Document 9wmNLnO2Ky7ewrZ6d5XpE7Vq

870 LEAD POISONING--MCDONALD AND KAPLAN !,1!1*L.VAI.I,V.1*A0- U- UJ v Iiimllir.'iin nr else the entire brain Mem in scattered f.i-bimi lil:ift-r;illy. In these eases Ilie signs were gen INCIDENCE OF LEAD POISONING IN e r a lly slight or moderate compared with the rot of THE CITY OF BALTIMOKE the picture, and 11icy related chiefly to the midhrain without evidence of involvement of the cranial nerve nuclei below the nbduccns. Alcoholic polioencephalitis superior may he distin guished from these cases by its character as a defi ciency disease: the alcoholism is outstanding, and there j o h n m . McDo n a l d , m .d ., d .p .h Director, Bureau of Occupational Disrate*. Baltimore Ci Health Department AND EMANUEL KAPLAN, Sc.D. Chief, Divinion of Chemistry, Bureau of 1-aboratonr*. Baltimore City Health Department L tire signs of general malnutrition. Changes in the skin H A L T ) XI OK F. and mucous membranes hear witness to lack of specific vitamins. The mental picture is characterized by rest lessness nr somnolence and often with disorientation. ] jstlv. apart from the oculomotor disorders and ataxia, localizing neurologic signs are not prominent. To summarize, the condition in the cases reported was characterized by a history of trauma of the head, Since 1935 tiie Bureau of Lalxmatories of the Ball/' I more City Health Department has provided a routine laboratory service for the quantitative estimation of lead in blood and other body fluids as an index of ahum- mal lead absorption in cases of suspected lead poison-.: ing.1 The cooperation of those physicians and hospitals A who made use of this service was solicited in order' a background of alcoholism (predisposing to trauma to make available tbe clinical histories of the persons'.' of the head): the development of signs over a period whose bloods were examined for lead. In this way 7 of days to a few months and a varialfle and fluctuating considerable information was obtained about the local ; course. All together, these features go to make up occurrence of both industrial and nonindustrial lead - a clinical picture consistent with subdural hematoma poisoning. and certainly warranting the suspicion of that condition. A summary of the incidence of lead ]>oisomng in the And. when that diagnosis is even suspected, the pres city of Baltimore during the period 1931-1940 is shown ' ence of signs of disease of the brain stem should not in table 1. These data were obtained from the follow- be considered to contraindicate exploratory trephi nation. T a b l e 1.-- Lead P oisoning in B altim ore, 1 9 3 1 -1 9 4 0 Notes on Paralysis oj Gaze.--A word of caution is in order with regard to the diagnostic significance of oculomotor signs. It is not sufficiently recognized that these signs arc not entirely specific and that impair ment is sometimes manifest as the result of generalized depression of the sensorium. Kestenbaum :l has pointed out that any gaze movement involves various levels of activity. Hence in stupor there often occur nonspecific disturbances of these functions. Upward gaze is the first to suffer, followed by convergence, and in deep Year Total Case* T o t a l ........................ ................ sus J0.1J.............................. IU.U.............................. .................. JW 3................................................ .................. 1935.............................. W3C.............................. 1037.............................. 1 W 8.............................. 19J'J.............................. ...................... 1940.............................. ................ 