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E SECRETARY Snter&att Commerce Commission itefjmgtan, 2B.C. 20423 I, SIDNEY L. STRICKLAND, JR., Secretary of the INTERSTATE COMMERCE COMMISSION, do hereby certify that the attached is a true copy of the American Railway Association Proceedings of the Twelfth Annual Meeting of the Medical and Surgical Section, held at Pennsylvania Hotel, New York City, June 13,14, 1932, the original of which are now on file and of record in the office of said Commission. IN WITNESS WHEREOF I have hereunto set my hand and affixed the Seal of said Commission this y day of Marph, A.D., 1993. SECRETARY OF THE INTERSTATE COMMERCE COMMISSION ./'HE `IV 5 ' A 5" / aa H5E"[ PLAINTIFF'S EXHIBIT AAR-t American Railway Associaticn ' PROCEEDINGS \ OF THE -TWELFTH ANNUAL MEETING ./ OF THE . MEDICAL AND SURGICAL SECTION f i I i PENNSYLVANIA HOTEL NEW YORK CITY JUNE 13, U, *932 PROCEEDINGS Of THE TWELFTH ANNUAL MEETING O? THE American Railway Association MEDICAL AND SURGICAL SECTION HELD A r PENNSYLVANIA HOTEL, NEW YORK CITY JUNE 13, U, 1932 'ICA* I'n^rtNO <' .Vt S. Y. INDEX Bancroft. frtdtfte atidree* on Cmm oi Failure ia Healing ia Board 14 Direct/*-*. .vwficm Ra<l*ar Dy-La**- chance in: remarks of L. A. c*.-------- Cauret of Failure in Heaiin* is Gran Wound*: FrMtrie *F. Bancroft. Gdumoia L'aivi::ty Cvilec* vi rJywsa* ***4 Committee u Direction. C-iaatittee on Urveicmoicat* Ketuiuoe iron Ptnoazc PSy*teal (ji __..I _____ ii Committee on iiiicftlwn "i Vie .~-ttr.uartl f:^t Aid P.'.Ct *s-io i 79. SO i$-Z) 02 C>a:suue on t ractures. Hrsort of_ :iCUt>2 OS. Committee un N<ruinau. Hcp-ift t-i------ Couumttee ou v.'raj'ai'oiia. .<aum uni f P.csort * ---- .... r.':.c*:?*iw3 -......... n. a: _______ ii "eacey. C. ii.. C";.ucmaa. t -iA-nuiic u.v^ton i'v-v;-si. .-Tiutu oy. IV.inteul. U. <ii*c*wuu* *.o r.: ---.v.*^ -i ettn..a ni -.* * U. il ;` ..a ; i.. e.i..fC\l x -2itl_ ... _. .............................................1J. }. T7 ? i n:seutoa m m :*.yr<i*y tr mlr-fU-i etnpioy-** _ ......................................................... iJ.rT.7S UisctuuwA c:sa:e ia tiy-f.aw....___.............................. .................................... 7? `t-.tioa re: ?*:--rr%a: : W. I(. U.An.__..,,........... ........... ....... J . j iCeetsen .it '"5!-, '.r<rih'f -I 0-.i:~.s:;tt.-e ! i5.r**:::a ii i'..t-ki S-.-.m- \>p..;css!.;:t: .: iV"<rs-------- T '.Ir^siunsef. i_ t : -naasa *" ->a ......................... ........_................................... -7 '> i!v. P-:*. -an: ; : !.- : -a r*r- r: aui."'-* a jv--.'.n*e*n*.* /~*'ii::r.r l -t.tsr.S.f.!- .......................................... '! i.v'.tor : i :'.. a ; >: . -:i -t. J. C,.. r-.-*-.r: J .?ner. J. It.: : i :>: ..: i <.. -a -a : .4 ........ e a i:.J w<:............................................. ................................................................. : ' t>i-:art i-<t .................... .... l..<** ..t i-.in** .. ______ Oi-eitie. i- ' - ix e-.a--tien v:;J train.'iisa.. ... <-v "..t.vrjia : ......... .... Mnpitma. C. '-V.: t-u;.\rxt to* < !(mn. A. .m rfryjrt U euamit!?* na ............................... ................. . . ______ _ i*r < t*a.Ufi1 ** i i-t t U S ll'.enimii v>i-l.*:^e ......... e i nJ^rnl ...... ... .... ....................................................... -.... ............. ...... ......... ................... .............. *> 44 V. ri-i..ft t INDELX--Continued un l fi**t i..| i-^r. < 1 --.b:- - .1:*--i-- - r..v ( t`* ; \i>:>u^l \!"iin{ ......'.r~,^ l . v j,:.-. u-- i . i fj.-iurn .H. <*-- r i--*..!* t ......................... < I'j.ii.s rantrie 1.. U i' - v ...\ i..v Marra*. i I mvnr'iiv W i~i f>aucr.uaiii'i............. ...................................................................... .-:i K -.* i):;y :-.r rtaiifa'aii r.miMmni: C- C. !>...UaJL_.................................... .v:?v:'-. , r-i:.ar* .> J.i9i- i.c>~_................................_ . . rB;>n rnn.imtin urvriKKumi* r**utiiis truta picrtuuic r><*yicai :. {' ia- ;. .;Bai r.biauk^o-Mi. rv.-a-< J. ii. .**'.? _... _.... i,. C-: nn r|MT vi c**Ai(uiuc on imuuM - ............................._. W.. ov. J;. a., a 5.*?: uut nil U-1* <: fri tr: vi rt.moaun* no ninnin ! u* <A Uaodani . .............. ................. .... ................................................ ................ ............ ......................... ... ..... . ......................... .. N-7n Vi. V* 41 ZZS^TV?' 1JLr* -t* wi'.ys American Railway Association It. H. AUluon, President M. .r. Gortr.iey, Executive \ VV. 0. Besler, First Hale Holden. second Vire-Pre^ideut Alfred P. Tr.nrrt, General Counsel II. J. Forster. .---cretary ana Treasurer Board of Directors it. II. Aisht^n. Pr^nit-m. Atucrtvan Railway A*.** iui;on. f.. W. Baldwin. President. Missnun Pause Ruiiroad. E. W. Beatty. Ci-atrman and President. Canadian Pauric ILuiw.iv. U\ R. Ode. President. f-outsviiie i Nashville Kaiiroud. J. M. Davis. President, Delaware, Lackawanna a: Wf-stem lLi.;.*oa-i. Charles Donnelly, President. Northern Paciric Railway. L. A. Downs. President. Illinois Central system. E. Gorman. President. Chi.-:;*to. Rock Island oc Pacitic Raihvav. C. R. Gray. Pr**td?tir. I'nton Pacific ."system. Fairfax Harrison. President. Southern Railway Hale Chairman. E.v*"itr.e C -muutte-. Soii'acra 1'u in-- Co.ms.-.nw Elisiui Lee. Vice-President. Ponnsvlvania uniimau. E. E. lamujis. President. I.*-u:^h Valley Raiiroad. A. C. N*:C*ilv<. Pr--oj.-nt, Norfolk .V Wo<r*fn Railway. J. Pcilcy. Pr*`:i:n:. Now York. New Haven .V H-artfor-.l lLuiro.ni. F. W\ Sar-o.-nt. P "-i.t*ait. C'.u-.crv .V N--::h \V..-rr`-n Rada iv, IV. n. >rr>rcy, Pr-'ident. Atchison. Topeka 6: .2ant.i l*' Railway rv.-om. r*ir f{*`rv V. Thornton. ICB E.. Clvurmr.n and Pr*~<i*iciir. Caa.id: m National Uaii.VMV.!. Pi-roy K. To*id. President. B.iavor a: Ar<.o;c*>k Railroad. R. C. White. President. Central Railroad Company of Now .i.in', Daniel Willard. President. Baltimore fc Ohio Railroad. F. E. Williaounn. President. Now York Central Lino.*. J. J. Bernut (ex-officio), President. Chesapeake fc Ohio Railwav, L. F. I.<>ax /-xH.fSi io). Chairmna. Eastern Presidents' Couiorencc Committee. i .l*'Tifr,ii JlittltWI Aff'O'H't'H DIVISION I--OPERATING Officers C- K. lAim-y. Chairman J. C: J. C. C-muon. Tviary !V. J \'T MEDICAL AND SCRGICAL SECTION Oncers Dr. Ji.ltsi Chairman Dr. W. L. ILsintun. Pir-' Vi*t -Chairman. J'". J, IJ. ::tn:.:i. j. C. C' '.v:*:..;., MEMBERS Or COMMITTEES Conn>:t;c o; Direction <Tr-r?: - .in:.-.. Dr. J*-hs Mr-Cornfe iCl-ai.-m:;:.;. L... : : 1 *:h ;. 1an :: liaiiways. Montreal, C_r.a>ia. Dr. W. I.. Hartman iFir.-' \ i.e-Cinartunitl. Minimi Duvet.ir, N-.v \. k CmrmJ Line.*. i>:*.*r>-t. Dr. .1. R. Nilsson (>?eotti Vice-Chaimtaui. Ciuvt Surinam. I -n-iii jv.et.i U:.i:ri;:ui. Ufr.aiia. Ni-*. Dr. C. G. Chi'-; samvii. C.</*y<r*-;n. Cb..-;uv. -.1. Dr. J. R. Gamer. Chief srr-*ti. Wcs***ra Runway i Ahaun.u. Au.it;'a. v... Dr. Donalu Guthri-. Chief riT.-in. Lenitth Valiev Rmirixu;. s;.yr.\ Dr. C. IV. Hopkins. Chief scr-reon. Ch.--nrv A' North 'A-=!'.-n R,,.hv.-.v. Chicago. 111. (Term evrnres Jur.c. ! ?-'j i) Dr. Hitravv Bar!it, Chief Mcuical Exurr.mcr. Pennsylvania Railroad. Phila delphia. P.a. Dr. G. IV. Calc. Jr.. Chief >vtr-c,s,:i. nr. I,wus: .'uthwesierti Runway, Tex arkana. Ark. Dr. F. E. south. Chief surreon, \V;:h..th Railway. Dwatur, 111. Honorary Members Dr. A. J. Chcjhry. secret nrv-Tre:'.:uror. C<:ircrence of state anti Previneial Health Authorities of Norrii Antvri'*::, c*t. Paul. Minn. Dr. H. n. Curtsminc. sunreon General. Bureau of Public Health service, Wafhmeton. D. C- Dr Dr Dr D: D E '.adian National _;v;nr. NVw York SPi**** . l nion r.u :Hi? `hie >. IH. i. ACuim. (i s. ' rn i: il-.viv. -1 ."-mre. Pr-K't'iiny.i of M<-iical and Sunned .vctn* . Committee on Nominations Dr. D. B. Mufs (Cbsirmaai. Chief Medical and Burned Omccr. Chicago. Burlington ic (gurney Railroad. Chicago. ill. Or. Duncan Eve. Jr.. Chief Buraeoa. Nashville. Chattanooga <i: it. Louis Railway. Nashville. Tcoo. Dr. A. W. Me. Chief Surgeon. Northern Pacino Railway. St. Paul. .Uir.n. Dr. S. C. Plummer. Chief Surgeon. Chicago. Rock Ular.u Pantic Railway. Chicago. ill. Dr. S. B. Taylor. Chief Surgeon. New Voric Central Railroad. Cuiuoiims. u. rD Committee on Occupational Diseases and Reoabilimaon Dr. 0. B. Zeinert (Chairman). Chief Surgeon. Missouri ihy-sric Railroad. it. Louis. Mo. Dr. G. W. Cale. Jr.. Chief .-grgv'in. ,-t. i.ouis Southwestern iL.dv.ay. Tex arkana. Ark. Dr. J. O. Frost. Chief Surgeoa. Chicago o: E,utcrn Illinois Railway, Chicago, ill. Dr. D. B. Mo&. Chief Medical and Pursiest Officer. Chnxigo. LmriuigtoO * Jutr.-y Railroad. Chi-'ugo. iii. Dr. I*. E. .-rnirn. Chief .':;.":wn. `.Vahjjh Railway, ."t. L-.'.i*. !. Representative from Committee of Direction Dr. .1. R. Garner. Chief 'irc'-on. `A'ljjtern Railway f Alabama. Atlanta, os. Committee oa Developments Resulting from PhrsicaJ Examinations Dr. S. R. T-vlor -Chairniaiu. Chief Stirg-.n. Now Vork Central Railroad. O t-ir.;lii!:.i . u. Dr. w S'. u;.m lilt. Chief 'nrgevn . Culi. M i-iie oc Northern Railroad. I-iuM. M Dr. J. c. L.n ii-n tir.rscr. Ci.ai vw'n. `re-nft Short line Rariro:!;l. Salt Like Ciry. r- ah. Dr. J. i". It.:. .. c :::! >,jrg'ft. Driver oc Itiu Grande WV-tcrn K,atlruud. L\ v i f. C Dr. R. D 0*. .\:^f. ' d a (id -i irgieitl Director. l>.bt:m<i.*e .g Ohio ii;: l<l. r..utir:-.vf'. M.l. R-l rt-enta tive m Conn::utt*e id Direction Dr. U: irv-y R.tr ! . Ch.-i Mom. -tl Examiner. t,r,m:>vlvama Railroad . Phila- it-lift!ia. ira. Committee oa Extension of l*se of standard First-Aid Packet Dr. T. It. Ci*w.|r (Chairman). Director. Dvfiartment f Sanitation and >tirgTv. I'uiltuan Company. Chicago. III. .; . :iiIhhi Dr. J. D. C-*3m*. S-.-ihonrd Air I.in'* Railway. Nnn'oo.. V.;. Dr. A. M. lb:m*. Odd >>jrtr'-nn. Ann .\rl/or Knil/*':n!, 0 **. Mi Dr. A. W, !i.\ Cl.iii >urroon. Northern Ramie Kailwsv. >?. Pan!. Minn. Dr. K. 11. M-N;iochi. Catej' >urc*-"n. 0<l`*railu i\: .'oinlirrn U_:lw;-.y. IVnvi- Pr. C>. G. C'i.: ' ir*iu Committer* or" Dsrs^'iwin -n. lllirir.i-. Central Chifas. Hi Jeisr Comssjrtee on Railway Saaiiatiaa i.:oj .'ViTie:.! .'*-1 iofi ]?etin*,ri?::tivi\*t Pr. T. 1. Cr**w:'-'. Cumjvtny. Clii'":?". 11!. Pr. J. Frank i huTst ii. Cm. ' Dr. I). J: M--v : o| .Sanitation ma: >ur*~.-rv. P;:`.'.:;. >*i . E:;e Railroad. C'.-v !un-i. < <* ... 1......... .v H. C- Iltniwi i! lO.nt.-ni..:: . > ::'-r::>*`srnu::r H'nier .--ir>i-ry. Oo-ai*-... Ilaiiw.iv. iln ntro.nil. \a. A. il. Pieti-v. h.'taim-rr Ware: .**ii:i:>i\. ii-rn tlmlwtw Sv-.tn. Wabatr-.*. lor:. U C Ft. W. .--attti.rv Wi-urrn i.atiwae. Tr-\:trkaaa. Ark. M*--:;.ir. :>iyn to-:iro>-t;;;;vv* H. L. Klein**. .\?itani Ci.o*:' *f Motive Power. Pcaaryivntua K.i*trv.'i. Phiiadt'lidcn. Pa. E. I'. Ln.itiev.-. iln.;j.s: .W Vorw Central I'Loiiro.iii. New Vork. X. V. John PurrciJ. AuMtant i< ^Vv-Prttsvdem. Atchison. Topeka <x .lama re Kaiiwav, Cuieaco. Ui. (Coned s:a:es Public Health Service Representative?) L M. Fisher. January Engineer iff C.'inrct*. Ini. .San. Disc. No. 1. C'nued State* rui-ii.- Hvmk:i .N-rvii-e. Sui*-TrcnMiry Buiiumc. New Vork. N. V. A. P. Mill*.'. Aso\ .San. Em:.. Int. Sin. Dost. No. U. Untied Suites Public Health Service, 3 "B" -St.. S. E-. lV....hmtftnn. D. C. H. . Turbetf. As***. Sin. Eut:.. United fct*.Ue? Public Health S'Tvir-e. Wa.diU. C. (Cnnwitati Health Department Reprc^mmivc) G. H. Fereuson. Ciiicf Smitarv Entrineer. Drpt. oi Pcurmns and Naiionni Hfnilii, Eicm Ml.!'.*,. Canada. Tirr.s sr-i'^r.'ywr'.! yj*"r *-~r,!k. V.I. Mina. .** iy, Denver. tan. ill. -ery, Pullman ;>>jrl:astm "*`'.i'-ake j. m. U"o.'hic^* *'m ILalwiy. l; -i V. V. 1 i//*n */ Mt:iicl 'iml .S"'/Ctl ,<ccUftrt ) Committee on Fractures Or. 3. C- Plummer [Chairman), ChM .