Document 8VQvk39edYXJv3LLqpMR8xEo5

6>oc*^pZf. **64 - - LEAD POISONING. [Mat r-i ipso. skin without tho alii of grafting, bu c Ii as has never fallen to my lot to bc o in eases treatod by methods other than tbompQuUc immunization. To Biun up the results of ray xporionco of vaccine therapy, 1 have not in a Binglo iastaneo had any reason to regret tlx. application of tho mothod in question; on the contrary, I am fully convinced that In all eases of localized bactorial infootion thompoutic immunization, which, as X have pointed out, includes tho determination of tho flow of opsonized lymph through the iufoctcd tissuo, gives better results than any other method. Lastly, I would point out tho situple giving of vaccines does not complete tho treatment of every caao of localized bacterial infection, *Tko pationt's opsonic content may be quite high, and yet, as I have already hinted, unless tho richly opsonized lymph can, and dees, reach tho germ* laden tissues, it is practically useless. .THE CX.-ASSIFICA.TXOK OF THE SYMFXO&IS OF LEAD FOISONIKGf * / By W. DOWLING PRENBFRGAST, M.D., H.On., M.A.O., D.P.H. Botblo 5. Containing liver: Total weight of cemteuis'... Weight of livor ... ... Tofcalload present ' ... ... 4 ]b. 31 ox. ..... 3 lb. 9?. o/.. ... 0.540 grain In this caso a gravo injustice might havo been done* to tho widow, as bko received 120 compensation. I quoto theso eases to show how obscure and difficult" it is sometimes to diagnose lead poisoning. My experience of lead poisoning has been gathered' mainly among tlio poitors of this district. Under the Compensation Act any potter suffering from tho cHoota of load is entitled to compensation, so that from a medico- legal point of view tho need of classification is obvious,' In tho potting industry the lead used is chiefly ^fclia carbonate of lean, and also tho silicate--the glaze being, composed of tho silic&to in what is known as tho hard material, which is ground at tho mill; tho soft carbonate is added to this. In tho different processes of dippings ware*cleaniug, glosfcplacing, in tho mixing sheds, lithotransfer making, in tho colours used in colour dusting,, also in majolica painting, lead is evolved ia a hue dust. I have on my clinical notes 405 eases of lead poisoning. 170 males, of the averago age 37.4 years. 235 females, of tho average ago 27.6 years.' Ar man J) Gau t ier has* enumerated seventy occupations in which the workmau 13 subject by his occupation to load poisoning. Wo haw also to consider tho fruits of their industry in tha materials for our common and everyday use, all impregnated with a salt of lead. From our earliest ago wo como in contact with tho poison, I have in my hand an ordinary child's toy tna sot, which in a child of 4 yours under my enro produced load poisoning; tho child suclccd tho paint off it. I had another caso of a child of 12 mouths, who was in tho habit of sucking tho leather oovoriug of its perambulator; tho leather oil analysis was found to bo impregnated with a salt of load. Mir Thomas Oliver, in his Goulntonian Lcoturos, cites tho ease of nn old gentleman whoso symptoms wero of a puzzling nature; lib consulted a leading London physician, who olicitcd that ho was an invotoralo snuff taker; tho snuff was found to contain lead; when it was discontinued, tho patient soon rccovorcd. Ho quotes another caao iu which tho nymptoma wore obneuro; ho noticed that iho pafciont for her ago had very block flossy hair, and found that sho was accustomed lo dye it with a wash which contained a largo amount of lead. A more remarkable series of casos occurred affecting tho French navy in 1378, whilst serving abroad. Iu tho first instance tho symptoms wero attributed to malaria; so gravo was. tlio outbreak that tho French Government appointed a commission, which found that tho outbreak was duo to tho largo amount of load used in tho paint for tho intornal docoration of tho warships. Sinco that time only zinc oxide paint is