Document 6BrB8XzRJz7gJzm82bQj80dV3

Journal of Diseases of Children NOVEMBER 1943 C o p y r i g h t , 1943, by t h e A m e ri ca n M ed ic al A s s o ci at io n N umber 5 / EFFECTS OF LEAD POISONING ON MENTAL DEVELOPMENT RANDOLPH K. BYERS, M.D. AND ELIZABETH E. LORD, Ph.D. BOSTON FOREWORD sudden tragic death of Dr. Lord on Jan. 10, 1943 occurred before the completion of final draft of this paper. It was she who first felt that the minor deviations found on psychologic examination of these children with lead poisoning might be of important significance for the future. It was she who maintained the file of cases, studying them from the psychologic point of view, without encouragement from any one for the first several years. T hat lead poisoning occurring in early life usually has a disastrous effect on mental development has not been generally recognized, though the subject of lead poisoning in children has been discussed by many observers. The manifesta tions of acute involvement of the nervous system have been adequately described, ahd the gross destructive lesions in the brain consequent to acute lead enceph alopathy accompanied by cerebral edema and high intracranial pressure have been recognized. On the other hand, M cKhann,1 for instance, stated: "The neurologic manifestations of lead poisoning usually subside without serious consequences if flie ingestion of lead is stopped and the removal of lead from the circulation and its deposition in inert form in the bones can be hastened, as described, by the use of a diet high in calcium together with the administration of cod liver oil o.viosterol to accelerate the laying down of new bone." 3^ ;T his point of view, which is pretty generally accepted, fails to take into account % effect of lead poisoning on the growth and development of the infantile nervous system. The present observations, in our opinion, demonstrate that this process may be seriously impaired, showing as they do that of 20 children with mild lead poisoning in infancy, only 1 has progressed satisfactorily in school, v The prim ary requisite for supporting such a contention is the proof of early lead poisoning. Aub, Minot, Fairhall and Reznikoff 2 in 1925 published a mono graph on lead poisoning and in it outlined standards for establishing the diagnosis based on earlier suggestions of Newman, McConnell, Spencer and Phillips. While criticisms of such an outline were undoubtedly valid, it may serve as a concrete basis for discussion. Of first importance was the recognition of a source of ingestion or inhalation of lead. In addition, at least two symptoms from the following list were required: marked pallor or anemia, colic or obstinate constipation, muscular incoordination, peripheral motor paralysis pf the most, used muscles Mrs. Penfield Roberts gave valuable assistance in summarizing Dr. Lord's notes on some of the psychologic examinations. Dr. Lord's work on this paper was done under a grant by the Earhart Foundation, and Dr. Byers' work, under a grant by the Commonwealth Fund. 1. McKhann, C. F .: Lead Poisoning in Children : Cerebral Manifestations, Arch. Neurol. & Psychiat. 27:294 (Feb.) 1932. 2. Aub, J. C.; Fairhall, L. T .; Minot, A. S., and Reznikoff, P .: Medicine 4:1, 1925. 471 V AMERICAN JOURNAL OF DISEASES OF CHILDREN (usually the dorsiflexors of the feet in children), basophilic stippling of cells, a lead line on the gums and lead in abnormal quantities in th e 1std6l*|i urine. If two of the foregoing symptoms were lacking, a presumption - ^ j poisoning could be established by the presence of three of a longer l i s t e d specific symptoms, among which were emaciation, loss of appetite, especially; breakfast, vomiting on eating solid food, abdominal pain, loss of s t r e ^ ^ r a j ache, insomnia, mental lethargy, tremor, dizziness, encephalopathy, hypQfgg and articular pains. ' Since these suggestions were made, some new criteria for diagnosis^HB developed. Vogt,3 Park, Jackson and Kajdi,4 Caffey 5 and Kraft and KatS^B pendently and more or less simultaneously, published papers shovwn^aBB ingestion lead. M tied by D .Another aque matint. It l1 fviously Fig. 1 (case 6).--Well marked deposits of lead at the diaphysial margins of a long bone. children during the period of rapid growth while the process of lead ingestion, was occurring lead was deposited in special concentration in abnormally dense bane.; at the growing ends of the shafts of the long bones and along the growing m'ajgm* . of the flat bones. These deposits formed a radio-opaque band, comparable. density to that of the lead numerals used to mark roentgenograms, and whenW^ f t | developed were very characteristic. When less well developed they could be lated by the changes of rapidly healing rickets, by deposits of bismuth saltSji* ' possibly of other metals and, finally, by the dense bands resulting from the admit}* 1 ____________ - ." *;-V.- 3. Vogt, C.: Radiology 22:87, 1934. 4. Park, E. A .; Jackson, D., and Kajdi, L .: Shadows Produced by Lead in X-Ray Picture* , of Growing Skeleton, Am. J. Dis. Child. 41:485 (M arch) 1931. 5. Caffey, J . : Radiology 17:957, 1931. 'T 6. Kraft, E., and Kato, K .: Fortschr. a. d. Geb. d. Rontgenstrahlen 46:249, 1932. or office i few da In re co-worke m the sV Althougl ihowed months i and by human 1 from it i the red tools and 1 of lead >t of less -ally for h, head- srtension B Y E R S -LO R D --L A T E E FFE C TS OF ' LE A D PO ISO N ING jji' of elementary phosphorus in cod liver oil. Typical dense bands at the Jg' margins of the shafts of the long bones, in conjunction with a history estion of lead, were considered by the various authors as reliably diagnostic i. Much of the roentgen evidence in the present series was seen and inter lay Dr. Vogt. jcjther roentgen sign rather nonspecific was the finding of flocculi of radioP'material in the intestinal tracts of children who had recently been chewing felt had been of clinical value mainly in calling to the attention of parents bsly unobserved pica. It was, of course, much more useful in outpatient ;stion bone rgins Ie in well imuts or min- Ek '2 (case 12).--Recurrent deposits of lead at the margins of the shafts of the long bones. 'pffice practice than in the hospital ward, where such evidence disappeared in jS||?ayspraffelation to diagnosis, it was also clear from the review of Aub and his Parkers * that lead in large amount may be retained in the body, especially Sie-skeleton, in the absence of any of the clinical evidence of lead poisoning, tnoiigh this lead had been regarded as harmlessly stored in the skeleton, they jyyyd that in animals free of symptoms of lead poisoning and protected for 'rifhs from ingestion of lead small amounts of lead were excreted both by bowel dyby kidney for a long time. Since practically all the lead in the bodies of ban beings and of animals that had been exposed to lead and then protected TO it for a considerable time was in the skeleton, such excretion presupposed 474 AMERICAN JOURNAL OF DISEASES OF CHILDREN continual solution and transportation by the blood stream of small an$ lead from the stores in the bones. The same authors also measured the5 and fecal excretion of lead by patients recovered from lead poisoning and virtually uninterrupted for long periods. The skeletons of persons exposed were found to contain from approximately 200 to approximately 900 mg. of 1 the rate of combined excretion through bowel and kidney of the recovered varied between 0.07 and 0.89 mg. daily. Under these circumstances^ take the person with the least lead about seven months to excrete. afiS rapid rate all the lead stored in the skeleton. Since the person within lead was an infant who had chewed the paint from her crib "fori-'pnt weeks," it seems likely that the amounts of lead involved in our cases? the same order of magnitude. It must also be remembered that in a pers such recent exposure to lead, considerable amounts of lead were contained jj Fig. 3 (case 6) .--Radio-opaque material in the intestinal tract, consistent in its ajip with that of flecks of paint. other than the bones. In addition, the rate of excretion in our patients probably in the neighborhood of the slowest rates of excretion, approximately jf| 0.1 mg. daily, for Aub showed that treatment with cod liver oil and a high calcium diet (used more or less faithfully for all our patients) reduced the rate of excretion to such levels. .TM|f8 It seems probable that the disappearance of the lead line from the bones of growing children is not to be taken as an evidence of complete excretiori'||||teb, It seems more likely that processes of reabsorption and redeposition tend tribute the lead more evenly in the bone and thus destroy the roentgenologic? evidence. For instance, 1 child (case 11) four years after the cessation W'pidt no longer had a lead line in her bones by roentgen examination but still stippled cells in her blood and new neurologic signs of damage to her^ncnroaP system. Another child (case 17) three years after her acute episode';:Sfe<i B Y E R S -LO R D --L A T E E FFEC TS OF LEA D PO ISO N IN G 475 j^soning no longer had roentgen evidence of lead in her bones but in connection SSh a bout of vomiting again showed stippled cells. -fe Indeed, Aub and his collaborators 2 in discussing the storage of lead in the Sones, where they felt it to be relatively harmless, stated: "This desirable situation ffiay not be permanent, for slight changes toward either the alkaline or acid side :df.the usual hydrogen ion concentration of the organism can readily reduce the ^Stability of the tertiary phosphate." Thus, under chemical shifts common in child hood concentrations of lead known to be significant may be recurrently liberated into the circulation. It is evident, therefore, that the criteria permitting a diagnosis of lead poisoning .'Sire ephemeral in relation to the total process of ingestion of lead and its subsequent excretion from the organism. They depend on the presence in the body fluids or tissues of a certain concentration of lead, and the question of whether the con- iong bones. A t the time roentgenogram C was made, the patient's blood showed anemia IsgJtKms to be discussed are due to the continual circulation of subclinical concen;|trations of lead derived from the stores in the bones, or to the increase in solubility ^Suggested by Aub 2 or to injury sustained by the developing nervous system at the 'jtitne of acute episodes must remain a matter of speculation for the present. Possibly ill three factors contribute. It is also to be noted that in most instances by the time the difficulties here Presented became evident, the diagnosis of lead poisoning, unless established earlier, Could no longer be made with certainty by methods now in use. A recent publi cation by Fairhall and Keenan,7 describing a relatively simple method for the quantitative determination of lead in urine, may render possible the diagnosis of lead poisoning during the long period of excretion of stored lead after the symp- ^ Fairhall, L., and Keenan, R. G .: J. Am. Chem. Soc. 63:3076, 1941. uJ' AMERICAN JOURNAL OF DISEASES OF CHILDREN toms and signs of the more acute phases of poisoning have subsided. The usefulneof this method has not yet been proved by wide application. During the past several years, a number of children who were admitted to tl hospital on account of lead poisoning have been repeatedly examined psychological] Age on Admis sion, Yr. Source of Lead Chewing paint Duration of Exposure, Mo. Chewing paint off crib and window sills 12 to 18 + Chewing paint off crib, window sills and furniture 20 Chewing paint off crib Chewing paint off About 6% yr. + crib and furniture Chewing paint off crib Weeks Chewing paint off crib and window sills Chewing paint off crib and window sills Chewing paint off crib, window sills and furniture Chewing paint off wooden furniture Pica (articles not remembered) Chewing paint off crib and window sills Chewing paint off repainted crib and porch railing Chewing paint Chewing paint off window sills and furniture Chewing paint Lead nipple shields used by nursing mother Lead water pipes; played with paint Chewed paint off crib and window sills by one of us (E. E. L.) and