Document 6B1NEmjm3bRmBMkoXzvBDk8LR

SUFFICIENT number of cases of refractory anemia following exposure to benzene have been reported to leave no doubt concerning the existence of the disorder as a clinical entity. In many instances, however, the clinical, pathological, and toxicological data are insufficient ' to allow a clear understanding of the nature of the disturbed hematopoiesis. This communication presents an account of 9 individuals (6 rotogravure printers, 1 chemist, 1 beauty parlor worker, and 1 person who used large quantities of a cement containing benzene) who were exposed to benzene fumesand who developed concomitant serious disorders of the blood. Sufficiently detailed studies were made of these cases to substantiate certain conclusions for which adequate evidence has not been available hitherto. e Selling (l),in a comprehensive review, stated that the erythropoietic tissue of the bone marrow was injured in chronic benzene poisoning, although thc circulating erythrocytes were relatively unaffected. Reznikoff and Fullerton (2) advanced n similar opinion and stated, asdid Selling, that benzene exerted a leucolytic effect. Greenburg (3), after citing many references, felt that in addition to the leucolysis there was an increased erythrolysis during Received for publication July 30, 1939 .. 422 JOURNAL O F ISDUSTRIAL HYGIEKE AND TOXICOLOGY [uol. 21, no. 8 human beings exposed to benzene, a Wright's method were made a t the finding which was assumed to indicate time of operation. abnormally active hematopoiesis. Examination of the Blood With the Other workers have found elevated exception of the differential counts of icterus indices in similar cases (Cabot, supravitally stained preparations, all S), (Schneider, 16), (Hunter and of the examinations were made of Hanflig, 17), (Martland, 18), (Ander- oxalated blood. Four cc. of venous son, Boyd and Jackson, 19). Schnei- blood were withdrawn and placed in der, (16), Oettinger (20), and Ron- small rubber-stoppered glass bottles chetti (21) have reported an increased containing 0.02 cc. of a 20% solution excretion of urobilinogen in the urine, of potassium oxalate as an anti- and the last author expressed the coagulant. Standardized pipettes and opinion that the increase mas due t o chambers were employed for cell a rapid destruction of erythrocytes. counts. The hemoglobin mas deter- Hemosiderosis of the liver, spleen, mined by the Sahli method. Enumer- kidneys, and bone marrom is a fre- ation of reticulocytes, determinations quent pathological alteration both in of mean corpuscular volume, icterus - human beings and in experimental index, and fragility of red blood cells, animals dead of benzene poisoning. were all made by the accepted methods 3Inllory (8) stated that the spleen in in common use. ' Cabot's case 13321, contained deposits Liver Funclion Tests. (a) The bili- of pigment similar to those found rubin excretion test described by in spleens of individuals dead of Harrop and Barron (24) was made by unequivocal hemolytic anemia. The injecting intravenously 1mg. of crys- suggestion, derived from clinical study, talline bilirubin per kilogram of body that a hemolytic process is abnormally weight. A retention after 4 hours of active is supported by experimental more than 5% of the injected pigment evidence. Ponder (22) has shown mas regarded as evidence of hepstic that benzene in concentrations of 10 dysfunction. millimols per liter accelerates the (b) The sodium benzoate conver- hemolytic action of saponin and sion test described by Quick (25) xas sodium taurocholate, agents known made by administering orally 5.9 p. t o destroy human erythrocytes. Sell- of sodium benzoate. An excre'tion in ing and Osgood (1) have shown that the urine in 4 hours of less than 3 gn~. benzene alone is not lytic for erythro- of hippuric acid in the presence of cytes in vitro until concentrations normal renal function was regarded a~ 0.1 to 0.5% are reached. evidence of hepatic dysfunction. METHODS Renal Function Tests. The urea clearance test (Peters and Van Slyke, Sternal Bone Marrow Biopsy. Bi- 26) mas uscd. The expected clear- opsies of sternal bone marrom were ance is between 70 and 100% of a made and the tissue was prepared for normal standard. histological examination as described Excretion of Urobi1it:ogen. The COP by Rhoads and Castle (23). Smears tent of urobilinogen in the feces d to be stained supravitally and by h the urine was determined qunnti- . . .. ,- .. tatively by the Watson-Terwen (27) mcthod, and the total amount escreted was considered to be an index of the rate of destruction of erythrocytes. Watson states that the normal excretion of urobilinogen in the feces may reach 250 mgm. a day in males, with 100% hemoglobin in the circulating blood. However, in 26 normal individuals with hemoglobin levels be- tween SO and loo%, studied in this laboratory, the amount of urobilinogen excreted in the stools varied from 75 to 150 mgm. daily, while the amounts excreted in the urine were less than 2.0 mgm. daily. CASE REPORTS Case 1. C. DuV., malc, aged 38. Hospital S o . 