- Email: [email protected]
Industrial pulmonary fibrosis with special reference to silicosis in Wales
PUBLIC HEALTH INDUSTRIAL PULMONARY FIBROSIS WITH SPECIAL REFERENCE TO SILICOSIS IN WALES*
MARCH Prognosis
Where the pulmonary damage from silica is considerable the outlook is usually unfavourable, and when, as By T. W. DAVIES, M.B., B.CH., B.SC., D.P.H., so often happens, this type of patient becomes tubercuTuberculosis Physician, Swansea Union Area, lous the prognosis is grave. Welsh National Memorial Association. Dr. Irvine, Director of the Miners' Phthisis Bui'eau at Johannesburg, writes as follows (1929) : " An uncom(Concluded.) plicated silicosis may undergo prolonged and sometimes Diagnosis apparently indefinite arrest at any stage, but in the end It is not proposed to discuss the clinical diagnosis, infection tends to get the upper hand, and when this except to say that generally speaking silicosis has no occurs the greater amount of original damage to the lung pathognomonic clinical signs. It should be borne in mind, however, that there must be a history of a dust by silicosis the more rapid will be the terminal breakhazard. Radiographic appearances afford the most down." This South African experience is to some extent absent in coal miners. reliable evidence in establishing the existence of the Everything considered, the silicotic who is removed disease, and symptoms increase in severity with the from further dust exposure has a fairly goood prognosis, progress of the lung changes as seen in the X-ray picture. but when tuberculosis intervenes the end is considerably Dyspnoea is the earliest symptom, is progressive, and hastened. The prognosis also varies with the industrial remains to the end the most important. conditions which cause the disease. Where the hazard First Stage.--The first stage is characterised by the is not very serious and the resulting damage to the lungs appearance of fine discrete shadows indicative of nodulaof slight or moderate degree, the prognosis is on the tion, together with an increase in the hilum shadows, whole good. On the other hand, where the exposure linear shadows, and pulmonary reticulation. Usually has been severe the case may proceed to a fatal terminawithout impairment of capacity for work. tion in as short a time as one year. Statistical evidence Second Stage.--In this stage dyspnoea and cough have as to the mortality does not give the true position. Many become established. The radiograph shows the whole of both lung fields occupied by these shadows with some companies accept liability after necropsy on a certified case with the result that the Medical Board is not coalescence forming more or less dense opacities. notified. It must also be remembered that a great Third Stage.--This stage implies a condition equiva- number of workers die from natural causes, and though lent to total incapacity. The radiographic appearances silicosis is often present it is not definitely tile cause of are those of massive consolidation and a total incapacity death. In such cases no claim for compensation is for work. made. The first and second stages can be sub-divided in Reverting to Dr. Keating's figures of the sixteen respect of the localisation, number, and distribution of cases that came to necropsy--the survival period after the nodules on the one hand, and the extent of the certification by the Board varied from one month to coalescence of the nodules on the other. Diagnosis is difficult only in the presence of complica- eight years, the largest group of nine cases being between one and three years after certification. More striking, tions, especially pulmonary tuberculosis, which may however, is the fact that in a group of seven diagnosed alter the symptoms, physical signs, radiological appearduring life as silico-tuberculosis with a positive sputum ances, and, indeed, the whole course of the disease. The the longest survival period after certification was only definite proof of the presence of a tuberculous fourteen months, the average for five cases being a focus, as stated previously, is the presence of the tubercle period of five to six months. On the other hand, two bacillus in the sputum. The radiographic diagnosis of patients diagnosed as cases of silico-tuberculosis, but infective silicosis in the absence of this confirmation" with negative sputa, survived eight years after certipresents many difficulties. In the Association's Memofication. randum (Powell and Davies, 1940) the figures supplied by Dr. Keating showed that 16 patients previously granted certificates died during 1939 and came to Complications and Sequelae necropsy. Evidence of silico-tuberculosis was found in Emphysema is a constant finding. all : of these, ten had been seen by tuberculosis physiCardiac Disease.