61 10 53 34 Fetnl Cawa Adult 7 1 1 i 5 1 1 C hild' 49 2 2 2 0 10 8 2 6 4 7 K o d U u I C bm . j Adult h; 12 2 5 13 1G 4 11 21 ChlW* M ; ' t7 4X 7 11 6 .7 7 t coma no gaze movements whatever may be elicited. In the review, already referred to, of 48 cases in the ing sources: ( 1) reports of occupational lead jmisoning, JUZ) Bellevue neurologic service between 1932 and 1940, (2) reports of deaths from lead poisoning and (3) there was a fairly high incidence of all kinds of oculo cases ascertained in a follow-up of the blood lead, motor disturbances in stuporous and semicomatose laboratory service. patients, and a similar incidence obtains with respect All the fatal cases were rcivirted to the Bureau of to a number of published scries. I have tried to select only those cases in which the level of cooperation was such as to warrant the analysis of eye movements. Vital Statistics. However, there is little tendency to report nonfatal lead poisoning. Lead [xtisoning in children is not a reportable disease in Maryland. Since 1934 at least 117 cases pf nonfatal lead poisoning have CONCLUSIONS occurred in all ages, yet 89 [ter cent of these cases were In cases of chronic subdural hematoma there occa ascertained only as a result of a follow-up study of tbe c .E sionally appear signs referable to disease of the brain stem. Because radically different approaches to ther apy depend on the appropriate diagnosis in such cases, and particularly liccnusc timely surgical intervention blood lead laboratory service. The table includes 40 cases of nonfatal lead poisoning which occurred in 1932 as a result of .the use of discarded storage battery casings for fuel.2 Fatal lead [xtisoning was a far more frequent happening in children than in adults. Eighty- is of such dramatic benefit in subdural hematoma, it six per cent of the deaths recorded in table 1 were is important that this fact be kept in mind and that indi those of children, the primary cause of death in practi cations for exploratory ojxiration be considered accord cally all (icing either lead poisoning or lead encephalitic ingly. On the other hand, in 5 of the 7 adult deaths lead When the other clinical findings warrant the sus [xiisoning was re|>ortcd merely as n contributory cause. picion of subdural hematoma, the presence of signs of The high frequency of fatal lead poisoning in children involvement of the brain stem should not stand in the reported from I3a)timore as compared with other areas way of o|>erative exploration. 99 St. Marks Place. 28. KcMcniuum, A.: Blickbeweg ungen und Blicldahmungcn, Cunfinia Neurologic* 2 1 9, 19J9. 1, Kaplan. Emanuel, and McDonald, J. M.*. Blood l-c;td Dciensi**- ^ li<m a* n Health Department Laboratory Service, Am. J. Pub. Heilli . 3 2 1 481 (May) 1942. 2. Williams, Huntington; Schulte, W. H .; Rothcliild, H. FI.; Browij A. S., and Smith, F. R., J r .: Lead PoUoning from the B Battery Catingi, J. A. W. A. XOOs M85 (May JJ) 19JL U4 40 41 / 42 (T i wwr""[ Vt*1* ui.-iu r o i s o x i N G --,M cD o n a l d a x d k a p l a n 871 vidi'iil in tn1>U- 2. compiled from Information fur- The-e facts again demonstrate the general lack of nde!. 1H.,| |,v the United Stales Hnrean of Census. Of (|uate statistical information on mortality and morbidity ? 7il2 "deaths from lead [xiisimiug in [xtrsotts under .. "ears of age which were reported in the entire ['niied States registration area (1936 population about r^g052.000), 49 deaths, or 24.3 ]kt cent of the total, from lead poisoning, a condition which lias been rcjieatcdly mentioned in the literature.* During the period 1931-1940 a total of 135 cases of lead |>oisoning occurred iu children in Baltimore City. r'c from the city of Baltimore (1936 |xi|)uhition altout The age. sex and color distribution of these children is shown in table 3, which includes lioth fatal and non- * r 2 .__A t iw l't'i' ('/ Deported D cnllis from Lead Poisoning fatal cases. The average age in this group is 4 years. by A ge Groups in Selected S to le s and in the However, the group includes 37 colored children of an U nited S ta te s, J 9 3 1 -J9 -W average age of 1 / years who were concerned in the 1932 outbreak of lead poisoning associated with the jyUJ t rilled fifties registration arc*........... C a l i f o r n i o ....................................................