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A SURVEY OF DANISH MEDICINE PUBLISHED BY UCESKRIFT FOR LfEGZR THE MEDICAL FACULTIES OF THE UNIVERSITIES OF COPENHAGEN AND AARHUS THE NATIONAL HEALTH SERVICE OF DENMARK l'"ui Bonuevie for Lrger EDITORS; Mocens F H.C. A. Lassen Niels BlixonkroucOIollor for Terser University of Copeotwsen University of Anrhut Assistant Editor: Fritz Fuclis Richard Friedberc Xationai Seaita Servlfe VOL 3 A Publication of THE DANISH MEDICAL ASSOCIATION Damns Mcdica. rojuuiJmsjeti IJ, Denmark 1956 1<S\C&5) 'N 202 DANISH MEDICAL BULLETIN Vl:: a, Haemolysis. Considerable haemolysis lias been reported in several earlier bubble oxvyenalors, but the meth od per sc need not be traumatic. It is important to use a non-wetablo material such as polyethylene. Undoubtedly a flexible system holds advantages over the rigid systems. Furthermore, it is important to break the foam effectively at the top of the oxygenator column, and no free fall of the blood should be allowed. In addition, fairly large tubes should be used in order to minimize turbulence. One and a half liters of freshly drawn citratcd human blood has been recirculated 100 times through the apparatus at flows up to 4 liters per minute. The haemolysis at the end of the experi ments varied between 20 and 70 mg per 100 ml of plasma, the greatest amount of haemolysis occurriug with the highest blood flows. Table 1. Results of recirculation with one tiler of human cilrnted blood 100 times through the machine at a flout rate of 1 1/minute, using carbogen for oxygenation. Hmage/2m0oOlymsils plasma ............. 0 After 100 passages 22 Leucocyte count 2720 2640 Fibrinogen /. . 0.29 0.29 Table 1 shows the amount of haemolysis, white blood cell count and fibrinogen analysis before and after one liter of human citratcd blood had been recirculated at a flow of 1.5 liter per minute one hundred times. Oxyuenaliny capacity. j The oxygenating capacity has been tested in vitro by one passage of venous blood through the system. In the model which we use in animal i \[,, ments, the capacity is limited to 1500 ml , minute with-a total extracorporeal blood of about 1200 ml. It can easily be altered in . creasing the diameter of the oxygenating eulim: Tabic 2. liesulls of eight dog perfusions of :i0-- i.'l niimi:,. duration (mean values). Flow rate ................155 ml pr. kg Venous Os-saturation 57 Vu (53 -- 6#) Arterial 0--saturation 90 % (93 -- 99) Arterial CO;-pressure 23.3 mm Hg. Free haemoglobin ... 42 mg/100 ml plasma {vC"n Perfusion experiments. Table 2 shows the results of eight experimr:.:. perfusions of dogs weighing from 10 to 15 k: grams. During the perfusions, cardiac vrr ' blood was aspirated from the opened right . trifle and returned to the venous reservoir. I i The present design is not to be consider^! : final. Work is still in progress to improve Hu . stem further. .: <***%f References: 1) Schrocdcr, 11'.; Arch. exp. Path. Pharmak. 15: 364. } 2) Clark, L. C. Jr^ F. Goltnn, 11. Gupta: Sc:. _ 1930, ill:35. r 3) DeWall, R.A.. R. C. Read, H. E. Warden; !\ \ R. L. Vorev (l. U'. I.illehei: Surgery, in |- } cit. Lillehei & al. 1956. 4) Lillehei, C. 11'.. R. A. DeWall, R. C. Read. II Warden St R. L. Vrco: Dis. Chest, 1936. i'J 5) Rygg, /. 11., F.. Kgnsgaard, F.. llusfeidt Si Fr. * kelsen: 44 A Heart-Lung Machine with a Di*|w.. Polystan Oxygenator System," reported j! Second European Congress of Cardiology. >'* hohn 1956. >**^ ASBESTOSIS WITH PLEURAL CALCIFICATION A3I0NG INSULATION WORKERS By J. FROST, J. GEORG anti P. FLEMMIXG M0LLER Pulmonary disease due to the inhalation of asbestos dust Itas been known for the last fifty years. The first case was described by M urray (1906). In Scandinavia, cases were reported from Norway and Finland by Wolff (1940), S c h r ti m p f (1941), Wegelius (l94(i) ami N'oro (1946). From the Clinic for Occupational Diseases (Chief: J. Frost) and the Radiological Department (Former Chief: Professor P. Flemming Moller), Rigsho.spitalct. University of Copenhagen, Denmark. In Denmark, asbestos does not occur u: natural state, and comparatively few pc!,u engaged in the processing of imported I vc (1950) reported one case of asboh'-,,v Frost (1950) three cases. These cases in factories making insulation product'. ; linings, and flooring material; the last r.i" a logger in a shipyard. v ; ~ * 3. - The discovery of l It esc cases led to ' vision of factories of this kind. Lagging - is usually undertaken by small firms. In L \<Mr*lllivr iyA DA.NISII MEDICAL BULLliTIX 203 ;i-n. employees of such firms have their own on, m) jt was found most convenient to carry examinations through the Union. As there were no statistics about occupational hazards in : :;iis trade, the Union was interested in having its f members examined. j After consultation with the Union officials, we : itcgau examinations in 1353 by selecting workers ; who had been in the