Document pRd83XG4vEJyddBwOZB227d7

`T i s r - P u t Putnam, J. j. Lea Lead-poisoning sim ulating other diseases: 466 TRANSACTIONS OF THE prescription had been taken at the last dose. It seemed to him that if that was so it was.a matter of considerable importance with reference to the combination of strychnia and hydrobromic acid. Strychnia is soluble in phosphoric acid, but it seems to be precipitated in the presence of bromine. He thought that the same thing occurred when any one of the soluble bromides is given in conjunction with strychnia. Dr. D ana replied that he imagined the precipitation is due to the fact that dilute hydrobromic acid is prescribed. He was quite sure that a ten-per-cent, solution of hydro bromic acid wil dissolve strychnia; at least his druggist had told him so, and he had used it accordingly. A t-the same time he did not wish to state with positiveness without further inquiry, because he had not made experiments him self with reference to this particular point. He had admin istered it with arsenic, and felt quite sure that dilute hydro bromic acid will dissolve arsenious acid; for when the dilute acid is mixed with Fowler's solution it makes a clear solution, and he had been accustomed to prescribe it in that way. Dr. J. J. P u tn a m , of Boston, then read a paper on " Lead poisoning simulating other diseases; a source of error in the analysis of the urine for lead." A number of cases had come to his notice within, the past few years, in which an examination of the urine has shown the presence of lead, which the symptoms and clinical history were not such as are usually considered characteristic of lead-poisoning; in fact simulated other types of diseases. One case resembled the so-called lateral sclerosis, one of the transient forms of poliomyelitis anterior; two others, a more diffused form of myelitis : while both were cerebral neuroses. It is of course nothing new to say that lead-poisoning may sfthulate other diseases, or that any one or all of the classical symptoms may be wanting. So far as he knew, the first case in which lead was suppossed to have given rise to symptoms simulating any other form of spinal diseases than poliomyelitis anterior, is one reported by Dr. F. Minot, of Boston, before the Medical Improvement Society, in 1881,  THE last dose. It seemed matter of considerable mbination of strychnia s soluble in phosphoric ted in the presence of ic thing occurred when s given in conjunction ined the precipitation romicacid is prescribed, ent. solution of hydroit least his druggist had >rdingly. A t the same h positiveness without made experiments himpoint. He had adminsure that dilute hydrois acid ; for when the olution it makes a clear med to prescribe it in read a paper on " Lead; a source of error in A number of cases had few years, in which an 1 the presence of lead, story were not such as c of lead-poisoning; in :s. One case resembled the transient forms of . a more diffused form al neuroses. ;ay that lead-poisoning : any one or all of the So far as he knew, the id to have given rise to n of spinal diseases than ted by Dr. F. Minot, of :ment Society, in 1881, AM ERICAN NEUROLOGICAL ASSOCIATION. 467 and recorded in the Boston Medical and Surgical Journal for the same year Here the symptoms of so-called lateral sclerosis were present to some degree; lead was twice found in the urine, and the patient improved materially under the use of iodide of potassium. Dr. Webber, at the last annual meeting of the Association, directed attention to a certain point in the pathology of lead-poisoning, and again brought forward this fact of the relation between it and organic dis ease of the spinal cord. Although the idea is not new, Dr. Putnam ventured to think that we had not, as yet, real ized how often this will occur. In none of the eight cases reported in his paper, were blue line on the gums, colic, emaciation, or discoloration of the skin, characteristic local ized trophic paralyses, or typical cerebral symptons present, and the diagnosis was established solely through the exami nation of the urine after the administration, for a few days, of the iodide of potassium. It is, of course, not certain that the symptoms reported were really due to the influence of the lead; and even if this could be shown, it would still be uncertain whether the lead acted in virtue of the special affinity for certain tissues, or indirectly by interfering with the nutrition of the cord, or the general nutrition, to such a degree as to allow latent susceptibility, or otherwise insuffi cient causes of disease, to become active causes,-- play a sim ilar r61e to that probably played by syphilis in the causation of tabes dorsalis. A ll the chemical work of the investiga tion was done in the laboratory of the Harvard Medical School under the supervision of Professor E. S. Wood. Un der the vague term lead encephalopathia, a variety of nerve symptoms have been described, of which delirium, mania, de mentia, epilepsy, and coma, are at once the severest and the better recognized; but the disease is