affection is also known as painter's colic, Devonshire colic, colica
pictonum, the last term being derived from Poitou. It occasionally
develops abruptly without previous symptoms. In the majority of cases,
however, the earlier disturbances of nutrition before pointed out
precede the attacks, often by a period of weeks or months. An
increased tendency to constipation with transient recurrent abdominal
pains, occurring sometimes immediately after food, more frequently at
irregular intervals, often characterizes the prodromic period. There
is, moreover, an intensification of the other symptoms of chronic
lead-poisoning. The appetite is decidedly impaired, so also are the
powers of digestion; the foul condition of the mouth becomes more
annoying, and the peculiar taste alluded to more persistent and more
marked. Constipation occasionally alternates with diarrhœa. The
colicky pains which constitute the attack are of variable intensity,
but usually severe. They are of the nature of true colic. Pressure
over the seat of pain almost invariably gives relief, particularly in
severe attacks. During the remission pressure is grateful to the
patient. The position of the pain varies. Its most common seat is in
the region of the umbilicus. It may occupy the epigastric and
hypochondriac regions or the lower part of the abdomen, extending from
side to side above the level of the pubic bone. These colics are of
some minutes' duration, recurring after short intervals, which are
characterized by a certain amount of continuous cramp. Tenesmus is
frequent. It may be accompanied by strangury or retention of urine,
with pain in the course of the ureters, the spermatic cord, or in the
penis. Shooting pains in the breast also occur. The abdomen {684} is
retracted, and scaphoid to such an extent in some instances that the
prominence caused by the bodies of the vertebræ is apparent in the
median line of the abdomen. It occasionally happens, however, that
retraction does not occur, the belly, on the other hand, remaining
prominent. As a rule, to which there are few exceptions, the bowels
are constipated. This condition is often stubborn. In rare cases,
however, the colic is accompanied by diarrhœa. Nausea is of common
occurrence. Vomiting is sometimes violent and distressing, being
ushered in by repeated attacks of retching. The vomited matters are
usually discolored by bile, and icterus of slight degree usually
occurs. The pulse is invariably diminished in frequency, sometimes as
low as 40 or even 30, per minute. It is at the same time full and
tense. The pulse-frequency is occasionally variable within
comparatively brief periods of time. Respiration is increased in
frequency during the attack. The urine is small in quantity and of
high specific gravity, and frequently contains small amounts of
albumen. It is sometimes entirely suppressed. Fever is absent, and the
slight increase of temperature occasionally observed is attributable
to the restlessness of the patient. The intellectual condition usually
remains clear, but in violent cases it is characterized by excitement.
The paroxysms of pain are more severe in the latter part of the day
and during the night. The course of the attack is irregular. Relapses,
which may occur in the course of some days or even weeks, are
frequent. The duration of the attack does not, as a rule, exceed a
week, but the illness is often protracted by repeated relapses, and in
continued exposure to the cause the tendency to colic may become
chronic. The termination of the attack is in most instances as abrupt
as its onset, and with the cessation of the colic the associated
symptoms, such as retraction of the abdomen, constipation, vomiting,
and diminished frequency of the pulse, rapidly subside. Lead colic is
not unfrequently associated with the other affections of chronic
lead-poisoning. The prognosis is favorable, the mortality being about
2 per cent.
3. The Arthralgia; Arthralgia saturnina.—The tissues entering into the
formation of the joints and the muscular masses contiguous to them are
frequently the seat of intense paroxysmal pains, which appear more or
less suddenly, either with or without prodromes, and run a course
similar to that of lead colic, exhibiting violent exacerbations and
occasional more or less complete remissions. These pains are
accompanied by painful contractions of the muscles. They are somewhat
relieved by pressure and friction and aggravated by exercise and
exposure to cold. Swelling and redness over the affected joints,
ligaments, and tendons are absent. These pains do not follow the
course and distribution of the nerve-trunks, and lack the tender
pressure-points of true neuralgias. They are more common in the lower
extremities, the knee being especially apt to be affected. When they
affect the upper extremity the elbow and shoulder suffer more
frequently than the other joints. The flexor muscles are much more
frequently attacked than the extensors. The muscles of the back,
especially the great masses of long muscles in the lumbar region,
whose function is to sustain the equilibrium of the body, are
frequently implicated. The intercostal muscles and the muscles of the
neck are also frequently affected. The small joints and the muscles of
the hands and feet as a rule escape. The pain is tearing and burning
in {685} character, and very often severe. It is occasionally
associated with tremor. The derangement of the alimentary canal,
especially constipation, which is so characteristic of lead colic, is
often absent. Fever does not occur.
