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Phthisis in the potteries
254
PUBLIC HEALTH.
PHTHISIS IN ~ H E POTTERIES, BY
JAMES MAGILL, M.B., CH.B., B.A.O., R.U.I., D.P.H. Tuberculosis Medical Officer, County Borough o/ Stoke-on- Trent, AND
JOHN B. McDOUGALL, M.B., fil4.B. (GLAsG.), Medical Superintendent Crossleg Sanatorium, Cheshire. Late Assislant Tuberculosis Officer, County Borough o] Stoke-on-Trent. WITH A NOTE BY s i r THOMAS OLIVER. THE
only excuse we have for bringing forward an article dealing with the incidence of phthisis in the Potteries is that we have some reasons for believing that a summarised exposition of our views might enable the authorities, not only in the County Borough in which we have worked, but also those in other places, to be on a more firm footing in combating tuberculous disease of the lung in pottery workers. I t is a well-known fact that the towns comprising the County Borough of Stoke-onTrent--viz., Fenton, Longton, Burslem, Hanley, Stoke, and Tunstall--are not noted for their magnificence. However jealously the potter may regard his citizenship, he must surely agree with the writer who has remarked, " T h e pottery district is most unlovely. Hundreds of kilns and furnaces throw out black smoke f r o m their chimneys, and; all plant life is grim and black." The reason for this is not far to seek. It is calculated that about nine-tenths of the pottery of Great Britain is manufactured here, and that there are, approximately, 48,000 people employed in the factories and workshops in this district. The towns comprising the Potteries cover an area of about II,OOO acres. * The district ,is about ten miles in length and two to three miles in width. The estimated population for 1914 was 241,43o , and the principal occupations are pottery manufacture, mining, and engineering. It is, however, with the first of these trades that we are specially concerned on this occasion. Hitherto, interest has been concentrated more particularly upon_the lead processes in the manufacture of pottery ware, and the relation o f these processes to the health of the workers. As a result of these investigations, two distinct purposes at least have been served: firstly, they have reduced the mortality and also the morbidity in
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lead workers; and, secondly, they have aroused public interest in such a way that " t h e man in the street," so to speak, not only knows the special branch of the trade with which the perils of lead poisoning are associated, but he has also been educated in a most comprehensive fashion, to take the necessary precautions against the metal during his work. That the pottery trade is prejudicial to the health of the workers appears to be a very long established fact. As far back as 17oo Ramazzini called attention to the frequency of diseases of the respiratory system in potters, although, of course, the description of the pathological lesions and the views as to their causation were, in the light of o u r present knowledge, very primitive. It was not until 1813 that Pearson postulated t h e view" that particles of dust, etc., were responsible for pigmentary changes in lung tissue. Following upon this, the casual relationship of miners' phthisis to coal dust was discovered, and soon the entire category of dust producing trades was shown to be an important factor in increasing and mainraining the mortality rate from diseases of the respiratory system. The importance which the processes involving the use of lead-glaze and other compounds of lead has assumed in pottery manufacture, has without doubt been responsible for much brilliant research, and the evidence now- to hand goes to show that the attention devoted to this branch of the pottery industry has been well worth while. It seems strange, therefore, that although the dangers arising from dust particles in potteries have always been reeognised, yet this question has received, in comparison, but slight notice, either from the clinical or from the public health point of view. Much of the difficulty has been the lack of statistical evidence to prove that special branches of the pottery industry were more affected than others. It will be well, therefore, to recal~ some of the salient features of former observations on this point before giving our own. We, in this County Borough, are indebted to the late Dr. Aflidge, of Stoke-on-Trent, for affording us with many facts concerning respiratory diseases in potters. He has pointed out that the average age at which male potters die is 46"5 years, and of nonpotters 54 years. Dr. Tatham, quoted by Sir Thomas Oliver, has compiled a useful
I916.
PUBLIC HEALTH.
table, which we give in an abbreviated form below. Reference to these figures shows t h a t the toll on pottery workers from phthisis and other diseases of the respiratory system is very large.
Unfortunately, the clinical evidence which bears out the statistical data is not very abtmdant. Dr. Raymond 3, on examining 3° potters, found 20 with signs of phthisis, and of 75 Mortality Figures. Diseases Of Resp. Phthisis. Organs.
ComparativeMortality Figures (All
Occupation.
Causes.)
Agriculturist ... Pottery Manufacture Cutler. . . . . . . . . Glass Maker ... Lead Worker ...
...
602
...
1,7o6
...
1,516
... •..
1,487 1,783
lO6 333 382 295 148
Lead Poisoning ... ... P h t h i s i s a n d o t h e r R e s p . Diseases ... ,,.. ,..,.
No. of W o r k e r s e x p o s e d t o ri s k.
figures
Average Annual Deaths attributable to employment.
5,299 About 21,ooo
Figures such as these from an authority like Dr. Reid must carry much weight, and when one takes into consideration the fact t h a t over 20 per cent. of the population of Stoke-on-Trent is employed in the manufacture of pottery ware, the incidence of phthisis and other respiratory diseases might, a priori, be expected to be large amongst the workers. Sommerfield confirms the high death-rate due to phthisis amongst potters. The followin5 extract from his table affords interesting :--
TRADE.
Copper Trade (Metallic Dust) ... Pottery Trade (Mineral Dust)... Wool and Cotton Trade ...
