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This fifth edition is a timely and welcome one because of recent management changes in the treatment of acute poisoning. The routine use of syrup of ipecac as the primary household emetic has been supplanted by immediately calling the Poison Control Center, which may then recommend ipecac or, more likely, other measures and actions. General management of poisoning and overdoses is more important than the use of specific antidotes. Nevertheless, important antidotes or antagonists are still useful and recommended for special situations. Each chapter ends with an in-depth discussion of the relevant antidotes for the particular type of poison. I particularly enjoyed the historical account of the "birth" of the Poison Control Center concept and movement, since I was a member of the first Accident Prevention Committee of the American Academy of Pediatrics when it made the survey of its 3000 members in 1952 seeking the most prevalent childhood accident.

As one who always found Dr Goldfrank's articles in the Hospital Physician journal informative and useful, I especially welcomed this expanded second edition of his handbook with eight contributors. The editors have compiled ten major sections and 46 case presentations, twice as many as in the first edition, which not only cover the primary toxicological problems of interest and concern, but also many of the current controversies in the management of acute and chronic poisoning.Major headings include "General Management of the Poisoned and Overdosed Patient," "Alcohol," "Analgesics," "Botanicals," "Toxic and Hallucinogenic Mushrooms," "Food and Plant Poisoning," "Cyanide," "Heavy Metals," "Insecticides," and "Mixed Problems." Also included are many other specific and general toxic drugs and chemicals. At the end of each chapter there is a list of suggested readings and ample references.A new segment of this second edition is the self-assessment section with 460 questions (ten per case study)

THERE are not many effective, useful, specific antidotes for poisoning, and their overuse often complicates the initial injury by producing other forms of poisoning. As I mentioned in part I (232:1272,1975), sensible selection and use of drugs and other therapy for symptomatic and supportive treatment of poisoning are more likely to save lives than ill-considered and heroically applied therapy. Tables 1 and 2 list most of the general and all of the specific antidotes now available to the physician for emergency use, and these can be combined with the symptomatic and supportive drugs and measures on hand. The "universal antidote" of burnt toast (charcoal), milk of magnesia (magnesium hydroxide), and strong tea solution (tannic acid) is ineffective and obsolete. It can do more harm than good, mainly because it often gives a false sense of security, and because preparing and administering it takes up valuable time. Antibiotics Antibiotics are often

ACUTE poisoning, unfortunately, is often mismanaged. It is impossible at times to determine whether recovery occurred because of or in spite of the treatment used. Although poisoning is a common pediatric problem, many other specialists are involved (obstetrician, neonatologist, internist, family physician, surgeon, etc), and it has an interface with many disciplines (environmentalism, sociology, and others). The basic treatment for acute poisoning, whether drug or chemical, is mainly symptomatic and supportive. Overtreatment of the poisoned patient with large doses of non-specific and questionably effective antidotes, stimulants, sedatives, and other therapeutic agents often does far more harm and damage than the poison itself. A calm attitude, with the judicious use of drugs, parenteral fluids, and electrolytes for homeostasis, and the maintenance of an adequate airway is far more effective than heroic measures, which usually are unnecessary. The four cardinal principles of good management are (1) identification of the drug or chemical

In this small monograph on general toxicology, with consideration for its molecular and biochemical principles, the goal is to provide briefly the three main phases of toxic action as it relates to various compounds: (1) the exposure phase, which includes factors that determine the uptake of the toxic agent from the environment, (2) the pharmacokinetic or toxokinetic phase, which includes processes such as adsorption, distribution, metabolism, and excretion factors that determine the biologic availability of the toxic substance, and (3) the pharmacodynamic or toxodynamic phase, which covers the various mechanisms involved in the induction of the toxic effect on specific organs or systems. Included in the publication are the dose-response and time-response relationships necessary for a full understanding of toxicological mechanisms, interaction among various compounds, a focus on the systemic site of action by toxic agents, which relates to the specific kind of injury produced, toxicological risks of dangerous substances

