Document 155jLVmEw83zDjDLZxboOR4zE

FILE NAME: Saranac 7th Symposium (SSY) DATE: 1952 DOC#: SSY006 DOCUMENT DESCRIPTION: Transcript of Presentation by Dr. Sander with Discussion 5153 FiEwEiVED F.H.H&S datl...M 3 1 m M.LM BY DOCTOR SiJTDER: Doctor Vorvald, Members of the Symposium: has been teaching students for the l&st fifteen I'm one vho _____________________________________________________ 2$*__ y e ars, th at pneumoconiosis la an o v e r a ll term covering a l l Inhaled d u sta , I t simply means duet In the lu n g s, and te me, lim itin g the term to those dusts which cause disease or cause symptoms, is lik e sa y in g i t su its our convenience now to say th a t the world is f l a t * Ve know Christopher Columbo sa id the world was round and they thought he waa crazy at that time* Ve f i n a l l y hare accepted that* V e i l , now, i t s u its our convenience, maybe because o f oar le g a l fr ie n d s , te say th at the world now i s f l a t again* To me, i t ' a ju s t as rid icu lou s to lim it the term 'pnsuaoooniosi* * te those conditions which cause symptoms* Shut in the lungs -- we a l l have acaae pneumocon i o s i s , every one o f u s , those who l i v e in the c i t y or liv e in c i t i e s , even the farmers have some pneumoconiosis, b e cause they in hale organic d u sts, I t * s ju s t as simple as th at to me* L e t*a assume everyone who comes to your o f f i c e has pneumoconiosis* Than, l e t ' s be s p e c if ic sifter th at* Vhat i s i t due to ? Speaking o f diction ary d e fin itio n s . Doctor Johns ton sent me t h i s , and I think i t ' s too good te pass up. I dc: ! t b e lie v e in d ic tio n a r ie s , and here is the l a t e s t d e fi n it io n , found in Blaokston**a S aw Gold X a d le a l D ictio n a ry , the la t e s t e d it io n . G rin d e r's Asthma la an i n t e r s t i t i a l j pneumonia due to in h a la tio n o f fin e p a r tic le s s e t fr e e in ji grinding s t e e l , and then i t s a y s , See F ib ro id P h t h is is , and 10. than you look up fib r o id p h t h is is , on Pag* 110, and I t saysi Chronic a lo v ly progressive pulmonary tuberculosie with ex ten sive fib r o a la and m ild aymptoma. That' s tha la t a a t e d itio n . Tha only textbook I know which haa defined pneuaooonloele' a an o v e r a ll term, gen eric tana, meaning any duet in tha lung la Doctor Johnston' s book. low, yom look up any medical textbook today, and i t w i l l eay pneumoconiosis is fib ro a ia due to tha In h alatio n of d u s t. Ve hare the evidence o f dusts which ceuae no f i b r o s i s , and i t ' s p e rfe ctly clear evidence. Va have i t , f i r s t of a l l , w ith the iron oxid e, an* wa have i t w ith tha t i n o x id e . Ve have i t w ith tha barium oxida and there are o th e rs. Wa c e r ta in ly have i t with aluminum o x id e . Aluminum oxida doean 't show, because i t * s not as radiopaque, but it * a deposited in the same way. Ve have i t w ith carbon pigm entation, and in carbon pi^aentatior the p a th o lo g is t says, there i t i s , the paro-vaseular lymph a tic s around blood v e s s e ls . I t looks lik e nodular s i l i c o s is , doesn't it ? I t ' a carbon pigmentation. I f that carbon were radiopaque as is ir o n , t i n and barium, we a l l would have nodulation by X -r a y , every one o f u s . Then we' d agree that we a ll had pneumoconiosis, but because our ch est film s are read as healthy lu n g s, we can' t believe that! we have p n eu m o con iosis, but we do. We're a l l carrying I 31* plenty o f m aterial In our paro-vaseu lar lym phatics, and i t ' s not doing any harm, not doing any mors barn than thsas l i t t l a oarbon p a r tic le s are doing in these paro-vascular lym p hatics. There is ju s t a l i t t l e d iffe re n ce in the c o a l pig*' mentation and co a l rea ctio n than you g e t w ith the simple soot in the atmosphere. C o al, being a hydrocarbon, causes i r r i t a t i o n , undoubtedly, in the bror chi ala and there i e an added fa c to r o f o b stru ctio n , which undoubtedly we ' l l hear about from our E n g lish frien d s and Doctor O renstein, but aoot in gra p h ite and n o n -ir r ita tin g m a