--A few articles in the literature call cians, but they, as well as the Medical Board, had not attention to silicotic fibrosis as a factor in cardiac arrived at a definite diagnosis. enlargement and break-down. An association between It is felt that if such cases were thoroughly investi- cardiovascular disease and silicosis has not been definitely gated by culture examination of the sputum, guinea-pig established. Recently Sir Thomas Lewis at Llandough inoculations, bacteriological examination of the faeces Hospital investigated two patients of mine for evidence and of the stomach contents after gastric lavage, etc., of right-sided heart failure. One was a Stage 8 silicotic a positive diagnosis would be established in a number with massive confluent shadows, and the other was an of cases. An attempt in this direction has been made example of the nodular type whose previous history recently at Cymla Hospital by a re-examination of a suggested right-sided cardiac failure. Sir Thomas was series of patients who were compensated some years unable to find any clear evidence of this in either case. ago. Sputum outfits were given to all and arrangements Gardner (1940) writes that personal experience and the were made to have the sputum cultured. No definite reports from the literature convinced him that in most conclusions were reached owing to the fact that many fatal cases of silicosis the heart is already damaged by of these cases had no sputum for examination. arteriosclerosis or other conditions, and that the presence * Paper read at a meeting of the Welsh Branch of the Society of a conglomerate area of fibrosis with emphysema merely adds to its burden. Post mortem, hypertrophy of the of Medical Officers of Health, 122
1942 fight side of the heart without arteriosclerosis and even greater involvement of the opposite side is a rarity. Pneumonia and oedema of the lungs are common terminal conditions. Bronchiectasis.--Dilatation of the bronchi may supervene as a secondary result of silieotic fibrosis. It is not very common, and as a rule does not reach the stage of a fully developed foul-smelling bronchiectasis. Carcinoma.--Primary carcinoma of the lung is arousing much interest and attention in connection with silicosis because of the possibility that the latter condition may act as a predisposing cause. Anderson and Dible (1988) have published their researches into the relation between silicosis and carcinoma of the lung. The sum of their findings was that a group of cases of pulmonary carcmoma exists in which the organs contain an excess of silica. The histological evidence shows the presence of silicotic fibrosis, and the authors think that the role of the silicosis is aetiological. Dr. T. W. Wade (19~6), in his report on the high mortality rates from tuberculosis occurring in slatequarrying workers of Caernarvonshire, quoted figures that showed there was some reason for thinking that slate dust, besides producing lung fibrosis, might also be a factor in producing cancer of the stomach, for it must be remembered that slate is swallowed as well as inhaled. I have not observed a case of silicosis complicated by pulmonary carcinoma, but one patient with silicosis was seefi who dicd from carcinoma of the stomach. Prevention
PUBLIC HEAI,TH MEDICAL MEASURES
These consist of the clinical and radiological examination of all entrants into the industry concerned. This, as stated previously, is applied to some industries in this country. It is interesting to note from the figures of the Medical Board that there is a decreasing number of disablements in the industries where initial and periodic examinations are practised. There can be no doubt that this, together with improvement in dust extraction methods and ventilation, has played its part in bringing about the decrease. Tuberculous workers should be kept out of the industry, and to this end all entrants into the industry should be X-rayed. This is one of the defects of the present system. In connection with the discovery of the infective case, blood sedimentation and blood counts have been advocated. Trail (1941) is of the opinion that an increased sedimentation rate is a definite indication of infective silicosis. Craw (1987), in a series of 50 haematite iron-ore miners, found blood changes when infection supervened. Aslett and Jenkins have investigated the blood in silicotic coal miners and have found no changes from the normal. Increasing attention should be given by health and school authorities to the nutrition and physique of the boys in the coal area who will be the new entrants into the industry. These should be of the highest possible standard.