A careful study of these cases establishes the fact that in a
considerable proportion of them the morbid condition is myalgic.
Whether it be due to simple muscular malnutrition or to some specific
action of lead upon the muscle-substance is not determined. The
analogy between these muscular pains and lead colic renders it
probable that in a large majority of the cases the latter view is
correct. These pains are frequently associated with the attack of lead
colic; sometimes, however, they precede the colic, while at other
times they follow it. After a series of remissions and exacerbations
the pain often ceases as suddenly as it began. As in other lead
affections, relapses are frequent. The prognosis is favorable.
The English physicians, and especially Garrod,[6] Todd,[7] and Bence
Jones,[8] have insisted upon the frequency of gout in chronic
lead-poisoning. Murchison,[9] Wilks,[10] and others regard this
association as causative. This view has not found general acceptance
in France. Lancereaux[11] in particular, after a comparative study of
the lesions of the kidney and of the joints in saturnine cachexia and
the corresponding lesion of gout, concludes that the gouty kidney and
the kidney of lead-poisoning have the same appearance, and are simply
varieties of interstitial nephritis, and that the articular and
arterial lesions in both affections are identical. So-called saturnine
gout differs in no respect, either in its clinical or anatomical
characters, from ordinary gout. It would therefore appear superfluous
to describe saturnine gout. At the same time, it must be insisted upon
that chronic lead-poisoning exercises an important influence in the
production of gout—a causal relation due to the fact that lead
diminishes the excretion of uric acid.
[Footnote 6: _Medico-Chirurg. Transactions_, 1854, vol. lvi.]
[Footnote 7: _Clinical Lectures_, London, 1856.]
[Footnote 8: _Transactions of the Pathological Society, London_,
1856.]
[Footnote 9: _Lancet_, 1868.]
[Footnote 10: _British Medical Journal_, 1875.]
[Footnote 11: “Nephritis et Arthrites saturnines: coincidence de ces
Affections paralleles avec la Nephrite et l'Arthrite goutteuse,”
_Arch. gén. de méd._, Decembre, 1881.]
4. Lead Palsy; Lead Paralysis; Paralysie Saturnine; Bleilähmung.—This
condition is fourth among the affections due to chronic
lead-poisoning, both in frequency and in the order of succession.
Nevertheless, like each of the others, it may be the first in the
order of appearance after disturbances of nutrition which are in some
rare cases of very slight degree. As a rule, however, the paralysis
has been preceded by colic or by joint affection, or by both.
Tanquerel[12] found that in 88 cases of lead palsy 25 had been
preceded by an attack of colic, 15 by two attacks, 3 by ten attacks, 1
by fifteen attacks, and that in single cases as many as twenty, and
even thirty, attacks of lead colic had occurred before the appearance
of paralysis.
[Footnote 12: _Loc. cit._]
The length of time over which habitual exposure to lead without the
development of palsy may extend was found by the same observer to vary
from eight days to ten, twenty, or even twenty-five years. One
individual first suffered from paralysis after fifty-two years of
exposure.
Without dwelling upon the sources of error in statistics of this kind,
{686} it must be conceded that they establish in a general way the
extraordinary differences in the susceptibility of individuals. There
are persons who every time they are attacked with colic, of whatever
degree of severity, suffer also from paralysis. Others, on the
contrary, suffer from repeated attacks of violent colic without the
development of paralysis.
Lead palsy is an affection of adult life. Of 102 cases, 2 only
occurred in individuals below twenty years of age.
Like the other specific lead affections except the encephalopathy,
palsy is more common in the summer than at any other season.
Those who have once suffered are very liable to successive attacks.
Tanquerel and Maréchal have observed many returns of paralysis,
presenting the characters of the original attack, many years after the
patient had withdrawn from exposure to lead.
Perverted sensations of the parts about to be affected, such as
coldness, numbness, and hyperæsthenia, may precede the attack.
Impairment of motor-power, manifested by feebleness, stiffness, or
awkwardness and tremor, also appears in the prodromic period. This
trembling consists in slight agitation of the muscles, rather than in
well-marked rhythmical contractions. These precursors may indeed
constitute the attack, which occasionally, and especially under
treatment, terminates at this point. The prodromic symptoms are less
severe during the day, while the patient is at work; at night they are
aggravated. After some days they end in the characteristic paralysis.
Colic is a common precursor. After the attack some stiffness of the
muscles is experienced, which terminates by rapid loss of power or
abruptly in actual palsy. Occasionally encephalopathy precedes the
paralysis. It is rare that prodromes are wholly absent.
