Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
CLINICAL TOXICOLOGY 1 2 ( 3 ) , pp. 291-296 (1978)
The History of Poison Control Centers in the United States
ROBERT G. SCHERZ, M. D. * Medical D i r e c t o r M a r y Bridge C h i l d r e n ' s Hospital Tacoma, Washington 98405 WILLIAM 0. ROBERTSON, M.D. C h i l d r e n ' s Orthopedic Hospital 4800 Sandpoint Way Seattle, Washington
From the a g e of 1 to 44, accidents head the l i s t a s the c a u s e of disability and death. The mental and physical immaturity and a s s o c i ated lack of judgment of the infant and young child have made them particularly prone to accidental injury and poisoning. In 1950 the American Academy of P e d i a t r i c s appointed a Committee on Accident Prevention to explore the problem, in hopes of finding ways of reducing the likelihood of injury to young children. A s u r v e y of the national committee, headed by Dr. George M. Wheatley, disclosed that a l a r g e percentage of the accidents and inj u r i e s of children that c a m e to the attention of pediatricians was due to accidental poisoning. T h e r e w e r e many r e q u e s t s f r o m physicians *Reprint r e q u e s t s to Robert G. S c h e r z , M.D., Medical Director, M a r y Bridge C h i l d r e n ' s Hospital, 311 South L S t r e e t , Tacoma, Washington 9840 5. 291 Copyright 0 1978 by Marcel Dekker, Inc. All Rights Reserved Neither this work nor any part may be reproduced or transmitted in any form or by any means. electronic or mechanical, including photocopying, microfilming, and recording. o r by any information storage and retrieval system, without permission in writing from the publisher.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
292
SCHERZ AND ROBERTSON
all over the country f o r up-to-date information on the toxic ingredients in common household agents. At that time there was no single source f o r information on the toxic substances present in over 250,000 different trade-name substances on the market in the United States. In the fall of 1953, one of the committee members of the Illinois Chapter of the American Academy of Pediatrics, Edward Press, M.D., together with s ever al other interested pediatricians, the Evanston, Illinois Health Department, and seven Chicago hospitals, banded together to pool r es our ces to establish the f i r st Poison Information Center. Consisting of a desk, a telephone, a clerk, and files, the Center reaches out to industry to compile ingredient information, toxicity potential, and treatment programs. A monograph was prepared by Dr. Press and published by the American Academy of Pediatrics, which, f o r s ev e r al year s , was the pediatricians' favorite referenceguide to chemical constituents of common household substances, listed together with treatment recommendations in c a s e s of accidental ingestion by children [ 11. Initially, the Poison Information Center responded only to local health professionals. However, the program proved so successful that within two year s i t was replicated in many other locations. These Centers were soon found to be duplicating each o t h e r ' s work, particularly in the area of compiling information regarding product content and toxicity. Furthermore, they w er e not sharing their joint experience effectively. In an effort to support poison control activities, a t the recommendation of a committee of the American Public Health Association, the Surgeon General of the United States designated the National Clearinghouse f o r Poison Control Centers as the Public Health Service Agency with official responsibility for providing poisoning information to Poison Control Centers and tabulating the experience of these Centers. This federal government agency, under the administration of the Food and Drug Administration, has been the principle l e ad e r in providing s er vi ces to the nation's recognized Poison Cont r o l Centers, which now, a quarter of a century l at er, number 661with m o r e than 100 in Illinois alone. Each s tate department of health has authority to designate facilities within i t s s ta te as official Poison Control Centers. The National Clearinghouse offers i t s s er vi ces to facilities s o designated. The development of Poison Control Centers, while meeting certain needs o r i n te r es ts , has been e r r a t i c and unccordinated in many ways. The Centers vary widely in staffing, policies, and number of requests for information. Many Centers respond to requests f o r information from health care professionals only, while others are open and respond to calls f r o m both professionals and the general public. Staffing v a r ie s from whoever happens to be near the phone when it rings, to a complex hierarchy of cl er ks , nur ses, and physicians with a backup of clinical toxicologists, pharmacists, veterinarians, botani s ts , and specialists i n a wide variety of toxic substances.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
