Document RjM64ODnrRM0mgD0V4oGBZZx7

iiiij UVJV-.UIVICIM I VVMJa INUI PPG INDUSTRIES, INC. DID NOT COME FROM >70 T' F&ESTWa SANtNOT BEJ NDE 31 Oktober 1964 1 BY_PPG INDUSTRIES. INC' r AiBESTOStS^.vsA..;, :t* I\s. Webster, B.5c.(Hons.). M.B., B.Ch.. Pneumoconiosis Research Unit, Council for Scientific and Industrial Research, Johannesburg A?r:>:osi5 has been brought to the forefront of industrial TABLE I. RADIOLOGICAL CHANGES CONSISTENT WITH ASBESTOSIS medicine in this country by a number of recent publi Mates Females cations. Smears were made from the cut lung surface of cases tV'm the autopsy sen ice in Cape Town. A relatively high percentage of cases showed the presence of asbestosis bodies in the smears.1 From this finding it has been suggested that the air is becoming increasingly polluted by Whites ,. .. Bantu .. .. Coloured .... Exposed 1 37 24 Figures expressed in percentages. Not exposed 2 27 5 Exposed 0. 2 9 Not exposed 0 1 2 eventually "indestructible and dangerous" asbestos fibres.- Mesothelioma of the pleura has been considered to be a rare tumour, but over 100 cases have been diagnosed in South Africa. Almost all of these cases have had an association with the North-Western Cape or the asbestos coming from there. The diagnosis of the cases found during the survey was made mainly on a radiological examination, where" even without any evidence of disability, the appearance of the film showed features consistent with the diffuse fibrosis o: asbestosis or when calcified pleural plaques were seen. Many of the methods which are used in the milling or THE INCIDENCE OF ASBESTOSIS .Asbestos of different types is used, unprocessed or as yarn, cloth, felt. tape, paper, millboard, in cement and in other different compounds. The unprocessed material is used in the chemical industry, in filters or for caulking; the yarn, in the manufacture of brake linings, clutch facings and gaskets: the cloth, in fireproof clothing, tapestry, blankets, theatre curtains, and oven linings; the felt, in acoustic and sound installations; the tape, in armature winding, conveyor belts and oil wicks; the paper, in linings for processing of asbestos preclude the use of water. In milling, for example, the asbestos fibre is separated from the grit by hot air. Although mining and milling conditions have been improved in the last few years, there was a period when the effluent from the mills did pollute the air in which people not employed in the industry lived or worked. In addition, some years ago the dangers of the inhalation of asbestos dust were not fully realized, even by research workers and industrial hygienists. The great binding property of asbestos grit was utilized in the making of roads and in certain places to make school play stoves and heaters; and the millboard for insulation. The grounds. asbestos cement is used in the manufacture of roofing, tiles, shingles, wallboards, in water pipes; and the various com pounds of asbestos in the manufacture of battery boxes, in stucco paints, plastic appliances and in the ceramic industry. Cases of asbestosis have also been found in factories not using asbestos in any process, but situated close n factories which were. In such cases, every effort was made by the experienced people to exclude any known exposure to asbestos dust It is difficult to obtain definite or comparable figures of the incidence of asbestosis in these different industries as diagnostic criteria vary from one country to another and in different parts of some countries. Such figures as are given vary from about 15 - 35% of employees examined. Such incidence figures are given in relation to the number of people examined at a certain time, and are often not related to the population at risk, which is indeed difficult to assess. Many reports only record the number of cases detected. Professor Thomson and his co-workers1 have shown that in 500 consecutive autopsies in subjects of 15 years et over, in a number.of cases asbestos bodies were found m smears made-from the bases of the lungs. It is suggested that asbestos dust is liberated into the urban air as j result of the increased use of asbestos materials. I: admitted, however, that the occupational histories, when available, were meagre, and it is com nonly accepted thy. in order to assess the industrial exposure of a person ia hazard, the examiner must have full knowledge of 'hr Because there were not accurate figures of the incidence different processes involved. of asbestosis and some of its possible complications, the Pneumoconiosis Research Unit of the CSIR