Document g28X019NJmw52evedKgBOwDZe

- %*::Vr.?'.'- '! SOI THE 'MEDICAL JOURNAL OF. AUSTRALIA ' .Mir 21. 1940 OCCUPATIONAL DISEASES OF THE CHEST. _:sbarp margins of the ravtiiac silhouette (Figure I'). EXCLUDING SILICOSIS.* ; ^Occasionally there are scattered, granular and punctate . mottled shadows, but these have not the weil-defiued : margins' :of the coarser silicotic noduiation. liy M.WSK-E Joseph, **i.R.C.P., F.R.A.C.F., , ' Hislologfeally. asbestosis produces . diffuse . fibrosis, Honorary physician. Thoracic Unit, Royal Prince 1 starting mainly around the terminal bronchioles and. Alfred Hospital, Sydney. . * atria as collar-Ilke ebeaths and extending peripherally as tbc disease progresses; It produces profound thickening `r-Vt* ` ' ' .of the alveolar walla, the interlobar septa and the pleura, Eves if one excludes silicosis, industrial lung disease is and throughout the lung/tissue are seen fibres of asbestos still a tremendous subject and far .too large even to . 'either singly or-In clumps, as well as the characteristic attempt to cover in one short lecture. 'I propose, therefore*' asbestos bodies. ' Those parts of the lung not Involved In to limit my remarks to two conditions which have come the fibrotic process oaturally become emphysematous. - within my personal experience more frequently than other Industrial lung diseases---namely, asbestosis and coal* . Dyspnea is the outstanding symptom, and.reduction of -*workers' pneumonoconiosie. Also I shall deal with these respiratory capacity will be progressive unless the patient ' '' from the point of view of the thoracic physician, and not that of the industrial hygienist Is removed from dust exposure at a very early stage of the disease. This Is readily understood; because the primary tfjTVj . condition Iis pulmonary fibrosiss - which becomes mors * Tbe U5<* of asbestos have been known for over two ; marked with tbe passage of time even'if the subject is ^.. thousand years, one of the earliest references to it being-.' .r.e_m__oved _fr_o__m___c_o__n_t_a_c_t__w__i_th_ t--he duust .Pleural thickening Herodotus in 450B.C.; he described how the Romans :.*and emphysema are. natural sequels and add 'to the u ,n tbe *uliaD Alp* and Urals and used It for*>vpatient's increasing respiratory disability.--.He becomes (4?5v08hroudinS tbelr corpses before cremation. .The name. Tillable, to chronic, or recurrent bronchitis; and ultimately N 'asbestos" is derived from the Greek meaning "inconsum--;. to the development of coy pulmonale... , able", and Plutarch referred to the wicks .of the lamps of &the Vestal Virgins as "asbesta". The dust assoclited with the handling of asbestos crested difficulties in those days -^''.^v-j^as at present, and Pliny is a.n. SO referred to the -use of 'jU.'V; respirators to avoid the Inhalation of dust ` * . . %. FrcSrn a study of 5 patients with asbestoslsr Hugh Jones, John-Read and'Roger Williams'(to be published) con* eluded that the primary disability wad a diffusion defect, 'as -would bo expected from the thickening of the alveolar walls. They also found that those patients who had much 'The Australian production of asbestos is not Urge: It''fibrosis had'diminished vital eapacities.but noapprecTable amounted to 2500 tons in 1054, of which all but 460 tons . 'reducUoa-ln maximum breathing capacity unless bronchitis ` came from Western Australia. This by no means satisfies .:'was. present. . tbe requirements of industry, and large quantities are.*-.1' -a * ' . ` imported, mainly from South Ajufrriiecas,. Iitt aarrrriivveess Imn skaicckkssas the crushed rock, and men emp. loy. ed in em.pt.yin.g these > ' x patient-recently studied was a man. aged 47 years, history'^ exposure to asbestos dust from 1927 until with.. 1954.