trade for twenty years or I more. Tito Copenhagen Union of Insulation Wor} Kors had about a hundred members during the \ mii-ties. These men often change from one firm : jo another and arc employed on all kinds of in I .tilation work. Before 1930 or so, lagging material j chiefly consisted of kieselguhr and magnesia, f mostly mixed with asbestos, or of asbestos ropes, ; ,>r. in the case of boilers, mattresses filled with i ;>bes{<'s flock. j Since about 1935 the use of rock-wool and glassj wool has gradually come to the fore in the in- .fiiation of hot-water pipes, etc. A special process j for the insulation of ships' walls, L spraying : with powdered asbestos, has been used to a cerj tain extent. Tlie Union urged all the workers who had been in tlie trade for more than twenty years to sub . .-nit themselves for examination: 31 attended; 3 | did not. The occupational history was recorded, [ mid a detailed clinical examination was carried with X-ray of the chest (frontal, lateral and .lique positions). The average age of the subjects was 52 years, ranging from 41 to 70; the period of exposure averaged 27 years, ranging from 20 to 45 years. Six of them complained of shortness of breath, which they considered abnormal for their age. All of them were working full time. RESULTS Roentgenographic examinations revealed ab normalities in 22 cases. 9 cases showed definite signs of pulmonary asbestosis, varying in degree -- usually a fine mottling or nodulation. In no less than 19 cases abnormalities of the pleura were found. These changes ranged from obliter ated sinuses and pleural adhesions to extensive thickening of the pleura with calcification. The pleural abnormalities were bilateral in 12 rases; unilateral in 7. Calcification of the pleura was bilateral in S cases; unilateral in 3. Parenchymatous lesions of the lungs alone wore found in 3 cases, and in l> cases combined with pleural lesions, 3 of which were calcifications. In a few cases the abnormalities of the pleura "`cre so widespread that no definite diagnosis vould be made regarding the conditions of the !l*ngs. suffered from any lung disease, f.., pleurisy with effusion 13 years previously. While U is generally observed that nsbestosis of the lungs is accompanied by pleural thickening and adhesions, wc have only been able to find one reference to pleural calcification in this connec tion. (Jacob & B o h 1 i g, 1955). . Calcification of the pleura is a rather rare finding in radiological examinations of the chest. The incidence among unsclcctcd cases is esti mated by Patch & Perry (1952). to be less than 0.2 per cent. Floyd & Hepburn (1939) found 23 in 15,000 examinations, and Kristian sen (1944) 15 in 10,000. In selected groups, con- Fig. 1. Insulation worker, age 70 gears, exposure io gears. Bilateral pleural calcification. COMMENTS was a surprise to find 22 subjects with ab* normalities of the chest out of a total of 31 lSnmincd. Only one of these stated that he had Fig. 2. Institution worker, age 57 years, exposure 3S years. Extensive pleural caicificution over lower Iwo-thirdx . of the lungs. . 204 DANISH MEDICAL BULLETIN Vol 3 no ; taining many cx-serviccmcn, Ulrich (1930) found 1(3 out of 5,700 (etiology: bullet wounds, 5 eases; pleurisy, 5 eases; tuberculosis, 1 ease; pneumonia, 1 ease; unknown, 4 cases), and B c h* rendt (2930) found 12 out of 9CG subjects (ctiology: bullet wounds, 5 eases; tuberculosis, 7 eases). Head (1934) considers tuberculous pleuritis and hemothorax the only causes definitely known to produce calcification of the pleura. Patch &. Perry point out that calcification is usually unilateral, but bilateral in the so-called idiopathic cases (approximately 20 per cent of all eases). A special investigation of workers exposed to dust was carried out by Smith (1952). She found 35 cases of pleural calcification out of 8,779 subjects examined. Only four groups showed a definitely higher incidence of calcification than that among the average population, viz., workers exposed to the dust in making bakelitc insulators, (1.5 per cent), calcimine (1.7 per cent), mica (1.0 per cent) and tremolitc talc (6.3 per cent). Tremolite talc is a calcium magnesium silicate, which structurally resembles asbestos. It is known to cause pneumoconiosis. Calcimine is composed of whiting, clay, talc, silica, mica ant^asbeslos. Four eases of pneumoconiosis were found in this group. Mica is a complex silicate of potassium, aluminium, magnesium, calcium and ' fluorine. Bakelite was mixed with talc and mica. No ease of pneumoconiosis was found among the workers exposed to mica or bakelite. No pleural calcifi cation was found among 261 asbestos workers. Smith suggests that it is the combined exposure to calcium and magnesium, together with a dust producing pleural irritation, which provokes the calcifications. None of the workers examined by us have been working with asbestos alone; all