Document BRnkwy6D0jj5q5OOkEKMbBk1o

FILE NAME: Railroads (RR) DATE: 1958 Mar DOC#: RR012 DOCUMENT DESCRIPTION: Proceedings of the 38th Annual Meeting of the Medical and Surgical Section - American Railway Association / -- U og A , i - i *t ' < ^ 4 *4* fe s - i* tj> i i PROCEEDINGS O F THE THIRTY-EIGHTH A N N U A L MEETING OF THE Association of American Railroads M EDICAL AND SURGICAL SECTION ! HELD AT THE EDGEWATER GULF HOTEL EDGEWATER PARK, MISSISSIPPI i MARCH 24-26, 1958 I INDEX Association of American Railroads: Board of Directors........................................................... ................. Officers...... .............................................................................................. Operations and Maintenance D epartment.......... ....... ...................... Operating-Transportation Division Officers.......... ............................ Burch, Dr. G. E., Address by:.......... .......................................................... Carney, K. A., Address by:_........................................................................ Chairman I. Goldowsky, Address by:... _ .... ............................................. Committee of Direction.............. Committee on Developments Resulting from Physical Examinations.-.. Report of...... ............................................................. Committee on Disability and Rehabilitation.............. Report of................................................................................................. Committee on First Aid-.............................................................................. Report of....... ......................................................................................... Committee on Medical Aspects of Air Conditioning of Cars... ............. Committee on Nominations, Report of...................................................... Committee on Trauma-................................................................................ Report of................................................................................................. Crawford, Dr. Stanley, Address by:...... ..................................................... Eve, Dr. Duncan: presenting Report of Committee on Nominations.... Hollo, Dr. V. W., Address by:.................................................................... Koch, Mr. Eugene E., Remarks by:......... Page 5 5 6 6 56-60 47-51 16-19 6 7 26-37 6-7 42-45 7-8 24-26 7 39-40 7 21-24 67-76 39-40 20-21 80 Medical and Surgical Section: Officers of Section and Personnel of Committees 1957-1958-____ Officers of Section and Personnel of Committees 1958-1959__ Election of Members to Committee of Direction............................. Election of Chairman and Vice-Chairman......................................... Representatives attending Annual Meeting.--............ .................... Rules of Order.............. 6-8 92-94 40 52 13-15 9-12 Medical Film Committee-............................................................... Ochsner, Dr. Alton, Address by:................................................................. Quattlebaum, Dr. Julian K., Address by.................................................. Report of Secretary....................................................................................... Representatives of Medical and Surgical Section on Joint Committee on Railway Sanitation.......... ................................................................ Report o f _ _ .......................................................................................... 8 80-86 53-56 19-20 8 90-91 Sessions of Annual Meeting: Monday Morning, March 24............................................................... Tuesday Morning, March 25-- .......................................................... Wednesday Morning, March 26............... Special Medical-Legal Research Committee--.......................................... Report of...... .............................................................................- .......... 16 39 61 8 62-65 iii ASSOCIATION OF AMERICAN (March, 1988) RAILROADS Officers Daniel P. Loomis, President. Gregory S. Prince, Vice-President and General Counsel. Walter J. Little, Vice-President. William M. Moloney, General Solicitor. R. G. May, Vice-President (Operations and Maintenance Department). A. R. Seder, Vice President (Finance, Accounting, Taxation and Valuation Department). W. M. Keller, Vice President (Research). P. A. Hollar, Vice-President--Assistant to President. J. Elmer Monroe, Vice-President and Director (Bureau of Railway Economics). Robert S. Henry, Vice-President (Public Relations Department). S. J. Strong, Secretary-Treasurer. R. E. Keefer, Assistant Secretary-Treasurer. Board of Directors W. T. Faricy, Chairman (ex-officio), Transportation Building, Washington 6, D. C. R. L. Dearmont, President, Missouri Pacific Lines, St. Louis, Missouri. Harry A. DeButts, President, Southern Railway System, Washington, D. C. F. G. Gurley, Chairman of the Board and Chief Executive Officer, Atchison, Topeka & Santa Fe Railway, Chicago, Illinois. Ben W. Heineman, Chairman, Chicago and North Western Railway, Chicago 6, Illinois. Clark Hungerford, President, St. Louis-San Francisco Railway, St. Louis, Missouri. D. B. Jenks, President, Chicago, Rock Island and Pacific Railroad, Chicago, Illinois. W. A. Johnston, President, Illinois Central Railroad, Chicago, Illinois. P. B. McGinnis, President, Boston and Maine Railroad, Boston 14, Massa chusetts. H. C. Murphy, President and Chairman, Executive Committee, Chicago, Burlington & Quincy Railroad, Chicago 6, Illinois. A. E. Perlman, President, New York Central System, New York, New York. W. Thomas Rice, President, Atlantic Coast Line Railroad, Wilmington, North Carolina. D. J. Russell, President, Southern Pacific Company, San Francisco, California. H. E. Simpson, President, Baltimore & Ohio Railroad, Baltimore, Maryland. John W. Smith, President, Seaboard Air Line Railroad, Norfolk, Virginia. A. E. Stoddard, President, Union Pacific Railroad, Omaha, Nebraska. J. M. Symes, President, Pennsylvania Railroad, Philadelphia, Pennsylvania. John E. Tilford, President, Louisville & Nashville Railroad, Louisville, Kentucky. W. J. Tuohy, President, Chesapeake and Ohio Railway, Cleveland 1, Ohio. H. W. Von Wilier, President, Erie Railroad, Cleveland 15, Ohio. L. L. White, Chairman of the Board, New York, Chicago & St. Louis Rail road, Cleveland 1, Ohio. 5 ' 7-- - .- ir/ii: y..>jC G .G G i-pi'* 6 Association of American Railroads OPERATIONS AND MAINTENANCE DEPARTMENT R. G. May, Vice-President OPERATING-TRANSPORTATION DIVISION W. C, Baker, Chairman E. M. Tolleson, Vice-Chairman A. I. Ciliske, Executive Vice-Chairman OFFICERS AND PERSONNEL OF COMMITTEES OF THE MEDICAL AND SURGICAL SECTION FOR THE YEAR 1957-1968 Dr. I. Goldowsky, Chairman Dr. M. B. Clayton, Vice-Chairman F. J. Parker, Secretary Committee of Direction Dr. I. Goldowsky, Chairman Dr. M. B. Clayton, Vice-Chairman (Term expires in 1958) Dr. It. M. Graham, Director, Department of Medicine and Sanitation, The Pullman Company, 165 North Canal St., Chicago 6, Illinois. Dr. C. F. Holton, Chief Surgeon, Central of Georgia Railway, Savannah, m Georgia. Dr. J. K. Stack, Chief Surgeon, Chicago & North Western Railway, 127 North Clinton Street, Chicago 6, Illinois. Dr. G. F. Cushman, Chief Surgeon, Western Pacific Railroad, 526 Mission Street, San Francisco, California. (Term expires in 1959) Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15th and K Streets, N. W., Washington, D. C. Dr. K. E. Dowd, Chief Medical Officer, Canadian National Railways, Montreal, Que., Canada. Dr. V. W. Hollo, Chief Surgeon, St. Louis-San Francisco Railway, St. Louis, Missouri. Dr. J. Huber Wagner', Chief Surgeon, Bessemer & Lake Erie Railroad, 525 William Penn Place, Pittsburgh, Pennsylvania. (Term expires in 1960) Dr. R. J. Bennett, Chief Surgeon, Elgin, Joliet and Eastern Railway, 208 South LaSalle St., Chicago, Illinois. Dr. I. Goldowsky, Medical Director, Central Railroad Company of New Jersey, Jersey City, New Jersey. Dr. W. E. Mishler, Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Dr. B. W. Stockwell, Chief Surgeon, Detroit and Toledo Shore Line Railroad, 3919 John R. Street, Detroit 1, Michigan. Committee on Disability and Rehabilitation Dr. James K. Stack (Chairman), Chief Surgeon, Chicago & North Western Railway, 127 North Clinton Street, Chicago 6, Illinois. Dr. J. F. DePree, Chief Surgeon (Lines West), Chicago, Milwaukee, St. Paul & Pacific Railroad, 1656 Medical and D ental Bldg., Seattle 1, Washington. r D r. S. M. English, B. & 0 . Cent! D r. J. W. Houk, 5 Terminal Tow Dr. R. S. Kieffer, C Missouri. Dr. Harvey Nelso Building, Min D r. G. Earle Wig: Windsor Stat-t Dr. B. W. Stockwe Railroad, 700 Dr. R. G. Carothei Railway, Cine Dr. Duncan Eve, ( 2001 Hayes St Dr. J. R. Gandy, ( Texas. Dr. C. F. Holton, Georgia. Dr. Southgate Lei; Box 1620, Riel Dr. W. E. Mishle Cleveland 15, Committee on D r. W. J. Longewi way, 520 Met! Dr. J. J. Brandabv Huntington, V D r. B. I. Derauf, Minnesota. Dr. J. R. Knowli Massachusetts Dr. J. M. L. Jensei Chicago, Mino Dr. R. S. Westline West 63rd Strc (One Vacancy) Committe< Dr. R. M. Graham tion, The Pulir Dr. M. B. Clayton Streets, N.W., Dr. K. E. Dowd, Montreal, Quo. Dr. E. C. Olson (C Stony Island A Is iPARTMENT )IVISION man ITTEES OF THE HE YEAR 1957-1968 n in icine and Sanitation, The igo 6, Illinois. orgia Railway, Savannah, estern Railway, 127 North ,ific Railroad, 526 Mission ilway System, 15th and K adian National Railways, ancisco Railway, St. Louis, & Lake Erie Railroad, 525 a. ) and Eastern Railway, 208 Railroad Company of New rad, 608 Republic Building, Toledo Shore Line Railroad, ehabilitation i, Chicago & North Western >6, Illinois. idcago, Milwaukee, St. Paul & Bldg., Seattle 1, Washington. Proceedings of Medical and Surgical Section 7 Dr. S. M. English, Medical and Surgical Director, Baltimore & Ohio Railroad, B. & 0 . Central Building, Room 217, Baltimore 1, Maryland. Dr. J. W. Houk, Medical Director, New York, Chicago & St. Louis Railroad, Terminal Tower, Cleveland 1, Ohio. Dr. R. S. Kieffer, Chief Surgeon, Missouri-Kansas-Texas Railroad, St. Louis 1, Missouri. Dr. Harvey Nelson, Chief Surgeon, Soo Line Railroad, 1453 Medical Arts Building, Minneapolis 2, Minnesota. Dr. G. Earle Wight, Chief of Medical Services, Canadian Pacific Railway, Windsor Station, Montreal, Que., Canada. Committee on Trauma Dr. B. W. Stockwell (Chairman), Chief Surgeon, D etroit & Toledo Shore Line Railroad, 700 Doctors Building, 3919 John R, Street, Detroit, Michigan. Dr. R. G. Carothers, Chief Surgeon, Cincinnati, New Orleans & Texas Pacific Railway, Cincinnati 2, Ohio. Dr. Duncan Eve, Chief Surgeon, Nashville, Chattanooga & St. Louis Railway, 2001 Hayes Street, NashviHe 4, Tennessee. Dr. J. R. Gandy, Chief Surgeon, Texas & New Orleans Railroad, Houston 1, Texas. Dr. C. F. Holton, Chief Surgeon, Central of Georgia Railway, Savannah, Georgia. Dr. Southgate Leigh, Jr., Chief Surgeon, Seaboard Air Line Railroad, P. O. Box 1620, Richmond 13, Virginia. Dr. W. E. Mishler, Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Committee on Developments Resulting from Physical Examinations Dr. W. J. Longeway (Chairman), Chief Surgeon, Colorado & Southern Rail way, 520 Metropolitan Building, Denver, Colorado. Dr. J. J. Brandabur, Chief Medical Examiner, Chesapeake & Ohio Railway, Huntington, West Virginia. Dr. B. I. Derauf, Chief Surgeon, Northern Pacific Railway, St. Paul 1, Minnesota. Dr. J. R. Knowles, Chief Surgeon, Boston & Maine Railroad, Boston, Massachusetts. Dr. J. M. L. Jensen, Chief Surgeon, Chicago, Rock Island & Pacific Railroad, Chicago, Illinois. Dr. R. 8. Westline, Chief Surgeon, Chicago & Eastern Illinois Railroad, 334 West 63rd Street, Chicago, Illinois. (One Vacancy) Committee on Medical Aspects of Air Conditioning of Cars Dr. R. M. Graham (Chairman), Director, Department of Medicine and Sanita tion, The Pullman Company, 165 North Canal Street, Chicago 6, Illinois. Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15th and K. Streets, N.W., Washington 13, D. C. Dr. K. E. Dowd, Chief Medical Officer, Canadian National Railways, Montreal, Que., Canada. Committee on First Aid Dr. E. C. Olson (Chairman), Chief Surgeon, Illinois Central Railroad, 5800 Stony Island Avenue, Chicago, Illinois. ' "i 8 Association of American Railroads Dr. V. W. Hollo, Chief Surgeon, St. Louis-San Francisco Railway, St. Louis, Missouri. Medical Film Committee Dr. R. S. Kieffer (Chairman), Chief Surgeon, Missouri-Kansas-Texas Rail road, St. Louis 1, Missouri. Dr. G. W. Benjamin, Chief Medical Officer, Western Maryland Railway, Hillen Station, Baltimore 2, Maryland. Dr. G. F. Cushman, Chief Surgeon, Western Pacific Railroad, 526 Mission Street, San Francisco, California. Dr. A. Nygood, Chief Medical Examiner, Chicago & N orth Western Railway, 127 North Clinton Street, Chicago 6, Illinois. Dr. J. R. Winston, System Medical Director, Atchison, Topeka & Santa Fe Railway, 80 E. Jackson Boulevard, Chicago, Illinois. Advisory Members from Committee of Direction Dr. R. J. Bennett, Chief Surgeon, Elgin, Joliet and Eastern Railway, 208 South LaSalle Street, Chicago, Illinois. Dr. R. M. Graham, Director, Department of Medicine and Sanitation, The Pullman Company, 165 North Canal Street, Chicago, Illinois. Dr. V. W. Hollo, Chief Surgeon, St. Louis-San Francisco Railway, St. Louis, Missouri. Representatives of the Medical and Surgical Section on the Joint Committee on Railway Sanitation D i. R. M. Graham (Chairman, Joint Committee on Railway Sanitation), Director, Department of Medicine and Sanitation, The Pullman Com pany, 165 North Canal Street, Chicago, Illinois. Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15tli and K. Streets, N.W., Washington 13, D. C. Dr. A. M. W. Hursh, Assistant Medical Director, Pennsylvania Railroad, 15 North 32nd Street, Philadelphia 4, Pennsylvania. 3 Representatives of the Medical and Surgical Section on the Special Medical-Legal Research Committee Dr. W. E. Mishkr (Chairman), Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Dr. R. J. Bennett, Chief Surgeon, Elgin, Joliet and Eastern Railway, 208 South LaSalle Street, Chicago, Illinois. Dr. I. Goldowsky, Medical Director, Central Railroad of New Jersey, Jersey City, New Jersey. Dr. Harvey Nelson, Chief Surgeon, Soo Line Railroad, 1453 Medical Arts Building, Minneapolis 2, Minnesota. ;o Railway, St. Louis, ri-Kansas-Texas Rail1 Maryland Railway, Railroad, 526 Mission >rth Western Railway, , Topeka & Santa Fe s. irection rn Railway, 208 South : and Sanitation, The ;o, Illinois. a Railway, St. Louis, il Section itation Railway Sanitation), , The Pullman CornSystem, 15th and K. mnsylvania Railroad, il Section mmittee ailroad, 608 Republie iastern Railway, 208 if New Jersey, Jersey l, 1453 Medical Arts Proceedings o f Medical and Surgical Section 9 ASSOCIATION OF AMERICAN RAILROADS OPERATING-- TRANSPORTATION DIVISION MEDICAL AND SURGICAL SECTION RULES OF ORDER 1. REPRESENTATION: As provided in the Plan of Organization, the representation of Member Roads in the Medical and Surgical Section shall be Chief Surgeons or other persons engaged in a similar capacity. The Railway Express Agency, Inc., and the Pullman Company are eligible for membership in this Section. 2. AFFILIATED MEMBERS: A representative of an organization col laborating or cooperating with the Section may become an Affiliated Member thereof upon the approval of his application by the Committee of Direction. An Affiliated Member shall have the rights and privileges accorded a Member Road representative, except voting or the holding of office. Officers and Committees 3. The officers of the Section shall consist of a Chairman, Vice-Chairman and Secretary. (a) As provided in the Plan of Organization, the CHAIRMAN and VICE-CHAIRMAN shall be selected by the Committee of Direction from its membership. Their terms of office shall be one year. A Chairman will not succeed himself. (b) The SECRETARY will be appointed by the General Committee of the Division. His salary shall be named by that Committee, subject to the approval of the Vice-President, Operations and Maintenance Department. (c) The COMMITTEE OF DIRECTION will consist of twelve members, territorially representative as far as practicable--one each from New England and Canada; four from the East; two from the South and four from the West--elected as hereinafter prescribed, each of whom shall serve for three years. The terms of office of all elective members of the Committee of Direction shall expire at the conclusion of the Annual Meeting. Vacancies in the committee membership shall be filled by appointment of the Committee until the next election. In addition to the above, the Surgeon-General of the United States Bureau of Public Health Service or a representative to be designated by him, and a representative to be designated by the Conference of State and Provincial Health Authorities of North America shall be honorary members of the Committee of Direction. 10 Association of American Railroads The Committee of Direction will select from its elective membership a Chairman and Vice-Chairman of the Section, whose terms of office shall be one year. A Chairman will not succeed himself. (d) The Standing Committees of the Section will be as follows: Committee on Disability and Rehabilitation Committee on Trauma Committee on Developments Resulting from Physical Examina tions Committee on Medical Aspects of Air Conditioning of Cars Committee on First Aid Medical Film Committee The representation of Member Roads on these committees will be, so far as is practicable, territorially selected, in approximately the same propor tions as th at of the Committee of Direction, personnel to be named each year by the Committee of Direction immediately following adjournment of the Annual Meeting. Duties of Officers 4. The CHAIRMAN shall have general supervision over the affairs of the Section and shall preside a t meetings of the Section and at meetings of the Committee of Direction. 5. The VICE-CHAIRMAN, in the absence of the Chairman, shall perform the duties of the Chairman and such other duties as may be assigned. 