Industrial pneumonoconioses, with special reference to dust-phthisis

1915.

PUBLIC

M I L R O Y LECTURES INDUSTRIAL WITH

(1915).

PNEUMONOCONIOSES,

SPECIAL REFERENCE DUST-PHTHISIS,

TO

BY

EDGAR L. COLLIS, M.B. (Oxon.), H . M . Medical Inspector of Factories. Continued [rom page 304, sept. " Public Health."

DUST-

PHTHISIS OR SILICOSIS.

PULMONARY

P r e v a l e n c e . - - T h e recognition of an intimate connection between dust inhalation and phthisis, a connection which has been emphasised from the earliest times b y writers on diseases of occupation when discussing certain dusty trades, was d e n t with in the first lecture. Popular recognition is also to be found in the common use of the term " rot " applied to the disease when it occurs among potters, masons, grinders, and knappers.

The data of Table 7, however, show that phthisis does not occur in excess in all industries in which dust is generated, b u t only in some (this point will be discussed later when causation is considered); and, that when phthisis is in excess the mortality experienced differs statistically from that of ordinary pulmonary tuberculosis (i) i n being always associated with a high mortality from bronchitis, b u t seldom, if ever, with a high mortality from pneumonia (points which have already been discussed in the previous lecture) ; and (ii) in exhibiting a latent period before it is fully manifested (varying with the intensity of exposure from two years for Transvaal goldminers to ten years for sandstone masons). The writings of Alison and of Peacock, already quoted, contain references to the comparatively late age-incidence of dust-phthisis, and many later observers have dwelt upon this characteristic which I have ventured to speak of as a " latent period." Statistically the existence of such a latent period is well seen in curves representing the phthisis mortality of certain classes at various age-periods. The curve for the shoemaker so closely resembles that for Occupied and Retired Males as to suggest the inference that the disease is due to the same predominating influence in both classes acting with varying degrees of intensity. Givre, who used this method of determining the influence

HEALTH.

1I

underlying an undue prevalence of phthisis, concluded (27), because the curves representing the annual tubercular mortality for silk workers and for the general population of the town of Lyons were parallel, rising and falling together and never crossing, that tuberculosis among these workers, Mthough more frequent than in the town, was due to the same influences as affected the general population, only accentuated b y the conditions of e m p l o y m e n t - - " la m~me cause efficiente agit sensiblement de m~me." Since phthisis has been stated (64) by a Committee appointed b y this College to be infectious and acquired, the curve representing the incidence of the disease among the general community, represented b y Occupied and Retired Males, m a y be taken to represent the effect of infection upon the community. Hence the deduction may be drawn that the predominating influence for the shoemaker is increased exposure to infection. In the case of the tin-miner, however, the curve is very different; and the latency it shows suggests some influence requiring time for full development. Probably this latency represents a period during which a change favourable to the occurrence of tuberculosis is slowly taking place in the lungs; and the condition of pulmonary fibrosis which is known to be present is direct evidence of such a change. The curve for publican, inn servant, gives a similar indication; and probably tile latency in this ease represents a period during which the tissues of the body as a whole are being adversely modified b y the influence of alcohol. Statistics m a y also give further assistance in pointing out what influence determines an excess of phthisis present in any given class. These influences may be grouped as shown in Table 8. Now, a localised influence, such as a dust which predisposes to phthisis, chiefly affects one organ, the lungs, and persons exposed to such a dust m a y b e expected to suffer also from other lung diseases, b u t not necessarily from any other cause (see Table 9)A general influence, such as alcohol, affects all the tissues of the body, and alcoholic subjects m a y be expected and are found to suffer in excess from other forms of disease. In the case of increased exposure to infection, on the other hand, no reason exists for anticipating excessive mortality from any other cause, nor do we find it.

~

"J# =

I

l

f

243 125

55

576 108 100

103

102

.

.

.

.

1'8|

0"93

0"81

0"95

0"64

I'10

3"27

''

1-73

1"40

1"36 2"02

NO

7-00

2"03

2"17 3"78

3"43

1-59

I"64

0"88

2"59

7,'32

1"52

1-76

2"86

2"35

0"89

2"46

2"34

I

III

1'84

2'39 1"92

2-24

1"88

0"83

2-19

1"44

2'24

1"71

2'15

1"79

0"70

0.15

0*81

1"51

16"4

24"5

14"6

36"5 30-0

34"5

23"4

13"9

13"2

13"0

14"9

17"7

16"0

11"5

10"4

9"0

10'6

9"6

44"5 24"0

47"2

71"7

21-3

43-2

21-3

2]-6

13"6

39"3

7.1

23-6

8"2

7"I 16"3'

6"I

5"7

3"9

5"8

5"9

4'7

5"1

9"4

9"1

5"2

16.5 52.6 19.4

15.5 31-1 2o-s.

In Exce~z

Normal

Nopn~al

In Excess

Some excess late in life Exeee;s late In life

Low

Normal slight e x c e s s

Nov,real

Low

Low

5"8

13"I

4"2

9"4

1"4

7" I 7-2

4"4

' ""

'

Normal

LOw

In Excess

Low

sltght excess

Some exce~s slight excess

Some exse~s

Low

Normal

In Excess

In Excess

Low

Low

Low Low

Normal

Low

Low

OF PNEUMONIA

Excess Low

Exce~s

.Ab.1. . ~ ' i a ~ , S t , t ~ c a l

44 53 to 54

43 to 44

4 8 to 4 9 45 4 6 to 47

39 to 40

44 to 4 5 4 5 to 46

37 to 38

44

4 2 to 4 3

37 to 38 42 44

39

39 35 to 36

35 to 36

35 to 36

33 to 34

38 to 39 39

39

36 to 37

4O

38 to 39

AT DEATH FROM PHTHISIS

MEDIAN AGE

IIIIIIII

]

I

'C';,'~,,te.g . . . . . . Hc,lh.... W C. "

Low NO Exoe;s

Excesz

Not k n o w n Low EXCess o n l y a t 2O-& 2 5 Not c e r t a i n Low

Not k n o w n Excess

In E x c e ~

In Excea~

In E x c e ~

In E x c e s s

In Excess

2"0 In Excezr~ ~1"4 " In Exces¢

1"5

1"3

0"9

1"~

1"4

1"5

1"1

1"6 2"0

0"8

0"2

t°0

1"4

75"0 GO'O 25"0 2"9 35"3 21"6 19"7 9"3 1"9 5"0 33.7 21.1

26"3

68"1

12"8

41"9

25"6 22"4

7 5 ' 0 84"4 37"2 44"9 23"1 35"0 35.3 30.6

45"7

69"8

34-0

52"5

70.0 65.6 66-5 50-0.36-2.28-4

33.3

28"6 27"8 45.0

50"0

46"3

35.4

31"3

37"5 37"0

34-6 41"5 29-4 19"4 50"0 48"8 51"3 34"5

38-7

46"7

26-9

18"4i 13"4

18-0

2 9 " 8 19"3

33"8! 24"1

5 6 " 8 49"4

38-3 21"1

23-2 14"6

6-0

4-9

~'3

OF BRONCHITIS

IIII

PREVALENCE

I IIIIIIIII

PREVALENCE

TE=--AII figures in excess of the stan~ar~ for uccup~ed and Retlred Males are underhncd.

