Document jgaX0MpX2QpVxMOjNa2KXav5p

1164 - . r.BA roisoxixo. [Ma t r.) J910, Birin without tho aiil of grafliog, bu c U as 1ms never fallen to my lot to bc o in enact) fcveatod by methods other than thcmpoutic immunization. To Biun up the results of ray experience of vaccine therapy, 1 Uavo nob in a singlo iasbanco 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 bsctorial infootion thorapoutic immunization, which, as I have pointed out, includes tho determination of the flow of opsonized lymph through the infected tissue, gives better results than any other mothod, lastly, I would point out tho simple giving of vaccines does not complete tho treatment of every caao of localized bacterial infection, * Tho patient's opsonic content may be quite high, and yet, as I have already hinted, unless tho richly opsonized lymph can, and does, reach the germ* laden tissues, it is practically useless. ' TUB CLASSIFICATION- OF THE SYMPTOMS OF LEAD POISONING.* . By W. DOWLING PRENBERGAST, M.D., H.Oh ., M.A.O., D.P.H. Bottle 3. Containing liver: . Total weight of couteuts... Weight of livor ... ... Total lead present ' ... ... 41b. 3&OK. 3 lb. 9.*. 0/.. ... 0.540 grain In this caso a gravo injustice might h&vo been dona to tho widow, as sho received 120 compensation. I quoto these eases to show how obscure and difficult* it is sometimes to diagnoso lead poisoning. My experience o lead poisoning has been gathered: mainly among tho poitors of this district. Under tho Compensation Act any potter suffering from the effocta 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 ^tha carbonate of lead, 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 dipping*. w&re*cleamng> glostplacmg, in tho mixing sheds, lithotransfer making, in the colours used in colour dusting,, also in majolica painting, lead is evolved in a hue dust. I have on my clinical notes 405 eases of lead poisoning. 170 males, of the average age 37.4 years. 235 females, of tho average age 27.6 years.' Aeman d Ga u t ie r has enumerated seventy occupations in which the workman i3 subject by his occupation to load poisoning. Wo have also to consider tho fruits of their industry in tho materials for our common and everyday use, all impregnated with a salt of lead. From our earliest Occupation.'. ; Males-- , No. , Percentage^ Glostplacers ... . ... -... 76 ... . 44. * Dmporo ... ' ..." . ... 74 ... 43 5 ' , Colour ... ... ... 8 ... 4.5 ' Nofislalod ... 1 ... 12 ... 7.0 ago wo como in contact with tho poison. I have in my hand an ordinary child's toy fcna sot, which in a child of Females-- Wuro-olcanors .. . . '... . ... 89 ... 37.8. 4 years under my caro produced load poisoning; tho child swelled tho paint off it. I had another caso of a child of 12 months, who was in tho habit of sucking tho leather covering of its perambulator; tho leather on analysis was Colour dusters .... Dippers ... ... Majolica jxiintressos ... Not statod ... - ... ... 56 ... 24.4' ... 34 ... 9.6 ... 25 ... 9.4 ... 35 ... 24.4. found to bo impregnated with a salt of load. Sir Thomas Oliver, iu his Goulstonian Lcofcurcs, cites tho ease of an old gentleman whoso symptoms wero of a puzzling nature; lie consulted a leading London physician, who olicited that ho was an invotoralo snuff hiker; tho snuff was found to contain lead; when it was discontinued, tho patient soon rccovorcd. Ho quotes another caao iu which tho symptoms woro obneuro; ho noticed that iho patient for her ago had very block flossy hair, and found that sbo was accustomed to dyo 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 due to tho largo amount of lead used iu tho paint for tho internal docoration of tho warships. Sinco that time only zinc oxide paint is used. Tho uso 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 thou improved considerably. In another caso I will cite I saw tho patient the day before ho died; ho was convulsed, and showed to me S/jMptomx. Males (170)-- ,` .VarnlyKis ... ... 1 ... 97 ... Totally blind................ ! ... 4 ... Partially blind ... .... 6 > ... Vision disturbed ... ... 17 ... Gastric trouble--colic ` vomiting ... . .. , ... 122 .... tfpilopsy ... Encephalopathy . .. : ' 29 ... . .. | ... 27 - ... Blue lino ... . .. 1 ...105 ... Insanity ... . .. : ... 1 llhoumatoid arthritis .... ... 10 .,. Gout... .............. ... v ... 4 ' ... 57 0 2,3 3.5 10.0 . 77.6. 27.6 25.0* Cl.T 5.8. . 2.4 Fomalos (235)-- ' Paralysis ... . .. ' ... 71 ... ' 30.0 Totally blind... . .. = ... 18 ... 