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704 THE NEW ENGLAND JOURNAL OF MEDICINE Sept. 24, 1970 The New England Journal of Medicine LEAD POISONING - THE SILENT EPIDEMIC Official Organ of The Massachusetts Medical Society Lead poisoning is a serious, sometimes fatal, ill ness of known cause, readily diagnosed and treated and completely preventable in most casesuThe dis Founded in 1812 as the New En g l an d Jo u r n a l Of Me d ic in e a n d Su r g e r y and continued in 1828 as Vol. 1 of the Bo s t o n Me d ic a l a n d Su r g ic al Jo u r n al ease presents clinically with a continuum of rather nonspecific gastrointestinal symptoms (anorexia, constipation, nausea, vomiting or colic) or central- Pu b l is h e d We e k l y b y t h e Co mmit t e e o n Pu b l ic a t io n s o f t h e Ma s s a c h u s e t t s Me d ic a l So c ie t y nervous-system symptoms (irritability, confusion, lethargy, coma or convulsions). It is often misdi Claude E. Welch, M.D,, Chairman Alexander Marble, M.D. Saul S. Radovsky, M.D. Samuel Proger, M.D. Leroy D. Vandam, M.D. agnosed initially unless the physician has a high index of suspicion. Routine laboratory studies, which may reveal anemia, basophilic stippling and "lead lines" in long bones, should serve as clues M, Joseph Garland, M.D., Ed it o r Eme r it u s but are not invariably present, particularly in the Franz J. Ingelfinger, M.D', Ed it o r more acute cases. Lead presumably exerts its dele terious effects by inhibiting essential enzyme As s o c ia t e Ed it o r s Jane F. Desforges, M.D. Jan Koch-Weser, M.D. Ronald A. Malt, M.D. Arnold L. Smith, M.D. George S. Richardson, M.D., Bo o k Rev iew s Robert O'Leary, As s is t a n t Ed it o r systems. It has been shown to interfere with hemo globin synthesis and specifically to block delta aminolevulinic acid (S ALA) dehydrase.1 However, tests based on the finding of elevated urinary coprophyrin or 8 ALA have not proved sufficiently relia ble for diagnosis although .they may be helpful in Ed it o r ia l Bo a r d some cases. The diagnosis of lead poisoning is es sentially based on the finding of increased whole- Alfred Kranes, M.D. Francis D. Moore, M.D. John A. Mannick, M.D. Charles A. Sanders, M.D. Lot B. Page, M.D. Jerome H. Shapiro, M.D. Fred S. Rosen, M.D. Ronald A. Arky, M.D. Isadore N. Rosenberg, M.D. Dana L. Farnsworth, M.D. Mark Aisner, M.D. John W. Littlefield, M.D. Norman G. Levinsky, M.D. Arthur A. Sasahara, M.D. Louis Weinstein, M.D. blood lead levels; values in excess of 40 jttg per 100 g are suspicious and 60 ng per 100 g or greater are diagnostic. Treatment consists of the separation of the patient from the source of lead, supportive mea sures and in cases with marked elevations of blood lead or severe symptoms, treatment with chelating agents (BAL, calcium EDTA and penicillamine).2 Milton C. Paige, Jr, Bu s in es s Ma n a g e r There is as yet no general agreement about a pre cise level of blood lead at which to initiate chela ... In f o r ma t io n t o Au t h o r s preparing manuscripts for submission to the Journal should be consulted. This material may be found in the first issue of every volume of the Jour nal, or it may be obtained from the Journal office. The entire manuscript, including references, should be typed double space, and all material, including figures, should be submit. ted in duplicate. Cas e Repo r t s , usually published in the "Medical Intelli gence'' section, should include only the pertinent details and reference to articles reporting closely related cases. A very short case report or a description of a technic submitted as a "Br ie f Re c o r d in g " should be limited to 500 words. Ma t e r ia l printed in the New England Journal of Medi cine is covered by copyright. The Journal does not hold itself tion therapy, and clearly this is an area demanding prompt definitive investigation. Similarly, a rapid, precise micromethod for the detennination of blood lead is sorely needed, as well as investigation of alternative diagnostic approaches. In their illuminating article in this issue of the Journal, Klein and his co-workers have called atten tion to the serious potential hazard of lead poison ing from ceramic glazes. As they point out, this problem has been recognized throughout recorded history, and its recurrence now may reflect more the alertness of the authors than a major increase in the responsible for statements made by any contributor. No t ic es should be received not later than noon on Mon day, 24 days before date of publication. Repr in t s : The journal does not stock reprints of the arti cles published. Requests should be sent to the author. Al t h o u g h all advertising material accepted is expected to prevalence of the disease. This comment in no way should minimize their important contribution but rather serves to reiterate the adage, that those who do not learn from history are destined to repeat its mistakes. The question of who now has the respon conform to ethical medical standards, acceptance does not imply endorsement by the Journal. Su b s c r ip t io n Pr ic e s : Domestic 10.00 per year (students, interns, residents 5.00 per year); Canada (U.S. Funds only) $11.00 per year; foreign (U.S. Funds only) 12.50 per year. Mic r o f il m volumes available to regular subscribers through University Microfilms, 318 N. First Street, Ann Arbor, Michigan. Co mmu n ic a t io n s should be addressed to the New Eng land Journal of Medicine, 10 Shattuck Street, Boston, Massa chusetts 02115. sibility to test and certify earthenware as safe for use with food remains unanswered. Furthermore, who will make available to those of us already em ploying such dishware a means of testing its safety? Apparently, the Lead Industry Association and the United States Pottery Association have initiated a program of testing and certifying commercially pro duced dinnerware, but this presumably applies only to domestic large-scale production.3 These questions N36954  Vol. 283 No. 13 EDITORIALS 705 deserve prompt answers by the Food and Drug Administration. Beyond our national interest there is the equally serious question of education and safety standards in other countries, particularly Mex ico, where large-scale daily use of such ceramics must pose a -considerable danger. As the authors have noted, lead poisoning in chil dren is well known, being associated in this country almost exclusively with deteriorated housing, the defective walls and woodwork of which provide a limitless source of ingestible old lead paint.