Document 65xwRn1VO4kawpkZXoK476v3

. HOLTS DI SEASES OF I NFANCY AND CHILDHOOD A TEXTBOOK FOR THE USE OF STUDENTS AND PRACTITIONERS BY THE LATE L. EMMETT HOLT, M.D., ant JOHN HOWLAND, M.D. RIJ'ISZD EY L. EMMETT HOLT, Jr, M.D. n o r u j c t o r r t s u r t i c i , x r v tocx u v n 'i u r r T c o u j c : o r x to ;n k .E ; duxctdc, o i n x * . i v 'i k d iu l u irict. itL irv j: noinTAi. * i* texi c m AND r u s t i n m c i n t o s h , m .d . C A iU K T in n o r r i K x o r F t s u T i i a , colvm iia u v r r x u i r r , akd DLXJ CTDt Of 7HI PDUT11C tf*TlCX Ik THI AIlLi KC*TOTAL, Kr v T W I CTTT ELEVENTH EDITION APPLETON-CENTURY-CROFTS, INC. NEW YORK LONDON v#*j ii -. >- * M t t - * : t ' I' nr '--*1 r l --T^ ha :j6S MISCELLANEOUS DISEASES Treatment,--Thu ii purely rymptomadc. Large amount; of sedative; are often required. Relief from the itching ii sometnmg obtained by placing the ertrearing in cold water or sponging with alcohol If the anorexia is o pronounced that a very mruSa'ent diet a taken, and if there k great lots of fieth and tttength, feeding by Civile ahould be resorted to. Numerous attempts have beer, aside to overcome c postulated diettry deficiency by superaiimenurion or parenteral injection of various food factors Large imounu of rittmiru A, Bj, C, D, nirotini: acid and ribcfiavin hive beer, fives with inconstint or negative results. The tSect of vitamin E, alone has seemed encouraging, but many more observations will be required to establish t dehnit: relationship to the disease. E u o n a s c i . G roup of C u t i of G a ia o w x E co lo gy. N o rtk w tit. M e d , / p u i j , ipso. B u c t r s k ' a n i M cJDk a v s . A c r o d y a i t ; i N e t t c n t i e P s t b o i o f i c P h y s i o l o g y . J . P t d i t u , >?n- B m o . A P o lyn eu ritic Syn d ro m e R tiem b lL n g P e l i i p r t ( A c r o d y n i s ? ) t v e e in V e r y V n u n j C i i i d r m . A m . J. D ii. C i i l d , >0:347, 151c. D * r , S k C T k i i s d BLu x c m a x . T t t t t e : F u n c t i o n c f V e g e t a t i v e N e r v o u i S y s t e m i n A c r o d y a i t . A m . J. D ii. C h ild , 5 7 3 $ ;, 1533. D x s i f a n d N f v c e . S u r le p r o b l t m e d e 1' e t i o i o j i t d e I' a c r o d y n i e i n f a n t i l e . A n n . p a e d i t u 'rS-'3JS, I>JV M A T i i x o r a . D ie A ir o p s tiie e drt E iad e islte rs, m il besoaderer b e r o c is ic h u g u o g de: infan- h l e n A k r o d y a i e . E r j e b a . d. inn. M e d . u. IDiaderfc., 5 4 3 * 5 , i j j l . O t T o v and B i v o t x . L e iio a i in t ie D a t t r s l H o r n i o f the S p in al C o r d in A c r o d y c u , P ella g ra and Pernicioui A n e m ia Bull. Neurol. Into N ew Y ork, /:jod, 15JI. P a t t s x i v an d G a r i v n X L D . E r y t h r o e d t r a i P o l y n t u r it it . Q u a r . . J. M , /y: , t p s j . a P f K U et al. a?j- Da repartition ptopraphique dr I'atrodynie in fan tile R e v. fra n p de p ed , rr:jJ5, S w i r e . T r a n a A u e u s i i i i i a M e d . C o o p , i j i a P- J 4 7 . W trro k.'. A c ro d y n it. A m i . P e d iit , 77:513, 1510. V r'tx c a n d W o o o . P in t D is e t i c . B rit. M . J , 4 : 5 :7 , 1 j j p. . Yt'r u u i tn d i m v . P ia i D ise ssc; M orbid A n a to m y w ith Note os T reatm en t. Arch- D ia C h i ld , d ::37, j j j j . LEAD POISONING Lead poisoning b cave of the common and moat serious forms of intoxication reeognixed in childhood. Infection a the usual mode of exposure, but tome cases of poisoning have followed the inhalation of lead or its absorption throufh the shin. Mott of the children who acquire the disease do so durinf the fiat few years of life when h is natural for them to put thingj unto the mouth. T&e ahnormaJ percatenet of this trait pia, in older children may be followed by lead poisoning. Nursing infants have developed symptoms fellowinf the mother's use of a lac nipple ahield or kad aerate ointment or. the breast. Outbreaks of poisoning in japan have resulted from the widespread us< of a toilet powder containing lad. Other sources cf the metal have been food or drinh hrpt in lead vessels or paed through ia pipes. The use cf etorage battery casings as fuel caused at least forty cases tn coe epidemic in Baltimore. The sort earnmar, source of the metal in children is teem gnawing lad paint from toys, furniture, railings or tills. Poisoning may follow either a single exposure to t lavse amount of lead or the repated ingestion of sms_ quxnrrici, arhich may proceed for months before producing signs cf intextcanecu 1 I f editivts l i t ofter. ring the extremities oouncrd tin! t very BBfah, feedine by sJ dietary deficiency r Large amounts of a with inconstant or ourxging, but many ship to thi disease. 