Document 0LykEY8z1VwxNrKznJKa5rzzJ

FILE NAME: Saranac 7th Symposium (SSY) DATE: 1952 DOC#: SSY026 DOCUMENT DESCRIPTION: Transcript of Presentation by Dr. Bristol v t W ill proceed to the f i r s t p ap er on the program by D octor Leonard B r ia t o l, on the inciden ce o f c l i n i c a l l y a a n ife a t d i f f u s e o b stru ctiv e emphysema* Doctor E * ` s t o l * BY DOCTOR BR ISTO Lt D octor McCann, L a d ie s and Gentlemen o f the Sympos-j iu as I should lik e to s ta te a t the o u tse t th a t th is is a prelim in ary r e p o r t. I t i s a combined >tady o f the D epart ments o f P h y siology , the R adiology o f the Trudeau Founda tio n and the p h y sio lo g ic a l d ata in th is paper has ben c o s p ile d by D octor George Wright and h is s t a f f . I should li k e to have i t c l e a r l y u n d e rsto o d th a t my p a r t in th is work was that of a ra d io lo g ist* The word emphysema i a d e riv e d from th e G reek and l i t e r a l l y means a blow ing. S t r ic t ly sp eak in g, i t ia defined a sw elling produced by gas or a ir d iffu sed in a c e llu la r t is s u e . I t i s a term o f broad g en eral meaning and, th e re f o r . , when i t i s employed f o r d e s c r ip t iv e p u rp o se s, one must d efin e c le a r ly Wist is meant by i t s u s e s . I h . c l i n i c a l d ia g n o s is o f ch ro n ic pulmonary emphy sema la n o t a l r p l a to --aka. no p h y s ic ia n sh o u ld h a t . d l t - j f i c u l t y 1= e a ta rn ish in g a d l a g n o .l . o f f a r ad .an o .d emphysan a, hut I t r e q u ir e s tho most keen c l i n i c a l In sig h t to d l ! ag n o s. c o r r e c tly a m ild to moderate emphysema. A la r g e ! p ro p o rtio n o f moderate emphysemas are overlooked w hile - I cases so d ia g n o se , are not confirm ed by p ath o lo g ic etudy. M Sj In * recen t p u b lic a tio n , Fem on s t a t e s * There i . no c o n s is t e n t r e la tio n s h ip between th e c l i n i c a l s e v e r ity d if f u s e d by l a t e r a l pulmonary emphysema and the e x te n t o f the p ro cess seen in n ecropsy. T h is, in g e n e ra l, has been our e x p e r ie n c e . H i s t o l o g i c a l l y , pulm onary emphysema i s a co n d itio n in which the a lv e o la e are d isten d ed , d is to r te d an^ in t e r r u p t e d . Continued a i r s a c s w ith in a lo b u le may c o a le s c e and a d ja c e n t lo b u le s may f u s e to form l a r g e a i r s p a c e s . Ai a r e s u l t o f t h i s , the t o t a l r e s p ir a to r y su rfa c e i s re duced and th e pulmonary c a p i l l a r y b e d i s d im in ish e d . The pulmonary e l a s t i c tis s u e i s frig h te n e d and ap p ear, to be reduced in amount. I t i s . u p r i s i n g th a t on. o f the c h ie f c l i n i c a l and p h y sio lo g ic a l f e a t u r e s , nam ely, a i r w ith an o b stru c tio n , h a . n ot, w ith the exception o f a rsc sn t papsr by S p ain and Amberson, been d e sc rib e d by h i s t o l o g i s t s . The term emphysema as u se d in m edicine i s v ery .c b lg u o u , and a . - 1 . fa r too o fto n amploy.d l a a a r j lo o a. r . ---- - Therefore, i t l a lm peratlTO t h a t . th in k c l e a r l y ,, to - h a t 1 . n ean t Whan - a - a . I t . S . v e r 1 v a r l . t l . a o f | t i l , c o n d itio n a rc roooBn lt o d . 1 a l n p l * hut a . t l , f a c t o r y , c l a a a l f l o .t l o n h a . bean d ev ised by Buhln - I hare th. | ! f i r s t s l i d e , ploaae -- aa fo llo - a i j Obstructive onphjacma c a u a c d by m echanical I n t e r - , ; fe r o n c . -1 th r e s p i r a t o r ,. Th. a u b d lv l.lo n . ho n o .th th a t, ; 1 as , ou aca i t , arc chronic hypertrophic bulbous f ,rna, 14-86. w o , common o b . t r u . t i TM -- hy-- " * d by b l '=r " t l o n ' ln th . thoraclo W l t o h ..t. referred to - ^ * Ipand " fU 1 * b " " 1 - 1 1 . or p o .tu l. W " -- I n W r . t l t l * emphysema e o n d llio n c h a r a c t e r is e d b y t l . m trauma or th . lo n g .; ro r compensatory - b y -- , *> ** * u. ^ vv,p h y s ic a l . d a r e . -- 1 r tt<> to most anatomic ra a d * tuatm ent and In creased fu n c tio n a l demands r e c i t i n g f r o . 1 os . o f t l . . u . u d . TM , 1 r0rM f OM oostpon.nt u .u a lly b ein g predom inant. i t t h l . tlm a , -- b y -- W d" * l0p ,Ud,1' n l7 * , slow ly and 1 . uauaHT b l - l . t a r d and g e n e ra lise d . T hl. - d lt io n msy o ccu r ln d .p a n d .n tly o f any pulmonary d l-- a a . ,, a c o m p lic a tio n o f lo n g -- d in g b r o n c h ia l ............... o r may b . a a .c c la tc d w ith other d l . . . . . . or - d fc m .a U c n . o f th . lung a or ch*t* F o r p u r p o ... o f d l . c u . a l o n I n t h l . p a p e r , we a h a l . u l t our oemel d eratio n to d l f f u a . o b .tr u c tiTM - * > - f o r t h . eh o n rle h y p e rtro p h ic fo rm , The a a l l . n t c l i n i c a l fe a tu re of which 1 . alrwey o h e tru c tlo n . bh ateyor th . * - stru c tiv e agent, tbs mscbanica of th is condition are ^ that a ir entering th . lung during ln .p ir .tio n 1 . .r .p l . w ax o lratlo n , the d iffic u lt y in turn with d if f ic u lt y during e* ? l r maximal b re ath in g c a p a c ity , a high r o - le ad s to a reduced maxima 1; s id u & l a ,i r and. ,inn li tt8s aaadvvea-nu ced s t a g e s , to a r e t e n t i o n of carbon dioxide in the lun gs and h y po xia. Tiwaa p h y sio lo g ic a l date can be rsco rd ad accu r a te ly in r e la tio n to an in d iv id u a l., to ta l re sp irato ry ca p a c i t y . I Bhoya& l i k e to p re se n t a c a se o f c l a s s i c d i f f u s e truotur.1 p h y s.m .. T hl. .U d . l " fo11 l n . p l r . t l o n and f u l l . x p i r . t l o n , t h . p r o m o tio n on y r l o f t b ein g t h . ln .p l r .t l o n mlerogram .n d th . on. 7 ur r ig h t in fu ll exp iratio n . I .h o u ld lik e to d ire c t your a tte n tio n to the la c i ,, r r l . o f th . d l.p h r.gn . In th . w l r .t o r y film nd th . m i n r . o f t h l . p . t l . n t t o empty h i . lu n g , on p l r . t l o n . m . I n f o r a . t l o n to b . g .th o r o d fro n t h l . . U d * 11 * * * tb* p . t l . n t l u . . low ~ x l u = b reath in g o p a c i t y .n d . h igh er r e s i d u e . I n . W. h a w p r . d l c d m x l m ^ h r . . t h l n g . > . e l t T Of tu.nty-tw o l i t . r . p .r m lnut. . t d.W rm ln.d t h l r * - o = .i r..ld u ^ L . l r , p r .d lo fd 1.36 *d d .to im l.d 1 .9 T h . d . f on t h l . . U d . .how . t h * t t h . p . t l i t h a . ,, . l . v . t M t o .rb o n d l o x l d . ocm tont, an .b n o r m l l y low hemo g lo b in sa tu r a tio n with .0 2 . T h .r. 1 . - PCCt ^ . low P02 . B . . . . -- " -- 01 " r '' 411 ^ l " d V" U * | la tio n o f the blood, i ! D i f f u s e o b s t r u c t i v e p b y . . m . 1 . hnown to b . o n . of th . com p licatio n , o f .U lo o .la . S l^ lo d l.c r o .t nodular | O illoooi. 1 . seldom ^ . o o l a t . d w ith c lln io U ly m ^ lf a .t d i f f f u s o O b s t r u c t iv e em physem a On t h . o t h . r h and, con f o r . 1 s i l i c o s i s 1 . a lm o st always coo U catod by d .,r.a of U-88, obo t r u c t lv c s e p h y s c . *> * * " " ^ tM t chronic pulm o.-ry empny.em. I - ' -- " d l " " lndl' ; a u d who h u d i s c r e e t n o d u la r e i X l c o s i s , b u t r a i s e . a s W I t s u n d e rly in g cau se when the two a r . . . s c o u t e d . ( I . I t d ir e c t ly r e la te d to the pulmonary d e p o sitio n or q u arts or 1 . I t e n tir e ly Independent p r o c e s s , Hnphysesia h a. been b i a s e d to be a c o a p llc a tlc n or a .b .s t o .l . . m t . problem -111 be d isc u sse d by Doctor G reg o lre. Bphysems 1 . s l . o s i e g e d to be cau sed by * . R a t i o n of c o a l d u st. R h y s e s - h as been observed In S i - u l s r b .r y lllo - w o rk e rs, b u t I s by no a e s n . U - s y . Pr " o n tobserved In person, , * to .11 -- E" ph7S" " r or !-- t duet end son . go so fa r a . to a ss o c ia te th ese In e rt d u st. In a eausal relation sh ip* Ko , to e s t a b l i s h a c a u s a l r e l a t i o n s h i p betw een emphysema and the in h a la t io n o f any f o r e i g n n a t e r i a l , r e q u ir e s the d em o n stratio n o f a h ig h p re se n c e o f empby ln fchos. so exposed as in a s im ila r group not so exp o sed . tfe p ro p o se to e x p lo re the q u e s tio n o f w hether on o t th ere i s a h igh er in c id e n c e o f emphysema in th o se ex posed to the in h ala tio n o f In e rt dust than in those not so exposed, in an attem pt to prove or d isp ro v e a c au sal re atio n sh ip between such in e r t dust and the development of d if f u s e o b s t r u c tiv e emphysema* 11 _ _ Q r * -t-'n i urn nm it it-89. i o c i d .n o . o f a . p b , . . . . 