* Chil dren between the ages of one and six constitute the majority of cases. Of those who present with encephalopathic signs and symptoms approximately a third have well documented permanent mental retardation, and many will require institutional care for life.4 Aside from the shocking human tragedy, institutional care for life may cost society in excess of 8100,000 per child! In studies conducted in New York City, Chi cago, Baltimore and Philadelphia over the past dec ade, 5 to 10 per cent of ghetto children in the age group from one to six years have been found to'be poisoned, and in selected housing units frequencies as high as 20 per cent have been noted. In spite of these facts only a few cities have any rational ap proach to this silent epidemic. New York City, in response to relentless citizen and professional pressuie, has developed the most serious effort to date to identify poisoned children. New York's blood lead screening is currently obtaining about 4000 samples a week. In an effort to prevent re-poisoning the City health code now requires repair of the child's apartment by the landlord (with tax-abate ment incentive) and, failing his compliance, by the City's own housing department. The screening pro gram has been most effective in areas where efforts have been made to work closely with ghetto residents, including paid teen-age workers. Skepticism re mains over whether the repair program will prove adequate to the increasing demand, and already se rious delays are being encountered. It should also be noted that this major effort is directed at find ing already poisoned children and in no way effec tively deals with the problem of prevention of poisoning in families not yet affected. Yet New York's efforts are probably the best in the country. An as yet unpublished study recently concluded by the New York Scientists Committee for Public In formation reveals that in only seven of 50 states and six of 30 major cities is lead poisoning a reportable disease. This study found only two states and seven cities with screening programs, and three of these cities have only pilot programs. This observation may be considered against a background of crude estimates in excess of 200,000 currently poisoned children in this country! Failure to attack this epidemic seriously is a na- "After World WaF.Il, titanium oxide paint became competitive and to a large extent replaced lead-containing inside house paint. tional disgrace.t One cannot help noting the fact that the great bulk of affected children are poor and nonwhite. The charge of genocide by neglect has already been leveled against the health profession regarding this situation. This charge cannot be read ily dismissed. The problem of lead poisoning m ghetto children will not be solved until we deal with our failure to provide truly comprehensive family care with an emphasis on preventive medi cine for all our citizens. Furthermore, in this partic ular instance of hazardous urban pollution we must reconsider our current attitudes toward housing, which here is clearly the epidemic vector. The solu tions will of necessity be radical, but we are dealing with a major epidemic. It would be a beginning for those reading this editorial to explore what their hospital and community are doing about this epi demic made possible by shameful neglect. In this particular situation, it should be clear to all who call themselves health professionals that "if you are not part of the solution, you are part of the prob lem!" Ed mu n d O. Ro t h s c h il d , M.D. Re f e r e n c e s 1. Mauzerall D. Granick S: The occurrence and determination of S aminolevulinic acid and porphobilinogen in urine, i Biol Chem 219:435-446, 1956 2. Chisolm JJ Jr: The use of chelating agents in the treatment of acute and chronic lead intoxication in childhood. J Pediat 73:1-38. 1968 3. Guitar MA: Rx for Philip. Good Housekeeping, May, 1970, pp 12-24 4. Byers RK: Lead poisoning: review of the literature and report on 45 cases. Pediatrics 23:585-603, 1959 tCurrently several bills in congressional committee are directed toward providing funds for lead-poisoning programs. These in clude HR9I91, 9192, 11699 (Ryan), HR17027 (Green), HR17234 and 17260 (Barrett), and S3216 (Kennedy). THE CRYSTAL BALL Res embl in g certain members of the animal spe cies, more than a few new drugs, while demonstrat ing admirable familial traits, also indulge in streaks of abnormal behavior. The volatile inhalation anes thetics provide no exception to this rule although early in the history of use, their deviations are apt to be concealed in the complications of surgery. Over the last 15 years chemists have concentrated on the synthesis of new halogen-substituted hydro carbons in an effort to eliminate undesirable fea tures of the primordial anesthetics. The result has been the introduction into clinical anesthesia of several compounds incorporating the most wanted characteristic -- inertness, therefore nonflammability and freedom from toxicity. The best known of the new breed is halothane (Fluothane). However, readers of this and other pe riodicals must have become convinced of the asso ciation between this volatile liquid and the de velopment of post-anesthetic hepatic necrosis, pre sumed by many to be a sensitizing phenomenon.1 DUP050315176