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Relationship of strain to an acute cardiac insult
Workmen’s Compensation for the Cardiac Relationship
of Strain I,ocus
H.
to an Acute SIGL.ER,
Brooklyn
N a previous communication’ I presented a short outline of a study made in New York State under the direction of the Moreland Commissioner,t Judge Callahan, relating to certain compensation problems. The medical phases of the study were intended to determint the possible relationship of strain to cardiac disability. It consisted of a questionnaire sent out to a number of cardiologists and internists lvith reference to the problem, and the answers received. The first question dealing with the possible relationship of work to heart disease has been discussed l))- me in another communication.” In the present paper, we shall take up the second question which reads as follows: “ S uppose the case is of a SO-year-old workman employed for 20 years in a job that re,gularl>required the lifting of 100 pound wrights. During the course of this work as customaril>performed, a coronary- occlusion with myocardial infarction develops. while lifting a 100 pound weight. From a medical Gevvpoint. would you consider the attack to be causall\related to the lifting of the weight?” Of 383 replies received. 185 or 48.4 per cent Ad yes or yes with some modiftcations and 197 or 51.6 per cent said no. Of those who replied in the affirmative, with modifications, a few believed that there was a “possible” relationship, or a “contributing,” “precipirating,” 01 “aggravating” factor that acted a> a “trigger mechanism” and a few that infarction could occur as a result of coronary insufficient\\\ithout coronary occliision.
I
M.D.,
Cardiac
Insult
F..\.c.c.*
New York
Those who replied in the negative, nasecl their views on the assumed facts that the man was doing his customary work to which he ~a\ conditioned; that there was no unusual effort or strain; or, that the heart attack was i~mnincn~ and it was merely- a coincidence thar it occurred \vhile he was vvorking. \7~~~~.~
I submitted
THE
C:OMMITTEI;
this
question
the
opinions
members
and
men
answered
who
OF
were
to
our
Goimnittee
expressed
as follows
In
the
:
One member replied: “I think the myocardial infarction was only coincidental since this man was doing his customary work. Howewx. if this man’s occupation had been a clerk which required nu physical exertion and he had had a myocardial infarction while shoveling snow, it would be m\- opinion that there was a causal relationship.” .\nother member, in his answer to the tirst question which, in the nature of his reply, is applicable also to the present question, wrote in part as follo~vs: ,‘I have seen a number of patients who have had heart attacks while performing duties that were unusually strenuous and not in their usual line of work. It has always been questionable in my mind as ti, \~hethel or not the exertion was a precipitating factor or merelya contributing faac.tor. Certainly, in my experience. more patients seem to suffer their attacks Ivhilr nor lvorking than while working. It would seem to me that if the ansvvci tu iirc. clue+ tion asked was answered in the affirmative. no cmployer would ever be willing to hire a person in .m age in which most heart attacks occur. .Uso: if the employer were to be responsible for such attacks it would seem to be prudent that he fire all emplovr-ri ahovr
‘* Chairnran, Workmen’s Compensation Committee, American College of <:ardiolog-y. t It has been brought to our attention that this survey was made by thr Medical Consultant investigation and had nothing to do with the Workmen’s Compensation Board itsrlf. Nrithrr thr conclusions reached wrr~ passed upon or publishrd by thr Board.
appuintcd qltewinn<
IUI the 11or the
262
Workmell’s
Compensation
such age and replace them with younger men. Certainly, if the employer is held responsible it will be increasingly difficult for anyone 40 years or older to either obtain or retain employment.” ,4 third member replied the following to the first question which also applies to the second: “It seems to me that many of the differences of opinion that are rendered by physicians on this subject are due to the inherent ambiguity in the law. As I understand it, if something probably has played a part in the production of the disability and this something is connected with a person’s work, then the illness is compensable, If this is only a possibility, then it is not compensable. It is my understanding that, in general, psychosomatic illnesses are ordinarily not judged compensable. For example, it would be difhcult to argue that an extremely unpleasant workman’s situation with a good deal of tension and strain is not responsible for the production of a duodenal ulcer and as such, a duodenal ulcer that develops under these circumstances perhaps should be considered a compensable injury. However, such has never been the case or certainlynot very frequently. If such reasoning should ever be established as a cause of compensable injuries, then there hardly are any limits to what compensation would and could cover and in effect, compensation would become health insurance for the worker. I believe this is fundamentally wrong. I do not believe that this was ever the intent of the law, and I think that it is terribly important to establish certain principles so that such illnesses will not be adjudged compensable in the future. If one wants to reason that such factors may play a part in the development of arteriosclerotic heart disease and myocardial infarction, I shall have to agree that it is true and I think most physicians would agree. However, it would seem to me to be a terrible mistake to ever permit such illnesses to be adjudged compensable.” Dr. I. Robert Frank of Boston. Massachusetts, in answer to the first question gave a lengthy and interesting discussion on the subject which may apply also to the second question presented in this paper. The following are pertinent parts of his expressions: “I frankly believe as do most observers in this field, that exertion, as such, cannot cause or produce heart disease. In some cases, it may aggravate a previouslydamaged heart. In general we all recognize that coronary sclerosis is the common denominator in all but very few cases of coronary arterial disease. By virtue of its presence, coronary thrombosis occurs, to be followed in most cases by coronary occlusion and myocardial infarction when. and if, the time and situation arises. Physical strain may increase aortic pressure and intracoronary pressure transiently, producing acute changes in coronary vessels where marked atheromas might exist; or emotionalism and strain may stimulate the sympathetic nervous system. thus increasing the epinephrine output leading to
for l’he Cardiac
vasoconstriction and increase in blood pressure, as well as to tachycardia, with resulting cardiac hyperactivity and increased demands upon the coronary blood supply; or that intimal hemorrhages brought on by strain. may permit blood to seep into the intima1 lining, thus lifting atheromatous plaques into the lumen, causing occlusion, and possibly c’ven by disruption and dissolution of intima lead to liberation of thromboplastin. which: of course, is one of the factors responsible for the clotting mechanism of blood. I believe that all thesr are in the background of answers to the question itself. In answering the question itself, I would like to make a few observations. In the first place a man who has been working at a certain job for many years has aged many years. .Atherosclerosis will probably be present in his coronary arteries cvcn if it was not present twenty years before. Thus. hc could be more vulnerable to an attack of coronal-) occlusion with much less stimulation, than 2U years before. However, this hypothetical attack is much more apt to occur while he is sleeping in bed, resting. watching an exciting program on TV, playing cards. etc., than while actually working. This is proved by; statistics. . .In the second place, emotionalism. in my opinion, does enter the picture very often. A man may have. an argument or after a party the night before which ended about 2 A.M. he comes to work, and about two or so hours after performing the same duties that he has had for many years he has a coronary occlusion, suddenly without any warning. It is obvious that an extra employment factor has entered the picture. In the third