- -when he-lSit the industry because ot increasing dyspnos. have been exposed to a high concentratioAnn o* f th*e: dust., - He h_ad jrof_ked m_a_in_l_y__a_s__a__lagger _a_nd-a_sbestos-m_attr_ess Asbestos fibres of extreme fineness can be obtained, spun; -.maker wfth' various firms, with a'break of four'yeirs during Into yarn and woven Into cloth which has a great variety:' which he served with the Royal Australian-Air Force. He . of uses. In addition to"being woven. It can be ground and :was dyspncele -on mild, exertion, and had a plethoric fades .' ' mixed with other materials to make insulating slabs," 'and definite dubbing of the fingers. Medium crepitations boarding, brake and clutch linings, electrodes for welding,' '-were heard over the lower lobes of both lungs, and an X-ray - acid-resisting filtering elotbs, packings, jointing* and- wrap* IjVyt pings for steam pipes. The dust given off in the process I* mostly less than 5a in diameter and 10a In length. As1 examination of bis chest,showed the appearance aeen in Figure II. It is interesting that the 'film token three years ago (1957) was passed as normal, and It was seen from a comparison of these skiagrams that the fibrosis has mainly other dust diseases of tbe lungs, the occurrence of developed ,sfint[c, ep hliTe l.eft the absestos Industry. The respiratory ..asbestosis depends upon the concentration of dust to which . *unction'*tests "were carried out by Dr. John Golebatch, with &b.K?,r;t'vhue wwowrkmeri is ce&xpyousaevud anudh voa tuh*e uduratuiounu eofi mexp^vosuriec^..: ^ mthe tfoullowing ressuults.' The. vital, capacity was - 3*8 litres *j7^ti' Tluhcerree aaarrrmee.. nmBecavvoeacarrtituhheealilaveaMsas,;silicosis, among workers I4unni<dutiliwvmiMdu<uu,ai1il vwairsiautoiounis,,; as wwwiiutthhu':':,,-.'(1\1jA0wA0O7%LV), -thhe, maximal .breathin.g c.apa.city.wa.s' 12 litres p. er apparently, expoaed .to'similar'- minute (72%), and the diffusion capaelty^for *earbon xnon* eTv`conditions. *-. ' - v- ./.v'^oiide was 10 (66% .of normal). .- __ gradually increasing intensity, often with a cough which Is g.en.e.ra.lly non-p..r.o...d..u...c..t.i.v..e....... There are a--sualiy no physi*c-a*-l %&re signs in the early stages of the disease, but later rkles ,s?cdevelop, with evidence of impaired respiratory.function and cyanosis and clubbing of the fingers In advanced cases. jfV;-.'-'*.*.;.'As was mentioned previously, the cough.Is mostly non- nroduetive. but examination of the scanty soutum produced *t>l- Clinically the mode of presentation Is with dyspnoea ofr* ment, the main detect is In the matter of diffusion .across thLeaasltvOeocltdo-bcearpaillagroyump eomf bsriaxnme.en su. fferin- g fro\m: , asbesto'sis was examined. They , bad all worked for a period of approxi mately ten years in-what was known as the "asbestos gang": whose work involved emptying 'bags of Imported asbestos Into a crushing machine. All'complained of dyspnoea'sod central asbestos fibre bare. Asbestos bodies obtained/. appearances'was not-close. * ' 'i-n a .pur.e. state b.y .try.ptic dig_estion of the lung-s ha,ve been: Asbestosis-is not only a crippling disease in Itself, hot found to consist of approximately 70% organic matter nd . renders the subject more susceptible to two serious 30% inorgani^jnatter^ They may be found In sputum diseases. The studies of Wood and Gloyne and of Middle before there' is any'^adidlogkaj evidence of asbestosis, and ton and McLoughlln indicate that there is ah Increased must be regarded as an indication of Inhalation of asbestos susceptibility to tuberculosis In patients with asbestosis. dust, but not necessarily of clinical asbestosis.-* although this has been questioned by other' workera " vRadioIogicaily the appearances are fairly characteristic.-.. Studies by Doll, and by Lyqch et alii, both la 1955, indicate ..Usually there is a diffuse haxiness throughout the lower:!. q^u--ite-d--e--f-in--i-t-e--l-y--,--t-h--a--t---c--a--r-c-i-n--o-ma of t--he- lun.--g has a-.hig-her 'long fields generally with obliteraUon of. the<normaiIy lnddence-In asbestosis sufferers than in the general popu- - . -<iKtiaw.- This high Incidence of bronchial, carcinoma bss^ at a meeting of the New South Walee Branch of-lhev'-*-.