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    "label": "Letters Received, September 27, 1937",
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    "title": "Letters Received, September 27, 1937",
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    "seq": 2,
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    "ocrText": "INDUSTRIAL MUGIENE\nDIVISION OF INDUSTRIAL HUGIENE, NEW YORK STATE\nDEPARTMENT OF LABOR\nLEONARD GREENBURG, M. D., EXECUTIVE DIRECTOR\nReprinted from The Industrial Bulletin issued each month at Albany, by the\nIndustrial Commissioner of the State of New York, Vol. 16; No. 7. July, 1937.\nLEAD POISONING DIAGNOSIS\nLaboratory Findings Vary\nBY MAY R. MAYERS, M. A., M.D., Division of Industrial Hygiene\nDuring this period, laboratory findings may vary greatly\nIn a reaction to the pre-laboratory days when a diagnosis\ndepending essentially upon the ratio of the amount of lead\nof lead poisoning was made on the clinical picture alone,\nwhich is being excreted to that which is being stored, and\nthere appears to be a growing tendency nowadays to make\nthe rapidity with which these processes are proceeding.\na diagnosis of this disease on the basis of laboratory findings\nFinally a point is reached, where from an examination of\nalone-largely disregarding the clinical picture as presented\nthe laboratory reports alone without any knowledge of the\nby the patient, or seriously discounting it when laboratory\nhistory of the case, one would have no suspicion whatever\nfindings are negative. It is so axiomatic it should not be\nthat the patient had ever contracted lead poisoning. Never-\nnecessary to stress the importance of the clinical picture in\ntheless, the patient's symptoms may not have completely\nthe diagnosis of any disease-whether it be lead poisoning\ndisappeared. Indeed, the whole subsequent clinical picture,\nor anything else-at the same time fully recognizing the\nin all of its many ramifications, is to a certain extent un-\nvaluable contributions of the laboratory as an aid to diagnosis.\npredictable-being determined essentially by the extent of\nMedical literature is full of warnings to physicians not to\nforget the patient while pouring over laboratory reports\nthe original damage to tissue cells ; the extent and adequacy\nconcerning him. And more and more, there is a yearning\nof processes within the patient's body which make for cell\nfor the old clinicians who, because they had no laboratories\nregeneration, and the length of time occupied by these\nto depend on, became such keen observers, and interpreted so\nprocesses. Where complete regeneration of tissue cells can-\nintelligently the clinical pictures presented by their patients.\nnot adequately be accomplished, permanent sequelae, and\nThere is no doubt that the laboratory was never meant to\neven permanent disability, may result.\nbe a substitute for good clinical medicine.\nIt is particularly during long drawn out periods of con-\nHowever much this may apply to medical diagnosis as a\nvalescence or when symptoms recur after the patient has\nwhole, it has special applicability to cases of lead poisoning\nbeen discharged as \"cured\" that the clinical picture which\nwhere absorption of lead may continue for a long time be-\nhe presents may be extremely difficult of interpretation.\nfore there are any clinical manifestations of disease; where\nPatients very often continue to complain for a long time,\nprolonged or permanent sequelae may persist long after ex-\neither continually or intermittently, of pain in the lumbar\nposure to lead has ceased; or where there may be exacerba-\nregion, for example; of constipation or other gastro-intestinal\ntions of symptoms from time to time due to mobilization of\ndisturbances; of weakness or pains in the muscles of the\nlead which had been previously stored in the body. It goes\narms or legs, etc. The fact that laboratory tests in such\nwithout saying that in every case where there has been lead\ncases are often negative for lead cannot be regarded as\nexposure at any time however far back-where lead poison-\ndefinite evidence, one way or the other, as to the part played\ning is suspected-careful laboratory tests of blood and urine\nby lead in these complaints.\nshould always be made, and carefully evaluated. It has\nSuch negative laboratory findings indicate nothing more\ntaken years to stress adequately the importance of doing this,\nthan that, at the moment, toxic amounts of lead are not\nand it is not the intention of the present article to throw\ncirculating in the patient's blood. The patient's symptoms,\nany doubt upon the efficacy of this procedure. The question\nhowever, might nevertheless be due to a continuation of\nat issue is rather that of the proper interpretation of such\npathological processes initiated at the time he was suffering\ntests where they are either indecisive or entirely negative\nfrom the original lead poisoning-possibly aggravated at the\nfor lead.\nmoment by his particular tyne of work, or any number of\nThe Laboratory's Function\nthings in his daily routine. For example, a low-grade\nIn acute cases of lead poisoning the laboratory will be of\nperipheral neuritis which was regarded as having cleared up\ninestimable value in confirming the clinical diagnosis. In-\nunder treatment, might become aggravated by a subsequent\ndeed, laboratory evidences of lead poisoning are usually so\njob requiring heavy manual work. The \"cure\" in other\ndefinite in these cases that it often takes very little clinical\nwords was not as complete as was supposed. Or, a patient\nacumen to make a diagnosis. In fact it is often possible for\nwho had recently recovered from lead colic, and whose\na layman to do so on the basis of the laboratory findings\nbowels had just begun to function normally, after constipa-\nand a history of exposure to lead, without even looking at\ntion of long standing, may suffer from renewed gastro-in-\ntestinal disturbances as a result of having been suddenly\nthe patient.\nshifted from day to night work. Though essentially \"cured\"\nHowever, in cases recovering very slowly from an attack\nof his lead poisoning, his gastro-intestinal tract was unable\nof acute lead poisoning ; or where, in a patient who had been\nfor the time being to adjust itself normally to such a complete\ndischarged as cured, there is a recurrence of symptoms after\nchange of routine.\nan interval of time has elapsed; in cases developing subacute\nor chronic symptoms where there has been lead absorption\nOn the other hand, a patient who had apparently been\nover a long period of time but never an acute attack of the\ncured of lead poisoning years ago may return with symp-\ndisease, and other similar situations, laboratory tests may\ntoms entirely analogous to those from which he originally\nbe very inconclusive, and the diagnosis must depend, essen-\nsuffered, although there had been no exposure to lead in\ntially, upon a proper clinical appraisal of the whole medical\nthe interim. Is this patient suffering from a recurrence of\npicture. It is in these cases-and they are very numerous-\nthe original lead poisoning due to a new mobilization of\nthat there is an unfortunate tendency to lean too heavily upon\nstored lead, or has he developed some entirely different and\nthe laboratory for information which, though ever so much\nunrelated disease? The laboratory may or may not throw\ndesired, it cannot possibly supply.\nuseful light on the question.\nIt is well known that while lead is actively circulating\nMost Puzzling Situation\nin the body it will, if present in sufficient quantities, cause\ninjury to tissue cells. During this period repeated examina-\nBy far the most puzzling situation, from the standpoint of\ntions of the blood will usually show a considerable number\ndiagnosis, arises when laboratory reports-one after another\nof stippled cells, and abnormal amounts of lead will be found\n-show \"occasional stippled cells,\" possibly no more than\nin the urine. When there is no further exposure, however,\none or two per 10 fields examined, with or without a very\nabsorption ceases, and the lead which was originally present\nslight increase in the urinary lead excretion. This situation\nin the blood is gradually either stored or excreted.\nalmost invariably leads to the practice of repeating the"
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