Charles D. F. (Charles Douglas Fergusson) Phillips.

Materia medica and therapeutics, inorganic substances; (Volume 2) online

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Epsom salts, in a glass of effervescent water (Lancet, i., 1878).

Polli and Galamini state that they have cured cases of biliary calculus
by peroxide of manganese, given in gramme doses daily as an electuary:
they explain the solution of the calculi by the action of oxygen from the
peroxide upon the cholesterine (Gazette de Paris, 1856).

Gastrodynia Pyrosis, Dr. Leared found that purified oxide of man-
ganese had decided power in relieving these disorders; he describes epi-
gastric pain, severe and radiating, coming on not immediately, but soon
after food, worse after albuminous food; the tongue generally red and
patchy, and the malady connected with too rapid shedding of epithelium
and exposure of a hyper-sensitive mucous surface; pyrosis and vomiting
are sometimes present.

Bismuth is a usual and excellent remedy for such a condition, but Dr.
Leared found manganese relieve it often more quickly, with the advan-
tage of not causing constipation. He states that he has treated several
hundred such cases with satisfaction, before venturing to recommend it
(Ranking, i., 1864). No mention is made of a drawback described by
Dr. Goddard Rogers, whose patients found the medicine so gritty and
unpleasant that they could scarcely continue it. He reports two cases of
gastralgia, " severe pain with occasional vomiting," one case of stomach
derangement sympathetic with the uterus, and one of pyrosis, with " irri-
table mucous membrane." All these got well rather quickly, with 10-gr.
doses of the oxide (Lancet, i., 1864, ii., 1865). We have not, however,
heard much of this remedy from other observers.

PEEPABATIONS AND DOSE. Manganesii oxidum preparatum : dose,
5 to 10 gr. ^Manganesii sulphas: dose, 10 to 20 gr. as a purgative.
Ferri et manganesii carbonas saccharata: dose, 5 to 10 gr. as a hsema-
tinic. Solutions of manganese salts are apt to change color on .exposure
to the air.

[PBEPABATIONS, U. S. P. Manganesii oxidum nigrum, and Manga-
nesii sulphas.]



LEAD. 249



PLUMBUM LEAD, Pb,=207.

This metal, rarely found in its native state, occurs more often combined
with sulphur or oxygen. Its commonest ore is galena, a glistening gray
sulphide, PbS, from which the metal is obtained by roasting it in a cur-
rent of air; it is not used in medicine.

COMPOUNDS OF LEAD.

PLTJMB1 OXIDUM OXIDE OF LEAD LITHARGE, PbO,=223.

PREPARATION. By roasting lead ores with access of air, when the
oxide is formed in a melted state, and separates on cooling.

CHARACTERS AND TESTS. Occurs in small glistening red or yellowish-
red scales, which should dissolve without effervescence in dilute acids, but
after exposure for some time to the air, the scales slowly absorb carbonic
acid and may then give some effervescence; they are soluble also in ex-
cess of potash.

The following tests are applicable to this, and to all soluble salts of
lead: (1) Sulphuric acid and soluble sulphates give a white precipitate
(sulphate of lead) insoluble in dilute acids; (2) iodide or chromate of
potassium gives a yellow precipitate of iodide or chromate of lead; (3)
sulphuretted hydrogen or sulphide of ammonium gives a black precipi-
tate of sulphide of lead, but if the proportion of lead be minute, the color
is brown rather than black (W. G. Smith).

PLUMBI ACET A3 ACETATE OF LEAD " SUGAR OF LEAD," Pb(C 2 H 3

O s ) a 3H 2 O,=379.

PREPARATION. By dissolving lead oxide in slight excess of acetic
acid by aid of gentle heat, then crystallizing.

CHARACTERS. Occurs in white crystalline lumps, not unlike sugar, or
in large four-sided prisms. The odor is somewhat sweet and acid, and
the taste at first sweet, afterward astringent. It effloresces in air, and
is soluble in water; with distilled water the solution is clear, but with
ordinary water it is turbid from the formation of carbonate of lead with
the alkaline carbonates always contained in such water; a few drops of
acetic acid will dissolve the carbonate and clear the solution.

LIQUOR PLUMBI SUBACETAT1S -SOLUTION OF SUBACETATE OF
LEAD 11 GOULARD EXTRACT," Pb(C 2 H 3 O 2 )*PbO(in water), =548.

