1964, Brit. J.
Radiol, 37, 337-344
II. The use of radiology in the early detection of lung cancer as
an industrial disease
A paper read in the symposium on "Industrial pulmonary disease" at the Annual Congress
of the British Institute of Radiology, April 5, 1963
By P. Lesley Bidstrup, M.D., F.R.A.C.P., M.R.C.P.
Chest Department, St. Thomas' Hospital, London, S.E.1., and St. Mary's Hospital, London, W.2
Lung cancer of occupational origin
It has been established on the evidence of investi-
gations using epidemiological and statistical methods
that the incidence of lung cancer among men
following certain occupations is greater than that
among males in the population as a whole.
The occupations concerned are:
(1) work involving exposure to radiations;
(2) the refining of nickel by decomposition of a
gaseous nickel compound, nickel carbonyl;
(3) the manufacture of bichromates from the ore
chromite;
(4) work involving exposure to asbestos dust;
(5) the manufacture of coal gas by a process which
is becoming obsolete;
(6) the mining of haematite.
There may be a similar risk for men employed in
the manufacture of isopropyl alcohol, in iron and
steel foundries, in sandblasting and in the manu-
facture of chrome pigments. The evidence on which
these conclusions are based is summarised in Cancer
Progress (Raven, 1960). More information on the
relationship between lung cancer and occupation
could be obtained if the full occupational history
were recorded in every case of lung cancer.
The number of cases of lung cancer reported
among men engaged in the occupations mentioned
is small when compared with the number of deaths
from this cause recorded for the male population
as a whole. As with cancer of occupational origin
arising at other sites in the body, such as the skin
and the urinary bladder, there is a long latent
interval between exposure to the carcinogen and
manifestation of the diseasecommonly 20 years
or more. It is not possible to distinguish on clinical,
radiological or pathological findings those cases of
lung cancer which are of occupational origin from
those which arise from other causes, and for both
the industries which are to be discussed in this
paper some of the cases which have been recorded
among employees were not necessarily due to the
occupation.
In this paper the results of routine radiology in
two groups of workmen in Great Britain exposed in
337
MAY 1964
the past to the hazard of lung cancer in their occupa-
tions will be discussed. The industries concerned will
be referred to as Industry I and Industry II. In Indus-
try I the hazard was recognised in 1925 whereas for
Industry II it was not established until 1955. In both,
measures including dust suppression and changes of
process have been introduced to eliminate the hazard,
and for Industry I statistical evidence indicates that
this has been achieved (Gwynne Morgan, 1958). For
Industry II insufficient time has elapsed to enable an
assessment to be made of the success of the measures
which have been introduced, but it is likely that for
this industry also, the hazard has now been elimi-
nated. Investigations will continue until this
contention is proved.
Industry I
Gwynne Morgan (1963) has analysed the results
of routine examinations, including chest radio-
graphy, in men employed in an industry in which
the existence of the hazard was established in 1925.
It is not appropriate to mention, for either of these
industries, the total number of cases of lung cancer
which have been recorded; the results will be given
in percentages and, since the actual numbers for
each industry are relatively small, percentages will
give only an approximate idea of the results ob-
tained by radiology in the diagnosis of industrial
lung cancer. Gwynne Morgan found that 36 per
cent of cases showed no radiological evidence of
malignancy until one to five months before death
and 26 per cent until six to ten months before death.
In 8 per cent of cases there were suspicious changes
in the X-ray appearancessuch as increased hilar
shadow, increased striations, thickened bronchial
walls, small areas of collapse, widened mediastinal
shadow, unresolved pneumonia, haziness and
fibrosisup to two years before death (Table I).
10 per cent were submitted to resection.
Industry II
The author has particular knowledge of Industry
11 for which the hazard of lung cancer was estab-
lished in Great Britain in 1955. A number of men
VOL. 37, No. 437
P. Lesley Bidstrup
TABLE I
RESULTS OF ROUTINE RADIOLOGY, INDUSTRY I
1925-60
Months before Percentage showing
death X-ray changes
1-5 36
6-10 26
11-15 16
