Document MM3x9Xo6KwOYm9J2JnYa0dQNj

FILE NAME: Household Contact (HC) DATE: 1946 DOC#: HC061 DOCUMENT DESCRIPTION: Medical Journal Article - Industrial Management and Occupational Cancer ne >ea rs...,.......... mu,c^ nirtcjoumnijvm|cei(t1c^asegs ^with less than two months is convincing evidence tint the r e m i - ruiicmbere 1. rho1wreav"e'r", t`i!,nat"?if!..tr.eatment istc1ontiJndue;d , more than eighteen months and then discontinued thyesultant remission might well he a n a t u r e it has been suggested tint thiunradl could not induce a relatively long remission because it produces ^ Mate" Jt j" h- 7 erP'astlc b` /,,all? inefficient tate. it has been recognized that a hyperolastic f relatively pernianenl re"missio"n oKf "Iniesnt.hyexropteorxieicnocsinisg superior to iodine however t it '"ouracu is its artinn nnrl nowever- a* it is more specific in ns action and induces a more complete and permanent remission in patients with this disorder. In^lieT eS - ment of selected cases of thyrotoxicosis, therefore Tins has been demonstrated bv the structure^ of th e tll_ i a` ,d' ~BrTMan"c'b,1- They; ' e"xramined sections bovf the thyroid gland removed several months after thv uracil treatment must be considered as a form of therapy which has promise, and ultimately it mav prove to be " as thyroidectomy i,, k gr ,, k o 7 pa,!e,,.s ro.dectomy and found the characteristic e v in c e 'of stimulation of the thyroid. Even though this state of yperpias,a persists. Preston and Thompson ' con cluded that a single thyroidectomy mav accomplish INDUSTRIAL m anagement and o cc u pational CANCER control of the toxic state sufficient!v to avoid subsequent W. C. HUEPER, M.D. operations m So per cent of the patients. ^ New York treatment with thiouracil has the same effect as t.ivroidectomy at least temporarily. This is accom- p ished bv reducing the function of the thyroid tissue ttuumoir^s wXhiclh0^origina0teTMi1nCp3necrseor"nsaPdPu]ireins gt0thmealicgonuarsnet iionlrin r ^ erenCf T th<! io<lille concei1tration and oxida , p t lC g a n d ` is entirely possible that the hyperplastic state of the thyroid inducer! bv thiouracil changes to a state of normal involution after a variable time. Evidence m support of this is to be found in he report of Shirer and Cohen.12 who observed a normal morphologic picture in a thvroid gland removed from a patient previously treated unsiccessfuHy 'for seven months with thiouracil. ' Further evidence of the active effect of thiouracil m producing a more permanent change in thvroid func tion is found in the case reported bv Barr* and in 1 otoerved m 0,,r series in vvhich iW o n m d n n d S ed exeard se So f c rerSUlt f the reSular and prolong comart whh f occupational activities which entail. cmoneLv ninn?01^ eX0^en0US- Ph-vsicaI or comical car-i. cancers a r e * nCtln*.)n.ProPcr intensity. Occupational fo im ln ime?raf nC? ieI`clted,b-v specific factors which : and thus ^ pa? ordmary working conditions and thus are not the result of some unforeseen acci- ; dental injury sustained while at work Although a few of the cancers so far recognized as ! of occupational origin have been known or have existd ! without correct recognition prior te the advent 5 lh e modern industrial era, such as the soot cancer of the j chimney sweeps and the cancer of the lung of the cobit ' picture of myx-edema recovered slowlv over a period of continued15 treatment with thiouracil was dis In our opinion this evidence indicates that thiouracil does more than iodine in that it produces a change in the thyrotoxic state which persists after the admin istration of the drug is discontinued. thed-riatnm ^ o n?rnerfS " Schneeber? and Joachimsfhal, : the i S r t of th , 'Vf 0ccuPatl0nal cancers appeared after aa rreessuulltt ooff i>t. DnPurrei-negntthnedluassttnaclendtuevryelothpemreenot cacnudrreads ' not only a constant rise in the absolute number of these i v S f T growths_but a decided increase in the 1 types of organs affected by them, in the number of exo enous occupational agents involved in their pro- ' CONCLUSIONS duction and in the variety of manufacturing establish- : Thiouracil may be used in about one third of the ments m which workers were afflicted with them thyrotoxic patients only as preoperative treatment since t lese patients possess nodular goiters which might deielop a malignant condition. Another 7 per cenfof the total number will require thyroidectomy on account nni r ? y ,'S f .uhe avaiIable data on occupational j S i l/n iS f S ,? ? n ,that the !