Document KGnxkkgojj53zjwqZMpBdbqZX

Ex h ib it 13 N39086 who states that excessive or patnoiogic contraction, '--^^nnallv induced by solution ot pituitary, is potentally ol pathologic states. There is an obvious reason ioiBtkm of pituitary, (fiven immediately after the delivery baby, does not frequently cause trouble. It requires from A to twenty minutes to produce a hard contraction of the L by this means, and in the majority of instances the ijBi will have been delivered before the expiration of that # It $eeni unnecessary to give solution of pituitary jmme* .j. after delivery of thf baby, vebm 700 out of 1,000 ^ m delivered with less than 200 ee. of blood toss, and ssase 2 per cent develop hemorrhage. I hope that Dr. |gU will substantiate h(s routine by preseating his figures .ins of Wood. and toys, informed of the danger to sinau ennaren trom the ingestion of lead faint, have cooperated by sub stituting other types of pigments for the lead pigments formerly used. New cribs are seldom painted with lead paint, and the better grades of toys are largely free from lead pigment. Painted' woodwork and painted furniture continue to present sources of lead available to the child. Intoxication following the ingestion or inhalation of lead appears to be dependent on a number of factors. Of primary importance are the amount of lead ingested and the period of time over which, it is taken in. The absorption of small amounts of lead by all persons, f. LEAD p o is o n in g i n c h il d r e n CHARLES if. McKHANN, S4.B. f k 4. &. AND EDWARD C VOGT, M.D. 8OST0 , ffce continued occi^irrence of lead poisoning in SAn-n despite the efforts of physicians, health and insurant* companies to disseminate dan concerning this preventable disease, war- Jjjsthe presentation o f a review of certain phases of ^condition and a fuxtfi.ier report of the cases observed clinic. s o u e Ce s o f l e a d i poisoning in infants may follow the prolonged jf> of lead nipple shields;1 in Japan poisoning has frequently from- the use by the mother of face containing lead.3 In infants and older children whether in urbaa or ia rural populations,- seems to be of normal occurrence and is said to be unaccompanied by danger. Ah increase in the amount of lead ingested, or the continuation of absorption over a period of time, may lead to rattetieitioa. Age is a third factor of importance. Children appear more susceptible to severe intoxication than .adults. A similar observation is made in 'experimental animals, for likewise the young animals seem more susceptible to lead poisoning than, do the 'adults of the same; eaes. Ia addition to the infiaeace of age on sti*eptifeiiity to lead, -there observed co&siderable. individual variation ia tolerance to the'mmL Sonse children, after die ingestion of moderate amounts of the metal, rapidly develop encephalitis. Others are capable of tolerating quite large- amounts with the minimal development pf symptoms but with, however, the deposition of abnormal amounts of lead. in the body, a coadifioa which we designate latest lead j mgesdon, over a petiod of time, of water containing fee small amounts of lead, may result in intoxication, fesntly (here was reportedgjan. extensive series of cases l.--Aga Incidence of Lead Ckil&rett's Hospitals, Smftes, 1924-1933 flead poisoning follovring the inhalation of fumes in " where storage- battery casings were used as However, most frequently the-ingestion oflead |t result of the habit observed in small children, of unusual substances.*. Under l year... 1 Ul years.-... 2 so s yearn.... itM ms.... 4 to a KUS..., " -6 f . -- $ |Ptrversions of appetite, designated pica, leading to Total > ingestion of foreign substances such as and, coal, hair or paint are observed in mentally: defective m neurotic children, in. those suffering from anemia Ipd in those harboring intestinal parasites. ' In the jtajority of cases of lead poisoning due tb ingestion of jurat, the" pica has apparently been merely a pernicious unrelated to anyj underlying abnormal condition, incidence of leadl poisoning (table I) is highest in and small chiilelqren in whom teeth are erupting in whom there is .a great tendency to put things the nsemtk poisoning, for under - certain' circumstances sura^-A- patients may mobilize the lead deposited in apparently"' inert form and thereafter develop serious manifesta*- ttons. -' . - _ SYMPTOMS 'I Usually the ingestion of lead in small amounts has taken place over a period of weeks or months before * symptoms are noted,".The early manifestations are,.