16-20 6 and Dr. J. Steven Faulds carries out detailed histo-
21-25 6 logical examination of specimens obtained at
26 + 8 operation or post-mortem. He has found that the
By courtesy of Dr. J. Gwynne Morgan.
employed in this industry took part in an investi-
gation, which included chest radiography, in 1949,
in an attempt to ascertain whether the hazard
existed in the industry. The results of this investi-
gation were inconclusive and the companies con-
cerned asked that the investigation should be
continued until a definite conclusion could be
reached. In 1955, a medical service which included
annual X-ray examinations was set up. It is pro-
posed to discuss the results of these routine radio-
logical examinations for the years 1955-62 inclusive,
and to omit from the discussion cases which
occurred between 1949 and 1955. Although infor-
mation concerning these cases is available the men
were not under regular radiological supervision
during that period.
Industry IImedical supervision
No one would suggest that X-ray examinations
alone, however frequently these were arranged,
would constitute adequate medical supervision of
persons exposed to the risk of lung cancer in their
occupations. All the men employed in Industry II
have pre-employment medical examinations in-
cluding chest radiographs on 14x17 in. film.
Part-time works' doctors see each man at least once
a month and the monthly interview includes the
recording of weight. Every man who is absent
because of sickness or accident for five days or more
is examined by the works doctor who has the
authority, with the co-operation of the general
practitioner, to refer a man for chest X-ray exami-
nation at any time. An excellent liaison is main-
tained with chest clinic physicians in the areas in
which the factories are situated and we are indebted
to them for carrying out pre-employment X-ray
examinations and follow-up supervision in cases
referred to them. A monthly sickness-absence
record is kept and general practitioners are con-
tacted when an employee is absent for prolonged or
338
repeated short periods. The men, their general
practitioners, chest clinic physicians and thoracic
surgeons in the area concerned are fully aware of
the hazard. From 1957 to 1961 Dr. J. Bamforth,
formerly Research Pathologist at the Imperial
Cancer Research Institute, examined several
hundreds of specimens of sputum from selected
cases of bronchitis with negative results in all cases
tumours often originate peripherally and that the
lungs rarely show fibrosis. The tumours are of all
histological types, though the majority are ana-
plastic oat-celled tumours.
Annual X-ray examinations
All employees are examined at work annually.
All the films for each man are almost exactly com-
parable and one can readily compare a film taken in
1955 with that taken of the same man in 1962.
Pensioners are invited to attend for X-ray examina-
tion and transport is arranged for them and for any
employee who is off sick but not bedridden at the
time of the examinations.
It is not possible to compel men to attend for
X-ray examination, but almost 100 per cent do so.
Those who fail to attend because of sickness or
other excuse are seen by the works doctor who
arranges for a radiograph at a chest clinic. It follows
that, in addition to pre-employment films, the men
in this industry are examined at least annually, and
many of them on two or more occasions in any one
year.
Results of X-ray examinations
This group of workmen represents a changing
population whose ages range from 20 to 83, al-
though the majority are aged between 40 and 65.
More than half of them have been employed in the
industry for ten years or longer. For the period
1955-62 inclusive approximately 10,000 X-ray
films have been taken of 2,772 men at the annual
works X-ray examinations, and of these men 865
have been radiographed at least five times. These
figures do not include pre-employment X-ray
examinations nor those made at the request of
works' doctors or general practitioners. Previous
films are available for comparison in all cases and the
age, work and health records are also known for
each man.
More than half of this group of workmen live in
Glasgow in the central Clydeside conurbation. In
the Annual Report of the Registrar-General for
 MAY 1964
Industrial Pulmonary Disease
Scotland for 1960 it is stated that the male death and 11 per cent have survived more than two years
rate in the conurbation was 1,274 per 100,000 com- (Table II). One man has survived eight years and
pared with 1,259 in the rest of Scotland, these rates another, discovered before 1955, for nine years.