PREPARATION. By boiling neutral acetate of lead with two-thirds of
its weight of oxide of lead, then filtering, and adding distilled water: a
basic or subacetate of lead is formed.



250 MATEEIA MEDICA AND THERAPEUTICS.

CHARACTERS. A colorless liquid of alkaline reaction and sweetish as-
tringent taste. It quickly absorbs carbonic acid from the air, and be-
comes turbid from formation of carbonate. It gives precipitates with
most vegetable coloring matters, with tannin, and with many animal sub-
stances, especially albumen. With gum it forms an opaque white jelly,
which the acetate of lead does not. It answers to the other tests of lead
already mentioned.



PLUMBI CARBONA8 CARBONATE OF LEAD "WHITE LEAD," 2PbC

O 3 PbO,H a O,=775.

PREPARATION. No process is given in the Pharmacopoeia, but the
carbonate is prepared on a large scale by exposing thin sheets or gratings
of lead, placed in earthen pots, to the combined action of acetic acid, air,
and carbonic acid gas.

CHARACTERS. A heavy white powder, insoluble in water, but readily
soluble in dilute acids, with effervescence.



PLUMBI IODIDUM IODIDE OF LEAD, PbI 2 ,=461.

PREPARATION. By precipitating a clear solution of nitrate of lead
with iodide of potassium, washing, and desiccating.

CHARACTERS. A bright yellow powder, darkened by heat, almost in-
soluble in cold water, soluble in boiling water, from which it is deposited
in golden crystalline scales; soluble in solution of acetate of sodium. It
fuses and sublimes yellow, but soon gives off violet vapor (Garrod).

PLUMBI NITRAS NITRATE OF LEAD, Pb(NO 3 ) 2 ,=:283.

PREPARATION. By dissolving lead, or its oxide or carbonate, in boil-
ing nitric acid, slightly diluted, then crystallizing out.

CHARACTERS. Octahedral crystals of white waxy appearance, and
sweetish, astringent taste, soluble in water and alcohol, not efflorescent.

ABSORPTION AND ELIMINATION. Soluble lead compounds, when intro-
duced into the stomach, are transformed probably into chlorides, but in
any case are readily absorbed, as shown by clinical results; it is presumed
that they circulate mainly as albuminates.

Workers in lead, such as compositors, plumbers, and painters, absorb
the metal in part by the skin, in part by the lungs, and sometimes di-
rectly with the food (from eating with unwashed hands), and injurious
effects are not uncommon from the application of cosmetics and dyes con-
taining lead, to the skin and hair (v. p. 257). Once within the system
lead remains for a long time, in small quantities at least, and may be de-
posited in different organs. It has been found not only in the blood and



LEAD. 251

in the liver, spleen, and kidney, but also in the muscles and bones, and
Chatin recovered 3 milligr. of lead sulphide from 150 grammes of
the upper cervical cord the tissue was dark gray in color (Comptes
Rendus, Soc. de. Biol., t. iv., 1862). Lead is eliminated chiefly in the
form of chloride through the liver, kidneys, skin, and mucous membranes,
especially those of the urinary tract; the process is markedly promoted
by iodide of potassium.

(It will be seen from the above observations that I cannot accept the
conclusions of Mayen9on, " that lead is not absorbed by the skin," and
that after being taken, " its elimination is prompt and complete " Med-
ical Times, i., 1873, p. 489).

PHYSIOLOGICAL ACTION (EXTERNAL). Solutions of acetate and nitrate
of lead, if not too strong, exert a local astringent and sedative action,
coagulating albumen, contracting the vessels, blanching the tissue, and
controlling congestion if present; on the other hand, if the solution be
too strong, and be applied to a delicate part, such as the conjunctiva, it ex-
cites severe irritation. The carbonate of lead, applied in fine powder, is
sedative and slightly astringent. The iodide is slightly stimulant and
absorbent. The nitrate and chloride decompose sulphuretted hydrogen,
combining with the sulphur, and hence they act as deodorants.

PHYSIOLOGICAL ACTION (INTERNAL). Digestive System. The acetate
and subacetate of lead are the only salts of this metal given internally,
and the effect of moderate medicinal doses upon the intestinal tract is to
diminish its secretions and to occasion sometimes slight colic. The more
pronounced effects of poisonous doses vary with the mode of receiving
them, and may be acute, subacute, or chronic in character.

