Document 4vqzw1dBykJZye3159Zd6VmDe

June 21, 1956 D r. T hom as F . M aticuso C hief, D ivision of In d u strial H ygiene D epartm ent of H ealth State of Ohio . 306 Ohio D e p a rtm e n ts B uilding C olum bus 15, Ohio . D ear M ancuso: ; I am p le ase d thaU you w ro te to m e about y o u r p ro p o sed m ethod of handling tne m edical p ro b lem s of lead poisoning as it coufrouts your D epartm ent. A s you m ay suspect, it is also a serio u s problem fo r u s, and fo r rno in p a rtic u la r, sin ce I handle th is b it of the w o rk of the L a b o ra to ry in a il m a tte rs except th a t of the actu al analytical, p e r f o r m a n c e , it is a d if f ic u lt p r o b le m , in v o lv in g q u ite a, l o t o f tim e in co rresp o n d en ce and in giving ad v ice. P a rt of the tro u b le stem s fro m m e m a n n er in which v ario u s people p re s e n t th e ir p ro b lem s to u s, and this tro u b le, I fe a r, w ill be g re a tly augm ented by such re fe re n c e to the L a b o ra to ry a s you have thought of m aking. T h e re fo re , 1 am glad to o ffer a few suggestions on th is point, and I also m ake a few tech n ical c ritic is m s w hich see m to m e to be v alid . It o c c u rs to m e to p o in t out to you, if you a r e n o t a w a re of it, th a t we a c t in a cap acity s im ila r to th at of y o u r D ep artm en t and its la b o ra to ry fa c ilitie s within, the C ity of C in cin n ati, in th a t w e do th e te c h n ic a l e n v iro n m en tal in v estig atio n s, a t the re q u e st of the B u reau of In d u stria l H ygiene of the H ealth D ep artm en t of the C ity and in co llab o ratio n w ith th e ir m edical, se rv ic e s , un d er an ag reem en t betw een the D ep artm en t and the B o ard of 'D irectors- of the U n iv e rsity . We know w hat y e a r p ro b le m s a r e , th e re fo re . M oreover, we constilt w ith in d u stria l o rg an izatio n s in th e se m a tte rs at th e ir re q u e s t, in Ohio and e lse w h e re . T h e re is no and of the am ount of w ork th at can be done, and w e too m u st lim it it in a n u m b er of w ays, d/e respond m o st e n th u siastic ally to re q u e sts fo r advice and se rv ic e in e sta b lish in g ad eq u ate m e a s u re s of m e d ic a l and h y g ien ic c o n tro l, and in th is w ay we s a v e o u r s e lv e s a.nd y o u r D e p a rtm e n t f r o m m a n y f u r th e r h e a d aches. I tu rn now to "A Note A bout O ccupational D is e a s e s . " I have gone o v e r th is c arefu lly and have w ritten in, in pencil n o tatio n s, the changes w hich N13162 D r. Thom as F . M ancuso - (2) - June 21, 1956 I w ould m a k e. You m ay o r'm a y not accep t th em , but I am taking the tro u b le to d isc u ss th o se w hich eeem to m e to re q u ire ex p lan a tio n . I hope you can re a d m y n o ta tio n s. I am not having the w hole thing rety p ed , sin ce I d o n 't w ish to fo rm a liz e m y re c o m m e n d a tio n s. They a re m ad e to you p e rso n a lly , to tak e o r to le a v e . I p re fe r to c ritic iz e y o u r sta te m e n ts p riv a te ly r a th e r th an p u b lic ly . I do w ant you to r e a liz e , h o w ev er, th a t m y c ritic is m s a re not h a stily o r lig h tly m ad e. R ath er th ey a re as I w ould m ake them publicly o r fo r publication, except fo r the fact th at I have not attem pted to add to y o u r sta te m e n ts but only to ed it th e m . idy f i r s t ch an g e is on page 1, w h e re , a s id e f r o m a few m o d ific a tio n s of v e rb ia g e , I have m