-., traceable to disturbed- function ol the gastro-intestinal . tract- Anorexia,* constipation, vomiting and akfataml .i ,, Frem the DCWnodnreaau'sst: More tba i of the Americas t Wifcffl*. L B.. * a: ilepon f fvt m. A.Ml UM -t(i) Hirei. L: , Arek. PetEca. 44 , .iSrtei!" 'inti Two the Efebtr-Foarti Hihrmdme, Jam IS, ISM. ` " - || m. Maniac M. sad Matsmmot* of SafastUe Ls2 An. tfe* DiSS1'* Di&, Child* 44t5^ are commonly. - observed,' associated witfcu a'."'ale degree of anemia. More serious symptom**---'' are. those referable, to the .central nervous - system, Peripheral neuritis, the- usual accompaniment of IcadA intoxication in adults,' is observed.-: infrequently, children, particularly. in- 'the younger-age groups. whensHHthe development of encephalitis is-' more - common.*-' W. H.: KaiAM, H. B.s Brora, A. P, _ __ Lea'l Poenmemamioi* i.-cBs ite Barms el Bmurg * *sa*Yfei. |. A. M. A. 10TT.S......(.M...ar U) 193S. . B.: Kecnrreot Memoaiti' Da* D. Child. St 177 (Ifor.) 1914. _ __________ _ Children, ibid. S8;3M (Sept.) - - Spedal Reference Pka, J. A. M. A, S^s 6. bira; E, A.: Sisw, GnfaBt- l&stest Tha Esemie F Lad br Uera Pcreone. J. A. M. A.- ITi 1 2031 (Dec, IS) 192S. Ste&es, M, A., -. aut, awl CUk, $.! On (be Mores'. Abaoiwwa sad Esetceun td Lad: L Lend Atejjtoa . . rad SxcretioB in Primitive Life; If. Lead Abaorptw* and tenliw sia T-.. Modem American Life; IV. Lead Abanrptiea and Eaeretfes im-CbiMm, }. Indiut. Hyg., to be published. . 7. MeJttasa, C. F.; Lead Mmiag in CiiMrec: Tte Cerebral Mask - . tajasries, Areb. N>L It Papist, SStSM-(Fab.) 19.12. ' T.V' . ._r- N39086.01 Evidences or die c-er ot encephalitis are a change ui die mental state or' the child and more persistent vomit ing, frequently of projectile character. Visual distur bances. alteration in rates of pulse and respiration, delirium, stupor, coma or convulsions may ensue. These manifestations often are accompanied by an elevation of the blood pressure, choking of the optic disks and. in extreme cases, separation of the cranial sutures. When death occurs it follows a period of Ta b l e 2.- \ldditwi:,i! D t.i nn l.ead Poisoning from the Infants' and Children's Hospitals. 1924-10.13 Number o? pajt tents teal !ntn\tentlrm ................................................. Number of pdttenra e'nrrphaiitic symptoms ........................ . 4.* Ttesthg fromlfead ratttflhftlltis................................................................. 11 Number at patients with neuritis without eneofttiulstfs...................... 4 rnmanrac Jte|im*!ae in li patterns, as follow*: Coimiksioos persisted in......................................................... 4 Cerehrkl a trophy .............................................................. 4 MentaJ retardation ................................................................. 6 Musctrijirr utmkmm ................. '2 spw* defers .................................................................... t Number of pa ^feists with roentgen ef!ine-3 of tend. but with rmuimsl *ytnptonisD| "latent lead poisoning"........................................................ l~ Total aurnbee lot eoaea of pttimhtem........................................................ coma or convulsions and appears to be due to central respiratory! failure, as the heart continues to beat for some time after respirations cease. Although localized lesions such as minute hemor rhages and cellular infiltrations have been found in the brains of patients who have succumbed to lead encepha litis,8 it is possible to attribute the train of symptoms observed ip the disease to the rapid development of generalized. n,crtsed intracranial tension due m hitense cerebral edqma. Cerebral in a child with lead poisoning present- trig cereb symptoms was observed by Chvostek in 1897. A girl with lead poisoning developed headache, ng, a slow pulse rate, coma, choked disks and disturbances. At necropsy the meninges were The whole b*ain appeared swollen, the convolution: were flattened, the medulla was pressed into the fi eii niagnuni. and the ventricles were very small. Th description of die gross appearance of the brain in elms succumbing to lead encephalitis has been confi repeatedly. Weller9 ed the pathology of lead encephalitis in expermv ijttal animals and observed a similar intense cerebral We also have produced lead encepha- litis in and in the course of our experiments have confi Weller's observations, If a chifc survives severe lead encephalitis there frequently in sequelae indicating cerebral injury of a penaa: t nature. Cerebral atrophy or degenera- tion may ite manifest in cerebral palsy, epilepti- form seizin o? mental deficiency. By encephalography the extendi" nature of die injury may be demonstrated, Although 1 is known to be deposited in the brain and may destruction y injure or kill the nerve cells, the brain tissue' which is observed need not be explained by a specific action of the metal but may lie attributed to degenerative processes resulting from 8. Ofcuba. A.. and' Tanaka. :H.: Hfett-Pathulofical Ctou in Lead Poiaooin#. J.: Pellat, (Tekjtot. no. 304. b. U2S, 1933. 9. Welter, C Vi, *nd:-Christensen* jA. D.: The Cerebrospinal Fluid in Lead PoisSonir Th* Ceteimsapm* [ Areh. Neurol. Fluid in Lead & Pcjrehiai. 14s 327 (Sept.J 1925; Poisoning, chap. 29 in The Human CerWTp*ali fhi d The Association for Keaieards is Nervous sad Mesial Disease. New Vo |k,, Paul 3. Hother, Ific., 1924. impaired circulation to the brain during the prolon state of intense cerebral edema. ^ While an encephalopathy is the usual form of | poisoning seen in infants and children, milder tvix-s?- intoxication are encountered which, although not a/'1 gerous to life, are of great importance in that th,"* recognition may result in the prevention of the mJr serious and frequently fatal encephalitis. X'euriti, h'J been mentioned. present in almost allCcaassetrso. -inItnesatidndailtiondisttourbthaonsceessynaip3re.' toms and rictrts which have been mentioned, the mgf,. tion suddenly of large amounts of lead may, by Uj q s irritation, induce bleeding into the lower intestinal tract with the passage of fresh or changed blood in tllc stock. Occasionally also the kidneys are irritated M, that a transient albuminuria or hematuria is observed. Glycosuria was seen frequently in our more severe cases, especially those with encephalitis. There was considerable doubt as to whether the elevated blond sugar level and glycosuria were due to injury to ^ pancreas, or whether they were of She type designated as cerebral and observed in other forms of encephalitis. The incidence of lead encephalitis in the series of cases of lead poisoning observed since 1924 in this clinic is shown in table 2. The relatively high fatality rate and the frequency of permanent sequelae are ii> be noted. DIAGNOSIS Lead encephalitis must be distinguished from other types of disease with cerebral involvement, notably various forms of encephalitis and meningitis. The his tory of ingestion of lead and the presence of symptoms of gastro-intestinai disturbance preceding the develop ment of cerebral manifestations suggest lead poisoning. In our opinion the cerebral manifestations are evi dences only of the cerebral edema and are not pathog nomonic of lead intoxication. Xor are the changes in the cerebrospinal fluid of diagnostic importance in dis tinguishing lead intoxication front other fonts of Tabl e 3.