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Acute toluene poisoning during painting
Forensic Elsevier
Science International, Scientific Publishers
109
32 (1986) 109-115 Ireland Ltd.
ACUTE TOLUENE POISONING DURING PAINTING
SANAE TAKEICHI*, Osaka
Medical
TADASHI
Examiner’s
YAMADA
Office,
Osaka
and ICHIRO
SHIKATA
(Japan)
Received December 30, 1985) Revision received March 31, 1986) (Accepted June 16, 1986)
Summary Autopsy findings on a man who fel1 from a height due to acute toluene poisoning while painting are described. Gas chromatographic examination revealed that the toluene concentrations of his blood, lung, liver and brain were 48, 35, 65 and 80 uglg, respectively. These toluene levels were not enougb to be definitely lethal, but were high enough to anesthetize the centra1 nervous system. Key words:
Fa11 from height; Acute toluene poisoning;
Painter’s
work
Introduction Death from toluene poisoning is usually observed in cases of suicide or in accidents of adolescents while sniffing thinner. This paper reports a rare autopsy case of a painter, who fel1 from a height of about 20 m while working in a nearly closed poorly ventilated chamber. At first, he was reported to have died of oxygen deficiency. But autopsy revealed high concentrations of toluene in his blood, brain and other organs. It is concluded that his fa11resulted from centra1 nervous system anesthesia due to inhalation of toluene mixed in the paint as a diluent. He died shortly afterwards from genera1 contusions, mainly of the cerebrum. Case report Case. K.M., male painter,
aged 20.
Past history
On April 24, 1981, the subject was occupied with rust-preventive painting work together with three colleagues inside the bridge pier of the Hanshin*To whom correspondence Professor SUW Takeichi, Tokushima, Kuramoto-cho
and reprint requests should be addressed: Present address: Assoc. Dept of Legal Medicine, School of Medicine, The University of 3-chome, Tokushima 770, Japan.
0379-0738/86/ $03.50 0 1986 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
110
highway, in a space 20 m high, 2 m long and 2.5 m broad, His colleagues felt unwell while at work and went out to take a rest from their work at about 1500 h, and then they became aware that he was missing. The relief squad was notified at 1900 h and found him dead at the bottom of the pier at 2000 h. They said that when they went into the space, where he had been working, it was pitch-dark and so stuffy that they had to use oxygen masks. There was also a sweet irritating odor. Although the paint “Eposyl NS Black-Brown” manufactured by KansaiPaint K.K., contained no solvent and there was a notice on the label stating “Do not add thinner”, a person in charge stated that before use they usually added 2% thinner to the paint as a diluent. The thinner was composed of toluene, ethyl acetate, acetone, methanol and butyl acetate, in a ratio of 70:15:5:5:5%w/w. Autopsy findings A postmortem examination was performed at 1400 h on April 25, 1981. General. The body was in a state of normal nourishment, being approximately 161 cm in length and weighing about 56 kg. Rigor mortis was advanced in al1 joints and lividity on the back was slight. There were many traumatic injuries to the whole body as described later. The scalp was covered by black hair. The lips were pale and cyanotic. The palpebral conjunctivae were congestive and there was a petechia on the left one. The pupils were round, measuring 0.5cm in diameter. The teeth were not remarkable and the tongue was behind the dental arch. Traumatic injuries on the body. Head: An irregular triangular contusion on the left tempora1 region measuring 4.4 x 4.0 x 0.8 cm extended to the skull. The left ear lobe showed a linear contusion about 1.5 cm long. A considerable amount of blood was seen in both external auditory meatuses. Face: Seven lesions of irregularly demarcated excoriations with intracutaneous hemorrhage measuring 7.2 X 2.2, 2.0 x 3.0, 4.2 X 1.6, 2.2 x 0.5, 1.4 x 0.4, 1.0 x 0.8 and 2.0 x 1.5 cm were seen. Subcutaneous hemdrrhage around the orbit was seen on both sides. Ne&: A subcutaneous hemorrhage with slight excoriation measuring 9.0 x 5.5 cm on the left side and two lesions of excoriation and subcutaneous hemorrhage measuring.2.5 x 0.2 cm and 2.2 x 1.4 cm on the other side of the neck were seen, Breast, Back and Abdomen: On the right sides of the breast and back, and on the left side of the abdomen, there were large lesions measuring 5.0 x 3.5 cm, 12.0 x 9.0 cm and 24.5 x 11.0 cm showing subcutaneous hemorrhage with excoriation. Extremities: A contusion measuring 6.8 x 2.6 cm on the posterior side of the left forearm and a complete fracture of the middle portion of the right humerus were seen. At a point 9.0 cm above the knee joint on the anterior side of the left thigh, a contusion measuring 4.5 x 2.8 cm with a complex open fracture of the femur was seen. Hemorrhage with soft coagula was seen in the muscle and soft tissue surrounding these fractures. Many other smal1 lesions of subcutaneous hemorrhage and excoriation were seen in various parts of the whole body
