BYSSINOSIS IN THE COTTONTRADE* · BYSSINOSIS IN THECOTTON TRADE this might have been due to transfers from the card-room taking upworkthere. Womenworking in the card-room, the engine-head

Brit. J. industr. Med., 1947, 4, 48.

BYSSINOSIS IN THE COTTON TRADE*BY

C. I. C. GILLOldham, Lancashire

(RECEIVED FOR PUBLICATION JUNE 5, 1946)

The word byssinosis is derived from the Greekword vacros., meaning fine linen. Originally theword was used in a wider, more general sense,whereas to-day it indicates a specific industrialentity. Byssinosis is a respiratory disease affectingworkers inhaling dust in cotton mills. The condi-tion has been known to exist for many years, andwas first recorded by Greenhow in a report to thePrivy Council of London in 1861. The cottontrade has been the Cinderella of occupationalhazards and it is only recently that research intothe causes of byssinosis has been undertaken.In 1930 the Industrial Health Research Boardpublished a study of sickness among operatives inLancashire cotton mills, and in 1932 the HomeOffice issued the Report of the Departmental Com-mittee on Dust in Card Rooms in the Cotton Industry.This report collected the existing information aboutconditions in the mills, types of machinery in use,and the nature of the cotton dust, and included anaccount of the clinical examination and radiologicalfindings in a group of workers suffering from thedisease. The post-mortem findings in a few caseswhere death had occurred were also described.

In 1936 Prausnitz published an account ofinvestigations on respiratory dust disease in opera-tives in the cotton industry. The mass of informa-tion from these two reports gives the most recentand authoritative knowledge on byssinosis, andforms the structure on which further investigationscan be based. Foreign literature on the subjectis scanty and does not contribute any additionalknowledge. Zipperlen (1935) reported on aninvestigation of patients suffering from asthma inWurttemburg, where there is a textile industry.His report contained the following statement:'A few words should be said concerning industry.In spite of all protective appliances cotton dustcannot be excluded, and we have actually observed

a large number of severe asthma patients in whomstrong allergic reactions could be obtained withsuitably prepared dust from the factories.'

The ProcessCotton is obtained chiefly from Egypt, America,

and India. Although cotton dusts show variations,there is no evidence that such variations materiallyinfluence the injurious effect of long-continuedinhalation. The cotton arrives in this country inbales, highly compressed and contaiming particles ofleaf and seed coat, cotton hairs, fragments of mould,and fine sand. The raw cotton has to be cleaned,and it passes through several processes in the cottonchamber and blowing room before being ready forthe card room. In the cotton chamber the balesare uncovered, and the tightly compressed cottonis pulled off in layers and hand-fed by the cottonfeeder into a machine known as a hopper baleopener. It then passes into the blowing room,where it is dealt with successively by hopper openers,hopper feeders, porcupine openers with high-speedShirley cages attached, and finally by Crightonopeners and finisher scutchers. The purpose ofall these machines is sinlilar, namely, to open outthe compressed cotton, to spread it well, and, bya beating action aided by powerful currents of air,to free it from a high percentage of its impuritiesand at the same time ensure adequate mixing of thedifferent qualities of cotton. With the exceptionof the cotton feeder tending the hopper bale opener,all the machines are enclosed in dust-proof covers.The machines, however, have to be hand-cleaned,and this is a particularly dusty job; the operativesengaged on this work are suitably clothed and wearrespirators. The cotton, emerging from the blowingroom, passes to the carding engines: and it is herethat trouble from byssinosis begins, for, though theIndustrial Health Research Board report showedthat blowing-room operatives had high sicknessrates from respiratory causes, it was thought that

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* Based on a paper read to the Association of Industrial MedicalOfficers in Manchester on May 16, 1946.

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BYSSINOSIS IN THE COTTON TRADE

this might have been due to transfers from thecard-room taking up work there. Women workingin the card-room, the engine-head tenters, slubbertenters, and intermediate tenters are only rarelyaffected by byssinosis. It is, in fact, the strippersand grinders, the operatives in charge of the cardingengines, who are the principal sufferers.

Usually each stripper and grinder is in charge of16 carding engines (fig. 1): each engine is cleanedfour times daily by a vacuum process (fig. 2), andtwice weekly it is brush stripped (figs. 3, 4, and 4A).The brush stripping is necessary because the vacuumprocess fails to clean sufficiently deeply, and theevidence is very strong that the dust liberated bythe carding process in the immediate vicinity of thecarding engine contains the injurious element orelements causing byssinosis. The farther awayfrom the carding engine, the safer the atmosphere.

