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THE LATE EFFECTS OF LEAD POISONING Do n L. Th u r s t o n , M.D., J. Ne a l Mid d el k a mp , M.D., a n d El iz a b e t h Ma s o n , Ph .D. S't . Lo u is , Mo . TIIE late effects of lead poisoning were subsequently hospitalized with on the physical and psychological intercurrent infections which precipi iloyelopment of children have receivedtated a return of the symptoms of little attention. Though thousands of lead intoxication. articles have appeared on lead only, To estimate the ultimate effects of Byers and Lord,1 E1 o n e n,? and lead poisoning on body and mind, an Afc (ioettsch and Mason3 have reported accurate evaluation of the original | nil the final effects of lead poisoning degree of lead encephalopathy is de I in patients followed for a variable sirable. From the data in Table I, period of time. The sequelae of lead the hospitalized patients were empiri I intoxication in children appear to be cally classified as mild, moderate, mainly psychological. Little interfer moderately severe, and severe. There ence in physical development has is d o concrete basis for such an evalua been reported, However, two of our tion. Blood and urine lead determina patients showed optic atrophy; onev tions vary with initial therapy (Cases with permanent blindness. 4 and 5). The severity of the central During the ten-year period, 1940 nervous system manifestations ap V- through 1949, twenty-six children pears to depend on duration of lead were treated for lead intoxication. intoxication, manner of exposure, and The source of the lead was either from precipitating illness (Case I). De paint, piaster, or lead toys. Seven tails of such factors are often difficult children (27 per cent) die,d, six on to elicit accurately from the parents. initial hospitalization and one two years later at another hospital with "lead encephalitis." Eleven of the remaining nineteen patients have been followed for a 5- to 10-year period during which repeated physical and psychological evaluations have been carried out, including roentgenologi cal and chemical lead determinations. Five of the eleven patients were diag nosed and treated on an outpatient basis and the other six were hos pitalized. Two of the former group From the Departments of Pediatrics and neuropsychiatry, Washington University. The symptoms in the five outpa tients were vague, nonspecific, mainly gastrointestinal, and of variable dura tion. They are listed in order of fre quency as follows: vomiting (four cases), constipation (three cases), malaise (three cases), anorexia (two cases), pallor (two eases), diarrhea (one case), irritability (one case). The signs, symptoms, physical and laboratory findings in the six children who were hospitalized for lead en cephalopathy are listed in Table I. Except for the convulsions, all the other symptoms exhibited by the 413 N40751 414 THE JOURNAL OF PEDIATRICS Ta b l e I X-RAY COM AGE PATIBLE (YR-) WITH *y: CASE. RACE SEX CONVUL SIONS GENERAL n eur o l o g ic al LABORATORY METAL POISONING SEVlIRjr. 1 2$W t Malaise Irritability Normal blood ami 4 MH.jT Anorexia urine Fever Pharyngitis I. - \ 2 %% $ w t Vomiting Hemiparesis Basophilic stippling. Constipation Papilledema Urine lead 0.9$ 4 Modem fi.h sewn* mg./L. CSF pres sure elevated. Pro tein 62 mg./lOO ml. I 3 m$w 0 Vomiting Weakness Basophilic stippling. 4 Severe Lethargy EEC indeterminate "Meanness" for age. CSF 575 Papilledema mm. pressure. Pro tein 254 mg./lOO ml. Neurosurgical decompression 48 hours after admission with continuous spinal drainage for 48 to 72 h<>a to prevent herniation through subtemporal decompressions. 4 2$w 0 Anorexia Marked Basophilic stippling. 4 Moderate Pallor irritability EEU not disordered. Constipation and weakness Urine lead 0,227 to 4.2 mg./L> CSF 200 \ mm. pressure. Pro tein 198 mg./lOO ml. 5* 3J t Anorexia Vomiting "Behavioral difficulties" Blood lead 1.1344 mg./lOO ml. EEC disorganized with paroxysmal trends. CSF normal 4 6 2 3/12 9W 0 Anorexia Malaise Pallor Papilledema Basophilic stippling, associated EEG moderately with "sprung" slow dysrhythmia. cranial CSF 650 mm. pres- sutures sure. Protein 72 rag./100 ml. 4 Normal values below 0.05 mg./lOO ml. fNormal values below 0.09 mg. tOne of identical twins, both having lead poisoning. Patient 5 also had hay fever, asthma, and developed a peculiar paniculitis. Mild Moderate SYMPTOMS Irritability Vomiting .Constipation Anorexia Malaise Pallor Abdominal pain Convulsions Papilledema Basophilic stippling Ta bl e II NUMBER OP PATIENTS PER CENT DURATION 8 72 2 wk.