Document n99k9je4j30BoDZKO0YEBkq0G

FILE NAME: International Harvester (INTH) DATE: 1948 Jan DOC#: INTH051 DOCUMENT DESCRIPTION: Proceedings - 8th Annual Congress on Industrial Health - Sponsored by the American Medical Assoc. westin com W estin h o t e l s k R E S O R T S EIGHTH ANNUAL CONGRESS on INDUSTRIAL HEALTH Sponsored by THE COUNCIL ON INDUSTRIAL HEALTH AMERICAN MEDICAL ASSOCIATION CLEVELAND AUDITORIUM CLEVELAND, OHIO JANUARY 5 -6 , 1948 R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO INDEX MONDAY MORNING JANUARY 5, 1948 OPENING SESSION C a l l to Order ................................................................................... Report o f the C o u n cil on I n d u s tr ia l H e alth - C a r l M. P eterson , M.D................................; .............* E s s e n t ia l Correlations Between M edicine and I n d u s t r ia l Research - Arthur J . Vorwald, M.D Panel - H ealth and W elfare in the Ladies Garment In d u s tr y : H is to r y - Max Meyer ............................................................... present Scope and Procedure - I F red erick P . Umhey ............................................................ I M ed ical and H e alth Im p lic a tio n s - Leo P r ic e , M. ............................. ........................................... Pages 1 2 -6 7 8 8 8 - 13 MONDAY AFTERNOON JANUARY 5, 1948 I CONFERENCE ON ADMINISTRATIVE PRACTICES 1Plans fo r Sm all P la n t M edical S e r v ic e s in New York 14 Kenneth C . Peacock, M.D. ..................................... ............... I Experiences in Health Education in Industry Harold M. H a rriso n , M.D. ............................... .. 14 - 31 Panel - How Good Should In d u s tr ia l M edical Exam inations Be? I Discussion Leaders: 34 Oscar A . Sander, M.D............................................................. George H. Gehrmann, M.D..................................................... 35 - 39 W illiam A . Sawyer, M.D.................................................... - 39 - 56 CONFERENCE ON INDUSTRIAL PHYSIOLOGY; I P hysiologic P rin cip les in A viation Medicine Jan Ho T i l l i s c h , M.D......................'............ ....................... P h y sio lo g ica l Requirements in In d u s tr ia l Machine D esign - Theodore F . H a t c h ........... .. The P h ysio lo g y o f the Bone Marrow in R e la tio n to in d u s tr ia l In to x ica tio n - Leonard J . 1 G oldw ater, M .D . ........................................................................................ D is c u s s io n .......................................................................................... 60 - 79 80 - 93 95 95 - 96 R ena H all. E ly CITIZENS BUILDING CLEVELAND 14, OHIO ii TUESDAY MORNING - 9;00 - 10;30 JANUARY 6, 1948 ' CONFERENCE ON RESPIRATORY INACTIO NS Pages Moderator: Austin Smith, M.Do ....................................... Discussion Leaders: M. V. Veldee, ........................................................................... Alvan L . Barach, M.'D............................................................ D is c u s s io n ...................... ............................* ............................ 97 " 99 100 " 120 -*-22 1^3 - 131 CONFERENCE ON NUTRITION IN INDUSTRY Moderator; James S . McLester, M.D. Discussion Leaders; Charles C . Lund, M.D.. ........................................................ Robert S . Goodhart, ..................................................... General Discussion ............................................................... 135--- 153 ^4 154 " 177 TUESDAY MORNING - 11:00 JANUARY 6 , 1948 CONFERENCE ON THE OUTLOOK FOR INDUSTRIAL MEDICAI SERVICE Moderator; A. J . Lanza, M.D. Discussion Leaders; R. L . Sensenich, .................................................................. Herman G. Weiskotten, M.D............................... James R. McVay, M.D............................................................. D i s c u s s i o n ......................................................................... -1-78 178 ^78 179-198 TUESDAY AFTERNOON JANUARY 6, 1948 CONFERENCE ON REHABILITATION Moderator; Frank H. Krusen, M.D.................................. Discussion Leaders; ' Donald C o valt, M.D............................................................... A. R ay Dawson, M.D. . ...................... Thomas B. McKneely, M.D................................................... Howard A. Rusk, M.D.......................... Discussion ................ 1 " _ 284 284 " 287 208 " 211 2^2 " 224 228 " 248 240 " 252 R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO iii TUESDAY AFTERNOON JANUARY 6, 1948 CONFERENCE ON OCCUPATIONAL CANCER Chem ical A sp ects - W illiam T. S a l t e r , M.D.............. C l i n i c a l A sp ects - W. C . Hueper, M.D........................... General D isc u ssio n ....................................................................... Pa g 254 255 255 _ 265 ADJOURNMENT R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 255 CHAIRMAN BROYtiN: We w i l l now go on w i t h th e t h i r d p a p e r b y D r . W. C . H u e p e r on t h e c l i n i c a l a s p e c t s . D r . H u e p e r i s w i t h t h e W a rre n I n s t i t u t e f o r T h e r a p e u t i c R e s e a r c h , New Y o r k . D ra Hueper! . . . D r . W. C . H u e p e r p r e s e n t e d h i s p a p e r . . . (A p p la u se ) CHAIRMAN BROWN; 'There i s , o f c o u r s e , no n e e d t o o v e r emphasize the im portance o f the papers o f the In d u s t r ia l Con f e r e n c e on t h e s u b j e c t o f o c c u p a t i o n a l c a n c e r . I am s u r e t h a t many o f you w i l l w ant to a s k q u e s t i o n s , so we w i l l go i n t o th e d is c u s s io n on t h i s t o p ic . D R . WILLARD MACHLE (New Y o r k ) M r . C h a ir m a n , I w o u ld l i k e to j u s t make one comment, t h a t i s , pulm onary l e g io n cau sed by b e r y lliu m i s a p a p illa t o m a . I t does n o t i n any way resem ble a m a l i g n a n t o r s o r t o f a h e m a t o i d p r o c e s s . To p u t i t i n t h a t c a te g o r y is in the realm o f pure p r o je c t io n and is c o n tr a r y to t h e e v a l u a t i o n b y e v e r y p a t h o l o g i s t who h a s s e e n t h e l e s i o n . CHAIRMAN BROWN; A n y comment? DR. SALTER: C o u ld I a s k D r . M achle to comment a l s o on \ a s b e sto s ? I would lik e to h e ar what D r. M achle th in k s about asbestos as a carcin o g en ic agent in the lu n g s. D R . MACHLE: My e x p e r i e n c e i s too l i m i t e d to o f f e r a n y comment t h a t would be v a l u a b l e . I would have to r e l y on the R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 256 comments o f o t h e r s vh i c h I d o n ' t t h i n k i s i n k e e p i n g w i t h a s u b je c t as im portant as t h is . CHAIRMAN BROWN: je c t has so many a n g le s . Other comments are in v it e d . The s u b B R . RUFUS P . MCCORMICK ( G o o d r ic h , C l e v e l a n d ) ; I would lij^e to in q u ire about th is leukem ic re a c tio n o f b e n zo l. Are you d is tin g u is h in g th a t from the a p la s t ic anemia or are you c a llin g i t th e same t h in g ? D R . HTJEPER* F i r s t I w i l l an sw er D r . M a c h l e . os I used t h e same e x p r e s s i o n / b r . G a r d n e r , th e l a t e D r . G a r d n e r who h a d p ro b ab ly a v e ry g re a t exp erien ce in i t , and he c h a ra c te riz e d these le sio n s a sarcom atoid, d escribed in the lit e r a t u r e . I , p e r s o n a l l y , j u s t s a y I have n o t s e e n on e, so what I have s a id is c itin g Dr. Gardner. Concerning the benzol leukem ia, n a tu r a lly pachyemia and leukem ia are d i f f e r e n t . They a re at o p p o site ends o f the r e a c tio n s c a le . In a pachyemia i t i s a d e s tr u c tio n o f the hemo l y t i c t i s s u e . The t i s s u e j u s t d o e s n 't produce any c e l l s , n e it h e r red c e lls nor w hite c e l l s . In leukem ia you have an over p ro d u ctio n o f white c e l l s . I t Is a h y p o p la sia which has reached the stage o f a m aglignant growth. CHAIRMAN BROY/N: A n y o t h e r com m ents? DR. R0U1TREE; ( L o u is v ille ) ; You mentioned a R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 257 w hile ago that u l t r a v i o l e t l i g h t and ta r may cause c a n c e r . In the case o f s i r i a s i s , what about the treatm ent o f s i r i a s i s ? That is one o f the treatm ents? DR. HUEPER: I th in k th ere is a bundant evid e n ce th a t u l t r a v i o l e t ray s when a p p lie d to the proper person and in the proper amounts w i l l produce can cer o f the s k in . I f you study the r e g io n a l d is t r ib u t io n o f can cer o f the sk in in the U nited S ta te s , in A u s tr a lia , in the A rg e n tin e , in southern Prance, you w ill fin d everywhere a h ig h ly in creased in cid en ce o f cancer of the skin of the exposed p a rts , which is a ttr ib u ta b le in a l l p r o b a b ilit y and taken to g e th e r w ith e x p erim e n tal e v id e n ce in a n im a ls, th a t i s due to the u l t r a v i o l e t p a r t o f the s o la r spectrum . Now th e t r e a t m e n t o f s i r i a s i s w i t h t a r , t h e m e d i c i n a l t a r i s u s u a l l y a wood t a r and n o t a c a rb o n t a r o r m i n e r a l - o i l t a r . W hile there are a few cases rep orted in which the use of m e d i c i n a l t a r o f a l l e g e d wood o r i g i n has c a u se d c a n c e r i n men t h e r e a r e v e r y fe w i n d e e d . So i f we m i s s i n t h e s i r i a s i s , th e c a rc in o g e n ic r e a c tio n upon the a p p lic a tio n o f ta r . . is probably due to th a t a f f e c t . I w ish to p o in t out the m e d ic in a l treatm en t o f s i r i a s i s w ith a r s e n ic i s due to a la r g e number o f m e d ic in a l arsenic cancers. CHAIRMAN BROWN: / Further questions? R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 258 D R . MACELE (New Y o r k ) ; I w o u ld l i k e t o c l e a r up t h i s sarcom atoid and s a r c o id . . D r. Gardner never fo r m a lly p u blish ed a n y th in g on e xp erim en ts w hich d .e a lt w ith the u l t r a v i o l e t . ' When s o l u b l e b e r y ll iu m compound i s i n j e c t e d in t o the r a b b i t s th e y u n if o r m ly a f t e r a p e r io d of 5 to 18 m onths produce s a r c o m a . The d o se s were one g r a m , mean p a r t i c l e s i z e was t h r e e m ic r o n s . That would be com parable to 70 gram dose in tr a v e n o u s ly t o man. The tumors i n c i d e n t a l l y w ere t r i e d on many o th e r s p e c i e s o f a n i m a l s . No tum ors were c r e a t e d and p ro d u c e d i n other sp ecies. To come b a c k t o t h e l u n g l e s i o n w h ic h o c c u r s w i t h some r e g u l a r i t y in man, the f i r s t cases th a t were uncovered were e rro n eo u sly diagnosed as s a r c o id , h av in g in mind the m u ltip le name " s a r c o i d " w h ich f o r many y e a r s was th o u g h t to be an an a lo g o u s r e a c t io n to t u b e r c u l o s is and o n ly r e c e n t l y has come to be a c c e p t e d b y some a s a k in d o f o r a f a m i l y o f the g ra n u lo m a to u s r e a c tio n o f the lung w hich can be produced by the tu b e rc u la r b a c i l l i and by o th er th in g s and o ccurs s p o r a d ic a lly in the p o p u la t io n , and were u s u a lly d is a b lin g d is e a s e . The o n ly te r m in o lo g y I have h e a rd a p p lie d to the b e r y ll i u m lu n g was t h a t o f s a r c o i d and i t i s r e a l l y c o n fu se d w ith s a r c o m a t o i d and some p a t h o l o g i s t s c o n s i d e r i t t h e same f a m i l y o f lesio n but not a ll. * R ena H all E ly CITIZENS BUILDING . CLEVELAND 14. OHIO 259 I would lik e to a v o id the im p lic a tio n th a t there has been e s ta b lis h e d any e t io lo g ic r e la tio n s h ip between b e ry lliu m and lu n g tumor u n t i l such r e la t io n s h ip has c l e a r l y been s e t up. There have been many thousands o f men, th ere have been 54,000 m an-years in one p la n t th a t b e r y lliu m has h an dled w ith p e r io d ic x -r a y w ith no occu rrence o f an y th in g b u t an o c c a s io n a l case o f lu n g granulom a from b e r y lliu m . Someone may n o t a c c e p t as f a c t the occurrence o f the granuloma b e in g evidence o f the p re-can cero u s le s io n . You have ju s t a case lik e most o f you have of a v a r ie ty of other lung conditions caused by other th in g s. DR. SALTER: I should lik e to endorse e v e ry th in g D r. Machle has s a id and to .a g a in r e p e a t th at in a l l our exp erim en tal evidence r e la tiv e to the in h a la tio n o f substances th at produce l e s i o n s w i t h i n .t h e l u n g we m u st n o t f a i l t o remember t h a t on t h e fo rm u latio n o f m align an cies w ith in the pulmonary t is s u e s , that re fe re n ce s to b e ry lliu m , although as D r. Machle has s a id , i t is in tr o d u c e d in tr a v e n o u s i n j e c t i o n o n l y ' i n one s p e c ie s o f a n im a ls . H o w ev e r, we h a v e n o t y e t s e e n a n y s i n g l e e x p e r i m e n t a l c a s e where neoplasms have developed e ith e r w ith in the lung or in any other p a rt of the body. R e fe re n c e has been made a ls o h ere to c a r c in o g e n ic a b i l i t y o f o t h e r d u s t s and I t h i n k r e f e r e n c e was made p a r t i c u l a r l y t o a s b e s t o s . Some fe w y e a r s ago and now a b o u t s e v e n y e a r s , we R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 260 reviewed a l l of the curren t lite r a tu r e r e la t iv e to raeconiosis and b y t h a t I mean a l l c a s e s s h o w in g a n y i n h a l a t i o n o f d u s t . We g e t b io lo g ic a l a c t i v i t y such as s i l i c a or asb estos or diatomaceou earth or any o f th o se, in clu d in g a lso the Schneeberg nine cases, wnere t n e r e n a s b e e n r a d i o a c t i v e s u b s t a n c e s , and we h a v e b e e n unable to dem onstrate the f a c t th a t the in h a la tio n o f these p n eu m o co tio tic agents have produced a m alig n an cy o f the pulmonary tissu e. 'There i s a q u e s t io n i n our m inds r e l a t i v e to a s b e s t o s , b u t a g a i n we h a v e f a i l e d to d e m o n s t r a t e a c o r r e l a t i o n b e tw e e n pulm onary neoplasm s and in h a la t io n o f a s b e s to s m a t e r ia l. L i k e w i s e , i n r e v i e w o f c l i n i c a l m a t e r i a l we h a v e be en u n a b le to show t h a t th e re i s a s i g n i f i c a n t in c r e a s e i n the p u l m onary m a lig n a n c y i n th o se i n d i v i d u a l s ex p o se d to a s b e s t o s . So I should be v e ry c a u tio u s in a s s ig n in g to any dust a c a r c i n o g e n i c p r o p e r t y u n l e s s we c a n p r o v e i t b e y o n d d o u b t . DR. HUEPER: You d is c u s s e d a s b e s to s . There are a t o t a l o f 2o c a s e s o f a s b e s t o s c a n c e r o n r e c o r d fr o m v a r i o u s c o u n tr ie s , - E ngland, Germany, and the U n ited S t a t e s . That compared w ith the number o f a u to p s ie s perform ed makes around 50 per c e n t . I th in k th a t i s an in c r e a s e d i n c id e n c e . M oreover, i n q u ite r e c e n t e x p e rim e n ta l work done in Germany i t has shown not r e la t io n of asb esto s dust to mice produces cancer o f the R ena Hall E ly ^CITIZENS BUILDING CLEVELAND 14. OHIO 261 lu n g and i n t e r e s t i n g l y enough, no.t an a lv e o la r ca n c e r o f the lung as norm ally but carcin o g en ic can cer, which is very susp icious of the o r ig in . - CHAIRMAN BRCHill; A n y f u r t h e r comment? DR. McCORMICK (G ood year)* Y e s . I would s t i l l l i k e to in q u ir e what ev id e n ce there is f o r t h is leu kem ia and a ls o fo r the k e lo id r e a c tio n o f b e n z o l. Working w ith rubber, I d o n 't -get the^ keloid re a c tio n . precludes k e lo id s. One o f y o u made t h e s t a t e m e n t t h a t i t DR. HUEPER: No, leu k em o id s. D R . McCORMICK: I am s o r r y . DR. MACHLE: I s th ere s t a t i s t i c a l p r o o f th a t th e le u k e m ia r a t e i s h i g h e r i n men th a n i n o t h e r p e o p le ? DR. HUEPER: There i s .ev id en ce th a t i s ra th e r r e c e n t and the evid en ce i s based on the o b s e r v a tio n o f leukem ic r e a c tio n s in workers exposed to b en zol over prolonged period o f t i m e , w h il e a t t h e same tim e w o rk e rs w o r k in g i n th e same e s t a b l i s h m e n t showed p l a s t i c a n e m ia r e a c t i o n s . M o r e o v e r , some o f th e w orkers d i d n o t show le u k e m ic r e a c t i o n b u t s im p le leu kosis. B o ltz has p u b lish e d som ething on th a t; o th ers have, too DR. MACIILE: I would l i k e to make one p o i n t . A d i s c u s s i o n o f le u k e m o id a c t i o n d o e s n o t b e l o n g i n t h e discussion. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO ' & d Leukemoid a c t io n i s a more or le s s norm al type o f r e a c t io n . I t may o c c u r a f t e r r e a c t i o n , n o t a f t e r a. number o f i n s u l t s . A H i t means i s th a t you g e t the appearance o f young forms in the blood in abnormal d is tr ib u t io n . U nless th a t p e r s is ts and is a s so c ia te d w ith permanent p a th o lo g ic changes in the bone tiss u e s and p e r m a n e n t l y a s l e u k e m i a , I do n o t b e l i e v e we c a n c o n s i d e r i t p ro p e rly w ith the m align an t tumor. MR. HUEPER: W e l l , we c a n g e t p r e c a n c e r o u s s t a g e . I co n sid er a leukemoid re a c tio n under those p a r tic u la r conditions o f e x p o s u r e a p r e c a n c e r o u s h y p o p l a s t i c r e a c t i o n and i f we c o n s id e r c a rc in o g e n s, th ey produce most o f the ben ign tumors and h y p e r p la s ia s and b e n ign r e a c t io n s , and m oreover are m a lig n a n t r e a c tio n s . Sim ply to sta te that because a c e r ta in rea ctio n occurs also under other conditions in th is precancer reactio n I would not a c c e p t as r i g h t . The n a t u r a l c o u rse o f e v e n ts shows q u ite o fte n in o c c u p a tio n a l can cer th a t i t w i l l be hypo p la s t ic r e a c tio n s , th a t there are re a c tio n s o f benign type lik e w a r t s , p a p i l l o m a s o r l e t ' s s a y s a r c o i d s , and th e n we g e t o u t r ig h t m alignant tumors, can cers, leukem ias. CHAIRI AN BROWN: A n y f u r t h e r co m m en ts, l a d i e s and gentlem en? Any fu rth e r q u estions? Any d iscu ssio n ? DR. SALTER: I m ight ju s t add t h a t the leukem ic end resu lt of bensol exposure has been destroyed p re tty w ell by R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 263 T r a c y M a l lo r y and F r a n c i s H u n te r a b o u t 10 y e a r s a g o . One c a s e I rem em ber, who s a t f o r a p h o t o g r a p h e r , who e a c h n i g h t m o un ted h is p ic t u r e s , u sin g a tube o f b en zol c o n ta in in g m u scilag e and a n o t h e r c a s e was t h a t o f th e u p h o l s t e r e r who d e n i e d a n y e x p o s u r e o f b e n z o l u n t i l 18 h o u r s b e fo r e he d ie d when he c a l l e d the in te rn e over and s a id , "D o cto r, I thought I should t e l l you I h a v e b e e n l y i n g h e r e t h i n k i n g . E a ch n i g h t I go b a ck to my room i n my shop when t h e o t h e r workmen a r e g o n e and I make my fo rm u la u p . I t c o n ta in s 20 per c e n t b e n z o l ." Those two c a s e s p o p p ed I n t o my head o u t o f t h a t M a l l o r y s e r i e s . T h ey were s u b tle , lo n g -co n tin u e d , m ild exposures as compared w ith the overw helm ing heavy exposure which produces a p l a s t i c anemia and t h e r e i s th e i r o n i c a l c o n d i t i o n t h e r e . The f e l l o w who i s o f t e n c a r e le s s has a chance to liv e , because he g e ts so s ic k f i r s t he h a s t o q u i t , w h e r e a s t h e f e l l o w who i s o n l y a l i t t l e c a r e l e s s may be wounded. D R . LAMB (B r o a d O a k ) ; The q u e s t i o n o f e s t r o g e n s was mentioned by Dr. S a lt e r . This i s n ' t e s p e c ia lly In d u s t r ia l, in i n j e c t i n g e s t r o g e n s i n women, i t h a s been known to cau se ca rcin o m a In woman. DR. SALTER: Of co u rse , th a t i s a v e ry h o t s u b je c t at th e p r e s e n t t i m e . The b e s t answ er i s I d o n ' t know. I n a n im a ls , c e r t a in ly one can p r e c ip it a t e can cer o f the b r e a s t and can cer R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 264 o f the uterus by the use of estro gen . A l i t t l e estrogen doesn' do, nor does a lo t of estrogen do. Heavy estrogen suppresses m i c r o t i c . One must h ave p r e c i s e l y th e r i g h t ra n g e o f c o n c e n tr a tio n in order to produce the e f f e c t . In the cosm etic in d us t r y th a t th in g r a is e d a g r e a t f u s s , the food and h e a lth and a l l the r e s t, because they d id n 't have the evid ence. I think t h e a n s w e r i s t h a t we d o n ' t h a v e t h e e v i d e n c e i n h a n d . The evidence is strong in anim als, p a r tic u la r ly in pedigreed m ice, th at are cancer s u s c e p tib le . That I th in k is as fa r as I can g o . Perhaps D r . Hueper can p ic k up from th e r e . DR. HUEPER: There i s an i n d u s t r i a l a s p e c t to t h a t . The E n g l i s h r e p o r t e d r e c e n t l y , t h a t i s i n th e l a s t two or th r e e y ears, in th e ir seb e stro l workers they observed h yp erp lasia of the b r e a s t in m ales, and I understand our Am erican fa c t o r ie s have th e same t r o u b le and have our typ e a c c o r d i n g l y . We may s e e a f t e r a f e w y e a r s c a n c e r o f t h e m a le b r e a s t i f e s t r o g e n i s c a r c i n o g e n i c and then we w o u ld h a v e d e f i n i t e p ro o f because n a t u r a lly , cancer of the b re a st in male is r e la t i v e l y r a r e and we w o u ld h ave t h e c o u n t e r p a r t to F a m m i l ' s e x p e r ience w ith male m ice, which u s u a lly , n a t u r a lly , d o n 't develop c a n c e r o f th e b r e a s t , who g a v e them e s t r o g e n s a n d t h e y d e v e lo p e d can cer o f tne b re a st under the stim u lu s o f th e e stro g e n . That would be an a n a lo g o u s c a s e . W hether i t w i l l d e v e lo p or n o t R ena Hall E ly CITIZENS BUILDING CLEVELAND 14, OHIO d e v e lo p , I don' t know b u t i t i s v/orth w h ile w a tch in g . CHAIRMAN BROWN: T h at i s a v e r y i n t e r e s t i n g d i s c u s s i o n and q u e stio n s. We h a v e a r r i v e d a t th e c l o s e o f t h e s e s s i o n . I would lik e to s tr e s s the a p p r e c ia tio n o f the C o u n cil fo r these v a lu ab le papers of D r. S a lt e r and D r. Hueper. . . . The s e s s i o n a d jo u r n e d a t 4 ;0 0 o ' c l o c k . . . ADJOURNMENT T R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO \ 1 MONDAY MORNING SESSION January 5, 1948 The f i r s t session of the Eighth Annual Congress on Industrial Health sponsored hy the Council on In dustrial Health, American Medical A sso ciatio n , convened a t 10:15 o ' clock , a.m ., in the Ballroom of the Cleveland Auditorium, Cleveland, Ohio. Dr. George P. Sykes presid in g. CHAIRMAN SYKES: I t is with a great deal of pleasure, as chairman of the lo c a l sponsoring committee in Cleveland, sponsoring this meeting, that I c a ll th is Eighth Annual Congress to order. This meeting is being sponsored, lo c a lly , by the Acadamj of Medicine, of Cleveland, and a lso by the Cleveland Chamber of Commerce. Our committee has included representatives of a llie d organizations such as the In d u stria l Nurses A ssociation , Public Health O ffic ia ls of the Gounty and C it y , The Public Sa fety O f f i c i a l s , Cleveland Sa fety Council, Ohio Sa fety Council, and various other organizations interested in the fie ld of Indus tria] Medi cin e. During the course o f these meetings some of these organizations w ill be represented by their members and we wel jI come them to th is meeting. $ Our f i r s t speaker today needs no introduction from R ena H all E ly C IT IZ E N S B U IL D IN G --------------- !---------------- T------- nr.................................................... . I .....'M in ili ........... ................. H'IH IHH')..... W ll.. I.. . W l'IB'IM...................... 2 me. He is a very hard-working and gen ial gentleman from Chicago, He is the Secretary of the Council on Industrial Health and in his travels throughout the country I am sure you have a ll be come acquainted w ith him. I t is with a great deal of pleasure that I now c a ll on Dr. Carl M. Peterson, Secretary of the Council on Industrial Heal th . DR. PETERSON: Dr. Sykes and frie n d s; I t has been our custom, at these Congresses, to present a short account of sig n ific a n t happenings since la s t we convened and by so doing to try to chart a course for the immediate period ahead. This has usually been the re sp o n sib ility of the Chairman of the Council, but since we have been without a Chair man fo r the la s t several months i t has fa lle n to mylot to f i l l in in th is capacity at th is time. For those of you who are attending the Congress for the f i r s t time, i t might be well to note that the Council on Industrial Health is a standing committee of the Board of Trustees o f the American Medical A ssociation. I t is our function to assim ilate a l l informaticn re la tin g to the health of employed groups, to make this information widely available to the pro fe ssio n , and to interpret the objectives of in d u strial health, not only in the medicines but also in relatio n to a l l other R ena H all E ly CITIZENS BUILDING 1 i 1 ................. 1 3 aspects of community medical hospital and health se rv ice s. This p a rticu la r meeting is something o f an experiment. As you know, the interim sessions of the House of Delegates are taking place in Cleveland at th is same tim e, and on Wednesday and Thursday of th is week there w ill be the interim s c ie n t ific sessions of the Council on S c ie n t ific Assembly. These w ill a l l be in this b u ild in g. A lso , as a feature o f the interim sessions and of this Congress, you have probably noticed both the commercial and s c ie n t ific exhibits cn the lower flo o r s . How, several events stand out in my mind as mil stones in in d u stria l medical progress during the past year. I think m e, and probably the most important, is the approval of residency and fellow ships in occupational medicine by the Council on Medical Education in the American Medical A ssociation . . x don 't mean to stress the importance o f that approval acceptance to physicians in the audience. Others, of course, who are not fa m ilia r with the sequential nature of medical ed ucation w ill need to be told that residencies are the essen tial framework for tra in in g in lim ited fie ld s in medicine, and over a longer or shorter period of training one q u a lifie s for a specialty in medicine. Now, th is f i r s t step, I may say, has been an imperfect one since there are a lre a d y some questions which have arisen R en a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 4 about the actual Implementation of th is type of tra in in g under our current approval o f programs. I t w ill be necessary, iten, for us to assimulate a considerable body of experience, and adjustments m ill have to be made from time to time in the type and character of the tra in in g , i t s e l f , and the f a c i l i t i e s nec essary for that kind cf tr a in in g . In i t s simplest form i t w ill supply a year of guidance and experience in occupational medicine. Under the current program we sh a ll use hospital laboratories and plant f a c i l i t i e s fo r the provision o f that kind of tr a in in g . In it s more expanded form i t becomes the basis for a ce rtify in g program in conformity with practices in other sp ecialty fie ld s . The second in chronology, but not in importance, is the revised United Mine Workers of America welfare and Re tirement Fund, and I speak from f a i r l y close association with that a c t iv it y . I think the important development in that section is the appointment of a Medical Advisory Board. No other comparable group has a more important assignment, and, c e r t a i n l y , no other group is being scrutinized more clo se ly or is beirg looked to fo r greater medical leadership. One can be sure that the patterns of medical service la id down here are representative of jo in t planning by labor and management Medicine w ill find many im itators, and here is R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 5 a fr u itfu l opportunity to test the p r a c tic a b ility of bridging the gaps between curative and occupational medicine wbi ch we, in industrial h e a lth , have so long advocated. F in a lly , i t seems to many of us th at the post-war period, and I assume we are s t i l l in the post-war period, rep resents a tr a n sitio n . This is a time when both individuals and organizations are seeking to restate o b je ctiv e s, to re-evaluate techniques and procedures, and to re -e sta b lish our sense of professional r e sp o n sib ility and s o lid a r it y . There is so much to do and so many people are tryin g to do the same thirg . I can, with confidence, assure you that the Council on Industrial Health is constantly aware of the necessity of o v e r-a ll blueprinting and planning. Given the right sense of direction I f e e l , and I do not h esitate to p red ict, that occupational health w ill be second to no other fie ld o f medicine in importance economically, c l i n i c a l l y , or s c ie n tific a lly . This sense of tra n sitio n is a l l the more keenly fe lt on our part because of our recent change in leadership. Dr. Stanley Sieger, who has been Chairman of the Council on Industrial Health during oar entire existence, has found i t necessary to retire. He came to us from Wisconsin where he bad distinguishe R e n a H all. E ly CITIZENS BUILDING CLEVELAND 14. OHIO himself as a surgeon, as an emminent medical leader, and as a statesman He is sin gu larly endowed with those attrib u tes of organization and genius which characterize the true medical adm inistrator. Almost every phase of our current a c tiv ity is an expression of his o rigin al conception of our real fu n ctio n s. I am happy to report that he is to hold the position o f member emeritus on the Council on In dustrial Health, and frcm that poinl of vantage we may expect to p r o fit from his wide experience and wise counsel for many years to come. This, then, gives me the opportunity to introduce our new Chairman. He is known to a l l o f you. His career recapitulates the growth of In dustrial Health from i t s meager beginnirg to i t s gradual emergence as a sp e cia lty in i t s own r ig h t. I take great pleasure and pride in ca llin g on Dr. Anthony J . lianza as the new Chairman of the Council on Industriaj Health in the American Medical S o cie ty . (Applause) DR. A. J . LANZA: Mr. Chairman, Dr. Peterson, lad ies and gentlemen: I am deeply sensible o f not only the honor but of the opportunities and re sp o n sib ilitie s that go with the Chairmanship of the Council. I can say that a l l the members of the Council appreciate the f a c t that at t h i s time the developments of the .J* , R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 7 industrial medicines, the applications of the p rin ciples of preventative medicine to the in d u strial scene, are second in importance to no other phase of medicine today, we are con fident that we w ill keep pace with both these re sp o n sib ilitie s and the opportunities that they represent. (Applause) CHAIRMAN SYKES: I now take pleasure in ca llin g on Dr. Arthur J . Vorwald who w ill present the f i r s t s c ie n t ific paper of the morning. Dr. Vorwald is from Saranac take, New York, and he is the Director of Research at the Edward t . Trudeau Foundation. He w ill speak to you on the Essen tial Correlations Between Medicine and In dustrial Research. .. .D r . Vorwald read his prepared p a p e r ... I w ill now turn the Chair oyer to Dr. Lanza. DR. LANZA: Ladies and gentlemen: For a number of years there has been conducted, in New York C it y , a remarkable, a unique, and also a pioneering enterprise in Industrial Medicinj and Industrial Health. Health Center. This enterprise is known as the Union This organization has been going along q u ie tly , in conspicuously, and very su c c e s sfu lly . I t owes it s inception la rg e ly , I think, to i t s f i r s t Medical D irector, Dr. George pr ic e , father of the present Medical D irecto r, and to the vision! ahd unselfishness of your next speaker, Mr. Max Meyer. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 8 Mr. Meyer, who is Chairman of the Board of Fashion In stitu te of Technology and Design, and Central High School of Needle Trades, and a member of the New York State Industrial Council, has been one of the mainsprings and supporters of the TJuxon Hoslth. CGjfttGi? .bout wtixcbi you. w ill uov/ h.i3?* I t gives me great pleasure, lad ies and gentlemen, to introduce to you, now, Mr. Max Meyer of New York C it y . ...M r . Meyer read his prepared p a p e r ... . CHAIRMAN SYKES: I have had the good fortune to liste n to a very stirrin g address. The next speaker on th is same l i s t , Mr. Frederick F. Umhey, the Executive Secretary of the International Ladies' Garment Workers' Union, w ill t e l l you something about the mach inery and methods of this organization. I t is my pleasure, la d ie s and gentlemen, to introduce to you Mr. Umbey. .M r. Unhey read his prepared p a p e r ... We now ccme to the th ird paper in this presentation of the health work-of the International Lad ies' Garaient Workers'! Union. I now introduce to you one of our fellow industrial Physicians who i s well-known to a l l of you, Dr. Leo P rice. ...D r . Price read his prepared p a p e r ... R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 9 DR. PRICE: slide, please. I have a few slid es to show you. First This slid e shows the building that was o r ig in a lly constructed far manufacturing in the garment industry. This building was o r ig in a lly constructed for the manufacturing of garments and most of the lo ft s were occupied by manufacturers. The Union Health. Center, a fte r i t got to a point where i t gave th ir ty thousand services a year, moved to th is twenty- f i f t h flo cr and it took about twelve thousand square fe e t . We had to expand very rap id ly and within a couple of years another half flo o r was taken. As you have already heard, a fte r the Health and Wel fare Funds were acquired, through c o lle c tiv e bargaining, the demand for services increased g r e a tly . The only way in which the expansion program was possible was through the purchase of th is b u ild in g. We are now located on the fiv e upper flo o r s , and we have the e n tire ground flo o r . In the lobby we take care of the pharmacy, a lle rg y departments, and reception area, where we have three or four hundred patients within a three-hour period. We a ls o have our appointment-system operated there, und on the other sid e, there, construction is going on now fo r a mass radiographic survey space where we intend to examine a l l R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 10 the new p a tie n ts, the post sick l i s t cases, with seven m i l l i meter film . Next s lid e , p lease. This is one of the recently constructed flo o rs showing the lobby where the patients are be ing received and sent on to the re gistra tio n group which you see in the fa r corner. There are about fourteen examining rooms on one side of th is f lo o r , and twenty physiotherapeutic rooms on the other s i d e .' Next s lid e , p lea se. This is the lobby reception room where the patients are waiting fo r a lle rg y treatment. The pharmacy, there, takes care of something lik e six to eight thousand prescriptions a month. Now that medical care is no longer re stricte d to the in d ivid u al' s a b i li t y to pay, certain s h ifts in emphasis have been noticed in the character of the work done. Between 1942 and 1947 a 483$ increase was noted in the number of diagnostic services performed at the Center. Just to give you an idea of the amount of service increases we are doing, - at the present time we are doing about six ty thousand, and in the mental sp e cia ltie s about eighty thousand, in the d iagn o stic about f i f t y thousand se rv ice s. Twelve thousand x-rays are taken annually, and th is R ena H aul E ly CITIZENS BUILDING CLEVELAND 14. OHIO 11 is very hard to keep down. I p re d ict, without any question, that i t w ill be eighteen thousand next year. Laboratory services, not counting urine, th ir ty thousand. Electrocardiogram s, about thirty-tw o hundred. Physio therapy, as I already mentioned, has had an unpre cendeted in crease. In this we have more than trip le d the number of ser vices done a year. I think we w ill ju st be lim ited to the number of rocms we have a v a ila b le Superannuated workers who have a l l sorts of a r t h ir it is and need therapy, - that has gone up. We have physiotherapy, in jectio n therapy, sick b e n e fits , and general medicine. Sick b en efits have increased considerably because a great many more youths have had the opportunity to in itia te sickness insurance programs which they did not have before. Next s lid e , please. That shows the average number of medical v is it s per thousand members, and i t shows you' the growth from 1942 to 1943, -- a growth of four hundred services per thousand members. In 1944, when we got under-way with some attempt at an expansion program, i t increased again. Ju st notice that now, in 1947, we have eleven hundred and seventy-two services per thousand members. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 12 That, in i t s e l f , may not look gre a t, but fortun ately we are re stricte d to our f a c i l i t i e s and the fa c t that there are a hundred and ninety thousand workers that have i t , some free and some have to pay for i t , a ll has an in flu e n ce . I can t e l l you about one unlimited group of three thousand workers where their minimum age is somewhere around fifty -se v e n years of age. They have unlimited medical services and they came in with a percentage of something lik e twenty- five hundred services per thousand. eight servic es pe r pa tie n t. We have had as many as Next s lid e , please. in the physiotherapy room. This is a glance down the h all Next s lid e , p lease. This is one of the t i l e hydro therapeutic rooms. This service is being given from early morning u n til la te at n ig h t. Next s lid e . We have not yet begun to operate our therapeutic x -ra y in any great way. The f a c i l i t i e s are a ll there and i t i s ju st a matter o f organization before we get started . This has been a new departure. We have never done any therapeutic x-ray work before, lim itin g ourselves to x-ray diagnosis. w i Next s lid e . This is one of the three general units &VS* which does the work. We have, in addition, the optical room in R ena H all E ly CITIZENS BALD IN G CLEVELAND 14, OHIO IS the mass chest x-ray unit downstairs, and we are now contem plating a special GI unit because o f the great demand in GI service. Next s lid e . This is a corner of the neurology room where we run a team of abcut fiv e neurologists on Saturdays. They work together with a consultant neurologist who comes in and makes the recommendations to surgery. Among the over-age group th is c l i n ic is very popular and we are running i t prac t i c a l l y every night in the week. Next s lid e . This is a corner of the surgery room which has ju st been completed. We do a certain amount of minor surgery there, but we also use i t fo r the patients th at come in for the consulting surgeon's advice. He recommends surgery by the medical departments. (Applause) CHAIR MAN SYKES: Gentlemen, we are very gratefu l to Dr. Vorwald and to the three speakers who came from New York to t e l l us about the Union Health Center. I am sure that th is has been a most in stru ctiv e and valuable program for a ll of us. The meeting stands adjourned. ...T h e meeting recessed at 12:3 0oclock, p .m ... . RE C E S SE D R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 14 MONDAY AFTERNOON SESSION January 5, 1948 Ttis second session of the Council on Industrial Health, convened a t 2:15 o' clo ck , p.m ., in Club Room B of the Cleveland Auditorium, Cleveland, Ohio. Dr. H. P. Worstell presiding. Subject: Conference cm Administrative P ra ctice s. CHAIRMAN WORSTEEL: Ladies and gentlemen, our f i r s t speaker th is afternoon is Dr. Kenneth C. Peacock, of New York, who w ill speak on "Plans fo r Small Plant Medical Services in New York." .. .D r . Peacock read his prepared p a p e r ... In order to conserve time I am going to ask that any questions or discussions of this and the follow ing paper be deferred u n til after the next speaker. At that time I am sure either speaker would be glad to answer any questions that you may have, or elaborate further upon the things they have discussed. Our second paper th is afternoon is th at of "Experience in Health Education in Industry," by Dr. H. M. Harrison of Toronto, Canada. DR. H. M. HARRISON: Mr. Chairman, ladies and gen tle men: Before I sta rt I think i t would be advisable to t e l l you what the organization is that I work fo r . R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 15 We a re a large baking concern manufacturing b is c u its , candy, bread, and yea st. We have about fiv e thousand employees scattered throughout nineteen d ifferen t fa c to r ie s , large and sm all The experiences I give you today are ju s t from our two Toronto p la n ts, one plant having fiv e hundred employees and the other four hundred employees. R en a H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 16 Address, by Dr. Harold M. Harrison, Medical Director for George Weston Lim ited, Toronto, Canada. Subject: Experiences in Health Education in Industry. Health education in Industry is of comparatively re cent o r ig in . I t is only in the la s t decade that it has become universally recognized as an e ssen tial part of a program of medical service in industry. Recently I had occasion to look through a monograph on Industrial Medicine published in 1935. In a l l i t s three hundred pages there was nothing re la tin g to education. In the index ''health" and Meducation" were absent. I ju st mention th is because when ore is dealing w ith part of a program vuhich is very much in i t s adolescence i t allows one to take certain lib e r tie s in discussing the su b ject. Therefore, you have my excuses i f I do not cover the subject in what you might fe e l to be an orthodox manner. Now, education is just th rowing lig h t on knowledge which is a v a ila b le . This means teaching the entire industrial group or just a sin gle employee. Any discussion on health education should be prefaced by a d e fin itio n of h ealth . One of our standard d ictio n aries defines health as ''Absence of disease or in fir m ity '' ; another, R ena H all E ly CITIZENS BUU.DING CLEVELAND 14. OHIO 17 "That condition of the body in which a l l functions are performed normally." To the average layman that might imply just physical health. The d e fin itio n set out in the constitution of the World Health Organization more c le a r ly sets out, I th in k , what we understand as h ealth . "Health is a state of complete p h ysica l, s o c ia l, and mental w ell-bein g, and not merely the absence of disease or in firm ity ." This implies a broad outlook on health. Note that so cial and mental health are given equal prominence with p h y s ica l. Nor/, there never was a time v/hen we could be as optim istic about the future of preventive and curative medicine as we are today. There never was a time in the history of c iv iliz a t io n when we needed more enlightenment on s o c ia l and mental h ealth. Tech n ical sciences have made tremendous advances, while advance; in social science has remained stationary or has gone backward. There are more maladjusted, unhappy people today than there ever were. Only a fra ctio n of these maladjustments reach our mental in stitu tio n s which are crowded to overflowing. I quote from a recent a r tic le by Elton Mayo: "We are techni c a lly competent as no other age in history has been, and we combine with this u tte r s o c ia l incompetence." Indie try today has developed technical s k i l l in two d ire ctio n s. One lin e is upward, based on s c ie n t ific and technical R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 18 knowledge. The other d irection ie downward. The boy or g i r l entering a facto ry from a school requires no s k i l l . The need for s k i l l has d rifte d downwards and he is now just a tender of machines, not a mechanic. However admirable the former, it is now my place to discuss the d e s ir a b ility of the l a t t e r . S u ffice i t to say, - that is the situ a tio n and we have to make i t work. The pride in workmanship no longer remains and th is loss of a sense 1of achievement has developed a mental in fe r io r ity ishich is having serious repercussions on our community l i f e . With th is as a background we have patterned our educational program in our own industry. As I go on you w ill very soon become aware of the fact that ours is a personal ser v ice . Doctor G. 0. Sappington in ''E sse n tia ls of Industrial Health" sta te s : ''The dissemination of health information is an exceed in gly d i f f i c u l t problem and f u l l of p i t f a l l s . One always has to answer two questions: ' How much sh a ll you t e l l ? ' and ' How shall you t e l l i t ? ' I t seems quite clear that one cannot describe in a small pamphlet, booklet, or poster the entire number of steps in reasoning which brings one to the conclusion that certain things are, in general, good for a person and certain other things are n o t ." As I understand that paragraph i t ' 4 - indicates the need for personal health inform ation. We have two obj e c tiv e s , and the fir s t is ''Education R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 19 directed t owards giving the employee a healthy m ind," and the second is "A heal thy body." I have no excuse to o ffe r fo r putting mental health f i r s t . In my experience I have seen more loss of production from unhealthy minds than I have from unhealthy bodies. These objectives are c lo s e ly knit together, and the e ffo r t expended w ill n ecessarily a ffe c t both mind and body in many ca se s. How ever, there is a d iffe re n ce , in that the unhealthy body is more lik e ly to have a maladjusted mental s ta te , whereas a healthy body w ill le ss frequently have an unhealthy mind. Now, where do we s ta r t to correct these conditions? The f i r s t opportunity i s at the pre-employment examination and you must have the background o f the employee. For th is purpose we f i l l out a so cia l survey blank. May I have the f i r s t s li d e , please? We f i l l out t h is blank: M arital and Family S ta tu s, Environment, Housing, Education, Outside In te r e sts, General Appearance, Other Comments, and the Social Service Index. I don't know what