Document LJnJvn74QrDVjp1nYb8knJBdg

v, V 7 - ( 0 c .f T I IK .IO P K N A I. OK P K D IA T K It'S W e lle r , T . I I ., u ih I t 'r a i j j , .1. M .: T h e I s n l a l i u ii <il' M i i i i i |m V i r u s ail A u t o p s y , A m . .1. I* ;.ill. 2 5 : I H i:., IlM lt. H u rs t, K. W .: K x p e riin e iilu l D en iy iT m u lin n in Ite h ilio ii to lliiiiiiiu a n d A n im a l D is e a s e . A m . .1. M e d . 1 2 : 7. T u r u lm ll, II. M ., a m i M .-liilu sh , .1 .: E m -e p h a lu m y e lit is F o llo w in y V aieeiniilioii, I < iit. .1. K x | n t . I 'u lla . 7 : IN I , I S e lia I f e r , M . F ., H a k e , (2., a m i llm io s . I I. I,.: Iso la tio n o f V iru s F ro m a P a tie n t. W i ll i F a il ail K m - e p h n li t is < * o n i|)lii* al i n n M e a s le s , A m . .1. H is. f l u i d . 6 4 : H |5 , 11M 2. t'liu , T . I I.. t'lie e \o r , F . F ., t'o o n s , A . II.. a m i D an iels, .lo a n I t.: D is trib u tio n o f M u m p s V iru s in th e F x p e rim e n tn lly I n f e e t m l M o u k e v I 'r o e . S im-. F \ | m i . I t i o l . A M e |. 7 6 : 5 7 1 .' 11151. S w a n , t'., am i M aw so n , .le s s ie u : K x p eri m e n ta l M u m p s; T rn iisiu issio ii o f th e D is ease to M o n k ey s: A tte m p ts to P ro p a g a te th e V ir u s in D e v e lo p in g l i e n s ' F u u * . M . .1 . A u s t r a l i a 1 : I I I . I t H . t . Ile n le , (le rtrm le , a m i M eD o ii^all, I.. M u m p s M eiiin ^ iM -iie ep h a lil is. I s o la tio n in t'h ie k E m b ry o o f V iru s F ro m S p iu ail F l u iil o f a P a t i e n t , P n s - . S is -. K x | n-i . I t i o l . A M e |. 6 6 : i' i i '.i . I *.7. K illu .iii, I .. Isw e i.s, .le n m -lle . a m i K m h is. .1 . F : N o n p a r a I \ l i e P o l i o i i i y . - l i l i - a m t M u m p s M e u iiro M -m e p l u i l i i i : j iilT e o -n t m l D i a u n o s i s . .1 \ M \ . 1 4 0 ' ` t l . l!M ! .21. E u d c r s . J . F .. a m i P e e b le s , T . I'ro p a R a tio n in T issu e f u ll a re s o f f \ In p u t ho jjellie A y e iils F ro m P a tie n ts W ith M e a s le s , P ro .-. Ss-. F \ | h i . I tio l. A M e d . 86: 277, l!5l. \H H K M U M Sitliscijiieiil to I In- siiliiiiissioii of litis |a|u*f lor pnMieat inti, hr. J. Iiialu iii ( Jrcctilicl.l ol l.oiiiluii. K it jr I a n il. lirolloht In tin- it11fill imi ol otic of Its ( \\\ Ii. |). ) I IlC l*C11.11*I IIV Collins itiol A rm o u r* itt l!>l'_\ of ;m mhlilioiuil eiisc of fillill |tost 111111111is encephalitis. T his concerned it hoy I I years of at^c who <h*velo|ieil I lie lirsl siyns of ciiccphalitis seven days .tiler I he onset of tint tit|s. A lte r three iluys f till her minor eomphiinls of ili/./iness. lie rapidly ileterioi-iileil ami <liel twelve days alter the nlisel of lull in ps. Accompanyiny the report are heanti fill photomieriioiiiphs ol |\ pii-.il peri \ iisettlar lesions. ' . i i i o i ' . .1 . . m a \ i n m o i i: <: \< m . ta ii i t . i i r a - \ I-..H..W o n . in o .t w .tk t .a Monies. Ii- \ V.iio.l a |--.l.i.i in l. OH.- 'riiio IjAt k lomorTs o r uoad p o i s o n i n o l > o \ L. T h u r s t o n , M l).. .1. N k.\i , M iii>ki.k a m i *. M l)., and L uzaiiktii Mason, I'm.I) St . L o n s , Mo. T l 110 la ir effects ol` lead poisoning on llir physical and psychological development of children have received lillle allcnlioii. Though thousands of ai l ides have appeared on lead only, live rs a nd L ord.1 10 I o n e u,* and Loci Isch and Mason have reported on the final effects of lead poisoning in patients followed lor a variable period of time. The seiplehle of lead intoxication in children a p p e a r to he niainl.N psychological. Little in le rf er eliee in physical development has lieeli re porte d. However, two of olll* patients showed optic alrophx : one with permanent blindness. I in li ne | | M. teii-xear period. III Id th ro u g h l!M!. Iweiilj six ehildren were treated for lead intoxication. The source of the lead was either from paint, plaster, or lead toys. Seven children rJT per **nl i died, six on initial hospitali/ation and one two \cars later at another hospital with "lead encephalitis." Llcvcli of the remaining nineteen patients have been followed for a to 10 Near period during which repeated physical and psychological evaluations have been carried on I. including rociitgcuologieal and chemical lead determinations. Live of the eleven patients were ding nosed and treated on an outpatient basis and the other six were hos pitalized. Two of the former group l*`e*mii tli<- I >(>;11 tnienl.o of I*-!i ; i Iri->c ;iin| ,\i-m<>|isvi'lii;itiy. W.