115 668 518 445 397
deaths among china-scourers at Limoges, 36 were due to phthisis. Reporting to the Departmental Committee appointed " t o enquire into the Dangers dependent on the use of Lead, and the Danger or I n j u r y to health arising from Dust and other causes in the mariufacture of Earthenware and China/' Dr. Russell, of Burslem, said, t h a t on examining 458 pottery-workers of varying ages, he found 52 per cent. of those over 50 years of age were subjects of respiratory trouble. I t would have been useful for purposes of comparison with our present inquiry, to have ascertained how many of the workers between t h e ages of 15
In 19o9, Dr. Geo. ReidL in a memorandum, worked out a series of statistics which very forcibly demonstrated the need for comprehensive detail in a subject such as this, which involves such a large percentage of the community. He deplored the lack of confirmatory figures, but in a most able article came to the conclusion that, roughly, 21,ooo pottery workers in North Staffordshire were exposed to dust in a form likely to be injurious to health, in the course of their occupation, and t h a t the mortality from diseases of the respiratory system was moxe than eight times t h a t from lead poisoning. Briefly stated, Dr. Reid's figures are :~-Nature of Industrial Disease.
255
AnnualDeathKate per I,OOO. 9"81 7'05
4"3 148
and 65 years were found to have lesions in the respiratory tract. Dr. F. Shufflebottom, on the same occasion, quoting from the Registrar General's Mortality Tables, said t h a t bronchitis caused 4"4 times as m a n y deaths.among potters as among the general population. In order to give our readers some further general indication of the estimated mortality from respiratory diseases in the County Borough of Stoke-on-Trent, we append the No. of Deiths due to Phthisis per 1,00o Persons.
5"31 14"o 5"36
No. of D e a t h s d u e t o P h t h i s i s pe r I,OOO D e a t h s .
520'5 591"o 554"1
PUBLIC HEALTH.
~56
following table constructed from Dr. O. Petgrave Johnson's (M.O.H. f o r Stoke-onTrent) report :-ii
t
YiCAR
i
......
D e a t h s f r o m all C a u s e s ...... Phthisis . . . . . . . . . Bronchitis ~-....
. . . . . . . . .
Pneumonia . . . . . . . . . Other Resp. Diseases ...
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From what has been said, it is obvious that what is desired is a combination of evidence, clinical and statistical, to show, firstly, that i
ii
I9io.
3,979
1911. ...... ......
4,6t3 313
...... ......
436
......
425
......
24i 49
....... ......
334 25
...... .......
283
3,714 300
1914.
...... ......
4,470 304
...... ......
4,240 308
391
......
483
......
391
276 69
...... ......
354 60
...... ......
386 87
,, ,,,,,
In endeavouring to arrive at a conclusion regarding the incidence of respiratory diseases in potters, it is necessary to bear in mind that the industry in question is one which involves persons of all ages between 15 and 65 years. During the year 1914 there were 280 deaths from pulmonary tuberculosis in persons between these ages in the County Borough of Stoke-onTrent, in the same year there were 1,588 deaths3rom all causes between the same ages-viz., I5 to 65. I n other words, I7"6 per cent. of all deaths between the ages of 15 and 65 years were due to phthisis. It might be further added that of the total number of deaths (1,588) between the ages 15 and 65 during I914, the mortality from all diseases of the respiratory system was 57I or 35"9 per cent. These figures include males and females of all classes within the age limits specified. The following table, which we have compiled from the Registrar General's Annual Report (I913), explains itself. It is interesting for purposes of comparison.
1913.
I912.
,, ,,,,
diseases of the respiratory system are more prevalent in potters than in other workers living in the same district, and, secondly, that such diseases are not equally common in all departments of the trade. We are not in a position to demonstrate these facts, but from a series of 455 successive cases o f phthisis occurring in pottery workers, we have made an effort therefrom, to comply with part of our proposition as regards pulmonary tuberculosis Our figures are taken from the records kept at the Tuberculosis Dispensary at Stoke, to which town patients from Longton, Fenton, Hanley, Burslem, Stoke and Tunstall come for diagnosis and treatment. The Dispensary has, since its inauguration in January, 1913, been under the control of one of us (J.M.), and we have taken special care in ascertaining wherever possible the exact nature of the particular occupation of the patient. The observations which we record relate only to pulmonary tuberculosis in Stoke-on-Trent. Since the opening of the Dispensary
¥E~&R. 19I 3.
PLACE.
T o t a l N o . of deaths between 15 a n d 65 y r s .
Halifax
. . . . . . . . . . . . . . .
697 4,882 2,7Io I,I42 I,O80
~v[anehest e r . . . . . . . . . . . . Sheffield . . . . . . . . . . . . . . . Oldham Cardiff
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leeds Bradford
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stoke-on-Trent . . . . . . . . . . . . England and Wales . . . . . . . . .
2,869 1,953 1,565 19o,865
T o t a l No. of deaths from Phthisis / Total Percentage B r o n c h i t i s , P n e u - i of D e a t h s , d u e t o monia, and other l~esp. D i s e a s e s . Kesp. Diseases.
I9o 1,815
950 356 322
28"6 37"I
35"0 3I"I 29"0
809
3 I'6
525
26"8
523 56,86I
33"4 29"7
,,, ,,,f,
Stoke-on-Trent, it will be noticed, stands well above the average in point of mortality from respiratory diseases.
(January, i913) , there have been altogether 1,43o patients admitted up to November 3oth, I915, and of these 455, or 3I'8 per cent., have
PUBLIC HEALTH.
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The last class inctfides I6 male patients, the nature of whose special employment has not been ascertained. It is also necessary to add that many of the warehousemen and women are really employed inspecial kinds of warehouses through which the ware must pass. On inquiry it was found that about one-half of those worked in what is known as the biscuit warehouse, but we have thought it
been associated with some particular branch of the pottery industry; 233 were females and 222 were males. The Turban-Gerhardt classification has been adopted for recording the clinical findings. The sub-division of the workers into nine classes has no doubt many disadvantages, b u t it has appealed to us as being representative of the more important branches of the trade. No. affected. C L A S S I. Slip-house Workers
. . . . . . . . . . . . . . .
Clay Carriers
. . . . . . . . . . . . . . .
M. F.
I --
Average Age.
--I
I --
27
. . . . . . . . . . . . . . . . . .
M. F,
48 2
4o"1 20"5
Casters
. . . . . . . . . . . . . . . . . .
