Document wqb1njvZrNoLLY7mrJ5pmy0XE

June 14, 1954 D r. D. John Lauer M edical D irector Jones and Laughlin Steel C orporation T h ird A v e n u e and Rosa s t r e e t Pittsburgh 30, Pennslyvania D ear John: I r e tu r n to y o u , so m e w h a t ta r d ily , I f e a r , your p a p er on ''C lin ic a l L ea d Intoxication. " A s I told you o v er the telephon e, this is a goad paper, and I sh a ll be glad to see it in print. I am m aking a few com m en ts, for such, u se a s they m ay be to you, sin ce I sh a ll co n sid er it u n n ecessa ry to com m ent on the points con cern ed in m y d is c u s s io n s . N otations have been m ade in the m argin of the text. P a g e s 8, 9 and 10 - The L ead L in e . The f ir s t statexnent{page 8) sh ou ld be m od ified b ecau se of m ed ico -leg a l con sid eration s to som ething lik e the follow ing: "The lead lin e is the m o st co n sisten t sig n of the o ccu rren ce of p oten tially hazardous a b so r p tio n of le a d , on the p art of th e in d u s tr ia l w o r k e r . " C o m m en ts (1) It is not a sig n of plumb is m , and should not be said to b e, sin c e the term p lu m b ism is -ta k e n g e n e r a lly , fo r m e d ic o -le g a l p u r p o se s , to m ean in to x ica tio n . (2) It is . r a r e ly seen in the child (b ecau se of the com m on lack of g in g iv itis in the child.) The second statem ent (page 8) should be m odified accordin gly, sin ce th is is not a le s i o n of "lead p o is o n in g . " I sh o u ld s im p ly d e le te th e s e c o n d s e n t e n c e . It is not s t r ic t ly c o r r e c t , s in c e th e d is c o lo r a tio n of the r e c t a l m u c o s a ?.3 a l s o a sig n of m etallic absorption, and sin ce the so called lead lin e is not n e c e ssa r ily due to lead , but to any m eta l that fo rm s a black su lfid e. The third sta tem en t (page 9) should m ake the ex cep tio n of ch ild ren , and of p e r so n s who have unusually sound and healthy gu m s, so as to link this lesio n to g in g iv itis. The line does not occur unless there is g in g iv itis. M y fourth com m en t r e la te s to the o m issio n on page 10 of the m o st d iffic u lt featu re of the d ifferen tia tio n of lea d lin e , in that the .natural p igm en tation of n e g r o e s and certa in other p erson s with h eavy pigm entation in volves the bu ccal m u cosa and the b u ccal 3ide oi the g u m s, and oc ca se tonally (very ra rely in m y e x p e rie n c e ) the lingual side of the gingival m u cosa. P a g e 10 - M u sc u la r W eakness?. The " ev a lu a tio n " of m u s c u la r w e a k n e s s is not a lw a y s d iffic u lt. S o m e tim e s it is v e r y e a s y . It d ep en d s upon th e d u r a tio n and se v e r ity of the w ea k n ess. D xtansor w eakness of the fo rea rm s can so m e tim e s be observed to be g ro ss. The exten sor m u scl* n o t only show their w eakness before the fle x o r s, but - m ore n - D r. D. Johr. L au er - (2) - June i4 , 1954 frequently than not are the only points of w eakness. I h ave n e v e r s e e n fo o t drop in le a d p o iso n in g in the adu lt. It is e x tr e m e ly r a r e , in contradistinction from arsen ic poisoning. On page 14, I have w ritten in certa in su g g estio n s for ed itorial changes w hich see m to m e to be n e c e s s a r y or ad van tageou s. On page 15, I have qu estion ed your fir s t sta tem en t, not only b ecau se I do not b e lie v e it is true in g en era l, hut a lso b eca u se som e stippling is , as we have show n, an e n tir e ly n orm al phenom enon. It is , u su a lly , I b e lie v e , a ju v en ile form of e ry th ro cy te, which is p resen t in in crea sed num ber when the bone m arrow is stim u la ted in any one of a v a riety of w ays. I would certa in ly not m ake so fla t a statem en t a s th is. This entire paragraph is open to serio u s objection . In y o u r s e c o n d p a r a g r a p h you s a y it is "a good m e a n s o f stu d y in g e x c e s s i v e le a d ab sorp tion . " A c tu a lly it is a c o m m o n ly u s e d and v e r y p o o r m e a n s to th is end. If one has no other m ea n s, it w ill have to se r v e , but it is not "good. " I w ould certain ly not encourage relia n ce upon th is phenom enon. You need not condem n it, if you don't fe e l lik e doing so , but you should not com m end it, excep t a s an a c c e s s o r y clin ica l p roced u re, without d isc u ssin g in co n sid era b le d eta il iti u sefu ln ess and its sh o rt com in gs. Your lim itation of it to the study of groups g iv es you a reason ab le out, but this w ill not be understood by m ost of your audience. M oreover, a s 1 have ind icated, it is n ever see n in tetraeth yl lead p oisoning, and so your sta tem en t of its ''constancy" is not c o rr e ct. /J / S everal of the points I have covered are those that com e up constantly in m ed ico le g a l c o n tr o v e r sie s, and if you put y o u r se lf on reco rd in p artial e r r o r , you m ake g r e a t trou b le fo r /o u r s e lf and fo r you r c o lle a g u e s . It is n e c e s s a r y , in d is c u s s in g the su b ject to be v e r y m eticu lo u s in your sp e e c h , and not to r e ly upon th e u n d er standing of your c o lle a g u e s. If, th er e fo re , I am m ore c r itic a l than I w ould be o rd in arily, it is b eca u se it is im portant not to say anything that is not s tr ic tly tru e. I repeat that the paper is good. H ow ever, I know the problem of preparing such p ap ers in b rev ity and h a ste , and I have no he filiation in c r itic ie in g a s w e ll a s in praising it. Sincerely yours. RAK ef Enc. Robert A. Kehoe, M. D.