry-- r^T ir 0 N Piocodxnys of the Royal Society of Mtdirine 20 L vG.'evio,.' n o d u l a t i o n is sc 1f-desc r ipt is c T h e nodul es t end to become congl ome r a t e 1 r so.i'c'-cc:,: bu;cc cnrhcr illustrations tna\ demons tr at e this to some degree 'fatir.c Mu. d o n s ,-- Mul t i pl e f luffy s h a d o n s a n d ma j o r consol idai s' >> have been descri bed ..nder the s. r gl e headi ng co m o h d a tio n --with these n a y be included advanced coalescer,t nod u l a t i o n -- it me r e l y defines a p r o c e s s i v e process T h e b u g b e a r is, of course, as mentioned before, superadded infection. T h e massive shadows may be confined to one lung, to one zone, they may be smai! or resemble a cricket ball in appearance; the edges may txr sha r p or t hey m a y be indefinite. At this st age e m p h s s e m a 15 al most i nvar i abl y present. F i e 1 3 --J C (9 7 35) i l l ust r at es a lesion confi ned to the u p p e r zone of ri ght lung, the left lung not being above suspicion A film t a k e n 1 6 42 showed heal ed t ub e r c u l a r di sease of 9th a nd 10th dor sal vertebrae Thi s act ual l y occur r ed since 9 7 35, but ne ve r has he h a d a ny pr oduct i ve cough nor a s p u t u m positive to T B , a nd yet t he hi gher K V. s e e me d to d e m o n s t r a t e a cavi t y in right lung 27 c r,tam ha?mat.te or e . kn m ' t i , dat i d d.sease shoT.d r e o- Ma l i gna nt G r e a s e c ' ' - n r * FlC lo -- T C Dr b - c' right lung Tr.e erb 0 evi dence of n b r csi5 cf eft .. suggests possible care.noma (' zone in which case superaodt- 1 Et c 17 - T H . aged 42 drifts Illustrative cf n. xed rr uIt 1 pie m a s s n e fibres.s 7 B The f iufjy l ype is nearl y ; 1~ any field a n a be confused w bronchiectasis or e.en g'-o*' very similar picture FI G 12 FI G 13 M G 11 A f ur t her r a d i o g r a p h , 24 1 44, showed toe lericn m ri ght ape^ to oe r a t v'C" m m e massi ve He does not wor k but has a meas ur e of reasonably gcoo health and st.h l^rcs salmon frem the Riser Eden F ig 14--By way of contrast, a case similar m a pp e a r an c e W M, referred to my d e p a r t m e n t 13 12 34, at wh i c h t i me I suggest ed he mi ght be sufferi ng f r e m si der o- t uber - cmosi s fie was r e f e r r ed agai n 6 9 28 wh e n by m e a n s of a film of high K V a cavity wus d e m o n s t r a t e d wi t hi n t he " m a s s '* in t he u p p e r zone of his ri ght lu.ng A cavi t y cf th.s type contains much debris which resembles tomato juice m appearance In this case tubercle bacilli were found m his sputum, in spile of this, he worked until the '" ' d d l e of 1939 a nd di ed in F e b r u a r y 1940, havi ng i nf ect ed wi t h t uber cul osi s five of his six children ' I have already stated that in my experience the distribution of tnese sinple shadows (massive! is most common m the cent r al field of the up p e r zone of right lung in pneumoconiosis--any dep ar tu re from this must suggest superadded infection as m the previous case, or tumour F ig 15. whi ch I shal l descri be in detail, is i nst r uct i ve J W , aged 48, i r on-cr e mi n er t hi rt y- f our year s Compl ai ni ng of shor t ness of b r e a t h for thr ee mont hs He had little cough and no s put um A mont h previously he coughed up about an ounce of bright red blood--this gradually stepped, but was followed by vomiting. He had a cold at the time but no night sweats, pl eur odyni a was compl ai ned of about a mont h ago. pain r adi at i ng into the scapul ar ar eas Chest expansi on 3 in. Good for a miner. Little to be found by means of stethoscope. S pu t u m negat i ve for tubercle. 