When Oliver Wendell Holmes wrote "To guard is better than to heal, the shield is nobler than the spear!" he must have had in mind the origin, many years later, of the poison control center movement. In 1952, the American Academy of Pediatrics (AAP), through a survey by its newly appointed Committee on Accident Prevention, found that the most common medical emergency in children was poisoning. The study brought forth many requests for up-to-date information on toxic ingredients in household products, as well as for improved therapeutic measures. This gave impetus to the development and implementation of poison control centers in the United States, an endeavor practically all-pediatric oriented. Then, the development of safety closures and packaging and the Poison Prevention Packaging Act in 1970 rapidly followed. This is a historical account of the AAP's role and the combined efforts of practicing and academic pediatricians in a mid-20th century movement that has saved countless children's lives.

The venoms of snakes are complex mixtures, chiefly proteins, many of which have enzymatic activities. Tu has, in one comprehensive volume, analyzed the venoms of snakes, scorpions, spiders, bees, wasps, ants, and Gila monsters to establish a better and more complete understanding of the chemistry and pharmacology of these variable toxins. During recent years it has been shown that the more deleterious and lethal fractions of snake venoms are certain peptides and proteins of relatively low molecular weight, some of which are 5 to 20 times more lethal than the crude venom. Tu describes in detail the enzyme and protein content of venoms, giving an extensive treatment of the molecular aspects of venom components. The effects on cell membranes, blood coagulation, and subsequent hemorrhagic complications are well documented. Even the metabolic and teratogenic effects of snake venom are briefly discussed. Added pluses for this book are the comprehensive reviews of

Since demands are increasing for toxicological information on every aspect of environmental hazards, the toxicological sciences must have a broad, multidisciplinary, and active role in providing a safer environment than now exists. This is a difficult task, indeed, and will become even more difficult in the future. The essentially negative attitude of the past—"What will kill?"—must be replaced with a positive position for the future, "What is safe?" Toxicology: The Basic Science of Poisons is a publication sorely needed to supplement the few available textbooks of toxicology for the increasing number of individuals entering training programs in this field. The book has four comprehensive sections or units. The first describes the method and approach that identify the science of toxicology, including those principles, such as dose-response, necessary for a full understanding of toxicological mechanisms. Unit II, which focuses on the systemic site of action of toxins, provides answers to two

In Reply.— The JAMA articles on poisoning were, of necessity, brief, and not all therapeutic and preventive measures could be included. I am very familiar with the Sobel and Margolis study and report, and I certainly agree that Dr Copan's eighth preventive measure is important and should be included. Family evaluation by the poisoned victim's physician should be part and parcel of the treatment, but, unfortunately, most practicing pediatricians are far too busy for any lengthy investigation, and early appointments with a child psychiatrist, if one can be found, are difficult to obtain. The millenium in poison prevention has never been reached—and probably never will.

This compendium on the treatment of common acute poisonings reflects the authors' experience in Scotland, where 80% of the incidence is due to self-poisoning in an age group of 18 to 25 years. This is in marked contrast to the United States, where the reverse is true. Because of the preponderance of small children involved, acute poisoning here is mainly a pediatric problem. The lack of enthusiasm for the use of syrup of ipecac as an emetic will be questioned by most pediatricians and others working in this area. The same might be said for the safe dose of apomorphine (followed by levallorphan tartrate [Lorfan], a narcotic antagonist), which is being used in some medical centers exclusively and effectively because of its prompt action. The chapter on "Basic Principles of Psychiatric Treatment," necessitated by the self-poisoning group, is brief and informative, with material usually not found in books of this

The numerous reports in the literature of poisoning due to salicylates apart from manifestations of an allergic idiosyncrasy to the drug indicate that salicyl compounds are not always the harmless household remedy that they are generally supposed to be. The ingestion of large amounts of salicylates by children accidentally or by adults with suicidal intent account for the majority of the reported instances of poisoning. Occasionally, however, intoxication results from intensive therapeutic use of the drug. The typical picture of salicylate intoxication has been described by many authors. A most common symptom is rapid, deep respiration. There are usually vomiting, extreme thirst, profuse sweating, moderate or high fever, mental confusion or delirium and sometimes convulsions. Late in severe poisoning there may be cyanosis, respiratory and cardiac failure, coma and death. There is often polyuria at first, with scanty urine or anuria as the intoxication develops. The urine reduces copper solutions

This 370-page comprehensive monograph, Acute Barbiturate Poisoning , deals with the subject in all of its aspects, including scientific information on biochemistry, pharmacology, and toxicology, as well as the diagnosis, specific treatment, prevention, and the psychosocial problems involved. The management includes special methods of therapy in detail, with an important chapter on evaluation of these treatments. There is also a chapter devoted entirely to barbiturate poisoning in children which will be useful and helpful to the pediatrician when this emergency arises. Intensive supportive therapy is emphasized throughout as the preferred treatment, with statements that alkaline diuresis is rarely needed, while peritoneal dialysis has a very limited role, with hemodialysis having a definite place only "in a few very select cases." Assessment of the patient with acute barbiturate poisoning is based primarily on the clinical criteria, and the blood barbiturate level is considered secondary in importance. It never takes precedence, because of

Foreword Wilburt Cornell Davison†, MA, MD, DSc, LLD, the son of a Methodist minister, was born in Grand Rapids, Mich, April 28,1892. On reaching this milestone, his 80th birthday, former students, colleagues, and Duke faculty members have put together this Festschrift as a small token of their esteem and warm affection for a man who, in 1927, at the age of 35, was chosen to plan, organize, and build the new Duke University School of Medicine and Hospital. While many helped at the outset and during the intervening years, the present Duke Medical Center and all that it has accomplished stands as its own tribute to the first Dean and Pediatric Chairman who directed the Medical School from the ground up and guided it to the place of prominence and eminence which it now holds. The dean, or "Dave," as he liked to be called, was a humorous, dynamic, and

This basic science text presents the various biological and chemical factors that are involved when chemicals produce harmful effects on biological cells, systems, or whole animals. Dr. Loomis draws upon his experience as a practicing toxicologist and professor of pharmacology to identify and describe the causes and mechanisms in chemical-induced toxicity. He discusses, among other topics, mechanisms in the translocation of chemicals within the biological specimen; biotransformation mechanisms which alter structure, pharmacological action, and toxicity; factors responsible for nonselective as well as selective action of chemicals on various biological specimens; genetic and immunologic mechanisms involved in toxicity; the merits and deficiencies of the use of statistics in evaluating of harmful effects of chemicals. Essentials of Toxicology is a valuable general source of information on the modern concepts of toxicity from chemicals.

Rowland 1 has suggested that Hand-Schuller-Christian disease is due to a primary constitutional alteration in the metabolism of lipoids, which results in an excessive accumulation of lipoids in the blood and in other tissue fluids and which gives rise to a massive storage or infiltration in various tissues of the body. Thus, this disease is viewed as belonging to a general group of lipoid disturbances which includes Niemann-Pick disease, Gaucher's disease and cutaneous xanthomatosis. Most descriptions of the condition refer to associated alterations in endocrine functions. Christian 2 regarded the disease as an "unusual syndrome of dyspituitarism." Diabetes insipidus, a common symptom, suggests possible involvement of the intermediate and the posterior lobes of the pituitary. The fact that the disease has been associated with intercurrent acromegaly, with adiposogenitalism, with dwarfism accompanied by genital hypoplasia and with pituitary cachexia (Simmonds' disease) is an additional reason for the belief that the pituitary

Of all violent deaths those produced by poison are the most difficult to discover, to prove scientifically, and to adjudicate. The cause of death in poisoning or suspected poisoning requires the cooperative efforts of attending physician, pathologist, and toxicologist. Toxicologic analysis of body fluids (blood, urine) or of the poison itself plays an important role in the diagnosis of accidental and acute poisoning due to certain common drugs (aspirin, phenothiazines, barbiturates, and many others) and for heavy metal (lead, arsenic, mercury, etc) and chemical determinations. Except for certain patients with chronic poisoning, treatment must be started immediately, and often it is difficult for a toxicologist to analyze a specimen of a completely unknown poison quickly. Even when this is possible, results are often delayed because of the techniques used. The purpose of Alan Curry's book, "to detect the unknown poison," is fulfilled in easy-to-follow sequences describing the new techniques which

