APRIL 1946
GRAPHITE PNEUMOCONIOSIS COMPLICATED BY CAVITATION
DUE TO NECROSIS
By LASAR DUNNER, M . D . ( B e r l i n ) , {Tuberculosis Dispensary)
and
D. J. T. BAGNALL, F . R . I . C . (Municipal Laboratories), Kingston upon Hull
Igraphite
N a previous paper, Dunner (1945) drew attention
to lung disease in workers who had been inhaling
dust for some years. This disease can be
recognised only by X-ray examination, which
reveals reticulation, patchy infiltration, fibrosis or
dense opacities, and, at least some of these mani-
festations indicate a pathological process due to a
reaction of the lung tissue to the inhaled dust. It is
apposite to stress this type, because a distinction
must be made between real lesions in the lung due
to such a reaction and a mere accumulation of dust
which can also produce mottling on the X-ray film.
Mottling, however, can also be the result of a
pathological reaction of the lung. It is, of course,
not justifiable to regard mottling as a manifestation
of an accumulation of dust simply because post-
mortem examinations in another type of occupa-
tional lung disease have proved the mottling to be
due to such accumulations. Conclusions like that
are unwarranted. In the cases of the five graphite
workers referred to in the previous paper, the X-ray
films did not show mottling, but obvious lesions.
On the other hand we have been informed of a
series of graphite workers whose films displayed
mottling. Its interpretation, however, must remain
in abeyance, until an opportunity is afforded of
carrying out a post-mortem examination. It may be
that the opinion of those who—prematurely in our
view—allege it is merely the result of dust accumula-
tion, will be confirmed by post mortem. It is
possible that the mottling stage in graphite workers
will finally develop into lesions similar to those seen
on the skiagrams of the five men on whom the first
report has been based. This problem can only be
solved by repeated X-ray examinations. If the
gradual development from mottling to real lesions
can be proved, it is neither evidence nor counter-
evidence that the mottling is caused by a deposit
of dust.
The symptoms of the graphite workers described
in the first paper were strikingly mild, even in
advanced cases.
Regarding the purity of the graphite inhaled, it
was stated by someone in a position to know that it
was pure graphite. This statement may have been
meant to imply that the graphite was free from any
admixture, but as native graphite contains some
silica and/or silicates as an impurity, it is possible
that the graphite in question was only of native
purity.
165
Pure graphite can be obtained by chemical treat-
ment of the native product. Hollmann (1928)
reported that the workmen examined by him had
been working with pure graphite. It may be, how-
ever, that he had to rely on statements concerning
its purity which may or may not have been correct.
It is possible that the statement referred to in our
previous paper that the graphite was pure, was not
strictly correct. The presence of silica in graphite
is, of course, of great pathological importance, for
inhaled silica may produce lesions in the lung.
Apart from this, the men concerned may have been
exposed to a siliceous dust prior to working with
graphite. A chemical analysis of this graphite could
not be carried out by us, for the management of the
factory concerned, after having been informed about
the result of our radiological examinations, would
not co-operate in any way.
Below are given the percentage results of the
analyses of (a) graphite contained in a product
manufactured by the firm concerned, (b) powdered
graphite as purchased in the open market, and (c)
the fraction separated by blowing a current of air
through (b) and collecting the air-borne particles.
(a) (b) (c)
Loss on ignition
(mainly carbon) 75-5 44-4 52-7
Total silica* .. 8-7 25-1
Soluble silica* .. 0-18 0-26
* Includes silica present as silicates, if any.
The soluble silica was estimated by the method of
Matthews (1938), who found that the solubility of
calcined flint dust, which is known to be extremely
dangerous, varied from 0-45 to 1-21 per cent.,
according to the fineness of the particles, the
number of particles less than one micron in size
ranging from 65 to 90 per cent. The size of the
majority of the particles in (c) was five microns or
less, with only a few over ten microns.
The fact that (a) contained silica in some form is
not proof, of course, that the graphite used by our
workmen in past years contained silica, and it is
possible that the silica found has been added in some
form during the manufacture of the product exam-
ined. Assuming that the men inhaled silica, two
questions arise concerning the silica, namely:—
(1) Was the solubility of the silica sufficiently
high to cause damage to the lung tissue and
produce pneumoconiosis?