you would c a ll that over here. In Canada it is the central body you would write to to get the information on the employee i f you need i t . A nurse does not s it down with th is paper in front of her and ask questions. That would be too obvious. Our nurses do blood pressure, weight, height, eyes, hemoglobin, R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO Wasserman, and take the personal and fam ily h isto r y . These are a ll t i l l e d out before I examine the employee la te r in the day. There i s ample opportunity to carry on a conversation and obtain the inform ation, which is put down on the blank a fte r the employee leaves. When the applicant canes for his examination th is survey is presented to me along with the p a r tia lly completed examination foim . This information is valuable right now but invaluable la te r on when the employee consults me for some complaint. We must remember that more than f i f t y percent ctf the v is it s to the medical center have l i t t l e or no relation to any organic or in fe c tiv e condition. The success of any program is shown in the use that is made of your medical department, and in small industry, where you have a part-time physician, the nurse plays the major role in popularizing your department. I am very fortunate in: having two w ell-trained Public Health Nurses who are d e fin ite ly s o c ia lly minded and anxious to help. Our personnel are more interested in the maladjusted individual than in any hypertensive or cardiac case. I have one man, at present, who has a blood pressure of 280/160. He makes pies and does a good job. He is seen by his own fam ily doctor at regu lar intervals, and I check him every R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO two months. He i s properly placed and everything has been done for him. Just beside him is a woman. She has two boys in the reformatory and one daughter who gives he r a lo t of worry. We are much more interested in the woman than in the man. The woman canes to see us every month or so and consults us about her problems. I think, and very d e fin it e ly , that emphasis shoul^ be placed on trying to help the m entally upset in iaadustry. I am certain that this type of individual can do more to keep down production than the properly placed organic case. When I speak of the maladjusted employee I am not referring to the psychotic., manic depressive, e t c ., which as soon as recognized should get s p e c ia lis t a tte n tio n . The one we can help is the psychological case, harried by in se cu rity, worry, fe a r, e tc. In our organization we have, as nearly as po ssible, eliminated the sense of in secu rity by h o s p ita liz a tio n , sick b e n e fit, pension plan, e t c . In seventeen years not one of our employees has been la id o ff for want of work. Now, these employees with a worry, anxiety or fear complex are handled by our medical department which tr ie s to train these people hm to liv e with themselves and others. Leaving out your psychosis, any physician or nurse who has R en a H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 22 practiced a few ye ats has picked up enough psychology to handle most of these people. A fter a l l , the psychology required to deal with these people and th eir problems is mostly common sense put into a ctio n . You a l l know that train in g them takes time and patience, and thsb the a b ilit y to be a good lis te n e r , on the part of the doctor, is the f i r s t re q u isite , I would just like to t e l l you a l i t t l e story. One day, about a year ago, I went to the o ffic e in the afternoon and the nurse said to me, "Doctor, I want you to see George M atullbut. George has been coming down to me quite frequently in the la s t two or three months and he has something on his mind. He has been having headaches, but I know he has nothing the matter with him p h y s ic a lly , I can*t seem to get i t out of him," I sa id , "Bring George in and give me h a lf an hour." He came down and I asked him a couple of leading questions. I f i r s t , of course, examined him. You have to do that before you ta lk to these nervous people. W ell, I asked him a few que stions , a fte r I had examined him, and a ll of a suiden he started to t a lk . I think that he went over a ll the h ells of so ciety that anybody could imagine. He took twenty minutes to do i t , as fa s t as he could bubble i t out, and I just R ena Hall E ly CITIZENS BUILDING CLEVELAND 14, OHIO 33 sat there and lis te n e d . When he paused toward the end, he was p re tty nearly through, I ju st looked at him and I sa id , "George, funny, is n 't i t , everybody is wrong except you." W ell, he looked at me fo r h a lf a minute and then he jumped up, shook hands with me and thanked me for what I had done which wasn' t anything but s it there and lis te n to him. He never came back to the medical department, but four months later the Personnel Department promoted him to a ss ista n t foreman in his department. Now, of course, you can' t a l l get s a tis fa c to r y results with th a t , - that is just an illu s tr a tio n which I probably couldn't repeat in fifte e n or twenty years' experience. But, it shows what can be dene by liste n in g to some of these people. The idea in large industry is the use of a psychiat r i s t j hewever, small industry w ill not srppert such an addition to the pay r o l l . The time is coming when physicians in small industry w i l l have to have more knowledge of th is branch of medicine. I have just stated a problem for which I have no solution except the handling of each case on i t s m erits. As I said before, we try to teach these people to liv e with themselvn and others. New, employees should be encouraged to get more R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 24 education, to improve their position in l i f e . They should be urged to take up hobbies, get outside in te r e s ts . Last September we tr ie d a new idea. We cortacted the various technical schools and the University of Toronto and obtained their winter programs for night c la s s e s . A notice was put up on the b u lle tin boards, in v itin g the employees to discuss these courses with the nurse. Quite a number came in and signed up for night c la s s e s . I have a fe e lin g that t h is program w ill develop and that i t should prove of d e fin ite value. About the f i r s t of May, every year, I send a mimeo graphed le t t e r , signed by m yself, to every employee. It is mailed to his home address and deals with summer hazards. I t deals with sunburn, poison iv y , what to do when the canoe upsets, advises about swimming, e t c . We used to have many c a lls fo r sunburn on Monday mornings We buy a two ounce ja r of sunburn cream and s e l l i t to the employee at c o st. I t is the same cream your army used in the South P a c ific (10$ Sa lo l in cold cream). It has p r a c tic a lly eliminated the Monday morning sunburn. During the year we send a le tte r to the housewife or mother, as the case may be, dealing with the economics of buying food, the cooking of vegetables, and a great deal of n u trition al advice. These le tte r s are worded so that a diction ary is not required to understand them. These are signed by the nurse. R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 25 fe fe e l sure, from comments heard around the fa c to r ie s , that these communicati ons are appreciated. Our le tte r s are always personal, addressed to the employee or his w ife , and mailed to the home. / I know i t is not necessary to point out to you the importance of nutrition in the working population. However, to add emphasis to intiat I have to sa y , and also to provide you with convincing argumerts, i f they are ever required, I shouLd like to quote frcm a recent address by the la te Commissioner > . of Public Health for the State of Michigan, Dr. S . M. DeKline : WI venture the opinion th a t, when and i f we learn to apply the knowledge we now have about n u tritio n , deaths from many of the degenerative diseases (including heart) w ill go down. The lite ra tu re which has accumulated on the subject of n u trition cle a rly indicates a very close re la tio n of food to health and disease. Carry with you the conviction that the science of nutrition is of paramount importance. I t holds the key, X b elieve, to the cause of many forms of i l l n e s s ." I should also lik e to refer you to the work of Xlr. Weston P rice , of this c it y , whose book "N utrition and Physical Degeneration" i s , in my opinion, the most worth while and read able book on the subject that it has been my p rivilege to read. The work of P rice , and also of Robert McCarrison, show that R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 26 prim itive and so -c a lle d u n civ ilize d races can teach us a l o t . This problem of teaching nutrition to the workers is one to Which I have given a good deal of thought. The more you think about i t the le ss sure you are that any of us has a sa tis fa c to r y so lu tio n . However, i t is only by re la tin g our experiences that we w ill eventually get an ideal n u tritio n al program for industry. I must confess to a fa ilu r e , and that is in gettin g r e su lts from s tu ffe r s , posters, e t c . We inserted lunch cards, breakfast cards, and balanced d iets in pay envelopes. Did you ever go out the anployees* entrance a fte r they receive these c a r e fu lly thought out stu ffe r s? W ell, we went out h a lf an hour a fte r pay time and the stre e t was litte r e d with balanced b reak fasts, e t c . We tried posters fo r a jear or so, the best we could get on n u tritio n , and we s t i l l had l i t t l e or no encouragement. Of course we asked the employees, when they came to the medical center, what they a te . The re p lie s were not s a tis fa cto ry . The obese individuals are the worst, - they a l l seem to be so d iscrim in atin g, so many never eat b reakfast. That seems, to than, to be a real achievement. One day a short chap, aged twenty-one, weighing 265 pounds, cane to me to get advice on how to lose w eight. I inquired regarding his d ie t and received the usual re p ly . In R ena H aul E ly CITIZENS BUILDING CLEVELAND 14. OHIO 27 desperation I handed him a paper and to ld him to write down everything he ate or drank, vdth the exception of w ater, for three days. Then I to ld him to come back and we wcnld discuss the matter fu r th e r . He did as I asked, and to my surprise I found he was taking five quarts of milk a day. He was ju st a lump of grease made up mostly of b u tter f a t . That experience taught me something. Then and there I decided to complete three-day d iet surveys on a l l employees. May I have the next s lid e , please? How, look a t the top. The top t e l l s you what we have done. A lo t o f ta lk has been broadcast and printed about diet and n u tritio n . It a ll sounds so complicated, but i t re a lly is quite simple to have a properly balanced d ie t . The top is put in the employees* pay envelope and the bottom is given to the employers. This three day d iet survey started in our two Toronto plants, and i t is now incorporated in our health program fo r a ll plants, and i t is even a part of our periodic health exam ination to those not in touch with the medical center. The fa cts I give you are ju st from the two plants which I person a lly supervise. I t might be of in terest to you to know, in a general way, what types of d iets we discovered. F ir s t , we have the fa t r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 28 g ir l * 1 0 prides h erself that she never touches potatoes, - that is f a ir ly general in th is group. Her breakfast consists of porridge or cornflakes and a cup of c o ffe e . At r e li e f she has a couple of sweet b is c u its . For lunch, getting rather hungry by now, a couple of chocolate bars and mare pop, and possibly some ice cream. For dinner she has macaroni, meat, p ie , and cake. At bedtime, cake, sandwiches made with white bread. Thi d ie t, as you see, is hardly a reducing d ie t . I t is a very fo r tunate thing i f th is g i r l has any skin blemish, p a rticu la rly on her fa c e . Draw t h is to her attention and you fin d her much more co-operative regarding a proper d ie t . You can hardly consider that as a reducing d ie t , but I have seen dozens and dozens who claim they don' t take potatoes and they consider themselves on the way to gettin g a streamlined fig u r e . Then we have the person who eats everything. This type usually f i l l s up on hamburgers, doughnuts, so ft drinks, sandwiches, te a , c o ffe e , potatoes, and p ie . I have already referred to the fa t person who eats nothing. Occasionally th is type gets going on the l i t t l e they e a t. I u su ally succeed in stopping th is flow of information by handing him the d ie t survey. In my opinam there are very few fa t people who do not eat more than they need. There may be seme glandular cases, but in my experience they are mostly R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 29 in side shows, ce rta in ly not in industry. These are just examples of types which are very common. Thy are not influenced by us in any way. We have no n u tritio n al posters in any of our fa c to r ie s , either in the plants or c a fe te r ia s . I f we bad such, i t is not unlikely that the employee migjit put down what he or she thought we wanted. Some thousands of these surveys have been done and I think the fig u re s I give you represent, f a i r ly accu rately, a cross section of the in d u strial d iet as we have it in Toronto. ' Not four percent of the d iets were considered adequate and balanced. Fourteen percent of the d ie ts lacked s u ffic ie n t Proteins. Then we ^ump up to fo rty percent that lacked s u ffic ie n t Vitamin C; forty-two percent lacked Vitamin A; f i f t y - s i x per cent lacked s u ffic ie n t Iron. Only forty-seven percent d id n 't have enough Vitamin B, and seventy percent lacked s u ffic ie n t calcium. Now, th is information was gotten from our i n i t i a l diet survey. Of course, we went back, a fte r th at survey, and did them a l l . We do them a l l , now, on the present employment examinati on. One thing I want to make quite clear is that I am f u lly aware that this is not a s c ie n t ific n u tritio n a l a n a ly sis. In my opinion n u trition is th e most f e r t il e f i e l d for m e d ic a l R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO U\ I research there i . to d ay. There i s a tremendous amount of re search going on now, and such a lo t to he determined, that i f y0u wait u n til you get a s c ie n t ific basis for your work the m ajority of us w ill not be here. Our method is to try to give the employees an optimal nutrition as opposed to usual n u tr itio n . To properly evaluate the re su lts i s quite un satis factory but I have a few figures which may have some bearing. We have a c a fe te r ia , supervise,-.d,3 >bvytr camn <ex"c{feillllenntt die t i t ian , when* a dinner i s served at noon. Today we serve twice the amount of whole wheat bread and our sale of milk is three hundred per cent, - th is is since fiv e years ago. Hours lo st in our Toronto p la n ts, during the f i r s t h a lf of 1947, were 5.8252. This take s in the chap whose alarm clock fa ile d to go o f f , weddings, fu n erals, as well as illn e s s . Five years ago the hours lo s t were more than double that figu re. The d i f f i c u l t y with figures is that so many fa cto rs enter in to the p ic tu r e , - your whole health program, not ju st n u tritio n , working conditions improved, e t c . However, I want to say that we are s a t is fie d . The majority of our employees have improved th e ir d iets and health since' coming under our observation, - our attempt at guidance. In conclusion I would like to say that i t is my R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 31 conviction that the health department is of great service to industry. Serious atten tion to individual psychic upseos; teachiig people proper nutrition and @>od health habits are, In my opinion, the essen tial prerequisites of a good medical program. (Applause) CHAIRMAN WCRSTELL: The papers of Dr. Peacock and Dr. Harrison are now open fo r general discussion or any questions from the flo o r . There being no general discussion, the remainder of th is meeting w ill be turned over to Dr. James Roscoe M ille r , of Chicago, fo r the panel discussion. DR. J . R. MILLER: Ladies and gentlemen: Industrial medical examinations are of vast and growing importance, The enactment o f laws making an employer responsible for ailments produced or aggravated by reason of employment gave impetus to pre-employment examinations. I t was soon apparent, however, both to employer and employee that these examinations could be o f much wider sig~ nificance. Early recognition of disease lead to correction in many in stan ces. Thus the candidate was b e n ifite d . Job place ment followed and then, for the protection of employer, employee, and the public, a lik e , periodic check-ups were inevitable. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO R ena H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO 33 in many c a p a c itie s, although he could hardly be considered a f i t subject to operate a public v e h ic le , or to operate a machine where a lapse might endanger the liv e s of others as well as h is own. The la te war emphasized the importance of careful inquiry in to the sta te of health of al 1 members of so cie ty , p a rticu la rly was our attention ca lle d to the underlying impor tance of mental and emotional balance and adjustment. This is a vast f ie ld which industry is doing much to explore. The next decade w ill ce rta in ly see substantial improveins nt s in methods and understanding of th is important phase* Nor should care in evaluating the mental and physical health of employees be re stricte d to the so -ca lle d hazardous jobs and those requiring physical stamina or s k i l l . Those responsible for the welfare of organizations have come to realize that i t is a sodhd practice to take inventory at frequent in te r vals of those in adm inistrative p o sitio n s. Emotional and mental stresses may be as in sid io u sly injurious as noxious fumes. When any organization contemplates placing an in d i vidual in a position o f r e sp o n sib ility i t behooves that body to make certain that the candidate is p h y sica lly and mentally f i t and, furthermore, that he stay that way. This information can only be supplied by a careful examination done by a competent R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO physician. While we are on the su b je ct, why not extend th is principle to public o f f i c i a l s 2 We supply a physician to the White House and to Congress for the purpose. Why not require fitn e ss on tte part of others to whom we tru st our welfare? What, then, are the objectives of in d u strial exam inations? They are performed fo r the b en efit of the employer ard employee alike ard, in many in stan ces, for the welfare of the p u b lic. They should be s o conducted as to uncover abnor m alities which make an employee u n fit fo r a s p e c ific task , and should aid in his placement. They should appraise him, whenever possible, of any e x istin g disease in order that correction can be undertaken. They should be a precautionary measure where an individual is on a job of hazard or t r u s t , and they have a pronounced influence on the Public Health o f a community. F in a lly , they offer a fe r tile source for valuable information to guide us in the fu tu r e . The purpose cf th is panel is to make pertinent inquiry into how e ffe c tiv e current p ractices are and to make suggestions * for improvement. The f i r s t speaker on the subject is Dr. Oscar A. Sander of Milwaukee, Wisconsin. .. .D r . Sander read h is prepared p a p e r ... The discussion w ill be continued by Dr. Gecscge H. R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO Gehrmann of W ilmingtm, Delaware. DR. G. H. GEHKMMN: Mr. Chairman, ladies and gentle Ben: I would lik e to preface whatever X have to say by the bole Statement that physical examinations cannot be too complete. X stand prepared to argue that one w ith anyone, based upon th irty' three years of experience. How, le t us consider fo r a moment what our objective is in making physical examinations. We are trying to set up, -and we are doll our job, a proper system of preventative med ic in e , and we are tryir to protect the liv e s and the health of our employees. We are try in g to protect the in terests of our cwn industry and we are try in g to do i t in an equitable manner without in ju ry to anybody. The problem is m edical, i t is by no means s o c ia l. So, we come f i r s t to the pre-placement examination which I lik e to c a ll se le c tio n . The problem i s , as I see i t , to properly se le ct individuals who can sa fe ly work on the job, taking in to consideration the physical e ffo r t required, tne amount of in te llig e n ce required, and the chemical exposure to be encountered. There are very few industries today that are not to some extent chemical and, therefore, they have within their own organization certain hazards which men must be protected r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO CITIZENS BUILDING CLEVELAND 14. OHIO 37 w t cf a fam ily history? You d c n 't get any, and a lo t of time ls wasted along that lin e . ^ Nav we come to the past personal h isto ry . This is necessary, of course, but you must take into consideration that ne cr she, as the case may be, is there to get the job and i f you ask, "How do you fe e l" you c a n 't expect them to say, " I feel lik e H e ll." They are going to sa y , " I fe e l f i n e ," despite what they f e e l . You go into what they have had in the past and maybe you get sco value out of th a t . I think you must bear in mind the f a c t 't h a t the ind u strial examination is e n tire ly d iffe r e n t than an examination! in a doctor's o f f ic e . Therefore, we must replace the d e ficie n cie s with other equipment. What is the other equipment which 1 fe e l is necessary? W ell, X think we must have a very complete visual survey. We have men working in every industry whose vary safety and e ffic ie n c y is dependent upon th e ir v isio n . How we come to tte ch e st, and I think that in every industry we must have a chest x -ra y because I don't believe that! in the h istory that one can get from on applicant, and the anountj of time we have to devote to a chest examination, that we can re a lly find out the real esse n tia ls as to what is going on in that ch e st. Along with that chest x -r a y , of course, there is revealed a certain amount of infom ation on the size and shape R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 38 S! R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO Then we com^e to 4t-nve^ sseeocounudu pj^axrt of our responsibility and that is periodic examinations. I could ta lk for a long time on th a t, but s u ffic e it to say that periodic examinations should be of such a nature as to reveal the very e a rly signs anl symptoms which might be expected from the chsaical exposure or tte working conditions o f the individual concerned. Obviously, that does not mod to be a complete physical examination. With the chemical compounds which a ffe c t the blood-forming elements cf the body we need a blood count. Think how fo o lish i t would be, for example, to use the blood count cn a man who tas developed a bladder tumor, - what he really needs is a c y s to s c o p ic . We could go through the whole category. That examination must be set up, and the money must be spent, and the time given to the examination must be s u ffic ie ijtly thorough to give you a l l the information that you need to decide i f th is man is commencing to be s ic k . I f we are going to wait for the time when he is sick and then propose to introduce some medical methods, - then I say that the medical program is e n tire ly in e ffic ie n t and should be given up. I thank you. (Applaus ) DR. MIDLER: Thank you, Dr. Gehnnann. The discussion w ill be continued by Dr. William A. Sawyer of Rochester, H. I . .Dr. Sawyer read his prepared paper... R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 40 DR. M I M E : Thank you, Dr. Sawyer. Before opening the meeting to general discussion X have been asked to again c a ll your attention to the program of "Amputees in Action" which 1 1 1 be held in the Ballroom tomorrowj evening at 8:00 o' clo ck . DR. s . L . SMITH ( Poughkeepsie, N. Y . ): I would like to ask Dr. Sander, - what can th is Congress and we, as individ uals, do to bring about b etter le g is la tio n aid better administration of the Compensation Law? That would be attacking one of the basic causes cf th is d istress in our f i e l d . DR. SANDER: Administrators o f compensation are pretty much dependent on the medical profession in formulating their d ecisio n s. So, I thirk th at the basic thing is more education of tte medical profession and the doctors who are I called upon to give their opinions before the adm inistrators. DR. W. P. AMDPRTON ( New York): There i s something that I haven't heard brought up in any of the d iscu ssion s. It affe cts us in our or gani z a ti cn. I realise that much has been said about tbs handicapped worker in employment, but very l i t t l e has been said about the man who, as a resu lt of employment, becomes handicapped and r e t i r e s to be f it t e d into what we refer] to as "lim ited d u ty". I t has been quite a problem with us. So .much so, in fa c t , that we have formulated more or le ss of a R e n a H all. E ly CITIZENS BUILDING CLEVELAND 14, OHIO paaeJ. of management, personnel, and medical to decide many of mI, oas6s for d is p o s itio n . I wonder what you gentlemen could te ll me.ttet I could carry hack, that would help us know as to whether we are on the right track. We have even gene so far as to standardize physical lim itations according t o t he le tte r s of the alphabet. We have found th is necessary because we find that a s t a f f of approx imately two hundred physicians are recommending d iffe r e n t types of duty and management won't take th a t. As a re su lt of this we have standardized. DR. GEHHMANN: I f 1 understand your question, it is about the handicapped employee that has become handicapped in your industry, your cardiacs, your asthm atics, your a r t h i r i t ic s , and your older people. DR. ANDERTON: We have a p articu lar problem in our industry along that lin e because our average o v e r-a ll age is about forty-s even with about twenty-two years of employment. DR. &EHRMAHN: Our p o lic y , as far as the handicapped employee i.s concern,,.emd, wwvh-ieonn hh<=e> hnaass hnaudu service with the coup any is to fin d him a job. Now, in our company, our employees have had ten or fifte e n years of service and th at i s very valuable to you. I f there i s one possibility or any possibility whatsoever of fin d in g R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 42 tM t man . 3 * . a 3o, to f i t t an in to , we do i t . Eet us ta lk for a minute about the fellow who has become handicapped because o f an acciden t. We considei that our O bligation, as long as he l i v e s , to provide him w DR. AHDERTOi: X was talk in g about the general run, * the type of illn e s s we run in to . We have hypertensive heart diseases, and we have plenty of them. DR. MI1SBR-: Dr. Sawyer, would you care to speak on that ? ^ DR. SAWIER: I would lik e to have you am plify, i f you w ill , What you mean b y 'your alphabetical standardisation. DR. ANDERTOH: As X sa id , we have a s t a f f of approximately two hundred physicians _ e n d i n g secondary work| We standardize on "A" no l i f t i n g , p u llin g , or pushing; "A-1" no l i f t i.n g , p u1l-mliwrtg , oorr* upuussnhxirnng over twenty pounds; wA -2", for example, no s ,t a.i r . . mhs w elmbing, no sta ir climbing over six ty a 1 ' uu steps a day; "0 -1 ", no driving of motor v e h ic le s. We designate that t o the fello w s by the le tte r s of the alphabet. dr. SAVREE: I think that is extremely valuable, and I think U t is one of the b ig problems that confronts every organization. I don't think, thorgh, that we have as good an answer to i t as you have. It is a constant p ro b l*. and one whick is R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO awfully d i f f i c u l t to so lv e , p a r tic u la r ly in finding the type of ob that is te s t suited to the in d iv id u a l. There aren' t many easy part-time or lim ited jo b s. DR. ANDERTON: May I have one word more? Ju st as you said, Dr. lawyer, industry can only absorb, at present day wages a certain number or percentage of that type of in d iv id u a l. I have been with my organization close on to twenty- two years. There was a time when a department of f i f t y men could hide-out e igh t, but today they can't do it anymore and it i s a que s t i on. DR. GEHRMANN: We go t o personnel and say, ''Find a job for this fellow with these r e s t r ic t io n s ." DR. ANDERTON: They come back and t e l l us that they ju st can' t place that fe llo w . When you are with us for fift e e n years we either disable the individual and give 'him. a d is a b ilit y allowance, or we retire him on a life -tim e annuity. This has become increas in g ly d i f f i c u l t . I t has become an increasing l i a b i l i t y . Unfortunately, we do not have the turn-over, in our industry, that others have. Vie ought t o be proud of keeping our workers so lo n g , --but i t has become a problem. DR. D. R. JOHNS ( East Chicago, Indiana): I would like to ask Dr. Gehrmann what he thinks of t h is , - where a man R ena H all E ly CITIZENS BUILDING $z CLEV ELA N D 14. OHIO shows d e fin ite sign s of to xic products a fte r he has worked for quite a number of years with that in stitu tio n ,1 and the doctor recomnBnds his change to another department, and there is a difference in the ra tio of wages from the job he had been per- fo rming for years to this other jo b . What is your opinion about that? Of course, I mean outside of the union end of i t . DR. GEHRMANN: Outside of what? DR. JOHNS! Outside of the union. Should they put this man at a differen t work, outside of the hazard, at the same wage he had been making at the hazard? DR. GEHRMANN; I f a man in our industry becomes d is abled because of chemical exposure and that other job pays a lower ra te , we maintain him on the rate that he had on his previous jo b . Yie figure that we were responsible far making him sick , th erefo re, we should pay for i t . . DR. G. R. ROYi/NTREE (L o u is v ille , Kentucky): I would like to ask Dr. Gehrmann his opinion on x -r a y s . Do you think, < doctor, that large x-rays are necessary fo r a ll employees, or would the 35 millim eter or 75millimeter fluorograph be s u ffic ie n t DR. GEHRMANN: We are using 35/70 for screening purposes. We also use the 4x5. DR. G. A. WOODHOUSE (C in cin n ati, Ohio): Dr. Sander, do they have any compilation of charts to show the variations R en a H a l l E ly - CITIZENS BUILDING CLEVELAND 14. OHIO 45 in state compensation requirements, such as you mentioned before? Are there any charts to compare the various states? DR. SANEES; Yes, the In d u strial Hygiene Foundation, of Pittsburgh, have a ll that material a v a ila b le . You can address them at the Mellon In s titu te in Pittsburgh. DR. JOSEPH SANDERS (Prudential Insurance Company, Newark, N. J . ) : I should lik e to ask a question in regard to i pre-employment examination. In the event that the f u l l - s i z e , 11x14, chest x-ray i s routinely taken, is i t necessary to perform a c lin ic a l examination o f the chest? . DR. CtEHRMANN: I f we are going to take a chest x -ra y , which we do on everybody, there is no use in wasting time on a c lin ic a l examination o f the chest. You don' t fin d out much anyway. DR. SANDER; I think you meant the follow -up, - pro vided the film shewed some pathology. Is that righ t? DR. SANDERS: That is in the event the film showed no pathology, and no change in cathardial silh o u e tte . I t could speed up such examinations in the case of females and not tie ( up the nurse. We have diaphragm-type of stethoscopes which we s lip under the g ir l's dress and Insten at the apex and two points of the bases. That is the point on which I want information on the general examination. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 46 heart. DR. GEHRMMN: We confine our examination to the As fa r as the stethoscope Is concerned, we don't use It for the chest at a l l . DR. E. K. LffiDK:! (Philadelphia, Pennsylvania): I ju st wanted to say that the American Journal fo r Surgeons has published a small pamphlet lis t in g the Compensati on haws cf various sta te s . Their headquarters can furnish you with that pamphlet. | I would also like to ask the gentleman on the panel how be discovers asthma and asthma bronchitis i f b.e doesn t use a stethoscope. DR. GEHRMANN: We digT enough pathology from our chestl x--nays to decide a l l questions. DR. SANDER: For industries where there might be ah increase of bronchitis and asthma we s t i l l use the stethoscope in addition to the chest film . DR. mtt.tjrr ; Dr. Sawyer, would you lik e to put in your nickel *s wor th? DR. SAWYER: I think you have to temper your program with the situ a tio n you are up a g a in st. I think where you have a lo t of the young people coming through, and you are in a great rush, the examination of the chest is s u ffic ie n t . Where you get older people and where RENA HAUL E ly CITIZENS BUILDING CLEVELAND 14, OHIO have c o n d it io n s t h a t s r e h a s a r d o u s , and you want t o know l ore t . n the k -r a y w ill -, - ^ ^ ,, _ x. one or th e o t h e r . x d o n 't t h in k you can a d h e re t a Rnd l a r g e , t r i e s t o g e t away w ith r . Gehrmann, by a*1*1 Lar& ' I think th at ju s t the X" raT' DR. L . A R M (Minneapolis, Minnesota): I would 4- on th e p a n e l i f th e y have had any experl l k e to ask th e d o c to r s on the pan ie n c e 4in g lTaarr.ea tt ee sspt ss f1ar com m ercial d r i v e r s , j _ beinr k e p t on th e in d iv i d u a ls and th e These records being * P , ,, h a t do you do about r e p o r t in g t o th e f a m ily f o llo w - u p s , - wnav uu 3 p h y s ic ia n about common c o ld s and t h in g s of th a t k in d . Y> r e fe r the people to the fa m ily p h y sicia n to do the follo w -u p T * the e p ile p tic ? You c a n ' t fin d than with What i s done ab ou t th e e p iie p v x x-rays or anything e ls e . DR. SAWYER: were two q u e s tio n s t h e n ., were there not? d r . a TM Y e s , - 1 asked you about th e r e c o r d s . * were t a l k i r g a b o r t how im p o rta n t th e y w e re , bu t you d i d n 't g0 on to say what you d id w ith a ft e r you fo llo w ed * P- Did you check over the records fo r sane te n or tw elve y e a rs , i j _ anfl you h a v e n 't been able and you found a l o t o f common c o l a s , and y ^ . x. tbera Do you r e f e r them t o th e f a m ily to do a n y th in g about them* uo * - p h y s ic ia n , or drTon vyoouu tt rr vy t^o do something about them? r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 48 DR. SAWYER: I think we do that in a great many cases. At least we urge than to go to the fam ily physician art we t e ll them we would be glad to exchange any Information we have with him. Very often we recommend ways of adjustin g their d a ily routine so as to possibly prevent trou b le. It is a variety of things you do. DR. ARIcIMj : DR. SAWYER: I f be doesn' t go, then what do you do? W ell, that sometimes becomes a problem but not often or u su a lly . DR. GEHRMMN: You asked me about the e p ile p tic s . Well, the e p ile p tic we do not take fo r plant work but we do, however, take them for o ffic e work. We are a chemical industry and we have some pretty dangerous operations, very dangerous for the e p ile p tic to be around. However, we find no objection to having them in the o f f ic e . DR. ARISING: What I want to know, - you spoke about the history aid that they didn' t give too much so you were not interested in the h isto ry . That was the statement which you gave. W ell, w ith the e p ile p tic s , they w ill not t e l l you about i t and then you discover i t la te r on. DR. GEHRMANN: We don' t usu ally find cut that they have it u n til they have been in the organization for some time. In that case you have to get rid of them i f they are on a R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 49 dangercu5 jo b . That 1 one of the d eficien cies in the h isto ry . TMy are there to g et the 3oh and i f they t o i l yon that they are an e p ile p tic they know they w ill not get i t . DR. W. H . DOWLIN (Canton, Ohio): What do you do with yw r se n io rity program? I do not M an in d u strial disabled, I mean physical-disabled in d u strial employees in your seniority program. How do you place them? How do you get them pined whBn, as a result of placing than, you are displacing another employee? DR. MISjySR: Dr. Gehrmann, do you care to answer that DR. DOmtHi: I ms an, - when a man is r e tu r n e d for lig h t woik in a department and there is no lig h t work m the department, what do you dj o wnini-tt-hh tihhaatt mmaann iinn rebgard to seniority? Haw do you handle those situation s? DR. SEHRMAM: I s t i l l don't quite understand, but X think I o answer i t th is way. L e t 's assume we have a man whose physical condition is such that he has to be given a minor job- DR. DOVffitlN: L i g it work. DR. GEHRMANN: A ll r ig h t , th e n t h e n e x t man moves up DR. DCMLffl: He displaces three men as a resu lt of that. DR. GEHRMANN: I don't see why* DR. DOWLIN: W ell, what do you do with those cases? DR. GEHHMANN: He just drops out of one job and into an othe r . DR. DCWicIN: You do th at in your own industry? DR. GEHHMANN: What is to prevent it ? DR. SAWYER: I think that is the same question brought up a moment ago. It is about the employee who begins to degen erate or deteriorate as a fu ll-fle d g e d worker and you have to find a ligjater job for him. That is one of the toughest things that confronts us today. I don' t think there is any one answer. Sometimes you can fin d the answer and sometimes you can' t . Sontimes you can re tire them on a p a r tia l d is a b ilit y . DR. DOWLIN: What i f he is a young man? DR. SANDER: You don't displace anyone in finding another job. I know that we d o n 't. DR. SAWYER: You put than in a job that is vacant. DR. DOWLIN : There is no such animal. We have twelve thousand employees in the industry I am talking about. DR. SAWYER: You shouldn' t have to displace anyone. A VOICE: I would lik e to ask the members of the panel about how much information they give an applicant that is re jected or cannot be accepted for the p articu lar job that he is applying fo r ? Do you t e l l him the reason, the physical reason R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO ta wby ho is being rejected or not? DR. MIIStER: Dr Sander, w ill you take th DR. SARDER: Yes, we do. That is one of the provisions Of the Wisconsin Examination Plan. The man gets a duplicate copy o f the examination report, in w ritin g, so that he kncws exactly what the pathology was and what the reason i s for t o re je ctio n . That i s , provided i t is an o u tr ig it r e je c tio n . DR. MILLER: Do you do the same, Dr. Gehrmann? DR. GEHRMANN: Yes, we t e l l the man why. DR. MILLER: Dr. Sawyer, do you care to comment? DR. SAWYER: I have always contended that i f the man has t o submit to the examination fo r a j ob he has the right to knew A YOKE: in the case of aggressive pathology, such as a cardiac pathology, you have the record of the physical examination am evaluation o f the man's a b ilit y at the time of entry in to the p la n t. Can you, by periodic examinations, deter mine the progress and the decline o f th is person's a b ility ? There is no doubt in our minds th at there is a d e clin e , but when the compensation adm inistration handles cases lik e th is too lib e r a lly i t puts the fin a n cia l load of compensation on the employer and tampers us in our re h a b ilita tio n program of the disabled. What can be dene in those cases to give these people R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO a chance t o make i t p o s s ib le fo r us t o h ir e them w ith o u t p u tt in g th e p e n a l t y on t h e on p i o y e r ? DR. SANDER: I mentioned that in my discussion. It 3s a matter of education. I t is a slow process, - i t i s n 't any thing that you can do overnight. Some of the State Industrial an A c c id e n t B oards do n o t h a v e a s e n l i ^ i t e n e d / a d m i n i s t r a t i on as th ey m ight h a v e . Bub, the s i t u a t i o n is im proving and the o v e r a l l p i c t u r e to d a y i s much b e t t e r than i t was te n or f i f t e e n years a g o . I t i s a m atter of slow e d u c a tio n in a l l p a r tie s involved* DR. G. SMITH (Rocky Mount, North Carolin a): I would like to preface my question with a few remarks about i t . We only hire about seven hundred people and we have ju st started an Industrial Medical Program. We have ju st been crawling and now we would like to walk a l i t t l e b i t . We would like to go into x-rays and we don't know which is b e st, fluoroscopy, 35/70 x -ra y s, 14/16 x -ra y s, or what. I am the so -ca lle d part-time director in t h is , but I am only a general p ra ctitio n e r. In the opinion of hie panel, which would be best fo r ns to use? DR. MILLER: Sta rtin g from l e f t to rig h t, Dr. Sander. DR. SANDER: First of a l l , fluoroscopy, no. You have no records of the fin d in gs except what someone saw. Miniature film s for Indus tri s not having a dust or fume hazard are per f e c t ly sa tis fa c to r y for screening fo r tuberculosis or other R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 53 pathology. For Industries with a d e fin ite s i lic o s is hazard, cr a fume hazard, 14/17 film for the best technique p o ssib le. DR. MULLER: Is there any disagreement from the panel? DR. SAWYER: None. DR. GILBERT: I would like to ask about the periodic chest x -r a y s . How often would you advise, once a year, once in six months, once in two years? DR. MILLER: Dr. lawyer, do you care to handle that one? DR. SAWYER: We started out doing them once every year. Then the depression came along and we had to save a l i t t l s money, believe it or not, and we la id out a program of every year ' or two years depending upon the age of the in divid ual, what was found at the tim e, and the work he was supposed to do. When an applicant is x-rayed a card is made out as to when the next x-ray is to be taken. I t may be in six months, i f there is something su sp icio u s, or i t may be a year, two years, or three years. I can *t give you any hard and fa s t rule beyond that . DR. GEHHMANN: We repeat them a l l every year. Some suspicious cases may be repeated as often as four times a year, ju st to keep track of them. R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 54 DR. GILBERT: Is there any reason for doing i t every year ? DR. GEHRM&.NN: Well, every year you pick up sonthing. There is an increase o f malignancy of the chest. , Not that it does you an awful lo t o f good to pick them up, hut i t is best to check at least once a year. DR. D. E . DORCHESTER (Sturgeon Bay, Wisconsin).: The last fellow got down to seven hundred employees. We have some railroads and u t i l i t i e s that have fu ll-tim e medical programs goirg on, but as Chairman of the Wisconsin State Society on Industrial Health, we have lo ts of smaller industries that don't have any industrial health programs. I wonder i f these three men can t e l l me how they get industry interested in putting these programs forward? DR. SANDER: W ell, Dr. Dorchester is from Tiisconsin and so am I . There are a good many small industries th at do have a medical program, but most of than have occupational disease problems and they are p retty well taken care o f. There are s t i l l many of the small industries that don' t have aa y special occupational disease programs, some that have no program at a l l . I don' t know how you can get them interested except, possibly, by the medical so cie tie s or the lo ca l Industrial Health Committees c a llin g nestings of your Manufacturer's R ena H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO 55 ^ Association groups. That has been contemplated in Milwaukee, as you toow, for within the near fu tu r e . We don't know of any other Way of doing it . A VOICE: ' What would consist of an adequate te st of the present employment fo r hearing a b ility ? Ju st how should it be recorded, by whispered voice, spoken vo ice, watch tic k in g , or going into something more elaborate as an audiometer? DR. SAWYER: I think the audiometer is id e a l. They f cost money and they don't stand up too well, at le a st that has been our experience whe n they are used constantly. The whispered voice is something we have used for years. I ran irit o some doctors the other day that were testin g by simply snapping the fingers at a certain distan ce. I think the whispered voice and watch tick in g is probably s u ffic ie n t in most cases. DR. G-EHRMANN: We found, in p a rticu la rly noisy places, that it was necessary to go to the audiometer because there is more and mere of a tendency, now, fo r men to say that the noise in the operation interfered with th e ir hearing. They say that they have lo s t th e ir hearing, or lo s t i t p a r tia lly , and the only way we can accurately determine j^st h.ow much was lo s t Is by the audiometer. With the noisy operations we R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 56 uSe the audiometer, bit not in general. DR. MILLER: Are there any other questions? I f not, 0 the participan ts want to tear each other apart? I f not, the meeting stands adjourned. ...T h e meeting recessed at 4:30 o 'c lo c k , p .m ... RECESSED R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 57 CONFERENCE ON IN D U ST R IA L PHYSIOLOGY Monday A fte rn o o n , Ja n u a ry 5, 1948 The C o n fe re n c e on I n d u s t r i a l P h y s io lo g y convened p .OO o ' c l o c k i n C lu b Room ,A, P u b lic A u d ito r iu m , C le v e la n d , a t <->v Ohio 3 p r . Raymond H u s s e y p r e s i d i n g . CHAIRMAN HUSSEY: By way o f i n t r o d u c i n g the program this aftern oon I should lik e to say th a t th is is the second y ea r th a t we h a v e h a d t h e b r o a d s u b j e c t o f i n d u s t r i a l p h y s i o l o g y Included on th e p r o g r a m . I t i s a s u b j e c t t h a t h a s b e e n n o t too well d e v e l o p e d an d one we a r e p a r t i c u l a r l y e a g e r t o g i v e emphasis to and g i v e due e m p h a s is t o . I t h i n k a l l o f u s who h a v e f o l l o w e d th e e v o l u t i o n o f m e d i c in e r e a l i z e t h a t i t w a s n ' t u n t i l we h a d t h e b r a n c h e s o f e t io lo g y and p h y s io lo g y th a t i t was p o s s ib le f o r m ed icin e to evej be th o u g h t o f as a s c i e n c e , and i t h a s b e e n th e a p p l i c a t i o n o f the p r i n c i p l e s o f e t i o l o g y and the p r i n c i