certain deviations noted. In order to make a tematic study of the matter, the records of the Children's Hospital for the f4st ten years have been reviewed and 128 cases discovered. The yearly rate of admission has tended to. decl.ine fro. m 21 in 1931 to 3 in 1,939; such cyc'lesmay,' however, tend to occur in relation to the interest of the staff in the subject. During j \ V\ B Y E R S -LO R D --L A T E E FFE C TS O F L E A D PO ISO N IN G th^'past year medical records of 71 children (38 boys and 33 girls) living near enough to Boston.to be available have been reviewed. Of this group, 12 (9 boys and 3 girls) showed gross evidence of cerebral damage at the time of discharge froin the hospital and were not further considered. Of the remaining 59 children it of Lead Poisoning twphalopathy k -jte -- Spinal Fluid \g t at Latest Exami nation, Yr. Present Status Still reading in a primer; sensorimotor defect Repeated first grade; now doing poor work in second grade Unreliable, impulsive behavior prevents friendship; unable to learn in school; cannot write name in spite of two years in first grade; sensorimotor defect Cruel, unreliable, impulsive behavior; runaway: unable to get on with other children or adults; excluded from school because of behavior Not progressing in reading or writing; sensorimotor defects Total protein, 36 mg. A nervous person, doing passing work in seventh grade; no sig nificant variation in sensorimotor sphere Serious behavior problem; unable to do school work; referred to remedial class; short attention span; special sensorimotor tests not given After a year in first grade cannot write his name, though he is considered smart; sensorimotor defects After a year In first grade has not learned to write or print his name or recognize any figure; sensorimotor defect Normal Normal Lively knee jerks, ankle clonus on left; restless and inattentive at school; Is having a hard time; beginning fourth grade; mild sensorimotor defect Babinski sign on right; repeated two grades; had emotional difficulties which were helped by tolerance; difficulties in sensori motor sphere Repeating fourth grade; to be put into special class Total protein, 124 mg* Expelled from school for setting fires; sensorimotor defect vk' Normal Behavior unpredictable and impulsive; unable to learn first grade subjects; death at 6 years and 2 months from agranulocytosis after use of sulfanilamide Convulsions recurrent at long intervals; unable to learn to read; sensorimotor defect jiV ^ o n s at 10 years PpfelrfV before M olaslon 7&?*iontane!; optic fflakB '5& 3K " V Total protein, 160mg.; xantho- chromia Total protein, 106 mg.; white blood cells 7 < Irregular mental development with extreme unpredictability in results of school work and mental tests; scattered convul sions; enlarged ventricles Convulsions recurrent after 5 years of age; after one year in first grade unable to write name or make figures; irregular mental development; mild sensorimotor defect Doing well In school; reads and writes normally for age; sensori motor tests average for age Mental tests not given 79 Repeated first grade; private teacher at home for one year; then second grade; repeating grades so that he will start fifth grade next fall; enuresis General intelligence level between 7 and 8 years; doing badly in third grade discharged as cured, many have received repeated examination by the psychologist, and of these, 20 have now entered the school system. These 20 form the basis of the present report. f e A tabular review of the 20 cases is presented in the table. In all but carsfi 2 30 adequate source of the lead ingested was disclosed by the history, for this child rp ; ftfl l - IP!:; HU, R ff t: J* 'P "td ` : ti I `WM : '%s-*... :- - i. "A-fir : |W - ;' 1 v- ` p |t . 1 -e ( ||. ; PA : ; mm M 478 AMERICAN JOURNAL OF DISEASES OF CHILDREN r-ij&t. lead poisoning was considered an unimportant subsidiary diagnosis in relation?* the acute mastoiditis for which he entered the hospital. In 18 cases the leajj obtained by chewing paint off cribs, window sills or furniture. In many,inj the parents stated that they had repainted the crib, a practice which would viti use of lead-free paint by the most conscientious of furniture manu The frequency with which children chewed window sills and painted;* points to the importance of preventing the use of lead-containing paiftjQl and all interior finish, on porch railings and on other objects which are. of children's teeth. In 1 instance ingestion of lead appeared to be the-; the use of lead nipple shields by a nursing mother. From the diagnostic point of view there seemed ample evidence Jtq$ these children as having had lead poisoning. All but 1 generously fulg diagnostic criteria outlined in Aub's article, and, in addition, all had A evidence either consistent with (designated by in the table) or char_ of lead poisoning (designated by -f- in the table). The 1 child who'dldi conclusive evidence of lead poisoning was a girl of 10 months who was to the hospital because of anorexia and failure to gain weight satisfactory birth. Her diet had been irregularly unsatisfactory throughout her Ti after she cut two teeth (all she had at the time of admission), she beg the paint off her crib. Two days before admission she became irritafj admission she was a small, irritable baby, continually whining and scrat" palms, soles and genitals. Except for a few beats of clonus at her left a physical examination was not remarkable. Cytologic examination 'of (ftp! showed no pathologic changes, but roentgenograms of her long bones showe metallic shadows at the ends of the shafts of the long bones, considered 'dj of lead. Treatment by protection from ingestion of paint and use of an ad been usr applied 1 hospital jtatemer. mental < years ol her fan children that 1 c dren" F of reasc mental of men Aft' poor r< to botl were c were c Wi succee the gi rating the in group sever; chi.ldr diet for her age supplemented with dibasic sodium phosphate and cod liv seemc was supervised for two months in the outpatient department. The it _ __ not s palms and soles continued. While it may be argued that actual poisoning by lea better had not occurred at this time, it was clear that she had ingested paint an^f' inade a heavy metal in her bones in the pattern characteristic for lead. T With respect to the nervous system the cases fell into three groups^!; level first group, 9 cases, there was no evidence suggesting involvement of the ne? insta system. In the second group, 3 cases, there was peripheral neuritis but nojt they sign of cerebral involvement, and in the last group, 8 cases, there was roq by a less conclusive evidence of encephalopathy. The symptoms and signs ambti desc latter were choked disks, bulging fontanels, hyperactive tendon reflexes, cony^^fflj gror confusion, choreiform movements and changes in the spinal fluid. In no case were-; forn these symptoms severe, and in every instance they appeared to have cleared com pletely at the time of the patient's release from the hospital ward. The presence or absence of evidence of involvement of the nervous system bore no relation tj|l the eventual intellectual development of the children; indeed, the only truly success- f*|| ful member of the group had the most severe encephalopathy encountered' the 20 children. Considering the early age at which the ingestion of lead began, it was .difficult to forecast what the intellectual development of any of the children would hast | . been. When the 20 patients were considered as a group, its motor develop^S^^ as obtained by history, fell in the normal range. Since most of the individuals began to be exposed to lead during middle infancy, other developmental were not applicable. Detailed developmental histories were not available:in.*8 f instances, but 8 of the children were reported to have sat alone at an average i f of 6.9 months, 14 to have walked at an average age of 14.3 months and 11J ' B Y E R S -LO R D --L A T E EFFE C TS OF LE A D PO ISO N IN G 479 using words at an average age of 18 months. These developmental items lied to 15 of the children; 2 more were 10 months old when admitted to the ital and must have been active to have obtained their lead; for another child the ement of normal development was not documented; for the nineteenth no developtal data were given, and the twentieth child was first seen when she was 6 ^ old because of failure to do school work as well as had been expected by ^family. It was the opinion of the medical staff that these were "normal ^dren" at the time they were originally seen in the hospital. It was obvious f 1 or 2 unsatisfactory children might be found in any group of "normal chilen" picked in this way at such an early age, but, on the whole, the expectation Reasonable average progress in school was justifiable for the group. The developftal data also disposed of the suggestion that these infants exhibited pica because lental defect. tter recovery from their lead poisoning these 20 children made an extremely record in competition with their fellows. Their difficulties were in relation ,th the intellectual and the emotional spheres. The intellectual difficulties capable of rather exact analysis, and, since in part the emotional difficulties dependent on them, they will be discussed first. ith one definite and a second possible exception, none of the 20 children Reeded in school. The causes of their failures were probably manifold. For "group as a whole, at about the time of entrance to school the intellectual igs averaged 90, with a spread from 67 to 109. The usual correlation between intelligence quotient and the ability to learn in school did not hold for the pj the second most successful child having an intelligence quotient of 82 while efal with quotients above average were unable to do school work. For the 5 dren with intelligence quotients ranging from 67 to 85 slow progress in school Red well enough explained by the low intelligence level. These children did stow the mental irregularities to be discussed in relation to the children with er intelligence levels, since special defects merged into the general intellectual equacy. throughout the psychologic examination of the children with good intelligence _>'and poor scholastic attainment, sensorimotor defects were found in most aces. This is not the place to discuss the tests used to show such defect, since must be varied to suit the age of the child examined, since they must be given fn experienced psychologist trained in their use, and since they have been well in the literature of psychology. In brief, however, in the earlier age ups sensorimotor defect was shown by inability to manipulate blocks, to fit R.into holes in a form board and to perform similar acts. In the preschool jrs inability to copy simple figures, such as crosses, triangles and squares, proved ifier important. In the school ages inability to reproduce by memory the designs ie Ellis Visual Designs Test8 or of the Pintner-Cunningham Test No. 7," to iT with the block designs of the Wechsler-Bellvue Test10 or to build up the Rsociations to pictures necessary for success in the Wood Picture Completion st11 were found. All of these tests are designed to bring out a subject's ability . 8. ( a ) Bronncr, A., and others: A Manual of Individual Mental Tests and Testing, Boston, ta ttle , Brown & Company, 1927. ( 6) Wood, L., and Shulman, E . : J. Educ. Psychol. 31:591, 1940. jfcJj 9. Pintner, R., and Cunningham, B. V .: Prim ary Mental Test, New York, W orld Book Co., `A .IO. W echsler, D .: T he Measurement of Adult Intelligence, Baltimore, W illiams & Wilkins -Company, 1939. T l . Wood, L . : J. Genet. Psychol. 