Document n9pKEK28GqdR4vy5wgbemVyYR

FILE NAME: ZW^W^ DATE: DOC#: W^ DOCUMENT DESCRIPTIONW:Z Ugeskrift for Lceger [Doctors' Weekly], Copenhagen Vol 112, No 37, 1950, pp 1284-1289 THREE CASES OF ASBESTOSIS by J~rgen Frost* Sumnary Three cases of asbestosis are discussed. In two the X-ray films were typical; in the third there were also nodular modifications. As a possible explanation of this it is pointed out that in this case the patient had worked with very finely pulverized asbestos, so that the mechanical effect of the asbestos needles was not prominent in the pathogenesis. Knowledge of the disease and precise occupational anamnesis are necessary if the milder cases are to be recognized in X-ray photography~ e.g. in routine examinations for tuberculosis. In Ugeskrift for Lceger~ 1950, No 14, Torsten Ive became the first to publish a case of pneumoconiosis caused by asbestos here in Denmark [5]. It is mentioned in the article that in recent years a total of four cases of this disease have been found. These four cases were diagnosed in examinations of workers in threatened jobs, instituted by the factory inspection service, which has had its attention directed toward this risk since the middle of the 1930's. -The disease presumably is not rare in Denmark, at least in its milder forms, so that there is reason to report additional cases as well, at the same time going into more detail on specific points. Asbestosis will presumably not be diagnosed unless the occupational anamnesis is compared with the clinical findings and the X-ray picture, since it is characteristic of asbestosis that the roentgenological modifications are slight in comparison to the often considerable reduction in heart and lung function. This is in contrast to the situation in silicosis, where the roentgenological modifications are evident even in the cases described as mild, and where marked roentgenological modifications are often found together with a well-preserved functional capacity. *Of the Labor and Factory Inspection Service and the Occupational Medicine Clinic of the National Hospital, headed by Prof Dr P. Bonnevie, chief physician. - 1- ., The roentgenoZogicaZ findings are in agreement with the pathoanatomical picture, since, as pointed out e.g. by di Biasi [2], there are decisive differences between the two types of pneumoconiosis: asbestosis is a diffuse interstitial fibrosis, beginning low in the lungs and often accompanied by basal pleuritis and an upward development of emphysema, while silicosis is characterized by the nodular modifications which begin in the midmost portion of the lungs. It is now more or less agreed that the granulomata in silicosis are due to the effect of crystalline silicic acid, even though the relationships are far from clear and for many years the view prevailed that only the inhalation of particles consisting of free silicic acid was dangerous. Also, the dangerousness of the dust seems to increa~e with decreasing particle size 1n keeping with the fact that for the most part only particles with a diameter of less than 5 make their way down into the alveoli and that particles with a diameter of about 1 are especially dangerous. It is still not clear how particles of still smaller diameter behave; there is a good deal to indicate that they cannot be retained in the alveoli to the same extent, and for the most part are suspended and carried out of the alveoli in exhalation. It is now clear that certain salts of silicic acid, such as asbestos and the closely related mineral talcum, are also capable of causing a pneumoconiosis --sometimes called silicatosis. As far as asbestosis is concerned, the question of the pathogenesis is not completely decided, but the general opinion now is that the mechanical irritation from asbestos needles is a necessary factor in the occurrence of the fibrosis (Sundius and Bygden [13], Beger [1]). Gardner [3] (see also [7]) showed in experiments with animals that in contrast to quartz and other forms of crystalline silicic acid, whose toxicity increased with decreasing particle size, the reverse is true of asbestos. He found its pathogenic effect only in the lungs, while quartz also has a pathogenic effect in other organs or when injected subcutaneously, and for that reason he thinks that it is only in organs where a rhythmic motion takes place, and only in particles large enough to have a mechanical effect, that asbestos can cause a fibrosis. King et al. [7], on the other hand, f?und in experiments with animals that in rabbits a nodular fibrosis developed that can be compared with an experimental silicosis, after inhalation of asbestos fibers 15 in length, while inhalation of fibers 2.5 long brought about a diffuse interstitial - 2- fibrosis. The circumstances are thus far from being clarified. In man, too, there are presumably varied asbestos pictures; e.g., Wedler [14] says that X-ray photographs of workers in different German asbestos plants showed somewhat different pictures. Besides differences in particle size and other physical circumstances this may presumably also be due to differences in chemical composition, since there are several kinds of asbestos. (Commercially the two main forms are amphibolic asbestos [horneblende] and chrysotile asbestos.) From Finland, Noro [11] has reported two cases of fatal outcome which were due to inhalation of Finnish asbestos (amphibolic asbestos), which is harder and more elastic than other asbestoses and is therefore regarded as especially dangerous. The asbestos needles found in the lungs were chiefly 9 in length or a little shorter, and the thickn~ss was always less than 1 . This is smaller than several other reports; e.g., Wedler says that the length of asbestos needles ... is generally between 25 and 150 and their thickness up to 3 , while Koppenhofer [8], in examining the same lung, finds that a very large number of the needles are far smaller--length 2 to 6 , thickness 0.006 to 0.01 . In that connection the same author discusses in detail the pathogenesis of asbestosis and the significance of the asbestosis bodies. A thorough discussion of asbestosis is to be found in Lanza [9], Merewether [10], and Wedler, with bibliography. In the last two works there are statements about large masses of clinical material. Course of the Disease Asbestosis rarely develops roentgenologically or clinically in less than 5 years even with great exposure. Of 310 from two German asbestos plants who were examined by Wedler, asbestosis was found in 22.6 percent, but only 7.7 percent were in Stage II or higher according to a clinical classification into Stages 0 to III. The tables show that with a working time of Oto 5 years (which em- braced 2h of the group), asbestosis was found in only 3. 3 percent and only Stage I. During the succeeding 5 years the percentage goes up to 60, but chiefly with mild cases. With increasing working life the percentage of more severe cases rises. Merewether reports examinations by the Silicosis and Asbestosis Medical Board in which among 749 examined with a working life of less than 5 years there were only 4 cases of asbestosis, while one fourth of those who had been employed for 20 years or longer were affected. In an examination of 1,512 workers the ratio - 3- of asbestosis cases among groups with 0-4, 5-9, 10-19, and over 20 years' exposure time was 1 : 5.6 : 30.4 : 53.2. But, as Merewether points out, it cannot be deduced from this that exposure for less than 5 years is without risk, for inhalation of asbestos dust in sufficient quantity even for a short period can lead to an incapacitating asbestosis if the person concerned lives long enough. Merewether states that an increased concentration reduces the time before asbestosis has developed and can be detected, but that this applies only up to a certain high concentration. If the concentration is increased further it will not lead to a further reduction of the time for development of the fibrosis, the "maturation period." On the other hand, an exposure to a concentration below a certain low level does not bring about an incapacitating fibrosis within the average working life.