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FILE NAME Colonial Sugar Refinery CSR DATE 1950 Nov DOC CSR027 DOCUMENT DESCRIPTION Journal Article - Occupational Factors in Pulmonary Dust Disease * EMBER 18 1950 * Specimens ns illustrating It be set up illustrating some irector of pathology ents appointed honorary iatric clinic of honorary the appointed honorary ical section of appointed honorary ion of the Royal ith A. Medical Politics ! Meeting Meeting Meeting : Clinical cil 1.A Ethics Com rtant Notice to apply for any first communicated concerned or with edical Association ry 135 Macquarie appointments ^fin ical Society Hall Services Limited tralian Prudential Federal Mutual | Provident Club or other appoint- M.A. House 225 sbane Associated indaberg Medical appointments and any COUNTRY are advised in eir Agreement to ary 178 ments in ments in North South South tary 205 Saint tal all Contract la All governof those of the journal cannot al articles foroffered to THE he contrary be e Editor The House Seamer : MW 2651-2 y the Manager Street Glebe ularity in the not accept any of receipt d within one others not in virtue of al Association the journal by book- ints and inning of any he rate is 3 of monwealth t and foreign AUSTRALIA THE MEDICAL JOURNAL OF VOL 37TH YEAR SYDNEY SATURDAY NOVEMBER 25 1950 No. 22 Table of Contents The Whole of the Literary Hatter in THE MEDICAL JOURNAL OF AUSTRALIA is Copyright ORIGINAL ARTICLES Page Occupational Factors in Pulmonary Dust Disease by Gordon C. Smith M.B. B.S. The Changing Face of Obstetric .. ee Infection Infection ae by 777 Arthur M. Hill M.D. D.G.O. F.R.C.S.E. Torsion of the Testis and its Appendages by S. H. * Brewer's Hepatitis Treatment with Neville Davis M.B. Ch.M. .. Yeast by .. .. .. .. North Australia Immunization Against Tuberculosis and New Guinea by E. A. M.R.A.C.P. and D. Jamieson North M.D. F.R.F.P.S. M.R.C.P. B.Sc. D.T.M. and H. .. ..) ..) 2. 787 790 792 REPORTS OF CASESSquamous Epithelioma Case Report by V. of the Renal S. Howarth .. Pelvis ..) .. A .. 797 RERVIEEVWIS EWSREVIEWS Pye's Surgical Handicraft .. .. .. Portraits Paraphilic Obstetrics and os te Diagnostic GyGnyenceocloologgyy Diphtheria Prophylaxis .. .. .. .. Asthma and Gold Therapy Autobiography .. .. .. BOOKS RECEIVED ..) 2. 2. ww wk wk LEADING ARTICLES A Considered Statement on PAS .. .. 1.) 1.) 1. (oo .. .. |. 4.) we we . 798 799 799 800 800 ok ew. 800 1...) .. 801 CURRENT COMMENT Advances in the Field of Cortisone and ACTH .. An Australian Contribution to Genetical Knowledge 802 803 ABSTRACTS FROM MEDICAL LITERATURE- LITERATURE- Obstetrics and Gyn^cology .. .. .. .. .. Page .. 80 BRITISH MEDICAL Scientific ASSOCIATION NEWS- 801 CORRESPONDENCE- The Australian Tuberculosis Association ++ oe. Myocarditis Acute 2 Resuscitator 4. 0... kd An Efficient Resuscitator 6. . 1. f) 1) 1) 811 811 811 OBITUARY- Edward Albert Woodward ee ee ee ee ee 817 DISEASES NOTIFIED IN EACH STATE RITORY OF AUSTRALIA tee ee AND ee TER- ge we 811 GRADUATE WORK The Graduate Committee in Medicine in the UnUinvievresristiyty of Sydney Sydney tere ne ne ne ee 811 Appointments NAVAL MILITARY ANAND D AIR FORCE FORCE ee 812812 MEDICAL PRIZES The Australian Orthopedic Association Prize 1952 12 NOMINATIONS AND ELECTIONS ee ne ee eee 812 DIARY THE MONTH FOR .. .. .. '. |. 1. MEDICAL APPOINTMENTS IMPORTANT NOTICE |. 812 |. 812 EDITORIAL NOTICES 2.) ww. 1. kw. wl, 812 OCCUPATIONAL FACTORS IN PULMONARY DISEASE DUST By GORDON C. SMITH M.B. B.S. Industrial Health Unit School of Public and Tropical Medicine Sydney Health THE Third International Conference of Experts on Pneumonokoniosis held recently in Sydney under the auspices of the International Labour Organisation 1950 adopted the following definition of pneumonokoniosis a diagnosable disease of the lungs produced by the inhala- tion of dust the term dust being understood to refer to particulate matter in the solid phase but excluding living organisms the term diagnosable indicating the presence of signs or symptoms but not always loss of function The implications and scope of this definition are very wide Whilst pneumonokoniosis in the etymological sense means dust in the lung and therefore is applicable to the pulmonary reactions due to all types of dust and fumes in practice it has been associated chiefly with silicosis asbestosis and in recent years with the lung disease due to coal diseases in which permanent fibrosis occurs abnormalities and with characteristic radiographic Of late it has become evident that acute semiacute and chronic pulmonary conditions may result from inhalation of a variety of dusts both organic and inorganic other than silica asbestos and coal Although the nature and severity of the tissue reaction vary according to the type of dust and conditions of exposure the term pneumono koniosis can be applied to these conditions Read at a meeting of the Section of Public Health Tuberculosis Tropical Medicine and Industrial Medicine Aus- tralasian Medical Congress British Medical Seventh Session Brisbane June 1950 Association The Occupational History in Pneumonokoniosis Whilst the diagnosis of pulmonary dust disease should never be made without proper consideration of the occupational history medical history clinical examination and | radiographic findings the first is of special importance Unless there has been exposure to dust of a harmful nature matter might there cannot be what the medical indicate and no a pulmonary dust disease no history or clinical examination matter how closely the radio- graphic appearances of the lungs simulate those of pneumonokoniosis Thorough and detailed inquiries should be made about any process in which the patient may have been exposed to dust nature and conditions of the work the type of dust and duration of employment at the process Unless these particulars are obtained accurately the industrial history may be rendered invalid with resultant error in diagnosis Negative evidence as to dust exposure is as important