Document 6Gb89oK00yMy9q5Y94bdKBq4

FILE NAME: Saranac 7th Symposium (SSY) DATE: 1952 DOC#: SSY015 DOCUMENT DESCRIPTION: Transcript of Presentation by Dr. Friedman Pneumoconiosis in Coal Miners in Alabama Thrrn F3CM PAGE 257, PHSOXDCCSIOSIS IB COAL h 'uS (Continued) 2iS0 to 5t$Q ?M. . Sept. * H l Cxarmm 0. A. Sandar, M. D. ; Paei&sosonlOBlB In Coal Minors in Alabsna 3 >onis ItPpl&sMaa, K. D. Ciscossioa 3 Pnlsss&cey Fsuotioa Studioa of Coal l-Jicara in Pennsylvania and West Virginia Barley L. I'ofclny, H. D. Pssisjsjjiasy Function Studies o f Coal Kinars in ales Philip Bagh-Joaas, M. D. MscuBEion BOOTOH SA5PS?.s Xsat's Lava tha asatlng costs to order. V' U carry -0 on with Black Tuesday* the Pneumoconiosis of Coal Miners day, and see if we can confuse and confound you a little more this afternoon. First of all, doctor Vorwald has an announcement. BY DOGTOR VORWALDt It's a very simple one, and that is we are re quested again to remind you, those of you who wish to at tend the banquet, to please register oefore tomorrow noon for the simple reason that the hotel manager must have the number of people who are coming so that he can prepare the adequate amount of food for the group and set up the num ber of tables that might be requested, so please register for the banquet and know also that the ladies accompanying j you are invited to the banquet. KV D OCTOR SAffDSRt The first speaker this afternoon has had a large clinical experience with a group of bituminous miners in | Alabama. He will tell you about it, his clinical experience with this group. Doctor Louis Friedman of Birmingham. m -DOCTOR FRIEDMAN: ' My remarks this afternoon will be based upon our j experiences in the study of about three thousand soft coal { miners in Alabama. When I wa. much younger and before I \ had the advice and counsel of people like Doctors gander, j 1 Vorwald and Doctor Lanza u d Doctor Hussey, I accidentally j _ TAKES FSCM PASS 25$* C o BjEEtaaiissaaft rssark8 tils aftaraooa ill t* ba*i apan o'er *g$*a& 6& eoB ia tbs study of aboat tfeoa tfceasaad soft coal raiaars la dlabsaa* hen I was such yooofar and bsfaare I fed tha advleo and cosbmI of peo^dJt Ilk a Der''sr Saader, V crvild aod Eo-stor La.s& aad $o.tssr Sissoy, I oasidsatally '-W called my d i s e ^ e anthraco-silicosis, with some justifi- j cation, I thoug: They have subsequently persuaded me, energetically and in a very friendly manner, to convert the title of my paper to Pneumoconiosis in Soft Coal Miners* and then when I mentioned that to Doctor Lanza, he added In Alabama*. I had nothing to do with the title. The pulmonary dust disease, as we see it in soft coal miners, is a disease whi. produce, disal-lity, both j on a structural and functional basis. My remarks to you j this afternoon will be from the point of view of a clinician as Doctor Sanders indicated, and our great concern is the correlation of X-ray findings, clinical history and func tional studies with the total picture presented to us by thjj patient,. Unfortunately, it is not always possible to des cribe disability on the usual standards in the case of coal workers' pneumoconiosis. Only so frequently do we find a lack of Roentgenographlcfladings and nevertheless, we arej confinced that the man's occupation fcaci something to do with his present disability. I would like to show you -- slide, pleaso in tne first slide, I would like to show you s ome of the j terminology that we use in Alabama, at least we use in our j clinic, to simplify the problem, llow, in presenting tnis . classification of clinical disability and Roentgenographic 2 3. classification of the disease, I do not mean to taka issue with Doctor Fletcher in x.he wonderful work that he has donej in breaking this Roenggenographic picture down to its fine elements# To no, this is the clinician*s idea of the classification in which you ascribe very little, in which you do not rely upon your X-ray for further than identi fication, ana in some instances only do you use it on the basis of very pronounced structural changes, to determine the fact that this man must obviously be disabled. We merely use the Roentgenogram to classify the particular disease and call it pneumoconiosis of soft coal workers, and then we use our clinical studies and laboratory stadias; to determine whether there Is any disability. We consider, in sensing a rearms disability, that a man is either disabled or not disab.id as a result of his occupational disease, and on that basis, you can have j ! a disease which is disabling, temporarily disabling, as I will "3how you later in the slides, or you can have a dis ease which is non-disabling, and for .those of us who so frequently '"Ind it necessary to sit on a fence, we have the fourth classification of possibly disab" ing disease, until we can make up our mind three months later when you come back for another X-ray and examination. Frdm the poins of view of assessing disability, I would like tc take this moment to say it is very easy for 261. a doctor to raly upon his functions tudies after tney'rs | donQ in the propar fashion and say `This man has forty I percent disability*. Well, that is from a medical point j 0f view, but you take a coal miner who has no education and j who has worked in a coal mine all of his life and a; the j age of forty-five, fifty or fifty-five, suddenly finds himj self with a Isease that will progress is he is exposed to his present occupation for any further time, to ray w&y of thinking, and I think that is shared by some of th members hero today, that nan is actually a hundred percent j disabled, because he can no longer find his economic place j | in society to gain a livelihood and taka care of himself j | and his family. J ! How, as regards the Roantgonograpnic class iij.-- cation, you will notice that we have Sype 1, which is a S linear variety, a linear change in the X-ray Which probably | corresponds to Doctor Fletcher's simple pneumoconiosis, !i and then the Type 2, the nodular variety which we do not j] see vary frequently in coal miners, and Typo 3, the mixed, J | on8 in which you see a picture of linear changes end nodu- j [ lar changes in the Roentgenogram, Type Ij., the conglomerate j j coalescent variety, naybo a progressive change from Type 1 , j t 2 or 3, so you may have conglomerate coalescont nodular j ; pneumoconiosis of soft coal worker? - and finally in Type 5, j ' the Roentgenogram itself, you can see that this is a i 262. complicated case, pneumonia, bronchiectasis, spontaneous pneumothorax or some other complication which we are able \\ to discern from the Roentgenogram, and, therefore, in send *i ing a communication to another doctor, another clinician, who doesn't gee too deeply into the breakdown of Roentgen- ographic types of disease, we could say that this man has non-disabling linear pneumoconiosis of soft coal workers and immediately he knows what we're talking about* Next slide -- No, on this first slide, you'll see -- I wonder if we put the lights off whether we couldn't have a better view of the screen. Now, on this first slid you see the :>ray of a twenty-seven year old boy who diea of accute monocytic leukemia, after working only three and a half years in a soft coal mine, and if you notice his Roentgenogram, there is not'- 'ng particularly reveal.ing about it and it could be classified as increased bronchio- \ vascular markings. However, the next slid -- you skipped -- Now, this slide shows a cross-section of his lung prepared by Doctor Go.fo in Wales, and you will see that he already j has the deposition of coal nodules throughout his entire j lung. Now, I use the term coal macules to correspond with j Doctor Eebbleston's description of the disease pathologi- j csilly. Now, if you will notice, although he has these i 263* marked macules throughout his entire lung field, there is no evidence of modulation in the X-ray and we have no evi dence from the X-ray that this man even had any changes compatible with an early type of pneumoconiosis. However, those of us who work with the disease and know that the changes, the early changes or the nature that we saw of tho X-ray of the patient, would suspect that something was present in this man's pulmonary tissue that wasn't present in a normal individuals chest. How, this is an example of another linear variety! of pulmonary dust disease in s of t coal workers and, a l t h o u ^ this patient doesn't look particularly disabled from Roent-| genogram, he is unable to participate in any gainful occu pation after having worked thirty-seven years as a coal worker in Alabama, Hext slide. . How, this is a slide also allowing only increased bronehovesicular markings and nothing par ticularly significant. This man died of accuta lymphatic sukemia after having worked thirty-five yearsin a soft 3ul mine. I would like for you to look at the apices of lis lung very carefully, because the whole lung eecvion inj ais case will not correspond at all with wnat you have j 1 esn from this man's X-ray. j _ _ ^ ^ +-V-s -r see the focal emphysema, the coal by Doctor Goffe, and you deposits and some evidence of silica spread throughout this na n 's lung field. Again, pointing out to us very clearly that you can not rely upon the Roentgenogram to determine either function or the degree of pathology wnicn you will find vuen you examine the tissue at necropsy. How, this is an example of nodular type of pneumo coniosis in the soft coal worker. That's wnat you think and that's what I thought, but it isn't so. This man work ed in the coal mine, but he actually wasn't a coal miner. Ea worked on a motor up a haulage way and for thirty-three years, he sanded a track in front of him and he was inhal ing pure silica during that entire period of time and it's only in those instances in Alabama that we are able to find both a motorman and people who do a lot of drilling in hard rock, evidences of the nodular variety of pneumoconiosis in soft coal workers, so actually this man, although he worked in a coal mine really wasn't a coal miner and he actually has a true case of silicosis. How, this is an example of a seventy year old nan and. as you =, da has bold nodules and linear chsneea ln both lung fielda symmetrical, and you would tnlnli fr= ; this X-ray, that tha nan should . -VO a great deal of dls- j ability. On the other hand, he iever complained of any j signs and symptoms referable to his - to his lungs, no j dypsnea, no cough, and ho died of a carcinoma of the stomach 26$. X wtuit to apologize foi* the fact that this was not prepared in color, tout as you sea in this wnole lung section interpreted toy Doctor Goffa, indicatos that this man not only had coal but a great deal of silica in his lung tissue. At this point, I would like to say that we have two groups of pati uts in our c&inic. We have coal workers and ore miners and, in our experience, it appeared that the coal miners suffer greater disability from their exposure to coal dust than do people who work in ora mints. In this particular casa, you can see the extensive changes in this man's lung field without any evidence of clinical disability for a men of his age compared to another man who had to work in a coal mine of the same age* The next line is the microscopic section and you sea here, you see the silica nodulos, you see some of the silica In whirls and in the middle of the nodule, you see dus t. The next slide. Now, this is an example deposited ! the coal Jj of a Ne gro who had worked twentym soma yours in a coal nine who came in complaining because of pain in his chest. We ex amined him very carefully and even though we maintain a ' high index of suspicious - of suspicion taat this man may j be sufferin' from pneumoconiosis of soft coal workers in j Alabama, we found no evidence to substantiate our finical | inuression that he may have the disease. Therefore, we did: some additional studies and in the esophageal examination with berium, revealed a little nick in his esophagus and because he had a widened mediastinum, we decided to explore this man and see what his trouble was. Well, that surgery, Doctor Charles Donald, a thoracic surgeon, performed this operation, found that both of his lung fields were full of nodular masses which we wa unable to see in a Roentgenogram, and this microscopic section was taken from the mediastinal lymph node which was the size of a tennis ball, and as you see in this mediastinal node, evidences of silica In whirls and coal deposits, so this was another example of more pathology j being present in the pulmonary tr'ssue than we were able to discern in the Roentgenogram. Now, this is an example of a man who died in his seventies, and of a cerebrovascular accident. He suffered from hypertensive arterial cardiovascular disease, and if you notice his Roentgenogram, examine- it carefully, you don*t see anything too revealing. You see the evidence of increased markings and for most of us who are really inter-| ested in disease we could possibly read into this focal j emphysema. j Now, notice the left lung and notice the right j lung and notice the next slide that appears. Focal emphy- : sema, evidence of the coal macule degenerating and causing tbs focal emphysema and similarly, in the left lung over there, ao you see again the evidence of the disease patho logically is much more extensive than you can discern in the Roentgenogram* Now, this is only a clinical example of what we term conglomerate coalescent pneumoconiosis in soft coal workers. Here you see a solitary nodule in the right apex. Now, I would like to say this, in the ensuing slides, you will see more examples of conglomeration and coalescence and wo experience a great deal of difficulty in attempting to orovo the diagnosis of tuberculosis in those patients. By very exhaustive laboratory studies which In clude smears, concentrates, culture.