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FILE NAME: Railroads (RR) DATE: 1965 Mar DOC#: RR019 DOCUMENT DESCRIPTION: Proceedings of the Medical and Surgical Officers 45th Membership Meeting - Association of American Railroads 1 \ n j} ^ fJV/ //w l j jf Jr?ms o f ^ ^ d ip t ! ? G A c o i t t J ^ . / / - i ~ ~ ffa -M t/e / & u > - / ? . ' ( - / l ' ru? m j ? t y ( ? ( k :<AJ C tO jf'-e w A j S a jb ^ l & t w t p X - /Y // ( % y r3fi~* Q/ y ~f - o -/7i- f f 2 & ) /fc -. ($Qs1&l& <? c - b J* r / 4 ^ i y s /u ^ ^ cei^ts p ^,~Q /-\ l i r f / 11c J ^ p . / u s 7 y \ J}y f* AjO (yLt7< *^ ^ ^ y ^ p d /, CJf &ULj2%/2p ^7 J/ ]^ApP (WA 'M ^ ^ ^2sltiS& ijsLjy<- z d p p p l ' ,f) (h " c ip l - a i m c o q / ^ y CJ 2u if d 'p j' j^Ltfi tr&riild&i I j % c W ^ vMj Viy?^}?3fj C^J|Srf#* f P- H t (^Sv/\. C S fM (ii f / f A X ' d 3'jl<P.A> ^ j 3 ^ l Q \ ^ S lciji\ x<i"j iiu v .ti lJ(k -Y & *i'f . r 716-884- 2 1 A& MICHAEL DORAN A TTV PAGE 0 PROCEEDINGS MEDICAL AND SURGICAL OFFICERS FO R TY-FIFTH MEMBERSHIP MEETING MARCH 3, 4 & 5, 1965 SHERATON-CHICAGO HOTE] CHICAGO, ILLINOIS ,, DEPOSITION EXHIBIT M E R I A N OF RA1LRO D S 1/ * 1 /a* s ii S 06/04/98 09:14 TX/RX NO.2243 P.002 06/04/1998 09:10 716-884-2146 MICHAEL DORAN ATTY PAGE 08 hind each o th er. T hey are a cou p le a t in ch es apart. You a r e taking- two disparate Im ages, and you are com bining them into a single Image. Now, this is binocular single vision . MODERATOR CLAYTON: And v ery briefly, fu sio n ? DR. WIFPEBMJW: Fusion is an o p tica l se n so r y reflectio n in which you are obtaining single binocular vision. MODERATOR CLAYTON; A ll right. D octor, stereo p sis ? DR. WEPPERMAN: Stersopais is a d egree o f fusion in which you obtain depth perception. Tbs first degree of fusion is sim ply super im position in which you can acknowledge that each eye is seein g an im age at the sam e tim e. Second degree fusion is where you pin the ta ll on the donkey and get the ta il in the right p lace. T his la su per-im position. And, third degree fusion, o r ste r e o p sis, or depth perception, is w here you r e a liz e that the bay i s stan d in g on one sid e Or the other o f the donkey. There is a depth perception factor. T his is the highest degree of fusion. MODERATOR CLAYTON: We h ave a few other q u e stio n s, but our tim e is up. Tom orrow we w ill talk shout diabetic retinitis on another program. ) t thank the panel ror a job w e ll done. Thank you. very much, gentle m en. for your attention. (Applause) CHAIRMAN OLSON: I am pow erful glad to get th o se la st th ree things straightened out in my mind. We w ill now take a short break and then we w ill resu m e and we w ill take up Pulm onary D isea ses. > (A short r e c e ss was taken.) CHAIRMAN OLSON: We want to adhere to the sch ed u le a s c lo s e ly a s p o ssib le . T he neat panel sym posium is on Pulm onary D isea ses and w ill be con ducted by D r. Kaplan. , ______ MODERATOR KAPLAN: Chairman O lson, officers of the A ssociation, guests: Pulm onary D isea ses is a rather unique subject for the railroad industry, since a of attention h as been directed to its im por tances M em bers of m y group have collected pertinent m aterial that should be of e x trem e in te r e st and -value. The panel m em b ers are: 190 06/04/98 09:14 TX/RX NO.2243 P.003 -S967' 0'4/l 998 t 09:10 71S-884-2146 MICHAEL DORAN ATTY PAGE 04 Stanl*y J . Cyrmn, M-D -. M edical D irecto r, Pennsylvania Railroad, Philadelphia, Penneylvanla. V . W. H ollo, M, D . , C hief Surgeon, St. L ou is-S an F ra n cisco R ail way, St. Louie, M issouri r W. J . Longeway, M. D . , C h ief Surgeon, C olorado fc Southern R ail way, D enver, Colorado. G. E a rle Wight. M. D ., C h ief o f M ed ical S e r v ic e s , Canadian P a cific Railway. M ontreal, Quebec, Canada. C , R. Z e is s , M. D.V C hief Surgeon, E lgin, J o lie t S. E astern R ail way, C hicago, RUnols. I am fu lly aware that I t Is la te in the afternoon, and, even though the ey e panel might not be resp on sib le for the h ea v in ess of our orb icu laris ocu li m u scles, it is the tim e o f day when lactic acid accum ulates and r esu lts in a state o f sem i-n arcolep sy. H ow ever, I do hope that you w ill rem ain a lert for at lea st an hour and fifteen to thirty m inutes, during which we w ill try to present to you the e e m p ie x itte s of th e pulm onary p ro b lem s, it i s a v ery d elica te one. We do not p ro fess to be exp erts In pulm onary physiology; we are not pulm on ary in tern ists, hut we are fam iliar with its relation sh ip to the railroad industry. Many o f you are acquainted with the h isto r ic a l background of lung can cer. The m iners o f Schneeberg and Jachym ou suffered from a pul monary d isea se for many y ea rs, but it was not until 1879 that it was r e c o g n ise d to be can cer a s a r e s u lt o f exp osu re to uranium in ttojkmifj -pitchblende. Later, chrom ates, nickel, arsen ic, beryllium , arfiaabes . Q ta j^ w ith it s m agnesium s ilic a te con ten t, w ere also found to be etic T t e t e r f in the production o f lung can cer. Morn recently cigarette sm ok ing h as entered the controversy. At p resen t the railroad industry is a lso becom ing Im plicated a s p o ssib ly being a factor in lung cancer because o f d iesel exhaust fumes. - During the past two or three decades, we have noticed a new factor insidiously creeping into the railroad Industry. T his is the m atter of a ir pollution and contamination o f shops and roundhouses with d iesel exhau st byproducts. T h is i s not a new tenet, but m ore and m ore litigation in this field Is being presented, and X*m su r e that none o f us are so naive that we are not cognisant of the problem s a risin g in our shops and roundhouses 06/04/98 09:14 TX/RX NO.2243 P.004 PROCEEDINGS MEDICAL AND SURGICAL OFFICERS FORTY-FIFTH MEMBERSHIP MEETING MARCH 3, 4 & 5, 1965 SHERATON-CHICAGO HOTEL CHICAGO, ILLINOIS , ASSOCIATION OF AMERICAN RAILROADS '5 EXHI BI T 3/  1 i I t O' I I i i I INDEX : O f f i c e r s ....................................................................................................................... 2 C o m m i t t e e P e r s o n n e l .... .................................................................................... 2 C a l l to O r d e r .......................................................................................................... 5 C h a i r m a n ' s M e s s a g e - D r . H a r v e y N e l s o n .................... 5 A d d r e s s - R . R . M a n i o n ....................................................................................... 2 Panel Symposiums M a n a g e m e n t , M a n p o w e r a n d M e d i c i n e ............................................. 12 P reparation for Three Doctor Board, National Railroad A d j u s t m e n t B o a r d an d T r i a l ............................................................ 60 C a r d i o v a s c u l a r D i s e a s e s ...................... ...........................- ................... 106 V i s i o n ...................................................................... 130 P u l m o n a r y D i s e a s e s .................................................................................. 150 D i a b e t e s ....................................................................................................... 173 N e u r o p s y c h i a t r i c P r o b l e m s ..................................................................... 192 * Com mittee Reports t M e d i c a l S t a n d a r d s ......................................................................................... 50 M e d i c a l - L e g a l ................................................................................................... 54 F i r s t A i d .............................................; ................................................................ 98 ,, T r a u m a .................................................................................................................. 98 , '** I N o m i n a t i n g .................................... 105 Attendance 22.1 OFFICERS AND COMMITTEES 1964-1965 H arvey N elson, M. D ., C h a irm a n E . C. O ls o n , M. D . , V i c e - C h a i r m a n W. E . T o d d , S ta f f S e c r e t a r y MEDICAL AND SURGICAL ADVISORY COMMITTEE (T e rm s ex p ire 1965) W. E. M i s h l e r , M. D . , C hief Surgeon, E rie - L a c k a w a n n a R a ilro a d , 608 Republic B ld g ., Cleveland 15, Ohio. E. C. Olson, M. D. , Chief Surgeon, Illinois C e n tra l R ailro ad , 5800 Stony Island Avenue, Chicago 37, Illinois. b ; W. S to ck w ell, M. D. , C h ief S u rg e o n , D e tr o it & T o le d o S hore L ine R ailroad and Grand Trunk W estern R ailroad, 1229-39 David W hitney Bldg. , 1553 Woodward Avenue, D etroit, Michigan. G. E arle Wight, M.D. , Chief of M edical S ervices, Canadian Pacific Railway, Windsor Station, M ontreal, Q u e., Canada. J. R, Winston, M .D. , System Medical D irector, Atchison, Topeka & Santa F e R ailw ay, 80 E a s t Ja c k so n B l v d . , C h ica g o 4 , Illin o is. (T e rm s ex p ire 1966) S t a n l e y J . C y r a n , M. D. , M e d i c a l D i r e c t o r , P e n n s y l v a n i a R a i l r o a d . 474 T h irtie th Street Station Bldg. , P h ilad elp h ia 4, P ennsylvania. R. M. G ra h a m , M. D . , D ire c to r, D e p a rtm e n t o f M edicine and S an ita tion, The Pullm an Company, 165 N orth Canal S treet, Chicago 6. Illinois. S outhgate L e ig h , J r . , M. D. , C hief S urgeon, S e a b o a rd A ir Lane R a il ro ad , P . O. Bux'1620, Richmond 13, Virginia. H a rv e y N elso n , M. D. , M edical A d v iso r, Soo Line R a ilro a d , 805 M ed i c a l A r t s B l d g ., M inneapolis 2, M innesota. V. M. S trange, M. D . , Chief Surgeon, Southern P acific Com pany, H os p ita l D ep a rtm en t, 1400 F ell S treet, San F ra n c is c o 17, C alifornia. V/ M. . K. V. J. R. ( T e r m s e x p ire 1967) B. C layton, M. D. , Chief Surgeon, Southern R ailw ay S ystem , 15th and K S tre e ts , N.-W ., Washington, D. C. E . Dowd, M. D. , Chief M edical O fficer, Canadian N ational Railw ays, P . O. Box 8100, M ontreal, Q ue., Canada. W. Hollo, M. D . . Chief Surgeon, St. L ouis-San F ra n c is c o Railway, 4960 L aclede Avenue, St. Louis, M issou ri. W. Houk, M. D . , M edical D ire c to r, N orfolk & W estern R ailw ay. Roanoke, Virginia. A. Johnson. M. D ., Medical D irector, New York C entral System . M ichigan C en tral Depot, D etroit 16, Michigan. 2 STEERING COMMITTEE H arv ey N elson, M. D . , (CHAIRMAN), M edical A dvisor, Soo Line R a ilro ad , 805 M edical A rts B ldg., M inneapolis 2, M innesota. E . C. O lson, M. D . , Chief Surgeon, Illinois C e n tra l R a ilro a d , 5800 Stony Island Avenue, Chicago 37, Illinois. B. W. S to c k w e ll, M. D. , C h i e f S u rg e o n , D e t r o i t & T o le d o S h o re Line R ailroad and G rand Trunk W estern R ailroad, 1229-39 David Whit ney Bldg. , 1553 W oodward A venue, D e tro it, M ichigan. R. A. Johnson, M. D. , M edical D irec to r, New York C e n tra l System , M ichigan C e n tra l Depot, D etroit 16, Michigan. J. R. W inston, M. D. , S y s te m M edical D i r e c t o r , A tc h iso n , T o p e k a & S a n ta F e R a ilw a y , 80 E a s t J a c k s o n Blvd. , C h i c a g o 4 , I llin o i s . C O M M IT T E E ON M EDICAL STANDARDS J. R. Winston, M. D. (CHAIRMAN), System M edical D ire c to r, Atchison, T o p e k a & S a n ta F e R a ilw a y , 80 E a s t J a c k s o n Blvd. , C h ic a g o 4, Illinois. W. J . L o n g ew ay , M. D. (VICE-CHAIRM AN), C h ief S u rg e o n , C o lo ra d o &. S o u t h e r n R a i l w a y , 502 M e tr o p o l ita n Bldg. , D e n v e r , C o l o r a d o . S tan le y J . C y r a n , M. D. , M e d ic a l D ir e c to r , P e n n s y lv a n ia R a ilr o a d , 474 T hirtieth Street Station B ldg., Philadelphia 4, Pennsylvania. R. M. G raham , M. D . , D irec to r, D epartm ent of M edicine and S an ita tion, The P u llm a n Com pany, 165 N orth C anal S tre e t, Chicago 6, Illinois. J . W. Houk, M. D. , M e d i c a l D i r e c t o r , N o r f o l k & W e s t e r n R a ilw a y , Roanoke, Virginia. J . M. L. J e n s e n , M. D. , C h ief S urgeon, C h ica g o , R ock Isla n d & P a c ific R a ilw a y , 139 W est Van B u ren S tre e t, C h ica g o 5, Illin o is. R. A. Jo h n so n , M. D . , M e d ica l D ir e c to r , New York C e n t r a l S y s te m , Michigan C entral Depot, D etroit 16, Michigan. R. S. K ie ffe r, M>D. , C hief S u rgeon, M i s s o u r i - K a n s a s - T e x a s R a ilro a d , St. Louis 1, M issouri. ' J . K. S ta c k , M. D. , C h ie f S u rg e o n , C h ic a g o &. N o r t h W e s t e r n R a ilw a y , 127 N o rth C linton S tre e t, Chicago 6, Illinois. G. E arle Wight, M. D. , Chief of Medical S ervices, C anadian Pacific Railway, Windsor Station, M ontreal, Quebec, Canada. MEDICAL-LEGAL COMMITTEE *4 t B. W. S tockw ell, M. D. (CHAIRMAN), C h ief S u rgeon, D e tr o it & T oledo Shore Line R ailroad and Grand Trunk W estern R ailroad, 1229-39 D avid Whitney B ld g ., 1553 W oodward A venue, D e tro it, Michigan. S tan ley J . C y ran , M. D . , M edical D ire c to r, P en n sy lv a n ia R ailroad, .474 T hirtieth Street Station Bldg., Philadelphia, Pennsylvania. G. F . C ushm an, M. D. , Chief Surgeon, W estern P acific R ailroad, W estern P acific B ld g ., 526 M ission S treet, San F ra n c isc o , Calif. K. E. Dowd, M. D . , Chief M edical Officer, Canadian National Railways, . M ontreal, Q ue., Canada. V. W. Hollo, M. D . , C hief Surgeon, St. L o u is-S a n F r a n c is c o Railway, 4960 Laclede A venue,'St. L ouis, M isso u ri. 3 U. A. Johnson, M. D. , M edical D i r e c t o r , New Y o rk C e n tr a l i v . n Michigan C entral Depot, D etroit 16, Michigan. I s a d o r a K a p la n , M. D. , M e d ic a l and S u r g i c a l D i r e c t o r , B a l t i m o r e am; Ohio R a i l r o a d , M e d i c a l D e p a r t m e n t , B a l t i m o r e 1, M a ry la n d . Southgate L eigh, J r . , M. D . , C h ie f S u rg e o n , S e a b o a r d A ir Line R a i l road, P. 0 . Box 1620, Richm ond, V irginia. V. M. S tra n g e, M. D . , C h ief S u rg eo n , S o u th ern P a c ific Com pany, 1400 F ell S treet, San F ra n cisc o 17, C alifornia. J . R. W inston, M. D. , S y s te m M e d ic a l D i r e c t o r , A tc h iso n , T opeka & S an ta F e R ailw ay , 80 E a s t J a c k s o n B lvd. , C h ica g o , Illinois. C O M M I T T E E ON TR A U M A Southgate Leigh, J r . , M .D. (CHAIRMAN), Chief Surgeon, Seaboard A ir L in e R a ilr o a d , P. O. Box 1620, R ich m o n d 13, V irg in ia . .V. W. H ollo, M . D . , C h ie f S u r g e o n , St. L o u i s - S a n F r a n c i s c o R a ilw a y , 4960 L aclede Avenue, St. L ouis, M isso u ri. W. J . L o n g ew a y , M. D. , C h i e f S u r g e o n , C o l o r a d o & S o u th e r n R a ilw a y , 520 M etropolitan Bldg. , D enver, C olorado. W. E . M i s h l e r , M. D . , C h i e f S u r g e o n , E r i e - L a c k a w a n n a R a i l r o a d , 608 Republic B ldg., Cleveland 15, Ohio. B. W. S to c k w e ll, M. D. , C h i e f S u r g e o n , D e t r o i t & T o le d o S h o r e L in e R ailroad and Grand Trunk W estern R ailroad, 1229-39 David Whit ney Bldg. , 1553 W oodward A venue, D e tr o it, M ichigan. V. M. S tran g e, M. D . , Chief Surgeon, S outhern P a c ific Com pany, H ospital D epartm ent, 1400 F e ll S tre et, San F ra n c isc o 17, Calif. A. H. W i n te r s , M. D . , C h i e f S u rg e o n , P i t t s b u r g h & L a k e E r i e R a i l r o a d R o o m 4 0 , P . &. L. E . A n n ex B ldg. , P i t t s b u r g h , P e n n s y l v a n i a . CO M M ITTEE ON FIRST AID E. C. Olson, M .D. (CHAIRMAN), Chief Surgeon, Illinois C entral R ail r o a d , 5800 Stony Island A venue, C h icag o , Illin o is. S t a n l e y J . C y r a n , M. D. , M e d i c a l D i r e c t o r , P e n n s y l v a n i a R a i l r o a d , 474 T hirtieth Street Station B ldg., Philadelphia 4, Pennsylvania. K. E. Dowd, M. D . , Chief M edical O fficer, Canadian N ational Railways M ontreal, Q ue., Canada. H. W'. H a m m a t t , M. D . , C h i e f M e d i c a l O f f i c e r , C h i c a g o , B u r lin g to n & Q uincy R ailroad, 547 W est Ja c k so n Blvd. , C hicago 6, Illinois. J . S. N ile s, J r . , M. D. , C h ief S urgeon, L ehigh V alley R ailroad, Sayre, Pennsylvania. MEMBERSHIP MEETING ASSOCIATION OF AMERICAN RAILROADS MEDICAL AND SURGICAL OFFICERS SHERATON-CHICAGO HOTEL CHICAGO, ILLINOIS W ednesday, M arch 3, 1965 The f irs t g en e ral se s s io n of the F o r ty - F if th M em bership M eeting of the M edical and S urgical O fficers of the A sso c ia tio n of A m eric an Railroad! convened at 9:30 o'clock in the Boulevard Room of the Sheraton-C hicago Hotel, Chicago, IUinois, with D r. Harvey Nelson, C hairm an, presiding. CALL TO ORDER CHAIRMAN HARVEY NELSON: I would like to c a ll to o r d e r the 1964 Annual Meeting now being held in 1965. T his is, by the way, our F o rty Fifth M em bership Meeting. F o r a tim e, I w ondered w hether we ought to ju st join one of the b ro th erh o o d s, o r a t le ast get into som e of the negotiations so we could know when to get to g e th e r. At any r a te , we a r e h e re . There are a few announcements. * * (Announcements concerning the m eetings.) I would like to say that this is your m eeting, and the p rogram is b ased on your m edical p ro b lem s and m a te ria l that cam e from you in an s w e r to q u e s tio n n a ire s . We want you to p a r ti c ip a te with q u estio n s and re m a rk s from the floor. You will note that our proceedings a r e being rec o rd e d . T hese will be edited by both the m o d erato r and the sp e ak e rs. L ater they will be sub m itted to the Medical and Surgical Advisory Com m ittee for final review before printing. CHAIRMAN'S MESSAGE \ I presum e as C hairm an I should have a m essag e. I wouldn't be much of a C hairm an if 1 didn't have som e ideas about our group and our work. T h ere is a feeling that perm eates the M edical profession of respon sibility to their work, to M edical organizations and even to community ac tiv itie s. O ver the y e a r s , I have often m a rv e le d at the cooperation and dedication of busy m edical m en to tim e-consum ing com m ittee work. This h as been p a rtic u la rly tru e in this organization. O ur attendance at m e et in g s is r e m a rk a b le when we co n sid er the fac t th a t o u r m e m b e rs come from a ll o v e r th e country. I have ju st briefly checked and we have had some 26 com m ittee m eetings in the -last two y e a r s . For this support, I want to thank you. and I want to assu re the future c h a irm a n that he can rely on this kind of help. since our la st Annual M eeting of 1963, a few changes have been m ade which I hope prove to be worthwhile. F irs t, it was your c h a irm a n 's im p re ssio n that we have not heretofore been sa tisfa c to rily c o m p re ssin g o u r Annual M eeting into a coupLe of naifday sessio n s. A m ore extended pro g ram seem ed n ecessary to cover our m a te r ia l sufficiently and to allow a fa ir e x p re ssio n of the efforts of the various com mittees. This has been done. - Secondly, som e of us thought that we have not been willing to openly a n d a d e q u a t e ly fa c e s o m e of o u r m o r e s e n s i t i v e m e d i c a l p r o b l e m s . It /'o u ld seem n ecessary then to find out what these problem s are. To this end, questionnaires were sent out, and the substance of the replies form a s u b s t a n t i a l f o u n d a ti o n f o r o u r p r e s e n t p r o g r a m . We h ope the r e s u l t will be interesting and inform ative, and the m aterial a supply for future com m ittee consideration. T hirdly, we have never, to m y knowledge, m ade.any concerted effort to have m anagem ent p a rticip a te in our p ro g ra m . F o r m anagem ent to un derstand the duties and the responsibilities of their Chief Surge.ms and Medical D irectors, as well as the ram ifications and implications of our railro ad m edical, m edical stan d ard s and m edical legal problem s. should be particularly im portant now as we confront the ever-ir.creasir.g m om en tum of labor, legal and w elfare prom otion. When Chief Surgeons and M edical D irecto rs were originally appointed, th e ir function was to tr e a t in ju red em ployees, and la ter to make em ploy m en t exam inations. They now p r im a rily a r e a d m in istra to rs in a com plex branch of industrial medicine. A few y e a rs ago, we w ere red u c ed o rg an iz atio n -w ise , to the statu s of a Medical and Surgical A dvisory Com m ittee with a questionable p e r m is sio n to have subcom m ittees and to have Annual M eetings of our whole organization. 'We cannot and have not o p era te d th is way. Econom ic s tr e s s w as a stated reason for this decision, but we, as m edical and surgical o ffic e rs, have to accept equal re sp o n sib ility fo r th is change. Outside of the ch a irm a n inviting his p re s id e n t to a d d re ss the annual banquet, and a few of his officers to attend, no effort was made to have m anagem ent understand the efforts and purposes of our organization. We, o u rselv e s, know the im p o rta n c e of o u r getting together p erio d ically to keep a b re a st of fast im pro v in g m e d ic a l p ra c tic e s and to exchange id eas in the field of ra ilro a d m edicine. But does m anagem ent know? T oday we have, th e re fo re , invited m anagem en t to p articip a te in our p r o g r a m and to a tte n d a s m u c h of i t a s th e y c a n . We e x te n d a c o r d i a l w e lc o m e to M r. Z im m erm an and m e m b e r s of the G en e ra l C om m ittee who a re h e re 6 and.to other m e m b e rs of m anagem ent who a r e on the panels and in the audience. Fourthly, for this p ro g ra m we have changed the form at to one largely of p a n e l sy m p o s iu m s. By m e a n s of th is m o r e in fo rm al, anti to som e ex tent im prom ptu type of discussions, we can all take part, m oderators, p a n e l s a n d a u d i e n c e . D is c u s s io n m a t e r i a l fo r y o u r c o n s i d e r a t i o n h a s 1. on accum ulated, but the d iscu ssio n s th e m se lv e s will be guided by each m od e ra to r. They will not n e c e s sa rily be confined to the listed m a te ria l o r in that order. F ifthly, a happy thought for m e was the form atio n of a new com m ittee, a s o r t of executive com m ittee, titled The S teerin g C om m ittee. T his group^ appointed by the C hairm an, and including Dr. E rn e s t C. Olson, D r. John R. W in sto n , D r. B enj a m i n W. S to c k w e ll, an d D r . R alph A. J o h n s o n , m e t as frequently as the occasion required. P rep arato ry planning, arranging of d etails and counselling the ch a irm a n w ere invaluable a s s is ts to our work. I heartily reco m m en d that this be a p erm an en t p a rt of o a r organization. Sixthly, an idea developed this la st y e a r which is worthy of your c o n sid eration. S everal m e m b e rs have ex p re ssed the thought that we should get together m ore frequently. O thers have frequently stated that we s o m e tim es are inadequately inform ed and are a rb itra ry in our decisions, and that it could not hurt us to know m ore about sp ecial fields or what m edical authorities think. ' F ro m these two nebulous reflections evolved the em bryo of a plan to have what might be called in te rim sym posium s, possibly tlu ee o r four tim e s a y ea r, on any w orthwhile m e d ica l subject concerned with railro a d m edical practices. As a tria l balloon, such a panel symposium was held in Chicago on J a n u a ry 12, 1965, on the su b je ct pf "Vision. " T h i s p a n e l c o n s i s t e d o f f o u r o p h t h a l m o l o g i s t s . D r. F r e d A. L au p p e of Wayne U niversity, D r. J a m e s Fox C ulver of the Air F o rce Base at San Antonio, D r. M a rv in D. H enry of C hicago and Dr. Kenneth L. Roper of Chicago, with D r. John Winston as a very capable m oderator. This program was interesting, instructive, and well received. The advantages of such interim sym posium s are obvious. The a s s im ilation of the m ost m odern and authoritative inform ation on any subject for the digestion and u se of o u r c o m m ittee s does not com pel us to abide by the thinking of-these specialists. It is not difficult to think of many subjects and different locations in which to have m eetin g s, as fo r exam ple n europsychiatric subjects in Topeka; vascular, s u r g e r y in M inneapolis o r Houston; pulm onary d ise ase s; hearin g; etc. Many of the su b je cts which co m e to mind pertain to m e d i c a l s ta n d a r d s , but not n e c e s s a r i l y so . B a c k s , d is c s , spinal fusions, cancer, average healing periods for specific in ju rie s, for example, would be som e of interest to the M edical L egal C o m m ittee. It should be of ir.- 7 finite value to have m o r e know ledge than we do on the m any su b je c ts we have to deal with. The resp o n sib ilities of your ch airm an have involved a lot of work, but it has been gratifying. It is only fitting that I acknowledge the unselfish and very capable assista n ce of your V ice-C hairm an, Dr. E rnest C. Olson. He will be a good le ad e r next y e a r. To sail our program on a different tack has been an interesting p ro je ct, and I hope you will like it. We w ere v e r y glad to fo reg o the p le a s u r e today of a s se m b lin g in a sunny clim ate in o rd e r to begin our p ro g ra m the day before the m eeting of the G en e ra l C o m m ittee of the O p eratin g -T ran sp o rta tio n Division of the'A ssociation of A m erican R ailroads, of which Mr. Z im m erm an is ^ h a i r m a n . A num ber from this com m ittee are in attendance today. We a l s o a r e d e lig h te d th a t a m e m b e r of t h is c o m m i t t e e , a s V ice P re sid en t of the O perations and M aintenance D epartm ent, was willing to leave Washington a day early to address our group. It i s m y p l e a s u r e to i n tr o d u c e y o u to o u r g ro u p , M r. M anion. It is o u r p le a su re to h e a r you talk and have this opportunity to becom e b etter acquainted with you. (Applause) ADDRESS: R. R. M anion, Vice P re sid e n t, O perations and Maintenance D e p a r tm e n t, A s so c ia tio n of A m e r ic a n R a ilro ad s T hank you. D r. N e lso n , G entlem en: I am honored to be included in your p ro g ram and very pleased to participate, and I am also very pleased that Dr. N elson was able to have his m eeting at such a tim e and place that m e m b e rs of the OT G eneral C om m ittee w ere able to come. T here are a num ber of them here, and I know a number more had tended to be h e re , but the bad w eather we have been having around the ><funtry h a s had its effect on r a ilr o a d o p e ra tio n s, so a num ber who planned to be h ere didn't m ake it. While this is the f irs t tim e I've had an opportunity to m eet with you, it is by no m eans m y f ir s t introduction to your activ ities o r the co n trib u tions of your m e m b e rs to the o rd e rly functioning of ra ilro a d s - esp ecially from an operating standpoint. Working with m ed ical ex am in ers and the local doctors as a su p erv iso r o r o fficer in both m a in te n an c e and operatin g w ork, I long ago ap p reciated the role of the R ailroad D octor in assistan ce to the operating m an in his p erso n n e l ad m in istra tio n and, v ery im po rtan tly , in the w elfare of em ployees. In an effort to le a rn m o re about yo u r plans ami p ro g ra m s, l found that th is m eeting had been scheduled tw ice before only to run afoul threatened railroad work stoppages. \ Dr. N elson m entioned that it m ight be advisable for your group to join one of the brotherhoods. It o c c u rre d to m e that neither Doc Wolfe nor the organizations really had anything against your holding a meeting. Some, however, may be excused for harboring a slight suspicion about this. You are to be congratulated both on your perseverance and ability to select a safe date for this meeting. Very interestingly, on your program , your first symposium, ad d re ss ing itself to the extrem ely im portant relationships of M anagement, M an power and M edicine, begins with a discussion of employee selection. Several extrem ely significant changes in the ch aracter of our industry during the p ast twenty y e a rs o r so - changes which have taken place in certain other industries also - have m ade it imperative that the selection of new em ployees be carefully m anaged and of the highest o rc e r possible. Some of the m o re im p o rta n t o f th e se changes - not n e c e s s a r ily in s e quence or o rd er of significance, are: . 1. H ig h e r o r d e r o f te c h n o lo g y a p p lie d to the in d u s try . 2. R ecognition of and d ete rm in a tio n to m eet competition. 3. A c c e p ta n c e of new c o n c e p ts in e m p lo y e e re la tio n s. The p a r t i c u l a r re fe re n c e is to stability of em ploym ent, costs associated with se v eran c e in case of reduction in em ploym ent levels, and extensive "fringe b e n e fits." The implications of these factors on the requirem ents fir developing and m a in ta in in g qualified and effective p e r s o n n e l a re c o n s id e ra b le . In view of yo u r extensive p ro g ra m - attacking, a s it does, many of these elem ents - and also Dr. N elson's welcome advice that about ten m inutes would be sufficient from m e - I'll point them up briefly. 1. W ith r e s p e c t t o te c h n o lo g y : By its v e ry n ature, o u rs has always been an industry req u irin g e x t r a o rd in ary d isc ip lin es. To achieve th ese, a la rg e segm ent of the work force had to m e a su re up to unusual sta n d ard s of stam in a, alerlnc.-.o, av ailability and devotion t o duty. Now, with the in c re asin g application of new teen oologies th ere evolves the req u irem en t for us all to adapt effectively to new environm ents, develop new skills and to se lec t and train people equal to these new needs. , k \ I submit that this will challenge not only the m anagers, the personnel experts, but will call for the full assistance of our m edical arm . It a p p e a r s to m e th a t th e r o le of the m e d ic a l o ffic er b e c o m e s m o r e useful and im portant than ever in assistin g in selection, screening, guid ing and guarding em ployees' health and safety. Do we not have much to acco m p lish - not only in s ta r tin g with p r o m is in g people - but in a s s is tin g o r en co u rag in g them to s ta y w ell and p ro d u c tiv e ? 2. iX ir In d u stry h as been a c c u se d c f r e a c h e s arc If th l ha t tim e s b e e n ju s t if i e d - :: is not w . T ic s tinent a re grow ing in population and production, and the c e n te rs of p r o duction are shifting. This m eans the needs for transportation are growing and shifting, too and in g rea t s trid e s . T he capabilities and lim itations of the s e v e ra l tran sp o rtatio n m odes a r e becom ing much b e tte r defined - and with this, it is becoming increasingly evident that the railro ad industry not only will continue to be the p rin cip al and m ost econom ical mode for the great bulk of freight, but has the capability and the vitality to vastly im p ro v e the handling of goods with the dependability of se rv ic e r e q u ir e d by our economy. I cite this situation only to em phasize again the im portance of m an ning a dynamic industry with people qualified to participate and both equal to and e a g e r fo.r the ch a lle n g es involved. /' 3. Now - f r o m th e s t a n d p o i n t of i n d u s t r y e c o n o m i c s : Along with som e other industries - but possibly at this tim e in a d vance of m ost - new concepts have been adopted re g a rd in g stability of em ploym ent, and - or - benefits to em ployees involved in work force r e ductions resulting from technological adjustments, m erg ers, relocations and method changes. These new factors im pose challenging burdens that will not perm it us to be inept or ca rele ss in the establishm ent and m aintenance of the quality of our work force o r its m anagem ent. It se e m s to m e that this p re s e n ts a f ir s t- c la s s challenge to your fine group to effect a p ro g ra m of p articip a tio n which can be supplied only by you. Also on the side-of economics - from discussion with Ken Carney, I 'm aw are of the im portant p a rt you play in the a re a of p erso n al injury c la im s. T o begin with, the o v e r-rid in g ly im p o rtan t thing is to reduce to the absolute m inim um the incidence of in ju rie s, next to m inim ize the ef fec t of accidents and next to provide to the claim s officer the g rea test of ^ ytupport which can be supplied only by your special abilities. Since World W ar II o u r in d u stry has had its ups and downs, and has had to m ake m any adjustm ents to keep alive. Some of these were painful som e were overdue - on balance, I inink the body will em erge m ore healthy than ever - along with this, our A ssociation has gone through some ad ju s tm e n ts ,- too. H ere and there we m ay have dropped something that should be retained. One of these of which I have becom e aw are is the printing of your annual proceedings. I take this opportunity to tell you that arrangem ents have been made to reinstitute the printing of your proceedings. I would like to add that y o u r invitation to the G en e ra l C om m ittee to attend was v ery w elcom e and was d iscu ssed , and I would like to add again that the OT G eneral C om m ittee has a great appreciation for what the d o ctors do. T hank you v e ry m uch. (Applause) CHAIRMAN NELSON: Thank you. M r. Manion. I have a few n am es of those other than our Medical O fficers, who have registered. I will just briefly read them. We h a v e a s o u r g u e s t s M r . O. H. Z i m m e r m a n , Vice P r e s i d e n t of Operating Department, Illinois C entral Railroad. M r . W. D. L a m p r e c h t , V i c e P r e s i d e n t of O p e r a t i o n s of th e S o u th e r n Pacific. M r. R. D. Shelton, V ice P re s id e n t of O perations, Santa F e. M r. C. S. S an d e rso n , V ice P re s id e n t and G en e ra l M anager of the L. & N. Mr. E a rl O liver, Vice P re sid en t of Personnel, Illinois C entral R ail road. M r. W illiam T . Roche, G en e ra l M anager of the Norfolk & W estern. M r. M au rice N. R ay, G en e ra l C laim s A ttorney, New York C en tral System. M r . G. M. D e L a m b e r t , D i r e c t o r of P e r s o n n e l of th e N. P . M r. D. L. B o r c h e r t, D i r e c t o r o f P e r s o n n e l of the Soo Line. M r. R. R. M inor, G en eral C laim s Agent of the Illinois C e n tral Railroad. M r. C lem M aloney, G eneral C laim Agent of the Belt Line of Chicagc Mr. B. R. H ow ard, G en e ra l C laim s Ageht of the Southern P acific in San Francisco. Mr. K erm it Johnson, G eneral Claim Agent of the N orthern Pacific, and, incidentally, the Legal C hairm an of the Medical Legal Com m ittee. Mr. E arl Z eigler, G eneral C laim s Attorney of the Atlantic C oast ^ Line Railroad. >I M r, E rn e s t A. Je n so n , C laim s A ttorney of Soo Line R ailroad. T here undoubtedly a r e o th e rs. I am s o r ry not to have a'full list. Welcome to our m eeting. , It is now about tim e to get into o u r f ir s t paneL Before that, we will have a brief coffee break. (A short r e c e s s w as t a k e n . ) 11 PAN E L - M A N AGEM ENT, M ANPOW ER AND MEDICINE? CIIAIRM/iN NELSON: T h e re was no pro b lem in selecting the m o d e ra to r for o ur first panel sym posium . All we wanted was som eone to set the tem po for our entire m eeting. Fortunately, such a man is just about a c h a r te r m e m b er of our group. You a re all fam iliar with his o rg an izatio n al and rh e to ric a l ability. He is the m o st conversant layman doctor that I know - M r. K. A. C a rn e y . Mr. Carney, will you introduce your panel, please. M O D E R A T O R K. A. C A R N E Y : If y o u d o n 't m in d . D r. N e ls o n , I would like to run this show my own way. (Laughter) F i r s t of all, I would like to com plim ent M r. Manion and Dr. N elson o r p rese n tin g our p ro b lem s, and what we propose to do now is to see now we can im plem ent what both the doctor and the executive officer of the AAR says the m edical d e p a rtm en t should do, and what m anagem ent ex p ects of a m ed ical departm ent. M r . T o u h y , the th e n p r e s i d e n t of t h e C. fit O. at W hite S u lp h u r S p r in g s , eig h t y e a r s ago, sa id he was a b y s m a lly ignorant. You know, I a m going to have to ca ll on "Chick" H o rsley to c o r r e c t m e in som e of these words. Y o u w i l l find out w hen M r . H o r s l e y g e t s in to t h is p i c t u r e , he w-.U usew ords that you will have difficulty in understanding, and we will have som eone interpret them for you, if you like, but nevertheless, Mr. Touhy sa id he was very ignorant of the things the medical departm ent w ere do ing. He knew they were im portant, and he valued the m eeting he attended in White Sulphur Springs im m easurably because he had learned for the f ir s t tim e how im portant you w ere in the a r e a in which you s e rv e so well. At the sam e tim e, the then C om m issioner of the Interstate C om m erce com mission com mented on the work of the doctor, how im portant it was "(o t h e s a f e t y of th e r a i l r o a d s . Now, our panel this m orning is com posed of some distinguished men, and I w ill introduce them beginning at the left end of the table. The first m a n you see is not a m e m b e r of the panel. He is John R isendal. He is m y a ssista n t, and he is h e re fo r the p u rp o se of reco rd in g and su m m in g up the consensus of the views of this group. The second gentlem an on the left is E. T. H orsley, the c a r r ie r m em ber of the National Railroad Adjustm ent Board. The next gentlem an is Ed Glennon, counsel for the Soo Line Railroad, from Minneapolis, Minnesota. Next is Maurice Ray, G eneral C laim s Attorney of the New York Cen tr a l at New York. 1 o Next is E arl O liver, recently appointed Vice President of P ersonnel of the Illinois C e n tral R a ilro ad , who consented at the last minute to take M aynard P ark s' place. Vice P resid en t-P erso n n el of the M issouri P a c i fic. We a r e v e r y i n d e b t e d to y o u , M r . O l i v e r , f o r c o m in g to us on t h is very short notice. Next is Otto Z im m e r m a n , Vice P re s id e n t, D ire c to r, of the Illinois C entral Railroad, Chicago. On my fa r right, of c o u rs e , you know Bill Todd and Nelson. T hen we have Dr. Olson, Chief Surgeon of the Illinois Central. Dr. Southgate L eigh,'C hief Surgeon of the Seaboard A ir Line R ail road. Dr. John Winston of the Santa Fe, and Dr. Ben Stockwml, of the G rand T runk, and p e rh a p s so m e o th e r railro a d . I don't know. (Laughter) At any rate, I would like to make one o r two announcem-nts first. We w elcom e the p a r tic ip a tio n of all of you. If a question is asked and you c a n b e a t a p a n e l m e m b e r to a n s w e r i n g it, p l e a s e do so. if u hav e a q u e s t i o n th a t you d o n 't f e e l lik e a s k i n g , but yo u w ou ld li'.n. * have i t a n s w e r e d , p l e a s e s u b m i t it o n a p i e c e of p a p e r . Have s w-. r b r i n g i: up h e r e , and if we h a v e t i m e , an d c a r e to a n s w e r it, we ... When you do ask a question, we would like you, particb ;rly those you in the audience, to state your nam e and your connects u\ To the panel m e m b e r s , let m e say we have a lim ited am ount of tit:.-:. We want to keep you on the ball and the point that is raised. Don't dev ate o r d e p a r t into a lo n g - w i n d e d t a l k a b o u t an y th in g .i A n s w e r t h - q u e s t i o n a s c o n c ise ly a s you can,-.and if you d is a g r e e , we hope that we evoke a ll kinds of criticism , all kinds of re m a rk s on both sides of the question, because that is the only way we a r e going to get any benefit out of the program . I think the relationship betw een the chief surgeon, the m edical d ep art m ent and managem ent, has alread y been answered. t Now, we a re going to im p lem e n t it a s we study these other' p hases of the work. T his is on p ag e 8 and I hope a ll of you w ill tu rn to that page because the second question is the development of reasonable physical standards applicable to applicants for em ployment and for continuation i n service. 4 D r. Winston has been w orking h a rd on p erfec tin g stan d ard s which a re going to be subm itted to th e M edical Section in due course because this is an a re a in which the then C o m m issio n er of the Interstate C om m erce C om m issio n said th e re was a g re a t need fo r sta n d a rd s that should be adopted by the railroads generally. 11 ' John, would you c a re to co m m ent a little bit on the situation in that area ? DR. JOHN R. WINSTON: T h e re was a tim e when m edical s ta n d a rd s w ere an e x t r e m e l y s i m p l e s e t o f r u l e s t o fo llo w . T h e m o r e we. b e c a m e e n l i g h t ened about m edical problem s, the g re a te r the responsibilities of the v a r ious rep resen tativ es of the railro a d in dustry becom e, the faster our train s, the tighter our schedules, the m o re com plex this subject becom es. Now, in o r d e r to get into the m e d ic a l sta n d ard s as such, re q u ire s an understanding of not only the duties and responsibilities and obligations of the job. It r e q u ire s a much g r e a te r understan d in g of the m an him self, not altogether from his physical capabilities, but also from his m ental capabilities. T hen we want to find out how long this fellow is going to be working for us. As U n d erliter said, and this re la te s to chief surgeons as well: Unlike clini'cal m edicine, which deals chiefly with the problem s of the p resent, in s u r a n c e - - I say ra ilro a d --m e d ic in e is co n cern ed to a g rea ter d egree with the rem ote future. In this function the physician plays the role of a prophet, ra th e r than a healer,, and believe me, in o rd er to put this into effect, takes just a little bit of tim e. Our old sta n d ard s w ere about this siz e . T his is the way they will probably look. (Holding up books) MODERATOR CARNEY: Thank you very much. Dr. Winston. I might say that Dr. Winston has been working on this a long tim e, and it is a te r, rific job. D oes anybody else c a re to m ake an observation in connection with standards ? MR. HORSLEY: About the necessity for standards, Mr. M oderator? I hould like to say that I have long advocated the n ecessity for sta n d ard s ^ ^ / p h y s i c a l f itn e s s for th is r e a s o n , that in 14 y e a r s of sittin g on the N ational Railway Adjustment Board, in defense of the c a r rie rs , I have found that disputes involving physical fitness for work on the railro ad . a ro s e out of the assertio n made consistently by labor that the opinion of a r a ilro a d doctor is no b etter than the opinion of the em ployee's p riv ate physician. Now, then, if you do not have stan d ard s of physical fitness upon which to base your opinion, then th e sta n d a rd of p hysical fitn ess that prevails in this adversary business of em ployee versus management, that standard is this: He is fat and warm , and he doesn't wet the bed. T h erefore, he can w ork. (Laughter) But the r a ilro a d d o cto r has opined he cannot work b e cause his physical condition does-not conform with the job requirem ents. 14 T h ere you have a dispute. Hence, M r. M oderator, I advocate the form ulation of standards of physical fitness. MODERATOR CARNEY: Thank you very much. Does anybody else have a com m ent? If not, the next observation h e re we m ake is: Should individual r a i l ro a d s adopt th e ir own o r accept AAR recom m end ed standards with such r e s e rv a tio n s deem ed advisable? And I would like to call upon Mr. H orsley again. MR. HORSLEY: I would say e ith e r one, e ith e r the AAR sta n d a rd s o r the adoption of the railro ad 's own physical standards, providing that the c a r r i e r 's adoption of its own physical standards is not m ore rigid than the AAR published physical standards, unless that increased rigidity is di r e c t l y r e l a t e d to a p a r t i c u l a r c r a f t a n d t h e job perform ar.ci.-s .'>t th a t c r a f t on that p a rtic u la r ra ilro a d because of the traffic that is unique to that railro a d , in a sense, or geographical conditions, but otherwise, yes, eith er the AAR standards o r the c a r r i e r 's own adoption of the standards. MR. OLIVER: I should like to com m ent on that and differ just a bit with Mr. H orsley. A question frequently a rise s as to whether the standards a r e r e a s o n a b l e . It s e e m s to m e a s a r a i l r o a d p e r s o n n e l o f f i c e r , th a t we would have a much b etter arg u m en t for the reaso n ab len ess of the stan d ard s if the sta n d ard s have the backing of the AAR, 'than if they are simply sta n d a rd s draw n up by the individual r a ilro a d and the em ployees can show that on the Grand Trunk, for example, the standards are far different from those on the Illinois C entral and so on. MODERATOR CARNEY: E arl, do you have any ideas as to whether or not the fact the AAR is identified with these standards and a railro ad makes an exception to them , would this have any effect upon your judgm ent at all? You don't want them to adopt them in toto. MR OLIVER: No, s ir , I think that the b asic sta n d ard should be the AAR s ta n d a r d s m odified to m e e t th e in d iv id u a l c a r r i e r ' s own p r e d ile c tio n s . MODERATOR CARNEY: P eculiar circu m stan ces. Are there any other ` o b se rv a tio n s? Dr. Wight. DR. G. E A R L E WIGHT ( C a n a d ia n P a c i f i c R a ilw a y ): As to t h i s q u e s tio n of rigid printed standards, I believe that is what you are talking about. I think th e re is a lot'of danger attached to this. In the United Kingdom some t i m e a g o th e y did a jo b a n a l y s i s . It to o k t h e m 10 y e a r s to do a c o m p le t e jo b a n a l y s i s , an d th e y f ix e d s t a n d a r d s f o r e a c h jo b . By t h e ti m e it was f in is h e d , th jo b s h a d ch a n g e d . T h e s t a n d a r d s w e r e no lo n g e r a p p lic a b le , and once you get a thing in p r in t and in w ritin g , it is awfully hard to gel it out, and I fe l that a printed, rigid standard is som ew hat dangerous. 15 And then, M r. H o rs le y 's c o m m e n t ab o u t w h e th e r the r a ilw a y s should have their own standards or the AAR stan d ard s. I believe he made the re m a rk that the railway standards should not be m ore rigid than the AAR. I think there is another way of looking at this. I think AAR sta n d ard s are m inim um stan d ard s applying to all railw ay s on the North A m erican co n tinent, and that any railw ay within itself should be p erm itted to have h ig h er s ta n d a rd s if they so d e sire . MR. HORSLEY: I agree with Dr. Wight, M r. M oderator, and I believe he ag re es with m e in my original sta te m en t, in that deviation from the AAR standards to m o re rigidity should be rela ted to the p articu lar reaso n s for there being m o re rigidity on the p articu la r railro ad involved, either geographically o r traffic conditions o r otherw ise. MODERATOR CARNEY: That is a factor in establishing the reasonableB s s of such sta n d ard s applicable to the p a r tic u la r operations involved. MR. HORSLEY: M r. M oderator, I should also lik e to m ention that Dr. Wight spoke of his experience with resp e ct to making standards for each jo b , and in my r e m a r k s I re la te d the s ta n d a r d s to the c r a fts , not each job, so that a cra ft standard would be m uch b ro a d e r, of co u rse, than an individual job function standard. DR. WIGHT: You warned m e to be ca refu l about this m an and sem an tics. I should have chosen my words carefully. (Laughter) MODERATOR CARNEY: You "ain't" heard nothing yet. (Laughter) M R . H O RSLEY : No, s i r , and y o u a r e not g o in g to. He h a s s p o k e n of m y v o ca b u la ry and a l l I would like to say is that he is wrong b ecause my v o c a b u la ry is e x tre m e ly lim ited by the p r e s e n c e of this lady r e p o r te r today. (Laughter) ilR . ZIM M ERM AN: b sed to be h ere to That makes interpret the my job m uch e a s ie r because cuss words they used. I was sup- MODERATOR CARNEY: Undoubtedly she has heard some before, so I would think that within reasonable lim its you m ay be free to indulge y o u r self. Are th e re any other com m ents ? If not, le t's p a ss on to the selection of m anpow er. I w arn everybody in the ro o m that we will not to le rate d is c u ssio n on anything except the selectio n of m anpow er, the applicant fo r em ploym ent. Wc a re not talking about in -se rv ic e em ployees. We a re talking, about a m an coming to your railro ad and trying to get a job. The first question is: Is It d e s i r a b l e l o s c r e e n a p p l i c a n t s f o r e m p l o y m e n t b e f o r e s u b m i t t i n g them for m edical ex a m in a tio n s? I would like E a r l O liv er to com m ent on 16 that if he would. MU. OLIVER: I think i t is highly d esira b le to sc re e n the applicants b e f o r e s e n d i n g t h e m to t h e d o c t o r f o r m e d i c a l e x a m in a tio n . It was d e s i r ab le y e a r s ago, but it is p a r t i c u l a r l y d e s i r a b l e now th a t a g r e a t m any of us are using the back x -ray s which are costly. On t h e I llin o i s C e n t r a l we u s e b a c k x - r a y s f o r m o r e than 50 p e r ce n t of the ap p lican ts. I think the m e d ic a l e x a m in a tio n a ll told am ounts to a b o u t $3 5. 00. T h a t is a lo t of m o n e y if you a r e n o t going to h i r e the a p plicant. We a r e r i g h t now in th e p r o c e s s of r e v i s i n g th e i n s t r u c tio n s to ou r em p lo y in g o f fic e r s and in s tru c tio n n u m b e r one r e a d s as follows: "Do not have applicant undergo a m edical exam ination until you are quite certain you will hire him, if he is physically qualified. " MODERATOR CARNEY: Are there any other com m ents? DR. NELSON: I would like to ask how thorough m o st railro ad s are in p r e lim in ary screening. Quite frequently I find that applicants come through fo r m e d ic a l exam ination, who n ev e r should have. P re -e m p lo y m e n t qu estionnaires and screenings a re exceedingly im portant, not only for o r dinary lay inform ation but for m edical and neuropsychiatrie inform ation as well. If th ese q u estio n n a ire s a r e not adequately review ed by resp o n sib le p eo p le, they a r e w o rth less. T h is , I b e lie v e , is th e re sp o n sib ility of p e r sonnel departments. M ODERATOR CARNEY: In o th e r w o rd s, you would like to know fro m Uns g roup h e re how m any have e x p e rie n c e s w here they a re nut p ro p erly screen ed by the employing officer before you examined them. DR. NELSON: That is right. MODERATOR CARNEY: Does anybody have any comments on that? Yes, Dr. Wight? DR. WIGHT: One sm a ll one. I agree w holeheartedly with the speaker. You a re putting too m uch resp o n sib ility on the doctor. You will get a man appearing before the doctor for em ploym ent as a waiter in a dining c a r * se rv ic e . He is 5'9" and weighs 260 lbs. Well, now, how can that man get a ro u n d ? And yet, he is being sent to the doctor for examination. He h asn 't been screen ed p ro p erly for his job. MODERATOR CARNEY: That is a good point. 1 Does anyone else have any experience along this line? MR. OLIVER: I m ight c o m m en t f u r th e r , M r. C arney. We have our e m ploying officer m ake out a m edical questionnaire. Of course, the em ploy ing officer is not attem pting to take over the m edical officer's job, but 17 lie know s th a t c e r t a i n th in g s w ill be d is q u a li f y i n g d e f e c t s , s o we h a v e h im ask the applicant quite a num ber of questions. For exam ple, do you have any trouble distinguishing colors ? The employing officer knows that one of our requirem ents for training engine serv ice em ployees is absence of color-blindness, and we have quite a list of questions. I think that this is helpful in a further screening of the applicants. We a r e a b le to se n d to the d o c to r th e n only th o s e who a p p e a r to the e m ploying o fficer as good pro sp ects. MODERATOR CARNEY: This i s a good point. I would like to r e la te a personal experience I had some y ea rs ago when I was in the claim d ep a rt m ent of the Illinois Central. We h a d a b a c k in ju r y g r o w i n g out of a t o w e r m a n who w as w a lk in g to h is job and fell down on the t r e s t l e , about 20 feet, and got v e ry badly h u rt. When we in v e stig a te d th is c a se , then we found in his application p a p e r s , which w ere c l e a r e d by the em ploying offic er, a h is to ry that while he was in high school he had a very nervous condition. He was sent to a hospital for about a year, a state hospital for correction, brought back and his en tire h is ic ry the re s t of the tim e in the hospital was one of instability. ' He got a job at N orthw estern U niversity in anim al culture, and they found that lie couldn't work well except u n d er the clo sest p o ssib le s u p e r v isio n . Y et, when we h ir e d h im , we put h im in a tow er a ll by h im s e if , throw ing sw itches, of co u rse , for the operation of trains. O bviously, he hadn't been adequately c le a re d . Now, our r e c o r d s in the c la im b u s in e s s a re r e p le te with people who a r e brought in to the r a i l ro ad s e rv ic e , who p re se n t g rea t h az ard s from that point of view. The doctor should not be called upon to exam ine anybody who has a re c o rd c o m p a ra b le to the one I d escrib ed o r any other kind of rec o rd that would in d icate any kind of instability in the work he is called upon to do. We have co m m en ted tim e and tim e again that d e p a rtm e n t s t o r e s s o m e tim e s s c re e n their applicants m uch b e tte r than we do. W henever we take on a m an who is unstable and is difficult, we a r e exposing o u rse lv e s to a $50,000 or $100,000 verdict or judgment for an insignificant injury. DR. ERNEST C. OLSON: M r. C arney, I would like to direct som ething to M r. O liver. Isn't it true that we have a ra th e r com prehensive in te rro g a to ry m ade to c e rta in c la s s e s of ap p lica n ts on the Illinois C e n tr a l by the em ploying officer that sc re e n s out a g re a t d eal of the m en tal asp ec ts in the individual ? MODERATOR CARNEY: What do you think of that, E a r l? MR. OLIVER: Dr. Olson, frankly, I am not fam iliar with it unless you are talking about the m e d ic a l q u e s tio n n a ire which we do use. 18 MODERATOR CARNEY: No, he is asking whether or not your employ tner departm ent does not u ndertake to exam ine these people and develop these apparently psychological problem s. DR. OLSON: I was r e f e r r i n g p a r tic u la rly to M r. R ichardson's set of questionnaires which he has, and I know that it is used rather extensively in the Chicago a re a . I don't know how m uch it is used on line. It seem ec to m e that from reading th e se questions and answ ers, that you got a pretty good idea of the stability, the m ental ability, the intellect and the suitability of the candidate o ther than his physical condition. MR. OLIVER: D r. O lson, we do have c e r t a i n te s ts that we give to c e r ta in em ployees, but th is is not u n iv e rsa l. The ran k -an d -file of employee do n o t g e t t h e s e t e s t s . t* Now, I think th e re a re som e questions in the m edical questionnaire that the employing officer m akes that gives some idea in this direction. DR. WINSTON: I would like to subm it another area that the m anagem ent m ight explore. That has to do with the testin g of vision, color sen se and hearing. I would think that th e hiring officer could c a r r y out these p r o c e d u r e s eq ually as well a s does the little g ir l up in the d o c to r's office who happens to be thinking about h e r boyfriend at that p artic u la r moment. MODERATOR CARNEY: A nother com m ent I think is appropriate at this tim e . S u m m in g up what v/e th in k about t h i s tiling g e n e r a lly , we a r e agre< I believ e, th at the em ploying o ffic e r, w hether he happens to be a c le r k in an outlying point o r h e a d q u a rte rs o r w hether you have a p articu lar depar m e n t f o r it, sh o u ld be t r a i n e d to p ic k up a s m a n y of t h e s e c a s e s a s p o s s i before subm itting them to the doctor. I'would like to subm it one m o re thought on behalf of the se rv ic e that we, in the AAR G en eral C laim s D ivision, provide, and which m ost r a i l ro ad s p articipate in. (Just two of the large railro ad s haven't yet got around to r e p o r tin g as they sh o u ld .) T h is i s , 1the r e f e r rin g to o u r office an indication that you a re going to em ploy X person, giving us his Social S ecu rity n u m b e r. We th e n give yo u a re p ly within 24 h o u r s , in d icatin g whether or not that man has had a previous claim against a railroad, or was reje cte d by som e other ra ilro a d for physical reasons. This inform ation is not a notice to you that this man is unemployable It is m e re ly a notice to you of the fact that he has been involved in sofne o t h e r s i t u a t i o n th a t b e a r s f u r t h e r i n q u i r y on y o u r p a r t. We hav e form'd m en who failed to d isc lo se th e ir p rio r ra ilro a d se rv ic e, their railr oad accidents, their p rio r rejectio n s, all of which the hiring railroad out ht to be cognizant of before em ploying an applicant. His answ ers to'the q u estio n n a ire and all this sort of thing, whether th e y a r e h o n e s t or not, is a n o t h e r in d ic a tio n . So, with th is, you have go a screening process that should save you money for medical examination if you properly clea r them , and also educate y o u r em ploying p e rso n u e L 19 Do you have anything, O tto? MR. ZIMMERMAN: I want to go back to that p rev io u s sta te m e n t that the doctor m ade with resp e ct to a clerk o r employing officer m aking color p erc ep tio n te sts on a m an. I don't think these laymen can be considered as qualified to make those perception tests. In the ca se of the gal thinking about h er boyfriend, the color is bound to be rosy, whether she can see it or not. (Laughter) I would r a th e r have the doctor m ake the exam ination as he is supposed to do. It is his sig n a tu re that is on that paper. If you com e to a c a se where co lo r p e rc e p tio n is an ite m in so m e s o r t of accident, I don't want so m e Joe Blow c le rk out h ere with his nam e on that form or anything that m ight indicate the doctor did not give the thorough examination on the eyes that1,e s h o u ld . I would like to take a little exception to that. DR C H E S T E R R. ZEISS (Elgin, Jo lie t and E a s t e r n Railway): I a g r e e with M r . Z i m m e r m a n 100 p e r ce n t. I d o n 't th in k anybody sh o u ld be d eleg a ted to do m e d i c a l w o r k o t h e r th a n th e M. D. o r th e N u r s e . I a l s o want to em phasize the im portance of Ken C a rn e y 's inform ation c e n te r h e re . We, unfortunately, had an experience j u st two months ago w here we got the inform ation from his service that an individual received a four thousand dollar settlem ent from one of our local railw ays. Our e m ploying o ffic e r, o r our superintendent, paid no attention to the word of advice that was given to him through our claim s d ep artm en t, and we h ired h im . Now, he w ants se v e n thousand d o lla rs b ecau se lie said he slipped on a piece of ice. The C laim s R esearch Bureau p resen ts a very valuable inform ation center. .M O D E R A T O R C A R N E Y : We w ill p a s s o n to q u e s t i o n 2. P r e - e m p l o y m e n t h y sic al exam inations. How com prehensive should they be? I should like v Stockw ell to talk on that question, if he would. D R. B E N J A M I N W. S T O C K W E L L : T h e r e m a r k s of M r . M a n io n a l it tle e a r lie r points up the n ec essity for a m o st com p reh en siv e p re-e m p lo y m e n t p h y sical exam ination, and I think he expressed it very well. The c o m p re hensive pre-em ploym ent physical examination really has a dual purpose. F irs t, it is for the protection of the company to m ake su re that the e m ployee o r applicant is physically and m entally able to do the work that is req u ired of him. And, second, it is for the protection of the applicant him self, because he should not be p erm itted to try to take on a job that he isn 't physically o r m entally capable of doing. We know th a t th e m a n who is w ell ex a m in e d to d e te r m in e w h e th e r he c a n do h i s jo b , i n s u r e s s a f e r o p e r a tio n , w ill have fe w e r i n j u r i e s , and we v/ill have definitely m o re efficient operation. ( think that Is o u r objective. 20 P re-em p lo y m en t physical examinations vary trem endously in this industry, unfortunately, and it may be som ew hat of a reflectio n on the physicians them selves. I think it behooves the chief m edical officer of the railro a d to m ake su re that his m edical exam iners do a good job, that the applicant is rea lly exam ined, that he has all of his clothing off at the tim e the exam ination is m ade, that the exam ination is dor.c in a w ell-light room and that the doctor has all of the facilities that are req u ired for making a head-to-toe, complete physical examination. T here is a trem em dous individual variation in the exam iners; the in te reste d ex am in er is going to do a good job. He is the m o st im p o rtan t part of our em ployee selection from the m edical standpoint. We have been v e r y m uch in te re s te d in advocating the u se of p r e employment x -ra y s and other studies to determ ine whether a man is able to do his job, but the r e a l, b asic thing is the v e ry careful!} .one p h y sic al ex a m in a tio n by a n e x a m in e r who is in te r e s te d and who knows what the applicant has to do. I m ay say that it is m o st im portant for the railro a d s to pay the ex a m in e r an adequate fee if they expect to get a good exam ination and a good report. MODERATOR CARNEY: Are there any other comments ? DR. OLSON: I would like to ask D r. Stockwell whether he thinks, aside from back x -ray s, you should include any technical laboratory or otrier x-ray examinations. DR. STOCKWELL: I think that it depends on the job that the man is being co n sidered for. In c e rta in occupations it is going to be n ec e ssa ry for us, fo r exam ple, to do an audiogram . If the applicant is going in to ce rta in noisy occupations, it m ay be n e c e s sa ry for us to have a determ in atio n of what his actual hearing is at the tim e he enters our service. O therw ise, if he has a defect, it m ight not be detected on the ra th e r in a c c u ra te d e t e r mination by listening to the whispered or spoken voice. MR. HORSLEY:: It is e a s ie r to get the floor before an a rb itra to r in my business. (Laughter) I The question is p re-e m p lo y m e n t exam inations, how co m p reh en siv e should they be ? If I m ay, I should like to b rin g the m eeting down to a specific case. A decisio n by the N atio n al Rai lway A djustm ent Board hawing to do with the v ery subject in which we a re m om entarily in terested , nam ely, how co m p reh en siv e should they'be. T his is the histo ry of a specific ca se as rep e a te d in the finds o f the a r b itra to r in a decision of the National R a il way A d ju s tm e n t Boar.d. May I read it ? It is v ery brief. C laim ant - and that was the one who was inju red - claim ant says: his m other told him that between the ages of 3 and 4 y ea rs he had frequent c o n v u l s i v e s i e z u r e s . T h i s c o n d i tio n was d o r m a n t u n t i l he w a s a b o u t 14 y e a r s of age; he began to have them again at irre g u la r in tervals, at which tim e he would becom e drowsy, and a great many tim es fall asleep and awake with a sev ere headache and lacerations on his tongue and lips. In the la st few y e a rs he has suffered a few dizzy sp e lls, but they p ass off without the lo ss of consciousness. On N ovem ber 15, 1961, he had a se iz u re while on duty, fell and hurt his hand, lost consciousness, and was c a r rie d to a hospital. That, gentlem en, is a train conductor. His h isto ry goes back to a tim e far p rio r to his employment. His history continues through his em p lo y m ent, and h is h isto ry finally com es out in an a r b itr a r y b o ard aw ard o st-ac cid en t, so relating this history to the question: How com prehensive ^ x h o u ld p re-em ploym ent physical examinations be ? I would just like to ac q u ain t you with this histo ry going back to the age of 3 o r 4 h e a rs, and p e r h a p s the p a n e l with the help of the floor can d e te rm in e how th a t h isto ry could have been developed, w hether by lay interview er, o r by a m edical exam iner. In any event, I think it should have been developed long before the p o st-a c c id e n t developm ent of it and the recitation of it in an arb itratio n proceeding. MODERATOR CARNEY: Dr. Stockwell is dying to say something. DR. STO CKW ELL: Ju st that this group is vitally in te reste d in what you a r e talking about at the m om ent. One of our p r im a ry functions as chief m e d i c a l o f f ic e r s is to 'e lim in a te the individual you a r e sp e ak in g of. D r. W alter Longeway, Chief Surgeon of the Colorado Southern Railway, h a s been v ery active in the com m ittee that has established pre-em ploym ent h y s ic a l ex am ination sta n d ard s, and a reco m m en d ed uniform blank which include all of the p ertinent questions, so that we can bring' these p rio r c o n v u lsiv e s e iz u r e s out in the m e d ica l h isto ry . T he m e d ic a l h isto ry , of co u rse , is ju st as im portant as the physical exam ination itself. DR.W ALTER J. LONGEWAY (Colorado and Southern Railway): The p re vious sp eak ers certainly have shown the vital necessity for a com plete p h y s ic a l exam ination. To re a lly do th e se, the e x a m in e r needs a guide, and for som e tim e now, the com m ittee has been working on a pilot study of the disqualifying conditions for the pre-em ploym ent physical exam ina tions. We also have been working on a new p re-em p lo y m en t physical exam ina tion form which could be used by all the different roads. MODERATOR CARNEY: Thank you very much. Dr. Longeway, I p e r sonally know, has been very active and has consulted the claim s and other dep artm en ts in the preparation of this recom m ended form . I urge 22 a l l of y o u w h en i t i s c o m p l e t e d to get c o p i e s of it, so th a t y..-u m i g h t l i able to im plem ent your own services. Are there any other com m ents ? MR. MAURICE N. RAY: On the New York C e n tral the average em ployee in ju ry c la im ru n s around $2,000 and the am ount paid in all em ployee claim s am ount to over five m illion a year. I think the answer should be t h a t th e e x a m i n a t i o n s h o u l d be a s c o m p r e h e n s i v e a s the r a i l r o a d chini , it can afford. I think it can affordvery com prehensive and very thorough examinatioi T he New Y o rk C e n t r a l is a little b it behind on s o m e of its thinking alo n g th is line, but we a r e putting in a new p ro g ra m on an ex p e rim en tal b a s is , and I a m qu ite s u r e th a t it will pay off in d o lla rs . We h a v e n 't enough experience to dem o n strate that conclusively as yet. MODERATOR CARNEY: Thank you, Mr. Ray. Now, D r. Nelson. DR. NELSON: I would lik e to d ir e c t a qu estio n to m a n ag e m en t. In w an dering through hospitals nowadays, it is rath e r astounding to see the am ount of bed space that is taken up by people who have various types of psychiatric conditions. One p ro c e d u re that I think we are going to have to co n sid er, if we a re going to keep a b r e a s t with other indu stries, is som e so rt of p re -e m p lo y m ent psychological testing o r screening. This would not be for the p u r pose of job placem ent, but for the elimination of certain obvious accidentprone people, and certain real or potential psychiatric conditions. This sounds ra th e r complicated, but actually, it can be made as sim p le as w ished. E x p l o r a t i o n of t h i s f i e l d could be w e ll w ort hv/hi 1 Our p sy ch iatrists in M innesota seem to routinely use the M innesota M ulti- phasic as p art of their regular examination. They tell me that such an examination can anticipate som e psychiatric cases and some accident- prone individuals. i It should not be too difficult to develop a psychological q u estio n n aire applicable to the ra ilro a d industry or c e rtain job c a te g o rie s as for example the operating m en. T his could be included in the application for em ploy ment questionnaire. Expense should be m inim al as a layman could direct the testing a s ^ t * prim arily consists of the applicant answering questions. The in te rp re t tation of the q u estio n n a ire can quickly be done by a doctor. I would like to h ear what Mr. Oliver or Mr. Zim m erm an and others m ight have to say about this. MR. ZIMMERMAN: W ell, dpetor, I think that you are on the rig h t trac k . T h i s g o e s b a c k to t h e o r i g i n a l q u e s t i o n r e a l l y , w hich w e l e t R e x M anio'n cover, and I think that alludes to the relationship between the doctor and his own individual railrpad. 23 I thir.k on our railro a d we have a re a l good relationship. As a m a tte r of fa c t, we d o n 't even c a ll him d o c to r. We c a l l h im "O le" m o s t of the tim e. On some other railroads, as I understand, it may be these r e la tionships a re probably not quite what they should be. The a re a of p s y ch o sis o r psychology is one that we have got to face. This is not only in the field of em ploym ent but in the a r e a w here em ployees a re alread y on the p ro p e rty , and som e tim es at m a n a g e ria l lev els, too. MODERATOR CARNEY: Don't get personal. (Laughter) MR. ZIMMERMAN: I know because this applies to you probably as much as anybody. (Laughter) But we have this a re a that many of us as laym en, and I think even th e d o c to rs r e f e r to, as alcoholism . While it d o esn 't n e c e ssa rily m ean you a r e a drunkard or a drinker, alcoholism affects us in many different ways. T his is another area, too, in this sam e field that I think you folks ^ / r e g o in g to h av e to guide us in if we a r e going to go th e p r o p e r d ir e c tio n . I a g r e e t h a t f r o m the s ta n d p o in t o f m a n a g e m e n t t h e r e s h o u ld be s o m e psychological studies made or some psychological action taken, doctor. D R . V E N C E L W. H O L L O (St. L o u is , San F r a n c i s c o R a ilw a y ): In r e f e r e n c e to M r. H o rsley 's com m ents about hiring an individual that has episodes of sy n c o p e, o r perio d s of unconsciousness, on the F ris c o R ailroad, we have had a questionnaire that is com pletely handled by the physician at the tim e of p re-e m p lo y m e n t exam ination which includes a question asking the in d iv id u al if he is subject to any periods of syncope o r unconsciousness. We have the individual sign that p articular questionnaire at the tim e the d o c t o r a s k s t h e in d iv id u a l. We h a d a n o c c a s i o n s e v e r a l y e a r s ago w h e r e an individual did not give a true sta te m en t in re g a rd to his periods of sy n co p e o r u nconsciousness and it was picked up approxim ately six months la ter; that individual was discharged from service. D R . B E N J A M I N W. R A W LE S , J R . ( A t l a n t i c C o a s t L in e R a ilr o a d ) : I yvould like to s tr e s s a point. I don't c a r e how co m p reh en siv e the m edical x a m in a tio n is , if the applicant has not given you a h isto ry as to these e p i le p t ic a tta c k s , th e r e is no v/ay that an o r d in a r y p h y s ic a l exam ination c a n find it out. I think that it is im p o rta n t fo r the em ploying officer to take an active p a r t in knowing the m an that he is interview ing, obtaining in fo rm a tio n and passing on all the inform ation that he m ay be able to gather to the doctor. MODERATOR CARNEY: Dr. Householder, you have something? DR. R. HOUSEHOLDER (Chicago, M ilwaukee, St. P au l and Pacific R ail ro ad ): D r. Hollo brought up a point that I would like to inquire into f u r th e r. In the p re-em ploym ent questionnaire we ask the sam e question r e g a r d i n g s y n c o p e o r u n c o n s c i o u s s p e l l s on t h e M il w a u k e e R a i l r o a d . We a r e confronted, quite frequently with the fact that the tru th is denied. If an applicant signs the questionnaire and subsequently has an episode of unconsciousness indicating that he has falsified o r withheld information, 24 does this constitute a valid reason for discharge from employment? MODERATOR CARNEY: "C hick," would you like to answ er that? MR. HORSLEY: I should like to have such evidence very much, doctor. It would be a fine point of evidence b e fo re the kind of tr ib u n a ls a t which I practice. MODERATOR CARNEY: Ed Glennon, would you care to com m ent from the legal point of view? MR. EDWARD M. GLENNON: I agree. . MODERATOR CARNEY: Are thei'e any other com ments ? DR. A. W. H O C H B E R G ( A k r o n , C a n to n and Y o u n g s to w n R a i l r o a d ) : In a l l these discussions of physical exam inations, I think the thing that is most im p o r ta n t is the co m m en t that D r. Stockw ell m a d e. T he d o c to r h as to be an in terested exam iner. Today lay people, doctors and the government equate com prehensiveness of exam ination with how much money you have sp en t. T h e d o c to r who is in te re s te d and who exam ines this patient, o r r a t h e r ta k e s h is h is to ry ca refu lly , d o e s n 't have to be a m e m b e r of the M e n n i n g e r g r o u p . If a boy h a s q u i t s c h o o l when h e i s 1G y e a r s o f age and was only in the seco n d grad e, and if on clo sin g his eyes he c a n 't stand up, I think you don't have to be a m an from M ayo's to know he lias som ething w r o n g with h i s e q u i l i b r i u m . You d o n 't h a v e to s p e n d $3 a like o u r r e s i d e n t s do when you feel a large spleen, to know that th e re is som ething wrong m the hemopoietic system. I think you could go on all through the d ifferen t sy stem s, and you can get a good examination and a very com prehensive examination depending upon the' examiner. I think that is the crux of the whole situation. Spendi ng another $100 fo r e x a m in a tio n s o r 15 c e n t i m e t e r s s ig m o id o s c o p ic e x a m in a tio n of the r e c tu m . S ure, we m ight pick up a polyp, but if the m an te lls you he is bleeding, I think that is sufficient, and when you get these personality p ro b lem s, the boy hasn't gone to school and he has dropped out, he has had 14 jo b s in the l a s t th r e e m onths and th e a r m y w ouldn't keep h im lo n g e r than four w eeks, I don't think you have to give him a M innesota Multiphasic exam ination by a trained psychologist. It ta k e s only a couple of questions to bring out these h isto rie s. 0 l ' I don't think that it is too much of a p roblem to d eterm in e w hether a man is a chronic alcoholic when he has difficulty like I do in speaking, but he h as a tr e m o r to go along with it, sw eating hands and big liver. You don't have to be a whiz to know that he is an alcoholic, and I think m ost of the tim e , in m y experience, if you ask these people, "How much do you d rin k ?" they will tell you. , I I h a d o n e e x p e r ie n c e ju s t r e c e n t l y with one o f o u r e n g i n e e r s . It was su sp e c te d that he was having fits, and he was seen by five or six different 25 m en te s tin g him. We spent $350 ju s t having h im tested . I ask ed h im the sim ple question, "How often do you have fits ?" He said, "Oh, once a week. " (Laughter) MODERATOR CARNEY: Doctor, thank you very much. DR. NELSON: I think that th e re is a m isconception of what a psycholog i c a l t e s t i n g is . It d o e s n 't r e q u i r e th e n e e d oi a p s y c h i a t r i s t . It d o e s not r e q u i r e a lot of tim e o r ex p e n se . T h e p sy ch o lo g ic al te s tin g is done by the individual who fills in a q u e s tio n n a ire and this is in te rp re te d by s o m e body who knows how to in te rp re t it in about five m inutes by using o v erlay s and m aking a graph. We a r e not ta lking about a lot of expense, we a r e not talking about anything excepting some tim e that the prospective employee h a s to put in. If it is so m e th in g th a t i s w o rth w h ile , l e t 's find out about it. If we ^ yrt e l i m i n a t e c e r t a i n a c c i d e n t s , c e r t a i n p s y c h i a t r i c i n d iv i d u a ls t h a t a r e ev en tu ally going to give u s tro u b le , le t's do it. M O D E R A T O R CARNEY: T han k y o u v e r y m u c h . D r. N elso n . We a r e going to have to move on. At the end of the p ro g ra m we can bring up any of th e se subjects again, but I don't want to fall too far behind schedule. We a r e now th ree and one-h alf m inutes behind. The next question is: When labor is in sho rt supply, due to general conditions, peak m ovem ents or em ergencies, should the physical re q u ire m ents of applicants be re la x e d ? If so, should the examining physician m a k e the s a m e c o m p re h e n siv e e x a m in a tio n ? M r. Z im m e rm a n , we would like to h ear from you. M R. ZIMMERMAN: If you a r e in a h u rry , the answ er is "n o ," to the f ir s t p a rt of it, and the an sw e r is "no, " to the second p a rt of it. M ODERATOR CARNEY: T hank you s o m u c h , M r. Z im m e rm a n . We apyeciate your comments. (Laughter) I a m s u r e they w ill do all of o u r m e m b e r s v e r y good. We d id n 't e x p e c t any m ore out of you anyhow. Would anyone else like to contribute som ething worthwhile? MR. ZIMMERMAN: I will have the Vice C h a irm a n --I could go ahead and elaborate, but I thought Bill L am p rech t would like to say som ething. MR. BILL LAM PRECHT (Southern P acific Company): I a g re e with Otto Z im m e rm a n w holeheartedly. H ow ever, the p ra c tic a l m a tte r is, you do re la x them , and you will in the fu tu re , if you have a situation like we had in W orld W ar II. You ta k e anybody th a t is w a rm . MODERATOR CARNEY: During this tim e, Mr. Lam precht, however, should you make that exam ination so that, in the event this fellow gets into trouble, you will have at least som e protection for what you have done. 26 ' MR. LAMPRECHT: To the extent that you can, yes. M ODERATOR CARNEY: You a d v o c a te th e n th at we do to the extent th at is possible, physically possible, under the circum stances. MR. LAMPRECHT: You will have the examination and the operating departm ent, w hatever d e p a rtm en t is involved, has to determ ine whethe they need the people badly- enough to take them. MODERATOR CARNEY: Of course, this is not the question. The quest is, you are going to take them . We know this. You have a peak m ove m ent. You have got to get it on the ro a d , but a re you going to examinq* the men you bring in for that purpose ? MR. LAMPRECHT: Yes.' MODERATOR CARNEY: Fine, that answ ers the question. Let's bring in the next. DR. OLSON: I want to ask one. Supposing you could find som e physical disabilities that a re im portant, and you take him anyhow. How does thal protect the railro ad from liability in the future ? MR. HORSLEY: It does not. MODERATOR CARNEY: What it does, it m erely gives you inform ation < which we can build whatever defense is available. DR. OLSON: I know, but under FEL A , you a re responsible for conditio: MODERATOR CARNEY: - -f o r aggravation of p re-ex istin g conditions. This is right, but again, in the testim ony that might be adduced from thi p e r s o n , he m ight deny th e s e th in g s, and we m ig h t be able to tr a p him . 1 m ean, if we a re in p o sse ssio n of inform ation, we can m ake fu rth er in vestigation to determ in e a lot of things that will be helpful to us. It is not a defense. It is m e re ly knowing what you have got. We d o n 't w ant to b e s u r p r i s e d in th e t r i a l of a c a s e . . I'm so rry , but we have got to p a ss on to the next one. Mr. Ray} I would like you to answ er the question #4. W here tem porary help is e m p lo y e d an d i t is e x p e c t e d t h e y w ill not w o rk o v e r 30 d a y s , s h o u ld th e y be required to undergo the sam e physical examination and screening proces as a re given to applicants fo r p erm a n en t em ploym ent? What is your feeling about that? MR. RAY: I think alw ays that applicants should be exam ined and e x am ined as carefully as p o ssib le, but under th is situation, I think it is jus an im possibility. You n e e d 'a thousand snow sh o v e lers after a blizzard, and what a r e you going to d o ? The snow w ill be gone before you can get any of th e m examined. (Laughter) MODERATOR CARNEY: Are there any other observations? These are not too im portant points, so the last one h ere, however, should the ex am ining physician inform the applicant resu lts of his exam ination? T his m eans if he is rejected, I would like to have Ed Glennon comm ent on that if he would. MR. EDWARD M. GLENNON: This involves, of course, a policy question as to what d ep a rtm en t is going to have the resp o n sib ility for p erh ap s a r guing with this fellow if he is turned down-- the m edical, personnel or operating departm ent. F ro m a d o c to r's point of view, I suppose that if it is a sim p le h ern ia , for exam ple, th e re is no h arm in telling the fellow and ending the su sp en se, and certain ly if you detect a serious type of injury or som ething that you x p ect is going to develop cancer o r som ething of that so rt, I suppose 'gain it is sim p ly a policy question. As a h u m an itarian , do you want to tell them ? .And also to be su re to avoid any possible basis for liability. As I understand it, som e doctors are concerned about telling the applicant the r e a s o n s fo r r e je c tin g him because of the po ssib le th eo ry , which h as had som e rec en t publicity, of a m alpractice action based on the e r r o r in judg m ent in disqualifying a person, and thereby keeping him out of a labor m a rk e t o r out of railroading. I think this is sim ply a theoretical basis of liability, and while perhaps d o c to rs a r e co n c ern ed aoout it, ultim ately I would ignore it as far as any b a s is fo r legal action. You are the p e rso n resp o n sib le for m aking ju d g m ent decisions. You m ight differ from the opinions of neighboring doctors o r the fam ily d o c to r, but ag ain, they a re not as ex p erien ced as you a re . You have had e x p e rie n c e not just in knowing what railro a d in g involves, but being ble to r e la te it to a p a rtic u la r type of situation o r an asy m p to m atic conition. If it is a congenital problem , a back problem , you are not going to argue with a fellow and just prolong any discussion when you are not going to h ir e him anyhow. But if th e re is a concern as to any legal liability, I would ig n o re it and re je c t the m an if your judgm ent re q u ire s you to do it. M O D E R A T O R C A R N E Y : E llsw o rth , w'ould you c a r e to c o m m e n t on th is ? MR. HORSLEY:' Just briefly, Adrian. I think the im portance of the q u es tion m ight be o verem phasized, but the em ploym ent of applicants is the one rem aining are a in which c a rrie r managem ent, I think, has full controL T h e r e m ight be a few o th e rs, but I haven't com e a c ro ss them in my w ork. N e v e rth e le ss, when a m an is found to be, by the m ed ical e x a m in e r, m e d ically rejectab le, I think that looking to the reason for him being there in the first place should govern. That is, he is there at the instance of the c a rrie r with resp ect to his physical condition. 28 He would ju st .as soon be employed, or rath e r be em ployed without a p h y sic a l ex am in atio n , s o the a n sw e r with re s p e c t to tie p h y sical am ination is owed not to him , but to the c a rrie r m anagem ent, so that i would s a y b r ie f ly th a t th e a n s w e r to th is q u e s tio n #5 sh o u ld b e "no. " If, h o w e v e r , m o d if y in g a l i t t l e b it an d a g r e e i n g w ith m y b r o t h e r , Mi Glennon, that if th e re is som e condition which the mar. shoe,Id know F would suggest that the doctor sim ply say to him that he cannot be employ as far as his physical condition is concerned, and that he strongly sug g e s ts th a t th is m an su b m it h im s e lf to an exam ination by his p riv a te phys cian. MODERATOR CARNEY: Thank you, M r. H o rsley . A nother thing t woul like to com m ent on, som e tim es when these m en have been rejected for physical rea so n s, and there is a reco rd from our office, som e clerk has an sw e re d an inquiry fr m the applicant who has been re je c te d with this s t a t e m e n t : W e ll, we got a r e p o r t f r o m t h e AAR. T h is s h o u ld not her don as the data we fu rnish is for inform ation only. It is incum bent upon ike individual railro ad to determ ine whether or not the inform ation suppled needs fu rth er investigation o r whether it does, as a m atter of fact, make the applicant an unusual ris k . What the clerk should tell the applicant, if he has m ade an ad v erse decision, is that the applicant does not fit the r e quirem ents of his company. DR. HOLLO: N um ber one, in re fe re n c e to giving the inform ation to an a p p lic a n t, in s o m e s ta te s th is is re q u ire d . In t h e state of O klahom a you have to give a copy of the physical exam ination to an applicant if he wants it. N u m b e r tw o , w ith r e f e r e n c e to p h y s i c i a n lia b ility in r ` j' Ctir.g, a.-: Mr. H o rs le y s ta te d , f i r s t o f all, the d o cto rs do not h ire or r e je c t people. All they do is rec o m m en d . It is m anagem ent that h ires p eo p L , with r e c o m m endation of the D octor that they m eet the physical standards for err.nioym ent. DR. J. ROBERTSON KNOWLES (Boston and Maine R a ilro ad ): Under the F a ir E m ploym ent Act of the state of M assachusetts, you not only have to te ll th em why you a r e disapproving them , and not approving th em , and also you will have to give them a written statem ent, should they demand it. i DR. ROLAND S. K IE F F E R (M is s o u ri-K a n s a s -T e x a s R ailroad): I would like to say you a r e d isc u ssin g the m a tte r of the m an who m a k es the e x a m ination, O klahom a City o r any other place, as to whether or not this man has asked for a physical examination, and that local exam iner giving the applicant the inform ation. Is that what you a re discussing? M ODERATOR CARNEY: Y es. sh all .the exam ining physician te ll this man why he has been re je c te d ? DR, K I E F F E R : b e l i e v e t h a t w ou ld g iv e r i s e to s e r i o u s t r o u b l e . We have a h a r d and fa st r u le that only the m e d ica l ex a m in e r n u k e s that O - cision and will supply the inform ation. We take the heat off our exam ir.'r by having him answ er the applicant to the effect that he can contact the medical director. MODERATOR CARNEY: Do you te ll him why? DR. K IE F FE R : T hat is right, because often the lo cal exam iner is not in possession of all the pertinent facts about this applicant. F or example, his em ploym ent application might indicate, for exam ple, that he does have som e history of previous employment in which he had had an accident, or he h a s had a m e d ic a l h isto ry of d isc h a rg e f ro m the a r m y , and things of that sort. DR. STOCKW ELL: The question is w hether a young m an who in all s e r -- io u sn e ss feels he is able to do the work, ap p lies for a job with the railw ay, . is entitled to any consideration at all after he has been rejected for phyV e sic a l reasons. Now, we all know it would be far e a s ie r to say to that young man: "Y our application for employment has not been approved. " But the p ra c t i c a l p a r t of it is th at he w ants to know why, and lie is going to ask s o m e one why. T he p ro b lem of how we are going to handle him , if he becom es v ery insistent, is a difficult one, and I don't know the answer. There is a m e d ica l-leg a l aspect to this, also, and that is the second point. 1 refer the m e d ica l m e m b e rs of the group to the August 1954 issue of the "Journal of O ccupational Medicine, " and an artic le by Dr. W arshaw and Thornton of New Y ork. They have docum ented som e litigation based on the m a lp ra c tic e of an exam ining physician, who has m ade the d eterm ination that the applicant is not physically fit, presum ably in e r r o r , and then deprived the young m an of employment. Then it becom es a jury question, so that th is is a p r o b le m that we a re going to h e a r m o r e about. We have had a great deal of re c e n t publicity about this p artic u la r item follow ing a co n feren ce in Ann A rbor at the U n iv ersity of M ichigan Law School. It is opening up a new field for the a tto rn e y s in the field of m a liS s _ - r a c tic e . I w i l l m e n t i o n t h a t b r i e f l y l a t e r i n t h e r e p o r t of th e M e d i c a l Legal Committee. MODERATOR CARNEY: Thank you very much. m ove on again because our tim e is running out. We a r e going to have to We are- now going to get into the a r e a of "A ccid en t P rev en tio n and H ealth M aintenance of Em ployees, " on Page 9. Should the standards for in -se rv ic e em ployees be relaxed at any tim e by m anagem ent and, if so, to what deg ree and under what conditions ? M r. Z im m e rm a n , would you care to comment ? MR. ZIMM2SRMAN: I won't be as b rief as I was on the o th e r because, r e g a r d le s s of w hether you like it o r not, we a r e going to go ahead with th is thing. You can cut it off any place you want to. Any exam ination th a t you have of an in -s e rv ic e em ployee should not be re la x e d in my opinion. I think it play s a r e a l big p a rt in th e o p era tio n of the railro a d , 3 0 to see that the folks on the job have p ro p er examinations. I don't see that th e re is any d e g re e o r any conditions under which it shoul ; be relaxed. MODERATOR CARNEY: Thank you very much, Mr. Zim m erm an. Earl, do you c a re to say anything? MR. O L IV ER: I c e r ta in ly a g r e e th a t the s ta n d a r d s should not be rela x ed , but I likew ise feel in tim e of w ar, for exam ple, when m anpow er is d e s p e ra te ly sh o rt, you m ay have to m ake som e exceptions to y our stan d ard s. Likew ise, I think that as a p ra c tic a l m a tte r,' we do m ake exceptions to our standards for certain employees. Som e of th e m w e r e f u s e to m ak e exceptions. Som e of then: we m ake an exception. It is a m a tte r of judgm ent on the p a rt of the.m ecueul officer and the operating officer J MODERATOR CARNEY: I would like to ask one question of these two gentlem en, M r. Z im m erm an and M r. O liver. How about the injured e m ployee whom we a re trying to rehabilitate, and we a re trying io make a s e ttle m e n t ? He w ants to com e back to the ra ilro a d . We have in sta n c e s w h ere th e s e m e n with s im ila r types of in ju rie s a r e working, and if it h e lp s in the disposition of the claim at a reasonable level, would you favor m aking an exception in such case? MR. ZIMMERMAN: I don't think I favor it, but we do it. (Lou-pitcr) I think it should be p u re ly on the b a s is of: can h e do the job, o r can he not do the job ? I think with re sp e c t to vision, this is one area that you might drop y o u r s ta n d a r d s a little bit, and by th at, I only m e an th at th e r e h:..; been enough technology in the optical field so that a man doesn't necessarily have to have 20/20 vision. It can be provided with g la sses. I would go along with that. DR. ABBOTT SKINNER (G reat N orthern Railway): I tak e issu e with Mr. Z im m e rm a n . He h a s already covered one of my ex am p les. T here a re c e rta in things in the aging p r o c e s s , p a rtic u la rly v isio n which is p erfec tly norm al, and yet, would not m eet the standards for an applicant. S im ilar ly, if we rem oved everybody from se rv ic e whose blood p re ssu re over a p e r io d of 20 y e a r s r o s e f r o m 130 to 170, we would h av e m a r k e d difficulty, and there are other exam ples. MR. OLIVER: May I speak. I think there should be two sets of standards. One for the a p p lic a n t f o r em ploym ent and one for the p e r s o n who is a l ready in serv ic e. C ertain ly the standards for the p erso n already in service will be le ss rig id than the standards for the applicants. MODERATOR CARNEY: A re there any other com m ents? _,irnot, we will go on to question #2: Should ac cid en t-p ro n e em ployees be given special physical examinations to determ ine whether physir H or m e n t a l d e f i c i e n c i e s m a y b e I n v o lv e d > D r. Olson, do you c a re to com m ent ? DR. OLSON: I would say that if it is possib le to determ ine such deficii-ncies by physical an d /o r m ental exam inations, it would be highly desirable. W hether this would disclose the an sw e r is questionable. P h y sical defects which handicap an individual to the point w here he cannot p erfo rm the du ties of his job safely should be obvious. A p e rso n who h as d eterio rated m en tally to any considerable degree would also be obvious, but I feel that th e r e a r e m any who do not p r e s e n t th e se d e fic ie n c ie s who a re s till accidentprone. MR. HORSLEY: Mr. M oderator, just briefly, when one determ ines that an em ployee's accident-proneness is established by a m edical o r mental ex am in atio n , that opens the question to c o n te st that has to do with the m e d ica l opinion and its sufficiency and could bring into play a threedoctor m edical panel after many, many months of treating the case. How- ^ r , on the other hand, if a m a n 's a c cid en t-p ro n en ess is left to d e te r n ation only by his work re c o rd , then it is, in m y opinion, much m ore p robative of the point of his accident-proneness than a m edical exam ina tion. of h im would establish. MR. OLIVER: May I ask Mr. Els worth T im m s H orsley a question? W ould it be, in your opinion, "Chick, " p o ssib le to support a d ism issa l of an e m p lo y ee who has a r e c o rd of being a c c id e n t-p ro n e , instead of going at it fro m a mc-dical standpoint. T hat is, go at it fro m the fact that the m an patently is an undesirable employee ? M R . H O R S L E Y : Y e s , a s I h a v e s a i d , M r . O l i v e r . ! th in k that a g-xt;! re c o rd of his on-duty injuries would be m o re clearly and m ore probatively e s ta b lis h h is ac cident-proneness on his job than could be established by a p s y c h ia t r ic o r a s tric tly m ed ical ex a m in a tio n of him , b ecause in the la s t in sta n c e , that se em s to be so easily attackable by som e other doctor s e c u re d by the m an 's rep resen tativ e which q u a rre ls with our examining re su lts. O LIV ER: And we could support d is m is s a l? . M R . H O R SL E Y : It has b een done. MODERATOR CARNEY: Thank you very much. Are there any other com m e n ts ? If not, we will move on to the next question. How can chief m ed ical officers contribute to safety engineering - design - construction, etc. , to reduce both the accident and se v erity r a te ? I would like Dr. Strange to com m ent on that, if he would. DR VANCE M. STRANGE (Southern Pacific Company): This is a subject th at is quite clo se to me. It has not alw ays been rig h t d ire c tly with the ra ilro a d itself, and I would like to u se an exam ple of an outside industry in w hich we had definitive c a s e s of te n o sy n o v itis of th e f o r e a r m , involving the fo re arm and hand. 32 These cases were working in a tin finishing m ill where there ere tin c l a s s i f i e r s . T h ey w ere a l l wom en. T hey w o rk e d 20 minuter; ind 20 m in u te s off. T h ey had ju s t b e e n on a s t r i k e when th ey cam e back and w ere quite active in th eir work and had been re stin g much like a ball play er would, actually. T h ese c a se s w ere hard to tr e a t. Some of them ran on for months and months and months; we couldn't get them back to work. M O DERATOR CARNEY: T his is so im p o rta n t, why do n 't you corne up front. Dr. Strange? DR. STRANGE: The cases I am going to d iscu ss w ere cases not a.-m ciated with the railro ad industry. These cases were tin finishers where they c l a s s i f i e d tin p l a t e . T h e s e p l a t e s w e r e a p p r o x i m a t e l y 30 in c h e s by 30 inches. They turned them over under lights to determ ine if there v ere p e r f o r a t i o n s o r f a u l t y d e f a u lts w ith in th e ti n . It i s a r e p e t i t i v e type c? o p e r a t i o n . T h e y w o rk 20 m i n u t e s on and 20 m i n u t e s off. T h ey d ev e lo p e d t e n o s y n o v i t i s of th e f o r e a r m s a n d h a n d s . A s y o u a l l know , they w-.-re v e ry difficult for us to trea t. T h e s e c a s e s went on m o n th s an d m o n th s . We co u ld not get any w here with them , and I finally went with the safety people to the chief engineer of the plant. We contacted oth er plants in the country and did devis a tin c la ssifie r that was autom atic. They ran on a belt, used an electric e y e , an d a lig h t s y s t e m , and t h e s e p l a t e s w e r e k i c k e d off. We did y/it r id of the tenosynovitis, and at the sa m e tim e, w here 100 girls v.ere e m ployed, we em ployed about ten. I think th is will illu s tr a te one ph ase of what we can do by going to the b o tto m of the c a u se and etiology of the in ju rie s. M O D E R A T O R CA R N EY : T h ank y ou v e r y m u c h , d o c t o r . D id n 't you do som e work also in connection with the construction o r rhabilitation of the cabooses to rem ove sharp c o rn e rs, replace ladders, handholds and things of this nature? DR. STRANGE: I have talked to our safety departm ent about this, but our safety people have actually done the work. AU I have done is just try to c r e a te th e ir in te re s t in the problem . MODERATOR CARNEY: A re there any other com m ents? I think you ought to know that industry generally, and p articu la rly the insurance in dustry, is going in a g reat deal for safety engineering in order to reduce co m p en sation c o s ts, and they have had a re m a rk a b le effect upon costs by reaso n of rem oving those areas in which inju ries a re m o re serious because of projections, sh arp co rn ers, and all this so rt of thing. This is so m e thing that I think we ought to c o n sid er and m e d ic a l d ep a rtm en ts ought to be p articu larly sensitive to, when they a re evaluating injuries and their, causes. G oing on to n u m b e r 4. Should r e g u l a r o r p e r io d i c in sp e ctio n s be m ade by chief m ed ical o fficers in all facilities p resen tin g hazards of ocev . - 33 tional disease - silico sis - derm atitis - inhalation of fumes, etc. ? Mr. Z im m e rm a n , would you c a r e to com m ent on this.? MR. ZIM M ERM AN; T h is i s one of th o s e fields w h ere we g et into an a r e a of d isag reem en t, I know, Ken, because frequently the doctor, when you want to m a k e t h e s e e x a m in a tio n s is so busy that he d o e s n 't h ave tim e to go with you. Eut I think it is im portant that it be done w here it is p o s sible at all for the doctor to m ake the examination of these facilities and make the checks that a re n ec essary to be made. MODERATOR CARNEY: I think it m ight be in terestin g for you to know that we in the C laim s R esea rch B ureau are docum enting the types of in ju r ie s and the p h y s ic a l conditions and re la tin g them to sp ecific p ro b le m s^ The M e d ic a l-L e g a l C o m m ittee, which is com posed of som e of the top 'aim s men of the country and top m edical m en, a re analyzing the trend ^ ^ / a l l in ju rie s grow ing out of inhalation of fum es and tunnels and v ario u s o t h e r p h a s e s th a t a r e b e c o m i n g m o r e p r o m i n e n t to d a y . We h ope, f r o m th is, to be able to pinpoint a re a s in which im provem ents might be made through recom m endations of this m edical-legal committee. D R . S TR A N G E : I would lik e to s a y th a t in o u r own o p e r a t i o n s , too, we a r e at the p re se n t tim e tying in with the indu strial hygenist, between the c h ie f s u r g e o n 's office and that of the safety d e p a rtm e n t, ar.d he w orks to g ether with the two of us just in this field. M O D E R A T O R C A R N E Y : V e r y good. Any o th e r c o m m e n t s '1 If r.ol. we w ill m o v e on to q u e s t i o n ft 5. S hould th e m e d i c a l d e p a r t m e n t h a v e p r o g r a m s to provide tetanus toxoid inoculations, polio and influenza shots for im m unization? Dr. Leigh. DR. SOUTHGATE LEIGH: I think I have given flu shots to at le a s t 7 5 p e r c e n t o f o u r e m p l o y e e s . We go o u t o v e r the r o a d an d a d m i n i s t e r th e m . We have cut down, in m y opinion, a s m uch as 40 p e r cent on the absentee te during the w inter tim e. B esides this proves to be a good public Nations g e s tu re to offer this se rv ic e to our em ployees. Now, the tetanus inoculations. S ev eral y ea rs ago we w ere having a - trem endous am ount of trouble with reactio n s to tetanus antitoxin. Now we have s ta rte d a p ro g ra m of a d m in isterin g tetanus toxoid prophytactically. I figure in our operation departm ent now, over our little railroad, that we have about 75 p e r cent of the em ployees im m unized with tetanus toxoid. MODERATOR CARNEY: Thank you very much. Dr. Leigh. D r. Stockwell, the d ev il's advocate, h as som ething to say, l believe. DR STOCKWELL: I am also a Colonel in the Confederate A ir F o rce, so I would like to d isa g re e with som e of the r e m a rk s that w ere m ade by Colonel Leigh. N um ber one, with the exception of the tetanus p ro g ra m , I feel that the adm inistration of vaccines of various types are the re - 34 sponsibility of the em ployee to obtain from his family physician. I think we have an obligation to reco m m en d those injections to our em ployees, but I believe that it should be their responsibility to obtain that type of protection. In the case of tetan u s, th e re is a d ifferent situation and I think that will be discussed a bit fu rther in D r. Leigh's rep o rt of the Com mittee on T raum a. M ODERATOR CARNEY: A re t h e r e any o th e r c o m m e n t s ? If not, le t's m o v e on to It 6 . Is a r e h a b i l i t a t i o n p r o g r a m e c o n o m i c a l l y f e a s i b l e ? T h i s is a kind of tough one. I don't know w hether we should go too far into it o r not, but the question is w hether physical rehabilitation pro g ram s a r e eco n o m ically feasib le. A ll in d u s try is u n d e r p r e s s u r e to help out . with the w o rk er, the citizen, who h as c e rta in physical im p airm en ts, to keep h im working and m ade h im productive, if p ossib le, and if you have an o ld -tim e r a ilro a d em p lo y ee, sh o u ld we attem pt to reh a b ilita te h im ? E arl, would you ca re to com m ent upon th is? MR. OLIVER: Ken, to quote M r. Touhy, as you did a while ago, tiiis is a subject on which I am abysm ally ignorant, and I would p refer to dodge. I think th e re a r e o th e rs at the table h e r e who would be much b e tte r q u a li fie d to s p e a k on the s u b je c t th a n I. MODERATOR CARNEY: I think Mr. Horsley has som e very violent opinions in this are a, if he c a re s to com m ent, as he did som e tim e ago, on this question. MR. HORSLEY: The A nsw er to the question is "No. " MODERATOR CARNEY: Thank you very much, Mr. Horsley. Does anyone else have any com m ent? ' MR. HORSLEY: Mr. M oderator (Laughter), the only successful reh a b il itation of an injured em ployee is accom plished by his secu rin g , say, an $80,000 verdict and judgment. Then th e re follows a m iraculous recovery and rehabilitation. Now, I would like to explain to the doctors that m y viewpoint is probably m ost restrictive. I can see grey areas. I am not strictly a w hite-and-black ar.ea man. I can se e g re y a re a s , but the c a se s with which I am charged as the defending of the c a rrie rs , arise from a verysm a ll p ercentage of the em ployees, but these em ployees are those who will exercise their right of a citizen 's tria l and action for $100,000 or $2 0 0 ,0 0 0 dam ages against the c a r r i e r because som ebody hit him in the coccyx with a 50-ton boxcar and then after he persu ad es a jury of his peers that he is entitled to at least $80,000, and judgment is satisfied by the c a r r i e r , and he has paid h is law yer and his other wife, and paid off the m o rtg a g e and has a new car, thi's m ira c u lo u s p h y sic a l re c o v e ry is a natural concomitant of all those circum stances. So, that is the rehabilitation that I say is about the only one of which i would take cognizance. T h ese convicted m u rd e re rs are in the sam e field. They can be re h a b ilita te d rig h t now when they a re walking down the aisle tow ard the g ree n door, so this rehabilitation se e m s to m e to be a kind of a thing with w hich we a r e not c o n c e rn e d , but with which we a re daily plagued and again I would like to excuse m yself before you all on the basis that this kind of case is the one that com es to my attention m ostly, and reh abilitation in the m inds of you gentlem en who a re s c ie n tis ts engaged in the field of h u m a n ita ria n ism might think of many, many c a se s in which rehabilitation would actually re s to re any em ployee to a bona fide situation, but that has not been in my experience. Hency, my rem ark s are perhaps vitriolic and at least disciplined. MODERATOR CARNEY: Thank you, Mr. Atheist, (Laughter) Dr. Stock-., well is dying to say som ething, and then Ed Glennon, so if you will get it ov er with, Ben. DR. STOCKW ELL: I have to d isa g re e com pletely with m o st of everything that Mr. Horsley has said. I think rehabilitation is extrem ely important. I think that it is one of our functions as m edical officers and as physicians, and surgeons. We s t a r t re h a b ilita tio n as soon as we see the in ju re d em ployee and have to rehabilitate him to get back to work, and then getting back to work itself is the most complete rehabilitation. I think we have to support any type of rehabilitation p rogram that we can within our own r a ilro a d , and I think that rehabilitation is p a r t of the medical treatm ent. MR. GLENNON: T his would involve again, of course, low ering of sta n d a r d s o r having two s e ts of s ta n d a r d s , but I think it is n e c e s s a r y with r e s p e c t to any e m p lo y e e who has been a good em ployee. You ju s t d o n 't kick him out on the street because he has developed arthritic changes o r som ething of that sort. In addition to a high v e r d ic t, an a d v e rs e v erd ic t w here he g ets noth ing, is also very good in effecting a cure. But beyone that, I think, that f r o m the legal standpoint if we d on't m ak e every attem p t we can to r e h a b ilita te th e m , we a r e r e a lly going to get s m a sh e d in a c o u rt ro o m , because the p erso n has no p lace to go but out in the s tre e t, and you ju st c a n 't avoid b ein g c lo b b e re d . Y o u 'v e got to t r y a n d r e h a b i l i t a t e h i m . T he r e a l p r o b l e m c o m e s , o f c o u rse , with the B rotherhood ag re e m e n t in shifting a rnan to an e a s ie r assignm ent, which he could handle, but which, because of the Brotherhood r e s t r i c t i o n s , p r e v e n ts you f r o m a c tu a lly re h a b ilita tin g the p e r s o n . You can give him a lighter assig n m e n t without any problem , b u t we w ere talk ing about a situation last night w here, on one railroad, for example, som e shifts have a 14-hour ru n , and som e have a 4 -hour run. It would be nice to put the person with an injury on the softer assignm ent, but the Grotherhood agreem ent prevents it. T hat is the rea l obstacle. But 36 certainly every effort should be m a d e to rehabilitate as m :-ii as possible. MR. RAY: F r o m m y view point, I should a g re e with M r. H o rsley if I think only of the cases that routinely come to my desk, bee m se I see the bad ones. I see the ones w here we a r e in trouble, where we a re in litigation, w here th e re is fraud, and I try to line m y thinking, though, with th e fact that I only see a tiny fra ctio n of the c a s e s , and those a re , as I say, the bad ones. I think M r. H orsley sees even w orm ones b e cau se they a re actually in th e m iddle of the battle o r after the battle. I am certainly in favor of any reasonable rehabilitation program that we can conduct with one caution. If the em ployee is obviously m aking no attem p t to co o p e rate and to go along with what you want him to do to r e habilitate him self, I think you a r e w asting your money. You m ight as well cut off the p rogram because he has m ade up his mind that he is going to be a s bad off as he can m a k e h im s e lf be, and it will cost you a lot of money for nothing. DR. RAWLES: This m atter of rehabilitation is something that I have been interested in a long tim e. It started during the war, and I will right briefly give you my firs t experience. I serv ed in Italy behind the F ifth A rm y for pretty nearly two y e a rs when the only r e s e r v e s we had w e re the boys who w ere in the hospital. We f o u n d - - w e w e r e o p e r a t i n g p r i m a r i l y in th e f i e l d - - w e had 10 g e t t h e m out in tents and get shoes on them and get them roughing again. If we didn't do that, they p retty soon got re c la s s ifie d into a non-com bat c l a s sification. The sam e way with our r a ilro a d men. I think it is im p o rtan t, and th e only way we a r e going to a c c o m p lis h th is , of co u rse , is .Hth m a n a g e m e n t ' s h e l p , and th a t i s to g e t t h e s e m e n bac k to s o m e kind, of ja b . I know th a t e v e r y b o d y h a s a r g u e d t h e p o in t th a t t h e `B r o t h e r h o o d a g r e e m e n t s , p rev en t us from doing this, but I believe that this is an a re a in which m anagem ent and labor can get to g e th er. I would certainly hope they would continue to>try to do som ething about re tu rn in g these men to corne so rt of work as soon as possible. We a r e t r y in g it on th e C o a s t L in e now. It h a s M r . R ic e , o u r p re s id e n t's w holehearted su pport. He has perso n ally taken an in terest. When the m e d ic a l d e p a rtm e n t h a s s a id , "We would like to see the m an back at w ork in so m e c a p a c ity ," he h a s a s k e d o u r o p era tin g people io do all in their power. F o rm e rly they im m ediately threw th eir hands up, and they said, "T h is m an c a n 't do every th in g he used to do, we don't want h im . 