Document 37eoVkbeL4Nxv4g0nOGMv3J7a

FILE NAME: Saranac 7th Symposium (SSY) DATE: 1952 DOC#: SSY007 DOCUMENT DESCRIPTION: Transcript of Presentation by Dr. Orenstein with Discussion t i m not pass *7, ! 1 Bp. ttsirw r, Ladias and O setleam t I * *fr id th at aiay e tte e s * oa ^ p art to laad t h is discussion w o ld bs to tab* up ^ tia a *K" you haw a t your d isp o sa l, and stra in your paticnoa tayood aiKOst aodur&noa. If you follasad at all sisat baa tean said P to e s w , you will faava craspod th* axtreaa caqiloxity of this qcastion. I bars had vary llttla tin* to propara for this, Ii \ j I 1 t ! 48. because mj masters gave me very little notice about coming here and I didn't really know at the time, what was expect ed of me* However, I thought that perhaps I might take up a side of thequestlon which is the - from my point of view, 1 a practical one, and that is definition from the point of view of the person who has to certify for compensation, that is to say the question which was in some respect dealt with then by Mr, Vagner* If one ie to attempt to deal with the point, with the definition itself, from the pathological and clinical point of view, strictly medical point of view, one enter* a very wide field Indeed. To attempt to add to the defi nitions, the importance of exact definition from the certi fying physician's point of view, is indeed a very wide field also* How, South Africa is a little, email country, but it has had experience with legislation on pneumoconiosis Ior strictly speaking, silicoaia, of some forty years today, and there it was the experience in legieletion, of attempts at definition of terms, over numerous acta, as Hr, Vagner mentioned in the days of certain of the states, where again and again, attempts were made to clarify the position for the benefit of the certifying physician. Il course, The first question that arises immediately is, what does one mean by disease. That, in itself, of ________________________________________ __ __________________________ 4 9 . i* a problem which could be discussed at considerable length* From the clinical -- pathological point of view, of court*, it waa laid down a century ago, by Vilhelm, that it it an abnormality of cell*, but you can hawe abnormality of eellt, a* you all know, in an area, or in an organ with out hawing any disability whatsoever, and, therefore, dis ease, in the sens* of the person who ha* to decide that something exists in an individual for which he ha* some i - for which he has to receive compensation. J i We, I think, or those of us who have to consider- ' j legislation from the point of view of compensation, oust i bear in mind two important and somewhat opposing points of j lew. One is that if you don(t define a disease, an indu* j 1 trial disease, with great exactitude, or with as such exact- I ltude as you can manage, grave Injustice would be don* or j might be done on the one hand, to the man who suffers from the disease, such as has been the case on a large scale in j South fr'alee, or you might, in the case of certain industries, \ damage the prosperity of that industry by excessive compen- : { s&tion being paid out, and therefore, in our concept, in > South Africa, we consider pneumoconiosis, silicosla, aui j incapacity of some sort, a disability of s o w sort* How, the legiwlation of South Africa has started with the Act of 1912, when it was first thought that diseas* ; existed which was due to quarts, and at that time, two i 50. stages of disease were defined and at that time, it wae, of course, called 'Miners' Phthisis', and the first definition vast "Miners' Phthisis shall mean silleosls of the lungs** Certain benefits are awarded when there is no serious or permanent Impairment, or more if there is serious or per manent impairment. Ho mention was made of tuberculosis. Four years afterwards, it was - the legislation was amended, and it was then said that, for the purposes i of this Act, the expression 'Miners' Phthisis' means sill- j oosis of the lunge, and tuberculosis means tuberculosis of j . | ths lungs or of the respiratory organs* i How, here it may be strange to am American audl- j ence to appreolate how the acts sire drafted* In our draft, j you start off by defining in the beginning of the act, every ; tirm that you u;e, as if it were a dictionary, and it Is | that definition that fixes the attitude of the Compensation ! ! Board toward the particular individual's troubles* 1 i How, In 1916, tuberculosis was Included and became ! i compensable, whether associated with or without sllioosls* ! Then, It was realized that the definition which was used ' then was not satisfactory, and a much more elaborate one ; was introduced three years afterwards under tfce so-called ! ! Consolidating Act, and a radical change was made# j At this stage - In this Act, a third stage of ! si 11costs was recognized and that Is the so-called ante- ! 