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Tuberculosis as an industrial accident
April, 1929]
TUBERCULOSIS
TUBERCULOSIS
AS AN
INDUSTRIAL
ACCIDENT
AS AN I N D U S T R I A L
ACCIDENT.
B y JOHN B. ItawEs, 2nd, M.]). Boston, Mass.
TH~ t e r m " industrial accident " usually brings ~o mind a picture of a w o r k m a n scalded by steam or molten metal or cut by a circular saw or definitely and acutely injured in some way while at his work. One does not ordinarily look upon the incidence of tuberculosis as an accident, industrial or otherwise. Yet in the broader i n t e r p r e t a t i o n of most of the W o r k m e n ' s Com pe ns at i on Acts in the various States of this c o u n t r y tuberculosis and o t h e r diseases which arise " o u t of and in the course o f " e m p l o y m e n t are regarded as industrial accidents for which compensation is properly paid. One of the first W o r k m e n ' s Compensation Acts in this country was that of M~assachusetts (General Laws, Chapter 152) passed some fifteen or more years ago, based in turn upon a similar act in :England of some years previous. A l t hough in many respects the Massachusetts Ac~ closely resembles t h a t of E n g l a n d there is one striking d i f f e r e n c e - - w h e r e a s the En g lis h Act applies only to " personal injury by accident " the Massachusetts Act and m a n y others in this c oun t ry have been given a far broader i n t e r p r e t a t i o n according to which the w o r k m a n is entitled to compensation who receives a personal injury which arises " out of and in the course of " his e m p l o y m e n t , the term " personal injury " including not only what we ordinarily look upon as accident, but likewise disease and diseased conditions which can be directly connected with ~he man's work. B e t w e e n the years 1911-1925 workmen's compensation laws of various kinds were enacted by forty-two States in this c o u n t r y and likewise by the F e d e r a l G o v e r n m e n t on behalf of its own employees. As 1 have previously stated, a l t h o u g h these compensation laws were passed primarily to provide for compensation on account of what we ordinarily call accidents, in the Massachusetts laws compensation was made available for disability caused by certain industrial and occupational diseases. One of the very early cases which occurred in 1914 on which this broader i n t e r p r e t a t i o n of the t e r m " industrial accident " was based was th at of a m a n who developed an optic neuritis t h r o u g h the inhalation of poisonous gases in the necessary course of his work. Damages were awarded to the plaintiff, the court saying, " T h e r e is not hi ng in the Act which leads to the conclusion tha~ ' personal iniury ' was t here used in a narrow and restricted sense." Another i m p o r t a n t early case likewise in 1914 was one in which an employee whose occupation had been t hat of grinding lead for t w e n t y years finally became incapaeitated from lead poisoning. T h e court stated in this instance as in the previous one: " Un d er the Act, ' p e r s o n a l i n j u r y ' is not limited to iniuries caused by ex ter n al violence, physical force or as the result of accident in the sense in which t h a t word is c om m onl y used and understood, but u n d e r the statute is to be given a much broader and more liberal meaning, and includes a n y bodily i n i u r y . " T he court f u r t h e r stated t hat : " I t is clear t h a t ' personal i n j u r i e s ' under our Act include any injury or disease w hi ch arises out of and in the course of the e m p l o y m e n t which causes i ncapaci t y
33'2
TUBERCLE
[April, 1929
for work and t he r eby impairs the ability of the employee for earning wages." These two cases and others of the same t ype paved the way for an i m m e n s e n u m b e r of claims along similar l i n e s - - s o m e on investigation with o u t foundation, some very real and some debateable ones. A m ong the f o r mer where the claim for compensation could not be granted are those in which certain diseases arose " in the course of " but not " out of " the claimant's employment. Incapacity, for instance, due to a neurosis or to a faulty posture which may take place while an employee is working at a certain t r ade does not necessarily arise " out o f " or because of his occupation. I n one of these cases, for instance, t h a t of a cigar m aker's neurosis, the