---Determinations of Lead and Calcium in the Cortex of the Shaft of the Femur and in the Lead Line at the Growing End of the Femur * Conn ot shaft.. Lead line............. Calcium. Me. {XT Gut. el Bone 509.0 315 Me.Lpeearda, m. ot Bose o.m S.MS CakMatGa. sj sks Mi# * By vhmlral examination the lead Use ms found In tMs earn ta contain over Ore times as much lead per cram ot bone as did the cortex of the shaft, while the Irad/eaIrfan ratio (column 3) wes thirteen timet aa errat In the lead line as In the shaft. Chemical examination! not matte through the courtesy of Sr. L. T. FairfaaiL encephalitis. In cases of lead encephalitis the fluid escapes under increased pressure, oftentimes as high as from 600 to 700 mm. of water pressure. The fluid is clear and colorless, contains usually a trace of globulin and shows an elevation of the total protein. Occasionally a slight pleocytosis is observed. Examination of the. blood for baSophHic stippling of the red cells is of diagnostic aid. Stippling of the red blood cells is not, however, peculiar to lead poisoning, nor is it found even with constancy in cases of the disease. Particularly it is likely to be absent in cases of -so-called latent lead poisoning,, and it may be absent even in children showing definite symptoms of intoxi cation. In patients and experimental animals the num bers of stippled cells in the circulating blood vary from .laylo ,.t tra m <l>e av.d V l lit i;-' >! ( :uiy v!tl> xalthT -inula -ilvcr An jriinsl dam. Tilts* t'aiTc awl 1 xit in bones ( pint the i the ?. dctiti the 1 ot tl with -how inert mute exan the bone loge- T ihe chiU case titan beer, nosi diet nosi imp % ptc fiht. line fus lorn vitr gro at t on!- not ing LEAD POIEOXIXG--McKHAXX AXD VOGT 1133 and retlect perhaps more accurately the level irt of lead in the blood than the total amount ]v 0r the amount deposited in certain organs icing symptoms referable to these organs, ul iiiie'ob.-erml in the gums of adults sutier- lea- d' in--t-o--x-iiscaftoiounnd rarely in children. ;\V of our patients had a lead line in tlie mar:he gums. When present the lead line is a sigrC although it nust be distinguished from ncs produced hy Jther heavy metals, notably the most iiset'u aids in the diagnosis of i in children ar|e the recently recognized in the bones demonstrable by roentgenogram, hanges, recognized independently by Park,10 and one of us (E. C. \".)!- in this country arious foreign investigators,13 consist of zones ised density at the growing ends of the long d at the margins of the fiat bones. The devel- of these changes, appears to be dependent on iased deposition of lead in place of calcium in ving ends of the long bdnes, as well as on a abnormality in the microscopic structure of e formation. The results of chemical analysis tone substance of the dense band as compared it of similar material taken from the shaft are in table 3 and indicate that, there is a.definite : in lead in the dense bands observed at the yseal margins of .the long bones. Microscopic atioa shows further that in cases of plumbism beoslae in' these rapidly .growing parts of the ire more numerous, and are more closely picked* r than in normal tone, change in the bones has proved to be one of jst constant observations in fad poisoning in n, and has led to the discovery of numerous vith minima]! sympbixn* or with unusual clinical stations. Rarely 'has the lead: line in the bones bsenfc la-one p&t&ht, 20 months' of age, a diag- sf fad $n*tephali!ti& was nf&de and confirmed by al aaaJysis-iof the excreta for fad, but the.'diag- lead line I`n the Mnes was absent The child fved gradualllyy and jmjithin a few weeks had devel- finite denstp found in lead poisoning. lines: in the esclrof the long bones are not ar to lead poisoning, as the ingestion of phos- .s a..n...d.....o. the. r s..u..b..s. tances may produce similar 5 Narrow.: lines;.d sufficient density to be con- with a lead line ma; 'be found at the ends bl die bones id healing arid in infants: with lin A defidleocy. f in the , normally ing child thifre may & softe ;of Ineiteasefl density e metaphyseal iof. .the legg; ibotfa, owing to a heavy deposit # tageasa, lilies should ie confused with faf siss^rifa i#; fa#' pofan- which are of idfasi^y ;aa<i' 'width' (0, 1). trthar confirms#; tie: fresence oil lead in the irospinal fit## or ;rtifey be. ^btafned iby spec i X-Rajr Pfctur# df ti* s a*S> (aSd ^MO. Part g..u!i SfaaOnro Jfrodqncl by Lead teSSfawo, ibid. 41! 