-

-

--

--

--

31"3

6"5

19"1 12"6

26"6 17'0

1 6 " 6 12-8

29"5

34"0

50"4 ~ 45"6

37-5

18"0

33-2

35"4

OVER

SgAND

PERCENTAGEOF ALL DEATHS AT A;E PERJOB

~ oOVER , . o , . ) o _ 1 , . ) 5 _ , 1 3 5 _ 1 4 5 _ . s s, _ ~

11"71 16'06 16-2~ 14"75

3"82 7"26 4"85

2"83 4"10 2"56 9"01 11"10 9-01

2-98 3"75

2"26 ~ ' 8 9

0"99

I'25

1"62

1 " 1 9 1-47

1"20 1'43

0"77

1'01

4"41 4.40 3"21

4"22

2"04 2'11

1"60 1"00

1"02 1"16

2"89 3"18

2"64 4 " 1 2

1-53

I'40

1"10

2"14

i1"7(); 2 . 6 5

2"38

1"01

0-89

0"90

1"13

1"65

2'95

2"11

1"23

0"12

1"09

1"60

$5-

PER 1,ooo LI¥1ND AT ~OE PERIOD

.o_1._1.:1.._

• Calculated from data given in Annual Report on the Health of Shei~eld for 1913, pp.

Limestoae GFanite

Sandstone,

|54 69 312

294

do.

439 263

i,067

4.47

148

255

409

149

403

1,806

1,133

368

83

1,254

61,598

'TOTAL NUMBER OF DEATHS FROM PHTHISIS

do.

do. do.

do.

do.

do.

Sand) C~a¥. EmePy 1 8 9 3 - 1 9 1 2 Metals CP~arGeal Metal & Quartz 1 9 0 8 - - 1 9 1 2 [vletal~ Bone~Emepy do. Linen~eto. Quartzite 1891--1911 Quartz 1910--1912 C a l c i u m Cal~bonate do. Q u a r t s (1/3},Felspar 1 9 0 1 --1919 ' & Mica Sand, Clay, Emery. 1 9 1 0 --1912 M e t a l . Chae¢oal Metal w~ Q u a r t z do. do. S~ate

Sawdust Metal Quartz~Bon% EmePy etc~ Clay a n d Flint Quartz

C o t t o n debris

WOOl d~bpiz

Clay

do,

do 0

Coal ~ Shale etc. Coal ~Sl~ale etc.

do.

do.

do.

do.

M a i n l y Coal

Coal only

Indoor Industrial do.

do.

do.

do.

19OO-190~

PERIOD UNDER REVIEW

~ Calculated from data courteously suppligd by General Register O ~ c e ,

Grinder of Metals S~ate Q u a r r i e ~ , W o r k e r

M e t a l Dressers & G~azePs

Dresser Mason

Ganister Workers ~Stone GetteP

~

~ Sheffield I G r i n d e r s Cut lets

Dresser~ o f I r o n Castings

P o t t e r E a r t h e n w a r e etc. Msmufaetune ~. Tin Miner

S a w y e ~ & Wood T u r n e r Coope~ et0. C u t l e r Scissors M a k e r

Co,ton Manufacture

Wool Wol~sted M a n u f a c t u r e

B r i c k Plain Tile T e r r a C o t t a M a k e r

noashipe

L2

(*'Durham & NorthumbePrand / } N o t t i n g h a m a D~rbyshire

Shoemaker

Tailor

Outdoor Industrial

Shipbuilding

Country Air

iiiiiiiiiiii I

Phthisis for Certain C/asses of Males distributed in Age-Periods.

Seaside A I r

Agricultural Districts

Males

EXPOSURE T O OUST

Death-Rates from

I III

Fisherman

Agriculturist

e~Ooeupied and Retired

~

CLASS

Table 7 .

I

j r Coal M i n e r s I M o n m o u t h ~ S o u t h Wa|es

~

I9~ 5.

13

PUBLIC HEALTH.

These statistical characteristics of phthisis mortality, varying as the disease depends on one or another preponderating influence, suggest a method,important for industrial hygiene, Table 8.

Dust-phthisis is also peculiar in showing a low degree of infectivity among contacts not exposed to dust inhalation. This point is borne out by the direct or indirect testimony

Tuberculosis An Infectious

Disease unduly

the prevalent in prevalent in certain due to

.......... incweased Infection

Le x p o s u r e caused

General Community Classss

but

l ....

to by

i

D i m i n i s h e d bodily r e s i s t a n c e caused b y

I

I

Localised Influences such 3s

Genersl Influences such Iss

Drinking Infected Milk

OvercPowding

l .... Starvation

P r e s e n t s of unusual number o f Gases

of determining which particular influence preponderates in a given industry, Thus, recent m o r t a l i t y data indicate that slate workers, who as a group are exposed to the inhalation of slate dust, suffer in excess from phthisis at every age-period, but the character of this mortality, which falls immediately, showing no latency, and absence of an excessive mortality from other respiratory diseases, Table 9 ~.

Cause

"

COMPARATIVE AGED 15

of Doath

Influenza ........ Alcoholism and ~__ Liver Diseasos ! CanceP Phthisis ............ Other- Lung }._

General Infection (Occuplep &Retieed males

I Alcoholism

I

I

Illness

1

I n j u r i e s ;n Childhood

of m a a y observers. Thus Agricola suggests it when he speaks of women in the Carpathian mountains who, owing to the high male mortality from this cause, married seven times. Thackrah similarly gives evidence (23a) that there were in the village of Arkendale (in the heart of the lead-mining district) not less than thirty widows under t h i r t y years of age. Greenhow, in 1858, said (37a), " It is the

MORTALITY YEARS AND

OF CERTAIN CLASSES UPWARDS 1900-2

InGressed InfoctiOn (Shoemaker)

)

Alcoholism Publican Inn Servant

Dust (Tin

Minor)

1 O0

167

171

1 O0

77

670

28

....i 0 4

100

108

110

101

100

1_45

173

436

100

84

148

419

Diseases NePvous Diseases- - Cir~ulatol, y "Diseases

100

101

178

84

1 O0

1 O0

144

BPight's Disease Aoq:ident. Suicide .........

t O0 1 O0 1 O0

86 38 1 O0

88 216

105 148 92

suggest that the excess of phthisis is due to infection arising from undue prevalence of phthisis in the locality, rather than to inhalation of dust.