place, I believe that the presence of other constitutional diseases. enters the picture, inasmuch as such people are more apt to be subject to coronary prob lems than people in excellent physical condition. It would be my opinion, therefore. . . that our question cannot be resolved into an affirmative or It is my- impression. negative conclusion as such. however, that. . chances of getting a coronary attack from the work alone, are quite remote, unless. other factors enter the picture. particularly rmotiona 1.tsm. . >> I fully agree with the essence of the statements made by my colleagues. Let us attempt. however, to analyze the situation and the facts more fully. In doing so I shall offer some of my personal views which are, of course, subject to refutation and possible modification at a later time. THE
SOCIOECONOMIC. PROBLEM
\Ve arc all fully cognizant of the fact that made for cardiac compensation payments especially in the arteriosclerotic disabilities, group which comprises the greatest number of cases, has a double-edged effect. It burdens rHE
AMERICAN
JOI’RNAL
OF
CARDIOLOGY
rhe defendant with d crenlendous o\.erheatl and it carries the danger of depriving the older These problems, howworkers of employment. rver? are not and should not be solved 1)~ the physician. The)- arc problems for the legisand philanthropists. Outlators, economists, testimon!. must in no wa!. t)r aff~tcd I,), them. We must realize that when a Inan tqins to work at about 40 )-cars of agr at a menial occupation and continues for a period of twcntb \-cars. the possibilities of accumulating enough tnone! to carry him through a long period of illness or a disability which may continue ‘L‘he salary hr the rest of his lift, arc slim. earned is not enough to help him za1.r for 21 If he is struck Iq myocalamatous illness. cardial infarction at the end of twenty years, some provision must be made in the law for his If thercx is some causal relationship protection. between the work he had performed at the time of the accident and the myocardial infarction, hc should be compensated by the employer regardless of the financial strain on the emplo)-er and of the effc=ctL on the \+orker’s future employment. For this reason, the law in most states takes a It considers very liberal view in these cases. a case compensable rven if the strain which caused thr, attack is not the sole cause or even the main cause, provided it is of suflicicnt \r\-erity to help briny about the attack. \Ve> as doctors, ha1.e no legal right to look ,lt the case from any other than ;I medical Our sole duty is to give honest and viewpoint. logical testimony in order to help solve* the If often knotty medical problems involved. the facts in thr case point to causal relationship, even if it is not. the sole cause, thr plaintiff is entitled to protection by appropriate tcstimon)-. If there is no possil)le causal relationship, the drfcndant should b(a protected. It is also the legal and moral dut)- of the doctor to help eliminate dishonest claims and malingerers and to help in rehabilitating the claimant so that he may return again to a productive life. It is onl>, along these channels that WC=>as doctors, can be of help in solving the socioeconolnic prot)lems involved in these casts. ‘TIIK MEmc:;il. :Uthough
(~:ONSIDERA'I'IONS
full knowledge
is lacking
pathologic hndings observed at alltops!’ and correlated with the clinical history- to form a reasonable opinion. In order to obtain a comprehensive picture of the situation \ve, as doctors, must learn to look at pathogc~ncsis from 21 broad viewpoint. All possit)lc factors that help to brinq about a t)rcakdo\\-n in an)- structure or organ of the t)odl- must be taken into consideration. We mu\t not pinpoint one factor as the onI>- cause of such breakdown. Even in known infectious diseases, such as tuberculosis, for instance. it is not the tubrrcte bacillus alone which i< rcThrre art= many sponsible for the disease. additional factors, such as lowerinr! the resistancc I))- overwork, improper rest, poor food, crowded environment, insufficient fresh air and sunshine and, most important of all. individual susceptibility, which are contributor\-. In conditions such as coronary disease, the’theory of a multiplicity of underlving causes is c.ertainlv to t)c entertained. That coronary atherosclerosis ii a slowly developing progressive process over man\ years has been discussed before.? It has also ‘lIeen pointed out that “aging” is not a factor in its pathogenesis. In the early stages it appears to be initiated I))- certain physiologic processes. Thr progress of the disease is due to a continuation of these processes associated with certain local metabolic and chemical changes and cellular alterations of an irritatil-c nature. These progressive processes must ultimatelycome to a stage when an acute process develops in a degenerated area of the coronary arteries, at which time the clinical manifestation5 of the disease brqin to exhibit themsel\.es. ‘T’HE ACI,TE PHASES OF COROKARY
as to the
Intermittent
pathogen& of coronary atherosclerosis and of an acute coronary insufficiency, occlusion, .Ind the resulting nl).ocardial in\rolvrlnent,
greater
t.nough
thr
is known
or can
be inferred
frorll
thr
Dcx.uE
‘The acute phases of coronar). disease may consist of one or more of the changes well enumerated b)- Dr. Frank in his discussion in this paper. These alterations ma). result in functional intermittent m\-ocardiai ischemia alone or more prolonged ‘ischemia, ischemic necrosis, and infarction. These are the underlying causes of the clinical manifestations of coronary disease. Before these chanqeq occur, coronary disease is asymptomatic. rrq-ocardial
appear when the coronaq PSS has rclached a stage or lesser
rnyocardiunl.
extent
ischemia
beyins
atherosclerotic which interferes
with
It exhibits
the blood itqrlf
to
procto a
suppI>- to in thr
an-
qinal s> ndru~r~e. Freedberg and co-wurkers’! observed that in nearly all their autopsy cases. patients who suffered from angina during lift. showed least
one
old
complete
main
occlusive
coronary
processes
syn-
When acute structural altr.ratiuns ill ;i coroIlar) vessel or vessels are more severe, the sympcoma tology I)ccomes nlore marked and prolonged, its severity and prolongation depending ;I ;reat deal upon thr degree of structural myocardial changes. ‘These changes may vaq from mere prolonged ischcmia to focal necrosis 2nd gross severe myocardial infarction, depending mainly upon the degree of interference with thr blood supply to a Kiven portion of the heart caused lq the acute coronary process. It is important to remember that marked Inyocardial changes ma)’ occur without complete occlusion of a coronary \,cssel and relatively little or even no damage may occur in a complete occlusion. It depends partly upon I he extent of the collateral circulation but lnainly to some of the other extrinsic factors already mentioned, especially the neurogenic and reflex elements. In Yater’s series,” of 050 ;tutopsies performed on patients who died of coronary disease, 13 per cent had no coronary occlusion in the presencr of myocardial infarction and others had no infarction in the presence of occlusiun. ‘I’hey also found that occlusion, when present, was due to atherosclerosis alone in 39 per cent of the cases, to thrombosis alone. in 23 per cent and to combined sclerosis and thrombosis in 25 per cent. Physical effort, especially when associated with emotional disturbances, Inay IX a precipitating cause of an acute curunaq. and myocardial insult of any form mentioned herein. ‘rhat the latter much more frequently occurs “spontanrousl) ” at rest or while ;ipparentl\ sleeping, ‘does not mean that there are no causative factors in I)ringing on thr attack in ;Ln individual whose atherosclerotic process is for such attack. Thus. if the attack “rip?” occurs while at rest in t)ed, it may conceivably I)e due to slowing 01’ thr circulation, thus [“edisposing to throIrlt)osis. It may also t)e due to postprandial lipemia after ingestion of a tlra\Fy meal in the evening. 11 may be due to ctlnotional strain under which the sufferer has I)een working during the day and which deprived him from proper sleep and rest during the night or predisposed him to certain frightening dreams. Nervous tension and strain during work in general, appear to have, in
prc-
\omr
in
ar
artery.
