Document v1XDXp8x17DR53m4R5RK4N57R

T h e Journal of the American Medical Association Publfmhed Under the Auopioe; of the Board of truster. VOL.78, NO. 9 C H I C.A G 0, I L L I N o I s MARCH 4, 1922 - during the year 1915-1916 I reported fourteen instances THE GROWING MEX-.LCE OF BENZENE (BENZOL) POISONI?JG I N AMERICAN ISDUSTRY of sudden acute poisoning with seven deaths? and sincethat time the danger of such an accident has become familiar to engineers and chemists and safety experts. The danger of chronic poisoning is less well known, . ALICE HAMILTON, M.D. BOSTOh' and it seems timely to call the attention of the medical profession to this increasing menace in American - -- industry, to describe the conditions under which it m a y - U p to 1914, comparatively little coal-tar benzene be looked for, and the warning symptoms. It is impor- (benzol, C,H,) was used in the United States. tant to take into account a possible confusion in names. Because of its solvent properties, it has long been Benzin is a petroleum distillate, far less toxic than employed on the continent and to a less extent in Eng- benzene. Another source of confusion is the use in land in the manufacture of rubber goods and of quick- industry of the term "solvent naphtha" to cover, not drying paints and for dry c l p i n g . But we had not petroleum naphtha, but a mixture of crude benzene, yet begun to produce it ourselves ;we imported it from toluene and xylene. . Germany, it was more than twice as expensive as the - petroleum solvents, and we therefore used the latter -for the great majority of industrial processes. The outbreak of the war did two things: It shut ._ . -. of the supply from Germany not only of benzene but also of amidobenzene, or anilin. which had become a ` ` valued ingredient of compound rubber, and it created a sudden demand for benzene and toluene for the - manufacture of explosives, and of anilin for the manu- facture of dyes as well as of rubber. Consequently, coke by-products plants were erected to secure benzene and toluene, and the latter was also obtained in the course of the production of illuminating gas. Then came the armistice, the sudden cessation of the manu- facture of explosives, and the need for new markets for the great quantities of coal-tar distillates which were thrown back on the hands of the producers. These markets have been found in the rubber trade, especially for tires, footwear, and hose; in sealing mixtures for tin cans ;in the shoe trade, for cement ;in - certain processes in the making of straw hats; as a solvent for fabrikoid, and as a substitute for gasoline in motor car fue1.l Benzene, which is a much more werful solvent than petroleum benzin and naphtha y"- or fats, gums and resins, is now below the latter in therefore a double that we shall pres- supplanted by the .quick drying paints ACUTE INDUSTRIAL POISONING The German literature yields, as one would expect, the largest number of instances of benzene poisoning, both acute and chronic. The German factory inspectors' reports for 1912 contained three cases, two of them fatal. One man was painting with benzene tar paint the interior of a barrel; another, in a dry cleaning establisliment, had climbed into the washing machine, which had a little residue of benzene at the bottom. The third, who was in charge of a distilling plant, had neglected to turn on the cold water for condensation, and the fumes that escaped killed him. A case similar to this was reported by the British factory inspectors in 1918. An increase of pressure caused a quicker distillation of vapor than the condenser could deal with. The man, being overcome, revived with oxygen; but, when he returned to work the second night after, he was again overcome and died. The earliest instances of acute industrial poisoning in A n d c a n industry seem to have occurred in connec- tion with war industries in 1915-1916. The men were pipe fitters or workmen engaged in distilling benzene or cleaning tanks or, in two instances, sulphonating benzene as a step in the production of phenol (carbolic zcid). In more recent years a decided effort has been made to avoid such accidents ;but, if a man is susceptible to benzene it rakes only a small quantity to poison or even to hill him. - -- -. _- f not in the making EXTRAORDINARY SUSCEPTIBILITY TO BENZENE rubber goods, as is --_- y-z:- Before the war, a few cases of chronic benzene 1, ! The differma bmecn the erhuu( ~ . cfrrom y o l i n e and t k oD1J-tar distillare m t o r u r fuel is described Hmdmm. k`m- J. Ldusut Hye. 3: 145. 