485 (March) Caffejr, J. P.S CStiifcal i :EsrtSPWWt' leads Poisoning: Sam igcaolafeie and Aftatoaie ips id OrMrifij: Bones, Radtolfa IV j 1931. Vogt, C.: A Sinn; of ifamKsiji, A;a. |. Roentgenol. 310, 1930;. Rosat',,----- Childres. J. A. 41, A. .STij'S"' l ijS):lIfu3T2. Polaonis* in; Iolanta . Koga* Satfo z cited joy Ksw. K,, and Kraft. E.s geabefundo ha Hr.vcr... i im Siadesalter, FortsdJt. a. d Geb. ofttgenaurafalea 4#s;249V',l . PhesBtsihBF, D.. .SLi Ther ... jPfgSflwTM on, Growing, Normal Diseased Bosaees J. A. yt* A 195, (Jiit o g s 8) 1918. troscopic examination.This determination is said to permit an exact diagnosis of the presence of lead within twenty-four hours after blood is withdrawn from the vein of the patient. The demonstration of lead in the excreta of children by chemical examination is not adequate evidence nt intoxication, as it has been shown by Kehoe" and con firmed in this clinic that normal children excrete small amounts of lead in the urine anti stools. However, patients with lead poisoning excrete much larger amounts of the metal than do normal children, so that quantitative determinations of lead in the excreta, prop erly appraised, may be accepted as satisfactory evidence of plumbism. TREATMENT Although it is impossible within the scope of this to discuss the chemistry of lead in the body, a E;bnet statement may aid in the understanding of the suggested methods of treatment. Aub and his co-workers 10 have pointed out that lead in the body is absorbed, .transported, deposited and excreted much as is calcium, so that, in general, factors Fi. J.--A, dense rsaswr#s. hands at the srerenns end* of the Seng boost observed in a child with lead pesiimaos. B, poentseaogram of to bos.: boM of the sun* patient (Bur mostfis later. Hate the greater braKiefc si the tends. which influence calcium metabolism might be expected to have an influence on lead. Lead is absorbed through the lungs or intestinal tract and, in rare instances, through the skin. It is carried in the blood stream presumably as the phosphate and is deposited in various organs, especially the brain, liver, pancreas and bones. Lead deposited in the organs of the body nay induce the symptoms referable to the various systems, but lead deposited in the bones is in an inert form. Thus in relieving lead poisoning measures are usually recom mended which tend to;hasten the removal of lead from the circulation and the deposition of the metal in the bones. To this end calcium salts ** or phosphates1* are administered to diminish the solubility of lead in the blood, and viosteroi is given to hasten the growth 13. Kiowa afcd Uehida, by Kato.5* Shipley. P. G.: Scott, T. f. M., and Blunter, H.: 1 Speetroyrapbie Detection of BloW m Bn Aid to the Qt loBkios Hosp-M! 327. 193; ~........ .... SHeil,^ Josajpisefi.ty of LSeia' dMiiJfifilLi nf I Kmc. The efriaKy nt thou therapeutic mea>ures isj (liflicult to evaluate, as the uiilcler cases ot intoxica tion slt>nv prompt improvement if the iiurestion of lead' is prohibited and if the child remains free from infec tion and in a good state of nutrition. Removal of lead from the body, or cleleading. may he accomplished by inducing an acidosis or an alka losis. by deprivation of calcium or by the administra tion of parathyroid extract-Collip.'' In view of the fa;t that acute infection or the development of acidosis may induce symptoms in a child who harbors lead in the bones but who has been symptom-tree for a period of time, and furthermore because efforts at deleading haw resulted in the recurrence of cerebral symptoms, we have given ap the attempt to delead our patients. vlTcct-. It would appear tiiat life can he prolonged or maintained by the use of drugs winch control the con. vulsive seizures, Imt the unfortunate sequelae cannot be prevented by these substances. In the more severe cases separation ot the sutures of the skull has occurred, resulting in relief to the patient through spontaneous cerebral decompression. The pressure required to accomplish this decompression t$ great and may account for the permanent cerebral injury that is so