Document b5pVd64ByNQajBOGRedG0z19g

. Atteri : Eileen S. Hunter, Medical Sectio State o f O hio _ C *-- Bu r e a u o f Wo r k m e n 's C o m pe n s a t io nN "2 \ * I<?u t 3S ` Claim No. Claimant SPECIALIST'S REPORT Address ....gOifr-AUDUBON-BaABy-C^ OHIO .... Date of Examination...Jfe.-^^ltiOtt.-...xeiW jrt..ffla..tb*..*iSBiie*-- Age- !- _____________________ o f t h e record. NOTE: Submit report under following headings: (1) History. (2) Complaints. (3) Examinations, including X-ray and laboratory work. (4) Discussion. (S) Opinion. Sign and mail T H R E E copies to the MEDICAL SECTION--Retain,one for your file, r ^ , - REPORT OF EXAMINATION TO BE RETURNED W ITH IN TW O WEEKS .'- FOLLOWING REQUEST. ! ' , ;r" V HISTORY A " Tli clinical record In the case of been reviewed. There appeared to be n o good reason for having this patient present himself Tor examination, since 7 ' the-Tacts in the case had been established, and nothing of real relevance could be added h y a e a n a of further raninations at this tine 'The important points for discussion this-case -are as follows <s- ; ' w . * w e . -op. v , C. V ,f . o (1) This aan had had opportunity for some degree of erposure to lod'for ;:&a number of years during his work as s stereotype Journeyman. However, it ls the coanxm .| .. experience of investigators that men doing this Job rarely develop lead intoxication. Our observations Bade from tine1to tine in a number of establ 1absents of this t ype'.have failed m'to obtain evidence of a significant degree of absorption of lead.. The'report'd! thec ^ " Industrial hygiene survey In this case indicates that the concentration of lead'in the atmosphere of this nan's work place m s of the order of .09 mg. per cubic neter'a t ^ h e *' 'point of emission of funs during the period hen the neltlng pots Could be expected "to 's:-% -.give off the highest concentration of fuae, (it was obviously lower in the usual breathing I - .tones of the employees). It is unlikely that the opening or the closing of windows would'- | 'Influence the concentration greatly at the points at which atmospheric saaples were ,,V; 1 obtained. rr avi > .'' t-f ' t .s =oj The conditions which lead to a significant degree of exposure to lead ' ` o n the par) ot people engaged in this occupation are those associated with poor house keeping, whereby dross frou the pots is permitted to accumulate and is distributed into - the atnosphere from dirty floors and equipment . ' K o indications! theexlstencS'ofeuch a L condition has been given in the report of an experienced and critical industrial hygiene^ . ^ . e n g i n e e r . ./ -Vv - i*,r ^ ", , r < In consequence of these facts,the concluslonis inescapable'thaithls nan, in the course of.his work, was not subjected;to a significant or dangerous'degree- of exposure to'-lead.'jiigsfw >: a -n nS"r*t - p*. ?,,**** f* **> r.-r" * (2) . The disease process as described in this case," of "fullness In his ear, numbness over the right cheek, a numb feeling in his right a m , and objective hypalgesia over the right oalar eninence," const ituteo a bisarro yndrooe." ;If ,th patient h a d " neuritle Involving the auxiliary branch of the trigeminal nerve,thla would n o t h a v e 7 explained the symptoms complained of in "the right a r a ^ d ear.'-'"#^/; _ - f'T.. If these symptoms are regarded os neuropathic,there Bust have been a -.-'-t, ~ polyneuritis of a sensory and asymmetrical type') !Although the neuropathy' of lead ?poisoning -Alls often that of a polyneurltio, the latter affects, specifically, the neuromotorapparatus, being,practically uniformly, lesions o f t h e e x t e n s o r musclesof' th extremities- (without ' : sensory changes as such), and being usually symmetrical in distribution. 'Primary sensory ' ... changes, far from being compatible with the effects of lead absorption, tend almost \f imperatively to exclude lead absorption and lead poisoning. .1 i"et/.:.- (3) The single blood saearexaalnedfor,"etlppling"wa* reported as negative. Invariably, in severe -lead poisoning, stippled erythrocytes are w een in abundance, and ' when neuropathy is present, lead poisoning is classified as severe. 'One cannot always ^ sure ,,.that the examination for stippling has been made by a p e r s o n o f e o a p e t e n c e and -' ^ perlence, so that the .failure to find'it-in this case may not be counted on as proof -a xa io i-o c u u .1, o r n i e v ld e s ^ .ia a iiiW O r f c ia it ^ a e v s r th e lS s s ';" " '1" -':'" -7'' - (4) A single 24-hour specimen of urine was reportt, by the Euyfleld laboratory, as containing .231 ng. of lead per liter, (the use of the third decimal is unjustified and is indicative of a certain unfamiliarity with the degree of precision that can toe expected in such results.) Such a finding, if valid, is indicative of an abnormal degree of absorption of lead, s However, one does not know how thiB sample of urine was collected or how it was analysed. -The method of collecting the specloen is of crucial Importance, since / ' -v-"'-.