Document dKy7qpoE1eGdwjGQqjRR2XB6

I -fnrm 7^^ - dt/hq ft ^ HeU/it>**~. 73-12-27 Deutsche Medizinische Wochenschrift, 1973 (43) P* 2034-2037* "On the So-called Vinylchloride Disease" By S. JUhe, 6. E. Lange, 6. Stein* and G. Veltoan University Skin Clinic of Bonn Director: Prof. Dr. Lelnbrock / Since 1938, when the first information on the hazardous health aspects to workers in the vinylchloride manufacturing industries was found, and especially since 1963, when the. same effects were found affecting workers in the polyvinylchloride industry (PVC), and through further reports on this subject (3* 4* 7* 8, 12, 28), attention has been drawn to this branch of the chemical industry. This deals with a disease similar to a skin and bone affecting scleroderma, but a disease un explainable in etiology and pathogenesis. The main symp toms of this have been the Raynaud syndrome, nodular to .. large area dense skin alterations and band-like osteolysis in the finger phalanges, Ve could report our first observations on this., disease / type in Germany in 1972 (15* 16* ?) As the clinical picture was at first comparable to a specialised form of progressive scleroderma, we submitted all employees to a painstaking UCC 006209 a internal examination to determine if visceral participation was also present. Recently, we reported completely (18) on the results found up until the end of 1972. These reveal new aspects to be used in the judgement of this disease and, as we believe, also may give new suggestions in the research. The 13 workers examined in the April-December 1972 tim period were 29 to 52 years old (average age: 39 years), and had worked at least two, and at most 18 years (average period: 7 years) in a FVC-manufacturing plant at alternating jobs, although mainly as autoclave cleaners. The first disease symptoms appeared one and one-half to three and one-half years after first working there in eleven patients, and in two cases seven and eleven years after first working* Symptoms and Findings i .7 The most frequent initial symptoms of the anamnetlcal details are increasing sensity to coldness in the hands and feet, a feeling of deafness, and crawling parletosis. In addition, pressure pain in single fingers, a thickening of the end finger joints and weakening of the nails as well as general complaints of excessive tiredness, forgetfulness and slowing down, syncopal dizziness, nauseau during work, increased perspiration and upper abdominal pain. A major role in the diagnosis of this disease is played by the alteration of the skin: Seven patients proved to have drumstick-like (clubbed) thickened finger end phalanges (club procurements and shortening, watch-glass nails, shortening of ucc 006210 3 the nail plate). We saw scleroderma-like skin alterations in 8 patients: small knots or more spread out; very coarse and relatively sharply defined, usually covering the surface skin projecting infiltrate on the outstretched hands, the distal third of the arms under the elbow, and the area of the cheeks. Three patients had no clinical skin alterations. The histology findings of the excision specimens (from the left or right hands) of all patients were relatively uni- form. Besides hyperorthocytosis and epidermidosis, there was cm expansion and increase of capillaries in the upper cutis. An increase, widening and homogenation of the collagen bundle and a clear rarefaction and fragmentation of the elastic fibers was evident. The same findings in the epi dermis and the fibers of the upper cutis were proven to exist in the patients without clinical skin alterations. The histology alterations in the epidermis and the collagen connective tissues are similar to the edematosis to. infiltra tive stage of progressive scleroderma. Here, however, a clearly defined border is seen between that of possible but to some extent considerable injury of the elastic fibers and the vessel alterations. So far, circulation disturbances are the most common symptoms: Nine of thirteen patients complained of this, and in fact eight of them gave this complaint as their first symptom. The degree of complaint ranged from increased sensitivity to the cold and "akrozyanose" to the Raynaud ucc 006211 4 syndrome (four Fatl nts). The circulation obstruction could be judged objectively with the aid of temperature measure ments, determination of the time required to rewarm after exposure to the cold, capillary microscopy, and arm-hand arteriography. In no case did oscillography and plethysmo graphy result in a certain pathological prognosis. From this, one can ascertain that the origin of the circulation obstruction is in the periphery and not in immediate range. * of the large blood vessels. This consideration is supported by the angiographic and capillary microscopy results. Four