being influenced to a large extent by those of Both men are in full employment. It is worth
Glasgow where the incidence of the respiratory recording, also, that 24 new cases of tuberculosis
diseasestuberculosis, bronchitis and pneumonia have been revealed at the annual works X-ray
was higher than in the remainder of the conurbation. examinations during the period 1955-62. All have
The author's experience of reading chest films of been treated successfully by chemotherapy and only
middle-aged men from Glasgow over many years two required time off work at the start of their treat-
is that one rarely sees a film that would be passed as ment.
normal in a chest clinic in London. Reports on pre- It is clearly impossible to compare the results of
employment X-ray examinations of older entrants routine radiology in these two industries either with
to the industry support this opinion. There is, each other or with results obtained by mass radio-
therefore, some difficulty in assessing the signifi- graphy surveys such as those reported by Posner,
cance of minor abnormalities in the chest films of McDowell and Cross (1959) for the Birmingham
many of the older employees. A further difficulty region or Nash, Morgan and Tomkins (1961) for
arises in referring for further investigation men in the South London lung cancer study. In the latter
whose films a minor change is detected, when the group males over 45 living in the London area are
man concerned, engaged in heavy manual work, offered appointments for six-monthly 100 mm chest
has had no time off work through illness in the X-ray films. Between December, 1958, and July,
preceding 12 months. Many men in this category 1961, 99,246 individual examinations had been made
are referred and found to have no evidence of neo- of which 44,298 were first examinations under the
plasm or other serious diseasebut they are often scheme and 55,128 were repeat examinations. A
reluctant to attend at the next annual examinations total of 92 cases of lung cancer were found, the
and may influence their workmates against attending. rates being 1-3 per 1,000 for the first examinations
It may be said that men are reluctant to remain away and 0-64 per 1,000 for the repeat examinations.
from work for financial reasons and that sickness The group includes men following a variety of
absence records may be of little significance, but occupations, the common factor being that they all
a company sickness benefits scheme enables a man live in the London area. The industrial groups
to be off work without loss of earning and there is discussed above each contain a very small number
also a special benefits scheme for men who develop of men of all ages, specially selected in that they have
lung cancer, and for their dependants. been exposed in the past to atmosphere known to
Of the cases of lung cancer which have been contain carcinogenic agents. In neither industry has
diagnosed in the years 1955-62 inclusive, among the carcinogen been identified, nor is the effective
employees and pensioners in Industry II, 50 per concentration known, but it is safe to assume that
cent have been diagnosed at the works annual in both cases, before the hazard was recognised,
X-ray examinations. 15 per cent of the remaining the concentration of the harmful agent in the work-
cases appeared within six months of the last normal ing atmosphere would have been higher than that
works X-ray examination and the majority after of known or suspected carcinogens present in the
nine months or more. In 40 per cent of cases death general atmosphere.
occurred less than six months after radiological
diagnosis. 27 per cent were submitted to resection CONCLUSIONS
It remains to attempt to answer the question
TABLE II posed by the title of this paper. What is the value of
RESULTS OF ROUTINE RADIOLOGY, INDUSTRY II
routine radiology in the early diagnosis of lung
1955-62 cancer as an industrial disease? Posner et al. (1959)
make the statement that "the community derives no
per cent epidemiological benefit from finding cases of lung
r Annual X-ray examinations 50 cancer whether they are curable or not, and the
rv J < 6 months later 15 results are purely personal". One cannot disagree
Diagnosis < 6 months later 15
9 months later 69 with that statement, but as a clinician who is
I
Radiological diagnosis 6 months before death
Submitted to resection
40
27
primarily neither a statistician nor a radiologist, it
Two-year survival rate 11 is important to the author that some men have
survived for a number of years a disease which, in

