Document 3eeE5GVaGLpqaXgooy0yq7DVD

FILE NAME: Railroads (RR) DATE: 1937 June DOC#: RR004 DOCUMENT DESCRIPTION: Proceedings of the 17th Annual Meeting of the Medical and Surgical Section - American Railway Association A --- ", Association, American Railroads P R O C EED IN G S O f THE ' SEVENTEENTH A N N U A L MEETING OS: TH MEDICAL AND SURGICAL SECTION i H O T E L T R A '/M O R E A T L A N T IC CSTY, N . j . JU N E 7, % 1931 W!> :- PROCEEDINGS or 11 f SEVENTEENTH AN N UAL MEETING O f ! HI Association ol A menoan Rcllioads M EDICAL AND SURGICAL SECTION < i HELD AT HOTEL T R A Y m ORE, ATLANTIC CITY, N. J. JUNE 1, 8, 1937 i'.. f jm -:\ I'iu.s ns., i IN D EX A - v .r h- . . ,,f y i.iiTH'u n H u i l r . m l1I ; 1 1tpi -1.1.o !a tini Mh.nle lj fi l.i 'e 1epurili.eiit M" 1itt o.i; 1 in ur p .i r tn li n i i N . is ..i . oli.ee I Mi 'Mi 1Ei 11 ' I : n i 1. . *, j, ni l I >'lai n i l ( ! . L t >. 1 |. !. ( `; I : : - < ; .1 . .11 - . i. -ju iti iii a - ; <,-i <.! i. *r * :.. ; t . ( i.,i.., t i h-.: it.-I -i I, it I '1.* 1>iu.' ! , W ii I ! : liti: - ' l l . t.i ;> t 1 1.bra. . K u i. f crs Mini mtihl.i-i ` of r. it.:. ) t ( .. "f tiirr> i i r - . j i l 'll Klnm.t. Kl<lin],,<- 1. : .'i fnuti.rv.s aympo'oui 1.t , .11.. 1)utu tiu. m ii u r k 't i.u iNEi-.'iuui' ti.ivir/i.M' ( il l, \. i D u f f pupe: on |i . i c l u r f r of tie* hj'ini l . e u . l ri. .1. \ ; I (<n fr n c it in ol t'.i- c/iii"^ Mi di.-. ;oi'l M.ryu'iil S'"-tK.ii I Min-. I I ' l t o l . i . f l .f 1`ii ii.lJ.iU ers | u ' t fi i d u i ;: un im i. i t; *!i;*- of order ,M(M' [. J , .S i ll ' t r if o r a II. I " Mt'M.li.'in. 'i 111lions M . ; ' i li. u. i n d i a t i Mo.... \ur.iio T.t pnper on finotun <1 M.<- n<. ! of it M . K { ' . : ut'iC"i.i .nj! tr.i'hil> i> to ``"l; \ Miti- i. M o^h, I ) 1'. : iiltlrrSH uh i li ai ri ni ti t, ir.-upi it i.*|m; 1 <l 1.-' M , .1 1 ( `i:v\ I ( n y pit j <<r on fr a r i tirer : l .-on . 1 l No-.-. 1 I i!.i: J( pit Iif r oli t rsiii-p--I l:.l : -i. :tii` l i r i n l i : I [ 'I i. m i l .oil ; ;. !1 1 l.oi..:t>- It ny pi nil- . " \ n l i . i.:il pr- .:r.i;ii of ().. I 5 INDEX Continued r ... o.'.. -, .i. M f.M i :"i. : ; I ,; 1H' 1 l.y f : u. :1; v -.,i L v : t- . i; a L i t ; -.vi ; i i . tr. !;. I M-'- i r . i - i s i n , ,i !,, i _! i ! -; r i . y .1. \ .< 1, i t r ' 1J.V-. , j I | ; r - J n . l 1 M -H w i I h i l l L- . U n ! . I , 11Y I ' '. I Y i i l I :i ! I\ l'':.. ' .; rii.- ^ m -. :-y \. (ti - l u l l \l r.l itr. i li . M>. .1!:I .:v U.M r 111 >! Vi'l'i- T U ! lll't r' L y Un- |>.*|l .< t L.. i . iy .i ->n .. . .'; Vi t.. 1<> !i W V. f , I f. .V- f i J A sso ciatio n of A m erican R a ilr o a d ; OJliCLK, i; \ ,1. M I ! r t ( t:1 . \ ! ! '( I *; . 1-1 OHM , ; , I I 1I - . 0 ;. ! l\ , Board of B in cters H. \\ . Cn i tV: i., i 'i .''l I . si Tu t i Oil.- ;, M i - ' . ' i i r S. T . hiwi-oc, i'M 'Itnt and 1'hainaan, T o [m <V Se ll I H r K a ii w a y . rut] `i i 1 t ' 11 ): I ; l i ( n `, A t e i : a- i M . \\ . ( 'If ' i i J, !, Hiv.-i d - M , I V n n m h a n i a K a d m a d ( On ;) m i .y . ( . 1 . 1)(*r:i!i \ , )*i c m ' a s i\. K n e K a ili oad ( o ; ,;|>an y . H. A . Down.-, Hre -sdent, Illin o is ( V n i r a ) Hy.-tem. C e o . B . K l l i ' i f i , P r e s i d e n t , A t ia 111i<C n a - I la n e K a i l m a d (. ' o m p a n \ . .K. ,S. K: en eh, Hi evi de nt, B i js((in A M a i n e H a i l m ad a n d M a i n e ( 'e n tra ] l i a i i m ad ( R/npaiiv. ( ' a i l H C r a y , Hi r - 111<fit , H n io n H a a d C H a d m a d . J . B. l d i , I 're-ideii 1 . I.ouias. ilie A _\a--h\ill` L K a d ru a d . } laie Hidden, (. 'Ham mu i, N ut! O ni 1'aeitC <'un| ani>. \ Y . V. K e n n e y , H i o i d - n , ( B e a t N o r t h e r n H n i l w a v . }f. A. Sean d n -U . T iu s t e e , ( `lu rayo, M ilw a u k e e , N l. Haul Hardie K a ilm a d ( A>iij} >ai)> . l)aniei W diard, Hivaident, Baltim ore A Ohio Hndmad ( oinpanv. H. la. W id ia ne-oh , 1Vesidf n t , Ne'e. \ o j k C e iilr a l .`M steii 0 onn.iton uj , \!)a ; >cnn 1,'nilit'iuls O PERATIONS AND M AINTENANCE DEPART M TNT J . \{ Sy no -, \ U'c - PiVMi Nil t DIVISION I OPERA TING-TRANSPORTATION Oificers ,1. ( A 11 U* 'i , ( 'I .urn an D M - t /.ii!:ln t \ ;i:i-1'L;li i ;ii ;i. ;i ( T i . Randall, Chao man, Ok ut i: 11 ( >!m11.i t1>e T, R. Knot See/v!ur\ MEDICAL AND SURGICAL SECTION Oflicers i Jr. I Tmenn I a e, J r . , <'half .'a,a/* Or i l a r . o y Kai t l e, \ nv- i n:ih'[i:;ui .!. ( '. I 'a vi- t on , S e n el ar y M EM BERS OF COM M ITTEES Committee oi Direction (Term Expires in 1Oils) Dr. I ni -tn Eve, J r . , + (P hiiinm in ). C h i e f N ,jah\ ; S, ( 'ha.' tano. ya -V M . C o r n - K a l i a \ , \ ;1. A i \ 1 i i*, T - h i i . Dr. H arv ey H e ' D ' i.Vnr-< hu im -a ni, i he-1 M M i e R O i,"..:- , I 'm O '- '. 1 ama Ii .i lift 'atl, t 'In i a Di hi aa , P i ! O'. ! 1 A. I V a l t V , ( haa' SlMLO^n, i sm Miaii iko'ihi1 K a :R\ a,;. , 'D o .in to , < o o .k Dr. .1. I` ra n i. ! *011:. J1. 0!. I;T So ; <;. -a ., D r*- K a o a aa i, l ']< ala 1. f O' D r . D . ( i. ; T , ' v d a H, ; :.a-i' S a r m - o n , i : h J; < , m l : R -n j ; l , i : o : ! : a Ml. jir. K . O. U , el >, (. ia i Sara' 1oi. f n o r. x mi I,, rn Kao a o', N1:; 'pok .. M nm Ci ro; i\f;j - ;)i 1'DC) Dr. D . M. N C v , ( T iD ' M a o v a i ( t C - i t . f . a-aa j , I T ;io ia ;0'0 .V yya.o \ K.u R road, ( Tiirayo, 111, Dr. S. M. T a y l o r , C hief S u nT i >n, N r w \ oi k l Vn I ra! Kao i oad, ( elom im.-, <D m. (T'ei'in .'Vpino in Pi hi) Dr. A. W , C D , i Tint' Sim mon, Northern P aOlic Hallw ay, S t . Paul, M in n . Dr, W. ). C ynraH er, Superintendent A: M n l i e a l Direeior, luan-t Depart m e n t, Athuilie Const lane Railroad, WMnunyMm N. D. Dr. A. R . Mot/., C hief Surgeon, ('lurnyo, iWiRvaukre, St. Paul A PaOiie Railroad, Chicago, Ml. D r . .loltn R . Nilsson, C h ief Su rgeon, U nion Paeific Railroa d, O m a h a , \<*hr. * T e r m as me mber of C o m m itt e e of Diree.iion expires m 1DoD. /'<<<i Jiiii/s "J M i me// ma/ Suiy/Cui da r/i"</ 7 Honorary IVIturibers Di'. A. J ( in-.-lrv, Seri ctuiy-TrcuMii e i , ( AhiitTrarr m Stali and I' ,'\ i.i .a! i'-alt I, Au! In Mil li vi ut Xortlr A Miai ira, M . Pani. Alma, i " . 'Di' Mna. 1';i ri a 1;, .1r.? Surgci i.a ( .ria i al, la irai u <a t l,< (d:i11>c 1it a !! : ma \aa , \\ a dilago m. D. { '. CmniniTtee un Disability and Ke da bi bl ai nw D i . .1 ]1 * i -i r i :. ; f < ]<;11 <11 ai a ;, l 'I,a ! An i .a a . \ \ > ' > : : At l ai n ' i. D. A -hi, Ai.'. ' i I v i Ab 'Ava ! i mD v . * M u o i o ( a , >.a F .d \ a U! ! .. , . M : : nvav. - i , .. M i n a . F . ] . ( ' \ \ . : ! ! ! i ,a-. ( ' ! . ; < i l i t - il M! M . ! la ii , Ai d. 'll. \ V i 1. ; , A i a P c p r e s e r d a t A a . f i c h i F m n m i f U <- of i i i i a i n M i n \V .1 ! : , Si i j ; ni ri i i i, : Li M r d r 'al 1 Jm <s , . , I d i , ' , Alla:: l a '(.a.-l I n a R a i i j r a d , \ \ Ii n 111 i p vj]i , N . P Committee on Fractures Dr. P rad Icy F. ( 'nicy (Chairman), ( A Di' Surgn >n, \ im D )k ( A ni ra 1 Ita !itaaid, X tw York, N. V. Dr. .1. D. ( 'oliliir, ( 'ilici' Surgeon, Seaboard A u Finn Hallway, Norfolk. \ a . J)r. T. F. Hansen, Dlnc Surgeon, Chicago, buri; Diami A Pacific RaiFvav, Chicago. 11!. Dr. \V la. I F F D U , , ('liicf Su rgeon , S( Finn- Si an ;i\t >i ri n R ailw ay F i l a 1.',, Texarkana, Ark. D i. (.). i>. '/iiili(1t, ('luci Surgeon, Missouri Pnnfir iiailiwad, Si. Foni--. AF,. Representative from Committee g Direction 1>r. K. (d. W'cFli, ( 'Ilici Srgenti, (Ircat Noil la ri i Railway , Miniirapuln Mimi Committee on Developments Resulting from Physical Examinations Dr. (F P, Mvcr- f( 'liainnan), Medical Director, New \ n;k ( 'antral System, 1Cl run , Mtch. Dr. Don 1iaal, Chad Surgeon, Chicago k 1linn-is Midland iiailu ay, S|irnig{CM, 11!. Dr. P. C\ O re m , Chief Surgeon, Texas X New Orleans Railroad. Ponsiun, Texas. 8 d.s.suemhmt of Am erirau Railroads Dr, D. 1'.. 1C msD-rui, .V -S- rant Snpriintrn'.Dnt ami Medical Direct.>v Ih-ia-f arid IVliMi!! I h pa! f Ilit 11^, \urt'*lk A Wcstn n Railway, KnaimD'. \ I. Dr. U. A. \\ il.-<v, 1 liiri Si it'i'i'i >n, > t . i .<ini'-San i-Ya;l* i hi d\\ ay, S t . i .. -a ' Mu. Representative from Committee of Direction Dr. A. lh M-'i:'. C D .A Sii"','; mi, C R aum, Milwaukee, St. Rant A i ';. ;; fhi !Ii o;i(i. ( liio-iLT'O i'll Committee on Medical Aspects of Air Conditioning of Cars Dr. T. I\. ( 'i.a d. r (C h airm an }, D i r . <*r. Dr pa11ineil, S*i:iitat.ion A: Suny iy, Riiiimao ( 'u a .nany , ( 'lucaim, 111. ()r !.. Y. Mdhmhitid, Medical and Sarirical Dhccfnr, Haiti more A Ohio Hal!r<>n 1, Rahi;m'in. Md. Dr. U. S. \ !;*( v. Mi deal Din-ctoi. M o - u u n - K a u . as-AVxas I meo Si-dalla, M... Representative from Committee of Direction Dr. I!. (1. D.c.wD.H, ( 'had' Snrtieon, Illinois (.Yntral System. Chicago, ill. Proceedings of Mcorco! arui Surgical Si et: -t 0 il Mi I ' 'i Ili lu-f ASSOCIATION OF AMERICAN RAILROADS n J('t : h\. iioiii'-kc, \ i. I liliriM". h .i i l w M ', S\. L u l l - . ; Direction 1j DIVISION I --OPERATING--TRANSPORTATION , u \. , S- l 'o iS hn'iir* MEDICAI. AND STRGICA1. SECTION I dioi:r: of C u m '.oi 1.P if Direction Sy a Cim-mm 11 t i KNEES OF ORDER 1 R E P R E S E N T A T I O N : A- pun. id. I m in. I'a, o| < 1.1;;.: Da:. I; pit '*! tl.liM , uj` 1!)t!. 1!Il ;ji.lt.i'- 11: l).,- i!;.-ii] iM'tl A t : ! Neel I.: 1l Un i Su.. i_'--i,ijs or oth< r j u t *M i - 11 . ni11 ,i .-lilt M CM ;.c| Ti.- J Y.\)'o A c Ti1*> . 111'., Mili t 1,i I'll! Id Mil ( "! ,,p r o me . i.gihl pii liull : 11 - >1 .iM !. A F F I L I A T E D M E M B E R S : A r. pd. St ; :1;:1iVe 1<1 Ml (IgM.1 dial " ; 1 0 "! n 1a ' ,l g Wild l ! Si t . n :di:l, Pi 1,. ... he 1he 1 a ll Hoe. ] e An adii sited n,< mher >ia ! E ''< i he i ights and pi i \11< n< idei! u mend ,er loud ivp.u -Mn1 TI \i , except ruling in iln ` holding ni olhre. Officers and Coinmitu-es 3. The e,Hirers nf tlir Sellimi shall consist of a Chairman. \ ice Chairman and Secretary. in) As provided in tin- Pian of Organization, tin- C H A I R M A N anil V I C E - C H A I R M A N shall lie solerteli hy the Committee of Itili Otioe, roin its memhir.-diip. Then terinr ol olin e .Indi lie one vi a l . A ( 'hail mali will )e '! Mil l'l l d lim is eli' . fh) T h e S E C R E T A R Y v. ill he appointed III t lie (L Pelai C o m u n i 11 c of the Divi-imi. the approval partment. H is salary shall Ik- named hv that Com m ittee, .-uhji.ct to ol the \ im-Picsidi n l , Operations and .Mainici,s in e 1ir . (< ) The C O M M I T T E E O F D I R E C T I O N mil musisi of tv.elm memhors, territorially repre.-rnta! ive a . far a- pra.'i u al ile-- one r a d . loan New England and Canada ; four irom ile- least ; two from the South and f o u r fl Oil! t h e \\ est -- r ie r i r d as Imi r i n a fh r P u sc l ,1 ,ed, e a c h ni v. Iioli I . h a l l serve for thire years. The terms of of lce ol ah e l e c t i m inenihii.- of t i c C o m e d i n o! J Erection shall expire at t ill eoliehi-ion of t he an n ua! Inei ling. \ n-ande.- in t hr eon ii nit tee meni I >ei> hi| i >i Il hr filli d hy ap| orni leent of : ! C .mHiitlee until the next elee! ion. In addition to the aim ve, the Surgeoii-t !i nevai ol tl.e Tinted Slates Durerai of Pullin' Health Servin' m a n presentali ve to he designated hy Iiini, and a representative lo he designated hy the Conferenee nf Slap- and Provincial H e a lth Autlioritiesof Nortli Ameriea shall he honorary ineiiilieis of the Committee of Direction. 10 Aa.wcintion of American liailrouth The Committee of Pireetion will select from its elective membership a, Chairman and Vice-Chairman of llie Section, whose e :n ;- of oilhv -diall lie one yenr. A ( 'Inui man will Not. succeed liim.-elf. (<1) The Siaiiding Com m uters of the Seetion will he as follows; ( 'onimil tee on Disability anil Rehabilitat ion ( omniiltee on I'Yuetarcs Comillittee on IJevelnpinents Resulting from Ri.) -iral Kxamtnat ions t 'oinmil toe on Meilieitl .Vsjloots of Air Condit inning of ( 'ars The representation of mein her roads on Ihose coni mi! tees will be. ,-i i bo as is practicable, territorially .-electee] in approximately the same pro portions as that of the ( 'ornnnt lee of Direction, personnel to be named each year by the Committee of Direction immediately follow-ini' adjourn ment of the annual meeting. Duties of Officers 1. The C H A I R M A N shall have general suiid-vision over the alfairs of the Section and shall preside at meet ini's of the Seetion and at meetings of the Committee of Direction. 5. T he V I C E - C H A I R M A N , in the absence of the Chairman, shall perform the duties of the Chairman and such other duties as may he assigned. G. (a) T he S E C R E T A R Y shall perform the usual duties of that office, and such other duties as may he assigned to him by the Chairman. (b) He shall receive six weeks in advance of the amend meeting each year the report, of the Committee on Nominations, as elsewhere provided for, and will submit to the membership at the annual meeting the nomina tions contained in that teport, to (ill the vacancies in tlie membership of the Commit tee ,f 1)ii ret io n . lie shall anil' nine,' the re-ail t of tlu- elect ioll pnsop! ! v to ihe iis-iini.-i-s. Duties of Committees 7. The C O M M I T T E E O F D I R E C T I O N shall; fa) I'.xereise gem-ia! silpei v/.-ioii over the inft-re-!.-; ami atfairs nt rim .-'ee! ion , b) lie ernpmveo d to act ..n Is hall of I he Section in the inieiim l.el Wec-n meetings and -hail submit at each mem mg a n poll eo'o-ring it- actions. tel Kxamioe ami decide what port ion of i oin aninnn Iions, paper- and reports shall In- a illicit i ed at the meetings, it shall debn mine whirl., if any, of tlie subject s present ed by the various ( oinn-. it n-i -hali la- o mro-d to the Gcnerai Committee of the Division. (d) Appoint two months in advance of the annual meeting each year a Committee on Nominations, consisting of representatives of live member roads, who shall not be members of the Committee ot Direction. (e) Appoint additional committees as required. (f) Submit to the Chairm an, General Committee, detail of con templated financial -requirements for conducting the work ol the Section as required or 11s called for by tlmt official. o . ( i\ H U H A HI I , '.I: 1 1WV K t. Si i. I Id i b- '.K b li-.n 1`ioc.triliny/i of M a lica ! ani Surgical Sedioli it.- eli live membership h.o-e tei ne u! oilice shall (ir) ('all aimna! meetings nf 1lie Sect mu, subject In the approvai ni the i ( enerul Co iil mit tee of the D C ision, if in its judgment e-midi turns wui rant. m &m m em m ' l ili be f,.limes. (Ii) Call meetings of the Section, upon not less than thirty days' not i n to each metiiher. It must eall special meetings of the Section upon tin- 1t If til tu.--, r; tc;i! I xanaun- 3 request, in writing, of a m i S The CO M M ITTEE ON N % .-hai! ret,: ut to t hi Sei at lea-t six ueehs in ad v a n c e of the an nua! m e et, `filili' -U r i ` :i!\* ing oi each yvar, at I; id 1mti.mat ion- h.r each impending v acancy to re- pile': t ic foti- 111! mi C :,i 1hf ( o lo m i i tel 111 1)(l el I oil v h , :-e t er m - e Xp i p tine I: iI:i: !i 'f t!<-{lvi.fillr!iIch.OMl fa/' * Vi Ta in, anddot tioo. fielli a1nlay \ r:Ct;.'iltli|iC:ViJ .,v ng ndjmmi- R E H A B 1 L 1 T A T I 0 N led! tilth and report, e n h su g go-1inn- o; : eenii'.ii.i nda- t lot;... on .-uch subjoin - tie t i s r .: to do will, Mie physics! cihcii ;,e\ to ;ni|h - o i e i c i of laili'oad employ i - ! 1 sliail ai'O c ole,d el VCIV: a]:d till all.- to! ti e relmiiilita'ioii of injured o 111c: i] 1.1 r-if a 11o i employ cr and the complete le slo ia - i \ i I ! ! r II IT: i tl. Tion of h.nc t ion. It). C O M M I T T 1.1. N O . 2 The C O M M I T T E E O N F R A C T U R E S sliail 1 bienni:.II,. sli.il! perform imy In a-signed, tulle- ni that nihee imi hi ( lei,rum:, he ;iM:U;:! meeting each >, a> ,1-, v. iu te provided lai moriing the nomine es in the membership of the le: nil ni 1he election study and report on the treatment and transportation of fraetnn cases inelud ing (a) Diagnosis of fractures, (I>) First mil and trun.-po; tation splints, (e) JYuetui'e report forms, (d) X -r a y work in connection with fractures, and similar ,subjects. 