patients with sensitivity to the cold were proven to have ampule-like widenings of the capillaries in the nail joints just as described in the Raynaud syndrome (14). All seven patients who underwent arteriography showed pathological vessel images. The alterations ranged from a slight narrowing of the Aa. digitales palmares propriae et communes with 'single segmentary localized closure^ to a high degree of stenosis and segmentary closures, and even to the extent of the loss of contents by the arteries in the entire length *of the finger and clear stenosis of the entire hand joints. ;' After the examination until this point, it appeared that a direct relationship existed between the length of exposure and the amount of vessel damage. The most obvious x-ray results of this disease were the band-like osteolysis between Processul unguicularis and the phalangen on single or all fingers in six of the patients. UCC 006212 5 In addition, fragmentation and border defects of the Pro cessus unguiculares could be found in six patients. It is also possible to determine different degress of bone alter ation: in light cases only a small lytic zone is visible, and in the advanced stage the phalange is almost fully de stroyed and the Processus unguiculares mounts onto the basis of the phalanx cap-like, A full restitution of the bone is not to be expected based upon the facts at this time (23|24). Remarkable herein is the solid correlation of acroosteolysis and the club-like expansion of the end phalanges. Thus, the 'drumstick fingers" are an expression of the lytic bone process and not of an internal disease* An examination of the blood building system and coagu lation drays our attention to this remarkable finding:* all thirteen patients shoved light to serious thrombopeny. The thrombozytic count lay repeatedly between 30,000 and 119,GC0/p<.Jl (under a normal limit of 150,0C0^), In.a sternal puncture given to six patients in search for. an explanation, there resulted in no case a reference to the Obstruction of the 'thrombosytopoese", osteomyelofibrosis, or osteomyelcsclerose. The other examinations shoved no deviations from the norm, except for a slight reticulocis in eight patients (between 16 and 26 %), and a slight leu kopenia in five patients (2350 to 3950 leudocytes/^JJ.), Reticulosis and leukopenia may be caused by the splenomegaly in the twelve patients. At this time, it is not clear if ucc 006213 6 $h thrombopeny Is also sc caused, but it is probable that it deals with a turnover disturbance or an increase in disin tegration in the periphery. It was observed in the anamnese that three patients re ported recidivisic pain in the left upper abdomen and one patient reported pain in the right upper abdomen and a feel ing of fullness, as earlier diseases of "Leber and Milz," yet long-time intake of medicines or extreme alcoholism were nop * discerned. However, three patients without the sclerodera' like skin condition and acroosteolysis had record histories pointing to a chronic liver ailment (Esophagus varices ble d- ing, splenoral anastomosis;portal hypertonus; esophagus varices, splenomegaly.). The bromosulfaline retention was clearly increased, but by comparison the values for serumtransaminase and-phosphates were for the most part nothing out of the ordinary. This discrepancy could also be proven in the other ten patients. Four patients had esophagus varices, and in twelve cases splenomegaly was proven scintallgraphically. The laparoscopic and liver biopsy results of five patients, which were available to us at the end of 1972, showed remarkable agreement: surface area of the liv r clearly or finely waved, capsule fibrosis, increased bloodand lymph-vessels, histologicaly a slight to clear fibrosis of the portal system and .indifidual cell necrosis, and slight coarse fat droplets. The result, that we could further ver ify at this tine let us express the following theory: Except UCC 006214 7 for the slightly toxic alterations of the liver cells, this results from the expansion of the connective tissues in the portal system into the diffuse circulation in the liver* In Advanced stages this leads to an interhepatic block (most like* ly because of the hinderances in the height of the portal system, possibly similar to a sinusoidal block), with esophagus varices. It remains to be found if the splenomegaly is only is a secondary condition or if this primarily the direct 'result * of toxic changes* . Of nine patients examined in the lung functions (anamn se, x-rays, spirometry, entire body plethysmography, and blood gas analysis) after references pointed to.mainly restrictiv r alterations, eight of these patients shoved partial insuffi ciencies. Further research must be undertaken to determine if these disturbances can be traced back to the fhct