Treatment In the present stage of our knowledge not much can DUST SAMPLING AND CONTROL. be done for sillicosis per se, apart from rest and symptoVarious methods are in use to define the degree of matic treatment, and no provision has so far been made exposure by stating the number of dust particles under for intensive investigation of the therapeutic possibilities. 10 microns in greatest diameter in millions per cubic Dyspnoea is the most distressing symptom, and it is foot of air. In certain industries laws have been enacted known from experience that bed rest alone combined which limit the amount of dust permissible in the with good food and fresh air are often of great value, atmosphere. surprising improvement being sometimes obtained, The control of silicosis is both an engineering and a probably due partly to the restoration of the impaired medical problem. The first and basic principle in nutrition and partly to the recuperative effect on the dealing with the dust hazard is to remove the dust at cardiovascular musculature. At Cymla Hospital certain its point of origin and thus prevent its dissemination into cases, after clinical and radiological examination, have the air. This is the only procedure to which the term been selected to undergo a course of respiratory exercises prevention may be properly applied. Once the dust is in order to improve their dyspnoea. It is conin the air the protection of the individual becomes sidered that these exercises will increase the vital difficult and often unsatisfactory. " Wet drilling" has capacity of the lungs by expelling the residual air in the been advocated, and so has drilling in the dry state. In alveoli and in this way decrease the dyspnoea. All the latter a dust trap must be used by means of which expenses of the investigation are defrayed by the the dust produced in drilling is drawn by suction into Association, and the exercises are carried out in the a co!lecting box made of dust-proof material. The Light Department of Cymla Hospital, Neath. The wearing of respirators is but a partial solution of the experiment is still in progress and no definite results problem. Workmen in Some instances are reluctant to have been obtained as yet. use them because they make breathing difficult. A Apart from treatment in an institution, much more highly satisfactory respirator, the Mark IV, which is can and ought to be done as regards the supervision-90 per cent. efficient, has now been devised. Its use medical, social, and economic--of the patients in their should be encouraged and the miners urged to co-operate homes. The silicotic, once certified, seems to be for their own sakes by persisting in its use. nobody's concern. The employers pay the compensation Denny and others in Canada have experimented with and retire from the picture. They intervene at times metallic aluminium in the prevention of silicosis. They to try to persuade the silicotic to settle his compensation have proved by experiment that silicosis can be prevented for a lump sum. The Trade Unions, having seen that in animals exposed to the inhalation of silica if they also compensation was obtained, rest upon their oars. inhale metallic aluminium dust. The favourable result Welfare organisations which provide facilkies for of these experiments has led to the method being tried recreation and subscribe to hospitals for the treatment out in several mines. The trials are still in progress and of acute disease spend nothing on silicotics, the industrial the results have yet to be reported. casualties from their own ranks. 123
PUBLIC HEALTH Compensation, Care, Rehabilitation
MARCH Sum~
Many miners on full compensation are not fit for 1. The industries included in the Silicosis and work, and are therefore unemployable. Compensation Asbestosis Medical Arrangements Scheme are reviewed. 2. The incidence of silicosis continues to be serious, varied according to the average weekly earnings over a year, but never amounted to more than 30s. per week. and in Wales occurs chiefly in the coalfields of South This has now improved, allowance being made for Wales and in the Slate Mines of Merionethshire. 3. Ninety per cent. of the total certificates of disdependants. Nevertheless, because of the disability ablement awarded by the Silicosis Medical Board in which he has acquired, the silicotic is thrown out of Great Britain in the coal mining industry are granted employment and is expected to keep himself and his to workers in the South Wales Coalfield. family with the help of public assistance. 4. The results of a survey of a group of Welsh slate Provision of care schemes for the tuberculous is the quarry miners is given, showing the high incidence of duty of local authorities by Act of Parliament. I silicosis in that industry. 5. Silico-tubercolosis is much higher in the slate suggest that such a scheme should also include silicoties. At least part of the scheme would have to be financed quarry miners than in coal miners, but it is suggested by the industry ; but if the industry were to display the that infective silicosis is more prevalent in coal miners same academic interest in a care scheme as is displayed than hitherto suspected. 