p l e s o f p h y s io lo g y t h a t have made i t p o s s i b l e f o r us to i n t e r p r e t d i s e a s e to d e v e lo p a r e a l c o n c e p t o f d i s e a s e a s we now h a v e i t , and i t i s o u r hop e in the fu tu r e th a t by a p p ly in g the p r in c ip le s o f e t io lo g y and p h y s i o l o g y t o t h e s t u d y o f h e a l t h we may d e v e l o p th e c o n c e p t o f h e a l t h i n th e same way we have th e c o n c e p t o f d i s e a s e and t h a t as a r e s u l t we may h a v e some' way o f e v a l u a t i n g h e a l t h , a c t u a l l y d i a g n o s i n g and a p p r i s i n g h e a l t h i n t h e same m anner a s we h a v e R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 58 CITIZENS BUILDING CLEVELAND 14, OHIO tt principles in Aviation Medicine Dr. TillisehJ R ena H a ll E ly CtTIZENS BUILDING CLEVELAND 14. OHIO 60 ' PHYSIOLOGIC PRINCIPLES IN AVIATION MEDICINE Paper b y : DR. JAN H. TILLISCH Thank you v e ry much. A v i a t i o n m e d ic in e i n i t s o r i g i n a l co n ce p t i n W orld War X had to do p r im a r ily w ith the s e le c t io n o f p i l o t s . W ith the grow th o f a v i a t i o n , e s p e c i a l l y i n th e p a s t 15 y e a r s , th e s t i m u lu s th a t was f u r n i s h e d b y W orld War I I , t h a t o r i g i n a l c o n c e p t has p r e t t y w e l l b e e n l e f t b e h i n d . We s t i l l a r e i n t e r e s t e d i n t h e s e l e c t i o n o f p i l o t s b u t i n a d d i t i o n t o t h a t we are i n t e r e s t e d in the s e le c t io n o f o th er a i r crew members, n a v ig a to r s , bomba- d ie r s , ra d io o p e ra to rs, f lig h t p r o o f m ech an ics, and people o f t h a t t y p e . We a r e a l s o i n t e r e s t e d i n t h e i r m a i n t e n a n c e i n h e l p in g them overcome the p h y s i o l o g i c a l h a z a rd s w hich th e y e n c o u n te r when t h e y go to a l t i t u d e . I n a d d i t i o n t o t h a t , we f i n d t h a t we h a v e a n o t h e r f u n c t i o n o f a v i a t i o n m e d ic in e t h a t has come on us s ire e or w it h World War I I and s in c e th e n , and t h a t i s the t r a n s p o r t a t io n o f p e o p le. A v ia t io n m edicine i s no lo n g e r f o r ju s t the s e le c t fe w , a s e l e c t s u b - s p e c i a l t y . P r a c t i c a l l y e v e r y man who h a s a n y t h i n g to do w it h m e d ic in e i n t h i s d a y and age w i l l e n c o u n t e r a v i a t i o n m e d ic in e i n one way o r a n o t h e r . The o b s t e t r i c i a n m ust decid e w hether the p r e g n a n t woman can f l y , how f a r a lo n g she R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO bl can be b e fo r e he can t r a n s p o r t h e r b y a i r . The p s y c h i a t r i s t must th in k w hether h i s p a t i e n t can be t r a n s p o r t e d or w hether i t may b r i n g on a p s y c h o t i c e p i s o d e . P r o b a b l y a l l t h e s p e c i a l i s t s of m edicine, the in te r n is ts are the group of d iseases most fr e q u e n tly met w ith in a v ia t io n m e d ic in e . P o r t h i s g r o u p h e r e , who a re i n t e r e s t e d p r i m a r i l y I n i n d u s t r i a l m e d i c i n e , we f i n d m any o f y o u who h a v e d i r e c t c o n t a c t with a v ia t io n m e d ic in e . You may have t e s t p i l o t s , those o f you who are w i t h a i r c r a f t c o m p a n ie s or y o u may h a v e p i l o t s who are f ly in g the company p la n e , or you must take p a r t in the s e le c t io n of p i l o t s , the m aintenance o f them, o v e rlo o k in g the equipment th a t has to do w ith the m e d ic a l p a r t o f i t . Not o n ly t h a t , b u t many o f you who a r e c o n n e c t e d w i t h c o n c e r n s w h o .d o n o t h a v e p l a n e s w ill fin d a la r g e number o f your e x e c u t iv e s , a la r g e number o f people in those concerns are goin g about by a i r at th is time and you w i l l f r e q u e n t ly have the q u e s t io n posed to y o u , i s i t s a fe f o r me t o f l y b e c a u s e I h a v e h a d a' h e a r t a t t a c k , o r t h i s o r th a t. In other words, every p h y sicia n should have a c e rta in knowledge o f a v ia tio n m e d ic in e . I t i s not a s p e c ia lt y fo r ju s t the s e le c t few . Nov/ f o r a n u n d e r s t a n d i n g o f a v i a t i o n m e d i c i n e i t i s n ecessary to have a c e r t a in concept o f the b a s ic p r in c ip le s of the atmosphere and o f the p h y s io lo g y o f the c a r d ia c and o f the R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO ,, s c a l a r s y s te m . I f y o u w i l l b e a r w it h me a few m in u t e s , I would like to review th ose. _ ( S l i d e ) The atm o sp h e re , a s we know, i s d i v i d e d I n t o t , , 0 d i v i s i o n s , th e tr o p o sp h e r e and th e s t r a t o s p h e r e . The troposphere exten d s up 33 ,0 0 0 f e e t a t the p o le s and 56,000 f e e t at the e q u a t o r . While the s t r a t o s p h e r e i s t h a t a r e a above i t . we, o f c o u r s e , are i n t e r e s t e d a t t h i s time p r i m a r i l y m the tr o p o s p h e r e , t h a t atm osphere i n w hich we l i v e . The tr o p o s p h e r e i s c h a r a c t e r i z e d by t u r b u le n c e and whe there are chan ges t h e r e i s a te m p e ra tu re d r o p . The h i g h e r we go the c o l d e r i t i s . The s t r a t o s p h e r e i s a more or l e s s c o n s t a n t tem perature, very l i t t l e weather changes and v e ry l i t t l e tu rb u lence. ( S l i d e ) Now as h i g h as i t i s p r a c t i c a l f o r man to go we f i n d t h a t th e c o m p o s itio n o f th e atm osphere does not c h a n g e . A l l o f us know the h i g h e r we go th e more a n o x ia we d e v e l o p . That i s n o t due to any change i n the c o m p o s itio n o f the atmosphere This rem ains c o n s t a n t , a p p r o x im a te ly 21 per c e n t ox y ge n , 79 per cent n itro ge n , and rare g a se s. These f i g u r e s , fe a t i s , w ithin the p r a c t i c a l i t y o f man, rem ain th e same. What i s i t , th en , t h a t b r i n g s about t h i s l a c k o f o x y ge n as we go t o a l t i t u d e ? ( S l i d e ) W e l l , i f we -think o f t h a t atm ospnere as a h a y s t a c k , perhaps we can g e t a b e t t e r c o n c e p t o f i t . The a i r , R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO o f c o u r s e , i s t e a r i n g down on us j u s t as t h i s h a y i s b e a r i n g down on any i n d i v i d u a l t h a t * u l d be a t th e b o tto m , b e see a t th ^ l e s s e r a l t i t u d e s w isp s o f h a , packed more c l o s e l y t o g e t h e r , j u s t as m o l e c u l e s o f h a y a r e . On th e o t h e r hand, the h i g h e r we g o , the more l o o s e l y packed are th o se w isp s o f hay so t h a t a c t u a l l y the w eight o f th a t column o f atmosphere i s 14.7 pounds per square i n c h a t s e a l e v e l . H ow ever, i f we g e t up h ere to 0 ,0 0 0 fe et> we f i n d th a t more than h a l f o f th e w e ig h t o f t h a t column l s c o n t a in e d i n t h i s p a r t o f the tm o s p h e r e . The h i g h e r we g o , the le s s t h a t w eigh t i s , o f c o u rs e . (S lid e ) As a r e s u lt o f th is decrease in pressure, the h i g h e r we go i4 n ao-lHt-iit-tu-ndriee wwee fuinn da a b u b b le o f ga s a t sea . , 1T. Ynu maY r e c a l l B o y l e ' s Law, l e v e l w i l l sta n d as i t goes u p . You may r which s t a t e s the volume o f~ the g,, ,,aos vv aa rr ii ee ss I n v e r s e l y to the p r e s s u r e e x e r t, e d. . TI n,, oo tthn ee rr wwuoxruds,, f o l l o w i n g t h i s s o l i d l i n e h e r e , we w i l l f i n d a b u b b le o f g a s w i l l expand I n t h i s way: perhaps i t is a l i t t l e b e tte r demonstrated by the next s lid e . (S lid e ) A t 16,000 to 18,000 fe e t a bubble of gas w il l have two times the volume i t does a t sea l e v e l . A t 25,000 f e e t , S tim e s; at 34,000 f e e t 5 tim es; and 39,000 f e e t 7 tim e s. This i s o f academ ic i n t e r e s t to us r i g h t h e r e , h u t i f we are i n a plane and t h a t bubble o f . ga s i s i n our m idd le ear or s in u s e s or g a s tr o in te s tin a l tra ct i t can cause a great deal of discomfort R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO ' How does t h i s l a c k o f p r e s s u r e cause the l g < * o f oXygen as we go h i g h e r ? ( S l i d e ) We f i n d , as I s a i d , th e r e i s about 21 per cen t o x y ge n i n our a tm o s p h e re . How ever, when we take a b r e a t h ,, d ilu te th at atm osphere.air in the r e s id u a l a ir w ith the complemental a i r t h a t i s c o n ta in e d in our lu n g s , so a c t u a l l y the percentage of oxygen that is in our a lveo lar is 14.5 per cen t. How th e p r e s s u r e a t sea l e v e l i s 760 m i l l i m e t e r s o f mercury b a r o m e t r ic p - e s s u r e , so we have an oxygen p r e s s u r e or oxygen te n sio n in our lungs norm ally o f 110 m illim e te r s of m e rcu ry . Now l e t us go to 1 8 ,0 0 0 f e e t , where we s t i l l have 14.5 per c e n t oxygen i n our lu n g s and where the b a ro m etric p r e s s u r e i s 580 m i l l i m e t e r s o f m e rc u ry , and we w i l l f i n d our oxygen te n s io n i s 55 m illim e te r s o f m ercury, ju s t h a l f . In other words, the pressure o f oxygen th at i s contained in th a lv e o lu s - when I sa y p r e s s u r e , I mean p r e ssu r e j u s t as p u sh in g fc is c h a ir - the amount o f push t h a t oxygen has to push i t s e l f th rou gh the a l v e o l a r membrane and the pulm onary c a p i l l a r i e s i s ju st halfwhat i t is a t sea le v e l. There i s one f u r t h e r c a t c h to t h i s . I d o n ' t mean to go i n t o h i g h e r m a th e m a tics or a n y t h i n g , b u t we do f i n d t h a t the a ir in our lungs i s sa tu ra te d w ith water vapor and as the body tem perature i s a lw a y s c o n s t a n t we have a c o n s t a n t amount o f watej R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO vapor in our lu n g s . That has been m easured and found to be a t e n s i o n o f 47 m i l l i m e t e r s o f m e r c u r y . So a c t u a l l y we d o n ' t have 760 m i l l i m e t e r s o f t o t a l p r e s s u r e ; we h a v e 760 m in us 4 7 . I f we t a k e 1 4 .5 p e r c e n t o f t h a t , we f i n d a p p r o x im a t e a l v e o l a r te n sio n i s 105 m illim e t e r s o f m ercu ry . In o th e r w ords, as th a t oxygen, t o t a l p r e s s u r e , g o e s down, we f i n d t h a t o u r o x y g e n pressure or oxygen te n sio n goes down. ( S l i d e ) To go on j u s t a m in u t e w it h t h i s w a te r v a p o r p r e s s u r e , w h ic h i s c o n s t a n t i n t h e l u n g s , we f i n d t h a t a t s e a le v e l i t d o e s n 't amount to v e r y much. In f a c t , i t o n ly takes up 6 . 2 p e r c e n t . H o w e v e r , i f we go to 6 3 ,0 0 0 f e e t , we f i n d t h a t th e t o t a l b a r o m e t r i c p r e s s u r e a t 6 3 ,0 0 0 f e e t i s 47 m i l l i m e te rs o f m e r c u r y . - I f we a l r e a d y h a v e 47 m i l l i m e t e r s o f m e rc u ry p r e s s u r e p r e s e n t i n o u r l u n g s due to t h e w a t e r v a p o r we fin d the w ater vapor tak es up 100 per ce n t o f our p re ssu re th ere To go on w i t h t h i s , we c o u l d g i v e a p e r s o n a t 6 3 ,0 0 0 f e e t 100 per c e n t o x y g e n . I t would do him no good w h atso ever because th a t t o t a l would be ta k e n up by our w ater vapor t e n s io n . The way we g e t a r o u n d t h a t i s b y b r e a t h i n g i tt p r e s s u r e i c e cabinets, which I w ill speak of in ju st a m inute, (S lid e ) Thus-we fin d c e r t a in changes take p lace in the body due to changes in the a l t it u d e and the most im p ortan t thing is th a t change in a ir p ressure which I have ju s t been d is - r e n a H a l l E ly CITIZENS BUILDING CLEVELAND !4, OHIO c u s s i n g . We f i n d we h a v e d e c r e a s e d o x y g e n p r e s s u r e . We f i n d t h a t we h a v e e x p a n s i o n o f g a s e s i n b o d y c a v i t i e s , g o i n g b a c k a g a i n to B o y l e s Law , th e h i g h e r we t a k e a b u b b le o f g a s th e more i t e x p a n d s . Vie f i n d a t h i r d t h i n g due to t h i s c h a n g e i n a i r p r e s s u r e , t h i s d e c r e a s e . T h at i s , the e v o l u t i o n o f g a s e s i n bod^ f lu id s . That m ight be lik e n e d to uncapping a b o t t le o f carb o n a t e d w a t e r . T h a t i s , we h a v e c a r b o n d i o x i d e d i s t i l l e d i n w a t e r under p r e s s u r e . When we u n c a p , we r e l e a s e t h e p r e s s u r e and CO b u b b l e s o u t . The same i s t r u e i n th e b o d y . The g a s t h a t b u b b le s o u t i s n i t r o g e n c h i e f l y fr o m t h e b o d y . When we go to a l t i t u d e , t h e p r e s s u r e i s d e c r e a s e d and we becom e u n c a p p e d and we h a v e b u b b l e s o f g a s e v o l v i n g i n o u r b o d y f l u i d s . The se co n d change t h a t t a k e s p la c e i s the change i n temperature with the in c r e a s in g c o ld , which at the p re se n t day i s n o t much o f a p r o b la n b e c a u s e we h a v e a d e q u a t e h e a t i n g i n o u r a irp la n e s . C h a n g e o f s p e e d i n t h r e e d i r e c t i o n s t a k e s p l a c e as we go i n t o th e a i r r a t h e r th an change o f sp eed i n two d i r e c t i o n s as we a r e a c c u s t o m e d to on t h e g r o u n d . , ( S l i d e ) Now o f th e t h i n g s t h a t h a v e t o b e c o n s i d e r e d a we go t o a l t i t u d e , p r o b a b l y o x y g e n l a c k i s t h e m o s t i m p o r t a n t and we f i n d we h a v e various t y p e s o f o x y g e n l a c k i n th e b o d y , o r R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO a n o x ia . V/e h a v e a c u t e a n o x i a and c h r o n i c a n o x i a , C h r o n i c i s that type where the body i s exposed to oxygen la c k fo r a s u f f i c i e n t l y lo n g p e r io d o f tim e so t h a t th e body i s a b l e to make a d ju s tm e n ts . The e r y t h r o c y t e s become h i g h e r . The h e m o g lo b in becomes h ig h e r . Our blood volume becomes g r e a t e r . They are able to a d j u s t . The acu te a n o x ia i s where the i n d i v i d u a l i s n o t exposed to low ered oxygen te n s io n fo r a s u f f i c i e n t l y lon g p erio d o f tim e so he , i s , . a b l e to a d j u s t t o i t , and v/e c l a s s a c u t e anoxia in to fou r types fo r convenience. They a re n ' t e n tir e ly accurate but they serve as a working c la s s ific a tio n Anoxic a n o x ia , which means a lowered oxygen te n sio n i n o u r a r t e r i a l s y s t e m . And v/e f i n d we h a v e two t y p e s o f a n o x i c an o xia , - th a t due to e x t e r n a l cau ses where th e re is low ered o xy g en t e n s i o n i n th e a i r we b r e a t h and t h a t o f c o u r s e i s the ty p e o f a n o x i a we e n c o u n t e r vh en we go to a l t i t u d e . I n t e r n a l causes o f an o xic a n o x ia m igh t be a f o r e ig n body, an o b s tr u c tio n in the tra ch e al where the in d iv id u a l i s unable to breathe a i r in to the lu n g s , o r i t m igh t be due to the c o n s o l i d a t i o n o f the a l v e o l i , such as pneumonia, so the a i r cannot be p assed in to the pulmonary c ir c u la t io n . T h e r e f o r e , t h e c h i e f t y p e o f a n o x i a v/e a r e i n t e r e s t e d in in a v ia tio n and in a lt it u d e is an o xic a n o x ia . However, these oth ers e n te r in to the p ic t u r e : Anemic a n o x ia , w hich means there R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 68 is not adequate hem oglobin to c a r r y the oxygen to the t is s u e s . S t a g n a n t a n o x i a i s where we h a v e a d e q u a t e o x y g e n breathed in and adequate hem oglobin to c a r r y i t b u t the c i r c u l a tion is too slow to g e t i t around w ith s u f f ic ie n t speed to s a t i s f y the demands o f the t i s s u e s . The t y p i c a l exam ple o f t h a t is in cardiac decom position, H i s t o t o x i c a n o x i a i s where we have a d e q u a t e o x y g e n , adequate hem oglobin, to o , and s u f f i c i e n t speed of the c i r c u la tio n to p r o p e r ly c a r r y i t around b u t when th e oxygen i s d e liv e r e d to the t i s s u e s th e r e i s a p a r a l y s i s o f the o x i d a t i v e p r o c e s s o f the t i s s u e s so th e t i s s u e s are n o t a b le to use th e o x y g e n . One o f the more common t y p e s o f h i s t o t o x i c a n o x i a i s c y a n i d e p o i s o n in g . A n o th er one you may be more f a m i l i a r w it h , th a t o f th e hang-over. That is p u rely a case o f h is to to x ic an o xia . ( S l i d e ) I n s p e a k i n g o f t h e s t a g e s o f a n o x i a , we h a v e a r b it r a r ily taken vario u s le v e ls . I wish to say before d is c u s s ing these s lid e s th at these fig u re s are not a b so lu te ly c o r r e c t. There i s tremendous in d iv id u a l v a r ia t io n in the d if f e r e n t s ta g e s , Vihere an i n d i v i d u a l goes fro m s e a l e v e l to 1 0 ,0 0 0 f e e t , th e r e i s not s u ffic ie n t oxygen la c k to r e a lly cause- any bodily-m ade a d j u s t m e n t s . We do f i n d an i n d i v i d u a l ' s n i g h t v i s i o n w i l l be c u t down som ew hat. That i s n o t o f s u f f i c i e n t im p o r ta n c e from the compensatory s ta g e 0 . R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 69 to ' From 1 0 ,0 0 0 to 1 4 ,0 0 0 f e e t we f i n d t h e b o d y ' s co m p en sa t o r y a b i l i t y w i l l be c a l l e d i n t o p l a y , and th e s e are p r i m a r i l y r e s p i r a t o r y and c a r d i o v a s c u l a r . We w i l l f i n d t h e i n d i v i d u a l w i l l b r e a t h some what more d e e p l y and a l i t t l e more r a p i d l y , to i n c r e a s e t h e amount o f o x y g e n i n h i s a l v e o l a r . We w i l l f i n d a s lig h t in cre a se in p u lse r a te and a s l i g h t in c re a se in the b lo o d p r e s s u r e so th e c a r d i a c e f f i c i e n c i e s a r e i n c r e a s e d and oxygen g e t s to' th e c a p i l l a r i e s . i When we g e t t o t h e d i s t u r b a n c e stage, which is from 1 4 ,0 0 0 t o 2 0 ,0 0 0 f e e t a p p r o x i m a t e l y , we w i l l f i n d t h e i n d i v i d u a l ' s compensatory p ro ce sse s are no lo n g e r ab le to p ro p e rly a d ju s t th e b o d y to t h i s o x y g e n l a c k , and we t h e n b e g i n d e v e l o p i n g t h e symptoms o f a n o x ia , w hich I w i l l d is c u s s i n j u s t a m in u te . * The c r i t i c a l s t a g e , 2 0 ,0 0 0 f e e t o r m ore, i s where the i n d i v i d u a l g o e s i n t o u n c o n s c i o u s n e s s . We w i l l f i n d p e o p l e who can go to 2 4 ,0 0 0 f e e t and w i l l n o t become u n c o n s c io u s ;. o th e r People may become u n co n scio u s at 17,000 or 18,000 f e e t . A g a in , these fig u r e s -are g e n e r a liz a tio n s which f i t the average i n d i v id u a l. ( S lid e ) Now, as to th e s ig n s and symptoms a p p e a rin g au th e d i s t u r b a n c e s t a g e o f a n o x i a . We may s e e c y a n o s i s . We w ill see im pairm ent o f the s p e c ia l s e n s e s , and the s p e c ia l sense t h a t i s m o st e a r l y a f f e c t e d i s th e v i s i o n . We w i l l f i n d a c u t - R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 70 PS R en a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 71 conscious. However, u s u a lly i f the in d iv id u a l is c lo s e ly w atch ed he w i l l d e v e lo p one o r a l l o f th e s e sym ptom s. Now, f o r t u n a t e l y , d e s p i t e what we f i n d f r o m o u r n e u r o pathologists th at fre q u e n tly anoxia w ill leave a great deal of resid u al damage, fo r tu n a te ly in the u su al an oxia encountered in a v ia tio n i f the person liv e s through i t he w i l l e n t ir e ly re c o v e r. In the E ig h th A in Force th e y had as many an oxic episodes as in any o f our a i r f o r c e s . I b e lie v e there were o n ly fou r cases re p o rte d where an in d iv id u a l su rv iv e d severe an oxic e p is o d e s who h a d a n y r e s i d u a l c e r e b r a l d a m a g e . U s u a l l y t h a t person w i l l r e c o v e r e n t i r e l y i n from 24 to 48 h o u rs a f t e r an anoxic ep iso d e. ih ey w ill have headache, le th e r g y , nausea and p r o s t r a t i o n . A f t e r 48 h o u rs i n th e a v e ra g e i n d i v i d u a l i t w i l l c le a r up e n t i r e l y . ( S l i d e ) Nov', how do we com bat t h i s l a c k o f o x y g e n * a t a l t i t u d e s ? O f c o u r s e , we com bat i t b y o x y g e n s y s t e m s and i n g e n e r a l , we h a v e f o u r t y p e s . The c o n s t a n t f l o w m ost o f u s are fa m ilia r w ith 0 That i s the type o f system used th e ra p e u tica l y i n your o f f i c e s . T h at i s the BLV mass and w ith a r e b r e a t h e r b a g . I t i s th e 'type o f s y s te m t h a t j u s t as i t s name i m p l i e s has a constant flo w . Oxygen w ill flow c o n s ta n tly through that m a s s . I t i s v e r y e x c e l l e n t up t o 2 0 ,0 0 0 to 2 5 ,0 0 0 f e e t . Above th a t, i t does not d e liv e r an adequate amount o f oxygen to take R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO care of I t . , The demand o xygen s y s te m , a g a in i s j u s t as th e name i m p l i e s . We b u i l d up a n e g a t i v e p r e s s u r e w i t h a t r i p l e v a l u e and th e o x y g e n i s d e l i v e r e d . When we b u i l t up a p o s i t i v e p r e s s ure w i t h e x h a l a t i o n s we d e v e l o p a t r i p l e v a l v e and s h u t o f f . In oth er words, i t comes o n ly w ith demand. In t h is type o f oxygen we a r e a b l e to go t o 3 0 ,0 0 0 to 3 5 ,0 0 0 f e e t . Above t h a t , i t f a l l s down. We th e n come t o th e p r e s s u r e ty p e o f m a s s , where o x y g e n i s d e l i v e r e d to u s u n d e r p r e s s u r e . Remember, when we f i r s t spoke o f oxygen I t was the p re ssu re th a t was the im p ortan t th in g and t h a t i s how we w ere a b l e t o go t o th e a l t i t u d e a b o v e t h a t . We a r e now u s i n g i n many o f o u r c o m m e r c ia l a i r c r a f t , th e D C -6 and the C o n s t e lla t io n and the S t r a t a c r u is e r a p r e s s u r iz e d c a b in where p re ssu re i s fo r c e d in to the c a b in and the in d iv id u a l i s then m aintain ed a t an a lt itu d e f a r below th a t in the a i r . ^ ( S l i d e ) This more o r l e s s shows d i a g r a m m a t i c a l l y the p r e s s u r e c a b i n . A i r i s f o r c e d i n h e r e so we may be f l y i n g a t 50,000 f e e t but the ca b in p re ss u re , the a lt it u d e , sim ulated a l t i t u d e in s id e th a t is about 8,00.0 f e e t . In o th e r words, a pressure, cab in i s ju s t the reverse o f a D ie s e l pressure chamber w h ic h we u s e d i n s c h o o l . T h e re you w i l l r e c a l l a i r was pumped o u t , a n e g a t i v e p r e s s u r e was b u i l t u p . H ere we pump i n and R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO develop a p o s i t i v e . T h at w i l l be the type o f a i r c r a f t g e n e r a lly within a few y e a rs most o f us w i l l be f l y i n g . ( S l i d e ) Now, as you r e c a l l , one o f th e e f f e c t s o f decreased p r e s s u r e was the a n o x ia . A n o th e r was the e x p a n sio n of gases in our body c a v i t i e s , and these are the th ree systems that are c h i e f l y a f f e c t e d by the expansion o f g a s e s . A l l o f you mho h a v e f l o w n h a v e f e l t t h e f u l l n e s s i n y o u r e a r s , w h ic h y o u have c le a r e d i n one way or a n o th e r . That i s m e re ly due to the f a c t th a t when you go up - say you have a p re ss u re o f 760 m illim e te rs o f m ercury in your m iddle ear and you go to 18,000 fe e t - the p re ssu re on the o u ts id e i s o n ly 380 m illim e t e r s . You have in c r e a s e d p re s s u re on th e m id d le e a r and t h a t c a u s e s p re ssu r e on the tym panic membrane and you have p a in . I f c a r r i e d on lo n g enough i t may ru p tu re th e m iddle e a r . What i s done i s open the E u s t a c h i a n tu b e and we do t h a t b y c h e w in g gum o r s a l i v a r y f l u i d o r c l o s e o u r n o s t r i l s and c a u s e g e n t l e p r e s s u r e u n t i l we hear our ears pop. which We come on down t o t h e p a r a n a s a l s i n u s e s / a re a f f e c t e d , u s u a l l y when t h e y are d i s e a s e d , and we do n o t h a v e an o p en p a s s age-way to the o u t s id e , and in t h i s group g o in g up or coming down you may h a v e p r e s s u r e c h a n g e s and q u i t e s e v e r e p a i n . The g a s t r o i n t e s t i n a l t r a c t , f o r t u n a t e l y , i s w e ll equipped w ith two o r i f i c e s w hich ca n u s u a l l y ta k e care o f t h a t R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 74 e x p a n s i o n o f g a s e s . H o w e v e r , o c c a s i o n a l l y we w i l l f i n d , e s p e c ia lly i n r a p id a s c e n t the gas w i l l become en trap p ed in an in t e s t in a l loop and you can im agine g o in g up to 25,000 fe e t where th r e e tim es th e volum e o r 4 5 ,0 0 0 f e e t v/here 7 tim e s th e volume, a bubble o f gas w i l l assume a g re a t d e a l o f im portance when i t i s t r a p p e d i n y o u r g a s t r o i n t e s t i n a l t r a c t . ( S l i d e ) T h i s i s a p a t i e n t who had p n e u m o th o ra x and I show i t j u s t to show th e e x p a n s i o n o f g a s e s . T h is p i c t u r e was taken a t ground le v e l and t h is taken at 10,000 f e e t . That i s as h i g h as we d a r e go w i t h t h i s i n d i v i d u a l . Y o u w i l l f i n d i t h e r e in the pneumothorax I th in k and here at 10,000 f e e t i t has e x panded and you cun see how t h i s a d h e s io n i s put on s t r e t c h . I t w o u ld n 't take much more to ru p tu re t h a t , and o f c o u rs e , t h a t can tke p la ce any p la ce in ,the;.bpdy where you have entrapped gas. The t h i r d e f f e c t o f a l t i t u d e , t h a t i s , th e e v o l u t i o n o f gases" i n our body f l u i d does n o t i n t e r e s t us too much to d a y because a c t u a l ly th a t i s more a problem o f m i l i t a r y a v ia t io n . We a r e n o t g o i n g h i g h e n o u g h i n c i v i l i a n a v i a t i o n f o r i t to assume any im p o rta n c e . What happens th e r e , a s I have s a id , i s l i k e u n c a p p i n g th e b o t t l e o f c a r b o n a t e d w a t e r and we h a v e b u b b le s / o f h itro g e n form in the b lood , u s u a lly c o lle c t in g around the jo in t s and sometimes cau sin g v e ry extreme p a in . I t is prevented R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 75 by b r e a t h in g 100 p er c e n t o xy gen f o r h a l f an hou r t o an hour b e fo r e a s c e n t . I t i s n o t h i n g a t th e p r e s e n t time n o r do I b e l i e v e we w i l l e v e r h a v e to be v e r y i n t e r e s t e d i n t h i s t h i r d e f f e c t of a ltitu d e in c iv ilia n a v ia tio n . ( S l i d e ) Now w i t h t h i s b a c k g r o u n d i n a v i a t i o n , how does i t a f f e c t our chem ical p r a c t ic e o f m e d ic in e , and f o r con venience I have provided our group of d iseases that are a f f e c t ed c a r d i o v a s c u l a r l y . O f th e c a r d i o , we a r e i n t e r e s t e d i n c a r o t i c j , s i n u s , p o s t u r a l , h y p o t e n s i o n o n l y i n r e g a r d s to th e p i l o t . We don' t want to have a p i l o t or at l e a s t I do n o t , ^ o i s g o in g to be u n c o n s c i o u s e v e n m o m e n t a r i l y , and t h e r e f o r e , we a r e a lw a y s v e r y c a r e f u l to c h e c k o u r p i l o t s f o r t n i s . As fcJ? as uhe p a s s e n g e r i s c o n c e r n e d , i t i s o f v e r y l i t t l e s i g n i f i c a n c e . He has no more rea so n f o r d e v e lo p in g u n co n scio u sn e ss in tne a ir I than on the ground l e v e l . v alv u lar heart disease gen erally w ill rule a p ilo t o u t . I am n o t s u r e we a r e c o r r e c t on t h a t , b u t I won' t go i n t o i t a t the p resen t tim e. However, v a lv u la r h e a rt d isease th a t is compensated fo r in a passenger can f l y w ith im punity. V a lv u la r heart disease that is not compensated fo r had b e st not f l y , be cau se , u n l e s s i t i s , we h a v e a n o x i a due t o th e c a r d i o . I f we / - add a n o x i c a n o x i a t o t h a t , we may b r i n g a b o u t v e r y s e v e r e c a r d i e em barrassm ent. I f a person were d e c a r d ia c , i t is b e s t fo r him R ena H all E ly CITIZENS BUILDING C L E V E L A N D 1A, O H IO 76 to take oxygen from the ground up. H y p e r t e n s io n , th e seme r e a s o n s may a p p l y . The i n d i v i d u a l w ith b e n ig n h y p e r t e n s io n - I a o n 't mean es p i l o t bu t os p p a s s e n g e r , may f l y . On t h e o t h e r h a n d , a p e r s o n w i t h hyp er tension w ith h eart d ise a se end c a re ia c com pensation hea b e tte r not f l y , or w ith any o f th e o th e r c o m p lic a tio n s . The person w ith coronary throm bosis w ith in d iv id u a l f l y i n g i s an i n d i v i d u a l p r o b le m . C e r t a i n l y an i n d i v i d u a l who had hod a re ce n t coronary throm bosis had b e t t e r n o t . k person w i t h a n g i n a p e c t o r i s h a d b e t t e r n o t b e c a u s e we h a v e n o t o n l y t h e a n o x ia b u t t n e r e i s no doub t e c e r t a i n amount o f n e rv o u s s t r a i n in t u e r e and i t may b r i n g on an a t t a c k , so in g e n e r a l I a d v i s e th e p e r s o n who h a d a c o r o n a r y t h r o m b o s i s n o t t o f l y u n l e s s i t is v ery n e c e s s a r y , nd i f ne f l i e s , to be sure th e r e is oxygen on th e p l a n e . As fa r as the r e s p ir a to r y d is e a s e s are con cern ed , in fe c tio n o f the upper re sp ira to ry tr a c t are not o f great s ig n i f i c a n c e e x c e p t t h e y r e n d e r t h e i n d i v i d u a l s u b j e c t bo a e r i o t i t i s , th at i s , expansion o f the gas in the m iddle e a r , and to a e r ia l s i n u s i t i s . I t u s u a l l y can be overcome b y some o f t h e b a r b i t u r a t e s ? such as benzedrine or tu lsm in e. The p a t i e n t w i t h pneum onia w\ o a l r e a d y h a s p r e s e n t a n o x ic a n o x i a , to add a n o x ia o f u l t u t u d e to t h a t may be s e r i o u s . R ena H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO I t may'cause d e fin ite respiratory fa ilu r e . For that reason, i f n ls necessary fo r a petient with pneumonia to f l y , he should be rriven oxygen from the ground up. The problem of the patient with pulmonary tuberculosis fly in g has not been e n tir e ly s e ttle d . I believe a patient with minimum pulmonary tuberculosis can f l y . However, there is one important thing in regard to tuberculosis, and that is in general a patient who is having pneumonia thorax or tuberculosis should not f l y . I think the x-rays m u s t showed you explain wir There have been deaths reported where individuals have gotten on a plane as a r e su lt and have not told the authorities about i t , and i t has been necessary to go to 15,000 fe e t or some extreme altitude and as a resu lt of th a t, have died either due t the tearing of the adhesions which might have occurred m the case or a mediostinalship or other com plications. Asthma - the average patient with asthma can usually f l y . I f he is in the midst of a severe attack , I think i t advis able for him not to f l y or i f he is subject to frequent attacks, i t is b etter fo r him not to f l y . We fin d frequently, perhaps due to nervous stim ulation, perhaps due to the mild anoxia, that many patients frequently have severe attack s. peptic ulcer in the g a stro in te stin a l system - these people can f l y without d i f f ic u l t y unless they have a . threatened r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 78 p e rfo ra tio n . I f th ey have a subacute p e r fo r a tio n , the expan sion o f gases in the g a s t r o i n t e s t i n a l t r a c t may be s u f f i c i e n t to cause a p e r f o r a t i o n and g i v e t r o u b l e . F o r th e same r e a s o n , ( p a t i e n t s who h a v e h a d r e c e n t g a s t r o s u r g i c a l p r o c e d u r e h a d b e s t In o t f l y u n t i l t h e i n c i s i o n i n th e wound i s h e a l e d . We may g e t jexpansion o f gas in the g a s t r o in t e s t in a l t r a c t and a b re ak in g (down o f th e s u t u r e l i n e an d th e r e s u l t i n g c o m p l i c a t i o n s . I n t r a c r a n i a l i n j u r i e s were tr a n sp o r te d by la r g e number Iin World War I I . However th e y were tr a n s p o r t e d a t v e r y low le v e lj. j 1 ,0 0 0 o r 2 ,0 0 0 f e e t . I n o r d i n a r y c o m m e r c i a l f l y i n g , we c a n n o t a b s o lu te ly guaran tee tr a n s p o r tin g an in d iv id u a l a t such low [ a lt it u d e . T h e re fo re , the in d iv id u a l w ith an in t r a c r a n ia l in ju r y probably as a b e st r u le had b e tte r not f l y u n t i l he has e n t ir e ly r e c o v e r e d . The r e a s o n i s t w o - f o l d . He may h a v e a i r e n t r a p p e d [which may expand and cause d i f f i c u l t y or he may have or a lr e a d y [do h a v e a c e r e b r a l a n o x i a due to t h e i n j u r y and i f we add th e a n o x ic a n o x i a o f a l t i t u d e we may do c o n s i d e r a b l e c e r e b r a l d am age.| |Along th a t l i n e , t h e y ta k e en cep h alo gram s and ta k e th e men o u t of the a i r m a il s e r v ic e u n t i l such time a s they are f u l l y re [covered. O therw ise, they w ill have comebacks o f p a in , headjaches and such as th e y have n ever had b e fo r e . The p s y c h o t i c p a t i e n t p r o b a b ly n o t due to the a n o x ia [but rhe s tim u la tio n o f f ly in g fr e q u e n tly w i l l become manic on R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 79 the p l a n e . I f you ta k e a p e r s o n who i s p s y c h o t i c and p u t him on a p la n e he may become b e s e r k . B e cau se o f t h i s and b e ca u se o f the p o s s ib le d an ger on the p la n e , I th in k i t i s a d v is a b le n o t to tra n sp o rt the p s y c h o tic by p la n e . The p a t ie n t s w ith n e u ro se s can f l y w ith o u t tro u b le e x cep t fo r one t h in g . They are more s u b je c t to a i r s ic k n e s s , bu t o th e rw ise th e y come to no harm . Ih e p a tie n t w ith an em ia, as anem ic a n o x ia tio n , how ever, i t i s u s u a l l y q u i t e m il d and he c a n u s u a l l y f l y v& t h o u t t r o u b l e . On th e o t h e r h a n d , a p a t i e n t w it h a s e v e r e an e m ia had b e s t n o t f ly u n less oxygen is p re se n t. I t h i n k t h e e n t i r e t h i n g may b e p r e t t y w e ll summed up in th e w ords o f C o l o n e l T u t t l e , who i s one o f th e d e a n s o f a v ia tio n m ed icin e and a form er commandant o f the sch o o l o f m e d icin e a t R an d o lp h F i e l d and now m e d ic a l d i r e c t o r o f U n it e d . He s a y s he t h i n k s th e a v e r a g e p e r s o n c a n f l y w it h o u t d i f f i c u l t y i f he w alks r ig h t , lo o k s r ig h t and sm e lls r ig h t . (Applause) CHAIRMAN H U SSEY: Thank y o u , D r . T i l l i s c h . The n e x t p ap er on our program t h is a fte r n o o n i s to be p re se n te d b y M r. Theodore H . H a tc h , R ese arch D ir e c t o r , I n d u s t r i a l H y g ie n e F o u n d a t io n o f A m e r ic a , I n c . , P i t t s b u r g h , who w il l speak on th e s u b je c t " P h y s io lo g ic a l R equirem ents in In d u s t r i a l M achine D e s ig n ." M r. H a tch i R en a H a ll E ly CITIZENS .BUILDING CLEVELAND t4 . OHIO 80 PH YSIO LOGICAL REQUIREME1!TS IN INDUSTRIAL MACHINE DESIGN Paper b y ; M r. Theodore p . H atch M r . C h a ir m a n , L a d ie s and G e n tle m e n * I am n o t g o in g to t a lk s p e c i f i c a l l y ab o u t the d e s ig n o f m ach in ery from th e s t a n d p o in t o f t h e o p e r a t o r . I vo u l d r a t h e r t r y t o p o i n t o u t th e need fo r more co n cern w ith t h is problem th an has been g iv e n in the p a s t . , I th in k i t i s more th an s i g n i f i c a n t th a t in the f i r s t is s u e T .t h i n k i t was o f G e n e r a l I n d u s t r i a l H y g ie n e 27 o r so y e a rs a g o , one o f th e le a d a r t i c l e s was on in d u s t r i a l p h y s io lo g y and in the v e r y f i r s t is s u e o f O c c u p a tio n a l M e d icin e th e le a d a r t i c l e was on th e s u b je c t o f i n d u s t r i a l p h y s io lo g y , and y e t d u rin g t h is p e rio d o f more th a n a q u a r te r o f a c e n tu r y p h y s io l o g ic a l problem s o f in d u s tr y c e r t a in ly have n o t o c c u p ie d much o f th e tim e o f th o s e o f u s who s p e c i a l i z e d i n t h i s f i e l d . T h ere is , o f co u rse, very good reason fo r th a t. Now in the broad sense, in d u s t r ia l hygiene is concern ed w ith f a r more than the d isco v e ry and c o n tro l o f o ccu p a tio n a l d isea ses. In the broad sense, i t is concerned with the vhole problem o f m aintaining the 'best p o ssib le r e la tio n s h ip between in d u s tr ia l worker and h is in d u s t r ia l environm ent. We are not only concerned with the occupational diseases but a l l other diseases that th is e s s e n tia lly a r t i f i c i a l in d u s tr ia l environment R ena H a ll E ly CITIZENS BUILDJNG CLEVELAND 14. OHIO imposes on a large section of the population concerned with the general well-being of the individual, with his efficiency and even contentment, if you will. ' Certainlv in terms of the total, industrial occupation- ^ " al d ise a se problem n ever was a v e r y b i g o n e . The t o t a l number o f p e o p l e a f f e c t e d b y th e c l e a r - c u t h e a l t h h a z a r d s a lw a y s was and c e r t a i n l y i s now a f f e c t i n g a v e r y s m a ll f r a c t i o n o f th e to ta l p o p u latio n . ' , - ' Furthermore, during the past 25 years we have seen a i ' , tremendous amount of progress made in the control of the occupa tional diseases, a great deal of progress in the technics of studying them, establishing the relationships between the disease and the nature of the oe-cupation. Many of' them have been b rougnt to a very high degree of'control and even for those occupational diseases that are not now under complete control the technics, the principles have been well established and it is only a matter of applying those principles and technics in a vigorous manner so that for the future there appears to be very little reason why a specific occupational disease should develop very fa r. ^ Those problems have occupied our attention almost ex clusively in the past. It is entirely logical that we should turn now more and more to some of the less obvious diseases of R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 82 in d u stry. The returns will not be as dramatic as they are in the case of the specific occupational diseases but will be of far greater benefit because of the greater number of human beings involved. Perhaps the b ig g e s t problem th a t fa c e s in d u s try today is the problem in human r e l a t i o n s . M r. G iv e n , p r e s id e n t o f th e A m e rica n B rake Shoe Com pany, sp eak in g a t the In d u s t r ia l H ygiene Foun d ation m eeting in November, em phasized th a t v e ry w e ll* 'in f a c t , he p u t the in d u s tr ia l h e a lth program on the v e ry to p o f th e l i s t o f m a tte rs th a t m ust be o f a c t iv e c o n c e rn to th e p r e s id e n t o f a modern com pany. I n d u s t r ia l h y g ie n e in t h is b ro ad sen se i s v e ry much co n cern ed , p la y s a v e r y g r e a t p a r t in t h i s problem o f human r e l a t i o n s , so t h a t f o r th e f u t u r e u n d o u b t e d ly we v / i l l s e e m ore and more a t t e n t i o n p a i d to t h e s e m ore s u b t l e s t r e s s e s . Now i n g o in g In to th e new a s p e c t o r d i f f e r e n t a s p e c t o f i n d u s t r i a l h y g ie n e we w an t to ke ep two t h i n g s i n m in d , as I see i t . A g r e a t d e a l of the p ro g re ss, v ery g r a t ify in g p ro g ress in in d u s t r ia l hygiene o ver th e p a s t 25 y e a r s com es ^ b o u t b e c a u s e o f two f a c t o r s . F i r s t o f a l l , i t has been c h a r a c te r iz e d b y team w ork. D r . Hussey men tio n e d a moment ago th e j o i n t e f f o r t o f p h y s ic ia n s , c h e m is ts , t o x ic o lo g is t s , e n g in e e r s , and e v e ry -d a y p h y s ic is t s w orking to - Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14. OHIO 83 gether and not s e p a ra te ly acco u n ts to a v e ry la rg e degree fo r the p ro g ress th a t has been m ade. The second f a c t o r I s th a t in i n d u s t r i a l h y g ie n e as p r a c t i c e d i n t h i s c o u n t r y we h a v e d e v e lo p e d to a v e r y h i g h d e g r e e the concept o f q u a n tita tiv e r e la t io n s h ip s , s t a t i s t i c a l co n cep t, i t is tr u e , but r e a l n e v e r th e le s s . So In the stu d y o f the e t io lo g y o f th e o c c u p a tio n a l d is e a s e s the stu d y i s one o f r e l a t ing the d is e a s e to the p h y s ic a l and ch e m ical fa c t o r s o f the o ccu p atio n . M ean in gfu l re la tio n s h ip s have been e s ta b lis h e d , th en , betw een the n a tu re o f the d is e a s e and th e in c id e n c e o f the d is e a s e among the exposed worle r s and f a c t o r s o f the environm ent which c o u ld be m easu red . M e a n in g fu l r e la t io n s h ip s have been e s ta b lis h e d and from t h is stan d ard s o f a k in d have been d eveloped so i t i s p o s s ib le th ro u g h q u a n t i t a t i v e m easurem ents o f th e environm ent to p r e d ic t in ;a u s e fu l manner the p ro b ab le e f f e c t from exposure to th o se en v iro n m en ta l fa c t o r s by com paring the le v e ls o f exposure as found in a g iv e n o ccu p atio n w ith the stan dards so d evelo p ed , i t is p o s s ib le to ap p ra ise the environm ent and e s t a b lis h th e c o n t r o l req u ire m en ts th a t have been n e c e s s a r y in order to b rin g i t under c o n tr o l. Now, as we go into these more subtle problems of industry, these two unique features of industrial hygiene become more important than in the past. In the case of a specific R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO o c c u p a tio n a l d is e a s e i t d o e s n ' t make a g r e a t d e a l o f d if fe r e n c e whether our sta n d a rd s are r ig h t o r n o t . By th a t I mean w hether the stan d ard is r ig h t or n o t is n o t g o in g to change the course of th e d i s e a s e . I f th e s t a n d a r d i s w ro n g , we w i l l c o n t in u e to have the d is e a s e . For the m ost p a r t, o c c u p a tio n a l d is e a s e s are f a i r l y c le a r - c u t . They p ro v id e in th em selves im m ediate y a r d s tic k s th a t t e ll ., us whether or not our c o n tro l procedures are e f f e c t iv e . I t is n o t a m atter o f o p in io n . There is l i t t l e o p p o rtu n ity fo r c o n fu sio n and c o n tr o v e r s y w hich alw ays a r is e when you d e a l in terms o f o p in io n . , When we go to th e m ore s u b t l e e f f e c t s , s u c h a s t h e e f f e c t o f n o is e o r the d e s ig n o f the m ach in e, you can see w hat an o p p o r t u n it y t h e r e w o u ld be f o r c o n t r o v e r s y i f we d e a l i n te r m s o f o p i n i o n . So i f we a r e to go i n t o th e s e o t h e r a s p e c t s o f t h e to t a l in d u s tr ia l environm ent, th ere is a g re a te r need fo r e s ta b l i s h i n g good r e la t i o n s h i p s betw een th e man and h is I n d u s t r i a l en viro n m an tal f a c t o r than th e re was in the. case o f the s p e c if ic o ccu p ation al d ise a se s. ' I n th e same w ay, i t i s e s s e n t i a l t h a t we d e v e lo p e v e n to a h ig h e r d egree the teamwork th a t has c h a r a c te r iz e d in d u s t r ia l h y g i e n e . C e r t a i n l y , when we d e a l w it h th e i n d u s t r i a l m a c h in e i t i s p r e tt y o b v io u s the p h y s io lo g is t co u ld n o t work by h im s e lf. R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 85 The i n d u s t r i a l m a c h in e m u st be c o r r e c t f u n c t i o n a l l y . I t m ust produce th e r i g h t k in d o f a p o t . I t m u st do i t i n an eco n o m ic m anner. The p rob lem i s n o t one o f l a y i n g down p h y s i o l o g i c a l re q u ire m e n ts q u ite In d e p e n d e n t o f th e f u n c t i o n a l . The r e q u i r e ment i s f o r e s t a b l i s h i n g them j o i n t l y . So t h a t a s we go i n t o t h is b ro a d e r a s p e c t o f th e work th e s e two c h a r a c t e r i s t i c s m ust be k e p t i n m in d , - team work and d e v e lo p in g m e a n in g fu l y a r d s t ic k s by m eans o f T/hich we c a n m e a su re p r o g r e s s . I d on ' t know a b e t t e r i l l u s t r a t i o n o f t h is th an in a company r e c e n t l y . One o f our la r g e in d u s t r ie s had a lo n g draw nout s t r i k e . That s t r ik e was draw n-out e s p e c ia lly in i t s l a t t e r stages because o f la ck o f agreem ent betw een the management and the u n io n over th e e x tr a tim e a llo w a n ce th a t was to be p ro v id ed over and above th e pure tim e m o tion req u irem en t f o r perform ance o f th e j o b . The m anagem ent had em p loyed a f i g i i r e o f 15 p er c e n t in k e e p in g Jwi th th e p r a c t ic e o f t h e ir in d u s tr y , a f t e r c a lc u la t in g th e p u re tim e r e q u ir e m e n t ad d ed 15 p e r c e n t f o r th e e x t r a tim e a llo w a n c e . The u n io n r e p r e s e n ta t iv e s s a id i t m ust be 30 p er c e n t, and so th e th in g hung f i r e , 100 p er c e n t d isa g re e m e n t so f a r a s th e m ag n itu d e o f th e tim e a llo w a n c e was c o n c e r n e d . The e n g in e e r in ch arge o f the tim e and m o tio n work in t h i s company trav eled about the country v is it in g oth er in d u s tr ie s , oth er fa c to r ie s in th is in d u stry to find out what th e ir p r a c tic e s w ere. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 86 He fo u n d th e 15 p e r c e n t v a l u e was t h e common t h i n g e m p lo y ed i n the in d u s tr y , but m ost s e r io u s ly he co u ld n o t fin d anywhere in th e i n d u s t r y an y good s c i e n t i f i c e v id e n c e to j u s t i f y the 15 per ce n t f i g u r e . I t had ju s t grown o u t and become a cce p te d p r a c t i c e . He came back to h is com pany, th e n , w ith t h is th o u gh t in m ind: I t i s the o p in io n o f management the fig u r e s h o u ld b e 15 p e r c e n t . I t i s th e o p i n i o n o f th e u n io n I t s h o u ld be 30 per c e n t, and th ey b o th have com p lete r ig h t to t h e ir r e s p e c tiv e o p i n i o n s . Now, we c a n ' t a l l o w a b i g i n d u s t r y i n t h e c o u n t r y to bog down and j u s t s to p p ro d u c in g o v e r argu m en ts t h a t a r is e from m a tte rs o f o p in io n . T h is g en tlem a n r e c o g n iz e d he would n e v e r be ab le to reduce the e x tr a tim e allo w an ce c o m p le te ly to f ig u r e s . You c a n ' t a s s ig n a l l o f th e se p e rso n n e l problem s q u a n t it a t iv e , v a lu e b u t s u p p o se t h a t yo u were a b le to do so to th e e x t e n t o f 50 p e r c e n t o r 75 p e r c e n t , th e 100 p e r c e n t d is a g r e e m e n t o v e r 25 p e r c e n t t h a t wra s l e f t w o u ld p r o b a b l y n o t be e n o u g h t o j u s t i f y a c o n t i n u a t i o n o f th e s t r i k e . So we h a v e g o t to h a v e m e a n in g f u l s c i e n t i f i c m ethods f o r m easu rin g such f a c t o r s as t h is one o f the ex tra tim e a llo w a n ce . Now i n k e e p in g w it h th e m od ern i n d u s t r i a l h y g ie n e program w hich em phasizes the p o s itiv e co n cep t o f h e a lth in i n d u s t r y , we a r e a l l f a m i l i a r w it h th e v e r y e x t e n s i v e p r o g r e s s th a t i s b e in g made i n jo b a n a l y s i s , th e p r e -p la c e m e n t e x a m in a tio n R ena H a ll E ly CITIZENS BUILDING CLEVELAND t4, OHIO 87 fo r the b e s t s e le c t io n o f w orkers f o r jo b s , the fo r m u la tio n o f t r a i n i n g p ro g ra m s , to t r a i n men b e s t to f i t them f o r s p e c i f i c jo b s . The a c t i v i t i e s in th is f i e l d i l l u s t r a t e I th in k v e ry w e ll th e c o m p le x it y o f m odern i n d u s t r y . ?le d i d n ' t h a v e s u f f i c i e n t th in gs in y e a rs gone by and la r g e ly because th ey v/eren't needed in the r e la t iv e ly sim p ler in d u s try o f the e a r lie r d ay. There i s an oth er p a r t to th is program th a t I want p a r t i c u la r ly to t a l k a b o u t , one th a t i s not commonly d is c u s s e d in a r t ic le s on job a n a ly s is and p re -p lace m en t s e le c t io n , p re placem ent e x a m in a tio n s . I would lik e to s u g g e s t .t h i s * That w herever i t i s n e c e s s a r y to s e l e c t men s p e c i f i c a l l y f o r jo b s I am t a l k i n g now a b o u t s p e c i a l s k i l l s - b e c a u s e t h a t jo b im p o se s c e r t a in s tr e s s e s on th e w orker, I w ould lik e to s u g g e s t th ere is som ething Tfrong w ith t h a t 'j o b . I t i s n ' t enough to fin d o u t what are the s p e c i a l s t r e s s e s and th e n f i n d men vh o a r e a b le t o cope w ith th o se s t r e s s e s . When you do t h a t , you are d raw in g on th e re se rv e s o f the p o p u la tio n . You are h a v in g to fin d p a r t ic u la r men to do p a r t i c u l a r j o b s . We n e e d to go one s t e p i u r t h e r and fin d o u t why i t i s t h a t a p a r t ic u la r jo b im poses c e r t a in s t r e s s e s a to what e x t e n t i t w ould be p o s s ib le to e lim in a t e Lhose s t r e s s e s from th e jo b , so i n a d d it io n to jo b a n a l y s i s , the s e a t in g up o f re q u ire m e n ts fo r th e jo b and th e s e l e c t i o n o f men to m eet th o se r e q u ir e m e n ts we m u st add t h i s t h i r d s t e p o f s t u d y i n g th e jo b to R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 88 gee w herein i t r i s p o s s ib le to e lim in a te from the job those s p e c ia l s t r e s s e s t h a t make i t n e c e s s a r y to p ic k men f o r the jo b . There is v e ry co n sid e ra b le o p p o rtu n ity I b e lie v e fo r doing th is in co n n e ctio n w ith the d esig n o f in d u s tr ia l m ach in ery. M e c h a n iz a t io n c h a r a c t e r i z e s A m e r ic a n i n d u s t r y . We h a v e in c r e a s e d our p r o d u c t iv it y f o r the p a s t 50 y e a r s a t a p r e t t y u n ifo rm r a t e of about 3 per cen t per y e a r . That means th a t in the course o f 30 y e a r s we h a v e d o u b le d o u r p r o d u c t i v i t y p e r m an . T a k in g a l l in d u s try as a w h o le, w ith s p e c ta c u la r im provem ents in p a r t ic u la r i n d u s t r i e s , we a l l know how t h a t c h a n g e d th e c o m p l e x it y o f o u r in d u s tr y . I t h as made p o s s ib le th e huge in d u s t r ie s o f to d a y . I t has very g r e a t ly in creased the problems from the standpoint o f the nature of the job* I t w ould s c a r c e ly have been p o s s ib le to d is c u s s m a tte rs o f m a ch in e d e s ig n 30 o r 40 y e a r s a g o . They are i n t e r e s t e d t o d a y b e c a u s e o f t h i s g r e a t i n c r e a s e i n m ech ai i z a t i o n . We now h a v e n e a rly 7 horsepow er of e l e c t r i c a l en ergy and o th e r form s o f energy a v a ila b le in In d u stry per w orker. I lik e to illu s t r a t e th is by c a llin g a tte n tio n to the fa c ie the w orker can - - , , n ot work h im s e lf a t much more th a n o n e - f i f t h h o rse p o w e r, so on the a v e r a g e we h a v e th e pow er e q u i v a l e n t 'to some 30 men u n d e r th e c o n t r o l o f e a c h w o rk e r i n i n d u s t r y . Now 50 y e a r s ago i f you had a crew o f 30 men you would have a fo re m a n sv e r y c a r e f u l l y Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14, OHIO 89 s e l e c t e d fo r e m a n , to s u p e r v is e t h o s e 30 m en . T o d a y , we a r e g iv in g one man th e pow er o f 30 men i n th e form o f th e com p lex machine. - F o r th e f u t u r e we may e x p e c t f a r g r e a t e r m e c h a n iz a t io n , We saw d u r in g th e w ar g r e a t a d v a n c e s i n e l e c t r o n i c s , i n s e v e r a l mechanisms in ' a u to m a tic c a lc u la t o r s and one th in g and a n o th e r, a l l o f w hich can be a p p lie d in in d u s tr y , w ith the r e s u lt i t w ill mean g r e a t e r m e c h a n iz a t io n ,, th e s i n g l e o p e r a t o r c o n t r o l l i n g f a r m ore1pow er th a n t o d a y . The o p e r a to r s t i l l p la y s a p a r t in the m a ch in e, no m a tte r how c o m p le x . T h ere i s s t i l l an o p e r a t o r . Now t h i s m ach in e we c a n t h i n k o f' fr o m a p h y s i o l o g i c a l p o i n t o f v ie w as m erely the e x te n s io n o f the man. In the o ld days o f.t h e manual la b o re r the m an's m uscle p ro v id ed the sou rce o f power and h is b ra in and a l l the r e s t o f him s e rv e d as th e c o n tr o lin g m echanism . W ith th e modern m ach in e, th e power i s fe d in from the o u ts id e . The m a c h in e c o n s i s t s o f a d e v ic e f o r th e u s e o f t h a t p o w e r, w it h s u i t a b l e c o n t r o ls w h ich when m a n ip u la t e d b y th e man c a u s e s t h i s power to perform u s e fu l w ork, so the m achine is an e x te n sio n o f th e man p h y s i o l o g i c a l l y . We c a n n o t ta k e i t f o r g r a n t e d t h a t because the m achine i s h ig h ly s u c c e s s fu l in i t s fu n c tio n a l p e r form ance th a t i t i s n e c e s s a r ily the b e s t d e sig n from the sta n d p o in t o f the r e la t io n s h ip betw een the m achine i t s e l f and the R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 90 o p e ra to r. There is a vague s o rt o f a r e a liz a tio n in in d u stry among tim e and m o tio n e n g i n e e r s , i n d u s t r i a l e n g in e e r s g e n e r a l l y , a vague r e a liz a t io n th a t there is som ething w rong, som ething la c k in g , and th a t th e re i s need fo r stu d y in g the p h y s io lo g ic a l requirem ents o f m a ch in e ry . In g e n e r a l, how ever, the e n g in e e rs around th ro u g h in d u s tr y are n o t a c q u a in te d w ith p h y s io lo g y and p h y s io lo g is t s . They have l i t t l e id e a o f how to s e t up syste m a tic s tu d ie s . E n gin eers by and la rg e are p r e tty su sp icio u s o f the s u g g e s t io n you can s tu d y man i n any s y s te m a t ic w ay. N e v e r- th e, l e s s , th e y do r e a l i z e i t i s tim e now to do more th a n m e r e ly d esign m achines from a fu n c tio n a l p o in t o f v ie w . M a n ,h a sn 't been n e g le c t e d . I d o n 't mean to s u g g e st t h a t , b u t the c o n s id e r a t io n o f man h a s b e en p r e t t y e le m e n t a r y . The m ach in e d e s ig n e r w ill have an a v e ra g e m an. He say s he i s so h ig h , h i s arms are so lo n g , h i s le g s a re so lo n g . The w o rk in g h e ig h t s h o u ld be so many in c h e s b ased on the a v e ra g e man, and th a t i s ab o u t as f a r as he g o e s. > Could I have the s lid e , p le a se ? (S lid e ) I have ju s t one s l i d e h e r e . I t i s a r a t h e r f a n c i f u l t h in g ta k e n from a r e c e n t a r t i c l e i n F o r tu n e M a g a z in e . I t s u g g e s t s w hat some p e o p le are th in k in g w ith re s p e c t to the m e ch a n iza tio n o f in d u s tr y . You may h a v e s e e n t h i s a r t i c l e , some o f y o u . I t a p p e a r e d a b o u t a Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14. OHIO 91 year ago on the a u to m a tic f a c t o r y , in w hich i t was s u g g e s te d in th e f a c t o r y o f the fu tu r e the m achine w ould be b u i l t n o t to b u ild a c e r t a in p a r t b u t to perform c e r t a in fu n c t io n s , as you break the m an u factu re o f a l l p a r ts , a l l p ie c e s o f ap p aratu s and equipm ent down in t o f u n c t i o n s , and th e n you w ould have one m achir whose f u n c t i o n i t was to bore h o le s and a n o th e r m ach in e whose .fu n c tio n i t was to tu r n o u t r i n g s , and so o n . And th a t th ro u gh a c o n tro l s ta tio n fe d in to the c o n tro l s ta tio n c e r ta in in s.tru e - . t io n s . Those in s t r u c t io n s would cau se m a t e r ia ls to be fe d to the m achine and would cau se th e m achine to p e rfo rm i t s n e c e s s a r y fu n c t io n s , and a t th e en d , a l l th ese v a r io u s p a r ts w ould be brought to g e th e r and s t i l l a c tin g on the in s tr u c tio n s from a c e n t r a l c o n t r o l box th e y would be assem b led in to t o t a l p a r t s . As I s a y , th a t is a b it in th e fu tu r e b u t I want to use t h is s lid e ju s t to i l l u s t r a t e th e r e la t io n s h ip betw een the man and th e m a c h in e . H ere i n t h i s s l i d e th e y h ave s u g g e s t e d the man i n th e fo r m o f t h e s e s e v e r a l s e n s e s an d m u s c le s o v e r h e r e on the l e f t , the o p e ra to r m a n ip u la tin g th e c e n t r a l c o n tr o l box w hich you see i s d e p ic te d as th e b r a in and in tu rn send m essages down to t h i s f u n c t i o n a l m a c h in e , h a s an arm o u t h e re w ith a cru d e fin g e r on i t , and one over h e r e , and th a t i s supposed to m anipu la t e p a r ts and p u t them on the m achine and th ro u g h the p ro p er in s t r u c t io n s in t h is c e n t r a l s t a t i o n ,t h i s m ach in e would do one R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 92 t h in g one d a y and sorte t h i n g e l s e a n o t h e r d a y . W e l l , v/e h a v e n ' t gone t h a t f a r y e t , h u t man s t i l l o p e ra te s a m ach in e th ro u g h c o n t r o l s . You know I t p e rfo rm s a l l the h e a v y w o r k . He h a s to a d j u s t s m a ll w e l l s and l e v e r s . He has to m an ip u late d e lic a t e c o n tr o ls w hich in tu rn through a system o f g e a rs and le v e r s and so on cau se the m achine to p e r form i t s t a s k . There is a g re a t d e a l o f data a v a ila b le in p h y sio lo g y r ig h t now, a v a ila b le in pam phlet form and o th e r f i e l d s th a t can be a p p lie d a t once to th e im proved d e s ig n o f m a c h in e ry . More im p o rta n tly , thdre i s e x p e rim e n ta l te ch n ic o f proved v a lu e w hich has been a p p lie d p a r t ic u la r ly in m ilit a r y p ro b lem s, w hich can be taken o v er alm o st b o d ily f o r th e stu d y o f in d u s t r i a l m achine from th e s t a n d p o i n t o f th e o p e r a t o r . We h a v e an y num ber o f i l l u s t r a t i o n s o f what ca n be done d u r in g ,t h e w a r. One v e r y e le m e n ta r y i l l u s t r a t i o n comes to my m in d ,,o f how f a r wrong you ' can go in the d e sig n o f a m achine i f the o p e ra to r is n e t taken in to a c c o u n t. One weapon I know ab ou t p roved to be u s e f u l or u sab le by o n ly the sm a lle st th ir d o f the m ilit a r y p o p u la tio n . Through im p rop er u se o f th e sp a ce t h a t was a v a i l a b l e i n th e weapon and around th e w eapon, th e y were fo r c e d to p ic k the s m a ll est th ir d o f the p o p u la tio n to o p erate the weapon. I am q u i t e s u r e i n a n t i - a i r c r a f t g u n n e r y t h e tr e m e n d o u s R en a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 95 number o f ro u n d s o f am m un ition t h a t were r e q u ir e d to b r in g down a s in g le p la n e came ab o u t n o t b ecau se o f any d e f ic ie n c y in the fu n c tio n a l c h a r a c t e r is t ic s o f the weapon b u t th rou gh th e i n a b i l i t y o f the o p e ra to r to u t i l i z e the m e ch a n ica l c a p a c it ie s o f the weapon sim p ly b e cau se he c o u ld n 't see f a s t enough to m a n ip u la te the weapon. Those te c h n ic s are b ein g a p p lied d ir e c t ly to in d u s try and we o n ly n e e d now to b r i n g th e p h y s i o l o g i s t and th e e n g in e e r to g eth er in in d u s tr y to s e t up th e n e c e s s a r y r e s e a r c h p r o p e r ly o rie n te d to th e in d u s t r ia l problem to g e t g o in g . Thank you v e ry much. (Applause) R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO CHAIRMAN H U SSEY: Thank y o u v e r y m uch. Is Dr. G-oldwater here? x neglected to tell you before we started this meet ing that Dr. Kehoe, unfortunately, had to leave yesterday, and therefore couldn't be here today, so for so many of you * o anticipated seeing him X am sorry you will be disappointed. Xhe next paper Is by Dr. Leonard J. Goldwater, Profes of Industrial Hygiene, Colum bia University School of Public Health, who will address you on the subject of "The Physiology of the Bone Marrow In Relation to Industrial Intoxication." r e n a H a w . E ly CITIZENS BUILDING CLEVELAND 14, OHIO 95 PHYSIOLOGY OF THE BONE MARROW IN RELATION TO IN D U ST R IA L IN TO X ICA TIO N P a p e r b y : D R . LEONARD J . GOLDWATER D r . H u s s e y , L a d i e s and G e n tle m e n ; To c o v e r c o m p le t e ly the s u b je c t o f th e p h y s io lo g y o f th e bone marrow in r e la t io n to i n d u s t r i a l i n t o x i c a t i o n w o u ld I am s u r e t a k e a c o n s i d e r a b l y lo n ger p e rio d o f tim e than any o f us are p rep ared to spend here th is a fte rn o o n . C o n seq u en tly , I s h a ll to u ch , and o n ly b r i e f ly , on some o f th e h i g h e r s p o t s i n t h i s r a t h e r l a r g e s u b j e c t . . . . D r . G oldw ater p resen ted h is paper . . . (Applause) CHAIRMAN H U SSEY: D r . G o ld w a te r ' s p a p e r b r in g s th e program to an end u n le s s some o f you h ave q u e s t io n s you m ig h t wish to ask D r . G o ld w a te r. I f you h a v e , you have the p r iv ile g e now o f a s k i n g th em . D R . BRIEGER ( P h i l a d e l p h i a ) : We h a v e s t a r t e d o n l y r e c e n tly to un derstand- and to exam ine the p h y s io lo g ic a l fu n c tio n o f th e bone m a rro w . W h ile we h a v e s w it c h e d fr o m c e l l u l a r p a t h o l o g y to f u n c t i o n a l p a th o lo g y i n o th e r f i e l d s , th e bone marrow has rem ained la r g e ly the o b je c t o f c y t o lo g ic a l e x a m in a tio n . O nly r e c e n t l y we h a v e l e a r n e d t h a t th e o x y g e n c o n s u m p tio n b y th e b on e m arrow i s a s t o n i s h i n g l y low I f we co m p ared th e h i g h c e l l u l a r a c t i v i t y w ith the bone a c t i v i t y .. . I t i s a ls o in t e r e s t in g to n o te th a t q u ite a number o f t o x ic s u b sta n c e s have a p e r ip h e r a l e f f e c t on the b lo o d and R en a H a l l E ly CITIZENS BUILDING CLEVELAND t4. OHIO 96 R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO CO H ER EN CE OH RESPIRATORY IN FE CT IO U S Tuesday Horning, Ja n u a ry 6 , 1948 The c o n fe r e n c e on R e s p ir a to r y I n fe c t io n s convened a t 9!20 o 'c lo c k , Moderator: Austin Smith, K .D ., c o u n c il on Phamacy and C h e m is tr y , American M e d ic a l A s s o c ia t io n . ,,OPERATOR SMITH: We promised to s t a r t a t 9:15 and s in c e i t is a few m in utes beyond, th en I b e lie v e the s e s s io n , vrn-4-v, n r o b a b lY a minim um o_-pf lmryihee PnUUuPp tlO IlS fl*Om ca n come to o r d e r w it h proD aox^ iow o n . . The o p e n i n g C o n fe r e n c e on - oni ratory R e s p ir a to r y ii nfections, m f a c t the op ening eonferenee f o r today i n t h i s p a r t i c u l a r room 1B one t h a t d e a l s w i t h a s u b j e p t i n w h ich a i l o f you are ^4. 4o one in which the in te n s e ly in te r e s te d , and fu rth erm o re, i t is gen eral p o p u la tio n has extrem e in t e r e s t . ^ e s e p e o p le , those , f y o u who a r e i n g e n e r a l p r a c t i c e , c o n s u l t y o u c o n s t a n t l y to u ,, t is the la t e s t treatm en t fo r f l u , the la t e s t inquire o f you what i prevention; what is the la t e s t treatment fo r colds, what is the ia te st prevention and what i s a sure cure. - b a b l y they have as much in te re st because of newspaper P u b licity in new advances as each of you have in those advances because of the benefits to rour medical practice. Because of the l a t e n e s s 'o f the h o u r , w ith yo u r p e r m issio n I w ould lik e to d is p e n s e w ith some o p en in g rem a rk s. They r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 98 w i l l be g iv e n to th e s t e n o t y p i s t and. p r o b a b ly a p p e a r i n th e l' p r in t la t e r , and in s te a d , co n ce n tra te on the th in g s w hich a re to f o llo w , two t a lk s w h ich w i l l be p r e s e n te d b y two o u t s t a n d in g a u t h o r i t i e s , f o l l o w i n g w h ich th e r e w i l l be a d i s c u s s i o n p e r io d and i f t h e r e , i s : tim e a v a i l a b l e f o r q u e s t i o n s . A l l o f u s who are on th e p l a t f o r m u r g e t h a t you s u b m it q u e s t i o n s . We h o p e th a t th e re w i l l be a fr e e d is c u s s io n . The f i r s t sp e a k e r, D r. M ilto n V eld ee is d ir e c t o r o f the D iv is io n o f B io lo g ic C o n tro l o f the N a tio n a l I n s t it u t e o f H e a l t h . A l l o f y o u I .am s u r e h a v e h e a r d h i s name and many o f you knoY/ h im p e r s o n a l l y . T h a t d i v i s i o n i s th e one w h ic h i s r e s p o n s ib le among o th e r th in g s fo r th e c o n tr o l o f serum s and v a c c in e s and a n a lo g o u s p r o d u c ts t h a t a re made a v a i la b le in t h i s c o u n t r y an d o f c o u r s e u n d e r v i r u s v a c c i n e s we h a v e many it e m s of p a r tic u la r concern to D r. V eldee and h is a s s o c ia te s . D r. Barach is A sso cia te P ro fe sso r o f C lin ic a l M ed icin e, at C o lle g e o f P h y s ic ia n s and S u rg e o n s, C o lu m b ia U n iv e r s it y , and l i k e w i s e i s known t o a l l o f yo u b y n am e, and I am su re to many o f you p e r s o n a lly , and he w ill d is c u s s a f t e r D r . V eldee the s u b je c t o f a e r o s o l th e r a p y . I w ould lik e to propose a t th is tim e t h a t we r e s e r v e th e q u e s t i o n s u n t i l th e two s p e a k e r s h a v e fin ish e d . A ls o s i t t i n g on the p la tfo rm is D r. T o r r e ll S o llm a n , R ena H a ll E ly .CITIZENS BUILDING CLEVELAND 14, OHIO 99 chairm an o f the C o u n c il on pharm acy and C h e m istry , fo rm e rly dean o f W estern R e se rv e S c h o o l o f M e d ic in e . He lik e w is e i s known to you and th o s e o f y o u who g r a d u a t e d i n n o t e v e n m ore r e c e n t years remember h is book on p h arm aco lo g y. Nov/ I w o u ld l i k e to t u r n th e m e e t in g o v e r i n so f a r a s comments a re c o n c e rn e d to D r . V e ld e e and to D r . B a r a c h . E a ch o f th e s e i n d i v i d u a l s h a s some s l i d e s to be show n, and once a g a in I w o u ld l i k e t o s u g g e s t t h a t we r e s e r v e th e q u e s t i o n s u n t i l a fte r D r . B arach has fin is h e d h is comments, and a t t h is tim e a l l of us urge you to p a r tic ip a te in the d is c u s s io n . D r. V eld eel R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO V IR U S V A C CIN E S - - A REVIEW AND EVALUATION Paper b y : M. V . V eld ee, M. D D r. Sm ith, Ladies and Gentlemen: The to p ic which h been a s s i g n e d to me i s r e v ie w i n th e e v a l u a t i o n o f v i r u s v a c c i n e s , in view o f the c h a ra c te r o f th is s u b je c t, I have chosen to m ie my re m a rk s a l t o g e t h e r e x t e m p o r a n e o u s ly r a t h e r t h a n a t t e m p t a form al p a p e r. I th in k perhap s I can b rin g out the p o in ts w hich I w ish a l i t t l e b e t t e r th a t way and s t i l l n o t g iv e i t the h ig h stan d in g o f a te c h n ic a l p a p er, w hich o f course i t cannot b e . The s u b je c t re v ie w in the e v a lu a t io n o f v ir u s d is e a s e s of the r e s p ir a to r y tr a c t n e c e s s ita t e s m en tio n in g s e v e r a l o f th o se d is e a s e s , b u t o n ly one o f them I s r e a l l y in v o lv e d in a viru s v a c c in e . There are f iv e d is e a s e s or groups o f d is e a s e s w hich need to be m entioned in the o p en in g rem arks in such a d is c u s s io n . The f i r s t o f th e s e i s th e d is e a s e due to th e p s i t t a c o s i s v i r u s . That has a v e ry d e fin it e c l i n i c a l im portance but as a p u b lic h e a lth m easure or as an epidem ic d ise a se i t has r e la t iv e ly l i t t l e im portance. As you know, the p s it t a c o s is - lik e v iru s produces a pneum onia or p n e u m o n itic -lik e in f e c t io n o f th e lu n g and th e r e fo r e is co n fu sed w ith a number o f o th e r in fe c tio n s o f the lu n g s . On th e o t h e r h a n d , i t i s c o n t r a c t e d a l t o g e t h e r b y r a t h e r i n t i m a t e R ena H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO contact or exposure to in fected birds with th is disease. There fore, i t does not appear in true epidemic form and for that reason there has been no real in terest in prophylactic measures, other than eliminate the infected b ird s. With those few remarks, I think we can drop that disease from further discussioj, The second disease or group that should be mentioned is Q. fe v e r. fever to most of us is a r e la tiv e ly new in fection so to speak, in that we have not encountered i t in the past. It prim arily was a laboratory in fe ctio n where most of us had the pleasure of securing i t at one time or another i f we happened to work in a laboratory where research work in that dls ease was going on. Under those circum stances, i t appears a l together to be an inhalation in fe ctio n but one of sh a ll I say not virulence but easy to co n tra ct. One apparently needs only to walk down the h a ll in the laboratory where work is going on and he may become in fe cte d . I presume the a ir from the cages is contaminated. Bore reoen tly, however, i t has come much more to the fore because there has been, as you know., reported outbreaks in workers in certain slaughter houses or associated with c a ttle Just at the present time there is quite a number of cases bein reported from southern C a lifo r n ia . They a l l have a connection with c a t t l e in one way or another. The t o t a l number of cases r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 102 a t th e p r e s e n t tim e i s n o t a c c u r a t e l y known b u t we do know- i t Is in a f a i r l y w ide, b u t s t i l l lo c a liz e d a re a q u ite p r e v a le n t. The means o f sp re a d have n o t y e t b een d e te rm in e d and i t i s p r o v in g to be a v e r y i n t e r e s t i n g p ie c e o f r e s e a r c h , b u t what s i g n i f i c a n c e i t w i l l have in th e o v e r - a l l p ic t u r e o f the to ta l p o p u lation is not yet f u lly e s ta b lis h e d . . N a t u r a lly , s in c e la b o r a to r y w orkers seem to be so r e a d ily in fe c t e d th e re was a g r e a t d e a l o f in t e r e s t in a tte m p tin g to d e v e lo p a v a c c in e fo r t h is d is e a s e , i f fo r no o th e r rea so n than to p r o t e c t la b o r a to r y w o rk e rs. Our group out a t Manton has b e e n a b l e a p p a r e n t l y t o p r o d u c e a v a c c in e a g a i n s t Q, f e v e r . / Being a r h a h h it s ia l d is e a s e , one w ould b e lie v e i t sh o u ld be f a i r l y e a s y t o p r o d u c e a v a c c i n e a lo n g th e l i n e we p r o d u c e R o c k y M ou ntain typ h u s v a c c in e . A p p a r e n tly t h a t i s b e in g the c a s e . The te tr o s e grow r e a d ily in the embryo in the egg and the p u r ifie d * v a ccin e can be p rep ared from th a t s o u r c e . In experim en tal la b o ra to ry a n a ly s is th is is producing a f a i r d e g r e e o f p r o t e c t i o n and we hope t h a t t h e r e w i l l be s u f f i c i e n t a g e n ic it y in th e v a c c in e to p r o te c t humans fro m the d is e a s e . W hether i t w i l l be a v a c c in e th a t w i l l have any r e a l need in p u b lic h e a lth p r a c tic e is a q u e s tio n , but c e r t a in ly i f we a r e to h a v e e p id e m ic s i n l o c a l i z e d s l a u g h t e r h o u s e s , th e im m u n ization o f s m a ll i n d u s t r i a l grou p s may become a d v is a b le . R ena H a ll E ly CITIZENS QUILDING CLEVELAND 14. OHIO 103 The third disease or group of diseases which need to be mentioned are the pneumonitis or a ty p ica l pneumonias which are mostly surely due to a virus of some nature. We hnow relatlv ely l i t t l e about this virus and since i t has not been isolates or or has not so fa r been cu ltivated in the laboratory. Under those circumstances, no progress whatsoever has been made toward |the,development of a vaccine which might be of value in this d ise a se . On the other hand, in view of the fa c t i t is not a true epidemic disease there i s , o f course, some puestion whether even i f the vaccine were available that i t would be of p ra ctica l use. Where the in fe ctio n is so a lig h t and the cases so scattere<j, of course, general population i-u n is a tio n is not a desirable procedure. That leaves, then, in the group to be discussed two diseases or groups of diseases which have real public health importance, and against which i t would be very nice i f we had effective vaccines. The f i r s t one is the common co ld . What is the common co ld , Obviously, there are a great many ir r ita tio n s and in fe e - tions in the upper respiratory tract which are lab elled by diagnosing common cold but i t I s a l epually clear I think that probably not a l l of them are due to the same fa c to r . We have, R en a H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO fo r exam ple, in the sp rin g o f the year the s o -c a lle d rose c o ld oi the c o ld 'which i s due to a l l e r g y . T h e n , a t o t h e r s e a s o n s o f th e y e a r we h a v e o t h e r i r r i t a t i o n s from odors and fum es and th in g s o f t h a t type w hich are ir r it a t io n s r a th e r than tr u e in f e c t io n s , but n e v e r th e le s s , ru n n in g th r o u g h t h a t w h o le g ro u p th e r e c e r t a i n l y a r e some w h ich are due to a common e t i o l o g y , and t h a t g ro u p s h o u ld p r o b a b ly be d e s ig n a te d e p id e m ic c o ld r a t h e r th a n common c o l d , s in c e i t d oes come i n e p id e m ic f o r m . E v e ry o n e who i s i n t e r e s t e d o r a c q u a in t e d i n th e f i e l d o f im m unology f e e l s t h is ty p e o f c o ld i s due to a v ir u s d is e a s e . Some y e a r s a g o , a s y o u kn ow , D r . D o s h a y an d h i s a s s o c i a t e s d id succeed in t r a n s m it tin g t h is in f e c t io n to ch im p an zee s, and th e y acquired a d ise a se v ery s im ila r to the d ise a se in the human. In view o f th e f a c t a t th a t tim e th e o n ly an im al a v a ila b le fo r study o f th is in fe c tio n was the chim panzee, n a t u r a lly , the r e search p o s s i b i l i t i e s were e x c e e d in g ly lim it e d . S in c e th a t tim e the'embryond;edegg has been d e v e lo p e d I n t o a v e ry e x c e lle n t labo r a to r y t e s t tu b e and th a t has opened up a wide ran ge o f r e s e a r c h w hich fo r m e r ly was n o t a v a ila b le to th a t la b o r a t o r y research w orker. I n th e l a s t y e a r , we h a v e h a d r e p o r t s fr o m two d i f f e r ent la b o ra to rie s in d ic a tin g th at they have succeeded in tran sm it- R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 105 tin g to the embryonated egg a.-virus which In a l l p r o b a b ilit y is the v ir u s o f the coamon c o ld . A group working at G alveston, Texas, reported In Science ,in September that they had succeeded in g e t t in g some thing in to the egg which in turn produced a d isease in humans in every way id e n t ic a l c l i n i c a l l y to the In fe c t io n as i t is in a person from 'whom the c u ltu re was o b tain ed . More r e c e n tly than th a t, two o f our workers a t the N ational In s titu te o f Health have reported In Science id e n tic a l r e s u l t s . They have bear a b le to take n a sa l washings from a group o f vo lu n tee rs at the lo c a l i n s t i t u t i o n in Washington and have succeeded in g e t t in g in to the egg something which is pro ducing or which is able to reproduce in other volunteers a d is ease which appears in every r e s p e c t to be the same as the common cold which in fe cte d the donor o f those n asal w ashings. The work, o f course, has not progressed fa r enough to say anything d e fin it e as to what the fu tu re p o s s i b i l i t i e s are in the way o f developing a vaccine fo r such a d is e a s e . So f a r , at l e a s t , and speaking now o nly from our own group, they were able to get something growing in the egg but, u n fo rtu n ately, i t produces no d isease in th a t egg and there i s no way so fa r o f id e n t ify in g which egg shows any growth and which one does n ot, and fo r that reason we can o n ly id e n t ify the f a c t th a t we have R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO s o m e th in g th e r e b y t a k in g some o f th e a l l i e d o r th e m a c e r a te d chick egg embryo membranes and r e ir .o c u la tin g o th e r v o lu n te e r s . That in i t s e l f , o f cou rse, i s a r e a l handicap towards making progress and a lso in developing a v a c c in e . Now th e o t h e r d i f f i c u l t y w h ich a p p e a r s to a r i s e i s th a t thus fa r th ere has been no in d ic a tio n th at tn ere is any im m unity r e s u l t i n g from su ch an i n f e c t i o n . One o f th e men p u r |s u in g t h is work a t th e I n s t it u t e seems to have one c o ld a ft e r a n o th e r . E ach tim e he p ic k s up a new egg he g e ts th e c o ld and as f a r a s he know s, i t i s s t i l l th e same v i r u s , and i f s o , i t in d ic a t e s , o f c o u r s e , th e re is no im m unity d e v e lo p in g fo llo w in g such an in f e c t io n .. S h o u ld t h a t be th e c a s e , th e n we w o u ld h a v e to c o n c lu d e I t h a t we do n o t a c q u ir e a n y a p p r e c i a b l e d e g r e e o f im m u n ity f o l l o w in g an i n f e c t i o n w it h s o - c a l l e d common c o l d . T h at p r o b a b ly i s in l i n e w it h th e e x p e r ie n c e w h ic h vre h a v e a l l e n c o u n t e r e d i n t h a t we seem to g e t c o l d s w it h o u t a n y r e a l p r o v o c a t i o n and a lm o stj a t any tim e d u rin g the y e a r . I t m ay, o f c o u r s e , be th a t fu r t h e r work w i l l b r in g o u t p o i n t s we do n o t now know and w h ic h m ig h t make i t f e a s i b l e to produce a v a c c in e o f some v a l u e , th o u g h I th in k i t i s f a i r to say th a t one would be v e r y , v e r y s k e p t ic a l a t t h is s ta g e In the game. R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 107 That b rin g s u s , th en , to the o th er d ise a se or group o f d ise a se s o f v ir u s o r ig in , o f th e upper r e s p ir a to r y t r a c t , nam ely, in flu e n z a . You g en tlem en know c l i n i c a l l y as much about in flu e n z a as I d o , I am v e r y s u r e , and i t i s h a r d l y n e c e s s a r y to r e v ie w the c l i n i c a l symptoms and th o se fe a t u r e s o f the d is e a s e . I o n ly propose to rev ie w in a b r i e f way a few th in g s r e g a r d in g the v ir u s and what can be a c c o m p lis h e d i n u s in g i t i n term s o f th e v a c c in e . The in flu e n z a v ir u s was f i r s t is o la t e d e a r ly in the t h ir t i e s by S m ith , Ladlow and Andrew s, E n g la n d , and th a t p a r t ic u l a r s t r a i n when is o la t e d h as been d e s ig n a te d Type A S t r a in V ir u s . Since th a t tim e, D r. F ra n cis in th is country is o la te d another v ir u s im m u n o lo g ica lly and o th erw ise w hich appeared q u ite d is t in c t from th e A S t r a i n . A t the same tim e ,' th e new s t r a i n d id p ro d u ce a d is e a s e w h ich c l i n i c a l l y was n o t d is t in g u is h a b le from th e d i s e a s e e a r l i e r i d e n t i f i e d a s Type A . Thus we h a v e a t th e .p r e s e n t tim e two s t r a i n s o f v i r u s e s , Type A and Type B , b o t h o f w hich produce c l i n i c a l in flu e n z a in d is tin g u is h a b le one from the o th e r and b o th o f w hich appear in epidem ic form a t one tim e or a n o th e r . A s tu d y o f in f lu e n z a i n th e la b o r a t o r y h a s been made q u i t e s im p le i n m any ways b e c a u s e we do h a v e l a b o r a t o r y m e th o d s o f g e ttin g o u t v ir u s and o f id e n t ify in g them . T h at, o f co u rse, is o f a v e ry g re a t h e lp in stu d y in g any d is e a s e , - a b i l i t y to R ena Hall E ly CITIZENS BUILDING CLEVELAND 14. OHIO f ln d th e organ ism and to handle i t in the la b o r a to r y . T h is has |been a id e d a g r e a t d e a l by th e developm ent o f a n t i b i o t i c s , v h ic h in tu r n are b a c t e r i a c i d a l . I t i s now r e l a t i v e l y e a s y to i s o l a t e the v ir u s o f in flu e n z a b e cau se you can r id n a s a l w ash in gs o f [most o f th e b a c t e r i a l co n tam in a so when you in o c u la t e your [parent or in o c u la te your eggs you have a lre a d y e lim in a te d the second e g g co n ta m in a n t and th e o rgan ism becom es much e a s ie r . A t th e same tim e ., th e re d c e l l a g g l u t i n a t i o n t e c h n ic p e r m its th e [study o f an tib o d y le v e l in p a tie n ts or people tre a te d w ith v a c c in e . T h is , o f co u rse , g iv e s a v ery good guide to agen ic p ro p e rtie s o f v a rio u s s tr a in s and a ls o the com parison o f the (r e s u lts w hich o ccu r fo llo w in g an a c t u a l in f e c t io n w hich fo llo w s the use o f e x p e rim e n ta l v a c c in e s . How a t t h i s p o i n t I s h o u ld l i k e to show you a few { s lid e s , none o f w hich are m ine, o f c o u rs e , b u t have been taken from v a r io u s p u b lis h e d p a p e r s , to i l l u s t r a t e what is acco m p lish ed | by an a t t a c k o f th e d is e a s e or im m u n iz a tio n f o l l o w i n g th e use o f I v a c c i n e . I f we c a n h a v e th e s l i d e s i n o r d e r , now , p l e a s e . >(Slide) W hat I w is h to e x p l a i n i n t h e s e f i r s t s l i d e s i s t h a t Ith e r e i s a d e g r e e o f m e a s u r a b le im m u n ity . Vie11, t h i s f i r s t s l i d e (is p r e s e n t e d to show m e r e ly t h a t f o llo w i n g an i n f e c t i o n w it h | c linical recognized i n f l u e n z a and c l i n i c a l l y p r o v e n i n f l u e n z a r e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 109 by is o la t io n o f the v ir u s we g e t a n tib o d ie s in the serum. This happens to be only in flu e n z a A. We should show e x a c tly the same r e su lts i f the s lid e were prepared fo r in flu e n z a B. What we are in te re ste d in here p r im a rily is the a n tib o d ie s in an outbreak of in flu e n za A. The t i t e r has gone up to t h is l e v e l , whereas in the co n tro l p o p u latio n i t was approxim ately 2 0 0 . That is hie red c e l l in the g lu te n t i t e r . C orresp on d in gly, in the same in d iv id u a ls there was no r is e in the t i t e r a g a in st in flu e n z a B. Roughly i t is about 150 and s l i g h t l y a c tu a l in your co n tro l popu la tio n . ( S lid e ) T h is s lid e shows what r e s u lt s from the i n je c t i o n o f one dose o f p o l y - v i r u s v a c c i n e , t a k in g A f i r s t . The a g g l u t i n a t i o n i n t h i s g ro u p was 1 4 7 . F o l lo w i n g th e i n j e c t i o n o f the v a c c in e i t ro se to t h is l e v e l , w hich i f you w i l l remember the p r e v io u s s l i d e i s r o u g h ly in th e same l e v e l a s r e s u l t i n g from an i n f e c t i o n . T h at i s 1780 t h e r e . The v ir u s a ls o c o n ta in e d in f lu e n z a B , and h e re the p r e - v a c c in a t io n was 249 and the p o s t one s l i g h t l y o v e r 1 ,0 0 0 , so y o u h ad a r i s e h e re o f a b o u t 12 tim e s in the an tib o d y t i t e r here and in th is in s ta n c e 5 .5 . Of co u rse , one m ust n o t take th ese fig u r e s too s e r io u s ly in th a t in an o th er co rresp o n d in g group th e d iffe r e n c e s m ight even have been in the re v e r s e o r d e r , but s t i l l i t does demon s tra te you can produce an an tib od y r is e in persons re c e iv in g R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO i n j e c t i o n s o f a n t ib o d y v a c c i n e and t h o s e r i s e s a re xn p r o p o r t io n to th e r i s e s w h ic h result fro m t h e r i s e s o f an a c t u a l i n f e c t i o n . ( S l i d e ) T h is s tu d y w h ich I t h in k was done by D r . g o lk e t o f M ic h ig a n i s shown to g iv e some id e a o f th e d u r a t io n o f antibody le v e l in persons r e c e iv in g v a c c in e , here a g a in , ta k in g th e ty p e A . The p r e - v a c c i n a t i o n a t 59 and two w eeks l a t e r 5 4 8 , a s lig h t grow th in fo u r m onths and a fu r t h e r grow th in one y e a r . Hie B com ponent s t a r t e d a p p r o x im a te ly th e same l e v e l and more or le s s fo llo w s th e same p i c t u r e . Now I do n o t b e l i e v e t h a t y o u c a n assum e from th e s e few f ig u r e s a t l e a s t t h a t Im m unity n e c e s s a r i ly la s t s f o r a f u l l year m erely because you had th is t i t e r , because i f you w ill r e c a l l from the e a r lie r s li d e , our c o n tr o l groups had a r e la t iv e ly h ig h t i t e r in th e m s e lv e s. So th a t one cannot say from th is s l i d e a lo n e t h a t th e s e p e o p le were immune f o r a w hole y e a r . T h ere i s a v e r y g o o d p r o b a b i l i t y t h a t t h e y w ere immune h e r e f o r two weeks and a ls o th e y had more th a n th e a v e ra g e im m unity f o r fo u r m onths, but a t the end o f the year th e ir s e n s it iv it y backed down t o n o r m a l. (Slid e) Now w hat i s t h e e f f e c t o f i n f l u e n z a v a c c in e in a p o p u la tio n w ith reg ard to the p re v e n tio n _of the d is e a s e i t s e lf? This ta b le , as you p ro b ab ly w ill reco gn ize rep resen ts th e summary o f the e x p e r ie n c e w h ich le d up to the a d o p tio n o f R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO in flu e n z a v iru s vaccin e fo r m ilit a r y u s e . There are c e rta in drawbacks to the ta b le and th a t is p r in c ip a lly th a t the in t e r v a l between im m unization and the outbreak was a r e l a t i v e l y short t i m e , a m a t t e r o f a few Y/eeks, so t h a t we h a v e no m e a s u re h e r e as t o th e d u r a b i l i t y o f th e im m u n ity and a l s o we h a v e no m e a su re as to i t s a b i l i t y to p r o t e c t a g a in s t r e a l se v e re i n f l u e n z a . These happen to be v e r y m ild o u tb re a k s , so t h a t w ith t h o s e e x c e p t i o n s we c a n s a y t h a t you do g e t a d e g r e e of p r o t e c tio n a g a in s t p r e v a ilin g typ e o f, in flu e n z a , a v a c c in e v h ic h thj-S r e p r e s e n ts . There were over 6,000 persons v a c c in a te d , a g a in another c o n tr o l o f an eq u al number, and the number o f cases you see were 139 i n the v a c c in n a t e d and 442 i n the c o n t r o l , v h ic h g iv e s you o f a l l the c a s e s 76 p e r c e n t ap p eared i n the c o n t r o l g ro u p : a <n d a b o u t 24 p e r c e n t i n t h e t r e a t e d g r o u p . Th o se a r e c e r t a i n l y n o t s p e c t a c u l a r r e s u l t s i n any w ay. I f you w e re to compare- t h i s , fo r exam ple, w ith the r e s u l t s o b ta in e d through the use o f te ta n u s, to x o id , the d iffe r e n c e c e r t a in ly would be most s t r i k i n g , b e c a u s e i n t h e u s e o f t e t a n u s t o x o i d i n th e m i l i t a r y td e r e s u l t s were alm o st 10 0. I n f a c t , th e y w ere so good i t i s tne outstanding dem onstration of what a good an tige n does accom plish.I I b eliev e i t is f a ir to say that th is is probably a t the o th er end of the s c a le . I t is a r e l a t i v e l y poor r e s u l t , but we m u st remember t h a t t h e y a r e p r e l i m i n a r y r e s u l t s w i t h ohe Rena H a ll Ely CITIZENS BUILDING c CLEVELAND t4. OHIO 112 vaccine which was s t i l l in the d e v e lo p m e n ta l s ta g e and p r o b a b ly n o t n e a r as good as i s now b e in g made or as c o u ld be made w ith .further experien ce. (S lid e ) I asked our slid e-m ak er to use the ta b le in t h is in s t a n c e b u t b y m is ta k e he e l e c t e d to make i t from the g ra p h . How ever, t h i s i s i n f lu e n z a B now. There were 600 persons in t h is g r o u p ,- t h is happened at Ann A rb o r, - 600 persons in the ` v a c c in a t e d and ab o u t h , 000 in th e u n v a c c in a t e d . As th e epidem ic proved to be by is o la t io n of the v ir u s , you w ill see i t is i n f l u e n z a B . I n th e u n v a c c i n a t e d g r o u p we h a d a t o t a l o f 109 -c a se s, the b la c k l i n e s , and a t o t a l of o n ly 7 ca se s which is r e p r e s e n te d by th e s e s m a ll s q u a r e s , so t h a t here th e r e s u l t s are q u ite s t r i k i n g in t h e ir < p ro tectiv e v a lu e o f the .in flu e n z a B com ponent again st th is p a rtic u la r outbreak. Now a g a i n , you m u st remember t h a t th e v a c c i n e was g i v e r o n l y a b o u t two w e e k s o r so b e f o r e th e o u t b r e a k o c c u r r e d . Two weeks i s p ro b a b ly the optimum I n t e r v a l a t w hich to i n j e c t in flu e n z a v ir u s v a c c in e based on a n tib o d y l e v e l t i t e r s . - (S lid e) This i llu s t r a t e s the r e s u lts at another sch o ol, namely, Y a le U n iv e r s ity , in a sm all outbreak of in flu en za B . There were two grou p s a t t e n d i n g th e u n i v e r s i t y a t t h a t t i m e . One had p r e v i o u s l y r e c e i v e d the p r e v a i l i n g i n f l u e n z a v i r u s v a c c in e , w hereas th e o th e r had r e c e iv e d no v a c c in e , and the Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14. OHIO r e s u lts are p re tty w ell indicated.. You see the o u tb reaks were proven by the f a c t th a t i n f l u e n z a B a c t u a l l y were i s o l a t e d fro m 13 o u t o f th e c a s e s s t u d ie d , and i n 36 o th e r s th e re was a d e f i n i t e s e r o l o g i c a l r i s e of in flu e n z a B . In terms o f a c t u a l c a s e s , the navy group v h ich had r e c e iv e d no v a c c in e had 132 c a s e s and the army had o n ly 3 c a s e s . Now I t h i n k t h a t i s a v e r y f a i r s t u d y i n t h a t t h e s e boys l iv e d under e s s e n t i a l l y the same c o n d itio n s and went throug. t h e same m e d i c a l c l i n i c f o r t h e i r c a r e , so th a t as n e a r as two groups co u ld be id e n t i c a l I th in k i t is c o r r e c t to say th a t these were i d e n t i c a l . J u s t a t the moment I do n o t r e c a l l how lo n g b e fo re th is epidem ic occu rred the army p e rso n n e l had re c e iv e d t h e i r i m m u n i z a t i o n s . I am s u r e i t i s c o r r e c t t o s a y i t was a r e l a t i v e l y sh o rt tim e . I th in k i t was a m a tte r o f j u s t a few m onths. ( S lid e ) T h is b r in g s up one o f the sour n o te s in in f lu e n z a v a c c in e up to th e p r e s e n t tim e . You p r o b a b ly are f a i r l y w e ll aware th ere seemed to be no v a lu e in in flu e n z a v ir u s vaccine w ith the season 1946-47, nam ely, the O a s t w in ter. Im m unization seemed to f a i l . Gases o ccu rre d ju s t as fr e q u e n t ly i n th e Immunized as i n th e u n im m u n ize d . One c o u l d e x p l a i n t h a t in e i t h e r o f two w ays: E i t h e r the v a c c in e was no good and d id n o t b u i l d up im m u n ity o r we w e r e c o n f r o n t e d w i t h a n o t h e r s t r a i n R ena H all E ly CITIZENS BUILDING > CLEVELAND 14, OHIO XJ.' : 0f vlruB which e v id e n tly wad d iffe r e n t from those used in pre paring the v a c c in e . As i t turned o u t, the l a t t e r proved to be the c a s e . You w i l l see here there is no p r o te c tio n in t h is group whatsoever, though they had p r e v io u sly been immunised ,it h the p r e v a ilin g v a c c i n e . The rate here i s 7.19 and here 8, sc that one group was no b e tte r p ro te cted than the o th e r. Laboratory studies in many places during tm t winter showed that a prevailin g strain was an tigen ip ally d iffe re n t and the strains used in the vaccine did not produce an matibody which covered or i.mmuni,,ze,, dj tthv,e, ,,arnittiiegen o f the s t r a in then p r e v a ilin g . I w ill refer back to that a l i t t l e la te r . (Slide) Now th is slid e is only presented to illu s t r a t what you gentlemen alre ad y know, namely, tha t the symptoms of the p r e v a ilin g type o f in flu e n z a is so u n c h a r a c te r is tic o f any s p e c ific d is e a s e . In oth er words, I t rep resen ts symptoms which we may have from in flu e n z a A . We c e r t a in ly have i t w ith many o f the th in gs which are c a lle d cold s and even ether m ild in fe c tio n s give a l i s t e f symptoms sim ila r to t h i s , so th at when we diagnose] a d isease as in flu e n z a In the community w ithout having i t v e n - fle d by la b o ra to ry is o l a t i o n of the organism i t may not mean very rriuch. Those are a l l the s lid e s . Now through these slides wh we have hurriedly looked over I think i t is f a i r to conclude r e n a H a l l Ely CITIZENS BUILDINC CLEVELAND 14, OHIO 115 th at there i s an an tib o d y