Document ZJK82jomkNbO106Le7DKeNogO

voslt male* . Age 49. yn-ara.*. MarrlOd. Teour.atlon Prior to flay of 1940 this man worked for lif. consecutive years as a spray painter in the Williamsburg Chair company* ., Be did f iniehiug on all Binds of furniture using stain, filler, tarnish, enamel ana lacquer. Spray' painting was done without using a mask of any sort* It was done 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 then 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 on might have injured him* As- far as he knows there was no change in the- nature of th ingredients used In his spray paint with th exception that about 2-1/2 years ago what he calls a synthetic enamel was added to the armomentarim of finishing agents* E is unaware that this might have affected him any differently than any of the other agents which he had used* up until 2 years ago he had not lost on day of work and had continued exactly the same kind of.'work for 14 years*. Because of illness ho was laid up for 3 vsalcs during the month of: Fay ana when ho cam back to mark In June he was put on a new job in the wrapping, room where he worked until September, hh quit ork entirely because of disability. There are several men working at the spray painting job; tom of whom have worked nearly as long, as fee has* Toft. has lost any time froef this.occupation. There is'one man, a Sr, hranvlll 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 'ssan was rather* suddenly seised with m **spell!l which he doserlb.es as extreme- weakness associated with sweating, dlaslness. Intense nausea and severe colicky pain in the abdomen* Tills was associated with severe constipation* He was laid up in bed for about a week where he was treated by his private physician. His private physician thought that he had*naphtha poisoning at that time. After a period of one weak he was able to go back to work* He worked for a period of 3 or 4 months during which his only complaint -was mild weakness and continued constipation. After about 4 months he had a similar attack which laid him up for 3 or 4 days* Tinea that time and until Fay of 194 he had several similar such attacks 2 (doesn*t know exactly how many) which varied little In character with the exception that besides having the symptoms above described they now became associated aith rather severe frontal and bltemporal headacne and cone aching ; alns In the bones and joints of bls_ legs, In :ray, 3^;d), ho had. p similar attach, unusually severe and coi-i.ar.scd while ct work* he was taken houe and out to bed where hlr doctor cllagnosed naphtha ooxsoning This diagnosis was msec beccupo of the Intense odor ~f this solvent upon |iij||ii|i||.o-chfi. This t|f|fe1 th also had raerked rnorsria* The colicky ; ulna in the abdomen would last anywhere frers 1/2 hour to 2 hours and then disappear folio? c*l . iry ^ce-cr&llsed soreness In she abdonsn* .tometines there wo-jli also ue rattier severe pains in hi a ksss and upper Is^, Occasionally tt.crc .as sowe dost ualrt at the .rase of til neck with no characteristic radiation. ,rhl3 ;Ime he was laid up in bed .`t C- 0 \ 2 - nc iv. proved very little th.a = .s constipation V:as 3 0 Intense that he had to have cathartics almost `ally sac .-.-as Ivon several enemas*- -1 th this Illnea he ho jar. to loco L. ht can : r cm --ay until about 2 mouths ago liaa lost io oounv.s he ..as now gained about b of it back* About the 1st of Jure he holt somewhat y|4f|#a|:' ^jpd- to .jo back'to 'work; and ask hiC' employer for a new job, which was &ivsn hin. vu then, worked in the wrapping room for a oerioct of p conthe and curing this J .months he had continued weight loss, frequent attacks of abdominal discomfort which tro a littlo less in frequency, associated marked soreness and pains In his le,,.s and profound weakness, he ceased work In ..-.pfecraber of lyLo 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 additional symptoms ; of insoamla v/it bout known reasons so far as 'the patient is concerned* Taere have been no abnormal creams* There has been Increasing nervousness and marked sweating throughout tho cay* u'e never vomited, vis stool 'x|p^er hfipn: o^hdr than,, normal in color and so. far as ho knows have not changed in caliber, there Mi no bisecting "rom the gums, no cotgh tvi fch hemoptysis and no evidence of jt^iuitja. last history e was born In Brown County and has lived there all of his life. a child he had measles, chicken-pox. whooping cough and typhoid fever* Had sail'd influenza in 191-8, To operations. yo serious accident. Mo history of venereal disease, yaximuts weight If? years ago was 160 lbs* Up .until last bay he?averaged about 150 lbs* lie then lost to 155 in September, In the last b weeks he has gained some of that weight back and I at- the present time at llf.0 lbs. HZ . 0016824 Marital history in 1912. Has 2 boys. Mfe bad one still-birth 9 yoara ago. -10 T.iccarrla.v.es. v?lf living and well* Two boy living and well. S$S3L Mother died of pneumonia at age `75* r'atiher was killed in an accident. Two brothers living 'and well* One sister died -- cause unknown. !ko history of family tuberculosis, diabetes* carcinoma* heart - trouble, hypertension or insanity. Social history Owns a small k-room house on a small farm* hives with Ms wife and 2 boys. They have an outside toilet. 