court defined this wisely and well as follows: " T h e Act relates to industrial conditions. I t has to do with e m p l o y m e n t of labour. I t affords no relief against general disease. I t is not a scheme for heal t h insurance. It deals only with personal injuries following as an immediate result from the e m p l o y m e n t as its direct cause. A disease of mind or body which arises in the course of e m p l o y m e n t with nothing more is not within the Act. I t m us t come from an injury, a l t h o u g h that injury m ay not be a single definite act but may extend over a continuous period of time. Poisoning, blindness, pneumonia, or t he giving way of the heart muscles all induced by the necessary exposure or exert i on of t h e e m p l o y m e n t fall within well recognised classes of personal injuries. On the ot her hand the gradual breaking down or degeneration of the tissues caused by long and laborious work is not the result of a personal injury within the meaning of the Act. T h e disease must be or be traceable directly to a personal iniury peculiar to the employment. It is difficult to establish b e t w e e n what is a personal injury within t he Act on t he one h a n d and simple disease on the other. :But personal injury and disease are not synonymous. One does not include the ot her . . . . although t hey m a y overlap in some instances." T h e r e are few employments which pursued w i t hout due regard to the laws of health and the requirements of a correct mode of life m ay not invite such forms of disease. Such diseases while t h e y arise i~ the course of a man's work do not arise out of or because of this m an's em pl oym ent . To summarise this whole matter, the m a n who breaks his leg in t he course of his work suffers a personal injury, and in no less degree the stone cut t er who develops pneumoconiosis or phthisis after years of stone cutting does likewise. On t he other hand, a day labourer who gets worn out after years of arduous work does not suffer a personal injury any more t han the clerk who comes down with consumption while working in the bank or store. T h e r e are, of course, m a ny border-line cases w here it is ext rem el y difficult to decide. I n this connection I would call a t t e n t i o n to t he i nt erpret at i on of the word, " possible " and " probable." In almost every case when called upon to testify as to the causal relationship bet w een an employee's work or accident, and a subsequently developing p u l m o n a r y tuberculosis, he will be asked whether there was a possible or a probable connection between the m a n's occupation and his disease. I n answering this question it is well to bear in mind t ha t industrial accident boards, and indeed t he law in general, are not interested in things t h a t are merely possible, but only in those t h a t are probable or positive factors in t he case. Tuberculosis developing among granite cut t ers is perhaps the definite
April, 1929]
TUBERCULOSIS
AS AN
INDUSTRIAL
ACCIDI~NT
333
and m o s t s t r i k i n g e x a m p l e of industrial accident in its b r o a d e r aspect arising out of and in t h e course of an occupation. W h e t h e r it be an old t u b e r c u l o u s process w h i c h was r e a c t i v a t e d into clinical activity, or w h e t h e r it was tuberculosis e n g r a f t e d on p n e u m o c o n i o s i s m a k e s little or no difference f r o m t h e legal view point. A n y g r a n i t e c u t t e r w h o has worked steadily for twelve to fifteen years at stone c u t t i n g is practically certain to have developed p n e u m o c o n i o s i s to a m a r k e d e x t e n t , w h i c h in itsel r e n d e r s t h e lung far m o r e susceptible to a t u b e r c u l o u s process t b a n o t h e r wise w o u l d be t h e case, and such a t u b e r c u l o u s process can be justly looked u p o n as an i n d u s t r i a l accident for w h i c h c o m p e n s a t i o n should be paid. A n o t h e r t y p e of case in which the d e v e l o p m e n t of tuberculosis has a direct r e l a t i o n to t h e o c c u p a t i o n is t h a t in w h i c h a m a n , a p p a r e n t l y s t r o n g and h e a l t h y , and w o r k i n g r e g u l a r l y with no s y m p t o m s or c o m p l a i n t s of a n y kind, u n d e r g o e s some u n u s u a l sudden strain or injury, w i t h the result t h a t one of two t h i n g s or occasionally both happens. H e m a y