6. (a) The SECRETARY shall perform the usual duties of th at office and such other duties as may be assigned to him by the Chairman. (b) He shall receive six weeks in advance of the Annual 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 report, to fill the vacancies in the membership of the Committee of Direction. He shall announce the result of the election promptly to the members. Duties of Committees 7. The COMMITTEE OF DIRECTION shall: (a) Exercise general supervision over the interests and affairs of the Section. (b) Be empowered to act on behalf of the Section in the interim between meetings and shall submit a t each meeting a report covering its actions. (c) Examine and decide what portion of communications, papers and reports shall be submitted at the meetings. It shall determine which, if any, of the subjects presented by the various committees, shall be referred to the General Committee of the Division. (d) Appoint two months in advance of the Annual Meeting each year a Committee on Nominations, consisting of representatives of five Member Roads, who shall not be members of the Committee of Direction. (e) Appoint additional committees as required. (f) Submit to the Chairman, General Committee, detail of contemplated financial requirements for conducting the work of the Section as required or as called for by that official. (g) Call General (h) Call to each request, in 8. The COI shall report to ing of each y place the fc>u th at year, an< The duties 9. COMMIT REHABILITA1 tions, on such ciency of railro rehabilitation tion of function 10. COMME and report on (a) Diagnosis report forms, 11. COMM RESULTING report, with periodic examir rant, the reeoir the forms used 12. COMMIT OF AIR CONi in its relation departments h. 13. COMMIT study and report tions for railroad matters involvinj 14. COMMIT concerned with medical films for 15. VOTING viva voce, by ns entitled to one sented shall be otherwise order mittee of Direct the ranking offi a t any meeting. Proceedings o f MeUtcal arid Surgical Section 11 (g) Call Annual Meetings of the Section, subject to the approval of the General Committee of the Division, if in its judgment conditions warrant. (h) Call meetings of the Section, upon not less than tliirty days' notice to each member. I t must call special meetings of the Section upon the request, in writing, of a majority of the Member Roads. 8. The COMMITTEE ON NOMINATIONS, appointed as above prescribed, shall report to the Secretary at least six weeks in advance of the Annual Meet ing of each year, at least two nominations for each impending vacancy to re place the four members of the Committee of Direction whose terms expire th a t year, and to fill any vacancy. The duties of the Standing Committees shall be as follows: 9. COM M ITTEE NO. 1--The COMMITTEE ON DISABILITY AND REHABILITATION shall study and report, with suggestions or recommenda tions, on such subjects th a t have to do with the physical efficiency or ineffi ciency of railroad employes. I t shall also consider ways and means for the rehabilitation of injured or incapacitated employes and the complete restora tion of function. 10. COM M ITTEE NO. 2--The COMMITTEE ON TRAUMA shall study and report on the treatm ent and transportation of fracture cases including (a) Diagnosis of fractures, (b) First aid and transportation splints, (c) Fracture report forms, (d) X -ray work in connection with fractures, and similar subjects. 11. COM M ITTEE NO. 3--The COMMITTEE ON DEVELOPMENTS RESULTING FROM PHYSICAL EXAMINATIONS shall analyze and make report, with recommendations or suggestions, on data made available by periodic examinations, etc. I t shall study and revise as conditions may war rant, the recommended standards covering physical examinations as well as the forms used in connection therewith. 12. CO M M ITTEE NO. 4--The COMMITTEE ON MEDICAL ASPECTS OF AIR CONDITIONING OF CARS shall study and report on this subject in its relation to the health and comfort of travelers, cooperating with other departments handling matters relating to air conditioning of equipment. 13. CO M M ITTEE NO. S--The COMMITTEE ON FIRST AID shall study and report, with suggestions or recommendations, on first aid instruc tions for railroad employes, a standard first aid packet, etc., and such other matters involving first aid as relate to railroad operation. 14. COM M ITTEE NO. 6--The MEDICAL FILM COMMITTEE shall be concerned with such study as required of matters relating to availability of medical films for railroad use. 15. VOTING AT MEETINGS OF SECTION: (a) Vote may be taken viva voce, by rising, by roll call or by ballot. Each Member Road shall be entitled to one vote. The vote of the majority of the Member Roads repre sented shall be required to decide any question, motion or resolution, unless otherwise ordered, (b) Voting for candidates for membership on the Com mittee of Direction shall be by ballot, (c) Unless otherwise designated by it, the ranking officer will be recognized as the Voting Representative of a road a t any meeting. 12 Association of American Railroaiis 16. LETTER BALLOTS may be taken upon any subject by order of the Committee of Direction and must be taken on all questions affecting physical property. The voting power of the Member Roads shall be proportionate to the ownership of miles of road. 17. ORDER OF BUSINESS: The order of business a t meetings of the Section shall, unless otherwise directed by a majority of the members present, be as follows: Approval of minutes of last meeting Reports of Standing Committees Reports of Special Committee Report of Tellers Unfinished Business New Business 18. Robert's Rules of Order shall govern the proceedings of this Section, including amendment to these Rules of Order. Asso c ia - The following v Me Atchison, Topeka way......... .......... Atlanta & St. And Alton & Southern Bamberger Railroa Bangor & Aroostoe Bessemer & Lake 1 Birmingham South Boston & Maine R, Buffalo Creek Raih Canadian National Canadian Pacific R: Central of Georgia ! Central Railroad of Chesapeake & Ohio Chicago, Burlingtor road............... ........ Chicago, Milwaukee, Railroad................. Chicago & North W< Chicago, Rock Islam road........................ Chicago, South Shor Railroad.________ Cotton Belt Railway. order of the affecting physical proportionate to meetings of the members present, of this Section, Proceedings o/ Medical and Surgical Section 13 ASSOCIATION OF AMERICAN RAILROADS MEDICAL AND SURGICAL SECTION Edgewater Gulf Hotel Edgewater Park, Mississippi March 24-26,1958 The following were present: Members Representatives Atchison, Topeka & Santa Fe Rail way......... ...............................................Dr. J. R. Winston, Medical Director, System. Dr. G. Wendell Olson, Local Surgeon. Atlanta & St. Andrews Bay Railway._.Dr. John T. Ellis. Alton & Southern Railroad................... Dr. V. P. Siegel, Medical Director. Bamberger Railroad......... ...................... Dr. Spencer Wright, Surgeon, Director. Bangor & Aroostook Railroad.-............. Dr. J. H. Johnson, Chief Surgeon. Bessemer & Lake Erie Railroad.............Dr. J. H. Wagner, Chief Surgeon. Birmingham Southern Railroad............Dr. C. L. Yelton, Chief, Orthopedic Surgery. Boston & Maine Railroad......................Dr. J. R. Knowles, Chief Medical Consultant. Buffalo Creek Railway........................... Dr. W. E. Mishler, Chief Surgeon. Canadian National Railways.................Dr. K. E. Dowd, Chief Medical Officer. Canadian Pacific Railway......................Dr. G. Earle Wight, Chief of Medical Services. Central of Georgia Railway...................Dr. C. F. Holton, Chief Surgeon. Central Railroad of New Jersey.............Dr. I. Goldowsky, Medical Director. Chesapeake & Ohio Railway.................. Mr. J. J. Smole, Special Represent ative. Chicago, Burlington & Quincy Rail road............... ................................._.....Dr. R. B. Kepner, Chief Medical Officer. Chicago, Milwaukee, St. Paul & Pacific Railroad................................................ Dr. R. Householder, Chief Surgeon, (Lines East). Chicago & North Western Railway..... Dr. J. K. Stack, Chief Surgeon. Chicago, Rock Island & Pacific Rail road....................................................... Dr. J. M. L. Jensen, Chief Surgeon. Chicago, South Shore & South Bend Railroad......... .......................................Mr. J. M. Seabright, Claims Attorney. Cotton Belt Railway...............................Dr. William Hibbitts, Chief Surgeon. ! - E* * 14 Association of American Railroads Members Representatives Delaware, Lackawanna & Western Railroad......... .......................................Dr. J. O. MacLean, Chief Surgeon. D etroit Terminal Railroad.....................Dr. B. W. Stockwell, Chief Surgeon. D etroit & Toledo Shore Line Railroad...Dr. B. W. Stockwell, Chief Surgeon. Elgin, Joliet & Eastern Railway........... Dr. R. J. Bennett, Chief Surgeon. Col. V. S. Adkins, General Claims Agent. Mr. H. L. Hackbert, Attorney a t Law. Erie Railroad...........................................Dr. W. E. Mishler, Chief Surgeon. Grand Trunk Western Railway............ Dr. K. E. Dowd, Chief Medical Officer. Dr. B. W. Stockwell, Chief Surgeon. Illinois Central R ailroad........................ Dr. E. C. Olson, Chief Surgeon. Illinois Terminal Railroad.......... Dr. J. A. Lembeek, Medical Assistant to President. Kansas City Terminal Railway.............Dr. G. Owens, Chief Surgeon. Lehigh Valley Railroad...........................Dr. J. S. Niles, Jr., Chief Surgeon. Louisville & Nashville Railroad............. Dr. Duncan Eve, Chief Surgeon. Missouri-Kansas-Texas Lines................. Dr. R. S. Kieffer, Chief Surgeon. Missouri Pacific R ailroad.......................Dr. J. A. Lembeek, Medical Assistant to President. Monon Railroad.......................................Dr. E. T. Stahl, Chief Surgeon. New York Central System..................... Dr. R. A. Johnson, Medical Director. Norfolk & Western Railroad.................. Dr. M. P. Moore, Medical Director. Northern Pacific Railway.......................Dr. B. I. Derauf, Chief Surgeon. Pullman Company....... ...........................Dr. R. M. Graham, Director, Medicine and Sanitation. Seaboard Air Line Railroad--.............. Dr. Southgate Leigh, Jr., Chief Surgeon. Soo Line Railroad................................... Dr. Harvey Nelson, Chief Surgeon. Southern Pacific Company.....................Dr. V. M. Strange, Chief Surgeon. Southern Railway.....................................Dr. M. B. Clayton, Chief Surgeon. St. Louis-San Francisco Railway.......... Dr. V. W. Hollo, Chief Surgeon. Terminal Railroad Association of St. Louis......................................................Dr. J. A. Lembeek, Medical Assistant to President. Union Pacific Railroad............................Dr. W. Bale, District Surgeon. Dr. J. O. Clanin. Dr. E. M. Pettis. Dr. R. O. Porter, Surgeon. Dr. Spencer Wright, Consultant. Associatio Baylor Me Central of ( Railroad R v, geon. rgeon. on. Claims a t Law. Officer. Assistant Assistant Director. Director, geon. Medicine ief Surgeon. 'urgeon. urgeon. urgeon. reon. Assistant ltnnt. Surgeon. eon. Proceedings o f M edical a n d S u rgical Section 15 Also Present Members Representatives Association of American Railroads.-. .Mr. K. A. Carney, Executive ViceChairman, General Claims Division, Director, Claims Research Bureau. Mr. F. J. Parker, Secretary, Medical and Surgical Section. Mr. R. L. Rose, Assistant to Secretary. Mr. Bruce Smith, Secretary and Assistant Director, General Claims Division. Baylor Medical College. Dr. E. Stanley Crawford, Assistant Professor of Surgery. Central of Georgia Railway Hospital.... Dr. J. K. Quattlebaum. Railroad Retirement Board................... Mr. E. E. Koch, Assistant Director of Unemployment and Sickness In surance. i " Stokesa and high er, or from it persists ully evalu1 to cease infarct the i man may nie type T inical data >gram th at rardiogram ent or not. An electro; heart was ; problems; is humanly gment and the patient tant in the ) approach :tor-patient >rmance as ac Patients, Physiology md Humid Man and in , American of Tropical ;ht and Left irican Heart d DeGraff, iac Output, i Resting in :h, for that >m the floor, d maybe we ery director rrch will try Ijoumed.. . . Proceedings o f Medical and Surgical Section 61 WEDNESDAY MORNING SESSION March 26, 1958 The Wednesday Morning Session of the Thirty-Eighth Annual Meeting, Medical and Surgical Section, Association of American Railroads, convened in the Edgewater Gulf Hotel, Edgewater Park, Mississippi, at nine o'clock, A.M., Dr. I. Goldowsky, Chairman, presiding. Dr. I. Goldowsky: Gentlemen, I am going to get on with the meeting because we have some additional content to our meeting this morning th a t is not marked in your program. We have with us the men from the Railroad Retirement Board who are going to give us a talk later: To Keep Experience a t Work which has to do with the present stabilization of employment. So, if you will bear with us and bear with them, we will go on with the pro gram. Now, at this time it gives me a great deal of pleasure to kick myself out of office, and I want to induct our new Chairman into the office the first thing this morning. Will Dr. Bennett and Dr. Olson escort Dr. Stockwell up to the the front. (Applause) D r. B. W. Stockwell: Thank you, gentlemen. D r. I. Goldowsky: Dr. Ben, it is a pleasure for me to turn over this gavel to you to start to break you into the headaches of this job. There are not too many headaches because I am sure th a t you will have the same co-operation that I have had the past year of every member of the Section and all your Committee Chairmen. So, without making any more speeches, the job is yours. D r. B. W. Stockwell: Thank you very much, Dr. Goldowsky, and mem bers of the Medical and Surgical Section: I t is indeed an honor to be elected your Chairman, and I cei-tainly do ap preciate it. I think, first, we should comment on the way th at Dr. Goldowsky has handled things during the past year. He has been an excellent Chairman. He has done a lot of hard work, and he has accomplished many things. He should definitely be complimented on the performance of a job well done. (Applause) This year the Committee of Direction will meet for the first time sometime 0 in the summer, and the various standing committees will be appointed at th a t time. The committees, as you are all aware, do the work of the Section. As soon as the appointments are made, we will try to get a news letter out to all of the members of the Section as to who they are and what to expect. I think it would be well, if we can, to let you know during the year what is going on instead of having that knowledge chiefly in the minds of the members of the Committee of Direction only. As I said, it is an honor and they tell me th at there is some work connected with it. I certainly hope that I can do half as good a job as Dr. Goldowsky. If any of you during the year have any questions concerning the operation of the Section or have any suggestions concerning our program for next year, we would welcome very much hearing from any of you a t any time. Thank you very much. (Applause) J ' " t 'V C V ' ' - , 62 Association of American Railroads Now, Dr. Goldowsky said th a t he was relinquishing his job. I don't quite agTee with that. This is still the meeting th a t was arranged by our ex-Chairmau. I think th a t it is only fitting th at he continue on until we are through here at Edgewater Park this year. So, Dr. Goldowsky, you didn't get out of the job. I will give you your gavel back for the rest of the day. (Applause) D h. Goldowsky: Our first committee report, and our most important committee this morning, is our Medical-Legal Research Committee; and our good Chairman, Dr. Mishler, Chief Surgeon, Erie Railroad, Cleveland, Ohio, will tell you a little about what has been going on the past year. Dr. W. E. Mishleii: The Medical-Legal Committee which was appointed during the past year is made up of Drs. R. J. Bennett, Chief Surgeon, E. J. & E. Ry.; Harvey Nelson, Chief Surgeon, Soo Line, and myself; also, Messrs. Ewing, General Claims, Atchison, Topeka & Santa Fe; W. II. Kelly, General Claims Attorney of the Chicago, Northwestern Railway; and R. R. Minor, General Claims Agent of Illinois Central. Two meetings have been held. While the Committee did not have a specific aim or purpose when it was formed, it was intended to aid and assist, if possible, the solution of some of the problems affecting railroads th a t are common to both departments. As our first project, it was felt th a t the Impartial Medical Plan as adopted at New York and Baltimore had merit. If possible, its adoption in other centers would be advantageous. The principal characteristics of the New York plan for those who are un familiar noth it are: (1) The fees of the impartial medical experts were originally paid by a foundation, b ut later on a showing of economies effected by the Plan, these fees were and are being paid by pubbc funds; (2) The panel of Medical Experts were set up by local medical societies with a number of doctors ap pointed to the various specialties th a t were considered appropriate. A list of these experts were kept confidential and were selected in rotation and without prior knowledge of their identity by the court or counsel. Only senior experts were selected, and usually they were men who do not make a practice of testi fying for either plaintiff or defendant; (3) Cases which were to be submitted to the impartial medical experts are determined by the trial judges on his own motion or at the suggestion of either party and usually a t the time of the pre trial hearing. The judge determines which specialty or specialties are required in the particular cases before him; (4) When a case is selected for expert hand ling, the clerk determines from a confidential list the expert next in order and the specialty required and makes all arrangements necessary for the ex amination by the doctor; (S) The expert in every instance is given a free hand to make a physical examination and make all laboratory tests and take all X-rays he feels necessary. He is also furnished with the reports of the doctors employed by the parties and results of laboratory tests, X-rays and hospital records, if any; (6) After examination, the expert -witness makes his report to the court and copies are furnished to both parties; (7) At the trial the expert may be called by the court or either party, and his examination is conducted in the same manner as any other expert except th a t the party called is usually not considered bound by the testimony; and the impartial appointment of compensation expert is made clear to the jury. At our meeting it was suggested th at Minneapolis and Pittsburgh were centers to be considered. I Proceedings of Medical and Surgical Section 63 I might say here at this point th at this committee has had immeasurable help from Mr. Ken Carney and his Research Bureau. I might say th at Ken Carney has done most of the leg work for this committee. He reports as follows as relative to Pittsburgh: " Pursuant to the understanding we had at the last meeting of the Medical-Legal Committee, I have gone into the situation at Pittsburgh, Allegheny County, Pennsylvania, with a view of determining whether or not there would be sufficient interest in the institution of the Impartial Medical Testimony Plan following generally the one in New York. " First of all, I have had a meeting of the heads of the claim departments of the various railroads operating in Pittsburgh, and found an over whelming sentiment in favor of the plan. " In addition, I also learned two outstanding orthopedic men, Drs. Kenig and Mazoni, had already started to get a resolution through the medical society for the adoption of such a plan. " I t was also learned th at Federal Judge Gorley had been in favor of some plan to provide impartial medical testimony. " At the suggestion