~ Thus a minimum amount of asbestos dust must be caught in the lungs to develop a fibrosis of significance, and a certain time must pass before that fibrosis is developed. Merewether makes statements that indicate that the risk in working with asbestos is comparable to the risk in silicosis-threatened occupations, and in fact is greater if anything. In cases with fatal outcome the average working time is 15.2 years for silicosis as compared to 13.3 years for asbestosis. Not all work with asbestos is equally dangerous. According to the literature processing raw asbestos (crushing and grinding) seems to be especially dangerous, but the manufacture of insulation mats also has a bad reputation. The dust developed in spinning, on the other hand, is said to be slight. The actual mining of asbestos takes place in the open air, so that the dust concentration may be assumed to be low. In Wegelius's material from Finland [16], however, which consists of 126 asbestosis cases out of 476 persons examined, 34 of the 126 cases involved workers who had worked exclusively in the mines. The prognosis can be gathered in part from what has been said. Wedler finds in follow-up examinations that among workers who were only exposed to a lesser degree and had contracted only an incipient or fairly mild asbestosis and subsequently left the dangerous work the majority showed only slight progression after observation times of up to 17 years. It was different among those who continued with the work. Here there was a progression, but it rarely exceeded one stage (in the clinical classification) in 3 to 4 years. Wedler does -4- not think, therefore, that it would pay to reexamine persons already affected at shorter intervals than that mentioned above. Wegelius has similar results: after an observation time of 2 years there is progression in a number of cases (maximum of one stage according to the roentgenological classification). The very pessimistic outlook for workers in the asbestos industry that appears from these studies presumably no longer holds. At any rate many of those studied were exposed to inhalation of asbestos dust at a time when the danger was not yet evident or the risk was not generally recognized, and there were no antidust precautions in the system. The efforts to combat dust arose on the basis of these studies. Even though the average risk may thus be assumed to be far less now, there is obviously no guarantee in the inaividual case. The prognosis in the individual case is difficult to arrive at, for it depends on many other factors besides the development of the fibrosis itself, e.g. the individual's resistance to bacterial infection, complicating diseases of the heart and lungs, etc. As in the case of silicosis, the inclination now is to assume that asbestosis does not predispose patients to pulmonary tuberculosis in the sense that individuals with asbestosis get pulmonary tuberculosis more often than others when the exposure to tuberculosis is the same. It is another matter that if a case of asbestosis is complicated with tuberculosis the prognosis is presumably worse. On the other hand, there are now many concurring reports that primary bronchial cancer is more common among persons affected with asbestosis. Hamburger [4] presented a survey in 1943 of the cases reported up to that time and said that with his own 3 cases at least 19 cases of primary carcinoma of the lungs had been reported. The frequency in his own institute is 4 carcinoma cases in 8 asbestosis autopsies. Wedler [15] states that in Germany a total of 4 carcinomata have been found in 29 autopsies of asbestosis patients, and that in the world literature 14 have been reported in 92 autopsies. Although the frequencies are widely varied and the material small, so that the percentages given are uncertain, there seems to be no doubt that asbestosis predisposes to lung cancer. Antiasbestosis measures follow the usual lines: incapsulation of the dust-raising work processes, local removal of dust by suction, room ventilation, and, lastly, personal protective devices such as masks. As usual, there are -5- efforts to make the last-mentioned unnecessary, since they hinder the work and masks are uncomfortable to wear, so that they are rarely used. The Author 1 s Own Cases First a brief description of the working conditions in the factory where the case described by Ive arose. The factory produces building materials (slabs, boxes, pipes, fittings, etc.) of a mixture of asbestos and cement. In 1940, at the request of the factory inspection service, 30 workers with working times of 1 to 12 years were X-rayed. The films were sent to Prof Flemming M11er for appraisal. No sure case of asbestosis was found. In 1948 X-ray films of three workers with long working times (11, 18, and 18 years) still showed no asbestosis. The workers were also checked at the local tuberculosis station. After the case described py Ive was confirmed, 14 other workers with working times of 9 to 42 years were examined, and no asbestosis was found among I.. them. Over the years the factory had been repeatedly inspected and improvements had been introduced in the form of incapsulation of work processes and dust re- moval by suction. The dust danger was especially present in the crushing and grinding of the raw asbestos (Chile mill and disintegrator), where the filling and emptying was done in part by shoveling, and in work with the ground asbestos in the silos where the trucks were loaded by shoveling and in the "hollanders" where they were dumped out into the cement mixtures. At the time of an inspec- tion in 1949 it was possible to take dust measurements. The asbestos used was very "short," since it is a waste product unsuitable for spinning that is used. Accordingly, the true needle content was between 20 and 30 percent of all parti- cles. Here are a few of the measurement results (furnished by D. Stubbe Teglbjcergof the factory inspection service's laboratory for occupational hy- giene): Particles/cm3 Asbestos Particles/cm 3 0.5 to 5 2-15 15-120 Chile mill during emptying and filling 990 85 150 Hollander during filling 5,500 350 800 The results of the measurements at the disintegrator and in the silo fell between these figures. According to Johnstone [6] the highest permissible concentration is 10,000,000 particles 0.5 to 5 in size per cubic foot (corresponding to about 350 per cm 3). - 6- Case Histories Case 1. Weaver, born in 1895. Work anamnesis: Was employed for many years in a factory where asbestos weaving is done on a rather large scale, for the manufacture of brake bands, etc. Since 1928 has operated a weaving machine equipped with a dust-suction system. To what extent the suction system was effective earlier is hard to say. Upon inspection it was not in order. Anamnesis: Says he was formerly healthy, aside from a phlegmon after an accident. Present illness: After several years' work at the weaving machine he began about 1930 to suffer from bronchitis. He was treated for it in the hospital in 1937 and 1943. In 1945 the symptoms increased; he had coughing, expectoration, and spells of difficulty 1n breathing, and had to be assigned to light work. After an inspection at the factory in 1945 the factory inspection service borrowed the X-ray films that were taken in 1937 and 1943. Prof Flemming Mller got the films for appraisal and said: The X-ray of 1937 shows a very coarsemeshed, somewhat blurry marking of the lungs on both sides; there is also reduced translucence of the lungs, and there can be no doubt that there is something pathological, in all probability an incipient asbestosis. On the X-rays of 1943 the modifications are seen to have developed; there is now a further coarse-meshed and dense marking in both lungs with the mesh boundaries somewhat blurred and in places running together to form irregular little spots. Left phrenicocostal sinus somewhat flattened. The picture is typical of an asbestosis at the transition to the second stage. The case was reported to the accident insurance agency and was recognized as an occupational illness. He was bedridden most of the fall of 1945 and had to stop work completely. The condition gradually grew worse, and he died in February 1948 (no autopsy). Working conditions have been improved since; there is effective suction at all