Document Ra1qOJRdDwrR02wk5X8BqD8z7

vatlt# male. . Age k$ .years*. ?*srricU ^caratlon Prior to flay of 191^0 this m m marked for llf. consecutive years as a spray painter in the ^illlaatsburg Chair company* 1 did -finishing on' all kinds of furniture ' using stain, filler, varnish, enamel ana lacquer. Spray' painting was done without using a mask of any sort* It was don in a small booth, with a ventilator fan in the hack of the booth* He never worked with any one type of spray agent- for more. than a short period of time and was usually exposed to several of them in any given day# For that reason he is unaware that any specific one might have injured him* As far as he knows there was no change in the- nafcuye of th ingredients used in his spray paint with the exception that about 2-1/2 years ago what he calls a synthetic enamel was added to the araamentarim of finishing agents* Be is unaware that this might have affected him any differently than any of the other agents which he had used* up until 2 years go he had not lost one fay of work and had continued 3exactly- the same kind of.'work for l{j. years# Because of illness- ho was laid up faff weeks during the month of:Fay ansi when ho cam hack m work in Juno he was put on a new job In she wrapping room where he worked until September, z.hQti. quit work entirely because of disability* There are several men working at the -spray painting job; some of whom have worked nearly as long as ho has# None has loot any time fros*. this .occupation* There is 'one man, a Sr, hranvilla smith, whom the patient believes to be ill with'a similar disorder to His own, but who has not quit work because of it, " resent Illness About 2 years ago this 'man was rather suddenly seised with a ``spell51 which he doserib.es as extreme- weakness associated with sweating, dizziness, Intense nausea and severe colicky pain in the abdomen* 11110 was associated with severe constipation* Ha was laid up in bed for about a week whore h was treated by his private physician. His private physician thought that he had"naphtha poisoning at that time. After a period of one week ho was able to go back to work# He worked for a period of J or 4. months during which his only complaint was mild weakness and continued constipation* After about l\. months he had a similar attack which laid hiss up for 3 or I4. days# cine that time and until Fay of X9M*:h had several similar such attacks 2 ( d o e s n *t know e x a c t ly how m an y) wh ich v a r ie d l i t t l e In ch a r a cte r w ith th e e xce p tio n th a t b esid es h a vin g th e ^ sym ptom s a b o ve d e s c r ib e d t h e y now becam e a s s o c i a t e d a i t h r a t h e r sever e fr o n t a l an d b item p oral h ead acn e and con e a ch in g p a in s in th e bon es and J o in ts o f h is _le g s . Jn lp|||:: ; ||g|.||||^ ly; ;.and c o ia a p a e d w h ile a t w o r k * lie waa t a k e n home an d o u t t o b e d iJ" ^il| | ^liSS*':' ' 'p o f bq^ f e g -, ' f s i ' .ll.t fh h s is wa s s is e e b e c a u s e o f fcfo i n t e n s e o d o r ~ f c h ic s o l v e n t u p o n | ^!| ii| i| | . OThS . ''"; I aM^ g' a lgo h a d r a t r ls d .-.n o r s x l a * Th e c o l i c k y ; a im ? in t h e a b d om en w o u ld l a s t an ywh ere fr oja 1 /2 h ou r to 2 h ou r and th en d is a p p e a r f o l l o e **- c y g e n e r a l i s e d s o r e n e s s I n ch e a b d o m sn . forat im e s th e r e w o vli a ir .o ca r a t n e r s e ve r p a in in h i a krsse and V t i l i 'WieijiS-sppa^pispis palh- # b 'the -rasa of til neck with no characteristic raRdeilation., hi"3 time be was laic, up in bet. .iC-O\C - ic iv.proved very little that tine .s constipation V:as SO Intense that he had to have cathartics aIpsoat `ally sac ,;:is Ivon several enemas. hfeill. 1 li'0isio3:^X1. t 'Ip.g weight UE1C TpOIS.HSiy Until about 2 mouths ago haa lost io u o n a w * ha ..as now gained about b of it back* About the 1st of Jure r.e holt somewhat boiler ar<i caclded to ;jo back to work and ask hid eifiployer for a new job, which was &iven bin. Ko than, worked in the wrapping room for a oerioct of p con the ana curing this J months he had continued weight loss, frequent attacks of abdominal discomfort which trovr a little less in frequency, associated marked soreness and pains in his leys and _ profound weakness, be ceased work in .