1= * * " * " d n" ' dU ,t7 W . mentioned b e fo re , d i f f u s . d b - tm c tlc . l t d i f f i c u l t tc a la g n o .. by mean. o f h isto ry or p h y s ic ^ .lam ination, .t c .p t in advance. caeae. H .n c, i t is iw -- . t l v . t h a t we lo o k f o r n o r . r . f i n d n o th o d s. in r e c .n t y e a r s , c lin ic a l p h y .lo lo g l.t . have de- T l. . . . . u r a t . te c h n iq u e s in t h . stu d y o f . n e e d and abnormal fu n c tio n , o f th . lu n g .. I h . . . rlo u a lu n g func tio n s t u d ie s o ffe r a method of a p p r a .in g pulmonary d l .a - b l l l t l a . o b je c tiv e ly . I f V. again r . f . r back to our o rig in a l o a s . whleh, a . you - i l l r . o a l l . - a . th at o f a p . t l t - l t h d i f f u a . O b stru o tlT . amphy.ema. i t - i l l b . s . . n tna th .r o . . . t h . p r . . . n c . o f a 1 maximum b r e a t h in g c a p a c it y . T h l. t c . t en u re. t h . maximum volume o f a i r th a t can b . breathed in a unit o f t in ., fb . P . t l - t 1 resid u al o f a ir . T h l. rep resen t, th . mount o f a ir rena - !ng in th . lung, follow ing a naninal resp iratory .f f o r . ^ I s o , th e re was a r e t.e n t io n rotfr' carbon dLioxxd and hypoxia* O b vim i.l,. i t 1. l ^ r a c t l c a l to enploy * " aethoda in undertaking a study o f a larg e s e r ie s o t t h t a la . T h erefo re, wehav. attem pted to find a n o r. prac- t i c l p r o c e d u r e . Tho maximum b r e a t h i n g c a p a c it y 1 . known ' * , . . . , lr that can be ex- to correlate h ieh ly w ith the c o lo n , o f a i r th F p olled in a unit tim e* G e n sie r h a . ahown t h a t the maxlnun b r e a t h i n g ^ no J20* c a p a c ity c o r r e l a t e s h igh ly w ith th e volume o f a ir e x p ire d In one s e c to r . In a sim ila r study c a rrie d out in cur phyalo lo g y la b o r a t o r y , V rig h t and h i s co -w orkers found t h a t the volume o f a i r e x p e lle d in e ig h t ten th s secon d fo llo w in g th e begin n in g o f the m ost ra p id e x p ir a tio n p o s s ib le , c o r re la te d w ith th e maximum b r e a t h in g c a p a c i t y o f *7 5 8 w ith a s t a n d a r d e r ro r o f .7 5 0 . I t w ill appear from these stu d ie s th a t the a ir ex p elled in e ig h t seconds durin g such a maneuver and h e re a fte r re fe rre d to as E2, i s to a lim ited ex ten t a sub s t i t u t e f o r th e maximum b r e a t h in g c a p a c i t y t e s t i n m ass s u r v e y s * May I h ave the n e x t s l i d e , p l e a s e * I t w ould aPPT lo g ic a l th at the enclosed area w ithin the silh o u e tte o f the th o r a c ic cage a t f u l l in s p ir a t io n would b e a r a r e la t io n s h ip to th e t o t a l volume of a i r w ith in the lu n g , th a t th e s ilh o u e t t e o f the th o ra c ic cage a t f u l l e x p ir a tio n would b e a r a r e la tio n s h ip to r e s id u a l a i r . The p o s s i b i l i t y o f u sin g th e r a t i o b etw een t h e s e two a r e a s i s a s u b s t i t u t e f o r th e a c tu a lj r e s i d u a l a i r t o t a l volume r a t i o , h as o c c u r re d to s e v e r a l In v e stig a to rs* On t h i s s l i d e , a - 3 r e f e r s to the a r e a a t f u l l e x p i r a t i.o n anda Ai -il t o iie a r e a o f f u l l i n s p i r a t i o n * In 1933, Gertado and h is co-w orkers showed th at the-a .= a lg n ific a n t c o r re la tio n between r e e ld u .l a i r and t o t a l volume r a t io and the are a en oloaed w ith in - a th oraolo p o r a g s. on a f l t a takan a t f u l l a x p lr .tio n , pro- Yid.d th at - in a . t a l l - -- f u i l ta .p lr a tlo n . FIT . ye(u. . 1 . W , in anoth er oom nunlc.tlon, h . . t a t . d th a t con- tr a x j to p reviou s r e s u l t ., the c o r r e la tio n between the r a tio , a r e . a t naxtaun exp iratio n divided hy -- * * " * 1,, in s p ir a tio n and . sextans, r e s id u a l U r d iv id ed by to t a l c a p a c it y , was low - 1 t a e l g n i f l e e n t . b u t no e x p la n a tio n o f th is state m e n t e v e r made* Kay I have the n ext s l i d e , p le a s.T R soantly, o e o r s . W righ t has a tu d le d two hundred end t h i r t y - f o u r e a rned showed a good c o r r e l a t i o n o f the r e s i d u a l a i r t o t a l volume r a t i o with the a r e . o f r a d io lo g ic a l I n s p ir a t io n , e r a . o f ra d io lo g ic In sp ira tio n , the c o - . f f l c l . n t bein g .772 and a stan d ard error or .0 2 , snd the rem in d e r o f th is p a p e r , t h i s r a d i o l o g i c r a t i o -1 1 1 be r e f e r r e d to a . A-- A T h is 1, the re g re ssio n form ula showing th a t high c o rre la tio n o f stock th a t Wright o b tain ed In t h i s stu d y , you w ill n o tic e In the righ t-h an d c o m e r Is narked 13k o ases t u t s in c e t h i s lamp s l i d e was n sd e , he h a . s t u d ie d a hun dred n o r ., making a t o t a l o f 23k c s s . . . f r o . th is re g re ssio n fo r m a l., - e can . . . th a t there i s a high c o r r e la tio n between the a r e s e x p ira tio n end area of In sp ir a tio n , with the P - - centage o f re sid u a l a i r . j / Nov, t h i s l a n t e r n s l i d e r e p r e s e n t s a f u l l _________ j_ kaz* e x p ir a t io n o f a norm al h e a lt h y m ale . The a r e a o f the f i l m , the a r e a o f the f i l m on y o u r r i g h t i e r e f e r r e d t o a s A-3 and the a r e a o f f a l l i n s p i r a t i o n on y o u r l e f t r e p r e s e n t s A -l. These measurements a re determ ined by a c lin im e te r and you can se e the t r a c i n g s w hich have b e e n made e s p e c i a l l y on the e x p ira tio n film , to determ ine ffcm th ese t r a c e s . The work we w ish to r e p o r t on t h i s m orning r e p r e s e n ts a stu d y o f 713 men in the G en eral K L e o tr ic p la n t in Schenectady, by msana o f in s p ir a tio n and e x p ira tio n f i lm s and measurement o f maximum e x p ir a t o r y v e l o c i t y . The men s t u d ie d made up t h r e e d i s t i n c t g r o u p s, one, a l l b u t two of those cu rren tly employed in the iro n and s t e e l foundry, or 237 p e rso n s; a l l b u t e ig h t o f th o se c u rre n tly employed in the p p ro elaln d iv isio n or 193 p erso n s; w orker, from the to o l and dye and punch p r e s s d iv is io n s , 229 p e rso n s; these i s s t were chosen by random sam plin g, b u t were allo w ed to refu se i f they did not want to p a r tic ip a te in the study. F i f t y more men from s a l a r y p e rso n n e l were a l s o s t u d i e d . H ost o f th e se have been employed more o r le-* s p o r a d i c a lly than th e l a b o r i n g group o f the d l r l s l o n e men t io n e d . The n on -duated g ro u p , a t the earn. a g . a t t r i b u t i o n . . d id the du cted g r o u p s. Bach man h a d the fo llo w in g stu d y t R oentgenogram , w e r. made on a fo u r b , f i v e f l a t f ilm the film , taken a . f o llo w .. One, f u l l l n .p l r .t l o n , two, fou r ten th s o f a Becond a f t e r b e g in n in g of the m ost r pld IP expiration p o te ib le ; th r ... .is M r ` " <1 , f t * r th . beginning o f th . n o .t rapid ex p iratio n p o .a lb lo . and fo u r, in f u ll ex p iratio n . w. a n * not re p o rtin g on th . four te n th , o r e ig h t tenth. ...e n d . f lln . at t h l. tin e . A ll P -- " . t on. tenth o f a ..c o n d , The k ilo w a t t, and high a n p e re . b ein g .lig h t ly over exposed fo r the f l l n In th a t p e rio d . Th. e x p ir e d a i r wea cau gh t In a a p lr o m .ta r l t h two i n d i c a t o r ., on. o f which v a . .to p p e d a t e it h e r fo u r tenth, or eigh t tenth. ..con d a fte r etp lratlo n -- beau t. The o th er r e g la t e r e d the f u l l r l t a l c a p a c it y . Th. w o l o f a i r blown In to t h . ap lro m ater during t h . fo u r tan th a or a lg h t tenth, .eoond period 1 . c o n .ld a r.d to be r .p r e .a n ta U W o f u l - n e x p ir a tio n t e l o c l t y . The maxlntn. b r e a t h in g capacity v aa measured in 233 o f the 713 asn * The fo llo w in g d a ta have been c a lc u la t e d r e g a r d in g th e maximum e x p i r a t o r y c a p a c i t y . The f i r s t th r e e l i n e a re p resen tativ e o f - define our sym bols. K -l eq u al* volume o f a i r e x p ire d in fo u r ten th s o f a second a t the f a s t e s t e x p ir a t io n p o s s i b l e . E -2 r e p r e s e n ts th e volume o f ^ r expired e ig h t ten th s o f a second a t the f a s t e s t e x p ir a tio n p o ssib le and E-3 v ita l capacitT at e x p ir a t io n p o s s i b l e . BE e q u a ls ih e c o - e f f i c i e n t oc c o r re l a t i o n . How, l d l