9717. Admitted January 4, 1936, complaining of weakness, dyspnea, occipital headaches and bleeding gums. History: In 1918 t h e patient and his brother worked in a studio in which benzene was used. T h e brother dcvcloped anemia and epistaxis, and died the same year. The patient changed his occupaLion and was not exposed to benzene again until 17 years Inter, when i n January, 1935 he began to use a rubber cement which contained benzene. He wes exposed to the fumes constantly for 14 hours a day; anorexia appeared in February] and by July his weakness was intolerable. A blood count revealed erythrocytes, 2,440,000, hemoglobin 44%, leucocytes 35,400. Differential count: polymorphonuclears 47%, lymphocytes 25%, atypical cells 25%. Fragility of erythrocytes, normal. Icterus index 8. A fasting specimen of gastric juice contained 29.5" of free HCl. The patient was treated with trausfusions, x-ray therapy, iron, and liver extract befotc admission. Physical Bzaminalion: A well nourished and well developed male showing a noticeable pallor with a slightly yellowish tint. The gums were hypertrophic and spongy with multiple bleeding areas. There was no enlargcment of the livcr or tlic peripheral lymph nodes. T h e t i p of t h e spleen 424 JOURXAL O F INDUSTRIAL HYGIENE A S D TOXICOLOGY [vol. a!, no. 8 gums, and the condition was diagnosed else- of persistcntly negative serological reac- where as Icucemia. tions. The last course was completed 9 Physical Examination: The patient mas months before admission. The patient was a well developed, well nourished young man with pallor of the skin and a slight icteric tinge t o the sclera. The gums were red, a day as a dry shampoo a urcpar;rtion con- edematous and swollen. T h e spleen could t a i n i n e 3nzcWne. On 2 occasions she be felt on deep inspiration and the periph- washed her own hair in this preparation and eral nodes were palpable. There were no on the second she fainted. Three months other pertinent findings. after t h e initial exposure she complained of Laboratory Findings o n Admission: fatigue and anorexia. Six months latcr she Erythrocytes 2,380,000, hemoglobin 54% became nauseated and dyspncic. Ecchy- leucocytes 3,500, platelets 120,000, reticulo- moses appeared on the extremities and cytes 14%. Differential count: polymor- trunk, and finally blceding from the nose, phonuclears 7%, eosinophils 1%, small -gums and vagina. lymphocytes 51%, intermediate lympho- Physical Examination: A well developed, cytes 31y0, large lymphocytes S%, mono- slightly obese, adult female with a pale cytes 2%. Icterus index 15. Fragility, yellowish skin marked b y purpuric spots. normal. Free hydrochloric acid present in The gums wcre red and edematous without fasting gastric juice. Daily excretion of bleeding. No enlargement of the pcriph- urobilinogen in feces was 570 mg., in t h e era1 lymph nodes or spleen. urine 1.54 mg. A sternal bone marrow Laboratory Findings: Erythrocytes 2,080- biopsy was done and the marrow wns found 000, hemoglobin 49%, leucocytes 2,709, t o be hyperplastic. A supravital diffcr- platelets 22,000, reticulocytes 8.0%. Dif- entia1 count of the living marrow cells: fercntial count: polymorphonuclears 49%, primitives 4%, neutrophilic myelocytes eosinophils 2'%, lymphocytes 46%, mono- 35y0,myeloblasts S%, polymorphonuclears cytes 3%. Fragility, normal. Histamine IS%, normoblasts 29%, erythroblnsts 570, induced 4G" of free hydrochloric acid in megaloblnsts 3%. Coagulation 15 min. the gastric juice. A sternal bone marrow Wassermann and heterophile antibody re- biopsy was done and the marrow found to actions were negative. be hypoplastic. A supravital differential Course: The patient was given liver ex- count of the living marrow cells: primitives tract and ascorbic acid orelly, nnd dis- 34%, neutrophilic myelocytes 15%, poly- charged after 2 weeks. With the exception morphonuclears 44%, normoblasts 6%, of an ischio-rectal abscess 6 weeks after erythroblasts 1%. Bleeding time 15 min- discharge, he improved steadily. I n 3 utes. Coagulstion time 41 minutes. Was- months the erythocyte count wns 3,940,000, sermann negative. hemoglobin 72%, leucocytes 6,550. Differ- Course: The patient was given daily for ential count : polymorphonuclears 79%, 6 weeks by mouth 200 gm. of rzw liver and eosinophils 2%, lymphocytes IS%, mono- 20 gm. of ventriculin. A small ulcer on the cytes 1%. Two years later he was in per- right tonsil appeared but healed. There fect Iicalth. was a gradual improvement up t o the time of discharge, niter which there was no re- Case 3. A. S., female, aged 35. Hos- currence in 4 years. pital No. 9174. Admitted June 23, 1931 complaining of dyspnez, weakness, purpura, T h e next 6 patients t o be discussed wcrc ecchymoses and bleeding from gums, nose, rotogravure printers who were exposed to genital tract and gastro-intestinal tract of atmospheres containing benzene, the con- 6 weeks duration. Five transfusions had centration of which varied from 21 to 1060 been given. p.p.m. parts of air as rcportcd b y rhc Divi- History: Fourteen years previously the sion of Industrial Hygiene, New York State patient was supposed to have had a positive Department of Labor. These cases iverc Wassermann test. Anti-luetic therapy had referred to us by this Division in the coursc been given once yearly for 10 yenrs in spite of a n investigation mnde by them of bcn- OCl zen ind ( so Pla Eric PI0 for mo inc Edl: for ch1 Er: leu fer Ip no: tni mi ma wn i me In( in vit - cei m! no mc SC uri ex I: a t 4 Oct. 29SOl BENZENE POISO?: ISG: HEhIATOLOGICAL EFFECTS 425 zene poisoning in t h e rotogravure printing tion: feces, 86 nig. and 74 mg. daily i n 2 industry. periods; urine 2.7 mg. daily. Bilirubin excretion test: retention 10%. Sodium Case 4- J. Z., male, aged 26. Hospital benzoate test: 3.5gm. benzoic acid excreted. KO.10557. Admitted April 21, 1935, com- plaining of weakness, epistasis, ecchymoses Case 6. W.R., male, aged 47. Hospital end salivation. No. 10481. Admitted hlny 19, 1938, com- History: The patient had been em- plnining of weakness and ecchymoses. ployed in a rotogravure printing company History: The patient had worked for a for 3 years before his admission. For 2 rotogravure printing company for 3 years, months before admission he noted gradually and only during the month preceding admis- increasing weakness, anorexia, salivation, sion had he noticed increasing weakness and somnolence and dizziness. One week be- fatiguability. He had used solvents con- fore a severe epistaxsis occurred and ec- taining benzene and was constantly exposed chymoses appeared. to the fumes. Ten days before admission, Physical Examination (before therapy): subcutaneous ecchymoses appeared on the Erythrocytes 2,620,000, hemoglobin 62%, extremities. /. -/ leucocytes 5,650, reticulocytes 5.2%. Dif- Physical Exatitination: The patient was ferential count: polymorphonuclears SS%, a well developed and well nourished male, lymphocytes S%, monocytes 470. Fragility showing no evidence of recent ecchymoses normal. Fasting gastric contents con- or purpura. T h e oral mucous membranes tained free hydrochloric acid. Urea clear- appeared normal and the liver extended ance llO-l20% of normal. A sternal bone 2 finger-breadths below the right costal marrow biopsy was done, and the marrow margin. There mere n o other pertinent was found t o be hyperplastic, although the findings. niegakaryocytes were reduced in number. Laboratory Findings: Erythrocytes Increased amounts of pigment merc present 2,700,000,hemoglobin 72%, leucocytes 2,450, in the reticulo-endothelial cells. Supra- platelets 50,000, reticulocytes 6.2%. Dif- \<tal differentialcount of t h e living marrow ferential count: polymorphonuclears To%, cells showed: primitives lo%, neutrophilic eosinophils 2%, lymphocytes 20%, mono- myelocytes 24y0,polymorphonuclears 25y0, cytes 8%. Fragility, normal. Icterus in- normoblasts 24%, erythroblasts 1270, dex 5. Fasting gastric contents contained megaloblasts 5%. Wassermann negative. free hydrochloric acid. Urea clearance Serum bilirubin level was 1.0 mg.yo. Fecal 135120% of normal. Urobilinogen ex- urobilinogen: Si, 90, 110 mg. daily, during cretion: fecal, 410 mg. and 336 mg. excreted 3 dificrent periods each of 3 days. Urinary daily during 2 periods; urine 3.8 mg. and urobilinogen: 2.9 mg. and 2.4 mg. excreted 1.1 mg. daily for 2 periods. -4 sternal bone dnily during 3-day test periods. Bilirubin marrow puncture was done and the marrow excretion: retention 10%. Sodium bcnzo- was found t o be normal. Supravital dif- nte test: 3.9 gm. of benzoic acid excreted in ferential count of the living marrow cells: 4 hours. neutrophilic myelocytes 2270, myeloblasts Course: Uneventful. I n the hospital 2y0,polymorphonuclears 21%, normoblasts the patient reccived liver extract and thia- 45%, erythroblasts 10%. Wassermann min intramuscularly for n period of 4weeks, negative. nnd in the out-patient department for 4 Course: Uneventful. The patient re- months. One year after admission the ceived liver extract and thiamin intramus- patient was perfectly well. cularly for 3 weeks in the hospital and Lcborctory Findings (5 monlhs ajter ad- 3 months in the out-patient department. niission and cJ'ter therapy): Erythrocytes Laboratory Findings (4 months after ad- ~I,-l'iO,OOO, hemoglobin loo%, leucocytes mission): Erythrocytes 3,830,000, henio- g,W,platelets 152,000. Differential count: globin 95%, leucocytes 7,700, platelets pdyxxorphonuclenrs 54%, eosinophils S%, 25G,000, reticulocytes 4.8%. Differential 1.vmpliocytcs24%, monocytes 14%. Serum count: polymorphonuclears 62%, eosino- IJilirubin 0.7 mg.%. Urobilinogen excre- phils 4y0,lymphocytes 38y0 and monocytes 426 JOURNAL OF IX\ruQ?rhIAL HYGIENE AND TOXICOLOGY [ ~ o l9.1, no. 8 6%. Serum bilirubin 0.85 mg.%. Uro- and was studded with purpuric spots. so bilinogen escretion: fecal, 191 mg. and 192 other pertinent findings. ' mg. excreted daily during 2 periods; urine, Laboratory Fiiidings: Erpthroc,.teJ 0.8 nig. and 0.6 mg. daily during 2 periods. 