Document OE1E3JLyGM0ezk7BpJZ7KXKMQ

'] j I o c c u pa t io n a l Dis e a s e s Pu b l ic He a l t h Pr o b l e m s Emery R. Hayhurst. M. D.f Ph,D. C o n s u l t i n g In d u s t r i a l Hy g i e n i s t 1925 CONCORD ROAD C o l u m b u s , O h io _ J u ly j t - T e l . KIn g s w o o d 4 8 4 1 Dr. Robert A. Kehoe Kettering Laboratory of Applied Physiology, University of Cincinnati, Cincinnati, Ohio Dear Doctor Kehoe: Let me spare no words of thanks for your letter of July 1 st, although you failed to enclose the reprint you mentioned, or perhaps it is coming in separate mail. ~ ~r' . / 7 ^*.-7 7 7 A > I am very pleased to have your carefully expressed views on the subject of definite standards in relation to the diagnosis and cafe of men in industrial establishments, and you can rest assured that 1 agree with you in every way. You will note the cautions I made along this line in the enclosed "Comments on the Diagnosis of Lead Poisoning8, the last revision of which appeared in 193^ in connection with my old Job at th Ohio Department of Health. I understand the same mineo coranents are still being distributed by the Department upon request. Items 3, k , 5 and 7 would apparently have a bearing on our present discussion. I am also obliged to you for your evaluation of the term "mean8 as you use it and your illustrations for it. I note that Leschke (Clinical Toxicology, 193^ `P* 12) undoubtedly agrees with your views, after reciting figures for granulated erythrocytes (P. Schmidt) where he recommends a suggestion by Coetzl and Teleky to use such descriptive terms as "no, few, or many such cells8, with some defining explanations. C\ 3 Vi My discussion of this subject with Dr. Straus has no medicolegal case in point, at least so far as I know, but is purely theoretical or, perhaps one might say, philosophical. I shall certainly insist on his accepting a broad interpretive point of view, but it is my fear that he wishes to administer his new Job on a too confined mathematical basis. Personally, I have not heard of him before in this field of work and I note that he is listed in the last AMA Directory as specializing; in Surgery. I have a faint inpression of knowing him before I left Chicago in 1913 He was a graduate of Rush in 1907 and I think was one of our quiz class masters when we were drilling for the civil service examination for internships In Cook County Hospital in 1907OS. But of course he may be pretty well founded in industrial health matters, including lead poisoning. Happily, discussions of this sort bring us closer together on general agreements, and in the matter at point we have to rely especially upon men with extensive research ex perience. Again thanking you, I remain Sincerely yours, N 5979 Comments on the Diagnosis of Lead Poisoning 1. Definitions* - LEAD-- -The element Pb (plumbum), its organic or inorganic compounds or forms, or admixtures thereof or therewith. LEAD EXPOSURE-- Any environmental condition or practice that permits of entry of lead into the body. PORTALS OF ENTRY FOR LEAD-- Refers to the respiratory tract and the digestive tract. Lead may likewise be implanted in the body through'direct physical means, by hypodermic injection, or by intravascular administration. With the exception of tetraethyl lead, and related organic compounds, its absorption through the skin or through abraded or lacerated surfaces may be considered negligible. ' tract. LEAD INGESTION-- When lead enters the body by way of the alimentary LEAD INHALATION-- When lead in a dust, spray, vapor or volatile form enters the respiratory passageways through breathing effort. - LEAD ABSORPTION-- When lead enters the body through any portal and is taken into the tissues. * LEAD POISONING or LEAD INTOXICATION-- When absorbed lead causes sub jective symptoms with objective findings. CHRONIC LEAD POISONING-- When absorbed lead causes protracted manifes tations with or without acute episodes. ' LEAD COMPLICATIONS-- When absorbed lead initiates or aggravates any other disease condition. . LEAD SEQUELA-- When a pathologic condition remains as a residuum of ante cedent lead poisoning. 