11. C O M M 1 T T F F X O . iC The C O M M I T T E E O N D E V E L O P M E N T S R E S U L T I N G F R O M P H Y S I C A L E X A M I N A T I O N S shall analyze anil make report, with recommendations or suggestions, on data made available by periodic examinations, etc. It shall study and revise as conditions may warrant, the recomniendeu standards covering physical examinations as will as tlie forms used in ronneelimi therewith. rest- and afians of the 12. C O M M l T T F i : N O . A- T h e C O M M I T T E E o n m e d i c a l A S P E C T S O F A I R C O N D I T I O N I N G O F C A R S shall study and report on this subject in its relation to the health and comfort of traveler-, cooperating with other de partments handling matters rclating to air eonditinning of cquipmi tit. ,n m t ia in tema hot ween imi ei v i ing it- net ions. la n;lira Pons, pap1 a 1id ledi ih m mine which, il imltee-. - ludi he refi Ired mil meet mg each year a ioni ir e.- oi fit e member I of Dl l ect 11 ,l\. ,mirtee, detail of con tile woi k of the .Section Ft. V O T I N G A T M E E T I N G S O F S E C T I O N : (a) Vote may be taken vi\a v o n , by rising, by roll eali or by ballot. Each member road shall be e lit tied to one vote. The vot e ol the majority of the member roads i epri-si nted shall lie required to decide any question, motion or resolution, unless othorwisi ordered, (b) Voting for candidates for member.-hip on the Committee of Direction shall be by ballot, (c) Unless otherwise desigmded by it, the milking oilicer will lie recognized as the Voting representative of a road at any meeting. U . L E T T E R B A L L O T S may be taken upon any subject by order of the Committee of ] Erection and must be taken on all questions affecting physical property. The voting power of the member roads -hall he propert innate to the miiici's]iip of miles of track. | i I N T E R S T A T E C O M M E R C E c O M ' v t,s *'lt>N 12 Association of American Railroads 1.1. O R D E R O F B U S I N E S S : 'flu' order of business at meet mas ,,f daSection shall, unless . i tlcn t is e three ted l.y a majority of Ila' m e i i i h c i s p r e s e n t , he ns follow:: Approval .if minutes i>f last inceline Reports of Standing l 'ornimi tecs R e p e ls of Special L'oim illir Reports oi 'Peilers ( 'nlinisheil Business N'eiv Business It). R o b e r t ' s Rules of o n i c i ' sitali govern the p ruee ci lin t's of t h i s Section, ineiuihiirr ameininieut to tliese Rules oi (Atuler. I l-.i T h e Wic.UMijS r Ak ro n , I 'an ton Ann Ai i.m R . P At Inni e W We I R e t t R v I o; <'.an 1e ! Ia . I \ a i ( V . - a i - o.e ,t 1 Co tV V, i/o ,V ' . o i l ; i ,e a . We I ! VW,, Mils , it It * ' s v e . ih.ef I it. i; Ih-.e R . R ( ieoii'ia R. R. Gulf, Molale & Illinois ( entrai i'i nrl t / in/.- o/ M n h n i tiful. Sfirljt'ti'l Nrrl/n/. Ri M EDICAL AND SURGICAL SECTION I lui '-i 'l i n e m o le, A l !:i n( ir ( '11\ . N . .1., .lune 7 1!U7 ' l l . i i i i' > i: iJ.: >i | ; SI, lili. ( !... '! S , . . ,; ni! Am, A l l , . i R i: A M 1,10 , , C i . l o i . m u g e , , . . Ai I:.',;: A V , , -1 K,n 1; );. .) R I I la . , ( lia i M e m .o I i C t !,... . i i|>i l,al:ii,.l,.;;o: ('aile: Se a! o, ( . ne u u mp 11.11 , 11~' A; i:11 1ir ( , e, M I .i r. R R A\ . .1 1.enre . Su},, i n u ,n d e n t ..u M e.lirel I lire. !.r, R. :e| I il 1In. ni Hi'lt R\ . ( ni I . .1 G , IV,, y i nef S.uyi Cuninll.lli National R '-. K 1 I l.e, ,|. A - r U n l . l I ! M . , i e .V ( 'lif.-ii) '.'i he A ( ))iiij R y . O i l,en .1 l 'rank I iiiitiri,. Su|,rr\ iMer S oil',-o)i. I. .1. l'.iniidalnir, A , ' M a n S u p e r vising Sill peon. Chicago & Kastern lilil'.le 10. . 1 . 0 I Yost. i. 'hie! Su rgeon. Chieagn A X or ii Western Ry. Alfred l i n m ii Division S n ip e , ni ,1. K . S t a r k , Assistant Su igeon . Chicago A Wiiiti'm lniliuna R. R. .). (1. Frost , ( 'lue! Sut peon Chicago, Ji a rii11tt<ni i (lumry R. R. It. It. Mas,., Oliiei Me.lira] Dllii'ei. Chicago, Milwaukee, Si. Rntil A l'a, u'i R. R A. li. M e t s . C hii f Surgeon . Chicago, Rock Island A I'ncihc Rv. TV R. Hausen, (')nel Surgeon. R. A. .laroleoii Cleveland, Cincinnati, t 'luengo A Si Rouis R y . !.. A. KiiMiiii.pi r, ('Inri Suipeoii. Delaware A: Hudson K . H. ( u n . .1. \A ( dun i n k y , Surpeun. Delaware, 1jsn-knwanua A \\ estar n R. R. .1. N o rm an Wl.iti , ( 'kief Surgi on 1Ini- R . R J. I'rank Dinneii. Oln, i Surgeon. AN. K. Misil || 1, A'M'laliT to (l.ie f ( ieorgu R. R. Gulf, Mobile A Northern R. R. Illinois Central System . 1, j\ . ( til : ht'l , ( ' i l l H S i n m Mi l . II ( Y;iw it.cti. U]itli:iluu.]n^i>r. \'. l\ dflis! ! ickv 1, ( 'tilc-uhilig i i i i n i i jst . l \ 11. P ain sey , A c ti n g D ijH' >ur^n.Jii. (. (. Puwd'tl!. ( Sni'Rcun. 1. llanisi'v, S u r d o n . 11 Association of American tiadronds L.,ng Island R. K. ......................... 1'.iiiMariH V Arkansas Ry. I olllnwllo A Nashville R. R. Missouri Paeilic R . R ................ .Nashville. C'h a ttslin ya A St. I. R y ......................................... New York 1Vntral Sy.sti in NY"i NNm k C e n t ra l R . K. \t-w \ <jf k , ( 'Ineat'll A S t . I.<mis R, R Norfolk A, Western Ry. . Northern Pacific Ry. Pennsylvania R. U. Pennsylvania-Rcading Seashore Lines Harvey llartle, (.'Lie! Medina! Lxain iner. I. S. Moses, Medina! L Vi, ;0 :11, r 1'. i d Abramson, Disirtrt Surgeon. Duncan Kve, Jr., Divisn n Singeon 0 . H Zeinert, (.`hief Su: eon. J. A. I.eiubcck, Visiting Singe*.n. 1). S. Long, Loral Surgeon. Diincari Lve. Jr., Chief Surgeon. (I. I '. Myers. Medical Director. Prank V'. Whiting, (leneral ('laimx Attorney. Bradley I.. Coley, Chici Surgeon. S. Li. Taylor, Chief Surgeon. J . I'rank Domen, Assistant Chief Sur geon. M. A. Johnson, Jr., Assistant Chief Surgeon. A. W. Ide, ( 'hief Surgeon, Ka.stern Division. R. ( Morse*, \ ice-President. (Pastern Region!. Harvey Baltic, Chief Medical Pxumilier. I.. .\11 xande.r, Me,Inal and ('on:* pan;, S u r y oil. W aller Ay e, M ed ical Pxanunor. \. Bruce (nil. Consultant <trihi.podie Surgery. 1. W. 11at jjc r, M edical P \ aminer. i! !*:. iI. .-tom M,*dma! Px.miinrr. I . S. Ilocard, Medical I.vitamer. C W flu: *1, Modi, a! ! iviainer. \ . R. 1. grah am A as etaiii ('enlist. \. i '. l.-.enherjr, Coir.puny Surgeon and Medical Iexaminer. L. B. L. .Ionian, Medical Pxniiiiner anil Company Surgeon. R. C . Kell, Neurologist. 1. S. Moses, Medical Kxaininer. I. Pdward Nickel, Medical examiner. 1. M . Persing, J r ., Assistant. Medical examiner and Oculist. I. A. White, Medical Kxaininer. V. P. Lsrnberg, Medical Kxaininer and ( 'ompuny Surgeon. I'roC'rtli//,'M nj .Vtthcal nini Suryicifi Srtiuxt 16 lief Medicai Kxain- Itl 1..'.an .ii,ir h.-tnct Surgeon. >1V1M. . Si.Igeali f Sari:'-. .1: R i n g Su.' g'-nn. Suri" Pcoriti & Piastern Ry.. Pullnmn Co m p an y .......... Railway Express Agency, Ine. Kein ling Company !.. A. Unsinniger, (.'im i .Surgeon T. R. Crowder, Direetiu, Dcpaitnient of Sanitation and Surg. iy, R . A. Jacobson, Surgi'. ,n. U S . Pei ria, ('luci M ed ical Uxamthrr and Chirf M ed ical ( (ihrer. ( P M . (tbi'issnirt \ Mctlic.'ll J-.X.-lIlill;M . J . M i n j >1j\ , M< liicitj ip\anii/icp. Adolj di XciijR itu-r. > i;j ), : ii, J i in ! P ie ' 11) ('1f 1 i !t - filli' ii>r Ji r J i r f ,\ 1 l .1 1 ! I . I 'l.ui.o i ( I... ; -a ! S u : g-m Arr 1 Sui : Sui - S t . I .. .i;i--'~'a I l 'i anca- . 11 S l . 1.inti S. .ni ! \\I .-0 li 1i y . Sea!.(.ani Air 1an- i l \ . Ti.edo 'IV; nana! K. f( J I P P i * ! , M r , l td -1 J \.:i. 'm . i ; a WtbiiHW, ' j i i l : Pj, (I 1 ) s Lfii ji. i u, d ] Rif) ' d. V i l l e iiii i iM U p, O i i u i .1 D ( 'ul.'.ifr r hit- >u;r* T II. R - i>\\ i,, s . U ' P u i ; Tunmtij, Hamilton A '>11(T;iii Ry G . R . ] > }M M ! t( 1 , ( '],:<! Mihirdp f )ii; h . A ' -nt ( 'l.icf l l IJ Mil Pl.Cifie il II J . R Xllu'HCi, {'":*' t S u i l ' i t '?1P IP Voting, \rui..i,.gi"i i S u rg .',e, Pietern | Wabash Ry. W, U. (hillings, Superintendent, V a P o -idi ni (Pastern Washington Terminal Cn bash Hospital. U. !.. Alexandre Medical Examiner m f Medicai Kxniii- Western Maryland Ils IP C . W an in g, Sr., Chit Resuii id Surgeon. Mi d'i'iil und (mi- Western Railway ni Alabama J . R . Garner, Chief .Surgeon, also nl Examiner. j istillali! <trilli Ipedjc M . Hunimes. Neurologist, St. Paul, Minn. Kdwaid l.aidiili, M . 1),, Washington, O. (P ical 1.xaminer. i O. R, Mayer, Columbia, S. ( . mal Examiner, IP II. Me Naught, M . D ., Den ier, ( 'ol,. lien! Examiner. A. T . M nore. Orthopedic Surge,.n, al Examine" Columbia, S. C. s.--inot Oculist, Irwin Sirin, Philadelphia, Pa. ujiany Singnati timi Association of Am erican Railroads J . ( '. Caviston, Secretary, Medical ami r Surgical Section. dica! Examiner nini Colum bia U n iv e r s ity ............................. (la y Ruy Murray, P. A Associate n .1 Professor of Surgery. .gli! The Johns Hopp ins University WP IP Dandy, Adjulao! Proies.--u of ,1 Exam iner. ; Neurn-Stlrgt tv Medica! Jxaiiiner. l 'nitori .Stall's Publie Heult h Servire Thomas Purvan, ,!t ., Hmgeon Gournd Asm-tant Medicai Uni versiti' of Pennsylvania I'.. !.. J'.liasou, Ip utessor of Surge! i . uliO. J A. if. Gill, Professor of Oriholiedm il Examiner. 1 Surgery. liciti Examiner timi j J . M . M cM illa n , Associate Professor of ii. f Cardiology. ;^-y.-v,rr :'v ; 10 \ Association of .{rtuTcan Riulfondx h r S-\ rnl A ' -iM.-ia un o City. V u - ,lr T h i , i ';[ u i W rm ui: I hr 1111.'! li by ( hr S v i v i . . . A, Tin-: S k o k M-' \>rui M, ui ; * _r:-r j._r j iyr '"'i S v i i o n Ou. O. (i, h- U;l . . . ''h r.iiilf'i ;m>l Su:v>r .1 i'i'l ( |i Mr .If 1ir 11 ! OC T O - , nl>j. n ! i \v> p u h l l C :j. ^ \V<Mi , *I(> U M iC Citi ; : i x a i i ; i i>, i n v i ; th:it (nr r | , r p v A-tv K n . ' . f i r **rir Proceedings of M edical and Surgical Section 17 M O N D AY M OKN JN O SESSION June 7, 19J7 The Seventeenth Annual Meeting of the Medical ami Surgical Section of the Association of American Kailroads convened at the Tniynmre Hotel, Atlantic C ity . New Jersey, at, nine thirty o'clock, Dr. D. H .Muss, fh::irm:ni, presiding. Tor: ( 'll a i H .M . iM .Meet ing. (ientleinen, Th e first it ( n. on the Jinitmii:: by I he Secret :u Announcement.- \u ml! now begin u , li Sr , i nte. *111, Amoco - " n n o n n i e n e os '' v, Ineb will he p, .--ei, n-,! T iik M .e u r r M iv : A few day- ago I roc ivod tic following wire fiom I >i MrC omhe, ol the Canadian National 1hti! v. ay.-, <it,! i i! ` Toi o n t o 1 "(neatly regret owing to cont mini ill lie,oil I: mi |>n.~ ibl< or me to attend annual H e e l ing of Sect on Hegardo'' Signed "Jo hn Met uii.br." Dn. (.1. (h DaiviiAM, (lllmoi- Central System): 1 inu\o that the Seen tnry lie requi-sied to wire D r. McCoiiihe and convey our extreme regieix tit In.-, unavoidable ahsi ncc, and our hope for his earl) icco w ry . with lots of love. . The motion was seconded, was put to a vote and unanimously carried . . The Secretary then wiied Dr. MeCom be as follow.-: "Medical and Surgical Section in convention assembled extremely regrets that illness prevents you from being present today. Best wishes from all for a speedy recovery." Tins C h a i r m a n : The next number on the program is an address by the Chairman. I haven't an address, but I have- a lew remarks to make on a sub ject which 1 think will become of increasing interest to us as time goes by; that is, occupational disease.-., and I want to refer particularly to the Jllinoilaw which was passed last year. O CCUPATIO NAL D ISEA SES TH E ILLINO IS LAW By D . II. M o s s , M . 1). The subject of occupational diseases has become a matter of great importance in the last two years, and is of concern to the employer, the employe, and the public, as well, because the. livelihood of so many citizens of the state depends upon the continuing good health of employes working in these recognized hazardous occupations. I have chosen this subject for discussion for the reason that for the past year I have been a member of a committee known as the Hailwav Engineering and Shop Committee. This committee was appointed by the 18 Association of American Railroads General Managers' Association of Chicago to make a survey of present practices and equipment of the railroads operating wil liin the state of Illinois and submit recommendations which would serve to bring these railroads into substantial compliance with the requirements of this new law. There are 31 ( 'lass I rail roads operating within the state, and considering .short lines, there are 7S railroad corporations more or less interested in the subject of occupational disease. This investigation and the reports which will be issued will be of the greatest importance to these roads, and nmy serve the interests of railroads in other state's, because the indications are that such legislation by other states will not be long delayed. From time to time, this commit tee has issued hullo: ins recommending pro cedures designed to minimize the risk ol exposure in occupations known to carry a hazard and which are, of immediate concern to the railroads Forty-six state-; now have Workmen's Compensation Acts which provide for compensation for accidental injury causing disability or death. Recognition of the principle of compensation for occupational diseases has been slow, and even now only lti states have any provisions for compensation for disability or death due to an occupational disease. M any of these states do not provide for complete coverage. The Illinois Occupational Diseases Act was approved March lb, lit;lti, to lake effect October t, lttiitj. Accompanying this Act were two others-- the Health and Safety Act, and the Grinding, Polishing and Bulling Act. This latter is a temporary measure bridging over the period until the Industrial ( `mmi-sion establishes rules having the effect of law to replace all previous legislation in certain fields, .`Vet ion (j o f the H ea lth and S a fe t y A c t provides th at the In dustrial t 'om 11;I s a '11 m ay appoint, an advisory e o m nntlee to suggest rules or ehanges m existing rules, lb presentation on this committee must be cquaily divided between em ploye r and employe s. It. is under Ibis provision that tile Railway Fngmeering and Shop Com mittee nets m assisting the railway member of 'he committee. Section '2 provides that this Act shall apply to all em ployers engaged iri any occupation, business or enterprise in the slate of Illinois, and their employes, i li only cxeinprion being the ag ricultural class. Section 3 provides that it shall In- t he duty of every employer under this A c to provide reasonable protection to the lives, health, and safety of all persons employed by such employer. The Industrial Commission shall from time to time make, promulgate, and publish such reasonable rules as will effectuate such purposes. .Section 4 provides that to effectuate the purposes stated in Section 3. the Industrial Commission shall make rules for (a) Proper sanitation and ventila tion of all places of employment to guard against personal injuries and diseases, (b) The arrangement and guarding of machinery and the storage and placing of personal property to guard against personal injuries and diseases, (e) The prevention of personal injuries and diseases by contact with any poisonous or deleterious dusts, vapors, gases, or fumes, (d) The prevention of personal injuries or diseases caused by exposure to artificial atmospheric pressure. i t : ; ; h i s 1; ur tw o l|,, Th e . n.ployi W J t i i r !;> J Tit Mint 1 :1 mini. ; r 1mi ft l l '- U u i n ! h \ r i i t iat I th e f u p V;h i c i l in n X|Ht '> ) y o r , I< V\ } u i i f u r . . Di l i , >i t li*' n mpl ( V T . The puma A to krocii's ( I i.m:!v Win n pm j > i.i t h :.t ( M.-oj l v v,. Ml' 1 ike ueh Be It mideiiinder the ci 1Ii- ii: h .inti .' line of not. n Ic.-s Bun $.",( mT w-c. d.iv m;' ' I. , 1; 1 n.i ti.i/.ii i- : ii Cl". ICC i | Mill JV c , 1 llllM, ami Ic.-- i vjic ha.' iic \ --111j,, Mpp.l-C' the 1hal i he mm an empioyim require Uu- h f ion. One cf tin : he prepay,a.1 I'roctt'-diinjf oj M edical anil Surfucid Srclm/i 111 It is this law for the pievi lit.ion o f disease or injury which urgently m m e m t our ln st thought. The Workmen's Occupational Diseao s Art. i- optional. The employer may eleel to operate under its provision by simply filwe, notice With dll' 1Inlu.-t rial ( 'oIliMiisrion to 1lost i licet, it! wllicll ra-1 hb habllltv i.limited to tin- ptoVl'icll; of the A f t . 