Document nk5J33K8qrNrEXanEXrExo3j6

June 14, 1954 D:. D, John Lauer Medical Director Jones and Laughlin Steel Corporation Third Avenue and B'osa Street Pittsbu rgh 3C*, Pennslyvania joear jOxui; I return to you, somewhat tardily, I fear, your paper on ''Clinical 7_,ead Intoxication." As I told you over the telephone, this is a good paper, and I shall he glad to see it in print. I am making a few comments, for such use as they may be to you, since I shall consider it unnecessary to comment on the points concerned in my discussions, flotations have been made in the margin of the text. Pages 8, 9 and 10 - The Lead Line. The first atatement(page 8) should be modified because of medico-legal considerations to something like the following: "The lead line is the most consistent sign of the occurrence of potentially hazardous absorption of lead, on the part of the industrial worker. " Comments (1) It is not a sign of plumbism, and. should not be said to be, since the term pluznbism is taken generally, for medico-legal purposes, to mean intoxication. (?,,} It is rarely seen in the child (because of the common lack of gingivitis in. the child.) The second statement (page 3) should be modified accordingly, since this is not a lesion of ''lead poisoning." I should simply delete the second sentence. It is not strictly correct, since the discoloration of the rectal mucosa is also a sign of metallic absorption, and since the so called lead line is not necessarily due to lead, but to any metal that forms a black sulfide. The third statement (page 9} should make the exception of children, and of persons who have unusually sound and healthy gums, so as to link this lesion to gingivitis. The line does not occur unless there is some gingivitis. My fourth comment relates to the omission, on page 10 of the most difficult feature of the differentiation of lead line, in that the natural pigmentation of negroes and certain other persons with heavy pigmentation involves the buccal mucosa and the buccal side of the gums, and occ&ssionally (very rarely in my experience) the lingual side of the gingival mucosa. Page 10 - Muscular Weakness. The "evaluation" of muscular weakness is not always difficult. Sometimes it is very easy, ft depends upon the duration and severity of the weakness. Extensor weakness of the forearms can sometimes, be observed to be gross. N13940 Dr. D. John Lauer - (2) - June 14, 1954 frequently than not are the only points of weakness. I have never seen foot drop in lead poisoning in the adult. It is extremely rare, in contradistinction from arsenic poisoning. On page 14, I have written in certain suggestions for editorial changes which seem to me to be necessary or advantageous. On page 15, I have questioned your first statement, not only because I do not believe it is true in general, but also because some stippling is, as we have shown, an entirely normal phenomenon. It is, usually, I believe, a juvenile form of erythro cyte, which is present in increased number when the bone marrow is stimulated in any one of a variety of ways. I would certainly not make so flat a statement as this. This entire paragraph is open to serious objection. In your second paragraph you say it is "a good means of studying excessive lead absorption. ' Actually it is a commonly used and very poor means to this end. If one has no other means, it will have to serve, but it is not ''good. " I would certainly not encourage reliance upon this phenomenon. You need not condemn it, if you don't feel like doing so, but you should net commend it, except as an accessory clinical procedure, without discussing in considerable detail its usefulness and its short comings. Your limitation of it to the study of groups gives you a reasonable out, but this will not be understood by most of your audience. Moreover, as X have indicated, it is never seen in tetraethyl lead poisoning, and so your statement of its "constancy" is not correct. Several of the points I have covered arc those that come up constantly in medico legal controversies, and if you put yourself on record in partial error, you make great trouble for yourself and for your colleagues. It is necessary, in discussing the subject to be very meticulous in your speech, and not to rely upon the under standing of your colleagues. If, therefore, I am more critical than I would be ordinarily, it io because it is important not to say anything that is not strictly true. I repeat that the paper is good. However, I know the problem of preparing such papers in brevity and haste, and I have no hesitation in criticising as well as in praising it. Sincerely yours, KAK e Snc. . Ke QGI21H8 -uii i.m_ .n ik-- "iHfeniW"- Robert A. Kehoe, M. D.