Document M0yGyMgLE0EJ8eXL3ed3vnEk

CtfKfCAl * OCCUPATIONAL DISEASES* ar DONALD HUNTER. LECTURE I, lead. Tetrc-etfyi featf. Arsenic. Arseniuretced hydrogen, Jtbosphortittd hydrogen. In iVmt k**Dir* it tuts Ixmix my pur- f**k i,, rvv'Kvc trwu tkv* {ml of vnnv of the rlmbrwM the Cr.4 prwWcju <it dw;i*c in icbi- t*> *. iw^vitfon. t have gftven HjwmJ *?}4w** >`iLv by h<*h powmins? rs ;i{ the nmms or jm vvutbm used. U b.-w Imu m-n-ogtry f}.n to uppromd; the *ni> bn hMorb'siHr m onlcr ir> show wbwt has U-.*m w hi yvt require** t<i be tinnv, t wish *1 to bo **kl that i am not enteorwd solely sdrh wht huppon* hi thw Hurntry; m> tvYrefc* takes fH"Sj>rsthni 1tws'*c hi any pnrt _>f fltv world. It follow* that l hare rmrnled wiam dfri{itions of working tomlitmtw ami diseases which I have imj'bud *bc o{}omtnUv t<> tttdy {vrsotwHy. iNIHSTRUL LEAD POISONISn. Htswav. White fwnt and rod lend art* omonztf the ddt*t pisnumt* known, and it iv possible tv iiwv their hi*n*vy with <ofoc wfonriiyv over n jK'H'td of at lv#i IV>i thmi-xond years. (Klein. UU3>. Tbt* .-sirtWf j>ri>Ttyjh* > white lead was rhc ;<iHe carbonate at* lead known . s ponissiff. Xmnjdnm (4<Kt B.C.i makes whrtl ** probably tlweariless wtetvmv to rim materhd which Hi' desrrtK* as ctTtissa and words tJvAt U was used as a mroetk, Vitruvius (IS B.C.) t*!trri*e to ml bad as sandarsca states that tf was tUscoveced fay accident va e rreimetic Jar of white lead which had been exposed to heat m the burning of a house at Pimua. Early m the Christian era it vras made by roasting eamae. ft was not untU much later that the method of manufacture from lead or litharge was disrovared. The many symptoms of plnmbiem wen noted long before they were ascribed w the actimv of lead. <5radially, however, physicians '\r-x a McrWv *f J*iur tcc^^rir* Riven ftf ibe Oe by U.OWdt &>:(( Stay. !?,, luffuf ap|rtlriii5i' {fn< <n* shi-**' dfs'm'- Imun-s ami tbv was suit'd sarlur. nism, ur HsnLwas cabvd by Jbo alrbemixt^ luriin^e i\ nbsoriw imd `H-v^iirx 51"* in sjxj>;>k. ali tfivt Hippo, rrato <3TfJ H,U.< wj>v junlydd)' xiw rjai ..i* thi atH'ii'Utx tu r'(,u'ruixc l<\ni us fib* rf tbr syutppjsjx, ut icuni he dvs<*riln`s u wim* uttivk of robe in a onui wife winn^f n>>*T;d-. TJit* ri'lnl'nnj^'ip >'f puiudiftalion, <}*', pnUuc, IMjraJysix. 4 urular divtuibiiin-rs u< Tin- jH-tien V fead on the IxkIj* svn nliv'wvd by Xli'aiidcr iti tl:' sworn! mitury fit', Pliny ATM wuites that tin1 niu U sus }jtutvd tlieir sJvijis with nlhp rrnw\ tho? Ivad jjoixon- iwj,* was known i hi* day. d rhat the nothers in lead pmlurts tied wp tlwh* fan'* in loose bags UnA they shortW mbak' the pernkhms ihsst. Dwscorides (1(10 A.T>A knew twit hnrcsiior? of Itad compotmds caused colic, paralysis, and delirium. He *ut that in bis timi' svhltc k>ad was mmlo srrifipisily frvjm b*ad a<tl vmrjtr. This 5* moiixiMy the rwvlicit rvp*>i<t nf the uris. fu'ial nj^mHiycun*,' \>< whin1 kad. 1 >;s of tb' v<*rib's! i'<,i*';'t,P`'-' t<> in in f'sivbu*? is JW1 ii> the Ubwr lbiK i Kdwvt*'l I i-*4'. win'r!' hr suvftwfrt i?i viukrrr| f.*v {wnthw matcrioK ^uppbrf for ibr icvut:n > ii *f thr Pointed Chamber. I'nul the 17th wisu.sry tin* Vene?lari'? appear to bw Ivcst ?H- priticipal maimfActQtvnK of white lead, and after that dote the ptwess was largely b`Voinja'd in Koliatid. Probably tbc caritcs? jvont*} of jKiwmmg atwwgHt white kud workvw i England h that of VmwHi 06?