Document jg4dmnMOVLynY7pZ5rvky7ndZ

March 24, 1959 Dr. `William F. Orr, e vat-Imeni '.ycnxatry, Scuoci of Medicine, Yandc*rt ilt University , Nashville, Tenn. Dear Doctor Orr I should like :o express my appreciation of your courtesy in seeing me on Vediresday, in talkin^vrti^ae about your patient/ aid in le :ting me see It was particularly 500. O to Interriipt ,your ous? discommode yourself at your lunch h o u r . I i.'eit and .1 feel apologotic,'bin view of my responsibi- lilies, i : seemed necessary to get from you at first hand the basis on which ;:ou had arrived at the diagnosis in this c a s e . H i---' $if C3 O o isidered of obtaining more information by he further study of Mr that would throw light on his ill- ness, and there a tvo matters in which it seems to me that I might make suggestions, I would like to make certain of the present facts with resoect to r^c lead metabolism. Therefore, I would like to have duplicate samples of blood and two samples of urine, the latter to be taken some hours apart or perhaps on successive days. Accordingly I am sending containers for the collection of the samples together with Instructions for the collection of both, and I would appreciate it very much indeed if you would see to it that the samples are obtained with meticulous care to avoid the possibility of their contamination. The instructions are specific and detailed and should be adequate for the purpose, . M y other suggestion relates to the possibility of establishing, at some later dat e , a more satisfactory and better substantiated clinical diagnosis M r . ^ i m ^ m a y recover completely or he may show progress! ve or retrograde changes of some characteristic type. I certainly hope the former will be the case, but inasmuch as the latter is a poss- bility, I should like very much to know what happens to him subseqxiently. If, therefore, it were possible to maintain contact with him and to follow up his case through you, it would be most useful to me. Since 1926 I have undertaken to obtain complete records on every base of actual or alleged tetraethyl lead poisoning that has occurred .n the United States (and elsewhere as well, so far as possible) When it is possible to deal with the matter on a strictly medical bd sis without threat of medico-legal complications, I should like to b able to obtain records, or at least all of the pertinent informatidm in the records, of this case from the hospitals at both Chattanoo a and Nashville. I have tried to gather all of the facts as far as they relate to the hazards of this industry in all parts of Dr. William P. Orr - (2) - .March 2 k s 1950 the world, so far as that has been possible, and I have attempted to make this the center for all of the experience and published infer matIon on tile subject. Consequently, I would like to maintain our records as nearly perfect as possible. If you should wish to follow through, on your Idea of undertaking to "de-lead" this patient, and thereby to try to demonstrate that he; has absorbed significant and unusual quantities of- lead, I should be glad to cooperate with you b y having the necessary analyses carried out in this Laboratory, In fact, If you wish to do this, I will suggest a means of collecting samples of food, feces, urine and blood so that you can have the data of approximately balanced obser vations for an interval' of time. At an earlier time I would have advised against, this procedure as being dangerous, particularly in relation to a case of suspected lead encephalopathy. Having established the fact that "demobilisation" of lead does not occur, even'tinder the most rigid limitation of the calcium Intake and the most extensive shift in the acid, base equilibrium that can bo tolerated, I do not fear the procedure, t would not anticipate tliat it would do your patient any good, and therefore I would not advise it, but on the other hand, I do not think ft will hurt him, and I shoull be willing to assist you in carrying Put suqfct observations, especially in view of your skepticism with respect to my statements. Inolden- '`\ _ our observations on patients, with respect to "mobilisation" and "demobilisation" of lead, and on concurrent symptomatology, have not been hlished for the lack of time in recent years to assemble the data of a rather large series of systematic investigations on which we embarked some years ago. 1 see no means by which this work can be pub lished except In monograph form, and I 've been hoc busy with the da y 's work to do more than outline s u c h 'a monograph., Thus our recent publications have been fragmentary, and I am at some considerab le disadvantage, since statements mads on unpublished evidence may well be regarded as ill founded. The evidence, however, is availab le, and In due course I shall cite seme of it, in a report on certain aspects of tills situation. Having exp ressed my tentative opinion on this case and on the evidence thus far a dduced toward a diagnosis, I shall not repeat it here. I shall inve stigate such aspects of the matter as are still opc-n to some quest icn and shall undertake to uncover any facts that might conceivabl y be pertinent and open to direct Inquiry. After* t obtain all the in oi-mation I can get, 1*11 vrr.lte a nummary cf my. own opinion, for such u se as it may be for the record and for the professional people con c e m e d . Cordially yours, BAK ef R o b e rt A.' KelibeT 'M. D. ;v; \ v p ..zX, .Dr. William F. Orr - (p) - March 24, 1950 P. S. An article lias just come to my attention in the March number of The American Journal of the Medical Sciences to which I commend your attention. It is that of Proctor and Kahn, on "Disodium hydrogen Phosphate Therapy in Lead Poisoning." . It illus.t rates a number of the errors of critical judgment and of inexperienee that have characterised most of the experimental work of this ype. (l) It Ignores the variability of the excretory response of individuals from day to day based-on variation In water oucput an d on other factors not too deadly elucidated but Important, Such varl ation is the greater, the larger the quantities of lead available n the tissues, (s) It fails to take into account the variabill ty in the intake of lead from day to day by "controls" in their fobd and beverages, (p) It fails to include observations on untreated individuals to show the order of magnitude of the decrease inary lead excretion following discontinuance from exposure, without ainy kind of therapy. In other words, this work has failed completely to include the control observations necessary to interpret highly variable physiological processes. It will be noted that no analyses were made on the blood. I call yc ur attention to this for the reason that no one who has mundertake,n to understand and to elucidate any other aspect of the mineral etabolism would accept such results and conclusions as these as having any validity. The authors are right when they say that "this for m of therapy merits further Investigation." Actually all they have' said that has any positive significance is that the administration of this medicament causes clinical Improvement. This may or ma;,y not be true, since the usual case of lead intoxication Improves in varying degree of promptness, when exposure to lead is brought o an end. The only evidence on this subject that is worthy of serious consideration is that obtained when the lead intake,and%Stput In the 'urine and. feces are studied simultaneously coincident with observa tions on. the changes In the lea$l concentration in the blood, all of these fi:E.dings being interpretedySarefully developed background of correspo:ding observations on untreated patients. B.A.K.