as positive pneumonokoniosis has been diagnosed in certain individuals with suspicious radiographie signs evidently on the film appearances alone for a proper inquiry as to the nature of their work would have revealed no history of industrial dust exposure in these cases Properties of Dust in Relation to its Disease- Producing Capacity Although all dusts if inhaled in sufficient quantities may be regarded as being potentially harmful some are known to be considerably more injurious than others Important information concerning the potential capacity of a dusty environment to cause disease of the lungs can be obtained from a study of the following factors i the composition and nature of the dust ii the size of the dust particles iii the intensity of exposure as determined by a the atmospheric concentrations of the dust b the duration of exposure 778 THE MEDICAL JOURNAL OF AUSTRALIA NOVEMBER 25 1950 The Composition of Dust An analysis for stituents should be the chemical carried out on or mineralogical conany dust suspected of causing pneumonokoniosis and preferably the borne dust should be examined The most injurious component of an industrial dust is crystalline free silica uncombined silicon dioxide The pulmonary reactions from amorphous or crystalline free silica are less severe while silicates that is silica in a combined form with the notable exception of asbestos a hydrated magnesium silicate are less harmful than free silica Most minerals which contain silicates also contain some proportion of free silica compounds of other elements such as iron aluminium calcium magnesium and potassium may also be present Because of the possible modifying or inhibitory Influence of certain substances on the action of free silica the analysis should be not only for free and combined silica but also where indicated for other likely constituents especially if these by themselves are capable of producing a lung reaction In regard to metallie dust and fume even though there may be no question of the presence of silica the concentration and chemical analysis of the atmospheric contaminant should be determined in order that a proper appraisal of the suspected hazard may be made In the case of siliceous materials as a general rule and other conditions being similar the higher the percentage of free silica in a dust the greater is its capacity to produce disease When pulmonary disease is caused by dusts which contain lower percentages of free silica than say sandstone or quartz greater exposures due to higher atmospheric concentrations of dust or to a longer working period or both are necessary Thus pneumonokoniosis has been found in men engaged in dragging bricks from continuous or patent kilns Tests in New South Wales have shown these men to be exposed to very high concentrations of dust containing about 25 of free silica The pulmonary changes in coal miners are out of proportion to what one would expect having regard only to the free silica content of coal dust which Smith and Whaite 1950 found averaged 1.8 in the under 10 micron fraction of sixteen samples collected from the coal face of five collieries in New South Wales but a long period of exposure seems necessary to produce disabling pneumono- koniosis Asbestos which contains no free silica produces pulmonary disease but the mode of action of the fibre differs from that of the silica particle a severe asbestos The pneumonokoniosis conference agreed that an analysis of material from which dust is derived does not of necessity represent the composition of the dust inhaled in in industrial process The free silica content of borne lust may be similar or may be appreciably increased or decreased compared with according to the nature Industrial process that in the parent material of the material and type of The problems associated with exposure to mixed dusts for example in foundries are of interest Foundry dusts nay comprise a mixture of carbon free silica silicates ron oxide and other metal particles as well as particles from carborundum and other abrasive materials Iron xide may play some part in the production of the nodular shadows seen in radiographs and may influence the action of of silica in the lungs certain foundry workers apparently affected with silicosis One may also question whether any of the nodulation seen in films of grinders with apparent pneumonokoniosis is due to particles from metals or synthetic abrasives The physical nature of substances whether hard and i try or soft and wet influences their capacity to produce | lust Thus the fact that work is being done in sandstone loes not necessarily mean that there will be a serious dust azard f th on despite the high k was wet and free silica soft little content of or no dust the rock would be breaking it up whereas if it was of a dry tightly cemented type dust high in free silica would be generated because more energy would be required to rupture it The Particle Size of Inhaled Dust The pneumonokoniosis conference concluded that in the case of fibrous dusts such as asbestos and certain vegetable dusts the larger sizes appear to be more harmful whereas in many mineral dusts the smaller sizes seem to be the most injurious In general whilst particles of mineral dusts except asbestos exceeding five microns in size are of minor importance the lower limit of the size of particles causing pneumonokoniosis has not yet been determined Particles of the harmful size range cannot be seen with the naked eye and it is well to remember that a dangerous concentration of dust of this particle size may be present in the air without being seen contain fine harmful particles innocuous size A visible as well as dust cloud may those of larger The actual number and size distribution of dust particles depend upon the method by which dust is produced and the nature of the parent material from which the dust is derived Experience in New South Wales like that of investigations elsewhere is that at least 70 and in some cases over % of dust particles generated in industrial processes are up to three microns in size About % of coal dust particles and only about % of sandstone particles are over five microns in size Thus not only is there a relatively small production of the larger particles but such particles settle out from the atmosphere more rapidly than the smaller sizes Further it is known that only a portion of inhaled dust is retained permanently in the lungs most particles of about five microns and larger being removed by the physiological mechanisms of the nasal and upper respiratory passages In a recent review of this subject Hatch 1950 that particles smaller than one micron in size the principal contributors to silicosis production suggests may be Vorwald 1950 showed in animal experiments that amorphous silica of particle size down to 0.005 micron produces profound lung changes and states that the rate of tissue reaction to dust is inversely proportional to particle size On the other hand in regard to asbestos it appears that the larger particles are more harmful than the smaller and that in the lungs they act as mechanical rather than as chemical irritants Gardner 1938 Wyers 1949 states that dangerous fibres measure about 20 microns Dust Exposure . In general exposure is measured in terms of concentrations of borne dust and the period of time during which the individual is exposed to those concentrations the the higher the average concentration of borne dust and longer the period of exposure the greater will be the risk of contracting pulmonary dust disease In the case of silicosis and related types of pneumonokoniosis including asbestosis the disease is usually of gradual onset and slow development It does not become evident until after exposure for a period of years the actual time varying according to the type of dust and industry Meiklejohn 1949 states that under present conditions in Great Britain silicosis in a diagnosable stage seldom occurs in under fifteen to twenty years exposure to the risk and in regard to coal miners McVittie 1949 gives a similar period for the development of pneumonokoniosis My own observations on a group of 416 New South Wales in coal miners showed that the average period of exposure the men with disabling pneumonokoniosis was thirty years their average age being four years Asbestosis apparently occurs after a shorter exposure Thus Wyers 1949 who investigated 115 fatal cases of asbestosis found the average exposure had been 10-4 years Under conditions of intermittent exposure it is more difficult to predict the likely effect on the lungs than the exposure was continuous but the severity of any dust dust NOVEMBI hazard is us however m exposures In the cas period neces generally m months or w instances a reaction The liter acute or exposures to following no In April 1 weeks after } of his indust he was enga From 1931 to fifteen month for two year in the sub using a wa pick for six His chest on two occ had left the 17 days befo the last exa of bilateral At autops silicosis of Microscopica immature fit to nodular a In October Industrial H in the baser been employ picks and a Nevertheless from 1150 t Owens's dust in 1937 were doubt that th dust inhalati Occupati The most dast containi commoner p mining or qu surfacing of and mouldin in iron foun milling silic brick industi facture of al handling of several of th specially mer but still cont Pneumonok other papers to asbestosis this country it is much m cessing and example text In recent } 1949 and M of the respir silica coal ai due to vegeta I propose b lung disorder of them hav industries or carried out h 80 we should risks : Fould be ired to t in the egetable whereas " be the mineral size are particles ined en with Ingerous present ud may flarger flarger particles ced and he dust - that of in some idustrial t % of particles there a les but ' rapidly t only a in the er being isal and suggests may be Vorwald rphous ces prof tissue e size ars that smaller er than ) states ncentrag which ns the and the the risk eumono- ually of become ars the ust and nditions seldom > to the ) gives coniosis h Wales osure in four xposure cases of .4 years is more than if ny dust NOVEMBER 25 1950 oa a THE MEDICAL JOURNAL OF AUSTRALIA 779 hazard is usually lessened in such circumstances This however might exposures not apply with very high intermittent In the case of metallic and vegetable dusts the exposure periodperiod necessary to produce a pulmonary disturbance is * generally much shorter than with other sometimes months or weeks or even less rather than years In some . instances a single exposure may be sufficient to cause a reaction contains The literature contains reports of the occurrence of acute or rapidly developing silicosis after short ~ exposures to high concentrations of silica dust and the ., following notes about a Sydney case are of interest In April 1942 a man aged thirty years died three - weeks after he had collapsed at work The significant details of his industrial history were as follows From 1917 to 1919 he was engaged in coal mining Cessnock for two years From 1931 to 1937 he was with the Water Board including fifteen months on rock work From 1937 to 1940 he was for two years a builder's labourer excavating in sandstone in the basement of a building Latterly he had been using a water pick but earlier had been using a dry pick for six months His chest had been examined by X rays in 1937 1940 on two occasions the second being some weeks after he had left 17 days the last the basement excavation work and again in 1942 before his death It was only in the film from examination that the radiologist reported evidence of bilateral nodular fibrosis At autopsy aortitis congestive cardiac failure and silicosis of the rapidly developing type were found Microscopically the lungs showed generalized somewhat immature fibrosis mainly diffuse but with some tendency to nodular arrangement In October 1939 the New South Wales Division of Industrial Hygiene