ade only one im p o rta n t ch an g e. The use of "toxicity'* in the sense em ployed, is , I think, confusing, I object, and have continued c o n siste n tly to do so, to th e coupling of n o n -to x ic ity (o r low to x icity ) w ith fa ilu re of ab so rp tio n . It is a sem antic p ro b lem , of c o u rse , but unfortunately it is a so u rc e of g re a t confusion to lay m en and to som e of the m ed ical b re th re n who a re not v a ry w ell in fo rm ed in m a tte rs of physiology. On page 2 th e re a re m any changes. I sh all dispo ss of m e m in o r changes b r i e f l y . U n d e r Z, h ie t e r m " p r i v a t e 11 Is not .veil c h o s e n . T h is h u b - o r a to r y is as "p u b lic" as an y . The o th e r changes in th is f ir s t p a ra g ra p h a rc m e re ly m a tte rs of choice. The re w ritin g of th e m id d le p a ra g ra p h is p rim a rily an a tte m p t to e x tric a te - th is L a b o ra to ry fro m d ifficu lties, seco n d arily to keep the nam e of the L ab o rato ry stra ig h t. T here is no K ettering In stitu te. The K etterin g .L a b o r a to r y , w h ic h o r ig i n a te d in th e D e p a r t m e n t o f P h y s io lo g y , 13 th e c e n t r a l u n it of this D e p a rtm e n t, a s in d ic a ted on o u r le tte rh e a d . The In stitu te of In d u stria l H ealth, on the c o n tra ry , is a functional o rg an izatio n in the G raduate School of A rts and Sciences in the u n iv e rsity of C incinnati fo r the p u rp o ses of g rad u ate in s tru c tio n . It is not s u rp ris in g th at th e re is som e m i s u n d e r s t a n d in g o f t h i s s itu a tio n , b u t it i;j i m p o r ta n t to h a v e th e n a m e s rig h t in public p rin t. , A s to the re sta te m e n t of the position of the K etterin g L a b o ra to ry , le t m e be fra n k in say in g th a t you m ay r e f e r to it or. not a s you ch o u se, but you should not te ll anyone th at we w ill c a rry out an aly ses fo r them . This is not an a n a ly t ic a l o r s e r v i c e o r g a n iz a ti o n . Vie w ill h e lp p h y s ic i a n s to w a r d a d ia g n o s is if th e y c o n s u lt u.3, s in c e th a t is a p r o f e s s io n a l d u ty . We w ill a id in d u strial m anagem ent, under ap p ro p riate c irc u m sta n c e s, in the hope of helping them find som e solution of th e ir m ed ical p ro b lem s, through obtain in g , a s a f i r s t s t e p , c o m p e te n t m e d ic a l s e r v i c e . Tv"< w ill n o t a n a ly s e a n y sam p les of u rin e o r blood o r of anything e lse sen t to us w ithout p re a rra n g e m e n t. We w ill in s tru c t people how to o b tain su ita b le s a m p le s , we w ill p ro v id e c o n ta in e rs fo r su ch sa m p le s, and in exchange fo r ad eq u ate m e d ic a l in fo rm atio n , we w ill c a r ry out th e a n aly se s w hich we choose to do if we a re D r. Thom as F . M ancuso - (3) - June 2 1, I95o r e im b u r s e d f o r th e a c tu a l c o s t oi' th e w o rk . (If p a tie n ts o r w o rk m e n cannot afford the co st of the w ork, we ab so rb it, w ithin c e rta in lim its w hich do not in c re a s e o u r o v erh ead ex p en se e x c e ssiv e ly . In th is way we do th o u sa n d s c d o lla r s w o rth of c h a r ita b le w o rk a n n u a lly , a s a p h y s ic ia n (or in th is in stan ce, a public m ed ical in stitu tio n w hich is conducted a c c o rd in g to p riv a te m e d ic a l ethics') m u st be p re p a re d to d o .) I ex p ect p h y s ic ia n s who c o m e to u s f o r th is help* to c o m e to m e (by te le p h o n e o r m ail) w ith th e ir p ro b le m , and to le t m e ad v ise th em how to d eal w ith it. This saves an enorm ous am ount of tim e and elim in ates a w orld of confusion. I have m ade significant changes in your sectio n on L ead P o iso n in g . A ll of th o se , in m y opinion, a re u se fu l, but com e a re m o re im p o rta n t th an o th e rs . 