'J 11 ' employe! who choose - to remain under he common I ,w taker- in, action lie Ini ;!i!;. i- lit iO e l otilv bv tin :, fi e , ii 1it l i V it i , Y t i e oi l y 11e; w e i g h I.;.' ;dl o! J in i o -I i-I { l i e - ' V - t ill i i . e t rot' o f ti n- r a - , e ve , j.r the,) j e ; , i e: i i | i t h, o ia v , n iu i ., x 10,1 i, z e J ' o i i t r t i e - 1e o , i , |, : ,! i j11 . T!. i o , >:. r; o i,, j . . v. t h a t i ' I . . h m a In i l i n i - e >h d t o , i , p. . e , ' X p i ----] i III, p! a U !V r UT|:< d lie I I - 1. < t !e, I lie 'll . , el , |e;, | h , ell , . [ i!i a he!' ,r ie (e.:t by l e i n d o l e ' ui u i Ilie,a -ei w, i i A I- . t *eo ;e . v a i t loll (it ! In m l , ' I t t lie | lie-ill h i o n ! k.il'i I A< ' ! :a i i '< I, ' : 1111e 11 , a I; I i . l t h , employe r Tte prituniy p i g p u - . , ,,| the Win hint-;.'- 1 o-;,11 ' i, ,i, I I h-ere-, - Act. nio tine W o r h n i e l i ' e (. o t n p i le-et loll . Vet , IS t o ] , 1 o\ e ll -I m i l l . t t he Oil Ipi I Vl I, 1 1 1 I lie intnii v vshei, In I' e \ etl a ki n by t h e t raie d v oi hi ei i nil! , o;- je-,f h . T i n p i u e e r e pUfp, is, o) t h e 1 I` : 11 11 1 1 1 1 1 S e l l t I . V' l , ! 1.1, J h t Ie p. 'on! t , i s proVIl i i (i to. 1: ,l!lH e Iii ei 'll: ply w i t h e - pi o v i m o Ii , i t o eon ipi 1 to. , in i,lo . , r o :i, - ta II -M, t o , je\ in oi' take such otle t aclioti in will protect the employe IV,,tu acciilt o' ,,i t,.-t a--, lii it understood that no employer, whet he! un.iei the e. mip-m-a! i >n :!ci or under tin- common law, is rehoveil of the n*-ff --ity ol complying with tin Health and Safety Act. The penalty lor the first failure upon conviction is a fine of titit less than S2."i ami nut more than $100, and subsispient failures no! less than Soil nor more than $200. Lnch day of failure constitutes a separate offense. Uefcrring ugam to the piovisions of Hie Occupational I Mscasrs .Act, Section f> provides that under the Act the emjiloyer shall he liable for compensation mi account of an occupational disease which oeeui- within one Year after the hot day of the last exposure to a hazard, except in eases o! silicosis ami asU-stosj, where the ha Iul it y extends to three Yeats Sect ion 11provide.-, t hat t lie emjili ,ycr under tin1comi'nun law is liable for three years after i he last day of the hoi exposure to the hazards of the disease, and that every such action for damage-in ease of death shall he commenced within one year after the death of sueli employe, ttrnl within five years after the last day ol the last exposure to the hazards of the disease. It is, quite evident, from these provisions that the em ployer is not immediately quit of lit, employe who re-igiis oi who leaves the service from any other cause. Prevention of occupational disease is of greater importance, more humane and less expensive, than the pallia) ive of paying compensation after 1he disease has developed. The principle of t his law is sound, and I In lieve that no person opposes the idea of compi nsntam for disability or death whenever it i? clem that the in: riled late Cause cun lie at t rihuf cd to a hazard which is associated with tin employment. The, proper application of the law will he ddhcuh, ami will require the inicliigr-iit cooperation of every alt, ncy concerned m its administra tion. One of the dangers lurking in the Work men 's Occupational Diseases Act is the propaganda in the educational program of the State Department of Labor. 20 A sxoct(Uu>H <>j .1 i/ivncun Raiirtmda W he n this A c t was a p p r o v a l a year ago, t housaiids of pamphl'-f < were printed am i distributed th rou gh ou t ( I k * .'*tae d escribin g in a fra gmenta ry way inn sy m p to m s ot various occupational di.-oa.ses am i the kinds <-A work which m a 1, cause them. T h e only purpiwo served will he (o create a. fear com plex, ami every eniplov'- who becomes til will imagine that lie h,a> an occupai seal chsea.-e, or the one discharged or relieved will imagine or ma linger mail)- of the ,-wmp- i on is ot some oiri'upat mi ml ( l a n a a ' i m l :i claim aall result. I I`.-lie v<* ! hi - is mere apt t> occur umler the Act than umier the c om m on law. In the agitation which lias led to legislation in the last (wo writs, silicosis has been em phn-i/ ed almost to the exclusion of other di.-ea.-i-s which ma\ ha\ e an orrupat ional origin. VVe m ay accept as ashotnai ic ! ha t dn>t from whatever source, d in an excessive am ount, is injurious. \ recent comment in the Journal til (he A . M . A . states that only silica is cap ab le of in d ucing silicosis, bur that ot her minerai dm-,Is under prolonged and gross exposure m av cause some in crease in ]mi mon ary (brusis. 1f t he rehu ve potent ial harm of silica is rated as 100, then oth< r mm -tox ic mineral dusts m ay la: rated only *m the order of A or 10. I hi-m in indu.-try are formed by processes of abra-ion, grinding, poli>hmg, blast mg, and the like. S u ch du.sis are not altered in an v wav, but m a m tam the same chemical composition as t.ln* material from winch the}' come, the only di(Terence hmng the part icio -i/o. T h e smaller t h.ese particles are ami t he lend er and less soluble they are, tin1more apt th ey are to cause permanent changes in the pulmonary tissue. 'Hiero are two schools of thought m n-gard to the method by which silica cam-es silicosis, on-* being that (lie hard particles of silica cause an irritation, prod ucing a defensive ribnms, and the ot her that the silica in the body undergoes a chem ical change and he'-umc- a cellular poison. T h e evidence appears to tavor the first view. S ilic a , a s h -U o s , ami f a d a re fin- principal - -;1 .u.umt s gem-ml mg toxic, dusts to wn :. *I; r.ul w.i \ -e.pl . \ may be e\p. sed. f . . l ht .m m a \ Ih : n.i ; >- a f I coa i d u - 1 gem rale- i in handling coal fj ua earn t. et :d '-hut'* or .-tic r ef - I place-, 1;ec -11so is !1 'i i wIv d u -t y w-nk. A : c'-' n ' pr-hmu :a ry epe a a s . - u .{ by lue 1 . S. Publie Health Service in a to ly of health condition'., .wimi-ng :/ii v -ic: .i x . i m i n a t i o n o f 271 ! m e n , ii 1 ' iil' -e 1*' p ( .' a ' ! v e a ,. i !: : `i t; i - :,! n N I V l U !\ a i u c . T h e p r e s e n c e o f ali 1hi a eu -, !. ; i . a 1! ;Mi g l i e- g ot !3 , ' Ll n- MU :t r. C; f 1 ,| / 1(- up I, f lut; d - c o a l l liil. il. g < f re d u - r \p< o u i e !<,. II, an A million p a r t i c l e s per c i. :'t. : u. i 1.i -i". 'al ai 111ra r<, -J l c - I ' , i V U C `o n ml . \ !.' m g a U e m p l o y e d UiOM t i i au 3A ai s : a d - c u i : i; U . g .1 : . e '1m Ml 11. :;u ; i. i !' to;, pa! f aJ'-. s per ell. ft . \\ . i , i . , i . . i ' . u f e a , 7 ' , d- 1 Ml,- ; 11act > m i ,.,( U ln-iv flic ilu.-t rom aim-il ' H i .; Mili, Il Tu IH!! ! 11 i 1i, . h .:,J ! n"l,M per c m ft. , ,"i 1 o f U. i ' r m p lo y r s di-V'e l o p e d a n r i e a i ljcosi s, a m i eM! il t il- Ilust ' m 1ail ill:g in e x e r t s o f 3 0 0 m i l l i o n particle. -, p o r 'U. f t ., - s ; ' " f t!,, , 'il 11>1><* exposed developed tin t hraeo-siljcosis. A n a ly sis of the d ata i'w the putpo.-e o[ determining sale limits of dust exposure indicates that, employment in an atmosphere containing less than AO million particles per cm ft. would produce a negligible number of cases of aiithraco-silicosis when the ijuurtz content of the dust was less than i>%. Where the silica content, wag ab ou t 13% a safe limit appeared to be 10 million to 1A million particles per cm ft. it is obvious that avoidance of great exposure to toxic dusts and other poisonous substances Procec.dniys of M edia)} and Surtju\il N* <v, i w d in or imnejated by manufneturiny: piuer.-.-e- and <f unfa\ u i u l l working C O i l l i l lotiS, Is the fi l ' d < 11!il! Hi j >'`I*\' I I iI iTt a n d <<>t *l i <' i11!. Lr <KT U J >.i! HC ia 1 i ' disease.-. A h u g e pa i t o! t h e p r o b l e ms \s i im*11 will a n - e will r d a t e to tin- qu d i o u oi d i s a b i l i t y , ;11mi Will be me d i c a l p r o b l e ms . runs quent !\ tin me d i c a l | >n 1 --on, j I t H'lila! i\ t lit W>i a ! < 10 t i 1t\-1>I Ml <It'" !!: Mr 1. lit 1 pha - - of iJUm1i<liM , It: U v. i) \ i-r i ,, a ;. T i ;< p*. , b j r m - w h ; d , w ij{ r rise in th--appimnf i- - m i l n i 1<.411i. ;j k ! S a |<c a ; .a ' t a ! 1 : . r 1 v. : \\ 1> < a { l t fir ria' ;M'-. 1ta-' it a ; ii;ia <a<; > \, . a- a - 'In a h;e : >v , r;. r . . . l ({!< < ! . 1! i n p p a :. a ' . t! n , t l:t i p i v . i M a a a mi ca: ; 1 d m - . . ; : - - . ; ... : ! [ a t ; . - t a . a - tt a la 1i I ' la I n - t ; a a. 1 ia i t<-t a i i kt i ail - 1 I" 'k I' a; . ..! ta <a .: ; ; e m s w h o J, .: !i a] . M e d ic a l t'- itX! 't 1- a . -a a ' id I.! , - r !a;ii. h.i : 1 |>a! a rIa : i' -i .. ; r\t i i:pi< Me at mg a -a! - a i ; > j : a.- ht h i - t o n a a a a i i i ' ] .hy- en 1 f.\aa a a i mi . raa.'iW: ];i .. ? :iH i . l a : , t. aa v at,;:, -i :-ia',.. t ii.i: ' it.o a - t i.. i <-a d , a him: , a a a i ! \ : a ;> laborato ry investiga tion winch i i,i p n v - o a f lim lm y- ma\ - o g g - ' t . 'I a. . a x'ii.n m ian i ji hirh a i <on;]'lo\r m ay !c i . vjvii'<a1 to wmls rriakr- iioca.'-ai - tit1- im juirv into t la- yf n-<>ii;*3a la i <irm p n! nina) na ior\ , 1u a.-,cart tin that 1it'-: a a 1." lil.*t>)!-y (if j 1 a v j' cxjxt.'-u/o v. Jiich ixiay Kaxt r-;ulot <] i;nf.airha -M - alni n*. fcti dtrion preM-nt which Jnuy h(- made v,oi>o hy tin ocrupat a );. 3t is* i m p o rtan t, also, that card'nl inq uiry he iirndt' im n tin- history of cna ))lo>(`S who com e fur iiid, if a correct diaguoai.s is to he ma de and a p m p r r : balance struck between diseas<-.s wh ich are unfavorab ly influenced by o c c u p a tion and other diseases in which occupation has no beaiin^. Therefore periodic \ physical exiiminatioii of all em)j]oy.-s? m so far a^* that is p osa ble , is iiuportam in xiccupatioiis in which known ha/.anh e\i>t >i;H. as when wurkeis are rx- )os'd haul or in samliklnstin^, exam inatio n should be made sem i-a n m m liy , or more frequently whenever 1he/e a p p e a ls to he imheat ion - for doitqt six, with transfer of em ploye s who are heeomm^ impaired, to ie>s hazardous work. j'jiemei'j inp is concerned in investiptiinfj; the ocrupationa! enV in'iuncnt, estim atin g tlie hazards sca-ntifically and institutin g the | ) m p n mrih.ni:- foi control, ami tliercafter supervisioji to make certain that the safeguard- wind, have been installed are ad eq uate am i then pv-ri'ormamv effective. AY hot hi the mattej- is rem oval of silica d u d , coal d ust, or the du>t oj- funu-s of lead or ziuc, the ha de principle remains unchanged - ventilation l>y a metljod best adapted to m o tinp the condition to he solved. A\ o have hn eoiisnl. rat i o n : {)) ri!n u^e of mechanical devices, simh .-o' exhaust vent lift !np system.- apjiliod to the room or T the ])lant as a whole, or local exha ust- ilnoiiph a suction hoou applied dose to 1h< ]>oint oi du-t poiuM'ation. {'2} ( 'lian^in^r the jirno-.'S's: Suh-titutiriir non-])oisonou> materials for th o x known to he poisonous; substi- tu tm p wet urmdinii for dry m i n d i n e ; or d jan p in u horn nat ural sandsion. , iii'indiiig; wheels to artificial a h r a s i w wheeh which are harder and contain hut little oi no free silica, (d) Personal protect ion: ('ontrol of hazard hy means of protective equipment furnished the individual employe, provided the device .,-spsw:wur''a . 0./ i ! 1. c ^ . >/hl d 22 Association of Am erican Railroads is effect.vo and the employe can 1)0 depended upon to wear it. contumouslv while at work. Thereafter it: is a matter of good housekeeping--"knowing that tiie atmosphere is maintained in a state wliieh is not a iia-:ard to the workmen. All dusts and all poisonous fumes may not, lie completely eiadieated, hut thee intty he Controlled and reduced to a degree which is recognized by .sanitarians and by experience to lie. non-hazardou-s. This can lie accomplished by fre.|ueur dust counts of t lie air at. a point where dust is generated, nr ehrmieal examina tion of air samples where lead or other poisonous materials are used. .Sand blasting is perhaps the most, dangerous dust producing agency to which em ployes may he exposed, because the sand used is a [Hire sill.-a which produces a veritable dust Hood. Sandblasting has come into extensive use on railroads in recent years. In t he shops it is Used for cleaning and poh.-lung small articles. It. is also used in removing paint from cars, Imil.nngs, and steel water tanks, preparatory to repainting. C'scd indoors it is imperative ttint all employes tie protected, consequently a dust-proof cabinet or room, lined with a local ex haust system, will lie required. Only tin: air pressure mask is safe for the em ploye engaged in sand-blasting ears or buildings, and this work should bn done only when other employes arc not required to work in the vicinity. The air Imse ,-houlo he long enough to bring the air from outside the dust zone, or the air should he washed by being forced through a water hath. A respirator is a filtering device lor removing particulate impurities from the air anil is not effective against, gaseous impurities. Special masks for this purpose are manufactured. The essentials of a respirator are a close fitting and diist-prooi face piece covering mouth and nose, with a minimum of dead spare to prevent accumulation of carbon monoxide, the inhalation and exhalation valves must not cause effort in breathing and must he du-t-pronf, the filtering device should hate all exposed surface a lea lai ge enough d. permit free breath ing, liie alter di-rs -hoiild he easily letnovahie for c-pl.-.i .-ment, and I hr- res pirator should lit com forta bly and not obstruct vision, and should permit of wearing spectacles or goggles. Th ere are vaiious i p e . s of r.-spuators wln.li may I.,- u-ed for non-toxic do.-ts or for short exposure to toxic dusts. 1 would reoomieemi the! onlv n-sjiira.lwis and gas masks wha-h s o approved by ;l,r !'. S. Ihireait of M im s he fin-nwh'd to e m p lo y s . Si lie,.'is an d as: i-..tosi,-; a re - 1net Iv du.-t. diseases, and . a n be e. mt ram e, i . any by breathing -lira or s-be-tos dust. I end poisoning is most I'm;[u<nt!\ '-ont n c i r d by bieatiang the du-t or fumes of lead, ruivlv by ing'wiing f ad Prevention ami coni rnl, I herefoi e, consists of protecting ! tie employe agam.-t exposure by the means best adapted to preventing tlie generation and disper sion of these harmful dusts. T h e C h a ir m a n : We have received the following wire from Mr. J. M. Syines, Vice-President, Association of American Railroads, same having bean addressed to Ur. ISartle as Chairman of the Program Committee: ` W a s i u n o t o x , l). June a, 1937. IV . Harvey Hurtle: Vour letter June second. Because of some pressing matters of un expected development here in Washington it will be impossible for me to a]tela wn h ' v.-ry i a n d ti 'fa . Ctt spr.-lkcr. I)H. Hal pleasure to I am peak I am m i a ! :-,n U. bin H. ( It." tir.-t In. 1 Was 11 at. the .,, as! a m< ! ar a pa I Os\m !, I r. . . or, '. 'I " I "! t . a: sl.il,- 'cl-i ,1 0O-.,! ,,n-d it! simply .Hart -.cry eio.-ciy ltlg, h Hen I many votes a c t i o n .' ff mvf- !i.-ld a nunilx.-i' of coii- S hut I j o UiWilloli of ubm itnd, >. Dllit.CTIO',, I * li M i ', ( 'iminiian. d ru! oi oidi i i 1io ( 'oiiibw. ( i -1 i I ir. ve, ( 'huirlil ina:: Tl.at 1. th tvason ' ;*j>|><.: ti:'- iiunir.- ol nny ni t (,, "m:il.. -ni o! t 111,niit tre oh t ', i ( 'umilili tce un i'roCtxJniifH of M ed im i and Surgical >Stnioi, ( ASSOCIATION (Circular M. A: S. 100i OF AMERICAN RAILROADS MEDICAI- AND SURGICAL SECTION REPORT OF COMMITTEE ON DISABILITY AND REHABILITATION i I: .1 I I . <' : o I i.'t I : . ( *M.-I 0 . . K O - l i : 1.1 II.: U i i l u i . y . Ur. T. !.. Ilio...-,. Ci-f Suivi:,.a Mock lr.'twifi iV I'aDiir I !i i ,vii v . - .11-01.11., Ola.,!:,, 111. W .1 i a - u s t i , ? U | <; . nl o >h;i M e < . i. d- . Medi cal O 'Jmi-i (\u: uiu, ii X a ' li a..: U.x.iways. i^,- r<-.si'iii:*.u\'ri fr-Mti P . i . n u i i 1 >-' o f >0 I);-. J . I:. O l i m i : . ( ' m u iSiiij," m i, W i l l e m i a i i w n of A I n h a n . x .Now \ 11u1:, N. f .. M ay ft, I '.idT. 'I'') Tin-'. All.on \i. a m i Si.'L iiii'a i. Si-.i T in s : "Y'f.u1 t ' i ennui Ic(ti-gn-t:- that A i: in 1:11>11t" idler ii'iieh nev. mult-rial in thi- report. An endeavor ha- been made to irview suinc (.1 tin previously d is cussed subjects and bring them up to date. We feel that in the future this Committee slmitld undertake more renews h work in the i-ehahilitat,ion ol em ployes who are disabled on account of injuries and diseases. The Committee will welcome any helpful suggest ions In this connection. The Use of Sodium Chloride by Workmen Exposed to High Temperatures During the past thirty year.