1 I believe reh a b ilita tio n is an a r e a w here we can work. DR. HOLLO: I would like to m a k e one statem ent. I agree with D r. Ben Stockwell and disagree with M r. H orsley, that in number 6, is the r e habilitation program economically feasible ? I think as physicians, our job is to rehabilitate everyone that it is humanly possible, first. I think th a t is part of our job on a ll in ju ries, an d , in fa c t, in any illn e s s , too. 37 [ think that it is up to the d o c to r to do the rehabilitating and it is not up to the employing officer o r the local su pervisor. I think that we can in itia te th is r e h a b ilita tio n p r o g r a m by talking to a patient and also encouraging h im and letting him know that he is not an invalid for the r e s t of h is life, and this has been accom plished. 1 am s u re , in many, many and hundreds of cases. You ju st don't label a m an as totally disabled because he has had a fractured ankle and he has som e ankylosis. These people maybe have worked 25 y e a rs. They have learned the job. They know how to co m pensate and adjust to it. T h ere a re many of these people that have had in ju rie s like this that a r e actually s a fe r than m any of your young, e m bryonic individuals who ju st have had one o r two y e a r 's se rv ic e. MODERATOR CARNEY: You don't m ean to im ply, how ever, do you, th at the m e d ic a l d ep a rtm en t alone is capable of doing th is? D on't you need the help of m an ag em en t? DR. RAWLES: You do, but they should recom m end and encourage it and initiate it. DR. KNOWLES: A s you know, I c a ll it le g itim a te hokus-pokus. You will ju s t have people on your back as long as you can hold on to them for the c la im s dep artm en t. The m inute you do not try to rehabilitate them , they go som e place else. MODERATOR CARNEY: Thank you very much. These comments have great validity, I am sure. DR. GLENN F. CUSHMAN (Western Pacific Railroad): I feel quite s tro n g ly on th is p ro b lem . I think the fact that we cannot im plem ent re h a b ilita tio n d ue to th e c r y th a t t h e r e is- no lig h t d u ty and union r e s t r i c t i o n s i n t e r fere, not only m akes it m ore difficult to rehabilitate, but frequently m a k es a m an that could be re h a b ilita te d unable to be reh ab ilitated afte r two o r three years of inactivity. I ju st wonder if m anagem ent has anything to offer in the way of g e tt ing th e se union c o n tra c ts softened so that we can do som ething about it. XvIR. O L IV E R : A c t u a l l y , i t i s e n t i r e l y p o s s i b l e . We hav e o n the I l l i n o i s Cen tra l, for exam ple, an agreem ent that was m ade a few y ea rs ago with the engineers and the firem en which p erm itted us, if the m edical d e p a rt m ent disqualifies a m an, to put the m an on a lighter assignment. We also can work around some of the union agreem ents in various ways, either form ally o r inform ally, but I think it is sim ply a m atter of focus, of effort, of an attem pt. If we decide we want to tr y to re h a b ilita te th e em ployee, we can do quite a bit with the unions tow ard that end. 38 DR, WIGHT: One m inute. Q uestion #6 is rea lly rh eto rical, isn 't it? R ehabilitation in m edicine is the sa m e thing. At tins stage, I don't know who I am agreeing o r d isa g re ein g with, but it is as sim ple a s that. MODERATOR CARNEY: You a r e as confused a s the r e s t of us. DR. WIGHT: Q uestion #5. I am s o rry to re v e rt. T etanus toxoid. I m entioned it a couple of y e a rs ago. Way up in our country the tetanus bug doesn't live. 'It is too cold for him, and I don't see why we should inoculate 75,000 people for a condition that we never see. Dr. Vaughan, have you seen any tetanus? DR. P E T E R VAUGHAN (Canadian N ational Railways): No. DR. WIGHT: Polio. We a re not in the p rac tice of medicine. That is the in d iv id u al's re sp o n sib ility . Influenza. A v ery large concern in Canada instituted this p rogram and kept it up for several years, kept v ery active re c o rd s and discontinued it. Psychologically, it may be of som e good, but m edically, they could s e e no benefit. MODERATOR CARNEY: Because of the p re s s u re of time, la m going to m ove on to the la st section of our d iscussion. I would like to rem ind all of you in the audience that, if you have any questions of any kind at all that a re not ra ise d in the list that we have h e re , please be p rep a re d to s u b m i t th e m . We w ill t r y to a n s w e r th e m in the r e m a in in g tim e we have. If you don't ca re to subm it a w ritten question and want to stand up and announce som e problem that you have that we a re capable of getting som e expression on from other m e m b ers, please do it at this moment, during this last period. Now, these a re the m ed ical-leg al p roblem s. \ might sta rt this out by saying that we believe in the claim s b usiness that the doctor p erfo rm s one of the m ost im portant functions in the successful handling of personal injury claim s. Liability is close to being absolute. We a r e still able to s u c c e s s fully defend a fairly reasonable percentage of cases under the F ederal Em ployers' Liability Act, but.they are getting fewer and fewer each year. We h a v e to be h ig h ly s e l e c t i v e , an d we h a v e to h a v e a v e ry good c a s e in o rd er to succeed. Now, this m eans that we have got to docum ent our m edical histories, t r e a t o u r people. We ta lk about m e d ic a l m a n a g e m e n t m o re than we talk about ju st the trea tm e n t itself. If a patient can have confidence in the doctor, half of the claim d ep artm en t's battle is won because our ob jective is to settle the claim d irectly with the man. O ur r e c o rd s re fle c t th is fact, that the a v e rag e amount of money paid to em ployees whose claim s are settled through lawyers are ranging b e t w e e n $ 1 2 ,0 0 0 and $ 1 4 ,0 0 0 a c a s e . T h i s l e v e l h a s b e e n m a i / i t d r o u g h l y d u r i n g the p a s t 11 y e a r s . It is an i n s i g n i f i c a n t i n c r e a s e c o m p ared with the in crease in wages, and wages have a g reat effect upon the am ount of m oney you spend in the se ttle m en t or the v e rd ic t of an FELA c a s e , because m ost v e rd ic ts and settlem en ts a re re la te d m o re to wages and prospective loss of wages than any other individual factor. So, the doctor is an im portant tool here, p a rtic u la rly with liability d is a p p e a rin g . T h e a c c e n t on d a m a g e s is such th a t, u n le s s we offer co n vincing proof of what we have done for this man and what he is capable of doing in the future, and are able to pro tect the ex am in atio n s, te sts, 3 nd so forth that we m ak e, we a re going to be confronted with ad v erse testim ony from other doctors and a jury. A law yer is going to have to decide upon this thing. And, unless we a r e fully p re p a re d to m e et all the things that a re constantly throw n at u s, why we a r e in tro u b le . So, th e re fo re , the doctor today has to be oriented from a m edical-legal standpoint. Not only m ust he trea t a patient for the known com plaints, but he has to apply, those te sts, those re m e d ie s, those o b se rv a tio n s, those com m ents f ro m th e m an which will enable h im to m ake it im p o s s ib le o r difficult for the law yer and the doctor working for the lawyer to say that c e rtain con ditions exist when your own te sts can disprove that they could have existed because of the reco rd s you keep. Now, th is is th e them e of what we want to talk about now. The firs t question is: What should a chief m e d ica l o ffic er know about the m e d ic a l-le g a l p ro b le m s in the settlem ent and t r ia l o: em ployee injury cases ? I would like the G eneral C laim s Attorney of the New Y ork C entral, M au ri ce Ray, to talk about this. MR. RAY: Heeding y o u r adm onition to be as b rief as p o ssib le , I can only say that he should know everything possible that he can be taught about those problem s. I think the claim men on ra ilro a d s a re the best m en to educate him . I think that the m edical d ire c to r and exam ining su rg e o n should be given all of the data that d e te rm in e s the r e s u lt in a l a w s u i t . We a r e d o in g t h a t . W'e e v e n s e n d c o m p l e t e r e c o r d s o f d o c t o r ' s testim ony that we have specially written, and even w here c a se s haven't .gone to the lim it, w here they are settled during tria l, we have sent m e d ic a l r e c o r d s , sten o g rap h ic sta te m e n ts from the tr ia l to o u r chief m edical 'o ff ic e r for his knowledge and for the m an 's record. I don't think that there can be too much that all of us in the claim and law departm ent can do to give all of our doctors, not ju st the chief m e d ic a l o ffic er, but all of o u r d o cto rs, all the inform ation, the tren d of the d e c isio n s, the way the things go in a c o u rt room . M ODERATOR CARNEY: D oes anybody else have any co m m en ts. Is Dr. Kaplan Here ? 40 DR. NELSON: He ju st c a m e in. MODERATOR CARNEY: Does anybody else care to com ment. Ed, would you c a re to com m ent ? MR. GLENNON: The closest possible relationship, of course, is ad visable between the law yer and the claim s departm ent and the d o cto r-the law yer and the claim dep artm en t, not n ecessarily being synonymous b ecau se e ith e r o u tsid e c o u n s e l o r the atto rn ey who is going to try the case is not a m em ber of the claim departm ent. The m ore the doctor knows about the case, including treatm ent, the less fear he has of the court action; the m o re he re a liz e s the im portance of the case the m ore he a p p r e c ia te s h is n eed to te s tify . T h e r e is n 't any such thing a s too much education of the doctor and too close a relationship as far as the successful defense of a lawsuit. MODERATOR CARNEY: Thank you very much. Does anybody else have any com m ents? DR. HOLLO: I would like to m ake one statem ent. I will m ake it v ery brief. It is my opinion that the m e d ica l profession o r the d o c to r's r e s p o n s ib ility in r e g a r d to th e s e d is a b ili tie s o r in ju r ie s s u s t a in e d - -I think that is what we a r e ta lking a b o u t - - is to se e that the m an has e x c e lle n t therapy and is rehab ilitated as ea rly as possible and re s to re d to his norm al condition as well as p o ssib le, and then give a rep o rt accordingly to the end resu lt. Now, if the c a rd s fall that th is m an has 5 p er cent disability, it should be so recorded. Now, in r e g a rd to the tr ia l and p reparation, I don't think it is a p a rt of the m ed ical p ro fessio n . I think this is a part of the law d ep a rtm en t, or else the claim s departm ent. I think that once this report is subm itted,, r e g a rd le s s who exam ines this p a r tic u la r individual, everyone will have a c o m m o n d e n o m in a to r and c o m e up with the sa m e r e s u l t s . In o th e r w ords, you cannot m in im iz e th e m a n 's injury, and you cannot go ahead and over-em p h asize it. MODERATOR CARNEY: So that you can fully understand Dr. Hollo, he is not in ferrin g at any point in th is d isc u ssio n that a doctor should give anything o ther than a thorough, h o n est r e p o r t of what the situation is in connection with an injury to an em ployee. We want that a b s o lu te ly u n d e rs to o d . Secondly, ho w ev e r, I think the d o c to r's obligation goes beyond w hat you a re talking about. You a re an officer of the ra ilro a d . You know th a t doctors a re testifying in co u rt today about conditions that don't ex ist, and unless you have knowledge of the m ed ical-leg al aspect of a c a s e , how are you going to perfo rm those tests, exam inations and so forth, which will make it im possible o r dif ficult f o r that d o c t o r to bring up th e se s it u a ti o n s at a l a t e r date ? DR, HOLLO: I would an sw e r thnt in * acceptable consultation from an o u tsider, and let him give a report which is to be used in se ttle m en ts and c o u rt as well as for m e d ic a l trea tm e n t. DR. STOCKWELL: Ken, we a re going to discuss this at som e length this afternoon. We have a m e d ic a l-le g a l aspect to ou r p an el this a f te r noon. I would just like to m ake just one b rie f com m ent. T hat is, that I think it is apparent to all of us that the chief m edical officer should know all about the m e d ic a l-le g a l p ro b lem s on h is p ro p erty , and that the ..only solution is the cooperative endeavor between three g ro u p s--m a n a g e m ent, legal, and medical. M anagem ent is v e ry m uch in te re ste d in the co sts, and I think they are v ery much interested in seein g that the best m edical defense to cut down this cost should be arran g ed for, and the support of our m anagem ent, 1 m a y s a y , h a s b een e x t r e m e l y h e lp fu l in fig h tin g th is F E L A p r o b le m . i MODERATOR CARNEY: Thank you very much. Does anybody else have any c o m m e n ts at th is tim e ? If not, we w ill p r o c e e d to q u e s tio n #2. What can be done to provide such education to m edical departm ents ? Do you want to take this up in the afternoon, Ben? DR. STOCKWELL: I just an sw ered it. M O DERATOR CARNEY: F in e, we w ill go to #3 then. What fa c to rs should be c o n sid e re d in the selection of a M edical Consultant in an on-duty in jury case ? Now, before I ask Ed Glennon to com m ent on this, let me make this one observation. Frequently the doctor is a little bit jealous about his se lec tio n of an expert to com e in, a consultant in a p a rtic u la r a re a , and a p articu la r case, involving an injury on duty. 'Sometimes they have selected m edical consultants who have been notoriously bad actors as fa r as testim ony is concerned, and this point, I think, is what Ed would like to touch upon from his ex p e rien c e as an em inent tr ia l law yer in M inneapolis. MR. GLENNON: The chief function of the m edical d ep artm en t is to act as a doctor and give p ro p er treatm en t, and any lawyer, whether it is a r a i l r o a d la w y e r o r anybody e l s e who a tte m p ts to buy m e d ic a l te s tim o n y is as guilty and should be d isb arred as far as I am concerned. On the Soo Line, we have n e v e r shopped for 5 m inutes for a f a v o r ab le opinion. So that as Ken C a r n e y sa id , we have to a s s u m e at a l l tim e s that we a re not asking any doctor to dirty him self by washing down his re p o rt. At le ast, I hope you a re all tre a te d the sam e way as we a re on the Soo Line. M a u ric e Ray ta lk ed about New Y o rk C e n t r a l 's annual b udget fo r c laim s. It is five m illion d o lla rs. T hat is a lot of m oney. It would perhaps be double that o r m o re if som e tim e was not spent in properly p rep arin g a case both from the liability standpoint and from a m edical 42 standpoint. While it is an a r e a o f sensitiv ity , perh ap s, and I am su re the doctors resent it som etim es, that the lawyer does suggest a p a r t i c u l a r c o n s u lta n t. C l e a r l y th e c o n s u l t a t i o n sh o u ld be in the a r e a of the p ro b lem , w hether it is o rth o p ed ics, neurology o r so forth, and there should be a com petent docto r, not ju st a p erso n a lity boy. However, you can't be blind to the rea litie s of the 20th century and the B rio's, a doc t o r c a n b e a v e r y , v e r y good d o c t o r in h is f ie ld , b ut he car, bo a c r a n k and a crab and somebody that no ju ry would go to if they had the choice. It is too bad, but this is the way life w orks, but as far as the m ed ic a l-le g a l asp ects is concerned, the doctor h as to be able to se ll to the ju ry the m e d ica l-leg a l asp e c ts of the ca se . You can't rea lly , in the tr ia l of a lawsuit, ignore and tre a t sep arately the liability and the m ed ical. If your m edical sm e lls up the ca se , the liability is going to go down the d rain with it, and vice v e rsa . You try to tell an integrated sto ry of fa irn e s s. If you a re wrong on the fa c ts, you a re going to lose, but we win so m e tim e s , too, and m any o f u s have the p le a s u re , at least, fro m tim e to tim e, and m o re frequently than one m ight expect, of at least keeping the dam ages down below what the plaintiff wants. We a r e faced with a situ atio n c e r ta in ly in the m etro p o litan a r e a s in FEL.A litigation, where there is a g ro ss amount of shopping as far as the a d v e rs a ry is concerned. I am not try in g to be too much of an advocate, but in M inneapolis, for exam ple, and St, Paul, we have a situation c u r rently, at least, that one p articu la r orthopedist--and this applied not j u s t to t h e Soo L in e , but o t h e r r a i l r o a d s , is in p r o b a b l y .00 p e r c e n t of the c a s e s on the other side for one B rotherhood firm , and we know what he is going to say. We could w rite his r e p o r t . We know th e re has got to be a disc, even if his head is sm ashed. The only situation I have c u r rently in which he is not involved is a ca se involving an im m ediate death, and th ere was no need for orthopedic exam ination. We have to be able to s e ll o u r s t o r y to the ju r y . You c a n 't sim ply p ass off the jury as being a bunch of give-aw ayers, because I really sincerely believe they are not. I p re fe r trying a case before the average jury, not in Chicago p e r haps w here you have different p ro b le m s, than I would before a judge alone. T he fact of the m a tte r is the ju r ie s have a certain ability to spot the phony. They also have a sen se of fairn ess, and while their sy m p a th ie s m ight be with som ebody who is in ju re d , they a r e n 't going to necessarily bomb you just because you are representing a railroad. To do all this properly, the doctor has to work with the lawyer in spite of the fact that he does not like to get into court because of a variety' of r e a s o n s . It is tim e-consum ing. It takes him away from his practice. He feels he is getting to be a c la im s m an r a th e r than a doctor, but beyond th a t, m any of th e m have a lack o f confidence in th e ir ability to withstand cross-exam ination. If the law yer does h is job and sp e n d s s o m e tim e b e fo re h a n d v/ith the docto r, d o esn't look for another whitewash but d isc u sse s the danger sp o ts as well and what you can do to m eet it, everyone should consider the case properly prepared for trial. MODERATOR CARNEY: T his is fine, Ed. D oes anybody else have any com m ents in this are a? DR. K IEFFER : I feel that the chief m edical officer of a railro a d has a v e ry heavy respo n sib ility working with the claim and legal departm ent. I am s u r e in my job I spend, I would g u ess, a th ird of my tim e doing just that, not to buy opinions o r color opinions o r anything of that so rt of thing, but to plan and prepare for the defense. L aw yers have told me that plaintiffs' lawyers usually p rep are their c a s e s b e t te r than the defense a tto rn e y s. I think the d o c to r can do a g re a t d eal in the direction of advising with r e g a rd to m ed ical defense, s o m e tim e s sitting in the court room and suggesting c ro s s exam ination when ad v erse m edical testimony is distorted and such testim ony occurs all over the country. D o c to r s know who th e se m en a r e , and I think we can co n trib u te a g r e a t d e a l . S ince we hav e s t a r t e d t h i s ty p e o f c o o p e r a t i o n , i t h a s t e e n a b ig d i f f e r e n c e in o u r e x p e r i e n c e . In 19G1 we h a d s e v e n F E L A c a s e s . We won e v e r y one of them . T h e r e w ere two in a county in T e x a s w here in the w hole h is t o r y of the r a ilr o a d we had n e v e r won a law suit of the r a ilro a d before. MODERATOR CARNEY: Thank you, Dr. Kieffer. That is extrem ely interesting.I I iiave h ea rd a com plaint from tim e to tim e against law yers as far as the d o cto rs are concerned, that they don't hear about these lawsuits until the la s t minute. Then they a re asked to com e in and testify with out adequate preparation. Does any doctor have courage enough to get up and tell us about this ? DR. K IEFFER: That is true. (Laughter) M O D E R A T O R CARNEY: Who s a id th a t ? D r. K ie ffe r ? DR. K IE F F E R : We have a t r i a l la w y e r in O klahom a City who in the p a s t y e a r has called me twice the day before a tria l and wanted to know if I could com e down. MODERATOR CARNEY: Fine. Does anybody else have any com m ent? MR. GLENNON: Could I just com ment briefly on that. That lawyer sh o u ld n 't be h ir e d by anybody who w ants to sp e n d any m oney fo r a good law yer. I can ask our people from M inneapolis, but we never do that, of co u rse. We usually arrange com prehensive m eetings well in advance of tria l. It is the m ost irresp o n sib le law y ers who follow that type of practice. 44 ; DR. KIEFFER: I was not prepared as a witness. MR. GLENNON: I appreciate that, but as far as the p re p a ra tio n is con- j cerned, again, "The quality of the lawyer" and if your lawyers are p re- | p a rin g le s s th a n th e p la in tiff's , fire them , b e c a u s e in o u r e x p e rie n c e , j at le ast, we have saved a lot of money because of sloppiness on the p a rt I of the Brotherhood attorneys, and I am speaking now about the re a l vol- j u m e , h e a v y l a w s u i t s . U n le s s o n e o r t w o - - I d o n 't w ant to g e t into p e r - j so n a litie s, but u n less one o r two of the leading lights try the ca se , the j r e s t of the office staff is sloppy, and we have been able to , by p ro p e r ! preparation, really work out som e good settlem ents. j *> ! The law yer should never have the doctor at the witness table because j then he is so obviously a p a rt of it. It is just too in co m p reh en sib le for ! w ords so fa r as I am concerned. He should do the hom ew ork before j trial. Have his cross-exam ination before tria l and not im provise during | t r i a l by h av in g a d o cto r slipping in qu estio n s, p lu s the fact that it takes ! a lot of the d o cto r's tim e, which is unrealistic. MODERATOR CARNEY: I should like to m ention at this tim e that Ed G le n n o n h a s a r e m a r k a b l e r e c o r d of d e f e n d in g F E L A c a s e s iri M in n e a p o l is . MR. G L E N N O N : And St. P a u l an d D uluth. I j u s t w ant to r Cl th a t in. (Laughter) M OD ERATOR CARNEY: You c a n 't win. (Laughter) Is there any place else you work? MR. GLENNON: That is it. MODERATOR CARNEY: Does anybody else have anything to com m ent? If not, the tim e is now 12:14. The Chair is open for any questions on : any subject that m ight be of in te re st to any o f y our d o cto rs and o p e r a t ing men, claim m en and law yers. Are there no further questions? You are all satisfied. Did you get the questions that you wanted , j answered? 1 ! D r. N elson, would you like John R isendal to sum this up now o r later. DR. NELSON: L e t's do it after lunch. | MODERATOR CARNEY: Fine, it will give him tim e to organize his j thoughts. i j I want to thank e v e ry one of you for the attention you have given to ; the outstanding m e m b e r s o f th is panel; to the p an el m e m b ers for their i good h o m e w o r k , and t h e i r good s h o w in g and f o r a l l of you v/L, , i r t i c i p , 1 in this pro g ram , I think we have d em o n strate d v ery definitely the im portance of die m edical p ro fessio n to the r a ilro a d industry in the con tro l of our costs through a b s e n te e is m fro m any cause. Thank you very much. (Applause) DR. NELSON: I think o u r confidences in you, Ken, and y our panel, certainly w ere justified. We are very appreciative of a very interesting m eeting. It is hard for us to judge fro m up h e re , but I hope you have enjoyed it as much as I have. T his afternoon's m eeting w ill be m uch of the sa m e , and I am su re that you a re going to enjoy ju st a s m uch on a little different angle, a little different subject. I want to announce a few m o re people th at a r e now h e r e . M r. S. F. D ingle, S ystem Vice P re sid e n t of the C anadian National, who is also a m em ber of the General Committee. Mr. C. A, Lauby, who i s the E x e c u tiv e V ice C h a ir m a n of the OT D iv isio n of the AAR. M r. J . H. M aneson, G e n e r a l C l a im A gent of th e Norfolk, and W e s tern. M r. George C. F la n d e rs, Chief C laim Agent of the Pennsylvania, and one additional interesting item is - I am not sure I can pronounce this right - Mr. Katzumo Kaniko, I would like to have you stand. Mr. Kaniko is the Chief of Internal Medicine of the Japanese National Rail ro ad s. (Applause) M r. H. A. S anders, Vice P re sid e n t and G eneral M anager of the Grand Trunk. M r . F . G. McGinn, V ice P r e s i d e n t o f th e M ilw aukee, will you stand, please ? (Applause) And will Mr. Sanders stand. (Applause) Thank you. The panelists are our guests at the luncheon. (The m eeting recessed 12:20 o 'clo ck .) ************ Wednesday Afternoon Session M arch 3, 1965 The second g en e ral se ssio n convened at 1:30 o'clock with Dr. Nelson, Chairm an, presiding. CHAIRMAN NELSON: T hose of you who m ight not know this, Ken C arney is intending to retire this sum m er. (Applause) MR. CARNEY: Thank you, gentlemen. (Laughter) CHAIRMAN NELSON: I might have known. Ken, the best wishes from o u r group to you and Ethel for a v e ry happy and healthy re tire m e n t. MR. CARNEY: Thank you very much gentlem en. (Applause) I m e re ly wanted to say I am not re tirin g . I am giving up work. (L au g h ter) So, w h at's new, he s a y s . (L aughter) CHAIRMAN NELSON: John R isen d a l, who is ta k in g K en's p la c e , has s u m m a r i z e d so m e of the things that w e re sa id th is m o rn in g , and we will give h im about 10 m inutes to do so. MR. JOHN RISENDAL: Thank you. Doctor. Gentlemen, I feel as our good friend, Mr. D eLambeck, suggested a few m inutes ago now, like the w hale. He d o esn 't get harpooned until he com es to spawn. T his is a good chance for me to be harpooned, but we are not going to to r e you with a lengthy recounting of all that was said this morning. As Dr. Nelson mentioned ea rlie r, the panel discussion this morning h as b een r e c o rd e d . It will be edited, p r in te d and d is trib u te d within the n e a r fu tu re , and it would be an im p o ssib le thing fo r m e to try to boil down into five o r ten m inutes the wealth of wisdom and knowledge that this le a r n e d g ro u p h as shown today, but it s e e m s to m e that Mr. M anion, in his opening address this morning, clearly outlined our present situation when he talked about the needs and the re q u ire m e n ts of the ra ilro a d in this changing world and changing economy. T he fact that advances in so m any a r e a s would re s u lt in the r e q u ir e - ' m ent that p e rso n n e l em ployed by r a ilro a d s m u s t be b e tte r equipped in many ways. They m ust be better educated, b e tte r trained, and better physically. With the reduced work force, the ra ilro a d s must be m e re r e s tr ic tiv e in the selection of p e rso n s to fill v ac an c ie s which do exist. The need also was very aptly pointed out for clo ser liaison between in itially the m edical and the operating departm ents in the selection of personneL The question of standards was firs t discussed. I think that we can say that uniform ly, there is a recognized need for definite standards, that these should be uniform. T h ere will be exceptions, of c o u r s e , but th e s e will be lim ited. T h ese exceptions should be p erm itted only on a p a rtic u la r situation which might e x i s t w ithin one 02 g a n i z a tio n , w ith in a c r a f t , o r due. to c e r t a i n g e o g r a p h ical or operating requirem ents. VVe a r e , I b e l ie v e , a l s o in a g r e e m e n t on the q u e s tio n of s c r e e n i n g these applicants for em ploym ent. Again, p a rtially it becom es a m a tte r of econom ics that the applicant should be sc re en e d on individual p r o p e r ties by the person to whom they a re applying for em ploym ent p r io r to being sent to a physician for an exam ination. Exam inations are expensive, and there is no use sending someone o v e r who, it is apparent, should have been r e je c te d p r io r, o r by the p e r son to whom he applied. T hus, only those who, it is felt, will be actually em ployed should be sent for those exam inations. Now, should the exam inations be co m p re h en siv e? I think that again, w ith o u r changing re q u ir e m e n ts in the in d u stry , we will find it n e c e s s a r y to be m o re selective. In o r d e r to do so, it will be n e c e s s a ry for m o re co m plete and com prehensive exam inations to be made. Now, again, individuals, m anagem ent, and those among the ranks of the m e d ica l men will differ as to the types of te sts and examinations that are n ec essary , but you are all striving tow ard the'goal of selecting the p erso n m ost qualified for a position which is open. A ll th e s e notes that I m ad e th is m o rn in g , I don't know how to boil them down into two o r th ree m inutes here. Many questions a ris e in connection with these examinations. Should an a p p lica n t be told the re a so n for h is r e je c tio n if he is disqualified by the m e d ic a l exam iner ? Now, c e rta in p h y sician s pointed out req u irem en ts in th e ir individual a re a s, sta tu te s which m ake it n ec e ssa ry to advise an a p p l ic a n t why he is d isq u a lifie d . In o th e r c a s e s the d o c to rs feel, and I think we will all a g re e , that it is the h u m a n ita ria n thing to do. If you find a man has a slight defect which req u ires m edical attention, this should be called to his attention. The g re a te r question a r is e s in the m o re s e v e re conditions which you often find on y o u r ex a m in a tio n s. What sho u ld be done ? If I m ight ju st try to bring to you the consensus, as I in terpreted it, of those present, it would be that the man should probably be told that he requires medical c a re , and perhaps it should be suggested to him that he consult his p e r so n al physician and the doctor who p e rfo rm e d the exam ination will be willing to discuss with the physician the findings of the doctor upon his exam ination. A fter a man is in serv ice, you have accepted him , should the stand ard s be the sam e for those in se rv ic e as they are for applicants? I heard no g re a t disagreem ent of the fact that we want the standards to be as high a s p o s s ib le , but that a s a p r a c t i c a l m a t t e r we do not alw ays in sist t h a t e m p l o y e e s who h a v e b e e n in s e r v i c e f o r - s o m e t i m e m a in ta in the s j .t : . 18 d e g r e e of p h y s i c a l f i t n e s s a s w e r e q u i r e o f o u r a p p lic a n t ;. Again, :...a is p r o b a b ly s o m e w h a t of a h u m a n i t a r i a n a p p r o a c h to th is '.hat we all recognize the difficulties which do a rise due to the aging process. we a l l g e t o l d e r , we h a v e a l i t t l e m o r e t r o u b l e , a n d s h o u l d v.-e be c r o s s d off ju st b ec au se we have taken on som e of the afflictions of increasing age ? In the m a tte rs of safety engineering, I was v ery much in terested in Dr. S trange's com m ents. I think this is som ething that management can w o rk with the p h y s ic ia n s in elim inating conditions which do c a u se ir.jurie which cause disabling conditions, resu ltin g in the loss of se rv ic e s of th e s e individuals. A b s e n te e is m is ex p en siv e.- We m ust elim in a te it whe ever possible. - With resp e ct to the question of rehabilitation, I doubt that there is any g r e a t d is a g re e m e n t. We all believe in it. The q u estion is , just how f a r should it go and I don't think it would be ap p ro p ria te for me to try to lay down a r u le to that end. You have all h e a rd the co m m en ts made, loo! ing at it both from the hum anitarian standpoint, from the legal standpoint an d I th in k yo u w ill a ll d ra w y o u r own c o n c lu sio n s on that. T h e one a r e a in which we a r e v ita lly c o n c e r n e d is in the m e d ic a llegal p ro b lem s. I believe that Mr. Glennon very aptly pointed out the p r o b l e m s which do fa c e c l a i m and law d e p a r t m e n t s in the handling of in ju ry c a s e s , the n ecessity then for a c lo s e r liaison bet a c t . the claim , law and m edical departm ents starling initially a ite r a r : a r . i bent occurs. All th ree p erso n s involved in die handling of this m an 's claim for in ju r ie s su stain e d on duty should be aw are of the devclonrn- nt of these c a s e s fro m day to day, and so diat ap p ro p riate action car. h - taken v:..ely. This is always important. As M r. Glennon also stated, what the claim and law departm ents wan from the m edical departm ent is a fair, honest and realistic appraisal of m an 's injuries, of his disability, of his lim itations and also, of course, an ap p ra isal of the individual him self. T his again is im portant to us becau se, as M r. Glennon pointed out, and as M r. Ray pointed out, th e se things co st a lot of money. When the r a il r o a d s a r e spending c lo s e to one h u n d red m illio n d o lla rs a y e a r in the handling of the settlem ents of disposition of personal injury claim s, this is som ething that is of im p o rta n ce to r a ilro a d m anagem ents. It is imp p o rtan t to those of us who a r e working lyith the problem . 1 So, gentlem en, in sum m ation, m ay I ju s t say that we should all s tr iv e , and I tr u s t we will, fo r the c lo s e s t p o ssib le liaison in all p o s sible fields, between our operating people, between our claims and legal people, and our m ed ical departm ents. Thank you. (Applause). CHAIRMAN NELSON: O ne o f our m o r e d i f f i c u l t assignm ent* is tr.3 t ,r' the M ed ical Standards C o m m ittee. It i s not e a s y to s e t up s t a n d a r d s th a t. 49 that are rigid enough and flexible enough to be of value and still acceptable to the num erous variab les and facets of ou r A m eric an R ailroads. It is a t r e m e n d o u s jo b and o u r e x i s t i n g s t a n d a r d s n e e d r e v i s i n g , and this will continue to be an unending job. As C h a irm an of this com m ittee, we have one of our profound and p r o g r e s s i v e th in k e r s . Y e s te r d a y , he h an d e d m e about 150 p ag e s of what he has been doing on this m edical stan d ard s work, and then handed m e a n o th e r 50 p a g e s which he wouldn't let m e have. I d on't know what it is , but it has to do with the sam e thing, so you can get a little idea of how much work this is. Our pro g ram this year was largely directed tow ard helping the Medical Standards Committee. At th is tim e , we would like to h e a r s o m e th in g about what h is c o m m ittee has done, and what they are planning, from the Chairm an, Dr. John Winston. REPORT OF MEDICAL STANDARDS COMMITTEE DR. JOHN R. WINSTON: Dr. Nelson, gentlem en: I would like to re c o g nize the o th e r m e m b e rs of the M edical S tan d ard s C o m m ittee, and if you will stand, p le ase , I would like for the audience to see you. W alter Longeway, Colorado and Southern Railway; Stanley C yran, Pennsylvania; Bob G r a h a m , T h e P u l l m a n ; H. W. H a m m a t t , th e B u r lin g to n ; J . W. Houk, N. & W .; Jo e Je n s e n , Rock Island; R alph J o h n so n , New Y ork C e n tral; R o lan d K i e f f e r , M. K. & T. ; J i m S ta c k , t h e N o r t h w e s t e r n , E a r l e Wight, Canadian Pacific, (/pplause) They have been assigned along with m yself quite a sizeable task. The In terstate C om m erce C om m ission C hairm an when he addressed this group last, said that the public has the right to a s s u re itself that all possible m easu res are being taken to protect p assen g ers, rail employees, the public generally. Then we have the admonition of the United S tates Suprem e Court which s a y s th a t we m u st e x e r c is e the h ig h e st d e g r e e of c a r e to p ro te c t the p u b lic. So, it would seem reasonably sim p le to get up som e m edical stand a r d s that will do just that and that has been done, and it read s as follows, and th is is th s ta n d a rd of the I n te r s ta te C o m m e r c e C o m m is s io n as it r e la te s to m o to r vehicle o p e ra to rs, larg ely to tru ck d r iv e r s , and it says: "No person shall drive o r shall any m otor c a r r i e r req u ire or perm it any person to drive any m otor vehicle unless such person p o sse sse s the following m inim al qualifications: Those qualifications a re am ong others: No m ental, n erv o u s, o rg an iz o r functional d iseases likely to in terfere with safe driving." 50 T hat is a b it of profound m e diocrity, I gu ess you might call it. (Laughter) Anyhow, it doesn't answ er the.question at all. So, we have been charged, we as chief m edical officers have been ch arg ed , to d eterm in e that for m edical re a so n s the em ployee is neither re q u ire d nor p erm itted to a s su m e duties o r resp o n sib ilities that would be to h is own d etrim en t, to d etrim en t of o th e r people, o r re su lt in in efficient operation of the property. Now, this begins, of co u rse, with the m edical selection of the p ro sp ective em ployee. I would like to am plify the sta te m e n ts m ade this m o r n in g , th a t by a ll m e a n s , th e s c re e n in g p r o c e s s s h o u ld b e m uch moiva thoroughly p erform ed before the man is sent to the m edical doctor lor th exam ination. At th a t tim e , of c o u rse , what you a re r e a lly try in g to do is to d e te r m ine w ill, can o r should. Well, this p e rso n is expected to safely and satisfactorily perform all the duties and responsibilities of his occupa tion. Now will he do that is largely a m atter of motivation, given average intellignece. The hiring em ployer can learn a whole lot m ore about w h eth er the m an will do the job than will the m ed ical ex a m in e r. Now, can he do the jo b ? Even then the em ploying o fficer can g enera get a better grasp of this m an's capabilities. That is, of course, a math largely of physical ability and mental efficiency. T hen it only com es into a m a tte r of p ro p rie ty as to w hether o r not this p e rso n should be p erm itted o r re q u ire d to assu m e th e se duties and responsibilities. You note, using two separate ite m s--d u ties and r e sponsibilities. Those responsibilities deal largely with him self, number one, with other people num ber two, and with the p roperty, number three. If we carefully avoid perm ittin g c r req u irin g a p e rs o n to get into any capacity that will p e rm it him to do dam age to h im self o r oth er people, it is highly unlikely he will dam age company p ro p erty . So, only in that instance does it come down to w here the m edical aspects become signi ficant. * t I Now, t h e s e p a g e s th a t H a r v e y t a lk e d a b o u t, it is abo u t like th is. We have divided this into, first of all, the objectives of the m edical exam ina tions for prospective em ployers. I should add this is strictly a working effort. It w as n e c e s s a r y to g et s ta r t e d so m e w h e re . In o r d e r to w rite som ething of this so rt, it is about like trying to write a tre a tise that says how a r e you going to o p e r a te a r a il r o a d . How a r e you going to se t up m edical standards ? It is, you can believe m e, not easy. But we will s ta rt off with som e o b jectiv es, and that is to avoid the injustice to the individual and to tits com pany of p erm ittin g a p e rso n to e n te r a field of endeavor for which he, is not fitted, and in which he will be unable to c a rry on successfully. It is n e c e s s a r y to d e t e r m in e w ithin p r a c t i c a l lim its of m e d ic a l i n vestigations that the prospective em ployee has no physical, em otional o r m ental conditions o r condition, n o r pred isp o sitio n to such conditions that m a y i n t e r f e r e with th e ( 1) e f f ic i e n tl y p e r f o r m i n g th e d u tie s o f h is o c c u p a tion, and I should add occupations to which he is expected to advance, and (2) without co m p ro m isin g the health and safety of h im self o r the health and safety of others and last, for prolonged period of time. I think we should add a n o th e r point at th is tim e. Although we a r e in the tra n sp o rta tio n industry, the c a r r i e r s are up to their eyeballs in the insurance business. They are not only insuring the safety of their co m m odity, but they a re in su rin g the life of the em ployee now. They a r e in volved in health insu ran ce. They a re involved in m edical in su ran ce, so as a p ro sp ec tiv e em ployee, we m u st keep depth in mind. Now, I have s e v e ra l p a ra g ra p h s about how the local hiring people m ight expedite th e ir s c re e n in g p r o c e s s e s . Then when it co m es o v er to the m e d ica l exam ination of the em ployee, the first pream ble is e s s e n tially the sam e, but we are there changing our position a little bit. T h e r e it is to p r o te c t the w elfa re of the em ployee by attem p tin g to place him in positions that will not jeo p ard ize his health, to attain the h i g h e s t d e g r e e c f s a f e t y to the end th a t the p u b lic m a y be a s s u r e d that all possible m e a s u re s a re being taken to p ro tect p assen g e rs, r a il e m ployees and the public generally, and to a s s is t in the efficiency of o p e r a tions and the protection of the com pany's property that otherw ise may be ad v e rsely influenced by an em ployee with an unfavorable m edical condi tion. I have listed for ready re fe re n c e quite a num ber of m edical condi tions that are exam ples of diseases o r conditions that may predispose a p erso n to an unfavorable resp o n se . So if th e p e r s o n lias one of t h o s e c o n d itio n s o r a s i m i l a r o n e , he should be given p a rtic u la r attention. I should acid that I did so m e r e s e a r c h - that is what I did. R e s e a r c h now adays m eans looking up a word in som ething a little bigger than a college dictionary, so I did som e re s e a rc h and found that of all those p eo p le who h a v e m e d ic a l p r o b le m s , th a t w e r e se n t in xor the c h ie f s u r geon's examination, three out of four of these problem s were detected, and the recom m endation was m ade by the su p e rv is o r ra th e r than all in the routine m edical examination. F u r t h e r m o r e , o n e o u t of 90 p e r c e n t - -90 p e r c e n t of th o s e p e o p le who w ere r e s tr ic te d , taken out of se rv ic e o r placed in some r e s tr ic te d s e rv ic e , this p ro c e ss had been o rig in a ted again by the alert su p e rv is o r. I don't know whether that speaks well for the alertn ess of the su p erv iso r on all our p ro p ertie s, o r whether it speaks a little disparagingly of som e of the m edical evaluations that we are getting. C ertainly, there is a tendency for m edical evaluations to becom e perfunctory. When they a re perfunctory, they are worse than not at all and I hope that my asso ciates in the m anagem ent field understand that as w e ll a s I, o r a r e a s f e a r f u l of it a s I am . Now, when it com es to checking this person, there are certain a s pects of the m edical exam ination that req u ire some particular evaluation T h e re was a tim e when we could check the m a n 's blood p re s s u r e and /isi and fe e l that things w ere w orking out p re tty well, but now then, a r b it r a r i I h a v e b r o k e n t h i s down in to t e n a r e a s th a t we f e e l should ho- e v a l u a t e d on each p e rso n and g raded at le ast in the ex am in er's mind. The first is a m easure of occupational responsibility. Obviously, that, of c o u rse , will be done e ith e r by job assignm ents o r by occupavions Obviously, C lass A, for exam ple, co v e rs those assignm ents in which the employee has a g re a te r than average responsibility for the b'ves and safety of others as,w ell as a g re a te r responsibility for the protection of property. To that end, it is im perative that he, at all tim es, use good judg m ent in his work, and that he not have any known conditions, either phy sical, m ental o r em otional, that would in c re ase the risk of his failure to resp o n d to his re sp o n sib ilitie s p rom ptly and properly. N um ber 2, this is a m e a su re of stren g th , m easu re of physical strength, stam ina, dexterity and so on. T h i r d would be a n e u r o p s y c h i a t r i c e v a lu a tio n . It can h-- s i m p l e , o r it c a n be s i z a b l e . A s i m p l e , o n e , of c o u r s e , is sim p ly fa s- r d h i m to the p o st office, and se e if he can get back to the depot. O ther -ban th at, y ;u can go a ll the way to the a b s u r d in the m e a s u r e of his in te llig en c e, e m o tio n a l s ta b ility , d e p e n d ab ility , ju d g m e n t, e t c . , but if he is r .ire fully evaluated, by e ith e r the p h y sic ia n o r e v a lu a te d tby the hiring o ffic e r ar.d it begins to take on a m e a su re of this m a n 's em otional state, he can com e up with a pretty good idea of his own, and feel that it will save him a lot of trouble. F ourth, we w ill go into the v a rio u s m edical deficiencies. T hese m e d i c a l d e f ic ie n c ie s a r e th e d e f i c i e n c i e s m e a s u r e d on the la s t 50 p a g e s that have been e x p e rie n c e d , and a s th e y c o m e in, we put them on a p a g e / * and ea ch one of th e m is a s s ig n e d a p a r t i c u l a r rating. The next tim e a:;' em ployee co m es in with the sa m e o r a v ery s im ila r condition, then we will have established a p rec ed en t that will at least indicate how we evaluate it in the p ast, and we can m ake co rrectio n s as necessary. Finally, we com e into distance, vision, air vision, color perception, fo rm field of vision, h e a rin g , and x - r a y exam ination of the low back and ce rta in o th e r la b o ra to ry p r o c e d u re s if and when they are thought d e s ir able. Each of those are divided into five areas, c la sse s of one, two, th re e , four, five. Thev are lifted h ---- 1 that it will be after a great, long effort, if we do, but we will try. Thank you. (Applause) CHAIRMAN NELSON: I am su re you can ap p reciate what the am ount of w o rk in v o lv e s, and all we can do is keep p ec k in g away at it and co m e out with som ething that would be of value to all of you within a reasonable period of tim e. One of our m ost im portant and very active com m ittees is the M edicalL e g a l C o m m i t t e e w hich i s c o m p o s e d h a l f of d o c t o r s w ith D r . B. VV. Stockwell, as chairm an, and the other half m em bers of the claim group of which K erm it Johnson is the co -ch airm an . D r. Stockwell is rea d y to tell you a little bit about what this com m ittee is doing. They a re doing so m e v e ry in te re stin g work with som ething that is quite re c e n t, that I know that you will be interested in hearing about. Dr. Stockwell. R E P O R T O F M E D I C A L - L E G A L C O M M I T T E E I* DR. B. W. STO C KW ELL: Thank you, M r. C h a ir m a n . M e m b e r s and G uests: You will note on page 4 of yo u r p ro g ra m that the m e m b e rs of the Joint M edical-Legal Com mittee are listed, that is, the m edical m em bers. I would like at this tim e to thank each of them individually for their a s sista n ce and cooperation, and specifically, for the work that they have done on th eir assigned projects. Dr. Stanley Cyran, M edical D irector of the Pennsylvania R ailroad, will you stand up. D r. C yran. Dr. Glenn Cushman, Chief Surgeon of the W estern Pacific Railroad. Dr. Dowd, Chief Medical Officer of the Canadian National, is not here. D r . V. W. H o llo, C h i e f S u rg e o n o f th e St. L o u i s - S a n F r a n c i s c o R ailro ad . D r. Ralph Johnson, Medical D irector of the New York Central. ' D r. Isadore Kaplan, Medical and Surgical D irector of the Baltim ore and Ohio. D r. Southgate Lefgh, Chief Surgeon of the Seaboard A ir Line R ail road. D r. Vance M. Strange of the Southern Pacific Railroad. D r. J. R. Winston, System M edical D irector of the Santa Fe. Thank you very much, gentlemen, for your help. (Applause) I would also at this tim e like to thank my c o -c h a irm a n , K erm it Johnson, G eneral Claim Agent of the N orthern Pacific Railway, and the . legal m em b ers of the com m ittee. F i r s t , M r . J o h n s o n , w ill yo u s ta n d up, p l e a s e . M r. J o h n s o n hr1s been v ery coo p erativ e and has done a lot of work for the com m ittee. Mi R. R. M inor is c o - c h a ir m a n of the Legal M em bers. lie is G eneral Clai Agent of the Illinois C entral R ailroad. M r. J . D. Book, S p e c i a l R e p r e s e n ta ti v e of the G e n e r a l C l a im s Agei Pennsylvania R ailroad, in New York. M r. R. E. H oehle, G en eral Claim Agent of the Elgin, Joliet and E a ste rn , h e re in Chicago. M r. J. A. L e e , G e n e r a l C la im Agent of the S o uthern R ailw ay Systei in W ashington. M r. R. P. O 'C onnell, A s s is ta n t Chief C laim Agent of th New Y ork C entral, Detroit. M r. J. D. C a ld w e ll, A s s i s t a n t G e n e ra l C la im A gent of the S outhern Pacific, San F rancisco. M r . C. S. R e s t e r , G e n e r a l C l a i m s A tto r n e y of th e S e a b o a r d A ir Line Railroad. M r . R. W. C e n te n , A s s i s t a n t to th e G e n e r a l A d j u s t e r o f t h e C h ic a g o M ilwaukee, St. P au l and P acific. M r. E. M. Glennon, who you know fro m this m o rn in g 's panel, is L egal A dvisor to the Com m ittee. And the o th e r m e m b e r is M r. L. B. Kyle, G en e ra l C la im s Agent of the Canadian N ational Railways in Winnipeg. t M r . W. H. K e ll y , C h a i r m a n of the G e n e r a l C l a i m s G r o u p , h a s a l s o been m ost cooperative and helpful. The C laim s R esearch Bureau of the A ssociation of A m erican R ail roads r e p r e s e n ts the backbone of this C om m ittee, and the active p a r tic i pation of and full cooperation of M r. Ken Carney, D irector of the C laim * R esea rch B ureau, M r. J. A. R isendal, A ssistan t D irecto r of the C laim s R esearch Bureau, and M r. W illiam Hawley, of the C laim s Research B u re a u , who a c ts a s s e c r e t a r y fo r the C o m m ittee, g r e a tly en h a n ce s the work. T h e re was som e delay in sta rtin g the work of this C om m ittee, as it was anticipated that new m edical m em bers of the group would be appointe at the m em bership m eeting which was initially scheduled for A pril 2 i, 1964, at Las Vegas, Nevada. However, in spite of this delay, there has been c o n sid erab le w ork done, and I will go over with you, briefly , , the p ro jects now under consideration. Before discussing our specific p ro je c ts at the m om ent, I would like to take just a lew m inutes to review the accom p lish m en ts of the Com m ittee. The extension of im p artial m edical testim ony in our courts, which was inaugurated by the m edical sociaty and judges of New York City was p ro m ulgated by this C om m ittee, and the C om m ittee was in stru m e n ta l in in stituting the plan in se v eral p arts of the county. The Com m ittee studied the problem of back injuries and claim s under the F ederal Em ployers Liability Act and developed a "Recommended Pre-Em ploym ent X-Ray P rogram for all R ailroads." This recommended p ro g ra m was sent to the Chief operating o ffic e rs of the m em b er ro ad s in 1963, and thus is available to all interested . T he re s p o n s e to o u r re c o m m e n d a tio n h a s b een g ratifying and we have been in p erso n al com munication with in terested people from a num ber of ra ilro a d s that do not as yet have such a p ro g ra m . , As we do not feel that any p roject is e v e r com pleted, the rec o m m en d a tions of the Com m ittee have been reviewed on occasion since our last m eeting, and the Com m ittee feels that the em phasis, as far as our p r e em ploym ent back x-ray program should be in the elimination of individuals with c o n g e n ita l d efects which will lead to b ack ache in the future. If we ca n e l im in a te th is one g ro u p , we have a c c o m p lis h e d a g r e a t deal. ' We have been re p e a te d ly asked to p ro d u c e s o m e p ro o f that a p r e em ploym ent back x -ra y p ro g ra m will re su lt in sav in g s to the railro a d s, and at the p r e s e n t tim e , we a r e in itia tin g a stu d y on o u r r a i l r o a d of our ex p erien ce in the past eight y e a rs which we think will be of som e s ta tis ti ca l im p o rtan ce and which will be rep o rted to you in the future. In the m eantim e, we feel that the c a se s that we have in litigation at the m om ent, who en tered our serv ice with congenital back conditions b e fo re we inaugurated our p ro g ra m , a re am ple proof of the value of the p ro g ra m , becau se the cost of each one of these c a se s is going to be t r e mendous. . T he m a jo r headache for the claim s and leg al departm ents of the T a ilro a d s h as been and continues to be, the em ployee with a back injury. I think M r. Carney will second that without question. MR. CARNEY: Right. DR. STOCK WELL: Thu^# the C om m ittee h as been in te re ste d in the ruptured in terv erteb ral disc problem , and a revised questionnaire has now been se n t out to all the ra ilro a d s, and we a r e req u estin g this infor m ation fro m you on all of your c a se s. I think the re sp o n se has been good. I think M r. Sherm an of the AAR can now tell us roughly how many answ ers we have had in the y e a r of 1964. Can you give m e that inform ation? 56 MR, SHERMAN: I am so rry , sir. I didn't com e to the me.-ting prepar' d to- do so. DR. STOCKWELL: Give us an estim ate. MR. SHERMAN: The disc questionnaire ? DR. S T O C K W E L L : How m a n y q u e s t i o n n a i r e s h a v e we h ad a n s w e r e d a.; far as these cases are concerned? MR. SHERMAN: I would say probably 225. DR. S T O C K W E L L : G e n tl e m e n , th a t i l l u s t r a t e s m y point. It is a good sta rt for an excellent study. The m edical m em bers of the Committee w o rk in g on th is p r o j e c t is D r . V an c e S t r a n g e , C h i e f S u rg e o n c.f the S o u th e r n P a c i f i c R a ilw a y C o m p a n y , and h i s l e g a l c o u n t e r p a r t Is M. J. D. C aldw ell, A ssista n t G en eral C laim s A gent of the Southern P acific Corrp-i We a r e v e ry p le a s e d to announce that a code for the tabulation of the in te r v e r te b r a l disc data has now been w orked out for reco rd , tg questions tiiat we a r e i n t e r e s t e d in, u til i z i n g th e d a t a p r o c e s s i n g c r Hr.'-'. equ ip m en t of the Southern P acific Railway. They have been m ost cooperative, and I am su re this study will be helpful to all of us. The C ardiovascular study is being conducted by Dr. Ralph Johnson, C h ie f M e d ic a l O f f i c e r , New Y o rk C e n t r a l R a ilw a y , and M r. ( P . O'Connell of the C laim s side of the New York C en tral. The C laim s R esearch Bureau has provided them with exam ples of the type of te stim o n y that is being given in co nnection with relatin g trau m a o r work exertion to the existence of h ea rt d ise ase . The Con mittee is co n s id erin g the question of how long a m a n can be kept working with h e a r t d is e a s e in view of the r e s p o n s ib ilitie s a s s u m e d under rha FELA . The C om m ittee is keeping in close touch with cardiovascular studies that are going on in various p arts of the country, and particularly one that has been conducted by the U niversity of M innesota Medical School in volving railway employees. As you a re aw are, to date, the study has been useful in proving that th ere is no d irect association between the railw ay m an's occupation o r so cidental trau m a to the existence of disqualifying heart disease. T his will be d iscussed fu rth er, I am s u r e , tom orrow at the panel on cardiovascular disease. The pulmonary disease proj ect is assum ing greater importance each y e a r, with in c re asin g claim s for pulm onary fib ro s is, pulmonary em phy s e m a , and carcinoma of the lung. An excellent study by Dr. Isadore Kaplan, M edical and Surgical D i r e c t o r of th e Baltimore and Ohio R a i l r o a d h a s b e e n conducted and he 57 . is the m ed ical re p re se n ta tiv e for this p r o je c t. M r. J. A. Lee of the Southern Railw ay System is the C laim s m em b er assigned to th is subject. A study of the effects of D iesel Fum es on our em ployees was initiated by the A ssociation of A m erican R a ilro ad s - we co n trib u ted $30,000 for the sta rt of the p ro g ram at the University of P ittsburgh School of O c cupational Health. Dr. Stanley Cyran, Chief Medical Officer of the P en n s y lv a n ia R a ilr o a d and D r. V e n c e l Hollo of th e St. L o u is -S a n F r a n c i s c o R ailw ay are the m edical rep rese n tativ es from the Com m ittee on this p ro jec t. At the end of the firs t y e a r the United States Public Health Service took over the project, that is, the continuing project, that p r e sum ably will continue for a num ber of years. At th e p r e s e n t tim e stu d ie s in d ic a te that th e re is no c o n n e c tio n b e -., tw een the inhalation of sqm e of th e se alleged noxious agents in the work environm ent and the pulm onary d iseases mentioned. In d is c u s s in g this p ro je c t with the g en e ra l c laim s group at th e ir m eeting la st y e a r, I called attention to the fact that all the p r e s e n t p u l m onary studies indicate that there is a direct connection between some of these d ise ase s and smoking cigarettes. We c a l l e d a tte n tio n to the fac t th a t u n d e r r a t e s that r e c e n t l y w ent i n to effect, som e life insurance com panies will issue a $50,000 life in s u r a n c e p o lic y for a n o n - s m o k e r f o r $61. 00 l e s s p e r y e a r th a n a s m o k e r of the sam e age. The in creased incidence of neuropsychiatrie claim s under the F ederal E m p lo y e rs L iability Act has been brought to the attention of die C o m m ittee, and a s e rie s of cases have been studied by Dr. Glenn Cushm an, Chief Surgeon of the W estern P acific R ailroad, who is the m e d ica l r e p r e s e n ta tive for this p ro jec t. No conclusive recom m endations have been m ade to date. A continuing study of som e of the aw ards of the National Railway Ady y ju stm e n t B oard in m e d ica l c a se s is a subject that will be developed f u r th e r in the following panel. Copies of som e of these aw ards have been forw arded to the m em b ers of the M edical-Legal Com m ittee and I believe that many of them should be forw arded to the entire m em bership because of their general interest. A new .project of the C om m ittee is the study of "M alpractice Liability in P r e - P l a c e m e n t E lim in a ti o n s . " We have touched on that th is m o rn in g . I m e n t i o n e d t h e a r t i c l e in t h e A u g u s t 19 64 i s s u e of the J O U R N A L O F O C CUPATIONAL MEDICINE, and I think that we will h ear m o re about that in the n e a r future. In this connection o u r m e m b e rsh ip has been asked fo r a r e p o r t fro m your ra ilro a d s to find out the m agnitude of the problem , and specifically w hether o r not a su it h a s been in stitu te d against y o u r r a ilr o a d b ased on the m a l- p ra c tic e o r e r r o r in judgm ent of one of y o u r exam ining p h ysicians in declaring an applicant for em ploym ent unfit. 58 ' Some of the answ ers are in, and they are very interesting, but w have not had sufficient tim e yet to analyze them. The problem of h earing and claim s for loss of hearing against the r a i l w a y i n d u s t r y h a s b e e n a p r o j e c t o f the C o m m itt e e . D r. K. E. Dowd, Chief M edical O fficer of the Canadian National Railways has been the m e m b e r of th e C o m m i t t e e i n t e r e s t e d in th is p r o j e c t . No s p e c i f i c r e c i n m e n d a ti o n s a r e b e i n g m a d e a t t h i s t i m e , but the p r o b l e m w, b eing "qu. ely' observed. As there are occupational hearing losses, and you may hear much m o re about this in the future. M a lig n a n c y p r o b l e m s , o t h e r t h a n c a r c i n o m a o f the Uir.g, hav e b e e n a project and you will hear m o re about this from Dr. Southgate Leigh, C h ie f S u rg e o n of t h e S e a b o a r d A i r L in e R a i l r o a d , who is the m e d i c a l -* m e m b e r assig n ed to this p r o je c t for the C om m ittee and who will d is c u s s som e aspects of it in the r e p o r t that he is giving as C hairm an of the C o m m itte e on T r a u m a to m o r r o w . M r. C. S. K e s t e r , G en eral C la im s A tt^ rn e of the Seaboard A ir Line R ailroad Company was assigned as the claim s rep rese n tativ e to work with D r. Leigh on this subject. A continuing study of "the a r e a of g r e a te s t p ro b lem s" wiiich we think is very im portant, is being continued through the facilities of the Claim s R e sea rch Bureau. In o th e r w ords, they a re advising the M ed ica l-L e g al C om m ittee when it is ap p a ren t th a t som e new problem is cropping up tnat m ay be of considerable im p o rtan ce to the industry. M r. J. D. Book of the P e n n s y lv a n ia R a ilro a d Company is the c la im s m em ber of the com m ittee who w orks with the Claim s R esearch Bureau in this connection. M r. R. R. M in o r, C o - C h a i r m a n of the C la im s group, with Mr. K erm it Johnson, C hairm an of the C laim s group, was assigned to handle the publicity aspects of the C om m ittee's work. t M r. R. W. C e n t e n , A s s i s t a n t G e n e r a l A d j u s t e r , C h i c a g o , M ilwaukee, St. P a u l and P a c ific R a ilro a d , w as as sig n e d the im p o rta n t su b je c t of p r o p e r m e d i c a l p r e p a r a t i o n of i n j u r y c a s e l it ig a t io n s , which we h a v e h e a r d som ething about this m orning and which we will hear m ore about in the following panel this afternoon. I have now m entioned the active participation of all m e m b ers of the Com m ittee except Dr. John Winston, System Medical D irector of the ` A tc h i s o n , T o p e k a Sc S a n ta F e R a ilw a y . H e is not m e n tio n e d l a s t b e c a u s e of the le a st contribution, but b ec au se of his assistan ce in coordinating the work of this Com m ittee with the im portant work of the Com m ittee that he heads, the M edical Standards Com m ittee. I think that the rela tio n ship of m ed ical sta n d ard s to the m e d ica l-leg a l problem s 'that we face a re very obvious. The Joint M edical-Legal Com m ittee is a hard-working, well func tioning com m ittee and we hope that it will continue that way in the future. 59 Thank you, (Applause) CHAIRMAN NEI-SON: Thank you, Ben. T h is h as been a very afore:;!:.-./ com m ittee because it does a lot o f w ork on a lot of projects. The m oderator of our next sym posium on Preparation for Three D octor Board, National Railroad A djustm ent Board and T rial, is equally cap ab le in the a rts of the o p era tin g ro o m and the co u rt room . I think you will find this a very interesting panel. Our needling friend, the p u r p o sefu l and inquisitive o b stru c tio n ist that we could not get along without, Ben Stockwell, will you kindly introduce your panel? PANEL: PREPARATION FOR THREE DOCTOR BOARD, ETC. M O D E R A T O R B. W. S T O C K W E L L : T h a n k yo u , H a r v e y . M ost of o u r p an e l m e m b e rs, gentlem en, you a re acquainted with as a resu lt of our excellent panel this morning. M r. Z im m erm an, Vice P re sid en t of the Operating D epartm ent of the Illinois C entral Railroad. M r. E a r l O liver, Vice P re sid e n t - P erso n n el of the Illinois C entral. M r . G lennon, A ttorney f r o m the Soo L ine, who h a s c o n trib u te d a great deal. M r. E. H orsley, C a rr ie r M em ber of the F irs t DivLi m ! thy N R ailroad Adjustment Board. M r . K en C a r n e y , D i r e c t o r o f th e C l a i m s R e s e a r c h i! D i . M. B. C l a y to n , C h i e f S u r g e o n of th e S o u th e rn R.i R-a.iv. D r. W illiam E. M ishler, Chief Surgeon of the E rie-L ack a wanna. D r. E rn e s t C. Olson, Chief Surgeon of the Illinois C entral. D r. John R. Winston, M edical D ire c to r of the Santa Fe. T he pan el has been assigned som e im portant subjects, some of which a r e c o n tro v e rs ia l, and we will a p p re c ia te the full participation of all of y o u . You. m a y a d d r e s s a q u e s tio n to a n y m e m b e r of the p a n e l o r the panel as a whole. will proceed with our assignm ent. / The first item is the preparation for the three-doctor board. I think we w ill follow th e q u estio n s h e r e , but ch a n g e it a little bit to s ta r t w ith if 6, i n s t e a d o f #1. It i s m o s t i m p o r t a n t f o r u s to h a v e a fu ll u n d e r s t a n d i n g of t h e N a ti o n a l R a i l r o a d A d j u s t m e n t B o a r d , and particula^. > when we a re discussing a th ree-d o cto r panel, or other sim ilar su^jic.s. so at this tim e , I will ask M r. H orsley if he will tell us what the Natmn*. R a i l r o a d a d ju s tm e n t B o a rd i s , how i t s h e a r i n g s are conducted, ar.u other com m ents that he w ishes to m ake. 60 MR. E . T . H O RSL E Y : T h a n k y o u . D r . S to c k w e ll. B e g in n in g v.-ilh q u e s tion HQ: What i s th e N a ti o n a l R a i l r o a d A d j u s t m e n t B o a r d ? I sh o u ld like to p r e f a c e m y a tte m p t to explain it by e x p r e s s in g a deep thanks to you of the m e d ica l fra te rn ity for ex p re ssin g an in te re s t in the N ational Railroad A djustm ent Board in the problem s that it has, which a r e , at least, on the p erip h e ry of your field because the help we get fro m you is m ost vital to the s u c c e ss of our defense of the c a se s that com e fro m your respective carrier properties. So, we do appreciate this in te re st very m uch. T h e N a tio n a l R a ilr o a d A d ju s tm e n t B o a rd i s a c r e a t u r e of s ta tu te . It was born of the Railway Labor Act, which was enacted by the Congress of the United S tates effective June 21, 1934, so it has been in existence f o r a long tim e. Ju st rec en tly , how ever, we have becom e em broiled in the problem s which now, I am glad to note, ad d ress your in te rests. The N ational R ailroad Adjustm ent Board is a bipartisan tribunal. It is com posed of four divisions. They have different jurisdictions. The F i r s t D iv isio n , o f which I a m a m e m b e r , h as to do with the o p e ra dog c ra fts , and I am su re my term inology is understandable to all o f y o u , with respect to the crafts. T h e S econd D iv is io n , tVie T h i r d D iv isio n a n d th e F o u r t h D iv is io n e a c h ' n s to do with a n o t h e r s e g m e n t o f r a i l r o a d c r a f t w o r k e r s . So That it b eing a b i p a r t i s a n b o a r d , I should Like to m a k e it v e r y c l e a r to you th m the m e m b e rs of the Board are not judges in any r e s p e c t. The m em b ers of the B oard a re by statute the chosen re p re se n ta tiv e s of the two p a rtie s to the Board, nam ely, labor and management. T h e re a re 36 m e m b ers of the Board, not counting som e supplem ental divisions which a r e n e c e s sa ry to reduce w orkloads on those divisions. T h e s e 36 m e m b e r s a r e chosen 18 by la b o r, the N ational L abor Unions in the r a i l r o a d s , and 18 by the c a r r i e r s . We, being the ch o s en r e p r e s e n ta tiv e s by sta tu to ry language, of our resp ectiv e in te re s ts , of co u rse, are not judges because a judge is not a chosen representative. It m a y s e e m to you th a t I a m la b o rin g th a t p o in t, but I believe it should be m a d e c l e a r b e c a u s e even today I h av e b een c a lle d by a r e p r e sentative of a c a r r i e r and asked if it would be ethical to com e and talk with me. To clarify the understanding in the field that we a re not judges, you can talk with m e and my asso c ia te s on the c a r r i e r side the sam e as you talk with y o u r co unsel with re sp e c t to a litigated m a tte r on the railro ad . If anybody wants to ra is e a question a s to why I happen to be the chosen re p re s e n ta tiv e on the F ir s t D ivision, we will r e s e r v e that d is cussion for later. (Laughter) It 13 a b i p a r t i s a n b o a r d . We a r e y o u r a d v o c a t e s . It is tJ.- eg.- , f o r m o f a r b i t r a t i o n , if I m a y s a y s o , b e c a u s e by s ta t frits the B o n n ; lo c a t e d in C h i c a g o , a l l f o u r d i v i s i o n s . We a r e p a id by, th e railroad.-. The labor re p re se n ta tiv e s are paid by the labor unions. It is a board sittin g in Chicago re p re s e n tin g both sid e s of the in d u stry and taking all cases that a ris e out of the collective bargaining ag reem en ts, all disputes arisin g out of those ag reem en ts, so that it is a cheap fo rm of a r b it r a tion, b e c a u s e it is alw ays sitting, and we ta k e the c a s e s as they com e. T h ere is an awful work load of cases which is another subject. There a r e 4 ,0 5 4 c a s e s now pending b e f o r e m y d iv is io n , th e F i r s t D iv isio n , of the R a ilr o a d A d ju stm en t B oard. T h is is due to r e a s o n s which do not a d d re s s , I think the in terest of this body at p resen t, but it is not my fault, I hasten to add. (Laughter) Now, I should like to p ass on to #7: How a r e its h e a rin g s conducted? T he h e a r ings of the F irs t Division a re conducted in c a m e ra , so to speak. U'e do not p e r m it the p a r tie s to a p p e a r b efo re the r e f e r e e and the B o a rd in a r g u m e n t of a c a se , so that th a t is the r e a s o n why we don't have any w i t n e s s e s . We d o n 't tak e any te s tim o n y . It is p u r e l y an a r b i t r a l situation in which the rep rese n tativ es on the B oard, as naem bers, r e p r e sen t you and use the subm issions o r the pleadings, if you p le ase , that a re sent in to the Board from both sides, and a re put together and c o n stitute the case. T h e h e a r i n g s t h e m s e l v e s a r e b e f o r e th e r e : .rer b e f o r e whom n lv the r e p r e s e n t a t i v e s of the p a r t i e s , m e m b e r s of the B>.ird, a p p e a r . e v e r , t h e r e a r e o r a l h e a r i n g s at e a r l i e r s t a g e s at w hich tlv- re < ,t p r e s e n t , the r e f e r e e being the a r b i t r a t o r , but it d o e s n 't do any g.-vd for tlv p a rtie s to com e before the Board, because at that stage, there is already a deadlock asp e c t to the case. But I would like to, at this point, say that it is m ost helpful when those r a il r o a d s do com e in to see us, who w ish to m ake th e ir c a s e a lit tle m o r e c l e a r to the B o a rd m e m b e r s an d d i s c u s s it w ith u s , a n d wc so licit such help from the railroads. O th e r th a n th a t, th e re is no f o rm a lity to the a p p e a r a n c e of the p a r t i e s before the adjustm ent board. D r. Stockw ell, should I proceed to these o th er q u estio n s until the q u e s t i o n a r i s e s ? It aj^. r e l a t e s to th e B o a r d . MODERATOR STOCKWELL: I think if you would go ahead with #8, "why it will benefit us to be inform ed of the aw ard s of the r e f e r e e , that it would be helpful at this time. MR. HORSLEY: D octor, I think it would be of g r e a t benefit to the m ed ical sta ffs to be fam iliar with the aw ards that a r e e n te re d by the Board, that have to do with m ed ical questions of p h y sic al condition, arm I have u ndertaken to keep M r. Ken Carney fully in fo rm ed of those aw a rd s, ami 62 if he h a s not p a s s e d th em out to th e se d o c to rs , I su sp e ct that Mr, Ken Carney should answ er that question, because he has all of th en . They have been made available to him, MODERATOR STOCK WELL: Thank you very m uch, Ken. I v.ould like to m ention at th is tim e you have been very co o p e ra tiv e in fo ra nr ding to the m e m b e rs of the M edical-L egal Com m ittee som e of the p ertin en t aw ards and 1 hope that we will have the opportunity of d iscu ssin g a few of them later in the p an el, because there are some differences of opinion as to how w e ll th e se c a s e s w ere p r e s e n te d to the B oard, and in so m e of them , w here the d ecisio n was unfavorable to the c a r r i e r it se e m e d a p p aren t from the r e p o rt that you issued, that there was good reaso n for the loss of the case. How far do you think the C laim s R esearch Bureau can go, and would be w illing to go, as f a r as the m e m b ersh ip of th is group is co n cern ed , in the sending of som e of these rep o rts out? MR. K. A. CARNEY: W ell, we have been distributing to claim d e p a r t m ents g enerally, and som e of the decisions to Bill Todd for distribution to the M edical Section, in th o se a r e a s where we think you are vim.lly interested. T here certainly is no objection to your getting any m aterial that h as to do with the p h y sic al d isab ilities of em p lo y ees, and tin e s to p pel question growing out of the contentions that em ployees art- permanently disabled, and then se ek to re tu rn to serv ice. We a r e in g re a t need, r e a lly , of som e m o re u n ifo rm p re s e n ta tio n of cases in this are a, so that our c a rrie r m em bers may make an effective p resen tatio n , and only if you know the problem s and how the re fe re e s are deciding th e se q u e s tio n s , can you adapt yo u r own p r a c tic e s to the r e q u ir e m ents. W ith re fe re n c e to H o rs le y 's com m ents about the f act that he ..ives th e m all to u s , I th in k t h e r e is a m odicum of tru th th e re . He so m e tim e s does give them all to u s , and we som etim es do forw ard them on to you, but occasionally, he lapses into forgetfulness. I p r e s u m e we a r e equally a s n eglectful of him . We, how ever, have rem ed ied that situation, I believe, to the point now that we are keeping each other better inform ed, and if you medical officers are not receiving th ese r e p o r ts r e g u la rly , you should m ake it known to Bill Todd, so that we c a n m a k e c e r t a i n that you do. MODERATOR STOCKWELL: I am thinking entirely of medical cases that have been presented. MR. CARNEY: Yes. MODERATOR STOCKW ELL: T hat h a v e gone to the Board. The question a ris e s im m e d ia te ly a s to why a m e d ic a l case e v e r does get to the Board, because so m any of the railroads have a working agreem ent that should solve the problem b efo re it is taken to th e N ational R a ilro a d Adjustmnt . : 63 Board. DR. C H E S T E R R. ZE IS S ( E l g in , J o l i e t & E a s t e r n R ailw ay): Who a p p oints the r e f e r e e s ? Who p ay s t h e m ? MODERATOR STOCKW ELL: Who appoin ts, is the question. MR. HORSLEY: The re feree is appointed by the federal government un d er a provision in the statute when we cannot agree on one. A re fe re e is an a rb itra to r. A re fe re e is an itin eran t philosopher. (Laughter) DR. ZEISS: Is he a Civil Service em ployee ? MR. HORSLEY: No. He is not. A case that com es to the Adjustm ent Board and the physical condi tion has been passed upon by a re fe re e , you will frequently find that r e feree has a Bachelor of Science, A M aster of Science, a Doctor of J u r is prudence, and post-graduate work at the University of Chicago, for ex am ple, in the study of adm inistration. D R . A'. J , S U T H E R L A N D ( L o u i s v i l l e & N a s h v i l l e R a i l r o a d ) : What p e r centage of the cases are involved with m edical problem s? MR. HORSLEY: With re s p e c t to the whole num ber pending before the N ational Railroad Adjustment Board, the percentage involving medical q u e stio n s is what som e people would c o n s id e r negligible, but the im pact of one of those cases could spread through the entire industry, and has. a n d c r e a t e s a l a s t i n g p r o b l e m , s o it i s n ' t q u ite the n u m b e r of c a s e s . It is the horrible m iscarriag e.o f both jurisprudence and judgment that causes the problem . MR. CARNEY: What is the answ er to the question, though? (Laughter) HORSLEY: He said what p erc en ta g e. Xsaid it is negligible. MR. CARNEY: Is it one p e r cent o r two p e r cen t? MR. HORSLEY: What is tw o? (Laughter) I don't know. MR. CARNEY: He asked a question and he didn't get an answ er. MR. HORSLEY: Of the 4 ,0 5 4 , I su sp ect that those pending now at my division would not be m o re than 25. Now, you figure out the percentage. MR. CARNEY: Thank you very much. MR. HORSLEY: What is the percentage ? (Laughter) T w enty-five out of 4,0 54, what is the p ercentage? I am asking a question. I want an answer. (Laughter) MR. CARNEY: What is the a n s w e r? MODERATOR STOCKWELL: R egardless of the percentage, I must say that som e of those cases are m o st in terestin g as far as the m edical a s pects of the problem s are concerned. M r. Oliver, you had a com m ent? MR. OLIVER: I should like to m ak e an o b se rv a tio n with re s p e c t to question ft8. I a g re e in p rin cip le with what "C h ic k " H orsley has said, but I would add a word of caution. Back in the ea rly days of the National R ailroad A djustm ent Board, we w ere inclined'to take the latest decision in any p a rtic u la r a r e a as gospel, as the law. And then we would modify o u r p ra c tic e s, o u r po licies, accordingly, but o v er the y e a r s , we began to le a rn that th e re was a great deal of in co n sisten cy in the aw ards, and we began to d isc re d it in our own thinking those aw ards that are patently nonsensical. So I th in k it i s well for the c h ie f m e d ic a l o f f i c e r s to be a w a re of the aw ards that are currently being turned out, but at the sam e tim e, they should re m e m b e r that any p a rtic u la r aw ard is not the final word. MODERATOR STOCKWELL: Are there any other questions concerning the Board at this tim e ? 1 am s u r e we will d isc u ss it m o re as we r a i s e o th e r questio n s, but at the moment, does anyone e lse have a question? V ery good, we will proceed to the p rep a ra tio n for a th ree-d o cto r Board. T h e re is som e confusion, of course, as to exactly what a th re e d o cto r B oard is , and I think the f i r s t thing that we should bring out is that it is dependent upon the working agreem ent that the individual r a il road has with the Brotherhood concerned. In m any of these ag re em e n ts th e re is a sp e cific p ro c e d u re e s ta b lish e d for ph y sical exam ination of disqualified em ployees. The im portance of the work of our Com m ittee on M edical Standards is e m p h a siz e d stro n g ly in th e se d isp u ted c a s e s . In o th e r w ords if we can have the su p p o rt of the AAR C o m m ittee on M e d ica l S tan d a rd s, it w ill be m o st helpful when we have a disputed case. It gives u s so m e backing in' our decision that the m an is physically unfit. That was mentioned this m orning, and I would like to again em phasize it. Obviously, we m u st be on v e ry stro n g grounds to disqualify for m ed ic al r e a s o n s an em ployee who h a s se n io rity . U nless we a re m ost c a r e ful in disqualifying m en with sen io rity , we a re going to have a m ost dif ficult job in s u s t a i n i n g it with the medical board o r b e f o r e th e A d justm ent Board. . ` ' M r, H orsley, would you agree ? Am. HO RSLEY: Y e s , I would. MODERATOR STOCKWELL: To exemplify the types of working a g re e m ent, b ec au se we find they v a ry trem endously fro m ra ilro a d to railro a d . I would like to p re se n t to you the specific provisions of the working a g r e e m e n t that we hav e on the G ra n d T ru n k W estern with th e B. of R . T . , and then we a r e going to co m p are that with the working a g re em e n t of one o r two o th e r ro a d s. T his ta k e s a m inute o r two, but I think we have to und erstan d what the s u b je c t m a t t e r is when we a r e talking about a t h r e e - m a n B o a rd on medical disqualification. "T he e m p lo y ee c o v e re d by this ag re em e n t d isq u alified for s e rv ic e on account of h is p h y sic al condition will, in the event he feels such d isq u a l ification is not justified, handle the m atter with the operating officers V d i r e c t o r through his rep rese n tativ e in the u su al way, and if the m a tte r is not disposed of in a m utually satisfactory m anner, the employee will provide w ritte n re q u e s t m ade by him within 30 days" (and this is im p o r tant) fro m the date notified of his disqualification, be given a physical re-exam ination under the following conditions: "Two, the em ployee involved will prom ptly se le c t a physician to r e p rese n t him , and the m anagem ent will prom ptly se lec t a physician to r e p resen t the com pany. The two physicians thus selected will promptly r e exam ine the em ployee and re n d e r a r e p o rt of th eir findings within a rea so n a b le p erio d . If the two physicians thus se le c te d shall ag ree, the co n clu sio n r e a c h e d by them will be final. " T h re e , the physician selected to re p re se n t the com pany and the p h y s i c i a n s e l e c t e d to r e p r e s e n t the e m p lo y e e " m u s t b e c a p a b l e . (I w on't read the entire wording. ) " F o u r, if the two physicians selected should d isa g re e as to the p h y s ic a l condition of the em ployee involved, they will select a third physician be a g r e e d upon by them who shall be of rec o g n ize d standing in the m edical profession. "T his B o ard of m edical exam iners" - (Now the term inology here is * im portant.) "T his Board of m edical exam iners thus selected will examine the em ployee involved and will, within a reasonable period, ren d er a r e port setting forth his physical condition and their conclusions as to his fitness for se rv ic e , and a decision of the m ajority of the Board is final and binding upon both p a r tie s to the dispute. ' Now, obviously, if it is settled at that point, th e re would be no r e a son fo r it going before the Adjustment Board. "A fter com pletion of the re-exam ination, the B oard shall render a r e p o r t o f t h e i r f i n d i n g s , s e n d two c o p i e s to t h e o f f i c e r d e s i g n a t e d by U.. com pany, and two copies to the employee o r his rep resen tativ e. 65 lfSix, th e c o m p a n y a n d th e e m p l o y e e in v o lv e d w ill e a c h d e f r a y th e expenses of th e ir p r o s p e c tiv e appointees. If the decision of the B oard selected does not confirm the justification for previous disqualification o r se rv ic e r e s tr ic tio n , the-em ployee will be p erm itted to retu rn to service from which he w as rem oved and com pensated for net loss of earnings. " I may say at th is tim e that this is the reason for proceeding with d is patch in these c a se s. If it does go on for a long p erio d of tim e, obviously if we lost it, we m ay have to pay out a lot of money for the tim e tnat that man disqualified. We have o th e r p r o v is io n s in the a g re e m e n t fo r handling individuals that do not re q u e s t re -e x a m in a tio n within the 3 0 -day p erio d , but they a re not pertinent to the p rese n t discussion. You will p articu larly note that at the point of a third doctor being brought into the picture, the exam ination is made by the three-doctor panel, sitting as a group. In other words, all three doctors are there. The m atter isn 't re fe rre d to the third doctor for a decision. All three d o cto rs m u st be p r e s e n t to m ake this decision. The reason for this is that the chief medical officer for the railro ad can dispute the a lle g a tio n o f the em p lo y ee who w ish e s to r e tu r n to w ork, that there is "no hazard in his tour of duty," o r that "he doesn't have any work to do. " I think this an sw e rs two questions, #10 and #11, on the p ro g ra m and illu stra te s again why it is m o st im portant to list the job duties re q u ire d for employees. I have asked the m e d ic a l m e m b ers of the panel to b ring with them a copy of t h e i r w o rk i n g a g r e e m e n t w ith th e B. of R. T . a n d we w ill a s k each one now to discuss the differences between his agreem ent and the one that I have mentioned. Dr. Clayton, what is the situation on the Southern ? DR. M. B. CLAYTON: When an em ployee is d isq u alified by a com pany physician and takes issu e and p rese n ts a statem ent from his physician that he considers him qualified, he has the privilege of asking for exam : ination by a neutral. T he p ro c e d u re henceforth is som ew hat as follows: 1. When a n d if t h e e m p l o y e e 's p h y s i c i a n c o n t a c t s th e c o m p a n y 's physician who found h im disqualified, an arran g e m en t is made between them to do a conjoint exam ination in the company p h y sician's office. 2. Should they a g r e e a f t e r th e conjoint ex am in atio n that he is d is qualified that ends the m a tte r. Should they disagree, then they decide upon a n eu tra l and w h atev er he sa y s is final and binding with the excep tion t h a t the em p lo y ee has the p r iv ile g e of re q u e s tin g that h is c.v..- i re-opened at any tim e. ' The em ployee's physician and the com pany's physician have the p riv ile g e of p rese n tin g any facts which m ight p e rta in to the n eu tral such as the n atu re of his occupation, the reaso n he was disqualified o r qual ified as the case may be. DR. KNOWLES: May I ask, what is the p ro ced u re when it is an engineer? Is th e re ar.y difference when you accept e n g in e e rs? DR. CLA Y TO N : T h e r e is no difference except two y e a r s ago we decided that o u r d o cto r and his doctor would not have to get to g eth er and do a conjoint exam ination. In o rd e r to save tim e, that they agree upon a n e u t r a l e. g. by telep h o n e , if they w ished to, and they would not have to do a conjoint exam ination. MODERATOR STOCKWELL: D r. M ish ler, will you te ll us how your ^ ree iae n t w orks on the Erie-L ackaw anna ? DR. WILLIAM E. MISHLER: I can s ta rt out by saying that I like the very c o m p le te a g r e e m e n t that you have. I h ad v e r y little to do with the d r a w ing up of conditions for the ag reem en t of o u r r a ilro a d except to the extent that we did have two things. N u m b er one, th e re has to be a d isa g re e m e n t in m ed ical findings w h ic h i s i m p o r t a n t , an d the s e c o n d is t h a t t h e n e u t r a l when t h e r e vs a d ifferen ce in m edical findings, shall be a man of the American II- a r d o r Jle s t a n d i n g . A c t u a l l y , I h a v e to m a k e th is c o m m e n t . A ch:-:i s-T.-e-.'n's duty is tw o f o ld . O n e i s to s e e th a t the p e o p l e who a r e p e r : >r:v.ir,g t:>-ir d u tie s a n d I a m t a l k i n g a b o u t m e n with s e r v i c e - a r e s a f e ir. t h e i r o c c u p a t io n s , and in doing so,* he c a n 't be a r b i t r a r y if he w ants to avoid cons'ar.t c o n flict with the unions. So th a t th e f i r s t ste p , when m en show up with things that I think m ight t /d e trim e n ta l in the p a rtic u la r job they a r e doing, is to see if I c a n 't find so m e p lace w here they can w ork safely. I think that has helped to a g reat extent. T h e r e a r e aLways going to be people who s till don't like y our decision, but if o v e r the y e a r you have helped a certain percentage of your employees the unions a re not too a g re ssiv e , but the w ording of o u r ag reem en t h as helped a great deal. T h e re h as to be a disagreem ent in the m ed ical facts, not in whether the m an can w ork o r not work, but w hether th e re a r e d isa g re em en ts of m edical facts.I I have alw ays m aintained with som e su c ce ss that, if the agreem ent b etw een m a n a g e m e n t and the m a n 's fam ily d o c to r is 100 p e r cent in a c c o r d , th e d e c i s i o n w h e th e r he can o p e r a t e a lo c o m o tiv e , o r w h eth er ..o can clim b a box c a r is mine. That is a m anagem ent decision and this is adhered to. I think the im p o rta n t thing is that th e re h as to be a d isa g re em en t on m ed ical fa c ts, and num ber two, to supplem ent what D r. Clayton sa y s, if we do pick o u t a m a n to act a s n e u tra l, he h a s to be a m an who is a d ip lom at of the A m erican Board. We then give him all the facts as to what the occupation of the man is, what his history is and what our findings w ere, and if the la b o r people would feel like they want to do anything, why they have the sam e privilege. We have been reasonably successful with this pro g ram . MODERATOR STOCKW ELL: In other w ords, .in an sw e r to the specific question as to w hether the th re e doctors exam ined this employee as a board o r not, the an sw er is "No. " DR. MISHLER: T he answ er is "No. " I am s o rry I took all that tim e. I could have said, "No. " MODERATOR STOCKW ELL: Very good. You brought up another v ery interesting point, one that is definitely controversial. Is it the duty of the m edical board to determ ine only the physical condition of the em ployee, o r is it the duty of the m edical board to make determ ination of whether o r not he may safely c a rry out the duties and resp o n sib ilitie s of his position? Now, that is the $64. 00 question. It would be a w onderful thing if the m edical board could only decide the udical aspects of the case, but unfortunately, it doesn't work that way, b e c a u s e th e q u e s tio n is w h e th e r the m a n c a n go b a c k to h i s w o rk a s a switchman, and the im portant question is whether he is safely able to do his job. M r. H orsley, would you com ment on that? , MR. HORSLEY: I should like to. In the a g re e m e n t th at you read. D r. Stockwell, 1 think one of the con cluding term s of it was the very question that shall determ ine whether the m an can go back to work. I don't want to ov er-sim p lify it, but if, as we sta rte d out discussing today, there was a table of physical standards to guide the m edical con s id e ra tio n of a m a n , th e n the question vyould be w h e th e r o r not the s u b ject m eets the c a rrie r's physical standards, and physical standards are p ro p e rly c re a te d , in m y opinion, by a c a r r i e r b e c a u s e a c a r r i e r has the. duty, as a com m on c a r r ie r , to its em ployee and to the traveling public and to the p r o p e rty of the sh ip p e rs which it h an d les, so that that is closely related to the condition of the men who actually p e rfo rm work. T h e r e f o r e , s ta n d a r d s could be fo rm u la te d w hich would have to do with th ese c ra ft job d u tie s, so that if a m a n 's p h y sic al condition is in question, the sole d eterm inative question would be w hether o r not he m eets the p h y s ic a l sta n d a rd s .' If he d o e sn 't, th e re is no question of going back to work. II' h e d o e s , th e q u e s t i o n o f g o in g b a c k to w o rk is s i m p l y a n s w e r e d the f i r s t q u e s tio n , s o tit a t w h e n , a s y o u h a v e v e r y w ell s t a t e d , we the q u e s tio n of w h e th e r o r not a m a n c a n go b a c k to w o rk , that m ight be and se e m s to me in a g re a t m any of o u r c a s e s is irre s p e c tiv e of his phy sical condition. He dem onstrates that he can clim b a ladder. Hence, it is concluded he can clim b the side ladder on a boxcar, so I am always fearful of the q u es tio n being w h eth er o r not he can go back to work, b ecau se the n e u tra l d octor in just perh ap s a few m o m en ts of briefing is certain ly not an authority, and he is the sole deciding factor as to whether o r not a man can go back to work in the tra in y a r d of a railro a d , and that is a dangerous questio n to put before any n e u tra l irre s p e c tiv e of his standing in the p r o fession. He might not fully understand it. May I take a m om ent. Dr. Stockw ell, to show what is p re s e n tly pending before o u r B oard on th is v ery question ? MODERATOR STOCKWELL: Surely. MR. HORSLEY: You stated that full observance of an agreem ent would certain ly settle the question, and I agree as between reasonable prudent m en it should se ttle the q u estio n , if it w ere followed out in te rm s of the a g r e e m e n t that you r e a d a s an e x a m p le . Rut such an a y ei-m er.: was m a d e o n a c a r r i e r , and we now h a v e t h e c a s e pend in g b e f o r e th e R oar 1. I should like to read very b riefly what the situation was. lh ;.t con ductor was in charge of suburban trains. It was su b m itte d to the d o c to r. T he do cto r said this: "If the duties should include o r re q u ire him to stru g g le with difficulty to open o r close doors on a train , o r jump on o r off moving c a rs, o r to do any work r e q u ir in g full use of the s tre n g th of h is rig h t a r m , re in ju ry to the m uscle attached io the scapula and to the tr a n s v e r s e long end of the right biceps, h u m e ru s m u scle would be likely to resu lt. "I do not believe that an a r m which has been as badly injured as has the right shoulder of this patient and subjected to three operations could w ithstand the strain and s tre s s e s of sudden jerking or heavy physical work. " T hat would seem to be definitive and d eterm in ativ e of the question. H ow ever, the neu tral doctor w ent on to say this: "it is m y opinion that this patient could perform the duties of conductor-collector on suburban tr a in s as he has describ ed these duties to m e, and as th e y have been d e s c r i b e d by M r. B, w ithout an y d a n g e r to h is r i g h t s h o u l d e r o r without likelihood of a rein ju ry . " B is his labor representative. Now, that opinion of the d o cto r which som ew hat m odified the defiju t i v e o p in io n w hich I f i r s t r e a d , w a s c e r t a i n l y b a s e d on t h e a%slf sta te m en ts of the patient h im s e lf and his la b o r rep rese n tativ e to the doc to r, which caused the doctor to go on to modify his opinion by saying that he could p e rfo rm those duties " a s he has d escrib ed them to me. " So th at we have a situ a tio n h e r e in which the a g r e e m e n t s e e m e d to be final and binding. The d o c to r's opening language in his opinion seem ed to be d e te rm in a tiv e , but it a ll blew a p a r t in th e m eth o d follow ed in p r e s e n tin g the c a se to the n eu tra l doctor, so that the n eu tra l doctor actually got right down into the question of w hether o r not the m an could do work re p re se n te d to him as being the work by the patient and his representative. So th a t it blew a p a r t, if 1 m a y s a y so, th e m e d ic a l opinion of the d o cto r, and the whole thing d isa p p ea re d on the b asis, o r is alleged to have d isa p p ea re d on the basis of th is m odified opinion o r p eroration that the docto r gave based upon the testim o n y of the patient, and that is what can h ap p en when you g et into the q u e s tio n of d isc u ssin g the work to be p e r fo rm e d , and p e rm ittin g those to be p r e s e n t who can m ake the s e l f - s e r v ing sta te m en ts and convince the doctor that they can do that work. T h is is the case of a m an who wants to go back to the very work in volving the opening and closing of the suburban doors in which he was injured to the extent of having three operations. T h erefo re, an agreem ent that is final and binding is not final and binding when they begin to kick it aro u n d , so the p ro c e d u re has to be w atch ed , v e ry clo sely . T h is c a s e is not d e te rm in e d y et by the Board. MODERATOR STOCKWELL: I think that case illu stra te s very well why it is e s s e n tia l that this p an el of th r e e d o cto rs h as m o r e to do than to decide the fellow has been injured in the a rm . They iiave to decide w h e th e r the injured a rm will p erm it him to c a rry out the requirem ents of his job. MR. HORSLEY: Yes sir, if those job requirem ents can be truthfully re p o rte d to him, MODERATOR STOCKWELL: That is the function of the chief m edical of f ic e r in p articipating in this jo in t th r e e -d o c to r board and then a decision is m ade. The decision is m ade that the m an ca n r e tu r n to work as a b rak em an , o r he cannot re tu rn to work as a brakem an. Now if that de cision is made under the agreem ent by this m edical board, is there any possibility then of its going to the labor b o ard ? MR. HORSLEY: That should be final and binding. M O D E R A T O R STO C K W E LL : We found i t to b e so. It w o rk s th a t way. MR. HORSLEY: I just want to caution you on what can be the procedure before the doctor to cause him to give som e credence to testimony from . . the o t h e r s i d e , an d t h e s e m e n , I a m n o t d e r o g a t i n g t h e m n o r dispnr.-. "ing them, they can speak for hours without r p w p t i - ' * " So that is what a doctor wouldn't recognize. (Laughter) MODERATOR STOCKVVELL: The rep o rt from the m edical board shoch. stu.e one of two things. It should state: this em ployee is physicailv ao.e to r e s u m e w o r k in h i s r e g u l a r o c c u p a t io n , o r is n o t a b l e p h y s i c a l l y to work in his u su a l occupation, and if you don't make that decision. I don't see how he will ev e r solve the problem o r settle the issue. MR. HORSLEY: T h at is right. Incidentally, in that p a rtic u la r case that man had filed suit under the FELA and had gotten a verdict for $39,000. MODERATOR STOCKVVELL: I am su re he has. MR. HORSLEY: E sto p p el w asn't in the ca se , though. DR. ZEISS: Isn't the im portant thing with this m an the fact that the th ree doctors are together when they make the decision? MODERATOR STOCKWELL: That is my point, yes. DR. ZEISS: I think they a re much m o re likely to ag re e, le t's say, in honesty if they a re all together and not quite se p a ra te in their rep o rt. MODERATOR STOCKVVELL: That is exactly my point. That is our p r o c e d u r e , and th a t i s why we have won 98 p e r c e n t of o u r c a s e s . D r. Ciso^j, what is your p ro ced u re? DR. O L SO N : Wo h a v e no f o r m a l a g r e e m e n t .<n .,ur r z j i r o a i. li.i' w. h a '. a c u s to m a ry handling which is somewhat in hue with the '.A : y. ; mentioned. 'The claim ant usually has had a private physician T h is /At s e l e c t i o n e x a m i n e h im and h a s se n t utir o f fic e a r e p o r t indie at m .; 'dial no f e e l s t h a t t h e i n d i v i d u a l is a b le to w ork. Wo h a v e a r e p o r t i r e m o-.ir own e x a m in e r in d ic a tin g that it is his opinion the em ployee is ur.abio to per-, fo rm the duties of his occupation. When the req u est is receiv ed , the patic-nt s e le c ts his own d o cto r, usually the s a m e one who m ade the o r i g inal examination. Each doctor is sent a letter from our office asking that the em ployee be exam ined in accordance with the p ro visio n s of o a r O p eratin g C i r c u l a r No. 18, which is e n c lo se d to the d o c to r, and attention is drawn to the stan d ard s which are set forth in this C ircu lar. We also provide authentic statem ents and these a re developed tram the em p lo y in g o f fic e r co n cern in g the n atu re of the d u ties of the m an in his occupation together with any graphic m a te ria l which m ay be available to fu rth e r am plify these duties. One c a s e th a t I r e c a l l was th a t of the d u tie s of a s w itc h m a n , and we show ed p ic tu r e s of his walking on uneven ground, clim b in g up the la e d e r, coupling c a r s , jum ping on and off. I think they w ere v ery im p re ssiv e in the mind of the neutral, at least. T he sa m e is done to o u r ex am in er, and both a r e then asked to s u b m it the r e p o r t of th e ir exam ination to o u r office. A ssum ing then dial 72 there is a diversity of opinion, and since there was origins / a dispute, the two e x a m in e rs a r e then ask ed to s e le c t a th ird p h y sic ia n . a n eu tra l, m utually a g re e d upon and to w hom the s a m e inform ation is s :i;t, s ta tic " th a t h i s o p in io n f o llo w in g th e e x a m i n a t i o n w ill d e t e r m i n e \v!v. t.her o r n e t the man is p erm itted to re tu rn to work. Incidentally, he is sen t the com plete rep o rt of the other examining doctors. The one big point of difference is that the patient may be ex am ined sep arately by these doctors. MODERATOR STOCKWELL: One other question, though, Dr. Olson, does this n eu tra l decide what the physical condition of the em ployee is o r does he decide w hether he is physically able to do the job? DR. OLSON: He decides, o r he is supposed to decide, the qualification of the m an to re tu rn to w ork on the basis of our medical standards and also gives an opinion about his ability to perform that occupation. MODERATOR STOCKW ELL: In other w ords, he is deciding the question whether he is physically fit o r unfit. DR. OLSON: T hat is rig h t, according to our standards. MODERATOR STOCKW ELL: D r. Winston, how do you handle it on the Santa Fe ? DR. WINSTON: T h e r e a r e a few a s p e c t s th a t a r e s li g h tly dif; .nt. One is that the e m p lo y ee h as 15 d ay s following n o tification of the :.-;ualification to m ake h is ap p e al for a tw o -d o cto r board. A nother is tiv e x a m in a tion of the two d o cto rs is m ade in the office of the company physician, and they m ake th e ir judgm ents based on their in terpretatio n of w hether o r not his physical condition does not justify rem oval o r restriction id ids se rv ic e rig h ts , so they a r e m a k in g a judgm ent based on th e ir own o b s e rv a tio n s . Now, the two of th e m appoint the n eutral doctor who m ust be a c e r tified s p e c ia lis t in th e d i s e a s e o r im p a ir m e n t that the em ployee h a s . It does not specify that this w ill be m ade in the com pany's office, but it does specify it is to be m ade jointly. T heir objective is to determ ine whether or not the employee m eets 1 the requirem ents of the com pany's physical examination rules, MODERATOR STO CKW ELL: P h y sic a l re-ev alu atio n ru les, in o th er w ords ? DR. WINSTON: It s a y s p h y sic a l exam ination ru le s. MODERATOR STOCKW ELL: F o r a m an with seniority. DR. WINSTON: I a m ju s t re a d in g you what it says. MODERATOR STOCKWELL: What does it mean ? DR. WINSTON: T d o n ' t Vnn..- .................... tion ru les. M ODERATOR STOCKW ELL: No, I don't say that. I can't in terp ret your agreem ent. I am just asking you. DR. WINSTON: But it says - req u irem en ts of the com pany's physical exam ination ru le s , so now how do you get into one of th e se? Well, that is a n o th e r s to r y , and b riefly , do you want m e to te ll so m e m o r e ? M O D ERA TOR STOCKW ELL: Surely. How do you handle it? How do you solve the problem ? DR. WINSTON: We have four g e n e ra l m a n a g e rs ' t e r r i t o r i e s , and each pf them is handled differently, it se em s. (Laughter) But g en erally , it goes like this, that the m en get together with the co m p an y 's m ed ical representative, and if the re s tric te d opinion was re a so n a b le on the p a rt of my office, we will say, the recom m endations a re re a so n a b le , then when the m edical rep rese n tativ e rep resen tin g the com pany explains to the p atien t's re p re s e n ta tiv e not only th is m a n 's d uties but also his resp o n sib ilities and his ex p o su re , and a lot of th is, of c o u rs e , depends not only on effort but h o u rs of w ork, re g u la rity of sc h e d u le s --th e re are a great many aspects of a jo b --if they are properly ex plained, then the neutral doctor--and I expect m ost of ours are settled rig h t th e re , if we were c o rre c t--h e usually would agree with us, I expect, in the g reat m ajority of those cases. MODERATOR STOCKWELL: Very good. DR. WINSTON: Now, that depends on die p ro p e r p re p a ra tio n . You sim p ly d o n 't go down there without p rep aratio n . M O D E R A T O R STOCKW ELL: I a m glad you m entioned that. It does r e quire p rep aratio n . (Laughter) "DR. W IN STO N : Now th en , you s e le c t a t h ir d d o c to r. T hen m o s t of the tim e , m a n y tim e s , it is done in the th ird d o c to r's office with the two other doctors. Now, again, if this third neutral doctor has been properly schooled as to why we m a d e these r e s tr ic tiv e rec o m m en d a tio n s in the firs t p lace, in th e g r e a t m a j o r i t y of in s ta n c e s , h e w ill a g r e e . So we d o n 't often lo se . We don't often lose a 3-doctor board. M ODERATOR STOCKWELL: Very good. T hat is v ery sim ila r to the m ethod we use. Mr. Zim m erm an, could you com m ent on the necessity for following the provisions of a working ag re em e n t? Now, it is in te re st ing that ap parently you don't have a working agreem ent in this particular field with the B. of R. T. on m edical disqualification. What is your at titude on that? MR. ZIM M ERM A N : We don't have th e m with any of o u r unions. D r. X .-1,1 o -.-r .7 ,v ..,rr. n > l.-.T .-' If One thing that I think that probably has been lacking was alm ost said a m om ent ago, maybe I should re ite ra te for em phasis, is the fact that the com pany d octor should be r a th e r ag g re ssiv e in th ese c a se s. C o n tra ry to what D r. M ish ler says, I don't agree that the union re p re se n ta tiv e s ' doctors a re not aggressive because I think that they are. In the in sta n c e s w here c a s e s have been lost, I think it is b ecau se the union doctor h as done a b etter selling job maybe than the company doctor, so c e rta in ly you should follow through on the thing and be an ag g re ssiv e doctor to put y o u r point over. In o th e r w ords, I suppose the best way t o s a y it is a good salesm an , but 1 do think you would have to adhere to agreem ents where you have them. MODERATOR STOCKWELL: It is a r e a l selling job, I agree. Mr. Oliver, would you m ake a com m ent on it? MR. O LIV ER : We d o n 't have the r e c o r d s on the Illin o is C e n tra l that you have on the G rand T runk. I think you said you won 98 p e r cent of your c a se s. We h a v e n 't had enough c a se s to r e fe r it to 98 p e r cent. I s u s p e c t we h a v e w on 90 p e r c e n t o f o u r c a s e s . I d o u b t th a t we h a v e h a d 20 c a s e s a l l t o l d i n t h e l a s t 20 o r 30 y e a r s . We h a v e d e l i b e r a t e l y s t a y e d away from m aking an agreem ent such as you have on the Grand Trunk, because we feel that an agreem ent put in the contract booklet tends to encourage the em ployees to dispute the findings of our m edical people. We d o n 't want to e n c o u r a g e th a t. So we h a v e h a n d l e d it oh a c a s e - b y case basis, sim ply as a m atter of policy. . We feel also that we can get into these individual,agreem ents made fo r the p a r t i c u l a r c a s e , b e tte r p ro v isio n s than we can get if we have a full fledged contract provision. F o r exam ple, so ia r we have not had any difficulty in getting into the individual a g re e m e n t a pro v isio n that the question to be decided is w hether the m an m e e ts the sta n d a rd s se t by the Illinois C e n tral R ailroad. Now that is v e r y im p o r ta n t. In o th e r w ords, the sta n d a rd s a r e not sta n d a rd s that the n e u tra l h im s e lf s e ts up. T h ese are stan d ard s that axe set up by the IC, and the question is sim ply a question of fact. Does this mar, meet those standards ? Now, so m e n e u tra l d o cto rs will tend to d epart fro m and ignore the stan d ard s u n le ss o u r rep resen tativ e on the panel does a good selling job, m akes h im u n d erstan d that the agreem ent m eans exactly what it says. We a l s o h a v e b e e n a b le to avoid by th is m e th o d a p ro v is io n s u c h as you have in y o u r a g re e m e n t about lo ss of earnings. We think that even though the n e u tra l m ay s a y th at the m an is now physically fit to go back to w ork, th a t d o e s n 't au to m atica lly m ean that he was physically fit to go . . back to work at the tim e the dispute arose. So, if the holding is ad v erse to us, and we have had only a couple or th re e a d v e rs e holdings, then that is a m a tte r fo r p erso n n e l o fficers to resolve a little later. F in a lly , as D r. Olson said, we do not re q u ire the p an el o r the Board to sit a s a group. Q uite frequently the em ployee will designate as his m e m b er a m an at New O rleans o r Baton Rouge o r whatnot. D r. O lso n w ill d esig n ate a s his m e m b e r a m a n at C hicago, and we f e e l it w ould be an im p o sitio n , c e r ta in ly on o u r people at C hicago, to go down to Baton Rouge, and we think that we would ru n into som e difficulty with th e union in in sisting that the d octor fro m Baton Rouge com e up h ere, so v/e h a v e follow ed the p r o c e d u re , and it h a s been fa irly s u c c e s s fu l, I think, of letting the two doctors m ake th e ir judgm ent independently, se-.. `l e c t a n e u t r a l , se n d the m an to the n e u t r a l fo r e x a m in a tio n with a ll of the supporting data that Dr. Olson described, and this is not simply in form ation as to his m edical history, m edical condition, but it includes a job d e s c rip tio n . It includes photographs and so on. I think that method has been pretty successful. MODERATOR STOCKWELL: Thank you. This is m ost interesting, that is the v a ry in g situation that exists on different ro a d s with re sp e ct to th e ir -labor relatio n s and the presence o r absence of agreem ent, ct cetera. DR. WIGHT: You have been com pletely ignoring those of us north of the b o rd e r. D r. Vaughan and I can talk with ex tre m e authority on this su b j e c t b e c a u s e we know nothing about it. (L a u g h te r) We hav en 't this p r o b lem at all. MODERATOR STOCKWELL: Proceed. DR. WIGHT: I am proceeding, but I would like to get back to this rigid physical sta n d ard that Mr. H orsley raise d . He wants rigid physical s ta n d a rd s . If you a re going to abide by yo u r rig id p hysical stan d ard s, none of th e s e m en will get back to w ork, b ec au se y our p h y sical standards are set for your pre-em ploym ent examination. MODERATOR STOCKWELL: No, I d isag ree. D r. Wight. DR. WIGHT: T h at is what was stated, though, w ere rigid standards. What we a re doing, in effect, is invoking a flexibility clause. All the a ir lines do it with our pilots. They a r e rig id s ta n d a r d s , but you can in voke a flexibility clause if a man has a little disability, but it is com pen sated by experience and that is, I think, what we do in every case, in voke a c la u s e o f that nature that d o esn 't e x ist in th e ra ilw a y , but we use it just the sam e. E ach case is decided individually. M ODERATOR STOCKWELL: I am s u r e . D r. W inston, who is the chairm an of the M edical Standards C om m ittee, will agree and te ll us that we have two d istin ctly different sets of stan d ard s, one for entrance into service . 