I

Inhalation of Iniurious Dust

injilrious character of which causes Alston, lead-mining district in place in which there is

32

the male occupation the most exclusively England, to be the a larger proportion of

15 60

20

25

I

I

ssi

/

45

"\/\

1

!

I

,

80

!6o 55

, ',~',~'"

50 -,,X

,,,,~.. .'"' "''~x"~ •

// "'"

" "

"--

--.-..

\ 40

"'"

."Sa.d~to.e Ma~e.

//

45

\ \

.__/I ..' / T " " ~ ' - ~' . • I~ .. ~ ///.."" ~ //. ~

'\

\

"... '. \. \.

""

\

~ , . aeti.ed

~

"', \

\.

2S

" k

~

!

35

30

"..,, .. \

"-

Males

i

Pepoentage of All Deaths

". \ ".. \

,,

o°ou.~e~a.d \

]

\ \

\

/ /

/

65

Mlne~

/

/

30

20

\T i n

/

35

$5

. ...\

i •

25

"

/~,o.-,.ke~ /

i

UFE

45

• %~

i 40

o~

%,.

i

/

35

1

i

50

rEAns

•\

20

".\

\-

\

"\

15

"'. \ \ \

",, \

~ \ \

.. NN~\

I0

15

\\ "'.

\

!0

5

17

17 16 15

i /

14 13

/

Miner

16

--....

IS

/

/

/

Tin

14 13

/

12 /

11 10

/

./

12

/

/ /

9 /

~8 /

7 6

/

/

*,~ /

Death Rate P e r 1~OO0 Living

. . . . . . .

/

'~

Publican Inn Servant

II 10 9

/

8

/

".

..

7

\

6 f

5

."

//

5

ShoemakeP

4 3

4

2

2 1 0

3

o' 15

20

25

r e , as

35

oF

45

ur~

55

65

8O

1915.

PUBLIC

widows than in any other place in the kingdom," and he gives data from which the following have been taken :-DEATH FROM

-, R A T E S

PULMONARY

PER

1,000

AFFECTIONS

Under $ years

20 y e a r s a n d o v e r .

District MALE

Alston

FEMALE

MALE •

(LEADMININO)

5"61

3"24

(TINMINING',

12"31

10"62

9"42

LivePI)ool

30 '92

2 3 '64

10 "44

ManohesteP

20 '09

1 6 "9IS

10"60

Redputh

New

Forest

4 "61

7" " 6 5

14'40

6 ":25

FEMALE

7"79 4"79 7 "59 9 "06 6 "61

Peacock, in 1864, pointed out (32) that among tin-miners the disease " usually occurs in persons who do not present any hereditary predisposition to phthisis--their parents and other relatives having often attained advanced age and being quite healthy." In recent years, as the result of his investigations, 19o219o4, into the nature and cause of excessive mortality among tin-miners, Dr. Haldane observed (77 b) that the wives and children of these men never seem to be affected, although occupying the same room as the affected men who never go to hospital, b u t sit at home and expectorate sputum loaded with tubercle bacilli. And in 19o 9 Steel-Maitland and Squire drew attention (IOO) to the number of widows of tin-miners in Cornwall, and of ganister workers at Wortley, even though, due to men outnumbering women in the latter district, the women often marry again. A paragraph in the daily press, to which Dr. tIaldane drew my attention, and which stated there were in Brandon eleven widows of flintknappers, led to an inquiry, which established (8) the same point for the flint-knapping industry (see Table 2). Dr. Matthew H a y independently made the same observation (79) in relation to female relatives of Aberdeen granite cutters. Dr. Wheatley has referred (8o) to the sam.e point for Grinshill masons and t h e i r relatives.. Dr. Barwise has noted (77 c) that although Derbyshire gritstone workers suffer in excess from phthisis, " the percentages of deaths of females living in stone-workers' houses is less than among agriculturists, although the proportion of quarrymen married is greater than that of the agricultural group."' My own investigations (77 d) into the mortality of stone-masons, their wives and widows, disclosed the same absence of any excessive phthisis mortality among

HEALTH.

~5

the latter. And quite recently Dr. Turner has told me that his inquiries in South Africa into the occurrence of phthisis in the native kraals have failed to establish that natives returning home with dust-phthisis from the gold-mines disseminate the disease among the tribes. No explanation of this curious low infectivity of dust-phthisis has been offered; but it is the more remarkable because where there is exposure to inhalation of a dust which does not predispose to phthisis, the phthisis mortality among females (not exposed to dust) may be higher than among males (exposed to dust), a point which has been dwelt upon for coal-mining districts b y Goldman (86) and by Trotter (87). Conclusion.--Exposure to inhalation of a dust which predisposes to phthisis must, then, be immediately suspected, if the mortality statistics for any group establish or suggest the characteristics detailed above, viz. : (i) latency of onset of the disease, (ii) the presence of an excessive death-rate from other respiratory diseases of which bronchitis is the chief, (iii) the absence of excessive mortality from nonrespiratory diseases (unless of course some other baneful influence is at work), and (iv) the absence of excessive phthisis mortality among contacts not exposed to dust inhalation. Conversely, the absence of these characteristics should raise the question whether the dust is one which predisposes to phthisis, however dusty the occupation of those concerned m a y be. The Royal Commission on Metalliferous Mines and Quarries (Ia) has summarised the question in these words: " If in any given class a high death-rate from pulmonary tuberculosis is found occurring at a later period of life than is usual for pulmonary tuberculosis, and if this high death-rate is associated with a high death-rate from other respiratory diseases, then this class is exposed to the inhalation

Phthisis Mortality

Table | 0 IN CERTAIN

DUSTY

INDUSTRIES

CLASS • Coal Mine~ ................. Cement MakeP. -Mason,Limestone fPlymouth & BPistoI) Occupied a~d ~. RetiPed Males Pottee Cut tRr(Sheff~eId ) Gv~tnite C u t t e P Tin Mine~ GPinder ( Sheffield ) Nlasonr Sandstone t ~Marlchester) ] . . . . . . .