6. The radiological appearances of silicosis is by some local authorities in Wales to-day towards care described. schemes for the tuberculous, I am afraid that much 7. The complications and sequelae are discussed. water will have flown under the bridge before such a 8. The prevention of the disease is both an engineerscheme for silicotics is formulated. Many of the ing and a medical problem. features of the Denbigh Scheme for the care of the 9. Tuberculous workers should be kept out of the tuberculous could be applied to the care of the unem- industry, and to this end all new entrants into the industry ployable silicotic. It should be remembered that at any should be X-rayed. 10. Institutional treatment should be given to all time during his life the simple silicotic might become silicotics on full compensation and they should be infective, and this onset might be expedited under economic distress, with grave results to the community. included in a care scheme on the same lines as such a scheme for the tuberculous. For this reason, seeing that it is a public health 1I. The rehabilitation of those workers on partial question, local health authorities might also take an compensation should be underfaken. interest in the scheme. I am greatly indebted to Dr. D. A. Powell, Principal The plight of those workers who receive partial compensation is most distressing. They have a dis- Medical Officer, my colleague Dr. Aslett, and Drs. ability and are not capable of doing their full work owing Keating and Thomas of the Silicosis Medical Board, for to it. T h e amount of compensation paid these workers much valuable advice and assistance. is so small that they must find some kind of employment. R~Fa~NC~ Naturally, work in or around the coal pit is the only Amor, A.J. (1941). X - R a y tltlas of Silicosis. Bristol. work they have been trained to do. They are not Anderson, C. S., and Dible, J.H. (1938). J. Hyg., 88, 185. allowed to work on the coal face, and therefore have to Aslett, E., and Jenkins, T . H . Personal communication. find surface work. This kind of work is not easy to find, Collis, E. L., and Gilchrist, J. C. (1928). 07. Indust. Hyg., 10, 101. nor do the employers take kindly to employing these Craw, J. (1937). Tubercle,19, 8. men. Cummings, D.E. (1935). Saranac Laboratory Report. Rehabilitation of these workers on the same lines as Cummins, S. L., and Weatherall, C. (1931).. Brit. 07. Exp. Path, 12, 239. suggested for the tuberculous is definitely indicated. T.W. (1939). Tubercle, 20, 543. This could be done by training them for an industry to Davies, Gardner, L.U. (1940). Saranac Laboratory Report. be set up near their homes. T h e products of this Gough, J. (1940). 07. Path. Bact., 51,277. industry would be sold in the open market, and should Irvine, L. G. (1929). Rep. Miners' Phthisis Medical Bureau, Pretoria. not be marketed on sentimental grounds, which is of Kettle, E. H., and Gye, W.E. (1922). Lancet, 2, 855. limited value only. T h e excellent quality of goods MacDonald, G., Piggot, A. P., and Gilder, F . W . (1930). manufactured by such institutions for the tuberculous Ibid., 2, 846. at Papworth, Barrowmore Hall, Preston Hall, etc., Powell, D. A., and Davies, T. W. (1940). Welsh Nat. Memorial Ass. Rep. Memo. carrying out occupational therapy, have been acceptable to the most fastidious buyers, and when made under Sen, P.K. (1937). 07. Indust. Hyg., t9, 2"25. Sutherland, C.L. (1940). Lancet, 1, 893. properly organised factory conditions, these goods are -Thomas, R.W. (1937). Ibid., 2, 1481. sure sellers in the open market. Trail, Hugh. (194I). Personal communication. If, as suggested, these factories were established Wade, T . W . (1926). Report on High Mortality Rates from Tuberculosis in the Slate Quarry Workers of Caernarvonshire. near the homes of the workers, thus obviating the Williams, E. M. (1933). Health of Old and Retired Coal necessity for them to leave home, I am sure that no Miners in South Wales. Cardiff. unwillingness to participate in the scheme would be found. The Ministry of Labour have started su.ch a scheme in connection with the making of munitions in " Triofax " triple dye jelly, the issue of which is anthe anthracite area. This is a war-time measure, and nounced by Burroughs Wellcome & Co., is a convenient there is no guarantee that it will be continued after the medium for the application of the triple dye-treatment war. The success of any such scheme would depend recently advocated for burns of the hands and face. The on the proper financing of it. There is no doubt that product contains gentian violet, brilliant green, and the money could be found if the employers and the euflavine, incorporated in a stable water-soluble jelly Union got together to work out a scheme for the benefit which is easily and quickly applied to the injured surface. " Triofax " is issued in collapsible tubes of two sizes. of these industrial casualties.