2,070,000, hemoglobin 63%, leucocytrg T h e patient recovered fully and was fol- 1,750, platelets 42,000, reticulocytes 3 . ; ~ . lowed over e period of 1year with no recur- Differential count: p o l y m ~ r p h o n u c l e ~ r ~ rence of symptoms. 72%, lymphocytes IS%, monocytes 12% Icterus index 8. Fragility 0.50-0.32 (nor- Case 6. J. L., male, 75. Hospital No. malO.44-0.32). Free hydrochloric acid \! 10454. Admitted April 20, 1939, complain- present in t h e gastric contents after ]lis- ing of weakness, ecchymoses, and nausea. tamine. Urea clearance: 155-1007, nor- History: The patient had been employed mal, Serum bilirubin 1.3 ms.%. Uro- for 2 years as a rotogravure printer using a bilinogen excretion: fecal, 225 mg. and 212 benzene solvent. For 6 months prior to mg. daily during 2 periods; urine 6.4 rn: , admission he had noticed increasing meak- 5.4 mg. and 3.8 mg. daily during 3 periods ness, dyspnea, nausea and ecchymoses of Bilirubin excretion test: 17.6% retention the extremities. Sodium benzoate test: 1.8 gm. of benzotr Physical Ezamination: T h e patient was acid i n 4 hours. A sternal bone marrow bi- an elderly, well developed and well nour- opsy was done and the marrow found t o b~ ished male with numerous ecchymoses a n d hypoplastic with a shift t o the left of the pale mucous membrancs without ulcera- white cell elements. Supravital differentia! tions. The physical examination otherwise count of the living marrow cells: primitives mas negative. lo%, neutrophilic myelocytes 2870, myelo- Laboratory Findings: Erythrocytes blasts 8%, polymorphonuclears 145, 4,130,000, hemoglobin SO%, leucocytes 6,500, normoblasts 290/,, erythroblasts GOJ,, mega- platelets 160,000, reticulocytes 3.8%. Dif- loblasts 5%. Wassermann negative. ferential count: polymorphonuclears 68%, Cowse: Uneventful. T h e patient re- eosinophils IS%, lymphocytes 8%, and mon- ceived liver extract and thiamin intra- ocytes 8%. Fragility, normal. Icterus in- muscularly for 2 weeks i n the hospital and dex 5. Free hydrochloric acid present in 4 months in the out-patient department; t h e fasting gastric contents. Urea clear- he was observed for over a year without rc- ance: 70% and 72% of normal. Serum currence. bilirubin 0.75%. Urobilinogen excretion: Laboratory Findings (5 months after od- fecal, 83 mg. daily; urine, 0.92 mg. daily. m i s s i o n and ajter therapy): Erythrocytes The bilirubin excretion test: 7.2% retention. 3,SOO,OOO, hemoglobin l O l % , platelcts 124- Sodium benzoate test: 3.6 gm. of benzoic 000, reticulocytes 1.2%. Differential count: acid in 4 hours. Wasserman negative. polymorphonuclears 7475, lymphocytes Course: Uneventful. T h e patient re- IO%, monocytes 16%. Serum biliruliin ceived liver estract and thiamin for 4 0.7 mg.%. Urobilinogen excretion: fecal. weeks in the out-patient department, and 72 mg. and 75 mg. excreted daily duriiiq '2 was followed without recurrence for a year. test periods; urine, 1.5 mg. and 1.8 nig. escreted daily during 2 periods. Bilirubin Case 7. M. S., male, aged 33. Hospital excretion test: 16.7Yo retention. Sodium No. 10467. Admitted May 3, 1038, com- benzoate test: 3.9 gm. of benzoic acid ex- plaining of weakness and ecchymoses. creted in 4 hours. History: The patient had been a roto- gravure printer for 18years but only during Case 8. L. P.,male, aged 29. Hospitnl the 2 years preceding admission was he ex- NO. 10500. Admitted June 14, 1935, coni- posed to solvents containing benzene. I-Ie phining of anorexia, fatigue and musrulnr noticed mcakness and ecchymoses 1 month cramps. before admission. History: The patient had been worhN Physical Eznmination: The patient was in a rotogravure printing establishmetit for a well developed, well nourished, pale man, 4 years and for 1 year had applied tvitli h u e whose skin had a peculiar yellowish color hands a benzene preparation. Anorelis ~ had been present for a year, fatigue and' Ireakness for 6 months, and pallor for 1 month. Physical Examination: The patient wss a small, well developed mnle. The skin was pale but without purpura. No other pertinent &dings. Laborafory Findings: Erythrocytes 1,8j0,000Jhemoglobin 47%, leucocytes 1,900, platelets 18,000, reticulocytes 4.5%. Dif- ferential count: polymorphonuclears 64%, eosinophils 4oJ0, basophils 4OJollymphocytes 12%, monocytes 16%. Fragility, normal. Free hydrochloric acid present in the fasting gastric contents. A trace of oc- cult blood in the stool. Urea clearance: 93 and %yo of normal. Serum bilirubin level 1.12 mg.