asbestos looms, and the exposed workers are reexamined annually. It is said that no more cases of asbestosis have been found. Case 2. Shipyard worker, born in 1894. Work anamnesis: Employed at the shipyard since 1918, since 1~35 insulating pipes, both aboard the ships and before installation of the pipes. Used asbestos cord and asbestos cloth; in recent - 7- years rockwool and glasswool as well. In 1945 he was advised to get other work and got a job as night watchman at the jail, which he held for a year and a half. Since then he has worked at the shipyard again, as a general unskilled laborer, but now and then he assists or relieves the man who took over the insulation work after 1945. The work on shore was done in a little shed with no particular room ventilation or local dust suction. The pipes to be insulated were up to 5 meters long. A noticeable amount of fluff and dust is given off during the work. The dust generation on board seemed greater, and it, too, was done with no removal of dust by suction. Anamnesis: Healthy when a child; young. Has never had rheumatic fever or lung complaints. Bothered by lumbago for a number of years. Present illness: Since the lung inflammation in April 1941, suffers from increasing shortness of breath and heart palpitation under exertion and by shooting__pcJ.ins and wheezing in the left side of the chest and behind the manubrium sterni in deep breathing and under exertion. Also irritating morning coughing, but rarely expectoration. Was tired and lost 12 kg in weight; for that reason was examined by a tuberculosis specialist in 1941. Was sent to hospital in 1941 and 1942, diagnosis pleuritis sicca sin. and nervosism. Has since been examined at the tuberculosis station several times; no sign of active tuberculosis has ever been found. Mantoux test positive. Ventricular septum negative for TB. Blood sedimentation normal the whole time. In 1945 he complained of pains in the right side, and signs of pleuritis were found here, too. After that he was advised to change jobs. In 1948, after his union had applied to the factory inspection service, he was again X-rayed and the films were sent by the factory inspection service for appraisal by ProLFlemming Mller, who gives the following description: The X-ray of the thorax shows that in the lower part of both lungs there is a slight but quite diffuse condensation, symmetrical in both lungs and partly obliterative. In addition, on the right side there is a flattening of the phrenicocostal sinus with adhesions to the dome of the diaphragm. This represents an asbestosis in a relatively early state (Figure 1). The case was reported to the accident insurance agency and recognized. Examination by a medical specialist the same year showed: objectively: - 8- average state of nutrition, dyspnea after even small exertions, cyanosis. Eyes, fauces, tongue: nothing to report. Thorax of natural shape apart from depressions over the clavicle. St. pulm.: boundaries shifting. Damping and weakened respiration on both sides, especially in the lower portion. St. cord.: boundaries indeterminable, ictus inside the medioclavicular line, sounds pure, action regular. Other examinations brought out no abnormalities. Quietly walking up one flight of stairs speeded up the respiration. Blood pressure: 150/90. Sedimentation rate: 12 mm/I hour. Electrocardiogram: nothing definitely abnormal; in particular, no sign of dextral influence. X-ray: unchanged conditions. His working capacity was judged to be less than one third, and in the first settlement he got compensation corresponding to 70 percent. He has since tried out at various lighter physical work, but could not do it. He even had to give up a newsstand, because in the winter of 1949-1950 he could not stand to bring out the newspapers. He was becl,ridden most of the winter, and his condition seems to have worsened during this last year. Case 3. Laborer, born in 1908. Work anamnesis: Served apprenticeship as grocer. Employed as such until in September 1939 he got a job in a plant that produces mater:i,a:l for asbestos floors. The material is a mixture of pulverized asbestos and magnesia cement. The raw materials are received in more or less pulverized form in sacks, and at the factory the necessary weighings, crushing, grinding, and mixing are done, as well as the weighing of the finished powder in sacks. Dust is generated in almost all manipulations, but especially in filling and emptying the mixin6 machine. The manufacture was done in a single locale, and no arrangements were made for removing dust by suction or for artificial room ventilation. An attempt was made to create a draft by leaving the door to the yard and a window open, but that was quite inadequate. After it became clear in 1944 that he had contracted a lung disease, suction devices were installed on the machines. After that, he worked less in the factory, and for - 9- the last year he has been employed as a driver and in work at the buildings, where the powder is delivered in vessels and water is added. This process generates some dust, but is done as far as possible in the open air. Anamnesis: As a child he drank soda lye, and has since had to have treatment from time to time for esophagostenosis. Otherwise healthy. Present illness: During the winter of 1943-1944 he coughed a good deal, and for that reason the company had him X-rayed in 1944. Signs of asbestosis or silicosis were found (chief doctor Sv. Brre Larsen). The films were borrowed by the factory inspection service and sent for appraisal to Prof Flemming M11er, whose description reads: There is a densely confluent marking on the lungs, almost symmetrical on the two sides and containing quite fine little spots. The modifications are sligntly below the center of both lungs and suggest a silicosis in "t:ransition between the first and second stages. He was treated in the hospital in 1946 for pleurisy and has since been reexamined at the Central Station. In 1949 he was treated for double pneumonia. Since we did not succeed in getting him to come to the occupational medicine clinic of the National Hospital, the X-ray films were borrowed from the Central Station. Prof Flemming Mller's description reads: In the X-ray picture of 21 January 1946 an incapsulated exudate can be seen on the right side, together with the same densely confluent lung marking as described at the time of the previous X-ray examination. A photograph of 18 February 1947 shows, as remnants of the exudate on the right side, some thickenings of the pleura along the thoracic wall, a flattening of the phrenicocostal sinus, and a flattening of the right half of the thorax. In addition it can be seen that the lung marking is now quite blurred, almost like a diffuse condensation, symmetrical in the two lungs. The last X-ray picture, of 30 August 1948, shows that this condensation has increased still further, and there is now a border of pleural thickenings like a mantle along the lowest part of the left thoracic wall. What we have here is an advancing asbestosis. In January 1950 we succeeded in getting him to come to the occupational medicine clinic of the National Hospital for an examination, presumably because his condition had worsened and he had difficulty in doing his work. (He was discharged on 13 January 1950.) - 10 - Present condition: Complains of increasing shortness of breath. Can walk on the level, but has difficulty if he has to hurry. Also has trouble in fast cycling. He lives on the fifth floor and has to rest three or four times to get there. Slight coughing all day long, and is bothered by coughing at night as well. Spits up only a little phlegm. No palpitation or edemata. Smokes 15 cigarettes a day. Objectively: thin. Slight cyanosis of the lips. in undressing and gets attacks of coughing. Becomes short-winded Stet. cord.: Boundaries normal, sounds pure. P2 perhaps a little larger than A2. Action regular. Stet. pulm.: limits costae 6-10, displaced about 2 cm at the posterior surfaces. Chest measurement in maximum expiration and inspiration 79-80 cm. Sibilant ronchi everywhere, with here and there sonorous ones (has a cold). No damping or respiratory modifications. Other examinations bring out nothing unusual, except