In the great majority of the cases the upper extremities and the
extensor muscles are first attacked. If the paralysis be slight other
muscles may escape. The characteristic form of lead paralysis consists
in loss of power in the extensors of the hands and fingers, especially
of the extensor communis, without implication of the supinator longus.
The muscles affected are in the region of distribution of the
musculo-spinal nerve. The deformity is known as wrist-drop. Next in
order, the triceps and deltoid are most frequently attacked. The lower
extremities commonly escape for a considerable time. When attacked,
the extensor muscles of the feet and toes are the first to suffer.
Paralysis of the dorsal muscles occurs in rare instances. It gives
rise to a peculiar stooping, uncertain, and tottering gait. Paralysis
of the intercostal and laryngeal muscles was observed by Tanquerel.
Paralysis of the muscles of the face or of those of the eye has never
been observed in consequence of lead-poisoning. The loss of power
never corresponds strictly to the distribution of the branches of a
single nerve-track.
The paralysis, as a rule, affects both sides, and frequently the
corresponding muscles of the two extremities. Sometimes, however, the
affected muscles of the two sides are not the same, and it
occasionally happens that the affection is limited to one side. In
very rare cases, the arm and leg on the same side being paralyzed, the
affection resembles hemiplegia.
Local paralysis may be limited to the extensor muscle of a single
finger {687} or may involve all the muscles of a limb. There may be
slight impairment of power in the flexor muscles. The enfeeblement of
certain flexor muscles, especially of those of the fingers, may,
Naunyn suggests, be only apparent, the position of the hands being in
pure extensor paralysis unfavorable to the exercise of the flexors and
limiting their function.
Sensation is not, as a rule, affected in lead paralysis. Pains in the
paralyzed muscles, in neighboring muscular masses, and in the
structures about the joints often precede the attack of paralysis.
Anæsthesia of the skin is rare. When present, it is usually of slight
degree, and corresponds to the region of the paralysis. Deep
anæsthesia has also been observed.
Atrophy of the paralyzed muscles is constant and rapid. It frequently
reaches a high degree, causing characteristic deformities, which are
rendered more marked by the fact that the adjacent non-paralyzed
muscles preserve to a great extent their original state of nutrition.
As the neuro-muscular lesion progresses other deformities arise, in
consequence of derangements of the balance of force between opposing
muscles and from other causes. Among these deformities are partial or
complete dislocations of the more movable joints, as the shoulder and
phalanges, with the formation of tumors, which, when they occupy the
dorsum of the hand, might be carelessly mistaken for the nodosities of
gout. It is to be noted that the latter are occasionally present as
complications.
There is rapid diminution, and finally complete loss, of the reaction
to the faradic current. With the galvanic current the reaction of
degeneration is usually well marked. The reaction of degeneration may
be demonstrated in the extensors of the limbs in lead-poisoning before
wrist-drop has occurred.
The course of lead palsy is very variable. In a few cases it is
progressive. When local emaciation or atrophy arrives at the last
degree of marasmus, the skin seems glued to the bones, to such an
extent are the paralyzed parts wasted; the muscles especially are so
thinned that the contour of the bones is easily distinguished. If the
paralysis attack the whole of the limb, then this organ, abandoned to
its own weight, stretches the ligaments and permits the head of the
bone to leave its cavity. In other rare instances the paralysis
remains stationary for long periods of time, only to grow worse after
each new attack of lead disease. Much more frequently lead paralysis
disappears spontaneously or under treatment in the course of some days
or weeks. The convalescence is gradual, and usually rapid, when the
gravity of the lesion is considered; occasionally it is complete in
the lapse of a few days.
The prognosis depends upon the degree of lead cachexia present, the
possibility of withdrawing the patient from the exposure, and finally
upon the degree and extent of the paralysis and of the atrophy. It is
rendered unfavorable by the necessity of the prolonged exposure of the
patient to lead, by a high degree of disturbance of the general
nutrition of the patient; and by the fact of his having presented for
a considerable period the evidences of lead disease, with occasional
attacks of colic or arthralgia; by the complete loss of power and
electrical reactions in the affected muscles; and, finally, by
absolute wasting of the muscular masses. The prognosis is less
favorable in relapses than in the primary attack.
{688} Progressive muscular atrophy has been frequently observed in
patients suffering from lead disease (Naunyn).
