JPRS ID: 8252 THE CARDIOVASCULAR SYSTEM AND OCCUPATIONAL FACTORS

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~ri~E CARUIOVASCULAR SYSTEM AND
C ~CUPATI ONAL. FAC'i ORS
U. S. JOINT PUBLICATIONS RE~EARCH SERVICE
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REPORt OOC'JMENTATION i_pEVOpr ~;o. I. R~up~~nl~. ~e~...~o~ no.
PAGE JPRS L/8252 I -
ru~. ,+Me t~ci,w - -
s, a�pon o.i.
THE CARDIOVASCULAR SYSTF2~t M1ll OCCUPATIONAL FACTORS 29 Janua 1979 =
a
.
_ 7. NANer(~) P~Aorm~ns Or~~~~ut~on P~pl. No
- N. M. Konchalovska a edit r
.?~Aamlep~ On~nlul+on H~m~ ~nd Addr~~� 10. Pro~~tt/T~~M/WorM Und No. ~
Jqint Publicatians Research Service -
1000 North Glebe Road ConlnNlC1 0~ Grantf6) No.
Arlington, Virginia 22201
' cc~
l~, fpontoH~ Or~snliatlen N~rn~ ~nd Addnu ~3. Trp~ of R~poR 6 P~r~od Cov~reC
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li fuppl~rrwnbry Nat~s
SERDC~HNO-SO~DDJ[STAYA SISTEMA PRI DEYSTVII PRC:ESSIONAL'NYKH FAKTOROV,
Moscow, 1976 -
is. nese..ee c~ ~oe.wa~'
Thie report ~onzain~ clinical data pertaining to the state of the cardiovascular
sysCem of individuals whose work involves exposure to such occupational and
industrial factors as noise, radio ~raves, ionizing radiation and che~icals.
The book offers methodological approaches and defines the diagnostic possibilities
- with regard to evaluation of cardiovascular diaturbances. Special attention is
. devoted to the mechanism of formation of cardiova~scular reactions under the
influence of various occupational faetors. The authors singled out and described
com~rehensively tbe clinical cardiovascular disorders that are most frequently -
encountered among vorkers, as related to the nature and intensity of different
occupational factors. Recommendations are offered for expert determinar.ion of
disability, rational employment and rehabilitation therapy of states that develop.
~s. oooww.~e M.y.~. w.c.+~t�.
_ i1SSR Noise -
Ca rd iov~scular Rad ia tion
Occupation Poisoning
e. a.~a~�.ioo.~*~+a.e r�~.
` ~"`n "''�~~'�10 6E 6 6 6S
ia A..u.ewq fe.e.,~.n~ If. s.whn u... er~:. n.oon, :1. oa. e~
, For Ufficial Use Only. Limited UNCLASSIFIED 1 73
NumbQr of Copies Ava ila ble Fran JPRS. so. s�w~r ca.. crti;, v,~., xz -
UNCLASSIFIED
p"�~�ip f� M~Mretl~w~ ~n R~wn~ O/f10NAL ?ONM 272 f~-~~
(Ia~+wAy NTIS-7S)
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JPRS L/8252
- 29 Jarluary ].979 _
~ THE CARDIOVASCUTAR SYSTEM AND
OCCUPATIOP~AL FACTORS -
Moscow SERDECHNO-SOSUDISTAYA SISTEMA PRI DEYSTVII
PROFE5SIONAL'NYKH FAKTOROV in Russian 1976 signed to press
- 6 Aug 76 pp 2-26, 46-166, 200-255 -
[Annotation, table of contents, foreword, chapters 1, 3-6, 8,
conclusions and bib,l~~craphy for book edited by Professor
- N.M. Konchalovskaya, Izri,atel'szvo Meditsina, 6,OC0 copies
256 pages]
CONTENTS PAGE
ANNOTATION 1
FOREWORD 2 ~
CHAPTER 1. Pathogenesis of Cardiovascular Reactions to Various
Occupational Factors 4
CHAPTER 3. The Cardiovascular System as Related to Industrial -
Poisoni:~g 22
CHAPTER 4. The Cardiovascular System as Related to Expasure to
, Occupational Radiation 66
CHAPTEK 5. The Cardiovascular System as Affected by Exposure to =
Microwave Radiation 87
CHAPTER 6. The Cardiovascular System as Affected bq Intensive
Industrial Noise 105
CHA�TER 8. Reactions of the Card iovascular System to Acute
Occupational Factors 11S
- a - [I - USSR - C FOUO]
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ror~ ;~r;~r~;rn~, trsr. ~~ct~.~r
CONTENTS (Continued) Page
CONCLUSION 145
B~BLIOGRAPHY 150
~ ~
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I
I~'0!t UI~'T'ICIAL U5C ONLX
PUULICATION UA1'A
~
English title : THE CARDIOVASCUI,AR SYSTEM AND
- OCCUPATIONAL rACTORS -
- Russian title : SERDECHNO-SOSUDISTAYA SISTEMA PRI
_ DEYSTVTI PROF~SSIONA.L'NYKH FAKTOROV,
= Moscow, 1976 -
Author (s) .
~ Editor (s) : N. M. Knnchalovskaya
_ Publishing House : Izdatel'stvo "Meditsina"
- Place of Publication : Moscow =
Date of Publicat~on ~ 1976
~ Signed to press ~ 6 Aug 76
- Copies ~ 6000
COPYRIGHT ~ Izdatel'st~rv "Meditsina" ~
Moskva, 1976
- c -
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_ ANNOTATION
~ [Text] This publication has been approved and recommended
for publication by the Scientific Publication Council of
the Presidium of the USSR Academy of Medical Sciences.
This~~tonograph aummarizea c~.inical data pertaining to the state of the cardio-
vascular syatem of individuals whose work involves exposure to such occupation-
al and induatrial facCors as noise, radio waves, 3onizing radiation and
chemicals. The book offers methodological approaches and defines the diag-
noaCic posaibilities with regard to evaluation of cardiovascular disturbances.
Special attention is devoted to the mechanism of formation of cardiovascular
reactions under the influence of various occupational factors. The authora
singled out and described comprehensively the clinical cardiovascular dis- -
orders that are most frequently encountered among workers, as related to
the nature and intensity of different occupational factors. Recommendations -
are offered for eacpert determination of disa,bility, rational employment and -
rehabilitation therapy of states that devel~~F~.
Thia book is intended for physicians specializing in occupational pathology.
= The book includes 15 f igures, 15 tables, and the bibliography lists 257 items. =
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FORE410RD
[Text] The planning and organizing of different public health services is
based largely on informaCion abaut the incidence of different diseases,
- their share of the morbidir.y and morCality structure, as well as the main,
so-cal].ed clirtical, patCerns inherent in these forms. The increasing re-
~ ~ative inciderice of cardiovasc~~lar diseases and their role in changing
general healtti of the public in the future are quite obvious to all highly
developed couritries. At the same time, the role of di.fferent occupational
- factors a~nong causes that induce or alter the incidence and course of
cardiovascular diseases is still far from clear.
An enormous amount of material has been accumulatEd, referable to the many -
years of obaervations of workers in different branches of industry, who
were exposed ~o diverse toxic, allergenic, physical and dust factors varying
in intensity. In these individuals, changes in cardiac and vascular iunction
occupy a certain place, sometimes a significant one, in the clinical findings,
- and this requires definition of questions of syndrome diagno:~tics and expert _
evaluation of such states, as well a;, making substantiated decisions as to
outimum ~ob placement. At the same time, the special role of the circula- -
- tory system in the overall system of adaptation of the body to exogenous
and endogenous factors, due to the constitutiona~ distinctions and condition- _
- ing distinetions, the high incidence of influences known to be pathogenic
:
for the cardiovascular system of a number of nonoccupational factors,
as well as the nonspecific nature of changes, make it difficult b~th to
- differentiate Setwe~n physi.ological and pathological deviations, znd to
establish the role of different factors in appearance thereof.
There have been substantial changes in the nature of work in the last few
years. The comprehe:.Qive reduction of levels of occupational factors has
extended tne period of zctive work fitness and raised the mean age of
_ workers with the correspondir.g change in general status, including that
of the cardiovascular system as a premorbid background, against ~~hich
changes of an occupational nature app~ar. The rare instances of possibly
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severe effects on the circulatory system are presently sel aguinst the -
- mnre common influence of facCors with relatively low inCensity, with a -
- large conCribution of intenstve, complex mental laUor, hypokinesia, _
- processing of exteneive information combined with the need Co make '
~ responaible current decisions. Such is Che work, for example, on control
� c~nsoles, aircraft engine testing, ad~ustment of guidance [sighting] _
devices, etc. Unquestionably, overall reacCivity of the body has also _
ctianged in view of the set of diverse Coxic and allerg~nic influences. `
In view of all of Che foregoing, it was deemed expedient to shed light, -
in this monograph, on Che basls of analysis of the literature and our
own data, on the main paChogeneCic mechaniams of action of the principal
work-related factors on the condiCion of Che heart and vessels, as well -
as meChodology of studying the reacti.ons thereof in differ~:.~nt occupational =
groupa; t~ syaCematize information about the condition of the heart and
_ hemodynamics in individuals exposed to physical, toxtc and dust factors; -
to determine the main variants of clinical syndromes, semeiotics, course
and prognosis thereof; to define the possible place of different occupa-
- tional factors in the overall sCructure of cardiovascular pathology and
= prodiction of morbidity and mortality due t:~ diseases in this grosp. As
a resulC, it is planned Co :~ubstantiate reasonable ~ob placement,
methads of treatment and prevention of long-term sequelae of the effects
_ of working conditions on the cardiovascular system.