This brightly covered book with its unique title represents the edited proceedings of a recent seminar on the "Clinical Pathology of Infancy" held in Washington, DC, under the auspices of the Association of Clinical Scientists. A total of 67 contributors have written brief and generally useful articles under four broad headings: congenital brochemical disorders, endocrinology and metabolism, clinical pathology of systemic diseases, and cytogenics. Many articles are concerned with new and useful technical procedures; others are clinically oriented. Illustrations and diagrams are clear. Except for a few chapters, references are ample and current. The chapter on laboratory diagnosis of respiratory disease, classification of sexual abnormalities, and the entire section on cytogenetics would be of interest to the practicing pediatrician as well as those concerned with investigative and laboratory services. The subject of congenital dysproteinemias suffers from brevity. This important area might have been amplified and more attention given to the

This is a 103-page monograph of a ten-year study of "Sudden Unexpected Death in Infancy" (SUD or Cot Death) occurring in Copenhagen, a city of 1,348,000 people in the northern part of the temperate zone. The relationship of SUD to total infant mortality, artificial feeding, age (2 to 4 months), seasonal variation of births and deaths (predominately in winter), simultaneous twin deaths (rare), and typical case histories are discussed. Legal autopsies were performed on 164 infants during a six-year period (1957 to 1963) at the University Institute of Forensic Medicine with complete histological examination of all organs along with extensive bacteriological and virological studies. On the basis of these examinations three separate and distinct groups were found. Group 1 was comprised of 43 infants in whom the cause of death was established convincingly. In group 2 (41 infants), minor pathological changes (predominantly slight respiratory infection) were found that were not

• The treatment of poisoning by ingestion is as complex as is the enumeration of poisoning agents. There are, however, many practical and general principles that may be applied to any case in which a poison has been taken by mouth. The essence of treatment of any type of ingested poison is the often life saving procedure of emptying the stomach as quickly as possible. Unless the patient is comatose or in cases of poisoning due to petroleum distillates and corrosive agents, gastric lavage should be carried out in every instance. Where emesis is impossible, chemical antidotes may be administered in the lavage fluid. While specific treatment and supportive measures are of great importance, prevention through education is the basic means of avoiding these tragedies.

History .—A colored boy, aged 6, entered Duke Hospital on Aug. 13, 1933, because of headache, dizziness and unconsciousness. He had been well until two days before admission. At that time, he complained of "stomach ache," which disappeared after catharsis. The next morning his head ached and, shortly afterward, he became dizzy and drowsy, and was too weak to climb into bed. His left arm and leg made spasmodic movements and his right limbs were powerless. Speech was only slightly impaired until later in the day, when he became stuporous. He had taken no food or water for twenty-four hours preceding admission to the hospital. The family history was interesting in that a brother had died several months previously after the onset and course of symptoms similar to those of this patient. A sister, aged 12, had had "rheumatism" for several years and her blood smears showed 25 per cent

The accidental ingestion of drugs causes 35% of deaths from poisoning in children 1 to 5 years of age. In this age group the incidence of poisoning from drugs is, however, far greater than that from household agents. Mellins and co-workers 1 reported the incidence of drug poisoning alone from the Chicago Poison Control Center as 50.6%. Recent figures from the National Clearing House, as reported by Cann and associates, 2 showed that 50% of the 4,000 cases reported from 29 poison control centers were due to the ingestion of drugs. Figures from the New York Poison Control Center are even higher—an amazing 70%. 3 In 1956 over 3.5 billion dollars was spent for drugs in the United States, so there is little wonder that poisoning is so frequent in infants and children who learn by exploration, questioning, sampling, and trial and error. They are particularly susceptible to the accidental