3<J, 19*0. loC. J- Pediiu, i t a is Very Youoc tycrtt ie Acrtxi.mii. u ':lc Ann. pttditu. t dcr iaftD- 1 A t . / o i l , P e l l i f r i I, ssaj-artn^ si p ti, r/.jta, 'ninnenu Arei. Dix. LLAD POISONING 1369 . In one child known to have ingested white lead or. only a tingle occasion the first rymptom occurred ic ten days and dexth followed in rwo weeks. Children as well *s industrial workers teen: to develop ome tolerance to the metal, tince t given amount of iexd in the blood of one person will be followed by tevere rymptoms, while in mother, pxra'eulxrly one who has hxd chronic absorption, it will be accompxnied by few if any ourwird tigns. When lead if xbtorbtd into the body ft cm be found in all the ri*ues, the greatest concentration being in the bong, liver, pancreas and brain. At the growing cndi of bona circulating lead is drpoaited as phosphate in the cirtiiaginouj matrix. Th: normal resorption of trabeculae fails to occur and there remains a rone of denac tres of intoxication re, but some cases 3 through the akin, first few yean of she abnormal perby lead poisoning. * of a lead nipple 1'!'.g ir, Japm have a d. Other aources s*ed through lead forty cues in one Qdren is from nay follow n of small ** c. intoxicanor- T k . i(a.--Taaitetr_st CstAcaj :* i X a tx Lias Potcimrc, Saowixc I x d ia ie nr D ixrrrr ax8 T ttcx x u : or Zone or pionsioxau. Caucincarsox. 1tad<00taining trabeculae proximal to the metaphyris. As the boon gTew this dense tret tends to disappear, but it may last for yean. The width of this tone in t growing r bone is tome measure of the length of time exeat lead has beer, circulating in the blood, tince it is constantly being deposited at the caralagr-ihaf: junction as long as a high blood level k maintained. In the liver, kidney and pancreas there are intra nuclear inclusion bodia which probably indicate that there has been rpecific cellular ctmige. In the brain of an infant dying of lead encephalitis there is found intense edema, many widespread areas of vascular damage with both hemorrhage and teepage of aerum. into the brain tissue. There is extensive destruction of brain cells, particularly in the cone. and cerebellum, with disintegration of neuroglia Much of this damage i k irreparable. In the neuritis or neuronitis due to lead the whole cel! is involved, I 1 3 7 MISCELLANEOUS DISEASES and no: only tht ixon but the cell itself miy be destroyed. Chronic vascular changes leading to arteriosclerosis sometimes occur. The black stippled line on the gums is due to the precipitation of lesd as the rulfide in the loop* of end capillaries just back of the gum margin. This line occun after the teeth hive erupted snd when onl hygiene is poor. Symptoms are little affected by race and sex but age influence* the form of the disease. The younger the child the more rulnerable the central nervoui system to injury by lead. Hence, symptoms of encephalitis usually bring the young child to the hospital. This may happen before anemia, colic and peripheral neuritis occur. Change in disposition, always for the worse, irritability, crying spells and intense restlessness occur. Headache and increasing drowsiness may be the first signs of illness noticed by tht parents, and persistent vomiting or convulsions are the most frequent manifestations for which they seek medical aid. The twitching movements tend to persist or to be followed by localised or generalised weakness. When the encephalitis is tevere coma is the rule.and may persist for weeks. Papilledema is fairly common in these cases. Peripheral neuritis is not one of the usual manifestations, but wrist drop and ankle drop appear occasionally. Once we aaw in a child of six yean ex tensive involvement of all the peripheral nerves, both motor and sensory, resulting in complete paralysis and almost total anesthesia. This is rare, particularly the loss of sensation, although