- numerous articles have been written on the use of sodium chloride by workmen exposed to high temperatures, following investigations hy physiologists and various medical officers of industrial con cerns. It was noted by these investigators that exposure of human beings to extreme heat causes both heat cramp and heat exhaustion. These two con ditions are essentially different as regards symptoms, treatment and prognosis. In heal cramps the etiological factor is a disturbance of the water salt metab olism, whereas in heat prostration the cause lies in a distui banco of the thermo regulating system. In heat, prost rulion the complaints are of weakness, head ache and vertigo, all of which develop so suddenly that often the victim collapses at work, hi cases of heat prostration the workman is usually fit to ret urn to work within two days, whilst in eases of heat cramp, it takes four or five days for restoration of body weight and of normal blood picture as fur as haemoglobin and salt are concerned. Heat cramps are also often called " Miners' Cramps." "Muscle Cramps" and sometime? wrongly called " The Bends." The condition consists in painful tonic spasms of any of the skeletal muscles, but usually of those most actively in use. m AaxitciiUioH of Am erican Railroads 1 Heat causes increased circulation through the capillaries of the -kin and mme i authorities claim (hat with high tempera! urc and high huimd-t v there a marked increase in the pube rate. systolic blond pre-wire and ill Imdv q-mpwalure. These all ` end In increase per.spii at ion. Surat contains at lea-! .'-'S'r ot chlorides principally mhIuiiii chloride. Prolonged nm -pirat mu h plete- iir.-t i W kl.c s\ pi i <a d * e p ic v< ;>"-o-d bv li, the sodium chloride content oi the Mood, (.hen the ehlornles from the mu-vlc-. The loss of chlorides through the .-kin is also shown hy the dcep-a.-e or di>- j Jippcanmco of the chlorides from the urine. The diminished ml! excretion i contimies lor some hours after the normal balance and concent rat ion in the blood is restored. The drinking of large quantifies of water to relieve thirsr further diminishes the percentage of chlorides in the blond Water without salt ingested under such conditions is not retained but is qmchiv 1r-q through the sweat ami the urine without replenishing the store of plasma in the muscles. About 11*23, J . S. Haldane, the English Physiologist, suggested that the cramps sutTered by miners were due to salt loss. 'They were urged to drink only 'alt water ill) grn. to the gallon). Most of them had no further cramps and they complained of less fatigue than formerly. It was also observed that Iwcpm;,,... , d o t \ ' ' ' l l ! -I allowed to If-. I- i/ard' iid to -u riie ic n f p ern will H.w be 1c, NYw 1 ,!' i VI 1 M f the men using the salt water did not drink such large quantities of water a.- del the other. In recent years dextrose solutions have been used extensively in some of tha large steel mills in the treatment of heat cramps and it appears that some .suc cessful results have been obtained. It is possible that dextrose may assist in tlie mobilization and utilization of salt stored in the tissues and needed bv tie.* muscles. i , i r . ift-j - i i l l ! m e . ' icsul 1 'nip!-:\ . IH11t " i.axcrd ! < <-i! 11* A n , - l . f i- -II l - nf ! l r The most important factors in the production of heat cramps are: r;* r r e a (1) High temperature surrounding (lie worker, high humidity and low air jV*-I t he- - p,q i, ' velocity. Cramps rarely oci*ur among men working in the open regardli -> of t he temper;:! ure. v2) Moscular effort.. (d) Physical condition of the worker. Keren! mgesimn -f alcohol, inade quate sleep, inadequate food and interctinvnl disease pr*-dispose io ciamps. f ( ly Acclimatization is also an important factor. Men who have been coiili iiu .iudv employed on the s'liim type of Work seem to be able to work amt sweat more efficiently than aider pm wds of unictivq v. Inexperienced men .starting on hard work a, tue k.-ai are particu larly liable to develop cramps. Cramps ami heat exhaustion are likely to apt>eu* on (.lie lirst hot lay following a cool spell. Then* does not apj>ear to be any constant racial predisposition a> far as black or white is concerned, hut the thin, wiry man is more com monly affected than his obese fellow worker. i . f I. i i i1 i m I f - 1` i I fen c m : di\ !' -:ng ! 11 It U concluded that heat cramps ure relieved hy the administration of salt solution. The question of administration of sodium chloride :es a prophylactic against the occurrence of this condition among certain groups of employes might be considered. a f mci j ,-\i. U ri-l . a, :iHl at i*a ii.3;;r i.inir a iueii !unulaU Proceuiinga of M edical artel Surgical Section (7 Syphilis While syphilis occupies a most important position as u hazard iiuimi); rail road employ, practically nothing oan be added to the <lala previously re ported by this Com m it!. Every effort should he exerted to prveut i inpluynieut of syphiliticully infected persons, and to this end a blood test of all applicant* for employment is strongly urged. While n negative blood chemistry does not preclude the presence of syphilis, it const it u p --th e only tangible measure for ex imnnt ion in the absence of obvious pathological ~yn>| a o n e . Employes omt met mg t l,c disease after cut mure 111110 0 . m should bi u v b drawn from service during the active stage of conunmiieab.ht\ . and sb mid b. allowed to resume their work only when they may safely 1 considered a- inoliazaninu.' to others. They should be kept unde! obseiwnt c m , Ir'urvei. for a sufficient period of tune to rei init a cure to be effected: under no eircimistanci wall th e |,e less, than two vein's. Neurosypliilis is of course the form Unit Const it ute; the greatv-t hazaid n railroad service, and any employe manifesting symptoms of m-urosvphilishould be removed fion, untestricted train service lamer therapy for the treatment of neuiosyplulis b eompai'ntiveiy new and while it offers relief for the mdortunate individual who has been so afflicted, its ultimate results ha\e not as yet been sufficiently proven to justify the re employment of individuals so treated in any position where they may become a hazard to either themselves or others. Attention i* aiso called to the untoward effects tlm1 frequently develop in patients of moderately advanced age when they are subjeeied to intense antisyphilitic treatment by the arsphenamines. It may be a better practice to sub ject these patients to a less vigorous treat incut and keep 1hem under continuous observation. Hypertension The terms arterial tension or blood pressure have come to mean the degree of pressure, within the arteries, as measured and recorded in terms of millimeters of mercury. The blood is essentially a passive medium; changes in pressure result from changes in the arterial walls. Early studies in the blood pressure were really studies of the pulse. It wa llet until 1828 that the U-shaped mercurial mtinometir was devised; the pres ent accurate method of sphygmomanometer' dates from then. The present type of sphygmomanometer dates from IKflti. N o specific figure may be stated us representing the normal arterial tension. During childhood the arterial tension is variable, the gradual childhood rise ('easing at approximately 18 years of age. In healthy adults the normal arterial tension ranges from 1ltl to 140 mm systolic and from 70 to 8 diastolic, gradu ally rising to higher figures with increasing age. Arterial tension may he detined as existing whenever the systolic tension exceeds lt>0 or the diastolic tension is 100 mm or more, or both. The pathogenesis of hypertensive arterial disease starts with increased arteriolar tonicity or spasticity. This hypertonia may result from anything which stimulates or irritates the. arterial walls. d II 68 Association of Am erican Railroad# O f tin' many sources of arterial irritation, certain factors starni mil v-m.. spicuously became of the frequency with which they appear. if ni rho-e m- I Wi,, i , , , , voiced, foci of infection, hereditary predisposi! ion, maladjuM meet .f the dietary, fatigue, endocrine dyTim ed* a;, etc., are the mo>t frcqnei.i . l'or practical clinical pmpu.-es the M in p lo t eln.-Mib'ation is pronnhiy i he ! M-i me, I!.. <|; j \ II. \ . | most useful. Arterial hyp'-rtension m,n he seen early, at nhw h ?ii;o a j " sp as tic ," with wide variations of too te ndo n on different ocra-hm.... dm- to | tnarked cha nges in tic* arterial tonus; ; f m ay be -eeu late. wJien it i - ' J,t w . " ; with 'dative fixed diastolic tension, duo to da- hbrntie changes m : tic \> -.-el j wails. T h e t vVo ty pes arc n o t , how e v a', ditTWrnf forms of arterial v!i^m -r, fair ! different, stagr-s of the same disease pn-ee^s. lyporteti non m ay or ma> not he { com plicated hy associated disease, lues or I hyr*>-t oxieor.d j In certain instances the progrmMmi <-f the arterial disease -; markedlv accentuated. Degen erative changes appear very early and progress is rapidly tO ! downward. To this group the terni malignant hypertension has been applied. In checking over records of ex am inatio ns of applicants for emplo\ a.- nl made t v enty years ago v\o find very few reject ions on account of high iT -ml j aim-arc. T h e m ajority of Miese were negroes. D uring the past few months a group of \ approximately three bundled men briwern twenty and forty y..r- of , w . ] showed a ten per cent rejection on account of h \ pert.en.sion. M a n y of the.-e * were y o u n g men who had not been perm anently em ploye d during the pa.se - four years. (Tute a few of these have been reehecked at frequent intervals, j and in a tew cn.se* following regular em ploym ent the tendon has r m u m v d to \ \}:- normal. i Epilepsy i So me ten w a r s ago t his (.0unmit t v began an cxtehM ve .aiivcy on die s u i qeri j of Kpdepsy, and nude reports to the Section at it', annual nmetings m 1:07, j laghS, am i d.O'h J in* .-'Ijbj'i'j has mam >n-idi o d d i' y a r Uv felpe a. [epilepsy, per -a*, present.-) no feat urw aim mg rain- >ad employ,-* v d w h d ille : ; m am,' n-.peer !i'"m pri-on s . ngagcd in -mv mh'-r purr iut; d'-- hazard, how- < w r , is oliva -si.- !v much greater v lam da- condition i- manite-.i; m ams-ad j .nephe ws and the hazard inei'-a.-vs p a mai ked degree if the a! flirted mnpw ye j he eng aged in engine, train, yard or -ivual -i t \ we. <H w w u d y any .applicant bu* e m p h >;<meat m railroad :-o \ ice a ho :ii n o \- dm j iii to/v -if epilepsy nr of unsi! i - f a d o n l y < dmiiool periods -<! ?:i. *i.... i. ,u - 1.: - [ .-ii-aild hi' icjeet ed . Harelv, howe-.xr. wiii die applicant admit -mm -rmir- \ rences, and a. p h v w n l exam ination made nmre than thirtv--i\ h airs u n - r an 1 epileptic seizure will fad to reveal an y diagnostic charm u i r de- u p li a -inge i exception of tr aum a th at lias been indi' ted up>m dm tongue. For tins rra-m ., all applicants for em ploym ent in an y posit ion where they may become a hazard j to either themselves or others the tongue ,-hould he carefully examined for j scars indicative* of its having been bitten during a convulsiva; seizure. Ques- j tinning the applicant as to the occurrence of nocturnal enuresis m ay cited, a j suspicion of epilepsy as this condition, when occurring in adults, is almost j invariably associated with epileptic seizures. Applicants are often unaware j of this significance and may admit the occurrence of enuresis while denying j epileptic seizures. i Proceedings of M a lien ! and Surgical Section ti'.i Whenever u railroad employe is r<-]n.i t<tl to have suffered from a sudden ami unexplained at.tnek of unconsciousness, or to have hud any kind of a convulsive seizure, the employe should he temporarily removed from service and a careful investigation instituted to secure all data as to the full and exact elmraetei of tla attack. Any such condition should he considered as epileptiform in character unless some very delimtch positive causative factor of another nature can he ascribed. suc11 employes should he reoioved (non service or tran.-feirej to a iionliasai dous occupation Peripheral Nerve Injuries Injuries to the peripheral neive- pis' an import:,;,! loir in the cent linn i di-ahildy o f railroad empl V ' lollov. im: arc ,lmil aI ii.jurie.-. 1'racMiiCs o f the long hones open are nerompai m ri by m . \e mpu a--. i it .her complete sia n r u c f oi eont ti.-a w of the nerve, re-ult ing h tempi ,.o y 01 (mi , nan,-at paielv.-is. 11ie tv .1 most common lesions are ll.o'i oi the ulnar ami of the peroneal nc; vest the injuries take plats where the nei a s ate exposed at the elhii\v and Inji nv tlie le ad o f t i c hinds Nri vi> frequently iicc.ui.c enmeshed in eallii- m SC.S! im l . i S ! ion, which in 1el f e r e s t n a VS! ' !!l,C degM e u i! h t h e i r 1m et it 111 I III ei hiein". v.iiii tin flinflioil of the nni'cnlo-spn ai nerve in fried tin1.- ot the Im merus resulting in the disabling "twist drop" is a sinking example. During ope rat ions for open reduction of ft aid ill e.- it is most im port a lit that the nerves he protected from injury. Close eollahoration between neurologists and surgeons is an lndispensihle factor for the accomplishment of good results in the rehabilitation of these patient'. While il is undoubtedly true that spon taneous cure will result in a large proportion of these injuries, it is not wise to wail too long before operative intervention. Most uulhnritcs are agreed that the effect of operation appears more promptly and reliably the earlier the Intervention is performed. Trichophytosis I'migu.- infect ions of the skin afflict, a very large proportion of the population. An examination of 3,100 freshmen in one of our large universities showed that 53.11 per cent of the men and 15.3 per cent of the women were infected upon entering the university. At the end of the year a re-examination showed 78.(i pel cent of the men and 17.3 per cent of the women to he infected. A survey in a large European university recently indicated (it) per cent of the students were infected. There is no doubt that as large, if not. a greater, percentage of rail road employes are similarly infected. T he simple eases ordinarily will not disable sufficiently to inteifere with work, hut severe eases and those with serious complications are all too frequent in the practise of busy dermatologists. 'The problem may he considered better by dividing into: (1) Diagnosis, (2) Occupational dermatosis and fungus diseases, (3) Treatment and (I) P r o phylaxis. 1. D I A G N O S I S Ti.e assumption that a fungus infection is present merely because there is slight maceration between the toes has led to many difficulties. The present i i( ! -h n ;v >u 70 hsoouUou dJ A nu-rican Railroad# u-iwlmicy to clinical diagnosis should be runt ioned against, for correct diagnosis depend:- upon clinical, microscopic and cultural findings. Considerations of allergic mamfeMations in fungus infection is important. 1)etenmmng where m\em ic invasion cmis ami allergic rc-actum begins is dillicult Out c.v m n m v sjiry a 1u n powerful fungicides arc to Or applied. 2. u C C U O V l l O N A l . 1)!''dt M A T ( KSIS A M . ) I ' l ' N t i l ' S D I S E A S E S It is considered that, primary fungus infection would Or so rare as to be practically nil, but the secondary fungus inirriimi occurring as a complication of a dermatitis may be fairly frequent. T THE ATM ENT Treatment is always an individual problem. M any people are naturally resiso-nt -o that with no ficafmerit at all they get well in ten days or less. The va.-t majority will do t his if t he early lesions are kept (Tam, dry. ventilated, and only mild antiseptic'' u x m I. Since the serious complications are more often streptococcus infections the thought of cleanliness and prevention in the.-e infeeuons should be kepi, in mind at. all times. The deep.-eated severe cases have must, always been aggravated by the powerful fungicides unwisely used. The combined use of iodine and mercury preparations to skin areas has caused many severe developments and should be cautioned against. LOCAL THEATM KXT -- The acute vehicular type is best treated by oinks and wet dressings, either of saturated boric acid solution, potassium permanganate 1 1000 or weaker or metnphen 1 -30(H). In the case of postulation the use of boric mad solution -oaks followed b\ the application of the Oiiwuimj: oinfmmit has proved va lua !