Document m04KG1Q2e59Dm3BYMO78oGx0

V REPORT ON A CLINICAL AND ENVIRONMENTAL SURVET MONSANTO CHEMICAL CO, NITRO, W, VA. The Kettering Laboratory in the Department of Preventive Medicine and Industrial Health College of Medicine University of Cincinnati Cincinnati, Ohio 1?53 ft* Section ' TABLE OF CONTENTS A* General objectives * PART Is CLINICAL SURVEY B. The clinical problem C. Subjects of clinical survey and methods D. Findings 1. Types of exposure 2. Pattern of symptoms 3. Case histories iu Clinical status of 36 persons surveyed in April, 1953 Interpretations 1. Clinical progress 2. Present symptoms and physical findings 3. Laboratory studies F. Individual clinical problems G Locker room E The Present and Future Appendix Table of laboratory findings Pathology report -- Hr. John Blackwell PART II. ENVIRONMENTAL SURVET Introduction Procedure Results Comments Summary Recommendations Appendix Table 1 Table 2 Figure 1 ligure 2 Concentrations of Organic Chloride and of Methyl Alcohol in the Atmosphere of Building 51 Concentrations of Organic Chloride and of 2,1;,5-T IXist in the Atmosphere of Building 3U Simplified Flow Chart of Operations in Building 51 Simplified Flow Chart of Operations in Building }>h 1 2 2 3 h 5 3U ho Uo U2 hh 50 51 5U 60 1 2 3 U 6 7 REPORT A Clinical and Hygienic Survey Monsanto Chemical Co. Nitro, W. Va. General objectives; 1. To determine the scope, extent and nature of the clinical problems which appeared to have resulted from the accident which occurred in Building No. ill in March of 19li9, as well as those which appear to have developed from a variety of operations concerned with the manufacture of 2,Lt,-T since October, 19h8. 2. To determine the types of exposure which resulted in the development of clinical symptoms. 3. To correlate the present clinical problems with results of the industrial hygiene survey. It. To recommend possible alterations which might be made to . improve present hygienic conditions. 5. To employ the clinical, laboratory and hygienic data as a basis for a fundamental investigation of the pathogenesis of "chloracne" in general and the toxicity and acncgcnicity of substances evolved in.2,l,5-T synthesis in particular, PART I - CLINICAL SURVEY B. The clinical problem According to records of the medical department of the company, there were 117 cases of "chloracne" and associated clinical conditions traceable to the ''accident" in Bldg, ILL, which occurred on March 8th, 19l9,% as described in some detail in the first clinical report of Doctors Ashe and Suskind, submitted on December 1919. Of the persons involved, 10 had left the employ of the company, 80 were regarded as recovered, 2l as having mildly, and 3 as having moderately severe illness, by the end of March, 1953 Ninety-- seven additional cases of "chloracne" and associated symptoms, according to the company's medical records, were believed to have originated from the regular operations in the production cf 2,1,5-T, which synthesis wa put into operation at the Nitro plant in the fall of 1916, By the end of March, 1953# 51 of the 97 cases were regarded as clear, 36 as mild and 3 as moderate in severity. Seven of this group had left the company since the onset. The total number of persons who developed symptoms referable to the combination of occupational conditions was 211. C. Subjects of clinical survey and methods Subjects were chosen to be representative cf the two major situations under investigation. The group of persons which was examined consisted of 11 affected workers involved in the accidental exposure, and 25 affected persons from the production operations concerned with the regular synthesis cf 2,1,5-T. The total number of workers examined was 36. All were -3- vhitc males. Each subject was interviewed by a qualified physician and questioned carefully regarding the onset and development cf the complaints, tho duration of symptoms, progression and/or regression of symptoms, and response to therapy. Each subject was questioned regarding the history of juvenile acne vulgaris* A detailed occupational history was obtained which included job status, duties, types of substances with which the subject worked prior to the suspected exposure, during the suspected operations, and at all other times up until the date of survey. A full description of hygienic measures employed, if any, during tho suspected exposure was obtained frem each subject. Following a complete systemic review, a complete physical exam ination was given to each man. In chosen..instances, hemograms were obtained, and urinalyses were done. Determinations cf urobilinogen (qualitative), urinary porphyrin, prothrombin activity, cephaIan flocculation, total lipids and total cholcst:rcl were / made when the severity of the symptoms and initial findings appeared to justify them. The present operations in Bldgs. Nos. 51 "*nd 3U were visits i to observe the workers cn the job, on two separate occasions (March 9, 195-> 2nd April 16, 1953). The locker room and washing facilities were also visited. D. Findings1. Types of exposure Among the 36 who were interviewed and examined, the follow!\g is the distribution cf types of exposure from which clinical symptoms ippcared to have developed: -b- _______ Type of exposure____________________________ 1) Accident in Bldg. No. hi 2) Regular operations, Bldg. No. 3h 3) Regular operations, Bldg. No. 51 b) Hauling 2,b,5-T 5) Maintenance of equipment, Bldgs. Nos. 51 and 3b 6) Combined exposures a) Bldgs. Nos . 3b and 51 b) Bldgs. No. bO (adjacent to Bldg. No. hi), No. b6 (for drying 2,h,5-T) and No. 3b c) Bldgs. Nos. 79, 16, 3b - grinding and drying d) Bldgs. Nos. b6 and 79, drying 2,h,5-T Total subjects Number of Workers 10 12 b 2 3 2 1 1 1 36 In addition to the above, according to the safety directors records, persons involved in laboratory work with "acncgenic" fractions, medical personnel who treated affected workers, persons "who visited the areas of exposure occasionally - c.g., safety director, also developed symptoms cf r,chlcracnc,l. 2. Pattern of symptoms From the histories which wero obtained from the 36 workers surveyed, it was apparent that the cutaneous symptoms in all except one developed prior to the other symptoms. The cutaneous manifestatiens were characterized by the appearance cf comedones, milia-likc cysts, papules, nodules, pustules and abscesses. The variation in extent and severity ranged from the appearance cf comedones on the cheeks and forehead in the very mild cases to a generalized eruption which usually consisted of all the types cf lesions designated above. From several weeks to two years after the cutaneous problem became apparent, other complaints which developed included severe aches in the lower extrem ities, especially tho calves and thighs, and in the shoulders, neck and lumbar area, together with excessive fatigue, irritability and nervousness, dyspnea and apparent loss or decrease in libido* Two of tho 36 subjects claimed that they developed an intolerance to cold* Although it was at our request that the most severe clinical problems in both groups were included among the subjects to be surveyed, it was apparent, too, that the severity of the syndrome which resulted from the accidental exposure was much greater than that of the symptoms developed in association with the operations for the production of 2,U,5-T. A distribution of the symptoms, past or present, among the 36 persons examined is shown below: Clinical Symptoms Number of Subjects Cutaneous lesions Fhtigue 35* : 21 Aches and pains 27 Dyspnea 9 Nervousness and irritability 17 Loss cr decrease cf libido 13 Vertigo h One subject complained of pains, fatigue and irritability, but never . developed acne* 3. Case histories The following arc* summaries of the pertinent facts from the medical histories of the patients who were examined: Roy Shank Age L18 Occupation - foreman lir. Shank was outside of Bldg. No. ill when the accident occurred on 0 -6- i March 8, 19h9. Five minutes following the explosion, ho was back In the building to supervise the cleanup. (He continued as the foreman of Bldg. No* hi until 1952.) Three months following tho incident, he became aware.ofcomedones on his face, following which, acncform lesions developed all ever his body. Many of the lesions became infected. He was treatod by a local derm atologist in 19U9 with peeling lotions without apparent improvement. Over a period of several years, the incidence of new lesions has decreased and now the only remaining cutaneous lesions are a few scattered comedones on the face. Approximately one year after the cutaneous lesions appeared, Mr. Shank developed severe aches in his lower legs and thighs, excessive fatigue, dyspnea, loss cf sexual interest, irritability, and mental depression. Sub sequently, aching sensations in infraclavicular and prestcrnal areas also developed. At one time, cramps in calves and portion of thighs ware so severe that the patic-nt had to soak his logs in a tub-of hot water "in erder to relax the muscles and get relief11. He also complained of cold intolerance. There has been noticeable regression cf all symptoms within the past year, and at present there are only occasional pains in infraclavicular and prestcrnal areas and excessive fatigue, Mr. Shank was reluctant to take time off because of his symptoms, but there were some mornings when his fatigue and pain were so severe that ho did not report for work, Kis total time lost was about 3--h months. In 1952, after having bcc-n the foreman cf Bldg. No. Ul for 6 years, he was transferred to another building. Frank Milan Age 35 Occupation - chemical operator Mr. Milan entered Bldg. No, hi fifteen minutes following the accident to clean up nthc mess". This was dene without benefit of protection. As a chemical operator in Bldg. No. hi, he worked in the building continuously for two years following the March, 19l*9> accident, Ihree weeks following this accident, he developed comedones and cysts on his face and exposed areas of hands and forearms. Six months following the appearance of the skin lesions, he developed aches in legs and shoulders, fatigue, and inertia. He expressed the comedones and cyst lesions himself# He was unable to work from June to December, 1950, because of the extreme fatigue and pains, 'When ho returned to work, he was transferred to another building# Improvement in clinical symptoms has been steady* since 1950, and at the present time his complaints consist of mild fatigue which becomes exaggerated on effort# Ralph Westphall Age 37 Occupation -- maintenance mechanic Three days following the accident, Mr, Westphall and another maintenance man installed new water lines in Bldg, lio# 1*1.