61.. primary stage, now called the first stage. The ante-primary stage was then defined, when It la found by the Bureau, that la to say the medical examin ers, that physical gigna of damage to the lungs, short of definite physical signs of silicosis - SHORT OF DEFINITE PHYSICAL SIGNS OF SILICOSIS - have become evident, and that such damage has supervened during and in consequence of e m ployment in a scheduled mine; and then the primary stage, with a certain amount of disability, and the secondary e stage with more disability* I have no time to read these, without detaining you too long* , low, the ante-primary stage was introduced whan a condition, ill-defined condition became condensable* The reason for that I don*t want to go into at the moment be yond saying in a word that the idea was then that If you remove the wan from exposure to duet early enough, the dis ease would not progress and, therefore, the man would be able to locate himself in some other occupation, and inci dentally, the people who were responsible for payiugbe compensation would be relieved of the higher condensation which, in the secondary stagos, meant pension for life and a pension to the widow or dependents. That, of course, in I the event neither of these expectations proved to be correct. ! We all know now that at least in relation to SI 0g, no j ratter how early you remove a person, a certain progression : J52a take* place* In 1920, in giving evidence before a Parliament ary Commission that dealt with this subject, I expressed very strongly the view that they barked up the wrong tree and that they passed legislation which, In Itself, was not reasonable and that they expected medical men to possess occult or supernatural powers in making a diagnosis of som e thing which didn't exist* Then, In 1926, an act was passed In which the ante-primary stage was defined, the earliest detectable specific signs - physical signs, of silicosis, and there after, the whole of the compensation question became be devilled by this word 'specific', because the interpretation was made that specific meant radiological, radiological end nothing else* Well, this went on for some considerable time until it became clear, as was said a while ago by several speakers, that the radiological signs do not necessarily or, for that matters, frequently even, bear any relation to disability, and so it came about last year, that the Miners Union memorialised the Government and said that unless a radical change is made in the function of the Government Bureau of Medical Examiners, they would boycott the Bureau, The effect cf that would have been a general strike, of ! course, because it is a crime to employ any person in a ; _65j dusty occupation in South Africa who is not possessed of a certificate of being free from silicosis and tuberc.losls, which he has to supply at periodic intervale* Now, ae a result of that, a Commission was appoint^ ed under the chairmans hi r> of a Judge of the Supreme Court, and they made certain recommendations with r ' g u d to alter ations in the act* Meanwhile, something had to be done to placate the Minera' Union, and rapidly, an amendment to the Silicosis Act was passed at the last session of Parliament early this year, or the middle of this year, In which ansndsent - an amendment was passed named 'Pulmonary Disability** Pulmonary Disability was defined very loosely as something or other which s man might acquire by working in a dusty occupation, hut which la not silicosis, but which disables his lungs or his heart or lung sued heart* That was passed while the Commission was in session and before the Commission was ready to advise with regard to the beat way of amending the act and the definition. Well, that particular amendment will probably be thrown out at the next session of Parliament and a new aefinition will be introduced. I - you already bad quoted to you the Sydney def inition of pneunc:onlosls with which I entirely agree* I thought I told you briefly about our difficulties, because they are difficulties which apply or might apply to anybody n54. in any country that attempts legislation of dust disease of the lungs, damage to the lungs due to working in dust* Ve have - the Commission of which I happen to be a member, felt that the definitions should be to the effect that -- 1*11 read to you Just this such If you*11 forgive me; it w o n 't take more than a few minutes -- It first of all stated in the definition of tents that the word 'Sili cosis' as used in the Act means any pneumoconiosis whatso e v e r the word sllloosls, so you turn this around and talk of a pneumoconiosis, but then Ur. Vagner and scats of the i \ lawyers here realise that when you have had a number of previous acts and you have to make an amendment, it ie al ways dsuageroua to change the name of the aot, because the effect - it might effect previous decisions of the court on previous compensation, So the particular technique ef say ing sillcosla means pneumoconiosis, you might just as wall have said if the word 'John Smith' is used in this Act, it will mean pneumoconiosis, it will have the same effect* And they defined it in these stages or proposed to the Government that the three stages be defined as follows* That a person