---- CSR-540 *5-* ,>! *' r iSnr *r tir &*. / ". ` - THE MEDICAL JOURNAL'. OP 'AUSTRALIA 33806 '.' -Yu en confirmed by others sod is widely accepted. Doll's of the terminal bronchioles, but dlstally extends tor a itiysis-haa shown that the average risk amoag meu variable distance op to the division ot tbe final order ot \ aployed In asbestos tor 20 years or more has been tea respiratory^ bronchiole, ot which there may be three,., aes that, experienced by the general population.; . depending upon the degree of dust accumulation. In the : ^ The second, topic I wish to present is coal-workers' course of time tbe ensheatbed bronchioles dilate, producing . icumonoconiosis, and again In the time available only what is known as focal emphysema. Until Heppleston's ' rtain^ aspects can be dealt with. The coal deposits of work (t was generally considered that focal emphysema... 2W: South -Wales are the most Important and'extenslvely was the result .of obstruction ot air passages by dust .'-'it orked in Australia, and are situated in the vicinity ot fibrosis.'-This* histological condition ot focal emphysema A`- eweaafle; Bulll and Llthgow, being referred to respee- .forms the basis on which It is possible to understand she '; rely as the northern, southern and western-coalfields, -'dyspnoea /of simple pneumonoconiosis. As respiratory." pproximately! 13.250 men;are employed in these^ines; :d-tbe extent of the pneumonoconlosls problem chn.be luged by the fact that at present 870 men are receiving '-'.-bronchioles'dilate, their cross-sectional area, and therefore;:-' .their-'volume, increases In proportion to the squares of..-' their radii. This is equivalent to an Increase in the volume ' xnpensation for this condition (420 total and 450 partial), o'functional'dead space, and leads to deficient aeration of great deal of work has been done on this subject1 by the .the'dually placed segments ot tbe airway. /AJ 'elr' National, School of Medicine at Cardiff, and our A -To . 'add ' -to * the ' coal-miners* disability, generalised io\ ft of the pathology of the disease is largely based vesicular emphysema not Infrequently develops. TbU is ' i the'observations ot Professor J. Gough. In oar own -'distinct from focal emphysema, and is characterized byr^.ljjg ate, pioneering work was done in this field by the late' : dilatation ot alveolar ducts, atria and alveolar sacs. The ;; tarles Badham and-carried on by Dr. W.-E. George and -'.cause of tbU condition in coal-miners is the same as that-vAf hers. -iS> V .... '. ,;la the majority .of non-miners who develop emphysema--o; It was'onee thought that miners who developed paeumono- A namely,, chronic bronchitis. Pemberton bas shown by a >nlosis did.so Ith coal -dust, because of the inhalation ot.-sillca and that the coal dust Itself *was mixed inert. .. careful:. comparative study that chronic bronchitis approximately, three, times as common In coal-workers is as -A ' R. James has zhown that the dust to which the miners ^ In other Industrial groups.* .In case it could be considered-"-.-^? ' South Wales are exposed rarely contains more than 1% ''that smoking was a factor, be investigated this possibility ea silica; moreover. In 100U cases of coal-workers' and -found that a greater proportion ot tbe coal-workers veumonoconlosls studied by James, 19 subjects had were lifelong non-smokers or had given .up smoking, than orked ag trimmers loading coal into the holds of ships -d had'' never been underground; seven ot these bsd in the non-mining groups studied. There was also a conalderably lower proportion ot heavy cigarette smokers influent massive fibrosis. This aecords with Gough's among the coal-workera. It would he surprising It the 1940) findings, and disposes ot the theory that the con- inhalation- ot dust-laden atmosphere over a long period ition is due to highly siliceous dust from rock strata ' Jjacent to the coal seams. Moreover, the pathology la did not cause such mechanical IrrlUtion as would, in thelong run, lead to the development ot chronic bronchitU.* .- iffarent from-that of silicosis. ` i.