Document N20oyVzYVYBmwGovBzo2Q2dYR

|'Y!3^:31,^-li|^^ifc^^;>-^^ir:: November; 1956 t&ffj S^C-viV;- - gg'fi-'' :P -t - r--^mJh ",1s-- ',ii. >v~>--,ui ^ <i,j.. it^.,Jm u\,~--~y /t- -.- .................. -.-.vyr -v.*r '`"Public Hceftb. AdmiaMgatSatt.' -. ....>,. 1037,, . Dnaaci due to Fangi jfcikaagnfty'end Vdfiu^^jll`iay^|^jy>oriff Pbeua ... ... -- .,._ :$:;''02dbood' tod Adofeacsocr :^u- 1031 y^p.^'71" --.- *** -;---. r "'!' *-i Cjb of Old - .. . ` ' . T>TTr^ Wy-rrir^ ' \ . w4 ih Qiroat. ' ' "-v1 ^ . . . r ... ._. . caily HI _. , ... .__ toffl:- Cteaparioaxl Hyjjcne and Toxicaicrgy T-socw;-M*dfca#''-' .:. 10" Apjmi Hy ... * ^jj ...- ' :* i&f?Bureau of^Hygiene' 'anet^Tropicat Diseases, .. ?v':* -' Vppr/ cri, Gower Street*, London. W.C.2 j;. ftiephem-sJduaem* StXT .-, . -- paiL'^lr4' -: " ,T| * . '/ `'L-' .'lv J r c mT*i ifgli iil V In, >0- u OCCUPATIONAL HTGIZNS . .C*I> TOXICOLOGY 1115 ^wikx. K. En&u kieselsiorehaltiger Stoffe jjrti kieseisiorefreie rur Bekampfung der Sili[Substitution of Siiic^Containing Material* ^ 5iHc*Free Materials in the Combat against jjlieosis] Zent. f. drbeitsmed a. drbeittsehvtu gS6, July, t. 6, No. 7, 167-71. [16 refs.] Germany three-fourths of the compensation pay* {or occupational diseases is on aeeoont of pnea^osis; in the German coal mines the total loaa this disease is 4 times that for accidents. ,^*1 measures for protection against dost hare areiy limited suecew and the substitution ot (pah free from silica gives the best prospect of the dancer. Examples are given. During Wnod 1546-49 among 47D sandblasters in the inn Kei industry in Southern Germany 1*4 per cent, iped serere pneumoconiosis annsally; silica-free itia were substituted*. e.g. steei-uwt and trtixbrasire wheels. Moulding.sand can be reraored (uas9 under exhaust drangbt and the sand itcieaned before refuse, pieces is made to machines for cleaning east* | vbich an economical and technically efficient as u brgienic. Where steel.shot is unsuitable for jot aad polishing, as with light metals, proprieatterisis are in use in Germany. Hydrobiast, a 100 stmosphem pleasure, can be useakto clean a csstiags snd cores with recovery of 80-90 per af the sand. Bentonite is referred to as a sab* for quarts in moulding sand; it is said to gire Proved technical results and is easily' rumored the sietaL Parting powders without silica are turned. Reference is made to the use of artificial adiag wheels in place of grindstones in Southern e*By. Warning is girea against the use of quarm jtfce binding material of artificial grinding wheels was officially stated La 13o*-U>-reach as moch 20 per cent, of uncombined quaro in some ^oea; it is essential to keep the siliea content to ^lowest--p,ribJe n'jn.ire'rmt the same principle Spool is the grinding of jewels and ornamental jp*. ' flU/erenee is made to .an Order of XS38 prohibiting ^ at of quartz sands as abrasive in grinding of this has led to the use of emery and silicon jpide ehich can be graded to give good results. fp higher cost of artificial abrasives is offset by jgter working speed and the same applies to the ^aic industry. Sandblasting in the glass industry jprohibited for all females and for males under 18; ^irrs over 18 should not be employed on this work 3i mere than 2 years; silicon carbide can be used for i pmcrts. In the ceramic industry the risk of 2kvus can be reduced by the use of powders free or low in. quarm for dusting unfired ware. > 'he refractories industry magnesite can reuisce * In ^h* shoe industry a risk of silicosis arises poiuning with machines using sond-oaoer with Its proportions of free silica in tbs abrasive; one pcxsr 'tutained 100 pep cent, disablement from after 12. years work on this process ; another ico.tuoenailoeia after 14 years of work. ir caroorandum ahould be used as the abrasive. Similar practice should be observed in the wood* working industry. For stone*dusting in coal mines slat* or chalk should be u-wsd. E. L. Middleton Rosinson, 2L the Ventilation of the Battery Con* taintn of Storage Battery Locomotives. Safety m Mines Research Establishment. [Portohello St, Sheffield.] Research Rept. No. 122. 1956, Feb., 22 mimeographed pp., 6 figs. <St 1 pL {2m. 3d.] . Wilson, H. E. 1 Haxbob, D. C. Development of Mechanical Breather for Evaluation of Respira* lory Equipment, dreh. Indvst. Health. Chicago. 1956, June, v. 13, No. 6, Sect. 1, 561-6, 6 figs. Paticnt, J. Wlsion et visibilite dans les mines. [Vision and Visibility in Mines'] JrcA, Hedges Med. Socials, Hyg.t Med. du Travail et Med. UgaU. 1956, Max., r. 14, No. 3, 97-114, 7 figs. The author discusses (1) the causes of poor visi bility in mine^--low intensity of illumination, poor refiectivity of surfaces and feeble contraswand (2) the efiects of adaptation to low levels of illumination and of glare. He describes some tests in which the effects of illumination and glare on visibility . were studied. As in other situations, the visibility in a mine with a given intensity of illumination depends on the nature of the visual task and on the quality of the lighting. Intensities of the order of only 0*5-1 lax do not make relatively detailed vision impossible if the contrast is sufficient, and especially if the back* ground is light. With an intensity of only 0*1 lux one can see antamished metallic objects that are not too small. With a black background, however, as, for example, at a coal-face, vision of detail is lost with illumination of about 0*5 lux. Types of mine lighting are discussed briefly, and the author favours the cap-lamp, which illuminates the working surface. There is. however, the difficulty that a miner working within 3 or 4 yards of another rear be exposed to glare from the other's cap-lamp. This effect ran be reduced considerably by using lamps with matt reflectors which, at a distance, give a much more feeble light than is projected by polished reflectors. Thomas Ahlboro. G. A* H.iNssnjf, C. .T. A*l>estos. En for Sverige ny yrkessjiikdom. f Asbestesis. An Industrial Disease which is New for Sweden] Srmska TSikartidninyen. 