Document en8k6GoQgzoOvkMxMqqBmbnE

I v gested also lium. Can vious arguir affection, recognition al irritation (anting the istory of a favours an in the only ratitis that perimental ophthalmic apparently antis. So that _tilese ave repretures was ant. This us greyish was found v- poor n. >ints developed pan men t. ween the keratitis, y, and in ly eye of acked by ationship punctate is merely i attack" at is, the many of periment he more he same olv have NOTICE: This Material may hs protected by copyright law. (Title 17 US. Code) O c u l a r P l u m b is m in C h i l d r e n 637 been the true explanation in all ? The rapid and early develop ments in the successful Madras cases may be held to correspond merely with the direct corneal traumatism inflicted in these experiments-- scratching and massage. Controls appear to be needed consisting of exactly similar traumatism at an epidemic period, without the use of any epithelial emulsion from diseased eyes, but possibly with the application of emulsions, filtered and unfiltered, taken from healthv eves. O C U LA R P L U M B ISM IN C H IL D R E N J. L o c k h a r t G ib s o n HONORARY CONSU LTIN G O PH TH A LM OLOG IST BRISBANE H O SPITA L FOR SICK C H ILD R EN ( S u m m ary.-- T h e cases dealt w ith in this pap er hav e no p yrexia. Th* mild ones are brought by their mothers because they have developed a recent internal squint. T h e squ int is due to paralysis of one or of both external recti. P a p illo ed em a up to -dx dioptres is found, due to increase of intra-cranial tension. The severe cases are me e evidently cases of lead encephalopathy. Explanation is given of why soluble lead is available, and why and how it is ingested. Lead is found in the urine. No album in is found in the urine.) A lthough I have written --n rhis suhjec: ;n Australia. I nave only published one paper in England. and mv knowledge has increased and become more accurate since then. The peculiar nature of the cases described has not as a rule been thoroughly recognized. They appear to have no parallel among cases of industrial lead poisoning, and nearly all writers on lead poisoning where the eves are implicated, have had experience of industrial lead poisoning only, and of that in adults. M y reason for frequent references to the cases I have seen in Queensland has been the desire of myself and of my colleagues, especially of those at the Hospital for Sick Children, to get a danger removed from our young children between the ages of two years and eight years ; and also to make isolated cases in other places and other countries less likelv to be undiagnosed as due to lead-- to bring lead at least into the differential diagnosis of such cases in young children. It has been difficult for those practising in other parts of Australia to recognize the special conditions under which our children live, and the special facilities they have for ingesting lead. It has proved quite impossible for m a n y 'o f those who have investigated industrial lead poisoning to grasp the fact that whereas industrial lead poisoning occurs owing to the inhalation of lead dust, our children are poisoned owing to the ingestion of 6 (LIT- X O f H-Tfh 15: 6 5 1 - M l , /?3/ 638 T he B ritish J ournal of O phthalmology powdered soluble lead carbonate. The explanation given of how this soluble lead carbonate is ingested, and the reason w"hy such poisoning among children is less common, or absent, elsewhere than in Queensland, industrial lead investigators are unable to appreciate. The British Medical Association, Queensland Branch, succeeded after many years in getting the Government to make it penal to apply lead paint to outside surfaces within the reach of young children. This law has been in force since 1923, though not always obeyed by master painters. It, and still more the persistent teach ing of parents by those of us who grasp the importance, has resulted in many fewer cases of hand and foot drop, and qf,j3cular plumbism. The ocular plumbic cases, if secured early and treated promptly, will recover without any defect in sight. I am personally answerable for claiming them to be due to lead, for claim ing them to be a result of increased intra-cranial tension, and for the explanation that the lead circulating in the vessels of the choroid plexus causes the increased secretion of cerebro-spinal fluid. The frequency of wrist drop and foot drop cases, which were readilv diagnosed as due to lead, caused me to diagnose the eye cases. I am sensible that it would have taken much longer to arrive at this conclusion