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U. S. DEPARTMENT OF LABOR BUREAU OF LABOR STATISTICS ROYAL MEEKER, Commissioner BULLETIN OF THE UNITED STATES) /WHOLE 0 ^ 1 BUREAU OF L A B O R STATISTICS J * * * \ NUMBER L I N D U S T R IA L A C C ID E N T S AND H Y G IE N E S E R IE S : NO. 17 M O R T A L IT Y F R O M R ESPIRATO RY DISEASES IN DUSTY TRADES (INORGANIC DUSTS) B Y FREDERICK L. HOFFMAN JUNE, 1918 WASHINGTON GOVERNMENT PRINTING OFFICE 1918 CONTENTS. Page. Chapter I .— General in tro d u ctio n ...................................................................................... 11-50 T he decline of tu b ercu losis.......................................................................................... 11,12 Wage earners in dusty trades....................................................................................... 12 Relation of atmosphere to life and h ealth ............................................................... 13 Practical im portance of atmospheric p u rity ........................................................... 13,14 A ir contam ination and disease resistance................................................................ 14,15 Chemical aspects of atmospheric p ollu tion ............................................................. 15,16 T he infectiousriess of tuberculosis.............................................................................. 16 Lung injury from irritating dusts............................................................................... 16,17 Varied forms of pulmonary tuberculosis.................................................................. 17,18 Comparative m ortality statistics................................................................................. 18,19 Industrial lung diseases................................................................................................. 19 Lim ited value o f occupational m ortality statistics............................................... 19, 20 Dusts and fumes, foes to industrial life ............................................................. .. 20-24 Observations on the air in m ines............................................................................... 24 Principles of tuberculosis prevention ....................................................................... 25, 26 Ventilation and dust rem oval...................................................................................... 26 Dust in relation to occupational diseases........- ........................................ .............. 26, 27 The dust problem in in d u stry..................................................................................... 27, 28 Scientific term inology of industrial dusts..................................................... .. 28, 29 Diseases resulting from dust inhalation.................................................................... 29-31 H armful consequences of industrial dust exposure.............................................. 31 Observations on nontuberculous respiratory diseases.......................................... 31, 32 British governm ental investigations.......................................................................... 32 T y pical forms of fibroid phthisis................................................................................ 32, 33 Fibroid phthisis and occupational disease.................................................. „ .......... 33-35 Sources of statistical inform ation............................................................................... 35 P rinciples of statistical analysis.................................................................................. 35-38 Industrial insurance mortality statistics.................................................................. 38 The proportionate m ortality from pulm onary tuberculosis................................ 38, 39 D escriptive definitions of industrial dusts............................................................. 39, 40 The classification of dusty trades............................................................................... 40, 41 Age in relation to occupation and dust exposure.................................................. 42, 43 Age distribution of em ployees in dusty trades...................................................... 43-50 Chapter 11.— Occupations with exposure to m etallic du st..................................... 51-161 The occupational menace of metallic du st............................................................ 51,52 Relation of variations in occupational conditions to dust exposure and m ortality......................................................................................................................... 52 Proportionate mortality— U nited States registration area................................. 52-55 Proportionate m ortality— industrial insurance exp erien ce................................ 55-59 English mortality statistics........................................................................................... 59 General conclusions.................................................................................. . .................... 59, 60 3 4 CONTENTS. Chapter I I .— O ccupations w ith exposure to m etallic dust— Continued. Pa^e. The iron and steel in du stry.......................................................................................... 60-82 Variations in occupational dust exp osu re....................................................... 60, 61 O ccurrence of injurious dust among steel w orkers....................................... 61, 63 Dust exposure at blast furnaces.......................................................................... 64 Dust exposure at Bessemer converters............................................................. 64-66 Dust exposure at open-hearth furnaces............................................................ 66 Dust exposure at puddling m ills ........................................................................ 66, 67 Observations on the physique of iron and steel workers............................ 67, 68 H ealth-injurious conditions at iron and steel works.................................... 68, 69 The hygien ic menace of steel d u s ts .................................................•............... 69, 70 Mortality of grinders and polishers.................................................................... 70 Dust exposure in the ch ipping of iron and steel castings.............................. 71 Mortality of iron and steel workers— U nited States registration a re a .. . 71, 72 Mortality of iron and steel workers— industrial insurance e x p e rie n ce .. 73-78 M ortality of pu ddlers..................................................................................... 74 M ortality of rollers.......................................................................................... 74, 75 Mortality of heaters........................................................................................ 75, 76 Mortality of furnace tenders........................................................................ 76 M ortality of laborers at iron and steel w orks......................................... 76, 77 M ortality of miscellaneous em ployees at iron and steel w orks.........77, 78 E vidence of unsatisfactory health conditions................................................ 78 English m ortality statistics.................................................................................. 79 R ecen t English occupational-disease in v e stig a tio n s.................................. 80, 81 Mortality from pneum onia among English iron and steel workers............. 81, 82 General conclusions................................................................................................ 82 Metal grinders................................................................................................................... 82-91 The hygiene of metal grin din g............................................................................ 82, 83 T y p ica l diseases of grinders.................................................................................. 83, 84 Injuriousness of dry-grinding processes............................................................ 84, 85 85 Im provem ent in the health of German cutlery grinders.......................... Sanitary precautions in German cutlery shops.............................................. 86 M ortality of Sheffield metal grinders................................................................ 86-88 Mortality of grinders— industrial insurance exp erien ce..............................88, 89 M ortality of insured grinders— m edico-actuarial exp erien ce..................... 89 Sanitary investigations b y the Ohio State Board of H e a lth .................... 89, 90 M ortality experience of the Stove Mounters’ International Union . . . . 90 General conclusions................................................................................................ 91 Polishers.............................................................................................................................. 92-98 Polishing processes in relation to du st..............................................................92, 93 Sickness experience of the Metal Polishers’ U n io n .....................................93, 94 Polishing processes in various in d u stries........................................................ 94, 95 Ventilation and sanitary con dition s.................................................................. 95, 96 Dust hazards in buffing......................................................................................... 96 Mortality of buffers, finishers, and polishers— medico-actuarial exp e rien ce.......................................................................................................................96, 97 Mortality of polishers— industrial insurance ex p erien ce............................ 97, 98 Card grin din g.................................................................................................................... 98, 99 File cu ttin g.................................................................................................................... 99-103 Variations in occupational exposu re............................................................. 99-101 D escriptive account of sanitary conditions in O h io................................. 101,102 File cutting b y hand and b y m ach in ery......................................................... 102 ~ ............................................ 102,103 Lead poisoning....................................... General conclusions................. *.................. .......................................................... 103 CO N TE N TS. 5 Chapter I I . — O ccupations w ith exposure to m etallic dust— Continued. Page. Tool and instrument m akers................................................................................... 103-109 Sanitary conditions of em ploym ent in Massachusetts................................. 104 Difficulties in effective ven tilation ................................................................ 104,105 Vital statistics of English tool and cutlery m akers.................................. 105,106 Mortality from pulm onary tuberculosis and nontuberculous respira tory diseases..................................................................................................... 106,107 M ortality of tool and cutlery makers— U nited States registration area. 107,108 M ortality of tool and instrument makers— industrial insurance e x p e rien ce................................................................................................................... 108,109 109 General con clu sion s............................................................................................... S a n db la stin g........................................................................•....................................... 109-114 D escriptive account of sand-blasting processes............................................. 110 Dust and other health hazards........................................................................ 110, 111 Most dangerous of all mineral dust hazards................................................ I l l , 112 Com bined m etallic and mineral dust e x p o su re ........................................ 112,113 Protective, safety, and sanitary d ev ice s...................................................... 113,114 Gold-leaf m anufacture................................................................................................ 114-117 Early occupational-disease observations...................................................... 114,115 Descriptive account of manufacturing processes...................................... 115,116 Mortality of gold-leaf beaters— industrial insurance exp erien ce.......... 116,117 General conclusions................................................................................................ 117 Jewelers........................................................................................................................... 117-122 Ascertained unhygienic conditions............................................................... 118,119 D escriptive account of the jew elry in du stry.............................................. 119,120 Mortality from tuberculosis and pneum onia.................................................. 120 M ortality of jewelers— United States registration a rea........................... 120,' 121 Mortality of jewelers— industrial insurance e x p e rie n ce .............................. 122 General con clu sion s................................................................................................ 122 T he printing trades..................................................................................................... 122-146 L inotype and m onotype o p e ra tio n ............................................................... 123,124 O ccupational hazards of the printing trade.................................................... 124 Sanitary and m edical considerations............................................................ 124,125 English and Am erican m ortality statistics.................................................. 125,126 Experience of the International Typographical U n io n .......................... 126-128 Comparative vital statistics of compositors in the State of New Y o r k .. 128 Excessive frequency of pulm onary tuberculosis....................................... 128,129 Sanitary control of the printing industry in Germ any................................ 129 Dust hazards in the printing industry in O h io......................................... 129,130 O ccupational diseases of printers................................................................... 130,131 Causes of excessive frequency of pulm onary tuberculosis..................... 131,132 Sanitary conditions in G overnm ent printing and engraving................ 132,133 Average weight and height of printers......................................................... 133,134 English mortality statistics of printers......................................................... 134-136 Facts disclosed b y the New Y ork State Factory Investigating Commis sion....................................................................................................................... 136,137 Special occupational hazards in the printing trades................................ 137,138 Mortality of printers— U nited States registration area............................138,139 M ortality of printers— industrial insurance exp erien ce.......................... 139-142 M ortality of printers— m edico-actuarial exp erien ce................................. 142,143 Special consideration of the m ortality and disease liability of com positors................................................................................................................143,144 Special consideration of the mortality and disease liability of pressmen. 144-146 M ortality of pressmen— m edico-actuarial e x p e rie n ce ..................... 145,146 General conclusions................................................................................................. 146 6 CO N TE^m Chapter I I . — O ccu pations w ith exposure to m etallic dust— C on cluded. Page. Engravers............................................................................ ............................................146-150 R elative freq u en cy of pulm onary tuberculosis...................... ....................... 147 148 Mortality of engravers— U nited States registration area .................... Mortality of engravers— industrial insurance e x p e r ie n c e ......................... 149 General con clusion s................................................................. ...........................149,150 Brass workers................................................................................................................. 151-159 Sanitary conditions in the British brass in d u s t r y .................................. 151-153 English m ortality statistics of brass w orkers.............................................. 153-155 Investigations b y the Illinois Commission on O ccupational Diseases. . . 155 Mortality of brass molders in O h io................................................................... 155,156 Medical aspects of the brass industry in C on necticu t.................................. 156 Mortality of brass workers— U nited States registration area ................. 157,158 158 Mortality of brass workers— industrial insurance exp erien ce ................... General conclusions............. .............. ................................................................ 158,159 Artificial flowers................................................... .......................................................159-161 Processes of artificial-flower m akin g........................................... .................. 159,160' General conclusions................................................................................................. 160 Chapter I I I .— O ccupations w ith exposure to mineral du st................................... 163-322 Mineral dust and pulm onary tuberculosis............................................................... 164 Lung diseases and mineral and m etallic dust exposu re..................................164,165 M ortality from pulm onary tuberculosis in occupations w ith exposure to mineral dust— U nited States registration area............................................ . 165,166 Inconclusive occupational m ortality statistics.................................................. 166,167 Comparative m ortality b y industries or occupations ...................................... 167-169 M ortality from nontuberculous respiratory diseases............................................. 169 Industrial insurance m ortality e x p erien ce......................................................... 169, 170 171 E xcessive frequen cy of pulm onary tuberculosis.................. ................................ Proportionate m ortality b y industries or o c cu p a tio n s .................................... 171,172 Mortality from nontuberculous respiratory diseases......................................... 172,173 English occupational m ortality data ......................... ................................. ......... 173,174 General conclusions..................................................................... ...............................174-176 Asbestos............................................................................. .............................................176-180 Methods of m in in g .......................................................... i ............................. 176-178 H ealth-injurious occupational con dition s................................ .................. 178,179 E vid e n ce of dust exp osu re........................................................ .. 179,180 M ica .................................................... .............. ...................... ....................................... 180,181 The stone in du stry......................... .......................... ................................................. 181-209 E arly observations on health-injurious con ditions....................................182,183 Experience of the Operative Masons’ S ociety of L on d on ............. ............ 183 D escriptive account o f occupational con ditions........................................ 183,184 Results of official investigation in Massachusetts...............*.....................184,185 U rgency of special scientific inquiries.......................................................... 185,186 186 Differential effects of dust exposu re...................................... .......................... Lung diseases of flint knappers and buhrstone dressers......................... 186,187 M ixed mineral and m etallic dust exposure................................................. 187, 188 Secondary im portance of bacillary in fection ..............................................188,189 M orbidity and m ortality of the stone workers of D erbysh ire............... 189,190 Comparative phthisis death rates according to dust exp osu re..............190,191 Am erican m ortality statistics........................ ................................................. 191,192 English occupational m ortality investigations.................. ........................... 192 M ortality of the granite cutters of A b erd een ..............................................192,193 Com parative occupational m ortality of the stone workers of A ber d e e n .................. - ................................................................... .............................193-195 CONTENTS. 7 Chapter I I I . — O ccupations w ith exposure to mineral dust— Continued. The stone industry— C on cluded. Page. Phthisis, and pn eum atic tools............................................................ ........... 195-197 Comparative frequen cy of lung diseases in A berdeen and in E din b u rgh . 197 P h ysique of stone w o rk e rs ..............................................................................198,199 Practical value of physical exam inations................................... ................ 199, 200 D escriptive account of silica or quartz............................................................. 200 Suggestions for protective precautions.................................... . .................. 200, 201 Injurious occupational con d ition s....... ................................... . . . .............. 201, 202 U rgency of drastic regulations.................. ......................................................... 202 Practical possibilities of dust prevention .................................................... 202, 203 M ortality of m arble and stone cutters—U nited States registration a re a .. 204 Tuberculous and nontuberculous lung diseases........................................ 204, 205 Comparative m ortality from nontuberculous respiratory diseases—■ U nited States registration area................................................................... 205, 206 Mortality of journeym an stonecutters— m edico-actuarial experience . . 206 Mortality of marble and stone workers— industrial insurance ex p erien ce. 207 General conclusions........................... ................................................................ 207-209 Marble w orkers...................................... ................................................. - ................ . 209-211 Slate w orkers..........................................— ............................................................... 211-217 212 H ygiene of the slate in du stry............................................................................. M ortality of slate-pencil m akers..................................................................... 212, 213 English sanitary investigations....................................................................... 213, 214 Social and sanitary conditions in the Am erican slate industry...........214-216 O ccupational hazards in slate m ills.............................................................. 216, 217 Lim e w orkers..................................... ................. ...................... ................................. 217-221 Lim e dust and pulm onary tuberculosis...................................... . .............. 218, 219 R elative in frequ ency of respiratory diseases................................................. 219 General conclusions........... .. ..............................................................................2I§ -221 Plasterers........................................................................................................................ 221-227 Early observations on the health of plasterers............................... .......... 221, 222 English m ortality data............................................ ........................................ 222, 223 R e ce n t Am erican investigations........................................................................ 224 Methods of plaster of Paris m an ufactu re.............................. .................... 224, 225 M ortality of plasterers— U nited States registration area........................ 225, 226 M ortality of plasterers— industrial insurance exp erien ce ...................... 226, 227 Cem ent w orkers.......................... ................................................................................ 227-241 Gas, fum e, and dust exposure in cem ent-m aking' processes............. ........ 228 Q uantitative extent of atmospheric p ollu tion ...... . . . . ............................ 228, 229 Processes of m anufacture................................... . ..................................... .......... 229 M edical observations on cem ent d u s t................................................. ........ 229-231 Com parative dust hazards in the dry and wet processes........................ 231, 232 Specific occupational diseases............ ............................................. . . . . . . . 232, 233 Efforts at restrictive legislation....... ............................................... .................. 233 E xperim ental m ed ica l research...................................................................... 233-235 Chem ical aspects of cem ent dust in relation to disease.............................. 235 M echanical aspects of cem ent dust in relation to disease...................... 235, 236 P h ysique of cem ent w orkers.......................................................................... 236, 237 In frequency o f pulm onary tuberculosis.......................................................... 237 Problem s of dust con trol................................................. « . . . ........................ 237, 238 Noninjuriousness of lim e dust................................. ....................................... 238, 239 Mortality of cem ent workers—industrial insurance experience........... 239, 240 General con clusion s................... .......................................... - ............................... 241 B rick r tile, and terra-cotta makers _ .__________________________ ___ ______ 241-247 Brickm aking p ro ce ss e s ................................................ ........................................ 242 8 CONTENTS. Chapter I I I . — O ccupations with exposure to mineral dust— Continued. Page. B rick , tile, and terra-cotta makers— C oncluded. H ealth-injurious con ditions............................................................................. 242, 243 243 N eglect of sanitary precautions.................................................................... .. G rinding, m ixing, and pressing...................................................................... 243, 244 K iln setting, firing, and drawing................................................................... 244, 245 M ortality of b rick and tile makers— U nited States registration area. 245, 246 M ortality of brick, tile, and terra-cotta makers— industrial insurance exp erien ce......................................................................................................... 246, 247 Potters............................................................................................................................. 247-271 Sanitary aspects of the pottery in du stry............................ ......................... 248, 249 Effects of silica dust............................................................................................... 249 L iability to lead poisoning and pulmonary diseases............................... 249, 250 Specifically injurious processes...................................................................... 250, 251 English occupational m ortality statistics.................................................... 251-253 Investigations b y departmental com m ittee on industrial diseases......... 253 D escriptive account of the Am erican pottery in du stry.............................. 254 D escription of processes according to dust e x p o s u r e .............................. 255, 25fr Pathology and sym ptom ology of the dust problem ...................................... 256 P otters’ asthma.................................................................................................... 256, 257 Comparative occupational m ortality statistics.............................................. 257 Results of sanitary im provem ents................................................................. 257, 258 Injuriousness of scouring process....................................................................... 258Injuriousness of flint du st................................................................................. 258-260 Continuousness of injurious con ditions............................................................ 260 Sanitary aspects of the pottery industry in O h io.................................... 261 Injuriousness of fiint-dust m aking..................................................................... 261 M old and sagger m aking................................................................................... 261, 262 Jiggermen, jollym en, and pressers................................................................. 262, 263 Lead poisoning and pulm onary diseases...................................................... 263, 264 M ortality of potters—U nited States registration a rea............................. 264, 265 M ortality of pottery em ployees— m edico-actuarial exp erien ce........... 265, 266* Mortality of potters— industrial insurance exp erien ce........................... 266, 267 Foreign sanitary regulations of the pottery in du stry.............................. 267-271 General con clu sion s................................................................................................ 271 Paint and color w orkers............................................................................................. 271-278 Chem ical aspects of paint m anufacture....................................................... 271, 272 Exposure to m etallic d u st.................................................................................... 272 H ygiene of the pain ters’ trade....................................................................... 272, 273 Sanitary conditions in the German paint in d u s t r y ................................ 273? 274 L ia b ility to m etallic poison ing........................................................................... 274 M ortality of painters, glaziers, and varnishers.......................................... 274, 275 Comparative mortality of painters, glaziers, varnishers, and agricul tural la b orers.................................................................................................... 276,277 M ortality of paint m ixers— industrial insurance exp erien ce................. 277, 278 General con clu sion s................................................................................................ 278 Lithographers................................................................................................................ 278-283 M ortality of English lithographers................................................................ 279-281 281 M ortality of lithographers— industrial insurance exp erien ce................... General con clu sion s............................................................................................ 281-283 F oundry-m en and m old ers....................................................................................... 283-290 M ortality of molders— industrial insurance exp erien ce.......................... 284, 285 285 Sanitary conditions in Massachusetts foundries............................................ Dust exposure in sand blastin g....................................................................... 286, 287 P hysical exam ination of molders in the Fall R iver d istrict..................... 287 CONTENTS. 9 Chapter I I I . — O ccupations with exposure to m ineral dust— C oncluded. F oundry-m en and molders— C oncluded. . Page. Nature and properties of m olding sands and d u s t s ................................. 287, 288 288 F oundry investigations in O h io......................................................................... A ir contam ination b y gas and sm oke........................................................... 288, 289 Dust exposure in casting cleaning..................................................................... 289 General conclusions............................................................................................ 289, 290 Core m akers................................................................................................................... 290-292 Sanitary conditions in foundries........................................................................ 290 New Y ork State factory investigation.......................................................... 290, 291 291 Mortality of core makers— industrial insurance exp erience...................... General conclusions................................................................................................ 292 The glass in du stry....................................................................................................... 292-304 Early observations on the health of glassw orkers........................................ 293 English occupational m ortality statistics................................................... 293, 294 Comparative m ortality from all causes and from diseases of the lu n g s ................................................................................................................... 295, 296 Materials used in glass m anufacture............................................................. 296-298 Labor conditions in Ohio and New Y o rk .................................................... 298, 299 O ccupational hazards in glass m anufacture................................................... 299 Practical sanitary precautions........................................................................ -299, 300 Present-day labor con ditions.......................................................................... 300, 301 301 Specific liability to respiratory and tuberculous diseases......................... Industrial insurance m ortality statistics..................................................... 301, 302 Mortality of glassworkers— U nited States registration a r e a .................. 302-304 General conclusions................................................................................................ 304 Glass cutters................................................................................................................. 304-310 Sanitary aspects of glass cutting and polishing......................................... 304, 305 Exposure to mineral and m etallic dusts..................................................... 305, 306 M ortality of glass cutters— m edico-actuarial exp erien ce............................ 306 M ortality of glass cutters— industrial insurance exp erien ce..................... 307 Labor conditions in Massachusetts................................................................ 307, 308 Labor conditions in Pennsylvania and O h io ............................................ 308, 309 General conclusions........................................................................................... 309, 310 Glass blow ers................................................................................................................ 310-319 D escriptive account of glass-blowing processes............................................. 310 Special occupational hazards......................................................................... 310, 311 F requ ency of lung diseases.................................................................................. 311 Glass blow ers’ cataract.......................................................................................... 312 312 M ortality of glass blowers— m edico-actuarial exp erien ce.......................... M ortality of glass blow ers—industrial insurance exp erien ce.................... 313 M ortality experience of the Glass B ottle B low ers’ A ssociation............ 313,314 Specific disease lia b ility of glass blow ers.................................................... 314-316 Predisposition to pulm onary tuberculosis.................................................. 316, 317 Possibilities of dust prevention ...................................................................... 317, 318 M echanical glass blow ing and pressing........................................................ 318, 319 D iam ond cutters.......................................................................................................... 319-322 Processes of m anufacture...................................................................................... 319 M orbidity of diam ond cutters and polishers.............................................. 319, 320 Health-injurious results of diam ond cu ttin g.............................................. 320, 321 General conclusions............................................................................................ 321, 322 Chapter IV .— The mineral industries (mines, quarries, ore reduction, and sm elting)............................................................................................................................. 323-437 Varied conditions of em ploym ent.......................................................................... 323, 324 Lim itations of occupational statistics.................................................................... 324, 325 10 CONTENTS. Chapter IV — T h e mineral industries (m ines> quarries, ore reduction, and sm elting)— C on cluded. Page. Com parative m ortality of E nglish'm iners................................................................ 325 R ela tive frequen cy of tuberculous and non tuberculous respiratory dis eases............................................................................................................................. 326,327 T he m ining in d u stry................................................................................................... 327-414 G old m ining in South A frica ........................................................................... 331-335 Miners* phthisis in South A frica............................................................ 332, 333 R eport of miners’ phthisis prevention com m ittee............................. 333 M iners’ m ortality in R h odesia ................................................................ 333, 334 Practical preven tive measures................................................................ 334, 335 M iners’ phthisis in New South W ales......................................................... 336-342 Official investigations in the U nited States and N ew South W ales. . 342, 343 A ccu ra cy of death certification...................................................................... 343, 344 Miners’ pneum oconiosis and anthracosis............- .......................... ................ 344 Differential diagnosis of m iners’ phthisis........................................................ 345 Questionable occupational statistics................................................................. 345 R ela tive frequen cy of m iners’ phthisis........................................................ 345, 346 Disease lia b ility of rock driHers.......................................................................... 346 Pathological considerations.................................................................................. 347 Pneum oconiosis and tuberculosis.................................................................. 348, 349 M ortality of miners and quarrymen— U nited States registration area. 349, 350 Mortality of miners from nontuberculous respiratory diseases................. 350 M ortality of miners and quarrym en— industrial insurance exp erien ce. 350, 351 E xcessive frequen cy of nontuberculous respiratory diseases................ 351, 352 G old and silver m in in g...................................................................................... 352-354 Lead and zin c m inin g........................................................................................ 354-366 Copper m in in g...................................................................................................... 366-370 Iron m inin g............................................................................................................ 370-377 C o a lm in in g ........................................................................................................... 377-414 ' M ortality of m iners in the U nited K in gd om ...................................... 383-389 M ortality of miners in the N orthum berland coal field .................. 389, 390 M ortality o f miners in the Lancashire d istrict.................................. 390, 391 M ortality of m iners in the W est R id in g district............................... 392, 393 M ortality of miners in the Derbyshire and Nottingham shire dis tricts........................................................ .................................................... 393, 394 Mortality of miners in the Staffordshire district............................... 394, 395 Mortality of m iners in the Monmouthshire and South W ales dis tricts............................................................................. ............................... 395-397 E ffect of variations in local conditions on th e m ortality from respiratory diseases................................................................................. 397, 398 R elative frequen cy of anthracosis......................................................... 398-400 Com parative m ortality in coal m ining and agriculture.................. 400-403 Anthracosis and phthisis.............. ............................................................ 403-406 M ortality of Am erican coal m iners............................................. .......... 406-411 General con clusion s............................................................................ 411-414 Q uarrying........................................................................................................................414-426 Am erican m ortality ex p erien ce................................................... ...................... 418 Dust hazards o f the quarrying in d u stry................... *................................. 419, 420 Vital statistics of the centers of the granite in d u stry.............................. 420-422 Vital statistics of the centers of the m arble in d u stry.................................. 422 Vital statistics of the eenters of the sandstone in du stry............................. 423 Vital statistics of th e centers of th e lim estone in du stry............................. 424 V ital statistics of the centers of th e bluestone in du stry......................... 424, 425 Vital statistics of the centers o f the slate in d u stry................................... 425, 426 Metallurgical industries...................................................................... ...................... 426-443 Som e general observations and co n c lu s io n s ..................................................... 437-443 BULLETIN OF THE U. S. BUREAU OF LABOR STATISTICS. WHOLE Nt>. 231. WASHINGTON, JUNE, 1918, MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. CHAPTER L— GENERAL INTRODUCTION. The administrative control of tuberculosis in American States and cities has heretofore been concentrated chiefly upon legislative enact ments, and their enforcement, for the registration of existing cases* the voluntary or compulsory segregation and detention of tubercu losis patients, the establishment of Federal, State, county, and m u-' nicipal tuberculosis sanatoriums, and the enforcement of sanitary ordinances against indiscriminate expectoration in public places. Some progress has been made in the direction of labor legislation aiming at the control of tuberculosis in industry, principally in the so-called dusty trades, but the results have been far from satisfactory, chiefly because of an inadequate realization of the seriousness of the situa tion. The statistical evidence that certain trades or occupations are distinctly more unfavorable to health and longevity than others is so entirely conclusive that no additional proof seems to be necessary to reemphasize the earlier conviction that the State regulation of indus try with special reference to the dusty trades and tuberculosis is a National and State labor problem of the first order in practical im portance, yet there continues to prevail a lamentable degree of apathy and indifference to the urgency of necessary changes and reforms.1 THE BECLINE OF TUBERCULOSIS. The mortality from tuberculosis, it is true, has gradually declined from an average rate of 32 per 10,000 for large American cities for the five years ending with 1884, to 16.1 per 10,000 for the five years 1 E sp ecia lly su g g e stiv e as reg a rd s m od ern e fforts in the d ire ctio n o f a d m in istra tive co n tr o l o f the d u sty tra d es are “ T h e L a b o r L a w and the In d u s tria l C od e,” o f the N eif Y ork S ta te D ep a rtm en t o f L a b or, A lb a n y , 1916 ; “ T h e S a n ita ry an d E n g in e e rin g In d u s tria l S ta n d a rd s,” p u b lish ed by th e D ep a rtm en t o f L a b o r o f th e S ta te o f N ew Jersey. 1 9 1 6 ; S pecial B u lletin N o. 8 2 o f th e D ep a rtm en t o f L a b o r o f the S ta te o f N ew Y ork on “ H ood s fo r R e m o v in g D u st, Ftrmes, a n d G a ses,” an d th e e x te n d e d d iscu ssio n oi d u sty occu p a tio n s in th e a n n u al re p o rt o f the D ep a rtm e n t o f L a b o r o f the S ta te o t N ew J ersey, f o r 1 910, T re n to n , N. J., 1917. 11 12 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES ending with 1914. This reduction in the death rate has, however, only to a limited degree affected the persons most seriously concerned— the workmen and workwomen employed in the so-called dusty trades. On the basis of a conservative estimate it appears that of the 44,130,000 American wage earners of both sexes, approximately 4,000,000, or 9.06 per cent, work under conditions more or less detrimental to health and life on account of atmospheric pollution or the relatively excessive presence of atmospheric impurities predisposing to, or accelerating the relative frequency of, tuberculous and nontuberculous respiratory diseases. WAGE EARNERS IN DUSTY TRADES. Table 1 presents the details of this estimate for the seven recognized branches of industry more or less exposing to health-injurious dust and fumes. T able 1 .—A M E R IC A N WACxE E A R N E R S E M P L O Y E D IN D U S T Y IN D U ST R IE S. T R A D E S , A N D OCCUPATIONS. [C om p iled fro m R e p o rt o f B ureau o f the C ensus on O ccu p a tio n occu p a tion s included, see pp. 4 6 -5 0 .] S ta tistics, 1910. Males. For Females. Trade group. Number. L. Metallic d u s t ..................................................................... 3. 4. 5. 6. 7. Per cent. Number. Per cent. Mineral industries.................: ............................ ............. Vegetable fiber dust ........................................................ Animal and mixed fiber dust ........................................ Organic d u s t ..................................................................... Mixed organic and inorganic (public) dusts............... 258,454 514, 693 844,897 336,323 183,937 531,911 594,285 7.9 15.8 25.9 10.3 5.6 16.3 18.2 33,255 15,332 550 296,135 149,262 177,545 1,399 4.9 2.3 .1 44.0 22.2 26.4 .2 T otal.............................................................................. 3,264,500 100.0 673,478 100.0 This formidable array of employments with exposure, more or less, to health-injurious conditions, attributable chiefly to the single factor of dust in its varied forms, suggests the practical importance of consideration, by those qualified, not only of the evidence itself, but also of the methods and means by which a truly deplorable situation can be brought effectively under administrative control.1 1 It has been p oin ted ou t in th is co n n e ctio n th a t the “ im p o rta n ce o f d ust o f va riou s kind s as a ca u sa tiv e fa c t o r in r e sp ira to ry diseases is bein g borne in u p on us w ith greater w eigh t. H eim and A g a sse -L a fo n t {A r c h . gen. de m ed., 1 9 1 4 ), a fte r re v ie w in g the va riou s ill effects o f in d u stria l dusts, cam e to the co n clu sio n th a t th e cla ssific a tio n should n ot re st upon the orig in o f the dust, b u t ra th er upon the n a tu re o f its h a rm fu l influence. T h e y recognize dusts o f an a ctiv e and o f a passive nature. T h e effects o f the first are to x ic , p red isp osin g o r in fe ctio u s , w h ile the dusts a ctin g p a ssively a ct by th eir m ere presence as fo re ig n bodies upon the su rfa ces o f the re sp ira to ry system . T hese p a ssively a c tin g m aterials m ay be o f s o ft or hard con sisten cy. T he la tte r are m ore effective in b rin g in g abou t the com m on ciiron ic p n eu m ocon iosis. T h ey p o in t o u t th a t the a ctiv e a gen ts are by fa r the m ost im p o r ta n t in b rin g in g abou t the acute re sp ira to ry d iseases o f w h ich pneu m on ia and acute b ro n c h itis are the m ost frequen t. T h ey do n o t fo llo w the ch ro n ic lesions resu ltin g from passive agents to a con clu sion to illu stra te the increased p re d isp o sitio n o f the dam aged tissues to o th e r secon d a ry p rocesses.” GENERAL INTRODUCTION. 13 RELATION OF ATMOSPHERE TO LIFE AND HEALTH. The relation of the atmosphere to human life and health has been made the subject of numerous scientific investigations. For a num ber of years prize essays have been published by the Hodgkins Fund of the Smithsonian Institution, established for the purpose of in creasing human knowledge regarding a problem of great practical and every-day importance. In 1896, through the medium of the fund, there was published an essay by Francis Albert Rollo Russell on “ The atmosphere in relation to human life and health,” 1 in which, among other basic facts, the following is laid down as a prerequisit-e for the rational understanding of the scientific ques tions involved in a consideration of the atmospheric influence on health and longevity: The average volume of air breathed in at each breath is about 30 cubic inches, and the volume of air which may be breathed in by an effort, and by expanding the chest, is about 130 cubic inches, or about four times as much. After a very full inspiration about 230 cubic inches can be expired by a man of average height and in good health. The total capacity of the lungs, however, is much more than this—about 330 cubic inches. Thus in ordinary quiet breathing we only fill about one-tenth of the available air space of the lungs. After every outbreath, or expiration, a quantity of air is left in the lungs. This residual air amounts to about 100 cubic inches. An adult at rest breathes about 686,000 cubic inches in the course of 24 hours; a laborer at full work, about 1,586,900 cubic inches—more than double. The amount of air passing into the lungs per diem har^been estimated at 400 cubic feet in a state of rest, 600 in exercise, 1,000 in severe exertion. The number of air cells in the lungs is estimated at 5,000,000 or 6,000,000 and their surface at about 20 square feet. The epithelium or membranous film between the blood and air is exceedingly thin, and in many parts the capillaries are exposed, in the dividing walls of cells, to air on both sides. The aveight of air inhaled in the course of the day is seven or eight times that of the food eaten. * The mechanical work of breathing represents energy expressed by the lifting of 21 tons 1 foot in 24 hours. From every volume of air inspired about 4^ per cent of oxygen is abstracted, and a somewhat smaller quantity of carbonic acid gas is at the same time added to the expired air.2 PRACTICAL IMPORTANCE OF ATMOSPHERIC PURITY. The foregoing extract emphasizes the importance of atmospheric purity under working conditions, since, as said in the statement quoted, the amount of air passing into the lungs in 24 hours in a state of rest is about 400 cubic feet, in normal exercise 600, and in 1 See also in th is co n n e ctio n “ T he a tm osp h ere In its re la tio n to the hum an m ech a n ism ,” by R. C. H olcom b, su rgeon , U. S. N a vy, in U. S. N aval M ed ica l B u lle tin , vol. 10, No. 3, W ash in g ton , 1916. 2 See a lso an a rtic le in the S cien tific A m erica n S up p lem ent, J u ly 1, 1916, on “ M od ern a ir ,” by P r o f. J oh n F . N orton , P h . D . 14 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY* TRADES. severe exertion 1,000. Considering' this fact in connection with con ditions of work in metal mining, for illustration, brings out in a startling way the strikingly injurious effect of the continuous inhala tion of air grossly polluted by minute particles of mineral and metallic dust, aside from gaseous impurities which, under given conditions, may add materially to the health-injurious results of dust exposure. As observed in the same essay, “ The deficiency of oxygen and excess of carbonic acid, which are common to nearly all living rooms, schools, churches, theaters, and workshops where many persons are gathered, are very favorable not only to the spread of various infec tious diseases, but to the maintenance of a number of minor ailments; and where the exposure to foul air is prolonged, as in workshops, offices, and mills, to a continued depression of vitality.” In the same connection it is pointed out that the normal requirement is the supply of about 3,000 cubic feet of fresh air per head per hour, which, it is safe to maintain, is rarely met with in any of the dusty trades in which the mortality from tuberculosis materially exceeds the average for out-of-door occupations.1 AIR CONTAMINATION AND DISEASE RESISTANCE. Aside from atmospheric impurities of an inorganic nature, of which dust in the more restricted sense of the term is chiefly constituted, the air is frequently contaminated by living germs, the microbes, bac teria, fungi, and molds, which may, or may not be, of a pathogenetic, or disease-producing, nature. Experiments have conclusively proved that microbes are much more abundant in the town than in the country, and, as a general rule, they are more frequently present in dwellings and workshops than immediately outside of the habitations or buildings concerned. Most of the germs and spores which are inhaled are not directly injurious, as far as known, but there are reasons for believing that the vitality is always reduced by a con taminated atmosphere, irrespective of the nature of the inorganic or organic impurities.. Russell, in his discussion of “ The atmosphere in relation to human life and health,” concludes that— Many severe forms of disease, especially of the respiratory organs, are caused by the dust inhaled in various trades and occupations. These are generally proportionate to the sharpness and angularity of the dust and its quantity. Coal dust is among the least harmful. Among lead miners, bronchitis and lead poisoning; in copper mines, gastric disorders; in pottery works, in stonecutting, steel grinding, in flax and cotton factories, in shoddy works, and m metal polishing, lung diseases are common, and the death rate is high. Thus the 1 See a p a p er b y M fller a n d C ocks on ** E ffects o f ch an ges in a tm o sp h e ric co n d itio n s upon th e u p p er re s p ira to ry t r a c t ,” in T ra n s a ctio n s o f A m erica n C lim a to lo g ie a l and C lin ica l A ss o cia tio n , 191 5 . GENERAL INTRODUCTION. 15 mortality of file makers was 300, compared with 108, that of gar deners; of earthenware makers 314, compared with 139, that of grocers; of cutlers and scissors makers 229, compared with 129., that of paper makers. The dust of soft woods and of flour seems to have little bad effect. As regards phthisis and lung diseases the figures of several trades are as follows, when compared with fishermen, 100: Carpenters, 170; bakers, 201; cotton workers, 274; file makers, 398; stone and slate quarrymen, 294; pottery makers, 565; northern coal miners, 166. The injuriousness of the dust in cotton mills is increased by the use of mineral substances for sizing. The mortality of cutlers, etc., from these diseases is almost as great as that of fishermen from all causes put together, including accidents. The comparative exemp tion of colliers in well-ventilated coal mines deserves investigation, for there would appear to be some ground for the supposition that it may be owing to the inhibitive action of this particular dust upon the development of tuberculosis; on the other hand, it may be simply through living in fairly good air of an even temperature, where the specific germs of phthisis are few or absent. The homes of the men are generally comfortable, and much larger fires are kept up than in the South, so that their rooms are dry and well ventilated. CHEMICAL ASPECTS OP ATMOSPHERIC POLLUTION. Within recent years there has been an important change of quali fied opinion regarding the health-injurious consequences of atmos pheric pollution due to chemical causes. In a publication of the Hodgkins Fund, issued by the Smithsonian Institution in 1913, on “ The influence of the atmosphere on our health and comfort in con fined and crowded places',” by Leonard Hill, Martin Flack, James McIntosh, R. A. Rowlands, and H. B. Walker, an effort is made “ to demonstrate that no evidence has yet been brought forward which shows that the chemical quality of the air has anything to do with these ill effects, and that, apart from the influence of infecting bac teria, the ventilation problem is essentially one of temperature, rela tive humidity, and movement of the air.” This important conclusion is diametrically opposed to the principles generally laid down in elementary textbooks on hygiene that the chemical aspect of atmos pheric pollution is of fundamental importance, and that the effects of life and work in ill-ventilated rooms or workshops are attribut able to changes in the chemical quality of the air, whether it be want of oxygen, or excess of carbon dioxide, or the addition of some exhaled organic poison, etc. The authors maintain that the terms “ devitalized ” or “ dead ” air are misleading, and, differing from the prevailing opinions, that the health-giving properties of a pure at mosphere are “ primarily those of temperature, light, movement, and relative moisture.” None of these observations or conclusions, how ever, bears upon the broader problem of atmospheric pollution by dust in any of its many varieties, which to a measurable degree re 16 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. duces vitality and predisposes to respiratory and tuberculous diseases, but chiefly tuberculosis of the lungs.1 THE INFECTIOUSNESS OF TUBERCULOSIS. As early as 1881-82, when the infectiousness of tuberculosis had just been determined by the discovery of the bacillus of the disease by Koch, Dr. Arthur Ransome, in an address before the Manchester and Salford Sanitary Association pointed out that— Wherever people are collected together, the death rate from con sumption is in direct proportion to the*degree of crowding together, and to the deficiency of ventilation. I will give only one instance of this, that was first remarked by Dr. Guy, with reference to letter press printers. He found that of 104 compositors who worked in rooms of less than 500 cubic feet for each person 12.5 per cent had had spitting of blood; of 115 in rooms of from 500 to 600 cubic feet, 4.35 per cent showed this sign of consumption; and in 100 who worked in rooms of more than 600 feet in capacity, less than 2 per cent had spat blood.2 LUNG INJURY FROM IRRITATING DUSTS. The same author, in an address on the “ Prevention of consump tion,” delivered on September 22, 1887, before the Sanitary Congress at Bolton, directed attention to the relation of the inhalation of irritating substances, or dusts, arising from various kinds of indus trial activities, such as steel grinding, glass cutting, brush making, etc., to the relative frequency of the disease, and he amplified his observations by quotations from the medical reports made by Dr. Headlam Greenhow to the Privy Council in 1860 and 1861, in Avhich attention was called to the large mortality from tuber culous-complaints among “ those who worked in an atmosphere im pregnated with dust consisting of fine particles of metal or of sand stone, etc.” Granting that no statistical evidence can materially aid in disclosing the immediate causative factors of the disease, Ilansorne observes that— No one, indeed, wTho has studied the vital statistics of these occu pations, or who has medically attended the workpeople, can doubt i-B a n d elier and R oep ke, in th eir trea tise on A C lin ica l S ystem o f T u b e rcu lo sis (L o n don, 1913, pp. 14, 1 5 ), m en tion am on g the a cq u ired p re d isp o sin g influences fa v o ra b le to the disease “ slig h t in ju rie s to the sm a llest b ron ch ia l tubes from the in h a la tio n o f p a r ticles o f m in eral, m eta llic, vegetable, o r a n im al d u s t.” T h e y add th e re to th a t “ the hard er, sharp er, m ore p oin ted the d u st p a rticles, the m ore lik ely are th ey to in ju re the lu n g tissue, to open the w a y to tu b ercle b a cilli, and to fa v o r th e ir d evelop m en t by se ttin g up ch ro n ic infla m m a tion . L ik ew ise som e substances, as co rro siv e v a p o rs and gases, cause ch em ica l in ju rie s .” T h ey con clu d e t h a t : “ A s a n a tom ica l lesion s m ay be ca u sed by v a rio u s fine m ech a n ica l irrita n ts, so g ross tra u m a tic in ju rie s fro m d ire ct o r in d ir e c t v iolen ce (p u n ctu re s, sh ots, b lo w s, fa lls , and cr u sh in g ) p rod u ce in ju r y to the lu n g tissu e an d fa v o r p ossib le in fe ctio n s . B u t m uch m ore freq u en tly it w ill happen th a t a la ten t in a ctiv e fo cu s, u su a lly in th e b ro n ch ia l glands, is b rou g h t in to a c t iv ity by an in ju ry , o r a la te n t b ut a ctiv e tu b e rcu lo s is m ade evid en t, w h ich , h ow ever, is the sam e th in g from the lega l p o in t o f v ie w .” 2 A C am p aign A g a in st C on su m ption , by A rth u r R an som e, M. D ., L o n d o n , 1915, p. 9. GENERAL INTRODUCTION. 17 the power of irritating dusts in inducing a state of the lungs that is favorable to the reception of the specific organism. He, therefore, concludes that— Just as in the case of lungs otherwise injured tubercle may readily be ingrafted upon a miner’s or a needlemaker’s lung; but the dis ease that is first caused by the particles these men inhale is not tuberculous at all. It is simply a chronic inflammation, affecting chiefly the connective tissue and causing the formation of a fibroid tissue in the alveolar Avails. It leads ultimately to a contraction, and, so to speak, a strangling of certain portions of the lung tissue. But no bacilli are found either in the tissues or in the expectoration of such patients, as I can testify from frequent stainings.1 This conclusion, which is of great practical importance, is fre quently ignored in superficial discussions, particularly of miners’ lung diseases, which' in their origin are not tuberculous, but rather a fibrosis ultimately terminating in a true tuberculosis in consequence of a subsequent infection. Ransome is, therefore, apparently quite justified in his statement that “ Dusts, although they are a serious danger, and though they ought on this account to be kept away from workpeople as a preventive measure against consumption, are yet only remotely a cause of the disease.” It, however, has probably never been seriously maintained by anyone familiar with the subject that the inhalation of health-injurious dust is to be considered a primary cause of tuberculosis, but it is rather to be looked upon as a more or less injurious contributory causative factor, largely amen able, within reasonable limits, to effective methods of administra tive sanitary control. VARIED FORMS OF PULMONARY TUBERCULOSIS. Pulmonary tuberculosis exists in many and varied forms. As said in a treatise on The Expectation of Life of the Consumptive after Sanatorium Treatment, by Noel D. Bardswell— The disease, for instance, may be very acute and prove fatal in a few weeks (miliary tuberculosis), it may commence very acutely and gradually develop into a more chronic process; or, again, it may from its commencement run a slowly progressive course, extending in all over a great many years. This last form, by far the commonest type of the disease, is generally spoken of as “ chronic ” pulmonary tuberculosis. It has for long been recognized that the prognosis, or expectation of life, in these various types of pulmonary tuberculosis is widely different; hence the necessity for considering them sepa rately when dealing with statistics as to the curability of the disease 83 a whole. * A C am paign A g a in st C on su m ption , b y A rth u r K ansom e, M. D ., L o n d on , 1915, p. 2 6. 106811°— 18— Bull. 231------ 2 18 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Unfortunately, the mortality statistics, as a general rule, do not permit of such a precise differentiation, and least of all in their practical application to tuberculosis as an occupational disease. The five forms of tuberculosis generally distinguished are tuberculosis of the lungs, acute miliary tuberculosis, tuberculous meningitis, tuber culosis of other organs, and disseminated tuberculosis. In the United States registration area, during the period 1911 to 1915, the mortality per 100,000 of population, from these five groups was as follows: Tuberculosis of the lungs, males, 13-9.8, females, 109.5; tuberculous meningitis, males, 8.8, females, 8.1; tuberculosis of other organs, males, 9.9, females, 9.T; and disseminated tuberculosis, males, 1.3, females, 1.2. It is therefore shown that tuberculosis of the lungs is of primary importance; but the different forms of pulmonary tuber culosis are not disclosed by the general mortality returns. COMPARATIVE MORTALITY STATISTICS. The term “ phthisis n is generally used as a convenient expression for the term “ tuberculosis of the lungs.”1 Extreme caution is neces sary in the use of international tuberculosis statistics, since there are reasons for believing that the same terms have not an identical meaning in foreign usage. The mortality from phthisis in England and Wales, for illustration,- is invariably lower than in this country; in contrast, the mortality from bronchitis, both acute and chronic, is decidedly higher. In England and Wales the mortality from tuber culosis during the period 1911 to 1915, per 100,000 population, was as follows: (1) Tuberculosis of the lungs, males, 115.8, females, 80.0; (2) acute miliary tuberculosis, males, 11.2, females, 9.3; (3) tu berculous meningitis, males, 15.-3, females, 12.T; (4) tuberculosis of other organs, males, 10, females, 13.1; (5) disseminated tuberculo sis, males, 6.9, females, 5.3. In other words, all the nonpulmonary forms of tuberculosis are more common in England and Wales than in the United States registration area. In the latter the mortality from bronchitis was 17.1 for males and 19.5 for females; but in con trast, the corresponding mortality for England and Wales was 1147 for males and 109.4 for females. These and many other statistical facts should be kept in mind in an effort to interpret with at least approximate accuracy the comparative international statistics of tuberculosis with special reference to occupation and the incidence of tuberculosis in the dusty trades. The table following shows the comparative international death rates for tuberculosis for the years 1911 to 1915, inclusive. l r F2ie s tr ic tly teefenrieal m etlicai a sp e cts o f the q u estion s in v o lv e d in th e p re cise defini tion o f tu b ercu losis versu s p h th isis are sum m ed up by M a u rice F ish b c rg , M. D., in his trea tise on P u lm on a ry T u b ercu losis, P h ila d elp h ia an d N ew Y o rk , 1916, p. 103. 19 GENERAL INTRODUCTION. T able 2.— DEATH RATE PER 100,000 OF POPULATION FROM PULMONARY AND ACUTE MILIARY TUBERCULOSIS, 1911 TO 1915. United States England and registration Wales. area. Scotland. Ireland. Year. Acute Acute Pulmo Acute Pulmo Acute Pulmo mili Pulmo mili nary. mili nary. mili ary. nary. ary. nary. ary. ary. 1911............. 1912............. 1913............. 1914............. 1915............. 132.5 124.8 122.8 123.1 123.0 5.5 5.0 4.9 4.7 4.7 99.1 94.3 91.3 94.5 106.6 9.3 10.3 9.9 10.0 11.3 110.1 108.1 104.3 100.6 107.9 6.9 5.8 5.4 4.4 4.0 169.4 164.1 163.4 160.5 172.2 3.6 5.9 4.8 3.0 1.8 Aus Hol tralia.1 land.1 70.5 67.7 67.7 63.2 62.1 118.8 110.7 106.4 107.3 110.1 Nor Switzer way.1 land.1 176.0 176.0 173.7 175.9 175.5 161.5 150.3 147.2 143.6 141.1 1 Includes b oth forms. INDUSTRIAL LUNG DISEASES. In this connection it has been appropriately said by J. M. Beattie, M. D., in an address on the “ Hygiene of the steel trade,” con tributed to the Transactions of the Royal Sanitary Institute of Great Britain (Vol. X X X I II , 1912, p. 501), that— A great deal of attention has been centered on the dust problem, and much of the legislation relating to the industries with which we are dealing is concef-ned with the protection of the workers from dust inhalation. A much more serious problem, however, is the pre vention of infection with B. tuberculosis, wrhich has not received justice at the hands of factory inspectors and factory legislators. During a five years’ experience in Sheffield it has been abundantly demonstrated that cutlers and grinders die from tuberculosis and not from nontuberculous fibrosis of the lungs. Dr. Beattie therefore strongly protests against the loose use of the word “ phthisis ” and remarks— Rightly or wrongly, phthisis is now understood by medical men to mean tuberculosis of the lungs, with cavity formation; and the term “ grinders’ phthisis 55should be confined to that condition of the lung in which tuberculosis is added to the interstitial fibrosis. For the condition which is produced by the inhalation of dust, the term “ fibrosis” is perhaps the most suitable; I shall therefore describe the condition resulting from the inhalation of dust as fibrosis. The misuse of the term “ phthisis ” makes it difficult to obtain entirely satisfactory statistics, and we can only, therefore, regard the usual data as an approximation to the truth. * LIMITED VALUE OF OCCUPATIONAL MORTALITY STATISTICS. Dr. Jacques Bertillon, in a paper on “ Mortality and the causes of death according to occupations,” contributed to the- Transactions of the Fifteenth International Congress on Hygiene and Demography (Vol. I, 1912, p. 339), points out that— The frequency of phthisis varies much with the occupation. I f a man is poisoned either by alcohol or by lead, phthisis is very common. 20 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. It is common, also, in most occupations in which the man is exposed to dustj especially mineral dust. It has an average frequency in occupations pursued in confined quarters. It is infrequent with shop keepers, in the liberal professions, and especially among farmers, as well as in most occupations carried on in the open air and involving muscular exercise. It is very uncommon among iron and coal miners. These are the general conclusions indicated by my figures and the diagram. They are subject to many exceptions which should be examined more closely. These cautious observations regarding the general use of occupa tional mortality statistics apply to English and American as well as to French, German, and other continental data. The same qualification applies to the terminology of the disease and the con tributory atmospheric conditions such as dust and gaseous impurities. Simeon Snell, M. D., in an address on “ Coal mining and the health of colliers,” contributed to the Transactions of the Sanitary Institute of Great Britain (Vol. X V I, 1895, p. 110), directed attention to the fact that— The influence of dust, whether metallic or nonmetallic, in the pro duction of phthisis is now well known, and the subject received atten tion in these lectures last year. A collier passes a third of his day in an atmosphere which is laden with fine particles of coal dust. Mines differ very much in the prevalence of this dust. Thus men speak of the mines in which they work as being dusty or not. A dry mine will be dusty/and a wet one not so much so. That colliers will be con stantly breathing these fine particles can not be questioned, and* yet Dr. Ogle says that “ Be the explanation what it may, there can be no possibility of doubt that the mortality of coal miners from phthisis is remarkably low.” DUSTS AND FUMES, FOES TO INDUSTRIAL LIFE. The relative immunity to pulmonary tuberculosis of coal miners seems to be conclusively established; but in contrast to a low death rate from tuberculous disease, coal miners almost invariably expe rience a high death rate from nontuberculous lung diseases. Among the important contributions to the subject are the results of the in vestigations of Sir Thomas Oliver, M. D., included in an address on “ Dust and fumes, foes to industrial life,” published in the Trans actions of the Fifteenth International Congress on Hygiene and Demography (Vol. I, pp. 309, 322, 327, 332), restated, in an abbrevi ated form, as follows: Dust, silioke, and fume are the products of industrial activity to be feared. In what relation do these stand to each other? Dust is usually regarded as matter in a state of fine division, but modern research shows that dust, from a medical point of view, is something more than this. Smoke and fume differ from dust in being the products of heat, and these two again differ from each other in this respect, that smoke is the outcome of incomplete combustion of GENERAL INTRODUCTION. 21 hydrocarbons, such as coal, wood, and oil, while fume is, firstly, the gaseous form of metals, nonmetals, and their compounds, and, secondly, the return of these from the gaseous to the solid state, as seen in the flue deposit of a lead smelting factory. Soot, on the other hand, is a hydrocarbon, which has not completely combined with oxygen to form gases. Although we are more immediately concerned with the effects of dust upon the lungs, yet the whole body, including the skin, mucous membranes, and the internal organs, suffers in due course by ex posure to dust. We seldom think of the part which dust and smoke have played indirectly in shaping the social habits of a people. How to get rid of dust and fume in the factory, of smoke in the atmosphere, and of the incidence of all these upon the skin and the respiratory organs of man has formed not only the subject of many a scientific discussion, but has stimulated enterprise and encouraged manufacture. In trying to combat their begriming effects we have become a well-washed people. The dispersion of these waste prod ucts has led to the manufacture and use of soap in proportions hitherto unparalleled in the history of man, white these again have indirectly added to employment, wealth, and health. Frequent ablu tion has become the rule, so that baths, a luxury to the Eomans in the palmy days of empire, and unknown in even large houses in my own country four or five decades ago, are now a necessity, for they find a place in many of the modern houses of the working classes. Dust and fume, begriming agents as they are, have there fore done something to socialize mankind, to promote health, and to advance civilization, for those nations are leading in the path of progress to-day whose workers not only require soap and water for themselves, but who, by the factory dust and smoke they create, oblige all of us to resort to similar usages. What are the possible remote effects of carbon monoxide? Pneu monia sufficiently frequentfy develops in miners who have been ex posed to the firing of explosives as to suggest a causal relationship between the two. Dr. Hotchkiss, of the United States Public Health Service, states that in the Cripple Creek district one man died of 'edema of the lungs, probably the result of exposure to powder smoke, and that in the same district 20 similar cases had been reported within 10 years, of which 18 proved fatal. Dr. Dale Logan tells me of two men who returned to a particular working in a coal mine three and one-half minutes after having exploded 1 pottnd' of gunpowder. Shortly afterwards both complained of the foulness of the air and of their work becoming more difficult; they also had headache, giddi ness, and vomiting. They made their way home, staggering all the way. In the case of one of the men speech was so thick that his wife could not understand what he said. Both men seemed to be intoxi cated. During the night one of the men vomited frequentty. Next day, although giddy and suffering from headache, he returned to work, but on the second day he developed pneumonia and died from it on the fourth day. The pneumonia was regarded as the sequel of carbon monoxide poisoning, and compensation was awarded. Among South African miners pneumonia is extremely common. It is very fatal both to white men and to black, owing largely to the diminished vital resistance, caused by breathing mine air charged with the 22 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. products of explosives. Sudden exposure to air containing a large percentage of carbon monoxide gives rise to serious symptoms which immediately attract attention, but the effects produced upon men by the combined influence of fatigue and of breathing for several hours daily small percentages of carbon monoxide in the high temperature of the mine are not so well known. Although the symptoms observed in miners after the use of explosives are for the most part due to CO, it is not maintained that nitrous fumes can be inhaled with im punity. On the contrary, owing to their irritating properties, they set up congestion of the lungs v* edema. In an ordinary way the symptoms appear much earlier than those caused by carbon monoxide. Shortly after exposure to nitrous fumes, a burning sensation in the nostrils and throat is complained of, followed by a dry, hacking cough, and by expectoration frequently tinged with blood. Should the miner die, the mucous membrane of the trachea and bronchi is found to be acutely congested, and there are signs of acute broncho pneumonia and hemorrhagic edema of the lungs. What becomes of the dust when it is inhaledl It is a natural sup position that, while some of it reaches the lungs, the major part of it is retained in the nares. Saito, working in Prof. K. B. Lehmann’s laboratory in the Institute of Hygiene in Wurzburg, has tried to determine experimentally the fate of dust breathed by workmen in factories. In his preliminary experiments dogs and rabbits inhaled air charged with white-lead dust from 1 to 33 hours. He found that the greater part of the dust was subsequently recovered not from the lungs, as might have been expected, but from the alimentary canal. In five out of six experiments 4 to 24 per cent of the total amount of lead dust breathed in was located in the respiratory organs and the remainder in the digestive. In an ordinary way the dust caught in the nasal mucous membranes mixes with the mucus which is secreted and is unknowingly swallowed. Experiments were also carried out on man with white-lead dust., the mouth and nares being previously carefully washed. The experiments were conducted from 10 to 15 minutes on 20 occasions, care being taken by the men not to swallow the saliva. Inspiration and expiration took place, through the mouth and nose, singly and combined, with the result that, provided sneez ing did not take place, 95 per cent of the dust inhaled remained be hind in the body, 50 per cent of which was primarily retained in the nares. ZZj processes of exclusion 12 per cent probably finally found its way into the lungs, for the bulk of the lead dust, 60 to 80 per cent, was recovered from the alimentary canal. Saito’s experiments demon strate that the principal portal of entrance of soluble dust into the body when inhaled is the alimentary canal and not the lungs. Where two such channels of entrance as the respiratory and alimentary are so close to each other, it is not always easy to say upon which the dust has exerted its baneful influence. In Laborde’s experiments with guinea pigs exposed to air laden with fine white-lead dust, the animals died within two hours. In the lungs were found intense congestion and ecchymoses. When the exposure was less intense and the animals lived longer, similar but equally profound vascular changes were found in the lungs, pointing, therefore, to direct irritation by dust. In my early cases of gold miners’ phthisis the physical signs showed that the disease was located for the most part toward the base of one GENEEAL INTRODUCTION. 23 or other of the lungs. The men, although bronzed and healthy look ing, were yet the subjects of a difficulty of breathing on the slightest exertion, a difficulty of breathing far in excess of what the physical signs on examination of the chest suggested. In its inception pneu moconiosis- is a nontuberculous disease; it is the direct result of dust irritation. The course of the malady is hastened by the recurrence of bronchial and pulmonary catarrh. The changes set up in the lungs by previous catarrh prepare the soil for infection by tubercle; but in some of my patients the disease ran its course from com mencement to finish without becoming tuberculous. Within recent years a change has apparently been taking place in the mines on the Rand. Ten years ago, when I first drew attention to gold miners’ phthisis, there was a much smaller percentage of tuberculous disease amongst the men than in recent years. In making this statement I am supported by the medical experts of the recent Commission, who report that it was the opinion of the medical men on the Rand who examined patients in 1902-1904, that at that period miners’ phthisis terminated fatally without any clinical or bacteriological evidence of tubercle and that man continued at work until a week or two of their death, which often came by heart failure, with cyanosis and urgent dyspnea. Death, indeed, sometimes came to men quite suddenly from heart failure when they were working in the mine. As it is not always easy to find the bacilli of Koch in the sputum even of ordi nary cases of pulmonary tuberculosis, so their absence for months from the expectoration of a gold miner is no proof that the disease in him is not tuberculous. When, however, tubercle bacilli are ab sent all through the illness and the lungs after death do not give evidence either macroscopically or microscopically of tubercle, then gold miners’ phthisis in its typical form is nontuberculous. Sooner or later, as the malady progresses, tubercle becomes grafted upon the pulmonary lesions, and with the invasion of the microorganisms the character of the illness becomes almost immediately changed. While the hard and fibrotic portion of the lung of a gold miner is not a suitable soil for microorganisms the concurrent catarrhal conditions in ether parts of the lungs offer little resistance both to the bacillus of Koch and the pneumococcus of Friedlander, and yet I have seen a Rand miner with silicosis in the early stage develop an acute inflam matory affection of the lungs, with high temperature and with physical signs indicating extensive consolidation, make an excellent recovery. In the case I refer to the microorganism found in the expectoration was the bacillus catarrhalis. In the Transvaal the high mortality rate of miners from pneumonia led the mining authorities of South Africa a few months ago, with the view of treating the disease by a vaccine, to call to their assistance the service of Sir Almroth Wright. The high death rate from pneumonia and the increasing number of cases of gold miners’ phthisis, which in later years have been assuming a tuberculous type, raises the question as to whether the mines themselves or the lodgings of the men may not be partly responsible for this fact. Since dust is the foe of workmen means ought to be employed for its removal from factory and workshop. General ventilation is all very good, so long as the question is simply one of a vitiated atmos phere due to the air having been rendered impure by the respiratory 24 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. products of the workpeople, and by artificial heating and lighting, but where the dust is generated by machinery or is evolved during the ordinary course of production general ventilation only dissemi nates the dust, so that recourse must be had to local ventilation such as is afforded by an exhaust apparatus. Exhausts are superior to water spraying. The wearing of respirators is no doubt in many instances a necessity, but the men complain of the heat engendered by them and of the restraint imposed upon their breathing. Still it remains a fact that men working in color grinding, when they have taken to wearing respirators, have recovered the weight they had lost and regained their health. OBSERVATIONS ON THE AIR IN MINES. In this connection the further observations by Sir Thomas Oliver on fumes more or less contaminated by dust are also of exceptional practical importance. The extract is from an address on “ The metallic poisons, lead and arsenic, as met with in our industries,” contributed to the Transactions of the Sanitary Institute of Great Britain (Vol. X IV , 1893, pp. 157-161) : Carbonic acid is one of the great dangers to the men, and there is a tendency for it always to be present in excess, as it is given off from the lungs of the miners in respiration, and the combustion of the candles, as well as from the strata in which the men are wTorking. Add to these facts the deterioration of the air of the mine by the use of dynamite and from the explosions of gunpowder, and you have an atmospheric condition in the mine which frequently obliges the men to retire to the mouth of the pit in order that the needs of respiration may be satisfied. What -with the impure air and the inhalation of the dust and grit from the limestone rock, the lead miner is exposed to risks that are in constant operation during the whole period he is at work. When to these are added the fact that the mines are warm and the men on leaving are overheated, owing to the exertion re quired in scaling the ladders, and are obliged to trudge home 2 or 3 miles across a bleak moor exposed to biting winds and in all kinds of weather, we can readily understand how it is that many of them succumb to such acute illnesses as pneumonia, or how the neglected cold or pleurisy, acting in conjunction with a family predisposition, too frequently throws the miner into consumption. When wTe come to consider the manufacture of wThite lead, we observe that at certain stages of the process a good deal of dust is evolved. It is the* inhalation of this fine penetrable dust, and the fact that women are largely employed in the trade, that have gained for this industry a bad name. We believe that women are much more susceptible to the influence of lead than men. This statement, for which I am largely responsible, has been disputed, but an increasing acquaintance with the subject, an extensive hospital experience of plumbism, and renewed experimental investigation upon animals, lend weight to the opinion that women are not only more susceptible than men but they are so at an earlier age. In addition, there is a greater tendency for lead poisoning to assume its most serious form, in which headache followed by convulsions and coma are the most prominent symptoms. GENERAL INTRODUCTION. 25 PRINCIPLES OF TUBERCULOSIS PREVENTION. The conveyance of tuberculosis infection through the medium of industrial dust has been referred to with brevity in an address of exceptional importance on “ The prevention of tubercular disease,” by Sir James Crichton-Browne, contributed to the Transactions of the Sanitary Institute of Great Britain (Vol. X V , 1894, pp. 445, 446, 448), as follows: The presence of tubercle bacilli and their spores in the air breathed by consumptive patients, floating independently or buoyed up by particles of dust, is now indisputable. Dr. Williams hung up glass slides smeared with glycerin in the ventilating shafts of the Brompton Hospital and shortly found tubercle bacilli adhering to the glycerin; and Dr. Cornet, by elaborate experiments, conducted in the rooms of private consumptive patients and in hospitals, has shown that tubercle bacilli are expired by consumptive patients in small numbers, and that they and their spores, which, remember, are very indestructible and will retain, their vitality even when dried, are given off in clouds from the handkerchiefs and bed linen of consump tive patients and from the floors or walls of the rooms they inhabit, if they are not scrupulously cleanly in their ways—from any place or thing, in short, with which their expectoration has come in contact. Cornet has further shown that tubercle bacilli may be caught in open spaces and in the air of streets and squares where tubercular persons are present, and in all these cases he has shown that the dust collected when inoculated into animals sets up tubercular disease. Klein has shown that guinea pigs become tubercular when finely divided tubercular matter is diffused by a spray producer in the air of their hutches, and he has succeeded in communicating tubercle to those animals by keeping them for a time in cages in the ventilation-extraction shaft at the Brompton Hospital, through which the foul air from the wards passes. And quite recently M. Straus has communicated to the Academie de Medecine in Paris a very in structive observation. By means of little plugs of cotton wool the dust and mucus from the nasal orifices of 29 healthy nurses and medical students serving in the wards of hospitals containing con sumptive patients were collected, and solutions prepared from these were injected into 29 guinea pigs, of which 9 manifested tubercular disease within a month. There can no longer be any doubt that the air of apartments occupied by consumptive patients is loaded with virulent dust; that the germs of tubercle exist in the atmosphere of all populous districts; and that the inhalation of the dried virus floating in the air is one of the commonest ways of the propagation of the disease. Then ventilation is not less necessary for the prevention of tuber cular diseases in mines, factories, and workshops than it is in public institutions. The loading of their atmosphere with particular kinds of dust appertaining to the trades carried on in them is a prolific cause of tubercle in the lungs, and we have come to speak of miners’ and knife-grinders’ and potters’ consumption. The dust in such cases penetrates the lungs and by its hardness and angularity wounds the mucous membrane, setting up irritation and catarrh and 26 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. creating that raw surface on which the tubercle bacillus loves to fasten ai}d batten. VENTILATION AND DUST REMOVAL. Dr. D. D. Kimball, in a paper on “ Ventilation and public health,” contributed to the Annals of the American Academy of Political and Social Science (Vol. X X X V II, No. 2, March, 1911, p. 212), directs attention to the fact that “ Many ventilating systems are worse than useless because the air is taken in at or below the street level or from other dust-contaminated sources, and is passed into the building without filtration, the result being that the last state of the building is worse than the first.” The problem of effective ventilation and dust control1 does not, however, fall within the scope of the present discussion, but it is necessarily of the first importance in any and all efforts to mitigate the lamentable consequences which arise out of a needlessly dust-contaminated atmosphere, under which so large a number of industrial processes are carried on at the present time. DUST IN RELATION TO OCCUPATIONAL DISEASES. The importance of dust as a factor in occupational mortality Jias attracted the attention of every authority on occupational diseases from Eamazzini to Sir Thomas Oliver. It requires no extended con sideration to prove that human health is much influenced by the character of the air breathed and that its purity is a matter of very considerable sanitary and economic importance. Aside from the risk of exposure to so-called air-borne diseases, the pollution of the atmosphere by organic and inorganic dusts is unquestionably the cause of a vast amount of ill-health and premature mortality, chiefly among men and women engaged in the many indispensable trades and occupations that minister to human needs. The sanitary dangers of air contaminated by disease-breeding germs are possibly not so menacing as generally assumed, while the destructive effects of the dust-laden atmosphere of factories and workshops are a decidedly 1 In a m ore recen t a d d ress b y S ir J. C rich ton -B row n e b e fo re the S a n ita ry I n s p e cto rs ’ A ss o cia tio n o f L on d on (M od ern H osp ita l, N ovem ber, 1 9 1 3 ), he observes th a t “ to w n d u st is m ost to be fea red as a ca rr ie r o f p a th og en ic germ s an d m icrob es o f m an y kinds w h ich can resist d ry in g and m ay be w a fte d a bou t w ith the p a rticle s. So ca ta rrh , influenza, hay fev er, etc., m ay be d issem in ated . T u b ercu losis, too, is sim ila rly spread in th e d ust o f the d ried sputum . In all d ust the d a n ger o f im p la n ta tion o f germ s, fresh o r dried, is e n h a n ced i f a ssocia ted w ith co rrosiv e, ch em ica l, or m ech a n ica lly w ou n d in g elem ents. S harp p a rticle s o f m in eral m a tter m ay p low a w a y in the tissu es th ro u g h w h ich p a th o ge n ic germ s m ay enter. E ven tetanu s m ig h t be caused b y roa d d u st ca rr y in g it to som e su p er ficia l w ou n d , fo r the org an ism lives in the a lim en ta ry ca n a l o f the horse, and so is fo u n d in the m an u re o f street refu se a s w ell as in the so il o f garden s and oth er places. T h e teta n u s a n tito x in is efficacious i f used im m ed ia tely, and in these da ys o f d u s t-s ca tte rin g m o to rs the p resid en t suggested th a t a tube o f a n tito x in m ig h t w ell form a p a rt o f the fu r n itu re o f a ca r, so th a t in case o f a ccid en t it m ig h t in s ta n tly be adm in istered i f any w ou n d com es in c o n ta c t w ith th e d u s t.” GENERAL INTRODUCTION. 27 serious menace to health and life. While the investigations of Dr. McFadden and Mr. Lunt seem to prove the paucity of bacteria in very dusty air, the evidence otherwise available is entirely conclusive that the risk to disease infection is much greater indoors than out in the open, where sunlight, rain, and wind in combination go far to purify the atmosphere by destroying the bacterial life contained in minute particles of suspended matter. Apart, however, from the transmission of disease through a dust-contaminated atmosphere, dust in any form, when inhaled continuously and in considerable quantities, is prejudicial to health because of its inherent mechanical properties, which are destructive to the delicate membrane of the respiratory passages and the lungs. It has long been known that those who live most of their time out of doors have a decided advantage over these who, because of their employment, are compelled to spend their work ing hours inside the home, the office, the factory, or the workshop, and it is an accepted axiom of modern sanitary science that measures and methods for the prevention of dust are an essential preliminary con sideration in rational methods of sanitary reform. All that sanitary science can suggest or that sanitary legislation can regulate and change should be done for humane reasons and as a matter of gov ernmental concern, to mitigate the needless hardships of those who suffer in health and life as the result of conditions over which they themselves have but a very limited control. The importance of dust as a factor in occupational diseases has been emphasized by all who have written on the subject, but by no one more precisely and clearly than by Sir James Crichton-Browne, in his address on “ The dust problem,” read at the Sanitary Congress held at Manchester, England, in 1902, from which the following pro foundly suggestive extract is taken: The mortality of the principal dust-producing occupations, com pared with that of agriculturists, who live and work in what is practi cally dustless atmosphere, is excessive to a startling degree. It is not suggested that this excess is to be ascribed to dust alone, no doubt various factors contribute to it, but the facts that it is due mainly to respiratory diseases, that it is distributed amongst the several occupa tions pretty much in proportion to their dustiness, and that it has diminished in some instances where dust has been effectually dealt with, justify the conclusion that it is largely dust begotten. THE DUST PROBLEM IN INDUSTRY. Sir Crichton-Browne in continuation of his remarks pointed out that a detailed examination of the conditions of work in each of the 22 principal dusty trades brought out clearly the fact that the un healthiness was born of or was primarily due to the dust inhaled by the workmen, and that there was always a well-defined relation 28 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. between the death rate and the quantity and quality of dust present in the atmosphere. There is apparently no very material difference in the manner in which the different varieties of dust act upon the human organism, except where, in addition to mechanically-injurious properties, the dust is of a poisonous character^ which leads to diseases such as lead poisoning, phosphorus poisoning, anthrax poisoning, etc. Industrial mineral dust apparently acts with greater rapidity upon the lungs than organic dust, which is slower and more insidious in its operations, but in a general way follows similar lines. All varieties of dust that are the immediate result of occupation are therefore com prehended under the term of “ industrial dust,” which is specifically limited by Sir Crichton-Browne as follows: I select this dust for my further remarks, because it is readily recognized and defined, because its pernicious effects are well marked and indisputable, because it is to a large extent, if not entirely, pre ventable or removable, and because the efforts already made to pre vent or remove it have been rewarded with conspicuous benefit. And I still further simplify and abbreviate what I have to say by restrict ing my observations to those varieties of it which are dust and noth ing more., which are injurious by their physical properties and mechanical operations, and not as poisons to the systems, chemical destructives of the tissues, or bearers of bacterial invaders. A similar but even more restricted limitation has been^adopted for the present purpose, and only such occupations will be considered in detail in the following discussion as expose to the continuous and considerable inhalation of metallic and mineral, or other inorganic fiber dust, and in which the evidence is at least fairly conclusive that the resulting disease liability and mortality from tuberculosis and other respiratory diseases is above the average for occupied males generally. SCIENTIFIC TERMINOLOGY OF INDUSTRIAL DUSTS. Preliminary to a discussion in detail of the mortality from tuber culosis in dusty trades it may prove of some advantage to those who do not have access to the original sources of information to present a brief summary of qualified medical opinion regarding dust as a factor in occupation diseases and mortality. In a course of lec tures on “ Unhealthy trades,” delivered before the Society of Arts, London, in 1876, Dr. B. W. Richardson1 placed injuries from the inhalation into the lungs of fine particles of solid matter, usually defined as dust, at the head of the causes responsible for industrial diseases, and from his discussion the following is quoted: The term “ dusts,” as I would here apply it, includes all those fine, solid particles which are thrown off from various substances in the processes of manufacture or treatment of articles in common use in 1 S cien tific A m erica n S upplem ents, N os. 9, 10, 18, 19, and F eb. 26, M ar. 4, A p r. 29, M ay 6, an d M ay 27, 1876. 22, d ated, re sp e ctiv e ly , GENERAL INTRODUCTION. 29 daily life, such as earthenware utensils, knives, needles, or mechan ical instruments, like files or saws; or ornamental things, such as ornaments of pearl, ivory, and turned wood; or articles that are \^orn, of silk, cotton, hemp, fu r; or things that are used for food, such as flour; or for creating warmth, such as coal; or for using as a supposed luxury, such as tobacco and snuff. These are only a few illustrations; many others will naturally occur to those who think on the subject. The dusts which inflict injury are of varied quality, as will be seen from the brief sketch just given. They are also of varied effect in regard to the specific injuries which they produce. We may profit ably study them divided into different groups, according to their physical characters, as follows: (a) Cutting dusts, formed of minute hard, crystallized particles which have Sharp, cutting, and pointed edges. These dusts are com posed of iron or steel, of stone, of sand or glass, of dried silicates in earthenware, of lime, of pearl. * (b) Irritant dusts, derived from woods, from ivory, from textile fabrics, fluffs of wool, of silk, of cotton, of flax, and of hemp, from hair, from clay. (c) Inorganic poisonous dusts, derived from some poisonous chem ical compounds used for coloring artistic products, or for preserving organic substances, such as furs. These dusts are charged with ar senical salts. (d) Soluble saline dusts, derived from soluble crystalline sub stances used for dyeing purposes. The sulphate of iron, copperas, yields a dust of this class. (e) Organic poisonous dusts, which are thrown off during the making up of tobacco into cigars and snuff.* These dusts carry with them particles of the dried tobacco plant. (/) Obstructive and irritating dusts composed of carbon, of fine particles of coal dust, of scrapings of carbon or of soot, of dust of rouge, and of flour. Whatever may be the kind of dust to which the workman is sub jected, to whichever of the above named he may be exposed, the primary cause of danger lies in the circumstance that the fine par ticles are borne by the air into the lungs. They pass, wafted by the air, through the mouth and nostrils into the windpipe; they pass along the bronchial tubes; in some instances they reach and traverse the bronchial passages which lie between the larger bronchial tubes and the minute air vesicles, or they even reach the air vesicles them selves.x DISEASES RESULTING FROM DUST INHALATION. An American authority on occupational diseases has referred to the subject at some length in an article contributed to Buck’s Hygiene 1 One o f the m ost im p o rta n t co n tr ib u tio n s to th e s cie n tific stu d y o f in d u s tria l d u sts is the secon d and en la rg ed ed ition o f a trea tise issued by th e M useum o f In d u s tria l H yg ien e o f V ien n a in 1895. T h e title o f the p u b lica tio n is “ In den g e w e rb lich e n B etrieb en vorkom m en de S ta u b a rten in W o r t und B ild .” T h e p u b lica tio n in clu d e s 14 p ages o f 5(5 m ic ro -p h o to g r a p h ic illu stra tio n s o f ty p ica l in d u s tria l d u sts an d an exten d ed ex p la n a to ry t e x t by D r. F . M igerka, w ith th e d iv isio n s o f : ( 1 ) m e ta llic d ust, (2 ) m in era l dust, (3 ) d u st in p olis h in g an d tu rn in g, (4 ) w o o d d ust, (5 ) te x tile dust, ( 6 ) m iscella n eou s d ust. I t is reg retta b le th a t th is v a lu a b le trea tise sh ou ld n o t h ave been tra n s la te d in to th e E n g lis h la n gu age. SO MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. and Public Health, printed in 1879. This writer, Dr. Roger S. Tracy, for many years registrar of vital statistics of New York City and sanitary inspector of the board of health, makes the following statement, with particular reference to the special form or type of disease resulting from the inhalation of metallic and mineral dusts: The disease comes on very gradually, like the more slowly de veloped forms of phthisis pulmonalis, and its duration may be ex tended over four or live years. It begins with the cough of irritation, dry and hacking at first, with very scanty expectoration, whitish and stringy in character; there is no haemoptysis, but sometimes nausea and vomiting in the morning. Auscultation at this time reveals puerile respiration,^ with occasional slight rales. The expectoration gradually increases in amount and becomes reddish, and soon after this tinge appears there may be haemoptysis. There is dyspnea on slight exertion, and dullness over the whole chest, with weak respira tion and mucous rales. There is no fever, and the appetite and strength are still good. I f work is abandoned at this time, recovery is not only possible, but in most cases probable. I f work is continued, the lung tissue begins to break down, and cavities form near the apices. Expectoration is very profuse, and there may be severe hemorrhages. There is general dullness on percussion, and the last traces of vesicular respiration give way to sibilant, large mucous and cavernous rales. Fever is continuous, with evening exacerbations, night sweats, emaciation, insomnia, and great dyspnea, soon followed by death. Very suggestive also are the observations and conclusions of Dr. John Syer Bristowe, F. JR. S., who, in an -address on industrial dis eases, read at the conference on sanitary subjects held in connection with the International Health Convention of 1884, discussed the effects of nonpoisonous irritants on the lungs, in part as follows: Occupations which habitually expose the workmen to the inhala tion of abundant solid particles that are incapable of solution or removal by the animal tissues or secretions, in many cases induce chronic diseases of the lungs, which are known as the asthmas or consumptions of the several occupations referred to, and tend very materially to shorten life among those engaged in them. Workers in coal mines and in copper mines, grinders, millstone makers, and flax dressers are perhaps especially liable to suffer from such causes. It is marvelous how tolerant the bronchial tubes and lungs are of for eign particles which are drawn into them with the breath. Wherever smoke impregnates the atmosphere, as in London and other manufac turing towns, its particles are conveyed in greater or less abundance into the lungs; whence some are expelled with the expectoration, which presents, consequently, a slaty or black appearance, while some get absorbed,. and becoming deposited in the tissue of the lungs, pro duce in them that black mottling which increases with advancing years, and is well known to pathologists. Yet, as a general rule, the soot-studded organs remain practically healthy, and no clinical evi dences of pulmonary disease manifest themselves. The same remarks doubtless apply to the inhalation of the siliceous particles of ordinary GENERAL INTRODUCTION. 31 dust. The effects are different* however, when such matters are in haled in large excess. * * * The symptoms under which the suf ferers labor have some resemblance to those of chronic phthisis, some to those of chronic bronchitis and emphysema, for either of which they may well be mistaken. They consist in gradually increasing shortness of breath, lividity of surface, feebleness of circulation, and cough, with more or less abundant expectoration; to which, at a later period, general dropsy and haemoptysis may be superadded. There is generally a total, or almost total, absence of fever. The only meth ods, so far as I knftw, by which the irritative diseases of the lung:?, just considered can be lessened or prevented, are by providing good ventilation, and (when possible) by adopting methods to prevent the diffusion of particles of dust in the atmosphere which the work men have to breathe. It is obvious, too, that since the diseases are insidious in their progress, and increase in proportion as the inhaled particles accumulate, it would be well for persons who present early traces of them to seek at once some other kind of employment. HARMFUL CONSEQUENCES OF INDUSTRIAL DUST EXPOSURE. The most qualified and extended discussion of the entire subject of the inhalation of dust, its pathology and symptomatology, with special reference to dusty trades, is by Dr. J. T. Arlidge, who, in 1892, published a treatise on The Hygiene, Diseases, and Mortality of Occu pations. u Few, indeed,” he argued, “ are the occupations in which dust is not given off,” and “ in none can it be absolutely harmless, for the lung tissue must be just so much the worse, and less efficient for its purpose, in proportion to its embarrassment by dust.” And in continuation—What occurs to the ordinary citizens becomes magnified ten or a hundred fold to those engaged in dusty occupations, and more espe cially where the dust itself possesses noxious properties. But unless dust has this latter quality, it is remarkable with what indifference its inhalation is treated by the majority of workmen. In one sense, indeed, it is unfortunate that it does not, for the most part, awaken attention by any immediate tangible consequences. Its disabling action is very slow, but it is ever progressive, and until it has already worked its baneful results upon the smaller bronchial tubes and air cells and caused difficulty of breathing, wTith cough and spitting, it is let pass as a matter of indifference—an inconvenience of the trade. OBSERVATIONS ON NONTURERCULOUS RESPIRATORY DISEASES. Arlidge called attention to the fact that bronchitis, asthma, and pulmonary fibrosis and tuberculosis were foremost in the causes of British mortality, holding that without doubt these maladies were largely attributable to the inhalation of dust operating per se, or in conjunction with constitutional proclivities and insanitary surround ings, In further ’continuation he observes— Pathologists tell us of the presence of bacilli in tubercular disease, and favor the belief that these minute bodies are the cause of it. 32 MORTALITY FROM RESPIRATORY DISEASES I^T DUSTY TRADES. This notion may represent a whole truth or only a partial one; in my opinion, the latter. For I doubt if these bacilli actually develop phthisis unless there be some antecedent change in the vitality of the affected tissue; a change wrought by depressing causes connected with the mode of life, or with constitutional debility and inherited taint, or with the occupation followed; of which contributory factors two or more may cooperate. And assuredly the breathing of dust may be reckoned as one such of no light energy. In other words, I look upon a phthisical lung as one prepared for the germination and multiplication of bacilli, and not a primary product of those micro scopic organisms, nor of the products of their organic existence. The conclusions of Arlidge are summarized in the statement that “ One practical lesson is to be gained by these considerations— namely, that p e r s o n s p r e d i s p o s e d t o r e s p i r a t o r y d is e a s e s a n d p h t h i s i s o u g h t n o t t o e n g a g e i n d u s t y o c c u p a t io n s BRITISH GOVERNMENTAL INVESTIGATIONS. More recently the subject of occupational diseases in their re lation to workmen’s compensation has been considered at length and in much detail by a British departmental committee appointed to consider the pressing and important question of workmen’s com pensation for industrial diseases. In its observations upon respira tory diseases, and in particular bronchitis, pneumonia, and phthisis, and their relation to occupation exposure, the committee concluded that— Pulmonary disease manifests itself in three kinds or forms—as ordinary tuberculous phthisis, acute or chronic; as “ fibroid phthisis,” and as a mixed form when a tuberculous process is ingrafted sooner or later upon the fibroid. Fibroid phthisis is always a slow disease. It consists in a chronic inactive inflammation around the many minute foci of dust inhalation, which by coalescence gradually in vades large areas, impairing and strangling the proper lung tissues in corresponding measure. Again, a lung so impaired is very apt to harbor bacilli, especially the bacillus of tubercle, by the influence of which it may be still further destroyed. Thus both fibroid phthisis uncomplicated and fibroid phthisis with the supervention of tubercle are in their nature occupational diseases.1 TYPICAL FORMS OF FIBROID PHTHISIS. The committee, in its final report, describes the typical forms of ilbroid phthisis as induced by the inhalation of industrial dust, hold:r.g that— The first symptom is a cough which insidiously, and for a while almost imperceptibly, becomes habitual. At first in the morning only, it gradually becomes more frequent during the day, and expec toration, nominal at the beginning^ becomes more marked, though 1 R e p o rt o f the D ep a rtm en ta l C om m ittee on L on d on , 1907, p. 13. C om p e n sa tio n fo r I n d u s tria l D iseases, 33 GENERAL INTRODUCTION. not profuse until the latter stages of the disease. Leaving out of account the more rapid progress of the disease in tin and gold miners, these symptoms of a negative phase of purely local damage ma}^ last for years—10 or 15 or even more—without advancing to such a degree as to throw the workman out of employment or even to cause him serious inconvenience. At some period, however, rarely less than 10 years and frequently more than 20, of continuous employ ment, in a like imperceptible manner the breathing gets shorter and the patient finds himself less and less capable of exertion. Yet, even when the cough and dyspnea have reached a considerable degree, there are no signs of fever, as is the case of pulmonary tuber culosis ; the flesh does not fall and the muscles retain their strength and volume. Thus even at a period when the malady is fully estab lished the general health may be but little impaired, and the patient may not be compelled to cease work. Herein fibroid phthisis pre sents a well-marked difference from pulmonary tuberculosis; and even if, as we have said, the disease becomes complicated with tuber cle, yet the rate of progress may be determined rather by the charac ter of the primary than of the secondary disease, though usually the supervention of tubercle hastens the sufferer into a more rapid con sumption.1 The results of all these researches into an almost neglected field of preventive medicine prove that occupation diseases, properly so called, demand the most thoroughly qualified medical supervision of factories and workshops and the periodical medical examination and inspection of persons employed in recognized unhealthy trades. For., as the committee referred to points out, “ If in the early stage of fibroid phthisis the workman leaves the dusty employment for work in agriculture or in other occupation in air free from irritating parti cles, the disease may be practically arrested; that is, although the part affected may proceed to obliteration, the disease would not ex tend to other parts of the lung, and the portion destroyed would be negligible as a factor of health and capacity.” 2 FIBROID PHTHISIS AND OCCUPATIONAL DISEASE. The conclusion of this investigation, the most important official inquiry ever made into the subject of industrial diseases, fully war rants the view that while ordinary tuberculous phthisis can not be regarded as a disease peculiar to any occupation, fibroid phthisis in its latter stage, and when the history of the case is known, can be clearly distinguished from tuberculous phthisis; so that it may be regarded as an established fact that fibroid phthisis is a disease peculiar to employment in certain trades, of which the committee mentions the following: Grinders continuously using either grindstones or emer}^ for the abrasion of metals, especially steel; potters engaged in certain 1 R e p o rt o f the D ep a rtm en ta l 1907, p. 13. 2 Idem , p. 14. C om m ittee 106811°— 18— B ull. 231-------3 on C om p en sa tion fo r In d u s tria l D iseases, 34 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. processes; stone workers employed on certain kinds of stone, espe cially if not working in the open air; tin miners, in particular such as have previously been exposed to the exceedingly unhealthy condi tions of the gold mines of the Transvaal; and ganister miners, in cluding men employed in certain processes of ganister brickmaking. The committee did not arrive at final conclusions regarding persons employed in the slate industry, or employees in the working of asbestos and many other recognized unhealthy trades, partly, no doubt, because of the limited scope of the inquiry arid the paucity of conclusive statistical data. It is pointed out by the committee that it was not possible to separate the English death rates for fibroid phthisis from those for other diseases of the respiratory system, since medical men do not, as a rule, distinguish that disease when certify ing the causes of death. It is clearly established by the results of the investigation that such a distinction should be made and that medical practitioners should qualify the death returns from tuberculosis in all cases where the death was the result of fibroid phthisis. The committee, having arrived at the opinion that fibroid phthisis is a specific and distinguishable trade disease, concluded that em ployers might properly be required to pay compensation to their workpeople who contract it; but it did not, however, recommend the extension of the workmen’s compensation act to the disease for two reasons. The first was that, owing to the long period of its development, it would not be right to lay the whole burden on the employer under whom the workman had been serving during the 12 months prior to the incapacity. The other and even more impor tant reason was that for several years before the nature of the disease can be definitely diagnosed the patient may suffer from symptoms that, while not distinctive, are sufficient to prevent him from securing employment. In the brief descriptive account of 118 industries and occupations considered in detail in this discussion only the most general facts have been included in order to emphasize, as far as possible, the in dustrial processes productive of conditions more or less injurious to health in general, and conducive to the development of tuberculosis in particular. Authorities are referred to only so far as this has seemed necessary to establish clearly, in the case of each trade or occupation considered, the facts of a more or less excessive degree of frequency of pulmonary tuberculosis, aside from the statistical sources of informa tion which form the basis of the subsequent conclusions, except in the case of a few employments for which neither general vital statistics nor insurance mortality experience are as yet available. The term “ tuberculosis ” is used in a very general sense, but as a rule limited to phthisis pulmonalis, or pulmonary tuberculosis, unless otherwise stated. All of the references to insurance mortality experience are GENEEAL INTRODUCTION. 35 limited to the mortality from phthisis pulmonalis and do not include that from other forms of tuberculosis or other forms of respiratory diseases unless specifically stated in the text, SOURCES OF STATISTICAL INFORMATION. The principal statistical data utilized in the present discussion are the following: First, the occupation returns according to age and sex as published in 1914 by the Thirteenth United States Census for the year 1910; second, the occupation mortality statistics of the Twelfth Census, published in 1904; third, the occupation mortality data published in the annual reports on the mortality of the United States registration area for the years 1908 and 1909; fourth, the occu pation mortality statistics published decennially as a supplement to the Report of the Registrar-General of Births, Marriages, and Deaths for England and Wales for the two periods, 1890-1892 and 1900-1902 (no later data have as yet been published) ; fifth, the corresponding decennial mortality statistics of Scotland; sixth, the industrial mor tality statistics of the Prudential Insurance Co. of America for the period 1897 to 1914, published in connection with the company’s exhibits at the British Congress on Tuberculosis, 1901, the Louisiana Purchase Exposition, 1904, the International Congress on Tuber culosis, 1908, the International Congress on Hygiene and Demog raphy, 1912, and the Panama-Pacific International Exposition, 1915; seventh, the industrial mortality statistics of the Metropolitan Life Insurance Co., presented at the annual meeting of the American Public Health Association, 1915; and eighth, miscellaneous occupa tion mortality statistics derived from special sources or made public in connection with local investigations, including, among others, medico-actuarial experience data, the mortality returns for the tex tile industry of Blackburn, England, the cutlery industry in Shef field, England, the quarry industry of Derbyshire, England, the stone industry of Aberdeen, Scotland, the mining industry of Corn wall, South Africa, Montana, southwest Missouri, etc. PRINCIPLES OF STATISTICAL ANALYSIS. At least four different statistical methods are available for the purpose of determining with approximate accuracy the degree of tuberculosis frequency in different trades or specified occupations. Absolute accuracy is not obtainable in investigations of this kind, nor is this absolutely essential for the practical ends in view. The first method is to determine the proportion of persons in specified occupations living at ages 65 and over, and to compare the same with the corresponding proportion for occupied males gener ally. This method is never conclusive by itself, but is occasionally useful in connection with the use of other statistical data. It is 36 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. self-evident that other factors besides mortality determine the pro portion of persons in different occupations at ages 65 and over. It has been shown, for illustration, by the census of 1910, that of the male population, ages 14 to 44, the proportion employed in gainful occupations is 89.3 per cent, in contrast with only 28.6 per cent for the female population. The proportion employed in the general population varies materially according to sex and age, there being a gradual increase from ages 14 to about 45, subsequent to which the proportion either unemployed for physical or retired for economic reasons gradually increases. At ages 21 to 44, for illustration, in the American population 96.7 per cent of the males but only 26.3 per cent of the females are employed in gainful occupations. The maxi mum proportion of employed among women occurs at ages 16 to 20, when 39.9 per cent are engaged in gainful occupations. In the general population, ages 10 years and over, according to the census of 1910, 81.3 per cent of males and 23.4 per cent of females were engaged in gainful occupations. The corresponding percentages in 1900, according to the census, were 80 for males and 18.8 for females. The proportions for the aggregate employees in the principal occupations with exposure to dust, according to the census of 1910, are shown in Table 3. T a b le 3 .