111
Primory im&on. A typical “I” incision was made. The subcutaneous fat tissue was 0.7 cm thick in the abdominal mid-line. Abdominal cauity: The diaphragm extended from the 5th rib on the right to the 5th intercostal space on the left. The mutual positions of organs were normal. The abdóminal cavity contained a smal1 amount of blood. Massive hemorrhagic lesions were seen in the mesenterium and fatty tissue around the left kidney, measuring about 10 x 10 and 12 x 10 cm, respectively. The transverse and descending mesocolons showed massive hemorrhages. PleuraZ cauity: Fractures of the left clavicle at a point near the sternoclavicular joint and of the 1st and 3rd ribs at points near the cartilages were seen. The 1st to 7th left ribs were also fractured at the Costa1 angles. Intramuscular hemorrhage was seen in the regions round the fractures. There was about 700 ml of blood in the pleura1 cavity: about 100 ml on the right and 600 ml on the left. The pericardial sac contained only a few milliliters of a light amber fluid. Heart (weight, 25Og). The epicardium showed a smal1 petechia. The pericardial fat was normal. The wal1 of the left ventricle was 1.6 cm thick, and that of the right ventricle was 0.3 cm thick. The myocardium, endocardium and ostia were not remarkable. The coronary arteries and aorta showed no significant changes. Lungs: The left lung weighed 400 g, and the right 430 g. Grossly, the two lungs appeared slightly edematous and slightly reddish, and insufficiently aerated throughout. The lower lobe of the left lung was contused and crushed, measuring about 8.0 x 4.0 x 2.0 cm. The upper lobe of the left lung and middle lobe of the right lung showed marked congestion. Sections through al! the lobes revealed numerous patches of hemorrhage. Numerous petechiae were seen on the visceral pleura. The lymphnodes of the pulmonary hila were not appreciably swollen. The trachea and bronchi were filled with a mucoidmaterial containing a large amount of blood and these mucosae were slightly reddish. Liuer: The liver weighed 1060 g and had an elastic firm consistency. The surface was smooth, but on the right lobe two ruptured lesions were seen of respectively 8.0 and 4.0 cm in length and 0.4 and 0.5 cm in depth. Sections showed no significant changes except marked anemia. The gallbladder showed no remarkable changes. Spleen: The spleen weighed 70 g. The capsule and sections showed no abnormalities. Pancreas: This weighed 70 g. It was normal in consistency and sections showed no abnormalities. Kidneys: The left kidney weighed 110 g, and the right 100 g. Grossly, both kidneys appeared similar and were slightly soft in consistency. The capsule was stripped off easily. In section, the cortex was sharply demarcated from the medullary tissue, and appeared normal. Adrenals: These showed no significant changes except slight postmortem softening of the medullary tissue. Urinary Bladder: The bladder contained about 300 ml of slightly turbid amber urine. The mucosa was pale. Digestive Z’ract: The esophagus showed no abnormalities. The stomach contained about 50 ml of milky-white, wel1 digested material, and no foreign matter. The duodenum, smal1 intestine, colon showed no significant abnormalities. SkuZZ: Numerous complicated linear fractures were seen running irregularly from the left
112
tempora1 bone to the parietal, frontal and occipital bones and reaching the opposite tempora1 side crossing the base of the skull. Bruin: This weighed 1280 g and showed diffuse subarachnoideal hemorrhage. Contusions of the cerebral cortex were seen under the right and left tempora1 lobes measuring about 3.0 x 4.0 cm and 2.0 x 2.0 cm with hemorrhage and congestion. The arteries at the base of the brain showed no significant changes. Anatomical
diagnosis
(1) Many’ excoriations and contusions on the whole body, and multiple fractures of the skull, clavicle, ribs, right humerus and left femur. (2) Cerebral contusion and subarachnoideal hemorrhage. (3) Hemorrhage in the thoracic cavity (approx. 700 ml), in the retroperitoneal space and mesenterium. (4) Lacerations of the liver and left lung. (5) Edema and diffuse hemorrhage of the lungs. Histological
findings
Sections obtained from various organs and tissues were fixed in 10% neutral buffered formalin and stained with hematoxylin and eosin. NO significant abnormalities were observed except acute hemorrhagic changes in the lungs and the muscle around fractures, supporting the macroscopical findings described above. Chemical
examination
The toluene concentrations in the blood and some organs were measured by gas chromatography as described by Kojima et al. [l-31. A Shimazu gas chromatograph, Model GC-8A, with a flame ionization detector was used with a 150cm glass column (0.26cmi.d.) packed with 60/80 mesh Chromosorb 101. The column temperature was 180°C and nitrogen was used as carrier gas at a pressure of 2.0 kg/cm2. One gram of tissue was homogenized with an equal volume of cold water in a glass homogenizer. The homogenate and 50 ~1 of 0.5% w/v ethylbenzene in ethanol as an internal standard were poured into a lO-mlvial, which was stoppered with a rubber cap. The via1 was then warmed in a water bath at 60°C for 20 min, and 0.5 ml of warmed air phase was analysed by gas chromatography. The amounts of toluene detected in the blood, lung, liver and brain were 48,35,65 and 80 kg/g, respectively. NO ethanol was detected by the standard method of gas chromatography [41 in blood from the heart. Discussion
