Document byqM9bVVgQdNOVD6X8VRRbxwk

Ja n u a ry 15# 1938 C o n tin e n ta l C a s u a lty Company Chicago* I l l i n o i s Re: c ase of A t t e n t i o n : Mr. C, V?, S a g e h o rn Dear S ir:- A fter some d is c u s s io n of various asp ects of the case of deceased* i t Is apparent th a t th ere are eerusm l^ypes of In fo r m ation n ecessary in order to a rriv e a t a conclusion as to the background of the i ll n e s s and d eath of th is man. F irs t# w ith referen ce to the p o s s ib ility of exposure of the deceased to c e rta in to x ic su b sta n c e s* I t Is w ell known th a t when carbon te tr a c h lo r id e is thrown in to a f i r e o r exposed to high tem p eratu res through c o n ta ct w ith heated su rfa c e s of m etal* or o th er non-com bustible m aterials# th a t th e re is a f a ir ly rap id decom position of th is m a te ria l whereby v a ria b le q u a n titie s of h y d ro ch lo ric acid a re . produced*. Under c e rta in co nditions phosgene# a v e ry to x ic g a s , i s produced a ls o In v a ria b le am ount. The q u a n titie s o f th e se d i f f e r e n t m a te ria ls produced in u n it tim e y a ry w ith th e tem perature# w ith the su rfa ce area of the heated m a te ria l, w ith the nature of the f ir e ( th a t is# w hether i t is fre e burning or w hether i t i s b u rn in g in th e p resen c e of In ad e q u ate oxygen )* and w ith the q u a n tity of carbon te tra c h lo rid e a v ailab le# . O bviously a lso th e c o n c e n tra tio n of th e se m a te ria ls which can , he found In th e atm osphere of an en clo sed space w ill depend upon th e volume o f th a t e n c lo se d sp a c e . In th is in stan ce a fam eless f ir e is reputed to have continued fo r from tw enty to tw en ty -fiv e m in u tes. In o rd er to determ ine th e d e g re e o f h a z a r d o f p e rs o n s who may h a v e b e e n in c o n ta c t w ith t h i s f i r e # one sh o u ld know th e a p p ro x im a te q u a n t i t y of the carbon te tra c h lo rid e used# the approxim ate d u ratio n o f th e f i r e # as much as p o s s ib le about th e te m p e ra tu re s produced# and th e e x te n t pf th e iva ted su rfa c e exposed to c a rb o n t e t r a c h l o r i d e # On s h o u ld a l s o know th e s i z e o f th e room and w h eth er o r n o t any v e n fc il tio n was p r e s e n t, o r w h e th er I t was n e c e s s a ry to open d o o rs and windows to allow the escape of i r r i t a t i n g fumes e ith e r during or a f te r th e f i r e . I t may be t h a t i t w i ' ' n o t be p o s s ib le to d e te rm in e a l l of th ese fa c ts # b u t as com plete d e ta ile d knowledge as Is p o s s ib le should be o b ta in e d . W ith re fe re n c e to the p resence o f s i g n i f i c a n t q u a n t i t i e s o f i r r i t a t i n g fumes in th e room# i t should be p o ss ib le to o b ta in adequate in fo rm a tio n from a n y o t h e r p r e s o n s who may h a v e b e en In th e room a t th e tim e - 2 ' o f th e f i r e * o r who may h av e g iv e s a s s i s t a n c e in ex tin g u is h in g th e f i r e . I f th e s e men d id n o t n o tic e h ig h ly i r r i t a t i n g vapors and i f they had no d i f f i c u l t y subsequehfcly, one can r e s t assu red th a t the q u a n titie s of e ith e r carbon te tra c h lo rid e , hyd ro ch lo ric acid or phosgene were s u b s ta n tia lly in s ig n if ic a n t. S e c o n d , th e n a tu r e o f Mr 4SH BK M H illn e s s should he determ ined as a c c u ra te ly as ^ fS s fe T b b y a c a re fu l exam ination of the com plete record of the h o sp ita l and every item of recorded inform ation should be examined c a r e f u lly in o rd e r to d eterm in e w hether o r n o t h is i l l n e s s wa3 o f any c h a r a c t e r i s t i c t y p e . The p resu m p tio n from th e m ea.-er d e t a i l s s u p p l i e d to me was. th a t th is was an acute In fe c tio u s type o f n e p h r itis to which e v ery o t h e r symptom and s ig n o f i l l n e s s was s e c o n d a ry . I f t h i s wa3 th e c a s e , th e o b s e r v a t i o n s made in th e h o s p i t a l , i f a d e q u a te ly re p o rte d and r e c o r d e d , sh o u ld show c l e a r l y . T here a r e two q u e s t io n s in v o lv e d h e r e , iVas th e m an' s illn e s s c h a ra c te ris tic of carbon te tra c h lo rid e in to x ic a tio n , h y d ro ch lo ric acid in to x ic a tio n , or phosgene p o isoning, or a com bination of th e se th re e ? Or was h is i l l n e s s e n t i r e l y d i f f e r e n t from what would be ex p ec te d in th e abovo p ic tu re and was i t c h a r a c t e r i s t i c of some o th e r wellknovm d is e a s e process? I f the a v a ila b le m edical data are inadequate to, answer th ese q u e stio n s, every e f f o r t m ust be made to o b ta in o th e r m e d ic a l d a ta and as a l a s t r e s o r t , I t may be n e c e s s a ry to have a n e c ro p sy perform ed so as to determ ine the p re c ise n a tu re of the i l l n e s s , and if .p o s s ib le , the cause of d e a th . I t must be recognized th a t th e n e c ro p sy may n o t g iv e e n ti r e l y s a t is f a c to r y e v id e n c e . On th e o t h e r hand i t i s v e r y l i k e l y to do so and i f s u ita b le in fo rm atio n is not otherw ise a v a ila b le , th is would seeia to be the only a d d itio n a l oroceijure th a t could provide the m ixsing in fo rm atio n . In c id e n ta lly i f a s s is ta n c e end ad v ice in the n a tte r of a necropsy is re q u ire d . D r, E rn e st Goodpasture a t V a n d erb ilt U n iv e rsity sh o u ld be a b le e i t h e r to p ro v id e th s e r v ic e o r to a d v is e as t o who m ig h t b e s t p e rfo rm t h i s work* _ The im p ressio n o f the w r ite r from th e In fo rm atio n given is th a t th e re was no cause o f in ju ry or of death a sso c ia te d w ith the exposure to the f i r e . , _S0?S quifce P ro b a b le t h a t th e man d ie d o f an a c u te in f e c tio u s n e p h r itis . Thl3 o p in io n is su p p o rte d by th e ap p aren t course of the illn e s s a3 m eagerly re p o rte d , and by the presen ce of p u s, blood and b a c te r ia in th e u rin e d u rin g the e n ti r e course o f th e i l l n e s s . T his would"' Su i r tiie r s u b s ta n t ia t e d i f th e h o s p i t a l r e c o rd showed t h a t she tem perature curve and the g e n e ra l c li n i c a l o ro g ress of t h is case was t h a t o f an a c u te i n f e c t i o u s n e p h r i t i s . Carbon t e t r a c h l o r i d e , on th e o th e r h an d , would be e x p e c te d to produce a c u te i n i t i a l symptoms w ith c e n t r a l nervous system d e p re s s io n - 3- and la tte r i r r i t a t i o n , a sso c ia te d w ith nausea* vom iting and 'perhaps such l i v e r d istu rb a n c e as ja u n d ic e , * h is process should bo w ithout fe v e r and.w ithout evidence of pus in th e u r in e . Exposure to fumes of h y d ro c h lo ric acid would w ith o u t e x c e p tio n produce an a c u te i r r i t a t i o n o f th e u p p e r r :e:s p i r a t ory t r a c t and o f th e lu fig s. U nder average co n ditions of endurable exposure to hydrochloric a c id , th is co n d itio n should be a t i ts w orst during th e f i r s t tw en ty -fo u r hours and should su b seq u en tly su b sid e w ith o u t g re a t d i f f i c u l t u n le s s an a c u te pulm onary edema were to d e v e lo p . In any c a se th e r e m ig h t be some d eg ree of b ro n c h itis follow ing a feu days a f te r the exposure, how ever i f d e a th were to occu r from th is c a u se , i t would c e r t a i n l y bo because of a pulm onary edema w hich would develop not l a t e r than fo rty -e ig h t hours a f te r the ex p o su re. Exposure to phosgene m ight produce v e r g ^ littie in th e way of i n i t i a l symptoms. In f a t a l c ase s phosgene poisoning of even in c ases of se rio u s in ju ry from phosgene, i t co u ld c o n f id e n tly be e x p e c te d t h a t some pulm onary edema would develop w ith in the f i r s t sev en ty -tw o h o u rs. I t s f a i l u r e t o do s o a t th l ,s tim e w ould p ro v e t h a t i t was n o t an im p o rta n t f a c t o r in th e d is e a s e p ro c e ss* 'Ihus in th e c ase of carbon t e t r a c h l o r i d e , one would e x p e c t to fin d the symptoms r e f e r r e d c h ie f ly to th e c e n t r a l nervous system and to the l i v e r , w hereas in h y d ro c h lo ric a c id and phosgene p o iso n in g th e symptoms would be p rim a r ily in the lu n g s . Tho c o m b in a tio n o f th e s e e x p o su re s w ould, t h e r e f o r e , produce prim ary in ju ry to th e lu n g s, the c e n tra l nervous system and th e l i v e r a s d i s t i n g u i s h e d from, p rim a ry e v id e n c e of d is e a s e o f th e k i d n e y s , h i t h th e s e ite m s 3n m in d , i t s h o u ld be p o s s ib le to make a d i f f e r e n t i a l d ia g n o s is from th e c l i n i c a l d a ta , i f such d a ta have bee-; p ro p e rly re c o rd e d . T his covers, the s itu a tio n as a d e q u a te ly as I am a b le t o do i t from thie a v a i l a b l e in fo rm a t i on Very tr u ly y o u rs, RAK*i s R o b e rt A. K ehoe, M.. KE" 0016844