Document wrDo15y3pBx5xVLanj6RMmvzD

(isso) HUMBLE SO U TH EAST ESSO REGION W ILLIAM B. TO W N SEN D , M. D. REG ION A L MEDICAL D IR ECTO R OIL & R E FIN IN G COMPANY NEW ORL EA N S 60, L OU I SI A N A POST O F FIC E BOX 6 0 6 2 6 December 21, 1962 Robert A. Kehoe, H. 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 L vLC-- a___ 'T William B. Townsend, M. D. K H o U J 36 N13228 D e c e m b e r 18, 1962 D r. J. N eil M arshall A sso ciate in N eurology M edical C ollege H ospital of the M ed ical C ollege of South C aro lin a 55 D oughty S tre e t C h arlesto n , South C aro lin a D ear D octor M arsh all: A ttached fo r your inform ation is a re p o rt of the re s u lts of u rin e and blood a n a ly se s fo r lead in the c a se o f T h e o rig in a l of th e re p o rt w as se n t to D r. T ow nsend on D e ce m b e r 10, along with a statem ent of analytical charges. S incerely yours, RTPD ef cc: D r. W illiam B . Tow nsend D r. F rank P rin ci Enc. R o b ert T. P . d e T re v ille , M .D . K 0 0 1 23 63 December 17, 1962 William B. Townsend, M.D. Medical Director Humble Oil and Refining Company Post Office Box No. 6062S New Orleans 60 Louisiana Dear Doctor Townsend: Dr. Robert T. P. deTreville lias called ray attention to a report of the analytical findings in the urine and blood of Mr.< 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. Eittenberg. after seeing the report I inquired about the patient and was given the available information which includes two 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. flflflpkas no history of occupational or incidental exposure to lead (one 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 William B. Townsend, M.D 2 December 17, 1962 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 EDTA. The result reported originally, before any therapy - that of more titan 4 milligrams - (the figure 4.438 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 anu checking it carefully. It should be rc-cognisaed 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 of 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 raicroanalysis and only tho.se skilled and accustomed regularly to the performance ox 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, fox' 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 XE 0012365 William B. Townsend, M.D -2 December 17, 1962 the body is considerably elevated, three and often four courses of intravenous Ca Na^ 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 1 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.jflH^will 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 0 0 1 2 6 6 0 Air Mail December 10, 1962 W. B. Townsend, M.D. P.O. Box #60626 New Orleans, Louisiana Dear Doctor Townsends Re your l e t t e ^ t o ^ r ^ P r i n c i dated November 20, c o n c e r n i n g ^ p ^ B ^ H V which has been referred to rae for reply. Attached are the results of the recent analytical studies 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. Yours very truly ccs nor. Kehoe Dr, princi Robert T.P. deTreville, M.D M r Mail mccmhmr 10, 1962 W, B* Townsend, M.J3. 9*0 * Bern #60626 flew O r l e a n s * L o u i s i a n a Pear Doctor Townsends . lRe your e t t e r t ^ P r . Prii^ci dated sioversber 20* concernin^|||^HHfe* which has been referred, to me for r e p l y ! ^ ^ ^ ^ Attached are the restsIts of the recent analytical studies on addition* the. Director of the Laboratry^sober t 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* Yours very truly* RPTswp cc* -pr* Keho pr* Princi Robert T.9. deTreville, M.D. 0012368 7m m n m tm u b c v v i o t CL!t,0S CE KSuCiSE m i& ib u irn sn k x ib m x c h j c i p h TZ 2 $ , o?;xo i M e & 'tim % 1#<S2 fot I te b ls e l i sxs seflfilR g Cassisasgr P*0. Box 6C62 . Kcw erle&a 60* Lsmisl&m A tteniioni K iliia a B* Sm-mmo&9 M*B* . dedicai Eit-'SCtar ' Fcr? f,eita?s$aiTfc si Tm Setter ;jigJ&fcca??-tory fr Iha r a is sia of ta yrine and bXoS l'or tfce dtfwfers,.ntti!:* e f lessi* 2 mlyse ai $12*50 eaeh.***** * ***.* ****#***** ******* a5*00 KB' 0 012 o 6 ;y 'ic S E R V IC E ^ "a?s of service desired ; e this message will be till rate telegram S E R IA L NO. VVDS.-CL. OF SVC. PD. OR COLL. WESTERN UNION W . P. M A R S H A L L . P R E S I D E N T CASH NO. CHARGE TO THE ACCOUNT OF 1206 ^ / I n t e r n a t io n a l s e r v ic e Check the class of service desired; otherwise this message will be sent a t the full rate SP FULL RATE LETTER TELEGRAM V IC T O R Y ^LETTE R rS H IP RADIOGRAM PD K ETTERIN G ADM INISTRATION Send the following message* subject to the terms on back h ereof which are hereby agreed to NOV 30 1962 DR J NEIL MARSHALL - DIVISION O F NEUROLOGY M EDICAL C O LLEG E H O SPITA L O F SOUTH CAROLINE. 