Deaths closely connected with acute thinner poisoning cited from several references 15-71 are summarized in Table 1. The present case showed lower levels of toluene in the blood and other organs than the case of death definitely due to toluene poisoning, but higher levels than three exceptional cases cited from Kashima et al. [71, in which death was reported to have
during painting
M
20
F
M
M
**Present case. ’Trace. -: Not detectable.
*Cases from Osaka Medical
12.
15.
18
ll.
during painting
35
10.
M
16
9.
19
33
8.
M
M
M
M
F
Examiner’s
POISONING
drowning after poisoning drowning after poisoning drowning after poisoning genera1 contusion (fa11 after poisoning
asphyxiation asphyxiation
asphyxiation
asphyxiation
acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning (?) acute toluene poisoning (? )
Cause of death
THINNER
Office for 1977 to 1980
vinyl bag
vinyl bag &
vinyl bag &
vinyl bag &
14.
28
7.
during painting
61
6.
M
17
5.
19
20
4.
13.
47
3.
M
during painting
15
2.
M
22
1.
35
Means of death
WITH ACUTE
with a a cord with a a cord with a a cord with a
Sex
CONNECTED
M
Age
CLOSELY
with a vinyl bag over the head with a vinyl bag over the head on a bed soaked with thinner on a bed soaked with thinner on a bed soaked with thinner with a vinyl bag & a cord round the neck on a bed
1
M
No.
Case
DEATHS
TABLE
t
-
48
18
18
16
18 15
26
6
10
25
43
29
79
110
Bloed
17
10
35
_
-
-
-
-
(+)
-
-
-
21
63
100
Luw
-
-
-
-
65
58 10
80
(+)
-
64
104
-
350
400
Liver
Toluene concentration ( pg/g)
-
-
-
-
-
-
80
75
28
106
186
312
590
740
Brain
(**)
et al. [SI Fukui et al. [SI Fukui et al. [61 Fukui et al. [61 Kashima et al. [71 Kashima et al. [71 Kashima et al. 171
(*) Fukui
(*)
(*)
(*)
Kashima et al. [51. Kashima et al. [51 Kashima et al. [51
Soume
114
occurred during rust-preventive painting work in a tank for raw sewage disposal. These painters drowned upon falling into water in the bottom of the tank. Their falling was attributed to disturbance of the centra1 nervous system due to acute toluene poisoning. Although the toluene concentration in each organ depends upon the time after inhalation [8,91 there are reports that larger amounts of toluene accumulate in the brain and fatty tissues than in other parts of the body 19-111. In the present case, the toluene concentrations in the blood and brain were high, but not so high as to be lethal, so the centra1 nervous system may have been strongly disturbed. Our latest experiment 1121and other papers 113,141 have shown that changes in cortical and subcortical electroencephalogramsappear in the early stages of exposure to a high concentration of toluene vapor or thinner. There are some reports of histological findings in toluene poisonings 115,161. In this case, no significant changes were seen other than acute hemorrhagic diathesis and congestion, especially in the lungs. NO fatty change or eosinophilia [51 of genera1 organs were observed. Thus the body may not have had enough time to react morphologically to invasion of toluene before death. Vita1 reactions, such as hemorrhage around contusions and fractures, etc. were observed. The toluene concentrations of the blood and organs were not so high as to be definitely lethal. Under the present conditions, death from toluene poisoning might take a very long time considering the capacity of the space (approx. 100 m3> and the oxygen consumption of humans (250 ml/min per man) 1171. The maximum allowable concentration of toluene has been set at 100 ppm [183. The wal1 of the space in which the painter was working was 180 m2 and the paint which contained 2% w/w of thinner or 1.4% w/w of toluene was used at 300g/mz. If 1/3 of the area had been painted at the time of death, about 250 g of toluene would have been applied to the wall. Based on the amount of toluene applied and the capacity of the space this value is calculated to be about 6 times the maximum allowable concentration. Moreover, the toluene concentration was probably higher towards the bottom of the space, because toluene vapor is heavier than air. Therefore, we conclude that the cause of death in this case was genera1 contusions, mainly cerebral contusion, due to a fa11from a height with acute sub-lethal toluene poisoning and some degree of oxygen deficiency. We hope that in future there wil1 be strict supervision of working conditions to prevent accidents of this type. References 1 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation Quantitative determination of toluene in tissue by gas chromatography. Jpn. J. Legal Med., 27 (1973) 255-257. 2 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation - Death due to toluene poisoning and the toluene tissue level. Jpn. J. Legal Med., 27 (1973) 258-262.