in the eve cases had it not been for the wrist and foot drop cases. The two conditions very rarely occur together. Latterly, I have been able to explain this, and W oollard's work with dyes has supported my explanation in an interesting manner, as I will explain later. W e tvere able to diagnose the limb cases and the eye cases for years before I was able to discover how and where they ingested their lead. In Queensland, houses are built on piles. The verandah floors and other floors are therefore several feet above the ground. All our dwelling houses, which are chieflv wooden, have verandahs more or less broad. They require verandah railings. These rail ings are of wood, and in the neighbourhood of towns they are painted. Except where other paints are insisted upon, they have been painted with white lead paint. In this semi-tropical climate, the sun soon converts this paint into a powderv substance. The powder rubs off easily on the hands. T h is powder our Government analyst in 1904 proved for me to be a very soluble carbonate of lead. Garden fences are painted with the same material. Such paint inside our houses or unexposed to the sun and outside atmosphere, does not powder at all appreciably. T he children between the ages of two years and eight years spend a large part of their time on the verandahs, girls more than boys. T hey are apt to finger and to cling to the verandah rails. I soon >f how / such where ble to eeded nal to oung hvavs each, has cular ptlv, iwerbe a ition uses were eve :cur and an for ted ors All ahs ailare .VP tfl he ur rv he he tr id s. )n Ocular P lumbism in Children found that the children in a fam ily who become affected with lead bite their nails, and the few who do not, suck their fingers, or occasionally suck the paint. It was found that more girls were affected than b o y s; that more cases occurred during the summer months than in the cooler months, because the moist hands of children during the hot months carry more of the lead powder to their mouths than the dry hands of winter. The cases of wrist drop and foot drop were first described by the staff of the Hospital for .Sick Children in 1892. I was then an Honorary Physician. Since then, Dr. A . Jefferis Turner especially, and other members of the staff, have published papers. The eye cases I have recognized since 1897, when I became Honorary Ophthalmologist to the Hospital. A t first they ^ere named by me ocular neuritis due to lead, and thought to be due, like other lead cases, to peripheral neuritis. Latterly, I have regretted this name, because ocular plumbism would be more accurate. Continued observations and treatment revealed the existence of increased intra-cranial tension in the ocular plumbic cases, and that the papilloedema and paralysis or paresis found in the external recti muscles was due to this increased intra-cranial tension. It was found that if the cases were admitted, i.e., removed from the c>pp<Ttunity of ingesting more lead before the increased intra cranial tension had lasted for long, a prompt lumbar puncture, followed, if necessary, by a second lumbar puncture in three days, very quickly resulted in reduction of the papilloedema and of the squint. I say " resulted " because we had been able to contrast what happened after I had insisted upon lumbar puncture becoming a routine practice with what happened when I did a lumbar puncture only in cases with marked head symptoms in addition to the papilloedema.and squint. I am, of course, conscious that the ocular plumbic cases are cases of lead encephalopathy, but to give them so high sounding a name might defeat my object, which is to get practitioners elsewhere than in large cities to deal with them promptly when a doubt exists regarding the aetiolgy. The removal of the child from further possible contact with powdery lead paint, and the performance of a prompt lumbar puncture, is the essential treatment, i.c., remove the cause or further cause, and reduce the pressure, wdfich will destroy the sight if it lasts long enough. (The amount of fluid removed on the first puncture varies from 2 drachms to 18 drachms.) The early cases hardly appear to be ill, and would be unrecog nized by their parents except for the sudden and fortunate develop ment of a squint. The severe cases are, if undiagnosed, again fortunate in being so sick that they are confined to bed and so removed from further ingestion of lead. T his limits the damage to 640 T he B ritish J ournal of Ophthalmology vision, but as a rule results in complete or partial- postpapilloedemic atrophy in one. or both eyes unless a timely lumbar puncture is done. The Government analyst, after taking every precaution to exclude contamination of specimens and reagents, found lead in sufficient quantities in the urine of the children to prove the absorption of lead. W h at the faeces contained had not necessarily been absorbed from the intestinal canal, and was not therefore of importance. Occasional cases similar in all respects occurred when children had been allowed access to fresh paints, either on recently painted houses or in pots of paint used by their fathers in the house. ''The following case is one in p o in t:-- October, 1913.