339
VOL. 37, No. 437
P. Lesley Bidstrup
FIG. 1. Case 1.
J. H., aged 65 years. Exposure 43 years: (Fig. 1) March, 1957; (Fig. 2) March, 1958.
FIG. 3. Case 1.
April, 1958. (By courtesy of Belvedere Hospital, Glasgow).
the present state of our knowledge and skill is
rapidly fatal in most cases. This makes routine
radiology well worth while. In addition 24 men have
been treated successfully for pulmonary tuber-
340
FIG. 2. Case 7.
culosis diagnosed at a stage when it would not have
been suspected on clinical grounds.
How frequently should X-ray examinations be
made in a community in which lung cancer is a
recognised occupational hazard? Although the
numbers of cases which have been recorded for the
two industries discussed are small, it is clear that
one cannot rely on annual X-ray examinations to
reveal most of the cases which may occur in any
one year and that about 50 per cent have no radio-
logical abnormality up to six months before death.
Administrative and other difficulties preclude too
frequent X-ray examinations, but analysis of the
writer's own results suggests that radiographs taken
at intervals of nine months rather than 12 would
result in the majority of cases being diagnosed at an
earlier stage. The numbers concerned are, however,
so few that it is impossible at this stage to draw
reliable conclusions, nor should one ignore the
findings of Stewart, Pennybacker and Barber (1962)
that in adults 8 per cent of leukaemias, other than
lymphatic leukaemias, were caused by diagnostic
X-ray examinations. It would seem prudent,
therefore, to use clinical sense to a high degree, and
to continue the search for a test other than routine
X-ray examination for pre-symptomatic diagnosis
of cancer not only of the lung, but of other sites as
well.
 MAY 1964
Industrial Pulmonary Disease
BRIEF ILLUSTRATIVE CASE HISTORIES Survival Eight years to date.
Case 1. J.H., aet 65 Exposure 43 years. In full employment.
(Figs. 1, 2 and 3) Diagnosed at works X-ray Type of tumour Unknown.
examinations. Case 4. A.S., aet 51 Exposure 27 years.
Sickness absence None prior to April, 1958, when Diagnosed at works X-ray
he was referred for further examinations.
investigation. Sickness absence Repeated absences since P.T.
X-ray changes diagnosed at works X-ray
1957 A small irregularity of the right examinations 1956.
diaphragm was ignored. X-ray changes
March, 1958 A round opacity at this site. 1956 Referred because of P.T.
April, 1958 Increase in size of this opacity. 1961 Right lower zone lesionreferred
Treatment Right lower lobectomy June, 1958 ? lung cancer.
Survival 17 months. Treatment Under chest clinic supervision
Type of tumour Mucin-secreting adeno-carcinoma. 1956-62.
Survival 20 months.
Exposure 16 years.
Case 2. J.B., aet 52 Diagnosed 11 months after works Case 5. R.B., aet 52 Exposure 13 years.
X-ray examinations. (Figs. 5 and 6) Diagnosed 11 months after works
Bronchitis and full investigation X-ray examinations.
Sickness absence May, 1958. Sickness absence Fractured thumb 1955.
Repair of hernia May-August, 1961. Fractured rib 1956.
X-ray changes X-ray changes
February, 1962 Right lower lobe collapse. February, 1961 Shadow in right upper zone.
Treatment Right pneumonectomy March, 1962. March, 1960 A faintly visible shadow was present
Survival Six months. at tip of first right rib.
Type of tumour Anaplastic oat-celled carcinoma. Treatment Right upper lobectomy September,
1961.
Case 3. N. McD., Exposure four years (1939-43). Survival 10 months.
aet 50 (Fig. 4) Diagnosed at works X-ray exami- Type of tumour Mucin-secreting adenocarcinoma.
nations. Case 6. H.B., aet 54 Exposure ten years.
Sickness absence Symptom free. Resumed work with (Figs. 7 and 8) Diagnosed at works X-ray
Company three weeks before 1955 examinations.
works examinations. Sickness absence Minor accidents only 1955-60.
X-ray changes X-ray changes
1955 Dense shadowing in right upper Shadow in right upper zone.
and mid-zones. 1960
1959 A faint shadow was present in first
Treatment Right pneumonectomy August, 1955. right intercostal space.
Treatment Right upper lobectomy June, 1960.
Survival Three years to date.
Type of tumour Well-differentiated epidermoid
carcinoma.
Case 7. G.W., aet 48 Exposure five years.
(Figs. 9 and 10) Diagnosed at works X-ray
examinations.
Sickness absence None prior to March, 1960.
X-ray changes
I960 Infiltration left apex and first and
second left intercostal space.
Treated as P.T.
1961 Collapse and consolidation left
upper lobe.
Treatment Left pneumonectomy June, 1961.
Survival Two years to date. In full
employment.
Type of tumour Epidermoid carcinoma.
Case 8. S. McA., Exposure 41 years.
aet 70 Diagnosed at works X-ray
examinations.
Sickness absence Pleurisy norm al
,
2.2.59-7.4.59 \ ,
19.2.60-3.5.60 } P^sickness
X-ray changes ' X rays
1961 Infiltration right upper zone.
Investigations difficult to follow
through.
1962 No doubt about diagnosis.
Survival Over two years.
Type of tumour Anaplastic oat-celled carcinoma.
FIG. 4. Case 3. Case 9. J. O'H., Exposure 23 years.
N.McD., aged 50 years. Exposure four years (1939-43). aet 58 Diagnosed ten months after works
March, 1955. (Figs. 11 and 12) X-ray examinations.
341
VOL. 37, No. 437
P. Lesley Bidstrup
Sickness absence Annually 1955-62 "myalgia" or Survival Less than one month.
"back-ache". Type of tumour Hodgkin's disease.
X-ray changes
January, 1963 Enlargement of right hilar shadow. Case 10. R.M., aet 56 Exposure 26 years.
Full investigation October, 1962 Sickness absence Frequent absences bronchitis and
negative. nervous debility 1958-62.

