Lead poisoning should be suspected in any patient whose work is associated in any way with the use of lead, if he comes with indefinite symptoms and no apparent acute definite disease. The symptoms causing the most suspicion are paleness, anemia, constipation, a metallic taste, muscle and joint pains, and tremors.

The prevention of chronic lead poisoning from fumes and from dust is the duty of the sanitary inspector and the owners of the plants. Chronic poisoning from carelessness, due to eating when the hands, face and mustache are dirty, or to drinking out of dirty, contaminated glasses, is entirely the fault of the individual. While lead poisoning possibly can occasionally occur from absorption through the external skin, it generally occurs by swallowing the lead into the stomach, and perhaps, rarely from absorption from the air passages.

POISONING FROM PAINTS

An investigation by Harris' of the susceptibility of painters to lead poisoning showed that a mixture of white lead, linseed oil and turpentine forms a particularly dangerous combination, and that vapors from this mixture could cause skin irritations, nausea, vomiting, headache, conjunctivitis, dizziness, irritation of the throat and bronchial tubes, and even faintness and strangury. Also when benzene is mixed with paints and the vapors are inhaled, nausea, vomiting, and cough may occur, and even more serious poisoning.

Harris found that benzol, acetone, wood alcohol and amylacetate are the usual ingredients of the varnish- and paintremovers employed by painters, and that amylacetate is largely used as a vehicle for bronze pigment. Men using these substances not only complain of the effects of the fumes, but also suffer from skin inflammations. Nearly half of the 402 painters examined by Harris showed evidences of some form of lead poisoning. Not infrequently painters using these combinations of substances are so overcome by the fumes as to become dizzy, and even occasionally fall from ladders. The urine was always more or less disturbed in these cases, having a strong 1 Archiv. Int, Med., Aug., 1918, p. 129.

odor, a high color, and causing more or less bladder irritation. Benzene seemed to be the ingredient of the combination that caused the most unpleasant symptoms.

BRASS FOUNDERS' CHILLS-SPELTER CHILLS

This poisoning occurs in those who work in brass or zinc founderies and are subjected to the vapors from the liquid metal. The younger the individual, the more he is susceptible to the poison, and women are more susceptible than men, and weak men than strong men, and, as with lead poisoning, those who use alcohol are more likely to have this form of poisoning. The symptoms are not dissimilar to malarial chills, except that there may be severe muscle pains, a prickling feeling in the throat, cough, and diarrhea. While a sturdy individual may withstand several of these chills, if they are repeated he becomes more or less incapacitated for work and seems to be predisposed to inflammation of the lungs, and especially to tuberculosis.

The treatment of such a chill consists of hot baths, applications of dry heat, and hot drinks of tea or lemonade to promote perspiration. If there is depression, hot coffee or caffeine should be given.

The prevention of this disturbance is, again, largely a sanitary problem, and factories should not employ young boys and girls, women, or weak, anemic individuals to do this kind of work. The individual prevention is, again, cleanliness and the removal at night of all garments used during the day, and a frequent change of undergarments, as the fumes of the poison are likely to be contained in the clothing.

These chills must not be mistaken for malarial chills, and the patient be improperly treated with quinine, and the cause of the poisoning be allowed to be repeated. Sometimes in such cases after repeated attacks paralytic symptoms have occurred, more especially a weakening of the legs. Such cases, however, are rare.

It may be parenthetically stated that there is absolutely no excuse for the administration of zinc in any form internally.

PHOSPHORUS

The official preparation of this drug is Pilula Phosphori (Pills of Phosphorus). There is no excuse for the drug or its

preparation. Phosphorus as such is not needed in medicine; phosphates and glycerophosphates are the phosphorus preparations needed.

Toxic Action.-Acute poisoning from phosphorus is generally accidental, due to children eating the heads of matches or to taking some rat poison. The fatal dose of phosphorus may not be more than 0.05 to 0.10 Gm. (about 1 to 11⁄2 grains).

The symptoms of acute phosphorus poisoning are likely to develop slowly, especially if there is food in the stomach, and sometimes symptoms may not occur for several hours after the poison has been ingested. There is a general feeling of nausea and weakness, with later vomiting, and the odor of the vomited matter is that of phosphorus, or of garlic. Sooner or later intense pain develops, although this may not always be an important symptom. Occasionally the poisoned individual dies early, but generally the symptoms continue for several days, and the patient may die after it was thought that he was convalescent, due to ulcerations of the stomach or intestines. In these cases of late serious symptoms the liver is always disturbed and jaundice is likely to develop, often preceded by diarrhea with mucus and blood in the stools. Soon cerebral symptoms occur, such as delirium, sometimes convulsions, and later coma and death. There may be hemorrhages from different parts of the body, especially from the nose. The urine is scanty, contains albumin, and sometimes sugar. If death does not occur from such severe poisoning, convalescence is very slow.