-isliinuloii I 'ni\crsil.v were siibseipiently hos pita li/(`d with interenrreiit infections which precipi ta te d a re tu rn o f tin* sym pto m s of lead intoxication. To estimate the ultimate effects of lead poisoning oil body and mind, an accurate evaluation of the original degree of lead encephalopathy is d e sirable. IY oiii the d a ta in Ta bl e I. the hospitalized patients were empiri cal ly classified as mild, moderate, modcratclv severe, and severe. There is HO eillle retc basis for such an cvalualion. Illo. >d a nd urine lead ileti rmin.alions v a n with initial th e ra p y i ( 'uses 1 a nd *i. The seve ril y of 1lie cent ral nervous sy stem uiauifeslalioiis ;ippear s to .de pen d on du ra ti o n .ni' iiii.i intoxication, manner of exposure, and p re c ip it a ti n g illness ( t 'use 1' He tails o f such factors a r e often <Ill'll.-III! to elicit aleeiiratelv from the p>arents. The sy m pto ms in the live ollt pa t icllls Wel e vague, iiouspeeifie. mainly gust ro in h -si inal. a nd of variahl e du ra lion. The y are listed in ord e r of Ire ipieUcy as follows: vomiting i four ease s), eons tip at ion (th ree e a s e s ), malaise t three eases), auorexi a (two eases), piill lor (tw o eases), d iarrhea (one ease ). ir r ita bility (one case). Tin* sift ns. sy mp toms , pliysii -al and laborat or;v findings in t lie six c hildreii who w eni* hospitalized for lead en e ep h a lo p a th y a re listed in Ta ble I. Lxcept for the convulsions, all the other symptoms exhibited by the 414 TH E JOURNAL OF PEDIATRICS At.K (VK.) RACK ASK SKX 1 -$w iuNVin. SIONS UKNKKAI. 1 Malaise Anon-sin l-Vver I'liarvii};itis NKl'Kot.iNilCAI. 1.AIKH!ATIit;V 1rrilaliility Normal Moml ami urine XKAY I'ADTIMItl.K WITH MKTAI. IIIISONINU SKVKiem + Mil.I 2 ?w t Vomitiii}; 11riui|mri'sis linsii|iliill.* sii|i|ilinr. l'misti|mtion Pn|iiliri|rma Urine leml O.O.'i 1 in};. L. USI-' |ies suit? elevated. I'm I<-iii 111! mt;., 100 ml. 4W Vomitiuj; WVaknt'ss Li'llmr^y 'Mi'iiinii'ss' I*:iI I L'iii Itnsopliilie atippliii};. KHO imlelfrminute for ai'i*. CSF f7" iiiiii. pressure. I'm loin If.'iI in*;, ion ml NcurnMir|;ieul ileenmpressinu is hours after admission with routunions s|iiual liaina^r for is in 7- linin' to prevent hi'rniation |luoiit;li sul.temponil deenmprrssiuns. J 9 W o Amui'\ia Mark.'.l llasnpliilii- si ippliii};. Pallor irlitaI>iIiIv '.nisii,.aIimi ami weakm- KI Kri(m'nIorta.I<lioM.Li-iJ>Tli'HI`,>,l. I 'J iiij;. I., i 'SK ,.'nn J :i ij S' W \ .mill iii^ MilliiI-.Pallor |:.lia\mi lilli. nil Pa,..II.. uilli l. in P 's in ;;. In n m l. I'.l...I lead 111I in .; I o n m l . 1.1 i . Ii-ioi;:iiii/..| uni. .'si ......aI Ila'ii|illill*' -ll|.|.llll; I II. IIH..I. lal. lx 'low I\-111vIliima Normal values la-low ii.ii.S nm l"" ml tNoriiiul valors hrlou li.n oik. Join- of 1.1.-iitit*iiI tuin>. In .ili liaxioi: I I l*aItrill r. also lia.l li.iv f.'.- ..stloii.i. III. m:: Inn ml lino;. Tmo II S\ Ml-I'll\ls 1rnliilnlitv \ omitiii}; <A'.nnoisrieix|uiail ion MuIniso Pallor AlaJoiiiinal ,iiiiii 1'onviilsions Papilledema 1tiisnpliilie siippliii}; jr.Ti.AT.. )ri s 1 4 A 7a:nJ-l7Jii 1 is Is :i An :t .'ill i lili 1*11.AI'HiN If uk. Ii III.. Ii uk. ii mo. 1 mo. 1'J mo. 11*.. VI. 1Iil.-Ilulllent I1tiiispiii.|.l|Md-raerr.-i.-lasiesIf71If|ISn.hr. \vi i; M. 111'.J.m. oaI.mII. 1 mu. _' uk. uk. THURSTON KT AL. : HATH KKKKCTS OK I,KAO I'OISONINO 415 eleven patients persisted for variable periods of time alter therapy as noted in Table II. On re cent physical exam in ati on all of the children were of normal height and weight for age except one with exogenous obesity. Two of the chil dren (18 per cent) had hilalcral optic atrophy and a third had a high de gree of myopia. The x-ray findings of the long bones of the eleven patients are pre sented in 'fable III. Like the s y m p toms in lead poisoning, the roentgeiiographie changes showed a variable degree of persistence. In the entire There was no consistency in regard to the tilin' of the initial or follow-up electroencephalogram as related to the time of initial lead intoxication. Cases 1, 2. !), JO, a n d 11 h a d none done. Case in itia lly w as in d e te rm i nate for age, but two years later the record was consistent with organic brain dis tu rb a nc e. Case 4. in 1048. showed a record consistent with the age of the child. In 1954, the child had several grand mal seizures, but then became well controlled on small doses of phciioharbital. In Case 5, r e peat records showed paroxysmal slow dysrhythmia for two to three years. T a h i .k III . ltAiiioa;.\riiie 'l Xlil Nils i.x l , o \ i . Monks | ASK i j I li 7 s o in 11 oNSKT oh' II I.NKSS | 1! 1 1 IRIS IRIS MUR IR IR IR IR 1R IR IR IR 1R Ui IR.'ill IR IR IR.'ill II II II * II (i KOI. .IIVV r 1 1954 a a ii n ii n ii n ii ii " series o f |\\ ell lx -six p atien ts, comp l e l c li sa p p c n a n c e o f In '' l e a d l i n e at th - d istal ell.l o f 1b s h a ft w a s e v e n t u a l l y in te d w ith re u rrc iie c six t o s c \ c n m o l 11 Its l a t e r in 1w o p a t i e n t s . T h e s e t w o | at ie lits \\ eri p r o v e d to h a \ e r c i u s l il u t e d t h e lJ i 111- c h e w i n g h a b i t . T h r e e p a t i e n l s In d x - r a y tiescript ions of rausversi linear distal dciisil ie s " 2 or cm. In mi the ends o f tin s h a ll i n l e r p l e l e 1 is '' m in im a l c\ idclloe o f b me grow tb r lardal ion. l <r i 11<* a n d III).nil 1. m l d e l e r n i i n n 1i o n s c o n t r i b u t e d n o t h i n g t o t h e f o b low-lip study L i e t r o e n e p l i a l o g r a i n s w c i v o b tainci in six o f th e ( lev eli p atien ts. a post erior trian gle loe is also being not ed on the latest xam inatioii. 'flic l e e o n s o f th is pal ellt h a v e s h o w n th e g c a t e s l d is o r g ini; at imi o f tinentire series and the child needs p s v e h i a t l ie g u i d a u e a t h e p r e s lit t inn*. I'li e r e m a i n i n g ( u s e s (i. 7. a n d 8 w e re alm ost ident eal in s h o w in g delinil e slow dysrhv tlimia o f a vari able i egree. T h e tr ea tm en t o f all p a tien ts w a s i<l e d 1 i al. S o d i u m oi l r i t e a l o n e o r w i t li i it l ie a c i d w a s g i v i ii t o m a i n t a i n a s l ig i l l y e l e v a t e d t ( c o n t e n t ( 2 8 h t :M) i m*i |. p e r lit r ) . ' f l i c d o s a g e v a r i e i f r o m ! to <i ( m . d a i l y in divide d doses, for P< r i o d o f f r o m T I I K .M H 'K N A I. O K I'K O I AT H U S tw o weeks 1o two ami one-half y e a r s . 1, " A sum m a ti on o f the fol low-up is pre sen te d in Table IV. l* S Y t'l lO L lM ilC A Ii KY A U ' A T IO N livers and Lord mde in their study of twenty ehildren who had lead poisoning in early infaney that despite normal motor development during in faney only one child lived up to the promise of his early development. In a few ehildren successive psychological examinations showed significant, drops incut in the sensorimotor sphere was the outstanding finding. Myers and Lord felt that the lead in the circula tion of an infant interferes with the changes normally occurring in the corte x and. in a high p e rc entage o| cases, prevents the normal growth and development of the cortex. Along with the dilatory effects of mental growth, a high percentage of behavior difliciillies were recorded by Myers and laud. Such difliciill ies arose from an inward drivciicss which ASK 1 2 3 4 5 0 7 8 1) 10 11 T ahi.k I V. S umma ti on ok t-'oi .i .ow i I.KM.TII OK TIMK S IN OK KXIUKCKK (VIS. > INITIAI. KYMI- .11MS III Kueeplialupatliy, ennvulsions. I *iu i \ ulsimis. diousiness. .i eeplialopalliy. right hemipuresis 0 1.(Iiargv, \oiniling lu iliil.ilil v - I'li|>li:il<| 111\ , eoii\ ulsim i-iasiiwi. sup i i \ 1lliesil V. i*liill esis 1lilaIma 1op1ie a11pii <'o\ ul'ioi,' ..........i.al I I *:. I.elia p,ol.|en, M iId g:i-li.inle>l mnl -mu ....... Tr.-s.led :is mil pa! ieul 10. Il< ilali/eU II III \\ till gstsl loiulest i(ill1sVli plums Kneeplialn|>ii 1liy, \\eakness 1Ii la1era1 opl ie almpl r, I Iasi roinlesl inn1symptoms. Tresiled sis |leel easei| ........ mil pal ieal rt (last roinlesl ina1symptoms Tlealeil as r out palieul (iaslroinleslinal symptoms Trealeil as mil patient. llospilali/.<`i| 0 mo. later uilli pneumonia 7 10 (last roinlesl inal symptoms Trealeil as out pat ieul High ..............' myopi in intelligence ipiotients. These drops were thought to be the result of failure of mental development rather Ihan actu al mental dete rio ratio n. As the chronological age advanced, men tal g ro w th did not keep pace with it. In others, however, the intelligence quotient, remained well within normal limits. A specific failure id' develop they classified as " forced reaction to stimuli in ihc environment." Straus and Lchtincii. Mender.s Makwin,0 and S t r y k e r 1" consider this as evidence of cortical damage independent of etiology. KlcbaiiolV and associates" describe Ilie hrain injur ed child as hyperkinetic, overactive, restless, im pulsive. and uncoordina ted, hut liy- T ill HUSTON KT A h .: I.ATK KFFKCTS OF I.KAI) POISONIN'! 