Document 5b1QEx76wVLgqzV6aaKDeOQOD

L. Tjjichloroethane Intoxication: A Report of Two Cases* F. It. llall. M.A** and C. 11. lliiw, M.D., Pli.D*** Reference to standard toxicological texts (1, 2, 3, 4) reveals large numbers of organic materials of a variety of compositions which have as their primary mode of toxic action depression of the central nervous system and the production of anesthesia. The majority of cases of intoxication from these agents nppear in industrial settings and they are rarely encountered as forensic toxicological problems, A review of 35,000 cases in the Coroner's Office of the City and County of San Francisco from 1950-1965, in which there were over 1500 cases of death due to chemicals and drugs, revealed only one previous case in which purposeful or ac cidental inhalation of a solvent substance was the immediate cause of death. It was of some interest to us, then, to uncover two cases of death from inhalation of the relatively safe solvent, 1,1,1-trichloroethane (TCE), in a short period of six weeks in 1964 and to learn of a third death from this substance in an ad jacent medicolegal jurisdiction during the same time. We are presenting here data relative to two fatal cases of TCE poisoning with reference to incidents surrounding the in halation, post mortem findings, detection of the material in the blood, and conclusions as to the probable mechanism of death. * Received for publication February 24, 1966. Accepted for publication April 26, 1966. ** The Toxicology Laboratories, Coroner's Office, City and County of San Francisco, California. *** The Department of Pharmacology and Experimental Therapeutics, School of Medicine, University of California at San Francisco and the Toxi cology Laboratories, Coroner's Office, City and County of San Francisco, California. 404 July 1966 SL 036591 The fi<f* ;i - t-f i. ;i uhit* San Francisco. In Dec, the deceased*- room on n him in bed, apparently o Deputy Coroner. on evai dressed in undent, car, iri to the touch. Kigoi moil sistent with tic- po-Piori i cloth, which u;r; di\ In I wore sevciai empty <;m < notes were found. Tiuue supposedly been de.-pondc body was noted to be that height and weighing 216 11 trauma. The bead ivtu tv and the pupils eiitially figlistening scroti- membra position. No fluid wa- pre clear, yellow serous fluid. The coronary vessels fnlh cardium showed early po.~ and glistening. The valvepanded and markedly inc grams. They were covered marked accumulation in all slightly blood-tinged, and i a small amount of mmoid frothy material. The liver intact, and the < ro-s sect There appealed to be son focal mottled yellowish art contained a large amount i the intestinal tract was v adrenals were normal. Tl around the pyramids, espet collapsed and contained 60 the brain was found to be c were symmetrical and the tiple cross sections througl On microscopic examim siderable congestion and et hemorrhage were present, tained minimal amounts o There -were no other notr\ Vol. 11 No. 3 __*i vlD JAN 1 5 1975 revfiiils ositions -ssion of rihesia. appear trensic :'onev's 1-1965, ds and or ac- *^ks in an ad- ises of the inin the death. Miration unity of i prutics. ho ToxiI'anrisoo, uly 1966 TRICHLOROETHANE POISONING CtlM! 1 Tho deceased, a white male, aged j'j( resided lon<- in an iinari.r/imt. in San Francisco. In December, ]'M'A the manager of the apartment went, to the deceased's room on routine business, entered with a key, and discovered hint in bed, apparently dead. The Coroner's office was notified, and the Deputy Coroner, on examination at the scene, found the deceased to be dressed in underwear, in bed, and in a supine position. The body was cold to the touch. Rigor mortis was present throughout and lividity was con sistent with the position in which the body was found. There was a wash cloth, which was dry to the touch, lying over the deceased's mouth. There were several empty cans of Chlorothene (cleaning solvent) in the room. No notes were found. There was no evidence of a struggle. The deceased had supposedly been despondent due to an unhappy love affair. At autopsy the body was noted to be that of a well-developed, well-nourished male, 6' 2" in height and weighing 215 lbs. The skin was intact and showed no evidence of trauma. The head was normocephalic. The sclera of the eyes -were clear and the pupils equally fixed. The abdominal cavity was lined by smooth, glistening serous membranes, the organs being in their usual anatomical position. No fluid was present. The pleural cavities each contained 50 ml of clear, yellow serous fluid. The heart was of normal size and configuration. The coronary vessels followed a normal pattern of distribution. The