of Mr. Peter G. Edward, I talked to Drs. Kenig and Mazoni and found they were under the impression it would be necessary to go to the legislature for relief for adoption of such a plan. " We further understood the m atter had not been progressed to any appreciable degree, would probably bog down unless some stimulation is provided. " Dr. David Cass of the Century Building, Pittsburgh, Pennsylvania, is the current President of the Medical Society and general claims agent. " The Allegheny Bar Association would, in our judgment, respond favorably to requests from the medical society to jointly sponsor such a plan. " The current and incoming presidents are both members of a defense law firm, however, and might be suspect, but I believe there would be enough influence brought to bear for such a plan th at we would probably have no real trouble with the Bar as a whole. " I have not proceeded beyond this point as it now appears th at P itts burgh would provide a likely place to adopt the plan, and if handled in an intelligent manner, would likely be adopted. " All those intervie'wed in this m atter are pledged to secrecy as it was made known to them th at any knowledge th at we were interested in sponsoring such a plan would do more to defeat its acceptance than any other single factor. " My attention was called to the fact the real need of the railroads in Allegheny County in connection with a plan of this kind is in the Federal District Court, and that the court probably has no funds available to put into operation such a plan unless the costs were assessed against both the plaintiff and defendant on a fifty-fifty basis to avoid any tendency towards favoritism toward the plaintiff or defendant. " If I can be of further service to you or your committee in this matter, I trust you will advise me of your wishes." -*Tr x- "> v 11 t v n *-> ^ 62 Association o f American Railroads Now, Dr. Goldowsky said th a t he was relinquishing his job. I don't quite agree with that. This is still the meeting th a t was arranged by our ex-Chairman. I think th a t it is only fitting th a t he continue on until we are through here at Edgewater Park this year. So, Dr. Goldowsky, you didn't get out of the job. I will give you your gavel back for the rest of the day. (Applause) Db. Goldowsky: Our first committee report, and our most important committee this morning, is our Medical-Legal Research Committee; and our good Chairman, Dr. Mishler, Chief Surgeon, Erie Railroad, Cleveland, Ohio, will tell you a little about what has been going on the past year. D e. W. E. M ishler: The Medical-Legal Committee which was appointed during the past year is made up of Drs. R. J. Bennett, Chief Surgeon, E. J. & E. Ry.; Harvey Nelson, Chief Surgeon, Soo Line, and myself; also, Messrs. Ewing, General Claims, Atchison, Topeka & Santa Fe; W. H. Kelly, General Claims Attorney of the Chicago, Northwestern Railway; and R. R. Minor, General Claims Agent of Illinois Central. Two meetings have been held. .While, the Committee did not have a specific aim or purpose when it was formed, it was intended to aid and assist, if possible, the solution of some of the problems affecting railroads th at are common to both departments. As our first project, it was felt th a t the Im partial Medical Plan as adopted a t New York and Baltimore had merit. If possible, its adoption in other centers would be advantageous. The principal characteristics of the New York plan for those who are un familiar with it are: (1) The fees of the impartial medical experts were originally paid by a foundation, but later on a showing of economies effected by the Plan, these fees were and are being paid by public funds; (2) The panel of Medical Experts were set up by local medical societies with a number of doctors ap pointed to the various specialties th at were considered appropriate. A list of these experts were kept confidential and were selected in rotation and without prior knowledge of their identity by the court or counsel. Only senior experts were selected, and usually they were men who do not make a practice of testi fying for either plaintiff or defendant; (3) Cases which were to be submitted to the impartial medical experts are determined by the trial judges on his own motion or a t the suggestion of either party and usually a t the time of the pre trial hearing. The judge determines which specialty or specialties are required in the particular cases before him; (4) When a case is selected for expert hand ling, the clerk determines from a confidential list the expert next in order and the specialty required and makes all arrangements necessary for the ex amination by the doctor; (5) The expert in every instance is given a free hand to make a physical examination and make all laboratory tests and take ail X-rays he feels necessary. He is also furnished with the reports of the doctors employed by the parties and results of laboratory tests, X-rays and hospital records, if any; (6) After examination, the expert witness makes his report to the court and copies are furnished to both parties; (7) At the trial the expert may be called by the court or either party, and his examination is conducted in the same manner as any other expert except th a t the party called is usually not considered bound by the testimony; and the impartial appointment of compensation expert is made clear to the jury. At our meeting it was suggested th at Minneapolis and Pittsburgh were centers to be considered. Proceedings of Medical and Surgical Section 63 I might say here at this point that this committee has had immeasurable help from Mr. Ken Carney and his Research Bureau. I might say th a t Ken Carney has done most of the leg work for this committee. He reports as follows as relative to Pittsburgh: 2 " Pursuant to the understanding we had at the last meeting of the % Medical-Legal Committee, I have gone into the situation at Pittsburgh, Allegheny County, Pennsylvania, with a view of determining whether or not there would be sufficient interest in the institution of the Impartial % Medical Testimony Plan following generally the one in New York. t " First of all, I have had a meeting of the heads of the claim departments I of the various railroads operating in Pittsburgh, and found an over whelming sentiment in favor of the plan. l I " In addition, I also learned two outstanding orthopedic men, Drs. Kenig and Mazoni, had already started to get a resolution through the medical society for the adoption of such a plan. ` " I t was also learned th a t Federal Judge Gorley had been in favor of Vil some plan to provide im partial medical testimony. " At the suggestion of Mr. Peter G. Edward, I talked to Drs. Kenig and Mazoni and found they were under the impression it would be necessary to go to the legislature for relief for adoption of such a plan. " We further understood the m atter had not been progressed to any appreciable degree, would probably bog down unless some stimulation is provided. " Dr. David Cass of the Century Building, Pittsburgh, Pennsylvania, is the current President of the Medical Society and general claims agent. " The Allegheny Bar Association would, in our judgment, respond favorably to requests from the medical society to jointly sponsor such a plan. " The current and incoming presidents are both members of a defense law firm, however, and might be suspect, but I believe there would be enough influence brought to bear for such a plan th a t we would probably have no real trouble with the Bar as a whole. " I have not proceeded beyond this point as it now appears th at P itts burgh would provide a likely place to adopt the plan, and if handled in an intelligent manner, would likely be adopted. " All those interviewed in this m atter are pledged to secrecy as it was made known to them th a t any knowledge th at we were interested in sponsoring such a plan would do more to defeat its acceptance than any other single factor. " M y attention was called to the fact the real need of the railroads in Allegheny County in connection with a plan of this kind is in the Federal District Court, and th a t the court probably has no funds available to put into operation such a plan unless the costs were assessed against both the plaintiff and defendant on a fifty-fifty basis to avoid any tendency towards favoritism toward the plaintiff or defendant. " If I can be of further service to you or your committee in this matter, I trust you will advise me of your wishes." J... 'ws?3 a ..,,. 4 V 'K j?gf\ :;.: '; c . ,v"k` ' ` '.'s''V' - 64 Association of American Raroads S-pz I have a communication here to Dr. Nelson by the law department of the Soo Line: "Dear D r. Nelson: "Enclosed is a copy of the resolution adopted by the American Bar Association relative to the Im partial Testimony and also a letter from the Bar Association in response to a letter of mine inquiring about what activity had been undertaken to expedite the adoption of such a plan. "After you read the same, return the same to me." The resolution adopted by the American Bar Association is as follows: "RESOLVED th a t the American Bar Association adopt a national program to be implemented a t the local level for fostering the creation of panels of impartial medical experts under court aegis in the pre-trial con sideration and trial of personal injury cases, especially in those communi ties where there is a volume of personal-injury litigation in the court and where there is sufficient number of qualified doctors available to constitute a panel; th a t the panel be selected by professional bodies on the basis of professional qualifications; th a t the panel be employed in the pre-trial and trial stage of such cases and th a t the copies of this resolution together with the attached report of the Section's Committee on Impartial Medical testimony dated August, 1956, be forwarded to all state and local bar associations represented in the House of Delegates with the recommendadation that this program be adopted." The Section on Publications and Services of the American Bar Association wrote to Mr. Beckman of the Soo Line as follows: "This acknowledges your letter of March 5th with regard to the report of the Committee of Im partial Medical Testimony. This report contained a resolution on the subject which was presented as amended upon recom mendation of the Board of Governors to the House of Delegates and adopted by the House. " We enclose the attached," which I just read. "You will note copies of resolutions together with the report of the committee before to all state, local bar associations represented in the House of Delegates with a recommendation th a t this program be adopted. This has been done. "The State Bar Associations of the States you mentioned, Illinois, %f4.; Wisconsin, Michigan, Minnesota and N orth D akota were included. We were unable to tell you w hat committees of these associations were con tacted; nor, are we able to tell you whether the Section of Judicial Ad ministration has received word from any of these organizations. This office has not. "We are sending a copy of this letter to Justice Clark of the Supreme Court, Washington, D, C., who is Chairman of the Section." T hat handles Minnesota. Shortly before this meeting, another member of this committee has con tacted the federal judges of another district other than Minnesota or P itts burgh on the merits of this plan, and it is anticipated th at a meeting of them which is to be held shortly will be fruitful in the adoption of such a plan. At the last Committee of Direction meeting--and this is changing the sub ject--the Pennsylvania Railroad proposed to the A.A.R. a study of the prob lem of the effects of diesel fuel in locomotive cabs and in shops. The subject has been referred to this committee, also. However, nothing has been done to date. Proceedings o f Medical and Surgical Section 65 Aa I mentioned before, Mr. Carney has given this committee a great deal of help, and I hope he will continue to do so because without him I don't think we would get very far. However, in conclusion, in spite of the fact we have only had two meetings, I w ant to say th a t this committee in my mind is going to be a very active, useful and busy one. Thank you. (Applause) D b. I. Goldowsky: Thank you, Dr. Mishler. y I just wanted to bring some of the men up to date. If they didn't know what i Doctor was talking about when he talked about the Impartial Medical Testi mony, there is an Impartial Medical Panel in the City of New York. The <- works have been published, and those th at are interested in getting some of y. the basic facts about this, I would refer to the title of the book which is: "Impartial Medical Testimony," published by McMillan and Company, New York. ,i I gave you the basic book. I think it is well worth reading. I think there is i much which could be changed in it which would be of benefit. Like everything new, it is only improved by aging. y Now, if you will bear with me, I am going to ask Ken Carney if he wants to say a few words on this. Ken has done all the leg work. As Dr. Mishler ex- ; plained to you, he has been the engine and spark plug in this. ; Ken, would you want to say anything on this? Mr. K. A. Carney: I don't think I have anything to add, Mr. Chairman. '.'I I think it is a very vital committee. I think they are going to make real progress. I am tickled to death with the way all of the doctors have taken hold of it. I t looks good to us right now. D b. I. Goldowsky: The legal group has named their own chairman; and Dr. Mishler is our Chairman from this Section. Are there any of you gentlemen who have any problems you think not only of interest locally, your own road, or some neighboring road, th a t you know is going to affect us nationally th a t needs some research, give it to the Com mittee of Direction; Ben Stockwell your new Chairman; or to Frank Parker. We will put it in the proper hands. I. Are there any other questions on this, or is there any other discussion? Dr. Nelson. Db. Habvey Nelson: Dr. Mishler mentioned Kermit Johnson's letter. I think we are going to have to contend with a certain amount of complacency in which many are willing to accept our medical situation as it is. The thing th a t I would like to urge is th a t this is a t least half, and I would say more than half, a doctor's problem, a m atter of cleaning house, of getting a better type of medical testimony. I don't agree with Kermit Johnson a t all on several points as I indicated in the letter to our group. This Medical Ethics Committee that we have in Minnesota has functioned b ut it hasn't had any teeth. Some things have been going on th a t those of us who are in the practice of medicine in Minnesota are ashamed of. I don't know if it has been quite made clear to the group here ju st exactly what this plan consists of. The thinking is th a t the state societies or the local - *. U Association of American Railroads A'............................* -* societies will select panels in the various specialties. These panels are to be kept secret as far as the court is concerned. The Impartial Medical Testimony expert will be selected in rotation so the court will not have jurisdiction as to j whom is going to be the one th a t is to be selected. * | Obviously, with such a plan, we are going to have much better type of j testimony. We are going to have men who are going to come in as neutrals and be willing to spend their time and effort in making an examination. And, a lot of our cases are going to be settled before they ever come to court. I would like to quote four results of the New York Plan th a t Mr. Ewing has mentioned. The project has improved the process of obtaining medical facts in litigation cases. I t has helped to relieve court congestion. I think it has been shown th a t many of the cases in the pre-trial period are settled because of a neutral medical opinion. I t has had a wholesome prophylactic effect upon the presentation of medical testimony in court. The modest expenditure in volved has effected a large saving in court costs by reducing the number of cases coming to trial. I t has pointed the way to better diagnosis in the field of traumatic medicine. Doctors with eminent qualifications who were unwilling to testify before, willingly served on the panel of Im partial Medical Experts. We know th a t this plan can be p u t in effect. The attorneys themselves have recognized the problem by passing a ruling which apparently they are to a large extent ignoring. We have a very enthusiastic committee, and we may be asking for some help from some of you in different localities. We feel, and I think I am correct in this, th a t the Federal courts even now have the power of appointing impartial medical experts. From there on it may get into the district courts. I am not in favor of dropping the m atter in Minnesota. I think we have the same problem there as we have everywhere else. I think merely because we have some of our plaintiffs' men on certain committees is not a reason for dropping this thing at all. D r, I. Goldowskt: Carter. D r. Wh ite: Union-Pacific. Mr. Chairman: We had in U tah a number of years ago a plan th a t worked very well in helping to tone down some of this testimony th a t was coming from doctors, you know, adverse to facts and things th at we think are not right. Under the Medical Ethics Committee of the State Medical Association, they had a very aggressive group of doctors of about six who made it their practice to attend the court sessions when medical testimony was given in liability ' cases based on physical or mental problems. When the doctors th a t were giving this testimony saw this group of six prominent doctors from the state society sitting there in the front row of the court to hear them give their testi mony, it had a very salutary effect, and the vicious type of testimony which had been the practice was practically eliminated. Now, our committee wouldn't hesitate to travel throughout the state and attend these things where major trials were being held. They had people who were willing to give their time, and people who were members of the Associa tion such as this and in other industrial practices as members of th a t committee. They just sat in the front row, and the doctor then going to give the testimony toned down very much what he might have to say. 1 2 ?V- to be as to type of neutrals And, ig has facts it has wise of upon ;ure innber of field of before, they are some help correct in mpartial we have because ;ason for j worked ing from right, on, they practice liability th at were the state heir teatimy which state and iople who ! Associammittee. estimony Proceedings of Medical and Surgical Section 67 D r. I. Goldowsky: Thank you very much. I can tell you for sure this committee and Mr. Carney have studied fully, and as p art of the program not only the New York Plan, b ut the Baltimore Plan, and also the U tah Plan, as each has its kinks, but we are throwing a pebble into the calm lake, and hoping the ripples spread. I am going to just make two more announcements. (Announcements.) "5 