FLUORINE INTOXICATION

A Clinical-Hygienic Study
WITH A REVIEW OF
THE LITERATURE AND SOME EXPERIMENTAL
INVESTIGATIONS
BY
KAJ ROHOLM
1937
NYT NORDISK FORLAG H. K. LEWIS & CO. LTD.
ARNOLD BUSCK 136, GOWER STREET
COPENHAGEN LONDON
PRINTED IN DENMARK
BIANCO LUNOS BOGTRYKKERI A/S COPENHAGEN
PREFACE

Cryolite intoxication, a hitherto unknown disease among the workers at the øresund
Chemical Works, Copenhagen, was found in November, 1932,
as a result of a profitable collaboration between the Industrial-hygienic Researches of the
Inspectorate of Factories and Workshops and the X-ray Department of the Rigshospitai.
Professor P. Flemming Møller, the leader of that department, interested me in the disease
and suggested that I should go more deeply into the problems of fluorine intoxication.
Through the medium of an appointment at private expense as Assistant Physician under
the Inspectorate of Factories and Workshops, I was enabled to complete the principal part
of the investigations which form the foundation of the present work. The material from
the first investigation was placed at my disposal, including the blocks for the illustrations
Fig. 16, 19—26, 28 and 29.
I wish to thank Professor Flemming Møller for inducing me to embark on the subject, for
kind permission to examine my material by X-ray at the Rigshospital, for passing
judgment on the radiographs of cryolite workers’ lungs, and for unflagging interest in my
efforts. To the Director of the Inspect- orate of Factories and Workshops, Mr. E. Dreyer,
and its Chief Physician, Dr. Sk. V. Gudjonsson, I tender my best thanks for their
confiding the task to me and allowing me a free hand to complete it as well as for their
interest and support. By his energetic labours for industrial hygiene in Denmark Dr.
Gudjonsson laid the foundation on which this work was started.
A great deal of the work was done at the Copenhagen University Institute of Hygiene and
the Budde Laboratory, to whose Director, Professor L. S. Fridericia, I am greatly
indebted for hospitality, the best of facilities, and friendly interest. I am obliged to the
staff of workers at the Institute for help and encouragement in the daily work. Miss
Kirsten Becker and Miss Lotte Hoim assisted me in tending the experimental animals and
with the preparation of microscopic slides. Preparations were photographed in
collaboration with Messrs. Henrik Jensen and E. D. Lange. Some of the
microphotographs are
the work of Miss Margrete Faick, of the Copenhagen University Institute of Pathological
Anatomy.
It would not have been possible to carry on the work without help and kindness from
many quarters. Dr. 0. Brinch discussed problems of bone pathology with me and gave me
valuable guidance. Dr. J. Engelbreth-Holm assisted me in judging the microscopic organ
changes. Mr. R. Bøgvad, M. Sc., examined bone slides in the polarization microscope.
Mr. H. Buchwald, the Chief Chemist, analyzed fluorine preparations for me and helped
with the analytical part. Mr. C. J. Howitz, of Viborggaard Farm, Herlufmagle, and Mr. S.
Hjortlund, the Veterinary Surgeon, Copenhagen, assisted me to tend and slaughter the
large experimental animals.
Materials of many kinds, comprising case-records, radiographs, autopsy
material and staistics, were entrusted to me by Professors H. M. Hou-Jensen,
Poul Møller, ‘k. Sand, Erik Warburg, and J. Collin, all in the Copenhagen
University; Professor J. J. Holst, School of Dental Surgery; Dr. M. Degerbøl,
Zoological Museum; the Chief Chemist H. H. Stevenius-Nielsen, of the Danish
Fertilizer Company, Ltd.; Chief Physician G. Biering, Kommunehospitalet;
Chief Physician Chr. I. Baastrup, Bispebj erg Hospital, and the Cryolite
Mining and Trading Co. Ltd., Copenhagen.
The sending out of an international questionnaire was made possible through the kind
assistance of Dr. Johs. Frandsen, Director of the Danish National Health Service, and the
Ministry of Foreign Affairs. With financial assistance from the Dano-Icelandic Union-
Foundation I was able to undertake a journey to Iceland in the autumn of 1935 to
investigate conditions connected with the sheep disease gaddur. When collecting
literature I was given excellent help by many Danish and foreign libraries, but especially
by the University Library in Copenhagen, where the officials were indefatigable in their
readiness to assist. By means of a grant from the Budde Foundation I was able to make
library studies in Berlin in the summer of 1934.
A number of investigators abroad very kindly placed materials of various
descriptions at my disposal: Professor E. W. Baader, Berlin; Dr. M. Bonjean,
Rabat; Professor J. Casares Gil, Madrid; Dr. Juan Chaneles, Buenos Aires;
Mr. H. T. Dean, D. S., Washington; Professor Niels Dungal, Reykjavik;
Dr. Leon Goldemberg, Buenos Aires; Dr. F. S. McKay, New York; Professor
L. Slagsvold, Oslo; Dr. Margaret C. Smith, Tucson, Arizona; Dr. H. Velu,
Casablanca.
It was possible to accomplish the work in its present form through considerable financial
support from the Øresund Chemical Works, Copenhagen. Mr.
H. Tuxen, the Manager, Dr. A. Westergaard, the Secretary, as well as the
employees and officials have displayed great interest in it and helped me in the course of
my daily collaboration with them. So did Mr. C. F. Jarl,
C. B. E., the Proprietor of the Works, who induced me to extend my investigations as far
as possible in order to find out available prophylactic measures. The translation of the
book is the work of Mr. W. E. Calvert, Copenhagen.
I tender my most cordial thanks to all who in any way have aided me in my work.
Blegdamshospitalet, Copenhagen .A. Kaj Rohoim.
February 1937
TABLE OF CONTENTS
Preface V
Introduction i