had investigated the working conditions in the basement of the building where this patient had been employed Water jets were fitted to picks and an exhaust ventilation system Nevertheless concentrations of sandstone the pneumatic was installed dust ranging from 1150 to 10,000 particles per cubic centimetre by Owens's dust counter were obtained The dust conditions in 1937 were probably worse than in 1939 there is little doubt that this patient contracted silicosis as the result of dust inhalation during the period 1937 to 1940 Occupations Dusts et cetera Associated with a Pneumonokoniosis Hazard The most important risks are those where exposure to dust containing free silica is likely to occur Among the commoner processes involved are tunnelling excavating mining or quarrying in sandstone or quartz cutting and surfacing of sandstone or granite sandblasting dressing and moulding in foundries especially machine moulding in iron foundries if siliceous parting powders are used milling siliceous ores certain pottery processes in the brick industry chiefly dragging in patent kilns manufacture of abrasive soaps and powders manufacture and handling of refractory materials and metal mining In several of these instances and in a number of others not specially mentioned here the dusts are of a mixed nature but still contain significant percentages of free silica Pneumonokoniosis of coal miners has been discussed in other papers and will not be further considered In regard to asbestosis which is of very infrequent occurrence in this country all the evidence from overseas indicates that it is much more common in workers engaged in the pro- cessing and fabrication of asbestos in factories example textile work than in asbestos miners for In recent reviews of the literature Perry 1947 Doig 1949 and Middleton 1950 have described disturbances of the respiratory organs due to mineral dusts other than silica coal and asbestos and have discussed the reactions due to vegetable dusts I propose briefly to mention the more important of these lung disorders because although to my knowledge most of them have not been reported in this country the industries or processes involved in their causation are carried out here or may be conducted in the future and so we should be familiar with the possible occupational ; risks Before referring to these however I wish to make a few comments about the lung changes which have been observed in basalt workers and biograph operators in New South Wales Basalt Work Basalt or blue metal is a basic igneous rock composed essentially of a bearing feldspar with smaller amounts of one or other of the magnesian minerals and a little iron oxide Free silica is typically absent but may be present up to % Thus basalt is a silicate with 40 to 50 of silica in combined form Whitworth 1947 Badham 1927 described a case of fine fibrosis of the lungs in a man aged sixty years who for twenty years had worked in a blue metal quarry and crusher house and was exposed only to the dust of orthoclase basalt which contains no free silica This man died but an autopsy was not performed In recent years I have seen two men aged forty years and three years respectively who as far as could be ascertained had been exposed only to basalt dust The first man had been a crusher attendant for fifteen years at the same quarry as Badham's patient and the second had worked chiefly on the crusher and screens for thirty years at another blue metal quarry The radio- graphs of both men showed a marked generalized fine type of nodulation throughout the lung fields in the film of the first man who was totally disabled there were also large shadows suggesting consolidation Biograph Operating Two brothers whom I first saw in 1947 were aged forty and forty years respectively and worked in the projection booth at the same had both suburban cinema elder for ten years and the younger for twenty years There was no history of exposure to dust in other employment The elder man complained of shortness of breath and loss of weight his brother of pains and tightness in the chest The chest radiographs of both men were similar and showed a generalized fine nodulation throughout both lungs Films of both men taken in 1949 showed no significant change since 1947 In 1946 the New South Wales Division of Industrial Hygiene had found that the concentration of dust in the air of the biograph box in the cinema concerned was approximately 6000 particles per cubic centimetre of air by the Owens dust counter the dust particles were mostly about half a micron or less in size The ventilation in the box was faulty A sample of dust obtained from the biograph room in 1946 on analysis gave the following result Total SiO .. .. .. Rare earth oxides .. : Al2Os Fe Cao on ignition we ee ignition Loss on ignition . Copper Fluorides ve : : P2O5 ee eee ee SOs tee ee ee 6.0 48.0 17.0 6.7 2.0 Trace Present Present Present Following the discovery of the unusual pulmonary condition in the two brothers seventeen biograph operators from fourteen other theatres were submitted to X ray examination Their period of employment ranged from seven to thirty years and some had worked in badly ventilated booths However no evidence of a lung reaction resembling pneumonokoniosis was found Several authorities have investigated gases fumes and dusts from carbon ares and the ventilation of motion picture booths MacQuiddy and others 1939 showed that some of the intensity carbon are ashes appear to cause mildly proliferative reactions when injected intraperitoneally in the albino rat They state that it might be deduced that if inhaled in sufficient quantities over long enough periods of time these ashes might cause a pro- liferative type of pneumonokoniosis On the limited evidence at present available and in the absence of autopsy studies it is not possible to say whe kod the lung condition biograph operators present in these is due to dust basalt wepulmonary Furthexception the we 780 THE MEDICAL JOURNAL