D r. I. Goldowsky: Now, the next is not in the nature of any apology, but Dr. Clayton has gone. I imagine you all know th a t he was our Vice- Chairman last year. Maybe some of you have wondered why he has not been elected Chairman for this ensuing year. He was nominated for the position, however, Dr. Clayton because of pressing things th a t he knows are coming up and feeling he would not have the time for about five or six months felt th a t it was his duty and it was his desire to withdraw his name from nomination as Chairman. As such, the Committee of Direction had to look around for a new Chairman, and Dr. Stoekwell was ...V3* chosen. Now, for our next part of the program, it gives me a great deal of pleasure to introduce a world-famed physician, I should say surgeon. M b. F rank Parker: I don't think Dr. Ochsner is here yet. Dr. Goldowsky: Is Dr. Crawford here? Dr. Crawford, are you ready to go on? While waiting for Dr. Ochsner, I am going to proceed with the program. We have an address of "The Use of Replacement Grafts in Arterial Diseases and Traumatic Lesions,'' by Dr. Stanley Crawford, Assistant Professor of Surgery, Baylor University, Houston, Texas. Dr. Crawford. (Applause) Dr. Stanley Crawford: Mr. President, Ladies and Gentlemen: First I would like to thank you very much for the opportunity to come to this nice area for some vacation. I gather th a t I am not alone in th at feeling because it seems to me there are some mighty good golfers in this group. Unfortunately, my talk is made up around slides, and Dr. Ochsner had a different type of slides. They are going to have to change the projectors. You know the disease arteriosclerosis for many years has been considered to be a diffused disease. And, with this concept, it was impossible to do any thing about it, but recently it has been realized th a t it is a localized disease, and consequent to this, newer techniques of surgery have made it possible to approach these lesions directly. One of the common lesions th a t is produced by arteriosclerosis is aneurysm. I t is, perhaps, one of the oldest known lesions in medicine. It is often a chal lenge to physicians and has been for a good many years. With the developments in Boston of about ten or eleven years ago, Dr. Huffnagel and Dr, Gross, i.i redoing some of the work th at Dr. Correl did in the dog many years ago, were able to show th a t materials or tissues from one person could be taken, prepared, sterilized and put into another in replac ing segments of the vascular system. Coarctation of the aorta when the gap produced by this lesion was so long that an end-to-end anastaraoais could not be performed, led to the develop ment of these techniques th a t are being presented here today. M any other surgeons have contributed to this field, and, of course, we are grateful to them. And, many, many physicians have referred us patients that have given us a great deal of experience, and, of course, we are extremely grateful to those people. There are a number of locations in the vascular system in which aneurysms occur: the thoracic aorta, the abdominal aorta, the femoral artery and in the popliteal artery. As you know, the complications th at these lesions produce are very serious. Perhaps the most common one is rupture, and, of course, along with th a t death. Fortunately, the patients live for several days after the lesion begins to rupture or after the first rupture takes place, either located behind the pleura or behind the peritoneum or in the groin or behind the knee, there is enough tissue surrounding these lesions to tamponade the first hemorrhage th a t comes about. At this time, even after rupture occurs, before final exsanguination takes place, the opportunity is available in most instances to excise these lesions and replace them with a graft. We read in the newspaper about very famous people very recently dying of these diseases, and, as you will also recall from reading your newspapers, they did live for a number of days before they did finally die. If I may have the first slide, please, in the thorax several problems are posed by the application of excision and graft to the lesions. We have to maintain circulation during the operation. This is an X-ray of a patient in whom a routine chest X-ray showed an en largement in the mediastinum and by special X-ray techniques and injecting % radiopaque substance into the arm vein and catching it in the aorta, we can IiT.' demonstrate this aneurysm here. I t also demonstrates another thing, and th a t is it is clotted. An aneurysm is not just a big empty sac or a big sac filled with liquid blood; it clots, laminated clot occurs in the aneurysm. The liquid p art is just the size th a t a normal aorta would be. Of course, the wiring opera tions are not too good. I t was intended to produce a clot, but, actually, they abeady had a clot. You can see this one extends throughout the descending aorta from the origin of the subclavian artery to the diaphragm. Now, excising this aneurysm, one would have to maintain circulation be yond the aneurysm while one is excising this in order to maintain circulation of the vital organs beyond the clamp, the spinal cord, the kidneys and so forth. N ext slide. Again, if the aneurysm is in the arch of the aorta, say it is here (indicating) in the transverse segment of the arch of the aorta, the main branches, as you see, going to the brain are involved. So, not only would we have to maintain circulation beyond to nourish the spinal cord and the kidneys and so forth, but we would have to supply blood to the innominate and carotid arteries here in order to nourish the brain in the operation. The brain can't do without blood b u t for about four or five minutes without some difficulties occurring. B ut in this situation here (indicating), the aorta is normal both proximal and distal. There is enough aorta th a t is of normal size between the heart & i and the aneurysm th a t a shunt can be sutured on as you see diagrammed here. S' W ith such a shunt in place, delivering blood beyond the aneurysm to the f descending aorta and the vessels of the head, then clamps can be safely applied here, aneurysm removed, and the graft p u t back in its place. N ext slide. and, of course, we are ferred us patients th a t rse, we are extremely a in which aneurysms oral artery and in the these lesions produce lpture, and, of course, the lesion begins to ated behind the pleura knee, there is enough emorrhage th at comes e final exsanguination tances to excise these very recently dying of your newspapers, they ral problems are posed We have to maintain t X-ray showed an enchniques and injecting it in the aorta, we can es another thing, and .y sac or a big sac filled aneurysm. The liquid mrse, the wiring operaiot, but, actually, they mding aorta from the aintain circulation be0 maintain circulation e kidneys and so forth, lie aorta, say it is here f the aorta, the main So, not only would we il cord and the kidneys nnominate and carotid m. The brain can't do thout some difficulties normal both proximal iize between the heart 1 see diagrammed here, i the aneurysm to the >s can be safely applied place. lation does not prevail, is not enough normal Proceedings o f Medical and Surgical Section 69 aorta between the heart and the aneurysm to put on a by-pass shunt as pre viously diagrammed. In this case here we have to use the artificial heart-lung preparation. The blood is removed from the superior-inferior vena cava. I t is unoxygenated blood returning to the heart. I t is put into this pump by-pass oxygenator. Some of the blood is pumped back to the femoral artery to the body distal to this clamp and then through another tube into the innominate and carotid artery to supply oxygenated blood to the brain. With th a t set up in operation, then one can safely clamp the aneurysm this distance to the heart and branches coming off of it. I t can be excised and a graft re-inserted. Next slide. This is an example of the descending thoracic aneurysm which has been excised and replaced by homograft. This is the subclavian artery here. This is the descending thoracic aorta. And this is a homograft in place following the excision of a rather large an eurysm of the descending thoracic aorta. Next slide. Now, one of the most common sites of origin of an aneurysm in the aorta is the abdominal aorta or where the patients complain of abdominal pain or pulsating mass in the abdomen. With the late publicity regarding aneurysms, the most common complaint our patients have is they can feel their heart beating in their abdomen. They, themselves, do spot it, a pulsating mass in the abdomen, or else they have pain in the stomach when they lie on the abdomen and have found it; or they have pain, and their doctor has found it, or their doctor finds it on routine examination. To confirm the diagnosis (I don't know whether you can see it or not), we frequently see by an ordinary flat film of the abdomen a soft tissue mass in the retroperitoneal area here (indicating). As you can see here, there is a little rim of calcium; maybe the next slide will show it better. Then you can see here the lateral. This is a lateral film of the abdomen. You can see a little calcified rim on this mass, retroperitoneal mass here (indicating). This is the abdominal aneurysm when it has been removed. You can see it corresponds quite nicely to this calcified ring in the region of the abdominal aorta. Next slide. This is an example of an abdominal and aortic aneurysm exposed at opera tion. This is a photograph taken a t operation. I t emphasizes one of the pathologic characteristics of this lesion. Above the aneurysm, the aorta is reasonably normal. There is a normal segment of aorta between the renal arteries and the aneurysm, making it quite a simple affair to control hemorrhage by applying clamps both proximaily and distally to the aneurysm for which it can be excised and replaced by a homo graft or some plastic material. This is, indeed, a fortunate situation, th a t is, in most instances the major channels in the abdomen are not involved. Occasionally they are. We have had twenty-six patients in whom the renal and superior mesenteric and colliac have been involved, but again because of the concentration of experience the patients who have been exposed elsewhere, in many instances, and sent down. By and large, this is the setup, and occasionally they do involve the big vessels. Even so, they can be excised and replaced. If a patient has one of these lesions here and has symptoms from it, we know enough about the condition now to be able to make certain predictions. Once the diagnosis is made and the patient has symptoms from his abdominal aortic aneurysm, we know that he will be dead within six to eighteen months, some where along in there. Exactly when, it is just hard to predict. I t might be 70 Association of American Railroads the next day, twenty four hours later, three months later, it is just hard to predict. We have had some patients drop dead in the air plane station on their way to Houston or coming up from the admitting office or down in X-ray. i. I t is a highly unpredictable lesion except in a general way; so th a t once symptoms occur, they are dead within six to eighteen months. Next slide. As indicated, they can be excised easily and replaced by a suitable replace ment. I t is in contrast to the bad prognosis the patients are now being treated Si almost routinely a t home, and the operating mortality is less than four per cent. If they are sixty-five years or younger and do not have heart disease, t;; we have done consecutive series, sometimes a hundred and twenty without a death. If they have heart disease, of course, the mortality goes up consider ably, and it is fifteen per cent. If they have ruptured already, th a t is about thirty per cent of those die. A third of our entire mortality has been in the r':- ruptured group, but this condition previously had led to death in all cases. Being able to get two-thirds of those patients through operation to be dis W.. charged reflects well upon this operation. f. This is an example of an aneurysm elsewhere. This man had two femoral aneurysms. You see they are quite small and will appear rather innocuous. They are in the sense when they rupture, they do not cause the patient to exsanguinate and die as one in the thorax or abdomen would. But, because the artery is surrounded by tissues th a t will hold the blood clot there, when rupture occurs, hematoma forms under pressure and occlusion takes place. The other complication is thrombosis. Because of its small, lumen thrombus formation which occurs inside of it, obstruction takes place. In summary, all the complications of the small, peripheral aneurysm is ar terial insufficiency of the extremity. In a study of the natural course of the disease of the femoral and popliteal aneurysms, sooner or later they will develop a complication th a t will lead to amputation in the majority of instances. Because of such complications, death can occur. In a group a t the Massachusetts General Hospital, they were treated with out removal; and a quarter of them eventually died as a result of their com plications. Ab you can see here through two small incisions these aneurysms have been removed and vessel continuity has been re-established by the insertion of these grafts, making it quite a simple operation and preventing the develop ment of these complications th a t lead to disability. Next slide. This is just an example of popliteal aneurysms. These, sometimes, are dif ficult to feel. In any routine physical examination, the pulses should be felt in the characteristic locations, in the femoral, popliteal and the feet. Not only does it give you some idea as to the adequacy of their circulation, but it also will help to pick up these lesions which may be silent a t the time. This is an aneurysm behind the knee, and it has been excised and replaced by this syn thetic substitute. The one that we are using routinely at the present is a knitted dacron substitute. Next slide. Now, the next, and perhaps the most common, arteriosclerotic and vascular th a t we see is an arteriosclerotic lesion th a t produces poor circulation, arterial insufficiency of the lower extremity. Again, you know, up until not too long ago we thought a fellow had poor circulation in his feet, th a t all of his arteries down his legs and feet were shut Proceedings of Medical and Surgical Section 71 just hard to off with arteriosclerosis; there wasn't much we could do about it except a ae station on lumbarsympathectomy. Since th a t increased the circulation of the skin, and, jwn in X-ray. after all, th a t is the way many of the lesions th at lead to am putation originated so th a t once from, we got some help from a lumbarsympathectomy. But, all too often symptoms were not relieved; in the more advanced cases, amputation was not averted. As time went along, it was discovered even here uitable replace- it is a localized lesion. I think you can see here this patient with symptoms w being treated in both legs and with absent pulses in both legs and on artriographie examina than four per tion, a complete obstruction just beyond the renal arteries here, but distally heart disease, ;nty without a up consider- 1 there was good filling of normal iliac arteries on both sides as you can see here thus quite nicely demonstrating the localized nature of this occlusive lesion. This shows another more advanced type of lesion with thrombosis ascending A that is about is been in the h in all cases, ion to be dis- up to the renal arteries, partially obstructing the renal artery on one side. .! Next slide. Vi Due to the localized nature of this disease, it is also treatable by the direct J .-i surgical techniques; in this instance here the diseased area was excised and replaced by a graft, thus allowing normal blood flow to go to the lower legs. d two femoral And in this situation here the obstruction was not excised. I t was merely ner innocuous, by-passed, using this new vascular replacement in an effort not to disturb the the patient to collateral circulation th a t he had and also to simplify the operation; in this instance the end of the graft was sutured to the side or above the occlusion hold the blood and then down below the occlusion the ends of the two iliac limbs of the graft e and occlusion were sutured to the patient's iliac arteries beyond the occlusion, thus allowing e of its small, the by-pass route around the obstruction to restore circulation. on takes place, N ext slide. neurysm is ar- In this situation here, again, the end of the graft was sutured above the occlusion, and then the two iliac limbs were brought through tunnels made 1and popliteal by blood disection down to the groin, thus by-passing a long, extensive oc sat will lead to clusion in the iliac system bilaterally. In this way a rather simple, not too complications, major, operation was performed and immediate pulsatile circulation was restored to the lower legs and the feet. e treated with- N ext slide. t of their com- This is another example of the type of operation th at can be performed. The lesion was excised here. This part of the lesion was excised because an sms have been aneurysm was in the process of developing as well as the obstruction. On one ie insertion of side an end-to-end anastomosis was made between the iliac artery and the iliac g the develop- end of the graft. On the other side it was by-passed down the groin. N ext slide. In all of the occlusions in the abdominal aorta and iliac arteries are sus- itimes, are dif- ceptable to these techniques. And, given a patient with arterial insufficiency should be felt of the lower extremities, whether it is pain at rest or ischemic lesions, early eet. Not only gangrene or whatnot, if he does not have femoral pulses in every single case a on, b u t it also normal circulation can be restored by those techniques. Consequently, just ne. This is an the mere demonstration is all th a t is necessary to say th at he is a candidate d by this syne present is a 1 for an operation. Now, in not quite half of all of the patients with arterial insufficiency, the lesion is not in the abdominal aorta; it is out in the thigh, out in the leg, as it is demonstrated here. c and vascular This is an' arteriogram of a patient with a segment of an occlusion in the lation, arterial superficial femoral artery. This is the femur, and you can see this gap in the column of dyes. T hat is a localized occlusion in the femoral artery. llow had poor feet were shut Patients who have the milder forms of arterial insufficiency will have such a set up like this in ninety per cent of the cases. If they have advanced f 3 w & r.