115 3 T. Kojima, T. Takeoka, M. Yashiki and H. Kobayashi, Toxicological study on toluene poisoning by inhalation - Effect of inhalation of toluene and ethyl acetate mixed vapor on death. Jpn. J. Legcrl Med., 31 (19’77) 280-290. 4 T. Ishikura, T. Ohsawa, Y. Kuroiwa, H. Kotsuka, Y. Nakazawa and T. Niwaguchi, Standard Methods of Chemical Analysis in Poisoning, with Commentary, 1st edn., Pharmaceut. Sec. Japan, Nanzan-do, Tokyo, 1974, pp. 61-63 (in Japanese). 5 T. Kashima, M. Fukui, Y. Masuda, C. Wakasugi and R. Hayama, Report of five cases, wbere an ordinary vinyl bag was used for suicidal purpose. Jpn. J. Legal Med., 23 (1969) 248-252. 6 M. Fukui and H. Kumaoka, Saiban Kagaku, 2nd edn., Hirokawa Publishing Co., Tokyo, 1972, p. 91. (in Japanese) 7 T. Kashima, M. Fukui, N. Mikake and C. Wakasugi, Saigai Iguku, 11 (1968) 1422-1426 (in Japanese). 8 K. Okamoto, Medico-legal st,udies on intoxication by organic solvent: detection of toluene in urine from glue-sniffers and its relationship to their clinical signs. Acta Crin. Japon., 47 (1981) 60-74. 9 K. Pyykkö, H. Tähti and H. Vapaatalo, Toluene concentrations in various tissues of rats after inhalation and oral administration. Arch. Toxicol., 38 (1977) 169-176 10 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation Correlation of toluene concentration on exposure with mortality and toluene tissue level. Jpn. J. hgal Med., 27 (1973) 282-286. 11 S. Takahashi, Toxicological studies on organic solvents. 11, Tissue distribution of toluene and hippuric acid leve1 in urine after toluene inhalation. Jpn. J. Legul Med., 36 (1982) 344-355’. 12 1. Tokunaga, S. Takeichi, K. Kobayashi and M. Maeiwa, Electroencephalographical analysis of acute toluene poisoning. Jpn. J. Legal Med. (submitted). 13 H. Mukoyama, S. Ikemoto, K. Sakai, H. Oki, E. Suzuki, R. Mukoyama, S. Seta and M. Kitahara, A study on the cause of death by thinner inhalation. 111, Anesthetic effect of aromatic hydrocarbon (toluene, benzene and Xylene) gas inhalation on living organisms. Rep. Natl. Res. Inst. Police Sci., Res. Forensic Sci., 25 (1972) 151-159. 14 P. Andersen and B.R. Kaada, The electroencephalogram in poisoning by lacquer thinner (butyl acetate and toluene). Acts Pharmacol. Toxicol, 9 (1953) 125-130. 15 N. Tsukada, Studies on experimental toluene poisoning, Tokyo Jikeikai Med. J., 95 ( 1980) 1298-1312. 16 E. Seta, R. Mukoyama, H. Mukoyama, K. Sakai, H. Oki, E. Suzuki, S. Ikemoto and M. Kitahama, A study on the cause of death by thinner-inhalation. (5 1Histological observations of animals inhaled thinner gas. Rep. Natl. Res. Inst. Police Sci., Res. Forensic Sci., 25 ( 1972) 19-26. 17 W.F. Ganong, Reuiew of Medical Physiology, 8th edn., Lange Medical Publications, California, 1977, p. 519. 18 The American Conference of Govemmental Industrial Hygienists. Threshold limit values 1982, Cincinnati, Ohio, USA.