>urce*fl. Chimso. Ro>*k Mund ct Facific Railway, Chicaso. III. Dr. ff. A. Beatty. Chiet r;urrrn. Canadian Pacific Rnilwnv. T>nmrn. Canada. Dr. Dur.r-;ta ve. -fr.. Cut?! >".fteoti. NV.siiviite. C.\-v:inn<--*:\ c I. Railway. .Vii'hv.iic. T*-nn. Dr. .C- C. <.'reen. Chit') surwoo. Texas a: Xew urienns K.uiroad. Texas. v* Dr. A. R. Metz. Chiet huracon. Chtcaan. Milwaukee. Railroad. Chicago, 111. Paul .v Recresetttative irtjtn Committee m Direction Dr. Donald Ciu:hr:r. Chad .-itraeon. Lvinan iailvy iLalro.t.i. .':?yrv. i\t. 10 ,-itntncnn ii'ulxnn .4rr:<j;rrn DIVISION !--OPERATING MEDICAL AND SURGICAL SECTION REGULATIONS Representatives I. K- = .*' r. ittctuLcr* :* Chief Sur- rr*> : it:rutsmiry. Tii**v staiil Ik* otticiaily di*Mirnati': i*v ti..- wm.iicr>r u-^rceui* m<*mlcrs thoy rvpre^cnt. i. Affiliated nir-tmw*** may * utcwuntcd by rt< Conunsnc** u Direction. >. Ti:- m tw >"..... . r.u.i a >,.*cyn,i \ :i Ch.:ri?iat. F:'i- Vr-r-Oriatraafi Cj=~:::;e ot Direction 4. Ti^rc snail he a Gunniutce oi Direction wotrn shah coo.vst ot JO rerir. - wntntivrs ot members r a.--iriaic meinour* ntu:n the .suction, lactudiou the Chairman, the First. V>> <-CLnirntr.n anu Secmui Vht-aJliatnnan ot tuv Fectvm. the pa^t Chairman i ;.-r hhiuin-r <*mce ami > tuner representatives oi nicmiiers. The Committee shall. it; uu.utinti. mi-iuue in its metnoersmp tnc .'iunteoo(vnrmV i>t the I r.:v-i stmv* iluroau nt Ihitilh- Health S^rvi**** or a rctirt*ent:i- live t in* uestsnaun ny him. a.tv t:,e Conference : Stair aai Provincial iicaitu Autnnntic* <>i N..rtn America. A. Ti.C Committee t LN.'--tinri sn.hi rnnuu<`l tbe <.ii*>mv* ..i t;.*: tv--t:-<n. authorize, oruer. ueritie uunv*. uetcrmmc toe uumwrw atm metiu.cr.- of suer* committees that may ie nwe*.ary 10 prwfwriy cunuuut tac or; of me Section. *. Regular mcetiocs of the G-:ntmtn*c of D.rcrtton saaii he held sermaanuaiiy. the date ar.u place to he uccniod by the Chairman, opeciai meet- ins? of tbe Committee mnv lie heid at the call of the Ciiairman. T. The Cli&irtuun **; ttir S-vtiun siu.il act --* the Chairman oi the Com mittee of Direction, in the absence of the Clairman bu duties shall devolve upon the First Vj.v-C:::i:.':n:;n. hi the absence of both the Chairman and the rim \ n.v-Cnatrntnn. \ ive-Cia:rtn:t:i m:w! preside. Sbouid tilt' Ci.a;mi:::i a:ai huti. Vn-e-Cui.irnien i<e abrvtit tlit* members shall eicct a Chairtituu pru tcm. Commtr.ee on Nominations .v There shall be r. Commit uv .*n Ni.mtnnti.rns to consist of five representa tives of members or as.-ocinte members not njfctrr? of the trectioo. . irs shall he Chief riurThey iuil he officially '.present. mmittee <ti Direction. . :t F:**t \ 'rMThaimun ,'di ronsi.it t*{ Id rvprc Section, including the hairman of the rieccian. .<entauv*of -member*. '3nor.<hip the .'urgeon* snervire or a represetua- Ims <{Mgnatt.il by the ; "i North Arnorirrv. unew id the ..*i I'vivrtiu tn-nvcT-* ii-Ui'.-t :iw w.rk >: -iv.il I ..mi* .i.'n.i:i. .*:! m-ec- ..mi in. ! a- C .ca- :! > devolve - \..;:!ww ::-A -i : .*:.!. .-hoi:;.! :i;--** -nail a ! !ivo r-*pmenta* Pr'Ket'itwis <V M+'iieal nrul .iurtfiral Section 11 9. As candidates for the Committee oo Nomination*. the Committee of Direction shall select the names of ten representatives, rive of whom *hail h- elected. The candidate recetvins the greatest number of votes for memoir* ship on the Committee oo Nominations shall act as Chairman of that Com* mittee. 10. The Committee on Nominations shall, prior to the annual meeting, delect the names of two or more representatives t memoers or a*.wate mem* hers as candidates for Chairman, two or more as modulates mr r ir-t v .- Chairman aud rwo or more as candidates mr hyi-omi "-C'aairntan. ..a t representatives of memoers or associate metnoers as candidates for tn<? Com mittee of Directton. v - 11. Any representative of a member or nasoctate memoers mav, at tr.e annual meeting, nominate for officers or memoers of tins Committee of Direc tion such representatives as desired, provided that such nominations nave been endorsed in writing by ten representatives of memoers or asw*ta(e members. 12. The representatives of members or associate metnoers nominated tor officers or for the Committee of Direction receiving tne highest numner i votes, suad be considered c.ecteu. Election 13. The Chairman and Vi-.e-Chuirmcn .mail he c:o-tea ar.nuauv :.y n jority ballot and shaii hold office for one year or until n-se of me at which thetr successors arc elected. The term of uffi<x* m members -no Committee of Direction snail lie two years and 3 tticmuvrs of ::te <_ :n;;::'.' --r snail ie elected annually. To provide for the inauguration <;' the tori-goitig. 3 membersot the Committee of Direction shall lit elected at the annual rr.e/t* imr in l`.2l to serve for one year and 3 members to ..erve for two ymrs. A; sttoserptent annual sessions 3 metoiiers shall he i*-cied to serve for two years. 14. The election of officers and mennen of -he Committee *t D.r<vt:in ,:;:d Loictnilfre on Nominations -hail h i*i* nrmt'ii ballot and owy -:a;iv Adgnated representative -nail be 'nink-d to v-x-. '.VC.-i a bdl-.t r vi-cti-m *f officers or members h i:e retaken. rc'ii*s m a lie ,-uvh aadit !.. A vote in sessions of "he .ewtimi may iie t ik.-n viva vcy. by r:-;r:g. ov ryil-cilt or by bailor. I; r`. 're is any douat .is to the rcsint of a viva vn<;e v V.'.e C.aariv.'ui eaii - f '.rr. -* -n *.-. "('i*-** !.sr,,>* m- mber*. ,*; k.'/u. ..>n ".urnaer of iiel.l i*v a av-raber. Meetings of Cj.TLtutties lb. M.-..*:ngi of nv .......unit * m iv ivM it t:v --.il of trie C'i iiriti in of - uii ofniiutV'e mi!*".* ("r -me ..penal r-- v^xi aotm' -kf.un -i rv !:.oi been iv t!i" Chairman oi r ii* ,evtion. * Annual iiu-v*.iug of the .>''t:on -hill be h*Mt in May >ir .bine, rb.c time ir.d place to ! lieeignatml by the C":umirfce m Direction, .special mm-itn-gs tr.av beheld at the vail of < he Commitu-e of Dir^-t ion. r r j American Railu.au Asftoaitr-n !7. I: n in-::*i.t-r ot ;t eonins:tt**<* is ni.**nt ;r..*n ............. . '' r-itilcu nievitrtc* ot die rommittre. his mcr:KT-hit <:!*- .::! :n- C<innui:'v '( Direction :rt 1(| v;-.":;:.- v IN. .'*ir'<ui-v i:;tr! th- r.-'' General l*.*. Tii" r:.M ( !:!! vr.:c . v.-sn-i m r : tv.- t: or *: j All CV~|?! IV ti-- !: :i ^ limn ci fin* .S^*iia ( :* trf:u*-T ni Jivi* ?;.--:t. - ;' im-tv 21. Tiw m.v i.-o am*ni'f Kv u n..:;*r:rv v:.i- :;r.v (r Mrf'.'iai M t}>oo}|.5. !'j*-- ( ,;|T . i i.v ;.' :: VAtinc men-1- * i v * t:.c ... A:s:i An- I l i * r. i t tArcai - niir.os i Louii^ Missoi * Jsfw \ Nt(( Se^' Nor. :/ .I i<`<!<it;on *fnc from two consecutive re^ubriy mocrshm 1`icto. and (he vuv.nrv from any other wu.*^. ' ;h*vr.< of (he Section, the Committee the Committee of Direction b r.ll -r h vnraney until (he next : -tren<l executive batons ihiil!_!>e `omie n-rnher* only. : may h* hol>! at the tedi of rhe Chair* "o represenrattve9f members. ( by a majority voce at any recubr * " approval iiv f.v<>.rhirtb of the / .V-bicei rerc'ti S-rUtm !* MEDICAL AND SURGICAL SECTION Pennsvlvania noti. New \:>rk, N. \.. June o-U. 10 -- The f*iUw.ne m>rcs*n,am`** w--* M ember* ?.trrsses:an?ss Ana Arbor R.. R................................ . . A. .U. Hume. Chief aurron. Atlantic Cuas* Line R. R. .. v........... . L. A. Drum. *2*u\ Examiner Baltimore Eastern 1L 1L................... ::u.-vtry tiartte. Chief .Ueuioii :::::nvr. E.v- Bannor sr Aroostook R. H................... ..il. C. Bundv. Chief riuruvon. Canadian National Rvs.-- _--------------...John McGxnbe. Chief Medical Crticer. lv. E. D>v.v.i. :o Chief Mcxiicai t^meer. Canadian Pacino Rv....................... -- A. B'*a:rv. Clue: Nurueon ;uiu -;ti Om. tr. Chessoenke it Ohio Ry......................... .. J. Prtn.x Dmnen. Chief SurtoMi. Chicago >.< Eastern iiuiioa Rv--...... .. J. 0. rp**C, Cb.ef >ur; ->u. Chi**;tuo .U niis-'ai Mt-iLiM ily....... >.1 Dvai. Chief 'i.-W-n. Chienuo North v\V.*t**rn My.-_... . C. V.'. Jt .r-Kir.x. Cii.vf .-iru-im. Churuso. Burimsron oc Cuinyv R. D. 11. Chief M--ami -"17-:- ,-.i .m.?er. Chi'-aito. R.k-'.c uLitui cc Oust Uy....... ,,s. C. Plummer. Chiv: "i.*y.'<>n. Calcaco. U>-k bland -a P-.vi-.uo Ry,... .s. C- Plummer. Chief S.uruein .v southern llv...................... T. H. MoNauuhr. Chief Surwn. Eiirin. I'lliet A Eastern iiv. -.......... -- .C. G- Davis. Chief Suruvon. u?:e R. R-.............................................. f. Frank Dicsen. C'iiivf Snrtren. 1 i -.rntr. Chi;-: Suru-'fti. Mi'Cnnivv. Chi'-: i rt'-At Rv. U. C. "A'-l.h. Cht-f ry.-*tn.. i i. i i. I .vil:-i!. Chi* f >-iru'*. L-hiim V.,,!*-.- 'R. 11. f.-.'UWlbc .V V .MU'liiC ii. U. M*.p. M. V- V- v- . < I.;::-. i Gnihrie. Chi*-; 0"r.can Evv. .Ir.. Ui<rri-r S*tru*fn (V !i. /.l iJs-'T. Chii i ."iru-'-'n. ! '*r. ;;ti .`"irV'-'A. A'. Lvt*.< M--`.*.-.*.1 Do-u-v I.;.*::::ar-r. Ciurf >':rvi''':i. : r-.::s \ . 'A'hum^. (h*:Kr:*l U. A. I" >'ii.-.u.T. CVutff C'iirn New V**'k. C.i` .iU'> .X i.><;:* li. i'. ./ Fr.uik Omavn. (.`hi -f Sitrc-m. N**w Virk. > 'ntario vW.-torfi llv. . 15. HuSnrr. Stir"*n. N-'ftnvta i' - iiu* Ry- A. i Siirurnn. rr*Sv\~ r?.rPS..` \ V ***. I .1 /?i::/:rvjii .4 Ohio River 4: Wf-tem Rv......................Karvev Chief M'-r- r-.l r>.. :.:n:j;ct. f'ennryivnnin R. R......... ...................... H:;.*vcv P;... f .*.Riirv.! 1!\. simnw. Quinry, Omaha a: Kansas City R. R.. D. H. M.*-- Chi. :' M.-dnat :m*l r:il Onisvr. Rc-auias: Rv. .?ytcni ....................... ... ;I*. S. ]\rr:i. Chief M*-iier.! K\ant:arr. Rutland R. R................................ ...-. V.'. Hac:nvnd. Chiu' >`irzn-u. Grand l.-h.:: i Rv . . .1. K. Ch-f >*. Kr:uv:y-i liv. ..........j;. A. U.-.t --v. trvni-eird Air I.iar Rv___ ____ _______ J. 1). C--!hi. CLi-:' .South Brooklyn Rv..... ...... .............. h. I:. Carr. M.-.it<-aj Dirt--"*.*. Tfantr^ Central Rv..................... . . Duncan Evr. .1*.. .-:truvnti. T-IV-Tai .v U>*i*rn U. . i:. A.. .-..r.... (h. > ....... U. U........... N C:. -' i>. i <-~:r: n. V.Vkisu ...........^.............. ... K. c'i.n-f .-vtre*-'.*.. WV-tcrn Maryi.uiu Rv. -- ...............1'. C. V. ..r.*::.a. M-tmui Lwaiav.-. \V<*j:m Hv. oi Aiunausn....... ............... J. R. C._*svr. C:. -: .-t:rr-- Won Jersey <s ;?ea>nor ic 1C. ____ih.rvcv Barite. c'-;ei Mvuieui Lx- i \i At.Choraiet-i CVotnatiy....................i;,,t or, Amertrsn Rahway Association.... J. C. C-viston. .-vcrciary (M. & a. <. : .*>:cr. .-cvrviarv at.u Treasurer. lit--kman Street and ctuyvesaat Square Ho-mtais.............. .................................R. If. Kennedy, Attending aurucun. Columbia University Coiicze of Phy sicians nno surgeons..... .............. ......T. W'. Baacroii. Associate Professor of Clinical surgery. C. R. Murray. Assistant Professor of Surgery. International Journal of Medicine aad surgery................................................... F. E. Lewis. M. D., Editor. i *;e. Chief Me.ii.-ul x. Chief Medical Ex- ''ef Medical and 5urei Medical Examiner, t. Chief burecon. .i:i-i ."Mirireon. 1 .'lift .-urr-.-on. :>-t Hral Director. District i-uruenn. .*..ef .>i:rcc>a. iu-r .-iu.'ccon. -strict .Surjcoo. Chief .*fiirreon. f .'fiicjcon. Medical Examiner. i**t .-urvcon.. Chief Medical Ex- tor. Secretary {M. a a. ^eiarv and Treasurer, .attemlmc .Surcton. -<!<*> r. Proct&iinqs of Mt'licnL *jd Surgiojl Section 15 MONDAY MORNING 5ES3ION .June 13. 1032 The Twelfth Annual Meeting of the Medical and Sunncni Section of the American Railway Association convened at the Pennsylvania Hotel. New York City, at ten o'clock. Dr. C. IV. Hopkins preswlinz. T'.-.z C.:i.vtr.uAX: The me-.-tmz wili *n order. The r-i*. number oq the nrozmfn us .n iwbr*?