JAN. 16, 1960 HAEMATEMESIS FROM PEPTIC ULCER MEDICAL JORAL173 his early return home and the economic gain from an early return to work must be appreciated, as well as the saving in hospital beds [calculated for this hospital for Medical Memoranda 1956 as 1,040 bed days (or £3,250) ]. Prolonged bed rest is traditionally recommended in the treatment of active chronic ulcer, but it does not Cadmium Poisoning seem to be necessary in cases of haemorrhage. One Cadmium is largely obtained in the smelting of impure reason may be that bleeding unrelated to progressive zinc ores as a by-product and less often as a mineral chronic ulceration may occur in response to salicylates called greenockite, which is cadmium sulphide. (Douthwaite, 1938; Muir and Cossar, 1955; Alvarez Cadmium can be highly polished and has good anti- and Summerskill, 1958), to alcohol, to infection, or to corrosion properties (Heyroth, 1949). If slightly unknown stimuli. The number of patients who had overheated, molten cadmium readily ignites. Its vapour consumed salicylates within the 48 hours prior to is heavier than air and burns with a bright flame bleeding (42%) agrees with the findings of Alvarez and producing brown fumes of cadmium oxide. Cadmium Summerskill (1958) in this hospital in 1957. Another as a fume is very toxic (Elkins, 1959). If the metal is reason is that patients bleeding from severe progressive heated, as in welding, fumes of cadmium oxide are ulceration often need emergency surgery and so have emitted which are responsible for the toxic effects not been studied here. Such patients may also account when inhaled from the working atmosphere. Even for the serious complications after D day which small amounts of molten cadmium can produce a toxic occurred during and in spite of bed rest. concentration of fumes. Cadmium vapour condenses in the air and is inhaled as a smoke of finely divided Early discharge from hospital necessitates early particles. A dust hazard may develop from grinding, radiological examination for diagnostic purposes. It cutting, or handling the dry powder. Probably the most has been held that a barium-meal examination too soon hazardous compound of cadmium is the oxide, which after bleeding might restart haemorrhage, but Zamcheck is an acute irritant affecting mainly the eyes, nose, et al. (1952) and Zamcheck (1955) showed that immedi- throat, and lungs. ate examination is both safe and reliable, and that patients tolerate the standing position for radiology In acute cadmium poisoning the patient develops sore better soon after admission than after bed rest. eyes, dryness of the throat, tightness of the chest, Certainly, no ill effects occurred in this series with breathlessness on slight exertion, and cough. In a few moderately early barium-meal examinations. hours he may have nausea, vomiting, shivering, general weakness, and pains in the joints. Pneumonitis may Only seven lesions were seen in 38 gastroscopies, develop. Death may be due to pulmonary oedema probably because the study was limited to male patients, or bronchopneumonia. At post-mortem examination who have a high ratio of duodenal to gastric ulcers cadmium is found particularly in the lungs, kidneys, and (Avery Jones, 1957), while cases of carcinoma of the liver (Elkins, 1959). stomach were excluded. The low proportion of acute Chronic cadmium poisoning may occur through long- lesions visualized was not due to delay in performing continued exposure to the fume or dust. The patients the examination, and the presence of blood in the develop lassitude, chronic cough, and dyspnoea due to stomach did not often invalidate the procedure. emphysema. This may be associated with recurrent epistaxis, anosmia, and irritation of the throat. Summary Cadmium is excreted in the urine, but its presence alone without symptoms does not warrant the diagnosis of The necessary duration of bed rest in hospital after cadmium poisoning. In chronic poisoning there is haematemesis and malaena from peptic ulcer has been sometimes renal excretion of a protein of low molecular studied by comparing the progress of two groups of weight which is detectable by the sulphosalicylic acid patients, one mobilized quickly and the other slowly. test (Bonnell et al., 1959). Patients mobilized as soon as massive haemorrhage Cadmium-plated articles should not be used for the had stopped did