1 can vouch for the c o rre c tn e ss of the technical changes. To discu s3 th ese h a stily lo t m e point out: ' . 1. th a t s o lu b ility is .not alw ay s o r n e c e s s a r ily a m a tte r of p a r tic le s iz e . Thus I have m odified your statem en t on this point, 2 . th a t le a d co m p o u n d s, g e n e ra lly , a r e not a b so rb e d th ro u g h the skin.; th e only com pound of le a l th a t is u sed in in d u s t r y th a t is a b so rb e d a p p re c iab ly th ro u g h the sk in is te tra e th y l le a d , and it is not no a b so rb e d if it is s u f f ic ie n tly -iitu te d in. g a s o lin e o r o t h e r s u ita b le s o lv e n t; 3. cue m in e r changes I have suggested in th e p a ra g ra p h Sym ptom s a re som ew hat m o re p re c ise than the o rig in al statem en ts; 4, under D iagnosis, 1 have m ade sev eral very n e ce ssa ry changes la sta te m e n ts c f a c t; th e u s e o f th e w o rd ' 's t o r a g e " o f le a d o r o f th e p h r a s e "le ad s to re d in the body" is o ften m is in te rp re te d ; it is b e tte r to sp eak o f l e a ^ 0a s h a v in g b e e n a b s o r b e d o r a s b e in g p r e s e n t in th e b o d y , f o r t h e r e is th e n /im p li c a tio n ox a n y th in g o b s c u r e ; th e p h y s io lo g y o f th e le a d m etab o lism has been confused enough, fo r a long enough tim e; it is w ise an; n e c e s s a r y to ta lk in s im p le and fu lly u n d e rsto o d te r m s ; 5 . In th is sam e se c tio n , the follow ing p o in ts m u st be se t s tra ig h t; (a) th e ra n g e of n o rm a l u r in a r y v a lu e s fo r s a m p le s of e m a il v olum e (w hich a re com m only d ealt w ith in th e se d ays) is as I have in d icated ; the rauige w hich you cited re la te s only to n am p lcs of la rg e volum e 2 to- 3 l i t e r s ; (b) e x c e s s iv e " s to r a g e " - ! , e . a b s o rp tio n - of le a d ca n n o t p o s s ib ly o c c u r w ithout elev atio n of the lead c o n c e n tra tio n in th e blood ex cep t w hen the m a te ria l ab so rb ed is te tra e th y l le a d ; the eq u ilib riu m w ith the blood is as inevitable as is the p re sen c e of inorganic lead in the body (you h a rd ly need w o ri'y about te tra e th y l le a d , sin c e th is type of poisoning is alm o st n ever aeon by physicians gen erally); 0012496 D r. Thom as F . M ancuso - (4) - June 21, 1956 (c) th e r e s o r t to the u s e of ED TA to r e le a s e le a d h a s no d ia g n o stic s ig n ific a n c e (I know fu ll w e ll th a t B r ie g e r h a s put out so m e in fo r m atio n on th is, but he w as and is m o st incautious in doing so); if the lead in the blood is not elev ated above th e m ean n o rm al lev el at a tim e when no th erap y w ith EDTA has been re so rte d to, th e re is no u n u su al o r h y g ien icaliy sig n ific a n t q u an tity of le a d in th e body; it is f o r this re a s o n th a t I h a v e d e le te d y o u r tw o s e n te n c e s ; I h av e added the d angerous le v els of u rin a ry and blood co n cen tratio n ; it seem s u n likely th a t anyone w ould q u a rre l w ith the evidence behind these fig u res. (d) I h av e m a d