common among the children who survive the acute encephalitic stage. The following case illustrates the course of severe hut non fatal lead encephalitis: REPORT OF A CASE R. M,, a girl, aged 2XA Fears, was admitted to the hospital because of anorexia, drowsiness and tremors of three days' duration. For three months she had vomited, suffered fro^ abdominal cramps and been constipated. The history revealed that for four and a half months she had been chewing pgjng from the woodwork and furniture. of the house. After admission to the hospital she remained in a stuporous state, refused food, continued to vomit almost everything taken, lad constant tremors of the extremities and periodically suffered from generalized convulsions. Examination of the Wood showed a moderately severe anemia, with numerous stippled cells present in the smears. Roeutgenograms of the long bones showed definite lead lines. The blood pressure was elevated. Severe papilledema developed rapidly, and over a period of three weeks the sutures of the skull gradually separated (fig. 2 A and B). The spinal fluid was found to be under greatly increased pressure; globulin was present, the sugar content was normal and the cell count was elevated, ranging in various examinations from 19 to 31 mononuclear cells. Therapy directed toward hastening the deposition of lead in the bones as well as measures designed to relieve increased intracranial tension were apparently with. out effect on the course of the disease. An operative procedure, in the nature of a widespread flap decompression, was contemplated but was not performed Following the spontaneous* decompression, whether or not because of it we cannot say, she begin gradually to improve. The tremors subsided s}nd the vomiting ceased. As she, teams less stuporous it was apparent that she had become mentally deleslive and that she was almost totally blind. With the dis. appearance of papilledema the optic disk became very pafe Encephalograms made seven .weeks after admission asi three week alter the subsidence of symptoms e mewssl intra cranial pressure showed considerable cerebral atrophy as evidenced fay markedly enlarged lateral ventricles and m of air over the cortex (fig. 2 C>. Further observation of the child over a period #f several months indicated that her mental condition gradually improved and fortunately heir visit returned at least sit part, but she remained obviously and probably pennaneatty retarded mortally. * j I ! 1 j i { ! < I , j j i 1 t V f | I j f i. ' of return of the symptoms of lead for some time, it gradually subsides spontaneous elimination of the metal. neat of children who have already devellead' encephalitis is not satisfactory. Lead ted it), the brain appears to induce intense ceredemai which is highly resistant to the ordinary bC combating cerebral edema. Intravenous ions p magnesium sulphate or of hypertonic solutions of salt or dextrose liave had only temporary .. .. CL a_m__d _H_u__q_w__ , D.: Lead Studies; XV. T&e Effect of achytroid'1 Ho[osrmeae' on th' e "E" xcretion of Lead and of Calcium in .Patients f: Lead Poisoamg, Quart. J. Med, JSs 123, 1927 In view of the failure of therapy in children with cerebral manifestations of lead poisoning, we have last prompted to undertake the experimental investigation of lead encephalitis. By means of organic ted salts given by mouth it was found to be possible to induce with great regularity a fatal type of lead encephalitis in rats, guinea-pigs and rabbits. After a few days die animals developed tremors which were followed bf ; generalized clonic convulsions. After a variable period : of convulsions death ensued from respiratory failure, . Measurements of the blood pressure of guinea-pigs a ; the stage of tremors or convulsions of lead encephalitis . showed at} elevation almost*SO per cent above the normal lew! established. by similar determinations is j control animals of the same age and weights. The brains of animals succumbing to lead encephalitis showed the intense edema described by Weller. Thus lead encephalitis Induced experimentally is. guinea-pigs resembled in many aspects the disease a . >erv?ii h i ini;mt> iunl children. Alter promiciiH: amt il nas oevti ,mmii uvwma ain rcaj,-ua:,:c a.ioi.i '..'