r is e fo llo w in g an in fe c t io n w ith the virus o f in flu e n z a . That antibody ris e s e ith e r w ith an in fe c t i o n o f i n f l u e n z a A o r w it h i n f l u e n z a B o r w ith some o f th e s u b strains of either o f these. ' A t th e same t i m e , th e a n t i g e n shows t h a t a s i m i l a r typ e of a n tib o d y r i s e ca n be s t im u la t e d b y the i n j e c t i o n o f h a le cu ltu re v iru s propagated from the f l u i d of the embryonated ch ick en egg, and in c l i n i c a l s t u d ie s , such as th e y a r e , and u n fo r tu n a te ly , up u n t i l now th e y a r e a l i t t l e b i t l i m i t e d , i t was d e m o n stra te d th at i f you have a s t r a in p r e v a ilin g in a community a n t ig e n ic a lly sim ilar or a n tig e n ic a lly id e n tic a l to the s tr a in used in prepar in g the v a c c in e , you can ' t expect a degree o f immunity which g iv e s p r o te c tio n a g a in s t th e p r e v a ilin g d is e a s e . Thus f a r , the evid en ce seems to be s a t i s f a c t o r y . Now, t h e r e are c e r t a i n d e f i c i e n c i e s i n t h a t e v id e n c e , and we m i g h t e n u m e r a t e them i n r a t h e r b r i e f o r d e r . The f i r s t d e f i c i e n c y . i s t h a t we h a v e o n l y h a d e x p e r i e n c e w i t h r e l a t i v e l y m ild I n f l u e n z a . The q u e s t io n i s alw ays r a i s e d , w i l l t h i s v a c c in e prevent against severe in flu en za, W ell, the tr u th o f i t , o f course, s u c h a s we h ad i n 1 9 1 8 - 1 9 . i s t h a t we do n o t k n o w . D u r i n g the 1918-19 o u tb r e a k th e m ethod f o r i s o l a t i n g the v i r u s was n o t known,' and a s a r e s u l t , we do n o t h a v e a v a i l a b l e a n y p l a c e a c u l tu r e from t h a t o u t b r e a k . E ve ry o n e assum ed t h a t I t was a t y p i c a l R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 116 in flu e n z a organism b u t th ere i s no c le a r - c u t and a ccu ra te data to back th at statem ent up. The n e x t d e f i c i e n c y i n o u r d a t a i s t h a t th u s f a r the im m u n izatio n or th e s t u d i e s have been made on s m a ll groups w hich ^ may n o t alw ays have b een a f a i r r e p r e s e n t a t i v e gro u p o f t h e co m m u n ity a s a w h o l e . Those o f u s who a r e e n g a g e d i n ' r e s e a r c h work know th a t a l a b o r a t o r y e x p e rim e n t som etim es does n o t alw ays prove the same when t r i e d i n a community e x p e r im e n t. W h ile I t h i n k i t i s f a i r to s a y t h a t we h a v e s u g g e s t e d th e co m m u n ity e x p e r i e n c e m i g h t be t h e s a m e , y e t we w o u ld f e e l much h a p p i e r i f vie had s u c h e x p e r i e n c e b a c k o f o u r d a t a . The o th e r d e f i c i e n c y i s t h a t the im m u nization s tu d ie s have been on a v e r y s h o r t - t im e b a s i s . The s l i d e s w h ich I showed you showed r e s u l t s o n l y from im m u n iz a tio n s h a v i n g r u n f o r two weeks or p e rh a p s a month o r some v e r y s h o r t tim e l i k e t h a t . O b v i o u s l y , i f we d o n 1t h a v e im m u n ity l a s t i n g l o n g e r th a n two weeks or a month, community im m unization becomes an im p r a c tic a l procedure. Wow what s t i l l are the problems un solved, problems r e la tiv e to the use of in flu en za virus vaccin e? This season at le a s t the great question i s , what coverage can we exp ect from in flu e n z a v iru s v a cc in e s? We have a lre ad y demonstrated that the e x is tin g vaccine can c e r ta in ly represent the best vaccine R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO that could be made on the basis of knowledge at hand. We have demonstrated i t fa ile d to cover the outbreak of la s t year. How Ioften w ill we encounter variations in the prevailin g stra in so that the vaccine used w ill not cover? I f this is going to occur: very frequently, vaccine production w ill lag about one season behind the prevailing epidemic. In other words, i t takes a matter of four, fiv e , six months or so to get a strain isolatedj, get i t acclimated to growing and to produce a vaccine, so that i t is at the moment at le a st impossible to keep ahead of the prevailing stra in i f that stra in is going to change a n tige n icall: |from season -to season. The chances there w ill b e such a change are quite remote I think. This one of 3a st year was the f i r s t one we had encountered since the research work with the virus was| |undertaken. T h i s y e a r , we a r e com m en cin g t o h a v e a n o u t b r e a k on the west c o a s t and from a l l in d ic a tio n s a t the p resen t time i t is a type A s tr a in which a n t ig e n ic a lly is covered by the p r e v a il i n g v a c c i n e s . So t h a t i f e v e n t u a l l y we c a n i s o l a t e en o u g h s t r a i n s fr o m e p i d e m i c s y e a r t o y e a r so we w i l l h a v e a l l t h e a n t i g e n i c s t r a i n s a v a i l a b l e , t h e n we s h o u l d be a b l e to p r o d u c e a v a ccin e w hich w i l l a n t ig e n ic a lly cover from one year to anothexj. Now t h e o t h e r p r o b le m fro m a p u b l i c h e a l t h s t a n d p o i n t is d u r a t io n o f the Im m unity, and u n t i l t h a t i s more a d e q u a te ly R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO solved we s t i l l w ill have a big question a s to whether immuniza tion is a public health practice which can wisely be undertaken. I t seems t o me a l m o s t i m p o s s i b l e to e x p e c t t h a t we keep the p o p u la tio n immunized i f immunity i s going to be o n ly a m atter o f m onths. Even i f i t v o u ld be o n ly one y ea r i t would s t i l l become a d i f f i c u l t problem to immunize the e n tir e p o p u la tion each year. On the other hand, i t might be fe a sib le to keep s e le c te d groups immunized on th a t b a s is j in d u s t r ia l groups or in s titu tio n a l groups could be p ro tected . The problems o f p ro d u c tio n o f the v a ccin e have been X th in k e n t i r e l y l i c k e d . I adm it i t seems a v e ry la r g e un d ertakin , to han dle so many th in g s and produce v a c c in e s in the la r g e q u a n titie s u sed . However, in d u s t r i a l methods have improved so that la b o ra to rie s are able to handle thousands of eggs eacn day and produce v a c c in e w ith r e l a t i v e l y s m a ll lo s s due to c o n ta m i n a t i o n or f a i l u r e o f th e v i r u s g r o w t h . One l a b o r a t o r y f i n a l l y a tta in e d the h ig h le v e l o f h a n d lin g som ething lik e 10,000 eggs e a c h d a y f o r s i x d a y s a w e ek . Now t h a t i s r e a l l y o i g b u s i n e s s in the h a n d lin g o f f e r t i l e em bryonated eggs and to most o f us who h a d a n y t h i n g to d o w i t h i t I t h i n k we a r e s t i l l s u r p r i s e d th at i t c o u ld be done and co u ld be done w ltn as l i t t l e lo s s as a c t u a lly proved to be the c a s e . Rena H a l l Ely CITIZENS BUILDIN CLEVELAND 14, OHIO 119 Now I t h i n k i n s u m m a r iz in g I s h o u l d l i k e to r e a d a short statem ent from a re p o rt which appeared in the August issu e of th e APHA and i s p r e p a r e d o v e r th e s i g n a t u r e o f a s t u d y com m itte e on v a c c in a t io n a g a in s t in f lu e n z a , as to the s p e c i f i c i t y of effect: "On the b a s is cf p r e s e n t kn o w led ge, in f lu e n z a v ir u s v a ccin e appears to have an e f f e c t o f a r a th e r s p e c i f i c n atu re a g a in s t i n f e c t i o n b y in f lu e n z a A and in f lu e n z a 3 There i s no e v id e n c e o f common c o l d s and o t h e r u n i d e n t i f i e d r e s p i r a t o r y i n f e c t i o n s . Nor is the e f f e c t o f v a c c in e as now c o n s t it u t e d a g a in s t a l l the p o s s ib le v a r ia n t s t r a i n s known. There i s no s a t i s f a c t o r y evid ence o f p r o t e c tio n a g a in s t such an epidem ic as th a t of 1918*" And then* "G eneral A p p lic a tio n . In flu e n z a A has occurred in epidem ic form at in t e r v a ls o f 2 to 3 y e a rs; in flu e n z a B, a t in t e r v a ls o f 4 to 5 y e a r s . I t was a n t ic ip a t e d on the b a sis o f the p re ce d in g e x p e rie n ce th a t an epidem ic o f in flu e n z a A would o ccur in the w in ter o f 1946-47; b lu s t e r y , ir r e g u la r o u t b re a k s o f th e d i s e a s e were i d e n t i f i e d i n th e s p r i n g . The tim e of the re cu rre n ce s can n o t, how ever, be r i g i d l y p r e d ic te d . Although the epidem ics have been w idespread, the c l i n i c a l d isease has b een g e n e r a l l y m ild and o f c o m p a r a t iv e ly low I n c i d e n c e . The r e s i s t a n c e In d u ced by v a c c i n a t i o n i s now known to p e r s i s t R ena H a ll E ly CITIZENS BUILDING K CLEV ELA N D 14. OHIO 120 e f f e c t i v e l y from one seaso n o f p r e v a le n t r e s p ir a t o r y I n f e c t i o n s to an o th er, and the expense o f the v a c c in a tio n must be c o n sid r e . "In view o f th ese c o n s id e r a tio n s , a recommendation fo r g e n e ra l employment o f in flu e n z a v a c c in e by h e a lth departm ents is not w arranted a d m in is tr a tiv e ly at the p re se n t tim e.'* (Applause) Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14. OHIO 121 CHAIRMAN SMITH: Thank y o u . D r , V e l d e e , f o r yo u r r e v i e and e v a lu a t io n o f v ir u s v a c c i n e s . T h is w i l l he fo llo w e d by a d is c u s s io n by D r . B a rach , C o lle g e o f P h y s ic ia n s and Su rgeon s o f Colum bia U n i v e r s i t y , whose d is c u s s io n i s on " A e r o s o l Therapy in G e n e ra l and I n d u s t r i a l P ra ctic e ." Dr. Barachi Rena Ha l l Ely CITIZENS BUILDING CLEVELAND 14, OHIO 122 AEROSOL THERAPY IN GENERAL AND IN D USTRIAL PRACTICE Paper by; A lvan L . Barach, M.D. Mr. Cnairm an, la d le s and gen tlem en; I propose to omit the h i s t o r y In tr o d u c tio n o f t h is paper and p re se n t to you f i r s t th e summary o f the r e s u l t s o b t a in e d , and then to I l l u s t r a t e certain featu re s of aerosol therapy w ith lan tern slid es,, I f time p e rm its, I s h a ll then d iscu ss the r e la t i o n o f the p a r t ic le s iz e to th e d e p o s itio n and a b s o r p tio n o f chem otherapy and a n t i b io t ic aero so l in the lu n g . . . . D r. Barach presented h is paper . . . (Applause) R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO CHAIRMAN SMITH: Thank you, D r . B a r a c h , f o r your revi. of a e r o s o l t h e r a p y m g e n e r a l p r a c t i c e . For a few m inutes w e .w ill have a qu estion p e rio d . I assume, lik e in c o lle g e days, you w ill want a seventh in n in g break, at le a s t before the n e x t sessio n b e g in s, but in the next f i v e o r t e n m i n u t e s we w i l l h a v e an o p p o r t u n i t y f o r th e a n s w e r ing of questions! In order to open the d is c u s s io n , I would lik e to ask D r . V e ld e e a q u e s t io n , b e ca u se I know t h a t i t has been c o n fr o n t ing many o f you at many tim e s . Dr V e ld e e , th ere are on the m arket today many soc a lle d v a ccin e s which the C o u n cil o f Pharmacy and Chem istry has n o t y e t r e c o g n iz e d f o r the v e r y sim p le r e a s o n th e y do n o t b e l i e v e them e f f i c a c i o u s . C o u ld I ask you to comment on t h a t ? D R . VELDEE: W e l l , D r . S m i t h , my f i r s t a n sw e r i s I do n o t s e e how y o u c a n immunize a g a i n s t a s p e c i f i c d i s e a s e b y th e use o f another a n tig e n which i s t o t a l l y d iffe r e n t in ev e ry way. My s e c o n d a n s w e r v o u l d be t h a t d u r i n g t h e y e a r 1920 the p r e v a ilin g o p in io n seemed to be t h a t many o f the co ld s were hue to b a c t e r i a l organism s commonly found in the upper r e s p ir a to ry t r a c t . A ls o due to the s t im u la t io n o f the Bess Reed Case o rk , the im p ressio n got around th at you co u ld immunize a g a in s t these organism s by the o r a l ta k in g o f c e r t a in v a ccin e s in ta b le t R ena H all E ly CITIZENS .BUILDING CLEVELAND 14. OHIO 12% f o r m . I am s u r e t h a t I am c o r r e c t i n s a y i n g t h a t s i n c e t h a t time b a c t e r i o lo g i s t s and im m unologists have ad e q u ate ly demon s tra te d not o n ly th a t you cannot produce immunity against these organ ism s i r r e s p e c t i v e o f how you a d m in is t e r them but a ls o th a t you p o s i t i v e l y c a n n o t p ro d u ce im m u nity a g a i n s t them when you take i t by m outh. So th a t on the b a s is o f ev id e n ce o f th a t tyPe j I think i t is f a i r to say th at th at p re v a ilin g opinion has lo n g s in c e a cq u ire d v e ry lon g g re y w hiskers and has been put away in moth b a l l s . N obody t o d a y who i s a c q u a i n t e d i n th e f i e l d w o u ld a t any tim e recommend th e ra p y o f t h is type to p rev en t a d is e a s e o f an e n t i r e l y d i f f e r e n t e t i o l o g y . CHAIRMAN SMITH; Thank y o u , D r . V e l d e e . There presum ably have been p u b lish ed in the lite r a tu r e in the p ast sev eral papers which on the su rfa ce would appear to p re se n t the b e l i e f , t h a t c o ld v a c c i n e s when ta k e n by m outh m ig h t be e ffic a c io u s. H o w e v e r , i t i s e n t i r e l y p o s s i b l y t h e y c a n be e x p l a i n e d as a s t a t i s t i c a l c o in c id e n c e , and I would l i k e to ask D r . S o llm a n to comment on th a t i f he would, because h is knowledge of e x p e rim e n t a l m ed icin e and th e ra p y exten d s o v er many y e a r s . D r. So llm an i DR. T. SOLLMAN: M r. C h airm an , from the a n c ie n t tim e s , as p o in te d o u t e s p e c i a l l y in B e aco n 's work, t h i s m atter o f coincidence of seein g the th in gs th at you want to see, th a t i t R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 12 would be n i c e to have o c c u r , im p r e s s i n g th e m s e lv e s upon y o u , i s - 'i very much le s s p a in fu l than the th in g s th a t would be d is a p p o in t in g, has been a p i t f a l l in to which everyone p r o je c ts h im se lf u n l e s s he p r o t e c t s h i m s e l f b y some m eth o d t h a t i s n o t so s u b j e c t i v e . The most e f f e c t i v e o f th o se m eth o d s, o f c o u r s e , i s the s t a t i s t i c a l a n a ly sis o f the r e s u lts in com parison w ith co n tro l g ro u p s. This m atte r o f the need o f c o n tr o l groups and then o f c a r e f u l co m p a riso n b y some s o r t o f s t a t i s t i c a l m ethod, w h ich need not be perhaps e n t ir e ly orthodox, as lon g as i t employs common s e n s e , some s o r t o f s t a t i s t i c a l c o m p a r i s o n ' i s a b s o l u t e l y in d isp en sab le i f a person is to g et any r e a l r e s u lt . I presume, D r, V eld ee, you have taken s t a t i s t i c a l data of th is so rt fo r the b a s is o f the statem ent you have made. CHAIRMAN SM ITH: Thank y o u , D r . S o l lm a n . D r. Sollm an has probably expressed the thought that sometimes w ithout c o n tr o l experim ents too much w is h fu l th in k in g enters in to the r e s u lts . . D R. 0 . A . SANDER (M ilw au k ee , W i s c o n s i n ) : I have been a s k e d , o f c o u r s e , and many o f y o u h a v e , s h o u l d we im m unize t h i s year or immunize n e x t y e a r . I heard D^. V eldee say t h a t because o f t h i s new s t r a i n l a s t y e a r , b ecau se, o f th e p o s s ib le new s t r a i n th is y e a r, th a t i t w o u ld be i m p r a c t i c a b l e t o recom m end v a c c i n a R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO tion o f in d u s tr ia l groups u n less a c le a r -c u t epidemic of A or B seemed t o be d e v e l o p i n g . Now th e L o s A n g e l e s e p i d e m i c w ou ld seem to be a c l e a r - c u t A ; i f i t b e g i n s to s p r e a d , I am w o n d e r in g i f D r . V e l d e e t h e n w o u ld a d v i s e t h a t we s h o u l d s t a r t v a c c i n a t i o n . CHAIRMAN SMITH; D r . V e l d e e ? DR. VELDEE: F o l lo w i n g th e i s o l a t i o n o f th e new s t r a i n ,, which p r e v a ile d a year ago, nam ely, the fm- 1 s t r a in as q u ic k ly as p o s s ib le the p ro d u ce rs o f v a c c in e on a co m m ercial b a s i s were urged t o g e t t h a t s t r a i n i n t o p r o d u c t i o n , so t h a t now the vaccin e which you purchase on the m arket not o n ly co n tain s the t h r e e s t r a i n s p r e v i o u s l y t h e r e , n a m e l y , PR-8 and v h i c h i s o f th e type A and Lee of the type B, but in a d d itio n , a c e r t a in p e r c e n t age o f th e FM-1 c o m p o n e n t s , so t h a t we s h o u l d h a v e t h i s s e a s o n a b e t t e r c o v e r a g e than we had a y e a r ago when v a c c i n e f a i l e d b e ca u se o f th e a p p e a ra n ce o f F M -1 . As i t now a p p e a r s , the o u t break which is p r e v a ilin g in southern C a lifo r n ia is c e r t a in ly o f a type A v a rie ty or s tr a in . But so fa r i t is not q u ite the time to say whether the p r e v a ilin g s t r a in le a d s more to the FM-1 s u b s tr a in of A or to the FRA, but i t does look as though i t i s covered by the p resent v a c c i n e . Nov/, w h e t h e r y o u s h o u l d im m unize o r n o t , I t h i n k w i l l have to rem ain a d e c i s i o n f o r y o u r s e lv e s , s in c e one can n o t l a y down, I b e lie v e e v e n .y e t , f ix e d r u le s fo r the co u n try as a w hole, R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO and I b e l i e v e t h a t i s w e l l b ro u g h t o u t in t h a t r e p o r t from th e committee from which I read. CHAIRMAN SMITH; Thank y o u , D r . V e l d e e . Now are t h e r e q u e s t i o n s ? DR. DINBERG (H arve ster, Company) ; I ( would l i k e to r e p o r t on an e x p e r i e n c e we h a v e n ' t p u b l i s h e d as y e t . We im m u nized 17,000 workers and had 7,000 c o n t r o ls , in the sp rin g o f ' 4 6 -'4 7 , and a f t e r e x a m i n i n g o u r f i g u r e s we came to t h e c o n c l u s i o n - t h e s e were a n a l y z e d s t a t i s t i c a l l y - t h a t we had no b e n e f i t fro m the v a c c in e a t a l l . As a m a tte r o f f a c t , there was a f l u epidem ic in the e a r ly w in te r o f 1947 and so f u r t h e r s tu d ie s - these w orkers were p r i n c i p a l l y i n the C h ica g o a re a - a t the U n i v e r s i t y o f C h ic a g o showed t h a t t h i s e p id e m ic was a g a i n an A v a r i a b l e i n s t r a i n . T h i s was a r a t h e r l a r g e e x p e r i m e n t and we fo llo w e d the workers from O ctober o f '46 to A p n il o f '47 and our r e s u l t s shew ed t h a t t h e v a c c i n e was i n e f f e c t i v e . We d e c i d e d , h o w e v e r , t h a t we w o u ld n o t go a h e a d w i t h t h e v a c c i n e t h i s y e a r . Should t h is epidem ic o f in flu e n z a in Los A n geles be s p e c i f i c a l l y to esk i d e n t if i e d as A, I should li k e again /th e same q u e s tio n as D r . S a n d e r . How l o n g s h o u l d we w a i t b e f o r e we go a h e a d and im m unize our people? . DR. VELDEE: The i n d i c a t i o n i s th e h e i g h t o f your I m m u n i t y r e s u l t i s _reache.iT i n a b o u t two w e e k s . D oes t h a t R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 128 answer? ' D R . KENNETH PEACOCK (New Y o rk ) : Many o f us t h a t had the u n fo rtu n ate o p p o rtu n ity o f seein g th a t t e r r ib le s t u f f in 18 and 19 f e l t so f a r a s we were a b l e t o k e e p t r a c k o f p a r t i c u l a r l y th e men i n t h e s e r v i c e who h a d I n f l u e n z a a t t h a t tim e, th a t p r a c t i c a ll y none o f those in d iv id u a ls had recu rren ces of in flu e n za . - Now i n y o u r e p i d e m i c s , as you s a y , p a r t i c u l a r l y th e one type o f v a c c in e , the one type o f A you m entioned re cu rre d g a y i n 4 y e a r s o r s o , i n e p id e m ic f o r m . Yv'as t h a t what y o u s t a t e d ? ' DR. VEEDEE: That was when I w as r e a d in g from t h is report, th at epidem ics o f A are apt to appear in that c y c le , but n o t n e c e s s a r i l y i n th e same i n d i v i d u a l . DR. PEACOCK: There are j u s t two p o in t s t h a t are i n t e r e s t in g to me. in the work you have done on in f lu e n z a have you any r e c o r d s o n vhow l o n g t h a t w i l l p r o t e c t , o r i f i t does p r o t e c t ? I f your ep id em ics do re c u r mare o r l e s s as you s t a t e , i s n ' t th at somewhat an in d ic a t io n o f more or l e s s mass p r o t e c tio n a f t e r a n ' epidemic has passed? DR. VELDEE: W e l l , I am s u r e t h e r e i s a p e r i o d o f im m unity i n th o se vho have h a d the d i s e a s e , but p e r s o n a l l y , I do n o t have s t a t i s t i c s to b e a r o u t how many y e a r s t h a t im m u nity would l a s t , bu t the f a c t rem ains as t h is r e p o r t s t a t e s , the o u t R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 129 b r e a k s do ap p ea r i n th e s e c y c l e s , b u t o f c o u r s e , t h e r e are a lw a y s p l e n t y o f i n d i v i d u a l s i n t h e com m un ity who did n o t h a v e th e i n f e c t i o n i n t h e p r e v i o u s o u t b r e a k and t h e y vo u l d - l i k e l y , be candidates fo r th is next one. ' CHAIRMAN SMITH: two more q u i c k q u e s t i o n s . I t h i n k we w o u ld h a v e tim e f o r a b o u t D R . LEONARD ARLING ( M i n n e a p o l i s ) : of the pneumococcus e ffe c t ? What i s your o p in io r D R . VELDEE: The e x p e r ie n c e w ith t h a t , o f c o u r s e , i s v e ry lim it e d in t h a t n o t many good c o n tr o l s tu d ie s have been made. T h at one i n N o r th D a k o ta was v e r y e n c o u r a g in g and a g a in I t h i n k th e q u e s t i o n i s who s h o u l d be im m u n ized and when? I th in k i t is f a i r to say th a t i t is not a type of immunity which you would want to a p p ly to a community ir r e s p e c t iv e o f age and o c c u p a t i o n a l s t a t u s . I may s a y t h a t we h a v e r e c o g n i z e d th e p ro d u ct f o r lic e n s e by the Squibb L a b o ra to ry and th ey hope to make th e p r e p a r a t i o n a v a i l a b l e f o r t h o s e who w ish to u s e i t . CHAIRMAN SMITH: T h a t i s i n t e r e s t i n g . I n c i d e n t a l l y , b e a rin g on th a t p a r t ic u la r problem , in the p a st o n ly p r o te in s have been regard ed as cap ab le of producing a n tig e n ic v a c c in e s and now you h a v e th e p o l y s a c c h a r i d s and th e r e i s some i n t e r e s t in g s p e c u la tio n s as to what i t n ay o f f e r . 1 D r . B a rach , have you any comment? R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 130 D R . BARACH: I t seems t o me i n t h o s e c a s e s t h a t e r e apt to pet re cu rrin g in fe c t io n w ith b r o n c h ie ta s is , in the case o f the b r o n c h ia l d ise a se th a t would be a worth w h ile th in g to immunize tnem w ith the p r o d u c t. DR. LONG (!; i l a a e l p h i a ) : I w ould l i k e to a sk D r . B arach i f he had any e x p e r ie n c e w ith o r a d v ic e on th e u se o f s t r e p t o m y c in a e r o s o l in ea r i p a c t i v e p u lm onary t u b e r c u l o s i s . " D R. BARACH: We h a v e u s e d s t r e p t o m y c i n a e r o s o l in cases o f la r y n g e a l tu b e r c u lo s is and a ls o in a n im a ls. I t does p r o t e c t in a n im a ls anu i t does seem t o oe o f v a lu e in l a r y n g e a l tu b e rcu lo sis. I t is also true th at streptom ycin interm uscular is o f valu e in lary n . e a l tu b e r c u lo s e s . Most o f the re p o rts use b o t h a e r o s o l en d i n t e r m u s c u l a r i n j e c t i o n o f t h e d r u t . We h a ven 't a c t u a lly used streptom ycin a e ro so l in e a r ly pulmonary t u b e r c u l o s i s . We h a v e n ' t u s e d i t now f o r t h e m ost p a r t i n c h r o n ic pulm onary t u b e r c u l o s i s . I do know t h a t D r . M cD sirm id and D r. Musbinhem have used i t in ca se s o f t u b e r c u lo s is th a t have s t a r t e d m ild and nave sp read so th e y ae t a rnonic l e s i o n . I w o u ld s a y i n o u r e x p e r i e n c e we h a v e n ' t t r i e d i t In e a r ly pulmonary tu b e r c u lo s is . CD AIRMAN SM ITH: T h an k y o u . I know we w o u ld l i k e t o have more q u e s tio n s and answer th em , but 1 1 :00 o 'c l o c k I s upon u s and on b e h a l f o f t h e s e i n d i v i d u a l s on th e p l a t f o r m , I w o u ld R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO I jp 130- lik e to express our ap p re cia tio n of the k in d , th o u gh tfu l a tte n tio n you have devoted to the su b je ct, and D r. V e ld e e , D r. B a rach , and D r . S o llm a n , I know I speak f o r the a u d ie n ce vhen I s a y we a l l e n j o y e d h e a r i n g y o u and we do a p p r e c i a t e y o u r being here. . . . The s e s s io n a d jo u rn e d a t l l j O O o ' c l o c k . . . ADJOURNMENT Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14. OHIO 133 _ ^ TUESDAY MORNING SESSION January 6, 1948 The Conference on Nub r I t ion In Industry convened in Club Room A of the Cleveland Auditorium, Cleveland, Ohio, at 9:30 o 'c lo c k , a.m . Dr. James S . M etester presid in g. CHAIRMAN McEKSTER: The future of the nation in these troublous times depends upon in d u strial capacity and t h is , in turn, depends in no small degree upon the n utrition of the workers In discussing N utrition in Industry, therefore, you are considerirg one of the means through which the destin y of the race can best be insured. ' We are fortunate today in th a t the discussion is to be lead by two men who have done outstanding pioneer work in thi s f ie Id . Dr. Charles C. Lund was the f i r s t man to point out the paramount importance of adequate nutrition to the surgical p a tie n t. His b r illia n t work has demonstrated that if the in jured person, or the person to be operated upon, is to have the best opportunity for recovery, then he must be adequately nourished. Dr. Robert S . Goodhart was Chairman of the Committee on Nutrition in industry of the National Research Council, and R ena H aul E ly CITIZENS BUILDING CLEVELAND 14. OHIO 134 much o f the wonderful accomplishment of the American worker, during the recent war, can be ascribed to his e ffo r ts and to that of his colleagues. Now, the f i r s t thing we are going to do is ask Dr. Lund and Dr. G-oodhart to say something, and then you w ill be invited to ask questions of these men and the y w ill answer. I wi 11 new c a ll on Dr. C. Lund, Assistant Professor of Surgery at the Harvard Medical School. R ena H all E ly CITIZENS BUILDING CLEVELAND A . OHIO Address by: Dr. C . C. Lund, A ssistan t Professor of Surgery, Harvard Medical School. Subject: Nutrition in Industry. What I am going to ta lk about is the result of a lot of cooperative work done with many colleagues in several d iffere n t departments of Harvard U n iversity, and of the Boston City Hospital. I w i l l begin with Dr. John Crandon, who is the Registered Surgeon in the service with which I served back in 1937 ard 1938 when I was studying Vitamin C in relation to surgical patients. Tten, going on t o Dr. Stanley Levison, in Ross Green, who was Resident on the burn assignment during the war. Then, in the Thorndike Memorial Laboratory, which is a medical laboratory in Boston, we have Dr. F . L . Taylor and Dr. Charles Davidson. In the Fatigue Laboratory, of Harvard Business School and th at is the right address, Dr. Robert Johnston and his colleagues. Now , my woik has to do with nutrition in relation to major surgery o f a l l kinds. I t is not focused e n tire ly on industrial surgery, but the implications of the work go righ t into industrial surgery. Many of the patients on which our studies were made were the re su lt of actual industrial accidents Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14. OHIO 136 X can point out one or two of them la te r . Now, my ta lk is going to be about the fa c to r s , n u tritio n al fa c to r s , that influence the recovery from injury and to some extent, the recovery from illn e s s . To repair a wound one has got to create in the neigh borhood of the wound the conditions o f n u tritio n , o f oxygen supply, of 1H, so that c e lls can divife. The division of c e lls cannot take place when there is too much difference from normal in any one o f a dozen known d ire ctio n s. Now, the facto rs that our data is concerned with, and that I w ill speak o f today, are the protein metabolism and the metabolism of Vitamin G, thiamine, rib o fla v in and nicotinamide and, presumably, there are many other factors that are o f im portance but on which I have no data. I f a p a tie n t, for in stan ce, is badly depleted in protein tis s u e , edema occurs spontaneously. I f a wound occurs in a person who is depleted, but not badly enough to have spontaneous edema of the ankles, there w ill be edems o f that wound. I f Vitamin C is too low the c e lls cannot la y down new c a p illa r ie s and cannot form in te r c e llu la r binding substances. I f thiamine is low, then the in ju ry is not so much a c e llu la r injury as an injury to the entire system, which makes the patient more susceptible to shock, traumatic shock. R ena H all E ly CITIZENS BUILDING CLEV ELA N D 14. OHIO 137 In c id e n ta lly , Vitamin C has a part to play in traumatic shock which, is not too well understood, and protein has a part to play in shock. A ll these substances, i f depleted, provide more shock than the patient would otherwise have. Riboflavin is important in re p a ir, and .niacin is also important in the same enzyme system. Now, what are the situ a tio n s that a surgeon is faced with in studying snd trying to correct seme d e ficie n cie s? How frequent are such d e ficie n cie s? F ir s t I must say t h i s , - that the keynote in recovery o f a patient with an in d u strial in ju ry, or any other in ju ry , is ''Su rgical C a re ." You can't make up for good surgical care by any n u tr itio n , but you can help out and save tim e with good surgical care i f the n u tritio n is taken care o f . / There is n ' t any quest 1on that many badly nourished people have recovered from illn e s s e s . We cannot, in surgery, put anything in front of good surgery. That means correct reduction of fr a c tu r e s , proper treatment of shock, proper prevention of shock, proper correction o f internal in ju r ie s , and a l l that goes with good surgery which I won' t go into new. Now, there are two situ a tio n s in regard to these p a tie n ts. The f i r s t situ ta tio n is th e, n u tritio n al status of the patient at the time he is in ju red , and there are a su rprisirg R en a H a l l E ly CITIZENS BUILDING C LEVELAND 14, OHIO 138 number of people In the population who have not gotten f u l l blown d e ficie n cy disease that you can spot as they walk down the street and sa y , "Here comes a man with scurvy." But, there are many vho are so close to these d e ficie n cie s that a very small injury w ill upset them greatly and on whom some nutritional be therapy w ill/ a great deal of help. I can point out one or two such patients in the charts that I w ill show. So, you can con sider that a certain percentage of your injured people may be in poor shape, n u tr itio n a lly , at the time they are hurt. Now, the second thing i s concerned with the damage to the n u tritio n that the injury i t s e l f does. In order to furnish the Vitamin 0, for in stan ce, that is necessary to re pair a large burn, the body w ill take it from any place i t can get i t , and that means it w ill take it" from the blood and from the body f l u i d s , and probably i t w ill deplete the fixe d tissues in the body rather ra p id ly . I say "probably" because I can' t prove it . A l l we know is that the patient with a large wound, of vshich a burn i s the most str ik in g example, does become depleted in Vitamin C very rapidly unless Vitamin C is supplied in large amounts. . - Now, w ith that introduction, I am going to go over sortB of the evidence with you by showing a few s lid e s . The f i r s t slid e is from the New England Journal of R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 139 Medictoe to 1939 or 1940, from an a r tic le by Crandon and my s e lf on toe recovery from scurvy that Dr. Crandon produced on himself He went on a s t r ic t d ie t, scurvy-producing d ie t , whil? working as a resident in the h o sp ita l. He maintained the d ie t for six months. At toe tod of that time we demonstrated, by an experimental wound, that the wound would not h e a l. Then he was treated fcr scurvy and this is the re su lt of i t . This is part of the record of the treatment. Three months before we had made a wound toich had healed. We made those wounds to a way so that we could not t e l l , w ithin any close range, whether healing was completely normal or not. There has been evidence shown by other workers, Dr. Chester Jones and Dr. Marshall B a r tle tt, of Boston, Massa chusetts, that three months deprivation of Vitamin C, in a patient too was otherwise normal, would produce a condition where healing is impaired, but i t does take p la ce . Now, at the end of th is tins , and fo r several weeks before, the Vitamin C le v e l in Crandon' s blood was absolutely zero. I t was also zero in his white blood c e l l s . On April 27th a gram of C was in jected intravenously, promptly, - i t was not given in a slow intravenous or by 10 c c ' s at a time. I t was a ll pushed in within a minute. That upper R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 140 left-hand chart is an excretion curve and a blood curve of the C . Now, these figu res over at the l e f t indicate the milligrams per hundred cc in the blood and the decigrams ex creted from the urine. Decigrams are not used much in medicine, but in order to have the fig u re s come out even we used them. What i t amounts to is that in the f i r s t hour one-tenth of that gram went out into the urine, and in the next two hours p r a c tic a lly nothirg, and at the end o f the hour tne plasma showed about l i t t l e more than twice as much C as the normal person would have. You notice hew; rapidly i t was excreted. At the end of one hour there was a normal fig u r e , and at the end of two hours it was almost down to zero. Fran then on there wasn' t any. The next morning the figu re was again zero. Tkat indicated that that gram of C, except fo r the one-tenth part of i t that went into the urine , was gobbled up by the tis s u e s . There was a great d e fic it and i t went right out of the blood into the tis s u e s . The next morning we gave him another gram, ju st the same way, and you can see that the blood figure went a l i t t l e b it higher. I t stayed a l i t t l e b it higher, and h a lf again as much went into the urine. I t s t i l l was, e s s e n t i a l l y , gobbled R ena H all E ly CITIZENS BUILDING '312 Jfa were giving her hat we thought were rather adequate doses cf a ll vitam ins, hut we had had so much to do, so many other things to study, that we hadn't dene t e s ts for Vitamin C op for any other vitam ins. During the e a rly stages she had a lo t of gra ftin g done end then she got in sueh had ^ape th at the dragstedts were not healing the g ra fts were melting away, and we couldn't understand it because we were pouring in the protein and we were giving vitamins a t the rate of two hundred and tw enty-five milligrams a day. That is shown hy th is colm n alor here. HOW, that was given in the form of three m ultioebrih capsules a day which gave her two hundred and tw enty-five milligrams o f C , plus three times the supposed d a ily require ment for the other well-lmown vitam ins. Y e t, when we f i n a lly got around, +to te stin g tnoerr oonn t^he two hundred and twenty-fourth day she bad zero in her hlood. So, the next day this dose, here, was given after that determination. We gave her a gram intravenously, in addition to what she was g e ttin g o rd in a rily , hut on the th ird morning i t was s t i l l sero. On the fou rth morning i t fi n a lly worked i t s e l f up to p o i n t - f a . f l f t h m0rnlnS " was up to p o in t-fiv e . Then we S h ifte d her to oral doses and it stayed a ll R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 143 right Now, that was one step that resulted in the fin a l re covery of this woman. That explained something to us that we hai had no conception of u n til the date of this warlq which was 1944, and that is that three times the d a ily requirements for the healthy person, of Vitamin C, is n ' t enough fo r certain persons with serious in fe c tio n s , such as burns. I t is n 't even enough to allow than to avoid scurvy. This patient had scurvy. She was lyin g on her back and she didn' t shew any sign s of i t , but she did. have i t . Next s lid e : Now, here are some saturation te sts that we did la te r , - not cn th is p a tie n t, but on another patient They are a l i t t l e b it confusing. ' This was a woman with a rather small burn, only about three percent of the body area. That would mean three times the size of her hand and fin g e r s , extend1 ed lik e t h i s , and th is burn was somewhere on her sid e . She was a housewife of about middle age--, and reason ably healthy looking. We discovered that she never liked f r u it and she never a te it She also d id n ' t like the hospital d ie t, and so she did n ' t eat the d ie t very w e ll. The best part of the d ie t was the fr u it and she wouldn' t eat th a t. We did a skin gra ft on her and got a complete, absolutely zero ta k e . This was ju st about the time we were getting started on t e s t determinations and so we did a saturati on R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO test. Now, here are some standards. These are h a lf, one and a half , two, two arfl a hal f , three hours a fte r a gram of C has been put In Intravenously. This shos what happens to I t . wait a minute, - th is is n o t a g r n . l e t ' s s ta r t over again. Thin is the zero point here, - th is is before the in je c tio n . This is not a gram, th is i s a quarter gram. This i s a small saturation te st which we used in sane of our experiments. A normal man sta rts at ju st over one poin t, zero, anj goes up in h a lf an hour to a l i t t l e under three, and then comes back in fo u r hours to where he sta rte d . ' This patient started at zero and went up to one and a h a lf , back to zero in two hours, e t c . We had some patients with true scurvy that were diagnosed on the medical ward. Some of than showed ataioet the same curve. ' Now, here is the excretion chart. These excretions are cumulative. That i s , you w ill firfl in the f i r s t h a lf hour specimen fo r ty m illigram s. In the next you have twenty and you add the fo r ty to th e twenty and you put your dot here. You get another tw enty-five here, and then you add so that th is is the t o t a l that tas been excreted in -th e four hours. This is the normal and you see th at about h a lf of the quarter gram is excreted. Here is the survey on th is patient and you w ill notide RENA H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 145 they are exactly the same . We treated this p a tie n t, in fa c t we over-treated her. We kept her going cn a large dose for a good many days ard then we did a curve again. We also treated the scurvy patients and you can see that they a ll gave the same hlood curve. Here you see that they a l l gave pretty much the same excretion, urine excretion , although th is patient even a ft e r tw enty-five days treatment was s t i l l storing the C, storing more than normal. Next s lid e : Ncwr, that was what a small burn w ill do That is the patient that I spoke of who comes to you with an in jury, who is close to scurvy, and then with a small bum gets scurvy that prevents healing* Now, here is an industrial accident ca se . This was a very healthy th irty -th re e or t h ir t y -fiv e year old machinist He was a high-grade man working on magnesium parts o f some c p licated machinery. There was a lo t of magnesium powder in a p ile adjacent to t be machine where it had gotten rubbed o f f by the cutter he was usin g. Somehew th is powder got on f i r e and that causes a very intense flame. Fortunately he was clothed in wool and didn' t have much grease on him and h is clothes didn catch f i r e . He got a fla sh burn of his face and o f his hands how, t h i s was a good, s t i f f f l a s h b u rn b u t i t w a s n ' t R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 146 third degree except for the tip s of his ears which he lo s t . Now, the face is three percent of the body area. His hands and a l i t t l e on h is forearms made another four percent of the body area and so the t o t a l was seven percent of the body area, - none of it third degree He d id n ' t eat anything for about fiv e days and his face swelled up. He was sueh a healthy man and he had such a good h isto ry of normal food in the past that we d e lib e ra te ly with held vitamins and high protein intravenous treatment because v/e knew that he wouldn' t get in too bad shape. So, we have a record of what happens to a man with th is moderate burn without any vitamin therapy a t the s t a r t . You see, promptly, his plasma of Vitamin C, on the fourth day, reached zero. Now, Crandon had to go without vitamir C for about seven weeks before he got to zero. So, something knocked th is man' s Vitamin C right down. Down in here his intake begins, but notice that i t is a very small intake. I t is .1 , .3 , .1 . A l l that is calcu lated out of oranges. We gave him large amounts of orange ju ice and, except for the saturation t e s t , he was given no Vitamin C intravenously or by mouth. * i You see, here, his output dropped right down to zero. This dotted lin e , across here, indicates average output of supposedly normal people who were not taking supplementation. Rena H all. Ely CITIZENS BUILDING CLEVELAND 14. OHIO Here we cone, fo r the f i r s t tim e, to thiamine fin d These are output fig u r e s . You c a n 't do thiamins in the blood* a s y e t , or any o f the B vitam ins. Here you see that it to d e f in it e l y low u n t il you come along here when he began to eat and his burns began to h ea l. The same thing is true with r ib ofiavin* and the same is true with nicotinam ide. Next s lid e : Here is the vitamin saturation te s t on him on about the tenth day. That is a bum figu re there, Aga we have to apologize fo r something going wrong in the laboratory because i t i s impossible fo r the c to jump up and then drop down and go up again when a l l of it was given at th is p o in t. The urine shews a p e r fe c tly good curve. Now, he was given a large saturation t e s t . He was given a whole gram, but he only put out a quarter of i t . That means he had a need for his tissu e s and he took i t up. This curve shows ihe same thing and maybe the bad thing there is that we got a h igh valu e. How, th is i s vbat a r e a lly te r r ib le burn w ill do. I aa not showing you many of these p ic tu r e s. This shows much no than vitam ins, m is shows proteins plus vitamin d e a c ie n cie This p a tie n t was treated long before w_e started the vitamin Ju d ie s and we gave him Vitamin 0 at somewhere between two and Tve m illig ra n s a day whi di we thought was p le n ty . 