124
MARCH Prognosis
Where the pulmonary damage from silica is considerable the outlook is usually unfavourable, and when, as By T. W. DAVIES, M.B., B.CH., B.SC., D.P.H., so often happens, this type of patient becomes tubercuTuberculosis Physician, Swansea Union Area, lous the prognosis is grave. Welsh National Memorial Association. Dr. Irvine, Director of the Miners' Phthisis Bui'eau at Johannesburg, writes as follows (1929) : " An uncom(Concluded.) plicated silicosis may undergo prolonged and sometimes Diagnosis apparently indefinite arrest at any stage, but in the end It is not proposed to discuss the clinical diagnosis, infection tends to get the upper hand, and when this except to say that generally speaking silicosis has no occurs the greater amount of original damage to the lung pathognomonic clinical signs. It should be borne in mind, however, that there must be a history of a dust by silicosis the more rapid will be the terminal breakhazard. Radiographic appearances afford the most down." This South African experience is to some extent absent in coal miners. reliable evidence in establishing the existence of the Everything considered, the silicotic who is removed disease, and symptoms increase in severity with the from further dust exposure has a fairly goood prognosis, progress of the lung changes as seen in the X-ray picture. but when tuberculosis intervenes the end is considerably Dyspnoea is the earliest symptom, is progressive, and hastened. The prognosis also varies with the industrial remains to the end the most important. conditions which cause the disease. Where the hazard First Stage.--The first stage is characterised by the is not very serious and the resulting damage to the lungs appearance of fine discrete shadows indicative of nodulaof slight or moderate degree, the prognosis is on the tion, together with an increase in the hilum shadows, whole good. On the other hand, where the exposure linear shadows, and pulmonary reticulation. Usually has been severe the case may proceed to a fatal terminawithout impairment of capacity for work. tion in as short a time as one year. Statistical evidence Second Stage.--In this stage dyspnoea and cough have as to the mortality does not give the true position. Many become established. The radiograph shows the whole of both lung fields occupied by these shadows with some companies accept liability after necropsy on a certified case with the result that the Medical Board is not coalescence forming more or less dense opacities. notified. It must also be remembered that a great Third Stage.--This stage implies a condition equiva- number of workers die from natural causes, and though lent to total incapacity. The radiographic appearances silicosis is often present it is not definitely tile cause of are those of massive consolidation and a total incapacity death. In such cases no claim for compensation is for work. made. The first and second stages can be sub-divided in Reverting to Dr. Keating's figures of the sixteen respect of the localisation, number, and distribution of cases that came to necropsy--the survival period after the nodules on the one hand, and the extent of the certification by the Board varied from one month to coalescence of the nodules on the other. Diagnosis is difficult only in the presence of complica- eight years, the largest group of nine cases being between one and three years after certification. More striking, tions, especially pulmonary tuberculosis, which may however, is the fact that in a group of seven diagnosed alter the symptoms, physical signs, radiological appearduring life as silico-tuberculosis with a positive sputum ances, and, indeed, the whole course of the disease. The the longest survival period after certification was only definite proof of the presence of a tuberculous fourteen months, the average for five cases being a focus, as stated previously, is the presence of the tubercle period of five to six months. On the other hand, two bacillus in the sputum. The radiographic diagnosis of patients diagnosed as cases of silico-tuberculosis, but infective silicosis in the absence of this confirmation" with negative sputa, survived eight years after certipresents many difficulties. In the Association's Memofication. randum (Powell and Davies, 1940) the figures supplied by Dr. Keating showed that 16 patients previously granted certificates died during 1939 and came to Complications and Sequelae necropsy. Evidence of silico-tuberculosis was found in Emphysema is a constant finding. all : of these, ten had been seen by tuberculosis physiCardiac Disease.