56:383, 1940. if Vi'i - 1- ti. "A K* ----- ---- T-fe. -/ '. - \ - A M E R IC A N J O U R N A L O F D IS E A S E S O F C H IL D R E N A.5SS| SgSffe* to deal with shape, direction, space and projected imagery, all matters of the utnL. importance in a child's success or failure in the fundamental school of techn^ijfpjlj the grades, inability to learn to write or read or deal with numbers in was the result of such defect, even though verbal ability might be good.' trast, many of the children showed normal or even superior abilities in the lan. field, and on this account several of the most severely handicapped children relatively high scores on the Stanford-Binet tests. Such children were? socially responsive, especially in their preschool years, and were considered *bj by parents and teachers, the latter often stating that the children couldifj if only they would try. One child, as previously intimated, appeared to have recovered cor at 7 years his intelligence quotient was 103 and he was progressing satiL in school. At 25 months, however, he presented intellectual difficulties hi that were permanent in other children of the group. He was an attract! f f M B natured boy, socially responsive, pleasant, imitative and amenable. His ing of language allowed him to carry out simple commands in the testis; appropriate for a 21 month old child. He associated the proper pi Mother Goose Rhymes, and he liked to listen to verses. In the use' 0 he was more like an 18 month baby in that he had a vocabulary of ' dozen words and did not combine words. From the point of view$j| behavior, he pushed single blocks imitatively but made no effort to ali He piled large blocks at home but could not make the necessary a pile small cubes, being less adequate than most 18 month old babies in thi He adapted the circle to the form board, but though he placed the other their holes he could not make the adjustments necessary to insert them, againd" with shape and spatial orientation like an 18 month baby. With a era' scribbled and made strokes as do most babies of 21 months. In sum; was imitative and resourceful, but the sensorimotor element in the adjustm'ej blocks and the fitting of forms into a board was definitely not as advanced^ understanding of language and his social response. As he grew older, thescsdftsoff motor disabilities diminished, and at 7 years he appeared to be intact. His as a baby to scribble imitatively with a crayon was not found in any of thi children of the group who were examined early. He was the only child j entire group who did well in school. Wfi'igs One other child in the group kept up with her class in school with difficulty. She was a pleasant, docile person, recognized as relatively incqmpB by her family. Her intelligence quotient at 7 years was 102, but at 12 yedf was only 82. Sensorimotor capacity as shown by the Ellis Memory Tesj below the twenty-fifth percentile for her age, and her ability to organize herjwstaK impressions as measured by the Wood Picture Completion Test was in the second decile for her age. Thus her difficulties were most obvious in the phere, but they were not far out of line as compared with her general intellectualjvj level. Eleven children were examined when they were between 18 months arid years of age. Each of the 11 exhibited more advanced reactions to language test* W than to the tests of sensorimotor control. Seven were using words as tydlJK|r one would expect for their age, whereas in 4 speech was delayed, but the piaj|f' with blocks and forms was consistently less adequate than speech. In all but tbt child already discussed as completely recovered a definite lag in the ability to make imitative adjustments with the crayon was found. Six children were examined between the ages of 4 and 5 years. The}- ahsW' comprehension questions well; some counted, and some even named colors,;5/! each >>: picture 5 year: was di attract i the wa >atd, mental qiiestio other t tion, si m ost 3 and h< ideatio legs a: ideatio than tl Th minor school d1r2enya1 work comnv child i help t niothe boy in this s that tl of the to wr gener; respoi learn sclioo afforc 11- other were exam were menu grow in iir varia deter K of ai Reap! as a vear: B YER S-LO R D --L A T E E FFE C TS O F LEA D PO ISO N IN G 481 each instance there was more than the average difficulty in adjusting blocks in ^picture puzzles and in reproducing drawings. Two of the children, approaching 5 years, had begun to be interested in making letters, but their copy of letters was disoriented and they were unaware of the displacement. One particularly .attractive little girl aged 4% 2 years made an extremely favorable impression in the ward. She was so friendly and cooperative with the doctors that one of them ^said, "I should like to adopt that child." On the Stanford-Binet scale she had a mental age of 4 % 2 years and an intelligence quotient of 112. The comprehension questions were answered adequately not only on the Stanford test but on several . other tests. Although she matched outline shapes, showing adequate visual percep tion, she had more difficulty in fitting the blocks in the Seguin form board than ."most 3 year old children. She had more than average difficulty in block building, ;i|hd her hand was unsteady as she traced the Porteus Cross. Although her ijdeation was good in the drawing of a man and she made a figure with head, eyes, legs and arms, the whole figure was disoriented. Here again are found good >ideation, verbalization and social response for a 4 year old child but less competence '(than that of the average 3 year old child in the adjustment of forms. These deficits in the younger children did not in themselves seem more than (minor deviations; but when children who still exhibited them encountered the .vschool system, severe difficulties in learning became evident. Two of the chil-dren have been promoted each year, to the fourth and seventh grades at 9 and } ) l2 years respectively, but complaints of inattention, restlessness and inaccurate ,^prk continue to be made about them. Of the children in the first grade, the Comment has been made that they "seem smart enough but do not learn." Another .child is "bright but restless and does not concentrate, is learning a few words with -S?lp from his mother at home but is having a terrible time with writing." A bother reported: "He is smart, and I have no complaints. Although the youngest jpJyjin his group, he is going to make his first communion with the others." When .Vdiis situation was explored a little more fully, it was found by the psychologist (that though he was 6l/ 2 years old and had an intelligence rating of 96, at the end e first year in school he did not recognize a single word and had not learned to write his name. He could make numbers, but they were disorientated. In .^general, these comments reflect the frustration of parents and teachers with these (.responsive, verbally able children who because of sensorimotor defect could not ;learn the technic taught in the first grades in school. The table summarizes the school situation in regard to all 20 children, and their clinical histories appended afford more detail. ajfer'In addition to difficulties in the general intellectual and sensorimotor spheres, Other evidences of interference with the normal development of the nervous system Were found scattered through the series. For a few children successive psychologic examinations showed significant drops in the intelligence quotient. These drops tvere felt to be the result of failure of mental development rather than of actual mental deterioration. As a result, though the chronologic age advanced, mental growth did not keep up with it. Cases 4 and 11 are examples. In case 16 the fall *n intelligence quotient was associated with recurrent convulsions and such great variability in intellectual function from day to day that it seemed likely that mental deterioration had actually occurred. Recurrent convulsions appeared in 3 of the children, at 4, 4^2 and 5fT years of age. Of these, 1 (case 16) showed enlarged ventricles on pneumoencephalo graphy examination at 12 years of age. One girl who had peripheral neuritis 3s a baby acquired a positive Babinski sign, first noted when she was 11 years old, and 1 boy, who was discharged from the hospital as well at about 3 ,i .# :1s- V. I i I AMERICAN JOURNAL OF DISEASES OF CHILDREN BYERS-L years of age, had hyperactive reflexes and sustained clon u s at the left anklet reexam ined at 9 years. pie c o n d itio n s it . tien ts a n d s e n s B eh avior difficulties w ere com m on throughout the series. M uch of this l W ritv and social c o u ld b e c la s s ifie d a s " fo r c e d r e a c tio n to s tim u li in th e e n v ir o n m e n t''- ^ ^ I f ? they could no b y S tr a u s s a n d W e r n e r 12 a s a n e v id e n c e o f c o r tic a l d a m a g e . I t w a s apparent r e su lt o f lo ss o f th e n orm al in h ib ito ry fu n c tio n , th o u g h t to resid e in th It w a s u su ally d escrib ed as unreliable im p u lsiv e b eh avior, cru el im pulsive;' f e I5- A t 8 y er I an intelligence I j sensorim otor d e` sh ort atten tion span and the like. It m ade several of th e children frieii difficult at hom e and in school. T hree w ere excluded from school ' I *re ihree' J he ! advanced ag of behavior, 1 for settin g fires in the school, another for repeatedly get! K t a in ly hum iliate d a n cin g on th e d esks and other fu rn itu re and th e th ird for sticking'!: a n o th e r c h ild 's fa c e . In som e children the untow ard behavior seem ed to occur u n d er'! c ir c u m s ta n c e s . A n e x a m p le is a b o y ( c a s e 1 4 ) w h o fir st c a m e to ofi,, at 2 3 m onths because of irritability. H is lead p oison in g w as d iagn osed an^ and he w as sent hom e as cured. From that tim e on, he presented a sevi problem , w ith crying, irritability, refusal to eat, soilin g, w ettin g and) pain. H is m other, a good-natured, kindly, hum orous w om an w h o j l y^ere th e d e fe c t! The last po [ jfotect her from L academic sul | *11 staffed publ I Lead poison ifae lead, all but f ^ view. None w ith adm irable tolerance and insight, w as given m any brisk talks by)i staff on how children should be brought up. F rom tim e to tim e he w; to th e h o s p ita l in a n a tte m p t to m o d ify h is b e h a v io r o r b e c a u s e o f a vsi appendicitis. In the w ards, h is behavior, though not as flagrant as' c o n tin u e d e s s e n tia lly u n c h a n g e d . I t w a s fe lt th a t h is im p r o v e m e n t i n ; 'tl w a s d u e la r g e ly to th e fa ct th a t a r o u tin e r eq u irin g m u ch o f o n e persoti?) cou ld be established for h im and in ad dition to the fact that the n urses carin g for him had no deep em otional attachm ent to him . Fundam ent rem ained irritable, im pulsive and distractable, and it w as im p ossib le for; to deal satisfactorily w ith him in the group situations in the kindergarten the first grade. 'jJj| O n the other hand, som e of the children acquired behavior difficulties m f in p a r t, a t le a s t, b y th e fr u s tr a tio n r e s u ltin g fr o m th e im p a c t o f s c h o la s tic "dis on their intellectual deficits. A n exam p le is a girl (ca se 1 1 ) w h ofw , th o ro u g h ly stu d ied at 5 y ea rs of a g e b ecau se of p eripheral n eu ritis du e tp at that tim e n o p sy ch o lo g ic d ifficu lties w ere su sp ected . A t 11 y ea rs of retu rn ed to th e h osp ital b ecau se o f d ifficu lty w ith sch o o l w o rk an d emi disturbances. She w as sullen, w ithdraw n and insecure and on m edical e tion w as found to have positive B abinski signs (a new ob servation) and c e lls in h e r b lo o d . P s y c h o m e t r ic e x a m in a tio n s h o w e d s e n s o r im o to r d e fe c ts, at w ith the assistance of an extrem ely intelligent school supervisor, a llo w a n c ^ to fjp h e r d is a b ilitie s w e r e m a d e a n d tr e a tm e n t fo r le a d p o is o n in g in s titu te d . .gTT b eh avior difficulties sm ooth ed ou t at on ce, and w h en last seen , at 15%2 yet [Ally 1 'Ned ui r * s parallel to \ recognizable lor quotient remai the sensorimot That failui ! development c jtudied by s< relation to ab; found that fr lesions, and *as common in a group < There is active functi tion of infa of adults, < dnctly diff< attained, to be due therefore, with the c prevents 1 she w as a pleasant, attractive-looking girl, w ith a quiet and poised m anner, a lo n g fairly w ell in the eigh th grad e b u t u n ab le to d o arith m etic. S h e had rej tw o grades, and her fam ily w ere hoping m ildly that she m ight reach high s A fol S h e had m ade real gain s in the specific sen sorim otor field, her score of the' or early M em ory T est being norm al for her age and her perform ance w ith the W e B ellevu e B lock D esig n s and th e W o o d P ictu re C om pletion T e st m ore nearly; e x p e c ta t io n fo r h e r a g e th a n b e fo r e . . T h e s e fin d in g s s u g g e s te d th a t h e r psych.? state at th e tim e of her depression w as due, in part at least, to a reacth her latent lead poisoning. 