11 works a good deal in the garden during the. surges*bias, but has not been able to be out since his illness last spring* Tmokes moderately using a pipe or cigarettes, tfssd no alcoholic beverages at all in-the last year* had an occasional beer before that, rrinks a very moderate amount of coffee; no tea* Diet has always been adequate, but since the onset of Ms anorexia he feels that he has not eaten sufficiently. gyatema history Head - frlor 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 the a.ra* and disappears by evening. lyes - To trouble until about 6 months ago when he notice that, no no longer could read as well as he could. ,,e attributes this to his increasing age* 'ose and throat - Negative. Ko history of frequent colds, ^onsils In. ' ttrs - Negative* Teeth - Kad all teeth removed about 6 years ago because of marked pyorrhea* Has upper and lower plates. Hock - Negative. !Jo history of goiter. _ Respiratory. system - n o history of chronic cough, bronchitis or tuberculosis* Has experienced some shortness of breathy 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 specific and no definite radiation. 00168zr, Hardiovas<______________ .Sine : Fay of 1%W has experienced: naloitaticm a. uite freq. uently. . .hen he, lies dav,, m, at night -he Teels a throbbing in each temple ana ns is nmole to lie on the left side partly became of the loud beating of his heart when he doe so* If has had no peripheral edema* phone has been some nooturnal dyspnea of a very " lid type : '* ifed rptleSjfeti&s s.:than V anyth!Av, else* He has no orthopnea, ".bars has been no " ......................................... ' ' astrointestinal system - Prior to the onset of his present illness he was almost unaware of having., a H.X, tract* His bowels moved regularly without any medication of any sort* He ate well and did vigorous work, both in the shop and at homo* Since tho onset of his present illness he has had tho above desori c= pains ano ha a had almost constant const.J.pe.tion* Ho believes t..at the frequency of tho attacks of pain and tha constipation pave markeeiy diminished since ust, soaaer, but he still cos to tnk cathartics frequently* He has had no jaundice; he has had no blooey, tarry or eiay* colored stools, then he has the attacks of abdominal pain tivy are severe and cramoirt^ In nature, and are generalized* 'her Is no specific part of the abdomen which Is more affected than the rest. ft is not associated witfc'distention, fhs last one was about a month ago* renitourInary 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 x.n, symptoms except an occasional nocturia* flier has been no pain on urination; no difficulty in starting the stream; and no hematuria. neuromuscular system - Except for pains in Ms legs, particularly about the knee joints, and generalized weakness he has had no specific complaints referable to his neuro muscular system cither during or previous to the present illness. Fental state This mn is very cooperative though this type of examination is new to him and he is somewhat frightened by it* da memory seemo quite clear,- and 1 think that it la only recently that he has come to the conclusion that he wlli not get well* l%& has thought that the illness wnich . he had was due to Ills occupation, because his doctor'told nim so, but until very recently there has been no doubt in His Mnd: that he would be able to go back to work* 1 is reasonably intelligent; has had no psychotic manifestations so far as I am able to determine Ever sine-'Jay &np. with HE 0016826 increasing severity he has been unable to sleep at i.i^ht. 'e know:-: no reason f- it. ;u i>uys the pattern of his thoughts at nl^ht are quit cliantowatle and never of a "-articularly .trass tug nature. 'Phan i-e sVoeM to sleep be sleeps soundly for a short period and then awakens and has ureat difficulty In going back to sleep again. Weight 1J9*1/2. Height .-68** Temp.- 98*2 Puls 86 Reap. 28 B.P* on the right 190/1201 on the left XcIQ/llg Grips right .60.| left hO This patient is a relatively well developed but poorly nourished white male of approximately 50 years of age who appears to b& chronically ill. His hair is gray. Els skin Is smooth, warm and extremely moist. Oe-.sweats profusely all the time and from every portion of ills skin. Hoad -> Th@ head is well formed, and there are no abnormalities. Eyes * The vision is somewhat -poor. There "la- som presbyopia, "the -pupils - are equal measuring p .am in diameter' ana roast rapidly to ll*ht and accommodation, The extra ocular movements are norml There is no nystagmus or hippua. .'here is no exophthalmos or nophthalms. Examination of the rkmci show the arteries- narrowed and tortuous. There is no exudate. The optic- nerve head and maculae are' normal. Eo.? * Negative. 'wars ~ Both tympanic meaihranee are slightly reddened. Air conduction is less than toons conduction. Air conduction is reduced approximately i*Q. The ebey does not latoralias, !