-f. ... - Radiologically, simple pneumonoconlosls is characterized ilper::isnrosidhgTaompsndcleauheenoev.arralp*enitiyddu*itrsicti'amocuio-dtsobflatpetsaiosffotulvha,hpsctfeatrceahotepalvtIhtocaosritraaIcsaetepvrnorar,snetmtydrpic.ipsc'smbiapdeev,lhIyeeeennniypsdeovadtost-oennuretosisfhleoramoofitset.lttplaooeu;hhrpsngtebdenah.gaitlesrecataeinsgtvaunatrtdriemhlTdnenThnehpeptgoahieauenvapeeIastltecdothmefoenmfuceycdidcoolbnsloi.tafianenehiasteoiielramnpeccoixlntorchtastisoyeyegdellsrIsniurnsdcooidtscvadutfoi*toseoalsftekmprhIc-ftaeetetoe.srhefstndeanheeted,dnsacce,lapfabietlb''fouo*sfopsnau*irnnauocnltns'tisrlcgnceuadehnufwltitaaiomtltowtihnnnteatntohooeddeosr,-.';;.-...."'ebo2wccpyff0ntrlh4eo-otouyfaoa5ie5alnosetlsmtairiutdlnoftsgoioSiaabintn,otegspobi'eenato1numyihlurcs5leohpceteaouhuSeorcstsspmrleiydmofsisamsWosifoI.cvtistnisepsbisteahItntmounrinlieoedspsitofsfnsheseaidawbUderhvicsiard4mocioosamect0oufsunutpsoa%ioareipdborcsertlltlep-oeimsr"edtywioge.eirbgrocio.dofrenigncburrdgetakyylaohwTTnelhnuehamIhehrtaa,ds*uneriias.sncambdy2shIdlelsnaoboeaearcfsSwecbhcesognlseuacaiacnredninvelusvsctsorcieesratoU3seeimd.brnifmlUslrioyeiee.ies.iobioesdtInpnelnnisoooutgJ*stfgniit--taAsneshtcisimeclondwoattramhhdemmpettloshsaiferlfImleoeiuefe-ttzidmiscvgrceonreaiuhinedaIssnn"sflelrs,1etryotektno9ute*omebc5itmiInlrnondun4eeea--...-' vs Vtv' ;OT "`ttggl Duat particles"greater than 10m In diameter seldom reach* believe that the bacilli penetrate into existing massive ie long alveoli, either settling out ot the atmosphere or lesions, one must postulate that the organisms reached cing filtered off by the respiratory tract; however^ their situations by being inhaled before or wltb tbe dust. articles less than 3m can reach the alveolar spaces In These lesions sometimes cavlate, causing tbe production , irge numbers. Here they are taken up by phagocytes of Intensely black sputum which bas been likened to `hlch apparently originate In the alveolar walls, and then printers' Ink. Confluent massive fibrosis bas been divided ither are watted upwards -gpd goally expectorated, or into categories A, B and C on the radiological appearances ater the lymphatic vessels end are transnorted to the of Increasing severity. .mpbold tissue ot the lungs and thence to the hilar 5 *In 1953 Caplan described another form of massive mph nodes, from where they may travel to the scalene ' fibrosis, in which tbe round opacities were multiple and odes which are accessible to biopsy. Still other pbago- well defined.'and distributed throughout both lung fields, ytes .with their carbon load gather in foci around the but particularly at'tbe periphery. These lesions occurred esplratory bronchioles, where they constitute the eharac* In coal-minera with a mild degree of simple pneumono eristic lesion of coal-workers* pneumonoconiosis.' -These coniosis who also had rheumatoid arthritis, and were jslons are stellate and intensely / black, are scattered shown to be histologically distinguishable from confluent arougbout the lung,.and vary in diameter from miero- " massive fibrosis. The condition has been given the name eoplc dimensions to about S mm.; but they contain com- . of **CapIan'a syndrome". '. arativeiy little fibrous tissue. Gough, by tbe use of whole- jog sections, has demonstrated these lealous beautifully, howing all gradations of simple coal-dust pneumonooniosls. , In reeent years It has become increasingly recognized that severe'respiratory disability can exist without radio logical evidence of pneumonoconiosis. There is a category 0 in coal-workera* pneumonoconiosis; that is, significant Gough pointed - out the essential difference between' and even disabling d^ease can exist with an X-ray picture an i-\ illcosls and coal-workers* pneumonoconiosis. and described In which recognisable dust opacities are either absent or he characteristic focal emphysema of the latter. 