*-v ~ * ~ ' r .......... arterial insufficiency with a lesion localised to the thigh, th a t is, they will have a good femoral pulsation but nothing beyond, only about half of them will have this. When they do have this, they are a candidate for operation. Those who do not have a good distal segment like this are ap t to have an arteriogram like this over here. As you can see, there is no distal segment of sufficient size in which the graft can be connected. Consequently, in the thigh, all the patients are not candidates for this direct operative maneuver. But, in the majority of them they are. The only way it can be determined is by an arteriogram because some of the most severe forms of arterial insufficiency will have a nice setup like this. Yet, some of the mildest forms of arterial insufficiency will have a setup like this. We have to do an arteriogram in order to select the patient. Next slide. The operations we prefer in the thigh will make it a simple operation. I t is not much more of a cutting sort of operation than the varicose vein operation. The arteries are exposed through two incisions, one is up in the groin, and the common femoral artery is exposed here. After controlling the vessel proximal and distal to where the incision is to be made, the incision is made, following which the end of the graft is sutured by a simple over-and-over suture to the side of the vessel, following which an instrument like a vein stripper is passed by blunt disection to the other incision vrhich has been made in the popliteal space over the normal distal segment. The free end of the graft is tied to the end of th a t vein stripper and is pulled down to the other incision. The exposed artery then is open, and the end of th a t graft is sutured to the side of the normal vessel. Thus, the operation, then, is designed merely just as to insert a collateral channel immediately of the size of the vessel th a t is plugged up. So, it is quite a natural sort of operation. The patients own collateral channels are not inter- ferred with. This is the desirable feature of any operation in as much if some thing happens and it fails, it doesn't make the circulation worse. Next slide. This shows such a graft in place in such an operation. This is a plastic tube sutured to the common femoral here. I t is under the skin down to here. The other end of it is sutured to the popliteal artery. Next slide. This is another example. You see the two smaller incisions here. In this incision, this plastic tube has been sutured to the femoral artery, to the side, above the occlusion and down here the other end has been sutured to the side of the patent vessel below. Next slide. Now, it isn't the leg and the abdominal aorta and iliac arteries th a t are attacked by this lesion. The carotid arteries are also involved. I am thinking now and speaking now of the stroke syndrome, CVA, stroke, hemiplegia, many common terms for patients, old folks, who develop strokes. The average doctor even today thinks th a t a patient has a lesion inside of his skull. He has just got a degenerative lesion, and th a t is tough. Do the best we can. Give him anticoagulants to keep him from getting worse. B ut since it is inside the skull and dealing with small vessels, it is felt th a t there is just nothing much to be done about it. Well, th a t is an erroneous concept because in a quarter of the cases of patients who have strokes, the lesion is not inside the 15 skull; it is out of the skull in the carotid artery. This is the internal carotid; this is the common carotid. You will notice in this patient here there is al most complete obstruction in the internal carotid artery. This patient wa have been called He had been com; talk. They would You can see thi Next slide. As I say, a qui accounting for th by. The reason other side. Here opposite side of and this patient no neurologic dehc Next slide. Here is anotb external carotid You can see tv-' artery. That Next slide. Unfortunate!) neurological defe the institution patients die. Consequently the lesion is outsi Next slide. Because of the we can perform ing, it is suscep1 operation. In the first which is done patient basis, lesion, it is do the carotid, are mobilized tion does not have to use If the operation We cut across arteries peal stored by an Next slide. I t is more ` get into the brain We do it inthii flow of blood Then we re-ap pressed, and line. And, as the proximal c!a external carotid they will have them will have a. Those who teriogram like fficient size in 11the patients l the majority n arteriogram /ill have a nice ufficiency will r to select the operation. I t 'em operation, the groin, and ng the vessel ision is made, over-and-over at like a vein las been made r and is pulled .nd the end of rt a collateral So, it is quite sare not intermuch if some- a plastic tube to here. The here. In this f, to the side, ed to the side eries th at are I am thinking liplegia, many The average his skull. He : best we can. nee it is inside s just nothing ; because in a not inside the ernal carotid; re there is al- I Proceedings of Medical and Surgical Section 73 This patient was having these transient strokes, and in some quarters they have been called "chills" lately. This patient was having interm ittent strokes. He had been completely paralyzed on the right side of his body and couldn't talk. They would last anywhere from five minutes to a half a day. You can see this localized area, occlusion, here in the carotid artery. Next slide. As I say, a quarter of the patients with strokes have such a lesion as this accounting for their condition. Now, a quarter of those patients seem to get by. The reason they get by is because they get collateral circulation on the other side. Here is a cerebral arteriogram showing filling of the brain on the opposite side of the occlusion. I t is filling through the intercranial vessels, and this patient, although he had an occlusion, had survived a stroke and had no neurologic deficit. Next slide. Here is another such patient. Because of good circulation through the external carotid through his eye, he had good circulation inside of his head. You can see these cerebral vessels being filled through the external carotid artery. T hat fellow got by. Next slide. Unfortunately, from this lesion only a quarter of them get by, the residual neurological defect persists in a third of the patients. And, in a third of them, the institution of care is required. Somewhere around ten per cent of the patients die. Consequently, therefore, it is important to realize in patients with strokes the lesion is outside the skull in the neck. Even so, the prognosis is poor. Next slide. Because of the localized nature of this lesion to a vessel of sufficient size th at we can perform an arthrotomy and dose it without producing undue narrow ing, it is susceptible to operation, and in most of these cases a very simple operation. In the first place, they are selected for operation by a carotid arteriogram which is done under local anesthesia using a small amount of dye on an out patient basis, if necessary. If they are selected for operation for the localzied lesion, it is done under local anesthesia. An incision is made in the neck, and the carotid, common carotid, external carotid and internal carotid arteries are mobilized like this. They are temporarily occluded. We feel th at circula tion does not have to be maintained during this period of planting nor do we have to use hypothermia because patients have chronic arterial insufficiency. If the operation does not take long, it is not necessary to maintain circulation. We cut across proximally this which we have shaded here, and the normal arteries peal back from over the atherosclerotic material. Continuity is re stored by an end-to-end anastamosis. Next slide. I t is more important, we feel, to make certain air bubbles and debris do not get into the brain. We feel it is important to make certain th a t does not occur. We do it in this way: The clamp next to the brain is removed first, and the backflow of blood compresses the air and pushes it out through the suture line. Then we re-apply th a t clamp right near the suture line. Again the air is com pressed, and the proximal one is removed, and goes out through the suture line. And, as a last gesture, the internal carotid is temporarily clamped when the proximal clamp is removed permitting air bubbles and debris to go into the external carotid artery. Next side. 74 Association of American Railroads This is the appearance of the artery in an actual operation at the end of the procedure. You can Bee here is a simple anastamosis, and this is the material th a t was removed that was obstructing the blood from this patient's brain. Next slide. This is before operation, you see the common carotid and the internal carotid almost completely occluded. Here is the situation after operation. For all practical purposes he has a normal channel taking blood to the brain. In this case it relieved it. I t has been over a year now, and he has not had a stroke since operation. Next slide. This is the material removed from another case. You can see how it beaded down to a very small lumin. Next slide. This is a photo micrograph of lesion to emphasize the localized nature of this lesion. This is an atheroma. As you know, when we cut it with a knife, a lot of it fragments and drops out. This is an atheroma right in here, almost completely obstructing the internal carotid artery. See how beautifully it is localized in contrast to the older thought th at when a vessel was sclerotic it was just a little pipe stem. Next slide. In other cases we have to use a graft end arterectomy. By the technique I have just described, it is not applicable. In such a case we use a graft. In this case here a graft was used to by-pass an obstruction in the origin of the internal carotid artery. Next slide. This is such a patient ; you see here the internal carotid artery being partially obstructed by this localized plaque. When this artery was exposed, it was found to be a type of artery th a t does not lend itself to endarterectomy, con sequently a by-pass graft was inserted. You can see it in place functioning in this slide here. Next slide. This patient was having eye symptoms, temporarily blind in the eye and temporarily paralyzed. Following the operation, he has not had any difficulty further. Next slide. The second common site of the lesions producing arterial insufficiency to the brain is where it originates from the aorta. Here is an example where it originated at the origin of the innominate which is the artery th a t carries blood to the brain on the right. I t had extended on to the subclavian and the carotid. In this case, through three incisions, two in the neck and one in the chest, we were able to anastamose a graft on to the ascending aorta, one limb of the subclavian and one limb of the carotid and restore circulation to the arm and the brain. We have had three such cases as this, and circulation was successfully re stored in all three of these patients. In fact, one patient had obstruction to both carotids. Next slide. This is a photograph of th at case. You can see w hat it is. This is the diagram here, w hat I have juBt described. This photograph is where th at square is. This is the ascending aorta with the stump of the graft here. Next slide. i t the end of the a is the material ient's brain. 3internal carotid eration. For all le brain. In this not had a stroke ee how it beaded icalized nature of it it with a knife, ht in here, almost ow beautifully it ssel was sclerotic Sy the technique I se a graft. In this igin of the internal .ery being partially as exposed, it was lartereetomy, coni place functioning ind in the eye and t had any difficulty rial insufficiency to n example where it artery that carries subclavian and the id one in the chest, >rta, one limb of the tion to the arm and was successfully re1, had obstruction to it it is. This is the graph is where that je graft here. Proceedings of M edical and Surgical Section 75 Now, this is the limb th a t is anastamosed to the subclavian artery, and this is the limb th a t is going into the neck. Next slide. This is an anastamosis on the common carotid artery, this point here, re storing circulation to the arm and the head. Next slide. This is angio-aortogram following the operation demonstrating patency of this graft. You have a photograph here demonstrating dyes flowing through this graft carrying blood to the arm id the brain. Next slide. Now, this is another condition. If it isn't arteriosclerosis, it is certainly related to it. T hat is a localized, segmental occlusion of the renal artery. This is a renal artery here. You can see it looks like a chain of beads or some thing of th a t sort. What that is multiple, localized occlusions with dilitations beyond the narrowed area. T hat is the phenomenon th at always occurs whether it is an arteriosclerotic artery. There's a dilitation beyond. That is what gives that appearance there. This is a young woman, thirty years old. She had severe hypertension. Her doctor heard a bruit over this kidney, and prompted us to give us the chance to do this study which we did, and demonstrated this lesion. By "2 removing th a t localized lesion and inserting a little graft, the kidney was saved, and her hypertension was relieved. i So, it is our feeling th at any patients with unexplained hypertension actually in the young-middle-aged group should be studied by this technique. Already hundreds of patients have been demonstrated to have such a lesion, and the hypertension can be cured either by removing the kidney or by restored circu lation to the kidney. Next slide. I am sure th a t anyone associated with any industry is interested in trau matic lesions. Well, the traumatic lesions are easy because we are, in most instances, dealing with normal vessels, and they sew well; they do sutures well. And, usually, the person is in good shape. He wouldn't be working if he wasn't in pretty good shape. I t is important if the person has an arterial injury to have th a t repaired just as soon as possible. The only thing th a t prevents a successful operation is undue delay of any operation. For example, if muscle tissue goes without blood for a sufficient period of time, it develops irreversible changes. If the lower leg becomes swollen and tense and anesthetic, the chances of restoring circulation, although possible, are not too good. I t is essential to have them operate upon it just as soon as possible. Now, in most instances, a graft is not necessary because the injury is a laceration or a stab, either by some sharp instrument or by a bone, and it is just a mere debriding or cleaning of the local area and bringing the lacerated edges together. Even in those instances where a considerable defect in the artery was pro duced by the injury, a graft still is not necessary, in most instances, because after the wound is properly debrided, the artery, being an elastic tube, can be mobilized and brought together under tension. I t is essential th a t these vessels be p u t together under tension in contrast to the bowel. In the bowel, we are very careful to make certain there is no tension. I t is the direct opposite in these vessels. They have to be under tension.  s s S ^ ^ i^ 76 Association of American Railroads '-W : By mobilizing sufficient length proximal and distal to the cut areas, the two ends can be brought together and matured in practically all instances. T hat should be done because all extremities, practically, can be saved in contrast to in olden times when ligation was the common form of therapy. For example, in World War II, when the femoral artery was injured and ligated, half of the legs were lost. In this day and time with our city and county hospital, this injury is not uncommon. Our residents repair those, and we don't lose any legs from laceration of the femoral artery. If the popliteal artery was lacerated and ligated, better than seventy-five per cent of those legs would drop off, where our residents repair popliteal lacerations. They don't lose any legs. Consequently, it is a form of therapy th at is associated with preservation of the extremity, and the prevention of deformity. Next slide. This is where we might speak, though, of some delayed traumatic lesions. This individual had a laceration of the brachial artery a t this level here. It was repaired at some hospital. Not too long after discharge, he developed a mass. He noticed th at it throbed and pulsated. i Next slide. I t was for that reason th a t he was admitted to University Hospital in Houston. You can see a t operation what had happened. Here is a blister or a mass on the. artery, and it was made up of clot. W hat happened was the artery had pierced by a sharp instrument. I t bled, and he developed a pul sating hematoma or a false aneurysm. Next elide. In this X-ray is demonstrated quite nicely the axillary or brachial artery here with this glob of dye in this particular area here which is in the aneurysm. Next slide. T hat was simply excised, and you can see it was several inches of excision which were required to get rid of th at lesion. Having mobilized it proximally and distall}', it could be brought together. I t was sutured by a simple overand-over 6uture. Next elide. This is a summary of the operations up to several months ago in our de partment in Houston in spite of the large number. I t is presented merely to indicate th a t in our opinion it is a field of surgery th a t is safely established. We feel as though this has permitted restoration of function and prevention of loss of both life and limb. I am going to pass around one of these new synthetic tubes th a t we have been using. It has a number of desirable characteristics. I t is flexible. I t is very tough, strong, and it lasts certainly for a long, long time. I t does not fray. I t can be cut with the scissors and sutured without having it frayed. You can make an incision in the side and sew another graft on the side of it without it fraying. The only unsound characteristic of this tube is like th at of all synthetic materials, and th at is it is porous. One has to be quite careful in the use of it as in all of them th a t new bleeding does not take place. But, by soaking them in the patients blood, preclotting is reduced to a safe minimum. Thank you very much. (Applause) Dr has b tom} years have have of pa the The} cent arten We good from and with were I have some teric and tion the Proceedings of M edical and Surgical Section 77 Db. R. J. Bennett: W hat is the longest period of time th a t one of these has been in place and found satisfactory? D b. Stanley Crawford: The longest period of time for a synthetic tube, to my knowledge, to be in place and use in human beings is approximately four years. The one th a t I have here of this substance, the dacron, the longest we have is about three years. Now, tills particular brand and manner th at we have treated this, about a year and a half. In laboratory animals, they have been in, I think, about six years now. Dr. R. J. Bennett: When you do an aortic, do your patients have a lot of pain? If so, how do you control that? Dr. S. Crawford : W hat we do is give the patient a barbiturate to prevent the development of convulsions, and also give them a good shot of demerol. They have at the time of the injection the contrast material, vve use fifty per cent Hyopaque, about eight ccs. which is injected in the common carotid artery. Patients have a warm feeling in the face and the eye and the throat, in most instances. I t is not too disagreeable, although they don't particularly like it. We have followed these cases along, as I said, on an out-patient basis for a good many months following operation. I think the fact th a t they still come from considerable distances and permit this type examination to be done over and over as a follow-up indicates to me it is not too bad. D r. I. Goldowsky: D r. Cushman. Dr. G. F. Cushman: I would like to know if Dr. Crawford has had any success in demonstrating mesenteric insufficiency,' and so, susceptible to treatment. Db. 8. Crawford: We have not had a patient with chronic arterial in sufficiency of the superior mesenteric artery. We have not had but one patient with acute arterial insufficiency of the superior mesenteric artery. The latter patient was one due to dissecting aortic aneurysm; although we were successful in restoring circulation to the bowel of the patient, he did not survive his disease. I am sure you are familiar with Dr. Robert Shaw's work in the chronic arterial insufficiency of the superior mesenteric artery, and the Massachusetts General Hospital where they have a very active gastro-intestinal clinic. They have quite a number of patients with the Sprue syndrome there. Knowing the patients have an embolus of the superior mesenteric artery or mesenteric thrombosis or what have you, frequently have diarrhea and so on. He studied some of these patients, these techniques, our ateriography and were able to demonstrate in some of them th at they had occlusions of the superior mesen teric artery. As I understand, he has operated on two of those patients now and has been using these direct techniques and has been able to restore eircula- ' tion and relieve them of their digestive disorders. Unidentified Voice: Is there any occasion now to use the old wiring of the aneurysm? D k. Stanley Crawford: I wouldn't. I am highly doubtful there is an occasion for the use of the wiring operation a t the present time, b u t I certainly 5 ,.