myo cardium showed early postmortem autolysis. The endocardium was smooth and glistening. The valves were within normal limits. Both lungs were ex panded and markedly increased in weight. The left lung weighed 1030 grams. They were covered by intact glistening pleura. Cross section showed marked accumulation in all lobes of edema fluid which was white, frothy and slightly blood-tinged, and easily expressed from the cut surfaces. There was a small amount of mucoid material in the bronchi admixed with the white frothy material. The liver was of normal size and shape. The capsule was intact, and the cross section showed a well-defined lobular architecture. There appeared to be some increase in greasy material in the liver and focal mottled yellowish areas were observed. The stomach was dilated and contained a large amount of air. The mucosa was intact. The remainder of the intestinal tract was within normal limits. The pancreas, spleen and adrenals were normal. The kidneys showed marked vascular congestion around the pyramids, especially on the periphery. The urinary bladder was collapsed and contained 50 ml of clear yellow fluid. On opening the skull, the brain was found to be covered by thin, filmy meninges. The hemispheres were symmetrical and the gyri nnd sulci were within normal limits. Mul tiple cross sections through the brain showed normal architecture. On microscopic examination, the pulmonary parenchyma showed con siderable congestion and edema. The vessels were dilated. Small areas of hemorrhage were present. The hepatic cells were of medium size and con tained minimal amounts of fat. The lobular differentiation was normal. There were no other noteworthy findings. The tubular epithelium of the Vol. 11 No. 3 405 SL 036592 JOURNAL OF FORENSIC SCIENCES kidney's cortex and medulla showed postmortem autolysis with moderate congestion of the medulla. Toxicological analysis of the blood did not re veal any barbiturates, but 13.0 mg% of TCE were present. No drugs or solvents were detected in the stomach contents. Case 2 The deceased, a white female, aged 19, had arrived recently from New York and was attending a sales clerk training class at a local Department Store. She was staying with friends who observed that for several days she had been sniffing Energine cleaning fluid and acting in an irrational manner. Because of this behavior she was asked to leave the premises, and she agreed to do so on the following day. At about 8:30 p. m. of the day on which she was supposed to have left, the owners returned to their prem ises and discovered the deceased dressed and lying in a prone position on the bed, apparently dead. The police were summoned and they reported the case to the Coroner's office. Examination at the scene revealed no evidence of a struggle. The temperature of the room was warm. The body was warm, with no evidence of rigidity. No suicide notes were found. In the deceased's handbag was found an empty, unlabeled prescription bottle. At autopsy the body showed a moderate degree of rigor mortis and there was livor over the dorsal aspect of the body. Close examination of the head and neck showed no unusual findings except for thick secretions within the oral cavity. The chest and abdomen were normal. The extremities revealed multiple recent and old contusions about the knee. No needle puncture marks were evident. There was an old incision of the right wrist and evidence of sutures in the area which were old and healed. The body cavities were lined with normal smooth glistening serosa containing normal amounts of fluid. The heart was within normal limits of size. The myo cardium was normal, was reddish brown, and had the usual firmness. The lungs were moderately poorly aerated showing passive congestion through out. The right lung weighed 325 grams. The parenchyma showed considerable amounts of thick, dark red blood and thin, frothy fluid in the dependent areas. The bronchi contained thick, yellowish-brown secretions. The vessels were congested. The stomach contained 25 ml of thick yellow material. The mucosa was hyperemic but otherwise unremarkable. The intestinal tract was normal. The liver was of the usual size, reddish brown, smooth and glistening, but had a moderately pale appearance. It cut with ease and this revealed normal lobular markings. The kidneys were of the usual size. The capsules stripped with ease and on section they showed normal architecture. The uterus and ovaries were unremarkable. The spleen was moderately enlarged and moderately soft. The usual markings were observed on section. The adrenal glands had dark yellow cortices and pnrliully uutolyzed medullae. The brain was within normal limits