19 5 42 The r a d i o g r a p h of chest shows t he t ypi cal s nowfl ake mot t l i ng as soci at ed with haematite iron-ore miners, together with the usual patchy areas of emphysema Lying m relation to the sha dow of the ant er i or end of secona rib an d in second int erspace on right - 15 ari opaque, r o unde d shadow' wh i c h has a dens e calcified w'all and lying to its out er aspect are tv, o " d a u g h t e r " sha dows, if not t hr e e T h e shadow' does not a p p e a r to be t vpi cal of t.,e " s n o wb a l l '* a r e a of consol i dat i on seen in t hes e m i n e r s --a nd suggest s csteoc .ondrema cf rib, screening m lateral plane, however, excluded this Hvdatid disease was su 1. ces t ed--*he tests for h v d a u d wer e ul t i mat el y car r i e d out a n d p r o v e d to be negat i ve 15 6 42 A series of t omogr a phs seem to i ndi cat e c h o n d r o m a of lung, an opi ni on e x pr essed by .Vorri st cn Davi es T o mo g r a p h s wer e t a k e n at t he de p t h s of 3. 5, 6. 8 a nd 11 cC* j Crn posterior skin surface, the patient being In the supine position The mass a.ready described in the upper portion of the right chest comes into definite view at 6 cm A .s seen to be of varyi ng density, to have a cal careous rim and to be lobul at ed The temegrap. s a.so show that the hilar and peri-hilar glands are dense and probably * 1 i 41 ! >- F ig IS --J J is an a d . a f . i r m e r 's lung ( ma Td > ha. s 'mew ha t si mi l ar to fi u fl > t s . p h i h s (see pr evi ous p u t ' ca Full history, clinical and I conclude with three pro;. F i c 1 9 --L A C . R A F ageplayer--admitted to R A F a' sl owl y a nd he w'as exa mi ne d sent h o m e F u r t h e r X- r a y e -> d agnos ed as silicosis and wa nut have contracted sihccsu fcotball match the p-evic^s c ir iron-ore mines This is t F i c 2 0 --J P aged 61 l stonemason, working co free 1 which trade he followed for 0 a.id he had lost 21 lb r a t h e r h, s left lung was not f u n d ; m t'onchilLS. 1918 to 1922 ) e g'O'jse on his moor died ir. L, may be a ccmc.dence The c: m m e n amongs t bi r ds He , M edicine 26 nu! to become conglomerate his to tome degree. ihdntiou have been described included advanced coalescent e bugbear is, of course, as lows may be confined to one ball in appearance; the edges j'liyscma is almost invariably upper zone of right lung, the th and 10th dorsal vertebrae, any productive cough nor a demonstrate a cavity in right 27 Section of R adiobgy 529 contain haematite or even possibly silica Note reticulation is not seen In tomographs. Hydatid disease should not be confused with pneumoconiosis, nor should lymphadenoma. Malignant disease of lung is a more difficult proposition. Fjc. 18.--T. C. Dr. Sutherland considers this to be a massive fibrosis of the upper zone of right lung. The patient died. No P.M. was available. There is of course, some evidence of fibrosis of left lung also and the collapse of a portion of right lower zone suggests possible carcinoma of a basic bronchus. Massive fibrosis may invade any lung zone. In which case superadded Infection Is usual. Fic. 17.--T. H., aged 42. Iron-ore miner twenty-five years, and worked cn stone- drifts. Illustrative of mixed infection. Note the coarser, denser nodulation, plus multiple massive fibrosis. T.B. positive. The fluffy tlipe Is nearly always bilateral and frequently very extensive aftd may Invade any field ana be confused with tubercle (and indeed most cases are T.B. positive) or bronchiectasis or even grosser secondary malignant disease--various mycoses give a very similar picture. F IG . 14 ex to be rather more massive, health and still lures salmon nee W. M , referred to my suffering from sidero-tubera film of high K.V. a cavity his right lung. A cavity of jice in appearance. In this ! this, he worked until the with tuberculosis five of his .ion of these single shadows pper zone of right lung in .cradded infection as in the e. J. W., aged 48, iron-ore l for three months. He had up about an ounce of bright muting. He had a cold at of about a month ago. pain Good for a miner. Little tubercle. .ike mottling associated with ,.reas of emphysema. Lying . in second interspace on right d wall, and lying to its outer dow does not appear to be miners--and suggests osteo ed this. Hydatid disease was and proved to be negative, ma of lung, an opinion exc depths of 3. 5, 6. 8 and 11 c supine position. The mass es into definite view at 6 cm. n and to be lobulated. The ds are dense and probably F IG . 