* Subsequently, his work took him in and out of this building# In the spring of 1950, ho assisted in tearing out the affected autoclave from Eldg. No, 1*1. In May, 19U9, about seven weeks following the accident, cutaneous lesions were first noticed on the face and subsequently, they spread widely on many parts of the body. Comedones, nodules, cysts and abscesses appeared on the shoulders, back, buttocks, thighs, abdomen and genitalia. In early 1952, almost three years following the appearance of the cutaneous lesions, Mr, Westphall developed aches and pains in the back, thighs and lower legs, severe fatigue, loss of libido, dyspnea and pain in right upper quadrant. He also developed a sandy feeling in the eyes. For the past 18 months, he has had recurrent swellings in the neck and grein. In June, 1952, according to Mr. Westphall, the non-cutancous symptoms became so severe that he left his work and has not returned since. For the past year, he has. been under the care of a local physician for -8 - his cutaneous and systemic complaints, as well as of an ophthalmologist for his eye symptoms. Rrom March 29th through April 2nd, 1953# he and Mr. J. G. Steele were hospitalized for diagnostic study which included biopsy of . inguinal nodes. At the present time, the patient complains of severe fatigue throughout tho day, loss of initiative, dyspnea on exertion, R.U.Q* pain, decrease in libido, vertigo upon awakening each morning, and occasional pains in thighs and calves. The patient seemed particularly anxious to convince the examiner that he was very ill and also that his illness was similar to that of Mr. J, G. Steele? Jesse G, Steele Age hi Occupation * pipefitter It*. Steele was one of the four patients who were hospitalized in * Cincinnati for study in 19h5? He worked in Bldg, No. hi in June, 19U_9, and during the second week of July, 19k9, was assigned to salvaging pipe fittings which were originally part of the affected autoclave installation involved in the March, 19U9, accident. . He was required to clean the fittings b y burning and buffing them. According to this worker, a few days after the assignment, he noticed an eruption on his upper lip and developed pains in the back, lower extremities and chest. Several weeks later, following a throat infection, he observed the appearance of acneform lesions on his face,' back, ` shoulders and neck. When he was first examined b y us in 19U9, in addition to his severe cutaneous symptoms, he complained of fatigue, dyspnea, soreness in chest, insomnia, irritability and nervousness, decreased libido, numbness in his hands, sandy feeling in his eyes, and pains in shoulder, neck and lower extremities. He complained of continued soreness in the right upper quadrant. Six months later, when'he was examined again, the R.U.Q. soreness, eye symptoms, pains in legs and neck had decreased considerably, but persisted. His loss of libido, insomnia and nervousness had regressed completely. (For details of previous examinations and diagnostic studies, see reports of December, 19h9, and April, 19$0, by Doctors Asho and Suskind.) A liver biopsy, taken b y Dr. Asho in April, 19$Z, vjus reported as normal liver tissue. Mr, Steele has been under the continuous care of a local physician for his dermatologic and systemic complaints and is being treated b y an ophthalmologist for his eye symptoms. From March 29th to April 2nd, 1953, he vas hospitalized for further diagnostic study during which time a cutaneous lesion on the shoulder and an inguinal node were removed for pathological examination. Mr. Steele worked at light duty until about 10 months prior to the present survey. He has been away from work since that time. His total time lost from work as of April, 1953/ was 23 months. His present complaints consist of pains in the ncok and shoulders, "sandy feeling" in eyelids, fatigue, nervousness, recurrent swelling in groin and nock, soreness in R.TJ.Q. , and occasional vertigo. Mr. Steele*s complaints were clearly verbalized and presented without hesitation. The verbalization of his syinptoms as to their type, severity, and part of the body affected, was identical with that of Mr. Wostphall. John Selby Ago h2 Occupation - pump maintenance man On the day following tho autoclavo accident in Bldg. No. hi, Mr. Selby checked the pumps in that building. During several weeks following the accident, he was in the building many times. He also worked overtime as a pipefitter and overhauled the involved autoclave* A cutaneous eruption was noted several weeks after the accident end apparently increased in severity following his going down into the autoclave to remove the baffles. The skin lesions appeared first on the face and subsequently on the back, in the groin, on the penis, buttocks and arms. In May, l$ k 9 , the patient became ill, developed a persistently high fever, and was hospitalized for 13 days during which time he was treated with Aurco rnycin. The illness was diagnosed serologically as Rocky Mountain Spotted Fever* He convalesced from this illness for 10 weeks before returning to work. Threo months following the first appearance of the skin lesions, he developed aches and pains in the lower extremities and extreme fatigue. It is net possible to ascertain whether this occurred during his acute illness or subsequent to it. He also had frequent nightmares and his hands became nunib. One year later, according to the patient, he developed severe fatigue, pains in the chest, low back pain, loss of libido, cysts in palpebral conjunctivae, occasional depression and vertigo. The total time lost from work b y Mr. Selby exceeded 18 months* He returned to work the day he was examined, April 13, 1953. His present complaints include persistent fatigue, pains in legs and chest, occasional depression and recurrent vertigo* Paul VJjUpjrd Age 39 Occupation - chief chemical operator Mr. Willard was one of the group examined previously in October, 19h9, and April, 1950* (See reports of December, 19U9, and April, 1950.} He entered the building of the accident several hours following the explosion and subsequently assumed normal duties of chief operator.. Cutaneous symptoms were noted six weeks following the initial exposure. A rash developed initially on the right leg, subsequently on the other leg, and then on the face, neck and lower extremities. By the middle of August, the eruption became generalized and severe. The pain in the legs appeared about the same time as the- initial eruption, and by July became so severe that hospitalization was necessary. He also developed pains in the chest, back and nock, dyspnea, insomnia, loss of libido, and a burning sensation in tho eyes. Six months after ho was first examined b y us, he was markedly improved. The pains had subsided except for mild occasional aches in legs and some sub sternal pain. He complained of a chronic cough and mild dyspnea. He admitted quite freely in April, 19f?0, that he didn't want to work and would avoid it as long as possible. Since the last examination in 19^0, Mr. Willard has remained cut of the plant for about half of the time. On the occasions of his return, he has done light work. 'He has had no trouble with his skin since 1950* He does . complain of p r c s t e m a l aching, marked dyspnea on exertion, frequent heart palpitation, flushing, low1back pain, posterior cervical pain, recurrent vertigo, "sandy feeling11 in the eyes, and depression. : Tho patient has been treated b y numerous- physicians in this area. His family physician prescribed pills for his nervousness, another recommended leaving the valley as an answer to the problem, a third told the patient that he had heart* disease and "high blood pressure". He was told that he would have to bo very careful about his activities because of his heart disease. Mr. Willard says that he worries continuously about his health and especially his heart. Lonnie Hurley . Ago 31 Occupation -- helper in Bldg. Ho. hi at time of accident One week after the accident, -Mr. Hurley went to work in Bldg, lio, hi. He did net operate the 2,h,-T autoclave, but the synthesis cf "Maul" in which he was involved was housed in the same building. In May, 19h9> he reported his skin eruption to the plant medical department. The acneform lesions first appeared on the face, forearms and arms, and subsequently became generalized. One year following the appearance of the skin lesions, Mr. Hurley developed pains in calf muscles. He complained of painful twitch ing of these muscles, especially at night. He also developed nervousness and generalized weakness and fatigue. Ho has been under the care of a dermatologist for his cutaneous lesions. In 1951,.he visited the Cleveland Clinic for a diagnostic study and treatment. The patient had acne vulgaris as an adolescent, Betwoen July, 19U9, and April, 1951* he was away from his work for a total of Hi months. He has hadt no lost time since 1951* - Mr. Hurley feels he has improved steadily and at the present time his complaints consist of a skin eruption on the face, raid fatigue which increases on exertion, together with nervousness and occasional leg pains. Barry Rudna.ll Age 63 Occupation - salvage mechanic ; Following the accident in Bldg. No. hi, Mr ', Hudnall steamed and buffed gauges, valves and steam traps from the involved autoclave. According to his story, on March 18th, 19h9, 10 days following the accident, he was sent to a dermatologist for a severe eruption on his face, trunk and extrem ities. He continued his dermatologic therapy until February, 1953* A few months following the appearance of the skin lesions, ho developed pains in the lower extremities and hips, and fatigue on exertion. During the past few years, the patient has developed shortness of breath._ He .has gained 25 lbs. in the past four years. He denied any history of high blood pressure or swelling of tho ankles or legs. Mr. Hudnall complained vigorously about a multiplicity of symptoms which included pains in lower extremities and hips, fatigue, the loss of his teeth, which he claimed was due to "chloracno,11 poor appetite following work, and a persistent cutaneous eruption. Ho talked continuously throughout the examination, and it was the unanimous impression of the examining team that some of the descriptions of symptoms were well-seasoned with exaggeration. This man lost 60*weeks of work because of symptoms apparently related to the exposure, Harold Young Age 38 Occupation - head operator Mr. Young was first examined b y us in April, 1950. On the evening of the explosion, he returned to work and boiled out the autoclave with caustic and water. Four days later, he developed an erythematous rash on the face which