PART X

INDUSTRIAL POISONING

Preventive medicine is perhaps the most important study of the age. Sanitation, care of epidemics, isolation of infections, and the prevention of poisoning and of injuries are subdivisions of this great work. In this section it is aimed to describe the treatment of the chronic poisonings that occur among the artizans of some of the industries.

The most frequent of these poisonings occur from lead, but not infrequently poisoning occurs from phosphorus, zinc, mercury, arsenic, hydrofluoric acid, uranium, manganese, and from aniline in the manufacture and handling of dye stuffs.

Mercury poisoning can occur in workman who make thermometers, and it occurs occasionally in the felt hat industry. The principal symptoms are tremors, ulcerations, salivation and digestive disturbances.

Arsenic poisoning is not now very frequent, but may occur from the fumes in some steel industries.

Hydrofluoric acid poisoning occurs among glass workers, and the symptoms are ulcerations of the skin and mucous membranes.

Uranium poisoning occurs from the dust of uranium oxide, which when swallowed into the stomach is dissolved and absorbed. After absorption uranium is a poison to the kidneys, causing nephritis. Uranium salts are poisonous, and there is absolutely no excuse for uranium as a drug, and the uranium nitrate of the Pharmacopoeia should be dropped from the next revision.

Manganese poisoning may occur among those who work in manganese dioxide. The symptoms of such poisoning are lassitude, drowsiness, muscle twitchings or cramps, and more or less mental and spinal depression. The condition is serious, and such poisoning must be prevented.

Investigations of the cotton mill industries have shown that the death-rate is very much greater than among other individuals of the same class in the same climate, and that the hazard from tuberculosis in cotton mill workers is excessive. Women operatives show a higher death-rate than men operatives in this industry.

LEAD POISONING

Most any salt of lead may cause poisoning, but perhaps the suboxide is the most dangerous of the salts that are used in the industries. This salt forms on the surface of molten lead and is given off in fumes, if the temperature is high enough; also this salt is the most frequent cause of poisoning in those who are subjected to the vapor of lead or those who directly handle lead as type setters, plumbers, and moulders. Oxide of lead, litharge, is another frequent cause of poisoning, as well as are the red leads and the carbonate of lead, white lead. These salts of lead are more likely to cause poisoning in painters and in those who lead carriage or automoblie surfaces and then rub them. down.

Plumbi Acetas, (Lead Acetate; Sugar of Lead).—An official preparation of lead acetate is Liquor Plumbi Subacetatis, which contains both lead acetate and lead oxide, so-called Goulard's Extract. From this preparation is made the official Liquor Plumbi Subacetatis Dilutus, which preparation is entirely unnecessary. The stronger preparation may be used, in solutions containing 5 to 10 per cent., externally as a sedative astringent, provided there are no abrasions of the skin and no possibility of absorption. It is not often that this preparation is needed. There is no excuse for using lead in any form internally, therefore a dose for lead acetate is superfluous.

Plumbi Oxidum, (Lead Oxide; Litharge.)—The official preparation of this salt is Emplastrum Plumbi, Lead Plaster (Diachylon Plaster). From this plaster is prepared Emplastrum Resinæ (Rosin Plaster, Adhesive Plaster). Also from lead plaster is prepared the official Unguentum Diachylon. It is doubtful if lead plaster, rosin plaster, or diachylon ointment are needed.

Toxic Action.-Acute lead poisoning generally occurs only from the acetate of lead, and the symptoms are those of a gastro

intestinal irritant. When taken into the stomach an albuminate is soon formed, which is more or less protective to the membranes, so that deep ulceration does not occur. However, if the dose is sufficient, immediate vomiting occurs, with intense pain, followed by collapse, numbness, paralysis, and finally coma. Associated symptoms are burning of the throat, a sweetish metallic taste, colicky pains, thirst, cramps in the muscles, then heart weakness, cold extremities, and collapse. As the patient rarely dies immediately from this poisoning, the urine soon becomes very scanty, later albuminous, and still later there is suppression. If the patient survives a day or two paralytic symptoms develop, and he may die in coma or convulsions.

Treatment of Acute Poisoning.—If vomiting has not occurred the stomach tube should be gently passed and the stomach washed out, or a hypodermic of apomorphine may be given. Then several doses of sodium or magnesium sulphate should be administered, not only to form the sulphide of lead but also to act as a cathartic. The subsequent treatment consists of demulcent drinks, drugs to combat collapse, and the administration of large amounts of water to relieve the kidneys from irritation.

