Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

A mother called me one Sunday evening to tell me that her se ven -year-old daughter was wheezing. They had just returned from a visit with relatives at the seashore. The girl was having no difficulty breathing, so I told the mother to bring her to the office in the morning.

The next day I arrived early and carefully reviewed Amanda's chart. There was a history of occasional attacks of hives, but no other notes on allergies - no hayfever and no asthma.

But I knew that this did not rule out a sudden asthmatic attack, for I personally had experienced my first asthmatic attack suddenly, after sweating profusely in a steam room at a health club and then diving immediately into an ice cold pool in the next room.

The mother brought her daughter to my office at 9:00 A.M. and I proceeded to take a history. I might add, at this point, that as part of my pediatrie background I had undergone a psychoanalysis and always obtained a careful emotional as well as physical history when there was any question.

Amanda was still wheezing slightly as she answered my questions. She never remembered wheezing before. She was visiting her cousin, a girl of 12, at their seashore home. Her cousin had two cats, the weather was warm and the girls went swimming. While she was visiting, her cousin had her first menstrual period - and the excitement and sight of blood disturbed Amanda greatly. She had no previous knowledge of menses.

Was this asthma, I thought, and if so, could it have been due to the emotional shock from being with and observing her cousin's first period, or could she have reacted to the cats or some other unusual factor in the environment?

I examined Amanda. She had no respiratory difficulty, but there was audible wheezing. Her nose, ears and pharynx were clean. The cervical nodes were moderately enlarged but not tender. On ausculation, the rhonci and some sibilant rales were limited to the right lung.

I had a flu oroscope in my office at that time, as did all well-equipped pediatricians. As a matter of fact the dangers of fluoroscopy were not yet completely known.

And so I stood the child behind the fluoroscope screen and pressed my foot on the floor pedal. I was shocked by what 1 saw - a large anterior mediastinal tumor on the, right side.

At the hospital Amanda was quickly diagnosed as having acute lymphoid leukemia. In 50 years of pediatrie practice I, fortunately, had very few cases of cancer among my patients. But, I shall never forget this little girl. She brings to mind several important facts for all pediatricians. First, in all children with acute wheezing, the first diagnostic approaches to consider, besides allergy, are other causes such as foreign bodies or masses obstructing the trachea either from without or within. An x-ray is always indicated. The second important admonition is to never consider a condition as one of emotional origin unless all possible physical causes have been ruled out first.

According to recent statistics, acute leukemia has an incidence of two per 100,000 in children under 15 years of age. Unfortunately, I had two cases among my private patients during my years of practice - both at a time when the diagnosis of leukemia was a death warrrant.

Having always been interested in medical history, and having lived through its most exciting years, I think back on those years when we were coming out of medical darkness - and some of those years are comparatively recent.

The accepted…

A mother called me one Sunday evening to tell me that her se ven -year-old daughter was wheezing. They had just returned from a visit with relatives at the seashore. The girl was having no difficulty breathing, so I told the mother to bring her to the office in the morning.

The next day I arrived early and carefully reviewed Amanda's chart. There was a history of occasional attacks of hives, but no other notes on allergies - no hayfever and no asthma.

But I knew that this did not rule out a sudden asthmatic attack, for I personally had experienced my first asthmatic attack suddenly, after sweating profusely in a steam room at a health club and then diving immediately into an ice cold pool in the next room.

The mother brought her daughter to my office at 9:00 A.M. and I proceeded to take a history. I might add, at this point, that as part of my pediatrie background I had undergone a psychoanalysis and always obtained a careful emotional as well as physical history when there was any question.

Amanda was still wheezing slightly as she answered my questions. She never remembered wheezing before. She was visiting her cousin, a girl of 12, at their seashore home. Her cousin had two cats, the weather was warm and the girls went swimming. While she was visiting, her cousin had her first menstrual period - and the excitement and sight of blood disturbed Amanda greatly. She had no previous knowledge of menses.

Was this asthma, I thought, and if so, could it have been due to the emotional shock from being with and observing her cousin's first period, or could she have reacted to the cats or some other unusual factor in the environment?

I examined Amanda. She had no respiratory difficulty, but there was audible wheezing. Her nose, ears and pharynx were clean. The cervical nodes were moderately enlarged but not tender. On ausculation, the rhonci and some sibilant rales were limited to the right lung.

I had a flu oroscope in my office at that time, as did all well-equipped pediatricians. As a matter of fact the dangers of fluoroscopy were not yet completely known.

And so I stood the child behind the fluoroscope screen and pressed my foot on the floor pedal. I was shocked by what 1 saw - a large anterior mediastinal tumor on the, right side.

At the hospital Amanda was quickly diagnosed as having acute lymphoid leukemia. In 50 years of pediatrie practice I, fortunately, had very few cases of cancer among my patients. But, I shall never forget this little girl. She brings to mind several important facts for all pediatricians. First, in all children with acute wheezing, the first diagnostic approaches to consider, besides allergy, are other causes such as foreign bodies or masses obstructing the trachea either from without or within. An x-ray is always indicated. The second important admonition is to never consider a condition as one of emotional origin unless all possible physical causes have been ruled out first.

According to recent statistics, acute leukemia has an incidence of two per 100,000 in children under 15 years of age. Unfortunately, I had two cases among my private patients during my years of practice - both at a time when the diagnosis of leukemia was a death warrrant.

Having always been interested in medical history, and having lived through its most exciting years, I think back on those years when we were coming out of medical darkness - and some of those years are comparatively recent.