shall be deemed to be or to have been Buffering -- that la to say on post--mortem -- fro* sillcoais t (a) In the first stage when the Bureau has found during life the earliest signs of silicosis demonstrable by radiological or any other appropriate examination, or when the Bureau has found demonstrable permanent impairment of respiratory or cardlo-respiratory function; or when the Bureau has found post-mortem early lesions of silicosis or chronic bronchitis and/or its sequelae. Provided that the impairment of the respiratory or c&rdio-reepiratory func tion or the chronic bronehitis and its sequelae shall, in the opinion of the Bureau, be permanent and have resulted fro* the performance of work in a dusty oooupation and shall have been found within a period of twelve norths since the person last worked in a dusty occupation. Then, it proceeds to define the second and third stages on the basis of incapacity for exertion. The Commission remarked, in defense of its pro posal, that "This definition has been drafted with the view to removing as much ambiguity as is possible and at the same time leaving the Bureau the same amount of latitude in exercising the science and art of diagnosis ax muat.be left to those called upon to deal with a subject which is by no means either static or easy, "The words 'specific", *moderately marked' and 'marked* have been deliberately omitted from the proposed definitions as being vague and too much the subject of a i variety of personal interpretation,and because their use j tends to over-emphaaiie the radiological findings and to i 56. obscure the overwhelming importance of incapacity workw-- for work. Furthermore, the word *cardlO"respir*tory* are brought into the definition in order to indicate ae clearly may bs that euch affections of the lungs aa are usually present in at least the later stages of silicosis cannot be dissociated from cardiac disfunction. The word exertion' has been substituted for the words 'manual work' in order to indicate that what is to be assessed is loss of power for sustained muscular effort.* Kow, finally I Just want to say one word in ea$>ha" sis of what has been said before, and because of our rather unfortunate experience, and that Is we must bear in adnd the danger of trying to use the radiograph as a measure of disability, ae a measure of disability, aa a measure of a man's impairment of function, except in a vary highest de* 8**** fibrosisj it is no seasurs of disability whatsoever and should not be used as such. I have seen in many law suits, as long as I have experienced, and it is a long experience, any number of people, and such pec ;>le brought before the Commission, who j radiologically, showed practically nosigns, very very { early signs of striation or slight noaulation, who were in- i valida in every sense of the word, hardly able to do any- j thing, certainly would have been handicapped if you asked ! thtm to walk rapidly down this room, and we hawo lean peoplo with advaneed nodulatlon, massive flbrosla of por tions of ths lung, who ara playing a vary good game of tennis, and thosa are extremes, of course, but what I sug gest to you gentlemen Is that, after all, wa, as Industrial medical men, must be deeply concerned with tha question of doing substantial Justice to tha people who look to us, as medical men, to advise those who drsift legislation which may mean the propserlty of a person or, at least may swan a person not being thrown Into the utmost depths of poverty , besause he - because somebody quibbled about the wording of a law or somebody has quibbled about what should be done to establish that man's ability to earn a living, or on the other hand, hit entitlement to compensation for something that has happened whilst he was directly or Indirectly In the service of the nation! We can not escape that, and to satisfy ourstlves merely with purely medical, olinical, pathological defini tions, does not - is not substantial justice to the task, the duty which Is thrown upon us aa Industrial medical men. (Applause). BY DOCTOR VORWALD; The meeting is now ready for the rebuttal, may I 8ay* ty the members of the panel who have heard one suiother 68 express their views, and the first one to call upon is Doctor Lansa. Do you have anything to add, Doctor Lanza, any other reoarksf BY DOCTOR IANZAl I don't think I have anything to add; I don't think there is as much disagreement between us as we night xPcted I differ with Doctor 8ander on the broad use of the word 'pneumoconiosis' and I think a lot more thought has to be given to the matter of inert dusts or active dusts* I don't know whether Doctor Kenneth I^nch is in the audience or not, but not long ago, he presented to me the facts on two cases, two fatal cases of kaolin. Veil, now, we always think of kaolin as an inert dust, yet k** *r two men who have died. wnat he was talking about. He had the lungs, so he Well, of course, it comes baok, Just as one of the speakers said, to the Question of dosage. These two had worked forty-seven years in the Industry, each one of them, and they had little - they had been smothered or drowned in kaolin. How, to quibble as to whether that is dust, inert or active dust, I don't think, gets us very far. I don't think I have anything else to add. BY DOCTOR VORWALDi Doctor Greenburgf BY DOCTOR CREE], BORG : _5S>*_ M r . Chairman, I don't think there Is any great area or difference between the speakers here this morning* I think perhaps some of us have one or two points of die* agreement with Doctor Sander, but I think that will all be straightened out after we get the record and read It over and discuss it a little more between ourselves* I would only like to emphasize two points* I first came to Seranac in about 1921, if I remember correctly or possibly *22, Doctor Gardner was then just beginning to get interested in the dust question and I had been working for a year or two on the Public Health Service. I started in April, 1918 to be exact, and 1 came up here and we spent time in the laboratory doing some foolish things* Among others, ws put salicle acid down the nostrils of soma guinea pigs to see what happened* Of course,, you know what hap* pened, most of them drowned, but anyway, one thing that did emerge over the period of years was this, that I've aeen a change in our attitude toward many different types of dasta which, at the beginning, we thought were con^letely inert* At that time, silica waa only supposed to be the only villain in the picture, and I remember the time when the question of talc dust, the effect of talc dust was brought up and it was said that the pathological effects of respir ation of talc dust were due to three - two or three or four percent of free crystalline silica, and today we know that 60. to be completely untrue, so I would eay that anything we do, we rajst keep an open mind and not say that this or that dust is completely free of damaging effect, because time hai proven us wrong again and again and again, the last time with the coal dust studies in South Wales. And, the ether point which I should like to em phasise is this point which has been mentioned by Doctor Orenstein, in *hich I believe I mentioned before, and that is the fallaciousness of attributing, reading too much into an X-ray picture. If you look at an X-ray picture of the chest and you see that there is no nodulation present, and thou wait until the autopsy of the lungs, taken out and blown tip, and take an X-ray pictura of the lunga, you will very frequently aee nodulation presant there, and I say that the difference between the early atages of dust inhal ation and incapacity, bear no o-relation to each other. Just as Doctor Orenstein has said, and that the Xpray pic ture is sometimes most deceiving, and I admit we may not have any tool to substitute for it, but we must be very careful in our interpretations based on X-ray pictures and try instead to use the X-ray picture,careful industrial histories and laboratory studies on the dust and studies of the functional capacity of the work. Thank you. BY DOCTOR VORWALD: Doctor S&nderf 61, BY DOCTOR SANDERi I seen to be In the minority on the overall use of pneumoconiosis, and before I talk about that, I would like to correct one misstatement. I fully agree that you can inhale enough, I mean ita theoretically possible to inhale enough inert material to drown yourself; there is no question about that. Ve hawe not seen, in industry, aufficient concentrations of dust to have that occur, at least not in our area, and we have these extreme deposits of tin and Iron in the welders, for example. Those welders have terrific exposure, inside of email tanks, and yet none of the* had symptoms, none of them have had symptoms elsewhere, Hone of them had a measurable decrease in the breathing capacity, perfectly normal lung function, so that in industry, out our way at least, and as far as I know in this country, we have not had sufficiently high concentra tions of inert material to cause any Impairment of lung function or disability. I aay it's theoretically possible, of course, and Doctor Fletcher cited one case where it probably was such ar, excessive concentration. ^ OI* the overall use of pneumoconiosia, X still believe in Btaying with the generic meaning of words. I'm a purist in that regard. I don't like to call something what it isn't, and here we are, going to limit a pneumoconicsis to fibrotic pneumoconioses, and what do we call these 62. others which w# have been able to show, and many others haws shown have been truely Inert. I throw out that ques tion and I think maybe we night get an answer before the week 1 over* BY DOCTOR V O R W A U i Hr* Wagner? BY MR. WAGNERi Dick? Wall, I'll Juet say one sentence from here* I don't think there is anything else I can add to what I've 16 I think, from the legal standpoint, the important thlng is, as has been pointed out, what diseases are we go ing to stake - what do we want to make - compensable? What are the diseases for which industry should bear a responsi bility for compensation? And then let's see if we can fit the terms closest to them, so as not to leave the courts to