7.7 Partially blind . .. - ... 24 ... 30.2' Vision disturbed . .. . ... 33- ... . 14.0 Gastric disturbance-- colic and vomiting ... .... ! ... 161 ... C9.8 Epilepsy Encephalopathy Bluclioo ... ... .. 40 . 82 . 143 17.0 34.9' 60.8 Miscarriages... ... 'Insanity ... Rheumatoid arthritis . 97 ' g: , '3 41.2. 2.5 * IS .unmistakable signs of lead poisoning. I will quote his wife's evidence at the inquest: Males-- Age. . ' ; ' ' Dr. A.'s locum tenons 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. camo the following Sunday, and confirmed tho diagnosis ol typhoid. Afterwards, the sanitary inspector came, Average ago for 68 cases ... Ago of the youngest ! ... Age of the oldest ... i ... Females-- ` ... 37.4 years*' ... .16 ,, ... 67 ,, _ and steps were taken to remove him to the Bradwell Sana . 4 torium, but there was no bed there for him. Deceased gradually grew worse, and tho following Tuesday be became ` insensible, and jumped out of bed. lie was convulsed from the Tuesday night until his death on Wednesday. * Average age for 80 cases . ... Age of tho youngest ... Age of the oldest ... < ... Uied. ... 27.6 years ... 15 ,, ... 63 ,, ' Tho man's organs wero analysed for mo by Professor Males ... ... ... , ... 16 = 9.4 por cent. j Bedson of Durham, with tho following result: Females ... ... * ... 15 ^ 6.4 ,, Bottle 1. Containing Icldnoys and spleen: Total \voii;btof contents ... ... 33 oz. Total lead presonfc ... 0.259 grain \ Bottle 2. Containing brain : . Total weight of couteuts................ 31b. Total lead present ... ... 0.176 grain Two main systcrusoOf classification may bo made. In? tho ono regard is liad to tho action of lead on (1) tho brain and nervous system ; (2) tho sonsori-motor: apparatus, including tho voluntary muscles ; and (3) on. tho involuntary muscles, including* tho vasomotor system* Tho other system, that which I propose to adopt in cases As*sRoocni.a<itiboenf.ore) liltu North Staffordshire Division of tho British Medical of lead poisoning, is classified under two main heads n (1) Satur&iua rnitior, and (2) Saturnine gravlor. DUP050314322 Ma y t .i, iQto,] LEAD TOISOSUNG. t3*? Tnrprs 11G5 I. Saturnian mitior would include the prodromata and Cho lesser aynqitouis, namely: 1. Disorders o digestion, such as dyspepsia and constipation. . 2. Cachexia. 3. SiiKl.it blue lino on gums. i. 4. Slight colic. 5. Anaemia, especially in women, with accompanying symptoms o a minor character, .0. Pains of an unde/ioed character in trank and limbs. 7. Loss of appotito, and vomiting, . 8. Polyuria. . . 9. Slight albuminuria. . If. Safurnina gravior would compiiso ; 1. Cachexia and emaciation of a marked character. 2. Aente colic, prolonged. . . 3. Fetid breath. `. 4. Paralysis of arms and limbs. . ', 5. Bluo lino well mavkod. . 6. Aento pains in tho head. . 7. Disturbance of vision. . 8. Tremors. v '9. Suppression of urine. 10. Epileptiform convulsions. From a clinical point of view, lead poisoning presents Swo aspects! in one tho poison enters daily into tho system in small doses, and is eliminated by tho main emnnetories--tho liver, tho kidneys, and tho skin; in tho ether, tho kidneys and tho liver are enfeebled from tho action of tho poison, and lose their eliminating functions, and tho poison exerts its baneful powers and produces tho major symptoms. . Armand Gautier, in his work ha cuivre ct lo plamb, says that a person may tako 100 to 300 mg. without showing any acuto symptoms of lead poisoning, but tho daily absorption of 8 to 20 mg. of load will in tirno result in a serious deterioration of tho hoalth, At the Chateau do Claroraonb 13 out of 34 pooplo woro affootod with lead poisoning through drinking for a Rhort time water which only contained 1 grain of load to tho gallon. Again, wo have to consider tho sox and tho idiosyncrasy of tho patient. Women aro moro subject to load poisoning than mon. Their nervous and uterine systems show quickly tho effects of tho poison; this is shown by tho comparative table: Coinpnra tivc Pciwutaye. Males. Fomalcs. M?aralyai3 m /,, 'Totally blind..........* vv ' ... .... Partially blind ... ........................... 13yos affected... ' .................. Gastric disturbance) .. . . ... . r ... GyUopgy ... ... Eacopbalojifitby Pot- coni. 57.0 2.3 3.5 10.0 - 77.C ' 17.S 15.0 2'ov CGUfi. 30.0 . 