'How- sparser than in tbe sundard category 1 film. I have seen . ver; It remained .for A. G. Heppleston, by painstaking a .number'of such patients from tbe Cessnock mines, and crlal section technique, to demonstrate that the proximal . the deUlls of one patient who had a lobe removed because .mlt of this sheath of dust cells Is regularly in the region :of a suspicious apical lesion will illustrate tbe point. THE MEDICAL JOURNAL : OF AUSTRALIA Mat'21. 19*0 ^ The patient was a man. aged 64 yean, who hd been a vainer for 40 year*, lie hnd first noticed dyspnoea three years before he was referred to me on June 19.-1958. This ' had reached the stage at which he said he found it difficult a worker with severe disability due to bis occupation may t .have no radiological evidence of poeumonocontosls. , . 4. Tests of respiratory functlou such as that of-the' to walk out of the pit. and even the exertion of bathing and maximal .breathing capacity and timed vital capacity, in - ' dressing caused breathlessness. He had only a slight cough, conjunction with-clinical evidence of respiratory disability; and the sputum he produced was white and frothy. Hie chest skiagram in 1936 hnd been passed at clear, but a current one showed an opacity At the apex of the right lung (Figure V). Tulierculosis was considered the most likely diagnosis: but repeated sputum tests gave negative /'results, and because of the possibility of carcinoma provide a better Indication of the state of the worker's' pulmonary health tban an X-ray examination, and should supplement tbe latter in tbe regular assessraent/of the miner. .' .... x Acknowledgements. . ' thoracotomy was advised. Clinically and radiological!/ the patient appeared to have marked emphysema, and this was confirmed by respiratory function test carried out by .Dr. . Colebatch. His vital capacity was normal (3-41 litres), but *" the maximum breathing capacity was considerably reduced. being 36*3 litres per minute (36% of the predicted value). My thanks are due to Dr. R. Hughes,-of the Msnufac-tT ` turers' Mutual Insurance Company, for the X-ray films - l* - of tbe patients with asbestoais, and to Dr. K: 0. Outhred i. and Dr. J. Colebatch, of tbe Joint Coal Board, for certain figures.and X-ray .films relating to patients with coal- :' '* - The total lung capacity was 136% of predicted level and . miners' pneumonoebniosis. I sm also grateful to Mr. : * . ' tbe residual volume 161%, giving a residual volume to total Woodward Smith, of the Department of Medical Ulu8tra-.: A lung capacity ratio of 63. He was subjected to surgery, and .tlon, University of. Sydney, for tbe photographic rspro- .!$ *.* although a less extensive operation would have been -.'preferred, a right upper and middle lobectomy had to be - performed because of technical difficulties. The lesion . ductlons. . , ' . Bibliography. . .- . . -..S'-.'dv,w ,. "'.Ui > ' proved to be tuberculous; but the Interest in the case is the . fact that examination of the lung sections showed a marked s. /.degree of pneumonoconiosls, despite tbe absence of dust opacities in the skiagram (Figure VI). , CaTuX, A.. (1963), "Certain Unusual Radiological Appearance* in the Cheat of Coal Miners Suffering from Rheumatoid Arthritis", There.r, S: 39. .. Casiwhtbi, R. -O., CoamuKB.'A. X*, GixAoh, J. C-, and *.' . Htootus, 1. T. T. (1966). 'The Relationship Between . j -y` > The lack of correlation between tbe radiographic appear* * -Ventilatory Capacity and Simple Pneumoconiosis in Coal-- ;. ,,-;:-aheea of pneumonoconiosls and tbe degree of respiratory . ' workers", Brit. J. induatr. Med^ 13: 166. . ,;V.-j- disability is also exemplified by studying tbe respiratory function testa of tbe patients whose - skiagrams I < nsed -.`.to demonstrate tbe radiological categories of simple 7 DotA, R-* (1956),."Mortality from lung Cancer ia'.Aebastos /-V| - Workers", Brit. J. nduatr. Med., 13: 3L - ' *. A*-: Goook, J. (1940), "The Pathology of Pneumoconiosle", Pm(- pod awd 36: 611. . . - pneumonoconiosls and confluent massive fibrosis. Reference Couoh, J. (1947.)