%. Urobilinogen excretion: feces, 150 mg. and 112 mg. daily during 2 periods; urine, 10, 12, and 17.4 mg. excreted daily during 3 periods. Bilirubin excretion test: no retention. Sodium ben- zoate test: 3.77 gm. of benzoic acid ex- creted in 4 hours. Asternal bone marrow biopsy was done and the marrow found t o be hypoplastic with a shift t o the left of the white cell elements. A supravital dif- ferential count of the living marrow cells: primitives lo%, neutrophilic myelocytes 2370, polymorphonuclears 19%, normo- blasts 3975,erythroblasts 7%] megaloblasts 2%. Wassermann negative. Course: Uneventful. The patient was given liver extract and thiamin intramuscu- larly for 2 weeks in the hospital and for 3 monthsintheout-patientdepartment. The patient was followed 1 year without recur- rcnce. Laboratory Findings (after 3 months o/ fherapy): Erythrocytes 3,930,000, hemo- globin 96%, leucocytes 6,700, platelets 82,OOO, reticulocytes 1.8%. Differential count: polymorphonuclears 667& eosin- ophils 4y0,basophils 2y0,lymphocytes 24%, monocytes 4%. Serum bilirubin level: 0.G mg.yo. Urobilinogen excretion: fecal 76 mg. daily; urine 4.1 mg. daily. Bilirubin i i excretion test 10.4% retention. Sodium benzoate test: 3.73 gm. of benzoic acid ex- i creted daily during 2 periods. i i Case 9. F. M., male, aged 20. Hospital KO.10503. Admitted June 16, 1938, com- plainingoffatigue, dyspnea, and irritability. , i: 1 t , Lx -3 tailling between 24 and lOG0 p.pm .*in all, o f ; the patients. The color and often washed their hands in the indices were elevated (1.1 to 1.5) ill chemical. Of the remaining 3 pa- of the g'patients, and the mean cor- tients, one was a hairdresser who mes were increased (9.1 worked in a small cubicle, one mas a but two. chemist who worked in an adequately the tissue removed by ventilated room, and one patient biopsy from the sternal bone IL'.qrroI\. worked in a poorly ventilated cellar of 8 p&&nts revealed histolo$cnl room. ich varied from a hypo. No correlation between the severity a left shift of the cellrllar of disease and the intensity of expo- a hyperplasia with norn1nl sure can be made. Symptoms ap- The erythroid-mycIoid peared after 6 months to 3 years of ratio of the marrow varied from 1:3 to exposure, and bad been present-from 1:l except'in 1 case. The myelocyte- 1to 6 months before medical aid was polymorphonuclear ratio varied iron1 sought. The most frequent com- 3:l t o 1:3. plaints were weakness, fatigue, head- The Wassermann reaction was ncgn- ache, anorexia, epistaxis, bleeding tive in all the patients although 1had gums and ecchymoses. received several courses of neoarsphen- The hematological findings varied amine following a single positive tcst (table 1); anemia (hemoglobin values 14 years previously. The last courzc from 47% to 81% and erythrocyte was finished 9 months prior to adniis- counts from 1,850,000 to 4,130,000), sion but only 2 months prior to leucopenia (leucocyte counts between exposure to benzene. Free hydro- 1,750 and 6,500), thrombocytopenia chloric acid was found in the gastric (platelet counts between 18,000 and juice of all the patients though t\\o 160,000), and elevated reticulocyte were achlorhydric until histamine was levels (from 14% to 3.8%) were pres- injected. Roentgenological examins- ent in all of the cases. The results of tions of the gastro-intestinal tract of the differential counts were markedly the 6 rotogravure printers revealed no dissimilar; monocytosis was present in abnormalities. The results of the 3 cases, eosinophilia in one, and lym- urea clearance tests were normal in phocytosis in one. The fragility of these 6 individuals also. The ictcrui the erythrocytes in hypotonic saline indices were determined in 5 patients, was within normal limits except in and were elevated in four. The serum one case. 'Varying degrees of aniso- bilirubin levels were 1mg. % or &ow cytosis and poikilocytosis were present in 5 of the 6 patients tested, whereas n * The Nntional Safety Council considers normal level was present in one ivho a liistory of long exposure to benzene and had vcry little anemia. Vaughn n t d t h e prcscncc of a leucopenia of less tlian 5,000 white blood cells per cubic millimeter t o be repso?able evidence for chronic benzene polsonlng. The Council also advises that a person working 8 hrs. a day should Ilaslewood (28) have shown that tlic normal serum bilirubin is bet\\('CII 0.2 and 0.8 mg.%. not be permitted to work in an atmospliere containing more than 100 p p m . (JVISS- LOW, C.-E. A.: Summary of Nntional Safety Council Stud of benzol poisoning. THIS J., 9, 61 (192Q.r AS treatment, the patients w r e ? oi course, removed from thcir espO'"lc to benzene and supplcmentary thcrsl)Y Ocl. 19S9] BENZENE POISONING: HEMATOLOGICAL EFFECTS 429 w& given, the value of which is mg. daily). After their recovery, 3 unknown. Of the 9 patients, 3 re- of the 4 excreted normal quantities, ceived orally 100-300 gm. of raw while the remaining one excreted less minced liver with 20-30 gm. of ven- than he bad previous to treatment. triculin daily for 2 t~ 4 weeks; 2 Although the quantitation of uro- received in addition, daily intravenous bilinogen in the urine is a measure of injections of 1 gm. of ascorbic acid for one of the hepatic functions, two other 1 week, while the 6 printers received, tests (bilirubin excretion test and intramuscularly, 5 cc. of liver extract, sodium benzoate conversion test) were with 20 mg. of thiamin twice a week made on the 6 printers before and for from 2-5 months. after recovery. On admission 3 of the After 2 t o 5 months of treatment, 6 printers, on whom the excretion 8 of the 9 patients were clinically test was made, had no retention of improved. The