of them have been exposed to kicselgulir, magnesium, rockwool and glass-wool too. The last three subst mees do not cause pneumoconiosis. Exposure io kieselguhr is known to involve a risk, as several eases of pneumoconiosis seemingly caused by this substance have been reported. According to Luton, C h a in p e i x, R a v c t & V a 11 a u d (1956) it is primarily a question of the alphaquartz content. Exposure to the amorphous form of kicselguhr involves considerably less risk than does exposure to the flux-calcinated substance, nearly ail of the silica of which may be in the form of alpha-quartz. The kicselguhr used in this country is not known to be flux-calcinated, and sample-analysis has not revealed the presence of alpha-quartz. In our eases the workers have been exposed to asbestos, which is .known to produce pneumoco niosis with pleural affection, and to kicselguhr, magnesia, rock-wool and glass-wool. Our findings thus give some support to S m i t h's contention that the incidence of pleural calcification may be connected with exposure to mixed dust; but it should be emphasized that our subjects have not been exposed to calcium. While smaller pleural thickenings and ad* hesions are a rather common finding in chcxi X-rays of persons not known to have had any lung disease previously or to have been exposed to dust at their jobs, the findings of pronounced bilateral pleural changes in the present series definitely point towards an occupational origin. The diagnosis of asbestosis may be made with confidence when these pleural changes are found together with parenchymatous lesions of the lungs. The occurrence of similar pleural changes without any definite changes of the lung proper may also, with reasonable certainty, be accepted as evidence of asbestosis in subjects known to have worked with insulating material of the sort used by the workers examined here. SUMMARY 31 workers engaged for 20 years or more in different kinds of insulation works were ex amined for occupational lung disease. They h:id been exposed to dust containing asbestos, kiesclguhr, magnesia, glass-wool and rock-wool. 9 were found to have definite signs of pulmonary* ns* bestosis. 19 showed abnormalities of the pleura. 12 of these being bilateral. In 11 eases calcifica tion of the pleura was found, being bilateral in 3 of them. Iieferetiees: 1) liehrendl, T.: Boitr. z. Klin. d. Tuberk. 1930, '>>: 129--164. 2) Floyd, C. Si li. It. Hepburn: Am. Rev. Tub<rv. 3) Frost, Ugeskr. Larger 1950. 332; 1284--1259. 41 Head. J.: Ann. Int. Med. 1934. 7; 1295--1307. 5) Joe, 7.: Ugeskr. Larger 1950, 332; 472--474. 0) Jacob. G. & II. Bvhiiij: Fortxchr. Gcb. Rontgen- strahlen 1955, $3: 515--525. 7) Kristiansen, l.: Acta tub. Scandinav. 1914. 310--325. 8) Luton, P., J. Champeix, M. linnet Si .1. Ynllnn-l: Arch. mal. profess. 1956. 37; 125--US. 9) Mereweiher, Z. li. .4.; Tubercle 2933--34, 15: f.*-- 81, 109--113, 132--159. 10) Murray, M.: cit. Merewether 1933--34. 11) .Voro, I..: Acta palhoi. ct microbio!. Scaiu:i:3v* 1940. 2.3; 53--39. 12) PttUh, I. C. L. Si K, M. .4. Perry: in Marsha!! i Ferry (edit.): Diseases yf the Chest London U1''-* 13) Schrumpf, .4.; Xord. Med. 1941, 9; 704--700. 14) Smith, A. li.: Am. .1. Roentgenol. 1952. 67: 375-- 382. 15) f.7rtc/i, K.: Rontgvnjwaxi*. 1930, 2: 212--222. It!) Wcyclius, C.: Acta radio!. 1947, ?.*>': 1.19--152. 17) Wolff. .4.: Nord. Med. 1910, 5; 53:)--541. 18) Wolff, .1.; Xord. hyg. Tids^rift 1 Did, 21: J--5S. \ l i i i i i I I i i 4 i i * i i ji * 4 i t i i ? ..... BULLETIN of HYGIENE n$aS ISSUED UNDER THE DIRECTION OF THE HONORARY MANAGING COMMITTEE .?: :z :V t ; VOLUME 32 (Nos. 1-12) JANUARY - DECEMBER, 1957 ti *# * [// 1 ' , IT as  .. ** * *. `^TSSCyf 260 - BULLETIN OF HYGIENE ' larch;il9o^? Voi. 35 It -might be reasonable to suppose in some cases that t was proportional to D,. irrespective of particie size, in which, case the volume is . .. . ' Li^VD* ..... ' mating .. . ' -j For spherical particle# ^.'is 2/3; the value for any ' other shape' is smaller and. the data for- siliceous .minerals .given in the paper-correspond to g . In the fifth chapter the relationship of the Stokes .and projected area diameters' is- ^**m**^ The separ ation; of 9 fraction by settlement defines the upper and lower Stokes diameters of the particles therein. Microscope sizing of the*- same fraction reveals a greater* range - of ' projected' area diameters which extend- only slightly-below- the lower limit of the : Stokes. range, but considerably above the higher limit.' In. order- to* relate the-two concepts of particle size .the- volume/surface diameter is deduced- for each. Tins quantity is defined as -' - D-r,-SNIP/END*. `Being concerned with cubes and squares of D it is little, influenced by the finer-particles in the. range and reasonable agreement is obtained between optical and electron microscope evaluation for dusts contain ing particles exceeding 