— A G E D IS T R IB U T IO N OF PE R SO N S IN G A IN F U L O CC U P A T IO N S W I T H E X P O S U R E TO IN D U S T R I A L D U STS. [Compiled from Report of Bureau of the Census on Occupation Statistics, 1910. see pp. 4G to 50.] Males. For occupations included, Females. Age group. Number. 10 to 13 years................................ 14 to 15 years................................ 16 to 20 years................................ 21 to 44 years................................ 45 years and over........................ Total, 10 years and over. 11,817 64,110 435,105 2,094,694 658,774 3,264,500 Per cent. 0.4 8,211 1.2 2.0 20.1 55,671 251,477 308,130 49,989 8.3 37.3 45.8 7.4 100.0 673, 478 100.0 13.3 64.2 By way of further illustration attention may be directed to the fact that of 5,606,789 farmers 2,457,572, or 43.8 per cent, were 45 years and over. In contrast, out of 210,566 males employed in cotton mills only 34,476, or 16.4 per cent, were 45 years and over. It, of course, would be quite erroneous to conclude that the differences in percentages measure the full effect of an excessive mortality, since for obvious reasons the age distribution is primarily determined by occupational requirements and conditions. The illustration is suffi cient for the purpose of emphasizing the practical limitations of the method of ascertaining occupational mortality by means of the pro portion of persons living at advanced ages in specified employments. GENEEAL INTRODUCTION. 37 The second method is to ascertain the average age at death in par ticular occupations from all and specified causes. This method was quite extensively employed in the earlier *registration reports for certain New England States, and while occasionally useful in con nection with other data the method by itself is frequently seriously misleading. According to the combined statistics for the State of Rhode Island (1852-1910), the average age at death of farmers was 67.4 years, against 55.86 years for florists. There are no reasons for believing that on the average florists experience a higher death rate than farmers and certainly not to the extent indicated by the difference of 11.5 years in the average age at death. Another interesting illustration is the high average age at death of clergymen, given according to the Rhode Island experience1 as 63.78 years, and the very low average age at death of electricians, given as 36.14 years. These illustrations are sufficient for the purpose of emphasizing the uselessness and misleading character of a method still occasion ally employed in determining the relative mortality in different occupations from all causes or special causes by means of the average age at death. The third method is to determine the exact mathematical rate of mortality from all causes or specific causes, such as tuberculosis or industrial accidents, by the ascertainment of the number of deaths occurring among every 1,000 persons of any particular trade or occu pation exposed to risk of death for a given period of time, usually a single year. This method is probably the most satisfactory; but it is often quite impossible to secure strictly accurate information regard ing the number of persors employed in particular trades or occupa tions and the corresponding number of deaths in precisely the same group of employments. Estimates of the numbers exposed to risk in particular occupations are quite likely to be seriously misleading, and the chance of error is materially increased by differences in the pre vailing methods of occupation classification. It is rarely the case that both the census enumeration and the occupation mortality re turns are ascertained in exactly the same manner by the census and the health authorities or registration officials throughout the country. The fourth method is to determine the exact proportion of deaths from a specific cause, such as pulmonary tuberculosis, occurring in the mortality from all causes, without reference to ages at death. When this method is used with the required caution, the proportions thus determined are often sufficiently suggestive of abnormal condi tions and occasionally conclusive. A fifth method is a modification of the fourth and is generally known as the proportionate mortality figure, by means of which the propor 1 F ifty -e ig h th R e g istra tio n R ep ort, R hod e Isla n d , 1910, p. 631 et seq. 38 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. tion of deaths from any particular disease, such as pulmonary tuber culosis, is calculated as a percentage of the deaths from all causes occurring during specified periods of life. This method has been extensively employed in the present discussion, since otherwise the available industrial insurance mortality statistics could not have been fully utilized. This method, in a measure, is, however, the most satisfactory and practically conclusive, since it presents with approx imate accuracy the true proportionate incidence of pulmonary tuber culosis or the degree of its frequency at specified periods of life. INDUSTRIAL INSURANCE MORTALITY STATISTICS. The industrial insurance mortality statistics utilized in the present discussion are derived largely from the experience of two thoroughly representative companies which have from time to time given publicity to the facts of their experience. The resulting propor tionate mortality returns, however, indicate a specific mortality from p'ulmonary tuberculosis somewhat below the actual, since the experi ence is, to a certain extent, modified by medical selection; in other words, the proportionate mortality from pulmonary tuberculosis, or the true, actual loss from the disease at specified age periods would have been somewhat higher if medical selection had not been made use of. In comparing this experience with the corresponding standard for the registration area of the United States the compari son is, therefore, somewhat more favorable to the various trades and occupations considered than would have been the case if the returns could have been derived from the registration records of the different States and cities comprehending the experience of the companies referred to. Of the aggregate number (34,997,474) of industrial policies in force with all American industrial companies on December 31, 1916, the proportion in force with the Prudential and Metropolitan com panies was 84 per cent. The experience utilized, therefore, may be considered as thoroughly representative for the industrial population of the country at large. THE PROPORTIONATE MORTALITY FROM PULMONARY TUBERCULOSIS. The proportionate mortality figures may briefly be explained as follows: At ages 25 to 34, out of every 100 deaths from all causes in the registration area of the United States during the 14 years ending in 1913, 30.5 deaths were from pulmonary tuberculosis. The corresponding proportion of deaths in the industrial insurance friortality experience of the Prudential Co. was 67.9 per cent' for grinders, 55.9 per cent for printers and compositors, 53 per cent for GENERAL INTRODUCTION. 39 upholsterers, 45.3 per cent for potters, etc. The difference between the average mortality from pulmonary tuberculosis for the registra tion area as a whole and the corresponding proportionate mortality from pulmonary tuberculosis in the occupations considered in some detail, measures approximately the health-injurious circum stances for different employments. It, however, does not follow that all of the difference is necessarily or specifically attributable to the employment as such, or to the health-injurious conditions under which the industry may be carried on. DESCRIPTIVE DEFINITIONS OF INDUSTRIAL DUSTS. Preliminary to the analysis of the mortality data and the observa tions having reference to the specific occupations or employments considered, the following descriptive definitions of industrial dusts, by Charles Baskerville, Ph. D., are included in explanation of the statistical data and groupings of occupations with exposure to indus trial dust. The extract is from an exceptionally useful and trust worthy dissertation on “Air impurities: dust, fumes, and gases,” in the New York Medical Journal, November 23 and 30, 1912. First, as regards insoluble inorganic dusts, it is said that “ this class includes metals (antimony, arsenic, type metal, brass, bronze, copper, aluminum, iron, steel, lead, manganese, vanadium and ferrovanadium, silver, tin,jsinc, and solder) in a state of fine division (dusts, atomized metals, metallic powders) ; flue dusts; various ore dusts (iron ore, etc.) ; silica, sand, emery, flint, glass powders; carbon graphite, diamond, coal, soot; brick dust, marble, granite, cement, terra cotta; lime, gypsum, plaster, meerschaum; phosphates, guano, etc.” The continuous and considerable exposure feto the inhalation of insoluble inorganic dusts, according to Baskerville (who is sustained by numerous other authorities) may result in fibrosis of the lungs, chiefly because of the inhalation of siliceous or metallic particles, as, for example, is the case in the so-called potters’ asthma and grinders’ phthisis. Pneumonia has been reported as frequent among work men in blast furnaces, owing, in part, directly or indirectly, to the inhalation of slag dust. The disease known as siderosis is commonly met with among metal polishers, knife grinders, and others engaged in metal working. Second, soluble inorganic dusts.—This class, according to Basker ville, includes such substances as are likely to be swallowed and ab sorbed, as, for illustration, metal particles, including lead, brass, cop per, zinc, arsenic, mercury, and silver, as well as soluble inorganic salts. Many dusts of this class, it is pointed out, “ are dangerous not only because of their irritating or poisonous properties, but also because of their inflammability, e. g., potassium chlorate.” 40 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T h i r d , o r g a n i c d u s t s .— This class is defined as comprising such widely varying materials as “ sawdust, fur, skins, feathers, broom and straw, grains and flours, jute, flax, hemp, cotton, wool, carpet dust, street sweepings, tobacco-box dust, hides and leather, felts, rags, paper, horsehair, etc.” Typical of the diseases caused by or ganic dusts are: “ Flax dressers’ disease, a kind of pneumonia due to the inhalation of particles of flax; pneumoconiosis due to the inhalation of dust by ganister workers; alkaloidal poisoning from African boxwood by workmen engaged in shuttle making; and ma lignant pustule and a febrile disease among rag sorters.” T H E C L A S S IF IC A T IO N O F D U S T Y T R A D E S . The occupational grouping adopted for the purposes of the present discussion is necessarily a more or less arbitrary one, since all em ployments involve exposure to more than one particular kind of dust* It is, however, safe to assume that the predominating characteristic of a particular kind of dust exposure primarily determines the resulting departure of the mortality from pulmonary tuberculosis from the normal for the general population. All the groupings of dusty trades which have been adopted by Benoiston de Chateauneuf, in Oesterlen’s JVledical Statistics,1 by Hirt, Sommerfeld, Merkel, Arlidge, Oliver, and others have this limitation in common, since no entirely con clusive scientific investigation has been made to afford the material for a final and strictly scientific classification of dusty trades. The present classification, however, will at least serve the purpose of a convenient arrangement, with a strict regard to the facts as they are known and understood at the present time. The occupational grouping as given below has been adopted to emphasize in a rather general way the principal dust hazards in 118 occupations or groups of employments, and to facilitate the con venient reference to the particular industries considered in more or less detail in the subsequent discussion. IN D U S T R IA L A N D O C C U P A T IO N A L C L A S S IF IC A T IO N A C C O R D IN G /T O T H E K IN D OF U N A V O ID A B L E D U S T E X P O S U R E , W I T H S P E C IA L R E F E R E N C E T O T H E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS . SECTION A.—INORGANIC DUSTS. Group 1.— Metallic dust. A rtificia l-flow er m akers. B ra ss w orkers. Chippers, at b last fu rn a ces and steel ro llin g m ills. C om positors and typesetters. C u tlery m akers. D ie setters and sinkers. E lectroty p ers and stereoty^ers. E n gravers. F ilers. G old beaters. G rinders. 1 H a n d b u ch d er m ed icin isch en S ta tistik . by D r. F r. O esterlen, T u b in gen , 1874, p. 389. GENERAL INTRODUCTION. G rinders, Jew elers, Polishers, P ressm en ca rd (cotton m ills ). m an u factu rin g. buffers, and finishers. and press feeders. 41 Sand blasters. Saw filers. Solderers. T oolm akers. Group 2.— Mineral dust. A sbestos w orkers. B rick , tile, and terra -cotta factories. C ore m akers. C olor m ixers. G lass blow ers. G lass fa cto rie s (oth er than b lo w e rs ). L a cq u erers, japann ers, enam elers. Lim e, cem ent, and gypsum factories. L ithograph ers. M arble and stone w orkers. M ica w orkers. M irror m akers. M olders. P a in t fa ctories. Paper hangers and helpers. P lasterers. Potteries. W liitew asliers. Group 3.— Mineral industries. M ica m iners. Ph osph ate m iners. Q uarries. Q uicksilver m iners. Spar m iners. Sulphur m iners. O ther and not specified m iners. A sph a lt m iners. B a u x ite m iners. C oal m iners. C opper m iners. G old and silver m iners. G raph ite miners. Iro n m iners. L ea d and zin c m iners. SECTION B.—ORGANIC AND MISCELLANEOUS DUSTS. Group Jf.— Vegetable fiber dust. B room and brush fa ctories. C orn shellers, grain thrashers, w ood saw yers, et<?;, in a gricu lture. C otton ginners. Cotton spinners. C otton w eavers. Other cotton m ill em ployees. H a y and stra w balers. H em p and- ju te m ills. K n ittin g m ills. L a ce and em broidery. Linen m ills. P aper and pulp m ills. P a p er-b ox m akers. R a g dealers. R a g pickers, sorters, and cleaners. R ope and cord age fa ctories. Sail, aw ning, and tent fa ctories. Straw factories. T e x tile m ills— dyeing, finishing, prin t ing. T e x tile m ills (n o t sp ecified ). W ood— cabinetm akers. W o o d — b ox m akers. W o o d carvers. W o o d — fu rn itu re fa ctories, excep t p ol ishers and finishers. W o o d — pian o and organ factories, e x cept polish ers and finishers. W o o d polish ers and finishers. W ra p p ers and packers. Group 5.— Animal and mixed fiber dust. C arpet m ills. F u rriers. H a ir w ork ers. H a t fa ctories. M attress m akers. U pholsterers. Silk m ills. W oolen and w orsted spinners. W oolen and w orsted w eavers. W oolen and w orsted m ills. 42 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Group 6.— Organic dust. B akeries. B on e and ivory w ork ers. B u tton factories. Candy factories. C ellu loid w orkers. C h arcoal and cok e w orks. C igar and tob a cco fa ctories. F e rtilizer fa cto ries. G love factories. G rain and flour m ills. G rain -elevator em ployees. H arness and saddle fa ctories. P ock etb ook and belt m akers. R u bb er factories. Shoe factories. Shoem akers (n o t in fa c to r ie s ) Tanneries. T ru n k factories. Group 7.— Mixed organic and inorganic ( public) dusts. C arriage and h ack drivers. Chauffeurs. Coachm en. D riv e rs and team sters. G arbagem en and scavengers. Street ca r con du ctors. Street ca r m otor men. Street cleaners. Sw eepers, car. W a ste produ cts (ju n k ) AGE IN RELATION TO OCCUPATION AT^D DUST EXPOSURE. For convenience and ready reference the so-called dusty indus tries, trades, and occupations have been arranged in seven large groups, which include specific subgroupings and an aggregate of 3,264,500 males and 673,478 females, as returned by the occupation census of 1910. The grouping in matters of detail is unquestionably open to criticism, but in the absence of a thoroughly worked out de scriptive account of the industries, trades, and occupations referred to it is exceedingly difficult to adopt a more satisfactory arrangement. Since each subgrouping will be discussed in detail, the errors inherent in the main groupings are not, as a matter of practical.certainty, of sufficient importance to invalidate the final conclusions concerning the specific injuriousness of particular forms of dust. Since the age distribution of wage earners in particular occupations varies widely, the details according to sex and for all the seven subdivisions are given in Table 6 (pp. 46 to 50), included in which is a column show ing for each and every industry, trade, or occupation the proportion living at ages 45 and over. The wide differences in age distribution disclosed by this analysis are of special importance in the scientific consideration of the mortality data and the descriptive observations concerning the conditions under which the various dusty trades are carried on. The same conclusion applies to differences in the sex dis tribution of employees; for, as elsewhere shown, the specific death rates from tuberculosis vary considerably, according to age and sex. For illustration, at ages 15 to 24 the mortality from tuberculosis of the lungs is 12.15 per 10,000 for males, against 14.15 per 10,000 for females; in other words, the normal tuberculosis mortality of females GENERAL INTRODUCTION. 4S is excessive at this period of life. If, therefore, an industry, trade, or occupation includes a disproportionately large number of young women wage earners, the general mortality from tuberculosis might be higher without necessarily implying a very definite relation to the more or less considerable degree of dust exposure. Conceding the general untrustworthiness of morbidity and mor tality conclusions based exclusively upon the age distribution of per sons employed in different industrial groups according to the kind of dust exposure, some value may safely be attached to this method of analysis when made use of with exceptional caution on account of the large variety of special conditions and circumstances which have an important bearing upon the age distribution of men and women in different industrial pursuits. Some employments are obviously only for the young, while others are chiefly for the old. In some no special trade ability is required, with the result that there are frequent occupation changes, while in other groups the required degree of specialized skill is such that the employment becomes practically the pursuit of a lifetime. Furthermore, in certain occu pations there is a constant elimination of employees with advancing age on account of unsuitability for the special industrial pursuits carried on, which, of course, tends materially to disturb the propor tion of aged persons under the conditions stated. A G E D I S T R IB U T IO N O F E M P L O Y E E S IN DUSTY TRADES. Table 4 shows the proportionate distribution of males in the seven groups of dusty trades according to three subdivisions of age—under 16, from 16 to 44, and 45 and over. It is most regrettable that the census age grouping by occupation should not have been extended to the age period 65 and over, which, of course, for certain morbidity and mortality purposes is distinctly more useful and conclusive than the age period of 45 and over: T able 4 .—P R O P O R T IO N A T E ACxE D IS T R IB U T IO N OF MALES IN D U S T Y T R A D E S . [Compiled from Report of Bureatfof the Census on Occupation Statistics, 1910. For occupations included, see pp. 46 to 50.] Per cent in age group— Trade groups. Under 16. 1 2 3 4 5 6 7 16 to 44. 45 and over. Metallic dust ................................................................................... Mineral dust . Mineral industries .................................................... - .......... ............... Vegetable fiber dust ............................................................................... Animal and mixed fiber dust ............................................................. Organic dust . . ................................................................................ Mixed organic and inorganic (public) dusts...................................... 0.54 1.86 1.74 7.73 4.06 2. 28 .77 82.52 78. 43 79.65 75.01 75.49 72.53 77. 91 16.94 19. 71 18. 61 17. 26 20. 45 25.19 21.32 Total..................................................................................................... 2.33 77. 49 20.18 44 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. According to this table, the proportion of young persons is largest in the group of occupations with exposure to vegetable fiber dusts, which, of course, is inclusive of the entire cotton-textile industry. The proportion is least in the group of occupations with exposure to metallic dusts, largely because of the practical absence of an appren tice system and the highly specialized skill required of a large number of employees in the cutlery, tool, jewelry, printing, and related trades. In the entire group of dusty trades the proportion of men aged 45 and over is 20.18 per cent, being lowest among the workers with exposure to metallic dusts, or 16.94 per cent, and highest among work ers with exposure to organic dusts, or 25.19 per cent. This result is of special significance in the case of men employed with exposure to metallic dusts, on account of the small proportion employed at ages under 16, which ordinarily, of course, would tend to raise the proportion at ages 45 and over. The abnormal age distribution in the case of this group of employees, therefore, confirms the mortality data suggestive of an excessive death rate among men employed in this group of occupations, particularly or largely in consequence of considerable and continuous exposure to metallic dusts. In the case of men employed in occupations with exposure to vegetable fiber dusts the proportion aged 45 and over is 17.26 per cent, but this low proportion is in part due to the very high proportion of persons employed at ages under 16. Here, however, also to a limited extent the high figure is fairly conclusive and indicative of a rela tively high mortality in middle adult life. The group of occupations following, in the order of the proportion of persons aged 45 and over, is composed Of men employed in mineral industries, followed by men employed in occupations with exposure to mineral dusts, which two groups, of course, have much in common, and for which the age distribution is almost the same. A more favorable propor tion is shown for persons employed in occupations with exposure to animal and mixed fiber dusts, or 20.45 per cent, and these are followed by persons with exposure to public or street dusts (21.32 per cent), and, finally, by persons in the group of occupations with exposure to organic dusts, or 25.19 per cent. As shown elsewhere, in this group of occupations the result of dust exposure is apparently least harmful where the proportion of workers 45 years and OArer is correspondingly the largest. In a general way, therefore, the age distribution fairly conforms to the conclusion based upon mortality statistics. . Table 5 exhibits the corresponding information for females, but the data must be considered distinctly less conclusive and, in the case of certain groups, practically valueless, on account of the small number of employees concerned. 45 GENERAL INTRODUCTION. Table 5.—PROPORTIONATE AGE DISTRIBUTION OF FEMALES IN DUSTY TRADES. [Compiled from Report of Bureau of the Census on Occupation Statistics, 1910. For occupations includedj see pp. 46 to 50.] Per cent in age group— Ai.c*u.e,gi.uuiJ, Under 16. 1. 2. 3. 4. 5. 6. 7. 16 to 44. 45 and over. Metallic d u st............ ................................................................................. Mineral d ust.............................................................................................. Mineral industries................................'............... *................................... Vegetable fiber dust................................................................................. Animal and mixed fiber dust................................................................ Organic dust.............................................................................................. Mixed organic and inorganic (public) dusts....................................... 4.27 7.99 7. 27 11.94 8.44 7.45 1.00 90.50 85. 26 80.91 81.75 82. 20 84.55 78.20 5.23 6.75 11.82 6.31 9. 36 8.00 20.80 T otal..................................................................................................... 9.50 83.10 7.40 No safe deductions can be based upon this table, which is merely included here for the purpose of completeness. The chief factor of uncertainty inherent in this table is the constant elimination of women from industry on account of marriage and for other reasons, naturally tending toward a decidedly lower proportion of women ages 45 and over in industrial pursuits, regardless of the fact that in the population at large the proportion of women at this period of life exceeds the corresponding proportion of men. Even subject to these qualifications it is suggestive that the proportion of women aged 45 and over employed in occupations with exposure to metallic dusts should be the lowest of the seven groups, 5.23 per cent, against 7.40 per cent for the aggregate number of female employees in occu pations with exposure to industrial dusts. There are practically no women employed in mineral industries, but as shown by the intro ductory tables most of the occupied females are employed in the occupations with exposure to vegetable fiber dusts, animal and mixed fiber dusts, and organic dusts, which are, of course, inclusive of all the different subdivisions of the textile industry. It is suggestive in this connection that no definite conclusions can be drawn from tfie table further than as stated. The analysis could have been extended to the 118 individual occu pations, employments, or industries, but the table following makes this unnecessary. The details, however, in the case of many occupa tions are distinctly indicative of unfavorable health conditions, and especially is this true for grinders, polishers, and buffers, toolmakers, and sand blasters in the iron and steel industries. An analysis in detail, however, is much more subject to the qualification of extreme care in the use of the data for the purpose of emphasizing the pos sibly injurious results of any particular occupation, industry, or trade on the basis of the proportion of men or women employed at ages 45 and over. The data are included primarily for the purpose of mak ing the statistics conveniently available, and to bring the facts of age distribution into intelligent correlation to the general discussion of 46 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. the circumstances and conditions more or less accountable for healthinjurious results of certain occupations, trades, and industries by reason of the approximately ascertainable exposure to different kinds of industrial dust. T able 6 . —AGE D IS T R IB U T IO N OF E M P L O Y E E S IN D U S T Y T R A D E S , B Y S E X A N D OCCU P A T IO N GROU PS. Compiled from Report of Bureau of the Census on Occupation Statistics, 1810.] G R O U P 1 .—M E T A L L I C D U S T . Sex and occupation group. Total em ploy ees. Number in age g r o u p 30 to 13. 14 to 15. Per cent 45 years 45 and and over. over. 16 to 20. 21 to 44. 267 1,665 62 21,902 889 290 510 1,850 320 103 1,070 66 1,243 4,241 6,851 20 387 97 2,282 672 11,166 722 70,726 2,894 1,996 3,097 7,574 1,769 327 5,346 726 4,257 21,759 16,677 65 4,910 278 14,1S6 235 2,999 181 18,834 945 454 660 1,864 895 165 1, 705 294 1,432 5,367 1,971 14 2,046 56 3,669 44,115 169,147 17. 07 65. 45 43,786 16. 94 MALE. Artifieial-flowpx makers . - .............................. Chippers (blast furnace and steel rolling m ill). Compositors and typesetters............................... Cutlery makers ........... .................. Die setters and sinkers .. ........................ Electrotvpers and stereotypers ...................... Engravers............................................................... F ile rs ...................................................................... G old beaters........................................................ Grinders................................................................... Grinders, card........................................................ Jewelers, manufacturing...................................... Polishers, buffers, and finishers.......................... Pressmen and press feeder*................................. Sand blasters, iron and steel............................. Saw filers .................................... Solderers................................................................ T oolm akers......................................................... 1,238 IS,912 96S 111,189 4,840 2, 744 4,268 11,315 3,016 607 8,214 1,087 6,943 31,772 25,951 99 7,345 434 20,212 Total.............................................................. 258,454 Per cent in each age group................................... 100. 00 7 4 5 1 4 15 57 82 3 23 107 4 1 27 31 12 93 1 11 401 437 2 3 75 36 0. 01 1,370 0. 53 Artificial-flower makers .................................... 8, 616 50 Brass workers..................................................... 1S7 Compositors and typesetters............................... 13, 681 Cutlery makers....................................................... 543 Die setters and sinkers.......................................... 4 Electrotvpers and stereotypers........................... 100 Engravers............................................................... 451 Filers ................................................................... 227 Gold b eaters........................................................ 76 G rin d ers................................................................. 364 Grinders, oard........................................................ 4 Jewelers, manufacturing...................................... 1, 435 Polishers, buffers, and finishers.......................... 3, 204 ......... i ‘ Pressmen and press feeders................................. 4,133 Sand blasters, iron and steel............................... 2 2 Saw filers............................................................... Solderers.................................................................. 161 T oolm akers.......................................................... 65 919 4 7 39 19.0 18.8 18.7 16.9 19.5 16.5 15. 5 16.5 29.7 27.2 20.8 27.0 2\6 16. 9 7.6 14.1 27.9 12.9 18.2 FEMALE. Total.............................................................. 33,255 Per cent in each age group.................................. 100. 00 51 0.15 3.791 S2 4, 567 263 2 27 158 100 32 189 1 550 1, 269 1,863 2 3,297 88 8,411 218 2 62 268 111 35 157 3 789 1, 577 1,862 2 73 16 2 85 44 1,369 4.12 12,985 39. 05 1 2 4 2 11 28 176 174 559 13 696 23 6.5 7.0 a. l 4.2 10 23 12 7 7 10.0 5 1 5.3 9.2 1.9 6S 181 134 4.7 5.6 3.2 1 5 6 7.7 17,111 1 1,739 51. 45' 5. 23 G R O U P 3 . —M I N E R A L D U S T . MALE. Asbestos workers.................................. Brick, tile, and terra-cotta factories.. Core m ak ers.......................................... Color mixers (not pain t)...................... Glass blowers......................................... Glass factories (excluding blow ers).. Lacquerers, japanners, enamelers. . . ! Lim e, cement, and gypsum factories. Lithographers........................................ Marble and stone yards....................... Mica w ork ers ....................................... . Mirror m aters............. ......................... 1,197 92,823 16.479 858 15,474 61,299 1,225 46,898 7,661 52,813 27 687 2 566 4 15 2,112 411 15 17 395 4.104 23 78 . 414 11 23 278 1 1 8 891 121 14,663 59,862 4,049 10 638 114 512 957 11,885 14.416 34,135 174 811 5,573 33,340 1.299 ‘ 5,001 4,138 33,731 10 14 100 482 168 15,620 1.377 217 2,615 8,249 217 7,493 1.3«L 14, 643 2 96 14.0 16.8 8.4 25.3 16.9 13.5 17.7 Hi 0 17.6 27.7 7.4 14.0 47 GENERAL INTRODUCTION. Table 6 .—AGE DISTRIBUTION OF EM PLOYEES IN DUSTY TRADES, B Y S E X AND OCCU PATION GROUPS—Continued. G R O U P 2 .—M I N E R A L D U S T —Concluded. Sex and occupation group. m a l e — concluded. M olders.................................................................... Paint factories........................................................ Paper hangers, apprentices, and helpers.......... Plasterers................................................................ Potteries.................................................................. W hile washers........................................................ Total em ploy ees. Number in age group— 10 to 13. 113,617 4,727 25,561 50,525 21,159 1,663 4 14 18 44 1 T otal............................................................. 514,693 Per cent in each age group................................... 100.00 1,150 0.22 14 to 15. 16 to 20. 37 : 8,165 91 730 255 2,362 147 3.452 488 3,578 4 65 8,431 1.64 21 to 44. 84,070 3,010 16.636 30,564 13,397 696 Per cent 45 years 45 and and oyer. over. 21,345 892 6,294 16,344 3,652 897 18.8 18.9 24.6 32.3 17.3 53.9 63.966 339,675 101,471 12.43 66.00 19.71 j FEMALE. Asbestos workers................................................... Brick, tile, and terra-cotta factories................. Core m akers........................................................... Color mixers (not paint)...................................... Glass blowers.......................................................... Glass factories (excluding blowers)................... Lacquerers, jap aimers, enamelers..................... Lim e, cement, and gypsum factories................ Lithographers........................................................ Marble and stone yards....................................... Mica w ork ers......................................................... Mirror m akers........................................................ Molders.................................................................... Paint factories........................................................ Paper hangers, apprentices, and helpers.......... Plasterers................................................................ Potteries.................................................................. W hite washers........................................ ............... 129 1,581 1,836 37 90 3,874 289 281 477 224 164 ' 33 66 213 823 8 5,202 5 Total. 15 332 Per cent in each age group................................... 100.00 21 135 90 3 2 451 17 9 1 22 6 2 2 21 4 55 613 1,016 23 39 1,957 140 87 222 85 119 10 20 109 18 16 377 2,030 62 0.40 1.163 7.59 6,543 42.68 8 33 1 1 3 47 711 708 10 45 1,338 120 146 238 96 36 19 35 70 466 4 2,438 2 6 114 22 1 95 11 39 16 20 3 2 9 10 335 4 341 3 6,529 42.58 1,035 6.75 4 4.7 7.2 1.2 2.7 4.4 2.5 3.8 13.9 3.4 8.9 1.8 6.1 13.6 4.7 40.7 50.0 6.6 60.0 G R O U P 3 .—M IN E R A L I N D U S T R IE S . MALE. Asphalt miners and laborers............................... Bauxite miners and laborers............................... Coal miners............................................................. Copper miners........................................................ Gold and silver m iners......................................... Graphite miners and laborers............................. Iron miners............................................................. Lead and zinc miners........................... ................ Mica miners and laborers.................................... Phosphate miners and laborers.......................... Quarries................................................................... Quicksilver miners and laborers........................ Spar miners and laborers..................................... Sulphur miners and laborers............................... Mines not specified............................................... Other miners and laborers.................................. 132 200 591,024 35.117 53, 869 178 45,917 18,526 277 4,582 73,954 126 501 485 19,117 892 T otal............................................................. 844,897 Per cent in each age group.................................. 100.00 1,292 16 5 1 152 4 3 80 118 1 2 11,319 86 43 2 427 100 8 131 815 10 1 15 4 14 1 55 16 106 14 9 128 36 34 73,514 402,631 102,268 2,632 27,034 5,349 2,154 32,915 18, 752 19 134 22 5,681 34,189 5,468 2,093 13,363 2,966 169 45 52 665 3,201 505 9,029 49,097 : 14,895 88 3 35 330 68 79 78 . 338 67 973 11,561 6,513 549 . 119 204 1,703 0.20 13,020 1.54 97,123 575,833 157,218 11.50 68.15 18.61 2 27 94 1 3 1 3 8 5 13 1 8 2 6.8 17.0 17.3 15.2 34.8 12.4 11.9 16.0 18.8 11.0 20.1 27.8 15.8 13.8 34.1 22.9 FEM ALE. Bauxite miners and laborers............................... Coal miners................................ ; .......................... Copper miners.................................... . ................. Gold and silver miners......................................... Iron miners............................................................. Lead and zinc miners.......................................... Mica miners and laborers.................................... Phosphate miners and laborers.......................... Quarries................................................................... Spar miners and laborers..................................... Oilier miners and laborers.................................. 1 368 15 39 32 14 29 11 28 1 12 2 1 1 1 214 12 19 17 8 10 9 18 1 6 T otal.............................................................. Per cent in each age group................................... 550 100.00 5 0.91 35 6.36 130 23.64 315 57.27 31 3 20 4 8.4 20.0 51.3 12.5 2 1 2 6.9 9.1 7.1 2 16.7 65 11.82 48 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Table 6 .—AGE DISTRIBUTION OF EM PLOYEES IN DUSTY TRADE S, B Y SE X AND OCCU PATION GROUPS—Continued. G R O U P 4 .—V E G E T A B L E F IB E R D U S T . Sex and occupation group. Broom and brush factories................................. Corn shellers, grain thrashers, wood sawyers etc., agriculture................................................. Cotton ginners, other miscellaneous industries. Cotton spinners..................................................... Cotton weavers...................................................... Other cotton-mill employees............................... Hay and straw balers........................................... Hemp and jute mills............................................ Knitting mills........................................................ Lace and embroidery............................................ Linen mills............................................................. Paper and pulp mills............................................ Paper-box makers................................................. Rag dealers............................................................. Rag pickers, sorters, and cleaners..................... Rope and cordage factories................................. Sail, awning, and tent factories.......................... Straw factories....................................................... Textile mills—dyeing, finishing, printing........ Textile mills, (not specified)............................... Wood—cabinetmakers........................................ Wood—box makers............................................. Wood carvers......................................................... Wood—furniture factories, except polishers and finishers...................................................... Wood—piano and organ factories, except pol ishers and finishers........................................... Wood polishers and finishers.............................. Wrappers and packers.......................................... Total em ploy- 10,563 Number in age group— 10 to 13. 39 14 to 15. 16 to 20. 21 to 44. Per cent 45 years 45 and and over. over. 370 1,825 6,096 2,233 21.1 1,810 1,383 8,985 32 144 2,421 325 97 72 381 9 18 304 34 9 692 1,266 a 432 107 81 ‘ 4,387 9,758 18,379 197 722 7,816 1,305 280 1,037 1,600 79 135 1,327 288 54 4,459 4,468 405 1,690 1,107 391 1,833 5,765 11,042 332 473 2,867 690 267 1,189 683 763 360 1,164 837 27 7,260 5,005 2,665 970 3,489 28.2 29.1 11.5 66 1,101 2,701 854 6,848 31,779 38,077 1,128 2,092 13,510 2,872 603 4,635 3,002 952 702 3,555 1,444 115 17,949 12,983 4,069 3,143 7,397 4,146 120 756 2,381 635 20,271 6,460 4 224 273 87 2,324 385 13,360 3,746 158 4,360 1,219 65,879 186,378 55.42 19.59 58,038 17.26 3,919 1,342 15,874 48,929 80,778 1,698 3,438 27,236 5,199 1,248 6,933 5,688 1,805 244 4,295 9 7 622 7 1 1,220 6,372 2,604 205 30,382 23,800 7,142 G, 382 12,054 Total............................................................. 336,323 Per cent in each age group................................... 100. 00 147 1 1,212 6,541 1.94 19,487 5. 79 199 1,018 3,520 330 1,242 5,906 2,047 5,664 163 7,237 1,266 135 138 1,865 4 56 410 44 77 6 13,564 11,867 21,030 1,361 28,682 5,747 • 584 1,076 7,014 32 393 1,991 281 589 1,446 10 455 369 45 6 66 65 2 1 117 4,058 167 2,717 11.8 13.7 19.6 13.8 10.5 13.3 21.4 17.1 12.0 42.3 29.5 18.3 32.1 13.2 23.9 21.0 37.3 15.2 28.9 21.4 24.9 21.5 18.9 FEM ALE. Broom and brush factories.................................. Cotton ginners, other miscellaneous industries. Cotton spinners...................................................... Cotton weavers...................................................... Other cotton-mill employees............................... Hemp and jute mills............................................ Knitting mills........................................................ Lace and embroidery............................................ Linen mills.............................................................. Paper and pulp mills............................................ Paper-box makers................................................. Rag dealers............................................................. Rag pickers, sorters, and cleaners..................... Rope and cordage factories................................. Sail, awning, and tent factories.......................... Straw factories..............................: ....................... Textile mills—dyeing, finishing, printing........ Textile mills (not specified)............................... Wood—box makers.............................................. Wood carvers......................................................... W’ ood—furniture factories, except polishers and finishers....................................................... Wrood—piano and organ factories, except pol ishers and finishers............................................ W'ood polishers and finishers.............................. Wrappers and packers.......................................... 2,359 39 32,151 43,911 59,372 2, 781 69,414 15,820 1,540 2,744 14,226 170 1,806 4,162 1,074 2,378 4,083 28,908 778 145 2 918 75 3 4 56 1 1 10 253 16 144 3 346 7,781 Total......... •................................................... 296,135 Per cent in each age group................................... 100.00 1 200 2,572 91 22 755 6,490 2.19 1,018 29 8,706 25,379 27,320 1,142 28,962 7,201 678 1,278 4,875 971 1,542 590 1,300 2,154 13,297 279 66 28,863 111,788 130,308 44.00 37.75 9.75 120 9 455 4,288 3,616 113 3,615 1,531 140 248 416 63 384 193 158 411 273 2,331 23 28 5.1 23.1 1.4 9.8 6.1 4.1 5.2 9.7 9.1 9.0 • 2.9 37.1 21.3 4.6 14.7 17.3 6.7 8.1 3.0 19.3 4.9 11.0 2.9 18,686 6.31 49 GENERAL INTRODUCTION. Table 6 .—AGE DISTRIBUTION OF EM PLOYEES IN DU STY TRADE S, B Y SEX AND OCCU PATION GROUPS—Continued. G ROU P 5.—A N IM AL AND M IX E D FIBER DU ST. Sex and occupation group. Total em ploy ees. Number in 10'to 13. e bg r o u p - Per cent 45 years 45 and .and over. over. 14 to 15. 16 to 20. 21 to 44. 3,680 1,168 467 4,162 524 1,971 7,503 11, 485 5,303 829 15,575 2,150 11,084 19,887 3,691 1,595 262 5,297 455 5,645 5,173 18.9 19.6 16.0 20.8 14.2 .30.0 14.7 89 1,671 2,060 8,502 608 3,887 11,718 24,534 1,441 969 3,252 9,828 67.0 13.8 18.9 21.5 37,608 20.45 M A LE. Carpet m ills ......................................................................... Fu rriers................................................................................ H air w orkers..................................................................... . H a t factories....................................................................... M attress m ak ers.............................................................. . U p h olsterers....................................................................... Siik m ills .................. ............................................................ W e a v ers (carpets, "blankets, etc ., n ot in fac to r ies).................................................................................. W c o le n and w orsted spinners................................. . W o o le n and w orsted w eav ers................................... W o o le n and w orsted m ills ........................................ . 19,534 8,127 1,636 25,500 3,202 18,808 35,165 4 146 656 58 61 458 65 104 2,456 2,151 6,997 17,197 45,620 2 23 10 106 11 447 157 2,650 T o ta l......................................................................... . Per cent in each age g ro u p ........................................ . 183,937 100.00 7,123 3.87 31,797 107,060 17.29 58.20 Carpet m ills ....................................................................... F u rriers................................................................................ H air w orkers..................................................................... H a t factories...................................................................... M attress m ak ers.............................................................. U p holsterers...................................................................... Silk m ills.............................................................................. W e a v e rs (carpets, blankets, etc., not in fac tories) ................................................................................ W o o le n and worsted spinners................................. W o o ie n and w orsted w eavers................................... W o o le n and w orsted m ills ........................................ . 14,163 2,734 1)894 10,735 924 1,291 52,504 662 64 187 563 29 13 6,098 5,063 921 773 3,631 307 318 23,027 7,180 1,458 624 5,425 477 706 21,495 1,250 291 305 1,099 107 254 1,601 8.8 10. ft 16.1 10.2 11.6 19.7 3.0 10,781 6,390 14,660 33,186 57 16 14 122 806 350 3,203 976 3,550 3, 728 12,465 4,098 1,883 9,002 15,584 5,528 135 1,566 1,836 51.3 2.1 10.7 5.5 T o t a l......................................................................... P er cent m each age group........................................ . 149,262 100.00 502 0.34 12,097 8.10 54,759 36.69 67,932 45.51 13,972 9.36 14,079 98 1,853 3,772 93' 1,036 14,644 12 1,036 2,506 540 1,736 894 2, 405 19,141 2,384 5,540 255 61,425 291 4,822 8,994 329 7,016 54,878 90 3,355 20,508 4,382 11,027 3,012 8,405 64,097 30,821 29,787 538 17,665 115 1,017 2,002 103 1,737 21,594 15 1,094 12,809 1,518 7,404 816 2,272 18,044 35,337 10,264 177 FEM ALE. 283 G R OUP 6 .—OR G AN IC D U S T . M ALE. B ak eries.................................................................................. B on e and ivory w o r k e r s .. .......................................... B u tto n factories................................................................ C andy factories.................................................................. C elluloid Avorkers.............................................................. Charcoal and coke w o rk s............................................. Cigar and tobacco factories.......................................... Fertilizer factories, m ix e r s.......................................... G love factories.................................................................... G rain and flour m ills ...................................................... Grain elevator e m p lo y e e s ........................................... Harness and saddle factories...................................... P ocketbook and belt m akers..................................... R u b b er factories................................................................ Shoe factories...................................................................... Shoemakers (no t m factories)................................... T anneries.............................................................................. T ru n k factories................................................................... 95,026 520 8,101 15,438 538 9,928 95,060 118 5,681 36,065 6,484 20,271 4,842 13,422 104,430 68, 788 40,142 1,057 T o ta l........................................................................... Per cent in each group................................................... 155 1 30 40 5 49 9 1 1 6 97 18 37 5 1,702 15 379 630 13 103 2,996 1 191 193 35 103 119 334 3,051 228 514 82 531,911 100.00 1,438 0.27 10,689 2.01 11,333 121 4,707 12,553 249 12 43 23 72 821 14 468 1,656 28 36 948 18. a 22.1 12.6 13.0 19.1 17.5 22.7 12.7 19.3 35.5 23.4 36.5 16.9 16.9 17.3 51.4 22.2 16.7 72,024 |313,777 133,983 13.54 j 58.99 25.19 FEMALE. Bakeries.................................................................................. Bone and ivory w orkers............................................... B u tto n factories................................................................ Candy factories.................................................................. (_ell” loid w orkers.............................................................. Charcoal and coke w o rk s............................................. 106811°— IS— Bull. 231------- 4 4,069 55 2,269 6,311 124 4 4,613 41 1,805 4,254 94 3 1,787 11 142 260 3 5 15.8 9.1 3.0 2.1 1.2 41.7 50 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 6 .—AGE DISTRIBUTION OF EMPLOYEES IN DUSTY TRADES, BY SE X AND OCCU PATION GROUPS—Concluded. G R O U P 6 .—O R G A N IC D U S T —Concluded. Sex and occupation group. fem ales— Total em ploy- Number in age g r o u p 10 to 13. 14 to 15. 16 to 20. 21 to 44. 45 and over. 36,719 7,278 188 6 147 415 4,257 24,060 5,438 1,978 55 128 488 2,181 6 121 28 28,968 4,199 130 5 88 545 2,853 14,423 148 749 145 12,132 6.83 65,085 36.66 85,028 47.89 concluded. Cigar and tobacco factories........... Glove factories................................. Grain and flour m ills...................... Grain elevator employees.............. Harness and saddle factories........ Pocketbook and belt makers....... . R ubber factories............................. Shoe factories.................................... Shoemakers (not in factories)____ Tanneries......................................... Trunk factories............................... 77,468 14,172 396 11 290 1,128 7,955 44,485 782 1,614 Total...................................... . Per cent in each age group........... 177,545 100.00 G R OUP 7. 5,463 704 20 1,099 0.62 " ” *49" 36 346 3,776 232 74 9 14,201 8.00 M IX E D O R 6AN IC AND IN O R G A N IC (PUBLIC) D U S T S . M ALE. 166 5 34 380 8 722 116 159 2,907 33 Street cleaners............................................... Sweepers, car (street and steam railroad). 57,844 44,973 25,171 332,141 4,227 56,932 56,218 9,946 6,833 2 5 22 27 Total..................................................... Per cent in each age group.......................... 594,285 100.00 600 0.10 3,990 0.67 Carriage and hack drivers........................... Chauffeurs...................................................... Coachmen....................................................... Drivers............................................................ Garbagemen and scavengers...................... Street car conductors................................... Street car motormen........................................ 4 6,113 36,183 8,208 34,775 1,534 16,379 38,461 209,103 310 2,653 3,573 48,174 1,057 46,432 270 4,571 675 4,554 14,660 1,869 7,065 81,290 1,223 5,181 8,729 5,081 1,572 25.3 4.2 28.1 24.5 28.9 9.1 15.5 51.1 23.0 60,201 402,824 126,670 10.13 67.78 21.32 F EM ALE. Carriage and hack drivers........................... Chauffeurs...................................................... Drivers............................................................ Sweepers, car (street and steam railroad) 36 32 67 1,264 Total..................................................... Per cent in each age group.......................... 1,399 100.00 1 12 6 3 15 163 2 0.14 12 0.86 187 13.37 1 20 25 35 827 10 3 17 261 907 64.83 291 20.80 27.8 9.4 25.4 20.6 C H A P T E R I I .— O C C U P A T IO N S M E T A L L IC W IT H E X P O S U R E T O D U S T . TH E OCCUPATIONAL MENACE OF M ETALLIC DUST. The continuous and considerable exposure of workmen to the inhalation of metallic dust in its various forms is generally recog nized by medical and other authorities on occupational diseases as probably the most serious health hazard with particular reference to a material increase in liability to pulmonary tuberculosis and nontuberculous respiratory diseases. The term “ metallic dust ” for practi cal reasons is for the present purpose limited to finely comminuted particles of iron, steel, brass, gold, silver, bronze, lead, arsenic, and other metallic substances. Some of these are exceedingly common in connection with industrial processes, while others are rarely met with. Occasionally the pathological aspects of the problem are complicated by chemical considerations, aside from the physical or mechanical properties of the several varieties of metallic dust referred to. In the vast majority of mechanical operations in which metallic dust is generated there is more or less intermixture with particles of min eral dust, which quantitatively may exceed in importance the ascer tainable presence of metallic dust. On account of the heavier weight of metallic particles the relative degree of air pollution in factories, workshops, mines, etc., where metallic dust is generated is considerably less than the corresponding amount of air impurities resulting from atmospheric pollution by mineral dust. The injurious consequences of industrial dust exposure are, broadly speaking, proportionate to the amount of dust inhaled into the lungs, but important exceptions to this conclusion are brought out by the consideration in detail of the several kinds of metallic dust, of which, perhaps, lead and arsenic are the most harmful, on account of the additional liability to indus trial poisoning. Quantitatively the most important kind of metallic dust as met with under typical industrial conditions is the dust of iron and steely which, however, is generally more or less intermixed with dust of other metallic or mineral substances. Pure iron and steel dust is rarely met with except under laboratory and other con ditions which are not within the plan and scope of the present dis cussion. Typical employments with metallic dust exposure are file 51 52 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. cutters, coppersmiths, engravers, printers, lithographers, nail makers, machinists, gunsmiths, etc. Persons in all of these employments or industries are subject, as a general rule, to an exceptionally high mortality rate from all causes, and a high specific death rate from pulmonary tuberculosis. Some emplojTnents in addition are subject to an excessive incidence of nontuberculous respiratory diseases, and particularly is this the case where there is quantitatively a consider able degree of intermixture with silica and similar forms of exces sively irritating kinds of mineral dust. The most common form of tuberculosis in occupations with iron and steel dust exposure is medi cally known as pneumoconiosis, met with in its most typical form in steel grinding and polishing processes, particularly in the manu facture of cutlery and tools and instruments. RELATION OF VARIATIONS IN OCCUPATIONAL CONDITIONS TO DUST EXPOSURE AND MORTALITY. The conditions of employment in the 13 industries, trades, and occupations which are considered in detail in the following discussion are so widely at variance with each other that a grouping of the mortality data results in averages which are applicable only with extra caution to particular employments with a more or less ascer tainable degree of exposure to metallic dust. Such exposure is nearfy always an important predisposing cause of pulmonary tuber culosis and is met with to an exceptional degree of frequency in the grinding and polishing of small metallic objects during the final (finishing) stages of manufacture. On account of the high degree of specialized skill required in many of these occupations, the social loss represented by prolonged illness and premature death from preventable pulmonary tuberculosis is, therefore, of special economic significance. PROPORTIONATE MORTALITY—UNITED STATES REGISTRATION AREA. Table 7 is merely intended as a general statement of the essential mortality facts concerning this group of occupations, with special reference to pulmonary tuberculosis, derived from the available official statistics of the Division of Vital Statistics of the United States Census. Subsequently, in addition thereto, tables are included of the more extended experience of a representative industrial in surance company. The practical usefulness of this analysis is natu rally rather limited for the reasons stated, but the data provide a fairly trustworthy measure of the relative frequency of pulmonary tuberculosis in the group of occupations under review with a more or less ascertainable degree of health-injurious exposure to metallic dust. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 53 T able 7 . — P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O SIS AMONG W O R K E R S E X P O S E D TO M E T A L L IC D U S T, U N IT E D ST A T E S R E G IS T R A T IO N A R E A , 3908 A N D 1909, B Y A GE G R O U PS. Workers exposed to metallic dust. Per cent o f deaths from- pulmonary t u b e r c u lo s is among— Deaths from pul monary tuber culosis. Age at death. Deaths from all causes. Per cent Number. o f deaths 'from all causes. A ll oc cupied males. Farmers, planters, and farm laborers. 15 to 24 years....................................................................... 25 to 34 years....................................................................... 35 to 44 years....................................................................... 45 to 54 years....................................................................... 55 to 64 rears....................................................................... 65 years and over............................................................... Age unknow n..................................................................... 1,230 2,006 2,291 2,166 1,738 1,944 10 412 719 656 378 150 80 1 33.5 35.8 28.6 17.5 8.6 4.1 10.0 28.1 30.9 24.0 14.4 7.6 2.6 8.3 23.5 26.2 19.1 12.1 6.7 2.4 7.9 Total, 15 years and over........................................ 11,385 2,396 21.0 14.9 8.7 In Table 8 are given data relative to the proportionate mortality from nontuberculous respiratory diseases among workers exposed to metallic dust, 1908 and 1909. T able 8 .—P R O P O R T IO N A T E M O R T A L IT Y FROM N O N TU BE R CU LO U S R E S P IR A T O R Y DISEASES AMONG W O R K E R S E X P O S E D TO M E T A L L IC DUST, U N IT E D STATE S R E G IS T R A T IO N A R E A , 1908 AND 1909. Deaths of workers ex posed to metallic dust. Cause of death. Number. Per cent of deaths from all causes. Per cent of deaths from all causes among— All oc cupied males. Farmers, planters, and farm laborers. Asthm a..................................................................................... Bronchitis................................................................................ Pneumonia..................................................................... ....... Other nontuberculous respiratory diseases....................... 23 92 969 132 0.2 0 .3 .9 7 .8 1.1 0.3 .8 8 .5 1.2 Total............................................................................... 1,216 10.7 10.0 9 .3 1 .2 7 .0 .9 The aggregate experience, according to Table 7, for the two years under observation (no subsequent official statistics having been pub lished), indicates a proportionate mortality from pulmonary tuber culosis among those employed in occupations with exposure to metal lic dust of 21 per cent. As subsequently shown, this compares with 21.3 per cent for occupations with exposure to mineral dust as ascer tained by an analysis of the corresponding data derived from the same official sources. The table indicates an excessive degree of frequency of pulmonary tuberculosis at every divisional period of life, but by reference to the corresponding statistics for occupations with ex posure to mineral dust the latter present an even more serious tend- 54 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. ency toward an excess in the proportionate mortality ; but upon further analysis of the occupations in detail it is shown that exposure to metallic dust is unquestionably on general principles more of a menace to health with particular reference to pulmonary tuberculosis than is exposure to mineral dust. In addition to an excessive mor tality from pulmonary tuberculosis the comparative mortality from nontuberculous respiratory diseases, particularly pneumonia, is higher among occupations with exposure to metallic dust than among occu pations with exposure to mineral dust. The details of the proportionate mortality from pulmonary tuber culosis in the principal occupations for which the information is ascertainable from the reports of the Division of Vital Statistics of the United States Census for the two years, 1908 and 1909, are, for purposes of convenience, shown in Table 9. T able 9 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS IN S P E C IF IE D IN D U S T R IE S OR OCCUPATIONS W IT H E X P O S U R E TO M E T A L L IC D U S T , U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A G E G R O U PS. 15 to 24 years. Occupation group. Brass workers............ Engravers.................. iTon and steel workers.. Iron and steel workers (listed as other)......... Jewelers, gold and sil ver workers, etc......... Metal workers, other. . . Printers, lithographers, pressmen..................... Tinplate and tinware workers........................ Total..................... Total..................... 45 to 54 years. Deaths from pul monary tubercu losis. Deaths from pul monary tubercu losis. Deaths Deaths from pul from pul monary monary Deaths Deaths tubercu Deaths tubercu Deaths from from from from losis. losis. all all all all causes. causes. causes. causes. Num Per Num Per Num Per N um Per ber. cent. ber. cent. ber. cent. ber. cent. 64.0 50.0 19.8 42 23 915 21 50.0 8 34.8 239 26.1 35 20 1,084 25.6 149 53 35.6 150 51 34.0 50.0 34.6 78 82 31 39.7 28 34.1 94 93 22 23.4 21 22.6 427 186 43.6 551 614 104 41 39.4 166 201 1,230 33.5 2,006 25 10 460 55 to 64 years. Brass workers................. Engravers....................... Iron and steel workers... Iron and steel workers (listed as other).......... Jewelers, gold and sil ver workers, etc......... Metal workers, other. . . Printers, lithographers, pressmen...................... Tinplate and tinware workers........................ 35 to 44 years. 25 to 34 278 50. 61 36.7 719 35. 65 years and over. 26 19 754 15.4 15.8 8.5 16.0 4.0 4.7 2,291 11 31.4 5 25.0 253 23.3 16.7 1 6.7 166 16.7 19.9 . 128 77 14.1 15.6 223 36.3 522 112 21.5 70 34. 248 656 2,166 Age unknown. 25.0 34 13.7 378 Total, 15 years and over. 201 112 5,035 64 31.8 23 20.5 853 16.9 133 14.3 142 73 8.5 6.8 177 97 3.4 1.0 686 475 350 7.7 381 3.7 2,-847 840 29.5 241 6.6 3.0 1,229 230 18.7 1,738 4.8 122 85 11,385 Table 10 shows the proportionate mortality from nontuberculous respiratory diseases in occupations with exposure to metallic dust. 55 OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. T able 1 0 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M N O N T U B E R C U L O U S R E S P IR A T O R Y DISEA SES IN S P E C IF IE D IN D U S T R IE S O R OCCUPATION S W IT H E X P O S U R E M E T A L L IC D U ST, U N IT E D S TA TE S R E G IS T R A T IO N A R E A , 1908 A N D 1909. TO Deaths caused b y — Asthma. Occupation group. Num ber. Brass workers................. Engravers........................ Iron and steel workers . Iron and steel workers (listed as oth er)......... Jewelers, gold and sil ver workers................. Metal workers, oth er... Printers, lithographers, pressmen...................... Tinplate and tinware workers........................ T otal..................... Bronchitis. Per cent. N um ber. Per cent. Pneumonia. A ll nontuberOther respira culous respira tory diseases. tory diseases. Num ber. Per cent. Num ber. Per cent. N um ber. 18 3 508 9.0 2.7 10.1 1 1 54 0.5 .9 1.1 22 4 609 10.9 3.6 12.1 Per cent. 3 1.5 0.2 35 .7 2 .3 11 1.4 54 6.7 11 1.4 78 9.8 2 2 .3 .4 8 6 1.2 1.3 40 49 5.8 10.3 *1 5 1.0 1.1 57 62 8.3 13.1 12 2 .1 14 .5 193 6.8 41 1.4 250 8.8 3 .2 15 1.2 104 8.5 12 1.0 134 10.9 92 .8 969 8.5 132 1.2 1,216 10.7 23 PROPORTIO NATE M O R T A L IT Y— IN D U ST R IA L EXPERIEN CE. INSU R A N CE The industrial mortality experience of the Prudential Insurance Go. of America is more conclusive, in that the number of specific occu pations is more representative of the industries and employments with exposure to metallic dust when considered as a group.1 The details of the experience are set forth in Tables 11 and 12. 1 A d d itio n a l in su ra n ce exp erien ce d a ta are con ta in ed in B u lle tin N o. 207 o f the B u rea u o f L a b or S ta tistics o f the U. S. D ep a rtm en t o f L a b or, en title d “ C auses o f D eath by O ccu p a tio n ,” O ccu p a tion a l M o r ta lity E xp erien ce o f the M e tro p o lita n L ife In su ra n ce C om p a n y , In d u s tria l D ep a rtm en t, 1 9 1 1 -1 9 1 3 , by L ou is I. D u blin, Ph. D., W a sh in g to n , 1917. T h is exp erien ce, h ow ever, w ith referen ce to d u sty tra d es w ith e x p o su re to in o rg a n ic d u st is p ra ctica lly lim ited to b lack sm ith s, coa l m iners, com p o sito rs and p rin ters, iro n m old ers, m a ch in ists, m ason s and b rick la y ers, p a in ters, p a p er ha n gers, an d v a rn ish e rs, an d p lum bers, gas fitters, a n d steam fitters. The m ost recen t d a ta are f o r the ye a r 1914, f o r the c it y o f N ew York* (R e p r in t N o. 400, U. S. P u b lic H e a lth S e rvice , W a sh in g to n , 1 9 1 7 ), fo r selected occ u p a tio n s . T h e p ro p o rtio n a te m o r ta lity fro m p u lm o n a ry tu b e rcu lo s is w a s as f o l l o w s : Proportionate mortality (per cent of all'causes) from pulmonary tuberculosis, New York City, 191$. Years of age. Occupation. 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 and over. Blacksmiths........................................................................... Cigar makers and tobaceo workers.................................... Compositors, printers, e t c ................................................... Machinists.............................................................................. Painters, paperhangers, and varnishers........................... Teamsters and drivers....................................................... 40.0 53.0 40.5 18.2 35.0 23.5 21.0 66. 6 30. 6 45.1 45.2 33.3 31.4 35. 7 34.4 32.2 44.0 15.1 31.1 27. 6 24. 6 23. 7 28.7 3.4 17.6 19.2 16.3 21. 5 12.1 3.5 6.2 10.3 1.8 6.1 5.9 All occupations........................................................... 33.6 33.5 24.8 15.9 7.8 1.9 56 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 1 1.— P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS AM O N G W O R K E R S E X P O S E D TO M E T A L L IC D U S T , IN D U S T R IA L D E N T IA L CO.. 1897 TO 1914, B Y A G E G R O U PS. E X P E R IE N C E OF PRU Workers exposed to metallic dust. Age at death. Per cent of deaths due to pulmo nary tu berculosis among all Per cent of occupied males. deaths from all causes. Deaths from pulmonary tuberculosis. Deaths from all causes. Number. 15 to 24 years......... ......................................................................... 25 to 34 years................................................................................... 35 to 44 years................................................................................... 45 to 54 years................................................................................... 55 to 64 years................................................................................... 65 years and over........................................................................... Age unknown................................................................................. 1,912 2,504 2,449 1,889 1,541 1,267 1 812 1,243 966 420 170 49 42.5 49.6 39.4 22.2 11.0 3.9 33.2 40.9 32.9 19.0 8.8 2.9 Total, 15 years and over.................................................. 11,563 3,660 31.7 20.5 T able 12 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M N O N T U B E R C U L O U S R E S P IR A T O R Y D ISE A SE S AM O N G W O R K E R S E X P O S E D TO M E T A L L IC D U S T, IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914. Deaths of workers ex posed to metallic dust. Cause of death. Number. Per cent of deaths from all causes Per cent of among all deaths from occupied males. all causes. A sthm a...................................................................................................................... Bronchitis................................................................................................................. Pneumonia............................................................................................................... Other nontuberculous respiratory diseases.................................................. 74 116 1,003 182 0.6 1.0 8.7 1.6 0.6 1.1 8.8 1.4 Total................................................................................................................ 1,375 11.9 11.9 The insurance experience is not strictly comparable with the gen eral mortality for the country at large in that the principle of adverse selection should be considered in view of the fact that only a consid erable proportion of the adult risks accepted for industrial insurance are at entry required to submit to a thorough medical examination. A much more important factor, however, is that the occupational analysis in the Prudential experience is more strictly limited to specific occupations with metallic dust exposure, as separate and distinct from industries or groups of closely allied employments which, it is safe to assume, are more representative of the census mortality returns. According to Table 11, the proportionate mor tality from pulmonary tuberculosis in occupations with exposure to metallic dust is 31.7 per cent for all ages, which compares with 21 per cent as shown by the census occupation mortality returns. The differences are quite marked and a maximum proportion is reached at ages 25 to 34 when out of 2,504 deaths from all causes among men with exposure to metallic dust, 1,243, or 49.6 per cent, were deaths OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 57 from pulmonary tuberculosis. The two groups of occupations are not identical and erroneous inferences must be guarded against which might seem justified in view of the apparent discrepancies in the re sults. Each class of data requires to be considered by itself, for under existing conditions no identical groupings can be made for the occupation mortality of the registration area and the more se lected occupation mortality of the industrial insurance company previously referred to. The extremely high proportionate mortality from pulmonary tuberculosis, particularly at the younger ages, among occupations with exposure to metallic dust confirms the earlier conclusion that this form of dust exposure must be considered as the contributory cause of the most serious form of pneumoconiosis, or dust phthisis, as the disease has been called in a strictly scientific discussion of the subject by Collis in the Milroy Lectures, 1915. The proportionate mortality by specific industries or occupa tions and by divisional periods of life is shown in Table 13, which will facilitate comparison with the corresponding table for the registration area, but which is subject to the same suggestion of ex treme caution as regards the scientific interpretation of the data de rived, as explained, from quite different sources. 13.—PROPORTIONATE MORTALITY FROM PULMONARY TUBERCULOSIS IN SPECIFIED INDUSTRIES OR OCCUPATIONS WITH EXPOSURE TO METALLIC DUST, INDUSTRIAL EXPERIENCE OF PRUDENTIAL CO., 1897 TO 1914, BY AGE GROUPS. T able 15to 24 years. Occupation group. Artificial-flowermakers Brass workers........... Compositors and type setters................. Cutlery makers......... Die setters and sinkers. Electrotypers and stereotypers........... Engravers............... Gold beaters............ Grinders................. Ironandsteel workers.. Jewelers.................. Polishers................. Pressmen................ Tool and instrument makers................. Total.............. 25to 34years. 35to 44 years. 45to 543«ars. Deaths Deaths Deaths Deaths frompul frompul frompul frompul monary monary monary m onary Deaths tubercu Deaths tubercu Deaths tubercu Deaths tubercu fromall losis. fromall losis. fromall losis. fromall losis. causes. causcs. causes. causes. Num Per Num Per Num Per Num Per ber. cent. ber. cent. ber. cent. ber. cent. 2 1 50.0 1100.0 1 91 53 58.2 149 76 51.0 146 904 505 55.9 851 795 368 46.3 11 5 45. 5 11 11 3 27.3 5 5 3 60.0 10 2 20.0 20 9 45.0 19 9 5 55.6 71 28 39.4 92 50 54.3 74 7 3 42.9 12 8 66.7 11 17 7 41.2 74 56 38 67.9 403 121 30.0 630 215 34.1 648 144 84 58.3 110 56 50.9 106 241 136 59 43.4 230 129 56.1 151 72 47.7 116 168 72 42.9 93 49 52.7 111 88 33 37.5 1,912 812 42.5 2,504 1,243 49.6 2,449 4 1 25.0 64 43.8 99 24 24.2 350 41.1 567 141 24.9 4 36.4 8 1 12.5 4 1 25.0 1 20.0 4 21.1 9 3 33.3 35 47.3 63 10 15. 9 4 36.4 8 2! 25.0 44 59.5 73 35 47. 214 31.3 606 89 It. 7 48 45.3 132 28 21.2 106 44.0 173 43 24. ■> 51 44.0 45 9 20. 41 36.9 98 33 33. 7 966 39.4 1,889 420 58 MORTALITY PROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 1 3 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U LO SIS IN S PE C IFIE D IN D U S T R IE S OR OCCUPATION S, ETC.—Concluded. 55 to 64 years. Occupational group. 65 years and over. Deaths Deaths Deaths Deaths from pul from pul from pul from pul monary monary monary monary Deaths tubercu Deaths tubercu Deaths tubercu Deaths tubercu losis. losis. losis. losis* from all from all from all from all causes. causes. causes. causes. Num Per ber. cent. Artiflcial-flower makers. Brass workers................ Compositors and type setters .......................... Cutlery makers.............. Die setters and sinkers.. E l e c t r o t y p e r s and stereotypers................. Engravers....................... Gold beaters................... Grinders.......................... Iron and steel workers.. Jewelers___\ .................. Polishers......................... Pressmen........................ T ool and instrument makers......................... T otal..................... Total. 15 years and over. Age unknown. 4 93 1 25.0 15 16.1 2 55 427 8 3 42 9.8 3 37.5 1 33.3 318 6 1 6 ' 41 4 55 550 144 112 27 1 16.7 3 7.3 2 43 U 30 459 176 72 16 14 48 16 16 3 Num Per ber. cent. Num Per ber. cent. 25.5 8.7 11.1 14.3 11.1 Num Per ber. cent. 4 30.8 232 36.7 13 633 1 14 4.4 1 16.7 1 3,863 1,420 36.8 17 3a 9 55 28 8 28.6 65 384 53 305 3,332 812 964 523 2.3 5 16.7 13 2.8 6 3.4 2 2.8 67 7 10.4 76 7 9.2 1,541 170 11.0 1,267 49 3. 9 22 127 17 143 700 238 355 207 533 33.8 33.1 32.1 46.9 21.0 29.3 36.8 39.6 170 31.9 11,563 3,360 31.7 1 On account of the importance of nontuberculous respiratory dis eases Table 14. is also included, showing the proportionate mortality from asthma, bronchitis, pneumonia, and other respiratory diseases among workers in occupations with exposure to metallic dusf, but without reference to divisional periods of life. T able 1 4 .—P R O P O R T IO N A T E M O R T A L IT Y FR OM N O N T U B E R C U L O U S R E S P IR A T O R Y D IS E A S E S IN S P E C IF IE D IN D U S T R IE S OR O CCU PATION S W IT H E X P O S U R E TO M E TA LLIC D U S T , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914. Deaths caused b y nontuberculous respiratory diseases. Occupation group. Asthma. N um ber. Artiflcial-flower makers. Brass workers................ Compositors and type setters........................... Cutlery makers.............. Die setters and sinkers E le c t r o t y p e s and stereotypers................ j ^ Engravers........................ G old beaters................... Grinders.......................... Iron and steel workers.. Jewelers........................... Polishers......................... Pressm en........................ Tool and instrument makers.......................... T o t a l................... Bronchitis. Per cent. Num ber. Pneumonia. Other. Total. Num ber. Per cent. Num ber. Per cent. N um ber. 7.7 .2 1 51 7.7 8.1 19 3.0 2 75 15.4 11.8 343 4 4 8.9 7.3 14.3 55 1 1.4 1.8 452 5 5 11.7 9.1 17.9 4 34 5 28 307 61 77 45 6.2 8.9 9.4 9.2 9.2 7.5 8.0 8.6 5 2 9 50 7 17 9 1.3 3.8 3.0 1.5 .9 1.8 1.7 5 43 7 46 430 83 104 59 7.7 11.2 13.2 15.1 12.9 10.2 10.8 11.3 Per cent. 4 0.6 1 1 19 .5 35 .9 1 3.6 1 2 1.5 .5 6 46 10 5 3 2.0 1.4 1.2 .5 .6 Per cent. 2 .5 3 27 5 5 2 1.0 .8 .6 .5 7 1.3 5 .9 39 7.3 8 1.5 59 11.1 74 .6 116 1.0 1,003 8.7 182 1.6 *1 375 11.9 .4 OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 59 Tt does not seem necessary to enlarge further upon the facts dis closed by the preceding comparative statistics which emphasize with a sufficient degree of scientific conclusiveness the obvious health* injurious consequences of considerable and continuous exposure to the inhalation of metallic dust. It is clearly recognized that the sta tistical data utilized for the present purpose are of limited intrinsic value, but they are in the main quite fully confirmed by the mora extended special consideration of occupations or industries, where the exposure to metallic dust is sufficient to warrant inclusion within the plan and scope of the present discussion. ENGLISH MORTALITY STATISTICS, In conclusion, however, it has seemed advisable to add to the pre ceding observations Table 15, obtained from English official sources and showing the combined mortality of tool and instrument makers, brass workers, and printers and compositors. This table may safely be considered sufficiently representative of the entire group of occu pations with exposure to metallic dust in the absence of more ex~ tensive information, which, unfortunately, is not available. T able 1 5 .— M O R T A L IT Y FR O M A L L CAUSES, FR O M P U L M O N A R Y T U B E R C U L O SIS , A N D F R O M O T H E R D ISEA SES OF TH E R E S P IR A T O R Y SYSTEM , IN OCCUPATIONS E X P O S E D T O M E T A L L IC D U ST, C O M P A R E D W IT H T H A T OF A L L OCCUPIED M A LE S, IN ENG L A N D A N D W A L E S , 1900 TO 1902, B Y A G E GROU PS. C’Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths* and Marriages in England and Wales.] Death rate per 1,000 due to all causes among— * Death rate per 1,000 -due to pulmonary tuberculosis among— Death rate per 1,000 due tu other diseases of the re spiratory system. Age at death. A ll occupied Occupations All occupied Occupations All occupied Occupations exposed to exposed to exposed to males. * males. males. metallic dust. metallic dust. metallic dust. 15 to 19 years......... 20 to 24 years......... 25 to 34 years......... 35 to 44 years......... 45 to 54 years......... 55 to 64 years......... 65 years and over.. 2. 44 4. 41 6.01 10. 22 17.73 31.01 88.39 2.73 5.28 6.29 11.68 20.97 36.03 92.52 0.54 1.55 2.03 2.74 3.04 2.16 1.11 0.73 2.73 3. 33 5.05 5.22 3.91 L 54 0.24 .48 .77 1.66 3.32 6. 54 17. 77 0. 30 .45 .69 1.62 3. 55 7. 94 22. 46 GENERAL CONCLUSIONS. According to this table the general death rate from all causes and the specific death rate from pulmonary tuberculosis among, men in occupations with exposure to metallic dust is decidedly excessive at all ages, and extremely high during the age period 25 to 54, which, for economic reasons, is obviously of special social and medical im portance. The mortality from nontuberculous respiratory diseases in the English experience was slightly below the average for occupa tions with exposure to metallic dust, a condition which is not con 60 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. firmed by the data derived from American sources. It should be considered in this connection that many important specific employ ments with exposure to metallic dust show a mortality from pneu monia, asthma, and bronchitis distinctly above the average. The relative frequency of these two groups of diseases among persons em ployed in occupations wTith exposure^to metallic dust occasionally involves serious difficulties in medical diagnosis and death cer tification, and the conclusion of Sir Thomas Oliver, with reference to miners applies to metal workers, though possibly to a lesser degree, that “ it is difficult to say where and how miners with pneumo coniosis become tuberculous, but there is nothing to suggest that they become infected differently to other people.” This, of course, applies to the precise process of infection rather than to the increased lia bility resulting from a preexisting mechanical injury to the lungs in consequence of considerable and continuous inhalation of metallic and mineral dust. As further said by Sir Thomas Oliver in this connection, u The infection must take place either in the mine, in the home, in the public house, or in some place of amusement.” It may safely be asserted, however, that “ in the absence of sanitary control of work places and a general conformity to sanitary rules, especially with reference to indiscriminate expectoration, the liability to tuberculous infection must be increased on account of the occupa tion in the case of persons employed in occupations with more than normal exposure to irritating dusts, whether of organic or inorganic origin, or both.” This conclusion applies as much to occupations w7ith exposure to metallic dust as to those with exposure to mineral dust, but of the two, under given conditions, persons engaged in the former are in all probability more liable to pulmonary tuberculosis than those engaged in the latter and less liable to nontuberculous respiratory diseases, particularly asthma and bronchitis. THE IRON AND STEEL INDUSTRY. VARIATIONS IN OCCUPATIONAL DUST EXPOSURE. The iron and steel industry is inclusive of such a large number of more or less specialized and widely varying employments that any and all general mortality data relating thereto can not be considered conclusive concerning any one particular group of occupations. The conditions of employment in the iron and steel industry in the United States, with detailed descriptive accounts of particular occupations, were reported upon by the United States Bureau of Labor Statistics in response to a Senate resolution, in 1911. The large number of individual employments therein described proves conclusively the practical limitations of general data concerning the mortality and morbidity of iron and steel workers considered as a group. Most of OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 61 these have, therefore, for the present purpose, been discussed sepa rately in the 14 groups of occupations with exposure to metallic and mineral dusts. Out of 172,706 enumerated employees in. the iron and steel industry, according to the report of the United States Bureau of Labor Statistics on Conditions of Employment in the Iron and Steel Industry, 61.9 per cent were employed in producing depart ments and 38.1 per cent in connection with power, mechanical opera tions, or the yard force. As to the branches of the industry in the producing departments, 18.2 per cent of the employees were at work on blast furnaces; 3.3 per cent at Bessemer converters; 8.5 per cent at open-hearth furnaces; 3.9 per cent at puddling mills; 0.4 per cent at crucible furnaces; 3.3 per cent at blooming mills; 3.4 per cent at plate mills; 2.6 per cent at standard rail mills; 2 per cent at struc tural, light rail, and other shapes mills; 1.9 per cent at miscellaneous mechanical mills; 10 per cent at bar mills; 1.4 per cent at garrett rod mills; 0.5 per cent at miscellaneous rod mills; and 2.5 per cent at tube mills. It is, therefore, shown that numerically the men employed in direct connection with producing operations at blast furnaces, Besse mer converters, open-hearth furnaces, puddling mills, and crucible furnaces constitute 34.3 per cent of the total labor force. The dust exposure in even these closely related employments varies quite con siderably, aside from important variations in exposure to heat, tem perature changes, etc. The remainder of the group of iron and steel workers, 27.6 per cent, were employed in iron and steel mills, including a large number of highly specialized occupations, with possibly even greater variations in exposure to dust, heat, tempera ture changes, etc. Conclusions applicable to the health or mortality of one group of employees, for illustration, connected with work at blast furnaces, would probably not apply to another group of employees at work in the plate mills. It is, however, quite im practicable to give individual consideration to the hygiene of all the numerous employments in the iron and steel industry, since most of the available mortality and morbidity data have reference only to the industry as a wThole. The experience of several important and longestablished benefit funds, if subjected to critical analysis, would un doubtedly throw much light upon important sanitary and medical conclusions concerning the health conditions in the steel industry; but thus far only a general analysis of the experience has been at tempted. OCCURRENCE OF INJURIOUS DUST AMONG STEEL WORKERS. The most qualified scientific investigation of the occurrence and mitigation of injurious dust among steel workers is by Dr. J. A. Watkins j of the United States Public Health Service in cooperation 62 MORTALITY FROM RESPIRATORY DISEASES IK DUSTY TRADES. with the Bureau of Mines (Technical Paper 153, Washington, 1917). The report includes a brief discussion of the pathogenicity of indus trial dusts, differentiating the three chief ways in which dust may act injuriously according to the character of the dust particles, (1) by irritant action, (2) by toxic action, and (3) by mechanical action. The conclusion is advanced that much of the dust inhaled never reaches the lungs because of its being retained in the nose, throat and mouth. Some of these dusts, it is pointed out, interfere with the proper physiological action of the stomach and intestines, while others have serious effects on the skin, acting as local irritants. The principal places where dust is found in steel works are storage bins, blast furnaces, gas stoves, gas washers and blowers, dolomite sheds, open-hearth furnaces, rolling mills, soaking pits, gas producers, Bessemer converters, foundries, and in connection with the grinding equipment. The observations in detail are entirely too brief for practically useful conclusions. In order to determine the extent to which the various dusts are found to be suspended in the atmosphere of the work places examined, an apparatus was used devised by Lanza and Higgins and described in Technical Paper 105, Bureau of Mines, Washington, 1915. The descriptive accounts of the dusts collected are exceptionally valuable. The description of iron ore dust is given in full as follows: The table shows that at times iron-ore dust is suspended in the atmosphere around the ore bins in exceptionally large quantities—as much as 23.5 mmg. per 100 liters. While this dust contains many particles varying from 4 to 10 microns in size, a characteristic feature noted in the study of this dust was the enormous number of ultramicroscopic particles. The larger particles readily break up into these ultramicroscopic particles in a fluid medium. A somewhat similar occurrence probably takes place in the respiratory tract; and if so would make the removal of these particles by coughing or ex pectorating very difficult, if not impossible. The larger particles are irregular, roughly spherical, and have few sharp edges but some points. Iron-ore dust has no toxic action and the particles examined were not very hard. Its physiological effect on man can be surmised only, but is probably limited to that caused by the mechanical action of the particles, which act as irritating bodies where they lodge in the respiratory tract. Additional descriptions are of coke dust, limestone dust, flue dust, graphite dust, dolomite dust, and other refractory material and roll scale. With reference to dolomite dust, it is said that— As regards industrial hygiene, dolomite, CaMgC03, is the most important dust in a steel plant, not only because of its character and action but also because of the enormous quantities of it suspended in the atmosphere of certain working locations. The dolomite par ticles examined are very irregular, with few sharp points, but gener ally with some sharp edges, and are hard. The particles examined OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 63 were 5 to 15 microns in size. Calcined dolomite contains a large per centage of free lime which on becoming moist slakes and is then very irritating to the tissues of the body, particularly those of the nose, throat, and eyes. Its effect on the delicate membranous lining of the respiratory tract can be readily surmised. Of special interest is the descriptive statement of ganister dust, in which it is referred to as a highly siliceous sandstone, used to some extent in patching and repairing the interior of an open-hearth furnace. The silica particles examined were 5 to 20 microns in size, irregular, angular, sharp, and exceedingly hard. The general methods of mitigating the dust menace in steel works are (1) preventing dust suspension, (2) removing suspended dust from air, and (3) providing against the inhalation of dust. A fourth method is “ to house in completely the department in which there is much suspended matter and prohibit employees from working or remaining therein.” The suggestions, to be entirely conclusive and practically useful, require to be further amplified by illustrations of existing methods which are known not to have been a matter of material interference with at least a moderate degree of working efficiency. It is, of course, a mere commonplace that a foremost among the methods employed for dust removal is that of an efficient system of exhausting and supplying air. A system of electric pre cipitation can be used, but its usefulness is limited largely to dust in flues.” Both of these are extremely difficult of installation in many plants constructed in conformity with the factory methods of the past. The observations in the report on the abatement of dust at the ore bins, the blast furnaces, and the dolomite shed are of considerable value. With reference to the dust problem in foundries it is said, in conclusion, that— Many and diverse conditions give rise to dust in the foundry. To abate the dust a great deal of effort and every means of prevention and mitigation must be employed. Castings should be cleaned and “ blasted ” in a separate room where only those men needed for the work are allowed to remain. These employees should be required to wear respirators. Casting, especially the casting of brass and similar alloys, should be done in a separate building where precau tions are taken to insure ample ventilation by natural and artificial means. The main foundry room should be given more floor space pjid, except where molds are made, should have suitable flooring of steel plate or brick. This flooring should be sprinkled with water frequently. In addition provision should be made for an abundant supply of fresh air. Grinding wheels should be supplied with an effective exhaust system, and as an additional safeguard the men en gaged. should be required to wear respirators. The report is a promising indication of more qualified scientific in quiries into a field of industrial hygiene which has heretofore been practically neglected almost in its entirety. 64 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. DUST EXPOSURE AT BLAST FURNACES. In the report of the Bureau of Labor Statistics each important branch of the industry is separately described and much useful information is contained therein regarding occupational exposure in at least the more important employments. At the blast furnaces, for illustration, the so-called larry men are exposed to the dust of limestone, coke, and other materials, including, of course, a more or less important proportion of metallic dust. So-called bottom fillers are considerably exposed to dust in connection with the shovel ing of materials into barrows, while top fillers and stove cleaners are still more exposed to dust and heat, in addition to the serious risk of overexertion, on account of the heavy physical labor required, and frequently, also, to trying weather conditions. The stove cleaners* it is explained in the report referred to, “ remove the cinder, dust, and various debris that accumulate in the stoves,” wThich obviously must involve an exceptional amount of metallic and mineral dust exposure. The so-called “ dustmen,” which term includes slag-dust laborers, dust wheelers, and dust-catcher men, “ remove the dust which accumulates in the gas flues and in the dust catcher,” and the work is particularly referred to as being “ disagreeable on account of the hot dust, and likely to be dangerous if the dust is not thor oughly wetted down while being removed,” which, it may be said, is not often the case. At the blast furnaces the so-called clay men “ prepare and deliver the clay for the stopping of the tap hole,” but the exposure here is to mineral rather than to metallic dust. Iron breakers, however, who break up the iron molds or “ pigs,” are in all probability subject to considerable inhalation of mineral dust mixed with minute iron particles, but in modern plants where pigcasting machines are used this risk is eliminated. These brief ref erences to a single important branch of the steel industry illustrate the widely varying conditions of dust exposure and suggest the prac tical importance of much more specialized investigations than have heretofore been made into the health-injurious effects of particular occupations or groups of employment. At the blast furnaces alone 35 particular occupations are differentiated or briefly described in the report of the Bureau of Labor Statistics previously referred to. DUST EXPOSURE AT BESSEMER CONVERTERS. At the Bessemer converters there are at least 29 specialized occu pations, of which apparently those with most serious dust exposure are the cupola hoist men, the cupola chargers, the cupola liners, the vessel scrapers, the vessel men and vessel men’s helpers, and, most of all, the bottom makers and helpers, who repair and rebuild con verter bottoms. The last-named operation is of special interest and OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 65 hygienic importance and is briefly described in the report of the Bureau of Labor Statistics, as follows: The bottom consists essentially of (1) a cylindrical steel casing sloping out at the top to the diameter of the vessel, the lower part of which forms the “ blast box ” into which the blast is admitted by a large pipe. This casing is provided with keys or with other appli ances by which it can be quickly and securely fastened to the body of the converter. (2) Above the “ blast box” is the refractory bottom, which is pierced by a large number of small holes for admitting and distributing the blast in the vessel. In acid vessels these “ti^eres” or holes are formed in fire-clay bricks of special design (in practice the entire brick is known as a “ tuyere” ) around which ganister is rammed. When the bottom is removed by the vessel men, the bottom makers and helpers cool it with water and then chip out all the ganister and knock out the “ tuyere bricks.” New tuyere bricks are then placed in position, and crushed moist ganister is tightly rammed around them until it ‘is level with their top. The entire bottom is then placed in an oven where it is kept at a steady heat until thoroughly dried. In addition to this work the bottom makers’ helpers in many plants also grind the refractory materials used for this purpose and also for repairing vessels and ladles. The ganister which is used in connection with this operation gives rise to a dust of a very high degree of injuriousness, but the degree of such exposure is much less in bottom making than in the manu facture of the dust itself. Ganister mining and crushing has been described in Oliver’s Dangerous Trades, in part, as follows: Workers engaged in crushing basic slag, in the breaking of cer tain rocks, in the manufacture of millstones, in stonemason's work, and kindred occupations, are peculiarly liable to chronic inflam mation of the air tubes, caused by the inhalation of dust of an irritant kind. This, it is believed, leads to lung fibrosis. Where the operatives form part of a large community in which individuals are employed in many and varied trades, it is conceivable that fibrosis of the lungs may be mistaken for tubercular pulmonary consumption, and it may not be realized that the cause is due to the occupation of the sufferer. Ganister is a hard, close-grained, silicious stone which often forms the stratum that underlies the coal seam. A footnote in Dr. Percy’s Fuel says: “ Dinas rock is believed to be a millstone grit of the car boniferous system, and the geological equivalent of the bed termed ‘ ganister’ at Sheffield.” It is found in Yorkshire, Durham, North and South Wales, and elsewhere. When crushed and ground into dust it is used as a fire-resistant, chiefly for lining Bessemer and other steel converters, for the manufacture of bricks likely to be subjected to great and continuous heat, and it is sometimes mixed with, or sub stituted for, Stannington or other clays, which, together with ground cinders and old ground pot, are used for the manufacture of crucibles in which certain kinds of steel are made. The exposure here, of course, is to mineral rather than metallic dust, but in the United States, at least, employments in connection 106811°—18—Bull. 231-----5 66 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. with ganister are chiefly in the iron and steel industry, and especially in the repairing and rebuilding of converter bottoms. For a thoroughly well considered discussion of the subject the extended account in Oliver’s Dangerous Trades, by Hamilton P. Smith, should be consulted.1 Other important occupations in connection with Bessemer con verters where the dust exposure appears to be exceptional are ladle liners, ingot strippers, and cinder men, the latter cleaning up and removing the cinder and metal from the pit or floor of the^Bessemer building, and taking care of the slag on the cinder dump. As ex plained in the report of the Bureau of Labor Statistics, this work, for the most part, “ is done under conditions of great heat, and, when working around and under the vessels and ladles, of great danger of being severely burned or of receiving minor injuries.” DUST EXPOSURE AT OPEN-HEARTH FURNACES. ‘ Twenty occupations of the open-hearth furnaces are described in detail in the report of the Bureau of Labor Statistics, and of these occupations the following involve the most serious risk of dust ex posure : Stokers, who unload the materials and sort and assemble the different grades of scrap iron in piles, etc.; charging-machine oper ators, who generally work on more or less dust-covered floors and in front of furnaces while discharging materials under, frequently, rather trying conditions; pitmen, who prepare the pit for casting, set the molds, build the runners, etc.; and general laborers, including ash men, ash wheelers, cinder dump men, clean-ups, grinding labor ers, mixing laborers, mixing-house laborers, etc. In most of these occupations the dust exposure is quite considerable, but naturally the major portion of the dust is of a mineral nature. The highest degree of health-injurious exposure is probably in connection with the relin ing of the furnaces where frequently all reasonable and necessary safeguards, such as the previous spraying of the materials, etc., are neglected. Most of the work, however, is done by casual labor, so that only in rare cases are occupations of this character followed for a long period of years. DUST EXPOSURE AT PUDDLING MILLS. In puddling mills the number of special occupations is not fewer than 23 and most of these involve more or less dust and heat ex posure, frequently, however, quite difficult of precise ascertainment. 1 See also S ir T h om a s O liv e r’ s o b serv a tion s on sla g cru sh in g, in A llb u tt and R o lle s to n ’ g A System o f M ed icin e, v ol. 5, p. 457 ; and his rem arks on g a n iste r cr u sh in g and m in in g, in the sam e volu m e, p. 456 ; and a d d ition a l ob serv a tion s in his D iseases o f O ccu p a tio n , p. 298 et seq. S ir T h om a s O liv er's m ost recen t co n clu sio n s a re set fo r t h briefly in K ob er and H a n s o n ’ s O ccu p a tion a l D iseases and V o ca tio n a l H yg ien e, N ew Y o rk , 191 6 , p. 222. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 67 Puddling is a highly skilled occupation and, according to the report of the Bureau of Labor Statistics, “ requires considerable experience, and the puddler’s work is perhaps the hardest physical labor in the industry, and, moreover, the largest part of it is done under con ditions of extreme heat.” Wherever work is done under conditions of extreme heat the dust exposure is increased on account of the ex treme dryness of practically all the materials used, directly or in directly, in productive operations. Puddlers’ helpers assist in the lining of the furnaces and in the charging and drawing of the metal, which naturally involves exposure to mixed mineral and metallic dust. Cinder men tap the slag from the furnace, quite frequently under rather primitive conditions, involving considerable dust ex posure. Many of the other occupations resemble those previously referred to. The crucible process in steel manufacture is now of relatively small importance, but of exceptional interest from sanitary and medical points of view. Conditions vary widely in different plants, according to whether the furnaces are heated by gas, coal, or coke, and whether modern processes or the antiquated methods of an earlier period are employed. The principal occupations are melters, pullers out, and molders. The latter prepare and set the small ingot molds into which the steel is cast, and they strip the same when the cast is completed. All this involves considerable dust exposure and the liability to sudden temperature changes. Frequently these men while at work near the furnaces are not properly protected against cold drafts and other trying weather conditions. Among the unclassified employments chiefly carried on by unskilled labor are mixers, pot shakers, pot boj^s, pipe makers, compounders, and ladle men, all more or less exposed to considerable mixed metallic and mineral dust. OBSERVATIONS ON THE PHYSIQUE OF IRON AND STEEL WORKERS. The foregoing are the principal converting branches of the modern iron and steel industry,' preliminary to manufacturing processes proper. The special occupations in these are also extremely varied but in most respects they resemble, as regards at least the most dan gerous employments, those previously referred to. Working gen erally in rolling, rod, and tube mills involves, naturally, a continuous and probably considerable exposure to the inhalation of metallic dust, aside from other more or less health-injurious conditions, such as sudden temperature changes, extreme heat^ etc. As a natural proc ess of occupational selection, most of the men employed in the iron and steel industry are physically of a superior class, and, therefore, more resistant to disease than ordinary laborers or men employed chiefly in indoor occupations. There is the additional advantage 68 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. that in most of these employments the wages are above the general average, while, except in the continuous processes, the hours of labor are rarely excessive. Regarding any and all of these employments, there is at present only fragmentary information as to the healthinjurious effects of the different employments, but considered in the aggregate the available data are fairly conclusive that the mortality and morbidity are not above the average. This conclusion, however, must not be carried too far, for it can not be made to apply to the numerous and thoroughly specialized occupations which are carried on under frequently very trying conditions of extreme heat* sudden temperature changes, and exposure to metallic and mineral dust. HEALTH-INJURIOUS CONDITIONS AT IRON AND STEEL WORKS. W. Gilman Thompson, in his treatise on “ The Occupational Dis eases” (pp. 191-196), refers at some length to the iron and steel in dustry, chiefly to foundry men and rolling-mill men, and he includes among the health-injurious circumstances exposure to toxic gases, glare of excessive light, and irritation of the lungs from steel dust, causing pneumoconiosis. He also suggests an exceptional liability to chronic nephritis and arteriosclerosis. He quotes Ropke to the effect that in German steel mills 20 to 22 per cent of the illnesses among the workmen concern the respiratory organs. He observes that— Iron is in no sense a chemical irritant to the body, being a natural ingredient of the hemoglobin. Iron and steel dust, however, by virtue of the hardness and sharpness of the particles, are irritant to the bronchial mucosa when inhaled, and foster the development of fibroid phthisis and subsequent acquisition of pulmonary tubercu losis. The smelting of iron and steel and various hardening processes are capable of being injurious in several ways. Thus the workmen are exposed to great heat and perspiration which is often suddenly checked, especially in winter. The excessive heat and light to which puddlers and founders are exposed when the glare from furnace doors reaches them may injure the eyes permanently, and they may acquire superficial or more serious burns. Particles of iron or steel may be driven into the skin of the face and exposed upper half of the body, marking it like tattoo. The workmen, as a result of frequent extreme changes in temperature, are prone to lumbago or myalgia and chronic rheumatism, and, from heavy lifting, frequently have sprains and muscle strain. In galvanizing sheet iron hydrochloric acid is used, the fumes of which are injurious. Various processes of steel hardening are liable to prove harmful through the action of other substances, such as the cyanides, ferrosilicon, etc. Cutlery and other articles of steel manufacture are dipped into baths of molten lead or boiling oil, the fumes from which may prove highly injurious. In the hot rooms in which smelting and hardening processes are con ducted the workmen are subject to acute and chronic nasal catarrh, and Sager and Weickert have found otitis media as a further not OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 69 uncommon result. Ropke (Berufskrankheiten des Ohres) has de scribed perichondritis of the external ear caused by the packing of hard metallic dust in the auditory meatus. He also found laby rinthine inflammation in some cases. The metallurgy of iron is of course quite closely related tojnetallurgical processes generally as carried on in continuation of mining industries. Smelting processes are elsewhere considered, though briefly, since thus far no extensive and conclusive investigations have been made concerning the differential occupational health hazards in the several important branches of the smelting industry with a due regard to the nature of the metallic substances produced. Conclu sions applicable to copper smelters are, for illustration, quite inappli cable to quicksilver reduction works, and the same observation applies to gold and lead smelting, separately considered. As ob served by Thompson— In smelting works the laborers are much exposed to the inhalation of toxic gases from the ovens, especially carbon monoxide derived from coke or otherwise. In such cases headache, vertigo, and tinnitus are complained of, and anemia and nervousness ensue. Kayser (Wiener med. Woch. 1893, No. 41) reported a case of such poisoning in which the victim remained 36 hours in coma, and on recovery pre sented symptoms of labyrinthine disease. Such extreme cases are very rare. Rohrer (Haugs klin. Yortr., Bd. 1, Heft 3) reported 5 cases among furnace stokers who were subjected to the inhalation of water gas, with the result of chronic carbon monoxide poisoning. They suffered from headache, nausea, and disturbances of hearing which were both nervous and due to otitis. Erosions of the nasal septum and atrophic rhinitis were also observed occasionally. THE HYGIENIC MENACE OF STEEL DUSTS. To a limited extent this observation applies also to the iron and steel industry, chiefly, of course, to work in connection with initial conversion processes. In the continuation of these processes and toward the final finishing of the product, it is quite apparent, as pointed out by Thompson, that the danger to the lungs in the clean ing of iron and steel castings is most serious, and that in open-hearth processes and in the breaking up of iron molds and castings particles of coal or charcoal and iron rust are inhaled and the workmen sweat heavily. They are, therefore, peculiarly exposed to nasal, bronchial, and middle-ear catarrh, and he remarks, in this connec tion, that— The sharp particles of dust accumulate in crusts with the nasal mucus and cause ulceration and epistaxis. There may be atrophic rhinitis with loss of sense of smell and uncomfortable dryness of the nose. The atrophy may involve the mucosa of the nasopharynx, which becomes reduced in sensibility so that mucus accumulates with 70 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. out exciting expulsive effort. This lack of sensation may favor the further entrance into the bronchi and lungs of irritant material. Graphite and coal dust were found by Merkel embedded in the lungs in four autopsies upon men who had been employed as iron molders. Particles of steel and iron dust which reach the pulmonary alveoli choke them up and become embedded in their walls, where they excite perialveolar irritation with inflammatory products, chiefly fibrous. MORTALITY OF GRINDERS AND POLISHERS. These observations bear directly upon the extremely important practical question of differentiating fibroid phthisis from ordinary pulmonary tuberculosis as modified by conditions of employment in the metal trades. The more delicate methods of manufacture with exposure to iron,and steel dust have been briefly described under grinders, polishers, and tool and instrument makers, as well as less important allied occupations. A statement, however, by W. Gilman Thompson, based on experience had at Sheffield, England, during the eight years ending with 1909, among steel grinders and polishers in the hardware industries may be here referred to, it being stated that the death rate was 30.4 per 1,000, of which, however, onehalf was attributable to tuberculosis and more than one-sixth to other pulmonary diseases. Thompson properly emphasizes the fact that this class of workmen is representative of a selected group as to age and original physical strength, so that the excessive mortality is on that account decidedly more significant. Thompson also refers to the mortality of Solingen, which is the center of the German cutlery industry, where during 1910 the general mortality from tuberculosis was 1.8 per 1,000, while in the cutlery and tool industry it was 9.3, and he quotes in this connection from a report of the State Board of Health of Massachusetts for the year 1907, with special reference to the tool industry at Northampton, Mass., that the grinders and polishers employed in these industries showed a mortality from pulmonary diseases, including tuberculosis, of nearly 73 per cent of the mortality from all causes. He also makes mention of a rather rare case of pulmonary emphysema reported to the New York State Bureau of Labor which resulted from manufacturing steel wool. He remarks in conclusion that—• In foundries, rolling mills, steel-plate works, and the like, the lift ing of heavy weights tends in time to strain the circulation and give rise to cardiac hypertrophy. Excessive sweating in these occupations leads to lessening of the fluidity of the blood and induces excessive thirst, which the workmen often assuage with quantities of beer and other alcoholic drinks. The combination of vascular strain and alcoholism leads to early arteriosclerosis, which in turn results in hypertrophy of the heart. When large quantities of cold fluids are drunk acute gastrointestinal catarrh is very liable to ensue. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 71 DUST EXPOSURE IN THE CHIPPING OP IRON AND STEEL CASTINGS. Among the minor but important health-injurious processes in the iron and steel industry a brief reference should be made to iron and steel “ chipping.” This employment has been briefly described by Hayhurst, as follows: Chipping of iron and steel castings is another exceedingly dusty and also dangerous procedure from the flying particles which are created by the use of both hand or pneumatic tools. The reference is particularly to the danger of eye injuries, but the metallic-dust hazard in this employment is of even greater im portance. Hayhurst suggests that outside of the use of respirators and individual goggles it is advisable to protect the ears by cotton, for where pneumatic tools are used the deafening noise is productive of shocks to the nervous system. Previous to the chipping castings are usually subjected to the so-called process of tumbling, which consists in the placing of a number of castings, as described by Hay hurst, “ in a revolving cylinder, called a 4rattler,’ in order to shake off the mold dust and to smooth down certain imperfections.” He explains that the cylinder which contains the material should be en tirely inclosed, since an immense amount of dust is created, but where this is not practicable an efficient air exhaust or blast system may be used for the control of the dust hazard. In employments of this char acter most of the labor, however, is of a casual nature and it is ex tremely rare to meet with men who have been exposed to the same occupational hazard for a long period of time.1 MORTALITY OF IRON AND STEEL WORKERS— UNITED STATES REGISTRA TION AREA. The mortality of iron and steel workers has been reported upon for the years 1908 and 1909 b}^ the Division of Vital Statistics of the United States Census Bureau, but no subsequent information has been made public and the data are, therefore, limited to the years re ferred to. According to the census report, out of 5,035 deaths from all causes, 853, or 16.9 per cent, were from pulmonary tuberculosis. The details of the mortality of iron and steel workers, by divisional periods of life, are shown in Table 16, compared with the mortality of all occupied males, and of farmers, planters, and farm laborers. 1 C on sid era b le p rog ress has been m ade in the d ire ctio n o f p e rfe ctin g m eth od s o f e ye p rotection , as illu stra te d by exh ibits a t the N a tion a l E x p o s itio n o f S a fety and S a n ita tio n , N ew Y ork C ity, u n d er th e au spices o f the N a tion a l S a fety C ou n cil an d th e A m e rica n M useum o f S a fety, G ran d C entral P a lace, N ew Y ork C ity, 1917. A perm a n en t e x h ib it o f s a fety g og gles o r oth er m eth od s o f eye p ro te ctio n is m ain ta in ed at the A m e rica n M useum o f S a fety, 18 W e st T w e n ty -fo u rth S treet, N ew Y ork C ity. 72 MORTALITY FROM RESJIRATORY DISEASES IK DUSTY TRADES. T able 1 6 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS OF IR O N A N D ST E E L W O R K E R S , OF A L L OCCUPIED M A LE S, A N D OF F A R M E R S , P L A N T E R S , A N D FA R M L A B O R E R S , U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A GE GR O U PS. iron and steel workers. All occupied males. Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Num ber. Farmers, planters, and farm laborers. Deaths from pulmonary tuberculosis. Deaths from Per all cent of causes. deaths from all causes. Num ber. Deaths from pulmonary tuberculosis. Deaths from Per all cent of causes. deaths from all causes. N um ber. Per cent of deaths from all causes. 15 to 24 years........................... 25 to 34 vears............................ 35 to 44 years............................ 45 to 54 years........................... 55 to 64 years........................... 65 years and over.................... Age unknown.......................... 460 915 1,084 992 754 826 4 91 239 253 166 64 39 1 19.8 34,985 26.1 56,001 23.3 63,093 16.7 68,903 8.5 69,254 4.7 113,469 618 25.0 9,837 17,326 15,128 9,910 5,231 2,992 51 28.1 30.9 24.0 14.4 7.6 2.6 8.3 6,130 6,665 7,227 10,224 14,836 45,510 203 1,441 1,748 1,377 1,234 999 1,105 16 23.5 26.2 19.1 12.1 6.7 2.4 7.9 Total, 15 years and over- 5,035 853 16.9 406,323 60,475 14.9 90,795 7,920 8.7 T able 1 7 .—P R O P O R T IO N A T E M O R T A L IT Y FROM N O N T U B E R C U L O U S R E S P IR A T O R Y DISEASES OF IR O N A N D S TE E L W O R K E R S , OF A L L OCCUPIED M ALES, A N D OF FA R M E R S , P L A N T E R S , A N D F A R M L A B O R E R S , U N IT E D ST ATE S R E G IS T R A T IO N A R E A , 1908 A N D 1909. Deaths of iron and steel workers. Cause of death. Deaths of farmers, planters, and farm laborers. Per cent Per cent Per cent deaths of deaths of deaths Number. of from all Number. from all Number. from all causes. causes. causes. Asthma ........................................ ................. Bronchitis......................................................... 1 P neu m on ia...................................................... Other nontuberculous respiratory diseases. Total........................................................ Deaths of all occu pied males. 12 35 508 54 0. 2 .7 10.1 1.1 1,031 3,522 31,889 4,280 0.3 .9 7. 8 1.1 262 1,049 6,333 824 0.3 1. 2 7.0 .9 609 12.1 40,722 10.0 8,468 9.3 Table 16 is suggestive of a rather high but not particularly exces sive mortality from pulmonary tuberculosis; but Table 17 shows that in addition thereto there is a mortality from nontuberculous respiratory diseases of 12.1 per cent for iron and steel workers. Of this group of diseases asthma causes a proportionate mortality of 0.2 per cent; bronchitis, 0.7 per cent; pneumonia, 10.1 per cent; and other respiratory diseases, 1.1 per cent. Combining pulmonary tuber culosis and nontuberculous respiratory diseases, the proportionate mortality from all lung diseases is 29 per cent, which must be con sidered relatively high, since the group of iron and steel wTorkers includes those in many occupations not exposed to particularly health-injurious conditions. The table confirms the results of other investigations into the mortality of iron and steel workers of the United States and other countries. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 73 MORTALITY OF IRON AND STEEL WORKERS— INDUSTRIAL INSURANCE EXPERIENCE. The general vital statistics of the iron and steel industry are, for reasons elsewhere discussed at some length, of rather limited practical utility. The most useful data for the Unite# States are the industrial insurance experience statistics of the Prudential Insurance Co., in cluding for the industry considered as a whole, 5,332 deaths from all causes, of which 700, or 21 per cent, were from pulmonary tuber culosis. The details of this experience, on account of the large num ber of deaths included, are of exceptional interest, and especially so with reference to the younger ages. T able 1 8 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU BE R CU LO SIS A M ON G IR O N A N D S T E E L W O R K E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L M ALES IN U N IT E D STA T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E GROU PS. Deaths of iron and steel workers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. All causes. Pulmonary tuberculo sis. Iron and steel workers. Males in registration area, 1900 to 1913. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 y ea rs .......................................................................... 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over ................................................................. 403 630 684 606 550 459 121 215 214 89 48 13 30.0 34.1 31.3 14.7 8.7 2.8 27.0 30.5 23.4 14. 7 7.9 2.6 Total, 15 years and o v e r ............................................ 3,332 700 21.0 13.9 It is shown in Table 18 that the proportionate mortality from pul monary tuberculosis among iron and steel workers considered as a group is only slightly excessive at ages under 35, but quite de cidedly so during the age period 35 to 44, while during the remainder of life the mortality conforms to the normal. Considering that the group represents many widely different occupations, it is self-evident that the data must be interpreted with exceptional caution, but it would seem a safe inference that the physical strain and stress at the younger ages is a factor of some importance in the excessive pro portionate mortality from pulmonary tuberculosis at ages 35 to 44. In addition to the relatively high proportionate mortality from pul monary tuberculosis, pneumonia is also relatively common, the nontuberculous respiratory diseases being accounted for as follows: Asthma, 0.8 per cent; bronchitis, 1.4 per cent; pneumonia, 9.2 per cent; and other respiratory diseases, 1.5 per cent. Combining all the nontuberculous respiratory diseases, it appears that 12.9 per cent of the mortality was caused by diseases of this group, which, com bined with the 21 per cent of deaths from pulmonary tuberculosis, 74 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. indicates that nearly 34 per cent of the mortality from all causes in the iron and steel industry is directly attributable to diseases of the lungs. The iron and steel workers considered as a group in the mortality experience of the Prudential Co. are made up of puddlers, rollers, heaters, furnace tenders, laborers, and miscellaneous employees. In view of the fact that heretofore no thorough analysis has been pre sented even of the principal groups of the iron and steel industry, the details of the present analysis are included, even though for cer tain occupations the data are quite insufficient for a definite con clusion, for, as shown by the table concerning laborers, the large majority of workmen in the iron and steel industry are not further designated as regards the specific occupation followed than that it is stated that they are “ laborers at iron and steel works.” M O R T A L IT Y OF P U D D L E R S . The mortality of puddlers includes 251 deaths from all causes, 26, or 10.4 per cent, of the deaths being from pulmonary tuberculosis. This low phthisis mortality is of special significance, in view of the relatively high mortality from nontuberculous respiratory dis eases, which is accounted for as follows: Asthma, 0.8 per cent; bronchitis, 1.6 per cent; pneumonia, 12 per cent; other respiratory diseases, 2 per cent; and for all nontuberculous respiratory diseases combined, 16.3 per cent; which compares with 12.1 per cent for all occupations in the iron and steel industry. The details for pul monary tuberculosis are shown in Table 19. T able 1 9 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU BE R CU L O SIS AM ON G P U D D L E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D STATE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A GE GROU PS. Per cent of deaths from pulmonary tubercu losis among— Deaths of puddlers, 1897 to 1914, from— Age at death. A ll causes. 