13. Gc Americar 14. L. 15. K Primate; 12. Strauss, A. A., and Werner, H .: Am. J. Psychiat. 97:1194, 1941. 1941 B YE R S-LO R D -- L A TE EFFECTS OF LEAD PO ISO NING , *;?The conditions imposed by present day culture on children with good intelligence quotients and sensorimotor defects are very difficult. Their excellent verbal capacity and social responsiveness make it seem impossible to parents and teachers that they could not learn if only they would. A good example is presented in case 15. At 8 years the patient was a pretty, outgoing child, large for her age, with an intelligence quotient of 91 and no ability to learn to read or write because of sensorimotor defect. The choices before those responsible for her school planning were three. The first was to keep her back in the first grade, where her large size and advanced age combined with her inability to compete in learning would certainly humiliate her. The second possibility was to put her into the second grade, where the defective preparation and learning defects would be certain to frustrate her., The last possibility was to let her go nominally into the second grade but to protect her from competition with the other children by giving her tutoring in ^fm^academic subjects. Such a plan could be worked out only in a tolerant and {`staffed public school system. ,ead poisoning in these 20 children began in infancy. In order to obtain |lead, all but 1 must have developed at an average rate from the motor point . 0. hw. None of them exhibited evidence of severe acute encephalopathy, yet lived up to the promise of his early development. In some, such failure parallel to a generalized defect in mental development, resulting in a readily cognizable lowering of the intelligence quotient. In others, though the intelligence .A;iquqtient remained well within normal limits, a specific failure of development in IS/.SfeSensorimotor sphere was the outstanding finding. ,hat failure of intellectual development is somehow connected with improper felopment of the cerebral cortex is well accepted. Sensorimotor defect has been lied by several observers. Goldstein and Scheerer13 found it especially in aj^f^Bpon to abstract designs, as an evidence of cortical disease or injury. Wechsler 10 that failure in his block design tests correlated well with organic cerebral is, and Lord and Wood14 have shown that failure in the sensorimotor sphere cbmmon in a group of children with known cerebral disease and uncommon in.a group of children under treatment for psychiatric disturbances. ere is ample evidence that the cortex of an infant is not as yet completely e'functionally. From the motor standpoint, Kennard 16 showed that decortica'of infant monkeys produced little disability as compared with decortication wilts, and Byers 16 showed that hemiplegia in early infancy produced a dis(Ctly different clinical picture from that found after the upright posture had been 'lined. The normal processes of intellectual growth and development are thought due to processes of maturation taking place in the cortex. It seems likely, efore, that the lead in the circulation of an infant in some way interferes gjiWith the changes normally occurring in the cortex and in a high percentage of cases Sr Prevents the normal growth and development of the cortex. ! SUMMARY - ' 'A A follow-up study of 20 school children who had been hospitalized in infancy i f r early childhood because of lead poisoning has been presented. None of them A .13. Goldstein, K., and Scheerer, M .: Abstract and Concrete Behavior, Evanston, III., y American Psychological Association, Inc., 1941, vol. 53, no. 2, p. 131. Lord, E. E., and Wood, L.: Am. J. Orthopsychiat. 12:414, 1942. ATS.'K ennard, M. A.: Relation of Age to Motor Impairment in Man and in Subhuman yrirnates, Arch. Neurol. & Psychiat. 44:377 (Aug.) 1940. W I6 . Byers, R. K .: Evolution of Hemiplegias in Infancy, Am. J. Dis. Child. 61:915 (May) 484 AMERICAN JOURNAL OF DISEASES OF CHILDREN exhibited striking evidence of encephalopathy during their primary admission all were adjudged to have made a complete recovery from lead poisoning discharged from the original hospitalization. 01 The length of the cycle of ingestion, storage and elimination of lead in relati to the relatively short duration of the symptoms and signs allowing a diagnn of lead poisoning is emphasized. It seems probable that lead poisoning 0f *u* sort here discussed can at present be recognized in only a small percentage of Failure of the normal processes of growth and development of the . prevented all but 1 of the 20 children from progressing satisfactorily Lead poisoning is a serious disease developing from entirely man-ma(ief'i^^^E',! 1 which should be controlled by appropriate legislation. REPORT OF CASES KST: C ase 1.-- A boy of 2 y ears 4 m onths was adm itted to th e o u tp atien t d e p a rtm e n t^ --- -- ... of lack of appetite. H e was the only child of healthy parents. H e sat at 7 months walked at 14 months but was talking only a little at the time of his first visit. Hef****1*^** the paint "off everything" when he was smaller, though at ju st w hat age and doi was not stated. H e was completely out of control of his parents at the tim e of hii TO,,, ,, screaming for w hat he wanted, refusing to give up his bottle and exhibiting irritable behavior. H e had been "pale for a long time." " Physical examination showed the boy to be small and pale but otherwise reveal remarkable. A blood smear showed moderate achromia but no stippled cells. H is nnofc normal. Roentgenograms of his long bones showed dense bands of metallic grow ing ends of the shafts, characteristic of lead poisoning. T w enty drops of h a iib ^ f% ^ | oil and a high milk diet were prescribed, and later iron and ammonium citrates' A fter visiting the hospital he continued to chew the paint off- the window sills andf a t home, but finally this habit stopped spontaneously. A t 4 years he was still smalfu become shy and repressed. Psychologic appraisal showed poor speech and Al difficulty in handling test materials, suggesting a general mental level below 'avdr mental irregularity due to specialized difficulties. A t about this time his mother died of pneumonia and he was boarded out. Treatment*witli vitamin D in various forms and dicalcium phosphate was, however, carried on. to be rather unsatisfactory physically, intellectually and emotionally. H eK contumed v ' A t 9^12 years he was in the third grade in school, though he had failed to learn tto read. A t home he was difficult and impulsive. A psychologic appraisal indicated an intelligence ' quotient of 87, with special disabilities in the sensorimotor sphere. H is score on the Wood 3*. picture completion test was at the third decile for his age, and on the Ellis visual design test it was worse than any calibrated score. iT F lF T AJba Case 2.--A boy of 1J6 years was admitted to the hospital because of projectile Vonutn-. "Ib of ten days' duration. H e was born normally at full term and did well as a baby.'.His doK';.-^| tition was late, beginning at 14 months, and he began to walk and talk just prior*to ins entry to the hospital. Two months before his admission scarlet fever and running" en developed, one of which continued to discharge to the time of admission. Tw o weeks befort entry he began to vomit projectilely at night, and he continued to do so to the time of admission. Physical examination showed a pale child with a discharging right ear. Roentgenograms A showed a clouded and eroded right mastoid and a broad band of metallic deposit at the ' growing end of the long bones, characteristic of lead poisoning. A roentgenogram of the abdomen showed much dense flocculent material, probably paint, in the intestinal tra c t His blood showed a secondary anemia (hemoglobin content 55 per cent and 4,100,000 red cells), many stippled cells on smear and an elevated percentage of polymorphonuclear leukocytes. A mastoidectomy was performed on the right side, and treatm ent w ith calcium gluconate, dibasic sodium phosphate and viosterol in oil 17 was carried out. H e did well and was dis charged after three weeks in the hospital. A t this time psychologic appraisal showed that be >,(; handled materials like a 15 month old baby, with no special defects. -' ' \ "> A t 9 n e years psychologic appraisal showed an intelligence quotient of 67, with no specialized v' defects. In school he was in the second grade, having repeated the first grade. ------------------ \ %! 17. The preparation used in this and succeeding cases contained 10,000 U. S. P. unitt of -?ji vitamin D per gram. B YE R S-L O R D -- L A T E EFFECTS OF LEAD POISONING m is s io n , and 5E 3 .--A boy of 18 months was admitted to the outpatient department because of on in g when jility and. crying at night as if in pain. His development was normal. H e sat up at iths, walked at 13 mouths and was using words at 18 months. When about 1 year of :gan to chew the paint off his ciib and had continued to do so. In spite of this, he I in relation ent home as presenting a behavior problem. a diagnosis ft"months later he reappeared with the same complaints and vomiting. His crib had d u g of tht Uvered with cloth, but he had taken to chewing the paint off window sills. Roent- ge of cases, the cortex in school, tms of his long bones showed a narrow band of metallic deposit at the growing ends long bones, but in spite of letters to his parents he did not report for treatment for six *weeks. A t this time his hemoglobin content was 40 to SO per cent and a blood smear yed no stippled cells. Cod liver oil ( /l 2 ounce [IS cc.] daily) and dibasic sodium phosphate le hazard?. r$ prescribed, and a further warning about ingestion of lead was given to the parents. A iftth later roentgenograms showed much more pronounced metallic deposits at the growing ls_.of the shafts of the long bones. I g jjf c few weeks later vomiting recurred once or twice daily, and the boy became irritable. ;h he had been prevented from chewing paint, it was discovered at this time that the ent because his home were leaden. He still had a secondary anemia (hemoglobin content 59 per months and apd 4,500,000 red blood cells), but on several examinations no stippled cells were found, had chewed - how long admission, mlsive and his' admission, when he was 2 J4 years old, he was seen by the psychologist, who found evelopment below the standards for the 2 years, in contrast to his chronologic age. He "discharged from the hospital; treatment with disodium phosphate, viosterol in oil and )barbital was continued at home, and the health department was asked to do what was ed nothing urine was .sit at tlie libut liver as added, furniture 1 but had nsiderablc age, with :$sary to free the drinking water from lead. Lf:8 years and 4 months he had difficulty in getting on with other children because of his |Iiable, impulsive behavior. He had not acquired his first grade technics, in spite of two gTof instruction, and was not able to write his name. Psychologic appraisal indicated sjital age of 61% 2 years and an intelligence quotient of 82. -ase 4.