-, guinea pigs, and all other varieties of tests which may ascertain the presence of tubercu! '-sis - of tubercle bacillus, we only too fre quently find that we are unable to demonstrate it. Perhaps Doctor Vorwald*s contribution last year or the year before j on the B. C. G. vasicine in silicotic animals could possibly, explain the fact that we have evidences of infection or at j least evidences of conglomeration, and coalescence in those j places in the lunS where <ou ordinarily find tuberculosis, j and still we are unable to find a tubercle bacillus. Perhaps it doesn't take too many tubercle bacillae to set the pro- ; cess in motion here and rater on, we just can't f m d them , either in life or in death. As a natter of fact, during 268, life, we only find tuberculosis in our patients in about ten or fifteen percent of the cases, whereas were able to double that at the necropsy table* This is another example of conglomeration and coalescence in a soft coal miner, and again we wore unable to prove tne existence of tuberculo3is, and incidentally, in tils particular case, the man's tubercular test was neg ative, Recently, I have come to the conclusion, whether it's right or whether it's wrong, that whenover you have conglomeration and coalescence in assyianetry in the lung j j fields of people who serve - who suffer from pnoumoconio* sis, I believe that ue are Justified in ascribing the assymetry of the conglomerate and coalescent lesion to a { superimposed infection, more tnan likely tuberculosis* Next slide* This, now, ir an example of a fifty- five year old coal miner who has bi-lateral conglomeration and coalescence which probably fits the terminology of angel-wing distribution of the disease, This man had open j I hemoptysis - the man hau hemoptysis on frequent occasions j and we examined his sputum on the time that he had hemopty-J sis and the times he didn't have hemoptysis and we have j Still been unable to prove a t u b e r c u l o u s I n f e c t i o n in this j particular case. Of course, he's terribly disabled, not ; only structurally from what we see in the Roentgenogram, and what we know will happen to tht man, but also on the 262* j: basis of functional studies# I' in the next slide you will see what I presume to || be an ensuing stage of this man's disease. Here you see ji cavitation in the right upper lobe and a similar type of `j lesion in the left lung as we demonstrated in the previous slide# Of course, we had no difficulty in this particular case in proving the existence of tuberculosis, tuberculosis !j ! in this patient# ! Hext slide. I believe that the slide before the ! one I just showed can go to either the tubercular stage ij that I Just showed you or else it can develop the conglomji arate coalescent features of the X-ray on the right or it 1 may go cn to develop the changes noticed here on the loft, |j in the left slide, the left X-ray# | It may be of interest -- one moment, please -- it j nay be of interest to you to know that both of these pai- j I ients at autopsy had tu'r.srculosis and exhaustive studies in \ _ !i both instances over a psriod of several yaars, failed to | revoal the presence of tubercle bacillae, and at the au^op , j: -- table, the tissue obtained was examined oy Doctor Casey, j ' the pathologist in our community# He had a great deal of j - dixTuculty in finally obtaining sufficient evidence to call ^ : this tuberculosis, but he did find the organism. | ; ITaxt slide. How, this is an example of another | coal miner ..no worked twenty-nine years in a coal mine 27.Q.M. excuse me -- twenty-six years in a coal mine and three yeari in an ore mine. Notice the conglomerate and coalescent lesions in his apices. This is not an unusual picture in Alabama, where our coal miners have to do a lot of drilllag, so we have a sufficient admixture of coal duet and silica to present this type of picture* I want you to notice the lower parts of both of these lung fields and the upper parte and then in the next slide, you can see the conglom erate coalescent lesion in the pathology and in the lower half of the lung field, you see nodules or macules of coal i which were not discerned in the Roentgenogram, indicating : again that the coal macule itself is not the radiopaque - has not the radiopaque character wnich we ascribe to j silica or fibrous tissue, and if you were to rely complete! on the Roentgenogram, you would miss so many cases of pneumoconiosis in soft coal worleers* Additionally, I want you to notice the focal emphysema in the lower half of this man's lung fields. | Now, this is an example of pneumoconiosis in a i sort coal worker with cavitation in the right upper lobe, jl I was convlaced, as well as everyone else, that saw this case, that this patient had tuberculous infection superr I; imposed, but instead he turned out to have -- next slide ' what Doctor Bollitsr has desaribed as a sceptic necrosis, y were able to find the cavity, but we were never able to wr 271 find any tubercle bacillae. Again X want you to notice the extent of symple pneumoconiosis in the right lobe and again in this lung over here, notice the large amount of coal de posits and the cavity without any evidence of tubercle feacillae, both in life and in death at the necropsy table, ana very careful studies* Next slide. Now, the problem frequently comes up, and the question is often asked, is pneumoconiosis a progressive disease? I think that in this slide and in ensuing Roentgenograms, I can say and show ;'ou that it is. If you notice, this first alias, incidentally, all of the whole lung sections in pathology which I am showing you today have been prepared ty Doctor Gox'fe in Cardiff, Wales and he lent me these tissues so I could demonstrate them to you* If you notice here, in this first whole lung sec tion, there are coal macules and in this lung we find no evidence of focal emphysema* However, in another case which had been a coal miner for a longer period of time, here you see the generating coal macules and focal emphysema and somej J coal macules maintain themselves without degeneration* j Now, what the contracture of the coal macule is due to is only a matter of conjecture. It may be that the I impure fractions in coal dust besides carbon, have a fiber- j genic tendency and cause this contracture over a long period 272 or else it may ta due to the mechanical effect of the macule and the effect on the macule of the surrounding tissue. Perhaps this man had some silica in his cod. macule, just enough to cause the fibrous contracture over a long period of time* And now you see, in ttxls final section here, all of the coal macules have disappeared and the entire lung field represents a Swiss cheese affair of focal emphysema* This, I believe indicates pathologically at least, that the disease is progressive, and you can see the progression in one slide, that the middle lung section - within that one section, you can see the focal emphysema and the macule before it has degenerated* While we're looking at these sections, we may see the reason why so many of the Roentgenogram a appear to have only increased markings* Of course, most of this, most of the macules and the tissue, as we see it, is not radiopaque and, therefore, in a large - in an X-ray of the entire lung, you have what may be called a little out effect, increased areas of translucency and increased areas of opacity, but they neutralize themselves when they finally come to the X-ray screen and that's wny we sea only evidences of linear markings, and of course, some of these linear markings may be i- scribed to what Doctor Vorwala pointed out this morning in his microscopic sections. i. 212m. Next slide. Now, this is a man who left the left his coal mining occupation in 191+-8, If you notice the first X-ray, this was taken in 19il9 Notice the type of X-ray he has. At this time, the man had already left his occupation in the coal mine and had no longer been exposed to any coal dust. However, in the second X-ray taken one year later, you see that he has developed conglomeration and coales cence in areas where previously it was only suggasted, that it had just started and then finally, in this last X-ray, another year later, you see that he has had additional pro gression of his disease. Now, whether the progression of the disease in this case is due to the effect of the coal dust upon the tissue, or whether it is due to the fact that he had a silica admixture in the dust that he breathed, or whe.uer it is due to superLx-osed infection, is not of material concern, Th8 fact of the matter remains that this man re Mi moved from his occupation, showed a progression of dis ease in his lung f 'elds which may be ascribed, directly or L Indirectly, to the basic pneumoconiosis. Next slide. Now, in dealing with these patients, we find certain complications wnich are more freauenttahn others and if you notice uhe first complication listed is emphysema, the second one, bronchitis and bronchiolitis, and then below I explain those two* Emphysema and bronchitis are so constantly as sociated with clinically significant disease that they should be probably considered part of the clinical entity rather than complications, llow, we also have recurrent pneumonia in tnese patients, cor pulmonale is very prevalent with associated cardiac decompensation. As a matter of facfy if the cardiologist would examine people who suffer from I! pneumoconiosis, they would not regard cor pulmonale as an !; unusual entity, butwouid find it not only has accute mani ,i festations, but we who are interested in dust disease of ii the lung find it is quite prevalent as a chronic disease ;'ust like hypertension. Bronchiectasis, we have found in a substantial number of our patients; tuberculosis is, of course, one of the complications. Spontaneous pneumotnorax, we have ob served about twenty to twenty-four patients; I don't Know f the exact number, in our series, and I think that's a higher incidence than you should find in the control population group. i And, finally, pulmonary osteoarthropathy, we do j find and I put that down as a complication because of the : manner in which you can see dramatic results, when you haveej tnis hypertrophic pulmonary osteoarthropathy, if you treat rnanI'S lungs, clear up the bronchiectasis, the bronchial 225jl edema and infection, and don't give him any aspirin for _ qj any specific measures for his arthritis, so frequently is there a manifestation of improvement in his pulmonary function, general pulmonary function, the effects of the pulmonary osteoarthropathy is gone, with few exceptions for inclement weather and so on, as long as you maintain a rather satisfactory situation in the man's lungs* Next slide. Now, this is an example of a patient who had pneumonia and then - now, of course, this man ex pectorates at a rate of sputum daily that I thought ha had bronchiectasis, but you can see from the bronchogrsa, it is within normal limits and in the rigit lower 2sobe whs re it doesn't fill, probably the result of accumulated secre tions, indicating that those people do have an entity which may be confused with bronchiectasis and has to be differentlated from the bronchiolitis which is associated, prob ably responsible for the bronchospasm and the bronchial edama, and a lot of these - a lot of disability, which one sees in these cases. When you clear up the bronchiolitis, those pa tients have experienced a great deal of relief, and are able to do many things that they haven't been able to do previously. Next slide. Now, this is an example of what we call temporarily disabling pneumoconiosis in soft coal 276. workers. In his lower left lung you til sea he has pneumonia; and then there you see about a month later or so, that the area of pneumonia has cleared. Now, this patient, when we first saw him was critically ill, and such is the case with all of our patients who develop secondary complications. They live in such a delicate cardio-respiratory balance that a sup. .'vening, intervening infection, pneumonia or | systemic Infection throws the weight of balance against ; them, and these people become critically ill and disabled, i However, when they're treated and they get over i their illness, they return