Document OzryJo9N4mpR2nvV7axV9Yr41

'.V.*/:* y*** " '--*.** . ?';? ' .* - ' . .' . - r ^ V JV* /v ^^n-;^vwv ^rr.*- ,*:. - . V : * * ,..' j * . # "* ' * : yi'/V ' *. *;"* '.* <"*; , * * v * ". * * K E P O P . 7 p a t t t .v: t 5 T r o m m c ?:s a ? :t p *.. V.* s*- ;, ** m - ; r .C H Z M 3 C A I . C O M P A Q . NTTP.O. V .. V A . ' . ! D e c e rr.b e r S. 1 -.S . : ' CS*.wii L V -_= -: __ _ g g \ p p 5 g | r rr. ? -- %.'*--**7-- - ~ v* . " ' ` f *v`i- ---- -- . ' y ' - . . * crc*. s ' h - 3 u H d i n ^ 3 f r t h e a a i c s y v a l v e a n d p i p e c o n n e c t i o n * b l e w '*.;? ' - ^r. T ': '. ` ' ;?'` \ h " *.-- , ; i p - v . . "*.:*. ' ..< ," t h - . .* t h e < ~ t xc-cre i c m t T e d th r o u g h o u t the i n t e r i o r oi t h e - ;. b u lld in j i t vrcll as o v e r the ru rro u n d in j le r r a in and structure*.. The ' * . * . ch em icals em ploved in this autoclave operation v t r e tetrachlor obenuene, . . . .* . . rr ' *:/;. . . .. ^ *cxdt-- b y d r c r i c e a a c m e t h a n o l . A c c o r d i n g to th e h i s t o r y . s u p p l ie d b y t v o o i t h e o p e r a t o r s v b t a r e i n c l u d e d in t h is t r u e 7 , th e t e m p e r a . r u re* and p r e s s u r e v-ithin the au to clave r o s e v e r y r a p id ly and exceeded .. r e i t l y the re actio n conditions u su a lly a sso c ta te c v : t i t v . i 'ftperttisr.. The m a t e r ia l w hich wa* e je c te d d ro m the autoclave cove roc the in terio r : of the' b u i l d i n g . It '-a e s c r i b e d v a r i a b l y . a s a f in e b.lacX p o w d e r and a t h i c k , s t i c l r y . da rV 'V c v r . s u b s t a n c e . ELrr.pl o y r e s who d e v e l o p e d s y m p t o m s w e r e f i r s t c r p o s e d to this* m a t e r i a l vrithir. a f e w h o u r s ' a i t e r the a c c id e n t a n c up to th ree and o n e-h a 11 months io iJ owing tnc a ccid e n t. A c c o r d i n g t o thie p l a n t c h e m i s t s the r e s i d u e l a s . to d a t e , b e e n a m i d c s t t l i e d . T h e o r e t i c a l l y it is p r o b a b l e that the rr--t e r i a l i s a p o l y m e r c l ar. h a l o * je n ilc d phenol. compound. F r o m r e p o r t s of the m en and data su bm itted to ut c o n c ern in g y ~zP i  &iijli lllilJ>jtMUtta4 .* *' v * * .?. <*iu. .'. n e c k which w a.*.accom panied by difficulty In b reath in g . He v a i'lrck lc-d axain 1 * %* in tra v e n o u s in je c tio n s .' Since .his Ja st b o rp ita liio tio n th e re . .. .. '. tv: .* .h.e m t>o ? c c c. ? T. c. n .c c.t .c f. t.h p. r a. c i o o r c e r v j c a j rp a i n . - h e d o t * h o v e an-* . . *` Sjr-qg P = = 1 ?&* ** V.-'-. ' *. - ?* .. . . ' o c c a s i o n a l - d u l l i c b e i n t h e r i g h t p o p l i t e a l do*s-a.v-J-Je c o m p l x i n s of i n r e m n t a ' . -.r :; J-r-V J ` ... : * ^ |g |g _--- ^ ------- - . . . . t _ . ; , ....... *: *. . * . . . . . . .' . i n s t a l l a t i o n i n v o l v e d i n t h e M a r c h E, 19*49 e x p l o s i o n . H i s w o r k r e q u i r e d S . . 52 h im to b u m and kuif flanges re tu rn e d fro m salvage. rf** % .* ' ** *.." . *5` .* r A b o u t t h e s e c o n d w e e k i n . J u l y h e n o t i c e d i n e r u p t i o n on h i s ...........* ' ' *.: -f -'. ' .'..