PART I
A REVIEW OF THE ROLE PLAYED BY
FLUORINE IN BIOLOGY
Chapter
I. Fluorine intoxication in man 9
II. Intoxication of plants and animals 36
III. Occurrence of fluorine in inanimate nature 46
IV. Distribution of fluorine in animate nature 52
V. Effects of fluorine on protoplasm and enzymes 6o
VI. Experimental investigations into the effects of gaseous fluorine
compounds 64
VII. Experimental acute and subacute fluorine intoxication 67
VIII. Chronic experimental fluorine intoxication 76
IX. Absoi’ption, storage and excretion 103

PART II
TECHNIQUE EMPLOYED IN OWN INVESTIGATIONS
X. Technique i i
PART III
INVESTIGATIONS INTO SPONTANEOUS
CRYOLITE POISONING
Chapter
XI. Cryolite and its manufacture I 2 I
XII. Number and employment-period of workers 130
XIII. Complaints of workers 136
XIV. Examination of osseous system 141
XV. Other results of physical examination 148
XVI. Examination of former cryolite workers 162
XVII. Morbidity and mortality 169
XVIII. Post-mortem examination of two cryolite workers i8o
XIX. Examination of children of female cryolite workers 195
XX. Survey of spontaneous cryolite intoxication 200

PART IV
OWN EXPERIMENTAL INVESTIGATIONS
XXI. Experiments on rats 213
XXII. Experiments on pigs 225
XXIII. Experiments on calves 234
XXIV. Experiments on dogs 244.

PARTV
DISCUSSION AND GENERAL CONCLUSIONS
XXV. The normal fluorine content of organic material 257
XXVI. Acute fluorine intoxication 262
XXVII. Chronic fluorine intoxication 269
XXVIII. Possibilities of intoxication 292
XXIX. Prophylactic problems 307
XXX. The physiological role of fluorine 312
Summary . 316
Sammenfatning (in Danish) . 322
Bibliography 328