VOL. XIX, No. 220
L. Dunner and D. J. T. Bagnall
(2) Is the effect upon the lung of carbon plus
silica less or greater than that produced by
these two substances when inhaled singly?
In this connection Matthews (1938) puts forward
the hypothesis that it may be possible to render
a dangerous dust innocuous by mixing it with a
second dust which reduces the silica solubility,
such as, perhaps, cement, or iron, or charcoal. The
first question could only be answered after a post-
mortem examination, and the second by carrying
out experiments on animals.
FIG. 1.
Radiographs of equal quantities of commercial
graphite and the purified product show that the
latter is relatively non-opaque, whereas the com-
mercial graphite has quite a considerable degree of
opacity.
Although the existence of pneumoconiosis in
graphite workers is unquestionable, the knowledge
of the disease is far from being complete. The
following subsequent history of Case 2 of the first
paper adds to our knowledge:—
H.D., aged 64, denied on close questioning ever to have
had a dusty job before working with graphite, which occu-
pation lasted for seventeen years. He stated that he started
coughing and spitting only after taking up this work. On
account of chest trouble he was examined and X rayed, and
pronounced tuberculous, and was therefore sent to a
sanatorium (1939). His sputum was found on numerous
occasions to be free from tubercle bacilli. After discharge
from the sanatorium he did not return to work with graphite
(probably on account of the "pulmonary tuberculosis"), but
166
was given light work at which he kept quite well for six
years. He did not mind the coughing and spitting. He was
first seen by me in the middle of 1944. In spite of his
age (63) he made a good impression. The clinical signs were
very scarce and his sputum was again negative. The
radiological findings on his chest were unchanged, when
compared with those of several films taken in and since
1939, all of which were at my disposal, and showed massive
reniform opacity in the right upper zone, similar, but
fainter opacity in the left upper zone, and a rounded opacity
FIG. 2.
the size of a golf ball, superimposed on the lower part of the
left rootshadow, obscured by the heart shadow (Fig. 1).
Since the beginning of 1945 he several times noticed
streaked sputum which he disregarded, as he did not feel ill.
In April 1945 he suddenly brought up large amounts of
black material. He was admitted to hospital, where he
stayed until July 1945. A summarised report of his con-
dition is as follows: His temperature was on no occasion
elevated. Clinical signs were rather scarce and by no means
indicated the findings of the X-ray film, which showed the
same manifestations as previously with the addition of
distinct cavitation of irregular shape within the opacity in
the left upper zone (Fig. 2).
The sputum, when it first started to be black in colour,
amounted to about 120 c.c. daily, and gradually decreased
within the next four months to about 20 c.c. It was
occasionally stained. It is unvaryingly black and has always
been mixed with small amounts of yellowish sputum. It
has never had an offensive smell or taste. The patient has
never noticed "mouthful expectoration". The sputum has
never sedimented in several layers in the spittoon. It was
found on numerous occasions to be free from tubercle
bacilli. No other significant organisms were detected.

Graphite Pneumoconiosis Complicated by Cavitation due to Necrosis
Elastic fibres were on occasions present in small numbers,
but not in alveolar formation. Only a few white blood cells
were found.
Samples of the undried sputum contained about 0-07 per
cent, of carbon, the size of the majority of the particles being
5 microns or less, with only a few over 10 microns. No
silica was detected in several samples of the sputum.
Since his discharge from hospital he feels weak, incapable
of work, and cannot even walk as well as he did before. He
becomes breathless on slight exertion. The general im-
pression of his condition is that a big change has taken
place for the worse.
DISCUSSION
The following points arise for discussion:—
(1) The significance of symptoms in graphite pneumo-
coniosis
In the first paper on graphite workers the paucity
and slightness of the symptoms (and signs) were
stressed. Even the patient mentioned above initially
supported this allegation. In fact, he had been feel-
ing fit for work and had been working until April
1945, when he started spitting graphite. Now he is
an ill man and his disability is obviously due to
his chest trouble, although his bad condition might
be—partly, at least—due to his advancing age. But
in any case the remarkable fact exists that the
pneumoconiosis, which had been present for many
years without causing any special trouble, has now
developed into a serious form of this disease.