Acute poisoning. After a dose of from 1 to 2 oz. the symptoms
begin quickly with the characteristic taste of the drug, followed, perhaps,
in a quarter of an hour by burning and pricking in the gullet, nausea
and vomiting, but the vomiting caused by the poison alone is not usually
severe; there is uneasiness in the stomach sometimes followed by violent
colic, but the pain intermits, and it may be relieved by pressure. There is
usually constipation, but sometimes an attack of purging, the faeces being
dark, and containing lead sulphide.

Subacute poisoning may be illustrated by cases which occurred at
Stourbridge in 1849, when acetate of lead was mixed by accident with
flour at a miller's. Upward of five hundred persons were attacked, a few
days after eating the bread, with a sense of constriction about the throat
and stomach, cramping pain near the umbilicus, and rigidity of abdominal
muscles; sickness occurred only in a minority of the cases, and did not
last long; there was obstinate constipation and a general lessening of
secretion; a dark blue line on the gums was noted. No cases were fatal,
but severe symptoms continued for a long time, and sometimes recurred
after apparent convalescence.



252 MATEBIA MEDICA AND THEKAPEUTIC3.

The subject of chronic lead-poisoning is exceedingly interesting to
the practical physician, but concerns us at present only as illustrating the
physiological action of the drug. 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. Christi-
son gave 18 gr. in two days without injurious effects, while T 1 ^ gr. given
two or three times daily for two months caused fatal poisoning in a child
(Letheby, Taylor). As a rule, it may be said that 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: 5-gr.
doses of acetate are largely used at Brompton Hospital without bad re-
sults.

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 solution of these salts in drinking-water, etc. (v. p. 257). After
some general malaise, disordered taste, dryness of mouth, fetid breath,
anorexia, and constipation, pain will usually be the most marked symp-
tom, but is not so invariably; Dr. Garrod finds it absent in 2 or 3 per
cent, of cases. When fully developed, it is much more intense than or-
dinary colic; it is referred mainly to the region of the navel (the colon),
but darts rapidly, like neuralgic pain, in many directions, toward the
loins, the scrotum, the chest, and the thighs: it has a twisting, tearing char-
acter, so that German miners name it commonly " Hiitten Katze " (" cat
of mines "). It comes on in paroxysms, remaining constant but dull in the
intervals, and 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, and drawn in, there is commonly tenesmus, and the
rectum has been felt to contract and relax spasmodically. The liver is
retracted (Potain) or actually lessened in size; the intestines also are
drawn into less space from contraction of their muscular coat, and in pro-
longed cases, after the abdominal fat has been absorbed, the retraction
of the belly becomes very striking.

Tariquerel (Trait'e, des Maladies de Plomb, Paris, 1839) and Burton
(" Medico-Chirurgical Transactions," 1840) 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 valua-
ble sign, and often present, it is not always so, nor does it necessarily
imply saturation of the system with the mineral; it varies in its time of
appearance according to the dose, but has been seen within twenty-four



LEAD. 253

hours of administration of one large quantity (Burton): 20 to 30 gr.,
in divided doses, may develop it, and when once seen it is very persistent;
similar colored patches may often be found on the buccal mucous mem-
brane. The coloring depends on formation and deposition of lead sul-
phide from the sulphuretted hydrogen evolved from particles of food left
about the teeth (Tomes), and by perfect cleanliness it may be prevented.
According to Dr. Hillipn Fagge, it is distributed in rounded loops corre-
sponding with vascular papillae of mucous membrane, and depends on
small pigmented granules, some of which are external to, others within
the small vessels. He concludes that the gas from food-particles diffuses
into the gum-textures, and then combines with lead circulating in blood
or plasma, so that particles of lead sulphide are really precipitated a
similar condition may be present in the intestinal membrane. Iodide of
potassium sometimes induces its rapid development (Lancet, i., 1876, p.
709).

We cannot so readily explain the pathology of the colic. It is in part
dependent on constipation, or accumulated mucus within the canal, for
it is relieved when purgation is secured; yet Briquet claims to have re-
lieved more quickly by faradaism of the abdominal wall without any ape-
rient effect. It is dependent partly also on irregular muscular contrac-
tion of the intestinal tube, following on partial paralysis and spasmodic
peristalsis; other characters again show it connected with an enteric neu-
ralgia (v. p. 254).