that the fingernails are somewhat domed, but that has always been the case. rate: mm 3 Height: 164 cm. Weight: 55 kg. Blood pressure: 115/80. Sedimentation 100 mm/1 hour. Hemoglobin: 120 percent. Erythrocytes: 5.95 million per Urine: no albumin, no sugar. Electrocardiogram: nothing abnormal. X-Pay examination of thoPax (Figure 2) shows by comparison with that taken by the Central Station on 30 March 1948 that the broad pleura border on the left side has now become much narrower. It is now only 1 to 2 cm wide, so that it is now possible to see the entire somewhat flattened left dome of the diaphragm. The lung marking itself, however, is quite unchanged. As before, both sides show a symmetrical, dense, almost confluent lung marking with rather clear, quite fine spots, especially in the lower half of the lungs. The heart is of natural shape and size. There is no sign of pulmonary heart. The diaphragm moves 2 cm. Functional examination: Vital capacity 1.45 liters (74 percent of total capacity), residual air 0.50 liters. Ventilation at rest 7.8 to 8.4 I/minute. Maximum ventilation 46 1/min. Arterial oxygen saturation at rest measures 93 percent with the oximeter. During work at 400 kgm/min. there is a pronounced drop in the arterial oxygen saturation (6 percent), and the patient gives up the work after 2 minutes' time. Ventilation during work 38 1/min., respiratory - 11 - frequency 46. Conclusion: Severe reduction of function, predominantly pulmonarily conditioned. There is a very low total capacity (58 percent of the calculated value), possibly determined too low because of insufficient blending, and little ventilative function. (J. Georg) Discussion Two of the patients (Cases 1 and 2) were X-rayed several times because of subjective symptoms, but but went under the diagnoses pleuritis sicca and bronchitis. The X-ray films in these two cases were characteristic for asbestosis, especially in the sense that there were only slight roentgenological modifications in view of the rather pronounced reduction of function in both cases. The X-ray findings were the usual ones in asbestosis: diffuse fibrosis low in both lungs with pleural thickenings_and reduced mobility of the diaphragm. In Case 2 the lung marking was somewhat finer meshed than in Case 1 and corresponded ~ especially well to the usual description of asbestosis lungs. There is hardly any doubt that knowledge of the X-ray findings in asbestosis and a good work anamnesis would have led to a diagnosis of asbestosis having been made and published earlier than was the case, and that those concerned would have been taken off the dangerous work, so that the prognosis would presumably have been less bad. In Case 3 the X-ray findings were somewhat different, in that there were also fine nodular modifications here, such as are seen in silicosis, especially in iron and steel cleaners. The diagnosis was made in this case, perhaps on that ground, at the time of the first X-ray examination, after 4 years' exposure and a short time after the first subjective symptoms appeared. The explanation for the fact that the X-ray picture deviated from the characteristic asbestosis picture may perhaps be that the asbestos used for asbestos floors is very finely powdered and is partly a waste product (asbestos flour). The very fine particle size may perhaps explain the more silicosis-like picture, since it is not the mechanical effect of the asbestos needles that prevailed, but the chemical effect. But, as stated in the introduction, the pathogenesis has still not been clarified. It has not been possible to find out in greater detail about the kinds of asbestos used, and there are no dust particle measurements available from the relevant periods of time. The subjective symptoms were those usual in asbestosis; Functional dysp- nea and coughing with little expectoration. In Case 2 it was stated that at the - 12 - beginning the coughing was the characteristic dry morning cough accompanied by pain and wheezing in the chest. The subjective symptoms appeared after 2, 4, and 6 years respectively. The corresponding exposure times were 17, 10, and 10 years. After that time the symptoms were so marked that the persons concerned had to stop working. No. 1 died 3 years later, No. 2 is now, after another 3 years' observation time, almost 100 percent incapacitated, and No. 3 is greatly incapacitated. In silicosis and asbestosis it must be taken into account that the lung trouble gradually leads to an overload on the right side of the heart, so that a chronic pulmonary heart develops. In the three cases discussed here it was not possible to show this clinically by electrocardiography or X-ray, not even in Case 3, where the heart was also_X-rayed in oblique diameters in order possi- . bly to be able to demonstrate a projecting pulmonary arch [12]. The functional test on the same patient showed an impairment, but principally pulmonarily conditioned. But lack of electrocardiographic or roentgenological signs of a hypertrophy of the right side of the heart does not exclude the possibility that it is present. Unfortunately, Case 1 was not autopsied. ;jf?_~ I certify that the staff mc>m6?r vvho t-::,nd,:tcn t:r0 foregoing is thoroughly fam,l.nr v. itl; th '7 and English languages en,-! tlv,t it is o true qr,.J -- 'J1 complete translation of document. (-~!-,, , -. the co I responding/~----,.,~_k Franklin W. Clark.~~ - 13 - . " BIBLIOGRAPHY 1. Beger, P.J., Archiv fur Gewerbepathologie und Gewerbehygiene [Archives of Occupational Pathology and Occupational Hygiene], Vol 6, 1935, p 349, 2. di Biasi, W., ibid., Vol 8, 1938, p 139 3. Gardner, L.U., American Review of Tuberculosis, Vol 45, 1942, p 762. 4. Homburger, F., American Journal of Pathology, Vol 19, 1943, p 797. 5. Ive, T., Ugeskrift for LcegerCDoctors' Weekly], Vol 112, 1950, p 472. 6. Johnstone, R.T., "Occupational Medicine and Industrial Hygiene," St. Louis, 1948, p 604. 7. King, E.J., J.W. Clegg, and V.M"". Rae, Thorax, Vol 1, 1946, p 188. 8. Koppenhoffer, G.F~, Archiv fur Gewerbepathologie und Gewerbehygiene, Vol 6, 1935, p 38. 9. Lanza, A.J. (edit.), "Silicosis and Asbestosis," London, New York, Toronto, 1938, p 439. 10. Merewether, E.R.A., Tubercle, Vol 15, 1934, pp 69, 109, 152. 11. Noro, L., Acta Pathologica et Microbiologica Scandinavica, Vol 23, 1946, p 53. 12. Samuelsson, S., "Chronic Cor Pulmonale, 11 dissertation, Copenhagen, 1950, p 389. 13. Sundius, N. and A. Bygden, Archiv fur Gewerbepathologie und Gewerbehygiene, Vol 8, 1938, p 26. 14. Wedler, H. -W., 11Klinik der Lungenasbestose, 11 Leipzig, 1939, p 152. (In "Arbeit und Gesundheit II CWork and Health], No 34. ) 15. Wedler, H.-W., Deutsche medizinische Wochenschrift [German Medical Weekly], Vol 69, 1943, p 575. 16. Wegelius, C., Acta RadioZogica, Vol 28, 1947, p 139. - 14 - uI ~ I U D G I V E T A F D E N A L M. D A N S K E L If. G E F O R E N I N G N R. 37 1 4. S E P TE M B ;:: R 1 9 S 0 1 l 2. A R G A N G . , l BUTALGIN tabletter 15 stlc , , , kr. 1.25 50 ............... 3,05 100 "' ,.., "" 5,30 BUTALGIN llquldum --4I I 5 ml .. . . kr. 1,80 50 - .............. - 5,30 100 ...... , ....... 9,b0 BUTALGIN pro Inject. 10 ml I h1etteglts .. kr. 2,90 BUTALGIN aupposltorler 1esker i 10 stk...... , kr. 3,05 ' i I befrier for selv de I strerk ) llI I L r 1277-rlO ~ l 'amrw rrr j ':lolger Danskes~ej 89 I 1 . i ~ ! . 