that similar changes occur in the lungs as in the collagen and elastic supporting tissues of. the skin, that is, that a beginning diffuse lung fibrosis is the cause of these* dis turbances. _ * The Initiating Factor This paper is concerned with an industry-caused.disease, in vhich the symptoms include (arranged in order of most common occurrence) thrombopeny,.splenomegaly* toxic liver damage, ventilation blockage, circulation obstruction, and and t bone alteration. This complex of symptoms has not yet been ucc 006215 8 'been assigned to a known syndrome. It is unexplained etioiogically and pathogenically. Is it possible to obtain a certain insight in the etiology and pathogenesis by a comparison of our results with those previously recorded in literature? What is then possible to be the initiating factor? At a simultaneous pressure and temperature increase, liquid vinylchloride is polymerized to polyvinylchloride with *m the addition of water and various additives, depending upon the different properties desired. In different countries, independent of the additive type, the Raynaud syndrome and acroosteolysis was present in workers cleaning autoclaves. The symptoms appear so characteristic that it lead in the past year to the disease designation of "occupationallyconditioned acroosteolysis" and was advanced to a diagnosis position (28). It is not assumed that the additives, differ ing by type, country of production and methods, play an import ant role, but the harmful combination of these with the vinyl.chloride can not be completely excluded. Therefore vinylchloride, the substance present in the largest amount, be comes the main point of our Interests. The monomer vinylchloride is pumped over a closed system of an autoclave. The exit possibilities of the gas - and thus the inhalation possibilities - consist then in more places within the pro* duction process: 1. Permeability of the autoclaves (intake and offtake) ucc 006216 9 during polymerization and recovery processes. 2. In the discharging and opening of the autoclaves as veil as In the drying process of the finished polyvinylchloride. The residual gas consists of up to 90% vinylchloride (6) and often leads to leaden tiredness and short-lasting disorientation in the employees. 3. From the polymer precipitation on the vails of the kettles. Therefore, from the technical viewpoint, it is completely possible that vinylchloride initiates the hereby described disease. Some facts are already known about the effect of vinyl chloride on human and animal organisms. The narcotic effects have long been recognized (22). Since 1958, reports have re- I peatedly been made concerning the angioneurotic obstructions and the Raynaud syndrome in workers (i, 10,' 21). In the literature one finds single references to the intoxication of vinylchloride, vherein a reversible dizziness, light to very noticeable giddiness, disorientation, giH" appearing as i. 4. a 2-degree burn, and lessened blood coagulation have been -* determined symptoms (6, 9, 11). One worker died as si re sult of poisoning. With the use of experiments involving animals, lung , * ** odem, blood congestion in the lung$ liver, and kidneys, as well as decreasing blood coagulation could be proven (20). In long term experiments it was possible to produce centrolobular degeneration in the liver and necrosis v/ith foamy vacuolization as well as periportal cellular infiltration (26). ucc 006217 10 . Recently, reports were made concerning skin, lung, end bone tumors and obstructions In the bone structure (27)* These results, based on animal experiments, lead again in 1970 to a depression of the MAK (maximum occupation concentration) to 100 ppm (13). It Is not yet known to us the regulations concerning gas concentrations at the occupational site* ,, , The symptoms related In the framework of this disease (Raynaud syndrome, toxic liver changes, obstruction in the' bone compositions and prenarcotic syndrome) may then be ..pro? duced by vlnylchlorlde* Thus, In the knowledge of the.occu- pational site we can express the conjecture that long term exposure to vlnylchlorlde is at least a, if not even the . disease-initiating factor. The fact that the name "occu-, <r J (_. pationally-caused acroosteolysis" hints only at a not necessarily determining symptom shows that a new name should ", *,. k j be coined. We have proposed the designation "so-called, vlnylchlorlde disease" for this syndrome because this diseas , influenced by the participation of numerous organs, obtains the character of a system disease. Pathogenesis The pathogenesis is, as before, unexplained. On-the basis of our research we discussed the theory that the diseas as a pathogenetic principle in the furthest sense is caused by an obstruction on the connective tissue or the