--A girl of 2 y 2 years was admitted to the hospital because of temper tantrums ^.abdominal pain occurring during the nine months prior to admission. Her development tn average. She sat at 6 months, stood at 8 months and talked at 15 months. From ie she was 9 months old she exhibited marked pica, and until the time of admission Jntinued to chew paint from her crib, the furniture and window sills. At about 20 mouths lent with continued fifegan to have attacks of screaming and banging her head, which lasted fifteen to ninety ^ IS, made her blue- and tremulous and left her exhausted. During the two weeks before ^admission she had complained of abdominal pain and vomited projectilely several times, to read, elligence e Wood -ign test tough she began to use single words at 15 months, she was using only single, rather tfelligible words at the time of admission. results of the physical examination and laboratory investigation were not remarkable, jtgenograms of the long bones showed dense bands along the diaphysial margins, conSj>Ewith lead poisoning. oniiting Iis den- to his !g ears before ime of Orthe hospital she fell out of bed and was taken home on this account by the parents. tears later, at the age of 6% years, she returned, having been excluded from school ise she danced on the furniture in the classroom and because of similar uncontrollable In addition, she was cruel to animals, bit people for the pleasure of seeing them ran away by hopping street cars. In the interim her father and mother had Strated several times and divorce proceedings had been instituted. She was unable to get T*Wh other children because she always insisted on having her own way. A large variety Punishments had failed to control her. Physical and laboratory investigation showed nothing unusual, sychologic investigation showed an intelligence quotient of 95 (Terman L), but a marked mental control. She could not apply herself to any problem for more than a very '!?Period, and she was unable to learn in school situations, even with individual instruction, ^ au d ito ry memory span was extremely short. She could repeat only three digits correctly. Ue.Could not learn a two line nursery rhyme. She could not learn the names of the individual |w r s comprising her name, though she could print her name. She was excluded from ||| |p "90l because she danced about on the desks and piano. dized ol SjfiafeCASE 5.--A boy of 17 months was admitted to the hospital because of diarrhea and vomiting * three days' duration. He had been born normally and had developed normally, sitting up ^ months and walking at 13 months. At the time of his admission speech had not developed, had had frequent bouts of diarrhea and vomiting, usually accompanying infections of the respiratory tract, which had begun when he was 2 months old. For some months admission he was known to be chewing the paint off his crib, which was made of ' i. P ap HL R ta l & t f . is p in il jM i? ; ? i. * S&WE ~i t--:`Ki 4iS s Vi :l<l}1 >1 : 1.; k 3 I I [ JpfcyS > (1 ii j v-5* ' ; fp g I'"-I; | $ * hjvM>*. 'j! *'$m<&: t%. -b{ \ri%' i.ii- . rF. ^iVt.--9"Vv-4iI*: Wt *i r f r *?; ._: .<v - r . V v" * . -T . if1 i \ e im m ` -. ?-S3 486 AMERICAN JOURNAL OF DISEASES OF CHILDREN On admission to the hospital he showed mild dehydration and was drowsy. Excep'.-tVf slight evidences of rickets, the physical examination showed no abnormality. Two days la w " blood smears showed a few stippled cells. Roentgenograms of his long bones at this showed a narrow band of increased density at the ends of the diaphyses, consistent with' w * poisoning. ' - igjfl He was treated for dehydration and was sent home on an average diet with added v io f j^ j' in oil (15 drops), dibasic sodium phosphate (30 grains [0.19 Gm.]) daily and calcium K (30 grains [0.19 Gm.]) daily. VkasCwMss, He returned a year later with tlie same complaints, and though he was 2 % years had not acquired speech. In spite of his mother's efforts, he had continued to Physical examination showed a screaming, unresponsive child who continued jl head about and beat it with his hands for some time after admission. His definitely unsteady, but otherwise nothing remarkable was found. His blood showed a mild secondary anemia, and on spectroscopic examination ni: the normal amount of lead was found in the blood. After three weeks of treatment .lj liver oil (2 drachms [7.75 cc.] daily) and a high calcium diet, this level was fouitdi greatly diminished. Roentgenograms of his long bones still showed heavy bands of the shafts. His irritability diminished, but psychologic examination showed that he did not-' and suggested sensorimotor disturbances. ` A few weeks later he returned with an acute otitis media and a digestive up subsided quickly. At this time his blood serum showed a trace of lead on specif examination, while the clot showed a good deal more. It was reported that his disappeared. At 3 years and 8 months he returned, drowsy and dehydrated after several projectile vomiting. His fundi were hyperemic, and the optic disks were pooriy5$j8fnejigS* Otherwise the results of the examination were unremarkable. A lumbar puncture'yras done, but the other usual laboratory procedures indicated no abnormal conditions. v 'R o ea^'S j; genograms of his bones no longer showed any suggestion of deposits of lead. A t 4 years and 5 months he was readmitted, with pneumonia, from which he'trgcovwed Ss) without incident. After this he was transferred to the neurologic ward for appraisal'l-iHi^ language development was normal for his age, but he had difficulty in the use of crayons and adjustment of forms and blocks, diagnostic of sensorimotor impairment. He has returned I for psychologic check-ups from time to time because has has been unsatisfactory teachers. At & % 2 years his mental age (Stanford-Binet) was 6X% 2 years and his intelligract 5'*,; quotient was 100, but it was impossible for him to do any of the cube designs which'ar* usually satisfactorily dealt with at 6 years. He was not progressing in reading' or'w ritinf in school. :f C a se 6 .--A girl of 6 years and 9 months was admitted to the hospital because of vomiting of six days' duration. Her own past history and that of the family were irrelevant except that she had chewed the paint off her crib and had exhibited other forms of pica from infancy until about six months before admission to the hospital. She had entered school in the first ' If grade eight months before, and disappointment was expressed because of her failure to learn as well as had been expected. There had been one previous bout of vomiting of two dayi duration initiated by a blow on the abdomen six months before admission. Abdominal pain and vomiting three or four times in twenty-four hours had begun six days before admission and were tending to become more severe. Physical examination showed a thin, pale, dehydrated girl with teeth in poor condition and a pronounced lead line on the gums. Her fundi showed no abnormalities, and no abnormalities were found on neurologic examination. Her blood showed a secondary anemia (hemoglobin content of 50 per cent and 2,600,000 red cells), and about 2 per cent of the red cells were stippled. Spectroscopic examination of her blood and spinal fluid showed a large and definitely pathologic amount of lead present The total protein content of the spinal fluid was 36 mg. per hundred cubic centimeters. Otherwise the fluid was unremarkable. Roent genograms of the long bones showed some density at the growing ends of the shafts of the long bones insufficiently marked to allow a definite roentgen diagnosis of lead poisoning. A roentgenogram of the abdomen showed much dense flocculent material in the intestines coo- .^in sistent in appearance with flecks of paint. Treatment with sodium phosphate and milk did not alleviate the vomiting, and because of continuing dehydration and acidosis she was given physiologic solution of sodium chloride subcutaneously and 10 per cent solution of dextrose intravenously. Two hours after this ^ she had a generalized convulsion, which was relieved forty-five minutes after its onset by 'A* paraldehyde given rectally. She was then treated with calcium gluconate, milk, sweetened Vj qu B YE R S-L O R D -- L A T E EFFEC TS OF LEAD POISONING fiiat juices and atropine. She gradually improved and was discharged on the twenty-second hospital day, eating well. At the time of discharge an increase in density of the dense bands _tt the ends of the shafts of the long bones was noted on roentgen examination. JVv'A psychologic examination given the day before her discharge showed an intelligence 'c Oibtient of 100 and adequate response to all tests. l^ T w o years later she was seen in the outpatient department because of nervousness and crying in her sleep. H er physical examination and her blood showed no abnormalities, and roentgenograms of her long bones showed faint scars of the previous dense bands in the diaphyses. ^ At years she was considered a nervous person by her father, but she was doing passing . ` work in the seventh grade in school. Mental tests revealed an intelligence quotient of 82, ,*ith no significant deviations. .i^riCASE 7.--A girl of 10 months was admitted to the hospital because of poor appetite and Afgfiisal of food since birth and irritability for two days. She was born normally at full d, and weighed 6 pounds 7 ounces (2,920 Gm.). Since birth she had eaten poorly and slowly. Orange juice and cod liver oil had been refused or vomited, apparently htitively. Since cutting two teeth (time unstated), she had chewed the paint off her crib. O n physical examination she was a small, irritable baby, constantly scratching her palms, lies and genitals. There was ill-sustained ankle clonus on the left, but otherwise results of /sical and neurologic examinations were unremarkable. H er blood showed no anemia and stippling. ^Roentgenograms of her long bones, taken because of the suspicion of scurvy, showed a line I >'of;'increased density at the growing ends of the diaphyses, characteristic of lead poisoning. r ^t`!*ghe was treated with an average diet, cod liver oil and dibasic sodium phosphate, which took well, but the scratching of her palms and soles continued in the hospital and for the j>.'months during which she was followed in the outpatient department. |S he was seen at long intervals because of infections until she was 6 years old, when the ol sent her back to the hospital because she was irritable, nervous and inattentive. At jrears she returned with the same complaints, to which was added the statement that in spite -an adequate intelligence rating she would not do her school work. She was considered to sent a serious behavior problem and had been referred to a remedial reading class. Her Qtion span was very short. Her intelligence quotient was 103 (Stanford-Binet), but primotor tests were not given. ^Case 8 .--A boy of 19 months was first seen at the hospital because of poor appetite and Sf of weight. His family history and his past history were not remarkable. At about 14 he stood up and chewed paint off his crib, and later he chewed it from window sills other beds. s'^Jthough he stood alone at 14 months, he did not walk alone until he was 23 months old, patently because of loss of strength. (it 2 years and 2 months he was admitted to the hospital because of refusal of food and plent behavior, consisting of tearing up toys, defecating on the breakfast table and the Physical and neurologic examinations revealed nothing remarkable. Laboratory examiation revealed no abnormalities of the urine, blood or spinal fluid. ^Roentgenogram s of the long bones showed broad bands of increased density at the ends of h? long bones, consistent with lead poisoning. ^.Psychologic examinations were given at 2% 2 and 2%> years. On the second examination .following facts were noted: "In the past five months the child shows considerable advance vocabulary, but there has been little or no advance in his ability to manipulate blocks and wniis or to use a crayon imitatively." | ^ years he had a mental age of 6 7 years (Stanford-Binet) and an intelligence I :f S p o tie n t of 96. In spite of this, he had not learned to write his name although he was at the lif e f the first grade. W ith four reversals, he made the numbers to ten. He had not learned ' fo read at all. For example, he read "boy, cat, dog, play" as "black, red, gray." y -- Case 9.--A boy of 3Ma years was admitted to the outpatient department because of pallor and eating paint and dirt. He was the third child of healthy parents, was born at term by low forceps delivery and seemed vigorous at birth. He cut his first teeth at 6 months, j^yalked alone at 14 months and was using words purposefully at 16 months. From the time ])C Stood up, at 10 or 11 months, he chewed the paint off his crib and window sills. He was itable and cranky. i ''Svaf physical examination he was pale and difficult to manage. His blood showed a hemo globin content of 55 per cent; his urine contained a slight trace of albumin, and roentgenograms Of his knees showed dense bands at the growing margins of the bones, characteristic of lead $0 \ `3** S I t 'S*:r v-H ,. ] ` : ' -^ '1 * 1 . ,! \\~A.