Document 2NKv9DY4k0DdbD1jYxoXQmJQ6

COLLEGE OF MEDICINE D EPA RTM EN T OF PUBLIC HEALTH AND HVGlENE P r o f esso r E M E R Y R. H A Y H U R ST , A .B ., A .M ., M .D ., P H .D As s is t a n t P r o f esso r s JA M E S SPR IG G W IL S O N , M .D ., M .S. N O RM A S E L B E R T , R .N ., B .S ., M .A . THE OHIO STATE UNIVERSITY W.G e o r g e R i g h t m i r e , Presiden t COLUMBUS A pril 1, 1930. V D r. R obert A. Rehoe, A ssociate P rofessor of Physiology, U niversity of C incinnati, C in c in n a ti, O hio. * - Dear D r. Kehoe: I have read w ith no l i t t l e i n t e r e s t yo u r r e p r in t "On th e D iag n o sis and Treatm ent o f Lead Poisoning" from th e C in cin n ati Jo u rn al of M e d ic in e , M arch, 1 9 3 0 , w h ich you w ere k in d enough t o send me u n d e r d a te of M arch'17th. I have a ls o taken occasion to a b s tra c t th e m a te ria l a t some le n g th f o r t h e A m erican J o u rn a l o f P u b lic H e a lth . T h is i s t h e b e s t t h i n g on le a d p o is o n in g I have come a c r o s s f o r some t i m e . I presum e y o u s e n t i t t o me f o r an y o b s e r v a tio n s o r comments w h ich m ig h t o c c u r t o me. The d a t a s u b m itte d i n t h i s r e p r i n t , w h ile b r ie f , appear to bear out your conclusions w e ll and I presume your more ex ten d ed a r t i c l e , when you have i t re a d y f o r p u b lic a tio n , w ill answer most of th e q u erie s w hich m ight a r is e . One o f t h e f i r s t t h i n g s w h ic h I n o te i s t h a t th e Com m ittee on Lead P o iso n in g (A .P .H .A .) may hav e t o r e c o n s id e r i t s d e f i n i t i o n o f Lead I n t o x i c a t i o n to meet more e x a c tly your c o n c lu sio n s as t o a c tu a l ev idence of in to x ic a tio n (m entioned in th e R ep rin t on p .6 , 2nd column, cen ter p a ra g rap h ). I have no doubt th a t you are rig h t in your conclusions th a t p ro g ressiv e changes in th e blood fin d in g s in th e n a tu re of a dim inution of hem oglobin mean a c t u a l in t o x ic a t io n w ith or w ith o u t th e p resen ce o f a s s o c i a te d s u b j e c t i v e sym ptom s. ( I am e x c e p tin g t h o s e in s ta n c e s ,w h ic h you c a l l a tte n tio n to , in w hich blood changes a re due to o th e r c a u s e s ). There would, o f c o u rs e , be no q u e s tio n w here s u b je c tiv e symptoms a re p r e s e n t. W hether i t is p r a c tic a l from a com pensation stan d p o in t to recognize lead in to x i c a tio n w ith o u t s u b je c tiv e symptoms i s q u ite a q u e s tio n . As a guide t o th e i n d u s t r i a l p h y s ic ia n who i s w a tc h in g Lead A b so rp tio n th e r e can be no q u estio n o f th e v alu e o f th e p ro g ressiv e changes w hich you emphasized in blood fin d in g s , and perhaps o th er p h y sical fin d in g s , as a guide to a c tio n . Under th e C om m ittee's d e f in itio n o f Lead A b so rp tio n and i t s e x p la n a tio n , I b e lie v e a l l w orkers so grouped should be under m edical su p e rv isio n , hence, should have th e ir m edical su p erv isio n fees paid by com pensation ag en c ies, com pensation i t s e l f being lim ite d to disablem ent only fo r th e p re s e n t. I m ention th is because th e re is a tendency abroad not only to pay m edical fe e s when th e re is no lo s t tim e from work but to pay an agreed upon pro r a ta f o r e a r ly s ta g e s o f o ccu p atio n al d is e a s e