0*1 micron in size. " Drs is found from the Stokes sue limits by assuming the exponential size distribution, referred ttfeabove, and taking the ratio of integrals/ which are equivalent to the summations in the microscope formula. This supposes that the- volume of a particle is pro portional to the cube of its Stokes diameter and the surface area to the square. On this occasion there is no analogue of Cauchy's theorem to vindicate even the-latter assumption. The rate of fall of a particie is proportional to the ratio of its volume to the diameter of a sphere having the same fluid resistance at the same rate of fall. This latter diameter can be evaluated for an ellipsoid and is a complicated function of the length of the 3 axes. It is certain that no justification exists for the simple assumptions made in this paper. ' The outcome, for 46 size graded functions covering Stokes diameter ranges of 4:1, and mostly less, is that the ratio of the count volume surface diameter to the Stokes diameter is 1-54*0*31. [The scatter of the count diameters themselves was much less than thi*. which confirms that the assumptions discussed above are unjustified and that the volume/surface diameter does not convey the information which its name implies. A similar criticism must also be levelled at the last chapter in which the estimation of specific surface from size distribution is discussed.] C. .V. Da cits Frost, J., Georg, J. Mollzr, p. F. Asbestosis with Pteurai Calcification among insulation Workers. Danish 3/erf. Sail. 1956, Nov., v. 3, No. 7, 202-4, 2 figs. [18 refs.] In Denmark only a few persons manipulate insula tion products, which include asbestos, kieselzuhr. magnacia, glass-wool and rock-wool. . The rst'*c.tV?Mi'*g have been regarded as fibrogenic to the- luugsrwbeftif A tab Tlte cor their dost is inhaled. In order to ascertainc-apy** occupational risk in the work 31 workers with-mom-i than 20 years' exposure were carefully examined^ clinically and by X-ray. The average age- ofie-tKiA S3: gen ta(t 24 dm cent, of subjects was 52 years, and- the average- period&jif! hopital exposure-was 27 years. Abnormalities were foundsgp results o 22. A total of 9 exhibited fine mottling wiih./nbda<| lataoa indicative of pulmonary asbestosis.^-Igfrjj s lead pallor; j paoana pleural changes, were seen, which.werafda to adhesions.and extensive thickening-with calcific^ tion. Tha abnormalities of the pleura were -sotMid^ muscular .lyoaniorr >ure (14C spread in. some instances as to obliterate others patsf changes. Pulmonary abnormalities. injg&r^gv of 31 persons was a surprising proporrion^! vork as t A table of 133 ca calcification- is unusual and may be ascribed, tovecu* ia a jirou biaed exposure to calcium and magnesium^ -es<i fume presence of fibrogenic asbestos dust. Sample-analysal `o be non of the kieselguhr in use did not revesl the prr--^ of alpha-quartz.. The finding of pronounced bit ji h.iemoi f--J cell cc pleural changes in the present series definitely,podd#* croup tha .to an occupational origin. - E. L-.C. ` 'h* range Tothmt, W\ ' Niehtsilikotische StaubschadehVua Lunge. [Non-Silicotic Oust Hazards] - Ztstim f.d.g. 3yg. u. ihve Grtnxgebiete. Berlin.-'lifiEf 'llar.-Apr.-IIay-Junej v. 2, Nos. 2/3, 22&-3fc*^ aaxima ninima ii ;he le.-ui { 0*162 rnne it \> ^mples. iiaxnoetic The following dust diseases are briefiy revit.w*,^.. of bas pneumonia caused by manganese dioxide ancLbana* The <lia, slag, beryllium and cadminm. ' A long list is girer ^ving ab* of dusts which cause bronchitis And asthma undwiick -uaibism * may often involve an allergic reaction, as for instaam ' <i'CJrs an paprica, flax and sugar-cane dust. Byssinosis-issu -n-eiice of to be often due to infection, by Aerobncter [Cloa3i * -owe ery eloonid. Dusts producing interstitial fibrotisuam aluminium and radium. The latter may also.csau, s present -d in the bronchial carcinoma. Other carcinogenic dostafaaj Tlie asbestos, chromates and, according to Japaaar fa th*. j workers, dusts from generators in the iron iodmay ''npfoms o and components of the tar fraction with boilinf.-po(% above 300*C. G. SugeiitjCmiiiSj '"^e above " blood j ^*5" 4 Claris-- C. E. & Fekkasdiz, J. J. 'Alguaax.csy urin ;irp sideraciones sobre saturnism entre los trsbadm* de ana fundicion. [Reflections on piumbisis.h the Workers at a Foundry] Her. Med. Dry* Lima. 19S6, July, r. 10, No. 1, 43-52. [12rd :`v main toiindr* English suramarv. TW' '* The article is based on an examination of^L** `IWMARCO, persons employed in all branches of a foundry ?** metal containing lead was smelted. For each till- art medical and occupational history was taken. Cliakf *<*n*azj radiological and laboratory examinations wete-o* Shifts if There was definite evidence of lead poisoning * ments a 133 employees. In 247 others there was evideaa* Examina absorption of lead but no symptom of poisoning (* 47. No each of these groups there were 3 who had in the foundry for only 30 days. The majority^ *Mrkers those with.lead poisoning were in the age group 25-' ** compin'. k CONTENTS PULMONARY VASCULAR LESIONS IN CASES OF PULMONARY HYPERTENSION by V. Kikebind and Fr. TUtrkthtn....... ......................... 