uaod. Tho use of tinned foods is prohibited as far as possiblo, and tho distillation of drinking water is no longer conducted by lead pipes. Tho health of tho men has sinco then improved considerably. In another case X will cite I saw the patient the day before ho died; ho was convulsed, and showed to me .unmistakable signs of lead poisoning. I will quote his wife's evidence at the inquest: Dr. A.'s locum fceuons called on January 3rd, and told her that her husband was suffering from typhoid. Ho was treated for typhoid from that day to his death. The witnoss added that Dr. A. came the following Sunday, and confirmed tho diagnosis of typhoid. Afterwards, the sanitary inspector came, and steps wero taken to remove him to the Bradwell Sana. torium, but there was no bed there for him. Deceased gradually grow worse, and tho following Tuesday he became insensible, and jumped out of bed. lie was convulsed from the Tuesday night until his death on Wednesday. Tho man's organs were analysed for mo by Professor Bedsou of Durham, with the following result: Bottle 1. Containing kidnoys and spleen Total woiijhtof coutentu... 33 oz. Total lead presont ... ... 0.259 grain Bottle 2. Containing brain ? Total weight of coutcuts... . ... 5 lb. Total lead present 0.176 grain * Uoad Wore thu Korth bUtfora-ihirc Division of the British Medical Auboclatiou. Males-- Glostplacers ... k Dippers Dolour ... Notstatod Occupation.' No. ... 76 ' . ... 74 ... ... a ..., ' ... 12 Females-- Wuro-olcauors ' Colour dusters Dippers Majolica paintressos Not stated ... 89 66 34 25 35 Percentage^ ... . . 44. 43 5 " ... 4.5 ... 37.8 ... 24.4' ... 9.6 ... 9.4 ... 14.4. Males (170)-- Paralysis ... ... 1 ... 97 Totally blind................ ! ... 4 Partially blind ... .... 6 > Vision disturbed ... ... 17 Gastric trouble--colic and vomiting ... ... ... 122 FpUopsy ... ... ; ...'29 .ICuccphiilopathy ... I .... 27 Blue lino ... ... 1 ...105 Insanity ... ... I ... 1 Ithoumatoid arthritis ... 10 Gout... ................ v ... 4 57 0 2,3 3.5 10.0 .77.6. 17.6 15.0* Cl.T . -2.4 Females (235)-- Paralysis ... Totally blind... ... 1 ... 71 ... = .... 18 Partially blind Vision disturbed ... ... 24 ... . ... 33- Gaotric disturbance-colic and vomiting ... KpiJopsy ... ... j ... 161 ... . . 40 Encephalopathy ... ... 82 * Blue lioo ... ... ' ... 143 Miscarriages... ... . ... 97.., 'Insanity ... .... j- ...* 6. Rheumatoid arthritis , ... 3 7.7 10.2 14.0 C9.8 17.034.9' 60.8 41.2. Males-- Age. ; Average ago for 68 eases ' ... Ago of the youngest ! ... Age of the oldest ... I ... .' ... 37.4 years*' ... 16 ,, ... 67 ,, Females-- ` Average age for 80 cases . ... Age of tho youngest ... Age of the oldest ... < ... ... 27.6 years ... 15 ,, ... 53 ,, Males ... Females ... ... Died. ... , ... 16 = 9.4 por cent. ... * ... 15 ^ 6.4 ,, Two mam systems-of classification may bo made. In? the ono regard is liad to tho action of lead on (1) tlio brain and nervous syBteni ; (2) tho souson-motor: apparatus, including tho voluntary muscles ; and (3) on. the involuntary muscles, including* tho vasomotor system* Tho other system, that which I propose to adopt in cases of lead poisoning, is classified under two main headsr (1) Saturnine, mitior, and (2) Saturmna gravior* DUP050314322 aur t.i, roto,] LEAD POISONING. tfirt T^nrrrsn ii >5 I. Saturnma mitior would include the prodromak, and forcing tho lead tnlt into tbo interslioes botween llto tcoth Cho lessor symptoms, namely: and tbo gums. If there bo no tooth there is no bluo lino ; 1. Disorders o digestion, such as dyspepsia and constipation. 2. Cachexia. 3. Slight blue lino on gums. i. 4. Slight colic. 5. Anaemia, especially in women, with accompanying symplomo o a minor character. .0. Pains of an undelioed character in trank and limbs. 7. Loss of appotito, and vomiting. 