Document zb901QQv2pEXo7qjGzBwXwe30

Treatment of Lead Intoxication WILLIAM C. WIUNTZ. M.O. ftrt* Aatoy, N. J. I I <k*> Ax *"V" y- ' -- Xtfnmttd ft*m Tkt Jtmtmal if tkt Amentia MHitnl Atuimu Ml /u_c-Jk. I*ta, IrHuAt, lV/**l. lfiMt, UH. Jtllt-MtlSlf Corrnear, I tit, r ^ Autaibtx IfxoiCAl Au o c u t io x Sis Son* Du u o m Smr CaieAM IS, III. v^ '*Vy V/ Primui tad PaUiikti m li* {M Stout if A meritt Rsr>;U'i ftn.n The Jjurxn. j, the A u on S(<jr<h 26, 1949. I'ul. 1j 9. f,t. S2-J2S -I,*,.. Capyrv/ht. 1949, 6v Sltdical Aaocwtion m TREATMENT OF LEAD INTOXICATION wiuuM c. w iu n t z , m.o. Perth Amboy, N. J. The method of treating the acute phase of lead intoxi cation has been well established and its rational univer sally accepted. However, the type of treatment that should be instituted after the subsidence of the acute symptoms is a controversial issue. While the approved treatment of the acute stage will be reviewed, this paper will deal primarily with the theories versus practica bility of storing and deleading. It would seem obvious that the entire therapeutic regimen should be directed toward (1) overcoming the intestinal colic, (2) correcting the anemia, (3) making the patient symptom free with no disability and (4) .returning the patient to a remunerative job as soon as possible. The following procedures are prescribed for the acute stage: 1. Hospitalization or ambulatory, depending on symptoms 2. If hospitalized, bed rest or ambulatory, depending on colic 3. High calcium diet 4. Warm water bag or electric pad for abdominal discomfort 5. One half to 1 ounce (16 to 31 Cm.) magnesium sulfate every morning on arising 6. Antispasmotics. such as tincture belladonna, phenobarbita! mixture, every four hours, or amprotropine phosphate (syntropan*) tablets or hydrochloride of diphenylacetyl diethylaminoethanol (trasentine hydrochloride*) and phenobarbital tablets for abdominal discomfort 7. Tea cubic centimeters of 20 per cent calcium gluconogaioctogluconate solution (neo-calglucon*) intravenously every four hours 8. Xo narcotics advised 9. Complete blood cell count and stippling determination, followed by red blood cell'count and stipple cell counts taken every three days lSLl-000022553 I 0000- 10. ar.d urin.lysis o: icad i;i urir.c f twenty-tour hour specimen) This routine therapy is predicated on the original contention of And ; and his associates that the direction of the lead stream is similar to that of the caicium. stream, that when calcium is being deposited in the bones, circulating' lead is being deposited in the bones and that when calcium is being pulled from the bones, some stored lead is also liberated. Deleading appears to be the method advocated by most authorities, but this does not tell the whole story, because it is unusual to and physicians who actually utilize this procedure: as a matter of fact, recently a questionnaire was sent to twelve actively practicing industrial physicians engaged in this work, ar.d their answers showed that only one physician was using deleading, two physicians formerly used deleading, but had given it up, and the remaining nine had never utilized deleading in any shape or form. METHODS OF DELEADIXG ADVOCATED 1. High Calcium Diet.--This method was claimed by Lederer and Bing: to be the optimum diet for deleading. Taeger1 2a*rr*iv5e6d at the same conclusion. Schilling and Hopper * expressed the belief that the use of calcium did not induce superior calcification, but ratlter had the opposite ettect. Gray and Greenfield ' reported that prolonged high calcium diet and regimen was the best means of deleading. On the other hand. Litzner, Weyrauch and Barth * claimed that a high calcium diet reduces lead excretion. 2. High Phosphorus and High Vitamin' Diet.--Gray and GreenfieidJ found the use of an optimal calcium diet with a high phosphorus and high vitamin diet 1. Auh, J, C.: The Biochemical Behavior of Lead ia ;be Body. J. A. M. A. 104:57 (Jaa. 12) 1935. 2. Lederer. L. G., and Bing, T. C.: Effect of Calcium and PhcJ.ru* on Retention of Lead br Growinf Organon, J. A. M. A. 114: ane 22) 19*0. Taeger, !