148 This was the worst surviving patient frcrn the Cocf&snut G-rove f i r e . I have shewn th is slid e before, and i t has been published, and some of you people may have seen i t . This picture daows th is man a very few days a fte r the fir e when he s t i l l remained f a i r l y w ell nourished. Here he is at the end of a hundred and f i f t y days when he is beginning to get b e tte r. A l i t t l e prior to that he got into a t e r r i f i c nu tr itio n a l edema. There is a loss of weight there of about sevei pounds. Those are bed sores on his r ib s , and there is another one over his illiu m which occurred because he had to lie on his face for such a long tim e . His whole back was burned. Next s lid e : Now, I want to say something about the nitrogen metabolism as w ell as the ascorbic a cid . A fte r a burn after certain other in ju rie s where there are very large drain ing wounds, a great deal of protein goes into the outside world in the form of pus or blood and is lo st n u tr itio n a lly . Early a fte r any injury a great deal of protein is broken down in the body and excreted by the kidneys in the form of pepsin and proteose. The result is that these p a tie n ts, with these severe in ju r ie s , have tremendous losses of wbight. We did some studies to see whether we could put protein into patients as fa s t as we were losin g i t . Now, here is a man who was burned at least as badly as the man you saw R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 149 and he did not su rvive, - we were not able to save him. On the f i r s t day he r e a lly got a good nitrogen intake, but that is a pretty a r t i f i c i a l figu re because that is calculated almost e n tir e ly on the basis of plasma and whole blood which was given to tre a t the shock. I t was not r e a lly given for nutritional purposes and may not have had much n u tritio n al effect. . Along here he got fiv e or s i s grams of nitrogen a day which is only h a lf the normal intake of protein fo r a per son wtoo is not i l l . Therefore, he dropped weight and strength very rapidly and just in the urine, without checking the protein losses on the su rfa ce , he put these amounts out. By the f i f t h day we r e a lly started treatin g him, mostly intravenously, and we were able to balance what he was putting exit in the urin e. Then we pushed him harder and harder both intravenously and through the stomach tube, but we couldn' t gain . As f a s t as we put protein in i t would go out and the excretion from the urine, aL 1 through here, represented the break down of a tremendous amount of tis s u e . Now, to show that we were r e a lly giving him calories as well as protein , - you can see we reached a point here where he was g e ttin g t h ir t y -fiv e hundred calories a day. He was given ascorbic a c id . The f i r s t day he was given h a lf a gram, Rena H aul Ely CITIZENS BUILDING CLEVELAND 14, OHIO 150 the next day one gram, the next day a gram and a h a lf . He was given a gram a day here and then we dropped it down and he received th is dose, here, mhi ch was about seven hundred m illigrim s a day. His plasma and ascorbic acid went right down to zero. A fte r two days of two grams a day i t f i n a l l y went up again. Now, I don't believe there was anything we could have done to save that man, but that shows what t e r r ific changes in nitrogen metabolism and vitamin metabolism occur in these patients that have th ir ty or fo r t y percent of the body burned in third degree burns. Next s lid e : Now, here is a surgical triumph. This was not an in d u stria l accident case, th is was a street accident This man was h it by an automobile-while he was a pedestrian and he was brought into the hospital with a very obvious com pound fra ctu re of the lower le g . A fte r he had been x-rayed and had returned to the operating room for something to be done to his le g , i t was noticed that he had bloody urine which hadn't been noticed be fo r e . I t was a lso noticed that he was going into shock. The Burn Assignment, at that time, was studying a ll kinds of shock. Our resident was called and i t was p e rfe ctly obyious that th is man had an inter-abdominal in ju ry , not of his bladder, and that he also had a kidney in ju ry . Rena Hall. Ely CITIZENS BUILDING CLEVELAND 14, OHIO 151 We operated on him, a fte r giving him a lo t of blood, and found free blood in the b e lly but i t was a ll coming from the kidney. So, h is belly was sewed up and he was turned over on his side and his kidney was taken out because it was busted completely. This operation was done under spinal and i t was found that he had a bloody spinal f l u i d . That led to the addi tional diagnosis of a fractured s k u ll, and on the next moping he had pneumonia. In the meantime he had been given almost his f u l l blood volume of new blood and so the next morning we gave him everything we could think o f that might do some good. He got very large doses of p e n ic illin ,a n d then he got n u tritio n al therapy in the form of intravenous proteins and intravenous vitamins. I a ls o want to t e l l you that he got nothing by mouth for a week, a l l th is n u tritio n al therapy was done intravenously and not by mouth or stomach tube. During the f i r s t week he was given over three thousand calories a day. Now, each time you see "nitrogen" here you m ultiply i t by six to make i t into protein. That f i r s t day he was given s ix ty grams of protein equivalent, but that was a l l plasma. On this day he was given a hundred and twenty grams of plasma equivalent, and that meant two b o ttles of arnidin On th is day he was given three b o ttle s , here two and a h a lf, Rena H all. Ely CITIZENS BUILDING CLEVELAND 14, OHIO LbZ and here two and a h a lf . With th a t, of coarse, you don't get a ll these calories of that amount of amldln, - you have to add some glucose besides. Wait a minute, we have to go back a minute because I was looking at the wrong column. The black columns are your urine outputs. He was given two b o ttle s of amidin a day, right through to re, and he did lose more than we gave him. This, here, represents his protein d e fic it. How, we gave him Vitamin C right from the s ta r t, a gram a day. We a lso gave him otter vitam ins, - a l l the vitamins you see on the next chart. Notice here that between the six th and seventh day the Vitamin C and the plasma jumped way up with the same intake. The Vitamin C output jumped way up showing thaJ we had caught up with th is destructive process, and at the same time we caught up with the destructive process in the nitrogen metabolism. Next s lid e : Now, th is is the same man, only with the nitrogen balances here, and showing the doses of the other vitam ins. I t shows the enormous doses, f i f t y grans of thiamine, twenty grams of r ib o fla v in , seventy-five grams of nicotinamide j and then a l l of a sudden the whole th in g, the nitrogen, the Vitamin C, ard the other vitamins a l l got caught up and this fellow got w e ll. r e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO I am taking a lo t of time on t h i s , but there are only a f ew more. Here i s another man that was not an in dustrial accident case. his vitamins. I won't take so long on him, - th is ju st shows This man was ccmplately intoxicated and he ran a fte r a t r o lly car, in our subway, missed i t and f e l l under i t and lo st both of his le g s . He was given treatment for shock and then his vitamins were studied and you w ill notice that with large in takes i t was about fiv e days before he was brought anywhere near normal. His was not as excitin g a case aS the other one. His depletion was not as bad. He was a much younger man than the othe r man. Next s lid e : This is that same man showing two Vitamin C saturation t e s t s . Thin one, right a fter the accident, in will oh the plasma figu res weren't too bad except that the peak was low fo r a man who was given a whole gran. His excretion was pi^actically zero while he was recovering fron shock whereas two days later his excretion was appreciably higher. I think that I had better stop now and wait for the question period. (Applause) CHAIRMAN McLEST'SR: Our next speaker is Dr. S. Goodhart, S c ie n tific Director of the National Vitamin Foundation. R ena H all E ly CITIZENS BUILDING CLEV ELA N D 14, OHIO 15 He w ill speak to us on "The Administration of an Industrial Nutrit i on Pr ogram. " DR. S. GOODHART: The subject of "Admini st r a ti on cf an Industrial Nutrition Program" is not quite as excitin g as the treatment of accident cases, but it is o f fundamental importance. I w ill make my formal presentation quite b r ie f be cause 1 think that in the answer and question period pertinent problems might be raised , - some much more pertinent than any I can bring up In the formal presentation. ...D r . Goodhart read his prepared p a p e r ... CHAIRMAN McLSSTER: Now we hope you w ill ask questions. I am going to ask each person to stand up and ask your que st ion loudly and d is t in c t ly so everyone in the room can hear. DR. t . J . GOIDWATHR (New York, N. Y .) : We have a plan in our company whe re we furnish the meal free of charge to the worker. I was won dering i f any studies have been made in dollars and cents as to the co sts, what i t costs our company, and what i t might save. Does i t save anything? DR. GOODHART : That question has been ra ise d quite a few times as to some way of measuring the actual economic worth of the in dustrial food service to the p la n t, and whether It pays the plant to subsidize, - whether food service should be s e lf - R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 155 supporting. That is a question of judgment on the part of management as to whether they are being benefited by the c a f e te r ia . We can 't measure it or figu re it out in d o llars and cent s* DR. GOLDWAIER: Have no studies been made? DR. GQODHA.RT: I t is impossible except for an in dividual p la n t. That would be the only way, - a plant to tr y i t far p r o fit , to break even, or to subsidize, and th at would have to be done by each individual plant concerned. no There is/doubt but th at the food service which is run jrim a rily to feed the workers properly is better than one run for p r o f it . There is no doubt about th a t, it can be proved over and over a ga in . I t depends on what extent the plants are subsidized t o the ca fe te ria or fo o l se rv ice . I t depends on the plantte own evaluation of what i t means to the individual p la n t. A VOICE: I would lik e to know what c r ite r ia one would use fo r deciding whether or not an in-plant feeding ser vice would be either necessary or d esirab le. DR. GOODHART: I mentioned something in my paper about th a t, but I think that there are a couple of items to be considered. One, of course, is the a v a ila b ility of commercial restaurants, whether or not these commercial eating places are serving proper food; whether the prices are too high, whether R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO or not they would meet with, the plantfs n u tritio n al d esires, and whether or not they are open for odd s h i f t s . factors. A ll these are Additional factors are the standard o f education in the homes of the workers, i f the majority o f the workers bring lunches frcrn heme and these lunches are very poor, i t is often d i f f i c u l t to get into the home s, and it is often easier to change those habits i f yeu have a ll the workers together in an in -p lan t food se rv ice . Whether or not there is food available during the rest periods is a fa c to r that might be a fin a l deciding fa c to r . Another one is whether or not i t i s necessary to supply breakfast to the worker. A ll of these things must influence tie decision of the medical department in deciding on the food se rv ice . I don't think the size of the plant is a major consideration because even a small plant can have a food service whi ch can be run by the employees. I don' t include that as a determining fa c to r . I think there is one fa c to r which the medical depart ment w ill have to judge for i t s e l f in makirg i t s recommendation, and that is it s own appraisal as to how fa r the plant would be w illin g to go in doing a good job because a poor job might leave everybody worse o ff than the y were before from the standpoint of morale R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 157 DR. J . D. WiULTERS: I have several questions here and I wonder i f both speakers wouldn't mind commenting on these points* . What educatiom l program do they have for the workers in regard to their h a b its , as well as educating the individuals on proper nutrition? Do you want one question at a time? CHAIRMAN McLESTER: Dr. Lund, would you care to answer that f i r s t qte sti on? DR, LUND: I believe that should go to Dr. Goodhart. DR. GOODHART: W ell, on the educational programs, I might say that at the present time there is no government pro gram on nutrition fo r workers, educational or otherwise. Some of the states have programs and a number of in d u stria l plants have worked out programs of t he ir own. During the war a number of papers were published by the Department of Agriculture outlining n utrition education programs that the in d u strial plant might consider. These can be obtained by writing to the United States Department of Agriculture or to the State Health Department which has access to these publications of the War Pood Adm inistration. New, as for recommending, a t th is time, a sp e cific program for any one p la n t, I think that would be out of order. I thiric that in a community of any size you w ill have individuals Rena Ha ll Ely CITIZENS BUILDING d E V E L A N D 14. OHIO 158 who have worked on these programs during the war. You can go to your lo c a l Red Cross N utrition Committee or sim ilar organizations, or your State Health Department could help you on outlined educati onal programs. One point I would lik e to make is that too often when people ta lk about programs they think of concentrated e ffo r ts to change the a ttitu d e of the worker and it is carried on with a bang for a short time and the thing is then dropped. That is a waste of money* We did a lo t of that through the war and we always do a lo t cf th a t because i t makes a big show, but it is no good. . What I mean by a good n utritional program for the workers Is a good, constant merchandising job in in -p lan t food service where there is one, or a constant education of the workers through the medical department as they come In , and a continuous day-by-day procedure in the plant and in the heme which becomes part of the organization of the medical department. That is what is needed rather than these sporadic outbursts of enthus iasm which don' t accomplish a great d eal. CHAIRiiAN McLESTER: Your next question? DR. WALTERS: What I meant, - I would like to see a program that would be very expressive, very s p e c ific , instead of pamphlets, booklets, e t c . I would like to see something R ena H all E ly CITIZENS BUILDING CLEVELAN D 14. OHIO j-o y i : ~ that takes the problem right to the individual who is consuming the fo o d . Per example, a l i t t l e chart right over a certain food that s ta te s , "Why is th is food being served to you today?" I f you have a certain season and you have a reason for selecting a certain food, that is s ig n ific a n t. You could t e l l them hew to get the most b en efit out of that food. CHAIRMM MCHESTER: You mean that the worker should have a l i t t l e n u tritio n a l education? DR. WALTERS: Yes. CHAIRMAN McIESTER: That is part of the over-all scheme. C h ild 's Restaurants tried th at a few years ago and went broke on it . The rest of the menus' had a l l the numbers of calories snd the numbers cf vitam ins, e t c . The man who was in charge at that tin e , I think, died about the time that scheme went broke. But, we agree that education is the thin g. DR. WAITERS: Wouldn't i t be of great benefit to a l l concerned, within the fa cto ry , i f there would be elim ination of vending machina s? Those machines se llin g coca c o la , tobacco, d eficien cy foods, - crackers, cookes, peanuts, and the l ik e , and to substitute a healthy food spot so that they can g e t the food in abundance, an apple, an orange or-some other food that is fresh.' You could teach them at the same time why these foods should be used. R ena H aul E ly CITIZENS BUILDING CLEVELAND 14. OHIO 160 CHAIRMAN MCHESTER: Dr. Hund, i f you don't om any coca cola stock would you mind answering that question? DR. LUND; Well, I haven't any coca cola stock, - I wish I had. I don't think that is such a serious matter. I am a general surgeon with a wide type of p ra ctice . I teach in the medical school a very small part of the time and I see a good many p a tie n ts, both in the o ffic e s and in the h o sp ita l, and some of-them are the borderline type of case where the surgeon, or the medical man, or the gynecologist can take part in the care. Tal the matter of hemorrhoids, take the matter of menopausal symptoms in women. I do gynecology as well as surgery and there are a good many patients to whom I have to give some n u tritio n a l and medical advice. I probably spend more time on nutrition than most surgeons do because I am interested In i t . I have a feelin g that there is something that is le s s than optimum in most Ame ri can d ie t s , of people who are doing sedentary work, doctors, lawyers, housewives, - I don't know that housewives are seden ta ry but at least they are not getting out and playing g o lf very much. I don't have as much experience with fellow s doing hard labor, farmers, woodsmen, and such because I am in a big c i t y . I don't believe that c u ttin g o ff the source of soft " drinks, coca co la , crackers, salted peanuts, and things lik e R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO that r e a lly gets to the fundamehtals of n u tr itio n . As you can see, I am very much impressed with vitam ins. I take them myself and I thirfc they do me some good. I give them to a l l my patients and they t e l l me they do good, except those that are trying to lose weight and they have the complaint that i t increases their ap p etite. I think that the whole public needs a lo t of education in diet ard that a great fraction of the population needs a not too strong vitamin p i l l , and they need to be encouraged to eat more meat and le ss fa t and sugar. I shouldn' t be too much a fra id of the men in the plants that are r e a lly consuming calo rl 3S in the day's work as I would be of the o ffic e people in the plant who are not consuming so many c a lo r ie s . I don' t know, I have never been a plant physician, but I should think that the em ployees would ju st laugh at you i f you tr ie d to take the coca cola machines out How about our own hospitals which are completely under the control o f the doctors? Even in the north, now, you go in to the operating rooms and you go by the front door of the hospital and there is a great big coca cola machine. CHAIRMAN McleESTER: to comment? Dr. Goodhart* would you care DR. GOODHAKT: I want to dicker on th is p articular R ena H all. E ly CITIZENS BUILDING CLEVELAND 14. OHIO 162 p oin t. There are other problems in connect! on with the vending machines. The f i r s t hs the character of the food served and the other is the c o st. As you may knar/, the food that is obtained through the vending machine, gen erally, is expensive. You are buying a packaged a r tic le in small q uantities at a r e la tiv e ly h ig i p r ic e , and in addition to that the type o f food that is served in the vending machines ce rta in ly needs serious consid erati on. I think i t is not uncoimion for workers in the south and west and some of the north to drink as much as s ix to f i f teen coca colas a day. What a ffe c t that has on the nutritional balance, or in-balance, of the in divid ual person today I don't know; but I know that twenty to six ty cents a day taken out of the income o f the average worker in a southern m ill, or in almos| any type of mass industry, is quite a out out of h is income. Now, if he is going to spend that amount of money a day for s oft drinks he is either going to do one of two thingsj. He is going to cub down cn the food he eats at lunch or his fam ily is going to have to cut down, - one or the other. I t becomes, on that score alcn e, an economic problem that ought to be c o n s i d e r e d by any medical department which is interested in the nutritional welfare of the worker. Of course, there are other problems in re la tio n R ena H a ll E ly CITIZENS BUILDING CLEVELAN D 14. OHIO 163 to the stro n gly a c id ifie d drinks such as erosion of the teeth ard things of that sort which are s t i l l open to argument. But, leaving those out of i t , it becomes an important economic fa c to r . I f you have a ca fe te ria and the plant i s p u ttin g on a good lunch for about s ix ty cen ts, and the worker also consumes a lo t of these s o ft drinks; you just stop and addup the income of the average worker with a fam ily of wife and two or three children. You ju st stop and figure out what happens to the money which he has budgeted fo r h is food. The th in g , then, becomes cne of very p ra ctica l importance. I am not against vending machines as such. I think vending machines as such can be important assets i f the foods which you serve through them are the righ t type and the prices are r ig h t . I agree with Dr. Lund in that our e y e rie n ce s have shown that those individuals who have a very high c a lo ric re quirement are le ss apt to have n u tritio n al d e ficie n cie s than those who have a low c a lo ric requirement. On t h is point I would like to make another sta te ment which I think is in con trovertib le. Most of us exaggerate or tend to exaggerate the ca lo ric requirements of the in d u strial worker. Most workers, in modern industry, do not work hard p h y s ic a lly . They do not eat enormous amounts of food. Three R ena H a ll E ly CITIZENS BUILDING CLEV ELA N D 14, OHIO thousand calo ries as an average, far the modern man, is too high. That is why some of your workers maintain their weight balances and their energy output on calorie intakes of less than three thousand c a lo r ie s . When you get down that low and you get into an economy where the a v a ila b ilit y of foods such as milk and cheese is not too good, then ycu get into a situ atio n where you have to pay pretty good attention to the balance of the diet in order to meet the recommendations of the food and nutrition board. I t is a d i f f i c u l t job and I think, in many of these cases, as Dr. Lund has pointed out, the wise use of vitamin preparations should be considered. CHAIRMAN McL.ESTER: I f a l l the vending machines would dispense milk you would a l l say that they are p ra ctical* DR. NORRIS W. GILLETTE (Toledo, Ohio): I am Medical Director of the W ill is-Overland plant an Toledo, and in addition we take care of the work o f f i f t y other plants or so. Vie em ploy, at tim es, e ig h t, ten, fifte e n or eighteen thousand men, and the question is not one o f whether we have ca fe te ria s in the p la n t. I t is a question of the supervision of those c a f eterias and the reascn for that i s that the men cannot possibly leave the plant for outside food. They cannot get the food from the out side* R ena H a ll E ly CITIZENS BUILDING CLEV ELA N D 14, OXIO Then, too, i t is a question as to whether the plant i t s e lf sh a ll serve th is food or run the c a fe te r ia , or whether it shall be run by companies that come in and supply this food. In the W illys Overland plant the arrangement is that an outside company canes in and supplies the food and runs the c a fe te r ia . Now, the W illys Overland, as are a l l of the auto mobile p la n ts, as you know, is very much managed by unions. That includes every subsidiary that comes into the plant to supply food or supplies fo r the p lan t. So, at the present time these cafeterias are suppliejl by one of the out side companies and these must be approved not only by management, but also by the union. Now, I have assumed that i t was a part of my job to have these ca fe te ria s inspected at regular in tervals and I send the physicians around to see them and I w ill then get a report on the condition of these c a fe te r ia s . I may find that the food is poorly served in ca fe te ria B, that the food i s not properly prepared, that there are open cans of food, or that the ic e boxes are unclean, or that some of the food is l e f t over from dajr to day. That is done and then the report is made to the management and to the union, and also tothe man that runs the R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO c a fe te r ia . Then i f there is any further question we go back and make a check up. Then, too, there may come some question. The man that runs the ca fe te ria says "That food is a l l r i g h t ," or "That food was good." I t is important for the medical man, in auto mobile plants at le a s t, to be on good terns with the head of the union. I take the head o f the union, and th is rep o rt, and go down and inspect it with hin and say, "This is the report I got from my man and these are the things that must be done." We have established our own regulations as to what wn think is good se rv ice , and the type of food to be served, the way i t is served, ard how much these men should be given free rein in the servirg of th e ir food and in the type of food that is given. I think that a l l comes under the medical department and we have assumed i t as such. Fortunately I am on excellent terms with the head of the union in th is pla n t. I take him duck hunting and that is a very good way to s it down and ta lk about things with him. You must have him believe you when you t e l l him that these things are necessary. You t e l l him, when you both shoot at a duck, that be shot i t and you did n ' t , even though you did i t , and he believes you a fte r th a t. That can be done in d iffe re n t ways. I t is important, f i r s t , for one who has charge of R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 167 things lik e th is to esta b lish a regulation within himself as to what he wants to do in the plant and then to put into e ffe c t these th in gs, and then to be able to have means to put them into effect. Those are a l l things that I think we should think o f. CHAIKMM McLESTSR: Thank you very much, Dr. G i lle t t e . A VOICE: Dr. Lund, you, I think, implied, but I am not sure whether I got i t a l l str a ig h t, that previous good n u tritio n makes a difference in surgical conditions. DR. MJND : Previous good nutrition makes a very large difference in recovery from acciden ts. Take, for example, the wounds patients recovered from during the war, - given good sur gery in plenty of time, as compared to the resu lts o f good sur gery in the average, let us say, brother of beast member of the civilian population. The so ld iers that were in good condition could stand the most incredible in ju r ie s , way beyond what people in c iv ilia n population could stand. That was based almost e n tir e ly on their awn physical condition, their own nutrition rather than on any post-oper ative n u tritio n a l e ffo r ts made at the front lin e . I have no doubt that some modern methods were used up on the front lin e , but they were not the determining fa c to r s . CHAIRMAN McLESTSR: I know Dr. Lund w ill agree with me R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 168 when I In je c t an explanation of-what he just sa id . The wonder fu l surgery seen during the war wasn' t e n tire ly due to the a n ti b io tic s used, but due la rg e ly to the good state of the so ld ie r . That leads me to bring in this and I believe Dr. tund w ill agree with me on t h is . The Pood Nutrition Board of the National Research Council estimates that the protein intake for the average man, we w ill say, is seventy grams. Now, the American soldien got a hundred and fo r ty grams of protein a day and, I think, he fought a l i t t l e b etter, and he got w ell a l i t t l e quick^ because of t h a t . Do you think that is tru e , Dr. tund? DR. MIND: I ce rta in ly do. I think that the Pood N utrition Boards standards are the best possible standards to be set up under present information, but I think i t is quite lik e ly that the iUture w ill show that in many regards they are not quite optimum. DR. GOLDWATER: In an eight-hour day s h ift with an additional h a lf hour fo r lunch, in a l i ^ a t , monotonous industry, in your opinion, when do you think the rest periods should be in the morning and afternoon? How long should they be? DR. GOODHART: Our recommendation on that score is about two and a h a lf hours a fte r the previous meal. I f the lunc hour is at twelve o' clock then the rest period would occur around tw o-thirty in the afternoon. Of course, on your breakfast R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 169 it is a l i t t l e b it more d i f f i c u l t because so many v/orkers don't have breakfast and Sr those that do, i t is d i f f i c u l t to determine just whe n they d id . But, the break should be at le a st two hours before lunch because, for one th in g, i f they eat such foods as milk during the rest period that w ill have an e ffe c t upon their appetite for lunch. In actual practice the rest period in the morning is not nearly so important as the r e st period in the afternoon. I think that the accident curves show an increase in the accidents from between 10:30 o'clock and 11:00 o 'clo ck in the momirg, and around 2:00 o' clock and 3:00 o 'clo ck in the afternoon. So, that would be the lo g ica l time to have the r e s t periods. DR. GOLDWATBR: How long should they be? DR. GOODHART: I c a n 't say exactly how long they should be, but you have another problem there that some other people could talk about. That i s , i f the rest period is too long the work <3?'s e ffic ie n c y drops o f f . I t has been shown, fo r example, that i f the lunch period is ha.If an hour the worker can resume his work at the le v e l at which he l e f t o ff before the lunch period. I f the lunch period is an hour he is sluggish in ge ttin g back into his s tr id e . There is a d e fin ite loss of momentum i f the break is too long. CHAIRMAN McLESTER : Are there any further questions? Rena H a ll Ely CITIZENS BUILDING CLEVELAN D 14. OHIO 170 DR. WALTERS: I am sorry to take up so much time, but I am very much interested in th is n u tritio n angle. Dr. Louis Andre and I have seen n u tritio n a l-d e fic ie n c y conditions under good n utrition and I would lik e to bring out a few more th in gs. I know these statements are s ta r tlin g , but I want to t e l l you a l i t t l e b it more about what we have found in regard to n u tritio As a dermatologist I practiced n u tritio n eighty per cent of the past fourteen years. Twenty percent of the time I put in on a lle r g ie s , x -ra y s, and the l ik e . By taking out these vending machines we have cleared a lo t of these so -ca lle d con ditions o f the fe e t , of the groin , et cetera. By stopping coffee we reduced headaches. Is that what we need to create to stop our headaches, - a good substitute fo r asperin? Do we have to give them coffee? Do we have to give them ca lo rie s in order to mate them use a lo t of the food? The more we tr y to work on calories the more we lose of our natural m inerals. I know that in many of these p a tie n ts, with good surgery, the wound would open up. You take Vitamin C le v e ls , they are below the natural le v e ls . I f you take natural manganese and supplement that in th eir d ie t , Vitamin Colanin, a good fib e r tissu e w ill fonn. You w ill fin d , the more you concentrate on the habits of these R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 171 in d iv id u a ls, that i f they are given enough sleep, enough r e s t, enough outdoor a c t i v it y , enough e x e r c is e , i f they are given happiness and removal of a lo t of the problems that they have, the mors they w ill get out o f n u tritio n . I t can even help in the case of cancer. Nutrition is ju s t one small phase of health, CHAIRMAN McLESTER: Dr. Lund, do you fe e l lik e comment ing on those suggestions? DR. LUND: W ell, I am very much in terested , and I am afraid my answer to your previous question was a l i t t l e f l i p . What made me take the lin e I did was the fa c t that I have not had experience in Industrial plants and I hadn' t rea lized that iu would be p ra ctica l to educate the workers s u ffic ie n tly so that they would accept the removal of the coca cola machines. I feel very strongly as you do that too much sugar is bad. I am as bad as Dr. Jo s lin on th a t, although I don' t see how you can treat diabetes. I think i t is wonderful that you have been able to achieve such a high degree of education. I was a l i t t l e startled about your remark on cancer, but perhaps we had b e tte r not go inb o that because I do have an in terest in cancer m yself. The fa c t that you have accomplished th a t, I should think, is well worth a s c ie n t ific paper. Have you any reference, have you written that up? R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 172 DR. WALTERS: I have written i t , - but I have found that education has to be taken very, very slow ly. For instance, on one of the papers that I have written on acne vulgaris I have lis te d about four hundred and f i f t y complaints that are present in a l l acre p a tie n ts. I gave the major ones down to the lowest ones and it covered a period of about six 2/ears. I documented th at paper with photographs and when I submitted i t to the various dermatology journals, w e ll, i t was too s c ie n t ific for cne and they suggested I should break it up into half a dozen papers. Then I submitted i t to another and before I knew it I had six or seven a r tic le s for th is one. I have put in to the lite ra tu re the p a tie n t's time, the lo g ic a l problems. I have put in the p articu la r reactions to i t , - hypertension. I have put a l l these in to the various journals and they have been published. The acne a r tic le has been accepted. I have a varicose aneurysm paper in preparation which is going to be accepted. It is ju st in the revision stage. I have t i le d to cover too much. There are around fortly or f i f t y d iffe re n t blood examinations that I make on the average derm p a tie n t. The average p a tie n t, who has had the entire routine thrown at him, is w illin g to do anything to find out wha is Throng, what has caused his condition. R ena H all E ly CITIZENS BUILblNG CLEVELAND 14. OHIO 175 So, I could write a r tic le s on Vitamin C le v e ls , Vitamin B le v e ls , phosphate le v e ls , albumin, etcetera. I could do a lot of work on t h is , but I want to ge t as much of th is into the literatu re as possible and I have found that by breaking it up you lose a lo t of it You lose a lo t of a lle r g ie s by gettin g into good n u tritio n . Each meal should be a ll fr u it or a l l vegetable and you could supplement i t by your proteins, and they come in with your f r u i t . Use your whole-grain cereals as much as pos sible . I think that is a short resume of how to get better ritio n and how to cure a lo t o f these so -ca lle d incurable conditions. A VOICE: I think I can s e t t le any doubts as to what can happen i f you take the vending machines out because I tr ie d i t . We had a s tr ik e . I read somewhere that i t takes ten years to change food habits and I think that is a rather conservative estimate because we have been trying fo r fiv e years and we haven't made very much impression. We have plants scattered a l l over the country and we find peculiar regional lik e s and d islik e s that are very hard t o change. For in sta n ce , in New England, in the plant we have up R e n a H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 174 there, they serve a p a r tic u la r ly , at le a st to me, revolting dish which I advised the supervisor of the ca fe te ria to get rid o f. There is a Portuguesename for it but I called i t a grease sandwich. W ell, we had a strike there too. So, I think that you have to approach the problem of in d u strial nutrition from the labor point of view. You just don't get anywhere at a l l . People have very fix e d ideas of what they want to e a t. I believe that i f you approach i t from that side you w ill be able to do something. CHAIRMAN McLESTER: We have agreed to adjourn at 11:0C o'clock fo r another meeting, so we have ju st about fiv e minutes. Dr. Iiund, w ill you close your discussion, please? DR. luTJND: W ell,I thank you for the interested questions and the apparent in terest in what I had to say. Some of t he m aterial that I talked to you about has been published. As a matter of f a c t , the charts on vitamins and bums came out in the Archives of Surgery, November issu e , which was delivered within the la s t week. The charts on vitamins and shock were in a paper e n title d "Ascorbic A cid , Thiamine, and R iboflavin in Acute Burns" with a long l i s t of authors. With the same t i t l e , the same vitamins in acute in jury was published in the Annals of Surgery, about October, 1946. Those who are interested in R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 175 g e ttin g more d e ta il w ill fin d i t there; material on protein nutrition and o v e r-a ll papers on burns are t o be found in S ,G , and 0 C o lle ctiv e Review on Bums dated about May, 1946. I guess you had b e tte r get the c o lle c t o r ' s review and go back from th a t, I thank you, (Applmse) CHAIRMAN McLESTER: Thank you, s i r . Dr. Goodhart, you am next, DR. GOODHAHP: There is just one thing I would like to say. I think we are a l l very pleased with Dr. G i l l e t t e ' s d is cussion. He agrees pretty much, almost e n tir e ly , on what I had put hem in this paper on how a progran should be run. Them are ore or two points I would lik e to make. F ir s t of a l l , in te re st in the n utrition of the workers in the plant should not be in te r e s t, prim arily, in changing dietary habits just fo r that sake. You should recognize that dietary habits are changed with d i f f i c u l t y , nevertheless they can be changed, and the changes should be brought about gradually through the clever merchandising o f food, - proper food. In addition to th a t, there are ways of protecting the diets in which the workers the mselves do not p a r tic ip a te , - i t does not involve changes in their dietary h a b its. For example, adding dry milk solute to bread, e t cetera. A l l of these are procedures which Improve and protect the n u tritio n al welfare R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14, OHIO 176 of the in d iv id u a l, but do not involve any obvious changes in his eating or d ie ta ry h a b its. I t hi nk i t is important for the medical department to use a l l the resources that are at i t s disposal in attacking the problem and in dealing with the in d ivid u a l, - t e llin g the individual not to eat so and so . A ll rigjat, you can do that i f he comes into your medical department, but you c a n ' t do it to him en masse. But, ycu can get together with his representatives and discuss means and procedures for improving the d ie ts of the workers as a to ta l in the p la n t. I caution you to be very careful that when you recom mend a change in d ietary habits you know e x a ctly what you are doing and why you are doing i t . For example, some n u tritio n ists or d ie titio n s w ill walk into a plant and say that something is bad, that you should take it out. W ell, i t is n 't bad, - do you know it is bad? There is no s c ie n t ific data of any kind to indicate that fr ie d foods are any le ss digestable than any other food. There is no reason to believe that r e la tiv e ly high fat content in that d ie t is bad. As a matter of fa ct i t may be good. Some people eat a d ie t containing around t h ir t y -fiv e to fo r ty percent fa t and they do very well on th a t. So, i t is necessary, before one goes in and undertakes R ena H a ll E ly CITIZENS BUILDING CLEVELAND t4. OHIO 177 any radical changes, to make sure Lhat the changes recommended are not based upon an individual su p e rstitio n , but are based upon some food knowledge, on some s c ie n t ific or actual nutri tional basis, (Applause) cmiffiAN McLESTER: I want to thank you a l l very much. The meeting is adjourned, ...T h e meeting recessed at 10:55 o' clo ck , a .m ... RECESSED R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 178 THESDAY MORNING SESSION January 6, 1948 The Conference on the Outlook fo r Industrial Medical Service convened a t 11:00 o' clo ck , a .m ., in Club Room B of the Cleveland AuUtorium, Cleveland, Ohio. Dr. A. J . Ianza presidm CHAIRMAN SAUZA: The f i r s t speaker on th is program is well known to a l l of you. He is the Presiden t-elect of the American Medical A sso ciatio n . I present to you Dr. R. L . Sensenich and I know he needs no introduction. ...D r . Sensenich presented his prepared p a p e r ... Thank you, Dr. Sensenich. The discussion w ill be continued by the Chairman of the Council on Medical Education and H o sp itals. I present to you Dr. Herman G. Weiskotten who also needs no introduction. ...D r . Weiskotten presented his prepared p a p e r... Thank you, Dr. 'Weiskotten. We are fortunate in having with us the Chairman of the Council on Medical Service, - Dr. James R. McVay. .. .D r . McVay presented his prepared p a p e r ... Thank you, Dr. McVay* . Gentlemen, you have listen ed to three penetrating and s tir r in g addresses on the subject of In d u stria l Medicine and It s Future. R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 179 The su bject is now open for discussion and, gentlemen, I trust that you w ill not be backward about coming forward with your questions Who w ill s ta r t the discussion ro llin g ? I might say, before th is gentleman speaks, that he is the Chairman of' the Committee on In d u strial Medicine of the New York County Medical S o c ie ty . It is a non-profit trust for that purpose* DR. K. PEACOCK (New York, New York): In a l l of our discussions and stu d ie s, in a l l of the good assistance and brains we have been able to c o lle c t to help us on th is problem, we s till have two main stumbling blocks. A ll of your discussions brought out the very d e fin ite problems that we have been fig h tin g and in each case you have put up a suggestion of a question. This is a question of how, fo r instance, can a program be pub over in in d u strial p la n ts, not the b ig plants because they are taken care o f, - in the small plants? No answer has been given to th a t, or any suggestion of an answer and I am very much interested because there have been many men here who are interested in small plants and they have asked me the question. We don't know, we are s t i l l tryin g to answer i t , - how to convince a small operator. In New York they are tough. Maybe they are tough R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 180 in other p la ces, to o , bub our small manufacturers and our small business men in New York are r e a lly tough. There i s n ' t any question about th a t. How are you to convince the small manufacturer to pub in medical care that w ill cost him something and, a fte r you have done th a t, where and how are you to convince enough medical men to go into in d u stria l work in small p la n ts, on a part-time b asis, in order to furnish the proper type of men for that work? I f you have any suggestions on those questions you w ill help us g r e a tly . CHAIRMAN LANZA: Dr. Sensenich, w ill you answer that? DR. SENSENICH: This shows how courageous or how reck less I am. As a matter of f a c t , the two points raised here are the most important. I would agree with the doctor that they are the most d i f f ic d t to answer, I don' t know that there is any given approach to the whole matter of these small p la n ts. The problem in the smaller communities is not so d i f f i c u l t , the reason being, probably, that the small raanufacturer in a smaller community fe e ls himself a b it more responsible in so far as the so cia l structure goes. He is closer to h is employees and he fe e ls his re sp o n sib ility in that direction . I t is less d i f f i c u l t , there, to have established a R ena H aul E ly CITIZENS BUILDING CLEVELAND 14, OHIO loi state of avoiding misunderstanding between the doctor giving the| medical service in the plant and the doctor o utsiae. I frankly think th at the matter must be approached with reference to the relation ship between the doctor doing the part tine service and the doctor on the outside. The approach there must be one of d e fin ite understanding in the medical profession. I t must be understood, f i r s t of a l l , that the plant physician who is on a part-time basis is not poaching on the practice of the physicians on the outside. I t must be under| stood that he is not using his acquaintance with the employee on the inside as a means of access to the fam ily work. The second one is th a t, in turn, the physician on the outside shall feel and respect properly the importance of the physician in the plant and his part in the o ver-all structure; rather than simply seeing him as an employee, even on a p a rt time b a sis, of th is employer of labor. Now, that is a long statement involving two essential poin ts. I f you can e sta b lish the proper confidence between the physician doing the part-time work and the physician on the outside not Interested in the industry, then you have made the fir st step. As I pointed out, or tr ie d to point out in my paper, i t would seem that i f the profession in that community approached R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 182 the matter properly that the y could very re a d ily estab lish that hind of understanding* The mn who is on a part time b a sis, i f he is respect ed by the rest of the community, could certain ly be respected as w ell in that particular a c tiv ity in industry as he would be in his practice on the outside. Now, when you come to the problem in New York, or where you are dealing with the small plant in the large community then you have, unfortunately, to deal with the matter that the doctor developed there and that is that i t is very d i f f i c u l t , f i r s t of a l l , to s e l l the employer the idea that it is his re sp o n sib ility to the community. I t is very d i f f i c u l t to s e ll him the idea of the proper relationship between himself and his employees in matters other than the frank, open re su lts of trauma in employment, or those th in gs which the law sets out as com pensable illn e s s e s . I know they have done a grand job there and I regret that I can't go any fu rth er. I have often thought th a t, possibly one of these Councils that have contacted the top management, the National Association o f Manufacturers and the labor unions,; that they perhaps might even go to the extent of sending a man in to a community, i f he could be h e lp fu l, to interview these employers and to try to estab lish that contact between the employer R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 183 . -- and the lo c a l raedicaL group. I don 't knar/ ?;hether that v/ould he p r a c tic a l. We have trie d to keep the American Medical Assoc ia tio n out o f in any way projecting i t s e l f into the lo ca l problems, but i t might be possible for some method of approach to be established which would not be in any way embarrassing to the profession but whe reby, much lik e the d e ta il man who calls at your o ffic e and talks about pharmaceutical preparations, that he might ta lk to the onployer about the health in his p a rticu lar in s titu tio n . He could talk about how i t would be to his advan tage as well as to the advantage of the employee to give serious consideration, and perhaps spend some money, in establishing that kind of service in his industry. I am sorry that I haven't been able to add more. DR. GRAY: I think Dr. Peacock's work has been wonder fu l and I think his alms are quite understandable, but I think maybe he is trying to do a big job too q uickly. Now, you c a n 't s e l l industry a plan, or at le a s t it is very d i f f ic u lt to s e ll them a plan such as you have evolved except on accomplishments. You can ta lk to them and even show them the figu res that th e ir own Manufacturer's Association has compiled, - you have a lo t of them, you know, even from the National Manufacturer's Association. I would suggest for a place lik e New York, - we have Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14. OHIO 184 a place that i s something like lew York, maybe they are not so hard-headed, but they are Connecticut Yankees and there Is not much that is so ft about them; I would suggest that you might try something that we are t r y in g . In Hartford we have gotten a small unit of fiv e plants and those plant services are performed on a part-time basis by a. f u l l -time man* in that way we knew that this ful3.