8. Polyuria. P. Slight albuminuria. , )E there bo a marked bluo liuo tho " plaques iatouica" of Gublor, tho tattooed marks on tbo buccal mucous mcmbruuo will bo observod. I kavu always found them present with erosion from a decaying molar tooth. Tho lino may not oxist in somo cares whoro lead is not absorbed by tho mouth; still, if it is not indicative oE lead poisoning, it is tho iingcr-post which directs us to tbo fact that tho indi vidual has absorbed lead in somo form or tho other. There is no other drug or poison which shows this bluo lino; carbon may show a black lino and copper a green ono. Slight colic is one of tho first and most frequent sym ptoms complained of. It was originally called colica II. Saturnina gravior would compiiso i Fictonum, a namo derived from a district in France, 1. Cachexia and emaciation of a marked character. 2. Acute colic, prolonged. 3. Fetid broath. `. 4. Paralysis of arms and limbs. 5. Bluo lino well markod. 6. Aento pains in tho head. 7. Disturbance 'of vision. 8. Tremors. v '9. Suppression oE urine. 10. Epileptiform convulsions. where wino was mado and stored in earthenware recep tacles, glazed with galena, or alquifoux--a soft glaze, the earliest of all glazos known lo tho potter. Tho wino dis solved the load in tho glaze, and people drinking tho wino contracted colic or intestinal cramps. This symptom is complaiuod of in satuvnina mitior, but tho great nerve centres aro not involvod. Ono other symptom which marks lead poisoning in its early stages is anaemia. Load liaB a very destructive action on the red blood corpuscles. Sir Thomas O.'rtr says: " I have never found tho normal number of red From a clinical point oE viow, lead poisoning presents corpuscles in a lead worker." Zinn says that the Swo aspects! in one tho poison enters daily into tho haemoglobin is decreased 50 per cent. Oliver puts it at system in small doses, and is eliminated by tho main 45 per cent, to 0 per cent, of the normal. In a paper cmunctories--tho liver, tho kidneys, and tho skill; in tho lately published by him, Kenneth Gcadby quotes 10 cases of other, tho kidneys and the liver are enfeebled from tho lead poisoning in which tbo red blood corpuscles varied in action of tho poison, and lose their eliminating functions, each case from 3,758,000 to 1,334,000, the normal being and tho poison exerts its baneful powers and produces tho about 5,000,000. Ho described a granular condition of tho major symptoms! red corpuscles, indicating a destructive tendency. There Armand Gautier, in his work ho cuivre ct lo plamb, is no doubt jbat tho unoliminated lead, circulating in tho says that a person may tako 100 to 300 mg. without blood, has a most deleterious effect, and is deposited hero showing any aento symptoms o! lead poisoning, but tho and tilers in the tissues. In women lead workers we daily absorption of 8 to 20 mg. of load will in tirno result liud In satura'ma mitior very often menorrhagia, tho sym`in a serious deterioration oE tho hoalth. At the Chateau ptoms of a minor character boing dyspnoea and palpita- do Claroraonb 13 out of 34 pcoplo woro affoctod with lead tion. Fains of an undefined character aro also com poisoning through drinking for a short timo water which plained of, somotimes in tho muscles, bat moro often in tho only contained 1 grain of load to tho gallon. joints. I have found these pains to be duo to (ho amount Again, wo have to consider tho sox and tho idiosyncrasy of uric acid circulating in tho blood, for it has been proved of tho patient. Women aro moro subject to load poisoning that lead favours the retention of uric acid, so much so than mon. Their nervous and utorino systems show that Sir William Boborts has described tbo condition as quickly tho effects of tho poison; this is shown by tho ono of uratosis. comparativo table: Polyuria and albuminuria are amongst the earliest symptoms wo liavo to deal with. Lead seems to act as an Comptira tivc Pci'contaye. excitant to tho kidney cells, at first in saturnina mitior; the albuminuria is of a transient charactor. Tho increase Matos. Fomalcs. in tho quantity of urine is markod, tho lead boing paralysis Totally blind............ * ' l*or coat. /,, 57.0 .... 2.3 l'or cant. 30.0 . 7.7 eliminated in tlio urino, as can bo proved by aualysis. Bouchard found tbo urine of a patient in tho early stages of load poisoning to bo highly toxio on injection. Ho again injected the uriuo when tbo patient wns suffering Partially blind 13yos affected... ............. ... ........................ ... . ... 3.5 10.0 10.2 v M.0 from tlio epileptiform convulsions of saturaina gravior, and ho found that it had lost this toxio properly. Oliver describes a parenchymatous nephritis which ns tho hGastric disturbance) ... - "v GyUopsy ... ' ... " - 77.C 17.S C9.6 ^ poisoning advancos finally changes into ah interstitial 17.0 nephritis. Thcso aro the stages of saturnina mitior as I would classify them. Eacopbaloyatby ............. 15.0 31.9 131uolino ... 2&sca.rriagcs ... ... .... (... ... ....................... 61.7 ' .60.8 - 41*2 Saturnina Gravior. If tho individual still continues to absorb lead in minute quantities the system becomos more onfcoblcd, and tho liver and kidneys ceaso their olimiuatory functions. The Sa.Lv.mina Mitior. cachexia which is characteristic of lead poisoning then If wo tako an ordinary case oE lead poisoning, wo shall devolops. Tho countenance assumes an ashen grey ho able to sco tho working out oE tho classification. An colour, different from that scon in tbo anaemia of the individual in good health continues to absorb daily ordinary or pernicious typo. Through faulty nutrition the a certain amount o load, either by tho skin, tho_respira emaciation is marked. tory or the digestive organs. He iicst complains of a A further Btnge is marked by tlio onset of acute colic, feeling oE malaise, accompanied by digestive disturbances tho pain being sovere and prolonged. This colic, in my -and constipation. A peculiar cachexia is tlion developed, opinion, is duo to a perverted peristalsis. In health tho owing to tho destructive action of tho leadon the red blood poristaltic action of tho intestineB is oE a rhythmic corpuscles. A sweet taste in tho mouth is desoribed, and character, aud goes on unnoticed. Tlio intostiocs with wo may then find a slight blno lino appearing at tbo their circular and longitudinal fibres havo tho plexus oE junction of tho .tooth with the gums. This is Burton's bluo lino. It is tho most diagnostic sign of load poisoning, and is formed by tho sulpliido of load, tho load boing acted on by tbo sulphuretted hydrogen oE tho buccal secretions. ParsonaUy I think tho lino produced moibaoicaUy, tho trituration of tho food in tho mouth Meissner between thorn to carry on and control this rhythmio aclion. Writers dcscribo this continuous spasm of tho intestines in lead poisoning as in parts nearly of tbo nature of an intussusception. Tlio sympathetic and splanchnic centres becomo involved, with consequent cxco33ivo action o parts of tho intestines, without duo ft;. DUP050314323 1166 iSSSU] CALCIUM PERMANGANATE IN PLUMBISM. [Ma y 34, igio, ccrrosponucnco o{ iuo p&rtfcorroltrtod. Tho existence of (amblyopia) or a complete loss (amaurosis) ensues. I find, this oxeossivo and porvort-ed peristalsis is proved by tlio amongst tho 235 women in my list, 75 had their eyes, faots that pressure mitigates the pain, and that it is affected: 18 woro totally blind, 24 partially blind, and 35 stopped 'ey lull doses of opium, which inhibits tlio had disturbod vision. All those caaos might ho diagnosed peristaltic inovowonts of tlio intestine. Suddenly,'follow- . os anfforing from optic neuritis. I agreo with.Leber and ing those acuto attacks of colic, wo may Cud the patient Deutschmami that load in tho blood acts os an irritant paralysed. Thu paralysis may attack any part'.of tho and causes an incroaso of fluid iu tho subaraolihoid spaces, system, hot it is most marked in tho forearm, producing this fluid incroaso being convoyed to tho vaginal sheaths tho dropped hand of load