vessel connective tissue. In'addition, as our theory shows that the toxic agent is effective not only per inhalationem, but ucc 006218 4 11 also perkutan, the fact exists that only uncovered main arteries exhibit scleroderma-like coatings and that the band-like os teolysis is only found on the finger phalanges. We saw sclerOdenna-like skin alterations as well as acroosteolytosis only in workers who had worked a long period with the cleaning of autoclaves. This can perhaps be explained by the fact that 600-1000 ppm of vinylchloride could be measured in the area of the autoclave walls (5). As an indication based upon the * obstruction of the connective tissues, we saw the qualitative and quantitative alterations of the skin and the multipli cation of collagenic fibers in the portal system of the liver. The increase and expansion of the capillaries was visible by capillary microscopy and histology in the upper cutis, in addition to the peripheral circulation obstruction proved clinically, angiographically, and thermographicallyi Even the alteration of the bone (osteolysis as a result of trophic obstruction by damage to the vasa nutrlcia) and the lung (restrictive and obstrictive ventilation blockage) can be synonomously explained. The prognosis of the disease judged quite optimistically by earlier literature-appears quite serious to us, especially with respect to thrombopeny, splenomegaly, and portal hypertensions According to our observations of alterations in the bone, this disease should be judged with reserve. Consequences for the Practice The triasslc formation of this disease system, serious UCC 006219 \z prognosis and relatively high mortality (from our investigation c certainly more than 10%) has led prevailingly youn men to sol icit us to place the following suggestions: 1* Execution of epidemologic and preventative medical experi mental tests. In our opinion, it is not sufficient any mor to search for only Raynaud syndromes and knotty skin alter ations because these symptoms , as characteristic as they are, already show the advanced stage of disease. Perhaps more _ . important, controls to determine the thrombozytic count in regular time periods should be given to all employees of PVC- producing industries. This should take workers with a con stant throabopeny out of this branch of the industry, as this appears to be the first objective symptom, before further and more serious internal damage occurs. 2. No employment given to those with liver diseases or circu latory problems. 3. Regular gas concentration measurements in different work sites to avoid exceeding the MAK limit. Experienced tech nical Improvement with the goal of greatest possible automation, andimprovement of the ventilation conditions to reduce the possibilities of gas inhalation to the lowest amount possible. 4. Compensation to diseased workers and recognition of this disease as liable to indemnity by inclusion in the list of BKVO. x More research, especially with animals, using vinylchloride with special consideration to the skin, bones, lungs, liver, and spleen. UCC 006220 13 BIBLIOGRAPHY: Uccratutt Anghc!v;u, M, Otmu, F, (Kibri- MfWV' L. G. Do**ntuvai. V, Gjnei: ConMikrjui dinrtO'patnzcnkc fvnoftknulm Riyntud U ainKiairii din mmIumcm polklofvni de \:nl. Med. intern* (Bwgil (IW.47J. (1) luaUcT, A. V,, A. N. Vum, A. G. Kochetkov; On the pschogcrmto f developing due in a long term expo*?* to ch dfav o( vinyl* dklondr. Gif. Tr. prod. Zabol. U (1973). 24. 09 Cboitia, A., F. Manikin: Un fdionw d`*cm-o*teoi>w d'wrigint penfernwmlle ct de coMrtifAft noMfttk n Fmom. I AadmL Elected* 4 (1947), 277. M Coctftr. J. C. rtno, M. J. ftlintl A. Sonin: Aowudotfii IWom c*c*it4m uwocft dm !* mini aMvctds an oectoyege d'limw daw Cah. Med. Travail 4 <194*|, ). (J9 Cook, V. A.. F. NL Ciever, V. D. Pi--a. H. J. Magnate*; Occupational mifpoemolyiii. II. An iodmliial hypan mady. Ank anitowB. Hldi 22 (1970,74. (Q Daaaigf, H.: Accidental pokoning If viayi dilorfde. Caoad. mad. Aaaoc. j. 12 (&ICDI, I2S, (7) Dinoian, 1. W, A. Cook, V. M. fliidHii, H. J. Megnaiuai Occopadonal avaomolyvi. I. A* cpidemmfegjal study. AcdL ctvinn*. HWia(19m,dL. 0) Dodaoo, V. N.t I. 0. Woman, W. M. Wfciukow A. N, M. Nw. K. J. Mipntm Otnpjfond am* mtlyiii. m A dinical mdy. Arab, wdn*. Hldi 22 (lf7])4 S3. m DoMta, L. j., R. I. Yam Ocrfi** rioftal kaaaedt and diagnostic rennet, lillaria No. iC (1933). tulle(m No. 41 (1940. UAA. Deyr* Labor, imtn kti Pmitgit L dfbatacioo. PwlMaF<wndm dm bi> dm KordrlMui'Yndilfli. Nr. ISIS (WmrdeunUftcr Vetlag; Koto IMG* (ID Jiihe. S.. C. Vdiman: luf Klimk der tog. Vuiyid)orkl-K.rank.\ctt I. Inter* nationalm Symptmum dcr lntiimv dcr dteauadtft Industrie, 27. 