Treatise on Poisons by Sir Robert Christison

the man’s illness was very like that of the worst or most acute form of _colica pictonum_. But in another example which came under my own notice, the symptoms were more nearly those of ordinary irritation,—namely, vomiting, burning, and pricking pain in the throat, gullet, and stomach, with trifling colic subsequently; but the patient recovered in two or three days. The quantity taken was supposed to exceed a quarter of an ounce. So, too, in a case which occurred to M. Villeneuve of Paris, the symptoms were chiefly vomiting and purging, with faintness and some convulsions. His patient swallowed intentionally above an ounce of acetate of lead in solution. Sulphate of soda and sulphate of magnesia were given promptly as antidotes; in an hour the symptoms had abated materially; and next day she was well.[1318] This was the case in which Orfila found lead in the urine. Of the same nature, also, are two cases briefly alluded to by Mr. Taylor, as having been caused in London in 1840 by Goulard’s extract. The subjects, who were children, were seized with vomiting, purging, and other symptoms like those of Asiatic cholera; and both died within thirty-six hours.[1319] In another instance, related by Mr. Iliff of London, where an ounce of the acetate was accidentally swallowed in solution, the symptoms were at first colic pains and vomiting, in the course of a few hours vomiting and tenderness, and, after these symptoms receded, a peculiar state of rigidity and numbness, which was not entirely removed for several days. In this case no remedies were used for three hours; and even two hours later, when the stomach-pump was resorted to on account of the slightness of the vomiting, lead was found in the first fluid withdrawn,—a new proof of the feeble action of acetate of lead, compared with some other metallic poisons.[1320] So much for the operation of the acetate of lead in large doses. Physicians, however, are much better acquainted with the effects of lead when introduced in the body continuously and insidiously in minute quantities. For all tradesmen who work much with its preparations are apt to suffer in this way, and many other persons have been brought under its action in consequence of articles of food and drink being impregnated with it. The disease which is thus induced may be divided into two distinct stages. The first stage is an affection of the alimentary canal, the leading feature of which is violent and obstinate colic. This symptom at times begins abruptly during a state of sound health; but much more commonly it is ushered in by a deranged state of the stomach, not unlike common dyspepsia, seldom so severe as to excite alarm, and commonly imputed at first to a wrong cause. There is general uneasiness and depression, a dingy yellowish complexion, weakness and numbness in the limbs, a sweetish styptic taste and fetid breath, a slaty tint of the teeth and gums, with a blue line along the margin of the gums where they touch the teeth, a slow hard pulse, great emaciation, loss of appetite and tendency to indigestion. This state, which was first well characterized by Mr. Wilson[1321] of Leadhills, and has lately been more fully described by M. Tanquerel,[1322] is of great moment as apprizing the workman of the necessity of taking active measures for preventing the more formidable effects, which otherwise are sure to follow. Of the warning symptoms none is so invariable or so characteristic as the blue line along the edge of the gums, an appearance which was first noticed by Dr. Burton of St. George’s, London,[1323] and has been since observed in every case of lead colic, whether impending or present.—If alarm be not taken in time, the obscure complaints hitherto mentioned become attended by and by with uneasy sensations in the stomach, stretching ere long throughout the whole belly. At the same time the stomach becomes irritable, and the food is rejected by vomiting. Cramps in the pit of the stomach then arise, and extend to the rest of the belly, till at length the complete colic paroxysm is formed. The pain is sometimes pretty constant; sometimes it ceases at intervals altogether; but much more commonly there are remissions rather than intermissions; and it is remarked that both the remissions and exacerbations are much longer than those of common colic. The pain is very generally, yet not invariably, relieved by pressure; even strong pressure seldom causes any uneasiness, provided it be not made on the epigastrium; nay, some patients have been known to bear, with relief to the paroxysms, the weight of two or three people standing on the belly.[1324] The belly is almost always hard, the abdominal muscles being contracted: sometimes it is rather full, more commonly the reverse, and the navel is often drawn in so as almost to touch the spine. The bowels all the while are obstinately costive. Either there is no discharge from them at all; or scanty, knotty fæces are passed with much straining and pain. This state, long supposed to depend on spasm, is now known to arise on the contrary from paralysis, of the intestinal muscular coat. In a few instances diarrhœa takes the place of the opposite affection. The urine is commonly diminished. The saliva has been described as greater than natural in quantity and bluish in colour; but Dr. Burton says he did not observe a single instance of this in forty cases which he carefully examined. From the beginning, or more generally after a few hours or days, the limbs are racked with diffuse cutting pains; which, according to Tanquerel, affect chiefly the limbs, especially near the joints, are worst at night, are often attended with cramps, and are relieved by pressure. The aspect of the countenance is dull, anxious, and gloomy: in advanced cases the expression of gloomy anxiety exceeds that of almost all other diseases. It appears from the latest works on this disease published in France, and particularly from the able treatise of Mérat, that the pulse is rarely accelerated, but on the contrary often retarded.