as well as those kept in bed. preparation of food because of the possible irritant Rapid mobilization involved radiological examiniation effects on the gastro-intestinal tract, causing an acute soon after haemorrhage had ceased, and no ill effects gastro-enteritis which is usually rapid in onset (Fairhall, occurred as a result of this. 1949; Sax, 1957). This condition can be treated by Our thanks are due to Dr. F. Avery Jones, and to the administering albumin (Dickinson, 1948). staff of the department of gastro-enterology, Central The maximum allowable concentration of cadmium Middlesex Hospital, for their help. We also thank the as recommended by the American Conference of Medical Committee of the Middlesex Hospital and the Industrial Hygienists is 100 g. /c.cm. (Sax, 1957). consultant physicians of the Portsmouth Group of Hospitals Local extract ventilation is necessary in processes for permission to study their case notes. involving a potential hazard from cadmium dust or fume, such as smelting, casting, grinding, or hot-metal REFERENCES spraying. Alvarez, A. S., and Summerskill, W. H. J. (1958). Lancet, 2, 920. In the United Kingdom, under the National Insurance Douthwaite, A. H. (1938). Brit. med. J., 1, 1143. (Industrial Injuries) Act, 1946, certain occupational Jones, F. Avery (1952). Modern Trends in Gastro-enterology. diseases are prescribed for industrial injuries benefit. Butterworth, London. Poisoning by cadmium is one of the prescribed diseases. (1957). Brit. med. J., 1, 719. Muir, A., and Cossar, I. A. (1955). Ibid., 2, 7. Zamcheck, N. (1955). A.M.A. Arch. intern. Med., 96, 78. INDUSTRIAL USES Cotter, T. P., Hershorn, S. E., Chalmers, T. C., Ritvo, M., In electronics cadmium-plated steel chassis are used and White, F. W. (1952). Amer. J. Med., 13, 713. in view qxf the low electrical potential letween the two 174 JAN. 16, 1960 MEDICAL MEMORANDA BRICALiOUs metals. In the atomic pile cadmium-coated control rods Treatment.-In the above case only symptomatic are used because this metal is a very good absorber of treatment was required. An apparently highly neutrons. The speed of the reaction can be controlled successful method of treatment has been reported. This by the depth of penetration of the control rods (Sears, consists in prescribing 0.5 g. of edathamil calcium- 1953).. In view of the intensity of radiation the rods disodium (calcium disodium versenate; E.D.T.A.) as a must be operated by remote control. Cadmium-plating pill every two hours during the day while the patient is has good anti-corrosion properties, and alkaline electric awake, for one week. It is recommended that one accumulators are manufactured with a cadmium cathode. week after the end of this course cadmium estimations Smelting and casting of cadmium occur in the in blood and urine should be made. This routine can manufacturing processes and in separating it from zinc be repeated until the patient becomes free of cadmium. ores. Copper-cadmium alloy is used for electric power In the three cases quoted there was rapid response to cables and overhead wires for trolley buses (Hunter, the chelating agent. The cadmium ion replaces the 1955) because the cadmium improves wear and strength calcium ion in the chelating agent. The cadmium is of copper without a significant change in the electrical excreted by the kidneys as a non-irritating chelate. No conductivity. unpleasant side-reactions occurred (Cotter, 1958). Cadmium-spraying of the molten metal is used both to coat and to build up metals, such as bearings. The halides of the metal are employed in photography. The SUMMARY salts, notably the sulphide, are used as pigment in A case of acute cadmium poisoning due to cutting paints and for the colouring of glass. Cadmium scrap metal with a welder's torch is described. carbonate, as a silver polish, caused the earliest reported Subsequent investigation following the recognition of case of cadmium poisoning in 1858. Cadmium oxide symptoms of cadmium poisoning revealed that included has been used in the chemical industry for coating among the scrap were some sections which had been luminescent powders and as a catalyst for the coated with a protective finish containing cadmium. manufacture of highly unsaturated alcohols by The industrial hazards of using cadmium without hydrogenation of unsaturated fatty acids or their esters. taking the