was followed within several days by the appearance of a generalized acneform eruption. Several months after the skin lesions appeared, he developed pains in lower and upper extremities, shortness of breath, loss of libido, and a severe conjunctivitis. While under dermatologic therapy; the skin of the face and neck developed a dark, greyish-brown pigmentation which resulted in self-imposed isolation from his usual social activities and work. (For details of early clinical history and findings, see report of April, 1950.) According to the patient, there has been steady regression of all . symptoms and of the cutaneous involvement. The patient has been under the * care of a local dermatologist and ophthalmologist. In April, 1951* he visited a dermatologist in Philadelphia who prescribed a cream to reduce the pigmentation. Kr. Young lost a total of approximately one year because of his symptoms. He has not lost any time since 1951 The- patient was married recently to a woman younger* than himself, and also acquired a "drive-in11 restaurant which ho and his wife operate. These new interests, according to observers, have had an excellent effect on his morale and attitude toward his physical condition. At the present time, ho complains of continuous, mild fatigue, slight irritability, aching in his legs and feot, recurrent cysts in the conjunctivae,- and residual skin losions. J. A. Hurley Age 60 Occupation - chemical operator Mr. Hurley was one of the four patients hospitalized for study in Cincinnati in 19 U9. A few hours after the accident of March 8, 19U?, the patient visited % Bldg. No. Ijl, but did not work there until six weeks later when ho was assigned to wash down the autoclave. He wore a respirator, goggles, gloves, and coveralls on this occasion. Two weeks following this assignment, an acneform eruption appeared on his face and neck and subsequently became generalized. Six weeks following the assignment, he developed pains 7111 the right hip and both feet, irritability, fatigue and insomnia. His emotional disturbance was so severe that he was not able to work. For greater detail, see reports of 19l;9 and 1950. In October, 19U9, Mr* Hurley was found to have a loss of all modalities of sensation, except position, on the dorsolateral aspect of each foot. He complained of continuous numb ness in each foot. The report on a peripheral nerve biopsy in October, 199 was that "of peripheral neuropathy associated with destruction of the myelin sheath and nerve fibres and replacement by connective tissue..." Ke has continued as an operator in Bldg, No. ljl, and for the last two years has had no contact with the autoclave synthesis of sodium trichlor-- phcnatc. Since April, 1 9 $0, when ho was last examined, the patient has been back at work except for tim off for a herniorrhaphy. There has been continuous and steady regression of all skin lesions and non-cutanpous symptoms. Ho " i, f.: ( -1 5 - is under the care of a dermatologist for his skin lesions, and of an ophthalmologist for his conjunctival cysts. His present complaints consist of insomnia, pains in hips, thighs and feet, involuntary twitching of muscles of arms and legs, swelling of the eyelids, slight nervousness and fatiguo. Dewey Meadows Age 28 Occupation - chemical operator While there may bo some question as to the etiologic group with which Mr. Meadows should be classified, it is apparent that the symptoms began almost 1-1/2 years prior to his working in Bldg. No. 3U. At the time of the accident and until 19$Z, Mr. Meadows worked chiefly in Bldg. No. UO adjacent to Bldg, No. ljl. He does not recall a n y `exposure to the accident residue. He did work for a short while in Bldg. No. hi on a pipe gang (date not recalled). He also worked for just one day in Bldg. No. U6^ when 2,h,5-T was dried there. He has been working* in Bldg, No. 3h since March, 1553. The acneform eruption developed on his face, arms and back three years ago. About 18 months ago, he developed pains in the thighs and knees. This pain became'worse when he was carrying heavy objects such as a tool . bag. The eruption and pains have regressed considerably during the past year. His present conplaints consist of excessive fatigue, loss of vigor,, and a moderately active skin eruption. Donald Stover Age hZ Occupation - chemical operator, Bldg'. Ho~. 3U (2/31 to 10/SlT . In March of 1951* four weeks after he began to work as a chemical operator in Bldg. No. 3h, Mr. Stover developed an acncform eruption cn the face. Two weeks later, the eruption appeared on the trunk, shoulders and genitalia. Ho claims that he had been working in Bldg. No. 3U fsr 5 mrnths -16- when sodium trichlorphcnate spilled on him, after which the eruption appoared to increase in severity* Six weeks after the onset of tho skin lesions, ho developed pains in legs, and subsequently dcvclopod nervousness, dyspnea on exertion, easy fatiguability, and a constant feeling of being tired* Some docrcaso in libido was noted. Ho has been off work or assigned to light duty since October, 1951* As a ;chemical operator in Eldg. No. 3U> ho had to cut the cake" from several centrifuges and shovel it out into the hopper. Vhcn the centrifuges were in operation, there was considerable splashing, because during that period they had no lids* Mr. Stover used rubber gloves and safety glasses during his work and changed his work clothes three times weekly. He is under treatment by a local dermatologist from whom he received x-ray therapy for 8 weeks. His comedones are expressed daily b y the plant nurse. During several weeks prior to this examination, his improvement has been rapid. The skin lesions have regressed, and there has been a noticeable decrease in fatigue. He has not complained of pains in the legs for 3 weeks. Charles Arthur Ago 31 Occupation - chemical operator, Bldg. No, 3U (1950-527 Two' months after starting to work as an operator in Bldg. Ho. 3U> Mr.'Arthur developed an acnoform eruption on the face and subsequently on shoulders, trunk, arms and legs. The eruption, reached the peak of its severity within two months after onset, and has improved considerably while being treated by a local dermatologist. He claims that a few months prior to his removal from the, building, he developed pain in the thighs, which became nest apparent on exertion. It has persisted to the present, but is mild and transitory. He also complained of decreased libido. He asserts that since December, 195^, when he was removed from the exposure, ho has bccomo "nervousn. Hr, Arthur claims that he changed his work clothes daily, vore rubber gloves and safety goggles. According to his statement, there was considerable contact through splashing from open-topped centrifuge, through contact with the cake and equipment when the former was being dug out, and from the dust of the dry, final product. William W. Workman Age 26 Occupation - chemical operator helper ' Bldg. Mo. 3k, 6 mos., Bldg. No# 51, 6 mos. Mr. Workman did not recall clearly just when or for how long he was assigned to a particular building or job, so that the information obtained from him about his exposure is not very accurate. In the early fall of 1951, Mr. Workman was. assigned to work in Bldg. No. 3h. Two months later, he developed an acneform eruption cn the face, and neck, and subsequently a few lesions on the back. The symptoms have been limited to the skin. He has had the plant nurse express the comedones on his face and neck periodically. Mr. Workman* s job in Bldg. No. 3U consisted initially cf pulverizing Z ,U,5-T prior to packing. He was then assigned to work cn the centrifuge, and to digging dichlorphcnyoxysodium acetate out of it. After 6 months of work, he was put on a "kicker schedule" and worked part of the time in Bldg, No. bS9 and the remainder in Bldg, No. 51 There ho sampled the autoclave, cleaned cut the filter press and blew finished batches of sodium trichlorphcnatc out of the autoclave. There has been nc time lost because of "chlcracnc" or associated symptoms -18- H. 0 Young Age 53 Occupation - machinist Mr. Young*s duties take him into many buildings including the structures vhich house both parts *of the 2,b,5-T synthesis. He worked in Bldg. No. hi for three weeks following the accident, but not on the involved equipment. Several months later, he repaired the agitator of the involved autoclave in the machine shop. For the past 2 years, he has been going down into the Bldg. No. 51 autoclave to make repairs. Periodically, he has been making repairs in Bldg, No. 3U which may keep him there for as long as 1-1/2 hours. In most instances, equipment from Bldg. No. 3U is brought to the shop for work. The patient noticed comedones of the cheeks and eyelids.in 1951. In 195&, he developed pains in the left hip which became worse when sitting down. He has had a folliculitis of the thighs *for several years, which he has attributed to cutting oils and/or greases used in the shop. He claims to have pains in the left chest occasionally and dyspnea on exertion for the past 2-3 years. Mr. Young has lost no time because of his cutaneous or associated symptoms. William h . Smith Age 2k Occupation - chemical operator Bldg, No. 3U - total of-6 mos. in 2 separate periods Bldg, No. 51 - 2 mos, _______ In the fall of 1951, Mr. Smith began to work in Bldg. No, 3b. There he had multiple duties which included operating the centrifuges, cutting and shoveling the cakes from them. He claims there was much splashing in the operation of the centrifuges and extensive contact with the cake when cutting or shoveling. He also shoveled the solid 2,b,5-T fi*om the filter box into drums prior to drying, and, when drying was done in Bldg. No. 3b, loaded the wot cake into drying pans. He remained in Bldg, Ho, 3U for Z months and than was transferred to Bldg. Ho, 51, where he worked twice weekly for Z months. He then returned to No, 3h for another U months, and he left that area in June, 195& When he returned to Bldg, Ho. 3b, he first became aware of comedones on the temple and cheeks, and subsequently acne lesions appeared on the chest. He believes his pain in the calves started while he was in Bldg. No, Jl, but he did not report the pains until he reported his cutaneous eruption. There were no other symptoms. Kr. Smith changed clothes daily, wore rubber gloves and showered daily while in Eldgs.. Nos. 3h and 51. There was no time lost because of cutaneous or-assodated complaints. E. W, Beckman Age h6 Occupation - foreman, Bldg, No, 3U Hr. Beckman was the foreman of Bldg. No. 3h in 19U8 when the Z ,k 9 5 r T operation was installed in that building. He has continued in that capacity up to the present time. He has been exposed to all of the operations in the synthesis of Z ,k ,$ - T for h-1/2 years. Such exposure has been comparatively brief during the supervision or instruction of the operators and helpers. Numerous revisions of the 2,U,5-T processes have been made since his first exposure to the original installation. About one year after the S,U,5~T operation was initiated, Mr. Beckman developed an acneform eruption which appeared first cn his face and subsequently on his neck, trunk and upper and lower extremities. Some of the cystic lesions have periodically become infected. In May, 1951, he developed pains in the legs and hips which became more intense while sitting or lying down. During the past two years, he has noticed that he becomes tired very easily and has little ambition. He- has become irritable and there has been a noticeable decrease in sexual --20-- r - activity* -He lias continued as foreman in Eldg. No* 3k but has no responsi bility in the 2,U,5-T section of the building. Persons who have known Mr. Beckman for many years believe that the slowness of movement! slurring speech and dull appearance which ho now presents and which might bo taken as evidence of faulty cerebration, have always been present and have not interferred in any way* with his functions as a supervisor and instructor of men*Mr. Beckman indicates that his pains in the legs and hips have decreased considerably in the past few months, but they recur with severity, at times. The total timo lost by this man because of his cutaneous or associated complaints is two weeks. Willard Forbes Age hZ Occupation - chemical operator Mr. Forbes has worked-in Bldg, No. 3U for /the past 7 years. Two years ago, when the' `'AC11 operation was shut down, ho spent lU weeks continuously as a helper in the 2,U,5-T process. During that period of exposure, he operated the centrifuges, dug out the "cake," operated the filter box and shoveled the final product into drums prior to the drying operation. His exposure was in essential correspondence with that of Mr. William H. Smith, described above. In October, 1951/ Mr. Fbrbes developed an acnoform eruption on the back and trunk. One year later, he developed pain in the back and lower extremities. The pains were more severe when he was in a recumbent position. These have persisted and arc relieved by salicylates. Six months after the pain developed, he noticed the acncform eruption on his face and cars. The patient had mild acne vulgaris as an adolescent. He had a "stroke" in 1952. In January, 1953, he developed hematuria following the making of a batch of "Bbc 257". His present' conplaints relate to the mild skin eruption and occasional pains in back and lower extremities. There has been no tine lost bccauso of "chloracnc11. Charles Fhrley Ago 27 Occupation - trucking (19U9-51) For two years, from 19h9 to 1951, Mr, Ehrley hauled 2,U,5-T from Bldg. .No. 3U to Bldg. No. 79 id* drying, ftiis took him in and out of Bldg. No. 3U r several times per day. About 6 months following the accident, he went into Bldg. No. 1|1 to which tetrachlorbcnzene was delivered. Three months after starting the hauling work, he developed an acnoform eruption on his face, nock, ears, bearded area, hair line and posterior nock region. Shortly after the lesions appeared, he developed pains in the lower extremities, shoulders and chest. He has been'under the care of a dermatologist for his skin condition. He has lost nG time from work, because of the problem.? When he was engaged in this hauling, this worker furnished his cwn clothes. Ho is now a raw materials handler, and handles tetrachlorbcnzene occasionally. His clothes and coveralls are now furnished and he changes twice weekly. Mr. Farley had mild acne vulgaris as an adolescent. His present complaints consist of a folliculitis of the bearded area, aching and shooting pains of the calves, thighs, arms and portion of the neck, nervousness, and continuous fatigue. His answers about his symptoms were glib, and ho seemed anxious to impress the examiner with his symptoms. Maxwell Galloway Age 29 Supervisor - Bldg. No. 3li(9/51 to 3/53) As supervisor of the 2,U,5-T operation from September, 1951 "to March, 1953, this man was exposed to all parts of the operation, but the exposures wore considerably less severe than those of the operators themselves^ As supervisor, he wore a shirt and trousers while at work. In November, l?l, he noticed the appearance of a few comedones on his cheeks. One of these became infected after squeezing, and he was hospitalized for Z days because of the infection, Mr, Galloway had mild acne vulgaris as an adolescent. He has had no difficulty other than mild ccmedonal acne, Basil Hoffman Age 28 Occupation - yard man This man worked nin production" for six years prior to December, 1952. For a while he worked in Bldg. No. 3U, but was not assigned to the 2,ij.,5-T room. In December, 1552, he developed symptoms of peptic ulcer, was removed from "production" and put on yard duty. During the latter part of December, he helped to tear out the interior of Bldg, No. 3U prior to its recon struction and replacement of equipment for the 2,U,5-T synthesis. There was much dust on the structural timbers and concrete, with which, during their demolition, Mr. Hoffman was in contact. He wore gloves, coveralls and glasses while engaged in demolishing Bldg, No, 3U. Early in January, 1953 , he noticed the appearance of a few comedones on the face and chest. He has experienced occasional mild pains in the left leg. This man has had a "burning feeling in the stomach" for the past 7 years. He is nauseated and vomits frequently after meals. Ho gave a history of having had acne vulgaris of shoulders and back as an adolescent, Enraitt Null Age 35 Occupation - chemical operator, Bldg. No. 5lf 2 years Kr* Null was included in this survey because of an accidental "T C P " exposure which occurred one week prior to the examination. On April 7th, 1953> while changing valves in a line leading from the autoclave in Bldg. No, 519 the contents of the lino (essentially sodium trichlorphenatc in 9 9 r ( A -23- i methanol) splashed over the right side of his' faco and in his right eye* The patient was brought to the dispensary vhcro tho cyo was irrigated with NaHC03 and vaseline gauze dressings were applied to tho ,rburnodn area. : Six days later, the burned area was healing veil with good replacement of epithelium, but papules, pustules and cysts were noted on the splashed side of the face and neck. Hr. Mull, had mild comedonal and cystic acne as .an adolescent and had residual cystic and comedonal lesions on the side of face and neck which was not burned. Millard R. M c d a n a h a n Age 30 Occupation - helper, Bldg. Mo. 3k (7/U9 to ll/geT This man was a first class helper in the 2,U,S-T operation in Bldg. Mo. 3h for about UO months. He worked for some time under conditions which were admittedly hazardous before the processes were vented, and: dug the cake out of several centrifuges which wore not covered during their operation. In 1950, he developed an acneform eruption of the face, and subsequently it appeared on his chest, neck, ears, back snd genitalia. About one year later, he developed aches and pains in the calves, knees, "thighs and lower back. The pains were most noticeable when ho was in a relaxed t position such as sitting or lying down. He also noticed a decrease in his sexual interest for several months, anorexia and continuous fatigue. Since his transfer to another building, his appetite and sexual interest have been normal. His pains and fatigue have subsided completely. -2U - i William Simmons Age 27 Occupation - chemical operator, Bldg. Mo, 3^> 1$ nos. In 1 9 W , Mr* Simmons hooped to start up the 2,U,-T process in Bldg. No. 3U. Ho had been-working here in another operation which was temporarily shut down, and was assigned to tho 2,U,5-T process during its first four months of operation. Within one month, he noticed an acneform eruption on tho face, nock, back, trunk and genitalia. Many of these lesions became purulent.' Following his 2,k,f>-T assignment, he was transferred to Bldg. No. 2$ where he was a chemical operator in the manu facture of PS-Cl^ for 2 years. In December, 1 9 51, he was transferred to Bldg. No. lil, where he became tho head operator in tho Waul" process. It was not until 19$1 that Mr. Simmons developed pains in tho shoulders, arms and right hip. During the li-month exposure to the 2,U,5-- T synthesis, an open reactor kettle was used. The patient was required to scrape the sides of the kettle from a manhole opening. The centrifuges were open and none of the process was ventilated. During that time, the workers supplied their own clothes and changed them when they wished. The patient was under the care of a local dermatologist by whom ho was treated for several years. His pain seems to have responded to injections of Vitamin Simmons has had severe and recurrent otitis which, in 19^2, required a mastoidectomy cn the left side. Ho has had a severe, chronic sinusitis which required a submucous resection in 19b6. A peptic ulcer was diagnosed in 19U8, and he received treatment for this condition for one year. He has lost no time from work because cf his occupational acne syndrome. Ervin G. Bailey-' . Ago 27 Occupation - chemical operator, Bldg, Mo. 51* Jan* 1951 to Jan, 1953 Mr* Bailey began to work in Bldg. No. $1 when the new autoclave was installed and operation started in January, 1 He worked as an operator twice weekly and as a helper the rest of the time. His exposure is identical with that of Mr. Saxton* s which is described herein, later. In March of 19?2, he developed an acneform eruption, consisting of comedones and small cysts cn the face, ears, neck, shoulders, chest and buttocks. Shortly after the appearance of the `skin lesions, he developed pains in the calves and knees as well as the back. The pains new occur most frequently in the early morning and at the end of a shift. In , addition to the acneform eruption and pains, Mr, Bailey presently complains of some nervousness, urinary frequency, and fatigue on exertion.' Mr. Bailey has not been associated with the 2,U,-T process since January, 1953* No time has been lest because of wchloracncM and associated symptoms. The patient has not consulted a private physician about his cutaneous or other complaints. Earl Harris Age 29 Occupation - chemical coorator, Bldg. No. 3U (10/iiti to 1/52) like Mr. Simmons, this man began to work in the 2,U,5-T operation when it was first set up in Bldg. No. 3U in October, 19U8. He worked there continuously until January, 19^2. For several years, the hygienic control of fumes, vapor and dusts was rather limited, and there were opportunities for direct contact with several varieties of intermediates. Subsequently many changes were mode in the hygienic control of individual processes as well as in measures of personal hygiene. In March, 19ii9, this man removed some drums from Eldg. No, ill, a few hours after the accident. -2 6 - According to this patient, he developed an acneform eruption in October, 19U9, but did not report it until 19$0. Acnoforra lesions appeared on the face initially and subsequently on the legs, chest, genitalia and perianal area. Many of these lesions becamo infectod, and incision was necessary. Within tho past yoar, this patient has developed aches in both knees. This does not seem to be related to position or work. The knee symptoms arc much improved p.t the present time. Soon after the patient reported his skin problem at tho end of 1950, ho was placed under tho care of a. dermatologist. No time has been lost because of his cutaneous problem. His previous medical history includes empyema, which he had 18 years ago following pneumonia; so-called "jungle ro.t" of the skin, while he was in Bougainville in 19h3; malaria, from which he suffered from 19UU to 19U7; hypertension and obesity, for both of tiich he is being treated b y a physician at the present time. George Ferrell Age 27 Occupation -- chemical operator, Bldg. No. U6 Mr. Ferrell has been working in Bldg. No. 1;6 from 1951 until the present time. For about-one month, July to August, 1952* his job included hauling drums containing 2,U,5-T and dumping the wot cake from tho drums into a rotary dryer.. There was apparently little dust in this part of the process, but a considerable amount of fumes. There was some dust involved in convoying the dried 2,1*,5-T from the dryer tc the drums prior to shipment. Mr. Ferrell works in Eldg* No. U6, but has not been in contact with 2,U,5-T since August- of 1952* He claims that sometime in July, 1952* he noticed comedones and small cysts on his face and, subsequently, on the posterior cervical region and the cars. Tho cutaneous eruption was treated in the medical department of the company. The patient has had no other complaints referable* to this exposure, and has lost no time as a result of it* During tho period of the exposure, he voro freshly-laundered underclothes and coveralls daily and usod glov.es and safety glasses f egularly# Mr* Ferrell bad mild acno as an adolescent* About one year ago, ho developed symptoms of peptic ulcer and Banthino was prescribed* He has noticed somo increase in nervousnoss during the past year* Roy Wright Age Ii7 Occupation - shift mechanic According to Mr# 'Wright* s history, he las been oxposod in some degree to the materials involved in tho accident in Bldg# Ho* IpL, as veil as to those concerned in the rogular synthesis of 2,U,S-T in Bldgs* Ho* $1 and Ho# 3lu About 2 weeks after tho accident, Mr. Wright worked on the lines and valves in Bldg# Ho* lil, but not in the soction with the autoclave# .He worked in this building when he was on night shift, and occasionally when he was on day shift# -Since the 2,U,5-T autoclave has been housed in Bldg* Ho* 51 he has been doing shift mechanic work in that building which includes steaming out tho lines, installing new lines, and packing pumps. In Bldg. No. 3U, his responsibilities have included changing the centrifuge cloths, steaming out-the lines, and repairing broken conveyor chains as well as packing pumps* Two yoars ago, in 19l, he noticod the appearance of an acneform eruption on his choeks, nock, cars, shoulders and buttocks# Some of these, lesions becamo infected* About 18 months after the skin lesions appeared, he developed pains in the hips, lower extremities and back. On occasion, the pains in tho hip become so severe that he has thought of laying off work. When working in these buildings, ho uses coveralls, gloves and safety glasses and showers regularly after each shift# Ho has lost no timo as a rosult of those'conplaints* William Saxton Arc 30 mos. ~Occupation - helper, Bldg# No 51 z6 Mr. Saxton began to work in Bldg# No. 51 when it first was put into operation. Ho has worked there over since# Daring the early days of its operation, the h e w e r s wore expo sod to tetrachlorobcnzeno during its removal from the drums and in the melting down process. At the prosent time, the TCB is pumped from a storage tank into a mcltcr and .then into the autoclave# Current possible exposures include the cleaning of the plate and frame filter, the sampling of tho methanol solution at the "end of a run" and at the "still". Prior to 1952, the workers supplied their own clothes, and the personal hygiene was not as good as it is at the present time. One month after Mr. Saxton began to work in Bldg# No. $ 1 , he developed an acncform eruption on his cheeks, lower lids and behind his ears. Tho cysts *in his earlobes, according to the patient, became quite large# "One year later, ho developed pains in tho knees as well as his back# During the past 3 years, Mr. Saxton says he tires easily and has become nervous# During his interview, Mr. Saxton appeared very anxious to provide complete information about the hazards which exist and the illness which he has suffered as a result of the exposure. The patient had a moderate amount of acne vulgaris as an adolescent. Ho had malaria from 19U3 to 19U7 and has ha d no recurrence since then. .He stated that he had been shown to be anemic when he was hospitalized for U days in 1951 for his low back pain. No time has been lost because of his cutaneous problem or associated symptoms except for U days as described above. Donald Payne Ago 31 Occupation - chemical operator Mr. Payne is not certain of the dates or duration of his exposure in the A* f*V." \ v.. '-2 9 - varicus operations, From 19U9 to 1951# Mr.* Payne had several short assign ments in Bldgs. Nos. 3U, 16 and 79 In Bldg. No, 3 k , ho helped operate a small dryer of the multiple tray type and he ground 2,U,5-T. This vas a very dusty operation. In Bldgs. Nos. 16 and 79/ ho dumped the vet cake into tho dryer trays# placed then in the oven, and dumpod the dry 2,h,5-T into fibre drums. This, too, vas a very dusty operation. In 1951, for 3 vccks, he vorked as a helper in Bldg. No. 3U, and performed duties similar to those described in the record of Mr. Earl Harris. In the latter part of 1950, before the 3-wock exposure in Bldg. No. 3k, he noted the development of an acncform eruption on his face. ' He claims, too, that during this time, rion he took his clothes to wash, his children,'who were at that time aged 2 and U, developed blackheads and papules on their faces and legs. Tho symptoms which developed in 1950 and have continued to the present time were limited to the skin. In 19U2, the patient was treated for "stomach trouble" and colitis. He was hospitalized for 10 days and was treated subsequently with hydrochloric acid. He was very nervous at that time. The patient has no gastro--intestinal symptoms at the present time. The patient appears to be very careless about his hygiene, and this might well explain the transporting of acnegenic material into his heme. He has lost no time as a result of these symptoms. Byron Jones Age 22 Occupation - trucking, 1951-53________ - grinder, Bldg. No, 3h, 1 week in 1951 For two years - from. January 1951 "to January 1953 -- Mr. Jones was employed in the trucking section of the company. Among other things, his job included hauling 2,li,-T to tho various buildings in which it was dried (Bldgs. Nos. 79 and L6), He hauled the dried 2,li,5"T back to Bldg. No. 3h for grinding*and packing, and then to tho warehouse. Iho area in which the dried 2,1*,5-T was ground and put into drums was, according to tho patient, very dusty. In 125l> for ono week, Mr. Jones was employed in the grinding soction of Bldg. No. 3U* While trucking, ho wore essentially his ovn clothes and no coveralls. However, both gloves and safety glasses were worn when ho hauled ,U,5-T. * At the end of 1951, the patient developed an acncform eruption on tho face, for *diich he was treated b y the plant nurse., For the past six months, he claims he has had aches in the thighs and calf muscles during heavy lifting. There has been no time lost because of cutaneous or related syaptoras * . Tho patient had acne as an adolescent. Harold Hedanahan Ago 25 Occupation - chemical operator, Bldg Ko; 3U> Nov., 1950 to May. 1951 trucking May 51 to rresent . For 18 months - from November, 1950 to May, *1951 -- Mr. M c d a n a h a n was exposed tc early operations of the 2,U,5-T synthesis. His assignments included "digging the cake11 out of the centrifuge, cleaning tho filter press, and checking the acidification and the dissolver. The conditions of his exposure were essentially the same as those of Millard R. M c d a n a h a n and Earl Harris. Fraa Kay, 1951 until the present time, he has been trucking Prior to the installation of the rotary drier in Bldg. No. 3U, 2,li,5-T was hauled to other buildings tc be dried, and Mr. M c d a n a h a n hauled 2,1i,5-T to Bldgs. Nos. 79 and 1*6, and returned the dried. 2,U,5-T to Bldg. No. 3U. Ho claims that this was a very dusty exposure. Six months after he began to work in Bldg. Ho. 3 h , he noticed an acncform eruption cn his forehead, neck and lower extremities. He was treated by a local dermatologist. His eruption was most severe and extensive Tdien ho was transferred from Bldg:. No. 3b to the trucking assignment in May, 1951# Mr, McClanahan has never complained of any* systemic symptoms since his exposero. ' While working in Bldg. No, 3b, ho was able to change his coveralls about every* 3 days. .Harold Newcomer Ago 3b Occupation -- operator on occasional shift, Bldg, No, 3U, j g & W f l T - ~ " chemical operator, Bldg. Ho, 3b, January? 1953 to prosent For two years, Mr, Newcomer was a utility man", who worked occasional shifts in Bldg, No. 3b until the operation was halted temporarily in December, 1952, when Bldg. No. 3b was reconstructed. However, during the last two weeks of this operation in December, he worked on the grinding mill in Bldg, No, 3b and was exposed to large amounts of 2,b,5-T dust. Since the process was revised, he has been working in the same building, and when he does, he operates the centrifuge and rotary drier. He also weighs and covers the drums which arc filled with the dried ,b,5-T. Early in December, 1952, he developed an acneform eruption on his face. This was at the time he was working in the grinding mill in Bldg. Nc. 3b, Since January, 1953* he has developed aches in the lower part of the back, thighs and calves which seem tc appear when ho is relaxed as in sitting or lying down. Theso pains arc not continuous and occur about once or twice weekly. They are net relieved b y aspirin. Hygienic measures at the present time include changing underwear, coveralls and socks before every shift, wearing leather gloves, which extend up to mid-forearm, and rubber shoes, and showering at the end cf . every shift. Ho time has been lost as a result cf his symptoms. James Kyle ' Ago 3$ Occupation*- `chemical operator-;'Bldg Mo 51, January, 1951 to present Mr Kyle is employed as a chemical operator in the building housing - the autoclave Ho has the same duties and essentially the same exposures * "> * * ' , t as Messrs Bailey and Saxton About U or 5 months ago, he noticed aching in the knees and in the area of the lover back He also claims that the texture of his skin" has become heavy, and the pores have becomo larger* Since he has taken Vitamin injoctions, the severity of the aching has decreased He claims the aching in the back and the knees persists continuously and appears to have no relation to sitting, lying down, walking or-working Mr Kyle also claims that during the last few months he has become fatigued and irritable His hygienic procedures are identical with those of Messrs, Saxton and Bailey* Mr. Kyle had mild acne, as an adolescent, and malaria in 191# and 19h3, while he was in Guadalcanal James F. Asbury Age 35 Occupation - helper, Bldg. Mo* 3k December, 1950-51, and January, 1953 to present time The 'patient was employed as a helper in the 2,U,5-T operation for nine months in 195 and 19$1, and has been 'employed there from January, 1953; to the present time. During his previous enployment in Bldg. Ho. 3k, his duties included digging the cake out of the centrifuge, cleaning the plate and frame filter, and grinding the dried,2,U,5-T. In March, 1951; four months after he began to work in Bldg, lio, 3k , he noticed an acneform eruption on his face, neck, chest and in the axillae. He was under the care of a local dermatologist for 2 months. There have been no ether symptoms. He has lost no time from his work. He injured his left testicle in 19U3 and since that time it has boen atrophic, T. A. Dent ' Are 1:9 Occupation -- instrument mechanic Hr* Dent has been an instrument mechanic for the last 8 years, and .maintains such equipment as thermocouples and the recorders in various buildings of the plant. He has been in arid out of many buildings, including Bldg. Ho, following the accident, Bldg. Nos. h$ and U9, when 2,U,5-T was being dried there, and Bldg* No. 3h during the period 1951-J&. He believes that his chief exposure occurred when ho had to fix a thermocouple over the second kettle in Bldg, No, 3U. During this "exposure,11 he wore glasses, but no other protection. About' one year ago, he noticed small, white cystic lesions under the eyes and on the cheeks. There have been no other symptoms referable to this exposure, Mr. Dent had a bladder tumor removed three years ago, which was attributed to a "PAD" exposure. r -31;- ( " ' 1;. Name R. Shank F. Milan F. Wcstphall / /J* G. Stcolc J. Selby P. Willard / CUKICftX STATUS OF j)6 PERSONS SURVEYED IN APRIL, 19^3 Present complaints Phtiguo, sensitivity to cold Abnormal clinical Few .scattered comedones in periorbital areas Mild fatigue Grade 1 aortic systolic murmur; residual acne scars on face Fatigue, nervousness, sandy feeling in eyelids; recurrent swelling in neck and groin for 18 months; pain in-R. U. Q. "like'Hr. Steele11 Numerous grouped comedones and small cysts on face; leukoplakia left lower lip and buccal mucosa; vcrrucao, on penis; A-V nicking - eye grounds; yellowish cysts of perianal area; skin sutures, right inguinal region Fhtigue, nervousness, sandy feeling in eyelids; aches in neck and groin; soreness R.U.Q.; occasional vertigo Scattered comedones and cysts on forehead, face and post-auricu lar areas; questionable deep R.TJ.Q. tenderness; liver edge dubiously palpable; mild erythem atous papules cn back and chest; skin sutures right inguinal and left shoulder regions Fitigue, vertigo; pains in legs and chest; occasional depression; all symptoms regressing Mild acneform lesions on the face; residual acne scarring face and neck, tender acne nodule on right buttocks; gingivitis; diminished acuity O.D. (atrophy of disc); scoliosis Eyspnca on exertion; prcsternal pain, cardiac palpitation; flushing, low back pain, recurrent vertigo, fatigue, nervous ness, depression, sandy feeling in eyes B.P. 160/90. Pulse 108 Periodic diaphoresis and flush ing; residual chloracnc face, neck and trunk; acne scars face, neck, trunk - Nane / / Lonnie Hurley Present complaints Cutaneous eruption; fatiguo, nervousness; pains in legs; symptoms regressing Abnormal clin ica l findings - A pril, 1953 Acne lesions of face, penis, peri anal area; residual acne scars', face and nock; nasal septal' doviation - left; gingivitis; diminished visual acuity; varicocele; mass in left lumbar area (kidney?) 6. Hudnall Cutaneous eruptions; severe aches in upper and lower extremities; fatigue; dyspnea B.P. m 2 / l l 8 Sovero punctate scars of face, neck and scalp - confluent sebaceous masses; loss of tactile sensation lateral aspect, left thigh; bilateral pitting ankle edema; cupping of discs and ' tortuous arterioles * --- Harold Young Continuous fatigue; resid ual hyp erpigmentation of face and neck; re current cysts on eyelids; slightly irritable; aches in legs and feet regressing Residual comedonal acne; pigmentation, side and back, neck; xerosis, trunk; . mass in right scrotum .A* Hurley Insomnia; "hands fall asleep"; aching in thighs, hips, feet; conjunctival cysts; mild S.O.B* on exertion; all symptoms regressing Few residual comedones; cutaneous scars; arteriolar thickening; no vibratory sensation from iliac crest down; repaired left Inguinal hernia B. Meadows Acncforra eruption, 3 yrs.; aching in logs, thighs and knees - 18 mos.; loss of ambition; fatigue Numerous comedones and cysts, forehead, face; papular, pustular acne ever both shoulders and back; '-mild folliculitis of thighs B Stover Phtiguc, inertia regressing; mild dyspnea; acne i Bony deformity, right chest;* mass, sole right foot; moderate comedonal and papular acne of face; keratosis pilaris of logs r r w ifM W ' amo C. Arthur W. Workman Present complaints Mild, transitory aches and pains; ` nervous- * ness; residual acne; fatigue; intolerance' . to cold Abnormal c lin ic a l findings - A pril, 1953 B. P..U6 / 9 0 Comcdonal and cystic acne; grade 1 apical systolic murmur; varices, left leg; i rocent spinal fusion ; Acneform eruption, faco . and back Mild comedonal acne 'face and back H. 0. Young Acneform eruption; pain * in left hip; oil folliculitis of thighs;pain left chest, period ically; occasional S.O.B;, very mild Wtau-H. Smith Acneform eruption; 'aches in calves E. W. Becknan Aches in legs and hips, severe when sitting or lying down; irritable; decreased sexual " activity * W. Forbes Mild acneform eruption; mild pains in back, thighs, calves B.P. lii0/90 Corneal scar OB; comedones in periorbital areas Comedonal acne of cheeks and forehead; seborrhea sicca; tinea cruris; tinea versicolor - Numerous comedones; poikoloderma; slurring speech and slow movement (faulty cerebration?) Comedones on cheeks and ears; perforated left ear drum; diminished visual acuity; grade 1 soft aortic systolic murmur; ?enlarged epididymis C. Parley Acneform scarring; pains in calves, thighs, neck, shoulders and chest; nervousness; fatigue Sycosis vulgaris; punctate scars, old acne, face, neck, shoulders much of this from juvenilo acne -3 7 - Abnormal clin ica l Name__________ Present complaints_________ ._____ findings - A pril, 1953 M. Galloway Few comedones on cheeks; no systemic complaints; acno as adolosccnt . Periorbital comedones; seborrhea capitis; tinea cruris and pedis; onychomycosis; . 'myopia ~ B. Hofftaan Few comcdonal lesions on face; slight, occasional pain left leg; history of peptic nicer symptoms; aone as adolescent B.E. 1 U S / H 8 Periorbital comedones; . papular, cystic acno of back, with scarring; undescended testis, right side; appeared very anxious E. Hull Contents of line in Bldg* No* 51 splashed on face and neck one week prior to examination; chemical burns treated with vaseline gauze; mild acne as adolescent and adult Skin of right side face and neck healing; scaling and numerous papules and pustules in burned area; scattered comedones and cysts on side of face and neck around burned areas; few come dones and nulia-like cysts left side of face and neck; residual of juvenile acne M.R. Kcdanahan Wm. Simmons Fatigued and loss of libido when in 2,U,-T, .not at present; history of aches in calves, knees, back; not at present Acneform eruption on cheeks and face; post-acne scarring, neck and scalp . (Only esqposcd U mos, 19U8U9) Acncform eruption,' face, nock, ears; chronic sinusitis and otitis; peptic ulcer 19U8 Numerous comedones and cysts on forehead, face, back, ears; scars on neck, back; sinusitis; otitis; peptic ulcer symptoms E. Bailey Acncform eruption since March, 19$2; aches in legs, -knees, back; common in A.Mf and at end of shift; abnorm al fatigue; irritability; urinary frequency Numerous cysts and comodones, face, ears, scapular area, back, hips; bilateral submandibular nodes; large right inguinal ring; slightly injected conjunctivas Namoe E, Harris Present complaints Generalized acne since October, 19li9; aches in knoes in past year oply; under physicians care for lypertension and * obesity 'G Ferrell W # Saxton R. Tftdght Acneform eruption since July, 1952; history peptic ulcer - 1 year ago; no other complaints Acneform eruption sinco February, 1951; aches in back since Spring, 1951; painful knee; nervous ness; fatigue on exertion Acneform eruption since 1951; occasional pains in calves, hips, lew back, thighs; feels well most of the time D. Payne Acneform eruption since 1950 B. Jones Acne lesions since end of 1951; aches in thighs and calves with heavy lifting, only six months * duration Abnormal c lin ic a l 'ffiinnddiinnggss -- AApprirlil,, 11995533 B.P. I50/ H O Few scattered sebaceous cysts and comedones on face; residual scars; scar left chest (empyema drainage); tinea pedis; onychomycosis; visual acuity 20/50 Comedonal, cystic acne of face Few scattered cystic and comcdonal lesions, face; tinea pedis Infraorbital comedones; residual acne lesion on shoulder; scattered comedones and papules over buttocks Acneform eruption on face, forehead, cheeks; keratosis pilaris of legs; sebaceous cyst - postauricular; suspicious bilateral testicular atrophy Papular and pustular acneform eruption side of face; alopecia areata of beard; dermatitis with scaling and hyperpigmentation dorsa both hands; keratosis pilaris thighs and legs 9 <$.. ~29~ Kane___________ Present complaints 1 H.McClanahan ' Acneform eruption, face and nock Abnormal clinical 'findings - April, 1953 Mild comedonal ache of . face, scattered comedones - buttocks; tinea pedis; dryness and ' scaling of left palm H. Newcomer Acne, face, since December, 1952 B. P. 150/108 Scattered comedones, forehead, . periorbital area; no scarring; testicular atrophy, post mumps J. Kyle ' C .. Aches and'pains in knees and lumbar area, 5 months1 duration; claims skin developed heavy texture; nervousness; loss of vigor and fatigue ? Mild folliculitis, back of neck; skin essentially* negative. (Complainer?) T. A. Dent Acne eruption, 1 year*s duration i Mild comedonal acne, periorbital; seborrhea 'sicca; seborrheic keratosis, right knee and right arm; deviated septum - left l E Interpretations 1. Clinical progress It is apparent fran the medical histories and clinical findings 'that those who developed in moderate or severe degree the syndrome characterized invariably b y an acneforra eruption, pains in the extremities and back, dyspnea, fatigue, loss of vigor, nervousness, and decrease in libido, generally improved." Those vho had theuwtaneous erup_taon.in-its-most,.-. 'severe and ^ ^ ^ ^ J ^ n o i 9 . w J ^ e , ^ e w . , p r ^ o _ a s j aye_.lesions. Those who had the cutaneous disease in association with one or more of the other complaints listed above, have had a gradual remission of their symptoms . and, with the exception of a few, have been able to return to work# In the cases of Messrs# Steele. Willard a n d W g g j ^ a l l , clinical syuptoms were such that, at the time of the present survey, they were not working^ In some cases, the subjects continue to complain of pains, nervousness and fatigue. However, according to the subjects themselves, the synptoms have improved considerably, and in most instances are steadily decreasing in frequency and intensity. Z# Present symptoms and physical findings Thirty-one of the 36 persons examined had active acncform lesions in some degree# The most conrnon site o*f comedonal and small cystic lesions was on the periorbital and malar areas. Lesions were also seen commonly on the forehead, postauricular areas, neck, shoulders# A few persons examined had lesions on the back, chest, buttocks and genitalia. Of the 31 persons with active piloscbaccous lesions, 7 could be classified as moderate in intensity# Few deep or infected lesions were noted# In the other 2k persons with acne lesions, the eruption vas mild. This vas in sharp contrast to the generalized, severo *eruptions vith many deep, infected lesions which were observed in four cases studied in October, 19U9. Of tho 36 persons interviewed, 8 admitted to having mild juvenilo acne vulgaris. A n additional three persons gave histories of having .. .a moderate amount of acne vulgaris lesions on face, shoulders and back, as adolescents. Twenty-three persons at the time of tho examination complained of symptoms other than cutaneous, which they attributed to the occupational exposure. These included the aches and pains, nervousness/ fatigue, loss of vigor,11 dyspnea, decrease in libido as described above. (See present clinical status chart for individual complaints.) In most vif the 23 cases, the other symptoms were mild except in instances1 cited b y Messrs. Westphall, Steele, Willard, Hudnall, Selby, Beckman and Stover. Because of the presenting complaints of aches and pains, vertigo], nervousness, the examiners were suspicious of possible neurological implications. No objective findings of neurological involvement were elicited, accepting two of rather bizarre character; t a) Loss of tactile sensation over the lateral aspect of the left thigh over- the area of distribution of the lateral femoral cutaneous norvo, was found in Mr. B. Hudnall. b) In Mr. J. A. Hurley, there was bilateral absence of vibratory sensation from the iliac crests, dLstally. -to - i No clinical evidence of acute or chronic hepatic disease was found among those examined on this occasion. The laboratory studies did not indicate any alteration of hepatic function No clinical explanation %* ** for the common complaints of aches and pains in 'the lower extremities and back, excessive fhtigue, loss of vigor, dyspnea, decrease of libido, was provided b y the results of the physical examinations. Of considerable interest was the case of Hr. E. Null who sustained . i a splash b u m with sodium trichlorphenate on the right side of his. face and neck 6 days before he was examined b y us. Die Irburan had been treated with vaseline gauze dressings. Inflamed papules, pustules and a few cysts were noted on the affected side of face and neck. However, scattered acne- form lesions were also noted on the unaffected side of face and neck and, when questioned, the patient said that ever since adolescence he has had scattered comedones and small cysts appearing on face and neck. The material with which Hr* Null was splashed may be acnegenic. The observations of Mr. Null, however, are inconclusive because the cysts on the ^burned11 side may have been present prior to the* splash, as they were on tho unexposed side. Also, vaseline gauze may give rise to a folliculitis which Hr. Null developed within the healing b u m site. .3* laboratory studies Die laboratory tests, other than tho hemograms and urinalyses, were chosen to provide suggestive information as to the status of the hepatic function and lipid metabolism of the patients. Both wore suspected of being disturbed in the patients studied in 19U9. There was clinical evidence of hopatic enlargement in at least two patients in the 19L9 study. In retrospect, however, the laboratory evidence presented at that time vas not conclusive* Fourteen persons, vho gave histories of having soderate-to-severe symptoms, .were chosen for the hepatic and lipid studies in this survey* None of the Hi had abnormal prothrombin time determinations* In 3 of them, the cephalin flocculation reaction was 2+ in 2U and/or U8 hours; in one, it was 2+ in 2U and 3+ in.U8 hours (Hr* Westphall), In another (Mr* Stover), the reading was 3+ ia. 2U and ItB hours* Mr* Stover was one of the moderately active clinical cases at the time of examination. Neither Mr* Westphall nor Mr. Stover manifested any objective clinical evidence of hepatic disease* '9 A 2+ cephalin flocculation reaction may be regarded as being within normal limits* Since the test depends upon the albumin and lipid fractions of serum, the results of these tests would have to be compared with those from a group of couparable normal males with the same dietary habits, alcohol intake, etc*, in order to acquire any possible significance* Spot sanplcs of the urine of 13 persons, of the group were examined for extractable porphyrins (coproporphyrin I and H I and uroporphyrin H i ) * The range of concentrations in mg/liter was found to be 0*07 to 0*26, with one value of 0*380* A11 of the porphyrin determinations may be regarded as being within normal limits* A control study using laboratory personnel (3 0 males) gave a mean value of 0*168 mg/liter with a standard deviation of i ,050, Scrum cholesterol determinations were made in l2i subjects, (See table of laboratory data*) Although the normal range of cholesterol is given b y the H. J. Thomas Memorial Hospital laboratory as 1jS*200 mg per cent, in many other laboratories 300 mg per cent is considered normal. The results, therefore, which in seme instances might be suspected of being_slightly on the high side, are not indicative of any disturbance of the lipid metabolism. The microscopic observations on Mr. John Blackwell* s tissues (see report in laboratory data) revealed changes which are commonly found in persons with longstanding disease of the coronary arteries, generalized arteriosclerosis, and cardiao decompensation. F. Individual clinical problems During the examination It became apparent that some of these men had symptoms or findings which appeared to be related directly or indirectly to the occupational exposure. In many instances, the clinical syndrome was so mild, or the symptoms had regressed 60 markedly, that the patient required little more than periodic cutaneous care* In several instances, however, the persistence of old symptoms or the development of new ones appeared to be disabling to some degree. In several persons examined, the abnormal r H Tribal findings not related to the occupational exposure require further medical consideration. Ve should like to present our opinions and suggestions in some cases, several of which, according to their medical histories, have been rather perplexing. Messrs. Westphall and Steele presented multiple complaints which, in addition to fatigue, nervousness and pain, included pain in the right upper quadrant, recurrent swellings in groin and axillae and "sandy11 feeling in the eyes. Mo clinical evidence of hepatic enlargement, neuropathy or lymphadenopatty vas found during the examination*- No conjunctival cysts were seen during examination. A mild residual acnefonn eruption persists in both men. Both men appear to be in good`physical condition; Since there is little or no objective evidence to substantiat the existence of any visceral disease at the present time, it is recommended that both men be advised to return to vork. .They should be given no duties in buildings in which the 2,U,-T operations are carried out. Both men still require some cutaneous care which should be maintained b y a qualified dermatologist, preferably one who has fulfilled all of the training requirements of the American Board of Dermatology and SyphUology. Ophthalmologies! care should be given when necessary* Mr. John Selby1s case has been complicated b y what was diagnosed, serologically, as Rooty Mountain Spotted Fever. The syndrome resulting from exposure to the "explosion11 products of Bldg. Mo. Ul was, in this mants case, rather severe and disabling. His non-cutaneous symptoms have improved considerably, and he was able to return to light work during the week of the survey. A mild acneform eruption persists. This nan should be maintained in some kind of productive work in accordance with his current ability and stamina. The psychological rehabilitation of persons vkio have ted long-term illnesses is an'important consideration in bringing this and other men in the group back to work. They should not be offered menial tasks "as light work", but should be given something which in their estimation is productive and requires the use of skills which they have been accustomed to using prior to their illness. When Mr# -Paul Willard was examined by us in 1950/ wo found no physical reason for his not r o t u m i n g to work# Since that examination ho has done some