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WORKMEN'S COMPENSATION BOARD OF BRITISH COLUMBIA 707 WEST 37th AVENUE, VANCOUVER 13, BRITISH COLUMBIA, TELEPHONE 266-0211 Doctor Robert A. Kehoe 345 Resor Avenue Cineinneti, Ohio U.S.A. , July 16, 1968 Dear Doctor: Re: Ferenc Iis radi Claim 67090380 Inclosed please find cheque number 9410-236480 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. lomaid y ledical Aid Division N13159 KZ 003 2 4 7 i WORKMEN S COMPENSATION BOARD o f Br it is h Co l u mb ia 707 WEST 37th AVENUE, VANCOUVER 13, BRITISH COLUMBIA. TELEPHONE 266-0211 bay 1968 hr. Ferenc M&radi, .'.'45 Sast 16tk Avenue, VARCOiV&i IX), 0. C. Bear Sirs Tour ci-iini has been reviewed by th Board of Review and Coms&ssio&ers and It has been racosasmjded that your claiia now !>e accepted && a Board responsibility*. Ton should oufcsait any accounts applicable to the condition for which you were treated on Doeeaber 16, 1967* We should also Hiss to have the date you first returned to esspLoyme&t after Owsamber 16, 1967 having this confismd by your <mpOoyrs, and the dates of any subsequent lay offs should bo included. BAM/cn Ittijff # 5 c.e.i c.c.s ve.c.t c.CoS c.e.t c.o.t Isetalex Idxdtod Ur. C. v/ K. Murdock - kr. Robert A* Rekoe Ur. 0, P. Jones iSr. Boll, Vancouver Gonaral Hospital Social Service Or. ife. S. Huckvalo N13159.01 Kg' 001247 2 When writing please refer to claim or firm number. 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 that 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 teat, but if it was done by a knowledgeable and experienced person, it has important diagnostic significance. N13159.02 R. M. Hayes, 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 inicrograms 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 disodium 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 + 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, HAK: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 ' 001247a 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. (Mrs.) Winifred Peaslee Secretary to Robert A. Kehoe, M.D. N13159.04 001247G Dr. Robert A. Kehoe, The Kettering Laboratory, College of Medicine, University of Cincinnati, Cincinnati 19, Ohio. Dear Doctor Kehoe: Be Claim 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 wist 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. 001247 V N13159.05 When writing please refer to claim or firm number. 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, /'/ RMH:lm ends. R. M. Hayes, M.B., M.R.C.P. Medical Officer K 0012478 905 - 750 . ost Broadway, TAHcouvbi ?, b .~. Tear Dr. Murdoch: it old rco that for the last nineteen months *m bos tsansuployod "in operatin'? a . 'urnuce to rrelt load 'catteries in company with about a dozen other ron. About four weeks ayo he noticed weakness in ccrtending the finders of his ri~ht hand (he bciny riyht-handed) and two vc-cks spo the left hand was similarly affected. There is weakness also in -extend in p the wrists. He docs not complain of any pain or numbness and ho has no trouble v;ith the ie-^s. His appetite has been poor race'tly but there is no history of abdominal pain.' lie rives a past history of lirb : i' pains durinp a five -enth period 1n"`X95i~-han ho was employed as a miner in Hungary. Otherwise his health has been ycod in the cast and he 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 uastiny. At rest the hands were siiyhtiy flexed at the wrists and the fin-pars more so. Voluntary dorcifiexion of the wrists could be done to a slight extent but not of the- finders whereas the flexor runcies wore strong. He was unable to abduct the finters but could do so a little when they were extended passively. Fewer in proximo! nur,cles was normal, sensation mas intact and the tendon jerks were normal and synwoirionl. In the lev or linos power, co-ordination, sensation and reflexes were nor~sl. The superficial abdominal reflexes were present and the olantar rssconses flexor. I ayrss that ha her; lead palsy and I think it would bo best if you admitted him to hospital now for chelation. Hy experience with chronic lead poisonin'' is rrecyre but according to the cooks the eventual prognosis is pood. Ha will need to find a different kind of job afterwards. I should bo root interested to sea him srain in -1. Yours sincerely, N13159.06 KC 0012479 DR . D . P. JON ES 750 WEST BROADWAY VANCOUVER 9, B.C. 4 Jonucry, I?o T'ccr Dr. 7o ? o f f $ / c tr Huelaait,. telephoned no today saytnr that ho thought i^NHHBfcsjrdpio'nu *.