[1325] This does not accord with the experience of some earlier writers;[1326] and in the few cases I have seen in this city the pulse has been always frequent. It cannot be questioned, however, that, as Mérat states, fever is not essential. The skin has a dull, dirty, cadaverous appearance, is often, though not always hot, and in either case is bedewed with irregular, clammy, cold perspiration. This, the first stage of colica pictonum, may end in three ways. In the first place, the patient may recover at once from it as from an ordinary colic; and it is consolatory to know, that a first attack, taken under timely management, is for the most part easily made to terminate in that favourable manner. In such circumstances it rarely endures beyond eight days. But it is exceedingly apt to recur, if, for example, the patient expose himself to what in ordinary circumstances would cause merely a common colic or diarrhœa; and if he returns to a trade which exposes him again to the poison of lead, the disease is sure to recur sooner or later, and repeatedly, unless he observes the greatest precautions. In one or other of these returns, sometimes even in the first attack, the colic is not succeeded by complete recovery, but gives place to another more obstinate and more alarming disease. This secondary affection is of two sorts. One, which occurs chiefly in fatal cases, is a species of apoplexy. The other, which does not of itself prove fatal, is partial palsy. In violent and neglected cases of colica pictonum, the colic becomes attended in a few days with giddiness, great debility, torpor, and sometimes delirium; as the torpor advances the pains in the belly and limbs abate; at length the patient becomes convulsed and comatose, from which state very few recover. Tanquerel, who is unnecessarily minute in subdividing the various affections produced by the poison of lead, distinguishes four kinds of affections of the head, coma, epilepsy, delirium, and a combination of all these.[1327] A very rare termination allied to that now described is sudden death during the colic stage, without any symptom which would lead one to suspect its approach. A case of this kind has been related by M. Louis. His patient, five minutes after talking to the attendant of his ward, was found at his bedside in the agony of death; and no cause for so sudden a death could be found on dissection.[1328] Somewhat similar was a case which occurred in 1838 at the hospital of La Charité at Paris. A man labouring for three days severely under the colic stage of the disease, began to breathe stertorously soon after straining at stool, and died in three hours.[1329] In a case which occurred to Dr. Elliotson death was owing to concomitant perforation of the stomach, a concurrence which was probably accidental, but which was also once observed by Dr. Copland.[1330] In cases, on the other hand, which have not been neglected, and particularly when the attack is not the first, the departure of the colic often leaves the patient in a state of extreme debility, which by and by is found to be a true partial palsy, more or less complete. This affection is sometimes present before the colic departs, but is apt to escape notice till the pain abates. Occasionally it supervenes on a sudden, but more generally it is preceded by a sense of weariness, numbness and tremor of the parts. The palsy is of a peculiar kind. It affects chiefly the upper extremities, and is attended with excessive muscular emaciation. The loss of power and substance is most remarkable in the muscles which supply the thumb and fingers; and in every case which I have seen the extensors suffered more than the flexors. The paralysis is hardly ever complete, except perhaps in the extensors of the fingers. When it is considerable, the position of the hands is almost characteristic of the disease. The hands are constantly bent, except when the arms hang straight down by the side; they dangle loosely when the patient moves; he cannot extend them, and raises one arm with the aid of the other. The palsy is attended, according to Tanquerel, with diminished heat in the parts, and feeble pulsation in the arteries which supply them. There is seldom any loss of sensation in the affected parts. But the paralysis sometimes affects the nerves of the other senses. Thus two cases of paralysis of the nerves of vision have been related by Dr. Alderson of Hull;[1331] and Tanquerel says this affection is not uncommon in Paris, and is attended with dilated and immovable pupils. The latter author also once met with deafness in the same circumstances.—Patients affected with lead palsy usually complain of racking pains in the limbs and arms, digestion is feeble, and trivial causes renew the colic. From this deplorable condition it is still possible to restore the sufferer to health, chiefly by rigorous attention to regimen. But he too often dies in consequence of a fresh attack of colic as soon as he returns to his fatal trade. The lead palsy, however, does not always come on in this regular manner. Sometimes the primary stage of colic is wanting, so that the wasting of the muscles and loss of power are the first symptoms. I have seen a characteristic example of the kind in a sailor who had been employed for a month in painting a vessel. He had great weakness and wasting of the arms and hands, particularly of the ball of the thumb; but except a tendency to indigestion, costiveness, and transient slight pain of the belly, he had suffered no previous disorder of the intestines. I have seen the paralytic affection confined to the extensors of one hand in a compositor, and Dr. Chowne met with a similar affection of both hands in a gas-fitter.