2. Blue line in gum margins. Examine after use of tooth brush. Examine both labial and lingual surfaces. The deposit occurs in the papulae of the gum mucosa so that a fine, stippled appearance may at times be seen when a hand lens is used. Is due to lead in the blood stream combining with sulphur in foods. Occurs in about 20 per cent of cases of Leading (Absorption or Poisoning). The condition is less likely to be found where oral hygiene has been good; also when gingivitis or gum atrophy occur (and those latter may be due to the lead deposit). NOTE: A dark line occasionally occurs after medicinal bismuth injections, hence this must be ruled out. Likewise, examine anal muco-cutanoous junction for blue line due to same causes as above. 3. Blood findings. Stippling, polychromatophilia, reticulocytosis, and baso philic aggregation are apparently but gradations of the same picture, according to technique used. These occur more readily in 'LEADING than in other pathological states. They indicate an increased concentration of lead (or its effects) in the blood stream. Although exceptions occur, they usually remain in the blood as long *"Lead Poisoning" - Report of the Committee on Lead Poisoning. Amer. Pub. Health Ass'n. (50 W. 50th St., New York, N.Y.). 1930. Price 75 cents. -X- as exposure to lead persists, and tend to decrease upon withdrawal from exposure, . even though the case passes into LEAD POISONING. They may reappear, or increase, during acute episodes in the course of Lead Poisoning*- Their number is taken as a rough measure of the amount of exposure (again, with individual exceptions). Hence, workers on the job who show these red cell changes, even without other evidences of leading, should have blood examinations made frequently (preferably weekly), and, advisedly, be removed from exposure on evidence of progressive increase of these cells. In LEAD EXPOSURE, hazard may be inferred when stippled cells occur to the extent of about 500 per million red cells (5 in 50 average fields), reticulocytosis or basophilic aggregation to l| - 2 per cent (of red cells). In general, the laager the granules in stippling, the greater the significance, as indicating ex cessive absorption of lead. > When LEAD POISONING is definitely established, fluctuating retrograde changes occur in tho whole blood picture. The more constant findings are (l) RBC - secondary anemia, disturbed coloring properties, variations in size and shape, and (2) WBC - slight or moderate leucoeytosis (increased with infected gums, etc.), slight relative lymphocytosis (changing to lymphocytopenia during acute exacerbations), and mononucleosis. 4. Reports of Analytical Findings of lead in the- urine, feces and blood are of doubtful value unless accuracy and delicacy of testing methods are assured, and the patient is under control as to extraneous sources of lead (food, water, tobacco lead-foil, cosmetics, etc.). Also, the test-observations must bo made over days and preferably weeks to get a true picture. "Normal lead" probably exists in the amounts of 0.05 to 0.10 mgm. per liter of urine, and to a somewhat higher proportion in tho blood. 5. Single or occasional negative laboratory findings do not rule out Lead Poisoning, but positive findings arc quite significant. Also, deferred labora tory tests (months after exposure) are usually negative as regards all specific or ^characteristic" findings for lead. Here, some have found them to return for a brief period during de-leading treatments. 6. Blood Pressure is subject to wide variations under the influence of lead. Hypotension is more common in early stages, hypertension in longer standing cases. 7. Therefore, the Diagnosis of Lead Poisoning is based upon tho weight of certain evidences: (l) Definite exposure to inhaling or ingesting lead or its compounds in amounts equal to at least 1^ to 2 milligrams per day, over 2 or more months' time - less time if greater concentration - and in the form of dust, sprays, molten fumes ; (2) objective findings of lead absorption (blue line, blood changes , etc.), neuro-vascular involvements (motor weakness inmost used parts, pallor, tension disturbances), and nutritional depletion (especially in chronic cases); and (S') the presence of a number of the subjective phenomena listed, - the more acute cases showing those toward the tops of the two columns. To be occupational, in dustrial exposure must be established. STATE OF OHIO D EPARTM EN T OF HEALTH S TA TE OFFI CE BLDG. COLUMBUS, S ii m iti S <i. ,''V:s / Vi '' U '. *m 'iiii- -.ri!