197 A HEART-LUNG MACHINE WITH A DISPOS ABLE-POLYETHYLENE OXYGENATOR SYS TEM by t. It. Fyyg, It. C Engel! and F.. Kyim- ynarj ......... ................................... ;....... 200 ASUESTOSJS WITH PLEURAL CALCIFICATIONS AMONG INSULATION WORKERS by J. Frost. 1. Geary and l*. Flemming Miller.................. . 202 BENZPYRENE AND OTHER POLYCYCLIC HY DROCARBONS IN THE AIR OF COPENHAGEN lv J. it. Campbell and J. Clemmeten ........... . 202 LEUCOCYTE AGGLUTININ RESULTING FROM TRANSFUSIONS IN A CASE OF CHRONIC MYELOGENOUS LEUKEMIA by S.-J. Kiltmann 21] PHKOCHKOMOCYTOMA AND ADRENOCORTI CAL FUNCTION bv ft. FtMbttg .................... 213 TREATMENT UY NORADRENALINE by .Vann* Gjel and A. Dgbkjrr ......... ......................... 216 THE ANTAGONISM OK K-ALLYL-N-DESMETHYLMORPHINE TO PETHIDINE by .V. Fjtldborg and S. Johansen ....................... ....................... 220 DEFICIENCY OF A FACTOR IN THE PLASMA THROMBOPLASTIN SYSTEM by AVE. SjfiUn 222 MEDIO*STATISTICAL INFORMATION FROM DENMARK FOR THE YEARS 1954 AND 1933 by K tren breger and Krna Frundsen ........... . 224 Subscription: njnar Munkss*nrd, G, Norrtgmb*, Cop<*nlasf.n Denmark Price: In Scandinavia Run. ('runns V..OO, In Knrapc !//, Oul>idc Europe $ 3.o( nr Equivalent Frv* cl (barjt tor MesKraWmlKutbrns r.n Request VOL 3 NOYKMIUM 19)5C^) A Publirafinu ot THE DANISH MEDICAL ASSOCIATION I>ittiiis3lcilirn,rtH*iilti|rnO.Draiiiork NO 7 PACKS 1U7--2iK Mn8riVa,'l*f,MTTiyaiTTa i - 1 Csii-iia ?w-: ^DA!U8K HKBlfAL BULLITTIS '"--V- ;" '' :;)! Ijjj ;:| j* 1 model which we use in animalexpcri- *. C^dSSSnS^^ ^ br^.' 'rental li U capacity. J* limited to iSOO. ml per* --" ' * minulc with a tola) extracorporeal blood volume be'aUcivl by in-^ oxygenating columns.: fRimUe minute*' [eeU^^ttihelop^^the^ygcMtot^colunv2 npTfrec'fin^oX; the ^bloodjdtMld4 ! Jibwit0 Quadrillion,fairly large tubes* should be used In'll *boi Orutanlioa 37 % (39--U) forder to minimize turbulence. - v*..^**; T*||>rUfW 0^l.nUh!V(W-t9):fe|^^ $?} One end half liters of freshlly drawn ettrated Arterial CO]*pmiarc23JkmmKf. " ,*,ifvn! human blood has been rceireulatcd 100 times Free haemoglobin ... 43mg/10C ml plasma through the apparatus at flows up to d liters per T;V minute. The haemolyxls at the end of the expert- meats varied between 20 and 70 mg per 100 ml of plasma, the greatest amount of haemolysis occurring with the highest blood /lows. ; Perfusion experiments. Table 2 shows the results of right experimental perfusions of dogs weighing from 10 to 18 kilo grams. During the perfusions, cardiac venous Table 1. . Aemits mf recirculation milk mi liter / Imma eltruted hlmtd 16C timer through the nothin* mt ftom rot* of fJ t/minnie, tntng eurbogto for ' oxygenation. ' blood was aspirated from the .ojxncd right ven tricle and returned to the venous reservoir. The present design lx net to be considered as final. Work is stilt in progress to improve the sy MC/100 ml plasma UtKICTt caaat Btri*iwlrpa stem further. Reference*: Before ............... 0 After 104 passages 33 3730 3640 949 649 Table 1 shows the amount of haemolysis, white blood -cell count and fibrinogen analysis before and after one liter of human citralcd blood had been recirculated at a flow* of 1.5 liter per minute one hundred times. . Oxygenating eopaiity. The oxygenating capacity has been tested In vitro by one passage of venous blood through the system. 1) Sehroeiter, W*.j Arch. exp. Path. Phartnak,, 1883. 15: 964. ; 3) Clark, L. C. Jen P. Gallon, 1*. It. Gapta: Science.' 1930, Sit: S3. 31 DeWolt, H. A,, K. C. Head, 11, E. HVrrfrJi, V. Gull. H. L. t*rro & G. It*. LiUehei: Surgery, in print, ell. LiUehei * al. 1936. 4} Utlehri. C \\\ H. A. DeWotl, H. G. Read. It. K. Worden A R. L. V;co; Dls. Cited. 1936. 39; 1. 6) Rygg, l. It., R. Kyoegaord, R, Hu*feldt & Fr. Ther* keluen: "A Heart-Lung Machine with u Disposable Ir,ly>(an Oxygenator System,** refwrted at The Semnd Kttropean Congress f Cardiology. StK*k- holm 1636, ASUEST0S1S WITH 1'LEUiiAL CALCIFICATION AMONG INSULATION WOKKEKS * ` Hu J. FROST, J. GRORG unit P. Fl.EUSflXG UpU.KU Pulmonary disease due. to the inhalation of In Denmark, asbestos does not occur in tin: asbestos dust has been known for the last fifty natural state, and comparatively few people are years. The first case was described by Murray engaged in the processing of iminirted asbestos. (lOOO.Tn Scandinavia, eases were reported from I vc (195(1) reported one case of ashexlosis, ami Norway and Finland by Wolff (194b), Frost (195(1) three rases. These coses occurred Sehrumpf (19411. WcrcUus (194G) and in factories making insulation products, brake Noro (191G). linings, ami flooring material; the last case was a tagger In a shipyard. i From tlie Clinic fr Occupational Diseases (Chief: J. Front) and the ItadUriogiral Department (Former The discovery of these cases led to closer super Cltirf: PndrsMtr /*, Ftemnttng Stutter), Kig^hti^piialrt. vision of factories of Ibis kind, tagging work, etc., t'nlversity of Cojwnliagrn, Denmark. V is usually undertaken by small firms. In Cnpen* ii il -anrati; - i**o u.iiiou au.uii }**#!