From clinical cxxperience, we all know that the an,qinal s\,ndrome may last at times manv months or iears. We also know that at times many days, months, or even years may pas\; I+, without any disturbances after the patient has had angina1 symptoms for weeks or months. This may be explained on the basis of the development of a collateral circulation, which Wiggers’ has shown to occur in slowly devctoping coronary narrowing. Furthermore, we also know that the attacks may be brought about 1~) cxtracardiac factors such as excitement, anxieties, cold weather, overdistention of the stomach tq food, postprandial lipemia reaching a peak of food 5 several hours after the ingestion pathologic conditions in organs above and tjelow the diaphragm which mav act as trigger and other conditions. Most of‘ mechanisms, these are explainable on the basis of reflex coronary spasm and at times on an increase in adrenalin secretion and metal)olic activities. :\ll of these would speak for the fact that t,esides the coronary disease, extrinsic factors enter into the picture. Physical strain, which increases the cardiac \+ork, is thr most important factor in bringing about attacks as is well known to all of us. Even here it is not the physical work alone but associated neurogenic, reflex, and other factors luentioned herein which enter as causes, evidenced b) the fact that a person can do 21 considerable amount of physical work at ont: time and not at another, under different conThus, a person may 1)~ able to do ditions. much walking in his place of business, t)ut ma)’ suffer pain when he does the same amount of {talking on the street. Also, the pain ma)’ l)t% absent when he Lvalks a certain time of the da) and be severe at other times, especially after a lrleal. The emotional element is also an ilnporl:lnt factor in bringing about an attack, as iq \,;ell known from clinical experience. It is thus seen that even at this stage of corutlary disease there arc many factors which cooperate drome,
in
bringing
although
about
physical
Remove dominant one. patient is f’reed from the cspeciall)
in the early
the
activity
angina1 is the
this factor and the attack in most casts.
stages.
cases,
a long-term
effect
in predisposing
a
person to acute coronar) changes. Friedman znd co-workers7 observed changes in the serum chc)lrsterol level and blood clotting time in
accountants during the time of the )-ear whet) they were compelled to work under se\.ert It may also he due strain to meet a deadline. to a gradually mounting tension of an emotiona I origin of months’ or )-ears’ duration, which Weiss and co-workers have observed to occur with great frequency in some cases of coronar! We can thus see that there is occlusion. undoubtedly always a cause for an acute attack, although we may not immediately discern it. I doubt if there is such a thing as ‘*spontanrit\-” in biologic processe:. h’PLICAI’IOh
‘I‘0
OUR
c:AYE
IN
@JESTION
Considering the case presented herein l’or we will observe from the disour opinion, cussions that the question is not specific enough and leaves out some elements that we would (1) Lrnder want to know before answering it. what environmental conditions was thr man (2) Did working at the time of his attack? he have an)- disturbing emotional experience? in recent hours:’ (3) How fast and how high did he lift his 100 pound load at this particular performance? (4) Did he work at this time. after
a heav!-
meal
or
after
restless
night
or other
would
lower
his resistance?
factors
must
answering I
be
havr
this
portant
been
was “the
was
factor
as such,
related.
The
this
of work
type
predisposed
to
extrinsic’ occurred.
lifting
of rhr
sole cause,
‘l’hc probleln of causal relationship between physical strain of lifting a 100 pound load, which a worker- \vas accustomed to doing fol 20 !.ears, and a resulting rnvocardial infarction is considered in this paper. It is pointed out that myocardial infarction or other- myocardial damage due to coronary disease is caused h> acute structural changes in a coronary artery ot arteries. There are many underlying causes which participate in precipitating the acute structural changes, such as lowering the rcsistancc of the individual blr insufficient rest and sleep, emotional disturbances, anxieties, extrinsic and intrinsic reflex factors, the advanced state of the athcromatous process, and others. It is belie\,ed that under such circumstances lifting of a hea\,) load may bring about an attack (bven if the same type of work was performed before without any apparent ill effect?, and is All therefore to t)e considered causalI), related. acute disease processes are known to have a tnultiplicit). of predisposing factors but the predominant cause in this case is the lifting of the load, which is to he conGd?rerl thP main r~~sponsihlc clcrnent.
‘Therefore, load
could
\vork
[here
is
no
of thr kind
1..
H.:
Results of a questxonnairc on reia~1,,I to myocardial infarction. 2: 781, 1958.
tionship of exertion J. 2.
Cnrdiol.
SIGLEK.
I,. H.: Iirlationship .lrrr. .I. C:/zrrl/oi. 3: 261,
ofwork 1959.
to heart
disrasr.
in the had
h(,
when
attack attack
hc>
b!-
would
thc~ not
though
be considrrctl
the important
to observe
SIGL~K.
track.”
are that
even
not
I.
be consideletl
acute thr
imim‘I’his
resulted
at a period
an
it is certainly
believe
betwecan
has
SUMMAR\
staltc.
important
of the load.
chances
factors,
It is interesting who
worker
prcan
advanced
it should
avoided
have
the
which
attack.
most
which
causally was
it1
thr
otht-1
that tjroke the camel’s
final
and,
the
was the lifting
last straw the
various
othrr
whatever
to the
of which
cause
attack
and
present
individual
one
It was
which
ronsideraticln
that
atheromatosis,
mediate
These
into
however,
might
disposed of the
taken
and
conditions
though years.
the question.
believe.
factors
a sleepless
adverse
;rgc is hazardous even I)ecn doing it for man)-
t h(* t h(*
cause.
that most clinicians causal this person
relationship performed
and his attack. would hesitate in allowing a 60-)-ear-old man to lift a 100 pound \vcxiKht. Evident]), the\ helir1.c. that such work at thix
4. ~YIGGEK~, C. .I.. ‘l‘hr functional nary rollatrrals. ~.‘irruln/ion
S:
importance 609, 1952.
nf wro-
5. tiuo, P. ‘1‘. and .lovNe~~, C:. K.: .Angma pectorls induced hy fat ingrstion in patients with coronarv .1,,4..tf.;l. 158: 1008. 1955. al-Wry disvaw 0. \‘ATI’R. w. h!.. WI.LSII, P. P., STAPLETOh., .I. F., Comparison of clinical and and (:L.ARK. %I.. L.: patholoqic aspects of coronary artery disease in mvn of \-arious age groups: A study of 350 autopsird rasw from the hrmcd Forces Institlltr of Pnth.l,~n. 4111..\fpd, 34: 352. 1951 0l0gy. -‘.