1956. v. 53. No. 21. 1376-S3. 2 fig*. In 1953 a ^year-old workman, whose employment had entailed contact with asbestos. compiainrd of growing dyspnoea on exertion during the past year. He was found to suffer from ashestosis in the third stage, with numerous asbestos bodies in his 'purnm. Under treatment in hospital he >howed some diminu tion of symptoms, and his vital capacity rose from 1.700 to 2.900 ml. Two months after his discharge from hospital he returned to it with pneumonia which proved refractory to treatment. This rase l*d to a i '11X6 * BULLETIN OF HYGIENE November, 1- scrutiny of the 60 men employed on asbestos work. the history of the disease from the time of it* r* Eight of them, between the acts of 43 and 63 years and with a history of exposure to asbestos dost for 5-17 years, were found to be suffering from first-etage or seconW-stnue asbestosia. None of them, however, nition in Lancashire in 1831; it was then called eos spinners phthisis. It is still a serious precis the cotton industry in Lancashire. Riga sorm rates from respiratory diseases led to enquiries v presented symptoms of a*be*to*is. The notification their cause. In 1909 Collis examined a atuoiar of the first case to the public health authorities was strippers and grinders of the carding engine followed up by an application for the extension to whom high mortality rate were reported, end ashestosis of the prophylactic measures already in condition became more identified with the eard-c force against silicosis. In Sweden ali workers whose and was the subject of departmental inquiries employment entails contact with asbestos are to be experimental investigations in the 1930s, The eoc subjected to periodic radiological examinations. Pro. carding proces is described. tective masks are to be used during work entailing the slightest risk of inhalation of asbestos dust. Other measures, providing for better ventilation of workshops, are also to lie adopted in view of the growim.' importance of the asbestos industry. During the 5-venr period before the last war Sweden imported onlv i.7-6 tons of asbestos, whereas during a similar period after the war the corresponding 6sure was 46*5 tons. Claude Lillingston Since the period 1910-12 the Ilegistrar-Geneni given death rates for strippers and grinders separ*' from other cotton workers, and it has been jvc-aitL assess the effectiveness of dust control. A departmn committee of the Home Office concluded, in 1932. : conditions in the card-rooms had much improved, they recommended a compenration scheme for won disabled by byseinoeis, which was instituted is U la the diagnosis of byssinosis from chronic broscs and emphvsema a significant fact is that bystacc Bauth. G.. Fxtx. H7. & ScnttomrAjfntt, H. Die Aluminiumlunge. Veriaufsbeobaehtungen and Neuerkrankungen in der Naehkriegszeit. [Pnewmoconiosis due to Aluminium Oust] Deut. med. H"nfh. 1956, July 13. r. 81. No. 23, 1115-19, 6 figs, on pi. [25 refs.] ebara-terued by a history of tightness of the cbe breathlessness on Mondays or on the first day at * after an absence. These symptoms may get wort* extend to other working days and eventually give to severe and permanent disablement. This hiat&r rarely found in ehronie bronchitis and. in the aa* of specific clinical and radiographic changes, the d During the second world war*neumoconiosis due to nosis by history is rexsonabiy reliable for'field stoa aluminium dust was not uncommon and because of its bad prognosis was regarded as a serious industrial hazard. It was hoped that the better conditions of post-war work would eradicate the risk, but several In a recent study of workers, aged 40-59 in 6 a spinning coarser grades of cotton [this Bulletin, li v. 31. 167], it was found that the nearer won group* are to the carding engines the higher is new <?n>es have been found in the last few years. prevalence of the disease; in a later invesrigstios Aluminium dust is manufactured in 2 forms, as mills spinning finer cottons the prevalence was foi stearin-coated polished particles used in paints and to be much lees. for other purposes and as uncoated particles known Byssinosis among spinners cannot yet be distnb as pyro-dust which i r"'red for making torpedo as an insignificant problem; in 1921-413 and in 195? fuses and signal flares. Workers in the industry are cotton spinners had higher death rates than all *' exposed to clouds of dust since adequate protection from respiratory and cardi>vascuiar-renal due* bv artificial ventilation methods has not been possible. Since the start of the-compensation scheme the ace Clinically, it was found that the pneumoconiosis in of pensions awarded has increased from 3 in IS*2 pre-war years when stcarin-coated dust was mainly 99 in 1955: but it most be noted that during 1 produced was -.lower in its onset and course than in period the scheme has been extended to include *ur= the war years when prro-dust was the chief who now account for about one-third of the aw** aluminium dust to t* mnmifartuml. Pyro^iust is the corron-wavre industry has also been included. < used also in peace time in fireworks. Some records the limits regarding tbe amount of disabiemeot k are included of IS workers who had worked for various been relaxed. The compensation scheme now rf periods of time before, during snd after the war. some 53.000 workers, of whom about 36,000 an There were 10 deaths in this group. Case histories and ciria. of 3 of these workers are given in detail. Patho In the second lecture reference is made to tbe ite logical changes were seen chiefly in the upper lobes rare on bvoinosis in other cotton industries in I=r of the lungs and these are described. In only 1 ease and the U.S.A. Byssinosis has been described it* was there evidence of tuberculous infection. M. Z, Vein field worker? in hemp and flax, but uot is juta. The W logical changes found in the lungs in hyssinau akin to those of nen-sneeine chronic broncaita 1 ScHtTLisc, R. S. F. Byssinosis in Cotton and other Textile Workers, lancet. 