-ris&^&BIii'llf"fisiifr^^^-'SBSi'liit'^ie*U?v>^'''-fs - \ --; 'v ; ' . ' 4:: fcj -, . -j.'^'i i /'' y x -.i-'.' w ''^ .. .- . ...y . *?'*?*-e-'--.. .-o - - ' . ,-.e^<:' .-. -. - .a, j W -.' .- . vr*" 78 Association. of American Railroads would w ant to be very careful in making such a statem ent as th a t saying never, because I was fortunate enough to be in surgery when that operation was still being done. I can recall patients who had severe bronchial obstruction, say with collapsed lung on one side and having a great deal of trouble, and we would wire the aneurysm; something would happen right afterwards; it would permit a better airway. This bronchus would open up, and the lung would become inflated. They would just be better, although their total life didn't seem to be extended a great deal. The aneurysm went ahead and ruptured a few months later. I have seen in some instances improved aneurysms, appear to be, by what was done; whether it was the wiring or not, I don't know. I can visualize the possibility of a patient with a large thoracic aneurysm th a t was obstructing the trachea of the bronchus, and the patient's age or general condition or something would not permit the excision and graft. I would think th a t there would be times when one would from the local anes thesia wire such an aneurysm, possibly. I don't know, but I think it would be a possibility. D a. I. Goldowsky: Any other questions? D b. F. S. M obrison: Dr. Crawford, th at was a very nice paper. I would like to ask when do you recommend carotid arteriogram to check for these carotid obstructions? right after the CVA or after they have recovered from them or had something to do with the extent of the original accident? In other words, if they have had a severe one, complete hemiplegic, do you recommend it a t all? D a. Stanley Cbawford : In my opinion, there is no definite way of making the diagnosis--there is no way th a t I know of--th a t you can be certain of tell ing whether or not the lesion is inside or outside the skull. In other words, there is no way th at I know of you can tell whether this patient is suitable for operation th a t will relieve him, short of an arteriogram. The only way you can be safe as to whether or not this patient is a candidate for an operation which in my opinion is being established. As far as I am concerned, it is estab lished. But, more and more referring physicians are being convinced of it which is a good sign, and I think they should be routinely performed on all patients who have strokes. Now, once the internal carotid artery occlusion becomes complete, although it is localized, the atheroma clots; a thrombus develops on top of it. There are no branches of it; there is a long segment of internal carotid outside of the Bkull. But, it has no branches. Even though this little short thing blocks off that, blood doesn't stay liquid in th a t big long segment; it clots. And, the lesion then does extend inside of the head. Under those circumstances it does become an impossible situation from a surgical point of view unless they operated upon him very early. Of the completely obstructed arteries of the internal carotid group th a t success was obtained was in one operation upon a patient right away. We were able not only to take out the atheroma but pull the clot out like pulling an angleworm out of a hole. Since this patient did not have a severe stroke and consequently had not had irreversible changes in his brain, he recovered. Now, there is no question b ut what the best group of those in which the occlusion is incomplete because it is still discrete and localized, and it is in th a t group th a t the syndrome is more ap t to be the small stroke, the transient one. The longer it takes to recover from it temporarily. Tb think over a becon I tb single A f. that 1 charge saved Ith hospit saddle service like to who 01 I t r< was as around donke\ droplet droplet conden let in 1 Ith able, have I tn longer able. Db I W (Ap: Has I the-r( very ments be put office If thing able Dr to cal Waite to be Wh recess (Sh Proceedings of Medical and Surgical Section 79 The fact that they have had this little thing and they have recovered, they think they might not have it again. But, the majority of them will have them over and over whether they are given anticoagulants or not. I t will eventually become complete and what I said would happen to them on th a t slide. I think th a t you have to appraise all these cases with an arteriogram, every single one of them. A fellow comes in with a bad leg, there isn't a doctor, certainly in Texas, I th a t has a patient with a bad-looking leg th a t doesn't jump on his white ! charger and have something done about it because he thinks his leg can be saved. I think the same thing about the strokes. I think it is a bad thing about the old CVA in a stroke patient. All the hospitals I have ever worked in, it has been a fight as to who is going to be saddled with those patients, the medical service trying to get the neurologic service to take them. Now they are very happy th a t the surgery service would like to take some of them. I t is condemning to doctors to attend to patients who ordinarily are not too agreeable. I t reminds me a little bit of one of my chemistry professors during the war was assigned to making booby traps for the army in North Africa. He looked around, and he made a very effective one. As you know, there are a lot of donkeys in North Africa. At th a t particular time it was covered with donkey droplet. Well, my buddy devised a booby trap th a t looked just like a donkey droplet. He said that the greatest thing he got out of this war was th a t he condemned the Germans to contemplating and inspecting every horse drop let in N orth Africa. I think these patients with the CVA's and what not are sometimes disagree able, and perhaps we are condemned to taking care of the type of patients th a t I have not been very popular in the past. I think since something can be done about these to relieve them, it is no longer an incurable disease, and in many instances they will not be disagree able. D b. I. Goldowsky: No more questions. I want to thank you very much Dr. Crawford for a very fine presentation. (Applause) Has Dr. Ochsner arrived? I have one little item I want to talk about. We have had quite a bit of offthe-record discussion here. I w ant you to know th at all these proceedings are very carefully edited before thay go into final print. We have made arrange ments for Mrs. Gore to make a separate typing or transcription. I t will not be put in the proceedings at all, but it will be available from Mr. Parker's office in Chicago for reference only. If anyone is in disagreement with that, please say so. If you do have some thing th at was said off the record th a t you want to refer back to, you will be able to get it from Mr. Parker. Dr. Ochsner is still delayed, so I am going to go on. At this time I am going to call on our Railroad Retirement Board, Mr. Eugene E, Koch and Mr. W alter R. Knolle. Will they come up here? I think they have a machine to be put in order. While they are marching up here and getting ready, we will take a short recess. (Short recess.) 80 Asaociftficm o f Am erican Railroads D b. I. Goldowsky: Gentlemen, will you kindly be seated so we can pro ceed with our program? A t this time I want to introduce Mr. Eugene E. Koch of the Railroad Re tirement Board. Mb. E ugene E. K och (Assistant Director of Unemployment and Sickness Insurance, Railroad Retirement Board, Chicago, Illinois): We are going to show you an audio-visual presentation about unemployment insurance. I This presentation has been developed by the Railroad Retirement Board and has been approved by the Association of American Railroads. As you know, the Railroad Retirement Board pays unemployment insurance benefits. These benefits are financed entirely by contributions made by the railroads. The management of the railroads have been increasingly concerned over the cost of unemployment benefits and measures th a t can be taken to keep ex perienced people working. i This presentation which we are about to show you indicates the accomplish % ments th a t have been achieved by the railroads, by the Railroad Retirement Board, working together. I t gives some indication of what we might hope for in the future. We are ready to show now. (Presentation "Keep Experience at Work." ) Dk. I. Goldowsky : I believe Mr. Walter Knolle has a few words. M b. W. Knolle (Railroad Retirement Board, Chicago, Illinois): I will let Mr. Koch speak for me. ! M r. E ugene E. Koch: Gentlemen, I really have nothing more to say. The film and soundtrack speak for themselves, but Mr. Knolle and I will be glad to answer any questions th a t you might have. T hat takes care of th at part of the program. D r. I. Goldowsky: Any questions from the floor? Does anyone desire to ask Mr. Koch any questions? If not, that is it. I would like to assure the Railroad Retirement Board the Medical and Surgical Section will do all it can to help keep the men on the job > and off the job in other jobs. 4 Mr. E ugene Koch: Thank you very much, Dr. Goldowsky. (Applause) Thank you all. Dr. I. Goldowsky: Now, a t this time I want to proceed with our meeting, and we will have our address on "Noxious Substances as a Causative Factor )i iSnchCoaorlcoinfoMmeadiocfinteh,eTLuulannges,U" nbiyveDrsrit.yA; DltoirnecOtocrhsonferS,uPrgreorfye,ssOorchosfneSrurCgleinryic, and Foundation Hospital; Dean of Visiting Surgeons, Charity Hospital; Consulting, Illinois Central Hospital, and Southern Pacific Railway. I can assure you, Dr. Ochsner, you may not have spoken to such a small group, but you probably have never spoken to such a select group. D r. Alton Ochsner (Ochsner Foundation, New Orleans, Louisiana): Thank you, Mr. Chairman: I t is indeed a pleasure for me to be here. When Dr. Olson called me and asked me if I would talk, of course, I was very happy to because I am extremely 4 grateful to tl have much t< Central and years. As many noma of the years ago, ai Been and ope The only rea thoracic surge We know matter of fa carcinogen Schneeberg of the carict This is du._ Chromates the monochro of carcinoma Germany. There is in individua among plum Probably smoke. I t doubt that The abov< now, to con lung cancer the general Exposure dockerers And bei cancer th Blast fi the Japan taken to Other arsenic w ess engrs versity st All of higher inc obvious tl eupations have in Aside ship betwi there is I attem was any , i , _ 11- - slS lS Proceedings of Medical and Surgical Section 81 grateful to the two railroads with which I am affiliated. I don't know th at I have much to do with them, but I have enjoyed my affiliation with the Illinois Central and the Southern Pacific. I have been with them for a number of f years. As many of you know, I have been very interested in the question of carci noma of the lung for a long time. My interest was started about twenty-five years ago, and I have had the rather unique experience of probably having seen and operated upon more patients with carcinoma than any other person. The only reason for th a t is I started my surgical career just a t the time when thoracic surgery was being developed. We know th a t radioactive substances produce carcinoma of the lung. As a m atter of fact, the first evidence of carcinoma of the lung was produced by a carcinogen was shown in the mines in Schelesia and Czechoslovakia where the I Schneeberg and the Joachimsthal miners were found to have a high incidence $ of the cariconoma of the lung. k This is due to radio-active substances, particularly uranium and cobalt. Chromates are also known to produce carcinoma of the lung, particularly the monochromates. In the United States chromates are accepted as a cause of carcinoma of the lung, although it is not compensable by law. I t is in f Germany. t There is very good proof th at asbestos is a cause of carcinoma. This is seen in individuals working with asbestos, particularly miners. I t is also seen among plumbers who work with asbestos, seamfitters, particularly. Probably the most important carcinogenic agent in lung cancer is cigarette f v smoke. I t is a known carcinogen, although there are 3ome people who still doubt th a t there is a causal relationship between smoking and cancer. The above mentioned factors are proven carcinogen agents, I would like, now, to consider factors in which there is a suggested relationship in that lung cancer occurs with slightly greater frequency among these workers than the general population. Exposure to certain metals (welders, for instance), Boiler Scalers, grain >* dockerers (have a higher incidence, particularly in England). And beryllium workers, there is a suggestion of a higher incidence of lung cancer than the general population. Blast furnacemen, and particularly steel furnacemen, have been shown by the Japanese to have a greater incidence of lung cancer. And, steps have been taken to prevent it. Other occupations are painters and varnishers, lubricating oil workers, arsenic workers, nickel workers, tobacco manufacturers, lithographic and proc ess engravers, tailors' clothing workers, drapers, bartenders, butchers, uni versity staffs, office staffs, commercial travellers, porters, and diamond cutters. All of the above mentioned occupations have been mentioned as having a higher incidence of brouchogenic cancer than the general population. I t is obvious th a t few if any of them have anything in common as far as their oc cupations are concerned. There is only one thing, I think, th a t they probably have in common, cigarette smoking. Aside from the first group I gave in which there is a very definite relation ship between the occupation and lung cancer, there is no occupation in which there is apparently a relationship. I attem pted because I was talking to railroad surgeons to find out if there was any study in which the railroads might be incriminated because I am sure th a t is the thing you people want to know about. , ^ ' ^ } f ? ^ k ^ ^ '/:^M & '?^r;-` 82 _________Association of Am erican Railroads There is only one study th a t 1 could find; th a t was by Heuber who, as you know, is a member of our National Health Laboratories and who has done a great deal of work on occupational cancer. Heuber did a study in which he showed there was a higher incidence of cancer among the operating staffs of the railroads than among the non-operating staffs. But, this was very incomplete because there was nothing in this study said concerning their smoking habits. Obviously, among the operating staffs of the railroads, there are very few women; most of them are men. The women are mostly in the offices. I think th a t th a t is probably the reason why the incidence of cancer of the lung was higher among the operating staff than among the non-operating staffs. I think if the smoking habits were known, it would be shown th at the indi viduals who have the cancer of the lung are smokers. I am convinced th at whenever you see cancer of the lung aside from those working with radio active substances or those working with chromates, or asbestos, that the indi vidual who develops cancer of the lung is probably a very heavy smoker, and that his smoking habit is the thing that is responsible for his cancer and not his occupation. Now, just a word about the incidence of cancer of the lung. I t is something about-which you and I must be concerned. In Massachusetts cancer of the lung is the most frequent cancer--superseding since 1950 even cancer of the breast. I t increased from 3.08 per 100,000 in 1930 to 42.16 in 1955! Cancer of the lung is now the most frequent visceral cancer in both sexes. I t has outstripped everything else. In 1930 twenty-five hundred people died of cancer of the lung; in 1956 I twenty-nine thousand died of cancer of the lung. T hat isn't coincidental. We know that cancer of the lung is much more frequent among men than among women. I t is thought to be due or said to be due to a sexual relation ship. I t isn't at all. Until the mid '30's the incidence of cancer of the lung was the same in both sexes. About 1934 there was a tremendous increase I in cancer of the lung of men, and there has been a slight increase in the inci dence of cancer of the lung in women. Why is this? In 1914 at the start of the First World War, men began smok ing cigarettes heavily. The twenty-year-long period from the First World War until the mid '30's is just about the length of time for the cancer-producing affects of cigarette smoking to produce its effects. In New York State where the vital statistics are also valid, from 1931 to 1950 there has been a 385 per cent increase in the incidence of cancer of the lung in men. And, during this same period of time, all other cancers increased only two per cent. In women the increase in cancer of the lung was sixty-eight per cent during which tim e all other cancers decreased fifteen per cent. Cancer of the lung is the only cancer