I:ctr~untAx.
hf.. ROTHMAN, K. H., and C.~RROI.L. V.: Changrs in the strum cholesterol and blood clottins timr in mr~~ subjected to cyclic variation nl ~~c~rlp.lti<,llnI
266
Workmen’s
Announcement
Compensation
of a Study on the Legal
Principles Involved and Trauma
The differences in the treatment of claims involving heart attacks by courts and workmen’s compensation commissions is the subject of a new study being made under a recent grant by the National Heart Institute of the LT. S. Public Health Service. Associate Dean Harold F. McNiece, of St. John’s University School of Law, has been named director of the study. When a workmen’s compensation award is made to a victim of a heart attack, it is often based on a finding that the stress and strain 01 the work being performed caused the attack, or that the attack was an “accident” arising When out of and in the course of employment. an award is denied, it is usually on the assumption that no “accident” occurred, or that there was no causal connection between the work and the attack. However, the variations of opinions in different states range from the view that almost any on-the-job heart attack is compensable to the opposite extreme. As a result, the legal status of the victim of a heart attack has t)ecome uncertain. The hIcNiecc study group plans to explore in detail the legal principles which are being applied and the procedures being utilized t)y, courts and workmen’s compensation commissions when granting or denying awards to persons who suffer coronary attacks while at work. Thus, they, hope to develop information that will lead to more equitable and consistent
Minutes
of the Meeting
for The (:ardisc
of Workmen’s
handling
in Cardiac
of these
on
the
question
were
how
caused
to what experts
whether
or
attenapproach
not
heart
attacks
will try to determine
and
medical
of testimony
particular
commissions
testimony
is heeded.
try impartial
medical
will also IX explored.
Others Paul
and
I)), stress,
extent
‘I’hc effect
will focus
courts of
Due to Strain
cases.
‘I’he investigation tion
Disability
associated
E. Gurskc,
with
former
the
investigation
Director
are
of the Bureau
of Labor Standards of the U. S. Department 01 Labor, who is to assist in the statistical aspects of the study, and a number of experts in the medicolegal field who will act as consultants, including Professor I,. W’hiting Farinhold of the University of Maryland School of Law. past chairnlan of the medicolegal committee of the Association of‘ American Law Schools: Bartlett S. Fox, forrncr New York State worktnen’s compensation referee : Dr. Milton Helpern, Chief Xledical Examiner of the City of New York: 1)r. Irvin Klein. Medical Directot of the New \I’ork State ~Vorktnen‘s Compensation Board; Professor .lohn \‘. Thornton of New York Crniversity School of Law. and Throclorc (:. \Vaters. (%I‘ttre Baltimore Bar. A11yo11t
\\,tlo
trright
have
an)
tttatcrials,
\uggestiuns, or views to otlcr is invited to get in toucll with I\ssociatr Dean hIcNiece at St. .lohn’s Univrrsity School of La\v, 00 Schrrmcrhorn Street. Brooklyn 1, New \r’ork.
Compensation
Committee,
American
College
of
Cardiology I. Ttze committee convened at 12 : 15 r’.hi. on May 28. 1959, in the Penn Room of the Benjamin Franklin Hotel, Philadelphia, Pennsylvania. II. The fdlowiq werepresent, constituting a quorum: L. H. Sigler. Chairman; G. W. H. Schepers, Acting Secretary; S. M. Horvath; J. M. Bodlander; I. R. Frank; D. Gelfand; R. Hamilton; and S. Dack. Drs. Bernstein and Kissane wrote to say they would be unable to attend. III. Review of the problem of the cuusul relntionrhip brtween the performunce of work und cardiovascular disensr. The following points were raised : 1. There is need for clarification of the denotation and connotation of existing legal phraseology relating to compensable heart disease. 2. No general rules can be formulated by the committee before legal concepts have themselves been standardized.
3. Existing so-called accepted criteria of compensable heart disease are not applicable to every case because of the wide range of individual variability. 4. Statistical evidence, although a guide, should not overrule the merits of the individual cast. Thus the fact that there is less heart disease in physical laborers than in sedentary workers. does not yet disprove a causal relationship between physical stress and cardiac incapacitation in an individual case. 5. Too much of what is considered as authoritative evidence is essentially opinion of individuals. There is great need for precise facts. 6. Aggravation of pm-existing cardiovascular disease is as much part of the problem as is the production of new disease by stress. Indeed, as most adult hearts are abnormal to a greater or lesser degree, aggravation is probably a factor in the majority of cases in which causality appears to apply. IHll
AMERICAN
JOI!KNAI.
OF
(:XRDIOI.OC:‘.
Workmen’s
(:ornpensation
7. Emotional stress is probably as important 01 more important a consideration as physical strain. The emotional factor, mediating its effects through hormonal and autonomic mechanisms. may play d role in the period prior to the occurrence of the episode of physical exertion as well as at the time of the incident 8. There is need for a special study of the effect of emotional stress on the coagulability of the blood. Studies such as these could probably be considerably facilitated if performed in relation to blood bank proceedings. 9. Greater administrative efforts should be made tlj record precise cardiological data at pre-employment , periodical. and discharge or re-employment physical This informaexaminations of industrial workers. tion would be of greater value if corporations would publish the statistical results of their studies. 10. While the committee recognizes that legalistik~ and sociologic factors are often the main determinants of workmen’s compensation decisions, which not infrequently deviate markedly from reasonable scientific criteria, the formulation of standards by the College seems nevertheless worthwhile. IV. R&u! of the progress made in connectiorl with the symposium on occupational aspects of coronary artery disease, which is currently under preparation by members of the committee, as reported in the minutes of the annual meeting o/ It emerged that it has been the universal ex7958. perience of all participants in this symposium that the tasks assigned to each member are too extensive to bl. dealt with expeditiously and synchronously by thf, It was resolved. therefore. that: memherq.
for ‘1%~ Chrdiac
1. Each member to whom a topic was assigned should be accorded the rank of project leader with the right to enlist the aid of as many other members of the (:ollege as the scope of his contribution may require. 2. The essays should, in the first instance, attempt to collate existing data published in the literature, stressing the limits of normality, the extremes of abnormality on record, and the nuances of variation brtween these extremes. 3. Individual members who have facilities to obtain new information by virtue of their association with appropriate institutions (industry, universities‘) are welcome to add this material. 4. Completed reports are to be forwarded to Dr. Sigher who will arrange to have them duplicated for review by the committee prior to the next meeting. 5. In view of Dr. Eichert’s death. as a result of an automobile accident, the review of the natural history, of coronary artery’ disease has been reassigned to Dr. Frank. No new projects were V. Yro(,u~uls /or vlezL’studies. The chairman will make proposals to agreed upon. the College President for revision of the membership. Vl. :Vext mretiq. Provisionally the committee will reconvene on the occasion of the interim College meeting at Philadelphia during November. 1959. VII. .4djouumzPnt. The committee adjourned at ?:tjfl P.M. G. W.
H. SCHEPERS,
M.D.. D.W.