15 to Pulmonary tuberculo Puddlers. sis. Males in registration area, 1900 to 1913. 24 ye a rs ...................... ................................................... to 34 yea rs..........- ............................................................... to 44 years............................................................................ to 54 y e a rs .......................................................................... to 64 y e a r s ......................................................................... 65 years and over................................................................... 4 21 36 60 4 9 5 19 .0 25 .0 8 .3 27.0 30.5 23.4 14.7 74 56 5 3 6.8 5.4 7.9 2.6 Total, 15 years and over............................................. 251 26 10.4 13.9 25 35 45 55 M O R T A L IT Y OF R O L L E R S . The mortality of rollers includes only 112 deaths from all causes, of which 20, or 17.9 per cent, were from pulmonary tuberculosis. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 75 The proportionate mortality was relatively high at ages 35 to 44, as shown by Table 20. T able 2 0 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U BE R CU LO SIS AM ONG R O L L E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R ED W IT H T H A T OF A L L M ALES IN U N IT E D STATE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E GROU PS. cent of deaths from Deaths of rollers, 1897 Perpulmonary tubercu to 1914, from— losis among— Age at death. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 y e a rs ........................................................................... 55 to 64 years............................................................................ 65 years and over.................................................................._ Tolal. 15 vp.nrs and ovp .r__ ______ __________ Males in registration area, 1900 to 1913. A ll causes. Pulmonary tuberculo sis. 12 21 17 20 16 26 1 6 5 4 3 1 8.3 28.6 29.4 20.0 18.8 3.8 27.0 30.5 23.4 14.7 7.9 2.6 112 20 17.9 13.9 Rollers. In addition to the mortality from pulmonary tuberculosis the mortality from other respiratory diseases was accounted for as fol lows: There were no deaths from asthma, but the mortality from bronchitis was 3.6 per cent; from pneumonia, 8.9 per cent; from other respiratory diseases, 0.9 per cent; and from all nontuberculous respiratory diseases combined, 13.4 per cent, which compares with 16.3 per cent for puddlers, and 12.1 per cent for all employees in the iron and steel industry. M O R T A L IT Y OF H E A T E R S . The mortality of heaters is even less representative, in that there were only 51 deaths from all causes, of which 8, or 15.7 per cent, were from pulmonary tuberculosis. T able 2 1 .— P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU B E R C U LO SIS AM ONG H E A T E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y AG E GROU PS. Deaths of heaters, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. Pulmonary tuber culosis. Heaters. 15 to 24 y e a r s .......................................................................... 25 to 34 y e a r s .......................................................................... 35 to 44 years............................................................................ 45 to 54 years ....................................................................... 55 to 64 years............................................................................ 65 years and over ............................................................... 11 6 6 11 10 7 3 1 3 27.3 16.7 50.0 1 10.0 Total, 15 years and over............................................. 51 8 15.7 Males in registration area,1900 to 1913. 27.0 30.5 23.4 14.7 7.9 2.6 13.9 76 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. In so far as the data can be relied upon the mortality from pul monary tuberculosis was distinctly excessive. The mortality from nontuberculous respiratory diseases in this group is accounted for as follows: Asthma, 2 per cent; pneumonia, 5.9 per cent; all nontuber culous respiratory diseases combined, 7.8 per cent. There were no deaths from bronchitis or other respiratory diseases. M O R T A L IT Y OF FURNACE T EN D ER ?. The mortality of furnace tenders is represented by only 62 deaths from all causes, of which 4, or 6.5 per cent, were from pulmonary tuberculosis. The details of the experience are shown in Table 22. T able 2 2 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U LO SIS AM ONG FU RN A C E T E N D E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R ED W IT H T H A T OF A L L M ALES IN U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G ROU PS. Deaths of furnace ten ders, 1897 to 1914, from— Age at death. A ll causes. Pulmonary tuber culosis. Per cent of deaths from pulmonary tubercu losis among— * Furnace tenders. Males in registration area,1900 to 1913. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to G4 years............................................................................ 65 years and over.................................................................... 4 7 11 9 16 15 3 1 27.3 11.1 27.0 30.5 23.4 14. 7 7.9 2.6 Total, 15 years and over............................................. 62 4 6.5 13.9 The mortality from other respiratory diseases in this group is accounted for as follows: Pneumonia, 6.5 per cent, and other re spiratory diseases, 1.6 per cent; all nontuberculous respiratory dis eases combined, 8.1 per cent. There were no deaths from asthma or bronchitis. M O RTALITY OF LABORERS AT IRON AND STEEL W ORKS. Laborers and allied unskilled employments not specifically re turned are obviously within the group of general employees at iron and steel works, and they are represented by 2,788 deaths from all causes, of which 628, or 22.5 per cent, were from pulmonary tuber culosis. The details of the experience are shown in Table 23. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 77 T able 23.—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU B E R C U L O SIS AMONG L A B O R E R S , ETC., IR O N A N D S T E E L W O R K S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D S TA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U PS. Deaths of laborers, etc., 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. Pulmonary tuber Laborers. culosis. Males in registration area.1900 to 1913. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and o v er.................................................................... 361 569 604 492 422 340 113 202 189 77 38 9 .31.3 35.5 31.3 15.7 9.1 2.6 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.............................................. 2, 788 628 22.5 13.9 Of the mortality from other respiratory diseases, 0.8 per cent were deaths from asthma, 1.2 per cent from bronchitis, 9.1 per cent from pneumonia, 1.5 per cent from other respiratory diseases, and 12.6 per cent from all nontuberculous respiratory diseases com bined. M ORTALITY OF MISCELLANEOUS EMPLOYEES AT IRON AND STEEL W O RK S. The remaining occupations, including nail makers, forgemen, iron melters, etc., are combined in the group of miscellaneous iron and steel workers in Table 24. There are only 68 deaths reported in this group, of which 14, or 20.6 per cent, were from pulmonary tuber culosis. T able 2 4 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U LO SIS AM ONG M ISCE LLA N EO U S IR O N A N D S T E E L W O R K E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R ED W I 1 H T H A T OF A L L M A LE S IN U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A GE G R O U PS. Deaths of miscellane ous iron and steel workers, 1897 to 1914 from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. Pul monary tubercu losis. Miscellane Males in ous iron registration and steel area, workers. 1900 to 1913. 15 to 24 years............................................................................ 95 to 34 vears ....................................................................... 35 to 44 years............................................................................ 45 to 54 y e a rs .......................................................................... 55 to 64 vears............................................................................ 65 years and over ................................................................ 11 6 10 14 12 15 4 2 5 2 1 36.4 33.3 50.0 14.3 8.3 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over............................. ............... 68 14 *20. 6 13.9 •78 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. The excessive mortality from pulmonary tuberculosis in this group is of special significance, in that most of the men are exposed to arduous strain, heat, dust, weather changes, etc. The mortality from other respiratory diseases in this group is as follows: Asthma, 2.9 per cent; bronchitis, 7.4 per cent; pneumonia, 10.2 per cent; or, from all nontuberculous respiratory diseases combined, 20.6 per cent. It is, therefore, shown that both tuberculous and nontuberculous lung diseases are proportionately more common in this relatively small but important group, however ill defined, than among heaters, fur nace tenders, rollers, and puddlers. EVIDENCE OF UNSATISFACTORY HEALTH CONDITIONS. The experience, of course, is too limited for entirely safe conclu sions, but it is distinctly suggestive of more or less unsatisfactory health conditions, apparently predisposing to both pulmonary tuber culosis and nontuberculous respiratory diseases. It is, therefore, re grettable that there should be no other statistics useful for the present purpose, for regardless of the considerable development of the iron and steel industry in England and Wales, the employees are not separatety returned, except under the rather general term of nail, anchor, chain, and other iron and steel manufactures. This group included, according to the census of 1901, 220,000 males above the age of 15 years, of wThom 216,000 were actively at work. It is said in the report of the registrar-general that— In this industry the mortality at every stage of life is above the standard for occupied and retired males, the excess ranging from 4 per cent at ages 20 to 25, to 25 per cent at ages 65 and upward. At every stage of life the death rate exceeds the average for metal workers generally. In the main working period the comparative mortality figure is 1,187, or 18 per cent above the standard. These workers appear to suffer heavily from influenza and respiratory dis eases, the former being above the standard by 29 per cent and the latter by 79 per cent. The mortality from diseases of the circulatory system is also above the average by one-fifth part, but on the other hand that from alcoholism and liver disease and from suicide is below the standard. It should be said, however, in this connection that there has been a marked decline in the mortality of the group under considera tion during the preceding decade, equivalent to a reduction of nearly 25 per cent, the decline having occurred in practically every group of diseases excepting cancer. The decline was most noticeable in the case of influenza, phthisis, and respiratory diseases. The data^ how ever, must be used with caution in view of the fact that the group includes too many widely different industries and employments to be strictly representative for any one of them. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 79 ENGLISH MORTALITY STATISTICS. The same observations, unfortunately, apply to other important occupations in the iron and steel industry with more or less exposure to metallic dust, combined in a single group in the official English statistics under “ Engine, machine, boiler makers; fitters, millwrights, engine fitters, etc.” This group in 1901 was represented by 351,000 persons, of whom 345,000 were actively at work. It is said with reference to this group that— In these occupations taken together the death rates were below the standard for occupied and retired males at every age group except 55 to 65 years, the rates for boiler makers being below those for engine fitters at ages under 25 and over 65 years but above them throughout the main working period of life. The comparative mor tality figure from all causes was 913^ or 9 per cent below the standard; the figure for engine makers being 893, or 11 per cent below the average, while that for boiler makers was 1,032, or 3 per cent above it. Among these workers collectively the mortality from nervous dis eases slightly exceeded the standard, but from digestive diseases and from accident and suicide their mortality was below it. If the fig ures for engine fitters and boiler makers be compared, it will be seen that the first-mentioned workers experienced higher mortality than the latter from influenza, phthisis, and Bright’s disease, but under every other heading the mortality of boiler makers exceeded that of engine fitters. Engine fitters appear indeed to be by far the healthiest section in the entire class of metal workers. The preceding observations can not be said to apply with even approximate conclusiveness to the iron and steel industry as the term is generally understood and used in the United States. Most of the occupations involve a fair amount of metallic-dust exposure which under given conditions, such as, for illustration, in the case of boiler makers, may assume serious consequences. The relative mor tality from phthisis among engine makers, fitters, millwrights, etc., or what in the United States would generally be considered ma chinists, in the broad sense of the term, was only 88 against 100 for occupied and retired males, and the corresponding mortality from nontuberculous respiratory diseases was only 85; but for boiler makers the relative mortality from phthisis was 80, while for nontuberculous respiratory diseases it was 119. In contrast, it may be pointed out that the relative mortality from phthisis for cutlers and scissors makers was 285, and for file makers, 207. It may fur ther be said in this connection that the relative mortality from non tuberculous respiratory diseases was 178 for cutlers and scissors makers, and 184 for file makers. In each and every comparison of this kind the mortality of occupied and retired males from the dis eases stated is taken as 100. 80 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. RECENT ENGLISH OCCUPATIONAL-DISEASE INVESTIGATIONS. Some exceptionally interesting observations on “ Industrial dis eases prevailing amongst iron and steel workers in the Middles brough district of England,” by J. Watkin Edwards, have been made available through the British Medical Journal (July 22, 1916). In a brief outline of the conditions which influence life and health in industry it is observed that— (а) The effects of overcrowding are more harmful during active work than when workers are at rest; and (h) The evils of overcrowding are aggravated by: (1) Exposure to changes of temperature; (2) Inhalation of dust and irritating particles; (3) Absorption of chemical poisons; and (4) The effects of undue strain and exertion. A formula is presented according to which if the amount of air inspired while at rest equals 1, the amount inspired when standing erect is 1.3, and while walking at the rate of 4 miles per hour is 5. It is, therefore, suggested that every effort should be made in industrial towns toward making the lot of the workmen, both while at work and when off wTork, as perfect as possible. In the district of Middlesbrough pneumonia prevails to an alarming extent, being nearly four times as frequent as pulmonary tuberculosis, and more than three times as common as bronchitis. It is explained, how ever, that “ these figures do not at all fully represent the amount of industrial disease prevailing in the town for there are many minor complaints which do not appear as causes of death, but which give patients a great deal of pain and practitioners a great deal of trouble.” The local adverse influences which appear to affect the general death rate, especially with reference to the mortality from industrial diseases, are said to be: (1) Working at high temperatures. (2) Long hours of work, fatigue, insufficient rest, sleep, and recrea tion. (3) Working at night. (4^ Careless exposure to cold and wet. (5) Intemperance. (б) Inhalation of dust. (7) Inhalation of poisonous gases, such as CO. (8) Trauma. With special reference to pulmonary tuberculosis it is stated that— This condition was the cause of 70 deaths amongst males. The causes which -lie at the root of its prevalence are: (a) Inhalation of dust at the works (where it is chiefly composed of inorganic particles), but especially in our streets and dwellings and places where people congregate. The disease known as pneu moconiosis is known to kill large numbers of Staffordshire potters, Cornish and Transvaal miners, and Sheffield grinders. Dust from OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 81 any cause, especially that produced in the manufacture of manure from basic slag, causes bronchitis, asthma, chronic cough and emphy sema, and pneumonia, and, no doubt, predisposes the body to the attacks of the tubercle bacillus. As these dust diseases develop in sidiously, the workmen engaged in such occupations should have their chests examined periodically, and any signs of commencing disease should be regarded as a disqualification for that particular kind of employment. MORTALITY FROM PNEUMONIA AMONG ENGLISH IRON AND STEEL WORKERS. On account of the exceptional mortality from pneumonia among males in the Middlesbrough district, it is of interest to note that during the working period of life, that is, ages 25 to 65, the death rate in the county boroughs of the North of England was 1.6 per 1,000; in Sheffield it was 1.2 per 1,000; in Middlesbrough, among females, 0.9 per 1,000; and in Middlesbrough, among niales, 3.4 per 1,000. It is said in this connection that “ The death rate from pneu monia in Middlesbrough is between two and three times higher than in the county boroughs of the North, in Sheffield, and in the country generally among males between the ages of 25 and 65 years, while it is between three and four times higher than that among females in Middlesbrough.” With respect to possible occupational causes, in explanation of the excessive mortality from pneumonia, the follow ing conditions are emphasized: {a) Working in high temperatures with sudden exposure to cold, strong currents of air, and to powerful blasts of fiery and^suffocating gases. (b) Inhalation of dust of various kinds, and especially dust given off in the manufacture of slag manure. (c) Injuries of any kind, especially to the chest. (d) Excessive fatigue, especially after nightwork. (e) Careless habits after leaving work. (/) Intemperance in food and drink. In the majority of cases it is held that “ the disease is conveyed by autoinfection. A condition of lowered resistance, due to one or more of the above causes, furnishes a state of ill health favorable to the growth of an organism either already present in the mouth or throat of the patient or inhaled with dust or bad air.” It is there fore suggested that patients who have suffered from pneumonia (as well as those who have not) should exercise the greatest care in keeping their teeth, mouth, and throat in a healthy condition. On account of the fact that pneumonia in Middlesbrough is of a very fatal type, accounting for one-fifth of all the deaths in 1911, it is advised that— The sputum should be carefully destroyed as soon as possible. For this purpose the patient should expectorate into squares of paper or 106811°— 18— Bull. 231------ 6 82 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. into small cardboard receptacles containing a layer of common salt or other suitable disinfectant, and the whole destroyed at frequent intervals by fire. Every reasonable care should be taken to prevent the patient coughing into the faces of the attendants, or onto the bedclothes, or upon the floor; such accidents frequently happen, especially in the case of semiconscious patients. The infected spots should be scrupulously cleaned with turpentine or spirit, and the clothing of the nurses and of those in attendance should be protected by over alls. The rooms in which pneumonia patients have been treated should be thoroughly disinfected, and I am glad to observe that this is now being undertaken by the municipality. GENEEAL CONCLUSIONS. The foregoing observations regarding pneumonia are of special importance in view of the obvious conclusion that the disease is unquestionably increased in frequency and possibly in severity by more or less continuous and considerable exposure to irritating metallic and mineral dust. That similar conditions prevail, though probably to a lesser degree, in the United States is made evident by a recently issued technical paper by the United States Bureau of Mines on Health Conservation at Steel Mills, by J. A. Watkins, of the United States Public Health Service. The paper includes observations on the medical supervision of employees, hospital facili ties, fatigue as a cause of occupational disability, the relation of industrial buildings to the .health of employees, noise as a cause of flowered efficiency, ventilation, temperature and humidity, hours of duty, washing and sanitary facilities, drinking water, food, etc. There are, fiowever, no observations in this interesting discussion on industrial diseases as such, and no reference whatever to the dust menace as common to a number of special processes in the iron and steel industry, chiefly, of course, in grinding and polishing during the final processes of manufacture. The discussion is, therefore, general and has reference rather to sanitary conditions than to occupational hazards, and a much more specialized investigation would be neces sary to establish the occupational-disease hazard in the American steel industry as carried on under modern conditions at such model plants as that at Gary, Ind., of which an admirable descriptive account was published in the Engineering and Mining Journal for December 26, 1908. M ETAL GRINDERS. THE HYGIENE OF METAL GRINDING. The grinding trade includes a large variety of employments, of which metal grinding, by either the dry or wet process, is hygienically as well as industrially the most important. The grinding of metal probably involves as much exposure to decidedly health-in OCCUPATIONS W IT H EXP0SU BE TO M ETALLIC DUST. 83 jurious conditions as does any other employment, if not more so. Chiefly as the result of the inhalation of relatively large quantities of fine metallic dust, and not inconsiderable quantities of fine mineral dust, the mortality from pulmonary tuberculosis in this occupation is decidedly above the normal for occupied males generally. While the sanitary and other conditions injuriously affecting the health of metal grinders never have been so notoriously bad in the United States as in England or in continental Europe, the observed mortality of this occupation as carried on in this country fully warrants the most serious conclusions as to the health-injurious effects of this group of employments. The mortality of metal grinders has been discussed by James H. Lloyd, M. D.? in his treatise on “ Diseases of occupations,’' included in the Twentieth Century Practice of Medicine, published in 1895. Lloyd, after calling attention to the well-known fact that the trade of the grinder is conspicuous above all others for the suffering that is entailed from the inhalation of metallic dust, describes in detail the different processes of grinding and their relation to health. He says in part: Grinding edge tools is of two kinds—wet and dry. The latter method is by far the more injurious, as, naturally, it raises far the greater amount of dust. For some tools both methods are used—the mixed method. The tools ground are scythes, saws, table knives, machine knives, various other kinds of edge tools, files, penknives, razors, scissors, forks, needles, etc. A great difference in their bad effects is observed among the branches of the trade according as the grinders use the wet or dry method and according to the tool ground. The smaller objects are far the most trying and exacting upon health. The worst of all branches are the fork grinding and needle grinding. This is because in grinding these small objects the wTorkman is obliged to lean close over the stone and therefore inhales larg~e quantities of the dust, and also because the dry grinding is used. The dust raised by grinding is composed largely of minute bits of steel. According to Hall, 12 razor blades forged in the rough, which weigh 2 pounds and 4 ounces, lose 10 ounces in the process of grind ing. This loss represents so much fine metallic dust, mingled of course with dust from the stone. This statement gives some idea of the immense amount of dust produced by dry grinding. According to Holland the concrete masses of this dust formed in needle grinding have almost the specific gravity of iron. TYPICAL [DISEASES OF GRINDERS. In discussing the symptoms of the diseases typical of grinders as the result of their employment, Lloyd points out further that— They are those of a slowly advancing bronchitis with asthma and sometimes with emphysema; later dilated bronchi with excavation are observed; then, consolidation, and breaking down of lung tissue 84 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. . occur as the terminal processes. The exact relationship of these processes to a tubercular infection in grinders is an interesting and important subject, which, of course, did not receive much light from the earlier writers. They endeavored, in fact, to draw distinctions between true 66consumption ” and grinders’ 66asthma,” but the st^te of pathological knowledge in their day was not such as to permit them to do otherwise. It is quite evident from reading their reports of cases that they had to do with a disease that was essentially tubercular, but it would be interesting to have the exact relationship of this infection to the grinders’ unwholesome occupation investi gated by the methods of modern bacteriology. I do not know whether this has ever been done. There can be no doubt that the influence of the grinder’s trade is that of a predisposing cause. The inhalation of the irritating particles of steel into the lungs causes a constant catarrhal bronchitis and pneumonitis, with increase of con nective tissue; and this prepares the soil for a tubercular infection which characterizes the latter stages of the disease. INJTJMOTJSNESS OF DRY-GRINDING PROCESSES. A recent and more qualified discussion of the health-injurious cir cumstances of dry and wet grinding is by Oliver, who, in his Diseases of Occupation, goes fully into all the details concerning the trade, including a brief account of the corresponding conditions in the cut lery manufacture of Germany, at Solingen: So far as the two methods of grinding cutlery are concerned, the dry method is, from a health point of view, the more dangerous to the workers. The dust is dry, and is in the form of a very fine powder, which readily reaches the lungs owing to the attitude of the men when at work. Steel grinders sit astride the grinding stone on a saddle, and as they lean forward keeping close to their work, they can not but inhale some of the dust, which is a mixture of steel and stone. Forks and needles are generally ground by the dry method; knives, scissors, and razors by the wet. Some are ground by both methods, e. g., the backs of razors and scissors are ground by the dry method and the remainder of the blade by the wet. It was in 1865 that Dr. T. C. Hall, of Sheffield, drew attention to the high death rate of steel grinders from pulmonary phthisis. The average age at death, of steel grinders was at this period only 29 years, but of late this has improved. Dr. Hall’s statistics referred to dry grinding. In wet grinding the running stone passes through a thin layer of water in a trough below the stone, so that, as its surface is always kept wet, comparatively little dust is given off during the process of grinding; but while the atmosphere is clearer of dust, the floors and walls of the workshop are damp and cold. The grinding is carried on in rooms called “ hulls,” which are bounded by three blank walls; the windows are without glass. Where dry grinding is car ried on there are fans, but these often prove ineffective. It is no uncommon thing to find men engaged in different processes in one large room, so that the dust which is generated affects not only the workman sitting at his own grinding stone, but the other inmates of the room as well. In Sheffield it has been ascertained that in OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 85 every 1,000 deaths among steel grinders pulmonary phthisis is the cause of 345 and other respiratory diseases 295; that is, collectively, pulmonary diseases account for 64 per cent of the entire mortality, whereas among the adult population of the country generally phthisis accounts for 144 deaths per 1,000 and other respiratory diseases 182, or collectively 32.6 per. cent. Steel grinders die comparatively young. Dr. Sinclair White, in Dangerous Trades, page 414, says that 458 grinders in every 1,000 die between the ages of 35 and 55, compared with 261 in every 1,000 of the entire male population of the country. Only 140 grinders out of every 1,000 reach the age of 55 and upward, whereas for every 1,000 of the adult male popula tion 391 reach 55 years and upward. Sinclair White is of the opinion that phthisis is not so rife among steel grinders as formerly. In Dr. Hall’s time the average age at death from phthisis was 29 years; at present it is 43.1 IMPROVEMENT IN THE HEALTH OF GERMAN CUTLERY GRINDERS.2 With reference to conditions in Germany and the remarkable im provement which has followed the introduction of sanitary precau tions, rational methods of ventilation, and other means of dust prevention, Oliver holds: In the town of Solingen and the neighborhood it is estimated that there are 29,000 persons employed in making cutlery. Here all sorts of steel goods are made— knives, forks, scissors, and swords. A good deal of the work is done by the people in their homes, and it is inter esting to know that the home industry is rather encouraged by the local authority, which provides the men with gas and electric power. So prevalent is pulmonary consumption among the grinders in So lingen that it has attracted the attention of the Government factory department. In the 10 years 1885-1895, 72.5 per cent of the deaths among knife grinders in the Solingen district was due to phthisis, against 35.3 per cent for the rest of the population over 14 years of age, and an official examination showed that out of 1,250 grinders only 85 men were over 45 years of age. Dr. Shadwell speaks approv ingly of the methods adopted in some of the Solingen factories to deal with the removal of dust. Oldeiidorf, in writing about che grinders at Solingen, states that 24.7 per cent reached 50 years of age and 3.3 per cent 70; that at Runsched 33.8 per cent reached 50 years and 8 per cent 70; while at Kronenberg the numbers were 32.9 and 8.7, respectively. The mean age at death of grinders employed in the dry methods was 39.4, of workers in iron 48.3, and of the rest of the male population 54.4 years. Taking all ages, the deaths from tuber culosis per 100 cases were for grinders 78.3, iron workers 59, other persons 46.3 1 D iseases o f O ccu p a tion , T h om a s O liver, pp. 230, 231, L o n d o n , 1908. 2 In th is co n n e ctio n see “ G esu n d h eitsbu ch fu r die K le in e is e n -In d u s trie ,” v o n D r. G. D. O rthm ann, B erlin , 1899 ; “ G ew erb lich e G esu n d h eitsp flege,” von D r. A . B ender, S tu ttg a rt, 1906 ; “ H a n d b u ch der A rb eiterk ra n k h eiten ,” v on D r. T h e o d o r W e y l, J en a , 1908. 3 D iseases o f O ccu p a tion , T h om a s O liver, p. 232. 86 MORTALITY FROM RESPIRATORY DISEASES IK DUSTY TRADES. SANITARY PRECAUTIONS IN GERMAN CUTLERY SHOPS. A very interesting account of the mortality of cutlery grinders in Solingen was also included in the Report of the Chief Inspector of Factories and Workshops of England for 1906, from which an abstract is made to emphasize the sanitary and labor conditions required for the reduction of the mortality of grinders to a minimum: The atmosphere of Solingen is bright and clear. It is seldom that black smoke is seen escaping from the factory chimneys. This is largely the result of careful firing and the use of coal briquettes in stead of ordinary coal, which avoids the use of slack coal. The day’s actual work is nine hours; on Saturday work ceases at 5.30 p. m. The factories in Solingen are said to be marvels of order and cleanli ness ; the floors are of concrete and the air space for each worker must be at least 565 cubic feet. Al] the grinding stones are protected by guards. The walls of the workrooms are limewTashed every year; the floors are swept every evening and damp-wiped once a week. The u raising ” of grindstones is never undertaken during working hours except under a stream of water or unless the stone is entirely inclosed in casing except at the working place of the raising tool. The floors are kept clean and provision is made for the removal of the dust during grinding. Cutlery manufacture is recognized as a dangerous trade in Solingen, and in recent years considerable improvement has taken place in the means to prevent dust. In Solingen the grind stones and polishing wheels are run toward the worker; in Shef field they are run away from the worker, so that the dust has an upward tendency and flies into the room.1 The subject is also considered in the Report of the Chief Inspector of Factories and Workshops for 1907, in which the rules or police regulations governing the trade at Solingen are republished in full. A remarkable improvement in the health of the workmen has fol lowed the introduction of these rules.2 MORTALITY OF SHEFFIELD METAL GRINDERS. Some exceptionally interesting and useful mortality data of mefcal grinders have been published for a period of years by the city of Sheffield^ England, but unfortunately the statistics were discontinued subsequently to 1910. Table 25 shows the mortality in detail of 2,190 grinders, of whom 1,070, or 43 per cent, died from pulmonary tuberculosis, with an additional mortality of 621, or 24.9 per cent, from nontuberculous respiratory diseases. 1 R e p o rt o f th e C h ief In s p e cto r o f F a c to r ie s an d W ork sh o p s, 1906, pp. 1 0 7 -1 0 9 . 2 F o r a d d itio n a l re feren ces on th e o cc u p a tio n a l d iseases o f G erm an file m akers and rela ted in d u stries, see A lb rech t, H a n d b u ch d er P ra k tisch e n G ew erb eh yg ien e, B erlin , 1898, pp. 96 a n d 7 9 6 ; S om m erfeld , H a n d b u ch der G ew erb ek ra n k h eiten , B erlin , 1898, p. 365 ( in c lu d in g sta tem en t th a t a v era g e age a t d eath f o r file cu tte rs d y in g fro m p u lm on a ry tu b ercu los is w a s o n ly 41.2 y ea rs an d from all oth er d iseases 46.1 y e a r s ). O f special im p o rta n ce is the m ore exten d ed d iscu ssion o f th is o cc u p a tio n in W e y l’s H a n d b u ch der A rb eiterk ra n k h eiten , J en a , 1908, p p. 80, 91, 106, 135 e t seq. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 87 T ABLE 2 5 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU B E R C U L O SIS A N D FR O M O T H E R R E S P IR A T O R Y DISEA SES C O M PA R E D W IT H T H A T F R O M A L L CAUSES, AM ONG G R IN D E R S IN S H E F F IE L D , E N G L A N D , 1889 TO 1910, B Y A G E G R O U PS. [Source: Annual reports of the medical officer of health, Sheffield, England. able in these reports subsequent to 1910.] Similar returns are not avail Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. Deaths from respiratory diseases o t h e r than pulmonary tubercu losis. Number. Per cent of deaths from ail causes. Under 25 years.................................................. 25 to 34 years..................................................... 35 to 44 years..................................................... 45 to 54 years ................................................... 55 to 64 years..................................................... 65 years and over............................................. 98 299 515 687 548 343 43 173 303 336 178 37 43.9 57.9 58.8 48.9 32.5 10.8 22 51 81 169 184 114 22.4 17.1 15.7 24. 6 33.6 33.2 T otal........................................................ 2,490 1,070 43.0 621 24.9 According to this table, at ages under 25 of every 100 deaths from all causes 43.9 are from pulmonary tuberculosis, the proportion in creasing to 57.9 per cent at ages 25 to 34, and 58.8 per cent at agss 35 to 44. Subsequently to this period the proportion declines to 48.9 per cent at ages 45 to 54, and to 32.5 per cent at ages 55 to 64; at ages 65 and over the proportion of deaths from pulmonary tuber culosis is only 10.8 per cent of the mortality from all causes. The corresponding mortality from nontuberculous respiratory diseases must also be considered excessive at practically every period of life. In view of the frequent use of the term “ grinders’ phthisis,” as based chiefly upon the morbidity experience of Sheffield grinders,1 the following observations by J. M. Beattie, M. D., are of interest. The extract is from a paper on the “ Hygiene of the steel trade,” pub lished in the Transactions of the Royal Sanitary Institute for 1912: A great deal of attention has been centered on the dust problem, and much of the legislation relating to the industries with which we are dealing is concerned with the protection of the workers from dust inhalation. The much more serious problem—the prevention of in fection with B. tuberculosis—has not received justice at the hands of factory inspectors and factory legislators. During a five years’ ex perience in Sheffield it has been abundantly demonstrated that the cutlers and grinders die from tuberculosis and not from nontuberculous fibrosis of the lung. Let me protest against the loose use of the word “ phthisis.” Rightly or wrongly, phthisis is now understood by medical men to mean 1 R e ga rd in g hea lth co n d itio n s am on g Sheffield grin d ers see “ T he V ita l S ta tistics o f Sheffield,” by G. C. H ollan d, M. D., L on d on , 1843, pp. 1 5 2 -2 0 5 ; “ U nhealthy T ra d e s,” by B. W . R ich a rd son , L ectu res b efore the S ociety o f A rts. R ep rin ted in S cien tific A m erican Supplem ent No. 9 (F eb . 26, 187 6 ) ; “ M o r ta lity o f D u sty T ra d es in Sheffield,” by S curfield. B ritis h M ed ica l Jou rn al, A ug. 22, 1908, p. 4 8 0 ; “ A nnu al R e p o rts on the H ea lth o f Sheffield, E n g la n d ,” S pecial T ables and O bservations on M o r ta lity in Sheffield T ra d es, 1 88 9 -1 9 0 7 . 88 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. tuberculosis of the lung* with cavity formation; and the term “ grind ers’ phthisis ” should be confined to that condition of the lung in which tuberculosis is added to the interstitial fibrosis. For the condi tion which is produced by the inhalation of dust, the term “ fibrosis ” is perhaps the most suitable; I shall, therefore, describe the condition resulting from the inhalation of dust as fibrosis. The misuse of the term “ phthisis ” makes it difficult to get at satisfactory statistics, and we can therefore only regard the figures given as approximate. MORTALITY OF GRINDERS— INDUSTRIAL INSURANCE EXPERIENCE, No extended scientific study, medical or otherwise, has been made of grinders’ phthisis, or the occurrence of pulmonary tuberculosis among the grinders in the United States, but some suggestive obser vations on different aspects of the grinders’ trade have been reported upon in detail by the division of occupational diseases of the Ohio State Board of Health. The only conclusive mortality data for the United States are the industrial insurance mortality statistics of the Prudential Insurance Co., limited, however, to 305 deaths, of which 143, or 46.9 per cent, were caused by pulmonary tuberculosis. This percentage is not much at variance with the corresponding figure for Sheffield grinders, but is, in part, no doubt, the result of important differences in age distribution, since the maximum number of deaths in the United States occurred at ages 35 to 44, against ages 45 to 54 in the English experience. The excess in the mortality of grinders from pulmonary tuberculosis is brought out with sufficient clearness and conclusiveness in Table 26, in which comparison is made with the corresponding mortality of males in the registration area. T able 2 6 .— P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS AMONG G R IN D E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L M ALES IN U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A GE G R O U PS, 1Deaths of grinders, 1897 to 1914, due to— Per cent of deaths due to pulmonary tuber culosis among— Age at death. All causes. Pul monary tubercu losis. Grinders. Males in registration area, 1900 to 1913. 15 to 24 vears............................................................................ 25 to 34 years........................................................................... 35 to 44 vears............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over.................................................................... 17 56 74 73 55 30 7 38 44 35 14 5 41.2 67.9 59.5 47.9 25.5 16.7 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over............................................. 305 143 46.9 13.9 According to this table, the proportionate mortality of grinders from pulmonary tuberculosis is excessive at all ages, but most pro nounced at ages 25 to 34, when out of every 100 deaths from all causes, 67.9 are from pulmonary tuberculosis, against 30.5 per cent for males in the registration area. The data, while limited, may OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 89 be accepted as trustworthy regarding the mortality of grinders from pulmonary tuberculosis in the United States at the present time. The evidence is sufficient to show that the disease is of exces sive frequency among grinders at every divisional period of life, and very considerably above the normal for the general male population. MORTALITY OF INSURED GRINDERS— MEDICO-ACTUARIAL EXPERIENCE. The foregoing observations are sustained by the medico-actuarial experience, which, however, is only with reference to the mortality from all causes. According to this experience, which includes cutlers, scissors grinders, ax, plow, and other steel grinders, but excludes foremen and superintendents, the actual mortality among 5,988 em ployees exposed to risk one year was 43 deaths, while the expected mortality was 36.69, or 17 per cent in excess; in other words, to every 100 deaths expected on the basis of the normal experience there were among the group considered 117. When the age factor, however, is taken into account, it appears that at ages under 40 the actual mor tality was less than the expected, while there wTas a rapid and very considerable rise in the excess at ages over 40. Unfortunately, the numbers under observation are insufficient for strictly scientific con clusions. The results, in detail, are given in Table 27. T able 2 7 .—M O R T A L IT Y FR O M A L L CAUSES AM ONG C U T L E R S A N D SCISSORS, A X , P L O W , A N D O T H E R S T E E L G R IN D E R S (E X C L U D IN G F O R E M E N A N D S U P E R IN T E N D E N T S ), B Y AG E G R O U PS—M E D IC O -A C T U A R IA L IN V E S T IG A T IO N . Age at death. Number exposed to risk 1 year. Actual deaths. E xpected deaths. Ratio of actual to expected deaths. 15 to 29 years........................................................................... 30 to 39 years............................................................................ 40 to 49 years............................................................................ 50 to 59 years............................................................................ 60 years and over.................................................................... 3,208 1,841 667 254 18 12 9 10 12 14.55 10.19 6.17 5.04 .74 82 88 162 238 Total............................................................................... 5,988 43 36.69 117 SANITARY INVESTIGATIONS BY THE OHIO STATE BOARD OF HEALTH. Some very useful observations on the health of grinders have been included in the report of the Ohio State Board of Health, by Hayhurst, who points out that— The process of metal grinding is one closely associated with foundry wTork and assembling processes upon both iron and soft metals. It properly includes also the dressing of castings by other means than grinding, such as “ sand blasting,” “ rattling ” in tumbling machines, and “ chipping ” by means of steel tools. Sand blasting has been considered elsewhere, while a word will be given here to each of the other subsidiary processes. Metal grinding is usually per formed with emery wheels, which may be stationary or may be moved about over large surfaces by means of a swing-belt attachment. Oc 90 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. casionally it is done mechanically by a series of traveling emery wheels, which pass up and down over the surfaces to be ground. Sometimes it is done by belts covered with emery or other exceed ingly hard abrasive substances. Carborundum and corundum, two substances of diamondlike hardness, are the chief abrasives used. In the investigation by Hayhurst, including 64 establishments em ploying a total of 1,979 male wage earners, modern methods of work were observed in 42 places, fairly modern methods in 14, and crude or antiquated methods in the remaining 8. Health appliances, espe cially those consisting of blower systems to remove the dust created, were considered good in 20 places, of only partial efficiency in 13, and found entirely absent in the remaining 31. In 20 of the work places other processes than metal grinding were carried on in the same quarters, such as sand blasting, forging, welding, polishing, buffing, etc. This condition is quite common throughout the dusty trades, and illustrates the difficulty, if not the impossibility, of completely separating one injurious process from another. As a broad generali zation, however, the present classification may be considered sufficient for the purpose. The Hayhurst investigation, while limited to the State of Ohio, may be considered fairly conclusive for the country at large, although it is pointed out that— It is probable that country-wide statistics w^ould be much more accurate, both because of the larger number of deaths and because persons with bronchial or respiratory diseases have a strong tendency to migrate to western States. MORTALITY EXPERIENCE OP THE STOVE MOUNTERS’ INTERNATIONAL UNION. The investigation concludes with an interesting table of statistics derived from a report submitted by the Stove Mounters’ Interna tional Union for the United States and Canada. These workers are engaged only about one-fifth of their time in metal grinding, and usually they are employed without the advantage of any pro tective devices whatever. Most of the time, however, they work in an atmosphere more or less contaminated with fine metallic and mineral dust. Table 28 is as follows: T able 2 8 .—P E R C EN T O F D E A T H S F R O M E A C H S P E C IF IE D CAUSE AM ON G STO V E M O U N TE R S TO W H O M D E A T H B E N E F IT S H A V E B E E N P A ID B Y T H E IR O R G A N IZ A TION D U R IN G T H E P A S T F IV E Y E A R S , IN THE- U N IT E D S T A T E S A N D C A N A D A (U N D E R D A T E OF S E P T . 17, 1914). Cause of death. Per cent. Tuberculosis.............................. Heart disease............................. A ccident..................................... Pneumonia................................. Other preventable causes___ Degenerative diseases............... A ll other causes......................... 27.95 20.93 11.67 9.31 13.88 9.23 7.03 Total................................. 100.00 OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 91 GENERAL CONCLUSIONS. The available evidence is, therefore, sufficiently conclusive that metal grinding in probably any and all of its various forms must be considered one of the most injurious occupations inciting a special predisposition of the workers to tuberculous and nontuberculous respiratory diseases. Aside therefrom, the Hayhurst investigation ascertained in 17 plants an occurrence of 22 cases of industrial dis eases, as follows: Chronic lead poisoning, 5 cases; pulmonary siderosis, 9; frequent attacks of brass poisoning, 2; bronchitis, 2; pneumonia, 1; tuberculous empyema, 1; brush burns of the hands, 1; conjunctivitis, 1. The results seem to indicate generally unsatisfactory working conditions, and they sustain the statement made by Hayhurst that— The better control of the dust is the first essential, while shorter work hours, alternation of work to overcome monotony, and the features mentioned under the respective hazards above, as well as medical examination and supervision, are necessary to control health iii this entirely unnatural and hazardous process. Concerning the conflicting character of the official vital statistics of grinders, it is stated in this connection, in the rej>ort on the draft regulations proposed to be made for factories in which the grinding of metals and the racing of grindstones is carried on, by Alfred Herbert Lush (Parliamentary paper Cd. 4913, London, 1909) that—The figures were not in all respects easy to reconcile; but it was clearly established that both the wet and the dry grinders were affected by diseases of the respiratory organs, and especially by fibrosis of the lungs and by phthisis, to an extent far beyond the average of occupied males, the mortality from phthisis amongst them being six times that average. The men who enter these trades are usually above the ordinary standard of physique and vigor, because weakly men are unsuited to the work; yet the proportion of damaged lives found by Dr. Collis was very heavy, and the duration of life is nearly the lowest of all the trades. The cutlers, who are said to be as a rule of weaker physique to begin with, suffer less from phthisis and have longer lives; but they appear to be more liable to the minor diseases due to dust irritation, and in no respect can their health conditions be considered satisfactory. This report is an exceptionally valuable contribution to the prac tical study of dusty trades, and should be consulted in further amplification of the observations on the special circumstances and conditions tending to increase the exceptional liability of grinders to pulmonary tuberculosis.1 1 See in th is con n ection “ T h e s tory o f the g rin d in g w h e e l,” by C. W . B lakeslee, in T h e Iron A ge, rep rin ted in the S cien tific A m erican Supplem ent No. 2125, Sept. 23, 1916. M en tion should a lso be m ade o f th e rep ort on the d r a ft re g u la tio n s p rop osed f o r fa cto rie s and w ork sh op s in* w h ic h the p rocess o f file cu ttin g by h a n d is ca rrie d on, b y C hester Jone^ (P a rlia m e n ta ry p a p er Cd. 1658, L on d on , 1 9 0 3 ). 92 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. POLISHERS. The polishing of metal ware is a widely diversified trade, and the term u polisher ” is one of general rather than of special significance. Under the term are included metal polishers and buffers working upon steel, brass, gold, and silverware, but no data are available which would permit of a proper classification of polishers according to the metal or material manipulated. POLISHING PROCESSES IN RELATION TO DUST. The health-injurious effects of this employment have been recog nized by all who have written upon the mortality of dusty trades, and the more important facts are summarized by Arliclge, in part, as foil ows: After being shaped and ground to the required dimensions, the next business is to burnish or polish the articles. This is accom plished by wheels covered by leather, and also by a thick bundle of linen rags cut and bound together in the form of a wheel, and which, by rapid rotation, assumes the character of a solid mass, and, at the same time, one so soft as to serve better than any other contrivance for the purpose of surface polishing. To assist in giving polish to the articles made, various powders are employed; for example, emery, whiting, rouge, powdered pumice, etc. The use of these materials adds vastly to the dust of the trade and to its pernicious results; but no data are in existence to indicate what is its share in the causa tion of disease as compared with the dust of the grindstones. Still, no question exists that these polishing powders, differing as they do among themselves in physical qualities, differ likewise in the range of their effects upon the lungs. The rather involved circumstances affecting the polishers’ health and mortality are also discussed in The Workers of the Nation, by Mr. Gilson Willets, whose attention appears to have been attracted by the particularly health-injurious conditions of the employment, and whose conclusions are decidedly suggestive: Metal polishers who have reached the age of 40 often look like old men. There can hardly be found a trade more deleterious to health, say those who follow it. Among the harmful conditions may be mentioned the liability of the workmen to get their lungs full of flying and impalpable dust, which is composed of metal, minerals, and cotton fiber. They are also, in many cases, deprived of the proper supply of light, and great injury to the eyes thus arises. It is not easy to wear goggles or glasses, as the operator’s sight must be of the keenest in order to detect blemishes. There are laws for the protection of this class of workmen, but they are too seldom em ployed. New York statutes require that at each polishing lathe there shall be an exhaust fan to carry off the dust, that each operative shall have 250 cubic feet of air space, and plenty of light. It has been claimed that not in 5 per cent of the shops do these desirable provisions prevail. A buffing wheel, making 2,500 revolutions per OCCUPATIONS W IT H EXPOSUKE TO METALLIC DUST. 93 minute, has wrecked many constitutions. From it, as the polisher applies the metal, a cloud of dust arises, made of particles of cloth and metal, and that is what the operator breathes. Generally the .windows are hermetically sealed. Often the walls and floors are covered with the accumulation of years. In the process of brighten ing silver-plated material there is given forth by the wheel a cloud of dust of which crocus is a large constituent, while from the plating room come fumes of nitric acid. In the process of polishing chande liers there is much dust set free, which is composed of particles of brass, and permeates the air of the shop. Metal polishers often do not care to complain, because their wages are high. Here is a good field for activity among the factory inspectors, who should force em ployers to maintain proper conditions in the shops.1 SICKNESS EXPERIENCE OF THE METAL POLISHERS’ UNION. More recent evidence has been presented in the published sickness and mortality experience of the Metal Polishers’ Union, regarding which it has been stated that— The treasury of this union, in spite of the fact that the men are steady and have no special temptations to excess, was found to be constantly exhausted. The reason is that the death claims eat up all the funds. An investigation of these claims showed that many of the men were dying from pulmonary tuberculosis. There were some deaths from accident, a few suicides, but the rest were all from pul monary diseases— and pneumonia was very rare as compared with phthisis. The statistics for the last four years show that in 1903, 45 metal polishers died, of whom 43 succumbed to some lung trouble. In 1904 there wTere but 38 deaths among the metal polishers, of which only 3 were due to other causes than pulmonary disease. In 1905 there were 70 deaths among the metal polishers, 65 of which were due to some form of lung trouble. In New York City a local union having 170 men working exclusively on the precious metals had 8 death claims in two years, 7 being due directly to tuberculosis, while 400 men employed in all the other branches of the same industry have had but 3 deaths from this cause in the same space of time. A medical journal", commenting upon the above-quoted facts at the time of their publication, argued very pointedly to the effect that—■ It would seem from these statistics that even the cleanest kinds of dust, without a trace of infectious material in them, may still prove a source of the greatest possible danger and be the indirect cause of tuberculosis. This has been known for some time, but so startling a confirmation of it is sure to emphasize the necessity for taking every precaution for the avoidance of dust. Even what might seem to be the most innocuous of dirt particles may, when inspired, constitute foci of irritation in which tubercle bacilli may readily find a favor able nidus for implantation and growth. The results of the earlier investigations by the Metal Polishers’ Union are in part confirmed by the statistics of the Metal Polishers, 1 The Workers of the Nation, Vol. I, p. 57. 94 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Buffers, Platers, Brass, and Silver Workers’ Union of North America, which, for the 5-year period from 1909 to 1914 include 242 deaths from all causes, of which 31.9 per cent were from tuberculosis. The details of the mortality analysis are as follows: T able 2 9 .—N U M B E R A N D P E R CEN T OF D E A T H S D U E TO EACH S PE C IF IE D C A U S -, AM ON G M E T A L P O L IS H E R S , B U F F E R S , ETC., 1909 TO 1914. Number. Per cent. Tuberculosis............................................ Pneum onia.............................................. Heart disease........................................... Violence (including 6 suicides)........... Other preventable causes..................... Other degenerative diseases................. A ll other causes...................................... 77 31 31 19 20 57 7 31.9 12.9 12.9 7.9 8.0 23.5 2.9 T otal...... , ...................................... 242 100.0 Cause of death. Table 29 is derived from the report by Hayhurst on “ Industrial Hetilth Hazards,” 1915, in connection with which there has been published a quotation from an official letter stating in explanation that— You will note from the report the large per cent of our members that die from pulmonary tuberculosis. All of these deaths we be lieve were contracted by working at this trade, but the sad feature is that at least 95 per cent of those that contract consumption, work ing at our dangerous trade, will not acknowledge they have the dis ease until they are too far gone for recovery. They then quit the trade and try to get a position out in the air, often as collectors, driving laundry wagons, on a farm, or, if fortunate enough, go West. These we believe eventually succumb to the disease contracted while working at the trade. We lose all track of them and have no record. If it were possible to keep this record, the percentage of deaths in our trade would be enormous. In addition to the table, it is said that the median age at death of the 242 metal polishers, buffers, etc., was 40.1 years, while for those who died of tuberculosis it was 37.27 years. Most of the men who enter this trade start work as mere boys, between 1C and 18 years of age, so that the health-injurious consequences are of increased economic significance. . POLISHING PROCESSES IN VARIOUS INDUSTRIES. The observations by Hayhurst in connection with polishing and buffing are of exceptional value, in that they are based upon an extended personal investigation, including 51 plants, in 11 different cities, employing a total of 846 wage earners. Since the surrounding circumstances of polishers and buffers vary considerably on account of the numerous industries in connection with which such processes are carried on, it may be stated in this connection that among the in dustries investigated in Ohio were those manufacturing brass and OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 95 bronze products, electrical apparatus, mirror making, cash regis ters, stoves and furnaces, foundry and machine shop products, coffin fixtures, cutlery and tools, copper, tin and sheet metal goods, automo biles and parts, jewelry, regalia, scales and balances, sewing machines and parts, scientific instruments, fiber combs, aluminum combs, signs and advertising novelties, etc. It is, therefore, quite clear that the statistical data concerning the mortality of a group of employees classified merely as polishers and buffers, and without reference to the special line of work iri connection with which these particular processes are carried on, can not be entirely conclusive. Hay hurst in the report referred to points out that— Dust in the breathing atmosphere was a negligible hazard in 12 places, fairly so in 17 more, but was bad in the remaining 22. It consisted chiefly of iron, steel, brass and bronze alloys, other soft metals, glass, etc., which were being worked upon, as well as the components of the polishing wheels (emery, silica, etc.) and of the buffing wheels (cotton and lint fibers, glue substances, etc.). In some places it was kicked up from the floors because of inefficient cleaning, and also dry sweeping during work hours. These dusts are, of course, the most harmful to which workers may be subjected, since they are exceedingly hard, crystalline, and very fine, or irritat ing, and, in the majority of instances, poisonous. There are so many consumptives in the trade that the infection factor is also added. VENTILATION AND SANITARY CONDITIONS. With special reference to ventilation, it is stated that conditions were good in 16 places, fairly so in 17, but the air was close and con fined and often contaminated with various fumes and gases from other processes in the remaining 18. Constant standing in a partially stooped posture with very little variation is referred to as an addi tional hazard in this industry. As regards the special liability to the contraction of communicable diseases, this was considered excep tionally serious in 24 places and considerably so in at least 18 more, “due particularly to promiscuous spitting on dusty floors and the absence of cuspidors.” As to the use of protective devices, it is said that, “ Occasionally some men were seen who were wearing respirators and endeavoring by this means to filter out the dust from the air which they inhaled.” Aside from the dust hazard, polishers and buffers were found to be subject to a liability to poisoning by lead, potassium cyanide, nitricacid fumes, phenol, amyl acetate, benzine, alum, crude paraffin, fur nace gas fumes, brass fumes, plating fumes, and acid-dipping fumes. The general health appearance of the workers in 24 plants was found to be good, in 13 it was bad, and in 14 ‘more it was only fair. Posi tive evidence of industrial disease was observed in 8 plants, includ ing 17 cases. Haylnirst concludes that— 96 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. As the constant breathing of harmful dust and the continual assuming of unnatural and strained postures are foreign to the physiology of the human organism, it is highly necessary that dust be kept out of the breathing atmosphere and to introduce measures which will vary the work for this class of workers. Unfortunately, it is looked upon as a skilled trade and this makes it difficult to intro duce work variations. This does not detract, however, from its hazardous character. ^ The toll of deaths from preventable causes bears this out. It is a process of modern times. One point which particularly impressed our investigators was that where blower sys tems were installed they were often very inefficient at the time of inspection and w^ere said to be so most of the time. There appears to be but one way of getting around this—to make it somebody’s business in each such room to see that such systems are in working order and to provide for compensation for this purpose. A metal or w^ooden “ chest protector ” prevents harmful pressure against the per son. Other features, the liability to poisoning, etc., require the same precautions as elsewhere. Especially should medical supervision be adopted for this class of workers, as they are at a process which ap pears to take 20 or 25 years off of their lives. DUST HAZARDS IN BUFFING. Some rather interesting additional observations in connection with the special dust hazard of buffing are contained in a descriptive ac count of the hazards of the tin and copper smith’s industry by Charles C. Dominge, of the New York Fire Insurance Exchange (Weekly Underwriter, Nov. 6, 1909), in part as follows: The buffing process is the most hazardous of all on account of the liability of spontaneous combustion. A very fine dust or lint is thrown off the buffers in this process. This dust is very hazardous, as the buffing wheels are in many cases saturated with oil used in polishing, and if allowed to fall to the floor, or accumulate in corners where oil or grease may be, it becomes an easy source of spontaneous combus tion. In most plants a small blower system empties the dust into a barrel about half full of water located in a metal-lined room. A standard condition would call for a blower system similar to that used in woodworking establishments, only, of course, on a smaller scale. The blowers should lead directly cn the outside of building to the roof, discharging their contents into a “ cyclone ” or separator, w7hence an outside duct carries the lint to a fireproof vault (with vent) detached at least 5 feet from main risk. Inspectors should satisfy themselves that there are no defects in the system, and should follow same from start to finish. MORTALITY OF BUFFERS, FINISHERS, AND POLISHERS— MEDICOACTUARIAL EXPERIENCE. The precautions called for by the introduction of adequate meas ures for the control of the fire hazard are quite certain to react favor ably upon the sanitary conditions of the industry. In American lifeinsurance experience, metal burnishers, buffers, finishers, and polish OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 97 ers, excluding foremen and superintendents, have proven decidedly unfavorable as a class of risks at ages 30 to 59, with an excessive mortality of about 14 per cent. The results of the medico-actuarial investigation with reference to this group of employees are shown in Table 30. The effect of medical selection must be taken into account. T able 3 0 .—M O R T A L IT Y FR O M A L L CAUSES AMONG M E TA L B U R N ISH E R S, B U F F E R S, FIN ISH E R S , A N D PO L IS H E R S , E X C LU D IN G F O R E M E N A N D S U PE R IN T E N D E N T S, B Y AGE G R O U PS—M E D IC O -A C T U A R IA L IN V E S T IG A T IO N . Age at death. Number exposed to risk 1 year. Actual deaths. Expected deaths. Ratio of actual to expected deaths. 15 to 29 years............................................................................ 30 to 39 years............................................................................ 40 to 49 years............................................................................ 50 to 59 years............................................................................ 60 years and over..................................................................... 7,601 5,500 1,422 316 35 28 35 ‘ 14 7 2 34.47 30.78 12.35 6.15 1.27 81 114 113 114 157 Total, 15 years and over.............................................. 14,874 86 85.02 101 The available evidence regarding the unfaithfulness of this group of occupations is, therefore, quite conclusive. In view of the relatively large proportion of young persons, both men and women, employed at polishing and buffing, the required sanitary precautions are of special importance. The efforts of the Buffers and Polishers’ Union to bring the most trying conditions to public attention are deserving of appreciation. The rigid enforcement of laws enacted to compel factories and workshops where polishing and buffing are being done to install exhaust fans to minimize the dust danger may be laid down as a principle of labor legislation of the first order of importance. Among the dusty trades there are few more typical, on the one hand, of the health-injurious consequences of the continuous inhalation of metallic and mineral dust, and, on the other, of the far-reaching practical possibilities of effective ventilating devices so constructed as to remove the largest possible quantity of dust at the point of origin and of preventing general air pollution to the largest attain able degree. MORTALITY OF POLISHERS— INDUSTRIAL INSURANCE EXPERIENCE. The most conclusive ^mortality statistics concerning polishers are the industrial insurance experience data of the Prudential Insurance Co. of America for the period 1897 to 1914, including 964 deaths from all causes, of which 355, or 36.8 per cent, were from pulmonary tuberculosis. 106811°— 18— Bull. 231------ 7 98 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 3 1 .—P R O P O R T IO N A T E M O R T A L IT Y FROM P U L M O N A R Y T U B E R C U L O S I S AMONG P O L IS H E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L C O ., 1897 T O 1914, C OM PARED W IT H T H A T OF A L L MALES IN U N IT E D STATES R E G I S T R A T I O N A R E A , 1900 TO 1913, B Y A G E GROU PS. T able Per cent of deaths from pulm onary tubercu losis among— Deaths of polishers, 1897 to 1914, from— Age at death. All causes. Pulmo nary tu berculosis. Polishers. Males in registration area, 1900 to 1913. 43.4 56.1 44.0 24.9 14.3 27.0 30.5 23.4 14.7 7.9 36.8 13.9 15 to 24 years........................... .............................................. 25 to 34 years............................................................................ 35 to 44years............................. ............................................ 45 to 54 years............................. ........................ .................... 55 to 64 years............................................................................ 65 years and o v e r . .............................................................. 136 230 241 173 112 59 129 106 43 16 72 2 Total, 15 years and over............................................. 964 355 2.8 2.6 According to Table 31, the proportionate mortality of polishers from pulmonary tuberculosis is relatively excessive at all ages, but particularly so at ages 25 to 34, at which 56.1 per cent of the deaths of polishers from all causes are from pulmonary tuberculosis, against an expected proportion of 30.5 per cent. The excess in the pro portionate mortality is, however, significant and suggestive at all ages, and sufficiently so to warrant the final conclusion that the mortality from pulmonary tuberculosis in this occupation must be considered as decidedly above the normal for the general popu lation, although somewhat below the corresponding average for grinders. CARD GRINDING. The so-called “ carding” of the cotton in the manufacture of cotton textiles is an exceedingly important process. Good card ing depends upon good grinding, for if the grinding is not done to perfection, the setting of the cards can not be done with anything like accuracy. The surface of the grinding rollers is usually covered with emery-filleting, and the grinding itself is principally done by the large grains of emery with which the outer surface of the roller is covered. There is, therefore, a mixed exposure of metallic and vegetable fiber dust, particularly in the cleaning process, since, when the grinding is considered sufficient or u finished,” the cards must be well brushed to clear away the dust, etc. The object of carding is to “ disentangle the fibers of cotton and lay them lengthwise and parallel with each other.” This process necessarily results in the production of a considerable amount of fine fluff, of vegetable fiber origin, inter mixed with the metallic dust resulting from the use of emery sub stances. The quantity of emery dust generated in this process is, however, apparently not very serious, and more importance is at OCCUPATION'S W IT H EXPOSURE TO METALLIC DUST. 99 tached to the cotton-fiber dust which must necessarily tend to increase the health-injurious nature of this, as well as all other employments in the carding room. Whether there is any essential difference in the health and mortality of card grinders as differentiated from carders is difficult to determine in the absence of trustworthy statis tical information. Such observations as have been made regarding the personal physical appearance of employees in connection with this process have been suggestive of health-injurious results. The total number of persons reported as being employed at card grinding during the census year was only 1,091, of which 1,087 were males and 4 females. On account of the small number reported employed, the age returns can not be considered conclusive. Card grinding, apparently, is quite often carried on in connection with other employments in the carding room,, and this is especially true of small cotton mills. FILE CUTTING. ] The specific effect of this occupation on health and longevity is medically recognized in the term “ file-cutters’ disease,” which is a form of pneumoconiosis. The occupation is rarely carried on en tirely by itself, and there are no trustworthy data regarding even the approximate number of men employed in this industry. The making of rasps and files is generally carried on in connection with other branches of the toolmaking industry. An important center of manufacture is the city of Newark, N. J., but no conclusive data regarding the mortality of men employed in this occupation have been made available through local vital statistics. How far file cutters require to be differentiated from file grinders is not ascer tainable at the present time. VARIATIONS IN OCCUPATIONAL EXPOSURE. ^ Much of the modern work is done on wet grindstones, by means of which the dust hazard has been materially reduced. Workers on dry emery wheels are, of course, excessively exposed to a mixed dust hazard of metallic and mineral origin. Aside from the dust hazard, there is a liability to lead poisoning in connection with the harden ing process. By some authorities the hardening process is considered more injurious than the dust exposure. The occupation is briefly diseussed in the Report of the Massachusetts State Board of Health upon the Sanitary Condition of Factories, etc*, 1907, in part, as fol lows: In the manufacture of files the workmen are exposed to a double danger, namely, exposure to metallic dusts and contact with me tallic lead. The best files are cut by hand, no machine having as yet been invented which can produce their equal. The blanks are first 100 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. ground smooth with the aid of stones, and in this operation consider able mineral and steel dust is caused. During the process of cutting the file lies on a base of lead and the lines are cut by a chisel struck by a heavy hammer. The leaden bed offers sufficient resistance, while at the same time it is sufficiently yielding to prevent a sharp recoil. As the file is cut it is constantly brushed off, usually with the hand, which thereby becomes to a certain extent coated with very fine particles of lead, and the air becomes more or less impregnated with lead and steel dust. A common habit of file cutters in manipulating the file is to wet the finger and thumb with the tongue, thus convey ing to the mouth particles of lead, which, through the acts of con scious and involuntary swallowing, gain access to the stomach. The work is very laborious, and the attitude which the workmen are obliged to assume is one which does not admit of normal respiratory movements, since they sit at a bench and stoop over the file. The workmen of this class are notoriously careless, and are inclined to reject the idea that their calling is not free from danger; but, although in the establishments visited an occasional workman was observed to be pale and sickly in appearance, it must be admitted that as a class they looked well and strong. Five shops of this class, employing from 5 to TO persons (150 in all), presented reasonably good hygienic conditions. All showed fairly good ventilation, and but two were not well lighted. In two, employing, respectively, 8 and 60 workmen, considerable dust wTas perceptible in the air. In 1903 the British Government published a report on the pro posed draft regulations relating to the process of file-cutting by hand, which among other observations includes the statement that— The trade of file cutting by hand is one that may be distinctly classed as dangerous and certainly in need of regulation; in addition to this, in Sheffield at all events, the trade is, generally speaking, car ried on under most insanitary conditions. The principal danger to the worker arises from the handling of the lead bed on wThich the file is cut, and from inhaling the lead dust produced by the blows of the hammer in cutting the files, and in brushing the files when cut. * * * It seems to be the better opinion that the danger arising from the handling of the lead bed was greater than that from the inhalation of the dust As the result of using the lead bed the file cutter by hand is peculiarly liable to plumbism and to nervous and urinary diseases. Phthisis is also a disease to which the file cutter is subject considerably in excess of workers in most other trades; this seems to be due to the insanitary conditions under which he works acting on a system already enfeebled by the mischief of the lead. * * * The expression “ file maker ” includes file cutters by machinery as well as file cutters by hand. Now, as file cutting by machinery does not involve the use of the lead bed and is not carried on under the insanitary conditions prevailing in file cutting by hand, file cutting by machinery can not be said to be a dangerous trade. It is therefore obvious that the mischief amongst file cutters by hand is greaterHhan that given by the tables as occurring amongst file cutters as a whole. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 101 The subject has also been discussed in the Third and Fourth Interim Reports of the Dangerous Trades Committee of the British Home Office, 1898-99. In the absence of strictly conclusive mortality data with a due regard to ages at death and the causes thereof, the available information must be considered rather inconclusive. DESCRIPTIVE ACCOUNT OF SANITARY CONDITIONS IN OHIO. Hayhurst has reported, for Ohio, the results of an investigation of four establishments employing 108 male wage earners, including some machine file cutting in two establishments. It is stated that there were no special devices which could be designated as health appliances in any of the plants, even the forges in a large plant being without hoods and vents. According to this investigation— Dust was a hazard to grinders in all places, although the principal work was done in the wet on large grindstones. The friction heat present, however, with the flying of sparks, caused a certain amount of fine dust to escape, in spite of the water. There were a number of unprotected emery wheels. Polishing was also done by sand blasts. A small but constant amount of dust was also produced dur ing cutting which always contained some lead scraped loose from the “ bed ” which supported the file. Workers’ faces were also quite close to the work. None of the places visited was exemplary in mat ters o*f cleanliness and order, while in three there was plenty of dirt and waste accumulations. A dirt floor was present in one place located in basement-like quarters. Dampness was a feature of the work in the grinding rooms, where the water occasionally escaped from the grindstones and soaked up the floors. The lighting of the quarters was good in two places and poor in the other two, in one of which oil lamps were depended upon for the principal illumination. The general ventilation of quarters was fair to good. The ceilings in one place were scarcely 7 feet high. Contamination existed from heating ovens, forge gases, tempering pots, and annealing furnaces, and from crude heating arrangements in two places. The question of fatigue is not debatable, at least for the skilled workers. There is an unusual amount of reduplication of the same movements and monotony in the hand cutting process (from continuous mallet and. chisel work) and also in grinding, with the assumption of awkward, stooped postures in both processes and pressure against the body. It is estimated that the cutter strikes 45,000 blows a day in turning out his quota of files. In one plant practically all work was piece work, while noise was excessive from trip hammers. The workday was 9 hours in the smallest place and 10 hours in the other three, with one-half hour for a noon recess. The liability to the contrac tion of communicable diseases was considerable in all places, due to the use of common drinking cups, promiscuous spitting upon the floors, and in dust and dirt accumulations, the absence of washing facilities in two places, poor toilet arrangements, and the presence of dust and dirt from the processes. The liability to industrial poison ing was considerable for the hand cutters where soft lead plates wTere used beneath the files worked upon, due to the creation of a fine dust and to the lack of personal care in keeping the soiled fingers away 102 MORTALITY PROM RESPIRATORY DISEASES IN DUSTY TRADES. from the lips. Again, in the lead tempering process (part of the tempering was done by heating in charcoal and coke and then im mersing in brine), there were the same hazards as described under this process elsewhere. Chronic or slow lead poisoning is the form of the disease most likely to be present, although the personal factor of carelessness might produce acute poisoning in a short space of time. In addition to the foregoing observations it is pointed out that special emphasis was placed upon the risk of lead'poisoning, and that in some places there appeared to be an unnecessary exposure to dust from grinding processes which apparently could have been easily equipped with a blower system. Reference is also made to a statement by Sir Thomas Oliver that— The death rate of the cutters from pulmonary phthisis and lead poisoning exceeds the mortality standard of ordinary occupied males by 90 per cent, and after 35 years of age it is still higher. FILE CUTTING BY HAND AND BY MACHINERY. The conclusion advanced in the report on the draft regulations con cerning the process of file cutting by hand, that file cutting by ma chinery removes part of the hazard, is sustained by the Ohio inves tigation. That the risk has elsewhere been recognized is brought out by the fact that the German Imperial Board of Health has issued a special circular concerning health precautions to file makers, the text of which, however, has not been available for the present pur pose. W. Gilman Thompson refers to the industry in his treatise on46The Occupational Diseases,” in part, as follows: In cutting the ribs of files the articles are ^imbedded in a block of lead, which offers the proper degree of resistance or rebound when the cutting chisel is struck by the hammer. Much lead dust, besides iron filings, is thus produced, and the workmen have the habit of moistening the fingers in the mouth to obtain a firmer grasp upon the cutting instrument. Thus they both swallow and inhale much lead dust. Wooden or tin blocks may be used to replace the lead, but are less satisfactory. The increasing use of file-making machinery is doing much to lessen the frequent cases of lead poisoning which characterize this trade, but as the machines strike from 400 to 1,000 blows a minute they raise considerable lead dust. LEAD POISONING. Thompson quotes White to the effect that a out of 100 English file cutters examined by him 74 exhibited the results of lead poisoning, while the mortality of the trade was found to be excessive. Leaning over the work and raising the lead dust by hammering constitute the special risk, apparently.” Thompson also quotes Sprenger, ac OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 103 cording to whom u among 93 file makers examined in Berlin more than 5 per cent were afflicted with lead poisoning after having been at work a little more than two years.” Apparently the risk of lead poisoning is more serious than the inhalation of metallic and mineral dust; but, as said before, ac curate and conclusive data concerning this occupation are not at present available. The only statistical reference of value occurs in the Supplement to the Sixty-fifth Annual Report of the Registrar General of Births, Deaths, and Marriages in England and Wales, in part, as follows: File makers experience more than twice the average mortality from nervous diseases and nearly four times the average from Bright’s disease, but cutlers experience comparatively little excess of mor tality from either of these causes. In both industries the mortality from phthisis is enormous, the figure for cutlers being nearly three times and that for file makers more than twice the standard, and in both occupations the mortality from respiratory diseases approaches double the standard. Both these workers, however, experience a low mortality from influenza, from alcoholism and liver disease, and from accident, while among file makers the mortality from cancer is also less than normal. GENERAL CONCLUSIONS. This statement sustains the earlier conclusion that this occu pation is not readily separated from other employments, chiefly the manufacture of cutlery and tools, with which it has much in com mon. The general conclusion is that the employment is one involving serious dust hazards demanding more qualified medical and admin istrative consideration. TOOL AND INSTRUMENT MAKERS. The manufacture of tools and instruments includes a large number of grinders and polishers, but it is not possible to classify the occupa tions in detail. In the United States census statistics the industry includes cutlery manufacture, while in English mortality statistics the group comprehends tool, file, and saw makers, cutlers and scissors makers, and needle and piti makers. The statistics of 1910 for the United States return 20,212 males of known ages, 10 years or over, employed in this industry as previously defined, and of this number 3,669, or lg.2 per cent, were 45 years of age or over. The propor tion attaining to old age was, therefore, somewhat larger than expected, considering the high rate of mortality of grinders and polishers, and others employed in the manufacture of tools, instruments, etc. 104 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. SANITARY CONDITIONS OF EMPLOYMENT IN MASSACHUSETTS, A special investigation into the sanitary conditions of this employ ment was made by the Massachusetts State Board of Health in 1907, and the report included a number of very valuable and suggestive references to conditions unfavorable to health and life, from which the following extracts are made: From a sanitary point of view, the one important part of this in dustry is the reduction‘ of the surface of the article in process of manufacture from the roughness of the original casting to the smoothness and brilliancy so necessary and desirable in the finished product. This involves successive treatment by wet grinding, dry grinding on emery and corundum wheels, and polishing with rouge on buffing wheels. Each of these processes, even that of wet grinding on large, coarse, and finer stones, causes to be cast into the air large amounts of fine dust, made up of very fine particles of steel and of the abrasive substance. In establishments properly equipped and conducted, provision is made to reduce the danger of this dust to a minimum by means of hoods connected with a system of exhaust fans or blowers. In spite of the precautions taken to protect their health, a very large proportion of grinders recklessly remove the hoods, and thus expose themselves unnecessarily to this especially dangerous form of dust. They assert that they prefer freedom of movement with dust to the protection afforded by hoods. The workmen are not, as a class, long lived; indeed, the nature of the work is not compatible with longevity, and a person entering upon it in middle life is unlikely to follow it many years. Whatever the age at which the trade is taken up, a man in sound health who has followed it a fewTyears is an acknowledged rarity. A study of the death returns of the city of Northampton, which is one of the centers of this industry, for the past 12 years, yields facts which can be interpreted in only one way. During this period tuberculosis is given as the cause of death in no less than 54.5 per cent of those wbose oc cupation is indicated by “ grinder ” or “ polisher,” and in 45.4 per cent of those designated generally as “ cutlers,” and of the latter 36.4 per cent died of pneumonia. Taken together, the “ grinders,” “ polishers,” and “ cutlers ” returns shbw that, during this period, diseases of the lungs were responsible for 72.73 per cent of their mor tality. As was shown in the preliminary report on this industry, the tuberculosis death rate for cutlers in Northampton is four times as high as that for the entire adult male population. DIFFICULTIES IN EFFECTIVE VENTILATION. A difficult problem in the cutlery and tool industry is how to secure effective ventilation, and many of the factories and workshops in spected were found to be seriously defective in this respect. A large proportion of the workmen, including many young boys, are exj)osed to considerable dust, chiefly, of course, in the grinding and polishing departments. While much has been done to improve the sanitary conditions by artificial ventilation, there has been but a very OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 105 indifferent cooperation on the part of the operatives themselves, and many in fact are interfering with the arrangements made for their protection to the extent of removing the hoods and exhaust pipes installed for the purpose of carrying off the dust. VITAL STATISTICS OF ENGLISH TOOL AND CUTLERY MAKERS. The most valuable official statistics are those for England and Wales, published at decennial intervals in the supplements to the reports of the registrar general of births, deaths, and marriages. Only two comparatively recent investigations are here referred to. The first of these, for the three years ending with 1892, included 2,529 deaths from all causes, of which 505, or 20 per cent, were from pulmonary tuberculosis. Of diseases of the respiratory system other than pulmonary tuberculosis, 384 deaths were from bronchitis, 286 from pneumonia, and 78 from other diseases of this group, a total of 748, or 29.6 per cent, of the mortality from all causes. Combin ing the mortality from pulmonary tuberculosis and other respira tory diseases, it is found that 49.5 per cent of the deaths of tool and instrument makers, as previously defined, were from diseases of the lungs and air passages. The most recent English mortality statistics of tool and cutlery manufacture are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Report of the RegistrarGeneral of Births, Deaths, and Marriages in England and Wales, in part as follows: In the occupation as a whole the mortality at ages under 25 is below the standard for occupied and retired males; but among file makers the death rate at these ages exceeds the standard. Beyond age 25 the mortality in the whole occupation, as well as among cut lers and file makers, considerably exceeds the standard. At ages 45 to 65 years the death rate among cutlers is 72 per cent and that of file makers is 84 per cent above the average. Within the main working period of life the comparative mortality figure for the whole occupa tion is 1,315, or 31 per cent, above the standard. The mortality from lead poisoning is nine times and that from phthisis is nearly double the standard, and these workers suffer excessively from nervous, cir culatory, respiratory, and urinary diseases. On the other hand, the mortality from alcoholism and liver disease and from accident is about half the average. Among cutlers and file makers the compara tive mortality figures considerably exceed the average for the entire occupation, the figure for the former being 56 per cent above the standard for all occupied and retired males, while that for the latter is 69 per cent in excess. Indeed, these two occupations appear to be the most unhealthy in the whole group of workers in metal. It should be mentioned in this place that the occupation of file maker is one that is specially liable to lead poisoning, the mortality figure for plumbism being no less than 56, whilst among all occupied and retired males the mortality is represented by unity. 106 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. File makers experience more than twice the average mortality from nervous diseases and nearly four times the average from Bright’s disease, but cutlers experience comparatively little excess of mortal ity from either of these causes. In both industries the mortality from phthisis is enormous, the figure for cutlers being nearly three times and that for file makers more than twice the standard, and in both occupations the mortality from respiratory diseases approaches double the standard. Both these classes of workers, however, experi ence a low mortality from influenza, from alcoholism and liver dis ease, and from accident, while among file makers the mortality from cancer is also less than normal.1 MORTALITY F0E3C PULMONARY TUBERCULOSIS AND NONTUBERCULOUS RESPIRATORY DISEASES. The English occupation mortality statistics for men employed at tool, instrument, and cutlery making are quite conclusive of the more or less unfavorable effects of this industry on health. In Table 32 a comparison is made of the mortality from all causes among men in this group with occupied males generally, and the result is de cidedly suggestive of conditions in this trade more or less unfavor able to life and health, but in particular at ages 45 or over, when the general mortality of this class exceeds the general average by from 8.24 to 12.26 per 1,000. 3 2 .— M O R T A L IT Y FR O M A L L CAUSES AM ONG T O O L ,IN S T R U M E N T , A N D C U T L E R Y M A K E R S , C O M PA R E D W IT H T H A T OF A L L OCCUPIED M A LE S, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E GR O U PS. T able [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate for tool, instrument, and cutlery makers. Age at death. 15 to 19 years............................................................................ 20 to 24 years............................................................................ 25 to 34 years........................................................................... 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over........: ........................................................... Death rate per 1,000 for all occupied males. 2.44 4.41 6.01 10.22 17.73 31.01 88.39 Rate per 1,000. 2.09 3.32 6.32 13.65 25.97 42.05 100.65 Greater ( + ) or less ( —) Per cent of than rate rate for all for all occupied occupied males. males. - 0.35 - 1.09 + .31 + 3.43 + 8.24 + 11.04 +12.26 86 75 105 134 146 136 114 The preceding table is self-explanatory. A more extended com parison, however, is made in Table 33, in which the mortality of tool, instrument, and cutlery makers from pulmonary tuberculosis and other respiratory diseases is compared with the normal mortality of occupied males from these diseases by divisional periods of life. The comparison shows that at ages 25 and over the mortality from pul 1 P a r t I I , Supplem ent to the S ix ty -fifth A n n u al R e p o rt o f the R e gistra r-G en era l o f B irth s, D eaths, and M arriages in E n gla n d and W ales, pp. lx ix , lxx. OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 107 monary tuberculosis is excessive among tool, instrument, and cutlery makers, and decidedly so at ages 35 to 64, inclusive. The table further shows that the mortality from other respiratory diseases is excessive among men in this class, but.decidedly so at ages 45 or over, reaching the highest rate at ages 65 and over, when the excess is 7.69 per 1,000. The two tables, derived from English experience, fully confirm the previous conclusion that the mortality of tool, in strument, and cutlery makers is excessive when comparison is made with the normal mortality of occupied males generally, and that this excess is largely because of a high degree of frequency of pulmonary tuberculosis, particularly at ages 25 to 64, when the excess is from 0.91 to 4.09 per 1,000. 3 3 .—M O R T A L IT Y FROM P U L M O N A R Y TUBERCULOSI-S A N D F R O M O T H E R DISEASES OF T H E R E S P IR A T O R Y SYSTEM AMONG TO O L , IN STR U M E N T, A N D CUT L E R Y M A K E R S, COM PA R ED W IT H T H A T OF A L L OCCUPIED M ALES, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A GE G R O U PS. T able [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Mortality from pulmonary tuberculosis. Mortality from other diseases of the respi ratory system. Death rate for tool, instrument, and cutlery makers. Age at -death. Deatih rate per 1,000 for all occupied males. 15 to 19 years....... 20 to 24 years....... 25 to 34 years....... 35 to 44 years........ 45 to 54 years....... 55 to 64 years____ 65 years and over. 0.54 1.55 2.03 .2. 74 3.04 2.1=6 1.11 Death rate for tool, instrument, and cutlery makers. Death rate per Greater ( + ) Greater ( + ) 1,000 for Gent or less ( —) Per cent or less ( —) Per all of rate of rate occupied Rate per than rate Rate per than rate ■for all -for all for all males. for all 1,000. 1,000. occupied occupied occupied occupied •males. males. males. males. 0.17 1.57 2.94 5.90 7.13 5.26 1.97 -0 .3 7 + .02 + .91 +3.16 +4.09 +3.10 + .86 31 101 145 215 235 244 177 0.24 .48 .77 1.66 3.32 •6.54 17.77 • 0.23 .56 1.14 2.01 5. 40 10.42 25. 46 -0 .0 1 + .08 + .37 + . 35 +2.08 +3.88 +7.69 96 117 148 121 163 159 143 MORTALITY OF T0OL AND CUTLERY MASTERS— UNITED STATES REGISTRATION AREA. The mortality of American tool and cutlery makers has been re ported upon by the Division of Vital Statistics of the United States Census Bureau only for the year 1909, and no subsequent information has been made public, so that the data are of rather limited value. According to the census report, out of 241 deaths of tool and cutlery makers from all causes, 58, or 24.1 per cent, were from pulmonary tuberculosis, which compares with 17,8 per cent for jewelers and 29.5 per cent for printers, lithographers, and pressmen. On account of the rather peculiar age distribution the general average, however, for all ages can not be safely utilized for comparative purposes. The details of the mortality of tool and cutlery makers by divisional periods of life are shown in Tables 34 and 35. 108 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 3 4 .—P R O P O R T IO N A T E M O R T A L IT Y OF T O O L A N D C U T L E R Y M A K E R S F R O M P U L M O N A R Y TU BE R CU LO SIS, U N IT E D S TATE S R E G IS T R A T IO N A R E A , 1903, B Y A G E G R O U PS. - Deaths from pulm o nary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years.................................................................................................. 25 to 34 years.................................................................................................. 35 to 44 vears.................................................................................................. 45 to 54 years.................................................................................................. 55 to 64 years................................................................................................. 65 years and over.......................................................................................... Age unknow n................................................................................................ 22 37 45 38 42 56 1 4 15 19 10 8 2 18.2 40.5 42.2 26.3 19.0 3.6 T otal, 15 years and over.................................................................... 241 58 24.1 T able 3 5 .—P R O P O R T IO N A T E M O R T A L IT Y OF T O O L A N D C U T L E R Y M A K E R S F R O M N O N T U B E R C U L O U S R E S P IR A T O R Y D ISEASES, U N IT E D S T A TE S R E G IS T R A T IO N A R E A , 1909. Deaths from nontuber cuious respiratory dis eases. Cause of death. Number. Per cent of deaths from all causes. A sthm a...................................................... ........................................................................... Bronchitis.............................................................................................................................. Pneumonia............................................................................................................................ Other nontubercuious respiratory diseases..................................................................... 3 23 3 1.2 9.6 1.2 T otal............................................................................................................................ 29 12.0 Table 34 emphasizes a decidedly excessive proportionate mor tality from pulmonary tuberculosis among tool and cutlery makers at ages 25 to 64, inclusive. There is also, as shown in Table 35, a relatively high proportionate mortality from nontubercuious re spiratory diseases, equivalent to 12 per cent of the mortality from all causes, chiefly attributable to pneumonia. The proportion of deaths from pneumonia is 9.6 per cent of the deaths from all causes, W 'h i c h compares with 5.8 per cent for jewelers and 6.8 per cent for printers, lithographers, and pressmen, according to the data derived from the same official American sources. MORTALITY OF TOOL AND INSTRUMENT MAKERS— INDUSTRIAL INSUR ANCE EXPERIENCE. The only other available mortality data of tool and instrument makers are derived from the industrial insurance experience of the Prudential Insurance Co. of America for the period 1897 to 1914, in cluding 533 deaths from all causes, of which 170, or 31.9 per cent* OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 109 were from pulmonary tuberculosis. Table 36 is not, however, strictly comparable with Table 34 on account of probably important differ ences in the classification of the occupations considered. T a ble 3 6 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU BE R CU LO SIS AMONG T O O L A N D IN STR U M E N T M A K E R S, IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R ED W IT H T H A T OF A L L M ALES IN U N IT E D ST A TE S R E G IS T R A TION A R E A , 1900 TO 1913, B Y A G E GROUPS. Deaths of tool and in strument m a k e r s , 1897 to 1914, from— Age at death. All causes. Per cent of deaths from pulmonary tubercu losis among— Pulmonary Tool and in Males in tubercu strument registration area, 1900 makers. losis. to 1913. 15 to 24 years............................................................................ 25 to 34 years........................................................................... 35 to 44 years........................................................................... 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and ovei*................................................................... 88 93 111 98 67 76 33 49 41 33 7 7 37.5 52.7 36.9 33.7 10.4 9.2 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.............................................. 533 170 31.9 13.9 According to this table the proportionate mortality from pulmo nary tuberculosis is excessive at every divisional period of life, but particularly so at ages 25 to 34, at which, of the mortality from all causes, 52.7 per cent is from pulmonary tuberculosis. The data for this group of occupations are not, of course, entirely conclusive, in that the group considered includes a number of special employ ments of a varying degree of metallic-dust exposure. Since tool and instrument manufacturing is frequently combined with the cutlery and related trades the latter must be taken into ac count for comparative purposes. In all of these trades grind ing, polishing, and buffing are incidental operations, and: though elsewhere separately considered, these are practically inclusive of the entire group of tool and instrument-making and the cutlery industries. GENEBAL CONCLUSION'S. With a.due regard to these rather serious limitations it is safe to conclude that, considered as a group, the manufacture of tools and instruments must be considered as one of the distinctly unhealthful trades, and primarily so on account of continuous and considerable exposure to the inhalation of metallic dust* SAND BLASTING. This is a rather obscure occupation, regarding which the literature is of very limited extent. The census of 1910 returns only 101 persons employed as sand blasters in connection with the iron and steel indus try, but in all probability the number so employed is much larger. 110 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. There are no occupation mortality data regarding this employment, which, from a hygienic point of view, is of considerable impor tance. DESCRIPTIVE ACCOUNT OF SAND-BLASTING PROCESSES. The most useful discussion of this occupation occurs in Hayhurst's Ohio Survey of Health Hazards, as follows: Sand blasting is a process in which fine sand or similar hard sub stance is forced through a pipe by compressed air against objects either for the purpose of cleaning their surfaces or of giving them an etched, frosted, or rough effect.„ Hence the process is used upon a considerable variety of materials. As it is very rapid, usually only a few workers are so employed even in very large establishments. Our investigations covered the process in 9 different industries, viz, automobiles, cars, carriages, electrical apparatus, brass^ iron, glass, cutlery and tools, and machine manufacture. There were 51 wage earners, all males, found so employed. For some work considerable skill is necessary, but in the majority of instances it is a process for unskilled labor. Retention at the process was good in 3 places, fair in 3, and very brief in the remaining 3. Health appliances, consist ing of isolation of the process in a room by itself and within a cup board through which the worker inserted his hands, or the wearing of a helmet covering the entire head—these features were found good in 3 places, fair in 3, and practically absent in the remaining 3. Instructions to limit the dust in order to conserve the health of the worker were good in 5 places, but very little attention was paid to the same in^the remaining 4. In but 1 place did the workers enjoy the privilege of a sick-benefit association. The work wTas done in the same quarters with other processes in 3 instances, so that other workers were exposed to the fine dust created. Of all the employees, 13 were over 40 years of age and 38 under 40. DUST AND OTHER HEALTH HAZARDS. Dust in the breathing atmosphere was a negligible factor in 2 places, a fair hazard in 4, and bad in 3. Cleanliness of quarters took about the same proportions. Dampness was no feature of the process, nor were harmful light effects. Heat, due to the proximity to other processes as a rule, was bad in 1 place, fair in 2 more, and no feature in the remaining 6. Cold weather, due to performing the work, protected only by a roof, was a feature in 2 places. Fatigue was not a special hazard, although hurrying piecework, monotony, and constant standing were features in one-third of the places. The workday was from 9 to 10 hours in all places. The noon recess was 1 hour in 1 place, three-quarters of an hour in 3, and one-half hour in 5 places. The liability to the contracting of communicable diseases was negligible in 3 places, a fair risk in 5, and bad in 1, due, prin cipally, to the breathing of fine dust in quarters where there was promiscuous spitting, absence of cuspidors, inadequate washing facili ties and improper closets, and the failure to inquire into the fitness of the workers for such work. Poisoning was no feature. The gen eral factors favoring stimulantism were the irritating effects of fine dust inhaled and swallowed and the absence of good drinking-water OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. I ll facilities in some places. The health appearance of the workers was not good in one-third of the places. The workers’ complaints were the breathing of dust, skin irritation in hot weather, and the ineffi ciency of some of the hoods used, while in 1 place the manager said they were having it done at night because it made so much dust. Comments.—Such work should be done in a manner to keep the dust away from the employee, such as confining the process within an impervious cupboard, through which armholes are made, or having it done in a dust-tight room in which the worker should be supplied with an impervious suit and helmet, to which is attached an air tube supplying him with fresh outdoor air under pressure. The simple wearing of respirators, even of helmets, without such air tubes is not at all efficient, as can be demonstrated by noting the amount of fine dust settled upon the workmen’s features when such coverings are removed. Many places substitute sand blasting by cleaning small ' pieces in a rattler. The occupation was inquired into by the New York State Factory Investigating Commission and briefly referred to in its second re port (Vol. II, pp. 420 and 479,1913). It is said that-^Sand blasting is still done in closed bins or basements by ancient and crude methods, without any other protection to the workers than a cloth over the mouth and nose. The fumes from pouring molds are allowed to disseminate in the air of shops, fume vents being found in but few plants. Temperatures are often very high, especially near the furnaces. With special reference to the use of respirators in connection with this process, it is stated that— Neither in sand blasting nor in lead works nor in any other occu pation where the presence of poisonous gases, and excessive amounts of dust vitiate the air have respirators been uniformly used. The managers and owners resort to the same plea, viz, the ignorance of the worker and his willful abandonment and neglect of these pro tective appliances. Few of these managers provide their employees with them, and still fewer make their use compulsory. A brief descriptive account of the process of sand blasting in con nection with castings, in open sheds, is given by Hanson, in his “ Dangers to workers from dusts and fumes, and methods of pro tection,” in Bulletin 127, published by the United States Bureau of Labor Statistics. 44It is observed in connection with the process that men who do the work are not properly protected, since the helmet does not prevent the inhalation of very fine steel, iron, or brass dust.” With reference to sand blasting castings in closed rooms, an “ im proved helmet” is described, but even this appliance is considered an inadequate protection. MOST DANGEROUS OP ALL MINERAL-DTJST -HAZARDS. The most recent and thoroughly well-considered observations con cerning sand blasting are by W. Gilman Thompson, and on account of 112 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. their importance they are quoted in full from his treatise on “ The Occupational Diseases” : The sand blast is an apparatus constructed to blow a stream of sand by means of compressed air with great force against metal castings, to clean them from the earth which adheres from the cast ing molds and to smooth roughened surfaces. It is also employed in cleaning stone and marble buildings and for the roughening of the surface of glass to make “ ground glass ” and sometimes to mark patterns upon glass, which is partially protected. Sand blasting constitutes probably the most dangerous of all the mineral-dust hazards, and it is impossible to engage in the work without protec tion of the eyes and face, for the sharp particles of fine silicious sand are driven with such force against the objects operated upon that they rebound toward the workman, and, despite the use of long hose to conduct the blast a.way from the operator, the surrounding air is constantly filled with flying sand, resembling a sandstorm in the desert. The helmets in use for sand blasting can not have glass windows, but fine wire netting shields the eyes, and cloths are in serted to breathe through. An important method of reducing the risk of dust from the sand blasting of metal castings is covered by a recent patent of C. Wedemeyer, of Hamburg. The operator stands in a cabinet directing the sand blast away from himself toward the casting. Over his head, at an angle of 45°, a strong blower fan directs a stream of air also upon the casting with such force that the dust of both sand and metal is blown downward toward the opening of a large exhaust tube just above the floor. In this manner a strong, continuous draft blowTs the dust away from the operator and out of the cabinet through the aspirator duct, which is connected wTith a powerful exhaust fan. The descriptive illustration by Thompson, in addition to the pho tographic reproductions of sand-blasting processes by Hanson, in Bulletin 127 of the United States Bureau of Labor Statistics, pre viously referred to, emphasize the necessity for thoroughly effective safety precautions, more or less in conformity to the German method, under which the operator is inclosed in a room or cabinet in which he directs the blast of sand and compressed air against the casting in front while a strong air current is forced from directly above his head by a fan and passes outward toward a revolving, aspirating drum' on the right. The illustration used by Thompson is from Rauch und Staub (ii, Feb. 5, 1912). COMBINED METALLIC AND MINERAL DUST EXPOSURE. The preceding statements suggest the existence of more or less health-injurious conditions, the control of which at present ap pears to receive inadequate technical consideration. Conditions, of course, must vary ^according to the quality and degree of fineness of the sand used. In the handling of sand in glass factories serious respiratory difficulties have been experienced in much the same manner as in sand-blasting operations, though apparently to OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 113 a lesser degree. The occupation, though of rather limited extent, is obviously one which demands more qualified technical consideration regarding its hygienic aspects and the probably quite needless waste of life and health. Of course in the actual operation of sand blast ing there results a mixture of metallic and mineral particles, of which the former are distinctly more injurious to health than the latter. It is for this reason that the occupation has been included among employments where the chief exposure is to metallic dust. As measured by the quantity of dust. exposure, however, sand blasting more properly belongs to the group of employments with exposure to mineral dust. Thompson for these reasons includes sand blasting under occupations where the chief exposure is to min eral dust. PROTECTIVE, SAFETY, AND SANITARY DEVICES. The most recent discussion of sand blasting wTith special reference to safety and sanitary considerations is by Joseph Brinker, in the Scientific American for September 2, 1916, who describes in some detail the work of the operator in one room while the blast is car ried on in another, and under conditions which practically exclude the dust hazard or at least the major portion of the same. It is ex plained at the outset that the preparing of metal surfaces for a cov ering of paint has given rise to the extensive use of the sand blast, especially in connection with the manufacture of automobiles. It is said that— When the outfits are constructed of sufficient size to accommodate large surfaces such as mud guards, hoods, and bodies, the problem of protecting the workmen has presented serious difficulties. After explaining that various forms of safety devices for the pro tection of the operator during the sand blasting have been tried, in cluding the common respirator with a sponge through which the operator breathes, though often under serious difficulties, and various forms of helmets similar to the one used in diving, in wrhich fresh air is supplied under pressure, it is pointed out that—The first renders it difficult to breathe; the second type is often so cumbersome that it is discarded by the workmen at their own peril. In fact the history of the use of safety sand-blast devices has proven conclusively that when these may be used or detached at will by the workmen, they are usually discarded, even if such neglect constitutes positive danger. This difficulty has apparently been overcome in the apparatus de scribed by Brinker w7hich makes it necessary for the operator to use the safety helmet if he is to work at all. A brief explanation of the new method is as follows: 106811°— 18— Bull. 231-------8 114 MORTALITY FJKOMRESPIRATORY DISEASES IN DUSTY TRADES. Each sancl-blast room is a small compartment of the double-hopper type in which the heavy particles of the sand used in the cleaning process are drawn out of the lower hopper and the lighter particles out of the upper by air suction. The material to be cleaned is laid on a grating between the two hoppers. It is introduced into the com partment through a door at one end. The sand-blast operator’s head dress, which is of canvas with a fine-mesh copper screen at the front, is securely attached to the inside of a curjbain which forms the front wall of the compartment. This curtain is fastened to sliding metal doors which can be moved horizontally from side to side. In this way it is impossible for the operator to see into the interior of the compartment until he puts his head in the helmet. This being ac complished, he stands on the floor outside the compartment, moving along as is necessary in the progress of his work by pushing the slid ing metal doors to either side with his elbows.1 GOLD-LEAF MANUFACTURE. The work of the gold-leaf beater is nearly all handwork, except in the operation of the rolling machines. The trade is carried on to-day in about the same manner as in ancient times. The weight of the hammer used averages 18 pounds, which is more than that of the hammer used by the average blacksmith. Girls, as a rule, are employed in connection with the less arduous operations and the final packing of the gold leaves in boxes and packages. The tissue used in connection with this process is coated with red chalk, the dust of which, of course, enters into the atmosphere of the rooms, usually badly ventilated. One of the chief difficulties in connection with the ventilation is the fact that the slightest draft of air will carry the scrap of gold leaf from one anvil to another and make packing operations difficult or impossible. Evidence that the fine particles of gold enter the atmosphere is found in the fact that work men with beards turn in less waste gold than clean-shaven workmen, and they are now required to wash before leaving th£ shop, the water being filtered for the recovery of the metal contained therein. EARLY OCCUPATIONAL-DISEASE OBSERVATIONS. Thackrah, writing in 1832, held that goldbeating must be con sidered a distinct employment, aside from the metal trade generally. Goldbeaters are about half the day engaged in beating the metai with heavy hammers and the rest in spreading the gold leaf on paper. By this change in employment the process affords an excellent alter nation of labor and comparative rest. In his opinion the men wTere not exposed to health-injurious conditions and were generally healthy 1 Of much practical importance is a descriptive account of the dustless Hoevel selfcontained sandblast automatic machine and a description in detail of a novel sand blast room, in Safety, published by the American Museum o’f Safety for January, 1918. OCCUPATIONS WITH EXPOSURE TO METALLIC* DUST. 115 and robust.1 It is difficult, however, to accept these conclusions in their entirety. The work of the goldbeater is carried on in rooms the air of which is more or less contaminated and where provision for proper ventilation is extremely difficult if not impossible. The work is often commenced at rather early ages and, in Europe at least, quite a considerable proportion of young persons are employed. Whether gold dust is itself injurious has never been scientifically determined, but it is quite probable that it is less injurious than other metallic dust. DESCRIPTIVE ACCOUNT OF MANUFACTURING PROCESSES. The number of goldbeaters in the United States is small, only 607 male and 76 female workers having been enumerated in 1910. An interesting account of the process of manufacture, by Edward Williston Trentz, is as follows: The goldbeater receives his material in the form of a ribbon about an inch wide and 24 feet long. This ribbon is first cut into 200 squares and placed in the “ cutch,” which is a pile of square pieces of a peculiar paper, part animal and part vegetable in composition, the preparation of which is a secret. A square of gold is placed between each two leaves and the whole mass is ready for the first beating. This is done with an iron hammer, weighing from 12 to 17 pounds, while the cutch rests upon a granite block which is supported by a heavy wooden post. Under the heavy measured blows of the hammer the sheets of gold begin to stretch or expand until, in half or three-quarters of an hour, they have reached the edges of the cutch. They are then removed and, with a thin strip of bamboo, are cut into quarters, so that the 200 pieces become 800. Next comes the “ shoder,” a collection of 800 pieces of skin, 4 inches square, made from the intestines of cattle. As in the cutch, each piece of gold is placed between two leaves of skin, and bands of parchment or vellum are slipped over the whole pile to keep it together. Another beating, this time with a hammer weigh ing from 8 to 10 pounds, now follows. This takes about an hour, during which the sheets of gold are all the time expanding. The last stage is the u mold,” which, like the cutch and the shoder, is composed of alternate leaves of gold and skin, but the mold is about 5 inches square and made up of goldbeater’s skin. The prepa ration of this is a jealously guarded trade secret. A mold contains 1,000 sheets. After the second beating the work man takes from the shoder a single leaf of gold at a time, handling it with bamboo pinchers and, when necessary, smoothing it with a rab bit’s foot. With the strip of bamboo he cuts each sheet into quarters again, so that the original 200 have now become 3,200. One shoder, therefore, contains more than enough gold to fill three molds. The final beating in the mold is done with a 7-pound hammer and requires from three to four hours. By this time the gold leaf should have expanded again to the edge of the skins and should be of the 1 Effects of Arts, Trades, and Professions on Health and Longevity, by C. Turner Thackrah, Loildon, 1832, p. 48. MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 116 requisite thinness, which is determined by holding it up to the light. If it transmits green rays, it is done, and will measure about one twohundred-and-eighty-thousandth (m Voo) an inc^ thickness. The hammers used in beating gold are slightly convex on the face. The art of the workman consists in so striking that the gold will always be thinnest in the center. He must pound with evenness all over the square in order that the sheets of gold may expand without losing their form, but at the same time he must keep the thickest part near the edges, so that when the sheets are finally trimmed to size the thicker portions may fall in the waste to be recast. No machinery has ever been devised which will do this successfully. The tools of the craft are interesting and peculiar. The rabbit’s foot is exceedingly soft and just oily enough to prevent the gold from sticking, and the bamboo pliers and cutting slips are the only things with which it is possible to do this delicate work. The gold does not adhere to the fibers of the reed as it does to steel. The goldbeater performs all this work standing. The use of the heavy hammers in such continuous pounding would, one would think, impose an almost intolerable strain upon the hands and arms. The men say, however, that their arms never ache. The only place where “ it catches them ” is in the bend of the knee. The lack of strain upon the arms is ac counted for by the fact that the hammer rebounds. It is an aston ishing but by no means rare thing to see a goldbeater change hands while the hammer is in the air and without losing a stroke. MORTALITY OF GOLD-LEAF BEATERS— INDUSTRIAL INSURANCE EXPERIENCE. On account of the limited extent of the occupation there are no gen eral vital statistics, but a fairly trustworthy basis of information is furnished by the proportionate mortality statistics of the Pruden tial Insurance Co. of America, as given in Table 37. 