necessary precautions are discussed. The It is also used to sensitize the photochemical reaction for commoner uses of the metal are also given. formation of hydrogen peroxide from water (Dickinson, 1948). I thank the United Kingdom Atomic Energy Authority for permission to publish this paper, and Dr. J. B. Lynch, CASE HISTORY Mr. J. M. High, and Mr. S. W. Maxted for reading and A man aged 60 reported to his works medical department, making helpful comments on this paper. giving the following history.. The previous day he had been working in a modern airy shop without any form of forced DARRELL M. EVANS, M.A., M.B., D.I.H., extract ventilation. He had been cutting scrap metal with United Kingdom Atomic Energy Authority. a welder's torch for about five hours. This process produced fumes which irritated his eyes, nose, and inside his chest. After several hours his legs began to feel weak, and during REFERENCES the afternoon he had a frontal headache with generalized Bonnell, J. A., Kazantzis, G., and King, E. (1959). Brit. J. industr. aches and pains. When he got home he felt cold, so went Med., 16, 135. to bed very early. He sweated profusely and had little Cotter. L. H. (1958). J. Amer. med. Ass., 166, 735. became but he no Dickinson, S. J. (1948). In Encyclopedia of Chemical Technology, sleep. His respirations rapid, had cough, edited by R. E. Kirk and D. F. Othmer, 2, 716. Interscience tightness of the chest, nausea, or diarrhoea. Next morning Encyclopedia, New York. he was feeling more comfortable, but the frontal headache Elkins, H. B. (1959). The Chemistry of Industrial Toxicology. remained, though it was less severe. He went to work as Wiley, New York. usual, but was persuaded by other workers to report to Fairhall, L. T. (1949). Industrial Toxicology. Williams and the works medical department. He was reluctant to do Wilkins, Baltimore. this, but fortunately was prevailed upon to attend. He Heyroth, F. F. (1949). In Industrial Hygiene and Toxicology, edited by F. A. Patty, 2, 685. Interscience Publishers, New reported during the afternoon of the day following the York. incident. At that time he complained of a slight frontal Hunter, D. (1955). The Diseases of Occutpations. English headache and some abdominal discomfort. The general Universities Press, London. malaise had gone. The eyes, nose, throat, cardiovascular Sax, N. 1 (1957). Dangerous Properties of Industrial Materials. system, and chest were all normal. A chest x-ray film Reinhold, New York. showed no significant change compared with a routine film Sears, T. P. (1953). The Physiciant in Atomic Defense. Year taken about five months before. Book Publishers, Chicago. He had a history of duodenal ulcer, and the last time he had had epigastric pains was six weeks prior to the present incident. "It is little appreciated by medical men as well as lay- About 48 hours after the incident he complained of undue men that the pattern of infectious disease in the community breathlessness on walking, with tightness across the front of is constantly changing. The important disease of one period the chest. He again had general malaise and felt weak. At disappears to be replaced by another, which was once this stage no abnormal physical signs were detected in his important. The rise in poliomyelitis is a good example; chest. He had to go to bed for several days. for some 30-40 years ago it was an infection of little On the 14th day he was seen again, when he felt much relevance to the community. It is a matter of great regret better. He still had some undue breathlessness on walking that the Staphylococcus has in the past been regarded as and tightness across the front of the chest on full inspiration. an unimportant organism for this must explain the fact His eyes, nose, throat, heart, and chest were normaL The that the steps to deal with what is now a redoubtable chest x-ray film remained unchanged. A full blood count pathogen have not included the obvious one that the revealed no abnormality. The urine was tested with infectious disease hospital is the place in which the severe sulphosalicylic acid, but no proteinuria was detected and examples should be treated." (Annual Report on the Work there was no reduction of Benedict's reagent. of the Infectious Diseases Hospitals, 1959. Western All symptoms had cleared within four and a half weeks. Regional Hospital Board.)