* "pneumoconioela la Coal Workers in Wales",.. Vl to Table 2 will show that a man in category 3 can bare Oceup. Mad* 4; 66. _ . , \ ... * ` .; . - Timx I. HsmwroN, A:\fi. (1963).'*The Pathological Anatomy of . Simple Pneumbconiosis In Coal Workers?, J. Path. BecL, , ' . 66: 336. . .. .. . . r ' of Bupiratary Paretian TrtU m Petfrvt* teki Caal-Waritn' J`naamaneeaniatit. HhKTWi. D. (1966). "The' Diseases of Occupation", .Ksgiiah Universities Press, London. . Vital Cipadty. . * Xaxlmel BreaUUnc CepeeUy. - Jambs, W. R. L. (1956). ."Primary Lung Cancer in South . Wales Coal Worker* with pneumoconiosie" Brit J. .. fnrfittfr. Mad., 13: 33. .. ". Jasias, W; R. 1,. (1967), "Paewnoeonlosia". Srtt J. glim, Prsc, jC>lseyy. A*. (Teut.) Yan In Rise. Dim rfSh Per- ee&u*e of Kennel. Zitree per Waste. Pereeatege Hamel. T'iLy.:-:' T.L.C.* ' 4.* - ' * .. *. Hi 164. . Y * ... .* .- ``Jakss, W.'JL 1a '(1964), rThe Relationship of Tubercalosls to :4i ' .1 the 'Development' *of Massive Pneumokoniosls la Coal - h,f .. .,--..Workers",-Brit J. Tsbere., <6: 69. ** .* = ?4V -* -Kttfanucae, O. &, KavrumroK, A.'. and Furcicak - ..-<1964), "Cavitation in.the.Masaivs FlbrosU of Coaiworksn*/-: ' . Pneumoconioela", rkores, 9: 360. . , ... X- 1 1 -A .63 *60 H S3 39 4*0 33 3*3 33 4-e 45 3-8 106 S3 ue 130 M 49 W1***''' Moaitow. C. aad-CoKaK, A. C (1969), "Pnetanocoriibaii",,. j 77. S3 ' . -80 . - Mai, Cite, V.' iwin-y 43: 17L : *:; s*. 86- 81 88>. 'Psmbwtoh, J. (1966), "Chronic Bronchltla, Emphysema and. -Bronchial- Spasm in Bituminous Coat Workers", A..M.A. .Y* 94 106 * 88 .* ./; : Arok. Uduatr. HUH, 13: 639.. . . : . . w -'.L. *,.1 B 70 33 1*8 so 30 84 86 ' . C . SO . 30 4*1 m 74 73 -S3 /;* Batto ef meiduel voluat to tobil Jni cspsdty. - ", (YDATID DISEASE IN A CHILDREN'S HOSPITk^'^*'* * ' - " 'Considerably less- respiratory disability., thas-r^one -in' *" ' * ' ikriio Category 2; that virtually'no" respiratory disability may j .exist with category A, confluent massive fibrosis, and a jfv:',fcategory c man may have appreciably better, respiratory i function than one in category B. As long ago *as 1948 Vv'iV-/Fletcher described tbe case of a coal-worker wbo was tbe raj:*..:'f.; local champion for tbe 76 yards sprint and whose chest- w%v-*`ft skiagram showed progressive massive fibrosis.**: gs*-;.. ........... Sixes 1938V72. patients with bydatid/diaeass have been admitted to the 'Royal- Children'* .Hospital, Melbourne. : -YEleven of tbese^ere teen for theJrst time in 1967./Tbe:J *- continued prevalebce of hydatla disease provided .'the' stimulus for a.-revKw of the/pmdiatrlc aspects of tbs.) * ' Conclusions* ' > condition. InfortoatioK. obtained from other centres Sa w %' ' From tbe foregoing, as well as from other published Australia indicates tbaVjfie problem is by no means; E*;*: /_ work which time prevents me from Including -in. this ` purely * local, because 1009 patients with hydatid si paper, the following conclusions must be drawn, * ..disease have .been.>d^fitteokto public boepitals ln>the af.r*.j| Y L The respiratory disability of coal-workers is primarily jrJ/`-."an airway diseMe^and ls-_due to .(o).. focalempbysema Wh-- V:and' (ft) chronic bronchitis and- generalised vesicular , emphysema. . ' - Capital-cities of Australia during tbe past, twenty years.* A* further 86 patients with pulmonary bydatld disease; have been-treatmr by Dr. S. C. FXxpetrlck of Hamilton,; Victoria,.Since ;^S20.. *. V. *. i I**.:'*:* *' i. There Is no correlation between respiratory disability *Y.Clinical Material.''^- * * ' and tbe X-ray appearances in tbe chest ` * Sixty-seVea of tbe patients were VictorObL three werei ` A In tbe mstter of determining compensation, tbe referrejK from Tasmania .and two came, frobs southern . X-ray findings in tbe chest may be misleading and unjust New>south Wales. Thirty-five of the Victorians, patients- in two directions: (o) a worker with radiologlcaliy evident living in Melbourne at tbe time of their aotoisstoa pneumonoconiosls may have no respiratory disability; (b) *tfThospital. Some ba^ previously lived, or spent holiday: