Document YjyMZJ2eE4Mv5kNq0NnevOggE

<rN b M ^D Z/zT- 6 L Tanquerel des Planches, M.D. 1809-1862 A Historical Review of his Classic Masterpiece on Lead Diseases TRAITfi DM MALADIES DE PLOMB O t SATI'RIN'INES, m L. 1 A N O ltK K L 1)ES PLANCHES. m mmtmunmm e r z u la n t u u mu Ai m m e. r*7 M * CAfm p* x , i p' m UWv, ei 4m 4 m tmm+t, f J Ux* m M H r> M a tto C M * . ' Mtl tM l u naU ncya*t*a*tfmr*im*m.4mIcmW >Mm.>m i W W-M r* m . im nm fmOtTimMMm riwi.MruEtrUiilnlUMAlm~ TOUfc PRE It IK II. ROBERT T. LEC C E, M.D. University of California Berkeley. California PARIS. r m i u , LI OR*IKE - LnITi;i u , ilx r cuim-itniTni. r it. 1889. One hundred twenty years ago there appeared on the horizon of the medical world a French physician, L. Tanquerel des Planches, of the faculty of medicine on the clinical staff at the Hospital of Charity in Paris where he published the results of his investigation on lead diseases. This remarkable investigator, whom Alice Hamilton called the "Columbus of lead poisoning," recorded 2,171 cases of lead diseases at the Hospital of Charity after eight years of meticulous clinical observations, plus careful occupational histories and clinical analysis. In studying the etiology of these cases he made numerous experiments on animals and performed many autopsies on deceased patients who succumbed to lead disease. He was familiar with medical history and with the writers of the past on lead poisoning. Dr. Tanquerel began his inquiries in 1831. Three years later he pub lished a thesis on lead paralysis and finally, in 1839, published the two volumes of his classic masterpiece entitled Traites des Maladies De Plumb on Saturnisms. This work was crowned with the Montyon prize of 6,000 francs awarded by the Royal Academy in 1841 as being the best work in extending medical knowledge and for diminishing the danger of contamination associated with certain trades in the mechanical arts. Tanquerel was a real scientist, preferring truth before all else; a prerequisite of the true investigator. He classified lead diseases under four well determined forms: colic, arthralgy, paralysis and encephalopathy. These affections have inde pendent existence and have no real or necessary relations except those of their common origin, yet they may coexist. Of lead colic, this being the most frequent and best known, he numbered 1,217 cases, arthralgy 750, paralysis 127 and encephalopathy 72 cases. He carefully described the primary effects of exposure and absorption of lead dust by the respiratory and digestive organs. The first characteristic manifestation is the leaden discoloration of the teeth and gums. He explained that this was due to sulfureted hydrogen evolved in the mouth com bining with the circulating lead in the tissues. Priority for the recognition of this sign is due him and not to Burton. Another commonly 514 Industrial Medicine and Surgery described effect is the lead taste, breath and odor. The third item was lead jaundice, the results of the accumulation and absorption of great quantities of lead particles which produce this earthy yellow color of the skin and tissues. The fourth is lead emaciation. He cites the various names given in the past by authors regarding this oldest occupational disease such as plumbism, saturnism, huttenkatze and colica pictonum. He well portrayed how lead is disseminated in the atmosphere as fine particles and how emanations inhaled or swallowed are absorbed by the mucous mem brane, transformed into oxides or salts that produce the lead diseases. He was definitely satisfied that lead colic is not produced by cutane ous absorption. As to the 1,217 cases of lead colic observed, every individual had an occu pational history as a worker in lead. The princi pal ones were red and white lead makers, paint ers, grinders, potters, type and bronze workers. He devoted a chapter to predispositions such as season, climate, age, sex, cleanliness, etc., and another to precursors of the phenomena of primary effects that precede lead colic. Lead Colic Beginning with lead colic, he devoted chapters to definitions, synonyms, history, causes, pre dispositions, precursors, symptoms, complica tions, progress, diagnosis, chemistry, seat and nature, and last, treatment. The other three lead diseases were likewise arranged. The symptoms of lead colic, as is implied, are severe pain principally located about the um bilicus, often in the epi- or hypogastrium, of a violent, moderate or light degree. He mentioned that the rigidity and depression of the abdomen and the relief of the colic pain by pressure is achieved in seven out of 10 cases. The nausea and vomiting, the contractions of the anus and rectum, borborvgmus, hiccough, characteristic breath, saliva, metallic taste and jaundice are familiar symptoms. In the differential diagnosis of other diseases of the digestive organs, provided by such metal lic poisons as copper, mercury and arsenic, he described how the symptoms differ from those of lead action, also of such pathological condi tions as ileus, peritonitis, nephritic and hepatic colic. Tanquerel performed postmortems on each of the 49 patients who died of lead colic. There were found no alterations in the digestive tube and only traces of congestion. Such patholo gists as Herat, Orfila, Grisolle and Dehaen con cur in that they had not been able to discover the slightest traces of inflammation in patients who have died of lead colic. It was Tanquerel's opinion that the seat and nature of lead colic is in the great sympathetics and nowhere else. Lead Ar+hralgy Lead arthralgv is credited to an affection of a neuralgic nature produced by lead and charac terized by lively pain in the limbs, lacking red ness or swelling, diminished by pressure ana increased by motion. It is accompanied by vari ous difficulties, such as cramps, hardness and tension of the painful parts. Next to colic it is the most frequent effect. Lead arthralgy usually accompanied colic, paralysis and encephalopathy in Tanquerel's cases. He defined paralysis in general as the loss or weakness of voluntary motions and sensibility, or of one of these faculties only. One of these states he termed paralysis and to the other he gave the name of lead anesthesia. Tanquerel made the statement that lead workers most frequently attacked with paralysis are those confined in an atmosphere, contaminated by lead emanations. Forty of 108 cases did not have a preliminary colic. Certain symptoms give notice of the approach of lead paralysis: lassitude, trembling, weight loss and coldness. Ninetyseven cases were affected in the upper extremi ties, mostly in the wrist, forearm and fingers. In 15 cases, paralysis developed in the thigh, leg, foot or toes. A few cases showed paralysis of the intercostals and vocal cords. Paralysis is one of the gravest diseases caused by lead. Of those who died, the autopsy findings, as to the appearance of the cord, spinal marrow and muscles, revealed no evidence of anatomical alter ations which would account for the phenomena of the disease. The muscles most frequently de prived of motion are found in the extensors of the limbs. No morbid phenomena have been observed in the central nervous system; which indicates the existence of an organic lesion as the origin of lead paralysis. Lead Encephalopathy Lead encephalopathy was known first by Dioscorides, the Greek physician of the first century A. D., who mentioned the delirium pro duced by lead. Symptoms came on suddenly, with violent cephalalgy, often limited to the forehead, usually accompanied by vertigo or amaurosis and pains in the orbits. Different functional derangements of the brain such as delirium, coma and convulsive forms frequently developed. Of this series of 72 cases, 16 died. At the autopsy there was found a flattening, a shrinking of the cerebral convolutions with increase or dimunition of cohesion of the cere bral pulp. Tanquerel recognized the value of chemical analysis by availing himself of the services of Devergie and Guibort who detected a notable quantity of lead in the brain tissues in encephalo- November, 1959 515 pathy. Subsequently, Devergie in 1886 detected copper and lead in normal human organs. This was confirmed by Orfila, the Parisian toxicolo g ist. Professor M. D. Chevreul, the father of organic chemistry, pointed out as early as 182-1 the existence of copper and lead in the human body as normal elements. This finding is of the greatest importance in legal medicine. Prevention and Treatment The final chapter of this great work is devoted to the prevention of lead disease by hygienic m easures, both personal and environmental. He especially emphasized avoiding inhalation and ingestion of lead emanations. He stressed per sonal cleanliness by baths, washing before eat ing, by mouth hygiene and clean clothing. He also developed a respirator in which a dampened sponge fitted over the nose and mouth. He pro moted clean working places, good ventilation and wet processes to avoid dust. As for therapy, he had no specific, only symptomatic methods. He discredited the use of the popular sulphuric acid lemonade, extensively used at that time. Tanquerel des Planches' immortal books on lead diseases earn for this astute clinician and investigator a foremost place in industrial medi cal history. Since-few copies of Tanquerel's book on lead poisoning are available anywhere, it is noted that these were translated into English in 1848 by Samuel L. Dana, M.D. under the title Lead Diseases. This same book contains the results of Dana's own investigation of lead poisoning from lead plumbing. This Dana publication is almost as rare as the Tanquerel volumes, but at least the American readers possess the virtue of hav ing a good translation into English. Occupational Cancer Repeated sunburn is perhaps the most widespread of the known causes of cancer. "The belief th at nothing is known about the causes of cancer is as mistaken as it is universal," says Charles S. Cameron, M.D., form er medical and scientific director of the American Cancer Society. " A great deal is known," he continued, referring to certain circumstances or agents which appear to favor the development of cancel'. "A lthough we do not know how or why." `Sunburn, for instance." he rem arked. "The con nection between the disease and sunlight is so striking th at long ago cancer of the skin was dubbed `sailor's cancer' or `farm er's cancer'." A large number of rats, in an experiment, placed in the sun for several hours a day over a period of months became cancerous. Nine out of 10 de veloped cancer of the skin and always in areas that were exposed and sparse in hair. "Very fair-skinned people in p articu lar must be careful," warned Dr. Cameron. He also mentioned other suspects that contribute to the danger of cancer. "Modern men and women who live in cities inhale a rich variety of smoke, dust and fumes. Roads and streets are covered with asphalt which is chemically related to substances that arc known to cause cancer," Dr. Cameron said. Occupational hazards such as those th at exist if a human being is working with dyes, arsenic, tar, creosote oil, crude paraffin oil, x-ray and radium, can. if the contact is long enough and intense enough, result in skin cancer. It must be remembered. Dr. Cameron stated, that these agents are dangerous in causing occupational cancer when the form and amount handled are taken into consideration. "Finally." Dr. Cameron said, "the known and suspected causes of cancer do not account for the majority of cancer cases. Evidently a more basic cause lies within the living organism itself. The nature of susceptibility is unknown but it is the core of the cancer problem." -- F ro m Whi t t i r r ( C a lif .) Scu-tt, Ju)> 1. 1959. A Hotf of t geon nois. G. Loui Loui Bro' R FR( Can Clin E fess Mec V Ass Uni J. fess Met pits C thii in wii: not yea wit pro ulc- 1 the pre fre i thf rec I tie i hit If res 518 Industrial Medicine and Smyery r ,, j ) U ZD SVR& L Z - S L Tanquerel des Planches, M.D. 1809-1862 A Historical Revieiv of his Classic Masterpiece on Lead Diseases TI I A I T fi MALADIES DE PLOMB Ot SATURNINKS, m L. '1A!\Ot EKE I, DES PU.NCIIES. OCTKL M LA fACLLTL M totC JK l K m u Po k ^ i A toatei j't ) n *i fcadrfl t r a p , J'j U xC nnr riitK tr f . <olirCUoft, rCL Jiw i r tirar l i e m e r lk , ft pou i rw la lro i Lrmt *pi a p fti o o ,, Oct r k i a n aoti cOrr ccf. mrur, p ar cj-4r>MB< ov u r l t o I . u l t u t m u n U c n d . , . . c m f a l l M t i i ra<|aj. TONE I'II t i l n i l . ROBERT T. LEGGE, M.D. University of California Berkeley. California PAIUS. r e n n a , l i m i a i ii k - t. n 11 i : m , R ill DCS GRARIft-.MXllR.'nW. N* II, 18Ml. O ne hundred twenty years ago there appeared on the horizon of the medical world a French physician, L. Tanquerel des Planches, of the faculty of medicine on the clinical staff at the Hospital of Charity in Paris where he published the results of his investigation on lead diseases. This remarkable investigator, whom Alice Hamilton called the "Columbus of lead poisoning," recorded 2,171 cases of lead diseases at the Hospital of Charity after eight years of meticulous clinical observations, plus careful occupational histories and clinical analysis. In studying the etiology of these cases he made numerous experiments on animals and performed many autopsies on deceased patients who succumbed to lead disease. He was familiar with medical history and with the writers of the past on lead poisoning. Dr. Tanquerel began his inquiries in 1831. Three years later he pub lished a thesis on lead paralysis and finally, in 1839, published the two volumes of his classic masterpiece entitled Traites des Maladies De Plumb on Saturnisms. This work was crowned with the Montyon prize of 6.000 francs awarded by the Royal Academy in 1841 as being the best work in extending medical knowledge and for diminishing the danger of contamination associated with certain trades in the mechanical arts. Tanquerel was a real scientist, preferring truth before all else; a prerequisite of the true investigator. He classified lead diseases under four well determined forms: colic, arthralgy, paralysis and encephalopathy. These affections have inde pendent existence and have no real or necessary relations except those of their common origin, yet they may coexist. Of lead colic, this being the most frequent and best