Document Jrrbv9YwNp7pNa6gemMbM1B6

November 15 19^-1 Dr. Morris Fishbein Journal of anerican Medical Association 535 Horth Dearborn street Chicago, Illinois Bear Doctor Flshbein: I as writing you about the paper ''Tetraethyl Loud Poison ing, with Report of Cases" by Philip Work and Pagnar J. Neas, Denver, Colorado that you accepted for publication recently, and am communicating with you at the suggestion of Dr. J. F. H&rrsond, vdth who I discussed this matter last week in your absence from Chicago. lly reasons for commenting upon this paper are three-fold: (1) There is a certain amount of misinformation in the parser that should be corrected; (2) Certain data of mine and Pr. Kehoe's were used without our consent or acknowledgment and more importantly, without our comment upon them end our interpretation of their meaning; (3) The inferences that were drawn from our data are, I believe, erroneous and since our own data was misused in this fashion, 1 feci that the matter definitely calls for some comment and action. For your information, X will outline the manner in which we became interested in these cases and the way In which the present situation arose. In February 19^1* we were called by Dr. H. J. Nees of Denver, for advice on the treatment of a case of tetraethyl lead intoxication which was presumed to have arisen during the course of operations involving the blending of tetraethyl lead with gasoline. ?'e have had responsibility for the hygionic supervision of men engaged In blending operations and have previously reported (in the Journal of Industrial Hygiene) on the state of health of over 2,000 men so engaged. Since there has never been a case of lead poisoning or oven 0021311 Dr. Morris Fish.beIn - (2) - Hovembor 15* 19^1 a measurable increase in lead excretion in that group of men, we were vary such Interested in hat a e c m d to be an unusual circumstance and went to Denver for the purpose of assisting With this case and of ascertaining the facts* While there, we learned that this case of poisoning had cojae about no the result of the operation of a small boot leg manufacturing plant and that a number of other individuals hod been exposed during Its operation* We arranged to examine the remainder of the employees, which examination 1 carried out in Dr* Hess* office* To my knowledge, Dr* Work did not see these cases, although he was the neurologic* consultant on the original case und assisted Dr* Bess In that patient*s ptanagemat throughout the course of his illness. Following lay return to Cincinnati, Pr. Hess expressed the wish to present those caaes to the students at the Medical Dchool m & to the County Medical Society* We were heartily in accord with this idea end sent Dr* Hess all of our clinical records and analytical data, together with certain interpretations. Since the case reports and analytic! data were our own, we expressed our desire at that tine to see and review any material that might be prepared for publication* After the materiel hud been used for presentation by Dr. Hess, it was some time later turned over to Dr. Work, who prepared the paper that you now have. We did not see this paper, nor to my knowledge did Dr* Hess see it in its finished form until a copy was sent him after it had been accepted for publication, I mention this latter fact to you merely to point out that though Dr* Hess* name la on the paper, what X have to say both above and subsequently ought not be taken as criticism or reflection ia any way upon Dr. Hess* position in this matter* He has been and is most cooperative, and in fact placed in our hands his copy of the paper as soon as feasible after receiving it* You can see that the manner ia which this thing developed has created a very unfortunate situation* It is not the matter of credit that concerns us, but I l;ave a very strong reaction against what is obvious misuse of data* There are minor paints of error* The principal aberration; which may be of significance, particularly from the medicolegal point of view, is the last conclusion in which the statement is made that organic lead intoxication may produce permanent clinical residua. Setting aside for K f 0021312 Dp . Morris Fishbein (31 - November 15* 19*H the moment the origin of date in the paper, X 3hould like to point out that the patient was discharged from the hospital, improved, but not recovered, in April, and that Dr. Work's last examination vras in July* Considering the seriousness of the man's illness and the nature of his exposure, it would not be expected that he would make a clinical recovery in that short period of time. By no stretch of reason would one be justified in considering any lesion or functional disturbance that persisted for only four months after a serious illness as being, of necessity, a permanent clinical residuum. Our experience has shown that clinical symptoms m y persist until the lead content of blood end excreta have resumed substan tially normal levels. In point of fact,, I examined this patient in company with Dr. Naso on Tuesnay, November h, ana found no evictenee of organic residua or of montai impairment. We are at the present time securing samples from this man find will have further information on the extant of his recovery cheaioally. Without regard to any of the foregoing const derations, a further point that must be nsdo, namely, that the exposure of this patient was not du to organic lead com pounds alone, but there was in addition, oerious and significant load exposure to Inorganic lead compounds In the form of dust and lead fumes* While one could not say that these alone would be adequate to cause an encephal opathy, yet the severe exposure to inorganic lead com pounds made this case atypical in its behavior, as was noted on our examination records. It ie well established that permanent residua m y follow encephalopathy from inorganic lead compounds, but in none of our cases of organic load intoxication have there been organio sequelae. Since this patient had both types of exposure of considerable magnitude, it is quite apparent that some type of logical tour de force is necessary to permit of the last conclusion. I have labored these points and gone into the faetB with considerable frankness since wo feel it is proper to call upon you for advioe as to procedure. Were this entire difficulty merely a matter of interpretation of previously published results, it would not"be tit all difficult to express our opinion in the form of a letter that could appear at the time of publication of the article. Kfc 0 0 2 1 3 1 3 Dr. 'orris Fiahbein - (h) - November l>, 19!M It is not so simple, however, and I believe you can wall realise that the scope of any latter that included all of the facts would of necessity have to involve soi&e state ment tru t would tend to reflect rather seriously upon the authors. 2 would .not like to do that if 8 better way can be found It occurs to us that sinon the paper has hot yet been printed, it nay be possible to get the opinion of a reviewer personally acquainted with this type of intoxication who could reconsider this paper in light of the cements that wo have made. lie would like vary much to be apprised of your rotation. It .la nocessary for rm to be in. Chicago fro time to tioei and if you or Dr. Hamomi feel that anything oun bo gained by further discussion, I ahull nafcs it a point to be there sone time when you are available. Tory truly yours, hiiivr H l a r d -Mche 1 U7 0021314