}-V:\ Kh W - ^ f i , .-;'i> i; I r 'r f"r'' iti July 1# 19^1* .:?! .} ' .*: V*. '. J- >-V fi::-- .j W i'/t- " 'h i < h i i : j i> ; r v -V i.--'; -- ''>*">>* " 'ri .: .i: o /=; . ' .v .. . . ..i...............<....,..*......'...r .^ .-vfV ,jiO .I. I^* Etaery R*-Hayhurst, ? ^ons ultlng Indus trial Ilygi en 1st, 1925 -Concord Road, - -' > *r , Columbus, Ohio* '-' ' v , * 'p ;/ Dear Dr* Hayhurstj .1-Vwi.iA-.vr, I am glad to write in reply t o - y o u r 'letter ofJune 25* and to express ray point of view on the questions you have raised. As a partial answer I am sending you herewith a reprint which gives something of- m y ,view-* point. " ... - * "-i`' ' , With respect td the significance of -"stippling**'.it is ray feeling that too much attention is being paid to the setting of definite standards in relation to diag nosis and the care of men in Industrial establishments* The fact of the matter is that this phenomenon Is not specifically related to lead absorption, and It does not bear any definite relationship in the individual / to the quantity of lead a b o s r b e d e x c e p t within certain very rough limits* These limits, indeed, are so rough that they do not provide adequate basis for judgment in the individual case* There Is no question that groups of normal persons displays findings with respects to ; f stippling which greatly overlap the findings obtained in groups of exposed Individuals, i ^ e ribne realizes this fact, it is necessary to realize that ho amount of Juggling of figures will evervanswer the problem. y f ; ; you are presented with the' question Of the significance of stippling in an individual base^ yo u will have to decide it on the basis of the range of variation dis played b y normal persons s well as the range of varia tion displayed by exposed persons. If the result in , point falls within the range 'w h e r e t h e s e two sets of I values overlap, It must be apparent that no decis i o n ...... can be arrived at on the basis of stippling* A c c o r - - dingly, in medico-legal cases the number of stippld .... cells present in the blood has little or no diagnostic .value, if it is.not clearly above the range seen even in hccaslhai normal" individuals* : --?; - c '{ -' . ' . ' ' ' ' ' : ' -f. . ? ' "v-. I n this situation it is quite clear the corroborative , evidence must b e available in order to permit a conclu sion to be drawn. It Is* therefore, in my opinion, en tirely futile for you and Dr* Straus to argue the ques v -- -t m n "! r; -- V: tion of what should he the arbitrary standard, indeed, In m y opinion, there should be no arbitrary standard. In the Individual .case caie should take all the facts Into consideration and arrive at a judgment which Is based on all the facts, rather than on.one or two Inade quate criteria* With specific regard to the "mean" value, I believe you have misunderstood its Implications* A "mean" value, in the sense we have used it, Is merely a mathematical expression which, with Its probable error indicates the probabilities for.the occurence of results In a sufficiently large universe. Any Individual taken at random can fall anywhere within .that universq an d so long as this is the case, there is simply no point in 't arguing whether he belongs In this universe or another. Such argument Is truly ficticious* ./The same Is true in the matter of values In the urine. If normalavalues range between *01 and *19 mg. per liter, thenArandom ob<* servation made on one individual that falls within this range must be accepted as evidence that the individual is normal, unless other additional evidence demonstrates to the contrary* , Returning again to the subject of stippling, I think it is fair to say that those of , u s w h o watch men. under eon- ditiahs of Industrial exposure set very little value to the actual number of sfclppleda cells*^ What is, important is evidence of a change.. If the stippling of an Indivi dual workman tends to increase progressively or abruptly, we may look for difficulty. So long- as it remains fairly stable, we do not expect trouble* This fact when taken with a ,known, variability of human beings in this respect means that a single observation on the blood.of a person suspected of having lead Intoxication is of no signifi cance, except as a part of a general picture which is com posed, of many other facts, c The,-exception to this is: that, generally speaking, the absence of atippl'ng is practical ly conclusive evidence; that lead Intoxication is not pre sent., In other words,,positive results must be looked at very conservatively,while negative results are imme diately Significant, . . . .