Document DvdZ4Jmr9qMXbrJ1zaqm0kbzM

August 1, I 9I 4I . Dr. David C. S tr a u s , Dparteent o f Labor, D ivision of Factory In sp ection , 203 'fV. !Wacker D r iv e , Chicago), '1 1 1 . Dear D^. S tr a u s : In r e s o n se to your l e t t e r o f J u ly 2 5 , 1 h a s t e n t o make r e p ly in o r d e r to c o r r e c t any doubt w h ich may be i n you r mind as to m eaning o f my p r e v io u s l e t t e r . what I s a id t h e r e in concerni in?o th e d an ger o f c o n fu s in g th e i s s u e s i n the d ia g n o - 3.1*3 o le a d p o is o n in g was n o t d i r e c t e d a t you p e r s o n a l l y , but rat her at the m u ltip lic ity o f a r t ic le s which are appear- in g on t h is s u b je c t. There are a number o f a s p e c ts to the problem' th a t can o n ly be s o lv e d by in t e n s iv e and e x te n s iv e i n v e s t I R ation and a t p r e s e n t th e d is c u s s io n o f t h e se p ro b lem s d|>o e s n o t le a d u s v e r y f a r . I am g la d you a re d e a lin g w ith a number o f th e s e m a tte r s In a r a t h e r c o n s e r v a tiv e man- n e r , ar d b e l i e v e me, I s h a l l b e v e r y happy to be o f an: further a ssista n c e to you in your e ff o r t s , but I have been v e ry s i ow in p u b lis h in g d a ta w hich we have w h ich I know should be In p r in t. I hope to be ab le to do t h is soon, fo r t h a t , o f c o u r s e , i s t h e b e s t way t o in th is situ a tio n . '1th k in d e s t r e g a r d s , C ordially yours, RAK e f R ob ert A. K eh oe, M. D. N 6318 M A R T IN P . D U R K I N . DIRECTOR JO H N M. FALASZ. CHIEF STATE OF ILLINOIS D W IG H T H. G R E E N , GOVERNOR DEPARTMENT OF LABOR DIVISION O F FACTORY IN SPEC TIO N OFFICE; 2 0 5 W . W ACKER DRIVE TELEPHONE FRANKLIN 5000 CHICAGO 240 J. T. FAUST Ch ief d epu t y July 25, 1941. R o b ert A# K ehoe, M.D. U n iversity of C incinnati C o lleg e o f M edicine C in c in n a ti, Ohio. > . Dear Doctor Kehoei ! Thank you v e r y much f o r your l e t t e r o f J u ly 1 9 t h . , w h ich j u s t rea c h e d me y e s t e r d a y , and f o r th e s e v e r a l r e p r i n t s , w h ich a r r iv e d a few days ago. , I r e g r e t t h a t you h a v e n o t t h e tim e t o r e a d my a r t i c l e b e f o r e i t i s siatraiitted fo r p u b lic a tio n b ecau se I would v a lu e any su g g e s tio n s th a t yoif migir; have to make. I had no id ea o f burdening you w ith e d it in g it. Your l e t t e r i n t e r e s t e d me v e r y much e s p e c i a l l y b e c a u s e th e s u g g e s t io n s you have[made are in e n tir e agreem ent w ith what I have w r itte n . I have f i r s t exp lain ed ju st what i s meant by lea d a b so rp tio n , quoting v e r b a tim fin q u o ta tio n marks) much th a t you have p u b lish e d con cern in g u rin e le v e ls of le a d , blood le v e ls of le a d , and s tip p le d c e l l cou n ts. In regard to th e l a t t e r I have quoted from your a r t i c l e in The Journal Of M e d ic in e , December 1 9 3 5 , and have p o in t e d o u t - t h a t "th e f i n d in g s in norma p e r s o n s , w ith no le a d e x p o su r e , o v e r la p th o s e o b ta in e d in a ctu a l c se s of lead in to x ic a tio n " . A lthough I have sta te d th e recen t attem pts to se t certa in standards in referen ce to stip p lin g , I have s t r e s s e d th e f a c t th a t s t ip p lin g when due t o le a d ex p o su re , m erely shows le a d a b so r p tio n , and th a t in order to e s t a b lis h a d ia g n o sis o f lea d in t o x i c a t i o n , th e in d iv id u a l must have