SymptomatologyFor convenience the symptoms of byssinosis

may be divided into two stages-early and late.The early stage.-Although not so common

to-day as it was some years ago, the conditioncalled mill fever, Monday morning fever, or factoryfever is known to many card-room operatives.On entering the card room on Monday morningthese workers experience a dry, irritative feelingin their throat and chest. This is followed by ashort, slight, dry cough. There may be an attackof sneezing; and, in a few cases, principally amongthe women, a slight urticarial type of rash appearson the forearms. Some operatives complain ofsore eyes; a mild conjunctiyitis is sometimes present.After a few hours-or at most a day or so-thesymptoms disappear, and for the remainder of theweek no discomfort is experienced. There is littleor no constitutional disturbance. The appetiteremains good, and the condition does not result in aloss of working hours. A few operatives exhibit amild pyrexia, not sufficient to incapacitate them.Many never experience mill fever. Others ex-perience it for a few weeks or months and thenapparently become immunized. Some years agothe condition was regarded by such workers as anecessary baptism to their trade. In some opera-tives-who might be described as the card-room-susceptible type-the condition subsides only torecur after months or years, or never subsidesentirely, but continues as mill fever. Exceptin strippers and grinders, mill fever at this stagerarely progresses any further or causes any seriousrespiratory damage. The symptoms and recurring,cyclic nature of mill fever, however, do seem to

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suggest an allergic sensitivity to some constituent inthe cotton dust.

The late stage.-The stripper and grinder is theoperative who usually succumbs to the late stageof mill fever. The symptoms of fever graduallyreappear ten or twenty ypars after the earlier attacks-that is, when the workers are 35 or 40. Thecough becomes dryer, harder, and of a metalliccharacter; and symptoms tend to spread over allthe working days of the week. At first there islittle sputum; after a severe attack of coughinga small quantity of clear, sticky, glairy mucus isbrought up with great difficulty. The patient atthis stage complains of easy fatigue, and his capacityfor effort is considerably reduced. After a weekor so off work most of the symptoms abate, thecough moderates, *the physical capacity improves,and the operative is again fit for his job. Withintervals of rest from work, the stripper and grindermay continue for several more years. Insidiously,however, the condition progresses. In the latercases expectoration becomes freer and possiblymuco-purulent; dyspnoea increases, and the capa-city for effort decreases. Operatives will tell youthat several times on their way to and from workthey have to stop to get their breath. They complainof tightness in their chest-' I feel as if I had a ropetied round my chest.' Inspiration is difficult.Attacks of bronchitis become increasingly frequent,and more and more time is lost. Ultimately thecontinued cough, dyspnoea, easily induced fatigue,and loss of sleep due to asthma-like nocturnalattacks, render the sufferer unfit for this work, and,unfortunately, in many cases unfit for alternativework: there is the tragic picture of a man in middlelife condemned to chronic invalidism. The con-stant complaint of strippers and grinders at this latestage is that they have to sit up in bed at night toget their breath.

Physical SignsClinical examination of operatives suffering from

mill fever in the early stage does not reveal objectivesigns except those already mentioned, thoughthe mucous membrane of the nasopharynx may besomewhat thickened and hyperaemic. Examina-tion in the late stage reveals the classical signs ofchronic bronchitis and emphysema. The patientsat this stage look ill, their skin has an unhealthy,sallow colour, the cheeks are sunken, and there isgeneral loss of weight. Respiration is laboured,with the accessory muscles called more and moreinto use. The diaphragm moves badly. Theshoulders are raised, and a stooping, kyphotic

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FHlu. I. Stripper and grinder 1fcedingthe cap into thlc taker in ' of thecarding engine- the Iir-st prcocess ofca rding. A good deail of duLst Is-rodLced at the taikcr in.'

FIG. 2.-Cleaning byvacuum process. (Itwas found unsatisfac-tory to take thisphotograph with themachinery actually inmotion.)



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FIG. 3.-Brush-strip-ping and grind-ing. Similaroperation using(a) brush, (b)emery roller.Requires twooperatives.

FIG. 4.- Stripper and grinder cleaning out ' fly,' ' trash' and fine dust from underneath the carding engine. Avery dusty job. (See Fig. 4A.)