construe those terms * BY DOCTOR VORWjtLDt Charles? Ex DOCTOR FLETCHER: I think Doctor Sander has misunderstood me. I don't want to restrict the tens 'pneumoconiosis' to fibrotie changes. Pneumoconiosis Is a process In the lung, and I think, theoretically, that process la Initiated when the | first dust particle is engulfed by the first lung cell. You can't get away from It, that's when the process is first 68. initiated. It becomes done, of oourse, when Doctor Vorwald can say there is a deviation from normal! I can say there i a significant deviation! Doctor Hugh-Jones can say there is a deviation, clinically, but you can say they are all pneumoconioses, right from the engulfment of the first particle by the cell. I want to make that quite dlear. All I hesitate about is the statement that a dust i is inert on two or three pathological cases. It may be quite true, I not denying it is true, I '* I frightened of it because of similar experiences In relation to coal. i The other point that I*d like to make, and that I tried to make ear Her , Is that I do strongly disagree 1 with Dootor Lansa that a pneumociniosis must be occupation* Perhaps he has a vested interest there. What would we say to a deep sea diver whose hobby was sandstone and who get pneumoconiosis fro* his hobbyt pry DOCTOR VORWALD I | There is n announcement that Doctor Parker ie I | wanted on the phone, call 154, Doctor Parker. | That brings us then to participation from the j j floor. How, what are your questions, what are your comment at I Doctor HusseyT I ! ! ! BY DOCTOR HUSSEY 1 j j; j like to say a word or two about one or two of , 64. th* matters that I Bade notea about. I don't want to be I d o n 't want to appear to be - I 'm not, but I don't want to appear to be pedantic about this. In the first place, I would like to emphasise that it hna been - or give further emphasis to the feet that we are discussing a subject about which our knowledge is Boat imperfect. How, does anybody disagree with thatf Definitions at their best are imperfect, so w e have a very complicated situation to try to formulate a definitione Then I'd like to say a word in defense of Doctor Zenker. So many people used the word 'pneumoconiosis' and refer to Zenker as having originated it. I'd like toeall your attention, if you don't know it, to the fact that Doc tor Zenker was a pathologist and he was not necessarily in troducing a term. If you will read his paper, you will find the very last sentence, almost in the last paragraph, the title of his paper was *The Pulmonary Diseases Due to In halation of Dust", and he eaid rather than to use this long*' winded expression, I will Bimply use the word 'pneumoconio sis', which means the same thing. That's the way the Greek! eay It, and I won't go into the Greek a bout it; you can find some Greek scholar for that, but that's the dope* Now, he was talking about an anatomical disease, not clinical disease. All of you are talking about clinical disease. Don't, then, blame it on Zenker. If he were nere : 65. today and he knew the story about Mary's little lamb that went to Pittsburg, I'm sure he'd speak of It that way. Now, also In making these various definitions, we have to keep In mind that, in most instances, if you look into the origin of our terms that we use in medicine, they are much lees secure than is the term pneuaonoconiosis, w h ^h I think must be, if you're going to accept the original way in which it was Introduced, mean diseases of the lung due to the Inhalation of dust* Typhoid fever is a term we derive from e, sparativ^ and statistical data. Tuberculosis is a disease that we derive from the appearance of tubercles, and finally, I'd like to indicate to you, the need, in thinking about all of these matters of definition especially, and this is one of the few, if not the only lnstanee in medicine, I don't mean the pulmonary dust diseases, but occupational diseases,when > our definitions have to stand a legal test and that's alwayi a difficult matter, but I do think it's very important for us to keep in Kind that we must have in our definitions, not Just vague words, but very definite expressions to in dicate as nearly as is possible, the exact meaning that we wish to convey, whether it's an anatomical meaning or whether it's a clinical meaning or whether it's a combination of th* two, and then finally, since the one consideration that's | of particular importance involved in all of these matters, ! T i ! the question of disability, the definition should alao include wove statement that permits one to determine, inso far as It's possible, the disability and the extent of it in connection vith that disease. BY DOCTOR VORWALDt Doctor Fletcher cited the fact, in agreement with ! Doctor Sander, and I saw Doctor Sander shake his head, that i as soon as a particle of free crystalline silica is depos ited in the lung, there Is a cellualr reaction. In study- i ing these many cases which come to us here, there Is always the problem, In my own mind, and that is looking at tissue, I see that eellular reaotion. kayoe one particle