symptoms and o b je c tiv e c l n i c a 1 f in d in g s "c h a r a c t e r is t ic o f what i s known o f t h e c l i n i c a l p ictu re of lead p o iso n in g ." I have str esse d the fa c t th at none of the laboratory fin d in g s, in th em selves, prove the presence o f lead poisoning^ blit m erely are evid en ces of lea d ab sorp tion . I am son}y t h a t you "a r e a l i t t l e f e a r f u l " a b o u t any s t a t e m e n t s I may make D uring my more th an t h i r t y y e a r s o f a c t i v i t y on th e fa c u lty o f Rush M edical C o lle g e , the l a s t tw enty o f w hich have been in a prof e s s o r ia l rank, and h a v in g p u b lish ed more than f i f t y papers d u r in g t h i s p e r io d , no s ta te m e n t t h a t I h a v e made a t m e d ic a l m e e t in g s , or th a t have p u b lish ed , has ever been c h a llen g ed . I have always been ex t rem ely c a r e fu l of any statem en ts I have made. I want ydu t o know how much I a p p r e c ia t e d b o th you r l e t t e r and. th e recen t r e p r in ts and valu e th e inform ation th ey contain* With k in d e s t p e r so n a l r e g a r d s , 0002457 C o r d ia lly you rs^ __ _ Ju l y 19, .19^1 D r, D avid G* S t r a u s , D ir e c t o r , I n d u s tr ia l H ygiene U n it, Department o f Labor, D iv isio n o f F actory Inspection 205 17. packer D r iv e , Chicago, 111* Dear Dr. S trau ssj I I am somewhat se t I t asid e tat ordyll ooooi nkk rep lying to up some o f your le t t e r o f the inform ation .Tune 2 7 . you r e - q u e ste d , bu t I have n o t \ad time to o b ta in th e in fo r m a tio n , and I r e a l l e : ow th a t I s h a l l n o t hove th e tim e t o do I t befojre I fcp on ray v a c a t io n . A c c o r d in g ly , w ith o u t r e s o r t to 3e no f t i.:--he ore av d ata1jr col-.*, e tira1 I s s o, to ha 1 lo ll t ok answer me s ay over f o your qu estio iQVi.Ver, t. a uscrir nast ;t aIs of svh.aellll your pasrobI abcalyn, article on th e d ia I would be .no3i s >la d oj lead do i t poisoning before i t s p u b lication , i f I had the t i r e , but a c tu a lly II have not had tim e to e d i t can not attem pt o th ers. n own . t i n g , and I am a f r a id The ty p e o f le a d p o is o n in g which c id . n o t g iv e r i s e to s t ip plln , by rea so n o f I t s overwhelming; c h a ra cter i s a b it unas u a l. c h ll dren I have brought see on n by a t few he 1 c agseesstioonf lead poison in g in of la rg e qran t i t i e s o f 1ead in one or two d oses which no s i g n i f i c a n t b lo o d cha es were seen . A lso , I de crib ed a s e r ie s o f ca ses of tetr unac a e th y l compan lea ied d by p o is blo o o n d in g ch a in ng J es . . A . T7 .hAes.e, in 192f- which were c a s e s m aybe so ^ e- what d iffe r e r it from th e o th e r s , in th a t the i n i t i a l d i s t r l - b u ti on o f le a d in the body i s somewhat d if f e r e n t , and, pro- simia tio n so n ! comp b ly , the t o some PS ounds, w i bone marrow, i s sp I have n from in d u s tr i thout stip p lin g . a e a re ve l I d froBi r seen exposur doubt i in ju r cases e to y oofr lesatidm srdlnary pu oi ai-lead f 3uch cases occur. Ther ; i s no r e l a t io n s h ip , t h e r e f o r e , betw een c a se s o f t h i s type and le a d cor c o n tr a tio n in the atm osphere. Tinhdeirec a is te d no an r d e la tio such n l s e h ip sio n b s etw as e en pa cases r a ly si s o , f e the nce p type h a lo J pa hav thy, e or o cate, come t iler oonr y cha vmereyn trpiaornocetmdeprtiOlsyJt i cmafe.lteesriicouantems . assIinveo rder