* /.' ~~ y^g-a.?: fc.iirgen, employees of *uch firm* have their own'.-suffered from any lung disease, /.., pleurisy with V [union, so it was found most convenient fo carry^effusion 18 years previously.'v\;s :|j ^ [exaraintlions through 'the Union. As thereWhile U U generally observed that asbestosis re^e jno^stalistirs about occupational haurds tnWbf the lungs is accompanied by pleural thickening s trade." the Union was interested In having ^members examined.;'t? C i****-J***"*' *. _ r~ jTiJrr ii 'f t ' i`"-|i wi Aft^w^oltatlog flhc tod adhesions, we have only been able to find one ^^aiassssss*Terence to pleura!calcification la this eonneo^ of the !U$^3f _________ [thirtlwT:;These mensoften-change from one " by Pa I ek'A^erfy (1952) .1 02 per cent. Floyd A Hepbura0939> Another'and art^eraployed on all kinds'of fo] i found 2S in 15,000 examinations, and K r l s t i a - suiation work. Before 1930 or so, togging material sen (1944) 15 in 1MO0. In selected groups, eon- [chiefly consisted of kieselguhr and magnesia, , _mostJy mixed with asbestos, or of asbestos ropes, ''^?^'.br, in the case of boilers, mattresses filled with '' !!." asbestos flock. ~. Since about 1935 the use of rock-wool and glass* wool has gradually come to the fore In the in* sulation of hol-waler pipes, etc. A special proeess for the insulation of ships* walls, i. spraying with jiowdcrcd asbestos, has been used to* a cer tain extent. The Union urged alt the workers who had been' io the trade for more than twenty years to sub mit themselves for examination: 31 attended; 3 * did not. The occupational history was recorded, and a detailed clinical examination was carried out with X-ray of the chest (frontal, talers! and oblique positions). D The average age of the subjects was 52 years, ranging from 41 to 70; the period of exposure averaged 27 years, ranging from 20 to 45 years. Six of them complained of shortness of breath, ** ** * * * ** J which they considered abnormal for their age. ' All of them were working full time. ' Pig. 1. Intuleiion worker, eye 70 years, tzpoture 4J greet. - Bilateral pleural calcification. RESULTS Kocnlgcnogruphic examinations revealed ab- . normalities in 22 eases. 9 cases showed definite signs of pulmonary* asbestosis, varying in degree * -- usually n fine mottling or nodulation. In no less than 19 cases abnormalities of the pleura were found. These changes ranged from obliter ated sinuses and jdciirn! adhesions to extensive thickening of the pleura with calcification. The pleural abnormalities were bilateral in 12 cases; unilateral in 7. Calcification of the pleura was bilateral in 8 cases; unilateral in 3. Parenchymatous lesions of the lungs alone were found in 3 cases, and in G cases combined with pleural lesions. 3 of which were calcifications. In a few cases Jhe abnormalities of the pleura were so widespread that no definite diagnosis ccuM be made regarding the conditions of the lungs. COMMENTS. It was a surprise to find 22 subjects with altnormalities of the chest out of a total of 31 examined. Only one of these slated that he.had *. Fig. 2. Insulation ti'orker, age 57 yeors, ejpotnrr SS years. Srtouiie pleural euleifientinn naer louu-r tmo-thirds hf the lungs. ' .1**^ 'i . *i .J ' . .<* ./<;* 'r/V-.'; .... r ' ,[) is UiaJag many ex-servicemen,. Ulrich, (1930)^. thus give some support to Smi t h's contention^ tfttmd.16 out of 5,700 (etiology: bullet wcra&ds, 5??rthat the incidence of pleural calcification..mmay be^ pleurisy;4 5 cases; tuberculosis, 1 *?:conceded with exposure to mixed dust; but paeoaeoaia, 1 ease; uaknowa/4 cases), and Beb* should be emphasised that our subjects have t a n d t (1930) . found 12 out of 9G6sttbjects (eti -`been exposed to calcium...: 'l ...... bolktTwoundsijS^castt;',^ *). H ea^Ul934)cottiiderstubercalous 7 ^thickenings and r ed* Maon^Cnding-in "IT - >|eaiui definitely wajto:prodaec caleifleaUoa^of th atcjiVfcP.err^p^nt^^Ltiut^ialdf^ __ ny MlUtcnh^i^^bnatcral ih the sonmlkd findings diopalhie eases *(approxlmateiy 20 per eest ' cases)." **.w^^be4ade'.----- A special investigation of workers exposed dust was carried out by Smith (1952). She found 35 cases of pleural calcification out of 8,779 subjects examined. Only four groups showed a definitely higher incidence of calcification than that among the .average population, te* workers exposed to the dust in making bakelite insulators, (1.5 per cent)? calcimine (1.7 per cent), mica pleurai cbonges are found rtogether '.with ;, parenchymatous lesions of the.'