to their previous status, perhaps i with some additional damage to their pulmonary tissue which ! we can't measure and want to resuma their work* i Incidentally, this patient is back at work in a l coal mine and does not want anybody to know about the fact j that he has pneumoconiosis because If they find out, they i I will take him off his job, which should be done. Eo has i | been advised to leave his occupation, but we as doctors, ji have no right to say to a man, 'You get out'. It's up to j him to make the final decision, because h o >3 the one who i: i; . i has to survive# : Incidentally, I only want to mention one thing ; about the treatment of these patients. You can not rely ' Up0n the parental administration of antibiotics and other agents. These peonle,to obtain the best results 277 . therapeutically, I don't care what you use as long as you use something that's indicated and that has been successfill in your hands. Parental therapy with penicillin, for example, in a case like this, would prolong the patient's convalenscence maybe two or three months before you find that he is able to go to work, whereas with aerosol thera py, you attack the disease directly either by hand or with intermittent breathing pressure unit designed by Doctor Motley, It doesn't make any difference, but remember, the aerosol route, the direct approach to the disease. Hext slide. How, this is an example of an indi vidual with cor pulmcnalo. Notice the lacy character of tbs changes in his lung fields. He worked in a coal mine for thirty-five years. He is seriously disabled and he is un able to take a bath. Incidentally, I'd like to point out that in our clinical experience, we find two very Important things to ask patients, because sometimes a patient comes to you be c a m e he knows that the disease is compensable and he comes with the idea that you're going to establish the diagnosis j and he comes in complaining of shortness of breath, cough, j can't work, can't sleep, can't do nothing, is mad at his j j wife, nervous, can't do anything, but there are a few tiling4 you can find out, \ For one thing, these people can't take a bath in i 278. hot water. If they take a lot of water, and if they really have pulmonary disutility on the oasis of their pulmonary disfunction, they become more short of breath and have to be helped from the tub. That's due to peripheral vasal dilltation and increased oxygen demand. Secondly, these people are always more short of breath in the morning than they are at any other time of the day except when they're working, so after they've had a good night's rest, when they wake up in the morning, if you ask them how do you feel, if they're really suffering from a dyspnea due to pulmonary disease, they'll tell you 'Doctor, I didn't sleep well and when ' got up this morning I didn't feel well; it took me about an hour to stir around and start .feeling better'. That's a good differential diag noetic point which we should keep in mind and it would also help us to differentiate between cardiac disease - dyspnea and pulmonary dyspnea. Next slide. This is an example of cardiac fail ure in a patient with pneumoconiosis and before you - and before you label this patient as having pneumoconiosis, you should correct his heart failure fir;.t and then re-examine his roentgenogram to see if he s^ill has evidences of pneu moconiosis. Here you can see the enlarged cardiac shadow on the left with increased markings of nodularity, and ! then here on the right you find that the cardiac shadow is j in both lung much smaller but he still has tne changes field, compatible with pneumoconic,1.. m portent to the management f PtlsntS' 1 ,..st you do not treat these patients " 7 do ,,ho h.e eardlao wlth cardiac f a l l - a - 7 or ,, terl.l failure on the basin of r h e u m a t i c ^ ^ ,, sclerotic disease. In Bak. .,m. a t t e s t to corre7ct ,fiirsnt bn - r t and 1 ,, e apt to craate a load on the ri * * f precipitate a fatal accident. but *axt slide. I don't know how this go I u i . . I d you -ind tahins thie out d leave It ^ i n s t . i it is* n 0f a patient with * ! . i. a Joher. How, thi. 1. - * ' onl0.ls haart failure and bronchiectasis. a pneumoconi Hotlc, th. dilated bronchi those thing, in on. P ^ failure In the 1,1 I r e . * 1 . patient 1. .till Uvlng. He 1 see niodle P C living lu " *7 `;sn *"" * \ in an oxygen tent, na , over two and a half years. cniofly i slide. this 1. an example f t d t h i n g s with son. evidence of nodulatlon ^ tan,cue p,-- ore* on tl left, on * e left-hand " d " S`'" . J . C J . can ha. U * " pulmonary dust die- j side. east, c wn0n d t disease , T ,, ay a nan has nodular pulmonary dust____ when I a __________________________ ; 280_s_ or mixed, I me anthat it's predominantly linear, that it's predominantly nodular and when it isn't predominantly one or the other, I call it mixed, because as a clinician, we have to have a simple method of approach to this problem that you can present to other doctors in the comunity, to doctorv who work in coal mining camps, so that they can work with you and understand what you're trying to accom plish, and when you get too scientific with them, when you get into the category of too much research, with a little actor who works in the country, you lose all of his coop eration, so we have to give them something that we can see and that's simple* Next slide. This man lived a little over three years, a little over three years in an oxygen tent and then died looking like a skeleton and if you Bee, in this lung field, he has evidence not only of silicosis, but also ovsfi* here you see evidence of anthraco -- excuse me - of pulmonary dust disease of coal miners, with focal emphysema and macula, _ habit will always come out. Now, next slide. Now, here you see the X-rays of tvo individuals who have about the same extent of pulmonary j change in the Roentgenogram. Now, the sixty-four dollar j quest on, how can an X-ray man tell me which one is and whicjh one is not disabled? But just to speed things,up, I'll tell you that tne man on the left is disaolec and the man on the: 281* right is not* However, I want to tell you that subsequent ly the nan on the right has developed disability, but at the time of this examination, he was not disabled* Next slide. Now, this is an example of extensive changes in the pulmonary field, in a patient forty-five years old, twenty-nine years a coal miner, no disability* Nevertheless, look at the extensive changes in his lung field, by comparison with some of the other Roentgenograms which you have seen both in this lecture and in the other lectures waich preceded mine# Next slide. Here is an example of a savoniyyear ole- man with an olevatod - with an elevated leaf of the diaghragm on this side, resulting from pleurisy, pneu monia, several years previous to this Roentgenogram. He is seventy years old; he works; he worked in a coal mine at the time this Roentgenogram was taken and ha had absolute ly no disability that we could find, either - either in th clinic, on clinical basis or in a laboratory. Next slide. How, this is an example of tissue reaction. These two boys worked alongside of each other for fourteen years. This man is thirty-six years old, I think, j and this one is thirty-four years old. Notice the differ- J ence in the way these tissues have reacted. Here you have j a nodular variety of change in this rsan's lung field and in ! t the one on the right, has chiefly a linear change in his lun; 282, field, indicating in this case that two people of different stock, working in the same occupation, reacted differently. Next slide. Now, here is an example of two boys who worked alongside of each other, I think, for thirty soma years. You notice the similarity of their Roentgenographic changes. Hext slide. Here are two other brothers, both with negative tubercular tests, both with negative tubercu lin test, and we can't prove tuberculosis. They worked nineteen years together and they've worked about ten years apart and you can't, well, you know, you have to 3ay they look alike anyway, ana it's Just remarkablo to see the sim ilarity of the changes in these two X-rays even though they worked ten years at another occupation. Eext slide. Now, these two, those two brothers are the first of four brothers. Now, notice how similar these two X-rays appear. These boys worked together forty- one years* Notice the similarity and the change in these Roentgenograms, but they're brothers, and now their other j brothers worked in another part of the same coal mine for j thirty-one years together. Notice the man on the right with the conglomeration and coalescence and the one who has only j worked about fifteen years already beginning to manifest j the change 3 of his brother alongside of whom he worked. ; Hext slide. You got the last one - you got the j ! 283. one you put up the first time - I asked you to put it last? And now, just to confuse you, as well as I'm confused,this is two brothers* These two brothers worked alongside of each other -- excuse me, not alongside of each other, they worked for thirty-seven years on opposite sides of a rail road car* They did loading and the reason they worked on opposite sides of the railroad car were because they loved each other and they wanted to be sure in case a rock would start falling on the brother, they would see it and they'd run over and save the brother* Look at these Roentgenograms * See how different they are* Worked on opposite sides of a coal car, so there I fore, even though Doctor Lanza is much oldor than I am. I'm going to improve on his terminology* I'm going to say fras now on when you talk about pneumoconiosis, you have to talk about pneumoconiosis in soft coal workers in Alabama in Jefferson County in Mine Number 9, Shaft Numbc..- 8 on the right-hand side of the railroad track, and that's about what it comes down to# Now, in conclusion - in conclusion, I think I have about two minutes left, is that right. Doctor Sander? BY "OCTOR n t- One# BY DOCTOR PR1EPYAN: That always happens when you deal with Yankees# m * .. | In conclusion, I'd like to remark as follows: That there i i' . a disease in coal workers, that it's due to their occupa- j tion, that the disease, once it manifests itself clinically, i is progressive, that different people may react differently i to the same exposure of dust over the same period of time, j! As a rule, I have sixteen pairs of brothers - that's why I I say as a rule - as a rule, brothers will react similarly, ij but you can't depend upon it, because I Just showed you* i ! (Applause)* i BY DOCTOR SAiiTPHRt Well, as you can see, Doctor Friedman has had a donsiderable clinical exper? nee with this coal miners dis-j ease* I have asked Doctor Fletcher to open the discussion j of Doctor Friedman's remarks, and then I would - I'm going to ask for questions from the floor after Doctor Fletcher has finished his discussion, and I hope you'll have a good j many questions to shoot this way. j BY DOCTOR FLSTCKSH; !; Doctor Sander has said that I could make one pre- i I lininary remark on my paper this morning, which I neglected ' to say this morning* I suggested that if we could abolish iJ , tuberculosis In mining areas we could abolish the worst ef- I ; i fects of disease. That might be taken to mean that pnsumo- j ooniosis la a form of tuberculosis. I just want to say that; any such Interpretation of my remarks is the exact opposite! 