-vpe of the resulting tumor, ! nn tl!lh f hC Iatent Penod Preceding its manifesta- ' tion the organ affected and the age of the person ! of complications which occur during thiouracil therapy. The most serious of these complications to be kept in mmd is agranulocytosis.* About 15 per cent o f the patients with thyrotoxicosis will leave^he physician's care for personal reasons of the patient. wliicli are i. ang?eennttV, ettdhheed tryPpenedanda i^ntencsbitayraocfteerxpofos^uree caanrdcinthoegean-iec j ot the person when the first exposure takes place The ' soot cancer of the scrotum found in chimney sweeps for . instance, was observed some hundred and twentv-five : years ago even in children, since boys as youn* as ` ? f f i o ^ a d f S p y e,ated t0 diffiC" UieS -- <- e d in rhfmn? Wer^ ,used in En?land at that time for cleaning ' In the remaining 45 per cent of the total group clin ncys. The exposure to the carcinogenic soot dur made up of loose with toxic hyperplastic goiter? thii- mg this operation was severe, and the degree of clean- 1 uracil therapy may be discontinued at the end of a hness among these unfortunate youth was very low. i ttle over an average of ten months with the prospect When, during the middle of the last century, the English ' that 60 to SO per cent of the patients will experience a government repeatedly raised the age limit of the ; relatively persistent drug induced remission. For this a?P[^n^ es of thls trad.e. there followed a gradual rise 1 range at wblch the scrotal cancers appeared i 10. K icnhoff, cited by F il* ." , Preston, F. VV., and Thompson. \V O * B among chimney sweeps. At the same time the institu *9!Tm S (J u n o TM .OWin? S" Thyrddcctom l' Arch I ^ T e " tion of better hygienic conditions and the improvement Th'2ro,SdhciarndJAnn: th' of working tools and of chimney construction reduced Krom the W arner Institute for Therapeutic Research. V olume 1J1 S iu m 9 OCCUPATIONAL CANCER--HUEPER 739 the degree of exposure to soot. As the result of these changes the scrotal cancer of chimney sweeps in England now appears at the same age as that found in members ot the general population affected by cancer of the ftrC! " i S a dtf TMction of the blood-forming tissue and n,, - ln..a .ta1ta! anemia when acting in large doses, but ^ e ]a } leukemic responses when acting in small scrotum of unknown etiology. Only the increased tissue and m SUUab!e intervals n the blood-forming incidence of this particular type of tumor among chim ney sweeps has remained as evidence of the action of an occupational carcinogenic agent. However, not ail occupational cancers have followed such a tavorahle development. Whenever the managers ot new plants and their medical advisers have neglected In, most cases of industrial cancer, experimental research on cancer has succeeded in demonstrating the specific carcinogenic agent involved by using these agents to reproduce similar tumors in animals. Definite proof of carcinogenic properties have thus been obtained or arsenic, tar pitch, soot, crude mineral oil, crude to prom, in the construction and operation of their estab paraffin oil. anthracene oil. shale oil, some fuel and lishments, from the adverse experiences previously had lubricating oils, creosote, benzene, aromatic amines by other manufacturers in the same fields, there has ultraviolet rays, roentgen rays and rays from radio appeared some ten to fifteen years later a renewed, acute active substances. In recent years, however, cancers and sometimes epidemic-like occurrence of occupational ot the lung have been noted among workers in chromate cancers in these industries. Such a course of events ;s, e;N'er`1Phhed by the incidence of cancers of the urinarv o.aaaer in workers of the aniline dve industry These tumors were first observed in 1895 in Gefman dve . wonts and were later found among the chemical w ooers oi other countries, such as Switzerland. Italy, England. _apan ana the Lnited States. The time of appearance ot cancers ot the bladder of this origin followed closely tne time oi large scale development of'chemical industnes m the countries mentioned. Thus the first cancers 01 "If -,la,dn ^ Irl dlemical " 'orkers of this country were noted m 19o_. that is, approximately fifteen years after tne American dye industry had reached large pronor- tl.onS' , " llm the short Penod of six years thereafter almost 100 cases ot this industrial cancer occurring m men oi relative youth were placed on record from one single chemical concern, attesting to the presence oi a relatively massive exposure of the workers to the causative agents--that is, betanaphthvlamine and benzi dine. The full significance of this incidence fi<n,,e becomes apparent from the fact that there