poisoning,caused by the paralysis surrounding the optio norvo; AH writers on load'poisoning. of tho oxtonsor muscles of tho forearm, the supinator --Oliver, Swansy, Lebor, ' Doutschmann, -and. others-- longus, singular to say, remaining intact, Tho muscles doscribo an' ongorgomont of tho retina, tho voins befog rotain voltaic and galvanic, but lose faradic, irritability. swollen and onlargcd -and tho arteries contracted, finally Why tlio flexor luusclos and tho supinators aro not ending in atrophy of tho disc. attacked -by paralysis is tho paradox of load poisoning. Epiloptiform convulsions generally mark a grave stage Very .ofton paralysis' of tho Duchonno-Erb typo dovolopss, of load poisoning; they woro well marked iu .tho mar, the doltoid and its corresponding group of muscleB boing : tho inquest on whom i quoted at tho beginning of this attacked. Tho muscles' of tho legs' often suffer,'the lead paper. Lancinating pains: in tho head are complained of, selecting tho extensors by preference. As to-whothor this and the urine is suppressed. Theso .convulsions may be- paralysis is central or peripheral, I would observo .that wo either uraemic, or eorobral due to on increase of fluid iu know of two dogonorotions of norvo tissue--tho -Wallcrian, tho brain vontricles. Tho convulsions aro: of a mixed: whore tho oontros aro involvod, and tho othor, whore tho character; the pationt is very violent, and if not restrained axos oylindovs aro attached. Erh and Eomak stato that may jump from his hod. After lasting a fow hours, or in, thodogonoration is Wallcrian. In my opinion, tho degenera others a fow days, death ensues. tion is peripheral, and my reason for making this state In 1854 Garrod brought forward his thoory that lead ment is, a fow yonrs agoI soloctcd 50 of my worst cases of poisoning is productive of gout; this has since than boom load paralysis, and sent them to Dr. Auriol Armitago, of given an accredited place in- our textbooks. X am not a- Wolverhampton, for electrical treatment. Dr. Armitago holiovor in Garrod's theory. Out of my 405 casos I find road tho results in a paper to tho British Modical Associa only 4 `afflicted with gout. ' One of theso had a family tion. Bemomboring what helpless cripples thoso patients history ` of' gout; tho other throe woro oxecssivo beer woro, tho effects of the troatmont wore marvellous; 75 per drinkers. In the Potterios tho male lead workers -con ooni. of tho paralytics woro cured, while 47 out of tho sume largo quantities of boor, no doubt on account of its 50 woro much benefited. Tho duration of troatmont action on'tho kidneys and bowels; among thoao mru-vre. varied from threo woolcs to throe months. I do not for a should find gent, but wo do not. I hnvo never aeon a. moment think that those bouolicial results could have beon cneo of gout in a foinalo lend worker. I hesitated to bring, obtainod if tho centres had boon involved, aB in tabes and forward thoso ideas in contradiction to such an authority infantile paralyses, for example. as -Garrod without further proof, and wrote to Sir Thomas The blue liue-deepons in colour, and in some cases.the Oliver asking .'his ..opinion, and received', the following plaques tatouics of Gablor may be seen marked on the reply: buccal mucous mombrnno. Abortion Is prevalent amongst Wo do not soe gout associated with load here, except on the. tho maxriod women, who work as ware-cloauors, dippers, rarest occasions; when I liavo there-has generally beon a family colour dusters, or libho-transfer makers, ground . layors, majolica .paintrosscs. Load is frequently used in: tlio l'ottorios as an abortifaciont, tho ordinary diachylon being scraped off and used in tho form of pills. A pationt tendency to gout, but casos of -phunbism aro probably too acuteto favonr- tbo development, and it'is just possiblo, tooptbat the bovorago drunk, by the load workers, doos not encourage.gout;. and yut in> tlio -London.hospitals.tho association of'tho two is. said to-bo common. . Under any ciraumstuncos gout Is not- I 'attondod took tvvonty-four of those pills at ouco, with for hor very happy rosults. M. Paul, who lias investigated this subject, says that women who work in load frequently abort. In 123 preg common hero as indicated by attacks of pains in tho bit! too, oto. Wo got plenty-of degenerated artorlos,-but-from other causes-than gout. - My oxporiouco confirms your own: i cannotrocall a o u bo of gout iu a fornalo lead worker. nancies ofload workers, 73 children woro born .dead. Of .