The accepted reference books on pediatrie therapy will frequently tell the story. Chemotherapy for childhood malignancies was first instituted in the late 1950s and scattered results were reported during the 1960s. It is interesting to note that in Shìrkey's Pediatrie Therapy, of 1968, Dr. M. Lois Murphy of Memorial Hospital, New York City, wrote "The physician who is trying to select a course of treatment for a child with cancer may be led into a pessimistic, do-nothing attitude because of statements that all chemotherapeutic drugs are toxic or into an overenthusiastic attitude based on the latest report of a new drug." She suggested waiting ten or 20 years until the reports of adequate studies could be reported.

Dr. Murphy noted that of 768 patients (506 children and 262 adults) with acute leukemia treated at Memorial Hospital from 1948 to 1958 only four patients survived longer than four years.

Contrast this with a report in a late edition of Current Pediatrie Therapy edited by Gellis and Kagan, in which it is stated that since the majority of children with acute lymphocytic leukemia now survive more than five years, cure, not merely palliation, should be the initial aim of treatment in every case (Dr. Carole Hurwitz, U.C.L.A.).

Fortunately, cancer in infancy and childhood is comparatively rare. But the fact that it is so rare and that early diagnosis is urgent if a child is to derive the best from modern therapy, makes quick recognition an obligation for all pediatricians.

Recognition is the first step; the second is to refer the child to an oncology center. The treatment of cancer is complex and should definitely be in the hands of specialists. More effective and less toxic chemotherapeutic drugs are always being developed. The oncologist not only has the experience of treating many children, but also has the advantage of receiving the latest therapeutic results from all centers.

This issue of Pediatrie Annals and the two subsequent issues will deal with the important subject - Cancer in Infancy and Childhood.

The Guest Editor for this symposium, a pediatrie oncologist with a wealth of experience, is Dr. Carl Pochedly, Director of Pediatrie Hematology/ Oncology at the Nassau County Medical Center, East Meadow, New York.

The total symposia will be divided into three segments: hematological malignancies, malignant tumors, and cancer therapy.

The first article is on "Acute Lymphoid Leukemia," and is written by one of the national authorities on the subject - Dr. W. Archie Bleyer, Scholar of the Leukemia Society of America, and Associate Chairman for Leukemia Studies, Department of Pediatrics, University of Washington, Seattle.

This excellent and interesting article clearly reviews our present knowledge of acute lymphoid leukemia.

Dr. Bleyer notes that although the cause of leukemia is still unknown there are certain contributing or predisposing factors including ionizing radiation, chemical carcinogens, certain viruses, and genetic factors.

The physical, laboratory, and differential diagnosis is then considered, followed by the modern methods of staging which not only forecast prognosis but direct improved therapeutic approaches. It is of importance to note that the initial white blood cell count is the most powerful predictor of outcome.

The article concludes with a discussion of current therapy and problems still remaining, such as the laboratory detection of residual leukemic cells as one of the attempts to define complete remission.

The second paper in this present symposium is on acute non-lymphoid leukemia in childhood, and is contributed by Dr. Carlton Dampier and Dr. Robert R. Chilcote, both of the Section of Hematology/ Oncology of the Department of Pediatrics at the University of Chicago, Pritzker School of Medicine.

The authors start by noting that this acute nonlymphoid leukemia (ANLL) is far more refractory to therapy than is acute lymphoid leukemia. Although the etiology of ANLL is unknown there is some evidence that in many cases chromosome abnormalities may be associated with it as well as some immune dysfunction. This interesting aspect is covered in the article.

The most recent treatment and supportive therapy are discussed, the latter referring to iatrogenic conditions occurring as a result of the therapy.

The next contribution is on "Hodgkin's Disease" and is written by Dr. Charlotte T. C. Tan, Attending Pediatrician, Department of Pediatrics at the Memorial Sloan- Kettering Cancer Center, New York City, and Dr. Ka Wah Chan, Assistant Professor of Pediatrics, University of British Columbia, Vancouver, Canada.

This is a clear and well-written review covering all aspects of the disease. Of special interest is the staging of Hodgkin's disease and the optimum therapy indicated. It is noted that irradiation in high enough dosage is curative for localized Hodgkin's Disease. However, patients with advanced stages require the addition of chemotherapy. With this combination, 75% of patients with advanced stages have achieved continuous, complete remission. The side effects of diagnostic and therapeutic maneuvers are also discussed including the impairment of growth and development.

The final article deals with "Non-Hodgkin's Lymphoma" and is authored by Dr. Renée V. Gardner and Dr. John Graham-Pole of the Division of Hematology/ Oncology of the U niversity of Florida. The paper begins by emphasizing that the adult and childhood forms of non-Hodgkin's lymphoma (NHL) show distinct differences: the pediatrie form being characterized by non-contiguous dissemination, a tendency for early leukemia conversion, mediastinal involvement and invasion of the meninges.

Possible etiological factors such as viruses and immunoregulatory defects are discussed, and it is briefly noted that genetic, environmental and possibly infectious agents all play a role in the genesis of NHL.

The authors note in their section on therapy how greatly the modern mortality figures have improved. Whereas in 1970 the median survival of children with NHL was approximately six months, today survival rates of 50% to 80% are being reported. With current chemotherapeutic regimens 90% of the children with this disease will enter remission. New approaches such as bone marrow transplants, interferon therapy and the use of monoclonal antibodies have been reported.

This issue of Pediatrie Annals should be of great importance and interest to all practicing pediatricians for it covers the most frequent malignancies encountered in childhood.

10.3928/0090-4481-19830401-01

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