*..................................... Ikioui-i.............. *-- *......................... imylund........... ..................................... Cny ol Baltim.o..r.e.............................................................................................. itenlgun...... ...................................... yimirl.......... .. *..................*............... -- >e cy............................................................... M Vork............................................................... OPrW-mov.'.).I.v.u..n.i.a.............................................................................. jutnalnder ot U n ited S ta te * r e g is tr a tio n a m . All Age* 1.033 51 70 <50 Vt Ot 30 St WJ 14*2 HI 8fJ 363 tin.b*r 15 Veil 15 Icar* to d Ov *02 633 2 40 0 Cl 4" 11 7 31 S3 3 57 1 32 10 4G V , IWi o 7fi )8 C3 41 344 Tlie population of the city of Baltimore la about 47 per cent of the total population of U>c state of M aryland. use of storage battery casings for fuel.5 The average age of the remaining 99 children is 2'/3 years. Practi cally all had a history of pica associated with the chew ing of objects painted with lead-containing paints. The age sj>ecifie morbidity rate for lead poisoning during the ten years 1931-1940 based on this group of 99 chil dren is more than five times as high among the colored ]>opulntion (13.7 |>cr hundred thousand) as it is among the white population (2.5 per hundred thousand). The colored group constitutes approximately 19 per cent of the total [xapulation. During the same time 93 cases of lead [Ktisoning occurred among adults. Colored persons were involved 838.700), which constitutes only 0.65 per cent of the population of the United States registration area. Based on cases reported in children during the ten year period 1934-3940. the death rate from, lead poisoning in Balti more would seem to have been about fifty times as high as in the remainder of the general population of the United States. That this situation was not gen erally appreciated is evident from the following state ment. which appeared in a statistical report1 on lead poisoning : A tabulation of deaths from lead poisoning in eighteen American cities in which lead-using industries arc more or less concentrated gives the following results: In the aggregate fee were 17V deaths during the period 1929-36, ol which 30 occurred in New York City. 29 in Baltimore, 28 in Phila delphia. 22 in Huston, 16 in Chicago, 15 in Cleveland and 10 in Providence. litis statement implied that the relatively large nttnthr of deaths from lead poisoning in Baltimore had occurred as a result of industrial cx)x>surcx. However, lltc implication was not in accordance with the known T a r u ; 3 .-- Land Poisoning in C hildren in B a ltim o re , 3 9 3 1 - 1 9 4 0 Ap-, Venr* but l-Ortrr 1, . 1... ........................ M... ......................... 19-11... Total A. Whit* Male Female Colored Male Female .' ! ._i * 7? 15 10 07 ' Jc's. Actually 36 cases of fatal lead [toisoning were gloried in Baltimore during the ]>criod 1929-1936. ' j-hly 4 of these deaths occurred in adults. On the other ` hand, 32 deaths, or 89 )>er cent of the total, were due * nonindustrial lead poisoning; that is to say, they deaths of children, mostly resulting from the .chewing of objects painted with lead-containing paint. 1 . hvtTm.-ui. F, 1..: t.rn.l 1'ui-inmiv in 1VJi, ami in F attier V ran . -1 ., Jutl.uf Krvicw. llnrrfti, of IjUmr S lalillic,. Li. S. lAtparlmcnt of February 19JS, Scriil No. K. 669. T able A.-- O ccupational D istribution of P ersons u-ilh Lead Poisoning in Baltim ore, 1 931-1940 Occupation T o ta l............................................ Pulntr r ......................................... J^inl ar^cDotc vorkcr................ Arc!yienr burner......................... Kmnnt`1 v, o rk rr........................... Piilnt m ukrr................................ Gii'-ultnr lank cleaner................ dunk mrtal worker..................... holder crindcr............................. P rinter.......................................... Miscellaneous occupations........ Knnorcupatlorinl, c l u l : ............ Nonnccupational, children........ Number of Cam# Total 228 54 i:< 12 10 68 581 L 4 135 White 123 22 a J.7 11 10 5 6 1 31 4 1 44 Colored 105 2 1 3 4 1 n Ul in 14 of these cases. The age specific morbidity rate among colored adults over the ten year |>eriod (1.2 per hundred thousand) is less :; - n the rate among the while [xtrsous (1.6 per hummed thousand). For the five years 1936-1941, which reflect the increase in our knowledge of the occurrence of lead poisoning (table 1), the corres|X3mling morbidity rates in adults are some what higher (1.5 [ter hundred thousand in the colored group and 2.5 per hundred thousand in the white group). An occupational distribution of persons with lend [Ktisoning is shown in table 4. The largest single group includes painters. It must be pointed out, however, that a number of painters in this scries had relatively mild lead intoxication. Nine of the 13 lead arsenate workers were white women employed in [tacking o]K-ra tions. One of the enamel workers was a white woman engaged in spraying enamel frit. There were no other cases of lead poisoning of occupational origin among women. The junk metal workers operated furnaces for reclaiming scrap lead in junk yards. The acetylene burners employed torches in shipbreaking. The printer 4. L anti. A. J.: Epidemiolopr of Lead Poiaoning, J, A. XI. A. 1 0 4 : 85 (Jnu 12) 1935. Hamilion, Alice: The Prevalence of Industrial Lead Poisoning n tnc United State*, chapter XX in Lead Poisoning, by J. (,' Auh. 1.. T. Pairhall, A. S. Minor and Paul Kernikofl, Medical Mono graph*. vol, 7 , llallwwrc, William* & W ilk in Co m p a n y , 1926. M c C o r d , C. 1'.. mid others: Lead Poiaoomg in the United Statei, Am. J . P u k Health 1 9 :6 3 1 (June) 1929. 1 872 H C L A M l'SlA --l'L A S S A. M A. ) J uly II. 1942 on-iil n portion nf liis daily time- rrmrlting Iv| kskimming ninl siftinn dross from the mnelt pot. The list includes nnc iioiioivupnlioiinl case, tlial of an adult uho was given lead ami opium j>ills in the treatment of tuberculous enteritis.* SUM MARY sucrose solutions in 10, mostly since 1032. Sco]xil- . . amine hydrnbromide, atropine, theophylline with ethyl ene diamine and mereuropurin were each given to 1 to 3 patients on special indication. Transfusions were employed twice in the presence of shock and hemor- rhngc, but lioth patients died. 1. Large! v as a result of studies associated with a follow-up of a blood lead laboratory service, it lias been MATERNAL DEATHS possible for the Baltimore City Health Department to acquire relatively accurate information concerning the incidence of lead {Misruling in the community in recent The total maternal deaths numbered 7, a fatality rate of 8.75 per cent. Six of the 7 women who died had anlcjiartuiii (4) or intrapartum eclampsia (2) before years. 2. In the ten year jicriod 1931-1940 at least 228 cases of lead |K>isoning arc known to have occurred in Balti more. Of these, 93 cases, or 41 per cent, involved adults, and 133 cases, or 59 per cent, occurred in chil dren. There were 7 fatalities among the adults, as compared with 49 fatalities among the children. 3. ` Lead poisoning was of more frequent occurrence among colored children than among white children. Adult lead jioisoning of occupational origin was more common among the white population than among the colored. _____ admission, while the other was a 45 year old primigravida who was delivered spontaneously, had a single convulsion one hour and twenty minutes later and died .*. from uncontrollable uterine hemorrhage and shock . (fibroid uterus) four hours after the seizure. Autopsy . was permitted for 3 of the other 6 patients and showed ; | the deaths to he due to (1) infection (Escherichia coli I septicemia) after vaginal hysterotomy, (2) bilateral L; I pneumonia with infarction of the anterior lobe of they, liyqiophysis (normal liver) and (3) cardiac dilatation,;:; pulmonary edema and eclamptic liver. Two of the patients for whom necropsy was not permitted died of shock (they had been brought 30 and 150 miles ECLAMPSIA AT THE UNIVERSITY HOSPITAL respectively to the hospital while having frequent