Document vLogJQ52p0ooDwaJedV8ENOR

iqsM iU r 24 mack with a refined antitoxin or globulin, according either to the old or to the new formula. Freezing o: a three L -{- dose mixture of toxin-anti toxin containing 0.3 per cent, tricresol, prepared with an antitoxin concentrated without the use of heat, resulted in an increase in toxicity of the mixture. Freezing of mixtures of toxin-antitoxin made with unconcentrated antitoxin and containing three L -jdoses of toxin, >n which tricresol or phenol is used as a preservative, results in an increase in toxicity of the mixture. Freezing c : such mixtures in which chlorbutanol or chloroform is used as a preservative, or in which no preservative :s used, does not cause an increase in toxicity of the mixture. . Only highly refined antitoxin or globulin should be used in the preparation of diphtheria toxin-antitoxin mixtures. Mixtures of diphtheria toxin-antitoxin containing one-tenth L ^ - doses should be the only formula permitted. 195 College Avenue. LEAD POISONING IN CHILDREN W IT H SPE C IA L R E FE R E N C E TO PIC A JOHN C, RUDDOCK, M.D. LOS ANGELES Pica, or parorexia, is a craving for unnatural articles of food-- a depraved appetite. It has been observed in hysteria, chlorosis, insanity and pregnancy, but more particularly among children in the latter half of infancy, children from I to 2 years of age. It sometimes begins in later childhood when from any cause the general health fails, and the child becomes anemic. S till1 stares rhat he has seen fourteen cases. In some of his cases, mud and mortar were especial favorites; in others, coal, cinders and gravel were pre ferred. In nine cases, the habit began in the second year of life; in one, it began at 8 months. Thomson,1 in a study of pica and its causes, divides this morbid craving in children into two groups: 1. Those instances in which the habit begins at any age, often associated with some marked deterioration of the general health (of which anemia is usually a symp tom), and lessens or passes off as the general condition improves. 2. A larger group in whom the morbid craving develops in early infancy, as opportunity for its indul gence offers, apart from any very noticeable cachexia, and without anemia, passing off gradually in most cases, even if untreated, when the child is about 3 years old. Patients in the former, or cachectic, class may be suf fering from a variety of curable and incurable condi tions, such as rickets, bronchitis, roundworms, appar ently idiopathic anemia, malignant tumor, tuberculosis and other chronic maladies. Koplik 3 believes that this peculiar condition in chil dren is an exaggeration of the normal habit in young infants of invariably placing everything within reach in their mouths. In children who suffer from pica, the sense of wholesomeness is lacking, and they crave sand, 1. S till, G . F . : G otzm cn D is o rd e rs a n d D is e a s e s of C h ild h o o d , L o n d o n , J c i a : ""O n P ic a , o r D ir t E a tin g , in C h ild re n , E d in b u r g h dirt, gravel, cinders, wall plaster, paper, paint and other substances. Although a child with pica craves' many different types of things, it is very fortunate that most of these things are inert, and, although they occasionally lead to minor ailments, such as constipation, fissure-in-ano and other intestinal disorders, they do not cause any serious disturbance of the health of the child. There is, however, one type of poisoning which these pica children acquire, and that is lead poisoning. This may easily be overlooked, because the average physician has never had his attention called to the fact, and also because the clinical picture is usually very different from that in similar poisoning in adults. There are many ways in which the child may acquire lead poisoning which the average parent could easily prevent. Some children affected with pica have a morbid crav ing to gnaw painted objects, such as window sills, white furniture, crib railings, porch railings and other articles around the home within their reach. A child lives in a lead world. There are many other ways in which lead may be introduced by mouth: in paint from toys; in buns.and candies colored with lead chromate; in printers' type used as a plaything; in ointment of lead oxid (litharge), and in water and milk that have stood in lead recep tacles. Or the child may become poisoned by improper medication, i. e., by taking lead acetate solution in treatment of poison oak; by sucking paint from the mother's face; by nursing after the use of lead ointment on the mother's breast, or by swallowing leaden objects, such as BB shot. Holt * reported one case due to inhalation of dust that contained lead. He also stated that the number of authentic cases of lead poisoning in young infants was very small, although much has been written on con genital lead poisoning in extensive studies of the families of workers in lead, in which, in many instances, both parents were suffering from lead poisoning. x Before taking up the general discussion and symp tomatology of lead poisoning in children, I shall report two cases, which have come under my observation during the last year: REPORT OF CASES Case 1.--A boy, aged 3 years, normal at birth and always well except for nervousness, caused by irregular sleeping hours and careless parents, for six months previous to obser vation had complained of severe abdominal cramps associated with vomiting, loss of weight and appetite, listlessness, irri tability, night cries, bed wetting and progressive anemia. The abdominal cramps were usually in the afternoon and evening, and were becoming more frequent. The child had beelf observed by several physicians in their offices, and in one instance the diagnosis of appendicitis was made. The correct diagnosis, however, might have been made by any one who called at the child's home, because every bit of paint on porch railings, window sills, crib, bureau, chairs ami even white enameled door casings, as high as the child could reach, had been gnawed off. The child was fairly well nourished, and was pale and pot bellied, but of normal height. There was a distinct lead line on the gums. The abdomen was relaxed, and no tenderness was elicited. The spleen was ju st felt. There was no paralysis. The laboratory data were: white blood corpuscles, 15,4C0; red blood corpuscles, 4,000,000; hemoglobin, 50 per ce n t A differential count was normal. There was no stippling, and the red cells showed only the usual "evidence of a secondaryanemia. Lead was recovered from both the urine and the feces. ^ 40Sj ,_ Kopiiic, H t r r y : T h e D iseases c f I n f a n c y a n d C h ild h o o d , P h i.a - 4. H olt. L. E-, J r.: L ead P oisoning in In fa n c y , A m . J . D is. C hild dclpbia, Lea & Feaigev, 1918, p. 793. 2 5 : 229 fM arch ) 1923. . '<r.. Iv' %**.*` . ,^ -V ' -V' >_-? As this child royid not gnaw varnished objects, it was easy to remove the scarce o f lead by refinishing the entire house; n-ithic two w eets, except for some anemia, the child was normal. C a s e ----A g ir l, a g e d 2 y e a r s , n o r m a lly d e v e lo p e d , w h o h a d alw a y s been weL d u rin g th e last m onth h ad h ad th re e series o f convulsions. T h e m o th er stated that the child gnaw ed the paint fro m th e crib a n d th e w indow sills, an d had an uncon tro lla b le d esire to chew an y painted object. E x a m in a tio n w as negative, except for a slight degree of in tern al stnaicsnm s o f th e le ft eye, w hich the m other had n o t noted b e fo re The red wood corpuscles numbered 4,520,000 per cubic m illim eter; the hemoglobin was 60 per cent. No stippling was seen. N o lead =as found in the urine, but there were traces of lead in the feres on tw o examinations. Since the source o f lead has been removed, this child has made a n uneventful recovery and is now normal. V. SYMPTOMATOLOGY 5 The history of the case is very important and may lead to an easy diagnosis after all other methods have proved failures. The appearance of the child is usually striking in the chronic cases of lead poisoning, on accounr of the degree of secondary anemia concomitant with it. In the ezrrr cases, a change of disposition is often the firs: symptom noticed. The child becomes fretful, peevish and restless a: night; the appetite becomes poor; the breath is foul, and frequently hemorrhages occur from the gums. The child may complain of pains in the epigastrium and tire legs. In chronic cases, the pains in the abdomen become continuous ; _d more severe. Constipation is present, Vomiting is zre. There is usually a degree of anemia present, but occasionally the parents overlook all mani festations until the development of cerebral disturbances. Very few cases reported show the characteristic wrist drop so common in adults, but paralysis of the .cranial nerves, particularly the facial and motor oculi nerves, is common. Gibson* reported a group of eye symp toms, which he referred to as "plumbic ocular neuritis." The temperature, as a rule, is normal except in the fatal cases and in those with cerebral disturbances, in which h may reach 105 or 106 F. before the death of the padent- O t the various forms of cerebral disorders produced bv lead, ccmvuisive seizure is by far the most common. There is no way, however, to distinguish the convulsions cue to lead poisoning from those due to other causes. All types of convulsions are seen. They may be local or general; they may be mild or severe. The cpnvul- sions do, however, have one characteristic, and that is 'that they are very persistent and are attended by a high mortality. Colic has been more frequently observed than para- Ivsis. but mors common than either are irritability, restlessness -rA a blue line on the gums. It should be remembered, however, that a continuous lead line is seldom found. The characteristic appearance is the presence of minute black dots in the margin of the mucous membrane around the teeth, which are covered with tartar. It is ditncult to see, and a hand lens should be used. The blood picture, except for a secondary anemia, usually tells us nothing, although this is determined by the duration of the poisoning. If the disease has been 5. A scriorion c t i e sym ptom atology of lead j B iackian. EL D .: Lead Poisoning poisoning in in C hildren, aTTp"m7 sT iu : 577 1917. Fic=:.biGc f Osc=n.UrJ .PJ*' .r T h e D ia g n o sis, P ro p h y la x is a n d T re a tm e n t of r i d s A m t- r e s t Q u e e n s la n d C h ild r e n , M . T. A u s tr a lia 2: tOl _>Se;c- S_1 15IT ; O r t i e Im p o rta n c e of D e-Io n iza tio n in th e T re a t- Em Q u e e r:s ta n d C h ild re n , ib id . 