M, F.
15 3
32"7 25"0
Turners
. . . . . . . . . . . . . . . . . . .
M. F.
7 1
42'8 34"0
5 4
I4"2
. . . . . . . . . . . . . . . . . .
M. F.
17"7
M.
23
34"0
F.
22
29"6
23
CLASS Pressers
Moulders
II.
Others, including Jiggerers, Jolliers, Handlers, etc.
I
Stage I.
27
F,
lh r .
257
C L A S S III. Mould makers . . . . . . . . . . . . . . . . . .
M. F.
--
C L A S S IV. Fettlers, Towers, and Spongers
M. F.
I 33
49
M. F.
31 --
M.
I0
Of D i s e a s e . II. III, I
- -
N u m b e r of Deaths.
~
O
- -
O
28
io
20
O
I
I
O
4 o o
IO i 6
I 2 I
3 1 2
O
I
O
I
4
I
o
o
I
I
2
O
I2
IO
I
8
I4
o
4 4
O
i
O
O
0
I
0
0
I6
13
4
7
36"6
I0
14
7
I2
8 8
37"8 38'6
3
2
3
2
5
2
I
I
M. F. •
7 7
29"5 28" i
1
4
2
3
I
5
I
o
M.
I 16
25 25
0
I
0
0
F,
I0
5
I
2
vnI. . . . . . . . . . . . . . . . . . .
M. F.
13 2
36"3 15" 5
4
8
I
5
2
0
0
0
2 18
33"5 28"9
0
0
0
. . . . . . . . . . . . . . . . . .
M. F.
2
Painters
9
9
o
I
Transferers
. . . . . . . . . . . . . . . . . .
F.
26
2y8
IO
I4
2
6
49"6 22"6
I
I
I
. . . . . . . . . . . . . . . . . .
3 24
I
Gilders
M. F.
14
8
2
4
i
26"0
O
O
O
. . . . . . . . . . . . . . . . . .
M.
I
Lithographers
F. M.
23 9
23"3 30"2
i0
i i
2
6
F.
II
21 ' 4
4 3
3 8
2 o
I 2
1V_[.
37
31 "9
F.
41
28"9
13 i8
20 18
4 5
~4 5
. . . . . . . . .
CLASS V. Placers . . . . . . . . . . . . . . . . . . . . . Ovenmen
. . . . . . . . . . . . . . . . . .
Others, including Saggerers, Flint Sifters, etc . . . . C L A S S VI. Dippers and Dippers' Assistants
CLASS Sorters
VII.
and Polishers
CLASS Printers
. . . . . . . . .
. . . . . . . . . . . .
Others, including Kilnmen, Papereutters, grinders, and Aerographers CLASS
Colour
. . . . . . . . .
F.
--
29"8
IX.
All o t h e r s , i n c l u d i n g W a r e h o u s e m e n , W a r e h o u s e women, Odd Men, ere . . . . . . . . . . . . .
258
P U B L I C ~H E A L T H .
advisable, in the absence of exact information on this point, to group all the " w a r e h o u s e " workers under one class. Of the 233 female patients included in the above list, the combined mortality is 39, or 16"7 per cent. of those affected. The average age at which death occurred in the 39 cases was 25"8 years, after an illness which lasted on an average about I I months. In the case of the male workers, the mortality works out at 68 or 3o'6 per cent. of those affected. The average age at death was 39"9 years, and the duration of illness was on an average 9"5 months. Of course, there is not the slightest doubt that the periods I I and 9"5 months respectively do not represent the actual duration of the illness, b u t it is interesting to observe that, so far as subjective symptoms are concerned, the patients have, as a rule, a comparatively short period of illhealth. From examination of many of the above patients made at short intervals b y one of us (J. ]3. McD.), acting as Resident Medical Officer at Stanfield Sanatorium, where 177 of the above patients have at some time or other been treated, we are able to state that, I. The physical condition of the majority of the patients is very poor. 2. A well marked hectic fever is present in many cases. 3- Physical signs in the chest are almost always to be found, and the spread of the disease m a y be noted at short periodical examinations. 4. H~emoptysis is comparatively infrequent. 5. Microscopical examination of the sputum seldom fails to reveal evidence of mixed infection, and tubercle bacilli were found in no less than 81 per cent. of 86 sputa specially examined. So far, then, the clinical evidence goes hand-in-hand with the statistical, more especially as regards the male workers. From the pathological side also there is material to show that acute destructive disease might be expected. It is a well-known fact that the extent and severity of dust diseases are dependent on the nature of the inhaled dust. Some forms of dust, e.g., carbon, are injurious to a very slight degree, whilst others, e.g., silica, promote extensive change in the pulmonary tissue. In the manufacture of pottery ware, the nature of the offending dust depends to a great extent on the process which is being
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carried on in the immediate neighbourhood. For instance, in Classes 2 and 4 in the above table, finely powdered hard-clay is a common contamination of the atmosphere, and in Classes 5 and 7 flint particles are continually present in the inspired air. These are examples of mineral particles which, as above mentioned, are prone t o produce wide and destructive tissue change in the lungs. Arlidge* has shown that the ash from a potter's lung contained tile following substances in the given proportions: ~ Silica, 47"78, Alum, 18"63, F%O v 5 " 3 5 . Other substances including alkaloids 28"2. Pulmonary tissue, devitalised, sclerosed and shrunken b y such irritant foreign matter, can scarcely be expected to offer much resistance to an invading organism, and the nidus thus afforded for tubercle bacilli is a most comfortable one. The number of deaths in Classes 2, 4, 5, and 7 in our series represents over 55 per cent. of the total number of deaths, and the percentage of male deaths is over 64 of the total male deaths. It has been established experimentally s that the amount of dust present in the atmosphere in the vicinity of pressers and fettlers amounted to 568 mgms. per I,OOO cubic feet of air where the exhaust was working, and to 1,2o 7 mgms. where the exhaust was not operating. In the case of towing, the dust evolved was shown b y the same series of experiments to amount to 31o mgms. per I,OOO cubic feet of air with the exhaust in operation. Similarly, 571 mgms. per I,OOO cubic feet of air were found in close proximity to- the breathing point of china-placers (Class 5), in which process ground flint is used in large quantities. The amount of dust existing in rooms " not generally regarded as dusty " was given b y Mr. Duckering as, on an average, 33 mgms. per I,OOO cubic feet of air. The evidence afforded b y these figures, when taken in conjunction with our findings, is most important. Returning for a moment to Class 8, which is comprised mostly of female workers, there does not appear to be any danger to the respiratory system from atmospheric contamination in the form of dust, b u t the high temperature found in these particular workshops and the sedentary nature of the occupations must be prejudicial to efficient pulmonary resistance. When the potter leaves his workshop he is unfortunately faced with a danger which, if less in severity, is similar in nature to that which surrounds him in his daily employment. The amount of coal necessary for the manufacture of pottery ware is immense, and tlle outside
1916.
