Document mmVao88pxbLZOz718VeDXY9o0

(Esso) HUMBLE SOUTHEAST ESSO REGION WILLIAM B. TOWNSEND, M. D. REGIONAL MEDICAL DIRECTOR OIL & REFINING COMPANY NEW ORLEANS 60, LOUISIANA POST OFFICE BOX 60626 December 21, 1962 Robert A. Kehoe, M. D. The Kettering Laboratory College of Medicine Eden Avenue Cincinnati 19, Ohio Dear Doctor Kehoe: Re: I want to thank you for your very prompt and excellent summa tion on the case of the above named. I have sent a Xerox copy of your letter of December 17, 1962 to Dr. J. N. Marshall. I will keep you informed of any future events. Thank you for your courtesies. Yours very truly. WBT/mjm William B. Townsend, M. D. KE 001286 December 18, 1962 Dr. J. Neil Marshall Associate in Neurology Medical College Hospital of the Medical College of South Carolina 55 Doughty Street Charleston, South Carolina Dear Doctor Marshall; Attached for your information is a report of the results of urine and blood analyses for lead in the case of The original of the report was sent to Dr. Townsend on December 10, along with a statement of analytical charges. Sincerely yours Robert T. P. deTreville, M. D RTPD ef cc: Dr. William B. Townsend Dr. Frank Princi Enc N13228.01 / December 17, 1962 William B. Townsend, M.D. Medical Director Humble Oil and Refining Company Post Office Box No. 60626 Hew Orleans 80 Louisiana Dear Doctor Townsend: Dr. Robert T. P. deTreville Has called my attention to a report of the analytical findings in the urine and blood of Mr.1 an employee, I believe, of Humble Oil and Refining "Company, who has been under the care of Dr. J. Neil Marshall, Dr. B. L. Freeman and Dr. H. Rittenberg. after seeing the report I inquired about the patient and was given the available information which includes tvro letters from Dr. Marshall to Dr. Freeman containing a Discharge Summary, and the summary of an Outpatient Visit. I am In no position to make a diagnosis of this man's illness, but I think it is quite safe to say that it was not lead poisoning. There are several good reasons for this conclusion, while there is only one, highly dubious reason for thinking of lead poisoning in relation to this illness. It is not too unusual, unfortunately, to find some difficulty in determining the cause and the actual site of certain obscure types of neuromuscular disease, and I would place this man's illness in that category. First, as to the matter of lead poisoning, Mr. tfflflphas no history of occupational or incidental exposure to lead Cone must exclude the possibility of his absorption of tetraethyllead, not only because, (1) it does not occur under the conditions of his work; and (2) tetraethyllead has never been known to cause any lesions of the cord, spinal or peripheral nerves. The man's brief bout of painting would not have been expected to provide a dangerous degree of absorption of lead had the paint been a lead base type. Even regular outside or interior painters are but rarely poisoned, unless they engage regularly in sanding, scraping or burning off old paint. Moreover, in this instance the paint appears not to have been a lead base type. It is possible, of course, for a person to be poisoned by lead from some undiscoverable or obscure source, but this in the case of adults is rare. In this instance, a history of exposure is lacking. Second, the presenting illness was at no time typical of lead poisoning, and one must stretch one's judgment very far to fit Kr 0 -\ 4P .A O L* Ui4ob4 N13228.02 William B. Townsend, M.D 2 December 17, 1982 the pattern of any type of lead poisoning. It is not impossible, perhaps, for lead absorption to produce disease in this form, but it is most improbable, and I have never seen such a case in a wide experience with the disease. Third, our analytical findings show that this man, on November 27th, only about 4 months after the onset of an illness which must be regarded as a severe form of lead poisoning, if indeed it was lead poisoning at ali (the neuromuscular form of lead poisoning occurs only when a large quantity of lead has accumulated in the body), has lead in his blood and urine in concentrations lower than that of the average American adult (these are distinctly "low normal" analytical findings). These findings make it highly improbable that Mr. Boyce had any large quantity of lead in his body in August of this year (1962). They suggest that the chelating therapy given in August depleted his usual or normal body burden of lead. They are not compatible with the analytical findings in the urine which were reported before and after the administration of CaNag BDTA. The result reported originally, before any therapy - that of more tnan 4 milligrams - (the figure 4,433 mg. is an odd representation of an analytical result, for there is no method of analysis which is that precise,) in a 24-hour sample is, of itself, presumptive evidence of the contamination of the sample. uch a high concen tration of lead in the urine in the absence of "deleading" therapy is virtually unheard of. No competent or careful analyst would report such a result without obtaining an additional sample of urine and checking it carefully. It should be rc-cogniaea that the collection of a 24-hour sample of urine in a hospital by the methods used ordinarily for that purpose (without careful instruction and supervision of the patient and all attendants) results regularly not exceptionally, but regularly - in gross contamination ox the sample with lead. This is one of the commonest difficulties in present diagnostic procedures in relation to lead. It is also true that the type of analysis done for lead in the usual hospital laboratory is not only worthless but grossly misleading. This is a difficult procedure of microanalysis and only those skilled and accustomed regularly to the performance of such analyses can be relied on to obtain even approximately correct results. Obviously, I know nothing of these matters in the hospital in question, but I have encountered this type of analytical result so often that I am justified in entertaining grave doubts as to its relevance. Even after the type of therapy employed, one would confidently expect that the lead in the body would have been but slightly reduced, for such therapy eliminates only that in the soft tissues, and a few weeks later this is replenished from that deposited in the skeleton, so that the concentration in the blood returns very nearly to its original level. In fact, when the quantity of lead in KE 0013365 William B. Townsend, M.D -2 December 17, 1962 the body is considerably elevated, three and often four courses of intravenous Ca Na2 EDTA are required to lower the lead concentration in the blood to anything like the normal level and keep it there. You will understand, therefore, why the results which have been obtained in this Laboratory have such significance at this time, I have gone to some length to explain these matters since I suspect that you will wish to transmit my opinion and the basis for it to Dr, Marshall. The point of importance here relates to the ultimate condition of this patient, in which both you and Dr, Marshall have reason to be concerned. 1 sincerely hope that Mr.jflHHPwill continue to improve and will recover completely. There is considerable likelihood, however, that he will not. One suspects that his is a progressive disease with a present remission. I shall be interested in learning what transpires, I shall be much better pleased, however, if his uneventful recovery leaves us in doubt as to the nature of his present illness. Sincerely yours. Robert A, Kehoe, M. D. RAK: ss Enel: Reprint of "Value of calcium disodium ethylenediaminetetraacetate and British anti`-'lewisite in therapy of lead poisoning." KH 0012366 Air Mail December 10, 1962 W. B. Townsend, K.D, P.O. Box #60626 New Orleans, Louisiana Dear Doctor Townsends Re your lette^toMDr^JPrinci dated November 20, conwhich has been referred to me for reply. Attached are the results of the recent analytical studies on^HpHHPl In addition, the Director of the Laboratory, Robert A, Kehoe, M.D,, has reviewed this case and will send you his inter pretation of the above results. We are also enclosing the statement for analytical laboratory services performed, according to instructions contained in your letter. Your very truly ___ ___Kehoe Dr, princi Robert T.P. tf.eTraville, M.D