4,1972; (Id Joke S., C'E. Lange? ShUruJtnuia* anige Hawmkfufl((m Raynaud- * Syndrom and Akrooa^olymp bet Ar* bdtnrvi dcr FVC-bmtcllcndo Industrie, DtaJt. mod. Wdr. 97 (1973;, 1922. (17) JfihcX C-E. Leap. G. Sum, G. Vefcatam Zor Kliaik dcr tog. Yinyb AbridKoakhtit, JjHftsr*pang Ocundo GcwUtdtaft (Sr Arbeittmedhi*. 24.10.1972. (lg) Lange. C*-E- S. jdba, G. Smtn, C. Vdtnuat Die an*. VinylAloridKrankbdc * cine bcrWtbfdicpe Syram akkroml tot. Arm. Ariieitimml, im. . Dtadb mftt, *. Midi* C. VdtoaR lota#. Kfeitp. ia >!> dor to, Va|ii jfcW^Knuttat jahranfuf Dm s. im.irti. ''iirlhttufi flip flrtiiinMiliii. it. at) Mwwm. L. A. M. RMr. H. Onjpae. H. Dwi*r. Acn ink. boon nxiaiy al noyl (Uoriic w Umn* wbihi Amcr. ifttawr. Hrt- Aw. J. 21 (1M0i JFP; bom at Mali* LL.LL Zic&abMJi . InduwrUi TmMw ..4 DnMb, m to. Piotbactm. ami Fiwniia, mi ' Fbtda JWw AMMdM Itwi.. Ul) OttMT. L >.I A MW iwpiiii m1 Am* k bn. J. mamp. Mmi. Udtnn.iM. (22) PMpIn. A. S., C D. Lake TW mbik hm mi fkilp Aiankf. j. PhuwMt. up Ttof. *t nN. 2M. (23) Swb. C.. 5. JuIh. C.-L. Lao*. . C. Vattnuic IndiMwif. Onsoiria i. da t^pAaiao*. 4m Hiklbitlit Fotodw. Uwpnir. Ill (1IF3L Ml . (M Fabaon, V. L. L ]. talakH.ia.aa. C. 1 Cio.ibirt Hypaamic aadidna. i. *i pwdiwiM ml *l AMA. Ci|. Tr. ptmL Zlboi t (ttitl. i uan i. NMk Ha.kH Eiapm. Aban. ao (1FU| lb,HF<. Oil Hwria. D. K.s Haakk pblm i. it MMlM.I Ml vac of ploiio. Me. J. abn: MM. It (IF5JI. 2i>i Matt im Make.. K. L.L L Zitlhai. Ml Muni Tukalufr and Dim. .h|p i. ta FlwivcnM ami Fnaacaai., mi Ftaa.a (Cbcaacr: AmafcfVaoi INH. ML 021 Kinb. D. *.. V. C. F. Ataaui An. .ilaulyaii ocmtui m wa aapjpil Im A* pplfMimw. pi uipl dilupMt. Ml. mr4. |. IMP.J. 712. (U) KmaUtr, H. |Hnp|i CpmA WioacMtla^c Arbciraaaoart. Tuaikvhm tMaafbinpipl iiarttrlapnapantap. UALVpnn (I ulp| Qaemv. Went, hta IF72). 04 JappPr. H.I FhPfHci* Dcrrtibla* PV*ttkPJ.kHtn to S;n,rl ikr Hl.kis- 04 Spm. G. I. JIM. C-t. In* G. VrtauO! Skdetracrindenoft. M dtt up. VwyUHloavl-Kjppikbqpbatpnpfaaii. Dpopfc. (23) Smm, L. j. Dpcimu, M. Vabakui CMribnii U anatnal IMakaiiiilM proA,pc dc ckanara 4c aM. IM. acema (Ik) li (1ML. PC'. (2D TopMha., T. L, F. OpK V. K. koa. Tka tvaibtF iaI anal tbldp a, JrtapaiioiC bp npPaipA pipawp to labnnwPF >wab. Amet. aatvier. Hyp: Am. ]. 22 UMI). lit-, inn in M.Ipco, K. .. IL L. ZkUnb icLIi IntuBpnal Tv.iaabpv aotf Diimjaclagy i. rim FfMaciM. anil FtoaHtap uf Hilda (itacract: Amateflam IPMp. (277 Viola, F. 1_, A. K*am. A. 6pM OaiupmiM iflpmp oP rap akm. In* an4 bPpl aa nap! tTilorata. Caocat In. 31 (IP7I|. ill. (2D Witama, . H.. W. t. McConakt. C F. Tatvm. J. L. Creedi: Oupiiiaail wwatpatyiip. J. Amt. met. Am. 201 (IH.1. J77. Or. Suiinne liiJie. Dr. C.-E. Lsnte, Dr. G. Smm, Prof. Dr. G. Vdt.nan UnivtM:cin-Hau:k!inik J3 Bonn I, Vmupbcr( I ucc 006221 CONFIDENTIAL. Copied by MCA. January 30, 1974 Translations Unit/?R.12.897b/'^nB/VS 8 January 1974 PVC GAS: 40 MEN TAKEN ILL Doctors say: "Very serious" Reference: KUlner Stadt.-Anzeiger, 14.12.73 EB Troisdorf - More than 40 workers at the Dynamit-Nobel Works in Troisdorf bei Siegburg have been attacked by a severe illness which is brought on by gases released during the production of the plastic polyvenyl (sic) chloride (PVC). Doctors at the Bonner Universitfltskliniken (Bonn University Teaching Hospitals), who have been studying the PVC-siekness for some time, describe it as very serious. It can, in severe cases, prove fatal, particularly in younger men. The most serious symptoms are said to be sensations of giddiness and cold, headaches, swollen finger joints, bone atrophy, difficulties in breathing, reduced blood clotting capacity and liver damage. (See Panorama) `re circulation Mr G J Sleddon, DSO-320 Dr D Winter, F-11 Translations Unit, R-J/3 ucc 006222 Copied by MCA. January 30, 1974 Ref: Weser-Kurier, No. 300. 20.12 1973. p. 11 Insidious Disease Chemical Workers threatened bv Hideous Disease due to PVC Gas Poisoning Bonn Ministry seta up Special Committee of Enquiry Bonn (our own correspondent). Chemical workers directly engaged in PVC autoclave production in large.chemical factories are threatened by a new and serious disease. At least 40 employees of a Troisdorf factory are reported to be poisoned by dangerous vinyl chloride gas. "A serious prognosis" for the/ victims, according to the Bonn skin specialist Professor Gunther Veltmann. Mortality from PVC gas poisoning is, reported tobe "relatively high" and particularly serious in young male workers. According to the medical specialists the frightening consequences of the gas poisoning are reflected in the softening, of the bones in hands and feet, enlargement of liver and spleen, ^ severe effects to blood formation and coagulation, and as sociated grave lung disorders. The victims have increasing difficulty with breathing, and varicose veins can form in the esophagus. This previously unknown disease, according to Professor Veltmann, is "irreversible," i.e. incurable. No