The intravenous administration of any appreciable quantity of fluid in cases of pneumonia has usually been considered a hazardous procedure because it increases the load of an already overtaxed myocardium and pulmonary circulation. However, there is little ground for the belief that the circulation will be embarrassed by transfusions at a time when the total circulating volume is decreased. To normal dogs with vascular beds that contained the normal quota of blood, Meek and Eyster1gave intravenous injections of whole blood, physiologic solution of sodium chloride and solution of acacia in quantities varying from 25 to 103 per cent of the total blood volume without increasing permanently the diastolic size of the heart as demonstrated by roentgen ray measurements. Estimations of the hemoglobin content indicated that most of the injected fluid was still in circulation; the capillaries and venules acted as reservoirs for the storage of excess fluid. Rose

The September 1969 issue of the British Medical Bulletin is a symposium on Mechanisms of Toxicity dedicated to Sir Rudolph Peters, the distinguished biochemist, on the occasion of his 80th birthday. It is very difficult to decide from limited observations on animals in the laboratory or on exposed human populations whether or not a degree of exposure to a toxic substance is having an adverse effect. Extrapolation of experimental animal data to humans is often unreliable, but nevertheless, without basic studies, our knowledge about toxic hazards in the human environment would be limited indeed. Mechanisms of Toxicity provides many clues for the study of reaction between poisons and the cells in the intact animal; how poisons attack a target organ such as the liver or the kidney, the whole field of drug and chemical metabolism, and many other facets involved in an interdisciplinary approach. Twenty-three outstanding British biochemists, toxicologists, experimental

To the Editor:— I am writing in defense of safety closure caps, as a reply to Dr. W. M. Schmidt's letter inThe Journal(180:1144 [June 30] 1962). With over 4 million babies born each year and with miniature drug stores in every home, drug poisoning in children, can soon become a colossal and even more tragic problem in a few short years. I should like to see a safety enclosure of some type (not necessarily the one in my published report) placed on all bottled medications, proprietary and nonproprietary, and on all household products with toxic chemicals as well. Over one-third of the poison fatalities in children are due to drugs, and the incidence runs a good bit higher—over 50% Safety caps are not fool-proof by any means. Children will at times circumvent any and all precautionary measures. Yet, for each child successful in removing the cap, there

The diagnosis of morbidity or mortality by poisoning is one of the most difficult to discover and to prove scientifically; It requires cooperation in the efforts of attending physician, pathologist, and toxicologist. If treatment of poisoning is to be effective, in most cases it must be started immediately; analytical techniques must be rapid and up-to-date so that an early diagnosis can be established. Kaye's Emergency Toxicology (third edition) describes rapid and presumptive tests for the common poisons, such as alcohol (ethyl and methyl), aspirin, salicylates, phenothiazines, barbiturates, arsenic, mercury, carbon monoxide, and bromides. These tests (including infrared spectrophotometry, gas chromatography, and thin layer chromatography) are reliable, relatively simple, and easily performed. Each is described in detail, and in most cases several tests for each poison are offered so that each laboratory will have the option of choosing those best suited to their facilities and needs. The book is divided

Disorders of the Respiratory Tract in children is a timely pediatric text, edited by Dr. Kendig, with 29 authoritative collaborators discussing these various disorders in considerable depth, a virtue lacking in most books devoted to general pediatrics. References at the end of each chapter are plentiful and current. (The item on "Congenital Malformations of the Lower Respiratory Tract" has two pages of references within its 31/2 pages of material.) The 38-page chapter on asthma by Susan C. Dees, MD, is one of the highlights of this book. Dr. Dees' long experience in this area is clearly demonstrated by her authoritative discussion of the symptomatology and treatment of asthma in its various types and degrees of severity. The section on "Aspiration Pneumonia" presents a good analysis of the controversy on gastric lavage for petroleum distillate ingestion. There are ample, excellent radiographic illustrations of the early and late pulmonary changes that occur