HISTORY O F POISON CONTROL CENTERS
2 93
In s u r v e y s of Poison C e n t e r utilization, a l a r g e percentage of Cent e r s handle as few as one c a l l p e r day, while a few C e n t e r s handle as many as 80 c a l l s p e r day. Currently, s o m e Centers s e r v e populations of only a few thousand people, while o t h e r s s e r v e areas that contain s e v e r a l million. Growing out of the concern that the quality of poison control services should be improved, numerous individuals and organizations, including the American Association of Poison Control C e n t e r s , have called f o r the development of fewer, m o r e appropriately staffed, and b e t t e r skilled Centers. Accompanying this need, t h e r e has been the actual development of m o r e sophisticated Centers that a r e b e t t e r staffed and b e t t e r equipped than those around them. Those C e n t e r s have established themselves as Regional Centers. T o date, the growth of Regional C e n t e r s and the s e r v i c e s that they provide have been quite variable in t h e i r objectives and programs. To aid Regional Centers in planning f o r expansion and coordination of activities within t h e i r a r e a s of influence, Temple and Veltri p r e p a r e d a P r o g r a m Guide f o r Regional Poison Control P r o g r a m s [2]. This well-written document d e s c r i b e s a regional program that includes staffing, funding, s p a c e requirements, information r e s o u r c e s , data collection, professional training p r o g r a m s , poison prevention, public education, and program evaluation. DEVELOPING A DATA BASE From the beginning, i t was apparent that t h e r e was a need to know m o r e of the potential toxicity of a myriad of plants, products, and div e r s e substances in the human environment. The information base f o r C e n t e r s throughout the U.S. has improved significantly o v e r the y e a r s . F i r s t and foremost, the National Clearinghouse of Poison Control Centers has produced and distributed monthly, on 5" X 8" c a r d s , information regarding c o n s u m e r products. These w e r e indexed under t r a d e name, and contained n e c e s s a r y information to institute e m e r gency treatment. To date, m o r e than 16,000 c a r d s have been distributed. Many of these c a r d s have been updated m o r e than four times. In 1957, a second information r e s o u r c e appeared with the publication of Clinical Toxicology of Commercial Products [3]. It put ingredient information on m o r e than 25,000 household products and treatment information on m o r e than 50 generic compounds into one l a r g e compendium. This volume has undergone five revisions, and is now s t o r e d on computer tapes f o r periodic updating. In 1972, the Clearinghouse c a r d s and the C T C P text w e r e complimented by the appearance of a computer-based information system. The Clearinghouse took a c r i t i c a l portion of i t s c a r d files, t r a n s f e r r e d them to computer tapes, and established s i x satellite t e r m i n a l s scat-
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
2 94
SCHERZ AND ROBERTSON
tered over the U.S. By simply typing the name of the product on a keyboard and pushing a button, a message is transmitted over a dedicated phone line to Baltimore, Maryland, processed on a computer, and returned virtually instantaneously, s o that the typist looking at the cathode terminal will s ee, in greenish lighted print, information regarding the product and management of poisoning. The information can be updated daily. This system is generated a t a significant cost, and consequently has yet to be fully implemented in al l Regional Cent e r s that would benefit from it, but had been expanded to fourteen in 1977. During the past six years, the us e of microfiche technology has markedly expanded the data base, and made it available to even the smallest Center with a minimum of storage space. A microfiche r ead e r f i t s easily on a small table, and the product plus poisoning management information for over 180,000 different products can be stored in a slender three-ring notebook. Such syst em s (e.g., Poisindex-Denver, Toxifile-Chicago) are conveniently indexed, rapidly manipulated, and updated frequently. Currently the Clearinghouse c a r d s , the CTCP, and microfiche s y s tems s er v ice the pr i m ar y c a r e aspects of most Centers. Howev e r , to provide gr eat er