[1332] Dr. Bright observed palsy without colic in the case of a painter three times in the course of seven years.[1333]—In like manner, according to Tanquerel, the neuralgic affection may occur severely without any precursory colic; and the same author has witnessed both coma and convulsions in the same circumstances. Colica pictonum, with the collateral disorders specified above, is the only disease which has been distinctly traced to the operation of lead insidiously introduced into the body. But many other disorders have been ascribed to its agency. Boerhaave seems to have imagined that consumption might be so induced; and Dr. Lambe thought that to this cause may be traced the increased prevalence of “scrofula, phthisis, dropsy, chronic rheumatism, stomach complaints, hypochondriasis, and the host of nervous complaints which infest modern life.”[1334] These conjectures are wholly destitute of foundation in fact. In whatever form lead is habitually applied to the body, it is apt to bring on the train of symptoms mentioned above;—the inhalation of its fumes, the habitual contact of any of its compounds with the skin, the prolonged use of them internally as medicines, or externally as unguents and lotions, and the accidental introduction of them for a length of time with the food, may sooner or later equally induce colica pictonum. Instances have occurred of colic being produced by the prolonged employment of the compounds of lead inwardly in medical practice. Such cases are so uncommon that it is evident some strong constitutional tendency must co-operate. But it is in vain to deny, as some do, that the medicinal employment of preparations of lead internally is unattended with any risk whatever of slow poisoning. Dr. Billing of Mulhausen relates a case of death, apparently from the comatose affection succeeding the colic stage of poisoning with lead, in the instance of a boy of fifteen, to whom he gave acetate of lead in gradually increasing doses for six weeks, till he took two grains daily.[1335] Tanquerel met with a case of colic produced by 130 grains taken in fourteen days, and another occasioned by 149 grains in sixteen days.[1336] Sir George Baker has mentioned similar instances.[1337] It would even appear that metallic lead may have the same effect when taken inwardly. Thus Dr. Ruva of Cilavegno has related the case of a man who was violently attacked with the colic form of the effects of lead after taking six ounces of shot by direction of a quack for the cure of dyspepsia, and was seized again with the same symptoms six days afterwards on taking four ounces more. On the second occasion he had violent colic, great feebleness of the limbs, constant vomiting of any thing he swallowed, severe headache, and other analogous symptoms, of which he was not effectually cured for seven weeks.[1338] A case somewhat similar, but less severe, has been described by Dr. Bruce.[1339]—With regard to lead colic being excited by unguents and lotions applied to the surface of the body, Sir George Baker mentions a case of violent colic brought on by litharge ointment applied to the vagina; he adds that children have been thrown into convulsions by the same substance sprinkled on sores: and he quotes Zeller for a case where symptoms of poisoning were occasioned by sprinkling the axilla with it, as a cure for redness of the face.[1340] Dr. Wall, in a letter to the preceding author, mentions his having seen the bowels affected by Goulard’s extract applied to ulcers; in another paper he has given two unequivocal cases, in one of which colic was brought on by saturnine lotions applied to a pustular disease, and in the other by immersing the legs twice a day for ten days in a bath of the solution of acetate of lead:[1341] and lately Dr. Taufflieb of Barr observed lead colic to arise from the continued use of diachylon plaster during eleven weeks for dressing an extensive ulcer.[1342] Such accidents are exceedingly rare, and some auxiliary cause must have favoured the operation of the poison in the cases now noticed; for every one knows that free use is made of lead unguents and lotions, yet we seldom hear of any bad consequences.—These cases, however, will probably remove the doubts which some entertain of the possibility of lead colic being induced by the application of the compounds of lead to the sound skin in those trades which compel the workmen to be constantly handling them. At the same time it must be admitted, that in all these trades there exists a more obvious and ready channel for the introduction of the poison; because the workmen are either exposed to breathe its fumes, or are apt to transfer its particles from the fingers into the stomach with their food.—Of all exposures none is more rapid and certain than breathing the vapours or dust of the preparations of lead. But for that very reason workmen who are so exposed seldom suffer; because the greatness of the risk has led to the discovery of means to avert it, and the openness of the danger renders it easy for the workmen to apply them. Tanquerel mentions a singular case of a woman who was attacked in consequence of the fine dust of white lead ascending through chinks in the floor from a room below, where a perfumer was in the practice of grinding and sifting that substance.[1343]—It may be added that Dr. Otto of Copenhagen has published an extraordinary instance of fatal lead-colic, originating in the habitual use of Macuba snuff adulterated with twenty per cent. of red lead.