{.: Calcium Therapy of Lead Pouoaiag, Alin. Wcknaeor. 16: 1613. 1937. *. Schilling. H. D., and Hopper. K. 0.: CaicawB aad Phoapbcrue Studiea. Bui!. Jozr.t Hopaim Heap. 35:196. 1946. 5. Gray, K.. and GreenAeld. I.: New Concept* in tke Treatment of Lead PoUoning. New York State J. Med. SB: 1513, 1954. 6. Utxaer, S.; Weyrauch, F., and Barth,.E.: ynteriuckcnger. uher Blciauatchftdung durch die Nieren und ihre Bteinnustung duren heuiinmte Koatfomca and Araeiaittel beta Menachea, Arch. i. Gewer* Upath. u. Gewerfcyg. 3*330. 1931. 0000-NLI-000022554 3 ('vitamin D particularly) the best treatment in these cases. Gray,r interestingly enough, observed a few years previously that ` a low calcium and high phosphorus diet (ration 1:4) was ideal in deleading; on the other hand, Lederer and Bing 1 disagreed with this statement and expressed the opinion that the addition of phos phate has no beneficial effect. 3. Low Calcium Diet.--As stated previously, Gray ' recommended a diet low in calcium. 4. Ascorbic Acid Therapy.--Holmes, Campbell and Amberg* observed much benefit from ascorbic acid Ta il i 1 ,--Ag* Factors Tool Sumter Istoxlcotion Ca m*................................................ ill group* a *****tetms ti-t* run tt *****tetw*a so-so retn U *****tervxa 404? star* 1 *** Si rtn 0 Arcriet *, mtoxicatioo c *m (r**n)........................................ Si AT*rtc* *jcpo*ur* (rttks)................................................... 12 AT*rr< t!m* lost from work (dr*>.......................................... S3 Ac* ot rousetft p*ti*st (r**r*i................................................. u Ac* o< old*t potlnt Or**r*>....................................................... S4 Expour ol rouncMt **** (<r**ka).............................................. Expooun ot old*t *** (w*kf).................................................... Snort*** cxpo*ur* *** (dr*>....................................................... Losc**t ixporurt **** <dr<)....................................................... * 1* 2? therapy in cases of lead intoxication; others have had no success with this form of therapy. 5. Other Substances.--Ammonium chloride, potas sium iodide (Belknap*), sodium bicarbonate, sodium citrate (Kety and Letonotf1*), parathyroid hormone and 2,3-dimercaptopropanol (BAL) antilewisite have been used.* S. * * * * 10 1. Gray. I.: Kccat Pr*cr*** in Lb* Tr**tmn( at Plumbum, J. A. 1L A. 104 200 </*. 10) 1915. S. Kobo**, K. W.; Campbell. K-, *ad Amterc, E. J.: Tte Adminmention ot Viumin C in tte Treatment ot L**d Psuoniac. J. Lab. k Clin. Md. S4t 1119, 1919. 9. Bikoa. E. L.: Control ol Load Poiaooinc in tte Worker, ]. A. U. A. 104t 29J (Jan. 19) 191S. 10. K*tr, S.. and Lmoneff. T. V.: Tb Treatment ol Lead Fotaoninc br Sodium Citrate, Am. J. It Sc SOS; 40*. 1941. 0000-NLI-000022555 4 Do these procedures actually delead? Kehoe " stated. . . there are grave doubts whether or not the elimination of the toxic agent can be materially accelerated by artificial means" and further added. ". . . this elimination can only be accomplished spontaneously over a considerable length of time." Aub 1 and his associates concluded chat complete delead ing cannot be done. Oliver 11 and many others have confirmed this observation. It is most interesting that practically all the advocates of deleading admit that the procedure is dangerous and must be attempted Ta SLX 2.--Hospital and Xonhaspital Studies Tout XuntUr Coon iwu-iw*....................................................... w Hospital taoM..................................................................... 13 XonSooMUl mu ...................................... ....................... 27 Hoapittl Cun Anne* ip................................................... SI ynn (2101) Ar*raf l*n*tn ot tzpoourc........................ to wttn* (i so soortMt toopiui lur................................. s iri Loogot boopltal U1T................................ St dart Avoraae hoopital tr.............................. it dart Auras# to** o( time................................. 11 dan (703) Xooiiotpital Caata Arrran an.................................................. Araran Irasta o( rapoaura........................ Ararat# loaa at .tiui#................................... rr* (2MJ) It *e#kU-3) IS dan (l-i`) only in specific circumstances. Johnstone11 stated, . . this procedure (deleading) has been discarded due to the beuei that lead is excreted from the body by normal physiologic processes." It is admitted by its advocates that rapid deleading is to be avoided, and, therefore, it is advisable to immobilize the lead in the bony structure during the acute toxic episode. It is also stated that deleading is then.advisable, since the liberation of this store of lead is an obvious factor in the onset of toxic lead U. Keboe# It. A*i Cbolak, I.; Hubbard. 0. M.; Rambach# K.. and McXary, R. JL: Experimental Seudica oo Lead Absorption of Exert* tioa and Tfacir Relation to the Diagnoaia and Treatment of Lead Poieon* ini, J- Induat. Hyg. & Toxicol. 23:71. 1942. 12. Oliver, T.: Lead Poiaoftini from the IadoatriaL Medical and Social Poiota of View, Xew Vork, Paul B, Koebrr, 1914. U, Johaatooe, R. T.: Occupational Medicine and Industrial Hygiene. St Louia. C V. Moeby Compear. 1142. 0000-NL1-OOOOW556 0 episodes (hiring metabolic upsets. It is this latter state ment which apparently is the principal argument used by the advocates of deleading. It sounds almost con vincing, but in my experience, in treating over 60 patients with lead intoxication and hundreds with absorption, not one patient had any such metabolic iI Ta *l i 3.--Blood Studies Period of Greater! Ctuoree In Count! and Sincart----7-14 d*yi alter acute ayuiptouu ante Period " hen Blood Cell Count* and Stneara Return to Normal (accordinc to wbetner or not hoepiteiUed) Horpital ease*........................................................... 4% moutlu Ambulatory ease*...................................................... 5 moouu Prrtod When Blood Cell Count* and Smear! Return tn Normal (accordinc to ace) Short expoaure care croup (below 10 week!) 4.4 montha Looc axpoaun caaa croup (beyond 10 weeka) 4.3 mootne Ranee nt Red Blood Ceil! * loweat count.................................................... (H) iuno.ooo (A) 1,720.000 Uicbeit count.....................................................(H) 4.1S0.000 <H) 4,710,000 Aeerace count................................................... (U) 1,373,000 (A) 4,004400 Sauce o( Hemoclobin Counu Lowcit count.....................................................(H) 34% (A) 6.% Hlcbeat count................................................... (H) 73% (A) 70% Avcrace count................................................... (H) 6S% (A) n% Ranee o( Stipple Count! (per 30 field!) Loweet count....................................................(H) 37 (A) JO Ulclwet count.................................................(B) 300 (A) 104 Arerict count.................................................(H) lli (A) 73 ' * (U), boepltai card; (A), ambulatory ram. upset, liberating stored lead to such a degree as to be incapacitated. I admit that some conditions can produce some free circulating lead into the blood stream, but the results are negligible and the persons are symptom free as far as lead is concerned. Belknap " stated, ". . . after an absence from lead exposure of one to two years, lead intoxication 14. Belknap. E. L.: Laid PoUomnf: Criteria ier Oiacnoaia, Indurt. Med. 1 SOS, 140. 0000-NLI-000022557 G practicaiiy never develops." Aub 1 stared, . . from a theoretical standpoint, deleading is advisable, but from a practical point of view, the answer is dependent on which procedure will advance most promptly to a Ta il s 4.--Disability Studies Nonhoapltal Cuts (S7) Arcrtgc lot* time................................................. is din c u t s Number cua with ao to* time......................... I Number e**e* with ton time................................ ID Number ea*e* with permanent disability award S Areran award................................................ 5% W-*-7) Hoepttal Caeee (S3) Artrace toaa time................................................. 31 dar< O H) Number *aa* with permaaeat dlMbUlty award 4 Ararace award............................................... M% Ta il s 5.