/

.

.

AT

AGES

eontallty pep 1,000 Living

.

.

.

.

.

.

1 "17

20

TO

t 4 "2 1 8 "O 1 8 "7

2?44

19 "8

3 "34 S "90

21 '4 26 "7 30 '4 38 '2 57'8

S "00 9 '42 1 5 ":ZO

64

PePcentage of Atl Deaths

6 0 '1

Flint KttappeP

77 '8

GanisteP WpPker

77 '9

t6

PUBLIC HEALTH.

of injurious d u s t ; and, further, pulmonary tuberculosis occurring in such a class does not exhibit the same incidence on the wives and families of those affected, as is characteristic of ordinary pulmonary tuberculosis. Causation.'--Study of the prevalence of phthisis in dusty occupations has established that there is no definite relation between the amount of dust present and the prevalence of the disease. Coal-miners are as much exposed to dust as tin-miners, cement makers are more exposed to dust than are granite cutters, masons who dress limestone are equally exposed to dust with masons who dress sandstone, while ill the processes of grinding and glazing metal articles in which the amount of dust present has been estimated* b y G. Elmhurst Duckering, I-I.M. Inspector of Factories, the point has been definitely established; in this industry metal articles are first ground b y operatives, known as grinders, on wheels of hard gritstone (sandstone) from Derbyshire an d Yorkshire, which usually revolve in troughs containing water, and are then glazed and polished on emery wheels and linen bobs b y men known as cutlers. Duckering found at the breathing level Of grinders from 36 to 5o milligrammes of dust in IO cubic metres of air where edge tools were being ground on wet stones--an amount much exceeded during the occasional process of dry racing, i.e., turning up the surface of the stones with a pointed rod, b u t less than he found where edge tools were being glazed b y cutlers (1,114 raiNgrammes in the process of hollowing and 647 milligrammes in that of flat glazing in IO cubic metres of air). Glazing wheels are formed of various substances--emery, alundum and coru n d u m - o x i d e s of aluminium,--and carborund u m - c a r b i d e of silicon (usually bonded with clay and sand), all substances which rank next to diamond in hardness, and are harder than siliea,--yet grinders suffer far more from phthisis than do cutlers. Further consideration, however, has shown that whenever dustphthisis is present, one special form of dust is also present, viz. : dust of crystalline silica. Silica (oxide of silicon, SiO~), as quartz, quartzite, flint and chert, forms a large portioi1 of the earth's surface, and in one or other form it is present in every dust, the inhalation of which has so far been found to predispose to *The method of determination employed b y Duckering is described in detail in the Annual Rcport of the Chief Inspector of Factories for x9IO, pp. 2oi-~o6.

Oc'roB~R,

dust-phthisis--the precious metals, gold and tin, and in many districts lead also, are found embedded in or associated with quartz and quartzite; sandstone dressed for building purposes is composed of quartz particles; ganister, used for the manufacture of refractory silica bricks, and buhrstone, used for the manufacture of millstones, are extremely hard quartzite rocks ; granite is composed of about one-third part of quartz; flint, which is pure silica, is used b y the potter, and also gives rise to the dust so injurious to flint-knappers ; while grindstones are composed of gritstone, and analyses of dust found' in the air of places where metal articles are ground on wet stones show that it is composed of from 5 0 to IOO per cent. of free silica, and that the amount of dust present and the percentage of free silica in it increased with the hardness of the stone used and the weight of the article ground. On the other hand, silica does not occur, or only in negligible amounts, in coal, cement, clay, emery, plaster-of-Paris, and limestone. The element silicon is not in itself the important factor, for it is present as a silicate in cement and clay, yet workers exposed to dusts of these materials do not suffer from dust-phthisis. The statement made above that there is no definite relation between the amount of dust present and the prevalence of dust-phthisis is not tree if silica dust only is considered, for there is evidence to show that the prevalence of the disease cderis paribus varies directly with the amount of silica dust present. Granite cutters, for example, suffer in proportion to their exposure to dust. This exposure, due to the use of pneumatic tools, is greater than that of stone-masons, but the phthisis mortality of granite cutters is less than that of sandstone-masons. Granite, however, is composed of only one-tliird part of quartz, as compared with 80 per cent. or over in most varieties of sandstone. Dundee stone-masons, again, though exposed to dust as much as other masons, suffer less from phthisis, b u t the stone they dress--Leoeh stone, which belongs to the old red sandstone series---is an abnormal sandstone containing only a small amount of quartz. A study of phthisis mortality rates in dusty occupations has, then, established the fact that when phthisis occurs in excess it is always found associated with exposure to dust containing crystalline silica. Detailed discussion

i915.

PUBLIC

here of these mortality-rates would extend this lecture too much, but reference may be made to the stone-mason's i~dustry. Here is an industry throughout which similar tools are used, and similar methods followed, where work is carried on in similar premises usually in the open air, and wages, varying somewhat in different districts, are rather higher in the sandstone districts of the North and t h e Midlands than in the limestone districts of the South-west--a trade wherein, all things considered, the conditions of life as lived by the men both at home and at work are practically the same throughout the country. "get Lhe m o r t a l i t y from respiratory diseases among masons in various districts differs considerably, Table 1 I

17

HEALTH.

tuberculosis, and have a shorter prospect of life. This evidence, from which every other influence except the different chemical composition of the stones worked can be eliminated, is sufficiently conclusive for me to adduce some figures supporting it, based on the assumption that a mason who died in a district where limestone is chiefly worked, worked chiefly on limestone, and t h a t a mason who died where sandstone is chiefly worked, worked chiefly on sandstone. This assumption can only give approximately accurate results, but fortunately for the purposes of this investigation, the migratory habits of masons have not been sufficient to obscure the issue; and the differences found are sufficient to justify

ABERDEEN GRANITE CUT'rERS

Causes of Deaths

Class of

Tuberc;ulosls RespiratoPy Diseases other than Tuberculosis " ' All other ~Diseases

Employment

•Building Section[open to the Air ~Monumental Section (closed -in) Building Section(open to the Air Monurnental Sectio,~closed-in) Building Set,rich(open tothe Air Monurrtental Section(closed-ln

percentage of Median Age All Deaths at Dez~th 25 38 13 1B 61 45

'0 '0

54 4 6 ~ 47 60 48 --49 56 --57 43--44

'B 'a

"2 "7

Compiled from lists of deaths p~btishe¢I annually in the " U n i t e d Operative Masons' and Granite Cutters' journal," published in Aberdeen.