-6 mo. 4 36 6 wk.-6 mo. 4 36 1-2 mo. 3 27 1-2 mo. 1 1*1% yr. 2 18 2 18 3 50 Intermittent 3 50 Bapid decrease 24-48 hr. 4 66 Disappeared 48-72 hr. AVERAGE 1-2 nio. V/j mo. 1 mo. 1 mo. 2 wk. 2 wk. DUP050058555 THURSTON ET AL.: LATE EFFECTS OF LEAD POISONING 415 *|t>yen patients persisted for variable periods of time after therapy as noted in Table II. On recent physical examination all ,f the children were of normal height and weight for age except one with rxogenous obesity. Two of the chil dren (18 per cent) had bilateral optic atrophy and a third had a high de cree of myopia. The x-ray findings of the long hones of the eleven patients are pre sented in Table III. Like the symp toms in lead poisoning, the roentgenographic changes showed a variable degree of persistence. In the entire There was no consistency in regard to the time of the initial or follow-up electroencephalogram as related to the time of initial lead intoxication. Cases. 1, 2, 9, 10, and 11 had none done. Case 3 initially was indetermi nate for age, but two years later the record was consistent with organic brain disturbance. Case 4, in 1948, 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 phenobarbital. In Case 5, re peat records showed paroxysmal slow dysrhythmia for two to three years, CASE 1 2 3 4 5 6 7 8 9 10 n Ta bl e III. Ra d io g r a p h ic Fin d in o s in Lo n o Bo n e s ONSET OF ILLNESS +' 1944 - + 1948 1948 + 1949 + 1949 + 1949 + \ 1949 + 1949 + 1946 1950 + 1949 1950 0 0 + + 0 + 0 + + 0 - FOLLOW-UP | 1954 0 0 0 0 0 0 0 0 0 0 0 series of twenty-six patients, com plete disappearance of the "lead line" at the distal end of the shaft was eventually noted with recurrence six to seven months later in two patients. These two patients were proved to have reinstituted the paint-chewing habit. Three patients had x-ray de scriptions of transverse "linear distal densities" 2 or 8 cm. from the ends 'f the shaft interpreted as "minimal evidence of bone growth retardation." Urine and blood lead determina tions contributed nothing to the fol low-up study. Electroencephalograms were ob tained in six of the eleven patients. a posterior triangle focus also being noted on the latest examination. The records of this patient have shown the greatest disorganization of the entire series and the child needs psychiatric guidance at the present time. The remaining Cases 6, 7, and 8 were almost identical in showing definite slow dysrhythmia of a vari able degree. The treatment of all patients was identical. Sodium citrate alone or with citric acid was given to maintain a slightly elevated CO > content (28 to 30 meq. per liter). The dosage varied from 3 to 6 Gm. daily in divided doses, for a period of from :! UV. v y? $ 416 THE JOURNAL, OP PEDIATRICS two weeks to two and one-half years.4' 5* 0 A summation of the fol low-up is presented in Table IV, ps y c h o l o g ic al ev al u at io n Byers and Lord note in their study of twenty children who had lead poisoning in early infancy that despite normal motor development during in fancy only one child lived up to the promise of his early development. In a few children successive psychological examinations showed significant drops ment in the sensorimotor sphere was the outstanding finding. Byers and Lord felt that the lead in the circula tion of an infant interferes with tin* changes normally occurring in tin* cortex and, in a high percentage of cases, prevents the normal growth ami development of the cortex. Along with the dilatory effects of mental growth, a high percentage of behavior difficulties were recorded by Byers and Lord. Such difficulties arose from an inward driveness which CASE 1 2 3 4 6 6 7 8 9 10 11 Ta b l e IV. Su mma t io n or Fo l l o w -u p LENGTH OF TIME SINCE EXPOSURE (YR.) INITIAL SYMPTOMS 10 Encephalopathy, convulsions, coma PHYSiCAL