were only about 300 cases of this particular occupational cancer reported, according to the statistics of the German "Ov- emment. irom the entire German chemical industry within a period of forty years, that is. from 1895 to 1935 Although no authentic data are available as to the occur rence and the incidence of tumors of the bladder among tne workers of other American chemical concerns the existence ot such cases is known. ' Cancers resulting from contact with radiant energy__ that is. the rays from radioactive substances and roent gen ra\, illustrate strikingly the influence which the tvpe and intensity of contact exert on the formation of the ensuing tumor. It appears that the inhalation of radioactive gases or radioactive dust causes cancer of the lung, such as that sustained by miners in Schneeberg and Joacmmsthal. whereas the local action of radioactive and roentgen energy on the skin causes the development of cancers of the skin, such as those seen in radiolo gists. roentgenologists, their assistants, and in x-rav tube manufacturers, physicists and engineers. The ingestion of radioactive matter, on the other hand, causes the development of cancers of the bones, such as those observed several years ago in girls who applied luminous paint to dials. However, in more recent years cancers of the blood, known as leukemias, have been noted in increasing number among physicians and radium chem ists ex])osed frequently to 'relatively small doses of roentgen rays or rays from radioactive matter. These deleterious effects on the blood-forming tissue have their cancerous equivalents in the leukemias observed among persons exposed to benzene. This organic solvent, like *>.* * \ w t m . , / . i . . . . .1 * . P f 1M 'e 1UCke rt hnenes and asbestos-manufacturing establishments. These tumors are either suspected or recognized as being of occupational origin. An inter esting teature of these cancers is represented bv the fact that the cancers of the lung in chromate workers were observed only m several German .plants, while the can cers ot the lung m nickel refinery workers were found exclusively m English plants where the nickel carbonyl process was used. Although the same process 'is employed in some nickel refineries located in Canada and the Lnited States, cancers of the lung have not been noted among the workers employed here if full credence can be given to the meager information available on this matter Cancer of the lung in asbestos workers, on r i0t !fr j an,d' rllaS heen rePrted from Germany, England and the United States. The actual causative agent in the production of cancers of the lung in chro mate. nickel and asbestos workers is still unknown. ` ih e rapid increase in the number of recognized and suspected agents causing industrial cancers which have occurred during the last forty years makes it more likely that new and heretofore unsuspected carcinogenic agents ot an industrial nature will be discovered during the coming years. Such a development is foreshadowed by observations made during recent years by American m\estimators. It was lound that cancers of the liver developed m mice exposed to carbon tetrachloride a commonly used organic solvent. The inhalation'of ethyl carbonate (urethane), which is employed for anes thetic purposes, resulted in the apj>earanc'e of cancers o! tiie lung m mice. Tumors of the bladder were termed in rats ted diethylene glycol, which is one of the newer widely used organic solvents. Tumors ot the peripheral nervous, tissue were seen in the ears ot rats to which crude ergot, a drug extensively used in obstetric practice, bad been fed over long periods Occupational carcinogenic agents produce cancers in numerous organs. Cancers of the skin are elicited bv contact with arsemcals. tar. pitch, soot or carbon black crude mineral oil, lubricating oil, shale oil. crude paraffin oil. anthracene oil. solar and ultraviolet ravs, roentgen rays and rays from radioactive substances. The number ot industrial cancers of this organ runs into several thousands. Cancers of the nasal passages have been noted alter occupational exposure to chromates, nickel carbonyl and radioactive substances. Cancers of the bronchi and lung have been traced to an industrial expo sure to arsenicals. chromates, nickel carbonyl, soot tar asbestos and radioactive substances: Cancers of the lip have appeared lollowing contact with tar and alter pro longed exposure In solar rays, while cancers of the mouth and of the tongue seem to he etiologieallv related to an industrial contact with tar and arsenical's. Cancers of ,-/L < 1 1 11 u.x A L CA NCE R -- H U E P E R J A. M A. Jtint 29. 