Document 99Q9ZnD7NZ219nzGG94EZGob7

WORKMEN'S COMPENSATION BOARD OF BR ITISH COLUMBIA 707 W E S T 3 7 t h A V E N U E , V A N C O U V E R 13, B R I T I S H C O L U M B I A . T E L E P H O N E 266-0211 Doctor Robert A. Kehoe 345 Resor .venue Cineinneti , Ohio U.S.4. . July 16, 1968 Dear Doctor: Re: Ferenc i-isradi Claim if67090880 Inclosed please find cheque number 9410-286480 in the amount of twenty dollars ($20,00) in payment of your account dated april 9, 1963 for services rendered this workman . Yours truly, JIK/dw enclosure J.D, Iom a i d Dedicai Aid Division N13159 K ? 0012471 W O R K M EN 'S COM PENSATION BOARD o f bk it is h Co l umbia 707 W E S T 3 7 t h A V E N U E , V A N C O U V E R 13. B R I T I S H C O L U M B I A . T E L E P H O N E 2 6 6 -0 2 1 1 May 10, 1968 P.r. Fo r m * 6a r a d i, i.'45 Bas t 16th. Avenus, VAhaouvsi i, s. c. De&r Sirs Tour cl,lift has been reviewed by the Board of Review andt C325is5ioners and It has been recesasonded that your claim now !>e accepted a a Board responsibility* You should oufcssit any account* applicable to the condition for which you were treated on Bocosbar 16, 1967* We should .also Ilk to have the date you first returned to employment after Iteember 16, 1967 having this confirmed by your employers, and the dates of m y subsequent lay offs should be included* BAM/cn 1& X # 5 c*c*t c *o .i '/c .c .j o .Go c.e.t c*e*t Iset&Iex limited Dr* C. w. K. Murdock , - Dr Robert A* Rehoe Sr* 1). P* Jones i*r. Bell, Vancouver Gonaral Hospital Social Servi Or* Mss* S* Huckvale N13159.01 Ke' 0012472 April 9, 1968 R. M. Hayes, M.B., M.R.C.P. Medical Officer Workmen's Compensation Board of British Columbia 707 West 37th Avenue Vancouver 13, British Columbia Canada Re: Ferenc MARADI - Claim 67090880 Bear Doctor Hayes: . I do not wonder tiiat you and your associates are in some doubt as to the correctness of the diagnosis of lead poisoning in the case under consideration as noted above. I find myself in a somewhat similar situation, by virtue of certain contradictions in the findings of fact, as well as the conflicting opinions expressed in the records sent to me. I shall undertake first to state the facts as I view the record, then to set the contradictory views opposite each other, and to express some skepticism as to the validity of certain data, and finally to give you my opinion for what it may be worth on the background of the uncertainties. 1. There seems little doubt that this man has had a sufficiently prolonged period of employment in a hazardous lead plant to have absorbed, plausibly, a dangerous quantity of lead. There is a valid question as to what he was doing, and it is important to recognize that the different jobs in these plants yield very different degrees of severity of exposure. Nevertheless, I tend to accept the probable significance of his exposure (subject however to the analytical evidence of the extent of the exposure, of which more later). 2. The finding of a "lead line" of the gums seems to have been confirmed, but this has been given undue weight in the diagnosis. This line, when present and due to lead is indicative of more than normal absorption of lead, but does not mean that such absorption is of sufficient severity as to justify the diagnosis of lead poisoning. (I have seen a well defined lead line in its development when the concentration of lead in the blood did not exceed 50 micrograms per 100 grams of whole blood at any time during the development of the line.) 3. Of considerably greater significance are the clinical findings of apparent weakness of the extensor muscles of the hand and wrist. The latter was not "wristdrop" as referred to repeatedly in the record, but rather was apparent weakness. The latter varied, it seems, with the method of testing and the time of testing, and could hardly have been certainly significant. The evidence of electromyography, however, indicates the presence of muscular impairment, which was of such a type as to be compatible with the effects of the absorption of lead. I do not trust this