as a sound adviser, may spend many anxious moments before he gives a definite opinion as to the advisability of operative procedure.

At

He should carefully consider all the circumstances of each particular case. the present day-within the last few years-some surgeons have been removing the uterus in a somewhat wholesale manner. They consider the operation advisable in a large majority of the cases of fibroids which enter their consulting rooms.

These surgeons may be divided into two classes: (1) The matured and brilliant surgeon, whose recognized skill and success in such operations makes him forget that a certain percentage of mortality must ensue. (2) The youthful enthusiastic operator, without experience of the life-history of such cases, thirsting for fame and practice, encouraged by the successes of the first class, he is the more dangerous of the two, the knife is in his hand, and he considers fibroid tumors exist to be removed.

In contrast with these, it is possible to go to the opposite extreme. There are physicians of mature years and senile notions who, looking back upon their past record of good work done and success achieved by methods which in years gone by brought them fame, do not seem to grasp the fact that the discovery of Lister, the work of the brains and hands of many surgeons, and the improvement in technique, have produced a comparatively low death-rate in an operation from which the mortality in their early days was terrible.

Who is more fitted in these extreme cases to guide by his report and observations the opinions of specialists than the practitioner who has watched the case, perhaps, for years?

The judgment of such an one must therefore be guided by his knowledge of the life-history of the patient, of the severity of her symptoms, of her circumstances of life, of her temperament, of what the continuance under the existing conditions would mean to herself and her family. He must not hesitate, when in consultation, freely and fearlessly to offer his own views, no matter whether in the presence of the mature and brilliant surgeon, of the youthful enthusiastic operator, or of

the senile physician, whom I have introduced as types only to illustrate my remarks.

[Written for the MEDICAL BRIEF.] Chronic Lead Poisoning.

BY CHARLES D. F. PHILLIPS, M. D., LL. D.
(ABERD.); LL. D. (EDIN.); F. R. S. ED.;
F. R. C. S. ED.; M. R. C. P. (LOND.).
Honorary Fellow of the Medico-Chirurgical
College, Pennsylvania; Member of the
Academy of Medicine of America; Late
Examiner in the University of Edinburgh,
Glasgow and Aberdeen, and Lecturer on
Materia Medica and Therapeutics at the
Westminister Hospital, London. London,
England.

Chronic lead poisoning is so common a complaint, is the bane of so many trades and occupations, is so widespread and produces such disastrous effects on almost every organ of the body that no apology need be offered for dealing with the subject from the point of view of the pharmacologist.

Workers in lead, such as compositors, plumbers and painters, absorb the metal in part by the skin, in part by the lungs, and sometimes from eating with unwashed hands directly with the food. Injurious effects are not uncommon from the application of cosmetics and dyes containing lead to the skin and hair.

Once with the system lead remains for a long time, in small quantities at least, and may be deposited in almost every organ of the body. It passes through the placenta to the fetus, and has been found, not only in the blood and the liver, spleen and kidney, but also in the muscles, bones, and nervous system. In two cases of lead poisoning which occurred at a lead factory in the east of London, the brain contained large quantities of lead, in one of them as much as 117.1 milligrammes of the sulphate. This may account for the serious nervous effects absorption of the metal produces. Ebstein records the case of a man, aged forty-three, a lacquerer, who had had lead colic for eight years; there was no blue line on the gums, lead was not found in the muscles, but it was in the brain.

Lead is eliminated chiefly in the form of chloride through the liver, skin and mucous membranes, especially those of

the urinary tract. This process is markedly promoted by iodide of potassium, iodide of lead, which is excreted with comparative ease, being formed.

The subject of chronic lead poisoning is exceedingly interesting both to the pharmacologist and the practical physician. Some of its symptoms have occurred from the medicinal use of the acetate, and from the continued use of minute quantities rather than from massive doses. Thus Sir R. Christison gave eighteen grains in two days without injurious effects, whilst one-fifteenth grain given two or three times daily for two months caused in a child fatal poisoning. As a rule, the worst effects of any medicinal use of lead limit themselves to an attack of colic, and the severe symptoms about to be described need not be feared from it.