PUBLIC
a t m o s p h e r e suffers in consequence. I t was, no doubt, this feature which occurred t o the p o e t ' s m i n d when he described the Potteries as t h e place " Where the minarets are chimneys ; Where the towers are potters' ovens." As far b a c k a s I 8 8 2 , F i n k e l b u r g m a i n t a i n e d t h a t the incidence of acute i n f l a m m a t o r y conditions of t h e lungs a n d bronchi was associated with a smoke-laden atmosphere. I t is quite probable t h a t this is an i m p o r t a n t factor in determining the course of the disease in m a n y cases. A l t h o u g h our figures represent o n l y the cases which have come u n d e r our notice as workers in the p o t t e r y industry, we have also on our books the names of m a n y patients who are n o t potters, b u t who are either related to, or live with some of those included in our list. A t present we are unable t o s t a t e the exact numbers, b u t when we say 2oo we are n o t far off the mark. I t is a l m o s t impossible to do justice to a subject so i m p o r t a n t in its nature, and so v a s t in its dimensions, in so brief a space. W e are conscious also of the fact t h a t the n u m b e r of our cases is small, b u t we h a v e a t t a i n e d our object if this article is looked u p o n as a p r e l i m i n a r y effort to elucidate the p r o b l e m of phthisis in p o t t e r y workers. NOTE.--Sir Thomas Oliver, of Newcastle-uponTyne, who has had an opportunity of reading the manuscript, writes as follows : - - " While within recent years attention to the health of persons employed in the Potteries has been centred upon the dangers incidental to exposure to lead, and its consequences, l e a d p o i s o n i n g , Drs. James Magill and John B. McDougall have properly and opportunely sought to indicate that another danger to the health of operatives with which the Medical profession has long been familiar still prevails and calls for notice. Compared with lead poisoning the number of deaths from diseases of the respiratory organs is far and away out of all proportion. Next to the Sheffield cutler, it is shown that among workers in pottery there is a very high death-rate from phthisis, and diseases of the respiratory organs. In their investigations Drs. Magill and McDougall have taken their figures from patients attending the Tuberculosis Dispensary. They have thus gained pretty accurate information as to the pulmonary health of workers in the six Pottery towns. The data concern 233 females and 222 males. With one or two exceptions it will be noticed that females suffer from pulmonary phthisis at aI~ earlier stage than males, a circumstance which I have observed in other trades wherein male and female operatives are together exposed to the same unhealthy influences. The average duration of the illness is on the whole
259
HEALTH.
greater in females than in males. The paper deals with an interesting subject, and any fresh light which can be thrown upon it deserves o u r careful consideration. We look forward to a further expression of opinion of the writers based upon accumulation of fresh material. They have taken up an enquiry which will prove most useful. REFERENCES. i. Medical Ob~ccr o/ Health's Report. (Dr. O. Palgrave Johnson.) 2. Report o/ the Departmental Committee appointed to inquire into the Dangers attended on the use o] Lead and the Danger or Injury to Health arising/rom Dust and other Causes in the Manu/acture o/ Earthenware and China. Appendices No. xxxiii. 3. Diseases o/ Oeeupatiou. Sir T. Oliver, p. 3o9. 4. Mdroy Lectures, 1889. Lancet i. 5- App. XL. IX:., of The Report o] tl~e Departntental Committee,
DENTAL HYGIENISTS. York a Committee of Dentists interested I N inNewSchool Dental Hygiene has induced the I,egislature of that State to pass a Bill legalising the formation of a body of trained persons known as dental hygienists, the provisions of which are as follows : - " Any dental dispensary or infirmary legally incorporated and registered by the regents, and maintaining a proper standard and e6uipment, m a y establish for women students a course of study in oral hygiene. All such students upon entrance shall present evidence of attendance of one year in high schools, and may be graduated in one year as dental hygienists, upon complying with the preliminary reqnirements to examination by the Board, which are : - " (a) A fee of 5 dollars. " (b) Evidence that they are at least 20 years of age and of good moral character. " (c) That they have complied with and fulfilled the preliminary and professional requiremerits and the requirements of the statute. " After having satisfactorily passed such examination they shall be registered and licensed as 'dental-hygienists' by the regents under such rules as the regents shall prescribe. " Any licensed dentist, public insLitution or school authorities may employ suctl licensed and registered dental hygienists. Such dental hygienists may remove lime deposits, accretions and stains from the exposed surfaces of the teeth, but shM1 not perform any other operation on the teeth or tissues of the mo~th. They may operate in the office of any licensed dentist, or ill any public institution, or in the schools under the general direction or supervision of a licensed dentist, but nothing herein shall be construed as authorizing any dental hygienist performing any operation in the mouth without supervision. The regents may revoke the license of any licensed dentist who shall permit any dental hygienist operating under this supervision to perform any operation other than that permitted under the provisions of this section."