15 Fig. 18.--J. J.. is an advanced case of what has now achieved the popular title of farmer's lung (mouldy hay dust). The patient died. The radiological appearance is somewhat similar to fluffy type--and may easily be confused with actinomycosis or ' syphilis (see previous publication, Fawcitt. 1940). Full history, clinical and pathological investigation are again stressed. I conclude with three problem pictures: Fig. 19.--L.A.C.. R.A.F., aged 35, three years ten months in the Service--a keen rugger player--admitted to R.A.F. as A.l. He developed pneumonia In Italy which cleared up slowly and he was examined radiologically. Diagnosis--miliary tubere'e--and he was sent home. Further X-ray examinations were made in this ccn try . Patient now was diagnosed as silicosis and was discharged from the Service with no pension as he could / con' racted silicosis in the Service. I saw him in November--he had refereed a football match the previous day--his chest expansion was 3 in. He worked seven years in iron-ore mines. This is the mottling of haematite. Fig. 20.--J. P.. aged 61. Enjoyed good health in youth. At age of 17 he became a stonemason, working on free stone which is known to cause silicosis, later on limestone: which trade he followed for twenty-three years, but left because his health was affected and he had lost 21 lb. rather quickly. He nad a chronic cough and was told in 1918 that nis left lung was not fu actioning. He has since had many colds, attacks ol influenza and bronchitis. 1918 to 1922 he was employed as a gamekeeper, and it is of note that the grouse on his moor died in large quantities in 1919 from some respiratory trouble. This may be a coincidence. The cause of the disease is not mentioned, but aspergillosis is common amongs* birds. He gave up this work because of his shortness of breath on jtf^inSnfor*^ Rroc-cohnys of the Royal .SooK/y of Medicine 2S t*y(*r'.!' r., and b e c a me a s ma l l hol der and publ i can, r el mvu- , hi r . g h.s Dnr nwor k m 1937 aoc.ause cf a severe at t ack of bronchitis and mtluenza C n m c o ! f i ndi ngs.-- Ai r ent r y c n left side of chest defi mtelv poor, a nd whol e c v esi moves p ^ r F h o ot h e r ver y definite clinical signs. P R 80 to 9j Nc mgr.t swe a t s Occasi onal morning s p u t u m --negative to T.B. 25 5 37 Radi ol ogi cal findings.--'The chest is r a t h e r d o m e - s h a p e d The left side more so t han the right and expansion is poor especially on l ef t Multiple calcified nodules are seem t hr oughout both lungs but mainly in the apex of right lung and out er p a r t of upper right lobe. Hilar shadows increased and calcified hilar glands present Such a p p ea r ances are seen at times in limestone workers. Co-existmg dusts may influence the picture (see full text). The radiological picture suggests a n old-standing inflammatory or infective condition of lung In which areas of calcification and fibrosis are seen FIG 19 f i g 20 FI G 21 4 G37 Afpco'opiccl / - n a m e s --Pet r i dishes ( bee: wor t ) ocul at ed wi t h t he sput um yi el ded ext ens i ve g r o wt h c i mi cr o- f ungi at 37' C. As per gt u..s. T. .m. d u l a n s ) , pni ci l l i um ^ . V rnUiCC>r ' y c ^ i r h k e growt h. Ad v a n c e d as per gi l l os i s gives rise to calcified nodul es wi t hi n lung tissue B u t j n J a n u a r y 1945 still a l i v e and keeps h:s sma l l c o u n t r y i nn F ig 21 T, B , age d 73. r e f e r r e d by Mr. Vent er s, E X T de p t X - r a v chest, ? t u m o u r o. a n e u r i s m Hi s . o i y of hoar sene ss for cme y e a r nd t wo m o n t h * --c o m c ' e t e Daral vs' s of left vocal cord _ The occupational history is of note-- seven year s f a r mwo r k , four year s c oal mi ner three vear s groom t went y- ei ght year s i r on-or e mi n e r ( ne ve r on p n e u m a t i c d r i l l s 1, f our ' year s umesvone quarryman. three years again iron-ore miner, but had an accident and gave up werk twenty-two years previous to present date, and has bred and