5. The Encephalopathy; Encephalopathia Saturnina.—This term was
suggested by Tanquerel to designate collectively the various morbid
cerebral phenomena produced by chronic lead-poisoning. It embraces,
therefore, those affections due to the action of lead upon the central
nervous system, and occasionally described as lead insanity, delirium,
convulsions, epilepsy, coma, etc. It is, of all the disorders produced
by lead, the most rare. Tanquerel met with seventy cases only. It
occurs only in those individuals who are exposed to large quantities
of lead, and in such a manner as to favor the absorption of the metal
and its compounds by the digestive and respiratory tract. Hence
house-painters and the workers in lead-factories supply the greater
number of cases. The time of exposure elapsing before the
manifestations of the special morbid action of the poison upon the
nervous system show themselves varies from a few days to many years.
In a large proportion of the cases the time has been less than one
year.
Women are much less liable than men—a fact clearly due to the nature
of their occupations even when involving exposure to lead.
The majority of the cases have occurred between the ages of twenty and
fifty. Alcoholic habits, insufficient and unwholesome diet,
privations, exposure, and an irregular life especially predispose
those working in lead to the affection. Lead encephalopathy has
developed with nearly equal frequency in warm and in cold weather.
Relapses are frequent.
Among the prodromes are headache, vertigo, agitated and interrupted
sleep marred by distressing dreams, and troublesome insomnia;
derangements of the special senses, dimness of vision, alterations of
the pupils, tinnitus aurium; dysphagia and a sense of constriction of
the pharynx have also preceded the attack of cerebral disorder. It is
usually preceded likewise, and often by a considerable lapse of time,
by the other lead affections above described—namely, colic,
arthralgia, and palsy. Psychical derangements—stupor, apathy, or
excitement—also precede the attack. In a small number of cases lead
encephalopathy has occurred abruptly without prodromes.
The symptomatology is exceedingly variable and irregular. Three forms,
the delirious, the comatose, and the convulsive, have been described.
These conditions may succeed each other in the same attack. The
delirium is variable in kind. It is apt to be at first tranquil; after
some time it becomes paroxysmal and furious. It is broken by intervals
of somnolence. At length true sleep supervenes, and the patient awakes
restored almost completely to his reason.
Coma may develop suddenly, even instantaneously. In a very few cases
the comatose form has developed itself alone during the course of
chronic lead-poisoning. As a rule, however, it is preceded by delirium
or convulsions.
The convulsive form is the most common. The convulsions may be
partial, involving the face or the one side of it, a single limb, or
one side of the body. They may be general, without loss of
consciousness. These incomplete attacks are apt to be followed, after
a period of dulness or unconsciousness, by acute eclampsia.
Epileptiform attacks may now follow each other in rapid succession,
ending in more or {689} less profound coma. The attacks are sometimes
separated by intervals of uneasiness, restlessness, or delirium. These
attacks continue several days. If they are very violent and frequent
death may rapidly supervene. In favorable cases consciousness is
gradually restored, or the patient may awaken suddenly from his
drowsiness after some hours or a day.
These attacks are not preceded by an aura.
Amaurosis is among the more important of the symptoms produced by the
action of lead upon the nervous system. It is usually accompanied by
dilatation of the pupils. The amaurosis gradually disappears as the
other symptoms subside, and with the improvement in sight the pupils
contract. Recovery is frequently complete. Occasionally vision does
not return with the improved general condition. Norris[13] saw, in two
cases of lead-poisoning due to the use of white lead as a cosmetic,
marked choking of the discs in connection with severe cerebral
symptoms. The terminal condition, when recovery does not take place,
is that of nerve-atrophy.
[Footnote 13: See this _System of Medicine_, Vol. IV.]
Albuminuria is common in this as in other lead affections. It may be
of moderate amount and due to the rapid breaking-down of the
blood-corpuscles which marks the exacerbation of the general
condition. Albuminuria may be a direct consequence of the eclampsia.
Finally, it may be due to coexisting nephritis.
The prognosis is in a high degree unfavorable.
MORBID ANATOMY AND PATHOLOGY.—There are no well-characterized
anatomical lesions in chronic lead-poisoning. Lead has been found in
almost every organ and tissue in the body. It exists in combination
with the albumen of the tissues. The changes in the nervous system
that have thus far been described are neither constant nor
characteristic. The same is true of the lesions of the intestines. The
paralyzed muscles are found to have undergone atrophy, with loss of
the striæ and increase of connective tissue. The nerve-trunks are also
the seat of atrophic degeneration.
