Document GpMjQ30X1LVM8qj67Vw3DbVN

L -- Jy>/ 4. ItHi'j At 9Vol. 281 No. 10 MEDICAL INTF.LUGENCE-LITT AND COHEN >3, n?. 65:605-609, ations in renal graphy. Surn. i in renal blood L. Variations in >f blood supply n of renal vev va in man. Am ions of inferior of this vessel. operative venocava. Acta ru- 3mmic August, 1968, was prompted by the development of ascites, physical examination also revealed distended jugular veins, a diastolic sound and hepatomegaly. The cardiothoracic ratio was 17:33. The electrocardiogram was unchanged since November, 1966. Reappearance of signs of right-sided heart failure with further reduction in cardiac diameter suggested the diagnosis of constrictive pericarditis. The patient died unexpectedly before further studies could be performed. At autopsy the heart was encased by thick, leathery peri cardium measuring 0.3 to 1,0 cm. The parietal and visceral lasers were firm, white and adherent to each other. There was no pericardial fluid. The heart with adherent pericar dium weighed 670 gm. All chambers were dilated and hy pertrophied. Microscopical sections showed small foci of individual myocardial-fiber calcification. The pericardium was thickened by wavy eosinophilic material containing fi broblasts and lymphocytes; a thick, fibrous band joined the 2 layers of the pericardium to each other. There was 6000 ml of straw-colored fluid in the peritoneal cavity. The liver weighed 2320 gm and gave evidence of severe chronic pas sive congestion. The kidneys were small and microscopically were characteristic of chronic glomerulonephritis. cardiac tamponade in chronic renal failure. Aart. tat. Med. 64:99099J. 1966. 3. Hampers. C. L.. Bailey. G. L.. Hager. E. B.. Vandam. L. D,, ami Merrill. J. P. Major surgery in patients on maintenance hemodialysis. Am.J. Sum. 115:747-734. 1968. 4. Moraski. R. E., Sandler. I. A.. O'Hem, J. A., and Bousvaros, G. Evaluation of right autography for detection of pericardial effusion. Am. J. M. Sc. 256:360-367. 1968. 5. Dye. C. L,, Genovese. P. D.. Daly. W. J.. and Behnke. R. H. Primary myocardial disease. II. Hemodynamic alterations. Ann. Ini. Med. 58:442-453. 1963. 6. Tradger. M. J., et al. Pencardite uremique a evolution constrictive subaiguii a propos d'une observation anatomo-dinique Chez un Bnghtique traite par les epurations extrarenale au long cours. Lyon med. 211:383-401. 1964. "Danger . . . Vapor Harmful": Spot-Remover Sniffing* X Iris F. Litt, Vf.D., and Michael I. Cohen. M.D. Discussion )ntc uremia is alone or open draincT*t |jies&Tn. fericardial lagic periitial eomplis now feasiailure under ve an elevated eated sporadie was referred ing this adniis:trocardiograoi kidney-biopst us glomeruli>e BUN 28 tug ul per minute I function was food urea and latient was atle dyspnea and jugular veins. . The urea tting per 100 ml. 21:33. He wa it and was iliai was heard innoimrutcd pciaracic ratio wa.'ITusion wits ditf hcmorrhagu ' March, IlMiS. if patient - and dis.i|r St admission in ilieal College. ami piial iailtire-- ic K-purtnienl, Vetee , N.Y, 1:20X1. In the absence of pericardial calcification the differentiation of constrictive pericarditis from other types of restrictive myocardial disease or severe congestive heart failure may be difficult or impossi ble even with the aid of cardiac catheterization.5 A definitive clinical diagnosis is even more difficult in patients with end-stage kidney disease being main tained by hemodialysis, for signs of circulatory' congestion are often secondary' to myocardial failure or to pericardial effusion. Such patients may not survive long enough for pericardiac calcification to develop and electrocardiographic abnormalities dtte to pericardial effusion or left ventricular hypertro phy may not change further with the development ot constriction. The most helpful finding is likely to he, as in this case, a decrease in the size of the car diac shadow on x-ray study, despite symptoms and signs of persisting or worsening congestive heart failure. , Review of the literature revealed only one addi tional report of a case in which pericardial constric tion was suspected and partial pericardectomy per formed.