285 of what I mean* The expression of this disease is by dust suppression* It Is ar. occupational disease; it is not tu berculosis, but if the utmost human endeavor fails to re duce dust levels, that in which no radiological activity provails, then the lessening of tuberculosis on this dis ease, might be lessened by stric~ tuberculosis control in this area* I am glad I have an opportunity to remove any misapprehension in regard to my remarks* In regard to Doctor Friedman*s excellent paper, I really want to sympathise with him from the bottom of ay heart, because I started studying this disease as a clin ician and it wasn't until I had been at it as a clinician for sometime that I managed to get my epidemiological col leagues to show me something about the disease* As a clinician one is grossly limited* He tells us that he sees spontaneous pneumothorax as a common ccsapl Ication of this disease* That means to say that patients I who have spontaneous pneumothorax with this disease coma to his clinic* It doesn't tall us anything about the frequen cy of that complication in the community of man with pneumo coniosis, and we clinicians are at a gross disadvantage in studying occupational disease in that we can not resist analv'ing our figures and thinking that they map mean some thing* It's a temptation that I have had to strenuously ! resist myself, under the most tremendous barrage of criticism 286. from Doctor Cochran, my epidemiological colleague, who thinks of clinicians with - as one of the lesser breed of rodents* So I Just want to sympathize with Doctor Friedman and congratulate him that he has derived so many interest ing conclusions to the severity of this disease. I would just like to quarrel with him about this temporarily dis abling pneumoconiosis. He says he has a man with a pneumo coniosis with pneumonia and he was grossly disabled. Hell, I have seen that in London* He was disabled when he came in. I think he had disabling pneumonia, whereas you might call it temporarily disabling pneumoconiosis. I want to quarrel with his suggestion that the coal macule is not as opaque as the silicotic nodule. The coal macule is smaller than the silicotic nodule. I believe the radiopacity is at great as collagen and the silicotic nodule is larger than the coal nodule, displaces more air and is, therefore, more visible. And lastly, I want to ask him one very important question, that is in this tubercular negativity of cases of massive fibrosis. That we have never observed. We j have found cases of massive fibrosis that only react to one it in a thousand tuberculin and I believe we have had one go up to one in a hundred but never a complete negative, and II, would like to know what strength of tuberculin he used for ! that negative test. Thank you very much, Doctor Sander. BY DOCTOR SAKDER: Thank you, Doctor Fletcher. Do you want to make your remarks now? Doctor Vorwald has a few remarks to make i to correct a false impression of this morning, right? i BY DOCTOR VORWALDt | Yes, I should like to do exactly what Doctor i Fletcher did, so that we do not leave a false impression ! wi th you. j First, in showing the slides stained for elastic I | tissue, Doctor Hussey called my attention to the point that I did call it elastic tissue rather than reticulin within I | the lung, and so I wish to correct that. The second correction whicn X should like to I being a correction, at least attempt to modify the Inpres- ( Bion wnich I left with you, and that is with respect to this ! focal emphysema and I demonstrated a series of cases of work I ors exposed to dust other than coal dust, where there was j! I focal emphysema, and called attention to the fact tnat this ;; focal emphysema was then not unique for the coal minors* I: lung. I n p r e s e n t i n g t h e s e c a s e s , s u c h a s f r o m t h e g r a n i ito worker, and from the limestone worker and from the g r a p h i t e w o r k e r , I w i s h t o i m p r e s s u p o n y o u t h a t t h o s e were the verv isolated cases, that it has certainly not involved ____________ _________________________________________ .5.86*-. the large group of individuals supposed to be exposed to these dusts* Pur them o r e , with respect to the magnetite worker and the hematite worker, the incidence of this focal emphy sema, about the foci of dust, is present probably to a great er degree than is present in the graphite worker in the other cases, and to a lesser degree in the coal miners* lung, but that does not mean that wit-- the deposition of graphite in the lung, with the deposition of magnatiti, with the deposition of hematite, and indeed with the deposition of limestone, that thoro mu3t also, therefore, be present a focal emphysema and thus, therefore, the man - the patient must also have a respiratory difficulty* I think that is fallacious and I don't wish to leave you with that impres sion* If I may go on and comment just % bit about Doc tor priadman's remarks, certainly Doctor Friedman has had a great deal of experience with the coal miners. I should like again to take a bit of exception vIth him on the - his statement with regard to the matter of progression, that it is of relatively little concern. He mentioned that it is of; little concern whether it be due to massive local concen tration o f dust or whether it be due to a complicating in faction. I think it is of concern. We must know whether 2d9 these coal miners' lungs are more susceptible to infection than is the lung of a worker with deposition of other kinds of dusts# Again, I shoulc. like to make a slight comparison as did Doctor Fletcher, that is, he spoke of emphysema, and that it is important to know the incidence by age also of emphysema, in the entire working population of the coal miners, and to compare that incidence with the incidence in the non-exposed population, by age and by racial character istics# I think that is also very important before we con clude that emphysema, in the coal miners, about which he has seen, as a common denominator of all of tho coal minora 32- posed and that it is highor than the incidence in the non exposed population# With respect to his last remark, that is that he will not only have to know wnather these coal miners coma from Alabama, and whether they come from Jefferson County and Mine Number 9 and the right side of the truck, I think that's precisely what he has to do, and we all have to do that, and furthermore, I should like to know, and I think wa * JI have to extend it, we want to know whether he comes up the j track or down the track# e want to kn-w whether that trach is outdoors or indoors# I I think those are the things tnat we must know if ; ) 1 we are to solve some of the problems relating not only to ' 290* the pulmonary changes in coal miners, but also the pulmonary changes in workers exposed to other dusts* One more comment and that is with respect to the Roentgenogram and the pathological manifestations of the disease; it is true that the pathology, the pathologies, - the pathologist frequently sees more disease in the lungs than manifested in the chest Roentgenogram. But I don't believe that that should be used as an argument to support the view that there is always something more in the lung than is present in it, than is visualized in the Roentgen- j ogram. Should we follow that reasoning, then we could all j - we should say than also, well, this Roentgenogram is neg ative, it shows no evident change, but there is something more in the lung than what we see in the Roentgenogram* Therefore, this man must have pneumoconiosis, because he frnH an exposure to coal dust, so we throw the Roentgenogram out the window, we throw the physical examination out of the window, and all we want to know is did or did not this man have an exposure to dust* If he did, then he belongs to the category of pneumoconiosis; if ha had n o exposure, j i then we may question* Thank you* j BY DOCTOR SAh'DigRt j We already h<-ve a few questions of Doctor Pried- , man. I'm going to ask one and then I hope we'll have some more from the floor and then we'll give him a chance to i 251a . answer tnara. I id like to know how he makes a diagnosis in a man who has been a miner for some twenty-five years, whose chest film at age sixty-five, when h e 's retiring, shows only emphysema, nothing beyond that. What - how does he go about making the diagnosis beyond the hot tub test and the - the history of his not feeling well when he gets up in the morning? What do you have besides his history, and _ i possibly the lung function test,which undoubtedly will show a low maximal breathing capacity, because he has emphystma? Anyone who has emphysema has a low maximal breathing ca pacity. At age sixty-five it's lower than it was at age forty-five, and if you have the additional emphysema, it*s going to be still lower. Kow does he make the diagnosis of coal miners* pneumoconiosis with that situation in raind?i Do we have some other questions? Doctor Kline? BY DOCTOR KLISBt Doctor Friedman, I didn't come in at the very be ginning of your paper and if you've answered my question, Im wasting your time, but you talked about cardiac failure ! in these cases, and you mentioned that before one gave ; digitalis or treated the patient with the other methods that t we have available for the cardiac failure, one should do j something about the pulmonary condition. I presume you war? referring to McMichael's work in England on the effect of j | digitalis on the veins of the body. This work has not been |{ widely accepted, and not generally confirmed, but I'm not taking any exception to that. I am asking this question. What does one do about the primary pulmonary condition? The disease of the heart is the result of increase in the pul monary artery and the right ventricle. Do you have some | therapeutic tool which corrects this condition before cor recting the cardiac disease? BY DOCTOR SffJTDDR 8 I ' | Any other questions? j . - K j" 1 b y doctor am bsrso h : * L' v . J I What was the time element between the last X-ray j film and the last post mortem examination? -- Doctor Ambsr-j | son -- This calculation effects me as batting about ninety- | seven percent, which is pretty good in any league. The timaj j element between the last chest film and the post mortem j I examination. I 8 I BY DOCTOR S&HDSRt j | In which case? I ' \ b y DOCTOR AM3SP.S0N; i . ! j x think there were two or three. j i! BY DOCTOR SAKDS3 : \ He had two or three. Any other q u e s t i o n s ? ; av nnr.-QR BRISTOL: ! Ild iikt to ask Doctor Friedman if he thinks It's 293. possible from the X-ray to make a diagnosis of focal emphy sema, number one, and X-ray alone, that is; and number two, do you believe that emphysema is a complication of simple t coal workers pneumoconiosis? BY DOCTOR SAMIHR; Any other questions of Doctor Friedman T (No response). You have the floor. Doctor Friedman. BY DOCTOR FRIEDMAN t On my way up again. I should have stayed home. Im really surprised. I thought it would be worse than that I don't know whether I'm going to answer these questions in order and I don't even know whether I'm going to answer then, but I'm going to say something about each one. As regards Doctor Fletcher's remarks about the incidence of spontaneous pneumothorax, that's true, it's clinicians' incidence of the disease and in vs$ particular situation, I am not in a position to compare a comparable control group of coal miners whom I study, because the people who come to see us, sick coal minors, we don't get a cross-section of the coal mining population. However, I do think, Doctor Fleocher, that the incidence of spontaneous pneunothorax, even without the j comparison, apoears to be higher than in the normal popula- 1 * ! tion group. Of course, I know that Doctor Goffe, and you j 29k. come from that; school of Doctor Goff a, feels that spontan eous pneumothorax probably Is unrelated to the disease be cause of the location of the blades, and when I made that statement, I knew I was on dangerous ground. I thought you'd overlook it. Regarding the tuberculin testing, we use one to one thousandth to begin with and we end up with one to one hundredth and if you*re ever down in Alabama, I'd like for you to come down and see some of our negative skin tests, because they really complicate the picture when we can't obtain a positive reaction, and we frequently teat them again in three months or six months. And then, about the location, then Doctor Vor- j wald made a remark about the incidence of emphysema in coal j workers. I took one hundred patients from the age forty to i sixty in our own clinic, random sample, men, and then I took a group of coal miners, forty to sixty years of age, and compared the incidence of emphysema in both groups. Now, I admit before I go any further, that it's not a fair comparison because the people in the control group who come between the age group of forty and sixty, j came in complaining perhaps of some heart disease or gastric disturbance or something of that nature, but the coal miners all cor- complaining of something wrong with tneir lungs, : but at least in that groi-o, I would like to give you the j benefit of what we found.