light duty for about one-half of the time, and has boon . off duty the rost. of the time# Cardiac palpitations, attacks of Hushing and sweating, prestornal aching and dyspnea on exertion, and blood pressure of l60/?0, are among the present complaints and findings* Ho. is terribly warriod about his heart which* a physician told him was diseased, and who warned him, against physical activity# While it is certainly necessary to rule out hyperthyroidism and to look carefully into the cardiac condition of this patient, it appears that ho has two major difficulties which may contribute considerably to his present disability. f 1# Ho is a rather unstable person who has made a very poor J psychological adjustment to his original illness. - : 2 There is tho serious possibility that his 11heart diseaso*1 is iatrogenic rather than organic# Mr# Willard requires careful rehabilitation# He needs to regain confidence in his own physical well-being and productive ability# Psychiatric help is definitely indicated. In addition, ho should be studied clinically with an eye to thyroid disease and .examined repeatedly to clarify his cardiac status# It is recommended that he treturn to work but receive psychiatric treatment and guidance to assist in the rehabilitation# Mr Lonnie Hurley still has & moderate amount of acne which requires dermatologic care This patient has a varicocele fo r which ho should receive surgical treatmont, and a rather severe gingivitis for which dental care is indicated (Several persons among the 36 examined wore in urgent need of dental attention A dental-hygiene-and-care program would add much to the medical welfare of those men, and probably would be looked upon favorably b y the men themselves,) Mr Barry Hudnall should be referred to a competent internist for a complete .cardiac and neurological workup* He also requires some dermatologic care for the residual acne on his face end scalp, Mr, Harold Toung has done remarkably well since we last examined him in 1950 He seems to be vigorous and energetic. She cutaneous lesions and residual symptoms do not appear to be disabling, Mr. Young not only holds down a full-time responsible job at the plant, but also helps to operate a private business during his off-hours and week-ends. Mr, J, A, Hurley was also markedly improved since we examined him in 19^0- (He was the patient whose previous physical findings and nerve biopsy were indicative of peripheral neuropathy. See report of December Jth, 19li9) The absence of vibratory sensation in both lower extremities from the iliac crests down requires further study. It is recommended that Hr, Hurley be referred for a detailed neurological examination. Dermatological and ophthalmolo'gical care should bo continued. Mr, Dewey Meadows, who was assigned to Bldg, Ho, 3U in March, 1953j has a moderately severe acnefoim eruption on his faco, shoulders and back which requiros the care of a dermatologist# In spite of the hygienic improvements which were made in Bldg. No. 3U, wo believe that if for no other than psychological reasons, persons with as much acne as Mr. Meadows has should not be assigned to the 2>U,5-T operation, i Mr, Donald Stover also has a moderate amount of acne which requires dermatologic care. His complaints of fatigue and pains in the legs have kept him from his regular job since October, Ke requires the care of a competent dermatologist as well as that of a dentist. His complaint of sinus infection should also be investigated. His rapid improvement during the months of March and April is encouraging. He, too, needs some psychological rehabilitation and should be assigned to some productive work in keeping with his current physical ability. Several workers, although lacking histories of hypertension, had blood pressures during this examination which might be considered elevated. They were: Charles Arthur H. 0, Toung Basil Hoffman Harold Newcomer It is recommended that tho plant physician determine their blood pressures on several separate occasions to determine whether the observed elevation was due to anxiety of the survey--examination or whether any of these persons -19- re quire further cardiac study* In addition, because of suspiciously abnormal urinary findings (microscopic and albumin) in the cases of Messrs. Charles Arthur and W j V H a m H* Smith, it is recommended that their urinalyses ,bo repeated. Hr. E. W. Beckman will continue to'require dermatologic care* His slurring speech and apparent slow concentration have made a previous examiner suspicious of multiple sclerosis* Despite the observations of friends who say nhe has always been that way11 -- Mr. Beckman requires watching and should be referred to a competent internist, periodically, for examination. His injections of Vitamin B Complex and Liver, as well as high doses of Vitamin A should be continued. Although they appear to be unrelated to the occupational problem, a slightly-enlarged right epididymis of Mr. >5.H a r d Forbes and the varicocele of M r , Charles Farley require further examination and possibly treatment* 'Mr* Basil Hoffman was found to have an undescended testicle on the left side* He is a very anxious person who has had gastric symptoms for several years but who has never had an adequate diagnostic workup for this complaint* A genitourinary workup is indicated, especially in view of the ` frequency with which undescended testes are the site of pathologic processes* Hr. William Simmons1 cutaneous lesions reqiire further dermatologic care. He has had a history of peptic ulcer, and is a rather anxious person* He is much more concerned with his severe chronic sinusitis and otitis, for which he has undergone surgery on several occasions, than he is xith his acne. His EliT problems should be discussed with him by the plant physician, and should be referred to a competent specialist for care. Mr. Ervin G, Bailey was found, also, to have moderate numbers of acne lesions on his face and shoulders, which require dermatologic care. He and 'Willi.ani Saxton are. tho only persons who developed cutaneous changes'while working in Bldg. No. Jl. Mr. Kylo. an operator in Bldg* No, 51, claims to have developed pains 5 months ago which, according to his description, are unlike those of the syndrome* He claimed that his skin has become `thick11 - but on examination, no abnormalities were notedT In examining Mr. Donald Payne* bilateral testicular atrophy was suspected. The patient was not aware of any testicular changes and has experienced no sexual difficulty. He has two children, aged U and 6 r Urological examination should bo considered. Gt Locker room Each man in the 2,U,5-T operation is assigned a full-size and half-size locker. He has been instructed to use the full-size locker for his street clothes, the half-size locker for his work shoes, and never to put his work clothes into the locker with his strict clothes. These instructions are not carried out with regularity. d e a n work clothes which include underwear, coveralls and socks arc issued daily, but thcro is no opportunity to clean off contaminated shoes fi*om day to day. It is a common practice, according to observers, to put contaminated shoes or work clothes into locker with street clothes. The rule about showering daily following the work shift is not adhered to strictly, Some attempt should bo made .to supervise the use of lockers for separating stroct'clothes from contaminated shoes A method of cleaning off thoso shoos, periodically, should bo provided. H The present and future The survey findings indicate that persons exposed to materials dispersed by an autoclave accident in March, 19U9, as well as to materials handled in a variety of jobs in the synthesis of S,U,S-T, developed a syndrome consisting of acneform changes with or without a: variety of other symptoms described within. Our positive findings at this time are limited to the skini Symptomatically, it would appear that the substance (or substances) is capabmlr,-me. oX*f exerting a toxic effect on nerves as well as certain of the .endocrines and, perhaps, on the liver* No evidence of hepatic \ dysfunction was found in the 3 6 patients examined, but changes which may have occurred in the acute or severe phase of the syndrome, could have subsided completely by the time of these examinations It would appear from the hygienic purvey and the fact that no new eases havo been reported from Bldg, No, 3b sinco its reconstruction, that' the present operations are fairly well controlled hygienicaUy. No new cutaneous eases, except those resulting from accidental spills, have been reported from Bldg, No, $ 1 during the past year. f/i Despite the * encouraging results of the hygienic survey and the decreasing significance of the clinical problem, it is essential that every present potential * -- T ,..- v t. . ' r* u r t j i - <- 111 '"I1 t . . . rrjp ^ source of exposure be regarded as a hazard>.~and that measures be taken to decrease or eliminate such exposure as recommended in Part II of this report. The information obtained in this clinical 2n d hygienic survey provides a substantial basis for more fundamental investigations. It shows the need, for exaiqple, of obtaining information about the toxicity of substances evolved during the 2 ,U,-T synthesis -- and particularly their effect on various organ systems in the experimental animals. By subjecting animals to the inhalation, ingestion and percutaneous absorption of these materials, one may determine the clinical 'and pathological changes -53- induced In the animal organism and may provide an explanation of the pains, fatigue, nervousness, dyspnea and sexual symptoms. Following adequate toxicologic investigation, these suspected materials can be applied repeatedly upon the skin of human volunteers in an attempt to induce the cutaneous changes found in the syndrome, and to study the other possible effects on human skin. In addition, some attempt might be made critically to appraise the usefulness and adequacy of the "rabbit ear" technique which has been reported to be a method of predicting the acnegenicity of a chemical substance for humans. fractions obtained from all stages of the 2,h,$-T synthesis, as well as pure substances from the synthesis should be examined in this fashion. from the Kettering Laboratory, in the Department of Preventive Medicine, College of Medicine, University of Cincinnati. Clinical survey by: Robert Akin, M.D. Alvin Davis, M.D. Raymond R. Suskind, M.D. Laboratory work by: Clara Keenan, B.S. Pathology report by: frank Cleveland, M.D. ) Interpretation and report by: Raymond R. Suskind, M.D. July 20, 1953 Approved R o b e r t a* nt;iiuu, r i.u . jjxxwuOOr The Kettering Laboratory