of size. The leplomeninges were thin, glistening, transparent and markedly in jected. The vessels about the base of the brain were unremarkable. The 406 July 1965 i ventricles contained prominent, and there On microscopic e\ atelectasis. There w;i bronchi contained d< normal, as was the medium size and had areas showed no nob revealed 72 mg'; of ' the stomach content, detected. Determination of 1 We routinely ust (5) in screening f In this procedure f an equal volume of i port of a Wilkens employ a hydroger * Northrup Speedom ' chart integrator, M j mesh Chromosorb 1 by weight, and cent in chromutographi 170 C injector tern ' i of carrier gas (nitr hydrogen gas 22 . numerous volatile s over 20 mg'' . In , recording. In case 5 for quantitation. W et al. (6) to analvf blood specimen. Sei with self-sealing rut 1 ml gas-tight Ham < pies. Standard solut ing the range of 10 accomplished by adc sulfate to vials whicl a mechanical shaker a water hath at GO head space gas was < Vol. II - No. 3 mm SL 036593 I iloratf not roiigs or m New .ivtmoTil nil days irational isosj and the dny iv premition on eported aled no he body und- In n bottle, tid there ihe head :ht wrist "he body r normal 'he myoess. The throughved cond in the ?cretions. k yellow ble. The ;h brown, cut with re of the ,v, showed hie. The markings rliees and s of size, kedly inable. The Ju\y 1966 TRICHLOROETHANE POISONING ventricles contained clear cerebrospinal fluid. The vascular markings were prominent, and there was acute passive congestion throughout the brain. On microscopic examination the pulmonary parenchyma showed some atelectasis. There was edema and congestion. The vessels were dilated. The bronchi contained desquamated epithelium. The capsule of the liver was normal, as was the lobular differentiation. The hepatic cells were of medium size and had pale cytoplasm. The central veins, sinusoids and portal areas showed no noteworthy findings. Toxicological analysis of the blood revealed 72 mg% of TCE, There was no unusual quantity of the solvent in the stomach content. No alcohol, hypnotic, narcotic or sedative drugs were detected. Determination of 1,1,1-Trichloroethane We routinely use a modification of the method of Parker et al. (5) in screening for the presence of volatile organic materials. In this procedure 2 microliters of a blood specimen diluted with an equal volume of water are injected directly into the entrance port of a Wilkens Hi-Fi Model 600 Gas Chromatograph. We employ a hydrogen flame ionization detector, and a Leeds and Northrup Speedomax Model H, 0-1 mv recorder, equipped with chart integrator, Model S. A 10-foot column packed with 60-80 mesh Chromosorb W, acid-washed, coated with 40% Castor Wax by weight, and contained in a stainless steel tube, Vs inch, is used in chromatographing the sample. Operating conditions are 170 C injector temperature, 115 C oven temperature, flow rate of carrier gas (nitrogen), 13.6 ml per minute, and flow rate of hydrogen gas 22 ml per minute. The procedure will detect numerous volatile substances when present in concentrations of over 20 mg%. In Case 1 no peak response was noted on the recording. In case 2 a peak did appear, but was not satisfactory for quantitation. We therefore applied the method of Bassette et al. (6) to analysis of the head space gas from the diluted blood specimen. Serum vials of approximately 3.5 ml capacity with self-sealing rubber caps were used as sampling bottles and 1 ml gas-tight Hamilton No. 1001 syringes for transfer of sam ples. Standard solutions of TCE were prepared in blood embrac ing the range of 10-100 mg%. Analysis of these samples was accomplished by adding 1 ml of blood and 0.6 grams of sodium sulfate to vials which were sealed with rubber caps and shaken in a mechanical shaker for 5 minutes. The vials were then placed in a water bath at 60 2 C for 3 minutes. A 1 ml sample of the head space gas was obtained by inserting the needle of the gas- Vol. 11 No. 3 407 SL 036594 JOURNAL OF FORENSIC SCIENCES tight syringe through the rubber cap, emptying and refilling several times before removing the needle from the vial, to in sure a uniform sampling. Head space gas was analyzed under the chromatographic conditions described above and peak heights measured. Satisfactory linear relationships were found and re coveries of known amounts of solvent added to blood were 90 5'/> Concentrations in unknown specimens were calculated by reading the quantities corresponding to the peak heights ob tained from a curve prepared by analysis of blood standards. Toxicity of 1,1,1-Trichloroelhane TCE, CH:1CC1;,, is a colorless, pleasant smelling liquid having a specific gravity of 1.336 and a