Document vqOnJR3zgzMe34gbDBQxyRMb

402 ROCKY MOUNTAIN MEDICAL JOURNAL June. 1944 BENZENE (BENZOL) POISONING* REPORT OF A FATAL CASE WITH AUTOPSY FINDINGS ROSCOE H. ACKERLY, M.D., and GARFIELD F. HAWLICK, M.D. PUDBLO. C O W . It was Sir W m . Osler who said, "It is the tragedy of today that man is so indifferent to the life of man. Yes; we surround the babe unborn with premonitory protection, deal wisely and gently with infancy and childhood and then hurl the product of a reasonably healthy youth into a maelstrom of blind chance, of dusts, fumes a n d fatigues, which wear down the stoutest body and cripple the most willing worker." The current emphasis on production today which has come about through the war effort is throwing a much greater responsibility upon the medical departments of indust.ria1 organizations. Wherever workers handle toxic materials, even though mechanical and engineering protection is adequate, medical vigilance must be unrelenting.' To emphasize this point and to add to the literature on benzol poisoning we feel this report to be of -particular interest because of the fact that ( a ) detailed studies had been carried out prior to, during and following a long illness, and ( b ) the concentration of benzol vapors in the working atmosphere were definitely known. CASE REPORT D. D., male, 35 years old; benzol poisoning chronic; hypoplasia red bone marrow, subacute bronchopneumonia; death; postmortem examination. This man entered Corwin Hospital on April 18, 1942, because of a progressive weakness, dyspnea an exertion, rapid pounding heart, a slight bleeding from t h e g u m s of one day's duration and physical imbility to perform his usual easy duties as a chejmist in the by-products department of a coke plant where he had worked for eleven months. His symptoms followed a cold that had developed in February, 1942, and had persisted, though it was not particularly sevea-e. The patient, working in a small room, had been in the habit of rinsing out distilling flasks with benzol six to eight times a day which required ten to fifteen minutes with each operation. The concentration of benzol vapors in the 1aboratol-g varied from 500 parts per million during the height 04 the operation to 30 parts per million Tive minutes after completion. Realizing that a definite occupational hazard was present'. crude solv-ent and cleaner's naphtha were substituted for benzol January 1, 1942. Physical nand complete Mood examination on the patient a few days before had failed to reveal m y significant physical f i n d i n g s or hematological changes. Inorganic urine sulfates were 72.7 per *From t h e Departments of Internal and Industrial Medicine of the Colorado Fuel and lron Corpordion, Corwin Hospital and Clinic. PuetJlo. Celiuado. cent and 77.8 per cent on two occasions a t this time aa determined by the method of Folin' and Yant, Schrenk, Sayers, Horvath and einharta. Physical examination on admission to the hospital revealed a very well developed, well now- ished white male. H e appeared chronically ill for the skin was lemon yellow and almost transparent, or wax-like. The mucous membranes were pale as were the conjunctivae but no signs of bleeding were noted. Cardiac pulsations were visible in the neck and were heaving over the precordium. The pulse rate was rapid and there was a soft hemic apical murmur. The spleen and liver were not palpable nm was there any adenopathy. Laboratory Findings.-Urinalysis: The specific gravity of the urine was 1.017. No,albumin o r pus was present. Inorganic sulfate was 92 per cent (taken three days after last exposure to knz01)4. Blood: Hemoglobin was 31 per cent; red blood count 1,550,000 with 3.7 per cent reticulocytes. T h e white blood count was 3,450 with 10 per cent stab forms, 10 per cent segmented forms and 50 per cent lymphocytes. Platelet count was 171,000. Bleeding time was 3 minutes, 1 0 seconds and the coagulation time was 3 minutes, 45 seconds. The Kahn and Kolmer were negative. Treatment and Clinical Coursc.-The patient was immediately started on supportive therapy including a high vitamin, high caloric diet, yellow bone marrow by mouth, liver extract intramuscularly, vitamin C and B by mouth and parenterally. hema- tinic plastules with liver and strict oral and per- sonal hygiene with much fresh air and sunshine. In addition, blood transfusions were given weekly. In spite of a teeling of well-being on the part of the patient, his progress was unsatisfactory. On Aug. 20, 1942, the hemoglobin was i-l per cent; red blood count 3,390,000; white blood count 5.100, with 4 per cent eosinophils, i per cent stab forms, 43 per cent segmented forms, 43 per cent lymph* cytes and 3 per cent monocytes. T h e patient, although only slightly improved, was very anxious t o go home for a few days. Permission was reluctantly &anted on Sept. 11, 1942; however, he returned fourteen days later with a severe chest cold of five days' duration. Physical examination at this time revealed an acutely ill patient. His temperature was 102.8 F., pulse rate 100 per minute and respiratory rate 28 per minute. He complained of masked sub- sternal tightness and coughed intermittently Producing a thick greenish yellow mucoid material. The lung fields were filled with coarse crackles throughout with scattered areas of bronchial breathing. Roentgen examination failed to visualize any pneum~nicprocess but there was a mild increase in the peribronchial markings. Laboratory Report.