no doubt capable of giving rise to a variety of less slowly marked but not less important signs. The pathogenesis of these conditions is obscure and certainly complex, but the relation of lead-poi soning to nephritis, gout, anaemia, points out more than one direction in which a rational explanation is to be sought. Apropos of the contamination of water from lead pipes, Dr. Putnam mentioned a point of practical interest obtained 1 4 6 8 TRANSACTIONS OF THE from an intelligent plumber. It is well known that hot water is more apt to dissolve lead than is cold, but it is not, probably, so generally realized that this fact makes it ob jectionable to run hot- and cold-water pipes side by side through houses, especially when the latter carry water for drinking purposes. The plumber assured him that coldwater pipes under such circumstances are apt to be consid erably corroded. Dr. Putnam then directed attention to a caution neces sary in the chemical examination of the urine for lead, and to the occasional, if not frequent, source of error. The detection of this metal is by no means without its difficul ties. The quantity of lead present in the urine, especially when no iodide of potassium is being taken, and also after this drug has been taken uninterruptedly for some time is very small. The quantity of urine, therefore, analyzed should be at least one quart, and should be collected during the administration of iodide of potassium, given either for the first time or after an interval of repose. One source of error has recently suggested itself to Prof. Wood, and it is that the tests hitherto used for lead apply equally well to bismuth, a drug that is very frequently prescribed both in private and hospital practice. How long the bismuth con tinued to pass off through the urine has not been shown, but it has been found in the tissues of the rabbit for eight days after the administration of a few grains, and also in the human liver and kidneys five days after the administra tion of fifteen grains. For the sake of investigating this point further Dr. Put nam took from thirty to forty-five grains of subnitrate of bismuth daily for two weeks. A t the end of this time, while still taking the drug, his urine contained bismuth. After ceasing to take the drug for twenty-four hours he again took iodide of potassium, and his urine again con tained bismuth. The most reliable way to avoid the error is to-make sure that the patient has taken no bismuth within a considerable period before the examination for lead is made. Dr. Putnam was obliged to omit two cases from his collection on account of this discovery. THE veil known that hot is cold, but it is not, ais fact makes it obr pipes side by side itter carry water for sured him that coldare apt to be consid- n to a caution necesle urine for lead, and aurce of error. The s without its difficulthe urine, especially taken, and also after :dly for some time is therefore, analyzed Id be collected during ium, given either for pose. One source of Prof. Wood, and it is apply equally well to ly prescribed both in Jng the bismuth conhas not been shown, f the rabbit for eight w grains, and also in after the administra- oint further Dr. Putxains of subnitrate of he end of this time, ; contained bismuth, twenty-four hours he his urine again conay to avoid the error ken no bismuth within amination for lead is nit two cases from his ? AM ERICAN NEUROLOGICAL ASSOCIATION. 4^9 i A t the close of the reading of his paper Dr. Putnam i ! exhibited a metallic urinal designed for females, to be used while sitting in a chair. On motion by Dr. W . A . HAMMOND the discussion on ! .Dr. Putnam's paper was postponed until the evening tJ session. i! The Association then adjourned to meet at 8:30 P.M. | F irst day, evening session. The Association was called to order at 8:30, P.M., b y the President. Present-- Drs. Edes, Eskridge, Weber, Webber, Morton, Walton, Shaw, Putnam, Ott, G. M. Hammond, Amidon, Dana, Sinkler. Remarks on D r. P utnam s Paper. Dr. WEBBER, of Boston, said that the paper was an inter esting one, and he believed that we had not yet got at the bottom of the influences which lead may have upon the nervous system. Dr. Putnam had spoken concerning vari ous sensory disturbances, particularly anaesthesia, which some of"his patients suffered from. Dr. Webber had no ticed in every case of lead-poisoning affecting the spinal cord, which he had examined, that the patients had various disturbances of sensation. These were sometimes so insig nificant that patients paid but little attention to them, and it was necessary to cross-examine and return to the subject time after time, in order to find out whether or not these disturbances of sensation existed. A t other times the dis turbances were so marked that the patients spoke of it themselves. Dr. Putnam had also mentioned one source of error in examining the urine for lead, and Dr. Webber wished to speak of another, namely, that if the urine is al lowed to stand and undergo partial decomposition, it be comes alkaline, and a chemical reaction takes