Document 5km7R2Z01zYJ3GG2wZy9XL8XR

FILE NAME: Saranac 7th Symposium (SSY) DATE: 1952 DOC#: SSY025 DOCUMENT DESCRIPTION: Transcript of Presentation by Dr. McCann [Introduction] kTL> CLINICAL ASPECTS O7, PNEUMOCONIOSIS Chairm anJ W illia m S . McCann, M, D* Incidence o f C lin ic a lly M anifest D iffu se O b s tr u c tiv e Emphysema L e o n a rd J* B r i s t o l M* D* D iscussion P u lm on ary F u n c tio n S t u d i e s i n Men E x p o se d f o r Tan or Mora Y e a rs to I n h a la tio n o f A sb e sto s F ib e r s F e rn a n d O r a g o lr s , M* D* D isoussion Maximum A b i l i t y f o r P h y s i c a l Work o f M oderate D u ratio n C o r r e la te d w ith V ariou s T e s ts o f pulmonary F u n c tio n G e o rg e W. W r ig h t, M. D* D isouseion C a r d io -C ir c u la to r y A sp ects o f the Pneum oeoniosss W illia m S . McCann, X . D. D is o u s s io n l a d b y James J , w a r i n g , M. D* BY DOCTOR McCAHNt L a d ie s and Gentlem en, sin ce the t i t l e o f th is m o rn in g *1o m e e tin g i s th e C l i n i c a l A ep eo ta o f p n e u m o c o n io s is , I s h o u ld l i k e t o ta k a t h e C h a irm a n 's p r i v i l e g e o f mak i ng a few In tro d u cto ry rem arks to th is session * T h e re h a v e b e e n s e v e r a l p o in t s w h ic h h a v e ccune up i n th e c o u r s e o f th e r e c e n t nee t i n g s w h ich se e n to me w o rth y o f comment* F i r s t o f a l l , i t was a g r e a t p le a s u r e to le a r n ________________ _______________ ____ _ ________________-- rI ikZM BY DOCTOR MIDIiR; Any fu r th e r q u estio n s? (Ho re sp o n se )# I f n o t, t h i s symposium w i l l a d jo u rn to 9 sO0 A# M# toinorrow# (Adjourned a t P H .) i Ttte+ii.* u n s TOM PASS 477. Sjt 'D*.vW- o By DOCTOR HC S * g i I*d iB tad Oontlaaan, Bine* tbo t i t l * of tld om iaf'a TOTt 1nc i tha C lin ic a l Aspaoto o f Pnaaooniosls, I ehaold l i l to taka tha ChalTHSJi'B pririJLaga of Baking Sow introductory raurkB to th is mbs! on. Ytiere here been gergral point# wfeieh h**o ombb op 4a thd course of tbs radont soatlnga which soaa to bo worthy of o h m * . Tirat of a ll, i t was a groat pLe&soro to lo a n _k78*. froic D o c to r P h i li p E ugh-Jones th a t th e r e l a ao much v a l i d i t y in th e c l i n i c a l a e s t im a t io n o f d i s a b i l i t y . He w as, o f co u rse , a peaicing of c lln ic ia n a , I w ish I co u ld be su re th a t h is rem arks a p p lie d e q u a lly to ua here in A m erica, w here, i t aeema to me c l i n i c a l m e d ic in e has f a l l e n to a lo w er s ta t< due to our n a tio n a l penohant f o r g a d g e te e rin g and sim onpure s p e c ia liz a tio n * N a t u r a lly the q u e s tio n a r is e s in you r mind as to why I t b ^nV t h e r e ' s so m eth in g wrong a b o u t s p e c i a l i z a t i o n * The a n sw er to t h i s i s s im p le . As one le a r n s more and more shout le s s and le s s , he tends to became u n able to see h is p a tie n t as a whole person a g a in s t h is whole environm ental backgroun d* T h is , i t seems to mo, i s th e v e r y e sse n ce o f u n d ersta n d in g th e n atu re and meaning o f d is