9<& lowed occupational exposure to aromatic amines m ic I, as naphthylamme. benzidine and aniline and occasion iimre consideration than it has been given in the na-t ally to tar and arsemcals. Cancers of the blood, called ,, 'C, exl)tncllce gained from the study of occupational leukemias, have resulted from contact with benzene, cancer, ant especially of its causative mechanism and roentgen rays and rays from radioactive substances.' !,s Pr^ention and control, should prove of great value ine latter are also responsible for the occurrence of in the future m fighting cancer in general at its source; cancer of the bones. that is, it should aid in the elimination of the causes The exposure time necessary for eliciting cancer ot cancer before they are capable of initiating the malig ous reactions in exposed workers varies greativ with nant growths. In waging this campaign it should be the type and potency of the carcinogenic agent, with the realized that a well planned, systematic and. probable, intensity of exposure and with the susceptibility of the prolonged attack must be launched if worth while results individual. The range is from six months to three to are to be expected. However, I am convinced that with four decades, while the average exposure time is from the necessary perseverance and determination this battle \e to fifteen years. In most instances occupational against occupational cancer in particular and against cancers appear in a younger age group than that found cancer in general can be won. if every one concerned aids m the effort. ' tor the same cancer of unknown etiology in the general population. Age and sex factors do not, as a rule, V inc!l,stry c^n be persuaded to finance the foundation play any role in the production of industrial cancers' atondthme asintutednyanocfethoef acnauosragtiaonnizaatnidoncoexnctrloulsivoefly'inddeuvsotrtieadl tTiohnesinncoitdeonncley rfaotre tohfethdeisffeertuenmtocrasrcshinoowgsendiecciadgeedntvsarbiuat cancers, not only will industry be the main beneficiarv also for the different operations and is directly propor of this move, but also it will greatly advance the fight tional to the potency of the carcinogenic agent and the against cancer in general, which is of direct concern intensity and length of exposure. Cancer of the bladder to every one, unless it is forgotten that every tenth adult dies from this disease. ' thus affects from 30 to 90 per cent of the severely exposed dye workers, while cancer of the lung kills KECUM M E N D A TIO N S FOR T IIE CONTROL OF from 75 to 80 per cent of the cobalt miners of the OCCUPATIONAL CANCER bchneeberg mines. Carcinogenic agents eliciting occu pational cancers of the skin, on the other hand/have a lower morbidity and mortality rate because the precan cerous changes of the skin preceding the appearance of the tumors gives ample warning, as a rule, of the 1. Plant management officials, industrial workers and members of the medical profession must be made increasingly aware of the fact that numerous agents ot our new industrial environment possess carcinogenic properties. threatening malignant condition, while the ready accessi bility of the skin to therapeutic measures enhances the prognosis of cure. It is of a certain importance from an industrial point of view that the skin of colored workers is less susceptible to the cancerigenic action of solar rays and of tar. pitch and similar substances than that of white, and especially of fair-skinned, workers. The total number of occupational cancers placed on record is small when compared with the large number of cancers of unknown etiology. It is obvious, however, that the latter group contains an undetermined number of cancers of occupational origin, as many of them either are not properly recognized or are not'made a matter of public information. Although today a great deal of evidence on the causes of occupational cancer and the conditions under which it develops is available, relatively little effort has been made to spread this knowledge among parties who are vitally concerned with this information, namelv the man agers and physicians of industrial concerns", although they carry the main load of controlling this preventable type of cancer. This situation is the more deplorable because the present rapid development of industry tends 2 Construction and chemical engineers should design buildings, machinery and apparatus with this hazard in mind that is, they should try to favor the closed system ot production, the installation of adequate exhaust ven tilation, the use of building material which does net absorb-taremogeme substances, the avoidance of nooks, crevices and ledges where carcinogenic dust can be deposited, and the employment of wall and floor cover ing that can be thoroughly and'repeatedly cleaned with water and steam used in connection with cleansers. _3. Adequate provision must he made for the removal <>t carcinogenic material from waste gases, fume, waters, dust and the like before these waste products are released into the air. public waters or other chan nels affording the contact of the general population with carcinogenic industrial wastes. 