|outh and throat * The mucous membranes appear somewhat pallid. The tongue Is normal. All of the*teeth have been replaced by artificial dentures* Hie tonsils are small and atrophic. The throat is negative. The gag reflex is present. Beck - 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-ymohatio system - There are a few lymph nodes in the submaxillary region on.both sides and a few in the inguinal region* }io others. Kone of these is particularly remarkable. HE 0016827 Physical Examination {Confer> Chest - The chest is symmetrical and moves ;sell* kuitSfiB, * flie'liMSgs are clear tm auscultation and. percussion. i'ha claphrsgus move .sell* The hr each sounds are normal* Heart - The heart is somewhat enlarged to the left. The x.axiisa, 1 "apical impulse Is 9-1/2 to 10 cm from the mldsternal line in the 6tb interspace,* Che impulse is 's'normalXy vigorous* The. heart sounds-, are of normal Quality* A* is greater than *. "'here is a soft systolic apical murmur# The peripheral arteries are somewhat thickened hut not particularly tortuous, `he.veins are negative. There is no evidence of increased venous pressure* There is no evidence of con., o stive heartfailure. Abdomen ~ The abdomen is soft and flat. There is very slight generalized tenderness* j?o organs or masses are palpable. There are no hernias. The abdominal aorta is easily palpable and is not widened* Genitalia * The external genitalia are negative* In the right groin there is a small black pedunculated mole. Rectal examination Sphincter normal. There arc a few external - and internal hemorrhoids which are not painful* 'Ice prostate is enlarged* Noth lateral lobes are enlarged and Irregular* They are nonj-tender. and not unusually hard. The seminal vesicles are negative* Extremities * The extremities are. -well formed* The arches of the feet are somewhat flattened. There seens to be a &iiCralieu muscular weakness which is not specific in any .group* fhere is no deformity of the bones or joints. To tenderness* Back .* The spine is straight* There is a moderate degree of tenderness in the right costovertebral angle*- The kidneys are. not palpable* Neurological examination Cranial nerves 1* Negative 2# _Negative 5* if. 6, Negative 7* -?usolos of expression are normal* Taste on the anterior two-thirds of the tongue is present and normal. 0016828 Physical;; SaarnSnatton,. (Cent.) 5* Sensations about the face are normal. Muscles of nastiestlnn appear to bo equal. ft* rodueod,, ' I this is not i^r^e: .ess ''but; 0bftd^afcip;t > gag reflexes are present, 'fast on .tii' pght 10 :,:S!*ifcihd "of lbs tlfewS'lS; normal. .li* 12 . protrudes In the sl&lln ?*iih a s degree of tremor. /gotor system - There la 'generalised muscular weakness.' ibofo is tressor of tho tonga,. of the head, of the fin* ora oiii of the f&G-t* Ail of the deep fcendcspB reflexes appear imrfcodly hyperactive. They are all present. There are no pathological tendon reflercos. Superflolal r f1 uses of the abdomen ava e-tro^ely active as veil. Thor is an niisustainod patellar ana snkl clonus*. Babinski, oppenh&ia and, Gordon are negative. Hoffman negative. ' oscular tone is diminished. Roaberg and Kernlg negative. senaonr system. * There is no alteration of light touch* pinprick* vibration, sfcer.aogaosis or qullibrlusu ?iwmary of positive.findings There is evidence of arteriosclerosis both In the oyegrounds 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* wars* moist skin and general, muscular weakness. There is a moderate degree of conduction deafness. There is & moderate diminution in visual acuity. There:, is a general appearance of a malnourished and chronically ill wan* I has chronic: benign prostailb hypertrophy* .Laboratory data Urine . - clear* yellow. Acid. Sp gr. l.OlO -Albumin negative. Sugar negative, f,edlatent negative. K 0016829 H22& RBC 1**630,000 ffB&:;'8*0$& Hb 10J4 Differentials Polys. 72.5' Bands* 3*5 Lymphs. 155 Monoe 8 Eosins. 0*3 B.M.R. -I* (good record) Blood cholesterol l6Q 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* rest the physical examination is unchanged except that there is rauoh less evidence of sweating and tremor* The reflexes are still markedly hyperactive* Sisouseion 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 present,; last May* That it ms occupational in origin'seems reasonably certain from the history* The extreme hyperreflexia* and the autonomic imbalance, while due possibly to hyperthyroidism* may well be residua of his previous intoxi cation* The role of hyperthyroidism may be tested therapeu tically by administering Lugol's Solution, Gtt. XV tid for two weeks, and his physician has been so advised. The intoxication may have been due to lead absorption* and this seems likely from the clinical picture* It may have been due to severe exposure to lacquer solvents* which* in our experience* can produce various disturbances of the nervous system. HE 00168-30 Associated, and probably unrelated abnormalities are present In the fens of hypertension, moderate cardiac hyper trophy without evidences of failure, benign profitable, hyper trophy, diminished auditory (conduction) 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 gain In weight and improved nutrition by increasing the diet and augmenting it with vitamin, pglght exercise (walking) out of doors should be encouraged, thereby lessening the need for cathartics and promoting restful sleep* Tha 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* HASsis Robert A. itehoa, ii.D* Kettering Laboratory Collage of Medicine Eden Avenue Cincinnati, Ohio Kf 4016831