1956. Aug. 11 A 12, 261-5: 319-25. 11 figs. [Numerous refs.] emphysema, with deposits of dust; M bodies " able with asbestos bodies, but rounded, were deseff by Gooch in the lungs of 3 Lancashire cotton werv In the clinical history and pathogenesis the trs This article comprises the 2 Milroy lectures delivered symptoms of the onset of dyspnoea is {he basic fen before the Koval College of Physicians of London in The author found a highlv significant reduction is February 1956. In the first lecture the author traced maximum voluntary ventilation in byssinosis p*o* * Svenska Lakcrticningen [Swedish Medical News], Stockholm Vol 53 Mo 21, 1956, pp 1376-1383 . '- ASBESTOSIS, AN OCCUPATIONAL OISEASE NEW TO SWEDEN* by Gunnar Ahlborg and Carl-Johan Hansson, of the Sahlgren Hospital, Goteborg Our report is occasioned by nine cases of asbestosis, including one death, to our knowledge the first in Sweden from this occupational pneumoconiosis. The first patient applied in 1953 and occasioned an examination of the 60-odd work ers employed in asbestos work in the Goteborg industry; the other eight cases were- found in that group examination. -- Asbestosis has been a subject of research abroad for a long time. For further study of this, the reader is referred to Hunter, 1955, and his bibliogra phy, and to Noro, 1946, and Wegelius, 1947, who described in detail the occur rence of the disease in Finland. Here we shall only relate our experience and give a brief survey of the conditions under which the disease occurs in Sweden and of its clinical symptoms and prof^laxis. - Our own material, as said above, consists of 9 male workers aged 43 to 63, with times of exposure to asbestos dust of from 5 to 17 years. During this time, however, they have also been employed at other work or with different in sulation material, so that the degree of exposure is very hard to judge. Seven of the cases got their asbestosis after insulation work and two after work at ~ asbestos spraying. One of the latter, the one with lethal outcome, could be classed upon first examination as asbestosis Stage III (see below), the other as Stage II. Of the others, four may be regarded as being in Stage I-II and the rest in Stage I or incipient asbestosis. ' Subjective complaints that can be attributed to the disease were reported only by the patient with Stage III. For that reason his case history will be recounted here in detail. At the time of examination he was 63 years old and had been employed at asbestos work for 17 years, mostly at asbestos spraying, and used respiratory protection only sporadically. A year ago he was bothered by increasing shortness *A lecture delivered to the GSteborg Medical Society on 29 February 1956. 1 of breath under exertion, by a dry night cough, and by evening fatigue, and at the examination he displayed conversational dyspnea, cyanosis of the lips and prominent veins, watchglass nails, and drumstick fingers. The lung examination showed damping and rale increasing toward the bottom of the -lungs. The X-ray picture of the lungs corresponded to what is found in asbestosis Stage III, and in the sputum there were abundant asbestos bodies (Figure 1, p 6). He had tachy cardia but otherwise no sign of heart disease in the physical examination of the heart; roentgenologically the heart showed general enlargement, and the electrocardiogram at the first examination showed nothin! remarkable. Later a branch block developed. He was treated with antibiotics and theophyllamine, whereupon the sub jective symptoms grew less and the vital capacity rose from 1,700 to 2,900 ml. He could be discharged and cared foT at home, but he returned after a few months with a pneumonia that' resisted all treatment. The autopsy (performed by Sourander) showed among other things a diffusely thickened, leathery visceral pleura on both sides. The upper parts of .the lungs showed edema and signs of pneumonia. In the lower % of the lungs the consist ency was uneven, granular, and noticeably firm, in section markedly tough. The fibrous transformation of the parenchyma of the lungs increased in the caudal direction and exhibited a coarsely po'rous, trabeculated appearance with rounded "cavities up to the site of hazel nuts between the reticular, slate-gray, fibrous stretches. Under the microscope the parenchyma of the lung was found to be strewn with broad strands of connective tissue and foci of a locally nodular ap pearance. The alveoli were found to be atelectatic. In the connective tissue there was an abundance of asbestos bodies and around them a rather heavy cell infiltration, consisting of alveolar cells, macrophages, and other multinuclear giant cells. In the bronchial glands, on the other hand, no asbestos bodies could be found. PAD: Pneumoconiosis + pneumoniae lobaris et oedema lobi sup. pulm. amb. bronchitis mucopurulenta + dilatatio sin. et hypertrophia dextr. cordis + sclerosis a. coron. cordis stasis chron. hepatis. The case that we classified as Stage II was'discovered in 19S3 and the patient desisted then from work with asbestos. In spite of that he has shown progression radiologically, but still without subjective complaints. For the other seven we still have too short a period of observation. 