start to spit up blood r e s u l t i n g f r o m t h e t e a r i n g off of an a d h e s i o n f r o m an old and a p p a r e n t l y healed t u b e r c u l o u s process, or he m a y be seized w i t h g r e a t pain in his chest, sudden and m a r k e d shortness of b r e a t h and often severe shock. On e x a m i n a t i o n a p n e u m o t h o r a x or occasionally a h ~ e m o - p n e u m o t h o r a x will be found to be present. T h e r e can be no d o u b t in t h e s e cases but t h a t a n active t u b e r c u l o u s process as s h o w n by t h e h m m o r r h a g e or the p n e u m o t h o r a x has arisen out of and in the course of the m a n ' s work. T h e fact t h a t each of these o c c u r r e n c e s m a y t a k e place, and not i n f r e q u e n t l y does take place, w i t h o u t a n y sudden strain or accident, or w i t h o u t any a p p a r e n t cause whatsoever, has n o t h i n g to do w i t h t h e s i t u a t i o n as far as the claim for c o m p e n s a t i o n is concerned. T h e r e is a !arge g r o u p of cases where the c o n n e c t i o n b e t w e e n the o c c u p a t i o n and the developing of tuberculosis is not so clear, and w h i c h can quite p r o p e r l y be a r g u e d on each side. T a k e , for instance, t h a t of a m a n w h o for only a c o m p a r a t i v e l y short t i m e - - t h r e e to four y e a r s - - h a d been w o r k i n g at t h e m a n u f a c t u r e of e m e r y wheels and was t h u s exposed to a c e r t a i n a m o u n t of dust. H e was t a k e n sick with an acute and severe a t t a c k of influenza, a f t e r w h i c h a h i t h e r t o l a t e n t tuberculosis of the lung b e c a m e active and r e n d e r e d him p e r m a n e n t l y incapacitated. His own lawyers, n a t u r a l l y enough, were inclined to discount the effects of influenza and to e m p h a s i s e t h e effects of t h e dust to w h i c h he had been exposed as the causal factor. As a m a t t e r of fact, in the m o d e r n m a n u f a c t u r e of e m e r y or c o r u n d u m pure silicon is no longer used, but only the less d a n g e r o u s silicates, while in addition the short period to w h i c h this m a n was exposed, and t h a t only i n t e r m i t t e n t l y , for not m o r e t h a n t h r e e or four years, m i l i t a t e d against his o c c u p a t i o n as being the cause of his b r e a k d o w n . On t h e o t h e r h a n d , influenz~ is, of course, notorious for its effect in a w a k e n i n g old t u b e r c u l o u s processes into activity, and in this p a r t i c u l a r case I was quite willing to testify t h a t in m y opinion it was t h e influenza and n o t the dust to w h i c h he had been exposed w h i c h had resulted in his incapacity. A n o t h e r b o r d e r - l i n e case was t h a t of an engineer, who, five years ago, fell and broke t h r e e ribs, which was followed by copious h~emorrhages f r o m t h e lungs l~sting t h r e e to four days. After two or t h r e e m o n t h s ' rest he w e n t back to work, and c o n t i n u e d at his work r e g u l a r l y for t h r e e years,
334
TUBERCLE
[April, 1929
when he had more h~morrhages, after which he was incapacitated. H e claimed th at it was the original injury three years previous which was the cause of his incapacity at t ha t time and of his present incapacity. On the whole I was unwilling to admit that an accident t h r e e years ago, followed by nearly three years of perfect health, during which the m an worked regularIy, could be a factor in causing a reactivity of tuberculosis at th e present time. A coalheaver engaged in loading soft coal on a t ruck at the chutes and delivering it to its destination claimed t h a t the coal dust he had i n h a l e d d u r in g the six years he had done this had aggravated his chronic tuberculosis and caused it to become active. H e r e was a case where t uberculosis developed in the course of this man's occupation, but w h e t h e r it developed out of and because of his occupation was open to a r g u m e n t . I n the first place coal dust is not one of the irritating or dangerous dusts; in the n ex t place this man breathed in the dust only a short period each day while he was loading his truck, as the coal had to be wet down before it was delivered ; in the third place his occupation kept him out-of-doors and in the fresh air the greater part of the time. I testified to the effect t h a t his