Science International, Scientific Publishers
109
32 (1986) 109-115 Ireland Ltd.
ACUTE TOLUENE POISONING DURING PAINTING
SANAE TAKEICHI*, Osaka
Medical
TADASHI
Examiner’s
YAMADA
Office,
Osaka
and ICHIRO
SHIKATA
(Japan)
Received December 30, 1985) Revision received March 31, 1986) (Accepted June 16, 1986)
Summary Autopsy findings on a man who fel1 from a height due to acute toluene poisoning while painting are described. Gas chromatographic examination revealed that the toluene concentrations of his blood, lung, liver and brain were 48, 35, 65 and 80 uglg, respectively. These toluene levels were not enougb to be definitely lethal, but were high enough to anesthetize the centra1 nervous system. Key words:
Fa11 from height; Acute toluene poisoning;
Painter’s
work
Introduction Death from toluene poisoning is usually observed in cases of suicide or in accidents of adolescents while sniffing thinner. This paper reports a rare autopsy case of a painter, who fel1 from a height of about 20 m while working in a nearly closed poorly ventilated chamber. At first, he was reported to have died of oxygen deficiency. But autopsy revealed high concentrations of toluene in his blood, brain and other organs. It is concluded that his fa11resulted from centra1 nervous system anesthesia due to inhalation of toluene mixed in the paint as a diluent. He died shortly afterwards from genera1 contusions, mainly of the cerebrum. Case report Case. K.M., male painter,
aged 20.
Past history
On April 24, 1981, the subject was occupied with rust-preventive painting work together with three colleagues inside the bridge pier of the Hanshin*To whom correspondence Professor SUW Takeichi, Tokushima, Kuramoto-cho
and reprint requests should be addressed: Present address: Assoc. Dept of Legal Medicine, School of Medicine, The University of 3-chome, Tokushima 770, Japan.
0379-0738/86/ $03.50 0 1986 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
110
highway, in a space 20 m high, 2 m long and 2.5 m broad, His colleagues felt unwell while at work and went out to take a rest from their work at about 1500 h, and then they became aware that he was missing. The relief squad was notified at 1900 h and found him dead at the bottom of the pier at 2000 h. They said that when they went into the space, where he had been working, it was pitch-dark and so stuffy that they had to use oxygen masks. There was also a sweet irritating odor. Although the paint “Eposyl NS Black-Brown” manufactured by KansaiPaint K.K., contained no solvent and there was a notice on the label stating “Do not add thinner”, a person in charge stated that before use they usually added 2% thinner to the paint as a diluent. The thinner was composed of toluene, ethyl acetate, acetone, methanol and butyl acetate, in a ratio of 70:15:5:5:5%w/w. Autopsy findings A postmortem examination was performed at 1400 h on April 25, 1981. General. The body was in a state of normal nourishment, being approximately 161 cm in length and weighing about 56 kg. Rigor mortis was advanced in al1 joints and lividity on the back was slight. There were many traumatic injuries to the whole body as described later. The scalp was covered by black hair. The lips were pale and cyanotic. The palpebral conjunctivae were congestive and there was a petechia on the left one. The pupils were round, measuring 0.5cm in diameter. The teeth were not remarkable and the tongue was behind the dental arch. Traumatic injuries on the body. Head: An irregular triangular contusion on the left tempora1 region measuring 4.4 x 4.0 x 0.8 cm extended to the skull. The left ear lobe showed a linear contusion about 1.5 cm long. A considerable amount of blood was seen in both external auditory meatuses. Face: Seven lesions of irregularly demarcated excoriations with intracutaneous hemorrhage measuring 7.2 X 2.2, 2.0 x 3.0, 4.2 X 1.6, 2.2 x 0.5, 1.4 x 0.4, 1.0 x 0.8 and 2.0 x 1.5 cm were seen. Subcutaneous hemdrrhage around the orbit was seen on both sides. Ne&: A subcutaneous hemorrhage with slight excoriation measuring 9.0 x 5.5 cm on the left side and two lesions of excoriation and subcutaneous hemorrhage measuring.2.5 x 0.2 cm and 2.2 x 1.4 cm on the other side of the neck were seen, Breast, Back and Abdomen: On the right sides of the breast and back, and on the left side of the abdomen, there were large lesions measuring 5.0 x 3.5 cm, 12.0 x 9.0 cm and 24.5 x 11.0 cm showing subcutaneous hemorrhage with excoriation. Extremities: A contusion measuring 6.8 x 2.6 cm on the posterior side of the left forearm and a complete fracture of the middle portion of the right humerus were seen. At a point 9.0 cm above the knee joint on the anterior side of the left thigh, a contusion measuring 4.5 x 2.8 cm with a complex open fracture of the femur was seen. Hemorrhage with soft coagula was seen in the muscle and soft tissue surrounding these fractures. Many other smal1 lesions of subcutaneous hemorrhage and excoriation were seen in various parts of the whole body
111