2 Asbestos Asbestos is a mineral consisting chiefly of magnesium or iron silicate and varying somewhat in composition depending on the locality--Canada, South Africa, Finland, and several other countries. It consists of flexible fibers. so that it can be carded, spun, and woven into tapes or cloths. Considerable strength, high melting point, and poor heat-conducting capacity are the basis for its use as a friction material (bralce bands) and insulation material. In technology we axe now dealing with extremes, in temperatures as else where, and it is therefore not surprising that the use of asbestos increases every year. During a 5-year period before the war Sweden imported 17.6 tons; in a corresponding time after the war, since the shortage after the blockade was compensated for, the figure was 46.5 tons. In Sweden asbestos is chiefly used as insulating material around pipes and the like on vessels, as fire-resistant material in ship's spaces or assembly rooms, in the manufacture of brake bands, and as a reinforcing material in cement and plastic. In asbestos-spraying for insulation against fire, the asbestos is first carded in a machine and then blown with air through a special spTay pistol to gether with water and a binding medium against the surface of the wall, so that the mass forms a layer up to a decimeter in thickness. The dust formation is 'considerable. The-insulation work -on ships-.is done with imported asbestos which as a rule has been carded. From this an insulating mass is made--often at the work site--consisting of asbestos, water, and some binding..agent; this may either be allowed to dry into blocks that can be sawed or smeared directly on the part to be insulated, or else woven into a sort of ticking which is then filled with carded asbestos, sewn together, and installed on tanks or other large objects. The greatest dust production occurs in mixing the asbestos mass and in making the tickings, but considerable exposure to dust can also take place in wrapping pipes with asbestos cords and in tearing away old material. In installations on land, safe insulating materials such as glasswool, rockwouip or-cinder wool are often used, but shocks and vibrations on board, unfortunately, make their use impossible on most vessels. -j - Pathogenesis Asbestosis results from inhalation of asbestos dust, which consists in - large part of needles ca. 1 y thick and from 1 to 70 y in length. The exposure time for occurrence of asbestosis naturally varies with the degree of exposure, but is said to be about half of that for silicosis. Hunter, 1955, recounts a case in which the time between beginning of exposure and death from asbestosis was only 18 months. The irritation due to inhaled asbestos fibers gives rise to a progressive fibrosis of the lungs. In experiments with animals it has been found that short fibers give rise to an interstitial peribronchiolitic fibrosis of more diffuse type, while longer fibers produce nodules of approximately the same type as silicosis nodules (King, Klegg, and Rae, 1946). The progressing fibrosis is usually accompanied by atelectasis, emphysema, bronchiectases, and pulmonary heart. In contrast to the conditions in silicosis, the modifications occur pri marily in the lower 2/a of the lungs, with lowering of the hilus area and develop ment of thickenings of the pleura. From extensive experimentation with animals, King et al. in particular reached the conclusion that the fibrcSis in asbestosis is due to purely mechani cal irritation, in contrast to the fibrosis in silicosis, where there are stTong reasons to suspect a purely chemical effect. For they could only induce asbestosis in the laboratory animals in mobile organs and by means of fibers that have retained their flexibility and sharpness and that have a certain length. Furthermore, they found no great signs of phagocytosis and no damage to the . * lymph glands. The particles thus are not removed from the lung to any great extent, and this contributes to the unfavorable prognosis in asbestosis, even if the patient promptly .discontinues the work. A characteristic feature is the presence in the lung and in sputum of what are called asbestosis bodies (Figure 1), which contain asbestos needles centrally and are covered at the pointed ends with a substance stainable with hematoxylin. The authors are inclined to interpret the formation of asbestos bodies as an attempt by the body to protect itself against the sharp fibers. It has also been possible to show in experiments with animals that inhalation of asbestosis bodies does not give rise to asbestosis. They are evidence not of asbestosis but of exposure to asbestos. 4 Clinical Picture Clinically, asbestosis differs little from other lung fibroses. The subjective complaints usually do not appear until Stage III, in the form of shortness of breath, dry coughing, especially at night, and fatigue. Watchglass nails and drumstick fingeTS may be found. The physical pulmonary findings are most often limited to rale; after the onset of pleura thickening and lung fibrosis, also increasing damping basally. Complications are commonly in the form of bronchitis, pneumonia, and pulmonary heart with their specific sympto matic flora, and are often the immediate cause of death. Tuberculosis as a com plication is by no means as common in asbestosis as in silicosis. Besides these complications, in very recent times a high frequency of lung cancer has been observed among patients with asbestosis. In a study of the causes of death in 130 asbestos workers, Doll, 19SS, found that the supermortal ity was substantial, or 39 cases against IS expected. The excess was due partly to vascular diseases, 22 cases against 7 expected, and partly to lung cancer, with no fewer than 11 cases against 0.S expected. This relationship, too, makes the prognosis for asbestosis more serious than for silicosis. Diagnosis is based on the work anamnesis and X-ray findings and can be completed by the finding of asbestosis bodies in .the