con- ' vulsions), while the third had clinical failure of the j left side of the heart and pulmonary edema unrelieved ' 1926 TO 1941 by venesection. FETAL SURVIVAL S E. D. PLASS, M.D. The survival rate among the 84 infants (4 sets of IO W A C ITY During the sixteen years between Jan. 1, 1926 and Dec. 31, 1941, 80 eclamptic patients were observed and treated at the University Hospital. Thirty-seven women were admitted in the convulsive stage, and 43 suffered the seizures after admission; all but 13 of the latter were admitted because of toxemia. Through out the series, eclampsia was viewed as a medical con dition and treatment followed a fairly consistent pattern. This communication deals with the results obtained and involves a discussion of the lessons learned by the experience. TREATMENT EMPLOYED twins) was 53.6 per cent (45 lived), with the salvage > according to birth weights as indicated in the accom- panying table. Exclusion of the 18 "previable" children, weighing f less than 1,500 Gm., among whom there was only 1 t survivor, leaves 66 with a reasonable chance of sur- viva!. The actuhl salvage was 44, or 66.7 per cenL -j Three of the other 22 children died during the first day, while 19 were stillborn, including 9 that were macerated. The toxemia appears, therefore, to have lieen the direct cause of the high fetal death rate either ' by inducing or necessitating premature delivery or by producing intrauterine fetal death. The essence of therapy revolves around the clinical incidence " observation that eclamptics generally do not have con vulsions when the respirations are less than 14 to 16 per minute and the deduction therefrom that there is some relationship between the respiratory exchange and the appearance of the convulsive episodes. Heavy sedation was therefore employed, and the dosage was regulated solely by the effect on the respiratory rate, which was reduced to 12 per minute as quickly as possible. The most commonly employed drug was morphine, which was administered in all hut 6 very mild cases in amounts varying from grain (0.016 (ini.) to (>"/(' grains (0.44 Cm .), with the average approximating 1pj to 1 grains (0.08 to 0.1 Gm.). Chloral hydrate (53 cases), magnesium sulfate paren- tcrally (28 cases) and various barbiturates (15 cases) were employed to complement the morphine; these During the interval under consideration there were ' 5 15,327 deliveries, and the incidence of eclampsia was 1 in 191. The yearly incidence varied from 1 in 57 ; ' deliveries in 1927 to 1 in 956 in 1940, for no deter- . mi liable reason. The greatest numbers of cases occurred ' ( in May (11) and June (10) and the smallest in August (2). There were 52 in the first six months as against 28 in the second half of the calendar years. This dis- j. tribution supports the old clinical observation that the v j late spring months show an increased eclamptic ind- _ ,. deuce. Three of the fatalities occurred in the first . six months (3 in 52, or 1 : 17), while there were 4 in . ; the second six months (4 in 2S, or 1 : 7). This suggests , that eclampsia may be less severe when it is more . ,. frequent. PARITY , . i. 7 drugs arc all respiratory depressants. Primigravidity is recognized as predisposing to - Other form s of therapy employed included vciipmt- eclampsia, and 59 women (73.7 per cent) of this series tion in 18 cases, mostly in the earlier years, spinal tap had not previously been pregnant. Greater interest. in 2, oxygen in 11 (7 during 1941), concentrated however, attaches to the 21 multigravidas in whom con- dextrose solutions intravenously in 49 and concentrated5 vulsions developed. The number of previous pregnan- (v | ;i n a 5. Grrnplil)-, \V. R.: EncrphnWrjmlbv from the Therapeutic U*c n{ I.c.vl nnfl Opium 1'iIH. J. A. M. A, 11*0: ?<>x 15) 193K. Front thr iJrp.irtmcm of Olmtctrici nnd (iynrcolojjy, State Univcritjr of low* CoIIcrc of Medicine. cies varied from one to twelve, and 13 women had had three or more. According to the histories, 12 had not had toxemia previously, although the majority had lad, ~