kept spaniels and trail , o u n u ^ l i e , ungs reveal t..e snowdiake mottling of haematite and some r ounded dens i t i es --nc. typical o. tht_ .uaemurtite w o r k e r --m u c h m o r e suggest i ve of hvda t i d di sease .fiC is a large area o: consolidation in right chest extending from upper middle zone l u" * to d i ap h r a g m a n d f.Umg half the r ight chest. This suggests to me p r i ma r y lung 0 0 ' a G sc " d a.r i cs. The p r o b l e m will ne ve r be solved, as the p a t i e nt di ed s u d d e n h me a n y a. t e r his X - r a y exa mi n a t i o n a n d no p e s t - m e r t e m w*as per mi t t ed. 1 have se.ected a few cases f rom literal!) thousands which have confronted me in PIO'C t h a n t he last t ver.t s sears In t he bri ef pave of h a l f an h o u r I ha i t onls t o uc he d 20 be ir.ngc of th.s e' : r .m . .i ne d W.S!) as descr L 1 fleets of nomous gmm < , ungs already conta;; .r g r e Concerning the ""..ir.ic Icterrents or adjuvants ir .he former theory Tncsc a' Much must confront rad with fairly exhaustive!) a' 1 Dece mb e r 1937. My thanks are due to n whose co o per at i on h a 1 T.-d* AMOR, I A ( 1011) Ad X rj , e .' CRAt r, j ( 0 j ?' 1* B.>'d d o ::gG,, aA T ., tmr d M;:LA Gj H. d- Uc c (t , tr i DONNER. D ' G . y " C. 12 2,1 FN7LR, N . ird S' . NLT -, o e 1 ( 1 FA'S CITT, P 'D-D " > GOUGH. ) ' D u Pt?c r ( -~ HART, V D , a.-i AELE T ; t `,` i ; a' Pt-a-m C' - Hf FRNMLISi R, G HOLLAND, T ! ' 1 v' ' Kl FLb \ , E [ l LODGE. T ..44 I n A l o n g s c o e e , to : , n r . 6o, 22 i f -O' t > V cU..j' F . - a - PANCOAST, H K . i ' j i t O L 'ENDLRGPO.SS, E P L " - S AN O R, O *1 : .1 '` ^ - r'-~ ' SI V.SON.J- V 5 J r 1 1 N. * STL* SET, " ; , i' d i i b - O 39, ' L / - . - . ; 4.. T V INING, 1 T ' 7 ' E Dr . J o h n Craw 1A : .. r hi ch ccrreb' :es : c - m. 1 mi n er s w 1th t he p j '.i G ladiolog'ca! shadow F r o m a large sor c> - f particles are !c>d t mm : r ) to 12 ', total sd,ca The fe h o w n g facts me f n t he last ter. scars, a * 1 *1 ogical anatom). ( 1) L i n e a r n a r i . -gs -- i ! o t h e r condition: c.m.s.' g cm (2) R e h c u 'a h c n - - T : ere a ib ) Lace Markings - fa) X-ray Reticula*.mi V well-csiablished X-:as ret . pathological entitv d the ^ t he l ung is usual!) a c.dd t great Nc rodT atir ; : nodul at i on cr even firmne-* Fig 2 shows an or Umar of small irregular shaped r dust All these arc it. per , r.d diligent search u f e r \ i e f c u l m fibres T h e r e .s ;. 532 Proceedings of the Royal Society of Medicine 30 Fi g 3 shows first a n o d u l e wi t h o r d i n a r y s t a i ni ng (A) T h e second (B) is t he s a me section after micro-incincration, with d a r k - gr o u nd illumination, a nd it should he noted that this section does not reveal any more particulate matter. Th ese slides show that almost the entire structure is particulate haematite an d silica CHEM ICAL ANALYSIS OF LU N G. ; Silic* to lung 0 05 % F e ,0 , to lung 7 7 0 Silica to u h 6 3 \ F e ,0 , to u h SO T o u l iLhca 2 35 gramme*. ( 6 ) Lace M a r k i ng s : T h i s type of X- ray ret i cul at i on is rare, a n d l hav e seen only two at post-mortem. Figs. 6 and 7 of Dr. Fawcitt's paper illustrate such a case. Again the cut surface shows no visible or palpable nodulation or other fibrosis and an ordinary F;G. 3.-- PenvavcuUr dust ccumulam* FIG . 1 --Reticulation. Contact print. F IG 2 -- x 15 M icroscopi. Section mi cr oscopi c sect i on ( x 8) s h o wn in fig 4 d e m o n s t r a t e s t he l i near a r r a n g e m e n t of t he dust with concentrated deposits. It shows a pulmonary atrium and, just at the bifurcation, wh e n st a i ne d wi t h W i l d e r 's r ct i cul i n st ain, it shows \ e r y defi ni te a n d fairly de n s e r e t i c u l a t i on (fig. 5). T h e silica a n d n o n c o n t e n t of such a l ung is \ c r v h i gh, in fact, al most t he highest in the entire scries ' CHEM ICAL ANALYSIS OF LUNG o Silic* lo lung 1 0 % SUica to sh 8 Toni it' % F etO , to lung 12 0 Fe.O , to u h J9 J c prunM o. (3) X- r ay n o d u l a l t