76 and a n o t h e r c o m p le te ly d iffe re n t s e t for in d iv id u als who a r e in o u r s e r v ice and have se n io rity . In fact, I don't know how w ec o u ld o p era te w ith out those two different sets of standards. In the f irs t se t of sta n d ard s, we can m ake them as rig id as we want. In th e second se t of sta n d a rd s, we have to prove that the individual is p h y sically unable to c a r ry out the req u ire m e n ts of his job. Is th ere anyone else ? DR. WIGHT: You m ay not have realized it, but I am agreeing with you. MODERATOR STOCKWELL: Thank you. (Laughter) DR. A BB O TT SKINNER (G reat N orthern Railway): A s a co ro lla ry to Dr. W ig h t's c o m m e n t s , an d an a d m itte d ly loaded q u e s tio n to M r. H o rs le y , I would g iv e th e q u e s tio n and th e n if you w ill give me 30 se co n d s b efo re he an s w e rs . How would s ta n d a r d s - -! don't c a re whether you say an old em ployee o r w h at-n o t--h o w would a p h y sical sta n d a rd help you in the s i t uation with your conductor opening and closing the doors ? Now, b efo re you answ er, to me and in o u r experience, if you make the sta n d a rd s rig id enough to p ro tec t the railw ays you are bound to make exceptions. Then, if a person gets injured, you will have let him work in defia n ce of o u r own s ta n d a r d s and 1 don't s e e how we can raakc o u r standards both rigid and flexible for the old em ployee. MR. HORSLEY: To an sw e r your question firs t, as to how would that af fect the o p en in g and closing suburban doors ca se , it would com pletely escape the fault in that case, because in that case the very question of evidence as to his ability to p e rfo rm the job functions was injected, and that q uestion, that evid entiary m a tte r with re sp e c t lo his ability to p e r fo rm the job function, was what changed the decision, so I a g re e with M r. O liver in that postulate that if the question is confined, as it should be, to w hether o r not the m an m eets the stated sta n d ard s of ph y sical fit n e s s , then th e r e is no question a s to whether o r not he can do the work, and that is s tr ic tly a m e d ica l question. It se e m s to m e that w hether o r not a m an can clim b up and down a g rab iron lad d er of a boxcar is not a medical question. If s o , i t w o u ld b e v a r i e d by: c o u ld he j u m p off it?, i f it w e r e m o v in g ? Could he jum p bn it and catch it efficiently if it w ere moving. And many other changes m in u tely in jobs perform ance are all in the picture, so that to confine it to whether o r not he m eets the stated standards of physical fitness is, o f co u rse , what I said to begin with might be over-sim plifying it, but certain ly is a goal at which to shoot. Now, as to th e rigidity of standards, I believe I stated at the begin ning with som e p erh ap s m isunderstood humor, that these should be rigid b ecause any deviation fro m the sta te d standard is u sed in another case to sh o w d i s c r i m i n a t i o n b y la b o r, and d is c rim in a tio n is th e cii .at i s s o f r e q u e n t l y b r o u g h t , tin fit s u c h ""-K ' I believe you gentlem en know what I m ean by that. T hat is , an e m ployee of a railro ad , as I said, facetiously this m orning, being struck in the coccyx by a 50-ton boxcar, and th ereb y cau sed what se e m s to me to be the in escap ab le m alady of som ething being w rong between his fourth and fifth lum bar v erteb ra. I never could understand why the sixth and seventh are not equally vulnerable, but I am not a doctor. But in any event, they win the case in co u rt afte r having evidenced th eir inability to ever resum e their work of a sw itchm an again through the opinion ev id en c e of a m edical ex p e rt su m m o n ed by th e m , paid by them to so sta te the c a se to the court and jury, assu m in g it is tru e in many cases. .A nd afte r that m an has made all these re p re se n ta tio n s as to his con-. tin u in g and fu tu re inability to work fo r a r a il r o a d again, he h as , a s I i ;ntioned th is m orning, gotten the judgm ent in his favor and becom e in stantaneously rehabilitated physically, mentally and m orally and demands within two weeks, the outstanding ca se --m an y of them two m onths--the m a n dem ands his r e tu rn to service. He goes to the y a r d m a ste r. The com m unications on the railro ad have been adm irably complete because the y ard m a s te rs have said, "You will have to see So-and-so. I u n d e r s ta n d you s u e d us in c o u rt and s a id you could n e v e r w ork again. We th in k t h e r e i s s o m e th in g w rong. You a r e now d e m a n d in g the rig h t to go back to w o rk ." Some of those cases have com e to the National R ailroad A d ju stm e n t B o a rd and at the o u tset, we w ere quite s u c c e s s fu l in r e l y in g --a n d I m u st m ention h ere --re ly in g upon the excellent spade work done by the Southern P a c ific Railway Com pany, in placing th ese estoppel c a s e s upon the books of the co u rts in the West C oast, so that the co u rts have h e ld that a m an who has m ade these inc o n siste n t r e p re s e n ta tio n s out of one sid e of his m outh in court, and out of the o th er side of his mouth tc the e a r n e r , and b e fo re our b o ard , is held to be estopped fro m making , such inconsistent rep resentations and is bound by those he made in court. P a re n th e tic a lly , not even disappointm ent in the am ount of the judgm ent Wj a p e s th e a p p l i c a t i o n of the d o c t r i n e ectively make such representations of e sto p p el to h im , any place else, and so he cannot the earlier c a se s have been closed on that basis. The Southern Pacific championed that cause and put som e excellent c a se s on the books, many of them, Wallace, Pendleton, et cetera. N o w , 'hen. s i n c e th a t t i m e we h a v e n a d s o m e d i s a p p o i n t i n g r e s u l t s fro m , again I re p e a t, tnese itinerant philosophers who look at it in this w ay, that h e r e is a m an who was injured and h e re is a m an who now m a i n t a i n s h i s a b i lity to do h is w ork. Who a m I to d i s a g r e e w ith h i m ? In m any cases they have put him back and o rd ered him to be paid, and many o th er cases ju st out of the blue they have applied the n o stru m of setting up a th re e -d o c to r panel ord erin g the th r e e -d o c to r panel to be se t up r a th e r, and th a t th e m a n b e p a id fro m the tim e he alle g e d h is ab ility to go back to w ork if he is found by the th ree-d o cto r panel as able to work. 80 That grew up into a case called the Hodges Case against the Atlantic C oast Line w here the c o u rt said, upon our objections to o rd erin g a th re e doctor sa n s any kind of an agreem ent w hatsoever, the board has a right by interim o rd e r to cause the creation of a th ree-d o cto r panel as an aid to th e b o ard in its determ in atio n of the dispute, the dispute being divided, as M r. O liv e r m entioned e a r lie r , in two p a r ts , nam ely , his p hysical, and second, the legal o r q u a s i-le g a l question of w hether or not he can go back to work. So th e c o u r t s a id in H o d g es th e b o a r d h av in g th e r i g h t to c r e a t e the th ree-doctor panel, that when it is created under the aegis of this decision, that the doctors m ust all subm it their rep o rts to the National R ailroad A djustm ent B o ard in an sw e r to the B oard's having c re a te d them as an aid to its deliberations. . A fter then getting the re p o rt from the th ree doctors, which has a l rea d y o c c u rre d in som e two o r th re e c a se s, then we reconvene the Board' on that ca se and c o n s id e r the m e d ica l opinions, if you p lease, and if the m e d ic a l o p in io n s a r e c l e a r that the m an can go back to w ork, then all th at is re m a in in g for the B oard to decide is from what date he sh all be paid. * We tr y not to get into those aw ards where it is inescapable under the c o u rt's ruling that we shall cre ate a m edical board in those c irc u m sta n ce s, we try to provide that the m ed ical board sh a ll d eterm in e also how long he h a s b een p h y sic a lly able to go to w ork, and a l l of th e s e th in g s are hum orous to you, but by gad, they are not to m e. (Laughter) Now, another kind of a case is this one in which the man m erely a l le g e s h is a b i lity to go b a c k to w o rk , and we c r e a t e th e t h r e e - d o c t o r panel, o r o r d e r him to go back to work - this "we" if you p lease is the a r b i t r a t o r , we o r d e r h im back to w ork and then the c a r r i e r will n o t apply that aw ard and the m an takes the c a r r i e r to co u rt in an en fo rcem en t p r o cedure, and the c a r r ie r 's defense is the doctrine of estoppel. We have been upheld in a ll of those. We have not been set aside in any, and another facet of that is that, when a man has em erged su ccess fully from an FELA proceeding, and he has a judgment for $80,000 and full satisfactio n in h is pocket and then dem ands his job be retu rn ed to him , c a r r i e r s have w altzed th e m an right back into c o u rt before that sa m e judge, if p o ssib le, who h e a rd the FELA action, and say, "Y o u r, . Honor, we a r e m aking petition for d ec la ra to ry judgment. We would like you to d e c la re o u r rig h t in the p r e m is e s now existing, those p re m ise s being in w ords and fig u re s as follows: T o-w it, those w ords and p r e m is e s being that th is m an h a s now com e back and wants h is job, but he said the c o n tra ry to all th is when he was before you a few m onths ago, and for which you and the jury gave him $80,000. " That is a d e c la ra to ry judgm ent proceeding, and in two of those p r o ceedings, the K irk lan d c a s e on the Jacksonville T e rm in a l R ailroad and the R i l e s c a s e on th e N e w Y o r k C r n t r - i ' r> - -n v ic to r io u s , been am az in g ly v ic to r io u s in view of the way we have beer, b a tte re d about at the National R ailroad A djustm ent B oard, by these r e fe re e s . T h ese a re cases in which your opinions have been vindicated by the courts in which the m an's judgment has been held binding upon him , if he attem pts to change it, and the ca se s are of outstanding import in this p articu la r field. The K irkland case against the Jacksonville T erm in a l R ailroad, the Riles case against the New Y ork Central, the Hodges c a se s, and the E z ra Jones case. Now, tite E z r a Jo n es case a ro se on the A tlantic C o a st Line R ailroad, and it is a ty p ic al estoppel case review ed by the c o u rt, and the m an was found to be fully and effectively estopped from m aking an inconsistent re p r e s e n ta tio n p o st-litig atio n on an FELA ca se , and we feel quite s u c c e ssfu l in those. My only re g re t is, and it is deep r e g r e t, that the m is-ta k e s m ade by the B oard with re fe re e have to be re c tifie d in this expenl y e way in p o st-litig a tio n by those c a r r i e r s who a re saddled with these T^Orrendous m is c a r r ia g e s of justice on the A djustm ent B oard. MODERATOR STOCKWELL: Thank you, Mr. H orsley, and with those com m ents we will rec ess for some coffee and then continue our program . (A s h o rt r e c e s s was taken.) M O D E R A T O R STO C K W ELL: G entlem en, we will continue. T h e r e have been s e v e r a l individuals that wanted to ask one more- sh o rt question on the A d justm ent B oard discussion before we p ro ce ed to the p rep a ra tio n of a F ed era l E m ployers Liability Act case for litigation. F irs t, D r. Nelson. DR. NELSON: Ben, all I wanted to com m ent on was som ething that I though: m ight be o v erlooked as we finish up th is p a rt of the p ro g ra m . It is obvious that the ra ilroads have many different types of agreem ents, w hich i s so m e th in g we cannot c h a n g e - - a t le a s t, a s d o c to r s we cannot ^nge. H ow ever, th e re are two com m on denom in ato rs which I think are v ery im p o rta n t fo r us to take hom e with us. One is the fact that we have ade-q u ate m e d ic a l sta n d a rd s to back us up in o u r d ecisio n s. T he o th e r is that we m ake m o re titan adequate preparation from the beginning in o u r d is puted c a s e s . T h is m ean s not just a p erfu n cto ry c o rre sp o n d e n c e with a doctor but-the subm ission of complete job duties, including hours of work, w eather conditions and any accessory inform ation regarding the work, the re stric tio n s im posed by seniority rights, and union ru le s, safety factors and m edical standards. T h is is som ething that takes work. Mr. Z im m erm an has said you have to be a g g r e s s iv e . T h is is tru e b ec au se if you do not su p p o rt your m edical opinion, no one will. That a positive approach can be su c c e ss ful is attested to by the resu lts obtained by D r. Stockwell, D r. Olson and others. MODERATOR STOCKW ELL: Very good. D r. Kaplan. DR. ISADORE KAPLAN (B altim ore & Ohio Railroad) Dr. Stockwell, first, 1 wish to congratulate the m em bers of the panel for their e x c el lent su ccess on this three-d o cto r board selection. I am fam iliar with the fact that many railro ad s a re n 't quite as successful, so perhaps this p roblem is not as sim ple as the winning m em b ers would have us believe. I wish to d ir e c t a bill of rig h ts to Mr. H orsley inasm uch as he is a representative of the c a r rie rs . I think consideration should be given to w a r d r e t i t l i n g t h i s B o a rd . We a l l know it a s a t h r e e - m a n o r t h r e e - d o c tor board o r th ree-d o cto r panel, and from a technical standpoint is not c o rre c t. It is not a th re e -d o c to r board any m ore, I think you a r e fam iliar with the c a s e of C la rk v e rs u s the B altim ore & Ohio R ailroad w here we had two d iffe ren t th r e e -d o c to r boards appointed. The em ployee lost both boards. The N ational Board then established a grievance com m ittee that m e t in B a ltim o re to h e a r the c a s e , and the r a il r o a d was favored. We a r e now being sued in c o u rt because we allegedly did not have a p ro p e r th r e e man doctor board. O ur orthopedic consultant, who, incidentally, was designated and reco m m en d ed by the em ployee's own doctor as the third and n e u tra l doctor, consulted a radiologist foj x - ra y film s. A very in fo rm a l r e p o r t w as se n t to the n e u tra l doctor defining exactly what he had ground, without making any conclusion. The plaintiff's attorneys have objected as a three-doctor board was specified, w hereas we used a consulting radiologist as a fourth doctor. This case is in litigation at the present tim e. MR. HORSLEY: On that point? t DR, KAPLAN: T hat is one of the points and it b rin g s up the question as to how m any d o c to rs can exam ine one em ployee who is s e n t for a th r e e man board exam ination. Suppose he has a cardiac as well as orthopedic defect. You r e f e r him to a cardiologist, and an orthopod. Both m ain tain the man is disqualified. We ca n only b r in g in one. T h e o rthopod w ill say: " I w ill have noth-, ing to do with the c a rd ia c pathology. " The ca rd io lo g ist will say: "I c a n not testify from the orthopedic standpoint. " P erh ap s we can get a little enlightenm ent on those two aspects. r MODERATOR STOCKWELL: M r. Horsley. (Laughter) MR. HORSLEY: To begin with, when you talk about re titlin g the board, I thought you w ere talking about my board, the F ir s t D ivision, and I have som e ex c ellen t e x a m p le s o f my own re titlin g of that b o a rd , but they a re not applicable h e re . However, if you a r e speaking of the th ree -d o c to r panel, d e s ig n a tio n o f such a panel, I agree with you. Dr, K aplan, that . is loose, but it com es from the lpose background o f th e se itinev- . osophers, and let me - "W e, th erefore, further find, d irec t and o rd e r that on o r before J a n u a r y 1, 1064, th e c a r r i e r and th e c l a im a n t o r h is r e p r e s e n t a t i v e shall each select a doctor qualified to determ ine the physical quali fications of claim ant for resto ratio n to the serv ice to which his sen io rity would entitle him. The two doctors, thus selected, th e re a f te r to a g r e e on o r before F e b r u a r y 1, 1964, upon a th ird s im ila rly qualified doctor, and all three doctors having full access to Mr. S c o tt's e n tire m edical history, to exam ine h im on o r before M arch 1, 1964, and b ased upon th e ir e x a m in a tio n and c o n s id e ra tio n of his m e d i c a l h i s t o r y , to e a c h m a k e a w r i t t e n r e p o r t o n o r b e f o r e A p r i l 1, 1964, to this Division of the National R ailroad A djustm ent Board. 1. As to M r. S c o tt's c u r r e n t p h y s ic a l q u alifica tio n s fo r r e s t o r a t i o n to se rv ic e and 2. If and to the extent they can do s o , a s to h is p h y s ic a l q u a lifi c a t i o n s f o r r e s t o r a t i o n to s e r v i c e a s of J a n u a r y 1, 19 62. " T his is the reaso n for calling it a th ree -d o c to r panel, because a c tually in the o rd e rs creating such a panel, which o rd ers have the appro bation of the United States Court of Appeals for the Fifth C ircuit in the Hodges C ase, it is a three-doctor panel because only three doctors are provided for. Now, if, afte r getting such an o rd e r as that fro m an A djustm ent Board with r e s p e c t to the p re c ise method by which a th ree-d o cto r panel is con s tru c te d o r cre ate d , you people have so prostituted the board's language a s to get s e v e r a l o th e r doctors into it, if I w ere a lawyer on the o th er s id e , I would say: What kind of an anim al is th is ? I a m s o r r y that I can be of no fu rth e r help. (Laughter) Did I answ er y o u r question. Doctor? (Laughter) D R . K A P L A N : I w ould like to, h e a r s o m e i n t e r p r e t a t i o n s of the h e a r i n g s . ' w . CARNEY: 1 would like to m ake one o b se rv a tio n . D r. Kaplan. You said you have accepted m edical rep o rts which m erely said the man is ab le to w ork. Do they not d escribe the n a tu re o f his p h y sic a l injury and ' his condition ? DR. KAPLAN: Apparently the labor relations branch has in their ag re e m ent s o m e statem en t to the effect that this will suffice. MR. CARNEY: It se em s to m e you should re q u ire a good and sufficient m e d ica l re p o rt of his m edical and physical condition. Is this not right? MR. HORSLEY: Oh, y e s, that is, of c o u rs e , what th e d o cto rs a re e m ployed for. I m ean, that is what o u r doctors a re em ployed for. Insofar a s the la b o r-s e le c te d doctors are concerned, the m en com e out of the h ills w ith a v a lise full of the d o cto rs' c e rtific a te s sta tin g . In my opinion, having e x a m in e d this m an y esterd ay , he was able to go back to work. 84 They don't even know what kind of a job he has. T h at is, 98.6 is his te m p e ra tu re , inclined to obesity is his g en eral configuration, and has no nocturia, which som e doctor told me he m eans he doesn't wet the bed. MODERATOR STOCKW ELL: I m ight add, M r. H orsley, he is breathing. (Laughter) MR. HORSLEY: R espiration norm al. MR. CARNEY: Isn 't it a fact you can ask the .doctor who has exam ined for the injured m an for good and sufficient rep o rt before you give con sideration to the establishm ent of a neutral th ree-d o cto r panel? MODERATOR STOCKWELL: I think this depends on the individual co m pany. In o u r com pany before a m an is exam ined for r e tu r n to work, he m ust p resen t a re p o rt from his attending physician or surgeon that he is physically able to do the work. Up to that point he isn 't entitled to the examination. D r. Winston. T hat is the last question on this subject. 0 DR. WINSTON: I would like f ir s t to ask a question and then make an observation. MODERATOR STOCKWELL: To whom are you directing the question? DR. WINSTON: I am d irecting it to the C hairm an for further distribution. MODERATOR STOCKWELL: Dr. Nelson? > DR. WINSTON: To you, and that is, how does this m ed ical p roblem rea ch the National L abor B o a rd ? And the observation is that we have always b e e n u s i n g p h y s i c a l s t a n d a r d s a n d p h y s i c a l l y d i s q u a l i f i e d , and I h o p e we will use the te rm "m edical standards" and "m edical disqualification'' for this reason. Wc u n d erstan d th is v ery well, but a num ber of y e a rs go one of our superintendents disqualified.a.m an for physical reasons. They said he was p h y s ic a l ly d i s q u a l i f i e d a n d p u t h i m o u t of. s e r v i c e . The case went on through the courses and ultim ately into the A djust m ent Board, and we put him back to work after about three years with pay, because he was physically fine. He was just crazy as hell, that was all. (Laughter) MODERATOR STOCKW ELL: C areful, gentlem en. Now, your o b se rv a tion is very im portant. Your question has been asked by several others as well, and we w ill a s k M r, H o rsley to a n sw e r th e question: How do tn e s e c a s e s get to th e Adjustment B o a r d ? MR. HORSLEY: T hat Is an excellent question, of c o u rse . I think that the Jurisdiction of the National Railroad A djustm ent Board is so o v e r stre tc h e d that it d o esn 't even contem plate what the C o n g re ss original;-/ nub in m ind, giving them c re d it for having anything in m ind, but wher. voa have a d is p u te th a t is a s s u m e d , the N atio n al R a ilro a d A d ju stm e n t B o n ro 's ju risd ictio n is over disputes arising out of the application of the co llec tively b argained agreem en ts between m anagem ent and the duly constituted la b o r o r g a n i z a t i o n , h av in g to do with r a t e of pay , r u l e s and w o rk in g c o n ditions. Now, how does that em brace a physical condition? I don't know. My firs t objection in handling these cases on the National Railroad A d j u s t m e n t B o a rd w as a p ro c e d u ra l o b je ctio n , a d je c tiv e law. It had to do w ith th e q u e s tio n : What ju ris d ic tio n do we h av e o v e r a m a tte r of a m a n ' s p h y s i c a l c o n d i t i o n ? We a r e l a y m e n , we a r e n o t d o c t o r s . O ur ' ' i s d i c t i o n is c o n f in e d to d i s p u t e s a r i s i n g o u t o f r a t e s o f p a y , r u l e s and king conditions. A m an's physical condition is som ething that has not b een co llec tiv e ly bargained for. Can it be d isp o sed of by a c o lle c tive bargaining rule? But I hav e lo st tim e and again with re sp e c t to this objection to j u r i s dic tio n . I have lo st it on this ground which has been accepted by a r b i t r a to r s . T h e co llec tiv e ly bargained agreem ent is the so u rc e of a m an 's s e n i o r i t y . A. m a n ' s s e n i o r i t y is in d ic a t iv e of h i s r i g h t to w ork. T h a t is the o r d e r in w hich he will work. He has a rig h t, t h e r e f o r e , to work a c c o rd in g to his se n io rity which is a product only of the collectively b a r gained agreem ent. T he Suprem e Court of the United States has ch aracterized seniority as a p ro p erty right. T herefore, when a mail has a physical condition w hich h ? s c a u s e d the c a r r i e r to say , "You m ay not work for us any m o re , in o th e r w ords, you may not ex ercise yo u r sen io rity , he and his labor union say, "Oh, y es, I may work for you under my seniority, because th a t is what the co llectiv ely bargained a g re e m e n t p ro v id e s for and if there i dispute as to my physical condition, it involves a question of my W. w io n 'ty a n d th e N a ti o n a l R a i l r o a d A d j u s t m e n t B o a r d h a s j u r i s d i c t i o n o v e r the collectively bargained agreem ent, nam ely, seniority. You are w ithholding my sen io rity fro m m e, and I am going to the Board to get it back. " Now, mayhe that is plausible. I don't know, but that is how these d isputes a ris e , if that is an answ er to the question. In so fa r a s the decision is concerned, if I m ay . D r. S tockw ell--just a second--insofar as these decisions are concerned, many court decisions a r e p a te n tly fo o lish too, but I think we have the r e c o r d with r e s p e c t to th e se r e f e r e e s . I would like to cite just v ery b riefly one c a se of a man who w as d isc h a rg e d by the c a r r ie r . He was a tr a in m an. He was in a baggage c a r while the train was stopped at a station. He, in public view, u r i n a t e d on a p a c k a g e o f D o lly M a d is o n c a k e s . ( L a u g h t e r ) And h e waz> discharged. 86 lie m ade a c la im fo r re in state m e n t. His claim cam e to the A djust m ent B oard. We deadlocked on it. I didn't want him to go back to work. I thought that was a re p reh e n sib le act on his part. We got a r e f e r e e by appointm ent. That r e f e r e e was an A ssociate Ju stice of the Suprem e C ourt of the State of N ebraska. He is now d e ceased. T hat r e f e r e e said that this man sh all go back to work because, while the c a r r i e r has charged him with urinating upon the shipm ent of Holly M adison ca k es, th e re is no evidence of re c o rd to estab lish the con trolling fact that the shipm ent was damaged. (Laughter) MODERATOR STOCKW ELL: Thank you, Mr.' H orsley . (Laughter) We w ill p r o c e e d to the la s t su b je c t to be d is c u s s e d by th is panei. MR. CARNEY: M r. C h a irm a n , I don't think M r, H o rsley has answ ered the question that was ra ise d by these gentlemen back there. They r a is e d the question as to who can file c a se s b efo re the Board. How do they get th e re ? Can the c a r r ie r file them , o r can th e individual file them. T his was the question. MODERATOR ST OCR W ELL: I think eith er can file th em , but go ahead and answer. MR. HORSLEY: The C h a ir h as answ ered the question. MR. CARNEY: Thank you. M O D E R A T O R S T O C K W E L L : P r e p a r a t i o n of F e d e r a l E m p lo y e r s Li a n ility Act litigation. F ir s t, I am going to ask one question of M r. Z im m erm an , concerning FELA cases against his company. Are you interested, Mr. Z im m erm an , in se ein g that the best possible p rep a ra tio n for the litig a tion is c a rrie d out p rio r to tr ia l? t MR ZIMMERMAN: I think that is alm ost academic. The better prep ared you a re , the b e tte r chance you have of winning the case. C e rtain ly , I am interested in seeing that the best preparation possible is available. MODERATOR STOCKWELL: I think you are expressing the opinion of m anagem ent in g en e ral. It is v e ry costly. . MR. ZIMMERMAN: I understand that. MODERATOR STOCKW ELL: It com es off the cream . MR. ZIMMERMAN: Ju st the b are facts of doing business today are costly. MODERATOR STOCKWELL: Thank you, Mr. Z im m erm an. the question. 'M; 87 You an sw ered B efore asking M r. C lennon to te ll us how a FEL A c a se should be p re p a re d , I would like to again m ake the com m ent that I made this m o rn ing, that I feel it is a team work job, that it req u ires the cooperative endeavor of the leg al d ep artm en t and the m e d ic a l d e p a rtm e n t with the f u ll s u p p o r t o f m a n a g e m e n t . We c a n 't le a v e it j u s t to th e le g a l d e p a r t m e n t, th a t v.e a s c h ief m e d ic a l o ffic e rs have c e r t a i n o b lig a tio n s to o ur r a ilro a d and to the legal departm ent to work with th em , to help them p r e p a re the c a s e m edically to the best of our ability. I don't m ean by that that we are going to pick the w itnesses they choose, but that we should put in the tim e that is re q u ire d for conferences on these individual cases, so that we are convinced that as far as the m e d ic a l p r e p a r a tio n is concerned, we have done a s m uch as p o ssib le to present the tru e m edical facts. M r. Glennon, will you talk about the best way of preparing a case? MR. GLENNON: Settle. (Laughter) But as D r. Stockwell com m ented, it is a te am effort, and it involves, aside from the p rep aratio n just to m e et the lia b ility o r the m edical aspect of it, m a n a g e m e n t's flexibility in its thinking is im p o rta n t, as fo r example, try in g to re lo c a te the m an, offer him som e other type of employment. I think m any of us s ta r t out by thinking everybody who su e s is a heel, and this is n 't tru e . V ery practically speaking, an em ployee som etim es is s o ld a b i l l of g o o d s. You find m e n who have been good e m p lo y e e s who have done a good job. They get hurt. They are insecure. They don't know w h e re th e y a r e going to get an o th er living and so fo rth . They a re v isite d e a r ly by the investig ato r o r by the official g r e e te r of the B rotiierhoodwho te lls them im m ediately what a bunch of no-goods the railroads a re . T h ey a r e going to cheat them , this and that, and they need th eir help and co unsel. He has kids and perhaps a wife who m ay o r may not be d o m in a tin g , b u t fo r m any r e a s o n s , he might decide to sign up with the herhood, and he is lost to you. Im m ediately the breech is created 1 een a fellow who has been a good em ployee and r e a lly a guy that you would like if you knew him socially, and a ll of a sudden you have got an area of distrust. The distrust exists between the claim s departm ent, for ex am p le, whom he thinks is try in g to cheat h im o r p e rh a p s con him into som ething. He may distrust the chief surgeon o r the local doctor becausehe is a "full company doctor, " notwithstanding that the sam e doctor may have taken ca re of h is fam ily in som e of the com m unities for y ears. This d is tru s t is built up within the mind of the em ployee. I am talk in g about the good guys now, who ju s t happen to sign up and who a re so ld , and it c r e a te s a r e a l p roblem becau se he looks upon the B rotherhood and its attorneys as his m eans of salvation, as the only people who a r e r e a lly going to defend h im and take c a r e of h im . You have t h e o th e r man,, of co u rse , who is sim p ly a no-good. P e r haps he h as been w aiting for som ething to happen so that he can claim to be in ju re d in o r d e r to have a big pay day. Som q, too, m ig h t think in te rm s of: if I r e a lly te ll the tru th , 1 am not going to get a dim e, because jt was all m y fault. " You have to expect th e se things. You can't a p p re ciate these men o r give them a m erit of honor award but these are things that you have to, at least, tem per your thinking about. The defense of a c a se begins with the o rig in a l investigation, and we hope that it is a good investigation by the claim s departm ent. Very often, unfortunately, the re a l claim of injury doesn't m anifest itself for some tim e, as in a back case. .V e ry often the claim departm ent might reg ard this case as one that really doesn't require much work, because it is a m inor injury. The local doctor says it is a m uscle strain. lie will be back to work in six w eeks o r le s s , et c e te ra , and then all kinds of things m ight develop. F ro m the m e d ica l aspect of it, at le ast, the biggest help, will be to have a good histo ry . This is very, v ery valuable. To re c o rd "hurt back while at work" doesn't mean a thing. As a m atter of fact, it se rv e s u ltim ately to b o lste r the em ployee's c la im b ecau se he im m ediately talked about the fact and you get the im pression that he was all right until he hurt his back. You can have a situ atio n w here the r e a l h isto ry would say: My back h u rt fo r a w eek and a half. It was getting s o r e r and s o r e r , and then all of a sudden, I couldn't stand up when I got out of bed o r did something. But u n less it is a com plete h isto ry , it may sim ply include the fact that y esterday at work I was doing some heavy lifting and all of a sudden I hu rt my back, when this was not the fact. One can ta lk a b o u t a l l kinds of in d iv id u al c a s e s , but we h ave r ig h t now a se rio u s c a se on our own ra ilro a d , involving the am putation of a leg of a brakem an, and the com plaint has now been filed. The suit is for $ 3 0 0 ,0 0 0 which d o e s n 't m e a n m uch. It ju s t s c a r e s th e d e v il out o f m e , that is all. (L a u g h te r) But the fact of the m a tte r is that the attending d o c to r, who is not r e a lly a "com pany doctor, " did the a m p u ta tio n . He has som e notes which a re not particularly detailed, but which p resen t a totally different s to ry than what will be given us when the deposition is taken. It has ju st been sa id , with a different sto ry in the com plaint, in that it h a s to do with w h ere he got off the p a r ti c u la r engine and w h eth er the step was defective o r not. I want to em phasize that an accurate, de tailed history by the doctors is m ost important. If you could do anything to encourage your local surgeons, I know they a re busy, to take a little bit m ore tim e and get a b etter history, it would be infinitely v aluable. In m any, many c a se s th e re are a v arie ty of sto rie s by the tim e the ca se gets to the court house, and certainly the story changes after the interview by the'B rotherhood representatives and the B rotherhood attorneys. If I sound as though I am criticizing some of th em , I m ean what I sa y . I have just had too many experiences with a com plete set of p e rju ry established, and I am not just talking as a railro a d man. I have a few special favorites and except for libel, slander and so fo jth , and m y d e s ire to stay out of court, as a defendant, why, I would like to nam e n a m e s, but I am su re that m ost of you in the n o rth w e s t , a t l e a s t , know who I am t a l k i n g about. But the alleged fact does change radically. I have had the situation of being in a hotel p r io r to taking depositions, and unfortunately, being close enough to h ea r the other attorney p rep arin g the w itnesses. I just heard the alleged facts develop. These were wholly d issim ila r from what our investigation showed. The original history from the doctors, whether he is treating him as the attending physician or as a subsequent consultant, the histo ry is v ery , very, very im portant. The m ore detailed, the better. The need for selecting com petent consultants, bearing in m ind what we talked about this m orning, the m edical care, really is p rim a ry after all. You a re d o cto rs. You a r e not claim s agents, and you a r e not co n -., cern ed p a rtic u la rly o r p rim arily , however, with the fact that a lawsuit m ight develop, because lawsuits are only a fraction of the injury cases. need for good m edical care by doctors you regard as very competent is essen tial. But also it would be well to keep in m ind the fact that you w ant d o cto rs who are thorough in th e ir re c o rd s as w ell as th e ir m ed ical care., who a r e r e s p e c te d by the m e d ic a l and le g a l p r o f e s s io n and who can, if needed, express him self and m aintain his opinions. Does the em ployee's word mean as much to the exam ining doctor a f t e r a c a se gets into su it? T h ere are cases w here, unknown to the c a r r i e r at least, a man has sought legal counsel, has signed up, has gone to a n o th e r d o c to r, and fro m that tim e on, I a m s u r e , in his own m ind he re g a rd s the chief surgeon really as an enemy. Usually the patient's a t titu d e changes fro m that tim e on and it becom es difficult for the chief s u rg e o n at th at point to evaluate the case pro p erly , becau se it is going to be shaded by the p e rso n 's statem ents to support a claim which may o r may not really exist. One of the questions is how to defend a case from gross exaggeration. ' W ell, it is v e ry difficult. Of co u rse, you a re lim ited in a se n se by the r t that after a case gets into suit, although you can have a m edical ^tnination of him , you no longer can subject him to sp ecific te sts as for exam ple spinogram or m yelogram studies. Usually the other side w ill have a lre a d y had these done as a m a tte r of ro u tin e, with nothing to lo se in building up th e ir claim s. T h e d o c to r can usually se n se by the p a tie n t's attitu d e w h eth e r he is reco v erin g as rapidly as he should and whether there are outside in fluences affecting norm al recovery. Claim s departm ents should be notified of th is as som e tim es it is helpful to evaluate a c a s e b efo re it is sued out, ju st fro m the standpoint of trying to decide what m ight occur and how to p r o p e rly p r e p a re fo r it. You can talk about the average lawsuit, the average fender bender o r w hiplash. T h e s e re a lly do not even get you excited. How m any tim e s do you ever find such cases in a railroad trial. FELA tria ls a re much m ore se rio u s than that and deserve and require the best m ed ical prep aratio n on the p art of a law yer, infinitely beyond the scope of p rep aratio n that you have in the average automobile liability case because the money in- volved is so great. The closest contact between the doctor and the law yer is a must. As far as the m isrepresentation is concerned, the proper medical p re p a ra tio n in the se n se of the good history, is the detailed h isto ry , the exam inations by com petent doctors in their field, and then it becom es a question of a good guy v e r s u s the bad guy, if I can c h a ra c te riz e it that way. T his is the way I try ca se s, at least, and I am not reg ard ed as a n i c e g uy in t h e c o u r t r o o m , b u t a t l e a s t we a r e h o n e s t . We d o n 't h u s t l e w itnesses or try to create some phony medical or som e phony witnesses on the liability, but you don't have to be a patsy, at least. I know from reading som e of your past m aterial that some feel, for example, the chief surgeon should never be a w itness. I disagree violently. I think when the chief surgeon is in the case at all and has seen the man, he knows his m edical history, his personnel record, bet te r than any o u tsid e r know s. P robably he h as even taken c a r e of him , operated on him for non-occupational illnesses or befriended him. if the chief su rg eo n can be b o lstered by back-up testim ony from a sp e cia list such as an o rth o p ed ist o r neuro lo g ist, it adds status and substance to what the chief su rg eo n h as to say, and he won't be d ism isse d sim ply as a company m an who gets a sa lary from the railroad. I am su re in by far the m ost cases the lay jury would consider the chief surgeon as a m an of responsibility in the community, a good doc to r. T h ere is no point in being asham ed of him . He should be used, but used rig h t by having him supported by other m edical testim ony. That is all unless th ere is something specific. MODERATOR STOCKWELL: Thank you, Mr. Glennon. I think you have covered it very well. A re th ere any questions o r any com m ents that any of you would like to m ake on this p articu lar subject now ? If not, we will go to question #15. Should o r should not a local d o c tor issue injured o r sick em ployees return-to-duty c a rd s when they are satisfied the em ployee is able to resu m e work, even when the employee h im s e lf s a y s he d o es not b e lie v e h e is r e a d y to go b a c k to w o r k ? That is a r e a l tough one fo r us som etim es and we will ask Dr. M ishler to s ta rt off the answ er fo r that. D r. M ishler. DR. MISHLER: I th in k --a n d this is an opinion--I think the doctor should issue a retu rn to duty ca rd when he is satisfied that the m an has r e - ' covered, and I say that both for ill people and injured people. F irst of all, in relation to injured people, this is im portant, and I am thinking in te rm s of tria l. A tto rn ey s have told me many tim es that at no tim e . did the com pany doctor ev e r qualify a man for work. I think that the determ ination of disability and the term ination, when it ends, is up to th e m a n who is treating him, he is best able to d ec id e th at. When he does issue such a card, we in sist, and I am talking about the local s ir g e o n - - w e in sist that a com plete and what we c a ll a final r e p o r t accom pany a copy of that re tu rn -to -w o rk c a rd to my office, and a copy of that is always sent to the claim departm ent. I think th is helps im m e a su ra b ly , p a rtic u la rly in in ju red ca se s. MODERATOR STOCKWELL: I will ask Mr. K erm it Johnson, the cochairm an of the M edical-Legal Com m ittee and G eneral C laim s Agent for the N o rth ern P acific how he would answ er that question. Does he p refer his d istric t surgeons or treating surgeons to issue a re le a se arb itrarily when the em ployee says he doesn't wish to retu rn to work and doesn't think he is able ? MR. K E R M IT JOHNSON: We have no r e t u r n - to - w o r k c a r d , and I could go on for an h o u r o r so why I do not p r e f e r one, but we would like a le tte r fro m the attending doctor at that tim e, showing that he has r e leased him from further attention. M O DERATOR STOCKWELL: How do you determ in e the end of disability if you don't have a return-to-w ork card? You m ean you use a letter in stead ? MR. JOHNSON: Y es, we do, o r a claim m an is in close touch with the atten d in g d o c to r. T hey have le a rn e d fro m the d o cto r that he is read y to w ork. T h ey r e p o r t to u s, and then we will ask for a le tte r o r final r e port. M O D ERA TO R STOCKW ELL: M r. Ray fro m the New Y ork C e n tra l, how would you suggest your district m edical officers handle that problem ? M R . RA Y : I th in k M r . J o h n s o n 's l e t t e r s u m s t h i s up v e r y n i c e l y . I think th e r e should certainly be a term ination , p referab ly in w riting. I don't c a re whether you call it a retu rn -to -w o rk card o r call it a letter, but I think it c e rta in ly is helpful in handling c a se s to know that at a c e r ta in tim e th a t a m an is able to go to w ork in the opinion o f th e d o cto r. MODERATOR STOCKWELL: Thank you. I have to d isagree again. DR. MISHLER; Mr. Chairm an, I didn't m ean to say when I answ ered the question that we gave anything to the em ployee. It is sent to the em ploying o ffic er and to my office. M O D E R A T O R S T O C K W E L L : We do g iv e t h e m a s l i p a n d , i n f a c t , it h a s always worked out well, and I don't know how the em ploying officer is g o in g to know that em ployee is able to go back to w o rk if it i s n 't conveyed to h im so m e way that the m an is able to do so. F u rth e rm o re , there is a question of whether o r not the m an is r e turning to work at the proper time. 92 Supposing the m an d ec id e s to go back to work if he third.j he was in jured because of his own negligence, and the attending physician doesn't think he is ab le to do i t ? We fe e l that the r e le a s e fo rm that we u se , which is a c e rtific a te that is given to the em ployee to take to his s u p e r visory office with a copy going to the general claim agent, is a very u s e ful device and it would se e m to m e m ost difficult to d eterm in e when the d isa b ility ends u n le s s so m eb o d y m ak es the d ec isio n and p u ts it down in writing. Are there any other com m ents ? DR. HOLLO: M r. C h a irm an , I would like to d ire c t a question to M r. H o rsle y in re f e r e n c e to sta tin g th e re should be no w ritten a u th o rizatio n , o r stating this m an can re tu rn to work, that he is d ischarged from further m edical care. T h ere are many people working that continue m edical care. MR. HORSLEY: T h at is tru e. When 1 said, r e tu rn to work should not be on the c e rtific a te given to h im , then the attending doctor o r the chief surgeon would inform m anagem ent that this man is discharged as of today and is able to go back to work from a m edical standpoint. That com munication should, of course, be made to m anagem ent. I am ta lk in g about th e m a n having it in h is h and that he is a b le >go b ack to work. Then when he is refu sed re-ad m issio n to the service for any reaso n by m anagem ent, and of which reaso n s there a r e m any, t .at he then h as this fro m the doctor as evidence which he p rese n ts n a final deciding officer, such as a Board or tribunal o r court, and he sa y s, "I can go back to work and the m anagem ent won't let m e. " MODERATOR STOCKWELL: Thank you, Mr. Horsley. Q uestion #16: When the doctor fills out any fo rm certifying as to em p lo y ee 's disability due to sic k n ess o r injury for in su ran ce n th e r purposes, including retire m en t sickness benefits, should he or should he not k e e p a co p y f o r h i s f i l e s a n d sh o u ld h e, in a d d itio n , s e n d or:.- to th e Chief Surgeon ? I will ask Mr. Glennon to answ er that question. MR. GLENNON: E m phatically y es. He should firs t of all do it ju st so he knows what he has been doing becaus.e the em ployee knows it and his attorney will know it. He certainly should advise the chief surgeon so the chief surgeon can have as com plete a fil as possible. MODERATOR STO C K W ELL: T hank you. We w ill go back to th is question of the re le a s e fo rm or re tu rn -to -w o rk form. I would like to ask Dr. Clayton, now that I have been thinking about it a little bit, how docs your in ju r e d e m p lo y e e get back to w o r k ? D o es he j u s t go when h e i s r e a d y , or what indicates when h is disability ends ? DR. CLAYTON:- The exam ining - -' r e f e r r e d the em ployee for exam ination as to w hether he co n sid ers him qualified o r not. It is not given to the individual. If tim e is an elerr.'.n; then the e m p lo y e r is a ls o in fo rm e d by telephon e o r m e s s e n g e r . MODERATOR STOCKW ELL: Does it go by m a il? DR. CLAYTON: By m ail o r to rep eat, inform ation can be given by te le phone if tim e is of the e s se n c e o r d istrib u ted by m e sse n g e r. M O D E R A T O R S T O C K W E L L : So t h e r e m ig h t be a d e l a y o f s e v e r a l d a y s . DR. C L A Y T O N : No, it should not. It is h an d led im m e d ia te ly . T h e r e should be no e x c u se fo r delay of s e v e ra l days at all. M O D E R A T O R S TO C K W E LL : It d ep e n d s on how good the United S tates m ail is working. V*/ DR. CLAYTON: Conceivably that could be, but there is always a te le phone, and if th e re is any delay, i t is handled by telephone. MR. Z IM M E R M A N : It a lso depends on how good the s u p e r v i s o r is at watching his em ployees. DR. CLAYTON: V ery definitely. M R . Z I M M E R M A N : So he w o n 't be s i t t i n g on h i s d o o r s t e p . MODERATOR STOCKW ELL: That is a very good point. DR. WINTERS: A re we talking about two things, the em ployee injured on duty getting back and the em ployee who has been out of work for m e d ical reasons ? M O D E R A T O R S T O C K W E L L : We a r e t a l k i n g ab o u t o n - d u ty i n j u r i e s . k,_>)R. W IN T E R S : We a r e t r y i n g to g e t h i m b a c k . M O D E R A T O R S T O C K W E L L : We a r e t r y i n g to g e t h im b a c k . T h e s o o n e r , . the b etter. DR. WINTERS: So we a re not arguing. M O D E R A T O R S T O C K W E L L : We want h im b a c k to w o rk is rig h t. How about the fellow that is off with a sprained ankle for a week, re a d y to go to w o rk ? Do you send a le tte r to h is em ploying o ffic er that he is re a d y to go back to w ork? DR. CLAYTON: He calls im m ediately. MODERATOR STOCKWELL: Telephone? DR. CLAYTON: Y es. and m ail also. MODERATOR STOCK WELL: Q uestion #17. How should local o r t r e a t ing su rg eo ns resp o n d to re q u e sts from the em ployee o r his attorney for reports of treatm ent, examination and prognosis? MR. GLENNON: I know th is is a question that plagues you from tim e to tim e. My ad v ice to that p a r ti c u la r do cto r would be to an sw er him so he d oesn't ignore him and so he would not get insulted in the court room . In the c a s e of a d o c to r who is out in the lines s o m e w h e re , I do think the re q u e s t should e ith e r go to the C hief Surgeon for a n s w e r to the atto rn e y after talking to the c la im s departm ent o r the law yer, o r else a sim p le, polite letter to the em ployee o r his representative, saying that he has been exam ined at the request of the railroad and he should secu re p e r mission from his employer. Very often, unless there is som e kind of a communication between the c h ief surgeon and the local doctor, nobody will be advised of the fact that this inform ation has been given. The lawyer, for example, will get copies of the m edical rep o rt from various doctors, but he does not get copies of th eir correspondence file and will be unaw are of it perhaps unless the doctor m entions it casually during the interview that the m e d ical rep o rts a re already in the hands of the opposing counsel. This might affect the strategy of the case because you always wonder how much they know. You know they a re afraid to call your doctor so m e tim e s, because they think they m ight get h u rt. It does affect the th in k ing, the planning for the lawsuit. Also, th e re is the te c h n ic a l thing that once the case is in su it, then very often the local doctor m ight not know that a lawsuit has ju st been recently com menced. He might examine him once or twice m ore or p e r haps continue to look at him on a local basis. T here is the technical a s p e c t that o n ce th e c a s e is in su it, in f e d e ra l c o u rt, and in the s ta te p o u rt in o u r state, the re q u e s t for a copy of the m edical rep o rt, if m ade to the attorney, thereby is a w aiver of privilege in som e cases as far as th eir own m e d ica l is concerned. I think we would advise on ou r ro ad , at least, that any req u e st be answ ered by the chief surgeon or by the a t torney if the ca se is in litigation. If it is not in litigation, by the chief surgeon simply saying that he sould get perm ission from personnel o r from his em ployer. It does put the doctor in an e m b a r ra s s in g position because he is treating the m an, and if he w ere your patient, I suppose ordinarily you would give h im one, but you a re really acting as a representative of the carrier. i _ .MODERATOR STOCKWELL: Thank you. A re there any other questions? DR. MISHLER: Q uestion. T hat was a long answ er and isn 't the truth of the m a tte r that the doctor has no choice ? He has to give him the r e port. M R . G L E N N O N : I don't think that i s the fa ct. I think that by s i m p l y 95 politely declining the an sw e r, and, again, this d o e s n 't apply to all c a s e s , but I am talking esp ec ially about the case that looks like it is goinv to involve a law suit, that I p re fe r to take the respo n sib ility in our c a s e s , of being the bad boy. If the doctor is asked on the stand: "Why didn't you do i t ? " I w ill v o lu n te e r that I asked h im not to b e c a u s e I c a n 't get yours and so, you know, le t's be fair about it. I think it takes the onus away from the doctor if he can answ er that he has been advised by the attorney. The atto rn ey can then take the resp o n sib ility and explain to the jury as to why he didn't respond. If this w ere tru e o th e rw ise , every doctor who exam ines him , I suppose, would be re q u ire d to send him a copy and I don't think that is the fact. DRf K IE F F E R : We have for many y e a rs, with a g re a t deal of sa tisfa c - 'on, in stru cted all of our local or treating doctors that when a request is ^ ^ /a d e to th em for that kind of inform ation, for them to tactfully inform the injured em ployee that he has been instructed that that inform ation could only be supplied by the m edical director. Even when they have come with authorization fro m their attorneys, and la te r to my office, for som e reaso n o r o th er fro m the great m ajority of cases, the plaintiff's attorney d o e s n 't p r o s e c u te the m a tte r m uch fu rth e r. We a r b i t r a r i l y sa y that any d e te rm in a tio n fo r a p p a re n t se rv ic e can only be m ade by the m ed ical d i rector. The local e x a m in e r m akes his recom m endations to m e, which I m ay accept or decline, and that has been a very sa tisfacto ry thing. Now, I will be v e ry brief. One thing about sic k n ess. The h eart c a s e . It h a s b een c a r e d fo r by h is p riv a te p h y sic ia n , and th o se , too, have to c le a r through the m e d ica l d ire c to r's office. When this man with the h e a r t d ec id e s he is re a d y to go back to w ork, he is a rm e d so m e tim e s with le tte r s f ro m his attending doctor, o r if he is n 't, he is in s tru c te d to obtain o r have his p riv a te doctor rep o rt on his c a r e to the m e d ica l di- cto r. T hen we d ire c t him to a specifically designated m ed ical ex am in er the com pany. In c id e n ta lly , we have b een doing it for y e a r s . We a r b i t r a r i l y do not . review any co ro n a ry for a m inim um of six months. MODERATOR STCCKW ELL: Dr. Winston's com m ittee o r panel will d is cuss this p articu lar problem tomorrow. If th e re a r e n 't any fu rth e r questions, for this panel, I would like to thank the panel- for th e ir contributions, and we will turn the m eeting back to the C h a irm a n , D r. Nelson. (Applause) CHAIRMAN NELSON: I think you will agree with m e that these two panels today have done a m arv elo u s job.I I want to thank the lay portion of the panel for their tim e and their contributions, which we have appreciated a great deal. 95 Our p ro g ra m fro m h e re on is m o re confined to m edical su b jects, but these are subjects that concern you people from the claim s cLpartm ent and you people fro m p e rso n n e l departm ent, as we a r e getting into five of the m ost im p o rta n t p ro b le m s that we have to contend with. I think we have a ssim ilate d as m uch in a day as we can today. The scientific meeting is adjourned until tom orrow morning. (Announcements concerning arrangem ents.) (The m eeting r e c e s s e d at 5:00 O 'clock.) ************ >U.': Thursday Morning Session M arch 4, 1965 The th ird g e n e ra l se ssio n convened at 9:40 o 'clo c k with D r. E. C. Olson, presiding. CHAIRMAN E R N E S T c. OLSON: G e n tle m e n , v.ill the m e m b e r s of the p anel p le ase com e up to the head table, and will D rs. K ieffer and Leigh also com e up here. D r.C yran, Dr. Graham, Dr. Johnson, Dr. Kaplan, Dr. M cEwan, and M oderator Dr. Winston. Good m orning, gentlem en. This day is going to contain another fo r m idable p ro g ra m which I am su re will rival the one of yesterday. T h ere a re a few ite m s p r io r to the panel, the first of which is the R eport of the. C om m ittee on F irs t Aid, of which I happen to be chairm an. R E P O R T O F T H E C O M M ITTEE ON FIR ST AID Relatively recently the pam phlet on F irs t Aid was revised and sub m itted and p a s se d and distrib u ted to the ra ilro a d s, and since that tim e th e re have been only two ite m s that I can re c a ll of any im portance that were submitted for consideration. One was the use of the pneum atic splints and the other was the ex tern al card iac m assag e, both of which were rejected. That concludes the rep o rt of the F irs t Aid Committee. The next item on the agenda is that of the Report of the Com m ittee on T raum a, Dr. Southgate Leigh. R E P O R T OF CO M M ITTEE ON TRAUMA DR. SOUTHGATE LEIGH: Dr. Olson, before this com m ittee report s ta r t s , I would like to com plim ent D r. Nelson, Dr. Olson, Dr. Stockw ell, Dr. Johnson and D r. Winston on the se t-u p of this m eeting so far. The panels se em to be getting better and better. The m em b ers of this com m ittee are Dr. Vence Hollo, F risco; Dr. Longeway of the Colorado Southern; Dr. M ishler of the E rie; Dr. Stockwell of the Grand Trunk; Dr. Strange of the Southern Pacific; and Dr. W inters of the P ittsburgh and Lake Erie. Thank you gentlemen. T h e re a r e two s m a ll things that 1 would like to m ention firs t of alL T h is c o m m itte e h a s h a d to do with f r a c tu r e s and tr e a tm e n t of tr a u m a . Now, that the College of Surgeons has come out with a very nice set of ru les and regulations on how to tre a t them , this com m ittee recom m ends that they be trea ted that way. The second item is tetanus. I understand that they don't have tetanus in Canada, but right ac ro ss the riv er in D etroit, they have tetanus. I understand they don't have tetanus w est of the M ississippi, but as soon as they get into Kentucky and T ennessee, they do have tetanus. 9 8 Now, we cannot dem and that our em ployees take the tetanus toxoid, but we ca n m ak e it e a s i e r f o r th e m to take it. Dr. Stockwell was telling m e that they go out with their m edical c a r to give p hysical exam inations. T hey put up a big sign and b ecause it is fre e , 'the em ployees will com e in and take it. Well, even if it is f r e e , we s till have trouble giving it, but I think at the present tim e on the Seaboard Railroad, among the operating type of em p lo y ee s, about 75 p e r ce n t a r e now im m u n ized ag ain st te tan u s , with the toxoid. You have the av erag e 17 o r 1 8 -y e a r-o ld boy just startin g to work. He has been im m unized in the ped iatric dosage of whooping cough, tetanus and diphtheria as a child. One does of it now, and he is back ju st as if he had just finished a new course, a complete course. Not only has the firs t w ork at W alter Reed Hospital been upheld, but the experim ental work up in Boston and in other p laces has shown that after a booster they will develop a titer that will protect them against te ta n u s even 20 y e a r s a f te r , (th at is , th e World War II boys who had their original course then). The th ird point that this c o m m itte e would like to bring up is ca n ce r. T h is s to ry h a s no r e a l beginning. It h as no ending. T h e re a re no r e a l c o n c lu s io n s , but t h e r e a r e s o m e w a r n in g s on what m ig h t be in s t o r e for us. We have rec o g n ize d fo r m a n y y e a r s that re p e a te d tra u m a can ca u se can cer; the asb esto ses, the re p e a te d tra u m a to burn s c a r s and o th e rs m ay go into some form of c a n c e r, but not acute tra u m a tic c a n c e r. It h a s been c la im e d th a t a sin g le tr a d m a m ay c a u s e c a n c e r. If su c h a possibility does exist, and evidence is not conclusive, certain factors must, be p rese n t, generally known as E w ing's postulates. N u m b e r 1, a u th e n tic ity of t r a u m a ; n u m b e r 2, a d e q u ac y of t r a u m a ; num ber 3, integrity of the trau m atized p a rt p rio r to the traum a; num ber 4, the identity of the site of trau m a with the site of the subsequent ca n c e r ; 5, adequate in te r v a l b etw een th e tim e of tra u m a and the a p p e a ra n c e of cancer. Number 6, the reliability of your diagnosis of cancer, and 7, the bridging sym ptom s. Now, the num ber 5 and the num ber 7 are the two about which a ll the argum ent takes place. F or instance, Dr. Longeway has a case here. The story is the sam e as in many of these. The em ployee had a burn on his hand and within th ree w eeks' tim e, the derm atologist says: "He has a b asal cell carcinom a of his hand that was due to this burn. " There i s n 't the adequate tim e in te r v a l. T h e c e ll c a n 't go th a t wild in that length of tim e . These a r e the problem s that we a r e running into. O ur lawyer friends are trying their b e s t to exclude a lot of these postulates. Pr esent day experiences have yielded additional evidence that has the tendency to deny o r ru le out som e of these p o stu late s, and that is why we have to keep a b re a s t of the problem and be cautious. W atch and see what develos. C a n ce r can be pro d u ced by a v ir u s . They a re saying that it is not being p ro d u c e d in h u m a n s, but we have one of the fam o u s c a n c e r r e s e a r c h s c ie n tists h e re in th is country who has been working on an im als with a fo rm of lym phom a. She has exactly the sam e lym phom a h e rse lf now. T here are other evidences. I can cite eight or ten of them that I saw at the National C ancer Institute the other day. They have brought c a s e s in, one all the way from N igeria, with this s a m e type of c a n c e r th at they have been giving to m ice. Apparently we a r e going to find thata lot of th e se things can be produced in the human. T his v iru s is not specific. I saw them give anim als one of these c a n c e r v iru se s . T hey developed the gland type c a n ce r, in the paro tid gland. They also had the skin cancer. They also had the intra-abdom inal c a n ce r; s e v e ra l different types of cancer, all from one v iru s. We m u st watch these things. In m a n , th e r e is a r e s i s t a n c e . If we only knew what c a u s e d th is r e s i s t a n c e , we c o u l d m a k e a f o r t u n e . T h e r e i s a r e s i s t a n c e f a c t o r th a t <s p re v e n ts the action of these v iru se s in the cell nuclei, and, th e re fo re , it p rev en ts c a n ce r. H ow ever, this resistan ce can be low ered either generally or locally, and can cer can develop. It has been shown that cortisone low ers the re s is ta n c e lo cally , and allows m etastasis and even prim ary cancer. Som e of these an im als had been given low doses of this c a n c e r v iru s , this sam e lym phom a. T hey w ere sep arated into two g ro u p s, one had been tre a te d with co rtiso n e that was supposed to p ro te c t them fro m c a n c e r; the o th e r group did not have cortisone. They found that with a su b m in im a l dose of the v iru s , som e anim als with c o rtiso n e developed can cer and o th ers did not. The cortisone was lowering th eir resistan ce. They also found that som e of them had been cortisone treated and not given the v irus, but becam e cancerous after being in the sam e cage with those that had had the cancer virus. D r. H ueper, who was at the NIH C an cer Institute, ca m e out definitely and said that th e re is no such thing as acute traum atic can cer, and the tg rm should be abandoned. T here is secondary traum atic cancer. T here are many different factors that can accentuate o r cause the spread of some of these m alignant growths. A c a se with Ew ing c e ll s a rc o m a of the fem u r, th a t h a s a pathological fracture, from a slight traum a, has certainly been accentuated, and un d er F E L A we a r e caught. 100 L e t m e m e n t i o n o n e h e r e . T h i s m a n c l a i m e d injury (<_ h is lo w e r back Septem ber 22nd, when he twisted his back. His occupation required that he c a r ry on his back a pack containing b atteries and instrum ents. He was 43 y e a rs old. O rig in al x - ra y of the back and pelvis showed nothing of note. Continued com plaint led to fu rth e r x - r a y s which showed invasion of the sa cru m and p e lv is by m etastatic carcinom a. The tum or was d e m o n s t r a t e d i n t h e lu n g . S u it w a s file d a l l e g i n g t h a t be b a d developed, a. ca rc in o m a of the p e lv is as a r e s u lt of being d ire c te d and re q u ire d to w ear c e r ta in gauge eq u ip m en t d u rin g th is p e rio d of A p ril to N ovem ber. We m u s t look at s o m e of the things that Dr. Winston was talking ^ about the o th e r day. When he w as an in te r n in a h o s p ita l in O klahom a City, they would b rin g th ese ch ild ren in with bum ps on th eir shin bones. T hey would be re d and s o r e . He would shave them up, paint them up, put on a dressin g and post them for an operation the next d a y . They would be o p e r a t e d o n f o r o s t e o m y e l i t i s . T h a t o s t e o m y e l i t i s is a com bination. >f two things; one, the bum p on the a n terio r m argin o f the shin; 'he second, the ro tten to n sils in the c h ild 's th ro at. The infection from 'he throat spread and "took root" in the tibia. As a word of w arning, 1 think we m ay have the sam e thing with c a n c e r and the s p re a d of c a n c e r v ir u s . We ce rtain ly a re going lo get many claim s along that line. Thank you. (Applause) CHAIRMAN OLSON: Thank you. Dr. Leigh. In an n o u n c in g th e m e m b e r s o f th e jjjanel, I i n a d v e r te n t ly r.v g le e te d to turn the page and forgot to m ention D r. Strange and Dr. Vaughan. Are there any com m ents o r questions about Dr. Leigh's report*? DR. STO C K W E LL : I th in k f o r th e r e c o r d we sh o u ld m ake a c o m m e n t o r two, and that is that re g a rd le s s of what the courts may say a t the p r e sent tim e, there is no conclusive evidence that there is any relationship whatsoever between cancer and traum a. CHAIRMAN OLSON: T h e r e w a s one p o in t y o u m e n tio n e d ab o u t the u s e of* ste ro id s which, of c o u rs e , h a s been recognized in the la st couple of y ears, and it strik e s m e that this could be a field for some trouble, because the degree to which it is being used today might raise som e q u es tions at som e tim e that m ight involve the ultim ate effect on a patient. D oes an yone have any com m ent to make on that point? DR, HOLLO: Y es, I would like to m ake a com m ent. I ju st sat in on a sym posium on the u se of ste ro id s in re g a rd to ulcerative colitis, and the in te rn ists on the p a n e l--the com plications of ste ro id s was brought up s tr e s s in g the prolonged u s e of ste ro id s with the developm ent of duodenal u lc ers with occasional secondary hem orrhage. And the consensus I got from the panel, or the opinion, was that this is not a big p roblem . In other w ords, if you have an u lcerativ e co litis, you s till give the ste ro id , and if the patient has a h e m o rrh ag e , you give him a blood tran sfu sio n . Maybe som e of our in te rn ist colleagues would like to c o m m en t on this. (Laughter) CHAIRMAN OLSON: It is open. D oes anyone v/ant to c o m m e n t? DR. WIGHT: I would like to com m ent, s ir. I was just going to say the treatm en t of colitis takes p referen ce over everything else, and the use of s te ro id s is a calculated risk . It is not every case that is going to develop a duodenal u lc e r. So, you sim p ly ju st go ahead and u se it. CHAIRMAN OLSON: Is th e re any other com m en t? I would like to raise., a q u estio n about the use of toxoid. Someone has said that it can be u sed i :n p la c e o f an tito x in , and th a t the effec t would be qu ick enough so th at ^>^it would p r o t e c t an in d iv id u al who h ad a wound that might h a r b o r the c l a u s t r id i u m te ta n i. Is th e re anyone who has any e x p e rie n c e with that who could say som ething about it? DR. RAW LES: I have had no ex p e rien c e. Dr. Olson, but it has been r e p o r te d by D r. O s c a r H am pton of St. L ouis, that the use of toxoid in tr a d e rm a lly p ro d u ce s a fairly high tite r , not the m axim um but at a lov.er level. I believe I am c o rre c t that it will produce within a period of about five days a bundle type, in traderm ally. T hat work, I understand, is con tinuing at the p resen t time. DR. ZEISS: The us : of the hum an antitoxin along with toxoid in o rig in a l in ju rie s gives you the g r e a te s t elevation in tite r against tetanus, and it is e x t r e m e l y e f f e c t i v e . We dc not u s e b o v in e o r eq uine a n t ito x in any m o r e but the use of the human type allows you to actively imm unize the patient 'a t the tim e of the accident without risk. ''-'CHAIRMAN OLSON: I think it is pretty well accepted now that the use of the immune- globulin is m uch to be p r e f e r re d , and I know at o u r h o sp ital v/e h av e d i s c a r d e d the equine type, but the point w as w h eth er one would feel reasonably safe in using the toxoid alone as an im m ediate protective agent. DR. LEIGH: N ever been im m unized before ? CHAIRMAN OLSON: That is the point, exactly. DR. LEIGH: You could with antibiotics. Your terram y cin would prevent it until the toxoid took over. CHAIRMAN OLSON: You would be willing to risk that ? DR. LEIGH: Y e s. 102 \ DR. HOLLO: I w ill m a k e o n e m o r e c o m m e n t only in rcgm-d to that. I had a patient back in 1939 who had a p erfo rated appendix with som e fecal m atter in the p eritoneal cavity to whom 1 gave a therapeutic dose of tetanus and gas antitoxin. Within 48 hours this patient developed gas gangrene of the a n te rio r abdom inal w all and expired a short tim e later. D uring the p resen tatio n of this p a rtic u la r case I was asked why I gave ATS and g as, and the only an sw er I had was that there v/as a lot of fecal m a tte r in the p e rito n e a l cavity, and I thought it was best. W e ll, th e y s a i d , "Y ou did r i g h t , " but th e p a t i e n t s t i l l d e v e lo p e d r n s '*' gangrene. CHAIRMAN OLSON: The point then is that ? DR. HOLLO: It can happen eith er way, but it is my recom m endation th a t th e ra p y should be i n s t itu te d a s h a s b e e n ou tlin ed by the C o m m itte e on T raum a, A m erican College of Surgeons titled "Prophiia.xis Against T etanus in Wound M anagem ent. " Subm itted is a copy of the gen eral p rin cip les, which a re outlined in specific m e asu res. PROPHYLAXIS AGAINST TETANUS IN WOUND MANAGEMENT Committee on Trauma, American College of Surgeons G ENERAL PR IN C IPLES r . I. Regardless of the active immunization status of the patient, renucr IMMEDIATE, METICULOUS SURGICAL CARE TO ALL WOUNDS. Removing ah devitalized tissues and foreign bodies. This is one of the most important measures in the prevention of tetanus. II. EVERY PATIENT SHOULD RECEIVE TETANUS TOXOID AT THE TIME OF IN JURY, as a booster for those previously immunized, or is an initial irr.-> munizing dose, unless he has received a booster or completed his im munization within the past 12 months. III. The decision to administer h u m a n or eq u in e t eta n u s a n t it o x in for passive immunization m u st be in d iv id u a lize d with every patient, depending on the wound, previous active immunization status, and con ditions under which the wound was incurred..VI IV. To every wounded patient, give a w r it t e n record of im m u n iz a tio n procedures, instruct him to carry it with him, and--if necessary-- to arrange for him to complete active immunization.  M M O n CY MEDICAL ID^n i i n c at; o n /V`.'s> \Vvvsi*y/ V. Basic immunisation with precipitated toxoid requires three injections. W ith fluid toxoid four injections arc prcferabld. $ I PPTD* j TOXOID 0.5 cc. 4 ! FLUID TCXOiD `--------C33------- 0.5 C.C. X TO i W EEKS X TO 4 W EEKS PPTD Predp iuted 4PPTO TCXOID \___1 0.5 c c 4FIL'D * TOXOID -------- C D ------- 1 0.5 c c 6 MONTHS TO 1 YEAR 4 TO 6 WEEKS 4FLUID * TOXOID ------- 5-- j------- 1 0.5 c c & MONTHS TO 1 YEAR 4PPTD IO aCI i) o^Tcc. 4- FLUIO TOXOID 0.5 c c FLUID TETANUS TOXOID LU 0.5 c c 0.5 cc. SPEC IFIC M EASURES I. P r e v io u s ly I m m u n iz e d In d iv id u a ls A . im m u n iz e d w it h in PAST 6 years ( in c lu d in g r e iu lb t c in g d o s e ) I . G ive 0.5 c .c . flu id te ta n u s t o x o id b o o ste r B. im m u n iz e d m oke t h a n 6 YEARS ag o (in c l u d in g r e in f o r c in g d o s e ) I. For the great majority of these patients with wounds (a) Give only 0.5 c.c. fluid tetanus toxoid booster TETANUS IMMUNE GL08UUN 1 (h u m a n ) 2. Only for those with wounds which indicate an overwhelming possibility o f tetanus (tetanus prone) (a) G ive 0.5 c.c. fluid tetanus toxoid (b) Give 250 units tetanus immune globulin (human)** (c) Consider the use of oxytctracyclinc or penicillin 250 UNITS** I I . Individuals N O T Previously Immunized A. CLEAN MINOR WOUNDS in w h ic h te ta n u s is u n lik e ly 1. Give 0.5 c.c. fluid or precipitated tetanus toxoid (initial immunizing dose) I 250 UNITS** B. ALL OTHER WOUNDS r. Give 0.5 c.c. fluid tetanus toroid (initial immunizing dose) 2. Give 250 units tetanus immune globulin (Human)** 3. Consider the use o f Oxytetracycline or penicillin 104 C. horse se r u m --Only if human antitoxin is rot available within 24 hours and only if the possibility of tetanus outweighs the danger of reaction to horse serum, question and test for sensi tivity to equine antitoxin If not sensitive, give at least 3,000 units equine tetanus antitoxin. I f sensitive to horse serum by history or test, give no equine antitoxin. Do not attempt deser,situation. Give penicillin or oxytUrcoydinc. 1 TETANUS TOXOID EQUINE + TETANUS a n tito xin -- crj-- j. TETANUS TOXO.D * * I a severe a c jlc c te d , o r o ld w o u a d i, 5 0 0 u a i u t e U m u im m u n e g lo b u lin (h u m a n ) n u y b e indicate <i CHAIRMAN OLSON: A re t h e r e any o th e r co m m en ts on the re p o rt of Dr. Leigh ? ' DR. RA W LE S: I th i n k we m u s t n o t n e g l e c t to s t r e s s o v e r u;~.d o v e r a g a in the im portance of initial wound su rg ery , and also the fact that patients who have n o tb e e n im m u n iz e d and who a r e not g ro ssly contam inated, can be p ro p e rly , adequately p r o te c te d by good, in itial wound s u rg e ry plus long-acting penicillin, bicillin. Many hospitals, of course, today have adopted program s of that so rt, stressin g that, and I think it puts you in the clear pretty much when that has been adopted as a police of institutions. 1 In R ichm ond, fo r in s ta n c e , o u r M e d ica l C ollege of V irg in ia h as adopted what is considered a safe p ro g ra m which puts you in the c le a r from the standpoint of m alp ractice in many of these cases, rath e r than indiscrim inately giving tetanus antitoxin. CHAIRMAN OLSON: Anyone else ? * Dr. Leigh, I want to thank you very m uch for a very interesting and provocative report. The next is the re p o rt of the Nominating, Com mittee, Dr. Kieffer. REPO RT OF NOMINATING COMMITTEE DR. KIEFFER: .Your N om inating C om m ittee consisting of Dr. Hollo, F r i s c o ; D r . K n o w l e s , B o s t o n &. M a i n e ; D r . N i l e s , L eh ig h V alley; and D r. Jim Stack from the N orth W estern, with m yself as Chairm an submit for y o u r action th e following list of c a n d id a te s fo r b alloting. F o r 3 -y e a r te r m s , ex p irin g in 1968. for the A dvisory C om m ittee: F o r the E a ste rn Division: D r . W. E. M i s h l e r , E r i e - L a c k a w a n n a . D r. B. W. S to c k w e l l, G r a n d T r u n k W e s te r n . D r. I. K a p la n , B a l t i m o r e an d Ohio. Dr. J. S. N iles, Lehigh Valley. Four candidates, two of whom you will vote for. T h e re is in that sa m e te r r ito r y an unexpired te rm held by Dr. B rew ster of the Pennsylvania, and by custom , we have been appointing the s u c c e s s o r of the m an whose te rm is unexpired who will stand for election at the next forthcom ing period, so we have suggested Dr. C y ran , who h as b een s e rv in g in that p la c e re p r e s e n tin g P ennsylvania. For the Southern T e rrito ry for the sam e 3 -year te rm expiring in 1968, two n am es, of which you will vote for one. Dr. E. C. Olson, Illinois Central. Dr. J. G. S harpley, C e n tral of G eorgia Railway. F o r the Canadian T e r r ito r y , voting for one of the two candidates: E arle Wight of the Canadian Pacific. R. E. N icholson, T o ro n to , H am ilton & Buffalo. F o r the W estern T e r r ito r y , two candidates, again one to be voted on: Dr. John R. W inston of the Santa F e, and Dr. Abbott Skinner of the G reat Northern. Agents will now p ass among you distributing these ballots on which you will m ake the a p p ro p riate m a rk to indicate your choice, and the r e su lts will be tabulated at a la te r date. CHAIRMAN OLSON: T hank you. D r. K ieffer. And I would like to a p point D r. Longeway and Hanson as the te lle rs to count the ballots and to t u r n iii the r e s u l t s to us. I think.the tim e has com e when this m ight be a good occasion to take a break, and then we can re su m e with the panel discussion. (A sh o rt r e c e s s was taken.) CHAIRMAN OLSON: The subject for this m orning's panel sym posium is: C a rd io v ascu lar D ise a se s. It w ill be conducted by our M oderator, Dr. John R. Winston of the Santa Fe. D r. Winston. PAN EL SYMPOSIUM - CARDIOVASCULAR DISEASES M ODERATOR JOHN R. WINSTON: It is no'doubt obvious to the audience that the type of p a n e l h a s ch an g ed m a te r ia lly fro m y e s te rd a y . It w ill soon be obvious that the type of panel m em bers has also changed. Y es terd ay we had people who w ere ex p e rts in th e ir field, at H ast they knew m ore about it than the average one of us in the audience. Today the average one of you gentlem en before me knows as much about this subject as does the average one of us on the panel. So, rea lly , this is sim ply a d isc u ssio n perio d , and what I expect to show will be that we all have a g en e ral idea and some degree of knowledge about this subject, that we also have a great deficiency in knowledge about this p articu lar subject, and perhaps there is room for further explore- _ tion. *** I shall forego introducing those on the panel inasm uch as I think they, without exception, have been introduced one way or the other. If they haven't, it will be no less detracting to their ability. In the bulletin th e r e a r e 14 q u e s tio n s. A g r e a t n u m b e r of those questions concern them selves with the problem of coronary arte ry disease A g reat m any of them re la te sp ecifically to coro n ary throm bosis, and m y o cardial infarction. I hope th at again those of you in the audience will be as active in the p articipation of these an sw ers as the panel. Now, let's talk a bit about the coronary arte ry disease, arteriosclerotic h eart disease. F i r s t of all, about the d ia g n o sis. T h at is r.ot specifically m e n tio n e d h e re , although question 7 ta lk s about re lia n c e being placed on the e l e c tr o ca rd io g ra m as a basis for re tu rn to work. L et's talk about that, then';::. How a r e we going to go about e s ta b lish in g a diagnosis of c o ro n a ry a r t e r y disease ? Without selecting som eone, would any one'on the panel wish to m ake a comment about this ? DR. HOLLO: I would like to ask D r. Johnson a question. If you have an enginem an who has been asym ptom atic and continues to be asy m p to m atic, and after working for the r a ilro a d 20 y e a r s , during the routine follow up, as som e rai-lroads do, this m an h as a EKG, and h as a rig h t bundle b r a n c h b lo c k th a t he did n o t h a v e fiv e y e a r s p r i o r to the t i m e o f h i s p r e - "* vious exam ination, how do you handle this problem , and what disposition do you m ake of it? MODERATOR WINSTON: T he question re la te s to the significance of a rig h t bundle bran ch block w hich we w ill discuss in due tim e. Well, le t's talk about the diagnosis of arterio sclero tic heart disease. DR. RA LPH A. JOHNSON: W ell, a s alw ays, and as h a s been pointed out by previous e s s a y is ts , the m a jo r point in making a diagnosis of co ro nary a r te r y d ise a se is the h isto ry . Invariably, it has to do with an , acute onset of su b ste rn a l pain, usually with radicular radiation. Usual!'/ i m with som e d egree of shock. In o u r society today these patients a re h o s p ita lize d in the vast m a jo rity of c a se s, and the m anagem ent of acute m yocardial infarction is fairly well standardized. T h e re is a group that believe in anticoagulant therapy. T h e re is a group who a re opposed to it, but I am sa tisfied that m ost-clinicians o rien ted in the field of c a rd io v a s c u la r d isease do feel that th e re is a place for anticoagulant th e ra p y in the acute case. MODERATOR WINSTON: E x c u s e m e. We a r e talking about the d ia g n o sis o f a r t e r i o s c l e r o t i c h e a r t d i s e a s e , not th e r a p y , and we a r e not ta lk in g about the diagnosis n ecessarily of a m yocardial infarction. D R. JOHNSON: I m i s u n d e r s t o o d the q u e s tio n . I th o u g h t y o u w a n te d t h e etiology of a m yocardial infarction. I don't know the cause of a rte rio s c le r o s is . I know that it is a p roblem , that it is the m ost prom inent facto r in c a rd io v asc u la r d ise a se today and ca rd iac d isease is the n u m b er one killer. Our friends orien ted in insurance are very well aw are of the in c re a s ing factor of a rte rio s c le ro s is , generalized as well as lim ited to the cardiac area, the renal are a and the brain as a risk. T h e re a re m any facto rs that a re thought to be cau ses in the d ev elo p m ent of a r te rio s c le r o s is . They a re as well known to you as they are to m e, but for the actual, fundam ental cause of this p ro ce ss, I re g re t to * say th a t I do not know that ca u se . MODERATOR WINSTON: P ete , establishing the diagnosis of a r te r i o s c le r o tic h e a r t d is e a s e , how a r e you going to do it? DR. P E T E R VAUGHAN: Well, f ir s t of all, every middie aged p erso n , I think, has some arterio sclero tic heart disease, some atherosclerosis of the coronary a r te r ie s . The thing to determ ine is w hether the d ise a se is significant, and as D r. Johnson sa y s, one of the best ways is a h isto ry , but quite frequently, a p erso n has significant disease without having h is tory of chest pain or anything else. The only o th er way to establish it, a good way and p ractical way, is by an e le c tro c a rd io g ra m . Of co u rse , th e re a re other sp ecialized t e s t s , a n g io g ra m s, etc. , w hich r e a lly don't co n cern u s, but if a p e rs o n does not have o r denies any sym ptom s of anginal pain, and if he has a negative electrocardiogram , I don't think you can make a diagnosis of coronary artery disease. MODERATOR WINSTON: D oes anyone wish to take exception to that ? DR. CYRAN: I think M attingly, Robb and M asters have shown that you can make a diagnosis of c o ro n a ry h e a r t d isease by doing a M a ste rs two step, and m ore.convincingly by doing the M asters double step. This will actually help show that there are electrocardiographic ab norm alities which can be suggestive of coronary insufficiency and co ro - 108 nary heart disease. MODERATOR WINSTON: D r. Wight. DR. WIGHT: I don't quite ag re e with D r. C yran. two step will not alw ays show the p re s e n c e of it. m The M asters double DR. CYRAN:' I didn't m ean to imply always; it may. DR. WIGHT: T h e re is an o th e r field that isb e c o m in g m ore and m o re prom inent, and that is v ecto r cardiography, and I think P. in Belgium leading the w ork in this field. H e'claim s that he can pick up abnorm ali ties a long tim e before th e re a r e any'changes shown on the EKG. P r o bably Dr. Johnson is fam iliar with this work that is being done there. DR. JOHNSON: A pparently not as w ell as you are, though I am fam iffi with som e of this work, but in essen ce, a vector cardiogram is only another tool, another m eans of interpreting the electrocardiogram . I believe that while it is an im p o rtan t tool, it takes such sp ecialize knowledge, that I do not se e it as 1 aving any re a l m e rit in the routine case myself. DR. WIGHT: I m ight add th at the e le c tro c a rd io g ra m taken by this m an is s p e c ia liz e d . You a r e q u ite rig h t, he u s e s 74 leads. He p uts a v e s t < the man. DR. JOHNSON: That is what I m ean. DR. OLSON: We h a v e b e e n u s in g an e r g o m e t e r in o u r h o s p it a l. We he been using an o d o m eter in se lec ted c a se s together with a te le m e tric sy stem , and we have picked up c o ro n a ry insufficiencies by this m ethod w here we did not get it with the sta n d a rd M a ste r two stop, and the poin that I wanted to m ake was you provide your ex ercise with the M aster t\ step, and by the tim e you take y o u r tra c in g , the effect on the e l e c t r o c a r d i o g r a m h a s d i s a p p e a r e d , w h e r e a s w ith 1th e t e l e m e t r i c s y s t e m , y o u catch it right as it is occurring. DR. CYRAN: The only p ro b lem with that is that they actually have bee m onitoring people for as long as ten and twelve hours with an attached electronic instrum ent which reco rd s their electrocardiogram on tape, and then they play this back at w hatever speed they want to, and they have shown even norm al people have changes that take place during the day. ' They have T wave changes, they have ST segment changes, and tht don't even know whether this is indicative of coronary disease. So, they a re getting a lot m o re false positives that iu y , and Is a m e a s u r e t h a t i 3 b e in g u s e d m o r e , b u t they a r e s l i d n * -crtalr. * it this paeans. - 100 DR. JOHNSON: I would call to this audience's attention Dr. Sam L evine's j com m ent about the best index of card iac insufficiency is shortness of j breath and breath lessn ess, and alm ost invariably this symptom, short- ! ness of breath, precedes m any clinical evidences that show im pairm ent of co ro n ary a rte ry flow. jJ I m e re ly bring the point up to u n d ersc o re the im portance of the c a re - ! ful history. When an individual com plains that walking a flight of s ta irs , so m e th in g th a t he could do for m any y e a r s without sh o rtn e ss of b reath , and now he finds that at the top of the s t a i r s he has to stop fo r a m o m en t and catch his breath, is perhaps as clear an index of early coronary in- j sufficience as we can have, and m any tim e s we will be unable to co n firm i that by many of our eso teric clinical investigative procedures. I DR. ZEISS: D r. W inston, what value do the experts place on d ire c t | visualization of the retinal blood v essels in the diagnosis of atherosclero- sis ? : DR. JOHNSON: C onsiderable. ; M O D E R A T O R WINSTON: I m ig h t s u m up b r ie f ly what we a r e ta lk in g j about r the diagnosis of arte rio sc le ro tic h ea rt disease. I F ir s t of all, if we wait until a m an has an infarction, then that is I u su a lly not difficult to diagnose. But we have waited too long b ecause i during that tim e, even though it is my understanding that he has not had ' an infarction, he is still a candidate for a sudden change in his relatio n - sh ip s with this world, even though he is not infarcted. So, it behooves j us to find this m an e a r lie r than we have been findiiig him . j We cannot depend on the h is t o r y , in that if u,,j ijian knew it, he i w ouldn't te ll you if he felt it was going to affect Job, as a g en e ral j rule. !I j We h a v e found th e i n a d e q u a c i e s of the r o u tin g v j l e c t r o c a r d i o g r a m . .i Wre h a v e found th a t u n d e r s t r e s s the v a l u e of the e l e c t r o c a r d i o g r a m i s i n cre ase d , and the m ost routine and generally used stre s s factor is the j M asters. I t has certain shortcom ings, and also, it has been shown that i if this man is taking certain drugs, that it will have an am eliorating ef- feet on the te s t, w hereas, without them , it m ight be positive, and with ' them it would be negative. w More recently they have been doing other stre s s evaluation includin the continued type of electrocardiographic m onitor which runs for any X j n u m b e r o f h o u r s . T h e u s u a l ta p e i s 10 h o u r s . ( O th e rs of th e m a r e doing c e r t a i n s t r e s s e f f o rts , u sin g p r i m a r i l y the;* treadm ill. 1 ' So, I want to com e back to the e r g o m e te r in tim e , but now then, le t's talk about the funduscopic findings as it m ight rela te to the suspicio of arteriosclerotic heart disease. i 110 Does anyone want to talk about that ? Dr. Cyran. DR. CYRAN: I am not aw are that exam ination of the fundus will allow you to predict coronary arte ry disease. DR. KAPLAN: Our consultant utilizes the funduscopic examination. In evaluation of o u r ca rd ia c p atien ts, o u r m ed ical consultant u tilises the visualization of the retin al v essels as one factor in deciding whether o r not the e m p l o y e e i s f i t o r n o t fit to r e t u r n to duty. It is not a p r i m e facto r, and I don't think that he w ill utilize this p e r se even if it w ere a grade 3 o r excessive amount of narrow ing of the retin al vessels as a factor in disqualifying the em ployee. However, if th ere was adequate evidence that the employee was hav ing, say, som e form of angina o r sh o rtn e s s of b rea th , and there was sufficient evidence to indicate that th e re was p erip h eral im ocirm ent of the blood vessels, and this included changes in the retinal v essels, he would certainly u se this as an additional wedge in disqualifying the employee from returning to work. MODERATOR WINSTON: D r. Vaughan. DR. VAUGHAN: W e ll, I th in k t h e e x a m i n a t i o n o f th e fundu..; is a v e r y good ro u tin e exam in atio n , but if you do find, as was said, : ,:nu n a r r o w ing of the r e t i n a l v e s s e l s , I d o n 't th in k y o u c a n m a k e a din-, u s of cor nary arte ry disease on that finding alone. If y o u g e t v e r y m a r k e d fundus c h a n g e s , of c o u r s e , 11. h e m a n k another condition which is disqualifying. M O D E R A T O R WINSTON: We m ig h t th e n c o n s i d e r th at th - .1.nation tile optic fundus is an isolated p icture of the a rte rio la r re of tin body. A rte rio s c le ro tic h e a rt d ise ase is often segm ental. ' , body is c o m p o s e d of t e n m i l l i o n t r i l l i o n s e g m e n t s , and you can : . .onab'.e sure that if the one segm ent is involved, o ther segment!; involved also, but that in itself will not establish a diagnosis. DR. JOHNSON: I think as an intern ist we all very much : io look at fundi, and it is an e a sy way to g et so m e idea of v a s c u la r -hangej if th e y a r e p r e s e n t , b u t I a m q u ite s u r e t h a t th e in d iv id u a l wh , a s k s the t u question is well aw are of the fact that internists and oculists have very > different ideas about what a funduscopic reveals. MODERATOR WINSTON: I think that m ight be w orth exploring. I am glad you m entioned that, Ralph. Would you com m ent a little further ? I m entioned that b e c a u s e o ften tim es those of us who are nol in te rn ists, o r many of you, p e rh a p s, a re receiving and m aking judgments of an optic fundus on inform ation that is reaching you from an ophthalmologist. DR. JOHNSON: T h ere is no question that an ophthalmologist depending on the fundus is f a r m o re valid than the in te rn ist, but many fundi that I classify a s g rade 1, the oculist will c la ssify a s 0, and unhappily, on sees-:on, these I d a ; changes being pre-sen a s n o r trial, he will c la s s ify as or T h e r e i s no g e t tin g aw a y f r o m t h e fa c t th a t the m a n who loess the eye all day, the o c u lis t, h as a f a r c l e a r e r insight as to abnormal;*.'-s b u t it is a n e a s y t o o l for a p h y s i c i a n to h a v e . It is p e r h a p s the n: ,- t d i s p e n s a b l e to o l in o u r a r m a m e n t a r i u m . We ca n g e t an id e a of tr.e h e a r : by d i r e c t a u s c u l t a t i o n . We c a n get an i d e a o f th e p u l s e by p a lp a tio n of the r a d ia l a r te ry , but th e re is only one way we can get into the fundus, and that is by use of the ophthalm oscope. MODERATOR WINSTON: I would think, by and large, the ophthalm olo g is t is looking p r im a r il y to w a rd d is e a s e s of the m acu la, p erh a p s of the nerve head, and incidentally, taking a look at the vascular system , where as the in te r n is t is u su ally r e v e r s i n g it and showing p r im a ry in te re s t in the v a s c u la r system . Now, le t's tr y to an sw er som e of the questions, o r at least talk about them. T hose who now have an estab lish ed diagnosis of co ro n ary a rte ry d isease. Bill. DR. MISHLER: I don't like to in te rru p t at th is point, except to point ; out th at, as this panel was d iscu ssin g this, the im plication was that the 1 p rese n ce of arte rio scle ro tic h e a rt d isease, coronary heart disease, is a serio u s thing, and that there is a sm all m argin of safety; at least, that was my idea. Many of the panel m e m b e rs pointed out that th ere are ' many ways of investigating this subject--fundusccpic examination, heart 1 size, rhythm and rate, shape, blood p re ssu re , album inuria, symptoms which the patient may o r may not adm it to. The patient's weight, x-ray of his chest, picture of the v e s se ls , his age, and his electrocardiogram , lastly, but I would be willing to have a show of hands of those people who, in this m o m , think that they do not have co ro n a ry a rte ry sc lero sis. M O D E R A T O R WINSTON: W ith t h i s b u n c h of o ld m e n . I doub; you *-. 11 find many hands. (Laughter) Dr. Hollo. DR. HOLLO: M r. C h a irm an , I would like to ad d re ss - -first of all. the subject m atter is the diagnosis of early arterio sclero tic heart disease, and I th i n k t h e r e h a s b e e n s o m e w o r k done by D r . Ju d g e at C l e v e l a n d C lin ic in r e g a r d to the d ia g n o sis of h e a r t d is e a s e in the young, and tr.e work that I rem em ber that he published was that arteriosclerosis or e a r l y t h r e n b o M s th a t o c c u r s in i n d i v i d u a l s b e t w e e n th e age of 30 and 10 u s u a l l y is on a c o n g e n ita l b a s i s , and th e y h a v e do n e a c o n s id e r a b l e am.vuai of w ork in doing sinography with cardioangiography, and they have shown a narrow ing in congenital defects of the coronary vessels. T his certainly is not a rte rio s c le ro s is . However, it is a defect and th ese a re the people who are p re d isp o se d to ea rly cc.mr.i. y throm bosis and occlusion. M O D E R A T O R WINSTON: And s o m e d e m i s e , c o n g e n i t a l o r u-..-.cr . . . are notwithstanding. 112 DR. HOLLO: Yes. MODERATOR WINSTON: A re th e re o th e r questions fro m the floor? My form field of vision, so fa r as I know, is not lim ited except in- sofar as my brain doesn't extend as far as my eyes will see some tim es. Now, le t's talk about the p erso n who has an established diagnosis of m y o c a rd ia l infarction and re la te that to his retu rn in g to work. Dr. Strange, tell me your thoughts about the employability. I should further qualify this that we are not ad dressing o u rselv e s at this moment to en t r a n c e to s e r v i c e e x a m i n a t i o n s . We a r e t a l k i n g abo u t th e m a n who i s a l read y in se rv ic e; tell m e, o r us, yo u r thoughts about how you people feel about retu rn in g to em ploym ent, and I will not r e s tr ic t you a s to what em ploym ent, a person who has had m y o c ard ial infarction. DR. STRANGE: In the o p e ra tin g d e p a r tm e n ts of m y r a il r o a d , people who have had a known co ro n ary , p roven and u n d er tre a tm e n t, and have r e covered, from the experts that we have, I have to look to other people like these people on the panel, not m yself, for this information that they have stabilized. We a r e v ery dubious about putting them back to th e ir regular o ccupa tions with r a r e exceptions. We m ight put them back to doing th eir re g u la r work. S h ould I go into the c a te g o rie s of w o rk ? Sw itchm en. MODERATOR WINSTON: I think that is adequate for the moment. D r. K ieffer, you a re sitting back with your feet on the handlebars. (L au g h ter) What is your attitude about em ploying the p e rs o n who has had m y o c ard ial infarction, retu rn in g to em ploym ent ? DR. K IE F F E R : I think we a r e a little bit to u g h e r than m ost r a ilro a d s . We do n o t p e r m i t an e n g i n e m a n , we do not p e r m i t a f i r e m a n o r lo c o m o tiv e e n g in e e r to go back on an engine un d er any condition who has a proven m yocardial infarction. The cardiologist gets a little nauseated about that, but we also feel that anybody who has taken anticoagulan ts is giving us p r i m a fa c ie evidence of the f a c t th a t he d o es have h e a r t d i s e a s e . It m a k e s our position a little ea sie r to m aintain with the Brotherhoods. MODERATOR WINSTON: I have h e a rd you say on o th e r occasions that before you co n sid ered this p e r s o n 's r e tu r n to em ploym ent, you wanted at least six months to have elapsed between the onset of his infarction and consideration to re tu rn to em ploym ent. DR. KIEFFER: That is right. M O D E R A T O R W INSTON: T h e n w e w ill t a l k a b o u t th e s p e c i f i c s a little bit la ter. DR. K IE F F E R : Now, that applies to a ll c a te g o rie s before we review him. 113 DR. VAUGHAN: We a r e not a s tough a s D r. K ieffer. I think, of cours, you hav e to c o n s id e r s e v e r a l f a c to rs in r e tu r n in g a m an to w ork a fte r a c o r o n a r y , l - i r s t of a ll, a s e v e r y b o d y k n o w s, t h e r e a r e v a r i o u s d e g r e e s of c o ro n a rie s . It is very im p o rta n t to a s s e s s h is p re se n t clin ical condition, and the next thing to a s s e s s is what type of w ork he is going back to, and the th ird factor, everybody has to co nsider, is the m edical- legal im plications of returning to work. Now, with an uncom plicated reco v ery , recovery from uncom plicated co ro n a ry throm bosis, if the m a n 's physical condition is otherwise quite n o r m a l and he has m ade a good r e c o v e r y , I d o n 't s e e why he sh o u ld n 't be re tu rn e d in safe work. Now, the question i s . - what is safe work? .MODERATOR WINSTON: I m ight in te rje c t also safe fo r whom? DR. VAUGHAN: Safe for h im self and safe, of course, for the traveling public. Now, just as there are various degrees of coronary artery disease, so th ere are various degrees of hardness and toughness of particular assignm e nts. N ow , we a l l know' th a t an e n g in e m a n in a c e r t a i n type of a s s ig n m e n t, p e rh a p s m ain line p a sse n g e r work, has a m ore responsible jo b than an enginem an in branch line se rv ic e , for instance, and we re tu rn ou r m en to w ork in the safe, relatively non-hazardous position alter an uncomplicated coronary. That is , after eight w eeks--eight weeks after his coronary, and we haven't had any trouble with that Policy, MODERATOR WINSTON: Does anyone have a different opinion? D R . K I E F F E R : I d id n 't m e a n to give th e i m p r e s s i o n th a t we d o n 't le t h im com e back to work, in any w ork category . I was talking only about engineers and firemen. MODERATOR WINSTON: A re th e re any o th e r com m ents from the panel about the elapse of tim e following the infarction before em ployability is considered. DR. KNOWLES: Dr. Winston, I would like to say that the M assachusetts H e a rt A ssociation thought th re e m onths was a m in im u m to allow a patient to r e tu r n to work after h is f irs t co ro n a ry . M ODERATOR WINSTON: We w ill next go to the diagnosis. I would say this is the next m ost im portant facet of this p articu la r phase. Dr. Olson. DR. OLSON: On our ra ilro a d , we disqualify all of th ese people on the b a s is of o u r m e d ic a l s ta n d a r d s , and th en if the com pany chooses to req u e st an exception, we then co nsider all of the factors that have been m entioned. We have not returned en gin eers to work as engineers. 1 14 We have r r t u r n e d t h e m a s f i r e m e n w h e r e it s e e m e d th e c o n d itio n p e r m i t t e d it. We h av e not p e r m i t t e d m e n in h e a v y o c c u p a t io n s , h eav y p h y s ic a l w ork, to re tu rn to work either. DR. K APLAN: D r. W inston, we have a c ce p te d the e n tire o p posite view, and in all probability, as a c la ss 1 ra ilro a d , we a re m ore lib e ral with o u r r e t u r n to duty following c o ro n a ry th r o m b o s is than any o th e r r a il r o a d in the country. T his h as not been done without much re se a rc h and taking into con s id e ra tio n that th e re is a calcu lated ris k . H ow ever, p rio r to going into th is change in p ro sp e c tiv e , we re v ie w e d s tu d ie s that had been done by co m p eten t au th o rities on this subject. Diam ond, of the New Y ork C e n tra l, has done a trem endous amount of work on railro a d w orkers as far as longevity stu d ies a re concerned. T ay lo r at M innesota has w orked on ra ilro a d w orkers, com pared sed en tary occupations, with those of men in hazardous phases. Z eigler, M a ste rs and Dr. Lowe of the M etropolitan Life Insurance Company have compiled statistical studies on cardiac longevity. They have done these studies o v er the period of f i v e , ten, fifteen and twenty-five year recovery periods from the i n i t i a l coronary. All ag ree on a common figure with the first four weeks is the danger p erio d . If they exclude these four weeks, and then take a c ro s s section, ab o u t 60 p e r cent of the e m p lo y e e s who r e t u r n to w ork following a c o r o n ary and go back to th e ir reg u la r o cc u p atio n s- - this is im portant reg u la r occupation including ra ilro a d w orkers - -w ill be alive after five y e a rs. The percentage, of co u rse, drops after ten y e a r s , and down to fif teen.' A fte r fiftee n y e a r s , you m a y h a v e 14 to 17 p e r cent s t i l l a liv e . On the b asis of these s ta tis tic s , we rev ise d o u r stan d ard s. We have a fu ll-tim e m edical consultant who is a card io lo g ist and the m ost im p o r tant restrictio n is that of an engineer going back into passenger service. So, we exclude an engineer fro m going back into p assen g e r serv ice w hether it is local or on the road, but in all other occupations, re g a rd le ss of w hether it is heavy duty o r w hether it is in a hazardous occupation, we p e r m i t the em p lo y ee s to get back to w ork if they can get p a s t o u r cardiologic consultant. DR. STOCKWELL: What do they think of anticoagulants? i I DR. KAPLAN: T h is is so m e th in g e ls e . We a r e d is c u s s in g a c a s e who i s n o t ta k in g n i t r o g l y c e r i n , h a s no a n g i n a , a n d no d y s p n e a . He h a s had h is c o r o n a r y and is not taking a n tic o a g u la n ts. MODERATOR WINSTON: T hat b rin g s up the next question that will be w o r t h e v a l u a t i n g , and that i s , u n d e r w h a t c i r c u m s t a n c e s n o w ? What p red ica tes do you req u ire b efore th is p erso n is p e r m i t t e d to return to work. What req u irem en ts are you asking of this m a n before you perm it him to assum e, it sa y s, heavy duty? i i <; D R. K A P I jAN: B e f o r e th e e m p l o y e e is r e f e r r e d to us f o r e v a lu a tio n , we can invariably get a hospital re p o rt of the attack of throm bosis that he lias s u s ta in e d . We a s k for a c o m p le te copy, and a r e willing to pay the r e c o r d in g c h a r g e s . In that way, we know ex a c tly how s e rio u s ly ill this m an w as, when he went into the hospital, and findings at the time of exam ination. What h a s th is m a n done s in c e th e o n s e t o f h is d isa b ility ? He m ust fu rn ish us with a c e rtific a te from his d octor to the effect that he is able to go to w o r k . T h e n we s u b j e c t h i m to e x t e n s i v e h i s t o r y ta k in g , a n d we inquire about anticoagulants and drugs he m ight be taking. We u su a lly like them to brin g their m ed icatio n s, to see if they are taking n itroglycerin, o r one of the long-acting vasodilators such as p eri+r a t e s . W e q u e s t i o n him' d i s c r e e t l y a b o u t the u s e o f a n t i c o a g u l a n t s b e i ^ y u s e we don't p erm it our operating departm ent em ployees, except c l e r k s , to go back to work if they a re taking anticoagulants. However, I do not w ish to get into the p ro b lem of an tico ag u lan ts b ecau se it is a su b j e c t in i ts e lf and i s w orthy of a lengthy d is c u s s io n of p r o s and cons. We, of c o u r s e , do e le c tro c a r d io g r a m s , and w here indicated, will do the M a s te r s te st. C hest x - ra y s are also p erfo rm e d to check card iac size. If o u r consultant finds that the ele c tro c a rd io g ra m has stabilized, th at the T w aves changes have retu rn ed to n o rm al, o r at least are sta b il iz ed , th e re is no ca rdiom egaly, and th e re is no evidence of any ren a l d is e a s e , and he is a young em ployee in his 40 's o r early 50's with good g e n e r a l p h y s i c a l c o n d itio n , we fe e l he sh o u ld be r e t u r n e d to h is r e g u la r occupation excepting p assenger and freight engineers without any r e s tr ic tion. re g a rd le s s of what his previous occupation m ight have been. MODERATOR WINSTON: What do you think about that. D r. Clayton? DR. CLA Y TON : I a g re e 100 p e r cent. T he doctor m ade one sta te m e n t " 'a t he thought he had an exceptional ra ilro a d . I d o n 't ag ree with him in respect. W e f o llo w h i s r o u t i n e a l m o s t i d e n t i c a l l y . I h a v e th is p o lic y . We r e tu r n to duty all em ployees with the exception of en g in ee rs, who had * e s ta b lish e d co ro n a ry occlusions, and I think this is im portant. I insistthat he furnish us with a written statem ent from his doctor that he con s i d e r s h i m a b le to r e t u r n to u n r e s t r i c t e d duty. T h e n we a r e p r o te c te d to a point in h is litigation, and also we think that the individual is p r o tected also. DR. KAPLAN: I m ight say over a fo u r- y e a r p e rio d , we have been ex t r e m e l y fo rtu n a te . We have been w ro n g a few t i m e s . Some have died befo re they even went back to work, but this has been the exception and in g e n e ra l, we have not had too m any r e c u r r e n t co ro n a rie s.I I don't think we have had any deaths on duty in the group that we p erm itted to re su m e duty follow ing an in itia l attach of coronary throtn bosis. 1 1 F. DR. CLAYTON: M r. C hairm an, I would like to m ake one other point. ' In looking at a study of the op eratin g d ep a rtm en t, I think certainly if . an individual has evidence of having unusual vascular changes, I insist : that we have a sta te m en t about the ocular fundi in th e se c a se s. J MODERATOR WINSTON: Dr. Johnson. | DR. JOHNSON: I have nothing to add. I think, too, that th e s e have to i be settled pretty much on an individual basis. Some individuals make a j very b rillia n t re c o v e ry from th e ir initial infarction; som e do not, and ! we need to have guiding rules, but specific applications a re always a i m atter of m edical judgment. DR. WIGHT: To get back to the engineman for a m om ent. T his question of how long he is going to be held out of se rv ic e , p r o viding he has made a satisfactory clinical recovery, Dr. Vaughan m en tioned eight weeks. Like some of the o thers, I feel this is short. I j think the p ath o lo g is t w ill a g r e e that it ta k es ro u g h ly th r e e m onths for it ' to be stab ilized . j Now, in o u r railw ay , it is th ree months. With enginem en, if th ere ' are any residual signs of coronary artery disease, they are restricted. : Y a rd S e rv ic e . No b r a n c h lin e s b e c a u s e on th e b r a n c h lin e s , the t r a i n s t are even running fa s te r than on the main line; they have to keep their schedule. But I would like to ask Dr. Johnson a question. ! In an e n g i n e m a n who h a s had a fra n k i n f a r c t , t h e r e a r e r o u g h ly 10 ' p e r cent of th e m that w ill r e v e r t to n o rm a l inc lu d in g the EKG. In this sm all group, does he perm it them to com e back on main line service ? I DR. JOHNSON: S p e c i fi c a l ly no. An in d iv i d u a l h a s o r h a s not had an in farct. If th e r e is c lin ic a l su b stan tia tio n of the fac t he has had m y o c a rd ial infarction, basically, on EKG evidence, and his e le c tro c a rd io gram has retu rn ed to norm al, that man has had an in farct, and the fact his EKG six m onths la te r is norm al, does not m itigate against the fact that he has had an infarct, and he is restric ted on my line. DR. OLSON: I stated our position on it previously, but I wanted to m ake one com ment about the value of the private physician's report. I don't know how that could protect the railro ad from any liability that one m ight want to th r u s t upon it fo r having allow ed an individual to go b ack to w o rk , know in g th a t he had a co ndition w hich w as u n p re d ic ta b le . I think the fact that it is unpredictable should make us pause in allowing th ese m e n to go b ack to c e r ta in types of w ork. MODERATOR WINSTON: You wouldn't object to having his family doctor's ; statem ent, though ? DR. OLSON: No, but I don't think it p r o t e c t s y ou f r o m anything. Dii. CLAYTON': May I c o m m e n t. We have had two s u its on o u r r a ilro a d in o u r d e p a r tm e n t, w hereby the c o u rt contended that the em ployee is p u t'' back to work with the knowledge of the chief surgeon and his medical sta ft, so ih a t s t a r t e d me to thinking along th is line. Now, I think th a t we would have a definite p r o te c tio n in the eyes of Uie c o u r t if we f u r n i s h a s t a t e m e n t th a t t h i s m a n c o n t e n d s th a t he had a f la r e - u p of h is c o r o n a r y , and if he goes b a c k to duty, but we did n 't do it on o u r ow n. We c a n s a y , " A l l r i g h t , h i s own d o c t o r s a i d he could do this, and that he was able to. " i Now, ce rtain ly we are not infallible in any resp e ct, but it does p ro - te c t us to a point legally because I speak fro m ex p e rien c e. M O D ERA TOR WINSTON: I don't know about legally, but we on o u r p ro p erty , and th e re is one of these form s in the p resen tatio n of yesterday, . -k a m a n to s a y th a t he can do it, and a s k the d o c to r to say he can do it, ^rf^d th e n we e v a l u a t e h im . D R . S U T H E R L A N D : We k e e p ta lk in g ab o u t e n g i n e e r s . M ay b e I have got the w rong sla n t on th is, but in the operating dep artm en t, I think that is the e a s ie s t job in the world. (Laughter) M ODERATOR WINSTON: T hat is a good point. DR. SUTHERLAND: I don't think it is any m o re h azard o u s for that man to go b a c k to w o rk than it would be for any of us s u r g e o n s to go back into the operating room after completely recovering from a coronary." I w ill bet th e re is n 't a surgeon h e re that w ouldn't be back after he co m pletely recovered from a coronary. DR. MISHLER: To give you our ex p erien ce, we don't follow eith er one e x tre m e o r the o th e r. A m an who has m ade a co m p lete recovery from h is c o r o n a r y an d h a s s u b m i tte d th e fam ily d o c t o r 's r e p o r t , that he is w i t h o u t s y m p t o m s , in th e t r a i n s e r v i c e , e n g i n e e r s , th a t i s , v.e d m ' t lo w t h e m o n t h e m a i n lin e , b u t we do t r y to f in d s o m e p l a c e fo r th e m :r..ch a y a r d fire m a n . In b rak em en and co n d u cto rs, we don't allow them to do stren u o u s o r laborious work which we think includes climbing cars o r setting brakes. T hat applies to the shop crafts for a sim ila r application of the rule. H o w ev er, in a ll this d isc u ssio n , I have alw ay s m a in ta in ed that due to the p ro g re ssiv e and eventually fatal course of this d isease, these people a fte r r e c o v e r y , irre s p e c tiv e of th e ir good re c o v e ry , should not be doing heavy, strenuous work. M O D ERA TOR WINSTON: You say you let so m e b r a k e m e n .g o back to w ork? DR. MISHLER: On ground level and switch tender. M ODERATOR WINSTON: T hat is fine. I was w ondering how he woulu be a brartem an and not clim b c a rs o r switch o r set brakes. 