^* -- 'The Accidents to the workmen ore, iRtm.ibntc jtn m the ^bwnsck, with exceeding rmfrHon< in the Guts, mtd Costivcnew that yields (tot lo Catharricks, hardly to often reiwairl Clywors ............. And these we find pffoct.vj pt*mct{wH> by }bc mineral sstoanw in the ca^uny of th`> pttc< of lead, and by lJt dost >? tb` flak*"? ............. Nest, n vertigo, or dittbu'ss in the iicad, with costinyal sat jutm in th< brmvs. ^430 CtiNICAi SUPPLEMENT insusceptible animal* aa mice. IK' waa aim- to show that the active growth of t he bacilli did not depend merely on the necrosis of the tissue, but was due to the actual presence of silica. ASBESTOSIS. The asbestos industry is 2,000 years old Herodotus (450 b.c.) relates how* the Romans mined it in the Italian Alps and Urol Mountome, using it"for "enshrouding their corpses before cremation to permit of easy collect ion of the ashes for burial. They named it ''amianthus.'* meaning undefilod, pure, incur* rufWiWr, Pby f >.if. 501 refers cot only to difficulties ut l he w^mvimv' of jisIkpho*. but also U the u*v of rvspiratoiN to void the inhabit ion of dust. Strabo (30 b.c.) and Plutarch t*,o. 70} refer to the defcx of' the lamps of the ces/al virgias > 'asbesta.**--the unquenchable, in* estinguisHable. or inconsumable. It u stated that Charlemagne possessed a tablecloth made of it, which was ricanwf by jmssage through fire. However, though asbestos omir* in every Country, it is. only within the hiat 50 years that ii has been used for industrial |mr;>osc*. In 1$W> the annual world production totality! only 500 tows, a figure which hud risen to 434.9SS tons m 1329, The term asbestos a collective name applied in 'ommerre to a variety of silicate minerals which differ from each other m chemical <nimport ion ntul physi* eal properties, but ivM'Uihto nr another in their finch rihron- iuihtr>- an*I flexibility. Their VSlltiv h'prinl> i>li H!i' I'a'dill wnli whivh they eao k< sjflit ij,, loiiu and h<ol ib-xihhfibres, thviv ivdstm*e to acid**. and iheir nun* luting properties with jvkihxu t heat and electricity. Moxt of the adnsuos in eommeive ik either fibrous serpenttra- sueb cb>ywtih\ or A fibrmt* mineral of the hornblende group, of which the most important are ergcUJolite and amosite. Chrysotile is essentially u hydrated silicate of magnesium, containing little iron and practically no calcium. The hornMende varieties contain less mgoodurn and usually more aluminium, and trim, rrntddolHc and amoaite being mainly silicates of iron. t'apablc of bvu spun into yarn ?md woven into cloth, or of mixing with ecioeHt. vtih1n*r. nwm. feaic/wc. graphite. n> ff*rm a variety *f us/'t'td pvodttclx. it provide the iiciimremit. electrical. hulidtup. < ricfo*<d and oi^-i .*r./de.s with materials of very great utility. These include a wide range of insulation products, as well as cement sheets for building work. brake and clutch linings* electrode* for welding, acid resisting filtering cloth' packings, jointings, nnd wrappings for steam pipes. Raw' asbestos in crude and fibre form is imjjorted chiefly from South Africa, Canada and Russia, and storod in sacks in open sheds. The. exude asbestos, as resuiiwd, is carried to.a rotary roifl and opened, two or three sack* at a time by hand. This process Is dnetv. The operation which follows is t haI of crushing, to separate the rock from the fibre, which then pawns by vacuum suction into a doxed-m machine for fiberishig. This machine delivers flOccident, soft, fibrous material, fr- from grit. It *k the custom in the lrude to blend the materia! and this involve* emptying out a number of sacks upon the floor and raking the material over to mix it thoroughly tfig. 42. Fjc, 42.