the conclusions t h a t if these influences could be eliminated the limestone mason would take a favourable position in tables of occupation mortality, while his fellow working on sandstone would be found in an even worse position than that the statistics now presented allocate to him. The positive and negative evidence in favour of this peculiar influence of silica

and this difference coincides with differences in the chemical composition of the stones worked. Thus masons in districts where limestones are worked do not suffer in excess from phtl~isis, and are at least as healthy as the community in which they live, while masons in districts where sandstones are worked suffer in excess from pulmonary

Percentage Mortality from Phthisis

Table 12 i

AMONG

CLASS

DISTRICT

MASONS

PERIOD UNDER REYlEW

Bristol Plymouth Dundee

Stone Masons

Males aged 20 Years and ovep

All

Capdiff Falmouth Birmingham Bradford Edinburgh Liverpool Newcastleupon-Tyne Manchester England and Wales Scotland

WHO

DiED

IN

--

1911

LARGE TOWNS

PERCENTAGE MORTALITY FROM PHTHISIS 12

"0

12

'5

18

'6

Stone

I Limestone, )

24

'9

37

'6

used

and Portland

e,g. Bath

.

Leooh S a n d s t o n e in w h i c h Q u a p t z is s u b o r d i n a t e in a m o u n t . Four partsLinteston~ to one part Sandstone.

21 '8 1871

CERTAIN

G r a n i t e , i.e. o n e - t h i r d Q u a r t z . About equal parts Limestone

and

Sandstone.

44'2 46 48

'1

'1

53

"O

56

"7

1871 1900

---

14

"6

1901

--

12

"7

F1 9 0 8

t

Sandstones

only

of

various

kinds

8

N o ~ r ~ . - - F u r t h e r extensive statistical details will be f o u n d in 1Kinutes of Royal Commission on Metalliferous Mines and Quarries, Vol. III., Appendices P, Q, and 1~, pp. 222-38 , 1914. W y m a n & Sons, L t d . (Cd. 7478.)

~8

PUBLIC HEALTH.

dust is so strong as to compel recognition ; and to suggest, even without clinical and pathological evidence, that inhalation of silica dust produces a condition which renders the individual more prone to succumb to pulmonary tuberculosis. The existence of a statistical latent period before this condition is fully developed points to some preliminary change requiring time for its establishment, and indicates that the predisposition to the disease is not simply a mechanical interference with the function of the respiratory mucosa, such as has been postulated to account for the prevalence of bronchitis and possibly of pneumonia in certain dusty industries. Pathology indicates what these changes are, and t h a t the respiratory 'apparatus is the part mainly affected; and justifies us in considering the predisposing condition one of Table

13

AVERAGE

CHEST

-

Age Period

Leisured Class

Factory Operatives not exposed to Dust

AbolPdeen GPaltite T r a d e vePyslightly C u t t e r s In exposed open sheds to Dust

o'31

*2 " 5 S

2'45

2 "57

202530--

*2 ' 7 9 *2 " 9 0 2 "87

35 -

.2 " 6 4

40-

2"35 2 "39 = "24 2"1.2 1 "87

2"24 t "64

|N

She/~eld

CERTAIN

Cutlery

CLASSES

Trade

PollshePs,l~

14-

45 5 0 -55-6 5 AND OVER

perhaps existed only from six to eighteen months ; when in combination with the other train of symptoms, it had probably been present as many years: emaciation, occasional profuse perspirations, increasing debility, and the slightly accelerated and soft pulse, were likewise generally observed." Peacock also recognised the distinction, and even went so far, after investigating the health of Cornish miners for the Royal Commissioners of I862, as to claim (32) for miners' disease, in which the causative influence of dust was not then recognised, a pathological entity separate from ordinary phthisis. Both Holland's classification and Peacock's claim must be allowed, if the changes produced by long-continued inhalation of silica dust are distinguished from those due to subsequent infection b y tubercle bacilli. Peaco'ck and Holland, however, made

EXPANSION IN INCHES OF MALES AT VARIOUS AGE PERIODS

1 7 --

2"84 .2"33 ~2'13 "20 2"15

Oc'roB~R,

"58 2"21 2"14 r) " 0 4 2 "07 1"9S 2 '04 1 "80

C u t t e r s in closed sheds

Cutlers

2"14 ~Z " 6 4

"."40 *2 " 6 0

2 "43 2 "27

.2 ' 4 3 .2"51

.2"44 2"11 1 "93

2"24 1 '96 .2 " 0 9 1 "g2

•'19 2"13 2"16 1 "02 1 "73

pulmonary silicosis, and the type of pulmonary tuberculosis which supervenes as tubercular silicosis. Clinical Sym~toms.--Certain defirdte clinical characteristics distinguish dust-phthisis from ordinary pulmonary tuberculosis. Holland perceived this (9Ia) in I843 and divided the eases of phthisis he saw into two classes--" in the one, we placed the prominent and clearsounding chest on percussion, in which the cough was often extremely troublesome and the expectoration copious, the breathing very hurried, almost without exertion; and yet the appetite was good, and the digestive functions regular; nor was the body much emaciated. In the other, the contracted or flat chest, and which on percussion emitted a somewhat dull sound, though not invariably, in which the expectoration was also often copious, but less frequently accompanied with severe fits of coughing, and the cough had

1 "80 1 "S7 1 "84 1"44 1 "56

I "73 1 "56 1 "49 1"50 1'13

Light Grinders

Heavy Grinders

2 "54

2 "67

2 "37 2 "45

2"49 2"19

2"40

2"19 2 "04

2"14

i -ss

2 "07 1 "TS 1 "58

1 "52 1;55

1 "58 1 "SS~

1 '51 1 "45

SitrippePs of Cotton Cardlni¢ Maehi.ee S "33 2 "75

.2 ' 4 5 1"S6 1"69 1'72

their observations before Koch had demonstrated that ordinary phthisis was due to the growth in the lungs of tubercle bacilli. When in I9o 4 the Departmental Committee appointed to inquire into the health of Cornish tin-miners pointed out (34/)) that tubercle bacilli could be demonstrated, either during life or after death in such a large proportion of cases of miners' disease as to justify the conclusion that a fatal issue was practically always due to tuberculosis, attention was so concentrated on the part played by tile tubercle bacillus that the disease came to be almost regarded as a subgroup of pulmonary tuberculosis. Oliver, however, has maintained (94a) that the condition which precedes a~d predisposes to tubercular infection must be carefully distinguished from the subsequent tuberculosis, and evidence from the Transvaal (8I) and from Western Australia (48) indicates that this condition may in itself, without the intervention of tuberculosis, lead

r915.