~
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_ CHAPTER i. PATHOGEII~SIS UF CARDIOVASCULAR R~ACTIONS TO VARIOUS OCCUPATIONAL
FACTORS '
_ [TexC~ Chief Mechanisms of Developm~nt of Cardiovascular Reactions `
~ Many years of observations have shown that diverse changes in the cardio- _
= vascular system are observed in individuals engaged in the most varied
occupations. Hypotheses have been expounc~ed concerning a consistent link
~ between the nature and incidence of some of Chem, on the one hand, and =
effects of worlcing conditions, on the oCher. It is assumed Chat both the
- direcC influence of some factors on tha heart and vessels and an indirect
influence, mediated by changes in neuroendocrine regulation of circulaCion. -
are involved. It is alsc+ unquestionable that, in the case of occupational
- ~ poisoning (carbon monoxide, nitric oxide and others) and acute radiation
sickness due to exposure to high doses of radiation, the cardiovascular -
- changes occupy a prominent place in the symptomatology and largely deter-
- mine the prognosie.
- Let us considex successively the possible meci~anisms of formation of reac-
tions as a result of the direct effects of some occupational factors on
the cardiovascular system. Thus, in the case of exposure to toxic agents `
with anoxemic ac:rion (carbon monoxide, cyanide compounds, amido and nitro -
derivatives of benzene, hydrogen arsenide, nitrogen oxides, phosgene),
= there is a reduction in blood oxygen capacity as a result nf changes in
sCructure, number and properties of erythrocytes and hemoglobin. In some
cases, inadequate oxygenation of blood is related to involvement oF the
- lungs (capillary---alveolar block of diverse genesis). There is also the
= possibility of direct iajury to the neuromuscular system of the heart,
vessels and their regulatory centers by high doses of radiation, intense _
heat, etc. In such cases, the symptoms of involvement of the cardiovascular
system appear at an early stagt and are prominent in the clinical manifesta-
- tions of d~sease.
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' t~ok c~i~t~ i.c:ini. us~: c~?vi,v -
In the case of hypoxemic t~ypoxia, changes occur in ce11 meCabolism of difFer-
_ ent body tissues und~ first of all~ in striictures that are the most sensl.tive
- to hypoxia, which incl~de the myoc~rdium. G. r. i.1ng combined the disturb-
ances referable ~n a complicated set of biochemical, phy~i~ochemic~l and
bioenergetic processes in ~:.?e myocardium in the concept of "myoczrdial
- dystrophy." There are grounds to asswne ChaC analogous pathoger.eCic mechan-
isrns are involved in development of disturbances i_n carbohydrate-phosp}lorus, -
protein and miner~l metabolis:n ~~nder the influence on the myocar.dium o.f a _
n~.mber of occupzticna~ factar.s, which were mentioned above. Some mechanisms
have been discovered in special experimenC~l studies of the effects of
radia~ion on the he~rt (Ye. I. Vorob'yPv et a1., 1971, 1973), while others
have yet to be submirted to clinical and e~tperimental invest3.gation.
Evidently, ~?im{lar pathogenettc mechanisms are at the basis of changes in -
the cardiovascular system, tn Che presence of so-called foundry fever.
However, here it is not so much the direct tux{~ effect on the myocardium
as the unique sensitize effects o~ met~al aerosols and compounds thAt play
the leading role, and they lea~l to development of acute allergic m}~ocarditis.
- The syndrom~ is polyetio~ogical and occurs under the influence of certain -
infectious agents, toxic agznCs and drugs. The lesion is ch~.racterized
- by acutely developing morphological signs in one of three typical (according
to Ya, L. Rapoport) variants: t~ypertrophy of muscle fibers alCernating with
=lelds ~~t myolysis, perivascuiar lymphoid and plasma cell infiltration and -
plasmorrhagia. The main pathogenetic mechanisms are nonspecific, for which
reason there are many feature~ in common in the clinical signs of myocarditis, ~
- regardless of its etiology: acute anset, enl.argement of the heart, dull
sounds, persistent tachycardj.a, dysproteinemia with increase in share of
coarsely dispersed proteins snd a2- and Y-globulin fractions, eosinophilia.
The electrocardographic ctianses ~re not notable for stabi3.ity. The previously
held view of mandatory malignant course with mainly po~3tmortem diagnostication
has recently been shaken, Forms have been isolated that have a chronic,
recurrent and occasionally more benign course (N. M. Konchalovskaya et a1.,
_ 196.5; M. I. Teodori, 1972; Gvozdi~ak, 1973). _
A similar mechanisms is apparently involvEd with exposure to radiation in -
_ doses that eliciC extenstve destructive processes :in tissues that are more
radiosensitive than the myocardium. The toxemic form of radiation sickness =
_ has also been singled out (A. K. Gus'kova and G. D. B~ysogolov, 1971). In
this case, tox�~c ar.d allergic influences are also expressed in the myo-
- ~srdium, and they can be the immedfate cause of death, by analogy to the
~ reaction of the hearC at the toxic stage of burn injuries (N. S. Molchanov,
- 1973) or extensive tr~umatic crushin~ with the compression syndrome (Ye. V.
Gembitskiy, 1973).
Another mechanism of direct effects on cardiovascular metabolism is -
- expressed via neurohorn~ones and the system of peripheral chemical mediation -
(epinephrine, norepinephrine, acetylcholine and others). �
_ The effects of organophosphorus compounds and certain other toxic factors
' tlead and its ethylated derivatives) on the cardiovascul.ar system are based
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~ rc~f; n~~;~ c?v~,ti~
~ on sCruc~ural and metabol.ic changes in the vasc~.~1.~r w~;1.1 and myocardium,
~y>>aptic activity of peripheral r~cept~~r.: ui ~itiferent classes, along with -
other symptoms of a myoneuraa. block. ;=yndr.omc:s r~sembling acute an~i:Ltis _
with regional impairment of he!nodynamics, crises with sudden circulatory ~
- insufficiency to the extent o� com~~, ocr.upy a place in trie symptuma~ology
of poisoning by such s~~U ~~~:~.~i~:~~s. 'Ttiis is the topic covercci by Ye. A.
Lushnikov (1964) in h~i~.~ studie:; of p~tient:~ wi.tl~ Chiuphos poison3.ns.
- Efforts at pathogenetic therapy of auch state:~ are relaCed to such concep-
tions; they are directed toward reactivr~tion of cholinesterases~ nnrmaliza-
tion of catecholatnine metabolism and nclrener~ic rec~pL�ors (S. N. GoLi.kov,
- 1971; A. L. Myasnikov, 1965, and ~~he~s).
Not infrequently, in poisoning cases, there is development of atherosclerotic
process~s with the correspor.tl:.ng clinical manifestations as a result thereof.
There is animated discussion in the literat~ire (A. K. Gus'kova, V. P.
~ Medvedev, 1973, and others) of. the quest~o~i of eEfects af some factors -
- (radiation, lead, electromagnetic fields) on the higher incidence and earlier -
_ detection of atherosclerosis.
- Vascular disturbances are based on local or general traumatization to vesaels
under the influence of vibration, overcooling and appearance of dise:inctive
coagulonathy. The role of other mechanisms is also unquestionable; in -
_ particular, pathological afferentation from receptors (local irradiation~
vibration, high-intensity radio waves). _
Changes in the cardiovascular system occurring in connection with severe
invol�,ament of the lungs and associated with developnent of cor pulmonale =
= occupy a special pl.ace in the symptomatology of occunational diseases. At _
first, there are compensatory changes in the cardiovascular system, directed -
toward elii,tinatio.r~ of. hypoxia, then a set of successively and differently
(depending on the nature of the main lesion) developing chan~es, which are
indicative not only of involvement of various adaptive mechanisms, but -
signs of insufficiency of different elements of the circulatory system.
~
Under the influence of occupa.tional toxic agents (carbon tetrachloride, -
polonium and o~hers) with selective tropism for organs of the hepatolienal ~
system and kidneys, signs of autotoxic myocardial le~j:.ns are added later on ~
to the vascul2r cvmponent. However, the features of the primary effect of
- these toxic agents on the hepatic parenchyma persist and dominate in the
clinical signs of the lesion. For this reason, it would be more correct
to refer to secondary involvement of the cardiovascular system in the -
presence of the acute, toxic hepatorenal syndrome.
, The period of active fitness for work and mean age of ~mployed individuals
- increase in the ca~e of a mild, but long-acting set of occupational factors. -
- In some uccupations, there is in~reasingly distinct prevalence of inental and
emotional tension over physical loads, and an increase in share of mono~onous, .
_ stereotypic operations with minimal exercise. At the same time, the role
of individual responsibility and need to process an enormous amount of
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inf.orm:ition are increasin,;, wlt;i reduceion in ,~ctive exercire (workLng on -
conrrol consoles, production llru~s, etc,),
- '1'he po�~ibility of lnten~;e :~nJ extr~~me factort~ w'.ll ;~till pr~~ent itt Che
immediate future for a small group of worker.~, wiCh a.iignific:ant contrt-
b~Ciuu of inental ~and emotional strec~ (astronauts, i?~dJ.viduals engaged i~i [
iroportank overhau] work, seamen expohed to adver~e climate, etc.). -
,
Under such circumstattceH the role of other ic~f.luenceh increases sharply:
ma~:'s environment, working and l.iving conditiouy, ur.reasonable nutrition~
bad habite (amoking~ alcohol ebuse), hypoks.nesia~ unwarranted c~xtensive
- use of various drugs and u~e of chen~istry in everyday life.