..it mtlyimr the of lead eiiccplialitis in normally in the excreta nt children, as ,,/ adults. The quantity pviard ot t unity piiuea-|nArs. ire undertmik to tot lie efficacy <>f varujiur ilicramitic ayeuts. Thus far n a series oi over nitty animals we have been unable to nfiuence the cotirstf of die disease if treatment has eii delayed mud the annual is in a state of convul iuiis. Control of the convulsive seizures has been ot lead that may .lie found under normal conditions is small. The levels oi lead in the excreta that can he demonstrated to have clinical significance are comparatively well defined. It is thus possible, with accurate analytic methods, to recognise the probable existence not only oi lead poisoning but also of lead exposure in unusual amounts, both in children and in adults. This method, as an adjunct to the much quicker and much ,ccomp!ished by the use of magnesium sulphate, pheisu- more convenient x-ray method, will aid materially the correct arbital. pentoharhital-sodium. amytal or paraldehyde, diagnosis of lead poisoning in children. .vitli considerable prolonsration of life but without effect Da. Ro b e r t A. >t k o .v o . .Yew Orleans: In 1914 I reported in the final outcome. The parenteral administration of a case ot lead encephalitis in a child IS months old and at the akium salts, sodium salts, including phosphates, iodide, time I could find only six other reports in young children, thiosulphate, ferricy article and thiocyanate, and other jnigs which theoretically .might have .some effect on the wlability of lead in the blood or the deposition of the metal in the body, lias been tried without influence on the course of the disease. Other.means of combating lead encephalitis in experimental animals are now- under investigation. ' SUMMABY although the literature at the time seemed to indicate that it prevailed extensively among adult workers in the lead industry in France. As the authors have stated, physicians must be lead conscious in order to be able to elicit lead poisoning. A considerable amount of lead poisoning fas been overlooked in these little patients. Since hearing papers such as Drs. McKhann and Vogt have presented, I have been more alert I have seen three cases in Xew Orleans during th* past winter in which the lead line was demonstrable. Unfortunately, the A diagnosis of plumbism can be made in children in cases had advanced until the central nervous system was the early stages of intoxication by the correlation of involved and consequently the case were not amenable to treat the history, physical signs and laboratory data in con junction with the roentgenologic findings. Cerebral manifestations seldom occur in patients who receive, at this stage of the disease, treatment directed toward hastening the deposition of lead in the bones. Although progress has been made and is being made in the under ment The authors have called attention to the fact that stip pling of she cells is by no means common to lead. Dr. Foster Johns, of the department of clinical medicine at Tulane, had his attention called to a widespread mortality among wild ducks around the husitijig grounds on the Gulf Coast of Louisiana. An ejtamirtjatton df the blood of these ducks revealed-the cause of the mortality. His observations were similar to those made standing of lead encephalitis, the treatment of patients by Dr. MeiGjrath :f; the Mayo Clinic a few years ago. Whin with lead encephalitis remains in an unsatisfactory the gizzards of the ducks were opened, it was found that they jtate. > The attack on lejad poisoning in childre^ must be made largely through prophylactic measures. Realiza tion by physicians of the dangers to cn.ldren of the continued ingestion of lead and the dissemination to mothers of information on the subject should result . in prevention of th| disease. were filled! with lead shots such as aw used in hunting dodo. The shot remove^ from the smarts were about one-third