SEQUELAE Obesity, enuresis 6 Convulsions, drowsiness, encephalopathy, right heraiparesis 6 Lethargy, vomiting \t Bilateral optic atrophy 5 Irritability Convulsions 5 Encephalopathy, convulsions Abnormal EEG, behavior . problem 5 Mild gastrointestinal symptoms. Treated as outpatient 5/49. Hospitalized 11/49 with gastrointestinal symptoms 5 Encephalopathy, weakness Bilateral optic atrophy 5 Gastrointestinal symptoms. Treated as Decreased vision outpatient 5 Gastrointestinal symptoms. Treated as outpatient 5 Gastrointestinal symptoms. Treated as out patient. Hospitalized 6 mo. later with pneumonia 7/49 3 Gastrointestinal symptoms. Treated as Higli degree of myopia outpatient in intelligence quotients. These drops were thought to be the result of failure of mental development rather than actual mental deterioration. As the chronological age advanced, men tal growth did not keep pace with it. In others, however, the intelligence quotient remained well within normal limits. A specific failure of develop- they classified as ` 'forced reaction u* stimuli in the environment." Strain and Lehtinen/ Bender,8 Bakwin,9 and Stryker10 consider this as evidentof cortical damage independent of etiology. Klelmnoif and associates" describe the brain-injured child as hyperkinetic, overactive, restless, ini pulsive, and uncoordinated, but by* 7\H M.-, vO S'. . >n TT DUP050058557 m THURSTON ET AL.: LATE EFFECTS OF LEAD POISONING pothesize that cortical maturation with compensatory development of function can occur since a less dif ferentiated infantile cortex is in volved, negating the influence of an injury which in an adult would have serious long-term sequelae.1* The psychological aspect of the 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 five years after the toxic state. Be cause of the immaturity of the group at the first testing it was possible only to obtain measures of intellectual and social development (StanfordBinet intelligence scale13 and the Vineland social maturity scale14), PSYCHOLOGICAL RESULTS Reference to Table V shows that at the time of the initial testing only Tah j .k V. Co mp a r is o n o f Re s u l t s o f In t el l ig e n c e Te s t in g in 1950 a n d 1954, o f So c ia l Ma t u r it y % 1*130 AND 1954, AND GOODENOUGH I.Q. IN 1954 FOR ELEVEN CHILDREN WHO HAD REAP POISONING 1950 CASE AGE AT ONSET <YR.) CHRONO LOGICAL AGE (YR.) BINET I.Q. 'I .0 3 4 5 6 7 8 9 10 11 Mean Mandard 1 Mia(ion 2 2% 2% 2 3 2% 2%2 21/l2 2 2 1M2 2.03 7*4 106 4,1 86 4.3 Appeared normal 3.1 59 3.3 127 2.1 100 3.1 82 3.1 78 3.1 97 2.6 116 3.1 93.77 18.37 Lank order correlation between 1950 and 1954 I.Q.'s r JVst between 1950 and 1954 I.Q.'s . eorrected for correlations) INTER MEDIATE TESTING 74 137 \ .08 2.12* Significant at ,05 level of confidence, tSigniflcant at .01 level of confidence.' 1954 CHRONO LOGICAL AGE (YR.) 11.5 8.1 8,3 7.1 7.6 6.6 7.3 7.1 7.3 6.3 6.7 7.6 BINET I.Q. 109 88 99 88 iio 122 87 84 99 111 125 102.00 GOOD- 1950 1954 ENOUGH VINELAND VINELAND i-q. I.Q. LQ, 65 115 114 86 116 102 Blind 87 S3 % 74 76 100 73 73 105 112 127 83 95 105 98 89 98 99 105 105 91 111 90 116 105 85.1 99.11 105.00 13.76 4.08 13.71 Rank order correlation for Binet and Goodenough I.Q/s 1954 T-Test for Binet and Goodenough I.Q.'s 1954 (corrected for correlations) 10.31 .05 3.281 intoxication in late infancy. No records of original intellectual func 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 testing was done in 1950 with re-evaluation in 1954. The time of the initial testing ranged from immediately after 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 the patients below the dull normal level, Case 4, was a hyperactive, irritable child who was extremely difficult to test, and the examiner felt that the I.Q. measure of 59 was minimal. At the time of the second testing none of the children were below the dull nor mal level of intelligence and four were DUP050058558 K. 418 ' THE JOURNAL OF PEDIATRICS in the bright average to superior Even greater significance is added to categories. The bright average to this finding when it was realized that superior children showed little uneven the one child who showed a decrease in ness in their functioning. The type of