The c~rdiovnecular system ic~ }~igt~ly reactive, it if~ functionally intimately
rel~ted co the nervous and endocrine systems. For this reason~ coneiderable _
difficulties arise in determining the etiological role of some occupational
factor. In some cases, it i~ even impossible to eingle out tlie pri.me r~ig-
nificance of a particular factor.
The main variants of neuroendocrine and nonspecific reactions consist, first
_ df all, of diverse changes in the main indicec of cardiac function and
, hemodynamics, that are within the ranges of rather broad physiological f~uc-
tuations. These reactions reflect~ first of all, the congenital and
hereditary constitutional distinctions of morphofunctional organizution of
regulation of circulation, wt~i.cl~ under~o aoecific ch~anges in the course of
ontogenesis artd are subsCantially altered L~ conditf.oning~ physical and
psycholo~ical training, upbringing, living ~:vnditions, as well as~ af course~
prior diseases and consistency wi[h the occ~pationa'L work load. Cong~~nital
distinctions of the cardiovasculer syatem undergo a cert.~in evolution at
different stages of life, and this does not occur smoothly; rather, they
are intermittent, differing in males and fe,males, with periodic chan!Ses
inherent in different phases of sexual activ=ty (menstrual cycle, pregnancy,
involution of reproductive glands, etc.). '
Of course, in view of the importance of the cardiovascular system to adapta-
tion of the body to changing environmental conditions, including occupational '
factors, one should expect ttiat, in the ~ourse of work, there would first
be development of orienting reactions that are adaptive in direc`'ion.
Many of the functional cha~nges in arterial pressure, pulse rat~, tonus of
the vascular. t+all, cardiac stroke volume and certain other parameters up to
a certain limit should be interpreted as compensatory and adaptational,
r�ather than pathologic:~l. Evidently, one coul~i try to d:sti.:o~ish between
some unique nonspecific reactions of the cardiovascular system inherent in
the effects of specific occupational factors varying in mechanism of action
on tt~e basis of time vf onset~ appearance of certain associations of
_ ct~anges and fullness of effect reached with them.
~Pirst, let us touch upon some general nonspecific Natterns of regulatory
mec}~anisms tt~a[ are sigr.ificant to formation of reactions to any exogenous
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H'~11, ~~t~ i f~: ~~11. I~~ (it~L},
factors. All resedrehere valldly .~ttri}~uc~~ .3 l.~rr,~ r~Jc t~~ ~h~ ic~;ulator;
influence of the central nervc~us ~ystcrn, r.irul.~rly s~cne of ity brancl~c~ss
, (hypoth;~lamic and cortical r~~~ions uf th~~ v~iscular center); e:here ~_or~d:-
tlon Lc~ largely determined hy ci~e lc~~el of bl~~ud supaly~ wh!]~~ di.;;t_ur~ance:,
of these ele~cent~3 l~ad ~'o funcr_i~~nai chany,eH in the cardiovasc~~l.~r sysr_e~n. .
'thus, changes in phy~iolo~~' ~.a] activity a~~d re~7ctivity c~f u~r.clia:. br.ain
etructureg are reco.d~ d yuite oft~n witi; exposure to carbun disulf.ide,
radio waves~ ionizit~~ radiation, etc. (D. A. Cinzbur~; ~t al.). Variou3
r_hanges are ob~erved in biuelectric activity of ehe brain (periods and
bursts of synchronized, hiYh-amplitude ~~scillcatteub of bi~potentinlg at
a freyuency of 3-6/s). These changes are :,ccasionally associated with
clinical syndromes of diencephalic diynrderR ~nd autonomic rrl8es des-
cribed by M. N. Ruzhkova~ K. V. Glorova, A. M. Monayenkova and ott~ers.
The incidence and severity ~F che vascular component ~re yuite varicd.
The impression is gain~~d that, und~r the influ~~n.ce of carbon disulf.ide and
certain other toxic a~;~nt5, vascul~r disorderri are observed ai~~re often
than manifeac.ations of hy~othalamic in~ufficiency, but the aeverity of
both fs similar. A. M. Monayenkova observed myocardial changes reliah;y
more often in individuala with symptoms of iropaired regulation of hypo~}~a- -
lamic centers. The hyperdynamic type of vasc~~lar disorders demonatrated
si~ns of neurogec~ic geneai~ thereof, as confirmed by the correlation betveec~
changes in indices of ieometric contracCion of the myocardium and signs of
hyperactivity of the sympathoadrenal system (changes in catecholamine
metabolism). Analogous correlations were observed t~~ K. V. Glotova and
C. G. Lyeina (1912) under the influence of high-intensity, superhigh frequency
electromagnetic fields.
Ye. Denisova et al. (1975), M. N. 5adchikova et al. (1972)~ Ye. V.
Gembitskiy (1969) and others observed a different type of reaction, mainly
in the vagotonic direction (bradycardia~ arterial hypotension) under the
influence of loa doses of 1oniZing radiation and different intensities of
Ladio waves. These hemodynamic changea were related to signs of altered
peripheral afferentation and disturbances in the syetems of such mediators
as acetylcholine and cholinesterase. There Was secondary appearance of ~
changes in the catecholamine system and central regulation of hormone
synthesis in the adrenal cortex (I. A. IGogan~ N. I. Corbarenko, 1971~ and
others). ~
There are data indicative of a conaiderable incidence of hypathalamic states
- among hot ahop workers. Along vith reflexly occurring changes in autonomic
regulation of circulation, some place belonga t.o fluid-electrolyte balance
disturbances in [he pathogenesis of such stateti. The blood pH changes, and
this affects the extracellular and intracellulrir concentrations of potassium
and sodium ioas and, consequently~ the electro:tyte gradient cetween the
liquid p'~1ase and structural componen[s of tissues. There may be changes in
heart rate~ frequency of cardiac contractions, widening of heart boundaries.
dull soun~s, arterial hypotension and electrocardiographic signs of
weakened contractility of the myocardium, as vell as symptoms of circulatory
insufficiency of cgrdiac genesis.
8
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r~k ot~ E~ rr, tn~. usN ~~N~ti. .
I'athologic~ll afferentati~;,~ from the periphery, primarily from v~~hcul3r
bnrorr_ceptoxs in tii~ part~ of the body r;ub~c~~.t to traumalir.ation, plays a
~~nrt in Il~r pnllinj;enr?~L: nf f~in~�t I~~n;~l ~�hE~n~;~~;+ ~r, lli~~ nc~rv~~uy rayalem r~dp~~rf-
~tli~~>end~t on th~ extent of involve-
menl it~ the pror_ess of othcr ory,;~~� and systems, :~s well ar3 the general
corr~lationf, established in thc~ patient~s organism. Uependin~; on the -
concrete ~yndro~ne~ its role at a~iven momer~t in thc cllnical findin~~
and prognogie~ r~s well as thanatogeneeiH~ this part may vary n~ to the
plece iC will hold in a c;omprehensive formulation o!' ttie di.ay,n~aie of
an occupetionr~l di.sease.
- ~ 21
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~ i, i i~ ~
- Cl{AP'CtiR 7. TtlE CARDIOYA~'.':' S~':iTFZi AS IZtiI.ATi:D TO INUUSTRLIL POI.''.Ut~I.'vG
(Text) Or~ uf the mc~at imn~~rtc+nt ast~ect~ ~~f control r~ c~jf,E11SLF o! r,},,
heact and ves~elR is identifir_atiun of th~. ~t~.OLUFy and path~y,ener,is ~rf -
such diseases. LnduBtrial `� ~C r~tio bctwc~en velocities (Cm/Ce) ~~nd elae,ticlt~
moduli /E ) nf vesr,cls uf the muscul~ar and elastic type (over 1.4) founcl
- in 70~ ofmthe patienCg indiCaCe~ th~t the Pl~qti~ity prnperti~s nf Che -
walls of musculnr grCeries are greater in these patiettt~ than Chose of -
elastic arteries.
The incidence of elevated I'WPV, hi~h r, /C and ~m/~e was reliably higher
among paCients with signs c~f func~ttona~ d~sturbances of Che h}�pothalamic
region than in patients with:~~~~ such signs.
According to vo].um~~t:rLc pul:~e oc~ digital plethysmo~r~itlly~ tonus of peripher.al
arteries wiCh amall caliber wae accentuated in the fingers of mosC patienCs
(60.79~) and Coeg of a conaiderable number of cuses (43.6%).
A ~omparison of indices of pulse wave velocity and plerhysmographic findiuge
to such clinical aigns as complaints of pnin in the limbs, coldneas and numb-
- nesa thereof~ revealed Chut pain of the extremities was associated with
si~ns of vegetoaensory polyneuritis~ which are often seen in paCients with
normal and accentuated tonus of arteries of the limbs. Complaints of
- cold and numb limbs were clearly asaociated with elevated pulse wave indices.
The higher incidence of increased tanus of peripheral arCeriea in patienta
wiCh ^:gna nf hypoChalamic involvemenC and increased sensations of cold and
numbn~ss in patients with eigns of hypothalamic pathology at times of
vegetative crises are indicate of a link beCwcen hypertonia of peripheral
arteries and involvement of the hypothalamic region~ which apparently
includes structurea that participated in regulation of vascular tonus.
