Document jNEbVv5MkwK8v9NyEqbNL3xO5

June 18, 1958 (J D r. Irving H. D avis, D istric t E ngineer D ivision of O ccupational H ealth M ichigan D ep artm en t of H ealth L ansing 4, M ichigan D ear D octor D avis: I sh all do m y b e st to an sw er the q uestions, d ire c t and im plied, in your le tte r of June 6. F ir s t le t m e say th at th e re is a tendency am ong physicians, w hich I g re a tly d ep lo re fo r m any re a so n s, to confuse p rev en tiv e m edicine w ith m ed ical th e ra p y , and th e re is no m o re d is tre s s in g exam ple of th is tendency than th at disp lay ed in re la tio n to lead . T h ese a re two d istin ct p ro b lem s and th ey should n ev er be confused in eith er th e m ed ical m ind o r in th at of resp o n sib le people in in d u stry . Now w ith th a t to s ta r t w ith, the p ro b lem of p rev en tio n of lead poisoning is sim p ly the p ro b lem of providing conditions u n d er w hich m en do not a b so rb dangerous quantities of lead . This m eans the environm ent, on the one hand, and th e b e h a v io r of in d o c trin a te d m an , on th e o th e r - th a t is , c lea n a ir (to c e rta in S p e c ific atio n s),ca u tio u s w ork and c le a n lin e s s (to p re v e n t-u n n e c e ssa ry in h a la tio n o r in g e stio n ), good su p e rv isio n of th e work and the w orkm en, and the use of a p p ro p ria te safety equipm ent when it is req u ired . U nder certain circu m stan ces, when the com plete control of environm ental conditions is difficult o r im p o ssib le (that is , th e re m ay be alm o st unavoidable p ro b lem s and la p se s in the efficiency of equipm ent and m en fro m tim e to tim e), i t m a y b e b o th n e c e s s a r y a n d s a t i s f a c t o r y to l i m i t th e d u r a tio n o f a. m a n 's exposure (that is , p e r day, p e r w eek, p e r m onth, p e r y ear) o r it m ay be n e c e ssa ry to te rm in a te it. T here a re c rite ria , in te rm s of the lead content of body fluids o r ex cretio n s, w hereby the duration of safe exposure can be estab lish ed w ife p re c isio n . W hen, th e re fo re , a m an needs to be rem oved fro m a jbb involving d an g ero u s ex p o su re, th is can be done, and w ithout ris k o f b e in g i n .,e r r o r , ;=, ;; .. .; . - The u se of m ed icam en ts to p ro m o te the e x c re tio n of lead in th e u rin e of m en who a re exposed to poten tially dangerous q u an tities of lead is not preventive m edicine ^ it is , in fact,; a cru d e and irre sp o n sib le fo rm of m edical pandering, a p e rfo rm an c e th at is only explained by: m ed ical ig norance o r a le ath ery m ed ical co n scien ce. When, th e re fo re , you te ll m e th a t "a plant (this m eans a doctor) has found it n e c e ssa ry to tre a t a ra th e r larg e num ber of individuals KE" 0015195 D r. Irving H. D avis - (2) - June 18, 1958 w ith th is com pound on a m o re o r le s s re g u la r schedule," you a re d escrib in g the v e ry thing which m y a rtic le in the A . M . A . condem ned. This p ro ced u re is nothing sh o rt of b a rb a ro u s, flying, as it does, in the face-of a ll of the tra d itio n s of physicians th at th e ir p rim a ry co n cern is fo r the health and w elfare of m en, and it ig n o re s th e p rin c ip le s of physiology. W hile I re a liz e th a t it is being done by p e rso n s of good in ten tio n s, I boil with fru stra te d indignation a t the com bination of ig n o ran ce and in sen sitiv ity w hich th is kind of m ed ical p ra c tic e re p re se n ts . It is the duty of a physician in the lead trad es to show up the d an g ers of lead ab so rp tio n , to in s is t th at th e re a re c rite ria of safety w hich should be m et, and n e v e r to condone dangerous p ra c tic e s in production. This can be done, and th e re fo re if is not u n reaso n ab le for the d o c to r to ex p ect it to be done,, and to in s is t th a t it m u st b e. It is nothing s h o r t o f