~Mthod used to apply exhaust ventilation for Meadiog of crushed asbestos. The draught sen direst!? above the middle of the heap. Sod1 a method a twpeirtdy to*J. (paste. (QfiJthnu*iCs WAUlvK*iM|MMcTnMMtH'tM>t XknlmHi (><wlupsiwtH For the manufacture of yarn and doth eottoit ts often incorporated with the fibre liefuro carding. The carding machine consists of large fast-running cylinders, covered with innumerable minute wire hooks to ensure that the fibres are laid parallel (fig. 431. From the end f th machine the material is received a* 0 sliver or rope. Stripping the carding machines (fig, 441 and cleanmg the cylinders with a wire brush i* a very dusty occupation.  LONDON HOSPITAL 6AZCTTS ocubie vacuum pUm for cleaning asbestos rdiAg machine. Note the revolving brush tied ugh a cover and connected to a vacuum leaner. ^1 tfe'frm"''-'*-*ucr art m 4** 7'1U< Fi.tiow, isii, doubling- and weaving follow the rattling. Dry weaving is usually for wet weaving has tin- disndvaii. sling certain filltugs on tho maehm* mwMcXttJw*. swell h sniilhourd*. a s is ctujifciyvd. Kiltorised asbestos is h rlay. mw*nt. and water anti mu t series of wdimentation tanks to <*f tin* pulp. This losses along ih- as an vnmiskin. Ikxmuiiing drier doughy on tl way. until it is event u* out ui*on a cylinder. From this it *<vcd. and dried in the drying twnt, 1 fer*d H*n.v sue!i us sawing, erhict12. and |n>]Idling, give rise to om*|i iiUtin;.' matI***>' aiv iiunle alimist *y Uwud it-m\\ U*n\Us \V &** air filial with filterUod asl**st< by p, or shovel. levelled hy Iwaling and * Si*wing. isers of ads-sto*. remained for long d. Tiny have eome to light with a discom-criing suddenness, The fii-st (stoKis known in this countrv was hi 1900 and tin* i*.md hi \9>4 chronic pulmonary usbcfiios* us a definite cl ini* ral entity (Merewether and Pvice. 1930'. Kvoiw that titne the view that dust from silicates is 1*0111paralively innocuous was u. longer tenable, l! is it;v sugge*u*d that wji.it rh<* silicate* of asbestos me dissolved hi the lung tissue silicic rrlti is Jiberutcd and acts as a chemical irritant to which connective tissue is particularly svnsi* live. 2cguhit kins Juivc uov bocn eppl:ed to Uw industry by the Home tiffieo. The principle of (orally applied exhattss vein thit ion is enforced to im'vcnl the escape of asbestos dust into the air of anv' room in which jHTsons work. Hand cleaning of the cylinder* of cording machines :s prulubhed while any other |hyson is present, nor may it Jw done hy hand xtr<efciw or other hand tools. Those cleaning cylinder*. filling insulating mettresses, and entering chambers muJoining loose jssIk-UOs should he provided with ;oi eflicicnt apparatus hy mean* of which they cun limitIic air five fitmi dust. These t regulations have xiirmj up other countries so that interest in t|><* mailer is now uor!.I-wide f IM'jMOts n ;i heavy incidence m siMH'xtnxi* have Ik'cn made ntvnlly in s utic (.ernrm Jociorms, vspvetaUy in l Vresdeu i Kruger. 