--A few articles in the literature call cians, but they, as well as the Medical Board, had not attention to silicotic fibrosis as a factor in cardiac arrived at a definite diagnosis. enlargement and break-down. An association between It is felt that if such cases were thoroughly investi- cardiovascular disease and silicosis has not been definitely gated by culture examination of the sputum, guinea-pig established. Recently Sir Thomas Lewis at Llandough inoculations, bacteriological examination of the faeces Hospital investigated two patients of mine for evidence and of the stomach contents after gastric lavage, etc., of right-sided heart failure. One was a Stage 8 silicotic a positive diagnosis would be established in a number with massive confluent shadows, and the other was an of cases. An attempt in this direction has been made example of the nodular type whose previous history recently at Cymla Hospital by a re-examination of a suggested right-sided cardiac failure. Sir Thomas was series of patients who were compensated some years unable to find any clear evidence of this in either case. ago. Sputum outfits were given to all and arrangements Gardner (1940) writes that personal experience and the were made to have the sputum cultured. No definite reports from the literature convinced him that in most conclusions were reached owing to the fact that many fatal cases of silicosis the heart is already damaged by of these cases had no sputum for examination. arteriosclerosis or other conditions, and that the presence * Paper read at a meeting of the Welsh Branch of the Society of a conglomerate area of fibrosis with emphysema merely adds to its burden. Post mortem, hypertrophy of the of Medical Officers of Health, 122
1942 fight side of the heart without arteriosclerosis and even greater involvement of the opposite side is a rarity. Pneumonia and oedema of the lungs are common terminal conditions. Bronchiectasis.--Dilatation of the bronchi may supervene as a secondary result of silieotic fibrosis. It is not very common, and as a rule does not reach the stage of a fully developed foul-smelling bronchiectasis. Carcinoma.--Primary carcinoma of the lung is arousing much interest and attention in connection with silicosis because of the possibility that the latter condition may act as a predisposing cause. Anderson and Dible (1988) have published their researches into the relation between silicosis and carcinoma of the lung. The sum of their findings was that a group of cases of pulmonary carcmoma exists in which the organs contain an excess of silica. The histological evidence shows the presence of silicotic fibrosis, and the authors think that the role of the silicosis is aetiological. Dr. T. W. Wade (19~6), in his report on the high mortality rates from tuberculosis occurring in slatequarrying workers of Caernarvonshire, quoted figures that showed there was some reason for thinking that slate dust, besides producing lung fibrosis, might also be a factor in producing cancer of the stomach, for it must be remembered that slate is swallowed as well as inhaled. I have not observed a case of silicosis complicated by pulmonary carcinoma, but one patient with silicosis was seefi who dicd from carcinoma of the stomach. Prevention
PUBLIC HEAI,TH MEDICAL MEASURES
These consist of the clinical and radiological examination of all entrants into the industry concerned. This, as stated previously, is applied to some industries in this country. It is interesting to note from the figures of the Medical Board that there is a decreasing number of disablements in the industries where initial and periodic examinations are practised. There can be no doubt that this, together with improvement in dust extraction methods and ventilation, has played its part in bringing about the decrease. Tuberculous workers should be kept out of the industry, and to this end all entrants into the industry should be X-rayed. This is one of the defects of the present system. In connection with the discovery of the infective case, blood sedimentation and blood counts have been advocated. Trail (1941) is of the opinion that an increased sedimentation rate is a definite indication of infective silicosis. Craw (1987), in a series of 50 haematite iron-ore miners, found blood changes when infection supervened. Aslett and Jenkins have investigated the blood in silicotic coal miners and have found no changes from the normal. Increasing attention should be given by health and school authorities to the nutrition and physique of the boys in the coal area who will be the new entrants into the industry. These should be of the highest possible standard.