PUBLIC HEALTH.
PHTHISIS IN ~ H E POTTERIES, BY
JAMES MAGILL, M.B., CH.B., B.A.O., R.U.I., D.P.H. Tuberculosis Medical Officer, County Borough o/ Stoke-on- Trent, AND
JOHN B. McDOUGALL, M.B., fil4.B. (GLAsG.), Medical Superintendent Crossleg Sanatorium, Cheshire. Late Assislant Tuberculosis Officer, County Borough o] Stoke-on-Trent. WITH A NOTE BY s i r THOMAS OLIVER. THE
only excuse we have for bringing forward an article dealing with the incidence of phthisis in the Potteries is that we have some reasons for believing that a summarised exposition of our views might enable the authorities, not only in the County Borough in which we have worked, but also those in other places, to be on a more firm footing in combating tuberculous disease of the lung in pottery workers. I t is a well-known fact that the towns comprising the County Borough of Stoke-onTrent--viz., Fenton, Longton, Burslem, Hanley, Stoke, and Tunstall--are not noted for their magnificence. However jealously the potter may regard his citizenship, he must surely agree with the writer who has remarked, " T h e pottery district is most unlovely. Hundreds of kilns and furnaces throw out black smoke f r o m their chimneys, and; all plant life is grim and black." The reason for this is not far to seek. It is calculated that about nine-tenths of the pottery of Great Britain is manufactured here, and that there are, approximately, 48,000 people employed in the factories and workshops in this district. The towns comprising the Potteries cover an area of about II,OOO acres. * The district ,is about ten miles in length and two to three miles in width. The estimated population for 1914 was 241,43o , and the principal occupations are pottery manufacture, mining, and engineering. It is, however, with the first of these trades that we are specially concerned on this occasion. Hitherto, interest has been concentrated more particularly upon_the lead processes in the manufacture of pottery ware, and the relation o f these processes to the health of the workers. As a result of these investigations, two distinct purposes at least have been served: firstly, they have reduced the mortality and also the morbidity in
Aucus¢,
lead workers; and, secondly, they have aroused public interest in such a way that " t h e man in the street," so to speak, not only knows the special branch of the trade with which the perils of lead poisoning are associated, but he has also been educated in a most comprehensive fashion, to take the necessary precautions against the metal during his work. That the pottery trade is prejudicial to the health of the workers appears to be a very long established fact. As far back as 17oo Ramazzini called attention to the frequency of diseases of the respiratory system in potters, although, of course, the description of the pathological lesions and the views as to their causation were, in the light of o u r present knowledge, very primitive. It was not until 1813 that Pearson postulated t h e view" that particles of dust, etc., were responsible for pigmentary changes in lung tissue. Following upon this, the casual relationship of miners' phthisis to coal dust was discovered, and soon the entire category of dust producing trades was shown to be an important factor in increasing and mainraining the mortality rate from diseases of the respiratory system. The importance which the processes involving the use of lead-glaze and other compounds of lead has assumed in pottery manufacture, has without doubt been responsible for much brilliant research, and the evidence now- to hand goes to show that the attention devoted to this branch of the pottery industry has been well worth while. It seems strange, therefore, that although the dangers arising from dust particles in potteries have always been reeognised, yet this question has received, in comparison, but slight notice, either from the clinical or from the public health point of view. Much of the difficulty has been the lack of statistical evidence to prove that special branches of the pottery industry were more affected than others. It will be well, therefore, to recal~ some of the salient features of former observations on this point before giving our own. We, in this County Borough, are indebted to the late Dr. Aflidge, of Stoke-on-Trent, for affording us with many facts concerning respiratory diseases in potters. He has pointed out that the average age at which male potters die is 46"5 years, and of nonpotters 54 years. Dr. Tatham, quoted by Sir Thomas Oliver, has compiled a useful
I916.
PUBLIC HEALTH.
table, which we give in an abbreviated form below. Reference to these figures shows t h a t the toll on pottery workers from phthisis and other diseases of the respiratory system is very large.
Unfortunately, the clinical evidence which bears out the statistical data is not very abtmdant. Dr. Raymond 3, on examining 3° potters, found 20 with signs of phthisis, and of 75 Mortality Figures. Diseases Of Resp. Phthisis. Organs.
ComparativeMortality Figures (All
Occupation.
Causes.)
Agriculturist ... Pottery Manufacture Cutler. . . . . . . . . Glass Maker ... Lead Worker ...
...
602
...
1,7o6
...
1,516
... •..
1,487 1,783
lO6 333 382 295 148
Lead Poisoning ... ... P h t h i s i s a n d o t h e r R e s p . Diseases ... ,,.. ,..,.
No. of W o r k e r s e x p o s e d t o ri s k.
figures
Average Annual Deaths attributable to employment.
5,299 About 21,ooo
Figures such as these from an authority like Dr. Reid must carry much weight, and when one takes into consideration the fact t h a t over 20 per cent. of the population of Stoke-on-Trent is employed in the manufacture of pottery ware, the incidence of phthisis and other respiratory diseases might, a priori, be expected to be large amongst the workers. Sommerfield confirms the high death-rate due to phthisis amongst potters. The followin5 extract from his table affords interesting :--
TRADE.
Copper Trade (Metallic Dust) ... Pottery Trade (Mineral Dust)... Wool and Cotton Trade ...
115 668 518 445 397
deaths among china-scourers at Limoges, 36 were due to phthisis. Reporting to the Departmental Committee appointed " t o enquire into the Dangers dependent on the use of Lead, and the Danger or I n j u r y to health arising from Dust and other causes in the mariufacture of Earthenware and China/' Dr. Russell, of Burslem, said, t h a t on examining 458 pottery-workers of varying ages, he found 52 per cent. of those over 50 years of age were subjects of respiratory trouble. I t would have been useful for purposes of comparison with our present inquiry, to have ascertained how many of the workers between t h e ages of 15
In 19o9, Dr. Geo. ReidL in a memorandum, worked out a series of statistics which very forcibly demonstrated the need for comprehensive detail in a subject such as this, which involves such a large percentage of the community. He deplored the lack of confirmatory figures, but in a most able article came to the conclusion that, roughly, 21,ooo pottery workers in North Staffordshire were exposed to dust in a form likely to be injurious to health, in the course of their occupation, and t h a t the mortality from diseases of the respiratory system was moxe than eight times t h a t from lead poisoning. Briefly stated, Dr. Reid's figures are :~-Nature of Industrial Disease.