te ria ls, lik e iron la n o n -ir r it a t in g . You can in je c t i t under the akin and i t is ths some th in g as a ta tto o mark. There i s no fib r o s is * There is no k e lo id . There is no r e a c tio n . I think ve might look a t these s l i d e s . Kany of you have seen these welders s e c tio n s , but I thought i t would ba q u it* important to review i t again, because i t is b a s ic . I hope you can see the absence o f any reaction what*> ever. Three out o f four here have seen these, but probably they're worth seeing again. This ia ths welder who worked inside o f a tank fo r ten or eleven y e a rs. There was no a t t e s t at v e n tila tio n so he had heavy welding fume exposure. Welding fume, you know, is ninety-nine percent p lu s , iron oxid e, very fin e d u st. He had no symptoms. He had th is nodulation. 32. which when we caw tha film in 1935# we acratched our heads and s a id , he probably has s i l i c o s i s * He has no s i l i o a ex posure* and we wondered, is there p o ssib ly a fr e e s ilio a lib e r a te d in the carbon arc from the coating o f the welding rod. A fte r a l l , there is sodiun s i l i c a t e binder in the c o a tin g , and we in v e stig a te d that and there was no evidence e f any Si02. V e i l , th is fe llo w , u n fortu n ately, died a year l a t e r , and we were able to get h is lu n gs. Kay we see the n ext, please? And, th is i s the low p a rt view , showing the deposits of pigment in the paro- aseular lym p hatics. fhe next i s a high power view . Io ta the absence o f f i b r o s i s . Here i s a high powar view, show in g the extreme amount o f pigment deposit in the paro- vsecular lym phatics. Shat pigment is Inside the paro- vaseJ a r s . G ro ssly , th at lung looked Ju s t lik e an anthra- pigm entatlon, which you see in most adults l i v i n g in cities^, but w ith some ferrous cyanide s t a in , we were able to prove th is was iro n oxide from h is welding fumes. Hote the ab sence e f f i b r o s i s , and in the next s lid e , is the one for connective tis s u e , showing complete absenoe o f f i b r o s is , 1 no fib ro u s tissu e r e a ctio n , no I n t e l li g i b l e v ir u s . I We have the a d d it io n a l e v id o n co from the t i n c a s e i I Ve have had - there have been two post mortem stu d ie s, one by Bartuk in Czechoslovakia, and the other by Doctor Hu^ies i'i and both showed a complete absence o f fib r o s is in these tin I 33* d e p o sits. U n fo rtu n ately, I d id n 't bring my s l i d e s , b u t you a l l hare seen the extreme pigm entation w ith the t in o x id e f and we hare two good post mortem ca se s, which show a com p le te absence of f i b r o s i s , and J u s t an in e r t d e p o sitio n . Bartuk did complete fu n ctio n s tu d ie s on his c a s es and found no decrease in pulmonary fu n ctio n . The barium cases o f Doctor Prendergast hare no symptoms o f any kind* There are not too many barium oases. There h a s n 't been th a t much barium exida exposure, t u t there again , wa hare th is marked deposition o f in e r t m a te ria l, which causes ne fib r o s is* T harsfors, I say there ia such a th in g as in a c tiv e dost and no matter how much iro n o x id e , no matter how sueh t i n o x id e , no matter how much barium oxide you in h a le , you are not going to g e t symptom*. We hare y e t to see a case o f t i n oxide w ith symptoms. They haven 't seen any in Cleveland whare they have uncovered a good many. Bartuk had no oasa w ith symptoms, in s p ite of the extreme X -ray evidence o f i t . So there is such a th in g , in my op in ion , c f in a c tiv e d u st, and I d o n 't lik e the U n a benign pfcosmo- e o n lo sis any more than you d o . I wish Doctor Gene Prendergast were here to de fend h i a s o l f . He coined the term, you know, about ten j yeare ago. Benign im plies th at the other pneumoconioses are m alignant. I don't lik e i t fo r that reason because 34-. they' re not e ll malignant either* I fcMnir in e r t pneumoconiosis would be a p e r fe c tly proper term fo r the pure Iron oxide, the pure tin oxide, nrf the pure barium oxide deposits* I think i t