1931 and Bcrlin <<H*vhjsaml lVk<>. 1932<. in five yea** 37 workers in asin's)os have uMewled my out-paItem department: 25 were women and 12 were men. Of these 30 were Judged to be suffering from jmcumoitokouitwhi due to the inhalation of asbestos. Seven of these lave since died; and in four autojwy showed that tbt* pnewonokoniosi* rv?is com* plicated hy pulmonary tul*cmttosw. Many had worked in more than one department, hut the principal occuptilions in urdcr of fioquoncy were ais follows:--spinner, weaver, dt-ittpv'ta* tor. mixer, matttv** maker, card dernier. storvkco$>ei\ shl> maker. pn-*ser. maciiinVu. The ftNerag** length of exposure lyfmv (he u**i of svmnfoms was s>vcu years, mi uw~paMcw*x win* lin'd, one was u weaver wlm had ls*ett cxjHiwd for IS tmuiths and miMhee a stun** k'C|*'r who had Isvn at work lor iff year.;, in many eases there was long iutcrvnl U'tw'etm iX'iiKA'al from oxiosui\' xd the onset of srmp< toms: the longest Mich interval uaseighi ccars. The jmewiting symptom was dyspiwra. This V < i \ Bs pro* litti ocet eul< ras ii mi wa> <lin: dur luu I iiirv 'S* via* * * ClfWJC* i SUMlfMlNt t Fig. 44.--Stripping <n s&buux carftfag crr4uo< before * awdere i?pe ofeibsuS ^cnuhrioB wss locally applied. <Rj* fctu4 oi BHO*6 MUif r-fl AMeiMa, 1*1.l wax nearly always ns&ialed with lum- nrochid ivc <vntfh. as nninv > lf< ea^cx haMnsr little ir no sputum ll^>nnij(UviN. tu-wr **eut*rvd hi tin* nhseiux* of j*ithium;ii> .nU'V* euiosis: it w` found th three vase*. in lo cases pam occurred between the sfunddvj'x. under the scapula, or behind the sU'iimtH; >1 was never more than slight. In two raw* diagnosis of ucnie pleurisy had !*v nude during the gwrioti of i tnpftiymrfif in asfeto<. Hut in no case had u pleural effusion n*urivd. .\ history of wart* was obtained in 13 case*, of lavytiRitis ill three, and nf coninnetivit is in two. The patients wnx* usually uy|( imuvixfusl Clubbing of the lingers was pre**m n dx -.is*-*. Cyanosis wax occasionally nolbvd Imi was only slurbt. Kxom,nation of tin* rhext showed (imitation f i(i respiratory eX'crfxton Mil both side*. Tin j-civtixsioii note \v> never seriously unpaired. Ini diuM dnlhn-e* ns sometime* found l the base*. The ht<-aU> x,un(< \eswuhu. surd it*vrd;..r.f" -^m*- I >tiir< tvve,t|**d scattered. ntedma . -* ;>il.ie< "'ten with a metallic tone, .n.-i Mru.io-d e>}eoudly at tin* bases. Added -xumiIh "<i`' absent on ivpe.tied ",\*attiinuti m Jen c.jsr*. i-'oj- obvious reasons the condition i> not uni lateral. and therefore displacement of the heart and other mediastinal structtin** was not Thirteen vases showed asbestod* bodies in tli< Njiuluui. The.*; are goldemyelhav .trtu*tres m\ elongated beaddike form, often with bulbous vttds *Cufce and IffIf. 29271. Th*- *f *uU> formed bodies ho* been *n*ix**I to U>,i<b U\ weeklaw. The Iteuds vary hi ;n:d make up an irregularly *xrmcnled body. ThfM* hiti'c bit'}! found Jil vary fo Ungih ir..m X* to over iJOO microns. An odiesu^ fibre t.irm*. th* -*i*trnl x>te in eHt W,y iijlm-m*.  