*4' ' ... * ' u p p e r lip , p a in in the h a c k , lo w e r e x tr e m itie s and c h e s t; At th is tim e h e - d e v e lo p e d a n i n f e c t e d t h r o a t w h i c h w a s t r e a t e d with p e n i c i l l i n and s u l f o n a m i d e s a n c wa s off f r o m w o r k f o r t w o w e e k s . It w a s a t t h is t i m e th a t he dins: ob serv ed that a skin eruption had developed cn his face, . . b u tto c k s, hack,* sh o u ld e rs and n e c k . ' 1 . .Following f .* * August feeling wt u t two week la y ? - he returned to work in early # * lig h th e a d e d . It w as re c o m m e n d e d by his . e m p l o y e r th a t h e r e . c o n tin u e w o r k in g b e c a u s e of h is sk in c o n c :t:c r.. ` T he skin eruption has b e c o m e 'g ra d u a lly m ore severe durtr.g the past Z ^ . m onths. * ... * * . * ** D u r i n g t he m i d J u l y c p i s o d e . h c a l s o d e ve l o p e d . R U Q t e n d e r n e s s . X - r a y stu d ie s ci the s to m a c h and g a llb la d d e r were re a d a* n e g ativ e. The ten d ern ess has p e r s is te d to the present. M i.: | *: * - , }.-f * * .. . ." :' | .. _4 / `* ^ S g a .-Jr.,- * . - ' - *?*-; ' V-* ** ' . : .*.*; * ! : bf both lo w e r le g s to z i p i o f t e e s , TvcmbneisTcf-both' Seel'. nervousness,".-' W -.r.- -.-.;y, .......... * ,,:. . v .V * ' . . '.. * ' in s em a.ia,-;fa tig u e ... .Y - '*"*'' ; ` '. '' -. !*'"* " * %* \ 'T h r o e y e a r s a g o w h ile w o rk in g in B ld g . <1 th e p a tie n t developed *. s c a lin g , p r u r i t i c e ru p tio n on h i t leg s/- h i n d s ,: la c e t a d w i i tr e a te d effectively*by a local p h y sician . \ * ' " "* -. . . *' ** */< *m * \ * # w. - : . *; All "four pati en ti "were seca by-several derm atoJejic consultants >o m ede the d iagnosis of c h lo ra en c . No definite diagnosis has been *CCe*t-ad f o r ' t h e i r on- c u rin e o u t sy m p to m s by previous- c o n su lta n ts r *. * Cutaneous fiadinr .. . * * la the fc.J c a se s'rtu d ie d the skin lesio n s followed, m ore c r ie s * . 0 * - * * an identical rnerp.'wogic p a tte m - The essential lesions are comedones 1 ' a n d -s m a ll y e llo w is h `c y s ts . T h e y involve in each c a s e th e skin of the f a c e , ( s e e k , s h o u l d e r * ,- t i p p e r e x t r e m i t i e s , b a c k , b u t t o c k s . I n - to m e i n s t a n c e s the abdom en, penis, .crotum andthigb* a re involved, la'two cases w h e r e i h e f a c e "is hea v ily l a d e n with c y s ts the pin n ae and lo b e s of the e a r * an d the u p p e r l i d s a r e a l s o i n c l u d e d . In. only one of the fo u r c a s e s w *s a m ild >.yperp:gm cniat>on of the exposed a r r a s noted. S c a tte re d am ong the > . corned once and cy*U axe ery th em ato u s papules, 'nodules. puctuJpi. xnC- V:. . .. . . reaction.,.; . Pundi* copie * saarrou* to -- . ' / .. t,ouooims . Mt3 ..* . . * . ' :-" T*i I?=5s*- r; -;. - . - . o n e - * ; - e r n e * ' . .... * * .'if * - **?*=* ' ' ZP a^ rr ^u s ;`]ut . P ar em m s V.,3 t a fv e 'i* " i' ' r>ev. n . * . !' n o rm ti norm al. norm al . ti ` ^ * r ` . ` , .* 41 `.Teeth*. . * Throat . KecX I-ym phatie* * l.