The ordinary "lead colic," or plumbism, is traceable most frequently either to the mechanical use of metallic lead, its oxides or carbonates, or to the ingestion of these salts dissolved in drinking water. After some general malaise, disordered taste, dryness of the mouth, fetid breath, anorexia and constipation, abdominal pain is usually the most marked symptom, but not invariably, for Garrod found it absent in two or three per cent of his cases. When fully developed it is much more intense than ordinary colic; it is referred mainly to the region of the navel (the colon), but severe cramp-like or neuralgic pains dart in many directions, towards the loins, the scrotum, the chest, and the thighs; it has a twisting, tearing character, so that German miners name it commonly "Hutten Katze" ("cat of mines"). It comes on in paroxysms, remaining constant but dull in the intervals, the whole attack lasting from a few minutes to several hours. It is often worse at night, but its recurrence is irregular. Relief is found from firm pressure and altered position, and the sufferer either lies flat on his face, pressing the abdomen or is doubled up, bending his legs, or rises suddenly, still pressing the painful part with his hands, till a violent paroxysm again sends him to bed. Restlessness is extreme, and the whole attention is concentrated on the pain. The abdominal walls are rigid, knotty,

The

and drawn in, there is commonly tenesmus, and the rectum has been felt to contract and relax spasmodically. liver is retracted, or actually lessened in size; the intestines are drawn into less space from contraction of their muscular coat, and in prolonged cases, after the abdominal fat has been absorbed, the retraction of the belly becomes very striking.

Tanquerel and Burton were the first to describe, as common in plumbism, a dark blue or gray line along the free edge of the gum, together with a brownish coloration of the teeth. Though a valuable sign, and often present, it is not always so, nor does it necessarily imply saturation of the system; it varies in its time of appearance according to the dose, but has been seen within twenty-four hours of administration of one large quantity; twenty to thirty grains, in divided doses, may develop it, and when once seen it is persistent, lasting twelve months at least after its Similar has ceased. cause colored patches may often be found on the buccal mucous membrane. The coloring depends on the formation and deposition of lead sulphide from the sulphuretted hydrogen evolved from particles of food left about the teeth, and it may be prevented by perfect cleanliness. It is usually distributed in rounded loops corresponding with the vascular papillæ of the mucous membrane, and depends on small pigmented granules, some of which are external to, and others within the small vessels. It is probable that the gas from the decomposition of food particles diffuses into the textures of the gum, and then combines with lead circulating in the blood or lymph, so that particles of lead sulphide are really precipitated. A similar condition may be present in the intestinal membrane. The administration of iodide of potassium sometimes induces its rapid development.

I can not so readily explain the pathology of the colic. It is in part dependent on constipation, for it is relieved when purgation is secured; yet Briquet claims to have relieved it more quickly by Faradism of the abdominal wall without any aperient effect. It is dependent partly also on irregular muscular contraction of the intestinal tube, and is

partly enteric neuralgia. Harnack, using the triethylate of lead, which can be injected directly into the blood, found that the nervous ganglia in the intestinal wall were stimulated, in consequence of which sometimes diarrhea resulted from increase of peristalsis, but more usually there was firm contraction of the intestine leading to severe constipation; the former was more often seen in animals, the latter in man. The contraction of the bowel, he held, explained the colic. I think, however, that the irregular muscular contraction of the intestinal wall, which is the physical basis of the colic, is due not to a direct action of the lead on the muscular fibre, but to an indirect action through the nervous system.

Ordinary medicinal doses of lead do not usually produce definite effects on the nerves or muscles. It is in chronic plumbism that affections of the nerves and muscles become marked and significant, various forms of neuritis and paralysis almost always appearing. The most common is a paralysis of the extensor muscles of the wrist and fingers, leading to a condition known as "wrist drop," from the peculiar manner in which the hand hangs down when the limb is extended. This occurs more often, or earlier, on the right side than the left-the fingers and wrists are flexed, and the hand pronated, the elbow stands out from the side, and the forearm bends on the arm-wasting of the affected muscles quickly follows, especially of the small muscles of the thumb. A special plastic, or fungoid, form of synovitis in the sheath of the extensor tendons has been described.

