Document EdzQaB7peoJj0bjQkbyDY7pRV

4 % Examination - November 8, 1926 Name ** Age 28 - white - married. Twoc hildren, aged five andtfaree. Employed by the Atlantic Refining Comnanv, as filling station attendant. ` - Previous history of illnesses Included a dropsical condition lasting two months a s a chile'; pneumonia following tonsllectoray several years ago; the loss of sight of one eye, as a result of an auto accident a few years ago. G, 0. in 1917. History otherwise negative. No family history of importance. He first worked two years in steel mills, making sheet stell, "roughing". He was *n the army 16 months up to the end of the war, in the ordinance department. This was followed by vocational training for 1-1/2 years as draftsman. Afterward he was engaged in repairing, wiring and Installing radio equipment. For five months previous to his present illness he was a filling station attendant, as above, beginning May 26, 1926. The Atlar tic Refining Company began to distribute Ethyl Gasoline in July 1926. The is no evidence of previous lead exposure. PRESENT ILLNESS - '< Prior to handling Ethyl Gasoline had no symptoms. In September, about 1 20th, began to note a diarrhoea and general weakness. A week later deve.' oped tingling sens -tion in flngefs, and could scarcely hold a pencil. Could grip but could not extend fingers. The condition became worse, an< he came to Cannonsburg Hospital on October 15, 1926. Was seen by Dr. Wrij of Pittsburgh Just before entrance into hospital. His bongue became sore, his gums were swollen, and he had abdominal cram; which wore uver localised in any one place. The cramps were inconstant and were usually on one side or the other, not in the mid abdominal regi above the-umbilicus. Weakness and tingling in the legs developed later. The weakness increased until the subject was put to bed and then sent to the hospital on the above date. At first he was restless and slept fit fully. He suffered pain in knees, ankles and wrists. (All of the above information was given by the patient, who as a result of the examinations and discussions of his physicians was well aware of the symptoms and signs of lead poisoining. There is little reason to dc his honesty, but thereis some evidence that he has emphasized certain symptoms and has neglected others, in a statement of the course of his illness. Exact details are difficult to obtain because of a lack of rc prior to his entrance into the hospital.) . The hospital record contributes little to the above story except a tem perature chart, which shows that on admission to the hospital his tempei ture was 98.8, going up to 101 that night. He continued to run an irrej temperature up to October 20, since which time it has been normal o p sul normal, and somewhat irregular. This according to his physician, Dp. J< A. Johnson - was due to a cold contracted in the hospital, though the patient says he had fever prior to being in hospital. ; A further observation noted, on the hospital chart is a urinalysis - sho` albuminuria, with casts. No stippling has been fouhd at any time. Subjects (continued) Present Complaints - Some constipation. Takes cathartics daily. Weakness. Pains in Joints - knees, wrltts and ankles. Headache for past three days. . t Tingling sensations in feet. A feeling of 'Vibrations''1 up and down spine. PHYSICAL EXAMINATION The subject is a young man, of fairly good color, slender in build and apparently somewhat emaciated, thou$i not strikingly so, lying in beg languidly but apparently comfortably. There is a scar completely obstructing vision in the right eye. The left reacts to light and accommodation normally. The muGosa of the nose is red and encrusted, and swollen. The turbinates, especially the inferior, are hypertrophied. The tongue is coated and fissured; the throat is red and edematous. There is a post nasal purulent exudate. * The cervical lymph glands on the right side posteriorally are palpable and tender There is a general suppurative gingivitis, and there is a carious left lower first molar tooth. No suggestion of a lead line is present. ' The first heart sound is a little weak, but there are no abnormal sounds. The left apex shows a slightly reduced resonance, and there is an increased transmission of the whispered voice. The breath sounds are rough, but there is no moisture present in the lung parehchyma No abnormalities are found in the abdomen. The reflexes are normal. Sensation was not studied with detailed care, but a definite area of hyperasthesia was found over the back beginning on both sides Just below the angle oi* the scapula and extending down to the upper liver border. There is no evident.loss of ordinary tactile or thermal or pain sensibility. There is no evidence of paralysis of any of the muscles. The hand shows no evidence of present weakness of a noticeable type, and there is no wasting of the muscles. Subject: (continued) \ The urine 1b acid in reaction, contains albumin, and a few casts are seen microscopically, A red coundT shows five million erythrocytes. One'faintly stippled erythrocyte was