`-enlarged to n Eils norm a] not enlarged; II not enlarged- V e*cl* n o rm a l norm al C h e s t ' B reasts Lungs * >lpan ' L iver Spleen - 'K id n e y s- ,* Abdomlna ] v il] O ther adbom ina] Penis- S c ro tu m Inguinal ring Xcctal - ` la rg e norm al clear n orm al* ** *.nol p a lp a b le M ,**- It clear norm al palpable not palp. W c B u rn ey c a r n o rm a l none none norm al i norm a] `n ii * . ..* *n n o n e .;dev, n . n o m a )] * n ii it .enlarged inguinal norm al ii t clear norm a] palpabJ e not palp. it normal n it it " none -. *. d e v . le f t * n o r m a l ' g S ^ S S i it , n ialse m, axillae end groin thickened* tortuous norm al it c le a r' norm al 7- p a lp a b le : not palp. . ii . . normal* ii it . it it L c/t pro:a< . tic lobe enlarged - fc.y > - ' - / f e * v T r d a i .'..:: --* * A * * '" .r` *;': ' ! ; ' -The c iisic a p a t i t i ojita-l iind:=E* d J-S-horatory ata are cernita rtsed is b eielo v-isE table : ` .* * -* n -* '*'*"* " *"" v,^ IS ? -W illard Sit-vJ p >fartgy v e ^ ^ ^ ^ yTijy ^ v ?- d1 ^ 2 * * < .* S L ? i " ' 5 -2^ ; / - y - v' 6 .5 x 200^ . ; k'T^T-'-' t r, *'? -* . yr--'* i a % s f o = Vij5 y y '<'.* "%*- ' ' w ' r , " . ^'r?7 v-^.-v.'-- f j f e s f e i S t ^ v 3 s2Sffi%*= S o >*-rO C.%-'C*iT*.-*..-*. b e .; j fc ^** ^.'r. . . -(217 (240 . 290 *- a s s : . - *:: 2 0 5 '^50:-- *: ^ ;9 0 6 - (W -- 6 . (4 ** 6.5 r4.-3-'-` 4 .2 ;a :^ 7 *.2.4 V*3'1 . 0 ' 7 9 .C , . s o . ,,.-:;..;4 2 "'7 .:'_. . 60 / :0 / ^ . ;. v -7 ' o '. - 0' 5- " :V ` 4 4. * 0.) 0.5 . 61 * 0.2 * * p. 6 54 * 4 .V 2 . o.'.i 0.6 5$ 2 .9 *- BMK -6 v /U r in e i n c r : * r .i c fv'.sht'.c ** SS * C h c c t X - r a y - no: a b n o rm a l fo r ape ( ill sicr.). 5 - 1 6 <23 b X - r a y a b d o m e n - no: abnorm al io r a^ e (oil m en). '.'- 3 1 o d .K ahn - n e c a l t v e ' o n a l l - m e n . . ' ' P S P Ov. e x c r e t i o n in 2 h r . : -erjsm-< - lo b e lia - 0 . 65 jlobel;:: C.a^ . / > x io s u lin 0. 95: Z X C > le i: oaric deviation;' m y o c a rd ia l an v a; .' ' . * N o r m a l n o t o v e r 150." . 'f U r i n a r y p l u c u r o n a i c e x c r e t i o n : M c C 120 tt. ; . / i . . ' ^ 2.1 / ^ m j . /-* S ^C^O^mp. / I . (N orm al m ean 115. K an jr.m ay be up to 100.1 .**' ---- ' - S p c c i i i c c r a v i t y r e r y h i p h . .* 5SS . a n d *thc l o l l i d e s a b c m a c l v c s . , M a n y o f t h e b r i i i c e s c i - t h e f o l l i c l e s ' l i n d x r e p lti g e d ^ .`S i r i l l . r ccJluli.r2-ccail*ectioas v c o<6tcr>*cd in focal p e riv a sc u la r ih c t..- ". ' . *** * T i c i n t a c t s e b a c e o u s - a c i n i r e v e a l s , n o r m a l d i s t r i b u t i o n . ... -hi l i p i d d e m e r i t s : . t r i g l y c e r i d e s , p h o s p h o lip id and c h o l e s t e r o l . .- T h e r e i s i s u g g e s t i o n th a : t h e r e m a y he m o r e f r e e c h o l e s t e r o l t h e n _ in the n o rm al sebaceous cell. . 'T h e ccm edonal plugs a re 'a ls o seen to contain trig ly c e rid e s ,, c h o le ste ro l ', phospholipids and keratin. . . .- . . 