417 pothcsi/.c that cortical maturation with compensatory development of function can occur since a less dif fere ntiate d infantile co rtex is in volved, negating the influence of an inju ry which in an adult would have serious long-term sequelae. The psychological aspect of tin* present study was undertaken to evaluate systematically the residual psychological effects in a group of children who had had proved lead covered from the lead intoxication to live years a fte r the toxic state, liecause of the immaturity of the group at th e first te stin g it was possible only to obtain measures of intellectual and social development (StanfordItinct intelligence scale" and the Vineland social maturity scale"). p s Y m o u x n c \ i, KKsiu/rx bVfermcr to Table V shows that at the time of the initial testing only \IU.K V. I'iiMI'AKISoK OK 1,'KSII.TS OK I NTKI.I.IUKNrK TKKTIKU IN H.r0 ANI ll)fl, OK Xot'IAI. M aTUKITY 1!).)(! a m i 1!).'>!, ANl (IMIIIKNOI'IUI l.lj. IN lOnl Mill Ki.KVKN ('IIII.IiKKN Wilt) 11Alt I.KAIi Poison ini. 1 \SK. 1 1 li 7 s i In 11 1 IHnO C ltliO N O AUK AT 1 i.HaeAi. i\ SIT a.a: . m : . 1 (U.\ , J 7.1 - 1j - 1`J 1.1 i.:t J :t 1* - 11 j j I :t.i j .i a. i :u a. I -M I ::.l | J INTKI; III \ KT ! \l KIMATK l . t j . I tkstini; inti Sli A,.,Ml,10,1 linllillli ."! 7 1 I-J7 I::7 Inn SJ 7s 7 1Hi *: 77 1!).' <lll.'ON'o MMill'AI. AUK ( Mi. ) 11 s.l s.:t 7.1 7.li li.lt 7.:t 7.1 7.A it.7 7.it HI NKT !# III!) SS aa ss 1in 122 s7 S| an 111 ij : inj.nn ciMin KMimii 'a tin Sli llliml iaro VINKI.ANIi !</ 1In 1Ili S7 Hint VINKI.ANIi iq. 1N 102 sa 71 7.A 112 s.A as aa ai an s.y i 7li 7a ar sa 11In 1Ili aa. 11 inn IOn 127 in.-, as in:, 111 in.', Itin.no i:i 1mmi ink inter hi Ih-Iwooi ri 1 P.ln \ . < y s Text hot\ .on in.'n anil IH.'.I i nilT o o l. 1 fill on rein1inns I IS..17 I'l.'iU .ns *SiKnill'.-int ;it level *f ennlMoncc. SiuMille.i|i| :11 .III level f eii||||i|el|e>-. l.;.7ii l.ns 1X7 1 Uniik n lor onrroln inn for l> not sin>1 ( SlMn1`llUllgll l.l^ ' iari T Test for Minot n 1(innilon i.tj.- Mini 1onrrooloil I'm- onrrolsilions) in :ti .tin a .i'.si intoxication in late infancy. No records of original intellectual tune tioning were available prior to the poisoning. Normal mental and motor developmental progress previous to the lead intoxication was assumed in each case because of the past histories given by the parents. Psychological te stin g was done in I!*-"<) with re ev al ua tio n in Ib.VI. The time of the initial testing ranged from imm ediately a f t e r the child re- two children had over all intelligence quotients below the dull normal level, and two were in the bright average to superior categories. One of (In patients below the dull normal level. Case 4. was a hyperactive, irritable child who was extremely diflicult to test, and the exam iner felt that I lie I.Q. measure of f>!) was minimal. At the lime of the second testing none of the children wore below the dull nor mal level of intelligence and four were 418 T IIK .HM'KN'AI, OK I'KDIATHICS in the lui^lit average to superior categories. The bright average to sii|Mrior eliihlreu showed little une ven ness in their functioning. The type of items most frequently failed by the eliihlreu in the dull normal category were items involving a list met t h in k ing. Although this is a characteristic failing id' eliihlreu with brain damage, it is also the type of th in kin g which would lie ex peeled of eliihlreu with dull normal intelligence natively. Three of the eleven children shown! some difficulty copying a diamond at tin; seven-year level, but there was no conclusive evidence in the over-all in tellectual functioning eharaelerislie of children with brain damage. It is recognized that intelligence tests, made at different limes on the same individual, may vary as much as ten points on the basis of chance do lors alone. Ib-ferenco to Table V shows that l.(J. changes in three of the eleven children (Cases 4. hi were significantly gre ate r than would be expected by chance. Two of these showed improvement, while one went down. However, with IIn* exception ol ('as** h who decreased, all of the other children showed tin increase of from li to !) I.Q. |M)inls. The difference be tween the averag e l.