Plumbism.

Synonyms.—Chronic Lead-poisoning; Saturnism.

Definition.—A chronic intoxication due to absorption of lead.

Etiology.—Individual susceptibility is much greater in some cases than in others, and sleeping in newly painted rooms, or drinking water flowing through lead pipes, has occasioned the disease.

The most common means of receiving the poison, however, is due to contact by workers in lead, such as paint manufacturers, painters, plumbers, workers in type-foundries, shot-makers, pottery-glaziers, lace-makers, calico-printers, glass-grinders, and the habit of dressmakers of biting off thread, some of which is lead-dyed.

It may be taken in the food, in which lead chromate is used to impart a rich yellow color, and may be found in bread, milk, butter, and candy. Chocolate, candy, and tobacco wrapped in lead-foil may also give rise to plumbism.

Women are more susceptible than men, and adults than children, though most likely on account of more frequent exposure rather than natural susceptibility.

Pathology.—The pathological changes occur in the peripheral nerves, muscles, kidneys, liver, mucous membranes, and bloodvessels.

The most constant changes are found in the peripheral nerves, the nerve-endings exhibiting a neuritis, to be followed by atrophy of the muscles. The cord is usually free from structural change, though degeneration may occur in patches, in the nerve-trunks. The atrophied muscles are pale in color, and, in advanced stages, show fibroid degeneration.

In lead-encephalopathy, arterio-sclerosis of the cerebral bloodvessels is found, which sometimes is followed by softening of the brain, and by hemorrhages. Parenchymatous degeneration of the kidneys and liver is common.

Symptoms.—The symptoms vary, depending upon individual susceptibility, amount of lead absorbed, and the length of time of exposure. Anemia is an early and characteristic symptom, and usually of the chlorotic type. The hemoglobin may be considerably diminished, though the erythrocytes are rarely less than 3,000,000. There is impaired nutrition, with consequent loss of flesh and strength.

An almost constant and characteristic symptom is a blue line at the juncture of the gums with the teeth, and is clue to the presence of lead sulphid, formed by the union of the lead in the blood with sulphuretted hydrogen, the latter resulting from the decomposition of tartar upon the teeth. If the patient's teeth be free from tartar, the blue line may be absent. The gums are frequently soft, swollen, and spongy, and there is a metallic taste, and the breath is fetid.

Gastro-intestinal symptoms are also characteristic, lead colic causing the most intense suffering. Commencing with an obscure pain near the navel, it radiates in every direction, until the entire abdomen seems involved. The pain is griping and excruciating in character, the patient not infrequently screaming in his agony. The pain may extend to the back, hip, thighs, and legs; in fact, no part of the body seems free from pain.

The abdominal walls are tense and hard, sometimes knotted, and the umbilicus is drawn inward. The bowels are not tender to pressure, neither does pressure alleviate the pain, as in some other forms of colic. The patient is frequently troubled with nausea and vomiting, the material thrown off the stomach being a slimy fluid, more or less mixed with acrid bile. The tongue is pale, broad, and flabby, and its movements controlled with difficulty; the skin is soft and moist, the pulse not at first affected, but when the disease is long continued and severe, it becomes soft, feeble, and increased in frequency.

The bowels are obstinately constipated; if anything passes, it is in hard scybalous masses, with a brownish water; the sphincters seem to be sometimes so contracted that neither urine nor feces can be passed, and it is v/ith greatest difficulty that we can introduce the nozzle of a syringe.

Paralysis is common, especially that affecting the extensor muscles of the forearm, producing wrist-drop. Less frequently the deltoid, the biceps, the brachialis and pectoral muscles are involved.

Saturnine arthralgia, pain in the articulations, is not an uncommon symptom.

Cerebral symptoms, or lead-encephalopathy, occur where large quantities of lead are absorbed, and it is characterized by convulsions, delirium, coma, neuro-retinitis, and sometimes insanity.

Diagnosis.—The history of exposure to lead-poisoning, the blue line on the margin of the gums, the wrist-drop, the anemic condition, and the lead-colic are such characteristic symptoms that the diagnosis is easily made.

Prognosis.—Unless degeneration of the heart and kidneys has taken place or severe cerebral symptoms develop, the prognosis is favorable.

Treatment.—"The first object of treatment is to mitigate the intense pain, and open the bowels, after which means to remove the lead should be immediately used. Among the most efficient means for the relief of pain is the administration of chloroform in doses of from twenty to thirty drops every half hour or hour; it may be administered in mucilage, water, rectified spirits, or, what is preferable to all, glycerin. I usually order it in the following" manner:

"Sig. Shake well, and give a teaspoonful as often as required.

"If this can not be obtained, or fails, opium, belladonna, or hyoscyamus may be used in full doses in its stead. With this, alum in doses of ten grains every two hours, or iodid of potassium, in doses of one or two grains every hour, should be given as antidotes to the poison.

"To open the bowels, I prefer the use of enemata of compound powder of jalap and senna, or the same may be used internally, or a pill containing from half to one drop of croton oil, is recommended in bad cases; if the last were given, I should make the mass of extract of hyoscyamus, two to five grains. Sulphate of magnesia has been used for the same purpose, and is highly recommended, as is also the white liquid physic heretofore named.

"As a local application, chloroform applied to the abdomen is one of the most efficient; in using it, drop fifteen or twenty drops on a wet cloth, and apply for a few minutes and repeat. Hot fomentations have been used, but without much benefit, as has also the cold-water bandage. A cataplasm of tobacco is highly recommended, and I have no doubt will prove useful.

"I prefer the warm bath to other means. If there are no facilities for giving an entire bath, a large wash-tub filled with water as hot as can be borne, the patient sitting in it, answers a good purpose. A bath containing the sulphid of potassium, in the proportion of four ounces to thirty gallons of water, is recommended for its specific influence. The use of electricity I know to be beneficial, not only in relieving the pain, but, in the form of a galvanic bath, in removing the metal from the system. In the anorexia and slight attacks of colic that are frequently met with in painters and other lead workers, I have found nothing better than sodium sulphate in small doses. I usually order a solution of half an ounce to four ounces of water, to be taken three times a day in doses of a tablespoonful." (Scudder.)

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.