th at is increasing in both sexes. This has been true not only in our own country, b ut it has been true in other civilised countries where people smoke. In Holland from 1924 to 1951 there has been a tenfold increase in the incidence of cancer of the lung in women, and a twenty-four-fold increase in the incidence of cancer of the lung in men. In England from 1920 to 1954 there was a thirty-eight-fold increase in the incidence of cancer of the lung in men. In fact, in England, 1953, of all the men who died from all causes between the ages of forty-five and fifty-five, the most productive years of a man's life, ten per cent died of cancer of the lung. 15 The st tween sn cidence more tha that the United have sine years ag terrific years, ten or fifi be almost Cancer greater greater This lung, fifty-five the lung Why one reas heart and tkrombo A dubi cancer-of disease himself no one I t is There the Cka tical. among number stand, Service But can Ca by two The by bar habits The non-sn Proceedings of Medical and Surgical Section 83 The statement is frequently made: There can be no causal relationship be tween smoking and cancer because, if there were, we should have a higher in cidence of cancer of the lung in the U. S. than in England because we smoke more than the English. This is a truth, b ut it is only a half truth. I t is true th a t the incidence in cancer of the lung is higher in England than here in the United States, and it is true th at we smoke more than the British do. But, we have smoked more than the British only for the past nine years. Prior to nine years ago, they smoked much more th an we; and they are now paying the terrific price for their tremendous smoking for the past twenty-five and thirty years. I t is frightening to me to think w hat is going to happen to us in another ten or fifteen years when our smoking habits catch up with us. I t is going to be almost a catastrophe. Cancer is a disease of older age; of all the persons ninety years of age, a greater percentage will have cancer than those eighty. Of those eighty, a greater percentage will have cancer than those seventy, and so on. This is true of every cancer except one. The one exception is cancer of the lung. Cancer of the lung increases very sharply to reach a peak a t the age of fifty-five following which with advancing age, there is a decrease. Cancer of the lung is the only cancer that doesn't follow the pattern of all other cancers. Why does it behave differently? I t behaves differently for one reason, and one reason only: The individuals who have smoked heavily and subjected their heart and blood vessels to the deleterious affects of tobacco, develop coronary thrombosis, die and don't live long enough to develop cancer of the lung. A dubious advantage of smoking, therefore, is th a t one can spare himself a cancer-of-the-lung death by smoking heavily and dying early of coronary disease. One might carry analogy a little further and say th a t one might spare himself a death from both these causes by shooting himself a t forty which no one would suggest, of course. I t is a slow form of suicide, but it is just as certain as shooting ones self. There have been several statistical studies made, which Dr. Little who is the Chairman of the Tobacco Committee outwages because they are statis tical. The basis of all our knowledge is statistics and everything in medicine, 1 don't have to tell you, is based upon statistics, ultimately. I am sure th at the railroads are run by statistical analyses. To poo-poo statistics as not being worthwhile, is simply abating tho question. There are two types of statistical studies in a problem such as this: One is retrospective, which consists of the determination of the number of smokers among a group of patients with cancer. There is some criticism to this method because it is a selected group. Prospective studies consist of determining the smoking habits of a large number of individuals and following them for a number of years and de termining what happens to them. There is no selection here. There are two studies which have been reported so far. A third one, I under stand, is to be reported very soon. T h at is being carried out by the Veterans' Service. B ut the two that I want to speak about today, one was done by the Ameri can Cancer Society here in the United States, and the other done in England by two physicians, Doll and Hill. The British study was concerned with the medical profession. I t was done i by having the physicians fill out a questionnaire concerning their smoking habits and then following them. And, this is the result Of th a t Study. The incidence of cancer of the lung per hundred thousand population, in the non-smokers was seven; in the pipe smokers, thirty-eight; in the pipe and _ V f. t. ^ S> 84 Amocinlion of American Railroads cigarette smokers, sixty-eight; and the cigarette smokers, a pack or more a day, 125. This study shows th at there is a relationship between smoking and cancer. I t further shows th a t not only waB there a relationship, but the relationship varied according to the amount smoked; the non-smokers seven; up to fourteen cigarettes a day, forty-seven; from fifteen to twenty-four cigarettes a day, eighty-six; and more than twenty-five cigarettes a day, 166. I t is almost like a mileage figure. One can determine how soon one wants to develop cancer of the lung by the amount th at he smokes. If he doesn't want to develop it a t ail, don't smoke as I don't. If he wants to develop it soon, smoke heavily, because he is going to develop it soon. I am frequently told: Well, it won't do me any good because I have smoked too long, and the die lias been cast. Dr. Graham said this several years ago and he used to chide me about my belief concerning the relationship of Bmoking to cancer. But then he became convinced th at there was, and he became quite intolerant of the people who smoked. The tragic fact is th at Dr. Graham who did the first successful pneumonectomy for cancer of the lung died of cancer of the lung himself. I t is not necessarily true th at the heavy smoker is doomed and th at he can't be benefited if he stops because the pre-cancerous changes are reversible we know now. And the studies by Doll and Hill show it. They Bhow th at in those th a t continued smoking, the incidence of cancer of the lung was 103; in those th a t discontinued smoking, but had discontinued less than ten years, it was fifty-nine; in-those who had discontinued over ten yeare, it was thirtythree; as contrasted with seven in which the group had never smoked. The American Cancer Society study consisted of twenty-two thousand voluntary workers, young workers in the United States, interviewing two hundred thousand men between the ages of fifty and seventy. These are the ages of which cancer of the lung are found. These young ladies had each of the men fill out an elaborate questionnaire concerning their smoking habits: whether they smoked at all, what they smoked, how long they had smoked, how much they had smoked, and if they have ever stopped. These questionnaires were filed a t the Cancer Society Headquarters, and | ehaacdhinyteearrvieeawchedofthteheyeyaorunbgefloardei.es Trehienrteerwviaeswaeldmeoascthaofnitnheetym-neinnewpheormcsehnet follow-up. After a six-year period of time, a little over twelve thousand men had died. In those th a t died, she got a photostat of the death certificate and sent it to the Cancer Society Headquarters. If they had died of cancer and had an autopsy or biopsy, she got a piece of the tissue and sent th a t in to the Cancer Society. The results of this study showed th a t the overall death rate was 105% higher among cigarette smokers than non-smokers; the death rate from heart disease was 115% higher among cigarette smokers than among non-smokers; and, the death rate from lung cancer was 800% higher among cigarette smokers than among non-smokers. I have yet to see the physician who doubts th a t there is a relationship except two individuals: One is an individual who is an employe of the tobacco com panies, and the other individual is the individual who is addicted to tobacco himself. Naturally, I am going to try to excuse th a t which I do. I am not willing to admit th at anything I do is harmful to me. 1 Several year; of the America: can be no cai,s were, why do Of course, talked to Dr. about it. He then started the name of membrane of smokers--the leading to car We have b Bumption in whereas, in dropped dowi There is consumption of Many more States, only are women. Smoking i fifteen, inclu from sixteen Dr. Graho tween smokn,, work showing th They used smoked sixty a drag for tw residue was this combinat three times At the en of applicatic site of the of the animal was indisting the animalB In the coi a t the end I emphasis Dr. Graham H e did not, The state cancer with tion. It producing Since we cancer, that there is a lrnnw there A.; Proceedings of Medical and Surgical Section 85 >r more a 1t Several years ago while attending a Cancer of the Lung Committee meeting of the American Cancer Society, I was distressed because someone said, "There td cancer, lationship 3 fourteen es a day, S: can be no causal relationship between smoking and cancer because, if there were, why do we not see pre-cancerous lesions?" Of course, not being a pathologist, I couldn't answer this. I came home and talked to Dr. Dunlap, our Professor of Pathology a t Tulane, and asked him about it. He thought for a moment. He said, "We don't look for it." They me wants le doesn't levelop it then started one of our senior students on a piece of investigation, a man by the name of Costello. This work demonstrated th a t although the mucous membrane of the tubes was normal in non-smokers, definite changes occurred in smokers--they were most marked in heavy smokers with precancerous changes 'e smoked -3ago and noking to ime quite ham who of cancer leading to cancer. We have become a cigarette-smoking nation. In 1880 the per capita con sumption in all persons fifteen years of age and over, annual, was sixteen; whereas, in 1953, it was 3,556. The only solace one gets is th a t in 1956 it had dropped down to 3,193. There is a parallelism between the incidence of cancer of the lung and the consumption of cigarettes. i th at he reversible iw that in as 103;in en years, as thirty- M any more men smoke than women. Among the non-smokers in the United States, only twenty-three per cent of them are men, and sixty-seven per cent are women. 3 Smoking is common among teenagers. Of the teenagers from thirteen to fifteen, inclusive, thirty-seven per cent smoke at the present time. Of those from sixteen to nineteen, inclusive, sixty-seven per cent smoke. ! Dr. Graham who originally thought there was no causal relationship be ' ? thousand wing two tween smoking and cancer finally with Dr. Wingner did the most conclusive ' !: work showing th at there was a carcinogen in the smoking of cigarettes. /- se are the They used a smoking machine which looks like a giant candelabra. I t smoked sixty cigarettes at a time, just as a human would. Every sixty seconds : stionnaire a drag for two seconds was taken. The smoke was collected, cooled and a tar 'hat they residue was obtained. The tarred residue was added to a solvent acetone and ad if they rters, and ! this combination of the tar and acetone was applied to the skin of animals three times a week. I At the end of eight months, one non-cancerous tumor developed at the site whom she of application of the tar. At the end of a year, one real cancer developed at the i per cent site of the application of the tar. At the end of two years, forty-four per cent of the animals developed at the site of application of the ta r a cancer which had died, sent it to d had an. tie Cancer was indistinguishable from human cancer in th at it metastasized and killed the animals. In the control group to which only the solvent was applied, not one animal at the end of two years developed either a non-cancerous or cancerous tumor. I emphasize this latter p art because the statement is frequently made th at 5% higher .rt disease ; and, the kers than Dr. Graham's work is of no value because he used cancer susceptible animals. He did not, because in the control group, not one animal developed cancer. The statement is also frequently made th a t one cannot compare animal cancer with human cancer. No attem pt is made to do so in this exprimenta tion. I t simply shows there is, without any question of a doubt, a cancer- lip except acco com0 tobacco 1 am not producing agent in the smoke from cigarettes. Since we know th a t cancer of the lung ia increasing more th an any other cancer, th a t it ia the most frequent visceral cancer today, and since we know there is a cancer producing agent in the smoke from cigarettes, and since w e. know there is a parallelism between the consumption of cigarettes and the , ' t . t v*. ; " - t ;V: 86_____________ Association of Am erican Railroads incidence of cancer of the lung, the only logical conclusion is there is a causal relationship. I am frequently asked if filters help. I always answer in the affirmative. They help sell more cigarettes. T hat is all they do. In 1954 we spent per capita in the United States eight cents for the control of heart disease, and we spent fourteen cents for the control of cancer. We spent twenty-two cents per capita to control the two principal killers. During the same time we spent thirty dollars per capita for cigarettes. In other words, we spent 136 times as much to cause or aggravate the two principal killers as we did to prevent them. The British are more courageous than we. The following is the inscription via large yellow posters--displayed in all public places in England. "To all smokers: "There are now the strongest reasons to believe th a t smokers, par ticularly of cigarettes, run a greater risk of lung cancer than non-smokers; the more cigarettes consumed, the greater the risk." I mention this simply to show the courage th at the British Government has in posting in all public places this poster. I t shows th a t they have assumed the obligation which I think government should. I am sure what I have said to you isn't going to make any difference in your smoking habits, but I hope th a t when and if anybody makes a claim against any of your railroads because of cancer of the lung, they have gotten on the job, th a t you go and find out what their smoking habits are. If they have an adenocarcinoma, it has not been produced by smoking because it is not related to smoking. I believe th a t smoking is the most valuable diagnostic criteria we have as far as carcinoma of the lung is concerned. Six years ago I made the statement th a t any person who has a lesion of the lung th a t might be cancer, if they do not smoke, it is either not cancer or it is an adenocarcinoma. In the six years, I have been wrong only twice. There is no other diagnostic criteria that is th a t accurate. Whenever a claim is made against the railroad because a patient has de veloped carcinoma of the lung, inquire into his smoking habits. And, I can assure you that man, if he has an epidermoid or undifferentiated carcinoma, which he is most likely to have because adenocarcinoma is rare (only about twelve per cent of all carcinomas among adenocarcinoma), has been a heavy smoker. He may not be a smoker a t th a t time. But, he will have been a heavy smoker, and I can assure you th a t his cancer of the lung has been pro duced by his smoking and not by his occupation. I would urge those of you who treat patients and those of you who smoke to have a chest plate done a t least every six months so when you do develop cancer, it can be detected a t a time while it is still operable. Because I am just as convinced as I am standing here, if you don't die of something else first, you are going to develop cancer of the lung. The only thing th a t will save you is th a t you might die of something else. Thank you very much. (Applause) D r. I. Goldowsky: Thank you very much, Dr. Oehsner. I think it iB a pleasure for our group to hear th a t there is one illness not blamed on the rail road industry. I think we have been blamed for most everything else and have suits and claims against us. Proceedings of Medical and Surgical Section 87 I think it is a compliment to your crusading spirit th a t I cast my eye over your audience, and I didn't see a cigarette being lighted during your whole talk. Are there any questions from the floor? Harlan Hackbert. Mb. H ackbert: I would like to ask the Doctor about the incidence of chromates and carcinoma of the lung. Chromates are used in the railroad industry in two forms; one in a powdered form as it is used in mixing cooling solution used in the diesel locomotives; and the other as the chromate is found in the cooling solution. Can you tell us something about the manner in which chromates affect cancer of the lung? Dr. Alton Ochsner: I have had no experience with chromates or car cinoma of the lungs produced by chromates at all. I can only give you what I have gotten from my reading. As far as I can determine, it is found only in individuals working with a very high atmosphere of chromates, and then only monochromates. I t is not extremely common, but I think it is found only in where it is mined and in the factories; th a t is as far as I have been able to determine. Mr. H ackbert: In the production rather than the use? D r. Alton Ochsner : In the production of it. I have never found anyone calling attention to the fact in its use. monochromate th a t is responsible; I think everyone is agreed to that. I t is a Unidentified Voice: Am I right in th at Dr. Little of Bar Harbor is being discredited a t this time; he is not a clinician. He is only a laboratory man. He lost his first mice in the fire up there, b u t his work was based wholly on laboratory and not on clinical findings? Dr. Alton Ochsner: Dr. Little has done no work a t all on cancer of the lung. He knows nothing about cancer of the lung. I doubt th a t he has ever seen a case. As you said, he is not a physician. He is a Ph. D. He is a geneticist. Dr. Little is talking about something he knows nothing about. H e is the front man. He is paid a salary of twenty-five thousand dollars, and, of course, I suppose persons will do a lot for twenty-five thousand dollars. Unidentified Voice: Dr. Ochsner, what possibility exists for removing the carcinogenic factor from tobacco? W hat is being done along th a t line? Dr. Alton Ochsner: Of course, th at is the thing th a t distresses me about the tobacco people. I feel th a t something can be done. There are two factors in tobacco which are harmful: One is nicotine. Nico tine produces heart disease. There isn't any question about th at. There are available today nicotine-free tobaccos. Those are not the so-called denicotinized cigarettes. Because, the denicotinized cigarettes have almost as much nicotine as do the other cigarettes. The denicotinized cigarettes advertise they have less th an one per cent nicotine, implying they have removed ninety-nine per cent of the nicotine. - its*, , 'V . i d ru, i b , ,, s W . * t >< SS Association oj American Railroads The average cigarette has only about one per cent. They have removed so little, it actually makes no difference. But, there are available today, which can be grown, tobaccos which have no nicotines a t all. The thing th a t causes cancer is not nicotine; it is tar. Whether this car cinogen can be removed or not, I don't know. I think it possibly can. But, there has been no attem pt to do so; th a t is the thing th at distresses me. There has been no attem pt to do it. They haven't assumed any obligation a t all. The industry and their Research Committee have spent their money trying to confuse the issue. For instance, they are trying to blame it on smog. One might accept smog. For instance, they say the reason for the high incidence in London is because of smog. There is a terrific smog in London, as everyone knows. But, im mediately across the English Channel in Denmark about thirty miles away where the people smoke the same as they do in England and where the incidence of cancer is the same as it is in England (as a m atter of fact, it has assumed epidemic proportions in Denmark), there is no smog whatsoever. The inci dence of cancer of the lung is higher in New Orleans than it is in any other city. New Orleans is first; Pittsburgh, eighth. Now, you might ask me why. The reason is in New Orleans for years people have smoked these Picayune cigarettes. For those of you who don't know what a Picayune cigarette is, it is a very strong cigarette. if The final reason why smog has nothing to do with it is th at if smog had ! something to do with it, women ought to have the same incidence. We always adm it th a t their minds are purer than ours, but they breathe the same putrid air we do. The reason is the man-made smog th a t he himself takes in; and I believe th at this thing can be solved. I think they ought to be spending their money, a part of th a t hundred million dollars th a t they are spending, for advertising, trying to find out w hat this thing is and giving those of you who have the infantile urge, the suckling reflex, a cigarette th a t is safe. T hat is all it is. I ! Unidentified Voice: Why the difference between cigar smoking and cigarettes? i Db. Alton Ochsneb: There are several reasons: One is th a t the cigar smoker doesn't smoke as much. The cigar smoker does not inhale. One must get the carcinogen in contact with the tissue to produce cancer. There is a third reason which the tobacco people have not made use of. I suppose they won't because of the cost. The third reason is th a t there is less of the noxious alkaloids in cigars than the other tobaccos because of the way in which it is cured. 