numbness and tingling of the fingen and toes is found much more often. Ataxia and coarse tTemon accompany the not infrequent cerebellar in volvement. Pallor is a common symptom but anemia is seldom severe enough to make the patient ill. Pains in the muscles and joints are of rare occurrence. It is interesting that the onset' of symptoms is much more common in the summer months. Laboratory examinations are of gTeat aid in the diagnosis of lead poisoning, especially the determination of the amount of lead in the circulating blood. Many normal individuals will have from o.ot to 0.03 milligram of lead in too ce. of blood. When the amount reaches 0.1 milligram clinical symptoms usually appear, and if the amount is greater than 0.3 milligram per 100 cc. in a child, severe or fatal encephalitis may be imminent. Either chemical or spectrographic methods may be used to determine the blood lead. Tht determination of the daily excretion of lead in the urine, normally not more than o.l milligram, is an aid in diagnosis. The blood shows a moderate anemia with a hemoglobin rarely below 50 per cent in uncomplicated cases. The red cells show polychromatophilia and punctate basophilia, which may occur in other conditions but is more characteristic of kad poisoning. These stippled cells appear intermittently but are usually found on re peated careful search. A leukocytosis is frequently present, but there is some question whether this b due to lead itself or to infection which so often antedates the severe symptoms. Urinalysis ihows nothing characteristic Albuminuria occun in about a third of severe ru-i and small amounts of sugar may appear. The blood augar is no: sfiected, although transient renal glycosuria has been observed. In lead encephalitii the apinal fluid findings are characteristic. The pressure is high when the symptoms are acute but may be normal during convalescence. The fluid b dear and usually free from pellicle formation. There is nearly always a large ni: vascular changes jp: on th; gums is end capillaries just ,pt:d and when oral xs the form of the nervous rstnn to the young child to tril neuritis occur. : spells and intense first signs of Alness : the most frequent movements tend to her. the encephalitis a is fairly common editions, but wrist Jd of six yean ex' -tsory, resulting 'v the loss of _ ound much |ueii. -erebellxr ini sevtTe enough to nrt occurrence. It sc in the summer of lead poisoning, ring blood. Many in loo ec. erf blood, ally appear, and if ild, invert or fatal c methods may be y excretion of lead iagnosis. irely below 50 per ihHii xnd punctite uncterirtic of lead uilly found on rerre is some Question antedates the severe n about a third of ugx: is t>o: affected, - pressure is _ Tne fiuid -rlj -ays a large LEAD POISONING 1371 amount of globulin, out of proportion to the increase in cells, which rarely exceed ICO per cu. m s. and ire nearly ill lymphocytes. We hive seen one child with extensive fttil neuritis due to lad ind another with marled cerebellar involvement who ihowed no change is the ipinal fiuid. Roentgen examination of the long bones is growing children is of great anistance. The presence of t tone of increased density at the ends of the shah suggests lead poisoning. It must be remembered that other besvy metals ind elementary phosphorus can produce similar tones, and narrower heavy lines are seen in scurvy and baling rickets. In the film, however, these last tppar as lines rather than tones. Sometimes far away from the epiphysis ire seen fainter binds of increxsed density indiexting pre vious exposure to the bavy metal. In roentgenograms of the abdomen there are often many hne fleets of metallic density scattered through the intestine. Tnese probibly result from the ingestion of piint or other metil-containing substances. The differential diignosis of lesd poisoning is extensive and includes miny chases which produce encephilitis, neuritis, colic and tnerr.it. Probably the most common confusion is with tuberculous meningitis or some other form of encephalitis. As long as there ts exposure to ieid, in fin until the amount of circuiting lad in the blood falls towird 1 normi! vilue, symptoms of poisoning ire progressive. Once encephalitis has become manifest there is an ever, chince thit the