occupation was not a factor in producing his tuberculosis, although I likewise stated t ha t I would not select his occupation for a patient of mine with a quiescent tuberculosis. Cases of this kind could be endlessly multiplied and are constantly coming up before the Industrial Accident Board in our courts. T h e r e are m a n y concerning which there can be no a r g u m e n t as, for instance, is the case with the granite cutter. T h e r e are m a n y others similar to the one cited above which are on the border line, and, of course, there is a large n u m b e r of cases in which the devel opm ent of tuberculosis is claimed to have been produced by the man's occupation, or because of an iniury, but which claims on examination are found to be ut t erl y without foundation. I n m any of these the diagnosis is wrong, tuberculosis being claimed to be present, when on examination it is non-existent. Th e public knows so much about the disease, tuberculosis, at the present time, and has such a wholesome respect for it t h a t it has a marked tendency to claim this as a factor when any accident is followed or accompanied by loss of weight and strength, or coughing or spitting of any kind. In these cases it is most i m por t a nt that t her e be a thorough, careful, detailed and impartial examination by one qualified to speak with a u t h o r i t y on the subject. Only in this way can those employees who are brought face to face with a disease which will incapacitate t hem perm anent l y, or at leasL for many months, receive compensation which t hey justly deserve, and others who are bringing forward u t t erl y false claims be weeded out. Of really more importance t han the p a y m e n t of compensation to this or t h a t individual employee, no m a t t e r how pathetic his case m a y be, is the fact that because guberculosis which arises in the course of and out of a certain occupation has been looked upon as an industrial accident for which compensation must be paid, insurance companies and t he more broad-minded employers of labour are seeing to it t hat working conditions are improved and brought to such a high standard as regards hygiene, fresh air, dust-removing apparatus, &c., t h a t t he incidence of tuberculosis is reduced to a minimum.
TUBERCULOSIS
TUBERCULOSIS
AS AN
INDUSTRIAL
ACCIDENT
AS AN I N D U S T R I A L
ACCIDENT.
B y JOHN B. ItawEs, 2nd, M.]). Boston, Mass.
TH~ t e r m " industrial accident " usually brings ~o mind a picture of a w o r k m a n scalded by steam or molten metal or cut by a circular saw or definitely and acutely injured in some way while at his work. One does not ordinarily look upon the incidence of tuberculosis as an accident, industrial or otherwise. Yet in the broader i n t e r p r e t a t i o n of most of the W o r k m e n ' s Com pe ns at i on Acts in the various States of this c o u n t r y tuberculosis and o t h e r diseases which arise " o u t of and in the course o f " e m p l o y m e n t are regarded as industrial accidents for which compensation is properly paid. One of the first W o r k m e n ' s Compensation Acts in this country was that of M~assachusetts (General Laws, Chapter 152) passed some fifteen or more years ago, based in turn upon a similar act in :England of some years previous. A l t hough in many respects the Massachusetts Ac~ closely resembles t h a t of E n g l a n d there is one striking d i f f e r e n c e - - w h e r e a s the En g lis h Act applies only to " personal injury by accident " the Massachusetts Act and m a n y others in this c oun t ry have been given a far broader i n t e r p r e t a t i o n according to which the w o r k m a n is entitled to compensation who receives a personal injury which arises " out of and in the course of " his e m p l o y m e n t , the term " personal injury " including not only what we ordinarily look upon as accident, but likewise disease and diseased conditions which can be directly connected with ~he man's work. B e t w e e n the years 1911-1925 workmen's compensation laws of various kinds were enacted by forty-two States in this c o u n t r y and likewise by the F e d e r a l G o v e r n m e n t on behalf of its own employees. As 1 have previously stated, a l t h o u g h these compensation laws were passed primarily to provide for compensation on account of what we ordinarily call accidents, in the Massachusetts laws compensation was made available for disability caused