found in 100 fields Differential coun< showed - Poly-Heutrophiles Eosinophiles Basophiles Mononuclear Lymphocytes 61 4 1 4 30 No abnormalc ells found Analysis of faeces and urine for lead showed the following: Faeces - Dry weight 18.15 gm - Pb found 0.25 Pb found per gm. ash - 0.09 mgs Urine - Volume 3720 cc - Pb found Qi.41 Pb found per liter - 0.11 mg. ,w : In view of the above physical findings I recommended X-Ray examinations of teeth f,nd chest, and a blood .Wasserman. The Lungs and spine showed no abnormalities The carious tooth showed an apical abscess The blood Wasserman was negative I attempted to get details of the onset and course of the condition prl to my examination from Dr. Johnson and Dr. Wright, but obtained no more tr.an is indicated herein. Dr. Wright stated that he was by no means su that the patient had lead poisoning. Inspection of the service station in order to get an idea of possible exposure, showed that the method of dispensing Ethyl gasoline ( Pressure system with valve on end of hose line) sometimes allowed skin contact with the gasoline. When a valve leaks the hose line becomes we and the operator Can scarcely avoid contact with It. About ore fifth o the total sales from this man*a station were Ethyl Gasoline and only on of the Ethyl hose lines showed a leak. The actual period of skin con tact with Ethyl Gasoline was not great, therefore, though such contact present. The spillage of gasoline at these stations Is rare. ~ J- Case No.. Ga sol ine Cor por at ion NOTES ON CASE 'J 1 , / J l Name. 'v f Atlantic Refining Company Pittsburg, Pa. * . Hovember 12,1926. Dr. George J* Wright, 121 University Place. Pittsburgh, Pa. My dear Doctor Wright: Some days ago X was notified of the development of a case of possible lead poisoning in a man in Pittsburgh, an employee of the Atlantic Refinfn^uompany, he being a server at a filling station for this company. As a consultant of the Ethyl Uaso* line Corporation of Kew 'fork, and in cooperation with the United States Public Health Service, I, and sever al assistants, have been keeping a continual check on the possible hazards arising from the manufacture and distribution of Ethyl fluid, as well as the men who are handling Ethyl gasoline which contains a very small quantity of this fluid* " In as much as this is the first reported case of anything which bears any resemblonce whatsoever to lead poisoning in men who have had to do with the handling of gasoline, several hundred men having handled it continuously over a period of over three and one-half to four years, an unu sual interest and importance attaches itself to this case. I, therefore, went to Pittsburgh as soon as the natter was reported to me* and made an examination of this man at Cannonsburg, fennsylvania. Doctor Sands of Pittsburgh reported to me that you had made an examination of this man some time ago, and I am, therefore, very anxious to determine what were your ob servations and findings and conclusions at that time. In as much as this man at present shows little or no indica tion of injury of the type which might be attributable to lead, and especially in as much as his only exposure to lead, which according to M s history, relates to a period of approximately two and one-half months during which time he was handling Ethyl Gasoline, and in as much as this ex posure to lead in terms of the experiences of several hun dred other men, and in terms of information arrived at ex perimentally on animals, it is entirely Insignificant even granting a remarkable susceptibility. It seems like ly that some other diagnosis mist be arrived at. I am making an attempt to gather together all of the facts and findings and to make stich further examinations as are in dicated in order to arrive at a certain diagnosis if possi- I 1 b . ; GJ Wright Page # 2 November 12,1926. ble, and I feol that the observations made on him as well as those which must be made from now on are of the utmost importance in arriving at a conclusion. 2 should appreciate it very greatly if you would inform me as to your findingo, and if you will give me a frank state ment of your own concerning the nature of this man* e ill ness. Very truly yours, P/i: OJ >' Hr. E* IV. V.rebb, .. c/o The Ethyl Gasoline, Corp, 25 Broadway, - Hew York, N.Y. ' ,, - ' My dear'Mrj* -Webbs . . ' . Following your suggestion by telephone from Jfew York, I went to Pitts burgh on Monday of this week* I first had an interview with Doctor Sands who made it possible for me to see the physician who was original ly in charge of the man whom I wished to see* I found he was in a hospital iix Cannousburg, Pennsylvania to*which point I went directly and made as careful an examination as was possible considering the some what meager facilities of the hospital* As you know this man had been seen previously by Doctor Wright of Pittsburgh* who is a rather well known man in his line of work which is essentially neuro-psycMatry* The diagnosis of all three of the men who had seen f H p H H H H V bad been agreed upon as lead poisoning* I have not seei^DoctorWr^it1s