sputum. The X-ray picture in asbestosis has been described in detail, among others by Wegelius, 1947, on the basis of 126 cases. The roentgenological lung modifi cations in our patients correspond to those, described by Wegelius, with the ex ception that in one of our cases we found suspected' calcifications of the pleura. Like other pneumoconioses, asbestosis has been subdivided into three stages. In the literature two such stage classifications are defined, one from Germany by Saupe, 1938, and the other from America by Shull, 1936. Shull in his stage classification puts greater weight on the pleura thick enings than Saupe does. Like the former, we observed such thickenings in several of our cases and for that reason considered that we got the most use out of his stage divisions in classifying our material. According to his classification the stages are characterized as follows: 'Siajge I. Incipient asbestosis. Slight interstitial fibrosis in both lungs down toward the bases. Stage II. Moderately advanced asbestosis. More pronounced interstitial fibrosis, which extends to the surface of the lung in the basal % of the lungs. 5 Slight thickening of the pleura and pericardium to the same height. Slight damage to the heart on the right side and moderate apical emphysema. Stage III. Advanced asbestosis. Very pronounced interstitial fibrosis in the basal 2/a of the lungs, very marked apical emphysema, considerable dextral heart hypertrophy, but the contours of the heart do not appear clearly because of condensations in the lungs. Almost always a marked thickening of the pleurae and pericardium. In accord with the animal experiments referred to earlier showing that asbestosis occurs only in mobile organs, X-ray modifications are found primarily in the basal, most mobile part of the lungs. The pleura modifications -are also found there, parietally and in the pleura diaphragmatica. In one of our cases, classified as Stage II, these pleura thickenings were so impervious to X-rays that it must be assumed that calcifications had occurred in them. Figure 2 shows a schematic view of their spread in a patient who had worked with asbestos for 10 years and was subjectively free of complaints. Fin. - Because of the fibrous destruction of the basal parts of the lung, emphy sema develops in the apices. In more advanced cases the condensations are so pronounced that normal lung tissue cannot be observed at all. The heart-lung boundaries are then largely blotted out. As usual in pneumoconioses, the roentgenological differential diagnosis must be supported by the work anamnesis, and just as in the case of silicosis. -6- repeated examinations are needed before it can be said with, certainty whether there is an incipient asbestosis or not. In asbestosis the conditions of- expoO sure are somewhat easier to learn in anamnesis than is the case with silicosis, inasmuch as a workman is aware of whether he has worked with-asbestos, but he has a hard time saying whether the mineral he is working on contains substances that cause silicosis or not. The treatment, of course, is only symptomatic. In the progressing case, cortisone treatment may perhaps be considered, which might possibly arrest the advancing fibroses. Thus far, however, the risk of spread of latent infections in the already greatly reduced respiratory tissues has restrained us from such therapeutic experiments. Prophylaxis Obviously, an effective prophylaxis against this disease is needed. In England, where the processing and use of asbestos was begun very early, it has been possible through prophylactic occupational hygiene measures to reduce the morbidity from around 3 percent of asbestos workers to practically zero for the time being. In Sweden, too, similar measures have been taken since attention was called to the danger. Thus the l^rst of our cases was reported in the fall r of 1953 to the Royal Medical Board with a request for regulations concerning preventive measures similar to those in effect for silicosis. Proposals are now being worked out concerning periodic X-ray examinations of all who are em ployed in asbestos work. Extensive dust surveys have been carried out by the State Institute of Public Health and are-now being evaluated. As soon as the first cases became -known, the factory inspector in Goteborg served notice that protective masks were to be worn by all workers at places where the slightest risk of inhaling asbestos dust could be imagined. But that safety measure must be regarded more or less as orovisional. The fac tory inspection service is now engaged in working out, wherever possible, other technical protection measures, which will come down in the main to ventilation and local removal of dust by suction at certain moments in the work. More de tailed studies in countries where the asbestos risk was observed earlier would -v be necessary, however, before it would be possible to arrive at specific regu lations for the asbestos industry in Sweden. 7 Through such occupational hygiene measures it can be hoped that this first asbestosis case in Sweden will also be the last. Asbestosis is too- seri ous a disease for anything other than complete protection for workers employed in asbestos work to be acceptable. i certify met th*.` stclt wno crans.crec foregone is thoroughly fem.liar with and English languages end that it is a true and complete translation of the coctesponding^-fr-^- document . \ iV-, F.anWn V/. OaA. Language Service Bureau, 1**. Dupont Circle 8uilding Washington, D.C 20036 8 fir SVENSKA IAKARTIDNINGEN ORCA.N FOR SVEKICEi L.AK.UII'ORBDD Ar%. $2 Ar 2 jL J.7 // /9.76 |/^r/ : 3fi,h'oefrr TVtl 1QM-ftsr<m /rr h^a*****^ yCv:>.