Treatment In the present stage of our knowledge not much can DUST SAMPLING AND CONTROL. be done for sillicosis per se, apart from rest and symptoVarious methods are in use to define the degree of matic treatment, and no provision has so far been made exposure by stating the number of dust particles under for intensive investigation of the therapeutic possibilities. 10 microns in greatest diameter in millions per cubic Dyspnoea is the most distressing symptom, and it is foot of air. In certain industries laws have been enacted known from experience that bed rest alone combined which limit the amount of dust permissible in the with good food and fresh air are often of great value, atmosphere. surprising improvement being sometimes obtained, The control of silicosis is both an engineering and a probably due partly to the restoration of the impaired medical problem. The first and basic principle in nutrition and partly to the recuperative effect on the dealing with the dust hazard is to remove the dust at cardiovascular musculature. At Cymla Hospital certain its point of origin and thus prevent its dissemination into cases, after clinical and radiological examination, have the air. This is the only procedure to which the term been selected to undergo a course of respiratory exercises prevention may be properly applied. Once the dust is in order to improve their dyspnoea. It is conin the air the protection of the individual becomes sidered that these exercises will increase the vital difficult and often unsatisfactory. " Wet drilling" has capacity of the lungs by expelling the residual air in the been advocated, and so has drilling in the dry state. In alveoli and in this way decrease the dyspnoea. All the latter a dust trap must be used by means of which expenses of the investigation are defrayed by the the dust produced in drilling is drawn by suction into Association, and the exercises are carried out in the a co!lecting box made of dust-proof material. The Light Department of Cymla Hospital, Neath. The wearing of respirators is but a partial solution of the experiment is still in progress and no definite results problem. Workmen in Some instances are reluctant to have been obtained as yet. use them because they make breathing difficult. A Apart from treatment in an institution, much more highly satisfactory respirator, the Mark IV, which is can and ought to be done as regards the supervision-90 per cent. efficient, has now been devised. Its use medical, social, and economic--of the patients in their should be encouraged and the miners urged to co-operate homes. The silicotic, once certified, seems to be for their own sakes by persisting in its use. nobody's concern. The employers pay the compensation Denny and others in Canada have experimented with and retire from the picture. They intervene at times metallic aluminium in the prevention of silicosis. They to try to persuade the silicotic to settle his compensation have proved by experiment that silicosis can be prevented for a lump sum. The Trade Unions, having seen that in animals exposed to the inhalation of silica if they also compensation was obtained, rest upon their oars. inhale metallic aluminium dust. The favourable result Welfare organisations which provide facilkies for of these experiments has led to the method being tried recreation and subscribe to hospitals for the treatment out in several mines. The trials are still in progress and of acute disease spend nothing on silicotics, the industrial the results have yet to be reported. casualties from their own ranks. 123
PUBLIC HEALTH Compensation, Care, Rehabilitation
MARCH Sum~
Many miners on full compensation are not fit for 1. The industries included in the Silicosis and work, and are therefore unemployable. Compensation Asbestosis Medical Arrangements Scheme are reviewed. 2. The incidence of silicosis continues to be serious, varied according to the average weekly earnings over a year, but never amounted to more than 30s. per week. and in Wales occurs chiefly in the coalfields of South This has now improved, allowance being made for Wales and in the Slate Mines of Merionethshire. 3. Ninety per cent. of the total certificates of disdependants. Nevertheless, because of the disability ablement awarded by the Silicosis Medical Board in which he has acquired, the silicotic is thrown out of Great Britain in the coal mining industry are granted employment and is expected to keep himself and his to workers in the South Wales Coalfield. family with the help of public assistance. 4. The results of a survey of a group of Welsh slate Provision of care schemes for the tuberculous is the quarry miners is given, showing the high incidence of duty of local authorities by Act of Parliament. I silicosis in that industry. 5. Silico-tubercolosis is much higher in the slate suggest that such a scheme should also include silicoties. At least part of the scheme would have to be financed quarry miners than in coal miners, but it is suggested by the industry ; but if the industry were to display the that infective silicosis is more prevalent in coal miners same academic interest in a care scheme as is displayed than hitherto suspected. 