-^pfccraber of 1M.L0 largely because of profound, weakness, nervousness, abdominal discomfort and constipation. Associated with the illness in May and continuing to the present elms have been the -djdltlonal symptoms of incarjila v/lthout known reasons so far as 'the patient is concerned* There have teen no abnormal crearns* Thors has been increasing nervousness and marked sweating throughout the cay* fe never vomited* III stools h^|'tipper ^g;en:o^h^r thaainorsa&X in polqr and so. far as ho knows have not charged in caliber, there has:been no blse&ing from the teas, no cooJO with hemoptysis and no-'evidence of piiitiuifia. ' "" Hast history Me was born in Brown County and has lived there all of his life, As a child he had measles, chicken-pox, whooping cough and typhoid fever* Had slid influenza in I9 1-S, Mo operations, yo serious accident. Ko history of venereal disease, Maxim weight If? years ago was 100 lbs* Up .until last May he?averaged about 150 lbs* lie then lost to 155 1 September* In the last b weeks he has gained some of that weight back and I at- the present time at llf.0 Id s . harried in 1912. Has 2 boys. U f a bad on still-birth 9 yoaro ago. To visearrlages* v?lf living and well.* 'giving and well. Ibther died, of pneumonia at age 75 *'athej? was killed in an ecldent* Two brothers living 'and well. On slater died - cause unknown, ''o history of family tuberculosis oiabetea* oarotnoma.j heart -trouble, hypertension or insanity. aopial history Owns a email i^rocan house on a small farm. Lives with his wife and 2 boys. They have an outside toilet. 11 works a good deal in the garden during the. summertime, but ' has not been able to be out since his illness last spring* imolees moderately using a pipe or cigarettes, tfsed no alcoholic beverages at all in-the last year* had an occasional beer before'that, rrinks a very moderate amount of coffee; no tea* plat has always been adequate, but since the onset of his anorexia ha feels that he has not aten sufficiently. gyaterns history Head - frior to his present illness h had never had a headache* Since that time with each bout of abdominal discomfort and with weakness he has had bitemporal and frontal headache which is rather severe in character* It usually comes on in t h e s.ra, and disappears by evening* l:JAg - to trouble until about 6 months ago when he notice that no no longer could read as well as he could. " attributes this to bis increasing age. i-bt.Q. "hd, throat - Negative Ko history of frequent colds. ,r-onsils In. "ars - Kegativ* Teeth - Kad all teeth removed about 6 year ago because of marked pyorrhea* Has upper and lower plateaT Heck - negative. Uo history of goiter. , . Hegp.lra.torv. evetern - ho history of chronic cough, bronchitis or tuberculosis* Has experienced so?a shortness of oreath^on exertion either at work or about the house for the past 2 years. This has never been profound. Ho pains in the chest except as described under present illness, and these were rather vague in nature with no-specifio and no definite radiation. * Sine hay of 1914-0 has srienesa palpitation quit frequently, lion he lies down ' hfc-he feels a throbbing in each temple ana he is <unable j -- -- because of the loud beating o* He has had no peripheral edensa* 1 dyspnea of a vary M i d type aociated M t h restlessness than orthopnea* "tiers' has been np gastrointestinal svstea - Prior to the onset of his present Illness he was almost unaware of having., a C-,X# tract, Bis feowels mowed regularly without any medication of any sort. He ate well and did vigorous work both in the shop anti at homo* Since tfao onset of his present illness ha has had the above desorisen pains ano has had almost constant constipation* U believes t..ac the frequency or the attacks of pain and tit constipation have markeciy diminished since ust, summer, hut he still aa to take cathartics frequently, :.'