by certain industrial and occupational diseases. One of the very early cases which occurred in 1914 on which this broader i n t e r p r e t a t i o n of the t e r m " industrial accident " was based was th at of a m a n who developed an optic neuritis t h r o u g h the inhalation of poisonous gases in the necessary course of his work. Damages were awarded to the plaintiff, the court saying, " T h e r e is not hi ng in the Act which leads to the conclusion tha~ ' personal iniury ' was t here used in a narrow and restricted sense." Another i m p o r t a n t early case likewise in 1914 was one in which an employee whose occupation had been t hat of grinding lead for t w e n t y years finally became incapaeitated from lead poisoning. T h e court stated in this instance as in the previous one: " Un d er the Act, ' p e r s o n a l i n j u r y ' is not limited to iniuries caused by ex ter n al violence, physical force or as the result of accident in the sense in which t h a t word is c om m onl y used and understood, but u n d e r the statute is to be given a much broader and more liberal meaning, and includes a n y bodily i n i u r y . " T he court f u r t h e r stated t hat : " I t is clear t h a t ' personal i n j u r i e s ' under our Act include any injury or disease w hi ch arises out of and in the course of the e m p l o y m e n t which causes i ncapaci t y
33'2
TUBERCLE
[April, 1929
for work and t he r eby impairs the ability of the employee for earning wages." These two cases and others of the same t ype paved the way for an i m m e n s e n u m b e r of claims along similar l i n e s - - s o m e on investigation with o u t foundation, some very real and some debateable ones. A m ong the f o r mer where the claim for compensation could not be granted are those in which certain diseases arose " in the course of " but not " out of " the claimant's employment. Incapacity, for instance, due to a neurosis or to a faulty posture which may take place while an employee is working at a certain t r ade does not necessarily arise " out o f " or because of his occupation. I n one of these cases, for instance, t h a t of a cigar m aker's neurosis, the court defined this wisely and well as follows: " T h e Act relates to industrial conditions. I t has to do with e m p l o y m e n t of labour. I t affords no relief against general disease. I t is not a scheme for heal t h insurance. It deals only with personal injuries following as an immediate result from the e m p l o y m e n t as its direct cause. A disease of mind or body which arises in the course of e m p l o y m e n t with nothing more is not within the Act. I t m us t come from an injury, a l t h o u g h that injury m ay not be a single definite act but may extend over a continuous period of time. Poisoning, blindness, pneumonia, or t he giving way of the heart muscles all induced by the necessary exposure or exert i on of t h e e m p l o y m e n t fall within well recognised classes of personal injuries. On the ot her hand the gradual breaking down or degeneration of the tissues caused by long and laborious work is not the result of a personal injury within the meaning of the Act. T h e disease must be or be traceable directly to a personal iniury peculiar to the employment. It is difficult to establish b e t w e e n what is a personal injury within t he Act on t he one h a n d and simple disease on the other. :But personal injury and disease are not synonymous. One does not include the ot her . . . . although t hey m a y overlap in some instances." T h e r e are few employments which pursued w i t hout due regard to the laws of health and the requirements of a correct mode of life m ay not invite such forms of disease. Such diseases while t h e y arise i~ the course of a man's work do not arise out of or because of this m an's em pl oym ent . To summarise this whole matter, the m a n who breaks his leg in t he course of his work suffers a personal injury, and in no less degree the stone cut t er who develops pneumoconiosis or phthisis after years of stone cutting does likewise. On t he other hand, a day labourer who gets worn out after years of arduous work does not suffer a personal injury any more t han the clerk who comes down with consumption while working in the bank or store. T h e r e are, of course, m a ny border-line cases w here it is ext rem el y difficult to decide. I n this connection I would call a t t e n