\ LV/;* ,/ /v /^ i I C ' 1376 Smimmrtf. * ACTI1 anti Coriisnne in Drrn)nlultjt/. Aihutnlnycs anil Risk*. The use of ACTU anti eoriistme can prolong life in pa tients suffering from certain fatal dermatoses, anti in others relieve distressing symptoms, prolong remissions in some chronic skin conditions, or completely suppress symptoms of acute, self-limiting, allergic reactions. The indications are briefly discussed. A series of 133 patients treated with these drugs for certain dermatoses over periods of time varying up to 2 years is presented. In view of the high incidence of compli cations (over 2* fe in this series) the importance of main taining very strict indications and constant supervision is stressed. * UHroturt . t. Suizbtrvtr, if. ft.: Proceedings Tenth International Concrr's of Dermatoloty, 1952. * 2. UtiUnttHm, S., HoUtirCm, Uunl, S. X Mngnasjnn, Jt.; Acta Ocrm.-Vetu 33: 285, 1252. 3. Sulzbrraef, if. B.; Modem Trends in riermatr.incT- Ed. H- M. B. MacKcnna. Butterworth'i medical publication*. 1954. 4. Pilftbmnt, if. X* Vrbarh, F.; Medical L'5-ea of Cortisone. Ed. D. AV. Lufceax. The BUfcestone Co.' Inc. New York. 1*54. 5. Saizberfwf, if. B. X Baer, ft. JL.' Year Hook of Dermatology and .* Srphiloiogj', 1952. The Year Unk Publisher*. Chicago. 4. Boilet, A. /,, Stark, Jt. <t Bunint, J. J.: J. Am. 11. A. 153: 459. 1953. ?. Bird, S.: Sard. Med. 53: 929. J953. . --Sr. LifcarUds. 53: 468. 1936. * t. Witten. T. a.: Aon. .V. York Acad. Se. 61: 534. 1933.. 19. Gemteil, C. Bird. S. * Xilsen, A.: Arts Dcrm-Ven. 33:327. 1953. U. Maikiamofi, F. D. A Feryaton, . 11.; J. Invest. Derm. 25: 281. 1956. ll. Umm^aad, C X* Hildebrand. J. F^ Xeff, /. .V. X- Smith, Jt. W.; A.MM Are*. Oera. 73:313, 1933. * " Fnin Sethlyrenska sjnkhnset, (iolcbnrg. Asbestos, F Sr Sverige nj yrkesxjokdom1 f * Ae \ J ; GmarrAMborg'ochiCari-iohcn;Hansson. Goleborg Vlft raeddeiande ir foranlett av 0 fall uv asbestos, varav etl dodsfail, oeh o* vetertigt de forsta i Sverige adenna yrkespneamoeanios. Den forsta palienten ankle 105.1 oeh foranledde en underaokning av det 6<M:il arbetare. soin sysaiade med asbertarbete inom Gntch'-rgsinrlu-drien: dafi vid upptieicies de ovrign 3. 1 Fundrac I Golcfcorts iSkanuilKW 2;*.2 *i :* s`** Asbestos bar ulomlamls varii fovcmal fr umlersokningur sctian gunska hinge. Kur narmnre slmiium av tlessa ban visas till Hunter (1035) oeh till bans lilteralurnnvi-ningar sa:nt UH Sam (1940) och UVi/ch'us (HH7), vilka sennre ulfurHut beskririt sjukilomens Alrikomsl'i Finland. liar skull endast reiateras vara erfarenbeter och grs cn smninunsk dver^kl over sjukdomens uppkomstbctingclsor i Sverige. dess klmik och profylnx. Vart eget maieriul utgures som sngt av 9 mnniign arheia- re i ildern 43 till 63 dr och med cn e*psiUon>tid fur asbest- dammar 5 (ill 17 dr. Under denna lid ha de cnteilerlid jven srsslatmed annal arbctc eller met! annul isolcringsmakTial. nrior exnosilionsgraden ar myckel svur all bedomn. * av fallen ha fall sin asbestos efter isoleringsarin-le. 2 cflcr nr- bete med asbesisprutning. 11 av de tenure, del med letai ; utgang, kunde rid forsla undersokmngcn rubriccras susum asbestos stadium 111 (se nedan,. del andru till stadium II. Av de ovriga 13 4 anses UUhora stadium I--II, do dtefxtuen- de stadium 1 eller borjande asbestos. 7 Subjektiva besvdf, som kunna hanforas till sjukdomen. ha endast angivits av patienten med siodium III. TInns sjuk- domshistoria skail darfor hur narmarc rdatcras. Vid undersGkningen var han 63 3r och hade under IT - irs lid sysslat med asbestarbeie, most med nsbest.sprulning, ; och anvande darvid endast andningsskydd sporadiskt. Sedan ; ett 4r tillbaka besvaradcs ban av okande andf3ddhct vid an- ttringning. nattiig torrhosta och krallstroUhet. och rid ' undersokningen forctedde han samtalsdyspnoe. Iuppcyanos och okad vfcleckning, urglasnaglar samt trumpinnefingrar. 'Lungfyndet ulgjordes av nedit tilltagande dampning och rassei. Rontgenbilden av iungan overenssfamde mod den. > nan finner'vid asbestos stadium III och i sputum fanns rik- tigl med asbestkroppar (Tig. 1). Han bade lachvcardi men i Svrigt inga teekenpd hjartsjukdom rid fysiknlisk undersok- Aing ar cor; delta var runtgenologiskt ailmanforsloral och ftk* Ttd forsta undersokning utan siiker anmnrkning. Scnare uticcxiade sig eti grenhlock. Han behandlades med antibiolika och thcophyllamin. var* *id de subjektiva besvaren minskade. och vitaikapaciteten ucg Iran i.Tuu till 2.90Q mi. Han kunde utakrivas och virdas 1 hemmet men iterkom efter eit par mdnadcr mod cn pneu- noni, som mdtstod all behasulling. Sektionen (Sounnder) visade bl. a. en diffusl fGrljockad* >v41ig pleura visceralis bilaternlt. Lungornas Gvre defar vir - ade odera och tecker od pneumoni.Konsistcnsen var i neJ* * ; fr: I t p c i 137$. . * j re ri av lungornn ujmiin. kmdlrig ueh ummlrkning.svurt Jjisl. i snillct synncrligm seg. Den fibroso ntuvandlingen ;iv lung, parenchymal dknde i kaiuiai rikfning oeh uppvisnde ell grovporiist, trabckulcrnl ulscende med upp lilt hassclnol- * slora, nindude knvrfclcr meUan do natformign. skiffergn:. fibrosa straken. Mikro>kopiskl fann man lungpnrenchymet genomsntt av bretia binclvavssirak oeh hfirdar av sliillvis nodulart ulscendc. Alvetiierna letide sip aUdcklaliska. I bindvuvon fanns rikligl med uslieslkroptv.tr oeh omkring (Jessa en rail kraflig cellinfillraiion. beslaemie av alveolar- ccllcr. mukrofnger uch en och annan flerfciirnig jalleceli. I bronchiaikortlarna diireniol kumic inpa asbeslkroppar aler- flnnas. PAD: Pneumoconiosis ~ pneumoniae loharix el oedema !obi sup. puim. umb. - Bronchitis mucopuruienta -e Dilata- lio sin. et hypertropbia dx cordis -r Sclerosis a. corun. cor dis -f Stasis chron. hepalis. Dct fail, soin vi rubriceral sasum sladiuiu II. upptackles 1933 och avkopphides da Iran arbclc med asbesi. Trots della bar han visal runlgcnologi.sk progress, dock forlfarnnde ulan ^subjektivn besviir. For de ovriga 7 ha vi annu for kort obser- valionslid. * - Asbesi. Asbesi ar en bergart. huvudsakligen