LONDON HOSPITAL 6 * 2 H ! f H-v art- w-eti ukh an oil iminer* and xbuw up dearly without staining icttow xtrumirw (fig. 45k They can <i by hematoxylin. The tnixitle *> M.nnd in tht sputum of fm< of the **. anti already four of these jwve fibrosis develops more rapidly. With continued exjwsur* to high concentrations of dust the fibrosis may |>e fully develoj>ed in seven years, and may cause death after about Id years* exposure. It must be remembom) that the existence of a clinically recognisable degree of usbestos fibrosis in any individual is an addt* tioual adverse factor in the prognosis of any acute infection of the lungs such as pneumonia ov broncho-pneumonia. Precise information as to the incidence of pulmonary tuberculosis amongst asbestos workers cannot be obtained, but there is reason to believe that the out* standing susceptibility to this complication 7n~ silicons doftTnot apply to the same extent Tn" as bestows. The fibrosis m asbestos is much more diffuse titan that due to silica. In silicosis it occurs in the farm of numerous more or lee* isolated foci, but in ashestoxis os a fine network throughout the lungs. In radiograms it is so fine as to resemble ground glass (fig 46h Homogeneous opavkic* oi* this nature arv ***cn a) both has*-*. mxl hiicr bf<inir diesuns* bodies from the lung juice in t case *asbestos pfievtooaokooioris (x 6o). A girl fat who hod been employed m tbe spinning ep*nmaa of as <Bxroi factor? for four euv Abnonnal signs were preset* in both agvaadasbestos* bodies and tubercle bacilli ere found inthesputum. At suiopsyasbestos aeusooeokoaioeie and pulmonarytuberculosis ere found in both lungs. -A-E-, ui( aged ST. Worked from * ici tlte spl&eiag department of an exiieatoe * tbr protcetioB from dust was poor. 3828: ttwft: slkoneess of breath, ted wca*iooa1 i aide of ehrat on breathing. On esacmaa* arte oa ftagera. the larges! S hv 2 nmt. ; >f fiagera. Pyepscea, out n<> eynmeal*. xh dtspUced. heart eoands aerm*1. w*ot of hase of right luag, with slight mtBisfeed breath aooath. and exrrt*m' eurith* rounds. A few erepitati*** at Ns spotam. X-ray: bean aornmily to bhraagaasMts opacities weemblhsg ground * of both luage (fig. 40). 1835: Phertaras arra; dry cough. Ob exseai&srinj!; t* tgm. Physical wga* ia eheei nsrltaugod. oyabinir tho UniHli ig tinto whirli ohv lobii i In* ba\ 7mn< lull' 193: stat. mxl adv. pres Sllii' r \ lh mm- \ in* juiii <Hlf } Sl||| (iii) Itigl prU* \ mow larv bohi cvci cart gr<-ii I be long h man dec imal Ibn min fitUi his . rosebki usk. fron l*h rcci'  CUNiCAt SUMlMtKT * obvious as a fine puix-tate stippling. The inter lobar pleura is usually thtekcmni, Ihimately tin* fine punctate mottling can be observed to have spread bcyynd th- limits of the lower aonc to the middle ami won the upper iom\ but the apices usually remain free {K11man, 3933), This fine, diffn.se, pimeiate mutt ling stands cut in definite contrast to the coarse nodttlsr muttlin? seen in silicosis. In fact in advanced asbestosis the degree of shadowing present wouldhavrdittie significance if seen in silicosis {Timmermans. I93l>. PH'OROSIS. In the middle of the nineteenth century many chemist* attempted the isolation of fluor ine from hydrofluoric acid, and more than one lai<l with his life for handling too frequently one of the most dangerous of known chemical substances. The danger arises from the vola tility and extremely eonosive nature of the vajtour of the anhydrous acid. Even when highly diluted with air it causes an intolerable prickling and burning sensation in* the nose, mouth and eyes. If inhaled it attacks the larynx and trachea giving rise to burning paid behind the sternum, cough, expectoration, and even hemoptysis. Cnkss handled with extreme core it may get under the Anger nails cansing great pain, and if drop comes in eontoot with the skin it has a caustic effect penduemg pro longed and painful ulceration. It is said that i*. Knox lost his voice jk'cmanontly tinring Ins early ex|x*rimciits on the electrolysis of the acid, and that T, Knox nearly died of its effects (Ivouyet. 