3 7 .—PROPORTIONATE M O RTALITY FROM PULM ONARY TUBERCULOSIS AMONG GOLDBEATERS, INDUSTRIAL EXPER IEN CE OF PR U D EN TIAL CO., 1897 TO 1914, COM PARED W IT H THAT OF ALL MALES IN UNITED STATES REG ISTRATIO N A R E A , 1900 TO 1913, B Y AGE GROUPS. T a b le Deaths of gold beaters,. 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. All causes. Males in Pulmonary Gold beat registration tubercu ers. area, 1900 losis. to 1913. 35 to 44 years....... ................................................................... 45 to 54 years ......... ............................................................ 55 to 64 years * . .......................................................... 65 years and over................................................................. 7 12 11 8 4 11 3 8 4 2 42.9 66.7 36.4 25.0 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over........... ................................. 53 17 32.1 13.9 15 to 24 years............................................................................ 95 to 34 years............................................................................ There were 53 deaths from all causes, of which 17, or 32.1 per cent, were from pulmonary tuberculosis. The proportionate mortality was exceedingly heavy at ages under 45, reaching a maximum at OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 117 ftges 25 to 84, when of the mortality of gold beaters from all causes 66.7 per cent was from pulmonary tuberculosis. The rather limited number of observed cases does not warrant final conclusions, but the statistical evidence would seem to confirm the view that the mortality from tuberculosis in this occupation is distinctly above the average. GENERAL CONCLUSIONS. The sanitary problems in this industry are complicated by the fact that, as a rule, the work is carried on in small shops in which it is difficult to apply rational principles of factory hygiene. The actual amount of gold dust inhaled is probably relatively small and, in so far as the tuberculosis problem is complicated by the dust factor, it is quite probable that other surrounding circumstances Teact more unfavorably upon the system than the relatively small amount of metallic dust inhaled during the gold-beating process. As observed by W. Gilman Thompson, “ OwTing to the value of the metal, where gold is being filed or beaten strong ventilation currents can not be used without dissipating the precious gold dust.” Thompson mentions a case personally know~n to him of a goldbeater’s shop “ in which there are no general ventilators and the windows have to be kept closed, but at intervals small hoods are let down over the worktables and the room is kept well aired.” How far it would be feasible to improve upon this method is merely a matter of conjecture. The industry, while of small extent, is, however, strictly within the classification of unhealthful trades and deserving of more careful attention on the part of the sanitary authorities. JEWELERS. The manufacture of jewelry in all its branches involves a large variety of manipulations, including the melting and refining of small quantities of the precious metals, and the handling, shaping, cutting, and polishing of precious stones. An important part of the indus try is engraving and die cutting, which, however, for the present purpose, is separately considered as a well-defined occupation, and although often included with jewelers, is equally often included with printers and compositors. Most of the articles made by jewelers are of small dimensions, such as chains, rings, brooches, pins, and buckles, which require painstaking care in handling and continuous eye-straining attention in shaping and polishing. Aside from the u^e of gold and silver, many other metals and mineral substances are employed, such as jet, coral, tortoise, bone, ivory, etc. Zinc is also extensively used as an alloy and for coloring purposes. The gems must be cut with extreme care, and the work of the diamond polisher and lapidary constitutes, next to that of the gold and silver smith, 118 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. important separate branches of the trade. The manufacture of arti ficial gems, made of a paste, chiefly of a vitreous substance pre pared from rocks and crystals of flint powder, subsequently treated with nitric acid with lead and borax as a flux, forms another im portant subdivision of the industry. ASCERTAINED UNHYGIENIC CONDITIONS. The work of the jeweler is naturally an indoor occupation, involv ing a stooping position, much like that of the engraver. The work shops are generally small and the ventilation is usually poor. The dust generated in the processes of hammering, cutting, shaping, grind ing, polishing, etc., is considerable, but very minute, and not easily observed. The dust accumulations are preserved and sold to refining plants for remelting and the recovery of precious substances. The health problem is complicated by the universal use of blowpipe apparatus and of gas for heating purposes. In large factories the use of machinery is increasing, but chiefly in connection with the manu facture of imitation jewelry and stones. The unhygienic condition of many jewelry workshops and the gen eral effect of this employment on health were discussed at some length in an early treatise by Thackrah, from which is quoted the following: The jewelers’ workrooms are generally crowded, and the atmos phere consequently fouled by respiration, animal effluvia, and the smoke of lamps, as well as by the specific exhalations of the manu facture. Its temperature is generally raised, and in summer the heat is excessive. The labor is light, but the confinement to a leaning posture, with the head much depressed, and the elbow^s generally fixed to the sides of the trunk, for 10, 14, or 16 hours a day, is irksome and injurious. Intemperance is general, and dram drinking es pecially prevalent. The disorders of which jewelers principally complain are pains and soreness of the chest, disorders of the stomach and liver, and plethoric affections of the head. They enter the em ploy at about 13 or 14 years of age and are obliged to abandon it generally at 45 to 50.1 Thackrah continues that “ an old jeweler is seldom to be found, and leaving work, they seem to leave the world as well.” That this rather unfavorable view regarding the health conditions in the jewelers’ trade is not exaggerated is made evident by the fairly trustworthy vital statistics of the trade. The English mortality data of jewelers and allied occupations for the three years ending with 1902 include 2,823 deaths from all causes, of which 598, or 21.2 per cent, were from pulmonary tuberculosis. In addition to a high mortality from pulmonary tuberculosis there were 164 deaths from bronchitis and 247 from other respiratory dis 1 Effects of Arts, Trades, and Professions on Health and Longevity, by C. Turner Thackrah, London, 1832, p. 115* OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 119 eases, a total of 1,009 deaths, or 35.7 per cent, from diseases of the lungs and air passages in the mortality from all causes.1 D E S C R I P T I V E A C C O U N T OF T H E J E W E L R Y I N D U S T R Y . The conditions of employment in the jewelry industry, with spe cial reference, however, to England and Wales, have been admirably described by Arlidge, in part as follows: Mere dealers in jewelry incur no liability to sickness or to a high mortality, except so far as confinement to their shops and insanitary surroundings concur to produce it. On the other hand, some special health conditions are connected with the manufacture of jewelry— of gold, silver, and precious stones. The incidentals are close, very sedentary work, and with it a bent attitude whilst sitting; close application of the eyes, much artificial light, heat from furnaces, crucibles, and the blowpipe, and acid fumes. The working with precious stones entails the minutest attention and observation,* to gether with strong visual exertion and most delicate manipulation with the fingers and forceps or other tools in use. The lapidary’s wheel is a source of dust from the polishing powders used— for the most part rouge, emery, and diamond dust—and, as we le,arn from Proust (Ann. d’Bygiene Publique, 1878), it is likewise a cause of lead poisoning when a lead cylindrical rod is used for polishing cameos. In this proceeding the cameo is held against the revolving rod, and from time to time moistened with a mixture of tripoli powder and vinegar, whence arises a dust consisting of acetate of lead. Nitric acid is largely employed for dipping and to brighten the surface of jewelry, and where many persons are employed in the same shop, and that not well ventilated, there is enough nitrous acid vapor given off to become a source of throat, chest, and stomach irri tation. The frequent contact of the acid also with the skin provokes sores, eczematous eruptions, and cutaneous fissures, besides doing injury to the nutrition of the nails. The leaning position of jew elers over their work aggravates all the other unhealthy incidents of their occupation. The evils of dust production attend the makers of polished steel ornaments in a much higher degree than lapidaries by reason of the larger quantity of polishing materials needed and the constant use of brushes. Arlidge also directs attention to the sedentary character of the jewelers’ work, its confinement, and the bent position long sustained, aside from the more or less injurious but very common method of artificial lighting and the heat proceeding from constantly burning gaslights and gas jets used for blowpipes to melt solder and heat soldering irons. In addition there is the waste of burnt gases, the acid vapors, and last, but not least, the dust from polishing stones and settings, all of which, according to Arlidge, “ represent a series of health conditions suggestive of the production of phthisis, bron l The English data include watch and clock makers, makers of scientific instruments, and other more or less closely allied trades. For this reason the English statistics are not strictly comparable with other data for jewelers and are not, therefore, presented here in tabular form. 120 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. chitis, anemia, and general debility with digestive troubles— an inference borne out by statistics.” He concludes, however, that there is much encouragement in the favorable aspects of the industry, in that the health-injurious conditions referred to are, for the most part, remediable by sanitary arrangements, “ foremost among which are ample working space and effective ventilation.” These, how ever, are unfortunately frequently wanting, quite generally so in the smaller establishments. MORTALITY FROM TUBERCULOSIS AND PNEUMONIA. Among the watchmakers and jewelers in Scotland, according to the latest published official statistics, “ the death rates from tubercu losis and pneumonia are not decidedly different from the correspond ing^ death rates of all males,” but the mortality from bronchitis, which is of considerable practical importance in this connection, could not be determined. Since in the corresponding investigations for England and Wales the mortality of jewelers from all causes was fairly normal, it is rather suggestive that in a similar study of the mortality of jewelers in Paris and Switzerland the death rates should have been excessive. The manufacture of jewelry includes, of course, quite a number of specific employments, carried on under widely varying conditions, but no strictly scientific study has been made with a due regard to such variations and the health-injurious circumstances of particular employments as would be necessary for the end in view.1 M O R T A L IT Y OF JEW ELER S— U N IT ED STATES R E G IST R A TIO N A R EA. The mortality of jewelers has been reported upon for the two years 1908 and 1909 by the Division of Vital Statistics of the United States Census Bureau, but no subsequent information has been made public, and the data are therefore of rather limited value. The information includes jewelers, clock and watch repairers, as well as gold and silver workers. According to the census report, out of 686 deaths of jewelers, including those in allied employments, as previ ously explained, 122, or 17.8 per cent, were from pulmonary tubercu losis. This relatively low average figure for all ages is, however, materially modified by reference to the proportionate mortality ac cording to divisional periods of life. The low average proportion for all ages is accounted for by the peculiar age distribution of jewelers, which, considered as a group, includes quite a large number of deaths at ages 45 and over and a comparatively small proportion at the 1 Conditions surrounding the industry of jewelry, clock, and watch making in Switzer land are clearly and exhaustively set forth in “ Enqu§te sur le Travail a Domicile chez les Bijoutiers du Canton de Genfeve,” by Dr. AndrS de Maday and Mme. Marthe de M aday-Hentzelt, Geneva, 1911. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 121 younger ages. In contrast, for illustration, to the mortality in the printing trades the proportion of deaths of jewelers at ages 45 and over out of the mortality at all ages was 65.2 per cent compared with 44 per cent for printers, lithographers, and pressmen, as derived from the same official American sources. The details of the mor tality by divisional periods of life are shown in Table 38. 3 8 .—PROPORTIONATE M O RTALITY OF JEW ELERS FROM PULM ONARY TUBER. CULOSIS, UNITED STATES REGISTRATION A R E A , 1908 AND 1909, B Y AGE GROUPS. T a b le Deaths from pulmo nary tuberculosis. Age at death. Deaths from all causes. Number. 15 to 24 years.................................................................................................. 25 to 34 years.....................................................................'........................... 35 to 44 years................................................................................................. 45 to 54 vears................................................................................................. 55 to 64 years.......................................................................- ......................... 65 years and over.......................................................................................... Age unknown........... . ................................................................... Total, 15 vears and over...................................... ........................... 66 78 94 128 Per cent of deaths from all causes. 142 177 33 31 22 18 12 6 50.0 39.7 23.4 14.1 8.5 3.4 686 122 17.8 1 It is here shown that the proportionate mortality from pulmonary tuberculosis at the younger ages was quite excessive, having been 50 per cent at ages 15 to 24, and 39.7 per cent at ages 25 to 34. Com pared with that of printers, lithographers, and pressmen, however, the proportionate mortality from pulmonary tuberculosis was relatively lower, with one important exception, at all ages over 25. The same conclusion applies to nontuberculous respiratory diseases, as shown in Table 39, which, in the aggregate, account for 8.3 per cent of the mortality from all causes among jewelers against 8.8 per cent among printers, lithographers, and pressmen considered as a group. The table, in a general way, confirms the data derived from other sources, and quite clearly indicates that the health conditions in the jewelry trade are far from satisfactory. 3 9 .—PROPORTIONATE M O RTALITY OF JEWELERS^FROM NONTUBERCULOUS R ESPIR ATO RY DISEASES, U NITED STATES REGISTRATION A R E A , 1908 AND 1909. T a b le Deaths from nontubercu lo u s respiratory diseases. Cause of death. # Number. Bronchitis.................................................................... ................................... ................. .............. Pneumonia . . - ........................................................................................................ Total............ 1............................................................................................................. Per cent of deaths from all causes. 2 8 40 7 0.3 1.2 5.8 1.0 57 8.3 122 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. MORTALITY OF JEWELERS— INDUSTRIAL INSURANCE EXPERIENCE. The mortality of jewelers in the industrial insurance experience of the Prudential Insurance Co. of America includes 812 deaths from all causes, of which 238, or 29.3 per cent, were from pulmonary tuberculosis. Of the mortality of jewelers from other respiratory diseases, 61 were from pneumonia, 5 from asthma, 10 from bronchi tis, and 7 from other respiratory diseases. The deaths from pul monary tuberculosis and nontuberculous respiratory diseases com bined show that 39.5 per cent of the mortality of jewelers was from diseases of the lungs and air passages. The excess in the mortality from pulmonary tuberculosis among jewelers is very clearty brought out in Table 40, which shows the proportionate mortality from this disease by divisional periods of life. T a b le 4 0 . — PROPORTIONATE M ORTALITY FROM PULM ONARY TUBERCULOSIS AMONG JEW ELERS, IN DUSTRIAL EXPER IEN CE OF PR UD ENTIAL CO., 1897 TO 1914, COMPARED W IT H THAT OF A LL MALES IN UNITED STATES REGISTRATION AR E A , 1900 TO 1913, B Y AGE GROUPS. Deaths of jewelers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. 15 to 24 years............................................................................ 25 to 34 years.......................................................................... 35 to 44 vears.......................................................................... 45 to 54 years............................................................................ 55 to 64 years.......................................................................... 65 years and over.................................................................... Total, 15 years and over............................................ Males in registration area,1900 to 1913. All causes. Pulmonary tuberculo sis. Jewelers. 110 144 106 132 144 176 56 84 48 28 16 6 50.9 58.3 45.3 21.2 11.1 3.4 27.0 30.5 23.4 14.7 812 238 29.3 13.9 7.9 2.6 GENERAL CONCLUSIONS. The preceding observations and statistical data confirm the conclu sion that jewelers as a class a*e subject to a decidedly excessive mor tality from pulmonary tuberculosis at ages under 45, but particularly so at ages 15 to 34, inclusive. There can be no reasonable question of doubt but that this excess is, in a large measure, the direct result of health-injurious circumstances connected with the employment. THE PRINTING TRADES. The printing and allied trades give employment to a large number of men and women, including a considerable proportion of young persons. The printing trades have undergone material changes in methods of composition, use of machinery, etc. To an increasing extent composition is done by machines, which are, strictly speak OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 123 ing, typecasting machines, operated in quite a different manner from the old-time process of setting type by hand. The best known of these typesetting machines are the Mergenthaler linotype and the Lanston monotype, both of which are extensively used throughout the country. L IN O T Y P E AND M ONOTYPE OPERATION. 4 As observed by Mr. Charles C. Dominge, insurance engineer, in an article on the “ Processes and hazards of printing,” including stereo typing, electrotyping, etc., in the Weekly Underwriter, August 5, 19 1 1In the case of small job work, small newspapers, pamphlets, and certain books the printing is done direct from the type, which is locked tightly in metal chases and securely fastened in the proper place in the press. Most of the modern newspaper composition, however, is done by means of linotype and monotype machines, the former of which is described by Mr. Dominge in part as follows: These machines derive their name from the fact that they set up one continuous line of type. The machine is operated by means of a keyboard and resembles somewhat a huge typewriter. When the operator strikes a letter on the keyboard the matrices (brass slugs on which is an impression of the desired character) fall down through a channel until a line is made up. Metal followers push the line across until it is dropped in front of a pot of hot type metal, where a chamber is formed around it, of which the brass matrix or type impression makes up one side. A plunger connected with the metal pot ejects a charge of metal into the chamber under pressure, and this metal, coming into contact with matrices, causes a line to be cast. This “ line of type ” is then pushed off to one side, to be fol lowed by other “ lines of type,” and the matrices are automatically conveyed and distributed to their respective tubes ready to be called upon again. The same writer points out as regards the monotype machines that— The monotype is perhaps more marvelous in its operations than the linotype. The operator takes the copy and proceeds to write it out on a machine somewhat like a typewriter, except that the result is a long strip of paper with innumerable perforations thereon. There are two perforations for each character, arranged in a series of combinations, the purpose of which will be explained later on. When *the operator has written out the “ story ” upon the strip this paper is placed in position on the casting machine. As the strip moves automatically through the machine two perforations are al ways brought into position simultaneously over a pair of “ lugs/’ which are forced through the perforations at once by means of com pressed air. These lugs govern the lateral direction of a matrix containing 226 characters, which moves laterally in two directions 124 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. until stopped by the lugs. Hence the necessity for the different “ combinations ” in the perforations mentioned above. Molten type metal is then forced against the matrix and a type is cast—not a line, as is the case with the linotype, but a single type. This whole process of casting takes about as long as it takes the average type writer to strike the keys of her instrument, so rapid is the action of the monotype. O CCUPATIO N AL H A Z A R D S OF T H E P R IN T I N G T R A D E . The occupational hazards of printing are chiefly in connection with the inhalation of a more or less badly contaminated atmosphere. The dust factor, while frequently serious, is, as a rule, of secondary importance to other unhygienic circumstances of the trade. As regards the operation of the linotype and monotype machines it is stated by Dominge that— The only hazard in connection with these machines is the lead pot, holding about 1 quart of molten lead, which is usually heated by gas. If the gas connection is made of rigid iron pipe instead of rubber tube, as formerly, the hazard is only moderate. In large shops these lead pots are now heated by electricity, and if approved by the underwriters this is the best arrangement. There is no reference here to the dust factor which, of course, as a fire hazard is of distinctly secondary, if any, importance. S A N IT A R Y AN D M E D IC A L C O N SID E R A T IO N S. The employment of printers differs in many essentials from most of the other occupations considered in this discussion, since it is homogeneous and well defined and common throughout the country. While in many of the modern printing establishments the conditions favoring health and life, with special reference to ventilation and light, are probably satisfactory, in the smaller workshops the sani tary conditions, as a rule, are decidedly to the contrar}^, and predis pose to tuberculosis. Thackrah in 1832 called attention to the diseases of printers, and in his opinion “ few appear to enjoy full health.” Pulmonary tuberculosis, according to this writer, was fre quent, but was apparently caused rather by the confinement or indoor employment than by direct injury to the respiratory organs. The trade is one which has received a considerable amount of atten tion because of its recognized unhygienic features, and, in addition to the general data upon this subject, the mortality experience of various t}^pographic associations has been carefully investigated. It is suggested by Oliver that “ Printing houses should be so con structed that free currents of air can get to them, and not, as is so frequently the case, shut in by other buildings.” OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 125 But such construction is even to-day the exception rather than the rule. Considering that, as a class, printers probably rank above the average mechanics in intelligence and earnings, it is difficult to un derstand why they should so persistently in the past have neglected the important problem of workshop hygiene. The successful effort to secure to the members of the craft in illness or old age a home in the mountain region of the West emphasizes what could be done by concentrated effort in other and even more important directions. In the historical sketch of the Union Printers’ Home, at Colorado Springs, it is, in fact, pointed out that the place was selected for the location of the home primarily because of the special liability of printers to all forms of lung and throat diseases, and in explana tion of the subsequent necessity for a hospital annex the statement is repeated that “ consumption is one of the diseases to which the printer is especially liable.” E N G L IS H AN D A M E R IC A N M O R T A L IT Y S T A T IS T IC S . Tatham, in commenting upon the excessive mortality of printers, as disclosed by an analysis of the English mortality data, remarks that “ like bookbinders, printers die very rapidly from phthisis, and probably for a similar reason, namely, because of the excessively unhealthful conditions under which their work is carried on.” 1 Tatham calls attention, however, to the decline in the mortality of printers, due among other causes to the decrease in the deaths from lead poisoning, which had fallen to one-half of the earlier figure. The frequency of phthisis among English printers had decreased during the decade by one-sixth of the former rate. In the occupation mortality statistics of the Twelfth Census, printers are grouped with compositors and pressmen, which is to be regretted since there are certain important differences in the disease liability of these allied employments which are sufficiently distinct to warrant separate consideration, at least in the case of pressmen, although the number of the latter is comparatively small. The total number of persons included in this group in the registration States, rtged 15 or over, according to the census, was 54,374, but of this num ber only 818, or 1.5 per cent, had attained to the age of 65 or over.2 This rather surprising result is confirmed by the statistics of the New Jersey Bureau of Labor for 1891, according to which out of 462 printers only 2 had attained to the age of 60 or over. The census mortality statistics of this group of printers, or as stated, composi tors, printers, and pressmen, are of some value though not entirely conclusive on account of probable defects in the census enumeration. 1 D angerous T rad es, by T h om as O liver, London, 1 9 0 2 , p. 15 1 . 2 R eport o f the B ureau o f the Census on V it a l S ta tistic s, 1 9 0 0 , p. cclxxx ii. been no subsequent census report giv in g com parable data. Ther.e has 126 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 4:1. —M O R T A L IT Y F R O M A L L C A U SE S A M O N G C O M P O SITO R S, P R IN T E R S , A N D P R E S S M E N , C O M P A R E D W I T H T H A T O F T H E M A N U F A C T U R IN G A N D M E C H A N IC A L CLASS A N D T H E M E R C A N T IL E A N D T R A D I N G C LASS, IN T H E R E G IS T R A T IO N S T A T E S , 1900, B Y A G E G R O U P S. T a b le [Source: Report of the Bureau of the Census on Vital Statistics, 1900.] Death rate per 1,000 among— Age at death. 15 25 45 65 Compositors, printers, and pressmen. to 24 years.................................................................................... to 44 years.................................................................................... to 61 years.................................................................................... vears and over............................................................................ 5.05 12.29 20.01 108.80 The manufac turing and me chanical class. The mercantile and Irading class. 4.43 8.35 20.16 105.43 2.60 6.72 19.91 93.79 According to Table 41 the death rate of printers at ages 15 to 24 is 5.05 per 1,000, compared with 4.43 for men in the mechanical and manufacturing class, and only 2.60 for the mercantile and trad ing class. At ages 25 to 44 the rate is 12.29 for printers, but only 8.35 and 6.72, respectively, for the other two selected groups of occu pations. At ages 45 and over the differences in the mortality of printers compared with that in other occupations are very slight, due in all probability to the fact that on the one hand most of those at all liable to tuberculosis had died an.d that on the other many of the impaired in health had left the trade. In addition there is also the factor of a possible defect in the census enumeration. E X P E R IE N C E OF TH E IN T E R N A T IO N A L T Y P O G R A P H IC A L U N IO N . At the forty-sixth session of the International Typographical Union, held at Milwaukee, Wis., in 1900, a statistical summary was submitted showing that out of 419 deaths of printers during the pre- • ceding year, 192, or 45.8 per cent, had been deaths from diseases of the lungs or air passages, including under this term bronchitis, asthma, pulmonary tuberculosis, pneumonia, and all other respira tory diseases. Of the 411 printers whose ages at death were known, 44, or 10.7 per cent, died at the age of 65 or over, while the average age at death was only 41.25 years, compared with 52.2 years for all males aged 15 or over in the registration area of the United States in 1900. Kober, in his article on “ Industrial hygiene,” in Bulletin No. 75 of the Bureau of Labor Statistics, refers briefly to printers, type founders, and typesetters, quoting Sommerfeld to the effect “ that among 38 occupations tabulated by him printers occupied the fifth rank in the number of deaths from tuberculosis.” It is to be assumed, of course, that this has reference to the death rate and not merely to the number of deaths without reference to the exposed risk. Kober also quotes Albrecht in the statement that “ the statistics of the Berlin Sick OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 127 Benefit Insurance Fund, covering a period of 33 years, show that 48.13 per cent of the deaths among printers are caused by consump tion.” He observes in this connection that— This may be due in part to the fact that many weaklings engage in this occupation, but the work itself is often performed in most unfa vorable environments and in an impure and dusty atmosphere, which has been found to contain traces of lead, arsenic, and antimony. Special attention should be paid to proper ventilation, and particu larly to the collection and removal of dust from the type cases. One gram of this dust has been found to contain 57.7 mg*, of lead, 186.8 mg. of antimony, and traces of arsenic.1 Strasser has suggested a type case with perforated tin bottom, which is placed within another case, so as to facilitate the collection and proper disposition of this injurious form of dust. The results of an extended investigation into the sanitary condi tions of the printing trade, as prepared by Mr. George A. Stevens, were published in the report of the New York State Bureau of Labor Statistics for 1906. This investigation included the entire mortality of the International Typographical Union for the five years ending with 1905, or 2,498 deaths, representing a mean death rate of 12.63 per 1,000. The rate was highest among the printers of New York City, or 16.32 per 1,000, and lowest in Chicago, or 10.12 per 1,000. The average age at death for all printers was not quite 45 years. The disease most frequent and severe among compositors was found to be tuberculosis of the lungs. The average age at death of composi tors dying from tuberculosis was only 36.33 years. Out of 2,498 deaths from all causes, 660, or 26.4 per cent, were from tuberculosis, equivalent to an annual mean death rate of 3.34 per 1,000. Pneu monia caused 258 deaths, or 10.3 per cent of the deaths from all causes, equivalent to an annual mean death rate of 1.3 per 1,000. In commenting upon the high degree of frequency of pulmonary tuberculosis the report points out that “ scarcely any other occupa tion furnishes so large a quota of victims from consumption. The domestic life of printers is parallel to that of other artisans in equal financial circumstances. They are fairly compensated for their labor, thus enabling them to have homes as healthful as those pro cured by the best-paid workmen in any community. Neither can it be said that compositors are ill-nourished and, therefore, rendered more susceptible to the tubercle bacilli. The determining cause of their susceptibility to the harmful process of the great white plague lies in a different direction—neglect of sanitary precautions in com posing rooms.” 2 Of the mortality at known ages, from all causes, 18.9 per cent were deaths at 60 years of age and over. Of the 464 deaths in this group, 1 R oasah egyi, A r cM v . fiir H ygien e, M un ich an d Leip zig, vol. 3, p. 5 2 2 . 2 R ep ort o f the N ew Y o rk S ta te B u reau o f L a bor S ta tistic s, 1 9 0 6 , pp. cxxi and cxxii. 128 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 321 occurred between the ages of 60 and 69, 122 between TO and 79, 19 between 80 and 89,1 at age 90, and 1 at age 96.1 C O M P A R A T IV E V IT A L S T A T IS T IC S OF CO M PO SITO R S I K N EW YO RK. TH E ST A T E OF The statistics by Stevens indicate a rather wide variation in the incidence of pulmonary and respiratory diseases among printers according to localities, as shown by Table 42. 4 2 . —A N N U A L D E A T H R A T E P E R 1,000 F R O M P R IN C IP A L C A U SE S A N D A L L C AU SES, A M O N G C O M P O SIT O R S IN C E R T A IN L O C A L IT IE S , F O R T H E F IV E Y E A R S , 1901 TO 1905. T a b le (Source: Twenty-fourth Annual Report of the New York State Bureau of Labor Statistics, 1906.] Death rate per 1,000. Locality. New York C ity......................... Other New York State.......... Total New York State........... Chicago, 111................................. Philadelphia. P a ...................... All other United States......... Total United States................ London, England______ . . . . Tuber culosis of lungs and other respira tory or gans. 3.82 2.54 3.48 2.42 3.65 3.38 3.34 3.69 Diseases Pneu of ner monia, vous sys tem. 2.42 .97 2.03 1.57 .70 1.07 1.30 .67 1.91 1.49 1.80 1.04 2.26 1.33 1.44 1.16 Diseases Diseases Diseases of genito of diges of the urinary tive sys heart. tem. system. % 1.63 .70 1.38 .98 -.70 1.02 1. os .51 1.37 1.67 1.45 1.44 1.39 1.37 1.39 1.97 0.99 .97 .98 .45 .52 .74 .76 .51 Acci dents and in juries. 0.89 .61 .82 .72 ........ *60' .64 .19 All causes. 16.32 11.14 14.94 10.12 12.35 12.20 12.63 12.19 E X C E S S I V E F R E Q U E N C Y OF P U L M O N A R Y T U B E R C U L O S IS . The corresponding proportionate mortality from pulmonary tu berculosis and other respiratory diseases among compositors varied from 30.2 per cent for London, England, to 26.4 per cent for printers in large cities of the United States, in contrast to a normal average of approximately 15 per cent for adult men and women in the ter ritory under consideration. As subsequently to be shown, there are reasons for believing that printers are physically below the average of men employed in other gainful occupations and that occupational selection has some bearing 1 A m ost im p o rta n t in v estig a tio n o f the h e alth o f prin ters is a recent bu lletin (N o . 2 0 9 ) o f the U . S. B ureau o f Labor S ta tistic s ( 1 9 1 7 ) , by D r. A lice H a m ilto n and M r. C harles H . V e rrill. T h is in vestigation includes a concise description o f p rin tin g p la n ts, observa tio n s on th e effects o f lead fum es and other poisons, descriptive accounts o f m odern m ethods o f prin tin g by m eans of lin otype and m onotype m ach in es, extended observations on the health o f printers in the U n ited S ta te s and foreign cou ntries, ob servations on the health conditions o f men en terin g the indu stry and the h ealth cam paign of the In ter n a tion al T y p ogra p h ical U nion. A p pen dixes describe a proposed schem e for th e inspection o f com posing room s in the D is tric t o f C olum bia, precautions fo r p rin ters published by th e M assa ch u setts G eneral H o sp ita l, and hygienic regu lation s fo r p rin tin g and typ e castin g establish m en ts published by the D epartm en t o f L abor o f the S ta te o f N ew Y ork. T h e rep ort is a m odel o f im p a rtia lity and scientific con clusiveness, sub ject, o f course, to the lim ita tio n s o f scientific research inherent in all in v estig a tio n s o f th is kind. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 129 upon the excessive mortality from tuberculosis in the printing and allied trades, aside from the special hazard of dust and fume ex posure. The statistical data of the mortality rate among printers for the United States are fully confirmed by the corresponding statistics for German printers which were published in a small treatise on the hygiene of the printing trade by Dr. Lewitt, of Berlin, in 1899. According to this authority, out of 1,390 recorded deaths of print ers, 798, or nearly 61 per cent, were from diseases of the lungs and air passages, including 630 deaths from pulmonary tuberculosis. Of the total number, 243, or 17.5 per cent of the mortality at known ages, had attained to the age of 60 or over. The suggestions made by this writer regarding the prevention of tuberculosis and other diseases in the printing trade are eminently practical and feasible in most of the workshops in which printers are employed. S A N IT A R Y CON TRO L OF T H E P R IN T I N G IN D U S T R Y I N G E R M A N Y . The regulations of the Federal Council of the German Empire with reference to the control of sanitary conditions in the printing industry, put into effect July 31, 1897, are reprinted in Bulletin No. 75 of the United States Bureau of Labor Statistics, and these regula tions as amended in 1907 and in 1908 are reprinted in Bulletin No. 209. The corresponding regulations issued by the Austrian Depart ment of Commerce have been reprinted in a special bulletin (No..76) on European Regulations for Prevention of Occupational Diseases, published by the New York State Department of Labor, Albany, March, 1916. D U ST H A Z A R D S I N T H E P R IN T I N G IN D U S T R Y I N OHIO. The investigations by Hayhurst with special reference to the State of Ohio for the year 1915 include 26 establishments, in 12 of which, however, printing was a more or less auxiliary feature. One of the practical difficulties of separating specific processes in the printing trade is that they are usually all carried on more or less in common. According to Hayhurst— Dust was a fair hazard in 10 places, bad in 1, and negligible in the remaining. Quarters were kept clean in 14, fairly so in 9, and not so in 3. Dry sweeping and dusting of fonts with an air blast are pernicious. Cold and dampness, due to inefficient heating, were found to exist in 4 places. Light was good in 17 places, fair in 4, and poor in the remaining 5. General room ventilation was only fair in 10 places and bad in 7 more. Fatigue seemed a negligible factor in 8 places, fair in 10, and bad in the remaining 8, due, principally, to hurrying piecework, monotony, constant standing, strain, chairs and stools without backs, faulty postures, and in some cases jarring 106811°— 18— Bull. 231------ 9 130 MORTALITY FROM RESPIRATOEY DISEASES IN DUSTY TRADES. processes and loud noises. Eyestrain and myopia are special hazards of the printers, and every such worker should be assured of the con dition of his eyes for such work. The chief complaints of the employees were with reference to poor ventilation, fumes, typesetting dust, risk of lead poisoning, and working with fellow workers infected with tuberculosis. Regarding typesetting machines and the special hazard in connec^ tion with linotyping, monotyping, stereotyping, etc., Hayhurst, on the basis of personal investigation, writes as follows: This class of procedure includes all processes in which type metal is melted and used, such as linotyping, monotyping, and stereotyping. (Electrotyping is practically identical with electroplating.) These are here reported upon as the result of our investigation in 15 plants. The total wage earners so employed was 361, of whom 348 were males and 13 were females. Seven of the places were union shops. The general attitude toward employees was good in 12 places, and at least fair in the remaining. The workers were of intelligent type in all places, except here and there a few non-English speaking laborers. Retention of workers was good in 12 places, fair in 1, and not so in 2. Health appliances, such as hoods and stacks over metal pots, furnaces, and burners, were good in 5 places, fair in 2, and absent in the balance* The dust factor in connection with these occupations was considered of relatively small importance; the chief conditions detrimental to health w^ere the escape of gases and fumes from the hot processes, and the absence of air agitators and means of effective ventilation. Fatigue was not found to be a particular hazard in any one of the working places examined. Industrial poisoning was found to be a considerable hazard in 7 of the work places examined and a fair hazard in 4 others, due chiefly to the absence of hoods and vent pipes over metal pots, especially over gas burners and furnaces.1 The actual printing process or pressroom work was investigated by Hayhurst in 13 plants employing 392 wTage earners, including 32 females. Health appliances, consisting of hoods and flues for drawing off escaping gas fumes in drying freshly printed work, were present in only 2 places. A slight amount of dust was observed in the air in the majority of places, but no strictly scientific investi gations were made with reference to the exact degree of atmospheric pollution. # O CC U PA TIO N A L D I S E A S E S OF P R IN T E R S . Occupational diseases among employees of printing plants have not been made the subject of a thoroughly qualified and strictly scien 1 See in th is connection Special B u lle tin N o. 82 o f the N ew Y o rk S ta te D ep artm en t o f L a b o r on “ H oods fo r R em ovin g D u st, Fu m es, and G ases,” prepared by the division o f in d u stria l hygiene, A lb a n y , M ay, 1 9 1 7 . See also P u blic H e a lth B u lle tin N o. 8 l , W a s h in g to n , 1 9 1 7 , on “ T h e E ffect o f G as-h eated A p p lian ces U pon the A ir o f W o rk S h o p s/* by C harles W eissm a n . OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 131 tific investigation.1 Exact information, however, is gradually in creasing, and among other recent investigations is one by Strumpf and Zabel, with reference to the physical condition of a large num ber of typesetters employed in Strassburg, Germany. According to the Journal of the American Medical Association of December 3, 1910— One thing which impressed them was the rarity of typical cases of lead poisoning. They observed, however, with great frequency, a clinical syndrome characterized by a fatigued expression, nervous ness, irritability, insomnia, exhaustion especially in the morning hours, vertigo, headache, particularly in the frontal and occipital regions, general or local muscular pains, neuralgic pains in the ex tremities, nausea and vomiting, and constipation. Mild, moderately severe, and severe cases were encountered. The authors find evi dence in the literature that this symptom-complex has been looked on as a manifestation of chronic lead poisoning. The patients showed no elevation of blood pressure, which, as Krehl has shown, is so common in plumbism from spasm of the arterial walls; the erythro cytes had no basophilic granules; and leucocytosis was lacking. Nor did the urine show traces of albumin or bile. On the contrary, the red count was almost or quite normal even in the severe cases with an absence of basophilic granules and there was leucopenia with eosinophilia between 10 and 25 per cent. (Typesetters without symptoms jpossessed as high as 9 per cent eosinophiles.2) The urine was normal and likewise the blood pressure. Since the facts observed suggested no connection with lead poison ing, further research led to the conclusion that the employees affected had been suffering from chronic antimony poisoning, subsequently confirmed by further investigations. As pointed out in the editorial of the Journal of the American Medical Association—■ Thus a new danger to typesetters working with antimonial com pounds is brought to light and a distinct contribution added to the growing subject of occupational diseases. C A U S E S OF E X C E S S I V E F R E Q U E N C Y OF P U L M O N A R Y T U B E R C U L O S IS . Among American printers, using the term in a broad and com prehensive sense, the health conditions have been reported upon by Dr. James Alexander Miller, of New York, in a paper read- before 1 A fa irly exten sive a n a ly sis o f the ava ilable m o rta lity d ata o f p rin ters is included in the bu lletin (N o . 2 0 9 ) o f the U. S. B ureau o f Labor S ta tis tic s (1 9 1 7 ) on the H ygien e oE the P r in tin g T rad es, by H a m ilto n and V e rrill. T o be en tirely conclusive, how ever, a m uch m ore specialized tech nical a n aly sis o f the s ta tis tic a l m aterial is required, w ith a due regard to the stric tly m edical asp ects o f a problem o f exceptional tech nical com p lexity. A really con clusive in v estig a tio n should include a sufficient num ber o f p h ysical exa m in ation s o f prin ters w ith a due regard to the len gth o f trade life and the variou s special occupation s follow ed in the p rin tin g trade from the begin ning o f the ap pren tice ship to the a tta in m en t o f perm anency in the branch o f the in d u stry selected as a per m anent m ean s o f gain in g a livelih ood. 2 E o s in o p h ile : In bacterio lo gy and h istology, applied to m icrobes or histologic ele m ents show ing a peculiar affinity for eosin s ta in . 132 MORTALITY FROM RESPIRATORY DISEASES IN' DUSTY TRADES. the Sixth International Congress on Tuberculosis in 1908. mary of his more important findings follows:1 A sum The main point in the investigation was not only to determine the extent of pulmonary tuberculosis but all other diseases were con sidered both in the history and the physical examination. It was found that almost all the men were young, native-born Americans, earning good wages, and living under good conditions; the majority of them used alcohol and tobacco; 20 per cent of all used them in excess, and about 20 per cent were total abstainers. One hundred and twenty-four complained of unfavorable conditions in the shop designated as follows: Poor ventilation, 49; metal fumes from un piped machines, 27; insanitary water-closets, 19; insufficient number or absence of cuspidors, 14; dirty walls and ceilings, 8; metal dust, 5; overcrowded rooms, 7; poor light, 5. The medical history and ex amination showed that catarrh of the upper air passages was fre quent, also dry pleurisy, bronchitis, and pulmonary tuberculosis. Pulmonary tuberculosis was present in 34 cases or 17 per cent of the whole number. Dr. Miller concluded that pulmonary ^tuberculosis is prevalent among printers and is largely due (1) to unfavorable shop conditions, especially poor ventilation, overcrowding, dust and dirt, promiscuous spitting, and poor lighting; (2) to the irregular habits of the printers, especially alcoholism, careless habits of eating, needless exposure to drafts, and insufficient outdoor exercise.1 S A N IT A R Y C O N D IT IO N S. I N GO V ERNM ENT P R IN T I N G AND E N G R A V IN G . A somewhat similar investigation concerning 4,000 persons em ployed in connection with Government printing and engraving was reported upon by Dr. B. S. Warren, of the United States Public Health Service, at the ninth annual meeting of the National Associa tion for the Study and Prevention of Tuberculosis, Washington, 1913. In part, Dr. Warren states that— My purpose in writing of this unusual condition is to submit the facts that here are 4,000 employees, working under very bad sanitary conditions, and the death rate is surprisingly low. The force con sists of engravers, printers, printers’ assistants, examiners, counters, mechanics, and all the help required in such an establishment. All the buildings of this establishment are very badly overcrowded. There are 1,731 employees working with less than 500 cubic feet of air space and 30 square feet of floor space per person. Ventilation is very poor, especially in the pressrooms, where from 150 to 300 print ers and printers’ assistants are at work. The poor ventilation is made still worse by the small gas stoves required by each printer to heat his plates. Ink fumes and often carbon monoxide rise from these stoves. The printing is done on piecework basis, and all are working at top speed continuously. In the ink-making rooms the employees are exposed to the dust rising from the dry, powdered colors. In the steel-plate hardening room, cyanide of potash fumes were in the air 1 F o r paper in fu ll, see T r a n sa ctio n s o f the In tern a tio n a l W a sh in g to n , 1 9 0 8 , V o l. I l l , pp. 2 0 9 - 2 1 7 . C ongress on Tu bercu losis, OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 133 all the time; in fact, every insanitary condition that surrounds any printing shop was noted. A V E R A G E W E IG H T AN D H E IG H T OF P R I N T E R S . Further and more strictly scientific investigations would be neces sary to produce the required evidence regarding the precise effect on health (if at all ascertainable) of the obviously numerous factors and conditions inimical to health in the printing and allied industries. Since the problem is quite complicated, particularly in view of the probably inferior physique of printing employees at entrance to the trade, Table 43, derived from the ordinary mortality experience (males only) of the Prudential Insurance Co. of America, 1886 to 1914, will prove of interest and value. 4 3 .'— A V E R A G E W E I G H T A N D H E I G H T O F P R IN T IN G E M P L O Y E E S C O M P A R E D W I T H T H O S E O F A L L O CC U P IED M A L E S , AC C O R D IN G TO M A L E O R D I N A R Y M O R T A L I T Y E X P E R I E N C E O F T H E P R U D E N T I A L IN S U R A N C E CO. O F A M E R IC A , 1886 TO 1914, B Y A G E G R O U P S. T a b le Male printers. Age at entry. Number. All occupied males. Average height (inches). Relative Relative Average Average 1 weight weight Male weight weight ‘ (pounds (pounds printers. (pounds). (pounds). per inch). per inch). All occu pied males. 15 to 24 years.................................... 25 to 34 years.................................... 35 to 44 years.................................... 45 to 54 years.................................... 55 to 64 years.................................... 65 years and over............................ 126 230 150 51 31 2.05 68.2 68.1 2.26 2.35 2.40 2.40 2.38 67.6 67.7 67.0 67.4 67.0 68.3 2.28 2.37 2.29 2.91 145 155 160 163 163 1*62 2.12 1 140 149 154 159 154 195 Total, 15 years and over. . 589 149 2.21 157 2.30 67.7 68.1 2.20 68.1 67.9 67.8 67.9 According to this table, at every period of life the average weight of persons employed in the printing trade, with one exception, is below the average for all occupied male£, to the extent of 8 pounds for all ages combined. The one exception at ages 65 and over is, of course, due to the fact that only a single case was under observation. Since there is invariably an important correlation be tween height and weight, the last two columns of the table are in cluded for the purpose of emphasizing the fact that printers, on examination, were not only below the average in weight, but also in stature. The differences here are not quite so marked as shown by the weight, but they are, nevertheless, of importance. Correlating the height and weight, the table shows the relative weight at entry in pounds of weight to each inch of stature, proving conclusively a sufficient difference in the physique of printers to re quire consideration in the correct interpretation of the subsequent mortality tables. The average relative weight of printers, according to this table, was 2.21 pounds per inch of stature, against 2.30 for all 134 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. occupied males. It may be said in this connection that the propor tion of deaths from pulmonary tuberculosis among the 589 printers under observation was 29.2 per cent for all ages, against 18.6 per cent for all occupied males in the company’s ordinary experience. E N G L IS H M O R T A L IT Y S T A T IS T IC S OF P R I N T E R S . The most recent English mortality statistics of printers are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales, in part as follows: The death rates of printers were above the standard for occupied and retired males at all ages up to 35 years, but above that age they were below the standard. Within the main working period of life the comparative mortality figure of printers is 994, which practi cally corresponds to the standard; they show a slightly excessive mor tality from influenza, nervous diseases, and Bright’s disease; and their mortality from phthisis exceeds the standard by 60 per cent. On the other hand, their mortality from circulatory and respiratory diseases is considerably below the average, and they appear to be subject to small risk from fatal accident, and to be but little addicted to alcoholism and suicide. Since 1880-1882 there has been a continuous decline in mortality from phthisis, liver disease, and accident. It is also worthy of notice that the mortality from lead poisoning is now only one-fifth part as high as it was 20 years ago. From the other causes shown in the table the mortality in this occupation has fluctuated considerably. The English occupation mortality statistics for printers are quite conclusive of the unfavorable effects of this occupation on health. In Table 44, which follows, the mortality from all causes among men in this employment is compared with that of occupied males generally, and the result is decidedly suggestive of conditions in this trade more or less unfavorable to life and health, but in particular at the early ages, or 15 to 34, when the excess in mortality is from 0.45 to 1.62 per 1,000. This table is deserving of particular consideration in that it emphasizes the health-destructive circumstances of this employment at a very early period of life. Among those who survive to age 35 or over there is not apparently a decidedly unfavorable mortality in comparison with other occupations, and in this respect the English statistics are confirmed by the United States census sta tistics previously quoted. While the actual excess in the mortality of printers at ages 20 to 24 is only 1.62 per 1,000, this excess is equivalent to nearly 40 per cent of the normal mortality at this period of life. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 135 4 4 . — M O R T A L I T Y F R O M A L L C A U SE S A M O N G P R IN T E R S , C O M P A R E D W I T H T H A T O F A L L O C C U P IED M A L E S , IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E G R O U P S . T a b le [Source: Part I I, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate for printers. Age at death. 15 to 19 years.................................................................................... 20 to 24 years.................................................................................... 25 to 34 years............................................................................... *. 35 to 44 years....................................................................! ............. 45 to 54 years................................................................................... 55 to 64 years................................................................................... 65 years and over........................................................................... Death rate per 1,000 for all oc cupied males. 2.44 4. 41 6.01 10.22 17.73 31.01 88.39 Rate per 1, 000. 3.19 6.03 6.46 10.19 17.76 30. 76 87.61 Greater ( + ) or less ( —) Per cent of than rate rate for all for all oc occupied cupied males. males. + 0 .7 5 + 1.62 + .45 - .03 + .03 - .25 - .78 131 137 107 100 100 99 99 The preceding table requires no further comment. A more ex tended comparison, however, is made in Table 45, in which the mortality of printers from pulmonary tuberculosis and other dis eases of the respiratory system is compared with the normal mor tality of occupied males from these diseases, by divisional periods of life.1 The comparison showTs that at all ages the mortality of printers from pulmonary tuberculosis is excessive by from 0.49 to 2.11 per 1,000. The excess is most marked at ages 35 to 44, but the dif ference is a material one at all ages, 20 to 64, inclusive. The corre sponding mortality from other respiratory diseases among printers was slightly excessive at ages under 20 and comparatively high at ages 65 or over, but below the average at ages 20 to 64, inclusive. Apparently the employment does not predispose seriously to respira tory diseases except such as assume the pulmonary form of true tuberculosis of a rapidly developing type most destructive to young printers at ages under 45. The table which follows is self-explana tory. i F o r a d dition al d a ta on the h e a lth o f printers see table included in the footno te on page 55 for th e year 1 9 1 4 for the city o f N ew York. Accordin g to this table, a t ages 25 to 34 the pro portiona te m o rta lity from pu lm o nary tuberculosis w as 6 6 .6 per cent for com positors and prin ters a ga in st 3 3 .5 per cent for all occupations. E v ery sta tistic a l in v estig a tio n o f th is kind confirms previous conclusions th a t the health o f prin ters is unquestionably seriou sly im paired in consequence o f occupational hazards a t the present tim e m ore or less ill defined and largely a m a tter o f conjecture. 136 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 4 5 .— M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS A N D F R O M O T H E R D IS E A S E S O F T H E R E S P I R A T O R Y S Y S T E M A M O N G P R IN T E R S , C O M P A R E D W I T H T H A T O F A L L O CC U P IED M A L E S , IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E G R O U P S . T a b le [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Mortality from pulmonary tuberculosis. Mortality from other diseases of the respiratory system. Death rate for printers. Death rate for printers. Age at death. Death rate per 1,000 for all occu pied males. 15 to 19 years........ 20 to 24 years........ 25 to 34 years........ 35 to 44 years........ 45 to 54 years........ 55 to 64 years........ 65 years and over. 0.54 1.55 2.03 2.74 3.04 2.16 1.11 Rate per 1,000. 1.03 3.41 3.65 4.85 4.27 3.42 1.60 Death rate per Greater Per cent 1,000 for ( + ) or less of rate for all occu ( —) than pied all occu rate for all males. pied occupied males. males. + 0 .4 9 + 1.86 + 1 .6 2 + 2 .1 1 + 1.23 + 1.26 + .49 191 220 180 177 140 158 144 0.24 .48 .77 1.66 3.32 6.54 17.77 Greater Per cent ( + ) or less of rate for Rate per ( —) than rate for all all occu 1,000. pied occupied males. males. 0.36 .37 0 55 1.24 2.17 5.16 20. 76 + 0 .1 2 - .11 - .22 - .42 - 1 .1 5 - 1 .3 8 + 2 .9 9 150 77 71 75 65 79 117 T A C T S D ISC L O SE D B Y T H E N E W Y O R K S T A T E F A C T O R Y IN V E S T IG A T IN G C O M M ISSIO N . There are no other recent mortality statistics for American printers obtainable through census investigations or the annual reports of State and local boards of health than those subsequently to be referred to. The most recent investigation of the existing labor conditions in the printing trade was made in connection with the work of the New York State Factory Investigating Commission. According to this investigation 2,245 workers were employed in 25 establishments^ including 60 per cent male employees, 39 per cent females, and 1 per cent children under 16; 14 per cent of the employees were found to be working in dirty shops, and 86 per cent w7ere at work in fairly clean or clean quarters. The statement is made that “ Print ers have improved in health and have suffered less from lead poison ing since the handling of type and inhaling of dust from the cases have been so largely superseded by the newer processes.” But it is added that there are still evils to be remedied, and special reference is made to air contaminated by fumes from linotype machines not provided with adequate ventilating devices. Some of the shops investigated were found to require better ventilation with special reference to gas or lead fumes. A large number of pressmen and paper handlers w7ere found to be subject to a high degree of heat and humidity, owing to the need for quick drying and smooth flow- of the ink. The dust factor is obviously less important than gas and fumes and un suitable atmospheric conditions, but, as said in the report of the same commission for the year 1913, “ There is a total lack of ade quate provision for ventilating printing establishments. The abun OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 137 dant dust from the type, the fumes from the molten lead, the par ticles of graphite from the stereotyping processes, the heat from the artificial illumination and from the gas-heated lead pots in the lino type, all these cause extreme vitiation of the air in such establish ments.” The investigations of the commission ascertained that me chanical ventilation was made use of in only 6 per cent of the shops. The statistical data of the commission are amplified by an ex tended review of the health of the workers, including many inter esting and useful observations derived from foreign sources. S P E C IA L O CC U PA TIO N A L H A Z A R D S I N T H E P R IN T I N G T R A D E S . In reply to the question, “ What are the dangers in the trade or conditions injurious to the workers? ” it is said that— As has been stated, the chief dangers are lead poisoning and tuber culosis. Lead poisoning is caused by the lead dust which is so com mon in printing shops, and also by the fumes arising from the lead in the various processes of machine composition. The dust in the shops, especially that in the type boxes, contains a large amount of lead and some antimony. Prof. Steingraber analyzed the dust from a type box in Cracow and found it contained 16.43 per cent of lead. Dust from the top of stove in a composing room contained 0.24 per cent of lead, while that from the floor of a gallery 16.4 feet high in the composing room contained 0.37 per cent of lead. Much of the lead dust is undoubtedly inhaled by the workers. A great deal of dust is raised by the foolish and highly insanitary method so prevalent in old printeries of cleaning the dust out of the type boxes with bel lows. Much lead dust is also deposited on the fingers and hands of the workers as well as upon their clothes, and remains there from lack of proper washing facilities. The dust is very often ingested with their food, which is commonly eaten at the workstand in the printing shop.1 These observations are in strict conformity to the facts and are suggestive of health-injurious conditions which have not heretofore received the required consideration. As observed by the New York State Factory Investigating Commission in their second report— Grave as are the dangers to the life and health of male workers in the printing industry, these are still greater in the case of women. It is well known that women are more subject to lead poisoning than men, and their general constitution is apt to fall a prey to the dangers of the trade sooner than that of the more robust male workers. Attention is also directed to the prevalence of tuberculosis among young persons employed in printing trades, and it is pointed out that;— 1 New York State Factory Investigating Commission, Second Report, 1915, Vol. JI, p. 525. MOETALITY FROM RESPIRATORY DISEASES IN' DUSTY TRADES. 138 Not only has legislation been introduced to limit the work of minors in this trade, but in England as well as Germany stringent medical examination is made of all minors entering this industry, and a large number of applicants rejected. The opinion is prevalent that no minors under 18 should be allowed to work in printing establishments, and then only after a thorough physical examination. Hahn as well as Teleky advocate a thorough medical examination of all workers in lead every three months, especially minors. M O R T A L IT Y OF P R I N T E R S — U N IT E D S T A T E S R E G I S T R A T IO N A R E A . Printers, lithographers, and pressmen, considered as a group, have been reported upon for the years 1908 and 1909 by the Division of Vital Statistics of the United States Census Bureau, but no subse quent information has been made public, and the data are therefore restricted to the two years referred to; in fact, the mortality of lithographers included in the group is for 1909 only. The data are of rather limited value, but on account of the large number of deaths included the conclusions may be accepted as representative for the printing trade. According to the census report, out of 2,847 deaths of printers, lithographers, and pressmen from all causes, 840 or 29.5 per cent wTere from pulmonary tuberculosis. The details of the mortality by divisional periods of life are shown in Table 46. 4 6 . — P R O P O R T IO N A T E M O R T A L IT Y O F P R IN T E R S , L IT H O G R A P H E R S , A N D P R E SSM E N F R O M P U L M O N A R Y T U B E R C U L O S IS , U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A G E G R O U P S. T a b le Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Number. 15 to 24 years.............................................................................................. ............. 25 to 34 years............................................................................................................ 35 to 44 years............................................................................................................ 45 to 54 years............................................................................................................ 55 to 64 years............................................................................................................ 65 years and over.................................................................................................... U nknow n............................................................................................ ..................... 427 551 614 522 350 381 Total, 15 years and over.......................................................................... 2,847 Per cent of total deaths. 186 278 223 27 14 43.6 50.5 36.3 21.5 7.7 3.7 840 29.5 112 2 4 7 .— P R O P O R T IO N A T E M O R T A L IT Y O F P R IN T E R S , L IT H O G R A P H E R S , A N D P R E SSM E N FR O M N O N T U B E R C U L O U S R E S P IR A T O R Y D IS E A S E S , U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909. T a b le Nontuberculous respira tory diseases. Cause of death. Number. 2 A sthm a............................................................................................................................................... Bronchitis........................................................................................................ ................................. Pneumonia..................................................... 1................................................................................. Other nontuberculous respiratory diseases.......................................................................... 14 193 41 Total......................................................................................................................................... 250 Per cent of total deaths. -* 0.1 .5 6 8 L4 8.8 OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 139 Table 46 indicates conclusively an exceptionally high degree of frequency of pulmonary tuberculosis among men employed in the printing trade, and particularly so during the early years of life. At ages 25 to 34, for illustration, the proportionate mortality from pul monary tuberculosis was 50.5 per cent, which is exceeded by the cor responding figure for few other trades or occupations with con tinuous and considerable exposure to inorganic dust. The table in r. general way confirms the data derived from other sources and quite clearly suggests the relative unhealtlifillness of employment in the printing trade, subject, of course, to the qualification that adverse physical occupational selection, as elsew'here pointed out, may mate rially affect the mortality returns. It may be said in this connec tion, however, that the mortality from nontuberculous respiratory diseases, as shown in Table 47, was 8.8 per cent of the mortality from all causes, which compares, for illustration, with 12.2 per cent for marble and stone cutters and 12.5 per cent for potters, according to mortality returns derived from the same official American sources. M O R T A L IT Y OF P R I N T E R S — IN D U S T R I A L IN S U R A N C E E X P E R IE N C E . The observations and conclusions of the New York State Factory Investigating Commission are in conformity with the results of other investigations, and are sustained by the insurance mortality statistics. Table 48 shows the results of the mortality experience of the indus trial department of the Metropolitan Life Insurance Co. for the three years 1911 to 1913. The experience is limited to white males. 4 8 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS A N D P N E U M O N IA A M O N G C O M P O SIT O R S A N D P R IN T E R S , M E T R O P O L IT A N L IF E I N S U R A N C E CO., I N D U S T R I A L E X P E R I E N C E , 1911 TO 1913, B Y A G E G R O U PS. TABLE [C o m p iled from B ui. 2 0 7 , U . S. B ureau o f Labor S ta tistic s, pp. 33, 3 4 .] .. = Deaths of printers and compositors, 1911 to 1913, from— Per cent of deaths from pulmonary tubercu losis among— Deaths of printers and compositors, 1911 to 1913, from pneumo nia. Age at death. Males in registration arfea, 19001913. All causes. Pulmona ry tuber culosis. Printers and com pose tors. 15 to 24 years.................................. 25 to 34 years.................................. 35 to 44 years.................................. 45 to 54 years.................................. 55 to 64 years.................................. 65 years and over.......................... 217 221 225 176 120 97 98 110 88 42 19 3 45.2 49.8 39.1 23.9 15.8 3.1 27.0 30.5 23.4 14.7 7.9 2.6 10 16 6 9 7 4 4.6 7.2 2.7 5.1 5.8 4.1 Total, 15 years and over. . Average age at death.................. 1,056 40.2 360 33.5 34.1 13.9 52 39.7 4.9 Number. Per cent. According to this table, out of 1,056 compositors and printers, 360, or 34.1 per cent, died of tuberculosis of the lungs, at an average age of 33.5 years. In addition there are 52 deaths from lobar and un 140 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. defined pneumonia, accounting for 4.9 per cent of the mortality from all causes, at an average age at death of 39.7 years. The investigation of the Metropolitan Co. includes also an ex tended study of the mortality of printers from other diseases than pulmonary tuberculosis. The details of the analysis are given in an abbreviated form in the table below, which has been derived from Bulletin 207 of the United States Bureau of Labor Statistics, on “ Causes of Death by Occupation.” T a b l e 4 9 .— N T 3M B E R AND C O M P O S IT O R S A N D PER CENT OF P R IN T E R S , BY DEATHS AGE F R O M S P E C IF IE D C A U S E S P E R I O D S , 15 Y E A R S AND AMONG O V E R -W H I T E M ALES. [M etropolitan L ife Insurance C o.— In d ustrial d ep artm en t— M ortality experience, 1911 to 1913.] A ges 15 years and over. Per cent of deaths d u rm g age period (years)— Cause of death. Num ber. Per cent. 15-24 25-34 35-44 45-54 55-64 65 and over. N u m b e r of deaths........................................... 1,056 217 221 225 176 120 97 T y p h o id fever................................................... Tuberculosis of the lu ngs........................... Cancer (all fo r m s)........................................... Cerebral hemorrhage, a p op lexy, and p aralysis......................................................... Organic diseases of the h e a r t................... P neum onia (lobar and u ndefin ed)___ Cirrhosis of the liv e r..................................... B righ t's disease............................................... Suicide (all form s).......................................... A ccid en tal violence....................................... A ll other causes............................................... 22 360 28 2 .1 34.1 2 .7 3 .2 45.2 .9 4 .5 49.8 .5 1 .8 39 .1 1.3 0 .6 23 .9 5 .1 15.8 5 .0 3 .1 7 .3 38 118 52 19 94 19 62 244 3 .6 11.2 4 .9 1 .8 8 .9 1 .8 5 .9 23.1 6 .0 4 .6 .5 1 .4 3 .2 10.1 2 4 .9 .9 5 .9 7 .2 .5 3 .6 3 .2 5. 4 1 8 .8 2 .2 1 0 .2 2 .7 1 .3 10.7 1.3 4 .8 2 4 .4 6 .8 13.1 5 .1 2 .3 18 .2 .6 7 .4 17.1 5 .8 19.2 5 .8 6 .7 11.7 1.7 28.3 12.4 23 .7 4 .1 2 .1 13.4 1 .0 2 .1 3 0 .9 T o ta l......................................................... 1,056 100.0 100.0 100.0 100.0 100.0 100.0 100.0 In connection with the table it is said in the text by Dr. Louis I. Dublin, the author of the report, that— In the age period 15 to 24 the relative index of fciberculosis of the lungs is liigh (133.7) ; this cause accounts for 45.2 per cent of all deaths, as against 33.8 per cent in the general group. Accidental violence has a low index (52.6). In the period 25 to 34 tuberculosis of the lungs is somewhat lower than in the previous age period, though still high (121.8). Bright’s disease is low (80.0) and accidental violence is still lower (43.2). In the age period 35 to 44 tubercu losis of the lungs (118.8) and organic diseases of the heart (132.5) are both high. Bright’s disease is high (137.2). Pneumonia is very low (33.3). Both suicide (44.8) and accidental violence (48.5) exhibit low relative indices. In the age division 45 to 54 the high relative index for tuberculosis of the lungs is maintained (129.2). Cerebral hemorrhage, apoplexy, and paralysis loom up as important in this age period; the relative index is 130.8. The index for pneumonia remains low (62.2) ; Bright’s disease is even higher than in the previous age period (164.0). Suicide remains low as before (23.1), and acci dental violence shows an increase over the previous age period (87.1). In the age period 55 to 64 tuberculosis of the lungs shows a very high relative index (183.7). Organic diseases of the heart (120.8) are somewhat higher than the average and pneumonia is lower (77.3). Accidental violence is very low (26.2). There are no cases of suicide in this age group. In the age period 65 and over OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 141 the cases in which variations from all occupations are noted are too few to warrant discussion. With special reference to tuberculosis it is said that confirmatory data are provided by the returns of the United States Census, the reports of the Registrar-General, and the experience of the Pru dential. All of the index figures derived from these sources are higher than those of the Metropolitan experience. The high propor tionate mortality definitely marks this occupation as one in which the environment favors the development of pulmonary tuberculosis. All investigators are agreed as to this, yet there is a diversity of opinion as to the exact causative factor. As regards the possible effect of lead dust, it is said that in the Metropolitan experience, out of 1,056 deaths of printers and com positors from all causes only 4 were from lead poisoning. It, how ever, is explained that44It must not be inferred that the exposure to lead is not a serious factor in the causation of tuberculosis. A similar relation has been suggested between lead poisoning and Bright’s disease, which also shows a high proportionate mortality in the ago periods 35 to 44 and 45 to 54, the relative indices being 137.2 and 164.0, respectively.” The experience of the Metropolitan Co. is fully confirmed by the more extended data derived from the industrial experience of the Prudential Insurance Co. of America for the period from 1897 to 1914, inclusive: T a b l e 5 0 .— P R O P O R T IO N A T E M O R T A L I T Y F R O M P U L M O N A R Y T U B E R C U L O S IS A M O N G P R IN T E R S AND C O M P O S IT O R S , I N D U S T R I A L E X P E R IE N C E OF P R U D E N T IA L C O ., 1897 T O 1914, C O M P A R E D W I T H T H A T O F A L L M A L E S I N T H E R E G I S T R A T I O N A R E A , 1900 T O 1913, B Y A G E G R O U P S . D eath s of printers an d com positors, 1897 to 1914, from — Per cent of deaths from p u lm o n a ry tubercu losis am ong— A g e at death. A ll causes. P u lm o n a r y tub er culosis. Printers and com positors. Males in registration area,1900 to 19i3. 15 to 24 years............................................................................................. 25 to 34 y e a r s ....... ................................................................................... 35 to 44 y e a rs........................................................................................... 45 to 54 y e a rs,................................................... ....................................... 55 to 64 y ears............................................................................................. 65 years an d over.................................................................................... A ge u nk now n .......................................................................................... 795 904 851 567 427 318 1 368 505 350 141 42 14 46 .3 55.9 41.1 24.9 9 .8 4 .4 27 .0 3 0 .5 23 .4 14.7 7 .9 2 .6 T o ta l, 15 years an d over........................................................ 3,863 1,420 36 .8 13 .9 The mortality of printers in the industrial-insurance experience of the Prudential Co. includes 3,863 deaths from all causes, of which 1,420,- or 36.8 per cent, were from pulmonary tuberculosis. Of the mortality of printers from other respiratory diseases, 343 were from pneumonia, 19 from asthma, 35 from bronchitis, and 55 were from 142 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. less frequent respiratory diseases. If the deaths from pulmonary tuberculosis and nontubercuious respiratory diseases are combined, 48.5 per cent of the mortality of printers was from diseases of the lungs and air passages. The excess in the mortality from tubercu losis among printers is decidedly suggestive of a typical indoor em ployment where the exposure to the inhalation of metallic dust, complicated by more or less injurious gases and fumes, is continuous and, in a measure, unavoidable. While, as shown by Table 50, the mortality from pulmonary tuberculosis among printers is excessive at all ages, the excess is most pronounced at ages 25 to 34, when out of every 100 deaths from all causes 55.9 are from pulmonary tuberculo sis, against a normal expected proportion of 30.5 per cent. The pre ceding observations and statistical data derived from American and foreign sources, including extensive industrial-insurance experience data, fully confirm the conclusion that the printing trade is unques tionably subject to decidedly unfavorable health conditions more or less predisposing to a high degree of tuberculosis frequency. The data suggest the necessity for an improvement in shop conditions in conformity with the Austrian and Swiss regulations covering sani tation in the printing trade.1 MORTALITY OF PRINTERS— MEDICO-ACTUARIAL EXPERIENCE. The data as to height and wTeight prove that a large propor tion of printers are physically below the general average, and by implication they suggest the great practical importance of a physical examination on entrance and of a physical reexamination from time to time for the purpose of ascertaining the earliest indications of physical impairment. Life insurance companies have never dis criminated. against journeymen printers and compositors, and a large number have been insured on the ordinary plan or with fra ternal insurance organizations. Since applicants for ordinary or fraternal insurance are, however, subjected to a fairly rigid medical examination, this class of risks wrould not be strictly representative of the general average. The results of the medico-actuarial investi gation with regard to journeymen printers and compositors can not, therefore, be considered entirely conclusive. The results, however, are shown in Table 51. 1 See in th is connection th e pro p ortion a te m o rta lity d a ta fo r N ew Y o rk C ity prin ters by d ivision al periods o f life and com p arative d a ta for selected occupation s as given in footn o te to page 5 5 . OCCUPATIONS \^ITH EXPOSURE TO METALLIC DUST. 143 5 1 .— M O RTALITY FROM ALL CAUSES AMONG JOURNEYM EN COMPOSITORS, B ^ AGE GROUPS—MEDICO-ACTUARIAL IN VESTIG ATIO N . T a b le Number exposed to risk one year. Age at death. 15 to 29 years............................................................................ . 30 to 39 years............................................................................ 40 to 49 years............................................................................ 50 to 59 vears............................................................................ 60 years and over..................................................................... Total, 15 years and over............................................... Per cent Expected actual are of expected deaths. deaths. Actual deaths. 118 6,428 3,706 962 261 21 35 20 7 6 29.64 21. 23 9.58 4.95 1.04 73 121 11,378 68 66.44 102 According to this table the actual mortality of the risks under consideration is 102 per cent, being highest at the two extremes, or 118 per cent at ages 15 to 29, and 121 per cent at ages 50 to 59. The table would seem to prove that the health-injurious effects of the printing trade are most pronounced in youth and after middle age. It would make a valuable contribution to the scientific study of the subject if the statistics of the International Typographical Union could be subjected to a critical analysis. The same conclusion applies to .the experience which has been had with sanatorium treatment at the home for sick and aged printers in Colorado. SPECIAL CONSIDERATION OF THE MORTALITY AND DISEASE LIABILITY OF COMPOSITORS. Compositors, considered as a distinct occupation (for many printers are also compositors), are exposed to practically the same healthinjitrious conditions as are persons engaged in the other occupations of the printing business, and in addition they suffer from eyestrain, which may, under given conditions, affect very seriously the diseaseresisting capacity of the system. Stereotyping might have been in cluded here, and its enormous development as a separate branch of the printing trade would warrant special consideration if any really authenticated observations had been made a matter of record useful for the present purpose. In stereotyping, the liability to lead poison ing is a serious factor, affecting especially the men employed in melting the alloy and ladling it into the forms.1 The same obser vation applies to operatives on linotype machines, but our present information regarding these employments is too indefinite to warrant the conclusion that the exposure to the risk of plumbism increases materially the mortality from tuberculous and respiratory diseases. 1 S t e r e o t y p in g is f u l l y d e s c r ib e d in t h e r e p o r t b y H a m i l t o n a n d V e r r i ll o n t h e “ H y g ie n e o f th e P r in tin g T r a d e s ” 2 0 9 ), in c lu d in g D is e a s e s as p a r e n t ly m ost (B u lle tin re fe re n c e s regard s th e lia b le , to th e occu rren ce o f th e fin d in g s of p r o p o r t io n a t e ly U n it e d of cases to th e S ta te s th e of B ureau o f L ab or Illin o is le a d C o m m is s io n p o is o n in g . n u m b e rs exposed on S ta tis tic s to r is k . No. O c c u p a t io n a l S te re o ty p e rs w ere A c c o r d in g ap to H a y h u r s t t h e p r o p o r t io n o f le a d p o is o n in g a m o n g li n o t y p e r s w a s 3J p e r c e n t a g a i n s t 7 . 0 per cen t a m o n g s te r e o ty p e r s. 144 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TEADES. There are no general vital statistics of compositors separate from those of printers and pressmen, since in both American and foreign statistics these employments are considered as a group. There is included here a brief extract from a letter by Mr. J. W. Sullivan, a New York City printer, in the Typographical Journal for November, 1903, and reprinted in the annual report of the New York State Bureau of Labor Statistics for 1906, reading in part as follows: Typesetting is exhaustive work. Standing hour by hour brings on backache, and in some men varicose veins and swollen feet. Sitting on the high printing-office stools doubles the typesetter up, constrain ing his arm motions and interfering with his digestion. The lino type operator’s stool is too low, as it throws his legs into cramped positions. From the pot of molten type-metal under his machine comes a trying heat and offensive gases. He must watch the delicate machinery lest it go wrong. The electric light thrown on his copy often sharply conflicts with the daylight. His keyboard work with wrist and fingers and his handling of hot slugs sometimes results in numbness that threatens scrivener’s palsy. Whether typesetter or linotype operator, the compositor’s brain is active every moment dur ing the workday. Composition can never be wholly mechanical. Attention must be given to deciphering the copy, to spelling, to capi talizing, punctuating, office style, and correcting the lines as com posed. Each of these distinct mental acts, on the whole tedious and monotonous, helps to drain the bodily forces. As the brain becomes fatigued its cells shrink. With every type a man sets there is a touch of wear on the cerebral tissue itself, only to be repaired by the restorative operations of nature—through food, rest, and sleep. SPECIAL CONSIDERATION OF THE MORTALITY AND DISEASE LIABILITY OF PRESSMEN. Pressmen in printing plants may also be separately considered, although the information regarding this occupation is rather frag mentary and inconclusive. Arlidge Comments on the hygienic aspects of the employment in part as follows: Their old mode of working has been superseded by the wonderful development of the modern printing machine, whereby the pressman has become little else than an attendant upon it; and we see the marvelous machine in newspaper offices strike off, fold, and count the sheets by thousands in an hour. Bodily strength is consequently at a discount, ^nd the disadvantages of the occupation limited to the heat of the pressroom—caused principally by the heated cylin ders of the press, and to a greater or smaller extent, where coai gas and not electricity is used for lighting, by the gas jets. Add to these the noise of the machines, the standing posture, and confinement in the pressroom and sustained attention to their work, and there re mains nothing else calculated to injure the pressman’s health, bar ring circumstances within his own control. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 145 The occupation of pressmen does not appear to have attracted the special attention of American writers on occupation mortality, but it is safe to assume that the disease liability of this class, and in par ticular the degree of frequency of pulmonary tuberculosis, do not materially differ from the observed mortality of men employed in the printing trade generally. More definite data, however, would supply a much to be desired addition to our at present very limited knowledge regarding the specific occupation mortality of this em ployment. M O R T A L I T Y OF P R E S S M E N — M E D I C O -A C T U A R I A L E X P E D I E N C E . The only available mortality data regarding pressmen as differ entiated from compositors are the medico-actuarial statistics, which, of course, are inclusive of deaths from all causes and not with special reference to tuberculosis. The number exposed to risk, espe cially at the younger ages, was relatively fairly large, and the experi ence shows that the actual mortality was 117 per cent of the expected, in contrast to 102 per cent for journeymen compositors. The data in detail are given in Table 52. T a b l e 5 2 .— M O R T A L I T Y F R O M A L L C A U S E S A M O N G J O U R N E Y M E N PRESSM EN, B Y A G E G R O U P S — M E D I C O -A C T U A R IA L IN V E S T I G A T I O N . A g e at death. 15 30 40 50 60 N um ber exposed to n s k one year. A c tu a l deaths. E xp ec te d deaths. P er cen t actual are of expected d e a t h s .' to 29 years............................................................................................. to 39 years............................................................................................. to 49 years............................................................................................. to 59 years............................................................................................. years and over.................................................................................... 5,674 3 ,012 976 310 15 32 15 10 11 2 25.99 17.02 9 .2 9 6.93 .51 123 88 108 159 392 T o ta l, 15 years and over........................................................ 9,987 70 59.74 117 This table is exceptionally interesting, in that it confirms the re sults of the previous analysis of the mortality of journeymen com positors, showing an excessive death rate from all causes at ages under 30 and at ages over 50. It suggests the practical value of fur ther and more specialized inquiries in connection with the different branches of the printing trade. It is of interest in this connection to draw attention to the industrial mortality experience of the Pruden tial Co., which, in a general way, confirms the results of other inves tigations. 106811°— 18— Bull. 231------ 10 146 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 5 3 .— P R O P O R T I O N A T E M O R T A L I T Y F R O M P U L M O N A R Y T U B E R C U L O S I S A M O N G PRESSM EN, IN D U S T R IA L E X P E R IE N C E OF P A R E D W IT H T H A T O F A L L ’ M A L E S IN T H E P R U D E N T IA L C O ., 1897 T O 1914, C O M R E G I S T R A T I O N A R E A , 1900 T O 1913, B Y AG E GROUPS. D eath s of pressm en, 1897 to 1914, from — Per cent of deaths from p ulm on ary tubercu losis am ong— A g e at death. A ll causes. 15 to 24 years............................................................................................. 25 to 34 vears............................................................................................. '65 to 44 vears............................................................................................ 45 to 54 years............................................................................................. 55 to 64 years............................................................................................. 65 years and over.................................................................... ............... 168 151 116 45 27 T otal, 15 years an d over........................................................ ’ J m 523 P ulm onary tuberculo sis. 72 72 51 9 P ressm en. Males in registration area, 1900 to 1913. 27.0 3 42.9 47.7 44.0 20.0 11.1 . 207 39.6 13.9 16 30.5 23.4 14.7 7.9 2 .6 GENERAL CONCLUSIONS. The mortality of pressmen from pulmonary tuberculosis is shown to be somewhat more favorable at the earlier ages than the corre sponding mortality of printers and compositors, but for the later age groups the numbers are insufficient for a safe conclusion. In a general way the differences are not sufficiently pronounced to sug gest material variations in the occupational hazards of the more important occupational groups of the printing trade. At all ages it is shown in Table 53 that out of 523 deaths from all causes amon^ pressmen, 207, or 39.6 per cent, are from pulmonary tuberculosis, against a normal proportion of 13.9 per cent among males in the United States registration area. The statistical evidence is there fore decidedly suggestive of more or less health-injurious conditions common to this particular occupational group, which are elsewhere shown to prevail in the printing trades generally. In this connection attention may be directed to an exceptionally carefully considered set of precautions for printers published by the New York City Department of Health, through its division of industrial hygiene, and published in the Monthly Eeview of the United States Bureau of Labor Statistics, for December, 1915. The suggestion made in these rules regarding the necessity of avoiding lead dust should, however, be amplified to apply to the avoidance of all forms of metallic or mineral dust common to the printing trades generally. ENGRAVERS. Engravers are a fairly numerous and widely distributed class of workmen, whose occupation is sufficiently well defined to warrant separate consideration. According to the census of 1910 there were 11,766 engravers in the United States. Engravers upon copper, steel, OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 147 or otlier metals are subject to much the same conditions injuriously affecting health and life, and the differentiation of the employment according to the kind of metal worked upon is not practicable. The employment decidedly predisposes to tuberculosis, and all the available data indicate an excessive proportion of deaths from this disease among engravers, at least during the active working period of life. Aside from health-injurious factors directly result ing from operations and processes inseparable from the employment, there is also the unfavorable effect of a sedentary occupation demand ing a fixed and stooping position. Arlidge has called attention to the fact that there are other accessory conditions unfavorable to health in this employment, such as the frequent use of strong light, severe taxing of the eyes,1 and the employment of strong acids. Some fairly conclusive data are available regarding the mortality of engravers, with particular reference to pulmonary tuberculosis, but as an interesting case of extreme longevity mention may be made of a Mr. Charles Harris, who died at the age of 93, and who for more than half a century had been an engraver of the American Bank Note Co. A somewhat similar case was that of a Mr. James P. Mayer, who, at the time of his death at the age of 83, was reputed to be the oldest steel engraver in America. RELATIVE FREQUENCY OF PULMONARY TUBERCULOSIS. These, however, are but illustrations of exceptions and rather mark the rule of the comparative infrequency of extreme longevity among men in this employment. Thackrah held that “ engravers and copper plate printers present few examples of old age,” and he may have included printers and lithographers and similar employ ments under this term. Tracy, writing with reference to more recent and American conditions, holds that engravers, in common with lapi daries and watchmakers, are very liable to phthisis. It is probably quite true, as pointed out by Sommerfeld, that the amount of metallic or mineral dust generated in this occupation is comparatively small in quantity, but it is practically certain to be injurious in its effects just because of the minuteness of the particles. According to Sommerfeld’s data, 23.6 per cent of all cases of sickness of engravers were diseases of the lungs and air passages. He suggests, among other things, as a precaution, extreme care in the physical selection of engravers’ apprentices to eliminate those already predisposed to pul monary tuberculosis. He further advises the proper A^entilation of the workshops, which in most cases is almost entirely neglected. 1 by For a n e x te n d e d d is c u s s io n o f th e c a u s e o f e y e s t r a i n , see B io g r a p h ic C lin ic s , V o l. I V , G eorge M o n t h ly M. fo r G o u ld , D ecem ber, M. D ., 1905. P h il a d e lp h ia , 1906, p. 61 et seq , ; a ls o P o p u la r S c ie n c e MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 148 MORTALITY OF ENGRAVERS—UNITED STATES REGISTRATION AREA The mortality of engravers has been reported upon for the year 1909 by the Division of Vital Statistics of the United States Census Bureau, but no subsequent information has been made public, and the data are, therefore, limited to the year referred to. According to the census report, out of 112 deaths of engravers from all causes 23, or 20.5 per cent, were from pulmonary tuberculosis. The details of the mortality by divisional periods of life are shown in Table 51. T a b le 5 4 .— P R O P O R T IO N A T E M O R T A L IT Y O F E N G R A V E R S F R O M P U L M O N A R Y T U B E R C U L O S IS , U N IT E D S T A T E S R E G I S T R A T I O N A R E A , 1909, B Y A G E G R O U P S . D eath s from p ulm onary tuberculosis. D eath s from all causes. A g e at death. Nu m ber. 15 25 35 45 55 65 Per cent of deaths from all causes. to 24 y ears........................................................................................................................ to 34 years........................................................................................................................ to 44 years........................................................................................................................ to 54 years........................................................................................................................ to 64 ye ars........................................................................................................................ years and o v e r ............................................................................................................... 10 23 20 15 19 25 5 8 5 1 3 1 5 0 .0 3 4 .8 2 5 .0 6 .7 15.8 4 .0 T otal, 15 years and o v e r ................................................................................... 112 23 20.5 According to this table the mortality from pulmonary tubercu losis is relatively high at the younger ages, but the data are too limited for entirely safe conclusions. In a general way, however, they confirm other statistics derived from American” and foreign experience. As shown in Table 55, the mortality of engravers from nontuberculous respiratory diseases was relatively low, or only 3.6 per cent of the mortality from all causes, the deaths being limited to pneumonia and other nontuberculous respiratory diseases, excluding asthma and bronchitis. T a b le 5 5 .— P R O P O R T IO N A T E M O R T A L I T Y O F E N G R A V E R S F R O M N O N T U B E R C U L O U S R E S P IR A T O R Y D IS E A S E S , U N IT E D S T A T E S R E G I S T R A T I O N A R E A , 1909. D eath s from n ontuber culous respiratory diseases. Cause of death. N u m ber. • Per cent of deaths from all causes. A s th m a ................................................................................................................................................................ B ronchitis ............................................................................................................................................ .. 3 2 .7 P n e u m o n ia ....................................................................................................................................................... Other n ontuberculous respiratory diseases........................................................................ 1 .9 T o ta l........................................................................................................................................................ 4 3 .6 OCCUPATIONS W IT H EXPOSURE TO METALLIC DUST. 149 MORTALITY OF ENGRAVERS— INDUSTRIAL INSURANCE EXPERIENCE. A large number of engravers are employed by the Bureau of En graving and Printing of the United States Government, which in the past had most of its bank notes and postage stamps printed by private concerns. In former years no doubt serious objections were properly raised against the conditions under which Government employees were at work in the Bureau of Engraving and Printing; but most of the earlier disadvantages have been done away with. The health conditions have correspondingly* improved and the more or less inevitable degree of dust exposure has been reduced to a mini mum. The vital statistics of this branch of the Government service if published would be of considerable practical value. At the present time the only available data are the industrial insurance mortality statistics for the period 1897 to 1914, covering 384 deaths, of which 127, or 33.1 per cent, were from pulmonary tuberculosis. The details of this analysis are given in Table 56. T a b le 5 6 . — P R O P O R T IO N A T E M O R T A L I T Y F R O M P U L M O N A R Y T U B E R C U L O S IS A M O N G E N G R A V E R S , IN D U S T R IA L E X P E R IE N C E P A R E D W I T H T H A T O F A L L M A L E S IN T O 1913, B Y A G E OF P R U D E N T IA L U N IT E D C O ., 1897 T O 1914, C O M S T A T E S R E G I S T R A T I O N A R E A , 1900 GROUPS. D eath s of engravers, 1897 to 1914, from — Per cent of deaths from p u lm o n a ry tubercu losis am on g— A ge at death. A ll causes. 15 25 35 45 55 65 P ulm on a ry tubercu Engravers. losis. M ales in registration area, 1900 to 1913. to 24 years............................................................................................. to 34 years............................................................................................. to 44 years............................................................................................. to 54 y e a rs............................................................................................. to 64 years............................................................................................. years an d over.................................................................................... 71 92 74 63 41 43 28 50 35 10 3 1 39 .4 54.3 47 .3 15.9 7 .3 2 .3 2 7 .0 3 0 .5 2 3 .4 1 4 .7 7 .9 2 .6 T o ta l, 15 years an d over........................................................ 384 127 33.1 13.9 GENERAL CONCLUSIONS. The general conclusions regarding engravers, including photo engravers, are briefly summarized by Dr. Kober, in Kober and Han son’s Diseases of Occupation and Vocational Hygiene (p. 615), as follows: The work of engraving upon steel, copper, or other material in volves not only considerable eyestrain, but also, in the absence of suitable work benches, a faulty position which interferes with the respiratory movements. Steel and copper plate engravers are also exposed to mercury, and makers of stamping devices and seals to lead and the fumes of nitric acid. The latter agent is likewise em ployed in mints in connection with the coinage of money. Accord ing to Sommerfeld, cited by Zadek, 73.6 per cent of all the deaths 150 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. among this class of workers in Berlin were caused by diseases of the respiratory system, inclusive of 62.1 per cent from tuberculosis; this is in part accounted for by the fact that so many weaklings engage in this pursuit. Visual defects, neurasthenia, and diseases of the digestive system are also quite common. Plate printers who have to look con stantly at bright plates suffer not only from eyestrain but occasion ally also from conjunctivitis and even retinitis. Photo-engravers han dle benzol for dissolving rubber films, alcohol, and ether, in collodium films, strong acetic acid for the removal of films; they are also ex posed to gas fumes and ammonium dichromate in sensitizing copper plates, and to ferric chloride and nitric acid fumes in etching. The Report of the Photo-engravers’ Union for 1914, cited by Hayhurst, discloses the fact that out of 217 deaths since 1903, 88, or nearly 41 per cent, were due to tuberculosis. During the year 1914 five cases of bichromate and one case of cyanide poisoning were reported. Apparently the dust hazard is, by the wTriter, considered of minor importance, which is not in conformity with the results of special ized statistical investigations into the mortality of engravers and allied occupations. Specific occupational diseases are unquestionably of considerable scientific interest, but they are of minor importance in comparison with the excessive amount of pulmonary tuberculosis directly or indirectly attributable to the employment, and more or less subject to control by effective methods of sanitation. BRASS WORKERS. Brass workers, exclusive of brass polishers and buffers, who have been separately considered, constitute a large group of widely diversi fied and often quite different employments. Brass casting, founding, and molding are arduous occupations exposing to the inhalation of considerable quantities of mineral dust more or less mixed with metallic ingredients. Whether brass dust, as such, is more injurious than the dust of iron and steel, for illustration, has not been deter mined. In the evidence submitted to the Departmental Committee on Compensation for Industrial Diseases by the National Society of Amalgamated Brass Workers,1 including about 7,000 members, it was stated that about 2,000 of these were engaged in casting. The trade was said to be divided into pattern making, chasing, casting, finish ing, burnishing, polishing, and putting together. The correspond ing classification of the trade in the United States follows practically similar lines.2 Of the divisions mentioned, casting and founding were considered the most injurious to health. Burnishing was held to be less injurious than polishing, but the so-called putting together was — ---------»— 1 G reat B rita in , H om e D epartm en t, M inutes o f Evidence, D epartm en tal C om m ittee on C om pen sation fo r In d u stria l D iseases, 1 9 0 6 , p. 75 et seq. 2 Th e num ber o f bra ss w orkers in the U nited Sta tes in 1 9 1 0 w as 4 6 ,7 2 2 , and o f th is num ber 3 ,0 6 2 w ere w om en. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 151 stated to be decidedly unhealthful on account of the use of white lead- Evidently, in so diversified a trade the degree of dust exposure must vary widely, and at best the degree of injury can only be meas ured approximately upon the basis of more or less indefinite mor tality data. The exposure of brass workers to dust inhalation is only one of a number of specific factors in a trade decidedly in jurious to health and life, and of these mention may be made of the exposure to fumes and vapors generated in the smelting processes. Brass founders’ ague is a well-defined occupational disease, the symp toms of which are tightness of the chest with indefinite nervous sensa tion, followed by fever and previous sweating. Zinc and other fumes inhaled are the chief causes of this ailment, and it is quite probable that the lung injury resulting from the inhalation of fine particles of metallic dust is a material contributory cause in brass founder’s ague. Arlidge, in summing up the views of other authorities on brass workers’'disease, points out that—■ Besides brass founding, there are other departments in the brassworking business that are damaging to health; and chiefly so by reason of the dust produced. These branches are brass casting, turning, filing, and polishing. The soft nature of brass is opposed to the development of very fine and acuminated particles, and its weight to its rising very freely and to its diffusion in the air. Never theless, those turning and filing it show clearly, by their clothes and hair, that it is largely dispersed, the latter getting green, as happens with brass founders. The inhalation of brass dust operates in simi lar fashion to that seen in connection with other metallic dusts, pro voking bronchial catarrh, which advances to bronchitis and ends in fibrosis. It is reported by some writers that phthisis is unusually prevalent, but no reliable statistics are available to support this statement. SANITARY CONDITIONS IN THE BRITISH BRASS INDUSTRY. More recent investigations in England fully confirm these earlier conclusions. In 1894 a departmental committee was appointed by the secretary of state to report upon the conditions of work as affecting the health of operatives in the manufacture of brass and kindred amalgams. In its report, which was published in 1896, the commit tee stated as the result of its investigation, first, that brass workers as a class were extremely liable to diseases of the respiratory or gans, and, second, that brass founders’ ague, so called, was found to result from the inhalation of fumes given off by the molten brass at the time of pouring, but in a less degree it was attributed to the contamination of the workers’ food by the fumes, and that this danger was in proportion to the amount of zinc used in the alloy. The subject was also reported upon in much detail in the Report of 152 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. the Chief Inspector of Factories and Workshops for the year 1905. From this report the following suggestwe extracts are made: Altogether some 500 brass workers were examined, and in addition to the filling in by each one of them of the appended form, note was made of the height, weight, chest measurement, and strength of grasp; the heart, lungs, gums, and teeth were, whenever practicable, examined, and the condition as to anemia, paresis, general health, and prevalence of brass founders’ ague was determined. The result of the replies of 216 casters and 199 polishers and others to the question, Do you consider that your health has been in any way injured by working in brass? was that 22.7 per cent of the casters and 11.6 per cent of the polishers and others said they had suffered. This is perhaps the strongest evidence obtained in the inquiry that the casters are exposed to more trying conditions of work than are other brass workers. The nature of the injury was, as a rule, only very vaguely ex pressed; in the case of the casters it was nearly always either u fumes ” or “ sulphur,” and in that of the polishers “ dust.” In one casting shop, where 19 strip casters were examined, of whom 9 said they suffered, illness or discomfort was attributed in some cases to resin fumes in addition to those ordinarily present. Among the casters there were indications that the older the workers were, and also that the earlier the age of commencement of work, the more did they say they had suffered, facts which could not be observed in the case of the polishers. In 8 casters (3.9 per cent) definite physical signs in the lungs were found, and similarly in 3 (1.5 per cent) of the polishers and others. In two of the casters these pointed to chronic phthisis, while the remainder pointed to bronchial catarrh. I am not inclined to draw any conclusions from these facts, because (1) the number of observa tions is too small, (2) the examination in some of the factories was carried out under great disadvantages, owing to the impossibility of securing a quiet room, and (3) it is well known that persons who are the subjects of disease of the lungs in any marked degree are not likely to be found at work. Very strong evidence of the beneficial effect of good exhaust venti lation in connection with all kinds of polishing operations, and indi rectly of the lowered state of health from the nonremoval of the dust, was obtained at one factory. Here the opinion of the occupier was that the installation had paid for itself over and over again in the better work which was turned out by the men, and by the im proved tone among them resulting from the absence of the obnoxious dust. 'The remarks of the polishers bore this out. One said, “ Worked for 18 years before the fan was put in, when the dust used to make me feel sick, but it is not so now.” A second said, “ I prefer this shop to any other.” A third, “ I never worked in a cleaner shop ” ; and a fourth, “ The fan is a great improvement.” A large amount of fluff, sand, and lime is given off in the process of polishing with calico mops. It is not, therefore, difficult to under stand (even although actual injury to health from it may be hard to prove) that removal of the dust is welcomed as tending to make the work healthier. A sample of dust taken from under a polishing bob was submitted to Dr. Thorpe, who reported: uThis sample con OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 153 tains a large proportion of fiber, the loss on ignition amounting to 37.6 per cent. The metallic portion of the residue—copper, zinc, lead, and iron— amounts to 10.56 per cent of the total sample. The lead present equals 0.22 per cent of the total samples, or 2.1 per cent of the above metallic constituents, or, excluding the iron, 2.33 per cent. Microscopically brass dust collected from near an emery wheel showed all the appearances of an injurious metallic dust—fine par ticles with irregular jagged edges.” Oliver concludes his observations regarding the hygiene of this employment with the following statement: The necessity of personal cleanliness on the part of workmen and of well-ventilated workshops is apparent. Means ought to be pro vided for a ready escape of the fumes and for the removal of dust. The workshops ought to be cleaned at least once a year and the walls whitewashed. Hot and cold water should be provided for the men to wash in. The workmen themselves have found out by experience that milk is both a prophylactic or preventive as well as a curative agent. While the use of respirators seems called for, the men can not work well in them. Women and persons under 18 years of age are not allowed to work in the casting shop. ENGLISH MORTALITY STATISTICS OF BRASS WORKERS. The most recent English mortality statistics of brass workers are for the three years ending with 1902, referred to in the report of the registrar general, in part, as follows: The mortality of these workers is somewhat below the standard at ages 15 to 20 and 25 to 35 years, but above the standard at every other age group. In the main working period of life their compara tive mortality figure is 1,154, or 15 per cent above the average; the greatest excess of mortality occurring under the head of phthisis, the figure for which disease is above the average by 45 per cent. The mortality from diseases of the nervous, circulatory, respiratory, and urinary systems, as well as from suicide is also above the average. These workers are only slightly liable to fatal influenza, and their mortality from alcoholism and liver disease is also low. They like wise suffer less than the average from fatal accident.1 The English occupation mortality statistics for brass workers are quite conclusive of the more or less unfavorable effects of this indus try on health. In Table 57 a comparison is made of the mortality from all causes of men in this group with occupied males generally, and the result is quite suggestive of conditions in this trade more or less unfavorable to life and health, but in particular at ages 35 to 64, when the general mortality of this class exceeds the general average by from 2.57 to 5.59 per 1,000. 1 P a r t I I , Su pplem en t to the S ix ty -fifth A n n u a l R ep o rt o f B irth s, D ea th s, an d M arriage s in E n g la n d and W a le s , p. lx x v . th e R egistrar-G en eral of 154 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 5 7 . — M O R T A L IT Y F R O M A L L C A U SE S OF B R A S S W O R K E R S , C O M P A R E D W I T H T H A T O F A L L O CC U P IED M A L E S , IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E G R O U PS. T a b le [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate for brass workers. Age at death. 15 to 19 years.................................................................................... 20 to 24 years.................................................................................... 25 to 34 years.................................................................................... 35 to 44 vears.................................................................................... 45 to 54 vears.................................................................................... 55 to 64 years.................................................................................... 65 years and over............................................................................ Death rate per 1,000 for all occupied males. 2.44 4.41 6.01 10. 22 17.73 31.01 88.39 Rate per 1, 000. 2.22 5.13 5.86 12.79 20.90 36.60 83.78 G reater(+) or less ( —) Per cent of rate for all than rate for all occu occupied males. pied males. - 0.22 + .72 - .15 + 2 .5 7 + 3 .1 7 + 5 .5 9 - 4 .6 1 91 116 98 125 118 118 95 The preceding table is self-explanatory. A more extended com parison is made in Table 58, in which the mortality of brass workers from pulmonary tuberculosis and respiratory diseases other than tuberculosis is compared with the normal mortality of occupied males from these diseases by divisional periods of life. The comparison shows that at ages 20 to 64, inclusive, the mortality of brass workers from pulmonary tuberculosis is excessive by from 0.42 to 1.79 per 1,000, the excess being greatest at ages 35 to 44. The table further shows that the mortality from respiratory diseases other than tuberculosis is excessive among men in this class, but decidedly so at ages 55 and over, when the excess is from 1.29 to 2.88 per 1,000. The two tables derived from English experience fully confirm the previous conclusion that the mortality of brass workers is excessive when comparison is made with the normal mortality of occupied males generally, and that this excess is largely because of the high degree of tuberculosis frequency, particularly at ages 25 to 54.1 1 A n excellen t accou n t o f the com p arative social and h e a lth con ditions o f brassw orkers, en titled “ B rassw ork ers o f B erlin and o f B irm in g h a m ,” w as published by P. S. K in g & Son, L o n d o n , in 1 9 1 0 . T h is is a jo in t rep ort by a rep resen tative o f a large brassw orks, the secretary o f the N a tio n a l Society o f A m a lg a m a ted B rassw ork ers, and a rep resen tative o f the B irm in g h a m H o sp ita l. T h e rep ort includes an in terestin g a c cou nt o f the B ra ssw o rk ers’ T rad e U nion and gen eral ob servations on the G erm an com pu lsory h e a lth insurance system . OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 155 T able 5 8 .— M O R T A L IT Y f E O M P U L M O N A R Y T U B E R C U L O S IS A N D F R O M O T H E R p i S E A S E S O F T H E R E S P I R A T O R Y S Y S T E M A M O N G B R A SS W O R K E R S , C O M P A R E D W I T H T H A T O F A L L O C C U P IE D M A L E S , IN E N G L A N D A N D W A L E S , 1900 T O 1902, B Y A G E G R O U P S. [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England, and Wales.] Mortality from other diseases of the respiratory system. Mortality from pulmonary tuberculosis. Death rate for brass workers. Age at death. Death rate per 1,000 for all occu pied males. 15 to T9 years........ 20 to 24 years........ 25 to 34 years. 35 to 44 years........ 45 to 54 years........ . 55 to 64 years........ 65 years and over. 0.54 1.55 2.03 2.74 3.04 2.16 1,11 Rate per 1,000. Greater(+) or less ( —) than rate for all occupied males. 0.49 2.17 2.93 4.53 4.61 2.58 .44 —«0.05 + .62 + .90 + 1 .7 9 + 1 .5 7 + .42 - .67 Death rate for brass workers. Death rate per P«r cent 1,000 for of rate for all occu all occu pied pied males. males. 91 140 144 165 152 119 40 0.24 .48 .77 1.66 1 3,32 6.54 17.77 Rate per 1, 000. 0.24 .52 .60 2.05 3.94 9. 42 19.06 Greater(+) or less ( —) Per cent than rate of rate for all occu for all pied occupied males. males. + 0 .0 4 - .17 + .39 + .62 + 2. 88 + 1.29 : 100 10S 78 123 119 144 107 INVESTIGATIONS BY THE ILLINOIS COMMISSION ON OCCUPATIONAL DISEASES. A number of special investigations have been made of the brass industry in the United States, but chiefly with reference to the occur rence of brass poisoning, or “ brass founders’ ague.” One of the most important of these investigations is by E. R. Hayhurst, the results of which were published by the Illinois Commission on Occupational Diseases. Brass being an alloy composed of copper and zinc, the actual degree of metallic dust exposure in the different processes is quite considerable. No specialized investigations have been made to ascertain the relative degree of dust exposure at the furnaces and the foundries and in connection with manufacturing processes. The dust inhaled is, of course, more or less mixed, and in the majority of cases may be more mineral than metallic in character. The so-called “ brass chills,7’ or “ brass founders’ ague,” occurs almost exclusively in brass foundries and never in the more specialized man ufacturing processes. According to Hayhurst, however, in addition to brass founders’ ague there is a distinct liability to respiratory diseases. MORTALITY OF BRASS MOLDERS IN OHIO. An investigation made in Ohio for the three years, 1910 to 1912, included 43 deaths of brass molders and brass workers, of whom 14, or 32.7 per cent, died from pulmonary tuberculosis. It is pointed out in this connection in Hayhurst’s report on Health Hazards that u While the number of total deaths reported is small, the high rate of consumption is in harmony with observations concerning this 156 MORTALITY FROM RESPIRATORY DISEASES IN' DUSTY TRADES. industry reported elsewhere.” Old age is rarely attained among persons employed in the brass industry, and, according to Sir Thomas Oliver, out of 1,200 brass casters in Birmingham (England) only 10 were found to be living beyond 60 years. How far this inferior lon gevity is the result of dust exposure is not, perhaps, directly ascer tainable, but there are reasons for believing that the excessive mor tality from tuberculous diseases among brass workers bears some rela tion to the relatively considerable and practically continuous exposure to metallic and mineral dust. This exposure, of course, is exceptionally great in grinding and polishing brass, which are elsewhere discussed in detail without particular reference, however, to the brass industry. The sanitary conditions of the industry are, as a general rule, far from satisfac tory, and in the Ohio investigation, for illustration, “ in no place were means adopted to confine and remove brass fumes during pour ing.” The general construction of brass foundries was determined as h3rgienically good in 42 places, fairly so in 21, and unsatisfactory in the remaining 43. All of the special processes, such as core making, metal grinding, casting cleaning, machine-shop practice, polishing and buffing, involve a more or less definite hazard of dust exposure. The air conditions in the foundry processes of the brass-working plants investigated in Ohio were found to be good in only 17 places, fair in 41, and decidedly hazardous to the health of the workers in 48. MEDICAL ASPECTS OF THE BRASS INDUSTRY IN CONNECTICUT. The medical aspects of the brass industry in Connecticut have been investigated and reported upon by W. Gilman Thompson, who states that: The inhalation of powdered brass, the dust of brass filings, etc.5 irritates the respiratory mucosa and lungs. The metal may also be swallowed after inhalation into the mouth, or conveyance to the mouth by unclean hands or food or plug tobacco. In this manner chronic poisoning in time results, with symptoms which differ considerably from those of the ague, above described. Chronic bronchitis is usu ally to be found and sometimes fibroid phthisis and tuberculosis. The digestive system is deranged, and the victim complains of dys pepsia, anorexia, gastro-intestinal catarrh, nausea, vomiting, thirst, irregular action of the bowels, occasional intestinal colic, and a metallic taste in the mouth. The tartar on the teeth may become green from a deposit of copper salts. Headache and general muscular pains are common, and the patients often become neurotic, depressed, and hypochondriacal. The evidence obtainable by means of such investigations would, therefore, seem to sustain the statistical data derived from American and foreign sources. OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. M O R T A L I T Y OF B R A S S W O R K E R S — U N I T E D 157 ST A T E S R E G IS T R A T IO N A R E A . The mortality of brass workers has been reported upon for the year 1909 by the Division of Vital Statistics of the United States Census Bureau, but no subsequent information has been made public, and the data are, therefore, limited to the year referred to. Accord ing to the census report, out of 201 deaths of brass workers, 64, or 31.8 per cent, were from pulmonary tuberculosis. The details of the mortality by age groups are shown in Table 59. 