information implicitly, but I am influenced by them. 4. The urinary coproporphyrin is said to have been appreciably elevated (3+). ~ If this was true, it is an important item to add to the other features of the case. I do not trust this analytical finding as the product of a non-quantitative test, but if it was done by a knowledgeable and experienced person, it has important R. M. Hayesj M.B., M.R.C.P Page 2 April 9, 1968 The contradictions seem to me to be as follows: 1. One clinician has regarded the so-called "wrist drop", i.e., the extensor weakness, as insignificant, from the aspect of a neurological lesion. 2. The analytical result of "0.56 micrograms of lead per 100 cc"of whole blood (only one is reported) if correct, is incompatible with the diagnosis of lead poisoning provided it was obtained during or in virtually immediate relationship to the exposure to lead that is credited with responsibility for excessive absorption of lead. (I do not accept the interpretation, given in the record, of the significance of the urinary findings, with respect to lead prior to or during the therapy with "versenate" /which I take to have been disodiura calcium versenate/. That this man had absorbed abnormal quantities of lead in the course of his work is reasonably certain, but there is no reason from these findings to conclude that hi3 absorption was in the range of amounts which are compatible with lead intoxication.) 3. "stippling" of the erythrocytes has no certain relationship to lead poisoning as a diagnostic test. When it is due to lead, and is increased beyond normal limits, it signifies abnormal absorption of lead, but not necessarily, lead poisoning. Conclusion: If I were certain of the accuracy of the result obtained by the analysis of a sample of blood obtained presumably at the height of this man's occupational exposure to lead, (there appears to be only one such result), I would not be able to arrive at a diagnosis of lead poisoning, for I have never observed the onset of lead intoxication in association with such a level of lead concentration in the blood However, the several items of evidence which favor the diagnosis of lead poisoning, when combined, make it impossible for me to offset them with the one analytical result on the blood. (The analytical error of the best of the analytical procedures and of the best of technical performances, is of the order of ih 10 percent. It is often considerably greater in relatively inexperienced hands. I would need to have knowledge of the analytical precision in this instance if I were to bank on it.) I cannot, therefore, either arrive at the diagnosis of lead poisoning, nor exclude it. Accordingly, I should be disposed to give the benefit of the doubt to the claimant in this instance, not so much because of the benefit to be derived from compensation, as from an unwillingness to subject him to the continuation of his employment unaer the hazardous conditions which might lead to irreversible disability (palsy). I regret that I find myself in this position. I am sure that if this man had been studied properly at the time of the onset of his apparent illness (with particular reference to the verification of the analytical findings), a firm diagnosis could have been arrived at. With the lapse of time and the application of chelation therapy, it is doubtful that a definitive conclusion could now be reached. Sincerely yours, RAK:wp Robert A. Kehoe, M.D. Professor Emeritus of Occupational .Medicine April 9, 1968 Tc: Workmen's Compensation Board of British Columbia 707 West 37th Avenue Vancouver 13, British Columbia Canada Attention: R.M. Kayes, M.B., M.R.C.P. For: Reimbursement to Robert A. Kehoe, M.D. For the Review and Recommendations in regard to Ferenc MARADI - Claim 67090880 $ 20.00 N13159.03 ' 0012470 R. M. Hayes, M.B., M.R.C.P. Medical Officer Workmen's Compensation Board of British Columbia 707 West 37th Avenue Vancouver 13, British Columbia Bear Doctor Hayes: Re: Ferenc MARADI Claim 67090880 This is an acknowledgment of your letter of March 18, 1968 to