PUBLIC

to a fatal issue; in such cases WatkinsPitchford says (44) " death usually results from cardiac failure due to the increasing dilatation of the heart." I have specimens from the lungs of (i) a Transvaal goldminer who died in this way, and (it) a Staffordshire potter whose end was similar. (7"o be c o n t i n u e d ) . LIST OF REFERENCES. 1. la. It). 2. 33a. 4.

5. 6. 7. 8. 9. io.

i i. 12. 13. 14. I5I6. 17. 18. 19. 20. 21. 22. 23. 23a. 24. 25. 26. 28.. 27. a7a, 27b. 29. 3o. 31. 32. 33. 3434a. 34b. 34e. 34d. 35. 36,

37. 37a. 38. 38a. 38b. 38c. 38d. 38e. 39. 39a. 39b. 39c.

Second Report o/ the Royal Commission on Melalti/erous Mines and Quarries, 1914, pp. 133-155. XVymau & Sons, Ltd- (Cd. 7476.) i b i d . p. 141. Ibid. p. 144. Chemical Pathology, 19o7 , p. 392. H. G. Wells. W. B. Satmders & Co. 32hiladelphim Prepared frolrt Supplement to Sixty-fi/th Annual Report o/ the Registrar-General o/ Births, Deaths, and Marriages in England and Wales, part ii,, I9o8. W y m a n & Sons, Ltd. (Cd. 2619. ) The Soot/all o/ London. The Lancet, 6th Jan., i912. Coal Smoke Abatement in England. Dr. Louis Ascher. J o u r n a l of Royal Sanitary Institute, Vol. xxviii., 19o8 , p. 89. Antiquity o/ Man. Sir Charles Lyell. Origia o/ the Aryans p. 181. Dr. Isaac Taylor. The Date o/ Grime's Graves and Cissbitry Flint Mines. Reginald Smith. Society of Antiquaries, 9th May. 1912. B¢inutes o/ Evidence. Royal Commission on Metalli/erous Mines and Quarries., Vol. it., i914, appendix J., p. 262. W y m a n & Sons, Ltd. (Cd. 7477.) Annales D'Hygiine Publique. T. Sixi me, p. lO. ]3enoiston de Chat eaunenf. 183i. Paris. OEuvres compltes d'Itippocrat¢ avce le texte'Grcc en regard, par E. Littrd, Vol. 5, 1846, P. 167- J. B. Bailli¢re, Paris. A Treagise of the Diseases o/ Tradesmen, written in Latin by Beru. Ran~zzini, Pro/essor ot Physich at Padua, and now done in English by Dr. James, 17o5, p. I4. London. Ibid. p. 1631 Ibid. p. 30. Ibid. p. 175. Ibid. pp. I7O-171. Cat4 Plinii Secundi, Historiw, Nataralis, lib. vii., see. i. Ibid. lib, xxxiii,, sec..xL De Re Metallica, Georgti Agricolw, 1557. Froben Basil. Bericht yon Bergwerekett, dutch G. E. Lohneiss, folio, 169o , p. 56. Stockholm u n d Hamburg. The Staffordshire Potter, by Harold Owen, 19Ol , p. 276. Grant Richards. Trans. Medic, Chirurg, Sou. Edinburgh, Vol. i., p. 373, 1824. Alison. M y Schools and Schoolmasters, H u g h Miller, i869. Twelfth Edition. William P. ~7immo, Edinburgh. The Effects o/ ArtS, Trades and Pro/essions, C. Turner Thackrah, I832 , Second Edition, p. 99. Baines & Newsom, Leeds. Ibid. p. 9o. Ibid. p. 55. Ibid. pp. 85-86, Ibid. p. 89. Ibid. p, 95. La Tubercutose ehe2 los ouvriers en sole. Th~se, Dr. Pierre G i v r e , 1889. Lyon. Ibid. pp. 14172, Ibid. pp. 92- 3. The Vital Statistics of She~eld, G. Calvert Holland, 1843, p. 193. Robert Tyas, London. Ibid. p. 196 and p. 2o1. Report o/ the Com~issioners appointed to i~uluire into the coaditions o/ Mi~es in Great Britain, 1864, appendix B., pp. 347-43I. Lyre & Spottiswoode. Ibid. p. 3. On Stone-Masons' Phthisis, G. !*' Gnlland, M.D., March, 19o 9. Edinburgh Medical Journal. Report on the Health ot Cornish Miners, 19o4, p. 2i. Lyre & Spottiswoode, (Cd. 2o91.) Ibid. p, 18, Ibid. p. 20, Ibid. p, 24, Ibid. p. I9. Archly. /ur pathog: duatom, und Physiol. und /at klin. Medic. yon Virchow, bd. xxxtx., p. 442. O# French Millstone-makers' Phthisis Medico Chirurgical Review, VoI. 25, 186o, pp. 214-224, T. ]3. Peacock. And Trans. Path, el. Soc. London, Vol. xii., 186o, T. ]3. Peacock, and Ibid., Vol. xvii., z866. Papers relating to the sanitary state o/ the people o/ England, General Board of Health, 1858 , p. 132. Lyre & Spottiswoode. Ibid. p. 63. Third Report o/ the MedicM O~eer o/ the Privy Council, 186o, Appendix Vl. Ibid. p. 133. Ibid. p. I42. Ibid. pp. 174"5Ibid. pp. 151-2. Ibid. p. I19, Fourth Report o/ the Medical O~icer o/ the Prioy Council, 1862, Appendix IV. Eyre & Spottiswoode. Ibid. p. 145. Ibid, p, 177, Ibid. p. 159.