of free crystalline silica, maybe more particles. There is a re action there of the lung to free crystalline silica. How ever, there has never been any evident clinical signs or symptoms. The radiograph appears normal; thera are no respiratory symptoms. We know the man has been exposed to free crystalline silica. We can recover free crystalline silica from the lung which may or may not mean a thing, and j the real problem then is, does this man have silicosis. I I am aware, as you are, of our definition of silicosis, that ! if a man is in the presence of brief nodular ohadowa, radioi graphirally,and nodular lesions in the lung; yet here we i have this case where frequently silica particles are in : I cells within the lung and there is cellular damage, yet 67 what we e?e does not conform to our definition. Does this j m.n have silicosis? Those Are some of the problems. j Again, it is open to the floor. BY DOCTOR BRODMANt Doctor Brodman? i l ! Hay I speak from here? I a* one of these intrepl^ thoracic surgeons that Doctor Fletcher referred to in a very hesitating manner. I can not help but think, we speak of looking at an X-ray, with nodulation, and since there are no symptoms, is there loss of function or isn't thereT How, sometimes it becomes my duty to take out a half a lung. How, there is no question at all in that case, that there la loss of pulmonary tissue, or I might say destruction of pulmonary tissue and still that patient without, or with a half a lung gone, is absolutely simuloua from the stand point of pulmonary disease. I should like to cite one case to which Doctor Fletcher referred, and that is a case of a young man of 21 j who had an exposure ti silica, and had diffused nodnlatlona J throughout both lungs, and six experts gave six different j diagnoses. I must confess it remained, it was left to me j as the thoracic surgeon to take out a small pif:e of lung ; Which did not involve too much surgery or excessive danger j to the patient, aside from the fact that he was quite die- i mayed, and somewhat anxious, but with that piece of lung, . we were able to very, very definitely determine that the man -------------------------------------------------------------------------aa : t had BaTCO-SilicOSiS, i BY DOCTOR VOKWALDf I>octor Merewether, would you care to say anything^ I call upon Doctor Merewether because, during recent day*, j we have had considerable discussion about these things, and| Doctor Merewether whom you will hear later on in the Sym- ! posium is alao a guest at the Symposium coming from England; BY DOCTOR MEREWETHER* Jtr* Chairman, Ladles and Gentlemen* The most expert exposition of this subject this morning has, as I | expeoted, served not to show grievance so much, as to throw ! up differences in the various aspects that the people have j to deal with In this matter* I have not prepared anything on it, and I feel rather like the new tenth husband of the famous film star, in a very humble and embarrassed position^ but more particularly, because - and more particularly be cause I feel that I canft give you any answers* j Doctor Raymond Eussey implies that the Greeks may j j have an answer to these things, but I think we should batter get down to the real priorities in this discussion, as much as possible, as must be obvious to all of ua The important thing is or the important things are really -- first prior-- ; ities are prevention and compensation for those unfortunate enough to get the disease, and its nomenclature and defi nitions which enable these matters to be facilitated forwardly and these are more Important that academic pro- | tectlon, and moreover, we cant expect total prevention of these diseases, hut only a proportion, and you, no doubt,' will come along way in this in the oourse of the future, but we must try and keep up to these things in practical prior-J itiea* Therefore, since - since the word 'pneumoconiosis! in the industries and amongst the people who suffer frost the disease, has a most sinister meaning, I deplore the use of the word except in medical circles, to indicate j something that does not cause disablement, sickness or I death. Mow, it's unfortunate really, that the word has coaj to stay. It's been in existence eo long, but it ia very necessary for operational purposes that ws should know what it means, as all the speakers have pointed out. Mow, there are three types in general, of people who consider or who have to consider the word 'pneumocon iosis *. The widest conception of it is that of the man who j is not the least bit Interested, the intelligent lejman, ! the doctor whonis specialising in some other - highly j specialised in some other line of buslnees, who uses it j merely meaning a dusty lung, but it sounds better to call ! It 'pneumoconiosis'. : The second is a wide definition and a particular ' definition like that adopted - adopted by the ILO, some years 70* ago. This la Important that the ILO has to adopt a high definition, so as to enable, in your somewhat Infrequent discussion, that they have dealing with particular subject, like