boiling point of 71.1 C. Its vapor pressure at room temperature is approximately 127 mm giving an air concentration at saturation of about 160,000 ppm. It has a number of industrial uses. Among these are cold clean ing in the aircraft, automotive, electronics and missile industries; maintenance and repair cleaning of motors, appliances and equipment; on-the-site cleaning of printing presses, food pack aging machinery and molds. It has not been recommended as a vapor degreasing solvent, fire extinguishing agent, or dry clean ing agent (7). Extensive toxicological studies have been con ducted both on animals and man (8, 9, 10). Rats have been shown to tolerate 10,000 ppm for half an hour daily with no organic injury. Male and female rats, rabbits, guinea pigs and female monkeys were exposed repeatedly for 7 hr/day to 500 ppm for six months with no detectable effect. The acute LDr,n value for the short-term exposure of rats is 18,000 ppm for 3hour exposures. Rats anesthetized with TCE showed a 33 % diminution in oxygen uptake in the myocardium, similar to that following chloroform anesthesia. Acute deaths are due to depres sion of the central nervous system and there is little capacity to cause organic injury with single or repeated exposure to vapors. Rennick et al. (11) have shown the compound to sensitize the heart to epinephrine in a manner similar to that seen with a number of organic solvents. Tests carried out on human volun teers indicated that concentrations of approximately 500 ppm for 90 minutes produced no effect other than recognition of the odor of the chemical (12). On longer exposures at this concen 408 July 1966 tration there was a 1rn< there were no signific pressure or equilibrium ppm. Slight ly below t minutes there was a let and equilibrium. With and within in minutes, during the exposure, ppm tor 5 minutes, pm riurn, with a very not m-, Two eases have orrurro< over-exposure in ronl'im having become j|) or ov' trations have been report Mechanism of Heath froi A variety of untowai inhalation of anesthetic these may be classified a.' (1) Ciirelntii) if firr-ii due to asphyxia or the r intense during induct ion deepens. Anesthetic hyj shock; the end result is h ly the halogenated hydro myocardium so that it be ing ventricular arrvthmia (2) Rcftpiivtniii ecru sudden apnea of central i late anesthesia. Drouth 1 geal spasm as the result also produce the end res ference with the movemei va, liquid debris from t) larynx all may impede air > (3) ac< lapse of the lungs secondat obstruction, convulsions tv vl. ]] - No. 3 refilling 1. to in* 3 under heights aiul iv- re 00 i.-ilcd by lits ohilnrds. ,\0 having .1 C. Its 127 mm .000 ppm. old cloan- lustries; ices and od packtied as a ry clean>een contve been ttffc no p^Prand y to 500 tte LI)r,,, .m for 3I a 33'; r to that o deprespacity to o vapors. sitize the n with a an volun- 500 ppm on of the s concen- July TRICHLOROETHANE POISONING tration there was a tendency to lose olfactory recognition, though there were no significant changes in pulse, respiration, blood pressure or equilibrium. An unpleasant odor was noted at 1000 ppm. Slightly below this level anti following exposure for 70 minutes there was a feeling of giddiness and loss of coordination and equilibrium. With 3 of 4 subjects the recovery was rapid and within 10 minutes. No abnormalities in the EEG were seen during the exposure. The highest concentration tested, 1900 ppm for 5 minutes, produced an obvious disturbance of equilib rium, with a very noticeable odor, and a positive Romberg test. Two cases have occurred in which individuals died as a result of over-exposure in confined spaces, and other instances of people having become ill or overcome due to exposure to high concen trations have been reported (13). Mechanism of Death from Anesthetic Agents A variety of untoward effects can occur subsequent to the inhalation of anesthetic substances. According to Guedel (14) these may be classified as follows: (1) Circulatory accidents. Sudden rise in blood pressure is due to asphyxia or the release of epinephrine. This rise is more intense during induction and is less likely to occur as anesthesia deepens. Anesthetic hypotension may follow hemorrhage and shock; the end result is hypoxic anoxia. Many solvents, especial ly the halogenated hydrocarbons, are capable of sensitizing the myocardium so that it becomes susceptible to factors precipitat ing ventricular arrythmia and fibrillation. (2) Respiratory accidents. Respiratory arrest occurs from sudden apnea of central origin, either in the induction phase or late anesthesia. Breath holding, pharyngeal spasm and laryn geal spasm as the result of reflux abduction