e a s e and as one becom es more and store s p e c ia liz e d , he becom es the v e ry a n tith e sis o f the c lin ic ia n . Now, the o th e r day, th e q u e s tio n came up o f t r y in g to make a d e f i n i t i o n o f d is e a s e . I made a v e ry lame a tte m p t a t i t , and X s h o u ld l i k e to d e v o te a moment o r two to an a tte m p t to d e fin e d is e a s e . D is e a s e s may b e re co g n ize e or c la s s if ie d by c e rta in c r it e r ia . P ir s t, th ere are sim ple - th e r e a re symptoms and s ig n s ; se co n d , t h e i r c a u s e s , t h ir d the n a tu re o r the p a th o lo g ic a l p ro c e sse s u n d e rly in g them, fo u r th , the ch a ra cte r o f the environm ental s e ttin g in which th ey o c c u r , and f i f t h , the p e r s o n a lity or c o n s t it u t io n o f I *WfrfMis.TUUi iPIH^ w ___________________________________________ ____________ l o a the p a t i e n t who s u r f e r s d is e a s e . T h e se a re the p igm en ts w ith w hich th e p ic tu r e s o f d ise a se a r e p a in te d . T ra cin g the h is t o r y o f n o so grap h y, Sydenham s a ld s *Symptomata se habent ad morbent u t f o l i a e t f u lt e r a ad p la n ta a u " Symptoms are t o d is e a s e a s the le a v e s and f r u i t s are to p la n ts , and fo llo w in g L in es n s , he tr ie d to c la s s if y them. Auehbruggor* Laonnoc, Stokes* Corrigan* Graves* B rig h t. Addison. Louis* A n d ral. B retto n eau . a l l r e la te d s ig n s t o m orbid an ato m ical ch an ges. P a ste u r and Koch began I the ooncept o f s p e c ific causes* P eop le lik e W illiam E arvey, I M agendle. Claude Bernard la id the fo u n c a tio n fo r p a th o lo g i- | ca l p h ysiology. j L o ca lise d environm ental s e t t in g s w ere f i r s t taken [ i n t o a c c o u n t by R am & isin l and th e f i r s t g r e a t c l i n i c i a n to | take account o f e n tire p e rs o n a lity o f the p a tie n t was Char i cot* j To C lau d e B e rn a rd we owe t h e b a s i c c o n c e p t o f d i s - ! ea se , th e e f f o r t to m aintain co n sta n t in te r n a l environm ent ! fo r the in d iv id u a l c e lls o f the body. j To th is end, ag greg a tio n s o f c e l l s , w hich we c a l l jj o rg a n s o r sy ste m s o f o r g a n s , h a v e s p e c i a l i z e d f u n c t i o n s in j m aintaining th is con stan cy, th is hosaeostasis. i; I i; These fu n ctio n s are in te g ra te d and re g u la te d by !; the m e d ia tio n o f th e n e rv o u s syA tem , c e n t r a l , p e r i p h e r a l and; U.8 0 , v i s c e r a l, and by the b alan ce in hormonal a c t i v i t y , w hich d e term ine the c h a ra c te r and c o n s titu tio n o f the person o r as we s a y i n d i v i d u a l p e r s o n a l i t y * Bach in d iv id u a l must adapt h im self to h is e n v ir onment, not on ly th a t wnich i s immediate o r l o c a l , b u t the e n tir e environm ent, p h y s ic a l, c lim a tic , r e lig io u s , m oral, ev ery in flu e n c e , w ith which each p erson m ust s t r i v e fo r a s u r v i v a l in p e a c e and c o m fo r t o r w h at we c a l l h e a lt h * Vhen environm