6. The radiological appearances of silicosis is by some local authorities in Wales to-day towards care described. schemes for the tuberculous, I am afraid that much 7. The complications and sequelae are discussed. water will have flown under the bridge before such a 8. The prevention of the disease is both an engineerscheme for silicotics is formulated. Many of the ing and a medical problem. features of the Denbigh Scheme for the care of the 9. Tuberculous workers should be kept out of the tuberculous could be applied to the care of the unem- industry, and to this end all new entrants into the industry ployable silicotic. It should be remembered that at any should be X-rayed. 10. Institutional treatment should be given to all time during his life the simple silicotic might become silicotics on full compensation and they should be infective, and this onset might be expedited under economic distress, with grave results to the community. included in a care scheme on the same lines as such a scheme for the tuberculous. For this reason, seeing that it is a public health 1I. The rehabilitation of those workers on partial question, local health authorities might also take an compensation should be underfaken. interest in the scheme. I am greatly indebted to Dr. D. A. Powell, Principal The plight of those workers who receive partial compensation is most distressing. They have a dis- Medical Officer, my colleague Dr. Aslett, and Drs. ability and are not capable of doing their full work owing Keating and Thomas of the Silicosis Medical Board, for to it. T h e amount of compensation paid these workers much valuable advice and assistance. is so small that they must find some kind of employment. R~Fa~NC~ Naturally, work in or around the coal pit is the only Amor, A.J. (1941). X - R a y tltlas of Silicosis. Bristol. work they have been trained to do. They are not Anderson, C. S., and Dible, J.H. (1938). J. Hyg., 88, 185. allowed to work on the coal face, and therefore have to Aslett, E., and Jenkins, T . H . Personal communication. find surface work. This kind of work is not easy to find, Collis, E. L., and Gilchrist, J. C. (1928). 07. Indust. Hyg., 10, 101. nor do the employers take kindly to employing these Craw, J. (1937). Tubercle,19, 8. men. Cummings, D.E. (1935). Saranac Laboratory Report. Rehabilitation of these workers on the same lines as Cummins, S. L., and Weatherall, C. (1931).. Brit. 07. Exp. Path, 12, 239. suggested for the tuberculous is definitely indicated. T.W. (1939). Tubercle, 20, 543. This could be done by training them for an industry to Davies, Gardner, L.U. (1940). Saranac Laboratory Report. be set up near their homes. T h e products of this Gough, J. (1940). 07. Path. Bact., 51,277. industry would be sold in the open market, and should Irvine, L. G. (1929). Rep. Miners' Phthisis Medical Bureau, Pretoria. not be marketed on sentimental grounds, which is of Kettle, E. H., and Gye, W.E. (1922). Lancet, 2, 855. limited value only. T h e excellent quality of goods MacDonald, G., Piggot, A. P., and Gilder, F . W . (1930). manufactured by such institutions for the tuberculous Ibid., 2, 846. at Papworth, Barrowmore Hall, Preston Hall, etc., Powell, D. A., and Davies, T. W. (1940). Welsh Nat. Memorial Ass. Rep. Memo. carrying out occupational therapy, have been acceptable to the most fastidious buyers, and when made under Sen, P.K. (1937). 07. Indust. Hyg., t9, 2"25. Sutherland, C.L. (1940). Lancet, 1, 893. properly organised factory conditions, these goods are -Thomas, R.W. (1937). Ibid., 2, 1481. sure sellers in the open market. Trail, Hugh. (194I). Personal communication. If, as suggested, these factories were established Wade, T . W . (1926). Report on High Mortality Rates from Tuberculosis in the Slate Quarry Workers of Caernarvonshire. near the homes of the workers, thus obviating the Williams, E. M. (1933). Health of Old and Retired Coal necessity for them to leave home, I am sure that no Miners in South Wales. Cardiff. unwillingness to participate in the scheme would be found. The Ministry of Labour have started su.ch a scheme in connection with the making of munitions in " Triofax " triple dye jelly, the issue of which is anthe anthracite area. This is a war-time measure, and nounced by Burroughs Wellcome & Co., is a convenient there is no guarantee that it will be continued after the medium for the application of the triple dye-treatment war. The success of any such scheme would depend recently advocated for burns of the hands and face. The on the proper financing of it. There is no doubt that product contains gentian violet, brilliant green, and the money could be found if the employers and the euflavine, incorporated in a stable water-soluble jelly Union got together to work out a scheme for the benefit which is easily and quickly applied to the injured surface. " Triofax " is issued in collapsible tubes of two sizes. of these industrial casualties.
124