hemoglobin values bilirubin, but after clinical recovery rose to between 78(r0 and 1 0 l ~ ot,he each had a retention (9.1, 10.4, and leucocyte counts to between 3,200 and 11.6%). The other three ,n admis- 9,300, the platelet counts to between sion had abnormal retention (7.2, 82,000 and 256,000, and the reticulo- 17.6, and lo%), but -after clinical cyte counts fell to between 1.2% and recovery the first had no retention, the 4.1%. The mean corpuscular volume second had less retention (17.6-16.7%) increased in 3 patients, remained the and the third showed no change. No same in 1, decreased in 3, and fell to explanation for these findings is a t within normal limits in 2. The color hand. The results of the sodium index increased in 2, remained the benzoate conversion test were normal Same in 2, and decreased in 5. Of the in 5 of the 6 patients both before and last group, in only 1 case did the color after recovery. The 1 case that had index fall below 1. The serum bili- a decreased excretion of hippuric acid rubin levels fell to between 0.42 and before recovery was able to excrete a 0.85 me.%. The marrow eventually normal amount after recovery. Of became leucemic in 1 case, whereas it the 3 hepatic function tests, the first returned to the normal state in the was most reliable in this series of other 8, as indicated by the complete cases since the amount of urobilinogen clinical recovery of the patients. excreted in the urine was quite closely Studies of the rates of excretion of correlated with the clinical condition urobilinogen showed that on admission of the patient. to the hospital 5 of the 8 patients Eight of the 9 patients recovered, studied had elevated levels in the feces as judged by clinical and laboratory (150 to 1000 mg. daily). The test evidence, within less than 6 months as repeated in the 6 printers after after admission; whereas 1 died of their recovery. The quantity ex- acute myeloid leucemia within the creted was normal in 5 but still same period of time. The 6 printers elevated in 1 (192 mg. daily). returned to work 6 months after ad- On admission 4 of the 8 patients mission, since the use of benzene was had increased rates of excretion of discontinued in the printing plants. luobilinogen in the urine (2.7 to 17.4 None had shown any return of their Before therapy (2/7/36) 1. Rospital number ....... 2. Sex..................... 3. Ago..................... 9717 male 3a a. Weaknes b. Ileadachc 4. Chief complaints....... e. Bleeding LeUCoc,ftes.. .......... 4fter Before ierapy therapy - (6/23/34) 9576 ~ male 23 Wenknes Fever Sore g u m 9174 female 35 Weakness Bleeding Hematemesk , Purpura I 2 months 23 months 9 months 6 months 51% 700.000 137,000 / 64% 2.360.000 6.400 120,000 14.0% 78% .74O,OOC 6.53 4.1% 49% 2,oso.0 0 2,103 22.000 8.0% herapy -8/5/34) ,10457 male 20 Wenkrieu Dizziness Ecchymo-s Epistaxis 2 mouth 3 yenn 94% ,980.OoE 8.54C 168.00( 2.0% 62% 2. CZO. 000 s,850 28,000 5.2% Aft, iern -Oi21 95 mi 25` 4. volume.. .......... Plasma bilirubin level Fragility of eryth Diffcrentid 1. Primitive cells.. 22% 3% 2% 63% 8% 2% ISO/l90 74 0.90 7% 79% 1% 2% 49% 2% 90% 2% 950/210 so0 1.17 18% 1% Biopeo 108 1.OS 46% 3% 940/105 100 1.22 18 0.44-0.34 Negative ypcrplastia (left shift) 4% 0.42-0.30 Negativo Hspoplasti 32% 88% 50/380 100 1.20 8% 4% 960j235 94 1.1 1.oo 0.44-0.31 Negutive Hyperplastic 10% 41% 15% 24% 9. Free hydrochlorio ac' in fasting gastri 16% 37% Present 44% 7% Present (hit tamine) 25% 41% Present 11. Liver function tcsh: .a. Bilirubin retain in plnsma....... 1.40 570 2.9 and 2.4 90.0 nnd I11 10% Removal from expo- sure 13. Thcrnpy............... Raw liver Gastric mucosal preparations 14. ncsult.................. Ascorbic acid Doath-myeloid leu- ...........15. Occupation.. aomia Used cement contair ing benzene Removal from expo. Removnl from expo sure sure Rnw liver Raw liver Anmrbio acid Gastric mumnl preparation Recovery Chemist 1I ~ Rmvery B z t y parlor opera * Including normoblamb, e r y t b r o b h l r and megdobtaats. 430 3.9 gm. 120 t; 110 Rotogravure printa --- 4y _ -*...~..,...f...:.. .;.\"-L'. 62' 4' 35 6 >3: 1 ( C A ~5E (\V. R.) -1- 95% S30,M 7.71 256.01 4.w 52% 4% 3S% 6% 935/21 90 1.23 0.65 10454 male 76 lVeaknc?s Ecchymoses NaUSS 10467 male 33 8. Weakness b. Ecchymoses 6 months 1 month 2 yeara 80% 4,130,000 6,500 160.000 3.8% 3 Y- I39% 4.0 60.000 8.600 IIS,OW 1.8% @% 2.070.000 1.750 ' 42,000 3.7% 68% 7% 72% 16% 8% 8% 970/330 SO 0.Q 0.75 5 0.42-0.32 Negative .9% 14% i0/360 16% 12% 940/210 I0.42 1.3 0.50-0.34 Negative Hypoplnstic (left shift) 10% 35% 14% 41% 101% 8i0,oOo 3,2m 124.000 1.2% Anorexia Muscular cramps in arms and legs 6 months 3 years 47% 1,850. COO 1.900 18,000 4.5% I - -CASE 9 (F.31.) Iter Before -crclpy therapy 15/33] (6/10/3S) .fter - 105W male 20 a. Fatigue b. Dyspnea c. Irritable- UeeS 5 months 3 Y- 96% IO.Mx) 6.700 12.00U .8% 81% 3.220.000 2.100 50,000 4_.1%- .- 94% 010.000 5. S50 152.000 1.6% 74% 10% 16% 9i0/390 105 1.3 0.7 64% 4% 4% 12% 16% 940/180 106 1.30 1.12 i% 1% !