ental fa c to r s cause s t r e s s , the s tr a in on th e in d iv id u a l to ad ap t t o i t p ro d u ces the symptoms o f d is e a s e * Hormal i n d iv id u a ls d e v e lo p symptoms and s ig n s on ly the s tr e s s i s u n u su ally g r e a t* Abnormal in d iv id u a ls , whose a d a p tiv e fu n c tio n s are lim it e d o r dam aged b y p a th o l o g i c a l p r o c e s s e s , show s t r a i n when th e s t r e s s i s n ot un u s u a lly la r g e or even when i t i s l e s s than u s u a l* D is e a s e may o c . u* th e n i n b o th n o m a l and abnorm al persons depending upon the d e gre e o f s tr e s s r e la t iv e to the c a p a c ity to a d a p t. As w illia m H arvey s a id , th e re are two kin d s o f d e a th , f a i l u r e from a la c k and s u ffo c a t io n from an e x c e s s . By t h i s p re a m b le , I w i l l now v e n tu r e to s u g g e s t a d e fin itio n o f the pneum oconioses* They a re a group o f d is e a s e s c h a r a c te r iz e d by sh o rtn ess o f b re a th and d im in ish ed c a p a c ity f o r e x e r tio n I and th e perform ance o f m ech a n ica l work caused b y the p ro lo n ged and rep eated in h a la tio n of p a r t i c le s of su b sta n ces w hich, in V T 't L.81. BU_ f f i c i e n t am o u n ts, a r e c a p a b le o f p r o d u c in g m o rb id anatom i c a l changes in the lu n ge and c ir c u la t o r y a p p a ra tu s, such as f i b r o s i s , emphysema, lym p h atic o b s tr u c tio n , pulm onary or pulm onic a r t e r i a l s c le r o s i s , h y p e r ... r ig h t h e a r t h y p er trop h y, ad h esive p le u r it ic , and so fo r th , in varyin g de g re e s and in varyin g perm utation s and com bin ation s. They are c l a s s i f i e d b y the c h a ra c te r o f th e d u s t, by the n ature o f the o ccu p a tio n a l environm ent, su ch as m ine, fou n d ry. Quarry, san d b lastin g , and so fo r th , and perhaps w ith in these c a te g o r ie s , lo c a l, d e sig n a tio n s such as W elch c o a l m ines o r L a n c a s h ir e c o a l m ines o r P e n n s y lv a n ia h a r d c o a l a r e aL - ao f o r t h . In evalu atin g the degree o f d is a b ility re su ltin g from these d is e a s e s , one must co n sid er the o o n s titu io n o f the whole p e r s o n a lity o f the in d iv id u a l p a tie n t in c lu d in g h is m otivation and h is cap a city to condensate fo r in ju ry in one organ system by improved use o f a n o th e r. I t must a lso take in t o accou n t o rg an ic im pairm ents which are n ot the r e s u lt o f o ccu p atio n al s t r e s s , such as a g e , h a b it s , nu t r i t i o n , in h e r ita n c e and en viron m en tal s t r e s s e s o u ts id e the occupation. This in vo lves a thorough gen eral d ia g n o stic stu d y . I n c lo s in g th e s e remarks, I w ould l i k e to comment j i on the p h y s ic a l d ia g n o sis o f emphysema. I have h e a rd i t j s a id th a t th e re is no pathognom onic s ig n o f emphysema and I , do n o t b e l i e v e t h i s . I th in k th e re i s one s ig n and th a t h a i to do w ith a u s c u lt a t io n . The b re a th sounds in emphysema