i k e to draw y o u r a t t e n t i o n to t h i s l i n e hero, ap p aren tly S-2 c o r r e la te , h igh ly and b .a t -1 th the .e t u a l maximum b r e a th in g o a p a o lt y . T hle le e l l t o e n ere s i g n i f i c a n t -h e n one r e a l l t e . t h a t w. - r e a to d y ln g a group o f ln d lT ld u .1 . -ho are alm o.t n on tol f r o . to . atto d p o ln t o f t h e i r maximum b r e a t h in g c a p a c i t y , * a I n d ic a te d p , t o . f a c t t h a t t h e ir mean maximum b r e a th in g c a p a c ity -- 135 l i t e r , p e r minute and t o . median W > l i t e r , per m inute. I f - . had had a la rg e r proportion o f p .ro n . - lt o a patho l o g i c a l l y l b - maximum b r e a t h in g c a p a c i t y , we p ro b ab ly uould hare had to .te n h ig h er c o rre la tio n e o - e f f lo lt o t . I f one would a c c e p t the contention th at the E -2 l t a f a i r l y r e p r a a e n t a t i r . m eeau r. o f t o . maximum b r e a t h in g capacity o .p .o la lly fo r group .t u d l c , on. cto d a r lr . f -- t o e r in fo r m a tio n from t o . .t o d y . On. hundred to d . l x men t a d a maximum b r e a t h in g o a p a o lty th a t f i l l - l t o l n o n . atamdtod d e r la tlo n o f th e ir p re d icte d normal fig u r e , and a hundred tod a ix ty f e l l - l t h ln too .tto d a r d d e r la tlo n .. * mean E -2 f o r t o e hundred and a l l men - a . 2 .9 3 d l i t e r . , and fo r the hundred tod a ix t y men, l t - a . 2 .8 3 6 l i t e r . . One may, th u e , ta k e the f i g u r e o f 2 .8 3 6 l i t e r . a s th mearn. Ew- 2? if o rr *a Kg ro u py o f men who h are norm al maximum breathing cap acity . Of th e e n t ir e g ro u p v h ^se maximum b r e a t h in g c a p a c i t y w as m easured, 32 ^ v e v a lu e s o u t s i d e the ra n g e o f n o rm al, t h a t l e beyon d to o s t a n d a r d d e v i a t i o n . on th 1 - ,A2 14. . naan a x l= u b ro ath ln g o ap aclty o f t h l . low group elgh ty -aigh t l l t o r . p .r -H TM * and th a lr .198 l l t o r . , in oon traat to th . n om al group. I t 1 . int th a t t h . E-2 w ill d l .e l o a . th . p ro .o n c . o f . low m axi- mm b r e a t h in g c a p a c it y * I f one s t a r t s w ith th e p re m ise th a t th o se mean , l t h . normal breath in g - B **i*> fro .th ln g o l t y , th at 1 . w ith in two .t a n d a r d d e v i a t io n , o f th o lr p r o d lo t a d , oom- p r l.a group vhloh 1 .. . * ^ bo an E - 2 p l u . two .t a n d a r d d . v l . t l o n . an d t h a l r th* ,` A. 3 U - 1 r a t i o p i n . two . t e n d e d d . v l . t l o n . o n a con trol fo r comparison w ith other groups mean maximum b r e a th in g c a p a c ity o f 160 men# w ithin t a tandard d .v l.tlo n . o f prodlotad, oovarlng n ln a t,- f i v . p aro an t of th o lr group, 1 . 139.97 l l t o r . . and 1 * poroaut o f prodlotad v alu e .. Th. 8-2 o f th l. g r ~ P 1 . v ith the stan dard deviation o f *551* g o i t . l i d o , p le a a o . FTon th lo d a ta , 1 I t - ! ! . . . n t h a t t h . n o n . E - 2 o f t h . . . 713 *> > ',* 11 " lth t b . moan E - 2 o f t h . 1 6 0 non whoa, naan maxlBUB b r e a th in g cap acity uao 97.17 p a r e n t o f pro d lo tad v a lu o .. Th. only e x c e p tio n waa In t h . Iro n foundry group and t h l . d l f f o r .n o . . . . only a l i g h t , tho d if f o r a n o . b a ln g .161p which 1 . H g t t - ty ic e th . .tan d ard e rro r o f the d i f f e r e d . . IV more than twice* uu OP t h e r e f o r . , th e re l a J u a t a a many p a t h o l o g i c a l U-96, ! - 2 . . in a l l g ro u p s, and in s o fa r as E-2 c o r r e l a t e h i^ ily w ith maximum b r e a th in g c a p a c i t y , w can s t a t e th a t th e r e aw ju a t a s many p e o p le w ith low maximum b r e a th in g c a p a c ity in the non-dusty trad e s aa th ere are in the du sty tra d e s. The n e x t q u e s tio n we must a sk o u r s e lv e s i s what i i the p e rc e n ta g e o f men w ith in the v a r io u s grou ps who f e l l below two sta n d a r d d e v ia t io n s o f the mean B -2 of 2 .8 3 6 . s l i d e , p l e a s e . From t h i s c h a r t , we can se e th a t th e re was one out o f f i f t y - s i x in the s t e e l foundry or 1 .8 p ercen t, f iv e p ercen t in the iron foun dry, 31 p ercen t in the p orce la in d iv isio n , $ .8 in to o l and dye, 8 .3 in P*neh P TM 9 ,3 in s a l a r i e d p e r s o n n e l. There were a s many men in th e n on -dusty t r a d e s who f e l l below two s ta n d a r d d e v ia tio n s a s th ere were in the dusty t r a d e s . This dem onstrates q u ite <o n clu siv ely fo r the grouj s t u d ie d , t h i s , t h a t th e re were a s many men, i f n ot m ore. In the non-due te d group who have a below normal B-2 a s t h a n are in the dusty o ccu p atio n s. B a x t s l i d e , p l e a s e . The mean A - 3 * l - l o f a x p lr .tlo n o r r . . o f In sp ira tio n , from tl t h a t L* " ** * ra d io lo g i c a l fllm a . from too film s o f tho.o non H aring a normal *a*im u H r..th in g cap acity . la .615 lth a atandard S a n a tio n o f . 05? . Sow, i t 1 . re a ao n a b le to ...u r n . from t h l . in fo rm a tio n , t h a t t h a r . 1 . <-- 1 - c r . a a . In ro o ld o a l l r In foundry tod p o r c e la in w o r t.r a , h u t not onough to o to .a jfflj . red u ction In th . E -2 , and *7 l n f . r . n c , th . . ! - * h r.a th ln g c a p a c ity . Th. nunbar o f ~ n In t h l . sroup vho hay. . p .th o lo glc.1 1-3. 1-1 - t l o . in o th .r orda. nor. o .tu rn e d don ation , fr o . th . .n of noral " . l a dem on strated on the n ex t e l i d e . The e t e e l fo u n d ry , 7 .9 p e r c e n t; Iro n fo u n d ry , 5.8 p a r e n t; p o r c .l.ln d in .lo n . S.9 p a r e n t, tool * d j.. 1 .8 p a r e n t , punch p r a . . . 5 P - e n t ; a a l a r l .d p .r .o n n .1 . 2 p a r e n t . H e , fr o . th l. v . can read ily . . . that th . nu.e r o f .a n m o h e . an l n c r .a ..d r . a l d e l a i r 1 . .U s h tlT higher In th . d e e d T .ra u . th . n o n - d e e d g ro u p .. low , in con clu sion , I should lik e to eay th at thli h a. been en e x p lo rato ry study mad. in an e f f o r t to obtain Information a . to th. d egree of emphysema p r e s e n t In e . r t a i n o ccu p at,io n s. Tmhvwe. Ev-2? oorf ^a l l Fg ro u*p s was ap p ro xim ately th e sam e, and. the Aa 3-?*tAX-Al r a t i o in the foundry and p o rc e lailn d iv is io n s dep arted only s l i g h t l y from th a t ,, ,, u p of .a n ..p lo y ed lh th . n o n -d e ty t r a d e . * _ h a. a high co rrelatio n u lth - a * - h re th ln g capacity the A-3x A ll r a t i o c o r r e-il a at.e._s hv<iicgyhVliiyT w ith r e s i d u a l a i r , - o+nHiaa in maso survey w ill i t i s easy to assume th at tnese stu ren d er r e l i a b l e in fo rm aat.io n a .. 4t-o0 tthhee qquu a n tityJ o f emphysema p resen t in any p a rtic u la r group. T h e . e t h o d . fa ile d to e e l *ny " f s ig n if ic a n t change econg th . m l o If 14-98, i B * p ,,lm on .ry d .p o .i t l o n o f d u .t 1. t h . . a w * o f on ! " " m th . ln c ld .n o . o f c p h j.. a . th .n on . would * . f r < toi . ln T .itlg .tlo n , to fin d I t c l.u cly d .*o n .tr 1 > l.. th . a l f f . . n c . b o t w ..n t h . two g r o u p , . t u d l . d , . o h . d l f f . r - nc was n o t a p p a re n t. in o lo .In g, I ihould I lk . to r . l t . r . t . that t h l. 1 . . p r .lin ln .r y r .p o r t and thnt th . In forn otlon to d . t . .U g g .c t . th a t t h .r o 1 . 3 u .t . . mch . n p h y . . . In t h . nonduotry tr .d a . . . In th . du.ty t r . d . . . ThuJc you. (A pplause)# BY DOCTOR McCAKSt Doctor B r l .t o l * . p . p I>*" f r 1<,B* BY DOCTOR BZNKBTT: Doctor Bennett, . W rk S t . t . W orincn.. C o c .n - ..t l o n H e r d . X h . l l . . . th . p a p and th . p r ...n t .t lo n Of i t . b l o . t t l . t l o l d a ta .h o u ld h . . . h .d th . a g . g r o ^ . r s f . r r o d t o . b . c a u . . t h l . may o l l th. u n lT .r.al . t . t l . - t l c . 1 com putation, namely th . .tu d y o f p b y n * In t P . d . . . Ho--. T . r , t h . a g . group 1 . an l n p o r t ^ t t h in g . BY DOCTCr. McCASgt jtro th e re any o th e r conm entsf D octor Hugh-Jon* BY DOCTOR HUGE^JONES: Bn. c h .l n .u i , I would I l k . to o o n g r .t u la t . Doctor W l g h t .no D octor B r i s t o l on t h l . - on t h . l r work. On. of the very d if f ic u lt th in g ., ln d c.d , 1. to fin d p r a c t i c a l . J9 3 i ft. on. c = . m . n .H . - 4 t n .,T . n* .on . thing -h lch 1. .x c d i n s l y d lfflo u it to do, -- ,, rin d . a u lta b le contolnatlon or th in *. t= d a ft a . P * = i - Og l 0 a l ! . . * T a v . a . t ab o u t d o in g a o n .th ln g othor p .o p la . alm llerly triad to do, and on. or * d i r n o u l t l .a h a . boon a lu e y . in l . t l n g group o to d . f l n . a p a r t ic u la r .yndroma, I f I l k . , m t h l . c a a . ^ " ' . o . , on. or th . d i r r i a u l t l a . 