'i 'l .,l <I :;:, I I 11./ .,,TILF.ELDE AF ASBESTOSIS A{ J(l)RGE.V FROST I Ugeskrift for Lregcr nr, 14/50 har Tors t c n I v e som den f~rsle h<'r i landet offentliggjort ct tilf:l'ldc af 1meumoronios{' frl'mkaldt af ashcst (5). I ariklcn nrevnes, at der i dt' sencre Ar ialt er fundct 4 tilfrelde af dcnnl' lidelse. Disse 4 tilfrelclc ('r 11ingnoslil'ercdc \'l'd u111ltrs~gclser af arbcj1krnc i de trucde crhvcrv, foranlcdigl'l af fabriktilsynl't, dcr sidcn midten af trl'dhcrne har haft opmrerksomhl'dcn rctll'l mod dcnne risiko. Lidelscn er nnlagelig ikkc hell sj:l'ldcn her i lnndet, i hvcrt tilf:cldc ikkc i de lcttere former, og der vii derfor va>rc grund til ogs:\ at offentliggJSre de JSvrige tilfrelde, samtidig med at man gllr nrermerc ind }>:\ cnkcltc punkter. Ashestoscn vii antagclig ikke blivc diagnosticcrct, mcdmindrc arbejdsanamncscn sammenholdes med dct kliniske fund og rJSntgcnbillcdct, da dct karaktcristiske for asbestosen er de ringe rJSntgenologiske forandringer i forhold til den oftc bctydelige neds:l'ltclsc af lunge- og hjertcfunktioncn. Dcttc er i modsretning til forholdenc ved sili cosen, hvor de r~ntgenologiske forandringer allcrcde ved de tilfrelde, dcr bell'gnes som Jette, l'r tydeligl', og h\'Or man ofte finder udtalte rpntgl'n ologiske forandringcr sammcn med en velbevaret funktioncl kapacitet. R',intnen{llndene c-r i o,<rc-nsstc-mmclse med dd pathologisk-anatomiske billc-ill', idet dcr, som f. ex. d i Bi as i (2) har fremhrevl'f, er af,::prmde forskcllc mellem de nrevntc to pncumoconioscr: ashesloscn er en diffus, interslitiel fihrose, begyndende nc-dad i hmgcrne og ofte lrdsnget af bnsale pleuriler og cmfysemudvikling opadtil, medens silirosen l'r kar:ikteriseret vl'd de- no1!11l:trl' forandringcr, dcr bcgynder i de midllrstc lungeafsnit. Der er nu no~enlundc- cnighl'd om, at granulomcrne veil siliC'osc skyl,les virkningen nf den krystallinske kiselsyre, selv om forholdene langt fra er afklarcde, og i mangr Ar hcrskl'1le der dl'n opfattelse, at kun indanding af partikll'r best:\endc af fri kiselsyre var farlig. Ligcledes synl's stpvets farlighcd at tiltagl' med aftagendc partikelstJSrrelsr i overcnsstrmmelsl' ml'd, at hovl'dsagelig kun partiklcr med en diameter mindre end 5 my trrenger ncd i alveolernc, og at sa-rlig partikler med diameter omkring 1 my er farlige. Man er endnu ikke klnr over, hvordan partikler med l'ndnu mindre diameter opfprer sig; meget tydl'r pl\, at disse kun i mindrc grarl tilbagehol1Jc-s i alvroll'rne, i1kl rlc som s,revl'dygtigc oftest ntll'r rpres ud ]wrfra ved exspirationen. :Man l'r nu klar over, at ogs/1 vissl' af kiselsyrens salte, f. ex. ashl'st og def na-rtst/lendc mineral talcum, er i stand Iii at frt'mknldc en plll'Umo<oniost Fra arhcjds- og fahriktilsynd og Higshospitalcts arhcjdsmcdicinskc klinlk. Chef: Profcs~or, o,crlagt, dr. nwd. I'. IJ01111e11ie, 1281 - af og tit benrevnt silicatosc. For asbestosens 1 vedkommendc er spprgsmalet om pathogenesen ikke helt afgjort, men den almindelige mening er nu, at den mekaniske irritation fra asbestn&lrnc er en n~dvendig faktor ved fremkomstcn af fibrosen (Snndius & Bygden (13), Beger (1)). Gardner (3, sc ogsa 7) har i dyrccxpcrimen ter vist, at i modsretning til kvarts og andre for mer af krystallinsk kiselsyre, hvis toxiditet tiltog med nftagcnde partikelstprrelsc, er det modsattr tilfreldet ved asbest. Dennl's pathogene ,irkning fandt han kun i lungerne, mcdens knrts ogsa i andre organl'r eller injiceret i subcutis virker pathogent, og han mcner derfor, at det kun er i or ganer, hvor der finder en rytmisk bevregelse sled, og kun ved partikler af en for mekanisk virkning tilstrrekkelig slprrclse, at asbest kan fremkaldc en fibrose. Ki n g og medarbejdere (7) har imidlcr tid i dyrel'Xperimenter fundct, at der hos kaniner udviklcde sig en nodulrer fihrose, der kan sammenlignes med en experimentel silicose, efter in halation af 15 my lange asbl'stfibre, me1lens inhalation af 2,5 my lange fibre frembragte en diffus interstitiel fibrose. Forholdenc l'r s:\ledes langtfra afklarede. Ogs;\ hos mcnnesker findcs antagclig forskel Jige asbestosebilleder; f. ex. anfprer W c d I c r (14), at rpnlgcnoptagelser fra arbejdl'rc i forskel-lige tyske asbestfabriker viste ct nogl't forskelligl billede. Foruden forskel i partikelstprrclsc og andre fysiske forhold kan dettc antagelig ogsl'I skyldes forskcl i kemisk sammensretning, idct der findes flcre asbestarter (handelsmressigt de to hovedformer amphibol-asbest (hornblende) og chrysotil-asbest). Fra Finland har N o r o (11) offentliggjort 2 d~Sdeligt forlJSbne tilfreldc, der skyldes ind:\nding af finsk asbest (amphibol-asbest), der er mere hllrd og mere elastisk end an<ll'n ashesl og dcrfor bctragtcs som srerlig farlig. De asbl'sln;\le, der fandtcs i lungernl', var hoYedsagclig af lrengden 9 my eller Iidt kortere, og tykkclsl'n var altid mindrc end t my. Dettc er mindre end flerc andre angivelscr, f. ex. opgiver We d I er, at asbestm\lenes lreng,lc i alminrlelighed Jigger mcllem 25 og 150 my og deres tykkclse indtil 3 my. Brg c r har lignende tal (25-110 my og 0,2-1 my), medcns Koppen h i:i fer (8) ved unders0gelsc af samme Junge finder, at srerdclcs mange af nAlene er langt mindre: lrengde 2-6 my, tykkelse 0,006-0,01 my. Samme forfattere diskulerer i sammcnhreng hermed udfprligt asbestoscns pathogenl'sc og nsbestoselegemernl's betydning. En udfprlig omtale af asbcstosen find es hos Lanza (9), :\lerewether (10) og Wcdler, hvor literaturen er samlet. I de to sidste arbejder findes opgprelser oYer store kliniske materialer. Forl0b, Ashl'slostn uclvikler sig sja'ldent qlntgenologisk dler klinisk p:\ mindre end 5 Ar selv yed stor exposition. I Wed I er s matcriale pa 310 under- s~gtc fra 2 tyske asbest\'irksomhedt>r fondles asbestosc i 22,6 'lo, dog kun 7,7 % i stadium II ellcr V f L 112/37 derover efter en klinisk inddcling i stadierne 0 til III. Af tabcllerne fremgllr, at vcd en arbcjds alder pa 0-5 Ar (der omfattcde 2/s af materialet) fandtes asbestose hos 3,3 % og kun stadium I. Dereftcr stiger procenten i det nrestc 5-:\r til over 60, dog hovedsagelig Jette tilfrelde. Vcd stigende arbejdsalder tiltager procenten af svrerere tilfreldc. M e r e w e t h e r refererer undersi,Sgelser ar the Silicosis and Asbestosis Medical Board, hvor der blandt 749 underspgte med en arbcjdsalder pa mindre end 5 flr kun fandtes 4 asbestosetilfrelde, medens en fjerdedel af de arbejdere, der havde ,reret beskreftiget 20 flr eller lrengere, var angrebnc. Ved en underspgelse af 1512 arbejdere var forholdet mellem asbestosetilfreldene i grupperne 0-4, 5-9, 10-19 og over 20 firs expositionsstid som 1 : 5,6 : 30,4 : 53,2. Man kan imidlertid, som M e r e w et h e r fremhrever, ikke heraf slutte, at en exposition pA mindre end 5 :\r er uden risiko, idl't indAnding af asbcststpv i tilstrrekkelig mrengde selv i en kort periode kan fpre ti1 en invaliderende asbestose, Iwis den pAgreldendc lever henge nok. Mere wet her anfprer, at en forpget concentration rcducerer tiden, fpr asbestoscn er udviklct og kan pavises, men at detle kun grelder indtil en vis, hpj, concentration. Forpges concentrationen yderligere, vii dcttc ikke fpre til ,n yderligcre Pa rrduktion af tiden for fibrosens udvikling, ma- turation period. den anden side vii en exposition for en concentration under en vis, lav, grrensr ikke frembringe en invaliderende fibrosc indenfor drn gennemsnitlige arbejdsal<ler. Allsa et minimum af asbcststpv mA. fangcs i lungcrne for at udvikle en fibrose a{ betydning, og en vis lid mA g:\, fpr dennl' fibrose er udviklct. Mere wet h c r bar opgprelser, der viser, at risikoen ved asbestarbejde kan sammenlignes med farcn i de silicosetruede erhverv, ja, mrrmest synes at overga den. Ved dpdeligt forlpbnc tilfrelde var den genncmsnitligc arbejdsaltkr vcd silicos(' 15,2 ar i sammenligning med 13,3 ar vcd asbcstosc:. Ikkr alt arbejde med ashrst er lige farligt. Eftcr literaturen synes srerlig hearbej,lning af rllasbest (knusning og maling) at vrerc farligt, men ogsfl fremstilling af isolationsmatter har ct darligt ry pa sig. Stpvud,iklingen ved spinding skal derimod vrerc rel ringe. Selve brydningen af ashl'st forcgar i fri luft, saledes at stpvkoncentrationen ma antagcs at vrerc lille. I W e g c I i u s' materialc fra Finland (16), drr beslar af 126 asbestost>tilfrel,k blandt 476 undcrspgte stammede imidlertid de 31 a{ de 126 tilfrelde fra arbejderc ved l'n afsluttende Corarbcjdning i mincrne. Prognosen fremgar delvis af det anfprte. Wedler finder ved eftcrunderspgelser, at hos arbl'jdcrl', dcr kun har vreret udsat i mindrc grad og kun h(!vde padragl.'t sig en hegyndende eller letterc asbestose og dcrefter havde forladt det farligc arbejde, var der kun ringe progression hos flcrtallet cftcr en obscrvationstid indtil 17 ar. Andcrledes slillcde det sig hos dem, der blev ved ar- bejdet. Her sketc en progression, der dog sjrel- dent i lpbet af en 3-4 ar oversteg ect stadium (i klinisk inddcling). Wed le r mencr derfor ikke, at en kontrol af allcredc angrebne lpnncr sig med mindre tidsinlerval end clet anfprte. W c- g cl i us har lignende resultater: cfter en ohserva- tionstid pll 2 Ar, er der