118 DR. JOHNSON: M r. C h airm an , Dr. Sutherland r a is e s a very good point, hut in an sw e r to it, we have to deal with engineers in labor relations aj v/ell as the m ed ical asp ect of it, and Dr. Wight alluded to that point when he said an individual who had had a m yocardial infarction and six months la ter had a n o rm al curve should he be perm itted u n restric ted in engine service ? Not in my te rr ito r y . If we have evidence of a m y o card ian infarction, that m an, because of that circ u m sta n ce , is r e s tr ic te d to y a rd serv ice. You have to have a policy. You have to adhere to it, and when you m ake an exception, which you believe in one specific c a se to be valid, it ap p e ars as though you a re waiving it in every case. I think i t is highly im p o rta n t that we ad h e re to so u n d , fu n d am e n tal m edical policies. DR. KNOWLES: I like D r. Johnson's idea. Now, you may have a man with a n o rm a l exam ination by a good, qualified m an. T hat man m ay be between 45 and 50 y e a rs of age, and then have a co ro n a ry unexpectedly. I think th at when you ta k e a m an who has had a known c o r o n a ry - I cay a known c o r o n a r y , s u r e , allow h im to go b ack on the m a in line as an engineer, and especially to run Budd c a rs , I think you a re open to lia bility. I think it is a very, very dangerous thing. M ODERATOR WINSTON: I don't think we have q u ite a n s w e r e d D r. S u th er la n d 's q u e s tio n y et. To m e it is e x t re m e l y i m p o r t a n t . - '.. DR. KAPLAN: Could I inject a little statem ent. T e c h n ic a lly , I a l m o s t a g r e e with the d o cto r. We cp u ld allow the engineer to go back to work in any capacity. H ow ever, you m ust rea lize th e re is a public im age that en te rs into this situation. R ecall the tragic accident that occurred on the Jersey Central about seven or eight y ears ago, when the c o m m u te r tra in went through a block s ig n a l and ended in the riv e r with many deaths. T here was quite a bit of hysteria, and much ado was m ade about it by the politicians in W ashington. They s ta rte d a S enatorial investigation, and wanted to know about the g en eral health of the engineer and firem an. Autopsies w ere perform ed on these men, and it was claim ed that they were hypertensives, were ill and unable and un fit to o p era te p a s se n g e r tra in s. T hus, you will re a liz e why an exam iner is relu c ta n t to p erm it an engineer who has had a coronary to go back to w ork in the face of thismounting opposition from the general public. You can have an accident in the yard that will cost the company a million dollars, and you won't h ear one word about it as long as there are no in ju rie s o r liv es involved, but have an accident involving p a s se n g e rs and the new spapers will blast you, especially if your engineer has had 119 some physical defect such as impaired vision or some previous heart attack or cardiac involvement. DR. K IE F F E R : I think that is the p o in t I w anted to speak of. As far as Or. S u th erla n d 's r is k of the e n g in ee r h im s e lf, I can see a g rea t deal to hat, but he does im p o se a potential r is k legally, and what m ight happen f som ething happened to him. D r. Vonosky told me at the tim e that those wo e m p lo y e e s w e re h y p e r te n s iv e . 1R. KAPLAN: T h a t is c o r r e c t. )R. K IEFFER : Then Dr. W inston's railro ad had another spectacular .ccident five o r six , seven o r eight y e a r s ago, that I am su re he can tell ou about. W ell, if th a t s o r t of th in g hap p en ed to an en g in ee r who w as a nown ca rd iac , you know, you are in a bad position. fu rth e rm o re , my position on this thing was arrived at after a u m b e r of y e a r s , and I think I am p ro b a b ly , b ec au se we are a little r a i l oad, c lo s e r to o u r claim and legal d ep a rtm en t than m o st of you fellow s. E very se ttle m e n t on the ra ilro a d goes ac ro ss my desk, and we, unke som e in d u stries, are not protected--and I say that very advisedly-y the W o rk m en 's C om pensation Act, and I have got to be, as far as my l i l r o a d is c o n c e r n e d , v e r y m uch lik e W inston C h u rc h ill who was unilling to liquidate the B ritish Em pire. iO D ERA TOR WINSTON: I want to com e back to that question, because it : o n e t h a t i s r a i s e d o fte n , and not in f r e q u e n t ly , bv the m e d ic a l staff, id quite frequently by the superv iso ry fo rc es, as I visit our people over e railroad. Why do you r e s t r i c t this m an from running the Super Chief? He is 1 d u t y t h r e e h o u r s an d f o r t y - f i v e m i n u t e s . He h a s a l a y - o v e r of -1 >urs. H e i s b a c k h o m e w ithin a l i t t l e o v e r 12 h o u r s . He i s o ff tw o d a y s "Now, you have h im r e s tr ic te d to w here he can only work in y ard rv ice, which is 8 h ard hours, daily, and in branch line se rv ic e , which eps h i m o u t 12 o r 14 h o u r s . " Why do y o u do . t h a t ? T h e r e a s o n i s e x t r e m e l y s i m p l e . We h a v e to loo k a t n o t on ly t h is a n 's d u ties. If h is condition wall not p e r m it h im to a ssu m e the physical fort, then, of co u rse , he shouldn't be doing any of these jobs. N ow , w hy c a n 't h e - d o t h e e a s i e r o n e s ? G e n e r a l l y , b e c a u s e t h e r e i s o re r is k , not only to h im self, but to oth er people, which is ex trem ely iportant, and also to com pany property. The traffic pattern is much m ore dense. He is traveling at a more p id s p e e d . A l a p s e o f c u a t i o u s n e s s o f a few s e c o n d s c a n m e a n the ciii* re n c e between a ca ta stro p h e and fa ir sailing. 120 What is the p r o g r e s s of th is pathology of those people who have coronary arte ry disease, m yocardial infarction ? Approximately onefourth of them will die suddenly. Of that group that dies suddenly, four out of five w ill a p p e ar to be in p e rfe c t h ealth im m e d ia te ly p rio r to th eir d ea th . So th e th in g th a t c a u s e s u s to ta k e an e n g i n e e r off high sp e ed m a in Line t e r r i t o r y in e n g in e s e r v i c e i s b e c a u s e in th e e v e n t of the i n c a p a c i t a tion, they m ight damage not only them selves, but many other people. As a m a tte r of fact, the likelihood is so g r e a t that we c a n 't face the f a m ilie s of th e s e people who a r e involved and s a y , "W ell, I.thought that he would do it all right. Sure I knew he was subject to sudden incapacitation, cut he only works a few hours. " It is unquestionably, so fa r a s p h y s ic a l e ffo rt is c o n c e rn e d , m uch the m o re d esira b le job for the man, but we have other obligations that supersede those. Now, Dr. E arle Wight. DR. WIGHT: I find this whole d is c u s s io n v e r y in te re s tin g . It re fle c ts changing m edicine, changing thought and so on and so forth. We have h e a r d how v a r io u s p eo p le h a n d le t h e i r c o r o n a r i e s . D o cto r K aplan r e f e r r e d to what they a r e doing. You a r e probably aw are of the fac t that in E n glan d they don't r e s t r i c t t h e i r en g in em e n . T hey let her.: go right back into re g u la r work. One f a c t o r th a t m a y h a v e a b e a r i n g on o u r a t t i t u d e in the f u tu re i.s, if we adopt th ese e le c tric a l a l e r te r s , in ste a d of the dead man pedal, !l;at will be a good safety factor. Dr. M ishler made a re m a rk that put the enginem an back in the y a rd a s f ire m a n . I a m a f r a id he w on't be ab le to do th a t m u c h longer. We have no firem en in y ard se rv ic e up in o u r country, and I am quite sure you won't have here very much longer. And then the re m a rk that D r. C lay to n m ade about accepting the c e r t i f i c a t e f r o m the d o c t o r . I th in k t h is is v e r y d a n g e r o u s in th a t we can't, h av e it two ways. In a lot of o t h e r c i r c u m s t a n c e s , we s a y that we will not a c c e p t the d o c t o r ' s c e r t i f i c a t e , th a t w e m a k e th e f i n a l d e c is i o n . We have the right to overrule the private doctor. Now, in effect, he is turning around and wanting to use the doctor's c e r tif ic a te , s h a ll we say , a s a m e a n s to le t th e s e m en go back to work, hoping that it will be accepted in court.I I don't think we can have it both ways. Say in one case the private doctor's certificate is as a final answ er, and in other cases, it isn't. MODERATOR WINSTON: I doubt that we h ave that in mind. DR. CLAYTON: You a re right. I didn't h ave it in mind. some physical defect such as impaired vision or some previous heart attack or cardiac involvement. DR. K IE F F E R : I think that is the p o in t I w anted to speak of. As far as Or. S u th erla n d 's r is k of the e n g in ee r h im s e lf, I can see a g rea t deal to hat, but he does im p o se a potential r is k legally, and what m ight happen f som ething happened to him. D r. Vonosky told me at the tim e that those wo e m p lo y e e s w e re h y p e r te n s iv e . 1R. KAPLAN: T h a t is c o r r e c t. )R. K IEFFER : Then Dr. W inston's railro ad had another spectacular .ccident five o r six , seven o r eight y e a r s ago, that I am su re he can tell ou about. W ell, if th a t s o r t of th in g hap p en ed to an en g in ee r who w as a nown ca rd iac , you know, you are in a bad position. fu rth e rm o re , my position on this thing was arrived at after a u m b e r of y e a r s , and I think I am p ro b a b ly , b ec au se we are a little r a i l oad, c lo s e r to o u r claim and legal d ep a rtm en t than m o st of you fellow s. E very se ttle m e n t on the ra ilro a d goes ac ro ss my desk, and we, unke som e in d u stries, are not protected--and I say that very advisedly-y the W o rk m en 's C om pensation Act, and I have got to be, as far as my l i l r o a d is c o n c e r n e d , v e r y m uch lik e W inston C h u rc h ill who was unilling to liquidate the B ritish Em pire. iO D ERA TOR WINSTON: I want to com e back to that question, because it : o n e t h a t i s r a i s e d o fte n , and not in f r e q u e n t ly , bv the m e d ic a l staff, id quite frequently by the superv iso ry fo rc es, as I visit our people over e railroad. Why do you r e s t r i c t this m an from running the Super Chief? He is 1 d u t y t h r e e h o u r s an d f o r t y - f i v e m i n u t e s . He h a s a l a y - o v e r of -1 >urs. H e i s b a c k h o m e w ithin a l i t t l e o v e r 12 h o u r s . He i s o ff tw o d a y s "Now, you have h im r e s tr ic te d to w here he can only work in y ard rv ice, which is 8 h ard h o u rs, daily, and in branch line se rv ic e , which eps h i m o u t 12 o r 14 h o u r s . " Why do y o u do . t h a t ? T h e r e a s o n i s e x t r e m e l y s i m p l e . We h a v e to loo k a t n o t on ly t h is a n 's d u ties. If h is condition wall not p e r m it h im to a ssu m e the physical fort, then, of co u rse , he shouldn't be doing any of these jobs. N ow , w hy c a n 't h e - d o t h e e a s i e r o n e s ? G e n e r a l l y , b e c a u s e t h e r e i s o re r is k , not only to h im self, but to oth er people, which is ex trem ely iportant, and also to com pany property. The traffic pattern is much m ore dense. He is traveling at a more p id s p e e d . A l a p s e o f c u a t i o u s n e s s o f a few s e c o n d s c a n m e a n the ciii* re n c e between a ca ta stro p h e and fa ir sailing. 120 What is the p r o g r e s s of th is pathology of those people who have coronary arte ry disease, m yocardial infarction ? Approximately onefourth of them will die suddenly. Of that group that dies suddenly, four out of five w ill a p p e a r to be in p e r f e c t h ea lth im m e d ia te ly p r io r to th e ir d ea th . So th e th in g th a t c a u s e s u s to ta k e an e n g i n e e r off high sp e ed m a in Line t e r r i t o r y in e n g in e s e r v i c e i s b e c a u s e in th e e v e n t of the i n c a p a c i t a tion, they m ight damage not only them selves, but many other people. As a m a tte r of fact, the likelihood is so g r e a t that we c a n 't face the f a m ilie s of th e s e people who a r e involved and s a y , "W ell, I.thought that he would do it all right. Sure I knew he was subject to sudden incapacitation, cut he only works a few hours. " It is unquestionably, so fa r a s p h y s ic a l e ffo rt is c o n c e rn e d , m uch the m o re d esira b le job for the man, but we have other obligations that supersede those. Now, Dr. E arle Wight. DR. WIGHT: I find this whole d is c u s s io n v e r y in te re s tin g . It re fle c ts changing m edicine, changing thought and so on and so forth. We have h e a r d how v a r io u s p eo p le h a n d le t h e i r c o r o n a r i e s . D o cto r K aplan r e f e r r e d to what they a r e doing. You a r e probably aw are of the fac t that in E n glan d they don't r e s t r i c t t h e i r en g in em e n . T hey let her.; go right back into re g u la r work. One f a c t o r th a t m a y h a v e a b e a r i n g on o u r a t t i t u d e in the f u tu re i.s, if we adopt th ese e le c tric a l a l e r te r s , in ste a d of the dead man pedal, !l;at will be a good safety factor. Dr. M ishler made a re m a rk that put the enginem an back in the y a rd a s f ire m a n . I a m a f r a id he w on't be ab le to do th a t m u c h longer. We have no firem en in y ard se rv ic e up in o u r country, and I am quite sure you won't have here very much longer. And then the re m a rk that D r. C lay to n m ade about accepting the c e r t i f i c a t e f r o m the d o c t o r . I th in k t h is is v e r y d a n g e r o u s in th a t we can't, h av e it two ways. In a lot of o t h e r c i r c u m s t a n c e s , we s a y that we will not a c c e p t the d o c t o r ' s c e r t i f i c a t e , th a t w e m a k e th e f i n a l d e c is i o n . Wo have the right to overrule the private doctor. Now, in effect, he is turning around and wanting to use the doctor's c e r tif ic a te , s h a ll we say , a s a m e a n s to le t th e s e m en go back to work, hoping that it will be accepted in court.I I don't think we can have it both ways. Say in one case the private doctor's certificate is as a final answ er, and in other cases, it isn't. MODERATOR WINSTON: I doubt that we h ave that in mind. DR. CLAYTON: You a re right. I didn't h ave it in mind. M O D E R A T O R W I N S T O N : It is a matter of sharing the responsibility. DR. ZEISS: D r. W inston, th e re have been many sta te m e n ts m ade in this ro o m about com plete rec o v ery from a coronary occlusion. I would su g g e st that th is t e r m be d eleted fro m the re c o rd , b ec au se it is m y opinion that co ro n a ry o cclu sio n is sim ply an objective finding of the pathology of the blood v essels of the heart. So, I don't see how anybody can make a com plete recovery from a coronary occlusion. M O D E R A T O R W IN S T O N : I would s u g g e s t t h a t t h e r e c o r d s t a n d , a n d we delete the te rm "com plete recovery" from our thinking. D R. M ISHLER: I th in k th a t D r. Stockwell had a p atien t who re tu rn e d to w ork with a d o c to r's c e rtific a te of reco v ery on the G rand T ru n k W estern. RAT OR WINSTON: I want to get to Dr. M cEw an without counting votes. I had him posted out there. I was looking out for my interests. I got to h im b efo re Abbott Skinner did, so he m isse d the firs t p a r t of th e d is c u s s io n , b u t I think we should give you a ch a n ce to sp e a k y o u r p iece, if you have som ething to say. DR. ALEXANDER MCEWAN: Our policy is entirely the sam e as Dr. J o h n s o n 's . M O D ERA TOR WINSTON: T hat is easy. Now, unless there are som e p r e s s in g q u estio n s about c o ro n a ry a r te ry disease, I would like to talk a little bit about som e of the other problem s. DR. STRANGE: John, May I say one thing? I think it is pretty well se ttle d as far as the engineers are concerned and everybody agrees they shouldn't go back, but I think, too, that these road s that are having such good luck are geographically well located. Ve a r e l o c a t e d i n a n a r e a in which lit ig a t io n i s e a s y , a n d we h a v e a i H ^ f it. At the p r e s e n t tim e , we probably have two to th r e e c a s e s going on rig h t now a g a in st us and against our d o cto rs on the b asis of 'r e tu r n to duty w ithout p ro p e r re stric tio n s. MODERATOR WINSTON: A re there any other questions about coronary artery disease? DR. GLENN F. CUSHMAN (W estern Pacific Railroad): I Would just like to m ake a com m ent about a le rte rs which was ra ise d a m inute ago.I I don't know how m any of the m en have rid d en on the sw itch with the a le rte rs , but they tell you about the carrying capacity before the thing g o es into effect. It ta k e s betw een 15 and 20 se co n d s b e fo re the engine stops. M O D E R A T O R W IN ST O N : D r . Johnson s u g g e s t e d th a t p e r h a p s D r . Kuma*-** 122 Noveka would have a bit of com ment about their attitude toward coronary a r te r y d is e a s e in in d u s try in g e n e r a l and r a ilro a d s in p a rtic u la r. You have any com m ents. DR. KUMASAKA NOVEKA (Japan): P ardon m e for my bad English. We h av e m u c h l e s s c o r o n a r y d i s e a s e in J a p a n th a n in the United S t a t e s , and we f e e l m o s t l y the s a m e a s the p a n e l m e m b e r s . We do not p e rm it them to r e tu r n to labor o r r e tu rn to work a s a d riv e r. T hat is very dangerous because they can damage people. In the o th e r jo b s , we allow th e m to r e tu r n to w o rk a fte r they have retired for three months. MODERATOR WINSTON: Thank you so much. DR. HOLLO: Dr. W inston, I would like to make one com m ent in re fe re n c e to the d o c to r's r e m a r k s , and Dr. Wight brought this out y e s te rd a y to m e, th a t on the J a p a n e s e R a i l r o a d th a t th e r e t i r e m e n t a g e is 50 up to j u s t r e cen tly and now th e y h ave i n c r e a s e d it to the age of 55. So I g u ess that redu ces th e ir problem in r e g a rd to a rte rio sc le ro tic h e a rt disease. MODERATOR WINSTON: L e t's now get into the g en e ral a re a of a n s w e r ing the question that D r. Hollo r a is e d e a r l i e r and that had to do with the development of right bundle branch block. It was found, a s I u n d e r s t a n d it, on a ro u tin e e l e c tro c a r d io g r a p h ic , in v estig atio n of a p e rs o n who was roughly 45 y e a r s old. P e rh a p s you would like to take a look at L au ren ce L am b 's p rev io u s discussion about electrocardiographic findings in the Heart Bulletin, Septem ber-O ctober 1961. Incidentally, they have done a trem endous am ount of work on c a r d io v a s c u la r d is e a s e s down at the A e ro sp a c e M ed ical C enter, of the School of Aviation Medicine at San Antonio. The most frequent finding, according to them, is p rem atu re v e n tri cular contraction. Let m e ask if so m eo n e wants to a n s w e r Dr. H o llo 's inquiry about the significance of a right bundle branch block? Dr. H anson? DR. O. L. HANSON ( A t c h i s o n , T o p e k a an u S a n ta F e ) : My own i m p r e s s i o n is that if you have a m a n 45 y e a r s old with right bundle b ran c h bloc!;, and this is his first e le c tro c a rd io g ra m , and he is asym p to m atic, I would not consider that indicative of cardiac disease. If he h as had p re v io u s e le c tro c a rd io g ra m s which have also shown a right bundle branch block, I would feel reasonably confident, if all other things were norm al, that he did not have organic h ea rt disease. If he had p rev io u s e le c tro c a rd io g ra m s , which w ere norm al, then this would be e v id e n c e o f possibly o r g a n i c h e a r t d i s e a s e . 123 M O D E R A T O R W I N S T O N : It is a matter of sharing the responsibility. DR. ZEISS: D r. W inston, th e re have been many sta te m e n ts m ade in this ro o m about com plete rec o v ery from a coronary occlusion. I would su g g e st that th is t e r m be d eleted fro m the re c o rd , b ec au se it is m y opinion that co ro n a ry o cclu sio n is sim ply an objective finding of the pathology of the blood v essels of the heart. So, I don't see how anybody can make a com plete recovery from a coronary occlusion. M O D E R A T O R W IN S T O N : I would s u g g e s t t h a t t h e r e c o r d s t a n d , a n d we delete the te rm "com plete recovery" from our thinking. D R. M ISHLER: I th in k th a t D r. Stockwell had a p atien t who re tu rn e d to w ork with a d o c to r's c e rtific a te of reco v ery on the G rand T ru n k W estern. RAT OR WINSTON: I want to get to Dr. M cEw an without counting votes. I had him posted out there. I was looking out for my interests. I got to h im b efo re Abbott Skinner did, so he m isse d the firs t p a r t of th e d is c u s s io n , b u t I think we should give you a ch a n ce to sp e a k y o u r p iece, if you have som ething to say. DR. ALEXANDER MCEWAN: Our policy is entirely the sam e as Dr. J o h n s o n 's . M O D ERA TOR WINSTON: T hat is easy. Now, unless there are som e p r e s s in g q u estio n s about c o ro n a ry a r te ry disease, I would like to talk a little bit about som e of the other problem s. DR. STRANGE: John, May I say one thing? I think it is pretty well se ttle d as far as the engineers are concerned and everybody agrees they shouldn't go back, but I think, too, that these road s that are having such good luck are geographically well located. Ve a r e l o c a t e d i n a n a r e a in which lit ig a t io n i s e a s y , a n d we h a v e a i H ^ f it. At the p r e s e n t tim e , we probably have two to th r e e c a s e s going on rig h t now a g a in st us and against our d o cto rs on the b asis of 'r e tu r n to duty w ithout p ro p e r re stric tio n s. MODERATOR WINSTON: A re there any other questions about coronary artery disease? DR. GLENN F. CUSHMAN (W estern Pacific Railroad): I Would just like to m ake a com m ent about a le rte rs which was ra ise d a m inute ago.I I don't know how m any of the m en have rid d en on the sw itch with the a le rte rs , but they tell you about the carrying capacity before the thing g o es into effect. It ta k e s betw een 15 and 20 se co n d s b e fo re the engine stops. M O D E R A T O R W IN ST O N : D r . Johnson s u g g e s t e d th a t p e r h a p s D r . Kuma*-** 122 Noveka would have a bit of com ment about their attitude toward coronary a r te r y d is e a s e in in d u stry in g e n e r a l and ra ilro a d s in p a rtic u la r. You have any com m ents. DR. KUMASAKA NOVEKA (Japan): P ardon m e for my bad English. We h av e m u c h l e s s c o r o n a r y d i s e a s e in J a p a n th a n in the United S t a t e s , and we f e e l m o s t l y the s a m e a s the p a n e l m e m b e r s . We do not p e rm it them to r e tu rn to labor o r re tu rn to work as a d riv er. That is very dangerous because they can damage people. In the o th e r jo b s , we allow th e m to r e tu r n to w o rk a fte r they have retired for three months. MODERATOR WINSTON: Thank you so much. DR. HOLLO: Dr. Winston, I would like to make one com m ent in re fe re n c e to the d o c to r's r e m a r k s , and Dr. Wight brought this out y e s te rd a y to m e, th a t on the J a p a n e s e R a i l r o a d th a t th e r e t i r e m e n t a g e is 50 up to j u s t r e cently and now th ey have in c r e a s e d it to the age of 55. So I g u ess that red u ces th e ir problem in re g a rd to a rte rio sc le ro tic h e a rt disease. MODERATOR WINSTON: L e t's now get into the g en e ral a re a of a n s w e r ing the question that D r. Hollo r a is e d e a r l i e r and that had to do with the development of right bundle branch block. It was found, a s I u n d e r s ta n d it, on a ro u tin e e l e c tro c a r d io g r a p h ic , in v estig atio n of a p e rs o n who was roughly 45 y e a r s old. P erh ap s you would like to take a look at L aurence L am b's previous discussion about electrocardiographic findings in the Heart Bulletin, S eptem ber-O ctober 1961. Incidentally, they have done a trem endous am ount of work on c a r d io v a s c u la r d is e a s e s down at the A e ro sp a c e M ed ical C enter, of the School of Aviation Medicine at San Antonio. The m ost frequent finding, according to them, is p re m a tu re v e n tr i cular contraction. Let m e ask if so m eo n e wants to a n s w e r Dr. H o llo 's inquiry about the significance of a right bundle branch block? Dr. H anson? DR. O. L. HANSON ( A t c h i s o n , T o p e k a an u S a n ta F e ) : My own i m p r e s s i o n is that if you have a m a n 45 y e a r s old with right bundle b ran c h bloc!;, and this is his first e le c tro c a rd io g ra m , and he is asym pto m atic, I would not consider that indicative of cardiac disease. If he has had p rev io u s e le c tro c a rd io g ra m s which have also shown a right bundle branch block, I would feel reasonably confident, if all other things were norm al, that he did not have organic h ea rt disease. If he had p rev io u s e le c tro c a rd io g ra m s , which w ere norm al, then this would be e v id e n c e o f possibly o r g a n i c h e a r t d i s e a s e . 123 Dii: WIGHT: You r e f e r r e d to D r. L a m b 's w ork a m om ent ago down at San Antonio. He p rese n ted the findings of a whole panel on, I think it w as, 55,000 ca se s that they had rev iew ed am ongst pilots and rig h t bundle b ra n c h block was of not too g r e a t s ig n ific a n c e . He d id n 't attac h too much im p o rtan ce to that. MODERATOR WINSTON: T h is is a relativ ely young group of people, but then, to a n sw e r the question, in a p e rso n p a st 40 y e a rs old, it is of questionable significance. As D r. Hanson indicated, if you happen to have had a p rio r one that was negative, then it probably is significant. Now, w hether it is clinically significant o r not is som ething we don't know, but certainly it shows a change has taken place, so it doesn't give you any comfort. N either can you use it as substantial information tO'Support restrictiv e action as I view it, on that alone. ^ ^ D R . WIGHT: They let the pilots fly? M O D ERA TOR WINSTON: Y es. DR. VAUGHAN: If I could com m ent a m inute, Dr. Winston, on right b u n d le b r a n c h b lock, we s e e a f a i r n u m b e r of c a s e s of r ig h t bundle b r a n c h block. .Some of them , if we have not a previous e lec tro c ard io g ram , we a s s u m e a r e of no significance. A lot of these right bundle branch blocks, a s you know, are congen i t a l . A p e r s o n who h a s had r i g h t bundle b r a n c h b lo c k a ll h i s life. In oth--r c a s e s r i g h t b u n d le b r a n c h b lo c k i s s i m p l y a d e f e c t in the co n d u c tio n . It can be caused not only o r not even prim arily , perhaps, by arterio sclero tic h e a r t d ise ase , but alm ost any infection which affects the conduction m e ch an ism of the heart. M ODERATOR WINSTON: What about left bundle branch block? DR. VAUGHAN: Left bundle branch block is m ore serious inasmuch as ^ ^ t a t i s t i c s have shown it is m ore indicative of an arteriosclerotic defect in the conduction m echanism . T h e re fo re , I think th ere should be some r e s tr ic tio n on people who develop a left bundle branch block. * DR. JOHNSON: Well, whenever I see right bundle branch block, I worry. In D r. H ollo's specific c a se of a 45 y e a r old individual whose initial c a rd io g ra m was showing right bundle branch-block, I would w orry. I know the percentages are in favor of it having been occurring in early adult life, maybe even in infancy as a resu lt of infection. It can be a m anifestation of an old healed rheum atic heart disease. I im agine se v e ra l other infections, but I ca n 't rule out the possibility th at it is of significance because rig h t bundle bran ch block is not the pattern of norm al electrocardiography. M O D ERA TO h WINSTON: T h e re a r e s e v e r a l o th e rs, but le t's talk about ju st briefly the significance of p re m a tu re v entricular contraction. T.i^. is p e rh a p s the m ost frequently en c o u n te re d ab n o rm ality in the routine 1 0.1 electrocardiogram. DR. CYRAN: I think it all depends on how many prem ature ventricular sy sto le s you have seen in the tra c in g s, how often they a re o ccu rrin g , w hether they are rnulti-focal o r w hether they are unifocal, whether they a re o c c u rrin g in ru n s, o r w hether they a r e actually p recip itated by e x e r c i s e , o r w h e t h e r th e y a r e d i m i n i s h e d by e x e r c i s e . It h a s a b e a r i n g a s to w hether the man is a young man o r older man. P rem ature ventricular s y s to le s by th e m se lv e s probably would be of no significance. O u r p r o c e d u r e u su a lly is to do a little bit of e x e r c is e to s e e w h eth er we can m ake them disappear. M O D E R A T O R WINSTON: I a m c o n c e r n e d a b o u t p r e m a t u r e 'v e n t r i c u l a r co n tractio n s because all too often it com es in to o u r m edical rep o rts that he h a s s o m e e x t r a s y s t o le s which a r e o f no s ig n ific a n c e . Thc-y a r e p e r haps of no significance, but it does req u ire investigation. L et m e ask one m o re q u estio n , and that h as to do with v alv u lar d ise a se . We have, unfortunately, not gotten into the valvular disease. F o rtu n a te ly , we don't see so m uch of th is, but we do have som e v alv u lar d ise ase , and the one that concerns m e p articu la rly is the d i s e a s e involv ing the a o r ti c valve. It is not u n u s u a l to develop in the o ld e r p e rso n . P e rh a p s it co n cern s me m ore if this is the stenotic lesion than i f it is a reg u rg ita n t type, but in either event, you have an ideal set-up and an ideal condition set-up that could and frequently does procude a sudden incapacitation. N ow , l e t ' s m e n tio n b r i e f l y a g a in a b o u t a n t i c o a g u l a n t s . We a r e g o in g to have to say this pretty rapidly. Does anyone have any rea l fixed ideas about the anticoagulants, that the person using o r taking anticoagulants should be r e s tr ic te d in th e ir efforts. DR. WINTERS: good. . M ost of th e m s e e m to not be ta k in g enough to do any ! MODERATOR WINSTON: A re th e re any o th e r com m en ts about it? Do I gather then there is not m uch concern about whether they a re taking them or not ? DR. KNOWLES: May I ask, is n 't th e re som e question as to the efficiency I would like-D r. Johnson to te ll us, a r e n 't the card io lo g ists in a good many cases getting away from anticoagulants ? MODERATOR WINSTON: Do you want to an sw e r that Ralph? DR. JOHNSON: I think this is still a m oot point. It is my observation that m ore and m ore cardiologists are getting away from routine, long te rm use, after m yocardial infarction, of anticoagulant therapy. Some tim es in these cases the risk of continued anticoagulant therapy and its m a n a g e m e n t is more difficult th a n t h e r i s k w ith o u t th e u s e of th e s e a g e n ts . 125 Dii: WIGHT: You r e f e r r e d to D r. L a m b 's w ork a m om ent ago down at San Antonio. He p rese n ted the findings of a whole panel on, I think it w as, 55,000 ca se s that they had rev iew ed am ongst pilots and rig h t bundle b ra n c h block was of not too g r e a t s ig n ific a n c e . He d id n 't attac h too much im p o rtan ce to that. MODERATOR WINSTON: T h is is a relativ ely young group of people, but then, to a n sw e r the question, in a p e rso n p a st 40 y e a rs old, it is of questionable significance. As D r. Hanson indicated, if you happen to have had a p rio r one that was negative, then it probably is significant. Now, w hether it is clinically significant o r not is som ething we don't know, but certainly it shows a change has taken place, so it doesn't give you any comfort. N either can you use it as substantial information tO'Support restrictiv e action as I view it, on that alone. ^ ^ D R . WIGHT: They let the pilots fly? M O D ERA TOR WINSTON: Y es. DR. VAUGHAN: If I could com m ent a m inute, Dr. Winston, on right b u n d le b r a n c h b lock, we s e e a f a i r n u m b e r of c a s e s of r ig h t bundle b r a n c h block. .Some of them , if we have not a previous e lec tro c ard io g ram , we a s s u m e a r e of no significance. A lot of these right bundle branch blocks, a s you know, are congen i t a l . A p e r s o n who h a s had r i g h t bundle b r a n c h b lo c k a ll h i s life. In oth--r c a s e s r i g h t b u n d le b r a n c h b lo c k i s s i m p l y a d e f e c t in the co n d u c tio n . It can be caused not only o r not even prim arily , perhaps, by arterio sclero tic h e a r t d ise ase , but alm ost any infection which affects the conduction m e ch an ism of the heart. M ODERATOR WINSTON: What about left bundle branch block? DR. VAUGHAN: Left bundle branch block is m ore serious inasmuch as ^ ta tis tic s have shown it is m ore indicative of an arteriosclerotic defect in the conduction m echanism . T h e re fo re , I think th ere should be some r e s tr ic tio n on people who develop a left bundle branch block. * DR. JOHNSON: Well, whenever I see right bundle branch block, I worry. In D r. H ollo's specific c a se of a 45 y e a r old individual whose initial c a rd io g ra m was showing right bundle branch-block, I would w orry. I know the percentages are in favor of it having been occurring in early adult life, maybe even in infancy as a resu lt of infection. It can be a m anifestation of an old healed rheum atic heart disease. I im agine se v e ra l other infections, but I ca n 't rule out the possibility th at it is of significance because rig h t bundle bran ch block is not the pattern of norm al electrocardiography. M O D ERA TO h WINSTON: T h e re a r e s e v e r a l o th e rs, but le t's talk about ju st briefly the significance of p re m a tu re v entricular contraction. T.i^. is p e rh a p s the m ost frequently en c o u n te re d ab n o rm ality in the routine 1 0.1 electrocardiogram. DR. CYRAN: I think it all depends on how many prem ature ventricular sy sto le s you have seen in the tra c in g s, how often they a re o ccu rrin g , w hether they are rnulti-focal o r w hether they are unifocal, whether they a re o c c u rrin g in ru n s, o r w hether they a r e actually p recip itated by e x e r c i s e , o r w h e t h e r th e y a r e d i m i n i s h e d by e x e r c i s e . It h a s a b e a r i n g a s to w hether the man is a young man o r older man. P rem ature ventricular s y s to le s by th e m se lv e s probably would be of no significance. O u r p r o c e d u r e u su a lly is to do a little bit of e x e r c is e to s e e w h eth er we can m ake them disappear. M O D E R A T O R WINSTON: I a m c o n c e r n e d a b o u t p r e m a t u r e 'v e n t r i c u l a r co n tractio n s because all too often it com es in to o u r m edical rep o rts that he h a s s o m e e x t r a s y s t o le s which a r e o f no s ig n ific a n c e . Thc-y a r e p e r haps of no significance, but it does req u ire investigation. L et m e ask one m o re q u estio n , and that h as to do with v alv u lar d ise a se . We have, unfortunately, not gotten into the valvular disease. F o rtu n a te ly , we don't see so m uch of th is, but we do have som e v alv u lar d ise ase , and the one that concerns m e p articu la rly is the d i s e a s e involv ing the a o r ti c valve. It is not u n u s u a l to develop in the o ld e r p e rso n . P e rh a p s it co n cern s me m ore if this is the stenotic lesion than i f it is a reg u rg ita n t type, but in either event, you have an ideal set-up and an ideal condition set-up that could and frequently does procude a sudden incapacitation. N ow , l e t ' s m e n tio n b r i e f l y a g a in a b o u t a n t i c o a g u l a n t s . We a r e g o in g to have to say this pretty rapidly. Does anyone have any rea l fixed ideas about the anticoagulants, that the person using o r taking anticoagulants should be r e s tr ic te d in th e ir efforts. DR. WINTERS: good. . M ost of th e m s e e m to not be ta k in g enough to do any ! MODERATOR WINSTON: A re th e re any o th e r com m en ts about it? Do I gather then there is not m uch concern about whether they a re taking them or not ? DR. KNOWLES: May I ask, is n 't th e re som e question as to the efficiency I would like-D r. Johnson to te ll us, a r e n 't the card io lo g ists in a good many cases getting away from anticoagulants ? MODERATOR WINSTON: Do you want to an sw e r that Ralph? DR. JOHNSON: I think this is still a m oot point. It is my observation that m ore and m ore cardiologists are getting away from routine, long te rm use, after m yocardial infarction, of anticoagulant therapy. Some tim es in these cases the risk of continued.anticoagulant therapy and its m a n a g e m e n t is more difficult th a n t h e r i s k w ith o u t th e u s e of th e s e a g e n ts . 125 N o n e th e le ss, th e re a r e individuals who have had a type of m y o c a r d u i infarction that m ost cardiologists feel m erits long-term anticoagulant therapy. The difference is that about six or eight years ago m ost cardiologists wanted to continue lo n g -te rm anticoagulant therapy in m y o c ard ial in fa rc tion of w h atever d egree. Today, m ost card io lo g ists a re confining an ti coagulant th e ra p y lo n g -te rm to individuals who have had a r a t h e r extensiw m yocardial infarct of the type of clinical classification of a serio u s m yo cardial infarction. M O D E R A T O R WINSTON: T h e o t h e r c o m m e n t I m ig h t m a k e ab o u t the usiof anticoagulants is that if the person is taking them , then it behooves you to know th at he is taking them in levels that a r e accep tab le clinically. Secondly, it tells you that the man has some m ajor underlying vascular o r significant m e d ic a l condition that you should be on top of. Now, about blood p re ssu re . Should an arb itra ry level for systolic and diastolic blood p re ssu re be established for purposes of disqualifica tion ? If so , what le v e l? If anyone wants to a n s w e r that in about half a dozen w ell-chosen words. DR. W'lGIfT: B e fo re we go into th a t, m ay I ask the p a n e l's opinion on fibrillation ? MODERATOR WINSTON: We a re talking about a u r ic u la r fib rilla tio n no* Does anyone want to say if au ric u lar fibrillation is sig n ifican t? Is your au ric u la r fibrillation of any p a rticu la r significance ? DR. MCEWAN: I think if it is not accom panied by congestive h e a rt fail u re, so m e tim e s it is com patible with a n o rm al life span, but th ese p e o p l e r u n t h e r i s k o f t h r o w in g off a n e m b o l u s an y t i m e , a n d th e n you *:< back to the an tico ag u lan ts again. Should you put all th ese people on an;, coagulants ? M O D ERA TO R WINSTON: How about it, V an c e? A u ric u la r fib rilla tio n , what kind of a flag does that put before your employee ? DR. STRANGE: Well, if we evaluate them , our ca rd io lo g ist usually tells us not to put them back to work. MODERATOR WINSTON: How about it. D r. K ap la n ? DR. KAPLAN: I p ass on to Dr. Johnson. He is a cardiologist. DR. CYRAN: We look on that with a little bit of inquiry. We wonder w hether the m an is a young m an o r an o ld e r m an, and in a younger nun. t h i s m a y l^e a p a r o x y s m a l th in g , not n e c e s s a r i l y m e a n i n g t h a t it i s in d i cative of serious h e a r t d is e a s e . 126 Iii an o l d e r m a n , o b v io u s l y , t h i s is p r o b a b ly r e l a t e d to c o r o n a r y j i t d is e a s e . We would r e s t r i c t t h e m . We in d iv id u a liz e e a c h c a s e . I . :i11 think we would a llo w t h e m to be a p a s s e n g e r e n g in e m a n o r a r o a d jiii t n g i n e m a n . We m i g h t a llo w t h e m to work in the y a r d . B r a k e m e n we ...bM r e s t r i c t f r o m c l i m b i n g and doing the r e g u l a r d u tie s of a b r a k e m a n , cause of the f a c t th a t th is is a c o n d itio n which ca n a b s o lu te ly i n c a p a c i ite somebody. MODERATOR WINSTON: P e t e r , a u r i c u l a r f ib r i lla tio n . . a. VAUGHAN: T h e u s u a l type of a u r i c u l a r f ib ri lla tio n , of c o u r s e , is . . abnormal finding. We r e s t r i c t th e m the s a m e way as we do c o r o n a r y '.cry d i s e a s e . It is an i n d ic a t io n of a r t e r i o s c l e r o t i c h e a r t d i s e a s e . I . .:.p. they sh o u ld be r e s t r i c t e d in th e s a m e way. i DERATOR WINSTON: It is a s e rio u s h e a rt d ise ase . Whether o r not man is c o m p e n s a te d o r d e c o m p e n s a tin g is of so m e im p o rta n c e to h im , insofar as p redictability, whether he is going to throw an em bolus and r sudden d e m is e is not p r e d ic ta b l e and t h e r e f o r e , he is p la c e d in the t,ury of one who is u n p r e d i c t a b l e . A. MISHLER: You m e n tio n e d v a l v u l a r d i s e a s e . I have as a p r o b l e m at present tim e a n u m b e r of m e n who have had valve r e p la c e m e n t , who been su b m ittin g r e p o r t s fro m both th e ir su rg e o n s and c a r d io lo g is ts they can do a ll kin ds of w ork. T h is in cludes a o r tic and m i t r a l valve , .jcement. I would like to have the p an e l's opinion about tills. MODERATOR WINSTON: Would an y o n e a n s w e r th a t r e a l q u ic k ? It i s oiem ely im p o r ta n t b e c a u s e we a r e getting into th is m o re and m o r e . l it. KNOWLES: I j u s t h a d a l e t t e r f r o m D r. H a r k in s in B oston. He had , .1 a cage b a ll in the m i t r a l v a lv e . He w ro te m e an d s a id , "I b e l ie v e th is ...ail can return to all types of work. " I couldn't let him. I know Dr. mu kins, but I did not a llo w h im to go b a c k to work. ..oDERATOR WINSTON: I would th in k it b ehoove s us u n til we l e a r n m o r e -i.nit it, to feel th is m a n 's life p e r h a p s h a s bee n e x te n d e d , and p o s s i b ly .ired for s o m e tim e , and he is q u ite fortunate. . :{. JOHNSON: M r. C h a i r m a n , I th in k a l s o we s h o u ld inclu d e a r t e r i a l ..ails in h e re and c a r d i a c p a c e m a k e r s . MODERATOR WINSTON: T h a t w ill go in the s a m e c a t e g o r y . To sum up, we will s a y until we le a rn m o re about them , although a ....ui's outlook p e r h a p s h a s b e e n i m p r o v e d . I n s o f a r a s h i s e m p lo y a b i lity critical occupations is c o n c e rn e d , it is questionable and not sug g ested this moment. Blood p r e s s u r e - and with th is , we will clo se. Blood p r e s s u r e . Does anyone have s o m e id eas as to w h e r e th e cu to ff p o in t sh o u ld b e ? 127 N o n e th e le ss, th e re a r e individuals who have had a type of m y o c a r d u i infarction that m ost cardiologists feel m erits long-term anticoagulant therapy. The difference is that about six or eight years ago m ost cardiologists wanted to continue lo n g -te rm anticoagulant therapy in m y o c ard ial in fa rc tion of w h atever d egree. Today, m ost card io lo g ists a re confining an ti coagulant th e ra p y lo n g -te rm to individuals who have had a r a t h e r extensiw m yocardial infarct of the type of clinical classification of a serio u s m yo cardial infarction. M O D E R A T O R WINSTON: T h e o t h e r c o m m e n t I m ig h t m a k e ab o u t the usiof anticoagulants is that if the person is taking them , then it behooves you to know th at he is taking them in levels that a r e accep tab le clinically. Secondly, it tells you that the man has some m ajor underlying vascular o r significant m e d ic a l condition that you should be on top of. Now, about blood p re ssu re . Should an arb itra ry level for systolic and diastolic blood p re ssu re be established for purposes of disqualifica tion ? If so , what le v e l? If anyone wants to a n s w e r that in about half a dozen w ell-chosen words. DR. W'lGIfT: B e fo re we go into th a t, m ay I ask the p a n e l's opinion on fibrillation ? MODERATOR WINSTON: We a re talking about a u r ic u la r fib rilla tio n no* Does anyone want to say if au ric u lar fibrillation is sig n ifican t? Is your au ric u la r fibrillation of any p a rticu la r significance ? DR. MCEWAN: I think if it is not accom panied by congestive h e a rt fail u re, so m e tim e s it is com patible with a n o rm al life span, but th ese p e o p l e r u n t h e r i s k o f t h r o w in g off a n e m b o l u s an y t i m e , a n d th e n you *:< back to the an tico ag u lan ts again. Should you put all th ese people on an;, coagulants ? M O D ERA TO R WINSTON: How about it, V an c e? A u ric u la r fib rilla tio n , what kind of a flag does that put before your employee ? DR. STRANGE: Well, if we evaluate them , our ca rd io lo g ist usually tells us not to put them back to work. MODERATOR WINSTON: How about it. D r. K ap la n ? DR. KAPLAN: I p ass on to Dr. Johnson. He is a cardiologist. DR. CYRAN: We look on that with a little bit of inquiry. We wonder w hether the m an is a young m an o r an o ld e r m an, and in a younger nun. t h i s m a y l^e a p a r o x y s m a l th in g , not n e c e s s a r i l y m e a n i n g t h a t it i s in d i cative of serious h e a r t d is e a s e . 126 hi an o l d e r m a n , o b v io u s l y , t h i s is p r o b a b ly r e l a t e d to c o r o n a r y j i t d is e a s e . We would r e s t r i c t t h e m . We in d iv id u a liz e e a c h c a s e . I . :i11 think we would a llo w t h e m to be a p a s s e n g e r e n g in e m a n o r a r o a d jiii t n g i n e m a n . We m i g h t a llo w t h e m to work in the y a r d . B r a k e m e n we ...bM r e s t r i c t f r o m c l i m b i n g and doing the r e g u l a r d u tie s of a b r a k e m a n , cause of the f a c t th a t th is is a c o n d itio n which ca n a b s o lu te ly i n c a p a c i ite somebody. MODERATOR WINSTON: P e t e r , a u r i c u l a r f ib r i lla tio n . . a. VAUGHAN: T h e u s u a l type of a u r i c u l a r f ib ri lla tio n , of c o u r s e , is . . abnormal finding. We r e s t r i c t th e m the s a m e way as we do c o r o n a r y '.cry d i s e a s e . It is an i n d ic a t io n of a r t e r i o s c l e r o t i c h e a r t d i s e a s e . I . .:.p. they sh o u ld be r e s t r i c t e d in th e s a m e way. i DERATOR WINSTON: It is a s e rio u s h e a rt d ise ase . Whether o r not man is c o m p e n s a te d o r d e c o m p e n s a tin g is of so m e im p o rta n c e to h im , insofar as p redictability, whether he is going to throw an em bolus and r sudden d e m is e is not p r e d ic ta b l e and t h e r e f o r e , he is p la c e d in the t,ury of one who is u n p r e d i c t a b l e . A. MISHLER: You m e n tio n e d v a l v u l a r d i s e a s e . I have as a p r o b l e m at present tim e a n u m b e r of m e n who have had valve r e p la c e m e n t , who been su b m ittin g r e p o r t s fro m both th e ir su rg e o n s and c a r d io lo g is ts they can do a ll kin ds of w ork. T h is in cludes a o r tic and m i t r a l valve , .aceiuent. I would like to have the p an e l's opinion about tills. iODERATOR WINSTON: Would an y o n e a n s w e r th a t r e a l q u ic k ? It i s oiem ely im p o r ta n t b e c a u s e we a r e getting into th is m o re and m o r e . l it. KNOWLES: I j u s t h a d a l e t t e r f r o m D r. H a r k in s in B oston. He had , a a cage ball in the m itra l valve. He wrote me and said, "I believe this ...ail can return to all types of work. " I couldn't let him. I know Dr. u.u kins, but I did not a llo w h im to go b a c k to work. ..oDERATOR WINSTON: I would th in k it b ehoove s us u n til we l e a r n m o r e -i.nit it, to feel th is m a n 's life p e r h a p s h a s bee n e x te n d e d , and p o s s i b ly .ired for s o m e tim e , and he is q u ite fortunate. . :i. JOHNSON: M r. C h a i r m a n , I th in k a l s o we s h o u ld inclu d e a r t e r i a l ..ails in h e re and c a r d i a c p a c e m a k e r s . MODERATOR WINSTON: T h a t w ill go in the s a m e c a t e g o r y . To sum up, we will s a y until we le a rn m o re about them , although a ....ui's outlook p e r h a p s h a s b e e n i m p r o v e d . I n s o f a r a s h i s e m p lo y a b i lity critical occupations is c o n c e rn e d , it is questionable and not sug g ested this moment. Blood p r e s s u r e - and with th is , we will clo se. Blood p r e s s u r e . Does anyone have s o m e id eas as to w h e r e th e cu to ff p o in t sh o u ld b e ? 127 DR. JOHNSON': I ca n k ic k off on th at if yo u w ish, K ortun.it. 1y . fast s e v e r a l y e a r s o u r an tih y p ertcn siv e agents hav : b e e n ' f a r t: : c e ssfu l in tne c lin ic a l m a n a g e m e n t of this p roblem than obt.i about six y e a rs ago. N o n eth e le ss, an individual who has a sustained systolic blood p r e s su re above 200 and a su stain ed diastolic blood p re s s u re over 100 is a potential risk , and if h is-p erso n al physician cannot bring that blood p r e s s u re down to a m o r e sa tisfa c to ry level, I would disqualify him. DR. STOCKW ELL: With o r without treatm ent? DR. JOHNSON: I a m sp e a k in g of the individual who is tr e a te d and whose blood p r e s s u r e m a in ta in s above 200 sy sto lic and above 100 d ia sto lic ould be disqualified. It invariably m eans he h as re n a l damage. MODERATOR WINSTON: And renal damage means v ascu lar dam age. DR. JOHNSON: Yes. MODERATOR WINSTON: And vascular damage m eans coronary and brain damage. DR. SKINNER: What about a diastolic p ressu re--y o u pick the level of 120 o r 130, r e g a r d l e s s of the s y s to lic ? DR. JOHNSON: T h a t is alw ays a tric k y one. I have se e n individuals who have a systolic blood p re s s u re consistently in the 140's and diastolic that w ill r e m a in a t 110. I am uneasy about th ese individuals, but I have som e difficulty in m aintaining the disqualification because of the absence of the elevation of the systolic. Nonetheless, as a clinician, I feel that this sustained elevation of the diastolic poses a grave prognostic signi ficance. W t. KNOWLES: Wouldn't you say the shortening in the pulse p re ssu re indicates a weakening of the h eart m uscles? Isn't there a little diagnostic point t h e r e ? A drop in the systolic, an in c re a se in the diastolic, pulse pressure lessening. DR. JOHNSON: W ell, m y point is that many tim e s u n d e r tr e a tm e n t we can bring these systolic p re s s u re s down to a sa tisfactory clinical level, but we a r e unable to have the sam e satisfacto ry effect on the diastolic p re s s u re . I am su re that is a point that Dr. Skinner is getting at. What do you do about individuals who have a co n siste n t and p e rsisten t elevation of the diastolic blood p r e s s u r e ? My an sw er is that I sw eat. MODERATOR WINSTON: I think I m ight sum up that by saying that the p r o b le m of h y p e r te n s io n h a s b ee n v a s tly c o m p lic a te d with the advent o. the recen t and m ore effective drugs. Those drugs them selves cause certain pro b lem s that a re highly troublesom e, one of which is mental confusion. The o th er h as to do with syncope incidents to o rth o static DH. NELSO N : Would you mind just from a practical standpoint answer ing five and six, for the m o m e n t ? MODERATOR WINSTON: I will answ er it for brevity. Should CVI be considered to be in the sam e category as a coronary throm bosis ? Yes, with o r without re sid u a l, it is all the sam e. 6 . If a c o ro n a ry is p e r m i tte d to r e tu r n to w ork, should he be p e r m u te d to continue and w ork a fte r a second attack ? It depends again on h is jo b and on his re sp o n s ib ility . In taking this into consideration, though, that with the second attach he has less m yo c a r d iu m available b e c a u s e o b v io u sly he h as lo st s o m e m o r e in the in f a r c ie d area. N um ber two, that he is getting tow ard the end of his string. J u s t one less in r e s e rv e than he had before. At this tim e he should be e n couraged, if at all possible, to get out of this rac k et and sta rt growing pansies in California before he sta rts pushing them. (Laughter) Mr. Chairm an, that concludes the panel. Thank you very much, gentlemen. (Applause) CHAIRMAN OLSON: D r. K ie ffe r, would you be good enough to com e back jjp to the head table. I wanted to make one co m m ent about the use of the letters "CVI" on q u e s tio n n u m b e r 5. In o u r h o s p it a l we u s e that te rm in o lo g y to m ean c e r e b r a l v a s c u l a r in c id e n t, an d the r e a s o n f o r it i s th a t we h a v e had s o m e p e o p l e that have made claim s against us for having said this patient died of a c e r e b r a l v a s c u la r a c c id e n t. T h e y m is c o n s t r u e the t e r m , and we have h ad no trouble since we have u se d that term inology. I want to thank the M o d erato r, the panel and the audience for a v ery i n t e r e s t i n g p r o g r a m th is m o r n i n g . I th in k y ou h a v e donfe an e x c e l l e n t job, and now I would like to ask Dr. K ieffer if he will give the re su lts of the election. DR. KIEFFER: The re su lts of the baliotting indicates that you have chosen D r. B. W. S to c k w e ll, D r . I. K a p la n , r e p r e s e n t i n g th e E a s t e r n D iv is io n ; the Southern T e rrito ry , Dr. E. C. Olson; the Canadian T e rrito ry , Dr. E a r l e Wight, and fo r the W e s te rn T e r r i t o r y , J. R. Winston. CHAIRMAN OLSON: B e fo re we conclude, I want to te ll you that our. luncheon is to be h e ld in th e K o n - T ik i P o r t s r o o m and th a t they a r e h o l d ing sp ace for us now. Will you p lease p ro c e e d im m e d ia te ly to that a r e a . (The m eeting r e cessed at 12:00 o 'clo ck .) ************ 129 DR. JOHNSON: I can kick off on that if you wibh. !'o r ter. iv. last s e v e ra l y e a r s o u r an fihypertensive agents hav : u e e i a r t: ce ssfu l in tne c lin ic a l m an ag em en t of this problem titan obt.i about six y e a rs ago. N o n eth e le ss, an individual who has a sustained systolic blood p r e s su re above 200 and a su stain ed diastolic blood p re s s u re over 100 is a potential risk , and if h is-p erso n al physician cannot bring that blood p r e s s u re down to a m o r e sa tisfa c to ry level, I would disqualify him. DR. STOCKW ELL: With o r without treatm en t? DR. JOHNSON: I a m sp e a k in g of the individual who is tr e a te d and whose blood p r e s s u r e m a in ta in s above 200 sy sto lic and above 100 d ia s to lic . ould be disqualified. It invariably m eans he h as re n a l damage. MODERATOR WINSTON: And renal damage means v ascu lar dam age. DR. JOHNSON: Yes. MODERATOR WINSTON: And vascular damage m eans coronary and brain damage. DR. SKINNER: What about a diastolic p ressu re--y o u pick the level of 120 o r 130, r e g a r d l e s s of the s y s to lic ? DR. JOHNSON: T h a t is alw ays a tric k y one. I have se e n individuals who have a systolic blood p re s s u re consistently in the 140's and diastolic that w ill r e m a in a t 110. I am uneasy about th ese individuals, but I have som e difficulty in m aintaining the disqualification because of the absence of the elevation of the systolic. Nonetheless, as a clinician, I feel that this sustained elevation of the diastolic poses a grave prognostic signi ficance. W t . KNOW'LES: W ouldn't you say the shortening in the p u lse p r e s s u r e indicates a weakening of the h eart m uscles? Isn't there a little diagnostic point t h e r e ? A drop in the systolic, an in c re a se in the diastolic, pulse pressure lessening. DR. JOHNSON: W ell, m y point is that m any tim e s u n d e r tr e a tm e n t we can brin g these systolic p re s s u re s down to a sa tisfactory clinical level, but we a r e unable to have the sam e satisfacto ry effect on the diastolic p re s s u re . I am su re that is a point that Dr. Skinner is getting at. What do you do about individuals who have a co n sisten t and p e rsisten t elevation of the diastolic blood p r e s s u r e ? My an sw er is that I sw eat. MODERATOR WINSTON: I think I m ight sum up that by saying that the p r o b le m of h y p e r te n s io n h a s b ee n v a s tly c o m p lic a te d with the advent o. the r e c e n t a n d m o r e e ffe c tiv e d r u g s . T h o s e d ru g s t h e m s e l v e s cau.-.e c e r t a i n p r o b l e m s th a t a r e h ig h ly t r o u b l e s o m e , o n e o f w hich is rr.< n..il confusion. The o th er h as to do with syncope incidents to o rth o static DH. NELSON : Would you mind just from a practical standpoint answer ing five and six, for the m o m e n t ? MODERATOR WINSTON: I will answ er it for brevity. Should CVI be considered to be in the sam e category as a coronary throm bosis ? Yes, with o r without re sid u a l, it is all the sam e. 6 . If a c o ro n a ry is p e r m i tte d to r e tu r n to w ork, should he be p e r m u te d to continue and work afte r a seco rd attack? It depends again on h is jo b and on h is re s p o n s i b ilit y . In ta k in g th is into consideration, though, that with the second attach he has less m yo c a r d iu m av ailable b e c a u s e o b v io u sly he h as lo st s o m e m o r e in the in f a r c t e d area. N um ber two, that he is getting tow ard the end of his string. J u s t one less in r e s e rv e than he had before. At this tim e he should be e n couraged, if at all p ossible, to get out of this rack et and sta rt growing pansies in California before he s ta rts pushing them. (Laughter) Mr. Chairm an, that concludes the panel. Thank you very much, gentlemen. (Applause) CHAIRMAN OLSON: D r. K ie ffe r, would you be good enough to com e back gp to the head table. 1 wanted to make one com m ent about the use of the le tte rs "CVI" on q u e s tio n n u m b e r 5. In o u r h o s p it a l we u s e that te rm in o lo g y to m ean c e r e b r a l v a s c u l a r in c id e n t, an d the r e a s o n f o r it i s th a t we h a v e had s o m e p e o p l e that have made claim s against us for having said this patient died of a c e r e b r a l v a s c u la r a c c id e n t. T h e y m i s c o n s t r u e the t e r m , and we have h ad no trouble since we have u se d that term inology. I want to thank the M o d erato r, the panel and the audience for a v ery i n t e r e s t i n g p r o g r a m th is m o r n i n g . I th in k y ou h a v e donfe an e x c e l l e n t job, and now I would like to ask Dr. K ieffer if he will give the re su lts of the election. DR. KIEFFER: The re su lts of the ballotting indicates that you have chosen D r. E. W. S to c k w e ll, D r. I. K a p la n , r e p r e s e n t i n g th e E a s t e r n D iv is io n ; the Southern T e rrito ry , Dr. E. C. Olson; the Canadian T e rrito ry , Dr. E a r l e Wight, and fo r the W e s te rn T e r r i t o r y , J. R. Winston. CHAIRMAN OLSON: B e fo re we conclude, I want to te ll you that our. luncheon is to be h e ld in the K o n - T ik i P o r t s r o o m and th a t they a r e h o l d ing sp a ce for us now. Will you p lease p ro c e e d im m e d ia te ly to that a r e a . (The m eeting r e cessed at 12:00 o 'clo ck .) ************ 129 Thursday Afternoon Session M arch 4, 1965 The fourth g e n e r a l s e s s io n convened at 1:30 o'clock with D r Olson presiding. CHAIRMAN OLSON: G entlem en, we will begin our afternoon se ssio n . We have two p a n e ls , one on V ision and the o ther on P u lm o n a ry D ise a se s. D r. Clayton will conduct the panel sym posium on vision. P A N E L SYMPOSIUM - VISION M OD ERA TOR M. B. CLAYTON: The protocol which I s h a ll p re s e n tly W . is entitled "V isual Standards - Applicants and E m p lo y ees." I have no intent to dictate s ta n d a rd s to this group. I sh a ll sim ply tell you what we use on our railro ad . I s h a ll give a so m ew h at p a n o ra m ic view cf the v is u a l p ro b le m as it p e rta in s to ap plicants and em ployees and which concerns the m ed ical d e p a rtm e n ts of all r a ilro a d s and then turn to the panel for a com bined d i s c u s s i o n ox t h e q u e s t i o n s a s k e d in the p r o g r a m . Such things as accom m odation, fusion, visual space sense, field of v isio n , s te re o p s is , m u scle balance, and other techr.i cal su b jects, of which th e re a r e m any, have not been elaborated upon. T im e v.ouid not p e rm it. You may be assu re d , how ever, that those standards have not b e e n a r r i v e d at w ithout due c o n s id e ra tio n being given to both the te c h n ic a l and the practical. What we wish to know o r establish is w hether o r not the applicant o r the em p lo y ee ca n se e w ell enough to do his work safely, efficiently, and <- ` i s f a c t o r i l y a n d w h e t h e r h e w ill o r w ill not be a h a z a r d a n d a l i a b i l i t y o what the future holds for him . T his inform ation can be obtained ef ficien tly and in a r e a s o n a b ly s h o r t tim e by o b se rv in g the follow ing p r o cedures: 1. F i r s t a h i s t o r y i s ta k e n . 2. T h e v is io n , m o n o c u la r and bin o cu lar, and c o lo r v ision a r e evaluated. U sually the Snellen test type is used to d eterm ine visual acuity and the Dvorin pseudo isochrom atic plates for color vision. 3. W hat kind of c h a rt to use ? I like the p r o je c t- o -c h a r t but any reco g n ized c h a r t is s a tis fa c to ry if the exam iner knows what he is doing and does the exam in atio n h im self. To know how to o b se rv e and in te rp re t the actions and rea ctio n s of the exam inee is just as im portant as the selection of the equipm ent with which to do the exam ination. It is not enough, for exam ple, to cover one eye and sa y , " R e a d .' It is n e c e s sa ry to know w h a t i s t a k i n g p l a c e b e h in d the c o v e r e d e y e . Is he s q u in t in g I>tr he continually move his head to different angles o r com m ent.about tne 130 light not being adequate, etc. In b r ie f , if the exam inee h a s difficulty in reading 2 0 / 2 0 o r within the 2 0 / 2 0 ran g e then it is up to the exam iner to d e t e r m i n e why and w h e t h e r th e c a u s e i s s u f f i c i e n t to. a d v i s e a g a i n s t h i s being em ployed o r .not. 4. An in spection is m ad e of the eye and its appendages and if in doubt the binocular loupe and the slit lam p are valuable additional aids. 5. T h e o c u l a r fundi a r e s t u d i e d . 6. Muscle balance is evaluated. 7. When indicated ten sio n should be taken by ten o n o m eter and without exception it is always well to palpate the eye with the fingers. 8. Visual F ields--T he exam ining ophthalmologist should decide w hether p e rim e tric studies should be done or not. Near vision. The object of the test for n ear vision is to determ ine w hether o r not .the individual can c a ll into use th re e d io p te rs of a c c o m m o d a tion and the Jaeger test card is com monly employed for this purpose. The Jaeger card is prep ared with six s e rie s of words. The first se rie s should be read by the no rm al eye at a distance not g rea ter than thirty-seven cen ii- jmeters; the second at fifty ce n tim ete rs; the third at sixty-two centim eters, etc. The card is held before the exam inee at a distance of thirty-three cen tim eters and he is d irec ted to re a d the first se rie s. If he does so, his near vision is recorded as J - l- 1 3 , " indicating that he reads Jaeger No. 1 at t h i r t e e n in c h e s o r t h i r t y - t h r e e c e n t i m e t e r s . If n u m b e r two is the sm a lle st that he can re a d ea sily , his n ea r vision is reco rd ed at J-2 -1 3 , ' indicating that he reads Jaeger No. 2 at th irty-three centim eters, or thirteen inches. The sm allest type that he can read at thirty-three cen ti m eters is die basis of his n ear vision. The norm al eye should read J - l -13. If this cannot be done it.indicates that his near vision is defective, and if distant vision is norm al, he is presbyopic. * When to quality o r disqualify is not always easy --sc ie n tifica lly , y es, p ra c tic a lly , no. U sually th e re should be no hesitancy to disqualify in the event of m uscle im balance or when glaucoma is present or following cataract extraction and when som e d isease is present such as ch o rio re tinitis and particularly when the m acula is involved, retinitis pigm entosa, and also when irre v ersib le co rn e al changes are present such as nebula, m a c u la , ieucom a, co n ica l c o r n e a , o r dystrophy, and this applies to both applicants and employees. The one-eyed employee always poses a problem and preferably should be h a n d l e d o n a n in d i v i d u a l b a s i s a n d w ithout c o n t r o v e r s y . Why d o e s it becom e n ec e ssa ry to disqualify the one-eye em ployee in certain categ o ries ? The answer is that the ability to j udge distance is many tim es m ore a c curate with binocular single vision than with m onocular vision. "in monocular visio n , there are elim inated the binocular p a r a lla x , convergence, and physiological diplopia. Therefore judgment m ust de pend upon the siz e of the r e tin a l im age alone. Thursday Afternoon Session M arch 4, 1965 The fourth g e n e ra l s e s s io n convened at 1:30 o'clock with D r Olson presiding. CHAIRMAN OLSON: G entlem en, we will begin our afternoon se ssio n . We h a v e two p a n e l s , o n e on V is i o n a n d the o t h e r on P u l m o n a r y D i s e a s e s . D r. Clayton will conduct the panel sym posium on vision. P A N E L SYMPOSIUM - VISION M OD ERA TOR M. B. CLAYTON: The protocol which I s h a ll p re s e n tly W . is entitled "V isual Standards - Applicants and E m p lo y ees." I have no intent to dictate s ta n d a rd s to this group. I sh a ll sim ply tell you what we use on our railro ad . I s h a ll give a so m ew h at p a n o ra m ic view cf the v is u a l p ro b le m as it p e rta in s to ap plicants and em ployees and which concerns the m ed ical d e p a rtm e n ts of all r a ilro a d s and then turn to the panel for a com bined discussion of the questions asked in the program . Such things as accom m odation, fusion, visual space sense, field of v isio n , s te re o p s is , m u scle balance, and other techr.i cal su b jects, of which th ere a re m any, have not been elaborated upon. T im e would not p e rm it. You may be assu re d , how ever, that those standards have not b e e n a r r i v e d at w ithout due c o n s id e ra tio n being given to both the te c h n ic a l and the practical. What we wish to know o r establish is w hether o r not the applicant o r the em p lo y ee ca n se e w ell enough to do his work safely, efficiently, and <- ` i s f a c t o r i l y a n d w h e t h e r h e w ill o r w ill not be a h a z a r d a n d a l i a b i l i t y o what the future holds for him . T his inform ation can be obtained ef ficien tly and in a r e a s o n a b ly s h o r t tim e by o b se rv in g the follow ing p r o cedures: 1. F i r s t a h i s t o r y i s ta k e n . 2. T h e v is io n , m o n o c u la r and bin o cu lar, and c o lo r v ision a r e evaluated. U sually the Snellen test type is used to d eterm ine visual acuity and the Dvorin pseudo isochrom atic plates for color vision. 3. W hat kind of c h a rt to use ? I like the p r o je c t- o -c h a r t but any reco g n ized c h a r t is s a tis fa c to ry if the exam iner knows what he is doing and does the exam in atio n h im self. To know how to o b se rv e and in te rp re t the actions and rea ctio n s of the exam inee is just as im portant as the selection of the equipm ent with which to do the exam ination. It is not enough, for exam ple, to cover one eye and sa y , " R e a d .' It is n e c e s sa ry to know w h a t i s t a k i n g p l a c e b e h in d the c o v e r e d e y e . Is he s q u in t in g I>tr he continually move his head to different angles o r com m ent.about tne 130 light not being adequate, etc. In b r ie f , if the exam inee h a s difficulty in reading 2 0 / 2 0 o r within the 2 0 / 2 0 ran g e then it is up to the exam iner to d e t e r m i n e why and w h e t h e r th e c a u s e i s s u f f i c i e n t to. a d v i s e a g a i n s t h i s being em ployed o r .not. 4. An in spection is m ad e of the eye and its appendages and if in doubt the binocular loupe and the slit lamp are valuable additional aids. 5. T h e o c u l a r fundi a r e s t u d i e d . 6. Muscle balance is evaluated. 7. When indicated ten sio n should be taken by ten o n o m eter and without exception it is always well to p alpate the eye with the fingers. 8. Visual F ields--T he exam ining ophthalmologist should decide w hether p e rim e tric studies should be done or not. N ear vision. The object of the te st for n e a r vision is to d eterm in e w hether o r not .the individual can c a ll into use th re e d io p te rs of a c c o m m o d a tion and the Jaeger test card is com monly employed for this purpose. The Jaeger card is prep ared with six s e rie s of words. The first se rie s should be re a d by the n o rm a l eye at a distance not g re a te r than thirty-seven c e n t im e te r s ; the second at fifty ce n tim ete rs; the third at sixty-two centim eters, etc. The card is held before the exam inee at a distance of thirty-three c e n tim e te rs and he is d ire c te d to re a d the firs t s e rie s . If he does so, his near vision is recorded as J - l- 1 3 , " indicating that he reads Jaeger No. 1 at t h i r t e e n in c h e s o r t h i r t y - t h r e e c e n t i m e t e r s . If n u m b e r two is the sm a lle st that he can re a d ea sily , his n ea r vision is reco rd ed at J-2 -1 3 , ' indicating that he reads Jaeger No. 2 at th irty-three centim eters, or thirteen inches. The sm allest type that he can read at thirty-three cen ti m eters is die basis of his n ear vision. The norm al eye should read J - l -13. If this cannot be done it.indicates that his near vision is defective, and if distant vision is norm al, he is presbyopic. * When to quality o r disqualify is not always easy --sc ie n tifica lly , y es, p ra c tic a lly , no. U sually th e re should be no hesitancy to disqualify in the event of m uscle im balance or when glaucoma is present or following cataract extraction and when som e d isease is present such as ch o rio re tinitis and particularly when the m acula is involved, retinitis pigm entosa, and also when irre v ersib le co rn e al changes are present such as nebula, m a c u la , ieucom a, conical c o rn e a , o r dystrophy, and this applies to both applicants and employees. The one-eyed employee always poses a problem and preferably should be h a n d l e d o n a n i n d i v i d u a l b a s i s a n d w ithout c o n t r o v e r s y . Why d o e s it becom e n ec e ssa ry to disqualify the one-eye employee in certain categ o ries ? The answer is that the ability to j udge distance is many tim es m ore a c curate with binocular single vision than with m onocular vision. "in monocular v isio n , there are elim inated the binocular p a r a lla x , convergence, and p h ysiological diplopia. Therefore judgment m ust de pend upon the siz e of the r e tin a l im age alone. " S i n c e j u d g m e n t of d i s t a n c e is m a n y time-. W ..s a c c u r a t e c i s io n d e p e n d s upon the s i z e of the r e t i n a l i m a g e .i ' o i c i: i m p o r t a n t f a c t o r s to be c o n s i d e r e d are physiological diplopia, lar parallax and convergence. " . . .... ..... 1.; ra ....... It is id e a l to have a stan d ard of 2 0 / 2 0 vision for all applicants, but w hether it is p ra c tic a l o r not is questionable. Applicants for clerical o r r e l a t e d p o s itio n s , and -o fficers o r p o te n tia l o ffic e rs a r e not to be d i s qualified if the vision can be c o rre c te d to 2 0 / 2 0 with g la s s e s and the v is u a l change is not o rg a n ic in origin with this exception that applicants whose vision is 20 /400 o r less should be disqualified reg ard less of their assign m e n ts , and r e f e r r e d to the Chief Surgeon for final decision. . It would be w ell to have a standard of 20/20 vision in each eye for a p p lic a n ts in engine and tra in se rv ic e and those doing p rec isio n work with js. u n d e r s t a n d i n g th a t sh o u ld the v isio n be l e s s th a n 2 0 / 2 0 th a t the e x a m in e r "State th e r e a s o n th e re fo r and re fe r the c a se to the Chief Surgeon for opinion. It m ay be that m ost applicants even though th e ir vision could be c o r r e c te d to 2 0 / 2 0 o r b e tte r with g la sse s and if it be re fra c tiv e in origin. T he fin al decisio n should be left to the Chief Surgeon. S e rio u s c o n sid eratio n should be given to the disqualification of e m p lo y e es in engine and tra in se rv ic e and those doing p rec isio n work whose vision in each eye is 20/40 and has resulted from lenticular changes or o th e r conditions than a refractive e r r o r and without exception they should be d isq u a lifie d if the b est binocular vision is 20 /40. E n g in e e r s and sw itchm en with m onocular vision should be disqualified without exception. O ther employees should be handled on an individual b a s is and r e f e r r e d to the chief surgeon o r chief m e d ic a l o ffic er fo r o p in ion as to qualification. ` E n g i n e e r s and sw itc h m e n who have h ad c a t a r a c t s u r g e r y should be disqualified. O th ers should be handled on an individual basis. E m p lo y e e s except office p ersonnel should not be p erm itted to wear co n tac t le n s e s u n le ss approved by the chief su rg eo n o r chief m ed ical o f ficer. The reaso n therefor has been given in a sep arate communication which is available upon request. V T he p o s t-o p e ra tiv e ca ta ra c t case has been elab o rate d upon in a se p a ra te com m unication, which is also available upon request and which. I have given you.1 1 w ish to r a i s e the question why h a s n 't th e e a r been included in this d is c u s s io n ? It is ju st a s im portant that a c c u ra te exam ination and ev alu a tion of the e a r be m ade as the eye for both applicants and em ployees. Now, gentlem en, I shall turn to my distinguished panel. I now w ish to introduce the m e m b e rs who co m p o se the panel syxnp o siu m on v isio n . All of them are distinguished in th e ir ow tvright and t h e i r c o o p e r a t i o n in c o n t r i b u t i n g to th e h a n d l in g of the s y m p o s i u m 1 prcciat'ed: S ta n le y J . C y r a n , M. D. , M e d ic a l D i r e c t o r , P e n n s y l v a n i a R:.i Iro a d , Philadelphia, Pennsylvania. H. W. H a m m a t t , M. D. , C hief M e d ic a l O f f i c e r , C h ic a g o , D a r lin g t o n & Quincy R ailroad, Chicago, Illinois. V. W. H o llo , M. D. , C h i e f S u rg e o n , St. L o u i s - S a n F r a n c i s c o R a ilw a y , St. L ouis, M is s o u r i. W. E . M i s h l e r , M. D. , C h ie f S u rg e o n , E r i e - L a c k a w a n n a R a i l r o a d , Cleveland, Ohio. P e t e r V au g h a n , M. D. , A s s i s t a n t C h ie f M e d ic a l O ff ic e r , C a n a d i a n National Railways, M ontreal, Quebec, Canada. F. F . W i p p e r m a n , M. D. , C h ief of O p h th a lm o lo g y , Soo Line R a i l road, Minneapolis, Minnesota. May I introduce Dr. Stanley J. Cyran, Medical D irector, Pennsyl vania R ailroad, who will discuss aphakia and the use of contact lenses. ' DR. STANLEY J. CYRAN: With an authority like Dr. Clayton h e r e , it if- s o r t of p r e s u m p t u o u s on m y p a r t to t r y to d i s c u s s th i s . I to ld 1 t . C layton we had n ee d for a m o r e u n ifo rm a p p r o a c h on o u r r a il r o a d to the p roblem of aphakia, both unilateral and bilateral. Because of this, I c o n s u lte d o u r o p h th a lm o lo g is t and t r ie d to evolve a p o licy which we a r e expecting to p r e s e n t to o u r m an ag e m en t fo r t h e i r a p p ro v a l and .hope, if this is finally approved, this will become a system policy. (D r. C y ra n a s k e d th at h is co m m e n ts be d eleted and a ,copy of his m o re lib eral contact lens policy be substituted, since this is now in effect on the P . R. R . ) MEDICAL POLICY GOVERNING T H E RETURN OF. TRAIN AND ENGINE SERVICE EMPLOYEES TO DUTY FOLLOWING CATARACT SURGERY APHAKIA U nilateral C orrection with Ordinary Lens: Enginemen - Not qualified. F irem en - Yard duty only. Trainmen - Not qualified. "Since judgm ent of distance is m any tim es h accurate cisio n d e p e n d s upon the s iz e of the r e t i n a l i m a g e .l ' o i e i: im p o r ta n t f a c to r s to be co n s id e re d a r e p h y sio lo g ica l diplopia, lar paraliux and convergence. " . . .... ..... 1.; ra ....... It is id e a l to have a stan d ard of 2 0 / 2 0 vision for all applicants, but w hether it is p ra c tic a l o r not is questionable. Applicants for clerical o r r e l a t e d p o s itio n s , and -o fficers o r p o te n tia l o ffic e rs a r e not to be d i s qualified if the vision can be c o rre c te d to 2 0 / 2 0 with g la sse s and the visual change is not o rg a n ic in origin with this exception that applicants whose vision is 20 /400 o r less should be disqualified reg ard less of their assign m e n ts , and r e f e r r e d to the Chief Surgeon for final decision. , It would be w ell to have a standard of 20/20 vision in each eye for a p p lic a n ts in engine and tra in se rv ic e and those doing p rec isio n work with u n d erstan d in g that should the vision be less than 2 0 /2 0 that the exam iner "S t a t e t h e r e a s o n t h e r e f o r an d r e f e r th e c a s e to t h e C h i e f S u rg e o n fo r opinion. It m ay be that m ost applicants even though th e ir vision could be c o r r e c te d to 2 0 / 2 0 o r b e tte r with g la sse s and if it be re fra c tiv e in origin. T he fin al decisio n should be left to the Chief Surgeon. S e rio u s c o n sid eratio n should be given to the disqualification of e m p lo y e es in engine and tra in se rv ic e and those doing p rec isio n work whose vision in each eye is 20/40 and has resulted from lenticular changes or o th e r conditions than a refractive e r r o r and without exception they should be d isq u a lifie d if the b est binocular vision is 20 /40. E n g i n e e r s a n d s w i t c h m e n wdth m o n o c u l a r v i s i o n s h o u ld be d is q u a lif ie d without exception. O ther employees should be handled on an individual b a s is and r e f e r r e d to the chief surgeon o r chief m e d ic a l o ffic er fo r o p in ion as to qualification. ` E n g i n e e r s and sw itc h m e n who have h ad c a t a r a c t s u r g e r y should be disqualified. O th ers should be handled on an individual basis. E m p lo y e e s except office p ersonnel should not be p erm itted to wear co n tac t le n s e s u n le ss approved by the chief su rg eo n o r chief m ed ical o f ficer. The reaso n therefor has been given in a sep arate communication which is available upon request. V T he p o s t-o p e ra tiv e ca ta ra c t case has been elab o rate d upon in a se p a ra te com m unication, which is also available upon request and which. I have given you.1 1 w ish to r a i s e the question why h a s n 't th e e a r been included in this d is c u s s io n ? It is ju st a s im portant that a c c u ra te exam ination and ev alu a tion of the e a r be m ade as the eye for both applicants and em ployees. Now, gentlem en, I shall turn to my distinguished panel. I now w ish to introduce the m e m b e rs who co m p o se the panel s y m posium. o n v isio n . All of them are distinguished in th e ir o w n - rich! and t h e i r c o o p e r a t i o n in c o n t r i b u t i n g to the h a n d l in g of the s y m p o s i u m 1 prcciat'ed: S ta n le y J . C y r a n , M. D. , M e d ic a l D i r e c t o r , P e n n s y l v a n i a R:.i Iro a d , Philadelphia, Pennsylvania. H. W. H a m m a t t , M. D. , C hief M e d ic a l O f f i c e r , C h ic a g o , D a r lin g t o n & Quincy R ailroad, Chicago, Illinois. V. W. H o llo , M. D. , C h i e f S u rg e o n , St. L o u i s - S a n F r a n c i s c o R a ilw a y , St. L o u is, M i s s o u r i . W. E . M i s h l e r , M. D. , C h ie f S u rg e o n , E r i e - L a c k a w a n n a R a i l r o a d , Cleveland, Ohio. P e t e r V au g h a n , M. D. , A s s i s t a n t C h ie f M e d ic a l O ff ic e r , C a n a d i a n National Railways, M ontreal, Quebec, Canada. F. F . W i p p e r m a n , M. D. , C h ief of O p h th a lm o lo g y , Soo L i n e R a i l road, Minneapolis, Minnesota. May I introduce Dr. Stanley J. Cyran, Medical D irector, Pennsyl vania R ailroad, who will discuss aphakia and the use of contact lenses. " DR. STANLEY J. CYRAN: With an authority like Dr. Clayton h e r e , it m s o rt of p resu m p tu o u s on my part to try to d iscu ss this. I told 1 r. C layton we had n ee d for a m o r e u n ifo rm a p p r o a c h on o u r r a il r o a d to the p roblem of aphakia, both unilateral and bilateral. Because of this, I consulted o u r o p h th alm o lo g ist and trie d to evolve a policy which w e a r e expecting to p r e s e n t to o u r m an ag e m en t fo r t h e i r a p p ro v a l and .hope, if this is finally approved, this will become a system policy. (D r. C y ra n a s k e d th at h is co m m e n ts be d eleted and a ,copy of his m o re lib e ra l contact lens policy be substituted, sin ce this is now in effect, on the P , R. R . ) MEDICAL POLICY GOVERNING T H E RETURN OF. TRAIN AND ENGINE SERVICE EMPLOYEES TO DUTY FOLLOWING CATARACT SURGERY APHAKIA U nilateral C orrection with O rdinary Lens: Enginemen - Not qualified. F irem en - Y ard duty only. T rainm en - Not qualified. C orrection with Contact Le ns: E n g in e m e n - Y ard. (L o cal and ro ad f r e i g h t . . . p e r m i s s a b l e if fire m a n in c re w .) F irem en - Qualified, all positions. T rainm en - Qualified, all positions. B ilateral. C o rrec tio n with O rdinary Lens: Enginem en - Not qualified. F irem en - Not qualified. T rain m en - Not qualified. ^ Spec ial consideration may be given if aspheric lenses a re p r e s c rib e d , but no p a sse n g e r se rv ic e for en g in em e n -firem en . C o rrec tio n with Contact Lens: E n g in e m e n - Y ard. (L o c a l and ro ad freig h t. . . p e r m i s s a b l e if fire m a n in cre w .) F ire m e n - Yard, local, and road freight. T rain m en - Qualified, all positions. QUALIFICATIONS 1. E n g in e r n e n - F ir e m e n , who w ear c o n tac t le n s e s , not p e rm itte d in sa m e crew . 2. T h o se with b ila te ra l co rn e al contact lenses m u st have a second p a ir of con tact len ses with them at all tim es. Second p a ir m u st have been w o rn and te ste d for w earing tim e equivalent to re g u la r to u r of duty. Enginem en-T rainm en-Firem en must wear approved protective goggles on duty if corneal contact lens being worn. 4. Initial m edical evaluation m ust be perfo rm ed at a full-tim e PRR m edical'office. 5. M u st hav e s ta te m e n t fro m atten d in g o p h th a lm o lo g ist that: (a) Able to to le ra te lens 8-10 hours. (b) H as had at le a st one m onth t r ia l w earing contact len s. (c) Is able to resum e regular duties of his position. .6. V isual acuity m ust meet G-45 requirem ents. MEDICAL POLICY GOVERNING THE RETURN OF EMPLOYEES OTHER THAN TRAIN AND ENGINE SERVICE TO DUTY F OLLOWING CATARACT SURGERY . Each ca se will have to be individualized in relation to the work to be p e rfo rm e d becau se of the n u m erous cra fts and work variations v.thin the c ra fts . T he im p o rta n t fa c to rs that m u st be considered in the individual case are as follows: 1. Can the employee function as a one-eyed employee. 2. Are there h azards associated with the job which might cause splashing of chem icals and resultant trapping beneath the contact lens. T h is is a c o n tra in d ic a tio n to the w earin g of co n tact le n s e s in in d u stry . 3. If w earin g o rd in a r y aphakic o r even the new a s p h e ric le n s e s , following b ilateral cataract su rg ery , will the in creased image perspective ham per his work perform ance. 4. Are the attendant h azard s of the job such that a sudden im p a ir m ent of v isu a l acuity (loss of contact lens, foreign object with b le p h aro spasm , e t c .) would com prom ise the safety of the em ployee (working at heights, on scaffolds, bridge inspectors, etc.). 5. C ra n e and d e r r ic k e n g in e e rs , m achine o p e r a to r s , re s p o n s ib le 6 for the safety of o th ers, canrtot be qualified. M O D E R A T O R C L A Y T O N : I now in t r o d u c e D r . H. \V. H a m m a t t , C h ie f M ed ical O fficer of the C hicago, B u rlin g to n and Q uincy R a ilro a d , who w ill d isc u ss the questions of relaxing visual req u irem en ts in em ploym ent exam inations, general visual acuity standards and color perception. DR. H. W. H A M M A TT: R a i l r o a d s h a v e c l a s s i f i e d a l l e m p l o y e e s in Class A, B or C categories. The C lass A, of co u rse , includes the enginem en, firem en , m o to r men, conductors, sw itchm en and brakem en. The C lass B and C will p e rm it possibly 20/20 in one eye and 20/40 in the o ther eye for entry to serv ice. I noted an en try re q u ire m e n t dated 1919 that a C lass C em ployee m ust have 20/30 in one eye and 20/50 in the other eye for entrance to serv ice. I do n o t know why t h e s e p a r t i c u l a r f i g u r e s w e re p ic k e d . We do know that defective vision may be due to retin al disease, re tin a l hem orrhages, congenital defects and development, glaucoma, and possibly circulatory disturbances. Most of the visual defects, of course, are basically on a myopic b a s is and they m ay be p ro g re ssiv e up to age 2 5 o r 30, depending on the individual's inherited tendencies.I I feel that an individual in a C lass A serv ice which is considered to be the m o st e s se n tia l p a r t of the r a ilro a d industry as a firem an o r a tr a in m a n , s h o u l d s t a r t o u t with a n o r m a l v i s i o n o f 2 0 /2 0 w ith o u t g l a s s e s . It is know n th a t th e A ir Corps w ill not p e r m i t any p ilo ts fo r tr a in im ' ; ih C orrection with Contact Le ns: E n g in e m e n - Y ard. (L o cal and ro ad f r e i g h t . . . p e r m i s s a b l e if fire m a n in c re w .) F irem en - Qualified, all positions. T rainm en - Qualified, all positions. B ilateral. C o rrec tio n with O rdinary Lens: Enginem en - Not qualified. F irem en - Not qualified. T rain m en - Not qualified. ^ Spec ial consideration may be given if aspheric lenses a re p r e s c rib e d , but no p a sse n g e r se rv ic e for en g in em e n -firem en . C o rrec tio n with Contact Lens: E n g in e m e n - Y ard. (L o c a l and ro ad freig h t. . . p e r m i s s a b l e if fire m a n in cre w .) F ire m e n - Yard, local, and road freight. T rain m en - Qualified, all positions. QUALIFICATIONS 1. E n g in e r n e n - F ir e m e n , who w ear c o n tac t le n s e s , not p e rm itte d in sa m e crew . 2. T h o se with b ila te ra l co rn e al contact lenses m u st have a second p a ir of con tact len ses with them at all tim es. Second p a ir m u st have been w o rn and te ste d for w earing tim e equivalent to re g u la r to u r of duty. Enginem en-T rainm en-Firem en must wear approved protective goggles on duty if corneal contact lens being worn. 4. Initial m edical evaluation m ust be perfo rm ed at a full-tim e PRR m edical'office. 5. M u st hav e s ta te m e n t fro m atten d in g o p h th a lm o lo g ist that: (a) Able to to le ra te lens 8-10 hours. (b) K as had at le a st one m onth t r ia l w earing contact len s. (c) Is able to resum e regular duties of his position. .6. V isual acuity m ust meet G-45 requirem ents. MEDICAL POLICY GOVERNING THE RETURN OF EMPLOYEES OTHER THAN TRAIN AND ENGINE SERVICE TO DUTY F OLLOWING CATARACT SURGERY . Each ca se will have to be individualized in relation to the work to be p e rfo rm e d becau se of the n u m erous cra fts and w ork variations v.thin the c ra fts . T he im p o rta n t fa c to rs that m u st be considered in the individual case are as follows: 1. Can the employee function as a one-eyed employee. 2. Are there h azards associated with the job which might cause splashing of chem icals and resultant trapping beneath the contact lens. T h is is a c o n tra in d ic a tio n to the w earin g of co n tact le n s e s in in d u stry . 3. If w earin g o rd in a r y aphakic o r even the new a s p h e ric le n s e s , following b ilateral cataract su rg ery , will the increased image perspective ham per his work perform ance. 4. Are the attendant h azard s of the job such that a sudden im p a ir m ent of v isu a l acuity (loss of contact lens, foreign object with b le p h aro spasm , e t c .) would com prom ise the safety of the em ployee (working at heights, on scaffolds, bridge inspectors, etc.). 5. C ra n e and d e r r ic k e n g in e e rs , m achine o p e r a to r s , re s p o n s ib le t f o r the safety of o th ers, canrtot be qualified. M O D E R A T O R C L A Y T O N : I now in t r o d u c e D r . H. \V. H a m m a t t , C h ie f M ed ical O fficer of the C hicago, B urlin g to n and Q uincy R a ilro a d , who w ill d isc u ss the questions of relaxing visual req u irem en ts in em ploym ent exam inations, general visual acuity standards and color perception. DR. H. W. H A M M A TT: R a i l r o a d s h a v e c l a s s i f i e d a l l e m p l o y e e s in Class A, B or C categories. The C lass A, of co u rse , includes the enginem en, fire m e n , m o to r men, conductors, sw itchm en and brakem en. The C lass B and C will p e rm it possibly 20/20 in one eye and 20/40 in the o ther eye for entry to serv ice. I noted an en try re q u ire m e n t dated 1919 that a C lass C em ployee m ust have 20/30 in one eye and 20/50 in the other eye for en tran ce to se rv ic e . I do n o t know why t h e s e p a r t i c u l a r f i g u r e s w e re p ic k e d . We do know that defective vision may be due to retin al disease, re tin a l hem orrhages, congenital defects and development, glaucoma, and possibly circulatory disturbances. Most of the visual defects, of course, are basically on a myopic b a s is and they m ay be p ro g re ssiv e up to age 2 5 o r 30, depending on the individual's inherited tendencies.I I feel that an individual in a C lass A serv ice which is considered to be the m o st e s s e n tia l p a r t of the r a ilr o a d industry as a fire m a n o r a tr a i n m a n , s h o u l d s t a r t o u t with a n o r m a l v i s i o n o f 2 0 /2 0 w ith o u t g l a s s e s . It is know n th a t th e A ir Corps w ill not p e r m i t any p ilo ts fo r tr a in im ' ; ih v i s i o n of l e s s th a n 20 /20 when they s t a r t out. T h e FAA a l s o will r.,,: p e rm it any C lass 1 pilots to function at their prelim inary starling pnr.t with vision of less than 20/20 in each eye without g la sse s . The eyes h..vc a te n d e n c y , a s we a g e , to h a v e a t t r i t i o n p r o c e s s e s develop in thorn, and they have a tendency, le t's sa y , in a few s h o rt y e a r s to show defects re q u irin g c o rre c tio n with len ses. So, th e re fo re , in so far as possible, the em ployee that is exam ined for the train se rv ic e , I feel, should sta rt out w ith n o r m a l v is i o n so t h a t v/e w ould h a v e l e s s d if f i c u lt y in th e l a t e r y e a r s of having defective vision. The o ther class of em ployees, B and C, which include the re st of the r a ilro a d em ployees, have been listed as 20/30 in one eye and 20/40 in th e o t h e r ey e f o r e n t r y to s e r v i c e . We p r o b a b ly do not have quite enough b a sis to lim it th em at that level. I p erso n a lly feel that an in dividual with a vision of tw enty-one hundreths, in eith er eye, which is possibly a negative 2 diopter lens, will not give us any m ore difficulty ln any so o n e r n u m b e r of y e a r s than an individual with 20/30 o r 20/40 in eves. I th in k in c e r ta in c a te g o r ie s su c h a s c l e r i c a l office w ork, that we could possibly even go as high as tw enty-tw o hundreths for entry o r twentyf o u r h u n d r e t h s if th e y h a v e not g ot a h a z a r d o u s o c c u p a tio n . When we go up to twenty-two hundreths, probably around a negative 4 diopter lens, and if that vision becom es stationary, it should not deteriorate any fu r th e r. If such an eye does not deteriorate any further, the employee can m a in ta in that vision and do sa tisfac to ry work. I feel, how ever, that an em ployee that is, say , out in the y ard s doing o u ts id e laboring w ork with a negative 4 diopter lens may be m ore of a h a z a r d than one with a negative 2 lens. So, I usually recom m end that o u t sid e em ployees o r those in the laboring, m echanical o r electrical dep art m e n ts , th at tw enty-one hundreths be co n sid ered as the lim it of approval for these categories. I m ight m ention a few things on color defects. C olor defects, of r--u rse, a re h ered itary basically. V ery, very few of them are acquired. L ^ y h a v e a couple of sa tisfa c to ry te sts which we should use. The yarn te s t has now been discarded. I feel the Ishihara and Pseudo-Isochrom atic c o lo r c h a r ts a r e sa tisfa c to ry and a r e co n sid ered to be the only ones a c ce p ta b le b asically to the A ir C o rp s, and to the C iv il F e d e ra l Aviation A ssociation. They have been recently recom m ended as the m ost accept able for the railro a d s. Individuals, of course, who cannot pass the Ish ih ara o r Pseudo-Isochrom atic plates may possibly be given a Williams L an tern te s t, which is consid ered the final te st to determ ine whether they have a com plete color blindness. I fe e l that C la ss A em p lo y ees in the r a ilr o a d in d u stry should be able to p ass the P seudo-Isochrom atic exam ination, o r the Ishihara color plate fo r qualification in that category. T h e re m ay be found a few individuals in C la ss A se rv ic e who were originally exam ined by the yarn te sts y e a rs ago who may be partially 136 color defective. In o th e r w ords, they could rea d the yarns at that tim e, but they cannot at this date rea d the color book, so th erefo re, they are only p artia lly red green colorblind. I feel those individuals, when they are d isco v ered in the se rv ic e , should be prev en ted from operating on the m ain line of the r a ilro a d and should be p laced in y a rd service on a restrictive basis. T h ere a re n 't very m any, however, of that type of individual, so that the actu al re s u lts will show that any em ployee who is a little bit c o lo r blind should not be put in a position in which he is r e q u ir e d to issu e o r ders o r in the operation of moving tra in s. If a perso n has been approved for s e r v ic e who is c o lo r defe ctiv e , he should not be t r a n s f e r r e d o r p r o m oted to su c h a position which r e q u i r e s the u s e of n o r m a l color p e r c e p tion. MODERATOR CLAYTON: Thank you. I would now like to introduce Dr. V e n c e l W. H o llo, C h i e f S u rg e o n of th e St. L o u i s - S a n F r a n c i s c o R a ilw a y , who w ill d is c u s s a d m in istra tio n of a v isio n p r o g r a m a s it applies to his railroad and other railroads. D R. V. W. H Q LLO : T h a n k y ou. D r . C l a y to n . A c tu a lly , D r. C layton has pretty well sum m arized the visual standards and also the method of exam ining and pre-em ploym ent standards of new em ployees. The only thing that I might com m ent on is that we have a perio d ic examination of people in se rv ic e , and in C lass'A - and these periodic exam inations are c a r rie d out biennially in people less than age 65. After the age of 65, they are ca rrie d out annually. The vision is exam ined and checked at these times. Of co u rse , the standards for people in se rv ic e a r e not the sam e as those for pre-em ploym ent standards. The m inim um standard for C lass A em ployees is 20/30 in one eye and 20/40 in the o th e r eye. However, I m ean, with g la sses, and of course, th e re a re also b o rd erlin e cases. We m ay detect early lens changes of senile c a ta ra c ts . t Many tim es these are incipient, and may s till be c o rre c te d to the acceptable stan d ard s. However, these people are then put under a m ore rigid periodic exam ination depending on the recom m endation of the o cu list, which may vary anyw here from 6 months to a y e a r, and even so m e tim es less. Once the standard or the vision is below 20/40 b in o cu lar vision, then, of course, co n sid eration should be given to c o rre c tio n with su rg e ry . The u n ilateral aphakic eye, or one eye having been operated, does p erm it binocular vision. T h e r e a r e c e r ta in o c u lis ts who will sta te th a t, with a contact lens on an eye that has been operated on, an individual may have binocu lar vision. How ever, we have not accepted this a s being acceptable to re tu rn people back into s e r v ic e , and we do not p e r m it contact le n ses in C lass I o r II e m p lo y e e s . T h e only o th e r c o m m e n t I m ig h t m a k e is that when defects a r e found, the em ployee is r e f e r r e d to one of our oculists to d e te rm in e the u n d erly in g c a u s e fo r p r o g r e s s iv e ch a n g es in vision, and if there a re any other m edical etiologic factors, such as diabetes, hyper tension o r o th e r degenerative d is e a s e s . 137 . v i s i o n of l e s s th a n 20 /20 when they s t a r t out. T h e FAA a l s o will r.,,: p e rm it any C lass 1 pilots to function at their prelim inary starting witii v is io n of l e s s than 2 0 /2 0 in e a c h eye w ithout g l a s s e s . The vy'.'s h..vc a t e n d e n c y , a s we a g e , to h a v e a t t r i t i o n p r o c e s s e s d e v e lo p in t h e m , a:nd they have a tendency, le t's sa y , in a few s h o rt y e a r s to show defects re q u irin g c o rre c tio n with len ses. So, th e re fo re , in so far as possible, the em ployee that is exam ined for the train se rv ic e , I feel, should sta rt out w ith n o r m a l v is i o n so t h a t v/e w ould h a v e l e s s d if f i c u lt y in th e l a t e r y e a r s of having defective vision. The other class of em ployees, B and C, which include the re st of the r a ilro a d em ployees, have been listed as 20/30 in one eye and 20/40 in th e o t h e r ey e f o r e n t r y to s e r v i c e . We p r o b a b ly do not have quite enough b a sis to lim it th em at that level. I p erso n a lly feel that an in dividual with a vision of tw enty-one hundreths, in eith er eye, which is possibly a negative 2 diopter lens, will not give us any m ore difficulty ln any so o n e r n u m b e r of y e a r s than an individual with 20/30 o r 20/40 in eyes. I th in k in c e r ta in c a te g o r ie s su c h a s c l e r i c a l office w ork, that we could possibly even go as high as tw enty-tw o hundreths for entry o r twentyf o u r h u n d r e t h s if th e y h a v e not g ot a h a z a r d o u s o c c u p a tio n . When we go up to twenty-two hundreths, probably around a negative 4 diopter lens, and if that vision becom es stationary, it should not deteriorate any fu r th e r. If such an eye does not deteriorate any further, the employee can m a in ta in that vision and do sa tisfac to ry work. I feel, how ever, that an em ployee that is, say , out in the y ard s doing o u ts id e laboring w ork with a negative 4 diopter lens may be m ore of a h a z a r d than one with a negative 2 lens. So, I usually recom m end that o u t sid e em ployees o r those in the laboring, m echanical o r electrical dep art m e n ts , th at tw enty-one hundreths be co n sid ered as the lim it of approval for these categories. I m ight m ention a few things on color defects. C olor defects, of r - u r s e , are h ereditary basically. Very, very few of them are acquired. L ^ y h a v e a couple of sa tisfa c to ry te sts which we should use. The yarn te s t has now been discarded. I feel the Ishihara and Pseudo-Isochrom atic c o lo r c h a r ts a r e sa tisfa c to ry and a r e co n sid ered to be the only ones a c ce p ta b le b asically to the A ir C o rp s, and to the C iv il F e d e ra l Aviation A ssociation. They have been recently recom m ended as the m ost accept able for the railro a d s. Individuals, of course, who cannot pass the Ish ih ara o r Pseudo-Isochrom atic plates may possibly be given a Williams L an tern te st, which is co n sid ered the final te s t to determ ine whether they have a com plete color blindness. I fe e l that C la ss A em p lo y ees in the r a ilr o a d in d u stry should be able to p ass the P seudo-Isochrom atic exam ination, o r the Ishihara color plate fo r qualification in that category. T h ere m ay be found a few individuals in C la ss A s e r v ic e who were origin ally exam ined by the yarn te s ts y ea rs ago who may be partially 136 color defective. In o th e r w ords, they could rea d the y arns at that tim e, but they cannot at this date rea d the color book, so th erefo re, they are only p artia lly re d green colorblind. I feel those individuals, when they are d isco v ered in the se rv ic e , should be prev en ted from operating on the m ain line of the r a ilr o a d and should be p la c e d in y a rd serv ice on a restrictive basis. T h ere a re n 't very many, however, of that type of individual, so that the actu al re s u lts will show that any em ployee who is a little bit c o lo r blind should not be put in a p osition in which he is r e q u ir e d to issu e o r ders o r in the operation of moving tra in s. If a p erso n has been approved fo r s e r v ic e who is c o lo r defe ctiv e , he should not be t r a n s f e r r e d o r p r o m o ted to su c h a p osition which r e q u i r e s the u s e of n o r m a l color p e r c e p tion. MODERATOR CLAYTON: Thank you. I would now like to introduce D r. V en c el W. H ollo, C h ie f S u rg e o n of th e St. L o u i s - S a n F r a n c i s c o R a ilw a y , who w ill d is c u s s a d m in istra tio n of a v isio n p r o g r a m a s it applies to his railroad and other railroads. D R. V. W. H Q LLO : T h a n k yo u . D r . C l a y to n . A c tu a lly , D r. C layton has pretty well sum m arized the visual standards and also the method of exam ining and pre-em ploym ent standards of new em ployees. The only thing that I might com m ent on is that we have a perio d ic examination of people in se rv ic e , and in C lass'A - and these periodic exam inations are c a r rie d out biennially in people less than age 65. After the age of 65, they are ca rrie d out annually. The vision is exam ined and checked at these times. Of co u rse , the standards for people in se rv ic e a r e not the sam e as those for pre-em ploym ent standards. The m inim um standard for C lass A em ployees is 20/30 in one eye and 20/40 in the o th e r eye. However, I m ean, with g la sse s, and of course, th e re a re also b o rd erlin e cases. We m ay detect early lens changes of senile c a ta ra c ts . t Many tim es these are incipient, and may still be c o rre c te d to the acceptable stan d ard s. However, these people are then put under a m ore rigid periodic exam ination depending on the recom m endation of the o cu list, which may vary anyw here from 6 months to a y e a r, and even so m e tim es less. Once the standard or the vision is below 20/40 b in o cu lar vision, then, of course, con sid eration should be given to c o rre c tio n with su rg e ry . The u n ilateral aphakic eye, or one eye having been operated, does p erm it binocular vision. T h e r e a r e c e r ta in o c u lists who will sta te th a t, with a contact lens on an eye that has been operated on, an individual may have binocu lar vision. How ever, we have not accepted this a s being acceptable to re tu rn people back into s e r v ic e , and we do not p e r m it contact le n ses in C lass I o r II e m p lo y e e s . T h e only o th e r c o m m e n t I m ig h t m a k e is that when defects a r e found, the em ployee is r e f e r r e d to one of our oculists to d e te rm in e the u n d erly in g c a u s e fo r p r o g r e s s iv e ch a n g es in vision, and if there a re any other m edical etiologic factors, such as diabetes, hyper te n s io n o r o t h e r degenerative d i s e a s e s . 137 . M O D E R A T Oli C L A Y T O N : Thank you. D o c t o r . I now introduce Dr. W. E. M i s h l e r , C h ie f S u r g e o n , E r ie -L a c k a w a n n a Railroad-. DR. W. E . MISIILER: On our ra ilro a d , entrance to tr a in s e rv ic e , both e n g in e and o tr .e r w is e , is 20 / 2 0 in both ey es. We do n o t allow m e n in tra in o r engine s e rv ic e to use co ntact le n se s, o r to put it another way, the only p la c e we allow c o n tac t le n s e s is in office e m p lo y ee s. In otherw o rd s, th o se p eople in o th e r than office work a re not allow ed to w ear contact lenseq. I think that we should m ention glaucom a. We have m any c a s e s of glaucom a, and when discovered, they m ust submit periodic rep o rts from t h e i r a tte n d i n g o p h th a lm o lo g i s t a t le a s t e v e ry 90 d a y s . We also have an o th er ru le which is kind of a c a tc h -a ll and that is tlr 'ith e r functional o r organic one-eyed m en a re not allow ed to work ar\rfd moving m achinery or cars. M O D ERA TO R CLAYTON: I would now like to introduce Dr. P e te r Vaughan, Chief M edical O fficer, Canadian National Railways. DR. P E T E R VAUGHAN: We have been under a lot of p r e s s u r e in ou r ra ilw a y la tely , as I am su re all of you have from tim e to tim e, to lib e r a l ize our vision standards. V ision sta n d a rd s for all ra ilro a d s in Canada a re uniform . T hey' a re se t by the ra ilro a d s and they a re enforced by federal legislation. E very few y e a rs these regulations are reviewed and som e changes made. F o r anybody who is in te reste d , I have a copy of ou r vision regulations for the y ear 1912. And also one for our recently revised regulations for 1964. T hey differ very little. The question that a ris e s im m ediately is: Why d o n 't they d iffe r? O perating p ro c e d u re s in ra ilro a d s have changed c o n s i d e r a b l y in t h e l a s t 50 y e a r s , a n d p a r t i c u l a r l y in the l a s t 10 o r 15 yes We don't have any m ore steam engines. The engineman now sits in sS ifo sed cab behine a wind sc re e n with direct forw ard vision. Our sw itc h in g o p e r a tio n s hav e changed. .We have au to m atic hu m p y a r d s . We have train -to -train radio communications, train-to-dispatcher, train- to -sta tio n rad io com m unication, and a whole lot of new o p era tin g p r o c e d ures. The point is that operating procedures have changed considerably making the necessity for vision qualifications less stringent. Because th e re is le ss p o ssib ility of e r r o r on the p a rt of the enginem en o r y a rd man w hoever it happens to be, and so many operations a re becom ing auto m ated why could we not liberalize our vision standards som ew hat ? With this in m ind, we have held a great many conferences throughout >ur r a i l r o a d s y s t e m d u rin g th e p a s t few m onths, with o u r r a i l r o a d m e d ical officers, and with our operating officers, to see if we could a rriv e at a b e tte r idea as to what our m odern operating p ro c e d u re s re q u ire . We h a v e r e c e i v e d a g r e a t v a r i e t y o f v e r y i n t e r e s t i n g a n s w e r s . We were told, for instance, that yard service, far from being so rt of a 133 waste paper basket in which to place disabled em ployees demands a very high d eg ree of perfectio n in vision and c e rtain oth er qualifications. Y ard service now is done at relatively high speed. You have many c r o s s overs, many signals, and it is really a harder job than road service. We w ere told, fo r in s ta n c e , that s te re o p s is was not n e c e s s a r y for an enginem an. A fte r a ll, why should it b e ? He w o rk s in a tw o -d im e n sio n al field. It is not n e a r ly so im p o rta n t for an enginem an as for a c o m m ercial truck driver, for instance. We w e r e to ld th a t 2 0 /5 0 v is i o n , u n c o r r e c t e d , in e a c h eye, w a s p e r fectly adequate vision. 