-moneys those, 64 woro abortions, 4 promaturc births, and 5 full timo. Of the 50 born alive, 20 died in tho first year, 8 in PLUMBISM ..TREATED Bid THE INTERNAL the second, 7 in tho third, and only 14 reached tho ago of 10 yeacsf\ Sir-T. Oliver also says that .load wonrora mis carry in much largor proportions than othor women. This ADMINISTRATION OP CALCIUM . V PERMANGANATE. has also been my experience. Unfortunately I did. not By G. ARBOUR STEPHENS, M.D.Lo k p., Segregate the married from the single women on my list, ' SWANBSA. but 1 find I have a series of 97 abortions, one woman having had as many as 12. I have mentioned the destructive, action of load -on the Las t year I drew attention in tho Biu t is h Mk d ic az. JoertNAi. to the value of calcium permanganate in the blood and its consequent interference with the ovarian,'the : treatment of gastritis and enteritis--that is, in inflam uterine, and nervous functions of a woman; we can ; matory conditions of . certain parts of the alimentary therefore easily understand its abortive powers. Tremors aro often complained of as a later symptom of tract. In tho JouitxAt, of March I26h, 1910, I pointed out the lead poisoning. The kidneys, after .undergoing parenchy- I origin of tho lead line on the gums as being duo to the matoua degonorntion, aro further attacked; Bowman's deposit of load in the form of tho snlphido on a pro- capsule becomes thickened and laminated, tho capillaries oxisttog rod lino, which was caused by irritating particles in the glomeruli being distended with' blood colls. Tho colls lying botwoen tho coils of oapillarioa undergo : extousivo proliferation, and aro finally destroyed with .an in tho atmosphere in which tho men worked. This red lino is undoubtedly an inflammatory effect, as shown by tho enlarged-and.engorgod papillae on tho-edge of the. exteusivo production of eonnoctivo tissue. A true inter gum, and it is an inflammatory lino that occurs at the stitial nephritis is thus produced and causes atrophy of anterior or upper end of the alimentary tract. tho kidneys. As I found calci-urn permanganate to bo' of -value in At a jioil mortem examination lundo with Dr. U. Alcoclt 'inflammation of Other parts'of tho- alimentary tract, I on a case of chronic lead poisouing it was difficult to find thought it worth whilo to test whether it would bo of tho kidneys; vro eventually found two small atrophied value also with this iuflsmmatoi-y line on the gums, and at orgauR, ouo weighing 2.} os. ami tho other 2:J ox. In such , the saiuo timo with tho lead line. eases the urine is suppi-iwuml ami tho gravest symptoms of Cas k i. haul poisoning ensue, ending iu acuto mania, bifodnoss, epileptiform convulsions, and death. j The first ;aUcnt to whom 2 mlvninistorod tho drug was annul, W. M., aged 3i, w horn l saw for the first timo on July Hdtlt, 1P011. Disturbance of vision is a common symptom of . load *1 poisoning. Tho ordinary Bymptoras of anaemia and ! iunonorrhooa being present, hoadacho'of a severe .typo b: complained of, and suddouly either a partial loss of vision ,j At that timo ho complained of pains iu tho arms and lego, ami of Inability to lift tlio rabble" at bis work, llo had a marked loatl l'mo.- aud. tha'.-tesfc-for.-potassium sulplioeyauido gavo a very Blight reaction. - Paralysis was not prasont, but there was soma .tendarposs over tho lower third of both solatia norvos. DUPO50314324