Document QJbXnZ4DB76OyYbvGEjw4v0K8

ity of Cincinnati Cincinnati, Ohio 45219 COLLEGE OF MEDICINE, EDEN AND BETHESDA AVENUES KETTERING LABORATORY DEPARTMENT OF ENVIRONMENTAL HEALTH August 24, 1971 Edward J. Huth, M.D., Editor Annals of Internal Medicine 4200 Pine Street Philadelphia, Pennsylvania 19104 ' Re: Ms. No. 71-617 Dear Doctor Huth: I have followed your request that I write unidentified comments and criticims relating to this manuscript, on the sheets attached to this letter. However, I have felt that I should write to you to convey my opinion about this paper in a more effective manner'than through detailed criticims. I regret very much to tell you that I would not accept this paper for publication. It contains a large amount of information, but it-is not in my opinion of the caliber suitable for so distinguished a Journal as the Annals. Specifically, it may convey what I consider to be the wrong type of thinking, in relation to an admittedly complex type of intoxication, to physicians whose function is to deal with the disease which is presented to them. For example, to arrive at a diagnosis of lead intoxication on the criteria which these authors suggest, or seem to suggest, is, I believe, to be mistaken oijten in ones effort. The diagnosis of lead intoxication is made on the characteristics of the sickness which presents itself in the patient, and not on the partial interpretations and the likely misinterpretations of a series of biochemical deviations from a ''normal" pattern. These biochemical phenomena are indeed important, 1 but, at be$t, most of them are manifestations of some - large or little - stress j exerted on the human (or animal) organism, which may or may not ultimately induce j illness or disease. In the industrial scene, these may well be regarded as warnings I of impending, undue stress to be dealt with wisely and carefully by the physician who supervises a group of workmen and aids in protecting them against a potentially hazardous environment. As a basis for action of any kind leading to cessation of employment or perhaps to compensation or litigation, they are not entirely trust worthy, anj in the hands of relatively inexperienced (as most of our physicians are on lead poisoning) and incompletely informed physicians, they make much needless trouble in our society. The problem of the effects of the absorption of small quantities of lead upon our general population is not one to speculate on apprehensively among doctors. It is one of the difficult ones of our time, and it should not be handled, in a paper written for physicians, as it has been in this manuscript. These authors are laboring under the truly tragic influence of their work on young children, who present a situation J.ike nothing else in our present consideration of lead poisoning, because of the greht severity of their absorption of lead. This is a black chapter in modern urban environmental life. It is entirely different from that of the problem of the introduction of lead into the air. It is induced by the ingestion of very large doses of lead, oyer relatively short periods of time, whereas the exposure to lead in the ward J. Huth, M.D. Page 2 August 24, 1971 air is that of respiratory exposure to a small daily dose over a long period of time, at most, over a lifetime. The problem has never been faced by medical people before, because we did not have the sensitive methods required to demonstrate its presence until this century, and certainly it cannot be thought of as in the same category as any other type of potential hazard due to lead. I find myself irritated (in the nervous sense) by the continued attempts to relate this one to others, especially so, since it appears that this is no new affair but one in which we, as a human society, have been living with, in some degree, since our species arrived on this earth, and one which, as an industrial society, has now been with us harmlessly, it seems, for practically a century (with some increase during the past 40 years). (The present problem of the children in the slums came into existence in this country only lately (i.e., during the last half century). To be specific about this review, its authors have gone well beyond their depth in undertaking to "cover the water front" on lead. They have not the experience or judgment, nor have they studied the matter sufficiently, to entitle them to speak on occupational lead poisoning, or on the potentialities of lead in the ambient air, or on an appraisal of the information now available on these matters in the literature. They should have limited themselves to the problem with which they have had the experience that woulcl enable them reasonably to judge the adequacy and accuracy of the rash of publications now available. Instead they have used information from some articles that are not to be trusted, and some which have been known to be wrong for the past 30 or 40 years. For example, the concept that lead is mobilized from the skeleton into the soft tissues by febrile illnesses and by alterations of the acid base equilibrium, including the presence or production of acidosis, was exploded long ago. Joe Aub arrived at this conclusion from experiments and observations made before we had analytical methods of sufficient sensitivity and precision, and while much of his work was of high quality and alert imagination, this aspect of it was derived from incorrect analytical results. These men should have learned this fact from a more thorough study of the literature, including the examination of the experimental basis for the concept, which, in these days, is clearly unacceptable. This is the sort of thing I find unsatisfactory in the review. It is not enough to cite the literature in this field at the present juncture. It is necessary to give it critical study, for, as in the case of the Scriptures, one can prove almost anything by this or that or the other citation of someones conclusion. I have spoken at length, here, and far beyond the usual scope of such statements, for the reason indicated at first, that I regret the necessity - to me - of advising the rejection of this paper. (It will probably appear elsewhere.) These men have done a laborious job and have brought to the fore the main body of present-day evidence on this subject. However, they have arrived at a number of opinions which are not justified, and while they inform, they also mislead. That is, they have not carefully separated fact from hypothesis and opinion and, at times, they are simply lacking in an understanding of the meaning of experimental observations. This is too bad, indeed, for this is an exceedingly difficult job in this period of almost explosive publication. Sincerely yours, RAK:wb Dictated but not read Robert A. Kehoe, M.D. Professor Emeritus of Occupational Medicine