Document Lp3wm5J35q9ZOdnK3KaZRyBQw

Dear Bob: \ >1 jbiJ V86V I appreciate the copies of the letter for the record. We are proceeding to process your letter. Sincerely yours. John MD 1 am l c j yuu zct vtian uu uic mcwuc* vr* wrc o4aff who is responsible for "Questions and Answers," because I am being sharply critical, not only of a reply that is given in that section of the Journal for May 4, 1964, but also the reference of such a question to a man who is not a physician, and who clearly does not understand the problem which is confronting the questioner. One does not jump all over a person whew he does not know, nor can he expect his right to do so to be granted under such cir cumstances. I am relying upon you to refer my letter to the proper person, or, alternatively, to take any other action that you may consider appropriate. It does not appear to me that the action in this instance was considered or responsible. In the previously mentioned issue of the Journal, p. 478, is a question raised by Dr. Lewis M. Davis of Greer, South Carolina, concerning the diagnosis of lead poisoning. This is answered by Martin Rubin, Ph.D. of Washington, D.C. I happen not to know Dr. (Ph.D.) Rubin, which is a bit odd, for I know practically everyone in the country who has contributed importantly to the subject in question, and I have not, at this busy time, taken the trouble to find out, although I shall do so, and write to him. (I shall also write to Dr. Davis for reasons which will appear further on in ray letter}) From the practical point of view - that of a physician in the practice of his art and science, this answer is almost as bad as it could be. The physician who raised the question does not understand that the diagnosis of lead poisoning cannot be made on the basis of"laboratory tests for lead poisoning" and he should have been so advised emphatically, as the first and most important part of the answer to his question. This diagnosis, now as in the past, is made on the bases of the symptomatic pattern and the physical findings, which are supplemented by the hematological findings, both microscopic and biochemical. The finding of lead, and its interpretation, quantitatively, relate not to illness, but to the severity of the exposure to lead in both time and intensity. The quantity of lead in the body may be such,(in association with information as to the temporal relationships of the alleged or actual exposure), as definitely to exclude lead as the causative factor, but it can never prove or differentiate the nature of the illness, which is either compatible or incompatible with the pattern of lead intoxication. It is not to be expected that these matters would be understood in their true significance by anyone but a physician, and put in their proper place. Dr. (Ph.D.) Rubin confuses the clinical pattern by speaking: of "subacute" and "chronic" lead poisoning, as though they were entities (this is an old, old story); he refers to absorption through the skin,{which occurs only in the case of the organolead compounds (which almost never come to the attention of the practicing physician); 6- 9-1964 - Letters to Drs. Davis and Rubin sent to Dr. Talbott. June 4, 1964 John H. Talbott, M.D., Editor The Journal of the American Medical Association 535 North Dearborn Street Chicago, Illinois (60610) Dear John: I am writing to you rather than to the member of the staff who is responsible for "Questions and Answers," because I am being sharply critical, not only of a reply that is given in that section of the Journal for May 4, 1964, but also the reference of such a question to a man who is not a physician, and who clearly does not understand the problem which is confronting the questioner. One does not jump aj.1 over a person whcra he does not know, nor can he expect his right to do so to be granted under such cir cumstances. I am relying upon you to refer my letter to the proper person, or, alternatively, to take any other action that you may consider appropriate. It does not appear to me that the action in this instance was considered or responsible. In the previously mentioned issue of the Journal, p. 478, is a question raised by Dr. Lewis M. Davis of Greer, South Carolina, concerning the diagnosis of lead poisoning. This is answered by Martin Rubin, Ph.D. of Washington, D.G. I happen not to know Dr. (Ph.D.) Rubin, which is a bit odd, for I know practically everyone in the country who has contributed importantly to the subject in question, and I have not, at this busy time, taken the trouble to find out, although I shall do so, and write to him. (I shall also write to Dr. Davis for reasons which will appear further on in my letter}) From the practical point of view - that of a physician in the practice of his art and science, this answer is almost as bad as it could be. The physician who raised the question'does not understand that the diagnosis of lead poisoning cannot be made on the basis of"laboratory tests for lead poisoning" and he should have been so advised emphatically, as the first and most important part of the answer to his question. This diagnosis, now as in the past, is made on the bases of the symptomatic pattern and the physical findings, which are supplemented by the hematological findings, both microscopic and biochemical. The finding of lead, and its interpretation, quantitatively, relate not to illness, but to the severity of the exposure to lead in both time and intensity. The quantity of lead in the body may be such,(in association with information as to the temporal relationships of the alleged or actual exposure), as definitely to exclude lead as the causative factor, but it can never prove or differentiate the nature of the illness, which is either compatible or incompatible with the pattern of lead intoxication. It is not to be expected that these matters would be understood in their true significance by anyone but a physician, and put in their proper place. Dr. (Ph.D.) Rubin confuses the clinical pattern by speaking of "subacute" and "chronic" lead poisoning, as though they were entities (this is an oid, old story); he refers to absorption through the skin,Cwhich occurs only in the case of the organolead compounds (which almost never come to the attention of the practicing physician); KE 0015188 N20300 John H. Talbott, M.D. - (2) - June 4, 1964 he leaves the matter of "lead lines" in the skeleton up in the air by saying it is seldom (rather than never), found, except in children. Worse than this, he speaks of ''high normal" or "slightly elevated" levels of Ifche concentration of lead in the blood and urine in "chronic lead poisoning resulting from long-terra, low-level, increased absorption of lead," whatever these terms may mean (it is apparent that they have little meaning to Dr. Rubin). And then he goes completely off the deep end by referring to a "provocative" test, as a confirmation of the suspicion of excessive body burden of lead." This test, to be sure, consisting of the administration of a chelating agent (calcium discdium "edetate"), and the measurement of the response, is difficult to perform and interpret at best, and is entirely out of the question in the case of the huge proportion of practicing physicians. In addition it is strictly an empirical procedure which often (since it is unpredictable, because of the many metabolic variables) yields misleading results. It is distinctly not the thing to recommend, for there is no procedure which is as unvaryingly reliable as the precise determination of the concentration of lead in the blood (under totally undisturbed conditions) in relation to the "body burden" of lead. I speak of this with authority, having spent many years of fay life in the careful investigation of the metabolism of lead, under a great variety of conditions. I cannot but wonder why anyone in AMA circles would refer honedical question involving diagnosis, to a non-medical man. Nor can I bring myself to grasp how it could be, when the principal source of information on this subject for the past quarter of a century has been this Laboratory, that such a question as that raised in this instance, was not referred to me. I am now put to the professional obligation of clarifying this matter with the persons concerned, since this is not an academic question, but one involving serious medico-legal consequences. The staff of the AMA should be able to do better than this, for if these questions are not dealt with with competence, they constitute a disservice to the physicians of the country. Sincerely yours. ) RAK:vr Robert A. Kehoe, M.D. Kf 0015180