OF AUSTRALIA NOVEMBER 25 1950 responsible the question arises whether it has fibrosis or is merely present as inert deposits caused It seems reasonable to associate the radiographic abnor- malities of the basalt workers with inhalation of dust at their employment but in the case of the biograph operators whilst occupational factors cannot be ruled out indeed one of these men was compensated for silicosis as they were brothers and as examinations of other operators gave negative results a industrial ^tiology has to be considered Although these cases are incomplete I mention them in order to emphasize that with present advances in industrial activity and with increasing knowledge of pneumonokoniosis we must constantly be watching for lung conditions due to dust not only from new processes but also in industries and occupations where previously they have not been suspected is said to be caused also by fumes of other metals When it is due to zinc there is an acute febrile reaction or chill of short duration and with no permanent lung damage metallic If other oxides such as cadmium or manganese may are involved a more serious pulmonary condition ensue Cadmium Johnstone 1948 states that cadmium has probably more lethal potentialities than any other of the metals The inhalation of dust or fumes from cadmium compounds especially the oxide for example in welding on cadmiumplated surfaces from the ignition of cadmium and from the use of cadmium in solder produces irritant effects which may be severe in the respiratory tract perhaps with pulmonary ^demaand death Beryllium Talc The literature on the pulmonary and other lesions Until comparatively recently asbestos was considered to be the only harmful silicate Now however there is pneumonokoniosis evidence of several investigators that talc a hydrated mag- nesium silicate which occurs in flaky and fibrous forms and is used in a number of industries may cause significant lung changes McLaughlin Rogers and Dunham 1948 described a case of confirmed at autopsy in a man aged fifty years who had worked for thirty- seven years in a rubber tire factory where he had been exposed to a fair concentration of talc dust and who died primarily from rheumatic endocarditis There was much fibrosis in the lungs and curious bodies similar to absestosis bodies were also present These authors con- clude that tale pneumonokoniosis and asbestosis are similar diseases and that pneumonokoniosis is probably caused only by the fibrous varieties of talc Graphite Doig 1949 and Middleton 1950 refer to recent reports by other authorities in Britain chiefly Dunner and Gloyne concerning pulmonary disease in graphite workers According to Harding and Oliver 1949 graphite plumbago which is a crystalline form of carbon may be mixed with up to 10 of free silica and with other affecting workers exposed to beryllium is now extensive many reports having been published during the past five years Abstracts of the various papers and articles were recently made in Australia by Taylor 1949 Two principal types of pulmonary lesion have been described an acute pneumonitis and a chronic diffuse granulomatosis A number of fatal cases have occurred It appears that the acute form which may follow a single exposure to toxic fumes occurs mainly among workers exposed to compounds in the extraction and refining of beryllium from the ore beryl usually within a few weeks of the first exposure The chronic or delayed form which resembles sarcoidosis Howevr is more persistent A period of from several weeks or may elapse from the time of the last exposure to the years This type usually onset and recognition of the disease occurs in persons who have been exposed to dust from fluorescent powders containing zinc beryllium silicate notably in the fluorescent lamp industry However eleven cases of the chronic type were recently reported amongst residents in the vicinity of a beryllium plant There was no history of occupational exposure Eisenbud and others 1949 minerals They point out that grinding of natural graphite produces the greatest dust risk and can lead to a disabling and fatal pneumonokoniosis which they describe as resembling both radiologically and histologically that of South Wales coal workers Other Silicates Abnormal reactions in the lungs of animals or man have been described following inhalation of dust from china clay mica sillimanite and fuller's earth Cement Cement is mentioned here because of its very widespread use and of questions which periodically arise as to its possible harmfulness The raw materials from which cement is made are chiefly limestone which has not more than about % of free silica and shale which may contain from 20 to 40 of free silica The finished product has practically no free silica Gardner and others 1939 examined 2278 employees from 11 making plants in the United States of America Only eight persons showed evidence of nodular fibrosis attributable to dust and in six of these exposure to silica dust in previous employment was presumably responsible Baetjer 1947 showed that in rats exposure to high concentrations of cement dust did not lower resistance to lobar pneumonia and did not produce any acute or chronic pathological changes in the lung tissue Manganese pneumonitis Doig 1949 mentions that since 1921 a relationship between manganese and pneumonia has been suspected following reports from Norway and Germany In England Lloyd Davies 1946 found that men exposed to dust of oxides of manganese experienced a high incidence of a No condition which he called manganese permanent lung changes were observed Three years later Lloyd Davies and Harding 1949 reported that pneu- monitis has continued to affect manganese workers both Firket 1950 states follows inhalation of that chemical nonia which dusts of manganese vanadium osmium and beryllium resembles virus pneuwmhoentihaer the clinically and histologically and he questionswhether they dusts themselves provoke the disease or activate viruses Iron