.^'v. longs. Tbe occurrence of similar pleural changes ' without any definite changes of the lung proper may also, with reasonable certainty, be accepted as evidence of aabeslosis in subjects known to. have worked with insalatiog material of the sort used by the workers examined here. (1.6 per cent):/*nd tremolite taic <0J per cent). Tremolite talc is a calcium magnesium silicate, SUMMARY which structurally resembles asbestos. It is known to cause pneumoconiosis. Calcimine is composed of whiting, day, talc, silica, mica and asbestos. Four cases of pneumoconiosis were found in tbis group. Mica is a complex silicate of potassium, aluminium, magnesium, calcium and fluorine. B,akelite_was m. ix.ed with. talc. and mi,c,a. Mo c. ase _ 31 workers engaged for 20 years or more in different kinds of insulation works were ex* emined for occupational lung disease. They had been exposed to dust containing asbestos, kiesclguhr, magnesia, glass-wool and rock-wool. 9 were found to have definite signs of pulmonary asbestosis. 19 showed abnormalities of the pleura, !LP"e^ .l "!! S Wv ?"d t5onf 12. o( these being WUterel. In It eases calcifies- exposed to mica or bakelite. No pleural calcifi cation was found among 2C1 asbestos workers. Smith suggests that It is the combined exposure (ion of the pleura was found, being bilateral in 8 of them. to ealclum and magnesium, together with a dust producing pleural irritation, which provokes the calcifications. -. None of the workers examined by us have been working with asbestos alone; all of them have been exposed to kieselguhr, magnesium, rockwool and glass-wool too. The last three substances do not cause pneumoconiosis. Exposure to kiesel guhr is known to involve a risk, as several eases Heftrtneet: 1) Behrendt, r..< Ueltr. s. Klin. d. Tubcrk. 1930, 76: 129--164. 2) F/oprf, C. A A. If. Hepburn: Am. Rev. Tubere. 3) Fred. J.: Ugeskr. Lcfer 1950, U7: 1284--1289. 4) Head. Ann. lnl. Med. 1934, 7: 1295--U07. 5) /or; r.: Ugeekr. L*ger 1950, 13S: 472--174. 6) Jacob, ii. A //. Hvhlig: Fortschr. Geb. Uoqtgen- strahlea 1955, 63: 525--325. of pneumoconiosis seemingly caused by this 7) Krfcfiansen, I..* AeU tub. Scandtosv. 1944, It: substance have been reported. According to I. u t o n, C h a m p c i x. It a v c t & V a 11 a u d (1956) it is primarily a question of the alphaquart* content. Exposure to ths amorphous form of kieselguhr involves considerably Jess risk than does exposure to the flux-calcinated substance, nearly all of the silica of which may be in the form of alpha-quartz. The kieselguhr used in this 310--325. )'btt/on, P~, J. Champtix, if. Haoet L A. Vulluud : Arch. mat. profess. 1955, 17: 125--148. 9) MeretpefAer, K. H. A.: Tubercle 1933--34, 13: 69-- 51, 109--115, 152--159. 10) idurruy. U.: rit. Mervwelhvr I3H--34. 11) .Yorw, L: Acta pathul. rt microbiul. Scandinu'*. 1945. 33: 53--59. . 12) Palrh. /. C. L. k 7,\ A/. A. Perry: in Marshall A country is not known to be flux-calcinated, and Perry (edit.): Phrases of the Chert London 1952. sample-analysis has not revealed the presence of alpha-quarlz. - Itf our eases the workers have hern cxjKKed to asbestos, which is known to produrr pneumoco niosis with pleural affection, and to kieselguhr, magnesia, rock-wool and glass-wool. Our findings 13) Schrumpf, A.: Nord. Med. 1941, 9: 704--700. 14) Smith, A. H.: Am. J. Horntgcim). 195?, 07: 375-* 332. 1S> VJrieh, K.: Rontgenpraxls 1930, 2: 212--222. If.) RVye/iu*. C.; Acta radio!. 1947, 2*: 139--152. I") Wolff, A.: Kurd. Med. 1940, 5: 535--541. IKj Wolff, A.: Nord. hyg. Tidsskrift 1940, */; 1--48. rumJC JJLAL7JI AND INDUS1KJAL MLDIUM. 357 diaMolic pressure above VO mm. Up. was frequent. Ik j"; INDUS! K1AL MLDICIN'L LC'G usually showed disturbance of rhythm, and thcic will* J'Jiurjil CukiJicaJiffi aniitfij; j jiiul\\o'kcr> i j frost. J. Oi.uiio. and I'. F. MoUIk. Jjaniih Mcthcal tMam (Oun. med. Hull.) 3. 202-204. Nov.. 1956. J :br^ l7 rcfv. was one case of simple aurieulo-venmculur block. It is concluded that cardiovascular changes arc signi ficantly frequent in both acute and chronic lead poisoning. In the initial stages these chances are functional tarteriolar spasm) and therefore reversible; they arc represented clinically by arterial hypertension, transitory at fir>t, but . Experience in many countries has established that leading eventually to chanzrs in the renal, cerebral, and j .ofJimen employed in Uc lucking of pipes and boilers coronary circulation, of which coronary spasm in young .. roy contract pneumoconiosis in the course of their persons is especially noteworthy, in the advanced .-mpJoymeni. Lapping materials vary in composition; stages Of lead intoxication the arteriosclerotic changes ( ,-pmmon ingredients are ktcsclguhr, magnesia, and become organic and irreversible. Of the cases here ' - ;iS*>tos. and in more recent years rock wool and glass reported. 