5 9 .— P R O P O R T IO N A T E M O R T A L IT Y O F B R A S S W O R K E R S F R O M P U L M O N A R Y T U B E R C U L O S IS , U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1909, B Y A G E G R O U P S . T a b le Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Per cent of deaths from all causes. Number. 15 to 24 Y e a r s ................................................................................................................................. 25 to 34 years.......................... ................................................................................. 35 to 44 years........................................................................................................... 45 to 54 years........................................................................................................... 55 to 64 years............................................................................................................ 65 years and over............ ...................................................................................... 25 42 35 48 26 25 Total, 15 years and o v e r ......................................................................... 201 16 4 4 64.0 50.0 31.4 16.7 15.4 16.0 64 31.8 21 11 8 6 0 .— P R O P O R T IO N A T E M O R T A L IT Y OF B R A S S W O R K E R S FR O M N O N T U B E R C U LO U S R E S P I R A T O R Y D IS E A S E S , U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1909. T a b le Deaths from nontuber culous respiratory dis eases. Cause of death. Number. Bronchitis.......................................................................................................................................... Pneumonia.............. .......................................................................................................... - ........... Ot.hftr nrmtnhArnnlmis rAsniratorv Hisfiases__________ _________ _ _ _____ ___ T otal_____________ - .................. ..... ............... ..................... 3 Per cent of deaths from all causes. 18 1 1 .5 9 .0 .5 22 10 .9 Table 59 is extremely suggestive and indicates an excessive fre quency of pulmonary tuberculosis among brass workers, which term unquestionably includes a considerable number of polishers and buffers. Aside from the relatively high proportion of deaths from pulmonary tuberculosis of 31.8 per cent in the mortality from all causes, other nontuberculous respiratory diseases as shown in Table 60 cause a mortality of 10.9 per cent, or, respectively, 1.5 per cent from bronchitis, 9 per cent from pneumonia, and 0.5 per cent from other respiratory diseases. The table in a general way confirms the data derived from other sources, and obviously suggests the relative un- 158 MORTALITY PROM RESPIRATORY DISEASES IN DUSTY TRADES. healthfulness of employment in the brass industries, without specific reference, however, to the particular occupations, as to which the information is not available. The results of this analysis of the available American vital statistics of brass workers for the registration area are further confirmed by the corresponding statistics derived from the industrial insurance experience of the Prudential Insurance Co. M O R T A L IT Y OF B R A SS W O R K E R S — IN D U S T R IA L IN S U R A N C E E X P E R IE N C E . T able 6 1 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS AM O N G B R A S S W O R K E R S , I N D U S T R I A L E X P E R I E N C E OF P R U D E N T I A L CO., 1897 TO 1914, C O M P A R E D W I T H T H A T OF A L L M A L E S IN U N I T E D S T A T E S R E G I S T R A T I O N A R E A , 1900 TO 1913, B Y A G E G R O U P S . Deaths of brass workers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. Pulmonary tubercu losis. Brass workers. Males in the registra tion area, 1900 to 1913. 15 to 24 years................................................... ......... ........... .......... 25 to 34 years.,................................................................................ 35 to 44 years.................................................................................... 45 to 54 years................................................................................... 55 to 64 years.................................................................................... 65 years and over......................................................................... 91 149 146 99 93 55 53 76 64 24 15 58.2 51.0 43.8 24.2 16.1 27.0 30.5 23.4 14.7 7.9 Total, 15 years and over.................................................. 633 232 36.7 13.9 2.6 The experience shown in Table 61 includes 633 deaths from all causes, of which 232, or 36.7 per cent, are from pulmonary tuber culosis. The proportionate mortality from pulmonary tuberculosis is decidedly excessive at all ages under 65. In support of the sta tistics quoted by Sir Thomas Oliver regarding the proportion of brass workers attaining to old age, it is suggestive that out of 633 deaths of brass workers at all ages, 55, or only 8.7 per cent, should have attained to ages 65 and over. The statistics of Sir Thomas Oliver, however, apparently have reference to brass founders alone, who are unquestionably exposed to greater health hazards than brass workers generally. Unfortunately the data for a specialized analysis by occupations, in detail, are not available for the brass industry at the present time. GENERAL CONCLUSIONS. In a general way the insurance mortality statistics confirm the data and observations derived from other sources. The dust hazard in the brass working trade is, of course, only one of many health-in jurious conditions inherent in the industry, all of which are sug gestive of the exceptional urgency of thoroughly efficient sanitary OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 159 precautions, and the use of protective devices on the part of those most seriously affected by the liability to brass poisoning and its related respiratory affections. ARTIFICIAL FLOWERS. 'T’his occupation is not strictly within the group of trades, indus tries, or occupations with continuous and considerable exposure to metallic dust. It is, however, included in view of the observations by Sir Thomas Oliver, that the workers employed in the manufac ture of artificial flowers, chiefly French roses, especially the double roses, “ complain of headache, nasal catarrh, dryness of the throat, probably from the dust, and also of vomiting.” In addition, he observes, “ In at least one-third of those who suffer, the symptoms are those of metallic poisoning, for on examination of the red leaves of the roses several are found to contain salts of lead.” He draws particular attention to the health-injurious effects of this group of occupations upon the young women engaged in salesrooms where artificial flowers are collected and distributed, and states that t(,*a few of them show^ a tendency to laryngeal and pulmonary catarrh, attended by a cough, owing to the dust given off by the flowers. Upon a microscopic examination of the expectoration it was found that particles of dust contained therein were identical with those given off from the flowers.” P R O C E S S E S O F A R T I F I C I A L -F L O W E R M A K IN G -. An extended account of the processes of artificial-flower making in the United States, by Walter O. Lincoln, is published in the Weekly Underwriter, New York, March 17, 1914. The different processes are not indicative of a considerable amount of dust ex posure, although mention is made of the use of tinsel including mica in its composition. In connection with the manufacture of leaves it is stated that the claim is made on good authority that “ the gasheated presses are injurious to the health of the operators, who are required to sit many hours with the lower limbs extended under the press, with gas burners near by, which overheat the abdomen and cause stomach trouble.” There are, however, no intimations that the manufacture of leaves or flowers involves a particular hazard of metallic or mineral dust exposure. A brief reference occurs in the Second Report of the New York State Factory Investigating Commission (Vol. II, p. 1156), accord ing to which “ The danger in this industry was reputed to be from the use of the arsenic greens for the purpose of dyeing and dusting the material.” The different processes are briefly described in the 160 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. preliminary report of the commission for 1912. In none of these investigations was definite evidence produced tending to prove an exceptional liability to pulmonary tuberculosis in consequence of exposure to the inhalation of metallic and mineral dusts, but more extended investigations would be required for the purpose of scien tific conclusiveness. An admirable discussion of the life and labor of artificial-flower workers by Miss Mary Van Kleeck was published by the Russell Sage Foundation in behalf of the Committee on Women’s Work (New York, 1913). The investigation is of special importance in view of the fact that it was made in the city of New York where three-quarters of all the artificial flowers produced in the United States are made. All of the shops in the Borough of Manhattan known to make artificial flowers, employing 5,240 workers, were visited. The proportions in various age groups of 371 home workers in 110 families were as follows: Children under 8 years of age, 10.2 per cent; children 8 to 14 years of age, 27.2 per cent; children 14 to 16 years of age, 11.3 per cent; and adults 16 years of age and over, 51.3 per cent. The proportions in various age groups of women shop workers employed in artificial-flower making were: Ages 10 to 16 years, 14 per cent; ages 16 to 25 years, 63 per cent; and ages 25 and over, 23 per cent. This compares with all women workers in manu facturing industries as follows: Ages 10 to 16 years, 9 per cent; ages 16 to 25, 53 per cent; and ages 25 years and over, 38 per cent. The artificial-flower making industry is, therefore, typically representa tive of female workers at the younger or immature ages. An analysis of the wages earned proves conclusively that the employments are decidedly underpaid. An inquiry into the hours with special refer ence to fatigue seemed to justify the conclusion that, regardless of the fact that the work* was light, the elements of fatigue were by no means lacking; that many of the workrooms were poorly ven tilated, and that the air was vitiated because of the use of gas stoves for heating the tools and sometimes by gas used in illumination. Complaint was also made that certain dyes used were poisonous, and, according to the author, “ this opinion was expressed so frequently by the workers that it seems credible, although no medical examinations have been made to support it. The girls say that they inhale the dust from cheap flowers and that the color frequently stains their hands and may inadvertently be rubbed on tfie mouth or eyes.” It is, therefore, suggested that44a special investigation of the physical effects of these dyes ought to be made, but in the broader sense the health aspects of the entire industry should be subjected to critical and qualified consideration.” OCCUPATIONS WITH EXPOSURE TO METALLIC DUST. 161 GENERAL CONCLUSIONS. Since in this industry women are almost exclusively employed, the industrial insurance experience data are inconclusive. There have been only 13 deaths of male artificial-flower makers in the ex perience of the Prudential Insurance Co. during the period 190T to 1914, of which, however, 4, or 30.8 per cent, were from pulmonary tuberculosis. Three of the deaths occurred at ages under 35, of which two Avere from this particular disease. The corresponding data for women are not available. On account of its practical im portance as an employment for young persons, chiefly girls of the period of early adolescence, it would seem a matter of some urgency that the health aspect of this group of occupations with special refer ence to the dust hazard and the probable liability to an excessive mortality from tuberculosis should be made the subject of a thor oughly qualified investigation. 106811°— 18— Bull. 231------ 11 CHAPTER III.—OCCUPATIONS WITH EXPOSURE TO MINERAL BUST. Mineral-dust exposure is most common in the stone industry, among potters, in cement manufacture, and in mining. Mineral dust varies widely and essentially in its mechanical and chemical prop erties, and much more so than is the case with the different varieties of metallic dust. The quantitative degree of dust exposure is also decidedly greater in the case of mineral dust, which frequently con taminates the entire atmosphere in a finely comminuted form for prolonged periods of time. Since all dust is primarily injurious on account of its irritating effects on the respiratory organs, it is selfevident that essential variation in the mechanical properties of the dust must correspondingly affect the consequential results on lung tissue and the development of lung fibrosis and pulmonary tuber culosis. It is estimated that at every inhalation an adult person inhales about one-half liter of air, and since the normal respiration is from 10 to 18 times per minute the approximate quantity of air inhaled is from 8 to 9 liters per minute and from 480 to 540 liters per hour. Continuous exposure, therefore, to* even relatively small amounts of atmospheric impurities may have proportionately serious pathological results. According to Hesse, a man working 10 hours a day inhales approximately 0.09 gram of dust per day if employed in a sawmill, 0.025 gram per day if employed in a flour mill, and 1.12 grams per day if employed in a cement mill. Regardless, however, of the fact that the quantitative exposure to dust inhalation in cement manufacture exceeds very considerably the corresponding exposure in many other occupations, it is apparently well established by rea sonably trustworthy data that the inhalation of cement dust is decidedly less injurious to lung tissue, with special reference to pul monary tuberculosis, than exposure to sandstone dust or granite dust, etc. One important factor which is frequently overlooked is the solubility or insolubility of the mineral dust inhaled, and the chemical nature of the dust may therefore be of even greater im portance than its mechanically irritating qualities. The degree of comminution is also of material importance in that in almost exact proportion to the degree of fineness the dust particles will penetrate into the remote portions of the lungs. It is therefore held that the more minutely comminuted the dust, the more serious, in general termSj will be the damage to the respiratory organs. 163 164 MORTALITY FROM RESPIRATORY DISEASES IK DUSTY TRADES. M INERAL DUST A N D PULMONARY TUBERCULOSIS. The term “ mineral dust ” for practical reasons is, for the present purpose, limited to finely comminuted particles of mineral substances as generally differentiated from metallic substances obtained by min ing, quarrying, or other extractive processes. No precise definition regarding mineral dust seems practicable in view of the truly enor mous range of minerals, varying from potash salts and fuller’s earth, phosphate rock, mica, slate, asbestos, mineral paints, graphite, cement, gypsum, borax, asphalt, lime, coke, etc., to pure silica or quartz, which for the present purpose must be considered the most injurious of all forms of mineral dust, approaching quite closely in degree of seriousness to the most irritating forms of metallic dust. The relation of mineral-dust inhalation to pulmonary tuberculosis and nontuberculous lung diseases is ascertainable only as regards the more important mineral products, such as slate, cement, lime, coal, silica, and other stones, chiefly marble, limestone, sandstone, bluestone, and granite. There are no trustworthy mortality statistics regarding dust exposure and its relation to health in connection with the mining of phosphate rock, mica, asbestos, sulphur, soapstone, graphite, borax, asphalt, and abrasive materials. Few of these in dustries are relatively important as regards the number of persons employed therein, but for scientific purposes it is most desirable that the health-injurious results of each and every form of mineral dust should receive the required extended and qualified consideration. The typical form of industrial-dust phthisis met with in occupations with exposure to mineral dust conforms more to the precise defini tion of industrial pneumoconiosis or nontuberculous lung disease in its initial development, although as a general rule there is a super induced true pulmonary tuberculosis which is properly returned as the immediate cause of death. In occupations with exposure to min eral dust it is therefore of even greater importance than in occupa tions with exposure to metallic dust that the nontuberculous lung diseases, particularly asthma and chronic bronchitis, should receive some consideration, aside from the invariably more important mor tality from pulmonary tuberculosis, although the latter often is not the primary but rather a contributory cause of death. LUNG DISEASES AN D M INERAL AND METALLIC DUST EXPOSURE. This conclusion is quite fully sustained by Table 62, which is derived from the industrial insurance experience of the Prudential Insurance Co. for the period 1897 to 1914, and which may safely be considered representative for the country at large. OCCUPATIONS WITH EXPOSURE TO MINERAL DUST. 165 C O M P A R A T IV E P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R CULOSIS A N D N O N T U B E R C U L O U S R E S P I R A T O R Y D IS E A S E S IN O C C U P A T IO N S E X PO SIN G TO M I N E R A L A N D M E T A L L IC D U S T , I N D U S T R I A L E X P E R I E N C E OF P R U D E N T I A L CO., 1897 TO 1914. T a b le 6 2 .— Deaths of workers exposed to— Cause of death. < Metallic dust. Mineral dust. Number. Per cent. Number. Per cent. Pulmonary tuberculosis.............................................................. 3,129 27.3 2,960 36.0 A sthm a......................................................................................... Bronchitis........................................................................................ Pneumonia...................................................................................... Other nontuberculous respiratory diseases........................ 105 173 -1,198 199 .9 1.5 10.5 1.7 47 70 696 132 .9 8.5 Total...................................................................................... All other causes.............................................................................. 1,675 6,653 14.6 58.1 945 4,326 11.5* 52.5 Total, all causes.................................................................. 11,457 100.0 8,231 100.0 .6 1.6 According to this analysis the proportionate mortality from non tuberculous respiratory diseases in occupations with exposure to mineral dust is 14.6 per cent, against 11.5 per cent for occupations with exposure to metallic dust. Every important form of non tuberculous respiratory disease is proportionately more common among occupations with exposure to mineral dust, but the propor tionate mortality from pulmonary tuberculosis is only 27.3 per cent, against 36 per cent for occupations with exposure to metallic dust. M O R T AL IT Y FROM PU LM O N ARY TUBERCULOSIS IN OCCUPATIONS W IT H EXPOSURE TO M IN ER AL DUSTS— U N ITED STATES REGIS TRATION AR E A . The conditions of employment in the industries, trades, and occu pations which are considered in detail in this chapter are often so widely at variance with one another that, as stated in the preceding chapter with regard to metallic dust, the mortality data represent averages which must be interpreted with extreme caution as regards their application to particular employments with a more or less ascer tainable degree of exposure to mineral dust. Such exposure is nearly always an important predisposing cause of pulmonary tuberculosis, but particularly so in certain branches of the stone industry and among potters. Tables 63 and 64 following are, therefore, merely in tended as a general statement of the essential mortality facts concern ing this group of occupations, with special reference to pulmonary tuberculosis and nontuberculous respiratory diseases, as derived from the available official statistics of the Division of Vital Statistics of the United States Census Bureau. A subsequent additional table presents 166 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. the corresponding facts as derived from the extended experience of a representative industrial insurance company. The practical usefulness of this analysis is naturally rather limited for the reasons stated, but the data provide a fairly trustworthy measure of the relative frequency of pulmonary tuberculosis in the group of indus tries and occupations subject to a more or less ascertainable degree of health-injurious exposure to the continuous and considerable inhalation of mineral dust. 6 3 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS IN O C C U P A T IO N S W I T H E X P O S U R E TO M I N E R A L D U S T , U N I T E D S T A T E S R E G I S T R A T IO N A R E A , 1908 A N D 1909, B Y A G E G R O U P S . T a b le Deaths from pulmonary tuberculosis. Deaths from all causes. Afre at death- Number. Per cent of deaths from all causes. i 15 to 24 yea rs.. . . . . . . . . . . . . . __ . . . . . . . . . . . . . . . . . . ____. . . . . . . . . . . . . . . . . . . 25 to 34 years.................................................... ........... »......................................... ........................................ ......... .............35 ............................................ to 44 years 45 to 54 years........ ............. ................................................. ............................. ..... 55 to 64 years............................................................ ..................... ....................... .. 65 years and over............................................................ ....................................... Age unknown....................... ..................... ........................................... ................. Total, 15 years and o v e r .. . ................................... 756 1,524 2,172 2,399 2,258 2,162 33.9 256 582 700 523 259 87 38.2 32.2 21.8 11.5 4.0 10 1 10.0 11,281 2,408 21.3 6 4 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M N O N T U B E R C U L O U S R E S P I R A T O R Y D IS E A S E S IN O C C U P A T IO N S W I T H E X P O S U R E TO M I N E R A L D U S T , U N I T E D S T A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909. T a b le Num ber of deaths. Cause of death. Per cent of deaths from all causes. Asth m a...................................... ........................................................................................................ Bronchitis.......................................................................................................................................... Pneumonia................................................................................... *___________ _______________ Other nontuberculous respiratory diseases.......................................................................... . 26 0.2 840 124 7.4 Total......................................................................................................................................... 1,086 9.6 INCONCLUSIVE OCCUPATIONAL MORTALITY 96 .9 1.1 STATISTICS. The aggregate experience, according to Table 63, for the two years under observation (no subsequent official statistics have been pub lished), indicates a proportionate mortality from pulmonary tuber culosis among men employed in occupations with exposure to mineral dust of 21.3 per cent, which compares with 21 per cent for occupa tions with exposure to metallic dust, as ascertained by an analysis of the corresponding data derived from the same official sources. The data can not be considered entirely conclusive on account of the fact that the industries and occupations with exposure to mineral OCCUPATIONS WITH EXPOSURE TO MINERAL DUST. 167 dust include a relatively large number of persons not exposed to the risk of dust inhalation to a serious degree. If it were practicable to separate those directly exposed to the dust danger from those not exposed to any such risk whatever, the resulting pro portionate mortality from pulmonary tuberculosis and nontuber culous respiratory diseases would, of course, be much more excessive. For illustration, it is noted that the pottery industry as a whole is chargeable with a serious risk of mineral-dust exposure. The particu lar dust hazard is experienced chiefly among flint-mill workers, mix ers, scourers, and sweepers. If the mortality rate of these employ ments could be correctly ascertained with particular reference to pulmonary tuberculosis, there can be no question of doubt that the proportionate mortality figure would be decidedly in excess of the corresponding figure for jiggermen, jollymen, throwers, and other numerically important pottery employees. The same conclu sion applies to the glass industry, where the handlers of materials and mixers are exposed to a readily ascertainable dust hazard, which to a lesser degree affects batch wheelers, carboy blowers, clay grind ers, clay trampers, gatherers, pot makers, etc., and to a still lesser degree, glass blowers, finishers, lamp workers, pressers, etc. As far as possible the occupational differences in particular industries are considered in detail in the discussion following, but it has seemed advisable to consolidate the available data for the purpose of ascer taining, as far as practicable, the general effect of mineral-dust ex posure, which, as previously observed, appears to be less serious with reference to pulmonary tuberculosis than continuous and consider able exposure to metallic dust. COM PAR ATIVE M O R TALITY B Y INDUSTRIES OR OCCUPATIONS. In addition to the mortality from pulmonary tuberculosis the com parative mortality from nontuberculous respiratory diseases, par ticularly asthma and bronchitis, is also distinctly excessive among occupations with exposure to mineral dust, and even more so than among the corresponding occupations with exposure to metallic dust. The details of the proportionate mortality from pulmonary tuber culosis in the principal occupations for which the information is ascertainable from the reports of the Division of Vital Statistics of the United States Census Bureau, for the two years 1908 and 1909, are, for purposes of convenience, shown in Table 65. 168 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T a b le 6 5 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS IN S P E C IF IE D IN D U S T R IE S O R O C C U P A T IO N S W I T H E X P O S U R E TO M I N E R A L D U S T , U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A G E G R O U P S . 15 to 24 years. Occupation group. Deaths from pul monary tubercu losis. Deaths from all causes. Brick and tile m akers1. Glassworkers.................... Marble and stone cut ters .................................. Painters, glaziers, and varmshers...................... Paper hangers1............... Plasterers.......................... Potters1............................. 14 176 3 21.4 83 47.2 429 15 48 13 132 30.8 4 26.7 25.0 46.2 968 36 108 27 Total........................ 756 33.9 1,524 12 6 Total........................ 26 407 1,474 33 205 12 2,258 N um Per ber. cent. 3 23.1 86, 42.6 5 27.8 56 33.1 13 202 Deaths from pul monary tubercu losis. Deaths from all causes. Num-| Ter ber. cent. 20 117 15.0 19.7 299 132 44.1 167 41.6 1,423 60 177 26 415 29.2 33.3 61 34.5 42.3 42 189 32 278 17.4 21.4 16.4 37.5 582, 38.2 2,172 32.2 2,399 41 101 45 to 54 years. 36.9 44.4 31.5 44.4 74j 43.5 357i 16 34' 12 65 years and over. 7.7 7.9 101 Deaths from all causes. Deaths from pul monary tubercu losis. N um - Per ber. cent, 170 55 to 64 years. Brick and tile m akers1. Glassworkers.................... Marble and stone cut ters .................................. Painters, glaziers, and varnishers...................... Paper hangers1............... Plasterers.......................... Potters1............................. Deaths from pul monary tubercu losis. Deaths from all causes. N um Per ber. cent. 16 35 to 44 years. 25 to 34 years. 20 11 Age unknown. 523 21.8 Total, 15 years and. over. 4.0 133 867 16! 12.0 260' 30.0 509 30.7 23.3 316 7.9 1,657 9.0 3.0 16 7.8 5 41.7 1,398 31 249 26 3.3 6.5 3.6 3.8 7,294 1,361 18.7 217 52 24.0 977 163 16.7 136 47 34.6 11.5 2,162 4.0 11,281 2,408 21.3 132 1 1 Data are for 1909 only. The table emphasizes the rather wide range in the mortality from pulmonary tuberculosis in the different occupations^ industries, or trades with exposure to mineral dust, a difference attributable partly at least to variations in conditions of employment, or, more precisely, to the proportion of all the employees of the industry con cerned who were considerably exposed to the dust menace. A much more important influence, however, on the tuberculosis rate is the variation in the chemical and mechanical properties of the mineral clust inhaled and the quantitative degree of dust inhaled, which, as elsewhere observed, probably reaches a maximum in certain processes of cement manufacture. The statistics for the United States regis tration area are unfortunately limited to a comparatively small number of specified industries and trades, but there are no reasons for believing that the proportionate mortality figure would be materially modified by the inclusion of similar or allied employments or occupations for which the information is at present not ascer tainable from official sources. The comparison of the different em- OCCUPATIONS WITH EXPOSURE TO MINERAL DUST. 169 ployments one with another is also subject to the further restriction, as regards practical usefulness, that while for some industries and occupations, such, for illustration, as painters, etc., the number of deaths is relatively large and sufficient for the purpose, for other occupations., such, for illustration, as brick and tile making and the pottery industry, the number of deaths is too limited for entirely safe conclusions. M O R T AL IT Y FROM NONTUBERCULOUS RESPIRATORY DISEASES. The limitations of the available statistics are even more serious in the case of nontuberculous respiratory diseases, but it has seemed advisable for the present purpose to include Table 66, which, how ever, gives data which refers only to all ages combined and not to divi sional periods of life on account of the relatively small number of deaths available for analysis. T a b le 6 6 . — P R O P O R T IO N A T E M O R T A L IT Y F R O M N O N T U B E R C U L O U S R E S P I R A T O R Y D IS E A S E S IN S P E C IF IE D I N D U S T R IE S O R O C C U P A T IO N S W I T H E X P O S U R E TO M IN E R A L D U S T , U N IT E D S T A T E S R E G I S T R A T I O N A R E A , 1908 A N D 1909. Deaths caused by nontuberculous respiratory diseases. Asthma. Occupation group. Bronchitis. Pneumonia. Other. Total. Num Per N um Per N um Per N um Per Num Per ber. cent. ber. cent. ber. cent. ber. cent. ber. cent. Brick and tile makers 1................................. Glassworkers.................................................... Marble and stone cutters.............................. Painters, glaziers, and varnishers.............. Paper hangers 1................................................. Plasterers.................................. ......................... Potters 1............................................................... Total......................................................... .3 .7 5 29 47 3 11 1 0.6 1.8 .6 1.4 1.1 .7 8 67 131 533 13 79 9 6.0 7.7 7.9 7.3 6.0 8.1 6.7 2 6 33 64 2 11 6 .2 96 .9 840 7.4 124 2 9 11 0.2 .5 .2 3 1 26 1.5 .7 2.0 .9 .9 1.1 4.4 10 80 202 655 18 104 17 7.5 9.2 12.2 9.0 8.3 10.6 12.5 1.1 1,086 9.6 1 D a ta are for 1 9 0 9 only. INDUSTRIAL INSURANCE MORTALITY EXPERIENCE. In view of the limited extent of the available official occupation mortality statistics of the registration area, the industrial mortality experience of the Prudential Insurance Co. of America is somewhat more conclusive, in that the number of specific occupations is more representative of the industries and employments with exposure to mineral dust. When considered as a group and for some of the more important occupations, the actual mortality data are also more extensive. The details of the experience are set forth in Table 67. 170 MORTALITY FROM RESPIRATORY DISEASES IK DUSTY TRADES. T a b le 6 7 .— P R O P O R T I O N A T E M O R T A L I T Y F R O M P U L M O N A R Y T U B E R C U L O S IS IN O C C U P A T IO N S W I T H E X P O S U R E TO M I N E R A L D U S T , I N D U S T R I A L E X P E R I E N C E O F P R U D E N T I A L CO., 1897 TO 1914. % Deaths from pulmo nary tuberculosis. Age at death. Peaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years........... .......................................................... ..................................... 25 to 34 years.............................................. ............................................................. 35 to 44 years............................................................................................................ 45 to 54 years........................................................................................ ............. .. 55 to 64 years........................................................................................ ............... .. 65 years and over.................................................................................. ................. Age unknown....................................................................................................... 1,141 1,920 2,280 2,303 2,127 1,684 2 365 875 823 602 355 109 32.0 45.6 36.1 26.1 16.7 6.5 Total, 15 years and over........................................................................... 11,457 3,129 27.3 T a b le 6 8 .— P R O P O R T I O N A T E M O R T A L I T Y F R O M N O N T U B E R C U L O U S R E S P I R A T O R Y D IS E A S E S IN O C C U P A T IO N S W I T H E X P O S U R E T O M I N E R A L D U S T , I N D U S T R I A L E X P E R I E N C E O F P R U D E N T I A L CO., 1897 to 1914. Cause of death. Number of deaths. Per cent of deaths from all causes. 105 173 1,198 199 0.9 1.5 10.5 1.7 1,675 14.6 1 Asthma______ - _ . ___ . . _ _____ Bronchitis........................................................................................................................................... Pneumonia......................................................................................................................................... Othfir nontuberculousresniratorv diseases___________ ________ . . . ___________ _____ , Total____ ____ ______________________ _____ ___________________ As observed in connection with the corresponding discussion of the occupations with exposure to metallic dust, the insurance experi ence is not strictly comparable with the general mortality for the country at large, for the principle of adverse selection must be considered, and the fact that only a small proportion of the risks accepted for industrial insurance are at entry subjected to a thorough medical examination. A much more important factor, however, is that the occupation analysis in the Prudential Co. ex perience is more strictly limited to specific occupations with mineral-dust exposure as separate and distinct from industries or groups of closely allied employments, which it is safe to assume are more representative of the census mortality returns; in other words, in the Prudential mortality experience the reference is rather to pot ters than to men employed in the pottery industry; to glassworkers rather than to men employed in the glass industry; more so than is the case in the returns made available through the Division of Vital Statistics of the United States Census Bureau for the two years 1908 and 1909. OCCUPATIONS WITH EXPOSURE TO MINERAL DUST. 171 E XC E SSIV E FR EQ UENCY OF P U LM O N A R Y TUBERCULOSIS. According to Table 67, the proportionate mortality from pul monary tuberculosis in occupations with exposure to mineral dust is 27.3 per cent for all ages, which compares with 21.3 per cent as shown by the census occupation mortality returns. The differences are quite marked, and a maximum proportion is reached at ages 25 to 34, when out of 1,920 deaths from all causes among men with exposure to mineral dust, 875, or 45.6 per cent, are deaths from pul monary tuberculosis, in contrast to a corresponding mortality of 49.6 per cent for men employed in occupations with exposure to me tallic dust. The proportionate mortality from pulmonary tuberculo sis among men employed in occupations with exposure to mineral dust must therefore be considered distinctly excessive, but particu larly so at ages under 45. The mortality from nontubercuious re spiratory diseases affects rather the more advanced ages, and this is especially the case with pneumonia, the incidence of which is appar ently increased by exposure to the continuous and considerable in halation of mineral dust, even more so than in the case of occupations with exposure to metallic dust.1 PROPORTIONATE MORTALITY BY INDUSTRIES OR OCCUPATIONS. The proportionate mortality by specific industries or occupations and by divisional periods of life is shown in Table 69 following, which will facilitate comparison with the corresponding table for the registration area, but which is subject to the same suggestion of extreme caution as regards the interpretation of the data derived, as explained, from different sources. ___ 1 T h e m o rta lity from pn eum on ia in the registration area has a p p aren tly been de creasin g du ring recent years, as show n by the fo llo w in g table, derived from official sources : M ortality from pneumonia ( exclusive of broncho pneum onia)— United S ta te s registration area, 1905-1915. [R a te per 1 0 0 ,0 0 0 o f p o p u lation .] Males. 1905-1909 1915 Females. Total. 116. 7 93. 7 ................................................................................................................ 105.4 1910-1914.................................................................................................................... SB. 8 ...................................... ............................................................................. 91.5 73.8 82.9 N o th oro u gh ly qualified an a ly sis has th u s fa r been m ade o f the m o rta lity from pneu m onia in the U n ited S tates, p a rticu la rly in its relation to the du sty trades. T h e subject is, how ever, deserving o f m ore extended and strictly scientific consideration. 96.8 172 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 6 9 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS IN S P E C IF IE D I N D U S T R IE S O R O CC U P AT IO N S W I T H E X P O S U R E TO M I N E R A L D U S T , IN D U S T R IA L E X P E R I E N C E O F P R U D E N T IA L C O., 1897 TO 1914, B Y A G E P E R IO D S . T a b le 15 to 24 years. Occupation group. 25 to 34 years. Asbestos workers............ Brick, tile, and terra Core m akers.................... GJassblowers----- .*........... Glass cutters.................... Glassworkers, other Lime, cement, and gypsum.......................... Lithographers.................. Marble and stone work ers .................................... Molders.............................. Paint factories................. Paper hangers................. Plasterers.......................... Potteries............................ Total....................... 3 22.9 31.9 45.1 39.6 31.5 18 70 52.9 40 81 57 58 77 38.3 23.7 40.0 35.1 34.5 31.2 228 540 26 175 163 137 1,141 365 32.0 1,920 11.1 60 266 10 Total. 1 121 N um Per ber. cent. Num Per ber. cent. 48 113 51 53 257 55 to 64 years. Asbestos workers........... Brick, tile, and terra cotta................................ Core m akers.................... Glass blowers.................. Glass cutters.................... Glassworkers, other----Lime, cement, and gy p su m ........................ Lithographers.................. Marble and stone work ers ...................... v........... Molders................ .*......... . Paint factories............... . Paper hangers................ . Plasterers......................... Potteries........................... 45 to 54 years. Deaths Deaths Deaths Deaths from from from from pulmonary pulmonary pulmonary pulmonary Deaths tubercu Deaths tubercu Deaths tubercu Deaths tubercu losis. losis. losis. losis. from all from all from all from all causes. causes. causes. causes. N um Per ber. cent. c o tta ................................... 35 to 44 years. 51 98 137 55 186 66.7 33.3 97 42 106 28 108 18.6 11.9 28.3 21.4 23.1 25.0 27 39.1 45 53 13 24.5 403 694 25 174 225 179 44.4 213 30.7 40.0 74 42.5 91 40.4 72 39.8 513 690 33 134 281 172 2,280 823 36.1 2,303 35.3 42.9 53.3 50.9 51.1 81 63 115 48 151 16 19.8 19 30.2 36 31.3 41.7 52 34.4 15 37.5 42 51.9 48 69 18 42 73 28 95 121 53.1 218 40.4 6 23.1 77 44.0 71 43.6 49.6 875 45.6 65 years and over. N um Per ber. cent. 181 20 12 10 Age unknown. 26 52 24 103 129 15 85 11 12.2 22 12.5 19 506 624 16 96 330 147 135 26.7 87 13.9 342 480 14 72 314 87 2,127 355 16.7 49 32 11 11.5 11.8 21.1 39 31 1,684 23.5 30.2 602 26.1 3 23.1 5.9 27.3 5.4 527 357 546 220 897 82 105 175 80 274 4.5 10.5 222 325 46 20.7 125 38.3 9.4 5.8 2,052 3,294 124 708 1,371 801 4.7 92 200 39.0 149 21.6 7 21.2 21 15.7 Total, 15 years and over. 13 10.7 11.5 15.4 8.3 15.5 10 22.2 3 13 4.2 4.1 109 6.5 11 12.6 690 758 27 206 300 258 15.6 29.4 32.1 36.4 30.5 33.6 23.0 21.8 29.1 21.9 32.2 11,457 3,129 27.3 MORTALITY FROM NONTUBERCULOUS RESPIRATORY DISEASES. On account of the importance of nontuberculous respiratory dis eases,1 Table 70 is included, showing the proportionate mortality from asthma, bronchitis, pneumonia, and other respiratory diseases 1 On the nontuberculous resp ira to ry diseases, see “ D iseases o f the B ronch i, L u n gs, and P le u ra ,” by F rederick T . L o rd M . D ., P h ilad elp h ia and N ew Y o rk , 1 9 1 5 , and “ System o f M edicin e,” edited by Sir C lifford A llb u tt and H u m p h rey D a v y R ollesto n , London, 1 9 0 9 . OCCUPATIONS WITH EXPOSURE TO MINERAL DUST. 173 among workers in occupations with exposure to mineral dust, without reference to divisional periods of life: T able 7 0 .— P R O P O R T IO N A T E M O R T A L IT Y F R O M N O N T U B E R C U L O U S R E S P IR A T O R Y D IS E A SE S IN SP E C IF IE D IN D U S T R IE S O R O CC U P A T IO N S W I T H E X P O S U R E TO M IN E R A L D U S T , I N D U S T R IA L E X P E R I E N C E O F P R U D E N T I A L CO., 1897 TO 1914. Deaths caused b y nontuberculous respiratory diseases. Occupation group. Asthma. N um ber. Asbestos workers........... Brick, tile, and terra cotta................................ Core m akers.................... Glass blowers.................. Glass cutters.................... Glass workers, other___ Lime, cement, and gyp sum ................................. Lithographers................. Marble and stone work ers.................................... Moldors.............................. Paint factories................. Paper hangers.................. Plasterers.......................... Potteries............................ Total....................... Bronchitis. Per cent. Pneumonia. Total. Other. Per cent. N um ber. Per cent. N um ber. 2 15.3 12.9 11.2 5.9 9.5 7.9 10 7 8 2 13 1.9 2.0 1.5 .9 1.4 89 48 49 25 94 16.9 13.4 9.0 11.4 10.5 N um ber. Per cent. N um ber. Per cent. 2 15.3 5 1 6 1 6 0.9 .3 1.1 .5 .7 68 40 32 21 71 6 1.1 3 1 4 .5 .5 .4 2 .9 3 3 1.4 .9 15 35 6.8 10.8 5 3 2.3 .9 25 41 11.3 12.7 28 25 1 1 9 25 1.4 .8 .8 .1 .7 3.1 52 51 2.5 1.5 2.4 2.0 1.1 1.7 1.7 9.6 14.1 8.9 8.6 9.8 5.7 49 65 8 23 14 198 463 11 61 135 46 9 9 19 1.3 .7 2.4 327 604 12 79 176 104 15.9 18.3 9.7 11.2 12.8 13.0 105 .9 173 1.5 1,198 10.5 199 1.7 1,675 14.6 It does not seem necessary, as observed in the discussion of occupations with exposure to metallic dust, to enlarge upon the facts dis closed by the preceding comparative statistics, which emphasize with a sufficient degree of scientific conclusiveness the obviously healthinjurious consequences of considerable and continuous exposure to the inhalation of mineral dust. It is clearly recognized that the sta tistical data utilized for the present purpose are of rather limited intrinsic value, but they are in the main quite fully confirmed by the more extended consideration of occupations in detail where the ex posure to mineral dust is sufficient to warrant their inclusion within the plan and scope of the present discussion. ENGLISH O C CUPATIONAL M O R TALITY D A T A . In conclusion, however, it has seemed advisable to add to the pres ent observations a table obtained from English official sources which shows the combined mortality of glassworkers, potters, paper hangers, plasterers, and lithographers, and which may safely be considered sufficiently representative of the entire group of occupa tions with exposure to mineral dust, in the absence of more extensive information which unfortunately is not available. 174 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T a b l e 2 1 .— M O R T A L IT Y FR O M A L L CAUSES, FR O M P U L M O N A R Y TU BE R CU L O SIS, A N D FR O M O T H E R R E S P IR A T O R Y DISEASES IN OCCUPATIONS E XP O SE D - T O M IN E R A L DU ST, C O M PA R E D W IT H T H A T OF A L L OCCUPIED MALES,. I N E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E GROU PS. [Source: Part II, Supplement to- the Sixty-fifth Annual R eport af the. Registrar^-General' o f Births, Deaths, and Marriages-in England and Wales..! Death rate per 1,000 due to all causes among— Death rate per 1,000 due to. pulm onary tubercu losis among— Death rstfc© per 1,000 due to other diseases of the respiratory system among— Age at death. Occupations All occu Occupations Occupations A ll occuAIT occuexposed to exposed to exposed to . pied males.. mineral dust. ,pied males.. mineral dust; pied males. mineral dust. 15 to 19 years.................... 20 to 24 years._____ ____ 25 to. 34 years ...... 35 to 44 years........... ......... ' 45 to 54 years.................... 55 to 64 years.................... 65 years; and over............. 2.44 4.41 6.01 10; 22 17.73 31.01 88.39 2.35 4.02 5-24 12.46 23.74 40. 23 92.. 60 0.54 1.55 2.03 2.74 3.04 2.16 1.11 a 55 1.44 2.01 3.96 4.91 3.94 1.13 0.24 .48 .77' 1.66 3,32 6.54 17.77 0.27 . 50' .78 2.12 6.05 12; 86 24.53 GENERAL CONCLUSIONS, Table 71 brings out clearly the fact that the mortality from pulmonary tuberculosis among men in occupations with exposure to mineral dust is decidedly excessive at ages 35 to 64, but that the mortality at the other ages is mot appreciably lower than for occupied males generally. Death rates are, however, not as useful and conclusive for purposes o f industrial hygiene as the proportion ate mortality figure which precisely emphasizes the quantitative im portance of a given disease or cause of death. The proportionate mortality from pulmonary tuberculosis and nontuberculous respira tory diseases is excessive at all ages among men with exposure to mineral dust, although the relative death rate per thousand exposed to risi: is not, at least according to English experience, decidedly excessive at certain periods of life. The data are not of sufficient importance to invalidate the general conclusion-, and in the main the death rates sustain the proportionate mortality figure, although this is not invariably the case. The death rate from nontuberculous respiratory diseases among men employed in occupations with ex posure to mineral dust, according to the English experience, is at the older ages so deeidedty excessive that obviously much more extended scientific consideration should be given to this group of diseases than has heretofore been given it. At ages 55 to 64,, for illustration, in the English experience there is an actual excess in the mortality from all causes among men exposed to mineral dust of 9.22 per 1,0.00, equivalent to 29.7 per cent,. but in the mortality from pulmonary tuberculosis there is an excess oi 1.78 per 1,000, equiva lent to 82.4 per cent, against an excess of 6.32 per 1,000 in the mor OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST* 175 tality from nontuberculous respiratory diseases* equivalent to 96.6 per cent. The results of this analysis* therefore* reemphasize the scientific concIusLveness of the extended discussion on “ Industrial ] neumoconiosis with special reference to dust phthisis,” by Edgar L, Collis* in the Milroy Lectures of 1915, and the corresponding obser vations on pneumoconiosis by Sir Thomas Oliver in Allbutt & Rolleston’s System of Medicine, Volume V, Diseases of the Respira tory System. Of interest in this connection are the observations by Dr. J. S. Haldane contained in a contribution to the Proceedings of the Insti tution of Mining Engineers, abstracted in a letter from London to the Journal of the American Medical Association, August 19, 1916. In the paper referred to Dr. Haldane pointed out “ that while up to the age of 50 the death rate from lung disease is much lower among colliers than in the rest of the population, above 50 the opposite holdsr and there is a marked excess of deaths from bronchitis-” In con tinuation, however, he stated that “ the deaths from this disease have greatly diminished since 1890, for which improved ventilation seems to be the cause. Fifty years ago miners often worked in air con taining so much black damp that lamps and candles burned dimly. In such air there is usually 2 or 3 per cent of carbon dioxide, which enormously increases the breathing during muscular exertion. The breathing is exactly regulated so as to keep an average of about 5.6 per cent carbon dioxide in the alveolar air; and with 3 per cent of this gas in the air, a man breathes twice as much air, so as to keep the alveolar percentage right. A man doing moderate muscular work in pure air breathes about five or six times as much air as dur ing rest. In air containing 3 per cent of carbon dioxide he would be breathing ten or twelve times as much air as during rest* and his breathing would be taxed to the utmost. He would thus be much more liable to contract emphysema. The better ventilation of coal mines is largely a consequence of the greater amount of fire damp and great heat encountered as mines have become deeper.” Dr. Haldane is inclined to think u that both the fire damp and the heat have indirectly caused great improvement to the health of miners. Where there is plenty of lire damp there is usually also plenty of fresh and dry air, and no harmful excess of carbon dioxide. The proportion of deaths from bronchitis among old miners was higher in Staffordshire in 1890-1892 and 1900-1902 than in any of the other coal fields; and Staffordshire mines are exceptionally sub ject to black damp. The excess in bronchitis among old coal miners has been attributed to the breathing of dust,” and Dr. Haldane was “ previously inclined to agree with this theory. But it is difficult to see why* if dust is the cause, there has been so great a diminution in 176 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES, the bronchitis mortality in recent years. Coal mines have, on the whole, become drier and more dusty with increasing depth and better ventilation; and, if dust were the cause, one would have expected the bronchitis to increase, whereas it has greatly diminished. Certainly an excess in mortality from bronchitis is associated with the breath ing of harmful dust. But this excess is accompanied by a far greater excess in mortality from phthisis, and begins comparatively early in life, unlike the bronchitis mortality in colliers. Experiments on animals carried out by J. M. Beattie show that both coal dust and the shale dust usually associated with it on mine roads are relatively liarmless.” It is therefore quite clear that much remains to be ascer tained concerning the true nature and extent of dust phthisis and that in the solution of this important industrial problem a consid erable advance is necessary in the practice of medicine, which to a much larger degree should be made to rest upon knowledge con cerning disease causation ascertained by means of autopsies in indus trial districts subject to an excessive mortality from pulmonary tuberculosis and nontuberculous respiratory diseases. ASBESTOS. The number of men employed in trades and industries involving exposure to asbestos dust in the United States is unknown. Aside from the mining of asbestos, in which exposure is rather limited, there are numerous processes involving the conversion or remanu facture of the materials which are distinctly more serious in their effects on health and longevity. Asbestos weaving and spinning are described by Netolitzki on the basis of observations in Bohemia, where the conditions were found to be decidedly unfavorable. For this country our information is very limited, although the quantity of asbestos used is very large. Its fire-resisting properties have led to its extensive employment for the covering of pipes, furnaces, etc., as well as its use in the form of wall plaster, roofing mate rial, etc. On account of its nonconducting qualities it is exten sively employed by electricians and also in the construction of stor age rooms of refrigerating plants. M E T H O D S OP M IN IN G . “ Geologically,” according to the Technical World Magazine,1 “ as bestos is a fibrous form of serpentine rock, occurring in strata of crystalline limestone. The veins run in an average thickness of onefourth to one-half inch, but sometimes attain to as much as -6 inches. 1 “ M in in g m in era l w o o l,” 1 906. by A u b rey F u lle rto n , in T e ch n ica l W o rld M a ga zin e, M a y, OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 177 The asbestos fibers are, as nearly as possible, crystals of serpentine rock.” According to the same magazine— The ore is mined mostly in open quarries. Overlying soil, to a thickness of sometimes 20 or 30 feet, but quite often forming only a thin layer on top, has first to be removed; and as soon as the asbestos veins are thus laid bare, the actual quarrying operations may begin. The rock is cut in a series of terraces, reaching a total depth of some times 150 or 200 feet. Underground work has not proved successful, the open quarry having been found both more economical and more effective, despite the disadvantages of exposure to the weather. Drill ing and blasting are employed much the same as in ordinary stone quarrying. When the rock is thus broken up it is rough sorted at the quarry. Two or more grades are selected, according to the length of the fiber, and are then sent on to the “ cobbing sheds,” where the further process of dressing goes on. This process is merely the separation of the asbestos fibers from the dead rock, and is done in some cases by hand, but to an increasing extent by machine. Hand cobbing is the very simple method of breaking the stone by small sledge hammers, throw ing the fiber into one box and the waste into another. This separa tion is ordinarily not difficult, since the fiber lies in layers more or less loosely clinging to the rock, and can frequently be picked off with the fingers. The crude fiber, thus separated as cleanly as possible from the waste rock and looking very much like mineralized wool, is packed in 100-pound bags, in which form it goes to the market and the manufacturer. Hand dressing is not, however, an absolutely thorough method. The waste material from the cobbing tables and the fine pickings from the quarries have still some fiber in them, and the utilization of this frequently represents the largest profits of the mine. All these fine pickings are mechanically dressed. In case the asbestos contains a large percentage of water, the moisture is first dried out, by ex posure to the air, by steam pipes, or by rotary driers, and the rock is then passed on to the crushers, where it is broken by successively finer-set rolls. Cylindrical fiberizers and the cyclone machine reduce it still further. The latter is the most effective apparatus yet devised for asbestos separation. It consists of two beaters, one of the screwpropeller type, driven within a cast-iron chamber at a violent speed, reducing the particles of stone almost to a powder. This is then passed over a shaking screen to remove the sand, and in some mills strong electric magnets are used to take up the particles of iron. In all of these operations there must necessarily be a considerable degree of dust exposure, which, however, becomes exaggerated in the spinning and weaving processes in connection with the manufacture of asbestos yarn and cloth. These processes are briefly referred to in an article in the Engineering Magazine,1 in part, as follows: The spinning and weaving of asbestos have offered many difficulties, as the asbestos fibers have no rough surface like wool or cotton, but 1 “ A sb estos, its m in ing, p rep a ra tion , m arkets, and use,” by E . S ch a a f-R eg elm a n , E n gi neerin g M agazine, O ct. 1907. 106811°— 18— Bull. 231------ 12 178 MORTALITY PROM RESPIRATORY DISEASES IN DUSTY TRADES. are very smooth, and thus have a tendency to slip by one another when twisted and subject to tension. An admixture of vegetable or animal fiber was therefore often necessary, but, while these facili tated the manufacturing operations, they impaired the fire resistance of the fabric, and special machinery and ingenious devices had to be invented to enable the successful spinning of a pure asbestos yarn. It is, however, now possible to make a single asbestos thread which, though weighing no more than 1 ounce per hundred yards, has a fair strength, and braided material can be made much more resi-stant to torsion and tension, while asbestos ropes, chiefly used by the fire department, can be strengthened either by interwoven wires or by having a wire-rope core. H E A L T H -IN JU R IO U S O CC U PA TIO N A L C O N D IT IO N S. On account of the rather limited extent of the asbestos industry in the United States, at least in the large centers of population, the industrial insurance mortality experience data are insufficient for definite conclusions. During the period 1907 to 1914 in the Prudential experience there were only 13 deaths, of which 3, or 23.1 per cent, were from pulmonary tuberculosis. At ages 25 to 44, there were 6 deaths, of which 3, or 50 per cent, were from this disease. Asbestos dust is not described in the extensive consideration of Dust Hazards, by Hayhurst, nor by W. Gilman Thompson in his treatise on The Occupational Diseases. In 1914 the production of asbestos in the United States was only 1,247 tons, or much less than in earlier years, indicating a very limited available source of supply. Most of the asbestos used in the United States is mined in Canada, and an excel lent report on “ Asbestos, its occurrence, exploitation, and use,” has been published by the mines branch of the Department of the Interior of the Dominion of Canada (Ottawa, 1905), wThich contains a de scriptive account of mining methods and of the dressing of asbestos by hand or by mechanical treatment, including the final crushing by meails of rollers, fiberizers, beaters, cyclones, and pulverizers. All of these processes unquestionably involve a considerable dust hazard, but the hygienic aspects of the industry have not been reported upon. It may be said, in conclusion, that in the practice of American and Canadian life insurance companies asbestos workers are generalty declined on account of the assumed health-injurious conditions of the industry.1 It is regrettable that there should be no further information avail able regarding the asbestos industry in its various branches, includ ing the utilization of by-products of manufacture, on account of the self-evident injuriousness of asbestos dust as a predisposing cause of pulmonary tuberculosis. The subject is not referred to by Kober 1 F o r a d e scrip tiv e a cco u n t o f the C an adian asb estos d istrict, see E n gin e e rin g a n d M in in g J ou rn a l, N ew Y ork , A p r. 30, 1910. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 179 and Hanson in their recently published treatise on Diseases of Occu pation and Vocational Hygiene, nor by Sir Thomas Oliver in his recent work on Diseases of Occupation. The rapidly increasing de velopment of industries using asbestos, as ascertained from domestic or foreign sources, suggests the urgency of more qualified medical consideration than has heretofore been given the subject. There are no references to asbestos in the Index Catalogue of the Surgeon Gen eral’s Library, which, however, brings the literature of the subject down only to 1896. The discussion of asbestos in the annual reports of the United States Geological Survey on Mineral Resources is lim ited entirely to the technical aspects of the mining industry, which during recent years has experienced a rather retrograde movement in that the production has diminished from a maximum of 7,600 tons in 1911 to 1,247 tons in 1914. In contrast, however, there has been a gradual increase in the quantity of the unmanufactured asbestos im ported, chiefly from Canada. The American production is prac tically limited to the States of Arizona, California, Georgia, and Vermont. Georgia has for years been one of the chief producers of asbestos in the United States, but no medical observations are on record as regards the possibly injurious results experienced in the mining and manufacturing of asbestos materials in that State. The industry itself has been described, however,- in a report on the asbestos, talc, and soapstone deposits of Georgia in Bulletin No. 29 of the Georgia Geological Survey, 1914. EVIDENCE OF DUST EXPOSURE. The relation of asbestos dust to pulmonary tuberculosis is reported upon at some length in the Annual Report of the Chief Inspector of Factories and Workshops for England and Wales for 1910. The in vestigation was made by Dr. Collis, who, states, in part, that— Following up information received from the registrar-general, it was found that five deaths of persons suffering from phthisis had occurred in five years among a staff of under 40 workers employed at a factory where asbestos is woven. The process which appeared most dangerous is the production of asbestos mattresses. These mat tresses, which are composed of bags of woven asbestos filled with short asbestos fiber, are placed on a table and beaten out flat by a man with a wooden flail, from which process much dust arises. Women who sew the mattresses into sections with asbestos threads worked close to the man who beat the mattresses and of necessity inhaled the dust. The reorganization of this process with the appli cation of localized exhaust draft was called for, and an annual medi cal examination of the workers by the certifying surgeon has been instituted in the hope of detecting and removing from exposure to dust those showing early signs of respiratory disease. Weaving asbestos has only become an important industry during the last 15 years. Two other large asbestos factories were visited, each of which was found to have its own specialty in the production of which dust prevention is required. 180 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. There is evidently an urgent need for a more qualified and exten sive investigation of the health aspects of asbestos manufacture; especially so, in view of the fact, as observed in the Scientific Ameri can (August 1,1916), that, on account of the restrictions placed upon shipments of asbestos from Canada, the possibilities of utilizing the asbestos deposits of this country are increased, as well as because of the much larger demand for asbestos products on account of the recognized value of asbestos for protective purposes in the further ance of the industrial safety movement. Of value in this con nection is the evidence of Dr. H. M. Murray before the De partmental Committee on Industrial Diseases, limited, however, to the single case of an asbestos worker, verified as regards diagnosis by a post mortem examination. In reply to a ques tion by the chairman of the committee as to whether, in view of the fact “ that there is something characteristic in the earlier stages of dust phthisis in the predominance of shortness of breath before physical signs become very obvious,” such a condition had been observed in the case of the asbestos worker under treatment by Dr. Murray, and under observation for fourteen months, the doctor said that it had been noticed in the case in question, and that, in other words, there was a definite relation between the course of phthisis and the physical incapacity resulting from the inhalation of asbestos dust. It is therefore to be anticipated that the condition of asbestos workers will attract more qualified attention in this country in the future than it has in the past. MICA. No special investigation has been made to ascertain the more or less health-injurious effects of mica dust. According to W. Gilman Thompson the dust is slightly irritating to the respiratory system, like dust containing any sharp solid particles, but as a general con clusion he states that the dust does not appear to be particularly injurious. Mica is extensively used in the manufacture of electrical machinery, as well as in the glazing trade, as a substitute for glass, and in the decorative trades, including the manufacture of wall paper. There are two principal varieties of mica, known as musco vite and phlogopite, but whether there is any essential difference between the physical and mechanical properties of the dust has not been determined. There are mica deposits in some 20 States of the United States, but the annual production has fluctuated considerably, reaching the lowest point in the last decade during 1914. Whether there are any special hazards in mica mining in consequence of the dust has not been ascertained. The occurrence, exploitation, and use of mica have been admirably described in a report published by the mines branch of the Department of the Interior of Canada. The re OCCUPATIONS' W IT H EXPOSURE TO MINERAL DUST. 181 port, however, includes no observations on the sanitary aspects of the various employments. It is pointed out, with special reference to the manufacture of ground mica, that the difficulties of grinding are. great, owing to the tough and scaly nature of the mineral, which may be assumed to indicate that even when reduced to a fine powder the dust is apparently not of very serious importance to the em ployees. Mica dust is briefly referred to by Kober and Hanson in their Diseases of Occupation and Vocational Hygiene, in which it is said that mica is “ a mineral of widely varying chemical compo sition, but is essentially composed of silicates of aluminum and an alkali, such as potassium, sodium, or lithium.” It is stated that the mineral splits easily into thin, flexible, colorless, transparent plates or scales, known as isinglass, and that in the powdered form it is em ployed in the manufacture of giant powder, and that it is also used for decorative purposes, chiefly in the manufacture of wall paper, illuminated designs, etc. The only medical conclusion arrived at by the authors is that “ mica dust is doubtless a frequent cause of in flammatory conditions of the eyes and air passages.” It is therefore suggested by inference that the dust in finely comminuted form may also have an irritating effect upon lung tissue, and to that extent predispose mica workers to pulmonary tuberculosis, although much more extended observations are required before definite conclusions can be arrived at.1 T H E S T O N E IN D U S T R Y . The stone industry in the United States is of vast areal extent and commercial importance. The product for 1914 was valued at nearly $80,000,000. Stone is quarried or produced in every State and Territory, and the number of persons employed in the stone in dustry exceeds 100,000. The principal varieties are granite, trap rock, marble, limestone, and sandstone. The industry may broadly be divided into the manufacture of crushed stone for road making and other purposes, paving stone, building stone, and monumental stone. The two latter are subdivided into rough and dressed prod ucts. Thetlabor conditions in an industry of such vast extent and fundamental differences in the nature of the product must neces 1 F or a valu a b le d e scrip tiv e a cco u n t o f m ica, see the N a tio n a l M useum R ep ort, 1899, p. 283. F o r a d iscu ssion o f m ica m in in g in the U n ited S tates w ith sp ecial referen ce to un d er g rou n d con d ition s, see a n a rtic le in the E n gin eerin g and M in in g J o u rn a l, M ay 8, 1909. W ith referen ce to m in in g m eth od s in C anada, see an a rtic le in the sam e p u b lica tio n in the issue o f A p ril 18, 1908. See also a n exten d ed d iscu ssion b y M r. C. H a n fo rd H en d erson on “ M ica and the m ica m in es,” in th e P o p u la r S cien ce M on th ly f o r Sept., 1892. A c c o r d in g to a sta tem en t by the m an ag er o f the C row n M iea C o., o f C uster C ity , S. D ., “ M ica m in in g is con sid ered very h ea lth y, as m ost o f it is done in op en cu ts .” 182 MORTALITY FROM RESPIRATORY DISEASES IN IHJSTY TRADES. sarily vary widely, but from a hygienic point of view the essential difference arises out of the mechanical and chemical properties of the dust produced in the quarrying, the dressing, and the polishing of the different varieties, which are too numerous to permit of even a brief technical description. E A R L Y O B SE R V A T IO N S ON H E A L T H -IN JU R IO U S C O N D ITIO N S. The health of stone and marble cutters has, from earliest times, been held to be notoriously bad, and the hygienic importance of this trade was recognized by Ramazzini, who, as far back as 1705, discussed the subject in an entire chapter in his work on Diseases of Tradesmen, stating that— In hewing marble or stones out of the rock, in polishing and cut ting them, they oftentimes suck in, by inspiration, the sharp, rough, and cornered small splinters or particles that fly off; so that they are usually troubled with a cough, and some of them turn asthmatic and consumptive. * * * Our medical histories give many in stances of stones found in the stomach and lungs of these workmen, for which we can assign no other material cause^but the dusty par ticles taken in at the mouth and gradually gathered into a heap. * * * Withal, all possible caution must be used to avoid the sucking in of these minute particles at the mouth. From the earliest to the most recent observers upon the health conditions in this trade, the conclusions have been decidedly un favorable and suggestive of circumstances more or less possible of material improvement. Oliver, in his Diseases of Occupation, remarks, with special reference to stonemasons: The occupation of the stonemason and of the quarryman has for long been regarded as one in which a higher death rate from lung disease occurs than in most occupations. The disease, which usually assumes a chronic character, is slow in its development and progress. As it is attended by the ordinary physical signs and symptoms ob served in other forms of pneumoconiosis, the malady calls for no special description other than this, that in contradistinction to miners’ phthisis, which occurs in men who work underground, stonemasons’ phthisis is met with in men who are working in the open air, a circumstance which becomes a strong argument in favor of the dust origin of pneumoconiosis as against the bacillary. After a time the lung disease becomes tuberculous, hence the extraordinary fact of the death rate from pulmonary tuberculosis among stonemasons and marble cutters, who are following an outdoor occupation, being six times that of bankers and brokers, who are leading an indoor life. This want of harmony between occupation and mortality from pul monary phthisis is observed in other outdoor occupations than stonecutting. It would appear, therefore, as if the predisposing causes of lung disease are often of greater importance than the exciting—in other words, that the soil is of as much, if not of greater, influence than the seed. The irritation of the lung caused by dust would seem in some instances, especially in the early stages of the disease, to OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 183 create a favorable soil for the implantation of the tubercle bacillus, while in the slowly developed forms of pneumoconiosis the hard and unyielding fibrous tissue does not offer the same attractions to the microorganism, and as a consequence it is in those parts of the lung where the structure is least fibrous that the tubercle bacilli exert their greatest power for harm.1 E X P E R I E N C E OF T H E O P E R A T IV E M A SO N S’ SO C IE T Y OF LONDON. The remarks of Oliver are fully sustained by the available statis tical evidence. The secretary of the Operative Masons’ Society of London, in his testimony before the committee on industrial diseases, produced the mortality record for Newcastle for the period of 1871 to 1896, including an account of 160 deaths of stonemasons, and of this number 71, or 44.4 per cent, had died from phthisis, at an average age of only 42.23 years. It was admitted, however, that conditions had improved, and more recent data resulted in a more favorable showing. Out of 253 deaths of stonemasons reported in 1905 by the same society, 79, or 31.2 per cent, were deaths from pulmonary tuber culosis. The same witness stated that the average age at death of those dying from phthisis during 1905 was 44 years, against 51 years for deaths from all causes.2 D E S C R I P T IV E ACCOUNT OF O CC U PA TIO N A L CO N D ITIO N S. Conditions are probably somewhat different in this country, due to the more general use of pneumatic tools, which generate considerable quantities of fine dust, the complete prevention of which is always difficult and often impossible. The degree of disease liability varies materially according to the specific occupation, and the risk is less in the case of paving-stone cutters and slate splitters than in the case of monument or custom work, which requires close atten tion in matters of minute detail and which is more often carried on indoors. Surfacing and carving and cutting with pneumatic tools are the most dangerous employments, the risk being less in polishing, grinding, sawing, and lathe work, most of which is car ried on by the wet process. Large quantities of dust are stirred up, however, in the brushing off and cleaning up of the accumulated dust, and in the moving of materials, dropping of slabs, etc. There is, therefore, more or less dust exposure in all branches of the stone industry, but the results of exposure vary according to the kind of material, which includes a large variety of stones, chiefly, however, granite, marble, limestone, sandstone, bluestone, and slate. The stonecutters’ trade is one which requires both skill and arduous physical labor. The men as a rule work in the open air, and in very 1 D iseases o f O ccu p a tion , L on d on , 1908, p. 305. 2 M inu tes o f E vid en ce, D ep a rtm en ta l C om m ittee on C om p en sa tion fo r In d u stria l D is eases, p. 322. 184 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. warm or wet weather under shelter; but all are liable to inhale the dust and small particles from the material upon which they operate. This on some kinds of stone is much more deleterious to health than on others, the stone containing the largest proportion of flints being much more injurious than that which has most lime in it. The re turns show that the present age of stonecutters is three years less than that of carpenters or masons, while the average number of years at work exceeds that of either by nearly one year. But this is ac counted for by reason of the difference in the ages at which they began to work, which for 63.9 per cent of stonecutters was under 15 years of age, while in the other two trades mentioned it was 13.8 per cent and 4 per cent, respectively. The explanation is that in England, Ireland, and Scotland, as well as in other European countries, seven years are the rule for apprenticeship of stonecutters, and a large proportion are taken when 12 years old, and quite a number under this age. Eightythree and one-half per cent of the total number were foreign born and but 16.5 per cent American born; and of the latter but ninetenths of 1 per cent began to work under 15 years of age; while 15.4 per cent of carpenters and 25.6 per cent of masons began to work at their respective trades after the age of 20 years and upward, none of the stonecutters had reached this age. This fully accounts for the differences above noted.1 In his discussion of the hygiene of this occupation Lloyd2 makes the following observations: Stonecutters and quarrymen suffer in various degrees from the in halation of dust. The extent of the evil in their cases depends upon, first, the character of the dust, and, second, the circumstances amid which the work is pursued. The quality of the stone has much to do with the extent of pulmonary disease among stonecutters. Some stone is much more dusty than others. A sedimentary stone, for instance, that was formed originally simply by the deposit of earthy and siliceous particles under water is much more liable to give off a large quantity of dust than is a stone that was fused in early geologi cal ages—the igneous stones, for instance, like granite. Although the particles from these latter stones are exceedingly hard,#yet there is not much true dust, only the particles actually displaced by the contact with the tool being thrown off. These probably do not carry far in the air, and are mostly too large to gain access to the alveoli as dust. This was the explanation given by Hamilton, of Aberdeen (quoted by Arlidge), for the fact that the masons and polishers at the Aberdeen quarries do not suffer much, if any, with industrial phthisis. R E S U L T S OF O F F IC IA L IN V E S T IG A T IO N I N M A SSA C H U SE T T S. A brief abstract from a special report of the Massachusetts State Board of Health on dangerous occupations,3 as suggestive evidence 1 F ou rteen th A n n u a l R e p o rt o f the B u rea u o f S ta tistics o f L a b o r a n d In d u strie s ,o f N ew J ersey, 1891, pp. 176, 177. 2 “ T h e d iseases o f o cc u p a tio n s ,” b y J am es H en d rie L lo y d , M . D ., p u b lish ed in T w e n tie th C en tu ry P r a c t ic e o f M od ern M ed ica l Science, N ew Y ork , 1895, V o l. I l l , p. 420. 3 C om m on w ea lth o f M a ssa ch u setts, S enate D ocu m en t N o. 250 , B o sto n , M a rch , 1907, pp. 78, 79. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 185 particularly applicable to American conditions at the present time, is included here: It is preeminently a dusty trade, and the workmen are therefore exposed to the danger of inhaling nonabsorbable and irritating par ticles of mineral matter. Accidents to the eyes from flying chips are also very common, but they are generally less serious than those due to fragments of steel from the tools employed. Of the various kinds of stone dust, granite is regarded as more injurious than marble, and soapstone the least of all; but different granites vary in this particu lar, some yielding a much finer dust than others, on account of dif ferences in texture. The greatest amount of dust comes from the sur facing machines, which are operated with compressed air. The tool is either a large hammer or an instrument which presents four smaller separate faces. Sometimes a bushing hammer, made of thin, chisel-like blades bolted together, is used; this creates the finest dust of all. The men who operate the surfacing tools rarely wear masks, but many chew tobacco and spit, in the belief that the practice serves to protect them from the effects of the dust to which they are ex posed. Some protect themselves from flying chips by means of wire screens placed about the hammer; some wear wire masks and some wear glasses. By a union regulation^ surfacing is done in the open sheds in the yard. While the operation of smoothing can not be done by the wet process, on account of clogging of the tools with the pasty material which would thereby be produced, polishing is conducted with the application of water, which prevents the evolu tion of dust. The sawing of granite and marble into slabs is con ducted ordinarily by the wet process, and is therefore unattended by dust; but soapstone sawing and cutting for joints is frequently done dry, and with the evolution of much fine dust Turning in lathes is conducted in the wet way, and is dustless. Of 343 deaths which occurred in the city of Quincy among stone cutters during a period of about 16 years, no fewer than 142 (41.4 per cent) were due to pulmonary tuberculosis, 41 (12 per cent) to other diseases of the lungs, 44 (12.8 per cent) to diseases of the heart, 24 (7 per cent) to violence, and 92 (26.8 per cent) to all other causes. Excluding accidents, the percentage due to tuberculosis was 44.5. These statistics show even more strikingly than those quoted in a report submitted two years ago the dangerous character of this occupation. Therein it appears that, of a total of 30,000 deaths among stonecutters, tuberculosis was the cause in 28.57 per cent. It must be said, however, that the average age at death of the victims of the disease in this industry, so far at least as the Quincy records show, is somewhat high (47.8 years), but it is to be borne in mind that the calling is one which is not open to the naturally weak, and that many of those who become incapacitated through infection drift into other lines of industry in which physical strength is not so essential, and hence at death are not returned as belonging to this class. U R G E N C Y OF S P E C IA L S C IE N T I F IC IN Q U I R I E S . No very satisfactory data for this country are available to deter mine with accuracy the probable degree of difference in the healthinjurious conditions resulting from the cutting or 'manipulation 186 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES otherwise of the different kinds of stone, such as granite, sandstone, limestone, bluestone, slate, etc., except marble cutting, to be sep arately considered as a well-defined branch of the trade. The term ‘’ stonecutters ” is, therefore, practically inclusive of workers in all branches of the industry and in all the different employments neces sary in connection therewith. An observer of conditions in the sandstone industry states that “ stonecutters who work on sandstone seldom live to be 50 years of age, and nearly all of them die of lung disease, due to the inhalation of mineral dust” ; but how far this is sustained by actual experience in the regions where sandstone is quarried and cijt can not be stated at present. A physician of long residence in the Bedford, Ind., limestone field, states that he has not observed very serious consequences to result from employment in that branch of the stone industry, but all such observations are sub ject to serious error in the absence of trustworthy statistical data for a period of years. D I F F E R E N T I A L E F F E C T S OF D U ST E X P O S U R E . These differences of qualified opinion regarding the relation of stone dust to health arise obviously out of the wide variations in the physical, mechanical, and chemical properties of the different kinds of stone subjected to modern processes of quarrying, dressing, etc., par ticularly in consequence of the extensive use of modern pneumatic tools used for stonecutting purposes. Among all branches of the dusty trades and occupations the stone industry is of the first order of scientific importance. Aside from the industry itself, as regards the production of stone for commercial purposes, practically the entire mining industry is in a measure a branch of the stone in dustry, in that all the metals and nonmetallic minerals obtained by mining methods are obtained by processes of extraction from rock material more or less identical with the substances which enter into the stones quarried and cut for commercial purposes. The most thorough and strictly scientific study of dust phthisis with special reference to the stone industries has been made by Dr. Edgar L. Collis, His Majesty’s medical inspector of factories, presented in the Milroy Lectures of 1915. The differential effects of dust containing a large proportion of free silica (quartz) and dust relatively free therefrom are emphasized in the most concise and conclusive manner. LU N G D I S E A S E S OF F L I N T K N A P P E R S A N D B U H R S T O N E D R E S S E R S . The correlation of these conditions to the relative frequency of true phthisis or of lung fibrosis, with a subsequent tuberculous in fection, is made clear on the basis of indisputable clinical evidence amplified by numerous Roentgen ray examinations. Stone dust con taining but a relatively small proportion of free silica, such as lime- OCCUPATION'S W IT H EXPOSURE TO MINERAL DUST. 187 stone, is considered comparatively harmless, while the extreme seri ousness of stone dust consisting chiefly of free silica (quartz) is illus trated by numerous concrete cases, of which the so-called flint knappers and French buhrstone dressers are the most striking and lamentable examples. Dr. Collis defines the term “ pneumoconiosis ” as one which should be restricted to “ disturbances in health follow ing upon changes induced in the lungs by inhalation of nonviable particles.” And he remarks that “ just as all germs are not patho genic, so all kinds of nonviable particles do not give rise to pneumo coniosis.” This extremely important conclusion in its particular application to the stone industry requires constant application to the more specialized consideration of its injurious results in employment in the different branches of the industry. Referring to the flint knappers of Brandon as the lineal occupational representatives of the oldest of all industries, that of the making of prehistoric stone tools and weapons, he states that they “ suffer a terrible mortality from phthisis induced by flint dust generated in their work,” and he recalls the results of earlier observations as regards the lamentable consequences produced among the population of Meusnes, France, by the introduction of the gun-flint industry, which, according to Chateauneuf, “ slays those who follow it ; it kills them before their time; for them there is no old age.” He illustrates these observa tions by a most interesting analysis of the mortality from phthisis among flint knappers in the Brandon district, shown in Table 72. T able 7 2 .— M O R T A L IT Y F R O M P H T H IS IS O F F L IN T K N A P P E R S C O M P A R E D W IT H T H A T OF C E R T A IN O T H E R CLASSES. Cause of death, stated as percent ages from— Class. All causes. Flint knappers1............................................... W ives (2) and widows (11) of flint knap pers. Brandon rural d istrict3 ............................... All males (England and Wales, 1900-1902)* Total Respira num tory dis ber of A ll Phthi eases other deaths. sis. other causes. than phthisis. Calcula ted death rate from Aver phthisis age per age at annum death. among 1,000 living. 100.0 100.0 77.8 7.4 15.4 14.8 84.6 27 13 46 78 100.0 100.0 6.5 11.2 11.7 17.6 81.8 63 71.2 509,567 (4) 41.0 .8 1.6 i Average number em ployed for 25 years estimated at 16.5. ^ Population about 5,150. The figures for this class, supplied b y Dr. A. Harris, M. O. H ., Thetford, Norfolk, are for all ages, 1901-1910. 3 The figures for this class, calculated from the Supplement to the Sixty-fifth Annual Report of the Registrar-General, are for all males aged 15 years and upward, 1900-1902. * Median age at death between 56 and 57. M I X E D M I N E R A L A N D M E T A L L IC D U ST E X P O S U R E . Next to the inhalation of steel dust the continuous and considerable inhalation of flint dust is one of the most serious industrial condi tions predisposing .to pulmonary tuberculosis. In the pottery in- 188 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. clustry (see pages 247 to 271), the employees who handle or employ flint dust in connection with production processes are known to be subject to an exceptionally high mortality from pulmonary tuber culosis ; so much so that flint workers generally are considered uiiinsurable by all American life insurance companies. SE C O N D A R Y IM P O R T A N C E OP B A C IL L A R Y IN F E C T IO N . The effects of stone dust in the mining industry are briefly set forth in the conclusions of the departmental committee appointed in 1902 to reinvestigate the causes of the persistently high phthisis mor tality among Cornish tin miners, which, excluding all other contrib utory circumstances, except dust inhalation, decided that— So far as the Cornish miners are concerned it seems evident enough that stone dust which they inhale produces permanent injury of the lungs—gradually in the case of ordinary miners and rapidly in the case of machine-drill men—and that this injury, while it is appar ently capable of gradually producing by itself great impairment of the respiratory functions, and indirectly of the general health, also predisposes enormously to tuberculosis of the lungs, so that a large proportion of miners die from tubercular phthisis. That the primary injury to the lungs is due solely to inhalation of stone dust would seem to be practically certain. In other words, the more generally recognized menace of baeillary infection in tuberculosis was considered of secondary importance as a causative factor in the production of so-called miners’ phthisis, more directly and specifically attributable to the continuous and con siderable inhalation of silica dust. A descriptive account of the different varieties of dust, based on the microscopical examination of their physical and mechanical properties, is, therefore, a prerequisite for a thorough understanding of the pathological consequences of dust inhalation in the different branches of the stone industry. It is pointed out by Collis that all classifications in general use are inad equate to the purpose and that in the main it seems best to ascertain, first, the relation of each of the main respiratory diseases to dusts, and then from that standpoint to examine the properties of the dusts which are associated with an undue prevalence of each of these dis eases. This, of course, implies a much broader plan and scope than the present investigation, which for practical purposes is limited chiefly to pulmonary tuberculosis. The chemical properties of dusts are occasionally of major importance on account of the solubility of certain kinds of dust, best illustrated in the case of the cement indus try. As observed by Collis— Only particles which are insoluble in the fluids of the body when carried into the air passages remain as foreign bodies either to OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 189 stimulate the ciliated epithelium to overaction for their expulsion, or, if they gain access to the lymph channels, to give rise to a pro liferation of the connective tissue; thus dusts of ivory, horn, bone, and other animal structures, and of calcium sulphate (plaster of Paris and alabaster), of limestone, and of oxide of iron are not associated with pneumoconiosis in the way that dusts of vegetable husks, emery, glass, sandstone, and flint are. He adds to this extremely important practical conclusion the ob servation that, “ generally #speaking, dusts are more injurious as their chemical composition differs from that of the human body, or from the elements of which the body is normally composed.” M O R B ID IT Y A N D M O R T A L IT Y OF T H E ST O N E W O R K E R S OF D E R B Y S H I R E . The most useful application of the theory and conclusions of Dr. Collis is to be found in the extended study which has been made of the different branches of the stone industry of Derbyshire by Dr. Sidney Barwise, in a report to the county council of Derbyshire, on the basis of a careful study of the relation of phthisis incidence to the surface geological formation. Dr. Barwise ascertained that there was an excessive frequency of pulmonary tuberculosis on areas showing millstone grit, and a preliminary investigation indicated that “ the key to the higher phthisis mortality in the gritstone area was to be found in the occupations of the males.” A subsequent analysis of the mortality record for a period of 10 years proved conclusively that the gritstone quarries experienced an exceptional mortality from phthisis. It was found that of the deaths of quarrymen 29 per cent was from phthisis, while only 4.6 per cent of the deaths of agricul turists was attributed to this cause. On the basis of the calculated death rate, without reference, however, to the age distribution of the employees, it was shown that the death rate from phthisis among the agricultural group of-the county was 0.72 per 1,000, while among the quarrymen and masons (stonecutters, dressers, etc.) it was 5, or seven times as great. Subjecting the data to a thoroughly spe cialized and qualified analysis, it was then ascertained that “ among the limestone workers there was not an excessive mortality from phthisis, so that the mortality of gritstone workers separately con sidered was even higher than indicated by the combined mortality rate for all quarrymen and stone workers in the section under con sideration. The results of this exceptionally valuable, and, broadly speaking, scientific investigation, are set forth in Table 73, derived from the 46Report on the Prevalence of Phthisis among Quarry Workers and Miners,” made by Dr. Sidney Barwise to the Derby shire county council, February 6, 1913. 190 MORTALITY FROM r e s p ir a t o r y d is e a s e s i n dusty trades. T a b le 7 3 .—D E A T H S F R O M P H T H ISIS OF M ALES O V E R 15, A N D N U M B E R OF M ALES O V E R 10 E N G A G E D IN C E R T A IN OCCUPATION S, W IT H D E A T H R A T E S F R O M PH TH ISIS P E R 1,000 M ALES O V E R 10 E N G A G E D IN SUCH OCCUPATION S, 1901 TO 1910. Stone-workers’ group. District. Matlock registration subdistrict (chiefly gritstone): The two Mattocks and the tw o Darleys.................... Certain rural parishes................................................... Phthi W ork sis ers. deaths. Rate per 1,000. Agriculture. Phthi W ork sis ers. deaths. Rate per 1,000. 426 233 31 15 7.3 6.4 473 245 2 3 0.4 1.2 Total, Matlock registration subdistrict.................. Bakewell registration subdistrict (gritstone and lime stone): Bakewell, Baslow, and certain rural parishes in Bakewell registration subdistrict........................... Tideswell registration subdistrict (chiefly limestone): Certain rural parishes in Tideswell registration sub district................................................................... 659 46 7.0 718 5 .7 530 20 3.8 1,079 10 .9 339 10 2.9 579 2 .34 Total, Bakewell registration district................... 1,528 76 5.0 2,376 17 .72 C O M P A R A T IV E P H T H I S I S D E A T H R A T E S A CCO RD IN G TO D U ST E X P O S U R E , According to this table the gritstone workers, who predominate in the Matlock subdistrict, show a phthisis rate of 7 per 1,000, or ten times greater than the agricultural group, whereas in the Bakewyell subdistrict, where both limestone and gritstone deposits are worked, the rate is only 3.8, and in the Tideswell subdistrict, in which the proportion of gritstone workers is still less, the rate is only 2.9. Subjecting the returns for the Matlock and the Tideswell subdistricts to further analysis, it is shown that the phthisis mortal ity during the period 1901-1910, limited strictly to the workers them selves, is 13.7 per 1,000 for gritstone workers (chiefly exposed to insoluble pure silica dust) ; whereas in the case of limestone work ers, chiefly exposed to a dust more or less soluble, the rate is only 1.2. In other words, the phthisis mortality of gritstone workers is more than ten times the corresponding mortality of limestone work ers. It should be said in this connection that the number of men ex posed to risk was 124 in the case of gritstone workers, with 17 deaths from phthisis, and 170 in the case of limestone workers, with 2 deaths from phthisis during the 10-year period. The results of the investigation are summarized in a convenient form in Table 74. T able 7 4 .—C O M P A R A T IV E P H T H ISIS D E A T H R A T E IN D E R B Y S H IR E C O U N TY, E N G L A N D , 1901 TO 1910. Persons. Gritstone workers ________ . . . ................... ........................................................... .. The two Matlocks and the two Darleys, stoneworkers (some in limestone)........... Bakewell registration district, gritstone and limestone works................................... Persons employed in and about limestone quarries and w orks_______ __________ Limestone w ork ers..............................................................- ...........................—............. Persons employed in and about coal m ines................................................................... Persons em ployed in agriculture..................................................................................... Standard phthisis death rate............................................................................................ 124 426 1,528 1,282 262 1,757 3,615 15,152 Rate ner 1,090. 13.7 7.0 5.0 1. 71 1.52 .68 .66 .77 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST, 191 In addition it was found that among those employed in gritstone working, the proportionate mortality from phthisis was 45 per cent, and among quarrymen and miners in the same district and working on the same material 36.6 per cent, in contrast to a proportionate mortality of 12.3 per cent for men employed as quarrymen and miners in the limestone area, and 7.4 per cent among the men em ployed in coal mining. The highest proportionate mortality among agricultural workers in the same district in which the proportionate mortality of gritstone workers was 45 per cent was only 7.9 per cent. The extremely injurious nature of gritstone dust, which is largely pure silica in a crystalline form, with special reference to pulmonary tuberculosis, is, therefore, conclusively established by these investi gations. A M E R IC A N M O R T A L IT Y S T A T IS T IC S . The Vermont State board of health has reported the mortality by occupations during the six years ending with 1905, and during that time there were 204 deaths from all causes among the granite and other stone workers in that State. Of these deaths, 80, or 39.2 per cent, were from pulmonary tuberculosis, and 27, or 13.2 per cent, from other respiratory diseases. Of the deaths from all causes among stone. workers in Vermont, 52.4 per cent were attributed either to pulmonary tuberculosis or to other respiratory diseases. The census mortality statistics for 1900 combine marble and stone cutters into one group, including 26,141 males aged 15 years and over in the registration States. Of the number stated, 659, or 2.5 per cent, had attained to 65 years of age or over, which compares with 3.9 per cent for men in mechanical and manufacturing industries gen erally. In the mortality from all causes the death rate is compara tively low at ages under 25, but high at ages 25 and over, as shown in detail in Table 75. The census mortality statistics, however, are subject to the criticism that in all probability the facts are under stated on account of defective enumeration. 7 5 .—M O R T A L IT Y FR OM A L L CAUSES AM ONG M A R B L E A N D STON E C U T T E R S, C O M PA R E D W IT H T H A T OF T H E M A N U FA C TU R IN G A N D M ECH AN ICAL CLASS A N D TH E M E R C A N TILE A N D T R A D IN G CLASS, IN T H E R E G IS T R A T IO N ST A T E S , 1900, B Y A G E GROU PS. T a b le FSource: Report of the Bureau of the Census on Vital Statistics, 1900.] Death rate per 1,000 among— Age at death. 15 to 24 years.............................................................. 25 to 44 years..................................................................... 45 to 64 years............................................................ 65 years and over................................... Marble and stone cutters. 3.35 9.32 24. 72 122.91 The manu The mer facturing cantile and and trading mechanical class. class. 4.43 8.35 20.16 105.43 2. 60 6.72 19.91 93.79 192 MORTALITY PROM RESPIRATORY DISEASES IN DUSTY TRADES. A further difficulty in connection with the vital statistics of stone and marble cutters results from the fact that men in this trade are a very mobile element, frequently moving from one place to another in response to better trade conditions, higher wages, etc., in other fields. The most suggestive result of the census mortality investiga tion is the extraordinarily high death rate from pulmonary tubercu losis, which is returned at 5.41 per 1,000, compared with 2.62 for the mechanical and manufacturing class, and 1.66 for the mercantile and trading class. E N G L IS H O C C U P A T IO N A L M O R T A L IT Y IN V E S T IG A T IO N S . For unknown reasons the Report of the Registrar-General for England and Wales does not specifically consider stonecutters, but combines them with quarrymen in stone and slate, which, of course, precludes the utility of the resulting averages in an effort to determine the relative degree of pulmonary tuberculosis frequency in a well-defined specific occupation such as the stonecutters’ trade* Even when considered as a group, however, quarrymen and stone cutters combined, according to English statistics, show an excessive mortality from pulmonary tuberculosis and other respiratory dis eases, but it is a matter of regret that the data should not be sepa rately available for men employed in the more important branches of the stone industry. The health and mortality of men employed in granite, marble, and stone quarrying, including stonecutters and polishers, has been reported upon at length by Arlidge, who observes, in part, that— All employed on these mineral substances suffer in various de grees with respiratory disorders, and, on the whole, more so than coal miners. The quality of the stone, in regard to its petrological characters, determines its severity of action; but observations have hitherto not been sufficiently numerous to establish the fixed relations between the character of the stone and the mischief caused by its dust. Speaking generally, sedimentary rocks composed of siliceous and readily detached particles do more harm on inhalation than primary rocks in which a fusion of their constituents has taken place. Other modifying characters are exhibited in the chemical composition and in the miscibility of the mineral dust with fluid. M O R T A L IT Y OF T H E G R A N IT E C U T T E R S OF A B E R D E E N . With special reference to granite cutting in the district of Aber deen, Scotland, it is stated that men employed in the cutting, dress ing, and polishing of granite are seldom victims of pulmonary lesions attributable to their occupation. Arlidge considers this a surpris ing fact, possibly explained by the density of granite and its lithological elements. He quotes Prof. Hamilton, of Aberdeen University, to the effect that the explanation may be found in the igneous char acter of the rock, which opposes itself to the throwing off of dust, OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 193 because its particles, unlike those of stratifiefi rocks, do not exist in granite ready formed, but must be made by the chisel of the work man. Prof. Hamilton concludes that— The dust in granite working would in all likelihood be coarser than in chiseling stratified rock, and would be caught in the superior respiratory passages without gaining entrance to the air vesicles where alone it seems to make its way into the pulmonary lymphatics. Whether this explanation is accepted or not, it is a fact of con siderable importance that the men employed in the granite-cutting industries suffer considerably from chronic bronchitis, but the severe lesions indicative of fibrosis and industrial phthisis are practically unknown among them. According to the report of the chief inspector of factories for 1880 (p. 8 1 ) It seems that a like immunity is enjoyed by the laborers in the Purbeck and Portland quarries. Here the material is a limestone of close, compact grain, and not a mass of imperfectly coherent par ticles of sand; in short, a marble—a substance recognized by those who work it as but slightly detrimental to the respiratory organs. In marked contrast, Arlidge directs attention to the extremely high fatality rate among men employed in the Edinburgh stone quarries, but no conclusive statistical information has been made public con cerning this. According to Dr. R. W. Philip, of Edinburgh, in a statement to Dr. Arlidge, “ A large number of cases of stonemasons suffering from phthisis seek relief at the local dispensary, and the average age at Which they come under observation is only about 35 years. As a rule, the cases run a very chronic course, passing from recurrent to persistent attacks of bronchitis.” Reference is made to a much earlier observation by Prof. Alison in 1824, according to which there was reason to believe “ that there was hardly an instance of a mason regularly employed in hewing stones in Edinburgh being free from phthisical symptoms to the age of 50.” C O M P A R A T IV E O CC U PA TIO N A L M O R T A L IT Y OF T H E ST O N E W O R K E R S OF ABERD EEN . It is self-evident that these conflicting conclusions are more or less attributable to important variations in the nature of the stone quar ried as well as to differences in the method of work. Modern pneu matic processes, for illustration, have practically revolutionized the stone-cutting industry, and the dust menace has been very materially increased in consequence. The mortality of stone workers in the Aberdeen district has been reported upon with admirable thorough ness by Dr. Matthew Hay in an appendix to his annual report as medical officer of health for the year 1909. He points out that—106811°— 18— Bull. 231-------13 194 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. A workman who has contracted phthisis in one occupation may change his occupation some months or years before' death, and his relatives on registering his death may or may not give his original occupation as his ordinary occupation. Much depends upon the length and nature of the last occupation, whether it is presumed to be inferior or not, and on the person to whom it may fall to supply the information required by the registrar. Even the registrars them selves act differently in such cases of changed occupation. Other difficulties are the probable incompleteness of returns re garding the number of persons employed, which by inference sug gests the possibly greater .practical utility and scientific conclusive ness of proportionate mortality data. Hay points out that— Considerable interest attaches in Aberdeen to the incidence of phthisis among stonecutters and masons, owing to their considerable number and to the danger to which they are exposed from the inhala tion of granite dust. All masons are not, however, so exposed, as a proportion of them, varying with the character of the building, are employed solely in building, and are known within the trade as “ wallers,” while the remainder are engaged in hewing and dressing stones. Wallers are not so distinguished in the death registers. Nor is any distinction made in the registers between masons, whether hewers or wallers, employed in connection with buildings and stone cutters employed in the numerous monumental yards. As a rule, a hewer working in the latter is known as a stonecutter, but he is not infrequently designated as a mason. The results of the investigation are summarized in Table 76. T a b le 7 6 .— A VE R AG E A N N U A L D E A T H R A T E OF PE RSO N S 21 Y E A R S OF A G E A N D O V E R (E X C L U D IN G E M P L O Y E R S ) IN A B E R D E E N , 1900 TO 1909, B Y OCCUPATIONS. Occupation. Esti Annual number of mated average annual Lung diseases. num ber of persons Phthi E x In over 21 clud sis. clud years ing ing of age phthi phthi em sis. sis. ployed. deaths per Circu latory and nerv ous dis eases. 1,000 persons due t o Tuberculosis. Other dis eases. All causes. Wives and wid ows. Un mar ried chil dren. MALES. Stonecutters and masons .. ,t. Stone polishers........................ Joiners, e t c ............................... Painters.................................... Tailors....................................... Bakers....................................... Engineers, e tc .......................... Printers, etc............................. Comb makers.......................... Carters...................................... Laborers................................... 1,750 420 1,420 420 620 360 2,600 380 345 1,450 3,600 5.7 2.5 1.8 2 .1 3.2 1.4 1.8 4.5 4.3 1.1 2.5 4.8 3.4 4.0 5.6 4.4 2.3 8.2 4.3 3.1 5.6 1.5 4.2 7.9 5.3 4.6 4.8 7.0 9.3 9.0 6.4 5.2 4.5 7.2 3.0 8.3 3.9 3.4 5.4 6.8 2.7 3.3 8.8 2 1.1 1.1 7.3 5.2 6 .1 8.8 5.8 4.1 5.6 8.6 5.4 5.2 8.6 5.2 8.5 8.3 4.8 3.7 6.7 5.0 9.8 5.4 18.1 17.3 20.8 20.7 26.5 20.6 14.1 13.7 22.5 12.2 1,220 2.3 3.8 1,750 3,500 2 .1 1.9 1.5 3.3 1.9 3.3 5.2 5.6 8.0 18.8 1.7 2.7 4.4 5.1 8.3 17.8 26.0 14.6 FEMALES. Dressmakers and m illiners... D omest ic ser vants.................. A ll males 21 years and , o v e r ............................ A ll females 21 years and over . ... 9.4 1.8 1.6 1.8 1.7 1.6 1.9 1.6 1.1 2.0 1.8 2 .1 1.1 4.7 5.5 3.7 4. 5 2.7 4.4 3.9 1.6 3.2 4.7 4.4 .7 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 195 This table is of additional interest in that it includes a number of other important occupations with more or less exposure to industrial dust. The table shows that stonecutters and masons rank above all other employments considered, with a death rate of 5.7 per 1,000 from phthisis, which is three times as high as the average of 1.9 for males above 21 years of age. Making allowance for persons not directly employed in the cutting and hewing of granite, it is quite probable that the true phthisis death rate of this class is 6.2 per 1,000. Next to stone workers, according to the table, come printers and lithographers, with a phthisis mortality of 4.5 per 1,000, which is slightly less than two and one-half times the average. In further explanation of the table it ‘is said that— As a rule, occupations with a high mortality from phthisis have also an increased mortality from other lung diseases. This is not the case with stonecutters and masons in Aberdeen, or with printers and lithographers, or with clerks. In all three occupations, the mortality from other lung diseases is under the average. Tailors and comb makers, however, follow the usual rule, having a somewhat high mortality from other lung diseases. The result is that, if the rates for phthisis and other lung diseases are combined, tailors and comb makers, with 8.8 and 8.6 per 1,000, respectively, take precedence of stonecutters and printers, with 8.2 and 5.6, respectively. For clerks it is 5.3. Indeed, the total death rate from lung diseases (in cluding phthisis) among clerks and printers is only very slightly beyond the average (5.2) for all male persons above 21 years of age. Soma of these differences in the incidence of phthisis and of other lung diseases are probably in some measure more apparent than real, being dependent upon the fact that the death rate from phthisis de creases after the age of 55 to 60, while the death rate from other lung diseases rapidly increases with advancing age. Occupations with a large proportion of old men have accordingly a lower death rate from phthisis and a higher death rate from other lung diseases than occupations with a smaller proportion of old men. Attention is directed to the exceptionally large number of deaths from phthisis among stonecutters after the age of 55, which is a relatively rare occurrence in other occupations. The rather involved terminology of English occupational terms precludes an accurate comparison with corresponding statistics for this country. Two occupations which show high death rates from phthisis in the Aber deen experience, namely, stonecutting and comb making, are both referred to as dusty occupations, and there are grounds for believing, not only from available statistics but from results of similar investi gations elsewhere, that the dust was the slow but ultimate cause of death in many cases. PHTHISIS, AND PNEUMATIC TOOLS. The subject of stonecutters’ mortality in relation to the use of pneumatic tools is considered briefly by Hay, who points out that— 196 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. In regard to the mortality from phthisis among stonecutters and masons, the question has been raised as to whether the introduction of pneumatically driven tools, which produce more fine dust than the old hand chisels, has increased the amount of phthisis and lung disease. I am informed that previous to 1900 very few pneumatic tools were in use in Aberdeen. Between 1900 and 1905, and espe cially after 1902, their use rapidly extended, so that by 1905 they had come into full use in practically all stonecutting yards. The following table gives the number of deaths among stonecutters and masons combined for each of the 15 years ending with 1909. The first five years, 1895-1899, represent a period in which pneumatic tools were coming into use; and the third five years, 1905-1909, a period in which the tools were in full use. Only deaths at ages of 21 years and upward are included. T a b le 7 7 .—N U M B E R OF D E A T H S FR O M P H TH ISIS A N D FR O M O T H E R L U N G D ISEA SES AMONG STO N E C U TTE R S A N D MASONS OF A B E R D E E N , 1895 TO 1909. Cause of death. Cause of death. Year and period. Year and period. Phthisis. Other lung diseases. Second period—concluded 1904.......... .................... 9 8 5 9 T otal.................. 50 31 Third period: 1905 1906............................... 1907 1908............................... 1909............................... 11 10g 11 8 3 3 T otal.................. 49 12 7 13 8 Total.................. 47 28 10 6 10 5 2 Second period: 1900................................ 1901 1902................................ 1903................................ 6 12 5 13 12 Other lung diseases. 5 First period: 1895................................ 1896 1897............................... 1898 1899................................ 9 Phthisis. 1 2 1 3 The numbers for 1900-1904 are slightly above those for 1895-1899 in respect both of phthisis and of other lung diseases. The total number for 1905-1909 is, however, considerably down; but the fall is practically confined to deaths from lung diseases other than phthisis. The first two periods are fairly comparable, except that allowance should be made for an increase of, perhaps, 10 per cent in the number of persons employed as between the first and second periods, and for the fact that during the two periods the mortality from phthisis in the community as a whole was falling. As probably the effect of the latter influence did rather more than equalize the effect of the former, a comparison of the first two periods would appear to show that the introduction of pneumatic tools had produced some increase, although not a large increase, in the death rate from phthisis and other lung diseases. As regards the third period (1905-1909), while the number of stonecutters and masons employed in monumental yards has not fallen off, but rather increased, there has been a great decline in the number of building masons in employment, due to unusual depres sion in the building trade. Some of these out of employment as mason hewers have, I believe, found employment as stonecutters in monumental yards, and thus checked in some measure the advance OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 197 ment of apprentices to the status of journeyman. Some have emi grated to America. Some have drifted into laboring, but not im probably in the event of death within two or three years of leaving their trade, their deaths have been registered by their relatives as the deaths of masons. It is difficult to know to what extent to make allowance for these disturbing factors. Probably, any reasonable allowance would not raise the total number of deaths from phthisis and other lung diseases combined above or even up to the number for each of the preceding two quinquennial periods, but it would raise the number of deaths from phthisis above the numbers for these periods. After a brief discussion of possible errors attributable to the erro neous use of apparently equivalent occupational terms, it is said with further reference to the use of pneumatic tools, that— About the time of the introduction of pneumatic tools for granite cutting, but not altogether as a consequence of it, the sheds, which had usually been entirely open along the front, as in the case of an ordinary builder’s shed, began to be closed. The closure, while increasing the liability to the inhalation of dust, must at the same time have afforded some protection against cold and possible chills. This may possibly account in part for the diminution during the past five years in the number of lung diseases other than phthisis. But the numbers dealt with are small, and allowance must be made for mere chance variations. C O M P A R A T IV E F R E Q U E N C Y OF L U N G D I S E A S E S I N A B E R D E E N E D IN B U R G H . AND IN In view of the foregoing, the final conclusion is advanced that “ the unusual combination, in the case of workers in stone, of a high mor tality from phthisis, with a low mortality from lung diseases other than phthisis, may serve to bear out the statement made by the late Prof. Hamilton, professor of pathology in Aberdeen, that a definite development of so-called lithosis, or a fibroid affection of the lungs due to stone dust, is rare among granite workers, although common among firestone workers in Edinburgh.” In part, this conclusion would seem to be sustained by the examination of a relatively small number of autopsy records. The strictly medical question, there fore, whether the form of tuberculosis met with among the granite workers of Aberdeen was to be considered industrial fibrosis with a superinduced tuberculosis, or strictly pulmonary tuberculosis in the more limited sense of the term, can not be considered finally decided by the information at present available. The investigation reem phasizes earlier conclusions regarding the importance of minute at tention to the character of the dust inhaled in the different branches of the stone industry; certain forms of stone dust are obviously much more injurious than others, and a general grouping of stone workers for purposes of mortality analysis is therefore quite likely to yield inconclusive results. 198 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. P H Y S IQ U E OF ST O N E W O R K E R S . Not only is it necessary to take into account the kind and nature of the dust inhaled, particularly whether of granite trap rock, sandstone, or limestone, but the different employments also re quire special consideration. Some occupations are unquestionably very much more exposed than others. Additional attention is neces sary as regards the conditions of employment, whether outdoors or indoors, and finally, there is the important relation of physique to disease resistance. Table 78 shows the average chest expansion of males in certain occupations, including the Aberdeen granite trade, and has been derived from the discussion on industrial pneumoconi osis, by E. L. Collis, London, 1915, in the Milroy Lectures. T a b le 78— A V E R A G E CH EST E X P A N S IO N IN INCHES OF M A LE S IN C E R T A IN CLASSES, A T V A R IO U S A G E P E R IO D S . Aberdeen granite trade. Leis ured class. Age period. 14................................................ 17................................................ 2.31 2.45 2. 79 2.90 2.87 2.64 2.35 2.39 2.24 20 95 ................................................ 20 ................................................ 35............................ 40................................................ 45................................................ 50................................................ 55................................................ 65 and over........ ........... .......... 2 .12 1.87 Sheffield cutlery trade. Factory opera P o t h tives ers, etc., Cutters Cutters not ex very Light in posed slightly in open closed Cutters. grind ers. to dust. sheds. sheds. ex posed to dust. 2. 84 2.33 2.13 2.20 2.15 2.24 1.64 2. 58 2.57 2.58 2.21 2.14 2.04 2.07 1.98 2.04 1.80 2.14 2.64 2.43 2. 51 2.19 2.13 2.16 1.92 1.73 2.40 2.60 2.44 2 .11 1.93 1.80 1.67 1.84 1.44 1.56 2.43 2.27 2.24 1. 96 2.09 1.92 1.73 1.56 1.49 1.50 1.13 2.54 2.37 2.45 2.40 2.14 2.07 1.75 1.58 1.58 1.53 Strip pers of cotton Heavy carding grind ma ers. chines. 2.67 2.49 2.19 2.19 2.04 1.89 L52 1.55 1.51 1.45 }■ | 3.33 2 . 