In spite of the eatablished opinion that tonus of cerebral arteriea is
increased in the presence of carbon disulfide poisoning, studies of cerebral
circulation by the method of orbital and temporal plethysmography, uaing a
cuff to occl~de the cervical veins, indicate that a decrease in tonus of
intrucerebral arteries (42X) and veins (52X) is the most frequent cause of
cerebral hemodynamic disordera, which are often dominant in the clinical
syndrome of inCoxicaCion. V. P. Zhmurkin observed analogous changes in
cerebral hemodynamics in the preaence of essential hypertension.
Virtually all of the patients (95z) eomplained of headache. However, it
was attributable to hypertension of cerebral arteries in only 167:, and
a different mechanism of hypertension (neuralgia, migraine) was involved
in 20X. In most cases (59X), headache was due to inadequate tonus of cerebral
veins. Of the S9x cn8es With typical dull or excruciating headaches of
occipital or frontal localization, which became worse when the body was
- inclined and often associated with vegetative disorders, SOX presented
rather marked hypotonia of cerebral vessels (hop>86 mm3)~ and in 25X of the
30 -
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I~UIt (11~1~ 1(,IAL U~~1~: t1NI~Y
cage~ it wa~ asgdc:inted with J deCreage in tonuy OC CCt'CbY~l nrtc~rie~,
cnusing difficult efflux df blood from ehe cranir~l c~viey. In 9~ of the
p~tienes, tdnug of ccrebral veins wa~ normnl~ bu~ ~ low arterinl Conus
(a~p>15 mm3)* CC1USCC~ excessive inEl.ux (Table 1).
The role of hypotonig of cerebr~l veins in the genemi~ of hend~che wu~
confirmed wiCh particular distinction in pharmacological tes~s. Wellbeing _
of patiente improved under the influence of a vasoactive ap,ent (no-ehp~~
(b, 7, 3'~4'~tetraethoxy-l-benzgl~l,~~~,4~tetrnhydroigoquinolone hydro-
chloride]) along wiCh increa~e in tonu~ of cerebral veins.
In tt~e light of the fnregoing, frnm the stattdpoint of therapy ir. ig importnnt
to know wl~ich vascular disCurbance (arterial or venous) is pruminent in
Che clinicul eigns of poisoning. -
The funCtional etate o~ Che myocardium is p~rticul~trly significc~nt in develop-
ment of hemodyngmiC changeg. _
Accdrding to the data of most clinicians (G. G. Lysina, 1956; V. G. ~elikov,
G. G. Z~kharov et al., 1965; G. Ya. Bakeyeva, 1969; Weist~ 1957, and others),
in the case of chronic exposure to carbon diaulfide, contacts often present
- complainta and changes referable to the heart (unpleasane sensations,
' sharp or compreasive pain, palpitations, dyspnea, dull sounds and syatolic
murmur over the heart). These symptoms and complaints progressed with
increase in work tenure involving contact with carbon disulfide (Ye. N.
Artem'yev~ T. K. Konovalova, 1962, and others).
A. A. Model' and E. S. Navrotskaya (1958), who made an electrocurdiographic
_ study of 66 patients with eerly signs of chronic cnrbon disulfide poisoning,
diacovered changes in T wave, S-T interval and low voltage of the QRS
complex, which they evalugted as a aign of functional weaknesa of the myo-
cardium occurring as a result of impaired corticosubcortical regulation; -
these aigne were present in addition to rhythm disturbarces (bradycardia or,
more often~ tachycardia).
C. Ya. Bakeyeva (1963, 1969) found changes in the terinal part of the
venCricular complex (shifting of S-T interval, decline or inversion of T
wave) and aigns of diminished myocardial conCractility, indicative of _
hypodynamia of the mycoardium, alang with functional disorders of the
nervous system, in over one-third of the patients she examined. The
physiological electrocardiographic, ballistocardiographic and polycardio-
graphic changes she demonstrated, combined with the complaints and clinical
manifestationa of intoxication, were evaluate3 as myocurdial dystrophy.
V. A. Vasil'yeva et al. (1966) describe analogous changes and interpreta-
tion.
~Hop and aop--tonus of cerebral veins and arteries, respectively, deter-
mined by orbi~al plethyamography.
31
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i~ui; ~~~'i~ic~ini. u~i~, c~Ni,~~
Pnthoanntomicc~l nnd p~thohi~kolo~icc;l das. Tender supraorbital and occipital points~ Erb's point,
neurovascular bundles on the forearms, legs, pnravertebral
pointa of the cervical and thoracic spine (D~-D~). Lively
tendon a~~d periostal reflexes, d ~ S; plantar: diminished on
- the left, absent on the right. Rocking in Romberg's position.
i~iild tremor of extended fingers. Hypersthesia of distal
_ parts of the arms (C6-D1) and loaer third of the thighs.
- Hands and feet are cold, with marbly skin. Pink dermographism
appearing within 1-8 s and lasting over 6 min. Pulse 74/min.
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Arterial preggure is in ttie r~nge of 110/70 to 140/90 mm Ng.
lleart boundarieg are within normal ran?e. Sounds ~re aig-
nific~ntly dulled. No p~tholo~y of. lungs and di~estive
organg. Examin~tion of eye grounds revealed moderate di- -
l~tution of retinal veins,
glood test: liemoglobin 144 g/R (14.4 g%)~ erythrocyteg
. 4.8�106/ uR (4~800,000), color index 0.9, leukocytes -
7.5�103/uR (75U0), lymphocyteg 31%, monocytea 6%~
eosinophils 2z, basophils z9~, sCnb 5%, segmented 54Y;
erythrocyte sedimentation rate 2 mm/h. Blood scrum: free
carbon disulfide 0.03 mg9:, bound 0.026 mg%, cholesterol
2.45 g/K (245 mg~G), sugur 0.94 g/k (94 mg%), acetylcholine
attd gcetylcholine-like gubstnnces 12 ug/m~, paeudocholinea- _
terase activity 0.4, cholinestera~e 0.96. Sublimate test
1.91~ formol neg~tive. Wassermac~nnegative. Epinephrine .
excretion in urine 1.44 ug/s, norepinephrine 6.7 um/s.
Tachyoscillographic recording of arterial pressure:
M--90, M--112, N--124, M--160, ~p--34, HS 36. PWPV -
770 cm/s in aorCa, 1280 cm/s in brgchi~l-r~di~l artery,
1200 cm/e femoralartery-dorsal artery of food. 5BV 60 m1~,
actual MV 6~ above due level; actual 5pR 25X above due
level and 26X above working level; EKG: sinus rhythm~ 76/min,
- RI� RII~RII~~ ~Vy~SVM~ Q~SIII small, TIII low, T~vL
_ flattened. orizontal,electric axis of the heart. Syatolic
phase structure: Q--first eound 0.06 s, sphygmic phase ~
0.23 a(92X of due level), isometric contractton 0.05 s,
tension phase 0.11 s; KB 2.4~ ISI 82.
After tregtmer~t (glutamic acid, belloid, ATP, glucose with
vitamin$ C and B1, papaverine, adonieid, galvanic baths wiCh
naphthalane emulsion), the patient reported improvement. But
very soon~ in spite of diacontinuing contact with carbon di-
sulfide, hi8 condition worsened. When admitted to the
institute clinic 1 year laCer, there was no improvement of
wellbeing and ob~ective condition. Hemodynamic parameters
presented no significant dynamics. Tachyoscillographic
recording of arterial pressure (mm Hg); Mri -94, My -110, Nw -
122, MX 132, ~p--28, HB 10.
pulse wave propagation in aorta 770 cm/s, in brachial-radial
artery 1280 cm/s, femoral artery-dorsal artery of food 1060;
SBV 45 m; actual MV equals proper level; actual SPR is 30x
above due levcl and 30X above working level. No dynamica
demonstrable on EKC (with the exception of isolated supra-
ventricular extrasystoles); the phase structure of the systole
also remained stably altered: Q--fi.rst sound 0.04, sphygmic
phase 0.25 s(95X of proper level)~ isometric contraction
0.05 s, tension phase 0.09 s; KB 2.8; ISI 82.
41
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_ In thig cn~e, n pntient whoqe work for 12 ycars invol.ved cottt~~ct with
egrbon dieulfide, there w~~ pr~dual devc~luE~ment of symptoms of chronic poi-
gotting, indiCaCive oi tnvolvement of ti~e central and peripheral nervous sys-
Cem (marked ngthenovegetatlve ~yndrome witli ~igns of hypothalamir involve- ~
ment, eign~ df polyneuriCi~ and xympnthetic truncitis). In spite of
tre~tment gnd diecont[nuc,' cuntacr. with c~rbon disulfide, the chat~geg in thc
n~r'voug system are s~_~ble. Ca.rdiovascular di~turbances (hyperten~ion, in-
Creaged Conug of v~:gHels and peripheral resistance, decreased systolic
effiCiency) arc also persistent, and thcy aggravate the course of poi~oning.
- patient D.~ 37 years old, has wnr.~:ed for 17 years as a spinner
aC a chemical fiber plant, has Ueen iu contncC for ehe last few
yeara with carbon di~ulfide in concentrations 4 times higher
than permigsible !~:�els.