(J. of !M at the time of initial testing and Id- at tin time of th e last testing shows an im provement in intellect mil level which is significant at the .Oo level of eonli deuce (would Is* expected to occur on the basis of chance only live limes out of 100). A continuing intellectual de d i n e a f te r tin* initial testing, as ex peep'd from tin' results of livers and Lord, was not found in our series. Instead, there was some evidence of an actual increment in intellectual fiiuct ioiiing. Kveil g re a te r significance is added to this finding when it was realized that tin* one child who showed a decrease in intellectual functioning was under psychiatric care. A complete psycho logical study on this boy three months previously was summarized as show ing: "Severely neurotic personality structure characterized by marked anxiety, regressive and repressive trends in a child of superior intelli gence (l.(^. I'-Mi). Kniotiounl pro b lems are affecting functioning and re lationships. Then* are also some o r ganic indications which need further evaluation. Treat mcul assets are: superior intelligence, ability of ego to maintain itself despite stress, eon fortuity and the anxiety itself." It seems possible that the decline in fundio tiiug ability in this one ease was due. at least in part, to a func tional psychological disturbance. On both testings, social develop nieiit. as measured by the Vineland Social Maturity, was somewhat above intellect mil development. Although these differences were not significant, the suggestion is present that these children are somewhat better able to perform in practical everyday siluaI ions. ( In the second testing, however, the intellectual measure obtained from the t ioodcnoiigh draw a man I -11'' was significant ly lower than that ob tained from the S ta n fo r d Lillet ill lelligciicc scale at the same lime. The difference between the average ( ioodelioiigh l<y of S.i and the Lillet l.tj. of 14Ilf was significant at the .01 level of confidence. Though the draw ing lest primarily measures visual motor functioning, while the intelli gence scale is prim arily a verbal test, THURSTON KT AO.: OATK KKKKCTS OK OKAI) 1`OISONING 419 tlie significant positive correlation which has been demonstrated between these two tests indicates that they measure two types of behavior which te nd to develop ;it simila r rates. The c o rre la tio n of .Ob between these two other words, it would seem that while the over-all intelligence of these chil d re n remains intact and is developing norma lly , a definite deficit, is seen in their visual-motor fnnetioniim. f u r thermore, (pialilative analysis of the T ahi.k VI. 19f4 Hijack 1`i.ackmknt, Hciioi.a-stic A n n kvkmknt, a m i Kksiji.ts ok Y isoai.- Motok 'I'ksts ok Oka in Damaukok K i.kvkn Cu ii.iuckn Wiio H aiI.kah I ntoxication in INKANCY ASK 1 :i i l i l J AKI I!>.~> 1 K Hl ' C A T I o N A 1. I.KV K.l. l a i l e . l ............. I Ki-a.le. H.iinjr .......... ... 't ' a t il l i n i r t ir ll.-l.l l.a .k K *'Ji 1 I'.lin .l. in s .-Iimm| I"., r l . l i n . l Srll.M.I p io l.lein S . I ll. nl | 1Iit I.-111 W 1OK KANOK Ae l II KV KM KNT KKAHINiJ | AIJIT IIM KT ie ii.il K 'li.le uia.le I.IJ AII A M lx K \ HA l.l. eATKl.Ol; Y O iir.lerlin e IJKNHKK OK ST AI .T l.olal.'.l .lesions, A ami .1 ; i l i l l i . u l l y w i t h sp a l ial n-lal inns N .in.ia l N orm al I'.lin.l I'.lin.l I '. l i n . l I '. l i n . l l.l l.l O ra in Ix'e x e r s e . l A : m i n i m i S ; .laniaoe.l |>ri ini t ix .- I ,.n|. a m l l i n e s ; . l i l l i . - u l l x ' xx ill i a n ^ iila l inn I'.ia in l.'n l a l e . l . l e s i o n s A , .'I, 1, l a m a ^ ,- ,| ."i, S ; | >r i l i i i l i x e l u n | . s , l i l l i . - u l l x xx il l i a i i H i i l a 1 -II I .J. l.l Om.l.-i line l.nlal.-.l .le sio n s A. :t; |..-i>-x.-ral.-.| n n 1 a m i J ; |>i i m i l ix>- I n n | in. . l i l l i . - u l l x xx ill i a n y n l a II. U l.a .k 1 -I.n l. s 1 11, 1.1 l . a . k - 1 1. .................................... 1 ..: l .a 11, 1.1 l . a . k K'a.I. III 1 1...... - XX. II l . l l I..'. ".! l.l O ta in I n m a t c - I O.i a i n , 1a l i u i n . ' l l I'.ia in lam a^.'.l \ hi ilia 1 1',-1 .-I a 1 i n n ; | ...... I -|.a 1ia 1 re la tio n s . l i l l i . - u l l x' xx i l l i a n ^ u l a linn mi 7 am i S 'i mill ixe lnn|is a m i lin e s ; |>nni s p a l ial re l a l i n n s : <1i ll i .- ul 1\ w i t h a n ^ n l a i inn nn 7 a m i s >1a 1 | . l e s i o n s . 1, 1. ."i, 7 : . l i l l i . - u l l x xx il l i a n ^ u la l i.m mi 7 a m i s 'ei'severnl inn in .