place betwee alkaline urine and the glass itself, by which lead is set fre and appears in the urine. He had therefore been in th 4 7 0 TRANSACTIONS OF THE habit of asking patients to put a small quantity of acetic acid into the bottles in which the urine was preserved, in order that this source of error might be excluded. Dr. M il l s , of Philadelphia, said that Dr. Putnam's paper had interested him in a direction of which he thought it worth while to speak; that it is a proper view concerning the nature of this and other metallic toxic poisons. He thought that not a sufficiently comprehensive view of cases of this kind was usually taken. Every one in practice had seen cases of toxic effects upon the nervous system produced by arsenic, copper, and other metallic agents, and also such as were manifested by diphtheritic paralysis, paralysis following various so-called zymotic diseases, and we were apt to take a too limited view with reference to these agents. Just as Dr. Putnam's cases had pointed out, while we are likely to have typical forms of the affection, we may get affections of all kinds, cerebral, spinal, and otherwise, and he had seen not only bilateral paralysis of the extensors, but almost every form of paralytic affection, and also some forms of tremor in lead-poisoning. In a paper which he had read on arsenical paralysis he referred to a number of cases found in literature, and quoted the view expressed by Ringer in his work on therapeutics, which is a very suggestive one. Ringer sug gests that these poisons affect protoplasm, and Dr. Mills thought there was a great deal in that single sentence of suggestion, and he thought that if cases of lead paralysis were studied in .their extreme minutiae it would be found that not only the nervous system was affected, but that other organs were involved, either in the way of diminution of their physiological function or their elective action, and that the nervous phenomena were perhaps largely in pro portion to the effect produced of this character. Certainly it is so in arsenical and phosphorus poisoning, and perhaps in diphtheritic poisoning, where myelitis may occur as a re sult of the action of the toxic agent, or neuritis attended "with myelitis, and the tissues everywhere affected; that is, the poison is a protoplasmic one, and has a particular selec tion, for reasons which we do not at present know, for cer tain parts and certain systems. 4 THE nail quantity of acetic irine was preserved, in be excluded, at Dr. Putnam's paper ich he thought it worth /concerning the nature s. He thought that not cases of this kind was ce had seen cases of n produced by arsenic, nd also such as were s, paralysis following id we were apt to take these agents. Just as while we are likely to e may get affections of se, and he had seen not but almost every form le forms of tremor in had read on arsenical ses found in literature, linger in his work on ive one. ..Ringer sugoplasm, and Dr. Mills at single sentence of ases of lead paralysis iae it would be found vas affected, but that the way of diminution ir elective action, and erhaps largely in pro- character. Certainly ioisoning, and perhaps itis may occur as a re, or neuritis attended lere affected ; that is, has a particular seleciresent know, for cer- AM ERICAN NEUROLOGICAL ASSOCIATION. 471 Dr. P u tn a m , in closing the discussion, said that his paper was prepared with special reference to two practical points. He thought it important to make routine examination of the urine in a great many cases, to see how far we can find lead where no characteristic symptoms are present. The second point was with regard to bismuth ; that is, that the same reaction is obtained with bismuth as with lead, and therefore it is important that bismuth should not have been taken for a considerable time prior to the testing of the urine for lead. It has not yet been positively determined how long bismuth remains in the body before it is entirely eliminated, but evidently it is not entirely eliminated for some time. A t a subsequent session of the association, Dr. Putnam added the following fa ct: that according to the last exami nation made by Prof. Wood, bismuth had been detected in the urine as late as four weeks after it had been taken. Dr. J. T. Eskridge, of Philadelphia, read a paper which included the report of " A case of general neuralgia." G. B., a German, twenty-nine years ofc age, married, a laborer in a foundry. Denied ever having had venereal, and there was' no external evidence of specific disease, and his children-- three in number-- were well developed and healthy. He enjoyed good health until the year 1873, when he suffered from an attack of pneumonia, affecting the left side, and was confined to his bed four weeks. Two years ago, after sleeping one night in a damp bed, he noticed a dull heavy pain in the dorsal and lumbar regions of the spine. This pain continued about one month, and was then accompanied by severe pain in the course of the left sciatic nerve. During these two months he managed to hobble to and from