depth backup and detailed searches of published literature, three additional data bases have been developed. Toxicity Bibliography Starting in 1970, the National Library of Medicine produce? from the Index Medicus, a quarterly update called Toxicity Bibliography, which in effect ext r act s al l publications relating to poisoning fro’m \ over 2500 journals. Toxline Toxline was established a few year s later, which now contains al l information included in Toxicity Bibliography, plus abst ract s from published and unpublished technical reports from both industry and the f ed e r al government-all of it converted to an on-line computer system. In this way the National Library of Medicine is establishing itself as the ultimate repository of toxicity information, and as a leader in the field of retrieval sciences. T h e T o x i c E f f e c t s of C h e m i c a l S u b s t a n c e s The Toxic Effects of Chemical Substances is published annually by the National Institute f or Occupational and Safety Hazards. This is a s o u r ce for data regarding the toxicity of 16,700 different generic chemical compounds.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
HISTORY O F POISON CONTROL CENTERS
295
Throughout the time span from 1950 to the p r e s e n t , efforts have been stimulated to prevent poisoning. These efforts have included distribution of Syrup of Ipecac, child-resistant packaging, and a wide variety of education p r o g r a m s aimed a t a number of t a r g e t audiences. These audiences include pre-school children, young school-age child r e n , parenting c l a s s e s , parents, health professionals, and paraprofessionals. That "something" is working is reflected in the marked d e c r e a s e in s e r i o u s poisonings of children under age five. Hospitalizations a r e l e s s than one-half, and deaths have been reduced from an annual r a t e of o v e r 400 in the late 1960s to about 100 in 1975. Despite the reduction of deaths from accidental poisoning of children under five y e a r s of age, there has been a d i s t r e s s i n g i n c r e a s e in deaths from poisoning in the U.S. during the l a s t five y e a r s in the age group from 15-24 years. During the next 25 y e a r s there will be a g r e a t e r emphasis on regionalization of Poison Information C e n t e r s , the development of stand a r d s f o r proficiency of Centers and t h e i r personnel, and m o r e effective methods developed to reduce truly accidental poisoning. With improved and m o r e rapid diagnosis of poisonings from unknown toxic substances, management of poisonings will become m o r e p r e c i s e and efficient, with resultant d e c r e a s e s in morbidity and mortality. The problem of nonaccidental poisoning may well i n c r e a s e , with the rising s t r e s s f u l tempo of o u r e v e r increasing technolpgic society. Yet those who a r e poisoned will receive p r o p e r c a r e and sooner, with a g r e a t e r likelihood of returning to society alive and less damaged than is the c a s e today. The nonaccidental poison is a special problem that is symptomatic of a m o r e s e r i o u s d i s o r d e r in o u r society, a diso r d e r that may be beyond o u r limits to prevent o r c o r r e c t , but one that w a r r a n t s cooperative efforts directed a t it before succumbing to hopelessness and helplessness. POISON INFORMATION CENTERS-U. S. A. Alabama
8
Georgia
Alaska
5
Hawaii
1
Arizona
17
Idaho
3
11
Arkansas
8
Illinois
102
California
9
Indiana
33
Colorado
9
Iowa
Connecticut Delaware Florida
10 1
32
4
Kansas
14
Kentucky
10
Louisiana
5 (Continued)
SCHERZ AND ROBERTSON
2 96
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
POISON INFORMATION CENTEFG- U.S.A. (continued) Maine
1
Pennsylvania
74
Maryland
6
m o d e Island
4
Massachusetts
6
South Carolina
2
Michigan
28
South Dakota
2
Minnesota
27
Tennessee
8
Mississippi
13
Texas
Missouri
15
Utah
1
Montana
3
Vermont
0
Nebraska
2
Virginia
19
21
Nevada
2
Washington
11
New Hampshire
1
West Virginia
16
New J e r s e y
34
Wisconsin
5
New Mexico
6
Wyoming
2
Canal Zone
1
New York
21
North Carolina
8
District of Columbia
1
North Dakota
7
Guam
1
Puerto Rico
5 4
Ohio
13
Oklahoma
8
Virgin Islands
Oregon
1
TOTAL
661
REFERENCES
[ 11 E. Press, Accidental Poisoning in Childhood, American Academy [2]
[3]
of Pediatrics, Charles C Thomas, Springfield, Ill., 1955, Library of Congress Catalog Number 56-6402. A. €3. Temple and J. C. Veltri, Program Guide f o r Regional Poison Control Centers, Contract No. 223-75-3013, Public Health Service, Food and Drug Administration, DHEW. M. N. Gleason, R E. Gosselin, and H. C. Hodge, Clinical Toxicology of Commercial Products, Williams & Wilkins, Philadelphia, Pa., 1957.