4. Carcinogenic material must be packed in leak proof containers. 5. Similar appropriate protective technical measure* should guard the persons handling roentgen ravs and radioactive substances from being exposed to deleterious quantities of radiant energy. to extend the hazards of the known industrial carcino 6. These measures must be sufficiently extensive tu genic agents while at the same time creating new ones protect also persons working or living in the immediate which may cause the appearance of cancers ten to twenty environment where physical or chemical carcinogenic years hence, unless concerted efforts are made in time agents are handled. ` to discover and control such dangers bv appropriate countermeasures. It is essential that industry should devote considerably more effort than heretofore to deter mining the cancerous or noncancerous nature of such of its numerous products as may be suspected on general grounds of cancerigenic properties. As occupational cancers are chance experiments on cancer in man. con ducted by modem industry on a large scale, which render direct, reliable and conclusive information as 7. Whenever the use of carcinogenic material in industry' cannot be eliminated by the use of substitutes, workers should be protected from contact with carcino genic agents by suitable protective clothing, gloves, masks and the like and by the enforced observance of adequate hygienic measures, such as the use of washing facilities, showers and special rooms for storing street clothes and for taking meals and frequent changes of working clothes. - to the cause and mechanism of human cancer, the inves 8. Frequent and experienced medical supervision of tigative study of these conditions deserves a great deal the workers exposed to carcinogenic material is impera- V olume J3i N umiei 9 ACUTE SYPHILITIC NEPHROSIS- -PARR ET AL. tive for effective control of the hazard. This supervision T ^ ment tfte " d WOrkers who have left the emplov- ment after havmg been exposed to carcinogenic agents nont l f atny ]onS or who have been shifted to noncarcmogemc operations. Clinical Notes, Suggestions New Instruments 7 41 and 9. A nationwide survey by skilled investigators should be made to determine the actual.scope of the problem 0 industrial cancer. Representatives of management ndustnal physicians, members of the Public Health bervice and of departments of industrial hygiene and possibly also representatives of the workers should par ticipate in such a survey. 1 1 10i ,Plrecancerous and cancerous industrial diseases should be made notifiable to the departments of indus trial hygiene of the various states. 11. Adequate compensation laws for occupational diseases should be passed for the protection of both management and workers against excessive awards or inadequate compensation, respectively, for claims that result from the production of occupational cancers. 12. Government inspectors should examine all indus trial plants at regular intervals to determine whether or not they meet the essential safety requirements nec essary for minimum protection of the workers against 'he hazards of industrial cancer. " : An 'nst' tute for the study of industrial cancer should be iounded and should be attached to or coordi nated with one of the existing large cancer research centers, m order to provide for proper integration of the results obtained by such investigations with those produced by cancer research in general. Such an organization would serve industry for consultative and investigative purposes on matters of occupational cancer. 14. A committee composed of industrial physicians cancer research workers, industrial phvsicists, chemists and engineers, compensation lawyers, members of the Public Health Service and of state departments of industrial hygiene, representatives of industrial manage ment and union officials should be created, whose mem bers should act as a body of consultants and special e x e rts to the Institute for the Study of Occupational Cancer. ' ACUTE SYPHILITIC NEPHROSIS SUCCESSFULLY TREATED WITH PENICILLIN y M.D.; ROSCOE mD`. ' ; LEhA'S, nM' .Dc.o; leM' AXm-dM-;ILLjE-R, *M.dOr.,,v e r ond L G. STRAUSS, M.D. Cleveland The nephrotic syndrome is defined as a clinical symptom S t S S i X T * by froieinria' p f f l lf h - Sen0US renal `"sufficiency or hypertension It may be seen m a variety of conditions and has been o bserari in connection with acute syphilis > observed REPORT OF CASE H isto ry .