Lead poisoning and lead absorption

by Sir Thomas Morison Legge; Kenneth Weldon Goadby

It is well to make all these points before asking any questions. After they are completed inquiry as to regularity of the bowels, existence of pain or discomfort, would follow. The speech should be noted, as slurring or hesitating speech is occasionally associated with early lead poisoning.

All these points can be gone through quite rapidly, and at the conclusion of the general examination, if judgment is in suspension, careful examination in the routine medical manner should be made.

In some factories all new workers are examined by the surgeon before they commence work in dangerous processes. At any rate, a list of such persons should be given to the surgeon at his visit, as naturally the question of personal fitness for employment should be decided at his first examination. Conditions which should lead to rejection are tubercular disease of every kind, idiopathic epilepsy, all forms of mental disease or weakness (hysteria, feeble-mindedness, and neurasthenia), obvious alcoholism, women who are pregnant or who give a history of repeated miscarriages prior to work in lead, persons with marked errors of refraction unless corrected by glasses, kidney disease of all kinds, evidence of previous chronic saturnism, and bad oral sepsis. Special attention will have to be paid to casual labourers, and it should be the aim of the surgeon to discourage this class of labour in lead industries. Work under special rules or regulations requires to be carried out under strict discipline, and this it is extremely difficult to maintain on other than regular workers, who recognize the need for cleanliness and observance of regulations.

Other aids to diagnosis cannot be carried out as a matter of routine, but will necessarily be used in particular cases, such as ophthalmoscopic examination of the fundus, electrical reactions of muscles, analysis of the urine, and examination of the blood-pressure.

A few words may be added on the significance of the two commonest signs—the blue line and anæmia. It cannot be too strongly insisted on that presence of the Burtonian line on the gums is, as a rule, indicative of lead absorption, and not of lead poisoning. As a danger signal its value is immense, and hardly less so its value in clinching diagnosis in doubtful cases. Whenever the line is seen risk is imminent, and poisoning (not necessarily of the individual in whom it is pronounced) among the workers is inevitable in the absence of adoption of precautions. Unfortunately, careful dental toilet, which the surgeon will necessarily lay stress on, may prevent development, or the practice, when adopted, cause disappearance of the line after the lapse of a few months. Under these circumstances, the merest trace will have all the significance of the fully-developed line in a worker neglectful of care of the teeth. Among new workers a commencing blue line should be strong evidence of the need for dust removal at some point in the process of manufacture. The line, in our experience, is dense in occupations giving rise to fumes or to dust of compounds of lead, but comparatively rare in those handling metallic lead or its alloys, as compositors, tea-lead rollers, solderers, and the like.

Some degree of pallor is so commonly met with in adolescence that it is the progressive development of the anæmia which the surgeon must especially watch for. As a danger signal, therefore, it has the same significance nearly as the blue line; but when lead absorption has affected the elements in the blood, progressive anæmia in new workers, attributable to the employment, and showing no tendency to improve after watching for a few months, is an indication for suspension or transference to other work. In older workers, with a duration of employment of five years or more, there may be a quasi-pathognomonic pallor which does not vary from year to year. In them it must be supposed that an equilibrium has been established, and development of other symptoms, such as tremor, wrist weakness, or albuminuria, becomes significant. Attention has already been directed to the distinct saturnine facies associated with anæmia, and characterized by loss of fat, particularly noticeable in the orbit and buccinator region of the face. “So far as the question of any worker’s suspension is concerned,” says Dr. King Alcock, “I prefer to make my instinctive primâ facie distrust of a saturnine pallor the basis for action. The pallor of plumbism cannot be summed up in hæmoglobin and corpuscular content; it is the expression of a complex toxæmia resulting from defective assimilation and excretion”[3].

The knowledge the surgeon should gain of the idiosyncrasies of the workers by his periodical examination will enable him to appraise at their proper value the nature and degree of the symptoms in notified cases.

Sometimes a rule is made that no lead-worker who has suffered from an attack of plumbism should be allowed to resume work. This we consider too harsh a measure. It may be true for painters, but when remedial measures, such as locally applied exhaust ventilation, can be applied, with consequent removal of the danger in the process at which the poisoning has arisen, prohibition of employment seems an unnecessarily drastic measure.

The health register in general use where periodic medical examination is required in pursuance of special rules and regulations is divided into two parts, in each of which entries by the surgeon are required at each visit.

Part I.
List of Persons Employed in Processes.						Particulars of Examination.
No.	Worker’s Name, in full.		Process.	First Employed in such Process.		Date Result.	Date Result.	Date Result.	Date Result.
				Age.	Date.
(1)	(2)		(3)	(4)	(5)	(6)	(7)	(8)	(9)
Part II.
Reference to Part 1.		Date of Examina- tion.	Number of Persons Examined.	Particulars of any Directions given by the Surgeon. Any Certificate ofSuspension or Certificate permitting Resumption of Work must be entered here in full.				Signature of Surgeon.
Page.	Col.
(1)	(2)	(3)	(4)	(5)				(6)