CLINICAL TOXICOLOGY 1 2 ( 3 ) , pp. 291-296 (1978)
The History of Poison Control Centers in the United States
ROBERT G. SCHERZ, M. D. * Medical D i r e c t o r M a r y Bridge C h i l d r e n ' s Hospital Tacoma, Washington 98405 WILLIAM 0. ROBERTSON, M.D. C h i l d r e n ' s Orthopedic Hospital 4800 Sandpoint Way Seattle, Washington
From the a g e of 1 to 44, accidents head the l i s t a s the c a u s e of disability and death. The mental and physical immaturity and a s s o c i ated lack of judgment of the infant and young child have made them particularly prone to accidental injury and poisoning. In 1950 the American Academy of P e d i a t r i c s appointed a Committee on Accident Prevention to explore the problem, in hopes of finding ways of reducing the likelihood of injury to young children. A s u r v e y of the national committee, headed by Dr. George M. Wheatley, disclosed that a l a r g e percentage of the accidents and inj u r i e s of children that c a m e to the attention of pediatricians was due to accidental poisoning. T h e r e w e r e many r e q u e s t s f r o m physicians *Reprint r e q u e s t s to Robert G. S c h e r z , M.D., Medical Director, M a r y Bridge C h i l d r e n ' s Hospital, 311 South L S t r e e t , Tacoma, Washington 9840 5. 291 Copyright 0 1978 by Marcel Dekker, Inc. All Rights Reserved Neither this work nor any part may be reproduced or transmitted in any form or by any means. electronic or mechanical, including photocopying, microfilming, and recording. o r by any information storage and retrieval system, without permission in writing from the publisher.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
292
SCHERZ AND ROBERTSON
all over the country f o r up-to-date information on the toxic ingredients in common household agents. At that time there was no single source f o r information on the toxic substances present in over 250,000 different trade-name substances on the market in the United States. In the fall of 1953, one of the committee members of the Illinois Chapter of the American Academy of Pediatrics, Edward Press, M.D., together with s ever al other interested pediatricians, the Evanston, Illinois Health Department, and seven Chicago hospitals, banded together to pool r es our ces to establish the f i r st Poison Information Center. Consisting of a desk, a telephone, a clerk, and files, the Center reaches out to industry to compile ingredient information, toxicity potential, and treatment programs. A monograph was prepared by Dr. Press and published by the American Academy of Pediatrics, which, f o r s ev e r al year s , was the pediatricians' favorite referenceguide to chemical constituents of common household substances, listed together with treatment recommendations in c a s e s of accidental ingestion by children [ 11. Initially, the Poison Information Center responded only to local health professionals. However, the program proved so successful that within two year s i t was replicated in many other locations. These Centers were soon found to be duplicating each o t h e r ' s work, particularly in the area of compiling information regarding product content and toxicity. Furthermore, they w er e not sharing their joint experience effectively. In an effort to support poison control activities, a t the recommendation of a committee of the American Public Health Association, the Surgeon General of the United States designated the National Clearinghouse f o r Poison Control Centers as the Public Health Service Agency with official responsibility for providing poisoning information to Poison Control Centers and tabulating the experience of these Centers. This federal government agency, under the administration of the Food and Drug Administration, has been the principle l e ad e r in providing s er vi ces to the nation's recognized Poison Cont r o l Centers, which now, a quarter of a century l at er, number 661with m o r e than 100 in Illinois alone. Each s tate department of health has authority to designate facilities within i t s s ta te as official Poison Control Centers. The National Clearinghouse offers i t s s er vi ces to facilities s o designated. The development of Poison Control Centers, while meeting certain needs o r i n te r es ts , has been e r r a t i c and unccordinated in many ways. The Centers vary widely in staffing, policies, and number of requests for information. Many Centers respond to requests f o r information from health care professionals only, while others are open and respond to calls f r o m both professionals and the general public. Staffing v a r ie s from whoever happens to be near the phone when it rings, to a complex hierarchy of cl er ks , nur ses, and physicians with a backup of clinical toxicologists, pharmacists, veterinarians, botani s ts , and specialists i n a wide variety of toxic substances.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
HISTORY O F POISON CONTROL CENTERS
2 93