HEALTH 39d. 39e. 40, 4oa. 4ob, 4oe. 4od. 41.

r9

Ibid, p. 162. Ibid, p, 166. Diseases o/ Occupation, J. T. Ar|idge, 1892, p, 245. Percival & Co. Ibid. p. 297. Ibid. p. 313 . Ibid. pp. 298-9 . Ibid. p. 252. E/jet des poussi res industrielles dans la production des affections broucho-pulmonaires, Helm. et Agasse-Lafont. Trans. X V I I t h Internal. Congr. of Medic., 1913, sec. xviii., pt. it. 4ia. Ibid. Discussion, p. 23. 42. Presse M d. Ist Sept., 19o6, Calmette. 43. Lead Poisoning and Lead Absorption, Legge and Goadby, 1912 , p. lO2. Edward Arnold. 44. The Industrial Diseases o/ South Africa, Watkins-Pitchford, 1914. The ivied. Journ. of South Africa. 45. Floating Matter o/ the Air, J o h n Tyndall, 1881, pp. 26-7. Longnmns, Green & Co. 45a. Ibid. p. 37. 46. The Ash o/Silisotic Lungs, J o h n MoCrae, i 9 i 3. The South African I n s t i t u t e for Medical Research. Horror & Co., Johannesburg. 47. Diseases o/tt~e Organs o] Respiration, S. XVest~ Vol. i., t9o2. Griffin & Co., Ltd. 47a. Ibid. p. i96. 48. Report of Royal Cor~missioner on pulmonary diseases amongst Miners, 191o, Perth, VCestern Australia, 48a. Ibid. p. 68. 49. ,~/Iiners" Phthisis at Bendtgo, XV. Summons, r9o 7, SfillwelI & Co.. Melbourne. 49a. Ibid. p. 38. 49b. Ibid. p. 3550. Flax Mills and Li~en Factories, ~, H, Osborn, 1894, pp. 182i. (C.-- 7287.) Lyre & Spottiswoode, 51. Mr. A. G. Finlaisol*'s Report on Sickness and Morlality, Friendly Societies' Return, 1853 , p. xxl. 52. Sickness and Morlality Experience of the LO.F. Manchester Umty during the Five Years, 1893-i897 , 19o3, p. 66. Manchester. 53. Annual Report o/the Chic/~inspretor o/Factories/or 19o8, pp. 203- 5 XVvman & Sons, Ltd. (Cd. 4664. ) 54. I~;dustrial Accidents and Trade Diseases in the United Stat, s. L. F. Hoffman. Transactions of the I~ifteentb International Congress on Hygiene and Demography, Vol. I., 32art it., pp. 764.769, i 9 i 3. Washington. 55. The Hygienic Aspect o / t h e Coal-~nining Industry, Milroy Lectures, 1914, F, Stlmqtebotbam, lecture iii. 56. Monographie hygi nique de la /abrication dn pl ire en France, Hdbert, Maute, and Helm, 1912. D u r u y et Cie., Paris. 57. Report on tLe Prevalence o/ Phthisis ar,*ong Ou~rry Workers and Miners, S. Barwise, i913. Derby County. 58. Royal Co*u.mission on Metalli/erous Mines and Q~arries, Minutes of Evidence, ¥oi. ilL, Appendix P., x9r 4. Vv~yman & Sons, Ltd. (Cal. 7478.) 59. Annual Report o] the Chic/Inspector o/Factories/or 191i , pp. 2o3- 5. XWyman & S o u s , Ltd. (Cd. 6239.) 59a. Ibid. pp. 23o-1. 6o faheesberiehte der Gewerbe-Aussichtsbeamten und Bergbehordeu /ur des .]ahr. 1911, pp. 384-419. BBerlin. 61. On the Mortality o/ Flax Worhers, C. D, Purdon, 1873. 62. Jute, H. J. Wils6n, Dangerous Trades, edited by T. Oliver, 19o2 , p. 660. J o h n Murray. 63. A n Address on Pneumonia, Sir James BBarr. ]3rifish Medical Journal, Jan. Ioth, 1914. 64. Report to the Royal College o/ Physician,s on the In/ectivity o/ Pultnonary Tuberculosis. British Medical Journal, April ixth, 1914. 65. The Experindental Production o/ Pneumonia, R. B. Armstrong. Supplement to ]3ritish Medical Journal J u l y i 8 t h 1914. 66. The Lumleian Lectures, Dr. P. Kidd. Lancet, VoI. i., 1912. 66a. Ibid. p. 159o. 66b. Ibid. p. 1668. 68. Los. Pneumonies ir scories, Monnier. Gaz, Mud. de Nantes, Nov. Iath, 1898, 69, Los Pneumonies i~ scories, Gautret. Tl~?-se de Paris, 189% 70. Final Report of DepartmenCat Committee on" Certain Miscclht~eoz~s Dangerous Trades, p. 13, 1899. Lyre & Spottiswoode. (C.-95o9.) 71. The Cause, Effect, Incide,~ee and Preventioa o/ Pneun~o*wco~iosis o/ Quarts Miners, ~1 S. Purdy. The Practitioner, February, ~912. 72. Miners' Phthisis at Be~digo, ~V. Summons, i9o 7, StitlweI1 & Co., Melbourne. 73. Report o/ the Royal Commissioner on Pulmonary Diseases amo gst Miners, p. 69, 191o. Perth, Western Australia. 74. Die Staubinhalations-Kra1*kheiten, Dr. L u d w i g Kirt. Die K r a n k heiten der Arbeiter, Erster Theih BBreslau, 1871. 75. Diseases opthe Lungs, 32owelI and Hartley~ Fourth Edition, 1911. H. K. Lewis, London. 76. Report o/ Departmental Committee upon Merionct~shire Slate Mines, 1895. (C.--7692.) t~yre & Spottiswoode. 77. Minutes o/ Evidence, Royal Commission on Melalli/erous Mines and Quarries, Vol. iii., 1914, p. i i 5. W y m a n & Sons, Ltd. (Cd. 7478.) 77a. Ibid, pp. 145-154. 77b. Ibid. p. 188. 77C, Ibid. p. 236. 77d. Ibid. pp. 181-189, a n d Appendix 32. 78. Recherches experincentales sur los eondition, s physiologiqaes du travail des ouvriers sableurs, z 9 i L ]3riault. Tb~se dn 32arts. 79. Report of Medical" Officer o/ Health /or the City o/ Aberdee~, 19o9, p. I07. 80. Report on the prevalence of Lung Diseases am.ong the Worhcrs at Grinshill Quarries, J. Wheatley,. 1912, Shrc**vsbury. 8i. Repod o / a Co~mission on Miners" Phthisis and Puhnonary T'ube~ eutosis in South A/rice, 1912 , pp. 7-IO. Cape Town. 82. Report o/ Medical O~cer o/ Health o/Johannesb**rg, ist J u l y 1912, to 3oth June, 1913, Cllarles Porter, M.D., p. co. Johannesburg. 83, Transactions o/ the Pathological Society o/ London, Wol. xx., I869. 83a. Ibid., Vol. xvi., i865, pp. 59-60. 84. Science #ore an Easy Chair, a second series, i912 , Sir Ray Lankester, pp. 191-2. Adlard & Son, London. 85. Rabelais, A new translation, W. 1a'. Smith, 1893 , Vol. i., chap. xxix., P- 343. Alexander P. W a t t . 86. Die Hygiene des Bergmannes. Halle. 19o 3, Goldman.