patient will die. Perhaps the most chirtcterittic feature of the generalised convulsions due to lad encephilitis is their persistence in spite of vigorous efforts it therapy. The less severe symptoms disappear when the metxJ is removed, and the body seems to be tble tc repair all the damage except that done to the briin. The prognosis of children who recover from the icute symptoms of lad encephalitis is bid. Only 1 small pro portion of them are normal, a Jew are idiots and most of them ire dull or obviously defective children with t tendency to convulsions. It is difficult in this last group to distinguish cause from effect since pica and hence lad poisoning arc more common in defective children. The rratment of lad poisoning is mot: unsatisfactory and is largely nonspecific. In 1 growing child the administration of ixrg: amounts of sodium phosphate and vitamin D may aid in the deposition of lad in the bones. In lead encephalitis the usual sedatives have little effect and the agents commonly employed to decrease cerebral edema seem powerless to shrini the badly damaged brain. It is probably wise to use magnesium sulfite, c.t gram per kilogram of body weight intramuscularly every four to six hours, during convulsions. Extensive ^surgical decompression if done early in en cephalitis has been of benefit in seme instances. Recently the use of large doses of vitamin C, from 200 to 400 milligrams of ascorbic arid daily, has been followed by improvement After recovery from the acute manifestations, the question of deleading procedures may be considered. Attempts at deleading by administration of ammonium chloride or fixed acid are unwise bemuse the blood lead level may be raised to such a point as tc cause a recurrence of symptoms. Hunter and Aub hive shown that a large part of the lead can be removed from the body by means of parathyroid hormone; in their cases the lexd did not produce symptoms on its wav out. This procedure is not always successful, for children vary considerably in their response to pxrxthjToic hormone; some are refractory and with others there it danger of overdosage. It is important to avoid infections, since they may mitiate symptoms in latent poisooLng; the acidosis which may 137 MISCELLANEOUS DISEASES accompany t i e r tends to promott the solution of csicium ta d ictd salts which normally would remain fixed in the bones. It is obvious then tint prevention of crporur: is the mrir. point of truck. Pirents should be educated to reccjr.iti the possible hrrm of pict, paint therrinj tad other common methods of requiring leid. In rpite of the either hifh Incidence of cues of lead poisoning there tre no laws in this country to prevent the ue of lead print in children's toy. tad furniture. In only three states i: it Beceasary to label paint sc that one may tscertrin that lead is an ingredient 's'. C G. Aci. T ie Eicchemlcti Behtrior of L eti it the Body. J. Ac. M. Ats, t o f A ' , , I j 35. Aui r. a!. Letd poisoninj, Medicine, 1915. Blaccka*. Letions of Lead Encrphilitis ir. Children. Bull. Johns Hoptini Kotp. 6 1 :1, 1537, --------intrtnueletr Inclusion Bodies in the Kidney tnd Liver Ctused by Letd Poisoninj. Bull. Johns Hopkins Hoip., 193L. C sm T , Clinicil tnd Experimental Letd Poisoning Kidiolopy, / ; : ? J7. 1931. Gornvns tnd Mssot. Glyeoiurit in Letd Poisoninj. Am. J. Dis. Child., 59:159, 1940. Housers, Cakmiul tnd A stute. Efiect of Vistmio C on Letd Poisooinp. J. Ltfc. k Clin. Med., 115, 1535H o l t . Letd poisoninj in Inftncy. Am. J. Die Child. /5315, 1313 H vvttx tnd AUl. Efiecs of Ptrtthjroid Hormone on Excretion of Laid tnd of Ciiciuro ic Ptiienss SuSerinj from Letd Poisoninj. Quin. J. Med., *0:113, ipry. Kato. Letd Meninpius in Inftnts. Am. J. Dis. Child., 44:549, 1531. McJLkakk. Letd Poisoninj. In Brennemtnn'i Prtctict of pediirrict- Prior, Htjtrstown, 1537. --------Lttd Poisoninj it Children. Am. J. Dis. Child. J.' :31, pa . Paxc, J acisos, Gocowts. tnd Ksjnt. X-rty Shtdowi in Growinp Bones Produced by Letd. J. PeditL, 1 - j 6s , 1933. Scxteurr et si. Bleiverjifsunj Erpebn. d. jes. Med. / J r j : : , 1515. Soul er si. Lnfiucnce of CAlcium, Phosphorus md Vistmin D 00 Letd in Eiood tnd Boos. J. Biol. Chec., /yaca3p, lpsn. TAS'O'Jlttl Dtr Plas' cssts. Letd Disttset. (Trtnsltied by Dtns.) Eixby, Lowell, U*I.