'This was told to us by ophthalmologists and m ed ic a l o ffic e rs , and we w e re told a g re a t many o th e r things along those lines. Now, we a r e re v ie w in g o u r m e d ic a l sta n d a rd s to see if p e rh a p s we couldn't liberalize them . F o r many y e a rs, we have been more lib eral than a lot of the r a i l r o a d s in the United S tate s. We h av e allow ed o n e - e y e d m e n to w ork in en g in e s e r v i c e in C an ad a. We h av e n e v e r had a c l a im or accident where faulty vision was blamed. As far as the other features-which have been mentioned here today, *our vision testing p ro g ra m is v ery s im ila r to what has been described. I think I ought to just say som ething about these automatic vision testing devices like the o r t h o r a t e r and the sig h t s c r e e n e r . We don't think v e ry much of them . We in sist on a Snellen type of te s t at 20 feet. In color v isio n , as was m entioned, we would like o u r ap p lican ts to be able to p ass the P seu d o -Iso ch ro m atic c h a rts, one type o r another. The W illia m s' la n te rn h a s r e a l l y gone out of b u s in e s s . It was n e v e r a good t e s t . We u s e d it f o r y e a r s , an d we d o n 't use it o f te n any m o r e . We use a modified Air F o rc e type of lantern which we find'm uch b e tte r. I m ight just m ention h e r e that th e re h as been so m e w ork out in England showing that color vision does d e te rio ra te with age, not through d ise a se but sim ply through senile change in the color perception in terp retatio n . We h a v e a l s o n o t i c e d t h a t . We h a v e no s t a t i s t i c s on it, but we n o t i c e d the older em ployees som e tim es have difficulty in in terp retin g color t e s t s . We do m a k e s o m e a l l o w a n c e s fob i t in t e s t i n g t h e m with t h e A i r Force lantern. MODERATOR CLAYTON: T h e re a re a num ber of things which Napoleon took into consideration for evaluation for officers for selection. Health and youth, for exam ple, w ere s tr e s s e d , but he said th is, "A body that can endure in te rm in ab le riding without fatigue, the pow er to sleep at any moment and wake whenever he p leases, a stom ach which can digest any thing and m a k e s no complaint at being put cn s h o rt ra tio n s , and eyes that s e e a n d a r r a n g e e v e r y t h i n g . " So the e y e a p p a r e n t l y i s a v e r y i m p o r t a n t organ in any field of endeavor. Dr. Wipperman is a v ery fine, capable, b oard -certified oculist from t v ' H n n f ' rrH PM r*f a f r v v > * v . o i - ,. o M O D E R A T O R C L A Y T O N : Thank you. Doctor. I now introduce D r. U'. E. Mishlcr, Chief Surgeon, Erie-Lackawanna Railroad-. D R . W. E . M IS H L E R : On o u r r a i l r o a d , e n t r a n c e to t r a i n s e r v i c e , both e n g i n e a n d o t h e r w i s e , is 20 / 2 0 in b o th e y e s . W'e do n o t a llo w m e n in tra in o r engine se t vice to use contact le n ses, o r to put it another way, the only p la c e we allow c o n tac t le n s e s is in office e m p lo y ee s. In o th e r w o rd s, th o se p eople in o th e r than office work a re not allow ed to w ear contact lense$. I think that we should m ention glaucom a. We have m any c a s e s of glaucom a, and when discovered, they m ust submit periodic rep o rts from t h e i r a t t e n d i n g o p h th a l m o l o g i s t a t le a s t e v e r y 90 d a y s . W'e a l s o h a v e a n o t h e r r u l e w h ic h is kind of a c a t c h - a l l a n d t h a t i s tlr A ther functional o r organic one-eyed men are not allowed to work ar\*K d moving m achinery or cars. M O D ERA TO R CLAYTON: I would now like to introduce Dr. P e te r Vaughan, Chief M edical O fficer, Canadian National Railways. D R . P E T E R VAUGHAN: W'e h a v e b e e n u n d e r a lot of p r e s s u r e in o u r ra ilw a y lately , as I am su re all of you have from tim e to tim e, to lib e ra l ize our vision standards. V ision sta n d a rd s for all ra ilro a d s in Canada a re uniform . T hey' a re se t by the ra ilro a d s and they a re enforced by federal legislation. E very few y e a rs these regulations are reviewed and som e changes made. F o r anybody who is in te reste d , I have a copy of ou r vision regulations for the y ear 1912. And also one for our recently revised regulations for 1964. They differ very little. The question that a rise s im m ediately is: Why d o n 't they d iffe r? O perating p ro c e d u re s in ra ilro a d s have changed c o n s i d e r a b l y in t h e l a s t 50 y e a r s , a n d p a r t i c u l a r l y in the l a s t 10 o r 15 yes We don't have any m ore steam engines. The enginem an now sits in ^W fosed cab behine a wind sc re e n with direct forw ard vision. Our sw itc h in g o p e r a tio n s hav e changed. .We have au to m atic hu m p y a r d s . We have train -to -train radio communications, train-to-dispatcher, train- to -sta tio n rad io com m unication, and a whole lot of new o p era tin g p r o c e d ures. The point is that operating procedures have changed considerably making the necessity for vision qualifications less stringent. Because th ere is le ss possibility of e r r o r on the p art of the enginem en or y ard man w hoever it happens to be, and so many operations a re becom ing auto m ated why could we not liberalize our vision standards som ew hat ? With this in m ind, we have held a great many conferences throughout tur ra ilro a d sy stem during the past few m onths, with our ra ilro a d m e d ical officers, and with our operating officers, to see if we could a rriv e at a b e tte r id ea as to what our m o d ern operating p ro c e d u re s re q u ire . W'e h a v e r e c e i v e d a g r e a t v a r i e t y o f v e r y i n t e r e s t i n g a n s w e r s . We were told, for instance, that yard service, far from being so rt of a 133 waste p aper bask et in which to place disabled em ployees dem ands a very high d eg ree of p erfec tio n in vision and c e rtain o th er qualifications. Y ard service now is done at relatively high speed. You have many c r o s s overs, many signals, and it is really a harder job than road service. We w e re told, fo r in s ta n c e , th at s te re o p s is was not n e c e s s a r y for an en g in e m a n . A fte r a ll, why should it b e ? He w o rk s in a tw o - d im e n sio n a l field. It is not n e a r ly so im p o rta n t fo r an en g in em a n as fo r a c o m m ercial truck driver, for instance. We w e r e to ld t h a t 2 0 / 5 0 v i s i o n , u n c o r r e c t e d , in e a c h eye, w a s p e r fectly adequate vision. 'This was told to us by ophthalmologists and m ed ic a l o ffic e rs , and we w e re told a g re a t many o th e r things along those lines. Now, we a r e re v ie w in g o u r m e d ic a l s ta n d a rd s to see if p e rh a p s we couldn't liberalize them . F o r many y e a rs, we have been more liberal than a lot of the r a i l r o a d s i n the United S tate s. We h av e allow ed o n e - e y e d m e n to w ork in en g in e s e r v i c e in C an ad a. We h av e n e v e r had a c l a im or accident where faulty vision was blamed. As far as the other features-which have been mentioned here today, *our vision te stin g p r o g ra m is v ery s im ila r to what h as been d escrib ed . I think I ought to just say som ething about these automatic vision testing devices like the o r t h o r a t e r and the sig h t s c r e e n e r . We d o n 't think v e ry much of them . We in sist on a Snellen type of te s t at 20 feet. In color v ision, as was m entioned, we would like o u r applicants to be able to p ass the P seu d o -Iso ch ro m atic c h a rts, one type o r another. The W illia m s' la n te rn h a s r e a l l y gone out of b u sin e ss. It was n e v e r a good t e s t . We u s e d it f o r y e a r s , an d we d o n 't use it o f te n any m o r e . We use a modified Air F o rc e type of lantern which we find'm uch b e tte r. I might just mention h e re that th e re has been som e work out in England showing that color vision does d e te rio ra te with age, not through d ise a se but sim ply through senile change in the color perception interpretation. We h a v e a l s o n o t i c e d t h a t . We h a v e no s t a t i s t i c s on it, but we n o t i c e d the older em ployees som e tim es have difficulty in in terp retin g color t e s t s . We do m a k e s o m e a l l o w a n c e s fob it in t e s t i n g t h e m with t h e A i r Force lantern. MODERATOR CLAYTON: T h ere a re a num ber of things which Napoleon took into consideration for evaluation for officers for selection. Health and youth, for exam ple, w ere s tr e s s e d , but he said this, "A body that can endure in te rm in ab le riding without fatigue, the pow er to sleep at any moment and wake whenever he p leases, a stom ach which can digest any thing and m a k es no complaint at being put cn sh o rt ra tio n s , and eyes that s e e a n d a r r a n g e e v e r y t h i n g . " So t h e e y e a p p a r e n t l y i s a v e r y i m p o r t a n t o rg an in any field of endeavor. Dr. Wipperman is a very fine, capable, b oard -certified o c u list fro m M'i n n n c-o tf* rrr? nf o Railroad. Dr. U 'ippcrman. will you c o m m e n t on what you hear! here t . , U y DR. \\ IPPE R M A N : T hank you. D r. Clayton. I am a p a r t- tim e a s s is ta n t iro fe s s o r at the U niversity of M innesota, but m ainly in p rivate p rac tice , md y e t I h e sita te to qualify m y se lf as a s p e c ia lis t becau se by definition * i sp e cia list is just an o rd in ary fellow a long ways fro m home and Mineapolis isn 't very far from. here. I would like to say that when the firs t announcem ent of the meeting am e up la st Ju n e, and it was postponed, I did sen d out a le tte r to eight xiLroad C hief S urgeons and M edical D ire c to rs including the Illinois c n t r a l ; the A t c h i s o n , T o p e k a &. s a n t a F e ; t h e P e n n s y l v a n i a ; th e C a n a d ia n ac itic ; the C anadian N ational; the B a ltim o re and Ohio; and the New York e n t r a l R ailro ad . I think the an sw ers to the q uestio n s a re relev an t to ,e d is c u s s io n h e r e today. S sf^ n sw er to the question, "Sould o r would not a m o re liberal visual a n d a r d or. e n tr a n c e to s e rv ic e be r e a l i s t i c ? " I got six r e p lie s fro m the ght r a ilr o a d s I contacted, and so m y an sw e rs a re in those p ercen tag es, vc a n s w e re d , " Y e s ," ana one an sw e re d , "No. " So, it se e m s to be of ncral opinion that the railroad com panies should liberalize their visual a n d a rd s fo r not only their new applicants, but for their older em ployees they a re m oved up to advanced jobs. In a n sw e r to the second question, "What is the m o st p ra c tic a l method determ ining color vision?" Five answ ered the Pseudo-Isochrom atic r te s " ; one a n s w e r e d the " la n te rn " ; and one " p la te s and L a n te r n ." So, s e e m s to be the opinion that the plates are the m ore p ractical and efient m ethod, and I assum e is the method that is being used most unirsally. Q uestion 3, "A ssum ing an em ployee has a c a ta ra c t, at what visual feet should he be taken out of se rv ic e ? " F our answ ered that he should ta k en out of se rv ic e when the vision is less than 20 /50. One answ ered ;s ^ ^ , 2 0 / 100. 5DERATOR CLAYTON: But that m eans correctable vision? .. W I P P E R M A N : C o r r e c t a b l e v i s i o n , r i g h t . "Is o r is not the em ployee with c a ta ra c t su rg e ry on one eye safe to .tinue in s e r v ic e ? " T h re e answ ered that they should not be kept in the asp ortation o r the running train se rv ic e, and th ree answ ered it should d ecided on an individual b a s is , so a p p a ren tly so m e of th e se m en do 1 that o n e-ey ed people who have sa tisfa c to ry c o rre c tiv e vision after a ra c t su rg ery can be put back on th eir job.I I want to m ake a few statem en ts about contact le n ses in a few m inutes, 1 think th is is p a rtic u la rly applicable to the m o n o cu lar aphakic, who sa tisfac to ry co rre c te d vision with contact lenses? But I thought you ild be in terested to know how your fellow railro a d s a re answ ering se questions. 140 T hey m ig h t not say it up h e r e , but h e r e to m e they s e e m to say hey won't q ualify th e s e people, but a c tu a lly , fro m a p r a c t i c a l standpoint hey a re putting people back to work in spite of their r u le s , it seem s to me. I know on the Soo Line we have s e v e r a l people who a r e m o n o cu lar aphakics and are doing y ard switch work. But these, again, are decided on an individual basis. I think we all know that som e people after cu m ract surgery a re clum sy and awkward and inefficient, and others just seem to be just equally as efficient as they w ere before ihe cataract surgery. So, we com e down to the next question: Would o r would not an in dividual with a sa tisfac to ry re s u lt from a c a ta ra c t s u rg e ry in both eyes be s a f e to r e t u r n to w o r k ? " (A) A t r a i n m a n ? W ell, two of the r a i l r o a d s a n s w e r e d , " Y e s . " T h r e e s a i d , " N o , " and on e h a d a n e q u i v o c a l a n s w e r , -- F o r sw itchm en, the sam e percentages. For shop crafts, four said they would r e tu r n the m an to work. One said , "No, " and one no an sw e r. Should an individual be p erm itted to w ear contact le n ses in the shop crafts? Five answered, "Y es." G entlem en, th e re a re nine m illion contact lens w e a re rs in the United Slates now, and this is going up a m illion a y e a r. T his m ean s that one out of twenty people w earing co rrectiv e lenses a re now w earing contact le n ses. I am su re the unions are going to face you with the sta tistic s and ada p ta b ility of the contact le n se s and say , "W ell, why c a n 't we let this m an go back to work with contact le n s e s ? " T his is a p ra c tic a l tiling that is going to face all of you. MODERATOR CLAYTON: P ardon m e, I think the unions will find a good a n s w e r to th a t q u e s tio n in " U s e of C o n tact L e n s e s in I n d u s t r y " by the Council on Occupational Health of the A m erican M edical A ssociation, which ap p eared in The Jo u rn al of the A m erican M edical A ssociation. A pril 27, 1964, copies of which have been d istributed . DR. WIPPERMAN: I am su re p a rt of the answ er to that, too, is the AMA's. MODERATOR CLAYTON: That is it. DR. W IPPERM AN: The A M A's an sw er which is an ex cellen t su m m a ry of the use of contact lenses in industry. They approach it with a word of caution, ana-it does have its disadvantages, but contact lenses are here to stay , and we have to face the p ra c tic a l applications of contact len ses. i On y o u r own r a il r o a d s in the a n s w e r s , o u t of the s ix , five sa id they would p e rm it an individual to re tu rn to the shop c ra fts , to be employed in the shop c r a fts , if they w ore contact le n ses. Q u e s tio n n u m b e r 7, "Should an in d iv id u a l be p e r m i t t e d to w ea r c o n ta c t le n s e s in the o p e ra tin g d e p a rtm e n t of the r a i l r o a d ? " T h e r e we got 100 per cent, "N o." Railroad. Dr. U 'ippcrman, will you c o m m e n t on what you hear! here f,L.Y DR. V\ I P P E R M A N : T h a n k y o u . D r . C l a y to n . I a m a p a r t - t i m e a s s i s t a n t iro fe s s o r at the U niversity of M innesota, but m ainly in p rivate p rac tice , md y e t I h e sita te to qualify m y se lf as a s p e c ia lis t becau se by definition * i sp e cia list is just an o rd in ary fellow a long ways fro m home and Mineapolis isn 't very far from. here. I would like to say that when the firs t announcem ent of the meeting am e up la st Ju n e, and it was postponed, I did sen d out a le tte r to eight lil r o a d C hief S urgeons and M edical D ire c to rs including the Illinois c n t r a l ; the A t c h i s o n , T o p e k a &. s a n t a F e ; t h e P e n n s y l v a n i a ; th e C a n a d ia n acific; the C anadian N ational; the B a ltim o re and Ohio; and the New York e n t r a l R a ilro ad . I think the answ ers to the q uestio n s a re relev an t to ,e d is c u s s io n h e r e today. S sf^ n sw er to the question, "Sould o r would not a m o re liberal visual a n d a r d or. e n tr a n c e to s e rv ic e be r e a l i s t i c ? " I got six r e p lie s fro m the ght r a ilr o a d s I contacted, and so m y an sw e rs a re in those p ercen tag es, vc a n s w e re d , " Y e s ," ana one an sw e re d , "No. " So, it se e m s to be of ncral opinion that the railroad com panies should liberalize their visual a n d a rd s fo r not only their new applicants, but for their older em ployees they a re m oved up to advanced jobs. Li a n sw e r to the second question, "What is the m o st p ra c tic a l method d eterm in in g color vision?" Five answ ered the Pseudo-Isochrom atic i t e s " ; one a n s w e r e d the " la n te rn " ; and one " p la te s and L a n te r n ." So, s e e m s to be the opinion that the plates are the m ore p ractical and or ient m ethod, and I assum e is the method that is being used most unirsally. Q uestion 3, "A ssum ing an em ployee has a c a ta ra c t, at what visual feet should he be taken out of se rv ic e ? " F our answ ered that he should ta k en out of se rv ic e when the vision is less than 20 /50. One answ ered ;s ^ ^ , 2 0 / 100. 5DERATOR CLAYTON: But that m eans correctable vision? .. W I P P E R M A N : C o r r e c t a b l e v i s i o n , r i g h t . "Is o r is not the em ployee with c a ta ra c t su rg e ry on one eye safe to .tinue in s e r v ic e ? " T h re e answ ered that they should not be kept in the nsportation o r the running train se rv ic e, and th ree answ ered it should d ecided on an individual b a s is , so a p p a ren tly so m e of th e se m en do 1 that o n e-ey ed people who have sa tisfa c to ry c o rre c tiv e vision after a ra c t su rg ery can be put back on th eir job.I I want to m ake a few statem en ts about contact le n ses in a few m inutes, 1 think th is is p a rtic u la rly applicable to the m o n o cu lar aphakic, who sa tisfac to ry co rre c te d vision with contact lenses? But I thought you ild be in terested to know how your fellow railro a d s a re answ ering se questions. 140 T hey m ig h t not say it up h e r e , but h e r e to m e they s e e m to say hey won't q ualify th e s e p eople, but a c tu a lly , fro m a p r a c t i c a l standpoint hey a re pu ttin g people back to work in spite of th e ir r u le s , it se e m s to me. I know on the Soo Line we have s e v e r a l people who a r e m o n o cu lar aphakics and are doing y ard switch work. But these, again, are decided on an individual basis. I think we all know that som e people after cu m ract surgery a re clum sy and awkward and inefficient, and others just seem to be just equally as efficient as they w ere before the cataract surgery. So, we com e down to the next question: Would o r would not an in dividual with a sa tisfac to ry re su lt from a c a ta ra c t s u rg e ry in both eyes be s a f e to r e t u r n to w o r k ? " (A) A t r a i n m a n ? W ell, two of the r a i l r o a d s a n s w e r e d , " Y e s . " T h r e e s a i d , " N o , " and on e h a d a n e q u i v o c a l a n s w e r , -- F or switchm en, the sam e percentages. For shop crafts, four said they would r e tu r n the m an to work. One said , "No, " and one no an sw e r. Should an individual be p erm itted to w ear contact le n ses in the shop crafts? Five answered, "Y es." G entlem en, th e re a re nine m illion contact lens w e a re rs in the United Slates now, and this is going up a m illion a y e a r. T his m ean s that one out of twenty people w earing correctiv e lenses a re now w earing contact le n ses. I am su re the unions are going to face you with the sta tistic s and ada p ta b ility of the contact le n se s and say , "W ell, why c a n 't we let this m an go back to work with contact le n s e s ? " T his is a p ra c tic a l tiling that is going to face all of you. MODERATOR CLAYTON: P ardon m e, I think the unions will find a good a n s w e r to th a t q u e s tio n in " U s e of C o n tac t L e n s e s in I n d u s t r y " by the Council on Occupational Health of the A m erican M edical A ssociation, which ap p eared in The Jo u rn al of the A m erican M edical A ssociation. A pril 27, 1964, copies of which have been d istributed . DR. WIPPERMAN: I am su re p a rt of the answ er to that, too, is the AMA's. MODERATOR CLAYTON: That is it. DR. W IPPERM AN: The A M A's an sw er which is an ex cellen t su m m a ry of the use of contact lenses in industry. They approach it with a word of caution, ana-it does have its disadvantages, but contact lenses are here to stay, and we have to face the p ra c tic a l applications of contact lenses. i On y o u r own r a il r o a d s in the a n s w e r s , o u t of the s ix , five sa id they would p e rm it an individual to re tu rn to the shop c ra fts , to be employed in the shop c r a fts , if they w ore contact le n ses. Q u e stio n n u m b e r 7, "Should an in d iv id u a l be p e r m i t t e d to w ear c o n ta c t le n s e s in the o p e ra tin g d e p a rtm e n t of the r a i l r o a d ? " T h e r e we got 100 p e r c e n t, " N o ." MIs t*',e use contact lenses after cataract surgery advantageous or not? I think we all have to agree that they are advantageous, Should an individual who has been w earing contact len ses s u c c e s s fully be h ir e d ? One hundred p e r cent, "No, " to that in the tra n sp o rta tio n train serv ice, and four out of six answ ered "Y es" outside the operating departm ent, and two an sw ered, "No. " I was in te reste d in this question: "How many railro ad com panies pay for an em ployee's routine refractio n examination, o r any, o r a p art of the e m p lo y e e 's safety g la s s e s ?" One out of the six ra ilro a d s p ay s a p a rt o r all of the re fra c tio n exam ination. One railro ad pays on an individual b a s is , and the o th e r fo u r do not h ave anything to do with paying fo r the fees of this. I would a p p re c ia te it v e ry much if we could show a couple of slid es w e- As an o culist and a practicin g ophthalm ologist, who fits contact le n s e s , I would like to show you a couple of the advantages of contact lenses. In o rd in a ry aphakic p erfec tio n , you get a rin g sco to m a produced by the o r d in a ry le n se s, and this illu s tra te s the rin g scotom a. T his is why I quite a g re e that tra in m e n should not be re-em p lo y ed in the o perating crafts after they have had cataract surgery, because of this ring scotoma. (Slide) T his shows the field plotted out, showing this ring scotom a. You p eople have been le ery about putting train m en back in se rv ic e , and ' you u n d ersto o d that th e ir field of vision was not full, but you m ay not hav e known exactly why. T his is one o f the re a so n s, because they get this rin g scotom a effect. Now, this, they do not have with contact lenses. A nother other le tr ic k you can tr y is th is. If you hold up your finger like this and y >te a r i n g w ith y o u r f i n g e r , h o ld i t r i g h t up c l o s e to y o u r e y e , h o ld it right up clo se to your eye and look through it, and see how much of a field you have. All right, now put your curled finger out about a couple of inches from your eye, and you will notice how much your field of vision is cut down. T his is sim ply the effect that you have when you c o rre c t an aphakic with o rd in ary spectacle lens. He not only has a re stric te d field by 3 5 per cent, he also has this ring scotom a effect. This is elim inated by contact lenses. A nother effect that you have with o rd in ary aphakic correction :s that you have a 25 p e r cen t in c re a s e in im ag e size. In contact le n se s, this is reduced to about 5 to 7 p e r cent. (Slide) Now, this show s the vision obtained by a contact lens. The field of vision is good, and you do not have the ring scotom a. 142 DR. MISHLER: Isn't that field only about 35 per cent as compared with the normal field of aphakic ? DR. WIPPERMAN: A re you talking about contact lens or aphakic ? DR.' M ISHLER: With c o n ta c t l e n s ? MODERATOR CLAYTON: I think what he m e an s, is that a full or n o rm a l field of vision is not p resen t with a contact lens. DR. WIPPERMAN: Y es. you have alm o st a full field. This shows the field of vision with y o u r contact lens. DR. MISHLER: I u n d ersta n d it is only about 35 p e r cent. DR. WIPPERMAN: No, that is not tru e . H ere you do have som e r e s t r i c tion out at the end, but this is a s e r ie s of v isu a l fields with contact len ses, and you can see th e re is s till som ew hat of a rin g effect, but it is well out in the periphery. (Slide) L et's see. This is sim ply to illu stra te the difference between looking through an ordinary cata ra ct lens and looking through a contact lens. You will notice that in the lower left-hand side here, there is a p ictu re of some ste p s, that the ste p s curve in from the p eriphery, and you have distorted peripheral vision, while on the right side, the stairs look straight. That is through a contact lens. In the u p p er left, you .have a fig u re of a g ir l, and you notice in the c e n tra l a re a that the figure is c le a r, but the im age in the p erip h ery is blu rred and distorted while that is through the ordinary aphakic c o r r e c tion. You will notice th e re is just a sm a ll a r e a in the center in which the picture is sharp and clear. Now, on the rig h t side, you have the contact lens. Actually, you h a v e a c l e a r i m a g e j u s t a b o u t in 1h i s a r e a , a n d th e r e s t is a l l c u r v e d and distorted. H ere you have a c le a r im a g e. T h is is certainly why th e re is a great deal of hesitancy about retu rn in g anyone to the operating train s e r v ic e who h a s had e i th e r m o n o c u la r o r .b ila te r a l c a ta ra c t s u r g e r y . I think that is the last slide on that. But again, I want to re p e a t that we a re fitting m ore and m ore contact l e n s e s . We a r e g e t t i n g m o r e an d m o r e d e m a n d f r o m people on c o n t a c t lenses. There are nine m illion contact lense w earers, successful w earers in the United S tates now, and it is going up about one million a y e a r, so you are going to be p resen ted with this problem . DR. MISHLER: The an sw er to that is that we a re selling more Cadillacs, too. MODERATOR CLAYTON: How m uch m o re tim e do we have. Dr. M3 O lson? MIs t*',e use contact lenses after cataract surgery advantageous or not? I think we all have to agree that they are advantageous, Should an individual who has been w earing contact len ses s u c c e s s fully be h ir e d ? " One hundred p e r cent, "No, " to that in the tra n sp o rta tio n train serv ice, and four out of six answ ered "Y es" outside the operating departm ent, and two an sw ered, "No. " I was in te reste d in this question: "How many railro ad com panies pay for an em ployee's routine refractio n examination, o r any, o r a p art of the e m p lo y e e 's safety g la s s e s ?" One out of the six ra ilro a d s p ay s a p a rt o r all of the re fra c tio n exam ination. One railro ad pays on an individual b a s is , and the o th e r fo u r do not h ave anything to do with paying fo r the fees of this. I would a p p re c ia te it v e ry much if we could show a couple of slid es w e- As an o culist and a practicin g ophthalm ologist, who fits contact le n s e s , I would like to show you a couple of the advantages of contact lenses. In o rd in a ry aphakic p erfec tio n , you get a rin g sco to m a produced by the o r d in a ry le n se s, and this illu s tra te s the rin g scotom a. T his is why I quite a g re e that tra in m e n should not be re-em p lo y ed in the o perating crafts after they have had cataract surgery, because of this ring scotoma. (Slide) T his shows the field plotted out, showing this ring scotom a. You p eople have been le ery about putting train m en back in se rv ic e , and ' you u n d ersto o d that th e ir field of vision was not full, but you m ay not hav e known exactly why. T his is one o f the re a so n s, because they get this rin g scotom a effect. Now, this, they do not have with contact lenses. A nother other le tr ic k you can tr y is th is. If you hold up your finger like this and y >te a r i n g w ith y o u r f i n g e r , h o ld i t r i g h t up c l o s e to y o u r e y e , h o ld it right up clo se to your eye and look through it, and see how much of a field you have. All right, now put your curled finger out about a couple of inches from your eye, and you will notice how much your field of vision is cut down. T his is sim ply the effect that you have when you c o rre c t an aphakic with o rd in ary spectacle lens. He not only has a re stric te d field by 3 5 per cent, he also has this ring scotom a effect. This is elim inated by contact lenses. A nother effect that you have with o rd in ary aphakic correction :s that you have a 25 p e r cen t in c re a s e in im ag e size. In contact le n se s, this is reduced to about 5 to 7 p e r cent. (Slide) Now, this show s the vision obtained by a contact lens. The field of vision is good, and you do not have the ring scotom a. 142 DR. MISHLER: Isn't that field only about 35 per cent as compared with the normal field of aphakic ? DR. WIPPERMAN: A re you talking about contact lens or aphakic ? DR.' M ISHLER: With c o n ta c t l e n s ? MODERATOR CLAYTON: I think what he m e an s, is that a full or n o rm a l field of vision is not p resen t with a contact lens. DR. WIPPERMAN: Y es. you have alm o st a full field. This shows the field of vision with y o u r contact lens. DR. MISHLER: I u n d ersta n d it is only about 35 p e r cent. DR. WIPPERMAN: No, that is not tru e . H ere you do have som e r e s t r i c tion out at the end, but this is a s e r ie s of v isu a l fields with contact len ses, and you can see th e re is s till som ew hat of a rin g effect, but it is well out in the periphery. (Slide) L et's see. This is sim ply to illu stra te the difference between looking through an ordinary cata ra ct lens and looking through a contact lens. You will notice that in the lower left-hand side here, there is a picture of some steps, that the steps curve in from the periphery, and you have distorted peripheral vision, while on the right side, the stairs look straight. That is through a contact lens. In the u p p er left, you .have a fig u re of a g ir l, and you notice in the c e n tra l a re a that the figure is c le a r, but the im age in the p erip h ery is blu rred and distorted while that is through the ordinary aphakic c o r r e c tion. You will notice th e re is just a sm a ll a r e a in the center in which the picture is sharp and clear. Now, on the rig h t side, you have the contact lens. Actually, you h a v e a c l e a r i m a g e j u s t a b o u t in 1h i s a r e a , a n d th e r e s t is a l l c u r v e d and distorted. H ere you have a c le a r im a g e. T h is is certainly why th e re is a great deal of hesitancy about retu rn in g anyone to the operating train s e r v ic e who h a s had e i th e r m o n o c u la r o r .b ila te r a l c a ta ra c t s u r g e r y . I think that is the last slide on that. But again, I want to re p e a t that we a re fitting m ore and m ore contact l e n s e s . We a r e g e t t i n g m o r e an d m o r e d e m a n d f r o m people on c o n t a c t lenses. There are nine m illion contact lense w earers, successful w earers in the United S tates now, and it is going up about one million a y e a r, so you are going to be p resen ted with this problem . DR. MISHLER: The an sw er to that is that we a re selling more Cadillacs, too. MODERATOR CLAYTON: How m uch m o re tim e do we have. Dr. M3 O lson? R. O L S O N : Twenty minutes. .ODERATOR CLAYTON: Dr. W ipperman, som e one nudged'm e and said a s k you w hat p e r c e n ta g e of o p h th a lm o lo g ists w ea r c o n ta c t le n s e s ? R. W IPPE R M A N : The m ost su c c e ssfu l contact lens v /e arer is the >ung a d u lt f e m a l e b e t w e e n th e a g e s of 15 and 2 5. ( L a u g h te r ) .ODERATOR C.LAYTON: D r. W ipperm an, if you w ere the h ead of the edical d e p a rtm e n t of a ra ilro a d , and the question aro se as to w hether m would p e r m i t an engineer to w ear contact lens. What would be y our jcision? Would you p e rm it him or not ? R, . '"tP P E R M A N : Dr. Vaughan made an interesting com m ent that is ; ? V e h e r e . T he tr a i n m e n a r e no lo n g er hangin g out th e window and oeratm g the engines, the coal-burning engines with a ir strea m in g past leir face. They are working behind nice, com fortable cabs, and is this at t r u e ? R. M ISHLER: No. [OD ERA TO R CLAYTON: But things can happen ju st the sa m e . You re never isolated from foreign bodies ? R. W I P P E R M A N : Y ou a r e g oing to g e t f o r e i g n b o d ie s in y o u r e y e w h e ler you are w earing contact lenses or not wearing contact lenses. IODERATOR CLAYTON: But if he gets it under his contact lens while n duty he will have to be away from his post of duty until it is rem oved nd th is should not occur. >R. W T P P E R M A N : I d o n 't th i n k h e is any m o r e d i s a b l e d . If a f e ll o w h a s for 'gn body in his eye, that he can't get out, he isn 't any m o re disb l e \ ^ i t h o r without his contact lens. IODERATOR CLAYTON: If he has to rem o v e the contact le n s, he would ave no one else to c a r ry on for him. That is one rea so n the a ir lines, I n d e rsta n d , do not p e r m it pilots to w ear contact le n ses. T h at is one easen. Another is that the lens may becom e blurred w ith m oisture .nd th e w e a r e r n o t be a w a r e of it and t h e r e a r e m a n y o th e r th in g s which ;an happen on duty. )R. MISHLER: They a r e m o re susceptible of u lc e r of the co rn e a, too. DR. W I P P E R M A N : T h a t i s t r u e . DR. W IG H T : A r e we a l l o w e d to a s k q u e s t i o n s f r o m t h e f l o o r ? I h a v e 1 few. You can d ire c t them to whoever you want. Earlier you said you disqualified applicants for employment with 144 20/100 vision for clerical work. MODERATOR CLAYTON: No. DR. WIGHT: You said that. I want to know why. MODERATOR CLAYTON: I think that you m isunderstood o r did not hear accurately what I at least m eant to say. I think that m ost applicants for c l e r i c a l w o rk if in th e y o u n g e r age g ro u p who have a v isio n of 2 0 / 1 0 0 o r l e s s sh o u ld be d is q u a lif ie d e v e n though it be r e f r a c t i v e in o r ig in . If the a p p l i c a n t h a s a g o o d f a m i l y h i s t o r y , no h i s t o r y of p r o g r e s s i v e myr.j. a and if his eye gro u n d s a p p e a r n o rm a l and th e re is no h is to ry o r p r o g r e s s ive condition, even with vision of 20/400 I would probably re c o m m en d his em ploym ent. DR. WIGHT: I am afraid that I a m not that in te reste d in the young g :ri who is ap p ly in g f o r w ork who has v isio n of 2 0 /1 0 0 who w ants to w ork. I am not going to dig into that. If she is c o r r e c te d ad e q u ately , we w ill . take h e r on. MODERATOR CLAYTON: What I have said has been based not only on p ractical but also technical studies. Without elaboration if it is your d esire to em ploy people with such findings that is your p rero g ativ e. Most of them will get along without difficulty in th e ir e a r lie r y e a r s but as they becom e o ld e r they m ay develop difficulty to the extent that it in terfere.; with th e ir efficiency. DR. WIGHT: Ninety p e r cent of them a re going to be g ran d m o th ers by then, and they a re not going to be working. (Laughter! DR. NELSON: A ren't you assum ing som ething that is not entirely tru e ? T h ere a re two things I would like to have cle a re d in m y mind. By far the m ajority of people that would have vision, say, 20/30, 20/40, o r even 20/50 a r e m y o p ic s . W ouldn't a c e r t a i n g ro u p of th ese have v ision in 5 o r 10 y e a r s th a t i s j u s t a s good a s th e o n e th a t is 20 /20 ? If a p e r s o n has vision of 2 0 /30, 20/40, 20/50, and has a co rrec tio n to 20/20, c a n 't we a s s u m e th a t he h a s no r e a l s e r i o u s o r g a n ic s itu a tio n in h is eye ? T he seco n d thing I would like to b rin g up is the fact that in o u r p r e s e n t c l a s s e s B & C , a v i s i o n o f 2 0 / 3 0 , 20 /40 an d e v e n up to 20 /50 ia a c cepted. I think that is an e rro n e o u s statem en t. I don't think we should accept those people u n le ss they can obtain c o rrec tio n to 2 0 / 2 0 , for the same reason that I have mentioned previously. I would like to clarify these two points which I think a re p ra c tic a l . and som ething we ought to know. MODERATOR CLAYTON: D r. W ipperm an, what do you think? DR. W IPPERM AN: I think this is a v e ry p ra c tic a l point. You can take a hyperope who is 20 y e a rs old and on his o riginal application, he sees ?0/20 o r even 20/15, and he may be a hyperope of two d io p te rs, and s till 145 R. O L S O N : Twenty minutes. .ODERATOR CLAYTON: Dr. W ipperman, som e one nudged'm e and said a s k you w hat p e r c e n ta g e of o p h th a lm o lo g ists w ea r c o n ta c t le n s e s ? R. W IPPE R M A N : The m ost su c c e ssfu l contact lens v /e arer is the >ung a d u lt f e m a l e b e t w e e n th e a g e s of 15 and 2 5. ( L a u g h te r ) .ODERATOR C.LAYTON: D r. W ipperm an, if you w ere the h ead of the edical d e p a rtm e n t of a ra ilro a d , and the question aro se as to w hether m would p e r m i t an engineer to w ear contact lens. What would be y our jcision? Would you p e rm it him or not ? R, . '"tP P E R M A N : Dr. Vaughan made an interesting com m ent that is ; ? V e h e r e . T he tr a i n m e n a r e no lo n g er hangin g out th e window and oeratm g the engines, the coal-burning engines with a ir strea m in g past leir face. They are working behind nice, com fortable cabs, and is this at t r u e ? R. M ISHLER: No. [OD ERA TO R CLAYTON: But things can happen ju st the sa m e . You re never isolated from foreign bodies ? R. W I P P E R M A N : Y ou a r e g oing to g e t f o r e i g n b o d ie s in y o u r e y e w h e ler you are w earing contact lenses or not wearing contact lenses. IODERATOR CLAYTON: But if he gets it under his contact lens while n duty he will have to be away from his post of duty until it is rem oved nd th is should not occur. >R. W T P P E R M A N : I d o n 't th i n k h e is any m o r e d i s a b l e d . If a f e ll o w h a s for 'gn body in his eye, that he can't get out, he isn 't any m o re disb l e \ ^ i t h o r without his contact lens. IODERATOR CLAYTON: If he has to rem o v e the contact le n s, he would ave no one else to c a r ry on for him. That is one rea so n the a ir lines, I n d e rsta n d , do not p e r m it pilots to w ear contact le n ses. T h at is one easen. Another is that the lens may becom e blurred w ith m oisture .nd th e w e a r e r n o t be a w a r e of it and t h e r e a r e m a n y o th e r th in g s which ;an happen on duty. )R. MISHLER: They a r e m o re susceptible of u lc e r of the co rn e a, too. DR. W I P P E R M A N : T h a t i s t r u e . DR. W IG H T : A r e we a l l o w e d to a s k q u e s t i o n s f r o m t h e f l o o r ? I h a v e 1 few. You can d ire c t them to whoever you want. Earlier you said you disqualified applicants for employment with 144 20/100 vision for clerical work. MODERATOR CLAYTON: No. DR. WIGHT: You said that. I want to know why. MODERATOR CLAYTON: I think that you m isunderstood o r did not hear accurately what I at least m eant to say. I think that m ost applicants for c l e r i c a l w o rk if in th e y o u n g e r age g ro u p who have a v isio n of 2 0 / 1 0 0 o r l e s s s h o u ld be d is q u a lif ie d e v e n though it be r e f r a c t i v e in o r ig in . If the a p p l i c a n t h a s a g o o d f a m i l y h i s t o r y , no h i s t o r y of p r o g r e s s i v e myr.j. a and if his eye grounds ap p ear n o rm al and there is no h isto ry o r p r o g r e s s ive condition, even with vision of 20/400 I would probably rec o m m e n d his em ploym ent. DR. WIGHT: I am afraid that I am not that in te reste d in the young g :ri who is ap p ly in g f o r w o rk who has v isio n of 2 0 /1 0 0 who w ants to w ork. I am not going to dig into that. If she is c o r r e c te d ad e q u ately , we w ill . take h e r on. MODERATOR CLAYTON: What I have said has been based not only on p ra c tic a l but also technical studies. Without elaboration if it is your desire to em ploy people with such findings that is your prerogative. Most of them will get along without difficulty in th e ir e a r lie r y e a r s but as they becom e o ld e r they m ay develop difficulty to the extent that it in terfere.; with th e ir efficiency. DR. WIGHT: Ninety p e r cent of th em a re going to be g ra n d m o th e rs by then, and they are not going to be working. (Laughter! DR. NELSON: A ren't you assum ing som ething that is not entirely tru e ? T h ere a re two things I would like to have cle a re d in m y mind. By far the m ajority of people that would have vision, say, 20/30, 20/40, o r even 20/50 a r e m y o p ic s . W ouldn't a c e r t a i n g ro u p of th ese have v ision in 5 o r 10 y e a r s th a t i s j u s t a s good a s th e o n e th a t is 20 /20 ? If a p e r s o n has vision of 20 /30, 20/40, 20/50, and has a co rrec tio n to 20/20, c a n 't we a s s u m e th a t he h a s no r e a l s e r i o u s o r g a n ic s itu a tio n in h is eye ? T he seco n d thing I would like to b r in g up is the fact that in o u r p r e s e n t c l a s s e s B & C , a v i s i o n o f 2 0 / 3 0 , 20 /40 a n d ev e n up to 20 /50 ia a c cepted. I think that is an e rro n e o u s statem en t. I don't think we should accept those people u n le ss they can obtain c o rrec tio n to 2 0 / 2 0 , for the same reason that I have mentioned previously. I would like to clarify these two points which I think are p rac tica l . and som ething we ought to know. MODERATOR CLAYTON: D r. W ipperm an, what do you think? DR. W IPPERM AN: I think this is a v e ry p ra c tic a l point. You can take a hyperope who is 20 y e a r s old and on his o rig in a l application, he se es ?0/20 o r even 20/15, and he may be a hyperope of two d io p te rs, and s till 145 - 0 / 2 0 , \ ^.'t 10 y o a i s l a t e r , he* c a n ' t s e c 2 0 / 4 0 , and h is c o r r e c t i o n is not changed. I c e rta in ly feel that if a p e r s o n is c o rre c ta b le to 2 0 /2 0 and lias no o c u l a r p a th o lo g y , he s h o u ld be c o n s i d e r e d for e m p lo y m e n t. It se em s to me now with the strin g e n t v isu a l ru le s you have, you a re p ass* ing up so m e good, intelligent people, and tu rn in g them down because of a visual problem . MODERATOR CLAYTON; I agree. That is essentially what I have said in the p ro to co l, gentlem en. I ag re e 100 p e r cent. DR, WIGHT: T h ere was one other. DR. NELSON: Is co rre c tio n to 20/20 an indication that th ere is not pathology ? DR. VVTPPERMAN: No, th is is not n e c e s s a r i l y tr u e b ec au se you can ^ v e glaucom a, retin al detachment, optic neuritis, a number of diseases and still have 2 0/20 vision. DR. NELSON: We a r e ta lk in g about a p p lic a n ts who a r e probably in th e ir 20 y e a rs which is a different situation. DR, WIPPERMAN: I am afraid I am lost, Harvey. DR. NELSON: We are talking about applicants for service. DR. WIPPERMAN: Yes, sir. DR. NELSON: Who probably are in the age 20 group. You are not going to be run n in g into som e of these things that you are talking about like glaucom a. DR. W IPPERM AN: Not ordinarily. NELSON: That is the group that I am talking about, is correction /20 for the average exam iner enough indication that a man doesn't have se rio u s pathology if he has vision u n co rrected to 20/30, 20/40 or 20/50? DR. W IPPERM AN: I would say this is c o rre c t under ordinary circ u m stances. DR. OLSON: I would like to ask D r. W ipperm an what uncorrected lim its would you se t on a m an in the tra n sp o rta tio n d ep a rtm en t, c o rrec tab le to 20/20 ? DR. W IPPERM AN: W ell, I hard ly place m y se lf on the pinnacle to answ er this question, but I would say with reaso n ab le safety that uncorrected vision of 20/40 or 20/50.1 1 th in k if you h a d 20 /100 to 2 0 /2 0 0 you g e t a h ig h m yope. T h is p e r son, of course, is m ore subject to retin al detachm ent and to degenerative diseases than a person at 2 0 /2 0 . 1 4fi DR. OLSON : Would you say a m a n at 20/50 is any greater risk, except for the need for glasses, than anyone with 20/20 at a comparable age ? DR. W IPPERM AN : I would sa y not. If we a r e dealing with a p r im a rily re fra c tiv e o p tical e r r o r , and an o p tical e r r o r of, sa y , a diopter of a s tig m a tis m , o r any one of the r e f r a c tiv e e r r o r s , I don't know why you should turn a person down because of this defect. DR. OLSON: I don't either. I ju st wanted to get yo u r concurrence. DR. NELSON: M r. C h a irm a n , could I have the seco n d p art of my question a n s w e r e d ? We now s a y 2 0 /3 0 , 2 0 /4 0 , 2 5 /5 0 v is i o n a s such is ad e q u ate for allowing these people to r e tu rn to w ork without any statem ent about their correction. MODERATOR CLAYTON: It should be u n d erstood that the vision will be c o rre c te d to a satisfactory degree. DR. NELSON: It isn 't so understood in o u r reg u la tio n s. M ODERATOR CLAYTON: I would not p e r m it any individual to re tu r n to w ork until his vision is co rrec ted to within n o rm a l lim its. If he has som e disease, it should be diagnosed. DR. NELSON: T his draw s on the point I m ade b efo re, that, if a p erso n h as got 2 0 /3 0 , 2 0 /40 o r 20/50 v isio n and c a n 't b e c o r r e c te d to 20/20, then we a re probably dealing with som e pathology. I think we ought to spell it out in our vision requirem ents. MODERATOR CLAYTON: In my p ro to co l, to which you have a c c e s s , I have stre s se d that the visual change m ust be refra ctiv e in origin. DR. KNOWLES: D r. Clayton, would D r. W ippermarv go on and te ll u s a little som ething about contact le n s? We have had the problem of "it steam in g up. " Have they o vercom e that. - It u se d to req u ire the rem o v a l of the lens about ev ery four ho u rs. Also when they firs t came in, we had heavy contact le n s e s . We had light co n tac t le n s e s and in som e c a s e s , they have not been a success. Would he tell us a little about th a t? Is th at overcom e, "the ste a m ing u p ," and so forth? DR. WIPPERMAN: You would like to know how you can co rrect the disad vantages of contact lenses? DR. KNOWLES: Some have to rem ove them , say , after four hours. Some 's te a m up. " DR. WIPPERMAN: E ven for the su c c e ssfu l co ntact lens w earer who can w ear his contact lens for a period of eighteen h o u rs, without any visual difficulty at all, we now rec o m m en d that they ta k e off these lenses every fo u r to five h o u rs , clean th e m , r e s t th e ir e y e s fo r ten m inutes to half an hour, and then re in se rt the lenses. S' t - 0 / 2 0 . \ *..*t 10 l e a : s l a t e r , h e c a n ' t s e c 2 0 / 4 0 , and h is c o r r e c t i o n is not changed. I certain ly feel that if a p e rso n is co rrec tab le to 2 0 /2 0 and lias no o c u l a r p a th o lo g y , he sh o u ld be c o n s i d e r e d for e m p lo y m e n t. It se em s to me now with the strin g e n t v isu a l ru le s you have, you a re p ass* ing up som e good, intelligent people, and tu rn in g them down because of a visual problem . MODERATOR CLAYTON; I agree. That is essentially what I have said in the p ro to co l, gentlem en. I ag re e 100 p e r cent. DR. WIGHT: T h ere was one other. DR. NELSON: Is co rre c tio n to 20/20 an indication that th ere is not pathology ? n R. VVIPPERMAN: No, this is not n e c e s s a r ily tr u e becau se you can ^ v e glaucom a, retinal detachment, optic neuritis, a number of diseases and still have 2 0/20 vision. DR. NELSON: We a r e ta lk in g about a p p lic a n ts who a r e probably in th e ir 20 y e a rs which is a different situation. DR. WIPPERMAN: I am afraid I am lost, Harvey. DR. NELSON: We are talking about applicants for service. DR. WIPPERMAN: Yes, sir. DR. NELSON: Who probably are in the age 20 group. You are not going to be run n in g into som e of these things that you are talking about like glaucom a. DR. W IPPERM AN: Not ordinarily. "pj. NELSON: That is the group that I am talking about, is correction ^ Lr/2 0 /2 0 fo r the a v e r a g e e x a m i n e r enough in d ic a tio n that a m an d o e s n 't have se rio u s pathology if he has vision u n co rrected to 20/30, 20/40 or 20/50? DR. W IPPERM AN: I would say this is c o rre c t under ordinary circ u m stances. DR. OLSON: I would like to ask D r. W ipperm an what uncorrected lim its would you se t on a m an in the tra n sp o rta tio n d ep a rtm en t, c o rrec tab le to 20/20 ? DR. W IPPERM AN: W ell. I hard ly place m y se lf on the pinnacle to answ er this question, but I would say with reaso n ab le safety that uncorrected vision of 20/40 or 20/50.I I th in k if yo u h a d 20 /100 to 2 0 /2 0 0 yo u g e t a h ig h m y o p e. T h is p e r son, of course, is m ore subject to retin al detachm ent and to degenerative' diseases than a person at 2 0 / 2 0 , 1 4fi DR. OLSON : Would you say a m a n at 20/50 is any greater risk, except for the need for glasses, than anyone with 20/20 at a comparable age ? DR. W IPPERM AN : I would sa y not. If we a r e dealing with a p r im a rily re fra c tiv e o p tical e r r o r , and an o p tical e r r o r of, sa y , a diopter of a s tig m a tis m , o r any one of the r e f r a c tiv e e r r o r s , I don't know why you should turn a person down because of this defect. DR. OLSON: I don't either. I ju st wanted to get yo u r concurrence. DR. NELSON: M r. C hairm an, could I have the second part of my question a n s w e r e d ? We now s a y 2 0 /3 0 , 2 0 /4 0 , 2 5 /5 0 v is i o n a s such is ad e q u ate for allowing these people to r e tu rn to w ork without any statem ent about their correction. MODERATOR CLAYTON: It should be u n d erstood that the vision will be c o rre c te d to a satisfactory degree. DR. NELSON: It isn 't so understood in o u r reg u la tio n s. MODERATOR CLAYTON: I would not p e r m it any individual to re tu rn to w ork until his vision is co rrec ted to within n o rm a l lim its. If he has som e disease, it should be diagnosed. DR. NELSON: T his draw s on the point I m ade b efo re, that, if a p erso n h as got 2 0 /3 0 , 2 0 /40 o r 20/50 v isio n and c a n 't b e c o r r e c te d to 20/20, then we a re probably dealing with som e pathology. I think we ought to spell it out in our vision requirem ents. MODERATOR CLAYTON: In my p ro to co l, to which you have a c c e s s , I have stre s se d that the visual change m ust be refra ctiv e in origin. DR. KNOWLES: D r. Clayton, would D r. W ippermarv go on and te ll u s a little som ething about contact le n s? We have had the problem of "it steam in g up. " Have they o vercom e th a t.'- It u se d to req u ire the rem o v a l of the lens about ev ery four ho u rs. Also when they firs t came in, we had heavy contact le n s e s . We had light co n tac t le n s e s and in som e c a s e s , they have not been a success. Would he tell us a little about th a t? Is th at overcom e, "the ste a m ing up," and so fo rth ? DR. W IPPERM AN: You would lik e to k n o w h o w you cam c o r r e c t the d is a d vantages of contact lenses? DR. KNOWLES: Some have to rem ove them , say , after four hours. Some 's te a m up. " DR. WIPPERMAN: E ven for the su c c e ssfu l co ntact lens w earer who can w ear his contact lens for a period of eighteen h o u rs, without any visual difficulty at all, we now recom m end that they take off these lenses every fo u r to five h o u rs , clean th e m , r e s t th e ir e y e s fo r ten m inutes to half an hour, and then re in se rt the lenses. This gives them better vision and gives a little tim e for the cornea to re a d ju st itself. The contact lens w ea re r whose vision b lu rs at the end of four h ours is probably not p ro p erly fit, or he may have a blepharitis co n d itio n , b le p h a r itis s ic a ty p e of thing. He gets a lot of o il on his len ses and he has to take them out and clean them. MODERATOR CLAYTON: Gentlemen, you have tim e for just a couple m ore questions. DR. WIGHT: P a r t of my firs t question. Dr. Cyran m ade a r e m a rk which ra th e r am azed m e. F irs t of all, he will let people wearing contact lenses work in certain occupations providing they w ear o rd in ary glasses. I would like to ask the question, if this man accidentally drops his con tact lens, how long is it before his vision returns to norm al: DR. CYRAN: We have d isc u sse d this with our o p h th alm o lo g ist. I was itinder the im p re ssio n at one tim e it takes quite a while, they said it is only a m a tte r of a few m inutes, actually. DR. W1PPERA1AN: T h is is a phenomenon called s p e cta cle b lu r, and in so m e people this is very disturbing. Some people, when they shift from co n tact lens to re g u la r g la sse s , it may only take a m inute o r two o r five m in u te s . Som e people it takes five hours and som e people it tak es five d ay s, b efo re they can see with re g u la r lenses. DR. WIGHT: And you s till let that p erso n work in the running tra d e s if it takes that long, if he loses his lens? DR. W IPPERM AN : I still feel the patient who takes five days has been im p r o p e r ly fit. DR. SKINNER: C olor vision is the com monest bugaboo I run into, out s i d e of t h e s e r i o u s c a r d i o v a s c u l a r p r o b l e m . We h a v e th e s a m e p r o g r a m that e v e r y o n e h a s m en tio n ed , but we a ll have em p lo y ee s who have been with us for many, many y ea rs before the F seudo-Isochrom atic tests. ^ -^T h ey do not p ass them . We let them by on lanterns, or w hatever facilities we have. Now, perhaps, they are having green-white e rro rs on the W illiams' lantern, o r w hatever lantern you have. 1 T here are field te sts given on an overhead, m idnight and behind a barn, with all so rts of lan tern s, and they pass those. Do you accept'these field tests, o r are we going to have to take a man of 20 o r 30 y e a r s 1 s e rv ic e with a p erfec t re c o rd , take him out of se rv ic e on the basis of the P seudo-Isochrom atic test. MODERATOR CLAYTON: I would not take him out of s e rv ic e . D octor, if he can recognize individual colors. I would keep him under observation. DR. M ISH LER: M ay I s a y s o m e th in g ? I don't c a r e w hat you do o r what a n y r a i l r o a d d o e s w ith a m a n , b u t I d o n 't t h i n k you s h o u ld a c c e p t so-v-all >1 148 , field te sts. The re a so n that I am against it and it should not he tolerated on any ra ilro a d , is because you have laym en who a re deciding m edical questions. MODERATOR CLAYTON: I a g re e with that. DR. RALPH JOHNSON: A man h a s had one c a ta ra c t operation, w here doe he stand? Is he a one-eyed m an? MODERATOR CLAYTON: Surely, he is one-eye unless he is w earing a contact lens and has binocular vision. DR. JOHNSON: He has a lens on the right side? MODERATOR CLAYTON: He can conceivably get binocular vision. T hat is a little unusual, isn't it? DR. WIPPERMAN: A m onocular aphakic with o rdinary sp e cta cle s does not get b i n o c u l a r , s i n g l e v i s i o n , but with c o n t a c t l e n s e s , S5 p e r c e n t do get binocular single vision. DR. ZEISS: Does the w e a re r of the contact lens reduce the sen sitiv ity of his cornea ? DR. WIPPERMAN: His se n sitiv ity is reduced because of the c a ta ra c t su rg ery , not because of the contact lens. DR. ZEISS: Suppose he d o esn 't have c a ta ra c t su rg ery and w ears contact lenses. DR. WIPPERMAN: They have a tolerance. The corneal sensitivity is somewhat reduced. They develop a tolerance. This has been tested many tim es with the nylon fiber test. M O D ERA TOR C L A Y T O N : Now, g e n tle m e n , we h av e a v e ry lim ite d tim e; we could go on indefinitely. D r. W ipperm an, would you b riefly te ll this group what is m eant by b inocular single vision? DR. WIPPERMAN: I can give a didactic answ er about binocular single vision. This is the p ro c e ss by which the visual protion of the ce reb ral se n so ry a r e a com bines with the s e n s o ry im p u lses initiated by two somewl) disparate retin al im ages of an object of reg a rd into a single perception. DR. MISHLER: Very good. (Laughter) DR. WIPPERMAN: Now, sh all I in terp ret that ? > MODERATOR CLAYTON: If you will please. DR. WIPPERMAN: With b in o c u lar single vision, you have to com bine a sensory receptive c e re b ra l organ with an optical retinal image into--and you a r e ta k in g two.dissimilar o b j e c t s b e c a u s e y o u r two e y e s a r e n ot b e- o 149 This gives them better vision and gives a little tim e for the cornea to re a d ju st itself. The contact lens w ea re r whose vision b lu rs at the end of four h ours is probably not p ro p erly fit, or he may have a blepharitis co n d itio n , b le p h a r itis s ic a ty p e of thing. He gets a lot of o il on his len ses and he has to take them out and clean them. MODERATOR CLAYTON: Gentlemen, you have tim e for just a couple m ore questions. DR. WIGHT: P a r t of my firs t question. Dr. Cyran m ade a r e m a rk which ra th e r am azed m e. F irs t of all, he will let people wearing contact lenses work in certain occupations providing they w ear o rd in ary glasses. I would like to ask the question, if this man accidentally drops his con tact lens, how long is it before his vision returns to norm al: DR. CYRAN: We have d isc u sse d this with our o p h th alm o lo g ist. I was itinder the im p re ssio n at one tim e it takes quite a while, they said it is only a m a tte r of a few m inutes, actually. DR. W1PPERA1AN: T h is is a phenomenon called s p e cta cle b lu r, and in so m e people this is very disturbing. Some people, when they shift from co n tact lens to re g u la r g la sse s , it may only take a m inute o r two o r five m in u te s . Som e people it takes five hours and som e people it tak es five d ay s, b efo re they can see with re g u la r lenses. DR. WIGHT: And you s till let that p erso n work in the running tra d e s if it takes that long, if he loses his lens? DR. W IPPERM AN : I still feel the patient who takes five days has been im p r o p e r ly fit. DR. SKINNER: C olor vision is the com monest bugaboo I run into, out s i d e of t h e s e r i o u s c a r d i o v a s c u l a r p r o b l e m . We h a v e th e s a m e p r o g r a m that e v e r y o n e h a s m en tio n ed , but we a ll have em p lo y ee s who have been with us for many, many y ea rs before the F seudo-Isochrom atic tests. ^ -^T h ey do not p ass them . We let them by on lanterns, or w hatever facilities we have. Now, perhaps, they are having green-white e rro rs on the W illiams' lantern, o r w hatever lantern you have. 1 T here are field te sts given on an overhead, m idnight and behind a barn, with all so rts of lan tern s, and they pass those. Do you accept'these field tests, o r are we going to have to take a man of 20 o r 30 y e a r s 1 s e rv ic e with a p erfec t re c o rd , take him out of se rv ic e on the basis of the P seudo-Isochrom atic test. MODERATOR CLAYTON: I would not take him out of s e rv ic e . D octor, if he can recognize individual colors. I would keep him under observation. DR. MISHLER: May I say som ething? I don't care what you do o r what a n y r a i l r o a d d o e s w ith a m a n , b u t I d o n 't t h i n k you s h o u ld a c c e p t so-v-all >1 148 , field te sts. The re a so n that I am against it and it should not he tolerated on any ra ilro a d , is because you have laym en who a re deciding m edical questions. MODERATOR CLAYTON: I a g re e with that. DR. RALPH JOHNSON: A man h a s had one c a ta ra c t operation, w here doe he stand? Is he a one-eyed m an? MODERATOR CLAYTON: Surely, he is one-eye unless he is w earing a contact lens and has binocular vision. DR. JOHNSON: He has a lens on the right side? MODERATOR CLAYTON: He can conceivably get binocular vision. T hat is a little unusual, isn't it? DR. WIPPERMAN: A m onocular aphakic with o rdinary sp e cta cle s does not get b i n o c u l a r , s i n g l e v i s i o n , but with c o n t a c t l e n s e s , S5 p e r c e n t do get binocular single vision. DR. ZEISS: Does the w e a re r of the contact lens reduce the sen sitiv ity of his cornea ? DR. WIPPERMAN: His se n sitiv ity is reduced because of the c a ta ra c t su rg ery , not because of the contact lens. DR. ZEISS: Suppose he d o esn 't have c a ta ra c t su rg ery and w ears contact lenses. DR. WIPPERMAN: They have a tolerance. The corneal sensitivity is somewhat reduced. They develop a tolerance. This has been tested many tim es with the nylon fiber test. M O D ERA TOR C L A Y T O N : Now, g e n tle m e n , we h av e a v e ry lim ite d tim e; we could go on indefinitely. D r. W ipperm an, would you b riefly te ll this group what is m eant by b inocular single vision? DR. WIPPERMAN: I can give a didactic answ er about binocular single vision. This is the p ro c e ss by which the visual protion of the ce reb ral se n so ry a r e a com bines with the s e n s o ry im p u lses initiated by two somewl) disparate retin al im ages of an object of reg a rd into a single perception. DR. MISHLER: Very good. (Laughter) DR. WIPPERMAN: Now, sh all I in terp ret that ? ' MODERATOR CLAYTON: If you will please. DR. WIPPERMAN: With b in o c u lar single vision, you have to com bine a sensory receptive c e re b ra l organ with an optical retinal image into--and you a r e ta k in g two.dissimilar o b j e c t s b e c a u s e y o u r two e y e s a r e n ot b e- o 149 2. Chronic bronchitis, bronchial asthma, pulmonary emphysema fibrosis, cor pulmonale. ' a. D iesel exhaust fum es b. Welding and burning operations c. Paint sprays d. G rinding operations e. Blast furnace operations f. Sand . Chlorine Gas h. Coal dust 3. Silicosis a. Tunnel w orkers b. A sbestos (pipe insulation) c. F i b e r g la s s ( ?) 4. T uberculosis a. Tunnel w orkers b. shop fum es P athologic effects other than respiratory l^*^nhalation of noxious fumes, gasses or m aterials a. Carbon monoxide poisoning (1) P e r ip h e r a l N eu ritis b. Lead poisoning (Plumbism) (1) P e r ip h e r a l n e u ritis (2) R e n al Intoxication c. T ric h lo ro e th y le n e , p erch lo ro e th y le n e and c a rb o n te tra c h lo rid e (1) U n c o n sc io u sn e ss and d eath ( c e re b ra l) (2) P a r o x y s m a l t a c h y c a r d i a and m y o c a r d itis d. D a m a g e d myocardium (1) C o r o n a r y insufficiency (2) A ngina p e c to ris In previous y e a r s , due to financial h a ra ssm e n ts, som e ra ilro a d s o v er looked shop ventilation. Even today, not all shops and roundhouses are equipped with v en tila to ry fans, and not all fans are in working o rd e r. D uring the w inter m onths, shops a re poorly ventilated, due to windows and doors being closed, and men actually are working under conditions less than ideal. In su m m e r, this problem doesn't exist because windows and doors are open, and there is adequate ventilation. The p a n e l's p rese n ta tio n is flexible, and you can in terject questions at any tim e. The subject is open, and, if you wish to in te rru p t the p a n e l is t, you a r e w elcom e to do so. Some q u estio n s will be d ir e c te d to an individual p an e list, and I m ay even take the lib erty of d iscu ssin g the rela tio n sh ip of w elding and burning fum es to p u lm o n a ry d ise ase . Although they a p p e ar inocuous, I have sufficient lite ra tu re and actual ca se s to im p ress you with the realization that welding and burning operations may have toxic possibilities. You m ight say that threshold lim its have been estab lish ed for the noxious gases resulting from these operations, and that our safety and testin g d epartm ents have found these gases a r e well within the th resh o ld lim its as estab lish ed by the A m erican Conference of G overnm ental In d u stria l H ygienists. H ow ever, if you re c a ll the sm og of L enora, P e n nsylvania, and the ones in G reat Britain and Los A ngeles, you will re c a ll that they, too, wer* a s s a y e d fo r a ir pollution content and w ere found to be well within the defined safe threshold levels. Yet, because of a c o m bination of o ther fac to rs, they certainly were enough tb produce death in those people who w ere su b je ct to u p p er r e s p ir a to r y in fectio n s. So, m e re ly to say that we have safe levels is not a s a tis fa c to ry answ er, and by the tim e we fin ish with o u r q u e s tio n and a n s w e r p e r i o d , you w ill be convinced that the pro b lem of pulm onary infection and pulm onary c a r cinom a is, indeed, a v ital one to the railro ad industry and well worth in vestigating. We a r e g o in g to s t a r t t h e p a n e l p r e s e n t a t i o n w ith D r . C y r a n , who i s go in g to d iscu ss b riefly the g en e ral te rm - chronic bronch o -p u lm o n ary d iseases and th e ir relatio n sh ip to d iesel exhaust. He will also elaborate on Doctor B attigelli's re p o rt, "E nvironm ental and C linical Investigation of Workmen Exposed to D iesel Exhaust in Railroad Engine Houses. " DR. CYRAN: Dr. Kaplan asked me to spend about seven o r eight minutes discussing chronic pulmonary disease, namely, em physem a, bronchitis and p ulm onary fib ro s is . O bviously, this d o esn't give m e much tim e to be v ery profound about th is. How ever, with yo u r indulgence, I would like to b r ie f ly d e fin e and d escrib e th is g ro u p of d i s e a s e s s o that we c a n be on com m on ground. JP 2. Chronic bronchitis, bronchial asthma, pulmonary emphysema fibrosis, cor pulmonale. ' a. D iesel exhaust fumes b. Welding and burning operations c. Paint sprays d. G rinding operations e. Blast furnace operations f. Sand . Chlorine Gas h. Coal dust 3. Silicosis a. Tunnel w orkers b. A sbestos (pipe insulation) c. F i b e r g la s s ( ?) 4. Tuberculosis a. Tunnel w orkers b. shop fum es P athologic effects other than respiratory l^*^nhalation of noxious fumes, gasses or m aterials a. C arbon monoxide poisoning (1) P e r ip h e r a l N eu ritis b. Lead poisoning (Plumbism) (1) P e r ip h e r a l n e u ritis (2) R e n al Intoxication c. T ric h lo ro e th y le n e , p erch lo ro e th y le n e and c a rb o n te tra c h lo rid e (1) U n c o n sc io u sn e ss and d eath ( c e re b ra l) (2) P a r o x y s m a l t a c h y c a r d i a and m y o c a r d itis d. D a m a g e d myocardium (1) C o r o n a r y in su fficien cy (2) A ngina p e c to ris In previous y e a r s , due to financial h a ra ssm e n ts, som e ra ilro a d s o v er looked shop ventilation. Even today, not all shops and roundhouses are equipped with v entilato ry fans, and not all fans are in working o rd er. D uring the w in ter m o n th s, shops a r e poo rly v en tilated , due to windows and doors being closed, and men actually are working under conditions less than ideal. In su m m e r, this problem doesn't exist because windows and doors are open, and there is adequate ventilation. The p an el's presen tatio n is flexible, and you can interject questions at any tim e. The subject is open, and, if you wish to in te rru p t the p a n e l is t, you a r e w elco m e to do so. Some q u estio n s will be d ir e c te d to an individual p an e list, and I m ay even take the lib erty of d iscu ssin g the relatio n ship of welding and burning fumes to p ulm o n ary disease. Although they ap p ear inocuous, I have sufficient lite ra tu re and actual cases to im p ress you with the realization that welding and burning operations may have toxic possibilities. You m ight say that threshold lim its have been estab lish ed for the noxious gases resulting from these operations, and that our safety and testin g d epartm ents have found these gases a r e well within the th resh o ld lim its as estab lish ed by the A m erican Conference of G overnm ental In d u stria l H ygienists. H ow ever, if you re c a ll the sm og of L enora, P e n nsylvania, and the ones in G reat B ritain and Los A ngeles, you will r e c a ll that they, too, wer* a s s a y e d fo r a ir pollution content and w ere found to be well within the defined safe threshold levels. Yet, because of a c o m bination of o th e r fa c to rs , they certain ly w ere enough tb produce death in those people who w ere su b je ct to u p p er r e s p ir a to r y in fectio n s. So, m e re ly to say that we have safe levels is not a sa tis fa c to ry answ er, and by the tim e we fin ish w ith o u r q u e s tio n and a n s w e r p e r i o d , you w ill be convinced that the pro b lem of pulm onary infection and pulm onary c a r cinom a is, indeed, a v ita l one to the ra ilro a d in d u stry and well w orth in vestigating. We a r e g o in g to s t a r t t h e p a n e l p r e s e n t a t i o n w ith D r . C y r a n , who i s going to discuss briefly the general te rm - chronic broncho-pulm onary d iseases and th e ir relatio n sh ip to d iesel exhaust. He will also elaborate on Doctor B attigelli's re p o rt, "E nvironm ental and C linical Investigation of Workmen Exposed to D iesel Exhaust in Railroad Engine Houses. " DR. CYRAN: Dr. Kaplan asked me to spend about seven o r eight minutes discussing chronic pulmonary disease, namely, em physem a, bronchitis and p ulm onary fib ro s is . O bviously, this d o esn't give m e much tim e to be v ery profound about th is. How ever, with yo u r indulgence, I would like to b r ie f ly d e fin e and d escrib e th is g ro u p of d i s e a s e s s o that we ca n be on c o m m o n ground. J? The many in te rp re ta tio n s of the clinical te rm s have led to confusion in an a ly se s of m o rb id y and m o rta lity of these d ise ase s, and especially through evaluation of the w orld's literatu re. For instance, the term ch ro n ic b ronchitis is w idely used in G reat B ritain where it is about the t h i r d c o m m o n e s t c a u s e of d e a th , while in th is co u n try , it has b een in som e disrepute and considered a sort of a waste basket covering a m ulti tude of resp ira to ry conditions. The National T uberculosis A ssociation and its constituent asso cia tions have undertaken a p ro g ra m of public education in chronic r e s p ir a tory d iseases, and it has also published a manual for physicians, prepared by a com m ittee of the O regon T horacic Society, sum m arizing som e c u r ren t concepts in the definition, recognition, and treatm ent of chronic obstructive pulmonary emphysema. In the hope of finding com m on ground for discussion, I would like h are these with you. CHRONIC BRONCHITIS is a d iso rd e r c h a ra c te riz e d by e x c essiv e m u c o u s s e c r e tio n in the bronchi, m anifested by chronic o r r e c u r r e n t p ro d u ctiv e cough, a r b itr a r ily from a m inim um of th ree months to a y e a r and fo r at le a st two s u c c e s s iv e y e a rs; in patients in which o th er cau ses of productive cough such as specific pulmonary infections, neoplasm, and h eart disease have been excluded. ASTHMA is a d ise ase ch aracterized by an increased responsiveness of the tr a c h e a and b r o n c h i to v a r io u s stim uli and m a n ifeste d by a w ide sp rea d narro w in g of the airw ays, that changes in severity w hether spontaneously o r as a re su lt of therapy. This area is best not applied to the bronchial narrow ing, which results solely from bronchial infection o r from destructive d iseases of lung such as em physem a or from card io vascular disorders. "CHRONIC ASTHMATIC BRONCHITIS" is a commonly used te rm r e i ing to patients with re c u rre n t or chronic bronchial infection a s s&m ated with b ro n ch o sp a sm . Some consider it p art of the s p e c tr u m of chronic bronchitis, asthm a, and pulmonary em physem a, and apply the te r m to p atien ts exhibiting the typical featu res of two o r m o re of these conditions. It has thus been applied to patients with chronic b ro n ch itis o r b ro n ch ie cta sis who w heeze frequently, especially during ex acerb atio n s of r e s p ir a to ry infection and to patients with a past h isto ry of p aro x y sm a l b ro n ch ia l asth m a who now have only interm itten t r.on-paroxysm al w h eez ing and dyspnea. It is also used to describ e em physem atous p atien ts in whom a chronic wheeze and paroxysm al cough are salient features. O thers use the te rm with the inference that there has been the onset of re c u rre n t b ro n ch itis and b ro n ch o sp a sm in m iddle o r la ter life on the b a s is of s o called b a c te ria l allergy a risin g from bronchial c r sinus infection. On the whole, chronic asthm atic bronchitis would be a m ore useful d e s c rip tive te rm if we could agree upon a specific definition. PULMONARY EMPHYSEMA can be described as an anatomic altc ra tioh of the lungs, ch aracterized by an abnorm al enlargem ent of the air 156 spaces distal to the terminal non-respiratory bronchiole, accompanied by destructive changes of the alveolar walls. EMPHYSEMA is probably am ong the m ost baffLing of the com plexities of re s p ir a to ry d ise ase . It is frequently com plicated and also o b scu red by a n u m b e r of a s s o c ia te d co n d itio n s in r e g a r d to functional, sy m p to m a tic , and m orphological c h a r a c te r is tic s . It ranks second only to h ea rt d ise a se in the n u m b e r o f w o rk in g m e n it afflic ts. A ctually, about one in ten people are developing the disease. S t a t i s t i c s , in 1962, s h o w e d th a t about 7. 2 p e r ce n t of the p eo p le w ere actu ally r e c e iv in g d isa b ility for em p h y sem a. R ecently, in B oston, I think, the s u r v e y s found t h e r e w e re about 12 p e r cent of the people r e ceiving disability for em physem a, so you can see that this is a rea l c o m plex problem . It is an im p o rta n t p roblem , and so im portant that it was even w ritten up in the Wall S tre e t Journal about a y e a r o r so ago. Vfhen we d i s c u s s P U L M O N A R Y F IB R O S IS , we r e f e r to .he f i b r o s i s that o ccu rs in a num ber of sp e cific and non-specific d iseases affecting the lungs. 'Too fre q u en tly , it is not p o ssib le to identify the basic, p r o c e s s f r o m the x - r a y e x a m in a tio n of th e lu n g s alone. It is n e c e s s a r y to c o r re la te the h isto lo g ic findings with a s s o c ia te d changes in o th e r o rg an s as well as clinical data and special laboratory reports. T hese aforem entioned te rm s a re those we probably are most fam iliar with arid of g r e a t im p o r ta n c e , b e c a u s e all can be claim ed to be in d u s tria lly re la te d e ith e r thro u g h ca u sa tio n o r aggravation. With expanding in d u s tria liz a tio n in th is co u n try , any ph y sician m ay be called upon to identify and tre a t d ise ase allegedly due to the w orking environm ent. . C e r t a i n l y , o u r r a i l r o a d s a r e no e x c e p t i o n , an d , a s we a l l know, o n ly too w ell, a r e m u ch m o r e v u ln e ra b le . T his could lead alm o st to s o r t of a defeatist attitude since many of the patients, who'have chronic sym ptom s and a re brought to the attention of a physician, have re s p ira to ry d ise a se of m o d e ra te o r even advanced d e g r e e . If we disqualify such a p atien t from his re g u la r occupation, then cannot place him in some other job, and he m u s t be r e t i r e d b e f o r e . t h e n o r m a l a g e , he b e c o m e s a p r o b le m . In today's litigation-m inded society, the FELA and the jury system , should he decide to s e e k le g a l c o u n s e l, the r a il r o a d is forced to a s s u m e the d e fense of a disease of non-specific etiology with many possible causative factors and/or aggravating ones. Dr. Kaplan in his little pam phlet lists som e of the preventive m e asu res that actually should be instituted and those he recom m ends should be in s t i t u t e d r a t h e r than taking a d e f e a tis t a ttitu d e , I think th e re is a p o s itiv e approach. One o f th e p o s i t i v e a p p r o a c h e s i s t h a t w hich D r . `B a ttig e lli h a s b e e n doing at the U n iv e rs ity o f P itts b u r g h . He s t a r t e d the p ro g ra m sp o n so re d in p a rt by a g ran t from the A ssociation of A m erican Railroads and also continued by the National In stitu te s of H ealth. What they did was in te rm s of c l in ic a l and p h ysiological a s s e s s m e n t , take a group of locom otive r e p a ir The many in te rp re ta tio n s of the clinical te rm s have led to confusion in an a ly se s of m o rb id y and m o rta lity of these d ise ase s, and especially through evaluation of the w orld's literatu re. For instance, the term ch ro n ic b ronchitis is w idely used in G reat B ritain where it is about the t h i r d c o m m o n e s t c a u s e of d e a th , while in th is co u n try , it has b een in som e disrepute and considered a sort of a waste basket covering a m ulti tude of resp ira to ry conditions. The National T uberculosis A ssociation and its constituent asso cia tions have undertaken a p ro g ra m of public education in chronic r e s p ir a tory d iseases, and it has also published a manual for physicians, prepared by a com m ittee of the O regon T horacic Society, sum m arizing som e c u r ren t concepts in the definition, recognition, and treatm ent of chronic obstructive pulmonary emphysema. In the hope of finding com m on ground for discussion, I would like h are these with you. CHRONIC BRONCHITIS is a d iso rd e r c h a ra c te riz e d by e x c essiv e m u c o u s s e c r e tio n in the bronchi, m anifested by chronic o r r e c u r r e n t p ro d u ctiv e cough, a r b itr a r ily from a m inim um of th ree months to a y e a r and fo r at le a st two s u c c e s s iv e y e a rs; in patients in which o th er cau ses of productive cough such as specific pulmonary infections, neoplasm, and h eart disease have been excluded. ASTHMA is a d ise ase ch aracterized by an increased responsiveness of the tr a c h e a and b r o n c h i to v a r io u s stim uli and m a n ifeste d by a w ide sp rea d narro w in g of the airw ays, that changes in severity w hether spontaneously o r as a re su lt of therapy. This area is best not applied to the bronchial narrow ing, which results solely from bronchial infection o r from destructive d iseases of lung such as em physem a or from card io vascular disorders. "CHRONIC ASTHMATIC BRONCHITIS" is a commonly used te rm r e i ing to patients with re c u rre n t or chronic bronchial infection a s sW ia te d with b ro n ch o sp a sm . Some consider it p art of the s p e c tr u m of chronic bronchitis, asthm a, and pulmonary em physem a, and apply the te r m to p atien ts exhibiting the typical featu res of two o r m o re of these conditions. It has thus been applied to patients with chronic b ro n ch itis o r b ro n ch ie cta sis who w heeze frequently, especially during ex acerb atio n s of r e s p ir a to ry infection and to patients with a past h isto ry of p aro x y sm a l b ro n ch ia l asth m a who now have only interm itten t r.on-paroxysm al w h eez ing and dyspnea. It is also used to describ e em physem atous p atien ts in whom a chronic wheeze and paroxysm al cough are salient features. O thers use the te rm with the inference that there has been the onset of re c u rre n t b ro n ch itis and b ro n ch o sp a sm in m iddle o r la ter life on the b a s is of s o called b a c te ria l allergy a risin g from bronchial c r sinus infection. On the whole, chronic asthm atic bronchitis would be a m ore useful d e s c rip tive te rm if we could agree upon a specific definition. PULMONARY EMPHYSEMA can be described as an anatomic altc ra tioh of the lungs, ch aracterized by an abnorm al enlargem ent of the air 156 spaces distal to the terminal non-respiratory bronchiole, accompanied by destructive changes of the alveolar walls. EMPHYSEMA is probably am ong the m ost baffLing of the com plexities of re s p ir a to ry d ise ase . It is frequently com plicated and also o b scu red by a n u m b e r of a s s o c ia te d co n d itio n s in r e g a r d to functional, sy m p to m a tic , and m orphological c h a r a c te r is tic s . It ranks second only to h ea rt d ise a se in the n u m b e r o f w o rk in g m e n it afflic ts. A ctually, about one in ten people are developing the disease. S t a t i s t i c s , in 1962, s h o w e d th a t about 7. 2 p e r ce n t o f th e p eo p le w ere actu ally r e c e iv in g d isa b ility for em p h y sem a. R ecently, in B oston, I think, the surveys found th ere w ere about 12 p er cent of the people r e ceiving disability for em physem a, so you can see that this is a rea l c o m plex problem . It is an im p o rta n t p roblem , and so im portant that it was even w ritten up in the Wall S tre e t Journal about a y e a r o r so ago. When we d i s c u s s P U L M O N A R Y F IB R O S IS , we r e f e r to .he f i b r o s i s that o ccu rs in a num ber of sp e cific and non-specific d iseases affecting the lungs. 'Too fre q u en tly , it is not p o ssib le to identify the basic, p r o c e s s f r o m the x - r a y e x a m in a tio n of th e lu n g s alone. It is n e c e s s a r y to c o r re la te the h isto lo g ic findings with a s s o c ia te d changes in o th e r o rg an s as well as clinical data and special laboratory reports. T hese aforem entioned te rm s a re those we probably are most fam iliar with arid of g r e a t im p o r ta n c e , b e c a u s e all can be claim ed to be in d u s tria lly re la te d e ith e r thro u g h ca u sa tio n o r aggravation. With expanding in d u s tria liz a tio n in th is co u n try , any ph y sician m ay be called upon to identify and tre a t d ise ase allegedly due to the w orking environm ent. . C e r t a i n l y , o u r r a i l r o a d s a r e no e x c e p t i o n , an d , a s we a l l know, o n ly too w ell, a r e m u ch m o r e v u ln e ra b le . T his could lead alm o st to s o r t of a defeatist attitude since many of the patients, who'have chronic sym ptom s and a re brought to the attention of a physician, have re s p ira to ry d ise a se of m o d e ra te o r even advanced d e g r e e . If we disqualify such a p atien t from his re g u la r occupation, then cannot place him in some other job, and he m u s t be r e t i r e d b e f o r e . t h e n o r m a l a g e , he b e c o m e s a p r o b le m . In today's litigation-m inded society, the FELA and the jury system , should he decide to s e e k le g a l c o u n s e l, the r a il r o a d is forced to a s s u m e the d e fense of a disease of non-specific etiology with many possible causative factors and/or aggravating ones. Dr. Kaplan in his little pam phlet lists som e of the preventive m e asu res that actually should be instituted and those he recom m ends should be in s t i t u t e d r a t h e r than taking a d e f e a tis t a ttitu d e , I think th e re is a p o s itiv e approach. One o f th e p o s i t i v e a p p r o a c h e s i s t h a t w hich D r . `B a ttig e lli h a s b e e n doing at the U n iv e rs ity o f P itts b u r g h . He s t a r t e d the p ro g ra m sp o n so re d in p a r t by a g r a n t from the A s s o c ia tio n of A m e r ic a n R a ilro ad s a n d a lso continued by the National Institutes of H ealth. What they did was in te rm s of c l in ic a l and p h ysiological a s s e s s m e n t , take a group of locom otive r e p a ir m en cu rren tly exposed to d iesel exhaust, and then com pared them to a co n tro l group of ra ilro a d w orkers which w ere m atch ed for size and age fro m the p a s t e x tra -p u lm o n a ry histo ry , but having no d ie se l contact. They su rveyed two engine houses and studied in detail the engine houses to obtain a re p re se n ta tiv e a sse ssm e n t of exposure conditions by som e three hundred fifty atm ospheric sam plings for analysis of the various constituents of d iesel exhaust. They did these su m m er and winter. They took them during different periods of activity and during different c lim a tic conditions. S u rprisingly, no alarm in g concentrations of the p ro d u c ts of d ie s e l com bustion were found. The re s u lts showed no sig n i ficant d ifference betw een the two groups relativ e to sym ptom s o r chest abnorm alities. They m easured their vital capacities, their forced expira to r y v olum e c a p a c itie s , th e ir m axim um breathing cap acities. They did diffusion stu d ie s and re sid u a l function studies, and found that actually th e r e was no diffe ren ce between these two groups. T he m a jo rity of com plaints in both groups was fro m the sm o k e rs. T h e re actually was b etter functional perform ance in the non-sm okers. The study would indicate that diesel exhaust is not showing any evidence of pulm onary disability, and m ost of the abnorm alities that were found w e re due to the sm oking of cig arettes. D r. Hollo show ed m e an address by M ario C. Battigelli, A ssistant P r o f e s s o r and D ire c to r, D iesel Exhaust R e sea rch , U niversity of P i t t s burgh, before the Forty-Second M ember ship Meeting of the Medical and S u rg ic al O ffic ers, St. L ouis, M isso u ri, May 28, 1962. His group also evaluated the carcinogenic potential of d ie se l exhaust, and h is opinion, I think, to date is that they have found that in the n o rm al functioning o r n o rm al efficient engine, there are no polycyclic h y d ro ca r bons that a r e of carcin o g en ic potential. H owever, in a d ie sel that is not functioning, and when the diesel is apparently not idling properly, there can be so m e d ie s e l exhaust which does have som e h y d ro carb o n s, especially 3 - 4 b e n z p y rin e , w hich have carcinogenic potential. T h ey show th is by ?' `ually painting the skins of certain anim als, and proving that skin cani ^ / c a n develop fro m the 3-4 benzpyrine. H owever, in stu d ies actually exposing a n im a ls to inhalations of 3-4 benzpyrine, they w ere unable to develop any evidence of carcinogenic activity. T h ese studies a re continuing, and will appear in the lite ra tu re . They w ill be of g re a t v alue to future claim s of c a n c e r fro m d ie se l exhaust. MODERATOR KATLAN: Thank you. Dr. Cyran. Now, to c o n tra st th is view that diesel exhausts a r e not d elete rio u s to th e h e a lth of an in d iv id u a l, I a m going to ste p out of b o u n d s a lit tle and go into the audience and ask Dr. Carouge, the A ssistant M edical and Sur gical D irecto r, fo r the B altim ore and Ohio R ailroad, to d iscu ss a case which was handled by the Mayo Clinic. T his will im p re ss you with the type of m edical-legal action that has to be anticipated due to exposure to d iesel exhaust. 158 ' DR. CAROUGE: In July 1963, a locomotive firem an rep o rted off sick and sought m e d ic a l c a r e f ro m his local attending physician. Ho told him that he was suffering with p e rip h e ra l neuritis, and in turn, re fe rre d him to the Mayo Clinic. Shortly a f te r th is, we w ere ad v ised by a le tte r fro m tiie attending physician, at the Mayo Clinic that it was felt this gentleman.'s p erip h eral n e u ritis was s e c o n d a ry to inhalation of fum es fro m h is w ork, i, in tu r n , w rote to the doctor and asked him to please advise the basis on which he felt that this was a fact. In a le tte r which I receiv ed , he said that, " A l though it is tr u e t h e r e is little , if any, docum entation in the L iterature o f p o s s i b l e r e l a t i o n s h i p o f p e r i p h e r a l n e u r i t i s to h y d r o c a r b o n : ; , -,ve h a v e seen a n u m b er of patients who have had p e rip h e ra l n eu ritis, in whom there was heavy exposure to various volatile hydrocarbons and solve:;', m ix tu re s, and the clinical co u rse which these patients dem onstrated leads us to believe that there is a relationship between peripheral neuritis and exposure to h y d r o c a r b o n s in th e s e i n s t a n c e s . F o r in s ta n c e , we have h ad u n d e r o b s e rv a tio n one in d iv id u al who was exposed to so lv e n ts and c l e a n e r s in his work and who developed a se v e re p erip h e ra l n eu ritis, winch cleared up a fte r h is ex p o su re was elim inated. A nother individual was -exposed to the fumes from gasoline and diesel m otors and had sim ilar difficulty which also c le a re d up afte r his occupation was changed. Although it is ex tre m ely difficult to prove the relationship of the developm ent of p e r i p h e r a l n e u r i t i s and t h e s e a g e n ts , at tim e s we have b ee n co nvinced enough about the p o s s ib le re la tio n sh ip that we felt ju stified in su g g estin g to this m an that he should a s s id u o u s ly avoid the heavy ex p o su re to h y d ro c a rb o n s to which he was subjected in his work. " We, in turn, put this p roblem to Dr. John C. K rantz, who is a Ph. D and p r o f e s s o r o f t! e D e p a r t m e n t of P h a r m a c o l o g y a t the U n i v e r s i t y of M a r y la n d . We to l d h i m w hat th e c o m p o n e n ts w e r e in the d i e s e l f u m e s which had been analyzed, and he wrote back and staged that, "Of a ll the constituents p re s e n t in the gas, the fum es to which the firem an was e x posed that might have caused peripheral neuritis, carbon monoxide is the only one that can be incrim inated: it has been shown that repeated e x posure to this agent c a u se s degeneration of the nervous sy stem , and m ic r o scopic exam ination rev e als specific damage to the nerve cells. Long exposure produces lack of sensitivity in the fingers which is indicative of neuritis. " Inasm uch as we felt th e re was not a high enough co n cen tratio n of carbon monoxide eith er in the diesel cab o r the atm osphere adjacent th e re to to cau se the n eu ritis, we would not accept his claim of re la tio n sh ip of the neuritis with his work. MODERATOR KAPLAN: D r. Hollo has also been in te reste d in any p o s sible rela tio n sh ip of d iesel exhaust to production of lung pathology and will now cite his experiences in this field. Dr. Hollo. DR. HOLLO: Thank you. Dr. Kaplan. F irs t of all, m y personal con ta c ts in stu d ie s of Carcinoma of Lung am ong ra ilro a d em ployees have' b e e n s t r i c t l y on a clin ic b a sis. All o f o u r p u lm o n a ry d is e a s e .; n.ring m en cu rren tly exposed to d iesel exhaust, and then com pared them to a co n tro l group of ra ilro a d w orkers which w ere m atch ed for size and age fro m the p a s t e x tra -p u lm o n a ry histo ry , but having no d ie se l contact. They su rveyed two engine houses and studied in detail the engine houses to obtain a re p re se n ta tiv e a sse ssm e n t of exposure conditions by som e three hundred fifty atm ospheric sam plings for analysis of the various constituents of d iesel exhaust. They did these su m m er and winter. They took them during different periods of activity and during different c lim a tic conditions. S u rprisingly, no alarm in g concentrations of the p ro d u c ts of d ie s e l com bustion were found. The re s u lts showed no sig n i ficant d ifference betw een the two groups relativ e to sym ptom s o r chest abnorm alities. They m easured their vital capacities, their forced expira to r y v olum e c a p a c itie s , th e ir m axim um breathing cap acities. They did diffusion stu d ie s and re sid u a l function studies, and found that actually th e r e was no diffe ren ce between these two groups. T he m a jo rity of com plaints in both groups was fro m the sm o k e rs. T h e re actually was b etter functional perform ance in the non-sm okers. The study would indicate that diesel exhaust is not showing any evidence of pulm onary disability, and m ost of the abnorm alities that were found w e re due to the sm oking of cig arettes. D r. Hollo show ed m e an address by M ario C. Battigelli, A ssistant P r o f e s s o r and D ire c to r, D iesel Exhaust R e sea rch , U niversity of P i t t s burgh, before the Forty-Second M embership Meeting of the Medical and S u rg ic al O ffic ers, St. L ouis, M isso u ri, May 28, 1962. His group also evaluated the carcinogenic potential of d ie se l exhaust, and h is opinion, I think, to date is that they have found that in the n o rm al functioning o r n o rm al efficient engine, there are no polycyclic h y d ro ca r bons that a r e of carcin o g en ic potential. H owever, in a d ie sel that is not functioning, and when the diesel is apparently not idling properly, there can be so m e d ie s e l exhaust which does have som e h y d ro carb o n s, especially 3 - 4 b e n z p y rin e , w hich have carcinogenic potential. T h ey show th is by ?' `ually painting the skins of certain anim als, and proving that skin cani ^ / c a n develop fro m the 3-4 benzpyrine. H owever, in stu d ies actually exposing a n im a ls to inhalations of 3-4 benzpyrine, they w ere unable to develop any evidence of carcinogenic activity. T h ese studies a re continuing, and will appear in the lite ra tu re . They w ill be of g re a t v alue to future claim s of c a n c e r fro m d ie se l exhaust. MODERATOR KArLAN: Thank you. Dr. Cyran. Now, to c o n tra st th is view that diesel exhausts a r e not d elete rio u s to th e h e a lth of an in d iv id u a l, I a m going to ste p out of b o u n d s a lit tle and go into the audience and ask Dr. Carouge, the A ssistant M edical and Sur gical D irecto r, fo r the B altim ore and Ohio R ailroad, to d iscu ss a case which was handled by the Mayo Clinic. T his will im p re ss you with the type of m edical-legal action that has to be anticipated due to exposure to d iesel exhaust. 158 ' DR. CAROUGE: In July 1963, a locomotive firem an rep o rted off sick and sought m ed ical ca re from his local attending physician. He told him that he was suffering with p e rip h e ra l neuritis, and in turn, re fe rre d him to the Mayo Clinic. Shortly a f te r th is, we w ere ad v ised by a le tte r fro m tiie attending physician, at the Mayo Clinic that it was felt this gentleman.'s p erip h eral n e u ritis was s e c o n d a ry to inhalation of fum es fro m h is w ork, i, in tu r n , w rote to the doctor and asked him to please advise the basis on which he felt that this was a fact. In a le tte r which I receiv ed , he said that, " A l though it is tr u e t h e r e is little , if any, docum entation in the L iterature of p o s s ib le r e la tio n s h ip of p e r ip h e r a l n e u r itis to hydrocarbon.:; , we have seen a n u m b er of patients who have had p e rip h e ra l n eu ritis, in whom there was heavy exposure to various volatile hydrocarbons and solve:;', m ix tu re s, and the clinical co u rse which these patients dem onstrated leads us to believe that there is a relationship between peripheral neuritis and exposure to h y d r o c a r b o n s in th e s e i n s t a n c e s . F o r in s ta n c e , we have h ad u n d e r o b s e rv a tio n one in d iv id u al who was exposed to so lv e n ts and c l e a n e r s in his work and who developed a se v e re p erip h e ra l n eu ritis, winch cleared up a f t e r h is e x p o s u re was e l im in a te d . A n o th er in d iv id u a l w as exposed to the fumes from gasoline and diesel m otors and had sim ilar difficulty which also c le a re d up afte r his occupation was changed. Although it is ex tre m ely difficult to prove the relationship of the developm ent of p e r i p h e r a l n e u r i t i s and t h e s e a g e n ts , at tim e s we have b ee n co nvinced enough about the p o s s ib le re la tio n sh ip that we felt ju stified in su g g estin g to this m an that he should a s s id u o u s ly avoid the heavy ex p o su re to h y d ro c a rb o n s to which he was subjected in his work. " We, in turn, put this p roblem to Dr. John C. K rantz, who is a Ph. D and p r o f e s s o r o f t! e D e p a r t m e n t of P h a r m a c o l o g y a t the U n i v e r s i t y of M a r y la n d . We to l d h i m w hat th e c o m p o n e n ts w e r e in the d i e s e l f u m e s which had been analyzed, and he wrote back and staged that, "Of a ll the constituents p re s e n t in the gas, the fum es to which the firem an was e x posed that might have caused peripheral neuritis, carbon monoxide is the only one that can be incrim inated: it has been shown that repeated e x posure to this agent c a u se s degeneration of the nervous sy stem , and m ic r o scopic exam ination rev e als specific damage to the nerve cells. Long exposure produces lack of sensitivity in the fingers which is indicative of neuritis. " Inasm uch as we felt th e re was not a high enough co n cen tratio n of carbon monoxide eith er in the diesel cab o r the atm osphere adjacent th e re to to cau se the n eu ritis, we would not accept his claim of re la tio n sh ip of the neuritis with his work. MODERATOR KAPLAN: Dr. Hollo has also been in te reste d in any p o s sible rela tio n sh ip of d iesel exhaust to production of lung pathology and will now cite h is exp erien ces in th is field. Dr. Hollo. DR. HOLLO: Thank you. D r. Kaplan. F ir s t of a ll, m y person al co n tacts in studies o f Carcinom a of Lung among railroad em ployees have' been strictly on a clin ic b a sis. All of our pulmonary disease.; n.ring s u rg e ry have been r e f e r r e d to o u r Consultant C hest Surgeon, D r, T hom as Burford, who is on the staff of Washington U niversity Group - B arnes Hospital. In a s e r i e s of c a s e s of one thousand and eight p a tie n ts with p r im a r y C a rc in o m a of the Lung, betw een January 1, 1948 and D ecem b er 31, 1955, the d istrib u tio n of Lung C a n c e r by Age is as follows, as re p o rte d by Dr. Burford: A^e 20-29 30-39 40-49 50-59 ' 60-69 70-79 80-89 T otals Number 2 . 22 164 375 361 80 4 1, 008 P er Cent 2 17 37 36 8 100 T he S u rg ic al Pathology Division at B arnes H ospital reco g n izes the following classification: A. E p id e rm o id C arc in o m a B. U n d iffe re n tia ted C a rc in o m a C. A denocarcinom a D. D ro n c h io la r (A lveolar Cell) C arcinom a E. S m all (Oat) Cell C arcinom a All cases of B ronchial Adenomata have been excluded from this se rie s. ^ y i e histologic natu re of the tum ors is as follows: lXE2 E piderm oid Number 572 U nd ifferen tiated 287 A denocarcinom a 107 Bronchiolar 13 Sm all (Oat) C ell 15 Mixed E piderm oid and Adenocarcinoma T otals 160 14 1.008 P er Cent 57. 0 28. 5 10. 5 1.0 1.5 1. 5 100. 0 Of the 35% o f the to ta l group that was r e s e c te d , 22% su rv iv e d 3 y e a r s . T h e re w ere no 5 y e a r s u r v iv o r s in the group that was not rv s'-o ted , no m a t t e r what the t r e a t m e n t w as. 70% of the n o n - r e s e c t e d group w ere dead within 6 m onths. If th o se who survived 5 y e a rs after resection a re related to th e t o t a l 1, 008 c a s e s , th e o v e r - a l l c u r e r a t e is 9%. Dr. B urford sta te d that the c ritic a l p erio d of su rv iv al in this s e rie s was the f irs t 30 m onths afte r resection. Of the patients who survived at l e a s t 30 m o n th s , 7 5% liv e d to b e c o m e 5 y e a r s s u r v i v o r s . Dr. B urford also sta te d that th ere is no g r e a te r incidence of B ro n ch o genic C arcin o m a am ong r a ilro a d w orkers than am ong the g en eral m ale population. 1 think everybody has repeatedly heard these papers presented. T here is only one p aper that has im p ressed me, and this is of great im portance w ith r e f e r e n c e to r a i l r o a d e m p l o y e e s . It w as th e r e p o r t f r o m tine1A d v i s o r y C om m ittee of H ealth, which was given to me by Dr. Kaplan, on railro a d d iesel gas and dust. T h is w ork was ca rrie d out by the Public Utilities C o m m is s io n in C a l i f o r n i a , and in s u m m a r y again th e y show no p a r t i c u l a r relationship between the d ie se l fum es in ra ilro a d w o rk ers as being of a g r e a t e r in c id e n c e a m o n g s t th is occupation v e r s u s o t h e r s in the lo c a le . Now, re tu rn in g to the re p o r t that D r. C y ran p re se n te d on chronic, obstructive pulm onary em physem a, I will read one paragraph from National Tuberculosis A ssociation, which I think w arrants reading: (7) T H E M E D IC O L E G A L A S P E C T S O F C. O. P . E. a r i s e not i n f r e quently, p a r tic u la r ly in w orkm en who m a n ife st the d ise a se and who a t tribute it to occupational exposure. T heir physicians may have supported su c h a c l a i m o ut o f th e c o n v ic tio n tha t ari e t io lo g ic r e l a t i o n s h i p to c o n ditions of em ploym ent existed. The present Oregon Industrial Accident Laws re q u ire that to be "occupational" a d ise a se m ubt be "P e c u lia r to the i n d u s t r i a l p r o c e s s , t r a d e , o r o c c u p a t io n " and " a r i s e o u t o f a n d in. th e scope of such em p lo y m en t. " In o u r p rese n t sta te of knowledge of em p h y sem a, especially the weight given to smoking in its causation, and fro m the experience of seein g the d isease in many "white co llar" w o rk ers as well as in those exposed to possibly noxious and ir rita tin g dusts and fu m es, one m ust conclude that g e n e ra lly speaking, C. O. P . E. does not fit into this definition of an occupational disease. Only in the occasional case of bronchial asth m a c le a rly re la te d to occupation and eventually com plicated by C. O. P . E. would on e d e c id e in fa v o r of th e w o rk m a n . It is p o s s i b le , and even p ro b ab ly , that o cc u p atio n al e x p o su re h a s a g g ra v ate d em p h y sem a in many p atien ts, if only by contributing to th e ir cough and bronchospasm , but exacerbation of a pre-existing disease by occupational exposure is not com pensable u n d er Oregon Law. " MODERATOR KAPLAN: Thank you. Sim ilar opinions are also e x p r e s s e d in my paper that was published in the Journal of the AMA (D e ce m b er 12, 1959). It p resen ted a r a th e r co m p reh en sive study o f 6,5 0 6 d e a th s a m o n g railroad w orkers; and th is included 800 deaths from a ll types of m alignancy of which 154 involved lung ca n c e r . T h is study indicated that noxi. r, g a ses actually w ere not a factor in the nrr>rinr*;nn n s u rg e ry have been r e f e r r e d to o u r Consultant C hest Surgeon, D r. T hom as Burford, who is on the sta ff of Washington U niversity G roup - B arnes Hospital. In a s e r i e s of c a s e s of one thousand and eight p a tie n ts with p r im a r y C arc in o m a o f the Lung, betw een January 1, 1948 and D ecem b er 31, 1955, the d istrib u tio n of Lung C a n c e r by Age is as follows, as re p o rte d by Dr. Burford: Age 20-29 30-39 40-49 * 50-59 ' 60-69 70-79 80-89 T otals Number 2 . 22 164 375 361 80 4 1, 008 P er Cent 2 17 37 36 8 100 T h e S u r g i c a l P a t h o l o g y D iv is io n at. B a r n e s H o s p i t a l r e c o g n i z e s th e following classification'. A. E p id e rm o id C a rc in o m a B. U n d iffe re n tia te d C a rc in o m a C. A denocarcinom a D. D ro n c h io la r (A lveolar Cell) C arcinom a E. Sm all (Oat) Cell C arcinom a All cases of B ronchial Adenomata have been excluded from this se rie s. ^ y i e histologic n atu re of the tum ors is as follows: IiE E piderm oid Number 572 P er Cent 57. 0 Undifferentiated 287 28. 5 A denocarcinom a Bronchiolar Sm all (Oat) C ell Mixed E piderm oid and Adenocarcinoma Totals 160 107 13 15 14 1.008 10. 5 1.0 1.5 1. 5 100.0 Of the 3 5% o f the to ta l group that was r e s e c t e d , 22% su rv iv e d 3 y e a r s . T h e re w ere no 5 y e a r s u r v iv o r s in the group that w as not rv s'-u ted , no m a t t e r what the t r e a t m e n t w as. 70% of the n o n - r e s e c t e d group w ere dead within 6 m onths. If th o se who survived 5 y e a rs after resection a re related to th e t o t a l 1, 008 c a s e s , th e o v e r - a l l c u r e r a t e is 9%. Dr. B urford sta te d that the c ritic a l p erio d of su rv iv al in this s e rie s was the f irs t 30 m onths afte r resection. Of the patients who survived at l e a s t 30 m o n th s , 7 5% liv e d to b e c o m e 5 y e a r s s u r v i v o r s . Dr. B u rfo rd also sta te d that th e re is no g r e a te r incidence of B ro n ch o genic C arcinom a am ong ra ilro a d w orkers than am ong the g en eral m ale population. 1 think everybody has repeatedly heard these papers presented. T here is only one paper that has im p ressed me, and this is of great im portance with r e f e r e n c e to r a i l r o a d e m p lo y e e s . It w as the r e p o r t f ro m t i n e ' A d v is o r y C om m ittee of H ealth, which was given to me by Dr. Kaplan, on railro a d d iesel gas and dust. T h is work was c a rrie d out by the Public Utilities C o m m is s io n in C a l i f o r n i a , and in s u m m a r y again th ey show no p a r t i c u l a r relationship between the d iesel fumes in railro a d w orkers as being of a g r e a t e r in c id en c e a m o n g s t th is occupation v e r s u s o t h e r s in the lo c a le . Now, r e tu rn in g to the r e p o rt that D r, C y ran p re se n te d on chronic, obstructive pulm onary em physem a, I will read one paragraph from National T uberculosis A ssociation, which I think w arrants reading: (7) T H E M E D IC O L E G A L A S P E C T S O F C . O. P . E. a r i s e not i n f r e quently, p a r tic u la rly in w orkm en who m a n ifest the d ise a se and who a t tribute it to occupational exposure. T heir physicians may have supported s u c h a c l a i m o u t o f th e c o n v i c ti o n th a t ari e t io lo g ic r e l a t i o n s h i p to c o n ditions of em ploym ent existed. The present Oregon Industrial Accident Laws req u ire that to be "occupational" a d ise a se mufet be "P e c u lia r to the i n d u s t r i a l p r o c e s s , t r a d e , o r o c c u p a t io n " and " a r i s e o u t o f a n d in. th e scope of such em p lo y m e n t. " In o u r p re se n t sta te of knowledge of e m p h y sem a, especially the weight given to smoking in its causation, and fro m the experience of seein g the d ise ase in many "white co llar" w o rk ers as well as in those exposed to possibly noxious and ir rita tin g dusts and fu m es, one m ust conclude that g en erally speaking, C. O. P . E. does not fit into this definition of an occupational d isease. Only in the occasional case of bronchial asth m a c le a rly re la te d to occupation and eventually com plicated by C. O. P . E. would one d e c id e in fa v o r of th e w o rk m a n . It is p o s s ib le , and even p ro b ab ly , that o c c u p a tio n a l ex p o su re h a s a g g ra v ate d em p h y sem a in many p atien ts, if only by contributing to th e ir cough and bronchospasm , but exacerbation of a p re -e x istin g disease by occupational exposure is not com pensable u n d er Oregon Law. " MODERATOR KAPLAN: Thank you. Sim ilar opinions are a lso e x p r e s s e d in my paper that was published in the Journal of the AMA (D e c e m b e r 12, 1959). It p resen ted a r a th e r co m p reh en sive study o f 6 ,5 0 6 d e a th s a m o n g railroad workers; and th is included 800 deaths from all types of malignancy of which 154 involved lung ca n c e r . T h is study indicated that noxi.. r: g a se s actually w ere not a factor in t he nrr>rinr*;nn ' Ac had n io i e iU.ig c a n c e r in o u r c l e r k s than we did in th o s e who -were exposed to diesel fumes and o th er noxious gases either in shop or engine operations. As stated b efo re, we a r e not going to discuss the tobacco controversy. V>e h a d a l s o in c lu d e d t h i s in t h e o r i g i n a l lur.g c a n c e r i n v e s t i g a t i o n , and, as in o th e r stu d ies, it indicated that lung can cer was definitely associated with an ex cessiv e am ount.of c ig a re tte sm oking, especially in clerk s. T h e next question is d ire c te d to D r. Z eiss: Should em ployees with lo b ecto m ies o r pneum onectom ies be p e rm itte d to re tu rn to w ork? DR. ZEISS: I believe we m ust consider the fact that we are dealing here with a .p e rso n who has a large p a rt of th e ir vital capacity rem oved, and so c o n s e q u e n tly , we m u s t be v e r y c a r e f u l in w h ere we p la c e th is in d iv id u.\ I a m quite in fav o r of p la c in g the individual only in a s e d e n ta ry p o w i o n and avoiding all h a r m fo r th at individual, b ecause in m y own p r i v a t e p r a c t i c e , I have had two o n e - lu n g p a tie n ts who w ere involved in au to m o b ile accid en ts; both th ese individuals had fra c tu re d rib s on the good s id e , and both died w ithin 24 h o u r s . When we in the ra ilw a y b u s in e s s a t t e m p t to p ut a m a n b ac k t o w o rk an d e x p o s e h im to h a z a r d s , we m u s t r e m e m b e r that he might injure the good side, break his rib s, get a c o n tused lung, pleurisy or even a pneumonia, cause alm ost instant death, and we are liable. M OD ERA TOR KAPLAN: Dr. R osen, a s a re p re se n ta tiv e of the R ailroad R etirem ent Board, what i s your attitude, or that of the Board as far as d isqualifying o r granting an annuity to an em ployee who has had a lobectomy o r p n eu m o n ec to m y and h a s been d isq u a lifie d by the c a r r i e r ' s m e d ic a l o f f ic e r , y e t h a s been co n s id e re d able for duty by his p e rso n a l p hysician? L et's say he has had a pulm onary carcinom a removed, has had a lo bectom y, and for all p ra c tic a l p u rp o se s ap p ears to have gotten a socalled " c u re ." DR^*^^OSEN: We u s u a l l y go a l o n g w ith the c a r r i e r and s a y t h a t he c a n work. MODERATOR KAPLAN: The c a r r ie r says he can't work, but the family physician gives us a c e rtific a te th at the m an is able to work. DR. ROSEN: Are we talking about to ta l and perm anent disability? MODERATOR KAPLAN: As an ex am p le, we have a p an elist who says he will not p erm it his em ployee to go to work because the latter has had a lobectom y for rem o v a l of p u lm onary c a rcin o m a . His fam ily doctor and his su rg eo n stated he could go to w ork. He h as had 30 y e a r s / se rv ic e , and is 60 y e a r s of age. DR. ROSEN: We would go alo n g w ith th e c a r r i e r . If the c a r r i e r r e c o m m ends that he is not able to w ork, we would go along with the c a r r i e r essentially. 1 RO You came up specifically with an occupational type of case, not a total and permanent disability case. MODERATOR KAPLAN: L e t's put it another way. Suppose he didn't have h is o c c u p a tio n a l r e q u i r e m e n t s , h a v in g but 17 y e a r s of s e r v i c e , and being 54 y e a r s of ag e. DR. ROSEN: Well, on that b a s is, I think that we would be influenced by p u lm o n ary function stu d ie s. If the v ita l cap acity w as substantially r e duced to one second and two seco n d v ita l cap acity , and if the m axim um b r e a t h i n g c a p a c ity w as s u b s t a n t i a l l y r e d u c e d , by th a t, I m e a n below 50 p e r cent, why, we would say that m an is totally and perm anently disabled. M ODERATOR KAPLAN: T h en p e r h a p s we a r e b ein g u n fair to the e m p lo y ee by disqualifying him without r a th e r thorough and extensive pulm onary stu d ies to determ ine w hether he has the functional capacity to work? DR. ROSEN: I think that is true. DR. HOLLO: F irs t of all, if an individual has had a pneumonectomy, o b v io u s ly h is f u n c ti o n a l c a p a c i t y is l e s s th a n 50 p e r cent. DR. ROSEN: That is not true. MODERATOR KAPLAN: We have o ther opinions on the subject. This is an important question, well worthy of discussion. DR. LEIGH: I always feel, re g a rd le s s of pneum onectom y d r oth er cau se, if you get a vital capacity of le s s than 60 p e r cent you have got an im p a i r e d m an who ca n r ot p e r f o r m in r a i l r o a d s e r v ic e . I would like to get an opinion from others w hether they agree o r not. , MODERATOR KAPLAN: L e t's suppose the em ployee has had a segm ental lobectomy or pneumonectomy, and postoperatively has a functional vital ca p ac ity in e x c e s s of 60 p e r cent. Would you disq u alify him from going back to work just because he had an operation for rem oval of carcinom a of the lung? V DR. LEIGH: If he g oes below 60 p e r c e n t, I fee l he is not going to do ' his work. MODERATOR KAPLAN: T his holds for any disease then ? DR. LEIGH: Yes. DR. CYRAN: W asn't th e re a c a s e , I think d isc u sse d in one of the AAR B ulletins a y e a r back or so , w h ere the New Y ork C en tral disqualified a man? MODERATOR KAPLAN: Y es, a trackman named BraswelL n o p v d h . Ac had n io i e iU.ig c a n c e r in o u r c l e r k s than we did in th o s e who -were exposed to diesel fumes and o th er noxious gases either in shop o r engine operations. As stated b efo re, we a r e not going to discuss the tobacco controversy. We h a d a l s o in c lu d e d t h i s in t h e o r i g i n a l lur.g c a n c e r in v e s tig a tio n , and, as in o th e r stu d ies, it indicated that lung can cer was definitely associated with an ex cessiv e am ount.of c ig a re tte sm oking, especially in clerk s. T h e next question is d ire c te d to D r. Z eiss: Should em ployees with lo b ecto m ies o r pneum onectom ies be p e rm itte d to re tu rn to w ork? DR. ZEISS: I believe we m ust consider the fact that we are dealing here with a .p e rso n who has a large p a rt of th e ir vital capacity rem oved, and so c o n s e q u e n tly , we m u s t be v e r y c a r e f u l in w h ere we p la c e th is in d iv id u.