intellectual functioning was under items most frequently failed by the psychiatric care. A complete psycho children in the dull normal category were items involving abstract think ing. Although this is a characteristic failing of children with brain damage, it fe also the type of thinking which would be expected of children with dull normal intelligence natively. Three of the eleven children showed logical study on this hoy 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 (LQ. 126). Emotional prob u some difficulty copying a diamond at lems are affecting functioning and re the seven-year level, but there was no lationships., There are also some or conclusive evidence in the over-all in ganic indications which need further tellectual functioning characteristic . evaluation. Treatment assets are: of children with brain damage. superior intelligence, ability of ego It is recognized that intelligence to maintain itself despite stress, con tests, made at different times on the formity and the anxiety itself/' same individual, may vary as much as It seems possible that the decline ten points on the basis of chance fac ip functioning ability in this one ease tors alone. Reference to Table V shows was due, at least in part, to a func that I.Q, changes in three of the tional psychological disturbance. eleven children (Cases 4, 5, 6) were On both testings, social develop significantly greater than would be ment, as measured by the Vineland * ) expected by chance. Two of these Social Maturity, was somewhat above showed improvement, while one went intellectual development. Although down. However, with the exception of these differences were not significant, Case 5 who decreased, all of the other the suggestion is present that these I > i!' children showed an increase of from children are somewhat better able to 2 to 9 I.Q. points. The difference be perform in practical everyday situa tween the average I.Q. of 94 at the tions. i time of initial testing and 102 at the On the second testing, however, the time of the last testing shows an im intellectual measure obtained from provement in intellectual level which the Goodenough draw-a-man test1* is significant at the .05 level of confi was significantly lower than that ob / '! dence (would he expected to occur on tained from the Stanford-Binet in the basis of chance only five times out telligence scale at the same time. of 100). A continuing intellectual de The difference between the average .V. cline after the initial testing, as ex Goodenough I.Q, of 85 and the Bim-t pected from the results of Byers and LQ, of 102 was significant at the .0`t Lord, Was not found in our series. level of confidence. Though the draw Instead, there was some evidence of ing test primarily measures visual- an actual increment in intellectual motor functioning, while the intelli functioning. gence scale is primarily a verbal test. t DUP050058559 THURSTON ET AL.: LATE EFFECTS OF LEAD POISONING 419 the significant positive correlation which has been demonstrated between lh\se two tests indicates that they measure two types of behavior which tend to develop at similar rates. The correlation of .05 between these two other words, it would seem that while the over-all intelligence of these chil dren remains intact and is developing normally, a definite deficit is seen in their visual-motor functioning. Fur thermore, qualitative analysis of the Ta b l e VI. 1954 Gr a d e Pl a c e me n t , Sc h o l a s t ic Ac h ie v e men t , a n d Re s u l t s o f Vis u a l Mo t o r Te s t s o f Br a in Da ma g e o f El e v e n Ch il d r e n Wh o Ha d Le a d In t o x ic a t io n in In f a n c y CASE 4 5 6 7 8 9 10 11 GRADE 1954 EDUCATIONAL LEVEL grade. Doing well now except arithmetic Held back % grade Blind, in school for blind 2 School problem 3 School problem 2* Does well 1 Held back 1 grade 1 Held back % grade 2 Held bock % grade 1* Does well 2* Does well Poor in drawing 195420 WIDE RANGE ACHIEVEMENT GRAHAM* KENDALL READING j ARITHMETIC CATEGORY 6.0 grade 3,6 Borderline grade 2.5 Blind 1.1 2.3 Blind 1.1 Normal Blind Brain damaged 2,1 2.3 Brain damaged \ 1.2 1.4 Borderline 1.0 1.4 Brain damaged 1.3 1.3 Brain damaged 1.6 1.5 Brain damaged 0,9 