Phosphorus poisoning causes fatty degeneration of the liver, kidneys, and pancreas, and degeneration of the heart muscle. The jaundice may be due to both obstruction of the bile ducts and to breaking down of the red blood corpuscles, i.e., it may be hematogenous.

Treatment of Acute Poisoning.-The first treatment is to cause vomiting as quickly as possible, and the best emetic for this purpose is sulphate of copper. Later the stomach should be washed out with large amounts of water, or a 1 to 1000 warm potassium permanganate solution, as the danger lies in a piece of the phosphorus sticking to the mucous membrane and grad

ually causing serious ulceration. Oils should not be given as they tend to promote absorption of the phosphorus. Dilute peroxide of hydrogen solutions have been suggested with which to dislodge the phosphorus and allow it to be vomited or washed out of the stomach.

The subsequent treatment depends entirely upon the condition of the patient. Purging with a saline is advisable. Collapse must be combated, and the future symptoms watched for and treated in the best manner possible.

Chronic Poisoning.-Those who work in phosphorus are now rarely subjected to the fumes, on account of proper sanitary precautions, but they are likely to inhale a sufficient amount to cause disease of the mouth, especially if there is any exposed bone or decayed or ulcerated teeth. Periostitis and necrosis of the bone are likely to occur, if such a condition is present. Phosphorus may cause salivation. If the fumes of phosphorus must be more or less inhaled, masks should be worn to prevent the possibility of poisoning in this manner, and all workers in phosphorus factories should have their teeth and gums particularly carefully supervised, as their mouths should be in perfect condition.

POISONING BY DYE-STUFFS

The opportunity for poisoning from these substances is constantly on the increase, and most anilines are poisons. Doctor Alice Hamilton' has investigated this danger, and finds that the dyes are founded upon benzene and its derivatives, and the most poisonous substances seem to be benzol, toluol, phenol and xylol. She found evidences of the toxic action of these substances in the eyes, in the gastrointestinal tract, and in the kidneys. Benzol causes destruction of the red and white blood cells and is a poison to the central nervous system, and in acute poisoning there may be intense cerebral irritation before death. There may be hemorrhages, and severe nose-bleed is often a beginning symptom. After mild poisoning the individual recovers, generally in twenty-four hours, but in severe aniline poisoning there may be acute prostration, with very low 1 Penn. Med. Journ., July, 1919, p. 655.

blood-pressure and the patient may be unconscious for several hours. Sometimes symptoms of aniline poisoning occur after the patient has left the factory. There are often chest pains, and sometimes eruptions on the skin.

It has been noted that there is a great difference in the susceptibility of patients to aniline poisoning, the same as there is to lead and zinc poisoning. Death can occur from aniline poisoning.

The nitrobenzenes have been found to be very poisonous, and carelessness in their use may cause vapors that are dangerous. Nitrochlorbenzene, which is used in making sulphur dyes, Doctor Hamilton found to be the cause of intense itching of the skin. Phosgene poisoning she found to occur in dye works, which sometimes has been fatal. Also sulphureted hydrogen can cause serious acute and even fatal poisoning.

As these poisons are all volatile, they enter the system through the respiratory tract, either as dust or fumes, but personal carelessness is probably a large factor, many times, in this poisoning. The greatest cleanliness is necessary, and changing the underclothing frequently, shower baths, etc., all tend to prevent such poisoning. Accidental poisoning from the sudden unexpected discharge of the fumes of these substances will probably frequently occur.

These poisonings are so insidious that it is suggested that individuals working in these plants be frequently visited by a physician, to note changes in the face color. If the individual looks gray, he should be quickly removed from his work to the outside air.

TRINITROTOLUENE POISONING

This substance, popularly known as T.N.T., is a high explosive which is produced by nitrating toluene, and is a benzene compound. When it is raised to a certain heat and then subjected to concussion it explodes; with heat alone it burns.

Although precautions are taken against poisoning from this substance, such poisoning does occur, and the fumes are toxic. It is a serious irritant to the skin, and the hands and arms must