599 PNEUMOCONIOSIS By A. MEIKLEJOHN, M.D. From the University of Glasgow7 Historical (I828) about the complete enclosure of carding and In medical writings from the ' Epidemics of spinning machines and how from the picking room Hippocrates' (460-370 B.C.) to the ' Treatise of alone 828 lb. of cotton dust was collected in the the Diseases of Tradesmen' by Ramazzini (I633- exhaust chamber during a single year. Calvert I714), the historian may discover references to the Holland (i843) discussed the advantages of down occurrence of lung diseases among workmen en- draught exhaust ventilation with flues under the gaged in dusty occupations, but the significance of floor-as against overhead hoods and ducts. these passages is largely speculative. By contrast On the clinical side, early detection of the the allusions contained in the texts (Meiklejohn, disease by regular medical supervision, chest 1947) of Benson's Patents, 1726 and 1732, for measurement, estimation of pulmonary vital grinding flints are precise and comprehensive: capacity and inhalation therapy, all are noted. ' Any person ever so healthfull or strong work- Lack ofco-operation bythe workmen then as now ing in that business cannot probably survive above was a problem:' We remark with regret the men's two years, occasioned by the dust sucked into his inattention to health, their indifference to the pre- body by the air he breaths, which being of a pon- vention of disease. They think nothing of in- derous nature, fixes there so closely that it is now jurious agents till their health is destroyed and the very difficult to find persons which will engage in time for prevention is past.' Employers have the business, to the great obstruction and detri- responsibilities and duties: ' It is especially in- ment of the said trade.' cumbent on masters to regard the health of the These statements appear authentic as it is re- persons they employ; to examine the effects of corded that calcined flint was introduced for use in injurious agents, to invent and provide remedies, earthenware manufacture in 1720 (Shaw, I829). and to enforce theit application.' But this cannot Thackrah of Leeds (I832) discussed at length be achieved voluntarily and so the need of Factory the health of ' operatives subjected to dust' and Acts is foreseen: ' Whatever improvement may be ever since physicians have recorded from their own effected without a legislative enactment . this local experience the melancholy tale of dust, con- improvement will be but temporary.' Finally, for sumption and premature death. Knight (I830) a the physician, there is wise counsel: ' He must not practitioner of Sheffield relates that, ' The fork be content with the loose statements of thoughtless grinders who use a dry grindstone die at the ages and prejudiced workmen ' (Thackrah, I832), and of 28 and 32 ' and among the preventive measures nowadays I, personally, would venture to add which he recommends is that this occupation employers and trade union officials. should be confined to criminals. In support of their arguments these early The disease then, as now, was incurable, and authors provide extensive statistical tables re- so the demand was for prevention and control. vealing the dreadful toll of fibroid phthisis in the There is scarcely a single modern measure or de- i8th and igth centuries, but repetition here would vice which is not recorded and discussed by the serve little purpose; indeed by false comparisons older writers. Thackrah (I832) mentions sub- might lead to a wholly unjustified complacency stitution of harmful by less noxious substances, ex- about the tragic present. I haust ventilation, wet processes in place of dry, The historical development of opinion on the face masks, alternation of employment and re- etiology and pathology of lung diseases in trades- duced hours of labour. In a very interesting men requires brief notice, but before this it is passage he describes the benefits of natural water necessary to examine the evolution of the nomen- infusion through fissures in the rock in lead clature of the disease. mines: ' The particles, on the contrary, are laid as they Nomenclature and its Significance are formed, by the continuous oozing, dropping During the i8th century the dust diseases of the and splashing of the insinuating water.' lungs were identified by terms descriptive of the At a Scottish cotton mill we learn from Ritchie clinical features, asthma, rot, phthisis or con- Si 6oo POSTGRADUATE MEDICAL JOURNAL December 1949 sumption, to which was prefixed the name of the plied in ' active' and ' inert' dusts and ' benign associated trade, as in knife-grinders' asthma and pneumoconiosis ' (Prendergrass and Leopold, potters' rot. The next phase in nomenclature was I945). The problem is still further complicated related to the study of morbid anatomical changes by attempts to embrace certain legal and ad- in the lungs observed at necropsy. In I838 ministrative considerations in relation to work- Stratton proposed the term anthracosis to describe men's compensation (Fletcher, 1948). And