e c h a n g e s in th e s ta te m e n t a b o u t " s tip p lin g " an d the p o rp h y rin s. The im portance of the la tte r is co n sid erab le fo r diagnostic pu rp o ses but p ra c tic a lly zero fro m the asp ect of the detection of dangerous absorption of lead before any form of intoxication o c c u rs; a sig n ifican t in c re a se in co p ro p o rp h y rin u ria is , I believe, a sign of intoxication; your statem en t th at the p ro phyrins o ccu r in high co n cen tratio n in a sso c iatio n w ith lead a b so rp tion, as such, th e re fo re is not ex actly tru e . 5. U nder T h erapy I have m ade few but sig n ifican t ch an g es. The re s o rt to "d eiead in g " a s such should not be e m p h a sise d . If EDTA is to r e m a i n w ith U3 a s a n im p o r t a n t a g e n t f o r th e r a p y , i t w ill b e b e c a u s e of its r e lie f of illn e s s , n o t b e c a u s e of th e d e le a d in g p e r s e . -The la tte r is ra re ly im portant, fo r it o ccu rs spontaneously and thereis ra re ly any good reaso n fo r hastening it. As a chelating agent, it rem oves lead ions fro m fu rth e r actio n ana allow s th e soft tis s u e s to be fre e d of th e ir lead quickly. It affects th at in the sk eleto n only seco n d arily , i .e . by d istu rb in g the eq u ilib riu m betw een the skeleton and the soft tissu e s w ith th e ir g re a te r and m o re u n ifo rm ly d istrib u te d c irc u latio n . This m ay not be the w hole s to ry , o r the a lto g e th e r c o rre c t sto ry of the actio n of EDTA, but th at is the way it looks a t th is tim e . The extent of the clin ical re lie f of sym ptom s is still to be d eterm in ed . 7 . (a) U n d e r p r e v e n tio n , s t a t e m e n t 1, y o u h a v e n e g le c te d to m e n tio n a n d to em p h asize m e a s u re s of m e d ic al c o n tro l. T he a p p lic atio n of .engineering m e a su re s in the f ir s t instance is -m anifestly e sse n tia l, but th a t is not the w hole s to ry . K eeping ev ery th in g in shape in the environm ent is as m uch a function of m ed ical as of engineering con tro l. T his needs to be sta te d , re s ta te d and in siste d upon. The sad sta te of o u r le a d tra d e s in Ohio and in the co u n try g e n e ra lly is e sse n tia lly the re s u lt of bad o r ab sen t m ed ical p ra c tic e in in d u stry . (b) I h av e r e v is e d y o u r s ta te m e n t 2 to p u t e m p h a s is on th e o n ly m e a n s by w hich p e rso n a l hygiene can be p ro m o ted . D r. Thom as F . M ancuso - (5) - June 21, 1956 ..... . . . (c) S ta te m e n t 3 i3 m ad e in a c c o rd a n c e w ith te c h n iq u e s w hich a r e com m on but actu ally a re obsolete. The p erio d icity of the m ed ical p ro ced u res should not be specified by law o r reg u latio n o r in any o th e r g e n e ra l w ay. They depend e n tire ly upon the d eg ree of h a z a rd . I know num bers of in d u strie s in w hich a check-up of the m en at in terv als of th re e , six o r even tw elve m onths is e n tire ly adequate. I know o th ers in w hich m onthly exam inations a re in su f fic ie n t. It is sim p ly not re a lis tic to ta lk about the p e rio d ic ity o r even the n atu re of the exam inations in a g en eral w ay. What we need is good in telleg en t m ed ical guidance of the people in the lead tra d e s . T h ere is no point in deceiving o u rse lv e s on th is m a tte r. T h e re fo re , we m u st not m is s any o p p o rtu n ity to point out th is e s s e n tia l n eed . We in Ohio a re d ecad es