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BRITISH JOURNAL OF INDUSTRIAL MEDICINE

FIG. 4A.-Cleaning out ' fly,' ' trash' and fine dust from underneath the carding engine by recently installedvacuum process. Note the dust extraction hood which can just be seen over the carding engine.

curvature is common. The patients sit in a charac-teristic attitude, the body bent slightly forward,the legs spaced widely, and the hands placed onthe knees. The thorax becomes typically barrel-shaped, with the usual prominent sternum. Infact the patient exhibits the physical signs of extremeemphysema. The vital capacity of the thorax isgreatly impaired, and the chest expansion of theselate cases is often found to be only one or one anda half inches.Between the early mill-fever patient and the late

stage just described, there are many intermediatetypes. The progressive tendency for the vital

capacity to decrease often precedes the stage ofadvanced pulmonary damage. Alternative workshould therefore always be advised for any opera-tives exhibiting this feature. Another early sign is aslow but progressive loss of weight.

Radiographic AppearancesAmong 100 patients* who had radiographs taken

of their chests, no specific appearances diagnostic ofbyssinosis were detected,. :Ithe late stage changes

* These cases were radiographed by Dr. George Fletcher, ChiefTuberculosis Officer, Lancs. C. C. My own series were radiographedby Dr. A. Richardson, Radiologist to the Oldham Royal Infirmary:his reports agree with Dr. Fletcher's.

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BRITISH JOURNAL OF INDUSTRIAL MEDICINEwere consistent with those of chronic bronchitis andemphysema. The films, however, tended to showbronchial shadows of a greater intensity than thosegenerally found in patients suffering from bronchitisand emphysema (figs. 5 and 6). Cotton dust is not' aggressive ' in the same way as the causative dustsof asbestosis or silicosis, and x-ray films are not,therefore, a pointer to diagnosis, as they are in theselatter diseases. Diagnosis of emphysema due tocotton dust rests, in fact, only on a history of expo-sure for many years, on the patient's symptoms, andon clinical examination. A successful appeal forcompensation for byssinosis requires that the patientshall have been exposed to the dust for a minimumperiod of 20 years. Claims for compensation aremade under The Byssinosis (Benefit) Scheme, 1941-assessment being in the hands of a medical boardappointed by the Secretary of State.

Pathological ChangesPost-mortem examinations have been carried out

in ten cases. The examination has revealed nospecific feature for byssinosis, the changes in therespiratory system being those of bronchitis andemphysema. Dilatation of the right heart was fre-quent in the series of cases examined post mortemby Dunn and Sheehan (1932).

Causative AgentA complete investigation of the causative agent of

byssinosis has been carried out by Prausnitz, whoused Shirley cage dust as providing the best cross-section. The dust consisted ofa greyish-brown fleecymaterial, which, if shaken, produced masses of finegrey dust which remained floating in the air fora considerable time. Microscopical examinationshowed the dust to consist of fragments of cottonfibre and green and brown scales of the leaf andhusks. There was no sand, and, in fact, no demon-strable mineral matter. When the dust was exam-ined by the ultra-microscope, extremely fine particlesbecame visible; there appeared to be no lower limitto the size of these particles. It was reasonable toassume that these ultra-fine particles could readilyfind their way into the deeper portions of the respira-tory system, even to the extent of passing throughthe alveolar wall into the inter-alveolar tissues.Animal experiments have demonstrated the power

of cotton dust to penetrate into the deepest parts ofthe lungs and to produce a chronic inflammatoryreaction. Numerous experiments have also beencarried out on individual fractions of cotton dust.From these experiments Prausnitz (1936) suggestedthat the pathogenesis of the illness was as follows:

1. Irritating soluble protein of the cotton dustpenetrated into the alveolar tissue and gradually pro-duced thickening of the alveolar walls.

2. Simultaneously, or perhaps even before, super-sensitiveness was acquired.

3. Superficial irritation of the bronchial mucousmembranes by the dust led to chronic bron-chitis and cough-in some cases; accompanied byintensive expectoration-and ultimately toemphysema.Probably a percentage of strippers and grinders

are predisposed to become sensitive to cotton dust,while others are immune. The allergic or sensitizedsubjects become the victims of mill fever. Theytend to develop a chronic cough, which, helped byirritation of the bronchial mucosa, leads to mildbronchitis. The deep penetration of the respiratorysystem by the ultra-microscopic portions of thedust-with their protein content-causes a thicken-ing of the alveolar walls and peri-bronchial inflam-mation; and this state eventually leads to thedevelopment of emphysema. It is difficult toescape the convictions that an allergic conditionpre-exists, and that it probably prepares the wayfor the late stage of peri-alveolar thickening. Theauthor has not yet seen a case of byssinosis in whichthe late stage has developed without a precedinghistory of mill fever and long-continued cough;usually the stripper and grinder with developedbyssinosis has been coughing fairly steadily for manyyears. Christie (1944) states that in emphysemathe primary lesion is loss of elasticity, the mostcommon cause of which is the stress and strain ofcough or respiratory obstruction on the structuresconcerned in respiration.