o n -- N o d u l a t i o n of <- . o f <uout ^ m m is r e l a t b c l y u n c o m m o n when there are no associated conglomerate mass^. A certain number do occur, and they are always in association with X-ray reticulation. Radiologically the nodules are without clear-cut edges, and the consistence of the shadow varies within the nodule. T h e cut surface of the l ung is characteristic. r h e l ung substance is cither nor mal or very slightly brown-stained, and dotted over the surface are areas of brownish or reddish- brown nodules. T hey look and feel slightly raised above the surface and are slightlv mor e r esi st ant to t o u c h t h a n t h e i n t e r v e n i n g l un g tissue (fig. 6). ' Fig- 7 shows a nodule stained with hemato xyl in eosin. T h e same nodule incinerated revealed m u c h fine particulate material, and, after HC1 digestion, m u ch insoluble residue. Fig. 8 is a m a r g i n a l field of this no d u l e af t er W i l d e r 's r ct i cul i n stain. De n s e r ct i cul i n is easily seen. In t he cent r e of the n o d u l e t her e is evidence of i m m a t u r e collagen f or mat i on. CHEM ICAL ANALYSIS OF LU N G. % SUIc* to lung 1-03 % F e.O . to lung 0 50 ' * Silica to u h 7 2 % F e.O , to aah 40 I have seen only one post-mortem case showing mature collagenous nodulation without massive shadows, and this confQrms to the X-rav type of fine nodulation. Fie. 9 is a contact print from such a case. ' Cut section of the l ung showed no fibrosis to the naked eye. FIG 6 --Coarse noduUuon. Fart of lung Reduced (u t Rad-o- graph, ng 8, D r. FawciU) FIG * rod*r cDenetnree - AV l 4-. t J uly-- Rad. 2 31 Section of Radiology 533 Medicine 30 ' Ccond {B) is t he s a m e section n should be noted that this ( u l j t e haematite a nd silica. rc, a n d I h a v e seen only two rate such a case. Again the .er fibrosis and an ordinary F IG . 5.--Reticulin fibres ( x 350). G Z.-- > 15 M icroscopi: Sccuon. linear arrangement of the i and, just at the bifurcation, itc and fairly dense reticulairv high, in fact, almost the i* o m is r e lat hcl y u nc om mo n number do occur, and they ally the nodules are without thin the nodule. The cut c is either normal or very as of brownish or reddishhe surface and are slightly (>) . . he same nodule incinerated, ion, m u c h insoluble residue, n st ain De n s e ret i cul i n is umaiurc collagen formation, c it agenous nodulation without ne n od u lat i on F ig 9 is a FIG 6 --Coarse nodulation. P m of lung Reduced (tet Radio graph, ng 8, D r. Faw citt) F IG . 7.-- M argin-! field of a hx m au te nodule after W ilder' reticulin *uin. Dense reticulation u easily seen. In the centre of the nodule there is evidence of miniature collagen formauon. F IG . 8.-- Marginal reuculauon. J a \ - R ad 2 F IG . 9 --Fine nodulation. Contact prim. 534 Proceedings of the Royal Society of Medicine 32 Fi g 10 is a ruicro-section. T h e nodul es are seen to be discrete, a v e r a g i n g 1 m m . or less in size a n d most l y of l r i e g u l a r sha pe It shows t he s a n a t i o n m size a n d sha pe of t he nodules, a n d t hey resemble the types described by Belt. T h e nodul es arc much s ma l l er t ha n t he pr csi ous l y des cri bed type of Modulation. Fi g 11 shosvs a n o dul e sshich in s t r u c t u r e near l y a p p r o a c h e s t he classical t ype. One of t he fess I b a s e f o u n d t h a t svas not associ at ed wi t h t uber cl e or ot h e r mas si ve fibrosis Ordinary staining shows concentric layers of collagen much more mature in the centre W i t h dar k-gr oun d illumination the refractive material was scanty, but after incinerating there was seen to be a very large a m o u n t of particulate matter, a nd after HC1 digestion the silica pattern was seen to be a r ra nged concentrically and less in a mo u n t in the centre. It is interesting to note t hat this nodule was subpleural, and, if a diligent search is made in eases showing no evidence of reticulin fibres in the dus t nodules f rom the centre of the lung, an occasional nodule