1921. Seil1~.L.: h i i . Johns Hophnr Hwp. 218 33, 1910. -. _--- Jour. A. Jb. A. M u a 4,1922 - btoody foam in the air and no bewne demoniem' found conspicuous empemmre. In large . narcosis, very deep quickened pulse, and 5. A narcotic effect CHROSIC BENZEKE POISONING PREVENTION OF ACUTE BEXZENE POISONING - -- - - - seems no reason why it should not become general for the detection of benzene. PATHOLOGY OF ACUTE BENZENE POISONING According to Beinhauer,O in acute benzene poisoning -the blood in the heart and vessels is fluid, in the veins 6. Beinhaurn. F.: Mfinehm. med. Wchnschr.. 43:915. 1896. which only 14 per cent. were polymorphonuclears. 7. S u y Bicnr: Vnljhnchr. f. p.utchtL M e d 49: 138. IS88. 8. Lehmum. IC B.: Kurzcs Lchrbuch der Arbeirs. und Geaerbehygiene, Lcipzig, 1919. p 249. ,;: & i r $ R C D G : ~g+;Il~i~~~~~d sb~Sp (Sept. 9 ) 19O1f6t.rn Rcpeacd Tmmfuon of ~1-dJ. A. M. A. 67: 793 11. Hamngmn. T. F.: Boston W. & S. J. 177:203 (Aug. 16) 1917. BENZENE POISONING- HAMILTON 629 Two hitherto unpublished cases of fatal purpura lhemorrhagica caused b benzene fumes were brought before the New York tate Workman's Compensation Commission in 1920. The men had been employed on a machine for coating fabrikoid which is thus described: The fabric is fed in from the front to an endless traveling apron, which carries it over heated pipes. pended The coating mixture runs above a 4 inch (10 cm.) down from a hole in front, can susand the whole is encased in a wooden box. The temperature inside the machine is sufficient to volatilize all the solvent. The coating mixture consisted at that time of nitrocellulose, pigment, castor Cm, grain alcohol, ben- zene and ethyl acetate. Fumes escaped from the hole in front, but still more the back, where the hot coated fabric left the machine. From evidence given at the hearing, it seems that nosebleed among the men in this department was of fairly frequent occurrence, and that the labor turnover was great. They worked eight hour shifts, sometimes sixteen hours, but the latter "not very often." Both of the men who died were young and had always been strong and vigorous UP to the time of their last illness. The first one worked for about nine months before he began to have bleeding from the gums, and he noticed small, red blotches on the skin between the ankles and the knees. Three weeks later, March 21, he had a severe nosebleed. H e was taken to the hospital, March 24, and died. April 7, after repeated nosebleeds, bleeding r`rom the mouth, tem- perature over 101, and the appearance of purpuric spots all over the legs up to the thighs. The second man worked for less than six months, sickened February 17, and died March 9. H e had been feeling ill, complaining of the poor ventilation in the shop and of Ioss of appetite, and was very pale. Then, on the night shift of February 17, he had what one fellow workman called a chill and another a convulsion, his nose began to bleed. and blood oozed from the gums, Evidence given by his physician shows that up to his death he had continual bleeding from the nose and mcuth, bruiselike blotches appeared on the legs and body, and the temperature ranged from 102 to over 104. In neither case was any blood examination made, and the medical details are very scanty, The company had made tests of the air around the coating machines, for it was anxious to prevent the escape of the solvent, which it was trying to recover and use again. Something less than 5 per cent. was reported to be the highest concentration of benzene found in the air, and it is evident that the officials con- sidered this amount too little to cause any anxiety. Xewton l2 of Akron, Ohio, has published the only article in .American literature on the early stages of slow benzene poisoning. Three chemists were exposed to benzene vapors for about two weeks. Onlv a m- e- -A_ - _.-.- - complained and loss of of -ill health : headache. lassitude, anorexia weight. and then a sudden attack of pain in .- the abdomec. nausea and vomiting. Kewton found the -AI- pdse and temperamre normal, bur there was a marked examinations of the blood in workers exposed to benzene. PATHOLOGY OF CHRONIC BESZENE POISONING Selling's la researches and those of Duke l4 show that the pathology of slow benzene poisoiling consists in: (1) a direct destruction of leukocytes with reduced formation of new elements; (2) a destructive action on blood platelets and on the megacaryocytes of the mar- row from which platelets are formed, and (3) destruc- tion of adult red corpuscles and the prevention of the formation of new ones. These changes occur in the order given, the effect on the reds being especially characteristic of very slow poisoning, the last to appear and the last to disappear with recovery. Of the white