would be p e r fe c tly proper becauae we have the p a th ologioal eridenoe that i t doee net cause re a ctio n , that i t d o esn 't cause symptoms i As for the retention or discard o f such terns as s n th r a o o -s ilic o s is or s id e r o - s i li c o s i s , I think i t would be p e r fe c tly proper to r e ta in s id e r o -s ilic o s is where you know that there has been both s i l i c a and iron exposure* Every iron m iner, no matter where he works, who has any exposure to s i l i c a , and most o f them do have exposure to s i l i c a , we have been looking fo r iron miners who have never had exposut a to a i l i e a , had only hematite exposure, and we haven' t found one eo fa r * Every miner has a s id A r o -s ilio o s is i f be de velops anything a t a l l . e know he has hem atite in his lu n gs, and I firm ly b e lie v e that eome day we' re going to be able to show that th is hematite i t s e l f , in i t s e l f , is add ing to the nodulation which we see by X -r a y . tfe have seen i t in a few po st mortarns in iron m iners, whore there was considerable iron pigm entation, which undoubtedly helped produce the nodulation* I have yet to f i n d , however, a m lr-r who had only iro n pigmenta tio n , th a t is th at he had a nodular pattern in his X-ray 35. f i l * whero the pattern w ii due only to iron pigm entation. Ve haven' t found such a c m . and we may n o t, because a l l o f the miners in the p a s t, the older men who have nodulation, by X - r a y ., always helped d r i l l the s h a fts , and the s h a fts , as you know, are in s i l i c a , in q u a r t*. They' re u su ally quart* v e in s , so even the saucker, who has only ore dust exposure, has had s i l i c a exposure in the p a s t, because he u su a lly helped in the d r il l in g o f the s h a fts . I believe, firm ly believe, that i t is perfectly proper to re ta in the term a id e r o - s i l i c o s i s . As fo r the coal miners pneumoconiosis, I ' m d e fin ite ly in favor o f j throwing out the term a n th r a c o -s ilie o s is . We know th at I there is a path ology, in the absence o f any s ig n ific a n t amount o f fr e e s i l i c a w ith coal d u s t. Doctor F le tch e r and h is ooal workers have shown th a t very c l e a r l y , and ycm w ill hear more about that l a t e r . I do not b e lie v e th a t ! that term i s proper in the m ajority o f coal n in e r i pneumo- , coniosia cases. How, aa fo r pneumoconiosis i t s e l f , I*m in favor I o f re ta in in g i t , and keeping i t as an o v e ra ll term, and i always d r iv in g hone to whomever you' re ta lk in g t o , when- | ever you' re th inking about i t , th at you and I , a l l o f ue j! have some pneumoconiosis. I. Thank you. Tins 7BQM fiCI 37. bt poem m m s* Ton bar* beard the represectatlT* ffre* tha legal 1 38. p ro fe ssio n , and I think I t i s evident th a t th a t profession is p lacin g upon the medical group, the ta sk , and pleading fo r c l a r if ic a t i o n and d e fin itio n s of terms by the m edical p ro fe ssio n , fo r use and a p p lic a tio n by the le g a l group. They look upon the medical profession fo r those d e fin itio n s and th a t c l a r i f i c a t i o n . Our next member on the panel oomes to us from En glan d. Doctor Fletch er Is D irector o f the Pneumoconi o ils Research U nit o f the Medioal Research Council In C a r d iff, V a le s , and has had much experience with co a l miners in th a t area, and he is also a le ctu re r o f the Post Graduate School o f M edicine, U niversity o f London, London, England, end I'm happy to introduce to you Doctor F le tc h e r . BY DOCTOR FLE T CH SB t ' Mr. Chairman and Gentlemant I'm in s lig h t d i f f i c u l t i e s , since th is i s the f i r s t ocoaelon on which I<ve attempted to tr ie part in a panel of th is kind and I don' t know to what exten t I'm expected to answer the questions th at Doctor Vorvald fir e d a t me across the A t la n tic , or to what extent I can throw brickbats a t the - some o f the remarks which I regard as h ig h ly debatable, which have been made already th is mctrnlng. I w ill attempt to con-bine the two I have been pleased w ith the d e fin itio n o f Hr. Chalrmn cad OsatlsnMU Z'a 2a slight difficaltloa, laoo this la tbs fir s t occasion iwhich I'ti attaoptsd to toko part In a pansl of this kind sad I don't to what sztsat I 'a xpsctsd to answer ths question* that Doctor terweld firod at m across ths itlen tle, or to vsbat extent Z can throw brickbats at tho- sem of ths wearies whleh I regard as highly dobetahls, which has* baaa aads already this nornlng. I w ill attanpt to ths two. I heto been pleased with ths definition of ____________________________________________ ________ 33.