of the vocal cords also produce the end result of temporary or permanent inter ference with the movement of air. Aspiration of thickened sali va, liquid debris from the lungs and a foreign object in the larynx all may impede air exchange. (3) Miscellaneous accidents. These include massive col lapse of the lungs secondary to shallow respiration and bronchial obstruction, convulsions which may be due to metabolic acidosis, Vol. li No. 3 < i 409 SL 036596 * JOURNAL OF FORENSIC SCIENCES carbon dioxide retention in the blood as well as oxygen lack, and cerebral asphyxia due to prolonged oxygen lack. In addition to the adverse effects cited by Guedel, we wish to point out a fourth untoward event related to a peculiar form of solvent exposure, that of aspiration. Though the hazard from aspiration of kerosene and related petroleum products is appre ciated by clinical toxicologists as the result of experiences en countered in the lavage of children ingesting these substances, it is generally not recognized that a number of solvents other than kerosene will cause a similar adverse effect on pulmonary tis sues. Gerarde (15) studied petroleum distillates of a viscosity and boiling range lower than that of kerosene demonstrating that it is possible to relate aspiration tendency, lung injury, mortality, viscosity, and surface tension. Viscosity was the most important physical property which determines aspiration haz ard. Human experiences incriminate liquids with viscosities below 45 Saybolt Universal Units at 100 F. We have demon strated this effect in rats with other classes of solvents such as ketones and esters administering quantities as little as 0.2 ml. In the experience of one of us (CHH) pneumonitis has been ob served in an adult after aspiration of carbon disulfide. Discussion Consideration of the pathologic findings at autopsy, concentra tions of TCE demonstrated in the blood, and antecedent history point toward two different mechanisms of death in these cases. In Case 1, based on the history of despondency the Coroner's jury arrived at a verdict of suicide by exposure to TCE. The low blood level of the solvent, which was only slightly greater than that reported by Stewart (12) to be present in minimally affected volunteers, would not be compatible with death due to respiratory arrest secondary to medullary depression. Both gross and micro scopic pulmonary findings were compatible with an acute chem ical pneumonitis and pulmonary edema secondary to aspiration of the liquid. We concluded, therefore, that in an attempt to produce acute anesthesia a large amount of the solvent was poured on the cloth held over the nares and mouth and that the deceased accidentally aspirated the material. In Case 2, there was a history of the decedent's having inhaled the contents of 410 July 1966 ' an Energine hoi lie f inhalation of vapom< adolescents and youn alcoholic intoxication Symptoms vary fror rarely encountered, plastic cements thou* employed (17). To o used for this purpose j a third case of which , occur in the future. 1 TCE in fatal cases. Y bon tetrachloride, chi suggested that a rar expected. At these le' occur. Gross and mi< congestion, were sugj. depression. We conch i and occurred from a! . None of the other acc substances seemed to 1 In neither of these < and TCE alone was rt significant amounts c ' inhalation rather thai body. Also the abeenc ! intestine made ingest ; perience in which in* I local irritation of the j The absence of any the minimal changes i on animals with regai ; of TCE. These are the ly used industrial chei that have occurred out: 1 Summary 1,1,1-Trichloroethan f dustrial solvent, posse Vol. 11 No. 3 SL 036597 \ t) .f n it i;ilt 1l>- -ity ing irv. ,iz- it*s 011- is In ob- tratory ISOS. ior's low than ctod itorv icro- hemation pt wilR t the there its of ly 1966 TRICHLOROETHANE POISONING an Energine bottle for several days. The practice of deliberate inhalation of vaporized solvents is increasing in frequency among adolescents and young adults (16). Sensations resembling acute alcoholic intoxication or late Stage I anesthesia are experienced. Symptoms vary from exhilaration to disorientation. Coma is rarely encountered. The sources of these solvents are generally plastic cements though gasoline and lighter fluid have also been employed (17). To our knowledge TCE had not previously been used for this purpose, though similar abuse of this substance in a third case of which we are aware suggests that such use may occur in the future. Data were not available as to blood levels of TCE in fatal cases. Examination of blood levels reported in car bon tetrachloride, chloroform and ethylene dichloride fatalities