approached the Asbestos Industry, the National Cancer Association, the Department of Mines, and the Department of Health, in order to carry out a survey of the asbestos areas. Financial assistance and moral support were most willingly given. One of the results of the survey mentioned confirmed that asbestos bodies could be found in the sputa of peer* with abnormal and with normal radiological fi'ms. Th' shows once more that the presence of asbestos bodies indicative only of exposure to asbestos dust, and also the question of the relationship of the asbestos body to " - interstitial fibrosis. The results of the survey are shown in Table I. which shows that a certain percentage of the people living in the pathogenesis of asbestosis vicinity of the asbestos mines or mills may have asbestosis. Recently Beattie and Knox.s examining ashed lung f" and an explanation for this must be sought. from cases of asbestosis. have shown that a smaher 1 Th's paper vvas privatelv presented at the 44th Congress of ? 'urh African Medical Association. Johannesburg. J ;!y centage of fibres over 15 u in length is found in severe degree of asbestosis than in cases of minimi moderate asbestosis. and in those cases with as -* i .,, j I BB 00 05353" A' ii ->* t \J . t "O t i7 Ci 1 i 8-- L < A'I ! T hOl October 1964 ;-'Oture but no evidence of asbestosis. S.A. M E D I C A l Journal _%. 'jS- ,-!+-* C.-U**J' .v: ' v 871 * - O' - . fiv'y - -'V.'. ...........-...S...'.-... obscure. In assccianoB with asbestosis they have been tue* considers that the' "asbestosis body' will reported by Kiviluoto* and this has been confirmed not (ally break down, but that usually this is a slow only by Wagner but also in this series. In 3 cases the and that fragmentation can occur without the plaques were fibrous in nature and were found on the il.<..opment of fibrosis. When, however, the break-dowpnarietal pleura; surface and on the diaphragm. It is of > -ipid, owing to pulmonary infection or congestionin,terest that similar calcified plaques have been reported hbmsis occurs. As the fragmentation of the body waisll occurring in talc miners by Siegal and his co-workers* j!'o include the fracture of the central fibre, an explanation and in people working with mica by Smith.9 Both of these * tiered by the smaller numbers of long asbestos fibres in substances, like asbestos, are fibrous silicates. -: ire degrees of fibrosis. In addition to the presence of asbestotic plaques, 50% Another explanation must be considered and that is that of the cases described here showed the presence of a &.i most fibrogenic particles of asbestos are not the long chronic non-specific pleurisy which in some cases produced fibres but rather the smaller particles. This would suggest marked thickening of the pleura. ib.it the fibrosis of asbestosis is caused by the fine particles end not ,by the asbestos body. malignancy in asbestosis These particles, being silicates, may produce the type of fibrosis found in the lungs of nepheline workers,1 which is indeed similar to that of asbestosis. But this concept will require a great deal of investigation. There can no longer be any doubt that there is an increase in the incidence of malignant disease of the lung in cases of asbestosis. In this series 26% of the cases It is probable that accurate records of service, correlated TABLE lit. MALIGNANCY IN ASBESTOSIS EXPRESSED BY DIFFERENT with the composition of dust retained in the lungs, will be of help, particularly in those cases with known exposure and no radiological evidence of asbestosis. Author Stoll, Bass & Angrist1* AUTHORS PATHOLOGY OF ASBESTOSIS The first change which is found in the lungs owing to the inhalation of asbestos is an aggregation of dust-laden phagocytes in the region of the respiratory bronchioles and below the pleura. The dust which reaches the inter Bonser, Faulds & Stewart11 Merewetheru Jacob & Bohlig15 Wagner4 'Expressed in perceoutc. Pulmonary malignancy* 13-2 7-5 14-8 M26-1 F 8-7 13-2 12--17 ' 18 stitial tissue causes an initial interstitial fibrosis in those regions. The fibrosis extends to the adjacent alveoli and wso^^d alveolar ducts. I^Bbrosis involves more and more of the .alveolar duc^^id alveoli supplied by the respiratory bronchiole and eventually there is no normal alveolar tissue between adjacent respiratory bronchiolar segments. Thus a histolo gical picture of widespread diffuse fibrosis is produced. Although it has been stated that asbestos affects mainly the lower zones of the lungs, the upper lobes may be affected without much fibrosis of the lower lobes. 