1.4 Normal 2.5 2.7 Brain damaged BENDER-GESTALT Rotated designs, A and 3; difficulty with spatial relations Normal Blind Reversed A; rotated 8; primitive loop and lines ; difficulty with angulation Rotated designs A, 3, 4, 5, 8; primitive loops, difficulty with angula tion Rotated designs A, 3 ; perseverated on 1 and 2; primitive loops, difficulty with angula tion Perseveration; poor spatial relations, difficulty with angula tion on 7 and 8 Primitive loops and lines; poor spatial re lations ; difficulty with angulation on 7 and 8 Rotated designs 3, 4, 5, 7; difficulty with angulation on 7 and 8 Perseveration in design 2, primitive loops and difficulty with angula tion Spatial relations poor on a 2, 4; difficulty with angulation on 7 and 8 Reported to be doing: well in school. measures for this group would indi cate that there is no relationship other than chance between the de velopmental rates of these two types of behavior for these children. In drawings revealed the disorganization in body image and immature draw ings which Silver10 describes as characteristic of children with brain damage. A3 U'' ' :;I . <*$ 420 THE JOURNAL OF PEDIATRICS It is of interest, then, to note, that despite intellectual functioning with in the normal range, only three of the eleven children are reported by their mothers to be doing: well in school, (See Table VI, Gases 6, 10, and 11.) Two of these patients (Gases 6 and 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 Graham and Kendall17 visual motor test with correction for chronological age, Cases 2 and 10 were within normal category : Cases 1 and 6 were in the borderline brain damaged category; and Cases 4, 5, 7, 8, 10, and 11 showed visual-motor deficit within the brain-damaged category. At the extreme end of the continuum of visual-motor deficit was Case 3 who is totally blind as a re sult of the lead poisoning. An even more-pronounced deficit was noted in the group's performance on the Bender-Gestalt visual-motor test,1 Case 2 was the only child who was able to copy the designs of this test in a fashion which was normal for her age level. All of the other children showed the rotation of . de signs, perseverations, difficulty with angulation, and substitution of primi tive loops and lines for dots which Silver16 describes as characteristic of children with brain damage. Case 2 is the one child in this group of eleven, then, who does not show a visual-motor deficit. This is of particular interest when it is re. membered that her toxic reaction was one of the most severe, and at Ihe 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 typo of errors made by these children in their visual-motor functioning shows behavior which is paralleled in their academic achievements. The rota tions of their drawings of designs placed directly in front of them sug gest that these children would find it difficult to learn to read in a teaching situation which requires them to recognize the visual picture rather than paying attention to the phonetic elements of the word. This was borne out in their reading tests by a considerable number of reversed letters, reversal of whole words, and of misrecognition of words due to attention to the first letters. d is c u s s io n Thorough physical and laboratory examination revealed little that could be attributed to the late effect of lead intoxication in a group of children followed for a five- to ten-year period of time. The effect of increased intra cranial pressure in Case 3 resulted in blindness as the only physical resid uum in the whole group. However, the organic brain damage that resulted is only apparent in the specialized psychological tests done repeatedly, and the results are quite similar to those seen in children with brain damage due to birth injuries or. more specifically, cerebral anoxia. DUP050058561 THURSTON ET AL.: LATE EFFECTS OF LEAP POISONING 421 From previous pathological studies ,f our own and others, serious vascu lar damage, cerebral edema, with reMilting cortical injury, is the under lying basis for the picture of lead encephalopathy.1 The intellectual deg radation as reported by Byers and Lord is not confirmed and the out 