known, he numbered 1,217 cases, arthralgy 750, paralysis 127 and encephalopathy 72 cases. He carefully described the primary effects of exposure and absorption of lead dust by the respiratory and digestive organs. The first characteristic manifestation is the leaden discoloration of the teeth and gums. He explained that this was due to sulfureted hydrogen evolved in the mouth com bining with the circulating lead in the tissues. Priority for the recognition of this sign is due him and not to Burton. Another commonly .514 Industrial Medicine and Surgery described effect is the lead taste, breath and odor. The third item was lead jaundice, the results of the accumulation and absorption of preat quantities of lead particles which produce this earthy yellow color of the skin and tissues. The fourth is lead emaciation. He cites the various names piveil in the past by authors regarding this oldest occupational disease such as plumbism, saturnism, huttenkatze and colica pictonum. He well portrayed how lead is disseminated in the atmosphere as fine particles and how emanations inhaled or swallowed are absorbed by the mucous mem brane, transformed into oxides or salts that produce the lead diseases. He was definitely satisfied that lead colic is not produced by cutane ous absorption. As to the 1,217 cases of lead colic observed, every individual had an occu pational history as a worker in lead. The princi pal ones were red and white lead makers, paint ers, grinders, potters, type and bronze workers. He devoted a chapter to predispositions such as season, climate, age, sex, cleanliness, etc., and another to precursors of the phenomena of primary effects that precede lead colic. Lead Colic Beginning with lead colic, he devoted chapters to definitions, synonyms, history, causes, pre dispositions, precursors, symptoms, complica tions, progress, diagnosis, chemistry, seat and nature, and last, treatment. The other three lead diseases were likewise arranged. The symptoms of lead colic, as is implied, are severe pain principally located about the um bilicus, often in the epi- or hypogastrium, of a violent, moderate or light degree. He mentioned that the rigidity and depression of the abdomen and the relief of the colic pain by pressure is achieved in seven out of 10 cases. The nausea and vomiting, the contractions of the anus and rectum, borborvgmus, hiccough, characteristicbreath, saliva, metallic taste and jaundice are familiar symptoms. In the differential diagnosis of other diseases of the digestive organs, provided by such metal lic poisons as copper, mercury and arsenic, he described how the symptoms differ from those of lead action, also of such pathological condi tions as ileus, peritonitis, nephritic and hepaticcolic. Tanquerel performed postmortems on each of the 49 patients who died of lead colic. There were found no alterations in the digestive tube and only traces of congestion. Such patholo gists as !\Ierat, Orfila, Grisolle and Dehaen con cur in that they had not been able to discover the slightest traces of inflammation in patients who have died of lead colic. It was Tanquerel's opinion that the seat and nature of lead colic is in the great sympathetics and nowhere else. Lead Arthralgy Lead arthralgy is credited to an affection of a neuralgic nature produced by lead and charac terized by lively pain in the limbs, lacking red ness or swelling, diminished by pressure ana increased by motion. It is accompanied by vari ous difficulties, such as cramps, hardness and tension of the painful parts. Next to colic it is the most frequent effect. Lead arthralgy usually accompanied colic, paralysis and encephalopathy in Tanquerel's cases. He defined paralysis in general as the loss or weakness of voluntary motions and sensibility, or of one of these faculties only. One of these states he termed paralysis and to the other he gave the name of lead anesthesia. Tanquerel made the statement that lead workers most frequently attacked with paralysis are those confined in an atmosphere contaminated by lead emanations. Forty of 108 cases did not have a preliminary colic. Certain symptoms give notice of the approach of lead paralysis: lassitude, trembling, weight loss and coldness. Ninetyseven cases were affected in the upper extremi ties, mostly in the wrist, forearm and fingers. In 15 cases, paralysis developed in the thigh, leg, foot or toes. A few cases showed paralysis of the intercostals and vocal cords. Paralysis is one of the gravest diseases caused by lead. Of those who died, the autopsy findings, as to the appearance of the cord, spinal marrow and muscles, revealed no evidence of anatomical alter ations which would account for the phenomena of the disease. The muscles most frequently de prived of motion are found in the extensors of the