In s u r v e y s of Poison C e n t e r utilization, a l a r g e percentage of Cent e r s handle as few as one c a l l p e r day, while a few C e n t e r s handle as many as 80 c a l l s p e r day. Currently, s o m e Centers s e r v e populations of only a few thousand people, while o t h e r s s e r v e areas that contain s e v e r a l million. Growing out of the concern that the quality of poison control services should be improved, numerous individuals and organizations, including the American Association of Poison Control C e n t e r s , have called f o r the development of fewer, m o r e appropriately staffed, and b e t t e r skilled Centers. Accompanying this need, t h e r e has been the actual development of m o r e sophisticated Centers that a r e b e t t e r staffed and b e t t e r equipped than those around them. Those C e n t e r s have established themselves as Regional Centers. T o date, the growth of Regional C e n t e r s and the s e r v i c e s that they provide have been quite variable in t h e i r objectives and programs. To aid Regional Centers in planning f o r expansion and coordination of activities within t h e i r a r e a s of influence, Temple and Veltri p r e p a r e d a P r o g r a m Guide f o r Regional Poison Control P r o g r a m s [2]. This well-written document d e s c r i b e s a regional program that includes staffing, funding, s p a c e requirements, information r e s o u r c e s , data collection, professional training p r o g r a m s , poison prevention, public education, and program evaluation. DEVELOPING A DATA BASE From the beginning, i t was apparent that t h e r e was a need to know m o r e of the potential toxicity of a myriad of plants, products, and div e r s e substances in the human environment. The information base f o r C e n t e r s throughout the U.S. has improved significantly o v e r the y e a r s . F i r s t and foremost, the National Clearinghouse of Poison Control Centers has produced and distributed monthly, on 5" X 8" c a r d s , information regarding c o n s u m e r products. These w e r e indexed under t r a d e name, and contained n e c e s s a r y information to institute e m e r gency treatment. To date, m o r e than 16,000 c a r d s have been distributed. Many of these c a r d s have been updated m o r e than four times. In 1957, a second information r e s o u r c e appeared with the publication of Clinical Toxicology of Commercial Products [3]. It put ingredient information on m o r e than 25,000 household products and treatment information on m o r e than 50 generic compounds into one l a r g e compendium. This volume has undergone five revisions, and is now s t o r e d on computer tapes f o r periodic updating. In 1972, the Clearinghouse c a r d s and the C T C P text w e r e complimented by the appearance of a computer-based information system. The Clearinghouse took a c r i t i c a l portion of i t s c a r d files, t r a n s f e r r e d them to computer tapes, and established s i x satellite t e r m i n a l s scat-
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
2 94
SCHERZ AND ROBERTSON
tered over the U.S. By simply typing the name of the product on a keyboard and pushing a button, a message is transmitted over a dedicated phone line to Baltimore, Maryland, processed on a computer, and returned virtually instantaneously, s o that the typist looking at the cathode terminal will s ee, in greenish lighted print, information regarding the product and management of poisoning. The information can be updated daily. This system is generated a t a significant cost, and consequently has yet to be fully implemented in al l Regional Cent e r s that would benefit from it, but had been expanded to fourteen in 1977. During the past six years, the us e of microfiche technology has markedly expanded the data base, and made it available to even the smallest Center with a minimum of storage space. A microfiche r ead e r f i t s easily on a small table, and the product plus poisoning management information for over 180,000 different products can be stored in a slender three-ring notebook. Such syst em s (e.g., Poisindex-Denver, Toxifile-Chicago) are conveniently indexed, rapidly manipulated, and updated frequently. Currently the Clearinghouse c a r d s , the CTCP, and microfiche s y s tems s er v ice the pr i m ar y c a r e aspects of most Centers. Howev e r , to provide gr eat er depth backup and detailed searches of published literature, three additional data bases have been developed. Toxicity Bibliography Starting in 1970, the National Library of Medicine produce? from the Index Medicus, a quarterly update called Toxicity Bibliography, which in effect ext r act s al l publications relating to poisoning fro’m \ over 2500 journals. Toxline Toxline was established a few year s later, which now contains al l information included in Toxicity Bibliography, plus abst ract s from published and unpublished technical reports from both industry and the f ed e r al government-all of it converted to an on-line computer system. In this way the National Library of Medicine is establishing itself as the ultimate repository of toxicity information, and as a leader in the field of retrieval sciences. T h e T o x i c E f f e c t s of C h e m i c a l S u b s t a n c e s The Toxic Effects of Chemical Substances is published annually by the National Institute f or Occupational and Safety Hazards. This is a s o u r ce for data regarding the toxicity of 16,700 different generic chemical compounds.