progression i en del tiJ. frelde (hpjst eel stadium efter rpntgenologisk ind- dcling). De mcget pessimistiskc udsigter for arbejderne i asbestindustrien, som fremgar af disse materia- lcr, grelder antagclig ikke mere. De underspgtc bar i hvert tilf:eldc delvis vreret udsat for indAn- ding af asbeststpv i en tid, hvor man ikke var klar over Caren, eller risikoen ikke var alminde- Jigt anerkendt, og stpvbekrempclsen ikke sat i sy- stem. Dctte er fprst sket pa grundlag af disse ma- terialer. Selv om gennemsnitsrisikocn saledes ma anta ges at vrere langt min rt re nu, er dct selvfplgclig ingen garanli i de enkelte tilfrelde. Prognose11 i det enkclte tilfrelde er vanskeligt at forudsigc, den afhrenger af mange andrc fak torer end selvc fibrosens udvikling, f. ex. indivi- dets resistens overfor hakkriel infcktion, kom- ))licerendc hjerlc- og hmgclidelscr etc. I lighed med forholdenc vcd silicosc er man nu mest til- bpjrlig til at antagl', at ashl'stosc ikkc disponl'rl'r for lungetuherkulose i 1kn forstan,l, at in,livi,lcr med asbestosc hyppigerc rnr lungctuhcrkulose end an,lrl', nA.r tkn t11lwrkul1lsl l'Xposition l'r den sam- me. En anden sag er, at kompliceres en asbestose med tuhl'rkulosl', forv:l'rres prognosen antagelig. Drr forl'ligg,r 1krin11HI nu talrigt samsllmmen,k meddelelsl'r om, at primrcr hronchialcancer er hy))pigl'rc hlandt ashC'stotikC'rC'. Ho m h u r ,:i er (4) har i 1943 gi\'d rn ovlrsigt over de indtil da mcddeltc tilfreldc og llll'ncr, at der med hans egnc 3 tilfreldc mindst er offentliggjort 19 tilfrelde af primrert lungPCarcinom. Hyppighl'den i hans cgct inslilut l'r 4 carcinom-lilfrcldc pl\ 8 ashestosrsek- tioncr. Wed le r (15) anfprer, at i Tyskland er ialt fundrt 4 earrinonwr pa 29 sektionrr af astm,t- osc1>atil'ntcr, og at der if~lgC" venknslileraturrn er offrntliggjort 14 pl\ 92 sC"ktioncr. Selv om hyp- pighedcn er strerkt varicrendc og maleriall'rne sma og prol'entangivl'lsc derfor usikker, synl's der ikkc at vrere tvi vi om, at ashC'slosc disponcrer ti! lungrkrrert. Asbeslosebel.rempelse11 fplgl'r ,le sredvanlige relningslinitr: indkapsling af de sl1hen1le arbejds- proecsslr, lokal afsngning, rumvcnlilalion og en- 1lclig pl'rsonlige hrskyttelsesmidlcr som maskc. Den sidstnrevnlc nwtodc spger man som sredvanlig at gprc ovl'rfhlllig, da arhej,kt h:l'mmes denl'd, og masker er ubl'l1ag11ige at brcrc, hvorfor de sjrel- 1lcnt henyttt-s. E<lNE TII.F.ELBE Fprst skaI urbejdsf01holdene kort omlallS i den virksomhrd, i hvilkl-n <kt af I v c brskrrvnc tilfrelde opstod. Virksomhcdcn fremstilkr bygningsmaterialer (platier, kasser, rpr, fittings etc.) af 14/9 1950 1285 en blanding af asb<'sl og cement. En 30-40 arbej- dere er heskrefliget ved dct stJ'ivcndc arbejdc. I 1940 blcv der pa fahriktilsyncfs foranledning rt1ntgcnfotografcret 30 arbejderc med en arbejds- alder fra 1 til 12 Ar. Der blev ikke fundet sikre tilfrelde af asbcstose (filmcne sendtes gcnnem fabriktilsynet til bedfSmmelse hos professor F Jem ming M ~ I J er). I 1948 viste r~ntgenfiJ- mcne fra 3 arbcjderc med Jang arbcjdsalder (11, 18 og 18 Ar) stadig ingcn asbeslose. Arbejderne er i~vrigt kontrollcrct pa den Jokalc tubcrkulose- station. Efter at def af Iv c beskrevnc tilfreldc var blcvct konstateret, undcrst1gtcs 14 andre ar- bcjdcre med en arbejdsalder fra 9 til 42 llr, og der fandtcs ingen asbestose blnndt disse. Igen- nrm arenc var fabrikcn gcntagnc gangc blevel inspicerel og forbedringcr i form af indkapsling af arbejdsprocesserne og afsugning indft1rt. Stjjv- faren var srerlig til stede ved st1nderdelingen og formalingen af den rll asbest (kollergang og drs- inlegrator), hvor fyldning og tfSmning delvis ske- te ved skovling, ligelcdes ved arbcjdct med den formalede asbest i siloerne, hvor vognene lresse- dcs vcd skovling, saml ved hollrendcrne, hvor de t~mtcs ud i cemcntvrellingcn, Ved en insprk- tion i 1949 var man i stand ti! at foretage slpv- malinger. Den anvenclte asbcst var megct kort, irlcl det er et affaldsprodukt, uegncl til spinding, dcr anvcn<lcs. lnlholdcl af egcntligc nalc Ill i ovcrensstemmclsc hcrmed mellem 20 og 30 % af samtlige partiklcr, Et par resultater af m:\lingerne ska! anf~res (magistcr D. Stub b c Te g I b j re r g fra fabriktilsynets Jaboratorimn for arbcjd'.ihygi- ejne): Kollergang Part /cm3 0.5 -5 p under t~m- A~bl'slpart./em3 2 15 p 15 - 200 ,ti ning og fyldning 990 85 150 1/oflrender under fyldning 5500 350 800 Hesultaterne af maling<.'rnc ved desintcgralor og silo IA herimcllcm. Efter Johnstone (6) er d<.'n h~jest tilladeligc concentration 10,000,000 partikler af st~rrelsen 0,5 ti1 5 my pr. cubic fool (srnrendc til ca. 350 pr. cm3), S11yehislorier: Tilfwlde 1. V:evl.'r, f!ldl 18!);;. Arbej1ls11nflmnese: Har i mangl.' iir va>r<'I ansat i l'n fahrik, hvor cll.'r forl.'gar v1cn1ing af asbest i rel stor stil, bl. a. ti! fremstilling af brem~l.'hand. Har sidl.'n 1!)28 passel en v:r-vemaski111.', der er forsynd med afsugningsanordningl'r. Hvor,idl dis~!.' tidligl're har va-ret effrktivl', er det vanskeJigt at udtale sig om. Ved en inspektion var de ikke i ordcn. Annmnese: Angivcligt tidligere ra~k, borlsl.'l fra en phlegmone eftl.'r et traum<'. Nuv:t'rendl' lidelse: Efll'r nogk itrs arhcjdl.' vl'<l v:e \'cmaskiuen hcgyndte han ca. 1!)30 at lide :tf bronchitis. Han blev hehandld hcrfor p:i SY!l<'hus i l!l37 og l!J43. I l!J45 var symptomcrne tiltagl't, han havde hostc, opspyt og anfa!cl af andenild og matte sa-tles Iii let arh<'jdc, Efll'r en inspektion pa ,irksomfiedcu i 1945 Jlinll' fabriktilsynet rpntgenfilmene, der var optaget i 1937 og 1943. Professor FI em ming M Ii I I er fik filml.'nC til bedpmmelse og udtalte: R!ointgenbilledet fra 1937 vlser en meget grovmasket, noget udflydende lungctegning pll begge sider; der er ogsll formindsket gennemskinnelighl'd ar lungcrnl.', og der kan ikke va-rc tvivl om, at der findes noget pathologbk, cfter al sandsynlighed en hegyndende asbestosc. Pa optagcl serne fra fehruar 1943 ses Corandringernc at have udviklet sig; der er nu en yderligere grovmasket og tret tegning i hlgge lunger ln<.'d maskegr:enserne noget udviskede og pa steder l!oihet samnren ti1 uregelmressigc smapletkr. Venstre sinus phrenico-eostal is affladet. Bllledct er ret typisk for en asbestose pit ovcrgangcn til 2. stadium. Tilfreldet anmcldtcs ti! ulykkesforslkringen og atll.'rkcndtes som erhvcrvssygdom. Han var smgeliggende det meslc af cfleraret 1945 og matte holde helt op at arbejde. Tilstandcn forvrerredcs cfterht111den, og han dpde Cehruar 1948 (ingen section). Arbejdsforholdcne er siden blevl.'t forhC'drcde; dcr er effektiv afsugning ved alle asbcstvre\'C'nc, og de ad satte arbejdcre kontrolleres !irligt. OC'r ska! ikkc siden vrerc fundct asbestosl'tilf:r-lde. 1'ilf1rlde 2. Skibsnl'rftsarhC'jdcr, f!idl 18!1-t. Arb,jdsanamnese: Sidl.'n 1918 ansat pa skihsvrerft. Siden 1!135 har han isolrrl't rpr, dels ombord pa skibl.'IH'. de!~ in- den rjlrcnes installulion, Han har anvendt aslllstsnorr og asbestlrerrcd, i de senere Ar ogsa rockwool og glas uld, I l!l4~, bit, han tilrltdd andl't arhC'jdc og fik ans:ettelse som natlerngt i arrestlms, hvilkct arbejdc han havdc i halvandel Ar. Siden har han atll.'r arhrj dct pa skibsnerfkt som almindelig arhcjdsmand, dog hjrelper og aflpser han af og til den mand. som sidcn 1945 ovcrtog isolationsarhejdct. Arhl'jdd i land foregik i et lille skur uden srerlig rumventilation cl ler Jokal afsugning. Rprene, der skulle isoleres, havde en lrengde pA op til 5 m. Der afgaves en dcl synlig fnug og shiv under arbejdct, Stjlvudviklingcn vrd arbejdet ombord skpnnl'des sl!oirre; ogsA delte forlgik Ud<:-n afsugning. Anamnese: Rask som barn og ung. Har aldrig h;1ft gigtfcber clll'r Jungclidclsrr. I en del ar gencrd af lumbago. Nuva>rende lidelsl': Efter lunglhC't:r-ndelse l april 1041 lidt af tillagendc kortltnddh<'d og hjl'rll'hankcn \'l'd anstrengelser, stikkcnde smrrll'r og knagcn i \'t'O stre side af brystet og bag manubrium stc-rni vl.'d d~h vejrtrrekning og vcd anslrengelscr. Tilligc irritcrende morgenhoslr, ml'n sjreldl'nl opspyt. Blev trret og table 12 kg l ,regt, hrnrfor han hlev underspgl af tuherku losespeeialist i t!l-11. Denne konstakrede 1.'fl t!Sr plru ritis pa venstrc side. Han var indlagt pn sygchus i ]!)41 og 1942 under diagnoscn pkurilis sieea sin. og nervosismus. Har senere va>r<'l unders!igt pa Tuber kulosrstationen flere gang<'; drr rr aldrig fundcl ll'gn pa aktiv tuhl.'rkulose. l\fontoux: +. Ventrikel~kylll' ,and: + TB. Srenkningen nornrnl hrle tidrn. I 194;, klagede han over sml'rler i hpjre sicii', og der blcv fundet tegn pa plcuritis ogsil hrr. Efll.'r cMtc hie, han tilradet at ~kifte arbejdc. I 1948 blcv han, cftcr en henvendelse fra sit fagforhu nd til fahrikl ils)nct, attc-r r!lnlgenfotogra frnt, og filmenc bin gtnnem fabriktilsynct scndt til bc- dpmmclse hos prof. FI cm ming ~r Ii 11 er, dl'r gi ver f,ilgcnde bcskrhclse: Rpntgcn af thorax viscr, at der nedacltil p!t hegge sider findes en svag, men ganske diffus udflydcndc fortretning, symmetrisk I beg- 1286 U f L 112/37 . Fig. 1. gc lunger, delvis udslcttcnde lungctegningcn. Desuden er der pa htsjrc side en affladning af sinus phrcnicocostalis med adhrerencer ti! diaphragmakuplen. Det drejer sig om en asbestose i ct forholds\'is tidligt stadimn. (Fig. 1). Tilfreldet er anmeldt ti! ulykkesforsikringcn og anerkendt. Ved undcrspgelse hos mcdicinsk specialist sammc Ar fandtes: objektivt: middel ernrering, dyspnoe sclv \'cd sma anstrengelser, cyanose. 