again the appearances which he had observed in a coal- how are we to regard byssinosis, bagassosis, miner's lungs. Later, about i866, Zenker re- berylliosis, aluminosis, manganese pneumonitis, corded the presence of red iron oxide in the lungs bronchomycoses and a host of others ? The con- of women engaged in handling this powder. This fusion is world-wide and 4,as become so great that condition he named siderosis and for the various it almost appears as if the original terminology affections of the lungs produced by the inhalation should be abandoned and that some authoritative of dust-like particles he proposed the generic title body such as the International Labour Office pneumonokoniosis (nvev'p'ov, lung and KOVL5, should endeavour to formulate and establish a dust). Following this practice Visconti, in I870, classification and nomenclature for universal use. introduced the term silicosis for those cases in At present in this country the practical every- which the noxious dust was composed of silex or day consideration is the legal definition for pur- flint, and Merkel added chalicosis when fine gravel poses of workmen's compensation under the or stone was the offending agent. Byssinosis was National Insurance (Industrial Injuries) Act, I946. the form associated with the inhalation of cotton, '"Pneumoconiosis " means fibrosis of the flax and linen dusts. Thus a stage of finality was lungs due to silica dust, asbestos dust or other reached whereby pneumonokoniosis was recog- dust, and includes the condition of the lungs nized as the general title signifying a condition of known as dust reticulation.' dust disease of the lung. Under this heading cer- This is fully discussed in the contribution by tain varieties were identified and named according Dr. Sutherland. to the causative dust, anthracosis, siderosis, sili- cosis, chalicosis and byssinosis. Collectively these Pathology and Etiology constituted the pneumonokonioses or dust diseases The earliest references to the noxious effects of of the lungs. At present there is considerable con- substances inhaled into the lungs are to the fusion in the use of these terms as exemplified by clinical manifestations in certain occupations, this definition in the current Compensation notably metalliferous mining. Thus Hippocrates Act (I946) in South Africa: ' " Silicosis " means writes of 'the wan complexion and the difficulty any form of pneumoconiosis due to the inhalation of breathing of the metal diggers' and Georgius of mineral dust.' Agricola (I557) remarks that 'when the dust is So in effect silicosis may mean asbestosis. This corrosive it ulcerates the lungs and produces reflects the fact that the original generic term has consumption.' proved awkward and pedantic in regular use. In Apart from recording the same illness in an practice it has become shortened to pneumo- ever increasing number of trades and occupations, koniosis; an attempt to abbreviate it still further to no advance occurred until the igth century when koniosis failed. Two forms of spelling, pneumo- study of the morbid anatomical changes at koniosis and pneumoconiosis, are in regular use, necropsy permitted correlation with the clinical but the latter receives most favour throughout the manifestations. Diemerbroek (I832) relates that world and is the only spelling recorded in the ' in dissecting the bodies of masons, dead from ' New Oxford Dictionary ' (I909 edition). Classical asthmatic affections, he found heaps of sand in scholars agree that both spellings are defensible, their lungs, and in dividing the pulmonary sub- but omission of the central ' no ' is wrong, render- stance, he seemed to be cutting a sandy body.' ing the term etymologically meaningless. Usage Gregory (I83I) describes the lungs of a miner as and convenience, however, have established the being infiltrated with black matter resembling, if shorter form; the need is to adopt a uniform not identical with, coal. spelling. Calvert Holland (I843) is among the earliest With the advance in knowledge of pathology of observers to suggest that in cutlery grinders' dust affections of the lungs, a more serious asthma the ' structural modifications in the lungs difficulty has arisen, namely, interpretation of the are of two distinct types and so admit of an easy term pneumoconiosis. Does it signify simply the classification.' accumulation of dust in the lungs, a dust-ridden ' In the one case, they (the symptoms) were state, or does it involve the concept of disease, a often accompanied with considerable constitutional departure from health ? That 'there is no agree- vigour, and though harassing in the extreme, ment is reflected in such distinctions as are im- interfered comparatively little with the appetite December 1949 MEIKLEJOHN: Pneumoconiosis 6oi FIG. i.-Male aged 40 years. Radiographic appearances natural for age. or the digestive functions; and in connection with lesions and associated changes in the lungs. these symptoms, the chest was observed to be Considerable controversy, however, has ranged prominent and well-developed.