cells, the polymorphonuclears suffer most. The blood picture, therefore, is largely negative; adult cells dis- - appear and no young cells are formed. The destruction of platelets accounts for the abnormal fluidity of the blood. Hekt~en,'n~oting that Selling's experiments showed . a selective action of benzene on the tissues and cells that are concerned in the production of antibodies and in defense against infection, studied the influence of benzene on the course of infection in animals, and found in rabbits an actual reduction of antibody forma- tion, together with grave lesions in the marrow, a reduction in the number of leukocytes and a reduction in their phagocytic power. Rusk,1Utwo years earlier, had shown that benzene-intoxicated animals produced hemolysins and precipitins less efficiently than normal animals. The work of Weiskotten l7 and his colleagues, although not carried on with this in view, has a decided bearing on industrial benzene poisoning. They have found that the results of exposure of rabbits to benzene vapor are of the same general nature as those produced by subcutaneous injection of an olive oil-benzene mix- ture. Jlaximal sublethal dosage causes leukopenia, hemorrhages and slight anemia. -After discontinuance of exposure, the total leukocyte curve rises to a perma- nent general level, lower than that existing before exposure. Their experiments also confirm those of Rusk and of Hektoen; for, during daily subcutaneous injections of an olive oil-benzene mixture, in four rab- bits there deveIoped evidences of active acute infertion, and in at least two of these it seemed that infections present before the injections began had been "lighted up" by the benzene. In these animals, polymorphonu- clear leukopenia did not occur; in fact, there was the usual leukocytosis of acute infection, and the animals died at its height. They conclude that the leukocyte count cannot be safely depended on in connection with the administration of benzene. It seems fair, therefore, to say that it cannot be absolutely depended on in the diagnosis of industrial benzene poisoning, although Newton's experience shows that it is of great value in detecting early cases. A year or so ago, a man employed in a Boston rubber works using ben- zene cement was taken with nosebleed, breathlessness and weakness, and bruiselike spots appeared over his body. The physician in charge, however, refused to regard the case as one of benzene poisoning because ` there was a high white cell count. One cannot help wondering whether careful examinadon might not ha= --- 1 I w.:13. 14. SdJTetn.pw, L. : katr. z. GU- paotfh.vAunuabLon(LZi.n dlK. the Path. P~ 5 1 : 576 M 191:. m. Int M d Zl: 100 (Jan.) 1913. 15. Hektoen, Ludmg: J. Inf- D*. f9:69 (July) 1916. 16. Rmk. G. Y.: Univ. WifornL Pub. Pathology O r 139. 19 17. Weiokotten H. G.: G i l h C. E. F Bo-. E. araad ton. E. R.; J. Ra. 4 i : I Z S <M.J)1920. rewaied some focus of infection wMch would have At the presaxt monxsr them are ne indktions that _ _ the con& of diphtheria dl p a d e l that- either of - SVEXTIDN OF CHBONXC BEKZENE POZSONIlQG question is, Can it be prevented? Is it @le yeilowfevaoroftypbid. Ifteisbetruethepresent-control measnrcs ordiphtkrk an not swressfal True, the nmrtdky fmm-diphtheria aud.ctonp per _- - _in View of the marked susceptibility of certain mdi- hundred thousandpopltI?tion in the United States has - ----. -.-avkglanaimlst to the benzene effect of to protect workers completely even small quantities- of this been reduced 75 per cent. in the last thirty years ( I W , 64 deaths per hrmdre&-papu!ation; 1920, l5.S- -- . p k n ? T. M, Legge tells. o a man dying of typical deaths per hundred thousand I). Nom- -this - benzene. poisoning after employment for some months reduction in mortality, the number af cases per h- in a Bntish rubber factory, yet analyses of the air a t dred thousand would seem to be approximately tfic-. difFerent points in the room showed only one part of same as thirty years ago. This is asserted on the basis benzene to 10,OOOof air. Recently, I was consulted by of the following consideration: During the early nine- - a large industrial establishment as to the "possible dan- ties, various authorities, from personal experience, ger" of exposing men and women to air containing one placed the case mortality rate at from 25 to 40 per cent part of benzene in 200 parts of air, and at times one On the basis, then, of an average 32 per cent. case mor- - part in 100. It should be noted that Lehmann found tality and a death rate of 64 ger hundred thousand . - that loss of consciousness might occur when them were population (40.677 deaths, 