FIG. 5. Case 5. FIG. 6. Case 5.

R.B., aged 52 years. Exposure 13 years: (Fig. 5) March, 1960; (Fig. 6) February, 1961. (By courtesy of Hairmyres
Hospital, East Kilbride.)

FIG. 7. Case 6. FIG. 8. Case 6.

H.B., aged 54 years. Exposure ten years: (Fig. 7) March, 1959; (Fig. 8) March, 1960.
342
 MAY 1964
Industrial Pulmonary Disease
X-ray changes This is a vascular lesionprobably
1961 Normal limits. Prominent right dilated pulmonary artery.
hilar shadow.
1962 Fully investigated with negative
results. ACKNOWLEDGMENTS
Case 11. S.C., aet 53 Exposure 30 years. The author acknowledges the assistance of chest physi-
Sickness absence None. cians and thoracic surgeons who kindly made radiographs
X-ray changes Shadow in 2nd right intercostal and records available, and also of Drs. J. Gwynne Morgan
space present in all films 1955-62. and F. A. Nash.

"

FIG. 9. Case 7. FIG. 10. Case 7.

G.W., aged 48 years. Exposure five years: (Fig. 9) March, 1960; (Fig. 10) March, 1961.

FIG. 11. Case 9. FIG. 12. Case 9.