his work, a distance of several squares, and was compelled to stand on his feet about two hours daily. The following summer he was able to walk quite well, although a lithe pain was experienced when the left sciatic nerve was firmly pressed upon. In October, i88i, melted iron fell into his left shoe and burned his ankle se verely. The bum was mostly superficial, but its area was greatest around the internal malleolus ; on the outer aspect of the ankle the area was small, but the wound extended to the bone. For this bum he remained in the hospital of the University of Pennsyl- 1 ijAW+A yf AJpWrfA; * r*. J . I O O ^ Z f r l l t m 1 AMERICAN NEUROLOGICAL ASSOCIATION. NINTH ANNUAL MEETING. Atnrf day, afternoon session. The American Neurological Association convened at the New York Academy of Medicine, June 20, 1883. Dr. W il l ia m A . H a m m o n d , of New York, the retiring Presi dent, called the Association to order at 2:30 P.M., and, after the following remarks, introduced the President-elect-- Dr. Robert T. Edes, of Boston. Present-- Drs. Edes, W. A . Hammond, Mills, Morton, Webber, Dana, Putnam, Gibney, Shaw, Birdsall, G. M. Hammond, Amidon, Spitzka, and Ott. Dr. HAMMOND said he had nothing special to remark with reference to the work of the Association at its last meeting, except to call attention to the fact that the papers read seemed to have attracted wide attention; for, at least half a dozen of them had been translated into al most every language in Europe, either wholly or in part. It seemed to him that there is a growing interest in neuro logical science, yet not so much, perhaps, as the subject de serves. He hoped that the proceedings of the meeting might be as decisive, with reference to the prosperity of the Society, as were those by which it had been preceded. Dr. Ham mond thanked the Association for the honor conferred upon him in electing him their presiding officer last year, and then introduced the President-elect, saying he had no doubt that Dr. Edes would receive fully as much considera tion as had been extended to him, and would probably give 449 46 6 TRANSACTIONS OF THE prescription had been taken at the last dose. It seemed to him that if that was so it was a matter of considerable importance with reference to the combination of strychnia and hydrobromic acid. Strychnia is soluble in phosphoric acid, but it seems to be precipitated in the presence of bromine. He thought that the same thing occurred when any one of the soluble bromides is given in conjunction with strychnia. D r. D ana replied that he imagined the precipitation is due to the fact that dilute hydrobromic acid is prescribed. He was quite sure that a ten-per-cent, solution of hydro bromic acid wil dissolve strychnia; at leasthis druggist had told him so, and he had used it accordingly. A t the same time he did not wish to state with positiveness without further inquiry, because he had not made experiments him self with reference to this particular point. He had admin istered it with arsenic, and felt quite sure that dilute hydro bromic acid will dissolve arsenious acid; for when the dilute acid is mixed with Fowler's solution it makes a clear solution, and he had been accustomed to prescribe it in that way. of Boston, then read a paper on ".Lead-- poisoning simulating other diseases; a source of error in the analysis of the urine for lead." 'A number of cases had come to his notice within the past few years, in which an examination of the urine has shown the presence of lead, which the symptoms and clinical history were not such as are usually considered characteristic of lead-poisoning; in fact simulated other types of diseases. One case resembled the so-called lateral sclerosis, one of the transient forms of poliomyelitis anterior; two others, a more diffused form of myelitis : while both were cerebral neuroses. It is of course nothing new to say that lead-poisoning may simulate other diseases, or that any one or all of the classical symptoms may be wanting. So far as he knew, the first case in which lead was suppossed to have given rise to symptoms simulating any other form of spinal diseases than poliomyelitis anterior, is one reported by Dr. F. Minot, of Boston, before the Medical Improvement Society, in 1881, and recorded in the Boston Medical and Surgical Journal for the same year Here the symptoms of so-called lateral sclerosis were present to some degree; lead was twice found in the urine, and the patient improved materially under the use of iodide of potassium. Dr. Webber, at the last annual meeting of the Association, directed attention to a certain point in the pathology of lead-poisoning, and again brought forward this fact of the relation between it and organic dis ease of the spinal cord. Although the idea is not new, Dr. Putnam ventured to think that we had not, as yet, real ized how often this will occur. In none of the eight cases reported in his paper, were blue line on the gums, colic, emaciation, or discoloration of the skin, characteristic local ized trophic paralyses, or typical cerebral symptons