1 . th a t .th o u g h yon w g . t a h ig h . . r e l a t i o n o f any on. f t . union t u n a t .ly . th. .m on Of pradlctlon 1. r y Could I ~ m t . 1 . 0 - l i b th . blackboard! I f you h a t. a r.la tlo n a h lp P b a t . . n OO. r u n e tlo n .uoh a . , a h a l l uhlch thoy dam onatratad, .a y , a maxi-- roluntany ..n t l l .t l o n and th . t in . o f 1 ton than you w ill fin d a o artaln a ta tle about Y ^ tal * th# r e g r e s s io n l l n * . U n fortu n ately , I f th . c o m .la tlo n 1. lou or -- a . high a . .7 . h .n you p r .d ia t on. Iron tha E. t a h ig h s c a t t e r ab o u t t h l . I f . - - . h a r a t l a d to uonk * - -- t h l . d l f f l o u l ^ a . t 1 . a ta t la tlc a lly , a d l.c r ln io a t. funotlcn i * t o us wfaat 1 # i ._ 0f t e s t s t o maximize s_ and t h a t i s to combine a s e r i e s o f t d iffic u lty or a differen ce. I d o n 't know wHheatthteerr I1 cc aann mate my p o in t c l e a r , but if you v i l - acceDt for accept r a moment th a t th e c l i n i c i a n can ^ _________ __ ___ ____ ______ d.rin. gross ..phy-eme - oop.r.d with the n o TM i . and Doctor Bristol ad.quat.Xy d.sdried that a. a possibility, teo you osn taka tb. different ts.ts, for a w l . , thay give esdju Tsntllatlon, r.sldusl capacity. Co.,. or th. ta.t. prodieted fro. the., end find abet Win.tionlt ,,lght be,three t i e . the predicted H. B. C ,, pie four tl... th. predicted reside! ospe.lty fro. error of th. file, * get a statistical function which mudmlsee the Cheng. fro. normal to abnormal When t h a t I s done, you e n o r .o u .ly ls ip r o t . th . d i f f i c u l t i e s o f a n , o n . t e s t b e in g . l a m e n t , and X would su g g e .t th a t a . a mathod In u sin g these p red icted t e s t s . YOU can g e t a d is c r im in a t e fu n c tio n which g l e e , the m e l e m d iffe r e n c e In accep ted n o r e l and . . t r e e emphysema, a=d then apply th at in th . f ie ld to t h . . . other th in g ., using the sim p le p re d ic te d t e . t s , Thanh y ou . b y TWTTOR WeCAKNt Are th ere any oth er comment.* Doctor F le tch e r* BV ryy.TOR FLETCHER? ! Ju . t want to aek two simple q u e stio n s. X . a l s o i n t e r e s t.e d^ itnn tthn ee aaggee e" t a n d a r d iz a t lo n . w hich, o f cou re .. I perhapsis n o t v i t a l , you d id t e l l u s t h a t some men w ere 1 - v e in<y t e s t e d , b u t you d id n t a llo w e d to s t a n d down from b e in g , ; t e l l u s tn e p e r c esannttaagzee oo if th e t o t a l p o p u la t io n th a t took advantage of that p r iv ile g e . __________ . JSoi, oth er s n a il p o in t 1 would J u t m * l t J0Ur e t e t .n .n t t h .t . . f - . * -- " " n S" " ;- that fib ro sis 1. elw .y l s " d '*lth q u ite . cowaon ... d e l e t i o n , b u t not 1 J . . Whi b ' | BY tw ".TOR HUEPSHt wl^et wee the le b o r tu rn -o v e r In th e v e rlo u e grou JOU t e e t e d t I th in k In d u e t* o c c u p .t lo n e . ro u ehould . - u e llj heve your higher turn-over end, th erefore, ehorter exposure tim e. I f ydu n s t e tls t lc s thet ! T ,rr b eau tifu lly . b y DOCTOR HERMAN I ^ ^ -- ^ n e ra e t .t e .e n t we. med. ebout d u .tr dedu c t i o n . . Bo thing . . . .e ld .bout the degree o f d u .t l n e ... extreme d u s t in e s s , any comments to he . nY DOCTOR McCASNx ^rvy o t h e r conm entsT nDooootwo rr B risto l# & would you lik e to answer these q u estio n s? t^v DOCTOR BRISTO L: I s h o u ld l i k e t o have D o c to r Wr g anawer th ese q u e s t i o n s # a s he i s i n a B e t t e r p o s i t i o n to do so th a n I aa. Doctor W right. a 0 2 S a i ^ ' . l l r i g h t . The q u e s t io n , neve .1 1 b e e n . t or co u rse, v err p e rtin e n t. P o .to r B r is t o l took - - * > ' f! to sa y t h i s i s a p r e -liMmminlnaarryv rr e pp o r t and__whe_n___th__e__f_i_n__a_l_ v- ^02. ,, P,, r t u * . . - - *>-- -- - u i b- 7 1 " !: ln p articu lar to. on .. th . d t " P" " " * " " * ' bop tu rn -orer. H. l t b . r o r t o o . . h a v . boon t o . . u b j . o t o f . . r u t , . . x . t B a t. 1 * a v a lla b lo and 1 . to to . p r o c ... of >.- in , T .t . *" . u rp ing looted a t . I an -*7 " * to . to r n^ ,, o r . . . I d t m p t o d to * y to . v a a t n .J o r it y in duaty t o a d ... th at bad b ..n to - * * - * m . , th irty y .a r a . I to -- riT . , w * * V SbUr^ ' '* * T 4 t t i. ware inform ation on i ,, to . au d l.n c., can g lv . you * l l t a * " t h a t , i f y o n o w anttls to awe py e r s o n a lly * in the f in a l re p o rt. t t . a g . d l.to ib u tio n . I can t o ll T * roughly about I t .t o t o - approninatoly tte n ty - fiv . to m - W ^ about* co n tro l group, to have the . . to o l p a in , to ehooatog our con trol group, . age d istrib u tio n . * , to . nattor or totatotog r o l u n f r . to to. woX and d y . - punoh p r ..a , to th . d u .to d t r a d . . . , - , ,, o r t o . p .o p l . . x c .p t toe t o t o . fo u n d ry, and obtained - 1 o f , ^ ^ p eo pl. uho ,, ,, . . . y on r* m **- * . ** a x L - t toto h t o a t our ................................ .. top U r.d " Xaelc o f t o o . , ton I n d i v i d u a l t o . r o - o r . r . l . t i v . l | f .u in d iv id u a l, -ho r .f u .o d vh.n m u * .t o d . to "" " 1 x dye and punch p r e s s . -That was a rand,om _s,,a_mr,p1 lae aannda t^h en th e T h at was ___________ ___ ________________ p .o p l . p l .k .d w ar. . . t o d I f thay would a o lu n ta a r . O a r . ,, . r . .o n * r . f u . 1 . , I can 't t .H you p r . c l - . l j <" *n y . I . , a f r a i d th a t mayba wa w o n 't b . f c l . to t a l l J0U th a t a t a l l , b . o . u , . I'm not aura th a t r .c o r d . w .r. k.p t a . to h o . .-n y r .f u a .d , but I w ill look Into th a t. I t 'a a good q u .8 t lo n and, f o r t h . . . k . o f o o . p l . t a n . . . , w. should hare i t * D o cto r B u g h -Jo n es* s u g g e s t io n ! * & on* # w lll . . . in th . n aat p ap .r th at w. a tta n p t.d to g at at th at to . 0. . a x t a n t b y f u l l t i n . o o r r . l . t l o n p r o o . d u r . . I - no eart a i n t h a t t h a t ' , t h . . th in g h a 'a M ik in g a b o u t. M 1l . a . th at h i. p ro o.d u r. 1 . a U t t l . b i t d lf f .r a n t and I t 1 . on. that X - not fa n lli- * -1 th . I oartaln ly 1 1 1 g . . i f u can ' t improve out togeth er w ith you afterw ard . nd see i f v . c ^ data* D id I le av e anybody outt rvirTQR BRIST<g.t Ihe com plication o f conglom erate. pv nfifiTOR WRIGHT I -- ---------- 1 Z 7 '.. p a rh a p . D o ctor B r l . t o l d i d n 't - a h . I t i e l . a r enough. I th in k he d id . a y . oommonly o r alm oat | w ay.. in regard to cp h y .a m . * c p llc .t lo n of oon- g lo m e r .t , d l . e a . . . W. c . r t o l n l y b a y . bad t h . . a p . r l . n o . In F the , vast m aljoo rr litt yy of or con glcarat, .lllco tlo a, of dem on.tra- 1 *-1 A v ld en ces o f emphysema. We have o n _e , -r -a.tVgl AaViAA A. BY DOCTOR WRIGHTt 0,, ,1 1 o f t b . . . p . o p l * . I th in k th rapl0;rm aat r e c o r d . . i l l -how th ey b a r . b . . t b .r o t . n t y , t . . t , - f l years* BY DOCTOR PRIEPMM* m d you know b o . many y *TM , tboy orkcd In bo*rd- our o o n cn tr.tio n b o . many 7 ` * * ` o t BY DOCTOR VfRIQHTt y e s , we h av e a l e t t e r - we have a l l th a t i n f o r - ,, t l o n on cor do, ond i t 1 . b .ln g gon. o t .r n o .. * t . i l l be In the fin a l re p o rt. BY DOCTOR KoCJUnf* I f tb .r o 1 . no fn r th a r d l.c u .o lo n , v . w il l p r o . * * to tb . n o it popor. ond . . going to o b g . tb . o r d .r f tb . p r o g r - .o tb o t Doctor W rlg b f. p .p .r . i l l p r .o .d . th at Of D octor G re g o ire . D octor V rlg k *. b y nnnrQR WRIGHT: | k p . chairm an. L ad les and Gentlemen: B efore p re - I sonting tb . - U r l l in ay P -P ~ . I -onld 1 U to on. ccoxaent to a x p llf y . to . . . t . n t . o n . o f tb , th in g , tb o t X th in k waa r a t.h. e r .im- apnorrttaanntt twh a t was "brought out toy our Chairm an, and, t-h, _a*t _ th e im portance o f the c l i n i c i a n In th e se v a r io u s s t u d i e s , annda tuhnee pv o s it i o n th a t g a d g e te a rin g and a tte m p ts to m easure- wxriii-tvhi ssoommee pp rr e c i s i o n h as In su ch a tu d ie a a s we are m ak in g. ___________ ZUXM FBCK F iB * 505* y r D0C70B Brfor. p c .- t t o to . ,, t t o l to >7 I*pr. I w old lito to - t o -- * to *w " f * to .