limbs. No morbid phenomena have been observed in the central nervous system; which indicates the existence of an organic lesion as the origin of lead paralysis. Lead Encephalopathy Lead encephalopathy was known first by Dioscorides, the Greek physician of the first century A. D., who mentioned the delirium pro duced by lead. Symptoms came on suddenly, with violent cephalalgy, often limited to the forehead, usually accompanied by vertigo or amaurosis and pains in the orbits. Different functional derangements of the brain such as delirium, coma and convulsive forms frequently developed. Of this series of 72 cases, 16 died. At the autopsy there was found a flattening, a shrinking of the cerebral convolutions with increase or dimunition of cohesion of the cere bral pulp. Tanquerel recognized the value of chemical analysis by availing himself of the services of Devergie and Guibort who detected a notable quantity of lead in the brain tissues in encephalo- Xovember, 1959 515 p athy. S u b seq u en tly, D ev erg ie in lSHti detected copper and lead in normal human organs. This w as confirmed by Orfila, the P arisian toxicolo g ist. P rofessor M. D. ChevreuI, the father of organic chem istry, pointed out as early as 1824 th e existence of copper and lead in th e human body as normal elem ents. This finding is of the greatest im portance in legal m edicine. Prevention and Treatment The final chapter of this great work is devoted to the prevention of lead disease by hygienic measures, both personal and environmental. He especially emphasized avoiding inhalation and ingestion of lead emanations. He stressed per sona! cleanliness by baths, washing before eat ing, by mouth hygiene and clean clothing. He also developed a respirator in which a dampened sponge fitted over the nose and mouth. He pro moted clean working places, good ventilation and wet processes to avoid dust. As for therapy, he had no specific, only symptomatic methods. He discredited the use of the popular sulphuricacid lemonade, extensively used at that time. Tanquerel des Planches' immortal books on lead diseases earn for this astute clinician and investigator a foremost place in industrial medi cal history. Since few copies of Tanquerel's book on lead poisoning are available anywhere, it is noted that these were translated into English in 1848 by Samuel L. Dana, M.D. under the title Lead Diseases. This same book contains the results of Dana's own investigation of lead poisoning from lead plumbing. This Dana publication is almost as rare as the Tanquerel volumes, but at least the American readers possess the virtue of hav ing a good translation into English. Occupational Cancer Repeated sunburn is perhaps the most widespread of the known causes of cancer. "The belief that nothing is known about the causes of cancer is as mistaken as it is universal." says Charles S. Cameron, M.D.. form er medical and scientific director of the American CancelSociety. "A great deal is known," he continued, referring to certain circumstances or agents which appear to favor the development of cancer. "A lthough we do not know how or why." "Sunburn, for instance." he remarked, "The con nection between the disease and sunlight is so striking th a t long ago cancer of the skin was dubbed `sailor's cancer' or `farm er's cancer'." A large number of rats, in an experiment, placed in the sun for several hours a day over a period of months became cancerous. Nine out of 10 de veloped cancer of the skin and always in areas that were exposed and sparse in hair. "Very fair-skinned people in p articu lar must he careful," warned Dr. Cameron. He also mentioned other suspects that contribute to the danger of cancer. "Modern men and women who live in cities inhale a rich variety of smoke, dust and fumes. Roads and streets are covered with asphalt which is chemically related to substances that are known to cause cancer," Dr. Cameron said. Occupational hazards such as those that exist if a human being is working with dyes, arsenic, tar, creosote oil. crude paraffin oil, x-ray and radium, cun. if the contact is long enough and intense enough, result in skin cancer. It must be remembered. Dr. Cameron stated, that these agents are dangerous in causing occupational cancer when the form and amount handled are taken into consideration. "Finally." Dr. Cameron said, "the known and suspected causes of cancer do not account for the m ajority of cancer cases. Evidently a more basic cause lies within the living organism itself. The nature of susceptibility is unknown but it is the core of the cancer problem." -- From W h it h 'i r (Calif.) S t i c * , Ju)> 1. 1959. A Hotc of t geon nois. G. Loui Loui Bro' R FRC Can. Clin E fess Med \\ AssUni J. fess Met pita c thir in will not yea wit pro ulct I the pro fro tha rec tiei hir If