s even when th e re is no im m ed iate d is a b l e m e n t . So f a r a s I know, we have n o t come t o t h i s concep t i o n anywhere in t h i s co u n try as y e t. In c e r ta in a f f lic tio n s lik e s ili c o s is in w hich an X -ray d ia g n o sis o f a f i r s t stag e means a c e r ta in amount o f i r re p a ra b le damage and an in c re a s in g lik e lih o o d o f pneum onia, or tu b e r c u lo s is , th e r e may be undoubted j u s t i f i c a t i o n f o r such a c tio n . As th e r e seems t o be ^ N 5986 D r. R obert A. Eehoe - Page 2 . no ev id en ce t h a t an e a r ly s ta g e o f le a d in to x ic a tio n may r e s u l t in i r re p a ra b le damage, however, th e co n d itio n s are not th e same. T herefore, my s u g g e s tio n i s t o l e t t h e C om m ittee*s d e f i n i t i o n f o r Lead I n t o x i c a t i o n s ta n d as. i t i s , "?fhen ab so rb ed le a d ca u se s s u b je c tiv e symptoms w ith ob je c tiv e fin d in g s'* . This w ill g re a tly sim p lify com pensation procedures d e s p ite th e f a c t th a t th e d e f i n i t i o n may n o t be c r i t i c a l l y c o r r e c t . I am v e r y much i n t e r e s t e d i n w h at you s a y a b o u t t h e p ro b a b le n eg ativ e e ffe c ts of lead upon th e blood v e s s e ls . I have re c e n tly ab s t r a c t e d an a r t i c l e b y Legge. who. a n a ly z e s some 1 0 ,0 0 0 c a s e s o f le a d p o i soning w hich o ccu rred d u rin g h is ex p erien ce as C h ie f M edical O ffic e r o f F a c t o r i e s , E ngland and W ales (1 9 0 1 -1 9 2 7 ), who comes t o th e o p p o s ite cone lu s io n ^ , i f I have in te r p r e te d him c o r r e c tly . H.G. W e lls, C hicago, once t o l d me t h a t he th o u g h t th e a r t e r i o - s c l e r o s i s o f a lc o h o lis m w as more th an lik e ly due to lead poisoning acquired from c o n ta in e rs. P ra c tic a lly a l l th e o lder lite r a tu r e supports th e a r te r io - s c le r o tic p o in t of view . However, some y e a r s a g o , S ir Thomas O liv e r an d , I th i n k a l s o Goadby, sug gested th a t th e s c le r o tic kidney o f p a in te rs was due ra th e r to tu rp e n tin e th a n t o le a d . I u n d e rs ta n d t h a t Aub w ould a g re e w ith y o u r p o in t o f v ie w . I doubt w hether th e q u estio n can be s e ttle d by anim al ex p erim en tatio n , u sin g th e o rd in ary la b o ra to ry anim als w hich, I u n d erstan d , are not so apt to show a r t e r i o - s c l e r o s i s as man. P erhaps th e monkey m ight prove s a t i s fa c to ry fo r th e purpose. At a ll odds, th ere is considerable controversy h e r e , and th e s u b je c t would be w e ll w orth a c a re fu l re s e a rc h . In th e R e p rin t, page 7 , 2nd column, end o f th e 2nd parag rap h , I am w o n d e rin g i f t h e p h ra s e " d e t e c t a b l e q u a n t i t y o f b lo o d " sh o u ld n o t re a d "d etec tab le q u a n tity o f le ad "? (ita lic s are m ine). I re c e n tly have had occasion to look up th e su b ject of la te n t lead p o iso n in g , rep o rte d p r a c tic a lly a lto g e th e r in o ld er lite r a tu r e and have come t o t h e c o n c lu s io n t h a t t h e r e i s "n o su c h a n im a l" . P r a c t i c a l l y a l l o f th e cases rep o rted had a h is to ry o f d e fin ite lead in to x ic a tio n dur in g th e tim e o f ex p o su re o r symptoms o f le a d in to x ic a t io n o c c u rre d /w ith in a few w eeks, and, a