-- H . H ., male, aged 5 years 8 months; sent to me by Dr. Coen, of Lismore, New South Wales. The illness began a month ago with vomiting withour relation to food and lasting ever since except for three days intermission ; frontal and temporal headache ; internal squint noticed for two weeks, and double vision. E x a m i n a t i o n : Child very pale. Paralysis of each external rectus and a very marked internal squint. E ating nothing to speak of until the last two days. Temperature n o rm al. In ten se p ap illo ed em a (choked disc) in each eye. Disc -; raised six dio p tre s: veins very distended ; retina surrounding each disc swollen : nc head retraction : said to see well-- can see m y fingers at six yards. Nails are all bitten. Th~ has no verandah railings, but th* gard*-n i- s u r r o u n d - : by r a : : - r e p a in te d with white lead five o r six vears ago. and now v* rv p-- x i-rv. H'> f.v.l er d soitw p a i n t i n g and mixe> white l-ad p ain ts in the hous- . H - has b---r. m ixing > rr lately, specially for a m o n th before the boy became ill. Sine- rhe bov h a s hern *dck. he has b^en too ill to go n e a r either his f a t h e r 's p ain ts or th'- g ard en railings. H e had been decidedly better for the last two days, his mother told m-. Family history excellent. I gained rhe impression that he was beginning to show benefit from being too ill to play w ith his f a t h e r 's p ain ts, an d therefore to continue the ingestion of lead. O cular plu m b ism w as the provisional diagnosis. An immediate lu m b ar puncture w as done. T he cerebro-spinal fluid w as under pressure, but not to the extrem e degr*^3 often found in lead cases and only two drachm s of fluid were withdraw n. (No doubt the extreme pressure was subsiding.) He slept well that night, and his headache > disappeared and did not return. The right external rectus showed some return in power next day. In four days the external recti were acting fairly well and there was little squint. In five days there was only two dioptres of swelling in each disc. In . 14 days only a trace of alternate squint persisted and the papilloedema had subsided. H e had been given, of course, dilute sulphuric acid and magnesium sulphate, followed after the first week with potassium iodide. He was allowed to return to his home in the north of New South Wales. In August, 1929, i.e., 16 years later, a broad shouldered, particularly healthy-looking young man-- a typical footballer-- called to tell me how grateful he and his parents had been to me. His vision was six-fifths with each eye. Each fundus was natural, and refraction emmetropic. One had to imagine that the slightly irregular edges of the discs may have been a legacy of the papill oedema. There was no sign of any ophthalmoplegia. The ocular plumbic cases being due, as I think, to the ingestion of a considerable quantity of lead during a short time-- a few weeks-- would notice expected to lead to the serious sequelae which chronic lead poisoning in childhood is supposed by some of my physician colleagues to be answerable for in young adults. Dr. Nye^ has nef of aet cas qu qu ac on ca of he is le ot P tl I b Ocular P lumbism in Children has, indeed, made out a very good case for the unusual number of nephritic young people in Queensland being a result of ingestion of lead in childhood. T his case and others help to confirm the aetiology of the more usual eye cases. The hand and foot drop cases are almost always a result of prolonged ingestion of small quantities of lead. The ocular cases, I believe, ingest considerable quantities over a short time. This explains what has always been a difficulty-- why some children get hand and foot drop, and others only ocular plumbism. W h y more massive doses over a short time cause eye symptoms may, I think, be explained by an observation of W oollard, who found that if small doses of dyes are given, no head