0jne, fauces, lunge: inlet srerligt. Thorax af naturlig form udovcr indtmkninger owr cla,icula. St. pulm.: grrenser forskydeligc. Drempning og s\'rekket respiration pa begge sider, srerlig nedudtil. St. cord.: grrenser ubcstcmmeligc, ktus inden for mediocla\'iculrerlinicn, lyde rcnc, aktioncn regclmressig. 0nige understsgelse frembyder inlet sa'rligt. Vcd rolig gang cen trappe op forceredcs rcspira1ionen. Blodtryk: 150/90. SR: 12 mm/1 time. Blodunderstsgelsc: normal. Electrocardiogram: inlet sikkert abnormt, specielt ingcn tegn pa bpjresidig pavirkning. Rpnl gen: uforandrede forbold. Hans arbcjdsevne bedpmtes til under en trcdiedcl, og ved fprste afgprclse fik ban en erstatning s\'arcnde ti! 70 %. Han bar siden forspgt sig \'ed forskclligt lettcre legemligt arbejde, men kunnc ikkc klare det. OgsA en aviskiosk bar han mallet opgivc, du ban i rintcren 1949-50 ikkc kunne talc at hringe aviserne ud. Han \'nr sengeliJ:gende dct meste af vintercn, og hans tilstand syncs at vrere for\'rerrct i det sidste Ar. Til/lt'lde 3, Arhcjdsmand, fpdt 1008. Arbejdsanumnese: l'dlrert urtckr.cmmer. Vreret heskreftiget som sadun, indtil bun i septembcr 1939 blcv ansut i en \'irksomhec.l, der frem~liller uc.lg:1ngs11iall'rialet til nsbcstgulve. l\fateriall'l er en blanding af pulvcriseret asbest og magncsiacement. Ramatcrialerne modtagcs i mere eller mindre pulveriseret tilstand i srekke, og pa fabriken forctagcs de n!id\'cndigc ah'ejninger, knusning, maling og blandingcr samt det frerdige pul\'ers afnjning i srekke. Stp\'udvikling forekommcr vcd nreslen allc manipulationcr, men isrer ved blandemaskinens fyldning og tpnming. Fabrikationen forcgik i ct enkell lokalc, og der var ikke truffet foransta ltninger til afsugning cller kunstig rumvcntilalion. Ved at lade porlcn ti1 garden og et vindue slit Ahcnt s1igte man at ~kaffe gl'nnemtrrek, men dcttc var ganskc utilstr:rkkeligl. Efter at man i 19-14 var hievet klar over, at han bavde padraget sig en lungelidC'lsc, blcv dcr l'lablcrct afsugning vcd maskinernl'. Han arhejdl'de i den f11Jgende tid mindre i fahriken og har i det sidsle arstid \'a-ret beskreftiget som ehauffpr og \'ed arbcjde pa bygninger, hvor pul\'eret breldes op i kar og tilsitltes vand. Denne proces stpvcr noget, men fong:'tr sa vidt muligt i fri luft. Anamnese: Som barn druk han natronlud og har siden af og ti1 mallet bchandles for psofagusslenosc. lpvrigt rusk. Nu,rerende lidelse: Vinlcren 1943-44 havdc han en del hostc, h\'orfor \'irksomhcden i l!IU lod ham rpntgenfolografere. Der fandtcs tcgn pa asbcslose ellcr silicose (overlrege S v. B pr re Larsen). Filmene blev !ant af f,1briktilsy11et og scndt ti! bedslmmelse hos professor FI em mi II g J\f p 11 er, hvis bcskrivelse lyder: Der findes nresten symmC'lrisk pit bcgge sider en lll't sammcnflydcndc lungetegning, indclioldende ganskc fine smApletler. Fornndringerne sidder lidt ncdenfor mldten af begge lunger og skyldes en silicose pA O\'ergangen mcllcm 1. og 2. stadium. I 1946 blev han behandlct i hospital for lungt"11indebet:cndclse og er siden konlrolleret pit Cenlralstationcn. I 1949 blev han behandlet for dohhcllsidig Iungebctrendrlse. Da det ikke lykkedcs at fa ham til at mpde til kontrol pa Rigshospitalcts arbejdsmcdicinskc klinik, bar man !Ant rpntgenfilmenc fra Ccntralstationen. Professor F I e m m i n g 1\111 I I e r s hl'skrivl'!sc lydcr: Pl, n111tgenbilledc fra 21/1-46 scs ct afkap~let exudat pa hjijre side og den sammc tret udflydcnde lungetegning, som beskrevct \'l'd forrige rpntgenunderspgelse. En oplagclsc fra 18/2-47 vise1 som rcslrr fra exsudatct pa hpjrc side noglc pleurafortykkelser lungs thorax\':l'ggcn, rn affladning af sinus phrcnieo-costalis og en affladning af hpjrc 'horaxhahdcl. Dcsuden ser man, at lungl'lcgningen nu er ganskc udflydcnde, n:rsten som rn diffus fortrelning, symmctrisk i beggc lunger. Den sidste optagelsc fra 30/8-48 viser, at dennc fortretning yderligere er tillagel, og dcr er nu tilligc kommet en brremme af plcurafortykkclscr som en kappc langs nederste de! af vcnslre thorax\'reg. - Dct drejer sig om en fremadskridcndc asbcstose. I januar 1950 lykkcs dct at flt ham ti! at mpdc ti! en undcrs11gclse pa Higshospitalcts arbejdsmedicinske klinik, antagelig fordi hans tilstand var fonrerret, og han havde bes\':cr med at klarc arhejclet (blcv afskedigct 13/1-50). Nuvrercnde tilsland: mager over tiltagcndc kortimdcthed. l{an git pa ja'\'11 \'C'j, men tr gcnrret, h\'is han ska) skynde sig. Ligelcclcs gcner nd hurtig cykling. Han bor pa 4. sal og mA h\'ile sig 3-4 gangr for at nfl derop. Sm{,hoskr luh dagl'n, og ogs:'t om natten er han plagct af ho,lt. Expeclnrercr kun li<lt slim. lngcn hjcrlt-bankcn eller pclcmer. Hyger 1~ cigarctltr dagl ig. Objekti\'t: magcr, Licit cyanost' af lahtrnc. Bli\'l'r kortAndet vecl afklredning og far hoslc'anfald. Stet. cord.: grren~cr norm:1lt, Iyde rcnl'. P2 m:iskc lidt stprre end A2. Aktiomn rcgelm:l'ssig. Stet. pulm.: grrenser costa fi-10, for,kydls ea. 2 cm pa bagfladcrnc. Brystomfang \'ed maximal l'Xspira- tt,/9 1950 1287 ret udtalte funktionsnedsrettelse i begge tilfreldc. Rntgenfundene var de sredvanlige wd ashestose: diffus fibrose ncdadtil i begge lungefelter med pleurale forlykkelser og nedsat bevregelighed af diaphragma. I tilfrelde 2 var hmgetegningen no- get mere finmasket cnd i tilfrelde 1 og svarede srerdcles godt lil den s:t'dvanlige beskrivelse af asbestoselungcn. Der er nreppe tvivl om, at kend- skab ti! rntgenfundet ved asbestose og en god er- hvervsanamnese ville have medfrt, at diagnoscn asbestose var blevet stillet e11er ventileret pii et lidligere tidspunkt, end tilfreldct var, og nt de pl'lgreldrnde kunne vrere blcvet fjcrnrt fra dcl farlige arbejde, hvorved prognosen antagelig hav- de vrerct mindre slct. I tilfrelde 3 var rpntgcnfundct ct noget andet, idet der her tilligc \'ar fine nodulrere rorandrin- ger, som dct scs \'Cd silicose, spcciclt hos jcrn- og stlilrensere. Diagnosen ble\' - maskc af dcnne grund - i dctte tilfrelde stillet ved frste r!'lnlgen- Fig. 2. undersgelse efter 4 Ars expositionstid og kort tid cfter, at de fprste subjektive symptomcr fremkom. lion og inspirnlion 79-80 cm. On~ralt sibillerende og cnkcll sonorc ronchi (er fork1llct). Ingcn drempningcr eller respirationsforandringcr. Forklaringen 1,a det for asbestosen afvigentlc r~ntgenrund kan ml'lske Yrere, at den asbest, der anvendes til asbestgulve, er mcget fint puherisc- Onige undersjlgelser fremhyder Intel srerligt, ud- rct og delvis et affaldsprodukt (asbestmcl). Den O\'cr at fingerncglrnc er nogtt kuplede, men det har meget fine partikelstrrelse kan maske forklare de altid v::eret. det mere silicoselignende billede, idet rlrn mrka- 1I H1ljdc: 16-l cm. Vagt 55 kg. lllod!ryk 115/80. Sil: 10 mm/1 time. llan10glohi11 120 %. Erytrocyfrr 5.95 mill/mm3. Urin: + alb. + sacch. Ekctrocardiogram: inlet abnormt. Rntgenundersgelse af thora.t: (fig. 2): viscr sammenlignet med optagclsen fra Clnlralstationcn 30/348, at den hctydclige pleurabrre111me pa ,enstre side nu er strerkt afsmalnet. Den er nu kun 1-2 cm bred, niske virkning af asbcstnalenc ikke gr sig greldendc, kun