`cro hysicriecl ia cri^in end not duo to loud poisoning# I had considered tho rocoibiiity of a fvnuiic-ici disorder ryuclf but eventually diocurded it on tho rr?curds that there voa too nuch norlitre ovLfonra. 1 cn euro that *t*. cuokvolr;*a opinion is one to folio-; in tills reno cut nevertSjuices 1 cn still aerrio-rS clout viol sould happen if isi it to: ;i notion rcro uisued end I vaalA favour cchinr the ?otrdfo perniosio:i fc * - W 1** - X adnission fer o fey c'oys. If tho canditicn is t.~ -. > ^ jvt- ^A1 lum could have boon cane by- u chert c-b'bjciou. It in ursocrtunoao on-: x have not experience ouor -h to oo firs tile; rice is cn present cvidc-noc but if ho does ro in 1 ciculf bo pied of tie >3 bin cooin. burs sincerely, ~TJ/c c*o* ' r& . * ioo.."V-.io c.c. ' orirnn{o ixicona alien. Zoori tie-in :!o, 6?.);1CC30. N131S9.07 MT 0012480 - U> ' i , ' H Z ' 0012481 N13159.08 1 ;**> VI'; r' , 1 j .- # C^:tKe_ In .o;?...; O.I.- r> `I /> L- l ,, . + Je 1 ih r\j oo C\2 o o * - - .. , . B F . Jo 3. K 0012483 DO NOT WRITE IN THIS SPACE d iag n o s is ___________ ? Lead neuropathy, ? Hysteria r el evant dat a .Kmi&ryDATE___>2th h2j9_____________________________________ r e o u e s T-W 3. ?. jrti'So REPORT 12th Jvjjiuarr 1968 dat e f in d in g s ___ t th-l * patient, thl a -t w : n:T for* nleefr.rrtdiagymatfe asaestgnant n` wrist droo, diagnosed alternatively as lead ijoiaoniag or hysteria, ri&d been viorkin^ j*lt4n I-sart batteries until a ?-onth a*o ana has haa progressive wrist drop s'tarting an the rigba six weeks ago, Clinically this i t* genuine a?i not hysterical. la intensity duration curve -.dotted r<ya the right extensor earoi raaialia .shewed a slightly siuggisn response to in ,100 jaiHisesood st.ijaii.va 1.9 iLiili-Sfut. rising to 7 .wiili-araos at .1 Billisecond. and 22 vdlii-aaps it o.l siiXliaecsand, the eleoiroayogrspa frea the s &s h * rsu.3a.l@ showed a train of fibrillation potentials at rest. On volition there was a soarse pattern of i.uw voltage &otor unit action potentials, with a tendency to po2yphau#laifcy. Ic^j&uetien limes were also recorded from the median -and ulnar nerves at m. ani do rm second *<*?*, 11 v**1v. This Tiatient shews definite electrical evidence of partial denervation. thongs of sdaor decree, supporting the diagnosis of load nsuropathy. Trie *. -;h).c:vjc-a veloaiti.es measured in the ctin!rally nnnffnctel rgrtl&n and \si o at nerves ard within aorml lisdta, though only .just in the forwer. 1.3th January 19&l X saw this patient again today, After discussion with i)r. Jones, for >7 ..,,V itrtn^w'rw -oVy rtf . '?> *-rd 1 4 * 5 n "* *'' < - .-* fibrillation and Titany positive potentials at rest, with a discreet pattern uf j-.-.i'l / ~-r-.i-.rtr Jjuif. j-.rtkl rt-i .--.-if ,r:'io1 >y /-> V] A>ri . i.lh.ar ,, .! '! * ..< ;,wis la silent at rest, with % complete pattern of nomad. r.tofcor unit action -- N13159.09 KB 0012484 1 -onduutioa. tiaaa _u tJfcs ri^afc-^raflian nur/s wars uztcs&cUal up to. ..-oint luTfjrt. a conduction velocity ir fcua upper spgpssrtt c? >3 p4sp- second, drpd,r teinrf 51 -*&* >*r second in b?se iVsraicms* ' tiw* sM,* --># t*w r-edi&n I'serv-e predocr*) an o.v; cn . e-tent!;*! -f i 4.17i-vei/us fits- the adductor .pellicle ivrevi3, -vs --ot '- rctess <?? rjiitru lu&ittrt -up tn 25 per second.- ' 's: t fherc is absolutely no doubt that the wrist"drop-isorganicj due to (radial) aerre dUunago, and not hysterical, as has been alleged. , .: : '-r. '! -. Jrnes -.-< F-ord-seh :te:.va! o hncKiar,, '.}, .Xiys.itad ;i rector o ;^.rsleal Horiicine REV.63 VANCOUVER GENERAL HOSPITAL CONSULTATION REQU ISITION J^ 0 ^ ^ < "2 'L Jvisiis DEPARTMENT REQUESTEririgSIC.Vli - LjjXCIHZ DIAGNOSIS. Leant pod soexi ng , RELEVANT DATA CONSULTANT Ti . u'f.J. i.iBiLLiE DATE ZJrd January REQUEST OP'1** REPORT v'ajCTiejry, I-jo-ij d at e f in d in g s ; tvfia 'ations .Cor trie -..hlrd time this roand-ng. niter ha _____________ - Vo.