Another graphite worker, recently encountered,
after a long period of well-being and fitness for
work, in spite of rather advanced pneumoconiosis,
developed shortness of breath and general weakness
to such a degree that he felt unable to do anything.
Observations like these impel the modification of
the allegation in the first paper that signs and
symptoms are necessarily strikingly mild. Addi-
tionally we have been told that several graphite
workers of the series referred to above had chest
trouble.
(2) Where is the process taking place and what is its
anatomical nature?
The man had been spitting a yellowish sputum,
probably due to bronchitis, for many years, during
which the radiological manifestations of graphite
pneumoconiosis were present. The fact that
graphite was suddenly brought up and expectorated
for a long period might be regarded as a proof that
this black material came from the lung tissue beyond
the air passages. This graphite must have entered
the lung at least six years before, because the man
had then ceased to work with graphite. The theory
that it has caused a pathological process within the
lung is supported by three facts, namely:—
(a) A distinct cavitation has developed since the
man has been spitting graphite.
(b) The finding of elastic fibres proves destruction
of lung tissue.
(c) The small haemoptyses prior to and during
the expectoration of graphite provide similar
evidence, even though of lesser value.
167
APRIL 1946
The process is not an abscess, the usual signs and
symptoms of which are lacking; no fever, no freely
expectorated purulent sputum. The bacteriological
examination of the sputum and the small number of
white bloodcells in it do not suggest the existence of
a purulent process or tuberculosis. The nature of
the process is necrosis. This theory is supported to
some extent by a paper by Koopmann (1924) who
reported the post-mortem findings on a man who
had been working for about fifty years in a graphite
mill. Apart from a short period of bronchitis he had
always been well up to his death; he was killed by an
accident. He had not been examined, nor X-rayed
whilst alive. Koopmann found pneumoconiosis and
cavities. He was able to pursue the graphite dust on
its way from the bronchi to the alveoli, and further
into the interstitial lung tissue. He found small
pigment corns, small dust splinters, and cells loaded
with pigment in the alveoli. Some small splinters
had pierced the wall of the alveoli. He points out,
that the dust can penetrate through the alveoli into
the septa and lymphducts which are found full of
cells loaded with dust. A chronic interstitial pneu-
monia, peribronchiolitis, and periarteritis nodosa
with extensive infiltration and fibrosis are en-
countered. The small blood-vessels within the
fibrosis are obliterated and the area concerned,
deprived of blood, becomes necrotic, which paves
the way to formation of cavities. (The graphite dust
can also be transported via lymphatic ducts and
blood-vessels beyond the lung into other organs,
where it was found by Koopmann.)
Two facts in the paper of Koopmann (1924) are
worth stressing:—
(a) The occurrence of a cavitation due to necrosis
(not to abscess or to tuberculosis) has been
anatomically proved.
(b) The presence of lesions in the lung due to the
reaction of the lung tissue and not to mere
deposits of the dust.
But it is not certain whether the man concerned
had been exposed exclusively to graphite for fifty
years. In his history are periods of occupation as a
miller and stone grinder. In the latter occupation,
silica may have been inhaled. The graphite the man
had been dealing with may also have contained some
silica. The question of silicosis has been overlooked
by Koopmann. Unfortunately the chemical analysis
was restricted to the determination of the amount of
graphite in the lung.
On the other hand, Koopmann apparently did not
find anything in his macroscopical and histological
examinations that suggested silicosis, and therefore
no chemical analysis for silica was carried out.