remedy has so far been discovered, and the only thing that can be treated, is the defective organ. The victim can only look forward to in creasing disablement and insidious encroachment of the disease. Experiments on animals are now being commenced to study the causes arid course of the illness and to find antidotes. This evil disease is not even recognized yet as an occupational illness. As a result of the alarming medical reports. Federal Labour Minister Arendt has set up a special committee to in vestigate and report back. The more seriously affected victims are now claiming disablement pensions. However, they have as yet no entitlement to a pension, since this particular illness is not yet officially recognized as an occupational disease by the health authorities. * The Committee for Dangerous Raw Materials of the Federal Labour Ministry considers that regular medical inspection of workers engaged in plastics production is essential. Guidelines UCC 006223 for technical countermeasures in respect of health hazards are also being drawn up. Local factory inspectors have already ordered individual firms to introduce appropriate safeguards. Meanwhile, the Troisdorf workers have levelled the serious accusation that they were used as guinea-pigs. One employee, aged 39, a sufferer for some 18 months, is reported to have swollen hands and feet with no more feeling left in them, and is afraid to venture on the street because of dizziness. He first became aware of the unusual symptoms when cleaning out a PVC autoclave three years ago. Another 47-year-old chemical worker attributes his chronic liver trouble to the poison. According to Professor Veltmann, the effects of the gas on the liver resemble;the liver complaints suffered by chronic alcoholics. 1 The 160 workers on the Troisdorf' autoclaves have become particularly uneasy about the situation.' However, both manage ment and works council have emphasized that the employees directly involved are not really worried, in view of the fact that none has accepted the offer of transfer to other work'on the site. A different explanation, on the other hand, is that these same workers are the top earners in the industryJ It is they, who are responsible for producing the material which is subsequently processed by their other 2,500 colleagues. PVC is one of the most widely used,plastics, with countl ss applications in the home and in industry.. However, medical specialists emphasize that nobody can sufifer ill effects due to contact with PVC products. The only people at risk are the workers directly engaged on the plants in which the colorless vinyl chloride gas obtained from petroleum is liquefied under pressure and converted into powder in large reactor. The danger arises from the gas, which can escape during the process either as a result of leaks, carelessness, or during the cleaning of the reactors. The maximum permissible concentrations of such leakage gases have repeatedly been reduced by the responsible authorities. According to the Troisdorf works, "nobody has yet died and production has not been irresponsibly pursued at the expense of workers' health or safety; moreover, *no efforts have been spared to safeguard the interests of their employees." Hans Wtillenweber ucc 006224 ' TH 12903 Translation from Der Spiegel No 50/1973 Copied by MCA January 30, 1974 MEDICINE Dangerous Plastic A new and deadly occupational disease has been discovered by Medical Specialists in Bonn: workers engaged in the production of PVC risk incurable diseases of the liver* Pipes and Venetian blinds, curtains and films and whole host of articles in common use are made from PVC, a hard, durable plastic which can be moulded into almost any product. German producers alone have distributed almost a million tonnes of polyvinyl chloride over the country in the last year. PVC has so far been responsible for the death of as yet unknown numbers of chemical workers. For the production of this much desired material, w.iieh can be combined in so many different ways with plasticisers, fillers and pigments that it has become one of the leading products of the plastics age within the last twenty years, is apparently very much more dangerous than had been previously been assumed. Medical specialists of the Bonn University Clinics have this year diagnosed a "vinyl chloride disease" in at least 40 of the 120 PVC workers in a labouring chemical factory. However, the number of eases is probably considerably higher than this. According to preliminary comments made by the doctors this newly discovered "occupational illness" is characterised by a "serious prognosis and a relatively high mortality rate in men of predominantly younger age groups". According to Prof. Giinther Veltman writing in the "Deutsche Medizinische