* in* rae Chairman. I have no prepared address or paper to oHivcr hue 1 *io wish to than* the Committee of Direction and the members of the thderent stamun; committe^a for the splendid work they have done bunaz the past year, i also wisn at this time :o express my appreciation for the consideration shown me a year ano when l was flat on my back and "bud -out cold." as you know. I am happy to say I am cettmp aionz very nicely amt am triad to be mttx von :o`tav. I am very sorry to say that Dr. Crowoer mil not iie nere. i have a i..-t:er from him. which I mil read, as follows: "Tc mv treat irzres t find it imoosstble to attend tnemeet-.nzos the fewtum next Mumiay and Tuesuuv. I have neketi Dr. lue o reau rsc report of he Committee on the Extension of the IV* oc biamtarti First Ai.i Pa Dr. < C iie. on nc<-oun: of illness -.nil not ie- i.rvecnt. President Aidhion iilcewi**. wmie me a inter -avinr that he ni uname to .mu cur ni-.-etmp on .i-c*nst wi 'he situatiun :a tV.-ishinztou -.vnen compeis him :o be there. We rerret very fnucu that he mil not be wiia us. Wcwai ad-v proceed with the prorrara.rnc first ju.bji.-et netr.r in address <>n "Pott s Fracture." illustrated by movsnp picture?, hy Dr. Clay ftay Murray, of New York. (Applause.) Dtt. Ctar H.v.r Mcasux: Mr. President ami C-ntl-men f w n ainud i*r a moment this morning -hat f would he more or ;>* m >.;u.:ti<in ::.c farmer wr.o was accustomed to earn* nis pri-tu-e * ?h- ir.arkc' ::itnivK. an i lurtnz the rainy - invuriaoiv, ,vh**n *'. w up :t rr.-m hill hi.< *r:.-k b-.--ame mired; a:'*-:r l-mj vp*-r:-a: '..un i *:* .,;dy in-.ay he .i.ui.i :! was :< ye: .i;r. unload the tru. k. u"C it ..'i*. ho r:u-i. aid t:i-n load it up nzain and no on. One day when he -.vis making the fr:n '> the marker, unknown to him the back :nrr. of :h- m--k '.-...me ;::i:a.rcn*-i and ail f in.s pr.'-i-i-- fdl.'A'hoa ii-r'-i-iic-i'!i-< *:! *n -ri-hiii. was O'U.ii.v -ti" ns* vick -i-o-nnie mir,,-i. M>* ' mivd i.<wn. .v.-a* *> -he <!{ t.> !.x.k ids _nd ' i h.s ;ustou'.M;av.i'. f.l . a\-y. ;!........ . -us -..-jui .:ml >.iui. ".murk, uy eoah. an.j l tu t unioa.l." l.au^h'er.j U .<eems that rh:s taikimr moiu'ii pn-iurv reuurrc? a r----rd reprotiurnun amt .v:.-..u\ we have not i-.-t. 'h'-rri.i.-i: wh'-ft it '.uies f.i ae inotion picture t'-irt l will have to tftve an iu:t:an<.n <>: rnv--if t.-.lkin< in the moving pictures. This iiursuon of Pott's fracture. I think i.s a very imiHtmiuc me. There is if,: AmcnC'in old that i: all dcuctui* on 'hw you u m what the r-rjrc will l-*-k like, and .so l think 1 li;ui irftliT toil vou wii*rr I .-it. l`nsVT:us:itvly. the term '`Puti'* fracture ' i- umM verv tniiisermitn.itelv to ic>'.Ti:-c :-.ii fracturr- nt><iut t.'.v ankle. ns one mtr.ntoidy <--.I!.s ail f.-arture* :.:*ojr :iicwn<t ('dies' fracture. Fr<nt riie stan.ijiouii .m neotitsnn-t tr^itttienf in: is vi-rv ur;ioni:nn:<-. i'cesti-e a?<out the only fracture ta the ankie rctr*n contain* ercut or :-rr::>nr:.::y diMiblinr the individual ami nn.lnitr*-!ctavuu*?'*twc t> a > fr.v'v.rv. A I\-tt. fracture * not a nu.iiti-:u* nurture. A Pott's fmeture. a* jar a-- '.tie libt is concerned. is a matter f r.n imwnsiKT at ail. TLe essential feature of a Port's fracture if a disruption 01 the inferior ttiiionUuiar joint. ..ad u is ilmi whirl; n;::k* the t **:?.:! ::m: iir.k-s ir.< tr.--ttTt*-t:i :.*:re!v cittvrenr Iren: lltA.il <! a.:- a irm turv mi- evurr.-: itixi.c**r.i.' me r**nval---<-n'-e i< rrifu.i. tr.t reduction is smifir. atm the chami> of nerrnatienl u:-`::*mtv i:'icr normal treatment art1 very Might. if one h;. fracture w tin* internal mam-mu- th.- same thine ns true. i'r is' one has a irarturc or noth tntrrnai ami x!frT:::r malifeuii the noic tr.atC is mis--i,rur:inM>. .Mtnim- n-:uct !.{;. fctiur.i iv short convalescence. aou notuice to wturv anout in live way u treatment. V. '.eu we cornu to fractures i the aa*ic cf.mttiicatcu ity uuvntittuo i tie- t:: ;.>;i:.uiar joiui, wc are u:> acuuisi a i-r;icrv. wmvu rvtmirv*. sr>>. a ussum** rc'iuetiun. .-croud. area: difficulty m mauiiuim&g rvuuciam. a:.u it.u.i. absolute necessity tor maintaining Uoit reutv-tma over a pron.ncm (vriwi << ' ::;ss. ai:d Jvurtii. a ij.'u.vuuvu u.->.> .* ;;.c s waring i--; .**. In the average external maiieoius fracture .r me avenue internal tnanonu-. iracturc. we are aiiowsnc ututmu within pain iitr.jts in itm Hire** am; ;ui`. weisat !icar;oL-. tvitn ouiy umi .wen :<> s-raipmn; -r w:thsa two or i\ur wcewi. la a true l'otl s :.*..cturv u i. un^aic to tvuinvc splints at ail iiefore four weeks; u l> upside to start any weieht t*eartnr until oe'weeo tne sixth and the eieath went: a:iu :: is uusaie to aiiuw full uncut hearar except hetween the twelfth and tiie smeeota week*, aud then with aiu and support which I will dcscrum. As you cao see. that means a tremendous disereaee. and you have to set that viewpoint of what i aeaa i.y a Pott's fracture to reaiue the points taat I am come to try to make. t made a very room stodei nf the i*.wer tiina aud hhuht with the astracnius lyisc in the so-called ar.kle mortise, and. is we understand how a Pott's fracture, so-called, occurs, it wiii l.w muck simpler to prasp the rationale of the treatment. it starts with a prooation of the iout. Simply, it is a rotation of the foot to the outer side fillustratioc with mode!). In this mechanism of pronation of the foot, the deterrent that exists ts the presence of the two malleoli; with those two malicoii intact, ana with the licaments intact, it is imnosihlc to evert the astracaius. No lateral rotary motion of the astmealus is possible. If under the force of forrea inversion of the foot eversum is tried, it is. irnttosoible for i: to co ou unless the internal licatacnt gives way in this wav (illustratine) or unless tne tnaileolus snatis oa. which amounts to exactly the same thine. So T5T vid tn what the pirture will - I ,-u. .-si very indiscriminately to miponiy valid all fractures ,mt iti resuiuand Treatment fracture m the ankle region .j;.*a;jsia? T.e mid A I`u'.' < j'r.wVir**. :u> nif ;`.S rv.n.-e .it ,iil. The .-'j-nfiai inferior ::iinhbubr joint. .* and makes the treatment ~.KIC. the vonvaltwceoce is ranui. :em umter normal f the internal r::::i!ooi(id the hoth internal anil external runic rcde-eion. .i .-i-iafivelv *.r.c way treatment. .wated by diarmuion of the .it rcquit"*. tirst. a mnv-uit reduction. ana 'iiiril. an. >ver a prolonged period r*t .unng p*r:ud. " avenge internal malleolus ..ix'iJi two or three weeks. ami stripping or bracing, it id unsafe to remove :~t any weight i-<itring :nril insate i> Vnil *.vvtihc r. wt--j<fi. -i.i.i rh-.-n with r.ce. -...ii n.got ".*-ithe that M'ljl.i wi: :|m ..Of'g.iiisa .i'U r::ti..n.n.-! fliff - . ii,.,n i he i.f in i: .riioacwinm *,un xm -.v.tfj ifm-iMfile 'o i-vi-f' fho 'is i.t rm-tdilile. ft under 'r:*N|. it tor '- wav i tHiudtrnrtmr) or *lv `he ;:hh thing. m Proceedings of Mciic-tl '/ 'iroicnl Section ir tar ad ire are concerned it id a giving awar of the inner 5ide of the root. Once that happens, and the inversion continues. the iorce m ngamst rheendt the hbula. It the fibula holds, and it the iorce continues, the mfertor ohi* nnuiaf ligament has to tear. It. on the other hand, that ligament hoUii. then rite runileolus breaks and you get & hi-madeuiar fracture. ho you set a sprained ankle or a fracture of the internal maiieolttd. nr. if continued, a fracture of the external malleolus, and if. la addition. v.>u nave rortionnt .-tram tne traduce -::v so on up the aiuitu. If. on rise aural. taat auuia holds. tr.en wr.at iiappcns id that the inferior imia b.uair ngunw-n'd tear, ana wren me tearing <.f those ligaments the nhula u ramei Lttcr.tiiv. oenuing nt from tne ::oia m this way (illustrating) and ad that henuiaz occurs tne next point of strain u he attachment ot the verv strong tnterosseoud roemorane. ami tne enan occurs there and you get typical fracture.--a men iracture of me mmu. witn or without a fracture of the internal maiieoiua. giving sui outward uisoiacement ms foot. And in audition to that. i-rause laid rnurtise is now untenea. and iienuse normally looked at from anove it is wide in front ana narrow m tne hack, the fooc can slide bes :uxd drop ;nco noitenor >iisoiacem**nt; tnen. :i the posterior tibial lip gives way. me fMit -tided.up. -o mat m iienu of me adtragaiud corned to lie actuaiiy iiehinu rite tuna. Ivco-.ving that, the reduction of a i'ou'd fracture becomes a .muiiuc umic. It ioesn t iiecocie what you very tr-yueauv r.ear--that to me .i ft! i fracture you put the foot at mriu acutes and m tuafkiM inversion. Oo.uz trial '.hw.luiMv nothing to no with me miuetton of a r fnu tiir-. V-.u h:vve to ".trn.* tne i*f from ice i;-pci' ei posuioii i*a>:K to wncre it :.*;o.ngd ana keen it there, and restore the normal nuirv.se <( the utikie punt aaa uoui it restored uatii such time ad the i.g.:::ent -J ueanai ar.u the inferior t:::a uauiar ;un t:*u is strong enough to l>ear :unc::onai use. T::at the logical aud necesiary treatment of a ihur's frai turc. 1: you put the foot in marked inversion it id probably the best mechanism tor .--.using the reoii-urrence of the d.ri'..rmifv "hat I know. It :s perfectly .'vious h if if ive rotore f i: morti.^e. :-.:ai '.hoc :ar: to turn the toot in ci.irxvd inversum. '.vciat we do > shove the iVouia out and push it .wav from rib:u. A::v time vou -e* a Pott s fracture pur -:p :n -x'lrme inversion wh'-ever has ioae if laid done iiid .`H'st to cau?e a c~urrvf\>-t. It :.t cnurcly wrong, entirely inaccurate, ami the cause. I l***i:eve. ..f a .leal of ivrmnucttt dti:d>iUty. Inversion id nothing iut a position of immooui.--.non and we slioutd be striving give rr.ereiv a t'.oraial .vight r:r:g .<i. aat I ,::n going to io r.ow is r.i -n.<w yu.i tiic eiini.-ai diagnosis of a I'oft's . fire. ;i:e ai-oinui ..f redo.cfiwi. J:ie .- irf.-ular type of -nlinv.gc are v.-iiig and me reasons, ana then io do-ciisd. wiaa ,a i-v*r--uciv itiiuoitaiit :n eases, the alter treatment. ->-"idcd. him :he prognosis, and fry to bring :* ?kc intuits on which the :uo*noris i- -i-i-cfii'n'. .Motion i'ictured.i Nw we will take up :v.c ai.sgno.M.i and the ir.ccininism t reduction and spimtmg of a I'oti - fra.-mre. Tliid id an actual patlent; an authentic case. The pauvtu. as you see. is under an anesthetic. Vou -ee .-<de *v tf)K normal leg and the injured ieg. and I am (Hunting out the diagnosis. 1 r~t i t*:- protnincnt uiteriiai fnalleoUi?. 'w IS .-tmeeictn U'V.iufiu .i**(ViaJ."'in Tlii? axis <'. rhc Jcu and <ii the friot n* looeer correspond la lui.htion von the marked sti-cibnc ami tin* ^rarular dctWnv.ty r.t tie- hmd.ir ira-tiirr. Tin* sncliitic is extensive aau runs considcrr-Mv un tr.r !;; umi involves the ankle > well Yo-i have an disidnrcmviii pushed backward and untvaet he :n tbi* 'tsv-t*j* tw-?*r:or ?;iiia stirtiua: ha?. Ixren broken nfl and dispiaciil. There is a iiaekward and upward di.'nl.t-^nwnf <( the ht. i;i ritirmt-iiiv* ?' r-t;:rc oi .-rf. ..t:r tr-rn i* ;o mb: i!..- .iiiwn ;:. i r :* t,.*rtn;d i-i<mon. Tl. ;: utSS rf-.-n-* t,, rtnft*-.. is v..b brrt.rti.v down and pu.di it forward. 1 Iv.t- arc the xr*v pictures of the rase. There is the displacement *u:wat! of the astruimbi*. Th-te i* *he iHsntaevti'vnt i>i the toot and the n-prurvr - of thy intern-I a..!: - :?> ;.... r.i .-.nmo' . r-- : --**7:..* w :;a i> (H.-riin<-cM i:j*wnr; *<. the '* ! . ' aa: ::r> v.v.'t ~ivws; * :r'loi*tai .\r*isnf::;:i,e ? *t i:*--' i- c::::.*::;-:-r:?Mc pnst'ma ( the imeiwc. What we 'v.pt t - !.. > to briny ttic loot down. nu.>ti it mrwitr.t. at..; it to the traer >u'- so ns to lnnc the t&aUeraii in rontsci. UV rrm-t *--..v the TTMireie* ? <--*to ; the reduction. V. ;.rc now the ix:; dmvo to normal position. This te.o-ti*rt insist ii* made w>tn t;r uriti vm seettiem.ano it tnut Jie a siei.dv, s-'u-.-- r.:> )-rkv motion, i: v.-u v.-ateh i think viji-.tn witit beet "'ms cmvr: :ru.. t:orma: pO'itie.:.. T:.. 