7.7 20.2 v R0 ` G9.6 17.0 31.9 forcing tho load tali into tbo interstices botween tho tooth and tbo gums. If there bo no tooth liicro is no bluo lino ; if tlioro im a marked biuo lino tho " phi/jncs taiondes" of Gublor, tho tattooed marks on tho buccal mucous mcm- brauo will bo observod. I have always found them present with orosion from a decaying molar tooth. Tlio lino may not oxist in sorno cares whore lead is not absorbed by tho mouth; stiii, if it is not indicative of lead poisoning, it is tho iingcr-post which directs us to tho fact that tho indi vidual has absorbed lead in some 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 ono of tho first and most frequent sym ptoms complained of. It was originally called colica Pictonum, a narno derived from a district in France, where wino was mado and stored in earthenware recep tacles, glazed with galena, or ahjuifoux--a soft glaze, the earliest of all glazos known lo tho potter. Tbo wino dis solved the load in tho glaze, and people drinking tho wino contracted colic or intcstiual cramps. This symptom is coroplaiuod of in sutuvninn mitior, but the great nerve centres aro not involvod. One other symptom which marks lead poisoning in its early stages is anaemia. Load haB a very destructive action on the red blood corpuscles. Sir Thomas O.'vtr says: 111 have never found tho normal number of red corpuscles in a lead worker." Zinn says that the haemoglobin is decreased 50 per cent. Oliver puts it at 45 per cent, to 0 per cent, oi the normal. In a paper lately published by him, Kenneth Gcadby quotes 10 cases of lead poisoning in which tbo red blood corpuscles varied in each case from 3,758.000 to 1,334,000, tho normal being about 5,000.000. Ho described a granular condition of tho red corpuscles, indicating a destructive tendency. Thors is no doubt jibat tho unoliminated lead, circulating in tho blood, has a most deleterious effect, and is deposited hero and tilers in tho tissues. In women lead workers we find in satarnina mitior very often menorrhagia, tho sym ptoms of a minor character boing dyspnoea and palpita tion. Fains of an undefined character aro also com plained of, somotimes in tho muscles, but moro often in tho joints. I liavo found these pains to be duo to (ho amount of uric acid circulating in tho blood, for it has been proved that lead favours tho retention of uric acid, so much so that Sir William Koboris has desoribed tho condition as ono of uratosis. Polyuria and albuminuria are amongst tho earliest symptoms wo have to deal with. Load seems to act as an excitant to tba kidney colls, at first in satumina mitior; tlio albuminuria is of a transient charactor. Tho increase in tho quantity of urino is markod, tho lead being eliminated in tlio urino, as can bo proved by analysis. Bouchard found tbo urino of a patient in tho early stages of lead poisoning to bo highly toxio on injection. Ho again injected tho urino when tho patient wns suffering from tho epileptiform convulsions of satumina gravior, and ho found that it had lost this toxio properly. Oliver describes a parenchymatous nephritis which ns tho poisoning advances finally changes into ah interstitial nephritis. Those nro tho stages of satumina mitior as I would classify them. . *131uolmo ... ... . .. ... ' ... ... 61.7 ' .60.8 Saiurnina Gravicr. ^sem-iafjes... ... ........................... - 41*2 If tho individual still continues to absorb lead in minute quantities tbo system becotnoa moro onfeoblcd, aad tho liver and kidnoys ceaso their oliminatory functions. Tho Salnrnina Mitior. . oacboxia which is characteristic of lead poisoning then If wo tako an ordinary case of lead poisoning, wo shall devolops. Tho countenance assumes an ashen grey 5)0 ablo to sco tho working out of tho classification, An colour, different from that scon in tbo anaemia of tho individual in good health continues to absorb daily ordinary or pernicious typo. Through faulty nntrition tho a certain amount of load, either by tho skin, tho_respira emaciation is marked. tory or tho digestive organs. He iicst complains of a A further Btage is marked by tho onset of acutc_ colic, feeling of malaise, accompanied by digestive disturbances tho pain boing 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 ieadon tho red blood poristaltic action of tho intestines is of a rhythmic corpuscles. A sweet tasto in tho month is desoribed, and character, aud goes on unnoticed. Tlio intestines with we may then iind a slight blno lino appearing at tho their circular aud longitudinal fibres havo tho plexus of junction of tho .tooth with ilio Gams. This is Burton's bluo lino. It is tho most diagnostic sign of