N13228.03 Mr Mail Deca^tr 10, 1962 W. B, Townsend, M.B, 9*0* Base #60626 flew Orleans, Louisiana Pear Doctor Townsends Re your lettej^fcc^r. Priaei dated November 20, concornin^^PIII^HHb, which lias been referred to me for reply*^^^^ Attached, are the results of the recent analytical studies on addition, the. Director of the Lahoratory^mbert A* Kehee, M.D., has reviewed this case and will send you his inter pretation of the above results* We are also enclosing the statement for analytical laboratory services performed, according to Instructions contained in your letter* Yours very truly. RjDTswp cc* -Dr, Keho Dr* princi Bobert T.P. deTreville, m.d . K 0012368 N13228.04 7Hd zura'mm i^b c v o imt CELLOS KEMCISE i,v**U' jVs;j*s 1;., i HLS.-i>. A V ;'PsisS'E CILCIFMf 1?# OhlO *# 5* i$6a fot ftesbXe oil &rd defining Co&ssargr !V5. Sox 60626 8%s orleaaa 60, Leals Lara Attention* KilLSas B* *W85, !4*B Nodical l&r-sctca- Scr? r,eibta?s<imafife of vrim asd LloosS for tha imi^isu of tho for tfc# dewferoanatioc of load* 2 m3j at 112*SO eaeh. KE 001236^ N13228.05 PD. OR COLL. WESTERN UNION W. P. MARSHALL. PRESIDENT CHARGE TO THE ACCOUNT OF 1206 INTERNATIONAL SERVICE 1 Check the class of service desired; otherwise this message will bei sent at the full rate *" FULL RATE LETTER TELEGRAM VICTORY ^LETTER SHIP RADIOGRAM TIME FILED KETTERING ADMINISTRATION Send the following message, subject to the terms on back hereof which are hereby agreed to NOV 30 1962 DR J NEIL MARSHALL DIVISION OF NEUROLOGY MEDICAL COLLEGE HOSPITAL OF SOUTH CAROLINE55 DOUGHTY STREET CHARLESTON S C SAMPLE KIT FOR URINE AND BLOOD LEAD IN CASE'OF tMH|B^IS BEING MAILED TO YOU AT THE REQUEST OF To w n s e n d h u mb l e o i l r e g i o n a l me d i c a l d ir e c t o r n ew ORLEANS LOUISIANA COMPLETE INSTRUCTIONS ARE CONTAINED RTPD ef CC: RON LEACH . ROBERT T P DETREVILLE MD KETTERING LABORATORY 0012370 N13228.06 @) OIL 8c REFINING COMPANY NEW ORLEANS 60, LOUISIANA POST OFFICE UOX 00626 November 20, 1962 Frank Princi, H. D. The fettering Laboratories College of I'edicine University of Cincinnati Cincinnati, Ohio Dear Doctor Princi: Re: This is to confirm our telephone conversation of November 19, 1962 on the above named. Enclosed are copies of two discharge summaries and an out patient visit for your information. Please bill to the Humble Oil & Refining Company to the attention of the writer. Yours very truly, HBT/mjm Enclosures b'illian 3. Townsend, H. D. Hedical Director KE 0 0 i o AMER! A'S L E A D I N N13228.07 November 13, 1962 Dr. 3. 3. Freeman 112 Ru sledge Avenue Charleston, South Carolina Dear Dr. Freeman: Re: OUTPATIENT VISIT - 10/25/62 MCli 0D-67336 I saw follow-up outpatient evaluation on 10/25/62 in tha Private Diagnostic Clinic of the Medical College Hospital. In the 12 days sines his discharge from this hospital there has boon a further progressive* generalized increase in muscular power, lie fools that strength in the arms is returning faster than in the logs and can now descend the stairs without much trouble, but on ascending steps ho i.a*. to proceed quite slowly and hold onto the rail for support. He can uov walk fairly well if he does it slowly, but still ia unable to run. he denies paresthesias or dysesthesias and has no more of the Joint dis comfort in his knees and hips which troubled him on. his first hospital admission. Ilic only pains are occasional aching in the low bacl; area. He has no other complaints and his system inquiry ia unremarkable. Further inquiry into the possible sources for lead poisoning reveals that, although ha painted the inside of his house during the summer of 1962, tliis was with rubber latex paint. Ha denies sanding any painted surfaces. He stated again as on his initial examination that hin intaica of alcohol was limited to approximately 3 beers in a year's time. On physical examination blood pressure was 136/92 and there were no ab normalities of the heart, chest, abdomen and joints. Mentally, he was clear and alert with appropriate affect, speech and mentation. Cranial nerves were all intact and there ware no sensory abnormalities. The deep tendon reflexes were equal and active bilaterally with