55 DOUGHTY ST R E E T ' '- CHARLESTON S C . S A M P L E K IT FO R URINE AND BLOOD LEA D IN CASE OF '^ I ^ I S B E IN G M A IL E D TO YOU A T T H E R E Q U E S T O F ^^T O W N SE N D HUM BLE OIL REGIONAL M EDICAL DIRECTOR NEW ORLEANS LOUISIANA C O M P L E T E INSTRUCTIONS A R E CONTAINED . RTPD ef CC: RON LEACH, . RO BERT T P D E T R E V ILLE MD KETTERING LABORATORY K* 0012370 (ksso) OIL & R E F IN IN G COMPANY NEW ORL EA N S 60, L OU I SI A N A P O S T O F F IC E UOX 6 0 6 2 6 November 20, 1962 Frank Princi, M. D. The fettering Laboratories College of I'edicine University of Cincinnati Cincinnati, Ohio Bear 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. Y ours v er y t r u l y , , Lillian 3. Townsend, H. B. I'edical Director WBT/mjm Enclosures O 't * i 'j u x /.o ( A. N13228.07 November 13, 1962 Dr. 3. I*. Freeman 112 Rutledge Avenue Charleston, South Carolina Dear Dr. Freeman: Re : OUTPATIENT VISIT - 10/25/62 Hr HCII 0D-67336 I saw H r M B ^ f o r follow-up outpatient evaluation on 10/25/62 in the Private Diagnostic Clinic of the Hedical College Hospital. In tiii 12 days since his discharge from this hospital there has boon u further progressiva* generalized increase in nuocular power. He fools that" strength in the arms is returning faster than in the legs and can now descend the stairs without much trouble, but on ascending steps ho has to proceed quite slowly and hold onto the rail for support. He can now walk fairly well if he does it slowly, but still is unable to run." lie denies paresthesias or dysesthesias and has no nore of the joint diacoafort in his knees and hips which troubled hia on his first hospital admission. II--., only pains aie occasional aching in the low back area. He has no other co;nplain to and his systca inquiry is unremarkable." * Fur tiler inquiry into tne possible sources for lead poisoning reveals that, although he painted the inside of his house during the suaner of 1962, tliis was with rubber latex paint. Ho denies s"a--nd^i--ng a-ny pa-i-n-t-e-d surfaces He stated again as on his initial examination that his intake of alcohol was limited to approximately 3 beers in a year's tine. ) On physical examination blood pressure was 136/92 and there were no ab normalities of the heart, chest, abdomen and joints. Hentally, he was clear and alert with appropriate affect, speech rid mentation. Cranial nerves were all intact and there were no sensory abnormalities. lha 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. Iiis 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 strong tli of his grip and asms. It would seem that the hands and arms are now almost back to normal, but he still shows about a 5-10% loss 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 is also ouch improved. With effort he was able to stand on the balls of both feet and with great effort could stand on both heels alone. He H i 0012 372 Dr. B. L. Freeman (2 ) Rei 0? Visit - 10'25/62 i-ir. MCH #5-67336 (contd) still was not able to clinb the stairs unless he used the examiner^ hand to pull himself uptiard. I felt Mr. 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 he is_improving, I see no reason for return follow-ups with me and lIr.4pP0P?ill return 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, ; M hi \' J. NEIL MARSHALL, H. D. Associate in Neurology . JNM/lkw cci PDC Chart ' Dr. H. Rittenberg 3910-A Rivers Ave, Chas. Hgts. Wa. B. Townsend, Reg. 'lad Dir. Humble Oil & Refining Co., New Orleans, La. K ? 0012373 November 13* 1962 Dr. B. L. Freeman 112 Rutledge Avenue Charleston* South Carolina Dear Dr. Freeman: Re: DISCHARGE SIE-E1ARY - #67336 H r. 404 D u r a n ^ E v e ^ N ^ H M * 10-3-62 to 10-13-62 During the period of ra-hospitalization of your patient, Hr. ay original diagnosis of peripheral polyneuropathy, probably due cc^!ead, regains unchanged- Eight days following discharge froa this hospital the patient was ra-a&nitted for a repeat course of Vorsinate therapy. Since discharge froa the Radical College Hospital there has been definite improvement of the patient's strength* On re-examination atrophy was still noted around the shoulder girdle and over the thighs. Diffuse, generalized weakness was present in the arras and hands, but ouch 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. Deep tendon reflexes were present and equal throughout with normal plantar responses. Routine urinalysis was normal. Hemoglobin 13.5 grams, EBC 4.2 million with normal white count and differential. During the 5 days of hospitalization the patient received Versinate, 1 gram in 500 cc's of 5% glucose b.i.d. Daily dcfcem i n acj&ng for porphyrina and