1 : 27 2 ( A p r il 5 ) 1919. present for some time, stippling o fAe red aai \>(cod corpuscles may occur. . . .. ^ Direct evidence of lead poisoning is\ b ta itw d fay t h e demonstration of 7 lead in the urine a: SeceSj il-, ere. is, however, always a larger amount i the -CeceS t lk a o ... in the urine, and it is often present in th1 feces ----- ' cannot be demonstrated in the urine. CLASSIFICATION IN TO GROUPS ABecause of the variability of the sensitiveness of chil dren to lead, a classification into definite groups is difficult, and when made must be based largely on the severity of the predominating system. Turner divides lead poisoning in children into four groups: -- -. - 1. Paralytic cases showing symmetrical wrist-drop, foot-drop, spasm of the calf muscles and, as a secondary r;-;-VAr:~ lesion, a persistent talipes equinus. 2. Cases characterized by pains in the abdomen and .' '.'V- limbs, concomitant with habitual constipation, and occa-. - 7*" i *. sionally a blue line on the gums. These children are usually irritable and neurotic. 3. Children suffering from ocular neuritis; viz., a \ 1 neuritis involving the optic, oculomotor, abducens and .. r : trochlear nerves. ...... 4. Eclamptic cases with severe and persistent convul sions, which often end fatally. . We are indebted to Australian observers for most of the literature regarding lead poisoning in children, and for an historical account of lead poisoning in the chil dren of Queensland, from the first recorded cases in 1892 to 1917. A recent article8 records the probable success of efforts to have an act passed prohibiting the use of white lead paint on veranda railings and outside surfaces within the reach of children's fingers. k TREA TM ENT The treatment of this condition may be considered from three points of view; 1. Prophylactic. Careful supervision of children during the age (from 1 to 3 years) in which pica is most prevalent. Wide publicity and education through periodicals and home journals, in order to educate the parents. 2. Symptomatic. For the spasms, chloroform inhala tion is the only agent that is efficacious; for the anemia, the various forms of iron and arsenic; for the local pal sies, massage and electricity, and for the permanent palsies, surgery should be resorted to, if possible. 3. Medicinal. For the removal of lead from th e ' system, potassium iodid, from 3 to 5 grains (0.2 to 0.3 gm.) three times daily with a morning purge of magnesium sulphate may be tried. This is the usual method, although in severe cases it is not well to give. the iodids, since, according to some writers, the libera tion of the lead that has been deposited in the tissues may increase the severity of the symptoms.' Gibson,8 in 1919, reported successful treatment by the two-ba:h ionization system. The patient places both hands on an aluminum plate immersed in a salt solu tion, which is connected with the negative pole, and both feet likewise in a similar bath, which is connected with the positive pole. From 7*/> to S1 * volts and 25 7. C o n sid erab le u rin e is ev a p o ra ted to d ry n ess, a n d 50 c.c. of fu m in g n itric acid is a d d e d ; a fte r th e reac tio n has su b sid ed , it is allow ed to sim m er over th e free flame fo r one-half h eu r, ar.d ^then 25 c.c. m ore acid is added th re e tim es each fifteen m in u tes. T h e fluid is then evapo rated to a sm all volum e, neu tralized w ith sodium hyuroxid. filtered anil th e lead tested w ith hydrogen sn ip hid, w hich will give a brow n precipitate. 8. A n H isto rical A cco u n t of th e O c cu rren c e an d C ausation c f L ead P o is o n in g A m o n g Q u e e n s la n d C h ild re n , i l . J. A u s tr a lia X: l-3 ( F e b . 11) 1922. - V INJURY OF RECTUM--MARBURY J our. A. M. A. M ay 24, 1924 ,, rr.iU iam p eres o ? c u r re n t g iv en fo r o n e -h a lf h o u r, d a ilv . T h e lead is d e p o site d o n th e a lu m in u m p late in th e n egative bath . ' CONCLUSIONS 1. P ic a is o n e o f th e m o st im p o rta n t etiologic fa cto rs in lea d p o iso n in g in ch ild ren . truck entered an alley, and crushed between it and the side of a brick wall. He was brought soon afterward to the emergency hospital. The pupils-w ere equal and reacted to light and in accommodation. T he tongue w as coated. The teeth and gums were in good condition. The tonsils were slightly enlarged, but the pharynx was otherw ise normal. / :. ' r&j I 2. T h e r e are m a n y m ild c a ses o f lea d p o iso n in g in . ch ild ren , m a n ife ste d b y sp a sm s o r colic, th e tru e n a tu re o f w h ich are n ever su spected . 3. E n e r g etic p rop h ylactic m e a su r e s sh o u ld b e e m p lo y ed w ith ch ild ren w h o h ab itu ally eat p ain ted a r tic le s . 