255
AnnualDeathKate per I,OOO. 9"81 7'05
4"3 148
and 65 years were found to have lesions in the respiratory tract. Dr. F. Shufflebottom, on the same occasion, quoting from the Registrar General's Mortality Tables, said t h a t bronchitis caused 4"4 times as m a n y deaths.among potters as among the general population. In order to give our readers some further general indication of the estimated mortality from respiratory diseases in the County Borough of Stoke-on-Trent, we append the No. of Deiths due to Phthisis per 1,00o Persons.
5"31 14"o 5"36
No. of D e a t h s d u e t o P h t h i s i s pe r I,OOO D e a t h s .
520'5 591"o 554"1
PUBLIC HEALTH.
~56
following table constructed from Dr. O. Petgrave Johnson's (M.O.H. f o r Stoke-onTrent) report :-ii
t
YiCAR
i
......
D e a t h s f r o m all C a u s e s ...... Phthisis . . . . . . . . . Bronchitis ~-....
. . . . . . . . .
Pneumonia . . . . . . . . . Other Resp. Diseases ...
AuGusT,
From what has been said, it is obvious that what is desired is a combination of evidence, clinical and statistical, to show, firstly, that i
ii
I9io.
3,979
1911. ...... ......
4,6t3 313
...... ......
436
......
425
......
24i 49
....... ......
334 25
...... .......
283
3,714 300
1914.
...... ......
4,470 304
...... ......
4,240 308
391
......
483
......
391
276 69
...... ......
354 60
...... ......
386 87
,, ,,,,,
In endeavouring to arrive at a conclusion regarding the incidence of respiratory diseases in potters, it is necessary to bear in mind that the industry in question is one which involves persons of all ages between 15 and 65 years. During the year 1914 there were 280 deaths from pulmonary tuberculosis in persons between these ages in the County Borough of Stoke-onTrent, in the same year there were 1,588 deaths3rom all causes between the same ages-viz., I5 to 65. I n other words, I7"6 per cent. of all deaths between the ages of 15 and 65 years were due to phthisis. It might be further added that of the total number of deaths (1,588) between the ages 15 and 65 during I914, the mortality from all diseases of the respiratory system was 57I or 35"9 per cent. These figures include males and females of all classes within the age limits specified. The following table, which we have compiled from the Registrar General's Annual Report (I913), explains itself. It is interesting for purposes of comparison.
1913.
I912.
,, ,,,,
diseases of the respiratory system are more prevalent in potters than in other workers living in the same district, and, secondly, that such diseases are not equally common in all departments of the trade. We are not in a position to demonstrate these facts, but from a series of 455 successive cases o f phthisis occurring in pottery workers, we have made an effort therefrom, to comply with part of our proposition as regards pulmonary tuberculosis Our figures are taken from the records kept at the Tuberculosis Dispensary at Stoke, to which town patients from Longton, Fenton, Hanley, Burslem, Stoke and Tunstall come for diagnosis and treatment. The Dispensary has, since its inauguration in January, 1913, been under the control of one of us (J.M.), and we have taken special care in ascertaining wherever possible the exact nature of the particular occupation of the patient. The observations which we record relate only to pulmonary tuberculosis in Stoke-on-Trent. Since the opening of the Dispensary
¥E~&R. 19I 3.
PLACE.
T o t a l N o . of deaths between 15 a n d 65 y r s .
Halifax
. . . . . . . . . . . . . . .
697 4,882 2,7Io I,I42 I,O80
~v[anehest e r . . . . . . . . . . . . Sheffield . . . . . . . . . . . . . . . Oldham Cardiff
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leeds Bradford
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stoke-on-Trent . . . . . . . . . . . . England and Wales . . . . . . . . .
2,869 1,953 1,565 19o,865
T o t a l No. of deaths from Phthisis / Total Percentage B r o n c h i t i s , P n e u - i of D e a t h s , d u e t o monia, and other l~esp. D i s e a s e s . Kesp. Diseases.
I9o 1,815
950 356 322
28"6 37"I
35"0 3I"I 29"0
809
3 I'6
525
26"8
523 56,86I
33"4 29"7
,,, ,,,f,
Stoke-on-Trent, it will be noticed, stands well above the average in point of mortality from respiratory diseases.
(January, i913) , there have been altogether 1,43o patients admitted up to November 3oth, I915, and of these 455, or 3I'8 per cent., have
PUBLIC HEALTH.
i916.
The last class inctfides I6 male patients, the nature of whose special employment has not been ascertained. It is also necessary to add that many of the warehousemen and women are really employed inspecial kinds of warehouses through which the ware must pass. On inquiry it was found that about one-half of those worked in what is known as the biscuit warehouse, but we have thought it
been associated with some particular branch of the pottery industry; 233 were females and 222 were males. The Turban-Gerhardt classification has been adopted for recording the clinical findings. The sub-division of the workers into nine classes has no doubt many disadvantages, b u t it has appealed to us as being representative of the more important branches of the trade. No. affected. C L A S S I. Slip-house Workers
. . . . . . . . . . . . . . .
Clay Carriers
. . . . . . . . . . . . . . .
M. F.
I --
Average Age.
--I
I --
27
. . . . . . . . . . . . . . . . . .
M. F,
48 2
4o"1 20"5
Casters
. . . . . . . . . . . . . . . . . .