--Risumi of Permanent Disability Cates Patient An. Tr. Expoaure, Waelm Cell Suability Oayt Cosat* Rr (Per- Obaernd turned maaent) Lon of Attar to Award, Tima. Aeut* Normal, Per- Says Pbaaa ' Month* eantac* Nonboapltal A. A_.............. ST 14 IS 442 7 74 J. A-............... SS s. a-........... m 4 *0 ao *7 *0 S Sto uo t 3.o Arerage................................................................................... S% Boapital Z.B................ s. w............ eo 4 30 a ao 430 3 17 s TJ 74 w. 0.............. a* rs 30 as 3 t j j. h _.............. ss as a 40 1 TA ATtraf*_............................................................................... 7J% recovery of health." I agree wholeheartedly with this declaration, but one can hardly miss the implication in this statement that deleading is not advisable from a practical point of view. In other words, it does not appear to tx the method of choice. 0000-NLI-000022558 7 It has also been stated tint circulatory lead may cause tissue damage but stored lead in the bones pro duces no deleterious effects. If this is so, and, so far as is known, it has been accepted by most men in this work, then what is the justification for employing a method as therapy which is acknowledged by its advocates as dangerous and uncertain as to its ultimate results? No method is available for the complete removal of lead from the body, and I can see no reason for deleading when it is well recognised and accepted that there is a normal metabolism governing the intake and output of lead from the body. It is my opinion that no remedy has been found to justify the dangers inherent in deleading. It is my contention that it is more advisable not to employ deleading procedures, in view of the fact that simple immobilization of lead within the skeletal structures of the body is the most rapid and safe method of bringing about a state of well-being. My method of treatment during the convalescent (subacute) and chronic phases of this disease is purely symptomatic (associated with observations of the blood). This is simple, direct and productive of excel lent results. In the subacute or convalescent stage, I prescribe as follows: 1. Regular diet 2. Mild laxatives 3. Calcium wafers 4. Iron aad vitamin B complex therapy for anemia and as a tonic 5. Monthly red blood cell count! and determination of stip pling and hemoglobin 6. N'o further lead exposure During the chronic phase, I use the following rou > tine: 1. Permanent removal from exposure Z Fresh air occupation (yard gang) 3. Adequate diet 4. Multiple vitamin therapy for fatigue, malaise and the like 5. Laxatives for constipation $. Calcium, oral therapy, if indicated 0000-NLI-000022559 s COMMENT Intravenous calcium therapy must bo continued ior at least three to four days alter all symptoms of colic have disappeared, and withdrawal must be gradual-- otherwise ail symptoms may return. Calcium wafers (oral therapy) are given after discontinuance of intra venous therapy. \'o iron or calcium (oral) should be given during the acute phase, as I do not believe that they can be absorbed and utilized. Vitamins, milk and special diets are acceptable, but their value' is ques tionable. Permanent removal from lead exposure is obligatory. Hospitalization is preferred in all cases except in cases of mild disease; I believe that calcium should be given intravenously around the clock for quick and best results. CONCLUSIONS 1. Deleading is not advocated because: (1) it is dangerous, (2) it prolongs hospitalization, (3) it pro longs length of disability and (4)- results are uncertain. 2. Calcium immobilization therapy is advocated because: (1) it is simple and safe, (2) it shortens hospitalization, (3). it shortens length of disability and (4) results are certain. It is therefore my opinion that until such time as some satisfactory deleading procedure is found, which will be simple, safe and able to shorten present length and amount of disability, I shall advocate calcium therapy as the method of choice. Printed *nd Published t the United Stattt if Amenta 0000-NLI-000022560