|esi.;n J. | i i m i l i x e l i m p s a m i l i t i i e i i l t \- xx il l i a u ^ u l a " XX. It I 'u n i m .Iraxx iit" 0.1 a i n la m a ^ e . l s p a l ial r e la liu n s p n u r nn a 1 ; . l i l l i .- u ll x- xx ill i j o i^ i i Ij iI i o n i measures lor this yroiip would indi cat e that the re is no relationship other than chance between tin; de velopmental rates of these two types of behavior for these children. In drawings revealed the disorganization in body imajre and immature d ra w ings which Silver"1 describes as characteristic of children with brain damage. 420 XIIK .JOl'KNAI. OK I'KDIATKICS I t is of interest, th en, to nolo, that despite intollootiuil functioning with in the normal range, only throe of th e eleven children a re re p o rt e d ly th eir m others to he doing well in school. (See Ta ble VI, Cases f, 10. and II.) Two of these patients `(Cases (i a n d 10) show academic achievement below their grade place ment. which suggests that they are actually having more difficulty in school than has been reported by their parents. Tests of visual-motor functioning which are specifically designed to measure behavior characteristic in the individuals with cortical damage reflected considerable deficit in this area. On the fSraham and K e n d all 1, visual motor test with correction for chronological age. Cases 2 and 10 were within normal category : Cases I and 0 were in the borderline brain da m a ged cat eg ory ; a nd Cases I. . . s. |(), and II sho wed visual nioloi deficit within the braindam aged category. At the e x tr e m e end of the continuum of visual-motor deficit was Case d who is totally blind as a re suit of the lead poisoning. An even more-pronounced deficit was noted in the g ro u p 's performance on the licmlcr <icstalt visual-motor test.'* Case 2 was the only child who was able to copy the designs of this test in a fashion which was normal for he r age level. All of the other children showed the rotation of dc signs, perseverations, difliculty with angulation, and substitution of primilive loops and lilies for dots which Silver"1 describes as characte ristic of children with brain damage. Case 2 is the one child in this group of eleven, then, who does not show a vis ual-motor deficit. This is of p a r tic u la r interest when it is re membered that, her toxic reaction was one of the most severe, and at the time of her hospital admission she suffered a left hemiplegia. This sug gests that there is no direct correla tion between the severity of the toxic reaction and the severity of the resid ual effects reflected in the psycho logical functioning. A closer consideration of the type of e rro r s made by these ch ild ren in their visual-motor functioning shows behavio r which is paralleled in th eir academic achievements. The rota tions of their drawings of designs placed directly in front of them sug gest that these child ren would find it difficult to learn to read in a leaching situation which requires them to recognize the visual picture rather th an paving a 11cut ion the pli* icl< on tils of the Wold This was borne mil in llo lr le ading tests bv a considerable num be r ol reversed letters, dl e v e l s . of wind* Wolds, and of misreeognit ion of words due I attention to the first letters nisei ss11x Thorough physical and lalmralorv examination revealed little that could lie a ttrib u te d to the late clTcd ol lead intoxication in a group of children followed for a live to ten vear period of time. The effect of increased in Ira cranial pressure in I `asc ! res ulted in blindness as the milv physical lesid i i i i i i i in l l i c whole group. However, the organic brain damagt that resulted is only apparent in the specialized psychological tests done repeatedly, and the results arc quite similar h those seen in children with brain damage dm- to birth injuries or. more specifically, cerebral anoxia THURSTON KT At,. : I.A'l'K KFKNOTS OF I,KA1) FOISON'INO 4`J I I'Yoin previous pathological studios of our own and others, serious vascu lar damage, cerebral edema, with re sulting cortical injury, is the u n d e r lying basis for the picture of lead encep halopa thy.1" The intellectual deg radation as reported by livers and Lord is not confirmed a n d Ihc o u t look should be definitely more hope ful. It would seem that, these children with visual-motor deficit are placed in an extremely frustrating position during their primary grades. Though their learning rapacities are within normal range, tin- vis ual-motor deficit presents a serious handicap to the c h i l d ill t h e p r e ; s c u t s e l l . m l s y s l e in. T h e p n i - s c i i l a t i o n 1b y v i s u a l s t i m u l i 1o r l e a r u i n g i s f r i i s l r ; 11 i 11 g . S p e c i a l t u t . u i u g i n 1 b i s n i l . a i e a o i | >1.a c i - i i i e l i t i n a s . h o . 