suggested that a range of 35 to 100 mg7" for TCE could be expected. At these levels respiratory arrest might be expected to occur. Gross and microscopic findings, including acute passive congestion, were suggestive of and compatible with respiratory depression. We concluded that death in this case was accidental, and occurred from abuse of the agent as an inebriating agent. None of the other accepted mechanisms of death from anesthetic substances seemed to be involved. In neither of these cases were alcohol and other drugs detected and TCE alone was responsible for the fatality. The absence of significant amounts of TCE in the stomach strongly suggests inhalation rather than ingestion as the route of entry into the body. Also the absence of local tissue changes in the stomach or intestine made ingestion improbable. In all cases in our ex perience in which ingestion of solvents has occurred, marked local irritation of the gastrointestinal tract has also been noted. The absence of any significant hepatic changes in Case 2 and the minimal changes in Case 1 confirm the observations made on animals with regard to the low hepatic damaging potential of TCE. These are the third and fourth fatalities from this wide ly used industrial chemical and the only ones to our knowledge that have occurred outside of an industrial setting. Summary 1,1,1-Trichloroethane, a relatively safe and widely used in dustrial solvent, possesses anesthetic and pulmonary irritating Vol. 11 No. 3 411 SL 036598 JOURNAL OF FORENSIC SCIENCES properties. Two cases are presented in which death occurred secondary to its abuse. The mechanisms involved were, re spectively, chemical pneumonia and respiratory arrest. A method is described for detection of TCE in the blood. REFERENCES 1. Browning, E. Toxicity of Industrial Organic Solvents. Chemical Pub lishing Company, Inc., New York (1953). 2. Fairhall, L. Industrial Toxicology, Second Edition. Williams and Wilkina Co., Baltimore (1957). 8. Lehman, K. B. and F. Flury, editors. Toxicology and Hygiene of Industrial Solvents. Williams and Wilkins Co., Baltimore (1943). (King, E. and H. F. Smyth, Jr., translators; Julius Springer, Berlin, 1938), 28-77. 4. Patty, F. A. Industrial Hygiene and Toxicology, Second Revised Edi tion, Interscience Publishers, N. Y. 2, 632-733. 5. Parker, K. D., Yee, J. L., and P. L. Kirk. Gas Chromatographic Determination of Ethyl Alcohol in Blood for Medicolegal Purposes: Separation of Other Volatiles from Blood or Aqueous Solution, Anal. Chem. 34,1234-6 (1962). 6. Bassette, R., Ozaris, S., and C. H. Whitnah. Gas Chromatographic Analysis of Head Space Gas of Dilute Aqueous Solutions, Anal. Chem. 34,1540-1543. 7. Chlorothene Nu, The Dow Chemical Company (1964). 8. Adams, E. M., Spencer, H. C., Rowe, .V, K., and D, D. Irish. Vapor Toxicity of 1,1,1-Trichloroethane (Methyl-Chloroform) Determined by Experiments on Laboratory Animals, Arch. Industr. Hyg. and Occup. Med. 1, 226-236 (1950). 9. Torkelson, F. 0., Oyen, F., McCollister, D. D,, and V, K. Rowe. Toxicity of 1,1,1-Trichloroethane as Determined on Laboratory Animals and Human Subjects, Amer. Industr. Hyg. Ass. J. 19, 853-362 (1968). 10. Hake, C. L., Waggoner, T. B., Robertson, D. N., and V. K. Rowe. The Metabolism of 1,1,1-Trichloroethane by the Rat, Arch. Env. Health, I,101-105 (1960). 11. Rennick, B. R., Balton, S. D., Moe, G. S., and M. H. Seevers, Induction of Idioventricular Rhythms by 1,1,1-Trichloroethane and Epinephrine, J. Pharmacol. Exp, Therap. 8, 327 (1949). 12. Stewart, R. D. The Toxicology of Methyl Chloroform, J. )ccup. Med. 6,259-262 (1963). 13. Stewart, R. D,, Gay, H. H., Erley, D. S., Hake, C. L. and A. W. Schaffer. Human Exposure to 1,1,1-Trichloroethane Vapor: Relation ship of Expired Air and Blood Concentrations to Exposure and Toxicity, Amer. Industr. Hyg. Ass. J. 22,252-262 (1961). 14. Guedel, A. E. Inhalation Anesthesia, The Macmillan Co., New York (1937). 412 July 1966 < j ! * j | t . | j j ; 15. Gemrde, H Aspiration .Mixtures. I Foundation ; 16. Glaser, N\ I -M. A. 181, 3(, 17. Kasson, \V. (1962), 850 Bryant Street San Francisco, Ca Vol. 11 No. 3 1 n 36599? t i>if TRICHLOROETHANE POISONING 15. Gerarde, H. W. Toxicological Studies on Hydrocarbons. IX. The Aspiration Hazard and Toxicity of Hydrocarbons and Hydrocarbon Mixtures. Presented nt the Cheni-Tox Conference, Industrial Hygiene Foundation 27th Annual Meeting, October 24,1902. 16. Glaser, N. H,, and O. N. Massengale. Glue-Sniffing in Children, J. A. M. A. 181, 300-304 (1962). 17. Easson, W. M. Gasoline Addiction in Children, Pediatrics 29, 250-264 (1962). 850 Bryant Street San Francisco, California 94103 VoL II . No. 3 413 SL 036600 ... ......... w- tf -i S' ,