* We found less than ten or twelve percent emphy sema in a control group whereas in a group of coal miners who came to.be studied, and we used maximal breathing ca pacity, both lung capacity, fluoroscopic examination. X-ray, we didn't use any gas studies, w e 're not equipped for it - we found that the incidence of emphysema by the most rigid standards in a coal mining standard, in the age group of forty to sixty was in excess of seventy-five percent# I admit, to begin with, that thats an unfair comparison, but as I say, I do n 't have a orosa-section and X wasn't able to X-ray all of the coal miners in an area whether they were sick or whether thoy weren't* I 'm glad that Doctor Vorwald felt that the loca tion of the m a n 's work was important* We all realise that, end I think we have to realize, not only the geographical location of the mine, but where he works in the mine, whet her h e 's a timberman, whether h e 's a short fire man, whether he does drilling or whether he does overhead pinning, these are all important factors, and those of you who may not be ' i familiar with some of the more modern me-hods of coal mining, X would like to tell you, and Doctor Fletcher made some re-- i m a r k t o u c h i n g o n t h a t t h i s m o r n i n g , i n t h i s m a c h i n e a g e o f jI m i n i n g w e 're b e g i n n i n g to s e e p a t i e n t s i n the l o w e r a g e groups who, after lower periods of exposure as coal workers* 296. are de'-eloping pneumoconiosis by Roentgenograph!c change and functional changes. It's because the machines don't know to cut through just coak, they cut through everything and they want to do that so you can get the most out of a seam of coal, and the overhead pinning, that is, of course, the same thing as drilling in pure rook, and you're going to get a pure silica exposure because the purpose of over head pinning is to fasten the roof of the coal mine and instead of with beams, you're going to fasten it to the overhead strata. I had the privilege last week to examine some coal miners in Peru, South America. I'm only sorry that they wouldn't let me have the X-rays to bring up here, be cause what we see in our coal mines isn't anything like what we see there, what we see in their coal mines isn't anything at all like what we see in our coal mines in Alabama and Doctor Fletcher didn't show anything that looked like any Peruvian coal miner, and if you think we have patients, they have many more, because their patients are Indians who live fifteen or sixteen thousand feat above sea level, and to beerin with, they have emphysema and then you have to start to eva luate the disability on th? basis of that, so we ought to be pretty glad our problem isn't complicated in that manner. i Now, Doctor Sander asked me, I think I have the , 297.J age right, in a man about sixty years old, who has worked I so many years in a coal mine, who has no Roentenographic changes, but just has evidence of emphysema by our standards how could I say this patient hac pneumoconiosis. I wished I could say so, Doctor Sander, because I 'm convinced in a y own mind that many of these people do not show Roentgano- graphic changes compatible with the results of their occu pation. I believe that they develop emphysema or rather I we should put it this way, I believe Just like another sixtyj year old man, they may develop emphysema in the usual course of life, but they*re more prone to develop emphysema if they've worked in a coal mine. The mechanical effect over a long period of time of the inhalation of non-soluble dusts, the effect in in ternal bronchial, with infection and without infection, causes an intermittent occlusion over a long period of time of a balance value of nature, and if you do that long enough and often enough for twenty to thirty years, y o u 're going to have some effect on your alveolae, and y o u 're going to have emphysema as a result of your occupation. The day will come, I 'm certain, that we will be intelligent enourh as doctors, and will find the correct diagnostic methods to be able to prove that the emphysema j we see in coal workers, even without Roentgenographic !! change s, m a y b e t h e r e s u l t o f t h e i r o c c u p a t i o n , t a k i n g i n t o !| 298 consideration the fact of the usual aging process in man# Now, Doctor Kline asked me about treating tae patient with congestive heart failure and something about why we didn't use digitalis first , and what corrected the pulmonary function before we treated heart failure. I 'm not familiar with the man's name you mentioned, that's only my own observation. We found that we are able, very quickly, to im prove the pulmonary function in an individual with the Jud icial - or judicious use of proper aerosol therapy and oxygen. We treat them fe- about twenty - about twelve hours for their lungs first. We give them aerosol therapy, oxygen, and then after we have improved their pulmonary I function to sceie degree, we then go ahead and digitalise rapidly with one of the popular new preparations that are designed for rapid digitalization. The reason we did that was because we had occas ion to treat several patients with pneumoconiosis and heart failure and we treated them with the standard methods and we lost a few patients, so we felt that we would give it a try and treat them from the other end first, treat the pul monary side first. We did and we found that it's been successful. Doctor -- Doctor* Bristol asked me how do we estab lish the diagnosis - will you restate your question; you 299. know I had a lot of trouble hero keeping up with you fellow! BY DOCTOR BRISTOL: Well, I believe you mentioned in your paper, that in demonstrating one of your chest Roentgenograms, you pointed to an area of focal emphysema and I asked you the question, do you think we can see focal emphysema on the Roentgenogram. BY DOCTOR FRIEDMAN s Well, now, I get it now. Now, when you see a lot of X-rays in coal miners, i t 's just like anything else in medicine, you get used to see ing something, you. tillme j you know something and after a while, whan vou*ve had au.vopsy specimens to go with Roentgenograms to compare, and then you can go back and compare your Roentgenogram with your pathology, then you can see some changes In another X-ray which at least suggest the same thing you saw prev iously, the diagnosis of focal emphysema is not a definite diagnosis from the Roentgenogram; it's presumptive on the basis of experience. B Y y>OC1'GR B R I S T O L : Well, would you enlighten me by telling me what characterizes, in your own mind, focal emphysema in the j i chest X-ray? j BY DOCTOR F RIEDMAN: j Well, in the c.'.est X-ray of focal emphysema, you 300. start to get the idea you're looking through something like a mesh work, like a dilated sponge. You get the idea that the areas of translucency, surrounded by areas of in creased density have a regular nature, but you can not de cide, it's a sort of a linear character of the X-ray, you can not make the diagnosis from the Roentgenogram, and it's a presumptive diagnosis, and after you've seen enough of them, I think you can usually guess correctly. Now, another Doctor asked me about the -- about the time element between the Roentgenograms and the necrop sy material, is that correct? Now, the Roentgenograms perhaps were thirty - a month before the patient died or a week, it doesn't make much difference, but just within that limit, I think, with the exception of one patient who died, the one with the spontaneous pneumothorax. He didn't die until about two and a half years after we had that X-ray, but I wanted to show the spontaneous condition. How, the radiologist didn't have a great deal of difficulty batting ninety-eight or ninety-nine percent, b e cause most of the X-rays that he looked at were pretty easy to diagnose as pulmonary dust disease of coal workers, to gether with their occupational history. However, as Doctor Eristol pointed out in his question, the X-ray man was not able to tell me, nor am I able to tell you definitely that this man, this patient was going to have focal emphysema I __________________________ 301 I in the pathologic specimen. It*a presumptive on the basis of experience* ; BY DOCTOR BRISTOL: Louis, did you forget my question which was, is emphysema a complication of simple coal miners pneumocon iosis? BY DOCTOR FRIEDMAN t Emphysema is a complication and, as I said ... i BY DOCTOR BRISTOL: Simple now* i! B Y D O C T O R F R I E D ! `A N : j Emphysema is a complication of simple pneumocon- j losis, focal emphysema, but you see bronchitis, emphysema and chronic bronchitis are so closely associated with pneumoconiosis that you should consider the part of the dis- i! e a s e e n t i t y . Y o u r e m e m b e r X s h o w e d t h e p a t h o l o g i c s p e c i m e n :! o f t h e d e g e n e r a t i o n i n t h e I n d i v i d u a l , a n d y o u s a w t h a t t h a t f was a definite change in the pathology and Doctor Vorwald i! ji d e m o n s t r a t e d t h a t t h i s m o r n i n g t o o * py DOCTOR SAhPSR: y s ir.e - t h a n k j o u v e r y m u ch , D o c t o r F r i e d m a n * We're a little bit late, but I think u two minute stretch would help all of us* (Recess t a k e n from 3*30 t o 3:50 P.H.) j 302 yill you take your seats please? We have two very interesting papers remaining this afternoon* the first one by Doctor Hurley Motley, recently of Philadelphia, who has done the most, one of the most outstanding pieces of work in lung function studies and therapy of pulmonary dust diseases. Doctor Motley is now heading for a more salubrious title. He is on his way to southern California as Asscciate Professor at the University of Southern Californi Medical School, Doctor Motley, BY DOCTOR MOTLEYS (Doctor Motley read a prepared paper which is on file at the Saranac Laboratory)* BY DOCTOR SAKDBRt I think you'll agree that's a lot to digest in forty-five minutes. I don't see how you could cover that much that fast. We'll withhold discussion on Doctor Motley *a paper until after the next paper, because they're on es sentially the same subjects. Doctor Philip Hugh-Jones comes to us from England* j He has been with Doctor Fletcher's pneumoconiosis research 1 in Cardiff, Doctor Hugh-Jones wants mo to stats, asked me , to state that his collaborator, Doctor Gilson, has worked j with him and would be one of the speakers had he been able J to come here today. Doctor Jones will give us his experience in the function studies of the coal miners in South Vales, j Doctor Jones* BY DOCTOR HUGH-JONES; (Referring to an exhibit on table) Just for the benefit of any security people, that isn*t part of an atom ic bomb* Mr. Chairman, Ladies and Gentlemen: The lung function studies I want to talk about this afternoon, as the chairman has told you, were done in collaboration with Doctor Gilson, and we were working under Doctor Fletcher in South Weiss where this extrema amount of coal workers pneumoconiosis has occurred* How, the most important symptom of pneumoconiosis is excessive breathlessness on exertion. But since this symptom is not specific in any way and neither are there any specific clinical findings of fee disease, the diagnosis, of pneumoconiosis in life, depends on the radiograph, and all too often, the disease is thought of &b a radiological abnormality. However, I know you would agree with me feat it is the disturbance of lung function and not the radio graphic changes which matter to the roan, and fee main pur pose of our work was to find out the functional significance, if any, of the radiograph. ! But before I describe that experiment, I would ! 1* :e to be cuite clear as to what this 'coal-workers i pneumoconiosis' is that we see in Britain. Hi -T.ologicall7 n m *. and pathologically, it's distinct from silicosis, that is j| the pure classical silicosis, and we know, for example, fron lj : I the work of Gough, who found it in the ooal-trimmers at the | docks, that it does occur, just from the exposure to coal dust onl-r, because those men who load the coal in ships !; *' jj have no exposure to rock dust, and they get typical X-ray i! If findings of coal workers pneumoconiosis, and in the mines, ' it usually occurs in the worker on the coal face. ; Now, the disease we see in Wales, radiologically, ! is no different, as far as we can make out, from the des !! criptions of the disease given hare in the United States, j given in other parts of Great Britain, given in Europe and given in Australia, eo I want to be quite clear that Im talking about coal workers pneumoconiosis, and the re suits ; I think are applicable to it in Males certainly, probably | in other parts of the world, but we have no reason to sup ! pose that the studies are applicable to silicosis, which is jj a different pathological condition. t Now, in describing our work, I shall use the ji International Classification of the X-ray which Doctor , !; Fletcher told you about this morning, and may I have the j i j- first slide please. j And, as you remember, from his remarks, that is j : divided into the simple pneumoconiosis. There is a typical j example of the stage tree of the simple disease, and into j 2.05m. the complicated or conglomerate shadows. May I Just have the next two slides. The first one there is a typical Stage B, and lastly Stage D, just to remind us what we're talking about, which snows the extreme distortion -- may I have the next slide, please -- the extreme distortion you gat of the lung structure* Hare is the slide, with the trachea moved right across and this large based emphysema which I think, radiologic ally, everybody would agree is basal emphysema.