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 capacities are within normal range, the visual-motor deficit presents a serious handicap to the child in the present school system. The presentation by visual stimuli for learning is frustrating. Special tutoring in this one area or placement in a school situation which would allow the use of other sense modalities in learning, such as phonetic or kines thetic approaches, might minimize this frustration. Case 5 is presented in support of this hypothesis. Though the pathol ogy in his home situation cannot he denied, the intermediate testing prior to entrance to school yielded an I.Q, of 137. During three school years, his teachers complained that he was "a negativistie, restless, poorly attentive child, who refused to learn.* ' Be cause of such behavior and because of the general family situation, psy chiatric help was advocated. The ex tremely frustrating situation pre sented to a boy of superior intelli gence who is handicapped in learning by poor visual-motor coordination cannot be overlooked. This handicap might be a contributory factor in bis need for psychiatric help. The pictures presented by Cases 1 and 3 are more hopeful and suggest that, with understanding help, the children may learn to adapt to the deficit. Case 1 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 primary grades presented difficulties characteristic of any brain-damaged child and there was failure to pass the second grade. Her mother reports that she is doing well in school now, but is slow in arithmetic. Her achieve ment test scores corroborate this, as she is at her grade level in readingbut is retarded in arithmetic. The visual-motor deficit is not as pro nounced as in many of the other cases. This suggests that the effects of cortical injury may be negated as the central nervous system matures. Patient 3 is totally blind and has been receiving training at the Missouri State School of the Blind. Neither difficulties in the primary grades nor the behavioral troubles are as marked as in the other children. At the time of the initial testing five of the children presented the driven, negativistie, hyperactive be havior which is characteristic of chil dren with brain damage. None of the children displayed this type of be havior at the time of the final ex amination. Cooperation was excel lent, even with the boy who is under psychiatric care. It was only when his mother entered the room that his negativism was evidenced. The one common personality trait exhibited by the group was that of strong motiva tion to achieve in all tasks, with re peated voicing of fears that they were 422 $ THE JOURNAL OF PEDIATRICS not doing well or might fail. Such dren should be of aid to their teachers 1 dissipation of hyperactivity or in and prevent to a certain extent the ward driveness with cortical matura development of problems as just *1 tion associated with some types of described. brain damage concurs with previous reports by other authors. s u mma r y The attitudes of the mothers to Eleven cases of lead intoxication I ward these children were of interest. have been followed for a period of I The fact that eleven mothers out of from five to ten years with repeat a possible nineteen brought their physical, psychological, and labora I children in for re-evaluation is an tory examinations. i evidence of their conscientiousness. The physical sequelae consisted of In most of the eases there appeared blindness and cerebral dysrhythmia. *! to be an overprotective attitude. The Sodium citrate was the specific mother of Case 1 wondered if she therapy in all cases and was given I "babied her daughter too much" and over a variable period of time or until feared the family was overprotective: there was no laboratory evidence of The child is obese and enuretic. lead intoxication. Case 2's mother has showered an There is no evidence in this series unusual amount of attention on her of continuing mental deterioration. child "because she has been so sick." Considering the major mode of in The child's teachers complain that struction in the primary grades, it is "she acts up in school and refuses to felt that these children are at a seri obey," although the