Wochenschrlft" : "Certainly more than 1035 as revealed by our enquiries1-'. * This occupational disease first came to the notice of dermatologist Veltman and his team in the form of characteristic changes to the skin, particularly in the fingers. However, they were soon forced to the conclusion that still worse was to be revealed by this already well-known PVC symptom : vinyl chloride harms blood and blood vessels, bones, nerves, liver and lungs. As summed up by Veltman : "A disease of the system". This plastics material apparently places at risk only those individuals actually present when the colourless vinyl chloride gas, obtained from mineral oils, is liquefied under pressure and compressed to form powder in the large reactors known as "autoclaves". This "polymerisation process" is necessary to- produce the PVC which is then sold as "Hostalit" (Farbwerke Hoechst) or "Vinoflex1' (BASF)t Products which are not toxic as far as the end consumer is concerned, unless, in the words of plasties experts, "Plasticisers migrate from them". Those cases in which these toxic substances have been liberated from such materials have indeed been reported for a considerable period of time. On the other hand, the "closed system" of the autoclaves gives rise tc dangerous leakages. The Bonn Medical Specialists have been investigating "possibiliti s of gas leakages and associated inhalation risks" at numerous points in the production process. VC-gas escapes when the reactors are discharged nod opened as well as through "leaks in the autoclaves". For many years doctors have been aware of the toxic nature of the gas and its narcotic effect. Almost without exception personnel engaged on the cleaning of autoclaves complain of feeling "dopey", giddiness and headaches. For this reason the "maximum allowable concentration" ("MAX") of the VC gas has been repeatedly reduced. According to Veltman, however, "we have so far not been aware of regular gas concentration measurements being carried out on production sites." UCC 006225 // // 2 Personnel responsible for cleaning the autoclaves - such as the majority of the diseased chemical workers - apparently inhale many times the quantity of the acceptable tolerable dose of the toxic substances. Industrial doctors in America have repeatedly measured gas concentrations of 1,000 ppm * in the neighbourh od of PVC autoclave walls, which is ten times the MAX value. The symptoms suffered by the diseased Bonn workers show that the air in German chemical factories is not very much better. The following changes in bodily organs has frequently been observed after only 18 months employment : Enlargement of liver and spleen with lasting destruction to the structur and function of their cells - collective tissues proliferate in th organs. Reduced circulation in the hands due to diseased narrowing of the arterial vessels. Finger bones gradually deteriorate, and were almost completely destr yed in cases of advanced disease. / Blood formation and coagulation were affected and breathing was- found to become increasingly difficult. The. majority of these illness-induced changes are considered non-curable by reason of the fact that the increase in connective tissues in all vital organs :s>f'irreversible". Specialists in internal'diseases accordingly hope at the mogt-for a "defective healing" in diseased livers;;. The chemical workers are ,leftfwith a thick-skinned and deformed organ such as that found in chronic alcoholics after many years over-indulgence -in felcohol. According to Prof. Veltman, the necessary "consequence" is "compensation for all diseased workers" and the recognition of the illness as an occupational disease.- Neither he nor his colleagues have ao far ventured to estimate the numbers of the victims of the PVC disease. Basic research into the medical problems of VC is also badly lagging. In the 100 year after the ability of vinyl chloride to polymerise was first discovered - in 18?8 - the doctors in Bonn are now demanding "experimental investigations in animals on the effects of the vinyl chloride with particular reference to skin, bona, -lungs, liver and spleen". * ' PTM : abbreviation for parta per million 3 parts (by volume) per million : a measurement unit used to indicate the quantity of trace substances eg in a gas mixture. Circulation: Mr G J Sleddon Or 0 Vinter Translations Unit ACH/MMB 9 Jan 74 UCC 006226 Copied by MCA January 30, 1974 Translations Unit/TR.12.897a/EHS/VS 4 January 1974 PVC DISEASE TO BE INVESTIGATED Reference: Frankfurter Allgemeine Zeitung, 20.12.73 Bonn/Troisdorf 19 December Many cases of illness among persons employed in the PVC plant at Dynaoit Nobel AG in Troisdorf have caused concern among the local population. As Dynamit Nobel AG confirmed on Wednesday, 43 workers so far have shown