Oxide Doig and McLaughlin 1936 described a fine nodulation in in the lung fields of welders who wecrlienicaaplpaarnedntlryadio- good health Later following further them and other investigators it became graphic studies by evident that the pulmonary changes were due to the in welding deposition of iron oxide dust which is present fume and which is relatively opaque to X rays and physical they were not associated with symptomsA asbinmoirlmaralcopnhdiytsiioncalcondition | signs or lessened cianpaoctihteyr fwororwkeorrsk than welders exposed has been reported Metal Fume Fever The If thethe ru m formform known example of a minor pulmonary reaction me in fever due to fume rather than to dust mostly exposure to zinc oxide fumes for example in bi or from welding on galvanized iron It to iron oxide examination Enzer and Sander 1938 made an autopsy of the lungs of a welder whose chest radiograph showed fine nodulation and who died following an accident there was no fibrosis in the lung tissue Nov Acco due to case d pletely and in Dust more simila Sinc experi metalli sideral alumi have b The there alumi cosis i therap - when under indust was e of alu Shu diseas engag oxide furna ture ( accort and 8 Rid to be that t The for [ alumi The Bruns abrasi the lu A minoi mate timbe Cot chitis ---- -- -- work elsew The other Ba the s cane the 3 respi work were broke revie one litis dust by yett WI to w incre 1941 -- -- -- -- r manganese may ndition as probably the probably . i compounds on cadmium- cadmium- the and from ffects which her lesions w extensive he past five rticles were Two prin- scribed an matosis A How a single ng workers refining of few weeks sarcoidosis 1 weeks or sure to the pe usually dust from in silicate ver eleven d amongst cing plant Eisenbud elationship suspected 1 England to dust of ence of a itis No ears later hat pneukers tia which vanadium onia both ether the ther they odulation rently in nd radiot became to the welding and that physical condition exposed mination showed it there NOVEMBER 25 1950 THE MEDICAL JOURNAL OF AUSTRALIA 781 _ _ According to Doig and McLaughlin 1948 the changes to iron oxide are not necessarily permanent In one due case described by them the abnormal lung shadows completely disappeared some years after cessation of welding and in another the shadows became less intense Dusts from compounds of barium and tin which are more opaque than iron are believed to behave similarly to the latter in the lungs Aluminium Since Denny Robson and Irwin 1937 showed that experimental animals exposed to quartz dust plus % metallic aluminium powder did not develop silicosis con- - siderable interest has been taken in the question whether aluminium dust damages the lungs and conflicting reports have been published The recent pneumonokoniosis conference decided that there was no conclusive evidence that the inhalation of aluminium in any form prevents the development of sili- cosis in man or that aluminium powder is of value as a therapeutic agent in human silicosis or that it is harmful when used for this purpose There was some evidence that under certain conditions the inhalation of aluminium in Industrial processes may be harmful and further there was experimental evidence that in animals the inhalation of aluminium dust aggravates pulmonary tuberculosis Synthetic Abrasives Shaver and Riddell 1947 described an unusual lung disease with fibrosis in some cases fatal in workers engaged oxide in the manufacture The process involves of corundum aluminium treating in special electric furnaces a mixture of bauxite iron and coke at a tempera- ture of 2000 C. Dense white fumes are given off which according to Jephcott 1948 consist mainly of alumina and silica Riddell 1948 states that the lung condition appears to be induced by an irritant of a chemical nature but that the precise agent has not been determined These findings are of interest because artificial abrasives for example carborundum that is silicon carbide and aluminium oxide have such widespread use in industry The observations of Smith and Perina 1948 and of Bruusgaard 1948 indicate that dust from synthetic abrasives when inhaled may produce nodular shadows in the lungs Vegetable Dusts A variety of respiratory disturbances some only of a minor nature have been attributed to dust from vegetable materials such as cotton flax hay grain bagasse and timbers Three examples may be cited Cotton A condition termed byssinosis chronic bronchitis and emphysema with a tendency to asthma has been reported particularly amongst room and room workers in the spinning industry in Britain and elsewhere There are no specific ray or autopsy findings The literature has been well reviewed by Caminita and others 1947 Bagasse This is of interest to Australians because of the sugar industry here cane after the sugar has Bagasse or megass is sugar been extracted and is used in the manufacture of wall boards Since 1941 cases of respiratory disease bagassosis have been reported in workers handling bagasse England the persons affected were those engaged on a machine shredder which broke up the bales of bagasse Hunter and Perry 1946 reviewed the literature fully and described eleven cases one of the patients subsequently died of acute bronchiolitis and pneumonia arising from the inhalation of bagasse dust They considered the disease was most likely caused by fine vegetable dust however its exact ^tiologyhas not yet been determined Wheat Dust Investigations have indicated that exposure to wheat dust may result in asthma Duke 1935 and an increased liability to respiratory disease Smith and others 1941 The fine hairs of the grain are believed to be responsible at least in part for these reactions Pulmonary Carcinoma Where an occupation which is associated with an appar ently high incidence of lung cancer has involved dust exposure it is reasonable to consider carcinoma in a dis- cussion of pulmonary dust disease The problem has been reviewed briefly by both Dolg 1949 and