>!(: Mereuroehrome Aquae Acidi salicyhei IVtrolati i.aiiolini cry-t.d.- gr x m x\ di'ams- - 1j o/.. W oZ - 1> The >! >lc:e.`11e and r ), r< me \ypes a re bes! M" a h `d with a .-ulpo ill and -alie;, lie oih* m M , -ix |irrc([il .-f rt ngth or Whit held A .mt mciit. One per cent t hymol i.aay la- added to ei Iher of t hex* oint melds. X -ray in t he sub:unite and chronic ca-i's .s of distinct vaha1 when used n fractional doses, having in mind its limitations and dangers, but it should riot be used in tdie acute types. The use of fungus extracts, Trichophyton and the Polyvalent Dermatomyeol which is prepared from 300 strains of fungi, has been unsatisfactory in the majority of eases, though the value of this therapy can not be projx'rly appraised at present. Kecent investigations or studies in the hydrogen ion concentration or acidity of sweat., the studies on carbohydrates, metabolism, oxygen tension, endocrine function and allergic sensitizations that are re ceiving attention in research institutions at present are to be approved ami encouraged toward the final solution of treatment problems in fungus diseases. i h i i ;- -I ' d i, 1 \ v is | i ... I eauaa. id ji A dm.- .' O' in ti.-* h" -m u ' t i m . - - k !!` ` \ - and ali- ;. < idea.- p M :d-i a g :.n. Mu mi the :... r : j if ,4 ; icanv -t a ax !*>, v d i V / . f , , .M: a '.'w this c.-is: Proceedings of M edical anil Surgical Section 71 4. P H U P H Y L A X I S -- Fungi grow host in numerated epithelial debris in the presence of heal and moisture ami darkness. Therefore, cleanliness, the avoidance of heat and the promotion of dryness and ventilation are of greatest importance. The simple rule of always drying between the toes after every bath and the application of dusting powder will be of great value in prevention. Magnesium carbonate powder is one of the best for this purpose. Other factors to be remembered are the necessity for frequent baths, clean socks, dry shoes, the use of rubbing alco hol on the feet at bed time and the use of (lusting powder in the morning are detail.- of individual ease of the skin surface, most often involved that will go a I Song way toward preventing the beginning of trouble. j In addition to this type of care the management of shower batle, lneke; room;- and the frequented public pinres tilumed f.-r tl,e great increase in the.-, di-e.-oe- need attention. Removable lattice fl.,ot- should be provided in the.-e places, which should be exposed fo sunlight daily, 1 he treatment is: always an indi\ iduttl problem. Mental Disorders There is tit; definite psychiatric disease or syndrome tlint is caused by rail road work regardles-- of I he particular kind of work performed by the ( niplu\ r. General cert-braf arteriosclerosis may develop in middle lile either gradually or rather quickly, and it times may be foretold by carelessness in dress, in eating, and in other habits, unpunctuahty and forgetfulness, verbosity, and the recounting of thing- long [last; also by quarrelsomeness, by childishnes-, by periods of drowsiness and dizziness, and physically by hand tremors, by elevation of the blood pressure or at times by lowering of the blood pressure, by stiffening of the arteries, by arcus senilis, and especially by the apitearancc of arteriosclerosis of the fundi. localizing cerebral arteriosclerosis leading to apoplexy may be told by some of the above signs, especially elevated blood pressure, periods of vertigo, and in addition headache, although in certain cases premonitory symptoms may be absent. Since the severe epidemic of influenza in this country in 1018, many eases of the various forms of encephalitis have been noticed. Railroad employes, like others, have developed this condition. After an attack of influenza the employe should be observed for lack of facial expression, for hand tremors, for stiffening of the muscles, for changes in gait, anti for slowing up in movement and in alertness, and also for mental aberrations of all sorts. After any serious illness, especially from infection or injury, the conduct and the mental re actions of the employe should be watched for an insidious onset of some psychiatric condition. A definite change in the personality of an employe is always a danger signal for the development of a possible psychosis. Tims the individual whose reactions to his fellows appear to become morose, self centered, and depressed, and win, develops ideas that lie has not done his full duty and is unworthy, is probably going into the depressed phase of manic depressive insanity; while on the other hand if a previously apparently normal man begins to make too many suggestions, becomes loud talking, shows elation of spirits and mental exhilaration, with a flight of ideas, be may be going into the manic phase of this condition. < 72 Association of American Railroads Exempt in quit vouug employes the danger of dementia praeeox is flight. slovenly, has oceasional temper explosions, and lias fanciful ideas in- should he investigated with the possibility of dementia praecnx in mind. On tin- other hand if his change of personality is siieii that he is suspicious, accusatory, feels. that he is persecuted, will not listen to argument, and wants to carry Ins difficulties to some high nuthority, a 1rend toward the development of pa raw n:i may he suspected. There are other forms of nervous and mental states which might he dtsru.-.-ed. (waving out mention of the dangers of alcoholism, acute, periodic, or chtoiiic. there is another danger of which wo should be on the outlook and that is the mental state brought on by drug taking. Morphinism fortunately is rare among railroad and other hard working men. But what, we do wish to men! ion is the habit of taking ail sorts of the easily obtainable depression drugs of the barbital and similar groups. An employe who is found to Use these drugs habitually in any excess should at first lie examined and cautioned and then if he persists in their frequent Use he should he removed from any potenteiily dangerous position. In 'lie handling of incutal eases it is advisable to secure the assistance of a psychiatrist and also members of mental institutions in order to provide proper care and rehabilitation. We know that wc have not adequately discussed the occurrence and handling of mental conditions in railroad employes, hut two tilings we feel certain of and on firm ground; first, Hint we can attack these problems, with any hope of beneficial effect, only at the price of eternal vigilance; and second that we must be firm in seeing that the suspected individual is immediately withdrawn from a responsible position and put under neuro-psychiatric rare. Pneumonoconiosis Pe.eumuuocouionis is the reaction of the lungs to the presence of any kind of dust. Silicosis is the reaction of the body, espoeially the lung.', to tin- piv-enee of Mlicon dioxide, or silica, in ,t finely divided state. It is widespread hhr,ist.-. During tlie l as t feu years silicosis has come to Indd a prominent plaee in t h e industrial world l.eeause of legi-lative action. Silicosis is an old d'-ca-e. Co!!is gives a very complete report, oil the htcratmc from the lime of H i p p o . crates up to the present. Little was written , the subject until 1717 when Kamazziiii wrote Ins famous hook "Diseased Tiadesinen." The Committee oil I'lieuiiioiinroninsis of the Industrial Hygiene Section of the American Public Health Association, defined silicosis as " a disease due to breathing air containing silica I'SiO), characterized anatomically by geiieial fibrotic changes and the development of miliary modulation in both lungs, and clinically by shortness of breath, decreased chest expansion, lessened capacity for work, absence, of fever, increased susceptibility to tuberculosis (some or all of which symptoms may be present), and by characteristic X -r a y findings." There are at least two distinct types--acute and chronic. Acute-- reported as early as 1713, may develop in two years, or even less. Chronic-- or most common type, takes from 10 to 1.1 years or more to develop. Etiology h Iff' iI >1, if 1H ` <i lilt hirti* : will i-t ,, in f;tr , hr tit -i f n ,] . ! HiK :t ill.' j hlr it- imi pile tti tlu.-T M. lint; if* l.y if, HIM)) r 1 m i <tu Lin i : 11!: tlnlit. -ilifnt 111t ; if |H`I Ui ,1 t if leu im'uin to ITS t'l in/ fnlllt i! ' 1- ! 1it! i lll^lll Hi ; 1if C: nsi lily i <>1 till' I . \i nj-ili; pr ii' I: S-7 Hirer ;v Ptft >v. i rvif It 'A l.' i'H In ii! T ill-.' ot lit' f. ;v, t 1kt-' ' 'n i; \ ,j,! .'i -I'l 1') i.'h ill .-n-it' n i l , J.u t it ' i ihi- 1 s. i'i 1i ( a i . t fie i b '; \ ir- j j Pathology: \-"i'ii:d.ng Vi I <! if 1h . i r. ii i ; j j |, ) * i j DegCI.ei a , iDLlVa.'!- :iI ;/( ir, 11<ii lUI f I n-.t ' ril;t< ' S j fiiptoms: i'hf l i - r i f f }-, , .I: .-.Tip! !!. :iiJ` i pij.-, first Sy im lftim tir. M ;m .ip I iiff`li iviti, r<M iirr<` r. *>. t.4.,i, ?*? A. jinu i'tix is slight. acted. mattentive idea- la -houid lit: ii.l. I >u the u!Ikt a, ii'Tii-alnry, feels rant- I f c a n v his line,i'll* uf paranoia M l g : t i t (i r - cus- r t . " k VM c i l ' . - I- : U .' , - till 'ty. a i a n I. . IIS M i ' ll M , . j 'a i : illy l i t ] i ti , it!, p : , ,pi : n i - ' ami handling 11 i t'i lain uf ami , v. it h a \ hi |nuf ml -.1( 'iii11 t hal ! ediat, y a ithdrawn ' ca 11 i nri "I any kind of Ill's, 1' I t ha pre-l-liee wide- jinanl hl'IDs!-. .niinaM place in (la is an illl disease. Ilia Inna of HiJl|liiI't iin! il l 717 when Hi yn iin .Sect iitii ni i - *'a ihsi -iM' line ! o Inin.illy by general i in Iloll, lungs, and n, Itssi iiini capacity H'iiIi i m isoinc or all X -ray fa ilings " .a Aruti reported < 'ai nia - ni most loin Prnre.tiilt7iyx uf M uliai! uhd A'uiyi.a: S n tmii 73 Etiology: Tlw primary cause of .silicosis limn, is five lien, 'duded in the form of dust. It has been demonstrated Mud this dual, in iirdei t. achieve its harmful effects on tiie lung tissue, must be in a tint: state of subd ' -mm, that the dint particles must, in fact, he less than it) microns in theii pti a C'l diameter. Most of tin dust penetrating the alveoli is less than 5 microns .. diameter, it is, therefore, a dust invisible to the naked eye, and its estm e'em depends on a definite technujue of dust sampling and counting. This t- - nique has been defined and standiitdi.;ed b\ the l r. S, Public Health Sente. Dust concentrations an naastm-d in terms of nnllioti |v:t>11cfi-s pet culiii Thi prob ab iiity of one acijinm ig m Iii-osi- i l . -1- up on: ft) N a i m e ot sthea du.-(; depend- upon t P minei.b cnmpn.-h ' H.e dti't Knopf states that t la - li.aim) lilin ol a ' |u;`. rt /.-(.id aminy; dusl . dl y in din-el ] i . .pm t ion to it- quartz cot,tent, (2i Sun of particle- of dm M'obat.ly the nio-t dangi-t- t'tJs is that ranging fio n , 2 to .'> microns, u> smsi . i'ccait'i these impalpable particle.- readily remain in ,-u-pen-ion in ti,e hi t. ,t long time, (it) (h.tantdv of dust Aeei.iding to l.orign tlm q uan tity of he- nee es'a iy eamiol h. givi n preci-ely. as t here is more or less nidi vidua 1.--me, ; . 1i!il> . K a t e of re-] .rat ion is al-o a iactor. Finon the results of a study run 1 oy the l . S Public llcalli, Service, it veto found iractieabli to Miggi-d a n : ' -vr Standard for Ha- uppi i limit III till'oval lie dustiness betMei n 1(1 tu.il 20 i. n part ieii - per cubic foot of air for workers exposed fn dml resuiting fr.n, granite cutting. '1i.e same limit would presumably lie applicable in the ce-. "Ihot dusts with ti.e s.'ime physical characteristics, particulujly with a qivutz content of 3d j>i]cent. (4) Length of dust exposure. In an investigation of Hie m an ile indtl-try the l'. >S. Public Health Service found that in a group of workers exposed to the heaviest dust, the first case of silicosis appeared alter approximately two years, and hy four years all in this group seemed to haw developed at least an early case of silicosis. Pathology: According to Gardner, silica particle.- smallei than 10 microns are inhaled into tiie alveoli and are taken up by phagocytes vdccli carry rhem immediately up ttie lymphatic channels from one node to another towards the hilum. The special irritation of silica particles scents to enhance this movement. Alter locating in various nodes the irritation continues and tiie same type of cellular reaction occurs that is seen in tubercle formation, except Hie tubercle becomes caseous, 'idle exact cause of formation of Ibis binotic nodule is still in doubt. Degenerative changes then take place in the.-e loci and the hyalin noduleincrease m size by extension of their periphery , ami eoalescent'c ol adjacent nodules hikes place and brings about involvement ot further areas of tiie lung. Sym ptom s: The disease is divided arbitrarily into three stage,- for convenience of description ami possible compensation purposes. First stage: Symptoms of uncomplicated Inst stage are few and often indefinite. Man apparently well, but law slight rhortnc-- of breath, dry cough, often with recurrent colds, are most usual symptoms Karlie-t specific indica- i t |: 5 74 Association of American liaihoails tion is ihe X -r a y iip|ivaranee, consisting of generalized arhori/.aliou throughout hull) lung fields with more nr less discrete motrling. Thi.-< rhurueten.-iie mot tling is due to sliinluws cast by the discrete individual nodules.if til.rolls tissue in the lungs, ami is essential to the diagnosis of silicosis; without this finding t he diagnosis of silicosis is not sustained except- hy autopay. Second stage: D efini'e shortness of breath on exertion, [min in chest, dry morning cough, sometimes with vomiting and recurrent colds more frequent, dyspneie on exertion, and chest expansion noticeably decreased. X -ray appearance--A generalized medium sized mottling throughout both lungs. Shadows of the individual nodules are discrete and well defined on a background of fibrous arborization, but there may be some larger but limited opacities due to irregular pleural thickening or aggregation of nodules. Third stage: Shortness of breath marked and distressing even on slight exertion. Cough is more frequent; expectoration is in most, cases slight, hut m ay be copious, individual's capacity for work becomes seriously and perma nently impaired; chest expansion is greatly decreased; loses flesh; pulse rate increased and heart may become dilated. X -r a y appearance further accentuated, m ottling more intense, nodules larger, and take on conglomerate form so that large shadows are shown corre sponding to areas of dense fibrosis. Diagnosis: For diagnosis a thorough and chronological occupational history is extremely valuable. Evidence of exposure to silica du.st. '>r lack of such evidence, must he of significance. Tin: cardinal sym ptom of silieo-is is shortr.e.-s of breath, and the cardinal sign is decreased chest expansion; the earlic-t specific indication 's the charac teristic X -r a y appearance. The diagnosis, however, should be made old) hy the correlation of all the fa d s, symptoms, signs, occupational history, and laboratory and X-ray observations. In autopsy, according to M cN ally , tiny lung containing over 2 tug. of silicon dioxide per gram of dried tissue, indicates undue exposure to a dusty atm o sphere. Prognosis: Silicosis i- an incurable disease, inn. the prognosis in the early stages is good if the patient can he removed and placed in the open; hut with the advance' of the disease the prognosis becomes less favorable, principally on account of the liability of tuberculous infection. Treatment: Change of occupation to open air work; high, dry, warm climate best. Prevention: The use of various mechanical means of elimination of dust,, both the form a tion and its removal. Em ployes entering service should he questioned carefully in order to obtain complete history, especially of any exposure to silica dust; also a careful phvsic-ii rx.-.iilll 11s-.iic for d u g o III |.d < Ij .1 and if -v i.pt-.e Tnc T ,.f vlfeCI I , . ' l l . ! ' an The h.'U,i,gills I -I-, are a - 1- illnv it ia!liie.^ 1. I ho same u . a k wages m other No comprls-lt wit inn one veai ik-case, except a die-a . i--lie I V. lav 111 :1a- in. : , " Of: \Iplii . ; 11. i <.j" itiir !m p p p 1; l-Xp<)-*'ii t. i.