symptoms result, because apparently the cerebral circulation^, is fenced against! them. If, on the other hand, large doses are given, head symptoms and convulsions occur. I believe that the lead circulating in the choroid plexus causes an increased secretion of intra-cranial fluid and consequent increased intra-cranial pressure, with resulting papilloedema and paralysis or paresis of the external ocular muscles, nearly always of the external recti. I have known all the ocular muscles implicated in a severe case brought too late to prevent blindness. The squint is always recovered from. A s said before, my chief object in again writing on subject is the hope that it may lead to isolated cases being at leas; provisionally recognized and treated, and blindness amongst children thereby reduced. I think also that my explanation of how and why papilloedema is caused is original and correct. W e have found that a good substitute for lead paint is zinc white. W h en used without admixture with lead, it lasts on exposed surfaces longer than lead. It powders less, and its powder is not poisonous. I have had only one voluntary explanation as to win- master painters resist wholeheartedly the use of anv paint whose basis is not lead. The senior painter in Brisbane said to me when I first began to urge zinc as a substitute: " You know, Doctor, we painters do not like this zinc craze." " W h v, M r..................." I asked. " It lasts too lo n g," came the answer. Those interested in white lead manufacturing resist for other reasons also. REFERENCES J. L ockhart G ibson: " P lum bic O cu lar N eu ritis in Q ueensland C h ild re n ." A ustralasian Med. Gaz.. O cto b er 20, 1897. P ainted R ailings the Source of Lead P oisoning." Australasian Med Gaz A pril 20, 1904. " Plum bic O cular N eu ritis." A u s tr a la s ia n Med. Gaz., 1904. T r a n s a c t i o n s o f th e A u s t r a l a s i a n M edical Congress, 1905, 7 th S e ssio n . B rit. Med. J l., N o v em b er 14, 1908. -. T he B ritish Journal of Ophthalmology J. Lockhart Gibson: " Im p o rtan ce of L um bar P u n ctu re in Plum bic O cular N eu ritis." A ustralasian Med. G az., Ja n u a ry 13, 1912. " T h e D iagnosis, P rophylaxis and T reatm ent of P lum bic O cular N eu ritis." Med. J l. o f A u s tr a lia , S ep te m b e r 8, 1917. " D e -io n iz a tio n in th e T re a tm e n t of P lum bic O cu lar N e u ritis ." Med. J l. of A u stra lia , A pril 5, 1919. " E xhibition of C ases of O cular P lum bism ." Transactions of the Australasian M edical Congress, B risb a n e, 1920. A. Jefleris Turner : A ustralasian Med. Gaz., 1897. W . E. Dixon and H alliburton : " C e re b ro -sp in a l P r e s s u r e ." J l . o f P hysiol., V ol. X L V II, N o. 3, p p . 283 and 287. H. H. Woollard : s '* " C a p illa ry E n d o th e liu m ." Med. J l. of A u stra lia , A ugust 4, 1928. D. Gifford C roll: " C h ro n ic N e p h ritis in Q u e e n s la n d ." M e d .J l. o f A u s tr a lia , A u g u st 3, 1929. L. J. Jarvis Nye : " C h ro n ic N e p h ritis in Q u e e n s la n d ." Med. J l. o f A u s t r a l ia , A ugust 3, 1929. EN D R E S U L T S IN M ONOCULAR ESO TR O PIA L u t h e r C. P e t e r , M .D . FROM TH E D EPA RTM ENT OF OPHTHALMOLOGY, GRADUATE SCHOOL OF M E D IC IN E , U N IV ER SITY OF PENNSYLVANIA, P H IL A D E L PH IA , PA ., U .S.A . O p i n i o n s are divided as to what may be expected as end results in monocular squint. Many believe that only parallelism can be obtained in the great majority of patients, with an exceptionally good termination now and then, including equal visual acuity in the two eyes and, to all intents and purposes, single binocular vision. In fact, not many years ago a member of this Society, an unusually good operator, expressed his belief in a paper that comparatively few children recover from squint with single binocular vision. There is, however, a minority of operators, in which the speaker is included, who believe the ideal goal can be obtained in the vast majority of young squinters, if systematic measures are instituted, if the squint is treated at the proper age, and if the co-operation of the parents can he obtained. It m ight be well to state just what the ideal goal embraces in order to say " the results are ideal." In my judgment, ideal results include, first, good visual acuity in the squinting eye; second, single binocular vision which will stand the proper tests; * R ead by invitation, at the A nnual M eeting of the Pacific C oast O to-O phthalm ological S ociety, M ay 29, 1931, L os A ngeles, C alifornia, U .S .A .