mother* denies ous disadvantage and should receive j this problem at home. The mother special attention to offset their visual- i of Case 5 wondered if her son's fear motor deficit. As the child matures i fulness, excessive sense of guilt, and there is a gradual loss of the inward "sissy behavior" were the result of driven hyperactive behavior fre lead intoxication and admitted the quently seen in brain-damaged chil need of protecting him because of his dren. There is no direct correlation lack of assertiveness. between the severity of the illness and The parents- naturally assume a the amount of residual effect. certain amount of responsibility for the lead intake and resulting lead in toxication. Such responsibility is associated with consequent guilt feel Pediatric counseling might be in fluential in reducing a parenteral overprotective attitude which adds to the child's problems. ings and is reflected in the overpro The authors would like to gratefully ac tectiveness of many of the parents in knowledge the assistance of iVm. A. Eaeseli* this series. Pediatric counseling of ner, M.D., Edward Pearcy, M.D., and Betty the parents of children with lead in Caldwell, Ph.J)., in the preparation of thi* report. toxication should help them with their i subsequent attitudes and do much to REFERENCES prevent the development of additional 1. Byers, R. K.t and Lord, E. E.: Am. J- i personality problems. Realization of the visual-motor deficits in these chil Dis. Child. 66; 471, 1943. 2. Elonen, A. S.: J. Genet. Psychol. 71* 187, 1947. ;* ^ . V* \ - ` Y \ DUP050058563 THURSTON ET Ah.: LATE EFFECTS OF LEAD POISONING 423 3. Goettsch, E., and Mason, H. H.: Am. ,T. Dis* Child. 59: 119, 1940. 4. Kety, S. S.: Am. J. M. Sc. 205: 406, 1943. 5. Mortenson, R. A.: Am. J. M. Sc. 212: 315, 1946, 6. Gedgould, John L.: Nebraska M. J. 3l: 48, 1946, 7. Straus, A. A., and Lehtinen, L.: Psy chopathology and Education of the Brain Injured Child, New York, 1947, Grime & Stratton, S. Bender, L.; Postencephalitic Behavior disorders in Childhood, New York, 1942, (Irune & Stratton. 9. Bakwin, H.: j. Pe d ia t . 34: 371, 1949, lit Stryker, S.: Train. School Bull. 22: 152, 1925. 11. Klebanoff, S. G,, Singer, J. L,,. and Wilensky, H.: Psychology Bull, 51: 1, 1954. 12. Goldstein, K.: After Effects of War Brain Injnried, New York, 1942, Grime & Stratton. 13. Terman, L. M., and Merrill, M. A.: Measuring Intelligence, New York, 1937, Houghton & Mifflin Co. 14. Doll, E. A.: Vineland Social Maturity Seale Manual of Directions, Educational Test Bureau, Minneapolis, Minn., 1947* 15. Goodenough, F. H.: Measure of In* telligence by Drawing, New York, 1926, World Book Co, 16. Silver, A. A.: J, Ped iat . 37: 129, 1950. 17. Graham, F. K., and Kendall, B. S.: J, of Abnorm. Social Psychol. 41: 303, 1946. 18. Bender, L.: American Orthopsychiatric Association, New York, 1938. 19. Blackman, S. S.: Bull. Johns Hopkins Hosp. 61: 1, 1937. 20. Jastak, J.: Wide Range Achievement Test, Wilmington, Del., 1946, Chas. L, Sroty. A Problem in Neurosurgery September 1644. One of the deacons of Boston church, Jacob Eliot had a daughter of eight years of age, who being playing vwith other children about a cart, the hinder end thereof fell upon the child \s head, and an iron sticking out of it struck into the child's head, and drove a piece of the skull before it into the brain, so as the brains came out, and seven surgeons (some of the country, very experienced men, and others of the ships, which rode in the harbor) being called together for advice, etc, did all conclude, that it was the brains, (being about half a spoonful at one time, and more at other times,) and that there was no hope of the child's life, except the piece of skull could be drawn out. But one of the ruling elders of the church, an experienced and very skilful surgeon, liked not to take that course, but applied only plasters to it, an withal earnest prayers were made by the Church to the Lord for it, and in six weeks it pleased God that lhe piece of skull consumed, and so came forth, and the child recovered perfectly; nor did it lose the senses at any time. Win t h r o p's Jo u r n al 1630-1649. J. K. Ho s mer , Ed it o r . New York, 1908.