s h a m e fu l th a t we have-ass -m uch le a d p o iso n in g a s w e ,do in A m e ric a , when the m eans of preventing it a re so su re ly known. A nd, m o reo v er, it is even m o re sh am efu l, th at m any A m e ric an ph y sician s a re both too ignorant and too com placent to do th e ir p a rt in seeing th at th is is dope. It is disgusting th a t som e, of them a re w illing to condone u n safe o p eratin g p ra c tic e s and to try to c o v e r u p f o r a n i r r e s p o n s i b l e o r u n s c r u p u lo u s m a n a g e m e n t. You w ill th in k m e h a rs h , p e rh a p s, but p e rh a p s you w ill u n d e rstan d m y indignation when you c o n s id e r th a t I h av e sp e n t m u ch , if n o t m o s t, .of m y tim e fo r m o re th an th irty y e ars in the developm ent of m edical techniques fo r the a p p ra isa l of lead ab so rp tio n and fo r the differentiation-of safe from dangerous lead absorption. H aving su cceed ed in c la rify in g th e se m a tte rs - not alo n e, cf c o u rs e , but with th e h e lp , c o lla b o ra tio n and c o n firm a to ry e x p e rie n c e of ,m an y o th e r p eo p le so th a t now they a re in no doubt a t.a ll, and so th a t th e in d u stry fo r which I am the M edical D ire c to r has not had a c a se of even b o rd e r-lin e lead poisoning in m o re than tw enty y e a rs , d esp ite the fact th at it is the m o st dan g ero u s, poten tia lly , of any of the lead tra d e s , I think I m ay be ju stified in expecting so m ething m ore of m j m edical colleagues in the lead-using in d u strie s. Now w hen one com es to the p ro b lem of th e tre a tm e n t of p e rso n s who a re ill w ith lead intoxication* the situ atio n is d ifferen t. Hare-, am ong o th er fo rm s of th erap y , the hastening of the elim ination of lead from the body under c a re fu lly co n tro lled conditions is ju stifie d . It is not w ithout som e ris k , blit the condition of the patient ju stifie s such risk as th e re is. This, in the ex p eri ence of good clin ical o b s e rv e rs , does not cu re the sym ptom s of lead poisoning a t once o r even prom ptly, in m any in sta n ce s, but it reduces the danger of in ju ry and ten d s som ew hat to sh o rte n the p e rio d of d isa b ility . I cannot go into th e d e tails of the th e ra p y of lead poisoning h e re , fo r it is a long sto ry . But, to su m m arize the sto ry of d iso d iu m -calciu m v e rse n a te , it is a th erap eu tic agent of w orth. It is, on the o th er hand, a dangerous prophylactic agent, and one w hich should not be u sed in lieu of an adequate lim itatio n of lead exposure. T h ere a re se v e ra l published accounts of m y view s of an adequate m edical p ro g ra m in the lead tra d e s , the b e st of w hich, w hile not fu lly up to d ate, is g e n e r a l l y s a t i s f a c t o r y , I r e f e r y o u to C h a p t e r 2 in V o lu m e II o f 1'I n d u s tr ia l 00151.90 D r . Irving H. D avis - (3) - June 18, 1958 H y g ie n e a n d T o x ic o lo g y " e d ite d b y F r a n k P a t t y . T h e f i r s t r e q u ir e m e n t1o f a good m edical program is an in te llig e n t d o cto r who knows som ething about the b eh av io r of lead in th e hum an o rg a n ism , and who a lso has "g u ts '' and convictions Incidentally you a re quite right about the value of d eterm inations of porphyrins in the u rin e a3 a m e asu re of m edical control in the lead-using in d u strie s. Even when the d eterm in atio n ? a re m ade w ith p re c isio n , an a th ey u su ally a re not, th e y do n o t a n sw e r th e p u rp o se . W hen C oproporphyria III is e x c re te d in significan tly ab n o rm al q u an tities in re sp o n se to ex cessiv e q u an tities of lead in the body, it is a sign of lead intoxication and so it shows up too late. It does not c o rre la te In quantity w ith th e quan tity of lead a b so rp tio n . Sincerely yours, . x\A A ex B obert A. Kehoe, M. D. KB 0015197