Doctor Robert A. Kehoe. He is presently on a business trip abroad and will not be back in his office until early April. I shall, of course, bring your communication to his attention upon his return, and I am certain you will be hearing from him sometime in April. Very truly yours, wp (Mrs.) Winifred Peaslee Secretary to Robert A. Kehoe, M.D. N13159.04 0012 4?t> Dr. Robert A. Kehoe, The Kettering Laboratory, College of Medicine, University of Cincinnati, Cincinnati 19, Ohio. KF Re Claim Dear Doctor Kehoe: Lead absorption and lead intoxication continue to present problems to this Board. In the past you were good enough to assess the evidence on a claim and make recommendations. We are having considerable debate and difference of opinion in this case and would again request your assistance. The claimant, above-named, is 35 years of age and has been employed with a metal salvage company for 19 months. Housekeeping in the plant leaves much to be desired and we have received and accepted several claims from employees of this company. I am enclosing copies of multiple consultants reports which will give you all of the clinical and laboratory findings. Our Industrial Hygiene Department wrote a memo to this file on March 12, 1968, which states as follows: "Tliis workman's urinary lead excretions have been well below the suggested safe limit of 200 micrograms per litre since mid 1966, with one exception in January 1967 when his urinary lead level was 320 micrograms per litre. The lead excretion during treatment (7 grams, 5 grams and 5 grams) was not significantly higher than that of unexposed persons on the same treatment. Multiple cases of lead poisoning amongst other workmen in this plant, the presence of urinary coproporphyrins and basophillic strippling support a diagnosis of excessive lead absorption by this workman. Limited symptoms consisting of a finger and w i s t weakness do not support this diagnosis and other possible causes of this should be considered." The present position of the Medical Department is that this man has absorbed considerable lead but his symptomatology and laboratory reports do not support a diagnosis of lead intoxication. 0 01247 V N13159.05 March 18, 1968. We will await your opinion with considerable interest and of course will expect your account for the usual consultation fee. Sincerely yours, /7' RMH:lm ends. R. M. Hayes, M.B., M.R.C.P. Medical Officer K 0012478 90S - 750 .ost Broadway, t a h c o u v i h ?, b .c . Tear Dr. ..urdoch: ____ _ k o 1(? rco that for the last nineteen months he hen boenexployod I n operating a furnace to melt load 'catteries in company with about a dozen other ron. About four weeks apo he noticed weakness in extending the finders of his riTMht hand (he bcinp riyht-handed) and two weeks epo the left hand was similarly affected. There is weakness also in extcidinp the wrists. He docs not complain of any pain or numbness and ho has no trouble v;ith the le-^s. His appetite has been poor race'tly but there is no history of abdominal pain.' lie rives a past history of limb pains durinp a five -enth period 1n"`X95i~-han ho was employed as a miner in Hungary. Otherwise his health has been pood in the past and ho cones from a healthy family. On examination he looked rather pale. There was a veil narked blue line alert" the pun ed~es, especially in the upper jaw. The optic disks <nd other cranial nerves were normal. In the arms there mas no wasting. At rest the hands were slightly flexed at the wrists and the fin-rare more so. Voluntary dorcifiexion of the wrists could be dene to a slight extent but not of the- finders whereas the flexor xuocics wore strong. He was unable to abduct the fi'T'crs but could do so a little when they were extended passively. Ferrer in proximo! nur,cles was normal, sensation was intact and the tendon jerks were normal and symmetrical. In the lower limbs power, co-ordination, sensation and reflexes were nor~al. The superficial abdominal reflexes were present and the olantar rssconses flexor. I ayree that hs has lead palsy and I think it would be best if you admitted him to hospital now for chelation. Hy experience with chronic lead poisonin'' is m e t r e but accordin' to the cooks the eventual prognosis is pood. Ha will need to find a different kind of job afterwards. -1.?n r v o rm n I should bo root interested to see him amain in Yours sincerely. N13159.06 KE" 0012479 DR . D . P. JO N ES 7 5 0 WEST BROADWAY VANCOUVER S.B .C . . k isricry, ly nr.