>t r' ??? .y > ... f;:-! i-i.'.i v ^a :-Vi J i r f _ 488 A M E R I C A N J O U R N A L O F D I S E A S E S O F C H I L D R E N poisoning. He was put on a liigli calcium diet with added iron and viosterol, and wa about further ingestion of lead was given his parents. With this treatment his family reno?'*' that he became much less irritable. His hemoglobin content reached 85 per cent in two mrm c and he was dismissed as well. At 6^12 years of age he returned in response to a follow-up letter. Afltcerr ,aa year in fi & grade he had not learned to write or print his name, to recognize any w_o.rd,,s,, or ~. figures. He was less adequate with picture puzzles and in copying designs than most old children, while his verbal capacity was relatively adequ.aattee. BR vy tthh ee Stanfotia^S-?! '& standards he had a mental age of SYi2 years and an intelligence quotient of 87. - Case 10.--A boy of 2y i years was admitted to the hospital because of fever in walking of a few days' duration. His father, aged 21 years, h ad' suffered' from attacks of syncope. His mother and one younger brother were well. He wa$ normally and did well as a breast-fed infant. He walked at 1 year, began to talk` `at':* 2 years and was talking well at the time of admission. He had had a few acufe^fiL of the respiratory tract but had otherwise been well. From the time he le a rn e d ':^ he had chewed the paint off his crib, window sills and furniture, a habit whichitorih been controlled. He had always been constipated. Three days before his admission-to hospital a fever developed, and tw'o days before admission he became weak and?dfi-*" ^ legs in walking. Physical examination showed a rather uncooperative child, whose left knee jerlc ankle jerks were absent and who showed bilateral foot drop. His blood showed a lifcln content of 85 per cent and a red cell count of 5,000,000, but on smear 0.7 per cent o ft cells were stippled. His urine and spinal fluid were normal. Roentgenograms" 6 f * showed bands of moderately increased density at the growing ends of the diaphyses '|u of lead poisoning. He remained in the hospital twenty-four days and was treated, with doses of calcium lactate (30 grains [0.19 GmJ) and viosterol in oil (10 drops).. ..TfaeStreiinw^.:* cleared up gradually, more quickly on the right side than on the left, and on the twerity-folrtk:)' day he was discharged in good condition, having gained 3 pounds (1,307 Gm.). His parent* ijS were instructed to guard against further ingestion of lead and to continue the use of VtbtttTOl and a high calcium diet. ' He was seen irregularly in the orthopedic department during the following year "forcareif the pronation of his feet. Two years later incisions were made in his ears because 'I m jacute ,J otitis, without incident. .,..11 At 7% years he was brought to the hospital because of nervousness. The father and mother had separated, and the children were in the care of their grandmother. The boy -wa* t? in the third grade and was reported to be doing well. The mother was told to improve 93 her discipline. VSt - At 8*942 years he returned with the same complaints. His knee jerks were lively/tnd *jl there was clonus at the left ankle. The school reported that he was restless and inafteotWt, 'Jf especially in the first two grades. 'J' Psychologic examination (Stanford-Binet) showed a mental age of 9% 2 years jftxj a* intelligence quotient of 105, but his ratingon the Ellis memory test was below the twenty^fiftfi percentile for his age. He was beginning the fourth grade. . Case 11.--A girl of 294a years was seen in the outpatient department because of vomiting;' of several weeks' duration and occasional abdominal pain. Except that her general condition was poor and that she was pale, results of her physical examination were not remarkable. Her blood showed a mild secondary anemia and her urine a moderate amount of pus. Although an appointment was made for a cystoscopic examination, she was not seen again until she wa* 4J4 years old, when she came with the history that the vomiting and abdominal pain had continued intermittently and that at fourteen months and again at two months before her admission to the hospital she had had fever and pains in her extremities. The account suggested muscular rather than articular pains. When she tried to get upafter the pi subsided, she could not walk because of weakness and had marked foot drop. When she wat seen after the second attack, her knee jerks were present. No other reflexes are recorded. A history of chewing wood was obtained, and her blood was examined for stippled cells, without success. v A year later, at Syi years, she was admitted-to the hospital with the same complaints. Her history revealed no new facts save that her development had been average. She had held vf> her head at 5 months and walked at 1 year. The age at which speech developed was not stated. She had never been well and strong since the original attack of pain and weakne** at the age of 3 years; though partly recovering, she had relapsed each late summer.ajidlfsB. At this time her family stated definitely that in chewing wood she had chewed painted articto ' of furniture. /v*' B Y E R S-L ORD-- L A T E EFFEC TS OF LE A D PO ISO N IN G 489 SjflJn this occasion she showed pronounced weakness of all her voluntary muscles, with i&Bjiiete paralysis of her diaphragm, demonstrated by fluoroscopic examination. There was jjjpSfoldence of intracranial pressure. H er tendon reflexes were abolished except for both yj-j-ps jerks, which could be obtained. Sensation seemed unimpaired. H er blood showed 1J8 per cent stippled cells and a mild secondary anemia. Roentgenograms of her long bones jjiowbd narrow dense bands at the growing ends of the shafts of all the long bones and, in addition, three less well defined areas of density proximal to these suggesting recurrent lead poisohing. Her spinal fluid was not remarkable. ?;SK*definite diagnosis of peripheral neuritis due to lead was made, and an attempt was made | for two days to cause excretion of the lead with use of ammonium chloride, but she vomited jo;severely that this was abandoned and treatment with calcium lactate and cod liver oil started, and she was transferred to the neurologic ward, where she was given massage and exercises in a tank. W ith this treatment her neuritis cleared slowly, and after three months o( treatment her blood still showed 2.3 per cent stippled cells. : Two years later, at 7 years of age, she was seen in the outpatient department in response to a follow-up letter and was thought to be entirely well. Roentgenograms at this time still showed faint bands of density some distance behind the growing ends of the long bones, thought to Jbe due to the old deposits of lead. Four years later, when she was 11, she was returned to the hospital because of difficulty * i* school work and emotional disturbances, depressional in character. She had been free | ^physical symptoms in the meantime. Physical examination showed slight pallor, slight less of the right side of the face, lively tendon reflexes and persistently positive Babinski on both sides. H er blood showed a secondary anemia (hemoglobin content 50 per cent jred cells 4,000,000) and a few stippled cells. Her urine showed a very slight trace of in. Spectroscopic examination of her blood, urine and spinal fluid showed about one Jfd times the concentration of lead found in_ normal persons. In spite of these results, ;Wjrtgenograms of the long bones showed no evidence of lead deposits. Encephalograms sbqwed no gross evidence of cerebral damage. Treatment for lead poisoning was again tosututed, and concessions commensurate with her abilities were arranged. ;$rr4\t 15^2 years she was a quiet, well poised girl, getting along happily but slowly in sjljl^pghth grade, though totally unable to do arithmetic. The family hoped she might get "high school and possibly finish it, but they were no longer pushing her scholastically. [-'Jplkpeated psychologic examinations were made. At 5%) years her mental age (Stanford- was 6% 2 years and her intelligence quotient 106. The test showed irregularities and lity to copy the square at the 4 year level, and her hand was unsteady as she traced the cross. ^er poor sensorimotor control was further shown by her inability at 6 p2 years to copy or write her name. p r,101% 2 years her intelligence quotient was 92 (Stanford-Binet), but in the Stanford Tg test her paragraph meaning scored at grade 2 .8 , her auditory memory was poor, and isorimeter capacity as tested by the Ellis Visual Designs test was very poor (score 3). A S ' A years she came in again. The Stanford-Binet test was not repeated, but the umotor tests were given once more. She had made a real gain in this respect. Her was average for her age on the Ellis Visual Designs test. She succeeded on three of the ilock designs, though they were more than usually difficult for her. On the Wood Completion test her score was 113, which was the third decile for her age. _,m .se 12.--A 4 year old girl was admitted to the hospital because of anorexia, loss of and progressive weakness of eight weeks' duration. She was the fourth child of healthy pjdtyorced parents and did well throughout infancy. She sat up at 6 months, walked at jWonths and talked at 18 months. Pica was noticed by the mother at the beginning of the t illness; the child broke bits of plaster off the wall and ate them. No certain conion of paint was remembered. Weakness developed rather rapidly over the period of ;Weeks so that she could not support her weight or pick up objects. ination showed a weak, emaciated little girl with great muscular weakness but no tw-<jte paralyses. The diaphragm hardly moved actively at all. All tendon reflexes were Kt There was marked bilateral wrist drop and toe drop. Sensation to a pin and to appeared intact. No evidence of intracranial pressure was found. & ^boratory investigation showed a secondary anemia (hemoglobin content 60 per cent at W tred blood cells 3,200,000) and about 1 stippled cell per high power field on smear. Her fluid was normal. Roentgen examination showed definite bands of metallic deposit at 1? ends of the shafts of the long bones, considered typical of lead. If %'Jb e patient remained for two months in the hospital on a high calcium diet with added ad cod liver oil. Her anemia improved fairly rapidly, but her weakess was still f : : . 4 j ii :.P : ' f-\ H i 490 AMERICAN JOURNAL OF DISEASES OF CHILDREN crippling. She remained in a convalescent home another four months. Two months her discharge from the home she was walking, and at the time of discharge she was wall;? well and seemed healthy. JjV ' Vomiting and abdominal pain were recurrent during the next four months, and five rnpntlw later they became severe and were accompanied with return of the peripheral n e u ritisjS ? was readmitted to the hospital unable to stand and with respiratory embarrassment sev? enough to require the use of a Drinker respirator. Physical examination and laboratory examination showed conditions similar to those previously, except that all were more pronounced. Roentgenograms of her skull - iB jS beginning separation of the coronal sutures. Her diaphragm was completely paralyzedS?! the metallic deposits in her long bones were more intense than ever. She was treatejS2? high intake of calcium, large doses of vitamin D and intramuscular injections of sulfate. Her strength returned gradually, and she was again discharged to a convalejjw home three and a half months after admission to the hospital, still unable to definite source of lead was identified. Psychologic examination at the time of her dr showed an intelligence quotient of 87 and difficulties in learning not explained by si intelligence alone. Soon after this admission her mother died of tuberculosis in a sanatorium. The, was placed in a convalescent home, where she remained six months, and was di able to walk, with straps to control her toe drop. At this time roentgenograms of her li no longer showed lead deposits. At lOj'fz years a psychologic appraisal showed an irregular mental examination,;; intelligence quotient of about 75 (Stanford-Binet). She was repeating the fourth looking toward a special class or an industrial class. Case 13.