M, F.
15 3
32"7 25"0
Turners
. . . . . . . . . . . . . . . . . . .
M. F.
7 1
42'8 34"0
5 4
I4"2
. . . . . . . . . . . . . . . . . .
M. F.
17"7
M.
23
34"0
F.
22
29"6
23
CLASS Pressers
Moulders
II.
Others, including Jiggerers, Jolliers, Handlers, etc.
I
Stage I.
27
F,
lh r .
257
C L A S S III. Mould makers . . . . . . . . . . . . . . . . . .
M. F.
--
C L A S S IV. Fettlers, Towers, and Spongers
M. F.
I 33
49
M. F.
31 --
M.
I0
Of D i s e a s e . II. III, I
- -
N u m b e r of Deaths.
~
O
- -
O
28
io
20
O
I
I
O
4 o o
IO i 6
I 2 I
3 1 2
O
I
O
I
4
I
o
o
I
I
2
O
I2
IO
I
8
I4
o
4 4
O
i
O
O
0
I
0
0
I6
13
4
7
36"6
I0
14
7
I2
8 8
37"8 38'6
3
2
3
2
5
2
I
I
M. F. •
7 7
29"5 28" i
1
4
2
3
I
5
I
o
M.
I 16
25 25
0
I
0
0
F,
I0
5
I
2
vnI. . . . . . . . . . . . . . . . . . .
M. F.
13 2
36"3 15" 5
4
8
I
5
2
0
0
0
2 18
33"5 28"9
0
0
0
. . . . . . . . . . . . . . . . . .
M. F.
2
Painters
9
9
o
I
Transferers
. . . . . . . . . . . . . . . . . .
F.
26
2y8
IO
I4
2
6
49"6 22"6
I
I
I
. . . . . . . . . . . . . . . . . .
3 24
I
Gilders
M. F.
14
8
2
4
i
26"0
O
O
O
. . . . . . . . . . . . . . . . . .
M.
I
Lithographers
F. M.
23 9
23"3 30"2
i0
i i
2
6
F.
II
21 ' 4
4 3
3 8
2 o
I 2
1V_[.
37
31 "9
F.
41
28"9
13 i8
20 18
4 5
~4 5
. . . . . . . . .
CLASS V. Placers . . . . . . . . . . . . . . . . . . . . . Ovenmen
. . . . . . . . . . . . . . . . . .
Others, including Saggerers, Flint Sifters, etc . . . . C L A S S VI. Dippers and Dippers' Assistants
CLASS Sorters
VII.
and Polishers
CLASS Printers
. . . . . . . . .
. . . . . . . . . . . .
Others, including Kilnmen, Papereutters, grinders, and Aerographers CLASS
Colour
. . . . . . . . .
F.
--
29"8
IX.
All o t h e r s , i n c l u d i n g W a r e h o u s e m e n , W a r e h o u s e women, Odd Men, ere . . . . . . . . . . . . .
258
P U B L I C ~H E A L T H .
advisable, in the absence of exact information on this point, to group all the " w a r e h o u s e " workers under one class. Of the 233 female patients included in the above list, the combined mortality is 39, or 16"7 per cent. of those affected. The average age at which death occurred in the 39 cases was 25"8 years, after an illness which lasted on an average about I I months. In the case of the male workers, the mortality works out at 68 or 3o'6 per cent. of those affected. The average age at death was 39"9 years, and the duration of illness was on an average 9"5 months. Of course, there is not the slightest doubt that the periods I I and 9"5 months respectively do not represent the actual duration of the illness, b u t it is interesting to observe that, so far as subjective symptoms are concerned, the patients have, as a rule, a comparatively short period of illhealth. From examination of many of the above patients made at short intervals b y one of us (J. ]3. McD.), acting as Resident Medical Officer at Stanfield Sanatorium, where 177 of the above patients have at some time or other been treated, we are able to state that, I. The physical condition of the majority of the patients is very poor. 2. A well marked hectic fever is present in many cases. 3- Physical signs in the chest are almost always to be found, and the spread of the disease m a y be noted at short periodical examinations. 4. H~emoptysis is comparatively infrequent. 5. Microscopical examination of the sputum seldom fails to reveal evidence of mixed infection, and tubercle bacilli were found in no less than 81 per cent. of 86 sputa specially examined. So far, then, the clinical evidence goes hand-in-hand with the statistical, more especially as regards the male workers. From the pathological side also there is material to show that acute destructive disease might be expected. It is a well-known fact that the extent and severity of dust diseases are dependent on the nature of the inhaled dust. Some forms of dust, e.g., carbon, are injurious to a very slight degree, whilst others, e.g., silica, promote extensive change in the pulmonary tissue. In the manufacture of pottery ware, the nature of the offending dust depends to a great extent on the process which is being
AuGus%
carried on in the immediate neighbourhood. For instance, in Classes 2 and 4 in the above table, finely powdered hard-clay is a common contamination of the atmosphere, and in Classes 5 and 7 flint particles are continually present in the inspired air. These are examples of mineral particles which, as above mentioned, are prone t o produce wide and destructive tissue change in the lungs. Arlidge* has shown that the ash from a potter's lung contained tile following substances in the given proportions: ~ Silica, 47"78, Alum, 18"63, F%O v 5 " 3 5 . Other substances including alkaloids 28"2. Pulmonary tissue, devitalised, sclerosed and shrunken b y such irritant foreign matter, can scarcely be expected to offer much resistance to an invading organism, and the nidus thus afforded for tubercle bacilli is a most comfortable one. The number of deaths in Classes 2, 4, 5, and 7 in our series represents over 55 per cent. of the total number of deaths, and the percentage of male deaths is over 64 of the total male deaths. It has been established experimentally s that the amount of dust present in the atmosphere in the vicinity of pressers and fettlers amounted to 568 mgms. per I,OOO cubic feet of air where the exhaust was working, and to 1,2o 7 mgms. where the exhaust was not operating. In the case of towing, the dust evolved was shown b y the same series of experiments to amount to 31o mgms. per I,OOO cubic feet of air with the exhaust in operation. Similarly, 571 mgms. per I,OOO cubic feet of air were found in close proximity to- the breathing point of china-placers (Class 5), in which process ground flint is used in large quantities. The amount of dust existing in rooms " not generally regarded as dusty " was given b y Mr. Duckering as, on an average, 33 mgms. per I,OOO cubic feet of air. The evidence afforded b y these figures, when taken in conjunction with our findings, is most important. Returning for a moment to Class 8, which is comprised mostly of female workers, there does not appear to be any danger to the respiratory system from atmospheric contamination in the form of dust, b u t the high temperature found in these particular workshops and the sedentary nature of the occupations must be prejudicial to efficient pulmonary resistance. When the potter leaves his workshop he is unfortunately faced with a danger which, if less in severity, is similar in nature to that which surrounds him in his daily employment. The amount of coal necessary for the manufacture of pottery ware is immense, and tlle outside
1916.