62,941,714population ') for from two to three parts in 100,OOO of air. 1890,there was an annual case rate for the total popu- . Benzene is used in industry as a solvent, which lation of 200 per hundred thousand. It will be noted means that the process is not complete till evaporation here that the case rate is determined from two fairly has occurred, till the solvent has passed off into the definite rates: case mortality and population mortality air. But the workman has tu breathe this air. Ideally, rate. So, then, we may say that in 1890 there was for &__ . - a strong suction exhaust should be installed at the oint of origin of the toxic fumes; but how is this to done in the varnishing of automobiles, removing the total population of the United States a diphtheria mortality rate of 64 per hundred thousand, a case mortality rate of about 32 per cent., and a caserate of 200 shellac from the pews of a church. spreading fabrikoid on textiles, cementing the seams of boots. or building automobile tires ? The practical difficulties are insm- mountable. The surface covered with benzene is so big that no artificial exhaust can be so placed as to catch all the fumes. Moreover, benzene passes through per hundred thousand. In contrast to the rates for 1890,it is found that in the registration area (87per cent. of the total population) there was for 1920 a mortality rate of 15.3 per hundred thousand, and, since the case mortality is about 8 per ~ e n t . ,th~e annual case rate for this average year is 200 per hundred thousand. As additional evi- dence that the rates for 1920 are approximately cor- rect, the following is presented from a more elaborate report of 1919.4 From sixty-eight cities with a com- bined population of 27,148,810 there were reported 65,823diphtheria cases : a case rate of 243 per hundred thousand population. There were 5,404 deaths, making a case mortality of 8 per cent. and a population mor- IS THE CONTROL OF DIPHTHERIA LEADING TO ERADICATION ? tality rate of 20 per hundred thousand. This popula- tion is purely urban, and, to apply these rates to the entire United States. correction must be made for the JAMES GORDON CUMMING, MD, I3st.P.H. WASRINGTON, R C rural population, where the disease is only 0.6 per cent. as prevalent as in the c i t i e ~ . ~When this is done it is for the control of diphtheria g toward the complete eradica- tion of the disease. Since the case rate is approxi- - m t e l y the same as that of thirty years ago, and the mortality rate has shown no appreciable reduction during the last few years, the factors utilized for control must be inadequate for eradication. Eradication is here used as meaning such perfect lrcontrol of the factors of a disease that epidemic spread becomes impossible. Inthis sense the term is_applicable to the status of yellow fever in the United States, where, during the last century, it frequently reached as found that the case rate is somewhat over 200 per hundred thousand population, the case mortality 8 per cent., and the mortality rate slightly over 15 per hun- dred thousand. , Comparing the year 1890 with 1920, there is 75 per cent. reduction in case mortality (from 32 to 8 per cent.), which results in a 75 per cent. reduction in the mortali rate r hundred thousand population (from &`to 1x3,. ut the disappointing feature is that the case rates per hundred thousand population would seem to be about the samtf(200) for the two average years in question. f a r north as Baltimore and Philadelphia in epidemic form; whereas at present its control is so perfect that this disease is no longer a menace to even our southern ports. Similarly, the control measures for typhoid are successful because both the case incidence and the mortality have been increasingly diminishing during the last twenty years. At the present rate of reduction typhoid as a cause of sickness and mortality should RESULTS OF ANTITOXIN TREATMENT During the last twenty-five years this reduction in mortality has been clue almost wholly to the use of antidiphtheritic serum, although the more a c c u r a t e laboratory-diagnosis has been of F e a t help. During the last twenty-five years, serum treatment has resulted in the saving of a million lives in the United States ` soon become practically extinct. Here the main factor - would seem to be the successful prevention of transmission and a cumulative elimination of sources of infection. 1. Mortalib Statistics. U. S. Bureau of the Cenrar 2. Vital Statistics. Part 1, Twelfth Census, U. S.. 1890. 3. Estimated from Pub. Health Rep., 1920. 4. Pub. Health Rep., Dec 17. 1920. p. 302% 5. Morblity Sbtistiw. U. S. Bureau of the Census. 1910, p. 41. -