- . . ffa ',:o ' I hope this clarifies m y opinion on this question, i With kindest regards, -, ... \ ' Sincerely yours, , - {. RAK ef .a - i , R o b e r t ,A*~,Kehoe, M*.,.-D* * - ' >...ir> , t.. . T. - w Oc c u pa t io n a l Dis e a s e s Pu b l ic H e a l t h P r o b l e m s Emery R. Hayhurst. M. D., Ph .D. C o n s u l t i n g In d u s t r i a l H y g i e n i s t 1 9 25 CONCORD ROAD Co l u m b u s , O h io June 2 5 , 19^1 T e l . K In q s w o o d 4 8 4 1 Dr. Robert A. Kehoe, Kettering Laboratory of Applied Physiology, University of Cincinnati, Cincinnati, Ohio ' Dear Doctor Kehoe: Thank you very much for your letter andL reprints of June 19th, with reference to my letter of June 13th, I am having something of an argument with Dr. David C. Straus, recently appointed Director, Industrial Hygiene Unit, Illinois Division of Factory Inspection, Department of labor, concerning the so-called standard of 500 per million (or 5 per 50 average fields) of stippled erythricytes as the proportion considered significant in inferring lead poisoning. Dr. Straus cites Dr. Sappington's report of your Virginia paper as published in Industrial Medicine, November, 19^0 (p. 552 2nd column, 1st paragraph) which gives even a lower average of "boo per million in normal persons, the range of variation being 2 to 1000 (SO being the factor for converting the number of stippled erythrocytes from the standard of 50 fields to standard per million)", Dr. Straus correlates this with the statement by Dr. Belknap (Industrial Medi- , cine, October, 19^0 p. 506, top of 2nd column), who gives "The socalled normal range of stippled cells" as "from one to 12 per 50 oil immersion fields or from 100 to 1000 per million red blood cells, ac cording to the European standards", (In this, Dr. Belknap is not con sistent as you will note from the marked passage in the folder en closed, entitled "Primer of Lead Poisoning", which was distributed by Dr. Meiter at the exhibit booth of the Wisconsin Employers' Mutuals' at the AMA. Meeting in Cleveland earlier this month). Prom yours and Dr. Belknap's papers cited above in Indus trial Medicine, Dr. Straus states, "The figure 12 per 50 fields fi gures out to be 960 per million, agreeing with the figure above from Kehoe's paper as being within normal limits". Thus, he appears to accept an occasional maximum as a mean to be generally adopted. Per sonally, I doubt whether you have meant to discard boo per milliQn as a generally accepted mean standard for normal. An analogy, of course, is seen in the matter of lead content in the urine where an occasion al normal considerably exceeds 0 .1 milligram, per liter. (Incidently, I am wondering if, in Dr. Sappington's same report of your Virginia paper, the statement "the mean was 0.97 milligram per liter" is not an error, and that this figure should read "0 .0 9 7 milligram per liter"? In summary, the point at issue between Dr. Straus and myself is whether we should accept 500 P er million (or boo as you mention) for normal persons, or change to 1000 per milliort, because such may occur as a variation. ?. I thought perhaps I could get more light on the point byobtaining a reprint of your original Virginia paper, and getting the whole background, and not bother you about it. I had in mind the fact that any errors occur in articles as printed in Industrial Medicine, as you have no doubt noted yourself. For some years I have tried to get Mr. Cloud, the Managing Editor, to forward galley pr page proofs for author's corrections, but have never succeeded as far as my own papers have been concerned, and invariably errors have crept in. My profoundest apologies for detailing all of this to you in the midst of your very busy trestle board, which you state rather modestly no doubt as being "pushed around a great deal" - something which I can well appreciate. - With many thanks, I remain Sincerely yours, '~Z~' kQ A A a j A ^ { a }