She was ~d~nict.ed r.c, the ic~stitute clinic with complaints of
headache and vertigo~ pain in the arms and le~g, coldness and
numbnesa thereof, cramps of the legs, sharp pain in the cardiac
region and palpitaCione, dyspne~~ upon physical exercise, _
irritabiliCy, poor memory, poor sleep with frightening dreams,
tremor of right extremities.
For tt~e firat 2 years on the job (period when the shop was
_ atarted up), the patient had several mild bouts of acute
carbon disulfide poi8uning; after working for 5 year8~ she
developed headachea associgted with nausea~ vomiting and
Weakneas. In 1957, she developed pain in the arms and legs~
then numbness and crampe of the legs. Her condition
woraened significantly in the last 3 years, with more frequent
attacks af headache, which began to be associated With
vertigo; appearance of tremor of the limbs, deterioration of -
memory; she began to tolerate poorly heat, odora and travel-
ing (aesociated with headache). She has a history of eczema
of the handa and cholecyatitis.
Objective examination;� temperature 36-37.2�C, well-developed
subcutaneous fatty layer. Tremor of right extremities, deterio-
ration of inemory. Emotional instability, tearfulness and she
is shaking throughout the examination. Pupils s~ d, with
attenuated reaction to light and convergence. The right corner
of the mouth is descended, the tongue deviates to the right.
Palatine and pharyngeal reflexes absent. Total hypesthesia
of superficial seasibility, more marked on the limbs, better
_ (but not normal) on the soles, around the oral and anal region.
Mild retropulsatton. Tonus of the legs increased, of the
extrapyramidal type. Periosteal and tendon reflexes altered
on the arms: d someWhat more than s. Knee reflexes (s ' d)
- lively~ abdominal (s = d) present but very transient, plantar
diminished. There are elements of bradykinesia (slow performance
42
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of te~Ce). [tl~ytl~mic pulge 48~52/min. Arterial pre~sure in
~he range o~ 170/110 Co 110/80 min Hg, ~lev~tion firy~ demon-
atr~ted and normalized 4 days n~ter admisyion. Uull heart
soundg over the apex; sCronger second sound over :~orta.
ItoenCgenogcopy of the he~rt showed some enlargemene of ehe � �
left ventricle, no ch~nge in gortct. No change in vesselg
of the eye grounds.
Blood rest: hemoglobin 128 g/k (12.8 g9~), erythrocytes
4.1�106/uR (4,100~000), color index 0.9G, leukocytes
4.1�103/u~, (4100)~ Lytllph~CyCe5 32%, monocytes 63~~ eosino-
phils lY~ basophile 1~, stab 4%, segmented 57~; erythrocyte
sedimentation rnte 11 mm/h. B1ood gerum: 0.020 mgX free carbon
disulfide, no bound carbon disulfide, cholesCerol 2.7 g/R _
(w70 mgX), ~ug~r 0.9 g/R (90 mg7~), lipoid phosphorus 0.073 g/R
(7.3 mg~), acetylcholine and acetylcholine-like s~bstances
189 ug/ml~. Pseudocholinesternse activity 0.320, cholines-
kerase 1.06. No epinephrine or norepinephrine in ur~ne.
NegnCive Wasaermann. Analysis of duodenal contents c.2gative.
Tachyoscillographic examination of arterial pressure (mm Hg):
. Mn--76, My--90~ N~,~--1-8~ MX--118, ~p--32, HB--10. PWPV
670 cm/s in aorta, 1220 cm/s (on the right) and 1150 cm/s
(left) in brachial-radial arter,y, 700 cm/s (right) and
1300 cm/s (left) in femornl-dorsL~l artery of foot; SBV 68.2 mk.
Actual MV 15X less than proper lev~l, SPR 28~ above proper '
level. EKG: sinus rhyChm, 51-54/min PQ 0.16 s, QRS 0.08 s~
QRST 0.40 s(normal 0.43 s). RI>RII>RIII~ ~Vs~SVs> S II,III,avf
accentuated, TII mildly positive, TIII avg ,avl flattened,
T~3 low~ Ty4_5 negative, T~6 mildly negative. Sinus brady-
cardia. Electric axis of the heart deflected to the left.
Marked myocardial changes. After therapy (tropacin, novocain,
papaverine, dibaxol) there was no appreciable change in the
patient's cvnditinn (some decrease in headaches). Nor were
- there subatantial changes in condition of the cardiovascular
8ystem. Auscultation ahows that arterial pressure indicea
are in the range of normal fluctuations (110/80-130/90 mm Hg)~
but tachyoscillography revealed elevation of inean And lateral
preasure.
- Arterial pressure indices after 3 weeks (mm Hg): Mn--92, -
M~,--106, Piw--126, MX--132, Ap--34, HB--6. PWPV 700 cm/s in
. aorta~ 1630 cm/s (on the right) and I.530 cm/s (left) in
- brachial-radial artery, 1130 cm/s (right) and 1200 cm/s (left)
in femoral artery-dorsal artery of foot. SBV 7.6 mlZ. Actual
MV SX below proper level. Actual SPR 28X higher than due and
24~ higher than working level. EKG: mild positive dynamics.
Sinus rhythm, 44-50/min, TI,II,III is no mildly positive, TV6
mildly biphasic, T~2~3 positive, Ty~_5 less negative.
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I~O+i t~l'r[Cir1L U5~ UNL,Y
In Chig cgse~ a woman, wiCh L7-ye~r tenurc�~~n a 3ob involving COt1t~Ct with
carbon dieulfide, whu begnn to wor~: when the mill waa started~ wh~n there
wug significnnt g~~ level, nnd who ~ufLered repeated bouts of mild
acuCe carbon diaul�ide pnl5or~in~, developed signg of chronic poisoning within
5 years. Th~reAfter, with ~~ntinued cont~ct witt~ carbon d~.sul_fide, her
illnees grgduglly pro~;z~~~ssed and, ~~t the time of vur examin~ition, wc~s
coneistent with thP ~ymptom complex di' toxic enCephalopoly~teuritie witt~
~~gns of extrapyramidnl and hypothalamic ~.?~volvement. riarked changes in the
nervous gystem were combined with cardiova~r.ular disordera (l~ypertensive
reacCions, increaeed tonus oE peripheral arterie~, impaired bioeleceric c~nd
conCr~cCile funcCiona of the myocArdium), which persisted even after Creat-
ment. .
Evett of the changes in the cardiov~~scular system, as well as nervous eystem,
do not lead to cardi~+~_ or coronary ineufficiency, they sCill play a signifi-
cant parC in ~ome cases ln llie symptomnCology of intoxication. Eor this
- reason, tt~e set of therapeutic mensures should include, along with therapy
direcCed Coward restorntion of nervous system function, agents that are
directed Coward eliminaCion or attenuation of cardiovascular disorciers.
Of course, when making experr determination of pntient fitness for work.
- one must take into consideration~ in each apecific case, the nature and
aeverity of functional disturbances of the cardiovascular system.
Individuals, in whnm poisoning is associated with neurocirculatnry disorders
(with great lability of arterial pressure, persistent hypotension or hyper-
tens{on) and diffuse dystrophic changes in the myocardium, should be trans-
ferred to ~obe involving no contact with carbon disulfide or other toxic
agents. Individuals presenting cardiovascular disorders that are not
occupational in nature, in whom carbon disulfide could aggravate Che
' courae of theae disorders, should also be transferred to work unrelated
to exposure to carbon disulfide.
In the light of the above material, and in view of the in~luence of carbon di-
sulfide on the circulatory system with possibility of development of the neuro-
circulatory syndrome, esaential hypertension and syndrome of myocardial dys-
trophy in the case of chronic exposure, it should be noted that, in iden-
tifying chronic carbon diaulfide poisoning, the demonstrated changes in
the cardiovaecular syatem (neurocirculatory dystonia with hypotensive or
hypertensive reactions, essential hypertension, myocardial dystrophy) should
be included in intexpretation of the diagnosis. -
Clinical Chsracteristics and Condition of Cardiovascular System in the
Presence of Lead Poisoning
Lead poisoning, which is the most common occupational disease, has been the
subject of numerous clinical and experimental studies since ancient times.
Most researchers and clinicians (I. G. Gel'man, 1928; L, A. Zorina~ 1965;
A. T. Aldanazarov, 1968; A. M. Rashevskaya, L. A. Zorina, 1968; N. S. Sorkina,
44
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~
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1971; Srt~mldt, 19Z9; Kc~elech, 1~)35; L~wer, 1955; Ambrosio, SE'CCI1~~ 1g68,
utid ~~thE+rH) bci irvc~ tlir~t 1ri~J IK n~~~~lyrr~~~?ir. ~~nir~on with, howc�ver, pre-
dumlunnl eCf~~ct utt llii~ bl~iucl, n~~rvuuH Hyt~tem, di~eF~riv~, or~~tne nnd por~
phyrin meeabolism.
In rl~e opinion of many rese~rchers, typic~l blood changeq ~~re among the
e~rly manifeetations of le~d poisoning; decren~ed hemo~lobin and erythro-
cytes~ inerenaed reCiculocytes nnd erythrocytes with basophil granulgtion.
- According Co the clinicophysiological studies of C. A, brogichina, L, A.
Okhnyanekayn et al. (1952)~ ~unctional changes in higher brnnches of ehe
central nervous system nre early sympComs of lead poisoning, clinically
manifested by aCten~ation of cortic~l activity with development of the
getheniC ~yndrome and diaturbances of the autonomic nervous system. In
the Soviet Union, because of improv~ment of working conditions, serious
organic disorders of the nervous system (lead paralysis, encephalopathy)
are no longer observed in Che presence of guch poisoning. Severe lead
colic hea also become a very rare form of intoxication.