to be in th e expowsuoureld. hPaavrealytosis de xocees h1coumnee ca ien o ftu eiax p foasus hr eio nto, I e ir aadeoevis'.y exn leees:eh a. le cuantheyne oth er hand, a s you undoubtedly know, p a r a ly s is can oe ore- .sen t as a sequel of lead poisoning long a fte r the lead is gone ftom th e body. Under th e s e C ircu m stan ces, r e w orld n o t ex p ect to f nd s t ip p lin g , or any oth er c l i n i c a l e v i dence of lead absorption. I an n p t q u it e a r e woat yo ooan in yo-'-r q u e s t io n con c e r n in g the r e se u o la r .e e o f c e r e o r a l s vac toss o f lead- in t o x i c a t i on t o th o s e o f d r a in tumor*. I should, th in k i t r a ci.er o o v io u s tha t o ra in tumor r.as to be ex clu d ed by d if f e r e n t ia l d ia g n o sis in any type o f encephalopathy f i n a l l y , J th in k 7 sh o u ld sa y to you th a t a-s a c o n se quence. o f n o t in g th e q u e s t io n s you h ave asked-, I am a l i t t . l a f e a r f u l th a t you w i l l be making some sta te m en ts in your a r t i c l e w hich may be regard ed a s somewhat d ogm atic on th e one h a r e , and c o n t r o v e r s i a l on th e o t h e r . I hope yo: wi [LI he c a r e f 1 n o t t o do th is. From th e p o in t o f view o f compensation and m ea lc o -le g a l c a s e s , th is f i e l d i s a i r eady muddy enough, vshat i t n e e d s i s c l a r i f i c a t i o n and s i r .p lific a tio n , r a th er than c la im , c o u n te r-c la im , and c o n t r o v e r s y . An a tte m p t i s b e in g made a t the p r e s e n t tim e to s e t certa in standards w ith referen ce to stip p lin g , the lead c or.centratione in e x cr eta , b lood , tis s u e s , e tc e te r a , and t ` s e a rc a l l b e in g pushed fa r beyond, t h e i r proper p r o v ln e . The d ia g n o s is o f lo a d p o is o n in g m ust be made prim ar l y from c l i n i c a l o b s e r v a t io n s . The man :!n q u e s t io n must b s ic k , and he m ust have a sic k n e ss which i s charact e r i 3 t c o f what i s known o f th e c l i n i c a l p ic tu r e o f le a d p o iso ng. A ll s o r t s o f vague -com plaints are being, r e garded in th ese days as lead p o iso n in g , and are confirm ed in the judgment o f the examiner by evid en ce w elch i s n ot v a lid . In g en era l, the lab oratory evidence is u sefu l in o n ly ohe way. That i s to s a y , i t dem on strates th e magni tude o f the lead exposure in r e la tiv a term s, i f i t is co ta in ed in th e r i Jilt way, and a t th e r ig h t tim e. In t ,' s evidcr p e, blood changes have been e x a lte d fa r beyond th e ir s i^ n if canoe. Fone of the blood changes seen in lead in to x ic a io n are s p e c i f i c , and th e r e f o r e , no d e f i n i t e l e v e l o f s t i pling. or r e t ic u lo c y t o s is can be s e t as d ia g n o stic . Moreov r , th e f in d in g s on norm al p e r so n s w ith no le a d ex posure overlap those obtained in actu al cases of lead in to x ic a tio n . For th is rea so n , th is type o f evid en ce must be con sid ered w ith the utm ost con servatism and judgment. There pre on ly two th in g s about t h i s w>ich I t is s a fe to say in any categ o ric fash ion : T hat a c t i v e symptoms o f le a d in t o x i c a t l on., e x c e p t fo r th e r a r e st c a se s, are a sso cia ted w ith e x is te n c e o f m ic r o sc o p ic b lood ch a n g es, and t h e r e f o r e , th e absence- o f such b lood c h a r g e s may be a c c e p te d as su b sta n tia l proof that the in to x ica tio n is not due to the le a d . 