'm- ca.o- we are renuentc now. It. is % essential tiiar the tw and sretniv. i ir.ink nwi ran tt rerr.1- <i.w*s .hjnr.v* rhc .ouro.t;... After that tiuii has aceutaniisutnj brmctnu tt anwn. w ran hnid the t.u.t down bv ctftmu tf:t: hand iu.c hi'/t a:;u tnr tnunm on ttic itorsutn u Ue *. Now we are suins to nusii ttw tmut iuwk ana mum ttie font tnnr.tra into ntirmai position s*> test we n nature ttic rotrr remiOMtuns. We pusn p.-ekwaru on lite tmia anti forwarn on the i<w.t witn our oartu osinind on the h<ri to ttt toe reouetton. utwe the toot comes torwaru it can ne tieia there bv roe thumn on tne dorsum ot the foot ami the liana on the back of the heel. This is the position--tne thunm in front and the nanu iietund. We cow have a nornii heel ouiime. and you can cauee that cuoically when you make the rccuctioo. We now attempt to reduce the outward uispUi*emem of the u-ot. to ^:un centner 1-ctween the artwuiar v.irfuees of the tuna nuu tiiiuia. We push the hhula ronileolus m acainsi the tibia to restore the contacted the joint sunaci'i. Don't bother now ;i:-jut in version of the toot. When we have the nhuia ljack the foot wiil eo back with it. My pressure here is outward oa tibia and mwnrd on hhuia- We are checking up to see if it ii au&cieat by findinc the laternal s'.idleoius and seems it it still remains prominent. ft* that redue the prominence of the internal malleolus, then we know the fr.teture is rcauccd. still our reduction is not complete, so now we are iacrcusinc our pressure until that internal malleolus ceases to l*c abnormally 1 t i t i - .-orrwpood. (a addition you see at the hbuiar irapture. The :*> the let; and involves the ankle or rhe foot. a an anirjlar backward displace* arkeb prominence of the heel is a > ruined backward and upward. .> iw*en broken otf aod displaced, nt of the foot. or*. -.:r r-ronlem is to null rhc .. Thai will correct two ssnforward. '.ere :a the di~nlni~cment outward of the ioit and the prominence . backward displacement of the -ach ^ displaced uoward so that at proloopcd appearance to the . the tractar*. rent down, onset ii forward, and coil in contact. must relax .ai position. This traction must .1 must he a src:uiy. stow pull-- ; cm see the iic*d come down into arc rcdinmir now. It is very hiak yetj tun *>* it .-ome down r it down, we can hoiJ the foot Jr vhe thumb on the dorsum of the sSg-'yod push the foot forward into Ao*opcr rcIation.'<uos. We push with our hand !-hinJ <.n the -. forward :r .-m e field rher" i*.:nd on die I'.i. k of 'nr iwi. hand : -hind. ily n ii-n accfr-..c..n...r..... .. . .'o v:un ;`-i:.i. V. . :ni.*h ; - ; .-a .n; a-."' *.fd :: -.c.r i-v the internal i onmierc. now wc arc > ra.-wt to lie abnormally reeui'wis ' Afvbojl *i*.d S'trmrri > .0 prominent. It is necessary that ail this .dmuid be bone fiowiv. with a steady pressure, with no jeritimr motion of anv sort. This is the reduced fracture. 1 think v.m can notice now that the foi lies in normal relationship with the hi. The prominence of the internal malleolus lias completed' disappeared. The r-nale on rlie outer side at the site of rihnlar fracture has disappeared ami there is merely sweiliair over he lower end of the fibula. In other wonts, we have corrected tne malposition of the foot and have brought it hack into normal relationship with the let; so that the axis of *he foot and the axis ot rite Uv coincide, in that ;>o5ition it must be splinted, md we use for that nunued piaster *ti.n:s. fo usin'- these .nimts e 'iso r.o fau-iaur a iiats>o*vcr vui'ik tin- inn flannel you ace. amt tr.c piaster i-aiiuaucs :u ruitoi to tc.c (ucaauren stria : caatoQ flannel. We use two splints--a posterior mm.ieii .-punt cxrenmns auuve tne knew and a suaar tom; up notit smes of the -_\ You see now me ii.uiuet is reined m over the eunes to keep the piaster from cutting uuo tne patient. That con be carefuuy molded to the soape oi die in, anu if accurateiv muu-u m produce oo pressure symptoms. You will notice oow tnac the toot is m a shunt d.iree of inversion. You notice also how the splint u molded in to ut accurately `nape .i ta hi. Y->ii avoid '.ti*is the possibility of pressure crnntoms one to more pressure at one point chan another. You notvea* this i?dune, I ha knee is hexed so as to kovo the mus.ie.i feutxv.i o :::at mere wui in* no mndency r<> cause ti.'iU.ui iucat ov niT.-ww '!..Moil. This must be m.ur.iameu. I am pr^.-om; tlie ii '..tr.or ad iiinc he spun; u iieir.u put on so mat the iut iwn ; .iuuin act. Now we are putting un the so-*:uaai .-uuar tonus. My hands arum me . 'inrnressinu ice maiieuii >o mat the joiuc will ir.tact. You widaee :u the x-ray how successful that can i. Ac.-.in the uiuidinc ot these xpiuils is aonu o make them rit accurately the surfaces to which they are opfx.sed. It eery important; o'iier.v . it .vouiu ii- very u.;r.cuit no.u ir.iciucir.s. H**re :s the crushed si-bnc running ve the knee. You r.o'c rne flexion of the knee, and how * i---<(- these si-burs apply in-msciccs m the contour ot the <TC::;::y. Y-.-.i notice *:;e !; :n ir'anai r-ia.mmsiup with the i-l. You -v the sdiiht deeM'-f inverse-n <; ... \ .-u e the . ppli- anou .if .!;e -;n:a;s .pujv.* ri.c km*'--.' ..v!v -re ai-pn-'d r-*uti-i i-.irciia. :Iv.** s> !tie picture 'he :>-:*i :*.a *hi,> unn Y - i t an ,-ce m tins picture that the axis the .istra-alus now ur.uef rhc tibia, the maiieoius is '.'here it ivl>>c;s. .viul trA-i'*' <!,.-- > .f,; i >:iia ;:,<l libuia. The ; - -A:.-re r :...... . -..si i have /. w.-ui|t- : -nrin ;!'!.a ai . :.cvn--, .u'i, ;:c-nn:.l. I ;:n -cid......... ...i .......................... .w . i;t.v anninn t-> tinr *' .t:r.<ir.-< <>i 'he -\tr- mi1 e. Wi,.;t ,.< ;uv done is : hive ; .auric iv-i-ut he;: i ;l:- u i: h tin* ::n.i<lt:t':d l*'f*.r Tilt V *\ hull tl.Ul m\ cv:A{. .1 .urra:. n K .- ' -- i. i'. :s uii' nv rc.i.uha' h.;pi-i`.* aid :.v : vv -;:vr *:;* i.v .|cp that wu can art rtic le-luatiMti AcoMupush.-sl .i-amitely. Yutuu^ ibe leu iu "0 .i^crjrv/. j; \ i > i -vrt-n: po.-i-i../? i r. << Hi mvi-i >.:(> it ml. A' y*u `-.it* ' v*.u j*ut the i.t : <:::**r-.n MH t>.. : ;*-u:i ol ir you ijn- ** prv -p:.rt :tc:un tv*. '.un<. vmi i:.i\- ixv,*; :.t v<> mud) trouble i.r;:.vuat together. I. T;.i` #*rv i. munrfu.;.:* 'v `f l!i** trrctMiM-nt oi i`> :t A i:r-- -;'v. V. u <:hi fr-ii.--- :i }' :t - "'hi.t :.* :i S.-writ ly :ui tlcf. otic by x-r:;v ect .1 t-Tr::;.H t-.t v ji*.- i W rm v.-ti have to realiii- t tic.: ;* \*;t`> !:, "arr i :. ??;*:rv : i*g~ run < the ti:vi t>r thv f ii. rt:. ini*-. !- r. : *.- rl<v g-oil as i: w;v* V.':-: y<- r. !.,- tj* :.i: ui nudhotu*. ;.it-. ib..: ;; .; . to ?.:. r.- V. bv..(j n-iure it y.ui eet .. Util-ac. it ti;i-.4 ihr-- f vcrae- <v\frrfi:.: ttt:;ii oliis tr:>'-turr nr niicnuil irt.crgf - j-::*--'i\ > i k-.- v. -I . . von r.r.K- *<< : i..>tfv.'tr. *T. - :< -:t-v *: *h`- u n: r v. :i uotvo* i-r-'-'Uc i': :h:.v in;.-ft-? to i -i t:;<i<-:; ~r:.n.. r:<.w rjfn-h 'rr;in tii.-.r un*i"r "-H-. l;i t: r.-.;'t.r (.* n - *r. m v. ;:><! tn. :ii t hr- !i..:nJn-<i!:-.r <>yr rnnttp** ts t rtr5f out :.;:u ? th^ tn.u; :wtn t(Su)a .ni;t nut : *ivJ iiui;. *ii tUv t>|- :<y t)r. tiinmsrli tit" ! muiivnU until ' h:v* iro'rcii aptm^tnoa Ikhwhi th" us.: un<5A tiufluf t ttiuv* <:oh*s wi-.tku:; nrounii n thvir 5:.*iif ttn' months utter the miration ur.vc znaiui'cu to auaiiitiei>uitumvr\. ii.iiicti. vimoiluvanarcobr tissueaeattntr ]' tliUje iirumvnt.* t< r .r:r.y jtrutit ttirty you itniciv -irt-rch ftit'm. I'juu us very irfivtou*. h .iu.st plain oramary none senw. *.vb;rh i.s a bitr component in ati imnure trenttnrm. Vo*i cut a rraouui n--ur- : 'urv os' i-.i- unsiaiiic auwic mat a ;>mh h i;h-ii i* mi'-iuimo oi suiautas strutu vuiiout the aid ot taotiumc tsuacte action. Vnu t:i>.Tticre cet muacte strain -.r. the ir unu static axsorueri whten commomv iuUou*. t ft*" spuots on tor lourwtvks wunout retnovintf tnem t ail. That is -.a comrnuiscactton to ali our wleals ot :r;w.iure treatment. Toe lucnl oi toe i treatment oi any iracture is to the iracmenu into piuce nan hold them there by "moral suasion" fftiik the patient coca on about hu business. Moral suasion h;vs to lx- ri'yrcseatcu ny puatef spiiots acre, anu is touch more bmuiog to tunetion. With an oriiiuarv nialieotui tnrruri: you can take thv sphnu off within ;>: i y--'isrm hour? tu order that tin.* r.int-tn cet some functional exercise; ui urilcr iv approurii tin' T:.c ki.utii <>l timt* t*J exercise can be fMuually incrcu-^-xl >o tiuit by tac cmc tt;e Sfnints come u? in three weeks the pat ivtit has had oi-cosion to practut- a meat ih-ai "i mottoti oi the aokie and hus Lxii a chance os civing the mux-irs electrical stimulation as well. With these Potts, because ot thv utsruplion oi the joint, that Iwromes a verv r:-kv procedure, and so the ic thing to do is to keep them unoer constant of-c.-vation. aud so ie put them to i.tu ior a period oi a week to ten Uavs with the leg elevated. subje-te<i to a low decree ot constant beat. ^ypfi'lwvgaa -.ou -an we. it you put the foot us a re-uit m it ynu ,ra. i fLivr been at so much trouble : H^mnins of :ie treatment of ju.-t :ia rtfiHenrly as that one ` ' . v\ .vit v ! have ro realize -!i -h- r,r ?hc hhul:i--. ... ;m stood :ts it was `ure t ..n 'nrernaj malleolus u !-'*n v`'` rdif^* :t you cct "*** "stornuf malleolus fracture :-j iwar weurht. and you rarelv *e 1.4 an :sm,iaP t,.*suc healing - -rhiit w-i.4 normaliv a dense faurn strain. ".a-n ytr~m that ankle mortise :n which this bunionon of the orocedure * ,dftir out - aisu a.1,uhl and put a steel :u* ai fiailfs<ii until we have `in. A mimiierof rhosecaso -^.ji utter jhe or**niti<tn have <UW an areolar tissue healim- straui eariy you simply lit'plain ordinary horse sense. *fnt- \ ou get a gradual recur- "*!* "f standing .strain 'r.vrWe get mtirefc- srma " :n..v:ng rfu-tn at -iil. `H-t ;H r:;r. Z-i ..... fht..n hi, M,.r;iJ *' *"' * ' h n.< !' i:;;uri;;/ j:;n ' *' ' V. r ,--.n j,,. 'hr.- rj,r ' ' ' f;k.:> ar.d has - uvli. '"rU- 'h.it become., ;i vrrv M in nn-[i:r ronst.int 1 a v.vk -,.n ""'bt-t lic-rit. PrncrcHin.n of Mflienl ntui ,'iuroicnl StrUoo. "fl Right otf the hat we have to realize, of mumc. as you men ail do hut as the average doctor usually doesn't. tbit a fracture is an economic nroolcm largely. Not only a there the employer, and the insurance company. but there w the man's wife and his children--all{-.vlm-li imve to lie talien into consideration. So this story of putting a sum to insl tor ten days is .sound. I am absolutely convinced that the ten days which this man spwtus m itd represent anywhere from ten weeks up saving in convalescence m these nses. I bid occasion at one time to go over a im of rhe fractures of iiotii bones of the led treated under industrial mnuitious in New Vork over ten vearj. Ti:e fracture gave au average disability time of nine montns. I rarae to inquire into the muses of disability. The cause of the disaoditv was the fact that the leg iivciied when the man stood on it and ic hurt him when it sweiied. That was a soft part disability. ' * We are perfectly convinced that the soft part circulation not oniy as regards t's connection with hone heaiiny. which is extreroeiy mtcresune. but as rrarus he convalescence of the patient suuscqucfltiy is a matter of extreme import ance. For some strange reason it u presumed that a man can uave a neoortu- .-.zc and inflammation in the n-zidn of a fracture which wul stav there *i.\ or ` eight weens and chon allow itseif to oc rubbdi out. Of course wnen you stop ;o think of it this -s perf'.'ce fiuiucfue. There is no aense to it. We know if w ret hemornmge or iiuiammatiou trait within seventy-two Hours it is organizing ;n:o tL-suo. and there is r.o reason :t '.von'' <* m a fracture, if you aiww these patients to iaive a ctfcuiatorv stasis during the arit days alter file time of the homorriutge, wnen it ts a fluid tiling ana cun i>e removeu by the normal mcviianism of i-ircuiatioa in the leg. you arc going to get scar tissue. Vu can't laugh it on. it is there. The oniy time you can get rid of it \a cariy. when it t fluid, when it can jttil be remove*!, io the essential thing to prevent dtsaiitiiiy. (iroviued you have acaimpuahv>l a reduction, is to i*;t rid of flic iiemorriinge and .