-ltlf* >aul Ji'-t rolrij A ` A.-, < -It;: ipiptrt'h !v, U . f i . i t - a t . k'i. .1 ft - it'Mlll-li i ; hr i-~> u n : i ! 1.1 - j <!<r !: tt i;rt' > . 1-ii r -j. tl p -f inpl. ' /I r \ j ,, ,:. f .nr r - 'v . f ! 1` i \ ... 1.' Pi;. `i a. 3 7 .. l b . nilt .\! m u i i lib days. TP Proceedings of M ed ia d and Surgical Section 75 physical examination should lie m ade, including X -r a y film of chest for lung tissue for diagnosis and future record. in old employes working in dust, periodical examinations should be made, and if sym ptoms are present, change in occupation . The Slid e of Illinois lias passed a W orkm en's Occupational Diseases A ct, effective October 1, 1930, for disabilities resulting from occupational diseases. The highlights of the A ct, especially ns it has reference to silicosis and asbesto- sis, are as follows: It defines "D isablem ent" as meaning disabled from earning full uug.-s at the same v.mk which caused the disease and with the same employe/ or equal wages in othei employment. N o coiiipeu.-.'itioii payable for occupational disease unle>- disablement occur.- within one year after the last day of the last exposure to the hazard-, of tic- disease, except in occupational disease caused by inhalation of silica du-t or asbestos dust where the time limit for disablement is three year- after the last day of the last exposure " Occupational D i-ease" is defined as a disease arising out of and in the course of the employment Ordinary diseases of life to which tin- general public is exposed outside ol the employment shall not be Compensable, except when- the said diseases follow us an incident of an occupational disease as defined. A disease ahull be deemed to arise out of tin- em ploym ent, only if there is apparent to the rational mind upon consideration of all the circumstances, a i direct causal connection between the conditions under which the work is per formed and the occupational disease, and which can be seen to have followed as a natural incident of the work as a result of the exposure occasioned by the nature o f the em ploym ent and which can be fairly traced to the employment as the proximate cause, and which does not come from a hazard to which work men would have been equally exposed outside of the em ploym ent. The disease must be incidental to the character of the business and not independent of the relation of employer and employe. The disease need not to have been foreseen or expected but after its contraction it must appear to have had its origin in a risk connected with the em ploym ent and to have flowed from th at source as a rational consequence. Am ounts payable in case of death are: m inim um $1,000.00, and a maximum of from #-4,000.00 to $5,500.00. Am ounts payable for disability: (a) In silicosis or asbestosis or either complicated with tuberculosis, employer must provide first aid, medical and surgical and hospital services to cure or relieve the diseases, but not exceeding six months from date of disablement. In all other cases, the employer shall provide the necessary first aid, medical and surgical services, and all necessary medical, surgical and hospital services thereafter, limited, however to that which is reasonably required to effect a cure from the effects of the disease. Th e employe m ay in any case elect to secure his own physician, surgeon and hospital services at his own expense. (b) Tem porary total disability--after six days, compensation (minimum $7.50, maximum $15.00 weekly) to be paid, and retroactive to first day after 30 days. 70 Association of American llailroails (c) In case of total ami permanent disability tl\e maximum compensation will be the death benefit. plus a pension of S-per cent, or in certain cases )2 per cent thereafter annually fur life, payable m onthly. On petition tlie Commission may order an .autopsy by competent patholo gist, where death may have been duo to silica or asbestos dust. Pathologist to make complete report (including laboratory findings), but offer no conclusions. Employes making claims for compensation most submit to physical exam i nation, if required by employer. Em ploye is m titlcd to copy of report if he desires. If employe leftist's to subm it to exam ination, compensation reuses until such examination is made. Employes with silicosis or asbestosis but not disabled prior to October I. 1(K!(>, may hie with industrial commission within (id days after effective date of this act, a request, to waive full compensulion for disability or death from silicosis or asbestosis, or any direct result, thereof, supported by satisfactory medical evidence. If the industrial commission approves such waiver the compensation payable after further exposure ami resulting death or dis ability shall be .">0 |ier cent of what it otherwise would have been, Xotiee of disablement im s l be given the employer is soon as practicable. Claim s for compensation must bo made within six months after disablement, and applications to industrial commission for compensation within one year. Any length of time however short Is sufficient exposure to support, a claim , if employe wais engaged in an occupation or process in which the hazard of the disease exists--except in eases of silicosis or asbestosis where the exposure must he HO days or mure. The employer liable shall be that one in whose em ploym ent the employe was hist exposed to the hazards of the disease claimed, except for silicosis or asbestosis. Mo employer shall be liable for enmpom at ion or damages under this Act in any ease in which the disablement on which claim i> [M edicated shall lot', c occuro-d prior to October 1, b.lifli. Chronic sVrthritis When rei'eiring to chronic arti.ritis we usually mean either of the two great types of chronic nnu-specihe arthritis. In the language of the baity we -peak of tin- as chronic rheumatism. We must not forget, however, licit tla a 1' arc definite clinical groups of chronic arthritides of known etiology, namely lues and tuliereiihir. These latter rue -pi-cific diseases m.-dy recognized as a rule and if ticated in the early stages of the disease processes, are amenable to treat m ent. Nrumbers .are cured permanently ami the f lid results in reference to disability are not clouded by the sinister throats of the crippling, agonizingly painful and deforming onslaughts of tlie chronic non-specific urthntidcs, rheumatoid arthritis and hypertrophic arthritis. Itheumatoid arthritis must be entirely separated from the acute disease of rheumatic fever; known also as chronic infectious arthritis, atrophic arthritis, arthritis deformans, rheumatoid arthritis is the most prevalent of these two disabling diseases. In a Cornell C lin ic series of 0 12 cases two-thirds were of the chronic infectious, or rheumatoid arthritis type. It is most often seen in /'MV female-, m o 1 o , , | n.-aiai t - . a ' I <-ir. a , i : but in-qUeM i , ... .. Etiology : 1h i , an h may bear up is I be act ua 1, u i \, ni ;m disease. < hiural si> of s. Ii r th r o at-, ul.M I disease will 11- 11:111. In rheum.it isin. C ecil's t"qj,'rini, k n o w n t o all. 1bs i ,,, and po>i 11 vn p ,n,r ruif incuts in' worknfs ;i,r, c h a i n e d - t . v p t o e o .- , t;.. we ,iis hue!v is 1 .M i, j Stw in ;d W orker : .-i:e .i tin- . o, nts and ',! , ( trl.els haw- M,iat,-d Co- a I I kt l --; I l u l i f W1:, 11I e l ,-r d germs w,-;. :- i I, S in a i a ; - t o ( V , 1" -. !. , 11, -(at d In . X i Ilie fm , S o Iui M', Me l - t . , e - , , T im ; ClMW , ,, d ' i.e . l i r u d t e i i i ; d , .,. 11, n i n 1 . , , u in idiue uv> ,- i y, llllil the tl MI partial iv e, 11,; d. ,. nil t lie disea-e .. 1,iw ink tlie long iJunes atr-qih gradual -u . . -set, dedisease are s v , u g ,,f t ankylosis and dc/ornut the disease may .-kip fingers present th" Ivp ` \ VyCu. -; a> - ompen-atiun tin ea-e.- 12- f-iit putholoath'.h.gi-! Ul Cl >fii'J <1 :: *II" . I i-\h i:,: icpoM if |lt111'.;. (, ( HI. ;f - i . T i-rt.,, (ii ;. f I. 1i ;i, N: t M .ic f . y v, m\ I'! ! ia'il h sk- or thi:' Art m shall have two great V We .-peak t 11i*-i* are aiiirlv hie- 1 as a I ha lf- t o I I t-;il 'frJVlir. In tgonmiliglv irtlm lalr-, (1i - r a " i - nf ' Ul\Hat IS, the-r two ACIC of the n .srrii in J Jr(H'i'(-<ini(is oj Mtuiiail u n J Nmi/mo/ Su-ti- females, in a ratio of tv.o to one and is cs-schtinllv a disease nf U,. young, the usual on-.-et bring at thirty live years, it i- not l<-i;t in tropica! zonc- hut' is frequently encountered in tcm peiate chma Etiology: Herein lies the setting- lor number! Clllit rov efwn-s. Such pi e- disjxis!ng factors as fatigue, trauma, shock, nir:i t , he eillty. e\po-U!'e, etc.. may boar u >some jia it, but an- not conwhem.; T !... i i defilUte joCUS of ilo lection witi, sul is tin actual or jUf lit a l i - n rpuo.u -1 b i 1jug <;. u-1 ..'.ii ..i .If: iJil.-ct IOU- pl'orr- 11 1' I \ 1 1 - 1ud-nt - of !i:;* dis. - ( 'i i l i i ' - . i i e- i d. i - . - e : ; e t < U p p r! I ' H . i e e : o ,, - \ I . I W ' O of -or di.-eio h n m b , . . i n f * - ' - d t ' -i 1i i . : e p c a i t o C. : h - ' M l ; t I: i <i: e h : . me k i . i ; i - ili U - H : d l y b* l o i i j i d m p :: l o ;: 1- - l i f t- ' I ! . ' It i. t '` .U l ; i : (! I 'l i i M U i r k,, , ,, Cer-ii -in. t-xpi i'Uui ni w a l . . 0 . i .: ^ m , . . \'i-\ N'.M k. a n know I. In all. a n d )'. s i t i w j; 11 - l u g ! : p i I'll.'! i ll " - I ri'l.Oe,'.!-- nil, pi ) o ! p . H t , I I , I; s\ r Is O , ,.,1 ; U t U e r. m e n t s by W olke; 11:J o l i g h o u t | h e H a l " 1 :. < V 'i, l - . i m d c h a i n e d . - t o p ' o ' - < I'll- i I- h i - \\ Ol i. .. !;i 1 i f' V . a ;,- 1. we a n - iike]\ ho i . .o ])H fall-. | . I I I ,< ,'l ihl- f h1 -o S e v e r a l w o r k e r since (V e i l have found a high p<-m h ; e o( si i r p t i m'i irrt, in the joint.- and blood >( patie nt- sufi'eiiim wi th ehiom ulen M<us art hn 11 Otia-rs ha ve i.-olahd -a iept o'-occus, but to a much ie-s dt er '.! per een! 1 Jo per cent. Fu rt h er, some workers have f a i l e d to ago ". it h ( 'r ed a n d hi co-worker.-; these reeem-d only 1 pel cent positive eultme.-; others, found none whatsoever. They regard the streptococcus as contaminants as the germs were isolated from the culture medium m two instance- u.-mg technique similar to Cecil's. In over o,00() consecutive blood eultutes at the M l. Siani Hospital in New York there was. a yearly incidence of from live to fifteen posi tive for .streptococci)-. The type of streptococcus i-olated by the various workers also curries from the attenuated hemolytic m repo.coeeu.- of (V eil. Some found streptococcus vundans and even tbploeocci were repotted. Thu.- we are iriet with um-oiivineing lata, leaving ample loom for doubt and skepti cism. In other wolds, we do not know the cause of rheumatoid arthritis. The on-set of rheumatoid arthritis may be sudden, m giadual, usually- the latter, ami the patient k- first aware of pan. and sUbne.-- m a single joint. Gradually the joint begins to swell. This swelling - due to active inllan-.ma- tion in the various parts of the joint, especially the synovia! mi. i-diranc. This membrane is soon converted into a thin layer of granulation ii--ue that extends in t ime over the joint cartilage with dest met ion of the cm tilag<. The c n p - u l e and the tissues sunounding the joint- are next involved and, if unchecked, partial or complete nnkylosi- occur-. This is a fibrou.- ankylosi- but later in the disease a bony ankylosi- may cent. Not only are thi- joints a Heeled, but the long hones atrophy us do the muscles and the skin. Whether acute or gradual in on-set, the disease becomes of a chronic nature. Feature- of the disease are swelling of the joints, its progressive character, ami the tendency to ankylosis and deform ity. The knees and fingers arc chiefly affected, although Urn disease may skip about from shoulder to elbow, wrists < spine. The fingers present the typical insignia of the disease; a fusiform swelling of the V; i V $ f i \- ; i i. ; g f I II 78 Association of American Railroads first phalangeal join t. This is culled " sausage finger." Subluxati.m of the jo in t m ay occur. Various other deformities such as llexation of the first phalanx and hyperextensinn of Ihe terminal one. Thus, a working man is deprived of the most essential portion of his anatom y in his struggle to keep active as a wage earner. The spine may be attacked; soon the normal curves are lost, and the typical "(joker" spine results. The muscles atrophy and respiration is impeded. These patients soon become poor, under-nourished and unfit. It the disease continues unchecked we sooner or later see a bed-ridden cripple with his contracted, deformed limbs and wasted muscles. The above resents a typical case of rheumatoid arthritis running uncheeked through an indefinite period of years. We do not wish you to believe that once a victim of this desouse there is no escape from the disabling m alady. Xum bers are aided; some are cured, bur, still far too many show impaired joints, par tially or totally disabled, and in extreme cases we are confronted by incurable cripples. Hypertrophic arthritis, degenerative arthritis, or esteo arthritis, is the second large group of the known specific arthritides. This is usually a disease of people past middle age. Old age is given as an etiological factor, along with traum a associated with the wear arid tear on the joints in men or women who for years have toiled on their feet. Obesity or overweight may add to this traum atic feature. Occupation lias an important bearing. Laborers or mechanics are most often affected. Incorrect position or abnormal si rain on joints and exposure seems to play a part, especially for people who lead a hard active life exposed to all types of weather, [fere again we see the. heavy toll that possibly can be exacted in our railroad workers. Cun anyone si ate sincertrly that railroad men do imt load a hard active life, do not h aw to toil j l laborious Work, exposed to every kind of inclement weather? Hypertrophic arthritis begins slowly and in.siduously. The patient noiires a slight ailTnc-s in ibe affected joints which gradually become more uncomfortable and painful, especially on usage-, until the (Jam becomes constant or more marked m the involved j o in t . Hips, knees, fingers and .-.(line are chiefly affected. C nit mry to findings ;n rheumatoid art licit Is, iiy pert r<iphic art lint is -uu-es a ill-finite cartilaginous destruction in the joint. The cartilage is worn away and lie- underlying hone is exposed. At lie- earl liagmo-.is edges lipping -veins and spurs form. Tin- j..m t does not, swell as a rule and the joint cavity is never obliterated. No synovial adhesions form and ankylosis does not oerur, but a certain am ount of locking may follow the outgrowing of bony spurs. Typical findings in hypertrophic arthritis are the haberdcti's nodes--a tiny bony outgrowth appearing at the bases of the terminal phalanges. T hus again we see a disabling disease that by its pain producing ability and by lim iting activity through mechanical locking of useful joints, robs numbers of skilled workmen and laborers of their ability to perform their tasks capably and in some eventually causes cessation of all wage earning activities. After this brief summary of these two disabling ailments we must now con sider the ideas advanced by many students that both are only different phe nomena of one disease. M uch evidence supports this theory. 1 . *. -CW /** *.v ... >*. ,f...-.i..-, v. (/.. '-J w> ./k/.j J v`* ' tr"o*/. .<' :*i ,si /^ . . <1</ . 1. s *u. I'mceidittyii uj \ i etilati unti Surgical Section 71) luxation of tile ! >n of I lie firs t 'rhing m a o is ' niggle to keep N mu In is of patients art- seen with insignia of both diseases at tin- same tune. Some jiicscnt the fusiform swelling of rheumatoid arthritis in one linger ami the next digit will show a ty picul Helierilen'K node. There is definitely a mixed form of chronic arthritis. Archer, of New York C ity , reports fifty instances of ; ini ila typ ica l li is i i i i [k -i le d . If t III' ili-e lis e I . I <|ill WIt ll Ills mixed arthritis in a series of 1,-lo'J eases ol chronic arthritis. Recently R igla, in an X -ray study of sixty cases, found that two-thirds showed a mixed tyjie of reiiclinn in the joints. <71ten we see a middle aged individual with what wi term iluuniatoid iirthnti- develop as lie grows older t|,e typical signs of l.ypertruphieart'hritis. ' hi' IJIH llls kl ll tl.at 'iiih i . N U lu lici - I ji :ots. p.u - 11 b y i i i r u r . i t i l e Tin I'loed pietun in the two dot axes offers very little In rheumatoid iirthnti.