1912 BMJ (Clinical Research Edition)  
The Teeth of Workers in Lead. WH1LE it has been proved that the direct inhalation of dust containing lead in some form or other in white lead factories forms the most fruitful method of poisoning with that metal, it is certain that other, more indirect means of absorption may play a part in those trades where metallic lead is handled in mass. Viktor Hinze (Berl. klin. WYoch., May 27th, 1912), of St. Petersburg, calls attention to one of these means. He has made observations on a large number of
more » ... n a large number of lead workers in an accumulator factory. He noticed that the gums and teeth of the men who were suffering from plumbism were in a bad condition. The former were swollen, hyperaemic, and infiltrated. Tartar encrusted the edges of the teeth. It occurred to him that the removal of the tartar and active care of the teeth and gums might lead to a limitation of the poison within the body. He therefore started by scraping the teeth and collecting the tartar, which he subjected to a careful chemical examination. In one case of a man who showed anaemia, atrophy of the extensor muscles of the left hand, etc., 0.329 gram of tartar was removed, which contained 0.48 per cent. of metallic lead. In this case the seventeen teeth which the man still possessed were extracted, and both the tartar and the teeth could be thus examined chemically. The examination of the teeth showed that the crowvns contained 0.038 per cent. and the roots 0.033 per cent. of metallic lead. It is therefore evident that a deposit of lead is present, which suffices to keep the symptoms of lead intoxication going. On removing the tartar from the teeth of other workers in the factory, he succeeded in curing the hyperaemia, tendency to bleeding, cyanosis and boggy sw-elling of the gums, and several obstinate cases of gingivitis soon cleared up. How far the general symptoms of lead poisoning can be avoided by excluding this one source of chronic poisoning is a point that requires more observation, but it is certain that only good can be done by attention to this point in all who are exposed to the dangers of lead poisoning. 2. Exophthalmtc Goitre. MARINE AND LENHART (Arch. of Int. Med., September, 1911) studied the anatomical and physiological relations and treatment in 69 cases of exophthalmic goitre. While the anatomical changes in the several body tissues are varied, the most prominent and constant one is active hyperplasia of the thyroid and lymphoid tissues, and although the exophthalmic goitre syndrome may coexist with a normal thyroid, colloid goitre, hyperplastic or atrophic thyroid, or with a tumour of the thyroid, it is believed that active thyroid and lymphoid hyperplasia has been present in all true cases during the developmental stage. The only defined physiological activity of the thyroid secretion is that determined by its iodine content. Iodine is related to the exophthalmic goitre thyroid in the same way that iodine is related to the thyroid of other clinical associations, varying inversely with the degree of active hyperplasia. The ability of exophthalmic goitre to take up iodine varies with the degree of active hyperplasia, inversely with the amount of iodine present, and iodine induces the same series of anatomical changes in this condition as in the other varieties of thyroid hyperplasias in man and animals. The temperature and pulse reactions, both before and after operation, vary with the degree of thyroid and lymphoid hyperplasia, and their reactions and the thyroid hyperplasia are parallel and resultant phenomena dependent on more general and remote causes. Myxoedema is the end stage of thyroid insufficiency, and, although it occasionally accompanies exophthalmic goitre, it never precedes it. The best index of the severity of the disease is the degree of active lymphoid ana thyroid hyperplasia. Treatment must be directed towards the correction of metabolic disturbances, particularly nervous exhaustion, and towards reducing and -counteracting the thyroid secretion. Mental and physical rest away from cares, social duties, and work, is of primary importance. Daily baths, active and passive exercise, and electricity, with avoidance of fatigue, are useful, and a cool, dry, pure climate should be selected. Stimulants should be avoided, and the diet must be plain, well cooked, wholesome, and taken at regular intervals, and-need not-be specially restricted, except where individually indicated. While the value of suggestion is generally recognized, confidence must be instilled, but anything in the way of hypnotic suggestion is to be condemned. Cardio-vascular and sedative drugs are a secondary consideration, their value lying largely in the mental impression produced, and upon the skill with which they are adapted to each particular case. Desiccated thyroid, in doses of from 2 tc 5 grains daily, is oftenbeneficial in secondary exophthalmic goitre cases and those developing myxoedema, and iodine in the form of the syrup of ferrous iodide in small initial doses does good. With regard to surgical measures, none of the recognized operations have been uniform in their results, and they should not be undertaken until the thyroid has returned to its colloid or resting state, and when indicated for a relief of pressure, for correcting deformity, for tumours, and for psychic effects. Moebius's antithyroid serum, the milk of thyroidectomized goats, the thyreolytic serum of Beebe and Rogers, and the Roentgen rays do not appear to give rise to any greater improvement than could be otherwise ascribed to rest, hygiene, and time, and no specific action's have been demonstrated. SURGERY. 3. Diagnos.s of Subcutaneous Wounds of the Pancreas. J. WOHLGEMUTH has shown that the Qmount of diastase in the blood increases after the resection of a-portion of the pancreas in dogs. He suggested that this was either due to the escape of the pancreatic secretion into the peritoneal cavity and its rapid absorption by the blood or to the congestion of secretion behind the sutures, leading to an abnormal amount being taken up by the blood. This result led to the thought that the increase of diastase in the blood Imight be utilized in the diagnosis of subcutaneous wounds of the pancreas in the human subject. He and Y. Noguchi (Berl. klin. Wl;och., June 3rd, 1912) have investigated this matter in dogs. They give the details of the method employed for determining the amount of diastase in the blood. The test is carried out by putting up a series of varying quantities of serum, adding to each a given quantity of starch solution, warming for thirty minutes at 400 C., cooling and adding A normal iodine solution, drop by drop, and determining which tubes yield the first suggestion of a blue colour. They cut through the pancreas of a dog under ether-morphine anaesthesia, stopped the bleeding, and closed the abdomen. Blood samples were taken before the operation and at each succeeding hour. The diastase value rose from 80 to 200 in four hours, to 332 in six hours, to 800 in twentyfour hours, and to 1,600 in forty-eight hours. The diastase in the urine rose correspondingly. In a second experiment a small stab was made into the pancreas, and the organ was slightly bruised by the fingers. In this case the value rose from 40 to 62.5 in four hours and eventually to 160 in forty-eight hours. They then examined a number of human serums, and determined that the average diastase value under normal conditions was between 8 and 16, and that the highest normal value was 32. It would therefore follow that if, after a stabbing wound of the abdomen, the diastase value of the blood wa's'found to be over 32, the deduction that a pancreas wound was present would be justifled. The raised value is maintained for seventy-two hours after the infliction of the wound, or even as long as ninety-six hours. The urine should also be examined, and the diagnosis of injury to the pancreas made when a greater value than 64 is registered. The apparatus for the Xest is very simple', the skill required is not great, and the test does not occupy much time. The authors consider that it' will be found valuable in determining what treatment'should be adopted in suspicious cases. Radiological Diagnosis of Intestinal StenosIs. ERNST V. CZYHLARZ (Wien. klin. Woch., No. 9, 1912) describes two cases of radiological diagnosis of intestinal obstruction, the obstruction in the first case being situated in the small intestine, and in the second in the large. The two cases presented the following points of resemblance: In each case (1) stenosis affected one coil of intestine only; (2) a collection of gas and fluid, the sign gf stagnation, waA 26 A
doi:10.1136/bmj.2.2688.e1 fatcat:5niniu3vrrejvag43rdrd4lqii