-xudation. and it is a fooiL-h thing to ,<iy there isn't much when yr*u i vatviuri-.T : !:o anpearance of : Su'.f woman's leg. If you let it -Mv tr.'Tt* i; ,,:ir ?:-siic whi.-ii s .-iff.ur.dtng the blood vessels anl nerves iisisirrariBg ;iu-m. ar.d ..f '-jursc vu'i gvt ni.-alulitv. (f you treat these cases i:,;.oi.'-gv* : --.in-nc'! .viridn ;-.r-t tveek '.vjien it can le removed. y-ii ''in >;..;vu fa:s ;eg <:i.;ib::;sv '*>rv ifv rhe mpi.-ymcnr measures viui-h .uni at that one thing, the restoration > :a:s:*ii as i>s.-ii>io -A i.ormit .irealatjr.n. - have nt the disability in three - mi a.df. i.. i *->tr id- biiu v :.. runs i;r fha l'<f t's :'met tire of th:.< :':-f<rn\i:::;;v:v -tvi.-.-n .wm, a r.vti man ran do iigiit w.-rk with an ankle . ;, ..( ".a.c ..or Liuv : .a -i\ i-i..tiihs :'..f light -.vork and f'.veen eigi.t a;:a nine months nmfiia.l .'utim: work. 'A e ;-al lin-.t . ircviatinn by gving :h- man to id right after the reduction, eva'ing i--,j ca-.i^r a.-iv. i-:;.v;iif *. -.t.d ai'hu'tgh i* rin't d. much i:i 'ho way of function, file pnf'a-ni cc.fi do one Oiing. whicu is tn keep his toes fis'.antlv going. anI we can keep .liter him all fhe time to give him some vMofct.'T. IV.' can i '"m il iil.* U-g. hut we can reacu his thigit muscle, and the normal .u-ttvitv ..f the thigii umscic hHtis the cireuiation. The c.-.scntial factor ;< nuiM-ie .I'-miiy. W'c - m lake a normal individual and eumjiielcly -plint r%" l,' A*J^ .Imenecn Rc:lutrt .1 --/v./T/iee the lower extremity and then walk him around (>.r tw<*ntv.:mir hour.-, and I can show you a brawny edema of the It*?. U'hii>.ui scm-ny the venous circulation is almos* and that -* " nv wi:<:; rciti* ms li- to I--tl and then get up, although therein noorram** di^eax at ail the extremity, u will nwetl. Normal muscle movemcat U essential. We feel that norma!, enostam bent eve? the !? ts le<ettrt:-.l. llich <iegfee of heat art* damaemc. hut a lw tor::- . wha? r< ticeu'xi. With ih'** Mtrrib* notai*iir*-*--!*:;.<* <.i : t*.e fattent. Lfclf*cti by artihciai niuscb* stiuiuiatu*) .tor wimi, tin: .'vicsr; coii L- un<iuestion- ahly the best, mechanism) oi the thieh iu.'**W. and a mu- decree oi beak-- we try to restore tin: normal etrruL.ta.tu Wc yvua'.tv had that tin* sw-::ir:?. i: :h i- .-ar.-iitiiv. <;;sjr.:-:i:v\i by tiic ctat ot the seventh tn it-* lent:. mv. wua a i, m* average time, asm which means tliat the rtn*uiataa l. rrsmr.Hi u<*r<- or i*>s it* normal. We turn pet the patient un anu we cot him uu ti.u wav; First. we. let ins tec oaag down nvc minutes out ot every n*ur: tr.e next ua v we tet it hr.ne uowu ten or hiteen minutes out oi evert* hour, amt so on until the ice nancs flown tor an hour at a time, That means a total v in tnc aosiutai oi ten uavs or two weeks. It sounds passibiy like iaise etinomy, xs 1 sav. As a matter ot inct it is absolutely reflected m results atm means a saving ot weens or moatns aiterwaras m toe story. We remove loose snuncs ior active motion wuiun patn hmus at the eau oi s`our weeks but ailow no wetciit i*ean.-ic wiiatsivevrr at that VV Cut don*n the spurns to ociow me knee at tne cna ot two w'eetts ana allow unce joint motion. That is practiced ana encouraged constantly in that secoau two weeks. At tbc end oi tour weeks we take me snimts otl daily and aiiow rnem acuve motion within pain limits and then replace tne counts. At the end of the sixth week we start them on partial weight bearing--ihe sixth or the eighth week, depending oo bow severe is the damage that has been done. At the end ot the tenth or the twelfth week we usually reach the . stage where the patient can have wetcht bearing with nothing Put a cane, and somewhere between tbc twelfth and the sixteenth week he is on full weight bearing. There are two things that are important. One is tiic iact that you must realize that you have given your patient a potential traumatic fiat-foot, fie has a very marked loss oi muscle power m the leg. lie started with a lesion which has elongated the structures on the inner side, so he has weakened muscles and stretched tissue on the inner side of the foot, all oi which tend to give him flat-foot. So that, from the tune the weight bearing starts we do two thiogs: one is to put a lift on the inner side oi the sole and heel of the shoe; second, we teach him to toe m slightly when he walks. Any time that the paucQt u seen walking in any other way he is ealied for it. We give him practical wavs of doing it. We tell him to keep his eyes oo the ground and touch the cnck on the sidewalk with the toe. Tlurd, we supply him with an ankle brace to gwe him support in this slight inversion of the foot. The oroi ankle, and the w*il. ' brace lacto bone suriro brae bat a ;> a If you h \tu have treatment .'A*r**** `"i. ,-ar th.ai tre.u mm tibimtouiar after a ionannic tract C^iicd Fov rr.on**y Thr.r.x T:ir C whicu D*' the Mccucto tnani address. I would it you are Dit. M good ma~ under a * tioo oi t average to work patient Tne Murray As D will go First A he wou his abs Da zespec Stanch * z-r*--*isr--.vrecrT'caw lo Ajjocunion a Around for twenty-four hours, and T e leg. Without activity the venous > by when patients lie in bed and then i*e at all of the extremity, it trill swell. ver the leg is beneheiai. High degrees rature. and a constant one is what is --rention of rhe toes hy the patient, :'-,r which the .'mart coil is uaquestien:."|i.'*cics. and a iow decree of bout-- ,:.it is done carefully, has disappeared ay, *hift is the avmri tune, and *M more or less to normal. We then -.-.is way: First. we let his ley hang next day w let it hang down tea or on until the Icy haocs down for an ia the hospital of ten days or two "umy, as l say. Xs a matter of fact r.caos a saving yi weeKs or months :on within pain limits at the end of whatsoever at that time. We cut .i end of two wccks and allow kaee ouraged constantly in that secood vines off daily and allow theta active (he squats. ^^em on partial weight bearing--the dgfcow severe is the damage that has ^twelfth week we usually reach the raring <vi:h nothing hut a cane, and \::een:h '.1'irk he is on full weight One : ho f.-;.:t f/U.t you must >tcnsi.d traumatic flat-foot. He -. the leg. Ho started with a lesion * mner -A- mi he lias weakened .t(l,,f .vru-iii lend to -v--ght hearing -tarts .. do .<{ i'uf We g[v him 'n rus rv*<fl on :hc ground and * riiirtj, *? s'ippiy him with an : ;ftvr-*ion <jf the foot. Pmceedmes of .tf<<iieal nd .Siinjtenf $iu>n 23' The ordinary ankle brace is made of a piece-of leather lacing around the ankle, and is o/ about as much value to the patient as hatting his head aeamst the wall. W have utilized what is known ns the skating ankle brace. which is a brace lacing around the aokie but has longitudinal poettets containing whale bone supports. That type of brace is a distinct help. The ordinary leather or elastic brace does nothing but make the pauent know he has something there, bot it is a waste of time as far as the treatment is concerned. If you have recognized the dismotion of the interior tihionbplar joint: if vou have secured a proper rcuucuon; u you have realized what tr.c attor treatment means, and rhat vonr disabddv later, rirovmed your none m corrected, will come from cireutMorv mstumance nnn from tac orouuetion ot scar tissue; and if you appreciatesne iact that you havg given every patient that comes into your hands with a Pott's fracture a potential fiat-foot anu treat him on that basis: acux if you realize toat toe aeauag ot tae interior tibionbuiar ligament by areoisr tissue is not eapooie of wetgnt neanag uatu after a long period, I am quite sure you can cut oowtj the uuwniiscv time of ankle fractures of thiy particular type, wmch ar&tne oniv ones tnat *aauwi be called Pott's fracture. This wiil result in an economy of uotn time anu money. Thank you- (Applause.) Tits CifAtsifAN: l am sure have ail appreciated the vaiuaoie Oaper which Dr. Murray ha3 presented and taat we wiii orou: by it. na ueruut of the Medical and surgical section ot the American ihidaay Associuuoa ; >-un to thank the doctor for the nme and trouble he luj ukq to -,'ive us tsu address. I would like to ask one question. Doctor, regarding the anesthesia. I take it you are dotn? this under a ioeai anesthetic.' Drt. Mcrnr: No. a jenerai anesthetic. Thu was <aa oxygen. We do a good many fractures under local anesthesia. Wc don't do the Pott's fracture under a local kc the reason that it .? nceeary to act.% very complete rciaxa(ion >f the muscles to vvrrmtas that upirard displacement. We had with the average patient, i: you allow itim fo aav ror.jn<ius he is apprehensive enough to work against you, and thU particular fracture, we like to have the patient as much out of the picture as p>>sibie. Tits CiiAinitAN: [ do n<-t iu-iicvc it u in order tu discuss or criticise Dr. Murray's address. A.r Dr. Kennedy, mir x -t*<-.kcr. is iv.t -at ti.o r.-*ra at this moment. -.vc a'dl go .hi (<s r!:- r-.*jrt >! -be C- mmsttcr (*n l A:.-n*.-'in .-i ri;r Uar <*f .fianlard I-irSt Aid Packets, I received a ic:f*r from Dr. Cnovdcr last night which said be would not be able to be orr-ent nut rh.it Dr. ld<: -vou'd present the report m his absence. I -vdl ,,. .-.id -a Ur. Me. Dr. A. XV. toe (Northern Pay.ir. Uiuiway}; Mr Chairman: This report :s respectfully submitted >v rhe C.nimt::o: **n the Kxtenmnu of the Csc of Standard first-Aui Packets. Dr. T. R. Crovv.i^r. Chairman, 1 l-T,' 1 ; l . - " w: " i" V . i J>.. nnn ;? ;'</ .1 (.'.../, "There has been no meeting of your dv.r.r.:: ;i*c \c:ir )u*t ou.wd. and ni developments of iminsM< have t?:-.r.Mun-<i, .- f;.r :i' known. mere has Ixvfi no Iccu'ktlion i*n the si>*-vt *{ :;r.*i-ni*l compnicnt i<<t cmtn in anv of the states and no retaliation* *f order* have in-eo i.u*-d liv pyhl.c --rvu-c cnmmtaMons or other bodies havmc jurn-hrtton. Nt {:::. t!s**r' -:>. .- far us known, any extension of tire uy of t.. standard /nickel* by rt.e r.<n.;* "As outlined in previous rn^irrs. the ixintic *<*rvire rofnmi>*n>n.< .<f 11;:rt.-~ :in<) yi:lwrhuset1* liuve approved the cuqivalent << :!ir neck* . i.-r - i;; those tS*e **'!?s Iain; :v*-tv 1 !..w f\>vr yiiif different or additional cquiumciu ace m v.'vt in C:iinnun. Mivhiunii. Indiana. Missouri. and Wisconsin. (Sec rc-xirt *: l<W|.i The reipnrenicnis under these laws are n* believed t i*r *< desindffe or > pmriimb:*- a the standard packet, hut tl.ev are neither onoo.,i,, rv?--nut r-r \ should arise, it is ajv.~i .v try* cnmtr.i"--e i i. i ev-- seive* toward rhaneit.s those laws a* Mib*tit**'e tt.- !.r::ir.i :.;v.e* i.-.* the present rfiiuirenwnc.-: but it o-'s ter I,.k:uc :uc \*.r e.;'ii on this fei.rc. If the quest mj^enme* us* tn oinrr Sta**-. nrt Tru*.n> arc :uivi>p'1. to urcc the adoption of the .Vanuatu twricet. to tuo ett tiuit umuinnit v may obtain. The committee win ctvr -:en iwtti us a vuit m tw* rotmrm.ir;. "In audition to the states aixwe rrtrrnMi to. tie iwmmttcv irtwrt <( 11*31 lists Sett- Hnmosntre and .Sutn (Jannuia as nstuinnc sr>atm**t t!r-:;t'i equipment on tratius. A rcrent survey oown tins u. *h- m error, i uc New Hampshire law ouoieu reiers nine to mnmi;aetiiri(i^ inaius anu sin*f*s. South Carolina has no law at ail on tar suojeet: ta- materials o<te*i a* rmuired there are only the n*tiT.:.- .* d ivt'uiuv iin- **y 'w ** j :*< iuiu-mui travcrrttii the state, ns u voluntary proveuwii. *`An omission in the d.*cvi'`u,< .^nr.f' a;o mtt>' Ue u--;>i. The i..