beslaende av magne sium- eller jarnsilikat och med nagol oiika sammansaltning. beroende pa fvndorten, Canada, Sydafrika, Finlanti med ficra lander. Den bestur av flesibla lradar, vilket gor alt den kan kardns. spinnas och vavas lill hand eller lyg. Betydande hdllfasthet, hog smaltpunkt och dulig vurmcledningsform;iga Iigger till grund for dess anvandmng snm friktionsmnleriai (bromshr.nd? och tsoierinRsmnJerinl. Inom lekniken rur ri oss ju for narvarande med ytlerligheler avert bclruffamie lemperaturer, och del ar darfor inle overraskande, ail anvanrfningen av ashes! okar for varjc dr. Under en femdrsperiod fore kriget imporlerade Sverige 17,6 Ion, under molsvamnde lid efler kriget, sedan brislen efler j avspormingen ersnlls, 46.5 (on. I Sverige anvanris asbesi framfur allt som isoleringsmaleri*l runt rurledningar och dylikl pti farlvg, som brandisoleringsmaleriai i fartygsuiryramen eller samlingslokaler. vid bromsbandsliUvcrkning samt som armenngsmnlenai i ce ment och piasL Vid asbestsprulning for brandisolering kardas forst asbeslen i en mnskifl <! blokes sedan med lull genom en s{>e- f r? i) r c C 7 I i:i7u rii'II sprtilpisloj tiUsamtnans med valten h*1i ett bindemedel unit viiggytan. s;i nil mavsan iiitihir ett upp UN decimeter- lager. DamndMldniugen at* b*tyd:inde. Vu] isoleringsarbeten pa fartyg utgar man fran impode- nul. i regel.kardad asbest. Av dentin lillverkas -- ofla pa arhelspialscn -- isoleringsmassa bedaende av usbcst, vatleii och nagot bindemedel, vilkon nntingcn far torka (ill f-agbarn block eller sHda> direkt pa den detalj. )in skal! isoleras: filer ocksa v:iva> madrns>-var, sum sedan fyllas med kartiad asbesl. sys <k*Ii munteras pa behallnre eller andra slorre lo- rental. Storsla damtnproduktionen upp>lar vid blandning av ' i asbeslmassa och vid liilvcrkning av madrasser. men aven vid lindning av ror met! nshestsaoren och rivrvng av gam- J mall material kan beiydandc dammcxjxjsilion uppkomma. `4i i Inom anlagsningar i land anvander man ofla som isoleringsmuleriui oiurlig glas-. sten- eiler slaggull. men skak- 4i ningama ombord omojliggnnt lyvarr dessas envandning pa de fiesta fartyg. -j Pu/oyen^f. Asbestos uppkommer genom inhalation av asbesldnmm. '| rilkel (ill stdrsta delen bestur av c:a 1 my tjoeka naiar med en Jangd-mellan 1 och 70 my. Exjxjsitionsiiden lor uppkon.s- i iea ar asbestos variernr givelvis met! exposilionsgraden r! men anges ungefar till halflen av den for silikos. Hunter '*1 (1955) reiaterar ett fall, dar liden mellan borjande exposi -1 tion och cxilus i asbestos endast utgjorde 18 mannder. Hel- -4 ningen genom inhaierade asbcslfibrer ger upphov till enfort- skridande fibrosering av lungorna. Vid ujurforsok har man 1 - fuanit. all korla fibrer ge upphov till en inierstitieil ]>eri- * ' broachiolitisk fibrosering av mem diffus typ, mctlan Jangre I i ". . fibrer {Ring, ge noduii av ungefar snmma Ivp som silikosnoduli Klegg och Rae, 1946). Hen progredierande fibrosc- ringen ger pd vaniigt sail alelcktas, emfysem, bronchiecta- i . her och cor poimonuie. < *- l motxsts till forhiUlandena vid silikos upplrader forand- riagarna framfor alU i nedre ^ av lungan med neddragning * bilusomradet och uppiradande av pleurafortjockningar. ' Genom omfaltande djurexperimentella underwkningar ha framfor aiil- King och medarbeiare kommil till den stul- saUen, aU fibroseringen vid asbestos uppkommer genom rent mekanisk reining. i motsals till fibroseringen vid sili- tios. Jar man ju har starka skal nit misslanka en rent ke- misk reining. De kunde namiigen endast erhdlla asbestov forsoksdjuren i rbriiga org:in o*h genom fibrer. v.m ha i i jr r c t. < i ' `1330 . ` * * kvar sin flcxibilitet och speisighet och som ha en visa longd. Vidare fann man ingen storrc ansats till phagocylos och ingen furstoring av rrgionam iymfkortlar. Partiklarna foras sdlunda icke i nagon stOrre utstrackning bort fnin lung* an, vilket bidrager till den daliga prognoscn vid asbestos, yven om patienten tidigt avbryter nrbetet. i Karakteristiskt ar forekorosten i lungan och i sputum av s. k. asbeslkroppar (fig. 1), som rentrnlt tnnehalla asbest- j FIs. 1. nAlar, i de spetsiga andarna kladda mod ett med hamaloxy- lin TSrgbart amne. Man har velat toika htldningen av asbest 4 * kroppar sdsom ett forsdk Tran kroppens sida alt skydda sig i "4 mot de apetsiga fibrerna. Dot har ocks5 pi djurfGrsuk kunnat visas, att inhalation av asbestkroppar icke gcr upphov - til! asbestos. De are bevisnnde icke for asbestos men val for asbestexposiiioo. ** Klinik. Asbestos skiljer tig kiiniski icke namnvart frdn andra lungfibroser. De subjektiva hesvaren upptrada vanligen forst i stadium til 1 form av andf5ddhet. torrbosta. framfor allt nattetid. oeh trotthet. ITrginsnnglar och trumptnnefing- i rar kunna forekomraa. Del fysikaiiska iungfyndet inskranker sig oflast (ill ressef. eflcr intradd pleurafortjockning och J lungfibrosering opptrader tilltagande dumpning basalt. Kompiikationer iro vsnliga i form av bronchiter, bronchiectasier, pneumonier oeh cor puimonaie med deras speciella i svnstomfiora och utgora ofta den omedelbara orsaken till i exitus. Tuberkulosen ar som komplikation inte alls si van* iig vid asbestos som rid silikos. Uiom dessa kompiikationer har pi sista tiden hos patien*ter med asbestos uppmarksammats den huga frekvensen nv i cancer pulmonis. Vid undersokning av dbdsorsakcn ho* 130 asbestarbetare faan Doil (1955). att overdddliKhelen var i < !* r c lirtydumle idler iW fall m'l vfmiade 1.V fivcrskuttel hcrudde dels |i vasculara sjitkdomur mrd T2 trtU mui vunlndc 7, dels |i:t cnnerr ptiismmis mot] ieke mindre fm 1! full mui vanlade O.S. Aven ilcltn furhallandc g.'