J.O'H., ?ged 58 years. Exposure 23 years: (Fig. 11) March, 1962; (Fig. 12) January, 1963. (By courtesy of The Victoria
Infirmary, Glasgow.)
343
1964, Brit. J. Radiol, 37, 344-357
P. Lesley Bidstrup
SUMMARY
1. The known occupational causes of lung cancer are
listed.
2. The results of routine radiology in two groups of men
exposed in the past to the hazard of lung cancer in their
occupations are discussed.
3. The fact that a few men have survived and been able
to work for more than five years following operation indi-
cates that routine radiology, combined with strict medical
supervision of persons at risk, is of value in the diagnosis
of lung cancer as an industrial disease.
REFERENCES
GWYNNE MORGAN, J., 1958, Brit. J. industr. Med., 15,
224; 1963, personal communication.
NASH, F. A., MORGAN, M., and TOMPKINS, G., 1961,
Lancet, 2, 46.
POSNER, E., MCDOWELL, L. A., and CROSS, K. W., 1959,
Brit. med.J., 1, 1213.
RAVEN, R. W., Cancer. Progress 1960. Industrial Aspects
81 (Butterworth & Co. (Publishers) Ltd., London).
STEWART, A., PENNYBACKER, W., and BARBER, R., 1962,
Brit. med.J., 2, 882.
The Annual Report of the Registrar-General for Scotland
for 1960. No. 106 (H.M.S.O., Edinburgh) 1961.

III. The radiology of chronic bronchitis

Contributed to the symposium on "Industrial pulmonary disease" at the Annual Congress of The British
Institute of Radiology, April 5, 1963
By G. D. Scarrow, M.D., M.Rad., D.M.R.D.
Department of Radiodiagnosis, University of Liverpool; Respiratory Unit, Whiston Hospital,
Prescot, Lanes.

In 1959 the Report of the conclusions of a Ciba that this pattern may be due to hyperaemia of the
Guest Committee on chronic pulmonary emphysema arterioles of the bronchial arteries in the walls of
and related conditions clearly defined the clinical the bronchi.
state of chronic bronchitis as chronic or recurrent Very strong evidence to the contrary was provided
cough with expectoration which is not attributable by the exhaustive work of Simon and Reid (1958)
to conditions excluded from chronic non-specific who showed that the bronchial thickening and hy-
lung disease. The words "chronic" or "recurrent" peraemia which occurred was of such dimensions as
may be defined as "occurring" on most days for at to be invisible on the normal radiograph.
least three months in the year during at least two In 1953 Simon and Galbraith examined the plain
years. Infection is frequently but not necessarily radiographs of 857 patients with a clinical diagnosis
present. The same report also precisely lays down of chronic bronchitis and were unable to detect any
the definitions, classification and terminology for changes in the intra-pulmonary vascular pattern
the associated reversible and irreversible obstructive apart from those attributable to emphysema. In 41
lung disease and emphysema. per cent of these cases they saw no radiological ab-
Unfortunately no such easy radiological definition normality and throughout the series they saw no
exists and to describe specific radiological changes in generalised abnormal shadowing which might cor-
chronic bronchitis and emphysema has been recog- respond to the larger bronchi or to peribronchial
nised as a most difficult task for nearly a quarter of a structures lying in juxtaposition to the vascular
century. Stuart Harris and Hanley in 1957 stated shadows.
that there are no radiological appearances which can These observations may not be so true in the
be used in a positive diagnostic sense and they con- future when with a greater use of a multiline grid of
sider that the main value of radiography is to the Schmit type and short exposures in the region
exclude other lung diseases which may present a of 3 jjus, structures of the order of 0-3 mm can be
similar clinical picture. Nevertheless, it is rare to seen.
find a radiologist who will frankly admit that he Perhaps the most valuable contribution by Simon
cannot recognise the chest radiograph of a chronic at that time was the recognition and detailed des-
bronchitic. In it he sees a variation from the normal cription of the specific bronchographic changes oc-
difficult to describe and inconstant in appearance. curring in chronic bronchitis. Leopold and Seal in
Numerous attempts have been made to explain 1961 described a further type of peripheral pool
these changes more precisely and for many years a thought to be due to the opaque medium lying in the
theory of peribronchial thickening was in vogue space created by areas of centrilobular emphysema.
which was thought to give rise to a more dense lung Diffuse interstitial reticulation has been observed
pattern than normal. Alternatively, it was thought by Lodge (1946), Simon (1958), Kerley (1962) and
344