\>> > C-nnectieut Juive a rettutrrraem i.m. dT-T .i uw tifte-nii .'lututee. lteviM.nu*uie nwapiud stretcher oo each train for use in case i mviuunt. "Ia conclusion, your commuter wisues iu cmuc.sa tunt it has served hut a me&ccr purpose dun&t; toe year. No inquiries nr suezesttnus nave cutne to us atter.uoQ, and n has not seen the way to useful: nor d<>vs it see auy tmeht prospect of beioe vitally useful ia :he immc*naie future. Hut tf a has ser\*cd without worthy resuit, n has also serveu without cyst to the sieetion, which in these times may he worthy in itscit. uir fate is m your hands. Tl;c com mittee is at your serwe--u>r erestmuarsH', if you wi.-ii it; for oi.'ciiarce uttii Unnur. u tluit is yv>ur pieasnre: or wuiti-u:.y.u s-. tioirc. Tiis Cii.uitUAN: Vou have heard tiie rcjxirt. Arc there any comments/ Dr. G. G. Dowdau. (Illinois Central Railroad/: it seems that ivc need a permanent committee for this purp*sc to take rare of conditions in the different stales. I succest that the committee he advised ot any new development in any state, tlint the committee he tlianked it its work, uftd the rvpor. accepted as a progress report. Th CiiAinaiA.v: You nut that as a motiun to continue the committee for, the vear.` . D:l. Dt:. !:!*.c t .ik thi kCt' 1- C.oa It in Tii train \V oi n 11 -.toi r Hi t r:i< i win- wou n the over slitt kno Act nut du< he tbi it. it tb dt ; ` -.^VT: yr^rjsa* p*rrossrsrrTwr**! my Ai*ci<uian committee during the year just pass#'!. ;ve transpired. rio far as known, there of tint-aid e^uinfococ for trams in any 'ra have been issued by public service rrtsdiction. N<p has there been, so jar Sc standard Packcn by the roads, v public server* commissions of Illinois jmvalcnt n{ the.-tarniard packer for use mi ItWO, respectively.) faiws requiring are tn eur-ot in California. Michigan, -v. report ! r-:i.) The rc'csircmcnM - l--oruoi-' .-r --* i-ra-gicn-ilc as the :wp"n n>r if '.pm.rtunity. uiittee trait chief surtonns exert them- - m axil-mute rhe siannard packet for recommend *akir.g the 'Aar Path on --ther stateii. chug surgeons are advised icket. tn the end that uniformity oiav ..in as t m '\v3 connection. .-red to. tiic Committee report of 1031 ruiina as rroiurtng <pectni first-aid has shown th:s t. ><o m error. The r to manuiactitr-.rig plants and shops, abject; the materials ii.-rod as required o.-cd by ..;;p ;f me ra:irna<ii traversing is also niu.-t n*.:L The laws of .7,7 M the (Jcncrai .natures. Revision tnpany shall carry a suitable iio.-pital '.accident. -s to eonfesj that it has Servesl but a _>'uiries or suggestions have route ro its ic useful: nor doi-stt -on any' bright r:nc*itu fuy.irv. tint sf it i.a.s o*rv<-<l : without vot i;.,- ui. .*. pirh *uf i.i'c :< in voijr h..ni:s. The *, it *.<! -a :< .li.-charge n nil ;f >o.j ... iic-irc." r*p<*rt. Are 'her* any rommciiM'.* -r:.; j ?; ns m t ?:- :::f>-r<-n r new '.vc'.oi'inf-e.t m t i* - work, and ti:e report .ivcer.fed 'ion t,, continue the comnjutr-o o.r Pmctcitittq* *f Moiiml `tn-i S-miaii n -'5 Dr. Dowd-vcl: Yes. Dn. S. C. PtcMstcn fChicagn. Ruck Island ,fc Pnririe Railway': I would like to second that morion. I think we ought to keen this committee as lone as there arc *tatcs that do not have a standard nrst aid packet. We ouuat to keep up <iuf missionary work and cut as many as possible to adopt our oacKuge. I see at least two chief surgeons m-m Missouri here and I would like to ask them about the law in their state. We were jacket! up by the Alt*nun orate Commerce Commission, or whatever they cull the hotly--that is what they eail it in Illinois. They called us tn trcn.;p.t irecan-c we oidnt have their first aid package on trains. Thev crated what the law w.is amt 1 never "'as more surnn.-cfl m mv life when 1 saw that one <<i the essentials was a camnrtc triangular namwee. of the sue ordinarily used for a .smt' to sustain the upwcini extremity to case oi fracture, impregnated wnh nime acid. VV'e wanted to rorooiy with the law out we found there was no maouiacturer of surgical supplies tnat ever made such a thiac. They gave us a certain icacca ot time to enmpiy with uie nruer, but we emtnio t because tnc manufacturers said they would have to experiment and tinti out how they could manufacture that thing and impregnate a hut <amoric iiandage with picric acid. They finally gut a speiaai tncliiod and aisue a spociai supply ior tnc tew necued. which ot nmrse cast a lot :a prupurtinn to tiicir value. I would like to kaow if you nave dune anything annul that iu Missouri, or whether you saii have that ansuni rruuiretoeot.' if you catvu. i un you would get them to du aomctuing uaTcrciU. Do. IL A. WiKiLotV i.-jt. Loiu-v>aQ i'mnctsco Hauaav): W- hau uefore the Missouri ktate Legislature what we <:u:ctl the Arnica idl. it w.u mauc over as muen as we rouid. 1 lin.ik n nronaoiv i:ul .-mei'r.:ng <iu wt;h the .-iing bandage imtmgmitcti with picric acid. It is *!:ll ;n nect. As lar as I kooiv it ius never been iuu. D.c Pf.fji.MEn: Ic i.s uicd un the Rock Island. i>n. Wikm.-sv: t dun t know uc.at vuu u.-c it for. i: is m rhu |ack;tge. Ai-.irting to m:c l.nv <(' the state wc have in supply ;t. tl-. cry train lias a ::um:*-r of tlu>e m.'C aid packets, and whcnyv-T onc-w h*-m is i-.miI llie <-on- lucior lias tu make a report of (he injury and of the Use uf the packet before ii>* van have the nacket rr-niaecti. lf is sell .n . :Tc-t -n<i [ d..u t kr-uv haw we are going to get :t changed. [ min-: .t n a - .<v :r:av die 'riangaiar "an.iagc m it . m frv :*i.mi with ,kA have ivg;da rury licit It i.a.'d !u ' With.'' Ou. Pf.rriMtn: 'A `ivn I gut iIns fuuir*-incnt I rnuidn ( believe u. (thought :f ccrt.-.udy w t.< a nustakc. but l n.ui our iaw department bok un the law and there it was m one i die very unprr*ivc volumes of the law. There was no donut aiHMit it. i *' :i - t' ' 1; A *,,?' 1_ ?6 rlmcnmn Radiew Ar'oeioit'W' Dn. A. M. Hcste (Ann Arbor Railroad): My recollection in that a few years ago when l took this matter up there was no eurii law in Mia-ourt. I may have overlooked it. hut 1 would like to know from the Doctor if he know* when that regulation wut put into effect. Dn. Woolsrr: It was four to six years aco--year?. I guess. Dr. Hcme: That was More my time. The Chairman: Are there any further remark* on the report? It has lieen moved and seconded that the rej>or: lx- accepted and placed in the Proceedings as u nmerrw rvjvft. The znooon was put to vote ami earned. The Cuauuiax: I understand Dr. Kennedy i nn- with us and he will address us on "Emergency Traction TreatmentI).*. Ki-r.uitW' {.\npuu.w.) Dr.. P.oev.nT H. Kkxvedv: Mr. Chairman. CicR.irmen: 1 want you to know that I r.tipireinic the honor that y.u have b\e me anting me to neak on the auhiect of "Etnertrcnry Tract ton Trent ni-su. I am come to conduct a'dcmonstmtion shortly of a method that we use for this treatment. I wish it to he understood tlvat l urn not attemntine to teach ahytntnc as far as emercency traction treatment is concerned. Vcu know the principle. All I wish to show you is how simntc ami practical a method it mav l>e. that it does not reouire a wree experience. and rj iorth. m tie hope that you may feel that it is a proper mine to eoofierate in tnis plan to help the injured man. Your work of prevention ha* been most ably earned on through inis organi zation. but there arc mam* injuries watch arc tromc to occur tn spite oiwhat any of us mar do. By and large, fractures will be tne most wnous croup that we will have to deni with, and the most permanently aiauoims. There have been various estimates as to toe number of fractures that occur in this country m a year. One estimate puts it at over 2UO.UOO in year. We made a survey in Xew York City, and a conservative estimate seemed to be about 23.000 in a year, if that is the case, the figure for the country as a whole would come nearer a half million than 200,000. How many of these occurin the industry which you represent you are better able to tell than i. Dunne recent years there has been on increasing oemaoo for better treat ment of fractures. There are several reasons: in the first place, by the institution of follow-up clinics, it became perfectly evident that the late results in fracture patients were commonly indifferent or bad. The public had come to expect that a brokeo bone meant quite uniformly visible deformity, permanent disability, or probably a diminished earning power. In the second place, the adoption of federal and various state compensation laws brought home to industry the extent of loss which was going oa through indifferent treatment. t't Annotation My recollection i,hat a few years - .14 no such Law m Missouri, t may know from the Doctor it he knows * .io--it y'vira. { ' remarks oa the resort? he report he accepted aaa oiaced in d. I.-ntwvtc is now with ui and he will menu'' Dr. Kennedy! (Applause.) rmao, Gentlemen: I want you to . have done me in askmc me to apeak Treatment." 'iiortly ot a method that we use tor i that l am not attempting to teach merit is concerned. Vou know the ,mple and practical a method it may nee, and so forth, in the nope that Sjtgfrooaerate ia this plan to help the .4^*1* ' 'ably carried on rhrnuua this organi* . :tre coin? to occur :n xpite of what will Ue i hr -eruu* croup that rmanently ns.ii.iir.c. he numin-r i that cur /.it .it uver ,,`isV*W>a v-ir. We .n.crv:itivi c-nmu'e .-corned to be rigur* ;>r the ifotr.tr*.' is i whole v Ai*i:r:n the u.> -n -...i ..a L f!-utc i!vei:ir.'j ;-*r for sreal- v-mo .uuio*. V <N"vrr.e ncricttly fiM -A.-r- .(.n;r:i'`ely indifferent '.it :i broken hon* meant quite .iulity, >r probably a diminished :1 --tut various Mate compensation : `m which whs ijornt oq througa Proceedings of Metiiml and Surgical Section 27 Third, increased efficiency in the economic management of industry showed that lose ot time, permanent deformity .ma permanent disability cut into the profits of industry m dedaite dollars ;uui cents. Improvement was needed from this point of view. Fourth, the popularization of the use of the X-ray by which the patient, the employer, the juries, and the Comoenaarton Boards of Review could actually see what the coooition was jo far us the position of the irr.smems was con cerned. made us ail feel that there must he improvement m the treatment of fractures. _ In addition, the wsr save a Ur^e number of sureeon**in opportunity to treat fractures and become interested in them, dome ot mem tl regret to say I do not thick it was a larze proportion! orousnt oacic mat interest and tne methods worked out to civil life. So we had that the puuhc. the employer, the employee, aumimsuauve boards, anu the metrical praieasma are ail coming to ueffisnu improvement m fracture treatment. This is evidenced, as far as hospital treatment is coocerneu. tn the (act that on a great many services it is demanded that the most expcricncvu meu uu me staff, or oat of the most experienced, shall have coarse oi fractures, rumer than Ins was the case when I was an interne in the hospital), having fractures left to the youngest interne. On many services now. wnen a fracture cornea ,u it is given the same attention asanacute appeuoix. i`. aiust cm otictuwU w the proper thins must Ive done risht away. Knowing mat Nature unmeaces the repair of a fracture as sooon as it occurs, it has seemed worm wnue to institute detinue treatment as soon os possible, and nut wait for reduction until after rounds the iollowmz day, .is has often been the custom. These are important factors and have dcasiteiy improved the results. But it is nwessary to go still farther bock, and to attend the injured man effectively at the sue where he received his injury. Large industry has taken up nrst aid quite .vnole-iioartediy. First aid crews nave lieen developed to a high decree. The Red C:"s through its H:*-v*e.s iias trained over nOO.UOO to Uvio as individuals nr groups. Such organizations wuh :o use the nest and simplest methods. Ti.c irm u:ics these can naturally obtained only from the surgical profession. In one croup of fractures trememlous importance attaches to the treatment .;vea at the site of the accident before the patient is movisj. This is fracture i 'r. lutic hoivs ut :he e\*.rctumcs. '.