- ' '.'V' --- -------------------------------- M'D` (CONTINUE REPORT DOW N FROM HERE) , . : is- it is the rule - not the exception, but the rule - that such specimens, collected \ y by the usual methods, in any other than a special (chemically clean) container, are found to be severely contaminated. Moreover, the result obtain can be interpreted _ only if one can be free of all doubt as to the competence of the analyst, and if one . knows the size of the reagent blank that is characteristic of the laboratory. A :single _ `analytical result,' which is not verified by such standards, is not to be relied'upon. This result, therefore, Is not acceptable as. evidence. -- - __ , ___ ful T h e pnrit.i[; n f t hwlaboratojy of Dr. Davidson)'Which apply to both the blood and urine, re In line with-the expectations of the occupational history, .a,-s and in addition they tend to confirm each other, since they are in complete agreement - ^ in being within normal (physiological) limits. (Dr. Davidson is not known to this reviewer but is known to Dr. Ashe, who had his experience in this matter while a member df the staff of this, laboratory and is known to be,both properly informed and adequately ; ' - critical.) i, . 1 ' > '-v- . - it has been suggested that the results obtained in Dr. Davidson's laboratory can be explained as being low because of the intervention' of chelation ;-r-- therapy with calcium dlsodium "versenate." .This is Indeed a naive suggestion'. In the -. ; first place, if the "versenate" had been administered intravenously in (me course, it ' , could not have lowered the blood and urine to the extent Indicated, in a case of severe plumbism. Secondly, the chelate was not given Intravenously but rather orally, so that its effect could not have been great. (This not a satisfactory method of therapy). At \ best) chelation therapy removes only a modest proportion of lead from the body, and ' in severe cases it has to be repeated several times - most commonly, three or four t intravenous courses of four or five days each,: with an Interval of a week or so between ;.:)' each pair of treatments, are employed. It is not possible, much less probable, to ' ' - remove the lead to such an extent as is indicated here, by a single course of oral ' Xi therapy. The conclusion is Justified, therefore, that the result reported as having been obtained by the analysis of a 24-hour sample of urine, is invalid and irrelevant''*; intexie atton . _ i- It is the opinion of this reviewer, after considering' the evidence,-'' that this man did not have lead poisoning.' The basis of this opinion lies In'the following facts:- - < - : - ' ' " '' ' ' - (a) 'The clinical syndrome described as having'been presented' by this patient was not compatible with the known effects of the absorption of lead, If by any stretch, it can be regarded as being due to lead, it was a very atypical Jij ease which would require incontrovertible evidence of the absorption of a comparatively v(b) The history of occupational exposure to lead is not such as' -i; to be convincing, T h i s m a n 's occupation, as a rule, does not result in eases f lead ^ poisoning. Rather, the occurrence of lead poisoning in this occupation is unusual. '' Instead of being a supporting feature of the diagnosis, the occupational'history' casts M grave doubt on such a diagnosis. ' -- * -* * mm : i :i!t!Sff(c)'`i:itt8 analytical data obtained to establish or exclude the '-;f"`r " absorption of lead in this instance, are contradictory. One result obtained b y a n '1'*" \ undescrlbed method of analysis of a single sample of urine collected without well- ~-.-v defined precautions, indicated the presence of a moderately elevated concentration c ,'f' of lead, A second pair of analyses, one of the blood and one of the urine, carried out 10 days after the first (after the intervention of a single unsuitable and almost certainly ineffectual course of chelation therapy) yielded results which confirmed each -^ other as being entirely within normal limits.. - ' ' -*> " ' ~ .nmv*, / Summary. The clinical pattern of the presenting disease being atypical of lead poisoning, and the evidence of lead absorption being negligible, the diagnosis of lead poisoning is untenable. The precise nature of this man's . neurological disturbance has. not been established. S.-S u-ffr J ; ; J K -Ei (D NOT W RITE BELOW THIS LINE) i-OJ. ^~ 0000171 (a ti3 s i h x w o a j SMidAX a n m x M o o x on o a )