__ pneumoconiosis proposed by the International Labor O ffic e Conference in Sidney two years ago, that pneumoooniosis Is a diagnosable disease o f the lungs produced by the in h a la tion of d u st, the tens dust being understood to re fe r te p a r tic u la te n a tte r in the s o lid phase but excluding liv in g organisms. The term diagnosable i s la te r am p lified in the report as meaning the presence o f signs or symptoms, with ra d io lo g ica l abnormality as being a sig n , but not always lo s s of fu n o tio n . To me, the word disease im plies any abnormal con d ition of the lu n gs. Row, i t f s d i f f i c u l t to define where normality leaves o f f and where abnormality b egin s. You can' t draw any sharp d is tin c tio n between the accumulations o f soot duet in a town dweller long in a smoky c i t y such aa Sh ef f i e ld , andthe early stages o f pneumoconiosis, and, o f course Zenker and S ch u lle r describe pneumoconioses in the town dw ellers in the apex. B u t, I should think here, we want to increase the acceptance w ith in the framework of medical knowledge of the s t a t i s t i c i a n and i f we do th a t, possibly even the lawyers may follow lie and reoognize s t a t i s t i c a l con cepts, and I r e gard ae abnormal, something which is two standard d e v ia tio n ! away from the normal, and where we can measure th at, we I! should admit th at as an abnormality or come to sane If0 > agreement u to what the number o f standard d eviatio n s we can admit are* Ve can do th a t by surveying the normal population and discovering the frequency of certain r a d io lo g ic a l p i e ta re s, comparing the* w ith the occupation were in tereated in , and we nay even aay the pathologiata to a t a r t , can be come q u a n tita tiv e in th e ir work so th at they can fo llo w u i ; with the r a d io lo g is t* and the p h y s io lo g is t* . *he p b y sie Hn* -- w e ll, perhaps l a t e r , they to o . With regard to the p ath o lo gical d e fin itio n , th a t, of cou rse, ia useless in I l f s , *nd I do deplore, I m ist **y, for l e g a l purpose*, a d e fin itio n based on fib r o s is which ean not be diagnosed without lung b io p sy, because much as I lik e *y ooUoagu.es, the lung surgeons, I think they a l ready have a tendency to be too e n th u s ia s tic . Por purposes o f couponsation, fo r s c ie n t ific purposes, I think w# must be quite s t r i c t and recognise a process in the lu n g , a ttrib u ta b le to dust. How, th at ia pneumoconiosis, whatever the lawyers want us to say. I t iD up to the lawyers to decide what they want to compensate.. Do th ey want to compensate *>* having an abnormal radiograph or fo r being disabled? Let the* say what I t ia they want to compensate. Then the doctor, in his te rn , can say how he w ill set so sort o f l i m i t , w ith, I p le a d , the help o f the s t a t i s t i c i a n . ___________________________________________________________________________________________________________ _ One of the d i f f i c u l t i e s o f the e o n fllo t between the compensatable pneumoconiosis end s o ie n t ifie pneumo co n io sis i s p sy ch o lo g ica l* The man who has pneiasoooniosls* diagnosed on a radiograph by one doctor* applies to compen sa tio n and is turned down and i s then disgruntled*or in aa area lik e South Wales* where there are hundreds - yes* tens o f thousands - o f d isabled men w ith pneumoooniosls* he de velops an anxietystate* Well* I suggest th a t olever doctors needn't be b a ffle d by t h is any more than they are by tuberculosis * I f we