\i;"v; h.i'ser&cgr .for le&a iutasdcatica* wrist tirop frosn a r;-srtpri^ml neuropathy. ^llntoally he ahosesi nmm in sasrierinor 111 pot#*** in bn* t`>usb, ri^t catanra c&a .Left. o < vo^uetioM tines wwr repeated front the ri|$xb sm&Mi nerve afc w i- ^dlllseomda at the Krltst &ts& 3,,y ^IJdaeeowto at the elfrcw, with an I H u distance of ;335 .* & comncticsn velocity or >3 jnetrea ;** soeoui the tarearru Ln the riaffit nistr tier*/ the fdiaaa were 3 "iilli~ Z tceectia at t?>a wrist, L3.? *dl3^aeutiU> in the upjjer era, with am is&ervfxnag UJ K iliflsaae of 43^ rmit ,..rivir&t a `sondBWfei&ft velocity of 56 metrm >ur geoanfl. C 3 I- `vka fra3 Urn tssUmn^ rollioia Imm? m&m&rr O z diatoms oowjaia and the I>reehi<a?fes4iali all chawed profuse fihtHletion o ____And positive psft^td&la at rest--11 these aaol< nr<d T.ha right o triceps, which was ailcert at rest, shesd aitemtioa in the jwbcr nnit action _____^hi,gh vor %ope rdlyr^aMa aral of l^r valfcaga than nffffw.'i. >H i..h * reduced suwaaiion pattern, particularly in the extensor digiioruss, ecassunia -^yl to a less eosfrmt in the ctgtettaor nalljgia loemia, irntyxs least In the triceps. Ifilff p&tient chows. ii` slight .rp?mepsnfc in oarva cond :>ut atlll_baa i-any dsmermtion potentials ad a mx*us& aXtereticsi in motor units. a,-.-;--dVf-a. i\--JcTi^ 3r* Fsasioch 3r....i, t..^aakysUe -LC.B. (2)^ ------ N13159.1 \i 0012480 DR. D . P. JONES 750 WEST BROADWAY VANCOUVER 9. 3 C V.G.K. Unit no. 6o-2y-I;; DISCHfEGE SUI-j UAHI This nan war admitted to hospital for inves ti~sim of presumed lead poisoning as described in my notes. He had been seen rri~r admission (on January 2nd) by a consultant '-'ho reported no positive nourol'-'-Lcni findings, and who did not find any symptom to suggest lead poisoning. investigations erior to admission: Dec. 20/67 blood urea 3n togs/. PSP: 67/ excretion in t::" h-'urs. Urine: large amount of cop roporphyrin. Blood lead $6 " pur 12 0 cos. (jih / Preliminary_ho3 pita.l tes ts : Urine: Coproporphyrin +3, otherwise normal. Blood: Haemoglobin 11.3 76 +2 nicrce;i:o3is Stippling present Lead.. Uly.-c per 100 ccs. Spinal Fluid: Protein 30 ngsy, Kolmer negative, pressure 18/ mm. .ssi' < I Effect of_ Chelationw The patient was given three courses of versenate treatment: January 16 - ip (7G), January 23 - 2o (~>Q), February 2-7 (pCx). Urinary lead excretion per litre) during the treatment oeriod was as follows: 16 /0 j 17 13 1700 00 no ) ) i? X 3 j 20 Li'S' r 21 22 ^ 2 23 r`. \ 21 09 / ' \j 26 27 2c 52 2 ' `L j j\j 29 S j S' 0 u.C`2 31 120 vers onare Urinary porprp-rins nn~nti 'eb. 1 2 u u o 7 c u 9 11 12 ou ICO) CC) 1CGG) 3?0) 60) 90 110 90 Urinary nornhrrins neg. N13159.ll K? 001248 V 2 DISCHARGE 5UH1ARY (continued} Other laboratory Investigations were as follows: Slectrc .myography: This was performed by Dr. Buckler on January 12th, 15th,' 23rd and 29th. It showed clear evidence of partial denervation of the affected muscles. Serial ohotograbhs of the guns: I think these showed improvement in the lead line. Kidney function: "' Blood urea 2k rg% and 22 v.g%. PSP (String Lab.) 73$ of normal. Blood creatinine 1.12 mg5. 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 upon which_ a_chypnosis of lead, neuropathy is made: 1. History ox possible exposure and the patient's statement that fellow-workers in the plant hove bean 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 EKG evidence of denervation, thus disposing of a suggestion that the condition is hysterical. I4. Blue line on the gums. 5. Anaemia. 6. Basophilic stippling. 7. Renal involvement. 8. Excess cocr0oornhyrinuria, disappearing with treatment (Ked. J. Austr. Feb. 23, 1?67, Br. J. Industr/Med. I967:2k.203) . 9. Massive lead excretion after versene treatment (See. Med. Hop. Paris i960:1.17*U27) * DISCUSSION: This man 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. Indusr. Med. 1966:23*263) and it is reported (Lancet Jan. 22, 1966, 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 dischange: Lead neuropathy. This patient is to be shown on Grand Rounds on Thursday, March 7th, 1968. Dpj/e Feb. l/68. HE 0012488 D.P. Jones, M.D.