{'at <ii the instruction is in methods .;i:.*h are nut ctficient even :f r>n*feriy applied. 'A- l.clico that traction is r.vi c.**ry to lessen pain and dawk and prevent further damage. The lone i.i.-ton splint which is used m a great munv places :w the routine treatment, will give a certain amount ..f immobilization. Hut a Liston spunt. I think you wiil agree with me. is much more uiriicuii than iracn..u to :jply properly. It -4 inure dan*zefus if uot applied properly than if nothing is put oti. It makes a pativiit difficult to move, unless an ambulance is handv, and when all is *uid and done you do not have nay traction iu keen the iruifnwius m place when you have applied the Liston splint. Overriding u chaniuternuic of these fractures. As n>(i as the continuity of Wne is broken. Nature attempts to splint the part i 1 H A 2S by rnu.vuiar I':..- pri.grc-Mve wvortuUnv:. "iih pr.-*tmc further to ntt:----.-. v*--*-1 <-r v-rve fr**rn the fragments. or a simple frwrturc nn-.v i..- cmivtT'cu mat :: .fiiiT-'iiad fracture. Tr:ct.ti suttincut to neutralize the ;jil ?" r::ti.*ci-- is nc--.*:ry ; prevent further damage and lessen |uua and .dnk. During t!..* later vmi- t.{ tie- World War the cnuw'i' V treatment of irar. tun-s of the extremities ':i evrelleni. j...rti. tib.rlv tn die Amrnran and British t armies. Xu nnritr in tin- liuyai Armv Mdtcal tArp v.as allowed i*. g> m the front unlcM ho "mid apnic a spim: nmprrly m a definite time. I have seen !* nv-n it; cm.:::** Sm through the ThortntS splint (trill-- fioi tin*< Hirers. i.i! 'I.< : turn. i.si* 5he nr.aiar.-1v>- of Hri?:.h T*-mn. v. and they were n.it :gi<\n-l i* g.i ! the ir.itif untii they c*.uiu apply the 1 Loituis splint ui, I think, two n.nmuv. The American artnv imnmvni the rvite m* splint ured and cave us the Ke:kr-Uhtke lutc-i'i ::t.C I'hc-r were in tin- front linr.< :;;..icr t.:*-a:..: wi:n<:s without one. i hearti Dr. N it*ijis : . in..mu mne i. the ttre**ing station .inn Ai.,xn sav he h:ui tin; experiem-eoi train ing over ;:.i-i in tin- kanming ti.:> :i:tn: during the war. tie S.std tr.uf an enure ieittaiio^Avas tnnnm m two .rnrec hours, not ju<t 10 put on r. splint in the uiien air. i.m wears:;*; gus ttuoxt* wiuic they were omc it. The stu'.iils were pm on iikw mhieuti- lonisitioiis. anu at tne enu of two or tr.ree l^niri tiwy couui aii put tiu-in on very wen. There neons to oe no uueuuate reason wnv civilian injuries of the same tvpe shmiai not <* given me same treatment as mey were iriven uunug me war. I tiiink von mi; agree tnat tin* average citizen ought, m ic able to put on a spiint as weii as a bmuh Tommy or an American dougnixiy. 'A i.'ii ui ininu. several years ait'* w tvmow at Un; iM-vkumn etrevt t >.<*- pttal. where weiiaua large imeture serve-,-. that wwle the men were tome uowu see the fracture* nmticuwteiy, there were a good ni:uiv i-u>es wnom wo icit had been tiistmniy uauiaced by not iavmc some emeieut spurn applied ueiore thev were iiroucui in. I rememoer a ease which brought this to mina very definitely. A sum was brouktnt tn with a compound fracture of the middle of tiie shaft of the femur. He was tiavtm; vonsuierabie hcmorriiace m the soft parts of the thich and was ! i i j I in extreme shock. He was watched for several hours. He was sumutatea and given a transiusion, but his coniiitiuu remaiocd the snine and six hours after wards we were still unable to do anything for the mao. Wc feit that any interference was comg to kill h:rn. We liad all iieen trained ia traction treat ment in the var hut we iud forgotten it when we came bark. Then someone said. `Why net put trertion on the k*c'.'" and to our relief within an hour s 1 time the blood pre^.iure rose and we could operate. Following tint, at the Beckman Street Hospital iu 19-G wc instituted trac tion treatment for all fractures of the lower and upper extremities before moving the patient from the place where he was injured. Originally we applied the full ring Thomas spitr.t for the lower extremity. Ac used various hitches, one after another. The made-up hitches were discarded. The reverse dove hitch was tried and we found that os tar as wc 4 BS2 ns I'f .1 SJOCtfUtOft - progressive overriding, with possible .crvc ifMin the frmmiems. or a simple .;und fracture. Traction sufficient to -i-*ctry to prevent further damage and ; War the emerccncy treatment of frac_imvuiariy in the American and British -jv Mt-lirrj Gift's ""aa allowed to eo to __i ,-piin: properly :a a terir.ite time. I : ng thrmi-'n the Thomas splint ilrill-- me ordinary type uf British Tommy, r-mt until they uid apply theThomas no of splint used and gave us the These were applied rn the front lines ;o moved hack to the dressing statioa siiv hr h-.ui the experience of train man during t::e war. Ue saw that or. are* hours, cut just to put on a splint while they were doing u. The spurns -.turns, and at the end of two or three j why civilian injuries ui rhe same type at as they were given durma the war. .-* i-itucn ought to he aijie to put on a .a American doughboy. . Cmtnd. at the Brvkmon street Hoswhiie the men were going down '^fttxrre a good monv ewes whom we felt *-:riflc some efficient spiint applied before .* '* mind -.vrv d-'initvlv. A man *vns Ji:c luni.i;.* ..f d.o .-haft of ifce h-mur. ,ii *!:* ~.n :::irn .,i rhe thigh and was --v* rni i. ! {- was .firuuu.v-d and mam.-d :h* -.-.trio and mx Imiir.i aftcr:.jiiy i-t ih- man. We ivit that any -d id ;..-i .'rauvd m ir-.'-'vn tnuf- '.-n i,;.: 1\. ! :.-ri -mc.oic ;r l ao'im .hi bom- ' i i-':i:r.d ;a we u-.-.united irac- : , u-r and aj.-jer rvi-'-miia-.- before a.i.* injured. Ungin.iuy we applied ' \fr<*rni:v. flier. n.e marlc-up hitches were `' - "'I md ac n.uftd that as iar us u c =wffi'[Wt *> MclienL <tnd Snntical jntion 20 were concerned it was not practical Cniess a man was puttinc on these hitches even- nay the onlv rhinr you could depend on was that when it came time to use it he could not remember how to make it and as a result could not tree ecod traction. -S> wc bended on a simple souare knot tied on either side of the extremity. We have been criticised for it but ail 1 can say u that the square knot has been in use for four years and as yet we nave never seen any disturbance of circulation. 'A'c lumen to the bait ring sunni bemuse wc felt hat for ordinary street work it -A .i.4 ifnr*ier to unniy :t .-mow irnm tin* s;c ban it was to make a mail change nanus ..U-J > leu it was not r.cev--arv to arry sptms of different .-ires. It did not 'nke up muen room in tin; nnumlanc* and was mure likely to remain graiosc the fg.'.*er xA-att than a full ring Thomas -punt. There is one thine to be said concerning the halt nnc spurns. As ordinarily s.id commereiailv. there is ho .-trap which keeps the thigh from jumping forward out uf the ."pitot. This is a must necessary part of it and as yet none f the nrrr.s nave added thiit to the splints, but it is ensv to add individuaiiv. There is naming new wnatsoever about tins method. We at Uvektnaa have simmv msi-tcu that as far as the ammilance service is cotievrniai every fracture of the lower extremity from the hip joint through the lower end of he thus and dbuia. h put m Thomas -pious netorc the case is nrouciu :n. The same hoibs trac w*fh the upper extremity. Any fracture from t:ie -houioer to (he m:::.itc <ti ;i:e farearm :s orouunt to the ho*mtai in trav(:<>n -i/iuit.-. There ate .-ertam uvhnue stnnuanls liiat are r.c-v--ary .:> tho Appiwaixm *'f ?h:s mct.T-i. : <ii>ea not make anv diilcn'Occ wnat i>.uu< ui.ir incinod one i*vi .is itiaz as <*ne appreciates' u hat * ;s trying r." oo. In the use of traction there are six requirements m any m.-tnod nm adopt: ;n the hr-t p-ace. you arc uoinis to put on some kind of hst<`h. and it :s neces sary to protect the part nece-Aih the hitch so that 'he skm wiil r.\t rubbed by :c. .'-n.i. ..ppli-xuinn of a traction hitch. i * rd. :m*:-t :? -of:c means : if.cr"a-it!^ the traction bv r.vi.-tmp #o r...: ;.-r amour.; ..f ;. an dc.-ifi*. ; '.urh. : the .-m-'mov in :he >oiin*. vt mVuon. yot tr.usf -wppnrt ' ..nd :;or . : : mcrclv n v. -ir *ra<*::on in.* ?!;c .nt:rc -'ii'mift '..c t:nui. : ,;;:i. ..;;ian-f i* bv -unpori*-! from -low. 1 iiit u is i:ci*c--ary io pre* vent larerr.i a'.ovvmvnt. 'Atr...: ;acent is h moved, r!i:en t:: c wii'jic -uiint must i;e suspended ; ...if.* a :v hat T.c ia-i w.ii '.'.or -- - ofl :tic i-'.und of 'he iworn! `he>-Ar V'..- > anhed ...i-...... ... Hor** :n mivn * ;re- : :-r.';v ant tacin on at : av i.itrom >.i .a v!c vai.-r i'aft. oil 'he dock of a -hip r .-a f:;c Wc -uupiv :-ivr rpo ;.;ti;-nt wi.'-rc he i- and apply a splint Ti;C .ii ..f tins rtftii'-i ha- tiruic rhe .i.-|i:irtn;cni enthusiastic .a-oit it .ui.-tf it d/o- not ti*r `ip fc-iffir Im,^. :vii:*nt rs not moved uu'it -utici|>ur rrioiion aitnt:cl to prevent j.irtncr damage. That li the particular (mint to lx cmpiiaoued. Aud what does it <lo.' 3f> .\nsmeAn 1.!<>ft ATI For the patsent it increase romiort and I<vt,en? sh^ic. For the doctor rt *tmnlide* reduction r.firr amvsl at th* h<tnttal. tt> - very f*wr patient* in whom there is nnv ..vcrridtnc. ns ..linwn m the iirimr:-:' X-ray. In fart, within the last month I Iiave reen two raws m whteh the rrir- ment ban tieen lreniv ovcrptiilcd ><(ore arrival and X-rnv wi* taken r*= fifteen minute* of the time the arewient hnnprnrd. Soirt ?sv it i im(w*w to cet sufiirifnt trii-lion l immnimh/** purr* I will fay t*. for { v e^en raw* ovorr-uilnl, This if f*v <t:mr**rwt* than itfutii'*tent puil. For the iwpual as weil as the patient it shortens the hospital stay hv r-**- motme earlier union. \\> cannot cive you figures on that m Hv, hut :t t* the belief of all of us who have been working tr:*h this trartmr or*.- - -. p*n'*d of six v<--.r.~ now that we rir?*r:te!v c--t vr.twnt *tit :n <*!*? "* There also lo-< v a*om nntmntnc union. Fmm the eeonom;'' vieTo:nt f h** orr**ne to totiustrv * *t?muiitie*i t-- the injured man spends fewer riavs m tne hopit;rl ann returns to *ws rrv>-" nuicslr. iicibre we have the demon?mtion. I want to eo thrmien in oerail weat w- consttiera typioi anpiiranon ot emereenev traetion. This texhihiune stmnt) is the orrirnnrr trr* ot snuot we use. The fuii rrrr Thomas is satist.vnorv tf vrm wwh. We issen it a nuooer or vrars. This t? tunse spiist. it hastne strap ann imrKie. and for eonventence we nsvesoiKiaa buckle. I; is a iicht spttnt wmeft a certain amount ot X-c*v will neaetrare. Itis made of an aliov. it is transportea reaoiiv tor u ts fiat. out any spiist ec the Thomas type wxit do. On the arm. the iuli fine Thomas would do ai*o. We use the Murntv-Joaes modification ot the arm spunt. it is net neressarv out it is easier to wore wita and easier to get the arm to toe side. With the mil rise Thomas it may oe cificult to make room tor the aoducteo arm. This is the fracture box. For our own convenience we have a fracture box which contains aU the thiacs that we use in ail types of fractures. The ociy things that we have tor fracture luppuea are t&ese two splint*. one of each, earned ia the ambulance, plus this fracture box. It contains the the dins that we use to cup the hammocks oo with, cotton bandaces, ropes, tongue depressors and adhesive piaster. Ail of our internes are instructed in treating fractures of any part of the body with the materials furnished in this box. Acoin, u is not necessary, but *e found it an economy to have all the thmes placed in a box. and then when it has been used it is repacked and ts ready for the next call. I will run through a standard application. Suppose we are dealing with a possible fracture of the shaft of the femur: 1. Cover the patient with blanket*. ?. Administer morphine, if available, under medical supervision. 