load poisoning, and is formed by tho sulphido of load, tho load boing acted on by tho sulphuretted hydrogen of tho buccal secretions. Personally I think tho lino produced mojhanicaUy, tho trituration of tho food in tho mouth Meissner between them to carry on and control this rhythmio aclion. Writers describe this continuous spasm of tho intestines in lead poisoning as in parts nearly of tho nature of an intussusception. Tlio sympathetic and splanchnic centres becomo involved, with consequent excosaivo action of parts of-tho intestines, without dua ft;. DUP050314323 3i i 66 f TKK 3017:03 Us h o ax. JounuAJ. CALCIUM BEBMAXGANATE IN PLUMBISM. [Max J4, igio. correspondence o{ tho partZfcorrolwted. The existence of (amblyopia) or a complete loss.(amanrosis) ensues. I find, this oxeossivo and pnrvoricd peristalsis is proved by the amongst tlio 235 women in my list, 75 had their eyes faots that prossuro mitigates the pain, and that it is affected: 18 woro totally blind, 24 partially blind, and 35 stopped tiy full doses of opium, which inhibits the had disturbod vision. All tboso caaos might bo diagnosed peristaltic movomonts of tlio intestine. Suddenly,'follow- . os snlloring from optic neuritis. I agreo with Leber and ing tboso acuto attacks of colic, wo may find the patient Doutschmann that load in tho blood acts as an irritant paralysed. The paralysis may attack any part , of tlio and causes au incrooso of fluid in tho subarachnoid spaces, system, but it is most marked in the forearm, producing this fluid incroaso being convoyed to tho vaginal sheaths tbo dropped hand of load poisoning,caused by tlio paralysis surrounding the optio norvo.' All writers on"load'poisoning. of tho extensor muscles of tho forearm, tho supinator --Oliver, Swanzy, Lebor, Doutscbmann, 'and-, others-- longus, singular to say, remaining intact. The muscles dosoribo an' ongorgomont of tho retina, tho voins hoiDg rotain voltaic and galvanic, but lose faradic, irritability. swollen and onlargcd 'and tho arteries contracted, finally Why tlio iloxor muscles and tho supinators aro not ending in atrophy of tho disc. 'attacked by paralysis is tho paradox of load poisoning. lipiloptiform convulsions generally mark a gravo stages Yery .ofton paralysis' of tho Duebonno-Erb typo dovolopss, of load poisoning; they woro well marked in .tho mar, the deltoid and its corresponding group of muscleB boing : tho inquest on whom I quoted at tho beginning of this 'attacked. Tho muscles' of tho legs' ofton suffer,'tha 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 obsorvo .that wo either uraemic, or oorohral due to on increase of fluid in know of two dogonorations of norvo tissae-Atho .Wallcrian, tho brain vontricles. ' Tho convulsions are- of a mixed whoro tho oontros aro involvod, and tho othor,. whore tho character; the pationt is very violent, and if not restrained axos oylindoi's aro attacked. Erh and Rernak state that may jump from his hod. After lasting a fow hours, or in, thodogonoration is Wallorian. In my opinion tho dogonora- others a fow days, death ensues. tion is poriphorc.1, and my reason for making this stato- In 1854 Garrod brought forward his thoory that lead mont is, a fow yoars ago I soloctcd 50 of my worst easos of poisoning is productive of gout; 'this has since thon boon, load paralysis, aud sent them to Or. Auriol Acmitago, of given an accredited place in- our textbooks. X am not a- Wolvorliampton, for electrical treatment. Dr. Armitflgo boliovor in Garrod's theory. Out of my 405 cases I find road tho results in a paper to tho British Modical Associa only 4 -alllictcd with gout. ' Ono of thoso had a family tion. Beuiomboring wliat helpless cripples thoso patients history 1 of- gout; tho other throo woro excessive boor woro, tho olTocts of tlio troatmont wore marvellous: 75 por drinker's. In the Potterios the male lead workers con- cont. of tlio paralytics woro cured, while 47 out of tho sumo largo qnautitios of boor, no doubt on account of its 50 woro much benoiited. Tho duration of troatmont notion on'tho lddnoys and bowels; among thoBo mon-we' varied from threo woolcs to throo months. I do not for a should find gout, but wo do not. I Uuvo never seen a. moment think that these bonolicial results could have beou caso of gout in a femalo lead worker. I hesitated to bring, obtained if tho oontros had boon involved, as in tabes and forward those ideas in contradiction to such an authority infantile paralyses, for example. as Garrod without further proof, and wrote to Sir Thomas. The blue line.deepons in colour, and in some cases the Oliver asking .'his ..opinion, and received'- tho following 'plaques tatouves of Gublor may be seen marked on tho reply.