75 2.45 } 1.86 } 1.69 } 1.72 . In connection with the table Dr. Collis points out that—Inhalation of silica dust takes several years, varying with the in tensity of the exposure, in producing any obvious effect, but gradu ally the affected person notices that on exertion his breathing capacity has become limited, and that a cough, slight at first, has become per sistent, though seldom accompanied by much expectoration; other wise he may look robust and feel well. This limitation in the breath ing capacity which has been noted by nearly every authority from Hippocrates to the South African Miners’ Phthisis Commission of 1912 has been described as pathognomic of the disease and may at first be the only objective sign present. In several inquiries in which some thousands of operatives have been examined, I have collected physical data which demonstrate this limitation, and the results are stated in the table; but as Dr. Cumpston points out, “ the actual amount of expansion in inches is not of so much importance as the manner in which the chest wall behaves when an attempt at ex pansion is made.” This diminution in chest expansion must^ how ever, not be relied on as an indication of exposure to silica dust, as OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 199 it is present, though not so markedly, among workers exposed to other dusts. In further explanation, it is said that should the condition progress until the age of 45 to 50 years, a definite clinical picture is presented, briefly described as follows: Such a man is usually somewhat below the average height for his class, for exposure to dust inhalation during the growing period of life appears to inhibit the normal growth; he looks well, but if he has just ascended stairs or has hurried, he is out of breath for a few minutes; and on being questioned, though unable to count 20 with out taking a breath, he speaks of himself as fit, and may even boast of being a credit to his trade; but he owns to frequent colds, espe cially in winter, and a troublesome cough; he expectorates but little sputum, and what there is is rejected with difficulty and is colored by the dust produced in his work; in some industries, particularly in tin mining and gold mining, he is stated to be subject to distinc tive attacks of dyspnoea, but this symptom is not prevalent among metal grinders or granite cutters. When he is stripped he is found to be well nourished, but respiration is seen to be carried on nearly entirely by diaphragmatic action, and even though urged he seems incapable of inducing his intercostal muscles to lift his ribs. P R A C T IC A L V A L U E OF P H Y S IC A L E X A M IN A T IO N S . These observations, arrived at after an exceedingly careful and conservative study of the subject, emphasize strongly the great prac tical value of physical examinations, and reexaminations at least once a year. The necessity for such an examination, includ ing a radiological photograph of the chest, becomes of supreme im portance in the case of men exposed to the risk of silica or quartz dust inhalation, particularly in confined spaces, such as stopes of deep mines, etc., for, as previously intimated, the general appear ance and general indications of health and strength may be very de ceptive, since the progress of the disease is often extremely chronic, lasting in some cases, according to Wheatley, “ upwards of 20 years.” Knowledge of the exact occupation followed is, therefore, of equal im portance and general conclusions, based upon groups of men in dif ferent specific employments, though following the same trade, can not be relied on as trustworthy. According to Collis— Silica dust is generated in the following among other industries: Gold mining, tin mining, and lead mining; quarrying and dressing sandstone and granite; flint knapping, making honing stones for scythes; building millstones, which are used and require dressing in such diverse industries as the milling of flour, ric,e, cocoa, cement (occasionally), and white lead; the manufacture of grindstones, which are used and require racing, trueing, and surfacing in the grinding of metal articles, mother-of-pearl, bone, horn, and other materials; sand blasting to clean castings and to etch glass; crush ing flints and quartz to make silica flour used in the manufacture of 200 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. pottery, certain abrasive soaps, sandpapers, chicken food, disinfect ing powders, and silica paints; the mining and quarrying of ganister and silica stone; and the manufacture of silica bricks. D E S C R I P T IV E ACCOUNT OF S IL IC A OR Q U A RTZ. Pure silica, or the oxide of silicon, is the substance commonly known as quartz, which is one of the most abundant of mineral substances. According to Frank J. Katz, in a report on “ The Production of Silica in 1913,” to the United States Geological Survey— Its occurrences of commercial importance are in a great many different forms, such as vein quartz; as a constituent of pegmatites; as sand, sandstone, quartzite, or flint; as tripoli; and as diatomaceous (infusorial) earth. In some forms, such as rose, smoky5 and ame thystine quartz, it has a gem value. This chapter deals with silica from all sources exclusive of gem quartz, of all forms of silica used for making glass, and also of all silica used in the form of sand, gravel, and crushed material for building, for concrete and mortar, for foundry and furnace work, and for cutting and grinding stone. As regards the principal uses of silica, it may be said, in the words of the same authority, that silica is employed in the manufacture of pottery, paints, scouring soaps, as a wood filler, and as a polisher. In pottery the use of silica: generally called flint in the pottery in dustry, diminishes the shrinkage in the body of the ware; it is also used in many glazes. Silica for use in pottery should contain less than 0.5 per cent of iron-bearing minerals. Considerable quantities of very finely ground silica are used in the manufacture of paint. In all of these processes it is self-evident that exposure to the inhala tion of silica or quartz dust must directly or indirectly result in serious disease complications. The exact proportion of pure silica in the dust inhaled should be ascertained in all cases where an effort is made to establish with accuracy the health-injurious conditions of an occupation with exposure to mineral dust. SU G G E ST IO N S F O R P R O T E C T IV E P R E C A U T IO N S. It is regrettable that no very extensive investigations should have been made into the health-injurious conditions of the more important branches of the American stone industry. Hanson, in his report on “ Methods of Protection from Dusts and Fumes,” illustrates the process of stonecutting and observes that— The strong blast of air keeps the granite clean, but gives rise to a great amount of dust. The surfacing tool is either a large hammer or an instrument which presents four smaller separate faces. Some times a bushing hammer made of thin, chisel-like blades bolted together is used; this creates the finest dust of all. The men who operate the surfacing tools rarely wear masks. Some protect them selves from flying chips by means of wire screens placed about the hammer, some wear wire masks, and some wear glasses. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 201 This is an admirable description of modern processes which, on account of the extensive use of pneumatic tools, have become ex tremely injurious in numerous individual cases. Only superficial precautions, as a rule, are adopted. The regulations of the Barre branch of the Granite Manufacturers’ Association, for illustration, provide: A rticle 6. C utters m ust p rov id e them selves w ith broom , and no air p ow er to be used to rem ove dust. A rticle 7. T u rn in g dow n grin dstones to be done ou tside o f w ork in g hours, unless said stones are th orou gh ly b oxed in. T h is agreem ent is m ade fo r th e pu rpose o f elim inating the dust from grindstones. A rticle 8. N o su rfa ce-cu ttin g m achine to be w ork ed in cu ttin g shed du rin g w o rk in g hours, unless properly equipped w ith effective air su ction or oth er dev ice to rem ove dust. H a n d su rfa cers shall n ot w eigh m ore than 12 pounds. W ork m en to be am ply protected at all tim es fro m du st fro m sa id m achines, w h eth er in the sheds or outside. T h is a rticle n ot to apply to pn eum atic tools w eigh in g less than 7 pounds. As a matter of fact, however, there is only inadequate protection from dust at most of the machines and in most of the sheds which have been investigated and reported upon, including the Barre dis trict of Vermont. IN JU R I O U S O CCU PATIO N AL C O N D ITIO N S. The occupation is also briefly referred to in a recent discussion by Baker,1 in part as follows: Much of the stonecutting is outdoors or in large, airy sheds. It consists of shaping, smoothing, and cutting the stones into smaller pieces, as for paving blocks. Formerly much of the work was done by hand, but now pneumatic tools are used considerably. These produce a finer dust and tend to increase the hazard. It is held by some that the dangers are greater in sedimentary stones than the harder stones, like granite, but no definite figures on this point could be obtained. Dust is also stirred up in sweeping and moving the stones about. Thirty-seven stonecutters were medically and physi cally examined, and of this number 12 patients showed respiratory disease, 9 being ill with chronic and 3 with acute diseases. Three workers had pulmonary tuberculosis, three emphysema, and one each chronic bronchitis, chronic pharyngitis, chalicosis, acute bron chitis, acute pharyngitis, and acute laryngitis. Although only one case of chalicosis is recorded, a greater number would probably have been noted if other factors were studied as closely as physical signs. In view of the fact that 21 of the stonecutters were over 40 years of age, the number ascertained to be affected with pulmonary tuber culosis is relatively small, but the number affected with respiratory diseases more or less predisposing to a terminal tuberculosis must be considered very large. There is no information as to the kind of 1 Journal American Medical A ssociation, May 6, 1916. 202 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. dust inhaled or the nature of the stone cut. The sanitary conditions of the shed were obviously far from what they should have been. U R G E N C Y OF D R A S T IC R E G U L A T IO N S. The importance and necessity of drastic regulations in stonecut ting, polishing, etc., have not been recognized in the factory legisla tion of this country. In the Edinburgh and Aberdeen districts of Scotland the local inspectors, according to the annual report of the chief inspector of factories and workshops for 1910— have been pressing upon the granite cutters the question of local exhaust. The pneumatic tools which are now universally used have largely increased the amount of fine dust breathed by the workers. Mr. Buchan says some idea of the action of granite dust can be gath ered from the fact that the glasses of the workers’ goggles become so dim by the constant impact of the fine particles of granite that monthly renewal is essential. Mr. Kirkwood says experiment has led to the successful removal of dust at the point of the tool by the induced draft, but he fears that the extra fitting with a pipe attached on the side of the tool may cause difficulties in the manipulation at fine work. One occupier has, however, undertaken to give the arrangement a fair trial, and the workers seem anxious that something should be done. P R A C T IC A L P O S S I B I L I T I E S OF D U ST P R E V E N T IO N . There are abundant reasons for believing that much more could be done to control the dust menace in the stonecutting industry than is at present being done in practically all American stonecutting districts. W. Gilman Thompson refers to the statistics of the Quincy, Mass., district for the year 1907, according to which 41 per cent of the deaths of stonecutters were from pulmonary tuberculosis, and includ ing all forms of pulmonary disease the proportion was 53 per cent. According to the same investigation, the tuberculosis mortality among stone and marble cutters and carvers was found to be five times greater than among farmers or lumbermen. The usual proc esses are explained and admirably illustrated in the work of W. Gilman Thompson, who observes, in part, as follows: The drilling of rocks and coal or mineral veins for blasting is almost universally accomplished by machine drill hammers, operated by compressed air or steam, which have replaced the slow method with the crowbar and hand-wielded sledge hammer. When this pro cess is conducted by machines in mines, tunnel boring, or any kind of hard dry stone without the use of a water spray to moisten the dust, it is one of the most dangerous of all the trades which produce chronic disease. When the drilling is done overhead, so that the dust falls back toward the face of the machine operator, the hazard is at its worst. These observations apply in a large measure to rock drilling in mines, tunnels, etc. In coal mining where the overlying strata are OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 2 03 usually of limestone, the dust menace is, of course, much less than in deep mining where the quartz rock consists frequently of almost pure silica. According to W. Gilman Thompson— To lessen the dust hazard from the drill holes various expedients have been devised. The simplest of these is the placing of wet cloths around the drill hole to catch the dust and mopping up the dust, procedures which are troublesome and time consuming. A recent in vention consists of a pipe attached to the drill at the mouth of the bore through which a fine jet of water is forced under pressure into the drill hole, where it unites with the compression air stream in mixing the dust into a harmless paste which flows back out of the hole. Another invention by Korfmann employs an exhaust pipe connected with the drill, by means of which the dust is drawn out of the hole, after the manner of a vacuum cleaner, and discharged into a vessel of water or a moist bag. These inventions have the advantage that they operate independently of the workmen and do not require pre cautions, which such workmen are notoriously reluctant to observe. Actual experience has unfortunately shown many of these devices to be rather impracticable in that they cause too much interference with the work and consequently bring about a diminution in earn ings. The use of dust-spraying devices, etc., as well as respirators in connection with exceptionally dusty processes where the dust consists largely of pure silica, should be made obligatory upon the emxDloyees as well as upon employers. Although not directly pertinent to the present discussion, the fol lowing interesting reference to a case of Raynaud’s disease1in a stone cutter using pneumatic tools has been reported by Dr. Charles H. Cargile, of Bentonville, Ark.: D. E. F., aged 26, married, with good family and personal history, except that he was neurotic, found that frequently and only when cutting stone with a pneumatic tool the index and middle fingers of his right hand would become white, cold, and numb. This instru ment, which oscillates from 900 to 1,600 times p&r minute, transmits strong vibrations to the hand of the operator. The patient told me of a fellow laborer who was similarly affected by using the same kind of tool. Whether there is a well-defined occupational relation between stone cutting and the occurrence of Raynaud’s disease has not been suffi ciently investigated to justify definite conclusions at the present time. 1 R a y n a u d ’ s d isease is defined by G ou ld and P y le as : “ A v a s cu la r d isord er ch a r a c te r ized by three grad es o f in ten sity : (a ) L o ca l sy n c o p e , observed m ost fre q u e n tly in the e x trem ities, and p ro d u cin g the c o n d itio n kn ow n as dead fingers o r dead toes ; it is a n a lo g o u s to th a t p rod u ced by intense cold , (ft) L o ca l a sp h yxia , w h ich usu a lly fo llo w s lo ca l syn cope, but m ay d evelop in d ep en d en tly. C h ilbla in s are the m ild est m a n ife sta tio n o f this c o n d i tion . T he fingers and toes and the ears a re the p a rts u s u a lly a ffected . In th e m o st e xtrem e d egree the p a rts are sw ollen , stiff and liv id , an d the ca p illa ry circ u la tio n is a lm ost sta g n a n t, ( c ) L o ca l sy m m etric g m ig ren e, th e m ild e st fo rm o f w h ic h fo llo w s lo c a l a sp h y x ia .’* 2 04 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. M O R T A L IT Y O F M A R B L E A N D ST O N E C U T T E R S — U N IT E D S T A T E S R E G I S T R A T IO N A R E A . Most of the preceding observations have been derived from foreign sources. The census statistics for 1900 can hardly be considered applicable to present conditions, nor are they conclusive regarding the different branches of the stone industry and the more specific occupations followed. The mortality of marble and stone cutters has been reported upon for the years 1908 and 1909 by the Division of Vital Statistics of the United States Census Bureau, but no subsequent information has been made public and the data are therefore limited to the two years re ferred to. According to the census report, out of 1,657 deaths of marble and stone cutters from all causes, 509, or 30.7 per cent, were from pulmonary tuberculosis. The details of the mortality by divi sional periods of life are shown in Table 79. T a b l e 7 9 . — P R O P O R T IO N A T E M O R T A L IT Y OF M A R B L E A N D STON E C U TT ER S FROM P U L M O N A R Y T U B E R C U LO SIS , U N IT E D S TA TE S R E G IS T R A T IO N A R E A , 1908 A N D 1909. Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years.................................................................................................. 25 to 34 years.................................................................................................. 35 to 44 years.................................................................................................. 45 to 54 ye^rs.................................................................................................. 55 to 64 years.................................................................................................. 65 years and over........................................................................................... Age unknow n................................................................................................ 61 170 299 401 407 316 3 16 74 132 167 95 25 26.2 43.5 44.1 41.6 23.3 7.9 Total, 15 years and over.................................................................... 1,657 509 30.7 8 0 __ P R O P O R T IO N A T E M O R T A L IT Y OF M A R B L E A N D STON E C U T T E R S FR O M N O N TU B E R C U LO U S R E S P IR A T O R Y D ISE A SE S, U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909. T a b le Cause of death. Number of deaths. Asthma.................................................................................................................................. Bronchitis............................................................................................................................. Pneumonia............................................................................................................................ Other nontuberculous respiratory diseases..................................................................... 9 29 131 33 T otal............................................................................................................................ 202 Per cent of deaths from all causes. 0.5 1.8 7.9 2.0 12.2 T U BE R C U LO U S AND N O N T U BER C U LO U S LU N G D IS E A S E S . Tables 79 and 80 are of exceptional interest and value in that they may be considered representative for the American stone in dustry at the present time. There are no reasons for believing that OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 205 material changes have occurred in the mortality during recent years. The data conclusively indicate an excessive proportionate mortality from pulmonary tuberculosis among marble and stone cut ters at every divisional period of life. Commencing with ages 15 to 24 the proportion of deaths, 26.2 per cent, is not exceptionally high in comparison with other trades or occupations with continuous and considerable exposure to metallic or mineral dust. Among plas terers, for illustration, the corresponding proportion, according to data derived from the same official American sources, was 25 per cent, and for potters, 46.2 per cent, and for glassworkers, 47.2 per cent. At ages 25 to 34, however, the proportionate mortality from pulmonary tuberculosis among marble and stone cutters was 43.5 per cent, which compares with 31.5 per cent for plasterers, 44.4 per cent for potters, and 42.6 per cent for glassworkers. The proportion con tinues high throughout the remainder of life; for illustration, at ages 65 and over, among marble and stone cutters, 7.9 per cent are from pulmonary tuberculosis, compared with 3.8 per cent for potters, 4 per cent for glassworkers, and 3.6 per cent for plasterers. Aside from an excessive mortality from pulmonary tuberculosis the mortality from nontuberculous respiratory diseases among marble and stone cutters is extremely high, or 12.2 per cent for respiratory diseases considered as a group, or, respectively, 0.5 per cent for asthma, 1.8 per cent for bronchitis, 7.9 per cent for pneumonia, and 2.0 per cent for other respiratory diseases. C O M P A R A T IV E M O R T A L IT Y F R O M N O N TU BER C U LO U S R E S P IR A T O R Y D I S E A S E — U N IT E D S T A T E S R E G I S T R A T IO N A R E A . On account of the exceptional importance of nontuberculous respiratory diseases among certain groups of occupations with con tinuous and considerable exposure to mineral dust the following com parison is included in the present discussion: T a b l e 8 1 . — C O M P A R A T IV E P R O P O R T IO N A T E M O R T A L IT Y FR O M N O N T U B E R C U L O U S R E S P IR A T O R Y DISEA SES IN S P E C IF IE D OC C U PA TION S E X P O S E D T O M IN E R A L , DU ST, U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1908 A N D 1909. Per cent of deaths due to each specific cause among— Cause of death. Marble and stone cut ters. Potters. Glassw-orkPlasterers. ers. 0.7 .7 6.7 4.4 0.2 .6 ! T otal............................................................................... A ll other causes....................................................................... 1.8 7.9 2.0 12.2 87.8 12.5 87.5 9.2 90.8 89.4 Total, all causes............................................................ 100.0 100.0 100.0 100.0 Asthm a..................................................................................... Bronchitis................................................................................ Pneumonia.............................................................................. Other nontuberculous respiratory diseases........................ 0.5 7.7 .7 0.3 1.1 8 .1 1.1 10.6 206 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Table 81 brings out the interesting fact that the proportionate mortality from bronchitis is particularly excessive among marble and stone cutters in comparison with other occupations with exposure to mineral dust, and with the exception of potters the conclusion applies equally to asthma and other respiratory diseases, excepting pneu monia. The data are not sufficient for final conclusions, but they suggest the practical value of thoroughly specialized investigations into the occurrence of nontuberculous respiratory diseases among marble and stone workers, particularly asthma and bronchitis. The data are derived from official American vital statistics and are quite generally confirmed by corresponding statistics derived from insurance experience or foreign sources. M O R T A L IT Y O F JO U R N E Y M E N S T O N E C U T T E R S — M E D IC O -A C T U A R IA L E X P E R IE N C E . In the medico-actuarial investigation journeymen stonecutters were fortunately considered separately, and the results, based upon a fairly extensive experience, indicate a truly lamentable condition. In the interpretation of Table 82 it should be taken into consideration that only the better class of stonecutters would be accepted for ordinary life insurance, since in former years at least quite generally the prac tice was to decline stone workers entirely. T a b le 8 2 .—M O R T A L IT Y FR O M A L L CAUSES AM ON G JO U R N E Y M E N S T O N E C U T T E R S , B Y A G E G R O U P S —M E D IC O -A C T U A R IA L IN V E S T IG A T IO N . Age at death. Number exposed to risk 1 year. Actual deaths. E xpected deaths. Per cent actual are ofexpecied deaths. 15 to 29 years............................................................................ 30 to 39 years............................................................................ 40 to 49 years............................................................................ 50 to 59 years............................................................................ CO years and over.................................................................... 2,579 2,289 681 138 3 17 32 22 5 11.96 13.44 6.75 3.20 142 238 326 156 Total, 15 years and over.............................................. 5,690 76 35.45 214 .10 According to this table the actual mortality of journeymen stone cutters in the combined experience of American life insurance com panies is 214 per cent of the expected, increasing rapidly with age to a maximum of 326 per cent at ages 40 to 49. The table, of course, includes all causes, and does not refer to pulmonary tuberculosis, but, as subsequently to be shown, the excess in the mortality is chiefly attributable to this disease. Out of 76 deaths at all ages of journeymen stonecutters not a single death occurred at ages 60 and over. This, of course, in part may possibly be the result of the lim ited extent of the experience under consideration. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 207 M O R T A L IT Y OF M A R B L E A N D ST O N E W O R K E R S — IN D U S T R I A L IN S U R A N C E E X P E R IE N C E . According to Table 83, the industrial mortality experience of the Prudential Co. with reference to marble and stone workers for the period 1897 to 1914 includes 2,052 deaths from all causes, of which 690, or 33.6 per cent, are from pulmonary tuberculosis. 8 3 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS AM ON G M A R B L E A N D STON E W O R K E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T O F A L L M A LE S IN U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U PS. T a b le Deaths of marble and stone workers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. Pulm o nary tu berculosis. Marble and stone workers. Males in registration area, 1900 to 1913. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years............................................................................ 5-5 to 64 years............................................................................ 65 years and over........................................... ........................ 60 228 403 513 506 342 23 121 179 200 135 32 38.3 53.1 44.4 39.0 26.7 9.4 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.............................................. 2,052 690 33.6 13.9 The proportionate mortality from pulmonary tuberculosis is ex tremely high at all ages, but particularly so at ages 25 to 34, at which out of the mortality from all causes 53.1 per cent was from pul monary tuberculosis, against 30.5 per cent among males in the regis tration area. I f it had been possible to separate this experience according to the different branches of the stone industry and the more important occupations with dust exposure, there are the most convincing reasons for believing that the results of this analysis would have been decidedly more suggestive of the seriously healthinjurious consequences of exposure to silica or quartz dust. G E N E R A L CO N CLUSIO N S. Inconclusive as these observations are with reference to the several branches of the stone industry and the more important specific occupations with dust exposure, the data are fully sufficient, for the present purpose, to emphasize the extremely dangerous nature of dust exposure in connection with practically all processes of stone quarrying, cutting, polishing, etc. This conclusion applies also and perhaps even more specifically to men employed in connection with stone-crushing operations, which during recent years have assumed very considerable proportions throughout the country. In practically all of these rock-crushing processes no protective devices whatsoever *are employed. Most of the men, it is true, work often only for a por 208 MORTALiTY FROM RESPIRATORY DISEASES IN DUSTY TRADES. tion of the year, and much of the labor is of an itinerant nature, so that the serious damage done to the lungs must frequently escape ob servation. On account of the extreme hardness of trap rock, virtually the equivalent of flint, it is a practical certainty that dust exposure in trap-rock crushing is very serious. The entire stone industry must be more thoroughly investigated for the purpose of ascer taining the most health-injurious processes as well as such branches as include work on limestone and similar mineral substances appar ently much less injurious than the so-called gritstone or granites, etc. In view, however, of the universal use of pneumatic tools in the stonecutting industry this aspect demands particular consideration for the ascertainment of the required methods and means by which the dust menace may be reduced to a minimum.1 The most recent medical observations on the mortality of stone cutters and marble workers are by Kober and Hanson in their treatise on Diseases of Occupation and Vocational Hygiene, where it is said, in part, that— We know now that the inhalation of mineral dust develops sooner or later pneumoconiosis which may eventuate in pulmonary tuber culosis. It is generally held that the liability to diseases of the respiratory passages is less in the case of paving stonecutters and slate splitters, and in the sawing, grinding, polishing, and lathe work which can be conducted by the wet process, than in the case of monu ment or custom work, and particularly in the surfacing, carving, and cutting with pneumatic tools! The greatest amount of dust is evolved by the surfacing machines wThich are operated with compressed air. Of the various tools employed the bushing hammer creates the finest dust. Unfortunately, work with pneumatic tools can not be done by the wet process, as the pasty material created by a mixture of water and dust clogs up the tools. This work is usually done in large open sheds or in the yards, but even under such conditions the men are exposed to clouds of dust. The sawing of granite and marble into slabs, turning in lathes, and the final polishing can be conducted by the wet process; soapstone sawing and cutting for joints is frequently done dry and is attended with exposure to considerable dust. Kober also refers to the fact that experience has shown that the mortality from pulmonary tuberculosis is generally excessive among workers in sandstone and relatively low among workers in limestone. No additional evidence, however, has been forthcoming in support of this point of view, which for practical reasons is one of considerable importance. The suggestions concerning the prevention of dust ex posure in the stone industry as advanced by Kober are also quite 1 A u sefu l trea tise on th e s u b je ct o f rock e x ca v a tion , in clu d in g o b se rv a tio n s on rock s a n d th eir p rop erties, m eth od s o f ha n d and m ach in e d rillin g , q u a rry in g , open-erat e x ca v a tin g , tu n n elin g , etc., is R o ck E x ca v a tio n , by H. P. G ille tte , N ew Y o rk , 1907. O f m o re g en era l va lu e is a recen t trea tise on the E lem en ts o f M ining, by G eo. J. Y o u n g (N e w Y ork , 1 9 1 6 ), w h ich in clu d es ob se rv a tio n s in d etail on rock breaking, b u t n o t w ith sp e cia l r e feren ce to rock cru sh in g for. roa d -m ak in g p u rp oses, w h ich is th e b ra n ch o f the in d u stry p rob a b ly m ost in ju rio u s to hea lth . OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. .209 inadequate for the purpose of the effective sanitary control of an in dustry which is so obviously injurious to health and life and with regard to which the evidence of a decided predisposition to pul monary tuberculosis is incontrovertible and conclusive. MARBLE WORKERS. Marble workers constitute a distinctive and well-defined group of the stone industry, which it has seemed best to consider separately, though most of the general statistics appertaining to the occupation are included in the stone industry considered as a whole. The American marble industry is centered chiefly in Vermont, where about 60 per cent of all the marble produced in the United States is quarried, and most of it is cut and dressed, sawed, or polished, as the case may be, in the locality where quarried. The Vermont State board of health for some six years (1900 to 1905, inclusive) reported the mortality by occupations, and of the 42 deaths of marble workers from all causes reported in that State only 5 were from pul monary tuberculosis and 5 from other respiratory diseases. The fact that Vermont is an otherwise exceptionally healthful State goes far to mitigate the intrinsic dangers of the occupation resulting from continuous exposure to the inhalation of stone dust. Bertillon, in his observations on morbidity and mortality, refers to stonecutters and workers in marble in Switzerland as being sub ject to a considerable mortality, principally from phthisis, which rapidly increases with age. Under 20 years of age, according to this authority, the mortality is lower than among the mass of the population. From 20 to 29 the death rate equals the average, from 30 to 39 it is twice, from 40 to 49 it is thrice, and from 50 to 59 it is four times the average rate of the Swiss as a nation. He also refers to Italian statistics, which are significant on account of the remark able development of the marble industry at Carrara, stating that stonecutters and pavers average fewer days of sickness than the whole population up to 45 years, but considerably more above that age. In Paris the workers in marble are subject to a high death rate at all ages. A very instructive descriptive account of the machine process as generally employed in the marble industry was included in the report on the stone industry for 1908, by Mr. W. C. Day, of the United States Geological Survey, from which the following extract is made as emphasizing the more or less health-injurious circumstances of employment in marble manufacture: After being sawed the slabs are placed on a 64rubbing bed,” which consists of a circular cast-iron plate, from 8 to 15 feet in diameter, the older forms having a circular opening from 1 foot to 18 inphfrS 106811°— 18— Bull. 231------ 14 210. MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. in diameter in the center. The plate is planed to a smooth surface and is mounted upon running gear so that it may revolve in a hori zontal plane. Fixed arms, usually four in number, are sustained radially about one-fourth of an inch above the plate, either by an upright passing through the central opening or by a framework overhead (in the case of the newer solid forms of bed). The slabs of stone to be polished are placed upon the bed in front of the arms, and the bed is revolved slowly beneath them in such a direction as to hold them firmly against the arms. An abrading material, such as sand, sometimes mixed with “ chilled shot,” or crushed steel, with a constant supply of water, is fed upon the plate. I f necessary, the stones are weighted to increase the friction. From this rubbing bed the slabs are removed to the emery bed, which is similar to the lormer, fine emery being used for abrasion. They are then rubbed down by hand with a fine, evenly grained sandstone, commonly called a “ Scotch hone,” with a sufficient supply of water, and smoothed off with pumice stone and wTater. The final polish is put on by rubbing the slabs upon a buffing bed, similar in form to the rubbing bed, but covered with a thick, specially prepared felt, upon which a small amount of “ putty powder ” (oxide of tin) is fed, to give a high gloss. The hand process consists in grinding on the rubbing bed as before, and then rubbing down by hand successively with Nova Scotia a blue stone,” “ red stone,” “ Scotch hone,” and pumice stone, after which it is glossed with putty powder, or, in case of cheaper “ onyxes ” and common marbles, with a mixture of two parts of oxalic acid and one part of tin oxide. In marble-cutting, as in the stone industry generally, the intro duction of pneumatic tools operated by compressed air has brought in a new and decidedly health-injurious factor, since the amount of very fine dust generated by this process is much greater than when the work is done entirely by hand with the ordinary chisel and mallet. Portable stone-dressing machines have been invented and quite widely adopted, since in part the quality of the work done by these machines is superior to handwork, while the productive capacity is claimed to be from eight to fifteen times as much as when the work is done en tirely by hand. Exhaust air is employed to keep the stone clean at the point of impact of the cutting tool, but the clouds of dust raised by this apparatus are considerable, even though the work is usually done outside of the shed. Aside from the dust generated in either machine or hand cutting, a vast additional amount of dust is proeduced during cleaning-up operations, and while labor organizations have, in part, provided against this risk by special regulations, the generation of much dust is practically unavoidable under the exist ing methods by which the work is carried on. The United States census mortality statistics combine marble and stone cutters, so that it is impossible to separately consider statistic cally the mortality of this employment. As has been previously pointed out in discussing stonecutters generally, the evidence is en OCCUPATIONS 'W ITH EXPOSURE TO MINERAL DUST. 211 tirely conclusive that the mortality from pulmonary tuberculosis and other respiratory diseases among this class is decidedly excessive. It is observed in a discussion of the mortality in the manufacturing and mechanical industries in the Report on Vital Statistics of the Census of 1890 (Part I, p. 144) that “ it will be seen * * * that among marble and stone cutters in the United States the greatest proportion of deaths was due to pulmonary tuberculosis, being much greater than the average proportion due to this cause in this class. The proportion of deaths * * * due to diseases of the respiratory system was [also] greater.” The respective death rates per 1,000 living were 3.15 for pulmonary tuberculosis for marble and stone cutters, against an average of 2.11 among occupied males in manu facturing and mechanical industries generally, and 1.91 for other respiratory diseases for marble and stone cutters against an average of 1.54. The more general aspects of marble dust in relation to health, and with special reference to pulmonary tuberculosis, are considered in the discussion of the several branches of the mineral industries. The available data are unfortunately far from conclusive, but in a general way it would seem that marble dust is distinctly more injurious to health than the dust of limestone and slate. The difficulty of arriv ing at definite conclusions is chiefly due to the defective and even misleading character of the occupation mortality returns in which marble cutters and polishers are combined with other stone workers, and even quarrymen. All of the available statistics, however, em phasize the lamentable fact that the proportionate mortality from pulmonary tuberculosis is exceedingly high among marble cutters and polishers, and there can be no question as regards an increased liability to the disease in consequence of the almost universal use of pneumatic tools for marble and stone cutting purposes. No final conclusions, however, can be arrived at until the entire subject of stone workers’ mortality has been subjected to a thor oughly critical and qualified analysis with a due regard to the chem ical and mechanical properties and especially the degree of fineness of the different varieties of stone dust and their relation to .tubercu losis and nontuberculous lung diseases. SLATE WORKERS. The slate industry is of practical importance in only two States— Pennsylvania and Vermont. Of the aggregate value of the product sold in 1915, $4,958,000, these States are credited with $4,200,000, or 84.7 per cent of the total. The reduction in output during the last few years is attributed to the increasing use of artificial roofing ma terials as well, as to the larger proportion of new buildings with flat roofs. The industry, with observations on the chemical and micro 212 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. scopical analyses of slates and methods of production, has been reported upon in considerable detail by T. Nelson Dale and others of the United States Geological Survey.1 H Y G I E N E OF T H E S L A T E IN D U S T R Y . The hygienic aspects of the slate industry have been briefly de scribed by Arlidge, with special reference, of course, to English con ditions, which, however, do not very materially differ from those common to the centers of slate production in this country. Accord ing to Arlidge, “ The dust examined microscopically appears made up of irregular but sharply angular particles, often serrated,” but he quotes Dr. Roberts to the effect that “ It is wonderful how little the quarrymen complain of any irritation or direct inconvenience from inhaling the dust. They soon become accustomed to their condition in life, and the only two discomforts which they generally seem to suffer are lassitude and thirst,” and these appear to be due to fatigue rather than to any other cause. In the actual processes of slate saw ing and dressing, Arlidge states that, this being done in closed shops, the workmen employed can not escape breathing the copious dust given off. In this country, however, much if not most of the slate splitting is done outdoors so that the dust hazard is materially re duced. Arlidge quotes Roberts in a statement that, taking all the circumstances into consideration, slate workers are subjected to con ditions highly calculated to produce respiratory diseases. M O R T A L IT Y OF S L A T E -P E N C IL M A K E R S . The most thoroughly scientific study of the sanitary aspects of the industry in Germany has been made by Sommerfeid, chiefly, however, with reference to the manufacture of slate pencils and school slates. The investigation emphasizes the unsatisfactory workshop conditions common to the industry and more or less subject to material im provements. When carried on indoors the work is considered decidedly injurious to health, particularly because of the unsatis factory economic conditions of the laborers. Tuberculosis is of fre quent occurrence, but in all probability the underlying causes are social and economic rather than directly attributable to the risk of slate-dust inhalation. Out of 260 deaths from all causes among slatepencil makers in two typical communities, 167, or 64.2 per cent, were attributed to pulmonary tuberculosis and 25 to other dis eases of the respiratory organs. At certain ages the disease attained extraordinary proportions, reaching 80 per cent of the mortality from all causes at 40 to 45. Comparing the proportionate mortality with certain other occupations in the same district, it is shown that among woodworkers 50.6 per cent died of pulmonary tuberculosis, and 1 “ S late in the U n ited S ta te s,” b y T . N elson D ale a n d o th e rs, U. S. G e o lo g ica l S u rv ey, B u lletin N o. 586, W a sh in g ton , 1.914. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 213 among all other occupations, excluding slate Avorkers, the proportion was 45.9 per cent. The percentages for all occupations indicate that the general health of the district was exceptionally bad and that the predisposing causes of the high mortality from pulmonary tubercu losis were induced more by social and economic conditions than by the liability to slate-dust inhalation. The average age at death for slate-pencil makers Avas 45.7 years and for woodworkers 55.2 years. But the former industry, in all probability, employs a larger propor tion of young persons. An analysis of a slate workers’ sick fund ex perience, including, however, only 189 employees, shows that nearly one-third had commenced to work at the industry below the age of 14, and some had been at work from the seventh year of life. Under such conditions, irrespective of the dust danger, it would naturally be expected that the liability to pulmonary tuberculosis would be exceptionally high. Upon physical examination it was found that 34 per cent were of an inferior constitution and 34.4 per cent exhibited some degree of lung impairment. The results of this investigation can not be considered conclusive or applicable to the American slate industry, which is carried on under decidedly better social economic conditions. The investigation by Sommerfeld of this particular trade is, however, one of exceptional importance and suggestive of the methods to be followed in corresponding investigations in this country.1 E N G L IS H S A N IT A R Y IN V E S T IG A T IO N S . The slate industry was quite carefully inquired into in 1907 by the English Departmental Committee on Industrial Diseases. Quite a number of witnesses with practical experience, both medical and otherwise, were examined, but the evidence obtained was far from conclusive. In the main, however, the experience seemed to prove that continuous and considerable inhalation of slate dust, according to the work folloAved, was distinctly injurious and a causative factor in the development of pulmonary tuberculosis. The evidence seemed to show in many cases a preceding fibrosis, often of long duration, suggestive of a considerable degree of similarity in the mechanical properties of slate and quartz dust. The opinion seemed to prevail that working in the quarries was distinctly less injurious than work ing in the mills, where, of course, the dust hazard would be much greater. It was made quite clear, however, that pure slate dust was xarely met with, but that as a rule the dust inhaled included a con siderable proportion of minute particles of adherent quartz. An exceptionally interesting and valuable post-mortem report was pre 1 Ila n d b u ch der G ew erb e-K ra n k h eiten , p. 225 et seq. by T h e o d o r S o m m erfeld , M. D ., B erlin , 1898, 214 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. sented by Dr. Robert Owen, who, quoting from his notes, stated as follows: Report of the post-mortem R. R., 48 years, slate quarrier, working in a quarry for 25 years. Permission only was given to open and examine the chest. The body was that of a man over 6 feet, very emaciated, and looked 10 years older than his age. Frequent attacks of bronchitis during the last 20 years. Three years before he died lie began to lose flesh and was short of breath. Bronchitis, followed by a good deal of expectoration, which was muco purulent; when his complaint was far advanced he was told that he was suffering from tubercular consumption, but when his sputum was examined, which was done repeatedly, no tubercle bacilli were present. Then the thought occurred to us that the patient was suffering from nontubercular disease of the lung—that is, fibrosis. He became weaker; Bright’s disease followed, and he soon died. That is the history of the case. On examination the right lung was adherent to the chest wall. The adhesions were so thick and firm that they had to be cut with a knife. The pleura was adherent. The lung did not collapse when removed from the body. The left lung was not adherent to the chest wall. In the right lung the pleura was very thick. The bronchi of both lungs were greatly thickened and surrounded by dense bands of fibrous tissue. Both lungs were diminished in size; they were hard and dense, almost like cartilage. Both lungs were somewhat of a buff color, but there was no distinct pigment observed. The bronchi contained much mucus and pus. On microscopical examination of the lung it was found to be a real specimen of fibrotic Jung tissue. This is partly a report I had from Glasgow, where I sent a tissue to be examined. The walls of the air cells were thick ened; also the walls of the minute arteries were in the same condi tion. The bronchial glands were enlarged (that is my own observa tion) and of a peculiar color. They were nothing like the glands you find in a coal miner. In this case no tubercular cavities were' found; there w^as no breaking down of the lung. The second case is not so important, as tubercular disease supervened, but the general condition of the lung was the same. I made no microscopical exami•nation in that case. It would seem from this examination that the conditions observed were quite typical of fibroid phthisis, more or less directly related to slate dust; but in the case of a slate quarryman the physical condi tion of the lungs would, of course, be less seriously impaired than in the case of a mill worker exposed more continuously and more con siderably to the fine dust inhaled. In the mill also the dust particles would be much more minute than in the quarry and the favorable outdoor conditions would be absent. SO C IA L A N D S A N I T A R Y C O N D ITIO N S IN T H E A M E R IC A N S L A T E IN D U S T R Y . In the United States, particularly in the Bangor slate district of Pennsylvania, somewhat similar conditions have been observed. The econcmic condition of the slate workers in this country is, how ever, so much superior to that of slate workers abroad that this OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 215 factor by itself unquestionably operates distinctly in the direction of a lower death rate from pulmonary tuberculosis. The hours of labor are reasonable, the wages are fairly high^ the proportion of home owners is relatively large, and the moral conditions, particularly as regards temperance, are distinctly good Slate work is frequently a family trade and is, as a rule, commenced rather early in life. Boys are often employed on scliool-slate work, which by itself is one of the obviously unhealthy branches of the industry. The specific occu pations are quite numerous, but most of the employed are returned as “ slaters,” millmen, hole men (quarry drillers), and quarrymen. Employments such as slate cutters and slate dressers are more gen erally covered by the term “ slaters ” or “ millmen.” Work at the quarries, which is all by the open or pit method, is considered danger ous, but not distinctly injurious, to health. The dust exposure is apparently not serious, but the ladder-climbing in and out of the quarry involves occasionally a heavy physical strain. Work at the channeling machines is also relatively free from dust, and no evidence is available to show that either quarrymen or those occupied in related occupations suffer above the average from pulmonary tuberculosis. After the slate has been quarried in good-sized blocks it is hoisted out of the pit to the banks where the shanties or huts of the “ split ters ” or “ dressers” are located in large numbers. These are among the principal occupations in connection with slate dressing, and, while there is a reasonable amount of dust exposure, the fact that most of the work is done out of doors reduces the liability to dust inhalation considerably. In connection with the work of the blocker, who performs the first operation which somewhat resembles the work of paving-stone cutting, the work is all done in the open air, and whatever dust is created by the process is rather heavy and falls readily to the ground before it has a chance to rise. The blocks are first wetted down by a swab or mop, which is essential for good cleavage, and which also tends to re duce the dust menace. The work is not considered seriously to predis pose to pulmonary tuberculosis. The men observed in this and related occupations in the slate industry present a favorable, robust, and healthy appearance. From the block maker or bank men the block or slab of slate goes to the splitter, who usually sits on a cushion or wooden seat on the ground, his legs being covered with rugs or an old blanket to guard against injury to the slabs of slate and- to protect himself from cold and dampness. This constrained position must in time have some effect upon health, particularly as regards circu latory and digestive disturbances. The dust at this stage of the opera tion is not very serious, except that on account of the splitter’s peculiar position near to the ground it is more readily inhaled. The dust danger, although present in this employment, is not considered 216 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. sufficient to produce an increased liability to pulmonary tuberculosis. The next operation is that of the dresser, who by means of a cutting machine trims the edge of the slate to the required size. The machine is operated by foot power, and the steady up-and-down movement of the right leg may in time have some health-injurious results, which, however, have not become a matter of official record. The power required to run the machine is quite considerable. Much dust is at times created by this process, according to the character of the slate. As a rule, however, the dust is heavy and falls at once to the ground. Most of the men in this employment have been at work for many years, and they give the personal impression of a healthy, robust, sober type. The very fine dust is not considered excessive, and no evidence is available to prove an abnormal frequency of pulmonary tuberculosis among this class of employees. O CC U PA TIO N A L H A Z A R D S I N S L A T E M IL L S . The remaining occupations are generally comprehended under the term “ millwork,” and it is in these that most of the dust injury occurs. Millmen and others employed in this group of occupations of the slate industry constitute about one-fifth of the whole. The work includes the making of marbleized slate, which involves an addi tional dust problem. A brief description is difficult, but the exist ing situation in the Bangor and similar slate districts may be summed up in the statement that the dust menace is fairly well recog nized and that no material conflict of opinion prevails concerning the relation of certain mill processes to pulmonary tuberculosis. How far it would be possible to control the dust problem in this branch of the industry has not been ascertained by qualified inquiry. The question was raised in the investigation made by the Departmental Committee on Industrial Diseases and the conclusion arrived at was essentially that effective ventilation would be quite difficult, but that more spraying might be employed to advantage. Concerning the control of the dust menace in the finishing processes in the manufacture of wTriting-slates it is stated in the report of the chief inspector of factories and workshops for 1910 that while a con siderable amount of dust is given off in this process, a certain amount or proportion of the same can not be exhausted by ventilating devices such as hoods and exhaust fans, on account of the weight of the dust, which by gravity falls to the ground. Mr. J. L. Edwards, of Wrex ham, suggested a perforated worktable with a water trough under neath, which in actual practice was found to give good results. It is regrettable that the available information regarding this important branch of the mineral industry should be so limited and, partly at least, inconclusive. The decline in production during the last few years no doubt accounts, in a measure, for this neglect, OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 217 which is so much the more regrettable since, aside from humani tarian and economic considerations, the scientific aspects of the slatedust problem are of special importance. There are as yet 110 trustworthy official vital statistics for this country, although an analysis of the mortality in slate-producing centers would unques tionably yield useful results. In the subsequent discussion of the mineral industries slate workers are again briefly referred to, chiefly with reference to slate quarrying. In a general way the data sustain the conclusion that the inhalation of slate dust is relative!}" less serious in its effects on the lungs than the inhalation of more irritating forms of mineral and metallic dust. In the industrial insurance experience of the Prudential Co, during the period 1907 to 1914 there were 93 deaths of slaters, of vvhich 12, or 12.9 per cent, were from, pulmonary tuberculosis. In addition, there were 10 deaths from nontuberculous respiratory dis eases, equivalent to 10.8 per cent of the mortality from all causes. There were also 7 deaths of slate makers, with 2 deaths from pul monary tuberculosis. The statistical evidence, although entirely too limited for final conclusions, apparently sustains the' point of view that exposure to slate dust is less serious in its effects than continued and considerable exposure to more irritating forms of mineral and metallic dust. LIME WORKERS. The lime and cement industries are so closely related to each other that for practical purposes it has been found difficult to give separate consideration to the mortality returns for each group of these em ployments, which have therefore been combined to provide a more substantial statistical basis in support of the conclusions ad vanced. Cement and lime, of course, have different properties, de pendent upon their chemical composition and the methods of manu facture, and are generally classified either according to the chemical reaction involved in setting or according to the conditions under which they will harden. Chemically pure lime is the oxide of calcium, which, as shown in the description of the cement industry, constitutes the major portion of the cement product. Lime is a strong caustic alkali which unites readily with many substances and is readily soluble in wTater at ordinary temperature. On this account it is claimed that the inhalation of lime dust is noninjurious, and some authorities go so far as to ascribe beneficial results to lime-dust ex posure as a precautionary measure against a risk of tuberculo sis.1 There are, of course, numerous varieties of limestone which may vary in their effects and unquestionably do so where there is a considerable degree of intermixture with shell, chalky, cherty, 1 “ T h e Influen ce o f C a lciu m ,” F . R . S. E ., E d in b u rgh , 1917. A p p e n d ix II, The C an cer P ro b le m , by C. E . G reen, 218 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. or other substances. The general processes of manufacture, with out reference, however, to sanitary conditions or dust exposure, have been described in a report of the Missouri Bureau of Geology and Mines on lime and cement resources (Jefferson City, Mo., 1907) and in part 2 of the Mineral Resources of the United States for the calendar year 1913, by Burchard and Emley, on “ The sources, manufacture, and use of lime.” The annual reports of the United States Geological Survey emphasize the magnitude of the lime industry, but no satisfactory statistics are available con cerning the health of this class of employees with special reference to tuberculosis other than the data elsewhere included in the discus sion. Hay hurst in his report on health hazards in Ohio reports upon conditions observed in seven establishments employing, how ever, only 188 persons.. A brief reference is made to dust exposure in the drawing or unloading of the kilns in connection with which no protective devices were employed. As regards grinding and packing, it is said that this is done in all plants but is practically a side practice or process of lime manufacture. It is explained that the lumps of lime- after cooling on the floor space are taken to the mill and ground to powder and then sacked by machinery. The health hazard is referred to as “ very bad.” The air is dense on account of the dust in some places, and in only one was there an efficient suction system, in connection with which it is pointed out “ the saving of lime collected paid a very good interest on the money invested in the blower system.” Skin irritation, especially in summer, is re ferred to as frequent, and eye inflammations were complained of, but there is no mention of a specific liability to pulmonary tuberculosis. The idea seemed to prevail that the inhalation of lime dust was bene ficial and in some communities medical evidence to this effect was quoted. Some of the men observed, however, were decidedly pale and a few were short of breath, an impairment acquired since enter ing the plant. L I M E D U ST AN D P U L M O N A R Y T U B E R C U L O S IS . The relation of lime-dust inhalation and pulmonary tuberculosis was investigated by Reckzeh, who, according to a brief statement in the Medical Record for December 5, 1903, concluded that— The statistics in lime-producing districts show that pulmonary tuberculosis is rare, and that sometimes when present its course is favorably affected. Various authors ascribe this beneficial effect to different features attending the occupation of lime burning. Such are, an effect of the inhaled lime dust in facilitating calcification of the suppurating foci, the dryness of the inhaled air, and the deeper respiration it makes necessary, the warmth of the inspired air which contains no tubercle bacilli, and the more active metabolism it causes. In order to determine the effect of the lime dust suspended in the air the author caused eight tuberculous patients to inhale air charged OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 219 with the dust by striking suspended bags filled with powdered lime. At first the inhalations were carried on for five minutes daily, but the time and frequency were gradually increased. The results were with out encouragement, no improvement in the pulmonary condition was noted, while there were marked undesirable secondary effects, such as headache, loss of appetite, and nausea. R E L A T I V E IN F R E C lU E N C Y OF R E S P IR A T O R Y D IS E A S E S . Selkirk subsequently investigated the same problem by personal inquiry among lime workers with special reference to the prevailing opinion that as a class they were exceptionally free from bronchitis and pulmonary tuberculosis. According to the Journal of the Amer ican Medical Association, for December 12, 1908— He was unable to find an instance of phthisis among them, nor could he learn on inquiry ot any worker in limekilns having died from tuberculosis. He asks whether those who inhale and swallow much lime are abnormally free from tuberculosis of the lungs. He discusses what is known of the therapeutics of calcium salts, and says it appears that the continued absorption of calcium from the lungs and intestines might maintain an abnormally high percentage of it in the blood. He suggests that the w7orkingman predisposed to tuber culosis might turn his attention to lime and cement wrorking as an occupation, and even hints at the organization of lime works as a curative tuberculosis, colony. A rapid increase of weight is com monly observed in new workers at the Warren Cement Works, at Hartlepool. G E N E R A L C O N C LU SIO N S. The same authority is also quoted, but in another statement, that he found the health of workers in limekilns above the average, and that there seemed to be far less than the normal amount of pulmonary tuberculosis and bronchitis. He therefore concluded that— It- is believed that the lime inhaled is dissolved by the carbonic acid in the lungs and absorbed. Calcium in the intestinal canal pre vents fermentation. Lime-dust particles may, however, be deposited in the lungs. It may be that continual absorption of calcium from the lungs and intestine may maintain an abnormally high percentage of it in the blood. The author asks. Does this occur in the lime worker, and is it preventive of tuberculosis in him? Or is his free dom due to the external lime dust being unfavorable to the life and growth of the bacillus outside of the body? It seems curious to sug gest an atmosphere of dust for the treatment of tuberculosis; it wTould have been as curious some generations ago to have suggested fresh air. At the least, have wTe not in this lime and cement working an occupation which we may recommend to the workingman predis posed to tuberculosis or already in the early stages of it? Or could the neighborhood of a limekiln be organized as a curative tubercu losis colony? These observations arrived at by conservative medical investigators seem to sustain the generally favorable conclusions concerning the relative noninjuriousness of lime dust with special reference to pul 220 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. monary tuberculosis. As a technical problem the lime industry offers exceptional opportunities for the- ascertainment of urgently required information concerning the differential effects of mineral dusts in their relation to health and longevity and possibly even concerning the therapeutic value of lime dust as intimated by the rather limited investigations of Reckzeh and Selkirk. An excellent descriptive account of 44Lime: Its properties and uses” has been published as a circular of the United States Bureau of Standards of the Department of Commerce and Labor (Wash ington, 1911). This account precisely emphasizes all the essential preliminary scientific considerations necessary for a thorough under standing of the underlying conditions which concern the health of workers in occupations, trades, or industries more or less injurious to health and life. The account includes a description of the method of lime manufacture, definition, and classification, followed by a description of general properties and an extended account of the uses of lime and the various kinds of limestone, lime, and hydrated lime in the chemical industries, including natural cement, sand-lime brick, glass, bleaching powder, fertilizer, etc. The classification of limestones according to their physical properties, as to whether hard or soft, porous or dense, coarsely crystalline or fine grained, implies probably widely differential results in health-injurious consequences, proportionate, of course, to the continuity and amount of dust ex posure. Limestone, when metamorphosed—that is, w7hen recrystal lized after deposition through the agency of heat—is known as “ marble,” wThich by inference suggests that marble dust in all prob ability is not as serious in its consequences as granite dust and possibly sandstone dust, both of which contain a larger proportion of pure silica. Some exceptionally interesting observations on dust exposure in the working of oolitic limestone on the Isle of Portland, England, contributed by Dr. Howard to the annual report of the chief in spector of factories and workshops (1913), include statistical observa tions for the 13-year period ending with 1912. The mortality from phthisis per 1,000 living was, among general laborers, 1.9; among stone quarriers, 1.5; among stone masons, 1.4; and among all other males, 1.1. Corresponding statistics are those of Barwise for Derby shire, elsewhere referred to, according to which the death rate of persons employed in gritstone quarries was 13.7, against 1.2 for lime stone workers. A brief reference is made in the discussion to an ad dress by Dr. Collis on the “ Effects of dust in producing diseases of the lungs,” read at the Seventeenth International Congress of Medicine held in London in August, 1913, in which after the effects of dust on those employed in various industries had been cited, the following conclusions were advanced: OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 221 1. Inhalation of all forms of dust is accompanied by diminished power of chest expansion. 2. Diminished power of chest expansion so produced is accom panied by high blood pressure. 3. Animal dusts, apart from the presence in them of pathogenic microorganisms, when inhaled, produce less effects than do vege table and mineral dusts. 4. Vegetable dusts, when inhaled, tend to produce a type of chest affection best described as asthmatic. 5. Of mineral dusts, those composed of calcium salts are least injurious. 6. Inhalation of mineral dusts which do not contain free silica tends to produce irritation of the upper air passages and respiratory diseases other than phthisis. 7. Inhalation of mineral dusts which contain free silica is associ ated with an excess of phthisis, an excess which bears a direct rela tion to the amount of free silica present. 8. In general, dusts appear to be more injurious as their chemical composition differs from that of the human body or from the ele ments of which the body is normally composed. Of the foregoing observations the conclusion that of mineral dusts those composed of calcium salts are least injurious is, of course, of special significance, in view of the preceding discussion regarding the health of lime workers, which it is regrettable could not be ampli fied by other American or foreign vital statistics of a sufficiently trustworthy character. PLASTERERS. The building trades are all more or less exposed to the inhalation of mineral dust, the injurious effects of which are probably most severe in the case of plasterers, masons, and allied occupations. This group of occupations is not clearly defined, since many plasterers are also masons, or bricklayers, while others are whitewashers or paper hangers. The English vital statistics combine plasterers, white washers, and paper hangers. E A R L Y O B SE R V A T IO N S ON T H E H E A L T H OF P L A S T E R E R S . The health conditions in this trade wrere commented upon by Ramazzini, who, in the quaint language of the day, states that “ Lime afid plaster are likewise offensive to those who burn them or handle them, or sell them,” and he continues: “ I have frequentty observed that those who boil, prepare, grind, sift, or sell it, do usually labor under a difficulty of breathing.” As a safeguard, Ramazzini points out that: “ Though such workmen have a cover for their mouth, they can not avoid receiving the flying particles at the mouth and nose, 222 MORTALITY FROM RESPIRATORY DISEASES I3ST DUSTY TRADES. upon which these particles enter the passages of respiration and mix with the lymph, rise up in hard, chalky concretions, or by daubing the winding passages of the lungs intercept freedom of breath. I . found that such as continued in this business did die asthmatic and cachetik.” He refers also to a still earlier author, Morton, who connected the. inhalation of the dust with pulmonary tuber culosis. He concludes his observations with the statement that: “ Care must be taken to observe the caution laid down above, with in tent to guard the mouth as much as possible from receiving the offensive particles.” All this was written more than 200 years ago ! Thackrah, writing in 1832, took a more favorable view of the employment, holding that bricklayers and. their laborers, while par ticularly exposed to lime dust, suffered from diseases of the eye and cutaneous eruptions, but not from internal disease, and he quotes an adage common to the wTorkmen in the trade of the period, that “ bricklayers and plasterers’ laborers, like asses, never die.” Re garding plasterers and whitewashes, who are also exposed to lime dust, he states: “ They suffer from no sensible injury,” and that “ they are more pallid and less robust than bricklayers.” Thackrah, however, did not support his observations with trustworthy data. E N G L IS H M O R T A L IT Y D A TA . The most recent English mortality statistics of plasterers and paper hangers are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Report of the RegistrarGeneral, in part as follows: Between the ages of 35 and 65 years the death rate in this industry exceeds the standard for occupied and retired males, while at ages outside of these limits the rates are below it. In the main working period of life the comparative mortality figure is 1,018, or within 1 per cent of the standard. The mortality from alcoholism and liver disease, from phthisis, from respiratory diseases, and from cancer slightly exceeds the standard, and except that these workers appear to suffer but little from influenza, the figures for other diseases agree closely with the average. The English occupation mortality statistics for plasterers are somewhat impaired in value by the fact that paper hangers and whitewashers are combined with this occupation, but the statistics may safely be accepted as indicating with approximate accuracy a higher disease liability of men in this employment to pulmonary tuberculosis and respiratory diseases. In Table 84 the mortality from all causes among men in this group is compared with that of occupied males generally, and the result is rather suggestive of conditions in this trade more or less unfavorable to life and health. The excess in the general mortality occurs at ages 35 to 64. when the death rate of plasterers from all causes exceeds the mor OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST1. 223 tality of occupied males generally by from 1.30 to 1.52 per 1.000. The mortality of the group is, however, below the average at ages under 35 and at 65 years or over. T a b l e 8 4 .— M O R T A L IT Y FROM A L L CAUSES AM ONG P L A ST E R E R S, P A P E R H A N G E R S, A N D W H I T E W A S H E R S , C O M P A R E D W I T H T H A T O F A L L O C C U P IE D M A L E S , I N E N G L A N D A N D W A L E S , 1900 T O 1902, B Y A G E G R O U P S . [Source: Part I I , S up p lem ent to the S ix ty -fifth A n n u al R ep ort of the R egistrar-General of B irth s, D e a th s, an d Marriages in E n g la n d an d W a le s.] D e a th rate for plasterers, paper hangers, and whitew ashers. D e a th rate per 1,000 for all occu pied males. A g e at death. 15 20 25 35 45 56 65 to 19 ye ars.................................................. .. ...................................... to 24 ye ars............................................................................................ to 34 y ea rs............................................................................................ to 44 y e a rs............................................................................................ to 54 y e a rs............................................................................................ to 64 years............................................................................................ years and o v e r ................................................................................... 2.44 4. 41 6.01 10.22 17.73 31.01 88.39 Greater ( + ) or less ( — ) Per cent of than rate rate for all for all oc occupied cupied m ales. males. R a te per 1,000. 1.52 3.44 4.07 11.52 19.18 32.53 72.18 - 0 .9 2 .97 - 1.94 + 1.30 + 1.45 + 1.52 -1 6 .2 1 62 78 68 113 108 105 82 The preceding table requires no further comment, except that it confirms the view that the health-injurious effects of this employment are not so pronounced as in many other dusty trades, particularly such occupations as stonecutting, pottery manufacture, and glass blowing. In Table 85 the mortality of plasterers, paper hangers, and whitewashes from pulmonary tuberculosis is compared with the normal mortality of occupied males from this disease by divisional periods of life. T able 8 5 . — M O R T A L I T Y F R O M PAPER HANGERS, AND PULM ONARY T U B E R C U L O S IS W H IT E W A S H E R S , C O M P A R E D P IE D M A L E S , IN E N G L A N D AND AM ONG W IT H THAT W A L E S , 1900 T O 1902, B Y A G E PLASTERER S, OF A L L OCCU GROUPS. [Source: P art I I , S up p lem ent to th e S ix ty -fifth A n n u a l R ep ort of th e R egistrar-G eneral of B irth s, D eaths an d Marriages in E n g la n d a n d W a le s .] D ea th rate for plasterers, pa^er h a n g e rs,a n d w hitew ashers. A ge at d eath . 15to 19 7 e a rs............................................................................................ ‘'O to 21 yea rs............................................................................................. 21 to 34 y e a rs............................................................................................. 3oto 44 y ea rs. . . .................................................................................. 45 to 54vears............................................................................................. 55to 64 v e a rs............................................................................................ £5years and o v e r.................................................................................... D eath rate per 1,000 for all occu pied m ales. R a te per 1,000. ! Greater ( - f ) or less ( — ) j Per cent of rate for all th a n rate occupied for all oc cupied m ales. m ales. 0.54 1.55 2.03 2. 74 3.04 2.16 0.41 1.06 1.22 3.98 3.62 4.01 —0.13 — .^9 — .81 +1. 24 + . 58 + 1. 85 76 6S 60 15 119 1*8 1.11 1.53 + 138 .4 2 224 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. R E C E N T A M E R IC A N IN V E S T IG A T IO N S . The most recent investigation into the existing health conditions is by Balentine C. Baker, M. D., published in the Journal of the Ameri can Medical Association for May 6, 1916. The results of this investi gation, made in connection with the Cornell University Medical College, are, in part, stated as follows: In the work of the plasterer there is exposure to dust, cold, and dampness. The source of the dust is from the plaster, which is usually composed of lime, sand, and hair moistened. Anyone at all familiar with the work of a plasterer knows what dust there is when the dried plaster is crumbled loose by walking, moving of objects, and sweeping. The drafts of air through the open doors and win dows fill the atmosphere with dust, and this the worker has to breathe. There is some controversy among investigators as to the danger of lime to workers. Selkirk was unable to find any instance of phthisis among them,, nor could he learn of any worker in lime kilns having died of tuberculosis. The special investigation included 36 cases of plasterers under treatment as patients at the hospital referred to, and of this number 17, or 47.2 per cent, were over 40 years of age. It is said in con clusion that— The respiratory tract of the plasterers is chiefly affected as in the preceding trades, there being 13 patients in this class. Seven patients had chronic and 6 acute respiratory disease. Three patients had pulmonary tuberculosis, 3 chronic bronchitis, 2 emphysema, 2 acute bronchitis, 3 dry pleurisy, and 1 acute pharyngitis. These observations are suggestive of nontuberculous respiratory rather than of tuberculous affections, but the number of cases under observation is too limited for a conclusive generalization. M E T H O D S OF P L A S T E R OF P A R I S M A N U F A C T U R E . A clear distinction, of course, must be drawn for practical purposes between the manufacture of plaster of Paris and the occu pation of plasterer. The former includes the crushing of raw ma terial, employment at rotary driers, and the so-called “ dust room,” with supplementary methods of bowl crushing .to a condition of minute fineness on buhrstones, and finally calcining in kettles with the terminal processes of handling through hoppers, bins, and conveyers. No conclusive investigations have been made with regard to the specific dust exposure in these processes and their relation to health, but W. Gilman Thompson writes of the occupation of masons and plasterers at some length, including concrete mixers, wTho, of course, are exposed to fundamentally different conditions. He points out that men in this group of employments inhale much dust of tile, brick, plas ter of Paris, gypsum, and cement, and that they are subject from these OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 225 combined conditions “ to catarrhs of the respiratory passages, and such diseases as asthma, bronchitis, rhinitis, and atelectasis are fre quently met with among them.” There would seem to be much simi larity in the dust exposure of these occupations to that observed in the case of lime and cement workers. The exposure to dust of this character is most serious in connection with house-wrecking opera tions, where heavy clouds of masonry and plaster dust are generated and inhaled in connection with particularly laborious work. Thomp son suggests, therefore, that in some cases, as in the tearing down of old plaster in confined spaces, in tunnels, etc., where sprinkling can not be resorted to, respirators may be used to advantage.1 M O R T A L IT Y OF P L A S T E R E R S — U N IT E D S T A T E S R E G I S T R A T IO N A R E A . The mortality of plasterers has been reported upon for the years 1908 and 1909 by the Division of Vital Statistics of the United States Census Bureau, but for the year 1908 the group includes whitewashers, who, of course, are engaged in a closely allied employment. According to the census report, out of 9TT deaths of plasterers from all causes, 163, or 16.7 per cent, were from pulmonary tuberculosis. The details of the mortality by divisional periods of life are shown in Table 86. 8 6 . — P R O P O R T IO N A T E M O R T A L IT Y OF P L A S T E R E R S FR O M TU B E R C U L O SIS , U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1908 A N D GR O U PS. T a b le PU LM ONARY 1909, B Y AGE Deaths from pulm onary tuberculosis. Age at death. Deaths from all causes. Number. P ercent of deaths from all causes. 15 to 24 years.................................................................................................. 25 to 34 years.................................................................................................. 35 to 44 years.................................................................................................. 45 to 54 years.................................................................................................. 55 to 64 years.................................................................................................. 65 years and over . , ....................................................................................... Age unknown ................................................................................... 48 108 177 189 205 249 1 12 34 61 31 16 9 25.0 31.5 34.5 16.4 7.8 3.6 Total, 15 years and o v er.................................................................... 977 163 16.7 1 T he d u st exp osu re in the m aking o f p la ster ca sts m ust he quite con sid era b le on a cco u n t o f th e close co n ta c t w ith the m ateria l d u rin g e ve ry o p e ra tio n fro m the m ak in g o f the m old s to the finished p roduct. E xp osu re is p ro b a b ly m ost serious in the scra p in g d ep a rtm en t, w h ich is sh ow n by illu stra tio n m a d e scrip tiv e a cco u n t on “ T h e m ak in g o f ca sts in gela tin m old s,” by W . F ra n k M cC lure, pub lish ed in the S cien tific A m erican fo r June 20, 1908. T h e w ea rin g o f fa ce p ro te cto rs is n ecessary in th is d e p a rt m ent. T h e o b je c t o f the s cra p in g is the rem ova l o f the m old seam an d o th e r u n av oid a b le d efects. M ost o f the dust exposure, how ever, resu lts fro m the sca tte re d m aterial w h ich d ries and is subsequently b low n a bou t. H ow fa r th is em p loy m en t is as a m atter o f fa c t rea lly h e a lth -in ju rio u s and a p red isp os in g cause t o re s p ira to ry diseases, w h e th e r p u l m on a ry o r oth erw ise, has n o t been a scerta in ed . 106811°— 18— B ull. 231-------15 2 26 M O R TAU TY PROM RESPIRATORY DISEASES IN DUSTY TRADES. 8 7 .—P R O P O R T IO N A T E M O R T A L IT Y OF P L A S T E R E R S F R O M N O N T U B E R C U LO U S R E S P I R A T O R Y D ISE A SE S, U N IT E D ST A T E S R E G IS T R A T IO N A R E A , 1908 A N D 1909. T able Deaths from nontuber culous respiratory dis eases. Cause of death. Number. Per cent of deaths from all causes. I) r ^nchitis_________________ _______ ________________________________________ ____ Pneumonia.................................................................... ................................... ............... Other nontuberculous respiratory diseases................................................................... 3 11 79 11 0.3 1.1 8.1 1.1 T o t a l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... . 104 10.6 The proportion of deaths from pulmonary tuberculosis in this occupation is fairly high, but not distinctly excessive, excepting at ages 35 to 44, when the proportion is 34.5 per cent for plasterers, against 24 per cent for all occupied males, according to data derived from the same official sources. Aside from the mortality from pul monary tuberculosis, the mortality from nontuberculous respiratory diseases was also about normal, having been 10.6 per cent for plas terers, against 10 per cent for all occupations, the slightly higher proportionate mortality from nontuberculous respiratory diseases being chiefly attributable to bronchitis; but the numbers under con sideration are hardly sufficient for entirely definite conclusions. M O R T A L IT Y O F P L A S T E R E R S — IN D U S T R I A L IN S U R A N C E E X P E R I E N C E . In this connection the statistics of the Prudential Insurance Co. are of additional interest and value, in that they include 1,371 deaths from all causes, of which 300, or 21.9 per cent, were from pulmonary tuberculosis. T able 8 8 .—P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O SIS A M ON G P L A S T E R E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, COM P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D S TA T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G ROU PS. Deaths of plasterers, 1897 to 1914, from— Per cent of-deaths from pulm onary tubercu losis among— Age at death. A ll causes. Males in Pulmonary tubercu Plasterers. registration a re a ,1900 losis. to 1913. 15 to 24 years............................................................................ to 34 vears............................................................................. 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over..................................................................... 58 163 225 281 330 314 20 71 91 66 39 13 34.5 43.6 40.4 23.5 11.8 4.1 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.............................................. 1,371 300 21.9 13.9 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 227 According to Table 88 the proportionate mortality from pulmo nary tuberculosis is excessive among plasterers at every divisional period of life, but particularly so at ages 25 to 34, when out of 163 deaths from all causes, 71, or 43.6 per cent are from pulmonary tuberculosis, against 30.5 per cent in the male mortality of the regis tration area. How far this excess in the mortality from pulmonary tuberculosis is the direct result of dust inhalation or due to contrib utory social and economic causes can not be stated at the present time. Nor is it possible accurately to differentiate plasterers from men employed in the manufacture of plaster of Paris and related oc cupations, but it may be said in conclusion that such investigations as have been made of existing conditions at plaster works prove that there is abundant room for material improvement, and that in most of the plants only the crudest and most unsatisfactory appliances are employed for the prevention of dust and its inhalation by the men employed. In this connection a brief reference may be made to an excep tionally valuable tabulation of industries with exposure to inorganic dusts in relation to the mortality from pulmonary tuberculosis and the presence of free silica in the dust, in the annual report of the chief inspector of factories and workshops of Great Britain, for 1912 (p. 216). As regards plaster of Paris, it is said that the composition of the dust is chiefly that of calcium sulphate and that free silica is not present; also that the mortality from pulmonary tuberculosis is not above the normal. A similar reference is made to cement, as regards the composition of which it is said that the dust consists of silicates of magnesium, calcium, and aluminum; that the percentage of free silica is less than 1 per cent (as compared, for illustration, with 30 per cent in granite dust and 75 per cent in quartz dust of the tin mines of Cornwall); and, finally, that the mortality from pulmonary tuberculosis is “ not above normal.” Attention is directed to the fact that the connection between silica dust and phthisis is now well established, and that it has led to the adoption of preventive measures to suppress this dust when generated in the process of sand-blasting glass for engraving purposes and in the production of finely powdered flint and quartz. Free silica, however, as brought out in this investigation, is not present in the dust of plaster of Paris which on that account chiefly is relatively noninjurious as re gards predisposition to pulmonary tuberculosis. The most recent ob servations, in Kober and Hanson’s Diseases of Occupation and Voca tional Hygiene, regarding plasterers, are regrettably inadequate and inconclusive. CEM ENT WORKERS. The health-injurious conditions of cement-making processes are quite well understood, being not only the dust, but also the noxious 228 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. vapors which arise through the process of burning. The vapors are probably more a matter of discomfort than injurious, but the subject attracted sufficient attention to suggest an investigation by the Royal Commission on Noxious Vapors in 1878.1 As a result of the vapors and the dust generated during the processes, cement works, as a rule, are now located outside of large cities. G A S, F U M E , A N D D U ST E X P O S U R E I N C E M E N T -M A K IN G P R O C E S S E S . The health conditions in American- cement works have never been fully investigated, but it appears to be the consensus of opinion that the effects are not as serious as assumed upon the facts of a casual in spection.2 Fatal accidents have occurred as the result of asphyxiation by carbon-monoxide gas, but such cases are very rare. Cases of gassing, so called, which do not terminate fatally, are said to be com paratively common. Arlidge considered the employment of cement making at some length, pointing out that the workmen are exposed to dust in an intense form, but experience would seem to prove that the effect on health is not so injurious as expected. He states that the raw materials of cement are clay with flint and lime, and he briefly de scribes the process of manufacture as follows: After the materials have been well mixed and ground together in a sort of mortar mill to the consistency of liquid mud, the next busi ness is to drive off the water by heat, and then to subject the dried substance in tins to a still higher temperature. Later all the cement is withdrawn and then ground between rollers to the requisite fine ness. The primary mixing and grinding, being done with a free sup ply of water, exhibits no insanitary conditions. In working the kilns the workmen suffer from great heat and dust, but the most continu ous dusty work is in the mill, the air of which is clouded with cement. Inquiry among the workmen elicited the fact that after a while they become short of breath and suffer cough, though not in a high degree, and that on arising in the morning they had to clear their chests by expectorating viscid mucus containing cement dust. Q U A N T IT A T IV E E X T E N T OF A T M O SP H E R IC P O L LU T IO N . The amount of dust generated in cement-making processes is enor mous. The workmen take practically no precaution to avoid this dust, and considerable quantities are of necessity inhaled. It is very rare to find employees who use a respirator or even a piece of 1 R ep ort o f the R o y a l C om m ission on N oxiou s V ap ou rs, L o n d o n , 1878. M inu tes o f E vid en ce taken b efore the R o y a l C om m ission on N oxiou s V ap ou rs, L o n d on , 1878. 2 T h is co n clu sio n is m od ified by th e in v e stig a tio n s o f D r. T u ck er, o f R iv e rsid e , C al. (see pp. 233 to 2 3 7 ). T h e in v e stig a tio n s o f D r. T u ck e r a re a n o ta b le c o n tr ib u tio n to the s u b je ct o f cem en t d u st in its re la tio n to hea lth , b u t th ey can n o t be co n sid e re d e n tire ly co n clu siv e, in th a t the s ta tis tica l d a ta — eith er th a t secu red b y h im fro m lo c a l s ou rces o r th a t d erived fro m in su ra n ce exp erien ce— are n o t su fficien tly re p re se n ta tiv e o f th e A m erica n cem en t in d u s try w ith a due reg ard to lo c a l v a ria tio n s in co n d itio n s in ju r io u s to h ea lth . OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 2 29 ordinary cloth to provide some protection against the health-inju rious conditions which surround them. The worst conditions are probably in the sacking or packing department, where such pre cautions are occasionally adopted. Every department, however, is filled with dust, and the avoidance of its inhalation by the majority of employees is under present methods practically impossible. The disease problem is complicated by a high degree of temperature in some of the departments, in particular at the kilns. While many descriptive accounts of the industry have been published, the hygiene of the occupation has been generally ignored. Tracy refers to it very briefly, holding that “ the workmen who make Portland cement are greatly troubled by the dust caused by shoveling the mass intosacks after it has been burned and ground. They have a persistent ceugh, and expectorate little lumps of cement. They find it impos sible to continue this part of their labor day after day, and are obliged to take intervals of rest.” P R O C E S S E S OF M A N U F A C T U R E . Parry, in his Risks and Dangers of Various Occupations, refers to cement workers as follows: Those engaged in the manufacture and use of Portland cement are • very liable to get the dust into their lungs. Portland cement is made from some substance containing carbonate of lime, such as white chalk, existing in such immense quantities in this country, and some material containing silica and alumina, such as a selected clay or alluvial mud. These are ground together with water to a muddy consistency, which is then dried by heating in chambers. This being a wet process, no dust is raised, but during the next stage, the digging out of the cement, a great deal of dust is created. The material raised is then calcinated, ground between rollers, and finally packed in bags. In the last two operations, the grinding and packing, much dust is also scattered. The particles are of a sharp, irritating char acter, and therefore dangerous. In Oliver’s Dangerous Trades the manufacture of cement from a hygienic point of view is briefly discussed and illustrated by a microphotograph of cement dust by Migerka. Oliver’s description is as follows: Under the microscope are seen a few sharp-edged little plates and amorphous masses like small clumps. The particles are not of them selves so dangerous as might at first sight appear. Although cement workers suffer from pulmonary disease, they do not do so to the great extent that might be expected. Probably the harmful effects are largely due to the hygroscopic character of the particles and their alkaline reaction. M E D IC A L O B SE R V A T IO N S ON C E M E N T D U ST. The cement industry has also been reported upon by Hayhurst with special reference to conditions in Ohio, including, however, only 230 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. two plants, employing a total of 98 men. It is stated that the work was found to be very dusty and dirty and that the quarters in one place were seldom cleaned. It is, of course, a foregone conclusion that it is practically impossible to keep a cement plant in a thor oughly clean condition while in active operation, since the product itself is the dust which permeates practically every part and por tion of the plant. According to Hayhurst, the dust is comx^osed of “ cement, lime, silica, and powdered coal,” and thus far practically no method has been evolved for the control of the dust menace. Heat was found to be intense for some of the workers and there was prac tically no protection adopted against it. This, of course, applies to the calcining furnaces, which do not essentially differ from converting furnaces generally. The medical observations are to the effect that there was great opportunity for contracting communicable diseases because of promiscuous spitting, absence of cuspidors, and the dust flying about. It was also noted that the cement dust tended to cake in the nose and that same was more or less contaminated by the dust of pulverized coal, which of course would probably not be a condition common to cement plants generally. The observations can not be considered conclusive in view of the very limited range of the inquiry. , On account of the truly enormous extent of the development of the ' cement industry during recent years, general conclusions should be accepted with extreme caution. Descriptive accounts of plant conditions vary widely, and for a thorough understanding of the con ditions inimical to health a much more extended investigation is required than has thus far been made In the special account of the cement industry of the State of Kansas, prepared in connection with the St. Louis Exposition, 1904, occurs a concise statement of the lola Portland cement plant, which sets forth the general processes and conditions with admirable brevity, as follows: The materials used in the manufacture of the cement are a very pure limestone nearly free from magnesia, a clay with about 75 per cent of alumina, and silica. One thousand tons of rock are used every 24 hours. These substances are mixed in the proper propor tion and then ground in a large rock crusher, which takes blocks as large as a man’s hand and has a capacity of 15 tons per hour. The gravel from these crushers then passes into a dryer heated by natu ral gas, where it loses 6 per cent of water, or 60 tons a day passing off as steam. Next the gravel is ground in 21 Griffin mills, which grind 2 tons an hour, or 48 tons per day, to a fine flour which will pass through a 100-mesh sieve of 10,000 holes to the square inch. This flour is then conveyed to the 15 agitators, large cylinders hold ing 90 cubic yards each, and it is thoroughly mixed in water by revolving propellers. When the material is thoroughly mixed to the satisfaction of the chemist it is carried into 21 rotary kilns. These are cylinders lined OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 231 with fire brick and are 6 feet in diameter. They are in constant rotation and inclined downward slightly toward the gas-heated end, where the temperature reaches over 3,000° Fahrenheit. Each kiln has a capacity of 160 barrels in 24 hours. The mixed flour mate rials pass out of the kiln in the form of a hard clinker, which is carried by elevators over into the cooling room. When cooled, the clinker is placed in a second set of Griffin mills, 21 in number. Each one of these grinds 9 barrels (or 3,420 pounds) in an hour to a fine flour. The finished cement now passes over into the storage room, where it is run into barrels or sacks. C O M P A R A T IV E D U ST H A Z A R D S I N T H E D R Y A 1TD W E T P R O C E S S E S . The manufacturing processes have also been described by Mr. John Calder, chief inspector of special risks for the Canadian Fire Under writers’ Association, who points out at the outset that there are two methods, generally known as the dry and the wet system, which natu rally involve processes and conditions quite varying in their effects on health and longevity. The dust danger in the dry process is, of course, most serious, particularly in connection with the crushing, mixing, and grinding briefly described as follows: The limestone being received at the mill passes through a jaw crusher. It then goes through rolls for a further reduction and is elevated to storage bins. From the storage bins the rock goes to the rock driers; these usually consist of metal cylinders from 40 to 60 feet long and 5 to 6 feet in diameter, with flanges inside and placed horizontally with a slight inclination and revolving on roller bear ings. These driers are usually heated by a coal furnace or by waste gases from the rotary kilns. The shale or clay is treated in a similar manner, the whole going to the raw-stock bins. From these the two materials are drawn and mixed, usually by automatic mechanical mixers taking in the proper proportions required from an analysis of the materials. The further reduction of the mixture is done by two grindings, the first usually in the Ball Griffen or “ Kominuter ” mills and the latter in ,the tube mill. The stock is then conveyed to the raw-stock bins ready for burning. W. Gilman Thompson has described the dust exposure in cement manufacture, with special reference to American conditions, observ ing in part that— In the crushing and drying rooms where the limestone is first treated, and in barreling or bagging, the workmen are exposed to risk of bronchial and pulmonary irritation as well as to irritation of the skin and conjunctivae. In the better class of mills the crush ing and grinding machinery is inclosed and connected with aspirat ing ducts or hoods through which the dust is drawn to settling rooms where it is filtered or precipitated with water. The packing in sacks for transportation is sometimes also done by machinery. The work men frequently further protect themselves by binding thin cloths over the nose and mouth or by wearing respirators. They often com plete the filling of the sacks by adding a few handfuls of cement to 232 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. make up the full weight, thereby scattering much dust and irritating the hands. Cleaning out the clinkers from the ovens in which the raw material has been roasted subjects the workmen'to dry heat as well as coarse dust. Regardless of even the most satisfactory precautions a consider able amount of dust exposure in cement plants is practically unavoid able. In plants in which insufficient attention is paid to dust pre vention the quantity of dust exposure is enormous. As observed by W. Gilman Thompson in this connection: Upon the whole, in proportion to the quantity of dust inhaled, cement dust, like coal dust, produces less damage to the respiratory system than might be supposed—less than the harder, sharper flint or glass dust, although chronic bronchitis, asthma, and pneumo coniosis may result from it. It causes considerable itching in the nose, to relieve which the workmen put their dusty fingers into the nose and scratch the septum. This only increases the trouble, and in some cases ulceration with perforation of the septum occurs, as in chromic-acid poisoning. Workmen with sensitive skins sometimes scratch the dusty skin so that ulcers form which are so slow in heal ing that they may be compelled to change their work. The cement dust mixes with the perspiration of the skin and gives rise to a gen eral pruritus which the workmen call “ cement itch.” S P E C IF IC O CC U PA T IO N A L D IS E A S E S . Cement makers’ itch is a new disease, apparently neither para sitic nor contagious, but produced by the chemical or mechanical action of the cement upon the skin. According to a brief discussion in the Medical Times (October, 1909) — Some physicians have attributed the corrosive action to Calcium carbonate and to sulphuric acid. Fresh cement, however, does not contain calcium carbonate; and it is questioned whether slacked lime or even partly slacked lime will produce this effect, for masons work ing with lime mortar are seldom if ever attacked with cement makers’ itch. The quantity of sulphuric acid in cement is very small. Possibly the effect may be explained by mechanical friction between the skin and very fine but hard particles of cement. Briquette makers, observes Scientific American, are subject to a similar but less serious annoyance. Cement makers’ itch and ordinary itch have one sympton in common—intense itching, especially at night. The itch ing appears to be increased by the heat of the bed, and is also more annoying in summer than in winter. Scratching may produce in fected wounds and swelling. Cement makers’ itch is an occupational disease; true itch is seldom such. The latter can be cured compara tively easy; but not so cement makers’ itch, which is likely to be followed by eczema and other complications. The managers of cement works should always require their workmen to wear cotton gloves and garments tightly fastened at the neck and at the wrists. Cement workers on arches or ceilings should wear masks. Both gloves and masks should frequently be washed. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 233 The reference is of some importance in connection with the still debatable question as to whether cement dust is or is not, at least in rare industrial cases, really seriously injurious to health. E F F O R T S A T R E S T R I C T I V E L E G IS L A T IO N . Under date of January 14, 1913, a bill was introduced into the senate of the State of California providing for the protection of the health of persons employed in the manufacture, packing, or handling of Portland cement, as follows: The people of the State of California do enact: S e c t i o n 1. In any fa c to ry or oth er place in the State, w here P ortla n d cem ent is m an u factu red , packed, or handled provision shall be m ade fo r p reven tin g the escape o f cem ent dust into the atm osphere o f any room or com partm ent w h ere p eople are em ployed. S e c . 2. T h e pa ck in g o f P ortla n d cem ent shall be ca rried on in com partm ents w hich shall be separated by d u st-p roof w alls, floors, and pa rtition s fro m a ll oth er parts o f the fa c to ry or establishm ent w h ere people are e m p loy ed ; and all co n veyors and eleva tors used fo r the con veyan ce o f P ortla n d cem ent shall be in closed in m etal or som e oth er d u st-p roof m aterial. S e c . 3. A ll P ortla n d cem ent m a n u fa ctu red in the State, or im ported from any oth er State or foreign cou n try shall be packed in d u st-p roof containers, and the com m issioner o f th e bureau o f labor statistics shall h ave the p ow er to issue ord ers to prevent the loa d in g or u nloadin g o f any P ortla n d cem ent in or fo r any vessel in any p ort in the State o f C a liforn ia or in or fo r any fre ig h t cars, or any ra ilro a d or ra ilw a y in the State o f C a liforn ia if such P ortla n d cem ent is n ot pack ed in a d u st-p roof c o n ta in e r ; and any person, firm , or corp ora tion w h o shall disobey such ord er shall be gu ilty o f a m isdem eanor. S e c . 4. A ll con tra cts entered in to by this State or any p olitica l su b d ivision th ereof, fo r the pu rch ase o f P ortla n d cem ent or oth er like com m odity or fo r the con stru ction o f p u b lic w ork w hich requires the use o f P ortla n d cem ent, shall con ta in a p ro v iso th at all cem ent to be fu rn ish ed in the con stru ction o f such p u b lic w o rk shall be packed in du st-p roof containers. S e c . 5. A n y person, firm, or corp ora tion w ho shall viola te or fa il to com ply w ith the p rovision s o f this act shall be gu ilty o f a m isdem ean or and shall, u pon co n v ictio n th ereof, be pu nished by a fine o f not less than $50 or m ore than $200, or by im prison m en t fo r not m ore than 60 days, or b y both such fine and im prisonm ent. S e c . 6. T h e com m issioner o f the bureau o f la b or statistics shall en force the provision s o f this act. E X P E R IM E N T A L M E D IC A L R E S E A R C H . The bill has been included in its entirety as an illustration of con templated legislation intended to correct an evil of a more or less debatable degree of seriousness by means practically equivalent to the destruction of the industry concerned. The contemplated bill in California led to perhaps the most thorough investigation of the health conditions in a dangerous industry ever made in the United States. The passage of the bill would have involved such serious financial considerations to the cement manufacture of California that 234 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. all the available information on the subject was brought together at the hearing held for the purpose, subsequently amplified by animal ex perimentation, etc., under the direction of Dr. George E. Tucker, in behalf of the Riverside Cement Co.1 A brief was presented by Dr. Tucker, which includes a review of the literature on the subject, the results of the original investigation, including hospital records, anthropometric data, physical examination of employees, with ref erence to time employed and dust exposure, etc. The investigation was extended to include an original inquiry into the records of Cali fornia public hospitals and other public institutions for the purpose of ascertaining whether an undue number of patients were being treated on account of tuberculosis possibly contracted in the cement industry, but the evidence was quite negative. The evidence of Dr. Tucker was subsequently presented in the form of a brief discussion on the “ Physical examination of employees engaged in the manu facture of Portland cement,’’ read before the American Public Health Association in 1914. Dr. Tucker presented a typical analysis of the raw mix or crude material which enters into the composition of cement, as follows: “ Silica, 15.18 per cent; iron alumina oxide, 5.06 per cent; calcium carbonate, 76.34 per cent; magnesium carbonate, 2.90 per cent; undetermined, 0.52 per cent.” In contrast to the fore going, the finished cement shows the following analysis: “ Silica, 22.98 per cent; iron alumina oxide, 8.80 per cent; lime, 63.10 per cent; magnesium oxide, 2.42 per cent; sulphuric anhydride, 1.42 per cent; loss on ignition, 0.52 per cent; undetermined, 0.69 per cent.” The difference in the silica content is of considerable practical im portance, as well as the very high proportion of lime, which, of course, is readily soluble. Tucker quotes Kehmann, of Wurzburg, to the effect that investigations have demonstrated that “ most in spired dust finds its way into the stomach and not into the lungs; and most of the dust which enters the upper respiratory tract is caught by the moist mucous membranes of the nose and throat and the dust laden secretion is then swallowed.” It is further stated that— In the case of insoluble particles the gastrointestinal path may furnish a most satisfactory channel for the consequent elimination of the dust from the body, but soluble dust finds a peculiarly favorable 1 A c c o r d in g to a re p o rt m ade to th e S ta te D ep a rtm e n t b y C onsul G en eral J o h n P. B ra y, o f S ydney, jtfew S outh W ales, a la b or co n tr o v e rs y has d evelop ed b etw een th e loca l cem en t m a n u fa ctu rers and the w h a r f la borers a t S yd ney o ve r the h a n d lin g o f cem ent in l>at?s, th e d u st from w h ich , it w a s cla im ed by th e la b ore rs, w a s in ju rio u s to health . On a cco u n t o f a v ir tu a l refu sa l t o ha n d le b agged cem en t in a fo rm in v o lv in g co n sid e ra b le c'.ust exp osu re it is sta ted th a t th e lo ca l cem en t com p a n y, w ith an a p p ro x im a te ou tp u t o f .‘jG.0 00 bags p er w eek, m ade a tria l sh ip m en t o f cem en t in bags lin ed w ith paper, but it w as fo u n d th a t th e co s t o f su ch bags w a s p r a c tic a lly p ro h ib itiv e , a n d th a t effo rts w o u ld be m ade to h a ve th e bags p rod u ced b y m ach in ery at a m ateria l re d u ctio n in co st. N o evid en ce is a va ila b le as regard s th e su ccess or fa ilu re o f th is exp erim en t o r w h eth er a con tin u ed refu sa l t o h a n d le cem ent in o rd in a ry b ags has led to fu r th e r la b o r difficulties, I t is p oin ted ou t, h ow ever, th a t sin ce paper bags are p rod u ced w h ich a re im p e rv io u s to coa l d u st it sh ou ld n ot be im p ossib le to p rod u ce b ags im p e rvio u s to cem en t d u st. OCCUPATIONS W IT H EXPOSURE TO MINERAL BUST. 235 chance for absorption along the same route, and the opportunity for chronic intoxications is thus easily established. In any event, the lungs escape the major part of the initial irritation. CHEMICAL ASPECTS OP CEMENT DUST IN RELATION TO DISEASE. The application of this conclusion to the cement-dust problem is of exceptional practical importance. It is pointed out by Dr. Tucker that it would appear that, since the principal ingredient of cement is lime in the form of calcium oxide, undoubtedly this material is dis solved in the stomach and converted into lime water, which must be considered to be without injurious effects, since the hydrochloric acid of the stomach would undoubtedly be able to convert the oxide into the chloride, and that this material can be ingested in large quanti ties over long periods of time without ill effects. Laboratory tests show, according to Tucker— That 99.7 per cent of five-tenths of a gram of cement is soluble in 500 c. c. of a one-tenth per cent solution of hydrochloric acid, and 99.7 per cent of five-tenths gram of cement is soluble in 250 c, c. of a twotenths per cent solution. The average per cent of hydrochloric acid varies from one-tenth to two-tenths per cent in the gastric juices of the normal stomach. Similar experiments conducted in the labora tory, using the so-called treater dust, or dust which escapes from the stacks of the kilns heated to 800° C., showed that 81.44 per cent of five-tenths of a gram was soluble in 100 c. c. of a one-tenth per cent solution of hydrochloric acid. This solution became neutral when reaction was complete. MECHANICAL ASPECTS OF CEMENT DUST IN RELATION TO DISEASE. These conclusions are important not only to the cement industry but to many similar employments involving a continuous and con siderable inhalation of mineral dust. There have been no other ex tended studies of this aspect of the dust problem, although the results would be of much practical value to the industries concerned. Ap parently strictly scientific and impartial investigations in California public institutions, as well as among the employees of the Riverside Cement Co., show a remarkable rarity of pulmonary tuberculosis. The results of the investigation are summarized in the statement that “ the membrane of the nose seems to exercise its complete function and eliminate the dust from the inhaled air.” Since the cement dust is practically sterile and chemically nonirritating there is very little inflammation caused by its presence in the nose. The results of the physical examinations of employees were subsequently confirmed by animal experimentation. Out of 956 employees physically examined 7.2 per cent were found to be in bad physical condition, while the proportion in this condition among 544 applicants for employment was 7.7 per cent. Since a large proportion of the employees 236 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. and applicants for employment were Mexicans and Armenians, the nativity factor naturally complicates the results. The average age of the employees was 31 years 8 months, the average height was 5 feet 6| inches, and the average weight was 149§ pounds. The physi cal condition of the applicants for employment in these respects was much the same.1 PHYSIQUE OF CEMENT WORKERS. In further explanation of the physical examinations it is stated by Tucker that— It should be understood that the men called “ employees” were not selected risks and underwent no physical examination prior to employment, nevertheless the average weight of employed men was the same as the average weight of the applicants for employment. The average age of employees in the packing house was 29 years 4 months 23 days; the average weight, 1534 pounds; the average height, 5 feet 6^ inches. The average weight of men employed in the packing department was about 4 pounds more than the average weight of all men employed. This is based on the examination of 73 men who had been employed an average of more than two years. In the dusty parts of the mill figures show an average age of 31 years 6 months; average weight, 162 pounds; average height, 5 feet 6f inches. This is an average weight of 13 pounds more than general average, and is based upon the examination of 106 men employed for more than an average of two years. i The only trustworthy information regarding the physique of Mexican laborers in this country is made available through an analysis of height and weight of 1,112 applicants for industrial insurance with the Prudential, during the period 1908-1916. Most of these applicants at the time were residents of southern California. The average height of the Mexicans (see table below) was 66 in., against 68.5 in., in accordance w ith the medico-actuarial standard. The average weight was 146 lbs. for the Mexicans, in comparison with an average of 156 lbs., according to the medico-actuarial standard. The adjusted relative weight wTas 2.2 lbs. per inch of height for the Mexicans, against a standard of 2.3 lbs. The average Mexican is, therefore, 2.5 in. below the average American standard of height and 10 lbs. belowr the average American standard of weight. From such investigations as have been made regarding the mortality of Mexican laborers in this country, it appears that the frequency of pulmonary tuberculosis among them is decidedly common. C om parative Anthropometry of M exican M ales. [Applicants for industrial insurance, experience of the Prudential, 1908-1916, and standard American males according to the medico-actuarial investigation.] Average height (inches). Average weight (pounds). Relative weight (pounds per inch). Age. Mexicans. Medicoactuarial standard. Mexicans. 24 years............................... 31 years............................... 41 years............................... 54 years............................... 61 years............................. 66 67 67 67 66 65 68.3 68.5 68.5 68.5 68.4 66.5 139 147 153 153 al45 ol57 147 155 161 165 165 166 2.1 2.2 2.3 2.3 2.2 2.4 2.2 2.3 &4 2,4 9.4 5 15 years and over........................ 66 68.5 146 156 2.2 2.3 15 to 25 to 35 to 45 to 55 to a Cases Medicoactuarial standard. too limited in number for safe conclusions. Mexicans. Medicoactuarial standard. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 237 It would therefore appear that the employment was not physically injurious to the extent of a loss in weight, but rather, to the con trary, a gain resulted among the men exposed in the most dusty parts of the mill. INFREQUENCY OF PULMONARY TUBERCULOSIS. Among all the employees there were only 16 cases of suspected tuberculosis and but two of these had worked in any dusty part of the mill. The employment of these two covered a period of 1 and 10 days, respectively; but others had worked either in the quarry or yard, departments in which there could be no substantial exposure to cement dust, and the average length of employment of these was four and one-half months. Among the applicants seven had physical signs indicative of previous tuberculosis, so that even among the 16 cases previously referred to, it is a safe assumption that a fair pro portion at least had contracted the disease before employment. The results of the investigation are summed up in the statement that— In conclusion, as a result of an investigation of the dust problem in conjunction with the manufacture of Portland cement, based upon the review of literature on the subject, the examination of 956 em ployees in one plant, examinations of men employed in the dusty departments of four other mills, the medical records of employees and guinea pig experimentation, there appears to me to be no evi dence of injurious effects from cement dust upon employees engaged in its manufacture. The reexamination of all employees and the con tinuation of the records will give us information of more value, and annual reports of the results of the work at the Riverside Portland cement plant will be available to any one interested in this most important phase of the cement industry. The California investigation has been referred to at length, in view of its exceptional practical importance. It is one of the most thoroughgoing efforts to ascertain precisely and conclusively the pos sibly health-injurious conditions in a leading American industry. Whether the conclusions are accepted or not, the method of inquiry itself is deserving of special recognition, particularly in view of the fact that the medical and statistical research was amplified by animal experimentation. PROBLEMS OF DUST CONTROL. In the case of the cement industry the problem is both simple and complex. The enormous quantity of dust which is itself the product of the industry must theoretically be assumed to be in jurious to health and a predisposing cause of respiratory and possi bly tuberculous diseases. Hirt, in the early seventies,1 presented data according to which the proportionate morbidity from phthisis was 1 D ie S ta u b in h a la tion s-K ra n k h eiten , by D r. L u d w ig H irt, B resla u , 1871, p. 30. 238 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. only from 8 to 10 per cent among cement makers, against 80 per cent among flint workers, and 70 per cent among needle polishers. The industry in the meantime, however, has undergone such pro found changes that these earlier observations are not of practical significance. Koelsch, in a more recent German contribution on mortality in relation to tuberculosis,1 refers briefly to cement dust as injurious, but without sufficient statistical evidence to sustain his conclusions. His data, derived from the mortality of Bavaria for the year 1898, are limited to four deaths of cement workers out of a labor force of 1,267 exposed to risk. The resulting mortality rate of 3.16 per 1,000 compares favorably with 3.07 for all occupations, but the number of deaths is too small for final conclusions. More trust worthy observations are brought forward in the report of the chief inspector of factories and workshops of the United Kingdom for the year 1911 (p. 183), who remarks as follows: Cement making has for years been regarded as one of the specially dusty trades in which difficulty has been experienced in confining the dust within reasonable limits during the processes of manufacture, grinding, and packing. The dust, however, has been held by some authorities as “ not so damaging to health as might have been ex pected,” though by others it is considered to cause “ slight bronchial and lung troubles as well as catarrh of the stomach and inflammation of the eyes.” Modern processes, it is pointed out, have, however, had a tendency to materially reduce the quantity of dust which was formerly allowed to escape into the atmosphere. On the basis of a careful inquiry among friendly societies insuring persons employed in the cement industry the conclusion was arrived at that— These appear to show that the trade is on the whole a healthy one; that deaths are few; that absence from work is rare and generally due to influenza, colds, or accidents; and that there is often more invalidity among workers in nondusty processes than in the dusty occupations of kiln drawing, milling, and packing. UOITCNJUILIOUSITESS OF LIME DUST. The general conclusion was, therefore, advanced, after a careful special inquiry into actual working conditions, that 46while the dust is not of an injurious nature, probably owing to the fact that free silica is present in very small quantities, usually less than 1 per cent, it does cause irritation and trouble in some cases, and if not injurious it is at least a nuisance, and efforts should be made to prevent and reduce the escape of dust wherever practicable.” This view has the indorsement of a letter in the British Medical Journal for May 7, 1900, in which, following a reference to the general conclusion that 1 A rb e it und T u b erk u lose, b y D r. m ed. K o e ls ch , H yg ien e, V o l. V I , pp . 2 9 , 212, 2 7 6 ; L eip zig , 1911. p u b lish e d in A r c h iv fu r S ozia le OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 2^? all dust is more or less seriously injurious to health, it is said that u a decided exception should be made in favor of lime dust.” In the writer’s personal experience “ those breathing it habitually at lime kilns are free from tuberculosis, and a similar observation has been made in France and Germany.” Furthermore, it is said that “ lime dust in abundant quantity, either by acting on the body or on the tubercle bacillus outside of the body, is antagonistic to tuberculosis.” This conclusion would seem to have much in its favor, and, while not entirely sustained by the available insurance mortality statistics, the data at least indicate a relatively lower incidence of pulmonary tuberculosis than is common to the obviously more hazardous dusty trades. MORTALITY OF CEMENT WORKERS— INDUSTRIAL INSURANCE EXPERI ENCE. Table 89 shows the industrial mortality experience among cement and lime workers as recorded by the Prudential Insurance Co. for 1897 to 1914. Of 222 cement and lime workers who died during that period, 16, or 20.7 per cent, died from pulmonary tuberculosis. T able 8 9 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU B E R C U LO SIS AM ON G C EM EN T A N D LIM E W O R K E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G ROU PS. Deaths of cement and lime workers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at deatli. A ll causes. Males in Pulmonary Cement and registration tuber lime area, 1900 workers. culosis. to 1913. IS to 24 years........................................................................... 