present, and the diagnosis was established solely through the exami nation of the urine after the administration, for a few days, of the iodide of potassium. It is, of course, not certain that the symptoms reported were really due to the influence of the lead ; and even if this could be shown, it would still be uncer'-' in whether the lead acted in virtue of the special affinity for certain tissues, or indirectly by interfering with the nutrition of the cord, or the general nutrition, to such a degree as to allow latent susceptibility, or otherwise insuffi cient causes of disease, to become active causes,-- play a sim ilar r61e to that probably played by syphilis in the causation of tabes dorsalis. A ll the chemical work of the investiga tion was done in the laboratory of the Harvard Medical School under the supervision of Professor E. S. Wood. Un der the vague term lead encephalopathia, a variety of nerve symptoms have been described, of which delirium, mania, de mentia, epilepsy, and coma, are at once the severest and the better recognized; but the disease is no doubt capable of giving rise to a variety of less slowly marked but not less important signs. The pathogenesis of these conditions is obscure and certainly complex, but the relation of lead-poi soning to nephritis, gout, anaemia, points out more than one direction in which a rational explanation is to be sought. Apropos of the contamination of water from lead pipes, Dr. Putnam mentioned a point of practical interest obtained 468 TRANSACTIONS OF THE from an intelligent plumber. It is well known that hot water is more apt to dissolve lead than is cold, but it is not, probably, so generally realized that this fact makes it ob jectionable to run hot- and cold-water pipes side by side through houses, especially when the latter carry water for drinking purposes. The plumber assured him that coldwater pipes under such circumstances are apt to be consid erably corroded. Dr. Putnam then directed attention to a caution neces sary in the chemical examination of the urine for lead, and to the occasional, if not frequent, source of elror. The detection of this metal is by no means without its difficul ties. The quantity of lead present in the urine, especially when no iodide of potassium is being taken, and also after this drug has been taken uninterruptedly for some time is very small. The quantity of urine, therefore, analyzed should be at least one quart, and should be collected during the administration of iodide of potassium, given either for the first time or after an interval of repose. One source of error has recently suggested itself to Prof. Wood, and it is that the tests hitherto used for lead apply equally well to bismuth, a drug that is very frequently prescribed both in private and hospital practice. How long the bismuth con tinued to pass off through the urine has not been shown, but it has been found in the tissues of the rabbit for eight days after the administration of a few grains, and also in the human liver and kidneys five days after the administra tion of fifteen grains. For the sake of investigating this point further Dr. Put nam took from thirty to forty-five grains of subnitrate of bismuth daily for two weeks. A t the end of this time, while still taking the drug, his urine contained bismuth. After ceasing to take the drug for twenty-four hours he again took iodide of potassium, and his urine again con tained bismuth. The most reliable way to avoid the error is to make sure that the patient has taken no bismuth within a considerable period before the examination for lead is made. Dr. Putnam was obliged to omit two cases from his collection on account of this discovery. AMERICAN NEUROLOGICAL ASSOCIATION. 469 A t the close of the reading of his paper Dr. Putnam exhibited a metallic urinal designed for females, to be used while sitting in a chair. On motion b y Dr. W. A . H am m ond the discussion on Dr. Putnam's paper was postponed until the evening session. The Association then adjourned to meet at 8:30 P.M. F irst day, evening session. The Association was called to order at 8:30, P.M., by the President. Present-- Drs. Edes, Eskridge, Weber, Webber, Morton, Walton, Shaw, Putnam, Ott, G. M. Hammond, Amidon, Dana, Sinkler. R em arks on D r. Put?iam's Paper. Dr. WEBBER, of Boston, said that the paper was an inter esting one, and he believed that we had not yet got at the bottom of the influences which lead may have upon the nervous system. Dr. Putnam had spoken concerning vari ous sensory disturbances, particularly anaesthesia, which some of his patients suffered from. Dr. Webber had no ticed in every case of lead-poisoning affecting the spinal cord, which he had examined, that the patients had various disturbances of sensation. These were sometimes so insig nificant that patients paid but little attention to them, and it was necessary to cross-examine and return to the subject time after time, in order to find out whether or not these disturbances of sensation existed. A t other times the dis turbances were so marked that the patients