% 4% 1% ,0/3S5 102 1.20 0.65 68% 2% 16% 16% 970/280 90 1.26 1.oo 62% 2% 5% 0/3S5 so 0.94 0.45 , 0.44-0.32 Negntive :ypoplatic (left shift) 10% 23% 19% 48% 444.32 0.44-0.34 Negat.ive Hyperplea 6% 34% 22% 38% Present 0 0.92 I91 s3.00 I. 9.1 7.2% I4.0 gm. 3.65 &m. 72 Present (hi! tarnine) 0.76 63.00 6.4 and 5.4 225 and 212 0.0% 3.60 gm. 17.6% 1.8 m. 100 .5 and I 72 and 7 16.7% 3.9 g m Prosent Present D. 12 and 1; 150 and 118 4.1 1.4 76 126 and 0.9 64 0.0% 3.77 gm. 10.4% 1.73 gm. 0.0% 3.9 g m 11.6% 3.8 Em. 98% Removal from exposure Intramuscular liver ex- tract Intramuscular thiamin 130% Removsl from oxPo- euro Intramuscular liver extract Intrarnuacular thi- amin Recovery ISame 432 JOURNAL OF IKDUSTRIAL H Y G I E N E AND TOXICOLOGY [uol. 21, no. 8 former symptoms after 1 year of cm- experiments suggest that a dietary ployment and no trentnient wvas given factor is concerned with the tolerance during that interval. to certain cyclic chemicals. DISCUSSION The cause of the anemia and leucopenia of benzene poisoning is not well With the increasing use of benzene understood, although a subnormal rate as a solvent of gums, resins, fats, rub- of production is widely accepted ber m d allialoids, and as a fuel, in- (Castle and Minot, 30). The exist- creasing numbers of human intoxica- ence of a subnormal rate is supported cations are reported. Chronic ex- by the histological findings in the vast posurc may cause varied hematological majority of cases with late stages of and clinical pictures as proved by the poisoning. As a n early effect, how- evidence here presented. Anemia, ever, the marrow is hyperplastic, and leucopenia, thrombocytopenia, reticu- this may explain the presence of locytosis, high color index, increased myelocytes and irritated forms of fragility of erythrocytes, urobilinuria leucocytes in the peripheral blood. and prolonged coagulation time may As the marrow becomes aplastic the or may not be present. The bone first reflection is a decrease in the marrow may be aplastic, normal, number of circulating leucocytes, om- hyperplastic, or leucemic, and the ing presumably to the brief life span changes are reflected by the peripheral of those cells. Thrombocytopenia ap- blood. The symptoms may vary as pears next, and varies in intensity with much as do the hematological findings, the susceptibility of the megakaryo- but headache, fatigue, dizziness, cytes to the absorbed benzene. Anem- nausea, anorexia, wealtness, nervous- ia is the last manifestation since ery- ness and hemorrhagic manifestations, throcytes are the cells of longest life as bleeding gums, epistaxis, and (Dekker, 31). menorrhagia predominate. The ex- Although the improper formation of treme variability of the manifestations blood cells is a prominent feature in is due possibly to the different concen- benzene poisoning, and possibly the tration of benzene fumes to which the result of an inhibition of some individual is exposed, the duration of unknown maturation precess in the exposure, and the individual suscepti- marrow,. there is clinical and labora- bility to the chemical, as suggested by tory evidence that the chemical may Hamilton. accelerate the normal mechanism for A dietary factor may be involved in the destruction of erythrocytes. I n individual susceptibility. Rhoads, the cases herein reported there was Barker and Miller (29) have shown much evidence for the presence of that dogs fed a deficient diet are more increased rates of hemolysis. Ele- susceptible to the hemolytic effects of vated levels of serum bilirubin, indol, a naturally occurring cyclic poikilocytosis, elevated reticulocyte compound, than are dogs taking nor- counts and increased outputs of mal dicts. This increased sus- urobilinogen were all found. Watson ccptibility vias prevented by the (27), Eppirigcr and Charnas (32), administration of liver extract. The Wilbur and Addis (34),Sparkman (35) Ucl. 1939) BENZENE POISONING: HEMATOLOGICAL EFFECTS 433 and others have indicated that the elevated color indices in benzene estimations of the urobilinogen of the poisoning, like those of pernicious stool constitute the best single measure anemia, fall to normal values on re- of the rate of destruction of red blood covery. This was true of the cases cells. All evidence of increased herein reported. hemolysis disappeared in 8 of the 9 The secretion of hydrochloric acid patients when they were removed from in the gastric juice varies in patients exposure to benzene. The anemia, suffering from benzene intoxication. leucopenia, and thrombocytopenia Weil (39) reported that 3 of 9 cases of vanished and the serum bilirubin benzene poisoning that he studied had levels returned to normal in all the achlorhydria. In the 9 cases described patients, as did the reticulocyte counts in this communication free hydro- and the fecal excretion of urobilinogen. chloric acid was present under fasting Clinical improvement was therefore conditions in seven, and histamine mas quite likely attended by the cessation required in two. of a destructive process as well as a Unfortunately, studies of the excre- restoration of normal hematopoiesis. tion of conjugated