-]. Y,, a white man aged 31, was first admitted of generalized ^d Sp,tals ,18; ^ 4 5 with a chief complaint one week's d u ratL TM een'U uIceratlons of approximately In the early part of June 1945 several superficial lesions developed in the coronal sulcus of the penis. These gradually mone oo8t! uussT(Ll. rGbSSr .)r. nwtnhUo lCmeraadteOnt'he Jdui'aygn2oshise owfaschsaenecnrobidv tahW < -and j tar,ed tHe Patient on sulfathiazole two wwhheinn tthhfe Urersurlt oSff thn3e1 ys'erolToghi'cS tWesatS focronstyinpuheildis "dmraiwl nJualty th6e, st interview' was reported as strongly positive. On Julv 7 he was given 0.04 Gm. of oxophenarsine hydrochloride (Mapharsen) intravenously, with no immediate reaction. However eight to twelve hours later he had a shaking chill and tempera l e elevation to 104 F. Within twelve hours the patient was gain symptom tree. July 10 another injection of 0 0^ Gm il " phenarS,nell-vdrochlride w-as given intravenously, Without etlemn of on JuI/ 15 and 'me had moderate edema of the face, legs, perns and scrotum and complained of general malaise, anorexia and low back pain. Xo urine exami nation was done at this time. On July 17, when he was seen again, the cilena of the face, legs, penis and scrotum was more severe The urinalysis revealed 4 plus proteinuria and an occasional red blood cell. On July 18 the edema was less etere and the urine contained only an occasional red blood cel! He was then relerred to University Hospitals for study. ' Art and Anatomy.--Among the great artists who engaged in dissection were Michael Angelo, Raphael and Albrecht Durer. Greatest of all was Leonardo Da Vinci (1-152-1519) This gifted and versatile artist, a man centuries ahead" of his time in original ^ideas, who visualized aviation and modern methods of warfare and who discussed many problems of engineering which were later put into practice, also made discoveries in anatomy, such as the maxillary sinus and the moderator band of the heart. He was the first to demonstrate tlie ventricles of the brain by wax injections and to depict correctly the fetus and its membranes within the uterus. Originally he set out to study the bones and muscles in their relation to art, but his interest grew, and he pursued his investigation of the deeper parts, the viscera, the brain the blood vessels and especially the heart. He intended to publish a great work on anatomy m collaboration with Marco Antonio della Torre of Pavia, but this project was abandoned owing to the death of his co-worker. It is only within recent years that the value of Leonardo's contribution to anatomy has been fully appreciated. He made hundreds of sketches and manuscript notes many of which are preserved in the Royal Library at \\ indsor and have only recently appeared in print. This apostle of naturalism m art must also be regarded as a leading pioneer Physical E.niiinnalwii. The temperature was 37 C. (98 6 F ) pulse rate 82, respiratory rate 18, blood pressure 124/72 weight Kg. He was well developed and well nourished He did not appear to in distress. There were no abnormalities of cor wbh S`VKCm' T`;C mUC0US membra"ts 'vere of normal es^cin There ' vas slight facial edema, especially noticeable about the eyes. There was no apparent edema aot fthe s^acrum,exeYxteemrnha'l' ^genTitahleiare, t'hig*hsmaondderaletegs P ^Tinhge VThheerreew'uaVs rarmwelnlmd/Kefin,0erd/ ,cfidrmt,e?freuerley- wmiotvhabTMle anbonnotremndaefrlelsyimonpsh. node in the right inguinal region measuring 2 by 2 cm There were two smaller lymph nodes similar in character in the left inguinal region. There was no other lymphadenopathy. There was moderate i>eriorbital edema. The conjunctivas were pale The corneas and scleras were normal. The mioils were equal and regular, measured 4 mm, and reacted normally KcM-rvf t m vfiM tv .S d n ^ l ,,f M nlicm e. 1 and " eslcrn lh e work <IcsitIk*iI m tins paper was done u n d e r a rn[1, r ,r , r nu-mleU bv the colmimi-,, on medical research lU w een he "i ,T lolms llo ,,[,, ',s il/.M,'. H a :1'b6C I lu m ai X>bhiliitc X cphr.,,,alines. Am. I. s,yph " t o *& & Xefirol 1 1 ' i o i ; Pp ihiliaad?e!lp0hr iay.- Ji.G o13h. r,LICi.'jipmDcoUttglaCso; mpAany,H1is9-t4o6r.y of Medicine, j p 4 i t ' \