PUBLIC

20 87. 88. 89. 90. 91. 9Ia. 9Ib. 92. 93. 9494 a, 95. 96. 97. 98. 99. Ioo. ioi. lO2. lO 3,

The so-called Anthraeosis and Phthisis in Coat-mi~wrs, R . S. Trotter. British Medical Ionrnal, 23rd May, I9o3. The relation between Anthracosis and Pulmonary Tuberculosis, b y 3". M. Wainwriglxt a n d I t . J . Nichols, American Journal of the Medical Sciences, 19o5, Vol. e x x x . , pp. 4o3-4~4M#wrs' Phthisis, Sir T. Oliver, British Medical Journal, i2th Sept,, I9o3 . Weavers" Cough, Annual R e p o r t of the Chief Inspector of Factories for 1913, p. 15o. W y m a n & Sons, I,td. (Cd. 7491:.) Diseases o/ the Lungs /rom Mechanical Causes, G. Calvert Holland, 1:843, p, 23. J o h n Churchill, London. Ibid. ppp.636-7. Ibid~ . . Diseases o/ Occupation, Sir T. Oliver, p. 294. 19o7. Methuen a n d Co. Report o/ Departmental Committee on Concpensation ]or Industrial Diseases, Minutes o/ Evidence, pp, I97-2o2, 19o7. (Cd. 3496.) W y m a n & Sons, L t d . Pne~*monoconiosis, Sir T. Oliver. S y s t e m of 24edicine, Allbntt a n d Rolleston, VoL v., I9o9 , p. 469 , Macmillan &; Co., Lid. Ibid. p. 462. Staubinhalation und S~aublnetastase, Julius Arnold, i885. Erhrankungen des Respirationsapparates, t~. Aufrecht, Nothnagel's Specielle Pathologle u n d Therapie, Bd. xiv. La Maladie des Ardoisiers ." la Schistose, Reims, 19oo. Imprimerie. Matot-Braine. Proceedings ol Royal Society o/ MedicMe, ~iectro-Therapeutical Section, Vol. vi., 1:914, pp. 93-98. Proceedings o/ Royal Society o/ Medicine, Pathological Section, Vol. vii., partiii., 191:4. Tuberculoid Pneumonoeoniosis, S. G. Shattock. The Rdation o/ Industrial and Sanitary Conditions to Pauperism, Mr. A. D. Maitland a n d Miss Rose Squire, p. io9, a n d pp. i25-6, 19o9. W y m a n & Sons, L t d . (Cd. 4653.) Annates de l'Institut Pasteur, Paris, 1914, xxviii. Staubinhalationskran.kt~eiten der Lungen, p. 171, Zenker. Deutsch. Archly. fur klin. Medic. Bd. 2, 1867. Ibid. pp. i16-172

CORRESPONDENCE.

The Editor does not accept responsibilitg /or the opinions of correspondents. To the Editor o[ PUBLIC HEALTH. GOVERNMENT G R A N T S . DEAR SIR,--The system of Government grants has of late been extending. They apply now to Medical Inspection and Treatment, Maternity and Infant Care work, and work under the Mental Deficiency Act. The reason for them is doubtless twofold ; on the one hand, they acknowledge t h a t certain work undertaken by local authorities is of a national as well as of local importance ; and on the othex hand they m a y be calculated to encourage and assist those local authorities which might otherwise be behindhand in appropriately undertaking new responsibilities. A new use has been found for them. An instance has come to m y knowledge where the medicsl officer of health has been appointed medical adviser under the Mental Deficiency Act. His salary hitherto has been £x. By " allocating " £5o of the £x salary to his work unde~ the Mental Deficiency Act, the .total salary of the medical officer of health remains the same, he undertakes the new work with no extra remuneration, and the local a u t h o r i t y by returning the £5o as a part of their " expenses " under the Act, obtains a grant of £25 per year in relief of the rates ! I suggest t h a t Government Departments concerned with making such grants should take steps to ascertain t h a t the expenses alleged are bona fide expenses. I refrain from commenting on the ethics of the procedure. I am, yours faithfully, E. H. S N E L L Coventry.

HEALTH.

OC'rOBER,

T H E T R E A T M E N T OF SCHOOL C H I L D R E N I N VICTORIA, AUSTRALIA. every country for some years past, the need I Nof increasing the scope of school medical work has been increasingly felt. The constant and unvarying cry of tile parent is heard, " Yes, you have told me of these defects and their bad results. You have sent me notices to say t h a t one boy needs attention to his nose and throat, a11cl the hospital doctor says his .post-natal growths should be operated on. His sister has to have her eyes examined by an oculist, aud perhaps have glasses fitted. The other boy requires attention for his ears ; while allthree badly wanttheir teeth fixed up by the dentist. How can I possibly afford to do it ? My wages are £2 Ins. a week, and the dentist says his bit1 will be £5 at least for the three of them." I n the country, the p a r e n t (say at Stawelt), adds, " Where is the ocntist you ask me to attend ? The nearest is at Ballarat--75 miles away. I t would cost me £I in fares alone for a single visit, quite apart from his fee and the cost of the glasses. I t is impossible l " Later on, he tries, perhaps, the travelling optician, and purchases glasses which m a y or m a y not be suitable, and which probably cost him £2 or more for the pair. This difficulty of providing adequate t r e a t m e n t at small cost faces us everywhere, and is a serious handicap to the effectiveness of the work. J u s t when we have educated the parent to a sense of the necessity of attention, tile obstacle of cost and want of facilities for treatment interpose and prevent even the most willing parent from carrying out our advice. This failure of medical and dentM facilities for treatment is more far-reaching and serious t h a n at first seems probable. We are told there exist iu almost every centre hospitals subsidized to about two-thirds of their income by the State to provide for the poor and destitute ; t h a t lodges have extensive and powerful organizations for medical benefits to those of small m e a n s ; and that, in every p a r t of the country or town, medical practitioners are available for those of more t h a n moderate means. After an experience of over four years of testing the possibilities of our present existing system, we can unhesitatingly affirm the gross inadequacy of the present facilities for treatment of school children in country districts, though even the metropolis is not exempt from criticism. Let us consider the present system as it reveals itself on inquiry. THE CHILD PRODUCT: The child product is the most reliable index of the slum. Overcrowding and associated housing defects reveal themselves in the child by dwarfed development, dirt, defect, disease and death.--From the Report o~ the Minister o~ Public Instruction, Victoria, I913-14 .