The mode of action of lead is not yet determined. The view of Henle,
that lead acts chiefly upon the unstriped muscular fibre, was at one
time generally accepted, and served to explain many of the
characteristic phenomena of the disease. On the other hand, there is
much in the clinical history to support the opinion of Heubel, that
its primary action is upon the nervous system. Whether the peripheral
degeneration by which the paralysis is to be explained is primary or
secondary to central degeneration in the anterior cornua of the gray
matter of the spinal cord, is yet in dispute. Some of the forms of
encephalopathy are doubtless due to the nephritis which is found in
many cases of chronic lead disease, and are, in fact, symptoms of
uræmia. In the great majority of the cases this is not the case. The
morbid condition must be explained by the direct toxic action of lead
upon the central nervous system. No theory adequate to account for all
the cerebral manifestations has yet been suggested. Naunyn has pointed
out the resemblance between the nervous and psychical derangements in
lead encephalopathy and those which characterize chronic alcoholism,
and suggests that lead, like alcohol, produces these effects not as a
direct poison, but indirectly in consequence of abnormal nutrition of
the whole system, brought about {690} by the continued circulation of
a foreign poisonous material in the blood.
Chronic Lead-Poisoning in Animals.—Animals exposed to lead under
conditions favorable to the development of the lead affections in man
suffer in like manner. Instances of this kind are of frequent
occurrence in and about large lead-factories. The drinking of water
containing lead also gives rise to these affections in animals.
Horses, dogs, cats, and fowls have frequently suffered from lead
colic. Horses used in lead-factories suffer from a form of laryngeal
obstruction due to lead paralysis of the muscles of the larynx. Relief
has followed tracheotomy and the introduction of a canula, and removal
to an atmosphere free from lead has resulted in recovery. Cats who
spend some time in red-lead workshops frequently are paralyzed. Even
the rats in lead-factories become paralytic (Tanquerel).
DIAGNOSIS.—The diagnosis of the affections due to chronic
lead-poisoning is, as a rule, unattended with difficulty. The
malnutrition, anæmia, poor digestion, foul mouth, stubborn
constipation, and the gingival line, considered in connection with the
history of prolonged or habitual exposure to lead, would warrant the
assumption that the relation between this poison and the symptoms is a
causal one. When there is added colic, arthropathies, and paralysis,
or the cerebral states having the characters above described, the
assumption becomes a certainty. The absence of any one of the ordinary
phenomena, such as the blue line or constipation, would still leave
the clinical picture sufficiently full to justify the diagnosis. The
reaction of degeneration, which is usually marked in saturnine
wrist-drop, with the escape of the supinators, distinguishes it from
pressure paralysis of the musculo-spiral.
TREATMENT.—_A_. Prophylaxis.—Free ventilation and scrupulous
cleanliness constitute, in general terms, the most efficient
safeguards for those whose occupations involve prolonged exposure to
lead. Workmen employed in lead-factories and those otherwise exposed
to lead should be compelled to wash their hands and change their outer
clothing before eating; they should also bathe regularly every day on
leaving work; under no circumstances should they be suffered to eat or
sleep in or near the workshops. As all kinds of work in the
manufacturing of lead preparations are not attended with equal risk,
the workers should from time to time be transferred from one
department to another or from in-door to out-door work. In order to
prevent the constant rising of dust, the floors are to be kept
constantly sprinkled or covered with moist sawdust. It is unnecessary
to go into further details in regard to the hygiene of the subject. It
is probable that towels and sponges worn over the mouth, or other
forms of respirators, because of the inconvenience which they occasion
and the false sense of security which attends their use, are of less
value than has been generally supposed.
It appears scarcely needful to here insist upon the avoidance of
cosmetics and hair-dyes containing lead, or upon the exercise of
reasonable prudence in the matter of the manufacture, sale, and use of
articles of food or drink which are liable either by accident or
design to become adulterated with lead compounds.
The use of sulphuric-acid lemonade is a measure of prophylaxis of less
real value than was at one time supposed, seeing that the sulphate of
lead {691} is in itself capable of producing the disease. Occasional
doses of magnesia sulphate are of use where a tendency to constipation
exists. Workmen who begins to show signs of chronic lead-poisoning
should without delay abandon their work and seek some occupation free
from its peculiar dangers.
The precautions against the use of water contaminated with lead have
been pointed out under the heading Etiology.
_B_. Curative Treatment.—When the disease shows itself, no matter in
what form, the primary indication is the discontinuance of exposure to
lead. Chronic cases of malnutrition, constipation, functional nervous
disorder, will occasionally be found upon careful search to depend
upon long exposure to lead in some unsuspected way. The cause being
removed, such cases often promptly recover.