Document VjaVX4q99o89vOaQyYE3DV5LZ

Se p t e m b e r 2 8 , .1. 953 M e s s r s . Fr=.nk A u st in an d D o n ald O st r o w 017 D elaw are Avenue JJ.t r on 3, O h io Gen tlem en : I r e gr e t th at the p r e ssu r e of p rep aration fo r an exten ded trip ab road h a s m a d e it i m p o ssib le f o r m e t o a n sw e r y o u r l e t t e r o f A u gu st 18 e a r lie r . M an y item s of u n fin ish ed w ork st ill r em ain beh in d m e a s I leav e today, but I can n ot be gu ilty of n eglectin g you r qu estion s com pletely d esp ite th e fact th at I can n ot an sw er ad equ ately. Th e d iagn o sis of-lead p oison in g is co v er e d ad eq u ately , I b e lie v e , in th e b ook let an d r ep r in t w h ich I sen d you , but th e th er ap y i3 a d iffer en t st o r y . L.et m e co m m e n t b r ie fly on v a r io u s a sp e c t s o f th e m a t t e r fo r su ch u se a s it m ay be to you. T h ere is so litt le in th e lit e r a t u r e on recen t asp e cts of the m atter, th at m y com m en ts m ay seem to lack docu m en tation , but th at w ill h ave to be as it m ay. On cer tain issu e s we sh all h ave to w ait fo r m or e in form ation , sin ce th e an sw er s ar e n ot av ailab le. Th erefore, all of u s m u st be patien t an d try not to ar r iv e at con clu sion s un til th e fa c t s a r e obtain ed. F ir st , le t m e say , w ith e m p h a sis, th at th e p r o c e sse s of "d e le ad in g" p e r se con stitu te an in valid ated fo r m of th erap y . Th ose ad vocated y ear s ago on the b a sis of the alleged p ar alle lism of the lead and calciu m m etab o lism , a r e n ot p o ssib le to ach ieve, sin ce th e h ypoth esis of the p ar allelism is in co r r e ct, in so far as it r e late s to p roced u res fo r "st o r in g " le ad , on th e on e h an d, an d "m o b ilisin g" it on th e oth er. Th e h ypoth esis w as elab orated b efo r e m eth od s of an aly sis w ere adequ ate a s applied to u rin e an d blood - to d em on strate its in applicability. Th e m etab o lism d oes not w ork th at w ay at all, for in deed lead an d calciu m a r e alm o st cer tain ly in com petition fo r the ph osph oru s lin k age, so th at th e on e in t e r fe r e s w ith th e oth er u n d er su itab le con d ition s. Th us th e lead m ay be in th e p r o c e ss of ab so r p tio n an d d ep osition when th e calciu m is bein g r e le ase d and excr eted , and vice v e r sa. Secon d , th e r e le a se of le a d fr o m c e r t a in t issu e s of th e bod y m ay be a c c o m p lish e d in so m e m e a su r e b ot h b y BAL, an d 3 D T A , b u t t h is, in Exp osu re to Lead Keh oe A C r it ic al A p p r aisal of C u r r en t P r a c t ic e s in th e C lin ical D iagn o sis of Lead In toxication - Keh oe M e s s r s . F r a ^ A u st in an d D on ald O st r o w - (2) - Se p t e m b e r 28, 1953 it se lf is n ot n e c e ssa r ily good th erapy. It is in terestin g in relation to m ech an ism s, an d th erefore im portan t experim en tally. H ow ever, th e . m at t e r of r e a l an d su st ain ed clin ical im p rovem en t is a w h olly d ifferen t m a t t e r . B A L r e l e a s e s le a d fr o m t h e b lo o d {e r y t h r o c y t e s} v e r y r a p id ly so that excretion , m ain ly via the u rin e, is greatly but b r iefly in cr eased . T h er e is no evid en ce th at an y "m o b ilizat io n " fr o m th e sk eleton o c c u r s, an d it a p p e a r s th at an y su ch action is sligh t an d of se co n d ar y im p o r tan ce, if it actu ally occu rs at all. The real problem , h ow ever, is the clin ical situ atio n , fo r n ot on ly is th ere no good evid en ce th at th e u se of BA L b rin gs about clin ical im provem en t, but th ere is som e th at se e m s to prove th at it m ay p r ecip itate m or e se r io u s illn e ss. (Th is h as not been ou r exp erien ce, bu t 1 can n ot ign ore certain ob servation s of o t h e r s.) In the c a se of ED TA, a lso , in cr e ase d excretion of le ad o ccu r s. F r o m sk etch y d ata, I th in k it sa fe to say th at th e p atter n of th e b eh avior of the le ad co m p lex w ith ED TA is d iffe r e n t fr o m th at of BA L, bu t w h erein it is d ifferen t is not c le ar to m e. Th ere is som e su ggestiv e eviden ce th at clin ical im p rovem en t o ccu r s in r e sp o n se to it , but I h ave n ot seen con vin cin g eviden ce in su fficien t volu m e. I am n ot p r ep ar ed to accept th e ap p ar en t im p rovem en t of or d in ar y ty p es o f in d u st r ial lead poison in g a s an yth in g oth er th an m ild ly su gge st iv e , w h ile th e ou tcom e, in th e c a se of ch ildh ood en ceph alopath y, h as n ot, so fa r as I know , been estab lish ed w ith su ffic ie n t ce r t ain t y . In an y c a se , w e h ave h ad e n t h u siasm ab ou t v ar io u s ty p es of th erap y b efo re on ly to se e th em d iscar d e d . We n eed an e ffe ct iv e t h e r ap y t h at wil l sa v e life . (You a r e p r o b ab ly aw ar e t h at th e d eath r at e am on g in fan t s an d ch ild r e n is 25 to 30 p e r cen t. ) If it w ill n ot do t h is, it is n ot good en ough . W e can elim in ate le ad poison in g fr o m in d u st r y w ith o u r p r e se n t k n ow led ge* an d t h is ou gh t to b e d on e. I am n ot even sligh tly in t e r e st e d in a p alliat iv e tr eatm en t of le ad poison in g th at w ill en cou r age in d u str y to con tin ue in the b e lie f th at le ad p oison in g is n ot m uch of a p rob lem , sin ce it is read ily and su cce ssfu lly tr eated . Certain ly we a 3 p h y sician s w an t to b e a s effectiv e in a ll th erap y a s we can . Bu t let u s not lo se ou r equ ilibriu m an d fo r get w h ere the p rob lem of in d u strial lead poison in g r e sid e s. Th is is not an am p le d iscu ssio n of th ese m at t e r s fr o m you r view poin t, l a m s u r e , b u t it i s t h e b e s t I c a n d o a t t h is t im e . I h o p e I sh a ll h av e a.n opportu n ity la t e r to t alk w ith on e o r both of you . Sin cerely y o u rs, RAKei Reprin ts un der sep arate cover. Robert A. Kh oe, M. D. g r 001S794