Acting Secretary (:ommittee on Workmen’s Compensatioii .American College of Cardiology
of Strain I,ocus
H.
to an Acute SIGL.ER,
Brooklyn
N a previous communication’ I presented a short outline of a study made in New York State under the direction of the Moreland Commissioner,t Judge Callahan, relating to certain compensation problems. The medical phases of the study were intended to determint the possible relationship of strain to cardiac disability. It consisted of a questionnaire sent out to a number of cardiologists and internists lvith reference to the problem, and the answers received. The first question dealing with the possible relationship of work to heart disease has been discussed l))- me in another communication.” In the present paper, we shall take up the second question which reads as follows: “ S uppose the case is of a SO-year-old workman employed for 20 years in a job that re,gularl>required the lifting of 100 pound wrights. During the course of this work as customaril>performed, a coronary- occlusion with myocardial infarction develops. while lifting a 100 pound weight. From a medical Gevvpoint. would you consider the attack to be causall\related to the lifting of the weight?” Of 383 replies received. 185 or 48.4 per cent Ad yes or yes with some modiftcations and 197 or 51.6 per cent said no. Of those who replied in the affirmative, with modifications, a few believed that there was a “possible” relationship, or a “contributing,” “precipirating,” 01 “aggravating” factor that acted a> a “trigger mechanism” and a few that infarction could occur as a result of coronary insufficient\\\ithout coronary occliision.
I
M.D.,
Cardiac
Insult
F..\.c.c.*
New York
Those who replied in the negative, nasecl their views on the assumed facts that the man was doing his customary work to which he ~a\ conditioned; that there was no unusual effort or strain; or, that the heart attack was i~mnincn~ and it was merely- a coincidence thar it occurred \vhile he was vvorking. \7~~~~.~
I submitted
THE
C:OMMITTEI;
this
question
the
opinions
members
and
men
answered
who
OF
were
to
our
Goimnittee
expressed
as follows
In
the
:
One member replied: “I think the myocardial infarction was only coincidental since this man was doing his customary work. Howewx. if this man’s occupation had been a clerk which required nu physical exertion and he had had a myocardial infarction while shoveling snow, it would be m\- opinion that there was a causal relationship.” .\nother member, in his answer to the tirst question which, in the nature of his reply, is applicable also to the present question, wrote in part as follo~vs: ,‘I have seen a number of patients who have had heart attacks while performing duties that were unusually strenuous and not in their usual line of work. It has always been questionable in my mind as ti, \~hethel or not the exertion was a precipitating factor or merelya contributing faac.tor. Certainly, in my experience. more patients seem to suffer their attacks Ivhilr nor lvorking than while working. It would seem to me that if the ansvvci tu iirc. clue+ tion asked was answered in the affirmative. no cmployer would ever be willing to hire a person in .m age in which most heart attacks occur. .Uso: if the employer were to be responsible for such attacks it would seem to be prudent that he fire all emplovr-ri ahovr
‘* Chairnran, Workmen’s Compensation Committee, American College of <:ardiolog-y. t It has been brought to our attention that this survey was made by thr Medical Consultant investigation and had nothing to do with the Workmen’s Compensation Board itsrlf. Nrithrr thr conclusions reached wrr~ passed upon or publishrd by thr Board.
appuintcd qltewinn<
IUI the 11or the
262
Workmell’s
Compensation
such age and replace them with younger men. Certainly, if the employer is held responsible it will be increasingly difficult for anyone 40 years or older to either obtain or retain employment.” ,4 third member replied the following to the first question which also applies to the second: “It seems to me that many of the differences of opinion that are rendered by physicians on this subject are due to the inherent ambiguity in the law. As I understand it, if something probably has played a part in the production of the disability and this something is connected with a person’s work, then the illness is compensable, If this is only a possibility, then it is not compensable. It is my understanding that, in general, psychosomatic illnesses are ordinarily not judged compensable. For example, it would be difhcult to argue that an extremely unpleasant workman’s situation with a good deal of tension and strain is not responsible for the production of a duodenal ulcer and as such, a duodenal ulcer that develops under these circumstances perhaps should be considered a compensable injury. However, such has never been the case or certainlynot very frequently. If such reasoning should ever be established as a cause of compensable injuries, then there hardly are any limits to what compensation would and could cover and in effect, compensation would become health insurance for the worker. I believe this is fundamentally wrong. I do not believe that this was ever the intent of the law, and I think that it is terribly important to establish certain principles so that such illnesses will not be adjudged compensable in the future. If one wants to reason that such factors may play a part in the development of arteriosclerotic heart disease and myocardial infarction, I shall have to agree that it is true and I think most physicians would agree. However, it would seem to me to be a terrible mistake to ever permit such illnesses to be adjudged compensable.” Dr. I. Robert Frank of Boston. Massachusetts, in answer to the first question gave a lengthy and interesting discussion on the subject which may apply also to the second question presented in this paper. The following are pertinent parts of his expressions: “I frankly believe as do most observers in this field, that exertion, as such, cannot cause or produce heart disease. In some cases, it may aggravate a previouslydamaged heart. In general we all recognize that coronary sclerosis is the common denominator in all but very few cases of coronary arterial disease. By virtue of its presence, coronary thrombosis occurs, to be followed in most cases by coronary occlusion and myocardial infarction when. and if, the time and situation arises. Physical strain may increase aortic pressure and intracoronary pressure transiently, producing acute changes in coronary vessels where marked atheromas might exist; or emotionalism and strain may stimulate the sympathetic nervous system. thus increasing the epinephrine output leading to
for l’he Cardiac
vasoconstriction and increase in blood pressure, as well as to tachycardia, with resulting cardiac hyperactivity and increased demands upon the coronary blood supply; or that intimal hemorrhages brought on by strain. may permit blood to seep into the intima1 lining, thus lifting atheromatous plaques into the lumen, causing occlusion, and possibly c’ven by disruption and dissolution of intima lead to liberation of thromboplastin. which: of course, is one of the factors responsible for the clotting mechanism of blood. I believe that all thesr are in the background of answers to the question itself. In answering the question itself, I would like to make a few observations. In the first place a man who has been working at a certain job for many years has aged many years. .Atherosclerosis will probably be present in his coronary arteries cvcn if it was not present twenty years before. Thus. hc could be more vulnerable to an attack of coronal-) occlusion with much less stimulation, than 2U years before. However, this hypothetical attack is much more apt to occur while he is sleeping in bed, resting. watching an exciting program on TV, playing cards. etc., than while actually working. This is proved by; statistics. . .In the second place, emotionalism. in my opinion, does enter the picture very often. A man may have. an argument or after a party the night before which ended about 2 A.M. he comes to work, and about two or so hours after performing the same duties that he has had for many years he has a coronary occlusion, suddenly without any warning. It is obvious that an extra employment factor has entered the picture. In the third