c l o w i n t e n s i t y and p it c h and the e x p ir a tio n i s o f lo n g e r d u r a t io n th a n th e i n s p i r a t i o n . How, i n a p p r e c i a t i n g t h e s e c h a r a c t e r is t ic s o f the b r e a th sounds in emphysema, I b e lie v e th at a steth oscop e is a handicap* A steth oscop e i s , a fte r a ll, a good deal lik e the re ce iv in g se t of a ce rta in ra d io . I t w i l l se p a ra te bands o f fre q u e n cie s o f sound and v e ry o fte n c e r t a in bands sire c u t cu t o r b lo ck e d b y th e s te th o scope* I , th e r e fo r e , th in k th a t one sh ou ld r o u tin e ly l i s t e r to the ch eat w ith the e ar d ir e c t ly , in o rd er to ap p reciate th is and to p ay a tte n tio n to in t e n s it y , p it c h and d u ra tio n o f sound* I n t h i s m anner, th e p r e s e n c e o f emphysema may be d e te c te d when the X -ra y p ic t u r e ia s o f u l l o f d e n s ity th at i t is obscured* How, th e r o le o f th e c l i n i c i a n in th e stu d y o f d is e a s e i s l i k e t h a t o f man t r y i n g to p u t t o g e t h e r th e p i e c e s o f a p i c t u r e c u t b y a ji g - s a w * He i s f i r s t t o exam ine the p ie c e s in ord er to guess a t the nature o f the assem bled p ic tu r e * The c l i n i c i a n must g u e ss, he must sp e c u la te , he must p o s tu la te as to the f i n a l p a tte r n i f he is to put ths p ie ce s to g e th e r q u ic k ly , q u ic k ly enough to be o f any use* He m ust h a v e so m e th in g l i k e c a t w h is k e r s i n h is mind w hich e n a b le s him to d evelo p a d ia g n o s t ic hundh as to how t h i s p i c t u r e i s g o in g t o tu rn o u t . T h is i s th e g " e a t  hort-eut and tim e is o f the e ssen ce , as H ippocrates s a id : "The o c c a s io n i s in s t a n t ." T h is a ttrib u te o f the c lin ic ia n is often not ap- J p r e d a te d b y the s c i e n t is t , u n t i l he h im se lf becomes a p a tie n t and h as reason to thank a good d o ctor fo r the speed o f h is s k i l l end acumen. The methods o f so ien o e are lik e the o ld three d eck er, w h ich took a w atch to s te e r and a week to sh o rten g a il. They are a p p lica b le to the study o f d ise a se s, bu t not Yery a p p lic a b le to the atudy o f the p a t ie n t . One f in a l word I would lik e to sa y about th e te a c h in g e f c l i n i c a l a e d i e in e . Someone s a i d , Y ery w i s e l y , that i f tea ch in g co n sisted only o f tra n sm ittin g fa c tu a l know ledge, th e re wouldn' t have been any excu se fo r u n iv e r - s it ie a or p ro fesso rs a fte r the d isco very o f p r in tin g . Ihe job o f the te a c h e r i s to endow the f a c t s w ith th e ir im ag in a tiv e consequences# Young p u p ils are o fte n s k e p tic a l snd th e y 'r e o fte n s t a r t in g in v e s tig a tio n s ju s t to prove the m aster i s w rong and i n t h is w ay, w hether he i s r i g h t o r wrong, knowledge advances u n le ss the w eigh t o f m a g is te ria l a u th o rity i s so g rea t th a t no one dares to ch a lle n g e i t . I was moved to make t h is l a s t rem ark b e