270 cases have been examined at autopsy and 38 (12%) showed the presence of areas of massive fibrosis, but this *as not necessarily related to the severity of the interit:tia! fibrosis. Active tuberculosis was found in 44 (24-4%) out of the '-')4 cases examined by Dr. J. C. Wagner* and in 21 out s: a series of 90 cases examined by the Unit since his -eoarture. In this latter group more "cases of active fuberculosis were found in the moderate and severe degrees Ibfa?f interstitial fibrosis. The evidence of active tuberculosis in relationshio to ptosis m one of the areas surveyed, is given in Table The relationship of tuberculosis to the peculiar bilateral showed the presence of malignant neoplasia of the lungs and of these 16 cases of malignancy described here, 7 were bronchogenic carcinomata, 4 multkentric bronchiolar carcinomata and 5 were mesotheliomata of the pleura. It does seem probable that asbestos dust can produce malignant change at different levels of lung structure, namely bronchi, bronchioles and pleura. Although the bronchogenic carcinomata can usually be distinguished from the other two with accuracy, it is sometimes difficult to be certain whether a tumour is primarily of mesothelial origin or bronchiolar, as the mesothelioma can spread into the lung parenchyma and the multicentric bronchiolar tumour to the pleura. The presence of hyaluronic acid in the mesothelioma has been used to d:fferentiate the 2 types of tumours. For this the specimen should be preserved in a fixative con taining formalin, alcohol and acetic acid or it could be done on a frozen section. Many specimens were preserved in formalin and in these the absence or presence of hyaluronic acid could not be established. In South Africa there are different types of asbestos, of which the main ones mined and milled are crocidolite. amosite and chrs'cfile. Crocidolite is found mainly in the tatcinad pleural and diaphragmatic plaaues of asbestosis North-Western Cape. There are also deposits in the North and their pathogenesis remains ern Transvaal, as well as those of a closely related asbes tos. knosvn as Transvaal Blue and the big and only s': stosis \5BEST05IS TO ACTIVE TUBERCULOSIS 4ctivc TB 37 (M'O 115 (7') .Vo active TB 175 1.577 Total 212 1.692 known source of amosite asbestos. Ail three of these are asbestos of which the main component is an iron silicate and they are associated with a banded ironstone. Other deposits or blue asbestos are to be found in Western Australia and. according to Conn.14 in the Lab'-ador troughs of Wv Quebec in Canada. Prospecting 152 it;: 1.904 in these latter beds has .not yet started. Tn Canada, New- > 872 S.A. Tydskrif vir Geneeskunde 31 Oktober 1964 fouudland, Russia, Rhodesia and in the Eastern Transvaal there are deposits of a magnesium silicate asbestos known as chrysotile Wagner. Sleggs and Marchand15 described a number of cases oi mesothelioma of the pleura in people associated with the North-Western Cape asbestos fields, or with the asbestos mined there. Over 100 cases in which the histo logical features are consistent with those of a mesothelioma of the pleura are on record and in only 3 is there no connection with this area or the asbestos from it. It must be mentioned that in some cases the association with the North-Western Cape was very short indeed, being days or a few weeks. Cases of mesothelioma of the pleura have recently been reported from Belfast, Southampton, Liverpool. Newcastle, Edinburgh and Portsmouth, and Wagner1 considers that they may have been exposed to asbestos in the repair or building of ships. This has been suggested in the cases from Belfast17 Keal15 has reported a number of cases of peritoneal mesothelioma at the London Hospital where there may have been exposure to asbestos dust. Such mesotheliomata have also been reported by Wagner in his series of cases with some association in the North-Western Cape. No case of mesothelioma has been found from the Northern Transvaal or from the chrysotile area of the Eastern Transvaal. However, 4 cases have been found in Canada in people exposed only to chrysotile asbestos.1 Deaths from lung cancer ICD 162 have been registered in Whites of the magisterial areas in which the amosite and chrysotile asbestos mines are situated.