---A boy of 18 months was admitted to the hospital because of vomitii weeks' duration. He was the only child of healthy parents, was born normally and as a baby. He held up his head at 5 months, sat up at 6 months, stood at 10 mcv walked alone at 13 months. At 15 months he had a vocabulary of 3 words. HeTbegan jjta chew paint off his crib at 8 months, and as soon as he learned to walk he chewed * window sills and furniture. Vomiting had gradually increased in frequency to sevenPf c ^ daily, and during the two weeks before admission he had exhibited strabismus and an l Physical examination showed a somewhat pale baby. His fontanel was closed, and percussion of his head gave a cracked pot sound. Both optic disks were choked, and :tb*re i was an alternating internal strabismus. ,) His blood showed a secondary anemia (hemoglobin content 55 per cent and red criU 5,400,000) and many stippled cells on smear. His spinal fluid was under greatly increased pressure and had a total protein content of 124 mg. per hundred cubic centimetersi4]Roeat;;J genograms of the skull showed separated sutures, and roentgenograms of the long 'Bona showed a dense wide band at the growing ends of the shafts of the long bones, characterisfic' of lead poisoning. He was treated with intravenous injections of 20 per cent solution of dextrose and.djs(jTOj|'| phosphate and percomorph liver oil by mouth, and he was discharged in three dayTmock improved. His family was instructed to protect him from paint and to treat him w ith^ Bjfc:; milk diet and percomorph liver oil at home. Two months later he returned to the outpatient department in good condition. His qrtji/ were straight, but the fundi were not seen. At 4 years he returned because of knockknees, and his mother gave a history of his havinc had two convulsions during the previous six weeks. At that time roentgenograms of his long;" bones showed some distortion of the ends of the diaphyses, but the heavy bands of lead deposit had disappeared. He next returned, at 6 years of age, because of behavior difficulties which had been growing more pronounced since he was 2 years old. In kindergarten he had stuck a fork into another boy's face. In first grade he had been expelled for stealing pencils and pens. At home he bad set the apartment on fire twice. Psychologic appraisal at 6]A years showed a mental age | of 6 years and an intelligence quotient of 92. In spite of this, he could not write his naa*)| legibly or recognize any of the simplest words. On a brief visuomotor test he showed v ajfj poor visual memory and even reproduced a square as an almost circular figure -. Case 14.--A boy of 23 months was admitted to the hospital because of irritability erf CMi year's duration. His history, except for pica, was irrelevant; the family history was moftsolr H e sat at 7 months, walked at 15 and talked at 18 months. BYERS-LORD--LATE EFFECTS OF LEAD POISONING before I about the time he learned to sit up he began displaying pica, eating several coats of .alking I p S t off the available portions of his crib, carriage and porch railing. He also had eaten th, papers of all sorts, curtains, gloves, matches and pencils, and his own stools and canine months 1 ftcjjjls as well. His appetite for food had suffered tremendously, and he had never eaten well. Sht 1 ty in g the year before his entry into the hospital he had been extremely irritable. During severe I the two months before entry he had become unsteady on his feet, and during the week or two JSfore admission he had had abdominal pain and diarrhea. f^|Physical examination, including examination of the fundi, showed no abnormality except poor nutrition and hyperactive tendon reflexes. His blood showed no anemia, but there were pomerous stippled cells on smear. Roentgenograms of the long bones showed heavy bands of 'density at the ends of the shafts, diagnostic of lead poisoning. His spinal fluid was not remarkable. Psychologic examination showed poor intellectual development at this time, which, Slten with his early developmental history, suggested a slowing up of development. rj|jpH e was treated with disodium phosphate and viosterol, and his family w'as instructed to ' j^tiard against ingestion of lead. At home his irritability continued, as did his pica, but his " ents attempted to remove all lead from his environment. He gradually improved in stability, ,Jany infection, such as one on the dorsum of a finger, brought out the old symptoms; how- child l i '-pjgy he steadily improved in language ability, larged R ^Spjiine months later he was again admitted because of irritability, frequent soiling and bones PJSetting of himself and a weak gait "like that of a little baby just learning to walk." His showed a secondary anemia but no stippling, and roentgenograms of his long bones still ndwed metallic deposits. An encephalogram indicated normal spinal fluid and normal ventricular dines. In the ward his behavior improved, but his play was more like that of a 20 to 24 pjh old child than that of one of 32 months and his concentration and attention were poor. he moment he returned home his behavior returned to its former low level. Vomiting and fominal pain appeared in bouts, once severe enough to cause his admission to the hospital suspicion of appendicitis. At 4'/2 years he was a problem in kindergarten, and the fol- ng year he entered the first grade, where he was having great difficulty in learning to ! and write, in spite of an intelligence rating of. 109. Vt 6 7i 2 years he entered the hospital with a severe tracheobronchitis, for which intubation ame necessary, and, in addition, he was treated with sulfanilamide for six days in doses ntaining concentrations of the drug between 10 and IS mg. per hundred cubic centimeters , and there Wood. Twelve days after the use of sulfanilamide was stopped, an agranulocytosis developed, n which he died in sixteen days. 3a s e IS.--A girl of 3 j i 2 years was admitted to the hospital because of vomiting of three t one half months' duration. H er father had been treated for syphilis for two years. The of his infection was unknown. Her mother was well, and there were five older siblings : were well. The oldest child had died, and the third pregnancy had resulted in mis- rnage. The patient was born normally at term and did well on bottle feeding. She had had [egular amounts of orange juice and cod liver oil through infancy, but since infancy her diet 10 been adequate. She walked at 1 year and began to talk at the same time. At 10 months >dium began to exhibit pica, eating paint, bark, linoleum and dirt. Three and a half months much K ^ S jfp re admission to the hospital she began to vomit from one to five or six times a day, to high her appetite, to be constipated and to have dreams bordering on hallucinations at night. She ; pounds (2,948 Gm.) during this period. eye* \'"hfpPhysical examination showed a pale, restless child with constant choreiform movements mild state of mental confusion. Her tendon reflexes were hot obtainable. ifeSjHer blood showed a hemoglobin content of 58 per cent and a red cell count of 4,700,000. There no stippled cells on repeated examination. H er urine was not remarkable. Her spinal contained 18 white cells and 63 mg. of protein per hundred cubic centimeters. Roent- 'piograms of her long bones showed moderately broad metallic zones at the ends of the long (pics, characteristic of lead poisoning. Wassermann and Hinton reactions of the blood and , pnal fluid were negative. psTS:. She was treated with disodium phosphate and large doses of viosterol daily. Her confusion *nd vomiting subsided promptly, but in the ward she showed pica which was very difficult control. She was sent to a convalescent home, where she remained two months. At first *,v *hc seemed dull for her age, but in a few weeks she became responsive and attractive. At 3% 2 years she reported to the outpatient department. At that time her right hand was unsteady that she used the left by preference. She played with the test materials on ^Aj-fcychologic examination like a 2'/* year old child, showing special difficulties in the dif f e r e n t i a t i o n of shapes, though her language was adequate for a 3 year old child. returned to the hospital at 7% years in a generalized convulsion. The mother stated she had been well and was in the second grade in school but was unable to learn to read. i 192 AMERICAN JOURNAL OF DISEASES OF CHILDREN She had shown no pica since the previous admission to the hospital. The convulsion controlled with ether and paraldehyde, and the next day, save for bites on her tongue, resultant physical examination were unremarkable. Cytologic examination of her spinal fluid and hbJj yielded unremarkable results. Roentgenograms of her long bones showed some disturbances' growth at the ends of the long bones but no metallic bands. After recovery from the convulsi* she used her left hand poorly as compared with the right for fine movement. ., ,n Psychologic appraisal revealed an intelligence quotient of 91 (Stanford-Binet). It had k_, 102 by the same examination a year before, with specialized defects in the field of spatial orw ! tation. She was above the average for her age from the point of view of general information' In school work she proved totally unable to learn to read, although she could copy readily. On the Wood Picture Completion test her associations were so simple that the^re^S were bizarre and unscorable. She failed in all the cube designs appropriate for. 6 year oU children. She did picture puzzles less well than the average 6 year old child. On the Cunningham Test no. 7 she made a great number of unpredictable errors, perseveratiMTJjWW one design to the next. Case 16.--A girl of 4% 2 years was admitted to the hospital because of convulsions.whid had first appeared when she was 4 years of age. Her family, birth and past history'were toot remarkable. She walked at 13 months and used single words at 18 months. She had been k ii ^ to chew paint, furniture and newspaper since before she was 2 years old. For some time 'she 'a had had a poor appetite and severe constipation. Isolated convulsions had accOmpant^i '.5 fever at 4, 4% 2 and 4% 2 years. -' Results of her physical and neurologic examinations were not remarkable. Ic,atora%otre ; studies showed no abnormalities save for mild secondary anemia (hemoglobin content;55` pjy cent). Roentgenograms of the long bones showed a broad band of increased density!at ends of the long bones, consistent with long-standing lead poisoning. A diagnosislof l i ^ f e poisoning was made and treatment with vitamin D and a high calcium diet institutedt'^^M i Scattered convulsions recurred during the ensuing three years, but from 8 to 10 years-'o^^^:<S she was free of them. At 10 years sudden recurrent attacks of gagging and hiccup developed, which were accompanied by confusion lasting a matter of minutes, and from 12 years of age " H she again had recurrent frank convulsions. Rneumoencephalograms showed symmetric enlarge ment of the lateral and third ventricles in a cranial vault of average size and were interpreted as indicative of diffuse cerebral atrophy. Psychologic examinations were made at various ages. At S years her intelligence quotient (Stanford-Binet) was 90, with pronounced irregularities, and she exhibited difficulty in learning new material in spite of the adequate rating. At 8 years similar results were obtained. A t 12ft. years she gave a very poor and irregular performance on the Terman test, her results indicating a mental age of 8 years and an intelligence quotient of 65. She could not deal with the picture absurdities or comprehension at the 7 year level, while she succeeded with two items of compre- v hension at the 9 year level. On the Wood Picture Completion test she did as well as the average 9 year old. 2 . In dramatic contrast to her low rating she attained fifth grade score in most subjects cm the Metropolitan achievement tests. Although her actual test performancewas so confused that she characteristically failed more tests than she passed, many of her failures were on the easier tests, while some of her successes were in fractions and decimals. 