In acute poisoning, the gastro-intestinal mucous membrane has been
found coated with a whitish-gray layer of coagulated mucus containing
the poison, and there have been patches of abrasion, congestion, or in-
flammation. In chronic cases the membrane is congested, softened, and
discolored, the walls are thickened, and the canal irregularly contracted;
sometimes intussusceptions are found; the coils of intestine are closely
packed together. In chronic plumbism, emaciation is notable, especially
about the face.

Nervo- Muscular System. Ordinary medicinal doses do not usually
produce definite effects on the nerves or muscles, but in acute poisoning
from large quantities, besides the pain and cramp already mentioned,
general prostration is a marked symptom. There may be also giddiness
or stupor, numbness or paralysis, and, in fatal cases, convulsion. In the
subacute cases at Stourbridge, the nervo-muscular symptoms were cramp
and rigidity of muscles, numbness, and partial palsy of lower extremities,
and collapse: the mental faculties were unimpaired.

But it is in chronic plumbism that affections of the nerves and mus-
cles become marked and significant, various forms of paralysis almost
always appearing. The most common is a paralysis of the extensors and
supinators of the forearm, leading to a condition known as " wrist
drop," from the peculiar manner in which the hand hangs down when



254 JIATERIA JIEDICA AISTD THERAPEUTICS.

the limb is extended. This occurs more often on the right side than the
left the fingers and wrists are flexed and the hand prone, the elbow
stands out from the side, and the forearm bends on the arm wasting of
the affected muscles quickly follows, and especially of the small muscles
of the thumb.

A special plastic or fungoid form of synovitis in the sheath of the ex-
tensor tendons has been described (Gubler: Britisfy Medical Journal, ii.,
1878).

Sometimes other muscles are affected thus, strabismus has been
noted from paralysis of ocular recti, and aphonia from laryngeal palsy.
Occasionally hemiplegia occurs, more rarely still paraplegia, and in ad-
vanced cases the extensors, at least of the lower limbs, are more or less
affected. Death has resulted from paralysis of respiratory muscles. Of
the special senses, sight is the most often affected, amblyopia occurring,
or amaurosis from anaesthesia of optic nerve; in such cases the pupil is
dilated. It is not uncommon for the hearing to suffer, and common sen-
sibility is often altered. There is usually partial anaesthesia, though
sometimes, as in the Claremont cases, excessive hypersesthesia is de-
veloped.

During an attack of lead colic the intellect is, as a rule, clear, but in
continued cases the moral courage and the spirits give way, and some-
times in the course of the illness distinct delirium occurs, generally of
the form " delirium of dread," not unlike delirium tremens. The patient
is extremely fearful of being alone, especially at night, and has visions
of black and creeping things. Three remarkable illustrations occurring
in women-workers at a lead-factory are furnished from the London Hos-
pital (Medical Times, \., 1869). Other cerebral symptoms, such as head-
ache, delirium, epileptiform convulsions, and coma, have been recorded;
insomnia is usual.

Theories of Plumbism. Whether the muscles or nerves are primarily
affected, and in the latter case whether the peripheral branches or the
centres 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 pres-
sure often gives pain, even over the iliac crests (where the intestines are
not), while firm supporting pressure relieves. Briquet, acting upon this
theory, faradized the skin of the abdomen with a metallic brush, and thus
relieved the pain by counter-irritation. That the paralysis also depends
on deposition of the metal in the muscles is suggested by the frequency
with which the right arm is affected in lead-workers, it being more ex-
posed to the poison than the left.

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



LEAD. 255

vanism of the sympathetic nerve-centres has been said to cause elimina-
tion of the poison quickly, and to cure palsy of the forearm without
direct local treatment (Medical Times, i., 1877).

Eulenburg considers lead colic " a mixed neurosis of motor-sensory
nature, in which the splanchnic nerves and vaso-motor branches from the
aortic plexus are affected " (Medical Times, i., 1870). He points out the
special determination of lead to the muscular system and its powerful
local effect in causing contraction of involuntary muscles.

Heubel argues that the peripheral intra-muscular extremities of nerves
are at fault rather than main trunks (" Bleive<rgiftung," Berlin, 1871), and
Althaus apparently takes the same view (Medical Times, i., 1874, p. 548).
On the other hand, Bernhardt asserts that the real lesion is in the gray
matter of the cord (Medical Record, 1878), and most modern observations
point to the same conclusion, at least in chronic conditions; lead has been
found in its substance in some cases (Chatin, v. p. 251), and a granular
partly atrophic state of spinal cells has been verified in one instance by
Lancereaux. The affected muscles and corresponding nerve-trunks are
much atrophied, so that sometimes scarcely one normal fibre can be
found.