38*3** showed a constant hypertension, due . - . ool. About 100 Uppers are employed in the shipyards in some to arteriosclerosis, in others to nephrosclerosis. . ip6 factories in and around Copcnliapen. The authors Cardiac complications in the form of coronary dis .-vjmincd 31 of these workmen who had been engaged turbance or left ventricular insufficiency or both occurred " I20 years or more in (he processes, and 9 were found in 21*2%. One case only of obliterating endarteritis . 9 have definite signs of asbestosis. In addition, 19 (Buerger's disease) was observed. ; Ethel Browning " (howed abnormalities of the pleura, and in II of these 4*re was calcification of the pleura, which was bilateral n S cases. (The main purpose of the authors of this paper was to ~vord the condition of " calcification " of the pleura in .Jxsios workers, they having found only one previous xference to such a case (Jacob and Bohlig. Funiehr, IlSS. The Bone Marrow ie Occupational Lead Poisoning. c (II midoilo osseo ncll'imossicazione professional' da ' piombo) *. - V. Pjlato and L. Fkmun*. Minerva ntediea [Sfinerza meet. (Torino)] 2. 1937-1345. Dec. 8, 1956. 2 figs., . . 38 refs. ` . lintgenstr., 1953, 83, 313).' Since being shown (his At the Institute ofIndustrial Medicine of the University . tales of radiographs in Copenhagen in 1934. the of Turin stained films of the sternal bone marrow of ' iWractcr has seen a series of similar radiographs from 24 patients with lead poisoning were examined. The . ubestos workers in (he mines in South Africa. The subjects were divided into three groups according to - dense, well-defined shadows are very striking, but as yet their clinical symptoms and length of exposure: (1) those / ' tteic is no necropsy evidence which confirms the deposi who were not regarded as having reached the fully v y ' tion of calcium salts in the plaques. Since dense pleural developed phase of poisoning, had had only short .V. ukrosis can simulate calcification such evidence of the exposure, had suffered frea fluctuating abdominal pain. ' , Tiorbid 'anatomy and pathology of the condition is and had no anaemia (7 pitiesis); (2) those who had seeded.] A. Meiklejohn had acute episodic attacks (11 patients, all except 2 being anaemic); and (3) those with a history of long 1157. Cardiovascular Changes in Lead Workers. (Le dierazioni cardiovascolari nci iavoraton del piombo) M. CKtrn. F. Goubaio, and G. ScAssrm. Minerva * uediea [Minerva med. (Torino)] 2, 3910-1918, Doc 8, j 1956. 6 figs., 37 refs. exposure and past episodes of.intoxieaUoa <6 patients, " .. of whom only one was anaemic, though ail showed increased peripheral retieulocytosis). In the great majority the erythroblastic activity of . . the bone marrow was mors marked than the feucoblastic. * the ratio being inverted in Group 2. The curve of ` ' The cardiovascular function of 73 persons employed erythrocytic maturelion was characteristic of a stimuli- .. for periods of 4 months to 54 yean in work involving tive effect, with a higher level of polychromatic than of exposure to lead was investigated by routine clinical and orthochromalic cothrobUsu. Karyokinesis was ia- . . electrocardiographic (ECG) examination at the Institute creased in Groups 1 and 2, and polyploidism (increase . ; of industrial Medicine of the University of Turin and in the number of chromosomes) in Group 2. but not ' | the findings coriclated with the results of laboratory to such an extent as reported by other investigators. ' tests which included a full blood examinaiton and the Erytbroblam with basophilic granulation were much - | estimation of porphyrins in the urine and blood and in more numerous in cases with severe anaemia, and in the . ' 1 ttme of urinary and blood lead content. more acute phases of intoxkxuoo. vr | The workers were divided into three groups: (1) those - Granulocytic haematopoiesis was generally unaltered. ] ihowing signs of lead absorption but no toxic symptoms; On the whole, except in Group 1, the reaction to lead .' | >2) those suffering from or having just recovered from intoxication in man appears to be stimulative, in contrast . - ia acute attack ofcolic; and (3) those with a long history to that in animals, whoe it has been reported as aplastic. . . i ef exposure to lead, end with a past history' of toxic This stimulative effect is regarded as a proliferative re- > tymptoms. In Group 1 there were neither clinical nor action to an abnormal destruction of erythrocytes-by | ECG changes; in Group 2 the blood pressure was raised lead, accompanied by increased rapidity of maturation. . ' j during the attack of colic, with either bradycardia or a With the cessation or decrease of haemolysis, both these j tendency to tachycardia, and there was some evidence phenomena return to the normal, the erythroblastic i of vagal hypertonia; in Group 3 hypertension, with a reaction first. >. . ` Etkel Browning ' ;,r '