5 You people who come from the tobacco areas know more about this than I. 3 The tobaccos for cigars are w hat they call "shed cured." The leaf is picked, and it is kept in a shed for many years. I happen to know the man who makes ; the King Edward Cigar, which you know is a cheap cigar. They keep the tobacco for the King Edward Cigar for three years. This is kept a t room temperature. As a result, there is an enzymatic process which occurs in the leaf which tends to break down nicotine and other alkaloids. All the other tobaccos are picked, p u t in the shed and heated to 140 degrees. That immediately stops the enzymatic process. T hat is the reason why the ! cigar tobacco ac other types. Unidentified not smoke? D r. Alton undifferentiating smokers. Me . H ackbert mean much to here. In what other other words, w possible cause of Dn. Alton Oc; to bring out tl them. I gave a causal relatio there had been them. Mb. H ackbert D b. Alton The first ca Pereival Pott Some of the their clothes bei is a lack of cleai There are ma I didn't go in extracted from I think what and remove the' Db. J. R. " D r . Alton einogen in toh I am sure e number of peo a t all. I t is p If one finds a just pure toba I think the of combustion. Unidentified D r. Alton  !-iff.:_Xvfi.^ ' ads They have removed so ., tobaccos which have no i tar. Whether this carnk it possibly can. But, hat distresses me. There any obligation at all. spent their money trying One might accept smog, ace in London is because sryone knows. But, imabout thirty miles away 1 and where the incidence c of fact, it has assumed ; whatsoever. The incian it is in any other city. Orleans for years people of you who don't know te. h it is that if smog had le incidence. We always breathe the same putrid kes in; and I believe th a t spending their money, a sending, for advertising, se of you who have the lafe. een cigar smoking and : One is th at the cigar ea not inhale. One must luce cancer. There is a : use of. I suppose they .ere is less of the noxious f the way in which it is lore about this than I. ed." The leaf is picked, now the man who makes > cigar. They keep the This is kept at room iccurs in the leaf which id heated to 140 degrees. ,t is the reason why the Proceedings of Medical and Surgical Section 89 cigar tobacco actually has fewer of the noxious substances than do all the I other types. Unidentified Voice: W hat percentage have you operated on th at did - not smoke? D a. Alton Ochsner: Those of the persons th a t had an epidermoid or undifferentiating carcinoma, ninety-eight and a half per cent were cigarette I smokers. f ii M b. Hackbert: You speak of tars carcinogenic factor; th at term doesn't mean much to me. I happen to be a lawyer, not a doctor like the rest of you here. I In what other substances are we going to find th at same tar element? In other words, what other causal factors may the railroad look to as being a possible cause of inhalation causing lung cancers? D b. Alton Ochsner: Well, I suppose there are other areas; but as I tried to bring out this morning, I explored all these areas, and could find none of them. I gave you here those occupations in which it was admitted there was a causal relationship, those factors. Then I gave you twenty-odd of where there had been a supposed increase. There is not a thing in common between them. M b. Hackbert : W hat other substances have the ta r in them? Db. Alton Ochsner: There are many carcinogens. The first carcinogen we knew was coal tar. The chimney-sweep type which Percival P ott described two or three hundred years ago is a type of tar cancer. Some of the textile workers developed carcinoma of the genitalia because their clothes became impregnated with oil if they didn't keep clean. But, th a t is a lack of cleanliness, and so it is with chimney-sweep cancer. There are many cancer-producing agents, * I didn't go into this, but there are a number of carcinogens th at have been extracted from tar. I think what the industry ought to do is to find out what these factors are aud remove them, which they are not doing now. D r. J. R. Knowles: The lead p u t in the paper to produce slow burning would have absolutely nothing to do with i t a t all; would it? D r. Alton Ochsner: I don't think so. I am convinced there is a car cinogen in tobacco itself. I am sure some of you, as we do here in New Orleans, see a rather large number of people th a t have a snuff cancer. Now, snuff, of course, isn't burnt at all. I t is put in the mouth. The most vicious type of cancer we can get. If one finds a very small lesion, we have to do a very wide excision. T hat is just pure tobacco. I t is not burned a t all. I think the carcinogen is in the tobacco. I don't think it is just a product of combustion. Unidentified Voice: Snuff cancer is seen in the nose, as well; isn't it? D b. Alton Ochsner: T h at is right. 0 Association of American Railroads D b. I. Goldowsky: Thank you again. (Applause) I am going to take the liberty a t this time to take a minute or two of Dr. Ochsner's time to maybe expound a little more on the chromates as a cause of cancer of the lung. Twenty-five years ago I was associated with the chrome industry in Jersey City, and the Mutual Chemical Company of America and its manufacturers. I wasn't long with the company when it was my unfortunate experience to run into a small epidemic of carcinoma of the lung. I started delving into the literature. About th at time, about the only thing I came up with, as Dr. Oehnser has told you, was in Germany it was compensable. We had three problems which I had to face as a physician with the chro mates, th a t was the chrome sores th a t hit these men. The amount of chro mates they used in the glass industry, they developed real chrome holes that used to look like a collar button hole. I t was a fine hole, and then it would branch out into a collar button. You really had to scrape them out, dig them out, to get them cleaned up. But, in my years with them, we never ran into any carcinoma of the skin as a result of the chrome sores. Again, we had the chrome holes in the nasal septums. I t didn't take more than about four months of a man's known employment with our company before he had no septum left. T hat stuff is better than any ear, nose and throat man can do. I t really tore a hole through them. As far as the carcinoma of the lungs, I think to expound further, in Germany it was compensable. They found th a t this type of cancer produced by the monochromates was a slow-forming cancer. I think it was recognized only in the compensation cases th a t a man had to be employed in the Schneeberg mines a t least twenty years. If they were employed two or three years, it wasn't recognized as an early form of cancer. I don't know if th a t will help you in your problem. I know it is a dichromate in the chrome you are concerned with the compounds th a t were used. We merely have trouble as far as claims, b u t we are going to leave it to you lawyers to defend them. Now, if you will just bear with me a few minutes, we are going to finish this three-day session. D r. Graham had to leave, but he left me a report th a t he had th a t he would like to have read: " Mr. Chairman and Members of the Section: "Several changes in the organizational setup of the Joint Committee on Railway Sanitation have occurred in the past year, which are reported to you as a matter of interest. "The Joint Committee's brief summary report for the year 1957 was included as a paragraph in the Medical and Surgical Section Annual Report for the Association. "As many of you know the Sanitation Research Committee of the A.A.R. Research Laboratory in Chicago was started in 1951 on the recom mendation of the Joint Committee and placed under its jurisdiction. In December, 1957, by action of the A.A.R. Board of Directors, Mr. W. M. Keller, formerly Director of Research in the Mechanical Division of the A.A.R. was appointed to be Vice-President of Research in the Operations and Maintenance Department of the A.A.R. and to have supervision of research in th a t department, including the office of Sanitation, Research and Development. Proa "The Joint Cor and be called on sanitation researcl " It is contemplc to exhibit an intei and work jointly v "R. M. Grahai Sanitation." I don't have a quoru: ing. Do we have any unfit D r. C. P. H olton: et cetera. . . . The motion was Da. I. Goldowsky: the hotel th at helped us Is there any motion f . . . The motion wa journed. . . . D r. I. Goldowsky: Eighth Annual Meetinj adjourned. While I have a little a 'til we meet next year." . . . Whereupon, the mi Proceedings of Medical and Surgical Section 91 "The Joint Committee will continue to report to Vice-President May and be called on to offer suggestions to Mr. Keller on the problems of sanitation research. "I t is contemplated th a t the Medical and Surgical Section will continue to exhibit an interest in m atters relating to railroad sanitation problems and work jointly with the United States Public Health Service." !`R. M. Graham, Chairman, A.A.R. Joint Committee on Railway f Sanitation." I don't have a quorum present. I don't even know if I can close this meet ing. f Do we have any unfinished business? Is there any new business? D b. C. F. H olton: I move the necessary thanks be extended to the hotel, et cetera. . . . The motion was duly seconded. . . . Dr. I. Goldovsky: Moved and seconded everybody be thanked around the hotel th a t helped us. Is there any motion for adjournment? . . . The motion was made and duly seconded th a t the meeting be ad journed. . . . D r. I. Goldovsky: I t has been moved and seconded th at the Thirty- Eighth Annual Meeting of the Medical-Surgical Section of the A.A.R. be 1 adjourned. While I have a little speaking voice left, I hereby say "goodbye, God speed 'til we meet next year." . . . Whereupon, the meeting was then adjourned.. . . 62 Association of American Railroads OFFICERS AND PERSONNEL OF COMMITTEES OF THE MEDICAL AND SURGICAL SECTION FOR THE YEAR 1868-1059 Dr. B. W. Stockwell, Chairman Dr. J. K. Stack, Vice-Chairman F. J. Parker, Secretary Committee of Direction Dr. B. W. Stockwell, Chairman Dr. J. K. Stack, Vice-Chairman (Term expires in 1959) Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15th and K Streets, N. W., Washington, D. C. Dr. K. E. Dowd, Chief Medical Officer, Canadian National Railways, Montreal, Que., Canada. Dr. V. W. Hollo, Chief Surgeon, St. Louis-San Francisco Railway, St. Louis, Missouri. Dr. J. Huber Wagner, Chief Surgeon, Bessemer & Lake Erie Railroad, 525 William Penn Place, Pittsburgh, Pennsylvania. (Term expires in 1960) Dr. R. J. Bennett, Chief Surgeon, Elgin, Joliet and Eastern Railway, 208 South LaSalle St., Chicago, Illinois. Dr. I. Goldowsky, Medical Director, Central Railroad Company of New Jersey, Jersey City, New Jersey. Dr. W. E. Mishler, Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Dr. B. W. Stockwell, Chief Surgeon, D etroit and Toledo Shore Line Railroad, 3919 John R. Street, Detroit 1, Michigan. (Term expires in 1961) Dr. R. M. Graham, Director, Department of Medicine and Sanitation, The Pullman Company, 165 North Canal Street, Chicago 6, Illinois. Dr. Southgate Leigh, Jr., Chief Surgeon, Seaboard Air Line Railroad, P. O.Box 1620, Richmond 13, Virginia. Dr. Harvey Nelson, Chief Surgeon, Soo Line Railroad, 1453 Medical Arts Building, Minneapolis 2, Minnesota. Dr. J. K. Stack, Chief Surgeon, Chicago and North Western Railway, 127 North Clinton Street, Chicago 6, Illinois. Committee on Disability and Rehabilitation Dr. James K. Stack (Chairman), Chief Surgeon, Chicago & North Western Railway, 127 N orth Clinton Street, Chicago 6, Illinois. Dr. J. F. DePree, Chief Surgeon (Lines West), Chicago, Milwaukee, St. Paul & Pacific Railroad, 1666 Medical and Dental Bldg., Seattle 1, Washington. Dr. J. W. Houk, Medical Director, New York, Chicago & St. Louis Railroad, Terminal Tower, Cleveland 1, Ohio. Dr. R. A. Johnson, Medical Director, New York Central System, Michigan Central Depot, Detroit 16, Michigan. Proc Dr. R. S. Kieffer, Chic Missouri. Dr. Harvey Nelson, Building, Minnea "Dr. G. Earle Wight, Windsor Station, Dr. Southgate Leigh Railroad, P. O. E Dr. R. G. C arothers,1 Railway, Cincinn Dr. Duncan Eve, Chic 2001 Hayes Stree Dr. J. R. Gandy, Chit Texas. Dr. C. F. Holton, C. Georgia. Dr. R. Householder, ( Railroad, Union t Dr. W. E. Mishler, < Cleveland 15, Ohi Committee on De Dr. W. J. Longeway ; way, 520 Metropc Dr. J. J. Brandabur, ( Huntington, West Dr. B. I. Derauf, Cl Minnesota. Dr. J. R. Knowles, Massachusetts. Dr. J. M. L. Jensen, C Chicago, Illinois. Dr. R. S. Westline, Cl West 63rd Street, Committee or Dr. R. M. Graham (Ch tion, The Pullman Dr. M. B. Clayton, C Streets, N. W., W Dr. K. E. Dowd, C Montreal, Que., C Dr. E. C. Olson (Chai Stony Island Aver Dr. K. E. Dowd, C Montreal, Que., C Dr. V. W. Hollo, Chiei Missouri. i l" t Proceedings of Medical and Surgical Section Dr. R. S. Kieffer, Chief Surgeon, Miasouri-Kansas-Texas Railroad, St. Louia 1, Missouri. Dr. Harvey Nelson, Chief Surgeon, Soo Line Railroad, 1453 Medical Arts Building, Minneapolis 2, Minnesota. Dr. G. Earle Wight, Chief of Medical Services, Canadian Pacific Railway, Windsor Station, Montreal, Que., Canada. Committee on Trauma Dr. Southgate Leigh, Jr. (Chairman), Chief Surgeon, Seaboard Air Line i Railroad, P. 0 . Box 1620, Richmond 13, Virginia. Dr. R. G. Carothers, Chief Suregon, Cincinnati, New Orleans & Texas Pacific Railway, Cincinnati 2, Ohio. Dr. Duncan Eve, Chief Surgeon, Nashville, Chattanooga & St. Louis Railway, i' 2001 Hayes Street, Nashville 4, Tennessee. Dr. J. R. Gandy, Chief Surgeon, Texas & New Orleans Railroad, Houston 1, Texas. Dr. C. F. Holton, Chief Surgeon, Central of Georgia Railway, Savannah, Georgia. Dr. R. Householder, Chief Surgeon, Chicago, Milwaukee, St. Paul & Pacific Railroad, Union Station, Chicago 6, Illinois. Dr. W. E. Mishler, Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Committee on Developments Resulting from Physical Examinations Dr. W. J. Longeway (Chairman), Chief Surgeon, Colorado & Southern Rail way, 520 Metropolitan Building, Denver, Colorado. Dr. J. J. Brandabur, Chief Medical Examiner, Chesapeake & Ohio Railway, Huntington, West Virginia. Dr. B. I. Derauf, Chief Surgeon, Northern Pacific Railway, St. Paul 1, Minnesota. Dr. J. R. Knowles, Chief Surgeon, Boston & Maine Railroad, Boston, Massachusetts. Dr. J. M. L. Jensen, Chief Surgeon, Chicago, Rock Island & Pacific Railroad, Chicago, Illinois. Dr. R. S. Westline, Chief Surgeon, Chicago & Eastern Illinois Railroad, 334 West 63rd Street, Chicago, Illinois. Committee on Medical Aspects of Air Conditioning of Cars D r. R. M. Graham (Chairman), Director, Department of Medicine and Sanitar tion, The Pullman Company, 165 North Canal Street, Chicago 6, Illinois. Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15th and K. Streets, N. W., Washington 13, D. C. Dr. K. E. Dowd, Chief Medical Officer, Canadian National Railways, Montreal, Que., Canada. Committee on First Aid Dr. E. C. Olson (Chairman), Chief Surgeon, Illinois Central Railroad, 5800 Stony Island Avenue, Chicago, Illinois. Dr. K. E. Dowd, Chief Medical Officer, Canadian National Railways, Montreal, Que., Canada. Dr. V. W. Hollo, Chief Surgeon, St. Louis-San Francisco Railway, St. Louia, Missouri. ' ' * *-,f - n' * 7 * ^ 94 Association of American Railroads Representatives of the Medical and Surgical Section on the Joint Committee on Railway Sanitation Dr. R. M. Graham (Chairman, Joint Committee on Railway Sanitation), Director, Department of Medicine and Sanitation, The Pullman Com- ' pany, 165 N orth Canal Street, Chicago, Illinois. Dr. M. B. Clayton, Chief Surgeon, Southern Railway System, 15th and K. Streets, N. W., Washington 13, D. C. t* Dr. A. M. W. Hursh, Medical Director, Pennsylvania Railroad, 15 North 32nd Street, Philadelphia 4, Pennsylvania. Representatives of the Medical and Surgical Section on the Special Medical-Legal Research Committee Dr. W. E. Mishler (Chairman), Chief Surgeon, Erie Railroad, 608 Republic Building, Cleveland 15, Ohio. Dr. R. J. Bennett, Chief Surgeon, Elgin, Joliet and Eastern Railway, 208 South LaSalle Street, Chicago, Illinois. Dr. I. Goldowsky, Medical Director, Central Railroad of New Jersey, Jersey City, New Jersey. Dr. Harvey Nelson, Chief Surgeon, Soo Line Railroad, 1453 Medical Arts Building, Minneapolis 2, Minnesota. ' I i