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
HISTORY O F POISON CONTROL CENTERS
295
Throughout the time span from 1950 to the p r e s e n t , efforts have been stimulated to prevent poisoning. These efforts have included distribution of Syrup of Ipecac, child-resistant packaging, and a wide variety of education p r o g r a m s aimed a t a number of t a r g e t audiences. These audiences include pre-school children, young school-age child r e n , parenting c l a s s e s , parents, health professionals, and paraprofessionals. That "something" is working is reflected in the marked d e c r e a s e in s e r i o u s poisonings of children under age five. Hospitalizations a r e l e s s than one-half, and deaths have been reduced from an annual r a t e of o v e r 400 in the late 1960s to about 100 in 1975. Despite the reduction of deaths from accidental poisoning of children under five y e a r s of age, there has been a d i s t r e s s i n g i n c r e a s e in deaths from poisoning in the U.S. during the l a s t five y e a r s in the age group from 15-24 years. During the next 25 y e a r s there will be a g r e a t e r emphasis on regionalization of Poison Information C e n t e r s , the development of stand a r d s f o r proficiency of Centers and t h e i r personnel, and m o r e effective methods developed to reduce truly accidental poisoning. With improved and m o r e rapid diagnosis of poisonings from unknown toxic substances, management of poisonings will become m o r e p r e c i s e and efficient, with resultant d e c r e a s e s in morbidity and mortality. The problem of nonaccidental poisoning may well i n c r e a s e , with the rising s t r e s s f u l tempo of o u r e v e r increasing technolpgic society. Yet those who a r e poisoned will receive p r o p e r c a r e and sooner, with a g r e a t e r likelihood of returning to society alive and less damaged than is the c a s e today. The nonaccidental poison is a special problem that is symptomatic of a m o r e s e r i o u s d i s o r d e r in o u r society, a diso r d e r that may be beyond o u r limits to prevent o r c o r r e c t , but one that w a r r a n t s cooperative efforts directed a t it before succumbing to hopelessness and helplessness. POISON INFORMATION CENTERS-U. S. A. Alabama
8
Georgia
Alaska
5
Hawaii
1
Arizona
17
Idaho
3
11
Arkansas
8
Illinois
102
California
9
Indiana
33
Colorado
9
Iowa
Connecticut Delaware Florida
10 1
32
4
Kansas
14
Kentucky
10
Louisiana
5 (Continued)
SCHERZ AND ROBERTSON
2 96
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 12/25/14 For personal use only.
POISON INFORMATION CENTEFG- U.S.A. (continued) Maine
1
Pennsylvania
74
Maryland
6
m o d e Island
4
Massachusetts
6
South Carolina
2
Michigan
28
South Dakota
2
Minnesota
27
Tennessee
8
Mississippi
13
Texas
Missouri
15
Utah
1
Montana
3
Vermont
0
Nebraska
2
Virginia
19
21
Nevada
2
Washington
11
New Hampshire
1
West Virginia
16
New J e r s e y
34
Wisconsin
5
New Mexico
6
Wyoming
2
Canal Zone
1
New York
21
North Carolina
8
District of Columbia
1
North Dakota
7
Guam
1
Puerto Rico
5 4
Ohio
13
Oklahoma
8
Virgin Islands
Oregon
1
TOTAL
661
REFERENCES
[ 11 E. Press, Accidental Poisoning in Childhood, American Academy [2]
[3]
of Pediatrics, Charles C Thomas, Springfield, Ill., 1955, Library of Congress Catalog Number 56-6402. A. €3. Temple and J. C. Veltri, Program Guide f o r Regional Poison Control Centers, Contract No. 223-75-3013, Public Health Service, Food and Drug Administration, DHEW. M. N. Gleason, R E. Gosselin, and H. C. Hodge, Clinical Toxicology of Commercial Products, Williams & Wilkins, Philadelphia, Pa., 1957.