report and was unable to get in connection with him as he was put of the city, so that I do not know how positive he was in his contusions* I shall correspond with him at the earliest convenience and determine just what his opinion is and upon what basis it was arrived at* My own examination disclosed the fact that this man has certain signs and symptoms which suggest lead poisoning of a chronic type* The his tory in bpJef Is as follows During a period of about two and one-half months in'Which he was handling Ethyl gasoline in a fashion customary for filling! station employees, this man had what is apparently his only exposure at?, any time to lead* 1 went carefully i n m a t t e r of pre vious exposures and found no evidence whatsoever of any'such exposure* His work at] the filling station had to do with the occasional filling of tank wagons, which involved no unusual spillage or exposure, and the routine filling of automobile tanks of which approximately one out of three were filled with Ethyl gasoline* The man himself states that he very frequently had his hands bathed in Ethyl fluid as a result of the leakage of sutffing boxes and hoses which carried the Ethyl gasoline from the meter Into the automobile tank* A careful check up at filling stations throughout the city, which 1 made later in the day, showed that it is only-rarely that one of these filling devices leaks badly and that it is,jtherefore, not likely that there was any continuous and con siderable soaking of the hands in Ethyl gasoline* So much for the history of exposure* ' ^^ , ; Having begul to handle Ethyl fluid in July, this man noticed in Sep tember a tingling sensation in his fingers and some loss of sensation and inability to use his fingers, so that it was very difficult for him to holdla pencil and very difficult to unclasp his hand after it was once clasped* Along with this he developed certain thgling sesfsa- felons with etching in certain parts of the body, notably the legs, and 1 -- . O3C3 H>5,K H , * O g;2^8^, lovember 10*1926* Webbi jit a general weakness with some restlessness at nighty without, kowever, having a real insomnia and without any disturbing or fright ful drearsa of any kind, This condition gradually increased* The only other thing arising being a rather severe diarrhoea for a few days in t;he very early stages* Shortly after this lie was seen byall of the physicians who have reported on him, all of whom arrived at a diagnosis of lead poisoning, presumably, largely on the basis of the history of lead exposure in connection with the handling of Ethyl gaso line* **- ' ' " ' r:- ' The physical examination shows the man at present to be a fairly health y looking young man with weakness undoubtedly and apparently borne loss of weight, although he is not severely eraatlafced* He has at present some evidence of an acute respiratory infection and has been running an intermittent fever since admission into the hospital, and according to his story since some days previous to his-admission to the hospital which was October the fifteenth* He has at present no paralysis at all and not apparent muscular weakness* That is to say whatever symptoms of wrist drop which he once had have now disappeared (it Is worth while to take notice of the fact that this disappearance occurred in the very short space of a fev; weeks)* He complains somewhat of "vibrations" by which as near as I can make out he means tingling sensations through his lower extremities and particularly through his back, and there are areas of extreme hyper-sensitivity in certain areas on his back There is no lead line on tile gums and there is no stippling in his blood at all, and according to the report of bhetor Johnson there has not been any stippling at any time* There is some suggestion of involvement of his chest over the left side* I think, however, that this is due to . his upper respiratory infection and has no significance as to the nervous lesions* At the time of his entrance to the hospital he showed signs of a kidney condition which may have been a general intoxication, but It more likely represented a localised infectious process in the kidney* Unfortunately I was unable to -obtain a specimen of urine for examination* I did, however, obtain specimens of -blood for count and for examination for stippling*- u `" - - :.a F.iy conclusions concerning this mn re that.although there are certain things characteristic, or rather I should say suggestive of lead poisoning in the muscular weakness and partial paralysis which he developed, that it Is much more likely that he hassome other condition* >iy conclusion is based on the following things#: First Of all, I regard his exposure to lead in handling Ethyl gasoline as beinginsignificant* It is, therefore, incumbant upon the physician to prove the -diagnosis of lead poisoning rather than to disprove it* -She Question, of course* will arise at once as to whether this man does not have a very striking and undue susceptibilityto lead* This can be answered in-general by saying - that it is very strange that several hundred other men who have had much more exposure do not present us with a single case of any signs or synp- toms of lead poisoning* , . - .... -. 