Circulatory System. Full medicinal doses of the acetate slightly
lower the force and frequency of the pulse (Laidlaw). In hemorrhagic
cases and in pneumonia this effect is often marked. Strohl found a
diminution of ten to fifteen beats per minute after daily doses of 25 to 50
ctgr., and Rabuteau verified a pulse-rate below that of health; it has been
explained by a direct action on the muscular structure of the heart. In
cases of acute lead-poisoning, the pulse has been sometimes quickened, but
has become slow in the stage of collapse. In subaciite cases it is markedly
slow and feeble. During a paroxysm of colic in the course of plumbism
the pulse is of characteristic wiry hardness, and generally lowered in
frequency, while the heart-action is so weakened as to be scarcely per-
ceptible. In half the large number of cases recorded by Tanquerel, the
pulse-rate was from 30 to 60 per minute, the hardness and slowness being
usually proportioned to the amount of pain; exceptionally the frequency
was increased. The peripheral circulation is commonly impeded, and
arterial ana?mia leads to pallor and chilliness, though in two cases re-
corded by Murchison a rise of temperature (102) was found (Lancet, i.,
1868). In chronic conditions of lead-poisoning the pulse is small, hard,
and usually slow, and the sallow, bloodless skin has an icteric tint, anaemia
is commonly marked, and there is more than normal water in the blood as
well as fewer red globules; Malassez states, however, that these are in-
creased in size (Archives de PhysioL, 1874). Cardiac murmurs are usual
in lead-workers, and it is said that 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



256 MATERIA MKDICA AND THERAPEUTICS.

lead circulating with the blood; certainly vascular tension is much in-
creased in plumbism, as clearly shown by the sphygmogram of Dr. A.
Frank (Dent. Arch. Klin. Med., Bd. xvi., Hft. 3). German observers,
besides corroborating this, have demonstrated the antagonistic effect of
pilocarpin during attacks of colic; very soon after its hypodermic injec-
tion the tracing shows greatly lessened tension, and simultaneously the
pain is relieved. Nitrite of amyl acts similarly (Medical Record, 1876).

Genito-urinary System. Chronic lead-poisoning often leads to abor-
tion, and if this does not occur, the children born are delicate. Of ]23
conceptions among lead-workers, 50 children only were born alive, and
of these but 14 survived infancy. It would seem that the influence of
one parent only affected by lead is enough to produce these results (M.
Paul: Archives de Meet., 1860). Amenorrhcea has been clearly traced by
Dr. Dowse to working in lead.

The influence exerted by this drug upon the kidney is of great practi-
cal importance: albuminuria is not uncommon in acute plumbism, and is
then connected probably with altered blood-conditions, but in chronic
cases a directly injurious action is exerted on the kidney structure, lead-
ing to fatty or albuminoid degeneration. Dr. Shearman has recorded two
remarkable instances of albuminuria in one family, clearly 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 albuminuria (Practi-
tioner, vol. xii.).

During a paroxysm of colic the kidney secretion is diminished, and is
passed with difficulty. It is proved, also, that the withdrawal of urates
from the blood in its passage through the kidneys is lessened under the
influence of lead, and the amount of uric acid excreted by the same or-
gans is lessened, hence a larger than normal amount remains in the blood,
and the patient becomes exposed to gouty attacks. Indeed, both Dr.
Garrod and Dr. Ringer have developed acute gout in susceptible subjects
by the administration of lead salts, and the former has calculated that 33
per cent, of gouty patients had been exposed in some manner to the ac-
tion of lead. Pains about the joints, and urate deposits, are not uncom-
mon in saturnine cachexia. Dr. Wilks adds testimony to their frequency
(British Medical Journal, i., 1875).

Glandular System. By the ordinary medicinal use of the drug all
secretions are diminished. According to Rutherford, the acetate of lead
is the only substance which lessens the secretion of bile without causing
purgation, and he considers this action to be direct, not indirect or reflex;
it is overcome by salicylate of soda. He connects the constipation partly



Online LibraryCharles D. F. (Charles Douglas Fergusson) PhillipsMateria medica and therapeutics, inorganic substances; (Volume 2) → online text (page 31 of 40)