1846), Humphrey Ibry wrote that he had suffered much from the dangerous effects of hydro fluoric acid, and it is said that he abandoned his attempts to isolate fluorine because of the risk involved. P. Louyet, who continued the researches of the Knox brothers, described how hb own health was profoundly altered from ttsing the acid- and how it caused him to suffer from cough and hemoptysis. According to Debrav (1886) the death of Ecuyet was a result of his work but no medical details arc available. In *$89 J. N'tcMes died from the effects of accidentally inhaling the va|ur of concentrated hydrofluoric acid (Core. 1869k fit spite of these dooth-v rife Yrek ;W/* rise fourth halogen went forward, until, in 1SS6 H. Moiisan isolated the clement fluorine daring rhv electrolysis of <i solution of poicnwium fluoride m anhydrous hydrofluoric acid. m un upjmrutus made wholly of platinum. lit lids wav -a wived one of the most difficult prob lems in modern chemistry. Compounds of fluorine have been increasing in imijortonce in industry _of late years. Hydrofluoric acid* is used'fbV flofiditfS et<??rf1e light bulbs, etching Mass. pickling metal and wire, and cleaning sandstone and marble. Owing to its corrosive properties it must be handled with every precaution. The fluorides outor into the cum*waition of artificial fertili sed. mid inwet ieides ami fumiganK lived in agriculture. Fed (1030) has rowinly empha sised the danger of poisoning from hydrofluoric uetd in the maimfitettiv of aluminium hy the electrolysis of cryolite. (ludjonssms has unearthed a new honor of modern industry, namely, fluorosis of the Sxme* and ligaments in cryolite workers. Working with Professor P. Flemming Moiler in the Occupational Hygiene Bureau of the Uihouv lns|wetorate in Copenhagen, he wa> at first concerned with the incidence of jMinimouokoiiioKiH among workers in dusty trades. In the vicinity of Oojwnhasren cryoirte crushed xnd refined for use in the manufacture of alu minium, Cryolite is a double fluoride of sodium and aluminturn, eontaming as much iw 4 (*r cent of fluorine, In the crude state it i< mixed with n tHUwidenihU' amount of quail*. and there is thus an added vbk of piivumouokon lysis. Roller and Cudjonsson {1932} examined 7S employees, all of whom had Iteen working in a cryolite faetorv for more than two years. They found the following four distinct lesions, 1. JP*ewonokoNios. This was present in various* stage's in half the subjects examined, the diagnosis being based on nidiograms of the chest, the conclusion is unavoidable that the disease of the Urnc* was due to the qua112 laden dust in the factory. 2. Fluorosis of bones and l%Qom<nH. As the radiographic investigations of the lung condi tion proceeded, it was found that the shadows of the ribs, clavicles, and cervical vertebra? showed unusual lendtv and abnormalities in ./ -- -. *