Chronic Lead Poisoning.-The name of plumbism has been given to chronic poisoning from this metal, which condition develops after the long continued introduction of very small quantities of lead into the system, apparently always through the gastrointestinal tract. Even if the dust or vapor is inhaled, the lead is probably swallowed into the stomach and poisoning thus occurs. Workers in lead, who are not exposed to vapors and dust, swallow the lead with their food from lack of cleanliness.

Besides the industries that are likely to cause poisoning, which have been above mentioned, accidental poisoning not infrequently occurs, and in such cases the diagnosis is very difficult. Poisoning from drinking water that runs through lead pipes does not often occur, but when the pipes are not properly filled and air reaches them a carbonate of lead is formed. Water running through the pipes, especially if it is soft and is not loaded with minerals, picks up some of this carbonate and when such water is drunk it will soon produce

chronic poisoning. Lead poisoning has occurred from canned goods, but newer methods of canning have minimized this possibility.

It has long been thought that sulphuric acid lemonade taken freely by those who worked in the fumes and dust of lead would prevent poisoning, but Doctor Alice Hamilton' after much investigation of the subject, has found that this acid lemonade is not a protection against lead poisoning.

The susceptibility to poisoning by this metal varies greatly, some individuals apparently being tolerant to it; others are poisoned within a few weeks, and Doctor Hamilton found that in some factories from 25 to 35 per cent. of the employees had some form of lead poisoning. Negroes are more susceptible to lead than white men, and women are more susceptible than men. Also, anything that fatigues the patient, or poor hygienic surroundings increases the susceptibility to lead poisoning, and those who indulge in much alcohol are more susceptible to it.

It has never been shown that lead poisoning could occur through the unbroken skin, but it has always been an interesting clinical observation that painters may develop wrist-drop, caused by a neuritis of the musculospiral nerve.

Chronic insidious lead poisoning presents multiple symptoms, the most frequent perhaps being anemia, either due to the action of the albuminate of lead (in which form it is absorbed) directly on the red cells, or to action on the red bone-marrow. Basophilic granules are frequently found in the red cells in lead poisoning. When found present they are very suggestive of chronic lead poisoning, but they are not pathognomonic and do not always occur in lead poisoning.

Another frequent symptom of lead poisoning is an increasing blood-pressure, probably due to irritation of the lead on the blood-vessel walls, which sooner or later causes endarteritis and perhaps atheroma. Later the increased pressure is due to interstitial nephritis, which is a result of long continued chronic lead poisoning.

Nervous disturbances occur, as cold hands and feet, and muscle cramps. There is always more or less constipation, 1 Journal A. M. A., Sept. 7, 1912, p. 777.

whether or not there is gastric indigestion, and there is likely to be an increased amount of indican in the urine, which is an indication that more irritants are acting on the kidneys.

These patients often have pyorrhea, and there may be a blue line at the junction of the gums with the teeth, but this blue line is by no means a constant symptom at the present day. Generally, careful analysis of a considerable quantity of urine will show lead in the urine, although lead poisoning can be present even if lead is not found in the urine.

Lead colic may occur at any time, or may never occur, in patients who have chronic lead poisoning. It may occur suddenly, or only after a long period of constipation, and with the colic generally occur vomiting, slow pulse, and high blood-pressure.

The treatment of lead colic. is a hypodermic injection of morphine and atropine; hot moist applications to the abdomen, or if the patient is able he should sit in a hot bath to relax the spasm. As soon as he ceases to vomit he should be given large doses of sodium sulphate. As this colic may be caused by blood-vessel spasm, nitroglycerin (or amyl nitrite) has been suggested, to relieve the contraction. Also, chloroform inhalations to primary anesthesia will stop the colic. Some of the symptoms of chronic lead poisoning and the colic may be due to a disturbance of the endocrine glands, especially of the suprarenals. The after treatment is the same as that of any chronic lead poisoning, but lead colic having once occurred, it is likely to recur unless further ingestion of lead is absolutely prevented.

Another frequent form of lead poisoning is that in which the nervous system is more affected. There are tremors and multiple neuritis, with sometimes paralysis of the extensor muscles of the hands and fingers, wrist-drop. The cause of this form is a neuritis of the musculospiral nerves. This generally begins in the extensors of the third and fourth fingers, then the extensors of the little finger, wrist, and thumb are affected. Rarely the ulnar and median nerves are involved. Generally the wrist-drop is bilateral, but it may be unilateral, and not infrequently the right arm is more affected than the