c a u se , in my own p r e s e n t a t i o n , I h a v e a llo w e d my im a g in a tio n to w ork on th e f a c t s to same e x t e n t , (A pplause), How, I th in k I h ave ta x ed you r p a t ie n c e o ve r lo n g THE* FRCM PAJ iM* V w ill proceed to tbe fir s t paper on tbs proerss by Doctor Leonard Bristol, ee tbs incidence of clin ically nanifest diffuse obstructive i f h j i w i . Doctor Bristol. Qt?lraaa*a Sare&qr, Siiyilnrtwr 2J| IM1 S tm tk ftlllaosla O otfim M filla le s l A cpw ti ( f FawBKWXwriortt M BeCaan hgi L 1 < I t u a p lM isn to 1m m A m Jr. W U f Jwn-- th at tear* ia aa m at t a llilt y to tba n <--'> artlaatlaa o f d isa b ility * Bo a t o f r a m , aptakia f o f Brltiah d is ta la a e . X X r a l i ba m that Ida w a i t s W ?i d a<gMU y ta aa bars ia Jasriea, it w a , i t asm s to aa olla io al B attalia baa f u l l * ta a lav a it at a. * ta w r national pwnifewt f w caisctaaaiag ant to r linnn pira a< a* ta a&traaa aysalf to asswar tba f a d i M d i d BStaratty ariaee i a yeer a ta t sh at la aa *WB tb eet tb s aaaaar la ai- pr, . | | e s , x sm a "asr* a t aora i W t Xaa* a t law * ba train ta bnaraa r a th is *o m b is p e tie st aa a i&ols agatiaat tba t e d p w B o f h ia id ola r a i w u d * y.i^ tba W f a f i d e n t n U a i tba aatara a a i affiasiai o f dlsaaaa* Aa aat oes*a a ai r a a wp*<oU.cai ba b w a a a tba way catitb aaia a f tba t w a1tffltftiaa< lo t e s attaapt a B afin iilaa * f dlr#at nay ba aeaegciTai aai tla aa lf iad J f i (I ) S a ir praatesM aai d n a i (S) tk ti9 r^ 4M l(3 ) t&s ca"ur* * f 8 ^ 8 * pgsagesai as& srlylsf tir a i (4 ) tba chsrostr a f tba 6^-fctjaa in wteLsh t&ay oom n aad (5 ) tba p aw oeallty ar *ooa*titabio*" af tba potlont abo raffers *dia-eass* Biana aan tba plgasota with which tbo sdotsrss o f rfirrm oa - eesep'sgshy i n p tisid < S^t'oh&a o^aptesata at hobeat a i nortxwt a t fo lia a t foltara a i plaotoa." iaeghruggor, Laeosaa* Stokaa, Corrlgoc, Gxwrao, Srifibt, fddlooa - Loda Aairal - Brwttoaaao, o tal - rakftai alma to tba gterbt A aat&gtefliL chaa^oa. Tastaar, B ttrtm l Aepooti f v .s . xem b hfli a. b e k , Tiiujii ( b t eontaf* o f speciA * Soopli Ilk * W llllm B u rn fi ta@8toLo# tp T*m 1 'll I too f i r s t gpmt illu rtria a to toko M o n t o f to* s a t i n iunroim olttr o f tto p e tis n i a * O ttfM it to S c ro u i vm s m too b u l l ooBMf t o f Alsdasa - tits o ffw t to ta trA rla w oetM l l i t o n a l a n l i c a n t fo r tho la iltU a il M ill of too M f to t o i l oA o ssrssstio o s i f M ill, taiefe so e ll orssas o r sy d sa* o f orpm o, hxf* spseislisoA f s i U s a i in n slo to la iag t o i l c e e s tc a ^ t o i l IssBSostaeio. toss* iS sr-lla si n 1otogn&o* m i rifR lsto d fagr to i m rtlatlw i i f too s * r? * s eystm , p e & p ta rsl, aaft r it o o n lj m i tor to* balsam l a te n sa sal es\L '*i& , h lA AaftsrrsiM th f to s r s * t a a l e so M ita tio a o f to o psgiaa o r * m m i IM lg l^ a il Seek to d iv i& a l a m t ofeoi to h is sSSiS^SS&k a a t O jr to s t dto i s ia a ta ls to , o r l e a l , t a t too * lr marlguiwiiiiial - ftgraim l* taU ^U rn* a s n l * m o t ln fia w a i v ith whieh