pneumoconiosis, there is opportunity to expand, folio, expert knowledge and focus research and compensation laws and prevention laws, and so forth, in the right direction. The third and more narrow types of definition are those which we commonly use in different form, in different tate. in different countires. They will probably always vary for other reasons, amongst themselves. In England, we have a rather tight definity, which in itself, has varied since 1926, 1926, the first main definition of these things i and that is likely to vary again as more knowledge comes along. At the present moment, pneumoconiosis is defined as fibrosis of the lunge due toeilica duet, as bestosdust or other dust,and includes the condition known as dust reticulation of the lungs. Eow, that is for a particular purpose. It is something that expert chest ph: aicians in your country, my ! country, and so forth, understand what it means, because I they have seen so many cases and they can apply it with j Justice. The word lother dust, if there was another dust, , then it would have to be scheduled separately and that i. what Is causing the troubi* *- _____ ^ trouble at the moment.Beryliiosi- i at i at the moment, for instance, is presently being compensated: 9 I\ aa beryllium poisoning. j i How, it is important to have a definition for j I compensation purposes, which can be applied by specialists ! in the field, for the reason that compensation is something: i for a - in this case, it*s something for a devastating dis-! i ease, and those people should be paid equivalent for it, this* that get it. It i8 Just to compensate them for such a j disease. j! It Is also unjust to compensate somebody who haa not got the disease, by making the definition too wide. In; our law, we also have a method, a provision in the Indus trial Injuries Act which provides for prescribing a disease with retrograde effect, a very unusual thing in any legis lation. that enables one, as soon as evidence Is found of 9 1 the occupational character of any disease, evidence that j t satisfys the criteria Just mentioned, It can be scheduled and people who have got the disease, after It Is, you know, on the list, can be compe nested. i How, I said I was going to add a few bits and i I pieces to the difficulties. Is carsinoma due to actual . trioxide dust, or nickel. If nickel is the cause, dust, or ; the bichromates pneumoconiosis. This Is not a pneumoconiosis by our own definition, so we have to put it In the Acta separately. How, mixed duet, some people suggest we should | I put the dust on, but :.ere surely we should have further j information from the c perts in minerology, and geology, j because you could have mixed dusts which are deliberately ; mixed, and they produce, as everybody knows, very mixed types of X-ray appearances. Then you can have mixed dusts which . are mixed in some areas of the country and not in others, , Thus, you can h tve a pure talc, or so-called talc, French chalk, call it what you like, which has no free silica in >. it. Yet, I have seen, I remember the last time I was j here ten ye a-a ago, through the courtesy of my old friend, that great man, that lovable great man, LeRoy Gardner, a slide of a lung which in the literature was labeled tale pneumoconiosis, and it was pretty obvious that the man died of silicosis, and asbestosis together, whatever else the talc did. It was obvious to anybody. He didn't label it I that. i Now, the quiet agreement that a thing is called ; inert, may be illustrated by Roy Gardner's magnificently i illuminating deliberations, that dust if inhaled, may cause , damage to the lung in spite of being classed as accive or | inert dust, and lastly, the main dust that causes disability in disease, we know, and if we can get a nomenclature suit able for them, we have achieved a priority, which will cause ----------------------------------- --------------------------------------------------- ----------------------... op help justice to be done to those known cases* It nay do a little damage to the researchers who are looking into the epoch type, but it is more important to see that justio# is done and do it quickly, BY DOCTOR VOKWALDi floort A r e there other questions or comments from the (Mo response), I We have had a discussion of disease* what is dia- ease* Anyone wish to comnent as to their interpretation of a disease. Doctor McCann, really, you should say something about it. Doctor Werner, care to make a r e m r k f BY DOCTOR TLtCATTgt This is a very difficult question to w hich to addresa oneself. An a clinician, I think we have to relate the word disease to the occurrence of symptoms and we anst *"**^** the outset, that disease in the sense that symptoms occur, is not so extensive that a - that it be comes a pathological process, A very skilled athlete may develop a system of distress if the emotional distress is great enough, so I think that we have then to take into consideration the fac tor of great stress, the factor of normality or abnormality I of the individual! we have to take the individual as a whoia i