incidence of Perry 1947 lung cancer in They mention the Schneeberg the high miners in Saxony and in miners in the Joachimstal area in Bohemia Arsenic and radioactive ores are both considered likely causes in these cases They also refer to reports by various investigators which indicate that workers in chromate factories and those exposed to arsenic and asbestos have a high incidence of pulmonary cancer In a personal communication Dr. J. H. Blakemore of Concord advises that in a chromate factory in New South Wales which has been operating since 1944 and which at present employs about 100 persons all workers engaged in the various stages of production have an ray examination of the chest before starting work and at monthly intervals thereafter To date nothing to suggest pulmonary cancer has been found In its early years this factory had a number of cases of nasal septal perforation and skin conditions due to chrome and relatively high concentrations of chromates were found in the atmosphere Prevention of Pulmonary Dust Disease The measures to be applied in the suppression and control of dust and for the protection of the workers are essentially the same irrespective of the industry and type of dust Briefly they include the following 1. The abolition of processes creating harmful dust If that is not possible the total enclosure of such processes in mechanically ventilated structures or their segregation from other operations in the factory Isolation can be applied either geographically or by time that is by carrying out a dusty process when no other workers are in its vicinity 2. The use of a harmless material in place of one that is dangerous 3. The removal of dust at its point of origin by local mechanical exhaust ventilation 4. The use of water or other wetting agent to prevent dust from certain processes becoming borne 5. Electrostatic precipitation 6. The provision of adequate general ventilation to dilute contaminated air 7. Maintenance of a high standard of plant cleanliness and housekeeping 8. Personal respiratory protection of the worker Respirators should be worn only when other methods of protection are not practicable or for jobs of short duration They should be well fitting comfortable and efficient and should be kept clean 9. Preemployment and periodical medical examinations including a radiograph of the chest of workers exposed to a dust hazard If these control methods or such of them as are applicable to a particular industry or process are conscientiously applied and maintained workers would be protected against hazardous exposures to dust ; Summary The term pneumonokoniosis is defined and its scope briefly outlined the need for a complete and accurate occupational history in the diagnosis of pulmonary dust disease is stressed The potential capacity of a dust to cause disease is discussed with special reference to its composition and nature particle size and intensity of exposure In addition to dusts containing high percentages of free silica others in which free silica is absent for example asbestos and certain metals are capable of producing severe pulmonary damage In most dusts asbestos being an exception the 782 THE MEDICAL JOURNAL OF AUSTRALIA NOVEMBER 25 1950 harmful particles are those less than about five size Intensity of exposure which microns in dusts depends on the varies for different and the duration of atmospheric concentrations of dust exposure rapidly developing silicosis Brief notes of a case of are given of The main occupations and dusts associated with a risk pneumonokoniosis are briefly discussed diseases In addition to made caused to by silica coal and asbestos reference is the radiographic abnormalities of certain workers and biograph operators and to the basalt effects of talc graphite cement zinc pulmonary cadmium beryllium bmaagnagsaseneasned iwrhoenataluminium synthetic abrasives cotton The occurrence of exposed to pulmonary carcinoma in workers chromates arsenic and asbestos is mentioned Measures for the control of dust and workers are stated protection of Acknowledgements I am grateful to the following for to clinical records of permitting me access films the patients and for the loan of ray Director of Public Health New South Wales the Chairman of New South Workers Compensation Commission Wales mittee New South and the Chairman Silicosis Com- E. Ford for Wales I am also grateful to Professor helpful Director criticism and to the Commonwealth of Health for permission to publish this paper References Badham C. 1927 Notes on a Fine Pneumonokontosis produced Type by Silicates and of Fibrous WRaelpeosrtfoorf tthhee YDeair ree ndc edt3o1srt DoefcePmubbleirc other Minerals Health New South 1927 page 102 Baetjer A. M. 1947 ) The Effect of Portland on the Lungs with Special Reference to Cement Dust Pneumonia Animal Experiments The SJuosucerpntailbiloiftyIntdousLtorbiaarl Hygiene and Toxicology Volume XXIX page 250 Bruusgaard A. 1949 Pneumoconiosis in Silicon Workers Proceedings of the Ninth Carbide Industrial Medicine London 1948 pIangte ern6a7t7ional Congress on Observations Pneumonitis Pneu- Lloyd Davies T. A. 1946 Manganese Journal of Industrial Medicine Volume III page 111 British monitis and Harding H. E. 1949 Manganese Further Clinical and Experimental British Journal of Industrial Medicine Volume VI McQuiddy E. Schonberger S. L Toliman J. P. La Towsky page 82 L. W. and Dusts The Jou1rn9a3 l 9 Tissue Reaction to Some Carbon Arc of Volume XXI page 498 Industrial Hygiene and Toxicology McLaughlin Talc A. I. G. Rogers E. Dunham K. C. Pneumoconiosis British Journal of Industrial 1949 Volume VI page 184 Medicine McVittie J. ~ 1949 Pneumoconiosis in Coal Graduate Medical Journal Volume XXV Miners The page 618 Meiklejohn A. ( 1949 Pneumoconiosis The Medical Journal Volume XXV page 599 Graduate Middleton L. 1950 The Pneumoconiosis paper not Etiology and Pathogenesis of Third International Conferenceyeotf pEuxbpleirsthsedon presented to the Pneumoconiosis Perry K. M. A. ( 1947 