\ I a m quite in fav o r of p la c in g the individual only in a s e d e n ta ry p o W io n and avoiding all h a r m fo r th at individual, b ecause in m y own p r i v a t e p r a c t i c e , I have had two o n e - lu n g p a tie n ts who w ere involved in au to m o b ile accid en ts; both th ese individuals had fra c tu re d rib s on the good s id e , and both died w ithin 24 h o u r s . When we in the ra ilw a y b u s in e s s a t t e m p t to p ut a m a n b ac k t o w o rk an d e x p o s e h im to h a z a r d s , we m u s t r e m e m b e r that he might injure the good side, break his rib s, get a c o n tused lung, pleurisy or even a pneumonia, cause alm ost instant death, and we are liable. M OD ERA TOR KAPLAN: Dr. R osen, a s a re p re se n ta tiv e of the R ailroad R etirem ent Board, what i s your attitude, or that of the Board as far as d isqualifying o r granting an annuity to an em ployee who has had a lobectomy o r p n eu m o n ec to m y and h a s been d isq u a lifie d by the c a r r i e r ' s m e d ic a l o f f ic e r , y e t h a s been co n s id e re d able for duty by his p e rso n a l p hysician? L et's say he has had a pulm onary carcinom a removed, has had a lo bectom y, and for all p ra c tic a l p u rp o se s ap p ears to have gotten a socalled " c u re ." DR^~I^OSEN: We usually go along with the c a r r ie r and say that he can work. MODERATOR KAPLAN: The c a r r ie r says he can't work, but the family physician gives us a c e rtific a te th at the m an is able to work. DR. ROSEN: Are we talking about to ta l and perm anent disability? MODERATOR KAPLAN: As an ex am p le, we have a p an elist who says he will not p erm it his em ployee to go to work because the latter has had a lobectom y for rem o v a l of p u lm onary c a rcin o m a . His fam ily doctor and his su rg eo n stated he could go to w ork. He h as had 30 y e a r s / se rv ic e , and is 60 y e a r s of age. DR. ROSEN: We would go alo n g w ith th e c a r r i e r . If the c a r r i e r r e c o m m ends that he is not able to w ork, we would go along with the c a r r i e r essentially. 1 RO You came up specifically with an occupational type of case, not a total and permanent disability case. MODERATOR KAPLAN: L e t's put it another way. Suppose he didn't have h is o c c u p a tio n a l r e q u i r e m e n t s , h a v in g but 17 y e a r s of s e r v i c e , and being 54 y e a r s of ag e. DR. ROSEN: Well, on that b a s is, I think that we would be influenced by p u lm o n ary function stu d ie s. If the v ita l cap acity was substantially r e duced to one second and two seco n d v ita l cap acity , and if the m axim um b r e a t h i n g c a p a c ity w as s u b s t a n t i a l l y r e d u c e d , by th a t, I m e a n below 50 p e r cent, why, we would say that m an is totally and perm anently disabled. M ODERATOR KAPLAN: T h en p e r h a p s we a r e b ein g u n fair to the e m p lo y ee by disqualifying him without r a th e r thorough and extensive pulm onary stu d ies to determ ine w hether he has the functional capacity to work? DR. ROSEN: I think that is true. DR. HOLLO: F irs t of all, if an individual has had a pneumonectomy, o b v io u s ly h is f u n c ti o n a l c a p a c i t y is l e s s th a n 50 p e r cent. DR. ROSEN: That is not true. MODERATOR KAPLAN: We have o ther opinions on the subject. This is an important question, well worthy of discussion. DR. LEIGH: I always feel, re g a rd le s s of pneum onectom y d r oth er cau se, if you get a vital capacity of le s s than 60 p e r cent you have got an im p a i r e d m an who canr ot p e r f o r m in r a i l r o a d s e r v ic e . I would like to get an opinion from others w hether they agree o r not. , MODERATOR KAPLAN: L e t's suppose the em ployee has had a segm ental lobectomy or pneumonectomy, and postoperatively has a functional vital cap acity in e x c e s s of 60 p e r cent. Would you disq u alify him from going back to work just because he had an operation for rem oval of carcinom a of the lung? V DR. LEIGH: If he g o es below 60 p e r c e n t, I fee l he is not going to do ' his work. MODERATOR KAPLAN: This holds for any disease then ? DR. LEIGH: Yes. DR. CYRAN: W asn't th e re a c a s e , I think d isc u sse d in one of the AAR B ulletins a y e a r back or so , w h ere the New Y ork C en tral disqualified a man? MODERATOR KAPLAN: Y es, a trackman named BraswelL n o p v d h . M ODERATOR K A PLA N : He c o lla p s e d while a s s is ti n g in c a r ry in g tie s and in ju re d h im s e lf. The court, r u le d that the r a il r o a d was not Liable for the in ju rie s b ec au se the plaintiff was unable to show a cau sal co n n ec tion for the collapse. T hus, from the legal standpoint. Dr. Z eiss, I think the co u rts a r e upholding us in allow ing these m en to retu rn to work following lobectom y. DR. G R A H A M : O n t h e o t h e r h a n d , to c i t e t h e o t h e r a n g le , we had a c a s e of t u b e r c u l o s i s in a W o rld W a r II v e t e r a n . He w as d is q u a lif ie d by sp e cia lists in the VA about six y e a rs ago because of m arked fibrosis, and he had about a 30 p e r cent loss of function. The man was having difficulty in w orking and w as only w orking about th r e e - f o u r th s of the tim e. He got a ra ilro a d re tire m e n t, and was off about two y e a rs when the sam e sp e c ia l i s t f r o m th e VA t h e n c e r t i f i e d h i m a s b e i n g a b l e to r e t u r n to w ork. We si h im to o u r s p e c i a l i s t s a n d th ey did lu n g function s tu d ie s on him . T?Wy s a i d he h a d a b o u t a 30 p e r c e n t l o s s , and th e y a g r e e d that he p r o bably could w ork, but m ight have a little sh o rtn e s s of breath on heavy exertion. We allow ed this m an to r e tu rn to w ork subsequent to fu rth er o b se rv a tio n , and we have had periodic r e p o r ts every two months, every four m onths and e v e ry six m onths. He has w orked ra th e r steadily for the last two y e a rs without any serio u s com plaint so far as we are con cerned. MODERATOR KAPLAN: Very true. L aboratory tests are frequently not an accurate index. DR. ROSEN: In th a t se co n d c a te g o ry , we m u s t go by c e rta in definitions of the law; and you people a re thinking in te rm s of putting him back to work. The second p a rt of the Act on total perm anent disability says, "T his man m ust be p e rm a n en tly disabled to p e rfo rm any reg u la r em ploym ent. " Now, "any re g u la r em ploym ent" in any industry . That takes in a lot of t e r r i t o r y . It d o e s n 't n e c e s s a r ily m e an th a t th is individual can do the work that he was doing in the railro a d . I don't know if you follow me on thi oint o r n o t. In o t h e r w o r d s , a n y d e s k j o b , a m a n with a GO p e r ccrtrtnaxim um breathing capacity should be able to perfo rm a desk job. 'M ODERATOR KAPLAN: In sum m ation, em ploy ees in laborious o ccu p a tions can be p erm itted to resu m e duty following lung surgery, provided the rem ain in g lung tissu e is norm al and th e re is adequate breathing capacity. Many individuals in the 55-60 y e a r group have a reduction in vital capacity corresponding to that of a lobectom y. Due to tim e lim itation, we will now d is c u s s noxious fumes in tunnel operations. It is fascinating to pass through the long tunnels in West Virginia and observe m em bers of this c ra ft at work. They have regular assignm ents as tunnel su pervisors, m echanics, trackm en and laborers, and generally spend th e ir working c a re e rs as such. T heoretically, one would assu m e that if exposure to d ie se l fum es and gases produced p u l monary changes, then this would certainly be the group of employees where we would find pathology, such as tu b e rc u lo sis, silico sis, pulm on ary em physem a, chr<5nic b ro n ch itis, fib ro s is , o r lung c a n c e r. H ov.c\cr our sta tistic s fail to reveal this. I am going to a s k D r. Wight, who has had much ex p e rien c e v/ith Canadian tunnel work, to elucidate on this subject, and tell us w hether or not he thinks em ployees should work with re s p ira to rs and how much tu b ercu lo sis o r silico sis is found in such w orkers. P erh ap s he might also d isc u ss the relatio n sh ip of tunnel fum es and gases to the production of certain respiratory d iseases, such as chronic bronchitis. DR. WIGHT: T h a n k you v e r y m u c h . B r e a k f a s t w ill be s e r v e d in 10 hours. (Laughter) Before answ ering that question, I would like to make a few r e m a r k s about some things that have been said so far. A ir pollution. A ir pollution is an im portant thing, but is is so m e thing that is m isunderstood to a c e rta in extent. People a re too im p re s s e d by figures. In England a ir pollution is v e ry high, p a rtic u la rly the sulphurs. T h e r e a r e m illio n s o f t o n s - - m i l l i o n s o f to n s p e r annum , it is p h y s ic a lly possible to rem ove the sulphur content from the gases, and they did in an ex p erim ent at the B attersb y P o w e r Works on the Tham es in London, w h ere they generate power from soft coal. They had the smoke bek.king out and polluting the a tm o s p h e re . Nobody paid any attention to it. They u sed that as a pilot study. They in stalled a m eans of rem oving the sulphur which basically was washing the gases with w ater from the T ham es, and they can rem ove the sulphur 9 5 p e r cent. They did this. After they had rem oved the sulphur 9 5 p er cent, they wore flooded with com plaints about sulphur in the a i r around the B attersby Power House. Ninety-five per cent of it had been rem oved. They couldn't understand it until they studied it further, and it was so sim ple. The hot gates com ing out burned through the clouds, dissipated through the countryside and n o body knew anything about it. The coal g ases, as they were, after they had washed the sulphur out, w ere re fle c te d in a num ber of m ushroom e f fects from the clouds and fell in a s m a ll a r e a around the power house, and the 5 p e r cent of the sulphur left everybody in that area com plaining about it. i Now, in answ er to the question: Should tunnel w orkers be forced to work with r e s p ir a to r s ? I d o n 't think so. We can 't se e any reason fo r it. MODERATOR KAPLAN:. Thank you . D r. Wight. Is th e re anyone else who m ight w ish to m ake a few com m ents on the subject of tunnel exhaust or fum es or g ase s ? DR. GRAHAM: W asn't this a CNR stu d y about four y ears ago? DR. WIGHT: No, the CNR did a d eta iled study under the river between D etroit and W indsor. D r. Vaughan can m m '-"'--.* - ' M ODERATOR K A PLA N : He c o lla p s e d while assistin ',' in c a r ry in g tie s and in ju re d h im s e lf. The c o u r t r u le d that the r a il r o a d was not Liable for the in ju rie s b ec au se the plaintiff was unable to show a cau sal co n n ec tion for the collapse. T hus, from the legal standpoint. Dr. Z eiss, I think the co u rts a r e upholding us in allow ing these m en to retu rn to work following lobectom y. DR. G R A H A M : O n t h e o t h e r h a n d , to c i t e t h e o t h e r a n g le , we had a c a s e of t u b e r c u l o s i s in a W o rld W a r II v e t e r a n . He w as d is q u a lif ie d by sp e cia lists in the VA about six y e a rs ago because of m arked fibrosis, and he had about a 30 p e r cent loss of function. The man was having difficulty in w orking and w as only w orking about th r e e - f o u r th s of the tim e. He got a ra ilro a d re tire m e n t, and was off about two y e a rs when the sam e sp e c ia l i s t f r o m th e VA t h e n c e r t i f i e d h i m a s b e i n g a b l e to r e t u r n to w ork. We si h im to o u r s p e c i a l i s t s a n d th ey did lu n g function s tu d ie s on him . TrWy sa id he had about a 30 p e r c e n t lo s s , and they a g re ed that he p r o bably could w ork, but m ight have a little sh o rtn e s s of breath on heavy exertion. We allow ed this m an to r e tu rn to w ork subsequent to fu rth er o b se rv a tio n , and we have had periodic r e p o r ts every two months, every four m onths and e v e ry six m onths. He has w orked ra th e r steadily for the last two y e a rs without any serio u s com plaint so far as we are con cerned. MODERATOR KAPLAN: Very true. L aboratory tests are frequently not an accurate index. DR. ROSEN: In th a t se co n d c a te g o ry , we m u s t go by c e rta in definitions of the law; and you people a re thinking in te rm s of putting him back to work. The second p a rt of the Act on total perm anent disability says, "T his man m ust be p e rm a n en tly disabled to p e rfo rm any reg u la r em ploym ent. " Now, "any re g u la r em ploym ent" in any industry . That takes in a lot of t e r r i t o r y . It d o e s n 't n e c e s s a r ily m e an th a t th is individual can do the w o r k t h a t h e w a s d o in g in th e r a i l r o a d . I d o n 't know if y ou follow m e on thi oint o r n o t. In o t h e r w o r d s , a n y d e s k j o b , a m a n with a GO p e r cetfPSnaximum breathing capacity should be able to perfo rm a desk job. 'M ODERATOR KAPLAN: In sum m ation, em ploy ees in laborious o ccu p a tions can be p erm itted to resu m e duty following lung surgery, provided the rem ain in g lung tissu e is no rm al and th e re is adequate breathing capacity. Many individuals in the 55-60 y e a r group have a reduction in vital capacity corresponding to that of a lobectom y. Due to tim e lim itation, we will now d is c u s s noxious fumes in tunnel operations. It is fascinating to pass through the long tunnels in West Virginia and observe m em bers of this c r a ft at work. They have regular assignm ents as tunnel su pervisors, m echanics, trackm en and laborers, and generally spend th e ir working c a re e rs as such. T heoretically, one would assu m e that if exposure to d ie se l fum es and gases produced p u l monary changes, then this would certainly be the group of employees where we would find pathology, such as tu b e rc u lo sis, silico sis, pulm on ary em p h y sem a. ch r 6 nic b ro n ch itis, fib ro s is , o r lung c a n c e r. However our sta tistic s fail to reveal this. 1 am going to a s k D r. Wight, who h as had much ex p e rien c e v/ith Canadian tunnel work, to elucidate on this subject, and tell us w hether o r not he thinks em ployees should work with re s p ira to rs and how m ud) tu b ercu lo sis o r silico sis is found in such w orkers. P erh ap s he might also d isc u ss the relatio n sh ip of tunnel fum es and gases to the production of certain respiratory d iseases, such as chronic bronchitis. DR. WIGHT: T h a n k you v e r y m u c h . B r e a k f a s t w ill be s e r v e d in 10 hours. (Laughter) Before answ ering that question, I would like to make a few r e m a r k s about some things that have been said so far. A ir pollution. A ir pollution is an im portant thing, but is is so m e thing that is m isunderstood to a c e rta in extent. People a re too im p re s s e d by figures. In England a ir pollution is v e ry high, p a rtic u la rly the sulphurs. T h e r e a r e m i l l i o n s o f t o n s - - m i l l i o n s o f to n s p e r annum . It is p h y s i c a l l y possible to rem ove the sulphur content from the gases, and they did in an ex p erim ent at the B attersb y P o w e r Works on the Tham es in London, w h ere th e y g e n e r a t e p o w e r f r o m s o f t c o a l. T h e y h a d th e sm o k e b-o ! .l; ing out and polluting the a tm o s p h e re . Nobody paid any attention to it. They u sed that as a pilot study. They in stalled a m eans of rem oving tn: sulphur which basically was washing the gases with w ater from the T ra m e s, and they can rem ove the sulphur 9 5 p e r cent. They did this. After they had rem oved the sulphur 9 5 p er cent, they wore flooded with com plaints about sulphur in the a i r around the B attersby Power House. Ninety-five per cent of it had been rem oved. They couldn't understand it until they studied it further, and it was so sim ple. The hot gates com ing out burned through the clouds, dissipated through the countryside and n o body knew anything about it. The coal g ases, as they were, after they had washed the sulphur out, w ere re fle c te d in a num ber of m ushroom e f fects from the clouds and fell in a s m a ll a r e a around the power house, and the 5 p e r cent of the su lp h u r left, e v e ry b o d y in that a re a c o m p la in in g about it. i Now, in answ er to the question: Should tunnel w orkers be forced to work with r e s p ir a to r s ? I d o n 't think so. We can 't se e any reason fo r it. MODERATOR KAPLAN:. Thank you . D r. Wight. Is there anyone e ls e who might w ish to make a few comments on the subject of tunnel exhaust or fum es or gases ? DR. GRAHAM: W asn't this a CNR stu d y about four y ears ago? DR. WIGHT: No, the CNR did a d eta iled study under the river between D etroit and W indsor. D r. Vaughan can rnm m m* . > DR. VALGHAN': A c s, we did two s tu d ie s . Wc have two m ain tunnels in o u r s y s te m , one un d er the St. C la ir R iv e r, as h as been mentioned, which is slig h tly over a m ile long, and one through Mount Royal in M ontreal which is about th re e m iles long. We did e x h a u stiv e studies in these two tunnels and we found that th e re w as no h a z a rd fro m se rio u s concentration of toxic gases. T h e r e w as an ac cum ulation s o m e tim e s of a la rg e am ount of p a r t i c u late m a tte r, which m ight have been irrita tin g , but it was an inert p a r ticulate m a tte r, and the gases really didn't reach any hazardous concen tration. MODERATOR KAPLAN: Thank you. D r. Vaughan. Incidentally, in 1959, I w rote to D r. H alperin who was and still is the Chief M edical E xam iner fo r th e C ity of New Y ork and as k e d h im about noxious fumes in th eir two tiV y l s ( L i n c o l n an d H udson). T h i s w a s o f i n t e r e s t s in c e I was at th a t tim e w ritin g the p a p e r on lung c a n c e r. He s ta te d , even though the sp e c ia l p o lic e w orked e ig h t-h o u r sh ifts, th e re w ere no unusual health incidents and th e y have had no m o re r e s p i r a t o r y d is e a s e o r lung c a n c e r than one would find in the gen eral public. T his is another factor which leads us to b elieve that gasoline and d ie sel fum es a r e not quite as noxious as som e of these a ir pollution experts would have us believe. M O D E R A T O R KAPLAN: D r. L ongew ay, would you be kind enough to a n s w e r t h e q u e s t i o n , s h o u ld r a i l r o a d e m p l o y e e s who ax-e c o n s ta n t ly e x posed to noxious fumes or lung irritan ts have routine chest x -ray s? L R. LONGEW AY: We know th at c o n s ta n t e x p o s u re to noxious fum es and lung irrita n ts cause pulmonary irritatio n and pulmonary disease. The sim p le s t way to detect these is by c h e st x -ra y . B ronchitis is probably the m ost common, and it may m ask a lot of things, such as carcinom a, tuberculosis or emphysema. So, I think p erio d ic ro u tin e c h e s t x - r a y s a r e v e ry much in o rd e r. V/ I also think it would be trem en d o u sly im portant, a lm o st as im p o r tant as back x - ra y s , to get chest x - r a y s to use as a base line o r guide. M ODERATOR KAPLAN: I think it is also of in te re s t to take p r e - e m p lo y m ent ch est x -ra y s from the standpoint of getting the approxim ation of the cardiac silhouette, because some young people have enlarged hearts, and tn e re is no re a so n to burden m anagem ent with a potential ca rd ia c when you can elim inate him at the pre-placem ent stage. DR. WINTERS: What are these noxious fum es ? A ll o thers have said th e re a r e no noxious fum es. MODERATOR KAPLAN: Do you want to get into that. Dr. Longeway ? DR. LONGEWAY: T here are a lot of noxious fum es. You gave us a paper which shows a lot of things that a re in terestin g there, and actually sm og is a very common thing that we see in som e of our cities, w hich.certainly , 1 acts as a noxious fume to just the ordinary citizen. M O D E R A T O R K A PL A N : On th e s a m e q u e s t i o n , as to what is m e an t hy noxious fum es, we know that d ie se l fum es have as by-products, car' n monoxide, carbon dioxide, nitrous oxide, su lp h u r dioxid-, and aide., des. These chem icals in high concentration can be very irritant, especially to lung tissue that is abnorm al. W hereas, em ployees with healthy L u g s can to le rate in c re a se d concentrations of d ie se l exhaust, o th ers with disea lungs will cough and become sh o rt of breath at the same exposure. Welding fumes also contain noxious g ases and can produce "m etal fume fever" due to exposure to zinc, co p p er o r b ra s s . With acetylene burning, the arc rod contains various chem icals, such as carbon, m an g a n e s e , n ic k e l, c h r o m e , s u l p h u r an d i r o n . S o m e r o d s hav e a s high a s .. 18% c h r o m iu m conten t and e c z e m a to u s h an d eru p tio n s and f a c ia l s e n s i tivity have been rep o rted in the m e d ica l lite ra tu re . A paper is being readied for publication concerning a possible relationship of manganese (14% in rods) to P ark in so n ism . Also, in burning operations, such as dism antling of old c a rs , there is e x p o s u re to lead in the paint. In the p a s t, m o st r a ilro a d s used paint and p r im e r undercoating having heavy lead content, and, when burned, the lead fum es are inhal-ed and absorbed into the blood, producing plum bis o r chronic lead poisoning. T here is a possibility of developing an allerg ic reaction due to e x p o su re to noxious fum es. If you are in te re ste d , here is a re p rin t of a v ery unusual case. One of our em ployees m aintained that, every tim e he welded with a sp e cific acetylene cy lin d er and rod, he erupted in h ives and becam e short of breath. We had him e x a m in e d in C in cin n a ti and a dia g n o sis was m ade of p u l m anary em physem a. However, he still m aintained that he was unable to w eld due to the e r u p ti o n an d s h o r t n e s s o f b r e a t h . We b r o u g h t h im to B a ltim o re and did an a c tu a l u sag e t e s t on him . He was taken to o u r local shop, and ch est and skin s p e c ia lis ts w ere a s sig n e d to o b serv e h im at work. The employee used his re g u la r welding unit, with the acetylene cy lin d er and "Airco" rod. Within five m inutes after p re -h e a tin g the ro d , he becam e sh o rt of breath, and within another three m inutes, broke out in u rtic aria over his body. T h e re is no q u estio n but that th is em p lo y ee was sen sitiv e to som ething in the welding p r o c e s s . We a r e not in a p o sitio n to proj ect the an s w e r, although it would be of s c ie n tific i n t e r e s t to d is c o v e r why he re a c te d . Was he sen sitiv e to one of the b y -p ro d u c ts of the acetylene burning, the acetylene itself, or could it have com e fro m the m e ta l rod contents (chrom e m anganese, etc.). It w a s d ecid ed that th is was a compensable issue and, following set tle m e n t, he ap p lied and w as granted a disability annuity. DR. VALGHAN': A c s, we did two s tu d ie s . Wc have two m ain tunncis ia o u r s y s te m , one un d er the St. C la ir R iv e r, as h as been mentioned, which is slig h tly over a m ile long, and one through Mount Royal in M ontreal which is about tn re e m iles long. We did e x h a u stiv e studies in these two tunnels and we found that th e re w as no h a z a rd fro m se rio u s concentration of toxic gases. T h e r e w as an ac cum ulation s o m e tim e s of a la rg e am ount of p a r t i c u late m a tte r, which m ight have been irrita tin g , but it was an inert p a r ticulate m a tte r, and the gases really didn't reach any hazardous concen tration. MODERATOR KAPLAN: Thank you. D r. Vaughan. Incidentally, in 1959, I w rote to D r. H alperin who was and still is the Chief M edical E xam iner fo r th e C ity of New Y ork and as k e d h im about noxious fumes in th eir two t ' V v l s (L incoln and Hudson). T h is was of in te r e s t since I was at that tim e w ritin g the p a p e r on lung c a n c e r. He s ta te d , even though the sp e c ia l p o lic e w orked e ig h t-h o u r sh ifts, th e re w ere no unusual health incidents and th e y have had no m o re r e s p i r a t o r y d is e a s e o r lung c a n c e r than one would find in the gen eral public. T his is another factor which leads us to believe that gasoline and d ie se l fum es a re not quite as noxious as som e of these a ir pollution experts would have us believe. M O D E R A T O R KAPLAN: D r. L ongew ay, would you be kind enough to a n sw e r the question, should ra ilro a d em ployees who are constantly e x posed to noxious fumes or lung irritan ts have routine chest x -ray s? LR. LONGEWAY: We know that co n s tan t e x p o s u re to noxious fum es and lung irrita n ts cause pulmonary irritatio n and pulmonary disease. The sim p le s t way to detect these is by c h e st x -ra y . B ronchitis is probably the m ost common, and it may m ask a lot of things, such as carcinom a, tuberculosis or emphysema. So, I think p erio d ic ro u tin e c h e s t x - r a y s a r e v e ry much in o rd e r. V y also think it would be trem en d o u sly im portant, a lm o st as im p o r tant as back x - ra y s , to get chest x - r a y s to use as a base line o r guide. M ODERATOR KAPLAN: I think it is also of in te re s t to take p r e - e m p lo y m ent ch e st x -ra y s from the standpoint of getting the approxim ation of the cardiac silhouette, because some young people have enlarged hearts, and th e re is no re a so n to burden m anagem ent with a potential ca rd ia c when you can elim inate him at the pre-placem ent stage. DR. WINTERS: What are these noxious fum es ? A ll o thers have said th e re a r e no noxious fum es. MODERATOR KAPLAN: Do you want to get into that. Dr. Longeway ? DR. LONGEWAY: T here are a lot of noxious fum es. You gave us a paper which shows a lot of things that are in terestin g there, and actually sm og is a v e ry com m on thing that we se e in som e of o u r cities, w hich.certainly 1 acts as a noxious fume to just the ordinary citizen. M O D E R A T O R K A PL A N : On th e s a m e q u e s t i o n , as to what is m e an t hy noxious fum es, we know that d ie se l fum es have as by-products, car' n monoxide, carbon dioxide, nitrous oxide, su lp h u r dioxid-, and aide., des. These chem icals in high concentration can be very irritant, especially to lung tissue that is abnorm al. W hereas, em ployees with healthy b r.gs can to le rate in c re a se d concentrations of d ie se l exhaust, o th ers with disea lungs will cough and become sh o rt of breath at the same exposure. Welding fumes also contain noxious g ases and can produce "m etal fume fever" due to exposure to zinc, co p p er o r b ra s s . With acetylene burning, the arc rod contains various chem icals, such as carbon, m an g a n e s e , n ic k e l, c h r o m e , s u l p h u r an d i r o n . S o m e r o d s hav e a s high a s .. 18% c h r o m iu m conten t and e c z e m a to u s h an d eru p tio n s and f a c ia l s e n s i tivity have been rep o rted in the m e d ica l lite ra tu re . A paper is being readied for publication concerning a possible relationship of manganese (14% in rods) to P ark in so n ism . Also, in burning operations, such as dism antling of old c a rs , there is e x p o s u re to lead in the paint. In the p a s t, m o st r a ilro a d s used paint and p r im e r undercoating having heavy lead content, and, when burned, the lead fum es are inhal-ed and absorbed into the blood, producing plum bis o r chronic lead poisoning. T here is a possibility of developing an allerg ic reaction due to e x p o su re to noxious fum es. If you are in te re ste d , here is a re p rin t of a v ery unusual case. One of our em ployees m aintained that, every tim e he welded with a sp e cific acetylene cy lin d er and rod, he erupted in h ives and becam e short of breath. We had him e x a m in e d in C in cin n a ti and a dia g n o sis was m ade of p u l m anary em physem a. However, he still m aintained that he was unable to w eld due to the e r u p ti o n an d s h o r t n e s s o f b r e a t h . We b r o u g h t h im to B a ltim o re and did an a c tu a l u sag e t e s t on him . He was taken to o u r local shop, and ch est and skin s p e c ia lis ts w ere a s sig n e d to o b serv e h im at work. The employee used his re g u la r welding unit, with the acetylene cy lin d er and "Airco" rod. Within five m inutes after p re -h e a tin g the ro d , he becam e sh o rt of breath, and within another three m inutes, broke out in u rtic aria over his body. T h e re is no q u estio n but that th is em p lo y ee was sen sitiv e to som ething in the welding p r o c e s s . We a r e not in a p o sitio n to proj ect the an s w e r, although it would be of s c ie n tific i n t e r e s t to d is c o v e r why he re a c te d . Was he sen sitiv e to one of the b y -p ro d u c ts of the acetylene burning, the acetylene itself, or could it have com e fro m the m e ta l rod contents (chrom e m anganese, etc.). It was d ecid ed that th is was a compensable issue and, following set tle m e n t, he ap p lied and w as granted a disability annuity. DR. NELSON: D r. K aplan, t h e r e is a ten d en cy today to use a c ry lic s in s p r a y p a i n t i n g i n s t e a d of the u s u a l lead p a in ts and e n a m e ls . It is my understanding the fumes from these acry lic sp ra y s don't have the tendency to se ttle down like the prev io u s p ain ts that they used. What has been your experience with the effect of acrylic sprays, and what have you don e to com bat exposure to th em ? MODERATOR KAPLAN: We actually a r e n 't using m any ac ry lics yet, but j t is in the lite r a tu r e that the a c ry lic s and epoxy r e s in s a re sensitizing, and I think they have had m ore derm atological than pulm onary problem s. DR, NELSON: I have seen some m en in this type of work and they develop a sth m a tic r a le s which usually c le a rs up when they are off duty over the weekend. M O i^lR A T O R KAPLAN: Has anybody else had any experience with acrylics or epoxy resins as far as pulmonary conditions are concerned? DR. CYRAN: T hat h as been re p o rte d in the lite ra tu re . I think there is an a rtic le in the Navy Bulletin that is sent out to the Navy R e serv ists d i s c u s s i n g epoxy r e s i n s and t h e i r toxic e f f e c ts in i n d u s t r y , and they do m ention that this is one of the com plicating factors. Some people can develop asthm atic sym ptom s. In fact, som e of them develop them so se v erely that even walking by an a re a that has been u s ing epoxy paint m akes them acutely asthm atic and this sensitivity ap parently p e rs is ts and may even last for th eir life. We a r e u s in g epoxy pain t in A ltoona, h o w e v e r, in s te a d of the p o ly am ine ca ta ly st, they use polyam ide, which is le ss sen sitizin g , and, with adequate v e n tila tio n , we don't have any p r o b le m s a s yet. We h a v e h ad the in d u s tr ia l h y g ie n ist c h e ck th is out and, b efo re we ipp ; any of the paints that are being used, we get a com plete break io\vn*?rom the com pany that m akes the paint. T his paint is then evaluated py the te s tin g d e p a r tm e n t, and, a s I sa y , o u r in d u s t r ia l h y g ien ist rev ie w s ;t and gives us an opinion a s to w hether this p ain t ca n be u sed safely and vhat p r e c a u t i o n s s h o u ld be ta ken. We a re using it, of course, with adequate ventilation and adequate iro te ctio n , r e s p ir a to ry protection and, so fa r, we have had no com plaints. )R. NELSON: Thank you. MODERATOR KAPLAN: I have one m ore sub ject that I would like to trow into the audien ce and the panel, and I think it is of trem endous importance. >R. WIGHT: B e f o r e we go on to t h a t , c o u ld we j u s t g iv e t h i s a l it tle more attention? 1 fifi Again I want to com e back to this question of published rep o rts and so on and so forth. You m entioned a while ago sm o g in Los Angeles and the incident at L enora. The incident at L enora in the Muse Valley, they w ere specific things, but the sm og in Los A ngeles and London are different problems. I am not trying to say that sm og is good. It is n 't, but, after the very bad episode they had in Los Angeles a few y e a rs ago, there was an epidem iological study done by the D epartm ent of Health. They took as a c r ite r io n the ad m issio n to ten m a jo r h o sp itals d u rin g and subsequent to this p erio d . In elderly patients with b ro n ch itic o r c a rd ia c c h e st condi tions g en e rally , to th e ir s u r p r is e , they found that th e re was no in c re a se in adm issions at all during this period. T h ere have been s im ila r studies m ade in London during the sm og epidem ics. I am afraid the studies there are equivocal. Some say that there is a g reater increase in adm ission to hospitals; some say there isn't. I am not trying to say that sm og is good, but what I am trying to say is le t's not be c a r r ie d away by the new spaper r e p o r ts that b la re forth te rrific a lly with figures and whatnot on these things. MODERATOR KAPLAN; Thank you. I am going to d irec t the next p ro b lem to Dr. Winston, and, if he doesn't feel in the mood, he may bow out gracefully. What are some card io v asc u la r effects that resu lt from toxic exposure to fumes ? I thought perhaps you might have the answ er, and, instead of asking you this m orning, I decided to save it for this afternoon. t DR. WINSTON; I am glad you saved it because I wouldn't have known any m o re about it this m orning than I do this afternoon. (Laughter) Now, then, will you ask the question again? MODERATOR KAPLAN; What a re som e ca rd io v ascu lar effects that result fro m occupational exposure to noxious fumes ? DR. WINSTON: I will defer the question to the C hairm an. (Laughter) MODERATOR KAPLAN: I think a m em ber of this group. Dr. Cyran, can take over very adequately, as the question concerns both the cardio vascular and the pulmonary panels. DR. CYRAN: You say you have read about th is . 1 would a lm o st p a s s to you, too. You are asking about the toxic effects on the c a rd io v a s c u la r s y s te m ? M O D E R A T O R K A P L A N : That is correct. As an exnmnle. w ' >-' I DR. NELSON: D r. K a p la n , t h e r e is a te n d e n c y to d ay to vise a c r y lic s in s p r a y p a i n t i n g i n s t e a d of the u s u a l lead p a in ts and e n a m e ls . It is my understanding the fumes from these acry lic sp ra y s don't have the tendency to se ttle down like the prev io u s p ain ts that they used. What has been your experience with the effect of acrylic sprays, and what have you don e to com bat exposure to th em ? MODERATOR KAPLAN: We actually a r e n 't using m any ac ry lics yet, but j t is in the lite r a tu r e that the a c ry lic s and epoxy r e s in s a re sensitizing, and I think they have had m ore derm atological than pulm onary problem s. DR. NELSON: I have seen some m en in this type of work and they develop a sth m a tic r a le s which usually c le a rs up when they are off duty over the weekend. MOiRATOR KAPLAN: Has anybody else had any experience with acrylics or epoxy resins as far as pulmonary conditions are concerned? DR. CYRAN: T hat h as been re p o rte d in the lite ra tu re . I think there is an a rtic le in the Navy Bulletin that is sent out to the Navy R e serv ists d i s c u s s i n g epoxy r e s i n s and t h e i r toxic e f f e c ts in i n d u s t r y , and they do m ention that this is one of the com plicating factors. Some people can develop asthm atic sym ptom s. In fact, som e of them develop them so se v erely that even walking by an a re a that has been u s ing epoxy paint m akes them acutely asthm atic and this sensitivity ap parently p e rs is ts and may even last for th eir life. We a r e u s in g epoxy pain t in A ltoona, h o w e v e r, in s te a d of the p o ly am ine ca ta ly st, they use polyam ide, which is le ss sen sitizin g , and, with adequate v e n tila tio n , we don't have any p r o b le m s a s yet. We h a v e h ad the in d u s tr ia l h y g ie n ist c h e ck th is out and, b efo re we ipp ; any of the paints that are being used, we get a com plete break io im tro m the com pany that m akes the paint. This paint is then evaluated py the te s tin g d e p a r tm e n t, and, as I say , o u r in d u s t r ia l h y g ien ist rev ie w s it and gives us an opinion a s to w hether this p ain t ca n be u sed safely and .vhat p r e c a u tio n s sh o u ld be taken. We a re using it, of course, with adequate ventilation and adequate iro te ctio n , r e s p ir a to ry protection and, so fa r, we have had no com plaints. )R. NELSON: T hank .you. MODERATOR KAPLAN: I have one m ore sub ject that I would like to nrow into the audien ce and the panel, and I think it is of trem endous importance. >R. WIGHT: B e f o r e we go on to t h a t , c o u ld we j u s t g iv e t h i s a lit tle more attention? 1 fifi Again I want to com e back to this question of published rep o rts and so on and so forth. You m entioned a while ago sm o g in Los Angeles and the incident at L enora. The incident at L enora in the Muse Valley, they w ere specific things, but the sm og in Los A ngeles and London are different problems. I am not trying to say that sm og is good. It is n 't, but, after the very bad episode they had in Los Angeles a few y e a rs ago, there was an epidem iological study done by the D epartm ent of Health. They took as a c r ite r io n the ad m issio n to ten m a jo r h o sp itals d u rin g and subsequent to this p e rio d . In e ld e rly p atien ts with b ro n c h itic o r c a rd ia c c h e s t condi tions g en e rally , to th e ir s u r p r is e , they found that th e re was no in c re a se in adm issions at all during this period. T h ere have been s im ila r studies m ade in London during the sm og epidem ics. I am afraid the studies there are equivocal. Some say that there is a g reater increase in adm ission to hospitals; some say there isn't. I am not trying to say that sm og is good, but what I am trying to say is le t's not be c a r r ie d away by the new spaper r e p o r ts that b la re forth te rrific a lly with figures and whatnot on these things. MODERATOR KAPLAN; Thank you. I am going to d irec t the next p ro b lem to Dr. Winston, and, if he doesn't feel in the mood, he may bow out gracefully. What are some card io v asc u la r effects that resu lt from toxic exposure to fum es? I thought perhaps you might have the answ er, and, instead of asking you this m orning, I decided to save it for this afternoon. i DR. WINSTON; I am glad you saved it because I wouldn't have known any m o re about it this m orning than I do this afternoon. (Laughter) Now, then, will you ask the question again? MODERATOR KAPLAN; What a re som e ca rd io v ascu lar effects that result fro m occupational exposure to noxious fumes ? DR. WINSTON: I will defer the question to the C hairm an. (Laughter) MODERATOR KAPLAN: I think a m em ber of this group. Dr. Cyran, can take over very adequately, as the question concerns both the cardio vascular and the pulmonary panels. DR. CYRAN: You say you have r e a d about th is. I would alm o st p a s s to you, too. You a r e a sk in g about the toxic effects on the c a rd io v a s c u la r s y s te m ? M O D E R A T O R K A P L A N : That is correct. As an exnmnle. w ' >-' I aggravation of pre-existing cardiovascular disturbances because of ex cessive inhalation of noxious fumes. DU. CYRAN: I s u p p o se the m o s t obvious c a rd io v a s c u la r effect fro m e x p o su re to p u lm o n a ry ir r ita n ts o r d u sts would be the late effects of e x p o su re to c e rta in d u sts like s ilic a , asb e sto s, o r the m ining of bauxite. The exposure an d the changes that take place in the lungs over the y e a rs p robably do b rin g about the d ev e lo p m e n t of c o r pulm onale ar.d eventually signs and sy m p to m s of rig h t h e a rt failu re. T hese would be ju st a few of The m a j o r p n e u m o n o c o n i o s e s . We can go into p u lm o n ary ir rita n ts such as vario u s ch em icals like sulphur dioxide, nitrogen dioxide, o r acrolein formaldehyde, or ammonia. T hese can c re a te quite a se v ere re sp ira to ry irritatio n , and then through the, a in o f e v e n t s , t h e r e s p i r a t o r y i r r i t a t i o n c a n c a u s e cough a n d b r o n c h iii^ o n s tric tio n , and with bronchial constriction, you get capillary d ilatatio n , ex u d a tio n of s e ro u s fluid, and this causes anoxia by in te rfe re n c e with gaseous exchange, which causes increasing blood p ressu re and ven ous p re s s u re with increasing exudation. Depending on the duration of ex p o su re o r the se v e rity of tiie ex p o su re, this will lead to in c re a se d v is cosity of the blood. Then I suppose, cardiac 'hlatation and, if you are exposed long enough, eventual death, un less asphyxia causes death first by l it e r a ll y " d ro w n in g in h is ow n s e c r e ti o n s . " If the exposure is not so s e v e re , that it causes death im m ediately o r shortly th e re a fte r, I suppose the m an with underlying coronary heart d ise a se who h as asy m p to m a tic h e a r t d ise ase might be incapacitated b e cause of the p o ssib le anoxia that develops and he might become p re d is posed to co ronary insufficiency, not n ecessarily coronary throm bosis, but 1 would suspect that prolonged coronary insufficiency might cause m yo c a rd ia l dam age o r perhaps even subendocardial infarction, which could be a resu lt of the toxic exposure. W hin an k d the im portant point here again the severity of the is the solubility of the pulm onary i r exposure. The m ore soluble ones aren 't quite as dangerous because they affect the upper respiratory tract, and the conjunctiva, and you get irritatio n of the eyes and mouth and the upper respiratory tract. The ones that are much m ore dangerous are the oxides of nitrogen, for exam ple. T h ese are not as soluble, and get down deeper into the bronchioles and alveoli, and then have delayed effects, so that the man actually may look all right after exposure, but a little while la ter may suddenly develop pulm onary edem a, and eventually die.I I think Dr. G raham was discu ssin g a case with m e this m orning in which his P u llm a n Com pany w as involved with o u r com pany in a m an who was exposed in a fire in a P u llm a n c a r , and I think they used a carbon tetrachloride fire extinguisher. The m an was seen and examined and there was nothing obvious. He had som e m inor burns. These were t r e a t e d . He w as s e n t h o m e and ab o u t tw elv e o r fiftee n h o u r s l a t e r a p parently started developing difficulty with his resp iratio n s. A physician who w a s n 't im m e d ia te ly a v a ila b le .) T h is was at 5:00. By 6:0 ' he died. By 7:00 th e p h y s ic ia n w as t h e r e , b u t o b v io u sly too late. T n is .vas c o n sidered probably due to som e of the products of carbon tetrach lo rid e, possibly phosgene, which D r. G rah am would take exception to, because I think carbon te trach lo rid e has to be exposed to pretty high tem p eratu re to break down into phosgene. It might have been som e of the m a teria l they have in the m a ttre s s . I know cellulose can give out toxic fumes which may cause resp irato ry em barrassm ent eventually. Some of the o thers - carbon monoxide, obviously through its anoxic effects will eventually cause som e cardiovascular problem s, again d e pending on the degree of underlying h ea rt d isease and duration of exposure. P erhaps a mild case of carbon monoxide poisoning escapes without any cardiovascular effect. However, the one that is exposed a little m ore severly may develop subendocardial hem orrhages, and actually may have a definite m y o c a rd itis a s evidenced by ST se g m en t changes and changes in the e le c tro c a rd io g ra m suggestive of m y o c ard ial damage o r at le a st tem porary damage. They may develop arrhythm ia. They may develop conduction, defects. Some of the m o re notorious cardiovascular toxic effects come from exposure to some of the chlorinated hydrocarbons like trichloroethylene or carbon tetrach lo rid e. T h ese can cause death eith er by r e s p ir a to ry p araly sis o r by v en tricu la r fibrillation o r cardiac standstill. MODERATOR KAPLAN: Thank you. Doctor. I think you can readily rea lize that these chem icals a re not extraneous to our w orkers. T ric h lo ro ethylene, carbon tetrachloride, and methyl chloroform are used very com m only in o u r shops as d e g r e a s e r s , and m en go down into the p its to clean out the grease. As you know, these volatile hydrocarbons settle and there have been c a s e s rep o rted where men have become unconscious through the in h a latio n of th e s e fu m e s . T h e y act as, a n e s th e tic s , and, in addition, can exert their toxic effect on the heart through cardiac stand still. DR. CLAYTON: How about p erchlorethylene ? MODERATOR KAPLAN: P erchlorethylene is another m ember of the sam e family, the arom atic hydrocarbons. I G entlem en, a re th ere any questions you would like to ask on the card io vascular-aspect or any other phase of the respiratory problem ? If not, we thank you, and we will now tu rn the meeting over again to Dr. Olson. (Applause) CHAIRMAN OLSON: Well, again, we hav e listen e d to som e v ery e ru d ite * discussions on a subject which is v ery tim ely and im portant to us. We thank the m o d e r a to r . D r . K aplan, a ll o f h is panel a s w ell a s you in the audience as participan ts. aggravation of pre-existing cardiovascular disturbances because of ex cessive inhalation of noxious fumes. DU. CYRAN: I s u p p o se the m o s t obvious c a rd io v a s c u la r effect fro m e x p o su re to p u lm o n a ry ir r ita n ts o r d u sts would be the late effects of e x p o su re to c e rta in d u sts like s ilic a , asb e sto s, o r the m ining of bauxite. The exposure an d the changes that take place in the lungs over the y e a rs p robably do b rin g about the d ev e lo p m e n t of c o r pulm onale ar.d eventually signs and sy m p to m s of rig h t h e a rt failu re. T hese would be ju st a few of The m a j o r p n e u m o n o c o n i o s e s . We can go into p u lm o n ary ir rita n ts such as vario u s ch em icals like sulphur dioxide, nitrogen dioxide, o r acrolein formaldehyde, or ammonia. T hese can c re a te quite a se v ere re sp ira to ry irritatio n , and then through the, a in o f e v e n t s , t h e r e s p i r a t o r y i r r i t a t i o n c a n c a u s e cough a n d b r o n c h iii^ o n s tric tio n , and with bronchial constriction, you get capillary d ilatatio n , ex u d a tio n of s e ro u s fluid, and this causes anoxia by in te rfe re n c e with gaseous exchange, which causes increasing blood p ressu re and ven ous p re s s u re with increasing exudation. Depending on the duration of ex p o su re o r the se v e rity of tiie ex p o su re, this will lead to in c re a se d v is cosity of the blood. Then I suppose, cardiac 'hlatation and, if you are exposed long enough, eventual death, un less asphyxia causes death first by l it e r a ll y " d ro w n in g in h is ow n s e c r e ti o n s . " If the exposure is not so s e v e re , that it causes death im m ediately o r shortly th e re a fte r, I suppose the m an with underlying coronary heart d ise a se who h as asy m p to m a tic h e a r t d ise ase might be incapacitated b e cause of the p o ssib le anoxia that develops and he might become p re d is posed to co ronary insufficiency, not n ecessarily coronary throm bosis, but 1 would suspect that prolonged coronary insufficiency might cause m yo c a rd ia l dam age o r perhaps even subendocardial infarction, which could be a resu lt of the toxic exposure. W hin an k d the im portant point here again the severity of the is the solubility of the pulm onary i r exposure. The m ore soluble ones aren 't quite as dangerous because they affect the upper respiratory tract, and the conjunctiva, and you get irritatio n of the eyes and mouth and the upper respiratory tract. The ones that are much m ore dangerous are the oxides of nitrogen, for exam ple. T h ese are not as soluble, and get down deeper into the bronchioles and alveoli, and then have delayed effects, so that the man actually may look all right after exposure, but a little while la ter may suddenly develop pulm onary edem a, and eventually die.I I think Dr. G raham was discu ssin g a case with m e this m orning in which his P u llm a n Com pany w as involved with o u r com pany in a m an who was exposed in a fire in a P u llm a n c a r , and I think they used a carbon tetrachloride fire extinguisher. The m an was seen and examined and there was nothing obvious. He had som e m inor burns. These were t r e a t e d . He w as s e n t h o m e and ab o u t tw elv e o r fiftee n h o u r s l a t e r a p parently started developing difficulty with his resp iratio n s. A physician who w a s n 't im m e d ia te ly a v a ila b le .) T h is was at 5:00. By 6:0 ' he died. By 7:00 th e p h y s ic ia n w as t h e r e , b u t o b v io u sly too late. T n is .vas c o n sidered probably due to som e of the products of carbon tetrach lo rid e, possibly phosgene, which D r. G rah am would take exception to, because I think carbon te trach lo rid e has to be exposed to pretty high tem p eratu re to break down into phosgene. It might have been som e of the m a teria l they have in the m a ttre s s . I know cellulose can give out toxic fumes which may cause resp irato ry em barrassm ent eventually. Some of the o thers - carbon monoxide, obviously through its anoxic effects will eventually cause som e cardiovascular problem s, again d e pending on the degree of underlying h ea rt d isease and duration of exposure. P erhaps a mild case of carbon monoxide poisoning escapes without any cardiovascular effect. However, the one that is exposed a little m ore severly may develop subendocardial hem orrhages, and actually may have a definite m y o c a rd itis a s evidenced by ST se g m en t changes and changes in the e le c tro c a rd io g ra m suggestive of m y o c ard ial damage o r at le a st tem porary damage. They may develop arrhythm ia. They may develop conduction, defects. Some of the m o re notorious cardiovascular toxic effects come from exposure to some of the chlorinated hydrocarbons like trichloroethylene or carbon tetrach lo rid e. T h ese can cause death eith er by r e s p ir a to ry p araly sis o r by v en tricu la r fibrillation o r cardiac standstill. MODERATOR KAPLAN: Thank you. Doctor. I think you can readily rea lize that these chem icals a re not extraneous to our w orkers. T ric h lo ro ethylene, carbon tetrachloride, and methyl chloroform are used very com m only in o u r shops as d e g r e a s e r s , and m en go down into the p its to clean out the grease. As you know, these volatile hydrocarbons settle and there have been c a s e s rep o rted where men have become unconscious through the in h a latio n of th e s e fu m e s . T h e y act as, a n e s th e tic s , and, in addition, can exert their toxic effect on the heart through cardiac stand still. DR. CLAYTON: How about p erchlorethylene ? MODERATOR KAPLAN: P erchlorethylene is another m ember of the sam e family, the arom atic hydrocarbons. I G entlem en, a re th ere any questions you would like to ask on the card io vascular-aspect or any other phase of the respiratory problem ? If not, we thank you, and we will now tu rn the meeting over again to Dr. Olson. (Applause) CHAIRMAN OLSON: Well, again, we hav e listen e d to som e v ery e ru d ite * discussions on a subject which is v ery tim ely and im portant to us. We thank the m o d e r a to r . D r . K aplan, a ll o f h is panel a s w ell a s you in the audience as participan ts. Friday Morning Session March 5, 19G5 The m eeting of the A ssociation of A m erican R ailroads, M edical and S u rg ical O ffic ers, held in .the Boulevard Room of the Sheraton Chicago Hotel, Chicago, Illinois, reconvened at nine o'clock, Harvey Nelson, M. D. , C hairm an, presiding. CHAIRMAN NELSON: The m eeting will com e to o rd er. I am p le a se d with the turnout we have this last day, which is always a little bit of a letdown, and starting a half-hour e a rlie r certainly did not h elp m a tte r s . I hope th e re will be o th e rs who will be com ing in la ter. .Ve h a v e tw o v e r y i n t e r e s t i n g a n d tw o v e r y e x c e l l e n t p o r t i o n s of o u r p r V a m co m in g up, one r e g a rd in g diabetes, which w ill be the f ir s t on the p ro g ra m in stead of the neuropsychiatric situation. D iabetes is one that we have not receiv ed for som e time. My recollection is that it is about 10 y e a r s , and, we ce rtain ly want to bring the m a tte r up to date. T he o th e r, on neuropsychiatric problem s, is som ething new; and I am su re all of you appreciate the fact that this is som ething that we are going to have to face m o re and m ore. B efore we actually s ta r t o u r p ro g ra m this m o rn in g , D r. M ish ler te lls me he has a w ord o r two he w ants to a n nounce to you. DR. WILLIAM E. MISHLER (Chief Surgeon, E rie-L ackaw anna Railroad): I have no rig h t to be h e re , being in an unofficial position, but without d e t r a c ti n g f r o m th o se who have c o n trib u ted to th is m e e tin g , a s id e fro m D r. H a rv e y N e lso n , I think it is only rig h t th a t we a ll a g re e th a t th is has b een .one of o u r b e s t m e e tin g s. I would th e re fo r e s u g g e s t th a t we all sta n d and give a hand to D r. H arvey Nelson who has a rra n g e d a v ery ex cellent program . ^ he A ssem bly arose and applauded.) CHAIRM AN NELSON: I am very much e m b a rra sse d . If I knew that was what D r. M is h le r was going to talk about I do not think I would have let h i m com? up h e r e . I a m s u r e th at a l l of you b elo n g to o r g a n i z a t i o n s and know that a p ro g ra m like this is not a one-m an show. T h ere have been o th ers who have put a trem endous amount of time into this, and I have receiv ed the cred it. L ater on, however, I want to give cred it to those who should have it. The question of diabetes is one that we should take a second look at. The p re s s u r e of the A m erican Diabetic A ssociation; the p re s s u re of the unions; the im proved control of diabetics as far as their safety and work ing ability a re concerned constitute som ething which we have to face, and I think w e, in a c c u m u la tin g o u r new m e d ic a l s ta n d a r d s , w ill have to co n sid e r that. It is with that in m ind that we felt we should b rin g up the sub je c t of diabetes at this tim e and take .a new look at it. 172 I know t h a t D r . G. E a r l e Wight w ill a d e q u a t e l y h an d le t h is p a n e l. In o u r p a n e l we have f iv e in te r n is ts and one su rg e o n . T h e r e f o r e , I think we will have all asp ects of this diabetic situation handled. I will ask Dr. Wight to p rese n t his panel. PAN EL SYMPOSIUM - DIABETES M O D ER A TO R WIGHT: We h av e a v e r y l a r g e s u b j e c t to c o v e r this m o r n ing, and we have v e r y little tim e in which to do it. You a r c going to listen to a few platitudes, but I think it is a good thing that we take stock of _ ourselves at tim es. We talk about changes taking place in the world. T h ere is nothing m ore dynamic, or changing as fast as medicine. If you c a r e to think b ac k 50 y e a r s ago, p r a c t i c a l l y a ll m e d ic in e o r all d ise a se s w ere tr e a te d on an em p iric a l b asis. They had to be because we did not know anything else about them. As recently as the first World War, when blood transfusions were used for the first tim e in any great quantity, nothing was known about blood typing o r blood grouping. This has all come about since. D ia b e te s f a lls into th a t c a te g o ry . Up u n til 1920, d ia b e te s was a fata l d isease. It was in 1924 that Banting and B est discovered insulin, and then the whole pictu re changed. In the late T h ir tie s , fo r the f ir s t tim e , d ia b e tic s could get in su ra n c e . This was quite an advance. The next m a jo r advance was the discovery of the o ra l hypoglycemic agents. There were som e disadvantages in connection with this, for the first hypoglycemic agent, the name of which I have forgotten, was used for five y ea rs before it becam e known that it was causing liver damage and was discarded. T h ere a re m ore o ra l hypoglycemic agents u sed now than ever before, but paradoxically there is also m ore insulin being used now than ever before. i I think that can be explained on the basis that m ore diabetics are b e ing discovered. They are coming forward for treatm ent. They were afraid of the needle of insulin before that. D i a b e t e s , a s we a l l know , is a p r o g r e s s i v e d i s e a s e u n d e r the b e s t of. c irc u m sta n c e s, but with good tre a tm e n t the ra te of p ro g re ssio n can be slowed down and the com plications delayed and becom e fewer in number. Conversely, with poor treatm en t the complications a re much greater. As a d is e a s e , d iabetes is one that with p erfect treatm en t and perfect co o p er a tio n o f the p a tien t can bo p retty w ell co n tr o lle d ar.f r>|) Friday Morning Session March 5, 19G5 The m eeting of the A ssociation of A m erican R ailroads, M edical and S u rg ical O ffic ers, held in .the Boulevard Room of the Sheraton Chicago Hotel, Chicago, Illinois, reconvened at nine o'clock, Harvey Nelson, M. D. , C hairm an, presiding. CHAIRMAN NELSON: The m eeting will com e to o rd er. I am p le a se d with the turnout we have this last day, which is always a little bit of a letdown, and starting a half-hour e a rlie r certainly did not h elp m a tte r s . I hope th e re will be o th e rs who will be com ing in la ter. .Ve h a v e tw o v e r y i n t e r e s t i n g a n d tw o v e r y e x c e l l e n t p o r t i o n s of o u r p r V a m co m in g up, one r e g a rd in g diabetes, which w ill be the f ir s t on the p ro g ra m in stead of the neuropsychiatric situation. D iabetes is one that we have not receiv ed for som e time. My recollection is that it is about 10 y e a r s , and, we ce rtain ly want to bring the m a tte r up to date. T he o th e r, on neuropsychiatric problem s, is som ething new; and I am su re all of you appreciate the fact that this is som ething that we are going to have to face m o re and m ore. B efore we actually s ta r t o u r p ro g ra m this m o rn in g , D r. M ish ler te lls me he has a w ord o r two he w ants to a n nounce to you. DR. WILLIAM E. MISHLER (Chief Surgeon, E rie-L ackaw anna Railroad): I have no rig h t to be h e re , being in an unofficial position, but without d e t r a c ti n g f r o m th o se who have c o n trib u ted to th is m e e tin g , a s id e fro m D r. H a rv e y N e lso n , I think it is only rig h t th a t we a ll a g re e th a t th is has b een .one of o u r b e s t m e e tin g s. I would th e re fo r e s u g g e s t th a t we all sta n d and give a hand to D r. H arvey Nelson who has a rra n g e d a v ery ex cellent program . ^ he A ssem bly arose and applauded.) CHAIRM AN NELSON: I am very much e m b a rra sse d . If I knew that was what D r. M is h le r was going to talk about I do not think I would have let h i m com? up h e r e . I a m s u r e th at a l l of you b elo n g to o r g a n i z a t i o n s and know that a p ro g ra m like this is not a one-m an show. T h ere have been o th ers who have put a trem endous amount of time into this, and I have receiv ed the cred it. L ater on, however, I want to give cred it to those who should have it. The question of diabetes is one that we should take a second look at. The p re s s u r e of the A m erican Diabetic A ssociation; the p re s s u re of the unions; the im proved control of diabetics as far as their safety and work ing ability a re concerned constitute som ething which we have to face, and I t h in k w e , in a c c u m u l a t i n g o u r new m e d i c a l s t a n d a r d s , w i l l h a v e to c o n s i d e r th a t. It is w ith th a t in m in d th a t we f e lt we s h o u ld b r i n g up th e s u b je c t of diabetes at this tim e an d ta k e .a new look at it. 172 I know t h a t D r . G. E a r l e Wight w ill a d e q u a t e l y h an d le t h is p a n e l. In o u r p a n e l we have f iv e in te r n is ts and one su rg e o n . T h e r e f o r e , I think we will have all asp ects of this diabetic situation handled. I will ask Dr. Wight to p rese n t his panel. PAN EL SYMPOSIUM - DIABETES M O D ER A TO R WIGHT: We h av e a v e r y l a r g e s u b j e c t to c o v e r this m o r n ing, and we have v e r y little tim e in which to do it. You a r c going to listen to a few platitudes, but I think it is a good thing that we take stock of _ ourselves at tim es. We talk about changes taking place in the world. T h ere is nothing m ore dynamic, or changing as fast as medicine. If you c a r e to think b ac k 50 y e a r s ago, p r a c t i c a l l y a ll m e d ic in e o r all d ise a se s w ere tr e a te d on an em p iric a l b asis. They had to be because we did not know anything else about them. As recently as the first World War, when blood transfusions were used for the first tim e in any great quantity, nothing was known about blood typing o r blood grouping. This has all come about since. D ia b e te s f a lls into th a t c a te g o ry . Up u n til 1920, d ia b e te s was a fata l d isease. It was in 1924 that Banting and B est discovered insulin, and then the whole pictu re changed. In the late T h ir tie s , fo r the f ir s t tim e , d ia b e tic s could get in su ra n c e . This was quite an advance. The next m a jo r advance was the discovery of the o ra l hypoglycemic agents. There were som e disadvantages in connection with this, for the first hypoglycemic agent, the name of which I have forgotten, was used for five y ea rs before it becam e known that it was causing liver damage and was discarded. T h ere a re m ore o ra l hypoglycemic agents u sed now than ever before, but paradoxically there is also m ore insulin being used now than ever before. i I think that can be explained on the basis that m ore diabetics are b e ing discovered. They are coming forward for treatm ent. They were afraid of the needle of insulin before that. D i a b e t e s , a s we a l l know , is a p r o g r e s s i v e d i s e a s e u n d e r the b e s t of. c irc u m sta n c e s, but with good tre a tm e n t the ra te of p ro g re ssio n can be slowed down and the com plications delayed and becom e fewer in number. Conversely, with poor treatm en t the complications a re much greater. As a d is e a s e , d iabetes is one that with p erfect treatm en t and perfect co o p er a tio n o f the p a tien t can bo p retty w ell co n tr o lle d ar.f r>|) treated; but I would not hesitate to say that the vast m ajority of diabetic? are poorly tre a te d . T his does not ju st apply to the sm a lle r c e n te rs o r i ru ra l d istricts; this holds tru e right in the cities. J Too often people ju st dish out tab lets. No attem pt is m ade to con- | trol the diet. Too often com plete reliance is put on the first m orning sp ecim en , which is the best sp e cim en of the day, incidentally, and the dosage is adjusted according to this. Now we sh o u ld have a little id e a o f 'o u r p ro b le m . It is e s tim a te d by v a rio u s people that on the N orth A m erican Continent, in the United State and Canada, about o n e -a n d -a -h a lfp e r cent of the people have diabetes and know it. A n other one to two p e r cen t have d iab etes and do not know it,, o r a re destined to have diabetes. In round num bers that m eans that in o u r two co u n tries th ere are approxim ately three million known diabet ^ n d two to f o u r m illio n a d d itio n a l unknow ns o r people who w ill have it. T h e re is a tendency nowadays to red u ce everything to fig u re s, and : is v ery com forting if you can put som ething down num erically. Out of a h u n d re d p e r c e n t, 65 p e r cent of d ia b e tic s do not r e q u ir e in su lin . Of th e r e m a i n i n g 33 p e r c e n t , 11 p e r c e n t m a y r e q u i r e in s u l in but w ill get off it l a t e r . Of th e 22 p e r c e n t le ft, 10 to 14 p e r c e n t m a y g e t by on the o r a l hypoglyccm ics for up to possibly th re e y e a rs, but they will eventua require insulin. The rem aining eight per cent are the problem cases, the juvenile o r brittle diabetic. With this v e ry brief outline we are going to put the panel to work. The panel m e m b e rs you all know, so I am not going to introduce them individually. F i r s t , I a m going to c a ll on D r. John Winston to sp e a k fo a few m om ents on his aspect of the disease. DR. J. R. WINSTON (System M edical D irector, Atchison, Topeka & Santa Fe Railway): The question you want me to answ er is No. 4 ? I i ODERATOR WIGHT: Talk a little on the o ral hyperglycem ic drugs. DR. WINSTON: I thought th e re was a question about the o ra l hypergly-:. cemic case. ! L et m e ta lk about No. 5, then. i MODERATOR WIGHT: Good! i DR. WINSTON: I know all of you can re a d , but in the event you do not have it before you, and so that I know what I am supposed to talk about; it says: "The theory is som etim es advanced that orinase and other ora agents are less hazardous than insulin. Is this tru e? " '< My im p re s s io n is in using this fra m e of re feren c e, it is h az a rd o u s b u t th e o r a l a g e n t s s e r v e a v e r y d e f i n i t e p u r p o s e . T o c o m p a r e t h e m w: insulin is so rt of like com paring a 12-gauge shotgun and a 300-m agnum r if l e . Roth of th e m a r e rood in t h e ir p a r tic u la r a r e a s . T h ey can be in changed to a d eg re e. One w ill do ce rta in th in g s that the other one is not exp ected to do. So, as a by and larg e m a tte r, I would counter this question by sa y ing that this question was d ir e c te d tow ard the a r e a of the le ss hazardous cause of hypoglycemic re a c tio n s. In that instance, perhaps it is --th a t is, the o r a l agents a r e le s s h a z a r d o u s and le s s likely to p ro d u ce hypogly c e m ic r e a c tio n s , fo r s e v e r a l r e a s o n s , and I w ill not a tte m p t to go into the ch em istry at all o r even d escrib e the hypoglycemic agents separately. The oral hypoglycemic agent, however, is almost always used in the adult o n se t, sta b le type of d ia b e tic . It should not be u se d in the ju v e n ile or the diabetic with com plications, o r in the brittle diabetic. T herefore, it is not used in the diabetic who is m ost susceptible to hypoglycemic reaction. The very nature of the drug is such that it also is less responsive as a hypoglycemic agent than is insulin, and for that reason you have fewer reactions. Let us not get into out thinking, however, that hypoglycemic agent re a c tio n s do not o c c u r with o r a l agents. T h e re a r e many in s ta n c e s in the lite ra tu re , and if you would like I can give you the re fe re n c e s, where hy p o g ly cem ic r e a c tio n s h ave o c c u r r e d with the use of o r a l a g e n ts. Now, did you want m e to talk a little bit about diabetes in the r e la tio n sh ip to o r i n a s e , d y m e lo r , and DBI ? If you did, 1 do not know anything about them, nothing that everybody else does not know. MODERATOR WIGHT: When the questions from the floor com e in c o v e r ing these p artic u la r subjects we will not hesitate to refer them to you, Dr. Winston. 1 Thank you very much. Dr. Johnson, would you c a re to talk on som e of the card iac aspects of diabetes? DR. R. A. JOHNSON (M edical D ire c to r, New York C entral System): T h e r e a r e no s p e c if ic c o m p l i c a t i o n s in the c a r d i o v a s c u l a r s y s t e m due td, diabetes except as a precip itatin g fac to r in athero and a rte rio s c le ro s is , o r individuals who have p o o r ly - c o n tr o lle d d ia b e te s who do have a te n dency to have vascular as w ell as neurological com plications, secondary to p o o r diabetic care. I would like to am plify yo u r point, M r. M oderator, and say that I am am azed at the relativ ely poor tre a tm e n t of .many diabetics on our System , because it is in the m ain so relatively easy to control diabetes today with the agents that we have available. . T he only difficulty is it r e q u i r e s s o m e s a c r if ic e , and I do not think o u r em p lo y ee s are any m o r e in c lin e d to s e lf- s a c r if ic e than y u r s . ITS treated; but I would not hesitate to say that the vast m ajority of diabetic? are poorly tre a te d . T his does not ju st apply to the sm a lle r c e n te rs o r i ru ra l d istricts; this holds tru e right in the cities. J Too often people ju st dish out tab lets. No attem pt is m ade to con- | trol the diet. Too often com plete reliance is put on the first m orning sp ecim en , which is the best sp e cim en of the day, incidentally, and the dosage is adjusted according to this. Now we sh o u ld have a little id e a o f 'o u r p ro b le m . It is e s tim a te d by v a rio u s people that on the N orth A m erican Continent, in the United State and Canada, about o n e -a n d -a -h a lfp e r cent of the people have diabetes and know it. A n other one to two p e r cen t have d iab etes and do not know it,, o r a re destined to have diabetes. In round num bers that m eans that in o u r two co u n tries th ere are approxim ately three million known diabet ^ n d two to f o u r m illio n a d d itio n a l unknow ns o r people who w ill have it. T h e re is a tendency nowadays to red u ce everything to fig u re s, and : is v ery com forting if you can put som ething down num erically. Out of a h u n d re d p e r c e n t, 65 p e r cent of d ia b e tic s do not r e q u ir e in su lin . Of th e r e m a i n i n g 33 p e r c e n t , 11 p e r c e n t m a y r e q u i r e in s u l in but w ill get off it l a t e r . Of th e 22 p e r c e n t le ft, 10 to 14 p e r c e n t m a y g e t by on the o r a l hypoglyccm ics for up to possibly th re e y e a rs, but they will eventua require insulin. The rem aining eight per cent are the problem cases, the juvenile o r brittle diabetic. With this v e ry brief outline we are going to put the panel to work. The panel m e m b e rs you all know, so I am not going to introduce them in d iv i d u a ll y . F i r s t , I a m g o in g t o c a l l on D r . Jo h n W inston to s p e a k fo; a few m om ents on his aspect of the disease. DR. J. R. WINSTON (System M edical D irector, Atchison, Topeka & Santa Fe Railway): The question you want me to answ er is No. 4 ? I i ODERATOR WIGHT: Talk a little on the o ral hyperglycem ic drugs. DR. WINSTON: I thought th e re was a question about the o ra l hypergly-:. cemic case. ! L et m e ta lk about No. 5, then. MODERATOR WIGHT: Good! i DR. WINSTON: I know all of you can re a d , but in the event you do not have it before you, and so that I know what I am supposed to talk about; it says: "The theory is som etim es advanced that orinase and other ora agents are less hazardous than insulin. Is this tru e? " '< My im p re s s io n is in using this fra m e of re feren c e, it is h az a rd o u s b u t th e o r a l a g e n t s s e r v e a v e r y d e f i n i t e p u r p o s e . T o c o m p a r e t h e m w: insulin is so rt of like com paring a 12-gauge shotgun and a 300-m agnum r if l e . Roth of th e m a r e rood in t h e ir p a r tic u la r a r e a s . T h ey can be in changed to a d eg re e. One w ill do ce rta in th in g s that the other one is not exp ected to do. So, as a by and larg e m a tte r, I would counter this question by sa y ing that this question was d ir e c te d tow ard the a r e a of the le ss hazardous cause of hypoglycemic re a c tio n s. In that instance, perhaps it is --th a t is, the o r a l agents a r e le s s h a z a r d o u s and le s s likely to p ro d u ce hypogly c e m ic r e a c tio n s , fo r s e v e r a l r e a s o n s , and I w ill not a tte m p t to go into the ch em istry at all o r even d escrib e the hypoglycemic agents separately. The oral hypoglycemic agent, however, is almost always used in the adult o n se t, sta b le type of d ia b e tic . It should not be u se d in the ju v e n ile or the diabetic with com plications, o r in the brittle diabetic. T herefore, it is not used in the diabetic who is m ost susceptible to hypoglycemic reaction. The very nature of the drug is such that it also is less responsive as a hypoglycemic agent than is insulin, and for that reason you have fewer reactions. Let us not get into out thinking, however, that hypoglycemic agent re a c tio n s do not o c c u r with o r a l agents. T h e re a r e many in s ta n c e s in the lite ra tu re , and if you would like I can give you the re fe re n c e s, where hy p o g ly cem ic r e a c tio n s h ave o c c u r r e d with the use of o r a l a g e n ts. Now, did you want m e to talk a little bit about diabetes in the r e la tio n sh ip to o r i n a s e , d y m e lo r , and DBI ? If you did, 1 do not know anything about them, nothing that everybody else does not know. MODERATOR WIGHT: When the questions from the floor com e in c o v e r ing these p artic u la r subjects we will not hesitate to refer them to you, Dr. Winston. 1 Thank you very much. Dr. Johnson, would you c a re to talk on som e of the card iac aspects of diabetes? DR. R. A. JOHNSON (M edical D ire c to r, New York C entral System): T h e r e a r e no s p e c if ic c o m p l i c a t i o n s in the c a r d i o v a s c u l a r s y s t e m due td, diabetes except as a precip itatin g fac to r in athero and a rte rio s c le ro s is , o r individuals who have p o o r ly - c o n tr o lle d d ia b e te s who do have a te n dency to have vascular as w ell as neurological com plications, secondary to p o o r diabetic care. I would like to am plify y o u r point, M r. M o d e ra to r, and sa y that I am am azed at the relativ ely poor tre a tm e n t of .many diabetics on our System , because it is in the m ain so relatively easy to control diabetes today with the agents that we h av e available. . The only difficulty is it req u ires som e sacrifice, and I do not think our em ployees are any m ore inclined to se lf-sa c r ific e than y u r s . ITS I a m d i s t u r b e d , h o w e v e r , at tin* c o m p l a c e n c y of (>>< !. *; . fescio n ; at the p e r s i s t e n c e of g ly c o su ria as we find it on peri.,,ta t rnation. N onetheless tlie attending physician will sa y that his pst; f r e e o f s u g a r in t h e u r i n e , a n d he h a s h ad a u r i n a l y s i s a n d th e b L Ht . is w ith in l i m i t s . Y e t, if we go o v e r o u r c h a r t s we fin d th e p a tie n tt h a a to 4 -plus g ly c o su ria; and it s e e m s to m e that individual is asking for tr I do not know that th e re is any specific c o rre la tio n betw een coronary insufficiency, hypertension, stroke, except as it is uncontrolled diabetes. T h ere is a v ery re a l risk to the individual in his late fo rties, early fiftie s , who h as d ia b e te s, who has m in im al h y p erte n sio n , who invariably has obesity, and having com plications in his card io v ascu lar retin al neuro V nal system because of poor control. I firm ly believe that adequate clinical control of diabetes can p re vent card io v ascu lar com plications as well as neurological ones. DR. WINSTON: If I m ay m ake a point here. Bill Wade, in DIABETES, M a rc h -A p ril 1959, rep o rted a se rie s, and he said that clinically signi f ic a n t c a r d io v a s c u la r r e n a l d is e a s e w as p r e s e n t in 29 p e r ce n t of the w orkers. T h a t w a s b r o k e n down th is way: th a t 23 p e r c e n t o f th o s e r e c e iv in g in s u lin , e v e n , h ad th is co m p lic atio n ; and 39 p e r c e n t not re c e iv in g insulin. I ju s t wanted to take a little exception to R alp h 's sta te m en t, that I fe e l so m e c o m fo rt if the m an is w ell-co n tro lled . I do not fee l s e c u re , however. M ODERATOR WIGHT: G entlem en, the situation is rapidly becom ing n o rm a l. We have the p an e l m e m b ers arguing am ong th e m se lv es. P lease ft fre e to in te rru p t at any tim e to ask any q uestio n s. T h eo retica lly whc we h a d p la n n e d .to do w as to co v e r a few of the f ie ld s , and th e c o m p lic a tio n s, and then we would get down to specific q u estio n s. D r,. Leigh, would you care to say a few words on the su rg ica l aspects? DR. SOUTHGATE LEIGH, JR. (Chief Surgeon, Seaboard A ir Line R ail road' : I think th at anyone who has am putated a leg on a diabetic is stru ck with the tre m e n d o u s am ount of fatty deposits in the f e m o ra l a r te r y , and in the popliteal artery. T h e r e is a m a rk e d n arrow ing in the lum en of th e se a r t e r i e s , and b ec au se of th at th e re is bound to be change in the m u s c le s , particular;;.the ca lf m u sc le s and the s m a ll m uscles in the feet.I I have noticed th e re s e e m s to be m o re In your supposedly centra d i a b e t i c o n t h e s e o r a l d r u g s . A p p a r e n t ly th e y a r c not c o n t r o l l i n g tl* atherosclerosis. I do not believe that som e of these enginem en who have those changes O vir a rte rie s in th e ir legs really know w hether they have their loot on ad man's pedal, o r not. yhat is not e n tir e ly on the a r t e r i a l side. A lot of that is the r.curoies. They say the neuropathies come only w here your diabetes is ;:^>t c o n t r o l le d , b u t a p p a r e n t l y we a r e s e e i n g a lo t of t h e m now in 'h e d i a betic who is su p p o se d ly u n d e r good control. The charcot joint, especially around the ankle and in the foot bones is readily observable. You see quite a lew of those in the supposedly well controlled diabetic. I c a n n o t h e lp but f e e l t h a t n e x t to th e h y p o g l y c e m i a th a t y o u c a n g e t . . .. from not taking your dru g p ro p erly , o r eating--not eating and taking your drug, and so forth, w here they have these periods of not knowing what they are doing, that, of co u rse , re p re se n ts the m ost dangerous thing in the railroad employee. Next to that, how ever, the changes in th e ir a r te r i e s , and the changes in the nerve setup, the nerve changes that they have as a result of d ia betes, se em to be significant. I noticed recently th e re have been a lot of studies. The x -ray people are having a wonderful tim e in injecting these a r te r ie s - - th e fem oral a r t e r i o g r a p h y . When th e y l i s t t h e i r c a s e s , a n y w h e re f r o m six to 20 p e r cent of these n arrow ed lum en that they have been injecting every two o r three y e a rs to see what kind of p ro g re ss is taking place in these a r te r ie s , anyw here fro m six to 20 p e r c e n t in the s ta t i s t i c s a r e in the d ia b etic. T h erefo re, we have to watch the a r te rie s , certain ly from the p o p li te al on down. ' I have trie d re c e n tly using a blood p re s s u re cuff around the foot to see if there is any ex c u rsio n in your sm a ll m a n o m eter, to tell what the pulse is in the an terio r o r p o sterio r tibial a rte ry . But you usually get them mixed up because the im portant one, the p o ste rio r tibial you have a difficu't tim e feeling norm ally, and with the blood p re ssu re cuff you can not distinguish between the an terio r or the p o sterio r tibial artery. F ro m the su rg ic a l point of view I cannot help but ag ree with John R. Winston. CHAIRMAN NELSON: M ight I ju st add to that, that the o sc illo m ete r Is an excellent addendum to d e te rm in in g the c irc u la tio n in the low er e x trem itie s, and I think m ig h t be so m e th in g we could c o n s id e r u sin g on V'Vople who h a v e q u e s t i o n a b l e c i r c u l a t i o n in th e l o w e r e x t r e m i t i e s . MODERATOR WIGHT; Dr. C layton, you are supposed to be up here with the rest o f the panel, and.w hile you are on your way up you had better hfjin thinking about what you are going to say, b ecause you are going to Uik about diabetic r e tin itis. I a m d i s t u r b e d , h o w e v e r , at tin* c o rn ,-la ce n ev of !. *; . fescio n ; at the p e r s i s t e n c e of g ly c o su ria as we find it on peri.,,ta t rnation. N onetheless tlie attending physician will sa y that his pst; f r e e o f s u g a r in th e u r i n e , a n d he h a s had a u r i n a l y s i s a n d th e b L Ht . is w ith in l i m i t s . Y e t, if we go o v e r o u r c h a r t s we fin d th e p a tie n tt h a a to 4 -plus g ly c o su ria; and it s e e m s to m e that individual is asking for tr I do not know that th e re is any specific c o rre la tio n betw een coronary insufficiency, hypertension, stroke, except as it is uncontrolled diabetes. T h ere is a v ery re a l risk to the individual in his late fo rties, early fiftie s , who h as d ia b e te s, who has m in im al h y p erte n sio n , who invariably has obesity, and having com plications in his card io v ascu lar retin al neuro- V tal system because of poor control. I firm ly believe that adequate clinical control of diabetes can p re vent card io v ascu lar com plications as well as neurological ones. DR. WINSTON: If I m ay m ake a point here. Bill Wade, in DIABETES, M a rc h -A p ril 1959, rep o rted a se rie s, and he said that clinically signi f ic a n t c a r d io v a s c u la r r e n a l d is e a s e w as p r e s e n t in 29 p e r ce n t of the w orkers. T h a t w a s b r o k e n down th is way: th a t 23 p e r c e n t o f th o s e r e c e iv in g in s u lin , e v e n , h ad th is co m p lic atio n ; and 39 p e r c e n t not re c e iv in g insulin. I ju s t wanted to take a little exception to R alp h 's sta te m en t, that I fe e l so m e c o m fo rt if the m an is w ell-co n tro lled . I do not fee l s e c u re , however. M ODERATOR WIGHT: G entlem en, the situation is rapidly becom ing n o rm a l. We have the p an e l m e m b ers arguing am ong th e m se lv es. P lease f( f r e e to i n t e r r u p t at any tim e to a sk any q u e s tio n s . T h e o r e t i c a l l y we h a d p la n n e d .to do w as to co v e r a few of the f ie ld s , and th e c o m p lic a tio n s, and then we would get down to specific q u estio n s. D r,. Leigh, would you care to say a few words on the su rg ica l aspects? DR. SOUTHGATE LEIGH, JR. (Chief Surgeon, Seaboard A ir Line R ail road' : I think th at anyone who has am putated a leg on a diabetic is stru ck with the tre m e n d o u s am ount of fatty deposits in the f e m o ra l a r te r y , and in the popliteal artery. T h e r e is a m a rk e d n arrow ing in the lum en of th e se a r t e r i e s , and b ec au se of th at th e re is bound to be change in the m u s c le s , particular;;.the ca lf m u sc le s and the s m a ll m uscles in the feet.I I have noticed th e re s e e m s to be m o re In your supposedly centra d i a b e t i c o n t h e s e o r a l d r u g s . A p p a r e n t ly th e y a r c not c o n t r o l l i n g tl* athcrosclc rogis. I do not believe that som e of these enginem en who have those changes O vir a rte rie s in th e ir legs really know w hether they have their loot on ad man's pedal, o r not. yhat is not e n tir e ly on the a r t e r i a l side. A lot of that is the r.curoies. They say the neuropathies come only w here your diabetes is ;:0t c o n t r o l le d , b u t a p p a r e n t l y we a r e s e e i n g a lo t of t h e m now in 'h e d i a betic who is su p p o se d ly u n d e r good control. The charcot joint, especially around the ankle and in the foot bones is readily observable. You see quite a lew of those in the supposedly well controlled diabetic. I c a n n o t h e lp but f e e l t h a t n e x t to th e h y p o g l y c e m i a th a t y o u c a n g e t . . .. from not taking your dru g p ro p erly , o r eating--not eating and taking your drug, and so forth, w here they have these periods of not knowing what they are doing, that, of co u rse , re p re se n ts the m ost dangerous thing in the railroad employee. Next to that, how ever, the changes in th e ir a r te r i e s , and the changes in the nerve setup, the nerve changes that they have as a result of d ia betes, se em to be significant. I noticed recently th e re have been a lot of studies. The x -ray people are having a wonderful tim e in injecting these a r te r ie s - - th e fem oral a r t e . i o g r a p h y . When th e y l i s t t h e i r c a s e s , a n y w h e re f r o m six to 20 p e r cent of these n arrow ed lum en that they have been injecting every two o r three y e a rs to see what kind of p ro g re ss is taking place in these a r te r ie s , anyw here fro m six to 20 p e r c e n t in the s ta t i s t i c s a r e in the d ia b etic. T h erefo re, we have to watch the a r te rie s , certain ly from the p o p li te al on down. ' I have trie d re c e n tly using a blood p re s s u re cuff around the foot to see if there is any ex c u rsio n in your sm a ll m a n o m eter, to tell what the pulse is in the an terio r o r p o sterio r tibial a rte ry . But you usually get them mixed up because the im portant one, the p o ste rio r tibial you have a difficu't tim e feeling norm ally, and with the blood p re ssu re cuff you can not distinguish between the an terio r or the p o sterio r tibial artery. F ro m the su rg ic a l point of view I cannot help but ag ree with John R. Winston. CHAIRMAN NELSON: M ight I ju st add to that, that the o sc illo m ete r Is an excellent addendum to d e te rm in in g the c irc u la tio n in the low er e x trem itie s, and I think m ig h t be so m e th in g we could c o n s id e r u sin g on V'Cople who h a v e q u e s t i o n a b l e c i r c u l a t i o n in th e l o w e r e x t r e m i t i e s . MODERATOR WIGHT; Dr. C layton, you are supposed to be up here with the rest o f the panel, and.w hile you are on your way up you had better hfjin thinking about what you are going to say, b ecause you are going to Uik about diabetic r e tin itis. DR. M I L T O N H. C L A Y T O N ( C m . u S u r , T ... . . M r . C h a i r m a n , will y o u r p e r m i s t . i . , 1 I w ould t,.4c t. re m a rk for a hali'-minute. A num ber of the men have com m ented about contact . ... seem to have the im p re ssio n that p erh a p s I was unalterably the u se of contact lenses. ` ! To the c o n tra ry , I am not. I a g re e with what Dr. W ipperm an has said, largely; but this is the thing which concerns m e, gentlem en. When the lens has been removed f r o m an e y e we h a v e a c r ip p le d eye, r e g a r d l e s s of how you look at it. T h e re is nothing going to take the place of the n atu ral lens any m ore than s o m e t h i n g i s g o in g to t a k e 't h e p l a c e o f a lim b . We u s e an a r t i f i c i a l a p pliance in our prosthesis. In the eye we a re using so m eth in g a rtific ia l. So, when you put on top of a crip p led eye an artificial appliance, som ething artificial such a s a c o n t a c t l e n s , then you h av e two s t r i k e s a g a in s t you. I think we have a p ro b lem , and h ere is our p ro b lem --in convincing the ophthalmologist. He h a s an e x c e l le n t r e s u l t te c h n ic a lly , but a s I se e it we m ake a g re a t m ista k e in putting on the engine a m an with a crippled eye, reg a rd le ss of what h is d istance o r near vision m ight be. Now we go to the subject of diabetic retinopathy. I think I can very w ell e x p r e s s th at in a case illu stra tio n which I sh a ll give you briefly. Only re c e n tly I saw an officer, a high officer on a railroad, whom I have known for so m e tim e. I also saw him seven y ea rs ago. A t t h a t t i m e h e a c c e p te d a p lu s 50 s p h e r e in e a c h eye. He h a s been to a n u m b er of ophth alm o lo g ists in the last two y e a r s and h as h ad h is g la s s e s changed a n u m b er of tim es. He is a diabetic; he is a p p ro x im a te ly 50 y e a r s of age; and he has gout. He w anted m y opinion. He was v ery confused about what was taking p la c e . T o d a y he a c c e p ts a p lu s 50 s p h e r e in his rig h t eye, and a m inus 2 sp h e re in the left eye. T h e o c u la r fundi a re essen tially n o rm a l in appearance with the e x ce p tio n I think, th e re is som e change in the n o rm a l and n atu ra l lu stre of the optic d isk on the left side. Som ething is taking place in this eye as a re su lt of his diabetes. I am convinced of this. So, we have a change of vision. We have v isu a l changes; lo ss of vision; fa ilu re of vision; frequent changes of g la sses; and that is a co m m on sy m p to m in the diabetic. N o w f o r t h e f i n d i n g s , a n d t h i s i s a v e r y i n t e r e s t i n g s tu d y . You A- not h av e to be an ophthalm ologist, gentlem en; I was in my b'-g'.r.mr.j * g e n e r a l s u rg e o n . L a te r I sp e cia liz ed , in those days you w n; -.it, so I h a v e h a d , i n m y a g e , a r a t h e r u n u s u a l type of t r a i n i n g which wo not have th e se d ay s. So, to m e I have le a r n e d an awful lot and I s till ,-an l e a r n a n a w f u l lo t by o b s e r v i n g the o c u l a r fu ndi in a n y c a s e . You ju s t jo it r o u tin e ly , b u t y o u h av e to have a s y s t e m . I will agree with Ralph Johnson that the working perso n , the person with w hom y o u a r e w o r k i n g is b e t t e r a b l e to m a k e the a s p e c t c l e a r ; but we c a n l e a r n r e g a r d l e s s of o u r f e e l i n g s . The clinical hallm ark is the presence of hem orrhage; exudates; co t ton wool patch; o r an in f a r c t in the p o s t e r i o r p o rtio n o f the fundus. One of the m o st se rio u s co m p licatio n s is the oozing of blood into the v itre o u s, brin g in g about a clouding of the m edia, with re tin a l detach ment. T his is a se rio u s com plication and not infrequently leads to blind ness. A nother se rio u s com plication that o c c u rs is the occlusion of the c e n tra l retin al vein, with the subsequent developm ent of an intractible glau coma. I am going to show a few slides later, and I will use the words "ex u d a t e s " a n d " c o t t o n w o o l p a t c h e s , " so the m e n w ill be in p o s i t i o n to evaluate this expression. What is the difference between an exudate and a cotton wool patch? Dr. W ipperm an, would you care to answ er that? DR. F. F. W IPPERM AN (Chief of Ophthalmology, Soo Line Railroad); I think we have to re a liz e that diabetic retinopathy is due to an alteration of hem o-dynam ics. The latest way of ex pressing the pathology of the re tin a is they a t t r i b u t e it. to w hat th e y c a l l a s h u n t m e c h a n i s m . I th in k if we u n d e r s t a n d this, we can u n d erstan d the basic pathological p ro c e s s . The sm all m icrocapillaries are com posed of neural and endothelial cells. F o r som e rea so n in diabetes, the n e u ra l ce lls se e m to disappear. T h is allow s a d e c r e a s e i n the c a p illa ry tone of the v e s s e ls ; and if you will im agine a figure Y, and the blood com ing through this Y, over here (Indicating) we have lo ss of the n e u ra l c e lls , and m o re blood is shunted off into th is a r m (indicating) o f th e Y. With th is shunting-off p ro c e ss you get dilatation of the m ic ro c a p il laries and form ation of these m icroaneurysm s. You get then transudates which produce the cotton wool exudates. In the o th e r b ra n c h of this v e s s e l you g et d e c r e a s e d blood flow, and anoxemia, and you get a m ic ro in fa rc t. It is the m ic ro in fa rc t that p r o duces y o u r h a rd , yellow , waxy d is c re te exudate, while in y o u r area of the m ic ro a n e u ry s m , which your transudate is , is where you g et y o u r cotton woo. p atch . 179 DR. M I L T O N H. C L A Y T O N ( C m . u S u r , T ... . . M r . C h a i r m a n , will y o u r p e r m i s t . i . , 1 I w ould t,.4c t. re m a rk for a hali'-minute. A num ber of the men have com m ented about contact . ... seem to have the im p re ssio n that p erh a p s I was unalterably the u se of contact lenses. ` ! To the c o n tra ry , I am not. I a g re e with what Dr. W ipperm an has said, largely; but this is the thing which concerns m e, gentlem en. When the lens has been removed f r o m an e y e we h a v e a c r ip p le d eye, r e g a r d l e s s of how you look at it. T h e re is nothing going to take the place of the n atu ral lens any m ore than s o m e t h i n g i s g o in g to t a k e 't h e p l a c e o f a lim b . We u s e an a r t i f i c i a l a p pliance in our prosthesis. In the eye we a re using so m eth in g a rtific ia l. So, when you put on top of a crip p led eye an artificial appliance, som ething artificial such a s a c o n t a c t l e n s , then you h av e two s t r i k e s a g a in s t you. I think we have a p ro b lem , and h ere is our p ro b lem --in convincing the ophthalmologist. He h a s an e x c e l le n t r e s u l t te c h n ic a lly , but a s I se e it we m ake a g re a t m ista k e in putting on the engine a m an with a crippled eye, reg a rd le ss of what h is d istance o r near vision m ight be. Now we go to the subject of diabetic retinopathy. I think I can very w ell e x p r e s s th at in a case illu stra tio n which I sh a ll give you briefly. Only re c e n tly I saw an officer, a high officer on a railroad, whom I have known for so m e tim e. I also saw him seven y ea rs ago. A t t h a t t i m e h e a c c e p te d a p lu s 50 s p h e r e in e a c h eye. He h a s been to a n u m b er of ophth alm o lo g ists in the last two y e a r s and h as h ad h is g la s s e s changed a n u m b er of tim es. He is a diabetic; he is a p p ro x im a te ly 50 y e a r s of age; and he has gout. He w anted m y opinion. He was v ery confused about what was taking p la c e . T o d a y he a c c e p ts a p lu s 50 s p h e r e in his rig h t eye, and a m inus 2 sp h e re in the left eye. T h e o c u la r fundi a re essen tially n o rm a l in appearance with the e x ce p tio n I think, th e re is som e change in the n o rm a l and n atu ra l lu stre of the optic d isk on the left side. Som ething is taking place in this eye as a re su lt of his diabetes. I am convinced of this. So, we have a change of vision. We have v isu a l changes; lo ss of vision; fa ilu re of vision; frequent changes of g la sses; and that is a co m m on sy m p to m in the diabetic. N o w f o r t h e f i n d i n g s , a n d t h i s i s a v e r y i n t e r e s t i n g s tu d y . You A- not h av e to be an ophthalm ologist, gentlem en; I was in my b'-g'.r.mr.j * g e n e r a l s u rg e o n . L a te r I sp e cia liz ed , in those days you w n; -.it, so I have had, in my age, a ra th e r u n u su a l type of train in g which not have th e se d ay s. So, to m e I have le a r n e d an awful lot and I s till ,-an l e a r n a n a w f u l lo t by o b s e r v i n g the o c u l a r fu ndi in a n y c a s e . You ju s t jo it r o u tin e ly , b u t y o u h av e to have a s y s t e m . I will agree with Ralph Johnson that the working perso n , the person with w hom y o u a r e w o r k i n g is b e t t e r a b l e to m a k e the a s p e c t c l e a r ; but we c a n l e a r n r e g a r d l e s s of o u r f e e l i n g s . The clinical hallm ark is the presence of hem orrhage; exudates; co t ton wool patch; o r an in f a r c t in the p o s t e r i o r p o rtio n o f the fundus. One of the m o st se rio u s co m p licatio n s is the oozing of blood into the v itre o u s, brin g in g about a clouding of the m edia, with re tin a l d etach ment. T his is a se rio u s com plication and not infrequently leads to blind ness. A nother se rio u s com plication that o c c u rs is the occlusion of the c e n tra l retin al vein, with the subsequent developm ent of an intractible glau coma. I am going to show a few slides later, and I will use the words "ex u d a t e s " a n d " c o t t o n w o o l p a t c h e s , " so the m e n w ill be in p o s i t i o n to evaluate this expression. What is the difference between an exudate and a cotton wool patch? Dr. W ipperm an, would you care to answ er that? DR. F. F. W IPPERM AN (Chief of Ophthalmology, Soo Line Railroad); I think we have to re a liz e that diabetic retinopathy is due to an alteration of hem o-dynam ics. The latest way of ex pressing the pathology of the re tin a is they a t t r i b u t e it. to w hat th e y c a l l a s h u n t m e c h a n i s m . I th in k if we u n d e r s t a n d this, we can u n d erstan d the basic pathological p ro c e s s . The sm all m icrocapillaries are com posed of neural and endothelial cells. F o r som e rea so n in diabetes, the n e u ra l ce lls se e m to disappear. T h is allow s a d e c r e a s e i n the c a p illa ry tone of the v e s s e ls ; and if you will im agine a figure Y, and the blood com ing through this Y, over here (Indicating) we have lo ss of the n e u ra l ce lls, and m o re blood is shunted off into th is a r m (indicating) o f th e Y. With th is shunting-off p ro c e ss you get dilatation of the m ic ro c a p il laries and form ation of these m icroaneurysm s. You get then transudates which produce the cotton wool exudates. In the o th e r b ra n c h of this v e s s e l you g et d e c r e a s e d blood flow, and anoxemia, and you get a m ic ro in fa rc t. It is the m ic ro in fa rc t that p r o duces y o u r h a rd , yellow , waxy d is c re te exudate, while in y o u r area of the m ic ro a n e u ry s m , which your transudate is , is where you g et y o u r cotton woo. patch. 179 DI. C L A Y T O N : Tlwnk you very much. G e n t l e m e n , I w ould lik e to s h o w y o u a few s l i T ' s which I :hi.-.i, *, g ra p h ic a lly te ll the sto r y b e tte r than we can in w ords. While we a r e w aiting for our o p e r a to r, I w ould like to read one statem ent which I think is of significance: "A diabetic retinopathy reflec ts n eith er the severity r.or the course of diabetes. " W ell, X w ill h ave to wait; go ah ead w ith th e slid es. (Slide) T h e s e s lid e s a r e all f ro m d ia b e tic s . In d iab etes, the vein s, a r e p r e d o m i n a n t l y d i s t u r b e d , m o r e s o th a n th e a r t e r i e s . H e re a r e thon erv e h ead s. H ere (indicating) is the c e n tra l retin al arte ry coming out i t h the te m p o r a ls , and so on, which is a b ran c h of the ophthalm ic, which, tu rn , is a branch of the internal carotid. T h e v e in s a r e elongated. T hey a r e stra ig h te n e d . We do not notice a p a rtic u la r change in the arte ries. H ere you s e e is a m acula (indicating). You can see these whitish r o u n d d o ts , w h ic h a r e c h a r a c t e r i s t i c o f d i a b e t e s , and when we sp e ak of t h e s e w hite s p o ts this is what we se e . You can see these roundish m icroaneurysm s, or hemorrhages. T h e r e is a lot of theory still about the extent of an eu ry sm s on a c o m p a ra b le b a s is , but we do see in d iab etes, h e m o rrh ag e s, and they a re usually of the round type. They can be of a flam e shape, but you will notice that n e v e r a re the la rg e r v e s se ls involved unless there is a h y p e r tensive neuroretinopathy. Diabetes is a capillary disease. (Slide) You s e e h e r e (indicating) th e white sp o ts which we have been , ;ing about; and you see h ere (indicating) are these hem orrhages scatter trrYoughout. (Slide) You see the sam e thing h ere again. Here is the macula ` (indicating); you can see them out on the peripheral part. Here (indicat ing) a r e the h em o rrh ag e s again. (Slide) T his is a rath er beautiful pictu re of these whitish formations. You s e e th e y a r e en c irclin g the m a c u la , the h e m o rrh a g e s, and w here they com pletely en circle the m acula you have a rin g shape. That is alm ost a c la s s ic a l p ictu re associated with diabetes. It is tru e , however, they m ight have som ething else. Here (indicat ing) you s e e the h e m o rrh a g e s again, and you w ill notice, gentlem en, one other thing; in the true diabetes you will seldom ever see a person w..h diabetes with any sw elling of the nerve head. When we get the hyperten s i v e , w e g e t a b l u r r i n g of t h e n e r v e h e a rt w ith h e m o r r h a g e s , ur..l You seld o m see that in diabetes p e r se. , 130 (Slide) Y o u see here the white patches (indicating); the hemorrhage.-, surrounding the macula, and so on. You c a n s e e t h e s e v e i n s s t r a i g h t e n o u t , a n d b e c o m e e l o n g a t e d , and s. on. (Slide) You see again these white spots and hem orrhages. (Slide) You se e (indicating) the w hitish c h a r a c te r is tic , and this is a b e a u tifu l p ic tu r e of y o u r r e a l m ic r o a n e u r y s m . You can s e e these round ish h em orrhagic a re a s , and it is a beautiful picture; and when you see that, believe m e, in my case I am going to begin to look for diabetes. (Slide) A lso , yo u s e e the l a r g e r v e s s e l s Eire n ot involved. You can see it is a cap illary disease. You see the pigm entary form ation, the h em o rrh ag e, and so on. (Slide) H ere is som ething which we not infrequently se e in diabetes, and this is a very disturbing thing. The ce n tral retinal vein I mentioned b e fo re not in fre q u e n tly in the s e v e re c a s e b e c o m e s o cc lu d e d , and then we get glaucoma, and usually blindness. H ere (indicating) is blockage of the s u p e rio r te m p o ra l p a r t of the vein. You can see this is just a beautiful picture. (Slide) You se e again these whitish spots s c a tte re d throughout, and so on; also, there you a re getting pallor of the entire fundus. Thank you very much, gentlemen. MODERATOR WIGHT: Thar.k you, Dr. Clayton. We w ill now g et down to s o m e of the p r a c t i c a l c o n s id e ra tio n s of d ia betes. , F ir s t of all, th e re is a question I would like to pose to the panel for th e ir opinion. T h e individual who is o v e r 40 y e a r s of age; g ro s s ly o v e r weight; has a diabetic c u r v e - - i s he a tr u e diabetic ? Who on the panel wants to answ er th at? DR. STANLEY J. CYRAN (Medical D irecto r, Pennsylvania Railroad): I think b e fo re we leav e diabetic re tin o p a th y an im p o rta n t point in d is c u s s ing so m e of the sym ptom s is in checking th e ir v isu a l acuity. If you are not checking them very closely you w ill find that they are not looking directly ahead into the Snellen ch art, and you may find that their vision is actually in c o rrec t because they w ere looking through the peripheral part of the retina. Most of the degeneration is m acular, and you lose a lo t o f c e n t r a l v i s i o n , and s o m e of t h e s e p e o p l e c a n c o m p e n s a t e by turning the head and allowing the image to fall on o th er p arts of the retina not involved. Would you a g re e with that ? 181 DI. C L A Y T O N : Tlwnk you very much. G en tlem e n , I would like to show you a few s liT 's which I *, g r a p h ic a ll y te ll th e s to r y b e t t e r than we c a n in wo re's. While we a r e w aiting for our o p e r a to r, I w ould like to read one statem ent which I think is of significance: "A diabetic retinopathy reflects n eith er the severity nor the course of diabetes. " W ell, X w ill h ave to wait; go ah ead w ith th e slid es. (Slide) T h e s e s lid e s a r e all f ro m d ia b e tic s . In d iab etes, the vein s, a r e p re d o m in a n tly disturbed, m o re so than the a r te rie s . Here are the n erv e h ead s. H ere (indicating) is the c e n tra l retin al arte ry coming out i t h the te m p o r a ls , and so on, which is a b ran c h of the ophthalm ic, which, tu rn , is a branch of the internal carotid. T h e v e in s a r e elongated. T hey a r e stra ig h te n e d . We do not notice a p a rtic u la r change in the arte ries. H ere you s e e is a m acula (indicating). You can sec these whitish r o u n d d o ts , w h ic h a r e c h a r a c t e r i s t i c o f d i a b e t e s , and when we sp e ak of t h e s e w hite s p o ts this is what we se e . You can see these roundish m icroaneurysm s, or hemorrhages. T h e r e is a lot of theory still about the extent of an eu ry sm s on a c o m p a ra b le b a s is , but we do see in d iab etes, h e m o rrh ag e s, and they a re usually of the round type. They can be of a flam e shape, but you will notice that n e v e r a re the la rg e r v e s se ls involved unless there is a h y p e r tensive neuroretinopathy. Diabetes is a capillary disease. (Slide) You s e e h e r e (indicating) th e white sp o ts which we have been , ;.ing a b o u t; an d y ou s e e h e r e (in d ic atin g ) a r e th e s e h e m o r r h a g e s s c a tte r trrYoughout. (Slide) You see the sam e thing h ere again. Here is the macula ` (indicating); you can see them out on the peripheral part. Here (indicat ing) a r e the h em o rrh ag e s again. (Slide) T his is a rath er beautiful pictu re of these whitish formations. You s e e th e y a r e en c irclin g the m a c u la , the h e m o rrh a g e s, and w here they com pletely en circle the m acula you have a rin g shape. That is alm ost a c la s s ic a l p ictu re associated with diabetes. It is tru e , however, they m ight have som ething else. Here (indicat ing) you s e e the h e m o rrh a g e s again, and you w ill notice, gentlem en, one o th er thing; in the tru e diabetes you will seldom ever see a person w..h diabetes with any sw elling of the nerve head. When we get the hyperten s i v e , w e g e t a b l u r r i n g of t h e n e r v e h e a rt w ith h e m o r r h a g e s , ur..l You seld o m see that in diabetes p e r se. , 130 (Slide) Y o u see here the white patches (indicating); the hemorrhage.-, surrounding the macula, and so on. You c a n s e e t h e s e v e i n s s t r a i g h t e n o u t , a n d b e c o m e e l o n g a t e d , and s. on. (Slide) You see again these white spots and hem orrhages. (Slide) You se e (indicating) the w hitish c h a r a c te r is tic , and this is a b e a u tifu l p ic tu r e of y o u r r e a l m ic r o a n e u r y s m . You can s e e these round ish h em orrhagic a re a s , and it is a beautiful picture; and when you see that, believe m e, in my case I am going to begin to look for diabetes. (Slide) A lso , yo u s e e the l a r g e r v e s s e l s Eire n ot involved. You can see it is a cap illary disease. You see the pigm entary form ation, the h em o rrh ag e, and so on. (Slide) H ere is som ething which we not infrequently se e in diabetes, and this is a very disturbing thing. The ce n tral retinal vein I mentioned b e fo re not in fre q u e n tly in the s e v e re c a s e b e c o m e s o cc lu d e d , and then we get glaucoma, and usually blindness. H ere (indicating) is blockage of the s u p e rio r te m p o ra l p a r t of the vein. You can see this is just a beautiful picture. (Slide) You se e again these whitish spots s c a tte re d throughout, and so on; also, there you a re getting pallor of the entire fundus. Thank you very much, gentlemen. MODERATOR WIGHT: Thar.k you, Dr. Clayton. We w ill now g et down to s o m e of the p r a c t i c a l c o n s id e ra tio n s of d ia betes. , F ir s t of all, th e re is a question I would like to pose to the panel for th e ir opinion. T h e individual who is o v e r 40 y e a r s of age; g ro s s ly o v e r weight; has a diabetic curve --is he a tru e diabetic ? Who on the panel wants to answ er th at? DR. STANLEY J. CYRAN (Medical D irecto r, Pennsylvania Railroad): I think b e fo re we leav e diabetic re tin o p a th y an im p o rta n t point in d is c u s s ing so m e of the sym ptom s is in checking th e ir v isu a l acuity. If you are not checking them very closely you w ill find that they are not looking directly ahead into the Snellen ch art, and you may find that their vision is actually in c o rrec t because they w ere looking through the peripheral part of the retina. Most of the degeneration is m acular, and you lose a lo t o f c e n t r a l v i s i o n , and s o m e of t h e s e p e o p l e c a n c o m p e n s a t e by tu rn in g th e h ea d and allow ing the im a g e to f a ll on o t h e r p a r t s of the re tin a not involved. Would you a g re e with that ? 181 Dl>. U II M'KRMAN': Y e s . I brought up aijuut this d is t ur be d vi I You can have a neuronal d eg rn erai mn, a ....... in t h e r e t i n a , w h ic h c a n p r e c e d e the vancul.-.r ch.a:.. . d i s t u r b a n c e o f v i s i o n in t h e s e p e o p l e . Y o u c a n Iook :r. ( .< , . . . a c t u a l l y w ill f in d i t l o o k s p r e t t y n o r m a l , a s n e a r a s y o u car. ..... r . . . ' M i c r o s c o p i c a l l y , h o w e v e r , t h e r e is d e f i n i t e l y n e u r o n deg.m .-ra;: m. accounts for som e of this visual disturbance. Secondly, in the c a s e th a t D r. C layton m entioned, in which he ha 1 p lu s-5 0 in one, and a m in u s-2 0 0 in the o th e r, obviously this mar. was having so m e n eu ro tic lens difficulty to m ake him m ore myopic ra th e r than diabetic. DR.- CYRAN: N ow to go b ac k to the o r ig in a l question. L j 1 know D r. Wight will disagree. If we take the definition of diabetes t5s a r e l a t i v e o r a b s o lu te d e f ic ie n c y of i n s u l in , no m a t t e r what the c a u s e . I would say that this m an m u st be c o n sid e re d a diabetic. S ure, you take h is \veight off, and h is d ia b e tic c u r v e i m p r o v e s , and m ay b e ho is again show ing a n o rm a l glucose utilization. If he gets obese again, however, he p e r h a p s will develop a d ia b etic c u rv e as c o m p a re d to a som ew hat o v e r w eight in d iv id u a l who does not have an a b n o r m a l c u rv e . T h e re m ust be s o m e r e a s o n why th is m a n h a s th e a b n o r m a l c u rv e ; if so , I would say he is a diabetic. M ODERATOR WIGHT: A re th ere any o th er com m ents from the panel? My question was; Is he a true diabetic? DR. CYRAN; W hat is y o u r definition of a " t r u e d ia b e tic ? " What do you m ean by that? M ODERATOR WIGHT; A tru e d iab etic--th e re is a pancreatic deficiency. t / CRY AN: Not if you go by the definition of a re la tiv e o r absolute d eficiency of insulin. In this c a se th e re is a re la tiv e deficiency of in sulin. * DR. CLAYTON: It has now been estab lish ed that you can find evidence of d ia b e te s, the c la s s ic a l d iab etes, in the o c u la r fundi. Yet, it has not b een e s ta b lis h e d by c lin ic a l te s ts , that is , by blood s u g a r, and so forth. So, diabetes is an insidious d ise ase . It is a hidden d isease. To m e it is t h e r e , r e g a r d l e s s , with the individual. I think it is la rg e ly genetic, a n d I t h i n k s o m e t h i n g is g o in g on w ith t h i s i n d i v i d u a l a n d w ill c o n t in u e 10 do so all of his days, even though he does not show an abnorm al amount of su g a r in the u rin e o r in the blood. DR. CYRAN: If you co n sid e r the tru e diabetic the one who has the g en e tic p r e d is p o s itio n , a s the id e n tic a l tw in o f a d ia b e tic , o r the p e r s o n who 182 , m other and fath er who a re d iabetics, if you co n sid er that person .' ' a e diabetic, that is one consideration. P e r h a p s I could not classify overweight- man in that category. V.. WINSTON: T h i s m a t t e r o f t r u e o r f a l s e in t h i s day and a g e is s o m e .;-:at a c a d e m i c . A s I v ie w i t , we m u s t c o n s i d e r t h is m a n a d ia b e tic . He sh o u ld c o n s i d e r h i m s e l f a d i a b e t i c , a n d h a n d l e h i m s e l f a c c o r d in g ly ; jr.d I f e e l t h a t t h i s h a s r a i s e d a good p o in t, a n d t h a t i s a l l to o often, we, or at le a s t s o m e peo p le, a r e in c lined to take s o m e c o m f o r t because this nan is not a tru e diabetic, if that is c o rre c t. When I am re v ie w in g the files that go o v e r my desk , it is not unusual in th is d a y to s e e a n o t a t i o n th a t th is m a n h a s g l y c o s u r i a . H e had h o t c a k c s for b rea k fa st, but he is not a diabetic. I think we should c o n s id e r anyone who h a s g ly c o s u ria , anyone who has an e le v a te d blood s u g a r above the allow able c u rv e , anyone who h as the typical o r unusual diabetic glucose tolerance curve, so far as I am concerned, is a diabetic, and I think that he should consider him self a diabetic, and with that in mind perhaps he w ill be able to tr e a t him self, and wi 11 be in a b e t t e r f r a m e o f m i n d to t r e a t h i m s e l f a s he sh o u ld be treated. MODERATOR WIGHT: T his is a question that is often d iscu ssed , and u was put to me at one tim e in a m an n er that I can u n d erstan d , this o v e r weight, over-aged individual is com parable to a p an creas that is s a tis factory for a Shetland por.y, but will not function p ro p e rly in a Clydesdale; and if you get his weight down he will have a n o rm a l curve. A re th e re any other com m ents on that? What do you people think about that? DR. A. J. SUTHERLAND (D istrict Surgeon, L ouisville & N ashville R ail road) : M r. M o d erato r, along that sam e line I would like to ask som eone on the p a n e l to d is c u s s this p a r ti c u la r ca se . I had one M onday, a fellow who had a c o r o n a r y in N o v e m b e r. He o rig in a lly w eig h ed 26 5, an d h e is six feet two. His doctor brought him down to 225, but had not put him on any o ra l or insulin therapy. I talked with him on the phone, and I asked him why they had not. His blood sugar is running around 200. He said that if I put him on o rin ase , o r any of the o r a l m edications, he will quit losing weight. Is that tru e with the use of the o ra l hypogly cem ic agents ? MODERATOR WIGHT: Would you c a r e to a n sw e r that ? 