2 , The o n s e t o f le a d p o iso n in g Is u s u a lly a ss o c a te d ivith a co n sid era b le in c r e a se in the s tip p lin g o f the in d iv id u a l above h is previous normal le v e l. The l a t t e r s t dem erit m eans, o f c o u r s e , t h a t th e a b s o lu te le v e l o f the stip p lin g o f an in d iv id u a l i s n o t n e c e ss a r ily r e la te d to h is lea d absorption* ' I t r u s t th a t what I have sa id w i l l g iv e yon sane h elp in th e p r e p a r a tio n o f you r a r t i c l e . I am send*rig you under s e p a r a te c o v er s e v e r a l a r t i c l e s w hich may be o f fu r th e r u se to y o u . The a r t i c l e "Lead A b sorption v e r su s Lead P oisoning" has n ot been p u b lish ed , and th e r e fo r e , w ill be o f l i t t l e use to you i n docum enting 'your a r t i c l e , and inasm uch a s I do n o t ijave m im eographed c o p ie s o f th e a r t i c l e , I am. n o t in a p o s itio n to send i t to you* C ord!ally yours, H eber t A. Keh oe, RAK e f / P. DURKIN. D ir e c t o r M. FA L A S Z . C h i e f STATE OF ILLINOIS DWIGHT H. GREEN , Go v e r n o r DEPARTMENT OF LABOR DIVISION O F FACTORY IN SPEC TIO N OFFICE; 2 0 5 W . W ACKER DRIVE TELEPHONE FRANKLIN 5000 CHICAGO J. T. FAU ST Ch ief d epu t y Dr. R obert A. Kehoe K etterin g Laboratory C o lleg e of M edicine C in c in n a ti, Ohii). June 2 7 , 1941, Dear D octor Kehoe: , Under s e p a r a t e c o v e r I an s e n d in g you a copy o f my r e c e n t a r t i c l e e n t i t l e d ''D ia g n o s is o f O c c u p a tio n a l D is e a s e s by t h e G en eral P r a c t i t io n e r " , w hich appeared in I l l i n o i s M edical J o u rn a l, March, 1941, as per your req u est. *,, ' At p r e s e n i I am c o m p le tin g t h e se co n d a r t i c l e o f th e s e r i e s . T his one i s on the D ia g n o sis o f Lead P o iso n in g . In preparin g t h is se c o n d a r t i c l e I h ave q u o ted much o f you r work and many o f your a r t i c l e s , which I f e e l are the o u tstan d in g con trib u tio n s- in the f i e l d . I sh o u ld l i k e to h ave you lo o k o v e r my m a n u sc r ip t and make any su g g e s tio n s you f e e l would be h e lp fu l, b e fo re I subm it i t to th e p u b lish e r . Would you c a r e t o do t h a t f o r me? I w ould g:; r e a t ly a p p r e c ia t e r e c e i v i n g a copy o f y o u r a r t i c l e , ''Lead Abso rp tio n versu s Lead P oison in g" , w hich I b e lie v e is as y e t unpu blish ed , and any o ther o f you r r e c e n t a r t i c l e s w h ich you may n o t a lr e a d y have se n t me. What a r e ome o f th e s h o r t e s t e x p o su r e s you h ave s e e n t h a t w ere f o l - lowed by d e f in it e le a d p o iso n in g , th e typ e you r e fe r to which are so overwhelm in g th a t th e p a t ie n t does n o t show s t ip p lin g o f t h e e r y th r o cytes? I n such c a se s, what has been the lea d con cen tration in the air? L ooking fbrw ard t o y o u r r e p l y a t y o u r e a r l y c o n v e n ie n c e , I am, w ith kind p erson al reg a rd s, i S in cerely yours D a v id C. S t r a u s , M.D. ,D ir e c t o i In d u str ia l H ygiene U n it. P .S. I would a p p r e c ia te th e f o llo w in g d e t a i l s on th e c a s e s w ith no s t ip p lin g - (a ) the number o f su ch c a s e s , (b) the number w ith p a ls y , (c ) th e number w ith en cep h a lo p a th y , and o f th e s e the number p r e s e n tin g symptoms rese m b lin g th o s e :of b ra in tumor, and f i n a l l y , th e outcome o f th e members o f t h i s group and th e