behind in th is m a tte r, w ith th e exception of a few in d u stria l o rg a n iz atio n s .w hose hygienic a c tiv itie s a re u n d er the d irectio n of re a lly com petent p h y sician s. A s an illu stra tio n of the p ro b le m w hich w e fa c e , th is D e p a rtm e n t h a s given two c o u rs e s of a S e m in a r o r Sym posium ty p e, in w hich w e have co v ered the e n tire p ro b lem of the hygienic co n tro l in the lead tra d e s , as w ell as the full m edical and clin ical asp ects of the p ro b lem . In d u strial physicians have com e from alt o ver the U .S .A . and som e have com e fro m ab ro ad , but p ra c tic a lly none of the Ohio p h y sician s - even th o se in C in c in n a ti - h av e c o m e . W hy? By and la r g e , o u r Ohio p h y s ic i a n s , w ith a few n o ta b le e x c e p tio n s , do n o t e v e n know th a t t h e r e is anything fo r th em to le a r n . A nd w hy is th a t ? In g e n e ra l m e d ic al . c irc le s in Ghb, we d o n 't even know th at In d u stry - a ll in d u stry needs a brand of occupational m edicine that is significantly d ifferen t fro m th at rep re se n te d by the treatm en t of injury and d isea se. I am not co m p lain in g , fo r I have liv ed in Ohio a ll m y life . I know the people and I know m e d ic a l p ra c tic e h e re in a b ro a d w ay. We sh all su cceed in changing th is situ a tio n . B ut we sh a ll not do it by accep tin g the old ways of doing th in g s. F o r th at reason, the m a te ria l fro m y o u r office sh o u ld , so fa r as p o ssib le, m ove tow ard the new e ra in w hich occu p atio n al m ed icin e in this 3tate w ill be p ra c tic e d by m en who know so m eth in g about it. The p ra c titio n e r can le a rn a ll he n eed s to know about lead poisoning and m any o th e r in d u stria l p ro b le m s, if he is show n th at th e re is som ething to know w hich he does not know. That is why I have put as m uch of th is m em orandum as p o ssib le in the te r m s o f m o d e rn m e d ic a l te c h n iq u e s. F ro m the a sp e c t of m ed ical inform ation we know how to elim in ate lead poisoning, u tte rly , fro m Ohio in d u stry . T hat th is is not being done is su fficien t evidence of the b ack w ard n ess of m ed ical p ra c tic e in in d u stry in this state and n a tio n . T urning now to y o u r re fe re n c e s I have m ad e only two su g g e stio n s, a sid e fro m the c o rre c tio n of the sp ellin g of B r ie g e r 's n am e. I a d v ise you to avoid any even im plied recom m endation of the book by Sax. It is full of e rro rs of fact and judgm ent, of m isstate m e n ts and incom plete statem e n ts. He should not have a ttem p ted su ch a w ork, and it w ould have been b e tte r fo r ev ery o n e if he had not. KH" 00124h,?d D r. T hom as F . M ancuso - (6) - June 21, 1956 On the o th e r hand, I am s o rry th at the APHA re p o rt to w hich I have re fe rre d is not cited by everyone who w ishes to b rin g som e un d erstan d in g of th is p ro b lem to E n g lish -sp eak in g p h y sician s. F o r som e re a so n the re p o rt has not had a w ide d istrib u tio n . It w ill have to be re v ise d , one of th e se d ay 3, in the m a tte r of th erap y , but if the physicians of this State w ere to study it, our d ifficu lties w ould be le sse n e d . I have taken a g re a t deal m o re tim e than I could afford to w rite on th is m a tte r, and th e re is s till m uch to sa y . I hope I have co n trib u ted som ething th at w ill be useful. W ith k in