1 s i t u a t i o n w 1i i . ' l i vv . m i d a l l . vv t i l l - IIS. o l o t h e r s e n s e m o d a l i t i e s i n l e a r n i n g , s u c h a s p l i o n c l it o r k i l n c.s1In 1ic a p p r o a c h . s. m i g h t m i n i m i / . e t h i s I'll isl i a t i o n . t 'asc IS p i c s . II l e d i n s u p p o r t o f t h i s ll.V p o t I n - s i s T h o u g h 1H i . p a t h o l og.v in h i s h o m e sil u a l i o n c a n n o t b e d e n i e d . 1 l i e i n 1.-l i n e . 1i a 1 c | c s l i n g p r i i o r t o . n i l ailfi- t o selliool v iel. l e d a n 1 of I IT. I n n i n g I l i n e school years. his teachers complained that lie was " a ncgal ivisl ic. rest less, poorly a tt e nti ve child, who refused 1o le a rn . " I'.c cause of such bcha\ior and because of Ihc general family si Ination, psy chiatric help was advocated. The ex tremely fr u stratin g sit nation pro senled a buy of superior intclli gence who is ha ndic appe d ill learning 11 \ poor visual motor coo rdination cannot In- overlooked. This hand ic ap might be a c o n tr ib u to r y factor in his need for psychiatric help. The pictures presented by Cases I and d arc more hopeful and suggest that, with understanding help, the children may learn to adapt to the deficit. Case I is the oldest child in the series and her lead intoxication occurred ten years prior to the last evaluation. She has attended paro chial school and has received a good deal of individual attention. The prim ary grades presented difficulties characteristic of any brain damaged child and there was failure to pass the second grade. Her mother reports t h a t she is doin g well in school now. but is slow in arithmetic. Her achieve ment. test scores corroborate this, as she is at her g ra d e level in reading but is re ta rd e d in arithmetic . The visual-nmlor deficit is not as pro nounced as in ma ny of tlx- other cases. This suggests that the effects o f cortical in jury may be negated as ihc central nervous system matures. I'alieiit ''<is totally blind and has been receiving train in g at the Missouri Slate School o f the Lliud. Neither difficulties in the prim ary grades imr the behavioral troubles arc as marked as in the o ther children. At Ihc lime of the initial testing live of the children pres ented I lie driven, ncgal iv isl ic. hyperact ive be havior which is c harac te ri s ti c of cliil drcii with brain damage. Nolle of the children displayed this type of be havior at the time of llo- final ex animation. t'.mpei at ion was excel lent. even with tin- boy who is und er psychiatric care. It was only when his mother entered the room that his negativism was evidenced. The one common personality trail exhibited by the group was that of strong nioliva lion to achieve in all tasks, with re pealed voicing of fears that they were 4 2 2 T IIE JOURNAL OF PEDIATRICS not doing well or might fail. Such dissipation of hyperactivity or in ward driveness witli cortical matura tion associated with Home types of brain damage concurs with previous reports by other authors. The attitudes o f the mothers to ward these children were of interest. The fact that eleven mothers out of a possible nineteen brought their children in for re-evaluation is an evidence of their conscientiousness. In most of the eases there appeared to be an overproteetive attitude. The mother of Case 1 wondered if she " babied her daughter too much" and feared the family was overproteetive. The child is obese and diuretic. .Case 2 's mother has showered an unusual amount of attention on her child " because she has been so sick." The ch ild 's teachers complain that " she acts up in school and refuses to obey," although the mother denies this problem at home. The mother of Case fi wondered if her son's fear fulness, excessive sense o f guilt, and " sissy behavior" were the result of lead intoxication and admitted the need of protecting him because of his lack of assertiveness. The parents naturally assume a certain amount of responsibility for the lead intake and resulting lead in toxication. Such responsibility is associated with consequent