tie size of shot that have never been used. These ducks died from lead poisoning as; a result of mistaking the shot in the bottom of the lagoons for the shall stones they usually ingest The authors have infobsed the that thfey few received the eoopea- tion of some of the manufacturer* ef toys and other articles which find their wpy. into the hande of;children and fay* received reasonable assurance that they (till fae something otter than lead fa the paint* used in coloring these articles. ABSTRACT OF DISCUSSION Da. KAtscj! Kat o , Chicago: Hits presentation on lead Da. R. A. Keh o b, Cincinnati: I shall emphasize a few poisoning remfedb tne of conditions in Japan, It is ratter by the authors and speak briefly on lead excretion. unusual in this country to see so many eases a* Drs, McKhaan Although lead enc< tenuring only when occurs in adults, it is relatively rare! and Vogt haw experienced in Boston in a period of nine or sive doses of lead have been absorbed. ten yearn, for even in Jaipaa then! is an awrage annual figure la children, on the otj hand, it is not infrequent. It is of of about ten cases of lead poisnniitf in the larger pediatric articular interest importance that in children with lead clinics. I am amcipts to point t shat mmg various forms poisoning there is a linking tendency tor symptoms of the of lead poisoning-,fthbra fa one particiitkr'type to which but tittle .eatral nervous systi to develop, indicating the fundamental attention;fas ;bnl paid fa the past? nataly, congenital saturnism, difference in the in children and adults. Encephalitis in or ted pofeamrtg, In Japan the source of lead has been chiefly children, as in adult has a had prognosis. From available in the hem of face powders. As present (he government figures- one concludes that the prognosis in children and the requires (hie use of .titanium instead of had in the; manufacture outlock for complete are even somewhat worse than of cosmetics. In spite of ithis. lead; fa jitill feeing used in a certain m adults. The ive aspect of this problem should there- percentage of face, powder. because lead seeen to git* a. better T fate be greatly Since the authors' figures have shown ' spreading; effect m the skin. The teniiws informed me that that (his condition at the period when children are most the pregnant mattes tots** greater tojew* fee ted. owing to "Jikehfcto eat abnc things and to chew various objects in the fact that the metal;. fa take# ttfl fa the rapidly growing theumvirotmient should be alert to note abnormal bones oi- (he fetus*. The Japanese ; waters contintemsly use and behavior, Pica being the most frequent cause of kad-sioatBfafag cosmetics on theilr ntelts, face*, shoulder* and lead .poisoning in chi! strenuous efforts must be devoted breasts during pfagsasKyi often ; thtoeattnt of -veritably whitt- rvery iviromneat. This situation is wasbtog (ft esptaw# -itatSts of ah* btete- Tfai* would #iwng|y. targe number of cases have suggest the 'possibility of congestitaforigin of. ted; pshsoaint e children play on weathered, in afa-v-totw inSsjunto. li* certain" etees bf emgenitol hy4- ead pigments have dusted out cephsta,. faw it-not be Seasonable-to! saspeet infera-ujterinettli of the roentgenologist to the mong the most significant in limitation that they are appiicable only to children! This; sign of the line in the bones is extremely important, Recognizing, however, that it may not always be possible to Idifferentiate this line from certain other densities that occur oh the epiphyseal end. it is of some consequence to stress the did;.gnostie importance of lead in the excreta. poisoning. as its cause? Again, in seme cases of Spastic paral ysis #i Ait litnliil* with or - wittottHt itemgsW* seissute*. urh&h are teoallf -thmgjht-'to be due ta-;intt(*Bf*iaJ- fcaRqirriaes, eaa- genital leil ipoisqtiiBg may be a mum. This stJgs*s at unite th|tt the sotoalled lead HSet: t* -.tbft OKfaphysiw of kfag bone* in (She nett-born Infant ptismgiiig toggetttwe; symptoms should be looked foe by making rorittgetsogiams. This fa impor tant both in diagnosis "and in trektatoat