d e st re g a rd s , S incerely yours, ; RAK ef Enc. R obert A, Kehoe, M. D. P . S. I send you h erew ith fo r su ch u se as they m ay be to you if you do not have th e m , two p u b licatio n of the A PH A in w hich we have had so m e hand. R .A .K . O ccupational L ead E xposure and Lead Poisoning - APHA M ethods fo r D eterm ining L ead in A ir and in B iological M aterials - APHA KF 0012499 HANK J. LAUSCHE, Governor RALPH E . DWORK, M .D., M .P .H . Director of Health 306 Ohio Departments Building Columbus 15, Ohio STATE OF OHIO DEPARTMENT OF HEALTH June 18, 1956 PUBLIC HEALTH COUNCIL Judsoa C* Schuler, L L .B . Chairman Henry N. Hooper, A .B ., M.B.A Vice Chairman J. Howard Holmes, M.D. George L. Sackett, M.D. J. F . Mear, Ph.G . Phillip T. Knies, M.D. Mr. Von H. Klepinger R o b ert A. Kehoe, M. D. M edical D ire c to r U niversity of C incinnati The K e tte r in g L a b o ra to ry C ollege o f M edicine-Eden Avenue C in c in n a ti 19, Ohio Dear Bob: We have had q u ite a s e r i e s o f o u tb re a k s o f le a d p o is o n in g i n Ohio. The number o f la b o ra to ry an aly ses re q u ire d has im pressed upon us the a d v isa b ility of developing a p o licy of lim ita tio n in th is reg ard . I t i s w ith t h i s th o u g h t i n mind t h a t we have p re p a re d th e a t t a c h e d memorandum w hich we a re c o n s id e rin g sen d in g o u t t o th e p h y s ic ia n s i n the a re a s in which th e se outbreaks have occurred and fo r fu tu re use under sim ilar circum stances. As you w i l l n o te , th e f i r s t p a r t p ro v id e s an in tr o d u c tio n ab o u t our se rv ic e s and the p o lic ie s in reg ard to th e la b o ra to ry se rv ic e s s t a r t a t th e bottom o f page one. T his i s continued on page two and i s fo llo w e d b y th e summary and r e f e r e n c e s i n re g a rd t o le a d p o iso n in g * This was p rep ared p rim a rily f o r g e n eral p r a c titio n e r s . The re a s o n I am d i r e c t i n g t h i s l e t t e r t o you i s b ecau se y o u r name and " K e tte rin g " has been m entioned i n t h i s memorandum, and s e c o n d ly , I would l i k e t o have you re v ie w t h i s m a te r ia l so t h a t you m ight make such changes as you wish to provide th e type of inform ation th a t you f e e l, from your ex p erien ce, would be most a d v isa b le . One d i f f i c u l t q u e s tio n f o r u s was what we sh o u ld do i n re g a r d t o th e l i s t o f p r iv a te la b o r a to r ie s t h a t m ight be a b le to do le a d a n a ly s e s . At th e moment, I f e e l t h a t o u r o n ly choice i s n o t to m ention any la b o ra to ry or to m ention one th a t is a lread y recognized n a tio n a lly . I t i s f o r t h a t re a so n th e memorandum i s p re p a re d i n t h a t f a s h io n . We must l i m i t o u r la b o r a to r y s e r v ic e s a s we have in d ic a te d i n th e p o l i c y to e sta b lish in g whether a h ealth hazard e x is ts . N13162.01 K & 0052500 Dr. R. Kehoe, C in c in n ati, 0 Page 2 June 18, 195>6 I would a p p r e c ia te i t i f you would go o v e r th e memorandum and make such s u g g e s tio n s as you w ish and when we have y o u r comments, we would be g lad to modify t h i s re le a s e a c c o rd in g ly . T his m a te ria l has n o t been s e n t o u t a s y e t a s we th o u g h t i t a d v is a b le to o b ta in y o u r advice f i r s t . Personal regards. Sincerely yours, j^ Thomas F . Mancuso, M. D. C h ief, D iv isio n o f I n d u s tr ia l Hygiene fr-iine_# o