183 Dl>. U II M'E R M A N : Y e s . I brought up ii'juut this d is t ur b e d vt I You can have a neuronal d eg rn erai mn, a ....... in t h e r e t i n a , w h ic h c a n p r e c e d e the vancul.-.r ch.'a:.. . d i s t u r b a n c e o f v i s i o n in t h e s e p e o p l e . Y o u c a n Iook :r. ( .< , . . . a c t u a l l y w ill f in d i t l o o k s p r e t t y n o r m a l , a s n e a r a s y o u car. ..... r . . . ' M i c r o s c o p i c a l l y , h o w e v e r , t h e r e is d e f i n i t e l y n e u r o n d e g e m -ra ;: m. accounts for som e of this visual disturbance. Secondly, in the c a s e th a t D r. C layton m entioned, in which he ha 1 p lu s-5 0 in one, and a m in u s-2 0 0 in the o th e r, obviously this mar. was having so m e n eu ro tic lens difficulty to m ake him m ore myopic ra th e r than diabetic. DR.- CYRAN: N ow to go b ac k to the o r ig in a l question. L j 1 know D r. Wight will disagree. If we take the definition of diabetes t5s a r e l a t i v e o r a b s o lu te d e f ic ie n c y of i n s u l in , no m a t t e r what the c a u s e . I would say that this m an m u st be c o n sid e re d a diabetic. S ure, you take h is \veight off, and h is d ia b e tic c u r v e i m p r o v e s , and m ay b e ho is again show ing a n o rm a l glucose utilization. If he gets obese again, however, he p e r h a p s will develop a d ia b etic c u rv e as c o m p a re d to a som ew hat o v e r w eight in d iv id u a l who does not have an a b n o r m a l c u rv e . T h e re m ust be s o m e r e a s o n why th is m a n h a s th e a b n o r m a l c u rv e ; if so , I would say he is a diabetic. M ODERATOR WIGHT: A re th ere any o th er com m ents from the panel? My question was; Is he a true diabetic? DR. CYRAN; W hat is y o u r definition of a " t r u e d ia b e tic ? " What do you m ean by that? M ODERATOR WIGHT; A tru e d iab etic--th e re is a pancreatic deficiency. t / CRY AN: Not if you go by the definition of a re la tiv e o r absolute d eficiency of insulin. In this c a se th e re is a re la tiv e deficiency o f in sulin. * DR. CLAYTON: It has now been estab lish ed that you can find evidence of d ia b e te s, the c la s s ic a l d iab etes, in the o c u la r fundi. Yet, it has not b een e s ta b lis h e d by c lin ic a l te s ts , that is , by blood s u g a r, and so forth. So, diabetes is an insidious d ise ase . It is a hidden d isease. To m e it is t h e r e , r e g a r d l e s s , with the individual. I think it is la rg e ly genetic, a n d I t h i n k s o m e t h i n g is g o in g on w ith t h i s i n d i v i d u a l a n d w ill c o n t in u e 10 do so all of his days, even though he does not show an abnorm al amount of su g a r in the u rin e o r in the blood. DR. CYRAN: If you co n sid e r the tru e diabetic the one who has the g en e tic p r e d is p o s itio n , a s the id e n tic a l tw in o f a d ia b e tic , o r the p e r s o n who 182 , m other and fath er who a re d iabetics, if you co n sid er that person .' ' a e diabetic, that is one consideration. P e r h a p s I could not classify overweight- man in that category. V.. WINSTON: T h i s m a t t e r o f t r u e o r f a l s e in t h i s day and a g e is s o m e .;-:at a c a d e m i c . A s I v ie w i t , we m u s t c o n s i d e r t h is m a n a d ia b e tic . He sh o u ld c o n s i d e r h i m s e l f a d i a b e t i c , a n d h a n d l e h i m s e l f a c c o r d in g ly ; jr.d I f e e l t h a t t h i s h a s r a i s e d a good p o in t, a n d t h a t i s a l l to o often, we, or at le a s t s o m e peo p le, a r e in c lined to take s o m e c o m f o r t because this nan is not a tru e diabetic, if that is c o rre c t. When I am re v ie w in g the files that go o v e r my desk , it is not unusual in th is d a y to s e e a n o t a t i o n th a t th is m a n h a s g l y c o s u r i a . H e had h o t c a k c s for b rea k fa st, but he is not a diabetic. I think we should c o n s id e r anyone who h a s g ly c o s u ria , anyone who has an e le v a te d blood s u g a r above the allow able c u rv e , anyone who h as the typical o r unusual diabetic glucose tolerance curve, so far as I am concerned, is a diabetic, and I think that he should consider him self a diabetic, and with that in mind perhaps he w ill be able to tr e a t him self, and wi 11 be in a b e t t e r f r a m e o f m i n d to t r e a t h i m s e l f a s he sh o u ld be treated. MODERATOR WIGHT: T his is a question that is often d iscu ssed , and u was put to me at one tim e in a m an n er that I can u n d erstan d , this o v e r weight, over-aged individual is com parable to a p an creas that is s a tis factory for a Shetland por.y, but will not function p ro p e rly in a Clydesdale; and if you get his weight down he will have a n o rm a l curve. A re th e re any other com m ents on that? What do you people think about that? DR. A. J. SUTHERLAND (D istrict Surgeon, L ouisville & N ashville R ail road) : M r. M o d erato r, along that sam e line I would like to ask som eone on the p a n e l to d is c u s s this p a r ti c u la r ca se . I had one M onday, a fellow who had a c o r o n a r y in N o v e m b e r. He o rig in a lly w eig h ed 26 5, an d h e is six feet two. His doctor brought him down to 225, but had not put him on any o ra l or insulin therapy. I talked with him on the phone, and I asked him why they had not. His blood sugar is running around 200. He said that if I put him on o rin ase , o r any of the o r a l m edications, he will quit losing weight. Is that tru e with the use of the o ra l hypogly cem ic agents ? MODERATOR WIGHT: Would you c a r e to a n sw e r that ? 183 OR. C ' i I!.\N : T h i s is t r u u of s o o n - o f lji .s.i]; i !j o r i n a s e , d ia biria.se. d y m e l o r . T n u y do c a u s 1 fai sy:/. la- ,. , * tiiey m ay cause an inci'ease in weight. Insulin h as'n sin .:'-'- put weight on. DBI, or P h en fo rm in --th e chem ical nam e--actu ally the drug is h - ing re c o m m e n d e d in th e se c a s e s becau se it h as a lipogcnetic snaring feet. It d o es not c a u se the in c re a s e d tendency to fat disposition; and thr o v e rw e ig h t d ia b e tic m ig h t be b e t te r off on D BI b e c a u s e he will u-nd to los.; weight. MODERATOR WIGHT: A re there fu rth e r questions? DR. MISHLER: I would like to ask Dr. Wight how many Clydesdales he has converted into Shetlands? M ODERATOR WIGHT: That is an academ ic question, I hope. N o --th e re are quite a num ber of cases in which the grossly o v e r weight individual had his curve com e down when he lost weight. T he problem , of co u rse, as I know as well as you do, is to get them to lose the weight. DR. MISHLER: That is the point. MODERATOR WIGHT: The first question we have here is: "Should or should not th e re be r e s tr ic tio n s on engine-men with diabetes with o r with out the use of diabetic agents?" D r. G raham , would you c a re to take that o n e? D R. R O B E R T M. GRAHAM (D ire c to r, D e p a rtm e n t of Medicine and Sanitation, The Pullm an Company): CVi e n g i n e m e n m y o p in io n w ould be y e s , d e f i n i t e l y . ^ J 3 D E R A T O R WIGHT: Is th e re any argum ent with that answ er? DR. WINSTON: Why? * DR. GRAHAM: Of co u rse , th e re again you have to analyze, as has been brought out before, the individual situation. If you have an individual, this obese individual, with this early d ia b e te s , that can be con tro lled with diet, and even in ce rta in instances with o r a l hypoglycem ic agents, then I would say that the man might be p e r m itte d to o p e ra te on c e rta in lines subject to continued fu rth er o b se rv a tion. F o rtu n a te ly th at is not the p ro b lem that I have to face. M O D E R A T O R W IGHT: D r . W in s to n , y o u a s k e d why; l e t ' have y o u r V~. * ** 18 -3. WINSTON: This question has two answers at least, and m a y prob.:i..v r/e more. Number o n e--th e d iabetic--the tru e diabetic whose d isease is con trolled, and we can go into the definition of "c o n tro lle d " if you would like for s o m e t i m e - - w i t h o u t th e u s e o f h y p o g l y c e m i c a g e n t s - - t h a t i s , by d iet alone--does not, as I understand it, present a p articu la r h azard insofar as h is d i a b e t e s is c o n c e r n e d , with th e ex c ep tio n th a t h e s ta n d s the r i s k of ' developing c e rta in com plications, p rim a rily those re la tin g to the vascular system , and possibly the kidney, and p erh ap s to the n erve cell, as a r e sult of his controlled diabetes. He is not, however, a candidate for sudden incapacitation, or the u s e of p o o r j u d g m e n t b e c a u s e of a c i d o s i s , o r b e c a u s e of h y p o g ly c e m i a . .. T h e re fo re , he is p e rm itte d to pilot the planes on the a irlin e s , and in our te rrito ry he is p erm itted to operate the locom otives. The one about the diabetic on, I presum e, hypoglycem ic agents is another q u e s tio n --a n d I would im agine you would want ano th er answer; certainly I would. MODERATOR WIGHT: Are there any com m ents on that? D r . H o llo , w ould y o u l e t an e n g i n e m a n o p e r a t e - - l e t 1s s p l i t the q u e s tio n --a n enginem an with diabetes who has his condition controlled with out the use of any m edication? Would you let him run ? DR. V E N C E L W. H O L L O ( C h ie f S u rg e o n , St. L o u i s - S a n F r a n c i s c o R y . ): Yes, I would. . DR. WINSTON: One thing that I should have added and that is that once the p e r s o n h a s d ia b e te s , h e, fro m then on, s h o u ld be s u b je c t to frequent o b se rv a tio n s. It is only through frequent o b se rv a tio n s that you are going to d e te rm in e that he continues to be a safe em ployee. , DR. MISHLER: How frequently a re they exam ined ? MODERATOR WIGHT: I will tell you what we do in an sw e r to that q u e s tion. An en g in em an who is not taking any m e d ic a tio n and w hose d ia b ete s is controlled, is p erm itted to operate. The frequency of the exam ination depends on the individual and his p h y s i c a l c h a r a c t e r i s t i c s - - b l o o d p r e s s u r e ; w e ig h t , a n d so f o r t h . We might ask for an exam ination quarterly, o r every six months, whatever the case calls for in the circum stances. DR. WINSTON: Until we have estab lish ed a b aselin e for this p a rtic u la r person, then it is my thinking that it should be not m o re infrequent than 30 d a y s . A fter a s e rie s of examinations at that interval, then perhaps you can exlend it; and we do, to three m onths. 185 D!\. C ' i RAN: T h i s is t r u u of s o o n - o f lji .s.i]; o r in a s e , (Jiabina.se, clyiueior. Tiwy do caus1 fat tiiey m ay cause an in c re a se in weight. Insulin h as'n sir put weight on. DBI, or P h en fo rm in --th e chem ical nam e--actu ally the drug is h-ing re c o m m e n d e d in th e se c a s e s becau se it h a s a lipogcnctic soaring feet. It does not c a u se the in c re a s e d tendency to fat disposition; and the o v e r w e i g h t d i a b e t i c m i g h t be b e t t e r off o n D B I b e c a u s e he w ill te-nd to los.; weight. MODERATOR WIGHT: A re there fu rth e r questions? DR. MISHLER: I would like to ask Dr. Wight how many Clydesdales he has converted into Shetlands? M ODERATOR WIGHT: That is an academ ic question, I hope. N o --th e re are quite a num ber of cases in which the grossly o v e r weight individual had his curve com e down when he lost weight. T he problem , of co u rse, as I know as well as you do, is to get them to lose the weight. DR. MISHLER: That is the point. MODERATOR WIGHT: The first question we have here is: "Should or should not th e re be r e s tr ic tio n s on engine-men with diabetes with o r with out the use of diabetic agents?" D r. G raham , would you c a re to take that o n e? D R. R O B E R T M. GRAHAM (D ire c to r, D e p a rtm e n t of Medicine and Sanitation, The Pullm an Company): CVi e n g i n e m e n m y o p in io n w ould be y e s , d e f i n i t e l y . ^JD D E R A T O R WIGHT: Is th e re any argum ent with that answ er? DR. WINSTON: Why? * DR. GRAHAM: Of co u rse , th e re again you have to analyze, as has been brought out before, the individual situation. If you have an individual, this obese individual, with this early d ia b e te s . that can be con tro lled with diet, and even in ce rta in instances with o r a l hypoglycem ic agents, then I would say that the man might be p e r m itte d to o p e ra te on c e rta in lines subject to continued fu rth er o b se rv a tion. F o rtu n a te ly th at is not the p ro b lem that I have to face. M O D E R A T O R W IGHT: D r . W in s to n , y o u a s k e d why; l e t 's have y o u r v~. * *r 18-1 -3. WINSTON: This question has two answers at least, and m a y prob.:i..v r/e more. Number o n e--th e d iabetic--the tru e diabetic whose d isease is con trolled, and we can go into the definition of "c o n tro lle d " if you would like for s o m e t i m e - - w i t h o u t th e u s e o f h y p o g l y c e m i c a g e n t s - - t h a t i s , by d iet alone--does not, as I understand it, present a p articu la r h azard insofar as h is d i a b e t e s is c o n c e r n e d , with th e ex c ep tio n th a t h e s ta n d s the r i s k of ' developing c e rta in com plications, p rim a rily those re la tin g to the vascular system , and possibly the kidney, and p erh ap s to the n erve cell, as a r e sult of his controlled diabetes. He is not, however, a candidate for sudden incapacitation, or the u s e of p o o r j u d g m e n t b e c a u s e of a c i d o s i s , o r b e c a u s e of h y p o g ly c e m i a . .. T h e re fo re , he is p e rm itte d to pilot the planes on the a irlin e s , and in our te rrito ry he is p erm itted to operate the locom otives. The one about the diabetic on, I presum e, hypoglycem ic agents is another q u e s tio n --a n d I would im agine you would want ano th er answer; certainly I would. MODERATOR WIGHT: Are there any com m ents on that? D r . H o llo , w ould y o u l e t an e n g i n e m a n o p e r a t e - - l e t 1s s p l i t the q u e s tio n --a n enginem an with diabetes who has his condition controlled with out the use of any m edication? Would you let him run ? DR. V E N C E L W. H O L L O ( C h ie f S u rg e o n , St. L o u i s - S a n F r a n c i s c o R y . ): Yes, I would. . DR. WINSTON: One thing that I should have added and that is that once the p e r s o n h a s d ia b e te s , h e, fro m then on, s h o u ld be s u b je c t to frequent o b se rv a tio n s. It is only through frequent o b se rv a tio n s that you are going to d e te rm in e that he continues to be a safe em ployee. , DR. MISHLER: How frequently a re they exam ined ? MODERATOR WIGHT: I will tell you what we do in an sw e r to that q u e s tion. An en g in em an who is not taking any m e d ic a tio n and w hose d ia b ete s is controlled, is p erm itted to operate. The frequency of the exam ination depends on the individual and his p h y s i c a l c h a r a c t e r i s t i c s - - b l o o d p r e s s u r e ; w e ig h t , a n d so f o r t h . We might ask for an exam ination quarterly, o r every six months, whatever the case calls for in the circum stances. DR. WINSTON: Until we have estab lish ed a b aselin e for this p a rtic u la r person, then it is my thinking that it should be not m o re infrequent than 30 d a y s . A fter a s e rie s of examinations at that interval, then perhaps you can exlend it; and we do, to three m onths. 185 T h e n a f t e r he h a s e s t a b l i s h e d h i m s e l f , a n d wc- g e t m o r e c o n ' ' d , - - c in h i m , w e w ill m a k e i t s i x m o n t h s . I d o u b t t h a t we s h o u ld e x te n d i t `be. yond the six-m onth period. M OD ERA TOR WIGHT: Dr. M is h le r. I w ill qualify my answ er in view of what Dr. Johnson said. When we d isco v er this m an, we take him out of se rv ic e im m ediately to get his condition under co n trol. Then if we a re satisfied that it can be c o n t r o l le d w ith o u t the u s e of m e d ic a tio n , we w ill le t h im go b a c k -and then we will exam ine him q u arterly , o r in that area. D K . H O L L O : I w ould lik e to m a k e o n e p o in t: W"hen we h a v e a p a t i e n t who has been diagnosed, as a diabetic, he is hospitalized, and then follow ed-as you said. \^ _ > E R A T O R WIGHT: Yes; investigated to e sta b lish his condition. Does anyone else have any com m ent on this aspect? DR. MISHLER: T h ere is one re m a rk I would like to m ake, and it is not r e a lly on h e re . T hat is in re la tio n to those people who w ere c o n tro l led by diet. I would like to have the second question answ ered. M O D ERA TO R WIGHT: Right.- T h o se enginem en, p roven d ia b etics, who have to take m edication of any kind, a r e they allow ed to o p e ra te a m ain line engine, o r a re they r e s t r i c t e d ? T h at is the se c o n d p a r t o f y o u r q u e s tio n . D r. Winston. You bro k e the question into two. D R. JOHNSON: I feel th at an enginem an who h as d iab etes, who re q u ire s h' g ly c em ic agents for co n tro l, should be r e s tr ic te d . ' T hat should be t^W ule. It w ill have to be m odified in sp e cific c a s e s ; but ce rtain ly the h az ard p o sed by o ra l as well as injectible hypoglycemic agents m eans perm itting that m an to work unrestricted is hazardous. M ODERATOR WIGHT: Does that an sw er it ? DR. MISHLER: Partly. If he is restric ted , how often is he exam ined? DR. JOHNSON: The m an who is r e s tr ic te d should be exam ined at least every six m onths. I m ean, if he is a diabetic on hypoglycemic agents. M ODERATOR WIGHT: D r. O lso n , how do y o u h andle y o u rs ? 186 dr'. E R N E S T C . O L S O N ( C h ie f S u r g e o n , D lin o ie C e n t r a l R a ilr o a d ) : 0 ^ r s is a flexible p ro g ra m ; and those who do not re q u ir e the use of a n t i- d ia b e tic a g e n t s a r e s e e n not at any p a r t i c u l a r i n t e r v a l s , but thrj.se who do a r e e v a l u a t e d on the s e v e r i t y o f t h e d i a b e t e s . And a m a n who t a k e s a relatively high dose of insulin certainly is restricted as an engineer. M ODERATOR WIGHT; Our tim e is ru n n in g on, and the a n s w e r to Q u e s tion N o. 2 I t h in k s h o u ld be th e s a m e a s t h e a n s w e r to Q u e s t i o n No. 1. Q u estio n No. 3: "Should th e re be r e s tr ic tio n s on d ia b etics in the shopcrafts ?" I think the answ er there is much the s a m e --if he is working around m oving equipm ent and is exposed to h a z a rd s of that n atu re. T h e re is one aspect that I have not touched on. I would like to ask somebody on the panel to explain this new term inology that has crept into the literatu re ra th e r recently. Reference is made to a "chem ical d ia betes. " D r. Johnson, can you explain what is m eant by a "c h e m ic a l diabetes ?' DR. JOHNSON: No, I cannot; but I know you can. MODERATOR WIGHT: T his ex p re ssio n has cre p t in recen tly , and it was thrown at m e a short while ago, and I m ust adm it I did not have the fog giest idea what people w ere referrin g to, so I had to look it up. I think it is another exam ple of w here we are try in g to make things m ore com plicated than ever. A p r e - d i a b e t i c v/e u n d e r s t a n d s l i g h t l y . It w a s r e f e r r e d to by D r. C yran, w here the parents are diabetic, o r in the case of an identical tw^n. You can assu m e that diabetes is going to be the re su lt. A c h e m ic al diabetic, as I u nderstand it, is the c a se in which with g ro ss stim ulation by the co rticoid s te ro id s you will get a little reaction in the curve; and you can suspect that that person eventually may become a diabetic. I think we are just asking for trouble when we try to b re a k things down as fine as that. A lot of the experts in m etabolism do not ag re e that th ere is such a thing. r A re th ere any com m ents on that? DR. CYRAN: I did not think you had to have the stim u la tio n with a d re n a l steroids for that. I thought the chem ical diabetic was one who had the abnormal curve and may be spilling sugar at the peak level, but he is not doing th is th ro u g h o u t th e day-- only on e x c e s s iv e lo ad s. 187 T h e n a f t e r he h a s e s t a b l i s h e d h i m s e l f , a n d wc- g e t m o r e c o n ' ' d , - - c in h i m , w e w ill m a k e i t s i x m o n t h s . I d o u b t t h a t we s h o u ld e x te n d i t `be. yond the six-m onth period. M OD ERA TOR WIGHT: Dr. M is h le r. I w ill qualify my answ er in view of what Dr. Johnson said. When we d isco v er this m an, we take him out of se rv ic e im m ediately to get his condition under co n trol. Then if we a re satisfied that it can be c o n t r o l le d w ith o u t the u s e of m e d ic a tio n , we w ill le t h im go b a c k -and then we will exam ine him q u arterly , o r in that area. D K . H O L L O : I w ould lik e to m a k e o n e p o in t: W"hen we h a v e a p a t i e n t who has been diagnosed, as a diabetic, he is hospitalized, and then follow ed-as you said. \^ _ > E R A T O R WIGHT: Yes; investigated to e sta b lish his condition. Does anyone else have any com m ent on this aspect? DR. MISHLER: T h ere is one re m a rk I would like to m ake, and it is not r e a lly on h e re . T hat is in re la tio n to those people who w ere c o n tro l led by diet. I would like to have the second question answ ered. M O D ERA TO R WIGHT: Right.- T h o se enginem en, p roven d ia b etics, who have to take m edication of any kind, a r e they allow ed to o p e ra te a m ain line engine, o r a re they r e s t r i c t e d ? T h at is the se c o n d p a r t o f y o u r q u e s tio n . D r. Winston. You bro k e the question into two. D R. JOHNSON: I feel th at an enginem an who h as d iab etes, who re q u ire s h' g ly c em ic agents for co n tro l, should be r e s tr ic te d . ' T hat should be t^W ule. It w ill have to be m odified in sp e cific c a s e s ; but ce rtain ly the h az ard p o sed by o ra l as well as injectible hypoglycemic agents m eans perm itting that m an to work unrestricted is hazardous. M ODERATOR WIGHT: Does that an sw er it ? DR. MISHLER: Partly. If he is restric ted , how often is he exam ined? DR. JOHNSON: The m an who is r e s tr ic te d should be exam ined at least every six m onths. I m ean, if he is a diabetic on hypoglycemic agents. M ODERATOR WIGHT: D r. O lso n , how do y o u h andle y o u rs ? 186 dr'. E R N E S T C . O L S O N ( C h ie f S u r g e o n , D lin o ie C e n t r a l R a ilr o a d ) : 0 ^ r s is a flexible p ro g ra m ; and those who do not re q u ir e the use of a n t i- d ia b e tic a g e n t s a r e s e e n not at any p a r t i c u l a r i n t e r v a l s , but thrj.se who do a r e e v a l u a t e d on the s e v e r i t y o f t h e d i a b e t e s . And a m a n who t a k e s a relatively high dose of insulin certainly is restricted as an engineer. M ODERATOR WIGHT; Our tim e is ru n n in g on, and the a n s w e r to Q u e s tion N o. 2 I t h in k s h o u ld be th e s a m e a s t h e a n s w e r to Q u e s t i o n No. 1. Q u estio n No. 3: "Should th e re be r e s tr ic tio n s on d ia b etics in the shopcrafts ?" I think the answ er there is much the s a m e --if he is working around m oving equipm ent and is exposed to h a z a rd s of that n atu re. T h e re is one aspect that I have not touched on. I would like to ask somebody on the panel to explain this new term inology that has crept into the literatu re ra th e r recently. Reference is made to a "chem ical d ia betes. " D r. Johnson, can you explain what is m eant by a "c h e m ic a l diabetes ?' DR. JOHNSON: No, I cannot; but I know you can. MODERATOR WIGHT: T his ex p re ssio n has cre p t in recen tly , and it was thrown at m e a short while ago, and I m ust adm it I did not have the fog giest idea what people w ere referrin g to, so I had to look it up. I think it is another exam ple of w here we are try in g to make things m ore com plicated than ever. A p r e - d i a b e t i c v/e u n d e r s t a n d s l i g h t l y . It w a s r e f e r r e d to by D r. C yran, w here the parents are diabetic, o r in the case of an identical tw^n. You can assu m e that diabetes is going to be the re su lt. A c h e m ic al diabetic, as I u nderstand it, is the c a se in which with g ro ss stim ulation by the co rticoid s te ro id s you will get a little reaction in the curve; and you can suspect that that person eventually may become a diabetic. I think we are just asking for trouble when we try to b re a k things down as fine as that. A lot of the experts in m etabolism do not ag re e that th ere is such a thing. r A re th ere any com m ents on that? DR. CYRAN: I did not think you had to have the stim u la tio n with a d re n a l steroids for that. I thought the chem ical diabetic was one who had the abnormal curve and may be spilling sugar at the peak level, but he is not doing th is th ro u g h o u t th e day-- only on e x c e s s iv e lo ad s. 187 M O D E R A T O R WIGHT: T i m e is r u n n i n g a lo n g , g e n t le m e n , ari.l > ju st one last r e m a r k I would like to m ake, and then ask for a few c T his applies not only to diabetes. It applies to e v e ry su b -n o rm al condi - ' tion. As e m p lo y e r s of a v e r y la r g e n u m b e r of p eo p le I feel that we m ust take our sh are of sub-norm als at the pre-em ploym ent stage. T he re a s o n I say that is that in som e co u n tries it is creeping in right now; in one country they m u st take th ree p e r cent of subnorm als at pre-em ploym ent stage. ; I say it is a pre-em ploym ent stage, not of the labor force, because in yo u r lab o r force you are developing your own percentage of su b -n o r m als', and th is is becom ing m o re com m on and we m ay be faced with it our two co u n tries before long. With th is in view, and this is a v e ry open q u estio n , would you employ a diabetic ? Now I a m not r e fe rrin g to the o p era tin g tr a d e s , but ju st generally. What is your feeling about employing diabetics. DR. P E T E R VAUGHAN (A ssistant Chief M edical O fficer, Canadian N ational Railways): O ur p o lic y h a s been as E a r l e sta te d . We have a g r e a t n u m b e r of em ployees who d e v e lo p d ia b e te s d u rin g s e r v ic e , and we think we a r e doing our best to w a rd d ia b e te s by continuing to em ploy th e se people in a position that is safe for them. We do not like to take on new d ia b e tic s; that is , applicants for e m p lo y m e n t th at a r e frank d iabetics, becau se it sim ply com pounds o u r p ro b lem la te r on in contributing to the whole problem of diabetes. We have been under some p re ssu re , as I am sure you all have, from t ^ r f S i a b e t i c a s s o c i a t i o n s to e m p lo y t h e s e p e o p le . We th in k we a r e doing all we c a n by continuing to em ploy those people who develop diabetes while they a r e in our employ without taking on new applicants with d ia betes. M O D ERA TO R WIGHT: Realizing when we take a p e rs o n on p re-em p lo y m en t, 18 o r 20 y e a r s of age, we hav e to a s s u m e that th ey a r e going to be with us un til they a r e 65 y e a r s of age, the fact re m a in s we have to take our share. Would you people employ them for clerica l work, or anything else?. Or, do you autom atically b ar them fro m em ploym ent? DR. MISHLER: We b ar them. M ODERATOR WIGHT: F ro m a ll c a te g o r ie s ? 188 M O D E R A T O R WI G H T : You will not be popular with the diabetic societies. DR. HOLLO: At the p re se n t tim e our sta n d ard s do not include employing diabetics. DR. OLSON: We do n o t, e i t h e r . M O D E R A T O R WIGHT: We do. Is th e re anybody else, o r a re we in the m in o rity ? Am I in the m in ority? DR. WINSTON: We a r e in the m in o rity , but we do o c c a s io n a lly em ploy a diabetic. It becom es a m a tte r of calculated r is k , a s I indicated the o th e r day. We a r e in the in s u ra n c e b u s in e s s as w ell a s th e t r a n s p o r t a tion business. This diabetic person generally will not liv e as long as the average. He will have m ore than his share of m edical pro b lem s, each of which costs the insurance program . The an sw er th e re is: What does this p erso n have to contribute to your industry? So, we want to select the job assignm ent carefully. The next question is: What is the applicant's attitude about his diabetes ? If he is c a r e l e s s , then we do not want him . his c a re of his p roblem , then the r is k is le ss. If he is m eticulous in I So, in c e rta in instances we assu m e this ca lcu lated ris k . DR. HOLLO: I am sure that our screening te sts are not sufficiently s tr ic t that we would know w hether we do em ploy e a rly diabetics, o r not, b e c a u s e o u r p r e - e m p l o y m e n t s c r e e n i n g t e s t in c l u d e s u r i n a l y s i s only. We do not use blood sugar o r glucose tolerance te sts. I a m sure there are som e early diabetics included in our new em ployees. MODERATOR WIGHT: I was re fe rrin g to the known diabetic. Would you em ploy thht p erso n in any capacity ? D R . H O L L O : No; we do not. t M O D E R A T O R WIGHT: It would appear that th ere a r e not v e r y m a n y of us who do. Are there further questions or com m ents from the floor? DR. VAUGHAN: I would like to ask a question about the detection of d ia - b . W h i t do v o n rl n w i t h t h e m a n - - . i s D r . W i n s t o n m e n t i o n e d - - ! MODERATOR WIGHT: T im e is running along, gentlem en, ami u ju st one last r e m a r k I would like to m ake, and then ask for a few T his applies not only to diabetes. It applies to e v e ry su b -n o rm al condi'-' tion. As e m p lo y e r s of a v e r y la r g e n u m b e r of p eo p le I feel that we m ust take our sh are of sub-norm als at the pre-em ploym ent stage. T he re a s o n I say that is that in som e co u n tries it is creeping in right now; in one country they m u st take th ree p e r cent of subnorm als at pre-em ploym ent stage. ; I say it is a pre-em ploym ent stage, not of the labor force, because in yo u r lab o r force you are developing your own percentage of su b -n o r mals", and th is is becom ing m o re com m on and we m ay be faced with it ' our two co u n tries before long. With th is in view, and this is a v e ry open q u estio n , would you employ a diabetic ? Now I a m not r e fe rrin g to the o p era tin g tr a d e s , but ju st generally. What is your feeling about employing diabetics. DR. P E T E R VAUGHAN (A ssistant Chief M edical O fficer, Canadian N ational Railways): O ur p o lic y h a s been as E a r l e sta te d . We have a g r e a t n u m b e r of em ployees who d e v e lo p d ia b e te s d u rin g s e r v ic e , and we think we a r e doing our best to w a rd d ia b e te s by continuing to em ploy th e se people in a position that is safe for them. We do not like to take on new d ia b e tic s; that is , applicants for e m p lo y m e n t th at a r e frank d iabetics, becau se it sim ply com pounds o u r p ro b lem la te r on in contributing to the whole problem of diabetes. We have been under some p re ssu re , as I am sure you all have, from tk.diabetic a s s o c i a t i o n s to e m p lo y t h e s e p e o p le . We th in k we a r e doing all we c a n by continuing to em ploy those people who develop diabetes while they a r e in our employ without taking on new applicants with d ia betes. M O D ERA TO R WIGHT: Realizing when we take a p e rs o n on p re-em p lo y m en t, 18 o r 20 y e a r s of age, we hav e to a s s u m e that th ey a r e going to be with us un til they a r e 65 y e a r s of age, the fact re m a in s we have to take our share. Would you people employ them for clerica l work, o r anything else?. Or, do you autom atically b ar them fro m em ploym ent? DR. MISHLER: We b ar them. M ODERATOR WIGHT: F ro m a ll c a te g o r ie s ? 188 M O D E R A T O R WI G H T : You will not be popular with the diabetic societies. DR. HOLLO: At the p re se n t tim e our sta n d ard s do not include employing diabetics. DR. OLSON: We do n o t, e i t h e r . M O D E R A T O R WIGHT: We do. Is th e re anybody else, o r a re we in the m in o rity ? Am I in the m in ority? DR. WINSTON: We a r e in the m in o rity , but we do o c c a s io n a lly em ploy a diabetic. It becom es a m a tte r of calculated r is k , a s I indicated the o th e r day. We a r e in the in s u ra n c e b u s in e s s as w ell a s th e t r a n s p o r t a tion business. This diabetic person generally will not liv e as long as the average. He will have m ore than his share of m edical pro b lem s, each of which costs the insurance program . The an sw er th e re is: What does this p erso n have to contribute to your industry? So, we want to select the job assignm ent carefully. The next question is: What is the applicant's attitude about his diabetes ? If he is c a r e l e s s , then we do not want him . his c a re of his p roblem , then the r is k is le ss. If he is m eticulous in I So, in c e rta in instances we assu m e this ca lcu lated ris k . DR. HOLLO: I am sure that our screening te sts are not sufficiently s tr ic t that we would know w hether we do em ploy e a rly diabetics, o r not, b e c a u s e o u r p r e - e m p l o y m e n t s c r e e n i n g t e s t in c l u d e s u r i n a l y s i s only. We do not use blood sugar o r glucose tolerance te sts. I a m sure there are som e early diabetics included in our new em ployees. MODERATOR WIGHT: I was re fe rrin g to the known diabetic. Would you em ploy thht p erso n in any capacity ? D R . H O L L O : No; we do not. t M O D E R A T O R WIGHT: It would appear that th ere a r e not v e r y m a n y of us who do. Are there further questions or com m ents from the floor? DR. VAUGHAN: I would like to ask a question about the detection of d ia b . W h i t do von rln with th e m . i n - - . i s D r. W in sto n m e n tio n e d - - ! lias m aybe eaten hotcakcs; he has a gly co su ria; he com es back wuii e a r l y m o r n i n g s p e c i m e n a n d it is n e g a t i v e ? A r e y ou going to sa y h, not have diabetes ? And then how a re you going to s c re e n diabetics ? Is A P -P C sugar enough. O r, do you want a full cu rv e? How about dextrose sticks as a blood sugar analysis? A re they any good, or not? DR. JOHNSON: If I have an applicant fo r e n tra n ce into se rv ic e in any category who has a glycosuria, he is disqualified. The burden of proof is with him , in his responsibility with his p erso n al physician. The b u r den of proof for the absence o r presence of diabetes is his responsibility with his p erso n a l physician. I will not accept the statem ent that the doc to r did a u rin a ly s is and it was norm al. I in sist the doctor do a glucose tolerance test. If I do not believe the te st is a sa tisfa c to ry one, I will continue this q u alifica tio n sta tu s; but there is a p ro b le m o f re n a l g ly co su ria, in which the individual does not have a true diabetes and the glucose tolerance test will v ery quickly disclose this type of condition which is non-hazardous. If the individual, however, does not com e back with a standard o p era tion glucose tolerance test I do not see him again. D R . J . R O B E R T S O N K N O W L ES ( C h ie f S u r g e o n , B o s to n &. M a in e R a ilr o a d ) : We w ork on the principle, after a g reat m any y e a rs of experience, of " tr u s t th e m but watch them , "; and we will not take a r e p o rt from another doctor. I w ill even sa y they m ust be told to void, if they did not bring in a m orning specim en. Also, I ask them , whoever sees them after they ta k e th e s p e c im e n to feel the u r in a l and s e e th a t it is w arm . We have had c a s e s w h ere urine has been brought in, in a bottle, which has been in a p o ck e t; o r , it is h a s been p o u re d into th e u r in a l in a s m a l l ro o m . So, ^ ^ k th em to be su re and feel the urin al and see that it is warm. M O D E R A T O R WIGHT; In o th e r w o rd s, you m u s t have a high suspicion index ? DR. KNOWLES: Yes; "trust them but watch them. " M ODERATOR WIGHT; Dr. Vaughan, did you have a com m ent? DR. VAUGHAN: We did not go into th at a s p e c t of things due to tim e. B riefly , in answ er to yo u r question I think it is u n derstood that a com plete curve is the best thing, but a lot of people will accept the one hour P C , o r the half-hour PC. The clinic sticks I think are a screening te st, and as a screening te s t a r e v e ry good. 1 think they are out in the h ig h e r levels. You cannot use th e m as a gauge as to the d egree. 190 DH. A L B E R T H.' W IN TERS {C hief S u r g e o n , road): He a s k e d a b o u t d e x t r o s e s t i c k s . Pittsburgh. Lake Erie IL.il- MODERATOR WIGHT: I am re f e r rin g to dextrose stick s. They are m en tioned in a recen t rep o rt in the NEW SLETTER, and it is commented tnat in the h ig h e r r a n g e s they a r e not v e ry a c c u ra te , but in th e lower ranges they are not m ore accurate but serv e as a screening test anyway. DR. CYRAN: We have been told they a re not as high as they should re; and they a re too low when they should not be too low; but in the m id -ran g e , they are all right. DR. WIPPERMAN: Gentlemen, as I am not a m em ber of this organization, and as a g u est p a n e lis t, and I have been out h e re tw ic e , I do want to take this opportunity to thank each and every one of you for the opportunity to be h ere . I see that you men are of such stature and friendliness that you are not above needling each other, and I somewhat feel, a fte r som e rem arks fro m D r. Clayton, that I have been stim ulated a little h e re this week, and I would, how ever, like to point out that from se v e ra l of the questions som e men m ay have felt that I was pushing contact lenses. I sim ply am em phasizing the fact that contact lenses are here, and they a r e h e re to stay , and you m en a re going to have m o re and m ore q u es tions about them. T h ere are certain advantages to contact lenses in certain areas. With those re m a rk s , I think you very much. M ODERATOR WIGHT; If the S e c re ta ry is p re s e n t, will he please note 'that D r. W ipperm an has ap p e ared on two panels. He g ets twice the n o r m al rate of pay. (Applause) G entlem en, I would just like to thank the panel for doing the work. I would like to thank you in the audience for your participation. There were not too m any questions that cam e in from outside left field, but I think the panel handled them selves rath e r well. Thank.you. (Applause) CHAIRMAN NELSON; Gentlemen, it ra th e r looks this m orning as though o ur panels are going to end on the sam e high plane as they began. T he next p an e l on NEUROPSYCHLATRIC PR O B L E M S will have two consultants on that panel. T his is som ething new. We a r e going to have to a p p r o a c h th is particular area, and I know th a t y o u w ill enjoy the pan e l discussion. 191 lias m aybe eaten hotcakcs; he has a gly co su ria; he com es back wuii e a r l y m o r n i n g s p e c i m e n a n d it is n e g a t i v e ? A r e y ou going to sa y h, not have diabetes ? And then how a re you going to s c re e n diabetics ? Is A P -P C sugar enough. O r, do you want a full cu rv e? How about dextrose sticks as a blood sugar analysis? A re they any good, or not? DR. JOHNSON: If I have an applicant fo r e n tra n ce into se rv ic e in any category who has a glycosuria, he is disqualified. The burden of proof is with him , in his responsibility with his p erso n al physician. The b u r den of proof for the absence o r presence of diabetes is his responsibility with his p erso n a l physician. I will not accept the statem ent that the doc to r did a u rin a ly s is and it was norm al. I in sist the doctor do a glucose tolerance test. If I do not believe the te st is a sa tisfa c to ry one, I will continue this q u alifica tio n sta tu s; but there is a p ro b le m o f re n a l g ly co su ria, in which the individual does not have a true diabetes and the glucose tolerance test will v ery quickly disclose this type of condition which is non-hazardous. If the individual, however, does not com e back with a standard o p era tion glucose tolerance test I do not see him again. D R . J . R O B E R T S O N K N O W L ES ( C h ie f S u r g e o n , B o s to n &. M a in e R a ilr o a d ) : We w ork on the principle, after a g reat m any y e a rs of experience, of " tr u s t th e m but watch them , "; and we will not take a r e p o rt from another doctor. I w ill even sa y they m ust be told to void, if they did not bring in a m orning specim en. Also, I ask them , whoever sees them after they ta k e th e s p e c im e n to feel the u r in a l and s e e th a t it is w arm . We have had c a s e s w h ere urine has been brought in, in a bottle, which has been in a p o ck e t; o r , it is h a s been p o u re d into th e u r in a l in a s m a l l ro o m . So, ^ ^ k th em to be su re and feel the urin al and see that it is warm. M O D E R A T O R WIGHT; In o th e r w o rd s, you m u s t have a high suspicion index ? DR. KNOWLES: Yes; "trust them but watch them. " M ODERATOR WIGHT; Dr. Vaughan, did you have a com m ent? DR. VAUGHAN: We did not go into th at a s p e c t of things due to tim e. B riefly , in answ er to yo u r question I think it is u n derstood that a com plete curve is the best thing, but a lot of people will accept the one hour P C , o r the half-hour PC. The clinic sticks I think are a screening te st, and as a screening te s t a r e v e ry good. 1 think they are out in the h ig h e r levels. You cannot use th e m as a gauge as to the d egree. 190 DH. A L B E R T H.' W IN TERS {C hief S u r g e o n , road): He a s k e d a b o u t d e x t r o s e s t i c k s . Pittsburgh. Lake Erie IL.il- MODERATOR WIGHT: I am re f e r rin g to dextrose stick s. They are m en tioned in a recen t rep o rt in the NEW SLETTER, and it is commented tnat in the h ig h e r r a n g e s they a r e not v e ry a c c u ra te , but in th e lower ranges they are not m ore accurate but serv e as a screening test anyway. DR. CYRAN: We have been told they a re not as high as they should re; and they a re too low when they should not be too low; but in the m id -ran g e , they are all right. DR. WIPPERMAN: Gentlemen, as I am not a m em ber of this organization, and as a g u est p a n e lis t, and I have been out h e re tw ic e , I do want to take this opportunity to thank each and every one of you for the opportunity to be h ere . I see that you men are of such stature and friendliness that you are not above needling each other, and I somewhat feel, a fte r som e rem arks fro m D r. Clayton, that I have been stim ulated a little h e re this week, and I would, how ever, like to point out that from se v e ra l of the questions som e men m ay have felt that I was pushing contact lenses. I sim ply am em phasizing the fact that contact lenses are here, and they a r e h e re to stay , and you m en a re going to have m o re and m ore q u es tions about them. T h ere are certain advantages to contact lenses in certain areas. With those re m a rk s , I think you very much. M ODERATOR WIGHT; If the S e c re ta ry is p re s e n t, will he please note 't h a t D r . W i p p e r m a n h a s a p p e a r e d on two p a n e l s . He g e t s tw ic e th e n o r m al rate of pay. (Applause) G entlem en, I would just like to thank the panel for doing the work. I would like to thank you in the audience for your participation. There were not too m any questions that cam e in fro m outside left field, but I think the panel handled them selves rath e r well. Thank.you. (Applause) CHAIRMAN NELSON; Gentlemen, it ra th e r looks this m orning as though o ur panels are going to end on the sam e high plane as they began. T he next p an e l on NEUROPSYCHLATRIC PR O B L E M S will have two consultants on that panel. T his is som ething new. We a r e going to have to a p p r o a c h th is particular area, and I know th a t y o u w ill enjoy the pan e l discussion. 191 We a r e p r e t t y m u c h on t i m e , a n d I would Like to f in is h at , v n r ' . m a te ly noon. I know th e re a r e a n u m b e r of you who have to leave at o.4. tim e. Our next pro g ram panel I feel is one of the m ore important panels we have on o u r agenda. It r e p r e s e n ts som ething new that we have not c o n siu e re d as su c h in the p ast. Dr. E rn e s t Olson has very kindly con sented to m o d erate this panel. We h av e two g u e sts on this p an e l, and I think you will find this to be an e x c e e d in g ly i n t e r e s t i n g p o r tio n o f y o u r o v e r a l l p r o g r a m , and we c e rta in ly en c o u ra g e , once again, questions and d iscu ssio n from the floor. D r. Olson. PA N EL SYMPOSIUM - NEUROPSYCHIATRIC PROBLEMS MODERATOR OLSON: Thank you, Dr. Nelson. The subject NEURO P S Y C H IA T R IC P R O B L E M S is one which I do not b elieve has been brought before us previously. We have with us a num ber of our own chief m edical officers as a part of th is p a n e l, a ll of whom you know, and in addition we have D r. Loren A very, who is the Consulting N europsychiatrist, for the Illinois Central R a ilro a d , and for the P re sb y te ria n -S t. L uke's H ospital, Augustana, and L u th e ra n D eaco n ess H ospital, as well as a C linical P ro fe s s o r of Neurology. D r. Avery. (Applause) We a ls o have D r. D. B e rn a rd F o s t e r , who is the D ire c to r of the Division of Neurology and N eurosurgery, at The Menninger Clinic, at Topeka, Kansas. D r. F o ster. (Applause) We a r e v e r y ahppy to have th e s e two g en tlem en on o u r panel, and we fe e l confident that they will be able to provide a ssista n c e in answ ering our ' academ ic and practical questions. O ur ap p ro a ch is n e c e s s a rily one which involves the a s s e s s m e n t of candidates for em ployment on railro a d s insofar as their m ental makeup is concerned and their suitability for em ploym ent in the various cate gories of railro ad work. It also involves decisions concerning the su itab ility and ability of em p loyees who have suffered som e n eu ro p sy c h iatrie disability in the c o u rs e of th e ir em ploym ent, to e ith e r continue o r to r e tu r n to work. F u r th e r , it also concerns the obligation and resp o n sib ility of the ra ilro a d to provide for em ploym ent in our so cial schem e for those indi viduals who. while they m ay not fall between pertain relatively narrow 102 limits, which we call norm al, may still possess some special skills which m ig h t m a k e th e m valuable to the r a ilr o a d an d a t th e s a m e tim e p r o vide em p lo ym ent fo r th ese people. The q uestio n also a r is e s about the r a ilro a d 's obligation to continue the a c t of e m p lo y m e n t o f in d iv id u als who h a v e s u ffe re d s o m e m e n ta l disability in the co u rse of th e ir occupation. As you know, th e re is a grow ing tendency for the ju d ic ia ry to take the position that public opinion and social custom consider m anagem ent as o b lig a te d to a s s u m e re s p o n s ib ility fo r any illn e s s o c c u r r in g in the co u rse of that individual's em ploym ent. D oes it then beco m e one of the risk s of b u sin ess to accept these liabilities? Does the question of national unem ploym ent because of certain disabilities obligate com panies to lake on le s s - th a n - s ta n d a r d r is k s ? Is it going to be p o ssib le to find jobs for those who a r e no longer able to c o n tin u e in t h e i r p r e s e n t o ccu p atio n , but who m ight be ab le to fu nction in so m e le s s e r c a p ac ity ? Can any a g re em e n t be reach ed which would p e r m it su itable em ployees to be tr a n s f e rr e d from one type of occupation to an o th er ? I r e a liz e that much of this is co n jectu ral, but the ch an g es which con tinue to o c c u r in o u r so ciety m ight b rin g q u estio n s of th is s o r t to o u r con sideration, of both candidates and em ployees. In o u r d is c u s s io n this m orning we a re not confined to the questions which have b ee n p rin te d in our p ro g ra m , nor is the d isc u s s io n to be lim ited to the panel m em b ers. We would like to begin with a consideration, of a m ethod of a p p ra isa l of the candidate for em ployment whereby certain p ractical estim ates can b: made by the average practitio n er, o r by a m anagem ent interview er of that individual's em otional stability, o r of any serious m ental deviation which would classify him as em ployable o r unem ployable for the p a rtic u lar occupation sought. It should be borne in m ind that while the individual, if accepted, may make the railro ad a lifetim e endeavor, and that considerable time and monc-y m a y be in v e ste d in h im to acquaint h im with a l l the re q u ire m e n ts of his job, o r future jobs, with the railro a d , n ev erth eless the appraisal is n e c e s s a r ily lim ited becau se of th e tim e involved, p a rtic u la rly by the m edical department. Most ra ilro a d s have ra th e r com prehensive m edical questionnaires and physical exam inations, and for m any em ployees a se rie s of technical exam inations which m ake the cost considerable. A neuropsychiatric ap praisal by its nature is a tim e-consum ing af fair and m ay o v erta x the busy p ra c titio n e r. It is unlikely that all of the pre-em ploym ent exam inations can be funneled into one a re a and must, therefore, be conducted by many different doctors as well as personnel We a r e p r e t t y m u c h on t i m e , a n d I would Like to f in is h at a --.r ><m a te ly noon. I know th e re a r e a n u m b e r of you who have to leave at o.4. tim e. Our next pro g ram panel I feel is one of the m ore important panels we have on o u r agenda. It r e p r e s e n ts som ething new that we have not c o n s id e re d as su c h in the p ast. Dr. E rn e s t Olson has very kindly con sented to m o d erate this panel. We h av e two g u e sts on this p an e l, and I think you will find this to be an e x c e e d in g ly i n t e r e s t i n g p o r tio n o f y o u r o v e r a l l p r o g r a m , and we c e rta in ly e n c o u ra g e , once again, questions and d iscu ssio n from the floor. D r. Olson. PANEL, SYMPOSIUM - NEUROPSYCHIATRIC PROBLEMS MODERATOR OLSON: Thank you, Dr. Nelson. The subject NEURO P SY C H IA T R IC P R O B L E M S is one w hich I do not b elieve has been brought before us previously. W'e h a v e w ith u s a n u m b e r of o u r ow n c h i e f m e d i c a l o f f i c e r s a s a p a r t of th is p a n e l, a ll of whom you know, and in addition we have D r. Loren A very, who is the Consulting N europsychiatrist, for the Illinois Central R a ilro a d , and for the P re sb y te ria n -S t. L uke's H ospital, Augustana, and L u th e ra n D e a c o n e ss H ospital, as w ell as a C lin ic al P r o f e s s o r of Neurology. D r. Avery. (Applause) We a ls o have D r. D. B e rn a rd F o s t e r , who is the D ire c to r of the Division of Neurology and N eurosurgery, at The Menninger Clinic, at Topeka, Kansas. D r. F o ster. (Applause) We a r e v e r y ahppy to have th e s e two g en tlem en on o u r panel, and we fe e l confident that they will be able to provide a ssista n c e in answ ering our ' academ ic and practical questions. O ur ap p ro ach is n e c e s s a rily one which involves the a s s e s s m e n t of candidates for em ployment on railro a d s insofar as their m ental makeup is concerned and their suitability for em ployment in the various categoi'ies of railro ad work. It also involves decisions concerning the su itab ility and ability of em p loyees who have suffered som e n eu ro p sy c h iatrie disability in the c o u rs e of th e ir em ploym ent, to e ith e r continue o r to r e tu r n to work. F u r th e r , it also concerns the obligation and resp o n sib ility of the ra ilro a d to provide for em ploym ent in our so cial schem e for those indi viduals who, while they m ay not fall between pertain relatively narrow 102 limits, which we call norm al, may still possess some special skills which m ight m ake them valuable to the ra ilro a d and at the s a m e tim e p ro vide em p lo ym ent fo r th ese people. The q u estio n also a r is e s about the r a ilro a d 's obligation to continue the act of em ploym ent of individuals who have suffered so m e m ental disability in the co u rse of th e ir occupation. A s you know, th e re is a grow ing tendency for the ju d ic ia ry to take the position that public opinion and social custom consider m anagem ent a s o b lig a te d to a s s u m e r e s p o n s ib ility fo r any illn e s s o c c u r r in g in the co u rse of that individual's em ploym ent. D oes it then beco m e one of the risk s of b u sin ess to accept these liab ilities? Does the question of national unem ployment because of certain disabilities obligate com panies to lake on le s s - th a n - s ta n d a r d r i s k s ? Is it going to be p o ssib le to find jobs for those who a r e no longer able to c o n tin u e in t h e i r p r e s e n t occu p atio n , but who m ight be a b le to fu nction in so m e le s s e r c a p ac ity ? Can any a g re em e n t be reach ed which would p e rm it suitable em ployees to be tra n sfe rre d from one type of occupation to an o th er ? I r e a liz e that much of this is co n jectu ral, but the ch an g es which con tinue to o c c u r in o u r so ciety m ight b rin g q u estio n s of th is s o r t to o u r con sideration, of both candidates and em ployees. In o u r d is c u s s io n this m orning we a re not confined to the questions which have been p rin te d in our p ro g ra m , nor is the d isc u ssio n to be lim ited to the panel m em b ers. We would like to begin with a co nsideration of a m ethod of a p p ra isa l of the candidate for em ployment whereby certain p ractical estim ates can b; made by the average p ractitio n er, o r by a management! interview er of that individual's em otional stability, o r of any serio u s m en tal deviation which would classify him as em ployable o r unem ployable for the p a rtic u lar occupation sought. It should be borne in m ind that while the individual, if accepted, may make the railro ad a lifetim e endeavor, and that considerable time and m oney m ay be invested in him to acquaint him with all the requirem ents of his job, o r future jobs, with the railro a d , n ev erth eless the appraisal is n e c e s s a r ily lim ited becau se of th e tim e involved, p a rtic u la rly by the m edical department. Most ra ilro a d s have ra th e r com prehensive m edical questionnaires and physical exam inations, and for m any em ployees a se rie s of technical exam inations which m ake the cost considerable. A neuropsychiatric ap praisal by its nature is a tim e-consum ing af fair and m ay o v erta x the busy p ra c titio n e r. It is unlikely that all of the pre-em ploym ent exam inations can be funneled into one a re a and must, therefore, be conducted by many different doctors as well as personnel With these thoughts in mind, let us now proceed to our discussion. The firs t question on our p ro g ram reads: "Should a pre-em p lo y m en t inventory be done (sim ilar to the M inne sota M ultiphasic) in enginem en and T ra in m e n ?" I would like to ask D r. A very if he will open the discussion on that question, DR. L O R E N W. AVERY (C onsulting N e u ro p s y c h ia tr is t, P r e s b y te r ia n St. L u k e 's , A ugustana, L utheran D eaconess and Illinois C e n tral Hospitals) While I am in accord that certainly som e survey of an applicant for e m p lo y m e n t on a r a il r o a d should be m ade, I am quite am bivalent as to some " th ese specific personality tests, because I am not su re, first, that t e s t s c o r r e l a t e well v/ith a m a n 's f u tu r e w o rk p e r f o r m a n c e , a n d I do not know, I have rea so n to doubt, that em otio n al stability; good continuity of v/prk; good in ter-personal adjustm ents--that those ch aracteristics are a sta b le entity in any one individual; that tim e, illn e ss, s tr e s s off the job, s tr e s s on the job, background play enter the role. It s e e m s to m e that w ork is a g rea t health facto r. A ctually in the ip ito m e of good p erfo rm an ce work should be m a n 's play, in the sam e way that p la y is ch ild 's work. T here is much re a so n to b eliev e that how a boy p la y s ; how h e e n te r s into com petition; how c r e a tiv e he is; how much in p lay they a r e solving problem s; m ay re fle c t a g re a t deal of how he will attack work as something that is pleasurable, as something of problem s to be so lv ed ; a contribution to be m ade; and an ach ie v em e n t to be obtained. I, m y se lf, doubt that such things as the M innesota T e st will afford you a good background upon which to a s s e s s the future p erfo rm an ce of the m an; but I do think that there are m eans of getting a fairly good idea as to how stable and staid an individual will be, and that at least he may not under the ordinary stre s se s but might under excessive ones. Thank you. M O D E R A T O R OLSON: In the event that t h e r e m ig h t be a d iv e rs ity of opinion about it, Dr. F o ster, would you c a re to com m ent on this question? DR. D. BERNARD FOSTER (D irector, Division of Neurology and N euro su rg ery , The Menninger Clinic, Topeka, Kansas): I s h a r e D r. A v ery 's doubts as to the u se fu ln e ss of such te s ts . May I differentiate personality patterns of testing from aptitude testing? The reco rd of aptitude testing is a fair one. F or instance, any p e r sonnel office is fully capable of scoring and adm inistering a sim ple test of in te lle ctu al function; of vocabulary sk ills; of rate of accu rate type w rit ing; of r a te of a c cu rate shorthand w riting, in .evaluating an applicant for a se creta rial position. S im ila rly , th e re a r e tests of m ech an ical aptitude which have a p retty high d eg ree of re lia b ility in a s se ss in g an individual's ability to c a r ry out the work, let us say, of a m achinist. The batting average of psychological tests in detecting the individual who is a c c i d e n t- p r o n e ; who is the sic k book r i d e r ; who is the u n r e lia b le em ployee; who does not show up at the appointed hour, is ex trem ely poor. P e rh a p s a little of our experience from World War II would be e x e m plary in th is re g a rd . P e rh a p s you w ill all r e c a ll that th e re used to be a n e u ro p sy c h iatrie exam ination included in the evaluation of d raftee s. I would have to say that the best that these neuropsychiatrie exam inations, w hich u s u a l l y h a d a d u r a t i o n o f t h r e e to 10 m i n u t e s w a s to s c r e e n o u t the grossly m entally retarded individuals, and the grossly schizophrenic in d iv id u als in b etw e en th re e to 10 m in u te s of s c re e n in g w ill not do the job.. . P erhaps an illustration from a m edical-school experience also might be h elpful in u n d ersta n d in g the r e s e rv a tio n s of D r. A v ery and m y s e lf in this respect. T h e r e h av e been a n u m b e r of s tu d ie s sin c e M e d ica l College. It is an expensive proposition for the school as well as for the individual, trying to figure out b e tte r m ethods of selecting applicants fo r m ed ical students. One that I would like to cite was c a r rie d out at the U niversity of Michigan s o m e y e a r s ag o , w h e r e the top 10 p e r c e n t o f th e c l a s s h ad a whole b a t t e r y o f p s y c h o l o g i c a l t e s t s , and th e b o tto m 10 p e r c e n t o f the m e d i c a l school class also had a battery of psychological tests. The tests were ab s o lu te ly n o n - d is c r im in a to r y in p icking out the top 10 p e r cent fro m the b o tto m 10 p e r c e n t. T h e y w e r e not good enough. In o u r M e n n in g e r School of P s y c h ia tr y , in T o p e k a , we have t r i e d to develop and devise te sts that would pick up the likely candidate to be a good p sy ch iatrist. Our batting average " s tin k s ," gentlem en, from these prelim inary te s ts . We cannot do it. And we a r e doing it fro m a t r e m e n dous battery of te sts that take two, th ree, four days, and not just the 60odd m inutes of the M innesota M ultiphasic T est. P e rh a p s o u r own em ploym ent p r a c tic e will te ll you what we have determ ined to be one of the b etter techniques, and that is every employee below the level of physician is considered a probationary em ployee for th ree m onths. T his works ten thousand p e r cent b e tte r than any p r e - em ploym ent test. Put the man on the job in the situation where you hope ho will m ake a useful employee; have him observed by his su p erv iso r. _ Both of them know that he is on tria l, so to speak. This is very, very much m ore satisfactory than any attem pt at a pre-em ploym ent ex am ina tion Nobody gets hurt if at the end of th re e m onths the individual is determ ined to be unsuitable for a p a rtic u la r job. The man or the girl has t r ie d . You see them perform ing in th e p la c e w h e re they a r e expected to p e rfo rm . ' .){'; ' Incidentally, the Armed S ervices have com e to approxim ately this same position. The Navy, for exam ple, at the end of th re e rnocrh . f With these thoughts in mind, let us now proceed to our discussion The firs t question on our p ro g ram reads: Should a pre-em p lo y m en t inventory be done (sim ilar to the M inne sota M ultiphasic) in enginem en and T ra in m e n ?" I would like to ask D r. A very if he will open the discussion on that question, DR. L O R E N W. AVERY (C onsulting N e u r o p s y c h ia tr is t, P r e s b y te r ia n St. L u k e 's , A ugustana, L utheran D eaconess and Illinois C e n tral Hospitals) While I am in accord that certainly som e survey of an applicant for e m p lo y m e n t on a r a i l r o a d should be m ad e, I am quite am b iv alen t as to som e " th ese specific personality tests, because I am not su re, first, that t e s t s c o r r e l a t e w ell v/ith a m a n 's f u tu r e w o r k p e r f o r m a n c e , an d I do not know, I have rea so n to doubt, that em otional stability; good continuity of work; good inter-personal adjustm ents--that those ch aracteristics are a s ta b le entity in any one individual; that tim e, illn e ss, s tr e s s off the job, s tr e s s on the job, background play enter the role. It s e e m s to me that w ork is a g rea t health facto r. A ctually in the ip ito m e of good p erfo rm an ce work should be m a n 's play, in the sam e way that p la y is ch ild 's work. T here is much re a so n to b eliev e that how a boy p la y s ; how h e e n te r s into com petition; how c r e a tiv e he is; how much in play they a re solving problem s; m ay re fle c t a g rea t deal of how he will attack work as something that is pleasurable, as something of problem s to be so lv ed ; a contribution to be m ade; and an ach ie v em e n t to be obtained. I, m y s e lf, doubt that such things a s the M innesota T e s t will afford you a good background upon which to a s s e s s the future p e rfo rm an ce of the m an; but I do think that there are m eans of getting a fairly good idea as to how stable and staid an individual will be, and that at least he may not ^ ^ ak under the ordinary s tre s se s but might under excessive ones. Thank you. . M O D ERA TO R OLSON: In the event that th e re m ight be a d iv e rsity of opinion about it, Dr. F o ster, would you c a re to com m ent on this question? DR. D. BERNARD FOSTER (D irector, Division of Neurology and N euro su rg ery , The Menninger Clinic, Topeka, Kansas): I s h a re D r. A very's doubts as to the usefulness of such te sts. May I differentiate personality patterns of testing from aptitude testing? The rec o rd of aptitude testing is a fa ir one. F o r instance, any p e r sonnel office is fully capable of scoring and adm inistering a sim ple test of in tellectu al function; of vocabulary skills; of rate of accu rate type w rit ing; of r a te of a c cu rate shorthand w riting, in .evaluating an applicant for a se creta rial position. S im ilarly, th ere are tests of m echanical aptitude which have a pretty high d eg ree of re lia b ility in a s se ss in g an individual's ability to c a r ry out the work, let us say, of a m achinist. The batting average of psychological tests in detecting the individual who i s a c c i d e n t- p r o n e ; who is the sic k book r i d e r ; who is the u n r e lia b le em ployee; who does not show up at the appointed hou r, is ex trem ely poor. P e rh a p s a little of our experience from World War II would be e x e m plary in th is re g a rd . P erh a p s you w ill all r e c a ll that th e re used to be a n eu ro p sy c h ia tric exam ination included in the evaluation of d raftee s. I would have to say that the best that these neuropsychiatric exam inations, w hich u s u a l l y h a d a d u r a t i o n o f t h r e e to 10 m i n u t e s w a s to s c r e e n o u t the grossly m entally retard ed individuals, and the grossly schizophrenic in d iv id u als in b etw e en th re e to 10 m in u te s of s c r e e n in g w ill not do the job.. . P erhaps an illustration from a m edical-school experience also might be h elpful in u n d ersta n d in g the r e s e r v a tio n s of D r. A v ery and m y s e lf in this respect. T h e r e h av e been a n u m b e r of s tu d ie s sin c e M e d ica l C ollege. It is an expensive proposition for the school as well as for the individual, trying to figure out b e tte r m ethods of selecting applicants fo r m ed ical students. One that I would like to cite was c a r rie d out at the U niversity of Michigan s o m e y e a r s ag o , w h e r e the top 10 p e r c e n t o f th e c l a s s h ad a whole b a t t e r y o f p s y c h o l o g i c a l t e s t s , and th e b o tto m 10 p e r c e n t o f the m e d i c a l school class also had a battery of psychological tests. The tests were ab s o lu te ly n o n - d is c r im in a to r y in pick in g out the top 10 p e r cent fro m ihe b o tto m 10 p e r c e n t. T h e y w e r e n ot good enough. In o u r M en n in g er School of P s y c h ia tr y , in T o p e k a , we have t r i e d to develop and devise tests that would pick up the likely candidate to be a good p sy ch iatrist. Our batting average "stinks, " gentlem en, from these p r e lim in a r y te s ts . We cannot do it. And we a r e doing it fro m a t r e m e n dous battery of te sts that take two, th ree, four days, and not just the 60odd m inutes of the M innesota M ultiphasic T est. P e rh a p s o u r own em ploym ent p r a c tic e will te ll you what we have determ ined to be one of the b etter techniques, and that is every employee below the level of physician is considered a probationary em ployee for th ree m onths. T his works ten thousand p e r cent b e tte r than any p r e - em ploym ent test. Put the man on the job in the situation w here you hope he will m ake a useful employee; have him observed by his supervisor. Both of them know that he is on trial, so to speak. This is very, very much m ore satisfactory than any attem pt at a pre-em ploym ent ex am ina tion Nobody gets hurt if at the end of th ree m onths the individual is d eterm ined to be unsuitable for a p a rtic u la r job. The m an o r the girl has t r i e d . You s e e them perform ing in th e p la c e w h e r e th e y a r e e x p e cted to p e r f o rm . ' Incidentally, the Armed S erv ices have com e to approxim ately th is same position. The Navy, for exam ple, at the end of t h r e e rnorrh . f naval service m a y dismiss ail individual without prejudice '/art.cuhir > and just say "unsuitable. " ' I would hav e to say that I would far m o re highly advocate tria l on the job on p ro b a tio n a ry sta tu s as a technique for picking out the useful e m ployee than I would any psychological test currently available. One of the p ro b le m s in the psychological te s ts , of co u rse, is the p ro b lem of neg ativ e m alin g erin g . If a m an is bucking fo r a job, the an sw ers that he p ro d u ce s on these fill-in types of psychological te sts, and that is w h a t t h e M i n n e s o t a m u l t i p h a s i c i s , a r e j u s t u n t r u s t w o r t h y . It is like a negative m a lin g e rin g you get with the SO-year.-old m an who com es in and tells you how stro n g and robust he is, and how he has not a symptom; w h ereas if you ask his wife and his next door neighbor, they will tell you quite a different story. kR D E R A T O R OLSON: Thank you. Dr. F o ster. I th in k th a t if th e re was com plete fre e d o m of choice on the p a rt of t h e r a i l r o a d to s a y to an in d iv id u a l, "W e d o n 't t h in k y o u s u it u s , " a f t e r a given in te r v a l of tim e, that it would be ea sy to handle the p ro b lem on this b a s is. Unfortunately, however, th ere is a tim e lim it which is set after which an individual acquires seniority; and the latest dickerings have in d icated that the railro ad s are going to be saddled with an individual the r e s t of his life after he acquires two y e a rs of seniority. He g o e s on th e r o s t e r in m o st p la c e s a f te r 60 days, and w hether o r not th is would be tim e enough to a s s e s s him , and w hether you could co n vince the union that because of our thinking about this man he is just not suited, I do not know. W hen a m an co m es in to your, we will say, h ospital, to get a p o s i tion a s a p h y sic ia n , you talk to him. You try to get so m e so rt of an idea of his personality; his general attitude; his ethics; his principles, and j q, to a s s e s s all of the qualities that make up a good physician. What can we do, then, in the p re lim in a ry in terv iew with an em ployee to m ake s u r e that he is not basically a high-grade neuropsychoneurotic; o r, th a t h e d o e s n o t hav e a p ara n o id tr e n d , and you do not happen to touch upon the questions that set him off? D oes anyone want to speak to that ? DR. AVERY: I think you can get quite a little from this man providing he has good ra p p o rt with you and gives you reasonably solid answ ers.I I think the answ er to the question, where did he com e fro m ? --is im portant. What kind of a family did he com e fro m ? How are his re la tio n ships w ith his s ib lin g s ? How does he p la y ? How did he go to school, esp ecially how did he accept discipline ? Did he accept the affection of his p a re n ts and accept the discipline as som ething that was natural, ac-^ ^ c e p t a b l e , a n d u n d e r s t a n d i n g , and j u s t ? Did h e go to s c h o o l ? Did he f.n.-* 106 If he w orked, if he h as had p re v io u s jo b s , what is his w o rk c o n tin uity? A man who is always changing from one job to another i s probnoiy uncertain. Has he had any severe emotional break? One has to be v e ry careful, th e re , because th e re a re many em otional breaks, and you might say the acute alteration of personality, disaster, or some toxic phenomenon, such as delirium , might be a circum stance; but if th e re is in the background and in this m an h im self repeated episodes of we will say d e p re ssio n , you m ay expect him to have them again. One h as, also, to be ca refu l because many people who are e x tre m e ly neurotic make excellent em ployees, and there are a great many psychoiics, I am s u r e , who a r e m a k in g a good co n tribution to o v e r a ll industry. We have to be c a r e f u l to s e e how th e m a n r e a c t e d ; h is s u s p i c i o u s ness; his reticen c e; and I think you could tell quite a little as to what kind of a m an, on a g r o s s lev el this m an m ight m a k e, that is as we used to say in electing to the h o sp ital c e rta in people, is he a man you would like to play golf w ith? Is he a m an you would like to know, accep t? MODERATOR OLSON: D r. F o s te r , do you think that an em ploying o f ficer would be in a b e tte r position to make this kind of an estim ate o: a m a n ? And, would th at be sufficient fo r a rec o m m en d a tio n to give him the re st of the physical examination that is req u ired for employment DR. FOSTER; I th in k th at you need the f ir s t te a m , so to speak, in the personnel interview for new em ployees. This is not a job that should be re le g a te d to the th ird , fo u rth , and fifth echelon of the p e rs o n n e l office. The longer an individual has been in p erso n n e l w ork the m ore e x p e r i e n c e d he b e c o m e s in r e c o g n i z i n g p r o b l e m e m p l o y e e s ; 1an d a s D r. Avery has m entioned, the skillful personnel officer of experience will ask many of the questions that the p sychiatrist will ask. He will certain ly take a detailed em ploym ent re c o rd . He will take an educational re c o rd . He will ask quite bluntly, "Do you have any kind of an a rre s t o r con viction rec o rd ? " He will c e r ta in ly ask,. "Have you been habituated to alcohol o r o th e r injurious agents?" He will certain ly ask about m arriag e; in te r-p e rso n a l relationships . in the fam ily. He w ill ce rtain ly ask about re la tio n s with p are n ts, which, to m e, r e p r e s e n ts one of the m o st revealing questions. He will c e rta in ly also ask about the kind of a m an o r woman who is applying for a specific job situation. A s I s a i d , the personnel Officer of e x p e r i e n c e w ill a s k th e s e kinds of questions. 1 07 naval service m a y dismiss ail individual without prejudice '/art.cuhir'.v and just say "unsuitable. " * I would hav e to say that I would far m o re highly advocate tria l on the job on p ro b a tio n a ry sta tu s as a technique for picking out the useful e m ployee than I would any psychological test currently available. One of the p ro b le m s in the psychological te s ts , of co u rse, is the p ro b lem of neg ativ e m alin g erin g . If a m an is bucking fo r a job, the an sw ers that he p ro d u ce s on these fill-in types of psychological te sts, and that is w h a t t h e M i n n e s o t a m u l t i p h a s i c i s , a r e j u s t u n t r u s t w o r t h y . It is like a negative m a lin g e rin g you get with the SO-year.-old m an who com es in and tells you how stro n g and robust he is, and how he has not a symptom; w h ereas if you ask his wife and his next door neighbor, they will tell you quite a different story. W sfoERATOR OLSON: Thank you. Dr. F o ster. I th in k th a t if th e re was com plete fre e d o m of choice on the p a rt of t h e r a i l r o a d to s a y to an in d iv id u a l, "W e d o n 't t h in k y o u s u it u s , " a f t e r a given in te r v a l of tim e, that it would be ea sy to handle the p ro b lem on this b a s is. Unfortunately, however, there is a tim e lim it which is set after which an individual acquires seniority; and the latest dickerings have in d icated that the railro ad s are going to be saddled with an individual the r e s t of his life after he acquires two y e a rs of seniority. He g o e s on th e r o s t e r in m o st p la c e s a f te r 60 days, and w hether o r not th is would be tim e enough to a s s e s s him , and w hether you could co n vince the union that because of our thinking about this man he is just not suited, I do not know. W hen a m an co m es in to your, we will say, h ospital, to get a p o s i tion a s a p h y sic ia n , you talk to him. You try to get so m e so rt of an idea of his personality; his general attitude; his ethics; his principles, and j q, to a s s e s s all of the qualities that make up a good physician. What can we do, then, in the p re lim in a ry in terv iew with an em ployee to m ake s u r e that he is not basically a high-grade neuropsychoneurotic; o r, th a t h e d o e s n o t hav e a p ara n o id tr e n d , and you do not happen to touch upon the questions that set him off? D oes anyone want to speak to that ? DR. AVERY: I think you can get quite a little from this man providing he has good ra p p o rt with you and gives you reasonably solid answ ers.I I think the answ er to the question, where did he com e fro m ? --is im portant. What kind of a family did he com e fro m ? How are his re la tio n ships w ith his s ib lin g s ? How does he p la y ? How did he go to school, esp ecially how did he accept discipline ? Did he accept the affection of his p a re n ts and accept the discipline as som ething that was natural, ac-^ ^ c e p t a b l e , a n d u n d e r s t a n d i n g , and j u s t ? Did h e go to s c h o o l ? Did he f.n.-* 106 If he worked, if he has had previous jobs, what is his work co n tin uity? A man who is always changing from one job to another i s probnoiy uncertain. Has he had any severe emotional break? One has to be v e ry careful, th e re , because th e re a re many em otional breaks, and you might say the acute alteration of personality, disaster, or some toxic phenomenon, such as delirium , might be a circum stance; but if th e re is in the background and in this m an h im self repeated episodes of we will say d e p re ssio n , you m ay expect him to have them again. One h as, also, to be ca refu l because many people who are ex trem ely neurotic make excellent em ployees, and there are a great many psychoiics, I am s u r e , who a r e m a k in g a good co n tribution to o v e r a ll industry. We have to be c a r e f u l to s e e how th e m a n r e a c t e d ; h is s u s p i c i o u s ness; his reticen c e; and I think you could tell quite a little as to what kind of a m an, on a g r o s s lev el this m an m ight m a k e, that is as we used to say in electing to the h o sp ital c e rta in people, is he a man you would like to play golf w ith? Is he a m an you would like to know, ac ce p t? MODERATOR OLSON; D r. F o s te r , do you think that an em ploying o f ficer would be in a b e tte r position to make this kind of an estim ate o: a m a n ? And, would th at be sufficient fo r a rec o m m en d a tio n to give him the re st of the physical examination that is req u ired for employment DR. FOSTER; I th in k th at you need the f ir s t te a m , so to speak, in the personnel interview for new em ployees. This is not a job that should be re le g a te d to the th ird , fo u rth , and fifth echelon of the p e rs o n n e l office. The longer an individual has been in p erso n n e l work the m ore e x p e r i e n c e d he b e c o m e s in r e c o g n i z i n g p r o b l e m e m p l o y e e s ; 1an d a s D r. Avery has m entioned, the skillful personnel officer of experience will ask many of the questions that the p sy ch iatrist will ask. He will certain ly take a detailed em ploym ent re c o rd . He will take an educational re c o rd . He will ask quite bluntly, "Do you have any kind of an a rre st or con viction reco rd ?" He will c e r ta in ly ask,. "Have you been habituated to alcohol o r o th e r injurious agents?" He will certain ly ask about m arriag e; in te r-p e rso n a l relationships . in the fam ily. He w ill ce rtain ly ask about re la tio n s with p are n ts, which, to m e, r e p r e s e n ts one of the m o st revealin g questions. He will c e rta in ly also ask about the kind of a m an o r woman who is applying for a specific job situation. As I sa id , the p ersonnel Officer of experience w ill ask these kinds of questions. 1 07 MODERATOR OLSON: Our Claim D epartm ent is represent d here to. day, and I know th e re a r e o th e rs from o th e r r a ilro a d s . I know ti.cv are p a r tic u la rly in te r e s te d in this p roblem , becau se the num ber of claim s they get a r e b ased in a fair percentage I think on the attitudes that are assum ed by individuals when they are injured. One o f the b a s ic p u rp o se s of this panel is to tr y to se ttle a question of how we a r e going to a s s e s s these people not ju st from their physical attrib u tes, but fro m th eir m ental stability as well. M any o f y o u have com m ented on the need f o r such a p ro g ra m . I think so m e of o u r own people should inject th em selv es into this picture and sta te t h e i r view s on how they think we can a c co m p lish this. S hall we at th is point a ssu m e that tim e is w asted by the u se of any these inventories? D r. W in sto n , do you want to begin ? DR. WINSTON: I would like to state for the re c o rd , which I believe is w h at m y l a w y e r f r i e n d s s a y , th a t we have p a i d a l l too little atten tio n to em ployee selection. T h at is not n e c e s s a rily a fault of the m e d ica l d ep artm en t, but it is so m e th in g , a situation that as I see it behooves us to ca ll to the attention of those in o th e r a re a s of the railroad m anagem ent. In o r d e r to buy a typew riter, o r a set of c a r tru c k s , o r a locomotive, an im m e n se am ount of investigation is c a rrie d on by test departm ents. The p u r c h a s in g people have a whole o rganizatio n of th e ir own, headed by a v ice-president, and I suppose most roads have a sim ilar arrangement. We w ill spend an awful lot of time dickering about an item that costs h u n d red d o lla rs ; and this item incidentally we can d is c a rd w henever we l ^ n t to; but we buy m anpow er that we will be ob lig ated to continue to s u p p o rt for an indefinite num ber of y ears, and we a re basing that on a brief m edical evaluation. A ll too often, too, that m edical evaluation is perfunctory and alm ost useless. So, h e re we have a product that is worth a half-m illion dollars, at least D r. K aplan's employee was worth a half-m illion dollars or so, and we a re devoting a rela tiv e ly few minutes to h im , to decide w hether o r not we want him . It would be id e a l if we could do as D r. F o s t e r s a y s , and have the p r e . ogative of rejecting this person. On o u r p r o p e r ty in c e rtain c ra fts we do not have th a t p rero g ativ e; and w ith c e r t a i n o th e r s we do. AU too often it is not u se d , how ever. 193 Insofar as an in te rv iew is concerned, that is practically never done, except that we a re s till in a relativ ely r u ra l p art of the nation, and at least for many y e a rs the prospective employee was known to his supervisor or boss, and perhaps there was som e screening at that level. I am also fea rfu l that th e re might have been som e screen in g in r e v erse . We knew th is fellow, and there are o th er connections that m ade the su p erv iso r em ploy him rath er than reject him. I, f o r m y p a r t , would be v e r y m u c h i n t e r e s t e d in developing so m e plans whereby, first, we can have som e way of screening out the grossly a b n o r m a l p e r s o n . I n a s m u c h a s we do not have a m a n p o w e r p u r c h a s in g d ep artm en t, then I would like to have som ething that could be done, eith er at the c l e r ic a l level, o r at the d o cto r's office th a t woulcf help s c r e e n outthe grossly abnorm al persons. Then, if we could get into something that would help screen out those who offe r to be p r o b le m s la te r on, I would very m uch like to se e th at h a p pen, too. I hope we get s o m e id e a s about it a s we go a lo n g h e r e . As I r e m e m ber the opening sta te m en t by Dr. Avery, he m entioned that there were ce rta in c o n s id e ra tio n s, he indicated to me at le ast that th e re are c e rtain m e a n s by which you could m e a s u r e a p e r s o n 's p o te n tia l. I would like to h e a r a little m o re specifically mentioned what te s ts he had in mind. MODERATOR OLSON: Do you want to talk about th at 12-point p r o g ra m ? Would that be ap ro p o s h e re ? DR. AVERY: Y es. T h ere is a p r o g ra m that has been brought out by the A m erican M ed ic a l A s s o c ia tio n , u n d e r its Council of O ccupational H ealth , and th is can be m odified to a p re-em ploym ent area. T his h as la rg e ly to do with the em ployability of an em ployee a fte r he h a s h a d a p s y c h i a t r i c i l l n e s s , and th e y b r in g o u t 12 p o in ts tha t c o u ld a l s o be of value, in the m ain in determ ining som ething of this m a n 's ability to perform a service for the company. I do not know o f w hat age they a re speaking, but I ta k e it th at all of th e s e a p p l i c a n t s a r e o v e r 16, and 17 o r 18. I think, i n the f i r s t p la c e , a lad who has not d ev e lo p e d som e continuity, som e stab ility at sa y 18 y e a rs of age, who, up to th at tim e , has been a dropout; a b e h a v io r p ro b le m ; a delinquent--I do not think th e re is m uch hope that he will develop into a firs t-c la s s employee. This 12-point p ro g ram indicates the following: And I have changed the initial sta te m e n t to, "W hat is the p erso n ality of this m an?" In that I m ea n , h ow d o e s he r e a c t to you? Is h e friendly? Does he take it for granted you a c c e p t him as an individual? Does he nllov. ..u MODERATOR OLSON: Our Claim D epartm ent is represent d here to. day, and I know th e re a r e o th e rs from o th e r r a ilro a d s . I know ti.cv are p a r tic u la rly in te r e s te d in this p roblem , becau se the num ber of claim s they get a r e b ased in a fair percentage I think on the attitudes that are assum ed by individuals when they are injured. One o f the b a s ic p u rp o se s of this panel is to tr y to se ttle a question of how we a r e going to a s s e s s these people not ju st from their physical attrib u tes, but fro m th eir m ental stability as well. M any o f y o u have com m ented on the need f o r such a p ro g ra m . I think so m e of o u r own people should inject th em selv es into this picture and sta te t h e i r view s on how they think we can a c co m p lish this. S hall we at th is point a ssu m e that tim e is w asted by the u se of any these inventories? D r. W in sto n , do you want to begin ? DR. WINSTON: I would like to state for the re c o rd , which I believe is w h at m y l a w y e r f r i e n d s s a y , th a t we have p a i d a l l too little atten tio n to em ployee selection. T h at is not n e c e s s a rily a fault of the m e d ica l d ep artm en t, but it is so m e th in g , a situation that as I see it behooves us to ca ll to the attention of those in o th e r a re a s of the railroad m anagem ent. In o r d e r to buy a typew riter, o r a set of c a r tru c k s , o r a locomotive, an im m e n se am ount of investigation is c a rrie d on by test departm ents. The p u r c h a s in g people have a whole o rganizatio n of th e ir own, headed by a v ice-president, and I suppose most roads have a sim ilar arrangement. We w ill spend an awful lot of time dickering about an item that costs h u n d red d o lla rs ; and this item incidentally we can d is c a rd w henever we l ^ n t to; but we buy m anpow er that we will be ob lig ated to continue to s u p p o rt for an indefinite num ber of y ears, and we a re basing that on a brief m edical evaluation. A ll too often, too, that m edical evaluation is perfunctory and alm ost useless. So, h e re we have a product that is worth a half-m illion dollars, at least D r. K aplan's employee was worth a half-m illion dollars or so, and we a re devoting a rela tiv e ly few minutes to h im , to decide w hether o r not we want him . It would be id e a l if we could do as D r. F o s t e r s a y s , and have the p r e . ogative of rejecting this person. On o u r p r o p e r ty in c e rtain c ra fts we do not have th a t p rero g ativ e; and w ith c e r t a i n o th e r s we do. AU too often it is not u se d , how ever. 193 Insofar as an in te rv iew is concerned, that is practically never done, except that we a re s till in a relativ ely r u ra l p art of the nation, and at least for many y e a rs the prospective employee was known to his supervisor or boss, and perhaps there was som e screening at that level. I am also fea rfu l that th e re might have been som e screen in g in r e v erse . We knew th is fellow, and there are o th er connections that m ade the su p erv iso r em ploy him rath er than reject him. I, f o r m y p a r t , would be v e r y m u c h i n t e r e s t e d in developing so m e plans whereby, first, we can have som e way of screening out the grossly a b n o r m a l p e r s o n . I n a s m u c h a s we do not have a m a n p o w e r p u r c h a s in g d ep artm en t, then I would like to have som ething that could be done, eith er at the c l e r ic a l level, o r at the d o cto r's office th a t woulcf help s c r e e n outthe grossly abnorm al persons. Then, if we could get into something that would help screen out those who offe r to be p r o b le m s la te r on, I would very m uch like to se e th at h a p pen, too. I hope we get s o m e id e a s about it a s we go a lo n g h e r e . As I r e m e m ber the opening sta te m en t by Dr. Avery, he m entioned that there were ce rta in c o n s id e ra tio n s, he indicated to me at le ast that th e re are c e rtain m e a n s by which you could m e a s u r e a p e r s o n 's p o te n tia l. I would like to h e a r a little m o re specifically mentioned what te s ts he had in mind. MODERATOR OLSON: Do you want to talk about th at 12-point p r o g ra m ? Would that be ap ro p o s h e re ? DR. AVERY: Y es. T h ere is a p r o g ra m that has been brought out by the A m erican M ed ic a l A s s o c ia tio n , u n d e r its Council of O ccupational H ealth , and th is can be m odified to a p re-em ploym ent area. T his h as la rg e ly to do with the em ployability of an em ployee a fte r he h a s h a d a p s y c h i a t r i c i l l n e s s , and th e y b r in g o u t 12 p o in ts tha t c o u ld a l s o be of value, in the m ain in determ ining som ething of this m a n 's ability to perform a service for the company. I do not know o f w hat age they a re speaking, but I ta k e it th at all of th e s e a p p l i c a n t s a r e o v e r 16, and 17 o r 18. I think, i n the f i r s t p la c e , a lad who has not d ev e lo p e d som e continuity, som e stab ility at sa y 18 y e a rs of age, who, up to th at tim e , has been a dropout; a b e h a v io r p ro b le m ; a delinquent--I do not think th e re is m uch hope that he will develop into a firs t-c la s s employee. This 12-point p ro g ram indicates the following: And I have changed the initial sta te m e n t to, "W hat is the p erso n ality of this m an?" In that I m ea n , h ow d o e s he r e a c t to you? Is h e friendly? Does he take it for granted you a c c e p t him as an individual? Does he nllov. ..u know h i m ? Is he not fearful of being scrutinized? This is in the ist category. T h en , d o es he h av e any s o m a tic d is o r d e r that m ig h t play a ro le in s em otional ad ju stm en t? That could be any of the chronic diso rd ers or utc d is o r d e r s , su c h a s asthm a; a tendency to colds; rh e u m a tic d iseases, d so forth. Then next is, what are the s tr e s s e s that he has off the job? That r what re sp o n sib ility does he have ? How does he handle h is resp o n oilities ? Is he having p ro b le m s at hom e with his children, o r his m o th er, or s father-, o r his w ife? How does he w ork in the c o m m u n ity ? Is he w c e p * " d ? T h en , you would have to co n sid er that this m an is an applicant for a rta in job. What a re the s tr e s s e s on that p a rticu la r job ? How much n tin u ity of e ffo rt is t h e r e ? A re the w orking conditions fa v o ra b le . Is -re s t r e s s ? A re t h e r e m a rk e d tim e lim its ? Is t h e r e h u r r y ? Is th e r e ^traction ? T h e n e x t t h r e e p o in ts would not be a p p lic a b le b e c a u s e th e y h av e to do th illness. So, u n d e r Item 8, then, you would want to see his attitude about life J his attitude about work; and I think this is the m ost im portant thing u can find out about a p erso n , is why is he working, and what does he mt to work fo r? Work is som ething that I think is guarded by every man and every >m a n , a n d w o r k i s s o m e t h i n g th a t when it i s d e n i e d t h e m t h e y a r e a p t d e te rio ra te , as is seen in the retirem en t deterioration, the retire m en t iry ^ ons. T h en I think you can s till go into actually how he r e a c ts to his fellow ople. You can get a fair idea as to the stability of this m an, and the w ork level. O ne in 10 o f a l l o f u s a t s o m e t i m e m a y h av e e m o t i o n a l o r m e n t a l eak d o w n . What y o u want to do, p e r h a p s , i s to c a tc h th a t one in 10. hink you will be lucky if you catch one in a hundred. 1. M ISHLER: I r i s e a g a in to be a n u isa n ce . T h is p a n e l so f a r has e su m e d to be talking p r im a rily about applicants. We have v e ry little ouble with applicants. That is my first point. N um ber two --we have very little trouble with our g ro ssly abnorm al psychotic patients. They are no problem on our railroads. The problem that w e have on our railroad, and I presume it is com nn on all railroads, is the so-called normal man. My q u e s tio n to the two p s y c h ia t r is ts is , how we as c h ief surg'.on.. in o r d e r to h o ld o u r j o b c a n , in s o m e w ay, c o m b a t the M a d is o n AVenn-, propaganda, or the propaganda of the Brotherhoods, and the ambular. c h a s e rs , afte r the m an is injured, w here avarice and the attem pt to live a life of ease at the ra ilro a d 's expense after the man is injured, enters the p ic tu re ? I think that is o u r big problem , not p rim a rily in the selection of new em ployees or the handling of a grossly psychotic individual. MODERATOR OLSON: Before I ask these gentlem en to a n sw e r I would like to make this observation. I think th e re is an in v e rse ratio between the stability of a man and the degree of his injury; and if you have a very stable individual, he can sustain a severe injury without developing these so -c a lle d traum atic n e u r o s e s , and p e r h a p s t h i s m i g h t be a good p l a c e to b r i n g t h i s up fo r discussion. T he m an who is highly u n sta b le r e q u ir e s v ery, v e r y little to set him off. F o r that re a so n I think it is fundam ental that we tr y to s e le c t people who will behave as nearly within the confines of what we c a ll norm alcy as p o ssib le in o rd e r to avoid this kind of a situation. DR. MISHLER: I d isa g re e with you. I do not think that a ll o u r people who are p ro b lem s a re of the so -ca lle d , what was the te rm you used? "Functional neurotics ?" MODERATOR OLSON: "T rau m atic n eurosis. " DR. MISHLER: "T raum atic neuroses. " l They are people who, if you give them $5,000.00 are perfectly n o r m a l p eople. T hey a r e not t r a u m a t i c n e u r o s e s . T hey a r e p eo p le who have been influenced by propaganda, et c e tra , and the w illingness to p r o long th e ir disability only for the sake of money. I think it is wrong to call them traum atic neuroses. MODERATOR OLSON: I can say , how ever, that you can talk to many kinds of people, and you would find so m e who would say that the com pany is "my company; I am part of it. " This is something that happened. I agree that the com pany has a d eg re e of liability, but I am not going to try to becom e a m illionaire for the r e s t of my life as a re su lt of it. The m ere fact that the money cu re s the problem is p retty good e v i dence to me that this is not a fundam ental organic illness at all; that this i s s o m e t h i n g in t h e m in d of the in d iv id u a L I do not, however, want to belabor the point. DR. MISHLER: M aybe I did not m ake m y question clea r . How can w e - - know h i m ? Is he not fearful of being scrutinized? This is in the ist category. T h en , d o es he h av e any s o m a tic d is o r d e r that m ig h t play a ro le in s em otional ad ju stm en t? That could be any of the chronic diso rd ers or utc d is o r d e r s , su c h a s asthm a; a tendency to colds; rh e u m a tic d iseases, d so forth. Then next is, what are the s tr e s s e s that he has off the job? That r what re sp o n sib ility does he have ? How does he handle h is resp o n oilities ? Is he having p ro b le m s at hom e with his children, o r his m o th er, or s father-, o r his w ife? How does he w ork in the c o m m u n ity ? Is he cep*"d? wT h e n , y o u w ould h a v e to c o n s i d e r th a t th is m a n is an a p p l i c a n t f o r a rta in job. What a re the s tr e s s e s on that p a rticu la r job ? How much n tin u ity of e ffo rt is t h e r e ? A re the w orking conditions fa v o ra b le . Is -re s t r e s s ? A re t h e r e m a rk e d tim e lim its ? Is t h e r e h u r r y ? Is th e r e ^traction ? T h e n e x t t h r e e p o in ts would not be a p p lic a b le b e c a u s e th e y h av e to do th illness. So, u n d e r Item 8, then, you would want to see his attitude about life J his attitude about work; and I think this is the m ost im portant thing u can find out about a p erso n , is why is he working, and what does he mt to work fo r? Work is som ething that I think is guarded by every man and every >m a n , a n d w o r k i s s o m e t h i n g th a t when it i s d e n i e d t h e m t h e y a r e a p t d e te rio ra te , as is seen in the retirem en t deterioration, the retire m en t iry ^ ons. T h en I think you can s till go into actually how he r e a c ts to his fellow ople. You can get a fair idea as to the stability of this m an, and the w ork level. O ne in 10 o f a l l o f u s a t s o m e t i m e m a y h av e e m o t i o n a l o r m e n t a l oakdow n. What y o u want to do, p e r h a p s , i s to c a tc h th a t one in 10. hink you will be lucky if you catch one in a hundred. 1. M ISHLER: I r i s e a g a in to be a n u isa n ce . T h is p a n e l so f a r has e su m e d to be talking p r im a rily about applicants. We have v e ry little ouble with applicants. That is my first point. N um ber two --we have very little trouble with our g ro ssly abnorm al psychotic patients. They are no problem on our railroads. The problem that w e have on our railroad, and I presume it is com nn on all railroads, is the so-called normal man. My q u e s tio n to the two p s y c h ia t r is ts is , how we as c h ief surg'.on.. in o r d e r to h o ld o u r j o b c a n , in s o m e w ay, c o m b a t the M a d is o n AVenn-, propaganda, or the propaganda of the Brotherhoods, and the ambular. c h a s e rs , afte r the m an is injured, w here avarice and the attem pt to live a life of ease at the ra ilro a d 's expense after the man is injured, enters the p ic tu re ? I think that is o u r big problem , not p rim a rily in the selection of new em ployees or the handling of a grossly psychotic individual. MODERATOR OLSON: Before I ask these gentlem en to a n sw e r I would like to make this observation. I think th e re is an in v e rse ratio between the stability of a man and the degree of his injury; and if you have a very stable individual, he can sustain a severe injury without developing these so -c a lle d traum atic n e u r o s e s , and p e r h a p s t h i s m i g h t be a good p l a c e to b r i n g t h i s up fo r discussion. T he m an who is highly u n sta b le r e q u ir e s v ery, v e r y little to set him off. F o r that re a so n I think it is fundam ental that we tr y to s e le c t people who will behave as nearly within the confines of what we c a ll norm alcy as p o ssib le in o rd e r to avoid this kind of a situation. DR. MISHLER: I d isa g re e with you. I do not think that a ll o u r people who are p ro b lem s a re of the so -ca lle d , what was the te rm you used? "Functional neurotics ?" MODERATOR OLSON: "T rau m atic n eurosis. " DR. MISHLER: "T raum atic neuroses. " l They are people who, if you give them $5,000.00 are perfectly n o r m a l p eople. T hey a r e not t r a u m a t i c n e u r o s e s . T hey a r e p eo p le who have been influenced by propaganda, et c e tra , and the w illingness to p r o long th e ir disability only for the sake of money. I think it is wrong to call them traum atic neuroses. MODERATOR OLSON: I can say , how ever, that you can talk to many kinds of people, and you would find so m e who would say that the com pany is "my company; I am part of it. " This is something that happened. I agree that the com pany has a d eg re e of liability, but I am not going to try to becom e a m illionaire for the r e s t of my life as a re su lt of it. The m ere fact that the money cu re s the problem is p retty good e v i dence to me that this is not a fundam ental organic illness at all; that this i s s o m e t h i n g in t h e m in d of the in d iv id u a L I do not, however, want to belabor the point. DR. MISHLER: M aybe I did not m ake m y question clea r . How can w e - - surgeons in s o m e way change the atmosphere a little bit so that we do lot have as large a problem as we have at the present time? IODERATOR OLSON: Again the point was made: a little while ago that n e of the p u r p o s e s of o u r d isc u ssio n was to try to get the kind of people vho w o u ld n o t d o t h i s . }R. F O S T E R : I d o n o t t h in k t h i s k in d o f p e r s o n is p r e d i c t a b l e by c o n entional techniques. I also quite agree that I cordially detest that term "traum atic neuosis. M ost often it is a neurosis, and the afflicted individual hangs is neurotic sym ptom ology upon a bump, a bruise, or an injury v/hich may r m ay not h av e been in c u rre d in line of duty, but which is alleged to ave been in c u rr e d in line of duty. 'rile a p p ro a c h to th is , it se e m s to m e, has to be in te rm s of p ro m p t xam ination by reliab le physicians. The traum atic neurosis problem is e m e n d o u sly a g g r a v a te d , as all of us know, by p h y sician s who a r e s o ra e ling le ss than honest. I think at every turn, when such a situation is apparent, th ere m ust i a p ro m p t d isp o sitio n of the com plaint, o r of the symptomology before is p e rm itte d to cry stallize in a long-term , fixed battle between law yers. I think, fu rth e r, that the claim departm ents or the insurance departlents m u st n e v e r "ro ll o v er" on these. If they do, they sim ply fu rther .e p r o b l e m . T h is p r o b l e m , I think, will always be with us to som e extent as long 5 th ere are frin g e p rac titio n e rs of medicine and fringe p rac titio n e rs of e law. I do not think you can get out of th is problem . J do not think they a re predictable. l a o th in k th at one of the big pro b lem s in this a r e a is in the a r e a of ;m m u n icatio n s; that is, the su p e rv iso r will know, many tim e s, of an dividual who is always skirting the edge of dangerous p rac tice s, but is in fo rm a tio n is not adequately com m unicated to m an ag em en t, and ich an in d iv id u al m ay be p e rm itte d to a ssu m e m o re and m o re re s p o n ble positions and higher and higher levels. Here, as I see it, is the oblem in the sen se that it is one of com m unication within an o rg an iz aun. ODERATOR OLSON: Before we leave this portion of the p ro g ra m , I ould like to ask Dr. Skinner to respond to this query: At what level of nployment should we ca rry out a com paratively detailed interrogatory tth the candidate ? Would you say that the o rd in ary la b o re r should not : subjected to th is kind of a s c re e n in g ? A m an who by v irtu e of h is o cipation could easily sustain injury and become one of these liab ilities? Where would you draw the line on it? DR. A B B O T T S K I N N E R (Chief Medical Officer, Great Northern Railway): That is a question about like, " H o w far is up?" I think this is an a r e a in which we would all agree there m ust be considerable upgrading, and any s ta r t would be good. If we em ploy at th e le v e l th a t y ou a r e not c o v e rin g , that is the le v el that you should go to. We know it is im p r a c tic a l at the p r e s e n t tim e, with the new p e r s o n a lity in v e n to rie s on o u r s u m m e r t r a c k la b o r. It m ight be d esirable. It could even be p r o v e d econom ical; but i t is im possible at the present tim e. G reat N orthern has a s e rie s of questionnaires o r te sts which are largely aptitude and p ersonality inventory, non-medical. I feel this is worthwhile; but this p r o g ra m should be extended. I cannot give you an answer. Any fu ll-tim e em ployee could benefit m anagem ent by revealing his problem, and his personality tendencies. MODERATOR OLSON: I would assu m e fro m your answ er that it would be in the higher cla ssifie d groups that you would apply this questionnaire or in te rro g a to ry . P e rh a p s they are less involved in claim s than the men who a r e e n g a g ed in m o r e ard u o u s o cc u p atio n s. Dr. Longeway, would you ca re to c a rry on about the use of it in let us say the train m en , enginem en, and brak em en , and those in the h ea v ie r occupations ? DR. W ALTER J. LONGEWAY (Chief Surgeon, Colorado & Southern Railway) I do not know w hether you r e m e m b e r when we made this pilot study last y e a r on p re -e m p lo y m e n t p h y sical exam inations, because on the last page we had an outline of th is AMA M ental h ea lth fo rm that D r ^ A very h as been discussing. It was on this p re-em p lo y m en t physical exam ination. Of co u rse , that was put th e re for this group to d isc u ss and to study, and our idea was that it should s ta rt right at the bottom. MODERATOR OLSON: You m ean with the common la b o re r? DR. LONGEWAY: It was put in this fo rm for such and c a r r ie d on fro m there. MODERATOR OLSON: Would you sa y that is a p rac tica l p lace? DR. LONGEWAY: Y es, and no. Some of them probably cannot even read it; but so m e p a r ts of it I think would be p rac tic a l, y es. MODERATOR OLSON: D r. H am m att, do you have any com m ents to m ake on it? . . Li surgeons in s o m e way change the atmosphere a little bit so that w e do lot have as large a problem as we have at the present time? MODERATOR OLSON: Again the point was made: a little while ago that n e of the p u r p o s e s of o u r d isc u ssio n was to try to get the kind of people vho w o u ld n o t d o t h i s . )R. F O S T E R : I do n o t th ink th is kind of p e r s o n is p r e d ic ta b le by c o n entional techniques. I also quite agree that I cordially detest that term "traum atic neuosis. M ost often it is a neurosis, and the afflicted individual hangs is neurotic sym ptom ology upon a bump, a bruise, or an injury v/hich may r m ay not h av e been in c u rre d in line of duty, but which is alleged to ave been in c u rr e d in line of duty. 