Sometimes other muscles are affected -thus, strabismus has been noted from paralysis of the ocular recti, and aphonia from laryngeal palsy. Death has resulted from paralysis of the respiratory muscles; in a case where this was imminent, recovery occurred under atropine, which was presumed to stimulate the respiratory center. Although the paralysis is generally of the forearm type, giving the double drop-wrist, yet it is not infrequently of the upper-arm type (in which the celtoid, biceps and supinator longus are implicated); sometimes it has the characters of an ordinary progressive muscular

atrophy (Aran-Duchenne), attacking first the small hand muscles, and in about thirteen per cent of the cases it attacks the legs first (peroneal type). Of the special senses, sight is the most often affected, amblyopia occurring sometimes without the presence of any changes in the fundus, though double papillitis or neuro-retinitis are not unfrequently seen. Oliver has recorded cases of primary papillitis, and Lockhart Gibson has described cases in children where there was much swelling of the disc. In these cases there was no albuminuria, but lead was found in the urine. Impairment of vision often persists, and in some cases ends in absolute blindness. Permanent loss of sight may occur also from a chronic atrophy of the optic nerves independent of papillitis.

It is not uncommon for the hearing to suffer, and common sensibility is sometimes altered. There are occasionally patches of anesthesia, and sometimes hyperesthesia is developed. From experiments on animals Curci concludes that lead specially irritates the vagus, and he thus explains the slowing of the heart action.

During an attack of lead colic the intellect is, as a rule, clear, but in longcontinued cases the moral courage and the spirits give way, and sometimes in the course of the illness distinct delirium occurs, generally of the form "delirium of dread," not unlike delirium tremens. The patient is afraid of being alone, especially at night, and has visions of black and creeping things. The encephalopathic, or fulminant, cases may result in death in a few hours. In the cases where recovery occurs, there may persist blindness, or epilepsy, or insanity.

The fits, which are due to the presence of lead in the blood, resemble those of uremia and alcoholism, indeed, are indistinguishable from true epileptic attacks. Other cerebral symptoms, such as headache, delirium and coma, have been recorded; insomnia is usual. A comparison may be drawn between the effects of alcohol and of lead, both upon the nervous system and the kidneys. Of one thousand three hundred and ninety cases of lead poisoning, there was colic in eighty-eight

rer cent, paralysis in seven per cent, and encephalopathy in five per cent.

Whether the muscles or nerves are primarily affected, and in the latter case whether the peripheral branches, or the centers are most at fault, has been much debated. Giacomini attributed the colic to direct muscular irritation from deposition of the metal in the abdominal muscles and the diaphragm, pointing out that superficial pressure often gives pain, even over the iliac crests, whilst firm supporting pressure relieves.

Tanquerel maintained that the colic was due to irritation of the great ganglionic centers, though signs of this could only be found in one out of forty post-mortem examinations.

Heubel argues that the peripheral intramuscular extremities of nerves are at fault rather than the main trunks. On the other hand, Bernhardt asserts that the real lesion is in the gray matter of the cord, and most modern observations point to the same conclusion, at least in chronic conditions; lead has been found in its substance in some cases, and a granular partly atrophic state of spinal cells has been verified in one instance. Popow finds that lead, like arsenic and mercury, produces a central myelitis of the spinal cord. The affected muscles and corresponding nerve-trunks are much atrophied, so that sometimes scarcely one normal fiber can be found. The view that the nerve centers are the seats of the lesion is supported by the fact that large quantities of lead are found in both cerebrum and cerebellum. In animals choreic movements occur, and even convulsions, without impairment of sensation or consciousness. It would seem that the motor areas of the central nervous system are more affected than the sensory.

Harnack explains the colic by an action on the intestinal ganglia. He holds that the action on the muscles is a primary one, although certain observers have stated it to be secondary to degeneration in the spinal cord. In acute poisoning, before any affection of the cord has had time to affect the muscles, he describes the latter as being easily fatigued so that they can not be tetanized by repeated electric stimulation.

Recent research has shown that it is more than likely that the whole neuron is affected by the lead poison. The peripheral nerves are undoubtedly degenerated, but the fact that the supinator longus escapes in the ordinary wrist-drop indicates an affection of the centers in the cord as well.

Of the cerebral phenomena, to which the term saturnine encephalopathies has been applied, epileptiform convulsions are the most common; they may occur early, and come on suddenly without warning, and are usually accompanied by headache, vertigo and dimness of vision. The convulsions which ensue later are usually associated with an albuminous condition of the urine.

Full medicinal doses of the acetate slightly lower the force and frequency of the pulse. In chronic conditions of lead poisoning the pulse is small, hard and usually slow, and the sallow, bloodless skin has an icteric tint, anemia is marked, and there is more than the normal amount of liquor sanguinis, as well as fewer red corpuscles. Malassez states that these are increased in size. Cardiac murmurs are common in lead workers, and the heart and great vessels have been found smaller than usual after death. Henle considers that the vessels are contracted (during life) by direct irritation of their muscular coat by lead circulating with the blood; certainly vascular tension is much increased in plumbism, as clearly shown by the sphygmograms.