4. T h e feces an d the u rin e sh o u ld b e e x a m in ed for lead in all ch ild ren w ith co n v u lsio n s in w h ic h th e e tio lo g ic fa c to r is n o t C lear. There were several palpable cervical glands. The chest was firm, and expansion was good and equal on the two sides. The percussion note was resonant throughout. The breath sounds were clear. The heart was not enlarged, but there was a soft systolic murmur at the apex not transmitted to the axilla. The abdomen was slightly distended and tender in the region of the bladder. About the rectum, running anteriorly, there 1002 Pacific Mutual Building. . ' was a laceration, which seemed to go through the TRAUM ATIC INJURY OF THE RECTUM sphincter. There was much \ ' l bleeding, some of which appeared to come from high A ".T 'lr-"-" ` R EP O R T . O F C A S E * . _ \V.. B. MARBURY, M.D. W A S H IN G T O N , D. C. up in the rectum. An at tempt was made to pass a catheter,' but this was un successful and only a little blood was obtained. On m In looking over the literature, including' that at the - Surgeon General's Library, on injuries to the rectum. I have been unable to find a case similar to the one .... reported here. Gant epitomizes sixty-four cases that - ' fell under his personal observation. These may be v classified as;- ' . ' - 1. Those due to injury from "foreign bodies, either further examination it was found that the laceration at the rectum included both sphincters and part of the perineal raphe. The finger could be passed upward anterior to the mucous membrane of the bowel, and F ig. 2. -- M uscles being su tu red over th e rectu m e n m asse; are a be tw een su tu red m uscle an d skin packed lightly w ith . gauze (not show n). ' - y,,'. .A , "during instrumentation or as result of accident. Among V; these, fish-hooks, gunshot wounds, falling on palings or stabs, and use of the speculum and dilators play a conspicuous part. / 2. Rupture of the sphincter*due to pederasty, or of the perineum during parturition. Rupture of the recto vaginal septum during copulation, 3. Rectovaginal r e n t the sharp edges of the " V - ,: broken ramus on the right side could be felt. A lso the urethra w as torn in this region, and urine was passed through the opening. Whenever the patient's legs w ere moved in any way, he experienced great pain in the region o f the symphysis. Once when we were moving the patient, the whole pelvis was seen to rock irregularly, and definite crepitus was obtained. There was no evidence of injury to the extrem ities. The patient was sent to the operation room. Under general anesthesia, and with the patient in the lithotom y position, a Cl induced by rectal disten more thorough examination was made. . T h e rectal tube was tion with an air-filled rub ber bag. 4. Perforation of the rectum by foreign bodies left in the abdomen. - 5. Ulceration due to phenol (carbolic acid) or turpentine. T h e anatomic struc tures most usually affect ed are the rectum or sig found practically intact, but the muscles anterior to it were tom and retracted on both sidcs so as to appear only laterally, and retracted far back toward the posterior surface. The rough edges of the fractured "descending ramus of the pubes could be felt. The opening in the urethra w a sm o tm a d e out. The tom sphincter muscles and th e :levator.' ani were brought together over the midline anteriorly and sutured with chrom ic catgut. This procedure was facilitated by keeping one finger . in the rectal tube/ The area above this was le ft open, and a sm all amount of packing was placed in the space for drainage and to control oozing. A cast w as applied from the knees t o . the costal margin. ' " A .'V - . - -1 F ig. rrcrura tor lartcr^jv-^ \ fev 4 r& sM S ^ *' *-> . ' \ w\\\1\ A\\ \\\ v\\\va > moid, urethra, one or Dr. G roover.reposed that exam ination of the lumbar spine, ' both sphincters, the leva pelvis and hips showed the presence of a dislocation o f the tor ani muscle, and the right innominate bone, with a fracture o f the descending r e c to v a g in a l septum . ramus of the pubes on the right sid e; the pubic sym physis 2Only in one case was there mention of any in- that was when the coccyx kick during a fight, case reported here are rectum were torn and tact ; rupture of the :ending ramus of the was separated approximately 1 inch and there was, of course, necessarily some compensatory damage in the sacro-iliac joints. .. ; N The following day the patient seemed a little better, though very restless. There was some abdominal distention, and he - complained of the cast being too tight. T his was loosened. e was copious drainage of pus from the peroneal wound, the temperature rose to 102.2 F . H e void ed involuntarily . through the urethral rent. T w o hundred cubic centi- 'l- __ rs of physiologic sodium chlorid solution was given by Bypodermoclysis. August 14, he had an involuntary defeca w h ile riding on the tion. He had a frequent desire to urinate by th e normal route, ' was thrown as the but without success. A ugust 28, or seventeen days after let of C olum bia M od- admission> there were sm e signs of the patient's regaining control of the bowels, but the urethral fistula persisted.