* * , -- or to . W W 1,* rte* t o ., , O roo*t ~ t * o o . - " * " taort" " * t t , .u o to to o to tt-- to rlo to rt U ~ , - a to . * lt lo . toot gto rt~ rf^ * .ttto p t. to -- * " -- " * tosh. cto&lM U W Bftkinf. i __________________________________SOlu I rin d m y i.lf in f u l l agreement w ith h in on tb s ^ question of th . in port.n o. o f tbs o l i n i . l to r . l y on la b o r sto r y p r o c e d u r ... T b l. r .l l a n o ., In o lin l c . l n sd l.ln s, 1. a m .n lf..t .tlo n p a r t i, o f tbs tr.nsn dou. b n rd sn th a t 1 . pot on a p h y s ic ia n . I th in k i f . a l s o , to sons exten t, a f a l s . r .l i a n a , in that w OK . . . f i g o r .. and nndsrstand g lg u ra. n o r. . . . i l , th> - can tb . th in g . th at go in to form ing an o p in io n . I do b . l i . T . , h o w .t.r, th a t Dootor became vonld b . t h . f i r s t to . a , t h a t v . n .d t b . . . g a d g .t a Mid t b . . . n oth oda o f . a a u r . n . n t i f f o r no o t h .r r .a a a o n tfcMi to ap p ly a an. .o r t o f . t s . t to our c lin ic a l accoun t., our e lln - ie a l ab ilitiea# c lin ic ia n h a . b .a n going on fo r ,o a r . .x p r ...- 1o o p in i o n ., and la c k i n g a l l - . t 1 . y . -- t in g t o know, bu t lackin g n o r. p roclo. tb o d a of confirnlng h i. o p ln i , ^ I would th in k th a t porh ap . on. o f t b . g r . a t . a t fu n c tio n . - n or. p r e c is. . u r .n .n t - 1. that o f applying -ort Of t s . t . to c lin ic a l a b l l l t i . . . " 1 1* in * " * ,, l n t h a t o u r work h a . boon carried o u t Mid t h . stu d y th a t I am to r e p o r t t h i s morning was d o n e. . May I have the r i r a t aliH oT B e o * * * * tH ls i . a j m ixed a u d ie n c e , I am g o ,in g,, at.o_ 4t.ankifea jiuvaiaut a few moments to | p r e p a r e some back, ground^ ffno rr tthhee ccooonnse n ts th a t I am g o in g t o ij make , and I .have .ho_pes ttHh aatt mmyy mw e d ical c o lle a g u e s w i l_l __fo r g iv e $07. a . f o r t h i s crude d iagram which, to my m ind, p o r t r a y , in an a t i l y understood manner, the v i t a l fu n c tio n , of r e s p i r a t i o n The r e s p ir a t o r y a p p a ra tu s i s in e s s e n c e , a b e llo w s , an a i r pump through w hich b lo o d c i r c u l a t e s f o r th e purpose o f bein g v e n tila te d . A ir en ters in to a bellow s and the ac tjo n o f t h a t b e llo w , i s a l l im p o rta n t. The a i r i s th en d i s t r i b uted through the f lows and b e in g co n stan tly re p la c e d , mail ta in s i t s way, w ith a h igh er p re ssu re o f oxygen and a lower p ressu re o f carbon dioxide than e x iste d in the blood th at flow s through i t * Tb MinouB b lo o d return to tb lu n g from th . p arlp h .IT , carryin g high lo ad o f odrbon d lo x ld . .n d b .ln g lo v in oxygen. A . th . blood c l r c u l a t .. through th . b . l l o - . , fU a c ro ss . c r y th ic k . . . b r a n . which ..p u - x ta x t h . blood p h c . f r o . th . g . phM . Of th . lu n g, oxygon gm g in t o t h . h lo o d Ahd c r h o n d l o x l d . com ing o u t . T h . b lo o d t t . h r e t u r n , to t h . l . f t . I d . o f t h . h . t .n d 1 . pu m ,.d out through the t is s u e s . y o u h av e, in e sse n c e h e r e , a pump and a d i f f u s i o n s e r v i c e . T h at i s the lu n g p r o p e r , and then we h av e, o f co u rse, a system th a t i s in tim ately in volved, i t simply can not be sep arated from the lung, nam ely, the c irc u la to ry sy stem , a pumping system which pumps the b lo o d in to the lu n g , a c c e p ts b lo o d back from the lu n g and then pumps i t out to the t is s u e s . 1 . r fi 508. How. t h . v u ln e ra b le p o i n t . o f n c h an a p p a ra tu s o f e o u r .e , i ^ d i a f l y a p p a r e n t. The a p p a ra tu . i . ulnarab le from the p o in t o f riew o f a i r flo w In to o f the l,,u n g , .n-am e! l*y, firroomm the p* i p* e . * Wkrcr airw a^y oh b t r u e t lo r m , vary obviously, i t . r f . r . w ith th . ot t t l* ' a p p a r a tu . to behave a . an a i r Pu p . p r o p e r d istrib u tio n o f s In tb l. h .llo w . m X ..d to region al poor v .n tll.tlo n *nd , " * * " " ..t u e liy i t 4 0 .. occur - . . . * " * ~ " D tl* L f d . t 1 1 . I t " " U 1 C lr Ul* W4T.U ,o u . M ood t h a t f l o u . through .u c h . . . d o . . * " " purpos. u h .tso .v sr, Th. b .llo v . ' 1 . . punp in th . sen s t h . t r o t h .r n . c h l o . l pump o p erates, Loo. of pov.r or - d .fo rn .b llity * -- or b e in g c h g . d in v o l t - . , - i l l ctoviou.1 7 i P . i r .C tiT ltJ P W * * " ^ T ,r7 . t h in man-- uh leh . . P . . t h . t l o o d f r o . t h . g I f l t b .c o n .s thickend or o t h .r - 1 .. h g . d , 7 ~ -- " l I l y u n d erstan d th a^t g a .s e a mmiaiTy hhaavvee tr o u b le i n g e t t i n g aerMI <4 then o f c o u r s e , the c i r c u l a t o r y MjnUm i t t h is b a r r ie r and then, s e l f 1 . v u ln e r a_b le , +tvh_e ttoo ttaa ll aa rr ee a which can r e c e iv e b lo o d o , . cross-se c tio n a l . . of t h . T a s u u l b .d - 7 h . 4 1 - mlnlshed, .0 t h . b lo o d i . P-p.d -ith d ifficu lty . | B1ood nay dsn back in th . lu n g, b ecau se o f f . l l u r . o f th . pumpon th . l . f t . i d . to m o ,, the b lo o d l o n g a s i t j l . a v s . i th e lu n g . The c i r c u l a t o r y a s p e c t i a g o in g to ba co v ered ! by D octor McCann. | I d o n 't, however, in our p resen tatio n , want you I to lo se s ig h t o f the fa c t th a t a lung ia n ot ju s t an a ir ! pump; i t ' s in tim a te ly a s s o c i a t e d w ith the c i r c u l a t i o n . I How, f o r a good many y e a r s , the - th e se in tim a te and d i s t i n c t fu n ctio n s o f r e s p ir a t io n ware not amenable to i Te ry p r e c i s e stu d y , b u t d u rin g the p a s t tw enty y e a r s , m eth ods have been developed which w ill perm it a f a i r l y p re c ise measurement o f the a c t i v i t i e s o f the r e s p ir a to r y apparatus e sp e c ia lly the study o f the vulnerable p oin ts that I have ju s t mentioned. I would lik e to sa y , a t th is p o in t, that D octor McCann and h i s g ro u p , D o cto r K o t l e r , who i s i n the a u d isn c a wore and continued to be p io n eers in th is stu d y . A really tremendous amount o f the work th a t we a r e t a l k in g about today stem s from i t , t h e i r own la b o rfi- o ry , and I J u s t th in k th is i s a rath er ap p ro p riate tim e to recognize th eir r o le | m stu d ie s o f re sp ira tio n in th is country and abroad. I How, some t h i r t e e n y e a r s ag o , D octor Gardner b e came In te re ste d in the fu n c tio n a l asp e c ts o f the e f f e c t * ' th a t the in h a la tio n o f d u st m ight have on lu n g and c i r c u la - | t i o n and i t was b e c a u se o f t h i s i n t e r e s t t h a t I came h e r e . j! i m igh t sa y a l s o t h a t i t g i v e s me seme p l e a s u r e to sa y t h a i ; I i t was through D octor M cCann's m ffo rts th a t t h i s was made j p o s s i b l e * I doubt i f many o f you know t h a t the I n i t i a l b u ild in g o f the la b o r a t o r y came ab o u t a s a r e s u l t o f con t r ib u t io n s fo r a number o f y e a r s from the D ep artaen t o f M edioine, not only o f money, b u t o f time and h e lp fu l in s t r u c t io n . We b eg an our s t u d i e s i n th e o n ly way th a t we lojew how a t th e tim e , nam ely, to s t u d y the in d iv id u a l a e t io n s o f the re sp ira to ry ap p aratu s. These procedures are those that you have been told about h ere by oth ers th at have talk e d on the su b je ct o f pulmonary fu n o tio n * Ve m easured the s i z e o f the b e llo w a , the s o - c a l l a i pulmonary volume; we m easured th e s t r o k e volume o r t h i s a i r pump, then the v i t a l c a p a c i t y . We m easu red th e power t h a t t h i s pump has to d e liv e r a i r p e r m in u te , nam ely, the m axi mum b r e a t h in g c a p a c it y . We h ave a tte m p te d , w ith r e l a t i v e l y l i t t l e su c c e ss, to measure the d is tr ib u tio n and m ixing of g a s s e s i n the lu n g . With some g r e a t e r s u c c e e s , we have b e e r able to measure the im pairm ent, i f an *, fo r the p assage of g a s s e s from th e g a s p h ase to th e b lo o d p h a s e , and t h i s i s done in two w ays, by stu d y in g the b lo o d g a s s e s o f the b lo o d sT te r i t has emerged from the lu n g , namely the degree to which the hemoglobin i s s a tu r a te d with oxygen and the degree to which carbon d io x id e h a s b een removed from the b lo o d , anc. in a l i t t l e more p r e c i s e way, we have m easured the p r e s s u r e , head th a t e x i s t s between the oxygen and carbon d io x id e in the gas phase and the oxygen an d ca rb o n d io x id e in the blood y we*"**-Tr-~g"v--~ .