Primory im&on. A typical “I” incision was made. The subcutaneous fat tissue was 0.7 cm thick in the abdominal mid-line. Abdominal cauity: The diaphragm extended from the 5th rib on the right to the 5th intercostal space on the left. The mutual positions of organs were normal. The abdóminal cavity contained a smal1 amount of blood. Massive hemorrhagic lesions were seen in the mesenterium and fatty tissue around the left kidney, measuring about 10 x 10 and 12 x 10 cm, respectively. The transverse and descending mesocolons showed massive hemorrhages. PleuraZ cauity: Fractures of the left clavicle at a point near the sternoclavicular joint and of the 1st and 3rd ribs at points near the cartilages were seen. The 1st to 7th left ribs were also fractured at the Costa1 angles. Intramuscular hemorrhage was seen in the regions round the fractures. There was about 700 ml of blood in the pleura1 cavity: about 100 ml on the right and 600 ml on the left. The pericardial sac contained only a few milliliters of a light amber fluid. Heart (weight, 25Og). The epicardium showed a smal1 petechia. The pericardial fat was normal. The wal1 of the left ventricle was 1.6 cm thick, and that of the right ventricle was 0.3 cm thick. The myocardium, endocardium and ostia were not remarkable. The coronary arteries and aorta showed no significant changes. Lungs: The left lung weighed 400 g, and the right 430 g. Grossly, the two lungs appeared slightly edematous and slightly reddish, and insufficiently aerated throughout. The lower lobe of the left lung was contused and crushed, measuring about 8.0 x 4.0 x 2.0 cm. The upper lobe of the left lung and middle lobe of the right lung showed marked congestion. Sections through al! the lobes revealed numerous patches of hemorrhage. Numerous petechiae were seen on the visceral pleura. The lymphnodes of the pulmonary hila were not appreciably swollen. The trachea and bronchi were filled with a mucoidmaterial containing a large amount of blood and these mucosae were slightly reddish. Liuer: The liver weighed 1060 g and had an elastic firm consistency. The surface was smooth, but on the right lobe two ruptured lesions were seen of respectively 8.0 and 4.0 cm in length and 0.4 and 0.5 cm in depth. Sections showed no significant changes except marked anemia. The gallbladder showed no remarkable changes. Spleen: The spleen weighed 70 g. The capsule and sections showed no abnormalities. Pancreas: This weighed 70 g. It was normal in consistency and sections showed no abnormalities. Kidneys: The left kidney weighed 110 g, and the right 100 g. Grossly, both kidneys appeared similar and were slightly soft in consistency. The capsule was stripped off easily. In section, the cortex was sharply demarcated from the medullary tissue, and appeared normal. Adrenals: These showed no significant changes except slight postmortem softening of the medullary tissue. Urinary Bladder: The bladder contained about 300 ml of slightly turbid amber urine. The mucosa was pale. Digestive Z’ract: The esophagus showed no abnormalities. The stomach contained about 50 ml of milky-white, wel1 digested material, and no foreign matter. The duodenum, smal1 intestine, colon showed no significant abnormalities. SkuZZ: Numerous complicated linear fractures were seen running irregularly from the left
112
tempora1 bone to the parietal, frontal and occipital bones and reaching the opposite tempora1 side crossing the base of the skull. Bruin: This weighed 1280 g and showed diffuse subarachnoideal hemorrhage. Contusions of the cerebral cortex were seen under the right and left tempora1 lobes measuring about 3.0 x 4.0 cm and 2.0 x 2.0 cm with hemorrhage and congestion. The arteries at the base of the brain showed no significant changes. Anatomical
diagnosis
(1) Many’ excoriations and contusions on the whole body, and multiple fractures of the skull, clavicle, ribs, right humerus and left femur. (2) Cerebral contusion and subarachnoideal hemorrhage. (3) Hemorrhage in the thoracic cavity (approx. 700 ml), in the retroperitoneal space and mesenterium. (4) Lacerations of the liver and left lung. (5) Edema and diffuse hemorrhage of the lungs. Histological
findings
Sections obtained from various organs and tissues were fixed in 10% neutral buffered formalin and stained with hematoxylin and eosin. NO significant abnormalities were observed except acute hemorrhagic changes in the lungs and the muscle around fractures, supporting the macroscopical findings described above. Chemical
examination
The toluene concentrations in the blood and some organs were measured by gas chromatography as described by Kojima et al. [l-31. A Shimazu gas chromatograph, Model GC-8A, with a flame ionization detector was used with a 150cm glass column (0.26cmi.d.) packed with 60/80 mesh Chromosorb 101. The column temperature was 180°C and nitrogen was used as carrier gas at a pressure of 2.0 kg/cm2. One gram of tissue was homogenized with an equal volume of cold water in a glass homogenizer. The homogenate and 50 ~1 of 0.5% w/v ethylbenzene in ethanol as an internal standard were poured into a lO-mlvial, which was stoppered with a rubber cap. The via1 was then warmed in a water bath at 60°C for 20 min, and 0.5 ml of warmed air phase was analysed by gas chromatography. The amounts of toluene detected in the blood, lung, liver and brain were 48,35,65 and 80 kg/g, respectively. NO ethanol was detected by the standard method of gas chromatography [41 in blood from the heart. Discussion
Deaths closely connected with acute thinner poisoning cited from several references 15-71 are summarized in Table 1. The present case showed lower levels of toluene in the blood and other organs than the case of death definitely due to toluene poisoning, but higher levels than three exceptional cases cited from Kashima et al. [71, in which death was reported to have