PUBLIC
a t m o s p h e r e suffers in consequence. I t was, no doubt, this feature which occurred t o the p o e t ' s m i n d when he described the Potteries as t h e place " Where the minarets are chimneys ; Where the towers are potters' ovens." As far b a c k a s I 8 8 2 , F i n k e l b u r g m a i n t a i n e d t h a t the incidence of acute i n f l a m m a t o r y conditions of t h e lungs a n d bronchi was associated with a smoke-laden atmosphere. I t is quite probable t h a t this is an i m p o r t a n t factor in determining the course of the disease in m a n y cases. A l t h o u g h our figures represent o n l y the cases which have come u n d e r our notice as workers in the p o t t e r y industry, we have also on our books the names of m a n y patients who are n o t potters, b u t who are either related to, or live with some of those included in our list. A t present we are unable t o s t a t e the exact numbers, b u t when we say 2oo we are n o t far off the mark. I t is a l m o s t impossible to do justice to a subject so i m p o r t a n t in its nature, and so v a s t in its dimensions, in so brief a space. W e are conscious also of the fact t h a t the n u m b e r of our cases is small, b u t we h a v e a t t a i n e d our object if this article is looked u p o n as a p r e l i m i n a r y effort to elucidate the p r o b l e m of phthisis in p o t t e r y workers. NOTE.--Sir Thomas Oliver, of Newcastle-uponTyne, who has had an opportunity of reading the manuscript, writes as follows : - - " While within recent years attention to the health of persons employed in the Potteries has been centred upon the dangers incidental to exposure to lead, and its consequences, l e a d p o i s o n i n g , Drs. James Magill and John B. McDougall have properly and opportunely sought to indicate that another danger to the health of operatives with which the Medical profession has long been familiar still prevails and calls for notice. Compared with lead poisoning the number of deaths from diseases of the respiratory organs is far and away out of all proportion. Next to the Sheffield cutler, it is shown that among workers in pottery there is a very high death-rate from phthisis, and diseases of the respiratory organs. In their investigations Drs. Magill and McDougall have taken their figures from patients attending the Tuberculosis Dispensary. They have thus gained pretty accurate information as to the pulmonary health of workers in the six Pottery towns. The data concern 233 females and 222 males. With one or two exceptions it will be noticed that females suffer from pulmonary phthisis at aI~ earlier stage than males, a circumstance which I have observed in other trades wherein male and female operatives are together exposed to the same unhealthy influences. The average duration of the illness is on the whole
259
HEALTH.
greater in females than in males. The paper deals with an interesting subject, and any fresh light which can be thrown upon it deserves o u r careful consideration. We look forward to a further expression of opinion of the writers based upon accumulation of fresh material. They have taken up an enquiry which will prove most useful. REFERENCES. i. Medical Ob~ccr o/ Health's Report. (Dr. O. Palgrave Johnson.) 2. Report o/ the Departmental Committee appointed to inquire into the Dangers attended on the use o] Lead and the Danger or Injury to Health arising/rom Dust and other Causes in the Manu/acture o/ Earthenware and China. Appendices No. xxxiii. 3. Diseases o/ Oeeupatiou. Sir T. Oliver, p. 3o9. 4. Mdroy Lectures, 1889. Lancet i. 5- App. XL. IX:., of The Report o] tl~e Departntental Committee,
DENTAL HYGIENISTS. York a Committee of Dentists interested I N inNewSchool Dental Hygiene has induced the I,egislature of that State to pass a Bill legalising the formation of a body of trained persons known as dental hygienists, the provisions of which are as follows : - " Any dental dispensary or infirmary legally incorporated and registered by the regents, and maintaining a proper standard and e6uipment, m a y establish for women students a course of study in oral hygiene. All such students upon entrance shall present evidence of attendance of one year in high schools, and may be graduated in one year as dental hygienists, upon complying with the preliminary reqnirements to examination by the Board, which are : - " (a) A fee of 5 dollars. " (b) Evidence that they are at least 20 years of age and of good moral character. " (c) That they have complied with and fulfilled the preliminary and professional requiremerits and the requirements of the statute. " After having satisfactorily passed such examination they shall be registered and licensed as 'dental-hygienists' by the regents under such rules as the regents shall prescribe. " Any licensed dentist, public insLitution or school authorities may employ suctl licensed and registered dental hygienists. Such dental hygienists may remove lime deposits, accretions and stains from the exposed surfaces of the teeth, but shM1 not perform any other operation on the teeth or tissues of the mo~th. They may operate in the office of any licensed dentist, or ill any public institution, or in the schools under the general direction or supervision of a licensed dentist, but nothing herein shall be construed as authorizing any dental hygienist performing any operation in the mouth without supervision. The regents may revoke the license of any licensed dentist who shall permit any dental hygienist operating under this supervision to perform any operation other than that permitted under the provisions of this section."