'rile a p p ro a c h to th is , it se e m s to m e, has to be in te rm s of p ro m p t xam ination by reliab le physicians. The traum atic neurosis problem is e m e n d o u sly a g g r a v a te d , as all of us know, by p h y sician s who a r e s o ra e ling le ss than honest. I think at every turn, when such a situation is apparent, th ere m ust ; a p ro m p t d isp o sitio n of the com plaint, o r of the symptomology before is p e rm itte d to cry stallize in a long-term , fixed battle between law yers. I think, fu rth e r, that the claim departm ents or the insurance depart:ents m u st n e v e r "ro ll o v er" on these. If they do, they sim ply fu rther .e p r o b l e m . T h is p r o b l e m , I think, will always be with us to som e extent as long 3 th ere are frin g e p rac titio n e rs of medicine and fringe p rac titio n e rs of e law. I do not think you can get out of th is problem . J do not think they a re predictable. l a o th in k th at one of the big pro b lem s in this a r e a is in the a r e a of ;m m u n icatio n s; that is, the su p e rv iso r will know, many tim e s, of an dividual who is always skirting the edge of dangerous p rac tice s, but is in fo rm a tio n is not adequately com m unicated to m an ag em en t, and ich an in d iv id u al m ay be p e rm itte d to a ssu m e m o re and m o re re s p o n ble positions and higher and higher levels. Here, as I see it, is the oblem in the sen se that it is one of com m unication within an o rg an iz aun. ODERATOR OLSON: Before we leave this portion of the p ro g ra m , I ould like to ask D r. Skinner to respond to this query: At what level of nployment should we ca rry out a com paratively detailed interrogatory ith the candidate ? Would you say that the o rd in ary la b o re r should not : subjected to th is kind of a s c re e n in g ? A m an who by v irtu e of h is o cipation could easily sustain injury and become one of these liab ilities? Where would you draw the line on it? DR. A B B O T T S K I N N E R (Chief Medical Officer, Great Northern Railway): That is a question about like, " H o w far is up?" I think this is an a r e a in which we would all ag re e th e re m ust be considerable upgrading, and any s ta r t would be good. If we em ploy at th e le v e l th a t y ou a r e not co v e rin g , that is the le v el that you should go to. We know it is im p r a c tic a l at the p r e s e n t tim e, with the new p e r s o n a lity in v e n to rie s on o u r s u m m e r t r a c k la b o r. It m ight be d esira b le . It could even be p r o v e d econom ical; but i t is im possible at the present tim e. G reat N orthern has a s e rie s of questionnaires o r tests which are largely aptitude and personality inventory, non-medical. I feel this is worthwhile; but this p r o g ra m should be extended. I cannot give you an answer. Any fu ll-tim e em ployee could benefit m anagem ent by revealing his problem, and his personality tendencies. MODERATOR OLSON: I would assu m e fro m your answ er that it would be in the higher c la ssifie d groups that you would apply this questionnaire or in te rro g a to ry . P e rh a p s they are less involved in claim s than the men who a r e en g a g ed in m o r e ard u o u s o cc u p atio n s. Dr. Longeway, would you ca re to c a rry on about the use of it in let us say the trainm en, enginemen, and brakem en, and those in the heavier occupations ? DR. W ALTER J. LONGEWAY (Chief Surgeon, Colorado & Southern Railway) I do not know w hether you r e m e m b e r when we m ade this pilot study last y e a r on p re -e m p lo y m e n t p h y sical exam inations, because on the last page we had an outline of th is AMA M ental h ea lth fo rm that D r ^ A very has been discussing. It was on this p re-em p lo y m en t physical exam ination. Of co u rse , that was put th e re for this group to d isc u ss and to study, and our idea was that it should s ta rt right at the bottom. MODERATOR OLSON: You m ean with the common la b o re r? DR. LONGEWAY: It was put in this fo rm for such and c a r r ie d on fro m there. MODERATOR OLSON: Would you sa y that is a p rac tica l p lace? DR. LONGEWAY: Y es, and no. Some of them probably cannot even read it; but so m e p a r ts of it I think would be p rac tic a l, y es. MODERATOR OLSON: D r. H am m att, do you have any com m ents to m ake on it? . , Li DR. H. W. H A M M A T T (Chief Medical Officer, Chicago, RurUntfon L Quincy Railroad): Yes. We h av e found th a t we have in c e r t a i n c a te g o rie s , w h ere the in d i vidual is not sufficiently intelligent to p ass even the elem entary p sy chiatric te sts, th ere is this circum stance. I feel, h o w ev er, that the tests should be given to all individuals, but it is not p r a c tic a l for the tra c k lab o rers o r the ex tra gang fellows. Wc h a v e b e e n giving the W onderlich T e s t 't o a ll new e m p lo y ee s. We have found that in the type of em ployee whom we use fo r our rec lam a tio n p lans we have had to low er the qualifications; oth erw ise, we would have em ployees. W So, I th in k th a t w'hat is going to happen is if you would s c r e e n out your e x tra gang la b o re rs , and extra trackm en, that th e re would be insuf ficient m en to handle the occupations. T herefore, I think the railro ad itself is going to have to take the resp o n sib ility and assu m e the r is k of p o ssib le tr a u m a tic n eu ro sis, which they will allege he h as. He certain ly m ust be a n eu ro tic o r he would not say that a m inor sc ra tch would require indefinite treatm ent. MODERATOR OLSON: Thank you. Doctor. D r. C ushm an, you have com piled som ething on the cost of this kind of a p ro b le m . I w onder if you would be willing to te ll us so m eth in g about it. DR. GLENN F. CUSHMAN (Chief Surgeon, W estern Pacific Railroad): I have not com piled costs on this type of program . The M edical-L egal Com mittee of last year brought the question wheo r not the p ro b le m of psychoneurotic p ro b lem s in ju rie s should be p u r s u e d f u r th e r and studied; and I was asked to go o v er the c a s e s that were com piled by the AAR from their settlem ent ca rd s, and I went over 44 c a s e s th a t c o m e in fro m January 1962 for a p erio d of som ew hat le ss than two y e a rs. T h ese re p o rts w ere all the way from a very superficial notation from the ra ilro a d involved to very com plete rec o rd s, including the depositions of the attending doctors and psychiatrists. On the whole they w ere, I would say, very inadequate for this p u r pose, because I do not believe the com panies realized what the M edicalLegal C om m ittee was after. J u s t to b rie f ly r u n down th e se, of th e se 44 c a s e s which w ere se ttle d either b e fo re , du rin g , o r afte r tr ia l, 20 of them re s u m e d work in th e ir own occupation; only one in a different job. Eight had not retu rn ed to work. Two re tire d on age. Thirteen had a settlem ent with resignation. One returned to work and then quit later on retirement. The diagnoses subm itted included five cases of schizophrenia; one of multiple sclero sis; and then a catch bag of all the re s t of them divided between conversion h ysteria and anxiety neuroses; traum atic neuroses, and so forth; and not being a p sy c h ia tris t I did not feel I was able to put these into pigeonholes, and th e re fo re just lumped them into the psycho neuroses. T h e re was a h is to ry of six c a s e s that should have been, by even a very superficial screening, not ever employed, because of previous h is tory of mental or neurotic disturbances. Three had other disabilities that should have been disqualifying. All five schizophrenic cases had shock treatm ent, and I could only find docum entation of psychotherapy, including the five who had sh o d : tr e a tm e n ts , in 11, o r 25 p e r c e n t of the c a s e s . The in ju ries involved w ere: Sixteen head injuries and the big group, 22, back, neck, and p elv is, with a sc a tte rin g in other in ju ries to o th er p arts of the body. T he c r a n e , y a r d , and en g in e m e n c o n trib u te d 16; the shop c r a f t s , 17 o u f of the 44, le a v i n g o n ly 11 f o r the r e s t o f the jo b c l a s s i f i c a t i o n s . My opinion on this review was that we did not have adequate in fo rm a tion fro m the co m p an ies, and that the only way we could get it if this was to be co n sid ered a m a jo r problem , would be to send out, as we are doing on the disk c a s e s , a questio n n aire which should be sen t both to the claim and legal departm ents for th eir evaluation of the case, and to the chief surgeon who should rev ie w all the m edical and givq his opinion. By and large, the evaluation is v e ry su perficial. N europsychiatrie consultation was apparently obtained on behalf of the plaintiff in the ca se of the plaintiff and in 16 c a s e s on b eh a lf of the com pan y . W hether o r not the com pany's psychiatric consultation was as a defense procedure against the claim s of the plaintiff, o r not, is not documented. T h at le ft 13 c a s e s w h e re the d ia g n o s is w as m a d e a p p a r e n tly by th e attending physician, o r a n o n -p sy c h ia trist, and on behalf of the plaintiff. I think th ere is one thing that should be em phasized here. As long as we a r e ta lking about tr a u m a tic n e u r o s is and p s y c h ia tric conditions, a true psychiatric condition, of course, is, as I understand it, a psychosis, which is one thing, and a n eu ro sis, no m a tte r what you label it, is s o m e thing else again. To point out that the firs t line o f defense in psychoneurosis is the a t tending physician, and w hether he knows it, or not, he is a practicing psychotherapist. He can do m o re , the f irs t m an who s e e s and tre a ts the n - .tt a - t th->n all s n h s o n u o n t c o n s u l t a t i o n s can p o s s i b l y do. DR. H. W. H A M M A T T (Chief Medical Officer, Chicago, RurUntfon L Quincy Railroad): Yes. We h av e found th a t we have in c e r t a i n c a te g o rie s , w h ere the in d i vidual is not sufficiently intelligent to p ass even the elem entary p sy chiatric te sts, th ere is this circum stance. I feel, h o w ev er, that the tests should be given to all individuals, but it is not p r a c tic a l for the tra c k lab o rers o r the ex tra gang fellows. Wc h a v e b e e n giving the W onderlich T e s t 't o a ll new e m p lo y ee s. We have found that in the type of em ployee whom we use fo r our rec lam a tio n p lans we have had to low er the qualifications; oth erw ise, we would have em ployees. W So, I th in k th a t w'hat is going to happen is if you would s c r e e n out your e x tra gang la b o re rs , and extra trackm en, that th e re would be insuf ficient m en to handle the occupations. T herefore, I think the railro ad itself is going to have to take the resp o n sib ility and assu m e the r is k of p o ssib le tr a u m a tic n eu ro sis, which they will allege he h as. He certain ly m ust be a n eu ro tic o r he would not say that a m inor sc ra tch would require indefinite treatm ent. MODERATOR OLSON: Thank you. Doctor. D r. C ushm an, you have com piled som ething on the cost of this kind of a p ro b le m . I w onder if you would be willing to te ll us so m eth in g about it. DR. GLENN F. CUSHMAN (Chief Surgeon, W estern Pacific Railroad): I have not com piled costs on this type of program . The M edical-L egal Com mittee of last year brought the question wheo r not the p ro b le m of psychoneurotic p ro b lem s in ju rie s should be p u r s u e d f u r th e r and studied; and I was asked to go o v er the c a s e s that were com piled by the AAR from their settlem ent ca rd s, and I went over 44 c a s e s th a t c o m e in fro m January 1962 for a p erio d of som ew hat le ss than two y e a rs. T h ese re p o rts w ere all the way from a very superficial notation from the ra ilro a d involved to very com plete rec o rd s, including the depositions of the attending doctors and psychiatrists. On the whole they w ere, I would say, very inadequate for this p u r pose, because I do not believe the com panies realized what the M edicalLegal C om m ittee was after. J u s t to b rie f ly r u n down th e se, of th e se 44 c a s e s which w ere se ttle d either b e fo re , du rin g , o r afte r tr ia l, 20 of them re s u m e d work in th e ir own occupation; only one in a different job. Eight had not retu rn ed to work. Two re tire d on age. Thirteen had a settlem ent with resignation. One returned to work and then quit later on retirement. The diagnoses subm itted included five cases of schizophrenia; one of multiple sclero sis; and then a catch bag of all the re s t of them divided between conversion h ysteria and anxiety neuroses; traum atic neuroses, and so forth; and not being a p sy c h ia tris t I did not feel I was able to put these into pigeonholes, and th e re fo re just lumped them into the psycho neuroses. T h e re was a h is to ry of six c a s e s that should have been, by even a very superficial screening, not ever employed, because of previous h is tory of mental or neurotic disturbances. Three had other disabilities that should have been disqualifying. All five schizophrenic cases had shock treatm ent, and I could only find docum entation of psychotherapy, including the five who had sh o d : tr e a tm e n ts , in 11, o r 25 p e r c e n t of the c a s e s . The in ju ries involved w ere: Sixteen head injuries and the big group, 22, back, neck, and p elv is, with a sc a tte rin g in other in ju ries to o th er p arts of the body. T he c r a n e , y a r d , and en g in e m e n c o n trib u te d 16; the shop c r a f t s , 17 o u f of the 44, le a v i n g o n ly 11 f o r the r e s t o f the jo b c l a s s i f i c a t i o n s . My opinion on this review was that we did not have adequate in fo rm a tion fro m the co m p an ies, and that the only way we could get it if this was to be co n sid ered a m a jo r problem , would be to send out, as we are doing on the disk c a s e s , a questio n n aire which should be sen t both to the claim and legal departm ents for th eir evaluation of the case, and to the chief surgeon who should rev ie w all the m edical and givq his opinion. By and large, the evaluation is v e ry su perficial. N europsychiatrie consultation was apparently obtained on behalf of the plaintiff in the ca se of the plaintiff and in 16 c a s e s on b eh a lf of the com pan y . W hether o r not the com pany's psychiatric consultation was as a defense procedure against the claim s of the plaintiff, o r not, is not documented. T h at le ft 13 c a s e s w h e re the d ia g n o s is w as m a d e a p p a r e n tly by th e attending physician, o r a n o n -p sy c h ia trist, and on behalf of the plaintiff. I think th ere is one thing that should be em phasized here. As long as we a r e ta lking about tr a u m a tic n e u r o s is and p s y c h ia tric conditions, a true psychiatric condition, of course, is, as I understand it, a psychosis, which is one thing, and a n eu ro sis, no m a tte r what you label it, is s o m e thing else again. To point out that the firs t line o f defense in psychoneurosis is the a t tending physician, and w hether he knows it, or not, he is a practicing psychotherapist. He can do m o re , the f irs t m an who s e e s and tre a ts the n - .tt a - t th->n all s n h s o n u o n t c o n s u l t a t i o n s can p o s s i b l y do. It i s only th e tliin c o r e , the o n e s th a t we c a n n o t r e c o n c i l e and get to the p s y c h ia tris t, and they re p re s e n t a ra th e r poor group of peopie for the p sychiatrist to do anything about. MODERATOR OLSON: Thank you. Doctor. We could p e r h a p s co n c lu d e th is phase by s a y in g that it is the c o n s e n sus that the conventional'inventory studies are not trustw orthy enough to w arrant th e ir g e n e r a l use; that th e o ra l in te rro g a to ry by a qualified in te r viewer would, p e rh a p s, uncover as much as can be uncovered. T hirdly, that within the lim it of time that is perm itted, that the ex tended o b se rv a tio n of the candidate would d eterm in e h is suitability to continue his em ploym ent. W think th a t th is s u b je c t v /a rra n ts co n sid erab le thinking on the p a r t of all of u s, and I think th a t it would be worthwhile to p u rsu e, at som e la te r meeting. DR. WIGHT: Is th e re audience participation in th is? MODERATOR OLSON: I am s o rry if it appears that we have monopolized the discussion. DR. WIGHT: D r. F o s te r m ade a re m a rk a sh o rt while ago, and I think it was agreed to by D r. Avery about the unreliability of these tests. I would like to c ite one exam ple of this which su p p o rts th em 100 p e r cent. A few y e a r s ago a country in E urope, which sh all be n a m e le s s , that has com pulsory m ilita ry training, put on a concerted effort to get their lads to go into the a ir fo rce. T h re e thousand a p p lic a n ts , th r e e thousand pi 'e a p p lie d f o r th e a i r f o r c e . T h e y w e r e a l l in t e r v i e w e d w ith a w hole baftery of tests. Out of th e t h r e e th o u sa n d , 30 w ere a c ce p te d fo r the a i r f o rc e . Out o f th e 30 t h a t w e r e a c c e p t e d , 15 b r o k e down in th e p r e l i m i n a r y t r a i n i n g . This ju st p ro v es the inadequacy of these te sts. I think we all know that had th e re been a w ar, out of 3,000 applicants probably 2500 w ould have made good pilots. MODERATOR OLSON: That would seem to be a ra th e r sad com m entary on the value of the te s ts . DR. WIGHT: T h e r e is an o th er way of looking a t it. DR. KNOWLES: D r. O lson, I would like to sa y som ething on p o ssib le traum atic neurosis. T h ere is one definite cure. The sooner you use it, the b etter, and th at is a good greenback poultice', that will clean them rig h t up. T h e s o o n e r y ou g e t th a t c a s e , the q u i c k e r h e w ill r*. aporv an> MODERATOR OLSON: That is right; and that is one of the things that has been quoted as proving that this was not an illness because money should not cure an illness. DR. WINSTON: I would also like to m ake the observation that you have cured him of that p a rtic u la r phase of his illness. You have accentuated his underlying, fundam ental instability, as I view it. MODERATOR OLSON: One of our p ro b lem s is the in c re asin g dem and on the exchecquer of the railro a d s for all kinds of things; and if it is possible to take a stand against som e of these things, I think it is much to the railro a d 's advantage, and we should probe into all of the avenues that might lead to it. We have a r a t h e r i m p o r t a n t s u b j e c t th a t m any of you h av e in q u ir e d about, and I think it w ill p ro b ab ly take the r e s t of th e hour. We a r e not going to be able to co v er all of the questions. That p ro b lem is one of alco h o lism . In Q uestion No. 10, it says that many m edical officers feel that alcoholism is m ore of a problem than m anagem ent a p p re cia tes. Would it, o r would it not aggravate the s itu a tion if a s t r i c t e r approach to the p ro b lem was instigated ? My thoughts on th is a r e th a t it m a y be tr u e that m an ag em en t does not ap p re cia te the extent of alc o h o lism , but I think that m o st com panies do. In the o p e ra tin g f ie ld s, the ru lin g h as b een en fo rc e d , and a fa ir n u m b e r of individuals have been put on p ro b atio n o r d ism isse d as a result of it. One angle, how ever, that o c c u rs to m e is the problem with the c u s to m e r s ' men who a r e r e q u ir e d to e n te rta in th e ir p r o s p e c ts frequently at midday, and then, because it is n e c e s sa ry to provide the suitable inhibitors before the m eal, one gets the im m ediate effect on the discussions that follow the luncheon. It h a s bee n s a i d t h a t m a n y of t h e c u s t o m e r s o b j e c t to t r a n s a c t i n g business because the re p re se n ta tiv e is not functioning at his best, and it is difficult to a rriv e at good judgm ents and prom pt handling of the p ro b lem s. I think that D r. Kaplan h a s done con sid erab le work in this field, and I would like to ask him to open th is d isc u ssio n . DR. ISADORE KAPLAN (M edical and Surgical D irector, B altim ore & Ohio Railroad): Dr. Olson, do you want m e to adhere str ic tly to the q uestion, or sh a ll I ' interject some of our experiences ? MODERATOR OLSON: You u se you r own judgment. We have about 15 m in u tes. DR. KAPLAN: T h e d rin k in g p op u lation o f th e U nited S ta tes is about TO m illion. Of th e se , fiv e m illio n a re identified as a lco h o lics. B u sin ess It i s only th e tliin c o r e , the o n e s th a t we c a n n o t r e c o n c i l e and get to the p s y c h ia tris t, and they re p re s e n t a ra th e r poor group of peopie for the p sychiatrist to do anything about. MODERATOR OLSON: Thank you. Doctor. We could p e r h a p s co n c lu d e th is phase by s a y in g that it is the c o n s e n sus that the conventional'inventory studies are not trustw orthy enough to w arrant th e ir g e n e r a l use; that th e o ra l in te rro g a to ry by a qualified in te r viewer would, p e rh a p s, uncover as much as can be uncovered. T hirdly, that within the lim it of time that is perm itted, that the ex tended o b se rv a tio n of the candidate would d eterm in e h is suitability to continue his em ploym ent. W think th a t th is s u b je c t v /a rra n ts co n sid erab le thinking on the p a r t of all of u s, and I think th a t it would be worthwhile to p u rsu e, at som e la te r meeting. DR. WIGHT: Is th e re audience participation in th is? MODERATOR OLSON: I am s o rry if it appears that we have monopolized the discussion. DR. WIGHT: D r. F o s te r m ade a re m a rk a sh o rt while ago, and I think it was agreed to by D r. Avery about the unreliability of these tests. I would like to c ite one exam ple of this which su p p o rts th em 100 p e r cent. A few y e a r s ago a country in E urope, which sh all be n a m e le s s , that has com pulsory m ilita ry training, put on a concerted effort to get their lads to go into the a ir fo rce. T h re e thousand a p p lic a n ts , th r e e thousand pi 'e a p p lie d f o r th e a i r f o r c e . T h e y w e r e a l l in t e r v i e w e d w ith a w hole baftery of tests. Out of th e t h r e e th o u sa n d , 30 w ere a c ce p te d fo r the a i r f o rc e . Out o f th e 30 t h a t w e r e a c c e p t e d , 15 b r o k e down in th e p r e l i m i n a r y t r a i n i n g . This ju st p ro v es the inadequacy of these te sts. I think we all know that had th e re been a w ar, out of 3,000 applicants probably 2500 w ould have made good pilots. MODERATOR OLSON: That would seem to be a ra th e r sad com m entary on the value of the te s ts . DR. WIGHT: T h e r e is an o th er way of looking a t it. DR. KNOWLES: D r. O lson, I would like to sa y som ething on p o ssib le traum atic neurosis. T h ere is one definite cure. The sooner you use it, the b etter, and th at is a good greenback poultice', that will clean them rig h t up. T h e s o o n e r y ou g e t th a t c a s e , the q u i c k e r h e w ill r*. aporv an> MODERATOR OLSON: That is right; and that is one of the things that has been quoted as proving that this was not an illness because money should not cure an illness. DR. WINSTON: I would also like to m ake the observation that you have cured him of that p a rtic u la r phase of his illness. You have accentuated his underlying, fundam ental instability, as I view it. MODERATOR OLSON: One of our p ro b lem s is the in c re asin g dem and on the exchecquer of the railro a d s for all kinds of things; and if it is possible to take a stand against som e of these things, I think it is much to the railro a d 's advantage, and we should probe into all of the avenues that might lead to it. We have a r a t h e r i m p o r t a n t s u b j e c t th a t m any of you h av e in q u ir e d about, and I think it w ill p ro b ab ly take the r e s t of th e hour. We a r e not going to be able to co v er all of the questions. That p ro b lem is one of alco h o lism . In Q uestion No. 10, it says that many m edical officers feel that alcoholism is m ore of a problem than m anagem ent a p p re cia tes. Would it, o r would it not aggravate the s itu a tion if a s t r i c t e r approach to the p ro b lem was instigated ? My thoughts on th is a r e th a t it m a y be tr u e that m an ag em en t does not ap p re cia te the extent of alc o h o lism , but I think that m o st com panies do. In the o p e ra tin g f ie ld s, the ru lin g h as b een en fo rc e d , and a fa ir n u m b e r of individuals have been put on p ro b atio n o r d ism isse d as a result of it. One angle, how ever, that o c c u rs to m e is the problem with the c u s to m e r s ' men who a r e r e q u ir e d to e n te rta in th e ir p r o s p e c ts frequently at midday, and then, because it is n e c e s sa ry to provide the suitable inhibitors before the m eal, one gets the im m ediate effect on the discussions that follow the luncheon. It h a s bee n s a i d t h a t m a n y of t h e c u s t o m e r s o b j e c t to t r a n s a c t i n g business because the re p re se n ta tiv e is not functioning at his best, and it is difficult to a rriv e at good judgm ents and prom pt handling of the p ro b lem s. I think that D r. Kaplan h a s done con sid erab le work in this field, and I would like to ask him to open th is d isc u ssio n . DR. ISADORE KAPLAN (M edical and Surgical D irector, B altim ore & Ohio Railroad): Dr. Olson, do you want m e to adhere str ic tly to the q uestion, or sh a ll I ' interject some of our experiences ? MODERATOR OLSON: You u se you r own judgment. We have about 15 m in u tes. DR. KAPLAN: T h e d rin k in g p op u lation o f th e U nited S ta tes is about TO m illion. Of th e se , fiv e m illio n a re identified as a lco h o lics. B u sin ess and i n d u s t r y c a n c o u n t a p p r o x i m a t e l y t h r e e m i LIion W o r k e r s a s b e in g a l c o h o l i c s . T h e y lo s t a n a v e r a g e of 22 w ork d a y s a n n u a lly , and a r e twice as accident-prone as the non-alcoholic. This is, of course, of g reat im p o rtan ce to c la im agents and legal re p re se n ta tiv e s. The national av erag e of alcoholic em ployees, from the industrial s t a n d p o i n t , r a n g e s a n y w h e r e f r o m on e to 12 p e r c e n t; h u t I th in k of a m ore rea listic percentage as being between six and eight per cent. As we know the p r o b le m of alcoholism , o r dipsom ania, it is now - c l a s s i f i e d by th e AMA a s b e i n g a d is e a s e . It is no lo n g e r a s c o u r g e , and m u st be c o n s id e re d as an illn e ss. It now ranks with h e a rt d ise a se , c a n cer, and m ental illness as one of the nation's four m ost serious health problem s. F or som e unknown reason, it has a great proclivity for m em bers of tlh |j^ e e l and ra ilro a d in d u stries. This may be because of poor s u p e r vision of tra in c r e w s , and the fact that em ployees a re on the ro a d w here they a r e subjected to tra v e lin g boredom , solitude, and fru stra tio n . The M edical D ep a rtm e n t of the B altim ore and Ohio R ailroad in its work classification unit has a separate, integral group that applies only to alcoholic p ro b le m s. Once weekly we have a p sy c h ia trist who com es to the M edical D e p a rt m e n t h e a d q u a r t e r s to e x a m in e a lc o h o lic s who have been r e f e r r e d to us e ith e r by m an ag em en t o r o u r own m edical exam iners. We evaluate these s t r i c t l y on a n a lco h o lic p s y c h ia tr ic and p h y sic al b a s is . Since 19S1, we h a v e f o u n d a t o t a l of 175 a l c o h o l i c s , p lu s 5-1 who h a v e b e e n d i s m i s s e d from se rv ic e because of Rule "G" violation. D u r i n g the y e a r 1964, 23 e m p lo y e e s w e re d i s m i s s e d f r o m co m p an y se rv ic e b ec au se of Rule "G: violation; and, during this sam e period, an a d d itio n a l 85 e m p lo y e e s w e re c la s s ifie d by o u r unit as a lco h o lics. Of th' -ro u p 19 w e r e in itia lly p e r m i t t e d to r e t u r n to w o rk , an d l a t e r an a d diW^rffal s e v e n w e r e a l l o w e d to go b a c k to w o rk f o llo w in g r e - e v a l u a t i o n . T h u s out o f the 75 a lc o h o lic s we w ere only able to r e h a b ilita te 26, and lost '49 of o u r tr a in e d em p lo y ee s. T he a v e rag e age for alcoholic disqualification by the M edical D e p a rt m e n t i s 45 y e a r s , a n d th e a v e r a g e le n g th of s e r v i c e i s 14 y e a r s . T h i s is v ery im portant because it involves an employee at the peak of his p e r f o r m a n c e . He i s w e l l - t r a i n e d , a n d h a s a v e r a g e s e r v i c e of 14 o r 15 y e a r s . If we a r e lo sin g 50 p e r ce n t of them , it m e a n s th e y have p r o g r e s s e d to the point where they have o rg an ic changes affecting both p h y sical and m ental faculties, such as enlarged liver, abnorm al blood ch em istries and wet brains. M anagem ent r e a liz e s th e c o s t of training a new em p lo y ee and to alert supervision to this problem , we have now instituted a program in the Baltimore area. 1 am very unhappy to te ll you that it has not been a great success. 208 A week ago I was with D r. F r a n c o , of C o n so lid ated E dison, who stated that th e r e a r e about 70 a lc o h o l p r o g r a m s in in d u stry . I told h im I was very much disillusioned and unhappy with the results of our work; that v/e had w orked h a r d fo r t h r e e o r four y e a r s , and had nothing to show but a group of disqualified a lco h o lics. He sa id this was c o r r e c t b e c a u s e in the beginning all you get a r e known alco h o lics, which m anagem ent is trying to dispose of. H owever, they will not re fe r the early o r u n re c o g nized alcoholic, unless specially trained in this aspect. The doctor further stated that in his initial program he had disquali fied as high as 75 p e r cent of th e ir a lc o h o lic s, but as tim e p r o g r e s s e d he was able to indoctrinate m anagem ent with the fact that he wanted the early hidden alcoholics (those who did not drink before they came to work or during lunch). When he was able to consult with this group, resu lts w e r e m u c h b e t t e r and it w a s p o s s i b l e to r e h a b i l i t a t e m a n y of th e m . At that point he was no lo n g e r getting known alcoholics. He m ade the o b s e r v a tio n that com pany alcohol p r o g r a m s could be m arkedly im proved i: m anagem ent would only p ro v id e b e t te r co o p e ratio n . We have noticed that th e re is a g re a te r p ercentage of alcoholism in our train m en as co n trasted with engineers and fire m e n o r y a r d m a s te rs , p assen g e r agents, w aiters, crew dispatchers, and operators. In the m e c h a n ic a l d e p a rtm e n t, fo r s o m e unknown re a s o n , the a f f lic tion is applicable to c a r m en and c a r in s p e c to rs . T his is w here we have our highest percentage of alcoholics. In conclusion, b e c a u se of tim e , I want to m ake a v e ry p e rtin e n t c o m ment regarding convulsive seizu res, o r what the laymen call "falling out" s p e l l s . W'e r e f e r t h e m to D r . M e r l i s a t th e U n i v e r s i t y o f M a r y la n d H o s pital as he is one of the w o rld 's g re a te s t in te rp re te r of electro en cep h alo g r a m s . He has a p p ris e d u s of th is little gem - many of th ese s e iz u r e s a re not tru e epileptic s e iz u r e s , and a r e in no way re la te d td epilepsy the> a r e found in alco h o lics who have been on drinking s e s s io n s and a re in the withdrawal stage. The electroencephalogram s show absolutely norm al tracings, and no abnorm al foci a re found; but we have been advised the whiskey c o n vulsions occur during the w ithdraw al syndrom e from the excessive use of alcohol. MODERATOR OLSON; Thank you . D octor. B e fo re we c lo se I would lik e to ask both of our consultants to com m ent on this problem of alcohol, and Xwould like to ask them one particular question. It has been m y im p r e ssio n that the A A 's have been THE m ost s u c cessfu l group, but recently lh a v e receiv ed som e letters saying that the p rofession its e lf , and a p a rticu la r h o sp ita l in C hicago, has been much more su ccessful in the treatm ent of these patients. and industry can count approxim ately three m illion w orkers as being a l c o h o l i c s . T h e y lo s t a n a v e r a g e of 22 w ork d a y s a n n u a lly , and a r e twice as accident-prone as the non-alcoholic. This is, of course of great im p o rtan ce to c la im agents and legal re p re se n ta tiv e s. The national av erag e of alcoholic em ployees, from the industrial s t a n d p o i n t , r a n g e s a n y w h e r e f r o m on e to 12 p e r c e n t; b u t I th in k of a m ore rea listic percentage as being between six and eight per cent. As we know the p r o b le m of alcoholism , o r dipsom ania, it is now c l a s s i f i e d by th e AM A a s b e i n g a d is e a s e . It is no lo n g e r a s c o u r g e , and m u st be c o n s id e re d as an illn e ss. It now ranks with h e a rt d ise a se , c a n cer, and m ental illness as one of the nation's four m ost serious health problem s. F or som e unknown reason, it has a great proclivity for m em bers of thN n^eel and ra ilro a d in d u stries. This may be because of poor s u p e r vision of tra in c r e w s , and the fact that em ployees a re on the ro ad w here they a r e subjected to tra v e lin g boredom , solitude, and fru stra tio n . The M edical D ep a rtm e n t of the B altim ore and Ohio R ailroad in its work classification unit has a separate, integral group that applies only to alcoholic p ro b le m s. Once weekly we have a p sy c h ia trist who com es to the M edical D e p a rt m e n t h e a d q u a r t e r s to e x a m in e a lc o h o lic s who have been r e f e r r e d to us e ith e r by m an ag em en t o r o u r own m edical exam iners. We evaluate these s t r i c t l y on a n a lco h o lic p s y c h ia tr ic and p h y sic al b a s is . Since 19S1, we h a v e f o u n d a t o t a l of 175 a l c o h o l i c s , p lu s 5-1 who h a v e b e e n d i s m i s s e d from se rv ic e because of Rule "G" violation. D u r in g th e y e a r 1964, 23 e m p lo y e e s w e re d i s m i s s e d f r o m co m p an y se rv ic e b ec au se of Rule "G: violation; and, during this sam e period, an a d d itio n a l 85 e m p lo y e e s w e re c la s s ifie d by o u r unit as a lco h o lics. Of th ' Tr o u p 19 w e r e i n i t i a l l y p e r m i t t e d to r e t u r n to w o r k , a n d l a t e r an a d diW^rffal s e v e n w e r e a l l o w e d to go b a c k to w o rk f o llo w in g r e - e v a l u a t i o n . T h u s out o f the 75 a lc o h o lic s we w ere only able to r e h a b ilita te 26, and lost '49 of o u r tr a in e d em p lo y ees. T he a v e rag e age for alcoholic disqualification by the M edical D e p a rt m e n t i s 45 y e a r s , a n d th e a v e r a g e le n g th of s e r v i c e is 14 y e a r s . T h i s is v ery im portant because it involves an employee at the peak of his p e r f o r m a n c e . He is w e l l - t r a i n e d , an d h as a v e r a g e s e r v i c e of 14 o r 15 y e a r s . If we a r e lo sin g 50 p e r ce n t of them , it m e a n s th e y have p r o g r e s s e d to the point where they have o rg an ic changes affecting both p h y sical and m ental faculties, such as enlarged liver, abnorm al blood ch em istries and wet brains. M anagem ent re a liz e s the cost of training a new em ployee and to alert supervision to this pro b lem , we have now instituted a p ro g ram in the Baltim ore area. 1 am very unhappy to te ll you that it has not been a great success. 208 A week ago I was with D r. F r a n c o , of C o n so lid ated E dison, who stated that th e r e a r e about 70 a lc o h o l p r o g r a m s in in d u stry . I told h im I was very much disillusioned and unhappy with the resu lts of our work; that v/e had w orked h a r d fo r t h r e e o r four y e a r s , and had nothing to show but a group of disqualified a lco h o lics. He sa id this was c o r r e c t b e c a u s e in the beginning all you get a r e known alcoholics, which m anagem ent is trying to dispose of. H owever, they will not re fe r the early o r u n re c o g nized alcoholic, unless specially trained in this aspect. The doctor further stated that in his initial program he had disquali fied as high as 75 p e r cent of th e ir a lc o h o lic s, but as tim e p r o g r e s s e d he was able to indoctrinate m anagem ent with the fact that he wanted the early hidden alcoholics (those who did not drink before they came to work or during lunch). When he was able to consult with this group, resu lts w e r e m u c h b e t t e r and it w a s p o s s i b l e to r e h a b i l i t a t e m a n y of th e m . At that point he was no lo n g e r getting known alcoholics. He m ade the o b s e r v a tio n that com pany alcohol p r o g r a m s could be m arkedly im proved if m anagem ent would only p ro v id e b e t te r co o p e ratio n . We have noticed that th e re is a g re a te r percentage of alcoholism in our train m en as co n trasted with engineers and fire m e n o r y a r d m a s te rs , p assen g e r agents, w aiters, crew dispatchers, and operators. In th e m e c h a n ic a l d e p a rtm e n t, for so m e unknown re a s o n , the a f f lic tion is applicable to c a r m en and c a r in s p e c to rs . T his is w here we have our highest percentage of alcoholics. In conclusion, b e c a u se of tim e , I want to m ake a v e ry p e rtin e n t c o m ment regarding convulsive seizu res, o r what the laymen call "falling out" s p e l l s . W'e r e f e r t h e m to D r . M e r l i s a t th e U n i v e r s i t y o f M a r y la n d H o s pital as he is one of the w o rld 's g re a te s t in te rp re te r of electro en cep h alo g r a m s . He has a p p ris e d u s of th is little gem - many of th ese s e iz u r e s a re not tru e epileptic s e iz u r e s , and a r e in no way re la te d td epilepsy the} a re found in alcoholics who have been on drinking se ssio n s and are in the withdrawal stage. The electroencephalogram s show absolutely norm al tracings, and no abnorm al foci a re found; but we have been advised the whiskey co n vulsions occur during the w ithdraw al syndrom e from the excessive use of alcohol. MODERATOR OLSON; Thank you . D octor. B e fo re we c lo se I would lik e to ask both o f our consultants to com m ent on this problem of alcohol, and I would like to ask them one particular question. It has been m y im p r e ssio n that the A A 's have been THE m ost s u c cessfu l group, but recently I have receiv ed som e letters saying that the p rofession its e lf , and a p a rticu la r h o sp ita l in C hicago, has been much more su ccessful in the treatm ent of these patients. DR, A V E R Y : I know the hospital has this group therapv which I think has been very successful. I do not know the details of it. T here a re . however, m any group therapies, or places where you can get group th erap y c a r r ie d on by e ith e r the staff of the hospital o r individ u als who ap p a ren tly do a fa irly good job with the alcoholic. alcohol for 24 h o u rs before he ta k e s off in the plane with the pilot at the controls. In co n tra st. A ir F ra n c e , does not have such a rule in effect; and I have been on A ir F ra n c e tra n sc o n tin e n ta l planes where the s te w a rd ess lugs the jug of wine right up to the o p eratin g p erso n n el of the a irc ra ft while it is in the a ir over the A tlantic Ocean. The AA has a good p r o g ra m for those who will m ake it work. I am not optim istic about the rehabilitation of a confirm ed alcoholic. I do think, a s the doctor sta te d , in those m en who are doing h a rd labor, and have responsibilities, that they take c a re o f their alcoholism better than the higher-up. H ere, you see, you have the clim ate, and this is what I am talking about when I say "clim ate, " w here alco h o lism i s acceptable. If we ev er get to the stage w h ere alcoholism becom es acceptable among operating p erso n n e l it se e m s to me we a re dead. We a re not operating safe railroads. I do not know that p sychotherapy has as yet made a g re a t in ro ad on oholism . MODERATOR OLSON: Dr. F o ster, D R . F O S T E R : I sh o u ld like to r e f e r to Q u e ry 10 in o u r f o ld e r s h e r e , w here it is indicated that the question is being asked: "Would it o r would it. not a g g ra v a te the situ atio n if a s t r i c t e r ap proach to the p ro b le m (that is, of alcoholism) was instigated?" It is tru e th at if one f e r r e ts out every la st instance of ev ery in d iv id ual who even takes a drink, th e re is a tendency to drive the pathological alcoholic undergrou nd so to speak. I have to say, how ever, that the clim ate of acceptance of heavy or p ath o lo g ic al a lc o h o lism is, to m e , a v ery im p o rta n t fa c to r in the incidenc of alcoholism. The other point to which I would like to d irec t a com m ent is under Q uery 11, in which it says: "A ssu m in g that alcoholism is a d isease, and as such the em ployee is entitled to tre a tm e n t fo r the d is e a s e " --m a y I make very clear that to me chronic alcoholism is a serious and severe addiction and I share Dr. A very's conviction that it is a very difficult addiction to b reak up. I do not a g r e e , h o w e v e r , th a t it is a d i s e a s e ; it is a sy m p to m . It i s a sym ptom of a great many different kinds of deviations, personality wise and otherw ise; but the individual in his fo rtie s who loses his wife, and m ay lose his b earin g s with the d ep re ssio n and take to the bottle for a couple of m onths, is not at al 1 the s a m e kind of a tre a tm e n t problem ; m anagem ent problem ; m edical problem ; p sychiatric problem as an in d i v id u a l who b e g a n h i s h ea v y d r i n k i n g at age 18 an d h a s b e e n p u ttin g away his pint a day, day in and day out for 20 y e a r s . They are quite different problem s; and to think of alcoholism as a disease entity is, I think, to ob scu re the issu e rath e r grossly. One has only to look for in stan c e, at som e of the g eo g rap h ical and " a c ia l in cidence of alcoholism . It is certainly no s e c re t that in c e rta in y t s of the B ritish Isles the incidence is te rrific . The incidence in the Scandinavian countries is te rrific. The incidence among Jews is extrem e low. As to the heavy pathological d rin k e r of 15, 20, 25 y e a r s ' duration, witli organic changes, I think th e re can be no question, if he is an o p e r a t in g e m p l o y e e , a s to w hat h a s to h a p p e n to h i m . He j u s t c a n n o t be p e r m i t t e d to continue in a job where he h as to be "on the ball. " This I think is where the m edical departm ents fail in an appreciable num ber of instances. What does this m ean? T h is m e a n s that it is a p a r t of the culture. It is a p a rt of the m o re s. It i s so cially acceptable for one to be a heavy and a path o lo g ical d rin k er. When one h as .the situation w here h ierachy, su p e rv is o ry m an ag em en t people a re well known as being pathological drinkers, you are dead. You sim ply cannot create the clim ate that to m e is necessary among o p era t ing em ployees of the non-acceptance industrially of heavy and pathologi cal drinking. P erh ap s a good way to epitom ize this point is from the airlin e pilot regulations. Among A m erican airlin es, a pilot and co-pilot a re governed by ru lin g s, and the equivalent of such ru ling is that no pilot m ay take any The physician m ay know that th e p atien t is a drinking m an, so to speak, by com m on rep u te of fe llo w -e m p lo y e e s o r by inform ation co m m u n i cated by the su p erv iso r.. T h e re is , in my view , too often insufficient exam ination of this individual's m e n ta l sta tu s to pick up what, to a c a r e ful psych iatrist o r a thorough psychological testing, would clearly show evidence of organic, intellectual enfeeblem ent, even when the patient had ` not been recently ingesting alcohol. Eet us face it--alcohol and the nutritional deficiency, and other problem s that go with it, r e p r e s e n t an im p o rta n t cause of enurological deficit status; and one of the co m m o n er ones among those who have been d rin k in g f o r too m a n y y e a r s i s organic i n t e l l e c t u a l e n fe e b le m e n t. DR, A V E R Y : I know the hospital has this group therapv which I think has been very successful. I do not know the details of it. T here a re . however, m any group therapies, or places where you can get group th erap y c a r r ie d on by e ith e r the staff of the hospital o r individ u als who ap p a ren tly do a fa irly good job with the alcoholic. alcohol for 24 h o u rs before he ta k e s off in the plane with the pilot at the controls. In co n tra st. A ir F ra n c e , does not have such a rule in effect; and I have been on A ir F ra n c e tra n sc o n tin e n ta l planes where the s te w a rd ess lugs the jug of wine right up to the o p eratin g p erso n n el of the a irc ra ft w hile it. i s in th e a i r o v e r t h e A t l a n t i c O c e a n . The AA has a good p r o g ra m for those who will m ake it work. I am not optim istic about the rehabilitation of a confirm ed alcoholic. I do think, a s the doctor sta te d , in those m en who are doing h a rd labor, and have responsibilities, that they take c a re o f their alcoholism better than the higher-up. H ere, you see, you have the clim ate, and this is what I am talking about when I say "clim ate, " w here alco h o lism i s acceptable. If we ev er get to the stage w h ere alcoholism becom es acceptable among operating p erso n n e l it se e m s to me we a re dead. We a re not operating safe railroads. I do not know that p sychotherapy has as yet made a g re a t in ro ad on oholism . MODERATOR OLSON: Dr. F o ster, D R . F O S T E R : I sh o u ld like to r e f e r to Q u e ry 10 in o u r f o ld e r s h e r e , w here it is indicated that the question is being asked: "Would it o r would it. not a g g ra v a te the situ atio n if a s t r i c t e r ap proach to the p ro b le m (that is, of alcoholism) was instigated?" It is tru e th at if one f e r r e ts out every la st instance of ev ery in d iv id ual who even takes a drink, th e re is a tendency to drive the pathological alcoholic undergrou nd so to speak. I have to say, how ever, that the clim ate of acceptance of heavy or p ath o lo g ic al a lc o h o lism is, to m e , a v ery im p o rta n t fa c to r in the incidenc of alcoholism. The other point to which I would like to d irec t a com m ent is under Q uery 11, in which it says: "A ssu m in g that alcoholism is a d isease, and as such the em ployee is entitled to tre a tm e n t fo r the d is e a s e " --m a y I make very clear that to me chronic alcoholism is a serious and severe addiction and I share Dr. A very's conviction that it is a very difficult addiction to b reak up. I do not a g r e e , h o w e v e r , th a t it is a d i s e a s e ; it is a sy m p to m . It i s a sym ptom of a great many different kinds of deviations, personality wise and otherw ise; but the individual in his fo rtie s who loses his wife, and m ay lose his b earin g s with the d ep re ssio n and take to the bottle for a couple of m onths, is not at al 1 the s a m e kind of a tre a tm e n t problem ; m anagem ent problem ; m edical problem ; p sychiatric problem as an in d i v id u a l who b e g a n h i s h ea v y d r i n k i n g at age 18 an d h a s b e e n p u ttin g away his pint a day, day in and day out for 20 y e a r s . They are quite different problem s; and to think of alcoholism as a disease entity is, I think, to ob scu re the issu e rath e r grossly. One has only to look for in stan c e, at som e of the g eo g rap h ical and " a c ia l in cidence of alcoholism . It is certainly no s e c re t that in c e rta in y t s of the B ritish Isles the incidence is te rrific . The incidence in the Scandinavian countries is te rrific. The incidence among Jews is extrem e low. As to the heavy pathological d rin k e r of 15, 20, 25 y e a r s ' duration, witli organic changes, I think th e re can be no question, if he is an o p e r a t in g e m p l o y e e , a s to w hat h a s to h a p p e n to h i m . He j u s t c a n n o t be p e r m i t t e d to continue in a job where he h as to be "on the ball. " This I think is where the m edical departm ents fail in an appreciable num ber of instances. What does this m ean? T h is m e a n s that it is a p a r t of the culture. It is a p a rt of the m o re s. It i s so cially acceptable for one to be a heavy and a path o lo g ical d rin k er. When one h as .the situation w here h ierachy, su p e rv is o ry m anagem ent people a re well known as being pathological drinkers, you are dead. You sim ply cannot create the clim ate that to m e is necessary among o p era t ing em ployees of the non-acceptance industrially of heavy and pathologi cal drinking. P erh ap s a good way to epitom ize this point is from the airlin e pilot regulations. Among A m erican airlin es, a pilot and co-pilot a re governed by ru lin g s, and the equivalent of such ru ling is that no pilot m ay take any The physician m ay know that th e p atien t is a drinking m an, so to speak, by com m on rep u te of fe llo w -e m p lo y e e s o r by inform ation co m m u n i cated by the su p erv iso r.. T h e re is , in my view , too often insufficient exam ination of this individual's m e n ta l sta tu s to pick up what, to a c a r e ful psych iatrist o r a thorough psychological testing, would clearly show evidence of organic, intellectual enfeeblem ent, even when the patient had ` not been recently ingesting alcohol. Eet us face it--alcohol and the nutritional deficiency, and other problem s that go with it, r e p r e s e n t an im p o rta n t cause of enurological deficit status; and one of the co m m o n er ones among those who have been drin k in g f o r too m a n y y e a r s is organic i n t e l l e c t u a l e n fe e b le m e n t. They m ay put up a good s o c ia l front. They may have a reasonable vocabulary. They may have a jocular attitude and other desirable traits a m o n g a g r o u p . B u t th e y c a n n o t c u t t h e m u s t a r d , so to s p e a k , when it "* com es to c a r ry in g out h ig h e r d isc rim in a to ry acts on the higher nervous system . I do not think we a re testin g these people carefully enough too often to pick out th is p a r tic u la r is s u e . I think this m ust be a m uch m o re s tr ic t and higher level of exam ination for the operating employee group than it does f o r th e n o n - o p e r a tin g e m p lo y e e group; and as I say , if we e v e r let our s ta n d a rd s down h e re we a re dead, it seem s to m e, in an em ploy ment sense. R egarding D r. K aplan's com m ents about the ru m fits, or the whiskey a v u ls io n s th a t m a y go along with the d ry in g -o u t s ta g e of a lc o h o lis m , nave a g r e a t d ea l of faith in the electroencephalo g ram . I have been using an e le c tro e n c e p h a lo g ra m fro m the tw o-channel days of 1939 and 1940. 1 like it v e ry m uch. I like the help it gives m e in the evaluation of s tru c tu ra l d iseases of the nervous system . I have to tell you, as Dr. Kaplan has told you, that m ost individuals with ru m fits have norm al electroencephalogram s. As a m atter of fact, the histo ry of a w ell-verified background of an overt grand m al seizure, with a negative elec tro e n ce p h alo g ra m , a le rts m e to the p o ssib ility that this w ell m ay be a ru m fit kind of convulsion. T hey a re v e ry apt to have negative electroencephalogram s. MODERATOR OLSON: Thank you. Doctor. A re there any com m ents? DR. KNOVVLES: I would like to a s k D r. Kaplan, how m any of the n u m b e r of c a s e s have d rie d out, and had he allowed them to re tu rn to w o rk ? How ^ ^ .ny o f h is g ro u p h av e r e a lly d rie d out a f te r a p e r i o d ? T he o rg an iz atio n has com e to you and they want to re tu rn the m an to work. DR. KAPLAN: In the 1964 we had 75 alcoholics who w ere o riginally r e f e r r e d to u s f o r e x a m in a tio n ; of th is g ro u p , 19 w e re o r ig in a lly p e r m i t t e d to re tu rn to w ork, and la te r we allowed an additional seven. An a lc o h o lism clin ic w as r e c e n tly estab lish ed by the C ity of B a lti m ore, and we are 'n o w using it and re fe rrin g our em ployees to the unit for rehabilitation. At this tim e som e of our employees attend their group therapy m eetings which are held at night. DR. WINSTON: I would lik e to e x p lo r e , ju st a m om ent m o re, the problem of organic intellectual enfeeblem ent. The overt p sych otic is not a big problem ; that is , we can recogn ize it ordinarily. 'l*' H e re , ho w ev e r, we a r e d e a lin g with a p e r s o n whose potential is m a te ria lly lim ited. O ftentim es, he is occupying a job of considerable responsibility; and this organic intellectual enfeeblement is not all caused by alcohol. T here a re m any o th e r ca u se s. In m y e x p e rie n c e it is the g r e a t e s t sin g le p ro b le m that I encounter. How would you go about d etecting org an ic intellectu al enfeeblem ent. Dr. Foster. DR. FOSTER: The m ore g ro ss d eg re es of it a re not particularly diffi cult to detect. T h e re a re a n um ber of m ore o r le ss routinized types of testing for intellectual function, which most astute psychiatrists or n eu r ologists will carry out as a part of a routine examination. We look for such things a s e x c e s s iv e g a rru lity ; we look for evidences of im p a irm en t in recen t m em o ry . F o r instance, we will ask the individ ual to re m e m b e r an ad d re ss for a few m inutes. "M r. Jones, I am a s k ing y o u to r e m e m b e r t h a t m y a d d r e s s i s 375 C e d a r S t r e e t . " We a t t e m p t to get him to rep e at it afte r us, and then five m inutes la te r ask him for this address. Depending on his intellectual level in education, we will push him to the lim its of his a rith m e tic a l calculations. How much is nine tim es eight? How m uch is twelve tim e s th ir te e n ? If apples co s t th re e fo r a nickel, how many can you buy for a q u arter? This, interestingly enough, is a common one that the organic flubs the dub on. You se e, the m ultiplication table is pure m em ory. Nine t i m e s e ig h t is 72; but. if y ou p u t t h e m u l t i p l i c a t i o n t a b l e in the f o r m o f a n a b s tra c t problem , such as apples cost th re e for a nickel, how many can you buy f o r a q u a r t e r ? - - h e c a n n o t do the a b s tr a c t io n , byt he can do the ote m e m o r y p r o b l e m . T here is the m atter of rev e rsin g the presidents. This is a very com m o n d ev ice. Who is the P r e s i d e n t o f th e United S ta te s now ? W ho p r e ceded h im ? Who p re c e d e d h i m ? And again, p ush the lim its as f a r b a c k w ard a s the individual can go. A nother common one is to ask the individual to p arap h rase proverbs. We will ask him , "What does this m ean: A ro llin g stone gathers no m o s s ? " Even the dull-w itted individual, without gross organism , will so m e how get back into the concept of h is an sw er that people who keep on the move too m uch, people who r o a m fro m job to job, do not e v e r am ount to v e ry m uch. In o th er w ords, they can a b s tra c t the concept and the k ern el from such a familiar proverb. T h e re a re m o re fo rm a l te s ts and again m o st p sy c h iatrists have a few pencil-and-paper tests in th e ir office desks. My particular one happens to b e c a lle d the S h ip le y -H a rtfo rd R e tr e a t T e s t, and in 20 m inutes this gives me an excellent idea of the individual's vocabulary ability as com - They m ay put up a good s o c ia l front. They may have a reasonable vocabulary. They may have a jocular attitude and other desirable traits a m o n g a g r o u p . B u t th e y c a n n o t c u t t h e m u s t a r d , so to s p e a k , when it "* com es to c a r ry in g out h ig h e r d isc rim in a to ry acts on the higher nervous system . I do not think we a re testin g these people carefully enough too often to pick out th is p a r tic u la r is s u e . I think this m ust be a m uch m o re s tr ic t and higher level of exam ination for the operating employee group than it does f o r th e n o n - o p e r a tin g e m p lo y e e group; and as I say , if we e v e r let our s ta n d a rd s down h e re we a re dead, it seem s to m e, in an em ploy ment sense. R egarding D r. K aplan's com m ents about the ru m fits, or the whiskey a v u ls io n s th a t m a y go along with the d ry in g -o u t s ta g e of a lc o h o lis m , nave a g r e a t d ea l of faith in the electroencephalo g ram . I have been using an e le c tro e n c e p h a lo g ra m fro m the tw o-channel days of 1939 and 1940. 1 like it v e ry m uch. I like the help it gives m e in the evaluation of s tru c tu ra l d iseases of the nervous system . I have to tell you, as Dr. Kaplan has told you, that m ost individuals with ru m fits have norm al electroencephalogram s. As a m atter of fact, the histo ry of a w ell-verified background of an overt grand m al seizure, with a negative elec tro e n ce p h alo g ra m , a le rts m e to the p o ssib ility that this w ell m ay be a ru m fit kind of convulsion. T hey a re v e ry apt to have negative electroencephalogram s. MODERATOR OLSON: Thank you. Doctor. A re there any com m ents? DR. KNOVVLES: I would like to a s k D r. Kaplan, how m any of the n u m b e r of c a s e s have d rie d out, and had he allowed them to re tu rn to w o rk ? How ^ ^ .ny o f h is g ro u p h av e r e a lly d rie d out a f te r a p e r i o d ? T he o rg an iz atio n has com e to you and they want to re tu rn the m an to work. DR. KAPLAN: In the 1964 we had 75 alcoholics who w ere o riginally r e f e r r e d to u s f o r e x a m in a tio n ; of th is g ro u p , 19 w e re o r ig in a lly p e r m i t t e d to re tu rn to w ork, and la te r we allowed an additional seven. An a lc o h o lism clin ic w as r e c e n tly estab lish ed by the C ity of B a lti m ore, and we are 'n o w using it and re fe rrin g our em ployees to the unit for rehabilitation. At this tim e som e of our employees attend their group therapy m eetings which are held at night. DR. WINSTON: I would lik e to e x p lo r e , ju st a m om ent m o re, the problem of organic intellectual enfeeblem ent. The overt p sych otic is not a big problem ; that is , we can recogn ize it ordinarily. 'l*' H e re , ho w ev e r, we a r e d e a lin g with a p e r s o n whose potential is m a te ria lly lim ited. O ftentim es, he is occupying a job of considerable responsibility; and this organic intellectual enfeeblement is not all caused by alcohol. T here a re m any o th e r ca u se s. In m y e x p e rie n c e it is the g r e a t e s t sin g le p ro b le m that I encounter. How would you go about d etecting org an ic intellectu al enfeeblem ent. Dr. Foster. DR. FOSTER: The m ore g ro ss d eg re es of it a re not particularly diffi cult to detect. T h e re a re a n um ber of m ore o r le ss routinized types of testing for intellectual function, which most astute psychiatrists or n eu r ologists will carry out as a part of a routine examination. We look for such things a s e x c e s s iv e g a rru lity ; we look for evidences of im p a irm en t in recen t m em o ry . F o r instance, we will ask the individ ual to re m e m b e r an ad d re ss for a few m inutes. "M r. Jones, I am a s k ing y o u to r e m e m b e r t h a t m y a d d r e s s i s 375 C e d a r S t r e e t . " We a t t e m p t to get him to rep e at it afte r us, and then five m inutes la te r ask him for this address. Depending on his intellectual level in education, we will push him to the lim its of his a rith m e tic a l calculations. How much is nine tim es eight? How m uch is twelve tim e s th ir te e n ? If apples co s t th re e fo r a nickel, how many can you buy for a q u arter? This, interestingly enough, is a common one that the organic flubs the dub on. You se e, the m ultiplication table is pure m em ory. Nine t i m e s e ig h t is 72; but. if y ou p u t t h e m u l t i p l i c a t i o n t a b l e in the f o r m o f a n a b s tra c t problem , such as apples cost th re e for a nickel, how many can you buy f o r a q u a r t e r ? - - h e c a n n o t do the a b s tr a c t io n , byt he can do the ote m e m o r y p r o b l e m . T here is the m atter of rev e rsin g the presidents. This is a very com m o n d ev ice. Who is the P r e s i d e n t o f th e United S ta te s now ? W ho p r e ceded h im ? Who p re c e d e d h i m ? And again, p ush the lim its as f a r b a c k w ard a s the individual can go. A nother common one is to ask the individual to p arap h rase proverbs. We will ask him , "What does this m ean: A ro llin g stone gathers no m o s s ? " Even the dull-w itted individual, without gross organism , will so m e how get back into the concept of h is an sw er that people who keep on the move too m uch, people who r o a m fro m job to job, do not e v e r am ount to v e ry m uch. In o th er w ords, they can a b s tra c t the concept and the k ern el from such a familiar proverb. T h e re a re m o re fo rm a l te s ts and again m o st p sy c h iatrists have a few pencil-and-paper tests in th e ir office desks. My particular one happens to b e c a lle d the S h ip le y -H a rtfo rd R e tr e a t T e s t, and in 20 m inutes this gives me an excellent idea of the individual's vocabulary ability as com - to'j have to r c m c m b c that in org an ic brain d ise a se , language, grarn7iar, sy n ta x a r e p r e s e r v e d to the b i t t e r e n d , so to s p e a k ; th a t the ind'ii d u a l 's flow of s p e e c h and his u se of w o rd s m ay be high av e rag e to ;u p e rio r, but his ab ility to think ar.d to d is c rim in a te and to a b s tra c t) as .ell as to c a r r y out con ceptual thinking and to use judgment and fo re ight may be trem en d o u sly im p a ire d in spite of a p retty good vocabulary. If it is a kind of a b o r d e r lin e s itu a tio n , we a r e in the happy c i r c u m tar.ee that I am w here we m ay r e f e r them to a psychologist who can * rry out much m o re detailed tests; and this is one of the areas where ie p sy c h o lo g ist is at h is b e s t - - t h e detection of the thought d is o rd e r; the itellectual deficits; the m em ory im pairm ents; the abstraction deficiencies; ie ju d g m e n t d e fic ie n c ie s of people with o rg a n ic b rain dam age and a articular problem . ^ ^ i r e a re two p ro b lem s in the a re a of evaluating. Does this indidual have acquired brain damage from alcoholism, or arteriosclerosis, whatnot ? The firs t one is the problem of the barely literate, dull, norm al r s o n with an IQ of 60 to 70 a s h is n ativ e en d o w m e n t, and the in d iv id u a l v e r y s u p e r i o r in te llig e n c e . You s e e , if you s t a r t off with an IQ of 0 o r 150, and you get som e organic brain dam age that may reduce your 1 by 20 o r 30 p o in ts , you s till m ay be in the high av e ra g e group. So, th e se a re the two a r e a s that we have our m o st trouble with in the tection of acquired organic damage. T here are a few other sim ple m otor tests that m ost physicians can my out, and which will give us an idea of rea ctio n tim e. R em em b er .3 : T h a t an e n g in e e r a t the h e lm of a tr a i n that is tr a v e lin g fro m 60 to m iles an hour has to see and respond appropriately on one railro a d h w hich I a m f a m i lia r about e v e ry 40 to 60 se co n d s. He h as to re s p o n d i : 'al. If he does not have good rea ctio n tim e, of co u rse he is going to be ' s i n g s i g n a l s . P l a y c a t c h w ith h i m . T h i s g iv e s a w o n d e r fu l i d e a o f : -hand reaction time. A nother sim p le thing is to ask him to kick as though he w ere kicking .lotball. The ability to stand on one leg, to get vision and hand and foot ordination ail into one piece is well p re se rv e d in the organically, well. grated individual; and it is not well put together and reaction tim e 1 eye-hand coordination are significantly and seriously im paired in many inics. 1DERATOR OLSON: Dr. Skinner, did you have a com m ent you wanted make ? . SKINNER: I w ill keep it v ery brief, M r. C hairm an. S everal of the m en have ask ed m e about the alcoh ol program on the Great Northern Railway Company. It w as s t a r t e d in 1951, and i t is c o n d u c te d a l m o s t e n tire ly by a social counselor and his wife, working fulltime. In the f i r s t decade, out of I, 224 c a s e s th e r e w ere 750 s a tis f a c to r y r e s u lt s ; 150 indicated no im p ro v e m e n t; and 300 e ith e r died o r w ere d i s m issed. T here a re ju st five item s to which we attribute the success of the program . F irst is vigorous support from top management. Second is early detection, and this includes the wives and fam ilies. Third is the confidential and p erso n al approach. The social coun se lo r sends a confidential re p o rt, which goes only to the president, vicepresident of personnel and operations, and the chief m edical officer. Contacts are made off the com pany property. The tre a tm e n t p ro g ra m , the A lcoholics Anonymous followup, is p e r haps the keystone of the whole p ro g ra m . A fter all, we realize there is no cure, and we m u st also em p h asize the fact that alcoholism is m ore than just drinking too much. R e f e r r a ls to the AA a re entirely on a v o lu n tary basis. I do not think I will go into the r e s t of it except to say that o u r h o s p i tal recovery rate among our em ployees is twice as good as that of the general population. , MODERATOR OLSON: That is excellent. I will ask the other m em bers of the panel, is there any com ment you want to make: 19 t h e r e an y o n e in the a u d i e n c e who w o u ld c a r e to c o m m e n t ? (No response) I am s o r r y that we have not b een ab le to c o v e r a ll of the item s that . w ere proposed, but I hope that what we have done has been of interest and value to you. I do want to thank all of the m e m b e r s of the panel and p a rtic u la rly the two consultants who took the tim e who have contributed so much to the program . '<> Thank you, gentlemen*ly (Applause) and the audience, to com e h e re and to'j have to r c m c m b c that in org an ic brain d ise a se , language, grarn7iar, sy n ta x a r e p r e s e r v e d to the b i t t e r e n d , so to s p e a k ; th a t the ind'ii d u a l 's flow of s p e e c h and his u se of w o rd s m ay be high av e rag e to ;u p e rio r, but his ab ility to think ar.d to d is c rim in a te and to a b s tra c t) as .ell as to c a r r y out con ceptual thinking and to use judgment and fo re ight may be trem en d o u sly im p a ire d in spite of a p retty good vocabulary. If it is a kind of a b o r d e r lin e s itu a tio n , we a r e in the happy c i r c u m tar.ee that I am w here we m ay r e f e r them to a psychologist who can * rry out much m o re detailed tests; and this is one of the areas where ie p sy c h o lo g ist is at h is b e s t - - t h e detection of the thought d is o rd e r; the itellectual deficits; the m em ory im pairm ents; the abstraction deficiencies; ie ju d g m e n t d e fic ie n c ie s of people with o rg a n ic b rain dam age and a articular problem . a re two p ro b lem s in the a re a of evaluating. Does this indi dual have acquired brain damage from alcoholism, or arteriosclerosis, whatnot ? The firs t one is the problem of the barely literate, dull, norm al r s o n with an IQ of 60 to 70 a s h is n ativ e en d o w m e n t, and the in d iv id u a l v e r y s u p e r i o r in te llig e n c e . You s e e , if you s t a r t off with an IQ of 0 o r 150, and you get som e organic brain dam age that may reduce your 1 by 20 o r 30 p o in ts , you s till m ay be in the high av e ra g e group. So, th e se a re the two a r e a s that we have our m o st trouble with in the tection of acquired organic damage. T here are a few other sim ple m otor tests that m ost physicians can my out, and which will give us an idea of rea ctio n tim e. R em em b er .3 : T h a t an e n g in e e r a t the h e lm of a tr a i n that is tr a v e lin g fro m 60 to m iles an hour has to see and respond appropriately on one railro a d h w hich I a m f a m i lia r about e v e ry 40 to 60 se co n d s. He h as to re s p o n d i : 'al. If he does not have good rea ctio n tim e, of co u rse he is going to be ' s i n g s i g n a l s . P l a y c a t c h w ith h i m . T h i s g iv e s a w o n d e r fu l i d e a o f : -hand reaction time. A nother sim p le thing is to ask him to kick as though he w ere kicking .lotball. The ability to stand on one leg, to get vision and hand and foot ordination ail into one piece is well p re se rv e d in the organically, well. grated individual; and it is not well put together and reaction tim e 1 eye-hand coordination are significantly and seriously im paired in many inics. iDERATOR OLSON: Dr. Skinner, did you have a com m ent you wanted make ? . SKINNER: I w i l l keep it v e r y b r ie f, M r. C hairm an. S everal of the m en have ask ed m e about the alcoh ol program on the Great Northern Railway Company. It was s t a r t e d in 1951, and i t is c o n d u c te d a l m o s t e n tire ly by a social counselor and his wife, working fulltime. In th e f i r s t d ecad e, out of 1, 224 c a s e s t h e r e w ere 750 s a tis f a c to r y r e s u lt s ; 150 indicated no im p ro v e m e n t; and 300 e ith e r died o r w ere d i s m issed. T here a re ju st five item s to which we attribute the success of the program . F irst is vigorous support from top management. Second is early detection, and this includes the wives and fam ilies. Third is the confidential and p erso n al approach. The social coun se lo r sends a confidential re p o rt, which goes only to the president, vicepresident of personnel and operations, and the chief m edical officer. Contacts are made off the com pany property. The tre a tm e n t p ro g ra m , the A lcoholics Anonymous followup, is p e r haps the keystone of the whole p ro g ra m . A fter all, we realize there is no cure, and we m u st also em p h asize the fact that alcoholism is m ore than just drinking too much. R e f e r r a ls to the AA a re entirely on a v o lu n tary basis. I do not think I will go into the r e s t of it except to say that o u r h o s p i tal recovery rate among o ur em ployees is twice as good as that of the general population. , MODERATOR OLSON: That is excellent. I will ask the other m em bers of the panel, is there any comment you want to make: IS t h e r e an y o n e in the a u d i e n c e who w o u ld c a r e to c o m m e n t ? (No response) I am s o r r y that we have not b een ab le to c o v e r a ll of the item s that . w ere proposed, but I hope that what we have done has been of interest and value to you. I do want to thank all of the m e m b e r s of the panel and the audience, and p a rtic u la rly the two co n su lta n ts who took the tim e to com e h e r e and who have contributed so much to the p r o g r a m . Thank you, gentlemen* T (Applause) .Tw-liiT 'C C H A I R M A N 7,N E L S O N : I liope that everyone will remain for just a few minutes. U e will bring the meeting quickly to a close. I want to thank D r. O lson, the m em b ers of his panel, and particularly Dr. A very and D r. F o s te r, fo r b ringing to us a new subject, and I am su re we are just touching on it, approaching the field, and it will have to be c o v e red m o re adequately in the future. Dr. M ishler has very kindly m ade some rem ark s regarding my s e t ting up th is p ro g ra m . Of c o u r s e , y o u r C h a irm an has a g re a t d e a l to do with setting the co u rse of your ship during the tenure of his office, and a rran g in g the fo rm a t of y o u r Annual P ro g ra m ; but this is h is job. If you feel that this type of p ro g ram has been worthwhile it m ore than com pen sa tes for the effort expended. I would, however,- like to rem in d you that the work of this o rg a n iz a tion is in co m m ittees, and without th e ir work there just would not be any organization o r any m eeting. P lease keep that in mind when you are com plim enting me about the amount of work that I have done. An im portant feature in this m eeting has been your resp o n se from the audience with the q uestions and re m a rk s which have certainly pepped up the panels. Secondly, the response of m anagem ent. T his was se t up as an in fo rm al m eeting with audience p articip atio n , and you have responded beautifully. I think I can a s s u re you, too, that we have made a su b stan tia l step fo rw ard in reaching so m e s o r t of understand in g with m anagem ent as to what a re our p ro b lem s; how im p o rtan t they are; how we are try in g to r e solve them; som e idea of the im portance of our work; and finally, what our ultim ate position in the railro a d stru ctu re will be, and in the AAR. We h a d e ig h t o r 10 m e m b e r s of the G e n e r a l C o m m i t t e e p r e s e n t d u r in g the firs t day of o ur m eeting. The word will spread well beyond them I . assu re you. This has been a considerable divergence from our previous program . We know now s o m e o f its a d v a n ta g e s and d raw b ac k s. F o r the ed ificatio n of the new C hairm an, would you like, in gen eral, th is type of p ro g ra m in the future ? I would like a few com m ents from the floor as to w hether this type of p ro g ra m has been too long; w hether it has been an education to you; whether you find that it is worthwhile ? DR. KNOWLES: It is an ideal program . ( R e p l i e s o f , " E x c e l l e n t , " a n d , " I a g r e e . ") ~ ~y -/. ~ '' y . ' . - S J l : I m'.W *'c,:i* *ri C h slrrn an ha* (n At th is tim e I would like to thank Bill Todd. All of the details that go into the s e ttin g up of the p r o g r a m and follow ing through a r e h is r e spo n sib ility . I p e rso n a lly do not fee l that we have e v e r had a b e tte r arrangem ent; a better room; and a b etter type of setup for our meeting. Bill, I, and I know everybody h e re , want to thank you for y o u r work. (Applause) T here is one unpleasant task and one pleasant task that I have before me as Unfinished Business. During the la st few months we have lost Dr. Duncan Eve; Dr. A rthur Metz; and in not too long a period of tim e. Dr. Washburn; Dr. Dick Bennett Dr. Ira Goldowski; and Dr. T hurm an Colton. If my re c o llec tio n does not fa il m e , each of these m en at so m e tim e was a chairm an of your group. Would you stand just a m om ent in resp e ct to their m emory ? (In M em oriam ) CHAIRMAN NELSON: I have the m ore pleasant task of announcing som e changes which a re inevitable as we p ro g re ss. Dr. Stanley Cyran, will you stand? Dr. Cyran has been on these p r o g r a m s . He is ta king the p la c e o f D r. Jo h n B r e w s t e r , a s M edical D ir e c t o r of the Pennsylvania Railroad. You all know D r. P e t e r V aughan. H e, too, h a s b een on th e se p r o gram s. P eter Vaughan is not yet officially the Medical D irector of the Canadian National. i Our good friend, Ken Dowd, h as officially resig n e d as of A p ril 1st, but in the usual m anner of a r a ilro a d m an, he is taking his last month for a vacation, and with his usu al resp ect for everybody's feelings he refu sed to com e to this m eeting and asked D r. Vaughan to attend. C hester Z e iss, you have big sh oes to fill in replacing our very e x cellent prior Chairman, Dr. Dick Bennett. Thank you for coming. (Applause) And fin ally, Frank Mahoney, is taking the p lace o f Dr. Ira Goldowski, of the Central New J ersey, and you all know him very well. That is all I have under the Unfinished B usiness. Is th ere any oth er U nfinished B u sin e ss before we go on to New B u si ness ? (Ni r r s p o n n e ) CHAIRMAN7, N E L S O N : I liope that everyone will remain f o r j u s t a few minutes. U e will bring the meeting quickly to a close. I want to thank D r. Olson, the m e m b ers of his panel, and particularly Dr. A very and D r. F o s te r, fo r b ringing to us a new subject, and I am su re we are just touching on it, approaching the field, and it will have to be c o v e red m o re adequately in the future. Dr. M ishler has very kindly m ade some rem ark s regarding my s e t ting up th is p ro g ra m . Of c o u r s e , y o u r C h a irm an has a g re a t d e a l to do with setting the co u rse of your ship during the tenure of his office, and a rran g in g the fo rm a t of y o u r Annual P ro g ra m ; but this is h is job. If you feel that this type of p ro g ram has been worthwhile it m ore than com pen sa tes for the effort expended. I would, however,- like to rem in d you that the work of this o rg a n iz a tion is in co m m ittees, and without th e ir work there just would not be any organization o r any m eeting. P lease keep that in mind when you are com plim enting me about the amount of work that I have done. An im portant feature in this m eeting has been your resp o n se from the audience with the q uestions and re m a rk s which have certainly pepped up the panels. Secondly, the response of m anagem ent. T his was se t up as an in fo rm al m eeting with audience p articip atio n , and you have responded beautifully. I think I can a s s u re you, too, that we have made a su b stan tia l step fo rw ard in reaching so m e s o r t of understand in g with m anagem ent as to what a re our p ro b lem s; how im p o rtan t they are; how we are try in g to r e solve them; som e idea of the im portance of our work; and finally, what our ultim ate position in the railro a d stru ctu re will be, and in the AAR. We h a d e ig h t o r 10 m e m b e r s of the G e n e r a l C o m m i t t e e p r e s e n t d u r in g the firs t day of o ur m eeting. The word will spread well beyond them I . a ssu re you. This has been a considerable divergence from our previous program . We know now s o m e o f its a d v a n ta g e s and d raw b ac k s. F o r the ed ificatio n of the new C hairm an, would you like, in gen eral, this type of p ro g ra m in the future ? I would like a few com m ents fro m the floor as to w hether this type of p ro g ra m has been too long; w hether it has been an education to you; whether you find that it is worthwhile ? DR. KNOWLES: It is an ideal program . ( R e p l i e s o f , " E x c e l l e n t , " a n d , " I a g r e e . ") ~ ~y ',r,; ,, W * : I ''.II ik ci* Chairm an t hat In At th is tim e I would like to thank Bill Todd. All of the details that go into the se ttin g up of the p r o g r a m and follow ing through a r e his r e spo n sib ility . I p e rso n a lly do not fee l that we have e v e r had a b e tte r arrangem ent; a better room; and a b etter type of setup for our meeting. Bill, I, and I know everybody h e re , want to thank you for y o u r work. (Applause) T here is one unpleasant task and one pleasant task that I have before me as Unfinished Business. During the last few months we have lost Dr. Duncan Eve; Dr. A rthur Metz; and in not too long a period of tim e. Dr. Washburn; Dr. Dick Bennett Dr. Ira Goldowski; and Dr. T hurm an Colton. If my re c o llec tio n does not fa il m e , each of these m en at so m e tim e was a chairm an of your group. Would you stand just a m om ent in resp e ct to their m emory ? (In M em oriam ) CHAIRMAN NELSON; I have the m ore pleasant task of announcing som e changes which a re inevitable as we p ro g re ss. Dr. Stanley Cyran, will you stand? Dr. Cyran has been on these p r o g r a m s . He is ta k in g the p l a c e o f D r . J o h n B r e w s t e r , a s M edical D i r e c t o r of the Pennsylvania Railroad. You all know D r. P e te r Vaughan. He, too, h a s been on these p r o gram s. P eter Vaughan is not yet officially the Medical D irector of the Canadian National, i Our good friend, Ken Dowd, h as officially resig n e d as of A p ril 1st, but in the usual m anner of a r a ilro a d m an, he is taking his last month for a vacation, and with his u su al resp e ct for everybody's feelings he refu sed to com e to this m eeting and asked D r. Vaughan to attend. C h e ste r Z e iss, you have big shoes to fill in replacin g ou r v ery e x cellent prio r Chairm an, Dr. Dick Bennett. Thank you for coming. (Applause) And finally, F rank Mahoney, is taking the place of Dr. Ira Goldowski, of the C en tral New J e rse y , and you all know him very well. That is all I have under the Unfinished Business. Is th e re any o th e r U nfinished B u sin e ss b efo re we go on to New B u s i ness ? The New B usiness will be ra th e r sh o rt. I have a resolution which was drawn up by m em b ers of our group, and I am grateful to Dr. Ralph Johnson for following through on this. The resolution reads as follows: " W h e re a s , K enneth A. C a rn e y h as devoted (exactly the right word) many y ears of service as D irector of the Claim s R esearch Bureau of ' the AAR; and I " "W hereas, His able assistance and advice, his ready and cheerful cooperation with the officers and m em bers of the M edical and Surgical A dvisory C om m ittee has appreciably expedited its work; and "W h e re a s, His devotion to the p rin cip les of good m edicine and r a i l ro a d a ffairs as well as his profound understanding of the clinical aspects of patient-em ployee care have avoided problem s that might otherwise have occurred; and "W h erea s, Air. C arney, affectionately known as 'Ken' to us a ll is soon to r e t i r e , this is his last official p articipatio n in our proceedings and it does se e m re tire e s a re getting younger all the time; now, th e r e fo re , be it RESOLVED: That the best wishes of the Medical and Surgical A d v is o ry C om m ittee in Annual Session assem b led be afforded him by the adoption of this resolution which exp resses our abiding respect and r e gard. " I would like to r e c e iv e a m otion to the effec t that we unanim ously a c cept this resolution. DR. WIGHT; I so m ove. (The motion was severally seconded.) CHAIRMAN NELSON: I will declare the motion seconded and unanimously carried. U nfortunately, M r. C arney was not able to be h ere. I think his wife becam e ill. She has not been very welL We w ill, how ever, fo rw ard this to him . I would like to m ake one additional recom m en d atio n , and that is that he be made an honorary and perennial m em b er of our group and be so notified of all the meetings that we have. DR. LEIGH: I w ill so m ove. DR, WIGHT: 1 w ill second the m otion. CHAIRMAN NELSON: The motion having been m ade and seconded, the C h air will indicate that this be included with the resolution that is to be sent to M r. Carney. At the M edical and Surgical Advisory C om m ittee meeting held y e s terday, after our proceedings the question of the location and the time of o u r next Annual M eeting was brought up. I a m only mentioning it at th is tim e. If th e r e is anyone who h a s any p r e f e r e n c e as to w here the m eeting should be held, I wish they would s p e 3 k u p at this tim e so as to assist our new Chairman. DR. WIGHT: I think it is only fa ir to sa y that th is was d iscussed at length, and it was felt that inasm uch as all the p re lim in a ry work had been done rela tiv e to o u r going to Las V egas, that due consideration should be- U given to that place next year. CHAIRMAN NELSON: Are there any other co m m en ts? DR. KNOWLES: I would like to say becau se of the p ro b lem s of other m e e tin g s the situ atio n has becom e so m e w h at a c u te . I w onder if we should go back and m eet just previous to the m eetin g of the su rg eo n s, which I un d ersta n d will follow in about two weeks o r th ree w eeks here in Chicago; o r, w hether we should pro ceed to m e et p r io r to the. A m erican Medical A s s o c i a t i o n m e etin g , so that we h a v e th e o p p o rtu n ity of attending two m eetings at the sam e tim e. I think that is a thought that should be con sidered. CHAIRMAN NELSON: D oes it m e e t with y o u r a p p r o v a l to leave th is up to the M edical and Surgical A dvisory C o m m ittee; and if they so feel in clined, to the S teering C om m ittee that D r. O lson will se le c t? DR. WIGHT: T h ere is just one re m a rk I think should be made apropos of D r. Knowles' suggestion. If we tie in d ire c tly o r indirectly with eith er of th e se m eetings, it will m ean that we w ill be absent for a prolonged p erio d of tim e; and two s h o r te r a b sen c es a re p re fe ra b le to one long one. CHAIRMAN NELSON: I might com m ent on this a little further. This was d isc u sse d in som e d egree. T h e re was d isc u sse d the question of the length of the m eeting. It was felt that th ree days w ere enough; that if you went beyond the th ree days it would take the en tire week. Inasm uch as we are thinking in te rm s of going back to a reso rt, and we have no re a so n fo r not thinking that way, I do not think we could v e ry w ell have an adequate m e etin g in le s s than th r e e d a y s , assu m in g we allow a little time for some recreation. As to the tim e, th ere are a num ber of facto rs. Dr. Knowles, that have to be considered. T h ere a r e a n u m b e r of m eetings that we have to dovetail in with, and the question of w eath er is a facto r, also. So, if we could leave it up to the M edical and S urgical A dvisory Com m ittee, and the S teering C om m ittee, 1 am su re they w ill con sid er all of your thinking. i V ' The New B usiness will be ra th e r sh o rt. I have a resolution which was drawn up by m em b ers of our group, and I am grateful to Dr. Ralph Johnson for following through on this. The resolution reads as follows: " W h e re a s , K enneth A. C a rn e y h as devoted (exactly the right word) many y e a rs of serv ice as D irecto r of the C laim s R esearch Bureau of ' the AAR; and ,, t I " "W hereas, His able assistance and advice, his ready and cheerful cooperation with the officers and m em bers of the M edical and Surgical A dvisory C om m ittee has appreciably expedited its work; and "W h e re a s, His devotion to the p rin cip les of good m edicine and r a i l ro a d a ffairs as well as his profound understanding of the clinical aspects of patient-em ployee care have avoided problem s that might otherwise have occurred; and "W h e re a s, Air. C arney, affectionately known as 'Ken' to us a ll is soon to r e t i r e , this is his last official p articipatio n in our proceedings and it does se e m re tire e s a re getting younger all the time; now, th e r e fo re , be it RESOLVED: That the best wishes of the Medical and Surgical A d v is o ry C om m ittee in Annual Session assem b led be afforded him by the adoption of this resolution which exp resses our abiding respect and r e gard. " I would like to r e c e iv e a m otion to the effec t that we unanim ously a c cept this resolution. DR. WIGHT; I so m ove. (The motion was severally seconded.) ' CHAIRMAN NELSON: I will declare the motion seconded and unanimously carried. U nfortunately, M r. C arney was not able to be h ere. I think his wife becam e ill. She has not been very welL We will, how ever, forw ard this to him . I would like to make one additional recom m endation, and that is that he be made an honorary and perennial m em b er of our group and be so notified of all the meetings that we have. DR. LEIGH: I will so move. DR. WIGHT: 1 will second the motion. CHAIRMAN NELSON: The motion having been m ade and seconded, the C h air will indicate that this be included with the resolution that is to be sent to M r. Carney. At the M edical and Surgical Advisory C om m ittee meeting held y e s terday, after our proceedings the question of the location and the time of o u r next Annual M eeting was brought up. I a m only mentioning it at th is tim e. If th e r e is anyone who h a s any p r e f e r e n c e as to w here the m eeting should be held, I wish they would spe3k up at this tim e so as to assist our new Chairman. DR. WIGHT: I think it is only fa ir to sa y that th is was d iscussed at length, and it was felt that inasm uch as all the p re lim in a ry work had been done rela tiv e to o u r going to Las V egas, that due consideration should be- U given to that place next year. CHAIRMAN NELSON: Are there any other com m ents ? DR. KNOWLES: I would like to say becau se of the p ro b lem s of other m e e tin g s the situ atio n has becom e so m e w h at a c u te . I w onder if we should go back and m eet just previous to the m eetin g of the su rg eo n s, which I un d ersta n d will follow in about two weeks o r th ree w eeks here in Chicago; o r, w hether we should pro ceed to m e et p r io r to the. A m erican Medical A s s o c ia tio n m e etin g , so that we h a v e th e o p p o rtu n ity of attending two m eetings at the sam e tim e. I think that is a thought that should be con sidered. CHAIRMAN NELSON: D oes it m e e t with y o u r a p p r o v a l to leave th is up to the M edical and Surgical A dvisory C o m m ittee; and if they so feel in clined, to the S teering C om m ittee that D r. O lson will se le c t? DR. WIGHT: T h ere is just one re m a rk I think should be made apropos of D r. Knowles' suggestion. If we tie in d ire c tly o r indirectly with eith er of th e se m eetings, it will m ean that we w ill be absent for a prolonged p erio d of tim e; and two s h o r te r a b sen c es a re p re fe ra b le to one long one. CHAIRMAN NELSON: I might com m ent on this a little further. This was d isc u sse d in som e d egree. T h e re was d isc u sse d the question of the length of the m eeting. It was felt that th ree days w ere enough; that if you went beyond the th ree days it would take the en tire week. Inasm uch as we are thinking in te rm s of going back to a reso rt, and we have no re a so n fo r not thinking that way, I do not think we could v e ry w ell have an adequate m e etin g in le s s than th r e e d a y s , assu m in g we allow a little time for some recreation. As to the tim e, th ere are a num ber of facto rs. Dr. Knowles, that have to be considered. T h ere a r e a n u m b e r of m eetings that we have to dovetail in with, and the question of w eath er is a facto r, also. So, if we could leave i t up to the M edical and S u rg ic al A dvisory C om m ittee, and the S teering C om m ittee, I am sure they w ill con sid er all of your thinking. . i V ' So, it is with a feeling of a letdown aiter the p resen t effort I have had directing your activities, but adm ittedly with a considerable feeling of re lie f, that I com e to my last p le asa n t duty as C hairm an. I will ask Dr. Milton Clayton and Dr. R obert G raham to escort our new C h a irm an to the podium . T h is election took p lace y e sterd ay a f te r noon. I p resu m e some of you know what has happened, but this is a form ality that we usually.like to conduct. With his c u s to m a ry hum ility , he has attem pted to com e in the back door. Your new C hairm an, Dr. E rn est Olson, is a person of considerable a b ility . He d e p re c ia te s it h im s e lf, but I c e rta in ly do not. I know his capabilities. E rn ie, h ere is the gavel, and with that, I ask that you introduce your new V ice-Chairm an. (Presentation of Gavel - A pplause.) (Dr. E rn e st Olson assum ed the C hair.) CHAIRMAN OLSON: Gentlem en, I am greatly com plim ented that you have ex p ressed this confidence in m e. I feel that it is going to be a bit difficult to m e a su re up to the kind of a p ro g ra m that D r. N elson has p rep ared for you; but if you can a s s u r e me of y o u r help I will c e rta in ly do m y best. Again, I want to thank you m ost sincerely. Dr. Winston, please, front and center. I understand he has had lots of tim e to p re p a re a speech, so, gentlem en, it gives me great pleasure to p rese n t the new V ice-C hairm an, D r. John Winston. (Applause) DR. WINSTON: I did p r e p a re a s p e e c h --th a n k you v ery much. (Applause) CHAIRMAN OLSON: That concludes o u r pro g ram . We stand ad jo u rn e d . (The meeting adjourned at twelve-thirty o'clock.) i ' it i ATTENDANCE r ATCHISON. TOPEKA & SANTA F E RAILWAY | J. R. Winston, M. D ., System. M edical D irecto r, Chicago, Illinois. D. D. B aird, Superintendent of Safety, C h icag o , Illinois. ! 0 . L. Hanson, M. D. , Chief Surgeon, T opeka, Kansas. ! R. D. Shelton, Vice P re sid e n t O perations, Chicago, Illinois. Gus Svolos, A ssistant G eneral Attorney, Chicago, Illinois. ATLANTIC COAST LINE RAILROAD B. W. R a w le s , J r . , M. D. , C h ie f S u r g e o n , R ic h m o n d , V i r g in ia . G. T. F airclo th , Division C laim Agent, Jackso n v ille, Florida. E. N. Z eig ler, G en eral C laim s A ttorney, Jack so n v ille, F lo rid a . BALTIM ORE & OHIO RAILROAD 1. K ap la n , M. D. , M e d i c a l & S u r g i c a l D i r e c t o r , B a l t i m o r e , M a r y Ian... G. M. C a ro u g e , M. D. , A s s is t a n t M e d ica l and S u rg ic a l D ir e c to r , Baltim ore, Ohio. M. M .-H oag, N u rs e , Chicago, Illinois E. L. Reeves, Superintendent, Chicago, Illinois. BELT RAILWAY COMPANY OF CHICAGO C. Maloney, G eneral Claim Agent, Chicago, Illinois. BOSTON & MAINE RAILROAD " - J. R. K n o w les, M. D . , C h ie f S u rg e o n , B o s to n , M a s s a c h u s e tts . CANADIAN NATIONAL RAILWAYS P e t e r Vaughan, M. D . , A s s is ta n t C h ief M e d ica l O fficer, M ontreal, Que. , Canada. S. F . D ingle, S y s te m V ice P r e s i d e n t , M o n t r e a l , Q u e . , C anada. t CANADIAN PACIFIC RAILWAY G. E a rle Wight, M. D, , C h ief of M e d ic a l S e r v ic e s , M ontreal, Q u e / ^ Canada. CENTRAL OF GEORGIA - SAVANNAH & ATLANTA RAILWAY J . G. S h a r p le y , M. D. , C h ie f S u rg e o n , S a v a n n a h , G eorgia. CENTRAL RAILROAD COMPANY OF NEW JERSEY F . W. M a h o n e y , M . D. , M e d i c a l D i r e c t o r , J e r s e y C ity , New J e r s e y . CHESAPEAKE & OHIO RAILWAY R. R. Brandon, M. D. , C hief M ed ical E x a m in e r , Virginia. J. J. Smole, Special R epresentative, Huntington, R. A. S traub, G e n e ra l C la im s A ttorney, D e tro it, Huntington, West West Virginia. Michigan. CHICAGO U NORTH WESTERN RAILWAY W. H. K e lly , C e n c r a l C l a i m s A t t o r n e y , C h i c a g o , niinoi:i. 271 So, it is with a feeling of a letdown aiter the p resen t effort I have had directing your activities, but adm ittedly with a considerable feeling of re lie f, that I com e to my last p le asa n t duty as C hairm an. I will ask Dr. Milton Clayton and Dr. R obert G raham to escort our new C h a irm an to the podium . T h is election took p lace y e sterd ay a f te r noon. I p resu m e some of you know what has happened, but this is a form ality that we usually.like to conduct. With his c u s to m a ry hum ility , he has attem pted to com e in the back door. Your new C hairm an, Dr. E rn est Olson, is a person of considerable a b ility . He d e p re c ia te s it h im s e lf, but I c e rta in ly do not. I know his capabilities. E rn ie, h ere is the gavel, and with that, I ask that you introduce your new V ice-Chairm an. (Presentation of Gavel - A pplause.) (Dr. E rn e st Olson assum ed the C hair.) CHAIRMAN OLSON: Gentlem en, I am greatly com plim ented that you have ex p ressed this confidence in m e. I feel that it is going to be a bit difficult to m e a su re up to the kind of a p ro g ra m that D r. N elson has p rep ared for you; but if you can a s s u r e me of y o u r help I will c e rta in ly do m y best. Again, I want to thank you m ost sincerely. Dr. Winston, please, front and center. I understand he has had lots of tim e to p re p a re a speech, so, gentlem en, it gives me great pleasure to p rese n t the new V ice-C hairm an, D r. John Winston. (Applause) DR. WINSTON: I did p r e p a re a s p e e c h --th a n k you v ery much. (Applause) CHAIRMAN OLSON: That concludes o u r pro g ram . We stand ad jo u rn e d . (The meeting adjourned at twelve-thirty o'clock.) i ' ti i ATTENDANCE r ATCHISON, TOPEKA & SANTA F E RAILWAY | J. R. Winston, M. D ., System. M edical D irec to r, Chicago, Illinois. D. D. B aird, Superintendent of Safety, C h icag o , Illinois. ! 0 . L. Hanson, M. D. , Chief Surgeon, T opeka, Kansas. ! R. D. Shelton, Vice P r e s id e n t O p eratio n s, C hicago, Illinois. Gus Svolos, A ssistant G eneral Attorney, Chicago, Illinois. ATLANTIC COAST LINE RAILROAD B. W. R a w le s , J r . , M. D. , C h ie f S u r g e o n , R i c h m o n d , V i r g in ia . G. T. F airclo th , Division C laim Agent, Jack so n v ille, Florida. E. N. Z eig ler, G en e ra l C laim s A ttorney, Jack so n v ille, F lo rid a . BALTIMORE & OHIO RAILROAD 1. K a p la n , M. D. , M e d i c a l & S u r g i c a l D i r e c t o r , B a l t i m o r e , M a ry la n ... G. M. C a ro u g e , M. D. , A s s is t a n t M e d ica l and S u rg ic a l D ir e c to r , Baltim ore, Ohio. M. M .-H oag, N u rs e , C hicago, Illinois E. L. Reeves, Superintendent, Chicago, Illinois. BELT RAILWAY COMPANY OF CHICAGO C. Maloney, G eneral Claim Agent, Chicago, Illinois. BOSTON & MAINE RAILROAD " - J. R. K n o w les, M. D . , C h ie f S u rg e o n , B o s to n , M a s s a c h u s e tts . CANADIAN NATIONAL RAILWAYS P e t e r Vaughan, M. D . , A s s is ta n t C h ief M e d ica l O fficer, M ontreal, Que. , Canada. S. F . D ingle, S y s te m V ice P r e s i d e n t , M o n tr e a l, Q u e . , Canada. t CANADIAN PACIFIC RAILWAY G. E a rle Wight, M. D, , C h ief of M e d ic a l S e r v ic e s , M ontreal, Q u e / ^ Canada. CENTRAL OF GEORGIA - SAVANNAH & ATLANTA RAILWAY J . G. S h a r p le y , M. D. , C h ie f S u rg e o n , S a v a n n a h , G eorgia. CENTRAL RAILROAD COMPANY OF NEW JERSEY F . W. M a h o n ey , M . D. , M e d i c a l D i r e c t o r , J e r s e y C ity , Now J e r s e y . CHESAPEAKE & OHIO RAILWAY R. R. Brandon, M. D. , C hief M ed ical E x a m in e r , Virginia. J. J. Smole, Special R epresentative, Huntington, R. A. S traub, G e n e ra l C laim s A ttorney, D e tro it, Huntington, West West Virginia. Michigan. CHICAGO U NORTH WESTERN RAILWAY W. H, K elly , C e n c r a l C l a i m A t t o r n e y , C h i c a g o , n iinoi:i. 271 CHICAGO, BURLINGTON & QUINCY RAILROAD H. W. H a m m a t t , M. D. , C h i e f M e d i c a l O f f i c e r , C h i c a g o . I llin o is . E . D. K r a m e r , G e n e r a l A d j u s t e r , C h ic a g o , I llin o is . C H IC A G O , M I L W A U K E E , ST. P A U L &. P A C I F I C R A IL R O A D R. H o u s e h o ld e r , M. D. , C h ie f S u rg e o n , L in e s E a s t . , C h ica g o , Illinois. F. G. McGinn, V ice P re s id e n t O p eratio n s, C hicago, Illinois. J. A. Jakubec, A ssistan t to Vice P re sid en t O perations, Chicago, Illinois. I CHICAGO, ROCK ISLAND & PACIFIC RAILROAD J. M. L . Je n sen , M. D. , Chief Surgeon, Chicago, Illinois. CHICAGO SOUTH SHORE & SOUTH BEND RAILROAD H. L. F e h n e r, G en e ra l A ttorney, M ichigan City, Indiana. CINCINNATI, NEW ORLEANS & TEXAS PACIFIC RAILROAD R. G. C a r o t h e r s , M. D. , C hief Surgeon, C incinnati, Ohio. COLORADO & SOUTHERN RAILWAY W. J . Longev/ay, M. D. , C hief Surgeon, D en v e r, C olorado. DULUTH, MISSABE & IRON RANGE RAILWAY H. J . M e y e r , M. D. , C h i e f S u r g e o n , D u lu th , M in n e s o ta . R. M. Downes, D irec to r of Safety & P lant P ro te ctio n , P ro c to r, M innesota. ELGIN, JOLIET & EASTERN RAILWAY C . R. Z e i s s , M. D. , C h i e f S u r g e o n , C h i c a g o , I l l i n o i s . ERIE-LACKAWANNA RAILROAD W. E . M i s h l e r , M. D. , C h i e f S u r g e o n , C l e v e l a n d , O hio. FORT WORTH & DENVER RAILWAY W. _P__ H ig g in s , M. D. , C h i e f S u r g e o n , F o r t W o r th , T e x a s . dRAND TRUNK WESTERN RAILROAD \ B . , W. S t o c k w e l l , M. D . , C h i e f S u rg e o n , D e t r o i t , M ic h ig a n . H>-A,_Sander$, Vice P resident & G eneral M anager, D etroit, Michigan. GREAT NORTHERN RAILWAY A. Skinner, M .D ., Chief M edical O fficer, St. P aul, M innesota. ILLINOIS CENTRAL RAILROAD E . C . O ls o n , M. D. , C h i e f S u r g e o n , C h ic a g o , Illin o i s . L. W. A v ery , C onsulting N e u ro p s y c h ia tris t, C hicago, Illin o is . O. H. Z im m erm an , Vice P re s id e n t O perations, Chicago, Illinois. E. O liver, Vice P resid en t - P erso n n el, Chicago, Illinois. E. Buelow, General M anager, Chicago, Illinois. W. R. H ovious, C hief C la im A g en t, C h ic a g o , Illin o is. R. R. M inor, General Claim Agent, Chicago, Illinois. MISSOURI PACIFIC HOSPITAL J. A. L e m b e c k , M. D. , C h ief M e d ic a l E x a m i n e r , St. L ouis, M issouri. JAPANESE NATIONAL RAILWAYS K atsum i Kaneko, Chief of Internal Medicine, Tokyo, Japan. KANSAS CITY TERMINAL RAILWAY G. O w ens, M. D. , C h ie f S u rg e o n , K a n s a s C ity , M is s o u ri. LEHIGH VALLEY RAILROAD J. S. N iles, J r . , M. D . , C hief Surgeon, S a y re , P ennsylvania. LONG ISLAND RAIL ROAD V. C apozzi, M. D . , Chief M edical E x am in er, Ja m aica, New York. LOUISVILLE & NASHVILLE RAILROAD A. J. Sutherland, M .D ., D istrict Surgeon, N ashviUe, Tennessee. C. S. Sanderson, Vice P resid en t & G eneral M anager, Louisville, Kentucky. C. Buffington, D istrict Claim s Agent, Birm ingham , Alabama. MISSOURI-KANSAS-TEXAS RAILROAD R. S. K ieffer, M. D . , M ed ical D ire c to r, St. L o u is, M issouri. MONON RAILROAD J . R. H in e s , M. D. , C h i e f S u r g e o n , C h i c a g o , I l l i n o i s . MISSOURI PACIFIC RAILROAD J. M. L. Jensen, M.D. , C hief C onsulting M edical O fficer, St. Louis, M issouri. NEW YORK CENTRAL SYSTEM i R . A. J o h n s o n , M. D. , M e d i c a l D i r e c t o r , D e t r o i t , M ic h ig a n . E . A. H a m i lto n , M. D. , C h i e f S u r g e o n , C h i c a g o , I llin o is . R. I. H u n te r , C h ief C l a i m A gent, C h ic a g o , I llin o i s . M. N. Ray, G eneral C laim s A ttorney, New Y ork, New York. J. T . Lynch, A ssistant to G en eral C laim s A ttorney, New York, York. New NORFOLK & WESTERN RAILWAY J. W.-Houk, M. D ., M edical D ire c to r - System , Roanoke, Virginia. J . K. H u m p h rie s, M. D ., A s s is t a n t M e d ic a l D i r e c t o r , Roanoke, Virginia. C. M. Benage, M. D ., Regional M edical D irecto r, St. Louis, M issouri. W. T . R o s s, G en eral M an ag er T ra n s p o rta tio n , Roanoke, V irginia. J. F. Jam ison, G eneral C laim Agent, Roanoke, Virginia. NORTHERN PACIFIC RAILWAY A. McEwan, M, D , , C hief Surgeon, St. P aul, M innesota. 223 CHICAGO, BURLINGTON & QUINCY RAILROAD H. W. H a m m a t t , M. D. , C h i e f M e d i c a l O f f i c e r , C h i c a g o . I llin o is . E . D. K r a m e r , G e n e r a l A d j u s t e r , C h ic a g o , I llin o is . C H IC A G O , M I L W A U K E E , ST. P A U L &. P A C I F I C R A IL R O A D R. H o u s e h o ld e r , M. D. , C h ie f S u rg e o n , L in e s E a s t . , C h ica g o , Illinois. F. G. McGinn, V ice P re s id e n t O p eratio n s, C hicago, Illinois. J. A. Jakubec, A ssistan t to Vice P re sid en t O perations, Chicago, Illinois. I CHICAGO, ROCK ISLAND & PACIFIC RAILROAD J. M. L . Je n sen , M. D. , Chief Surgeon, Chicago, Illinois. CHICAGO SOUTH SHORE & SOUTH BEND RAILROAD H. L. F e h n e r, G en e ra l A ttorney, M ichigan City, Indiana. CINCINNATI, NEW ORLEANS & TEXAS PACIFIC RAILROAD R. G. C a r o t h e r s , M. D. , C hief Surgeon, C incinnati, Ohio. COLORADO & SOUTHERN RAILWAY W. J . Longev/ay, M. D. , C hief Surgeon, D en v e r, C olorado. DULUTH, MISSABE & IRON RANGE RAILWAY H. J . M e y e r , M. D. , C h i e f S u r g e o n , D u lu th , M in n e s o ta . R. M. Downes, D irec to r of Safety & P lant P ro te ctio n , P ro c to r, M innesota. ELGIN, JOLIET & EASTERN RAILWAY C . R. Z e i s s , M. D. , C h i e f S u r g e o n , C h i c a g o , I l l i n o i s . ERIE-LACKAWANNA RAILROAD W. E . M i s h l e r , M. D. , C h i e f S u r g e o n , C l e v e l a n d , O hio. FORT WORTH & DENVER RAILWAY W. _P__ H ig g in s , M. D. , C h i e f S u r g e o n , F o r t W o r th , T e x a s . dRAND TRUNK WESTERN RAILROAD \ B . , W. S t o c k w e l l , M. D . , C h i e f S u rg e o n , D e t r o i t , M ic h ig a n . H>-A,_Sander$, Vice P resident & G eneral M anager, D etroit, Michigan. GREAT NORTHERN RAILWAY A. Skinner, M .D ., Chief M edical O fficer, St. P aul, M innesota. ILLINOIS CENTRAL RAILROAD E . C . O ls o n , M. D. , C h i e f S u r g e o n , C h ic a g o , Illin o i s . L. W. A v ery , C onsulting N e u ro p s y c h ia tris t, C hicago, Illin o is . O. H. Z im m erm an , Vice P re s id e n t O perations, Chicago, Illinois. E. O liver, Vice P resid en t - P erso n n el, Chicago, Illinois. E. Buelow, General M anager, Chicago, Illinois. W. R. H ovious, C hief C la im A g en t, C h ic a g o , Illin o is. R. R. M inor, General Claim Agent, Chicago, Illinois. MISSOURI PACIFIC HOSPITAL J . A. L e m b e c k , M. D. , C h ief M e d ic a l E x a m i n e r , St. L ouis, M issouri. JAPANESE NATIONAL RAILWAYS K atsum i Kaneko, Chief of Internal Medicine, Tokyo, Japan. ; KANSAS CITY TERMINAL RAILWAY G. O w ens, M. D. , C h ie f S u rg e o n , K a n s a s C ity , M is s o u ri. LEHIGH VALLEY RAILROAD J. S. N iles, J r . , M. D . , C hief Surgeon, S a y re , P ennsylvania. LONG ISLAND RAIL ROAD V. C apozzi, M. D . , Chief M edical E x am in er, Ja m aica, New York. ; LOUISVILLE & NASHVILLE RAILROAD A. J. Sutherland, M .D ., D istrict Surgeon, N ashville, Tennessee. C. S. Sanderson, Vice P resid en t & G eneral M anager, Louisville, Kentucky. C. Buffington, D istrict C laim s Agent, Birm ingham , Alabama. MISSOURI-KANSAS-TEXAS RAILROAD R. S. K ieffer, M. D . , M ed ical D ire c to r, St. L o u is, M issouri. MONON RAILROAD J . R. H in e s , M. D. , C h i e f S u r g e o n , C h i c a g o , I l l i n o i s . MISSOURI PACIFIC RAILROAD J. M. L. Jensen, M.D. , C hief C onsulting M edical O fficer, St. Louis, M issouri. NEW YORK CENTRAL SYSTEM i R. A. J o h n s o n , M. D. , M e d ic a l D i r e c t o r , D e t r o i t , M ic h ig a n . E . A. H a m i lto n , M. D. , C h i e f S u r g e o n , C h i c a g o , I llin o i s . R. I. H u n te r , C h ief C l a i m A gent, C h ic a g o , I llin o i s . M. N. Ray, G eneral C laim s A ttorney, New Y ork, New York. J. T . Lynch, A ssistan t to G en e ra l C laim s A ttorney, New York, York. ^ New NORFOLK & WESTERN RAILWAY J. W.-Houk, M. D ., M edical D ire c to r - S ystem , Roanoke, V irginia. J. K. H um phries, M. D . , A ssistan t M edical D ir e c to r, Roanoke, Virginia. C. M. Benage, M. D ., Regional M edical D irecto r, St. Louis, M issouri. W. T . R o s s, G en eral M an ag er T ra n s p o rta tio n , Roanoke, V irginia. J. F. Jam ison, G eneral C laim Agent, Roanoke, Virginia. N O R T H E R N P A C IF IC RAILWAY A. M cEw an, M, D , , Chief Surgeon, St. P a u l, M innesota. 223 I r G. M. de L a m b e rt, D ire c to r of P e rso n n e l, St. P aul, M innesota. K. W. Jo h n so n , G e n e ra l C la im A gent, St. P au l, M innesota. PENNSYLVANIA RAILROAD S. J . C y r a n , M. D. , M e d ic a l D i r e c t o r , P h ila d e lp h ia , P e n n sy lv a n ia . J. D. T h o r n t o n , M. D. , R e g io n a l M e d ic a l O ffic e r, C h icago, Illinois. G. C. F la n d e rs , Chief C laim A.gent, Chicago, Illinois. H. H. H all, C hief C la im A gent, P i t t s b u r g h , P ennsylvania. W. H. T u r n e r , C la im A gent, C o lu m b u s, Ohio. A. M. H a rris, G eneral M anager Transportation, Philadelphia, Pennsylvania. T. F. Schaekel, Manager C ar Service Rcords, Philadelphia, Pennsylvania. P E O R IA & PEK IN UNION RAILWAY R. M. Sutton, M. D ., Chief Surgeon, P eo ria, Illinois. P I T T S B U R G H &. L A K E E R I E R A IL R O A D A. H. W i n t e r s , M. D. , C h i e f S u r g e o n , P i t t s b u r g h , P e n n s y l v a n i a . TH E PULLMAN COMPANY R . M. G r a h a m , M. D. , D i r e c t o r , Illinois. Medicine & Sanitation, Chicago, RICHMOND, FREDERICKSBURG & POTOMAC RAILROAD B. W. R a w les, S r. , M. D . , C hief Surgeon, Richm ond, V irginia. ST. LOUIS-SAN FRANCISCO RAILWAY V. W. H o llo , M. D. , C h i e f S u r g e o n , St. L o u is , M i s s o u r i . SEABOARD AIR LINE RAILROAD S o u th g a te L eig h , J r . , M. D. , C h ie f S u rg e o n , R ich m o n d , V irg in ia . S a m H. M c G u irt, S u p e r v is in g C l a i m A gent, R ichm ond, V irg in ia . SOO LINE RAILROAD H arv ey N elso n , M. D ., M edical A d v iso r, M inneapolis, M innesota. F . F . W i p p e r m a n n , M. D. , O c u l i s t , M in n e a p o l is , M in n e s o ta . D. L. E o rch ert, D irector of P erso n n el, M inneapolis, Minnesota. E . M. C lennon, A ttorney, M inneapolis, M innesota. E . A. Je n se n , G en e ra l C laim A ttorney, M inneapolis, M innesota. SOUTHERN RAILWAY M. B. C l a y t o n , M. D . , C h i e f S u r g e o n , W a s h in g to n , D. C. SOUTHERN PACIFIC COMPANY V. M. S tra n g e , M. D ., C hief S u rg eo n , San F ra n c is c o , C alifo rn ia. W. D. L am p re c h t, Vice P re s id e n t O p eratio n s, San F ra n c isc o , C a lifo rn ia. S. B . B u rto n , A s s t. G e n e r a l M a n a g e r , San' F r a n c i s c o , C a lif o r n ia . B. R. How ard, G eneral C la im s Agent, San F rancisco, California. N. E. Williamson, Special A ssistant, San F rancisco, California. A. C. Thomson, Assistant General Claims Agent, Sacramento, California. UNION RAILROAD W. B. F i n n y , G e n e r a l C l a i m A g e n t, E a s t P i t t s b u r g h , P e n n s y l v a n i a . WESTERN PACIFIC RAILROAD C>. F . C u s h m a n , M. D. , C h ie f S u r g e o n , San F r a n c i s c o , C a l i f o r n i a . MENNINGER CLINIC D. B e r n a r d F o s te r , M. D. ,, T opeka, K ansas. NATIONAL RAILROAD ADJUSTMENT BOARD E . T . H o r s l e y , C a r r i e r M e m b e r , F i r s t D i v i s i o n , C h i c a g o , I l l i n o i s . / "N UNITED STATES RAILROAD RETIREM ENT BOARD B. B. R o s e n , M. D. , C h i e f M e d i c a l O f f i c e r , C h i c a g o , Illin o is. J. E. Schwartz, Chief, Division of Disability, Chicago, Illinois. WABASH HOSPITAL ASSOCIATION D. A. P e n c e , M. D. , S urgeon in C h a r g e , D e c a tu r , Illin o is. ASSOCIATION OF AMERICAN RAILROADS K. A. C a rn e y , Executive V ice -C h airm a n , G eneral C laim s Division, Chicago, Illinois. H. W. H aw le y , A s s is t a n t D i r e c t o r , C l a im s R e s e a r c h B ureau, Chicago, Illinois C. A. Lauby, Executive V ice -C h airm a n , O p eratin g -T ran sp o rtatio n D iv is io n , W ashington, D. C. R. R. Manion, Vice P resident, O perations & Maintenance D epart m e n t, W ashington, D. C. i F . J . P a r k e r , A ssistan t Staff S e c re ta ry , C hicago, Illinois. J. A. Risendal, A ssistant Executive V ice-Chairm an, General C laim s Division, Chicago, Illinois. R. E. Shelgren, Assistant Executive V ice-Chairm an, Operating- T ran sp o rtatio n Division, Washington, D. C. J. A. Sherm an, A ssistant D irector, C laim s R esearch Bureau, Chicago, Illinois. A. C. T isdahl, A ssistant D irector, C laim s R esearch Bureau, Chicago, Illinois. W. E . T o d d , S taff S e c r e t a r y , C h i c a g o , I llin o i s ************ r G. M. de L a m b e rt, D ire c to r of P e rso n n e l, St. P aul, M innesota. K. IV. J o h n s o n , G e n e r a l C l a i m A g e n t , S t. P a u l , M in n e s o ta . PENNSYLVANIA RAILROAD S. J . C y r a n , M. D. , M e d ic a l D i r e c t o r , P h ila d e lp h ia , P e n n sy lv a n ia . J. D. T h o r n t o n , M. D. , R e g io n a l M e d ic a l O ffic e r, C h icago, Illinois. G. C. F la n d e rs , Chief C laim A.gent, Chicago, Illinois. H. H. H all, C hief C la im A gent, P i t t s b u r g h , P ennsylvania. W. H. T u r n e r , C la im A gent, C o lu m b u s, Ohio. A. M. H a rris, G eneral M anager Transportation, Philadelphia, Pennsylvania. T. F. Schaekel, Manager C ar Service Rcords, Philadelphia, Pennsylvania. P E O R IA & PEK IN UNION RAILWAY R. M. Sutton, M. D ., Chief Surgeon, P eo ria, Illinois. P I T T S B U R G H &. L A K E E R I E R A IL R O A D A. H. W in te r s , M. D . , C h ie f S u rg e o n , P itts b u r g h , P e n n sy lv a n ia . TH E PULLMAN COMPANY R . M. G r a h a m , M. D. , D i r e c t o r , Illinois. Medicine & Sanitation, Chicago, RICHMOND, FREDERICKSBURG & POTOMAC RAILROAD B. W. R a w les, S r . , M. D . , C hief Surgeon, Richm ond, V irginia. ST. LOUIS-SAN FRANCISCO RAILWAY V. W. H o llo , M. D. , C h i e f S u r g e o n , St. L o u is , M i s s o u r i . SEABOARD AIR LINE RAILROAD S o u th g a te L eig h , J r . , M. D. , C h ie f S u rg e o n , R ich m o n d , V irg in ia . S a m H. M c G u irt, S u p e r v is in g C l a i m A gent, R ichm ond, V irg in ia . SOO LINE RAILROAD H arv ey N elso n , M. D ., M edical A d v iso r, M inneapolis, M innesota. F . F . W ip p e r rr ia n n , AI. D. , O c u l i s t , A lin n e a p o lis , A lin n e so ta . D. L. E orchert, D irector of P erso n n el, Alinneapolis, Minnesota. E . AI. G l e n n o n , A t t o r n e y , A l i n n e a p o l i s , A lin n e so ta . E . A. Je n se n , G en e ra l C laim A ttorney, Alinneapolis, Alinnesota. SOUTHERN RAILWAY M. B. C l a y t o n , M. D . , C h i e f S u r g e o n , W a s h in g to n , D. C. SOUTHERN PACIFIC COMPANY V. M. S tra n g e , M. D ., C hief S u rg eo n , San F ra n c is c o , C alifo rn ia. W. D. L am p re c h t, Vice P re s id e n t O peratio n s, San F ra n c isc o , C a lifo rn ia. S. B . B u rto n , A s s t. G e n e r a l M a n a g e r , San' F r a n c i s c o , C a lif o r n ia . B. R. How ard, G eneral C la im s Agent, San F rancisco, California. N. E. Williamson, Special A ssistant, San F rancisco, California. A. C. Thomson, Assistant General Claims Agent, Sacramento, California. UNION RAILROAD W. B. F i n n y , G e n e r a l C l a i m A g e n t, E a s t P i t t s b u r g h , P e n n s y l v a n i a . WESTERN PACIFIC RAILROAD C>. F . C u s h m a n , M. D. , C h i e f S u r g e o n , San F r a n c i s c o , C a l i f o r n i a . MENNINGER CLINIC D. B e r n a r d F o s te r , M. D. ,, T opeka, K ansas. NATIONAL RAILROAD ADJUSTMENT BOARD E . T . H o r s l e y , C a r r i e r M e m b e r , F i r s t D i v i s i o n , C h i c a g o , I l l i n o i s . / "N UNITED STATES RAILROAD RETIREM ENT BOARD B. B. R o s e n , M. D. , C h i e f M e d i c a l O f f i c e r , C h i c a g o , Illin o is. J. E. Schwartz, Chief, Division of Disability, Chicago, Illinois. WABASH HOSPITAL ASSOCIATION D. A. P e n c e , M. D. , S u rgeon in C h a r g e , D e c a t u r , Illin o is. ASSOCIATION OF AMERICAN RAILROADS K. A. C a rn e y , Executive V ice -C h airm a n , G en eral C laim s D ivision, Chicago, Illinois. H. W. H aw le y , A s s is t a n t D i r e c t o r , C l a im s R e s e a r c h B u reau, Chicago, Illinois C. A. Lauby, Executive V ice -C h airm a n , O p eratin g -T ran sp o rtatio n D iv is io n , W ashington, D. C. R. R. Manion, Vice P resident, O perations & Maintenance D epart m e n t, W ashington, D. C. i F . J. P a r k e r , A ssistan t Staff S e c re ta ry , C hicago, Illinois. J. A. Risendal, A ssistant Executive V ice-Chairm an, General C laim s Division, Chicago, Illinois. R. E. Shelgren, A ssistant Executive V ice-Chairm an, Operating- T ran sp o rtatio n Division, Washington, D. C. J. A. Sherm an, A ssistant D irector, C laim s R esearch Bureau, Chicago, Illinois. A. C. T isdahl, A ssistant D irector, C laim s R esearch Bureau, Chicago, Illinois. W. E . T o d d , S taff S e c r e t a r y , C h i c a g o , I llin o i s ************