Environmental Medicine: Integrating a Missing Element into Medical Education

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dilatation of the hands, which normally follows heating of the trunk and legs, was absent. This capacity was regained with the use of tolazoline hydrochloride (Priscoline) and tetraethylammonium bromide. Farquhar et al.³² described increased urinary sympathin in 3 of 4 cases of acrodynia as compared with normal children. Cheek and his associates³³^,³⁴ demonstrated that calomel potentiates the effect of epinephrine in the rat, and suggested that mercury potentiates sympathetic activity in acrodynia. Peterson and Laughmiller³⁵ reported the relief of symptoms in 6 of 7 cases of acrodynia treated with tolazoline. Bower³⁶ noted relief of all symptoms except for photophobia with sympatholytic drugs such as hexamethonium tartrate and pentolinium bromide; he confirmed the relief of arteriolar spasm in patients with acrodynia by these drugs. Ritzel, Berger and Roulet³⁷ recently observed increased catechol amine excretion in a case of acrodynia. Now that better methods for the determinaton of urinary catechol amines are available, sympathetic activity in acrodynia should offer a field for fruitful investigation.

Another interesting and unique finding in this case is the apparent source of mercury in the house paint. The demonstration that potentially harmful levels of mercury could result from vaporization of these paints supports this conclusion. The patient’s home, household contents and surrounding areas were examined by both the New Hampshire Department of Health and ourselves. The only source of mercury that could be detected was found in the paint. The amount of mercury in the urine and the length of time during which it was excreted implies that the inhalation of mercury vapor by the patient occurred over a long period. The discovery of mercury in the paint and our studies of the continuing emission of mercury into the air surrounding the painted surfaces present a new and potentially common cause for mercury poisoning. One wonders if there may be patients with some of the more subtle signs and symptoms of acrodynia in whom this diagnosis is not being considered. The paint manufacturer’s responsibility is a matter of public-health interest. Mercury-containing paint should be labeled properly and should indicate the possible danger to children upon ingestion or exposure to the toxic vapors. These mercury-containing paints should be limited to outdoor use.

SUMMARY AND CONCLUSIONS

A case of acrodynia in a patient who had increased urinary excretion of mercury is presented. New methods for mercury analysis are described. The source of mercury was found in house paint, and the epidemiologic implications of this finding are discussed.

The patient was treated with N-acetyl-D,L-penicillamine, which markedly increased the urinary output of mercury.

The rationale for this form of therapy in acrodynia is presented and compared with previously reported therapeutic methods.

Increased excretion of catechol amines was found in the urine. The relation of this finding to theories of the pathogenesis of acrodynia is considered.

We are indebted to Dr. Douglas W.Walker of Laconia, New Hampshire, for referring this patient to our service and for assistance in the collection of essential data, to Drs. Harriet L.Hardy and John D.Crawford, of the Massachusetts General Hospital, for inspiration and guidance, to the New Hampshire State Department of Health for help and interest, to Mr. Frederick Viles, Jr., and Mr. Richard Chamberlin, of Massachusetts Institute of Technology, for aid in the mercury determinations and to Dr. Nathan B.Talbot, chief of the Children’s Service, Massachusetts General Hospital, for guidance and helpful suggestions in the preparation of the manuscript.

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