- buccal mucous mombrano. Abortion is prevalent amongst Wo do not see gout associated with load here, except on thetho marriod women, who work as ware-oloanors, dippers, rarest occasions; when I havo there.has generally boon a family- colour dusters, or litlio-tranBfor makers, ground layors, majoliea .paintrossos. Load is frequently used in. tho Potteries as au abortifaciont, tho ordinary diachylon being scraped oil and used in tho form of pills. A pationt toucloucy-to gout, but cases of 'plumbiam aro probably too acuteto favour- tbo development, and it- is just possibla, too, 'that theboverago drunk, by the load workers,ilooa not encourage.goutt and yet in> tho'hondou.hospitals.tho association of'tho two issaid to-bo common. Under any ciraumstnneos gout Is not- I 'attendod took twenty-four of those pills at ouco, with for hor vory happy results. M. Paul, who lias investigated this subject, says that women who work in load froipiontly abort. In 123 prog- common lioro as indicated by attacks of pains in tho-hig too, oto. Wo got plenty of degenerated artorles, -but-from other causes'tban gout. MCy oxporionco eonllrms your own: 1 cannotrocull a oaso of gout in a foraale lead worker. nanoios of load workers, 73 children woro born .doad..' Of A rr;i"r:!i7ir"rr:= thoso, 64 woro abortions, 4 pvomaturo births, and 5 full timo. Of tho 50 born alive, 20 died in tho first yoar, 8 in PLUMBISM ..TREATED BY THE INTERNAL the second, 7 in tho third, and only 14 rcachod tho ago of 10 yaari",. Sie-T. Oliver also says that load workers mis carry in muoli larger 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 marriod from the single women on my list, SWANS1SA, but f find I liavo a series of 97 abortions, one woman having had as many as 12. _ ' I have mentioned the destructive, action o load -on the Las t ;yoar I drew attention in tho Biu t is h Mk d io a a Jotmx.vr. 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 Jo u k h al of March 12th, 1910, I pointed out the load poisoning. Tho kidneys, after .undergoing parenchy origin of tho lead line on the gnms as being duo to tho matous degonoration, aro further attacked; Bowman's deposit of load in the form of tho sulphide on a pre capsule becomes thickened and laminated, tho capillaries existing rod lino, which was caused hy irritating particles in tho glomeruli being distondod with blood colls, Tho in tho atmosphere in which tho men worked. This rod colls lying botween tho coils of capillarios undergo ; line is undoubtedly an inflammatory effect, as shown by extonsivo proliferation, and aro finally.destroyed-with .an the enlarged'and.ongorgod papillae on tho edge of the. extousivo production of connective tissue. A true inter -gum, and it is an inflammatory line that occurs at the stitial nephritis is thus produced and causes atrophy of anterior or upper end of the alimentary tract. tho kidneys. ' At a pouf marUm oxn.minii.tiou mnflo with Dr. It. Alcock As I -found calcium permanganate to boot -value in inflammation of Other parts'of the-alimentary tract, I on a case of chrome lead poisouing it was difficult to find thought it worth while to test whether it would bo of tho kidneys; wo eventually found two small atrophied value also with this inflammatory line on the gums, and at orgauR, ouo weighing 2.J os. ami tho other 2:J ox. In such the snmo time with tho lead lino. oases the urine is suppressed and tho gravest symptoms of loiul poisoning otisuo, muling in acute mania, blindnoss, Ca s k i. Tho drat ivatient to whom 2 mlmmiatorod the drug was a mtui, opilopliform convulsions,, and death. W. lA, aged 3S, whom 1 saw lor the first timo on July 20th, 1P0U. Disturbance of vision is a common symptom of load poisoning. Tho ordinary symptoms of anaemia and.! ainonorrlioca being prosont, lioadaoho'of a sovero .typo is ' complained of, and suddouly either a partial loss of vision , At that time its complained of pains tu tbo anna ami logo, ami of Inability to lift tho ** rabble'' at Ida work, llo hud a marked load-fine,' aud. tha-'toab for.-potassium sulphooyauido gave a vory Bligbt roitctioiK- Paralysis was not prosont, but there was soma, tendorposs over tlio lower third of both soiatlo norvos. ! , ; i ; j : p I | f | | J j J f | I ' i | ' - * , ; DU PO50314324