symptoms of the mystery illness, which is known only as "PVC disease" at present. Two foreign workers are said to have become completely incapable of working already. PVC (polyvinyl chloride) is a widely used plastic that is produced by a number of other chemical companies apart from Dynamit Nobel AG. How seriously the situation- is regarded is apparent from a statement issued by the West German Minister of Labour on Wednesday to the effect that the government had instructed investigations to be carried out into the hitherto unknown causes of the disease* Details are to be laid downin January by a panel of experts. According to the Ministry of Labour, the relevant employers' association is working on the assumption that the disease is caused by vinyl chloride. It was stated that the Ministry of labour Committee considers that operatives working in the neighbourhood of PVC autoclaves must be medically examined. When the various cases of illness became known local factory inspectorates ordered steps to be taken to provide increased health safeguards on the plant. The symptoms of the condition are unconsciousness, attacks 6f dizziness, changes in the hands and feet, headache and nausea. According to a report from the works in question, the first cases of physical damage to workers in the PVC plants were observed in Germany in the Spring of 1973. Dynamit Nobel have been producing PVC since 1951- The Press Section at the Troisdorf works stated that: The government industrial medical officer, in agreement with the Chemical Industry Employers' Association, has Instructed Professor Rudolf Gross, who holds the chair of Medeeine at the University of Cologne to examine some of the affected persons and to produce a report. 6 patients from the PVC plant have now been examined by Professor Gross at the university teaching hospital. A report on some of his findings will be issued in December. Copied by MCA Translation.* TR.12,917 January 30, 1974 Ref: Frankfurter Allgeraeine, Zeitung, 2 Jan 74 LIVER DAMAGE IN PVC PRODUCTION In spite of abundant warning signs no adequate supervision Like many other occupational diseases, the damage incurred during the production of polyvinyl chloride, or PVC, is only now, more than 30 years after the start of industrial PVC production, being fully realised. The scale of the health hazard involved in PVC production was first exposed in a publication by doctors of Bonn University Teaching Hospital (UniversitHtsklinik Bonn), who found skin damage, changes in the ends of fingers and toes, as well as liver and spleen damage, in 45 workers at Dynamit Nobel AG's PVC plant in Troisdorf, According to reports by H J Marsteller of the Medical Klinik and Susanna Juhe f the Skin Klinik in the "Deutschen Medizinischen Woehensehrift" (Vol. 98* p 2311), 45 of the 120 workers in this plant have so far been exhaustively examined in Bonn. Some of these patients were suffering from skin changes, in others the examination was carried out on prophylactic grounds* Most of these workers were found to be suffering from various types of liver damage of obscure origin. In addition to enlargement of the liver, biochemical malfunctions of the liver were detected. Histological tissue changes were finally established. -'~& Since, in spite of the diversity of the liver changes all the patients hsd been engaged in PVC production for 1.5 to 21 years. This can only be an occupational disease involving FVC. In 1963 circulatory disorders, inflammation and hardening of the skin, thyroid deficiency and enlargement of the liver in PVC workers were reported for the first time in Roumania. It was only after re-publication of this work in 1967 that similar observations were reported in Germany, France, England and the United States. But here the emphasis was on changes to fingers and toes. This led, according to the Marsteller and Jtihe report, to "att nti n being directed to the liver damage first noted in PVC production in the Soviet Union in 1949". The scientists are making no statements about the prognosis of the PVC liver damage. Even the frequency of this illness among other PVC producers is unkn wn. Possibly the threat to personnel is heavily dependent on local working conditions. Sines the morphological picture of these liver changes corresponds to chronic toxemia, such as also occurs from contact with chlorinated hydrocarbons, eg chloroform, the health risk could be determined by the concentration of th gaseous initial product, vinyl chloride, in the atmosphere. Since such a hazard was certainly not unforseeable, and must indeed have been expected in view f the existing piblicationa, the question arises as to whether either the v.nyl chloride concentration or the health of the workers were properly supervised in theee plants. ucc 006228