ILLUSTRATIONS Placed on or
Figure opposite page
i. Mottled teeth in man 32
2— 9. Spontaneous intoxication in sheep 42
ro. Apparatus for determination of dust ill
I 1—15. Processes in cryolite manufacturing 124
i 6—ax. Radiographs of cryolite workers 144
32. Diagram illustrating occurrence of osteosclerosis 145
33. Picture of cryolite worker 145
34—46. Necropsy findings in cryolite workers 184
47. Mottled teeth in children of cryolite workers 184
48—5 i. Weight curves for rats 216
52. Weight curves for rats 223
53—60. Intoxication in rats 224
6i. Weight curves for pigs 226
62—76. Intoxication in pigs 232
77. Weight curves for calves 236
78—90. Intoxication in calves 240
91—96. Intoxication in dogs 248
“Vous vo,yèz, mon ami, quel travail important et immense ii reste a faire sur l’analyse
des substances animales, seulement pour y rechercher l’acide fluorique. M. Morichini a
qui Ce travail appartient de droit, Se propose de l’entreprendre; mais le champ qu’il
qffre est si vaste qu’il peut bien suffire 8 l’activité de plusieurs chimistes.”
Letter from Gay-Lussac to Berthollet, 3oth Fructidor,
An XIII (1805).

INTRODUCTION
The basis of the present work will be better understood if an introduction is given in the
form of a brief description of the chemistry of fluorine compounds, a historical review of
research work on fluorine in biology, and finally, an account of the extent of my own
investigations.
The Chemistry of Fluorine Compounds
In the Periodic System fluorine is placed at the head of the halogen group; in many ways,
however, its position is a special one as compared with the other halogens. Several
aspects of the chemistry of the fluorine compounds have been studied only to a small
degree. The element fluorine is the most electro-negative of all elements; its affinity to a
number of elements is very considerable. Free fluorine plays no part in toxicology, as it
immediately reacts with water, forming hydrogen fluoride.
A non-silicic fluorine compound treated with a strong, non-volatile acid will by heating
and distilling produce hydrogen fluoride (HF), a colourless liquid (b. p. 19.4°) readily
soluble in water, forming hydrofluoric acid. Hydrogen fluoride is a rather weak acid; its
degree of dissociation is low compared with the strong mineral acids. In its various forms
hydrogen fluoride displays considerable chemical affinity, especially to silicic acid
compounds. When hydrogen fluoride attacks quartz, the result is silicon tetrafluoride
(SiF4) a colourless gas hydrolyzable by water to hydrofluosilicic acid (H2SiF6)
3SiF4+4H2O—2H2SiF6+Si(OH)4
Fluorides are salts of hydrogen fluoride, represented by the general formuhe of MF, MF2,
MF3 . .., where M indicates mono-, di- and trivalens elements respectively. At lower
temperatures hydrogen fluoride occurs in the form of
H2 F2 and forms acid salts, for example MHF2, which under heating break down to the
corresponding normal salt and (anhydrous) hydrogen fluorine. The properties of the
fluorides often differ from those of the corresponding salts of other halogens. Silver
fluoride, for instance, is soluble in water. Calcium fluoride is almost insoluble, a fact of
essential importance to the pharmacological mode of action of fluorine. Another point of
importance is the great tendency of the fluorides to form complex compounds. The
solubility of the most common fluorides is given in Table i; as a rule the solutions react
neutrally.
Silicofluorides or fluosilicates are salts of hydrofluosilicic acid, of the formuJ. M2 SIF6,
MSiF6, M2 (SiF6) s... Generally they are more readily soluble than the corresponding
fluorides (Table i), and in solution they give an acid reaction, as there occurs a hydrolysis
according to the equation:
3 M2SiF6+ 4H2O 6 MF+2 H2SiF6+ Si (OH)4
Fluoraluminates are also of toxicological interest — salts of the hypothetical acid
H3A1F6 they are stable, sparingly soluble and are not hydrolizable in aqueous solution.
Organic fluorine compounds are only of slight interest to toxicology; the introduction of
fluorine in an organic compound may increase its toxicity (499).
In commerce we find hydrofluoric acid and hydrofluosilicic acid, the minerals fluorspar
(CaF2) and cryolite (Na3A1F6), silicofluorides, which are a by-product of
superphosphate manufacturing, and divers synthetically made fluorides. The solid
fluorine compounds are usually colourless, crystalline or amorphous substances; usually
they are very pure products.
TABLE x.
The Water Solubilitj of Some Fluorine Compounds. *)

*) Unpublished investigations by Buchwald.

• Solubility at 25° C.
Compound Fluorine content and per I 00 c.c.