2) Cy> s . Vrjthin the d e rm is a r e m o d era te siued cy stic . t r u c r e r e s whose w i l l s c o n s is t'o f fa tte n e d - e p id e r m a l eell.s of the p r i c k l e c e l l t y p e and the c o n t e n t s e w h ic h w ith s p e c i a l s t a i n s r e v e a l ~ rnall am ounts o ' lipid su b sta n ce s: neutral /at and phospholipid; Ur^-c a m o u n ts of combined ch olesterol and perhaps fre e cholesterol a nd k e r a t i n / In s o m e i n s t a n c e s the n e c k of th e c y s t s arc- v js u a J ia e tl . w i t h .a p l u g g e d p a s s a g e w a y to t h e s u r f a c e o ' ih_r r p i d e r m i s . _ j j p p q s g ITZI- S& A is V * . ' . * :^ - * 'S o m e t p c cirr>cn* ^ e r e s e c t i o n e d to o u p e r i i c i i l l y >-->d e v a i u i - r` ' r^.-.y`t i o n o i t h e i r ^ p a t h c O o f c x h a j i g o * have to iu rtb t? sectioning. T he com edones- and cyst conical i r e to be eackrniaed /o r trich l orphcnol . ^ b e r i .1 s u i t a b l e a n a l y t i c a l m e t h o d `b e c o m e J i v i i b l e . P e r ip h e r a l N e rv e B io p s y .. , . ( M r , J o h n H u r l e v ) ' Stained P 7 A, several sm all subcutaneous nerves ir e e c a mil i s c r o <4 e c t io n end tb e l a r g e r n e r v e sho>*.Ti i s the H 4 i u a ls o d e m o n s tra te d . T h e se n e r v e s sho*.1 m a rk ed diiiu se in c re a s e in coll c gen-throughout th eir stru ctu res* nth x lijb t in c re a s e in ce llu lx rtty b u r th e re is no evidence oi in fla m m a to ry ce ll in filtratio n . -Mye-.-n ` sh e ath s in th ese n e rv e s a re scan ty and ap p ear to be sw ollen and * d i s i o r i c d i n . m a n y c a s e s . S o m e oi th'c d e e p e r b lo o d v Cs s e i s - a p p e a r t o ' s * _ f b e w i i b r o o . - t l i i e k . n l n s of t h e i r U ' r * `>> , e m c ei ,h* ' w m l n . . The 'c h . n j . i in the n 'c r-c . e re e o n ifrm .d by B i c H c W k y . ) .rss.n.hFgra i fr-JWy .r. ^ ; i .V2^rs*;.- .^r.^ *!iiil'riT > i r T M r o v t m e t ^ V i t ` c|C1 a n n h a h . . T h e r e vva* j J jo xrV ;cd n p t o m i i i r x_.hi_____ i __ *~_i-a'll'. ,j _- i> -r'-r: JJ'''c--r-T''**',v . I * --v>>>*>->*. & k r a i c s lccts r u y J c s t i f y b c d ia g n o s is I c h lo ra c n c .h ttj^ e re r-Is'-iin le ., " w- .x u L ^ - ^ g r - -- ` -- -; iS a .a y J. t n d o r m a t i c r . r c p o ' n c d c o n c e r ^ i a * m e t a b o l i c Jig s y s t e m i c ':" . \.Tl_- C C S l i J O C U t e d >**itii I e r a c h c . V l a t h e c x e x b e r e m , r e p o r t e d m etabolic ^ - tad system ic ._______m a n i f e s t a t i o n s o t h e r than the s k in t r e ____________ ____________ ________________ p ro rnin ^ .; _ * la the c a se s ht r -a rep o rted m etabolic and system ic 4 m an ifestation s other tl the skin w ere prom inent. T h e ir c o u r s e to date s u jjfe s t s that th e re .w ill pro b ab ly be slo w im p ro v e m e n t in *U m anifestation-w ith -u U im ate complete^ r e c o v e r y . ' T h r e e o f the "men h a v e a l r e a d y r e c o v e r e d f r o m s )*m p to,r...s of p e rip h e ra l n eu ro p a th y . The sk in s of m ost of the men have , i --'.p r o v e d , and m a y b e e x p e c t e d to c o n tin u e to i m p r o v e r a p i d l y u n d e r |t 5*; . V r^-w. ` * i>yricnic*c-re;^'iici> i r t c i r o n i r r i t a n t A t n b r p L c r e ( , a * t' : r , : . :,.; . , . r . ...... . - . . * \ ? m . I*. A t c , ) * .D .( . A . C . P . - . . . - '</' '' ''* y.'- \ ;-;. . v rV .v ' . : ;.^ & ^ V c r n b r S, 1 ^ 9 Js.Ayrnor> -r\. S u c k n d ,. V .. S ta li D crrrv ato lo jiit -5 '" ; (V. .**. .. *\.,. V ; V " '