during painting
M
20
F
M
M
**Present case. ’Trace. -: Not detectable.
*Cases from Osaka Medical
12.
15.
18
ll.
during painting
35
10.
M
16
9.
19
33
8.
M
M
M
M
F
Examiner’s
POISONING
drowning after poisoning drowning after poisoning drowning after poisoning genera1 contusion (fa11 after poisoning
asphyxiation asphyxiation
asphyxiation
asphyxiation
acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning acute toluene poisoning (?) acute toluene poisoning (? )
Cause of death
THINNER
Office for 1977 to 1980
vinyl bag
vinyl bag &
vinyl bag &
vinyl bag &
14.
28
7.
during painting
61
6.
M
17
5.
19
20
4.
13.
47
3.
M
during painting
15
2.
M
22
1.
35
Means of death
WITH ACUTE
with a a cord with a a cord with a a cord with a
Sex
CONNECTED
M
Age
CLOSELY
with a vinyl bag over the head with a vinyl bag over the head on a bed soaked with thinner on a bed soaked with thinner on a bed soaked with thinner with a vinyl bag & a cord round the neck on a bed
1
M
No.
Case
DEATHS
TABLE
t
-
48
18
18
16
18 15
26
6
10
25
43
29
79
110
Bloed
17
10
35
_
-
-
-
-
(+)
-
-
-
21
63
100
Luw
-
-
-
-
65
58 10
80
(+)
-
64
104
-
350
400
Liver
Toluene concentration ( pg/g)
-
-
-
-
-
-
80
75
28
106
186
312
590
740
Brain
(**)
et al. [SI Fukui et al. [SI Fukui et al. [61 Fukui et al. [61 Kashima et al. [71 Kashima et al. [71 Kashima et al. 171
(*) Fukui
(*)
(*)
(*)
Kashima et al. [51. Kashima et al. [51 Kashima et al. [51
Soume
114
occurred during rust-preventive painting work in a tank for raw sewage disposal. These painters drowned upon falling into water in the bottom of the tank. Their falling was attributed to disturbance of the centra1 nervous system due to acute toluene poisoning. Although the toluene concentration in each organ depends upon the time after inhalation [8,91 there are reports that larger amounts of toluene accumulate in the brain and fatty tissues than in other parts of the body 19-111. In the present case, the toluene concentrations in the blood and brain were high, but not so high as to be lethal, so the centra1 nervous system may have been strongly disturbed. Our latest experiment 1121and other papers 113,141 have shown that changes in cortical and subcortical electroencephalogramsappear in the early stages of exposure to a high concentration of toluene vapor or thinner. There are some reports of histological findings in toluene poisonings 115,161. In this case, no significant changes were seen other than acute hemorrhagic diathesis and congestion, especially in the lungs. NO fatty change or eosinophilia [51 of genera1 organs were observed. Thus the body may not have had enough time to react morphologically to invasion of toluene before death. Vita1 reactions, such as hemorrhage around contusions and fractures, etc. were observed. The toluene concentrations of the blood and organs were not so high as to be definitely lethal. Under the present conditions, death from toluene poisoning might take a very long time considering the capacity of the space (approx. 100 m3> and the oxygen consumption of humans (250 ml/min per man) 1171. The maximum allowable concentration of toluene has been set at 100 ppm [183. The wal1 of the space in which the painter was working was 180 m2 and the paint which contained 2% w/w of thinner or 1.4% w/w of toluene was used at 300g/mz. If 1/3 of the area had been painted at the time of death, about 250 g of toluene would have been applied to the wall. Based on the amount of toluene applied and the capacity of the space this value is calculated to be about 6 times the maximum allowable concentration. Moreover, the toluene concentration was probably higher towards the bottom of the space, because toluene vapor is heavier than air. Therefore, we conclude that the cause of death in this case was genera1 contusions, mainly cerebral contusion, due to a fa11from a height with acute sub-lethal toluene poisoning and some degree of oxygen deficiency. We hope that in future there wil1 be strict supervision of working conditions to prevent accidents of this type. References 1 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation Quantitative determination of toluene in tissue by gas chromatography. Jpn. J. Legal Med., 27 (1973) 255-257. 2 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation - Death due to toluene poisoning and the toluene tissue level. Jpn. J. Legal Med., 27 (1973) 258-262.