place, I believe that the presence of other constitutional diseases. enters the picture, inasmuch as such people are more apt to be subject to coronary prob lems than people in excellent physical condition. It would be my opinion, therefore. . . that our question cannot be resolved into an affirmative or It is my- impression. negative conclusion as such. however, that. . chances of getting a coronary attack from the work alone, are quite remote, unless. other factors enter the picture. particularly rmotiona 1.tsm. . >> I fully agree with the essence of the statements made by my colleagues. Let us attempt. however, to analyze the situation and the facts more fully. In doing so I shall offer some of my personal views which are, of course, subject to refutation and possible modification at a later time. THE
SOCIOECONOMIC. PROBLEM
\Ve arc all fully cognizant of the fact that made for cardiac compensation payments especially in the arteriosclerotic disabilities, group which comprises the greatest number of cases, has a double-edged effect. It burdens rHE
AMERICAN
JOI’RNAL
OF
CARDIOLOGY
rhe defendant with d crenlendous o\.erheatl and it carries the danger of depriving the older These problems, howworkers of employment. rver? are not and should not be solved 1)~ the physician. The)- arc problems for the legisand philanthropists. Outlators, economists, testimon!. must in no wa!. t)r aff~tcd I,), them. We must realize that when a Inan tqins to work at about 40 )-cars of agr at a menial occupation and continues for a period of twcntb \-cars. the possibilities of accumulating enough tnone! to carry him through a long period of illness or a disability which may continue ‘L‘he salary hr the rest of his lift, arc slim. earned is not enough to help him za1.r for 21 If he is struck Iq myocalamatous illness. cardial infarction at the end of twenty years, some provision must be made in the law for his If thercx is some causal relationship protection. between the work he had performed at the time of the accident and the myocardial infarction, hc should be compensated by the employer regardless of the financial strain on the emplo)-er and of the effc=ctL on the \+orker’s future employment. For this reason, the law in most states takes a It considers very liberal view in these cases. a case compensable rven if the strain which caused thr, attack is not the sole cause or even the main cause, provided it is of suflicicnt \r\-erity to help briny about the attack. \Ve> as doctors, ha1.e no legal right to look ,lt the case from any other than ;I medical Our sole duty is to give honest and viewpoint. logical testimony in order to help solve* the If often knotty medical problems involved. the facts in thr case point to causal relationship, even if it is not. the sole cause, thr plaintiff is entitled to protection by appropriate tcstimon)-. If there is no possil)le causal relationship, the drfcndant should b(a protected. It is also the legal and moral dut)- of the doctor to help eliminate dishonest claims and malingerers and to help in rehabilitating the claimant so that he may return again to a productive life. It is onl>, along these channels that WC=>as doctors, can be of help in solving the socioeconolnic prot)lems involved in these casts. ‘TIIK MEmc:;il. :Uthough
(~:ONSIDERA'I'IONS
full knowledge
is lacking
pathologic hndings observed at alltops!’ and correlated with the clinical history- to form a reasonable opinion. In order to obtain a comprehensive picture of the situation \ve, as doctors, must learn to look at pathogc~ncsis from 21 broad viewpoint. All possit)lc factors that help to brinq about a t)rcakdo\\-n in an)- structure or organ of the t)odl- must be taken into consideration. We mu\t not pinpoint one factor as the onI>- cause of such breakdown. Even in known infectious diseases, such as tuberculosis, for instance. it is not the tubrrcte bacillus alone which i< rcThrre art= many sponsible for the disease. additional factors, such as lowerinr! the resistancc I))- overwork, improper rest, poor food, crowded environment, insufficient fresh air and sunshine and, most important of all. individual susceptibility, which are contributor\-. In conditions such as coronary disease, the’theory of a multiplicity of underlving causes is c.ertainlv to t)c entertained. That coronary atherosclerosis ii a slowly developing progressive process over man\ years has been discussed before.? It has also ‘lIeen pointed out that “aging” is not a factor in its pathogenesis. In the early stages it appears to be initiated I))- certain physiologic processes. Thr progress of the disease is due to a continuation of these processes associated with certain local metabolic and chemical changes and cellular alterations of an irritatil-c nature. These progressive processes must ultimatelycome to a stage when an acute process develops in a degenerated area of the coronary arteries, at which time the clinical manifestation5 of the disease brqin to exhibit themsel\.es. ‘T’HE ACI,TE PHASES OF COROKARY
as to the
Intermittent
pathogen& of coronary atherosclerosis and of an acute coronary insufficiency, occlusion, .Ind the resulting nl).ocardial in\rolvrlnent,
greater
t.nough
thr
is known
or can
be inferred
frorll
thr
Dcx.uE
‘The acute phases of coronar). disease may consist of one or more of the changes well enumerated b)- Dr. Frank in his discussion in this paper. These alterations ma). result in functional intermittent m\-ocardiai ischemia alone or more prolonged ‘ischemia, ischemic necrosis, and infarction. These are the underlying causes of the clinical manifestations of coronary disease. Before these chanqeq occur, coronary disease is asymptomatic. rrq-ocardial
appear when the coronaq PSS has rclached a stage or lesser
rnyocardiunl.
extent
ischemia
beyins
atherosclerotic which interferes
with
It exhibits
the blood itqrlf
to
procto a
suppI>- to in thr
an-
qinal s> ndru~r~e. Freedberg and co-wurkers’! observed that in nearly all their autopsy cases. patients who suffered from angina during lift. showed least
one
old
complete
main
occlusive
coronary
processes
syn-
When acute structural altr.ratiuns ill ;i coroIlar) vessel or vessels are more severe, the sympcoma tology I)ccomes nlore marked and prolonged, its severity and prolongation depending ;I ;reat deal upon thr degree of structural myocardial changes. ‘These changes may vaq from mere prolonged ischcmia to focal necrosis 2nd gross severe myocardial infarction, depending mainly upon the degree of interference with thr blood supply to a Kiven portion of the heart caused lq the acute coronary process. It is important to remember that marked Inyocardial changes ma)’ occur without complete occlusion of a coronary \,cssel and relatively little or even no damage may occur in a complete occlusion. It depends partly upon I he extent of the collateral circulation but lnainly to some of the other extrinsic factors already mentioned, especially the neurogenic and reflex elements. In Yater’s series,” of 050 ;tutopsies performed on patients who died of coronary disease, 13 per cent had no coronary occlusion in the presencr of myocardial infarction and others had no infarction in the presence of occlusiun. ‘I’hey also found that occlusion, when present, was due to atherosclerosis alone in 39 per cent of the cases, to thrombosis alone. in 23 per cent and to combined sclerosis and thrombosis in 25 per cent. Physical effort, especially when associated with emotional disturbances, Inay IX a precipitating cause of an acute curunaq. and myocardial insult of any form mentioned herein. ‘rhat the latter much more frequently occurs “spontanrousl) ” at rest or while ;ipparentl\ sleeping, ‘does not mean that there are no causative factors in I)ringing on thr attack in ;Ln individual whose atherosclerotic process is for such attack. Thus. if the attack “rip?” occurs while at rest in t)ed, it may conceivably I)e due to slowing 01’ thr circulation, thus [“edisposing to throIrlt)osis. It may also t)e due to postprandial lipemia after ingestion of a tlra\Fy meal in the evening. 11 may be due to ctlnotional strain under which the sufferer has I)een working during the day and which deprived him from proper sleep and rest during the night or predisposed him to certain frightening dreams. Nervous tension and strain during work in general, appear to have, in
prc-
\omr
in
ar
artery.