* Now, for our work* The m i n intent, as I have said, was to find the functional significance of the dif ferent X-ray stages, but we also wanted to know why coal workers were breathless* May I have the next slide* So I can put down that was our first object of our experiment, the cause of the breathlessness and its severity in relation to the radiograph. Now, the second intention was a more ambitious one, and that was to try and find out the interrelation of the different lung function tests we were using, that is to what extent one test overlapped with another, and what j precisely they were measulng in the lungs* | N o w, I s h a l l deal tills a f t e r n o o n , w i t h o u r f i r s t i object and the second I will put out as a demonstration for ; the results of that* Now, of course, many other workers have tried to get out this first object, but a review of 306. the literature has shown us that very few people claimed that there is much relationship between the radiograph and | the functional state of the map. But also a review of the literature convinced us that workers who have claimed to have found this lack of relation had very little real ! power to make that conclusion. And I have put up here, and I hope you'll forgive me, what I think are the necessary criteria before one can accept any work relating the X-ray to the functional state | I of a man. First of all, it must be an unbiased sample and a hospital population is particularly unsatisfactory from this point of view, because obviously, the breathless man comes up to the hospital, and 1 would disagree with Coctor Motley when he says that his patients were unsslcc tscL. Be t may have not selected them, but when he draws a conclusion that there is no relation between the X-ray and the func tional. state of the man, I wou'd submit that his work is done on what is, inevitably, a biased s&mpla, if it were volunteers coming up to a hospital. Secondly, there must be allcwanco made for other independent variables which everybody wi 1- agree effects t h a t f u n c t i o n b e s i d e s p n o u n c c o n i c s i s . T h e o b v i o u s o n e I s Ij I age, bu*r there are ma ny others. j Thirdly, there must be adequate functional tests j ana we must know their accuracy, tneir reputability, and j JO Jj what I have called their discrimination, that is their power of segregating the normal from the abnormal, I will explain that later if you people are interested. And finally one requires precise radiological description, Ky own impression of the literature is that physiologists nave gone to a great deal more trouble over their physiological tests than they have over the radiograph and there are very few physiologists who are meticulous enough to accept carefully graded tests to give the same criteria of excellence to their radiographic selection. Well, bearing those points in mind, we designed the following experiment -- may I have the next slide, please -- which was designed go try and naet those require ments, We selected, at ages thirty-five, forty-five and fifty-five years approximately, eight men in each of the different radiological categories, normal working man, that is men with less than simple pneumoconiosis, men showing Category 1 or 2, men showing Category 3 or k- B and the Ds. The men were selected entirely on their radio graph, on no other basis at all and ths radiographs were classified, and read in duplicate, by independent observers. Furthermore, we al'o selected, a3 another control besides the control miners, we selected forty men who were non miners and we chose them simply to be sure whether mining 308 itself night have an effect on lung function as opposed to j the radiograph. Well, now, besides all these men, we did, as you will see in the talk, select some other workers as other controls or some other men. We selected five cases of ad vanced non-industrial emphysema, chosen for use by Profossor Christie in London, who sent us them as undoubtedly cases of emphysema, and we also selected two rather reare cases of a curious fibrosis in the lung, where it was thought that there would certainly be a gas transfer defect. That is those other cases were simply put in as controls to make sure that the appropriate lung function tests did measure what they were meant to. That is, if we got negative find ings in pneumoconiosis, we wanted to be sure that the tests themselves were not at fault. How, before the men were tested by ourselves, they were examined cardiologicaily and clinically, and the clinicians were two independent observers, who not only examined the men, all these men, a hundred and sixty-five cases, but they graded them according to their degree of breathlessness. Kay I have the next slide, please? And their breathlessness was graded purely aymtomatic ally on a series of Question, as to whetner they were undoubtedly as good as other run when they were walking about on the flat, whether 309. ; they were able to walk with raen of their own age on ties i : level, but they got behind on hills or stairs, whether they | were able to keep up with menon the level, but they dropped ! behind after a long time, or whether they could only walk H |j fifty yards or finally whether they were breathless at rest. |; Now, such a classification is obviously open to ij : observation rather, but when two independent clinicians did it and we have found that such a grading of breathlessness does at least enrile one to define men into, shall we say, | four categories o_ breathlessness with which to compare lung function studies. Now, for our own tests. Kay I have the next slide please? I haven*t got time to go through in detail all of I these tests, but I think and hope they're fairly familiar ! techniques. The exercise test was a stepping test in which ! every man did work at the rate of 350 killogrameters a I minute, and we measured the amount of air he needed to do |i that standard anount of nork. We also, in some cases, !' measured the arterial oxygen saturation of the blood before li ! and after the exercise. |i ! | Now, the exercise was, in fact, similar to the ! I: I I sort of exercise that one gets on a bicycle or a pedometer, j i: i n t h a t i t w a s i n d e p e n d e n t o f t h e w e i g h t o r s i z e o f t h e m a n . I T h a t .s s t a n d a r d i z e d o u t . W e m e a s u r e d , as y o u s e e t h e r e , ; i maximum voluntary ventilation and we also tried to determine whether a man had any bellows apasmor not, by using adrenalin We measured the arterial capacity, using our closed eircuit, which compares very well with the open cir cuit technique described by Doctor Motley here and first put out by Dootor Kellner, and finally the last test In which we tried to find the in tra-pulmonary gas distribution and the rapidness of gas transfer into the blood* I must spand a little time on that* How, our men, as I told you, were not volunteers eomlr* tip to the hospital* They were men selected at ran dom from the whole of the coal field, many of them working miners, and we would, therefore, think, that it would un justifiable to do arterial puncture on them, and ao - and we wanted to try and get a test which would give us the information with as little as possible in the way of dis turbance to the man, and wo chose to give them an inhala tion of air in which some of the nitrogen was replaced by helium simply to act as a trace gaa, and in which there was a small quantity of carbon monoxide Introduced* The i--3a was that helium goes into the lungs and is distributed without going through into the blood scream* It'5 the less soluble o f all gasses in the blood* The carbon monoxide on tue othor hand, goes across into the blood stream, and In lung ' mcentrations, exerts negligible back-tensions. Kay I have the next slide, please? I 311* Tcu will ... her. th. th. n.t re.ulta of to. f t . Bar. I am Pitting up Bar. th. ooncntratlan of E,, that th. men hraatha out after h. atop, * * L f . t . - * - ~ * " * * ~ i forty br" t ,, fifty hraatha, a normal auhj.ot 1. hra.thlng out : breathing In In th. ugy of hallum.n On th. other htod. th. carbon monoxide aoraa up and than flatten, o . difference hare being do. to th. rate, due to th. at.orp- . . *i, blood, stream, tlon of the carbon monoxide in - How, the results, &a* -Jyoouu s.* there, they not ,.ry helpful and they do n..d methamatlol ^aly.i. 3m to. form and component, of th... ' " " d 1 " 't S into that no., hut I .onld I f to t.ll you that In n o r ^ l subjects, th. hollum dlatrlbutlon o u r TM in th. hlood ahd to th. lng. i" th. .ort of thing you u l d oxpoot If followed through f lunge. That U - a x p o n e n U ^ and in emphysema, It It tontllatad- - ^ duiokly and waahad out of gaa much mor. olo*ly parts, .0 that Inat.ad of h.lug a alnglo P -- ^ tahesthe c o n a t i o n of two arpon.ntl^ our,.., - : mathema tical aannalyysis Is entirely different. to P.plae. th. It takes m x c h longer u I eas in his lungs and the replacement la In i . ol7 express that in terns ol two nixing form, and we simply exprea Hich I shall describe and they do represent U e indices which I snaxx ___ 312. degree to which the lungs are unevenly Ventilated. That, i I shall use later on, aa a physiological definition of en- | physema* ! The carbon monoxide is expressed as the proportior of gas removed from tfca inspired gas, because that gets over the difficulty of the different ventilation of different sxibjects when expressed like that* How, for the results. May I have the next slide, pleaseT Here you see the standardised ventilation. That is the amount of air the subjects need for doing a standard amount of exercise, and hare are our different radiologool groups and you will see that a-apart from a few men lyhng outsids these lines, most of the men did not need a par ticularly increased amount of air compared to the normal subjects, to do the exercise. In fact, in other words, they had only about a twenty percent rise, this is about twenty percent here, greater than the normal. In the moat abnormal subjects, in their ventilatory requirements for a given amount of work. 30 it's perfectly clear that the cause of the breathlessness 13 not primarily an increased need for air when doing a j standard amount of work, in pneumoconiosis. | If, on the other hand, you look here at the M x t a m voluntary ventilation or If you llko.tta n^irnun -hat represents the maximum output of hraathinz capacity, 113. the pulmonary bellows. It tells you how much air a man can pass in and out if he tries his hardest and you will see that, first of nil, there is a very marked falling off of the maximum voluntary ventilation with disease, hut second ly, there is a very wide scatter about this average and if you look at this diagram, these crosses represent the thir ty five and the circles elderly men and you will see there is a big age effect. Mostly the young men are at the top here and the oil men are at the bottom, so now if we take out this effect of age -- the next slido -- and you see the i results now of the mean maximzm voluntary ventilation of those different radiological groups against the ago in years, you will see that normal men drop their maximum power of their lungs as they get older, certainly men with simple pneumoconiosis, but you will notice that simple pneumoconiosis or the degree of it doesn.t make much effect| jho 3ts are just as had as the 2 `s and even tbs none, without pneumoconiosis, or shall say without any radiological pneumoconiosis, are worse than the other men, put not seriously worse, hut when you come to the compli e d disease, you will see that they have a marked fall ing off of the maximum ventilatory power of their lungs, particularly In Group ,,ay I have the next e ide, please? Here is the , or^i-ber wav. It'S the fora of a result really shown in another way. x solid histogram. You will sea the base of It Is our orig inal experimental plan. Hers are our different age groups and here are our original - here are our different radiol ogical i v">up8 on the bottom and the height of the groups represents the average blocks at the top. On the top of the clinician*s effect of their breathlessness done entire ly Independently of the history, and the bottom it says dyspnoea index used by McCann', in which we express the amount of air a man had to use as the amount of exorcise In proportion to the amount he conceivably could use* How, it's obvious when you stop to think shout it, if you* re using all the air your lungs can take in and out, you're feeling extremely breathless whereas if you're only using about twenty percent of It, you're not feeling vary breathless, and this index we do find agrees remark ably well with the assessment of breathlessness given by the clinicians, but it*s a more sensitive test. It's not surprising, you can measure the thing better than you can - well, I wouldn't like to say guess, 10.1 say estimate j It, and you see here that the normal subjects get slightly j more breathless vii.n age, but the Important thing is that j simple pneumoconiosis, although it puts a s. premium on, normal aging, doesn't h a w much effect until the men are , very old, that Is, fifty-five years, but the complicated pneumoconiosis pu.s this marked premium on aging and swf- 31$. 