diagnose* on a radiograph* a hem olytical sear* we d o n 't t e l l the man he has g o t tu b e rcu lo sis. We ignore i t * but we make a record in our own notes that he has had tubercu l o s i s ; he has some aign o f tubercular in fe c tio n * The saxss sign can be used in pneumoconiosis, and ws have not found i t d i f f i c u l t to e x p la in to minera that they hare dust in th e ir lu n g s, but th a t is not ccsapena stable pneumoconiosis. Most miners have signs o f dust in th e ir skin where they have wounded the skin or have got dust in the s k in . We can e xp lain i t i s not a dust d isease; i t is dust in the s k in . They have dust in the lung and they w i l l ac-- copt that explanation. M o r e o v e r , we have fo u n d th e m iner much more w i l l in g t o a c c e p t th e f a c t t h a t two d o c to r s may d i s a g r e e in j I th e ir o p in io n abou t an X -ra y f i lm than our d o cto rs in s e r v ic e . Mi A ctive and In a c tiv e du sts, I d o n 't think you can make any d is tin c tio n without ao much a p e c ific a tio n th a t the d is tin c tio n loses any value* In the case of s i l i c a , a cle a rly a ctiv e dust, i f given in high dose, the e ffe c t w ill be d e a r l y shown, but the same q uan tity spread over a long period o f time w ill have no e ffe d t whatever on an anim al's l i f e * A c tiv e or in a c tiv e f I t depends on the dose* And, fo r th at reason, I am very much a fr a id o f Doctor Sander's statement about inaotive dusts, that soot is in a ctiv e * Krause and Oatner, rece n tly in Germany, have eonfirmed the observations o f Locke, that man working exposed to high concentrations o f pure so o t, 99*9 percent so o t, pure carbon, developed r a d io lo g ic a l abnorm alities, and I have seen them m yself, id e n tica l w ith co a l gas* la aoot r a d io lo g ica lly in a ctiv e f l o , not i f i t 'a Inhaled in so such quantity th tt i t d isp laces a ir from the lun g*; s o lid ice tsria l up again st a ir in the lungs w ill cause a r a d io l , le a l p ic tu r e , so aoot is as r a d io lo g ic a lly opaque as edema f l u id when i t replaces that in the lu n g, and you see the shadow, and I don't lik e the quotation o f two or three cases o f tin oxide, barium oxide lungs and iron in the lung# as evidence that no matter how much of these dusts these man in h a le , they would s u ffe r no damage* I could match Doctor Sander's path ological p i c tures w ith coal miners lu n es, with lu s t about as much ----------------------- -- ---- -- ________________ y._ <hist, ju s t About as much r e a c tio n . A ll righ ts would argue Doctor Bad dor, thare is no such thing as a dangreus quan t i t y o f co a l A ist* Coal is an in active dust. Lt 0cme to South Vala and see what happens when the man inhales enormous aaounts or q u a n titie s o f coal over lo i periods of time. Then, Indeed, there is a reaction* And, I euspect th a t these diseases due to the s o -c a lle d in e r t dusts hare th e ir character determined very la r g e ly by the quantity o f dust that is inhaled, and th a t any in e r t dust or so -o a lle d in e rt duet, simply because i t i s not s i l i c a , as the visual meaning fo r the term, any such in e rt duet inhaled in s u ffic ie n t q u an tities, w ill cause l i a b i l i t y to d i s a b i l i t y , e s p e c ia lly when com plicated by tuberculous in fection * Doctor Vorweld asked me, whether e illo o s ie was a disease or a condition* I>m a fr a id th at these two words have very l i t t l e differennoe in th eir smaning in Great B r ita in * I t 1* one o f these meanings th at art d i ffe r e n t , o f course, 'because we think we ta lk E n glish and you th in k we ta lk E n g lish and a c tu a lly I think our languages are, in *' same r e sp e c ts, d iffe r e n t . But I would almply value the | d istin ctio n , i f i t is necessary, o f cla ssio a l nodular s i l i - ! I 1 oosla as one p a r tic u la r form o f e i l i c c s l s , w ith the par t i c - ' ' I I ular process in the lungs s t r i c t l y attrib u tab le to the j ; I j in h a la tio n o f s i l i c a , by which I mean c r y s ta llin e fre e ;