spoke of it themselves. Dr. Putnam had also mentioned one source of error in examining the urine for lead, and Dr. Webber wished to speak of another, namely, that if the urine is al lowed to stand and undergo partial decomposition, it be comes alkaline, and a chemical reaction takes place between alkaline urine and the glass itself, by which lead is set free and appears in the urine. He had therefore been in the 4 7 0 TRANSACTIONS OF THE habit of asking patients to put a small quantity of acetic acid into the bottles in which the urine was preserved, in order that this source of error might be excluded. Dr. MILLS, of Philadelphia, said that Dr. Putnam's paper had interested him in a direction of which he thought it worth while to speak; that it is a proper view concerning the nature of this and other metallic toxic poisons. He thought that not a sufficiently comprehensive view of cases of this kind was usually taken. Every one in practice had seen cases of toxic effects upon the nervous system produced by arsenic, copper, and other metallic agents, and also such as were manifested by diphtheritic paralysis, paralysis following various so-called zymotic diseases, and we were apt to take a too limited view with reference to these agents. Just as Dr. Putnam's cases had pointed out, while we are likely to have typical forms of the affection, we may get affections of all kinds, cerebral, spinal, and otherwise, and he had seen not only bilateral paralysis of the extensors, but almost every form of paralytic affection, and also some forms of tremor in lead-poisoning. In a paper which he had read on arsenical paralysis he referred to a number of cases found in literature, and quoted the view expressed by Ringer in his work on therapeutics, which is a very suggestive one. Ringer sug gests that these poisons affect protoplasm, and Dr. Mills thought there was a great deal in that single sentence of suggestion, and he thought that if cases of lead paralysis were studied in their extreme minutiae it would be found that not only the nervous system was affected, but that other organs were involved, either in the way of diminution of their physiological function or their elective action, and that the nervous phenomena were perhaps largely in pro portion to the effect produced of this character. Certainly it is so in arsenical and phosphorus poisoning, and perhaps in diphtheritic poisoning, where myelitis may occur as a re sult of the action of the toxic agent, or neuritis attended with myelitis, and the tissues everywhere affected; that is, the poison is a protoplasmic one, and has a particular selec tion, for reasons which we do not at present know, for cer tain parts and certain systems. AMERICAN NEUROLOGICAL ASSOCIATION. 471 Dr. PUTNAM, in closing the discussion, said that his paper was prepared with special reference to two practical points. He thought it important to make routine examination of the urine in a great many cases, to see how far we can find lead where no characteristic symptoms are present. The second point was with regard to bismuth ; that is, that the same reaction is obtained with bismuth as with lead, and therefore it is important that bismuth should not have been taken for a considerable time prior to the testing of the urine for lead. It has not yet been positively determined how long bismuth remains in the body before it is entirely eliminated, but evidently it is not entirely eliminated for some time. A t a subsequent session of the association, Dr. Putnam added the following fa ct: that according to the last exami nation made by Prof. Wood, bismuth had been detected in the urine as late as four weeks after it had been taken. Dr. J. T. Eskridge, of Philadelphia, read a paper which included the report of " A case of general neuralgia." G. B., a German, twenty-nine years of age, married, a laborer in a foundry. Denied ever having had venereal, and there was no external evidence of specific disease, and his children--three in number--were well developed and healthy. He enjoyed good health until the year 1873, when he suffered from an attack of pneumonia, affecting the left side, and was confined to his bed four weeks. Two years ago, after sleeping one night in a damp bed, he noticed a dull heavy pain in the dorsal and lumbar regions of the spine. This pain continued about one month, and was then accompanied by severe pain in the course of the left sciatic nerve. During these two months he managed to hobble to and from his work, a distance of several squares, and was compelled to stand* on his feet about two hours daily. The following summer he was able to walk quite well, although a little pain was experienced when the left sciatic nerve was firmly pressed upon. In October, J88i, melted iron fell into his left shoe and burned his ankle se verely. The burn was mostly superficial, but its area was greatest around the internal malleolus ; on the outer aspect of the ankle the area was small, but the wound extended to the bone. For this burn he remained in the hospital of the University of Pennsyl-