25 to 34 years..... ..................................................................... 35 to 44 years............................... ............................................ 45 to 54 years............................................................................ 55 to 64 years..................................................................... ..... 65 years and over...................................................... ............. 18 40 48 45 49 22 2 15 12 10 6 1 11.1 37.5 25.0 22.2 12.2 4.5 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.................... . ....................... 222 46 20.7 13.9 The data are particularly suggestive at ages 25 to 34, when out of 40 deaths from all causes 15, or 37.5 per cent, were from pulmonary tuberculosis, against 30.5 per cent expected on the basis of the mor tality data for the males of the registration area. The American cement industry has within recent years attained to such nation-wide importance that the preceding considerations are applicable to a labor problem which at any time may assume serious significance, as made evident by the proposed measure in California aimed at the regulation of the industry by exceedingly 240 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. drastic methods, as regards the impervious packing of the product, not with reference to the men engaged strictly in cement-making processes but solely for the protection of men employed in the subse quent handling of the finished product while in course of transporta tion. This suggests future possibilities which make it exceedingly important that the facts concerning the injuriousness or noninjuriousness of cement dust should be ascertained with impartial and strictly scientific accuracy. Cement is produced in practically every State of the United States, although the principal centers of produc tion are Pennsylvania, Indiana, New York, Illinois, California, Mis souri, Michigan, Iowa, New Jersey, and Kansas. These 10 States in 1914 produced 82.6 per cent of the aggregate output, and there are no reasons for believing that a material change occurred during more recent years. How far local and important variations in the chemical and mechanical properties of cement dust may affect the preceding conclusions regarding the apparent noninjuriousness of the dust in its relation to pulmonary tuberculosis can not be stated at the present time. As observed by Kober and Hanson in their treatise on “ Diseases of Occupation and Vocational Hygiene,” the manu facture of Portland cement varies in different countries, and they remark that— In England, where chalk is plentiful, this is used in connection with some material containing silica and alumina, such as selected clay or river mud. The raw materials are mixed in certain proportions and ground together to the consistency of liquid mud. The excess of moisture is driven off by heat, and the residue is dried in ovens at a high temperature. The preliminary process, while sloppy, is not dusty work, but the subsequent grinding between rollers and the sacking and packing of the product is an extremely dusty process. According to Koelsch and other German authors catarrhal affections and diseases of the respiratory organs constitute from 30 to 40 per cent of all the sickness. Diseases of the eyes and ears, impacted ear wax, ulceration of the nose with perforation of the nasal septum, and eczema, or cement itch, are also quite common. Kober refers to a report made by Wittgen with reference to the results obtained in German cement works in the direction of dust removal and in consequence of which respiratory diseases were re duced fully one-third within a period of five years after the installa tion of exhaust ventilation, and the number of days lost by sickness was reduced proportionately. Further investigations of a more involved scientific nature are essential to the purpose of determin ing more conclusively the facts of a controversy, which is of impor tance not only to the cement industry of this and other countries, but also to every occupation involving more or less exposure to inorganic dust. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 241 GENERAL CONCLUSIONS. On account of the common occurrence of pulmonary tubercu losis under all labor or industrial conditions, it is self-evident that no crude statistical analysis of this kind can precisely measure the health-injurious effects of any particular occupation, trade, or industry. At best such data are only of approximate value, unless the incidence of pulmonary tuberculosis is so pronounced as to justify unqualified conclusions. In the case of cement dust it is apparently shown that the results, if serious at all, are much less so than in the case of most of the other dusty trades considered. It is difficult to accept, without due reserve, the conclusions advanced by Tucker in their entirety, and particularly his statement that 44outside of the packing room and the sack-cleaning room there is no department in which cement dust escapes into the atmosphere in any appreciable quantities.” It may be stated with confidence that practically all branches or "departments of cement manufacture involve considerable exposure to the dust hazard, and while the evidence may be wanting that cement dust is a predisposing cause of tuberculosis, there can be* no question but that certain forms of respiratory affections are rela tively common, at least among certain classes of employees. In the entire absence of official vital statistics for the States and sections in which the cement industry is represented by a sufficiently large number of employees, it would seem of sufficient importance to suggest that special inquiries should be made in the more important centers of the cement industry in conformity to the admirable methods of scientific investigation developed by the Riverside Cement Co. BRICK, TILE, AN D TERR A-COTTA M AKERS. These occupations are too complex to permit of a satisfactory analysis of the available mortality data which, almost without ex ception, are quite general and do not refer to specific industries or employments. The dust hazard necessarily varies widely in an industry of such vast extent and which is carried on under such varying conditions. Brickmaking has during recent years under gone material changes on account of the extensive introduction of machinery. It.is estimated by Mr. W. Frank M’Clure in the Scientific American for October 7, 1905, that one machine employed in extricat ing processes accomplishes the work of 75 men. The same writer explains that— After coming from the pug mill the pasty material is cut into the shape of bricks by machinery which works automatically, and modern methods also provide for the use of exhaust steam and heat from the kilns for the heating of the drying house. 106811°— 18— Bull. 231------ 16 242 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. BRICXMAXING PROCESSES. The processes of brickmaking in general are described with ad mirable brevity by this writer, as follows: From the cars the clay and shale are shoveled into grinders, which reduce these two products to a powder, which in turn is carried by a bucket elevator to a big hopper. After it has been sufficiently screened the powdered clay and shale next go to the pug mill, fcha# which will not pass the screen going back to the grinders again. In the pug mill—a sort of conical trough—the raw material is tempered with water and kneaded by means of a device somewhat resembling a screw propeller in shape. From this mill it is forced through a mold into one long, continuous brick, and this, as it comes from the mill, is carried on a wide belt to a cutting machine, which automatically cuts the continuous brick into many bricks of the desired size, the machine cutting 16 bricks at one time. As the bricks come from the cutting machine, still soft and still resting on the belt, they are loaded onto flat cars and removed to the drying house, where they remain not less than a day and night. The capacity of a large drying house is about 100,000 bricks. The different apartments of this house are brick lined. The brick next go to the kilns for baking. One of the engravings gives a good idea of the manner in which these brick are piled within the kilns. Five or six men often work three full days in filling one kiln, which fact gives some idea of the size of the interior. After the entrance to the kiln has been closed and sealed the fire beneath is started. The baking process is then continued for 9 or 10 days, the temperature maintained within being 2,300° F. Then, when the kiln has been cooled, the bricks are taken out and are ready for ship ment. Where 15 or 16 kilns are in use the daily capacity of ordinary sized brick may reach 150,000. HEALTH-INJURIOUS CONDITIONS. In all of these processes there is a considerable degree of dust ex posure, the injuriousness of which, however, is materially reduced by the fact that most of the operations are carried on in the open air. The evidence presented to the departmental committee on industrial diseases by Dr. Chalmers was to the effect that brickmaking could, not be considered a healthy occupation. The same conclusion had been arrived at in the earlier investigation into the experience of the British Friendly Societies reported upon by Radcliffe. Apparently the most injurious processes are in connection with the molding, drying, and burning, where the dust exposure is occasionally quite considerable, in that the dust is reduced to an extremely dry and finely powdered condition. The process of manufacture with special reference to tempering, molding, drying, and burning has been de scribed by Mr. T. C. Naulty, inspector of the Underwriters’ Associa tion of New York, in the Weekly Underwriter, for June 4, 1910. The only comparatively recent investigation into the sanitary condi tions of brick and tile making, with special reference to grinding OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 2 43 and mixing is by Hayhurst.1 This investigation included 9 estab lishments in the State of Ohio, employing 67 workers in the processes of grinding and mixing. In only two instances, however, were health appliances, such as blowers, etc., present, it being observed that boxed-in chutes rendered much aid in limiting the dust. Only 5 of the 67 employees were over 40 years of age. It is said by Hayhurst that— The chief objectionable features to this process, from a health point of view, were the breathing of clay dust, and the red coloring com pound often mixed with it, the dirt underfoot, the dampness, and, for cooler weather, the absence of heating arrangements, all of which were fair to bad hazards. In two places the work was housed in so that the light was poor, and a similar condition existed for ventila tion in two places. In one place the mixing machine was so close to a kiln that the workers were affected by the heat. In all places there was a moderate risk of overfatigue, not so much from laborious work, which was not the rule, but from monotonous application, constant standing, and the loud noise from the grinding machine. NEGLECT OF SANITARY PRECAUTIONS. It is further pointed out by Hayhurst that the liability of contract ing communicable diseases was found to be bad in all the places in vestigated, except in one, due to promiscuous spitting into the dried-up day dust on the floor, the absence of cuspidors, and the lack of proper washing facilities. It is stated, however, that the outdoor character of the work in most places mitigated against this hazard, but attention is directed to the risk of contracting hookworm disease on account of the primitiveness of the sanitary arrange ments. GRINDING, MIXING, AND PRESSING. The general appearance of the workers was found to be good in only 40 per cent of the cases observed, but none of the men seen presented a decidedly sickly appearance. The concluding observa tions with reference to grinding and mixing are to the effect that—■ These workers, as well as the rest of those in brick and tile works, should be provided with proper sanitary and drinking facilities because of the risk of typhoid fever and hookworm disease. Work ers predisposed to lung troubles should not engage in any part of the brick industry. For certain intervals of very dusty work the workers should put on respirators. Grinding and mixing processes everywhere could be rendered entirely dustless for the places in which the workers are required to remain, as was observed to bo the case at one plant. The same investigation included the pressing process, which fol lows the grinding and mixing, and which, in general terms, is 1 Industrial Health Hazards, 1915. 244 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. almost entirely mechanical. This investigation included nine estab lishments, employing 200 men, of whom only 1 was over 50 years of age and 5 per cent were under 20 years. Dust from -the drying of wet clays under foot was found to be a bad feature in three places, and fairly so in three others, while in two places it was negli gible; but in one large place the dust was so thick in the air “ that one could scarcely see 30 feet.” In six of the nine places the work was damp enough to be considered hazardous, and workers were found to be unable to keep dry, especially with the forms of footwear and’ clothing used. In six places there seemed to be a number of factors productive of fatigue. The general conclusions were of much the same effect as previously stated with regard to grinding and mixing. KILN SETTING, FIRING, AND DRAWING. Work at the kilns was investigated at nine establishments employ ing 116 men in setting, firing, and drawing the kilns of brick and sewer pipe. There were found to be no appliances which could be considered as having to do with the conservation of health, nor were there found to be any instructions or placards suggestive of qualified advice in this direction. Of the 116 men, practically all unskilled laborers, 14, or 12.1 per cent, were over 40 years of age. According to Hayhurst— The chief hazards of this process were exposure to heat, alternating with weather conditions. This seemed bad in 3 places, and some hazard in all of the remaining. It depended somewhat upon the methods of drawing the kilns. In some places workmen were put upon them while the temperature was yet extremely hot. In one place premises around the kilns were kept very neat and clean. As else where in this industry, fatigue factors were present, and probably more so in this process than any other. Arranged in descending order, as nearly as possible, these were: Monotonous application, with constant standing for long periods, hurrying piecework, with evi dence of speeding up, laborious work under considerable strain, pres sure against the body, and long hours. In conclusion it is said that the appearance of the workers was generally good in most places, but some were found who complained of their health and others who appeared to be in a decidedly inferior physical condition. The conclusion advanced is that “ This^is a process requiring hard, laborious work at intervals, but this should not proclaim it necessarily unhealthy, provided the many other fea tures mentioned were not present to menace the health of the work ers.” These observations are far from conclusive and .they only indirectly bear upon the question as regards the relative frequency of tuberculosis in consequence of undue exposure to health-injurious conditions. The conclusion, in the main, however, indicates labor 245 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. conditions far from satisfactory and, broadly speaking, probably predisposing to general ill health. These conclusions apply also, in a general way, to terra-cotta workers and tile makers, at least as regards some of the processes, which are more or less identical with brickmaking, but to a less extent than to brickmakers who in addi tion, of course, are exposed to numerous other health-injurious con ditions, such as the risk of inhaling lime or mortar dust, especially in brick-cleaning processes and the taking down of old walls, etc. MORTALITY OF BRICK AND TILE MAKERS— UNITED STATES REGISTRA TION AREA. The mortality of brick and tile makers has been reported upon only for the year 1909 by the Division of Vital Statistics of the United States Census Bureau, and no subsequent information has been made public, so that the data are of rather limited value. Ac cording to the census report out of 133 deaths of brick and tile makers from all causes 16, or 12 per cent, were from pulmonary tuberculosis. The details of the mortality, by divisional periods of life, are shown in Table 90. P R O P O R T IO N A T E M O R T A L IT Y OF B R IC K A N D T IL E M A K E R S F R O M P U L M O N A R Y TU B E R C U LO SIS, U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1909, B Y A G E GR O U PS. T able 9 0 .— * Deaths from pul monary tuberculosis. Age at death. Deaths from all causes. Per cent of deaths from all causes. Number. 15 to 24 years.................................................................................................. 25 to 34 years.................................................................................................. 35 to 44 years.................................................................................................. 45 to 54 years.................................................................................................. 55 to 64 years.................................................................................................. 65 years and over.......................................................................................... Age unknow n................................................................................................ 14 13 18 20 26 41 1 3 3 5 3 2 21.4 23.1 27.8 15.0 7.7 Total, 15 years and over................................................................... 133 16 12.0 Table 9 1 . — P R O P O R T IO N A T E M O R T A L IT Y OF B R IC K A N D T IL E M A K E R S FR OM NONTU BE R CU L O U S R E S P IR A T O R Y DISEASES, U N IT E D STATE S R E G IS T R A T IO N A R E A , 1909. Cause of death. Deaths from nontuber cuious respiratory diseases. Number. Per cent. Asthm a.................................................................................................................................. Bronchitis............................................................................................................................. Pneumonia........................................................................................................................... Other nontubercuious respiratory diseases................................................................... 8 2 6.0 1.5 T otal............................................................................................................................ 10 7.5 246 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. The number of deaths under observation is too limited for entirely safe conclusions, but in a general way the table is sustained by insur ance experience and foreign data. The proportionate mortality from pulmonary tuberculosis is below the average for all occupied males at ages under 35 and only slightly above the average at ages 35 and over. It may be said that the mortality of brick and tile makers from pulmonary tuberculosis approaches so closely to the normal for all occupied males that there are apparently no decidedly healthinjurious conditions in this employment predisposing to pulmonary tuberculosis, and, as shown by Table 91, to nontuberculous respira tory diseases. The proportionate mortality from this group is 7.5 per cent for brick and tile makers, which compares with 10 per cent for all occupied males and 9.2 per cent for glassworkers.1 MORTALITY 0 * BRICK, TILE, AND TERRA-COTTA MAKERS— INDUSTRIAL INSURANCE EXPERIENCE. Additional statistical data as shown in Table 92 are available for this group of employments through the industrial mortality statistics of the Prudential Insurance Co. of America for the period 1897 to 1914, including 527 deaths from all causes, of which 82, or 15.6 per cent, are from pulmonary tuberculosis. T able 9 2 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS AM ONG B R IC K , T IL E , A N D T E R R A -C O T T A M A K E R S, IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L MALLES IN U N IT E D ST A T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G ROU PS. Deaths of brick, tile, and t e r r a - c o t t a makers, 1897 to 1914, from— Per cent of deaths from pulm onary tubercu losis among— A ge at death. Brick, tile, Males in Pulm o terra registration A ll causes. nary tuber and cotta area, 1900 culosis. makers. to 1913. 15 to 24 years............................................................................ 25 to 34 years................... , ...................................................... 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55to 64 years................................................ .......................... 65 years and over.................................................................... 48 51 81 97 121 129 11 18 16 18 13 6 22.9 35.3 19.8 18.6 10.7 4.7 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and over.............................................. 527 82 15.6 13.9 The proportionate mortality is relatively high at all ages, but not excessively so when compared with more decidedly health-injurious processes with exposure to metallic and more irritating mineral dust. The corresponding industrial mortality experience of the Metro politan Co. is limited to masons and bricklayers considered as a 1 F o r e a rlie r referen ces t o th e h ea lth o f brick m akers, see th e J o u rn a l o f H ea lth , V ol. I I , p age 28G, and the C om p a ra tiv e R ates o f M o r ta lity in V ariou s O ccu p a tion s, pages 11, 27, and 45. F o r m odern o b serva tion s on the h ea lth o f b rick m akers w ith special re fe re n ce to h e a lth -in ju rio u s co n d itio n s, see the E n g lish re p o rt on In d u stria l D iseases, 1907* evi dence by C halm ers, page 4304. 247 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. group. It includes 1,748 deaths from all causes. Table 93 is derived from Bulletin 207 of the Bureau of Labor Statistics, on “ Causes of Death by Occupation.” T able 9 3 .—N U M B E R A N D P E R C EN T O F D E A T H S F R O M S P E C IF IE D CAUSES AMONG MASONS A N D B R IC K L A Y E R S , B Y A G E P E R IO D S , 15 Y E A R S A N D O V E R —W H IT E MALES. [Metropolitan Life Insurance Co.—Industrial department—Mortality experience, 1911 to 1913.] Ages 15 years and over. Per cent of deaths during age period (years)— Cause of death. Per cent. Num ber. 15-24 25-34 35-44 45-54 55-64 65 and over. Number of deaths.................................... 1,748 59 124 250 327 475 513 Tuberculosis of the lungs...................... Cancer (all form s)................................... Alcoholism ............................................... Cerebral hemorrhage, apoplexy, and paralysis............................................... Organic diseases of the heart............... Acute and chronic bronchitis............... Pneumonia (lobar and undefined)___ Cirrhosis of the liver............................... Bright’s disease...................................... Suicide (all forms).................................. Accidental violence................................ A ll other causes...................................... . 332 113 18 19.0 6.5 1.0 28.8 45.2 1.6 2.4 42.0 2.8 1.6 26.6 4.6 1.8 10.5 10.3 .4 3.3 7.8 .6 136 227 18 132 34 178 29 133 398 7.8 13.0 3.4 1.0 7.6 10.2 1.9 10.2 *\” 5 .Y 1.7 1.7 25.4 7.6 22.8 25.4 .8 6.5 .8 7.3 .8 3.2 .8 8.1 22.5 2.4 8.0 6.0 2.0 5.6 1.2 9.2 19.2 2.4 9.2 .6 10.1 1.8 10.1 1.5 9.8 21.5 12.2 14.7 .6 6.7 2.9 12.2 1.9 5.7 21.9 12.3 18.9 2.3 7.2 1.6 12.9 1.9 5.1 26.1 Total............................................... 1,748 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1 This title includes foremen and workmen: stonemasons, bricklayers, masons, bricksetters, tile layers, and plasterers. This table includes a number of other specified causes of death, but throughout the most important disease is pulmonary tuberculosis, which accounts for 19 per cent of the mortality from all causes at ages 15 and over, and as much as 45.2 per cent of the mortality at ages 25 to 34. As observed by Dr. Dublin in his interpretation of the table, “ the United States figures, the English figures, and those of the Prudential Insurance Co., all confirm the occurrence of rising relative indices in successive periods up to age 65, suggesting a direct causal relationship between tuberculosis of the lungs as a cause of death and the duration of service in this occupation.” The inherent limitation of all data of this character is due, however, to the in clusion of widely varying employments in a single group, which rather requires the highly specialized consideration of carefully segregated branches or specific occupations to determine the true incidence of health-injurious conditions. POTTERS. The pottery industry includes the manufacture of earthenware, china, and porcelain. It always has been recognized as one of the unhealthiest of trades, but the health-injurious effects vary widely according to particular employments. The most seriously exposed are the dippers, flint-mill workers, ground layers, mixers, scourers, 2 48 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. and sweepers. In all of these employments except the first the ex posure to health-injurious mineral dust constitutes a serious menace to health. In the case of dippers the liability to dust inhalation is modified and increased in seriousness by the risk of lead poisoning. The degree of dust exposure is also very serious in the case of kilnmen, mold makers, placers, pug-mill workers, sagger makers, and slip makers. In the aggregate the industry gives employment in the United States to about 26,000 persons, of whom one-fifth are women. The sanitary conditions of the trade have often beeii investigated, and the most recent evidence is to the effect that there have been material improvements within the last few decades.* The most careful and useful observations of the industry were made by Arlidge, who for many years lived in the Staffordshire pottery district of England. Before quoting Arlidge the fact may be briefly referred to that as early as 1T05 Ramazzini, in commenting upon the diseases of potters, pointed out that “ not all who go by the name of potters are subject to the particular disease of the trade,” and that, therefore, discrimi nation was necessary in the medical treatment of the different classes of employees. Ramazzini made a curious observation bearing upon the question of eye strain, which has received qualified consideration only within recent years, stating, with reference to potters, that “ those who sit at the wheel and form the vessels by turning it about with their feet are apt to have a swimming in the head if their eyes are otherwise weak.” SANITARY ASPECTS OF THE POTTERY INDUSTRY. Arlidge, in discussing the effects of mineral dust in the manufac ture of pottery before the Sanitary Institute in 1893, remarked at the outset that— Scarcely any other manufacture has so strong a claim upon the at tention of sanitarians as has that of pottery. It stands nearly at the head of the list of unhealthy occupations, and exercises its pernicious effects almost wholly upon the respiratory organs, by production of bronchitis and of consumption. Thus it is found that while workmen engaged in other employments have a mortality from chest diseases of 7.86 per cent, potters exhibit one of 12.29 per cent. Likewise with respect to phthisis—nonpotters present one of 9.27 and potters one of 12.90. After describing the various processes of manufacture and their relation to health-injurious circumstances, Arlidge discussed the rela tion of clay dust and its irritating effects upon the mucous mem brane and epithelium of the lungs, holding the opinion that— Clinical observation abundantly confirms this fact. For a consid erable time the inhaled dust is arrested in its advance toward the lung tissue proper by the mucous secretion in the bronchial tubes, and by the expulsive energy of the cilia lining of those tubes. But at length these-resistant forces weaken before the constant entry of fresh OCCUPATIONS W IT H EXPOSURE TO MINERAL BUST. 249 dust, and in course of time the noxious material passes into the lymph channels, and also along the finer bronchi, until it reaches the intimate structure and the air cells themselves. Here as a foreign substance it sets up inflammatory action; lymph cells spring up, the air vesicles become choked with inflammatory products, the tissue around them gets indurated (lung sclerosis), and useless as breathing tissue. The history of these pathological changes is reflected in the symp toms exhibited by the sufferers. In the primary stage little incon venience is felt; there arises a desire to clear the throat of some im peding mucous at the end of the day’s work, or upon transition to the outer air from the warm shop, and especially on rising in the morn ing. This expulsive act soon develops into a cough, and relief is ob tained by the expectoration of more or less blackish viscid mucus. Presently there is a feeling of tightness in the chest, and the breathing grows less free and full. As time goes on these signs of disturbed lung function become more pronounced, and in the end the patient grows asthmatic—a victim of potters’ asthma. Until this advanced stage of disorder is reached it is singular to notice how little attention and anxiety are bestowed upon the pul monary derangements. This is because the general health is, for the most part, not seriously affected, and inasmuch as while the sufferer breathes a warm air in his workshop or home, his lung trouble is felt as little more than an annoyance; or as something which is to be taken as a matter of course, and, like his wages: as an unavoidable incident of his calling. As with chronic maladies at large, so with potters’ bronchitis and asthma, the tendency is to grow worse and the lung lesion to extend, and soon the damaged respiration reacts upon the whole frame; the sufferer can not get proper outdoor exercise, his appetite fails,’ his sleep is broken, the expectoration augments and grows muco-purulent, the body wastes slowly, while the increased effort to breathe entails strain upon the heart, leading not infrequently to disease of that organ, with the after consequences in the shape of dropsical effusions. We now have before us the fully developed disease known as potters’ consumption or potters’ asthma. EFFECTS OF SILICA DUST. The injurious effects of clay dust in the pottery industry are fur ther increased by minute particles of flint, and a possible additional factor injurious to health is the extensive use of plaster of Paris, employed in the making of molds and models. According to Arlidge, the effects of plaster of Paris dust, however, are not apparently as serious as the very destructive effects of silica dust and small par ticles of flint. He draws attention to the necessity of an efficient system of ventilation as the only means by which material improve ments can be brought about. LIABILITY TO LEAD POISONING AND PULMONARY DISEASES, The health-injurious effects of lead, extensively used in potteries, 'which do not properly fall within the present discussion, must here be 250 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. passed over.1 It is true, of course, that a considerable amount of lead dust is inhaled, but the effects are rather upon the system generally than upon the lungs. The observations of Arlidge are so entirely sus tained by other qualified observers that it is not necessary to further enlarge upon the sanitary aspects of this trade. The evidence, statis tical or otherwise, is conclusive that potters as a class suffer more, per haps, from phthisis and other diseases of the lungs than employees in any other occupation, and their mortality from bronchitis and other respiratory diseases is many times as high as the mortality of occupied males generally; but it has been pointed out by Tatham, in his contribution to Oliver’s “ Dangerous Trades,” that— Potters succumb to nontubercular disease of the lungs much more rapidly than they do to tubercular phthisis; and it is certain that much of the so-called potters’ phthisis ought properly to be termed cirrhosis of the lung. Deaths from this affection should never be in cluded under the head of phthisis, which term is now restricted, by universal consent, to the tubercular malady of that name. It is also necessary to keep in mind, in discussing the pottery in dustry, that it divides itself broadly into two principal departments— that is, first, the making of the articles from potters’ clay, and, second, their ornamentation by painting, gilding, etc. The latter group of occupations is usually defined as decorators, and sometimes as print ers, and because of this fact many errors occur in occupation sta tistics as the result of erroneous classification—not based upon the industry as.such, but upon the specific title of the employment. SPECIFICALLY INJURIOUS PROCESSES. One of the most health-injurious employments in the industry is that of the brushing,, or dusting off, of the ware after it is taken from the kilns. Oliver, in discussing at length the sanitary aspects of china and earthernware manufacture and in particular potters’ asthma and pulmonary tuberculosis, draws special attention to this process as observed in the porcelain potteries at Limoges. He remarks that— The brushing off or epoussetage of the fired or biscuited ware is done both by women and men by means of soft feather brushes. It is a very dusty operation, and where there are no fans for its removal, as in some of the factories I visited, the air was thick with dust. The windows were open at the time, but currents of air obtained by this 1 W ith resp ect t o lea d p o iso n in g in the p o tte r y tra d es see : D ep a rtm en ta l re p o rt on “ T h e P o tte r y In d u s try in F ra n c e ,” b y T h o m a s O liver, M. D . L on d on , 1899. D ep a rtm en ta l r e p o rt on “ T h e E m p loy m en t o f C om p ou n d s o f L ea d in the M a n u fa ctu re - o f P o t te r y ,” by T h orp e an d O liver. L on d on , 1899. D ep a rtm en ta l re p ort on “ L ea d in th e M a n u fa ctu re o f E a rth e n w a re a n d C h in a ,” V ols. I . I I . a n d I I I . L o n d o n , 1910. B u lle tin o f the U. S. B u rea u o f L a b or, N o. 104, “ L ea d P o is o n in g in P o tte r ie s , T ile W ork s, e t c .,” by D r. A lic e H a m ilton . W a sh in g ton , 1912. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 251 means exercised no very appreciable influence upon the dust. It is not this kind of ventilation that is required under these circumstances. In the matter of the provision of artificial means for the removal of dust and the renewal of air in the potteries of Limoges, some of the manufacturers seemed to me to be rather behind than in advance of the owners of large factories in Staffordshire. Accordingly I was not unprepared for the information that among the potters, especially the brushers off or scourers, in Limoges, the mortality from pulmo nary consumption and chest diseases is high. The harmful operations in porcelain works are the emptying of the kilns, the removal of the ware from the saggers and the brushing of this ware, while the hard dust that rises during the polishing of the all but finished articles is equally dangerous. The polishing has for its object the removal of any roughness from the edges or surfaces of the ware, and it is gen erally done on a revolving wheel by means of a broken piece of china, the workman using this as a smoothing agent. The men and women employed in these operations are usually well covered with dust, yet it is seldom that they wear respirators. Fans for the removal of the dust were present in only very few of the factories. The employees objected to them on the ground that they created a strong draft of cold air. Dr. Raymondaud, one of the professors in the School of Medicine, Limoges, has made a special study of the diseases of por celain makers, particularly of pulmonary consumption and chronic bronchitis. He found that the potteries furnished a larger number of patients suffering from lung diseases than did the other trades of the district. Of T5 deaths registered in Limoges as occurring among china makers, 36 were due to phthisis, and of 30 potters whom Raymondaud examined, 20 were suffering from pulmonary consump tion. Pulmonary phthisis is regarded as the principal disease affect ing the workers in the Limoges potteries. ENGLISH OCCUPATIONAL MORTALITY STATISTICS. The most recent English mortality statistics of potters are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births* Deaths, and Marriages in England and Wales, in part as follows: Between the ages 20 and 35 years the mortality of potters falls below that of occupied and retired males generally; at every other age, however, it shows an excess which amounts to no less than 74 per cent at ages 45 to 55 years, and to 66 per cent at ages 55 to 65 years. In the main working time of life the comparative mortality figure is 1,493, or 49 per cent above the standard. The principal excess falls under the head of respiratory diseases, for which the mortality figure is 473, or nearly thrice the standard. There is also a considerable ex cess in the mortality from phthisis, from nervous and circulatory diseases, and from suicide. These workers are also specially liable to lead poisoning, but from accident as wTell as from influenza, Bright’s disease, and alcoholism their mortality is low. In the last decennial supplement the mortality of potters was de scribed as enormous. From the present report, however, it will be seen that since 1890-1892 their mortality has declined at every stage of life; and in the main working period the comparative mortality; 252 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. figure has fallen from 1,970 to 1,420, or by no less than 28 per cent. It is satisfactory to note that in the recent period the mortality of potters from plumbism has fallen to less than half its former amount, while there has also been a substantial decline under most other head ings; the mortality from respiratory and urinary diseases having fallen by about one-third, that from phthisis, nervous and digestive diseases by about one-fourth, and that from circulatory diseases by about one-fifth part. Potters, however, now fall victims in increased proportion to accident, and to suicide, and the mortality from cancer has increased by more than half. Since 1860, ’61, ’71 the death rates of potters both above and below 45 years of age have fluctuated some what, but the recent modified mortality figure is by far the lowest on record. Since 1880-1882 there has been a continuous decline of mor tality from phthisis, from liver disease, and from diseases of the nervous and digestive systems. The English statistics for potters are quite conclusive of the un favorable effects of this industry on health. In Table 94 the mor tality from all causes among potters is compared with that of occu pied males generally, and the result is decidedly suggestive of conditions more or less unfavorable to life and health, but in par ticular at ages 35 or over, when the mortality rate from all causes exceeds by from 4.30 to 29.86 per 1,000 the corresponding mortality of occupied males generally. Table 9 4 .— M O R T A L IT Y F R O M A L L C AU SES A M O N G P O T T E R S , C O M P A R E D W I T H T H A T OF A L L O CC UPIED M A L E S , IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E G R O U P S. [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate among potters. Age at death. 15 to 19 years................................................................................... 20 to 24 years..................................- ............................................... 25 to 34 years.................................................................................... 35 to 44 years.................................................................................... 45 to 54 years,.................................................................................. 55 to 64 years.................................................................................... 65 years and over............................................................................ Death rate per 1,000 for all occu pied males. 2.44 4.41 6.01 10. 22 17.73 31.01 88.39 Rate per 1,000. 2.62 3.68 5.26 14.52 31.64 54.15 118.25 Greater ( + ) Ratio to or less ( —) than rate rate for all occupied for all occu males. pied males. + — — + 0.18 .73 .75 4.30 + 13.91 +23.14 107 83 88 142 178 175 +29.86 134 The preceding table is self-explanatory. A more extended com parison, however, is made in Table 95, in which the mortality of potters from pulmonary tuberculosis and from other diseases of the respiratory system is compared with the normal mortality of occu pied males from these diseases, by divisional periods of life. The comparison shows that the mortality from pulmonary tuberculosis among potters is decidedly excessive at ages 35 to 64 by from 1.05 to 4.10 per 1,000. Still more marked is the excess in the mortality from respiratory diseases other than pulmonary tuberculosis among potters at ages 35 or over, which varies from 1.63 to 17.27 per 1,000. OCCUPATIONS W IT H EXPOSURE TO MINERAL BUST. 2 53 Table 9 5 .— M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS A N D F R O M O T H E R D IS E A S E S OF T H E R E S P I R A T O R Y S Y S T E M A M O N G P O T T E R S , C O M P A R E D W I T H T H A T OF A L L O CCUPIED M A L E S , IN E N G L A N D A N D W A L E S , 1900 TO 1902, BIT A G E G R O U PS. Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Mortality from pulmonary tuberculosis. Mortality from other diseases of the re spiratory system. Death rate for potters. Age at death. Death rate per 1,000 for all occu pied males. 15 to 19 years........ 20 to 24 years........ 25 to 34 years........ 35 to 44 vears........ 45 to 54 years........ 55 to 64 years........ 65 years and over. Rate per 1,000. 0.54 1.55 2.03 2.74 3.04 2.16 1.11 IN V E S T IG A T IO N S B Y 0.62 1.34 2.00 3.79 7.14 4.37 .97 Death rate for potters. Greater Ratio ( + ) or less to rate ( —) than for all rate for all occupied occupied males. males. +0.08 - .21 - .03 +1.05 +4.10 +2.21 - .14 115 86 99 138 235 202 87 Death rate per 1,000 for all occu pied males. Rate per 1,000. 0.24 .48 .77 1.66 3.32 6.54 17.77 D E P A R T M E N T A L C O M M IT T E E D IS E A S E S . 0.46 .58 .64 3.29 10.78 23.10 35.04 Greater ( + ) or less ( —) than rate for all occupied males. Ratio to rate for all occupied males. + 0.22 + .10 .13 + 1.63 + 7.46 +16.56 +17.27 192 121 83 198 325 353 197 ON IN D U S T R IA L With further reference, however, to the excessive mortality from respiratory diseases among potters, which, as subsequently to be shown, is confirmed by American industrial insurance mortality ex perience, reference may be made to the discussion of the occurrence of potters’ asthma, in the Report of the Departmental Committee on Industrial Diseases. The evidence submitted to the committee dis closed a decided improvement in the disease liability of potters to the fibroid form of phthisis, based upon the records of the North. Staffordshire Infirmary, at Stoke-upon-Trent, covering the period 1873-1906. Upon a basis of 10,000 patients, the number of cases of fibrosis of the lungs was found to have been 145 during the six years ending with 1878, 107 during the six years ending with 1897, and only 4 during the six years ending with 1906.1 In the opinion of a qualified medical witness, the diminution was not the result of a difference in the practice of diagnosing, but a real reduction in the prevalence of the disease. The improvement in the disease liability was attributed to a betterment in the conditions of work and a more effective method of factory supervision, inspection, and control. Aside from these favorable conclusions, however, the general mor tality statistics of this trade indicate continued unfavorable circum stances, reflected in the decidedly excessive degree of pulmonary tuberculosis frequency and a correspondingly excessive mortality from other respiratory diseases in the more advanced years of life. 1 M inu tes o f E vid en ce, D ep a rtm en ta l C om m ittee o n C om p en sa tion fo r In d u s tria l D is eases, L on d on , 19 0 7, p. 60. 254 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. D E S C R I P T IV E ACCOUNT O F T H E A M E R IC A N P O T T E R Y IN D U S T R Y . These preliminary observations are strongly indicative of an in dustry in which the dust problem is of exceptional importance in its relation to health and longevity. The aggregate value of pottery products in the United States in 1915 was nearly $40,000,000, or al most twice the value reported for 1901. The principal branches of manufacture are (1) red earthenware; (2) stoneware and Rocking ham ware; (3) whiteware, including CC ware; (4) china, bone, delft, and belleek ware; (5) sanitary ware; (6) porcelain, electrical sup plies; (7) miscellaneous. The number of active manufacturing plants in 1913 was 426. The principal pottery-producing States are Ohio, New Jersey, and West Virginia, which, combined, produce 76 per cent of the total product. The pottery industry has been admi rably described in a report of the Bureau of Foreign and Domestic Commerce,1 including descriptive accounts of the various special processes, with observations on methods and labor conditions in other countries. The principal departments of the industry are (1) prepa ration of materials; (2) forming the ware; (3) firing the ware; (4) decorating; (5) packing, etc. Each branch consists by itself of numerous and often highly specialized processes, which do not permit of being briefly described. Practically without exception, however, it may be said that all processes involve more or less dust exposure, the nature of which, of course, will vary considerably according to the product. As a general conclusion, based upon reasonably thor ough investigations in this country and abroad, it may be said that the sanitary and other conditions affecting the health of potters in this country are decidedly better than those which affect the health of potters, for illustration, in England and Wales. The workshops in this country, as a rule, have a greater abundance of light and venti lation and more adequate provision for heating during the winter. The more extensive use of machinery, by which most of the very hard labor in mixing the clay and running the so-called jigger and jolly machines is largely done away with, is also a factor of considerable practical importance. On account of the specific liability to lead poisoning in the pottery industry, it is suggested that the propor tion of lead used in the dipping processes in this country should be generally much less than in England and Wales. The climatic con ditions in the United States are also in favor of a lower mortality rate from respiratory diseases resulting from weather exposure.2 1 T h e P o ttery In d u stry . M iscella n eou s Series, N o. 21. D om estic Com m erce. W a sh in g to n , 1 915 . * L ead P oison in g, by Sir T h o m a s O liver. L ondon, 191 4 . U . S . B u reau Of F oreign an d OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 255 D E S C R IP T IO N OF P R O C E S S E S A C C O R D IN G TO D U ST E X P O S U R E . The disease liability of employees in the various branches of the pottery industry in the United States, roughly approximated, is as follows: 1 1. Office workers, dust exposure very slight and general conditions favorable. 2. General outside laborers, dust exposure slight, but general con ditions often far from favorable. 3. Mixers of materials for glaze, etc., dust exposure very consider able, especially of clay, flint, and white lead. 4. Slip makers, pug-mill workers, etc., considerable dust exposure and dampness. 5. Mold makers, some dust exposure, chiefly to plaster of Paris. 6. Throwers, some dust exposure. Occupation is more or less ob solete. 7. Jigger men and jolly men, considerable dust exposure, but fairly favorable indoor conditions. 8. Pressers of hollow ware, some dust exposure, but fairly favor able indoor conditions. 9. Pressers of flat ware^ some dust exposure, but fairly favorable indoor conditions. 10. Pressers of sanitary ware, a lesser degree of dust exposure, but occasionally considerable dampness. 11. Sagger makers, exposure to dust and dampness and frequently heavy physical strain. 12. Kiln men, placers, considerable exposure to flint dust and other unfavorable conditions. 13. Kiln men, drawers, considerable exposure to dust and fre quently extreme heat. 14. China scourers, brushers (women), very considerable exposure to irritating flint and other dust. 15. Dippers and dipper helpers, exposure to risk of lead poisoning and much dampness. 16. Decorators, printers, and fillers-in, exposure to mineral poisons, lead poison, and atmospheric pollution on account of odor of tur pentine. 17. Ground layers (decorators), very considerable exposure to risk of inhalation of dry dust of mineral paints. 18. Warehousemen, slight degree of exposure to inorganic dust. 19. Packers, considerable exposure to dust of straw and inorganic dust. 20. Sweepers, exceptionally serious exposure to flint and clay dust. 1 T h is liat is based u p on p erson a l in v e stig a tio n s in to tb e p o tte r y i n d u s t r y c h i e f ly in the States o f N ew J e rs e y , O hio, a n d W est V irgin ia . 256 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 21. Flint-mill workers, considerable and continuous exposure to the most dangerous form of irritating flint dust. These observations are only approximate, and it should be consid ered that the different employments are frequently, carried on in conjunction with or in continuance of one another. The most ex posed employments are those of china scourers, ground layers, sweepers, and flint-mill workers. P A T H O LO G Y A N D SY M P TO M O LO G Y O F T H E D U ST P R O B L E M . The pathology and symptomology of the dust problem in the pot tery industry has attracted the serious attention of all authorities on occupational diseases. A concise and exceptionally conclusive though very brief contribution to the study of lung sclerosis in porcelain workers was made by a French authority—Dr. Lemaistre—■ in Le Progres Medical and translated in the Medical Record for December 27, 1890, in connection with which it is stated that— Sections of the lung are generally colored, according to the mate rial that has been introduced; but here the lung is blackish, although the substance introduced may be white, owing to inflammatory con ditions. The symptoms are analogous to tuberculosis and the diag nosis is difficult. The posterior aspect of the lung is most frequently the seat of the sclerosis. Sometimes the sounds of pulmonary em physema or of pleurisy may be heard. It is, however, differentiated from emphysema by the absence of tympanitic sounds. The sputa are characteristic. There is no hectic fever or nocturnal sweating. Men are more frequently attacked than women. He has found bacilli in the sputa and regards the disease as a tubercular fibrosis. The siliceous particles produce ulcerations in the bronchi, upon which the tubercular matter is grafted, and continues to exert an irritant action which induces hyperplasia of the connective tissue. This, to a certain extent, is salutary. P O T T E R S’ A STH M A . Partly in consequence of this condition inimical to the health of pottery employees generally the term “ potters’ asthma ” has been widely accepted as typical of the highly specialized conditions under which respiratory affections resulting from continuous dust exposure in the pottery industry are likely to occur. In a measure potters’ asthma resembles miners phthisis, but it is frequently in distinguishable from true tuberculous phthisis, without the preceding lung fibrosis. It was brought out in the evidence collected by the departmental committee on industrial diseases that china scourers and biscuit placers were probably the most liable to potters’ asthma, but all the indoor occupations in the potteries are more or less af fected, though, of course, to a considerably varying degree. A table was presented by Dr. Dawes of the deaths of potters in Longton, OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 257 Staffordshire, for the period 1898 to 1906, showing conclusively the excessive incidence among potters of deaths from bronchitis, potters’ asthma, and fibroid phthisis. All of these terms are more or less inclusive of each other. C O M P A R A T IV E O C C U P A T IO N A L M O R T A L IT Y S T A T IS T IC S . A table was also introduced into the evidence by Dr. Tatham, based upon the mortality of England and Wales for 1900 to 1902, including comparative statistics for other dusty trades, as follows: Table 9 6 .— C O M P A R A T IV E M O R T A L IT Y F R O M P H T H IS IS A N D D IS E A SE S OF T H E R E S P I R A T O R Y S Y S T E M IN C E R T A IN SP E C IF IE D O C C U P A T IO N S, E N G L A N D A N D W A L E S , 1900 TO 1902. Phthisis and diseases of the respiratory sys tem. Mortality figure. Occupation. Mortality figure. A griculturist.................................................................................. Dock laborer, wharf laborer...................................................... Potter, earthenware, etc., manufacturing............................ Cutler, scissors maker.................................................................. Tin miner......................................................... ............................... Nail, anchor chain, and other iron and steel manufac tures.................................. ............................................................. Stone, slate quarrier................................................................... Brass, bronze, manufacturer, founder, finisher, worker.. Bricklayer, mason, builder........................................................ Ratio. 100 Phthisis. Diseases of respiratory system. 161 632 741 812 1,577 393 460 504 980 79 291 277 516 838 82 341 464 296 739 493 390 469 364 306 242 291 226 182 186 262 188 311 204 207 176 Note.— This table is to be read thus: Among a certain number of males aged 25 to 65 years in the general population, 1,000 deaths occurred during the years 1900 to 1902; of these 1,000 deaths, 186 were due to phthisis and 174 to diseases of the respiratory system. Among an equal number of agriculturists living, at the same ages, there were 79 deaths from phthisis and 82 from diseases of the respiratory system. Among an equal number of dock laborers, 291 and 341, respectively, and so on. R E S U L T S OF S A N IT A R Y IM P R O V E M E N T S . Attention was directed in the evidence to the material improve ment in the health conditions of the pottery industry of England and Wales during the last 30 years, particularly by Dr. Frank Shufflebotham, who presented data relative to the frequency of fibrosis of the lungs as observed in the experience of the North Stafford shire Infirmary, Stoke-upon-Trent, which is a center of the English pottery industry. The seriousness of the existing situation, however, in 1907, when the departmental committee on industrial diseases made its investigations, is concisely set forth in a brief statement by Dr. C. Petgrave Johnson, as follows: I find that during the seven years, 1900-1906, of potters’ pressers living in Stoke, 47 died. Of these, 14 died of bronchitis, 15 of phthisis, and 5 of pneumonia, i. e., over 72 per cent of the deaths were due to lung diseases. If the deaths in the North Stafford In firmary and the Stoke-upon-Trent Union Hospital are included, 106811°— 18— Bull. 231-------17 258 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. then 112 deaths among potters’ pressers occurred in the same seven years. Of these 31 were due to bronchitis, 43 to phthisis, and 4 to pneumonia, i. e., 70 per cent of the deaths were due to lung diseases. These figures are correct. I find that during the seven years, 1900-1906, in not a single in stance in any of the deaths amongst potters’ pressers occurring in the North Stafford Infirmary or in the workhouse hospital or in the borough of Stoke, is fibroid phthisis or potters’ asthma, or cir rhosis of the lungs, or fibroid pneumonia given as the cause of death. Bronchitis, phthisis, pulmonary tuberculosis, pneumonia, are the dis eases of the lungs which are mentioned. I should like to supplement this by stating that the changes in the lungs caused by particles of dust progress very ^lowly, years pass ing during the development. Should tuberculosis of the lungs super vene, the man dies in a comparatively short time, and any lung changes due to dust do not attract attention. Should bronchitis de velop, however, he survives for years, and latterly, in the intervals— if any—of comparative freedom from bronchitis, the lung changes due to dust may attract attention or may not. The bronchitis symp toms, however, always attract more attention. IN JU R I O U S N E S S OF SC O U R IN G P R O C E SS. These general observations concerning the pottery industry as a whole are amplified by an extensive amount of evidence concern ing health-injurious processes in detail. Concerning china scouring, for illustration, it is said in the report of the chief inspector of factories and workshops for 1908, that— “ Scouring ” is one of the many operations to which china is sub jected during the course of its manufacture and is comparatively simple, being, in fact, merely subsidiary to the manufacturing proc ess. In order to prevent the pieces of soft unbaked clay from be coming fused to each other, or to sides of the saggers in which they are placed during the firing in the kiln, each piece is separately buried in a bed of fine flint dust with which the sagger is filled. After the firing is accomplished this flint dust, which resembles fine sand, has to be removed. The heat causes a considerable portion of it to become fused to the surface of the baked ware to which it adheres, and it is therefore necessary to get rid of this by scrubbing each piece of ware with a dry and very stiff brush. The operation, as its name implies, is more drastic than that of mere dusting. The piece is first uknocked” and the sharp jars cause the loose dust to fall off, then scrubbed with a revolving motion with a stiff brush (often worked by power), and then it is rubbed with coarse flannel; finally, the re mains of the rough adhering particles are smoothed off by means of sandpaper. From this description it will be seen that the operation is a very dusty one. IN JU R I O U S N E S S OF F L I N T D U ST. Attention is directed in this statement to the difference between china scouring and earthenware “ towing,” it being stated that in earthenware the material to be removed is soft clay dust, while in OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 259 china it is a very finely ground flint, the microscopical particles of which are sharp and jagged. The conditions are particularly unfa vorable in small plants where rules and regulations regarding mechani cal methods of dust removal can not be effectively applied except at prohibitive expense. At the same time it is thoroughly well recog nized, and as pointed out in the report referred to, that “ a micro scopic examination of the flint in which china is bedded shows that owing to the shape of the particles it forms one of the most mechani cally injurious of all dusts.” And in the Staffordshire district the relation of this dust to pulmonary tuberculosis is so well known that death certificates frequently merely mention as cause of death the significant term “ flint.” Since most of this work is done by women, in the United States as well as in England and on the Continent, the mortality data, usually limited to males, have not become available. A special investigation, however, was made in the Longton district concerning the female population, with the result shown in Table 97. 9 7 . — M O R T A L IT Y F R O M R E S P I R A T O R Y D IS E A SE S (IN C L U D IN G P H T H IS IS ) IN L O N G T O N : C H IN A SC O U R E R S A N D T O T A L F E M A L E P O P U L A T IO N C O M P A R E D , 1896 TO 1898. T a .b le [Rates are based on female population in 1891 (10,561) and number of cliina scourers in 1898 (160), ages 15 to 70.1 Deaths from respiratory diseases phthisis) among— A ll females. Year. Number. 1896...................................................................................................... 1S97...................................................................................................... 1S98 1.................................................................................................. 45 49 29 (including China scourers. Rate per per annum. 1,000 4.3 4.6 5.5 Number. 12 11 6 Rate per per annum. 1,000 75.0 68.9 75.0 1 From January to June. The data, of course, are of rather limited extent, but they are quite sufficient for the purpose of emphasizing the extreme injuriousness of china scouring as carried on under existing conditions which, as a general rule, preclude adequate consideration of effective methods for the control of the dust evil. As is well said in connection with the foregoing table in the report referred to— In order to reduce the appalling death rate shown in the table it is necessary to prevent the inhalation of flint by the workers. It is a fact that every form of dust produced during the course of a manu facturing process can be extracted from the workroom by means of a sufficient number of properly placed and efficiently contrived ex haust fans. The important point is that this should be done in such a manner as to prevent the dust from becoming dispersed in the air or from being drawn past the faces of the workers. In several fac tories we found that fans had been introduced, and when these were 260 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. efficient the atmosphere and the clothes of the women themselves were strikingly free from flint. In two factories we found substitutes for a fan, but we observed no difference between these and the places in which there were no means of removing the dust; in most cases the benches are placed directly in front of the windows, so that when these are open the dust is blown directly into the faces of the workers. The structural conditions of some of the smaller china factories are such that we are in agreement with the opinion of the medical mem bers of the committee of 1893, and with that expressed in the special report of Profs. Thorpe and Oliver that u they are wholly or in part unfitted for use as work places, inasmuch as work can not be carried on in them without injury to health.55 In others, however, alterations entailing a small expense would very materially improve the conditions, while in ail, so long as they are permitted to remain in use, effective means of drawing off the clouds of unhealthy dust are a necessity. C Q N T IN U O U S N E SS OF I N JU R I O U S C O N D IT IO N S. This lamentable condition has remained practically unchanged in the pottery industry since its development on a large scale, for, as shqwn by the evidence before the royal commission of 1841,1 inquiring into the employment of children and young persons, the excessive frequency of respiratory diseases resulting from exposure to flint and other dust was thoroughly well recognized at the time but con sidered inherent in the conditions under which the industry was car ried on. Conditions in this country have not been subjected to an equally thoroughgoing scientific investigation, but the recorded ob servations of factory inspectors, health officials, and others quite fully confirm the prevailing view that while the health and mortality of potters in America are more favorable this is chiefly because of better sanitary surroundings, housing, food, etc., higher wages and shorter hours, and a decidedly lesser incidence of habits of intoxication. Dr. H. E. M. Landis, of the Phipps Institute of Philadelphia, in an in vestigation regarding American potteries points out that— His own observations had led him to believe that more care should he exercised on the part of the workmen in the disposal of the frag ments of clay which were thrown off in the fashioning of the various utensils. Too much of it was allowed to fall on the floor about the work bench, and as a result was walked upon and quickly pulverized into dust. Face masks had been repeatedly advocated, but had never been particularly successful, for the reason that the wrorkmen were averse to using them. He believed that these individuals, especially those working in the dusty departments, should be subjected to fre quent medical inspections. A compulsory examination three or four times a year would undoubtedly result in detecting many cases which would otherwise pass into the terminal stages of potters’ asthma or tuberculosis.2 1 P h y sica l and M oral C on d ition o f the C h ildren and Y ou n g P erson s E m p loy ed in M ines and M a n u fa ctu res, L on d on , 1843. 2 M ed ica l R e co rd , J u ly 25, 1914. OCCUPATIONS W IT H EXPOSURE TO M IN E R A L DUST. 261 S A N I T A R Y A S P E C T S OF T H E P O T T E R Y IN D U S T R Y IN OHIO. Hayhurst in his numerous reports on industrial conditions in Ohio has extensively dealt with the pottery industry, and in a gen eral way the results of his investigations confirm conclusions based upon foreign experience. Concerning slip making, which means the removing of the clays in the form of dust and lumps from the stock bins, followed by grinding, water washing, and ^sifting proc esses, through the use of pug mills, agitators, compressing machines, and drying kilns, the dust hazard was found to be serious in 23 work places, fairly serious in 6, and of small importance in 9, out of a total of 38. It was found that the chief causes of dust in the atmos phere in connection with slip making were the more or less constant shoveling of clays in the dry form, its escape from grinding ma chines, and its being raised from the floor by moving air currents, etc. In 20 of the places dampness was an additional occupational hazard, chiefly because of faulty floor drainage, leaky vats, etc. The general appearance of the workers was not more than fair in 30 of the 38 work places. Many prematurely aged, pale, and under weight men were seen among those longest employed. According to a report in the Ohio Public Health Journal for January-March, 1916, “ the chief complaints of the workers were the breathing of dust, damp quarters, heat, fatigue, poor washing facilities, and general insanitary quarters.” Excepting, however, the dust hazard, none of the other conditions was considered seriously injurious to health. I N JU R I O U S N E S S OF F L I N T -D U S T M A K IN G . Flint-dust making without question is the most hazardous process in the pottery industry. Only a few of the large firms were found to employ this process on their own account, but the attention of the investigators was directed to two firms employing foreign laborers engaged in making this product, which involves crushing, grinding, conveying, and packing, in connection with all of which there was observed “ an unusual amount of fine, hard flint dust, which pervaded the air of the work place and coated the openings of windows, doors, and roof vents with a white flourlike powder.” It is, therefore, properly suggested that dust-confining machinery, short hours, and respirators are needed in all such places. M OLD AN D SA G G E R M A K IN G . In the same investigation the process of mold making was reported upon for 16 plants. The molds are made of plaster of Paris, which involves considerable exposure to a recognized injurious form of mineral dust. Health appliances to handle and confine the dust 262 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES, mechanically were found to be absent in all places. In 10 of the 16 places the dust was considered to constitute a fairly serious health hazard. In 10 of the work places the appearance of the workers was considered unsatisfactory. The chief complaint was on account of the breathing of the dust and general unsanitary features. It is suggested that it would appear “ that mechanical means could bo contrived to convey and weigh the dusts used, for being a dusty oc cupation and an injurious type of dust, workers should be under medical supervision, and, in addition, respirators should be furnished and worn during the performance of unavoidably dusty operations.” Sagger making is described by Hayhurst as consisting in the mak ing, shaping, baking, finishing, and repairing of the clay containers in which the pottery ware is baked in the kilns. This occupation employs relatively few persons in the pottery industry. The dust factor was considered of importance in 10 out of 19 plants investi gated. The chief cause of the dust was 44the careless handling and dumping of clays and the disturbance of the dust on the floors and benches by the workmen or by air currents.” The chief occupational hazard, however, was not the dust, but the liability to chronic lead poisoning. The general complaint was on account of the breathing of dust and exposure to dampness, with resulting liability to rheuma tism. Heat exposure was not considered serious. JIGGERMEN, JOLLYMEN, AND PRESSERS* Pottery-making processes proper include the work of the throwers, the jiggermen, the jollymen, and the pressers. More precisely the employments in the Ohio pottery industry are stated by Hayhurst to include 44batters-out, pressers, jiggermen, jollymen, turners, han dlers, stickers-up, dish-specialty makers, finishers, machine pressers, mold boys (called also mold runners and dog trotters), and helpers.” The processes in connection with these employments were investi gated in 53 plants, including all branches of the industry, employing 3,048 wage earners, of whom 2,521, or 82.7 per cent, were males and 527, or 17.3 per cent, were females. The majority of all potters, it is stated, are employed in the bisque-making rooms. The class of work ers was found to be mostly native and above the average. In 40 of the work places the employees were found to be exposed to a con siderable hazard on account of the breathing of fine clay dust. Some machine pressrooms were free from dust, but others were very dirty, apparently because clays were handled drier. The finishers, chiefly women, who scrape rapidly revolving articles, ran the greatest dust hazard, while the mold boys and helpers, who handled the dried bisques in the ovens, suffered next in hazards. In no places were local exhaust systems found for the protection of finishers. Dampness OCCUPATIONS W IT H EXPOSURE JO MINEEAL BUST. 263 was quite common and was found to be a serious hazard in 25 of the work places investigated. Complaint was made of insufficient heat ing, and poor ventilation was reported in more than half of the plants investigated, especially during the winter months. The basis of this 'complaint was the large number of work people assembled together, the presence of the baking ovens, and the lack of air agita tors and air-conditioning systems, and often to the absence of ordi nary vents in types of buildings which it was impossible to ventilate sufficiently without mechanical means. The general appearance of the workers was favorable in only 10 places, but in the balance many fatigued, under-weight, and physically inferior employees were ob served. The usual complaints were on account of the heat, fatigue, dust, poor ventilation, dampness, and cold. It is held that this particular process is the chief source of tuberculosis in the pottery industry, and that many instances of the disease were brought to the attention of the investigators of the Ohio State Board of Health by both workmen and employers, usually, however, with the informa tion that its occurrence was unavoidable. Among the hygienic short comings pointed out, the investigation emphasized the injurious nature of atmospheric changes and the absence of physical examina tion. Attention is directed to the fact that pneumonia is a frequent occupational disease among those who inhale clay and other mineral dust, The generally dust-contaminated nature of the atmosphere in the workrooms was sufficiently established to justify the conclusions arrived at. Similar conclusions apply more or less to other processes in the pottery industry, the dangers of which in some cases, however, are materially increased by the risk of lead poisoning. How far there is a possible relation between lead poisoning and pulmonary tuber culosis has not been determined.1 It is, however, fair to assume that whatever conditions result in a diminution of vital resistance gener ally must more or less act as a predisposing cause of pulmonary tuberculosis. LEAD POISONING AND PULMONARY DISEASES. The dangers of lead poisoning in the pottery industry have been reported upon in numerous official investigations, including Bulletin 104 of the United States Bureau of Labor Statistics. Dr. George Reid, in a discussion of the evidence of the departmental committee appointed to inquire into the dangers attendant on the use of lead in the manufacture of earthenware and china, published by the 1 Sir Thom as Oliver, in M s “ Lead Poisoning/* London, 1914, pp. 83—88, carefully con siders the question as to whether or not lead poisoning of itself predisposes to tuberculosis, including the opinion of Prof. Hahn of Munich and the animal experimentation of G. Loriga. Oliver concludes that 4t the only way in which it can do so is by reducing the general vital resistance of the individual.” 264 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. British Government in 1910, raises, however, a very important ques tion when, according to the British Medical Journal (Sept. 24, 1910), he remarks that, “ without minimizing the gravity of the situation so far as lead poisoning is concerned, the mortality from this cause is a cipher compared with the deaths from phthisis and respiratory diseases—the death rate from plumbism per 1,000 being 0.81 com pared with 7.05 for phthisis.” In the same publication it is said that another interesting and far-reaching problem, which was also raised by Dr. Reid, was with reference to compensation in cases of lung diseases among potters, which is referred to as a problem bristling with difficulties. In proportion, of course, as industrial lung diseases are brought within the range of workmen's compensation for indus trial injuries, as possibly quite separate and distinct from industrial diseases in the strictly limited sense of the term, the necessary methods and means of dust prevention will receive more adequate considera tion. The report of the departmental committee on the pottery trade is one of the most important contributions to the literature of occu pational diseases, and although chiefly with reference to the dangers of lead poisoning, the report includes a mass of related evidence of exceptional usefulness in general consideration of the health prob lem in industry. The investigation of the special committee included 550 pottery works employing 63,000 persons and 7 lithographic trans fer works. It was found that out of 63,000 workers 6,856, or 11 per cent, were brought in contact with lead, whereas 23,000, or 37 per cent, were exposed to the inhalation of dust. The latter conclu sion, however, must be accepted in a restricted sense, since the com mittee apparently concerned itself only with dust obviously seri ously injurious and sufficiently determinable as to quantity and health-injurious qualities. It is difficult to accept the conclusion that 53 per cent of the workers in English potteries, as stated in a letter in the Journal of the American Medical Association, dated London, July 9, 1910, “ are not exposed to any particular danger to health.” Investigations in this country, particularly in Ohio, indicate that a much smaller proportion of pottery employees is engaged in rela tively harmless employments. MORTALITY OF POTTERS— UNITED STATES REGISTRATION AREA. The mortality of potters has been reported upon only for the year 1909 by the Division of Vital Statistics of the United States Census Bureau and no subsequent information has been made public, so that the data are of rather limited value. This is particularly regrettable in the case of so important an occupation as the pottery industry, for the mortality returns for the United States registration area for the OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 265 year referred to are limited to 136 deaths from all causes, of which 47, or 34.6 per cent, were from pulmonary tuberculosis. The details of the mortality by divisional periods of life are shown in Table 98. T able 9 8 .—P R O P O R T IO N A T E M O R T A L IT Y OP P O T T E R S FR O M P U L M O N A R Y T U B E R CULOSIS, U N ITE D STATE S R E G IS T R A T IO N A R E A , 1909, B Y A G E GROUPS. Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years ......................... .................................... ................ 25 to 34 vears ___ . . . . . . . . . . . . . . . ............. .................. ............. . 35 to 44 vears .................................. - - ................................*................. 45 to 54 years*................................................................................................ 55 to 64 years ...................................................................... - ............ - ........ C5 years and over....... ......................................................... 13 27 26 32 12 26 6 12 11 12 5 1 46.2 44.4 42.3 37.5 41.7 3.8 Total 15 years and over..................................................... ............. 136 47 34.6 T able 9 9 .—P R O P O R T IO N A T E M O R T A L IT Y OF P O T T E R S FROM N O N T U B E R C U L O U S R E S P IR A T O R Y DISEASES, U N ITE D STATE S R E G IS T R A T IO N A R E A , 1909. Deaths from nontuberc u 1o u s respiratory diseases. Cause of death. Number. Per cent of deaths from all causes. B ron ch itis........................................................................................................... Pneumonia ........................................................ ............................. . Other nontuberculous respiratory diseases................................................................... 1 1 9 6 6. 7 4.4 Totak.......................................................................................................................... 17 12.5 0. 7 *7 Table 98, although limited to a relatively small number of deaths, quite conclusively sustains the results of other investigations as re gards the excessive frequency of pulmonary tuberculosis in the pot tery industry throughout practically the entire working period of life. Aside from the distinctly excessive proportion of deaths from pulmonary tuberculosis the mortality from nontuberculous respira tory diseases, shown in Table 99, is also excessive, or 12.5 per cent, compared with 9.2 per cent for glassworkers and 10 per cent for all occupied males, according to data received from the same official American sources. MORTALITY OF POTTERY EMPLOYEES—MEDICO-ACTUARIAL EXPERIENCE. The only really conclusive statistics regarding the mortality of potters in the United States are derived from life insurance experi ence. As a general rule both life insurance companies and frater- 2 66 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. nal societies are extremely cautious in accepting risks on the lives of persons employed in at least the more health-injurious processes of the pottery industry. Dippers, fiint-mill workers, ground layers, mixers, scourers, and sweepers are generally declined, uncondition ally. Kilnmen, mold makers, placers, pug-mill workers, sagger makers, and slip makers are occasionally accepted, but at somewhat higher premium rates than those charged men in recognized healthy employments. Most of the risks accepted in the pottery industry include decorators, fillers-in, jiggermen, jollymen, pressers, printers, throwers, and warehousemen. These observations require considera tion in view of the results of the medico-actuarial investigation con cerning pottery employees, chiefly molders, excluding foremen and superintendents. T able 1 0 0 .—M O R T A L IT Y FR O M A L L CAUSES AMONG P O T T E R Y E M P L O Y E E S (C H IE F L Y M O LD E RS, E X C L U D IN G F O R E M E N A N D S U P E R IN T E N D E N T S ) B Y A G E G R O U PS. [Medico-Actuarial Investigation.] Age at death. Number exposed to risk one year. 15 to 29 years....... - .................................................................. 30 to 39 years ......... ................................................................ 1,194 999 59 t o -59 years ....................................................................... 00 years mid over.................................................................... Total............................................................................... Actual deaths. Expected deaths. Ratio of actual to expected deaths. 45 16 13 9 4 1 1 5.44 5.93 3. 68 .66 .74 239 152 109 152 135 2,645 28 16.45 170 3 9 1; It is shown in Table 100 that the general mortality of pottery em ployees, subject to the preceding qualifications, is 70 per cent in excess of the expected. The small number of risks under observation pre cludes final conclusions, but the data are decidedly suggestive of dis tinctly health-injurious conditions inherent in the American pottery industry, even after excluding the recognized unhealthy branches of the trade. In industrial insurance no such discriminations pre vail, all employments being accepted. Unfortunately, in the mortal ity returns the death certificates frequently fail to state the precise occupation, and on account of the peculiar nomenclature common to the pottery industry there is a considerable degree of confusion. Thus decorators, pressers, printers, warehousemen, sweepers, etc-, may be returned under entirely different occupational terms unless it is specifically stated that the employment was in connection with the pottery industry. MORTALITY OP POTTERS— INDUSTRIAL INSURANCE EXPERIENCE. In Table 101, derived from the industrial insurance experience of the Prudential Insurance Co- of America, the term “ pot ters ” is limited to only such deaths as were clearly of persons con OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 267 nected with the pottery industry, which, in part, explains the rather limited mortality under observation. The table includes 801 deaths of potters from all causes, of which 258, or 32.2 per cent, were from pulmonary tuberculosis. 1 0 1 .—P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O SIS AM ONG P O T T E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D STA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A GE GROU PS. table Deaths of potters, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. A ll causes. 15 to 24 years........................................................................ 25 to 34 years........................................................................ 35 to 44 years........................................................................ 45 to 54 years........................................................................ 55 to 64 years........................................................................ 65 years and over............................................................... Total, 15 years and over . ........................... . Pulmonary tubercu losis. Potters. Males in registration a re a ,1900 to 1913. 77 137 181 172 147 87 24 68 72 52 31 11 31.2 49.6 39.8 30.2 21.1 12.6 27.0 30.5 23.4 14.7 7.9 2.6 801 258 32.2 13.9 The table exhibits an excessive frequency of pulmonary tuberculosis at all ages; in fact, an extremely high proportion is maintained throughout the older ages when in the general experience other dis eases tend to predominate. The experience confirms the preceding observations and conclusions derived from American and foreign experience, that the pottery industry in general, and among many of the more specialized processes in particular, must be considered seriously injurious to health and life, and for the reasons stated the requirement of thoroughgoing sanitary rules and regulations is selfevident. While there has been some progress in the direction of im proved methods of factory supervision in this country with special reference to the pottery industry, we are as yet far from having at tained to the more well-considered governmental practices of Euro pean countries. FOREIGN SANITARY REGULATIONS OF THE POTTERY INDUSTRY. Attention may be directed in this connection to the regulations adopted under date of January 2, 1913, by the British Government with special reference to the manufacture and decoration of pottery, reprinted in a special bulletin of the New York Department of Labor.1 The particular regulations concerning the suppression of dust, the use of respirators, and ventilation are as follows: 1 E u rop ea n R eg u la tion s fo r P re v e n tio n o f O ccu p a tio n a l D iseases. S pecial B u lletin N o. 76, pu b lish ed by the N ew Y ork S ta te In d u s tria l C om m ission, A lb a n y , March* 1916. 268 MORTALITY FROM RESPIRATORY DISEASES R e g u l a t io n s for the S u p p r e s s io n IN of D DUSTY TRADES. ust. ( a) The following processes shall not be carried on without the use of an efficient exhaust draft: (i) The fettling of flat ware, whether china or earthenware, by towing or sandpapering, provided that this shall not apply to the occasional finishing of pieces of china or earthenware without the aid of mechanical power; ( ii) The sand-sticking of sanitary ware; (iii) Any other process of fettling on a wheel driven by mechanical power, except where: (a) The fettler is fettling, as an occasional operation, only ware of his or her own making; or ( b ) The fettling is done wholly with a wet sponge or other moist material; or ( c) The fettling is done by the worker who has made the articles, whilst the latter are still in a moist state. (iv) The sifting of clay dust for making tiles or other articles by pres sure, except where: ( a) This is done in a machine so inclosed as effectually to prevent the escape of dust; or ( b ) The material to be sifted is so damp that no dust can oe given off. (v) The pressing of tiles from clay dust; an exhaust opening being connected with each press; this clause shall also apply to the pressing from clay dust of articles other than tiles, unless the material is so damp that no dust is given off. (vi) The fettling of tiles made from clay dust by pressure, except where the fettling is done wholly on or with damp material; this clause shall also apply to the fettling of other articles made from clay dust, unless the material is so damp that no dust is given off. (vii) The processes of bedding and flinting. (viii) The brushing of earthenware biscuit, unless the process is carried on in a room provided with efficient general mechanical ventilation or other ventilation which is certified by the inspector of factories for the district as adequate, having regard to all the circumstances of the case. (ix) Scouring of biscuit wrare which has been fired in powdered flint, except where this is done in machines so inclosed as effectively to pre vent the escape of dust. (x) Batting of biscuit ware which has been fired in powdered flint. (xi) Glaze blowing. (xii) Ware cleaning after the application of glaze by dipping or other process, except as set forth later in this regulation. (xiii) The preparation or weighing out of flow material which yields to dilute hydrochloric acid more than 5 per cent of its dry weight of a soluble lead compound calculated as lead monoxide when determined in the manner described in the definition of low solubility glaze. (xiv) The lawning of dry colors, except where not more than an ounce at a time is lawned for use in painting. (xv) Ground laying, including the wiping off of color after its applica tion to the surface of the ware. (xvi) Color dusting, whether underglaze or on-glaze, including the wiping off of color after its application to the surface of the ware. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 269 (xvii) Color blowing or aerographing, whether underglaze or on-glaze. including the wiping off of color after its application to the surface of the ware. (xviii) The making of lithographic transfers, including the wiping off * of color after its application to the surface of the transfer sheets. ( b) In the process of mold making, every bin or similar receptacle used for holding plaster of Paris shall be provided with an efficient exhaust draft so arranged as to prevent the escape of plaster of Paris dust into the air of the work place, except where a cover is provided for the bin or other recep tacle and the plaster of Paris is conveyed in a sack, the mouth of which is tied and only loosened after it has been placed in the bin or other receptacle. (c) The dry grinding of materials for pottery bodies shall be done either with an efficient exhaust draft for the removal of dust, or in machines so inclosed as effectually to prevent the escape of dust; except that it shall not be deemed necessary in pursuance of this regulation to provide an ex haust draft to remove small amounts of dust given off at the hopper of an inclosed machine in the course of feeding the same, if an outlet into an exhaust duct or to the outside air is fitted to the receptacle into which the powdered material is delivered. (cl) In the process of sand sticking of sanitary ware, suitable provisi m shall be made for collecting any material which falls on the floor. ( e) In the process of making tiles from clay dust by pressure, supplies of material shall be conveyed to the •workbenches in such a manner as to dis perse as little dust as possible into the a ir; clay dust shall not be carried into any press shop in sacks except where hoppers or similar receptacles are provided for receiving the clay dust, in which case a sack in sound repair shall be used and the mouth of the sack shall be tied and only loosened after it has been placed in the hopper or other receptacle, which shall be provided with a cover. This clause shall also apply to the making from clay dust of articles other than tiles, unless the material is so damp that no dust is given off. (/) After one year from the date on which these regulations come into force, biscuit flat ware which has been bedded for firing shall not be removed from the saggers after firing, except at a bench fitted with an efficient exhaust appliance for the removal of dust. ( g) Flat knocking and fired-flint shifting shall be carried on only in in closed receptacles, which shall be connected with an efficient exhaust draft, unless so contrived as to prevent effectually the escape of dust. (Ji) In the process of wTare cleaning of earthenware after the application of glaze by dipping or other process, wherever it is practicable to use damp sponges or other damp materials they shall be provided in addition to the knife or other instrument, and shall be used. (7c) Nothing in these regulations shall render it compulsory to provide an exhaust draft for ware cleaning if this process is carried on entirely with the use of wet materials; or if the ware cleaning be done within 15 minutes after the moment when the glaze was applied; but an efficient ex haust draft shall always be provided and used if any dry materials or im plements, such as knives or scrapers, are used after the glaze is dry or more than 15 minutes after the moment when the glaze was applied. (I) In the process of ware cleaning, after the application of glaze by dipping or other process, sufficient arrangements shall be made for any glaze scraped off, which is not removed by the exhaust draft, to fall into water. All water troughs or other receptacles provided in pursuance of this clause 270 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. shall be cleaned out and supplied with fresh water as often as necessary, and in r o case less often than once a week; and no scrapings of glaze shall be allowed to collect in a dry condition on the sides of the water receptacle. Where grids or gratings are fitted over the water trough or other receptacle named in the foregoing paragraph, they shall be kept clean by repeated spong ing or wiping with wet material during the time that the process of ware cleaning is being carried on. No boards or other articles shall be placed, even temporarily, on any such water trough, in such a way as to interfere with the efficient use of the trough. { m) In all processes the occupier shall, as far as practicable, adopt efficient measures for the removal of dust and for the prevention of any injurious effects arising therefrom. ( n) Every process for which an exhaust draft is prescribed shall be carried on inside a hood or exhaust funnel, provided that where the occupier can show that this is impracticable it shall be sufficient if the work is done within the effective range of an exhaust opening. R e s p ir a t o r s . ( a) No person shall be allowed to work without wearing a suitable and efficient respirator, such as a damp sponge tied across the mouth and nostrils, in any of the following processes: (i) The emptying of sacks of plaster of Paris into a bin in a moldmaking shop. (ii) The weighing out, shoveling, or mixing of unfritted lead com pounds in the preparation or manufacture of frits, glazes, or colors con taining lead, or any process carried on in a room wherein any such weighing out, shoveling, or mixing has taken place within the previous 30 minutes. unless an efficient exhaust draft is provided to prevent the escape of dust into the air of the work place. (&) All respirators required by this regulation shall be provided and main tained in a cleanly state by the occupier, and each respirator shall bear the distinguishing mark of the worker to whom it is supplied. V e n t ix a t io n . ( а) Every place in which any worker or workers are employed shall be thoroughly ventilated. (б) All workrooms in which articles are left to dry shall be ventilated in such a way as to insure a continuous movement of the air in the room in a direction away from the workers and toward the articles in question. (c) All drying stoves shall be ventilated direct to the outside air by shafts having upward inclinations and terminating vertically or by louvers in the roof or by other effective means. ( d) All mangles shall be so ventilated as to provide for the maintenance of a flow of air into the hot chamber from the adjoining workroom. In the case of vertical or “ tower ” mangles : (i) The pipes for heating the mangle shall be fixed above the top of any opening at which workers put in or take off ware; and (ii) There shall be a free outlet into the air above so formed and placed as to insure an outflow whatever the direction of the wind. ( e ) Fresh air shall, where practicable, be admitted to all workrooms by inlets placed along the sides of the room at a height of as nearly as possible OCCUPATIONS W IT H EXPOSURE TO MINERAL BUST. 271 6 feet above the floor level, hopper opening being used for the purpose wherever possible. ( /) Where it is not practicable to provide such fresh air inlets arrangements shall be made for the entry of an adequate amount of pure air by a flue with apertures at intervals along its length or other means, which will secure an even distribution o f the air through the room. (g ) In no case shall fresh-air inlets be so arranged that a -draft can blow direct from them onto any worker. ( h ) Wherever the natural air currents are found to l)e insufficient without assistance to afford thorough ventilation, exhaust fans, or other artificial means of creating a •current o f air shall be provided and maintained In use. (1c) Where an exhaust draft is provided for the removal of dust generated in a manufacturing process precautions shall be taken to prevent dust being drawn into the general atmosphere of the room from other sources of dust in places in the vicinity; communication with sueh places shall be stopped wher ever possible, and the fresh-air inlets hereinbefore mentioned shall be so arranged as to insure that no extraneous dust is drawn toward the workers by the exhaust draft. GENERAL CONCLUSIONS. These rules find regulations are an admirable illustration of really effective methods by which the intrinsic health-injurious factors in a given industry can be reduced to a practically attainable minimum. The conclusions, while specifically applicable to the pot tery industry, are equally suggestive of a far-reaching reduction of occupational hazards in other dusty trades. P AINT A N D COLOR WORKERS. The dust hazard in paint and color manufacture is chiefly of a mineral nature, but the use of metallic substances frequently includes industrial poisons which it must be assumed tend to increase the resulting hazard to health and life. Antimony, arsenic, chromium, lead, manganese, mercury, zinc, etc., are the usual ingredients of paints and colors used extensively in the industries and arts. Mineral paints are divided into three groups— (1) natural mineral pigments, (2) pigments made directly from ores, and (3) chemically manu factured pigments, all of which during ordinary processes of manu facture expose the workmen to a considerable amount of dust. Many minerals or mineral products, it is stated in the annual report of the United States Geological Survey.for 1914, by James M. Hill, u are used in the paint trade, such as asbestos and products derived from it, aluminium, asphalt, barytes, clay, graphite, gypsum, magnesite, mica, pyrite, quicksilver, shells, silica, talc, tripoli, and many by products.” CHEMICAL ASPECTS OE PAINT MANUFACTURE. How far these wide variations in the basic nature of the materials used affect health and life with special reference to pulmonary tuberculosis is at the present time not even a matter of scientific con 272 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY. TRADES. jecture. The natural mineral pigments which constitute an important group, comprise, according to the same authority, “ ocher, umber, sienna, ground slate and shale, metallic paint, and mortar colors.” The three ores of iron, hematite, siderite, and limonite, are the basic constituents of metallic paints which enter to a considerable extent into numerous processes of manufacture directly or indirectly, as the case may be. Pigments made directly from ores, it is stated, comprise zinc oxide, leaded zinc oxide, sublimated white lead, and sublimated blue lead.1 In the chemically manufactured pigments basic carbonate white lead, litharge, red lead, orange mineral, lithophone, and Venetian red are extensively used. The importance of the mineral paint industry is best illustrated by the statement that during 1914 the United States product was valued at nearly $10,000,000. EXPOSURE TO METALLIC DUST. The amount of metallic dust in paint manufacture would be rela tively unimportant were it not for the frequently poisonous nature of the substances used. As observed by W. Gilman Thompson with reference to white lead, the material is first dried, then pulverized, and diluted with oil and pigment, in connection with which processes the dust hazard is quite important, while there exists the additional risk of an increased susceptibility to pulmonary tuberculosis. Paint ers, in connection with the use of paints, are probably exposed to a jesser liability to dust inhalation than is common to dry-color grind ing and related processes, but it is quite possible that the risk of lead poisoning is more serious. HYGIENE OF THE PAINTERS’ TRADE. The hygiene of the painters’ trade has been reported upon with admirable completeness, but with special reference to industrial poisoning, by Alice Hamilton, M. D., in Bulletin 120 of the United States Bureau of Labor Statistics. The importance of dust as a cause of lead poisoning is emphasized by Dr. Hamilton, it being stated that British experiments show that lead enters the bronchial tubes and lungs and even penetrates the capillaries, thus reaching the blood stream. She refers to German authorities as holding that “ if any lead is absorbed through the respiratory tract, it must be small in amount, and while it is true that the breathing of lead dust causes poisoning, this is not because the lead reaches the bronchial tubes, but because it is caught in the mouth and throat, mixed with the saliva, and swallowed.” Lehmann, a German authority, is quoted to the effect that44the great bulk of the inhaled dust finds its way into the stomach and not into the lungs.” It is said that the dust lodges on the nasal and pharyngeal mucous membrane, and that 1 Lead and Zinc Pigments, by Clifford Dyer Holley, M. S., Ph. D.f New York, 1909. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 273 the dust-laden secretions are then swallowed. It is estimated that at most less than one-fourth of the dust reaches the lungs. Soluble dusts are easily absorbed, and the conclusion is advanced that, irre spective of the theory accepted, “ there is no question that poisoning takes place more rapidly the dustier the occupation, and therefore those parts of the painters’ trade that are accompanied by dust pro duction are the most dangerous.” These observations bear directly upon the broader question of in creased liability to pulmonary tuberculosis in consequence of metallic or mineral dust inhalation. The serious importance of lead poison ing in paint manufacture and the painters’ trade probably account for the very limited consideration which has been given to the equally important question of a possibly enhanced liability to pulmonary tuberculosis. SANITARY CONDITIONS IN THE GERMAN PAINT INDUSTRY. The most important investigation into the health of persons em ployed in the manufacture of paint was published in 1893 through the cooperation of the color manufacturers, Meister, Lucius & Briining, of Hochst a. M., and Dr. Grandhomme, who thoroughly examined into the sickness experience for the preceding decade and whose ob servations include the results of a study of factory conditions, raw materials, and the processes of manufacture in detail, but with special reference to the analine-dye industry.1 On account of the excellence of hygienic precautions and the emphasis placed upon the personal hygiene of the workmen, the observed experience is probably not con clusive with regard to paint and color factories in the United States. The amount of sickness was relatively high and apparently on the increase, but the average duration of the sickness was comparatively favorable, having varied between 5 and 9 days per case and between 4.1 and 8.4 days per workman per annum. The medical results of the investigation are too involved to permit of a brief analysis, but with special reference to pulmonary tuberculosis it may be said that the number of cases observed was apparently not excessive. Of the entire morbidity, including 18,723 cases of sickness, 2,762, or 14.7 per cent, were attributed to diseases of the respiratory organs, including pulmonary tuberculosis. The mortality from all causes during the period 1883-1892 was 7 per 1,000, which can not be considered exces sive, although the proportion of young persons employed was prob ably relatively high. Out of 126 deaths from all causes, 55 were from pulmonary tuberculosis, 11 from pneumonia, and 12 from other respiratory diseases. An excessive amount of mortality from tuber culosis and other respiratory diseases is, therefore, conclusively 1 Die Fabriken der Aktien-Gesellschaft Farbwerke vorm. Meister, Lucius & Bruning zu Hochst a. M., Frankfurt a. M., 1893. 106S110— 18— Bull. 231------ 1? 274 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. brought out by the mortality analysis, although apparently in con tradiction to the morbidity experience. This is in part explained by the relative frequency of digestive disorders and general nutritional disturbances, as well as affections of the skin. Aside from the con siderable number of cases of industrial injuries, as far as the expe rience permits of a definite conclusion, it would appear that the mor tality from pulmonary tuberculosis in the German paint and color industry, even under a well-considered plan of hygienic supervision is unduly high, and that it is safe to assume that the excess in the incidence of the disease is directly attributable to the more or less considerable risk of continuous inhalation of metallic and mineral dust, increased in the severity of its effects by the presence of poison ous substances, generally arsenic and lead. LIABILITY TO METALLIC POISONING. The paint industry was inquired into by the New York State Fac tory Investigating Commission. In the report for 1913 (vol. 2, p. 1152) it is said that six factories were inspected and that three used arsenic colors, but to a limited extent, the principal output being lead colors. No cases of poisoning were found among the workers, and the information secured was, therefore, negative. It is stated, how ever, “ That there is danger can not be doubted, for the reports of other countries and the report of one case to the department of labor demonstrate the fact. The process wherein the danger lies is from the dust created in handling the dry arsenic color. In this indus try there is danger of mixed poisoning.” Other observations on the part of the commission have reference to the risk of lead poisoning, but there is an extended description of a plant engaged in the manu facture of arsenic color with regard to which it is said that the special process of mixing the materials is “ very dusty.” No pro vision was made for keeping down the dust or exhausting it. It is interesting to note that one worker was examined who said he had been employed for 32 years, but who showed no symptoms and gave no history of ever having had arsenic poisoning. The irritant action of arsenic dust was fully demonstrated by experimental inquiry, and the conclusion is advanced that the chief danger from the dust is in the processes of drying, bolting, and packing. No direct relation between arsenic dust inhalation and a predisposition to pulmonary tuberculosis was shown to exist by the investigation referred to. MORTALITY OF PAINTERS, GLAZIERS, AND VARNISHERS. The mortality of painters, glaziers, and varnishers considered as a group has been reported upon for the years 1908 and 1909 by the/ Division of Vital Statistics of the United States Census Bureau. The group, unfortunately, is so very large and inclusive of so many widely different specific employments or occupational conditions OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 275 that the results of the analysis must be accepted with reserve. Pro portionately, of course, painters predominate in the group under con sideration and it is a safe assumption that the other occupations do not very materially modify the proportionate mortality figure from pulmonary tuberculosis. Thoroughly specialized investigations, however, regarding particular employments (for, of course, even the term “ painter ” covers quite a group of more or less varying occu pations) might and probably would disclose important differences in the specific liability to pulmonary tuberculosis, particularly with reference to exposure to health-injurious minerals and metallic dust. Among painters, naturally, the liability to lead poisoning is a special occupational danger, but the actual mortality from lead poisoning is proportionally so small, at least among American painters, that the relative effect of the same can not be considered of material im portance. According to the census report, out of 7,294 deaths of painters, glaziers, and varnishers from all causes, 1,361, or 18.7 per cent, were from pulmonary tuberculosis. The details of the mor tality by divisional periods of life are shown in Table 102. T able 10 2 .—P R O P O R T IO N A T E M O R T A L IT Y OF P A IN T E R S , G L A ZIE R S, A N D V A R N IS H E R S F R O M P U L M O N A R Y T U B E R C U LO SIS , U N IT E D STATE S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A G E GROU PS. Deaths from pulmonary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years.............................................................................................. 25 to 34 years.................................................................................................. 35 to 44 years.................................................................................................. 45 ta 54 years................................................................................................ 55 to 64 years.................................................................................................. 65 years and over............................................. .......................................... Age unknown............................................................................................... 429 968 1,423 1,598 1,474 1,398 4 132 357 415 278 132 46 1 30. 8 36.9 29. 2 17.4 9.0 3.3 25.0 Total, 15 years and o ver................................................................... 7,294 1,361 18.7 T able 1 0 3 .—P R O P O R T IO N A T E M O R T A L IT Y OF P A IN T E R S, G L A ZIE R S, A N D V A R N ISH E R S FROM N O N TU BE R CU LO U S R E S P IR A T O R Y DISEASES, U N IT E D STATES R E G IS T R A T IO N A R E A , 1908 A N D 1909. Deaths from nontuberc u 1o u s respiratory diseases. Cause of death. Number. Per cent of deaths from all causes. Asthm a.................................................................................................................................. Broiichitis............................................................................................................................. Pneumonia.................................................................................................................. ........ Other nontuberculous respiratory diseases.................................................................... 11 47 533 64 0.2 .6 7.3 .9 T otal.... ....................................................................................................................... 655 9. a 276 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. COMPARATIVE MORTALITY OF PAINTERS, GLAZIERS, VARNISHERS, AND AGRICULTURAL LABORERS. The proportionate mortality from pulmonary tuberculosis among painters, glaziers, and varnishers considered as a group was above the average for all occupied males throughout the entire working life time, but the excess does not assume serious proportions, which, how ever, does not preclude the conclusion that more selected groups of occupations in the entire group of allied employments under con sideration would show a much more decided liability to pulmonary tuberculosis than is shown to be the case for the employment con sidered in the aggregate. In a general way, however, the mortality of painters, glaziers, and varnishers from pulmonary tuberculosis conforms to the general average for all occupied males, but it is de cidedly above the average when comparison is made with agricul tural employments, as is shown in Table 104. T able 1 0 4 .— C O M P A R A T IV E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U LO SIS AM ONG P A IN T E R S, G L A ZIE R S , A N D V A R N IS H E R S , A N D F A R M E R S , P L A N T E R S , A N D F A R M L A B O R E R S , U N IT E D STATE S R E G IS T R A T IO N A R E A , 1908 A N D 1909, B Y A G E G R O U P S. Per cent of deaths from all causes due to pul monary tuberculosis. Age at death. Agricul tural em ployments. Painters, etc. 15 to 24 years......................................................................................................................... 25 to 34 years......................................................................................................................... 35 to 44 years......................................................................................................................... 45 to 54 years......................................................................................................................... 55 to 64 years......................................................................................................................... 65 years and over.................................................................................................................. Age unknown....................................................................................................................... 23.5 26.2 19.1 12.1 6.7 2.4 7.9 30.8 36.9 29.2 17.4 9.0 3.3 25.0 Total, 15 years and over........................................................................................... 8.7 18.7 The preceding comparison is especially suggestive in that it em phasizes the inherent limitations of a mortality comparison in which all occupations are considered the standard. For the present pur pose it has seemed advisable to compare painters, who, of course, numerically constitute an exceptionally important group of occupa tions, with employments typical of outdoor labor carried on under the most wholesome conditions as regards physical activity, air, relative freedom from dust exposure, etc. The comparison, through out, is distinctly in favor of agricultural employments, and em phasizes the more or less health-injurious conditions under which painters, glaziers, and varnishers, considered as a group, are em ployed throughout practically the entire working period of life. How far the relatively high mortality from pulmonary tuberculosis as determined by this comparison is attributable to the special risk of lead poisoning can not be determined at the present time; but it is a safe conclusion that there is some such relation, although the recorded mortality from lead poisoning among American painters OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 277 is comparatively low; in other words, it is rather because of compli cations resulting from gradual lead absorption as a factor in other diseases, including pulmonary tuberculosis, than as a direct cause of death that lead poisoning assumes importance in occupational or industrial hygiene. Aside from the relatively high proportion of deaths from pulmonary tuberculosis the mortality from nontuber culous respiratory diseases among painters, glaziers, and varnishers in comparison with farmers, planters, and farm laborers is not ex cessive. For painters, etc., considered as a group the proportionate mortality from all nontuberculous respiratory diseases is 9 per cent, which compares with 9.3 per cent for farm laborers. The pro portions for asthma, pneumonia, and other respiratory diseases are about the same, but for bronchitis the mortality figure for agricul tural workers is exactly twice the average for painters, considered as a group, or 1.2 per cent against 0.6 per cent. These conclusions, however, must not be carried too far, in view of the fact that two groups are compared which include quite a number of employments with a more or less varying degree of exposure to conditions un favorable to health and longevity. MORTALITY OF PAINT MIXERS— INDUSTRIAL INSURANCE EXPERIENCE. There are no conclusive vital statistics of men employed in the American mineral paint industry, whether considered as a group or according to its several more important subdivisions. In the ex perience of the Prudential Co. ,(1897-1914) 36 deaths from all causes in paint factories, excepting mixers, occurred, of which 6, or 16.7 per cent, were from pulmonary tuberculosis. The experience is, of course, too limited to be conclusive. Among paint mixers, separately considered, however, there were 88 deaths from all causes, of which 21, or 23.9 per cent, were from pulmonary tuberculosis. This expe rience is given in detail in Table 105. T able 1 0 5 .—P R O P O R T IO N A T E M O R T A L IT Y FROM P U L M O N A R Y TU BE R CU LO SIS AM ONG P A IN T M IX E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, COM P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D STA T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E GR O U PS. * Deaths of paint mixers, Per cent of deaths from pulmonary tubercu 1897 to 1914, from— losis among— Age at death. A ll causes. Pulmonary tuberculo sis. Paint mixers. Males in registration •area, 1900 to 1913. 15 to 24 years ........................................................................ 25 to 34 years............................................................................ 35 to 44 years....................................................................... 45 to 54 years............................................................................ 55 to 64 years.......................................................................... 65 years and over.................................................................... 6 17 16 27 13 9 4 5 5 7 66. 7 29. 4 31.3 25.9 27. 0 30.5 23.4 14.7 7.9 2. 6 Total, 15 years and over............................................. 88 21 23.9 13.9 278 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. The statistics, though unfortunately too limited for entirely safe conclusions, may be accepted as a sufficiently trustworthy indication that paint mixers are unquestionably liable to an excessive mortality from pulmonary tuberculosis, which in all probability upon further inquiry will be found to correspond proportionately to the nature and the quantity of the dust inhaled in the mixing processes. Even in the case of men employed in paint factories, excluding mixers, the experience is fairly suggestive of unfavorable conditions, though obviously much less so than those known to exist in the mixing processes separately considered. When the data for paint factories are made to include mixers, the experience is represented by 124 deaths from all causes, of which 27, or 21.8 per cent, were from pul monary tuberculosis. At ages 35 to 44, out of 25 deaths, 10, or 40 per cent, were caused by pulmonary tuberculosis, which, of course, is decidedly excessive. GENERAL CONCLUSIONS. In the absence of more definite and trustworthy data, the fore going brief observations concerning an important and rapidly in tending industry are suggestive of the urgency of better sanitary conditions, chiefly the use of practical methods of dust prevention, both by more adequate dust-removing processes at the point of origin and the use of respirators in processes where the control of the dust danger must necessarily be one of exceptional difficulty. LITHOGRAPHERS. Lithographers constitute an important branch of the printing trade. According to the census of 1910 there were some 8,138 lithographers in the United States, of which number 477 were females. For hygienic reasons the employment of the lithographer should be con sidered separately from printing and engraving, since the former is exposed chiefly to mineral dust, while the latter are exposed pri marily to the inhalation of metallic dust. Lithographic stone has been defined as a fine, compact homogeneous limestone, practically all of which is (or was) imported from Germany. The small amount of lith ographic stone quarried in the United States varies in its mineral and metallic constituents from the Bavarian stone, containing nearly 7 per cent of magnesia. No accurate observations have been made a matter of record to determine the degree of possible lung injury resulting in the case of the lithographer’s occupation, but it is safe to assume that the employment should be included in the group of dusty trades. This conclusion is fully sustained by a knowledge of the technical processes which constitute the lithographic art. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 2 79 The sanitary conditions of this employment received consideration by Sir John Simon in his report as medical officer of the Privy Council. Simon called attention to the dust resulting from the use of colors and pigments, against the inhalation of which only very few of the workmen had adopted intelligent precautions. The most pernicious of the mineral or metallic colors employed in connection with lithography were emerald green and bronze. Simon did not connect the inhalation of this dust with the occurrence of phthisis, but the inference would seem warranted that such a connection exists, at least in exceptional cases.1 Parry, in his “ Risks and Dangers of Various Occupations,” confirms the earlier opinion, and holds that in lithographing green arsenical pigments are used, the poisonous dust of which is inhaled and conveyed to the stomach. It is evident that the poison ous character of the colors or pigments is a more serious factor than the dust of the stone itself, but how far either form of dust increases the liability to tuberculosis has not been determined. MORTALITY OF ENGLISH LITHOGRAPHERS. The most recent English mortality statistics of lithographers are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales (p. lix), in part as follows: At all ages except 20 to 25 and 45 to 55 the death rates among these workers exceed the standard for all occupied and retired males. These workers experience a lower mortality than printers up to the age of 45, but beyond that age the mortality in the two occupations differs but slightly. In the main working period of life the com parative mortality figure of lithographers is 964, or 4 per cent, below the average. Their mortality from influenza and phthisis consider ably exceeds the standard, while that from respiratory diseases is below it by about an equal amount. The English mortality statistics for lithographers are rather in conclusive as to a decidedly unfavorable effect of this industry on health, and while in Table 106 a comparison is made of the mortality from all causes of men in this group with occupied males generally, the death rates are, as a rule, below the average for occupied males generally except at ages 20 to 24 and 45 to 54, inclusive. 1 Report of the medical officer of the Privy Council for 1860, pp. 30 et seq. and 102 et seq.; for 1861, pp. 11 et seq. and 138 et seq.; for 1862, pp. 10 et seq. and 126 et seq.; and for 1863, pp. 29 to 31. 280 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. T able 1 0 6 .— M O R T A L IT Y FR O M A L L CAUSES OF L IT H O G R A P H E R S , C O M P A R E D W IT H T H A T OF A L L OCCUPIED M A LE S, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y AGE G R O U PS. [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate for lithographers. Age at death. 15 to 19 years............................................................................ 20 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years.................. ........................................................ 65 years and over.................................................................... Death rate per 1,000 for all occu pied males. 2. 44 4.41 6.01 10. 22 17. 73 31. 01 88. 39 R ate per 1,000. Greater ( + ) Ratio to or less ( —) than rate rate fcr all occupi:d for all occu males. pied males. 1. 55 5.36 5.62 8. 41 19.94 30. 84 82. 25 —0. 89 -j- . 95 — .39 —1. 81 +2. 21 — .17 -6 .1 4 64 122 94 82 112 99 93 The preceding table is self explanatory, but a more extended com parison is made in Table 107, in which the mortality of lithographers from pulmonary tuberculosis is compared with the normal mortality of occupied males from this disease, by divisional periods of life. This table shows that the mortality of lithographers from tubercu losis is above the average at all ages by from 0.23 to 2.17 per 1,000. The excess is not very marked and does not warrant decidedly un favorable conclusions. » T able 107.—M O R T A L IT Y FROM P U L M O N A R Y TU BE R C U L O SIS AM ONG L IT H O G R A P H E R S , C O M P A R E D W IT H T H A T OF A L L OCCUPIED M ALES, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E GROU PS. [Source: Part II, Supplement to the Sixty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Mortality from pulmonary tuberculosis. Death rate for lithographers. Age at death. 15 to 19 years............................................................................ 20 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years........................................................................... 