-time man is a man that tas had some public health train ing and has had train in g in industrial medicine, and is f a i r l y w ell versed in minor surgery. We have very c a r e fu lly worked out the medical plans for these fiv e in d u strie s. They w ill be reported on very shortly so I don' t want to go Into d e ta ils , but I can t e l l you one thing and th a t is that there has been a cut of seventy-five percent in the amount of money that the insurance companies have had to pay for medical and su rgica l d is a b i li t i e s . ' It demonstrates, too, doctor, what you have said and i t is so important, --the relatio n sh ip between the doctor in irdustry and the doctor outside industry. By showing the de s ir a b ilit y of that and the ca re fu lly controlled experiment we can show how a w ell-con trolled job w ill work. Not;, one of the things that is done in th is l i t t l e experiment of ours is consultation se rv ice . The individuals get R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 185 this service and as a resu lt of that, a ctu a lly hundreds, in the eighteen months this ha s been going on, have been sent back to the fam ily physicians The outside physicians lik e th is service Now, this man does not do any major surgery, - he recommends the surgeons that have been acceptable in these industries previously. He does emergency work and he does re dressings, and the surgeons lik e i t immensely because they have a f a i r l y good diagnosis when the man is sent to the hospital* It is a l l worked out so that the man is sent into one of the three hospitals that we have there in Hartford to be taken care of by a particular person that that factory wants. It is worked out so that tie interne knows when he comes in from that particular factory that he is to be Dr. Smith's p a tie n t. Dr. Smith knows that it is to be his case and he has some diagnosis on i t . He knows that the patient w ill go back to some-1 body who w ill take care of him. There is a health educational program carried on in these particular industries and I am quite sure, when we are prepared to show ?fhat is accomplished in ge ttin g them to cone in , we w ill have to bar the doors. - The thing that is worrying me more than anything else is the lack of trained men that we have to do this job. I know that there has been a great deal more emphasis put on Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14. OHIO 186 preventative medicine in our medical schools in the la s t few years, but the average physician, I fe a r , who would be w illin g to take up this work, the general p ra ctitio n e r, w ill have to be very carefu lly supervised in th is work because he can make or break the j ob. I would lik e t o see a train in g program in stitu te d in many of our u n iv e r s itie s , and I don' t mean t o say, n ecessa rily, among the undergraduates except to the extent that that can be gotten into the curriculum. There should be post-graduate work for these men. We know what they should have, we know what they are going to be up again st, and we know how tremendously valuable a f u l l time-man in part-time work, i f I may use that expression, can be in the industry for medicine, and in the community. I t is one o f those wonderful opportunities in which a doctor is well paid for his work and the industry, ju st as they profit in manufacturing a product, gets a very d e fin ite return on the amount of money they put in to i t . You have a better worker in the community and everything is a question of gain . Just as a l i t t l e idea of what good medical service can do in the ranoval of an occupational disease, - I ju st want to say one word about the work in Danbury, Connecticut. They were forbidden the use of mercury in the making o f hats. I was told by the R etail Merchant' s Association that the fa c t that R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO mercury vas now prohibited was worth several m illio n d o llars a year to Danbury. Consequently, they were better able to under stand their r e sp o n sib ility and it a c tu a lly had been worth more than a m illion d o llars to the r e ta il merchants in Danbury. You can see what ju s t the removal of that particular hazard accom p li she d. DR. W. A. SAWYER: Dr. Sensenich mentioned the p o s s ib ility of cooperation between the doctor in the plant and the private physician. I want him to knar/ of th is experience we had in Rochester. I hate to bring i t up, but this was our actual experience. Through our lo ca l Tuberculosis and Health A ssociation , with th eir assistance and through County assistance we conducted a mass radiography program. I t was evident that there was a desire on the part of the small plants to form some sort o f health service from a community standpoint. A canmittee was appointed, consisting of doctors and in d u s tr ia lis t s , to see whether something could be s e t up. The County Medical Society was asked to p a rtic ip a te . They were askec. i f they couldn' t delegate some young men, as they came back from the service, to in te re st themselves in th is part-tim e e f f o r t . I t was taken to the County Medical Society and was voted down s o lid ly , - "Hands o f f , we want nothing to do with i t . " DR. SEMSSKICH: Yes, things of this nature have been R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 188 coming to my a tte n tio n . DR. SAWYER: Now, Dr. Sensenich, there is one thing that has to emanate from American Medical Association sources i f y/e are ever going to influence some of these County so cie ties in th eir thinking because th is thing has been stopped and we can-1 not go ahead without the doctor's h elp . DR. GOLDwATER: I think i t migjht be in terestin g to add another experience sim ilar to that reported by Dr. Sawyer. I believe i t was Dr. Peacock who reported his d i f f i c u l t y in in terestin g industry in in d u stria l health programs. I happen to know of an instance where a group of manufacturers, representing aboub tw enty-five small plants in the community, thanselves got together and decided they would lik e to have a medical program, an in d u stria l health, program for theii particular group of c lie n t s . They c a lle d upon persons presumably experienced in planning such th in g s. Before this plan had progressed very far a memorandum or resolution came to the head or leading member of th is group. I t was signed by a number of the physicians saying that they were opposed to the development of any plan having to do with in d u strial h ealth . That was followed shortly by a resolution from the Secretary of the County Medical Society and they also were opposed to anything of this sort being R ena Hall E ly CITIZENS BUILDING CLEVELAND 14. OHIO 189 established wit hi n the County. I would like to know whether the gentlemen on the platform would have any suggestions as to how that situ a tio n might be met. DR. PEACOCK: May I say a word on that? That is one problem we don't have in New York, th is program having been worked out in the County Medical So cie ty in New York C it y , by the special Industrial Committee for ju s t that purpose. ' The Comitia Minora unanimously authorized our program. The authorization fran the Comitia Minora was brought up in an open medical meeting and was passed unanimously.. There was not one dissenting vote in the County Medical S o c ie ty . So, you can see we don 't have that problem in New York. DR. SENSENICH: W ell, I don't want to in je c t my answers to a l l these problems. In the f i r s t place, I recognize that in certain areas, and I shouldn't say ju st certain areas as I thin k th at might p ossibly happen in a good many areas i f the problem is not properly approached. Unfortunately, medical men who are pretty busy do not give very much thought to the problems that we have discussed here. I think the proper way t o do th a t, c e rta in ly , would be to approach the medical so ciety and in each medical society there are s u ffic ie n t numbers of substantial individuals who are not going t o be awayed by immediate reactions to something which Rena H a ll Ely CITIZENS BUILDING CLEVELAND 14. OHIO 190 they fe e l is encroaching upon th e ir f i e l d , general practice or the medical f i e l d . I f those men are given an opportunity and an explanation, and a l i t t l e time, I think that in most instances that kind of problem can be met before i t p re cip itates an adverse opinion on the part of the so cie ty , I hope I am not over-stating the situ a tio n , but I can fra n k ly state that I don' t know, a fte r a period of somewhere around eighteen years in a c t iv it y in medical a f f a i r s , - I don't know of a situation in a County Medical Society that could not be solved i f properly approached. I would in s is t that in each community there are a su ffic ie n t number of s u ffic ie n tly broad minded and righ t-th in k in g medical men to influence the situation i f it is brought up to them and they are given s u ffic ie n t time to consider. Perhaps Dr. McVay can say something about th a t. In his work he contacts County Medical S o cie tie s a l l the tim e. DR. McVAY; I think often tim es, in the individual communities considering these problems, in which they have not been able to work them out, there has not been close enough cooperation between, for example, in d u strial situ a tio n s and the medical s o c ie ty . I think i t is a two-way problem. I don't think you can say i t is the blane o f the medical so c ie ty , e n tir e ly . I R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 191 think in many instances, where you analyze the situ atio n care f u l l y , you w ill find that both of them are somewhat to blame. They tave a meeting devoted to in d u stria l health and you w ill find a very small sprinkling of the men in that community at that meeting. I think a great deal could be done by both the Council on Medical Service and the Council on In d u strial Health in attempting to develop through the state committees and down to the local county le v e ls a closer cooperation between those two groups. I believe th at is the way that problem w ill have to be approached. A VOICE: I would lik e to know i f Dr. Sensenich, cr Dr. McVay, or other doctors here, from th e ir experience, are they prepared to submit something in the character of an accep table pattern, something that is not t ig h t ly bound but something that would be acceptable, would be a reasonable basis for d is cussion, immediately, when i t is submitted to the medical sociebies. Maybe Dr. Gray can t e l l us something fran the success fu l experience they are having over in Connecticut. DR. McVAY: You mean for the Counties? A VOICE: Yes, to be submitted by these various groups. DR. PEACOCK: We had our thing well prepared. Vile pub in three or four years work on i t before we brought it to the R ena H a ll E ly CITIZENS BUILDING c CLEVELAND 14. OHIO Society as a whole. There was not a thing there to be objected to . ^ DR. GRAY: I f they have an Industrial Medical Committeje of their State Medical So cie ty , then the thing I should have done was go to than and get than to s e l l the idea. I know that the idea we have i s n 't ju st the idea we had when we went there It was studied over and then worked out so that when i t was put in i t was accepted. But, it was f i r s t brought up to the in d u strial Medical Committee of the State Medical So cie ty . We had some big fellow s who knew the b ig fellow s in the Societies. I wonder i f this doctor went ahead and figured out what he thought was a g ood plan and then put i t into view. I expect he got an explosion* DR. PRICE: I just want to add to the sour note sounded. I think it is very tim ely because of some of the re marks made this morning. I think the experience of Dr. Sawyer and the experience o f Dr. Goldwater have been repeated through out the country. I think i f we would follow the Tuberculosis A sso ciatio n 's experiences we woul a f ind t hat there i s n 't a section of the country in which th is experience hasn't been gone through by s one community. Therefore, it seems to me that Dr. McVay prefers segmental medicine. The segments treated in th is manner are R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 193 going to r e v o lt. I think th at i f these lo ft y standards have been placed by some of the leaders in medicine, then they should be gotten rid of and the medical associations in the small communities, w e ll, the entire country would be better o f f . I am Vice Chairman of the Community Council with Dr. peacock and I think we are ge ttin g somewhere by getting every segment represented. DR. A. M. PTHjEO; I would lik e to ask Dr. Sawyer and Dr. Goldwater why th e ir plans were re je cte d . What were the reasons given? DR. GOLDWATSR: I didn' t say in my description that th is plan had been presented to the County Society in the very, very early stages and it had been drawn up to f i t in with the acceptable practices in the f i e l d of in d u strial medicine approvec by the American Medical Association and by the American College of Surgeons, and by other responsible groups. The objectors stated no reason for the objection s. I have my own opinion as what they were. DR. PTJLEO: What are those opinions? DR. GOLDWATER: They were worried they might lose some business. DR. SAWYER: I have no s p e c ific knowledge of the objections e ith e r, but on th is committee was the Vice President R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 194 of the County Medical Society (he is new president) and he was for this plan. He took i t to the Comitia Minora and i t was voted down. They gave no reasons, but private practitio n ers were not liked. DR. GRAY: I think i t is e n tire ly a lack of under standing. DR. SENSENICH: Maybe the Comitia Minora needs the educat iqg . DR. E . L. HENDERSON: I only want to add a lo ca l note to th is statement. Pour years ago we proposed the plant program in ffestChester Gounty, or in certain d e fin ite areas involving, at that tim e, tw enty-five practicin g physicians. Since that time we have sixty-th ree men p racticin g in that area. In proposing th is plan I went d ir e c tly to the Comitia Minora of the West chester County Medical Society and tossed i t on the t a b le . I said , "Here i s Waat we propose, what do you fellow s think about i t ? " I told them to think i t over, kick i t around a b i t . I sa le , "We won' t do a darn thing u n til you give us the l i g h t ." We had several sessions and nothing came of i t . I t was passed and i t has been operating fo r four years. We put in one additional statement and th at was that we v/ould not change it without f i r s t asking Comitia Minora* s approval. Two things have come up in the interim . The f i r s t Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14, OHIO 195 was the use of the influenza vaccine which they approved. The other was the use of p e n ic illin areosis in minor s in u s itis and b ro n ch itis, - this they disapproved. Me gave the vaccine but we haven't given any p e n ic illin . We are getting along a l l r ig h t, but I think the answer is in two d ir e c tic n s . Number one, - you have to go to the doctors e a rly . I f the doctors fin d out something is in the wind and they haven't been consulted, n atu rally they w ill be against i t . Number two, - you want t o have enough members of the Comitis Minora that are frien d s of yours. CHAIRMAN LANZA: I think you have something there. There are lo ts of ins and outs to th is whole business and I am sure some of you have other angles that you would like to bring up. DR. L . H. GRIGGS (Syracuse, N. Y .) : I would lik e to ask the panel their opinion of the evaluation of industrial health teaching days. They could be scattered throrrghout the larger centers of the state with the approval of the lo ca l 'County Medical So cie ty . DR. WEISKOTTEN: Dr. Griggs, I believe that is a question which you people should ans?ier. Attempts have been made by County Medical S o cie tie s and by certain medical schools to o ffe r refresher and graduate courses, and a series of post R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 196 graduate courses in the f i e l d of in d u strial h ealth . I would lik e to ask you, - how much are we accomplishing? DR. PEACOCK: You ought to get Dr. Lanza to answer th a t. He is the man on that su b je ct. CHAIRMAN LANZA: I can say t h i s , and I am very glad to have the opportunity of making th is point; As we have heard in the la s t few days, and th is morning, and at the meetings we have in the evenings, we go around to County Medical S o c ie tie s , et cetera. There are quite a number of plans being tried out. Some of them are in operation, some of them are sponsored by lo c a l medical s o c ie tie s , some of them are sponsored by groups c f doctors, some of than are o ff-sh o o ts of one or another form of group insurance. You are going to see many more o f them and the trend i s , as the second speaker said th is morning, towards that sort of medicine, namely, bringing a large proportion of the population under some form o f pre-paid medical service plan. However, one of our main r e s p o n s ib ilitie s , as fa r as the Council on In dustrial Health is concerned, and one in which several members of the Council are a c tiv e , is to see that there is provision made fo r the proper tra in in g of those who are con cerned in carrying out an in dustrial medical program or in dustrial medical service. R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 197 Two s k ills are involved, - the doctor and the engineer. The plans are being formulated and are a c tu a lly under way in various centers now to develop a graduate oasis traxnihg fo r doctors and engineers in the f i e l d of in d u strial hygiene and in in d u strial medical service Does that answer your question? I might say that there have been in the p a st, and are s t i l l being carrbd on a number of refresher courses at d ifferen t medical schools. I t is short, intensive train in g on various points of in d u strial medicine, but the o v e r-a ll tra in in g of grad uate doctors and graduate engineers is ju st now beginning to blossom out. . DR. GRIGGS: That p a rtly answers my question. I am Chairman of the Committee of Industrial Health for tte State of Hew York and, of course, in upstate New Yoik we are not accepted as a part of Hew York C ity . In the past couple of years, - and I assure you that I didn' t expect to get up here wit h my friend Dr. Weiskotten, we haven' t accomplished very much in getting out into the sm aller communities. I want to repeat that I am Chairman of the Committee on Industrial Health fo r the State of New York and that we are not r e a lly a part of Hew York C it y . We are in the backwoods. But , the point is that we haven' t accomplished very much, we have trie d th is and that and the plan that I feel might R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 198 be the most successful is to organize sort of a teaching set up and have Industrial Health Days scattered throughout the s ta ti in I fe e l that the man for us to reach, prim arily, is/our own backyard. Insurance carriers t e l l me that th eir greatest problem is to get proper medical care fo r the in d u stria l socalled compensation cases. I had the idea that we could set up some so rt cf a teaching s t a f f , derm atologists, minor surgeons, et cetera, who could organize these afternoons and go out through out the s t a t e . That was my question. DR. SENSENICH: I t is some so rt of machinery as that which I suggested in mentioning the Council on industrial Health Obviously that should be done w ithin the s ta te . Have you attempted anything of tha t kind? DR. GREGS: lie did th a t, but that was before my tine . About three or four years ago we had one meeting in Syracuse and we invited the nurses and manufacturer's repre sentatives and we had quite a successful day. But, I fe e l that the whole crux of the situ atio n is to reach the man who does it or has the contact with the industrial worker. That i s the p oin t, to bring him Into that meeting. CHAIRMAN LANZA: Thank you, doctor. I f there are no more questions the meeting is adjourned. ...T h e meeting re cessed at 12:30 o 'c lo c k , p .m ... RECESSED R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 199 TUESDAY AFTERNOON SESSION January 6, 1948 Th.6 Conference on R h a b ilit t!on convened, a t 2;00 o 'clo ck , p .m ., in the Cleveland Auditorium, Club Room B, Cleveland, Ohio. Dr. Frank H. Krusen presiding. CHAIRMAN KRUSEN: The meeting w ill please come to order I t tea been said by the la te great Dr. Francis Peabody, of Boston, that "Death is not the worst thing in the wo:: Id ard to help a mai to a teppy useful career may be more of a service than the saving of a l i f e . " The rapidly developing f ie ld of physical medicine re h a b ilita tio n which leads physicians away from th e ir pre-occu pation with simply saving liv e s and guides them into new methods of providing happy liv e s is worthy of serious consideration. The amazingly fin e programs in re h a b ilita tio n in the Army, Navy, Veteran' s Adm inistration, and p a rticu la rly in the Army Air Forces during World War I I has stimulated the in terest of in d u stria l physicians and c iv ilia n p ractition ers throughout the United S ta te s . _ I desire to pay p articu lar tribute to General David Grant, the air surgeon, fo r his vision in recognizing the impor tance of re h a b ilita tio n , his wisdom in placing it under the R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 200 leadership o f Colonel Howard Rusk, and for his unswerving support of the A ir Forces R ehabilitation program which has revolution ized our concepts cf convalescent care and the management of handicapped persons. We are very fortunate in having with us today not only Dr. Rusk, whose amazing achievements in re h a b ilita tio n have brought new hope to handicapped c iv ilia n s , but also two of his former a sso c ia te s, Dr. Donald Covalt and Dr. A. Ray Dawson. Then, to complete our galaxy of sta rs we have Dr. Thomas B. McKneely, Chief Medical O ffic e r of the O ffic e of Vocational Rehabilitation. Physical medicine includes the employment of the physical agents for physical and occupational therapy and physical r e h a b ilita tio n . Occupational therapy has been defined as "m edically prescribed a c t iv it y (other than gymnastic) with a remedial o b je c tiv e ." Physical reconditioning is the procedure followed in the prevention cf physiologic retrogression during convalescence, and i t is directed toward the restoration of f u l l strength and stamina to convalescent p a tie n ts. R ehabilitation includes the employment of a l l forms of physical medicine in conjunction with psychosocial adjustment and vocational retra in in g in an attempt to achieve the maximal function and adjustment of the patient and to prepare him R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 201 p h y sica lly , m entally, s o c ia lly and v o ca tio n a lly for the fu lle s t possible l i f e compatible with his a b i l i t i e s and d is a b ilit ie s . I t is g r a tify in g to note that medical educators f i nail are beginning to give serious attention to the development of teaching and research in the fie ld s of physical reh ab ilitatio n and physical me-di.cine. Dr. D. B a ily C a lv in , dean of the U n iversity of Texas School of Medicine wrote re ce n tly : "In the f i e l d of physics as related to physical medicine and physio logical chemistry, great advances nts have been made. I f health is to be construed as normal equilibrium , with proper function in a l l organs doing \ their job in proper manner, then disease must be considered as a departure from dynamic equilibrium . The need, th e re fo re , is fo r the physician to serve as a health engineer, an analyst whose function is to re-ad ju st the e q u ilib ria of the body and bring them back into normal homeostatic b alan ce." This is exactly the approach cf the physician sp e cia lizin g in physical medicine who devotes great attention to dynamic physical recon d itio n in g , to the employment of physical procedures for analysis of disorders of function and to the a p p lica tio n of physical agents for restoration cr maintenance of a normal or nearly normal physiologic s ta te . In an a r tic le e n title d "Transition in Medical R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO Education," Dr. Alan Gregg, Director of the Medical Sciences D ivision Of the R o c k e fe lle r Foundation, observed that "D uring the past sev e n ty -fiv e or e igh ty years, one of the most s i g n i f i cant e ffo r ts of medicine has directed i t s e l f to finding the cause of d ise a s e ." He pointed out that t h is "preoccupation with the cause of disease has g re a tly influenced medical education." He added that "Etiology became, as i t were, the hus band of diagnosis and the father of treatm ent." This led Gregg to the conclusion t * t "preoccupation with the causation or etio lo gy of disease a l l too often e clip ses the lig h t that might cone from a study of the dynamics o f the disease process." He added, "We take such a primary concern for the cauie as p e rfe ctly natural. I wonder i f we don't exclude thereby some| other very Important aspects of disease? Witness the singularlyj freshness of Howard Rusk's ideas upon the p o s s ib ilit ie s of in te llig e n t convalescent ears. I f we had cared as much fo r therapy as for e tio lo g y , we should have l i t t l e to learn f r m Rusk, Instead of much.." To the physician who is interested in physical | sb d i d ne and r e h a b i l i t a t i o n , i t is pleasing to observe that medical educators having the broad vision of Calvin and Gregg foresee advances and tran sitio n s in medical educatibn which indicate a diversion o f i n t e r e s t of medical educators from theirl R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO UO preoccupation with e tio lo gy and an advancement into a stage In which therapy begins to assume i t s r ig h tfu l place m medical education. I t is reassuring, moreover, to pejceive that proper attention to the treatment of the patient as j person and as a whole is beginning to receive serious consideration. Certaim ly, the importance of the maintenance of dy namic equilibrium w ill become more and more apparent as th is new trend develops, and ju s t as ce rta in ly , physical medicine and reh ab ilitatio n w ill continue to forge to the jfront as this trendj Ii becomes more evident. J I t i s , th erefo re, sin gu larly f i t t i n g that this group of experts should discuss th is very subject v|ith you. We have been assigned certain subjects for discussiorj and we have agreedj that each man sh a ll ta lk for about ten minutes concerning his own subject and then we w ill have some questions and general discussion. I I am goirg to ask Dr. Donald CovajLt, now Associate Professor of Rehabilitation and Physical Medicine at Hew York l m University College of Medicine, formerly Assp.stant/Physical Medicine R ehabilitation in the Veteran' s Adm inistration, and now the C lin ic a l Director of the new New Yobk U niversity Re h a b ilita tio n C lin ic in New York C ity to operj the next phase of th is conference w ith a discussion o f the ''Demands of D aily R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 1 J** CITIZENS BUILDING CLEVELAND 14. OHIO 205 The f i r s t time they tr y It i t raay take them two or three hours. In our experience at Bellevue, we have ju st com pleted a service of ore hundred hemiplegias. Out of these ninety were able to become ambulatory, around f i f t y percent had to have braces, th ir ty of these were able to return to work. This is only one aspect o f r e h a b ilita tio n . I say it Is only one a sp e ct, but i t is a most impor tant one and one in which the physical th e ra p ist, the occupt!onfcL th e ra p ist, and the physical educator might well take a p art. They would a l l have to take a part to have the program succeed. One other example that I wish to c ite to you is that of a hundred and twenty neurological cases at our Minneapolis hospital of the Veteran's Adm inistration. Most'of these individuals were World War I veterans and many o f them had been in for as long as ten years. Some o f them had been f l a t on ttieir back for over two years. Some of them had to be carried cn stretchers to th e physiotherapy department for the fir s t tine . The whole endeavor, which took approximately nine months, was under the direction of Dr. Baker, who was with us tody; the whole team of the physical therapy department, and a l l of the re h a b ilita tio n workers concentrated on these one hundred and twenty. You w ill ask, "Was th is worth while?" I want to R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 206 shew you what can he dene with hard work and a l i t t l e imagination. At the end of nine months in re h a h ilita tio n , twenty- fiv e of these World War I veterans had l e f t the hospital and returned to work, th ir t y others discharged and capable of s e l f support or care Part of them were able to do part--time work, and of those remaining in the hospital th ir ty were ambulatory, tw enty-five more were capable of s e lf care, and a ll but ten had progressed in th e ir r e h a b ilita tio n , - only ten were con sidered hopeless. Let us think of this outside of humanities. These individuals had a l i f e expectancy of at least six years. They had gore into the hospital to remain there far the next six years of their l i f e ' s expectancy at a twelve dollar a day patient co st. That is average throughout the Veteran's Administration. I t means a saving to the government and t o you as tax payers of over a m illion d o lla rs, - just these f i f t y - f i v e patients leaving the h o s p ita l. One other point in the a c t iv it ie s of d a ily liv in g th a ; is most important and a f i e l d that needs to be investigated and research work done in is in our tuberculosis p a tie n ts. I think the average for the entire country is something like fa r.ty -fiv e percent of the tuberculosis patients leave AWOL. or against medical a d vice. In the Veteran's Administration i t is R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 207 fo r ty percent. Where an active r e h a b i l i t a t i o n program is m progress, aid this must be under medical d ire ctio n , one planned according to Wia t that p atien t can do in terms of his chest disease, - give these men a plan that gives them hope and they w ill work and they w ill stay in the h o sp ita l. In time very f i r s t re h a b ilita tio n program on these tuberculosis patients the AWOL' s and against medical advice discharges has g one dow from fo rty percent to eleven percent. t a s t l y , in trying to work a program out i or the handicapped persons we, at Bellevue, have three principles that we start out with before we can have any program. F i r s t , range of motion of the handicapped person. Second, muscle t e s t s , and th ir d , those a c t iv it ie s of d a ily liv in g that they can now do. With those three fa c to r s you can s i t down with a patient and work out his program of physical therapy, occupational therapy, and start in to make this man ambulatory, able to walk, able to go up and down curbs, able to go across s tr e e ts , and then I t is possible to work out a vocation that i t is possible for this man to accomplish. I thank you. (Applause) CHAIRMAN KHUSBN: Thank you, Dr. C c v a lt. The next discussion from a member of our panel of experts on rehabilitation w ill be by Dr. A. Ray Dawson, Assistant Medical Director in charge of Physical Medicine Rehabilitation R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 208 in the Veteran's Administration. Dr. Dawscn w ill speak to us on a subject which is cf particular interest to th is group, "Correlating Rehabilitation and Industrial P r a c tic e ." DR. A. RAY DAWSON: In order th a t we might immediately arrive at an area of common understanding I would lik e to presen the views of the Council on Industrial Health. The follow ing was taken from the March, 1947, issue of Occupational Medicine and is by Dr. Seeger. I quote: "The Council is of the opinion that reh ab ilitatio n is preeminently a medical problem and lik e ly to continue as such for. many years to come. Physical restoration is the fun damental principle in the re h a b ilita tio n of the crippled and dis abled, and these services can be adequately carried out only under medical direction and supervision. Other aspects of the problem, notably vocational train ing and placement, are also important btfc must rest fundamentally on the best possible medical reduction of the d is a b i li t y . I t is believed that the members of the medical profession are not generally conver sant with the size aad urgency of the problem of re h a b ilita tio n , and the Council expects, th e re fo re , to give more and more attention to reviewing t h is whole fie ld and the place of medicin in i t ; to educate the members of the profession about current R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 209 trends and methods; to maintain a clearing house of information; to fo ste r e ffe ctiv e states re la tio n s; to maintain proper contact with o f f i c i a l and voluntary agencies, and to work c lo se ly in t h i s 'f i e Id with other o f f i c i a l groups in the American Medical A ssociation , more p a rticu la rly the Council on Physical Medicine The views of the Council have been very stim ulating to us who devote our f u l l time to these endeavors. The dissemination of information r e la tiv e to medical, re h a b ilita tio n is most urgently needed and in th is conne ction I' d lik e to praise the Editorial Board of Occupational Medicine fo r th e ir se le c tion of such fane professional a r tic le s on this su bject. Medical r e h a b ilita tio n has been termed the th ird phase of medical care. This is most ce rta in ly true and it in cludes the restoration of em ployability. With th is as our goal in treating the sick or disabled it is evident that the in d u stria l physician i s intim ately involved in th is phase of medical care, and he w ill go as far along the road of re h a b ilita tin g the disabled individual as is p ra ctica l fo r his s p e c ific industry. Therefore, in discussing this subject I think that i t would be wise for us to divide the areas o f in dustrial practice in to , one: Industrial practice in small o n e-activity p la n ts. Two: Industrial practice in large m u lti-a c tiv ity p lan ts. Three: Industrial practice in large insurance carrier R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 210 type of p la n t. No discussion of Correlation of Rehabilitauion and In dustrial Practice would be complete without a discussion of the attitude of Industry. In this connection I ' d like to present for your ccnsideration that it has been said that in dustry has passed through three stages of development. The f i r s t is processing , the second is mass production, and the third is mass s e llin g , and i t is now in the fourth stage, that of management and public r e la tio n s . As medical re h a b ilita tio n is an accepted fa c t of good management and is an element of superb public re la tio n s, it would seem that industry is await ing the guidance of the medical profession in establishing large? a c tiv itie s in th is f i e l d . The grand report of England' s in d u strial progress during the la st h a lf of 1947 is a il the more impressive when we take into consideration the large problem of medical rehab ilit a t io n and in dustrial placement which tor industries faced . I was told la s t summer by physicians of the Bureau of Pensions of this problem, hew i t was being met and of the fir e cooperation of management and labor. England needs more man power and every individual is apparently being reh ab ilitated t o Indus t r i a l pla ceme n t. F in a lly , i t is hoped that we never again face the R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 211 c r is is of a war that di d so much to stim ulate the employment of the handicapped, but ce rta in ly the experience of the war did demonstrate that medical re h a b ilita tio n is a p ra ctica l and profitab le procedure . This morning Mr. Hansen, Vice President of Liberty Mutual, gave me the la s t s t a t is t ic s on th e ir re h a b ilita tio n in f armati on. First le t me t e l l you that th is covers seven hundred and ninety-seven in d u stria l accident cases that were treated by the Liberty Mutual in Boston. Now, six hundred and seventy-three or eighty-four percent of the cases improved. The number of cases not improved by treatment were a hundred and tw enty-four, or sixteen percent. It would seem that without the pressure of the war we could reh ab ilitate for the sake of humanity and for the enjoyment of the individual as w ell as for greater production and p r o f i t . I thank you . (Applause) CHAIRMAN KBUSEH: Thank you, D r. Dawson. Our next expert is Dr. Thomas B. McKneely, Senior Surgeon, United States PubLic Health Service; Chief Medical O ffic e r , O ffice of Vocational R eh a b ilita tio n , who w ill discuss the relatio n sh ip of the federal and sta te program to the medical profession with particular emphasis on i t s re la tio n to physical medi cine R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 212 DR. THOMAS B. McKMEELY: I have as a subject one that is of p articu la r in te re st to me. I am not an expert in physical medicine. I have to sit in Washington and see that things go right in so fa r as it is possible in the programs that the states are actually operating in the f i e ld of vocational rehabilitation. I would lik e to point out, f i r s t , that under th is program of reh ab ilitatio n we have a lim itin g phrase or-an ad je ctiv e modifying r e h a b ilita tio n , namely, vocational r e h a b ilita tio n . As we look at the program and read the d e fin itio n of reh ab ilita tio n services we w ill appreciate how broad a program th is can be. Vocational Rehabilitataon Services may be defined, and I quote: "Any services necessary to render a disabled individual f i t to engage in remunerative employment." The ob je ctiv e of t h is program, then, is placement o f an individual who has a d is a b ility in employment. Row, physical medicine has as i t s purpose the physic a reh ab ilitatio n or record it ion ing of a disabled person, or yen might say the restoration o f function through the application of physical means. That, obviously, is as broad a d e fin itio n of the vocational services as can be given. This phase of the practice of medicine is of p articu lar Rena H a ll Ely CITIZENS BUlt-DiNG CLEVELAND 14. OHIO 213 laberest to those o f us who are engaged in this program of vocational rehab i l l ta tien because it seen to us to o ffe r hope to many of our s everly disabled c iv ilia n s . Physical medicine and vocational re h a b ilita tio n certain ly have a common in terest in the restoration cf fu n ctio n s, however, vocational re h a b il ita tio n as we operate i t under the Public Law 113 has many ran i f i cations th at are beyond the simple restoration o f function The Federal-State program of Vocational R h a b ilit tio is a jo in t endeavor, having as i t s o b je ctiv e , the placing of persons with physical or mental vocational handicaps in remun erative employment. To accomplish th is purpose, persons of em ployable age now unemployable because of physical or mental con ditions must be made employable through the provision of necessa vocational rehabilitation services. Vocational rehabilitation serv ice s, I repeat, may be defined as "Any services necessary to render a disabled individual f i t to engage in remunerative occupation." These services may be enumerated as follo w s: 1. Medical diagn osis, including sp e c ia lis t examina tion and h o sp ita liza tio n needed to arrive at a medical appraisal of the person's physical and mental condition. 2. Medical and surgical' treatment, including h o sp ita liz a tio n , drugs, nursing se rv ice s, con valescent home care. 3. Provision of prosthetic appliances. R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 214 4. Counseling and guidance, which, continues through out the course of vocational re h a b ilita tio n and gives direction to the process. It is through the counseling and guidance technique, coupled with psychological measurements and the medical diagnosis that a vocational diagnosis is made. On the basis o f the vocational diagnosis, a job objective is jo in tly determined by the c lie n t anc. the counselor. 5. Training for the selected job, which may include train in g o f varying direction and ccm plexity, rangi rg from simple touch-up on s k ills by on-thejob train in g to a college course, 6. Placement in the proper job, which involves physical demands analysis and physical capacities app raisal. The mental and emotional components of the c l i e n t ' s make-up must not be overlooked in placement. 7. Job adjustment through follow-up v is it s to the c lie n t and employer a fte r placement. This lis t in g o f services is not intended to be com plete and in d e t a il. Its purpose is to give a broad conception of the many ram ifications involved in the vocational rehabil itatio n of an In d ivid u a l. An attempt is made to view every dierjt in his e n tir e ty , evaluating his every asset as well as his l i a b i l i t i e s . Generally, wre w ill find that the c l i e n t ' s assets can be made to outweigh his l i a b i l i t i e s or handicaps. There are a great many points of sim ila r ity between the vocational rehab ilitation program of the State agency and a well-managed personnel department in industry. In both there is medical a ssista n ce, counseling, and guidance. Both want a good R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 215 medical examinat ion t o determine physical lim itatio n s and the presence of hidden disabling con ditions; both want psychometric te sts to uncover outstanding in te re sts and a b i l i t i e s ; both want to place an individual in a job for which he is suited and on which he can produce Some industries w ill provide training courses to f i t an individual for a job. Industry, however, i s dealing largely with able-bodied persons, whereas vocational re h a b ilita tio n agencies are devoting th e ir energies only to persons who have been unable to secure employment because of mental or physical conditions which have prevented them from obtaining employment. In considering the place of physical medicine in vocational r e h a b ilita tio n , it would be well to summarize some of the ch a ra cte ristics of c lie n ts served by State vocational reh ab ilitatio n agencies, including the nature of their d is a b i l i t i e s . During the f i s c a l year ending June 30, 1947, there were 43,874 disabled persons reh a b ilita ted into employment, seventy-two percent of vhom were males and about eighty--six percent of those were w hite. About h a lf were between fift e e n and th ir t y years of age. An analysis of the h isto ry of onset of d is a b ilit ie s in this group indicates th a t th irty-o n e percent of the d is abling conditions originated in employment or other accidents, R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 216 fifty -o n e percent originated in d ise a se , fifte e n percent were congen ital, and about three percent resulted from either m ilita ry or c iv ilia n war s e r v ic e . Now, in about three-fourths of the persons re h a b ilita te d the d is a b ilit y originated before the age of t h ir t y , thus the bulk of persons reh ab ilitated are young and have many useful years of liv in g ahead of them. The nature of disabling conditions is of in te r e s t. Disabled persons with various types of orthopedic involvements, amputations, and corgenital absence of members comprise about h a lf o f the to ta l number re h a b ilita te d . Now, we have broken this down into rather broad catego ries. The orthopedic d is a b ilit ie s , other than from p o lio m yelitis and cerebral palsy are about twelve thousand; the residuals of poliom yelitis about tw enty-six hundred; from cerebral p alsy, a small number, fiv e hundred; amputations and congenital absence of members, about s ix thousand. Now, there are a number of other categories which might be lis t e d but I believe these are the ones that are of particular in te re st in th is discussion since these are u su ally more amenable to physical medicine. Not every client with d is a b ilit ie s such as lis te d above is e lig ib le fo r medical and/or su rgica l treatment. Those responsible for the operation of the Federal-State program R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 217 of v o catio n a l're h a b ilita tio n want reasonable assurance that tne treatment recommended w ill either remove or su b sta n tia lly reduce the handicapping condition w ithin a reasonable period of time. Medical or physical restoration se rv ice s, as well as other ser v ic e s , are looked upon as an investment in the c l i e n t ' s future and there is a desire for a return on the investment. We are a l l aware that the prqgran is tax supported, and that unnecessary or unwise expenditures are to be avoided. Pur the r, the condition must be s t a t i c , not acute, or so rapidly progressive as to endanger l i f e or make the formulation of a rehab ilitation plan u n fe a sib le . For example, a Sta te agency would not accept fo r phyr ic a l restoration services a clie n t with a recent fracture or a recent burn but i f d is a b ilit y remains a fte r a certain period has passed physical restoration services might be provided. It is of in te re st to note that medical services may only be provided i f the person is unable to pay in whole or part for the necessary services frcm his .own resources. I i he is unable to pay for any of the needed se rv ice s, physical restor ation services are provided without cost to the individ ual. Otherwise, he contributes to the cost of treatment and other i medical services in accordance with a b ilit y to pay. The above describes in a general manner the sp ecific R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 218 provisions contained in Public Law 113, of the 78th Congress, which defines the area within which the State agency m y be re imbursed from Federal funds fo r medical services provided client i The law f u r t h e r 'provides th at States w ill not be reimbursed for periods o f hospitalisation in excess of ninety days for any one condition. Regulations under the law sp ecify that fo r a clie n t to be e lig ib le for physical restoration services, the condition must constitute a substantial employment handicap. These ser v ic e s , as I implied, are not provided to make a clien t happy, but rather must be a necessary part of the vocational rehab ilita tio n plan. Those services I mentioned e a r lie r as vocational re h a b ilita tio n services are provided to disabled people by eighty-seven agencies in a l l of the fo r ty -e ig h t states and the D is tr ic t o f Columbia, Puerto R ico, Alaska, and Hawaii. In th ir t y -s ix of the se states separate agencies provide vocational reh ab ilitatio n services for the b lin d . I have ju st come frcm a meeting of a day and a half in which themedical consultants of the eleven states compris ing the region out of the Chicago o ffic e have been meeting to discuss problems concerned with the operation of the medical aspects of th is program. I mention th is sin gly to point out that in the state agencies there i s medical s u p e r v i s i o n a n d R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 219 medical guidance to the program. Medical direction is given by part-tim e or f u l l time medical consultants on the *ta te s t a f f , supplemented in man; states by d is t r ic t medical consultants. Each State agency has a Professional Advisoiy Committee to a s s is t the medical consultant and State director in formulation of medical p o lic ie s , v/ith respect to treatment, each State agency u t iliz e s the services of physicians having sp e c ia lty q u a lifica tio n s in the applicable fie ld . States tr y to have their c lie n ts treated by those physicians c e r tifie d by the American S p e c ia lis t Board, those e lig ib le for c e r t ific a t io n , or those otherwise q u a lifie d as s p e c ia lis ts . Physicians receive fees for t h e ir services in accordance with a schedule of fees for sp ecified services. We fe e l that the service of the best a v a ila b le s p e cia lis t is the most economical. Many of the persons applying fo r vocational rehabil it at icn services have disabling conditions that have existed untreated fco? years; many have conditions whiclh represent fa ilu r e s of e a rlie r inadequate treatment; many come tc us a fte r being offered no hope by the physicians in their home community. Each