u k pm * a n t s tr im f i r e u rrira l la p m * cad cec fari o r bailtS i. to m serty em sstal S ta to n oaaso ir tm t - too sfcnla o f too iad lT id tal to afejit to I t p t o m sjsp ta e i s ta algos of Bonsai in S i^ d to li d srslco * sign* o n l/ to m too g&rffsa i s iRBMgoUjr grab. f i s n a l IsdiTi/JaaLi, adaptivo fto w tio n i o n I M U i o r d s a s id fey petbe* p n e s s o o i, show o tia ln t o n the stg o o i i s aot nmoiwlljr la rg o r w t o * i t i i lo ss tom w a i l . P irsm my ooeur tom i s both noraal and ite o m l proooo topooilas *poo tos dogroa of itrom n l a t l n to tho capacity to wtoj* h i % C iitia ! Aapesta af Pmwiiloan><tools - W . MoCiss A Sasvar a tU - "B n n *'* two (dads o f t e t k - fa lla y a A m a iM k ad saffbes&lm t r * w e****' tilth tisie p?ashl Z Kill saw wstw to sasgsMt s d a flsllia n of ta ggspgaSter era a crowy af t t m o a ahasaatasissd hr ohartaaaa o f hrastk aad d iaiaish sd aaps& tr for c ssr tio s sod tfea parfiosna&ss o f s oohfflrtaal wwki aeasad t r tk i i s e l o ^ i e a t rapaa&sd lak alsttn a o f partlalsa o f ehstaasas, w h l* i s aaffled eot aasrais as* owfohla o f prodaala aosfeld rao&aalaal afeaoas i s tb s Leass* tsd airrcda&ajijr ag^sratas, soak as f lb m io , a ^ M M f Z^pbetia featpstaMaa* p ila o io o it a i f f it o M U , r l^ t haart t yporti^ fty , iftMtTO pZsaritla* at ., i s 4y nM> **o is w jH U j paartottoM and aoaiMrattions Soar is o t l t s s i / l s i t r tba ^ s a s ta v o f tba dart, t r tia aafauri i f tha o M s^ U so tl fumolsy , tfaagsp, etss& lssU ad, oto<) Zs * i tia| to 6&?aa <hf m elt tin Aroa tkraa dis^sos ess ssst saasidar tsa scss&r!as ef tka whsla psoosiiitr of tfco isiio id a t pa^ad, is - aUdUn his eatloaAlss rad his c^seltr ta aaepeasste for i*r is eea ca^s tr iapwrod m af ts o tte , Zt o u t alaa tala lsfea aaaaaat arg&ais fc^tisaadi t&idh era sat tia stsoll of eesupatisral okmai esak aa a*a, fcohiia, astsllica, rad rl2<3esBSl sI tsssss cc&sL$a tfca oasspatlaa. This IsvalToa s tharw^i s^sral Ia cifcc-ia* tes> rraarks, Z Qld li&a to ccaargst ca tbs *jftzgi;&Z af 1 i t esid that thora is so paUsagjaaoBia ts of $*ywa Vat Z & at hollars th is. I think t&ara ia geo dpi) rat that has to da with *fea We&th eoasda is aspkraaaa ara of lew istoasltr ead pltsh, aad tha a&irsHga is a f 1 dtoatloa U a l&opixmtlea. tha uaa af a stat^eooopo is a ( y tq w te irlE 2tiT eas8<|Bass** Ssrag *** W *4-*1 * * lAXX ***** # U r i i-.-s ssti^ tiia a t t e p v t * tfe I t o W wfs* a s* i * tk U T , ^feelSwr h* 4 t r ms& & ksat&Bi&t s^raas*. nwlfflss to * w al^ A s f w ^osH y i s e p o t tfefiA as d s n s % d a l l w y ifc* * w r r rvt,w 'r 5M " r * S. McCuot, M. D. .t h o im oHmam th* universitt of rochbster SCHOOL OF MEDICINE AND DENTISTRY AND STRONG MEMORIAL HOSPITAL l 6o CUTTENDEN BOULEVARD ROCHESTER DO, NEW TORE October 1 , 1 9 5 2 Dr . Ar t h u r Vo r w a l d Saranac Labo rato ry Saraha c La k e , h I De a r Ar t h u r : Do YOU WANT CUTS OF THE S L I DE S USEE FOR T HI S PAPER? I f n o t , here: i t i s ready for p r i h t i n g . Wi t h k i h d r e g a r d s . S incerely yours, Wi l l i a m S . Mc Ca n n , M. D. IVSM/ u