lead were taade on 24-hour collection of urine in a lead-free xttfcle. -All 5 specimens ware negative for" hxprhhrlnl Head"determinations were as fol- ' lews: First day, l.c rags/day; second day, negative; third day, 2.040 mgs/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. HEIX, MARSHALL, M. D. Aosociata in Neurology JHM/lhv cc: 2 - I-JCH Chart Dr. H. Rittenbarg /3910-A Rivero Avo, Chas. Hgts* \ A . Wta. B. Townsend, Reg. lied. Director ^ Humble Oil & Refining Co New Orleans, La. ARTMENT OE MEDICINE .VISION OF NEUROLOGY M EDICAL COLLEGE HOSPITAL of the M EDICAL COLLEGE OF SOUTH CAROLIN A 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: Re : Mr. MCH #D-67336 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 M r . ^ ^ m ^ 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. S i n c ^ c M s 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, , , i Ends. JNM/lhw ce: Dr. B. L. Freeman 112 Rutledge Ave, Chas. Dr. H. Rittenberg 3910-A Rivers Ave, Chas. Hgs J. NEIL MARSHALL, M. D. Associate in Neurology October 9, 1962 Dr. B. L. Freeman 112 Rutledge Ave Charleston, South Carolina Dear Dr. Freeman: Re: DISCHARGE SUMMARY - #67336 Hr. 4HrV0/S4> Durant Ave, t0 9-17-62 to 9-29-62 During the period of hospitalisation of your patient, Mr. have arrivedaf the following diagnosis: Peripheral polyneuropath^^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 weakness 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. 0a examination BP was 140/90. 'Hie remainder of his general physical examination was not remarkable. On neurologic testing he showed moderate, symmetrical weakness of the hands and arms as xjcll as marked weakness of the lower limbs, especially around the pelvic girdle. The muscles were tender to squecse. There were no other? neurologic abnormalities. Routine hemogram, urinalysis, BUM, calcium, phosphorus, chlorides, sodium and potassium were all normal. He had a normal PHI and LB cell preparations were negative on three occasions. Blood uric acid was 3.7 mgs2, and 2-hr. postprandial blood sugar was 30 mgs7.. Total proteins were 3.5 gn% with albumin 4.75, alpha globulin 0.92, beta globulin 1.40 and gamma globulin 1.43 ga%. Dr. Ilarry Gregorie obtained a muscle biopsy from the left thigh which showed 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. ^ 0 f k i a . d a polymyositio; however, urinary excretion of lead in 24,hours was 4.438 ago, per.day....(normal 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 s u m c r 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~ 0G12G7o Dr. B. L. Freeman Charleston <2 ) Re: Disc Mr. 9-17 7336 (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-ring the fifth clay of treatment shored 6.35 nga. 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 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 4. Material: Submitted: Required : Urine and Blood 11*29-62 by Br. V* B. Townsend, P. Q. Box 60626, Nev 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 Number Grams Mg. Pb/1GG 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. \Y w i b C f i\ da ^ U\ l-ix Robert T. P. deTrevllIe", 'M.D. Samples Collected? 11-27-62 Samples Received: 11-29-62 Samples Reported: 12-5-62 Y-G //' / THE KETTERING LABORATORY COLLEGE OF 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 . FAILURE? 2*C0MPLETE THIS SECTION OF THE FORM FULLY will result in delay in q _ out both the analysis and the subsequent interpretation (where cable) of the results. Please PRINT or TYPE . Patient : H 0 4 U L Ix^ks'ia H s c "Address Ci'ty Zone. '"Sta'te Race (jJ Sex Age 3 ^ Indigent____ Private ^ Other Hospital: \t-cli & 0 i1C (jg CS X, X) oQ UUX W Name ` Address' ' : Vity'* Zone A -______ ,, S.C j '"State" Requested b y : D r .t O Q ,, ~\~Q Name $Q Myi ycyl ,t P,Oi (-2>yc`Yy~f' &-- D&wJ- ^r tA__f_c___V_________ Address Duty Zone . State Bill : Doc tor Hospital 01her ~JbV~ t \ ) , & , To o i JTp^ 4 Send Reoort To: Doctor ____Hospital_____ Other n Investigation Desired: >P Q Y \ ' s \ P 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. /) /7 , s / /* / i^ ( J i i U v v v ^ , ^ t j p ^2 gt, cT ^i P*<*u a e w a s y '-jv*~ tu C c , 'cC.C/f' Pertinent Laboratory Findings s . ' A_1 y Y ,, -x . ` `7,, Impression : <7 M .w M L ^ l / 3 / J ^ y X.... " -X / , \ <-*' /':e_^X > /? C A XrL ^{ Treatment: () ~ % i V Specify medications'and dates o f /institutionand completion of therapy. ., 6. 0 /.. j / t \ L b /> C h / - ' CV / o - ;f' / o ./ 3 T / The Kettering Laboratory is a totally self-supported research unit of the University of Cincinna,ti engaged in research in the fields of industrial hygiene and medicine. 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