Faulkner (1940) reported on a man who had been
working for many years as a "bench moulder" and
developed typical lung abscesses. At autopsy, the
abscesses and extensive anthracosis, silicosis and
siderosis with pulmonary fibrosis were found. But
he makes no mention of any analysis of sputum and
 VOL. XIX, No. 220
L. Dunner and D. J. T. Bagnall
pneumoconiotic tissue for the presence of silica, graphite sputum. We strongly warn against precipi-
graphite, and iron. tate conclusions. Several personal communications
Necrosis and cavitation in pneumoconiosis is and annotations on our first paper published in
known, e.g., McCloskey (1943) has described, from the British Medical Journal (1945), show some
an anatomical point of view, cavitations in both proneness to pronounce an opinion as to the nature
upper zones in a case of anthraco-silicosis. These of the graphite pneumoconiosis, such as whether it
cavitations were not apparent on the X-ray film. is silicosis or not, whether the radiological manifesta-
The present case is the first one of graphite tions are due to a mere deposit of graphite or real
pneumoconiosis in which cavitation due to necrosis lesions. In a "letter" recently published in the
has been diagnosed in the living subject. British Medical Journal we have refused such
(3) The significance of the sputum, especially its chemical speculations. We wish to repeat the point of view
analysis that only by facts gained from post-mortem exami-
nations, and to some extent by experimental work,
(a) The patient had been expectorating graphite can a sound opinion about the nature of this special
for a long time, discernible macroscopically, type of pneumoconiosis be formed.
and confirmed by chemical analysis. We were
given the opportunity of measuring the size of SUMMARY
the inhaled graphite particles, which was The first case of a lung cavity due to necrosis in a graphite
5 microns or less with only a few particles worker whose X-ray film revealed pneumoconiosis and
over 10 microns. This finding is in keeping graphite,cavitation, has been described. The black sputum contained
but no silica was detected.
with the statement in the literature that very The distinction between native and purified graphite and
few dust particles exceeding 10 microns in their content of forms of silica have been discussed.
diameter enter the lung.
ACKNOWLEDGMENT
(b) No silica, in any form, was found. This finding We are indebted to Dr. N. Gebbie, Medical Officer of
is not irrefutable evidence of the purity of the Health for Kingston upon Hull, for permission to publish
graphite. It may be that the inhaled silica has this paper. We wish to extend our special thanks to
been dissolved away during the intervening Dr. A. R. R. Cumming, Medical Superintendent of
Beverley Road Hospital, who gave us access to the patient
years. Also it is possible that silica and carbon whilst in the hospital and willingly afforded any help and
have been deposited in different parts of the put the case at our disposal for publication.
lung, which might account for the absence of
silica in the sputum. REFERENCES
DUNNER, L., Brit. Journ. Rad., 1945.
CONCLUSIONS DUNNER, L., Brit. Med. Journ., 1945, p. 195.
The case reported on reveals undoubtedly several FAULKNER, W. B., Jr., Diseases of Chest, 1940.
striking findings: Localised necrosis and destruction HOLLMANN, R., Zeitschr. f. Tbc, 1928.
KOOPMANN, H., Virchow Arch., 1924.
of the pneumoconiotic lung resulting in cavitation, MATTHEWS, J. W., Analyst, 1938, lxiii.
expectoration of graphite, lack of silica in the MCCLOSKEY, B. J., Amer. Journ. Roentg., 1943.

REVIEW
The Roentgen Density of the Cystine Calculus, Axel
Renander, Ada Radiologica, Supplementum xli,
Stockholm, 1941.
The Swedish people have a wonderful record of
contributions towards progress in radiology, not the
least of these achievements being this book by Dr.
Renander. He begins with a general review of the
chemical and physical characters of cystine and of
its occurrence and physiology, continues with a
general discussion on cystinuria, and concludes with
a review of clinical and experimental findings. The
report is based on 37 cases of cystinuria with
lithiasis collected from the whole of Sweden. Of
these 37 cases, 27 were complicated by the formation
of calculi, and X-ray examinations had been made
in 18. In 15 cases the stones gave very good
shadows, but in 3 cases there were small stones
which could not be distinguished. In most instances
the shadows were homogenous, but in others the
stones appeared granular and some were lamellated.
Small stones had a characteristic loose and vacuo-
lated structure. On analysis most of these stones
proved to be nearly pure cystine, having an ash
content of only 1-2 per cent.; some vesical calculi
had as much as 25 per cent, of ash. The report
concludes with a long and very critical experimental
analysis of a series of cystine stones, which shows \
quite conclusively that in the great majority of cases j
a radiological examination can be expected to give j
positive findings when stones are present. F. H. K. j

J
168