applicant, i f otherwise e lig ib le , must be evaluated to determine whether physical restoration services R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 220 can a s s is t in vocational r e h a b ilita tio n . Wot a l l can be helped by medical treatment . It is d i f f i c u l t to determine the pro portion which would be acceptable, within the lim its of the A ct, to treatment. The percentage would vary considerably between d iffe re n t parts of the country, depending in part on the a v a il a b ilit y o f good public medical care. In some southern states the percentage may be in the neighborhood o f fo r ty or f i f t y percent. In others i t may be l e s s . As we have gained experience in the provision of the broader services authorized by Public Haw 113 in 1943, i t has become apparent that in many lo c a lit ie s availab le services s t i l l are not adequate to re h a b ilita te c lie n ts with certain types of d i s a b i li t i e s . We rather g lib ly refer to the severely disabled group . I t is d i f f i c u l t to define the term "seveieLy disab led ." I hesitate to define i t in relation to p articu lar categories of d is a b ilit y . There is a tendency to think of the "severely d is abled" c lie n t as one who cannot be reh ab ilitated through the u tiliz a tio n of services usually available in a community, or one that requires the ap p lica tio n of special services, - medical cr otherwise. At any ra te , the d e fin itio n of the term Is not exact, but is r e la tiv e to many fa c to r s , including job opportunity There is an increasing in terest bn the part of State vocational re h a b ilita tio n agencies, among others, in this so-callLed R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 221 severely disabled group. There is a growing fe e lin g that many of the special services needed by th is group can only be provided in a rehabilitation center, which is another term that needs son d e fin itio n . The OVR conceives a re h a b ilita tio n center to be the integrated provision of a ll necessary vocational rehabilitation services, whether these services be concentrated la r g e ly under one roof or be located in several places in a community. I r respective o f whether services can be concentrated or dispersed in a community, there is need for the in clu sio n of adequate pro visions for physical medicine in a l l it s m od alities. The V irgin ia State Vocational R ehab ilitatio n Agency opened a vocational r e h a b ilita tio n center la st month in a part of the buildings of the former Woodrow Wilson General Hospital near Staunton, V ir g in ia . One of the f i r s t positions on the center s t a f f to be f i l l e d was a s p e c ia lis t in physical medicine, and almost the f i r s t service placed in operation was the physical medicine department. Only a casual glance at the f i r s t c lie n t group accepted was needed to see that the m ajority were using crutches, braces, or were in wheelchairs, - a l l probably scheduled for physical medicine measures. Among the disabling conditions that we fe e l can only be served in a center such as the one in V irgin ia are recent amputees or le ss recent amputees \tio have not learned to use an R en a H all. E ly CITIZENS BUILDING CLEVELAND 14. OHIO 222 a r t i f i c i a l limb; paraplegics; the more deforming and re sista n t residuals of p o lio m y e litis; p e rip h e ra l nerve in ju r ie s ; and other conditions re suit ir^ in substantial lim ita tio n of motion in sig n ific a n t p a rts. This li s t i n g is not intended to be in e lu siv e , even of those conditions which may respond to physical medicine. During die. past year, with the assistance of our consultant on orthopedics and prosthetic appliances, the O ffice of Vocational Rehabilitation has been attempting to increase the interest of the medical profession in the problems of the c i v i l i a n amputee. Out standi rg among these problems is the proper f it t in g of the prosthesis and adequate train in g in it s use. Of course, consideration of the to ta l problem goes further back than this would indicate* I t goes back to the surgeon' s decision to amputate and his selectio n of the level cf the amputation. However, in the State-Federal program, most of the amputations have already been performed when the c lie n t applies for se rv ice , which accounts fo r our p articu lar emphasis on proper f i t t i n g and adequate tr a in in g . In c iv ilia n l i f e , a ll too frequently the orthopedic surgeon is not s u ffic ie n tly interested in proper f i t and tr a in in g. Muct of the re sp o n sib ility for these matters reverts to the salesman of a limb company simply through d e fa u lt. The sa les man frequently wears a limb himself and attonpts to teach on the R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 223 basis of his own experience. He undoubtedly has bad some success, because many c iv ilia n s wearing limbs s a t is fa c t o r ily were so instructed. However, i t is known that there have been many fa ilu r e s , too, because State vocational re h a b ilita tio n agencies have surveyed the group provided with limbs and found that an appreciable percentage have not used the limb su cc e s sfu lly , or have la id i t away e n tir e ly . Exactly which professional sp e cia lty group should have resp o n sib ility fo r the f i t t i n g or the train in g is a matter for others to d e cid e . However, State vocational re h a b ilita tio n agencies do feel that there is a need fo r professional super vision in this area. E a r lie r in my discussion I indicated the number of clie n ts among those reh ab ilitated in 1947 who had orthopedic conditions. This figure does not include those with orthopedic conditions who were not r e h a b ilita te d . There are a number of possible factors contributing to fa ilu re in the un-rehabilitated c lie n t . Undoubtedly, in a number of in stan ces, fa ilu re may have been due to the u n a v a ila b ility of appropriate therapy. Some times a lack of awareness on the part of a lo ca l physician that something can be done elsewhere prevents the c lie n t from ever reaching that source o f se rv ice . Prom these observations I believe you w ill gather R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 224 that State vocational r e h a h ilita tio n agancies are v i t a l l y in te r ested in the p o te n tia litie s of physical medicine and have among th eir c lie n ts many who need the services of th is sp e cia lty group, State vocational reh ab ilitatio n agencies also wish to work c lo se ly with physicians and to encourage early referral of those patients whose conditions may in terfere with successful employment. The value of early referra l is sim ilar to value of early diagnosis and treatment in medicine. (Applause) CHAIRMAN KKUSEN: Thank you, Dr. McKneely. We ccme, now, to the la s t expert on our panel, Dr. Howard A. Rusk, Chairman and Professor in the Department of R ehabilitation and Physical Medicine, New York U niversity College of Medicine, Associate Editor of the New York Times, and formerly Chief of Rehabilitation in the Army Air Forces. Dr. Rusk w ill discuss the "Place of R ehabilitation in the Practice of Medicine, 3 3 R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 225 DR. HQ/vARD A. RUSK: Ladies and gentlemen, I want to ta lk very rapidly because there are a lo t of things I would lik e to share with you today, - a lo t of headaches we have had in the past eight months in se ttin g up a program of r e h a b ilita tio n in the general h o sp itals, and also some of the l i t t l e v icto rie s that have come to us within th is period of tim e. Eight months ago, in Bellevue H o sp ital, we established the f i r s t service of th is type in any general hospital, that we know of in the country, for the care of the c iv ilia n disabled. Vie are a major department in the hospital on a par with medicine and surgery and I must say th a t we have had complete and total cooperation of the entire s t a f f . Cooperation, I b e lie v e , based on our basic philosophy in the program and that is that we are a service department to a l l other departments in the h o sp ita l. Nose and th ro a t, for example, - the laryngectomy has to learn his speech. The b lin d , the d e a f, although we don' t have a s p e c ific program in fo r the blind and deaf because of other agencies available in New York, but that is a part of our orthopedic p a tie n t. The a r t h r it ic , the maladjusted, the cerebral p alsy, the p o lio m y e litis, the neurological problems, when d e fin ite medicine is over, when the fever is down, when the danger to l i f e is p a st, when the sutures are out, - what happens from that time to prod uctivity is our problem. R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 226 Vie have no d irect admissions in our ward, but we see patients through a l l the other services in the h o s p ita l. Our c r ite r ia for acceptance of patients are these: Is the m edical co n d itio n s t a t i c or p ro g re ssiv e ? I f i t is pro gres s i v e , can we progress fa s t e r than the progression of the disease? Second, - can we accomplish something to allow th is individual to liv e a purposeful l i f e by train ing him? I f these two c r ite r ia are met and a bed is available the patient is admitted. As Dr. Covalt to ld you, beside the routine range of motion we have muscle te sts and they are tested far the inherent needs of d a ily liv in g . Now, we don't c a ll them patients in our wards, we c a ll ttem students because they go to cla ss from nine o'clock in the morning to fiv e o'clock in the afternoon, with two hours o ff for lunch. Those with lower d is a b ilit ie s work three hours a day in ambulation and e leva tio n . The elevation room is set up with ramps, steps, a h a lf of a municipal bus, an actual bus so that when an individual has mastered i t they can travel on a public vehicle any place in the country. They begin with mat exercise and go clear through the needs for ambulation in a c it y lik e New York. To show you how such a program works, Dr. Deever, R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 227 my a sso cia te , has been running a survey for the New York Chapter of In fa n tile Paralysis on p oliom yelitis cases who have had the disease for at le a st a period of fiv e years. The survey is n 't complete, but in the la s t s ix weeks we have had fiv e p o lio m y e litis cases in the women's ward, alone, who have been home bound because they have not had proper tra in in g . One was a paraplegic poliom yelitis without abdominal: . She had had four major spinal operations and six or eight other types of surgical procedures. She could walk on a le v e l, but hac. been home-bound because she couldn't get up a curb or c o u ld i't get on the bus. I t took a week to teach her the curb and she could get on the bus in the f i r s t fift e e n minutes. At the end of that time she l e f t the hospital to go out on a Job as a trained stenographer, - she had had that training but hadn't been able to work because she couldn't get on a bus. That is Ju st an illu s tr a tio n of the patients that we se e . Patients carry th e ir records with them. You can stop a patient in the h a ll at any time and look a t the record anc. say, "Why aren 't you here, or why a re n 't you there?" Ko\mds are made before and a ft e r classes and the whole program is dove ta ile d to the need of th is in d ivid u a l. I think I can show you how the vh ole program works by showing you our organizational se t-u p . We have a R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 228 director service here, and our t o t a l program is divided into the physical medicine section and the physical re h a b ilita tio n se ctio n . We have d irect physical education, and under reha b ilit a t io n we have social service. Me have two so cia l workers assigned to our eighty beds who are absolutely indispensable in th is program because you have to know when the patient comes in what your fin a l distribution is going to be. You have to have a place fo r them to go because th is program is not a dom iciliary-care program for chronics. We have dynamic ther apeu tics, dynamic training, and when the individual has readied his maximum improvement he has to be released. About ten per cent w ill go to dom iciliary care, - the f a ilu r e s . The rest w ill be distributed ifco the homebound program, sheltered workshop, se le ctiv e placement in industry, or fu ll-tim e employ ment in industry. In th is program we have an individtaL calked a "vocational counselor," and it is his job to s t a r t , within fo rty -e ig h t hours, to evaluate the vocational p o s s ib ility of this Individual. Then we have a psychologist who works at th is level in the program, a speech th erap ist, and a volunteer program. In our program at Bellevue the Junior League has furnished us with fu ll-tim e volunteers who come in and work under a supervisor* R ena H a l l E ly CITIZENS BUILDUPS CLEVELAND 14, OHIO 2S9 of volunteers. They serve for a two year period, under her supervision. They help with the occupational therapy, they a s s is t the so cia l workers, and they work in adm inistration. In addition to that the volunteers have the recre ation program and recreation in our hospital sta rts at fiv e th ir ty and goes from then on u n til eight or nine o'clock at n igh t. I t doesn't consist merely of bringing in entertain ers, there are discussion groups one week, there are film s , and there is one group on home gardening. I t is amazing what you can do with a d o lla r , imagination, a few seeds and a l i t t l e know-how. This home-gardening is a tremendous thing for shutins and we have had a great deal of interest in i t . We hope to eventually write i t up as a project and make i t available gen erally. But, a l l of t h is group is our f i r s t lin e team. Then we have fiv e sp e cia lly assigned consultants, a p s y c h ia tr is t, an orthopedist, a n eurologist, and a p la s tic surgeon. The remainder of the consultation is taken care of through general consultation services, but a ll of these in d iv iduals are sp e cia lly assigned because they have a special part to play in th is program, and they make th e ir rounds weekly. Now, when the individual has reached his maximum improvement he is moved out of the program. I f he requires preventive medicine, i f that becomes primary, he is referred R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 230 back t o the special ward, to f i t his need. When train ing is primary, then it is our r e s p o n s ib ility . I t has been our experience in th is program that one of the most valuable things about i t is fo r the individual to be working with other disabled people because he has space lin es he can fo llo w , those worse o f f , those better o f f , et cetera. He can see what train in g can accomplish. We don' t fe e l that the hmiplgies should be segregated from the paraplegics. We have ft found a very h ealth fu l a ffe c t in having them together, even with some of our psychoneurotic problems. With patients with physical d i s a b i li t i e s , i f you put them in the to ta l program you w ill fin d that the general a ffe c t is not unsalutary. Our p sych ia tric problems on the wards are p r a c tic a lly n i l . You give these patients a l i t t l e hope, and a l i t t l e know-how, and a plan and you don' t have to go from "a" to "z " with them. I f "a " is a to ta l confinement to bed and "s" is complete a c t i v it y , - i f you can take a patient who has been in bed for three months or three years and teach him se lf-ca re and le t him walk to the lavatory and not have to use a bed panr teach them to bake care of th e ir own d aily needs and that is a ll you need. 'We do have great p sych ia tric problems when the individual gets out of the hospital and for that he has to be R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 231 ---- conditioned. Ourtfiole s t a f f has to p a r tic ip a te in th is program. Their primary objective is to g e t that in d ivid u al to the point where he can go out at his le v e l and work in d ig n ity . That, in gen eral, is our set-up in the h o s p ita l. As I said, and would like to r e p e a t, we have had a hundred percent cooperation with the other manhers of the s t a f f . We now teach f o r t y hours to the undergraduates on indoctrination in the care of the p a tie n t. In those lectures we ta lk about lit t fe th in g s. We t a lk about observation o f l i t t l e th in gs, - the patient treated as a whole in d ivid u al and how the various basic signs f i t in to make up the t o t a l i t y of an indiv id u al. In the soptomore year we ta lk about occupational therapy, what is i t , #iat does it do? I t i s n ' t just something to take up time u n til two, three, or four o ' clo ck and make a rug on a loom, - what is the purpose of i t ? We teach physical therapy and physiology. The physiology of early amputations, the tie -u p of physiology and chemistry and physics to the whole program. In the junior year we get in to the basic therapeutic 3 problems in physical m edicine. In the senior year we have sixteen c l i n i c s , hemipleg ia , one on amputees, a r t h r it is , et c e te r a . We hope, e v e n tu a lly , to se t up a program in dronic R en a H a l l E ly CITIZENS BUILDING C LEVELAN D 14. OHIO 232 disease ao th at a freshman student can be assigned to a patient that we know is gping to have the r e st of his l i f e Impaired by some chronic disease or d is a b ilit y , and l e t that individual student follow the patient through the four-year period in order that he nay see, focused on one person that he has seen and follow ed, the problems, the t o t a l i t y of the individual and the necessity far tre a tin g the individual rather than the d ise a se . We talk about th is country, or some people do, that there are no new opportunities and no new arrivals Many of us, I think , who practice c lin ic a l medicine fe e l that a ll research is going to be done in the lab oratories, that great amounts of money are going to be spent in lab o rato ries, and that the cause of the disease doesn't depend so much on us but on the trained s c ie n tis ts in the la b o ra to rie s. . In this fie ld of medicine the research f ie ld is absolutely untouched. Take, fcr example, the largest oecupatfonsl group in Arne r ic a , - the disabled housewife. There are fiv e m illion of them, two m illion of whom are either on crutches or wheel ch a irs. There has never been a time study or motion study made so that a woman can take care of her own house com petently from a wheel chair . There i s no re a so n u n d er the s h in in g sun why i t c a n 't be d o n e. Vacuum c le a n e rs w ith sh o rt h a n d le s , c e r ta in type R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 233 of simple fix tu r e s in the bathrooms, s i l l s away from the doors, bedrooms planned so that they can get Inbetween them with a wheel ch air. There is no reason in the world why a woman in a wheel chair ca n 't be p e rfe ctly competent in her own home, and th is is ce rta in ly true of a woman on crutches. * The most in terestin g case is a cardiac in industry. Me studied the jobs and in many jobs you could reduce the energy requirements f i f t y percent. Now, the borderline cardiac, - i f you can go in and prescribe for her a metnod of taking care of her house with a reduced energy requirement of tw enty-five per cent you w ill mske that woman a competent individual Cancer, - you don't think of i t in terms of rehab i l i t a t i o n . How about une proper exercise fo r post operative individuals? The individuals with eradicated breasts, - what exercises can they take and should they take, to prevent or reduce the edema? What exercises can they take to relieve the condition of the abdominal muscles? How are they going to be trained to liv e psychologically and p h ysica lly with that condition? There are problems fo r the amputee in cancer and we see them a ll the time. There is rhe individual who has had his leg o f f . He has a good stump, a good jo b , and he buys a leg but i t doe sn ' t f i t . We had a woman in our service la s t week. She had R ena H all E ly CITIZENS BUILDING I CLEVELAND 14. OHIO E 234 hor legs off for three jean s. They had bought two legs but she came in on the arm o f her husband and used a cane simply because nobody had ever taught her to use balance. Somebody had told ber that she had to cons down on her heels f i r s t and she was to ta lly inadequate and insecure. I t took three weeks of tra in ing to get her o ff the cane and out of the house by h e r s e lf. A ll of these are fie ld s untouched. Take a r t h r it is , we have two experimental cases new. One is a young man who tad been in bed four and a h a lf years, - h is legs were to ta lly fix e d . He had good f orearms and good shoulders and by simple balance he was taught to swing his s t i f f legs out over the bed. The crutches were at the top of his bed and he could pick them up and walk a four-point g a it with his crutches. into bed the same way. He can get back He went into our watch repair unit and was fine except that after four hours his fe e t got sore. So, we had to devise some way for him to take the weight o ff his fe e t . We f i r s t tried a b icycle se a t, but that proved inadequate. Now we are working on the basis of the thing that happens to you when yon ride a bony horse, - where do you carry the weight? We have made a horse out of wood and spotge rubber and he can no?/ take a part of tne weight o f f his heels and give them r e l i e f . How i s he g o i r g t o s i t down? W e l l , we w e n t to R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO ~ ------------------------------------------------------------------------------------------------------------------------------------------ Hollywood for bhat one. You know these reclin in g seats the actresses use when they can 't sit down because they mi^it muss th e ir dresses? w ell, he backs up on that and the table is tilte c . up on that and that is his ch a ir. Now, he c a n 't travel because he can't s i t down, tut he has shown himself so p ro ficie n t that we are se ttin g up a home program for him to assemble watches. Buiova watch people set up the program. Now, here is a boy tw enty-fair and a h a lf years old who would have spent a ll of his time in a chronic hospital in bed. Now he has a home progran ta ilo re d to meet his own needs. He thinks i t is worth while and so do we. Hemiplegia: When do you start to train ? Retraining starts the day they regain ccn scbusness. We know the shoulders w ill freeze in three to six weeks i f they aren 't properly exer cised . I f they are kept in bed i t takes a week to get than in the upright position because of the hyper-3tatic phenomena. I f we get them early we can save them months of d is a b ilit y . Dr. Covalt has told you that fo r ty percent of our hemoplegias, in the f i r s t se rie s, we have been able to get back to work. Tuberculosis: I think we are learning from the graphic reports coming in that you c a n 't put a p a tie n t's mind in a c a s t. To say to a man that has a fam ily and fin a n cia l problems, "Go to bed and don 't worry," anybody knows that is R en a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 236 not possible for him. So, he goes back to that heavy job and he is going to break down. That is why two-thirds of our hos p ita l sanitarium beds are f i l l e d w ith relapsed tuberculosis p a tie n ts. They either die or relapse within the f i r s t fiv e years after tte discharge. But, we have evidence from a l l over the country that you caa reduce th a t to three or four percent with proper tr a in in g , re tra in in g , hardening periods, et cetera. We have ju st had beautiful evidence of Dr. C o valt's point at our Sea View Hospital at Staten Islan d . The number leaving again st medical advice has been reduced to one percenb . It ju st goes back to the simple point that you have to treat t ne individual rather than the d ise a s e . - We have worked out, in Bellevue, a l i t t l e welcoming pamphlet for the p a tie n ts. We t e l l him why he is going to be exercised, what his schedule means, and what his outlook is in simple, factual language. We took two old wards and made them over, vie cut them up and made a men and women's ward. We are short of nurses, short of personnel, so we took th is course. We made these wards into doimitories and i f the patient progressed rapidly in his train ing he was graduated into the dormitory. When he went there the lig h ts could be kept on longer, he had certain p riv ile ge s that the ward patients d id n 't have, but for R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 237 that privilege the patien ts took care of the dornitory. They swept i t , made the beds, ard they don' t have nice four-cornered beds, but the patients make them and they are happy and they are doing the things there that they are going t o have to do when they leave. The morale has been t e r r i f i c . A great many of them help each other. Tom Francis, who is one of our patients being # treated for p o lio m y e litis, has been helping us in speech therapy. We find individuals vho can help teach in the program in addition to the buddy-type of teaching. They have small groups of patients that they get together and indoctrinate them in some of the techniques they have learned the hard way. We have e igh ty beds in Bellevue now. In the new Bellevue we are t o have six hundred. The master plan has been published i t ha s been recommended that in 1950 there were to be eight thousand beds, in greater New York, fo r convalescent care and r e t a b ilit a t i on. That is twenty percent of a l l the hospital beds in New York. I thiric, with a l l the ho sp ital building, with a l l the talk of chronic disease, that we should take into consid eration some of the experiences we have had in the management " of chronic disease. We who have been working in th is program, and only for a few months, know that these are only our f i r s t R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO 238 observations, but we are sure enough of our ground to say, f l a t fo o ted ly, that with a dynamic train ing program there is abso lu te ly no lim it to wba t can be accomplished. It is going to be much more, I think, thaa most of us think possible. The average person with a chrcni c disease can be trained to go out o f the hospital for dom iciliary care, can be taught s e lf-c a r e , can be taught to do some l i t t l e gain ful work, even i f in a home-bound program, and can liv e some sort of a normal l i f e outside of an in stitu tio n . What are we going t o do about i t ? This has to be a part of iredical education. Our fa c u lty believes th is is a necessary part in the teaching of the student. You coula get a few hours in medicine, a few hours in surgery, a few hours m orthopedic, on this subject, and i f everybody pitches in and gives you a l i t t l e that you can pass back to the students, yours and th e ir s , that d ir e c t ly a ffe c t s their sp e cia lty , then there is no problem in working th is into the curriculum. Disabled c itiz e n s in th is country have a right to know what can be done with dynamic tr a in in g . Doctors have to be indoctrinated as to the techniques, and they are very simple. This is a program of a lo t of l i t t l e th in gs; hard work, imag in a tio n , attention to d e t a il, utilization of simple engineering principles, et cetera. R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO Tom Francis, oaar poliom yelitis patient here, has spent six years in general h o sp ita ls. He came to us in Ju ly . He had no protractors and his medical care had been e x ce lle n t, but he wa3 in a home fcr incurables because he couldn't do four or fiv e simple th in gs. He had a rocker-arm sp lin t fo r his aim, but he didn 't have m ough strength to use i t . In three weeks he could tee i t . We got him an IBM typev/riter and in two weeks he was able to write two single-spaced le tte r s to his mother which was the f i r s t communication they had had in s ix years. I t took us s ix weeks to teach him to turn over in bed. He is s t i l l workirg with the th e ra p ist, but he turns over in bed fifte e n times every morning as a part of his routine. As a resu lt of th is work he now has a job and i s going back to practice law the f i r s t of January. Doctors must know such opportunities e x is t . Patieni must know. Industry must know that disabled people make good workers. I think it can best be sold to industry by the simple explanation that nature has been kind, that we have tremendous powers of over-training and ov er-compen sat ion; that the blird man put in a job where he can use the type of sensation that nature has increased, such as hearing, can do a better job in that particular job than the normal man. Put a deaf man in a job that requires visual acuity R ena H all E ly CITIZE N S EJJJILDING CLEVELAND 14. OHIO 240 and he w ill do a better job than the normal man. Put a peraple* in a job where he can s i t down end use the strength in his fin gers and arms and he can out-work the normal man. There are dozens of studies that show i t , - one, two, three, four; better production, less accidents, less labor turn-over, less absentee ism. I t goes straight across the board and th a t is the way we se ll i t to industry. Then the le g is la to r s have to know. This vocational program should have ten times as much money as they have to spend. They had about eighteen mi 11in d o lla r s, I think i t was, la s t year, but when you ta lk in terms of airplanes and b a ttle ships i t is a drop in the bucket. Now they have to go back and ask for a two m illio n dollar deficien cy appropriation. I wrote a le tte r about i t la s t week and I was ashamed to do i t because i f t be in divid uals who make the laws understood the d iffe r e n t needs that such a program has not only in humanities, but in dollars and cen ts, - i t is the soundest p o lit ic a l program that any man could back. Those of us working in the program understand that we have to continue th is program of education in these four fa ce ts i f we are going to r e a lly practice dynamic therapy in chronic diseases and give patien ts to ta l medical care. I thank you. (Applause) R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 241 CHAIRMAN KRU3EN: We have only a short time l e f t because at th re e -th irty Dr. Henry H. Kessler w ill have the Amputations C lin ic in th is room. We have only fift e e n minutes more and there are a few questions that have come to the panel. We are going to tale these questions f i r s t and i f there is time I w ill l e t you ask seme additional questions. But, to start the b a ll r o llin g , there are a few questions here that the mem bers of th is group have asked the panel to answer. The f i r s t question has already been answered, p a r tly , by Dr. Rusk. The question i s , "Is it sound economy to employ the p h ysica lly handicapped person in industry?" I have before me a statement by Louis I . Dublin, a hardboiled s t a t is t ic ia n of the Metropolitan L ife insurance Company. He says, "Humanitarian considerations apart, a con certed drive to apply modern knowledge to the problem o f the handicapped would be sound economics." Dr. C o valt, have you additional points you care to point out? DR. COVALT: I think quite possibly that Dr. McKneely should answer t h a t . I think their experience in their service of cases in 1944 would be most in te r e stin g . DR. McKNEELY: I won' t quote figu re s d ir e c tly , but our s ta tis tic ia n s have surveyed the increase in income of person; R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 242 reh ab ilita ted and compared th at with the income before reha b ilit a t io n and they have arrived at the conclusion that within two or three years, follow ing r e h a b ilita tio n , or even le s s , the c lie n ts w ill have returned to the government in the form of income taxes and other taxes more than the cost of th eir rehabilitat ion. CHAIRMAN KRNSEN: Dr. Dawson, would you care to add anything? DR. DAWSON: I think the s t a t is t ic s which I have just referred t o are quite in d icative along, that lin e . Of the seven hundred and ninety-seven cases surveyed, four hundred and th irty -fo u r were dropped from compensation, - at lea st compensation was terminated. Three hundred and s ix ty -th r e e , at the time of this study, were s t i l l indeterminate. S ix ty - four percent, in other words, of those cases that were improved were back on a f u l l employment sta tu s. CHAIMAN KRUSEN: To show the v e r s a tility of the handicapped worker, Dr. Kessler in his new book on reha b i l i t a t i o of the handicapped mentions that four thousand four hundred and fo rty -fo u r handicapped persons are employed in s ix hundred and fift y -t h r e e d iffe re n t types of work. That indicates th e ir great versatility. Dr. Rusk, have you any additional comments? R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 243 v dr. RUSK: I have ju st on. In an unpublished report made by the Bureau ci* Labor, taking eleven thousand handicapped workers to eighteen thousand normal workers in a cross section of industry, - every type of job had the same re sults quoted. CHAIRMAN KRUSEN: Here is a question that w ill in terest the experts here. I t is a question that has been asked ty an in d u stria l physician. ^ re a lly the doctor' s job? The question i s , " is re h a b ilita tio n _ Why can' t so cial service handle i t ? Who would like to take that? Dr. Rusk. DR. HJSK: This is a team-work job. It is primarily a medical problem and the doctor' s r e s p o n s ib ility . To go back to the hemiplegia, I don't think that we have dore a' job with our hemiplegics when we give them potassiun iodate and s ix ounces of sodio-bromide and leave than to sit in a rocking d ia ir . Their ham may be fin e , but they are the un happiest people in the world. This is a team, as I trie d to point out, and i t is an attack of the problem from the p h y sica l, psycho, s o c ia l, and vocational standpoint. I don' t think i t is the resp o n sib ility of social service anymore than it is the physiotherapist's job. I t is a l l a team-work proposition. CHAIRMAN KRUSEN: T h an k you v e r y much D r . R usk and R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 244 Dr. Covalt. DR. COVALT : I would lik e to point out on your cardiac and tuberculosis p a tie n ts, - there Is no one but a doctor could take charge of the re h a b ilita tio n of those two cases. CHAIRMAN KRUSEN: The time Is about past ?/hen the surgeon can*say, "Your stitch e s are out, you can go home and go back to work," or whe n the interne can say to the p a tie n t, "Your temperature is down, you can get out and go back to work." It ju st doesn't work out that way. ' this I think/is a question from an in d u stria l doctor, too. The question i s , "Why should I ask my company to take the risk of hiring handicapped people when there is now an adequate supply of f i t workers a v a ila b le ?" DR. RUSK: I think we have pointed out that i f you use these people where they can use their over-compensated senses that they would out-work the normal person. I saw a report recently from a large company where th ir ty of the top executives were examined in January and there was not one single one o f the th ir t y who were p h y sica lly f i t . Y e t, that company doubled it s income in the next year. I think you have to stay p h y sica lly f i t fo r whatever you are doing. Everyone is n ' t going to run the m ill every morning and i f you us \ R ena Hall E ly CITIZENS BUILDING CLEVELAND 14. OHIO Il 245 $ f ! i V % j\ \ people in jobs where they can use th e ir over-trained, overccmpen sated senses, then that is good business. They don' t want a hand-out. They don't want four balls and a free tr ip around the bases. They also don' t want two strik es on than before they come up to bat. I f my obser vations are co rrect, axl they want is a chance to take a cut at the b all on the same basis as anybody e ls e , and i f they make a h it to get around the bases. But, i f they get around the bases in time the run ought to count. CHAIRMAN KRUSEN: Any further comment? I think that has been pretty w ell answered. Here is anothe r que stion : "is the Peoria plan applicable to other communities?" Dr. Rusk, do you want to take that? DR. RUSK: The Peoria plan, as I understand i t , is a community-industrial group who have orgaa ized to have a unit set up where handicapped employees may register and where in dustry can pick from that reservoir of handicapped individuals those they can f i t into s p e c ific jobs in their p lan ts. For in stan ce, the C a te rp illa r Tractor Company, - I don't think they hire e p ile p tics because they are in heavy industry, but they are used by certain other industries in Peoria. Certain other types are taken by C a te rp illa r that other R ena H all E ly CITIZENS BUILDING CLEVELAND 14, OHIO 246 small companies can' t take They have cne of the one hundred and f i f t y community re h a b ilita tio n centers that give certain types of train in g services to disabled people. There are only one hundred and f i f t y such centers in the en tire country. I thihk th is plan applies to any community except when you get into the very large c i t i e s . I think it would be a l i t t l e bulky in the larger c i t ie s and would have to be unitizeid. CHAIRMAN KKUSEN: I think I can add a l i t t l e to this discussion. ' Peoria, I l l i n o i s , affords an outstanding example of a community vihich planned well in advance to set up a coordinate program for veterans, and it has seen the wisdom of applying it to non-veterans as w e ll. The Peoria Plan for Human R eh ab ilitati had it s 'r o o t s in the wartime needs of local industry. In dustrial leaders, physicians, c iv ic and welfare workers got together and developed a d e fin ite plan for employing disabled people in suitable jobs. Cooperation was sought and obtained from each group, in .a meeting, to meet a p a rticu la r r e sp o n sib ility in the to ta l program. The onL y paid employee at the beginning was a coun s e llo r , and lo c a l c itiz e n s and organizations bore the c o st. Prom t h i s m o d est b e g i n n i n g , t h e r e d e v e lo p e d f i r s t a r e h a b i l i t a t jlon R ena H all E ly CITIZENS BUILDING CLEV ELA N D 14, OHIO 247 plan fo r returning veterans of the community, and f i n a lly for a l l disabled residents of the area. With the recent expansion, support and guidance from state and federal sources nave been required, but the Peoria Plan w ill serve as a useful model for other industrial c it ie s of moderate s iz e , and i t should be extended into other communities. This is the next question, "Should the industrial physician p articip ate in a community re h a b ilita tio n plan? DR. DAWSON: Yes. CHAIRMAN KRTJSEN: Dr. Dawson said, "Y e s." Can you amplify? DR. DAWSON: What we need is a d e fin itio n of in d u stria l medicine. As I understand i t , the d e fin itio n of in d u strial medicine means "Determining the em ployability of an individual and try in g t o keep him employed." That means trying to keep him cn the job and i f we include in th at the th ird phase of i t , care, the restoration of em ployability; I don' t know of anyone that is more interested in re h a b ilita tio n than the in d u stria l physician. He is the man who is going to take our product and use i t . I don't see how he can be a success without being interested in r e h a b ilita tio n . He is lim ited somewhat in r e la ti to how large his industry is and whether i t is a s in g le -a c tiv it Rena H a l l Ely CITIZENS BUILDING CLEVELAND 14. OHIO industry or whether i t is larger and has many a c t i v i t i e s . But, that becomes an individual problem. DR. RUSK: I t is part o f his job, too, to take these people and get than back to work. CHAIRMAN KRUSEN: Thank you, Dr. Rusk and Dr. Dawson I notice that our time is running short, - are there any statements that any of you care to make? DR. RUSK: I neglected to say one thing and that is that we have worked out admission procedures, discharge procedura organization ch a rts, nursing procedures in re h a b ilita tio n wards and they are available at Bellevue. I f any of you are interested i f you w ill drop a card t o me at Bellevue Hospital I w ill be glad to send you a package of th is entire material we have worked out i f i t w ill be useful to you. CHAIRMAN KRUSEN: Dr. Sawyer, have you any comments to make from the standpoint of an in d u strial physician? DR. SAVOER: I agree with Dr. Dawson and Dr. Rusk. I don't see how you can neglect the importance of th is develop ment.. . ' I think there is one thing that might be mentioned, Dr. Rusk, that you d id n 't mention and that is that there is value in employing these people in the encouragement i t gives to others. They can see what can be done i f they should one R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 249 day become handicapped. ' DR. DAWSON: Dr. Sawyer i s from the Eastman Kodak Company. . DR. R. A. SUTTER ( S t. Douis, M issouri): I would lik e to ask the panel, "Hew do you overcome the psychological barrier to the su ccessfu l reh ab ilitatio n of a man who has a claimed p artial d is a b ilit y ? " CHAIRMAN KRUSEN: Dr. Rusk, w ill you take that? DR. RUSK: Well I th in k , in certain cases, that you ca n 't do it u n til some type cf settlement is made. I think the chronic backs have been one of the best indications and when the individual gets an anxiety complex over a long period of time i t is a d i f f i c u l t problem. I t is psychotherapy, it is confidence, - he has to be assurred that he can come into a program anl wcrk far an agreed period of t i : . The combined e ffo r ts of the entire team can assure him and his doctor that he can g e t back to a job, that a settlement can be made, or tha he can be put on a t r ia l basis fo r a period of months. But, i t is d i f f i c u l t when they are fix e d , when they have an anxiety in addition to the physical d is a b ilit y . DR. SUTTER: Then i t takes it out of the realm of the in d u strial problem and i t becomes a public problem. DR. RUSK: Y / e ll, you can gam ble a l i t t l e t r a in in g R ena H a ll E ly CITIZENS BUILDING CLEVELAND 14. OHIO 250 noney on th e b a s i s t h a t you g e t him bade to work and o f f th e r o a d . I t h in k i t t a a t o be an e n li g h t e n e d a t t i t u d e on th e p a r t of in d u s tr y , the p u b lic , the r e h a b ilit a t io n p e o p le , and the doctor . You ca n 't premise, tut you can take him in and r e a lly give him a t r y . I t is the same way that you attack a questionable cancer. Yen ca n 't say to a p a tie n t, " I am going to operate on you and remove th is can cer." You can only say, " I am going to operate and do i t , do the best that I can. We are going to do i t i f it is humanly p o ssib le ." That is what you say to the individual that has a fix a tio n and an an xiety. CHAIRMAN KRUSEN: In order that Dr. Kessler may come in on time we w ill have to close our session . In c lo sin g , however, I should like to read to l you cne statement which I thirk. is one of the most unique and in terestin g of a ll statem ents. John G a ls w o r th y , a t the A l l i e d Conference on the A fter Care of Disabled Men, way hack in 1919, said; "Restor ation i s at le a st as much a matter of sp ik it as of body and most of i t is central tru th . Body and s p ir it are in extricab ly conjoined. ' To heal the one without the other is impossible. I f a man's mind and courage and in terest be enlisted in the cause of his own salvation healing goes on apace and R e n a H a l l E ly CITIZENS BUILDING CLEVELAND 14. OHIO the sufferer is rsrade. I f n o t , no mere su rgica l w on d ers, no c a r e f u l n u r s in g w i l l a v a i l t o make a man o f him a g a i n . T h e r e fo r e I w ould s a y t h a t from the moment he e n t e r s th e h o s p it a l lo o k a f t e r h is mind and h i s w i l l . Give him fo o d ; n o u rish him in s u b tle w ays; in c r e a s e th a t nourishm ent a s h is s tr e n g th in c r e a s e s . G ive him in t e r e s t in h is fu t u r e . l i g h t a s t a r f o r him to f i x h i s e y e s on so t h a t when he s te p s out of th e h o s p i t a l you s h a l l not have t o b e g in to t r a i n one who fo r m on th s, perhaps y e a r s , has been l i v i n g m in d less and w i l l i n g l e s s , the l i f e of a half-dead, creature . That th is is a hard task none who know hospital life can doubt. I t needs special q u a litie s and sp ecial e ffo r ts quite other than the average range of hospital devotion is obvious, but i t saves time in the end and without i t success is more than doubtful. The crucial period is the time spent m the h o s p ita l. Use that period to recreate not only the body, but mind and w ill power, and a l l sh a ll come out r ig h t; neglect to use it thus and the heart of him a sufferer and of him a would-be healer w ill break from sheer d is couragernenb . A niche of usefu lln ess and se lf-r sp e c t e x ists for every man however handicapped, bt that niche must be found for him. To carry the process of restoration to a point short of 'this is to leave the cathedral without a sp ire . To restore R ena H a l l E ly CITIZENS BUILDING CLEVELAND 14, OHIO 252 him, and with Urn the future of our co u n tries, that i s the sacred work." The meeting stands adjourned. ...T h e meeting adjourned at 3:30 o' clo ck , p .m ... ADJOURNMENT R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO 253 CONFERENCE ON OCCUPATIONAL CANCER Tuesday Afternoon, January 6, 1948 The Conference on Occupational Cancer convened at 2r30 o 'c lo c k , Dr. Ernest Brown, presiding. CHAIRMAN BROWN: Ladies and Gentlemenr I regret very much to say Dr. Shields Warren, who was to have presided at th i session has not yet arrived. We hope he w ill arrive in a reasoi ably short time, end in order to avoid delay, I think we w ill now proceed with the second paper, which w ill be presented by Dr. William T. S a lte r , New Haven, Connecticut, Professor of Pharmacology, Yale U n iversity School o f Medicine. Dr. Salter 1 R ena H all E ly CITIZENS BUILDING CLEVELAND !4. OHIO CHEMICAL ASPECTS OF OCCUPATIONAL CANCER Paper by D r. W illiam T. S a lte r D r . Brown: I f e e l a l i t t l e em barrassed ab o u t opening t h is m e e tin g , b e cau se I u n d e rsto o d I was g o in g to be w e ll p r o t e c t " ed on e i t h e r f la n k b y a man from B o s to n on one hand and a man fro m jiew Y o rk on th e o t h e r . B e c a u s e New H av e n i s a lw a y s i n t h a t s i t u a t i o n , I f e l t r i g h t a t home . B u t now I f i n d I am p l a y i n g t a c k l e w ith an unguarded lin e and alth o u g h th a t p la y worked p r e tty w e ll a fe w w eeks ago i n th e Y a l e B o w l, I am n o t so s u r e th e p l a y w i l l work so w e ll in C le v e la n d . . . . D r. S a lt e r p re se n ted h is paper . . . (Applause) R ena H all E ly CITIZENS BUILDING CLEVELAND 14. OHIO