may be found 1/10 mm. in si^c showing primitive attempts at laying down of i mm at u re collagenous fibres. This type of nodule, when stained with naematoxylin and van Cieson, shows definite fibrous tissue with fine mar ki ngs in the centre, and, when viewed with dark-ground illumination, shows m u ch less particulate matter, as it has been obscured bv fibrous Sectional page 19 Procredirgi m FIG 1 0 -- Fine nodula'aon x 20 FI G 11 -- Nodule t>-pe' (Ocular a o 1 'j mm obicctis c ) tissue V* he n i n c me i a t c d t her e is show n m u c h fine par t i cul at e ma t t e r , a n d finallv, when di ges t e d with HCI , t he p a t t e r n of silica is Town T h e a p p e a r a n c e s i mu l a t i n g the classical nodule Nodules such as these are always subpleural in location and \er\ small The nodules which arc situated deep in the lung are of a t\pica! t\pc seen m previous ivpe of Modulation " CHEMICAL ANALYSIS OF LUNG eo Silica to long n 9 r F e , 0 , to long 7 4 c0 Silica to ash 5 % F c , 0 , to ash 44 C onclusions (1) X-ray r et i cul at i on of haemat i t e i r on-or e mi ner s shows as a verv dens e r adi ol ogical shadow, which is due to the simple accumulation of particulate Kxman te, Pathologically there is no stimulation of collagenous fibrosis and practicalU no increase in the amount of reticulin fibres. ' (2) N o d u l a t i o n wi t hout massi ve fibrosis is a rare c ondi t i on T h e l ar ge t vpe shows mostK tight packing of dust in perivascular locations, with moderate collagen formation, and the small type shows a percentage of the nodules to be verv similar to the classical ts pe ` (3) Large- s i zed classical no d u l a t i o n onl y occurs ,n t he pr esence of e s t abl i s hed t ubercul osi s and is always associated with solid fibrotic masses ' _ (4) T h e fibrotic response in the l ungs bears no r el at i onshi p to t he total a m o u n t of silica or h xm a t i t e present in the lung tissues. .1 desire to r ecord m y sincere t ha n k s to Dr. J. S F aul ds, Pat hol ogi st to Carlisle Infi rmary, who has supplied me with the results of the chemical analysis of the lungs, and has helped me m u ch in this work. _ Dr. F. H. Kemp gave a brief account of an investigation which had been carried out with Mr. K J. Cook and Dr. D. C Wilson into t he risk of pu l mo n ar y injury in boiler cleaning at one of the great railway depots. They had examined nine woikcrs who had been e mpl oyed whol e- t i me in cl eani ng boilers at t his work. E i g h t of these m e n consi dered themselves healthy but one complained of indigestion and breathlessness on exertion. The radiographs shewed n o , 'ignificant changes in any of these cases. Dr. Kcmo said that they had concluded that the changes which have been described by other workers may have been due to different methods which are practised in other works or that there were significant differences in the ph\ si cc hemical constitution of the scale and flue dust. A full a ccount of this wor k will be p ubl i s he d shor t l y Sectio rv v - DISCUSSION ON ' lie " F. C \V. Capps T h e r u n , apt to become a m a t t e r n! To deal with th.s, a team ^ ' n terms medical and ^,cia' 1 l urri ed decision at a Cnc c <. 1 j g i c a ! r esponse t o e n v i r o n m ;:on of ihc mouth Lrc.i'hcr a ' ,nd orthodontist, to r c ' t i ' t t single pathological entitv w t he br onchi al -vst em ns il c the sinuses with the oOjct: , tissue radiographs in `ho" t tonsils t hat are subject to re cularlv where morbid chan.,- In the child , should U , logical slate supeivenes 1 children in a general clinic T h e t ea m at pr esent cut orthodontist. Children are . same day. We should aho 1 . The persistent mouth-bre; r hi nol ogi s t a n d o n h o d o n t st and Somerville Hastings reo the Section of Odontology m i During childhood the r:r . tissue undergoes phvsiclogisa It is of interest to r o n d e v e l o p m e n t c o m p a r a b l e w.t , replaced by a process of at u when the sinuses are imma; . tissue may follow. J uly-- Laryng. 1 <ftf ")____