--.- phase* One o f th e g r e a t sh o rtc o m in g s, and I th in k i t i s s t i l l a sh o rtco m in g, a lth o u g h a l o t o f work i s b e in g don ! on i t , i s th a t we have n o t been a b le to m easure w ith n e a r ly the o n e degree o f accuracy, the ro le of the c irc u la to ry a p p a r a t u s . I aw ait w ith g r e a t e a g e rn e ss the day whsn Baxd> mum c a r d ia c o u tp u ts can be m easu red , and when the p r e s s u r e r e l a t i o n s h i p s ab o u t w hich D o cto r McCann w i l l t e l l you, t h a t govern the flow o f blood through the lung, can be measured under conditlons o f s t r e s s . ^ fta r about four years o f work, m easuring the a s r a r io u a thing , th e se in d iv id u a l fu n c tio n s o f the lu n g , we ,, Em, to th e r e a l i s a t i o n t h a t we were n o t r e a l l y doing what v e had s e t o u t t o d o . I t i s th ro u gh , w c o u ld r e c o g n is e , f a i l u r e o f the b lo o d to be p r o p e r ly v e n t i l a t e d . V co u ld re c o g n ise Impairment o f the pumping ac tio n o f the lung or th e r e s p i r a t o r y a p p a r a t u s . We c o u ld r e c o g n is e p o or d i s tr ib u tio n o f g a s s e s , and I have been g u ilt y , ae have o th e rs, o f c a l l i n g th e se d i s a b i l i t i e s , and th e re b y , we have co n fu se d some o f our l e g a l f r i e n d s , b e c a u se we have f a i l e d to be p r e c i s e , and say th e s e w ars d i s a b i l i t i e s : o r c e r t a i n t h in g s . A low maximum b r e a t h in g c a p a c ity i s a d i s a b i l i t y fo r b reath in g power. A poor a r te r ia l satu ratio n is a d is a b i l it y fo r blood gas tr a n s fe r and th at Is a l l th at the d i s a b i l i t y i s . T h a t's a l l we have m easu red , and we and j 512. oth ers have sometimes not been c a re fu l to say whether or not th is d is a b ilit y to breath in g power is a d is a b ilit y in terms o f a man's a b i l it y to work* A fter, as I say , about fo u r years of e ffo r t along th e se l i n e s , we were r e p e a t e d ly s t r u c k w ith the f a c t t h a t c e r t a i n men were rem ain in g on tn e Job d o in g a f u l l d a y *a work who h ad c o n s id e r a b le im pairm ent o f b r e a th in g pow er, who h ad some d egree o f a r t e r i a l u n s a t u r a t i o n , who had ab n o rm a litie s o f the pulmonary volum ena, and thick-headed as we w ere, to o k a lo n g tim e to r e a l i s e th a t we sh o u ld b e much more c a r e f u l in the u se o f t h a t word d i s a b i l i t y , and should define i t p re c ise ly every tim e th a t i t is u sed . The word i t s e l f means e x a c t ly what i t s a y s , lo a s o f an a b i l i t y , and we sh o u ld bo c a r e f u l to s a y what a b i l i t y . B eoauee o f t h i s d is c r e p a n c y , we, a s have many o th e r s b efo re u s , c a s t a b o u t f o r so a e way o f t r y i n g to r e l a t e th e s e s p e c i f i c d i s a b i l i t i e s to the gen eral a b i l it y o f a person to p er form as a p h y sic a l engineer - en gin e. How, you may u se v a r io u s p ro c e d u re s in t h i s r e g a r c . The e a r n in g power o f a man i s the - to .o n e e x t e n t , a m eas ure o f h is a b ility to perform as a ph ysical engine, but i t i s n o t a v e ry p r e c is e one, and many f a c t o r s are in v o lv e d in t h a t , perh ap s I ' l l have o c c a sio n to say more about th a t th is afternoon. Xs d o c t o r s , we w ere, o f c o u r s e , i n t e r e s t e d in t h e in human b o d y , and t h e r a f o r e , i t i s o r would be n ic e i f we c o u ld f i n d some way o f m easu rin g the in t e g r a t e d man, what he can do in the way o f p h y s i c a l p erfo rm an ce. Some work h as been done along th ese li n e s , m easuring peak a b i l i t i e s to - fo r p h y sical output, fo r example, the w onderful r e cords th a t have been s e t in d istan ce running and in other forms o f p h y sical f e a t s , i s , in a sen se, a measure of an a b i l i t y . There i t a more p r e c i s e way o f g e t t i n g a t i t . The human en g in e i s a g r e a t d e a l l i k e an o rd in a ry in t e r n a l com b u stio n engine. Fuel is burned, oxygen is req u ired in th at bu rning, and carbon d io xid e is the r e s u lt o f th a t burning, and Ju s t as you m ight r a te the power output o f any engine i n te r n s o f i t s oxygen con su m p tion , the human body can be s t u d ie d in e s s e n t i a l l y the same way. j h . n e x t s l i d e , p l s a s s . Ons c sn s t u d , s m Imi-- perform ance e b l l l t l e . by having th s In d iv id u a l w alk on treedn l.ll se tte r - c ir c u la r c n .- l l . tra c k , end trenendous -- cunts o f e x c e lle n t kork he. been don. in the Peck Leboretory e t H arvard. stu dyin g f in . e t h ls t e . sod s c . o f t h a t d a te I k i l l hOk you in J u s t e messent. Ve have stu d ie d e c u fror- the p o in t o f v le k o f h e ir g re a te st a b ilit y to put out physical energy, by havrag then a l k on a t r a a d n l l l . We chose t h a t r a t h e r than th ^ ,1 c ,c le because in th is country, our people are not accustomed o rid in g . b ic y c le . I " ad d itio n , th . e x .r e la . Involved la Ot u fr a s i t i t In w a lk in g . T tiB l a aimply a p ic t u r e o f a man w alk in g on a ^ a d m i l l vhifc r a r io u a measurement ar blng mad. Next a i d . . Studying th . In d iv id u a l In t h l. way, a t t e a r .a .t a g L n ten altl.a o f p h y .lc a l a x a rtlo n , c e rta in . . a n r - n t . can a. xada, a . r .p r .a .n ta d In * 1 . -U d a . T h l. 1 . o f a p . r . aha h a . b .e n . . I k i n g o r who h a . h .a n w a lk .d a t a o o n .t u r t ap aad , a . you . a . . In t h . forw ard rig h t-h an d oolunn, a u ra , and a h a lf l l a n hour, b u t in o ra a a ln g tha la v a l on whieh h . walked u n t i l f i n e l y K > v .l 1 . raao h ad whloh 1 . th . u t . t th at h . can aoooRpllahi In other w ord., a hlghar la v a l. t b . ,, e lk ta tM .ln .ta d a t an a a r l l .r period than . hav. o r h&d ohofltn# T h at, w alk. w ar. a l l o f a l l nlnutea duration and, ty In o raaaln g t h . g rad , on which th . Ran w alk ., -a f i n e l y ^ t to a p o in t w h.r. t h . nan car, not walk fo r th . f u l l a l l R ln u t.a ; h . - u a t gat o f f and oornal In d iv id u a l., b a c .u a . o f . or. a e v e r . l o g w eakn ..= " d,gr' f b" ath l" "' How, I t ' a a p p a re n t t h a t th a hunan en gin e l a q u i t , s im ila r to t h . In te rn a l conhuation an g in a. Th. oxygen up t a k e . a . ,= u would - a l l P < " = t , ' " own In t h . f a r ! o o lnnn, I n c r e a s e , ar.d g o t . up t o a peak o xy g.n uptake o f 2 ,9 5 0 -rartf^r~.a t*s of oxygon# 'KrpaqprT _ai 1 . the g r e a t e s t . h i n t , ' th a t t h l . In d iv id u al had Tor oxygen u p tak e * I f you would p lo t th a t o u t, you would e e . th a t ae the l a s t two e x e r c is e s were c a r r ie d out and a p la te a u was re a ch e d , th e re I s eery l i t t l e Increm ent In th o se l a s t two e x e r e l s e s , and h are eon . d a ta to show a . In o t h e r s , t h a t . p la t e a u I . re a c h e d In oxygen u p tak e a t a t i n . when th e minimum v e n t i l a t i o n o r b r e a th in g f a c i l i t y o f th e lu n g s oan s t i l l be augmented and t h l . h a . le d along with other e r ldence, to the co n clu sio n th a t In the normal man, the c i r cu latio n 1 . the governing fa c to r fo r peak p h y s io l output o f m oderate d u r a t io n . V . ' r . n o t t a lk in g now sh ou t s h o r t b u rst* of energy output# I b e lie v e th a t I won' t need to la b o r the p o in t .ny fu rth e r, but can sim ply s f t h a t th e - o n . o f the m easu re , mid p s r b .p . o n . o f the b e s t S t p r s .s n t a v a ila b le , o f . man' , a b ilit y to perform , en I n t e g r a t e d b a ln g , 1 . t h . h e ig h t t e which he cm. m e r e . . . or r a is e h i . oxygen p te k e . T hl. 1 . c e rta in ly a function n ot only o f r e . p i r . t l o n b u t o f c i r c u l a t i o n , mid I b a i l e e . ! . prim arily a function of circu lation or c h l.f l, . . . i The o th e r t a b le s th a t I w ill ahow y o u , w i l l I n d u e s , . s Doctor K otley e t a t .d , th at . . have onorsue r .e - p ir .to r y r e s e r v e ., f e r g re a te r thm, w. do c ir c u la to r y . Sow, w. have chosen ae our measure o f the a n ilit y o f t h i s human en gi,n e,, ttno mp errfioorrrmo,, th__is__rp_e_a_k__o_x__y_g_e_n__u_p__t_a_k_e_,__ '** 516, and each man s tu d ie d in th e d a ta th a t I w i l l show you was c a rrie d in a s e r ie s o f w alks of th is so r t to the peak oxygen u p ta k e . The f i r s t two or th re e e x e r c i s e s can be done in on* I d ay . su b seq u en t o n es, e s p e c i a l l y th o se r e q u ir in g , when you| g e t n e a r th e to p , you c a n 't do more than two i n one d a y , b e l cause i t ' s Yery strenuous work. I t ' s very time-consuming, a s you can s e e , s o t h a t what w i l l be r e f e r r e d to a s maximum oxygen u p ta k e , i s t h i s bottom f ig u r e on the le f t - h a n d s i d e , your le ft-h a n d sid e , and expressed in sq u are m eters o f s u r f a c e a r e a , l i t e r s p er m in u te, and what we have atte m p te d to do o r what we have accom p lish ed In our stu d y o v e r the l a s t ten y e a rs, i s to run v ario u s te s ts o f s p e c ific re sp irato ry fu n etio n in conjunction w ith th is measurement o f peek oxygei u p ta k e , Mext s l i d e . How, here are fo r ty - o n e norm al man c a r r i e d to the peak oxygen u ptake on the t r e a d m i l l . On the, i on th e l e f t you see p l o t t e d on the o r i b t , the oxygen u p tak e in l i t e r s p e r square m eter o f body s u r fa c e , and here the age in y e a r s . There i s a l o s s o f a b i l i t y , as the man b e comes o l d e r , which i s o n ly conmon s e n s e , th a t f i t s in w ith . what you a l l know. The degree o f sp re a d i s in t e r e a t i n g in t h a t I d id j li a n tic ip a te there would be a g re a te r v a r ia tio n . I t i s a ; good sized v ariatio n , stan dard deviation i s approxim ately j t h ir t e e n p e rc e n t o f the mean and th a t means th a t an in d iv id u a l S ru n i g h t __w e ll, 1*11 eay more ab ou t th a t t h is a fte rn o o n -- r e a l l y w ith norm al mean b e a r in g . The n ex t s l i d e shows some abnormal i n d i r l d u a l s In re sp e c t to peak oxygen u p tak e, I might a lso say th at the r e s t in g oxygen uptake i s in d ic a te d , the amount o f oxygen in tak e f o r a le v e l w alk i s a lso In d ic a te d showing what re s e r v e s we p o s s e s s . T hese a r e abnorm al in d iv id u a ls an d , to confirm the n otion th at peak oxygen uptake i s a p re tty good m easure o f a man* a a b i l i t y to p erfo rm , I have p lo t t e d d a ta taken from a paper th at appeared in Soience, by Robinson D i l l , end t h e i r oo-w o rk era, on p eak power o f p h y s ic a l p e r form ance o f some o f our fin e a t h l e t e s . The very top f i g u r e i s the d a ta from Don L e e ch , whoa many o f you w i l l remember was our very f in e two n a i l s ru n n e r, and v e ry f i n e c r o s s - c o u n tr y ru n n e r. The th r e e th a t are p l o t t e d below him a r e Glen - Gene B en ske, Glen Cunning ham and A rc h ie San Romani, who were a l s o very f in e d is t a n c e ru n n ers. They have a p e r fe c tly phenomenal a b i l it y fo r oxy gen uptake. Laach could su sta in that le v el not fo r fiv e o r e ix minutee b u t fo r twenty m inutee. Row, t h i s i s an a b i l i t y t h a t i s f a r beyond any th in g th a t i s p o s s e s s s d by the r e s t o f us mere m o r t a l s . The average normal In d iv id u a l, as in d icate d by the very heavy l i n e . These are some p a t h o lo g ic a l s u b j e c t s . The s q u a r e s , f i l l e d In s q u a r e s , a r e emphysemas. There i s one pneumonectomy o v er h a re , who e t i l l p o s s e s s e s a q u it # good a b i l i t y . Some o f the s i l i c o s i s and a s b e s t o e i s o a s e s e ra scatte re d around, Hext s l i d e . Now, I w ould l i k e to show you a s e r i e s o f c o r r e la t io n o o - e f f i c i e n t s in which we atte m p te d t o d is c lo s e or fin d out which o f th e se s p e c if ic measurements seem to p a r a lle l a man's g r e a te st a b i l it y fo r oxygen uptake and, by in feren ce, h is a b ility to perform as a p h y sical e n g in e . The v i t a l c a p a c ity c o r r e l a t e d in a r a t h e r s u r p r is in g ly good fa sh io n . I have been on* who. in the l a s t ten y e a r s, has belab o red the p o s itio n of the v i t a l c a p a city measurement. I'm not r e tr a c tin g a l l that I s a id about i t , b u t I m ust say t h a t t h i s gave me some re a so n f o r s u r p r i s e . a d I think D o ctor Hugh- Jo n e s , in h i s paper the o th e r d a y , a l s o s a i d th a t they were eomewhat s u r p r is e d to r in d a way i n which v i t a l c a p a c ity c o r r e l a t e d w ith a b i l i t y o f a man t o p e rfo rm . T h is d a t a , I must Bay, t h a t 1 ,TB 6o t iB o b ta ln a d on 180 ln d ia id u a la , and ambracea n il n e t pulmousrjd i s s s s s . Thara a r . aa rco ld , th a w a ra pulmonary glanulom a* ou ph ja.u a, b ron ch iectases, n o n -a p .a ific pnaumoconloal. th at . vara b l. to dlagnoao, . i l i a " - ! . , aab aato aia. d u a t, man w ith l l n a a r a x p o .u r . and s o on, a co n g lo m o rat. group and ranges a l l th s v .y from p a o p l. ho can Ju a t b e r a - w walk on tha l . v . l a t on. and a h a lf m lla . an hour f o r 51 f i v e m in u te *, to men who had asto u n d in g a b i l i t i e s to p e r form , and i t i s , I b e lie v e , going to be p o s s ib le w ith fu r th e r working o f our data to fin d out th at there are sp e c ific d i s e a se s in which the v it a l c a p a c ity does g iv e the erroneous in fo r m a tio n , and o th e r s in which the in fo rm a tio n i s more r e l i a b l e . J i t you run down, you can see th at th e re i s very l i t t l e improvement in the c o r r e l a t i o n when th e v i t a l c a p a c it y i s ex p ressed as a p ercen t o f the p r e d ic te d , in other w ords, where you attem pt to c o rre c t fo r age and su rfa c e a r e iHow, the r e s i d u a l c a p a c it y , o r the r e s i d u a l a i r a l s o c o r r e i a t e s w ith a <iuite high c o r r e la tio n , a s you would w e ll ex p e c t , and a s th o se have shown in the norm al i n d i v i d u a l s , the c o rre la tio n i s very poor; in order to d is c lo s e the co rre l a t i o n , one m ust add i n o th e r p e o p le , nam ely, th o se who havi had seme impairment o f th e ir r e s id u a l c a p a c it y . I t s r a th e r i n t e r e s t i n g to thow what D octor G m e o lr. " H I l t r w * . th a t In a a b e .t o a la , then . 1 . no correlation w h atso ev er. Maximum breathing capacity correlate* somewhat h a t te r than does the v i t a l c a p a c ity . The n ex t s l i d e . S p l i t t i n g up the maximum b r e a t h in g c a p a c it y , you see t h a t lm -- 1 i n d i v i d u a l s , the c o r r e la tio n drops co n sid erab ly , and I think th is i s fu rth e r e v ldence th a t we p o s s e s s f a r g r e a t e r r e s e r v e s f o r b r e a th in g 4 520* power than we do f o r c i r c u l a t i o n . I f the maximum b r e a th in g c a p a c ity In normal men was a stro n g d eterm in an t o f a b i l i t y to perform , the c o r r e la tio n should be h igh er and I'm su re th a t when we a re a b le to m easure c a r d ia c o u tp u t d u rin g p eak e x e r c is e , we w i l l f in d a very h igh c o r r e l a t i o n . However, when you have im pairm ent o f the b r e a th in g pump a s o c c u rs in a s b e s to s la and s i l i c o s i s , the c o r r e la tio n Is somewhat im proved, esp ecially in s i l ic o s is . Hext s l i d e . The a b i l i t y o f the lung to remove carbon d io x id e from the b lo o d i a , I t h in k , one o f the very im p o rtan t o n e s, and we were c u rio u s ae to how tn a t m ight c o rre la te , and there i s a c o rre la tio n , b u t i t i s o f a rathei low o r d e r . Very poor c o r r e la tio n , ae you se e , between a e r t e r i a l hem oglobin s a t u r a t i o n d u rin g e x e r c is e - t h e s e wert b lo o d sam p les removed w h ile the man was w alk in g on the m ill - very low c o r r e la tio n between any o f the gas exchange * * " urements and peak a b ilit y to work. I r a th e r w ish t h a t D octor M otley were h e re b e c a u sr he co u ld c o r r e c t me i f I'm wrong i n my im p re ssio n th a t he l e f t , th at perhaps I*m wrong in t h is , because as I under- stand what he sa id , hie b e lie f ie th a t d ic a t io n o f whether a man i s normal o r the not single b est infram a respim - , J tory p o in t o f view, i s whether h ie blood g a sse s are norm al, | and I think you see here a f a ir ly convincing dem onstration j th at a m an's a b i l i t y to work depends r e l a t i v e l y l i t t l e on j h i8 arte ria l saturation . This is not d i f f ic u lt to understand i f on. w ill r . l l th . great c lv lllt tlo n . hare been b u ilt a t altitu d e , whar. av .ry o n . a a u n a a tu ra ttn . and today aom. o f our p r o a n c tlv . m ine, o p .r a t. with ah a. p h y .lc a l - o r g y .z p .n d .d on t h . p a r t of t h . non, a t a l t l t u d . . w h ar. . r . r y o n . 