NaF olo g.
CaF2 45.46 4.210
Na2SiF6 48.63 0.0017
K2SiF6 60.57 0.759
51.70 0.176
BaSiF6 40.68 0.024
Na3A1F6 (cryolite) 54.26 0.039
Na3A1F6 (synthetic) 52.50 0.063
History
Fluorine minerals have been known since the Middle Ages. The name is derived from
their characteristic property of acting as a flux, i. e. to promote the fusion of other
minerals. The Nuremberg artist Schwanhard (1670) is credited with the first attempts at
etching glass by means of the vapours that are generated when fluorspar is treated with
sulphuric acid In 1771 Scheele produced the aqueous solution of hydrogen fluoride. Gay-
Lussac and Thénard described the corrosive effect of the acid on the skin (1809). The
element fluorine was first isolated in i886 by Moissan (589).
An Italian chemist Dominico Morichini in 1803 demonstrated the presence of fluorine in
a fossil elephant-tooth found outside the city of Rome. Together with Gay-Lussac he
showed later that fluorine is also present in fresh teeth, of both animals and man. The
discovery made quite a stir and was the cause of a protracted controversy. About the year
1846 George Wilson, the Scottish chemist, made investigations on a broader basis and
showed that fluorine is widespread in nature, in springs and sea-water, in vegetable ash,
in blood and milk of animals. The French chemist Nicklès formed similar conclusions.
The toxic properties of fluorine compounds were studied for the first time in animal
experiments, by Rabuteau in 1867. Round about 1890 Tappeiner and Schulz published
more detailed records of investigations on acute experimental poisoning, and Brandi and
Tappeiner attempted to produce chronic poisoning in a dog. Waddel made certain
interesting but not very well known clinical observations. In the period from 1890 to
1920 the interest in the toxicology of fluorine was limited and kept alive solely by
sporadic cases of acute poisoning and by the occasional employment of the fluorine
compounds in the conserving of foods and in therapy. During the past ten or fifteen years,
however, the question has been stidied with steadily increasing zeal, for several reasons.
In 1912 Bartolucci observed a cattle disease resembling osteomalacia roind about an
Italian superphosphate factory, and he expressed the opinion that its tiology might be
connected with the fluorine content in the waste products from the factory. His
observations attracted no great attention. It was only when a similar cattle disease broke
out endemically in the neighbourhood of a Swiss aluminium factory during the Great
War that the incentive was given to a series of investigations into fluorine poisoning by
Cristiani and co-workers. The cattle disease, however, continued to be a riddle. But in
1934 important observations were published. Slagsvold described chronic fluorine
intoxication among herbivora in the vicinity of Norwegian aluminium fact1*
ones, and Rohoim was able to identify a domestic animal disease (gaddur), long known
in Iceland, as a poisdning by fluorine compounds.
McCollum, Simmonds, Becker and Bunting showed in 1925 that rats fed on a diet
containing fluorine display peculiar degenerative dental changes. A dental disease in
man, mottled enamel, which Black and McKay described in 1916 as occurring in
Colorado, has proved to be rather widely distributed in several parts of the world. The
tiology was unknown until 1931, when Smith, Lantz and Smith demonstrated by means
of animal experiments that the disease was caused by a relatively high fluorine content in
the drinking water. Independently of their work, Velu proved that a common dental
ailment in North Africa among animals and man, darmous, was of the same origin.
Since the close of last century there are records of a number of cases of acute poisoning
in man by various fluorine compounds. Chronic human poisoning with bone symptoms
was described for the first time in 1932, by Flemming Møller and Gudjonsson, in cryolite
workers. In the last decades two uses for fluorine substances especially have given rise to
investigations into its toxicology, particularly in U. S. A.: that of native phosphorite
containing fluorine as a source of calcium and phosphorus in the rearing of domestic
animals, and that of fluorine compounds for combating plant parasites. Many works have
appeared in the last few years; those of Margaret C. Smith and co-workers and of Phillips
and co-workers may especially be mentioned.
Own Investigations
Above all the present work is a hygienic investigation, arriving out of Flemming Møller
and Gudjonsson’s observation of cryolite poisoning, which previously had been
unknown. In June 1932 the writer was entrusted by the Inspectorate of Factories and
Workshops with the task of investigating the effects of cryolite on man, but with a free
hand as to how the investigation was to be carried out. In order to determine if cryolite
poisoning was an intoxication by fluorine, the effects of cryolite and fluoride had to be