-a has had no jaundice; he has had n blooey, tarry or lay colored stools, ".lien he has the attacks oi' abdominal pain tivy are severe and cramoirt^ in nature, and are generalized* ''here le no specific part of the abdomen which la sore affected than the rest. ;;t is not associated with distention. Ins last one was about a month ago. Genitourinary system - Five years ago he had a kidney stone which he passed spontaneously without a severe renal colic. Since that time he has had no f.u, symptoms except an occasional nocturia, fher has been no pain on urination; no difficulty in starting the stream; and no hematuria. Neuromuscular system - Except for pains in M s legs, particularly about the knee joints, and generalized weakness he has had no specific complaints referable to his neuro muscular system either during or previous to the present illness, Cental state This m n Is very cooperative though this type of examination, is new to him and he is somewhat frightened by It. '.is memory seers quite clear,- and I think that it is only recently that he has corns to the conclusion that he will not get well* He has thought that the illness wnich . he had- was due to M s occupation, because his doctor'told aim 3 0 , but until very recently there has been no doubt in hie --"irKi that he would be able to go back to work* be is reasonably Intelligent; has had no psychotic manifestations so far as I as able to determine Ever since&ay anp with Increasing severity tie has been unable to sleep at x.i^ht 'e -c r o w s no reason for it. ;u ays the pattern of his thoughts at right are quit chantsbis and never ox' a particularly He^TOcainr nature. 'Phan he --3 ok to sleep he sleeps soundly for a short period arc then awakens and has t . ; :! last:.going back tO' sleep agmln* ! Physical IS^gailnst.tlm Weight 139*1/2.Height 68* Tem p*- 98*2 Puls 08 Reap. 28 , S.P* on the right190/120|- on the left iSO/ll^' Grips right hOj left hO . This patient is a relatively well developed but poorly nourished white male of approximately 50 years of age who appears to be chranioally ill. His hair is ray. Etc skin is smooth, warm and extremely moist. Oe-.sweats profusely all the time and from every portion of his skin. Hoad Tb@ head is well formed, and there are no abnormalities. byes * The vision .is somewhat -poor. There "is- som presbyopia, The -pupils -are equal measuring ;; -.a In diameterana roast rapidly to ll*ht and accommodation, The extra ocular movements are norml There is no nystagmus or hippua. .'here is no exophthalmos or nophfchalsaos, yxaminatton of the fund I show the artsrica narrowed and tortuous. There is no exudate. The optic nerve head and maculae are' normal* Toe * negative. Tars ~ Both tympanic membranes are slightly reddened. Air conduction is less than bone conduction. Air conduction is reduced approximately ipOi. The obey does not lateralis, Mouth and throat * The mucous membranes appear somewhat pallid* The tongue Is normal. All. o f .the teeth have been replaced by artificial dentures* Hie tonsils are small and atrophic. The throat is negative, ?h gag reflex is present. ~ , Heck The neck is quite thin and mobile. There is no tracheal tug. I 'believe that there is a slight enlargement of the left lobe of the thyroid gland, L-Tmphatio system - There are a few lymph nodes in the submaxillary region on. both aides and a few in the inguinal region* No others. None of these is particularly remarkable Physical M s t js m is m t ih n (Cont, > . ghost Th chest is symmetrical and .-novas vsell* h u m ,- Th# -l^ags are .dear m auscultation and. percussion, 'he olaphragne novo sell* The breach sounds are normal* Heart - The heart is somewhat enlarged to the left* The maximal apical impulse is 9-1/2 to 10 &m from the aidsternal line in the 6tb interspace* the impulse is 'abnormally vigorous* "'he `rears sounds ar of normal Quality* Aa is greater than p*. "'here is a soft systolic appeal aurmur* the peripheral arteries are somewhat thickened hut not particularly tortuous* The.veins are negative. There is no evidence cf Increased venous pressure* Thar is no evidence of congestive heartfailure. Abdomen - She abdomen is soft and flat. There is very slight generalized tenderness* lie organs or masses are palpable. There are no hernias. The abdominal aorta is easily palpable and is not widened* Genitalia * T h e external genitalia are negative* In the right groin there is a small black pedunculated mole* FIoctal examination Sphincter normal. There arc a few external -and internal hemorrhoids which are not painful* The prostate is enlarged* Soth lateral lobes are enlarged and irregular* They are non-tender *. and not unusually hard. The seminal vesicles are negative. - Extremities - Tile extremities are. ell formed* The arches of the feet are somewhat flattened. There seems to bo a &iieralias, muscular weakness which is not specific in any ^roup* There is no deformity o f the bones or joints. To tenderness* Bade - The spine is straight* There is a moderate degree of tenderness in the right costovertebral angle*.