Clinical ~nd laboratory studies of recent yeurs have shown thaC impairment
of porphyrin metaboliam is the earliest sign of the effects of lead on Che
body (Yu. P. Yevlashko, 1965; N. S. Sorkina, 197a.).
In the patienCs we examined (10 women and 92 men mainly up to 40 yeara of
age, working in the most hazardous occupations--furnace operators~ stokera~
_ battery chargers and lead aheet conters, who ~re exposed to lead fumes and
duat for long periods of time),the clinical findings referable to the chief
complaints (painful extremitiea, general weakness and fatigability, head-
ache~ more or less intense abd~minal pain, etc.), changes in the blood, .
porphyrin metabolism, nervoua system, gastrointestinal tract and other
organs are consistent with the typical, commonly described clinicul symptoms
of lead poisoning. Out of 102 patients, 63 were mild poisoning cases~
32 were moderate and 7 were severe.
Unlike the patient~ wiCh carbon disulfide poisoning, Che patients with lead
~ poisoning preaented considerably fewer compleints referable to the nervous
system, in the presence of inhibition and low lability of autonomic reac-
tions. The chan~es in the nervous system were characterized by mild signa
of the asthenovegetative syndrome (21X), asthenia (12X), vegetovascular dys-
function (12X) and some mild symptoms of vegetosensory polyneuritis (31X).
Althoug}~ many patients (SSX) complained of pain in the cardiac region, this -
was not the prime element of symptomatology, and in most cases (S1X) was
manifested in the form of periodically occurring unpleasant sensations,
sharp or boring pain.
_ On the whole, lead poisoning differs from chronic carbon disulfide poisoning
in that the course is more favorable, with a tendency toward significnnt re-
duction and disappearance of signs of intoxication after treatment and dis-
continuing contact with lead.
45
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~>>'rT(:[,~i, u::i~: ~~N~.Y
It han been lnng knnwn, on the ba~i~ of exn~riment.~l a?~d clinical ~Cudiep,
Ch~C lend ha~ ~ gp~~~~ic ~~ction. K. Kh~irchenka (1929), I3. A. Atchabarov
(1960), Minden (1963). liolytein (1'J61+) :?nd otherg intcrpr~t spasm oE tlie
cut~neou~ ve~eel~ ag one vf the cardin~l. symptomg of poisoning, "lead
Coloring" (di~tinctiae p~~.e eareh color of the integument). 5uch n m~rl:c~l
_ syndrome df intoxir.ation lead colic ig a criqis with ~brupt on3et as~c~ -
ciated wiCh exritattun of the ~utonomic nervous system and sp~stic-atotttc -
ataCe of the integtine A. bro~ichina, 1952, and other~). 'The per- _
sieCent headache~, transient amblyopie ~nd convulsive seizures, which ~are
ob~erved at the height of a lend Cc~lic atC~._k, are related by researr.her~ _
to c~r~brnvascular spgsm. Diminislied diuresis in the pregettCe of lead
colic is also atCributed to spnsm of renal veg~els (Minden, 1963, and oehers).
The spastic effeCt of lead cnn exCend to the coronary vegsele as well. Thus,
A. M. Breytburg obser.ved 3evere spnsm of coron~ry vesselg under the in-
fluence of lead in experiments on ttnimals. Sput~ler (1940) demonstrated dis-
tincC cor~?iary changea on the EKG of a 4k-year-old putient with lead colic,
whose earlier EKG presenCed no pathological changes or rnpid normalization
after disappegr~nce of signs of acute poisoning.
A. I. Knopov (1958), N. M. Konchalovskaya et al. (1965), rt, M. Abayeva (1967),
Salvini (1953) and others have observed marked cardiovascu'i$r crises neao-
- ciated with L~KG changes ~appearance of cotonary T waves) in the presence of
severe lead colic. With disappearance of signs of lead colic, these
changea regreaeed and even reverted back to normal.
In one case~ a patient 26 years of age, we obaerved conaiderable diffuae
low~ring of T Wave during a marked aCtack of lead colic associated with
eleva[ion of arterial pressure, increased peripheral resistance and
tonus of arteriea of the extremities, and the former disappeared 2 days -
after the attack. These very transient changes, along with complaints of
presaure pain in the heart, can apparently b e related to impaired coronary
- circulation due to cardiovascular spasm.
Obaervation of patients suffering from lead poisoning revealed that the main
cardiovascular changes (Table 1) are quite similar to those associated with
carbon disulfide poisoning. In a considerable number of cases, there was a
statiatically reliable (p ~i5y, lc:ukor,ytc~l.l�103/tii� ().700),
lymphocytera 6F~7,, mori~~r.yer_n 19,', bn~c,uhf ~n 3q. stab 49;, ae~-
mented 25Y; er~~nr~cytc tt~tdzm~~;l~.;,r.(vr~ r~tt~ 5S mm/ri.
~ b
f ~ , li.{,~-14-HII~ ~I~~i!IIi~I~fI~IIII
~ ~ ~ ~ ~ Illlll _
~�!'t"'~'~ I~~~ ~ i~~ ' jl ~.l.;~I~llll
~ ' ~'~.~I, ~If '
,~~Illi~llllflllll~l IIYIII~I~~ IFI~I~I
`p-N~',, ~~~l~~
YJ'I'!'ll: 'I`~, '','~{IIII
~V ~
, v~ I I(~
~ I I ~ I e
_ Vf I ~
~ I i i ~ ~ -
V~~I ~!I " ' y
~ 6~~~~ _
C
1 I � .
j ~ (
~ Y) I
~
~
, ,
i i ~
~ I I I I s. ~ I
~?I!il
~6 ! i -
i i I I I I I
Figure 2. EKG of patient F.
a) at start of illnesa b) 2 years later c) 6 years later _
64
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I~Uk OI~I~ICIN, U5E ~NLY
On the E;KC there waN a t~lir~r.p dror of '1' w~ive i.n standard ~nd
rip,ht chest lec~dg~ while V3_~ bec~7me neg.~tive in the left
chest leadf~.
In view of the fact th~t Che circulatory sy~tem i~ one of the chief inechnniamx
of compensution o� hypoxi~ in ti~e preaence of anc~mic s~ates, iC muet be con-
ceded thet diaenses of tt~e cc~rdiovugcular ~y~Cem are also a contraindication
- for work involving contacC with benzene ns well n~ a deterrent Co continui~g
work with Auch coneact.
Thus, the clinicophysiologicnl studies of functional state o� the cardio-
_ vASCUlar syaCem in the preaence of three differ.enC occup~~tional disenses
are indicuCive of clrculatory disturbanceg, which nre, on the whole, in the
_ nature of vegeCovaecular dysfunction (neurocirculneory syndrome) and myo-
cardial dysCrophy. They are not apecific for any particular type of
poisoning, since anaingous cardiovascular c}~an~es are observed under Che
influence of other occupational factors, for example, with exposure to
induetrial noise and vibration, ionizing radiation, as well as other aub-
stances. At the aeme time, with each of the intoxications studied, we
detect some diatinctive features and uniqueneas of chang~s in the circula-
tory syetem, the nature and severity of which are related to severity of the
chief pathological process, determined by the predominant area of applica- -
tion of the deleterious factor nnd initial condition of the organism.
Cardiovascular disturbancea~ which appear at the early stages of poisoning
referable to some toxic agent or other, sometime~ become Che prime eymptoms
that determine the clinical course of intoxicution. ~
65
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FU~. Uf~['1.CIr\l. G~~I? UNf.,~'
CHAPTER 4. THE CARDIOVASCiT~.:1~ SYSTEM A5 RELATED TO EXPOSURE TO OCCUPATIONAL
BADIATION
[Text) Ti~e reactionsof the cardiovascular system are an inseperable part
of the body's general responae to radiation as one of many environmental
stimuli~ and they ean also reflect the direct eff.ecCs of in~uries Cu struc-
tures that constitute the ~natomical subatrate of the cardiovusculur aystem. -
There are a number of works dealing with investigation of Che curdiovascular
system with exposure to ionizing radir~tion; thev summarize numerous inves-
tigations on a~iimala in acute and chronic experiments, information about
reactions of the cardiovascular sysCem in the courae of radiation therapy
of various parta of the body, data on the state of cardiovascular funeCion
in individuals expoaed to large doaes of radiation and suffering from acute
- radiation aickness. There are relatively few worka dealing with the cardio-
vascular system as related to long-term exposure to low doses of occupational
radiation.
T?r� biological effects of radiation on organs and tissues depend, first of
~11~ on ehe magnitude of absorbed energy~ its distribution in the body and
time. A distinction is made of the more specific effect of radiation on
the body, ita direct deleterious effect on cell reproduction, associated _
with a change in the process of DNA synthesis. The nonspecific rea~:tion
to radiation is another biological mechanism, a respons~ to an adequat~~
stimulus of several systems with the property of excitability, reactivity.
Interaction between these two classes of reactions is determined both by
the characteristics of absorbed energy and distinctions referable to struc-
ture and radiosensitivity of tisaues c~r organs.