115 3 T. Kojima, T. Takeoka, M. Yashiki and H. Kobayashi, Toxicological study on toluene poisoning by inhalation - Effect of inhalation of toluene and ethyl acetate mixed vapor on death. Jpn. J. Legcrl Med., 31 (19’77) 280-290. 4 T. Ishikura, T. Ohsawa, Y. Kuroiwa, H. Kotsuka, Y. Nakazawa and T. Niwaguchi, Standard Methods of Chemical Analysis in Poisoning, with Commentary, 1st edn., Pharmaceut. Sec. Japan, Nanzan-do, Tokyo, 1974, pp. 61-63 (in Japanese). 5 T. Kashima, M. Fukui, Y. Masuda, C. Wakasugi and R. Hayama, Report of five cases, wbere an ordinary vinyl bag was used for suicidal purpose. Jpn. J. Legal Med., 23 (1969) 248-252. 6 M. Fukui and H. Kumaoka, Saiban Kagaku, 2nd edn., Hirokawa Publishing Co., Tokyo, 1972, p. 91. (in Japanese) 7 T. Kashima, M. Fukui, N. Mikake and C. Wakasugi, Saigai Iguku, 11 (1968) 1422-1426 (in Japanese). 8 K. Okamoto, Medico-legal st,udies on intoxication by organic solvent: detection of toluene in urine from glue-sniffers and its relationship to their clinical signs. Acta Crin. Japon., 47 (1981) 60-74. 9 K. Pyykkö, H. Tähti and H. Vapaatalo, Toluene concentrations in various tissues of rats after inhalation and oral administration. Arch. Toxicol., 38 (1977) 169-176 10 T. Kojima and H. Kobayashi, Toxicological study on toluene poisoning by inhalation Correlation of toluene concentration on exposure with mortality and toluene tissue level. Jpn. J. hgal Med., 27 (1973) 282-286. 11 S. Takahashi, Toxicological studies on organic solvents. 11, Tissue distribution of toluene and hippuric acid leve1 in urine after toluene inhalation. Jpn. J. Legul Med., 36 (1982) 344-355’. 12 1. Tokunaga, S. Takeichi, K. Kobayashi and M. Maeiwa, Electroencephalographical analysis of acute toluene poisoning. Jpn. J. Legal Med. (submitted). 13 H. Mukoyama, S. Ikemoto, K. Sakai, H. Oki, E. Suzuki, R. Mukoyama, S. Seta and M. Kitahara, A study on the cause of death by thinner inhalation. 111, Anesthetic effect of aromatic hydrocarbon (toluene, benzene and Xylene) gas inhalation on living organisms. Rep. Natl. Res. Inst. Police Sci., Res. Forensic Sci., 25 (1972) 151-159. 14 P. Andersen and B.R. Kaada, The electroencephalogram in poisoning by lacquer thinner (butyl acetate and toluene). Acts Pharmacol. Toxicol, 9 (1953) 125-130. 15 N. Tsukada, Studies on experimental toluene poisoning, Tokyo Jikeikai Med. J., 95 ( 1980) 1298-1312. 16 E. Seta, R. Mukoyama, H. Mukoyama, K. Sakai, H. Oki, E. Suzuki, S. Ikemoto and M. Kitahama, A study on the cause of death by thinner-inhalation. (5 1Histological observations of animals inhaled thinner gas. Rep. Natl. Res. Inst. Police Sci., Res. Forensic Sci., 25 ( 1972) 19-26. 17 W.F. Ganong, Reuiew of Medical Physiology, 8th edn., Lange Medical Publications, California, 1977, p. 519. 18 The American Conference of Govemmental Industrial Hygienists. Threshold limit values 1982, Cincinnati, Ohio, USA.