den kemiske. Som anfprt i indledningcn er Jlathogcncsen dog ikke klarlagt cndnu. Det bar ikke vreret muligt at fa oplyst nrermere om de asbcstartcr, dcr har vreret anvendt, og Jigeledes foreligger der ikke stvmalinger fra relevante tidspunkter. saledcs at man ser hele den venstrc, nogct affladede De subjektive symptomer har vrerct de sredvan diaphragmakuppcl. Selve lungctegnini:cn er lmidlertid ganskc uforandrcl. Som tidligerc scs pa brggc sider en symmctrisk, tret, nresten sammcnflydcnde lungetegning med rel tydelige, ganskc fine smapletter, isrer i ncdersle hahdel af Jungefclterne. Hjertet er af nalurlig form og sljlrrelse. Der er ingen tegn pa cor pul- ligc ved asbestose: Funktionsdyspnoe og hoste med ringe expectoration. I tilfrelde 2 er oplyst, at hosten i begyndclsen var den karakteristiske tr re morgenhoste ledsaget af sting og knagen i bryslct. De subjektin symptomcr fremkom eftcr hen- monalc. Diaphragma he\'reges 2 cm, holdsvis 2, 6 og 4 ar. Tilsvarende expositionstider Funktionsunderspgelse: Vitalk:ipacitet 1.45 I (74 % \'ar 17, 10 og 10 ar. Symptomerne ,ar cfter dette af totalkapacitet), residualluft 0,50 1. Hvileventilation 7.8-8.4 I/min. llfaximahentilation 46 I/min. Arteriel iltmretning i hvilc findes til 93 % med oximetcr. Under arbcjde pa 400 kgm/min. kommcr dcr et udtalt fald i den artericlle iltmretning (8 % ), og patienten opgivcr arbejdet eftcr 2 minuttcrs for)jlb, Ventilationen under arbcjdct 38 I/min., respirationsfrckYCns 46. Honklusion: Svrer funktionsncds,l'tlelsc, o,ernjen- dc pulmonalt hetingd. Der findcs en mcgct !av totalkapacitct (58 % af beregnet vwrdi), mulig\'is bcstemt for !av pa grund af mangelfuld opblancling, og ringe ,entilatorisk funktion. (J. G co r g). tidspunkt sA udtalte, at de pl'lgreldende matte op hpre med arbejdet. Nr. 1 dpde 3 Ar hercftcr, nr. 2 er nu efter yderligere 3 ars observationstid nrermest 100 % invalid og nr. 3 er strerkt invalideret. Ved silicose og asbestosc ma man regnc med, at Jungelidelsen efterhanden medfrer en overbeJastning af hjre hjerlehalvdel, s:\ledes at dcr udvikles et cor pulmonale chronicum. Delle har ikke kunnet p:hises klinisk i dr 3 omtalte tilfrelde ved electrocardiogrnfi ellcr ved rntgen, cj heJler i tilfrelde nr. 3, hvor man med hrnblik her- DISKllSSION De 2 ar patienterne (tilf. 1 og 2) er rnlgenfoto- grarerede flere gange pa grund af subjektive sym- pa tillige rpntgenfotograferede hjertet i skradiameterne for om mulig1 at kunne phise en fremspringende pulmonalbue (12). Funktionsprven hos samme patient viste en nedsrettelse, men ho- ptomcr, men er gaet under diagnoscrnc plenritls si cca og bronchitis. Hntgenfilmenc i disse to til- ,edsagcligt pulmonalt betinget. Manglende eleklrocardiografiske og rpntgenologiske tegn p:\ h!Sj- fa,Jde har vreret karakteristiske for asbestose og- residig hjerlehypertrofi udelukker imidlertid sa i den forstand, at der kun har vrerrt ringe ikke, at en shdan findes. Desnerre blev tilfrelde 1 rntgenologiske forandringcr i bctragtning af den ikke obduceret. 1288 U f L 112/37 Rtsmrn 3 tilfrelde af asbestosi~ omtalcs. I de 2 var rtintgcnfilmcne typiske, i d't tredie fandtes tillige nodulrere forandringer. Som en nmlig forklaring herpa anfpres, at der i dette tilfrelde var arbejdet med meget fint pulveriscret asbest, st\led(s at den mekaniske virkning af asbestnalene ikke var fremtrredende ved pathogencsen. Kendskab til sygdommen og en n~jc crl1"ervsanamncsr er npdvendig, hvis de lettere tilfrelde skal erkendes ved rpntgenfotografering, f. ex. ved rutincmressig unders~gclse for tuberkulose. Literatur: 1. Beger, P. J.: Arch. f. Gewerbepath. u. Gewerbehyg. 6: 349, 1935. 2. di Biasi, lV.: ibid. 8: 139, 1938. 3. Gardner, L. U.: Am. Rev. Tubere. 45: 762, 1942. 4. llomburger, F.: Am. J. Path. 19: 797, 1943. 5. Ive, T.: Ugcskr. f. Lirgcr 112: 472, 1930. 6. Johnstone, R. T.: Occupational Medicine and In- dustrial Hygi,mc. St. Louis 1948. Pn. 604. 7. King, E. I., I. W. Clegg and V. M. Rae: Thorax t: 188, 1946. 8. Koppenhoffer, G. F.: Arch. r. Gewcrhcpalh. u. Ge- werbehyg. 6: 38, 1935. 9. Lan:a, A. I. (edit.): Silicosis and Asbestosis. Lon- don, New York, Toronto 1938. Pp. 439. 10. Merewetl1er, E. R. A.: Tubercle 15: p. 69, 109, 152, 1934. 11. Noro, L.: Acta path. et microbiol. Scandinav. 23: 53, 1946. 12. Sam,ielsson, S.: Chronic Cor Puhnonalc. Dispu- tats. Kbll\'n. 1950. Pp. 389. q_ S11ndi11s N. und A. Bygden: Arch. f. Gewerbcpath. und Gcwcrbchyg. 8: 26, 1938. 1 l\'edler, H.-W.: Klinik der Lungenasbestose. Leip- zig 1939. l'p. 152. (In Arheit und Gesundheit, left. 34). 13. 'edler, H.-W.: Deutsche med. Wchnschr. 69: 575, . 43. 16. l1 r,eli11s, C.: Acta radiol. 28: 139, 1947. stoffer at stilbpstrol-typen. Selv et sa almindeligt frenomcn som de strogen-inducercde postklimakterielle metrorrhagier er nreppc tilstrrekkclig kendt af alle, der anven,ler dennc terapL Selv om de fleste, som nrevnt, rcgner pstrogenbehandling for ganske uskyldig - selvf1gelig bortset fra de almindclig kcndtc, forbigaende gener af subjectiv art som f. eks. dyspepsi ved peroral anvendclsc - hnr der dog ogsa fra forskellig side rejst sig advarende rster, og man har her frst og frcmmest peget pi\ mulighedcn af at en strerkere og lrengcrcvarende dosering af pstrogene stoffer kan blive en mere eller mindre va-sentlig faktor i det komplex, der betinger udvikling af maligne lidelser i den kvindelige organismc, fprst og fremmest i uterus og mamma. Hele dettc sprgsmal syncs ikkc tilstrrekkcligt paagtet hcrhjemme og synes ikke tidligere at have vreret genstand for nogen samlet bcarbcjdelse i skandinavisk literatur. Denne terapiforms cftcrhandcn kolossale udbredclse gpr det imidlcrtid n~dvendigt, at spprgsmalet dragcs frem, sclv om det ikke cndnu er sa afklarct, at der kan tagcs dcfinitiv stilling til det. Denne frygt for en vis cancerigen virkning af pstrogener er opstact ud fra forskelligc synspunkter: 1. Rent teordiskc ov'rvejclsl'r over ,Jc natnrlige pstrogcncrs kemiskc slregtskab med crkendt canccrigene stoffcr. 2. Kendskabl't ti! fistrogenernes megct bctydelige proliferationsinducercndc Yirkning pa cpitelet i den kvindelige genitaltractus. 3. Patologernes pavisning af en nrer relation rent morfologisk mcllem bcnignc, pstrogent-irnlucerede proliferationer i endometrict og regte maligne endometriclidelscr. 4. Dyrcexpcrimentcllc undcrs~gelser. 5. Kliniske data. 6. Erfaringer fra pstrogcn I.iehandling af kvinder. KEMISK SL.EGTSKAB Dt 0STROGENE STOFFERS Efter at W i n d a u s, B u t e n a n d t m. fl. omkring 1933 havdc fastslaet de naturligt forekom- BETY.)NING FOR UDVIKLINGEN mcndc pstrogeners konstitutionsformcl og vist, at AF C1. NCER CORPORIS UTERI \ alle var nrert beslregtede og afledede fra en cyclopentanofenantrcnkernc, la dct nrer at hrefte sig -.4/ AKSE~RP ved dct formelmressigc slregtskab med visse af de sakaldtc canccdgenc kulbrintcr - og dcraf fprst I De pstrogcn , stoffcrs gennemgaende fortrinlige og fremmest med methylcholantrenet - der kort \'irkning ovrrft r de ofte gcnercndr, men relativt i forvcjcn var blevct isolercdc fra tjrereprodukter uskyldigc, sul.ij, ctive klimaktrricllc gcner har l'ller syntctiscredc (Cook ct al.), navnlig cfter at / I gikjol,ret mdienndnset litlearn,,cp' ifpoartmicnotcvrenreo.rdentlig populrer, bdreitnvtearr hpaavvdisct,psattrovgiscsnc vaifrkdniisnsge. cDacntcehrairgeimneidkleurl-- I Ti! de!,; som ct cvn fra hormontcrapiens vor- tid vist sig, at det konstitutionsm:rssigc bindcled dcn, Inor man kun havde svage ovaricekstrakter mcllcm de to grupper stoffcr - cyclopentanofe- Iii n'ttlighed, gpr m:. 1g, sig n:rppe tilstrrekkclig nantrenkerncn -- ikke er npdvendig hvcrken for klarl, hvor belydelig, forandringcr i genitalia og den J:Sstrogene virkning (cstilbiner) eller den can- drlvb ogsa i mammre 'le nu anvcndte hetydelige ccrigcnc virkning, ligcsom det ogsa er vist~ at den og Jangvarigc doscrinr.:-T kan fremkaldc - det eancerigcnc og den pstrogcne cvne ikke er idcn- rn:rc sig genuine strogl' 1c stoffcr eller syntetiskc tiskr, i<let dcr findcs talrigc slrerkt aktivc cance- rigenc kulhrinltr, tier ikkc har ringcstl' ~strogen Fra Herning S~gehus, kirur,.isk afdeling. Chef: Ov<.'rkirurg E. Tplbpll. virkning. Ydcrmcrc ma man nreppc J::egge for stor yregt pa et sadant kemisk slregtskali, idct dct er 14/9 1950 1289