t i o n to t he i nt erpret at i on of the word, " possible " and " probable." In almost every case when called upon to testify as to the causal relationship bet w een an employee's work or accident, and a subsequently developing p u l m o n a r y tuberculosis, he will be asked whether there was a possible or a probable connection between the m a n's occupation and his disease. I n answering this question it is well to bear in mind t ha t industrial accident boards, and indeed t he law in general, are not interested in things t h a t are merely possible, but only in those t h a t are probable or positive factors in t he case. Tuberculosis developing among granite cut t ers is perhaps the definite
April, 1929]
TUBERCULOSIS
AS AN
INDUSTRIAL
ACCIDI~NT
333
and m o s t s t r i k i n g e x a m p l e of industrial accident in its b r o a d e r aspect arising out of and in t h e course of an occupation. W h e t h e r it be an old t u b e r c u l o u s process w h i c h was r e a c t i v a t e d into clinical activity, or w h e t h e r it was tuberculosis e n g r a f t e d on p n e u m o c o n i o s i s m a k e s little or no difference f r o m t h e legal view point. A n y g r a n i t e c u t t e r w h o has worked steadily for twelve to fifteen years at stone c u t t i n g is practically certain to have developed p n e u m o c o n i o s i s to a m a r k e d e x t e n t , w h i c h in itsel r e n d e r s t h e lung far m o r e susceptible to a t u b e r c u l o u s process t b a n o t h e r wise w o u l d be t h e case, and such a t u b e r c u l o u s process can be justly looked u p o n as an i n d u s t r i a l accident for w h i c h c o m p e n s a t i o n should be paid. A n o t h e r t y p e of case in which the d e v e l o p m e n t of tuberculosis has a direct r e l a t i o n to t h e o c c u p a t i o n is t h a t in w h i c h a m a n , a p p a r e n t l y s t r o n g and h e a l t h y , and w o r k i n g r e g u l a r l y with no s y m p t o m s or c o m p l a i n t s of a n y kind, u n d e r g o e s some u n u s u a l sudden strain or injury, w i t h the result t h a t one of two t h i n g s or occasionally both happens. H e m a y start to spit up blood r e s u l t i n g f r o m t h e t e a r i n g off of an a d h e s i o n f r o m an old and a p p a r e n t l y healed t u b e r c u l o u s process, or he m a y be seized w i t h g r e a t pain in his chest, sudden and m a r k e d shortness of b r e a t h and often severe shock. On e x a m i n a t i o n a p n e u m o t h o r a x or occasionally a h ~ e m o - p n e u m o t h o r a x will be found to be present. T h e r e can be no d o u b t in t h e s e cases but t h a t a n active t u b e r c u l o u s process as s h o w n by t h e h m m o r r h a g e or the p n e u m o t h o r a x has arisen out of and in the course of the m a n ' s work. T h e fact t h a t each of these o c c u r r e n c e s m a y t a k e place, and not i n f r e q u e n t l y does take place, w i t h o u t a n y sudden strain or accident, or w i t h o u t any a p p a r e n t cause whatsoever, has n o t h i n g to do w i t h t h e s i t u a t i o n as far as the claim for c o m p e n s a t i o n is concerned. T h e r e is a !arge g r o u p of cases where the c o n n e c t i o n b e t w e e n the o c c u p a t i o n and the developing of tuberculosis is not so clear, and w h i c h can quite p r o p e r l y be a r g u e d on each side. T a k e , for instance, t h a t of a m a n w h o for only a c o m p a r a t i v e l y short t i m e - - t h r e e to four y e a r s - - h a d been w o r k i n g at t h e m a n u f a c t u r e of e m e r y wheels and was t h u s exposed to a c e r t a i n a m o u n t of dust. H e was t a k e n sick with an acute and severe a t t a c k of influenza, a f t e r w h i c h a h i t h e r t o l a t e n t tuberculosis of the lung b e c a m e active and r e n d e r e d him p e r m a n e n t l y incapacitated. His own lawyers, n a t u r a l l y enough, were inclined to discount the effects of influenza and to e m p h a s i s e t h e effects of t h e dust to w h i c h he had been exposed as the causal factor. As a m a t t e r of fact, in the m o d e r n m a n u f a c t u r e of e m e r y or c o r u n d u m pure silicon is no longer used, but only the less d a n g e r o u s silicates, while in addition the short period to w h i c h this m a n was exposed, and t h a t only i n t e r m i t t e n t l y , for not m o r e t h a n t h