- The kidneys are. not palpable. curlogical examination Cranial nerves 1, Begafeiv 2# _Negative . 5* 4 * 6, Negative 7* 'hisoles of expression are normal* Taste on the anterior two-thirds of the tongue is present and normal, ' I ,, m Physical;; Ssamlmtlon,. (Cent) 5* Serrations about the fas are normal. Muscles of n&sticatinn appear to bo equal. 8* _ t...*4ext9$4 i,teii^. this is not ng*fi *** but conduction deafness..' reflexes are present, fast on the.'p0,m h*.th&hd "bi 'til tissue. in normal. 1! ae tongue protrudes In the slslln alo dsgr of trsnor. /gotor sysfcera ** fhere- la 'generalised muscular aimas-s. -boro la troor o1 t-h tanga,. of tha head, of ti..o ll;:ora ::c of fche fe-ot. 11 pf the doep tendn rai'lexes ap-pear imrtesly hyperactive. Thay ars all oresent. Thare ara no pathopLogical tendn re:larcos. Suporflol-al roficie o* tha abdomen av o -trormly active as wall. ITaore ia an unsustalaad. cataXlar ano ardil clprraa.i Babinskl* Oppenliaiffi an borden'aro negativo. Hoffptan negativo, bscala? teme is diainshed* Hoaborg and Kernlg negativo. sonaonr YStmn. . bero is no alteration of light temah* pinprick, vibration, ster.aogaosi or equilibrium. ' Sums?,ary of positive; findings . flier is evidence of arteriosclerosis both in the eyegrounds and in the larger peripheral arteries. Thera is evidence of hypertension and hypertrophy of the heart. There is a palpable hut slight enlargement of the left lob of the thyroid and associated with It one finds a generalised tremor* marked hyperactivity of all reflexes* warm* moist skin and general, muscular weakness, Thera is a moderate degree o f conduction deafness, there is a moderate diminution in visual acuity. There:, is a general appearance of a malnourished and chronically 111 tin, 1 has chronic: benign prostat.lb hypertrophy. .Laboratory data brine -' nlear, yellow. Acid. Sp. gr. l.OlO 'Albumin negative. Sugar negative, tediwent negative. . K 0016829 Labors toFy_datai,,(ConfeU Ss RBC li-,t6 3 0 ,ODO ?B0 90 50 Hb 10 1$ Differential? Polys, ?2#5 Band:, 3*5 Lymphs. l|.5 Monos 8 lesina, 0*5 B.M.B, -if. (good record) Blood cholesterol l60 mg % X-ray Chest plate shows some enlargement of the heart in the region of the left ventricle and a somewhat prominent aortic knob. Progress note After a night*a rest the physical examination is unchanged except that there is rapoh less evidence of sweating and tremor. The reflexes are still markedly hyperactive, , Siacussion The nature of this man's illness cannot he determined at this time# with assurance because of the disappearance of the physical and laboratory evidence which may have been presents last May, That it was occupational in origin seems reasonably certain from the history* The extreme hyperroflexia, and the autonomic imbalance, while due possibly to hyperthyroidism may well be residua of his previous intoxi cation, The role of hyper thyroid!sm may be tested therapeu tically by administering Dugol* Solution, Gfet. XV tid for two weeks and his physician has been so advised. The intoxication may have been due to load absorption* and this seems likely from the clinical picture, It may have been due to severe closure to lacquer solvents, which* in our experience* can produce various disturbance of the nervous system. K E 00168-30 Associated, and probably unrelated abnormalities are present in the form of hypertension, moderate cardiac hyper trophy without evidences of failure, benign proatatic hyper trophy': 'diminished audi tbry Cconduction)., and visual, acuity. Despite the eardio-vascular abnormalities, it would seem that this man would improve considerably under proper therapy, and that he could engage In light restricted activity for several years to come. Suggested therapy consists of inducing pin in weight and improved nutrition by increasing the diet and augmenting it with vitamin. Sight exercise (walking) out of doors should be encouraged, thereby lessening the need for cathartics and promoting restful sleep. The use of Lugol *s Solution will determine whether or not such therapy will prove beneficial. A thorough urological study, some months hence, is indicated to determine the degree, if any, of renal damage, and further therapy, or the desirability of surgical intervention will be indicated by the results. , HAS:Is Robert A. Kehos, 1I.D. Kettering laboratory College of Medicine Eden Avenue Cincinnati, Ohio H E 5^ 0 1 6 8 3 1