into account, in regard to his ability to adapt himself to j i stress* He may have a pathological process in one organ, ! for which he will comensate by the adapted irocessea in another, ao that under the same stress, he may react dif- j ferently from his neighbor. I think lta one word to try j to define disease as distinct from a pathological process} i he would have to take these things into account, aside f r o m ! i an as individual with definite pathological process recognized being produoed by silica, who may never be put under J j stress sufficient to bring out symptoms, so that from a clinician's standpoint, I think he would have to say then that disease is the difference in adaptation to stress pro- | duced by a pathological process, to such an extent that the ! Individual is unable to adapt with ease to the extent that a normal man would do so. This is very difficult. Bf DOCTOR VORWALDt We will get some remarks here. We're going to clss the session immediately because we are late. But there is considerable agreement between our thoughts con cerning definitions. However, I think that all of ua will agree that there la considerable disagreement aleo, and j i that there are terme which we are - which we use today which need definition and clarification, and thinking about this, i anticipating that we would come out of this discussion with : something that might not be concrete enough, I thought | that it might be well to make something concrete out t: ~ I I_____________________________________________________________n - i this discussion, and In debating this thing with my col* i j leagues, it was thought that we better present this to ths | j i Symposium, that this Symposium regrets the confusion caused' ! by the use of the word 'pneumoconiosis' with uncertain sseanf j lng and that this Symposium invites Doctor Seward Hiller, i ; Doctor Peterson of the Industrial Counsel, Doctor Miller j of ths United States Public Health Service, to constitute j I a small committee, to constitute a small committee under j [ the heading of representatives from bodies and individual i experts specifically concerned with the use of the term i 'pneumoconiosis', to consider its definition, having regard j to its application in the research, clinical, operative, and legal fields, with the aim of common interpretation, and that that committee should report* Yhat is your comment, do you think that such a committee should be constituted under the segis of a group I | having interest, such as ths industrial counsel, or on In- j I duetrial health, or the United States Public Health Service^ j to appoint this oommittee and this committee will consider | ' these terms and that there shall be letters - there shall j | be also corresponding members to the committee, our friends j ; from England, our friends from South Afraica and elsewhere, ! i who Blight write their views to the conmilttee. Is that ` j worthwhile? I think it is. Any expression? | ' BY DOCTOR PAUL RICHARDS: 1 I- 76. j I make a suggestion that your suggestion bs sad# j j a* a notion and I aacond tha notion. { BY DOCTOR VOHWAID: j My suggestion - it has bean suggeatod that sty sugj gestion ba mad* a motion and that that notion ba seconded. It has bean seconded. So It has been done, so is it your wish then, by a voice merely, that this be dona, and then I think Doctor Seward Hiller and Doctor Peterson in tha audi ence, and I shall place tha burden of responsibility upon either one or both of them to subrange such committee. Is that your wish by voice vote? Those in favor? (Response of ayes). Those against it? (Ho response). I take it it's unanimous, then. Doctor Peterson. BY DOCTOR PSTSRSOUt I*d like to sea in that representation, tha Amer ican Public Health Association. B Y DOCTOR VOrTtfALD* American Public Health; I*m sure Doctor Seward here and Doctor Peterson and they have heara your recaa-mendatlon, and theywill take consideration of it. j BY DOCTOR GRSSHBURGt j j | j Mr. Chairman, the American PublicHealthAesocia- i tion now has a c&nmittee at work on it* j | BY DOCTOR VOHWALD j | Well, perhaps the American Public Health As^ocia- ___________________ | ji ; .j ifcmtaiiiiW Joit i|n ti.filii.iiii 1 __________________________________________________ 77. tion should be a tri-part members of this group, with Doc tor Hlllsr and Doctor Peterson to formulate a defhition undsr the aagis of individuals, specifically concerned with the use of terms* Then I place that responsibility upon Doctor Seward Hiller, Doctor Peterson, hoping they can ar range this committee. (Adjournment of morning session 12*20 P.M.) SUB JSCTt THE ISHALATION OP CERTAIN INDUSTRIAL SUBSTANCES Chairman* Theodore P. Hatch Honday, Sept. 22. 2*00 - 5*30 P. H. Brief Beviews Silica Thomas X. Durkan Asbestos Arthur J. Torwald, X* D* Beryllium Harriet L* Hardy, M* D* Bauxite 0. O. Shaver, M.D. and Donald Solandt, K. D. Discussion* New Synsthetic Silica Philip C. Pratt, H. D* The Pats of Inhaled Particulates Merril Eisenbud Discussion, led by Theodore P. Hatch. BY DOCTOR VORWALD: i j. A-ft.^i_.* hAsikAAd ->?