_ The cardiovascular system is morphologically and functionally heterogeneous,
and this also applies to the effects on it of ionizing radiation. As shown
66 -
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f
I~UIt I)I~I'I(:1~11. U:;I~; i1PJl.},
ln num~rour~ s;tucl[~~r~~ ~~ne 4livul~l rsln};1~~ ~~~~t the~ r~~~c~tic~ns uf Lhe myor~irdium,
great ve~3sely, rtc~uror~:~~u],~tory mcrli;i~it:;m;; u,' ~�;~~~rl;,~~� (~~~~~tion, c;~pLll~~r.iea,
v~~cul.c~r endnthelium an~l tjy:;L~~mi~~ I~emc~el~~~,irnic:;. 'C~i~~ uryuc;~rdium i~ more
radioresl.sLttttt tl~~it ~api l.l ar i~~s ot� v~tr;~u 1:~r ~~nd~~t li~~l I utn wl~ [c~l~ nre ii i~~1i' y
sensilive Cu radiatloti. Myoc;~rdi,~l r.h~~n~;es ~~1:;~, r~rcur second~~rll.y~ a5 a
re3t?l.t c~� di~turbances iu ve~;;els that �~~urish tl~e myocardlum.
In addiCion to radiation c3use (which could I~ave a deleterious eff:ect or .
elieit only funcCio~~al seimulatio~i wi.lh submicros~op[c chan~r_s), th~_~ are..~
exposed to rpdiation is importc~nt to reactions of. thf~ cardi~~vascul_r.~r c,y~~tem
to ionizing radi~7tion, A disrinr_tioi~ t5 m,1de between total-body rr~cliat~iun ~
and loc~l expo~~.~e of ~ ~peci.f.ic re~ton: the Imnicdiate r.egtan of. the heart,
great ves~el~ ~nd reflexo~;enic vr~scular regl.oiis.
Numeroue~ experimenLal studies have dcmc~nstrated the corrclation between
dosage and n~ture of radi.ition. Seudt~as were made on diLferent animal spe--
cies of the ~ondition of the hear~, cardiac functi~n systemir_ hemodynamt.cs -
- and local circulation, as wel.l as re;icrivity of the c~ardtovascular system.
Morphologicnl changes in the heart were the most markecl ..~t the early stage
following total-body and local exposure to radiation in doses exceeding
1000 rem. 'Phey consisted of appearance of stromal edema, perivascular in-
filtration~ plethorr~, dystrophic and degeneraCive changes in the myocardium,
as well as in nerve ganglia and fibers of the cond~ction system (N. A.
Krayevskiy, 1954; 0. V. Mikhaylova, 1964; M. Ariel', 1965; Ye. I.
~orob'yev, 1965-1973; Ye. F. Lushnikov et al., 1970, and others), At the
late term, animals developed marke~ sclerotic changes in coronary vessels
and the hearC, leading to a reduc~~on in weight of ttie heart. Somewhat less
severe changes were present after exposure to doses of 500-600 rem, but their
nature and outcome were the same. Along with vascular c}~anges, dystrophy,
fibrosis, hyalin and fatty de~eneration of mtiscle fibers with necrosis
- thereof, signs of focal i.nfarction, degeneration of ner.vous plexi and
vascular receptors were observed (P. D. Gorizontov, 1960; 0. V. Mikhaylo�~a~
1964; L. L. Aver'yanova, 19G7; I. A, Oyvin et a1., 1971, 1972, and o~hers).
Most authors believe that lesions to blood vessel.s are the first to appear ~
under the influence of radiation; they lt~ad to dystro~hic changes in -
miscle fibers~ innervation system of the heart, nutonomic neural pathways
and conduction system uF the heart. Myocardial circulatory disorders pre-
cede the cl~an~es in muscle fibers.
Along wir_h structural rhanges in the heare, func_~ional disturbances of the
heart, :rystemic and local hemodynamics have been described wfth exposure
both to total-body and local radiation of thc cardiac regic~n in ht~ti doses.
It was demonstrated that there are phasic charibes ic~ arterial pressure and -
~ pulse rate corresponding to the ptiases of the acute radiation syndrome:
tachycardia followed i~, brady~-;~rdia, transient hypertension followed by
_ hypotension witl~cir.o~> of both diastolic and systolic pressure, decreased
vascular torius, slower blood flow and elevation of venous pressure (Ye. I.
Vorob'yev, 1968; L. A. Yakovleva, 1912, and others).
67
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~ ,r, ~ ~ ~ , ~ . . ~
The CKG chan~es ~rr. ~h~~1C~irh~tt' iz~~d b~� per; i si:i~u; .~~~~�.I i~tc~ ciL w':ivc~ volt,t~t~,
nhiEting of 5-T 1n[er ~~.1 ~n~l ~~r.r~~:;to~~al ~~.r.i~~~: c,f ,itrt,~vc~ni.r[c�t~lar i,l~,~:i:.
Thc LKC ci?~ngey are more ~ac.~~ru ~~I~i~ 1,.~~~,~1 irr;~cli,~ttun r.f ;.h~~ ~~.~r~i.~~c r~�~,ic~n
ehnn wieh expos~re c~f othcr p.~r�r;: ~t: r:l~~, hoclv. I~~cre~+s~cd v:~~~:uLf r.~r~
Ln thc uia ii~ y_;cou{~ of' i n~l i vidur~ 1~> l i~:ui in (}tc c�~~n' r-u I. 'i'I~c~sc ~~nrin~;crr~c:;~,r~~ an~J n t:~�nri~�n~~i ~~~~,:~r~, ~�!~�v:lrl.~~fl ~~r ci~~~�1 inc. 'i'ii~~rc~ were
a~ 1~'�i ~;,,:'I~.~ ~11, i~~ . , -
I
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- !'~;~1 i~ i,'I;'~,; ;�~,I ~ ~
leAS fr~quent c:hany,e:~ ln PW('V Ici vc~:;r;elr; nf n1s~;;tic~ IyPf.~. A nnr.rnn~.
correlr~lion between :'WI'V 1~~ mus~.~~lar i~ I.,~,ct~� r~r rf 1;~ wn,; ~~h- ~
serv~~d in 50"/< of Ch~ sul~,je~~~5. li~ ;ill c;,:+~~~, ci~~~ ~:V~,~nf;~~ wa~; ctu~_
ch~n~e Sn PWPV in vesHels3 r~f th~~ mu~~~uJ:ir t:ypc~. In 1_h~~ c~~ntrly in reF;lr,n,~.l cixcul~~-
tion. The syndrome of neu.ocircular_or,~ dy:~r:~ui~, ub:~crvr.~i in tf~1J ~;i.nup ~.~f _
aub~ects was characterized by sever.al clir~fcal di~~~in~~~iac~;:. Tht~. p.,t:i~~~;tr~
' compluined of headache (mainly long-1.~.~cing, almost coiis~_~mt, loc~il:iz~,i in
Che region of the forel~ea~l, templc:.; 1nd occiput), insomnia, tncr.e~:~ed ~
, fatigability, general weakn��r;t, vertigo, especially in r.he mornings. Their _
integument waK pale. Dul.l he~lrt sounds and a?i apic~l sy:~r.olic murcnur. wer.e
found in ltalf the aub;jecr_~, Thr_re w.i:. ~ir,.E~rial h~~T~otcrl;~ion :ir l
brctdycardia ~31~). Vascular tonus w3s decreasad (slow ~'WP~' in vesr,E~~.;; ut
thc muFr_ular type, slower propagation of the rt?eo~raptitc wavE~, chan~;e in
type and quantitative par~meters of rheo~rams) in peripher.a.l. and cerebral
vessels, purCicularly veins, with signs of ~,easts. An :(.ticrease or tcndency
toward increase was demonstrated ~.n systoli~: aud minute Uloo>ild be tnter~~reLed ,~5 c1y::tn~~ttilx~l.tc, ~ly:,-
trophtc. 7'hi;3 concapt i.:, ~~on:;L~;Lent tai.tl~ t:h~~ rli;~uge I.n level:; n1' iu~~t,~buli;~m
in lhe myocF~rcl:lunt (A. V, lvatiov, K, f~. K~n-;:h~ikc~vr~, l~F,2; Y~~. 1~ , 1.ur:{ini kov~
196~), ~ind others). At this c,t1F;e of obsc~rvaC:i.un, thc~;~> clcvtrttions dc~ i~ot
we~ken myocnrdiul contrac~[.lity, as ittdicaLed by f~c~modynarnics and re:iu.l.t:y
of tne3aurement of systolic and minute voliunc~:~.
Autonomic disturbances and a tend~ncy towarcl loweriug uf Skin i.empr~ral ~?re 4
in distal parts of t}te limbs, asy~muetry oE slt.in Lemperature and ~~ers~~ir~it.ton,
changes in senst~ivity Co pain iu the ditital prires (hypesthesl~n) wete demon- -
strated in patients wieh neurocirc~u.lal:ury dys~onin, which is i.ndicattve of
disorders of receptor systems of a primar~y nature, as co~~11 as those reiared _
Co circulatory disturbances. Postural reflexes (orthostatl.c, cl.inc~statLc),
Aschner-Dagnini oculucardinc reflex, physical lo~~d tests were .inr.lic~itive
of increased reactivity of rhe nervous system wiCh con:~i.derable invol.vem~nt
of its parasympathetic branch.
Examination of biochemical indices failed to demonstr.ate appreciable dis-
turbances, but there were ch.inges intierent usually in older age gruuE~s _
(moderate increase in alpha-2 and gamma globulins, increase In bet~~ lipo- _
proteins, etc.), as also indi.cated by Ye. V. Gembitskiy (1969), V. N.