normal plantar responses. On inspection his shoulders still show mild atrophy, especially in the suprascapular and deltoid areas as well as the pectoralis major. His thighs were still rather flabby and showed mild atrophy. Occasional muscle fasciculations were seen in the shoulders, quadriceps and pectoral musculature. There was marked improvement in the strength of his grip and arms. It would seem that the hands and arms are now almost back to normal, but lie still shows about a 5-107. Io eg of strength in the shoulder girdle musculature. The legs also showed marked improvement in strength so that now there is only about a 10% loss of strength in his thighs and even less in his calf muscles. He still walks with a slightly wide-based, waddling gait, but this ia also ouch improved. With effort he was able to stand on the ballo of both feet and with great effort could stand on both heels alone. He H 0012 -3 v & N13228.08 ' 'I Dr. B. L. Freeman (2) Re I 0? Visit - 10'25/62 itc, JICH #5-67336 <contd) still was not able to clinb the stairs unless he used the examiner^ hand to pull himself upx^ard. I felt Mr. ^BP^had made a marked improvement in his strength in com paratively snort time. Really, this was faster progress than I antici pated and it now seems that outlook for eventual recovery is good. As long as heis improving, I sea no reason for return follow-ups with me and saturn to Dr* Rittenbarg for continuation of his general medical care. His only medication at present consists of oral B-Complex vitamins inthe form of Surbex-with-C, one b.i.d. Thank you again for the opportunity to follow him with you. His illness has been very interesting and I hope his rapid improvement continues. With best regards. Sincerely yours, hi\; M J. NEIL MARSHALL, M. D. Associate in Neurology JNM/lhw cc; PDC Chart Dr. H. Rittenberg 3910-A Rivers Ave, Chas. Hgts. Wa. B. Townsend, Reg. 'lad Dir. Humble Oil & Refining Co., New Orleans, La* 0012373 November 13* 1962 Dr, B. L. Freeman 112 Rutledge Avenue Charleston* South Carolina Dear Dr. Freeman: Re: DISCHARGE SlE-EiARY - #67336 Hr. 404 Duran^wS^N^HHv 10-3-62 to 10-13-62 During the period of ra-hospitalization of your patient, ny original diagnosis of peripheral polyneuropathy, probably due tc^nad, remains unchanged, Eight days following discharge from this hospital the patient was re-admitted for a repeat course of Vcrsinate therapy. Since discharge from the Hadical College hospital there has been definite improvement of the patient's strength* On re-exaaination atrophy was still noted around the shoulder girdle and over the thighs. Diffuse, generalized weakness was present in the arras and hands, but much improved over the previous examination. He still showed moderate weakness of his legs. Scattered fasciculations ware present over the shoulder girdle and in the thighs and calf muscles. Seep tendon reflexes ware present and equal throughout with normal plantar responses. Routine urinalysis was normal. Hemoglobin 13.5 grams* HBC 4.2 million with normal white count and differential. During the 5 days of hospitalization the patient received Vcrsinate, 1 gram in 500 cc's of 5% glucose b.i.d. Daily acternlnaclgngjior porphyrina and lead were made on 24-hour collection of urine in a lead-free Settle. All 5 specimens ware negative 5irysggm>r!hs7 Sea<T~doterainafelons were as fol lows: First day* 1.3 rags/day I second day, negative; third day, 2.040 ogo/day? fifth day, negative. He was given an appointment for outpatient follow-up visit on 10-25-62. Thank you again for the opportunity to see this very interesting gentleman, ^inccrely yours* '/J. NEIL MARSHALL, M. 9. Aosociata in Neurology JHM/lhw ccs 2 - i-icn Chart Dr. H. Ritteabarg /3910-A Rivero Ave, Chas. Hgts. i /ot* Wta. B. Townsend* Reg. lied. Director ^ Humble Oil & Refining Co New Orleans* La. f(E 0012374 N13228.09 ARTMENT OF MEDICINE VISION OF NEUROLOGY MEDICAL COLLEGE HOSPITAL of the MEDICAL COLLEGE OF SOUTH CAROLINA 55 DOUGHTY STREET CHARLESTON, SOUTH CAROLINA November 13, 1962 Dr. William B. Townsend Regional Medical Director Humble Oil &. Refining Company P. 0. Box 60626 New Orleans, La. Dear Dr. Townsend: Enclosed with this