[1344] To these observations on the various ways in which lead insidiously enters the system a few remarks may be added on the trades which expose workmen to its influence. The most accurate information on this subject is contained in the work of Mérat. He places foremost in the list miners of lead. In this country miners are now rarely affected, because the frequency of colica pictonum among them formerly led their masters to study the subject, and to employ proper precautions for removing the danger. It has been stated by Dr. Percival, and is generally thought, that the whole workmen in lead mines are apt to be attacked with the colic,—those who dig the sulphuret as well as those who roast the ore.[1345] If this idea were correct, it would be in contradiction with the general principle in toxicology, that the metals are not poisonous unless oxidated. But the opinion is in all probability founded on error; for, according to information communicated to me by Mr. Braid, and confirmed since by personal investigation, the workmen at Leadhills who dig and pulverize the ore, although liable to various diseases connected with their profession, and particularly to pectoral complaints, never have lead colic till they also work at the smelting furnaces. Next to miners may be ranked manufacturers of litharge, red-lead and white-lead. The workmen at these manufactories are exposed to inhale the fumes from the furnaces or the dust from the pulverizing mills. It has been chiefly among the workmen of a former white-lead manufactory in the neighbourhood of Edinburgh that I have had an opportunity of witnessing the lead colic. By a simple change the proprietor made in the process, and which will be mentioned presently, the disease was almost extirpated some years before the manufactory was given up. Next in order, perhaps in the same class with colour-makers, are house-painters. The causes of their liability is the great quantity of the preparations of lead contained in the paints they use. It would appear that lead colic is most frequent among people of that trade in cities of the largest size. In Geneva, as I am informed by my friend Dr. C. Coindet of that place, colica pictonum is now almost unknown and never occurs among painters. In Edinburgh it is also little known among painters. A journeyman painter, a patient of mine in the Infirmary, had been seventeen years in the trade, and yet did not know what the painters’ colic or lead palsy meant. In London, according to the Dispensary reports, and in Paris, according to the tables of Mérat, many workmen of that trade suffer. I have been informed by an intelligent workman, once a patient of mine, who had been a journeyman painter both in London and Edinburgh, that the number of his acquaintances who had been affected with colic in the metropolis was incomparably greater than here. This man ascribed the difference to the working hours being more in the former place, so that the men had not leisure enough to make it worth their while to clean themselves carefully in the intervals. This appears a rational explanation. I do not know how the great prevalence of colic among painters in Paris is to be accounted for. Plumbers, sheet-lead manufacturers, and lead-pipe makers, are also for obvious reasons apt to suffer; but as they are not necessarily exposed to the vapours of lead, and suffer only in consequence of handling it in the metallic form, it ought to be an easy matter to protect them. They themselves conceive that a very hazardous part of their occupation is the removing the melted lead from the melting pot, to make the sheets or pipes; but this operation cannot be dangerous if the melting pots are properly constructed. A few cases of lead colic occur among glass-blowers, glaziers, and potters, who use the oxide of lead in their respective trades. There are a few also among lapidaries and others, who use it for grinding and polishing, and among grocers and colourmen who sell its various preparations. Printers seldom suffer from the colic, but are generally thought liable to partial palsy of the hands, which is ascribed to frequent handling of the types. I have met with one case apparently of this nature. Lead is not the only metal to which the power of inducing colica pictonum has been ascribed. Mérat has mentioned several instances of the disease occurring among brass-founders and other artizans who work with copper.[1346] Tronchin quotes Scheuchzer for a set of well-marked cases in a convent of monks, where the malady was supposed to have been traced to all the utensils for preparing and keeping their food having been made of untinned copper.[1347] The same author mentions two cases, one of which came under his immediate notice, where the apparent cause was the long-continued use of antimonial preparations internally.[1348] Mérat likewise found a few iron-smiths and white-iron-smiths in the lists kept at one of the Parisian hospitals.[1349] Chevallier alleges that colic occurs at times among money-changers at Paris, and others who constantly handle silver.[1350] Cases have even been noticed by Mérat among varnishers, plasterers, quarrymen, stone-hewers, marble-workers, statuaries, saltpetre-makers;[1351] and Tronchin enumerates among its causes the immoderate use of acid wine or of cider, checked perspiration, sea-scurvy, and melancholy. But the only substance besides lead, whose operation in producing colica pictonum has been traced with any degree of probability, is copper; and even among artizans who work with copper the disease is very rare. As to the other tradesmen mentioned by Mérat, it is so very uncommon among them, that we may safely impute it, when it does occur, to some other agent besides what the trade of the individual exposes him to; and in general the secret