From clinical cxxperience, we all know that the an,qinal s\,ndrome may last at times manv months or iears. We also know that at times many days, months, or even years may pas\; I+, without any disturbances after the patient has had angina1 symptoms for weeks or months. This may be explained on the basis of the development of a collateral circulation, which Wiggers’ has shown to occur in slowly devctoping coronary narrowing. Furthermore, we also know that the attacks may be brought about 1~) cxtracardiac factors such as excitement, anxieties, cold weather, overdistention of the stomach tq food, postprandial lipemia reaching a peak of food 5 several hours after the ingestion pathologic conditions in organs above and tjelow the diaphragm which mav act as trigger and other conditions. Most of‘ mechanisms, these are explainable on the basis of reflex coronary spasm and at times on an increase in adrenalin secretion and metal)olic activities. :\ll of these would speak for the fact that t,esides the coronary disease, extrinsic factors enter into the picture. Physical strain, which increases the cardiac \+ork, is thr most important factor in bringing about attacks as is well known to all of us. Even here it is not the physical work alone but associated neurogenic, reflex, and other factors luentioned herein which enter as causes, evidenced b) the fact that a person can do 21 considerable amount of physical work at ont: time and not at another, under different conThus, a person may 1)~ able to do ditions. much walking in his place of business, t)ut ma)’ suffer pain when he does the same amount of {talking on the street. Also, the pain ma)’ l)t% absent when he Lvalks a certain time of the da) and be severe at other times, especially after a lrleal. The emotional element is also an ilnporl:lnt factor in bringing about an attack, as iq \,;ell known from clinical experience. It is thus seen that even at this stage of corutlary disease there arc many factors which cooperate drome,
in
bringing
although
about
physical
Remove dominant one. patient is f’reed from the cspeciall)
in the early
the
activity
angina1 is the
this factor and the attack in most casts.
stages.
cases,
a long-term
effect
in predisposing
a
person to acute coronar) changes. Friedman znd co-workers7 observed changes in the serum chc)lrsterol level and blood clotting time in
accountants during the time of the )-ear whet) they were compelled to work under se\.ert It may also he due strain to meet a deadline. to a gradually mounting tension of an emotiona I origin of months’ or )-ears’ duration, which Weiss and co-workers have observed to occur with great frequency in some cases of coronar! We can thus see that there is occlusion. undoubtedly always a cause for an acute attack, although we may not immediately discern it. I doubt if there is such a thing as ‘*spontanrit\-” in biologic processe:. h’PLICAI’IOh
‘I‘0
OUR
c:AYE
IN
@JESTION
Considering the case presented herein l’or we will observe from the disour opinion, cussions that the question is not specific enough and leaves out some elements that we would (1) Lrnder want to know before answering it. what environmental conditions was thr man (2) Did working at the time of his attack? he have an)- disturbing emotional experience? in recent hours:’ (3) How fast and how high did he lift his 100 pound load at this particular performance? (4) Did he work at this time. after
a heav!-
meal
or
after
restless
night
or other
would
lower
his resistance?
factors
must
answering I
be
havr
this
portant
been
was “the
was
factor
as such,
related.
The
this
of work
type
predisposed
to
extrinsic’ occurred.
lifting
of rhr
sole cause,
‘l’hc probleln of causal relationship between physical strain of lifting a 100 pound load, which a worker- \vas accustomed to doing fol 20 !.ears, and a resulting rnvocardial infarction is considered in this paper. It is pointed out that myocardial infarction or other- myocardial damage due to coronary disease is caused h> acute structural changes in a coronary artery ot arteries. There are many underlying causes which participate in precipitating the acute structural changes, such as lowering the rcsistancc of the individual blr insufficient rest and sleep, emotional disturbances, anxieties, extrinsic and intrinsic reflex factors, the advanced state of the athcromatous process, and others. It is belie\,ed that under such circumstances lifting of a hea\,) load may bring about an attack (bven if the same type of work was performed before without any apparent ill effect?, and is All therefore to t)e considered causalI), related. acute disease processes are known to have a tnultiplicit). of predisposing factors but the predominant cause in this case is the lifting of the load, which is to he conGd?rerl thP main r~~sponsihlc clcrnent.
‘Therefore, load
could
\vork
[here
is
no
of thr kind
1..
H.:
Results of a questxonnairc on reia~1,,I to myocardial infarction. 2: 781, 1958.
tionship of exertion J. 2.
Cnrdiol.
SIGLEK.
I,. H.: Iirlationship .lrrr. .I. C:/zrrl/oi. 3: 261,
ofwork 1959.
to heart
disrasr.
in the had
h(,
when
attack attack
hc>
b!-
would
thc~ not
though
be considrrctl
the important
to observe
SIGL~K.
track.”
are that
even
not
I.
be consideletl
acute thr
imim‘I’his
resulted
at a period
an
it is certainly
believe
betwecan
has
SUMMAR\
staltc.
important
of the load.
chances
factors,
It is interesting who
worker
prcan
advanced
it should
avoided
have
the
which
attack.
most
which
causally was
it1
thr
otht-1
that tjroke the camel’s
final
and,
the
was the lifting
last straw the
various
othrr
whatever
to the
of which
cause
attack
and
present
individual
one
It was
which
ronsideraticln
that
atheromatosis,
mediate
These
into
however,
might
disposed of the
taken
and
conditions
though years.
the question.
believe.
factors
a sleepless
adverse
;rgc is hazardous even I)ecn doing it for man)-
t h(* t h(*
cause.
that most clinicians causal this person
relationship performed
and his attack. would hesitate in allowing a 60-)-ear-old man to lift a 100 pound \vcxiKht. Evident]), the\ helir1.c. that such work at thix
4. ~YIGGEK~, C. .I.. ‘l‘hr functional nary rollatrrals. ~.‘irruln/ion
S:
importance 609, 1952.
nf wro-
5. tiuo, P. ‘1‘. and .lovNe~~, C:. K.: .Angma pectorls induced hy fat ingrstion in patients with coronarv .1,,4..tf.;l. 158: 1008. 1955. al-Wry disvaw 0. \‘ATI’R. w. h!.. WI.LSII, P. P., STAPLETOh., .I. F., Comparison of clinical and and (:L.ARK. %I.. L.: patholoqic aspects of coronary artery disease in mvn of \-arious age groups: A study of 350 autopsird rasw from the hrmcd Forces Institlltr of Pnth.l,~n. 4111..\fpd, 34: 352. 1951 0l0gy. -‘.