-Urinalysis : The specific gmvity was 1.033. Blood: The. hemoglolbin was 79 per cent; red blood count 3,650.000; white blood count 3,3QO with 12 per cent s b b forms. 53 per cent segmented farms, 32 per cent lymiphocytes and 3 per cent monocytes. Sputum: Repeated typings were negative for pneumococcus. 0 The patient was thought to be suffering frum a pneumonic process but in view of the sen30116 Maod findings sulfanol dnrgs wem affnraan&cated. He WBB pia~edin an oxygen teni and predare 1944 at this in- and t 1. lie hos1 nour. 111 for .parent, re pale leeding ible i n xdium. a soft 'r \!-ere ipe-cific min o r 92 per ure to i blood IS. The it stab 50 per 171,000. nd the . The nt was includr bone ulai ly, hemaId perishin e. eekly. lait of 3.. o n cent; 5.100, foims, -mphoatient, nxious as reer. he chest ed an 2.S F., - rate 1 SubY protelial. wkles nchial J visvas a iecific : red I with 1ented cent e for 'om a -rious catetl. brious June, 1944 ROCKY MOUNTAIN MEDICAL JOURNAL 403 therapy was resumed. His course was septic, the sectioned organ was a deep reddish brown and t h e temperatuie showing a daily elevation to very soft. 104 F., with a corresponding increase in respira- Liver: The liver was not enlarged, but the ex- tion and pulse late. Because of t h e poor progress ternal surface was a pale reddish brown. The cut u; of the patient, sulfadiazine later was administered, turface was not remarkable. 2 gm. initially with 1 gm. every four hours. This Bone Marrow: The appearance of the marrow produced no relief of symptoms or seeming effect obtained from ribs, sternum, and vertebrae was on the blood picture. The last blood study per- similar. I t was grayish red, moist and abundant. formed on Oct. 26, 1912, revealed a hemoglobin Marrow obtained from the upper tibia was of the of 54 per cent: a red blood count of 2,630,000; a yellow adipose type. white blood count of 4,600 with 3 per cent eosino- Microscopic Examination.-Lungs: The bronchi phils, 19 per cent stab forms, 35 per cent s e g were slightly to moderately dilated. The mucosa mented forms, 40 per cent lymphocytes and 3 per was intact but was extensively infiltrated with cent monocytes The patient died on Nov. 3, leukocytes including lymphocytes and monocytes, 1942, after an illness of appioximately nine months. with scattered granulocytes. The bronchial lu- mina almost all contained mucopurulent exudate Autopsy Observations in large quantity. Some of the' small bronchi i Autopsy \\a? performed twenty-three hours post- were partly filled with granulation tissue as well mortem and twenty hours after embalming. An as exudate. The lung parenchyma showed a abstract of the important findings follows : patchy exudate, more or less purulent and partly i I I , r, i c i ! Fig. 1. Spleen. Lymphoid hypoplasia. x150. Gross Examination.-The body wa.s that of a \vel1 developed and well preserved young adult male. The skin had a pallid, m t h w yellowish tint. No free fluid was present in the body cavities but all organs had a pale appearance. Lungs: The right and left lungs presented similar changes. The visceral pleurae were mottled with a dark anthracotic pigment. A few friable adbesicns joined the left lower lobe to the diaphragm. To palpation firm nodular areas were 1;oted with intervening crepitant areas. The lower lo'bes were heavy and many more nodular areas were present. The cut surface of the sectioned lungs was reddish brown, exuded a reddish frothy fluid and the nodular areas were conspicuGUS. From the cut smaller bronchi a white mucoid material could b e expressed which was similar to material in the trachea. and bronchi. Spleen: This organ was not enlarged. To palpation i t was rely flaccid. The cut surface of Fig. 2. Lirer. Fatty metamorphosis. xli5. 0 1 ganized, tilling scattered groups of alveoli. There was moderate anthracotic pigmentation of the interstitial tissue and atelectasis and emphysema were present throughout. Spleen: In some areas the sinusoids were empty, dilated with large lining cells, and elsewhere were ccmpressed. The pulp spaces contained normoblasts, myeloid cells and occasional megakaryocytes and also many phagocytic cells loaded with brown granular pigment. Malpighian bodies were reduced in number. Those remaining were small and were without germinal centers. Liver: Contained abundant pigment of two types. One was seen in liver cells and bile canaliculi. It was dense, yellow-green and hyaline. The other was brown, granular and appeared in sinusoidal lining cells. Liver structure was not normal. The central veins were not well defined, and the lobules were correspondingly distorted. The liver cells were coarsely granular, with unevenly stained irregular nuclei. Fatty metamorphosis was present I cells a n d blood vessels t l i i l ~ not ;i[~pear to be significantly ;ilteiwl. The erythroblastic. elements were i,eliresented hy small clumps of small (lark staini ng c-r11s. chie'fly 11ormobla st R . Megalit1lyocytes \\'ere nun~ei'ous. irregularly spaced. with I clear percentage is the best index of early poisoning. These same authors also report cases with increased leukocyte counts, eosinophilia, thrombocytosis and thrombopenia. There may be a tendency to polycythemia but the usual tendency is for a progressive anemia to develop with a corresponding depression of the hemoglobin. The pathology of this condition has been admirably described by Mallory, Gall and Brickleys. They describe the entire hematopoietic system undergoing marked changes. Long exposure to benzol produces extreme marrow hyperplasia and extramedullary hematopoiesis and is the more common finding. Short or long exposure may produce a severe hypoplasia of the hematopoietic tissue or there may be a n intermediate reaction. summary 2 1. A fatal case of benzol poisoning has 3 been presented with autopsy observations. 2. T h e duration of exposure, concentra- tion of the vapors and clinical course are W - eL'/"k';cprcTd? dis3c.ussTehd.e pathological changes present in Fig. 3 . Vei.tebixl konr nxiimw. Hypc~pli~sio:f~ this case are consistent with the findings of eryt11imbl:iatic. elenients. s 1 i 5 . Mallory, Gall and Brickleys in chronic ex- m a lied \ - a r i a t i o n i n size. shape and nuc1e;ir con- figuraricn. All of' the myeloid elemenrs wei'p pres- ent. t u t n1iIture zixiiu~ocyteswere less numerous than 1101nial. Eosinophilic granulocytes were present t u t \\-ere ~ i i ~ o ~ ~ o i ~ i o nraedt eucl yed i n number. ~ h r~:i~edcmin;itcr ell wan undifferentiated n o n - p i : ~ ~ ~ \u\-lit;ii~ ~i i .1ai.ge reticular. roiintl. oval or indented nucleus. Pisnent. deposition was not demcnnrmblr i n rile bone niarmv-. posure to benzol in what they describe a s the intermediate group of cases. 4. Brwchopneumonia was a complicating and terminal factor. 5 . Prevention of this condition must be brought about by more efficient medical and engineering control and by education of the Comment worker. T h e authors wish to thank Dr. William C. Ccntinucd 01' intermittent exposure to ben- Black, Professor of Pathology, University zol prcauccs i n certain indiL-iduals irre1,ersible of Colorado School of Medicine, for prepar- change... T n e r c cnanges depend upon dura- ing the microscopic report and furnishing the .tion :., CI.:X?-LTL concentration ci the \.apors photamicrog raphs - a n d :z:::.::.>I;;. -:i>,:cncinlllr~: T h e iasi iactor seem: . L - . ?i :;T.DGrian: IC.- i: na5 been BIBLIOGRlLPW 'Standards on Allowable Concentrations of Toxic 3 i f I I Von >honu- early report :s, eobpenia. iia but inemia :ession - s been 11 and tmatolanges. xtreme r` heminding. severe sue or ig has ms. :en trase are ent in ngs of iic exibe as icating ust be a1 and of the iam C. versity meparing the f Toxic )ciation. erndina- L: Hor`atePeisure. J. 6. R. R: e Expo- lune. 1944 ROCKY MOUNTAIN MEDICAL IOURNAL mi MANAGEMENT OF THE SILICOTIC PATIENT PAL% J. BAMBEIRGER. . \ I D * CLIMAX. COLORAD( ) Silicosis. by the very nature of the disease, does not lend itself t o effective treatment and our efforts, once the disease has been acquired, must necessarily be directed toward halting the process short of disablement. T h e problem therefore resolves itself into one of proper management of the patient rather than of treatment in the usual sense of the word. That the problem of adequate supervision and treatment of workmen in the dusty trades is the problem not only of the indus- With these conditions aggravated by the war. the family physician must inevitably assume a greater share of the responsibility for the proper management of silicotic patients. Good practice in the management of the silicotic a s well as in the solution of the whole problem of silicosis demands that physicians assume a greater responsibility for the conditions under which their patients work. It should be required that the air these patients Fig. 1 Fig. 2 trial physician but of the general practitioner as well is indicated by the results of a recent survey of the industrial hygiene problem in fifteen states, including Colorado, Idaho, and Utah'. From these results it was estimated that over 1.000,OOO workers in the United States are exposed to silicious dust. Of special interest to the mining W e s t is the fact that of 55.676 workers in 548 plants devoted to the extraction of minerals. not more than 40 per cent had the services of a plant physician either part time or full time. - *Resillwit I'l~ysician. C l i m a x ~ l o l y l ~ d e n u r nCompan?-. ( " l i m : i \ , (*OIL breathe be made to conform to established minimum standards of freedom from dangerous dusts. T h e physician who fails to do this is not justified in permitting the patient to continue in his hazardous employment. Unortunately, the removal of the silicotic worker will only result in a healthy worker being exposed to the s a m e hazard and the physician thereby contributes to the perpetuation of the disease. T h e primary responsibility of the physician who undertakes the management of the patient with silicosis is to advise him intelligently and truthfully as +o the necessity for