- tla ie may U> a mild a m n .l.i. Patients in both group- may run a slight h uki-ey'to; I - . The unin is essentially negative. 'Mills, again we see a similarity m tl e eluoiiie nen-sjxciiic arthritides. Pi ml" n o n . in lus text bo.,k. stater that whatever the o m n ia we aeeept, the two git .at types of arthritis cannot definitely and finally lie wholly divided one from the other. Years ago we thought the primary chancre and tala s doisnlis t II i : l i - . i.- tlic were two di-tinct and separate disca-e entitles. Today we know they ate . ,, 11\ .i i l l - ' , i- i caused by the same organisms attacking in a different way. Thu- chronic ' . c l" iu r w it li C l t l. l ll l -1 Wtill . 1- m ill t-i t i n - atlhrit is. whatever the etiology may he, can surely cause dissimilar end results. Whi-thet v,e separate the arthritic tvfx's or in.I is of little consequence. We know that the disea.se of chronic rheumatism is quite prevalent and that as M tborer- or days go hy we h a m none too much about its etiology. I it.al si rum on . l e h a d a } i ; i i <1 What then for treatm ent? One need only peruse text hooks and papers on the subject since thr disease was known to find that countless drug5 and treat I hi- heavy to ll ments prescribed am i, us frequently changed, denotes a certain futility in the : turn- stati .-in- treatment to date. Physicians huve used iodides in various forms, guiaeol, i h :i VC to t o ll at dried thymus gland, thyroid, arsenic, sulphur, and of course salicylates. II vjxTt lupine 'Sprue; waters, vaccines, foreign proteins, diets, liniments, physiotherapy, rest, i -ligh t s tilila .- - sunshine, diathermy, electricity, colonic irrigations, and countless other I in n i J>a111f 111. medicines and fuds have l>ocn tested. And none of these listed treatments III :i ' k 11 in tin1. .1 today offer any great cause for rejoicing. Sufferers are relieved hy the above various forms of therapy hut as a rule this relief is temporary. Yarcines seem ' l.i it is ('a ll- i s a to offer the liest plan of attack , hut now Cecil states that lie tries vaccines for worn uw sv ami three or four months and if it fails to help he stops this therapy. p ut: occurs am i What then cun wo do? In the early cases in which the disease has not pro i i vity i- never gressed over six months the removal of a focus of infection, especially the i,'t o f i u r. Ia n a tonsils, will cause a remission in a large percentage of the cases and a cure in a purs T y p ic a l a tiny Imny smaller number. This m ay make us doubt whether these early cases are similar to the progressive arthritis that goes inexorably to bony deformity and :it' ab ility anil I' ll' I 111II11i .. t asks 1-a p.1 ! ! v : i , it it's must How C"H<I :fi i !<) 11 ] t! a - ankylosis in spite of the removal of foci. However, early in the disease, it is most wTe to clear up all possible infectious foci. Once a case of advanced we treat the patient nnd not tbo disease. We study eucb case carefully, correct all abnormalities, and observe the effects on the course of the disease. What Archer terms as reasonable measures of treatment are: (1 ) O rtho pedic procedures, first to combat and secondly to overcome joint deform ity. (`) Physical therapy in approved forms. (3) Drugs to relieve pain. (1) A clim atic change from the humid and cold north to the warm and dry south. * I 1 i I i! 80 Association of Anu'rictin !{ ';drnnih S u r e l y offers little but resection of ankylo.sed joints with resultant shorten ing and no relief of ankylosis, but in most eases relief from pain, ['at wius so benefit fed still must be handicapped by a stiff joint a curse, indeed, to the laboring man dependent, upon his physical ability to insure a job. Com pilation of ligurcs in our Railroad Hospital are i r t ai hand, but far too olten are we visited in olir elhiies and hospilals by patients suffering with chronic non-specific arthritis. We ferret, out the foia of infect ion, hake the affected joints, use salicylates for the pam. and lately have tried the new sulphur preparations. Relief i~ obtained hut if is discouraging to sec these stime patients return repeatedly sooner or later for help help we willingly try to bestow, resen ing for our own contemplation the final scene when these strong, 'willing, supporters of families must acknowledge defeat and become reconciled to a painful existence disabled for duty. Thus, the more we pause to consider chronic arthritis, the more we view with dread the insidious onslaught of rheumatoid arthritis and hypertrophic arthritis, diseases of which we know so little as to etiology and means of treat ment, and diseases which at this writing continue to he the " hugaboo" of physicians the world over. Respectfully submitted, Co.MMITTKK ON DlS.AHII.rnf AND REHAIUUTATION, ,1. D . C o m a n s , Ch airm an . T hk C hairman". T h e report, of the committee is now open for discussion. I'pon motion regularly made mid seconded if was voted that the report be accepted as a progress report. . . T ut: Cit mum w : It now give-- me plea-aiic to introduce l>r. Thomas M . M cM illa n , Associate I' r o m . - o r of Cardiology, of the C ra d u ale H ein d ef Medicine of the I,'nivei-iiv of I'eunsylvauia, who will speak on "T h e Heart in In d ustry." D u . T h o m a s M . M . M il i. \ \ : M r. Chairm an: 1 first wish to express my appreeiat ion to you fur asking me to lie with you tod ay. In f he second place, I waul h i say that 1 am w it at all cert ain t hat I am er. tireiy lit ted in discuss the subject of "T h e Heart in Imlu lr y ,;' because, although I come in emit act with a good deal of heart di.-eu.~e in m> d a y 's work, 1 am not. particularly assoeiatmi with the heart as it occurs in industry. However, on thinking over the matter I have decided Halt, after all, tie heart, in industry isn't very different from the heart in general medicine. So 1 have persuaded myself to attem pt to discuss this m atter ns well as I can. I am fully aware that the heart, isn't, your only problem. Y ou are equally concerned with the other systems and organs of the body, but. today, in order to make our discussion orderly and system atic, we will om it all other phases of disease and consider only the heart. As I visualize the duty of the medical department, of a great industry, it is, first, of all, to determine that an individual's heart is able to terform the job Pro,- K\V`Tt hue. n :T 11! `Mr : ht c, ! ' I j - h a - Mitili v 1 m jure h:s n : .. < - ja i lh ' a t c Hr. h.i y c :i m V.IU A f -bl' i i c , a m i ; < ( l a - a :Mi ! iif iii.(!)* *.-f ii* [cat ( ' u . ' f d n i a i i ! y . . i n <. p i n i i : (.iMj, tiiv -yiMj imeriiiMticit thii'm hrii \ l'iau.-M an* Inutili' .1 u(m] the - \ in}.1 dll'-. a :.-.t/rs n hi i .v n iia l K ill, '.v litd i, ,r- .i 11 - c t ' is ! , . li..* \ Mil ; . y i v iiftiru c t! iwM !>v :i k a m i t h a t v- u iiiii .-t ' < M IhiviM ,' ' ; c h--;;n ii I 'AMi: r c , --.y .. j id d cf'i-'c' / ' h ' - h- :.i : Itll <! it 1` ;/; ' : : 1: ;. ' d i s e a s e i~ a , a: 1 i ! . . . , g lias . 1 c - i n - e ; H r i ; . . . . i t Ii 1? i \1 d in \ I W lin e Cl -! . ! r . infectious myocarditis, p iru o rrh .i, diph'b'-ria an problem. Bacterial endor is common. '1'):is really is heart disease ; f .r bacteria o n l y in those ab e.td v d i-.- easy to recognize when it < very conspicuous murmurs Common. When they exist. ,>i> -v - Proeeediga of M & licol and Surgical Section 81 given him without endangering the wifely of other*, lint that is only one side fit' the question. There is another very definite duty, and though it is a product of rather recent developments, it is none the less a real one. Your joli as industrial physicians is also to see that the joh you give a man to do does not injure his heart or his health. For hotii of these duties our industrial organizations have a moral and a legal responsibility. Y ou r work, as 1 see it, therefore, us far us tin heart is eomvrneii, is largely diagnostic, and for this rcusm v,hut 1 have to say will he concerned mainiv with Mm- diagnostic features oi heart disease. Custom arily, an opinion on a leart is hase,I upon a consideration of (lire, things: first, the sym ptom s; second, the physical tindings ; and tlm d , the intoniiMUen furnished hy rertan graphic sitnher. Son, like in-m am-.pl.y-e eiaie, aie handicapped by having to discount to a great i x o n t , 1 should imagine, the symptoms. A m an, for instance, <ciiwi t FI, to he i, 11r< d. He wishes to go on with he work, and he may ilchiii ratch tell you i,e ha- no p ;, cordial ]iain when, a.- a m atter of fact, he may have preennha! pains ,So n seem- to me y<,n njay ju-t a- well make 1151 ynui mind tie.: lie- laiuahlt iiionnalion given hy a k n o c k ,|g c o| the symptom,- will have to 1 given up, and that you must come to rely more and more upon other methods ol studying the heart. 1 want to say first a little hit about one method that, helps greatly, I think, in deciding whether a heart is normal or abnorm al; this is what m ay he called an tiologie approach to heart disease. This consists, in recognizing that heart disease is not som ething mysterious, but that every instance of heart disease has a cause; that these causes of heart disease are not numerous, and that discovering the presence or absence of an adequate cause for heart disease may in itself constitute evidence for or against, the existence of the heart disease. Jx-t us briefly consider the causes of heart disease. (Slide) 1 have placed on this first slide all the causes of heart disease that 1 know of. A ctullay when we come to consider various headings that 1 have listed here, many of them are found to be extremely rare, and m ay be ignored on the grounds of their rarity. (1) Acute pericarditis. All tyjies of this condition are rare: one doesn't see it frequently. In the second place it occurs in association with some de finite disease such as rheum atic fever, tuberculosis, uremia, etc., and its recognition is thus facilitated. Idiopathic m yocarditis; This is a rare form of disease in which myocardial change of severe form occurs without lecognizublr or demonstratahlc cause. It is extremely uncommon. The same with Acute infectious myocarditis. This occasionally develops with diseases such as pneumonia, diphtheria and typhoid. I doubt if this will ever become your problem. Bacterial endocarditis. The streptococcic, form is the only one that is common. This really is not ft cause of heart disease: it F a complication of heart disease; for bacterial endocarditis does not occur in healthy hearts but only in those already diseased. Congenital heart disease. This is rare, and easy to recognize when it exists because of the fact that, it is accom panied by very conspicuous murmurs. Thyroidal heart disease. These are not very common. When they exist their recognition should not bo difficult. T h ey will ( iI 82 Association of American Railroads tic correctly diagnosed if one recognizes the existence of hypo or liv| rthyroidism. The remaining four are the common forms ami types of heart, disease, ami these four-- hypertension, coronary arteriosclerosis, rheumatic fever, and luetic diseases-- will account for 1)5 per cent, of all the heart disease that comes before us. Therefore we should all have in mind that those first four otologies are the main causes of heart, disease. Now, each of these four great typ'`s of heart disease--'hypertensive, arteri osclerotic, rheumatic, ami luetic--presents a very distinctive picture. There are no two of them exactly alike. Kaeli one has a pretty definite course, and if we understand these four types, ami know their life histories, so to speak, and are aide to reeognize these four types of heart disease when they exi.-t, we come pretty close to knowing about nil there is to know of heart disease. W e can't consider these types of heart disease in any detail. The luetic and rheumatic forms are usually quite easy' to recognize. Both have a predilection for certain age groups. Both cause conspicuous valve lesion, the luetic pro ducing aortic insufficiency, and the rheum atic, mitral stenosis alone or asso ciated with aortic insufficiency. T h ey therefore offer no particular diagnostic problem, as a rule. And so with hypertension. The hypertensive hearts are of course accom panied by hypertension and are therefore easy to recognize. B u t the fourth form , the arteriosclerotic, is not so easy to recognize. This is a form of heart disease that is very insidious in its development. 1 am not referring to the sudden acute occlusion of a coronary artery, but I am referring to the gradually developing coronary arteriosclerotic changes that narrow the coronary arteries slowly but progressively, and thus diminish the blood supply to the muscle and cause certain small areas of the muscle io die. 1 should say that the arteriosclerotic I vpe of heart disease should be of particular interest to you; for a great, deal of coronary ancriosclrm sis may take place before definite abnormal physical signs appear. The early stages of coronary arteriosclerotic heart disease, are signaled by sj inptoms alone, ami these sym ptom s, I think, you will usually not be old of. Such symptoms as unaccustomed breathlessness, vague indigestions, undue palpitation, oppres sion in the i liest after exercise, or following excitem ent, or after eating; Inter perhaps frank anginal pain. All of these1 vitally important, symptoms may exist for a "on.-iderable time before there are any reeugni/uhle physical signs, and you, in your work as railroad physicians, will not know of the existence of those symptoms very often, T feel sure. Vet it is most essential that you should recognize the existence of arteri osclerotic heart disease; for it is precisely the type of coronary arteries asso ciated with these hearts that are so prone to develop an acute thrombosis; an event which in many railroad employes might result in an extremely tragic result. How, then, are you to recognize the existence of early coronary arteri osclerosis when you are deprived of a reliable history, and when there are, as yet, no definite physical signs? I --------- --------....... Pi'tH'di ^ i sir probi'u a in ii-. 1 physicians. T! y hk.a g o in g to rev,on ` -M` 1,1 If) HlJphc;i.t ,u of |t l a p h n : 1 tile eiVcrroonrdi ' L'rapli ' w it h in liv e y ,-ara sio .it.ui ol l.'i vein-, of r We i1Vlll't shu V. S 1lo IiriUi'ML'n N o on e 11 tr a n s la t e s u s tain ii ri risiii ei ii nio v a tatal or incapacitating ance coinp.Hnu's nri4 am\ i . X - r a y s , y o u too sh 'U jl d b< d u n e all 1h a t it LS jk Jr. ; bji >"<abit- c a r d ia c dfltwl Ml d on e all ( h a t is {H1 .bin '''U(lit/|(;'ap!ai`a JJ1 rot 1 d o h o t wi.sh to in- Hi g r a p h i c m e t h o d s will .-i,. e v id e u e e of p ,, ;, . n h a l l y h; t h e y will nut i 'h r y wiJ n u m b e r of patio n ls, .uiti applying. I f should n,,w like to d p o r ta u c e ,,|>, n i. ! h " d .a * I n c lir.-t is : . s ii:u ;a u 1f111'll ,ft , t.. . t. . ^ory d'll.ru:' ; - 1i,ClV:o[-( , 'Ai.i l! w- ! 1 i,n h ea rt. A.s -s .i :Jt } i ' 11i11a >:'fi n ]. . - i- '' 'H ..I '.t * !' t m 'utility. Ki ij '` til- m V . - i ,j i iit'Ui'f- urn i.; . !!t n :i Jv ! " j i ; v f i t t >i r 1.< n , o v ( [,kf " '' u <!.< u; i>' u> his mii.i" u vu- into partial it llapra*. hospital with whii'h 1 ufo <( clinical ?1 /1s or con-nary Ogruph. Till* pu:i,l f V. ;Wit before thi.s coronary oCcIumo H e had been to one doctor a I, including tlu* gall bladder an po or liyixT- t disease, and c fever, and se that romt"four etologir- .iirive, urtf n vtuiv T Im-M' i- euur.-c. it!,>! , so to spcsk. n Mu y e \ i-i. heart dm-i.-lie lutlie ai.d n predilection lie luel ie pr<>,lohe or a1-.Inr diagim-tic oursi acrom- ni/e. Tlii> l--, t J uni not am referring ,t. narrow tinblood supply should be of iderosts may early stages us alone, and lyinptoriis as Lion, oppres s i n g ; later upturns may lysical signs, existence of ee of arleriirterins assothronitiosis; finely tragic nary artenIbere are, as Proceedings of M edical and Surgical Section 83 Y ou r problem in this connection is very similar to that faced by insurance physicians. T h ey likewise are not told of sym ptom s very often, and 1 an. going to recommend to you the course they have followed: nam ely, a wide applieation of graphic methods of cardiac stu d y ; specifically a broad use of the elect room diograpib and the X -r a y . 