r e e or four years, m i l i t a t e d against his o c c u p a t i o n as being the cause of his b r e a k d o w n . On t h e o t h e r h a n d , influenz~ is, of course, notorious for its effect in a w a k e n i n g old t u b e r c u l o u s processes into activity, and in this p a r t i c u l a r case I was quite willing to testify t h a t in m y opinion it was t h e influenza and n o t the dust to w h i c h he had been exposed w h i c h had resulted in his incapacity. A n o t h e r b o r d e r - l i n e case was t h a t of an engineer, who, five years ago, fell and broke t h r e e ribs, which was followed by copious h~emorrhages f r o m t h e lungs l~sting t h r e e to four days. After two or t h r e e m o n t h s ' rest he w e n t back to work, and c o n t i n u e d at his work r e g u l a r l y for t h r e e years,
334
TUBERCLE
[April, 1929
when he had more h~morrhages, after which he was incapacitated. H e claimed th at it was the original injury three years previous which was the cause of his incapacity at t ha t time and of his present incapacity. On the whole I was unwilling to admit that an accident t h r e e years ago, followed by nearly three years of perfect health, during which the m an worked regularIy, could be a factor in causing a reactivity of tuberculosis at th e present time. A coalheaver engaged in loading soft coal on a t ruck at the chutes and delivering it to its destination claimed t h a t the coal dust he had i n h a l e d d u r in g the six years he had done this had aggravated his chronic tuberculosis and caused it to become active. H e r e was a case where t uberculosis developed in the course of this man's occupation, but w h e t h e r it developed out of and because of his occupation was open to a r g u m e n t . I n the first place coal dust is not one of the irritating or dangerous dusts; in the n ex t place this man breathed in the dust only a short period each day while he was loading his truck, as the coal had to be wet down before it was delivered ; in the third place his occupation kept him out-of-doors and in the fresh air the greater part of the time. I testified to the effect t h a t his occupation was not a factor in producing his tuberculosis, although I likewise stated t ha t I would not select his occupation for a patient of mine with a quiescent tuberculosis. Cases of this kind could be endlessly multiplied and are constantly coming up before the Industrial Accident Board in our courts. T h e r e are m a n y concerning which there can be no a r g u m e n t as, for instance, is the case with the granite cutter. T h e r e are m a n y others similar to the one cited above which are on the border line, and, of course, there is a large n u m b e r of cases in which the devel opm ent of tuberculosis is claimed to have been produced by the man's occupation, or because of an iniury, but which claims on examination are found to be ut t erl y without foundation. I n m any of these the diagnosis is wrong, tuberculosis being claimed to be present, when on examination it is non-existent. Th e public knows so much about the disease, tuberculosis, at the present time, and has such a wholesome respect for it t h a t it has a marked tendency to claim this as a factor when any accident is followed or accompanied by loss of weight and strength, or coughing or spitting of any kind. In these cases it is most i m por t a nt that t her e be a thorough, careful, detailed and impartial examination by one qualified to speak with a u t h o r i t y on the subject. Only in this way can those employees who are brought face to face with a disease which will incapacitate t hem perm anent l y, or at leasL for many months, receive compensation which t hey justly deserve, and others who are bringing forward u t t erl y false claims be weeded out. Of really more importance t han the p a y m e n t of compensation to this or t h a t individual employee, no m a t t e r how pathetic his case m a y be, is the fact that because guberculosis which arises in the course of and out of a certain occupation has been looked upon as an industrial accident for which compensation must be paid, insurance companies and t he more broad-minded employers of labour are seeing to it t hat working conditions are improved and brought to such a high standard as regards hygiene, fresh air, dust-removing apparatus, &c., t h a t t he incidence of tuberculosis is reduced to a minimum.