1 furthermore, this Group D, the rata of change with age is very ouch steeper# Kay I have the next slide, please? Now, Doctor Motley expresses most of his results In the terms of resid ual air percentage of the total lung volume, and here I know you will forgive me, If I disagree with him to some extent, First of all, in some of his papers, end he did this afternoon express his other results in terms of this one test, and it does soem to me that automatically then, that test Is labeled as a hundred percent and everything else is worse than that, and 1 don't quite see why he ohooa-j es that test for emphysema and not some others. Secondly, I would like to show a difference in our results than the ones he got. Here is the residual capacity percent and you will see that in the pnsunoccn- l0l. cas.a, thara 1. a rlaa. but not a very ark o d rlsa. 1. . rlsa, you will not., with ag. In normal outjo.t. and th.ro 1 u slight lncroas. with dls.aaa particularly, in th. group D, but lt>s nothing libs * marled as in th non-Indus trial em pnys.m. P P l nd - there I s on . slight point bars, and that la with regard to hospital populations. ' When we took a hospital population, we found ex- ; aetly th, tarns rosults as hs did. that at L a s t fifty par- ^ cont of the men had a largo residual air parentage In that _314, c s .b 9 , whereas here only about nineteen percent had one in the general population with pneumoconiosis. May I have the next slide, pleaset Furthermore, I would like to analyze the meaning of this residual air percentage. Here you will see the absolute figure, express ed, and what's noticeable here is not so much the rise of the residual air itself, but the fall in the total lung volume, end I believe you're seeing in pneumoconiosis ex actly the same thing by looking at the residual air percen tage as you are in measuring the M. V. B. or tee fall in the vital capacity. The percentage in pneumoconiosis is, hy and large, noised because of the foil in the conplinentsry .lr, where- j ,, in some of the non-lnduo trial emphysema, both the roold- | ,,el capacity 1. increased, and th. total lung volume Incroan- so that th. poro.nt.go la .till up. hut you mey got a j nis. of r.aldo-1 air pere.ntag. fron two different defects. J on. fro. an increase in th. ah.oluto volume and you got | that, notice, in Category D pneumoconiosis, where X belie*. | they ere developing true hypertrophic emphysema on the | radiograph, whereas in our people it look, to no an if it j one to a fall in their bellows, namely, their vital , , p.city, rather than a rise in tho roslduol elr. Kay I have th. neat slide, pleaset How, we-ve mentioned this tern emphysema. Well. we 1 g h t dl..._____ ^17. i afterwards what wa moan by emphysema, but tha sue thing la j dear out and It" a baan domonatratod wary ably In Fhlladel- j phla in tha states by Fowler and Conroe and his grout | there, that In this emphysema, you do get this Inequality of! mixing or gasses In tha lungs, as rind exactly tha some j and this is the result of this helium mixing index whloh ex, .esses the primary exponential - tha binary exponential replacement of gaa, and you will eoa that the normal binders. If I nay call them that, are grouped with the normal .object., truely uoroal. Ihe simple pneumocon- j Inals are grouped with Category B, and it'a only ategory D that you gat a very marked falling off of tha Index. If you compare that with the advanced non indue trial emphyoesui sent to ns from London, you will see that the teat does show a marked effect In non-industrial hypertrophic emphysema. Bow, It 1. tempting to suggest that this might represent what Gough deaorlbss pathologi cally as foosl emphysema, because al ter all, there la no reason to see why a massive shadow per e. In this group B should alter the gas distribution in the lunge, and it is ecually tempting to augg.at that this c -responds with the iarg. fuller emphysema of the radiograph. Anyway, w. have not got enough pathological correlation to make that point dearly. Bev.rthel.as, I think the results are suggest!TM. May I have the next slide, please* How, JLastly^ 318 4 what about the g w t r a w le r d e fe c t In p n .u n ocon lo.ls f W ell, do you remenber when 1 . t a k i n g .t o u t the e x e r e l . . r e - j e u itt, X d U eay th at th ere ww a r ic e o f about twenty p e r-' cen t on ly, in the -w o n t o f a i r fo r a given enount o f work and th a t would, to me, e u g g .e t en In d ic a tio n e ith e r o f g w a t t r ib u t io n in the lunge or gw tre n .fe r being d e fic ie n t. H er. are the r e .u lte o f the cerbon nonoxld. p t ^ . you w ill . . . th at there 1. not a narked deficiency o f carbon n onoxide uptake u n t i l you g e t down to th e Group D. and even then I t i s n ' t very g r e a t and when you renonber the s c a t t e r about these averages, y o u 'l l fin d th at the r e .u l t . h a r. r e b a r e ly , o f b a re s i g n i f i e s 110* TbaBa e re the c a te g o r y D w wa have bad b o fo r a t thoaa are the Category B and . the a ln p l. pneunoconlo. 1 . , b u t to e tc - you that th a t te a t doe. r e f le c t gw trad e - f OP d e fe d te when i t o c c u r s , h ere are th o se c a s e s o f r . r . f l b r o . l . which haw. been p u b lish ed re c e n tly in the r e d i d Jo u m o le , end you w ill fin d th e t those te n were . . i t h c u rio u s f l b r o e ie In the lu n g s, do tak e P W ont , twenty p e rc e_n t oo ff the ccaarrbe o nx monoxide in the m ix-up, w here- ; . . these people take up about seventy percen t. ; So I think you can say th at gw tra n sfe r 1 not . marked e f f e c t In pneum oconiosis except in I t s l . t e r . toge . end then I t i s o fte n a sso c ia te d with h e a rt d i . e . s . and e a rd ia c f a ilu r e In our ex p erien ce, and I think t n a t ^ 319. r,,,,ult a... fit in with to. cllnl.al .b..rr.tlon that y oel, 1 . not . comnon f.ator. of pn.unoc.nlo.1., It-l..an.a> on axartlon to... ton K . -- * br.atol.tonaa. at reet nor cyanosis So, May I ju.t try tod draw .on. .on.lu.lon. about t o l . work. tod to . o e s t f catio n .. F ir st of a ll, It d o .. *" te P l1 ' to to to a t w. h av . - tto llo l-to on tb . a t .r a g o , th a t to o r . 1 . * r .la tlo n s h lp b . . . t o . X-ray and t o . fu n c tio n a l . t a t . o f t o . n an . y .t o d on to o . t a r n s . and in g r o u p ., to d X think t o . r a n on K to p e o p l. h a t . ml t o t o a t r . l a t l o n s h l p I s b o o t o .. t o .y to t . boon working a l t o b l a . p o p n latlo n . tod tooy h a t . not taken the effect* of age into account. I don't know A e t h e r you remember that the slide I put on of the dyspneao index, did show that young cn Hith - even with Category D pneumoconioBia, may not he very breathle.o wh.ro.. th. old ton nay b. .atratoly braathl..., . x _aT in conjunction with age, 7 ou Set "f and if you read an X-ray In co j 1 average, of the man's breathlessness, hut that Idea on tne average, , work in individuals, because the scatter abou j nd you do need functional tests to precisely say | average, *na /uu "" - i how dlsaoTlaedd aa nmaann I***. *ad no nornial amount of readir^, | . h. helps you. on the other hand, the relation the radiographs helps y , . Ship to the radiograpvh., T -t-viinV. I think, il s. ii m.portant f 'om the point , n a t i o n of the disease. Wye have s- own that of view of prevention o _______ ^ 320. It is the common disease which is the disabling disease, whereas the simple pneumoconiosis, whatever it's degree, j ! and notice I say whatever lt degree, does not produce serious disability. That gives one a guide as to how one can cheek the efficacy of dust suppression in the mines. It means . that one can afford to let a man develop the very earliest atages of simple pneumoconiosis without thinking that he wiXl be seriously disabled by it, and you can then sey to the engineers, look, this mine is not safe and if the man goes on, on repeated radiological examination progressing, he will be liable to serious disability, by catching, ir you lifce, or by developing progressive massive fibrosis and complicated disease, and the epidemiological studios have shown the complicated disease, whether it's due to tubercu losis or not, I don't know, but in itself, does not occur, and this is a significant and marked - at least Category 2 I staple pneumoconiosis in th radiograph, so I think the j practical importance of this work is in relation to preven tion of tha disease by periodic X-ray examinations. Then, lastly, there ia the question of compensa tion and disability, Which I know many people will be ask- I ing. Well, first of all, there is tha very intrigueing and; elightiy worrying result that ve found, that the normal j dinars, with less than Category 1 pneumoconiosis ir their__ n 321. .re significantly dl.abl.d compared with th. trusly normal non-miner., and that was oonflrmad In a pit where nsn war. working underground and compar.d wlt> non-orklng population, but obviously that-, got to b. dona on much larger group, of man in oth.r lndu.try, heavy .teal indus try, farming workers, shall ve say, b.for. w. can su*. an assertion, but it is lnt.re.tlng that, shall w. say, . guass if you Ilka, that breathlessness oan ooour in miners compared with non-ml.nars,,, at.o,, ,snonmae aeascrtteent., and ona mig^at * arguo that the n. disability is a. th tvhainnsx on which th functioh- G al taste ebould give a precise answer. The loss of faculty* IT you 1U3. what tha clinician ha. to ....... a. th. meaning of th. fun.tional teat, and I think, personally, oompsnsatton should dopond on that. Lastly, I have said nothing about th. interrsla- tion of th. tests which was tha other object of our work. How, Doctor Motley, for exmspla, augge.ted that a battery of tore, tests, vital capacity, maximum breathing capacity snd reaidual breathing capacity percentage. could form a useful measure ef v.ntll.tory function. It - perhaps I | understood - or misunderstood Doctor Motley, but it did | a,, to me that he compared them Individually with to. sum | total of the three. I would like to get bis cogent about I that 322. But what we have tried to do. Instead of arbitrary selecting tests, is to try and find the precise mathemat ical relation to our problem and this rather curious look ing obeJet hare which I have put out as a demonstration does show that. The angles between eaoh of these knitting needles represents the degree to which tests are measuring the same thing. It's all right - this will be out on demon stration. you can see it somewhere else. If tests are at right angles, it means they're entirely independent, measuring sea*thing to the - some thing totally unrelated. The nearer they come together* j the more 'they*re measuring the seme thing, end we have also tried to relate those to the fundamental properties of the lung, nemsly, the bellows, action, the size of the lungs, the distribution of gas and gas transfer and we believe* through this method w h o h can be got out, is an interest ing one in doing two thingsx One, in enabling people to formulate a logical battery of physiological teats because you obviously don't need to use two testv which are isaas- I uring the seme things; secondly, it doss show you in rela tion to the X-ray and age, the type of physiological lesion which onegets in coal workers* pneumoconiosis. | (Applause). BY DOCTOR SANDER? 1 Thank you very much. Doctor. I'm going to ask j 123*. Doctor George Wright to open the discussion. Will you come up, George, please? Doctor George Wright of the Trudeau Foundation who has done all the lung function work here at Trudeau. You going homo? BY DOCTOR WEIGHTt Yeah, I was Just on ray way home. It was a pleasure for ae to say a few words about these last two papers. This is, of course, a field that I am intonsely interested in and I suppose some of you had a bit of difficulty in following the enormous amount of data that was presented. I must confess to hawing had the same difficulty. This sort of work does not lend itoelf well to easy digestion, and takes sometime going over in order to come up with an intelligent discussion. I shall confine say remarks, therefore, to some generalities. First of all, most of the questions that I had posed for Doctor Motley have been posed for me by Doctor Jones I believe that conditions here are a little bit different than in England. I can only envy Doctor Jones* opportunities to make a study of a group of individuals which embraces all types of experiences, in which ha can set up his experimental approach and before he begins to get his nan* In our country, we*re pretty much forced to take I the case* as they c me, and I think that Dpctor Motley would, he the first to say that Us material is not necessarily re presentative of the industry as a whole, but so far, we have | not been permitted to go into a field and take all of the i men or sample them in a random fashion, sad I think perhaps the finest thing about Doctor Jones* presentation is that that is precisely what he has done, I wish that we had an opportunity to do that here, I have some little doubt about this term breath lessness, All of us are seeking for some final criterion of a man's ability to work. Breathlessness is not a simple I I thing. It is an extremely complicated one, Those who practice medicine know that. The psychological aspects of exertional dyspnea are enormous, and I wonder whother or I not breathlessness is an adequate criterion of a men's j ability to work. It is certainly one of the things, but I it should be subjected to the same scrutiny that Doctor I Jones has subjected his X-rays and other tests to. i! Now, at the end of this day, now, I had hoped | that I would learn whether or not the coal problem in Eng- j | land was the same as that in the United States, How, I sunt confess that I don't know whether it's the same. Now, I've l had no experience with coal miners* disabilities, tut j would appear to me from the paper of Doctor Motley and also D o c t o r J o n e s , that the d i s a b i l i t i e s are essentially the same j: ,, that that has already been found and well doecrlbed by ; McCann'a group, by ourselves, and by othera abroad. In j' allleosls that occurs in metal miners or foundry workers, i In that the discreet nodulation and the linear exaggeration j jj type of abnormality, little in the way of disability is die- j! closed, and that it's only In the conglomerate disease that j! one meets moderate to severe grades of disability. If I* j jj wrong in this, I would welcome correction, jj I had wondered whether or rot the changes in the j coal mining industry wars distinctly different from that In j other industries. I still don't know, however, from the j! papers given by our Aaaerican coal workers, as to whether or not what they are seeing in the coal industry is the sams that is being seen by Doctor Fletcher's group in ! Britain, I I want to make one thing very clear, I know full ! well the enormous amount of work that has gone into these j two papers, and I think the two mon are to be co.