-O.V'.r. irr-'ouh. 90i> - 7rO ".est. 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I bevo n o i c zp ric rm c c u o r -h i o r e t o a f i r n e]I r - u c c io cn preservi cvidorvjo b u i i f ho deca ro in I chculp l o plud o f th chea co to eco hin erein. "bure c iric c ro ly . ~7J/e c .e * i r * * -.. ce* ' '3?br=en*o f-rrrp o n se tio a l o t r l i i e .i n ilo* 670?ubt0* N13159.07 K f 00124S0 , - t:> ' ' K B 0012481 N13159.08 . . i t ' J J - ,* ; l".. * ;;; ' .. : : :i ; \ -j O. ;: ; 'j L' * t -r r* C , 0 ' '* :** r- * : :*- - ;J O ,* V> ;\ i - .4 e t l-J :^ j i - * i..-. .j \ ) 1j ; .J ; r.r-'* C i 1 f. _j , j a U-* ~ vj . 4 ; & i ir i' * , -J " ! A *! ` i iTM .f ~ ,t .-.kit r.- V l- ~ i ik] r, *y i r ... H* ' \ r. \T rr i- : Vi e L* Vr - cv ; o i r .* o'j ( * /; - ; T r r [ ; ; - v p* '( *f ri*- i cM rj t` , * ! J Ui .'.L ci* .L .. . . . w \ fi Ci , ;.l r-J *; * V' ` T. i . . . .. O "...A < r ; } ; '' ) V t vr * \ !' D , 1 CO j s 1- t [ :" 4 f : r r / t 1 f ! .i C.j .. '* r * p ' p r r r i * ; *.' ! .1 i ; : - . 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J-,?"--Ip'--l / ri i r i uJtiJ DEPARTMENT REQUESTED'vlYSiO ;.L MIDI CIifia_______ CONSULTANT W. GTJ . /HlSLSS d ia g n o s is __________ ? Lead H su ro p ath y . ? H y s te r ia ____________ .______________ RELEVANT DATA_________________________________________________________________ DATE__>2th .Tmn&ry_______________Sjs. REQUEs 3. T*. REPORT ( 12th Ja n u a ry 19oB_______ d a t e f in d in g s 7 vrrrtf PVl * path <wt. tM a T u rn in g r o r i &:urvyh fs^rn^ntA c, a s a e otRnant r f il&'C.em.i w i s t drop, diagnosed alternatively as load poisoning or hysteria. he fiad haen w orking l t i n g l-sari b a t t e r i e s u n t i l a. r~onih ago and h a s haa_____ o ro g re s s lv wrist trap s'feartin g on t h e r i g h t s i x weeSro ago* C l i n i c a l l y t i l l s j.3 Tgthijno a?i n o t h y s t o r i e a l . ____________________________________________________ ___________ ci I n t e n s i t y d u r a tio n c u rv e p l o tte d from th r i g h t .a ^ & n s o r c a r p i r a a i a l i a .shewed a. s l i g h t l y s i u g ^ s n re s p o n s e t o in * -100 .railllseecsad s tin u iv n At 1 .9 r i s i n g to 7 - r L i- a a p s a t .1 r^ jH l seco n d . aa4 22 niU.l~a>Lpa it 0.1 second. DO NOT WRITE IN THIS SPACE Tas eleotroayograpii i'roa the u&cws saiool siiwsd a train of fibrillation ootsatials at rost.__ Cn voiiM-ga_.thers,was a aparaw pattern of slightly low voltage tor unit action potentials, with a tendency to pelyphaalsity. lcafid'iwti.on tifaes were a ls o recorded frees th e v.odiaa '&nd nlnar n erves a t K^ yn-ij + Tm** ?*>fir-vi _____________________________ ________ This raafcienfc ahcwa definite elect,rico.l evidence of partial denen'atim. thotsgn o f sdnor tia$ree, supp orting th e d ia g n o sis o f load neuropathy. Trie Tcudnctica yeloaltdes ^easurad In the e Uni rally unaffected r&dlan and uluar___ nerves are w ith in norm ! X irdta, though only lu s t in th e forw er. 13th January 19 i saw t h i s p a tie n t ag a in to d a y , &fisr diaatuosioa w ith Or. hon es, fo r pi.gd-ro^^r,rhj ansala*.--- lia ^ t e n sor-pollials-longu-s ,->hawa..prafuao-- -- f i b r i l l a t i on and ntany p o s it iv o p o t e n t ia ls a t r e s t , w ith a O lsc r o e t p a tte r of __ T-.-I ,,,]. 4 4pha.ui? .-.;t>tr-unifc g.otio.-t-pctw ti& tq e w -v o litk a a ,-----'iSva -^j&toctor y o l U a i ----- r ev ia I s l i e n t a t r e s t , w ith a -aon;pl<ais p a tte rn o f n o ^ A l r.tofcor u n it a n tic a -.'. t*'t.:.g M valiti,h ?