'pij&tf'.'- The school reported that in the sixth grade she was a desirable pupiland worked consci- A'- entiously under a slight strain to keep up her grades. Her mental capacity was so unpredictable that it was felt that plans for her education should be formulated more with reference to her teachers' attitudes than to the child's actual ability to keep up. : During the past winter she has been out of school for ten weeks because of appendicitis. Case 17.--A girl of l 1}-). years was admitted to the hospital because of convulsions and a rash. Her mother had observed that she was chewing paint at 1 year and 10 months. One week later, in connection with fever, she had a convulsion which left her exhausted for several days. Her local physician demonstrated stippled cells in her blood at this time and referred her to the hospital, where roentgenograms of the long bones showed dense bands at the end of the diaphyses, consistent with lead poisoning. After that she remained well as far as her family knew, except that she vomited easily and often. When the vomiting was severe, at 5 years, her local physician again found stippled cells in her blood and treated her successfully with calcium and vitamin D. At 5 years and 3 months she displayed frequent lapses of consciousness lasting one or two minutes, sometimes accompanied by falling and involuntary voiding and usually followed by sleepiness for some minutes. j>.v . . Pneumoencephalograms at this time showed normal ventricular outlines. Roentgenograms of the long bones showed no evidence of lead, though stippled cells had been found three months before. . V- BYERS- LO RD--L AT E EFFECTS OF LEAD POISONING Psychologic examination at 6 years, when she was in the first grade, showed irregularities of ttectual development. On the Stanford-Binet test her intelligence quotient was 94. She had ijjpior memory for stories, and after nearly a year in school she had not learned to w rite her suite or make figures, though she had learned to read. *%Case 18.--A boy of 10 months was admitted to the hospital because of irritability and Vqtjtiting of three days' duration. H e was born by forceps delivery, and, because he spit up Mflqd on the first postnatal day, he received one transfusion. H e was breast fed up to the time (^admission to the hospital, and his mother had used lead nipple shields throughout his life. At Kfinonths he sat up with assistance. Three days before admission he became irritable, vomited ptpjectilely and complained of abdominal pain. These symptoms continued to the time of admission. '.JfOn physical examination he was pale, his fontanel was bulging and there was a slight degree of edema of both optic papillae. H is tem perature ranged between 102 and 103 F. for two weeks. .iiJLaboratory examination revealed a mild secondary anemia (hemoglobin content 70 per cent "1:3,300,000 erythrocytes) and 2 to S stippled cells per oil immersion field on smear. [His spinal fluid was xanthochromic, was under increased pressure and showed a total protein Bent of 160 mg. per hundred cubic centimeters and 12 mononuclear cells per cubic millimeter. entgenograms of the long bones showed dense bands at the end of the diaphyses, and nfgenograms of the skull showed separation of the cranial sutures. <(S3tie was treated by intravenous injections of 25 per cent solution of dextrose, intram uscular injections of magnesium sulfate and large doses of viosterol in oil. jgHis irritability diminished slowly, and his blood pressure remained about 120 systolic and Mjfcdiastolic. D uring the third week a transient right wrist drop was noted. Even at the end of his three and a half week stay there were still a few stippled cells to be found in blood smears. -jwas discharged with the statement that a good deal of cerebral damage had probably been done. m month later his blood pressure was 90 systolic and 40 diastolic, and he seemed happy and <%erful. A t 14 months he was standing and saying "dada," and at 16 months he was noted W-j>ne of us (E . E. L.) to be acting like a 10 to 12 month old baby. At 19 months he seemed to^all observers except the psychologist to have caught up with other babies of his age, but on psychologic examination he showed difficulties in dealing with space and direction, which persisted to the age of 5 years. H is intelligence quotient at that time was 90. A^jThe boy entered first grade at the age of 6 years and was promoted each year. A t 7 years jpj_)iad an intelligence quotient of 103. T here was no evidence of visuomotor disability, and mid read and w rite well for his age. Ase 19.--A 2 year old boy was admitted to the hospital because of weakness and limping ais left leg of one week's duration. H e was delivered by forceps after a three day labor, .jjy a s weak after delivery and would not nurse. A t 2 weeks of age he was taken to the flsjljjsachusetts Eye and E ar Infirm ary, where he was treated for four weeks because of disA lrging eyes. H e was discharged considerably below his birth weight, but at home he did ^ k o n formulas prescribed by another hospital (the nature of the formulas was not stated). WpcTliver oil and orange juice had been taken in adequate amounts from early infancy. `"f i l e lived with his family in an old nine room house, in which the piping was entirely of lead. His father was a painter. The patient had been known to play with paint left about the house, though he had not been known to eat any. 4 tH is development was average. H e held up his head at 3 months, sat up at 6 months and talked at 14 months. H e was not talking, however, at 2 years. v A week before his admission to the hospital the patient showed a disinclination to walk and Ppgan to drag his left leg. . The weakness became gradually more pronounced. ^ Physical examination revealed nothing remarkable save that in walking the left foot was ot raised off the floor; the leg was rotated externally, and the foot dragged forward. The t^don reflexes were lively and approximately equal on the two sides; perhaps the reflex on left side was somewhat livelier. The plantar reflexes were normal. His blood showed a secondary anemia, with a hemoglobin content of 50 per cent by the Tallqvist method and a red cell count of 4,800,000. Several smears failed to show stippled cells. _Roentgenograms of the long bones showed dense bands at the ends of the shafts consistent 't'fh lead poisoning. He was discharged unchanged after three weeks, on a high calcium diet with cod liver oil (3 drachms [11.7 Gm.] d aily). No investigation of the water was made, but the parents were ^ m e d of the danger of allowing him to eat paint. A month later he returned to the outpatient department and was regarded as well. 494 A M E R I C A N J O U R N A L OF D I S E A S E S OF CH I L D RE N A year later he returned because of pallor, irritability and loss of appetite. A t this ti he was definitely known to chew paint off objects, though his family tried to prevent him. Th* weakness of the leg had not recurred. e Physical examination disclosed nothing remarkable except pallor, which was confirmed by hemoglobin content of SO per cent, a red cell count of 2,600,000 and a smear showing moderat achromia but no stippled cells, Roentgenograms of the at the growing ends of the shafttsc. H e was discharged long on a bones high again showed dense ba calcium diet with iron a nd ammonium citrate and cod liver oil (3 dj r__a__c\h__m___s r[11 11 .7n G/" m.]i dj aiil_y. \). In a month__________i.i_ ihis hemogl*ot!-^ ccoonntteenntt wwaass 8SO0 pneerr cceenntt aannOd h1-iiisc rreefdt cceellll cccoiunnntt 44,000000,000000. A t 12 years he returned to the outpatient department because of enuresis. H e cav* general impression of being dull. H is mother gave the following report of his school progro * ``H e started to school at the age of 5 years. H e spent tw'o years in the first grade. The nevi year he had a teacher at home. start the fifth grade in the fall." The following year he spent in the second grade. Psychologic tests have not been given. H eiV ll "* Case 20.--A girl of 3 years was admitted to the hospital because of vomiting and abdominal pain of three months' duration. H er father and mother were separated at the time. Her birth and early development had been normal. She walked at 13 months and talked at 14 or IS months. From the time she began to move about she chewed anything and everything, including from her crib and from window sills. About three months before her admission to the hospital she began to vomit, and the vomiting increased in frequency. A month later abdominal pain, irritability and pallor supervened. One month before admission strabismus was noted. Duriiw this period a gradual loss of weight occurred. She had complained of headache during days before admission. J- On physical examination she was dull and drowsy. H e r optic disks were noticeably choked, and her skull was hyperresonant on percussion. H er tendon reflexes were everywhere, hyper. 1 active, and Babinski signs were elicited on both sides. H er hemoglobin level was SO per c e n t; her red blood cell count was 2,600,000, and her bfood smear showed achromia and 8 to 10 stippled cells per high power field. H er spinalffltnd*^^ under increased pressure and contained 18 cells per cubic millimeter and 108 m g.'.'hfS ^td" protein per hundred cubic centimeters. ,' :ic2 $jHJF - Roentgen examination showed heavy bands at the grow ing ends of the long bones, Consistent with lead poisoning, over a long period of time, with an especially heavy recent d eposit" Increasing drowsiness and vomiting continued in spite of treatm ent with hypertonic solution of dextrose (20 per cent) and dibasic sodium phosphate, and on her fifth hospital day bitemporal decompression was performed. \ Frequent lumbar punctures were performed, with the removal of large amounts of spina! fluid (up to 200 cc. on one day), during the next four weeks. A fter that the patient gr^jluallv became interested in her surroundings, her vomiting stopped and she made a rapid recovery during the last two weeks of her stay. Six w'eeks after admission she was playing "normally" in bed, but psychometric examination showed a general level of intelligence around 3 rather than approaching 4 years, with special disabilities in the field of spatial relationship. She was dis charged on the fifty-first day in the hospital, weak and underweight but able to walk and showing an active interest in life. . Ajfe. In spite of her mother's efforts she continued to eat paint at home, stripping all the paint off the porch railing before she was caught. A year later she was again admitted because of vomiting and abdominal pain. H er decompression wounds were bulging, but her optic disks' were normal. H er gums showed a lead line. H er hemoglobin content was S3 per cent and her red blood cell count 3,900,000, with marked achromia and many stippled cells on smear. Spectroscopic examination of the blood showed a level "very much above anything found in normal controls." Roentgenograms of her long bones showed wide bands of lead deposit with ' recent accentuation at the growing ends. Roentgenograms of her skull showed no evidence of, pressure. A lumbar puncture showed fluid under apparently increased pressure, with 6 mono cytes per cubic millimeter and a total protein content of 46 mg. per hundred cubic centimeters. She was discharged on a high calcium diet and 18 drops of combined fish liver oils daily, and with assurance that she would be protected from paint in the future. She was next seen when she was 9 years and 6 months of age, in response to a follow-up letter. Although she was friendly and outgoing, she was doing badly in school in the third grade, had a mental age of 7%2 years and an intelligence quotient of 80, with special defects in spatial orientation. H er score on the Ellis visual designs test was 1.5, which was below the