*0 Intrapleural inoculation of animals with the different types of asbestos has produced a small number of tumours with histological and histochemical appearances similar to those of a mesothelioma. Also most of these have been found after inoculation of crocidolite, but one has been produced by chrysotile and another with silica. There are. therefore, many unsolved problems in regard to the incidence and development of mesothelioma in asbestosis, which may be summarized as follows: (a) No cases have yet been found from the Northern Transvaal, although crocidolite is to be found there. (b) Cases have been found in people only exposed to chrysotile (Canada). (c) Bronchogenic and bronchiolar carcinomata have found with exposure to all 3 types of asbestos. In regard to the carcinogenic agent a further problem arises. If the hydrocarbons found in crocidolite and amo site asbestos are to be incriminated in the production of mesothelioma, why have there been no cases from the amosite area and why are there cases of bronchogenic carcinoma and mesothelioma found in people with only chrysotile exposure? Only trace amounts of the hydro carbons have been found in some specimens of chrysotile.-- CONCLUSIONS The pneumoconiosis produced by the inhalation of asbestos dust still presents a Urge number of problems, and the main ones appear to be: (a) The particular property of the dust which causes fibrosis and how it does this. (b) The length of exposure or dust load necessary to produce such fibrosis. (c) The reason for the increased incidence of pulmonary malignancy m asbestosis. It is a disease produced by the inhalation of dust and as such can be prevented. The managements of the asbestos industry have introduced many procedures to prevent aerial pollution in the last few years and the principals of these applied to manufacturing concerns using asbestos will reduce the contamination of the urban atmosphere. Under such conditions an ever-increasing atmospheric dust hazard, as has been suggested by some workers in South Africa, is not anticipated. Reference to the survey carried out by the Pneumoconiosis Research Unit of the CSIR, and reproduction of the Tables, is made with the consent of the Director of the Unit REFERENCES 1 Thomson, J. G,, Ksschnli, R. O- C. and MscDonald, R. R, (19f3): S Afr. Med. J., 37, 77. 2. Editorial (1963): Ibid.. 37. 629. ,, . 3. Beattie. J. and Knox. J. F. in Davies. C. N., ed. (I960: 7nrTM/.TMil Sy mpo.num on Inhaled Particles and Vapours, p. 419. London: Peita- moa. 4. BcaLtie. J. In Dgvies. C. N*, ed. (I960: Ibid,,p. 434. 5. Barrie. H. J. and Gosselin, L. (I960): Arch. Environm. Kith, 1. I0*. 6. Wagner. J. C. (1962): The pathology of asbestosis in South Africa. pt>, 66. 67. Thesis. University of the Witw*tersrand. 7. Kiviluoto. R. (i960): Acta radiol. (Stockh.). sum>t. 194. 8. Siegal, W., Smith, A. R* and Grcenburg, L* (1943): Amer, J. Roent* peaol.. 49, 11. 9. Smith. A. R. (1952): Ibid., tf7. J7J. . 10. Stoll. R,, Bass, R. and Anffrist, A. A. (1951): Arch. Intern. Med. 8S 831 -* 11. Bonser.' G. M.. Fanlda. J. S. and Stewart. M. J. (1935): Amer. J. Clio path.. 25. 126. 12. Mermther. E. R. A. (1956): in Industrial Mediant end Hytienr. p, 216. London: Butterworth. ,, 13. Jacob. G. and Bohlig, H. (1955): Arch. Gewerbepath. Gewrrbeh*1, 14. 10* #,, -a 14 Conn. H. K_ (1961): in Transactions of tht Sewnth rommow** Mining and MetalUtrfictd Congress, Vol. I, p. 120. Johannesburg South African Institute of Mining and Metallurgy. M _. - 15. Wagner. J. C., Sleast, C* A- and Marchand, P. (1960): BnL L Irdustr. Med., 17. 260. 16. Warner. J. C.: Personal communication* _ 17. MzCaughev, W. T. E., Wade. O, L. and Bmes. P. C. (1962); Bn*. Med. J.. i. 1397. 18. Keal. E. E. 'I960): Lancet. 2, 1211. 19. Cutter, P.: Personal communication. 20. Osttli. G.: Personal communication, 21. Harington, J. S. and Smith. M. G. (1964): Arch. Environm. HJ the press). i i i ii I * l AN EMERGENCY DRUG CUPBOARD FOR USE IN HOSPITALS Jvmes I. Aitxen, M.P.S., Senior Pharmacist, Groote Schuur Hospital, Cape Town The provision of some system whereby urgent medicines can be obtained, when the pharmacy department is closed, is necessary in every hospital. After a period of trial and error a system has been evolved in '.'-.is Hospital which may prove not only of interest to hospital pharmacists, but also act as a guide to medical super intendents of smaller hospitals where no pharmacist is em- ployed. For this reason the emergency medicine cupboard sa lts contents will be described in some detail. , The cupboard, as will be seen from Fig. 1, consists m sections. The upper section which is 48 inches in height, inches in width and has a depth of 101 inches: this is _ di'.ided into 2 compartments, each 39 inches in width, .a-compartment has at present 7 shelves, but as the height ot - * S. . Xj i J i s '3 w 4 j i j yj 'iLLb CG ING? ____ l_B_05355 j