letter are copies of the hospital discharge summary for 9-17-62 and 10-8-62 as well as the record of outpatient visit on 10-25-62. After obtaining the patient's written permission, these records are being forwarded to you as you requested. Mr. would be quite willing to have blood determination for lead. Sinc^chis examination is not made at this hospital, the specimen would have to sent elsewhere; however, I would be glad to draw this specimen if you would send me the necessary materials. I would be interested to see if the blood lead determination verified my diagnosis. I hope the enclosed information will be satisfactory for your purposes. Sincerely yours, Ends. JNM/lhw cc: Dr. B. L. Freeman 112 Rutledge Ave, Chas. Dr. H. Rittenberg 3910-A Rivers Ave, Chas. Hgs. v J. NEIL MARSHALL, M. D. Associate in Neurology 0012675 N13228.1 7 October 9, 1962 Dr. B. L Freeman 112 Rutledge Ave Charleston, South Carolina Re: DISCHARGE SUMMARY - #67336 Dear Dr. Freeman: 404 Duront^wo^il^TSasy 9-17-62 to 9-29-62 During the period of hospitalisation, of your patient, Mr. VBl have arrivedat the following diagnosis: Peripheral polyneuropatny^probably due to lead. Tills 39 year old gasoline cruel; operator entered the hospital with com plaints of pain in hi3 bad; and legs which had begun about August 1, 1962. On August 6, 1962, following extraction of some teeth, he noted the onset of progressive vcalcaess in his hands, arms and legs. There were no sen sory or sphincter disturbancos. A copy of the admission note by the neurologic house officer is included for your files. On examination BP was 140/90. The remainder of his general physical examination was not remarkable. On neurologic testing he showed moderate, symmetrical weakness of the hands and arms as well as marked weakness of the lower limbs, especially around the pelvic girdle. The muscles were tender to squeeze. There were no other?, neurologic abnormalities. Routine hemogram, urinalysis, 3UN, calcium, phosphorus, chlorides, sodium and potassium were all normal. He had a normal FBI and LE cell preparations were negative on three occasions. Blood uric acid x/as 3.7 mgs.% and 2-hr. postprandial blood sugar x;as 30 mgs7.. Total proteins X7ere 3.5 gm% with albumin 4.75, alpha globulin 0.92, beta globulin 1.40 and gamma globulin 1.43 gaSi. Dr. Harry Gregorio obtained a muscle biopsy from the left thigh which shoxjed minor degenerative changes of the cytoplasm. These changes appeared to be related to relatively small groups of adjacent bundles and would suggest the likelihood of neural origin. The biopsy showed no evidence of inflammatory process. Initially, it was felt that Mr. ^(((Phad a polymyositio; however, urinary excretion of lead in 24,hours was 4,43S_3gs. per_..d5y;,..Cnomal less than #15,., ngs.per"day). Further questioning revealed that although Mr. Boyce had worked for many years as a gasoline truck operator, he had, in addition, during the summer of 1962 painted his house although not all of it was lead paint. Since lead can present in adults as a symmetrical motor neuropathy. K 005 237u N13228.1T Dr. B. L. Freeman Charleston <2) Re: Disc' Mr. 9-17 #67336 (contd) ho was begun on a 5-day course of intravenous Versinate therapy. The urine remained clear of any evidence of lead on the third and fourth day; however, folio-wing the fifth clay of treatment showed 6.35 tags, of lead per day. Scrupulous attention to avoid contamination by the use of lead-free bottles was carried out and I feel fairly confident that lead is die offending agent. During hospitalization there was some improvement in Mr.