1 ; :| Secondly, there are certain things i n ,the clinical picture of this case which are not at all typical of lead poisoning in spite of reports to the contrary* He did;hot have a lead line and in my opinion has never Peg 3 Mr. E* W. Webb Kotebef* 10,1926 had lead liae : i all |^bability batts^stlie history of these cases uniformly shows that a leadline, If existing at all, persists over a period of.months rather than a few short weeks* He did not have stippling in his blood and according to the report of one of hjjps physicians has never had# Then again it is not characteristic of lead neuroses to disappear so.rapidly, they.ordinarily persist for many months and show increase in severity for some.time rather.than a decrease* Then again the initial diarrhoea and the apparent intermittent fever are also a stumbling block In the diagnosis of lead poisoning* For these reasons I feel that it is necessary to proceed with all possible means to making a positive diagnosis* There are at least threipossibilities other than lead poisoning in the case of this man# The best of these, I think, is that of an infectious poly-nueritls, the cause of which might easily have arisen in several badly infected teeth* This posslbllit;; is supported to some extent by his having an elevation of temperature over apparently the greater part of his illness* Another possibility is that of hysteria which I am inclined to think is not very likely since this man shows no temperamental condition suggestive.of that state* Another possibility and a fAirly good one is that of a syphilitic infection of the spinal cord* Tills has been discouraged to some extent because of a negative blood examination, but can only be checked up by examination of his spinal fluid# One other possibility which is a remote one I think but which must never the less be taken into consideration is that of spinal cord lesion, which in this case would most probably be syringomyelia* It is necessary in arriving at a diagnosis to make a careful check and sys tematically rule out each one of these things before arriving at a diagno sis of lead poisoning, for there is no question from our experience that lead poisoning is the less likely diagnosis of any of those mentioned* How the above things, however, apparently have not been taken.into con sideration in the case of this man, largely because of what appeared to he in the minds of the doctors who saw him the significant history of lead exposure,{may I degress a moment at this point and point out to you that that is just exactly the condition which I fear may repeat it self frequently if we have a considerable portion of men of various kinds of ability in positions of partial responsibility in looking after men who are handling Ethyl fluid and Ethyl gasoline* The question now is as to how wo shall proceed to make a positive diag nosis on this .man* I have begun this by requesting that several examina tions bo made# I have asked for an xray examination of the chest and of the .spinal column and for a considerable quantity of urine and feces to be mailed into our laboratory for analysis# It is difficult for me t get more information than this* . . Three possibilities present themselves* The first of these is to report this matter immediately to Doctor Leake asking him to obtain a neurologist whom we both agree to be perfectly satisfactory in making a diagnosis, and to go with him to Cannonsburg ,to see this man and to make what further examinations are necessary in order to establish a diagnosis* As a matter of fact, Doctor Wright of Pittsburgh would be a satisfactory man for this thing in my opinion* The second possibility would bo to write to Doctor Wright himself pointing out the extremely insignificant exposure to lead which this man has had, and suggest tact- . jtf" I ' ^ag if *1 ' ' " " ' '' November 10,1926* ' Mr* E* W*:Webb* '. fully the possibility of other diagnoses* suggesting to him that-at our expense he go to whatever trouble is necessary in order to sys tematically rule out the various possibilities and to fasten upon one of these as the diagnosis* The-third'.possibility is to get this man into a hospital either in Pittsburgh or get him to Cincinnati There it would be possible to obtain such information and to make such ob servations as would clinch the diagnosis one way or the other* How for obvious reasons I do not say that this is not lead poisoning, nor do I have any bias whatsoever in the matter* if however it is lead poisoning as it might be by stretching the imagination to the utmost, it is best t^at I know It and that you know it* The main thing* how ever, is to make a diagnosis if it can be made* If you have any sug gestion to offer as to any other method of procedure, pleas let me know at once. I trust that this will acquaint you completely with the situation and that you will not have any undue alarm from it. - With kindest regards. Very truly yours, RAKjOJ