Kozlovskiy (1977_) and others. According Co the data of G. G. Lysit~a (1975), .
maxtmum oxygen tension was also higher in tlic same individ~ials than in the _
control~ while th~ index of tissular oxygen uptalce was tiigher than the
index of oxygen transport. After an oxygen load, ttiere was less increment
of oxygen than in ttit coi~trol, and tl~is is prabably attributable to the
higher "ini.tial level" of oxygen tension befor.e. the load. The overall
indices of redox processes (oxygen disapper.ance ratc in blood and urine)
did not differ from data for the control group and corresponded to the -
lower range of. normal. There was an increase in external respiration (in-
creased minute volume of respiration and oxygen absorbed per minute),
indicative of an increased oxygen requirement. 'lhe authors related L-he -
observed disturbances to disturhances of. ~as er,change regulation, and they
, considered them to be aclaptational. _
- Not all suhjects developed the syndrome of neuroci_rculatory dystonia. In
most cases~ there was only an initial reactii,n to r.,zdi.ation, apparetitly of -
en adaptive nature to adjust Lhe body to nea~ conditions.
In ~tddition to ionizing radiation, i.ndividual discinctions of. the_ body
(extent of ~daptabi.lity to envi.ronmental changes, level of development of
functional sys~ems, re~L~latory sy~tem), as welt as the etfects of other
factors (psychoemotional loads, mental tension, trauma, prior disease~,
bad habi[s, etc.), are probably of some signif-icance, and they could crzate
a certain background of increased sensitivi.ty Lo exogenous tactors. -
- 81
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~)f: Ol'1~ 1 l; f ~1L tl:'~ li ~!N f~)'
With incre~se in cumulative r~?di~Cion dc~:,r.: e~~ 2U~)-4~n rem, ~.h~us;~:s mr~>�
_ nppear ,in other urg~~n:~ and aystems, ~?i~~'~~~Li.n;; ehe. b~laod, ~;;i~:erol.c~t~~st(~~~~1
tractywt'espiratory urgant3, rind ,ome in~lividuals, Je~~elop ctir~~n~c cad9.~r.~~~n
~icness. In such cases, ef~erE~ is also ar-.cond~~cy :tuvolvement iri t:~~c~ proc~~ss
_ of the cardiovasculnr system due to injury to morc~ r;~di.osensir.i.ve or~ans
and systems. This W~15 ab5erved in pat:i~,nt:, wLr.l~ C}1T'Of71C ~~r~~~La~-ic~ci ~i.c;:ne..:;,
- for example, medical_ r~entgenol.og.ists wi.th :Lot~F w~~r~ Ct~nur.~~ ~~xp~~;~cd to
cumulaCive radigCion of rhe order. of 150-~~00 rem (V. A. SoldaCnva, 19G7-
].973), eg we11 ~s individuals working w~.th radium ~1~. A. 5olodova, 19ti'7).
Thus, with exposure to up tu 100 rem l�her.e are no overt s3~n;; ui r~.diat:ioit -
sickness, but there is impairme?tt of i~eurovascular regul.aCiun and �~~vn, l~)6'.)). ~i},n,~
ol :tmpa:I.rt~d pertpheral c1.r~~ulatlou ,~re alsc, f~~u~~ 1~ cynnosi~;, cold e::tremi.-.
Cies, chan~,c~. !n o~cll.lnti.on curves, rheovatiof;r..ims ~i~z~l c.ipi Ll.,iry blc~od f'.l.o~a.
_ rnadequacy ot cerebral circu.L~irion u?tder the lnf lueuc~ oE rncli.~it~.uu mny hc
m~nife:~ted Jn the tr~rm o~ preclominant clrcre~.~:~~~ c~~~ ii?cr~~;itii~ iu t~.,uu~; ot:
cerebral ~r.teries nrid veins (C. I. KlrsC~
~ u Gl N MI '.1 w~ fA W'b 00 1~ 'r~ 'J h-1 Gl O 3d '.9
.C ~'C! tl CJ .C tA 3-i ~1 .C ~ O t3~ a.l CJ tA
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t~ .C t~i1 H~ W q q~'C H.G U ~ O rl H f3 N Cl
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w; o b'~U 'U~ ~ U ~ c~d a~.~ c~d ~ Gl i~+ d ~ w~
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FOR OFFICIAi L'SE 0?VZY
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FOR OFFICIAt. [.'5E ~ItiI.Y
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i'd!t pi~'YiCIAi. U5l~: t)NLti`
Yoi~dning Uue to 5om~ c:iic~.~2 r:~ i c�:
~~1 Wi c;enetal '~rxic Actior. ~
( I Agentg With Anoxemir i1~~rt~.~~~
!
~ Hyd~~g~t~ ~u] f. ide : i~~ cl~,~
aC.utp poir~oni ti?e ~~er .1~~,;~, ~~r~d
r ( c~rdinvgsCUlar gygtems ~re chlefly
gtricken. '~ticre ig inhib.ttion vf
~ intr~cellular ti~~ul~r regpir~ti~~.~
~ I (impgirm~nC ~f red~x proceques qr+d
I~ their Cntglygtg). I~or thia reason
y~N ~ the ~ell ig inc~pgble nf ~tilixing
~ ~ blood nxygen. Thet'e is nnset nf
I II II I~
hypnxip of tigs~e~, org~ns :~rd, wh.~t
?'p i~ particularly impor~a~~t~ t~~'~~~~~
i I center~. OcCagion~lly~ death c?ay
o~cur immediat~ly When Ch~re ie a
~,1 H~~ high concenCr~tion of t~ydrogen gu1-
I ~ I I i fide ("in~tgntan~oug f~rm") c~s n
+ regult dt cnrdlac p~ralysis; mure
~4 often~ d~nth occura due to develop��
III ment of ~sphyxia and Comatoee stete.
ys 11,'~~ ~_l ~ Patienta cnmplain of hendache, pein
( ~ u~1~~ in the region of the fienrt of a
,III compreesing type~ seneation of
intermitten pulge and general weak-
� ~ neas. Clinically there are labiliCy
Figure 6. of pulee~ rnchycardia~ mild elevation
EKG of p~tient V.; explained in teKt d~cline,iWideninguof heart~borderg
and dull sounda. Not infrequently,
there ie developmeat of toxic pulownary edema asaociated with very marked
dyspnea, cyanosis, moiat rales in the lunga. On the EKG there is a decline
of P and T aaves, elongation of electrical systole of the ventricles, signs
of myocardial hypoxia~ "caronary" changes or foral lesions to the myocardium
(Z. P. Kaluzhnikova, 1949; Schram, 1957. and otinere).
We eubmit a case history on a p~tient vith acute hydrogen sulfide poisoning
end "apoplectic" form of heart le8ion:
Patient 0.. 24 years old~ a laboratory technician, aas ad-
mitted to the tayon hospital on 21 December in serious condi-
tion due to acute hydrogr.n sulfide poisoning associated With
comatoge state and toxic edema of the lungs. She vas un-
conscious for 10 h; there vas cyanosis of the lips, pallor of
th~ integument~ gurgling respiration, tachycardia~ dull heart
sounde. Arterial pressure not demonatrable. Diffuse dry and
aooist ralee in the lungs. Repeated vomiting of bile. After
apptopriate therepy the condition impraved and arterial pre~sure
120
POR OFFICIAf. L'5E 0~'LY
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rc~k t~rr'tCtnt, i~~t~: ~Nt,~~
rdge ta 9U/30 mrn itg, `There w~s att~nu~n~ion oT. t~chy~~rdi~
gnd ~igng d~ pulmonary edema.
~rom the very fir~t daye of hospitaliz~titton, the patient w~~
troubled with squeezing pain in the he:~rt. On tt?e 40th day
of illnegs (31 Janu~ry) ~he wag tr~n~ferred to the ittgtitutc
_ Clinic in sati~i~~:tn~y condition. 5he complained of dyspnea
durin~ phy~icul exercige, peciodt.~ borin~ pain in the cerdinc
regie~n (irrddidein~ to th+~ left ~capul~), moderate rnugh wiCh
prdducCinn of ~putum, hendache, p~in tn the lumbar r~gi~n~
lnaer end upper extremities, m~rked weakne~g. '~he integument
ig pgle pink, l~bi~l mu~o~a is elightly cy~notic and grlera -
gr~ gubict~ri~. i~ulmdnnry gound in the lungg, ve~icular~
gam~wh~t weak re~pirgtion. pu~se 70/min, rhyehmic, gdod
filling. Left margin of the he~rt shifted 1 cm later~lly
fr~m the m~dig~tinal-clnvi~ul~r line. Neart gounde nte
gnm~WhaC du11. ~y~tnli~ murmur ~t the apex and point V.
ACC~nt~d ~~rc~nd tdne in pulmnnary artery. Arterial pre~sure
120/75 mm Hg. Venoug preggure 40 rtm~ w~ter. L1ood f1dW rg~~
(lobeline test) lg g. ~KG (~ie�re 7) taken on 5ti~ day of
il~negs (a): cnrr~ct t~inus rhythm, 6J/min; p-Q 0.15 s; QR5
compl~x 0.08 e; Q-T 0.48 (n~?rmal 0.~8 s). ~:lertriC~l ventri-
cul~r gyaCnl~ 0.1 a longer; py 1_4_ accenruated; RI