Document xdkj0O58Qa9rqjajmOjo0d2Jg

May 13, 1955 Dr. George L. Maison Hiker Laboratories, Inc. P. O. Box 3157, Terminal Annex Los Angelos 54, California- Dear George: At the risk of being objectionably persistent, I am impelled to respond to one or two of the remarks in your last letter and to two features of Dr. Karr's letter. Both your attitude and that of Dr. Karr misses completely the essential point in my approach to this matter. I shall attempt to clarify this later. In addition, Dr. Karr raises some objections to my position on technical (physiological) grounds, and questions my professional viewpoint as to the uses of therapy. I shall not go into the former objections in any detail. Perhaps I may plead that my knowledge of and experience with the metabolism of lead in the human body is not negligible, and that the data in our hands on the long term release of lead following the termination of occupational, nonoccupational (children) or experimental human exposure are probably more extensive than the combined data from other sources. The quantities involved, and the quantitative influence of various measures for speeding up the excretory loss, including that of "Calcium Disodium Versenate, " are fairly well known to me. (Incidentally we plan to study this more completely in an experimental subject now available, and are waiting to do so only until the subject reaches a suitable point (suitable for ether experimental reasons) in his situation following the termination of his exposure). Therefore, if Dr. Karr does not knew of the existence of evidence to show that prolonged and'Virtually continuous" use of the agent would be required to accomplish a satisfactory rate of elimination, I can provide him with certain references. A study on his part of the quantities involved and the length of time required for elimination of lead absorbed and retained following prolonged experimental ingestion of lead (in experiments involving much smaller quantities of lead than those retained by men hi certain lead trades) might be enlightening, as might an examina tion (or re-examination} of some information published by us in 1933. (References, including the last are given below.) It is proper, obviously, for a physician to treat cases of lead poisoning wherever and whenever he finds them. I have not inveighed against this ancient duty of the physician. Dr. Karr's implication that I do not go along with such therapy, and his and your references to my attitude as equivalent to the abandonment of the victims of war and venereal disease, are irrelevant and even, if I must say so, flippant, although I do not think Dr. George L. Maison - {2) -*May 13, 1955 they were so intended. What neither of you take into account, if you are aware of it, is that the physician who is responsible for the medical supervision of men in the lead trades, has a responsibility - a very direct medico-legal and professional responsibility, which he cannot avoid through either ignorance or incompetence or denial of responsibility, or bv looking the other way - for the conditions under which the men work. It may take time and effort and patience on his part to educate the owners or managers of the business on what they are doing or failing to do, and in bringing them to do what is necessary, or it may require him, as an honest man, to give up the job, if he finds them intractable and insensitive to their duty. We are now beyond the point when an industrial physician can be regard ed among his own colleagues as competent and professionally aware, if he is willing tc treat oocupational disease and ignore the conditions, which induce it. I know, better than either of you, that we have poorly trained,ignorant and irresponsible physicians in. industry, and that the blind practices of the past continue to exist. But times have changed and are changing rapidly, and far from being "frustrated** in my "viewpoint, " I am most pleased that the efforts of recent years within the profession, to raise the standards and to realise the. scope of occupational medicine, are succeeding. In this change, the emphasis is on preventive medicine, and the industrial physician is the prime member of the team that appraises and corrects tire threats of the industrial environment. At present, to the extent that the lead trades (those in which there are physicians ~ some have no physicians) are giving rise to a high incidence of lead poisoning, the fault, in large part, resides in the doctors, who are too lazy, too ignorant and or complaisant to know their job and to do it. The techniques of recognizing the hazard, measuring it, and dealing with it, medically, are available. There is no mystery in it. Moreover, the techniques of environmental control are not beyond achieve ment. And if, by reason of economic pressure or because of emergencies, potentially unsafe exposure tc lead seems unavoidable, the men can be managed, by rotation of jobs and similar procedures, so as to avoid dangerous accumulation of lead in their tissues. This is not a matter of guess work but of completely demonstrated techniques, and there is no present valid excuse for any industrial physician in the lead trades to be unaware of them. You see, therefore, I am talking about industrial physicians and their responsibilities and their need to know and perform their jobs. I am quite sure, from what lias already transpired in this matter of the use of "Calcium Disodium Versonate" that the appeal of the use of the drug (except for those experimentally minded, who are in a different class, but do not always act in the spirit of physicians) lies mostly in the minds of the untutored, unoriented (in the modern sense) physician in industry, who is not aware of his direct responsibility for the conditions which he is trying to palliate. HE 0008309 * Dr. George L.. Maison - (3) - May 13, 1953 One such a man spoke on the subject at the Buffalo meeting. It was a piti ful performance, which was justly criticized. This is what I mean when I 'suggested that you might find yourselves on the "side of the devil, " in the sense that your jiroponents {or perhaps followers) in this use of the drug will bs the outsiders and the lower forms of industrial medical life. I have no criticism of the physician, outside of industry, who treats his patient in this manner if he can do nothing better for him. I think he will find it possible to do something better for him, and in addition to treatment, in most instances, but certainly he cannot be accused of any moral fault in attempting to do what he can. I do, however, and shall continue to, criticize severely the physician engaged in the medical supervision of men who con tinue to work in a lead trade in a dangerous environment, for promoting the neglect of the only measures of preventive medicine that are valid, though giving the impression, which is inevitable, that-he is coimteracting the danger. If the physician understands his job and his responsibility, he is immoral if he depends upon this procedure. If he does not understand his job and his responsibility, he is seriously lacking in experience, sensitivity, intelligence, or desire to learn. I have said my sa.y on this, and I do not intend to carry the discussion farther. However, I shall exert my best efforts (I) to learn all 1 can about the physio log ical effects of the use of "Calcium Disodium Versenate, " and (2) to inveigh against its use by industrial physicians as a substitute for a good brand of industrial hygiene. The lead trades are being cleaned up in this country at a fairly rapid rate, by the application of long needed but now available methods of environmental appraisal. Many of them are in an excellent state. Others, through ignorance and inertia, are willing to dodge the truth about themselves. The results to a goodly number of men who work in these plants are most unfortunate. Such results will not be lessened appreciably by anything other than a thcrogoing housecleaning in tne form of adequate industrial hygiene. This may be delayed by unwise palliative measures of a variety of kinds, including the present inheritant of a long line cf inadequate medical measures, but it will not be postponed much longer. I am concerned greatly for the position of the doctor in the interim. We need to be wise, socially responsible, and technically sound leaders cf thought and action in the development of a .sound industrial society. We cannot afford to be on the fringe of things and events, sticking to our little bags of tricks, in ignorance of the main stream of action and its consequence The therapeutic picking up of the bits and pieces of our industrial life, which seems quite capable of destroying itself, is somewhat like the attempts to eradicate malaria by treating those sick of it in an area in which it is ram pant. both because the therapy affects so little change in the situation, and ou-cauce. even in the individual case, a recurrence of the disease is almost KF 0003610 Dr. George L. Maison - (4) - May 13, 1955 certain. This doea not mean that the humane physician should not do what he can when and where he can, but it does mean that the wise physician will look to the best means of accomplishing his goal and will not let obstacles stand in his way if he can prevent their existence. With kindest personal regards, Sincerely yours, Robert A. Kehoe, M. D. References: J. I. II. 15, 321, 1933 J. I.K. and T. 25, 71, 1943 ,Occupational Medicine 3: 156 1941 RAK. e 00086 1 i