t m ost, w ith in a few m onths, fo llo w in g lead exposure. Thus, th e se cases should more p ro p e rly be c a lle d r e la p s in g ,o r, a t th e m ost, delayed lead p o iso n in g . Even h e re , I have grave doubts w hether subsequent e x p o s u re s t o le a d w ere c a r e f u l l y r u l e d o u t . I am s u p p o rte d i n t h i s v ie w by th e f a c t t h a t no p h y s ic ia n s o f th e S ta te o f Ohio have e v e r re p o rte d a long d e fe rre d case o f le ad p o iso n in g to th e S ta te departm ents so fa r as I have been ab le to fin d out and I have ra th e r c a re fu lly w atched th is fe a tu re fo r th e p a s t 17 y e a rs in c o n n e c tio n w ith some 2 ,2 0 0 c a s e s o f le a d p o is o n in g r e p o rte d to th e S ta te D epartm ent o f H e a lth s in c e May, 1913. Tihile you have n o t d isc u sse d sym ptom atology in t h i s paper i t would be i n t e r e s t i n g t o know th e symptoms a s s o c ia te d w ith th e case " J .G ." , r e fe rre d to in Table IX, as com pleting th e p ic tu r e . Your fin d in g (page 8 , column 2 , 1 s t p arag rap h ) t h a t th e re i s no evidence th a t lead is fix ed in any tiss u e of th e body w ith th e exception of th e c e n tra l nervous system , a p p a re n tly re fu te s Aub' s fin d in g s . A lso, i t should be made c le a r in t h i s co n n ectio n th a t th e d is tr ib u tio n o f le a d as shown in T a b le IX and p e rh a p s i n some o f th e o th e r t a b l e s p r e s e n te d , does not represent fixed lead . ' D r. R obert A. Kehoe - Page. 3 T his d is c u s s io n on page 9 is n o t v e ry c le a r t o me, p a r tic u la r ly th e d is c u s s io n in th e 2nd column. In co n n ectio n w ith Table X II, is i t meant th a t lead in i t s norm al d is trib u tio n in th e tis s u e s is found in such la rg e r e l a t i v e l y q u a n titie s in th e c e n tr a l nervous system ? I was under th e im pression th a t th e c e n tra l nervous system was ra th e r spared in e a r ly le a d in to x ic a tio n , b u t I can see th a t when le a d once re a c h e d i t , i t may become f ix e d , a s you s t a t e . In t h i s c o n n ec tio n have you any evidence a s t o how i t i s f i x e d and w h e th e r t h e r e i s an y d i f i n i t e p a th o lo g y p r e s e n t? Can th e le a d b e I d e n t i f i e d i n t i s s u e co m b in atio n ? O liv e r d is c u s s e s such pathology, but not anything c h a ra c te ris tic . I am c e r t a i n l y im p ressed w ith th e r a t i o n a l o f y o u r p la n o f trea tm e n t as i t appears lo g ic a l from th e b io lo g ic a l, i . e . , p h y sio lo g ic a l, p o in t of view , a ls o , i t agrees w ith g en eral m edical experience in tre a tin g lead poisoning in th e p a st. The Above r e p r e s e n t s my im m ed iate r e f l e c t i o n s on th e s e v e r a l new p o in ts or c o n tro v e rsia l p o in ts w hich you have developed in your v ery p ra is e w o rth y e f f o r t s . I know you a r e v e r y b u sy and am n o t e x p e c tin g you t o ta k e th e tro u b le o f re p ly in g p o st h a s te , b u t should be glad to have your views som etim es when we m eet a g a in . I s h a ll a ls o be v e ry p le a se d to be remembered w ith r e p r in ts o f your p u b lish ed a r t i c l e s w henever you have them fo r d i s t r i b u tio n . Yours v e ry s in c e re ly , 72-29 Emery E . H ay h u rst, M .D., P ro fesso r of H ygiene.