PreventionIt was not until 1908 that attempts to control the

dust were made. Obviously the ideal method is toensure that the cotton dust does not escape intothe atmosphere. This has not yet been foundpossible. Considerable improvements have beenachieved by the introduction of dust covers andexhaust fans for machines in the cotton chamberand blowing rooms. Unfortunately today, evenin the best equipped mills, at least one-third of thetrash is carried into the card room in the laps; itis this third whicr vis eliminated in the cardingprocess. The sliver)-emerging from the cardingengine 'is almost dust-free. , The modern flat cardingengine is not totally enclosed-there being consider-able technical difficulties in achieving this. Arecent attempt to do so was made by completelyhooding the whole of the top of the carding engine,

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and exhausting by means of a quarter horse-powermotor fan-the air, drawn through the hood,being filtered before re-entering the room. Theunder-space of the carding engine is completelysealed off, and to clean under the engine the stripperand grinder has only to pull a small lever: theentire collection of dust is then swept away by thecreation of a vacuum. This arrangement hasgreatly reduced the amount of dust in the atmo-sphere; 3 66 lb. were extracted from the hoods of12 carding engines, through which 11,400 lb. ofcotton had passed in 44 hours. These figures donot include the weight of debris from underneaththe carding engine.Many mills have insufficient air space, with the

machinery crowded into too small an area. Greaterair space means a greater dilution of the dust.Improved air conditioning, in conjunction withimproved dust extraction, is necessary. Air condi-tioning must include a correctly controlled tempera-ture, the right humidity, and adequate air movement-and these are also the best conditions for thecotton fibre.A careful selection of operatives for the card

room, and regular examination of existing workers,offer the best protection. All intending card-roomoperatives should be medically examined beforeengagement, and every effort should be made toexclude those types likely to be susceptible to thedisease. Any operative who gives a personal or

family history of asthma, bronchitis, hay fever,eczema, or recurrent urticarial attacks should beexcluded from the card room. The general buildand shape of the thoracic cage should be noted,and also the type of respiration. Mouth breathersare bad subjects. Malformation of the nasalbones, deflected septums, nasal polypi, enlargedtonsils, and extensive adenoid vegetations are allcontra-indications for card room workers. A chestexpansion below two and three quarter inches issuspect. All operatives are urged to practise nasalinspiration and to wear protective respirators. If asimple skin patch test for allergy could be obtainedit would be a valuable help, both in the examinationof intending card room operatives and as a diagnosticmeasure in suspected cases of byssinosis. To-daythe disease is not nearly so common as formerly,but it still exists, and constitutes one of the mainindustrial hazards in the cotton industry.

REFERENCESBrockbank, E. M. (1942). Clin. J., 71, 89.Christie, R. V. (1944). Brit. med. J., 1, 105, 143.Dunn, S., and Sheehan, H. L. (1932). Report on ten autopsies on

cotton-mill workers. Appendix III of Report ofthe DepartmentalCommittee on Dust in Card-rooms in the Cotton Industry.H.M.S.O.

Medical Officer of the Privy Council (1862). Fourth Report, p. 173.Prausnitz, C. (1936). Investigations on Respiratory Dust Disease in

Operatives in the Cotton Industry. Spec. Rep. Ser. No. 212.M.R.C. Lond. H.M.S.O.

Report of the Departmental Committee on Dust in Card-rooms in theCotton Industry (1932). London. H.M.S.O.

Study of Sickness amongst Operatives in Lancashire Cotton SpinningMills (1930). London. I.H.R.B. Report No. 590.

Zipperlen, V. R. (1935). Arch. Hyg. Berl., 113, 1.

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BYSSINOSIS IN THE COTTONTRADE* · BYSSINOSIS IN THECOTTON TRADE this might have been due to transfers from the card-room taking upworkthere. Womenworking in the card-room, the engine-head