^HB*strength. At discharge ho could support his weight on either leg alone for ten seconds and could stand on his toes which he was not able to do on admission. He was unable to step ap onto a stool with either leg even though he held onto the bed for balance and support. He was discharged on oral B-Complesc vita mins and arrangements were made to readmit him about one week for another course of intravenous Versinate therapy. Thank you very much for the referral of this very pleasant and most in teresting gentleman. I shall keep you informed of ay further findings. With best regards. Sincerely, JNM/lhw J. NEIL MARSHALL, M. D. Associate in Neurology K 001 Name: Materials Submitted! Required: Urine and Blood 11*29-62 by Dr- V# B. Townsend, P. 0. Box 60626, New Orleans, Louisiana for Medical College Hospital, 55 Doughty Street, Charleston, South Carolina Lead Analyses URINE Analysis Number Volume Specific Gravity Mg, Pb/Liter 62A* 6991 120 ml. 1,007 0.02 BLOOD Analysis Humber Grams Mg. Pb/100 Grams 62A*6992 Spectrographic Slthisone 16.5 16.7 0.025 0.015 The urine and blood lead levels are completely within normal limits and are, in fact, at the lower end of the normal range. Robert T. P. d'eTrevli leI4."d . Samples Collected; Samples Received; Samples Reported: 11-27-62 11-29-62 12-5-62 /< 00 12 3 7 a N13228.12 Z 7' // / THE KETTERING LABORATORY COLLEGE CF MEDICINE, UNIVERSITY OF CINCINNATI - EDEN AND BETHESDA AVENUES CINCINNATI 19, OHIO INSTRUCTIONS : BEFORE PROCEEDING PLEASE READ THE REVERSE SIDE OF THIS FORM - The information" required below is" of major importance for the performance of the service that you have requested. FAILUR^JiG^cOMPLETE THIS SECTION OF THE FORM FULLY will result in delay in c^r^TOfeng but' 'both 'the 'analysis and the subsequent interpretation (where OTp^cable) of the results. Please PRINT or TYPE. H0H lx C/wvks^H ^ f' , "'Address Ci"ty 2one 1 Stats Requested hy: Pr.tOQ,' j o uAt,x$ein<l . Name Address Cofy Zone Bill : Doctor_____ HospitalOther "lbV- (Ay /j>t ' i p<nj i\ S?cm^ py 'state.. Send Reoort To: Doctor Hospital Other Investigation Desired: ^('oocjt >P Qy \v \6 (l History : Include nature of exposure, actual time of exposure if known or surmised, and especially the last day or hour of exposure; character and time of onset of illness; course of illness and present status; previous pertinent medical history. CXJ~C)X^-Z_ 07? <2A-4-giZA^> /) /7 s / /" / Finding -J*** ,4-e.vrs-~n , sm* ^ i Yc>y^ (y\s{/'L-C yQ p-eyO- A./ /^cCyj: ^P^atory.Findings : a/ -y ^ c~'i y / Anw. Impression: Cy ,'1/^ r? '$.> / o 7,CJ,y i t*. c>(J_P /y , , Xka <Lt LM Treatment: Specify medications'and dates of/institutionand completion of therapy. cf Pu'- . ( -, i ^ c tXi- ^^ ^ 'c;i /c p /o / y 1# Cl yyi i ,',f 1 < c < '> 1 <c ^ g- 0 v) 1 ? '*> ^ ' N13228.13 The Kettering Laboratory is a totally self-supported research unit of the University of Cincinnati engaged in research in the fields of industrial hygiene and medicine. The Laboratory is not a medical service laboratory, and clinical diagnostic services, as such, are not performed. We do undertake to assist physicians with toxicologic problems or other special problems in this and related fields, as a courtesy, when adequate facilities are not available locally. We shall make every effort to be of assistance provided that we can obtain the information we require, and if the work that is to be done will yield, in our opinion, information that will be helpful in establishing a diagnosis, in the management of a case, in teaching, or in contributing to a better understanding of physiologic or pathologic mechanisms. NO SPECIMEN WILL BE ACCEPTED FOR ANALTSIS UNLESS PRIOR ARRANGEMENTS HAVE feEEN MACE BY TllE ATTENDING OR OTHER RESPOISIBIE PHYSICIAN WITH A PHYSICIAN IiFt h E' KE'TTBRx NG1 LABORAT0RVT~~~TTSs'~Ie necessary for a number of reasons . F"irst, unless.. proper specimens are collected with specified care, in specially processed containers, and in adequate amounts, they are likely to be contaminated or unsuitable for analysis. Second, we must be sure that we are aware of pertinent historical facts and clinical findings since we provide frequently interpretations of the results. Third, our staff members must frequently revise work schedules on sponsored research in order to carry out the analysis . The Laboratory makes a charge for re:'mbursement of the actual cost of the service performed, since otherwise funds earmarked for research will be expended for medical service. Deviation from this policy is made when patients are indigent or when the cost of the service would cause undue economic hardship. Therefore, it is requested that the attending physician assist us by marking the appropriate line on the reverse side of this form.