1 . to ( W , x t . n t . u n . a t u r . f d . To b . . u r . , c o m p .n a .t lo n . on t h . p a r t of t h . b o d , do oocu r, b u t t h . .am. th in s 1 . t r u . j p t h . d l a . a a . d man, a . P o o f r McCann w i l l u n d o u b f d ly d . . - c r i b , f you, ao th a t a r t e r i a l b lo o d g . . . . . a u r p r U - in gly poorly correlated * HOW, th . 02V, th at l a a f rm th at I an at d .f l n . Her you. and oould ap p ly on o n . o f t h . p r .v l o u . a l l d . . . I t 1. what . r . f . r M a. th. v e n tila tio n eq u iv alen t. I t 1 . o b ta in e d by d iv id in g t h . minimum v . n t l l a t l o n by o xy g.n u p f j c , and .* p r . a .d . I f . a ln p lJ .x p ro .slo n o f th . b r .a t l lu g l o a d . I f . t h . amount o f a i r t h a t a man a n a t b r e a t h , fo r a c e r ta in .mount o f .m an y e a p .n d .d , m d I t 1 . a u r p r l.jn g ly c o n a fn t In normal p .o p l ., h a. a very narrow ran g. of T arietion * How,' you . . . h e r . a f a i r l y h igh c o r r e l a t i o n , h erein h igh er than w. had a n tic ip a te d , -.60. and I .h a ll junp now, just to the wery last one, in which we had a m u ltip le correlation. Incidentally, we had m u ltip le c o r r . - lation, w ith m o.t o f th..., d I - nhovlog t h l, o n ^ * g y :y gv>y- r : g22, h e c a u s . i t i f the h lg h e .t t h a t w. o b ta in e d . I f o n . com b in e s maximum b r e a th in g c a p a c it y and v e n t i l a t i o n e q u iv a le n t a s a s in g le f a c t o r , and I w i l l show you some s c a t t e r g r a p h s i n a moment on th a t to p o in t t h a t o u t, then the c o r r e l a t i o n e q u iv a le n t 1 . a s u r p r i s i n g ly h ig h on e, .901,. T h is came as somewhat o f a s u r p r ise to me. I s t i l l have d i f f ic u l t y in b e lie v in g th a t i t means what i t seems to s u g g e s t, nam ely, t h a t th ere i s t h is v ery h ig h dependence on H .B .C . and 02V vhen one w ishes to study peak a b i l i t i e s to perform . On the o th er hand, i t i s somewhat common s e n s e , l . n ' t I t , because neximns b reath in g cap acity l a . In a a a a n c , breath in g power, y .n t ll.t lo n equivalen t l a , in essen ce, b reath in g lo a d and the a b i l it y o f an ord in ary angina to p o rfo rn la c e rta in ly d l r .c t l y r e la te d to the power o f the ongino and to the lo a d th a t one puta on i t . S o r t s l i d e . How. wo ware I n t e r e s t e d in whether o r n ot t h is c o r r e la t io n would h o ld u p , o f M. B . 0 . and 02V r o r .u a oxygon up t a t e when o n . d iv id e d the d s t s by d i s c s , . . , ,, d you w ill . . . that th . co rrelatio n did hold up. ig a ln . f o r n o m el in d iv id u a ls , t h . c o r r e la tio n 1 . nowhere hear t h . ^ l o h w. found in d is e a s e d in d iv id u a ls - T h is was an o th e r ev id en ce t h a t b r e a th in g r e s e r v e , a re sruch g r e a t e r then circulatory reserves. Hext s lid e . Now, i t ' s a lw a y s w e l l to l o o k a t scattergrap h s, because as Doctor Eugh-Jones pointed out , rpr; ) 523-* the c o r r e la t i o n c o - e f f i c i e n t s u s u a l l y look much b e t t e r than do th e s c a t t e r g r a p h s , and the s c a t t e r w ill show you a t once | the wide r a r ia t io n which can a l s o , of c o u rse , be e x p ressed by th e sta n d a r d d e v ia tio n which I w i l l show y o u . T h is i s || v i t a l c a p a c ity v e r su s maximum oxygen uptake and th e re i s , || o f c o u r s e , t h i s g e n e ra l s l a n t , which i s d e fin e d by the c o r - | relation co -efficien t. j The sta n d a rd d e v ia t io n i s l a r g e , a s i s shown by f t h is wide s c a t t e r , making i t , o f c o u rse , very d i f f i c u l t to use the v i t a l c a p a c ity a s a good measurement in an in d iv id - | u a l, but fo r c la s s stu d ie s or group stu d ie s, i t i s a b e tte r j| t o o l* I H ext s l i d e * T h is shows a maximum b r e a th in g c a p a c ity a g a in s t peak oxygen u p tak e, and you w il l se e a t o n e. th a t th ere i s a - somewhat l e s s s c a tte r e d e f f e c t , s t i l l ovei l a r g e , and th ere a re some e x c e p tio n s th a t a r e alw ays more i n t e r e s t i n g . H ere, we f i n d thx. e in d iv id u a ls way down h ere a l l a lo n e . These three p erso n s were cases o f pulmonary j granulom a in b e r y lliu m w o rk e rs, who p o s s e s s e d a norm al maximum b r e a t h in g c a p a c it y , b u t whose a b i l i t y to e x e r c is e was very lim ite d becau se o f the very high v e n t ila t io n e q u iv a l e n t . and when you c o r r e c t the v e n t i la t io n e q u iv a le n t, they J f a l l back in to the body o f the c h a rt, as you w ill see in the n ex t s l i d e . Leave t h i s one on j u s t a moment. \ You s e e , i f you tak a above the a v e ra g e p eak o x y g e * *4 y -v: 52U | uptake above 1 . 3 , the s c a t t e r l a trem endous, much more so i than i s true In the lower percen tages h ere, in d ic a tin g th a t I re sp irato ry re se rv e s are fa r g re a te r than circu lato ry or I a t l e a s t in r e l a t i o n to w ork. T h is shows you the M. B . C . Iand 02V combined a s a f a c t o r , and h ere you have a s c a t t e r th a t i s c e r ta in ly f a r l e s s , a g a in more s c a tte r e d in the range o f norm al, b ecau se the H. B . C. h as undue w eight a t I th is or in th is p o rtio n o f the d istr ib u tio n o f our d a ta . But h ere we have a q u it e n ic e d i s t r i b u t i o n . The n e x t s l i d e . As I s a y , i t ' s one th a t su r p r ise d b . I throw t h i s on p r im a r ily s o t h a t you can se e the c o e f f i c i e n t o f v a r ia tio n which d e fin e * m ath em atically the d e gree o f s c a tte r around the re g re ssio n lin e . V ita l cap a city tw enty-one, 1,98J+ maximum b r e a t h in g d a p a c ity an d v ery g r e a t - v e ry g r a t i f y i n g l y , much s m a lle r f o r th e co m b in atio n o f H. B . C. and 02V. The n e x t s l i d e b r in g s you back a g a in to the same d i s t r i b u t i o n o f M. B . C . over 02V u s in g , coming down now to aero in ste a d o f stan d in g a t th re e , with a drawing o f a g r id which combines the re g re ssio n lin e and the stan d ard e I d e v ia t io n on the two a i d e s . : The n e x t s l i d e -- o r , t h a t 's a l l , I th in k . I I want to summarise t h is ra th e r lon g p e r io d o f work by sa y in g I th a t as one would alm ost have a n t ic ip a t e d , and 1 presume : i f I had gone to an en g in eer and s a i d , "How, lo o k , we w ould 525. l i k e to know what determ in es peak oxygen u p t a k e " , he would e a y , "W ell, w h a t ' s the lo a d and w h at' s the p o w er", and we Oo u ld have a v o id e d a l l t h is work, b e c au se i t ' s J u s t a com mon se n se c o r r e l a t i o n . I b e li e v e th a t th e c o r r e l a t i o n i s a rath er su rp risin g one. I can certain ly say i t * s a su rp ris in g one to me. I don' t u n d e rsta n d why i t s so h ig h . I woul' th in k th a t c ir c u la tio n should have entered in to this more th an i t d id . We had no one in the s e r i e s who had been i n o r w as in co n g e ste d f a i l u r e . Im su re we had some e a r ly c o r pulm onale a i n the g ro u p . U ndoubtedly, we have had sosae c a r d i a c p a t i e n t s in th is s e r i e s , s e v e r e c a r d i a o s , we w ould have found a l i t t l e d iffe re n t r e s u lt . I b e lie v e that th is type of study ap p lied to the c a rd ia c group would be very rew arding. In c lo sin g , I would l i k e t o say t h a t tMs study I s th e end r e s u l t o f the l a b o r s l a r g e number o f p e r s o n s . X s impl y h ave the p le a s u r e o f p r e s e n t in g i t to you. I t ' s b een c a r r i e d on over the p a s t ten y e a r s and the men who have worked in the la b o r a t o r y hav . n taken a p a r t in i t . Thank y o u . (A pplause). B1 DOCTOR KcCANKt cince the next sp eak er' s m aterial covers areas - much the same a r e a , I th in k i t w ould be b e t t e r to d e f ^ r the d i s c u s s i o n on the two p a p e rs u n t i l we can have the two I p a p e r s to g e th e r , so I ' l l now ask D octor G re g o ire to p r e s e n t