.r asbeshjens progno* allvur* Jjpare an silioo*ens. Diagnosen slftllc* p;i yrkovinsunnes <rh runigenfynd och . kan fullstandigas gemmi fymj a\ .isbc>tkri[(;>r i sputum. HuttigrnbiUlcn vid aslicsios liar ulf"rligl heskriviis bl.a. av Wcrjfiittx f 11>47'1 p;i urunilval av I Uf* fall. I)c runlgenulo- giska lunpforantlrinaarna hos vara puticntvr uvcrcnsstiim- ma med de av beskriviwi. mod undanlng av alt vi funnit suspektu plcuraforkaiknlapar i ell av vjira fall. Uksom andra pncumoconio^cr bar 5vrn usbestoscn indelats i Ire stadier. 1 liUcnituren finnas Ivy dylikn stadieindeiningar definicrade. den ena fmn Tyskland av Saupe 093$), den andra fran Amerika ;n Siuili 1931*/. Shall lugger i sin studuMndelnmp xU.rre vikt vid plcurnfortjockningarna an vad Swipe pur. Vi fia liksom den forre iakitagjt sadnna fiirtjnckningnr i firm av vara fall och ha tiarfor anselt oss ha most nylla av hans sludieindelning vid klassificerigen av vurt material. Enligt bans indeining kurakleriseras tie uiika sladierna ji lolj.imle sail: Stadium 7. Incipient asbestos. IJill inlcrstiliell fibros i bada lungorna ner mot ba&erna. Stadium 11. MMtiigt avanccrad asbestos. Mcr uttalad in* * lefslitieil fibros, som siracker sip ut till lungytan pi de ba- ala Vs av lungorna. Lull fOrtjockning av pleurae och perieardiun i samma hojd. Lull hoperfbrstoring av hjirtat och -- mauiigt apicalt emfysem. : Stadium 111. Avancerad asbestos. Mycket uttalad Interstitie# fibros med forlalninpar i de basuia Vt av lungorna, . mycket markerat apicalt emfysem, iydiig hogersidig hjirt* f` avpertrefi, men konturerna av hjartat framtrada otydligt f . pi grund av fortatningarna i lungorna. JViistan aillid utta' lad fortjockning av pleurae och pericardium. ^ I overensstammelse med tidigare relaterade djuresperi* "Tnenleila umiersokningar, visande aU asbestos endast upp* t4r i roriiga organ. Tinner man ronlgenfonindringarna framfor ailt i lungnns basnla, mest rorfigu delar. Aven pleuraforindringama Tinner man diir, parielalt samt i pleura diaphragmatica. I ett av vira fall, klassificerat som Stadium JI, var dessa plenrafortjockninpar sa rbnlpentala, atl man RUtsie foruisuttn, att del uppkoinnuJ forkalkninuar inom desamma. Fir. 2 visar en schcmali>k bib! av des.sus uibred- i f f r r k i i ning hos cn patient, som i 20 drs tid arbelat met! asbest och som vnr subjektivt besvarsfri. i P:i grund av den fibrosa dcstruktionen av de basala par- tierna inom lungan uppknmmer ]>a spetsarnn emfvsem. I mcra avanceradc fail uro de stnikformiga fortatningarna su utlnlade. all normal lungvuvnad overhuvud taget icke kan iakttagas. Iljarl-lunggranserna uro da till storsta delen utsuddnde. Den rfmtgrnoiogiska differentiaidiagnosen maste* som vaniigt vid pneumoconioscr stddja sig pa yrkesanamnesen, och liksom vid silicos fonlrns del upprepade undersokningar for alt med s'akerhet kunna saga, otn del rOr sig om in 'A cipient asbestos eller inte. Esposilionsbelingelsema rid as bestos ur emcHertid lattare att annmncstiskt fi fram an vid silicos, beroende p4 att en orfaeiare ral kinner till om ban ; ~ arbetat med asbest men ju bar svdrt alt ge uppgift om, hururida den bergart, ban bearbetar, innehiller sillcosfram- kailande amnen eller inte. Behandlingen ar givetvis endast symtomatisk. Man kan kanske i progredierande fail diskulera cortisonbehandling, som mojligen skuile kunna hejda den fortskridande fibroseringen. Risken for utbredning av tysia infeklioner i den redan stark! reducerade respirstoriska vavnaricn bar emei- lertid hiltills svhdllit osa frdo sddana lerapifursok. Pnfylax. -. { Effektiv profylax ar givetvis nodvandig mol denna sjuk- ** < dom. I England, dar man mycket tidigt borjade bearbeta och 1 anvanda asbest, kunde man ocksd genoni profyiaktiska yrkeshygieniska ilgarder nedbringa morbidiieien fran om* kring 3 % hos asbestarbetare till for narvarande praktiskt taget 0. Aven i Sverige ha liknandc itgarder vidlagiis, sedan 1' I f l 4: 5 C C .Ji'rM -'M - (man uppmarksammat faran. Siilumla uninoldcs dot ftirsla av vir fall l`.)53 til! Kunpi. medieinaMyreUen med heparan cm beslammelscr nupacndf forehyguamlc alpiirdcr i iikhel mcd dem. som puller ffir silicas. Kiirslag bailor nu ocksa pa att utarhelas hotriiffutulc pcriodiska rrmlpenumicrsoknmiwr av alia i asbcslarbctc syssclsnltu. Omfuilanlc dnmmundersokninpar ha liven ulforts av Slalcns inslilul fur foikhalsan och bailer pa alt benrbctns. Sa fort dc lursla fallen ldivit kanda. mcddclade vrkesinspektdren i (iOleborp anvisning. all skyddsmnsk skuile ba rns av alia nrbetare p;i pinlser, dar minsla risk for inhala tion av asbosUlamm kundc lankns forckomma. Denna skyddsutgard far dock i viss man bclmklas som eti provisorium. Man ur f. n. inoni vrkcsinspcklionen -- i samarbele , mod arbetspivarnu -- sysselsall mod all. dar sa nr mojiigt, utarbeta anrira lokniska skydd, vilka i huvudsak kommer all - ga ut pa ventilation och lokala ulsucningar vid vi.sn nrbets^ moment. Narmare sludler i lander, dar asbeslosrisken Udi- gare observernts, lordo oniellertid bli nudvamiiga. innnn man kan konunn from till sarskilda bestiimmelser fur asbest[ . industricn i vart land. ; Genom suduna yrkeshypicniska algarder kan man hoppas, ; att dcssa fursta asbestosfal! i vart land ocksa skall bli dc y sisla. Asbestocen ur en nlllfOr aUvuriig sjukdom, for ait man l.i. skall kunna acceplera annul an fullslandigt skydd fur inom 5i;Ubeslarbete svssclsalla arbelare. Uiterotor: R.: DHt. J. Ind. Hy*^ !*: SI, 1233. flutter, D.: The Discssco of Occupations. London, 1955. IIegg i Rat: 1946. Cit. Hunter. Acta path, et microhm). Scmi_ 33: 53. 1946. Sospe, Z.: ftiotEenatla* dcr Asbestos* der Lunjen. Thi' J. R.: RadioioKT. 37: 279, 193G. epef/a*, C.* Acta Radiol., 2A: 133. 1947. Obsfipationens behandling Ay Erik forsgren, Svenshdgen Furstoppmngcn 5r en ov civifisalionens mer eller mindre oesvarlipa forbannelser. Vi Ifitcr i stor ulsirackning maskinerna utfdra kroppsarbetet och behmer durfur mindre mat. "4 blip <iet ocksi mindre avfail nllra heist som vi hittat p:t ! i i[ I t ! \ i: <1 I *f! if t