-.ratu2ated^ j; oa the very fine piece of work. I'm sure that 'as the years ! bo by, we - they will bo deriving more and more good infor-j a*.cion from the data that they already possess. i (JLpplausa). j B Y D O C T O R SAITDHRs j Dc I hear any other coments fi'om the floor or any questions? I'm sure you all have questions but you probably don't want to ask thorn* Ko questions? (No response)* Doctor Vorwald has a few announcements to make* Thank you very much for the excellent papers* BY DOCTOR VORWALDt Members of the Symposium, during the course of f-vi stay, you've heard some outstanding studies* I resrely want to say many is the man who has pointed to the faot that we need mors studies* I plead with you to make it available, make those studios available to us hero, else where in this country, whereby we might come further, ecm* closer to the solution of the problems confronting us with respect to coal miners, coal workers and the pulmonary changes which they show* I think You will Join with me in complimenting the speakers of today - Doctor Motley, Doctor Fletcher, Doctor Jonas, Doctor Hugh-Jones, for the contrib ution whioh thay have made to this Symposium* Thank you* BY SDCTOH SAHPggt I'm very corry I didn't give Doctor Motley sand Doctor Jonas an opportunity to answer the questions whlsh ! were asked* Will you take over for a minute, Doctor Motley* EY DOCTOR HOTLSYi j With regard to Doctor .Tones* question on empty- : sema being a reduction in vital capacity only, that is not our experience. He find thao the vital capacity is reduced, 22U but wo find also that the absolute residual volume la in creased. In our fourth group, the ones for advanced im pairment, It*s more than a hundred percent increased, that is the predicted residual volume is thirteen hundred; ita over twenty-six* In some instances, we have residual voluae, as high as forty-five hundred c.c.'s. True, the vital capacity may be only two thousand, but we have the absol ute Increase in residual volume. I did perhaps not make it cloar In my evaluation of emphysema, we have really three things, tha residual nitrogen percent in the expired air at the end, after breathing oxygen for seven minutes - if that is elevated, that is significant; secondly, the absolute volume as a residual volume with r :pect to the normal predicted, and thirdly, the residual predicted on volume* I hoped - I tried to make it clear, I mean to point out the correlation with that arbitrary classification, yhen the residual volume is more than thirty-five percent of total on volume, lung volume, we have a fairly niee correlation with direct blood studies, getting rid of the Ctirbon dioxide and lower, of tha air in the air sacs as a result of the increased volume of residual air* The ventilation factor, Doctor Jones, is simply i help before I analyze all my cases with respect to this figure. I used to evaluate independently, the residual, 328* th maximum breathing capacity. This aimply gives me a figure. How, by and large, if that ia from eighty to a hundred, that includes a alight group,from eighty to sixty ore moderate, sixty to forty an advanced and below forty far advanced. Now, the only thing that upsets that, if the oxy gen saturation rocks, and I think it is most important that va have blood saturations, because as I pointed out, we hav* normal resting saturations that may go down ten percent or more with exercise. Ihat Indicates disability. If that man is trying to work, ho is working with a reduced oxygen saturation, a temporary degree of impoteney, which we know increases arterial blood pressure, increases pulmonary T&scul&f ! Doctor Wrights question regards a conglomeration for total disability. In eenoral, we find that is true. However, we do have some cases that would fell in Stage 1 or 2 or even in some, you would call it. normal X-ray, with ! a history of thirty-five or forty or more Inside exposure, ^ are totally diS' led. Wo have found lust as sovere emphy- ; sema, Doctor Jones, in our coal ialners as we have found in ^ idiopathic emphysema In non-coal miner groups; some of have gone up as high a* seventy-five percent. Doctor Jones, I would like to ask you why you use air cons urn;: ion, as I understand that, that Is the total volume of air rather than the actual oxygen uptake on the toaaie of body eurface area. Isn't there a possibility of air in theiH. due to individual ventilating alveolae that are not profused insofar as arterial punctures go? We don't have any more hesitation In doing them than we do a venal puncture; it's just about as easy and we do that rou tinely* I have no trouble with our coal miner group. It is true that we're not able to go out and take the whole coal mine and work it* that is these men have made application* uito a number of the men that I have studied are still working. They made application to come In for study during their vacation period. We probably have, oh, around a hundred in such a category* BY DOCTOR S&ffKSRt Doctor Hugh-Jones, do you have anything to close the discussion? BY DOC`I*OH HCTG5-JQHBS: | probably have s a id enough, b u t there are ju s t a few p o in ts th a t do occur to mo. F i r s t o f a l l , I d o n 't want to s o r t of take up p u re ly t e c h n ic a l p h y s io lo g ic a l p o in ts , but I thin k,D octor M otley, I might - I must disagree w ith you again on one p o in t, th a t you say th a t if a nan's ; oxygen uptake and h is carbon dioxide output are normal, j then he's normal as fa r as h is lu ngs are concerned, T don't think I qu ite agree w ith you there. iio.- j| BY DOCTOR KOTLSY: jj j u s t on p a r t* ji BY DOCTOR KUGH-JONSSt Iji T t seems to me i t r a th e r h in ges on D o ctor W right*# | p o in t about b reath lessn ess and i t a ls o r a i s e s the l a s t ques*' i tio n Doctor Motley asked, why I measure a i r consumption* l> I !: B r e a th le s s n e s s i t s e l f i s a symptom and we were a t p a in s to i' ji g e t somewhat - some way o f c o n s u lt a t i v e ly m easuring b r e a t h - I lo s s n e s s and i t i s , a f t e r a l l , we th in k , the amount o f b ello w s or b ello w in g and a ir l i f t i n g , i f you l i k e , t h a t a C ! has to do, compared w ith the amount t h a t he c o n c e iv a b ly can do, which g iv e s some measurement of b r e a th le s s n e s s or what h is sensation o f b reath lessn ess is * ! I agree w ith Doctor M otley from th e p h y s io l o g ic a l I p o in t o f view , we are a l l o fte n in t e r e s t e d , f o r o th e r r e a s ons, in knowing oxygon consumption, and a ls o knowing carbon ji monoxide up take which we o fte n remember* The reason fz* j, carbon monoxide, there i s no way known y e t o f g e t t i n g over f the back tension in the d iffe r e n t p a rts o f the lu n gs, in j e v a lu a tin g oxygen fcranafe r , b u t th e r e i s the c a r d in a l p o in t j which cones out from a l l t h i s , and t h a t i s what i s the j cause o f the b r e a th le ss n e ss o f pneum oconiosis, and I hope j j j-acia i t clear that as far as vs v e r s concerned, we think j it is exertional .'vspnea, due mainly to the bellows n o t ; being able to have- the reserve that they normally should have the maximum ventilatory capacity is reduced. In a few cases, the air requirement, or if you liko, the oxygen requirement, but the two don't min quite hand In hand, in increased, but that is subservient to the main cause, which is this diminution of bellowing pwoer in the lungs. Now, the cause of that, and I think Doctor Vorw&la this morning posed what were the causes of breathless ness In pneumoconiosis, and he suggested four, I think, and one was focal emphysema, another one was blocking of the arteries, another one was a ventilation profusion upset, and quite honestly, I think I would 1-ke to say that in the main, it's due to a fifth one, which he didn't measur# or mention, and that is, I believe myself, that It la mainly a mechanical upset in the lungs, but we don't yet know the SiiBwer to this. The causes of diminution of maximum voluntary ventilation is a thing which badly needs studying. Otis, i" America, started a very useful method of thinking about I t , and he points out that you can get diminution in the poT<nn-n bellows due either to the power of the muscles working the bellows, due to the diminution of the air flow, forms of bronchial spasm, due to a lowering of the vital capacity, which is the stroke of the bellows, or finally, due to the elastic properties of the lungs, the degree of i!2 . drag th a t you g e t through the a c tu a l s h i f t i n g in and out o f the lu ng su b sta n ce, and we hare n o t y e t g o t down to th a t form o f a n a l y s is , but i t does seem f a i r l y c le a r th a t in pneum oconiosis, th e main t f f e e t i s an a c t u a l reduced s ia e o f bellow s which one g ets and sees in the drop o f the v i t a l c a p a c ity , and i t i s in t e r e s t in g in a way, how w e ll v i t a l c a p a c ity comes out as a f u n c tio n a l t e s t in rneumoconiosia for th at reason, I think rather su rp risin gly w e ll, because i t I s n ' t r e a l l y a dynamic t e s t o f fu n c t io n , as ybu w i l l see from th a t model, , Than, l a s t l y , th ere i s t h is n e x t q u e s tio n o f what I s the r o l e o f emphysema. Our r e s u lt s a r e , and i f you w i l accept m , t h a t ' s only i f you w ill a ccep t, th a t bad gas d istrib u tio n could be defined as onoof the e ff e c t s of o s physema. Our r e s u lt s do su ggest th a t the f o c a l emphysema dsseribod by Gough, is n ot i t s e l f , o f n e c e s s ity , d is a b lin g . J In so fa r as we have g o t, b u t th a t the same p r o c e s s , p h y s io - j l o g i c a l ppc '.ess which gives rise to i t , a ls o u p se ts the elasticity o f the lung substance, which diminishes the j maximum b re a th in g c a p a c ity , b u t th a t is speculation. j The whole business of what is emphysema, is an j extremely difficult project, or idea, and we are trying to ! S at down to analysing hew one could define physiological j emphysema and how that overlaps with what the clinic!ana , talk about and what the radiologists talk about, because n T '____________________________________________________333. li r> i| ! i t does seem to me th a t the word 'enphysema* i s sh am efu lly j!l misused in the sense th a t i t i s p robably a syndrome which !; aay g ir o r is e or may a r is e from v a rio u s causes w ith in the |l | lungs, | And l a s t l y , th ere i s one p o in t and t h a t i s about i d i s a b i l i t y , which I hope I made c l e a r , I d id say that I thought conglomerate pneumoconiosis o r com plicated pneumo c o n io s is i s the main and e s s e n t i a l l y r e a l l y d is a b lin g p a r t o f the d isease, b u t I think you w i l l n o tice th at in the i sim ple d is e a s e , as age in cre a se d , and b y the time people r ! have g o t Category 3 simple pneumoconiosis a t age f i f t y - f i v e they were beginning to g e t f a i r l y d is a b le d * What happens a f t e r f i f t y - f i v e we d o n 't know. We d id n 't go above th a t, and I would s t r e s s th a t cur r e s u lts are lim ite d over those y ea r a* because wo d id n 't go beyond age f i f t y - f i v e , which was the range we were in te r e s te d in ourselves, Shank you, i j! ET DP"TOR BANDER8 i| ' ' ' !! Did this discussion formulate any questions? !j (Ho response), >! j, If not, I want to thank all the rpoakera this J; afternoon, Doctor Friedman, Doctor Motley and Doctor Eugh- this excellent discu33lcn. 'fhsnk you vary JKUCh, (Cession adjourned at 5 ^ 5 ? M. ) ____________