* The patient did not stmive surgery. At autopsy there was thickening of the pericardium with partial adherence of the parietal and visceral layers by organizing blood clots -- that is-, an earlier pathologic stage than the one observed in our pa tient. Tltese two reported cases suggest that con strictive pericarditis is an unusual sequela of peri cardial effusion in patients with chronic renal fail ure undergoing hemodialysis but very important to recognize since it is potentially correctable. We are indebted to Dr. Orlando Hines for permission to eport on tins patient and to Dr. Monica Bishop for the pathological report. References I Schupak, E.. and Merrill. J. P. Experience with Ions term intermittent hemodialysis. Ann. far. Med. 62:509-5|H. 1965. - Beaudry, C.. Nakamoto, S.. and Kolff, W. J. Uremic pericarditis and SL 036644 ON every label of a popular spot remover (Carbona) appears the warning: "Danger . . . Vapor Harmful." In spite of it, spot-remover sniffing is becoming popular among adolescents as yet an other method for getting "high." The purpose of this paper is to alert physicians to the potential dangers of this habit. Trichloroethylene and 1,1,1-trichloroethane ate the main components of the spot remover. These chemicals are widely used in the cleaning industry, where Federal law requires their concentration in the air to he maintained below 100 ppm. Accidental inhalation has been associated with encephalopathic symptoms and peripheral neuropathy.1 As Trilene, trichloroethylene hits been an effective, and report edly, nontoxic inhalation anesthetic.1 Experimental inhalation in animals results in tran sient disturbances in equilibrium, increased saliva tion and hyperexcitability, with no histologic changes in liver or kidney.*-7 Intraperitoneal injec tion of either chemical causes SCOT elevation, neu trophilic infiltration in liver sinusoids and portal areas, decreased phenolsulfonphthalein clearances and calcification of kidney tubules. Pretreatment with ethanol potentiates the hepatotoxic effect." The observations reported below indicate that these compounds do have the potential for serious hepatic and renal toxicity when sniffed by adoles cents. Subjects, Methods and Results Ten teen-agers, 12 to Ifi years of age, were found to have sniffed the spot remover by the Adolescent Medicine Service of the Division of Pediatries. Complete blood counts and urinalyses, as well as liver chemical and urea nitrogen determinations, From the Division of Pediatrics, Monlefiore Hospital anil Medical Center, and ihe Department of Pediatrics, Albert Einstein College of Medicine (address reprint requests to Dr. Litt al the Department of Pediatrics, Montetiorc Hospital and Medical Center. Ill E. 2ID St.. Bronx. N.Y. 10467). t 544 THE NEW ENGLAND JOURNAL OF MEDICINE Sept. 4, 1969 Vid. 281 N were obtained. Five Itatl abnormalities of liver func tion as indicated ly !)ilind>in (range tf 2 to 11 mg per 100 ml), SCOT (range of 340 to 1110 Karmen units), alkaline pliosphatase (range of 7 to .`50 Ik-ssevLoxvry units), prothrombin time (range of 17/12 to 20/12 seconds) and thymol turbidity (range of 8 to 15 units). Four of these five patients ltecaine jaundiced within one week of sniffing the spot re mover. All five had in common the experience of nausea immediately after inhalation, and diagnoses of gastroenteritis were made. Nausea was experi enced by only one of the group without hepatotoxicity. In one patient hepatic coma developed. Eleva tions in BUN (114 mg and 147 mg per 100 ml) were found in the two patients with proteinuria. In one of them acute renal failure developed, requiring hemodialysis. Three of the five with abnormalities of liver func tion had also sniffed glue, and one had snorted her oin. In one patient a peptic ulcer, and in another, a hemolytic crisis secondary to G-6-PD deficiency developed. Two patients reported symptoms refera ble to the nervous system (paresthesia, tinnitus, ataxia and headache). All patients survived. The five patients without chemical abnormalities of hepatic or renal function were seen between two weeks and one year after inhalation. Since even the most severe chemical abnormalities in those with hepatic or renal toxicity were transient, it is possi ble that minor chemical abnormalities existed ear lier in the other, seemingly unaffected patients. Sniffing of this spot remover or similar products should now be considered in the differential diag nosis of gastroenteritis, hepatitis and acute renal failure in the adolescent age group. The diversity of socioeconomic backgrounds and equal sex distribu tion of our patients suggest that it may be a wide spread phenomenon in the New York metropolitan area. Those who have abused other drugs are using it, but so is the otherwise "drug-naive" teen-ager. The extensive use of drugs during the develop mental \ ears of adolescence has introduced a num ber of new and different medical problems. This form of sniffing further complicates an already difficult situation. References 1. Feldman. R. G,, and Mayer, R. F. Studies of trichloroethylene imoxica'ioi in man. Neurolopy 18:309, 1968. 