603

Smoking histories obtained from PMP notes and from relatives.

The 20 men include some coalworkers enrolled in a larger post-mortemsurvey but not fulfilling the criteria for this study. Only PMP histories fromwithin 5 years of death are included. Abbreviations as in tables I and III.

Pathologists differ in their terminology for emphysema incoalworkers. Heppleston distinguishes focal emphysemafrom other causes of centilobular emphysema.,18 whereasRyder et al. have used focal emphysema to include evensevere grades of emphysema in coalworkers.6 We haveavoided the term altogether and assessed centrilobular

emphysema, pigmented or not, as defined at the CIBA

symposium in 1959.12 Slight degrees of this type of

emphysema in coalworkers would correspond to focal

emphysema. In the coalworkers in our series the emphysemawas found around the dust foci, and there was an associationbetween the size and distribution of dust foci and the severityand distribution of centrilobular emphysema (table IV). Itseems unlikely that the emphysema precedes dust deposition,which begins in youth for most coalworkers, and there isevidence from animal studies that less dust accumulates in

emphysematous areas of lung.I9 A causal relation betweendust foci and subsequent emphysema seems plausible.When men with PMF of any size were excluded, the

estimated relative risk of emphysema in coalworkers fell from10 - 35 to 5’67, probably because coalworkers with PMFtended to have more emphysema than those without.

Although the association between PMF and emphysema wasnot significant at the 5% level, it had an effect on the relativerisk because a high proportion of the men with PMF werecurrent smokers over 60 years old; this category accounted formuch of the difference in emphysema between coalworkersand non-coalworkers in the whole group.If underground dust exposure were to become accepted as a

cause of emphysema in coalworkers this would have

implications for the assessment of coalworkers’ disability forthe purposes of disability benefit. At present the assessmenttakes only limited account of disability from emphysema.This study supports the hypothesis that there is an excess ofemphysema in coalworkers, and further work is under way toinvestigate the associations between emphysema,radiological appearances, and underground exposure.We thank Dr P. C. Elmes for X-ray reading; Mr W. Sullivan, Mr D.

Munday, and their colleagues for preparation of pathological material; theLlandough Hospital mortuary technicians for their cooperation; Miss C. Exallfor visiting relatives; Miss C. Squance for help with extracting PMP notes; andDr F. J. Darby, Chief Medical Adviser, for permission to use PMP material.A. C. was funded for this work by the Welsh Scheme for the Development ofHealth and Social Research.

Correspondence should be addressed to A. C., Dept of Medicine, CharingCross Hospital Medical School, Fulham Palace Road, London W6 8RF.

REFERENCES

1. Gough J. Pneumoconiosis in coal trimmers. J Pathol Bacteriol 1940; 1: 277-85.2. Heppleston AG. The pathological anatomy of simple pneumoconiosis in coalworkers.

J Pathol Bacteriol 1953; 66: 235-46.3. Reid L. The pathology of emphysema. London: Lloyd Luke, 1967.4. Snider GL, Brodie JS, Doctor L. Subclinical pulmonary emphysema. Am Rev Respir

Dis 1962; 85: 666-83.5. Heard BE, Izukawa T Pulmonary emphysema in 50 consecutive male necropsies in

London. J Pathol Bacteriol 1964; 88: 423-31.6. Ryder R, Lyons JP, Campbell H, Gough J. Emphysema in coalworkers’

pneumoconiosis. Br Med J 1970; iii: 481-87.7. Rae S, Muir DCG, Jacobsen M. Coalworkers’ pneumoconiosis Br Med J 1970; iii: 769.8. Fletcher CM. Emphysema in coalworkers. Br Med J 1970; iv: 176.9. Gilson JC, Oldham PD. Coalworkers’ pnumoconiosis. Br Med J 1970; iv: 305.

10. Naeye RL, Mahon JK, Dellinger WS. Effects of smoking on lung structure ofAppalachian coalminers. Arch Environ Health 1971; 22: 190-93.

11. Lamb D. A survey of emphysema in coalworkers and the general population. Proc RoySoc Med 1976; 69: 14.

12. Report of the conclusions of a CIBA guest symposium, terminology, definitions andclassifications of chronic pulmonary emphysema and related conditions. Thorax1959; 14: 286-99.

13. International Classification of Diseases (9th Revision). Geneva: World Health

Organisation, 1977.14. Lyons JP, Ryder R, Seal RME, Wagner JC. Emphysema in smoking and non-smoking

coalworkers with pneumoconiosis. Bull Eur Physiopathol Resp 1981; 17: 75-85.15. Cockcroft AE, Wagner JC, Seal RME, Lyons JP, Campbell MJ. Irregular opacities in

coalworkers’ pneumoconiosis-correlation with pulmonary function and

pathology. In: Walton WH, Critchlow A, eds. Inhaled particles V. Oxford:Pergamon Press (in press).

16. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospectivestudies of disease. J Natl Cancer Inst 1959; 22: 719-48.

17. Mantel N. Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Statist Assoc 1963; 58: 690-700.

18. Heppleston AG. The pathological recognition and pathogenesis of emphysema andfibrocystic disease of the lung with special reference to coal workers. Ann NY AcadSci 1972; 200: 347-69.

19. Gross P, Tuma J, de Treville RTP. Emphysema and pneumoconiosis. Arch EnvironHealth 1971; 22: 194-99.

In England Now

So I went to a psychiatrist. Why did I go to the psychiatrist? Verysimply it was to ask him to rid me of my sanity and make me as stupidas everyone else. I am sick and tired of always being in the right.Much the same sort of conflict bedevilled Edmund Gosse’s father in

Devonshire, but in his case it was he who was invincibly stupid inthe face of the evolutionists. With me it is the other way round, ifyou see what I mean.As a child I soon recognised that Grown-Ups were much much

stupider than I was. This was borne out later by a prize competitionin one of the weekly journals, which asked: Why are adults so muchmore stupid than children? The prize was won by a ten-year-old whosubmitted: "Because they’ve been longer at it".There are, of course, degrees of stupidity. I would settle for being

as comfortably stupid as our local bureaucrats. I tangled with onerecently. An absolute shocker. In our village there is a dangerouscrossing. On one side of the busy coast road is the gap in the cliffsleading down to the beach; immediately opposite are a car park, abus stop, a cafe, and a fun fair. People cross the road at this point likemad. In my opinion it needs at least a zebra crossing if notpedestrian-controlled traffic lights. But the bureaucrat told mewith an air of triumph, "Well, there’s never been an accident yet,has there?".An hour or so later, when I had got my breath back, I sat down and

wrote him a letter. How serious had an accident to be, I asked, toqualify for a zebra crossing? Fatal? A simple fracture? Concussion?Did children and old-age pensioners count? And did all the zebracrossings in the country commemorate the sites of accidents? Anddid he himself eschew mortice locks and window catches because hehadn’t been burgled so far? In my letter I used the word

"prophylaxis"-and this was a mistake. It evidently is not in a CivilServant’s vocabulary, for in his curt reply he nearly accused me ofhaving a dirty mind. He is bound to be promoted to some highersphere; and then I will have a go at his successor.

I got no joy from the psychiatrist.