----- -- -- -- ----------------------------------------------- --- '"y -- N13159.09 i,! ? L2 ; s r^cs- tie adductor pellicle feints, -*/$ -r'st `i 'irit inrs--'^f ffttif '?f 7>i-itrulS:i?t '*r5 tt*5 2$ pet *SJfnTSfj ~ '*:ra fhere is absolutely no doubt that the wrist"drop- is organic^ due 'f . . ->r.cs .. ,?. i K-'ird-'jeh ' ^5 -. # i %- , s v * ieii 4. O 3. (2)y iix '& itn r -> :fc y s ic a i HediuSne 0012485 D.O.B. Cob. 25/32_________ d r . d . p .j o n e s 7 5 0 WEST BROADWAY VANCOUVER 9. 3 C I i Unit ;To. 66-2p-l; DI30HFRGS SUlleAPI This nan was admitted to hospital for inve; >ar.ion of presumed lead poisoning as describee in rny notes. He had been seen r: 'r 5-. admission (on January 2nd) by a consultent who reported no positive n enrol- I'.oi findings, and who did not find, any symptom to suggest lead poisoning. investigations priory top admission: * / Dec. 20/67 blood ure'a 3U mgs/. PSP: 6 7 / excretion in t::- h-rrs. Urine: large amount of cop roporphyrin Blood lead /6 'per 110 ecu. /O i Preliminary hospital tests: Urine: Coproporphyrin +3, otherwise normal. Blood: Haemoglobin 11.3 3 / +2 microcytosis Stippling present Lead / / per 100 ccs. Spinal Fluid: Protein 30 mgs/, Kolir.er negative, pressure 18/ mm. Effect of Chelation: The patient was given three courses of versenate treatment: January 16 - Ip (70), January 23 - 2o (/C-), February 2 - 7 (50) Urinary lead excretion per litre) during the treatment period was as follows: J an. 16 17 18 19 20 21 22 23 21 0---mT 26 27 25 27 j0 31 90 ) 1 7 C0 ) 00 no ) 03'--, j Li. ' : 33 "33 r`. . \ / ' ~' .-1'- ~ \j , " 63 3 .' j\ j - 3 x.c'3 30 3 Vers onate urinary porphyrins n e -n tiv e Feb. 1 2 J' as 0 7 uC 0 11 12 so 10 0 ) cc) lo c o ) 350 ) 360 ) 90 110 90 -- na,te Urinary porphyrins ne N13159.ll 2 DISCHARGE 5UAKARY (continued} Other laboratory Investigations were as follows: Electromyography: This was performed 'ey Dr. Buckler on J anuary 12th, 15th, 23rd and 29th. It showed clear evidence of partial denervation of the affected muscles. Serial nhotogranhs of the pure: I think these showed improvement in the lead line. Kidney function: "' Blood urea 2k rg% end 22 mg/. PSP (String Lab.) 7354 of normal. Blood creatinine 1.12 mg/. Course in hospital: Physiotherapy and occupational therapy led to slight improvement but it is anticipated that recovery will take place only slowly. The patient will attend for further treatment as an outpatient. Evidence uoon w;hich_ a_ci_^rrosi3 of lead, neuropathy is made: 1. History of possible exoosure and the patient's statement that fellow-workers in the plant have teen affected. 2. A typical clinical picture of weakness affecting the extensors of wrists and fingers, right more than left in a right-handed man. 3. Incontrovertible EH! evidence of denervation, thus disposing of a suggestion that the condition is hysterical. I4. Blue line on the gums. 3. Anaemia. 6 . Basophilic stippling. 7. Renal involvement. 8. Excess cocr0oornhyrinuria, disappearing with treatment (Ked. J. Austr. Feb. 23, 1?67, Br. J. I n d u s t r M e d . I9 6 7:2k.203). 9. Massive lead excretion after versene treatment (See. Med. Hop. Paris i9 60 :117-U27). DlSCUSSIOh: This mam was shown at neurology ward rounds and one (only) speaker discounted the diagnosis of lead poisoning - on the grounds that blood and urine lead levels had been mostly normal. There is evidence in the literature that examination of a single ' specimen of urine is meaningless (Brit. J. Incusr. Med. 1966:23*263) and it is reported (Lancet Jan. 22, 19 6 6 , Med. J. Austr. Feb. 25, 1967) that bleed and urine examinations for lead do not provide infallible evidence: rather, the results of these tests are to be considered not in isolation but as components in a range of tests. The Lancet editorial states "In spite of the new diagnostic aids, however, lead poisoning remains firmly a clinical diagnosis, and it is for the physician to decide, on the basis of clinical and laboratory data, when a man is being poisoned by lead". Diagnosis on discharge: Lead neuropathy. This patient is to be shown on Grand Rounds on Thursday, March 7th, I968 . B?j/e D.P. Jones, M.D.