Chronic lead poisoning often leads to abortion, and if this does not occur, the children born are delicate. Of one hundred and twenty-three conceptions amongst lead workers, fifty children only were born alive, and of those but fourteen survived infancy. It would seem that the influence of one parent only affected by lead is enough to produce these results. Amenorrhea and menorrhagia have been traced to working in lead, and pills of diachylon are largely used to procure abortion, especially in factory towns.

The influence exerted by this drug upon the kidney is of great practical importance. Albuminuria is not uncommon in acute plumbism, and is then connected

probably with an altered condition of the blood, but in chronic cases a directly injurious action is exerted on the kidney structure, leading to chronic interstitial nephritis. It is said to be due to the deposition of earthy matter in the looped tubules, causing their blocking, and consequent cirrhosis. Shearman has recorded two remarkable instances of albuminuria in one family, traceable to the use of drinking water impregnated with lead; characteristic palsy was also present. The cases recovered for a time after removing the cause, but later one died of apoplexy, the other of Bright's dis

ease.

In a clinical lecture on the subject, Oliver concluded lead to be a "special poison to the renal cells," but all metals, if absorbed, affect the kidneys more or less severely.

During a paroxysm of colic the amount of urine is diminished, and it is passed with difficulty. It is proved also that the excretion of urates, urea and uric acid from the blood in its passage through the kidneys is lessened under the influence of lead, hence a larger than normal amount remains in the blood, and the patient becomes exposed to gouty attacks. Indeed, acute gout may be developed in susceptible subjects by the administration of lead salts, and it is calculated that thirty-three per cent of gouty patients had been exposed in some manner to the action of lead. Pains about the joints and deposits of urates are not uncommon in saturnine cachexia.

Of the different workers in lead, oxide of lead, or "white lead" (carbonate), those who grind it in factories are most liable to suffer, though less so now that the powder is ground with water, but house painters and coach painters, plumbers, pewterers and compositors, makers of certain white glazed cards, hat pressers, bleachers of Brussels lace and glazers of pottery are often affected. Severe symptoms have sometimes arisen from sleeping in a newly painted room, or from breathing the smoke of burning painted wood. Amongst exceptional and little suspected causes of plumbism, are the handling of vulcanized rubber and black horse hair colored by lead sulphide, the use of hair washes, dyes and cosmetics containing lead salts, breathing

dust from "American cloth" whitened with lead salts, and in the process of making yellow cord fusees (chromate of lead). The case is recorded of an infant one and three-quarters years of age, who developed lead poisoning from the treatment of a general eczema with diachylon ointment. Poisonous symptoms have followed in an infant after the application of strong lead lotions, or "metallic shields," to the mother's nipples, and in children from yellow confectionery (chromate). Chewing "tea lead" (in which tea is wrapped), using snuff that had been wrapped in similar "foil," the use of soda water from lead syphons (free tartaric acid is said to help in this case), bathing in water impregnated from a leaden pipe, drinking wine from bottles which had been cleansed with shot, have all caused plumbism. Cases of lead poisoning have been recorded in a shoemaker from putting nails in his mouth, in a cigar roller from cutting cigars on a lead plate and putting the knife in his mouth; in a diamond worker who fixed small diamonds in masses of lead before proceeding to cut them; and from the manufacture of artificial flowers.

Two epidemics have occurred-one at Taunton (England), another in France -from flour ground between millstones that had been mended with lead, and even the handling of lead machines, as in ice-cream making, or cameo polishing, or cleaning "beer engines," or brass handles (as engineers do), has induced colic. Cases of lead palsy occurring in children in Australia were traced to the drinking of ginger beer which was found to contain one milligram of lead in twenty-four ounces.

There is reason to think that "dry colic," or enteric neuralgia, of tropical countries is connected with lead. Gubler gives instructive instances of its development from the use of lead cosmetics in creoles. Mialhe and other French physicians speak of lead colic being frequent on shipboard, and connect it with the action of a saline atmosphere on lead. It is especially frequent in Newcastle, "the home of the lead trade."

Excepting in the trades mentioned, the most frequent source of lead poisoning