I:ctr~untAx.
hf.. ROTHMAN, K. H., and C.~RROI.L. V.: Changrs in the strum cholesterol and blood clottins timr in mr~~ subjected to cyclic variation nl ~~c~rlp.lti<,llnI
266
Workmen’s
Announcement
Compensation
of a Study on the Legal
Principles Involved and Trauma
The differences in the treatment of claims involving heart attacks by courts and workmen’s compensation commissions is the subject of a new study being made under a recent grant by the National Heart Institute of the LT. S. Public Health Service. Associate Dean Harold F. McNiece, of St. John’s University School of Law, has been named director of the study. When a workmen’s compensation award is made to a victim of a heart attack, it is often based on a finding that the stress and strain 01 the work being performed caused the attack, or that the attack was an “accident” arising When out of and in the course of employment. an award is denied, it is usually on the assumption that no “accident” occurred, or that there was no causal connection between the work and the attack. However, the variations of opinions in different states range from the view that almost any on-the-job heart attack is compensable to the opposite extreme. As a result, the legal status of the victim of a heart attack has t)ecome uncertain. The hIcNiecc study group plans to explore in detail the legal principles which are being applied and the procedures being utilized t)y, courts and workmen’s compensation commissions when granting or denying awards to persons who suffer coronary attacks while at work. Thus, they, hope to develop information that will lead to more equitable and consistent
Minutes
of the Meeting
for The (:ardisc
of Workmen’s
handling
in Cardiac
of these
on
the
question
were
how
caused
to what experts
whether
or
attenapproach
not
heart
attacks
will try to determine
and
medical
of testimony
particular
commissions
testimony
is heeded.
try impartial
medical
will also IX explored.
Others Paul
and
I)), stress,
extent
‘I’hc effect
will focus
courts of
Due to Strain
cases.
‘I’he investigation tion
Disability
associated
E. Gurskc,
with
former
the
investigation
Director
are
of the Bureau
of Labor Standards of the U. S. Department 01 Labor, who is to assist in the statistical aspects of the study, and a number of experts in the medicolegal field who will act as consultants, including Professor I,. W’hiting Farinhold of the University of Maryland School of Law. past chairnlan of the medicolegal committee of the Association of‘ American Law Schools: Bartlett S. Fox, forrncr New York State worktnen’s compensation referee : Dr. Milton Helpern, Chief Xledical Examiner of the City of New York: 1)r. Irvin Klein. Medical Directot of the New \I’ork State ~Vorktnen‘s Compensation Board; Professor .lohn \‘. Thornton of New York Crniversity School of Law. and Throclorc (:. \Vaters. (%I‘ttre Baltimore Bar. A11yo11t
\\,tlo
trright
have
an)
tttatcrials,
\uggestiuns, or views to otlcr is invited to get in toucll with I\ssociatr Dean hIcNiece at St. .lohn’s Univrrsity School of La\v, 00 Schrrmcrhorn Street. Brooklyn 1, New \r’ork.
Compensation
Committee,
American
College
of
Cardiology I. Ttze committee convened at 12 : 15 r’.hi. on May 28. 1959, in the Penn Room of the Benjamin Franklin Hotel, Philadelphia, Pennsylvania. II. The fdlowiq werepresent, constituting a quorum: L. H. Sigler. Chairman; G. W. H. Schepers, Acting Secretary; S. M. Horvath; J. M. Bodlander; I. R. Frank; D. Gelfand; R. Hamilton; and S. Dack. Drs. Bernstein and Kissane wrote to say they would be unable to attend. III. Review of the problem of the cuusul relntionrhip brtween the performunce of work und cardiovascular disensr. The following points were raised : 1. There is need for clarification of the denotation and connotation of existing legal phraseology relating to compensable heart disease. 2. No general rules can be formulated by the committee before legal concepts have themselves been standardized.
3. Existing so-called accepted criteria of compensable heart disease are not applicable to every case because of the wide range of individual variability. 4. Statistical evidence, although a guide, should not overrule the merits of the individual cast. Thus the fact that there is less heart disease in physical laborers than in sedentary workers. does not yet disprove a causal relationship between physical stress and cardiac incapacitation in an individual case. 5. Too much of what is considered as authoritative evidence is essentially opinion of individuals. There is great need for precise facts. 6. Aggravation of pm-existing cardiovascular disease is as much part of the problem as is the production of new disease by stress. Indeed, as most adult hearts are abnormal to a greater or lesser degree, aggravation is probably a factor in the majority of cases in which causality appears to apply. IHll
AMERICAN
JOI!KNAI.
OF
(:XRDIOI.OC:‘.
Workmen’s
(:ornpensation
7. Emotional stress is probably as important 01 more important a consideration as physical strain. The emotional factor, mediating its effects through hormonal and autonomic mechanisms. may play d role in the period prior to the occurrence of the episode of physical exertion as well as at the time of the incident 8. There is need for a special study of the effect of emotional stress on the coagulability of the blood. Studies such as these could probably be considerably facilitated if performed in relation to blood bank proceedings. 9. Greater administrative efforts should be made tlj record precise cardiological data at pre-employment , periodical. and discharge or re-employment physical This informaexaminations of industrial workers. tion would be of greater value if corporations would publish the statistical results of their studies. 10. While the committee recognizes that legalistik~ and sociologic factors are often the main determinants of workmen’s compensation decisions, which not infrequently deviate markedly from reasonable scientific criteria, the formulation of standards by the College seems nevertheless worthwhile. IV. R&u! of the progress made in connectiorl with the symposium on occupational aspects of coronary artery disease, which is currently under preparation by members of the committee, as reported in the minutes of the annual meeting o/ It emerged that it has been the universal ex7958. perience of all participants in this symposium that the tasks assigned to each member are too extensive to bl. dealt with expeditiously and synchronously by thf, It was resolved. therefore. that: memherq.
for ‘1%~ Chrdiac
1. Each member to whom a topic was assigned should be accorded the rank of project leader with the right to enlist the aid of as many other members of the (:ollege as the scope of his contribution may require. 2. The essays should, in the first instance, attempt to collate existing data published in the literature, stressing the limits of normality, the extremes of abnormality on record, and the nuances of variation brtween these extremes. 3. Individual members who have facilities to obtain new information by virtue of their association with appropriate institutions (industry, universities‘) are welcome to add this material. 4. Completed reports are to be forwarded to Dr. Sigher who will arrange to have them duplicated for review by the committee prior to the next meeting. 5. In view of Dr. Eichert’s death. as a result of an automobile accident, the review of the natural history, of coronary artery’ disease has been reassigned to Dr. Frank. No new projects were V. Yro(,u~uls /or vlezL’studies. The chairman will make proposals to agreed upon. the College President for revision of the membership. Vl. :Vext mretiq. Provisionally the committee will reconvene on the occasion of the interim College meeting at Philadelphia during November. 1959. VII. .4djouumzPnt. The committee adjourned at ?:tjfl P.M. G. W.
H. SCHEPERS,
M.D.. D.W.
Acting Secretary (:ommittee on Workmen’s Compensatioii .American College of Cardiology