55 to 64 years.....................*...................................................... 65 years and over..................................................................... Death rate per 1,000 for all occu pied males. 0. 54 1. 55 2.03 2. 74 3.04 2.16 1.11 Rate per 1,000. 0. 77 2.68 2. 70 3.13 4. 27 4.33 1. 44 Greater ( + ) Ratio to or less ( —) than rate rate for all occupied for all occu males. pied males. . +0.23 +1.13 + .67 + .39 +1.23 +2.17 + .33 143 173 133 114 140 200 130 The preceding table, derived from English experience, requires no further comment except that it may be pointed out that the data un der observation are far from sufficient to warrant definite conclu sions. The occupation has been investigated in the United States by Hayhurst, with regard to 10 establishments in Ohio, employing OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 281 539 persons, of whom all but 11 were males. Only 50 of the em ployees were over 40 years of age. There were no special complaints of importance, except as relating to the ventilation of lithographic workrooms. Neither the fume nor dust hazard seemed to be of seri ous importance. W. Gilman Thompson only briefly refers to litho graphers, stating that they suffer from sedentary work and close application, resulting in dyspepsia and anemia, and that they have a somewhat high mortality from tuberculosis. MORTALITY OF LITHOGRAPHERS— INDUSTRIAL INSURANCE EXPERIENCE. The conclusions based upon Table 108 are sustained by the indus trial insurance experience data of the Prudential Co. for the period 1897 to 1914, according to which, out of 325 deaths from all causes, 125, or 38.3 per cent, were from pulmonary tuberculosis. ta b le 108.—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU B E R C U LO SIS AM ONG L IT H O G R A P H E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L M ALES IN U N IT E D STATE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U PS. Deaths of lithogra phers, 1897 to 1914, from— Per cent o f deaths from pulm onary tubercu losis among— Age at death. A ll causes. Pulmonary tubercu losis. Lithog raphers. Males in registra tion area, 1900 to 1913 15 to 24 years.................................................T........................ 25 to 34 years............................................................................ 35 to 44 years....... . . ................................................................ 45 to 54 years.......................................................................... 55 to u4 years............................................................................ 65 years and o v e r ... .- .. * ...................................................... Age unknown.......................................................................... 70 81 69 53 32 19 1 37 42 27 13 4 2 52.9 51.9 39.1 24.5 12.5 10.5 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and o v er.. . ................................... 325 125 38.3 13.9 GENERAL CONCLUSIONS. The mortality from pulmonary tuberculosis is, therefore, extremely high in this occupation at ages under 45 and in marked contrast to the mortality from this disease among the male population of the regis tration area. The statistics, .though limited, may be accepted as conclusive and indicative of more or less unsatisfactory sanitary con ditions common to the lithographic industry. For reasons partly inherent in the occupation, ventilating devices are often quite defec tive and occasionally impracticable. The dust hazard is only one of several which tend#to make this employment a particularly un healthy one, and this conclusion is sustained by the fact that out of 325 deaths of lithographers at known ages from all causes, only 19, or 5,9 per cent, were of ages 45 and over. It is regrettable that the mortality of lithographers was not sepa rately considered in the occupational mortality statistics of the Divi 282 MORTALITY FROM RESPIRATORY DISEASES 11ST DUSTY TRADES. sion of Vital Statistics of the United States Census Bureau, in which lithographers are combined with printers and pressmen. It has been observed in this connection by Kober, in Kober and Hanson’s u Dis eases of Occupation and Vocational Hygiene ” (p. 614), that the work of chromolithography “ is often carried on under unfavorable hygi enic conditions as regards light, air space, and ventilation, which is all the more regrettable, as some of the processes involve the employment of injurious agents, such as arsenic pigments, chromium, lead, and bronze powder.” It is said further that— The lithographic process varies in different establishments; the design or picture may be engraved by means of a diamond or steel needle upon a fine-grained sandstone, generally imported from Bavaria, or the drawing may be made upon the stone with a greasy composition. In photolithography the printing surface is largely prepared by a photographic process. In all of the processes of chromolithography the stone is dampened on those portions of the design which are not to appear in'the first printing; this prevents taking the ink or colors. The actual application of colors and presswork is performed by another set of operatives. According to Leiser (WeyPs Handbuch der Gewerbekrankheiten, 1908, p. 339), in a total membership of 11,807 employees in this industry in Berlin during 1904, 2,002 males and 1,840 females, or 32.6 per cent, were reported sick, with 90 deaths; of the sick about 12 per cent suffered from tuberculosis; 11 per cent had skin affections, especially obstinate forms of eczema caused by contact with acid dips, bronzing powder, toxic color pigments, impure turpentine, etc.; 10.5 per cent of the sick suffered from disorders of the digestive system: and 19 per cent of the females were anaemic. There were 356 accidents, mostly con tusions of the fingers contracted in presswork. Cohen estimates that about 45 per cent of the lithographers suffered from near sight or other visual defects. The possible serious exposure to bronze dust in chromolithography can not be discussed on account of the want of precise and conclusive data. As far as the available information derived from fairly trust worthy sources justifies a preliminary conclusion, there does not ap pear to be an excessive incidence of pulmonary tuberculosis among men employed in the manufacture of bronze powder. As regards the bronzing process in chromolithography, Kober observes that this may be done by the dry or wet method or Ky hand or machinery, and that in spite of the metallic covering of the machinery and methods of exhaust ventilation the bronze powder escapes freely into the air and the employees who tend the machine “ wear handkerchiefs over the nose and mouth ” and “ look pale and unhealthy, and all show the characteristic green perspiration due to contact with bronze.” The great majority of employees, however, he remarks, appear to be healthy, which no doubt has reference to the men not directly con nected with dust-producing processes. In the absence of more con- OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 283 elusive information and the required statistical evidence derived from official or insurance sources, no final conclusion can be arrived at further than that with reference to lithographers as a class the evidence is entirely sufficient to prove the excessive incidence of pul monary tuberculosis and the prevalence of more or less decidedly unsatisfactory sanitary conditions in the lithographic industry. FOUNDRY-M EN AND MOLDERS Foundry-men and molders are to a considerable degree exposed to the continuous inhalation of both metallic and mineral dusts. While the proportion of metallic dust is quantitatively small, it is probably the more injurious of the two’, although its effects are modi fied by the relatively much larger amount of mineral dust. The in dustry is varied, of large extent, and widely distributed throughout the country. The conditions affecting health naturally vary, and chiefly so on account of the metal used in casting, which may be iron, steel, brass, etc. The employments in foundry practice are chiefly those of molders and clay mixers, of which molders, again, are sub divided into those who work at a bench, or in the making of small ware, and those who work on the floor or in the pits in the making of castings of larger size. Within recent years labor-saving appliances have been extensively introduced into the large foundries, chiefly in connection with iron and steel works, but corresponding progress has not been made in the smaller establishments. The introduction of machinery has led to the employment of much unskilled labor of. low grade, which complicates the use of the available mortality returns. It is also necessary to take into consideration the not incon siderable accident liability of men employed in foundries, and the occasional or general exposure to extreme heat and the liability to overstrain inseparable from the lifting of heavy weights of metal. An investigation into the sanitary aspects of this employment made by the State board of health of Massachusetts disclosed the fact that at 14 foundries in which castings of all kinds were made, in 7 the conditions as to light, ventilation, and dust removal were very poor. Of 9 stove foundries inspected, 4 presented moder ately bad and 1 distinctly bad conditions affecting the health of employees. In the polishing room of one factory, conducted under almost ideal conditions, the emery wheels were well-equipped with hoods and exhaust ventilators, but the report states that “ the men, unmindful of the protection provided, habitually remove the hoods, and become covered with emery and iron particles.” In reporting in some detail upon the establishments found to be more or less unsatisfactory as to light, ventilation, and dust removal, the report states that one shop “ employs 275 men, in low-studded, 284 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. poorly lighted, unventilated buildings, in which there is no attempt to remove the dust arising from the processes of polishing and buff ing, by hoods and exhaust ventilation. In the tumbling room the dust is so thick that objects a few feet distant can not clearly be made out. Many men refuse to work in this establishment in the hot months, on account of the excessive heat and general discomfort.” The high mortality of foundry-men and molders from pulmonary tuberculosis observed to occur at advanced ages is decidedly sugges tive. Evidently the progress of the disease in these occupations is slow, and often, if not as a rule, assumes the form of fibroid phthisis. There can be no question of doubt that there is in these occupations an intimate connection between the continuous exposure to metallic and mineral dust inhalation and the relative frequency of the disease. Considering the nature of the dust inhaled, this is what wTould be ex pected. The dust being largely mineral, but partly metallic, the pro portion of iron dust, while considerable, is not so excessive as the iron or steel dust inhaled by men engaged in cutlery grinding or file cut ting. No doubt many of the dangers of the employment could be guarded against by attention to safety devices, chiefly respirators, to be worn during some of the mold-making processes. The employ ment, by its very nature, however, precludes radical methods of dust prevention, and the most effective safeguard would be short hours of labor and a more rational use of leisure hours and vacations.1 MORTALITY OE MOLDERS— INDUSTRIAL INSURANCE EXPERIENCE. There are no official vital statistics of these occupations either for the United States or for England and Wales. The recorded indus trial insurance mortality statistics of foundry-men and molders are very extensive and include 3,294 deaths from all causes, of which 758, or 23 per cent, were from pulmonary tuberculosis. Of the deaths of foundry-men and molders from nontuberculous respiratory diseases, 25 were from asthma, 51 from bronchitis, 463 from pneumonia, and 65 from other diseases of this class. If the deaths from pulmonary tuberculosis and from other respiratory diseases are combined, 41.3 per cent of the mortality of foundry-men and molders were from dis eases of the lungs and air passages. The mortality of foundry-men and molders from pulmonary tuberculosis was excessive at all ages over 25, but the excess was most pronounced at ages 25 to 34, when out of every 100 deaths of foundry-men from all causes, 40.4 were from pulmonary tuberculosis, against a normal expected proportion of 30.5. The analysis of the mortality from pulmonary tuberculosis of foundry-men and molders in detail is set forth in Table 109; 1 F o r a b r ie f b u t p r a c tic a lly u sefu l a cco u n t o f occ u p a tio n a l h a zard s in fo u n d rie s, see “ P r a c tic a l S a fe ty M eth od s an d D e v ice s,” by G eorge A . C ow ee, N ew Y o rk , 1916. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 285 1 0 9 . — P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y TU BE R CU LO SIS AMONG F O U N D R Y -M E N A N D M O LD E R S, IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L M ALES IN U N IT E D STATE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E GROU PS. T able Deaths offoundry-m en and molders, 1897 to 1914, from— Per cent of deaths from pulm onary tubercu losis among— Age at death. A ll causes. Pulmonary Foundrymen and tubercu losis. molders. Males in registra tion area, 1900 to 1913. 15 to 24 years............................................................................ 25 to 34 years............................................................................ 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over.................................................................... 266 540 694 690 624 480 63 218 213 149 87 28 23.7 40.4 30.7 21.6 13.9 5.8 27.0 30.5 23.4 14.7 7.9 2.6 Total, 15 years and o v e r............................................ 3,294 758 23.0 13.9 The preceding observations and statistical data, derived from industrial insurance mortality experience, confirm the conclusion that this employment is more or less injurious to health, and that the degree of frequency of pulmonary tuberculosis is excessive at ages 25 and over. SANITARY CONDITIONS IN MASSACHUSETTS FOUNDRIES. The sanitary conditions in foundries have been investigated by the Massachusetts State .Board of Health and reported upon under date of April, 1911. Two hundred and nine foundries were in spected, including a large variety of processes of more or less impor tance from a hygienic point of view, but with special reference to extremes of temperature, and more or less irritating dust, gases, and vapors. Many of the foundries inspected were found to be improp erly heated during the winter months, and the workmen were said to suffer more or less discomfort from the cold. In the immediate vicinity of the furnaces, however, particularly in the pouring of the metal, the heat was apt to be excessive. Gases and vapors were ascertained to prevail in some instances to an injurious degree, and especially was this found to be the case in brass foundries, with refer ence to the occurrence of so-called brass-founders’ chills. It is a fair assumption that unfavorable temperature conditions and continuous exposure to noxious vapors must tend in a measure to reduce vitality and predispose to diseases, particularly of the respiratory organs, for as has been thoroughly well established for the metal mining industries, a preexisting condition of fibroid phthisis materially in creases the liability to pulmonary tuberculosis. Fibroid phthisis con tracted in consequence of dust exposure predisposes to pulmonary tuberculosis. The same conclusion applies to other unfavorable health conditions tending toward a lowering of vital resistance and an increased predisposition to particular specific diseases. 286 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. DUST EXPOSURE IN SAND BLASTING. In the Massachusetts investigation of foundries it was found that the floors, benches, and the hands of operatives were covered with sand dust, and it is explained that the dry sand from which the cores are made is sifted on a fine wire netting, a process which gives rise to considerable fine dust. This process, however, is not usually carried on to any prolonged extent, but is done, for the most part, several times a week for only a few hours at a time. In one foundry the dust generated was decidedly objectionable, and upon the suggestion of the State inspector of health a covered sifter was provided to remove this source of annoyance. The most dusty process was ascertained to be the cleaning of castings, elsewhere briefly referred to under sand blasting. It is explained in this connection that— Castings are cleaned in tumbling mills, by sand blasts, emery wheels, or by hand with wire brushes. The tumbling mills are bar rel-like chambers in which the castings are placed, together with small pieces of scrap iron. After the doors are closed, power is ap plied and the mills are set in a rotary motion. From the constant action of the castings upon each other and upon the scrap iron the surfaces- are smoothed and the castings are cleaned of any sand which may be adherent. The dust generated by this process was, in most foundries, removed by exhausts. Moreover, these mills were usually located in some corner away from the workmen who did not have to attend to them during operation. The emery wheels on which the castings were cleaned were in many cases provided with hoods and exhausts. These observations apply in a general way to modern foundries, but exceptions are sufficiently numerous to suggest the urgency of qualified and continuous supervision of the processes referred to. Neglect in this direction is invariably followed by health-injurious consequences, for as pointed out in the Massachusetts report— A serious exposure to fine dry sand was observed in those foun dries where sand blasts were in use for cleaning the castings. This process, which is usually carried on in a room separated from the rest of the foundry, consists of playing a stream of fine dry sand, by means of compressed air, upon the castings. So great is the force of the sand stream that the steel nozzle which is used is quickly cut through. In some foundries exhaust fans and hoods were provided to carry off the dust, although in spite of this precaution the rooms were so filled with dust while the sand blasts were in operation that objects could n®t be clearly seen. When doing this work the work men usually wore masks to protect the eyes. These masks, however, did not prevent the inhalation of dust, which appeared to enter the respiratory passages with a good deal of force. In one factory a man was observed to wear a helmet with a tubing through which fresh air was supplied from the outside. In another foundry such a helmet was provided, but the man did not use it “ as it was too much bother to put it on and take it off.” The length of time a man can keep at OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 287 this work is said to be short; in about a year or a year and a half he begins to show the effects of the work and is forced to leave. PHYSICAL EXAMINATION OE MOLDERS IN THE FALL RIVER DISTRICT. The foregoing observations have been quoted in full as evidence of the thoroughness with which the Massachusetts investigation was carried out. In the Fall River district physical examinations were made of 320 molders, wTith the following results: Bron chitis, asthma, and emphysema were ascertained in 41, or 12.8 per cent, of the molders examined. In addition thereto 39, or 12.2 per cent, were suffering from diseases of the heart, chiefly valvular disease or dilation; and 23, or 7.2 per cent, were suffering from dis eases of the kidneys. In the aggregate, of the 320 examined 103, or 32.2 per cent, were found to be in a more or less serious condi tion of ill health. The ages of those examined ranged from 45 to 72, so that the conclusions apply entirely to molders well advanced in years, and no doubt for a considerable period engaged in the occupation. NATURE AND PROPERTIES OF MOLDING SANDS AND DUSTS. In the main, the health-injurious exposure is to the highly com minuted sand disseminated in the form of dust throughout the foun dries, but chiefly in connection with cleaning and so-called sand blasting processes. The nature and properties of molding sands have been described by Mr. Percy Longmuir before the British Foundrymen’s Association, in the Engineering Magazine.1 Sand used for casting iron molds usually contains 84 per cent of silica and, in addition thereto, varying amounts of alumina, magnesia, lime, and metallic oxides. The pure silica is, however, recognized as the most injurious form of dust, but especially so when very finely comminuted, as is generally the case in molding processes. The health aspects of fou n d s work are, therefore, of special importance, but particularly so with reference to the control of the needless degree of dust exposure. What can be done in this connection is emphasized in a brief reference to the subject in the annual report of the chief inspector of factories and workshops for the year 1913, m which it is said that— Early in 1913 the prevention of dust in various departments of iron foundries was discussed at Falkirk with representative em ployers, and it was agreed that steps should be taken to improve the conditions in dressing, grinding, and fitting shops. Satisfactory arrangements have already been installed in some of the foundries, and before long it is hoped that all principal machines will be dealt 1 E n g in eerin g M a ga zin e, v ol. 30, M a rch , 1906, pp. 9 0 9 -9 1 1 . 288 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. with. Experiments are also to be tried to devise means for carrying off dust generated by the hand brushing of castings, as this operation frequently leads to most undesirable conditions. Meanwhile some effort is being made to keep floors cleaner, so as to reduce the dust stirred up by the movements of the workers. EOTJNDRY INVESTIGATIONS IN OHIO. Quite recently, also, the conditions of employment in iron foun dries have been investigated by Hayhurst, of the Ohio State Board of Health, including 43 establishments in 14 cities, employing a total of 4,721 wage earners. Foundry processes, it is said, are carried on in connection with a variety of industries, chiefly, however, foundry and machine shop products, iron and steel mills, stoves find furnaces, agricultural implements, automobiles and parts, musi cal instruments, brass and bronze products, electrical apparatus, etc. Reference is made to a report by the financier of the International Molders’ Union of North America to the effect that, out of 204 deaths in the Ohio branch of the molders5 union in the five-year period 1909 to 1913, the chief causes of death were pneumonia, 30, or 14.7 per cent; heart disease, 30, or 14.7 pqr cent; tuberculosis, 27, or 13.2 per cent; and violence, 18, or 8.8 per cent. With reference to the ex perience of the same organization, it is said that— We can well understand that foundry conditions are such as to promote the prevalence of both throat and lung disorders, and also rheumatism. The violent changes in temperature, the drafts and dampness of the foundry, are conducive to suffering of this kind. It might truly be said that rheumatism in its several forms appears to be the nearest approach, if any, to what might be designated as an u occupational disease.” These observations were in a large measure confirmed by the in vestigations' of Hayhurst, who states that— The presence of foundry dust appeared a negligible hazard in 7 places, fairly so in 17 more, and bad in the remaining 19. This dust was composed chiefly of mold sand, iron oxides, iron, dross, slag, cinders, and dirt. Of these the first is to be considered the most harmful. While it is practically impossible to avoid dust in iron foundries, the presence of subprocesses, such as casting cleaning, and furnacing, as well as other processes, which might be carried on in separate quarters, add greatly to the amount of fine dust floating in the air. AIR CONTAMINATION BY GAS AND SMOKE. Further reference is made to air contamination by mold fumes, gas fumes, smoke, and steam, and in a number of work places the air was badly vitiated during the winter season by the presence of coke-burning braziers used for heating, placed about in the quarters and yielding immense amounts of invisible coke gas due to the ab- OCCUPATION’S W IT H EXPOSURE TO MINERAL DUST. 289 senee of flue connections to the outside. Cold, due either to the lack of efficient heating or to the rush of cool drafts, was considered a hazard to many workers in at least 15 of the places inspected. With reference thereto it is said by Hayhurst that— It is but natural that chilling of certain muscles and groups of muscles, which at intervals must be called into sudden severe strain ing actions, usually in hot places, should be greatly affected with sprains and rheumatism, shown as lumbago, wry neck, sciatica, neu ritis, severe chest and shoulder pains, stiffness of joints, etc. Par ticularly is this condition favored by the going out-of-doors to closets, or at noontimes, or going home while wearing sweaty underclothes. The results of the inquiry are summarized in the conclusion that— Founding is an example of an industry which in itself should be harmless; in fact, should promote health and longevity the same as any application requiring the general use of nearly all of the body functions. It is rendered dangerous chiefly because it is done in doors. On this account a great many precautions are necessary to be taken, as indicated, including the general medical supervision of the workers. DUST EXPOSURE IN CASTING CLEANING. With special reference to casting cleaning it is said that this is necessarily a very dusty process, as usually performed, and whether done by hand or steel brushes or with sand and air blasts, or by knocking and tapping, laborers so engaged should be protected from the dust, probably best by helmets supplied with compressed-air blasts, and the tumbling of small pieces or cleaning within inclosures or other dust-confining means should be used wherever possible. GENERAL CONCLUSIONS. Regardless of the foregoing conditions, which are quite generally known and understood, there has not thus far been the required de gree of sanitary progress urgently called for by the highest consid erations of the health and longevity of the men employed. The special liability to pulmonary tuberculosis as brought out by the statistical analysis of the available mortality data is confirmed by specialized investigations, summarized in an editorial note on tuber culosis among metal molders in Massachusetts, in the July (1914) issue of the Journal of the Massachusetts State Sanatoria, where it is said that— The chief factors, then, in the molder’s life in connection with the development of tuberculosis are the exhausting nature of the work, the overheat and subsequent exposure while exhausted to cold out door air, the exposure to dust and gases, and, as stated, the exposure of certain molders to the debilitating effects of the fumes of poison ous metals. And to these must be added that factor so common to 106811°— 18— Bull. 231------ 19 2 90 MORTALITY FROM RESPIRATORY DISEASES IN t>USTY TRADES. all exhausting occupations, the abuse of alcohol, which appears to be almost a direct result of the nature of the work.1 CORE MAKERS. Core making is an essential branch of foundry practice. This occu pation gives employment to a considerable number of young persons, mostly boys, but of late years girls have been drawn into the trade, although it is held that the more arduous duties and surrounding con ditions of the occupation are unsuited to the female sex. No qualified investigation appears to have been made into the health conditions of this employment, but in a general way the conditions approximate those of foundry practice in general.2 There is a considerable ex posure to both mineral and metallic dust, but the fact that large num bers follow this occupation for only a comparatively short time no doubt prevents the more serious results which would follow if the exposure were continued for many years. SANITARY CONDITIONS IN FOUNDRIES. The process of core making in connection with foundries is, of course, quite general to the iron and steel industry, the brass industry, etc. The general exposure, however, is rather to mineral dust than to metallic dust, although under given conditions the latter may as sume prior importance. The dust in connection with the core-making process is described by Hayhurst3 as consisting of sand, earths, and mold powders, but this conclusion no doubt was one based upon gen eral observation rather than upon microscopical analysis. Among related sanitary features injurious to health Hayhurst refers to damp ness, poor light, and poor aeration, the latter, of course, being chiefly due to the fumes and smoke. Variations in temperature conditions are also noticed, and fatigue is mentioned as a considerable hazard in the majority of the work places investigated. The chief com plaint of the workers was the breathing of burned-gas fumes and smoke; but apparently no specific complaint was made of healthinjurious dust. NEW YORK STATE FACTORY INVESTIGATION. The condition of foundries was inquired into by the New York State Factory Investigating Commission, who directed particular attention to the employment of women, chiefly in connection with 1 A m erica n J o u rn a l o f P u b lic H ea lth , 1914, p. 1254. 3 O f sp ecia l in terest an d va lu e in th is c o n n e ctio n a re th e R u les a n d R e g u la tio n s o f the N ew Y o r k S ta te D ep a rtm en t o f L a b o r re g a rd in g fou n d rie s and w ork in co re -m a k in g ro o m s m w h ich w om en a re em p loyed . (L a b o r L a w an d the In d u s tria l Code, A lb a n y , 1916, R ules 5 8 2 -5 8 5 .) 3 C ore m ak in g is d iscu ssed b y H a y h u rs t in the O h io S ta te B u lle tin o f th e B o a r d o f H ea lth , F eb ru a ry , 1915, p. 165. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 291 core-making processes.1 They state, as a result of their investigation, that molders were found to suffer from rheumatism, pulmonary dis eases, and kidney troubles, which by implication applies also to core makers. They refer to the fumes and the heavy dust from the cast ings cleaned in the workrooms, which, being inhaled by the workers, render them more or less susceptible to all forms of respiratory diseases. They give expression to the opinion that “ the employment of women in work of this kind in the foundries of the State should be prohibited.” MORTALITY OF CORE MAKERS— INDUSTRIAL INSURANCE EXPERIENCE. The only available vital statistics of core makers are those derived from industrial insurance experience, including 357 deaths, of which 105, or 29.4 per cent, are from pulmonary tuberculosis. The details of the mortality are showTn in Table 110. P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U BE R CU LO SIS AM ONG C O R E M A K E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M PA R E D W IT H T H A T OF A L L M ALES IN U N IT E D STATE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U PS. T a b le 1 1 0 .— Deaths o f core makers, 1897 to 1914, from— Per cent of deaths from pulm onary tubercu losis among— Age at death. All causes. 15 to 24 yoars............................................................................ 25 to 34years................ ...................... . . . ........ .................... 35 to 44 years............................................................................ 45 to 54 years.......................................................................... 55 to 6-± y e a r s .......................................................................... 65 years and over.................................................... - .............. Total, 15 years and over............................................. Pulm onary tubercu losis. Core makers. Males in registra tion area, 1900 to 1813. 113 98 03 42 26 15 36 42 19 5 3 31.9 42.9 30.2 11.9 11.5 27.0 30. 5 23. 4 14.7 7.9 2.6 357 105 29.4 13.9 When considered by divisional periods of life it appears that the proportionate mortality from pulmonary tuberculosis is highest at ages 25 to 34, when out of the mortality from all causes 42.9 per cent are from this disease, against 30.5 per cent expected on the basis of the mortality experience for the United States registration area. There are no corresponding statistics available for women. The data suggest the importance of further investigation and the possibility of a material improvement in sanitary conditions in con sequence of the use of dust-laying devices. It may be said in con clusion that, according to the United States census of 1910, the num ber of male core makers was 16,479, and of female core makers, 1,836. A considerable portion of core makers of both sexes were under 20 years of age. 1 F o r a b rie f d iscu ssion o f th e em p loy m en t o f w om en in co re room s see N ew Y o rk S ta te F a c t o r y In v e s tig a tin g C om m ission R e p o rt fo r 1018, V ol. I, pp . 2 5 5 -2 6 3 . 292' MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. GENERAL CONCLUSIONS. Core making is so generally carried on in connection with foundries that the occupation is frequently combined with molders, etc. Core makers in brass and iron foundries are briefly referred to by Kober and Hanson in their recent work on “ Diseases of Occupation and Vocational Hygiene,” but the observations are quite inadequate and inconclusive. In view of the fact that a large proportion of women are employed as core makers, it is reasonable to assume that with them the health-injurious consequences are more serious on account of dust exposure than in the case of men more resistant to disease and more inclined to change their occupation. Kober observes in this connection that core and mold makers are “ exposed to the inhalation of large quantities of dust, especially in sifting the sand for the cores and in dusting the completed molds with powdered charcoal and graphite.” He also remarks that female labor is often em ployed in the making of cores for small castings, and that the men engaged in breaking up the hot molds “ naturally inhale large quan tities of dust,” determined by Ahrens on the basis of German inves tigations to amount to 28 mg. of dust per cubic meter in the air of foundry rooms, and by Hesse to amount to 71.7 mg. per cubic meter in the air of the cleaning and polishing room, which it is calculated would subject each operative to the inhalation of 42 grams of dust per annum. It is self-evident that the occupation is one which re quires thoroughly well-considered methods of factory supervision if the readily apparent dust hazards are to be reduced to a harmless minimum. On account of the considerable employment of relatively young persons, including women, in core-making processes^ intelli gent supervision and control are urgently required. THE GLASS INDUSTRY. The glass industry in the United States in 1909 gave employment to some 69,000 wage earners, of whom about 5 per cent were children under 16 years of age. The industry is a varied one, including among others the manufacture of blown and pressed ware, of window glass and plate glass, and finally of so-called crystal or cut glass, which for the present purpose is considered as a separate industry. The Jabor division of the trade includes numerous and well-defined occu pations, each of which is subject to more or less injurious circum stances, but of these the handling of materials and the mixing are the most liable to the risk of continuous inhalation of mineral dust. The most important employment is that of the glass blower, but there are few accurate statistics which separate this employment from the industry as a whole. For the present purpose, however, it has seemed best, as far as practicable, to consider separately the mortality of OCCUPATIONS W IT H - EXPOSURE TO MINERAL DUST. 293 glass blowers, although the medical and statistical observations sub sequently to be quoted refer more or less to glassworkers as a class. Changes in manufacturing processes and the introduction of laborsaving machinery have resulted in sanitary improvements, which in consequence have had a favorable effect upon the health of glass blowers, at least in the United States, as far as the rather fragmen tary statistical data can be relied upon. Among glassworkers as a class pulmonary tuberculosis is of exceptional frequency, in addition to which there is a comparatively high mortality from other respira tory diseases, lead poisoning, and heat prostration.1 EARLY OBSERVATIONS ON THE HEALTH OF GLASSWORKERS. Thackrah, writing in 1832, held that glassworkers as a class were liable to catarrh and cough, but not to pleurisy and pneumonia. He commented upon the appearance of a fine dust at the furnaces wThich, however, in his opinion did not produce any marked effect on the health of the operatives. He also mentioned individual cases of glass workers remaining at their employment at ages TO to 80, but in the majority of instances failing eyesight at ages 50 to 60 disqualified for the employment. Thackrah’s account of this occupation was, how ever, very superficial, and some of his conclusions were not at all in conformity to the facts as reported by other authorities. Tracy, writ ing in 1879, held that— In the manufacture of glass the workmen who grind and powder the siliceous material inhale great quantities of very irritating dust and suffer from constant hacking cough and conjunctivitis. It is rare to find a sound man among them and they are not able to con tinue long at the work. According to Hirt’ they should not be allowed to labor, at a stretch, more than two or three weeks, and should then work at something else, or, at any rate, give up this occupation for at least double the working time. In this way, by the use of relays, the health of the men may be sustained.2 ENGLISH OCCUPATIONAL MORTALITY STATISTICS. As shown by the census returns the actual numbers, as well as per centages, of glassworkers at advanced ages are surprisingly small. It is evident that the rapid diminution of the number at work after age 35 must be partly, at least, the result of a high death rate at the younger ages, and in particular due to an excessive mortality from pulmonary tuberculosis, which at this period of life causes from one1 See, W o rk in g C on d ition s and E fficien cy as A ffected by H ea t, by B a sil M. M a n ly , in R e p o rt on C on d ition s o f E m p loy m en t in th e Iro n and S teel In d u stry . U. S. B u rea u o f L a b or S ta tistics, V ol. I l l , 1912, pp. 2 8 7 -3 3 2 . 2 B u ck ’ s H yg ien e an d P u b lic H ea lth , V ol. I I , pp. 36, 37. 294 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. third to one-half of the deaths from all causes. Tatham, in Oliver’s “ Dangerous Trades” (p. 139), considers this employment at some length, and his observations, based largely upon English mortality data, are quoted in part as follows: The making, blowing, and engraving of glass occupies a promi nent place among unhealthy trades for several reasons. In the first place, the workers are exposed to extreme variations of tempera ture—in some processes, that of glass blowing especially, the opera tives are constantly exposed to the intense heat of the furnace, as well as to that which radiates from the pots of molten glass which they are engaged in blowing. The intense heat and profuse sweating naturally induce painful thirst, which the workmen evidently allay by excessive drinking; this is shown by the fact that their mortality from alcoholism and from nervous disorders is nearly double that experienced by operatives in other trades. * * * The compara tive mortality figure for glass makers is 1,487, and is, therefore, in excess of the average by 56 per cent. Phthisis and diseases of the respiratory system are especially fatal to workmen in this industry, and they suffer more severely than other occupied males from dis eases of the circulatory, digestive, and urinary systems, as well as from cancer. Since 1881 the mortality of glassworkers has in creased considerably, and this is true of the younger as well as the older workers in this industry. The English mortality statistics upon which these conclusions rest include 1,092 deaths of glassworkers, and of this number 229, or 21 per cent, died from pulmonary tuberculosis. At ages 25 to 34, how ever, out of 177 deaths of glassworkers from all causes, 79, or 44.6 per cent, were caused by this disease. Of the mortality from other causes, bronchitis caused 146 deaths, pneumonia 123, and other respiratory diseases 25. These combined with deaths due to pul monary tuberculosis make a total of 523, or 47.9 per cent, from diseases of the lungs and air passages in the mortality of glass workers from all causes. The most recent English mortality sta tistics of glass manufacture are for the three years ending with 1902, referred to in the Supplement to the Sixty-fifth Annual Eeport of the Eegistrar-General of Births, Deaths, and Marriages in Englard and Wales, in part as follows: In this occupation the death rates exceed the standard for occu pied and retired males at all ^stages of life by proportions ranging from 12 to 32 per cent. In the main working period the comparative mortality figure is 1,260, or 25 per cent above the standard. The ex cess of mortality among these workers is most marked in the case of plumbism, phthisis, respiratory diseases, and Bright’s disease; they also suffer heavily from influenza and from diseases of the nervous and circulatory systems. The mortality from alcoholism, accident, and suicide, however, is below the average. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST* 2 95 COMPARATIVE MORTALITY PROM ALL CAUSES AND FROM DISEASES OF THE LUNGS. The recent English mortality statistics for glassworkers are quite conclusive of the more or less unfavorable effect of this industry on health. In Table 111 the mortality from all causes among men in this group is compared with that of occupied males generally, and the result is decidedly suggestive of conditions in this trade more or less unfavorable to life and health. The excess in the general death rate of glassworkers is met with at all ages, but the relative and actual excesses are greatest with advancing years, being 6.41 per 1,000 at ages 45 to 54, 10.83 at 55 to 64, and 30.99 at 65 and over. 1 1 1 .—M O R T A L IT Y F R O M A L L CAUSES AM ON G G L A S S W O R K E R S , C O M P A R E D W IT H T H A T OF A L L OCCUPIED M A LE S, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E G R O U PS. T a b le [Source: Part II, Supplement to the Sixty-fifth Annual R eport of the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Death rate for glassworkers. Age at death. 15 to 19 years.......................................................................... 20 to 24 years........................................................................... 25 to 34 years........................................................................... 35 to 44 years.... .............................................. ...................... 45 to 54 years.......................................................................... 55 to 64 years........................................................................... 65 years and over......................... .......................................... Death rate per 1,000 for all occupied males. 2. 44 4. 41 6. 01 10. 22 17. 73 31.01 88. 39 Rate per 1,000. 3.22 5.09 6. 74 13.14 24.14 41. 84 119.38 Greater(+) or less ( —) R atio to than rate rate for all for all occupied occupied males. males. + 0 78 + . 68 + . 73 + 2.92 + 6.41 +10. 83 +30. 99 132 115 112 129 136 135 135 A more extended comparison is made in Table 112, in which the mortality of glassworkers from pulmonary tuberculosis and other respiratory diseases is compared with the normal mortality of occupied males from these diseases, by divisional periods of life. The comparison shows that the mortality from pulmonary tubercu losis is excessive at all ages, 15 to 64 inclusive, the excess being most marked at ages 35 to 54. The table further shows that the mortality of glassworkers from other respiratory diseases is excessive at all ages, the excess being most marked at ages 45 or over. The two tables derived from English experience fully confirm the previous conclusion that the mortality of glassworkers is excessive when com parison is made with the mortality of occupied males generally, and that this excess is largely because of the high degree of pulmonary tuberculosis frequency at ages 25 to 54, and a high mortality from other respiratory diseases at ages 35 or over. 296 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. 1 1 2 .—M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O SIS A N D F R O M O T H E R D ISEASES OF T H E R E S P IR A T O R Y SYSTEM AM ON G G L A S S W O R K E R S , C O M P A R E D W IT H T H A T OF A L L O CCUPIED M A LE S, IN E N G L A N D A N D W A L E S , 1900 TO 1902, B Y A G E GROU PS. T a b le [Sourcc: Part II, Supplement to the Sixty-fifth Annual Report o f the Registrar-General of Births, Deaths, and Marriages in England and Wales.] Age at death. Mortality from pulmonary tuberculosis. Mortality from other diseases of the respi ratory system. Death rate for glassworkers. Death rate per Greater 1,000 for Ratio to ( + ) or less rate for all occu Rate ( —) than all occu pied males. per 1,000. rate for all pied occupied males. males. Death rate for glassworkers. Death rate per Greater 1,000 for to ( + ) or less Ratio all occu Rate ( - ) than rate for pied all occu males. per 1,000. rate for all pied occupied males. males. 0.54 1.55 2.03 2. 74 3. 04 2.16 1.11 15 to 19 years....... 20 to 24 years....... 25 to 34 years....... 35 to 44 years....... 45 to 54 years....... 55 to 64 years....... 65 years and over. 0. 56 1. 81 2.88 4.56 4. 87 2.97 +0. 02 + .26 + .85 + 1.82 + 1.83 + .81 104 117 142 166 160 138 0.24 .48 .77 1. 66 3.32 6.54 17. 77 0. 28 .60 .99 2. 43 5. 76 10. 75 28. 68 + + + + + + + 0.04 .12 .22 .77 2.44 4.21 10. 91 117 125 129 146 173 164 161 MATERIALS USED IN GLASS MANUFACTURE. The American glass industry has made considerable progress dur ing recent years, but it may be questioned whether material modifica tions have been introduced into the manufacturing processes with special reference to necessary precautions against health-injurious conditions. The processes have been described in detail by Charles C. Dominge, who, with reference to the materials used, states that—The principal ingredients are washed and dried sand (white), lime, soda ash, potash and cullet, i. e., old broken glass and waste from melting pots. In some risks you may also find charcoal, oxide of lead, kelp, saltpeter, and cobalt (the latter used for coloring purposes). The lime and charcoal should be skidded and kept under a tight roof. The saltpeter or niter bags are likely to take fire spontaneously, there fore they should be removed from the building as soon as they are emptied. The same authority describes the actual process of glass manufac ture, in part, as follows: The above materials are mixed together, forming what is known as “ batch,” which is placed in a fire-clay pot, inserted in brick-inclosed pot furnace, with soft coal feed. This “ batch ” is then subjected to a temperature of approximately 2,500° F., which causes a perfect union and fusion of the materials. When this “ batch ” (i. e., glass ready for working) has cooled to a temperature of, say, 1,900° F., it is ready to be gathered. This is done by means of an iron blowpipe, which is thrust into the fire-clay pot, the molten glass clinging to the end of the pipe, resembling a ball. - To make his material perfectly true, concentric with his iron pipe, the worker rolls it dextrously on an iron table or wooden block of special design. The glassmaker then blows OCCUPATIONS W IT H EXPOSURE TO M IN E R A L DUST. 297 through the blowpipe, which inflates the batch “ soap-bubble fashion,” at the same time deftly shaping, altering, coaxing it into form and proportion with cunningly devised hand tools. The glass design is then placed in a water-jacketed mold, after which it goes to the brick-set tempering oven (known as “ lehr ” ), which resembles a long, horizontal, brick-set boiler. These lehrs are fed by coke or gas, with the heat directly at the entrance, where the glass objects are placed on a traveling platform. About 1,000° F. is maintained here. The object is to give the glass the vital “ temper,” a provision against the piece bursting later in the decorator’s hand. The glass cools slowly in its travel from the entrance where the heat is maintained to the other end, sometimes 40 to 125 feet long. Some of the heavier glass pieces require a week before they are removed from the oven. Conditions of employment, with special reference to occupational hazard, vary, of course, according to the type of melting furnace used. Dust exposure is apparently more serious at the old style pot furnaces than at modern tank furnaces, which are* usually built in three compartments or sections, each of which is he.ated to a different temperature. It is explained by Mr. Dominge that— The newer factories now use what is known as the melting tank or melting furnace or continuous tank. They are usually built in three compartments or sections, each of which is heated to a different temperature. The heated glass runs through an orifice near the base of the first section into the second section, where it is refined, after which it flows into the third compartment. The glass is now ready to be “ gathered ” by the glass worker. The temperature in the first section is about 2,500° F., the molten glass being at this stage color less and translucent. The temperature in the second section is about 1,900° F., while the last section is so heated as to allow the glass to get into a form resembling paste. Other processes involving heat and dust are the working of the so-called “ glory holes,” which are small, brick-inclosed circular fur naces used for heating glassware, for edge trimming, and other purposes; annealing furnaces, “ which resemble somewhat a baker’s oven., arranged in a series of three or four adjoining and heated by open and gas flames about waist high above the foundation.” Into this “ the hot glassware is introduced by hand and removed from one oven to the other, each being heated at a reduction in tempera ture to perfect annealing without rupture.” The so-called “ lehr ” or tempering furnaces are of quite a different type, but the work involves about the same degree of temperature and dust exposure. Theoretically the most hazardous process is probably the so-called “ pot making,” which consists in the making of the furnace mold of fire clay molded by hand and the grinding up of old pots •on the premises, with a considerable exposure to irritating mineral dust.1 1 A u seful and d escrip tiv e a cco u n t o f th e gla ss-m ak in g p rocess o ccu rs in the A nnu al R e p ort o f the N ew Jersey B ureau o f L a b or fo r the y e a r 1906. T h e a cco u n t includes all o f th e essential su b div ision s o f the in d u stry and a m on g oth ers w ood en -m old b low ers, ca rb o y Dlowers, lam p w ork ers, b a tch m akers, ten d in g boys, shearers, etc. 298 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. LABOR CONDITIONS IN OHIO AND NEW YORK. Hayhurst, in a brief description of glass-making processes, *adds much new and useful information, stating that the process consists “ in combining the various siliceous materials, alkalis, and other in gredients,” and that the work is usually done in part by machinery and in part by hand labor, “ the latter causing a great deal of dust because of shoveling and scooping.” Dust in the air was noted in all work places investigated, and in the majority the conditions were bad, “ due to the manner of handling the ingredients.” With special reference to the mixing process it is suggested that “ this work should be done in light, ventilated, dry quarters^ above ground preferably, and, where mechanical means will not confine dust, workers should be furnished respirators of some sort and compelled to wear them. Those handling or exposed to poisonous dusts should be selected for intelligence, properly instructed, and seen by a physician at least once a month.” This last suggestion has special reference to ex posure, to dust contamination by arsenic and red lead. The glass industry was also briefly inquired into by the New York State Fac tory Investigating Commission, who, in their second report, 1915 (Vol. II, p. 1115), refer to two different kinds of glass manufac tured— a flint glass containing no lead and used principally for bottles and a glass containing lead compounds and other poisonous ingredients used chiefly for other purposes. It is explained that— The lead and other compounds are weighed and mixed in one room, then taken to the furnace room and mixed with a quantity of old glass; the entire mixture is then put into the furnace or pot and fused. The material in the pot is kept in a liquid state by high tem perature, and into this the glass blower dips his pipe, taking out the amount he wishes to work. The greatest danger is from the handling of the dry ingredients and inhaling the dust created during the weighing and mixing. Conditions in a typical mixing room are described, and it is said that during the mixing process no methods were employed “ to carry away the dust created, but although the men were furnished respira tors none were found to wear them.” Evidence of lead poisoning was met with in a number of cases. The chief factor of neglect is the absence of precautions to guard against dust. Analyses of samples taken in the mixing room showed 3.3 mg. of lead per cubic meter of air. In another plant it was also found that no special precautions were employed, and while mixers were furnished respirators they would not wear them. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 299 OCCUPATIONAL HAZARDS IN GLASS MANUFACTURE. The most recent observations with regard to American conditions are by W. Gilman Thompson, who points out that—Glassworkers are subject to four prii*cipal forms of occupation hazard, namely, (1) exposure to great heat; (2) mechanical and chemical dust irritation; (3) poisoning by certain metals, such as lead oxide, zinc oxide or arsenic, used for coloring, etc.; (4) irrita tion of the eyes, caused by excessive heat and light. It is explained that certain raw materials, such as flint, sand, quartz, powdered marble, limestone, soda, Glauber’s salt, and potash, are finely ground and mixed, usually in open vessels, which he con siders extremely dusty work. The temperature near the heating fur naces may reach 140° F., and the workmen in winter are, therefore, subjected to great changes of temperature in passing in and out. He explains further that— The result of inhalation of so many kinds of dust, from the raw materials used, the particles of ground glass, and the grinding mate rials, such as emery, etc., may give rise to pulmonary fibrosis and chronic bronchitis, which predispose to tuberculosis, but emphysema is not produced by glass blowing, as formerly supposed, despite the deep inspiration and prolonged expiration employed in the process. Emphysema is due to connective tissue changes in the lungs, and this disease is no more frequent among glass blowers than among any similar group of workmen when due regard is had for age, alcohol ism, chronic pulmonary disease, and other predisposing factors. PRACTICAL SANITARY PRECAUTIONS. Thompson concludes these exceptionally interesting and useful ob servations with suggestions for the prevention of the more specific health-injurious conditions, as follows: The raw materials of glass, when being mixed, should be kept in covered receptacles as much as possible. The introduction of mechan ical apparatus for glass blowing is doing much to mitigate the evils of this occupation when performed by mouth. Workmen should be examined by a physician, and all who are actively syphilitic ex cluded. The excessive heat from the furnaces may be guarded against by the use of asbestos screens and forcible introduction of a stream of cool air by means of a blow fan and duct. The eyes should be protected from the light and heat of the ovens by blue and gray goggles, and face masks may be worn to protect the skin of the face from blistering. All grinding rooms should be thoroughly cleaned daily and dust removed from the wheels, tables, and benches. The wheels should be incased as much as possible, and a strong exhaust duct should be operated in connection wTith them. Women and chil dren should be excluded from the more hazardous departments of w^ork. When handling sharp-edged glass vessels or working with lamp chimneys or thin bottles which are liable to explode, the hands 300 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. should be protected from injury by stout leather gloves. The grind ing or cutting of quartz, crystal and jet, jade, and similar substances presents the same hazards to the respiratory system as those of glass grinding. PRESENT-DAY LABOR CONDITIONS. An exhaustive report upon labor conditions in the glass industry, with some extended references to sanitation and mortality, was in cluded in the Senate report of the Commissioner of Labor on the “Condition of Woman and Child Wage Earners in the United States,” Washington, 1911. This report includes a descriptive account of American glass-making processes, with observations on physical strain, interchange of occupations, dust, fumes, heat conditions, hours of labor, night work, etc. The mortality data are limited to glass blowers, elsewhere referred to, but in a general way the conclusions are applicable to glassworkers as a class. An extended descriptive account is included, from the. Twenty-fourth Annual Report of the Bureau of Statistics of Labor and Industries of New Jersey, for 1901, which in a large measure is applicable to the present time. Attention is directed in this report to the improvement in working conditions introduced into glass works during the last two decades, but apparently much remains to be done to eliminate many objec tionable features, especially such as refer to weather exposure, damp ness, extreme heat, etc. It is said in this connection, however, that the improvements referred to “ have removed some of the most seri ous causes of ill health, and they hcvve greatly lessened the workmen’s liability to contract disease while at work.” A new element of danger, however, has been introduced in consequence of the extensive use of the so-called “ continuous-tank .furnace,” which is said to be “ severe upon all blowers and especially so on the older men who have been accustomed for years to work out of a pot furnace and only during the day.” The heat of a tank furnace is much greater than that of a pot furnace, and “ the alternation from day to night work weakens the system and reduces its power of resistance to attacks of disease.” In concluding the report, it is pointed out that “ it is certain that the environments of the workmen” (in glass fac tories) “ create tendencies'to disease, which, taken with their own lack of care have greatly aggravated attacks of sickness and in many cases caused them to assume characteristics very difficult to treat.” Out of 814 cases of sickness specifically reported there were no cases of pulmonary tuberculosis, but there were 18 cases of pneumonia, 21 of inflammation of the lungs, 16 of inflammation of the throat, and 10 of bronchitis, aside from 76 cases of la grippe. It is self-evident, of course, that without a qualified medical examination of the em ployees the true extent of incipient tuberculosis could not be ascer tained, and it is a reasonable assumption that in a more advanced OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 301 condition of the disease the employee would not be at work. The statistics, however, suggest a relatively high frequency of respiratory diseases, which, as elsewhere observed in the general discussion of pneumoconiosis, is generally a predisposing condition in pulmonary tuberculosis. SPECIFIC LIABILITY TO RESPIRATORY AND TUBERCULOUS DISEASES. In so far as the evidence is available, the general conclusion is dis tinctly unfavorable regarding employment in the glass industry, with special reference to an increased liability to respiratory and tuberculous diseases. The rather inconclusive American evidence is quite fully confirmed by more extensive investigations into the hygiene of glassworkers in Germany1 and Austria, referred to at some length in the report of the Commission of Labor on the con dition of womah and child wage earners in the United States, with special reference to the glass industry, which should be referred to for more extended consideration. It seems sufficient for the present purpose to conclude these observations with the following extract from a^translation 'of a German treatise on the diseases of glass workers, by Dr. C. F. Schmidt: In the foreground among all diseases of the glass grinders stands the damage to the lungs by glass dust. This glass dust produces its effect by the mechanical irritation of the fine, sharp-angled and needle-pointed particles of glass. The dust particles may at length find their way into the lymph current and be deposited in the lungs and bronchial glands. Meinel, for example, found in the lungs of a glass blower a siliceous content of 30.7 per cent. Soon there super venes a chronic catarrh of the larger bronchial tubes and bron chioles, the desquamated and inflamed mucous membrane of which finally affords a congenial soil for colonies of tubercle bacilli. Tuber culosis of the lungs makes early victims of .a large proportion of the glass grinders. This is readily explicable, because, even as appren tices, they are exposed to the glass dust. These observations, in addition to the foregoing statistical data and descriptive references, quite fully sustain the conclusion that employment in the glass industry must be considered as obvi ously injurious to health, with a measurable predisposition to pul monary tuberculosis, partly, if not largely, on account of the con siderable and continuous exposure to the inhalation of mineral dust. INDUSTRIAL INSURANCE MORTALITY STATISTICS. Since glass blowers and cutters are separately considered, and in view of the foregoing observations with special reference to mixers 1 A m ost u sfu l referen ce t o h y g ie n ic con d ition s in the G erm an glass in d u stry o ccu rs In the rep ort o f C onsul G en eral F ra n k D illin g h a m , re p rin te d in th e D a ily C on su lar a n d T ra d e R ep orts, W a sh in g ton , Feb. 4 , 1909. 302 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. and handlers of raw materials, as well as workmen generally exposed to the dust hazard, the following vital statistics derived from the industrial insurance mortality experience of the Prudential In surance Co. of America are only for glassworkers other than blowers and cutters. Table 113 includes 897 deaths of glassworkers not other wise specified, and of this number 274, or 30.5 per cent, are deaths from pulmonary tuberculosis. 1 1 3 .—P R O P O R T IO N A T E M O R T A L IT Y FR O M P U L M O N A R Y T U B E R C U L O SIS AM ON G G L A S S W O R K E R S , E X C L U D IN G B L O W E R S A N D C U T T E R S , IN D U S T R IA L E X P E R IE N C E OF P R U D E N T IA L CO., 1897 TO 1914, C O M P A R E D W IT H T H A T OF A L L M ALES IN U N IT E D S TA TE S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U PS. T able Deaths of glassworkers, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at deatli. Males in registration area, 1900-1913. A ll causes. Pulmonary tuber culosis. 15 to 24 years............................................................................ 25 to 34 years........ ................................................................... 35 to 44 years............................................................................ 45 to 54 years............................................................................ 55 to 64 years............................................................................ 65 years and over.................................................................... 257 186 151 108 103 92 81 95 52 25 16 5 31.5 51.1 34.4 23.1 15. 5 5.4 27.0 30. 5 23. 4 14.7 7.9 2.6 Total, 15 years and over............................................. 897 274 30.5 13.9 Glass workers. The table shows further that the proportionate mortality from pulmonary tuberculosis was extremely high among glassworkers not otherwise specified at ages 25 to 34, or 51.1 per cent, against the expected normal mortality of 30.5 per cent. The data are extremely suggestive and emphasize the importance and in fact the necessity of thorough-going methods of factory supervision and State control of industrial processes inimical to health and longevity. MORTALITY 0 * GLASSWORKERS— UNITED STATES REGISTRATION AREA. The mortality of glassworkers has been reported upon for the years 1908-1909 by the Division of Vital Statistics of the United States Census Bureau, but blowers and workers in general are in cluded only for the year 1908. No explanation is made in the text of the report regarding the inclusion or exclusion of particular occu pations for either one of the two years, during which the analysis was made by industries or occupations with reference to specific causes of death by divisional periods of life. According to the census report, out of 867 deaths of glassworkers from all causes 260, or 30 per cent, were from pulmonary tuberculosis. This is distinctly ex cessive when contrasted with 14.9 per cent for all occupied males and 16.7 per cent for plasterers. The details of the mortality by divisional periods of life are shown in Table 114. OCCUPATIONS W IT H EXPOSURE TO M IN E R A L DUST. 303 T able 1 1 4 .—P R O P O R T IO N A T E M O R T A L IT Y OF G L A S S W O R K E R S F R O M P U L M O N A R Y TU B E R C U LO SIS, G R O U PS. U N IT E D S T A T E S R E G IS T R A T IO N AREA, 1908 TO 1909, B Y A G E Deaths from pulmo nary tuberculosis. Age at death. Deaths from all causes. Number. Per cent of deaths from all causes. 15 to 24 years.................................................................................................. 25 to 34 years.................................................................................................. 35 to 44 years.................................................................................................. 45 to 54 years.................................................................................................. 55 to 64 years.................................................................................................. 65 vears and over........................................................................................... Age unknown................................................................................................ 176 202 169 117 101 101 1 83 86 56 23 8 4 47. 2 42. 6 33.1 19. 7 7.9 4.0 Total, 15 years and over.................................................................... 867 260 30.0 T able 1 1 5 .—P R O P O R T IO N A T E M O R T A L IT Y OF G L A S S W O R K E R S F R O M N O N T U B E R CULO U S R E S P IR A T O R Y DISEA SES, U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1906 TO 1909. Deaths from nontuber culous respiratory diseases. Cause of death. Number. Per cent of deaths from all causes. Asthm a.................................................................................................................................. Bronchitis............................................................................................................................. Pneumonia........................................................................................................................... Other nontubarcuknis respiratory diseases.................................................................... 2 5 67 6 0.2 .6 7. 7 .7 Total............................................................................................................................ 80 9.2 According to Table 114 the proportionate mortality was excessive at all ages throughout the entire working period of life, but par ticularly so at ages 15 to 24, when out of the mortality of glass workers from all causes 47.2 per cent were from pulmonary tuber culosis. The corresponding proportion for potters was 46.2 per cent, and for marble and stonecutters 26.2 per cent. At ages 25 to 34 the differences are less pronounced, the proportion of deaths from pul„ monary tuberculosis having been 42.6 per cent of the mortality from all causes among glassworkers, against 44.4 per cent for potters and 43.5 per cent for marble and stonecutters. In a general way the table confirms other investigations and may be considered fairly conclusive, except in so far that the same applies to the glass industry in general rather than to specific occupations or employments subject to the most trying conditions of mineral dust exposure, complicated, of course, by physical strain, heat exposure, temperature changes, etc. Aside from the mortality of 30 per cent from pulmonary tuberculosis glassworkers show an additional mortality from nontuberculous respiratory diseases of 9.2 per cent, which compares with 12.5 per 304 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. cent for potters and 12.2 per cent for marble and stone workers. As far as it is possible to judge, therefore, the mortality from non tuberculous respiratory diseases is not distinctly excessive, for in comparison the mortality of all occupied males is 10 per cent, or respectively, 7.8 per cent for pneumonia against 7.7 per cent f :• glassworkers, and 0.9 per cent for bronchitis against 0.6 per cent tvr glassworkers. GENERAL CONCLUSIONS. Employment In the glass industry, therefore, while predisposing to pulmonary tuberculosis, appears to have no directly measurable relation to the occurrence of nontuberculous respiratory diseases. This conclusion is of special importance on account of the assump tion that heat exposure and sudden temperature changes* which are quite common to the glass industry, predispose decidedly to pneu monia and other nontuberculous respiratory diseases. In the Ameri can glass industry this is apparently not the case. GLASS CUTTERS. Glass cutters, including under this term all who are employed in the manufacture of crystal or so-called cut glass, constitute a separate and well-defined occupation division in glass manufacture. SANITARY ASPECTS OF GLASS CUTTING AND POLISHING. The most important employments are roughing, smoothing, polish ing, and puttying, but of these the last named is the most injurious, chiefly because of a specific liability to lead poisoning. The sanitary aspects of the employment have received the special consideration of a British committee on dangerous trades, which, in its Third Interim Report, remarked with special reference to the injurious effects of putty powder in the form of dust that— It will thus be seen that all persons employed in places where “ putty powder55 is used, though themselves not handling it, are liable, through inhalation of the dust, to illness and even death through juxtaposition with those engaged in its use. Under existing circumstances the wet powder splashes onto the clothes not only of the polisher who uses it, but onto those of his neighbors; it gets dry after a time, comes off in fine dust, and enters the system either by inhalation through the lungs or by swallowing or through the pores of the skin. Among other recommendations for the amelioration of the more Dr less health-injurious conditions inherent in this employment, the committee suggested that all persons engaged in the department of glass cutting and powdering, where so-called putty powder is used, OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 305 should be examined once a month by the certifying surgeon for the district, who should be empowered to order temporary or permanent suspension of work. EXPOSURE TO MINERAL AND METALLIC DUSTS. Aside from the exposure to the inhalation of dust containing lead or other metallic ingredients, there is a further liability to the inhala tion of considerable quantities of mineral dust in a large variety of forms. It would obviously be very difficult to estimate with even approximate accuracy the degree of lung injury resulting from dust exposure in glass cutting and polishing, but it is the opinion of quali fied authorities that practically every branch of the trade is more or less affected, with a resulting excess in the mortality from pulmonary tuberculosis. Tracy comments briefly upon the health-injurious aspects of this occupation, in part as follows: But the most dangerous work is that of the grinders and polishers of cut glass. About 35 per cent of them have chronic pneumonia (phthisis), and their average age at death is variously given at from 30 to 42 years. Putegnat (de Luneville) has described a peculiar form of gingivitis which he has observed among glass cutters, and which, he says, attacks 95 out of every 100 workmen. It comes on in about three months after the person begins work, and toward the sixth month is well developed. It attacks by preference the upper jaw, and is accompanied by the same blue line that is found in cases of lead poisoning. The acid secretion of the gums destroys the enamel of the teeth, which soon become pointed, brittle, and.break off close to the alveoli, leaving a permanent stump. The gums remain soft and spongy, and the breath is very fetid. At no time is there any pain or hemorrhage. He supposes it to be caused by malnutri tion, bad air, etc. (Tardieu.) These symptoms certainly appear suspiciously like those of lead poisoning, and the suspicion is ren dered stronger by the fact that French flint glass contains about 20 per cent of lead, and that other symptoms of lead poisoning are not uncommon in glass cutters, as colic, constipation, muscular pains, etc. Garrod has noticed the frequency of gout among them, and brings it forward to support his theory of a connection between that disease and saturnine poisoning. The grinding or etching of glass by the sand blast fills the rooms with a dust composed of particles of sand and glass mingled. The business is a comparatively new one, and the workmen so far do not appear to be injured by it, with the exception of a slight tickling cough when they first begin work. The dust is rather coarse and heavy, and I am inclined to think it does not penetrate very far into the lungs, perhaps not even getting beyond the trachea, whence it is easily expectorated. Lloyd also considered this employment, holding that— Flint glass contains lead, being chemically a compound of silicon (silicic acid) with an alkaline and an earthy base, the latter being 1 0 6 8 1 1 °— 18 — B u ll. 2 3 1 -------- 20 306 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. represented by lead. It is this flint, or lead, glass that is used for cut glass because of its brilliancy. The glass cutter’s mill is a revolving disk of wrought or cast iron on which is fed a mixture of sand and water, with which the cutting and polishing are accomplished. In this process, which requires the artisan to bend closely over his mill, dust and fine particles of glass are given off. Emery and putty pow der also are used, the latter containing lead. These are the noxious agents by which these cutters and polishers of flint glass acquire lead poisoning. Unfortunately there are no official vital statistics of this occupa tion, since the comparatively small group of cutters of crystal glass is included in the census vital statistics with glassworkers generally. Cutters of crystal glass are continuously and considerably exposed to the inhalation of fine particles of mineral dust, which must indeed disastrously affect the lungs of the workmen, but in particular such as are otherwise predisposed to pulmonary tuberculosis. The sugges tion of Oliver and others that crystal glass polishers and cutters should be periodically medically examined for cases of lead poison ing applies equally to the purpose of discovering incipient cases of tuberculosis more or less the result of the employment.1 MORTALITY OF GLASS CUTTERS— MEDICO-ACTUARIAL EXPERIENCE. According to the medico-actuarial investigation, which, however, combines glass bevelers, grinders and cutters, excluding foremen and superintendents, the relative mortality from all causes was extremely high, or 46 per cent in excess of the normal. The details of this experience are shown in Table 116. T a b l e 1 1 6 .— M O R T A L IT Y F R O M A L L C A U S E S A M O N G G L A S S B E V E L E R S , G R IN D E R S , A N D C U T T E R S , E X C L U D IN G F O R E M E N A N D S U P E R IN T E N D E N T S , B Y A G E GROUPS. [Medico-Actuarial Investigation.] -------------- <2 Age at death. Number exposed to risk one year. Actual deaths. Expected deaths. Ratio of actual to expected deaths. 15 to 29 years........................... .................. ............................ 30 to 39 years........................................................................... 40 to 49 years............................................ - ............................ 5ft to 59 years........................... ......... ..................................... 00 years and over............................ ............................. 4,857 3,187 813 193 39 26 33 9 6 3 22.24 17.45 7. 73 3.43 1.75 117 189 116 175 171 T otal............................................................................... 9,089 77 52.60 146 1 F o r a d d ition a l referen ces to the h e a lth -in ju rio u s circu m sta n ces in gla ss cu ttin g and po lish in g , see th e R e p o rts o f the C h ief In sp e cto r o f F a cto rie s and W ork sh op s fo r 1895, V o l. I, p. 3 6 ; 1896, p. 2 5 ; 1899, pp. 16, 3 1 3 ‘; 190 0 ; p. 2 0 7 ; 1901, £>art I, p. 220. F or a d e sc rip tiv e a cco u n t o f the va riou s m a n u fa ctu rin g processes, see S cien tific A m erican f o r A p r. 30, 1904. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 307 MORTALITY OF GLASS CUTTERS— INDUSTRIAL INSURANCE EXPERIENCE. It is regrettable that the foregoing experience should not be avail able with reference to causes of death. The mortality from pul monary tuberculosis among glassworkers is, however, clearly shown in Table 117, derived from the industrial insurance mortality experi ence of the Prudential Insurance Co. of America, for the period 1897 to 1914, including 220 deaths from all causes, of which 80, or 36.4 per cent, were from pulmonary tuberculosis. T a b le 1 1 7 . — P R O P O R T IO N A T E M O R T A L IT Y F R O M P U L M O N A R Y T U B E R C U L O S IS A M O N G G L A S S C U T T E R S , I N D U S T R IA L E X P E R IE N C E O F P R U D E N T IA L CO.. 3 897 TO 1914, C O M P A R E D W I T H T H A T O F A L L M A L E S IN U N IT E D S T A T E S R E G IS T R A T IO N A R E A , 1900 T O 1913, B Y A G E G R O U P S . Deaths of glass cutters, 1897 to 1914, from— Per cent of deaths from pulmonary tubercu losis among— Age at death. 15 to 24 years.......................... . .............................................. 25 to 34 years.................................... ............ ......................... 35 to 44 years___ . . . . . ............... ............................................ 45 to 54 years.. . . . . . . . .................................................- .......... 55 to 64 years...........- ...........................................- ................. 05 years and o v e r ...,................................................... ........ Age un know n._______ ____ ___________ _ Total, 15 years and over......... . Males in registration area, 19001913. A ll causes. Pulmonary tubercu losis. 53 55 48 28 24 11 1 21 28 20 6 2 3 39.6 50.9 41.7 21.4 8.3 27.3 27.0 30.5 23.4 14. 7 7.9 2.6 220 80 36.4 13.9 Glass eutters. According to this table the proportionate mortality of glass cutters from pulmonary tuberculosis is highest at ages 25 to 34, when out of 55 deaths from all causes 28, or 50.9 per cent, are from pulmonary tuberculosis. The mortality from this disease, however, must be con sidered excessive at every divisional period of life. There appears to have been no material improvement in the health condition of glass cutters during recent years; and, with possibly the exception of the reduction of the liability to lead poisoning, there can be no question of doubt but that sanitary conditions are generally far from satis factory and that effective dust-removing devices are frequently ab sent. There are no reasons for questioning the possibilities of a material improvement in the health conditions of this specific group of occupations in the glass industry, nor can the conclusion be called into question that the principal cause of ill health is the dust gen erated in connection with glass-cutting processes and inhaled to a more or less considerable and measurable degree. LABOR CONDITIONS IN MASSACHUSETTS. Glass cutting and polishing were reported upon in the Massa chusetts investigation of 1907, but it should be considered that 308 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. the industry is, relatively, of very limited extent in that State. It is said in the report referred to that— Operations which cause glass dust in the air are recognized as especially dangerous to health, such dust being quite as irritating as steel dust, if not more so. This being the case, glass cutting and polishing are conducted with a minimum of danger in the wet way. In cutting, the pattern is marked out with red lead or with graphite, and then the object is held against a rapidly revolving steel wheel upon which fine quartz sand and water are dropped continuously, or upon a wheel of fine emery and corundum. When the pattern has been cut out the glass is plunged into hydrofluoric acid in lead tanks, connected with the exhaust pipe of a steam-propelled blower. This smooths the cut surfaces, but acts on the uncut parts to such an extent as to make polishing necessary. This is done with pumice or rottenstone and water or oil on revolving brushes, and putty powder or rouge and wax on wooden wheels. The use of oil or water serves to prevent dust, and the employment of wooden shields pro tects the worker from being spattered with the mixture of oil and glass powder and other materials thrown off in the process. For successful work good light is very necessary, and in this respect all five of the establishments visited were found to be beyond criticism. The conditions as to ventilation and toilet arrangements were found to be equally commendable. All cutting and polishing is done by the wet method, and in no instance was any dust perceptible. In two of the establishments in which glass blowing also is carried on the employees are necessarily exposed to high temperatures and to the possible danger which resides in the use of blowpipes, which are introduced indiscriminately into the blowers’ mouths. Otherwise no objectionable features were noted. The number of persons employed in the several factories ranged from about 30 to several hundred. As a class they appear to be of a rather high order of intelligence and to enjoy good health. These observations should be accepted with caution for the reason stated. L A B O R C O N D ITIO N S I N P E N N S Y L V A N IA A N D OHIO. In Pennsylvania, where glass cutting is quite extensively developed, no qualified investigation has been made by official authority, but private inquiries have disclosed a considerable variation in sanitary conditions, sufficiently so to suggest the possibility of material and far-reaching improvements. Hayhurst, in the Ohio survey of 1915, gives expression to the opinion that “ the work at glass grinding was done only at intervals and created a great deal of dust.” This may have reference to excep tional conditions in Ohio plants, for as a rule cut-glass grinding is a continuous process and relatively free from health-injurious dust when sufficient water is used and the surroundings are kept scrupu lously clean. The dust danger rises chiefly from unsanitary conditions rather than from the grinding which, as a rule, is carried on by the wet process. The danger to be guarded against is rather the liability OCCUPATIONS W IT H EXPOSURE TO MINERAL DTTST. 309 to lead poisoning, but there are reasons for believing that the occu pation also involves, though only to a limited extent, an increased liability to pulmonary tuberculosis. The four essential processes of roughing, smoothing, polishing, and puttying all involve exposure to widely varying conditions, but the risk is most serious in the puttying, chiefly on account of the liability to lead poisoning. In this process a mixture of oxide of lead is used, which, by means of a brush wheel, is applied to the nearly finished article for the purpose of giving the same the brilliant polish, which is the most distinctive feature of the highest grade of cut glassware. A “ dust,” or rather a splash,” is created, and small particles of the same are readily observed on the faces and hands of the operators. The. hands are constantly dipped into a mixture of lead, putty, and water, and unquestionably some lead is occasionally introduced into the sj^stem in small quantities, either by inhalation or by habits of uncleanliness. Lead poisoning resulting from this occupation has, however, been very materially reduced during recent years, and cases of lead paralysis are now rarely met with. Reference may be made here to a brief statement regarding glass polishing in the Report of the Chief Inspector of Factories and Work shops for 1898. The evidence is cjuite conclusive that in this country lead poisoning in glass cutting is less common than in the United Kingdom. The most recent investigations in this country have been reported upon by the New York State Factory Investigating Com mission, 1913 (vol. 2, p. 1116), chiefly with reference to the risk of lead poisoning, but it is said in conclusion that “ in this industry the principal measures to be taken are cleanliness, especially on the part of the worker; and while there may be some dust in the air, it is negligible, as the results of our analyses fail to show any lead present in the samples taken.” This conclusion, of course, has reference only to lead and has no bearing upon the question of mineral dust in relation to lung diseases, whether of the tuberculous or nontuber culous variety. G E N E R A L C O N CLU SIO N S. In a general way it would seem that the available evidence regard ing glass cutters and polishers indicates a very marked improve ment in the hygienic conditions of the principal plants which have been thoroughly investigated and the practical elimination of lead poisoning. In the principal centers of the glass-cutting industry in the United States cases of lead paralysis are now extremely rare. The process of puttying has been largely eliminated and in place thereof the use of the method of dipping the nearly finished glass ware into hydrofluoric acid has become quite general. The underly ing cause of the practical elimination of lead poisoning is, however, the decidedly more sanitary condition of the shops, which by inference 310 MOKTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. suggests a similar improvement in the partial control of the dust hazard. Processes of ventilation and dust removal have not been as thoroughly developed as would be desirable, but there can be no reasonable question of doubt as regards a material recent improve ment in the health and longevity of glass cutters and polishers in contrast to the truly deplorable conditions prevailing in the past. GLASS BLOWERS. The hygiene of glass blowing with special reference to pulmonary tuberculosis is of exceptional interest as a labor problem in the glass industry. The number of blowers employed proportionate to the total number of wage earners is relatively large, and, from a wage point of view, the employment is of the first order of importance. D E S C R I P T IV E ACCOUNT OF G L A SS-B L O W IN G P R O C E S S E S . In a descriptive account of the glass industry, published in the Pennsylvania Labor Report for 1888, it is stated that— The occupation of blowing requires great dexterity and nimblcness of the fingers to manipulate the glass; and while not laborious in. the sense of requiring great muscular power, every limb and muscle is brought into use in molding a bottle, whether a large or small one. The blower in a shop is constantly on his feet, moving in a circle, and usually takes from six to seven steps to each bottle he molds. When it is considered that in making some sizes he molds from 175 to 200 dozen in a day we have some idea of the endurance required. There is scarcely an affliction that man is liable to that does not inter fere with his work. The least sore on any of his fingers, hands, or feet, sore lips, sore throat, or toothache, or any of these, and he is obliged to lay off. The gaffer sits while at his work and is not liable to be laid up by so many ailments as the blower. Although subjected to heat, dust, and the gases that arise from the use of coal or oil in heating the glory hole, his workmanship is not impaired by most of the afflictions that disqualify a blower. Hence gaffers are usually superannuated blowers. S P E C IA L O CC U PA TIO N A L H A Z A R D S. Health conditions vary considerably, according to the nature of the blowing process, whether for the purpose of bottle making,1 1 F o r a b r ie f b u t t h o ro u g h ly scien tific a cco u n t o f gla ss b o ttle m a n u fa ctu re fro m the m ix in g o f th e in g red ien ts to the m o ld in g o f b ottles by m a ch in e ry , see th e S cie n tific A m erican S u p p lem en t, N o. 213 5 , fo r D ec. 2, 1916. W ith re fe re n ce to th e in g red ien ts used it is said in p a r t th a t “ T h e b asis o f b o ttle g la ss is a s ilicio u s san d, t o w h ich is som etim es a dded lim eston e, to g e th e r w ith s u lp h a te o r ca rb o n a te o f soda . T h ese in gred ien ts, in p u lv erized fo rm , are th row n in to a la rg e tan k fu rn a ce , w h ere th e y are m elted and com b in ed , fo r m in g a th ick liq u id o f siru p y co n siste n cy . In th e fa c to r ie s th a t m ake th e b etter grad es o f gla ss su ch as tab lew a re and w in d o w glass, it is p e rio d ica lly d esirab le to clea n ou t th e ir m e ltin g p ots, an d th e re is a lso con sid e ra b le d am aged m a te ria l th a t m ust be d is c a r d e d ; th a t is ca lled “ cu lle t,” a n d is sold to th e b o ttle m ak er, w h o m ixes it w ith his m a teria ls, tog eth er w ith a ll the d a m a ged b o ttle s t h a t a ccu m u la te a rou n d th e fa c t o r y .” T h e re la tio n o f th is p rocess to d u st exp osu re and h ea lth -in ju rio u s co n d itio n s is o b viou s. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. carboy making, or window glass, etc. Oliver— 311 According to Sir Thomas The risks to health incurred by makers of glass are mainly those due to exposure to excessively high temperatures, e. g., bronchial and pulmonary affections; many of the men die from phthisis. They bear pneumonia badly, owing to their intemperate habits. Dr. Scheele, in the Berlin Kleinische Wochenschrift, March, 1900, has drawn attention to what is known as “ glass-blowers’ mouth.” Large swellings like air cushions can be seen and felt in some glass blowers, extending from the angle of the mouth to below the ears. The swellings look like mumps. They involve the parotid gland only. They crepitate under the finger and by pressure can be made to dis appear. It is only recently that these swellings in the cheeks of glass blowers have attracted attention, and especially in France. The relaxation of the cheeks, the jous casees of French glass blowers, is by some attributed to a faulty method of blowing. From glass blowers under my care in the Newcastle Infirmary I have ascertained that the malady is not unknown among the men in the work on Tyneside. Dr. Scheele found that it was present in only 2.5 per cent of blowers, some of whom had worked for years. In those who had thus suffered the duct that leads from the interior of the mouth to the parotid gland had become dilated, owing to the repeated entrance of air into it under considerable pressure; the mucous membrane of the inside of the cheek, too, showed thick pale patches, plaques opal ines, which Guinard regarded as the result of the great pressure and straining the buccal mucous membrane was exposed to during the act of blowing. Under ordinary forced expiration the pressure inside the closed mouth is equivalent to from 6 to 9 millimeters of mercury, but in glass blowing it may rise to 90 and even as high as 110 mm. In the course of an ordinary day a good workman will blow as many as from 600 to 700 bottles. F R E Q U E N C Y OF L U N G D IS E A S E S . The foregoing observations are far from conclusive, but they em phasize the urgency of more extended investigations. A brief refer ence to lung affections in glass blowers occurs in an abstract of a paper on the subject by Prettin,1 as follows: Prettin found that the muscles seem to adapt themselves to their task, so that glass blowers are not apparently more liable than others to have pulmonary emphysema. But, on the other hand, he found an unusually large proportion of tuberculous lesions among them. Fully 20 per cent of the workmen presented evidences of a tuber culous lung affection, while emphysema was observed in only 5 out of the 230 glass blowers examined. It was very slight in the 2 subjects between 40 and 50 years old, and the 3 others were 52 to 58 years old, and had been glass blowers for 34 to 43 years. He cites Fischer to the effect that not a single instance of emphysema was found in 500 members of military bands, as published in 1902. 1 Journal American Medical A ssociation, Mar. 19, 1904. 312 MORTALITY FROM RESPIRATORY DISEASES,IN DUSTY TRADES. G L A SS B L O W E R S ’ C A TA R A C T . Medical interest has rather been confined to the question of glass blowers’ cataract, a description of which, however, is outside of the scope of the present discussion. The affliction is one of serious im portance, especially with reference to workmen’s compensation and as a medical problem in relation to the syphilitic infections. Since any and all diseases which impair physical efficiency or result in a diminution of disease resistance have an indirect bearing upon, the frequency of pulmonary tuberculosis, the following reference to glass blowers’ syphilis in the Medical Record (Feb. 11, 1888) is included: Prof. N. De Smet, of Brussels, in commenting upon a case of syphilis occurring in the mouth of a glass blower, referred to several epidemics which have been reported as having occurred among artisans of this description. He said that only two plans for pre venting these outbreaks had been devised, viz, giving a separate movable mouthpiece to each man, and instituting frequent, rigorous, and periodical inspection of the persons of the employees. The first plan is always declared by the workmen to be impracticable, from the loss of time which wTould be occasioned by fitting the different mouthpieces on the tubes. The second wyould, of course, be resisted by the men, but he thinks their objections could be overcome by showing them the danger to themselves and their families which arises from the present system. M O R T A L IT Y OF G LA SS B L O W E R S — M E D IC O -A C T U A R IA L E X P E R IE N C E . The mortality, of glass blowers not using machinery and excluding foremen and superintendents was investigated by the MedicoActuarial Association, with the result shown in Table 118. T able 1 1 8 .— M O R T A L IT Y F R O M A L L C A U S E S A M O N G G L A S S B L O W E R S N OT U SIN G M A C H IN E R Y , E X C L U D IN G F O R E M E N A N D S U P E R IN T E N D E N T S , B Y A G E G R O U PS. [M e d ico -A ctu a ria l I n v e s tig a tio n .] ^ Age at death. 15 to 29 years................................................................................... 30 to 39 years................................................................................... 40 to 49 years................................................................................... 50 to 59 years................................................................................... 60 years and over........................................................................... Total .................... ............................................................. N umber exposed to risk one year. Actual deaths. Expected deaths. 5,002 4,216 1,008 144 13 26 30 12 2 22.95 22. 75 8.91 2. 83 .46 10,383 70 57.90 .Ratio of actual to expected deaths. 113 132 135 71 121 The experience shows that the actual mortality of this class of workmen is 21 per cent in excess of the expected, the excess being most marked at ages 30 to 49. 313 OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. M O R T A L IT Y OF G L A SS B L O W E R S — IN D U S T R IA L IN S U R A N C E E X P E R I E N C E . The only available statistics of glass blowers’ mortality from pul monary tuberculosis are the data derived from the industrial insur ance experience of the Prudential Insurance Co. of America for the period 1897 to 1914, which includes 546 deaths from all causes, of which 175, or 32.1 per cent, were from pulmonary tuberculosis. T able 1 1 9 .— P R O P O R T IO N A T E M O R T A L IT Y FROM PULMONARY T U B E R C U L O S IS A M O N G G LASS B L O W E R S , I N D U S T R I A L E X P E R I E N C E O F P R U D E N T I A L CO., 1897 TO 1914, C O M P A R E D W I T H T H A T O F A L L M A L E S IN U N I T E D S T A T E S R E G IS T R A T IO N A R E A , 1900 TO 1913, B Y A G E G R O U P S. Deaths of glass blow ers, 1897-1914, from— Per cent of deaths from pulmonary tuberculo sis among— Age at death. A ll causes. Pulmonary tuberculo sis. 15 to 24 years.................................................................................... 25 to 34 years................................................................................... 35 to 44 years................................................................................... 45 to 54 years................................................................................... 55 to 64 years................................................................................... 65 years and over........................................................................... 51 137 115 106 52 85 23 73 36 30 Total, 15 years and over........ ......................................... 546 Glass blowers. Males in registration area, 1900-1913. 27.0 30.5 23.4 14.7 7.9 5 45.1 53.3 31.3 28.3 15.4 5.9 175 32.1 13.9 8 2.6 According to Table 119, the proportionate mortality from pul monary tuberculosis is excessive at all ages, but especially so at ages 25 to 34, when of the deaths of glass blowers from all causes, 53.3 per cent are from pulmonary tuberculosis, against 30.5 per cent among males in the United States registration area. The table may be accepted as fairly conclusive, but, as said before, health and sani tary conditions vary considerably in the different branches of glass blowing, but no data are at present available which would permit of definite conclusions. It is, however, a.safe assumption that carboy blowing, which requires much more strength than bottle blowing, is probably more injurious and involves an increased predisposition to pulmonary tuberculosis. How far the excessive liability to tuber culous diseases is increased by the dust factor can not be determined at the present time. The occupation group is one deserving of much more qualified medical and other technical consideration than it has heretofore received. M O R T A L IT Y E X P E R I E N C E OF T H E G L A SS B O T T L E B L O W E R S ’ A SSO C IA T IO N . The foregoing observations and conclusions are quite fully sus tained by an analysis of the mortality of glass blowers, presented by the records of the Glass Bottle Blowers’ Association of the United States and Canada for the period 1892 to 1908, inclusive, contained in the report of the United States Commissioner of Labor on the 814 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. Condition of Woman and Child Wage Earners in the United States, with special reference to the glass industry, Washington, 1911. The experience includes 898 deaths from all causes, of which 287, or 32.0 per cent, were from pulmonary tuberculosis. In addition, there were 8 deaths from other forms of tuberculosis, or 0.9 per cent of the mortality from all causes; 69, or 7.7 per cent, from pneumonia; and 28, or 3.1 per cent, from other diseases of the respiratory sys tem. Combining the mortality from tuberculosis and nontuberculous respiratory diseases, the proportionate mortality from this group of causes in the mortality from all causes was 43.7 per cent. The mor tality in detail, by divisional periods of life, is shown in the usual form in Table 120. T a b l e 1 2 0 .— M O R T A L IT Y OF GLASS B L O W E R S , GLASS B O T T L E B L O W E R S ’ ASSOCIA T IO N O F U N IT E D S TA TE S A N D C A N A D A , 1892 T O 1908. A ge at death. Deaths from all causes. Deaths from pulm onary tuberculosis. N um ber. Per cent. 15 to 24 years. ......................... 25 to 34 years............................ 35 to 44 years............................ 45 to 54 years........................... 55 to 64 years............. ............. 65 years and over.................... Age unknow n........ , ............... 48 266 272 140 86 74 12 24 119 93 34 9 4 4 50.0 44.7 34.2 24.3 10.5 5.4 33.3 Total, 15 years and over.. 898 287 32.0 Deaths from other tuberculous diseases. Num Per ber. , cent. 5 3 1.9 1.1 8 .9 Deaths from pneumonia. N um ber. Per cent. Deaths from other respiratory diseases. N um ber. Per cent. 5 20 27 7 3 7 10.4 7.5 9.9 5.0 3.5 9.5 2 4 7 5 3 7 4.2 1.5 2.6 3.6 3.5 9.5 69 7.7 28 3.1 It would be outside of the purpose of the present investigation to enlarge upon the frequency occurrence of other causes, but it may be said in this connection, with special reference to alcoholism, that there were 7 deaths from this cause, or 0.78 per cent of the total, and 11 deaths from cirrhosis of the liver, or 1.22 per cent, which, however, can not be considered conclusive evidence regarding an excessive amount of gross intoxication among glassworkers, which is fre quently assumed to be of relatively common occurrence. It is also suggestive that the mortality from pneumonia, which is often as sumed to be increased in frequency by exposure to extreme heat and variable weather conditions, was not excessive in the experience re ferred to. The average age at death of all glass blowers was 41.4 years, and of those who died from pulmonary tuberculosis, 38.8 years. S P E C IF IC D IS E A S E L I A B I L I T Y OP G L A SS B L O W E R S. The statistical analysis in the report referred to is amplified by ex tracts from reports on investigations into the hygiene of glass workers in this country and Germany. According to an account of the diseases incident to the glass industry, in the Twenty-fourth An OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 315 nual Report of the Bureau of Statistics of Labor and Industries of New Jersey for 1901, glassworkers are much exposed to unfavorable weather conditions, working, as they frequently do, in a temperature exposure of from 100° to 130°. It is said further, with reference to habits of life, etc., in the report of the United States Commissioner of Labor, that— Irregularity in eating and sleeping, disregard of ordinary pre cautions, the habitual use of large drafts of ice water, are the prime factors in creating acute attacks of dyspepsia and indigestion, from which glassworkers suffer so much, and imprudent and unnecessary exposure aggravate and intensify diseases which attack the air pas sages. There is scarcely a glass blower to be found who does not suffer from some form of catarrh. Forethought and care exercised in guarding against the change from a high temperature to a low one would greatly improve the health conditions of men who work in the intense heat of the glassworks. When a workman leaves the high temperature of the factory, say 90° to 100°, in midwinter to face the temperature outside, say 10° to 12°, his underclothing wet with per spiration, without preparing himself thoroughly for the great change, he certainly invites disease to fasten upon his throat and lungs or give a dangerous chill to the circulatory system no matter how stalwart his frame or how robust his general health may be. The reaction is too sudden and severe.1 In contrast, it has been maintained by Mr. Denis A. Hayes, presi dent of the Glass Bottle Blowers* Association of America, in an ad dress before the American Academy of Political and Social Science, May, 1906, that— It has been the common belief for years that glass blowing is an unhealthy occupation. Some insurance companies discriminate against the workers in this industry, but their action is based more upon suspicion than facts, because I doubt if glass blowing, so far as the work itself is concerned, is any more injurious than many other indoor occupations. There are, however, conditions which surround the work that are a menace to health and long life, but these unfavorable conditions can be and are being removed.2 Of interest also is the statement by Mr. Hayes that— The sudden changes in temperature experienced by men in this condition may be resisted while youth and vigor remain, but, owing to the early age at which they go to work, their strength and vitality are not given a chance to fully develop or are almost entirely de stroyed at an age when other men are entering the prime of life. Being deprived of schooling they can have very little knowledge of hygienic rules or laws, hence do not sufficiently know how to protect themselves against the conditions here described. The result is that early in life they become victims of rheumatism, catarrh, throat troubles, and tuberculosis. The latter disease especially is most dreaded by our members.1 1 R ep ort o f U . S. C om m ission er o f L a b or on W om a n and C hild W age E a rn ers in the U nited S tates, V ol. I l l , G lass In d u stry , pp. 2 54 , 255. a Idem , p. 257. 316 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. According to German observations by Dr. C. F. Schmidt, con tributed originally to Weyl’s Handbook of Occupational Hygiene, but translated for the report of the Commissioner of Labor on the glass industry, 1911, it is stated that— As a rule, glass blowers are people of stalwart frame. Some have a pale but many a ruddy complexion, caused by the intense heat. They are generally spare, for they are obliged to undergo great physical exertion, and, in consequence of this exertion and the great heat, they perspire freely. The constant exercise makes the muscular devel opment of the upper part of the body, especially the arms, excep- ' tionally powerful, while they are sometimes observed to be bowlegged on account of continual standing.1 As glass blowers are forced to work in an atmosphere of a high temperature and are constantly exposed to the cool draft which rushes in through the open door of the factory, they are predisposed to colds. On one hand there are rheumatic inflammations, on the other catarrhal diseases of the bronchial tubes and of the lungs from which they suffer. Smoke often tends to produce bronchial catarrh, especially in the older factories where it is occasionally driven by unfavorable winds, directly from the openings of the furnaces, ail through the factory. Sin<ce acute catarrhs of the larynx and bron chial tubes are often repeated, chronic bronchitis occasionally super venes, from which pulmonary tuberculosis sometimes results.2 It was formerly believed that glass blowers often contracted emphysema of the lungs, and theoretically this seemed quite probable, since they are obliged continually to inhale a great volume of air and then by forced expiration to drive it out through the contracted glottis, by which means great demands are made upon the elasticity of the lungs. This opinion was refuted by Prettin and Leibkind. They examined 230 blowers from different glass factories who had followed this occupation for at least 10 years. Two hundred and eighteen of them were from 25 to 50 years of age, and 12 were from 51 to 62. One hundred and two had been blowing glass more than 10 years, and an equal number more than 20 years. Among the blowers under 40 years of age practically no emphysema was found. Of 54 blowers from 40 to 50 years old, only 2 had emphysema in a slight degree. Among the 12 oldest, there were but 3 cases of severe emphysema of the lungs. Of the 230 blowers, therefore, only 5 in all had emphysema, and even with these it was doubtful whether the emphysema was superinduced by the blowing or by other diseases of the lungs. But it was demonstrated by spirometric tests that the vital capacity of glass blowers’ lungs is very large, for the spirometer indicated'an average amounting to 3,350 cubic centimeters (183.25 cubic inches.)2 P R E D IS P O S IT IO N TO P U L M O N A R Y T U B E R C U L O S IS . All of these observations reemphasize the earlier conclusion that glass blowers unquestionably are subject to an excessive mortality 1 R ep ort o f U. S. C om m ission er o f L a b or on W om a n and C hild W age E arn ers in the U nited S tates, V ol. I l l , G lass In d u stry , p. 265. 2 Idem , p. 267. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 317 from pulmonary tuberculosis, largely in consequence of the con tinued and considerable inhalation of mineral dust. It is, therefore, of special importance that any and all measures concerning dust pre vention should receive sufficient consideration, and that, as far as practicable, they should be adopted. With special reference to the possibilities of sanitary and other improvements, it is suggested by Dr. Schmidt that— Since it has been demonstrated that pulmonary emphysema is not due to blowing, except in very rare instances, the necessity for a mechanical blower no longer appears so urgently requisite as it was formerly assumed to be. An apparatus has been invented by means of which glass masses are blown into shapes- required by compressed air. By the use of this contrivance not only might the need of strenuous exertion in blowing be obviated, but the danger of syphi litic infection and of the transmission of tuberculosis might also be removed. But in most of the factories the pipe continues to be used, because, it is claimed, the inflation by this method is more uniform. The transmission of syphilis may be prevented by a simple device, namely, by the use of an individual mouthpiece for every blower. But this method is opposed by the blowers because by its employment they are hindered in their work. Regular examinations are also recommended, but the workmen rebel against such inquisitorial regu lations. The attempt has been made to reduce the intense heat radi ation by placing asbestos-coated iron curtains in front of the ovens. These curtains are raised by a lever so arranged as to be automati cally set in motion by the weight of the workman’s body. For lower ing the temperature revolving fans have also been installed in prox imity to the working place. These create an artificial breeze to cool the workmen. Blue or gray panes of glass placed before the open ings of the furnace serve as a protection for the eyes.1 P O S S I B I L I T I E S OF D U ST P R E V E N T IO N . Finally, on the question of the prevention of dust, it is said: The prevention of dust presents the greatest difficulties, though a large part of it is held captive by means of water. In polishing with the sand blast the sand is so drawn up by the agency of a suction appliance devised by Gutmann that no dust can escape. The dan gerous explosions of lamp cylinders are now prevented in a glass factory at Weisswasser by a mechanical apparatus by which tlu cylinder is heated in a narrow zone throughout its entire circum ference, and then by a light blow with a sharp instrument it is cracked off. But in the grinding department even the simplest pro tective arrangements are often wanting, or are not employed be cause the work is retarded by them. Above all, sufficient ventilation should be provided for, and a scrupulous daily cleansing of the grinding rooms. In every room, too, there should be an adequate supply of cuspidors. By systematic instruction of the grinders the danger of tubercular infection may be minimized. Personal hygiene 1 R ep ort o f U. S. C om m ission er o f L a b or on W om a n an d C hild W age E arn ers In the U nited States, V ol. I l l , G lass In d u stry , p. 270. 318 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. would be promoted by the installation of bathrooms in the factories; and, in addition, good drinking water should be supplied.1 Most of the methods of dust prevention and other sanitary im provements are practical, if not in their entirety at least in part, and suggestive of much more extensive consideration in this country than has, heretofore, been the case. M E C H A N IC A L G L A SS B L O W IN G A N D P R E S S I N G . Glass blowing and pressing by means of mechanical devices are of comparatively recent introduction. Entirely automatic bottleblowing processes date from 1898, and the work in connection there with practically dispenses with glass blowing in the generally ac cepted sense of the term. Such processes, however, are quite fre quently carried on in conjunction with typical methods of glass blowing and related operations, so that in a general way the occupa tional hazards have remained much the same. There are no vital statistics of mechanical glass blowers and pressers, but it is quite probable that when carried on under proper sanitary supervision the use of machinery may prove distinctly advantageous to health and longevity. The blowing of window glass by machinery is of much more recent introduction and the process thus far has not be come extensively developed. (See Scientific American, July 19, 1913.) Glass-making machines are of three important types, as described in the Report of the Bureau of Labor on the Condition of Women and Child Wage Earners in the United States, with special reference to the glass industry (Washington, 1911). The first type is the press machine, the second the blow^ machine, and the third the automatic machine which improves upon the simple blowing ma chine by using a self-feeding and self-pressing device. In all of these processes human labor is to a considerable extent dispensed with and no skilled glass workers are required, since machinists, in a restricted sense of the term, are sufficient for the purpose. One advantage of the automatic machine is that it tends greatly, accord ing to the report referred to, to reduce the number of boys employed, and it tends further to raise the age of the boys that are employed, and older boys are usually preferred. No statistical information is available as regards the possibly beneficial results to health in consequence of the universal use of glass-making machines and the practical elimination of glass blowing by hand. It, however, would seem to be a safe inference that in the absence of thoroughly efficient methods of sanitary supervision and control, with special reference to the dust hazard, the specific 1 R e p o rt o f U. S. C om m ission er o f L a b o r on W om a n an d C h ild W ag e E a rn e rs in the L n ite d S ta tes, V ol. I l l , G lass In d u stry, pp. 270, 271. OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 319 liability to pulmonary tuberculosis in the glass industry is not likely to be materially reduced as the result of the extensive and even universal introduction of glass-making machinery. DIAMOND CUTTERS. Diamond cutting, although an employment of rather limited extent in the United States, is of interest and*importanee as an occu pation with exposure to mineral dust. Hand cutting is very rare and machine cutting is at the present time the general rule in the trade, as carried on under American conditions. There has been a decided improvement in labor conditions as the result of the active efforts of the Diamond Polishers’ Union, which has a membership of about 400 in ISTew York City alone. The occupation has the ad vantage of being well paid, at least in many individual instances, and some of the cutters are reported to receive as much as $80 and polishers as much as $60 a week. P R O C E S S E S OF M A N U F A C T U R E . The process of diamond cutting and polishing consists of two parts. After the stone has been cut it is taken to the polishing rooms, where the setter selects a suitable sized brass cup, called a dope, fills it with a mixture ©f lead and tin, and melts it in a gas flame. After working the solder to its proper shape, he places the diamond in the center, leaving only a very small part exposed. A mark is made on the solder before it becomes fairly set, and then the stone is passed on to the polisher. By the mark made on the solder the latter knows at once the exact run of the grain and the way it will polish to the best advantage. The polisher uses a circular disk composed of very porous iron, so that as the diamond is polished away in the form of dust it enters the pores of the iron, the result being that diamond cuts diamond. According to Hirt, the first part of the process is exceedingly un healthful. The bent position of the workman, the heat, and the dan ger of lead poisoning all contribute to make the occupation an un healthful one. The principal bad features of the second part of the process are the dust inhalation and the straining of the eyes. While very little dust escapes into the air, the little, according to Hirt, is very bad in its effects, as the particles are angular, sharp, and, of course, very hard. M O R B ID IT Y OF D IA M O N D C U T T E R S A N D P O L IS H E R S . Arlidge in his observations upon the diamond cutters’ trade re marks, however, that— From our own observation of diamond cutting and polishing we can scarcely imagine any definite morbid result from the dust of the gem. It is far too precious to fritter away into dust by any coarse 320 MORTALITY FROM RESPIRATORY DISEASES IN DUSTY TRADES. grinding likely to give off a tangible quantity of this substance, and we suspect that the recorded ill health of diamond workers is chiefly attributable to accidental circumstances connected with the charcoal furnaces formerly used; to overheated and badly ventilated work shops; and to dissipated habits among the employees. So far as diamond dust may possibly be thrown off in the polishing process, so far, doubtless, woul(l it be an irritant to the respiratory organs by reason of the very sharp and angular character of its atoms. Tracy comments upon the sanitary aspects of the employment as follows: In diamond cutting the amount,of dust created is small, and }^et the occupation is a very injurious one. The “ setter ” prepares the diamond for the cutter by soldering it on the end of a copper rod with an alloy of 4 parts lead to 1 of tin. He does this with a char coal fire, and is exposed to great heat, as well as to poisonous gases. The setters suffer from headache, tinnitus aurium, impaired diges tion, and irregularity of the bowels. In Coster’s factory, at Amster dam, 73% per cent oi them were pale and emaciated, 57 per cent had palpitation, giddiness, prcecordial distress, 56 chronic headache, 36 asthma, etc. The use of solder produces lead poisoning. Out of 90 examined, 30 showed traces of poisoning. In general, they are all sick men, and suffer from lung troubles. Nine per cent had phthisis. The cutters or polishers grind the gems on iron wheels covered with diamond dust and oil. The dust inhaled by them, though small in quantity, is enough to cause frequent chronic lung troubles. In Coster’s factory, 52 per cent of them were thin and pale, 40 per cent asthmatic, 33.75 per cent suffered from headaches, etc. H E A L T H -IN JU R IO U S R E S U L T S OF D IAM O N D C U T T IN G . The extensive development of the diamond industry in Holland, chiefly in Amsterdam, has been reported upon by United States Consul Frank W. Mahin, who points out that there are some 70 establishments in Amsterdam which cut and polish diamonds and employ more than 10,000 work people, of whom about 1,700 are cleavers and cutters and 4,700 polishers, the remainder being en gaged about the offices and in other work. He explains the occupa tional process, in part, as followTs : Cleavers split the diamonds; cutters take off the rough and sharp edges and corners and make the general shape of the stone; polishers polish the stones and make their facets; turners turn the diamonds around in the apparatus which holds them, so that the facets can be made, every diamond worked in a first-class manner having from 58 to 64 facets; sawers saw stones which can not be cloven or which it is more profitable to saw; sometimes a stone is cleft and the parts are then sawed, but very small stones can not be sawed. A more extensive technical account of the Amsterdam diamond in dustry has been contributed by Sir Thomas Oliver, in his report on Industrial Lead Poisoning, published by the United States Bureau OCCUPATIONS W IT H EXPOSURE TO MINERAL DUST. 321 of Labor Statistics (Bulletin 95), Washington, 1911. Upon the basis of his personal investigation he states that he found the workrooms overheated, owing to the large number of gas jets in use, and that the rooms generally were badly ventilated. u Work under these circum stances,” he observes, “ creates on the part of those following it an oversensitiveness to changes of temperature and a diminishing re sistance to colds.” Aside from a serious liability to lead poisoning, Sir Thomas Oliver’s investigation failed to establish a special pre disposition or liability to pulmonary tuberculosis. The occupation, however, has not been sufficiently investigated, but there are con vincing reasons for believing that the dust factor in diamond cutting and polishing is of sufficient importance to prove inimical to health. Unquestionably important variations in liability are met with in the five principal groups of employment, viz, cleavers, polishers, turners, cutters, and sawers. Eyestrain is an important factor, and to the extent that any disease or physical disability tends to undermine health generally and reduces vital resistance. This factor, together with the liability to lead poisoning, is deserving of serious consider ation. Although quite extensively developed in this country, chiefly through American branches of Amsterdam firms, there are no Amer ican vital statistics of this occupation, which, however, for the rea sons stated, seems to require inclusion among unhealthy trades in which the mortality from pulmonary tuberculosis is quite probably above the normal, G E N E R A L C O N C LU SIO N S. Diamond cutting is briefly referred to in Kober and Hanson’s Diseases of Occupation and Vocational Hygiene, but chiefly with reference to the risk of lead poisoning. On account of the European war the industry has been quite extensively developed in the United States, and, according to the Scientific American Supplement (Oct. 7, 1916), New York instead of Amsterdam is now the center of the diamond industry. In a descriptive account of diamond-cutting methods in the article referred to it is said that in the process of cut ting about 60 per cent of the weight of the rough stone is lost, but as far as practicable “ every particle of waste material from the splitting and sawing of the stone is carefully saved for use in the sawing and other subsequent operations.” This, of course, implies the pos sibility of a fair degree of diamond dust intermixture with the general atmosphere and the consequential mechanical injury to the lungs on account of the inhalation of the diamond-dust particles. It is suggested in 'this connection by Kober that “ all polishing processes should be carried on by the wet process and guarded by hoods and efficient exhaust ventilation.” Aside from necessary safe100811°— 18— Bull. 231------ 21 322 MORTALITY. FROM RESPIRATORY DISEASES 1ST DUSTY TRADES. guards against lead poisoning, Kober recommends attention to gen eral ventilation, adjustable workbenc