1 think ] am safe in predicting fiat within five years no insurance company will risk as much as 125,000 on a person of T> year.- of up- or over, Without first assuring themselves that that person's bean shows in, electrographic or X -ray evidence of cardiac abnormality. No one can translate into dollars and rcnis the loss that a railroad might su.-tain if certain employes might devilop at some critical moment, let m say, a fatal or incapacitating coronary occlusion. But ] feel sum that if the insur ance companies am unwilling to risk '>,0(10 without electrocardiographs and X -rays, you too should tit- unwilling to take the risk involved without having done all that it is possible for you to do to look for and to recognize any fore seeable cardiac defect in any of your vital employes, and you will not have done all that is possible until you have studied all persons over -Id, eh-ctro- eardiograpbirally anil rnciilgenolugirally. 1 do not wish to be misunderstood. 1 am not meaning to say that these graphic methods will show the existence of early cardiac trouble or reveal evidence of potentially had coronary arteries in all instances. Em phatically they will not. They will, however, reveal these defects in a considerable number of patients, and these, it seems to me, make the met bods worth applying. ' 1 should now like to discuss certain signs and symptoms that have im- jxirtance often in the diagnosis of heart disease. The first is asthm a. Ordinary allergic asthm a, I presume Ls not of great importance to you. But many persons will frequently interpret certain respir atory difficulties as asthm a, which in reality are paroxysms of cardiac dyspnea. Therefore, when we obtain a history of asthm a, we should always consider the heart. As u rule it. is not difficult to different ate between cardiac dyspnea and true asthm a. 1 can only mention two points that m ay help. One is the duration. Cardiac dyspnea resembling asthma does not last for years. Allergic asthm a often does. The second point is the familial incidence. True allergy is neary always present in some form or other in more than one member of a fam ily. O f course cardiac dyspnea rarely is. The second sym ptom 1 want to take up is indigestion. Vague, indefinite indigestion is often an early sym ptom of arteriosclerotic heart disease, ft may be present before there are any recognizable physical signs of heart disease. 1 would like to give you one exam ple. Not- long ago a busy executive on his way to his office was seized with this sudden agonizing chest pain and went into partial collapse. Some friends got him into a taxi and rushed him to a hospital with which 1 am connected. When I saw him he presented all the clinical signs of coronary occlusion, which was proven by the electrocardi ograph. The point 1 want to emphasize in this case is this: For five years before this coronary occlusion, this man had had vague, atypical indigestion, lie had been to one doctor after another for this. H is gastro intestinal tract including the gall bladder and the colon were carefully studied clinically and 84 Association of Am erican h'aih'oatls by \'-r:iy and always with negative result.-;. Vot ho persisted in having indi gestion until it finally culm inated in -tn arete episode. A t the end it was |<lam enough that his indigestion was sim ply a manifestation <d the coronary artery disease, yet, during five years there were no clinical signs evident of heart disease. So i say vague, atypical indigestion should be looked upon v, il.h suspicion. 1 want to say a word about, systolic murmurs. We all know that many entirely undisrased hearts present murmurs. On the contrary, murmurs may be a definite evidence of disease. How shall we determine when a murmur means disease and when it. doesn't? It seems hardly fair to debar a man from earning his livelihood simply because there happens to be a murmur if his heart is perfectly sound. I bdieve th at we will not go far astray if we adopt in industrial medicine the attitude of modern cardiology: nam ely, a systolic murmur can he overlooked if there are nu sym ptoms, no known etiology and if the heart is entirely normal by X -rav and by electrocardiographic study. In my own experience I do not believe. 1 go astray very often in following this rule. Mow, we must not have an_v rule that is too rigid. There are some instances where a systolic murmur is loud or rough or has some peculiar quality that, our clinical judgm ent tells us we should not ignore even if in every other way the heart appears normal. We do not. ignore systolic murmurs, for instance, if they are accompanied by definite thrills. Hut the point 1 want to make--1 can 't go into this in any detail --is that many systolic murmurs arc perfectly harmless, meaningless phenomena and can be entirely safely passed over. Next I would like to say a word about arrhythm ias. 1 imagine this is a problem you i: iV`tn consider. These are diifieult to interpret and kilos' the me '.ue-g of Peril Use in many ills' an res they occur in col ma! unde-rased la arts. How shall you interpret extra systoles? 1 believe that we c;,n follow the pr:u lire oi tin- insurance physician again mid irgaril extra -ysiolcs as n! no gieal 1111 poi fa nee if all other !f atures of the heart examinai ion are negative, and if the i \tra. -)s!o|.-s are oeeasional ami not too frequent. If they are too ''rcqucni I do not 'innk that Voii wdl be justified m. ignoring them, for this re,-is a i: M any forms of paroxysmal tachycardia are simplv a m-ies m extra -.y-;o!es, and when these isolated extra sy-loles occur frri|i|c|if ly it is not m e coianii n for them to lead to paroxysmal !achy'."iplia. Now, there arc some forms of paroxysms.! tachycardia that occur frequently m entirely normal hearts. Tins is notable the case with the auricular tach y cardia, the commonest type. I have a patient who Is 7b, and she tells me she iuis had paroxysmal tachycardia ever since she was a girl. I think you should bear this point, in mind: Although these paroxysms of tachycardia do not necessarily indicate that there is any organic disease, they may greatly disturb the circulation, and not infrequently cause severe attacks of giddiness and even fainting. This is particularly the case when paroxysmal tachycardia develops in older individuals. I will not have time to discuss the various types of paroxysmal tachycardia, hut I am going to show you one slide of one type that I think m ight be of some interest. (Slide) This is auricular flutter in which the ventricles do not re- having indiit was plain rnary artery ent of heart h suspicion, that many murmurs may a murmur a man from mrmur if his medicine the overlooked tirely normal ;nce I do not ime instances ility that our ther way the instance, if to m a k e are perfectly ssed over, gine this is a and know the seased hearts, m follow the toles as of no are negative, they are too hem, for this ries of extra it is not un- ur frequently icular tachy- tells me she k you should ardia do not eatly disturb less and even dia develops tachycardia, it be of some s do not re- M1 Proceedings of Medical and Surgical Section 85 spond as they usually do to every second auricular beat, but to every beat. This disturbance gives us the most rapid hearts that we know of. In this case the ventricular rate is 260 per minute. When the ventricle is beating 360 a minute the diastole is so short that the ventricles do not have time to fill Droperly and the circulation as a result may be considerably disturbed. In this particular case we could discover nothing abnormal in the heart or circulation between these attacks. But when the paroxysms set in the patient quickly lost consciousness. This would not be a good thing to have happen to an engineer. Therefore, in my opinion, you should look upon paroxysmal tachycardia as a contraindicating employment in many of the vital jobs in the railroad in dustry, certainly when it occurs in individuals who are 45 or 50 years of age. Now, cardiac enlargement. We all know the importance of cardiac enlarge ment. Every heart that is at all enlarged is abnormal. B y clinical percussion and palpation are the only methods available for detecting an increase in the total diameter of the heart. I wish to emphasize that there are many hearts that arc enlarged in which the. total diameter is not increased. Those cannot be detected by physical examination. They have to be discovered by X-ray and only by X -ray, for this method gives us not only a measurement of the heart in centimeters but it reveals certain characteristic shapes, or enlargement of certain chambers that you can't demonstrate by percussion. 1 always like to quote a statement I heard Sir Thomas Lewis, the great London cardiologist make: " If 1 could retain only one method of examining the heart and had to choose between palpation, percussion, auscultation, electrocardiography and roentgenoscopy, I would without hesitation choose the X -ra y ." Fortunately we do not have to limit ourselves to the use of one method in examining the heart. We can use all methods. N o examination can be calied really complete unless we have included in that examination the X -ray. The more I use it, the more I am convinced that of all the methods of studying the heart it is perhaps the most valuable. Now , hypertension. Unquestionably hypertension seriously damages the heart. It is the heart that fails and causes death in at least fifty per cent of all cases of hypertension. Christian has stated that hypertension is the chief cause of heart disease. I think most of us will agree with that statement. Therefore to you in your particular work hypertension is to be looked upon as a contraindication in most of your employes. The difficulty lies in saying what blood pressure reading constitutes hyper tension. M ost insurance companies say anything over 140-90 is abnormal. Should this particular reading, 140-90, be looked upon as dangerous? 1 hardly think so, provided that the heart is normal in all other particulars. What about a systolic pressure of 160? Shall we look upon that as the danger mark? The answer to that I suppose would be qualified. I f the physical examination is entirely negative, if the electrocardiograph and the orthodiagram are negative, and if there are no symptoms, perhaps an individual with a blood pressure of 160 might safely do his work. The. catch lies in the latter provision. I doubt if you will often discover symptoms in such patients even when they exist. i. *,# :'l S6 Association of American Ituilroads Non', I have chosen the Mood pressure rending of 1(10 li, discuss In a iL -c it happens to he tlie m u lin g in two railroad engineers that have eonie to my attention, Let me briefly review their eases. The first, u man in his early sixties, was referred to a physician in I'hiladolphin who specializes in allergy, lieeause of what was thought to he asthm a. T h is allergist, finding his blood pressure to be 100 and finding his heart by elinieal examination to he oil the borderline of enlargement he inspected that his attacks of dyspnea might he card inn and referred him to me for cardiac study. This engineer gave me the history of severe attacks of angina pectoris. lie laid not, however, revealed tin'; existence of these attacks to the railroad physirian who last examined him. I found his heart, by X -ray to be definitely onlarged. The T waves in Lead I of the electrocardiograph were deeply inverted. The picture was clearly one of grave heart disease, and yet that man was running a passenger engine. I debated seriously whether ) diould inferm the railroad of my findings, and linally decided to hand the responsibility fo the physician who referred him to me. I was very relieved to learn later that with the patient's consent the railroad was informed of the m an's condition and lie was retired. To me that was a very impressive example of how' you are handicapped by lack of sym ptom s. This man didn't want, lo give up Ids job. lie told none of you th at he was having severe seizures of angina. The information regarding the second engineer which came lo my attention has come to nut most indirectly. Hut as [ had the story the patient, who was in his fifties, had just completed a run and was preparing to take ins engine out of the terminal when he suddenly developed a coronary occlusion and sub-eipiently threw off ml embolus t,. the brain. There is -sune uncertainly in my indirect, infmami'ion as to whether In- had the coronary occlusion first, but that, is unim portant. Th e point 1 wish lo emphasize is that this man gave a history to ins private doctor of having a blood pressure of 11i0 (which of course was pmbniilv known by the railroad physician) and he also gave a history of having had lor some time previously severe attacks ,,f angina pect'-n's. These the railroad physician ad no informal ion i*onei ,-nmg. Therefore 1 -h aild -iiv to you that even a mild hypertension - hotli of these men had a blood pro: -urn of only Ifili - -often is accompanied by -o-, ere -.cmploins of which you often will not be aware, and it - 11<)u1,1 horofure always be looked upon with suspicion. If you were sure I here Wi-re no symptoms perhaps you could disregard mild hypertension, but f don't believe you can tie sure. Now, the last thing I want to discuss is age. There is some age beyond which the heart on the mere ground of age alone must he regarded as incapable of hazardous work. W luit that age is I am not prepared fo say. However, as we have watched the development of coronary occlusion in recent years we are convinced that the average age of its development is becoming steadily lower. A few years ago the average age. was put at 57, then at 55; now, more recently, at something like 52. W ith this in mind 1 am sure that there are not many individuals over 70 who have not at least potential coronary trouble. D o n 't m u m 'CO j i s , : i." a , 1 ! erne, cm J , , m 'el, !; i r . I i , 1 j in T' ohg, 1 I ho ' e U' l II cm .! > mil | s l i d m i n e , i>t t, j M g ! ) ' i . o i T l e. j s i l U s - I SI ' iIS, 1 exsm u'.i 1 cm h j sil of t hose sV; j ) I - o'. - u , T } j J! T i n . < 'Ji ,| s:.d 11 i s m i s W. '.' ,C,W i :;.g in,n. i'e . : j ; j ! j ! I ! , > I j j ii i il fillio- (! lijV !x ili:-, (i: .il ' liV li I citi II!.'-. 1 : I- ! 1 u' iJt!: *V l ' runxdiUQH o f l U t d i c o l and >S u iy tc a i S t . c u o / i IS7 ihbitmdersUuid me. There are some. But in scl'-cting thc.sc I feci limi \ou must o ercise greut atre. S o f a ? a>, 1 c i u j u d t f c l ? y t h fnei.s c a r e , a n d ] C o n g r a t u l a t e y o u ; l'o r a e a ilu h Je 1 tlnnk io m e v m j b ave flit m i i u I k t o f seriole' * p v a t carde:- a i T . i d u u s t o r a i l r o a d e m p l o v e s m u s i i>e v e r y Io\v. Iri dosine, I would like to say t hai il scems to me tliat ny or all of \he inctor.- \v< Lave hi-cii discussine*, namelv imim nirs, ari hythm ias, hypertem ioe ecco v, hen )t e miiii. su.-pcrfod (tardine erdariicmenl, a tip ica ! indurosti-m, n-Phm.i, fi !. 1 I *r:v-, . Ol })<TV t ili i W( h . ' i S C ! ! d lsC U s> '(! a I! V O f fili ( >: tlies} H i p 0*J i ; ; h !'1d eaiM y-iii io i>c pari rcularly cari lui and mahyou wahi le s--.-u: * a): fi.- c ; .o h 'c po-.>;M- Tiic\ cali i---' n<P t., |s ejoviu! ph\- .-.e teU fm \u:;.\ ami ch-el i oeiu-di ij^; arci Mii'P-:- :e- vi l i :.\ ai' o: the.-c -volp i-un- ,n',ii' :m ; o o. n }/a!dei 1 pa r; .cu.a -r., ; .<! ! i r a n c i e. ui i ; -a 1 1 i- - v , k uU o d - a - n u i ' ! p H? e p e r - u: : s u - m : U ' v. 11!1' li t 1m M i ; j 5h e - p i a | .! ; e s! u- i .e . * d- u h i l < a \ e., <.e |u e , . ; : hcr (Applau- . ; T i i ) . i hi.- h m .s N . i n . M c M i l i a n , y o \ ir n d d re.v- L a - Bei. n ? a ll']ie.-l CiCt i V. i;!;:! \U t 1 !U11h >'<*tj t!)F 1iC 1H *t, 11! \ ; I I'1V! ^ i, m * r - - y Y- w..\ ' ' a -a r tic re pori <>: i l e ( 'un n.L ` - - e i >. \<-ii . a ` - li--- :` nv; from }'?!} .irai lixanhmd imi, ny 1ir. !dc. I d . A . W . Ide read the prirUed rcpoi'i o: i C'<o " :; : e , o n 'a " . p- m e n ts iv ^iih iiy fr o m P hy.sical i'ixiu i'.ieaio h . ;'HV j h