Dusts Diseases of the Lung Resulting from Occupational other than Silica Thorax Volume page 91 II Journal Riddell A. R. Employees 1948 Pulmonary Changes Encountered engaged in the Manufacture of Alumina in Pathologic Aspects Occupational Medicine Volume Abrasives Shaver C. G. and Riddell A. R. 1947 Associated with the Manufacture of Alumina V page 710 Lung Changes of Industrial Hygiene and Abrasives The page 145 Toxicology Volume XXIX Smith A. R. Greenburg L. Siegal W. Diseases ( 1941 Respiratory among Grain State Department Handlers Industrial Bulletin New York of Labour Volume XX page 33 Smith A. R. and Perina A. E. from Synthetic Abrasive 1948 Pneumonoconiosis Volume V page 396 Materials Occupational Medicine Smith G. C. and Whaite H. M. into the Incidence 1950 " An Investigation of Pneumoconiosis in New South Wales Coal Miners and its Relation to Dust Collieries paper not Exposure at Selected yet International Conference of published presented to the Third Taylor C. R. 1949 TheExperts on Pneumoconiosis VictoriaVictCoriiracular 15 Defence ReseTaorxcihcitLyaboofraBtoerriyelsliMuamriIbnyfronromnag- Pneumoconiology Pneumoconiosis Vorwald A. J. 1950 Problems in not yet published presented to the Third ference of Experts on paper International Con- Whitworth H. F. 1947 personal_communication personal_communication Wyers H. 1949 Asbestosis The Graduate Journal Volume XXV page 631 Medical Medical <9 _ PtuhebliRcespHieraalttohryBuTlrlaecttininNuImnbdievridu2a9l7s Exposed to Cotton Dust PreDveennntiyonJ. J. Robson W. D. and Irwin D. A. ( 1937 The of Silicosis by Metallic Aluminium The Canadian MedDiociagl AA.ssTo.ciation Journal Volume XXXVII page 1 1949 Graduate Other Lung Diseases due to Dust The Medical Journal Volume XXV page 639 ances of and McLaughlin A. the I. G. 1936 Ray Appear Volume I pageLu7n7g1s of Electric Are Welders The Lancet Journal 1948 Clearing of Ray Shadows in Siderosis ibidem Volume I page 789 Welders Duke W. W. 1935 Wheat Hairs and Dust Cause of Asthma among Workers in Wheat as Flour a Common of the American Medical Mills The page 95957 7 Association Volume CV XXXI Journal Eisenbud Harris W. M. Wanta R. C. Dustan C. Steadman L. T. The B. Woloff InBd.usSt.ri1 al949 Occupational Berylli- , page 282 Hygiene and Toxicology Volume Enzer N. and Sander A. O. 1938 Chronic in Electric Arc Welders The Journal Lung Changes and Toxicology Volume XX page 333 of Industrial Hygiene Firket J. 1950 Belgium December Industrial Pneumopathies conference in 1949 The Lancet Volume I page 225 of GaSirldinceosrisL. U. 1938 Experimental Pathology Section V and Asbestosis edited by A. University Press New J. Lanza Oxford York page 257 Indus- H. L. Durkan T. M. 1939 Survey in Brumfield D. M. and Sampson pheric Dusts and Seventeen their Effects Cement Plants of Atmos- Hundred Employees The upon the Lungs of Twenty Journal Toxicology Volume XXI page 279 of Industrial Hygiene and Harding H. E. and Oliver G. Lungs Produced B. 1949 Changes in the Industrial MedicinebyVoNlautmueralVIGp raagpehi9t1e British Journal of Hatch T. F. 1950 Analytical Requirements for of Dust Exposure Third paper not yet published Appraisal presented to International Conference of Experts on the Hunter D. and Perry K. M. A. Pneumoconiosis 1946 Bronchiolitis ing from the Handling of Bagasse British Journal Result- Medicine Volume II page 64 of Industrial International Labour Organisation national Conference of Experts on 1950 Third Inter- MEDICAL JOURNAL OF Pneumoconiosis THE AUSTRALIA Volume I page 514 Jephcott C. of Alumina M. 1948 Fume Exposure in the Manufacture Abrasives Review Chemical Factors Occupational of Associated Physical and Johnstone R. T. 1948 Medicine Volume V page 701 Occupational trial Hygiene page 265. The C. V. Medicine and Mosby Company St. Louis THE CHANGING FACE OF OBSTETRIC INFECTION By ARTHUR M. HILL M.D. D.G.O. Melbourne F.R.C.S.E. F.R.C.O.G. Gynacologist to Patients The Women's Hospital Melbourne THE last fifteen years of the century have seen the greatest advances of all time vention and treatment of obstetric infection now ending in the preThis is due predominantly modern to the introduction and development of tant chemotherapy and antibiotic therapy but impor- contributory factors are improved bacteriological knowledge and methods of investigation and a clearer appreciation of the place of maternal resistance in com- bating infection It is proposed to review the major effects of these advances on puerperal morbidity on the death of the main bacterial types of puerperal and rate abortional infection and on modern obstetric practice at the Women's Hospital Melbourne over the past ten years During that period period 41,643 women % of whom had attended our own ante- natal clinics were confined and 18,285 cases of abortion of which 5175 were diagnosed as septic were dealt with The annual morbidity following the confinements is shown in Figure I. Sulphonamides were in use in the earliest of general years although the compounds employed were in general toxic and less efficient than those now avariemleamibnbfeeclrtieoend obstetric addition they were not always given in adequate and their use was largely restricted to the established infection However when it remembered that less than 10 of all cases of sulphonamide sulphonamidseulphonamide likely to be of a bacterial type responsive to sulphonamide years more avilable In dosage dosage of are sulphonamide Gynecology Read at Association meeting Section sulphonamide a meeting of Medical Section of ObstOebtsrteitcrsics Obstetrics Australasian Medical Congress British June Brisbane Seventh Session Brisbane June Obstetrics 19159050 and Medical therap in pu antibi 1944 i freely coinci therap tion o Routin Gra of penic every t followed be given figures incidenc standard morbidit patients wh ~~ YEAR m PER fe ws DEATHS ww Year #MC D Of consi in in the me main bact during the Hospital problem of that of fo cocci Stre pyogenes & serious ty Bacterium streptococc will not b four main