2. Goodman. L. S., and Gilman, A. The Phorniacolnpical Basis of Therapeutics. Third edition. New York: Macmillan, 1967. P. 97. 3. United States National Institutes of Health. Von Octtingen. W. F. The ItulayeHalt'd Aliphatic. Otejwic, Cyclic. Aromatic, and Aliphatic-Aromatic Hydrocarbons Inclttdinp the Haioptnated In secticides: Their ttaicity and potential danpers. 19S5. (Public Health Service Pub. 414.) 4. Adams. E. M., Spencer, H. C., Rowe. V. K.. and McCollister, D. D. Vapor toxicity of trichloroethylene determined by experi ments on laboratory animals. Arch. Indus!. Hyp. 4:469-48). 1951. 5. Stewart. R. D. Toxicology of methylchloroform. J. Occup. Med. 5:259-26:, 1963. 6. Torkelson. T. R., Oycn, F.. McCollister. D. D.. and Rowe. V. K. Toxicity of 1.1.1-trk.hlorocthane as determined un laboratory ani mals and human subjects. Ant. Indust. Hyp. A. J. 19:353-362, 1958. 7. Prcndcrgasl. J. A.. Jones. R. A.. Jenkins, I.. J.. Jr., and Siegel. J. Effects on experimental animals of long-term inhalation of trichlo roethylene. carbon tetrachloride. I.l.l-trichlomethane, dichlorodifluoromethane. and l.l-dichloroethylcnc. Toxicol. A Appl. I'liar macol. 10:270-289. 1967. 8. Klaasscn. C. D.. and Plaa. G. I.. Relative effects of various chlori nated hydrocarhons on liver and kidney function in dogs. Toxicol. d Appl. Pharmacol. 10:119*131. 1967. this period scientific lutigle tra\ Iu 1926 scum expi magnified) before. Ill util of the DOCTORS AFIELD aeeount of Thomas William Francis Gann -- Mayan Explorer* stature as his approat scholarly. Francis H. McGovern, M.D. J. Eric 'i ,and the jo the Maya THE extraordinary and colorful career of Thomas William Francis Gann as an explorer and au plislunents Among thority on the ancient Mayan civilization is a strik some mur. ing example of a physician who achieved fame in a Ril.i, in ni field other than that of his chosen profession. Although not generally appreciated, Gann's contri butions to our information of pre-Columbian Middle America tire impressive. His discoveries of Mayan ruins of great importance, his bibliography of 40 books and articles on his jungle travels and archeologic findings and the unparalleled Gann collection of Mavan jade and other material in the British Mu seum testify to the extent of his achievements. Gann was born at Murrisk, Westport, County Mayo, on May 13, 1867. He was educated at the King's School, Canterbury, and the Medical School of Middlesex Hospital, London, where he qualified as LSA in 1889, and as MRCS and LRCP in 1890. In his early medical career he practiced in London and Yorkshire and participated as officer in charge of a medical relief expedition to the victims of an earthquake in Guatemala. In 1894 he was appointed district medical officer in British Honduras, where he served for nearly 30 years in several capacities, including those of acting district commissioner, die finest 11mud in ll die costun: which thes According her of irnpi ern British Cuba, in C lehpaatun 11927); and 11936). Perhaps t his ability unpenetrah popular bor .e-louishing .miui.il life and custom graphically ' "u-ring, u min. His di principal medical officer and member of the Legis lative Council.1-* For a man with boundless energy, a restless de sire to travel and an intense curiosity, the beckon ing nearby jungle provided an ideal setting for the hobby Gann was to pursue for the remainder of I"' long life -- searching for lost Mayan ruins and seek ing to uncover the secrets of the Mayan people. Within a year after his arrival in Belize, Gann wrote his first article4 describing his exploration of two mounds in British Honduras in the area of the n"w partially restored mins of Xunantunich, and for the next 27 years, the reports of his studies appeared periodically in the anthropologic literature.** After his retirement from medical practice i" ... The c mii(|ue. It giound, evi ''one or ha Nniiit-nse bi on the Am' 1 oinlmiatior h licii we f nopaal fot ranis of tf r< c, but ir hiiK-xione a 'Nim-white hi i phn bush h' the thoi 'nisi have l>"|>N!uiion " must hav 1923, Gann intensified his jungle explorations an1' his archeological investigations. His writings durii'i: '"/bi flic in At/cent From the Departmem of Otolaryngolofy, University of Vus1"1School of Medicine. Charlouesx ille (address reprint requests io P' McGovern at 139 S. Main Si.. Danville Va. 24541). ** biologist Gannr ....... .. the SL 036645 f