metabolic products Moreover, laboratory evidence exists of benzene were not possible in this that benzene accelerates the action of series of patients. Of the absorbed agents lytic to erythrocytes in vitro benzene, over nine-tenths is excreted (Ponder, 22) and that it causes a by the lungs (Feil, cited by Browning) destruction of circulating erythrocytes and a portion of the remainder is in experimental animals (Climenko excreted by the kidneys either as and Abels, 36). ethereal sulfates (Yant and coworkers, Watson showed that the output of 40) (Jephcott and Bulmer, 41),glucu- urobilinogen in the urine is one of the ronides (Jost, cited by Browning), or most sensitive measures of liver func- as mercapturic acids (Stekol, 42). tion; any increase indicates an in- It is of interest to note that one of nbility of the liver cells to excrete the patients developed leucemia, a normally the pigment into the gastro- possible sequel to benzene poisoning intestinal tract. In this series of patients the rate of excretion of urobilinogen in the urine could be correlated with the clinical condition of the patient. This was not true of 2 other test,s, which measure different liver functions (the sodium benzoate conversion test and the bilirubin excretion test). The degree of macrocytosis in benzene intoxication varies greatly (Browning and Hamilton), and in which has been mentioned in the literature. Selling and Osgood (1) cite 6 cases that developed evidence of leucemia following exposure to benzene. (Lymphoid, 1 case-Falconer; myeloid, 5 cases-Weil, Hunter and Hanfiig, Cabot, Delore and Bergomano, Schneider.) Hamilton (5) reported a case of leucemia, observed by Martland, following benzene exposure. Perrin, IGssel, and Pierquin (43) have certain instances may simulate that of described recently a case of "acute pernicious anemia (Stodtmeister, 37). benzene leucosis." Dimmel (38) has shown that the The patient (Case 1) herein re- ,. . .. .. 434 JOURNAL O F INDUSTRIAL H Y G I E N E AND TOXICOLOGY [ool. H,no. 8 ported, developed leucemia while being and the post mortem fkdings mere studied to ascertain the cause of an typical of that disease. unexplained anemia following 6 months' exposure to benzene. The SUAlaULRY symptoms, the physical findings, and 1. Nine patients with bggzene poi-- - . the hematological findings of leucemia soning are reDorted and--th_c_-ar-iecd_L developed insidiously. During the hematological findings these cases _---last 4 months of his life the patient are discussed. Eight .of the patients became weaker, the peripheral lymph =vered and one died"--o-f--._ml_yeTor21- nodes and spleen gradually enlarged, leucemia. and the number of circulating leuco- --27FMiience' is presented that an , cytes increased as did the percentage increased rate of destruction of eryth- of immature cells. The patient died rocytes may be one cause of the of leucocythemic, myeloid leucemi5,- anemia of benzene poisoning. BIBLIOGRAPHY 1. SELLING, L.:A preliminary report of 7. CREMIRUR, .: La forme anhmique grave some cases of purpura hemorrhagica de l'intoxication benzhique. J. de due t o benzol poisoning. Bull. Johns Med. de Lyon, 6,251 (1924). -. .Hopkins Hosp. 91, 33 (1910). 8. CABOT, R.C.: Diseases of the blood, in Benzol as a leucotoxin. Johns OSLER- ~ N DMCCRAE:Modern medi- Hopkins Hosp. Rept., 17,81 (1916). - AND OSGOOD, E. E.: Action of cine. Lea and Febiger, Philadelphia, 1927. benzol, roentgen rays and radioactive -: Case Records of Massachusetts substances on the blood and blood- General Hospital, Case 13321. Bos- forming tissues. Handbook of hema- ton Med. and Surg. J., 197,236 (1927). * to!ogy. Edited b y H AL DOWNEY. 9. ANDERSON, D. H.: Benzol poisoning Paul B. Hoeber Inc., New York, 1938. with hyperplasia of bone marrow. 2. REZNIKOFFP, ., AND FULLARTON, R.: Arch. of Path., 10, 101 (1931). The action of benzol on granulocytes. Am. J. Physiol., 101, 87 (1932); and Folia hemat., 60, 454 (1933). 3. GREENDURGL., :Benzol poisoning as an industrial hazard. Pub. Health Rept., 41, 1347,1410, 1516 (1926). 4. BRANDINOG,.: Cited by HAMILTON. 5. RAXILTONA, .: Benzene (benzol) poi- soning. Arch. of Path., 11, 434, 601 --.(1931). Industrid poisons in the United 10. WEIL, P. E.: La I e u c h i e post-ben- zolique. Bull. e t hlem. SOC.Med. d'h6p de Paris, 48, 193 (1932). 11. PENATI, F., AND VIGLIANI, E.: SUI problema della mielopatie aplastiche, pseudoaplastiche e leucemiche da benzolo. Rass hfed. Industr,, 9, 345 (1938). 12. LIGNAC,G.0. E.: Die Benzolleukiimie bei Menschen und weissen Mausen, States. Mncmillan Co., New York, -. .1925. Industrial toxicology. Harper Krankheitsforech., 9, 403 (1932). 13. PAUL, W. D., FRIEDLANDER, A., AXD MCCORD,C . P,: Basophilic materinl Brothers, New York, 1931. 6. BROWNINGE,,: Toxicity of industrial organic solvents. Med. Res. Council, in benzol poisoning. Tms J., 9, 193, (1927). 14. MITNIK, P., AND GENKIN, S.: Zur Indust. Health Res. Bd., Rept. no. IClinik der chronischen Benzolver- 80. H. hL. Stntionery Office, London, giltung. Arch. Gewerbepath., 8,457 1937. (1931). . ..-- - : I .-.- -