investigated in animal experiments. It was necessary to examine the affected workers in
order to obtain, if possible, more complete knowledge than had been feasible at the first
preliminary examination. For throwing light on the significance of cryolite poisoning it
was considered desirable, partly to make comparisons with any other forms of fluorine
intoxication described in the literature, partly to endeavour to produce similar conditions
in animals. Consequently the plan of the work was as follows:
(i) A critical-.ynthetic exposition of fluorine intoxication on the basis of the literature,
there being no collective work on the subject*). This proved to be a comprehensive task,
for there were many individual works of interest to the subject, especially dating from
recent years. These works are spread over all kinds of spheres, often difficult of access
and not uncommonly contradictory. Furthermore, during the time it took to collect the
literature, a considerable number of investigations were published, and these had also to
be taken into consideration. This exposition, necessary as it was on account of the wide
scope of the task, forms Part I. A practically complete bibliography on the subject
concludes the work.
(2) An investigation on human cryolite intoxication, as extensive as possible under the
prevailing circumstances. This means a clinical examination of the workers, one that had
to be carried out at the factory and in working hours, as well as an investigation on
morbidity, fate after discharge and other matters connected therewith. Quite
unexpectedly, two workers died of intercurrent disease and this gave an opportunity for
patho-anatomical examinations (Part III).
() A series of intoxication experiments on animals, intended for widening present
knowledge. This work was planned and carried through without knowledge of a large
part of the literature referred to in Part I. As, judging by the preliminary perusal of the
literature, the various animals differed in their reaction, several kinds of animals were
used. Relatively large animals were chosen in order to be able to demonstrate bone
changes by X-ray examination. Considerations of economy, space, and the compass of
the work made it possible to use only a limited number of animals of each kind. Of
necessity the intoxication symptomshad to be studied in broad outlines and the
description had to be concise. For this reason the value of the experimental investigations
must particularly be appraised in the light of the fact that they confirm and supplement
works then available or published afterwards (Part IV).
(4) By means of putting the results of the literature studies and those of own
investigations together, it now proved possible to obtain an idea of the various forms of
fluorine intoxication and their mutual relationship. This exposition has been made in
systematic, but brief form, taking due regard to the phenomena that may be regarded as
certain or probable. By this means it was possible to throw light on important points
connected with human cryolite intoxication. As the fluorine problem proved to be
very wide one, and of considerable actual interest, an account of intoxication possibilities
and a review of the prophylactic problems, based on an international inquiry, has been
added. A summary concludes this section (Part V).
A work of this kind suffers from conspicuous weaknesses. Of necessity it is extensive,
burdened by the literature apparatus and yet showing the uncertainty arising from the fact
that the problem is new and far reaching. On the other hand, the time had arrived for the
first systematic examination of the question, and it was necessary in the present case to
take it up on a broad basis. The author hopes to have contributed something towards
consolidating and to some degree increasing present knowledge, and to have indicated
domains where further research is desirable. Fluorine intoxication is of considerable
interest. Michaëlis (581) recently, without knowing the modern works on the subject,
uttered the following prophetic words:
“Mit grosser Wahrscheinlichkeit sind bei der Erforschung des Fluorstoffwechsels
theoretisch und praktisch neue, wichtige Ergebnisse zu erwarten. Zahlreiche und
muhevolle lJntersuchungen werden notwendig sein, urn auf die gestellten Fragen klare
Antworten zu erhalten. Nicht nur die Besonderheiten der chemischen Bestimmung des
Fluorgehalts, sondern die enge Verknupfung des Fluorstoffwechsels mit zahlreichen
anderen physiologischen Faktoren anorganischer und organisch.r Natur werden die
Losung der Aufgabe erschweren. Sicher ist es, dass hier em grosses, teils unbekanntes,
teils ubergangenes Material sich darbietet, das wert ist, grundlich und mit Ausdauer
bearbeitet zu werden.”

*) In 5933 DeEds (228) and McClure (535) published review works on fluorine
intoxication, but only briefly and without going into important aspects.