guilt feel ings and is reflected in the overpro tectiveness o f many of the parents in this series. I'cdiatric counseling of the parents of children with lead in toxication should help them with their subsequent attitudes and do much to prevent the development of additional personality problems. Realization of the visual-motor deficits in these chil dren should be of aid to their t < i and prevent to a certain extent development of problems asdescribed. summary Kleven eases of lead into\i, have been followed for a peri-, from five to ten years with n physical, psychological, and I. tory examinations. The physical sequelae consist, blindness and cerebral dysrhu Sodium citrate was the st therapy in all eases and was over a variable period of time there was no laboratory cvitl. lead intoxication. There is no evidence in this of continuing mental deteri.o Considering the major mode struction in the primary grad* fell that these children are at oils disadvantage and should special attention to offset llieii motor deficit. As the child n there is a gradual loss of the i driven hyperactive behavini qiicntly seen in braiu-daiiiau ' dren. There is no direct mi between the severity of the ilIn* the amount of residual effeel. Pediatric, counseling might fluential in reducing a par* overproteetive attitude which the child's problems. The million* wonltl like to graiknowledge tin* assiHlioien of Win. A aor, M.D., Edward I'oarey, M.P.. : Caldwell, Pli.P., in Hid |irc|>nr;iti*-r report. REFERENCES 1. livers, It. K., niul Lord, II. I Pis. Child. 66: 471, 1943. 2. Etonen, A. 8.: J . Genet. P187, 1947. THURSTON KT A L .: DATE EFFECTS OK i .k a i> I1IISONINU 423 if>*h K., a n d M ason, II. H .: Am. Mi- Child. 59: 119, 1940. s . S.: Am. J . M. He. 205: 4IMJ, l .rinisoii, K. A.: Am. .1. M. He. 212: . 19Mi. .mill, .lolin I..: N e b ra s k a M. .1. 31: v 19Ml. A. A., am i t a h l i n e n , I..: I'sy ; ni liologv am i K ducnl ion o f I lie |iijnr<*l Cliibl, New Y ork, 1947, .... \ M iration. |,.r l'o slciicep h n litie. K eh av in r . t l.-rs in U hildliood, N ew Y o rk , 1942, . \ Stratton. H .: J . I 'KIMAT. 34: 371, 1949. S.: T ra in . Heliool Hull. 22: ...... S. <!., H inder, .1. I... nml I. x, II.: H svehology Hull. 51: 1, 12. (io lilsteiu . K .: A f te r K H irt* o f W ar H raiu In ju r ie d , N ew Y ork, 19*2, (Jru n e k S trut Ion. 12. T e rin a n , L. M., am i M e rrill, M. A.: M easuring' I ii te llig e n c e , New Y ork, 1937, I lo u g h to n k M i111i ti (V). I I . Doll, K. A .: V in elan d S o e ial M a tu rity Si'ale M anual of D irections, Kducnt ionnl T e st H u reau , M in n eap o lis, M inn., 1947. 15. (ioo d en o tig li, F. II.: M easu re o f Inte llig e n e e by D ra w in g , New Y o rk , 1926, W orbl Hook t'o. 10. S ilv e r, A. A .: .1. HkiMAT. 37: 129. 1950. 17. (ira lin ia , F . K., am i K em la ll, H. H.: J . o f A b n o rin . S o c ial P sv clio l. 41: 3<>2, 194ti. IS. Item ler, b .: A m erican O rth o p sy ch in tric A sso c ia tio n , N ew Y o rk , 193S. 19 H la c k u ia n , S. S .: Hull, .lo lm s H o p k in s llo sp . 61: I, 1937. 20. .lasln k , .r.: W iiln ltungo A ehievem ent T e s t, W ilm in g to n , D el., 1 9 Ml, ('lias. I* S ro ty . .4 I 'm b li m in S i n i h n iii i/i i'if i.I r M ill. O ne o f the d em o n s o f Host on chillch, .1:....... 13ml li:i I ii d a u g h te r a i- o f age, who l iug p lay in g w ith o th e r c h ild re n ab o u t a c a l l , th e liim ler l fellupon th e c h il d 's hem l, nml an iro n s lic k in g out o f it s tru c k in to th e I. am i d ro v e apiec e o f th e sk u ll b e fo re it in to th e b ia iu , so a s th e b r a in s cam e veil su rg e o n s fso m e o f th e c o u n try , \ c r y e x p e rie n c e d m en. a n d o th e r s o f th e f rode in th e harbor* b ein g called to g eth e r for a d \ ice, etc, did all conclude, the brains, (Iw ing about h alf a spoonful at one lim e, and more at other I th at th e re w as no hope o f th e c h il d 's life , e x c ep t th e p iece o f s k u ll co u ld be Hat one o f Hie ruling elders of th e chureh, an experienced and very sk ilfu l i -d not to lak e th a t course, lad applied only p la ste rs to it, an w ithal e a rn e st made bv the Church to the l.ord for it, and in six w eeks it pleased (lod th at l 'k a il consum ed, a nd so cam e forth.*.pm l Jjie c h ild rec o v e re d p e rf e c tly ; nor the senses a t any tim e. W i\ t iii;o|'*k .lot icnai. I <130 1(519. .1. I \. liosMKt:, K niiog. New Y oik, 190S.