3. The toot, with or without shoe on. is grasped drmly by an assistant by both hands placed laterally. 4. Gentle, steady, firm traction is made in the axis of the extremity. Main tain manual tractioo until epliot traction is established. 7 Aisocfntion , .?rt ud lessens shock. ton niter arrival nt the hospital. We see ,,iy ovtmdmt, as shown in the immediate ta I have seen two cases in which the frag-fore arrival and X-ray was taken within :*ot happened. Some say it is impossible .ire the parts. I will say it is, for I have dangerous than insumeient pull. .rient it shortens the hospital stay by pro* -.ve s-ftu hemes on that in days, but it is . working with this traction problem for a r.-tcly get a patient out in a shorter time. litunz union. 'TDcnse to industry is diminished because a the hospital and returns to work more -. 1 want to go through <n detail what we rcenry tractjoo. '.'.ry type of .soiint we use. The full ring `Ve used it a number oi years. This is * sic. and for convcntence we have a double - <-ertain amount of X-ray will penetrate. *-'d readily for it is Hat. But any splint of <vuid do also. V'e use the Marrav-Jonos nc necr^acy hut it is easier to work with ?.. With the full ring Thomas it may be ed am. aiiwa convenience we have a fracture bo* ^e-use in all types of fractures. The only rpliee are these two Apliata. one oi each, rmeture box. It contains the hammocks. ..-nocks on with, cotton bandages. ropes. -r. AH <>f ottr internes are instructed in --W wh the materials inmished in this vc iVin-i i: ,:n economy to have ail the ;n it h.tj been used it is repacked and is itH'n. ;* . 'he .`h.ifi of rhe femur: T.cnicai -upervuion. *T-..<|ied hrmly by an assistant hv m itic nx or tho extremity. Main- :"n 'f-Ahiiihcd. Proeeedinpa of Sfedxeni and Surreal 31 5. While traction is being made the whole limb is slowly lifted several inches from the ground. 6. Slip the half fine splmt from the outer side beneath the extremity. 7. Make certain that the siue hat* are in the medial horizontal plane of the thigh and that the ring rests against the tuber ischii. d. Buckie the strap over tr.e anterior surface of the thigh. i-. -? .k.. m< till applying traction. 10. Protect the ankle region. There are various methods. We use cotton wadding but the shoe will do. 11. Apply traction micii. We use ordinary cotton bandage with a juuare knot. You ran use the army traction strap or various other tames--** nacever 12. Fasten traction hitcu to the enu of splint. 13. Increase iracuon by Spanish windlass actioa. We use two tongue depressors. You cast use aoy ruck, something you can twist with and that wul go over the side bars of the spunt. At this point manual traction is released. The assistant has been keeping up traction up to this as* so that the patient is relieved of his pain. 14. Support extremity in spime. We accomplish this by ousim hammocks and ciip* applied beiore the souat u put on. You can use ungs. baauuges or anything eise that will support the extremity after you apply the piinu lo. Prevent lateral movement by muniin bandage aboveaau heiow tne kae or by carrying triangular sling used for support around extemuy sou splint. lb. suspend end of ipiiat to stretcher bar or to roui oi aciiiub-nce. Any method to keep the heel from resting oo anything. 17. if the patient has to travel for twenty-tour or thirty-set uours it ed a* better to have some sort of foot piece. Dr. Rice cave s demonstration of the application of traction treatment to a fracture of the leg and of the arm. (Two illustrations of application of splints follow.! Hniltcay Astnr.tniion Pratrrrii/Hjx nf Mtdicnl nnd Surmenl Scctifl* 33 I'm . 'i.-- I'm elurc o( nrm w ith Ituclim i l<v(ut 34 .4 mrncnn ttail'rnv AsmcwiOiwi Da. Ksnnedt: Vou can reckon a from three to four minutes on the arm and aot over four minutes oo the femur. { Usdr Now I would like to take ttn some of the direction* I have heard to this f even treatment. There are probably other objections that 1 have aot heard. f mott< Tlc surprising thine to me is that when we started to u?e this to 1920 we l app*" did aot apnrmate that w? wore dome anything that was not done all over t lie prtr United states. After developing the method we showed it at one of our clime* vino and I was perfectly ruuaird to iini the interest of the men. On puesttoning I found it was used very little, and since then we have had the opportunity vf T'l. seeing the method crow ia popularity. j f,,r r Oae of the first objections we heard was that there were no donors available. { <l*-v It h< at^itmnv unnf!rfg(.<trv that thoro should lie a K'tor :o atmiv u. V.'h-~ ; you realize the fart that the iintcdi Tommv ;mu me American uougiuiov uui it 1 do not thiak it is fair to say tnat anvheay in ttniustrv. or a i>*rvman or a t fireman cannot nut u on just as well as a doctor. The oniy thins u to upprcci- 1 ate the stanuaras that are necessary. A second oojenioa is the exocase. bniiots have been oiiemt to me tor nnv- where irom il.aO to **#. 1 would aot reeotnmenu etihcr tne $1.30 one or tnc $9 one. 1 think the former prooaoiv is poor economy aau tne latter too expensive for routine use. j All*" There is a midair course oetweco St.30 anti $9 wnere you can erta fiertecuv satisfactory spimt. Xacn oi these spurns mown coat our aospuai id.73. Liut they are ioth of better material than is absolutely nereasm.-. fhcv are maue of an ailoy that does aot transmit X-ray completely iiut iietter uiau stevu t aco ;>:kf The other supplies are ao more expensive than tne supplies oae would have to use to put on a boston spent, or a Cabot spitat. it u a taattcr oi ounuaucs sad abacs. We use these maue-up muslin supports plus the paper cups impty because we and it les expensive to use the same tiuop several tunes. Another objection we have heard is that it is unnecessary, (bat the preseat methods are perfectly satisfactory. I caa't argue warns; that oae. I have seea too maoy people brought ia ia Liitoa sphau which are doing tittle for the T.rr 13 t TKwer am att patient. We feel we are not doins; justice to the extremity fracture mb*** we use this traction. It U hard to say present methods are satisfactory unless oae screes that it is proper to let a iemur fracture wait for reduction until after Nature ha? been trying to repair it for twenty-four hours or more already. Sa de-. or Some say u is unnecessary for it is such a short liaui usually to the hospital I think that point- is cot weii taken.' If a case is brought to our hospital by. taxicab, and the aursc thinks that there is a possibility of a fracture, im mediately that case has a Thomas splint applied io the emergency room before anythin?: else is doae. The patient goes to the X-r*y room or he goes to the ward with this traction applied. The removal of his clothes is supervised 6o that the traction is maintained and immediately reapplied. The distance does not couat. You ran do as much damage in the five minutes it takes to traasnort a psticat from the X-ray room to the ward as you can at aoy other time. The main thing is to nave the man constantly in tmetioa from the Tery first moment that you can. Some say that it is dangerous ia long hauls. I will say on several-occasions fe It t: we have used this tractioa method for as long as eighteen hours in the hospital because the mao was aot in shape to have anything done before that time. *: lXniUeny A-i.<r>ciatim :.)Q oo from three to four minutes on the Arm .1} ierour. ume 01 the objections have heard to this "thor objections that t have not heard. .vu hen -e started to use this ia 1926 we :omit anything that was 00c done all over the * the method we showed it at one of our clinics -i the interest of the men. On questioning I : -mce then we have had the opportunity of intv. .-.nt -xx< that there were r.o doctors available, here Mtnuid be ft doctor to apply it. UTten di Tnramv :ud the American doughboy did anybody m industry, ora policeman or a -tl as a doctor. The only thin? is to aopreci* i/y, -c. .Splints have been ottered to me for any. . not recommend either the it.50 one or the Katiy is pior economy and the latter too 11.30 .ind $9 where you ran get a perfectly : qdinM shown cost our nospirai .$6.75. But in is absolutely necessary. They are made X-mv >*nun-tiy but better than steel, xpcasive than the suppues one vouid have a Csixit >ilint. It is a matter of uamiages uiuslio supports plus the paper clips 3imply .1 use the same thine several times. *nLis that it is unnecessary, that rbe present T I can't argue against that ooe. I have '"Liston spiiata which are doing little for the : justice to the extrctniiv fracture unless we v pr^-ent methods arc. .*AtufftCtary unless .1 i-mur fracture wait for reduction until .ir it f..r r.v.>nry-nmr hours of more already. ' ' *uen .1 diort haul u-iiady to the hospital If a c.i.-e i.< iinment to our hospital by. 'here is a pc^sibiidy of a fracture, im- 1 -idint applied 'he ememnev mom ; ur <> I." .\'-r iy room or be goes to ; r-nsivu r.f h.;.< cinrh.* is .-Minorvi-jed t <u.u<-iy nvippibni. The distance 0 f.wnnv in the rive minutes it takes to o*n r.>A-.ir<| x* you ran at any other "an oii.-f.nitly m traction from the very r hauls, f wifi sav on several*occasions 1/1 long .-13 <uzhten hours in the hospital have anythin* done l>etore that time. Prweduwj of SttdiaiL nrui Sunficnl Section 33 Under those circumstances there is a ruiiag that the foot must be inspected every K*if hour, but it is very rarely that we have to release the traction eveQ momentarily. don't feel that it is nearly as dangerous to have traction applied for eighteen noun as it would be to Have the man moved without proper immobilisation of the fragments. Certainly, if a man u able to get sufficient training to put on the spunu. there is no reason why he should not be able to inspect the foot and know whether the circulation ts being saut on. Then am toid it ia dangerous in eomoound fractures. That ia amusing, for remember, the whoie meiiww was startru in comround fractures, it was developed in war (tees tor u.-e tn ituiict w.>untis anti ohcii wminus. Our men are trained, if they had a comoouau fracture, to use iodine on me wnunu and on projecting fragments ot^ne bone. They masmao attempt to rcauce the fragment. If the fragment notices itseif on sopucauon of tracuoo. * 0 v worry about it/ Vou are going to have to operate on tnc ease anv way. it seems more feasible u> us to have that fragment oacic m place, if it docs go oage in place, with some iodine aopiied than it is to have it sdexuig out tor the duration of time uatii treatment ts started. Of course, if it u matter of the fragment being retraced aou then aiying nothing is going to lie uooc. teat u another point, out that ia c modem surgery. What has been sccompiiaed so far toward getting the treatment auooieu.' First, the Fracture Committee of the American College or .'surgeons nas adopted the standard mot any particular method--we are not oacsicg any particular method), and are working at the present time foe its general t-*e. Seconuiy, within the lait three months an order has guuc out ;rain Cr. Green. Coramtssioacr of HogpiaLt in New York City, that every amoiuance in the city or Mew York must be equipped with Thomas arm and leg spnnu. That is a matter of about 1? ambulances, and I might say that bat year mere were aoout b.OOQ fractures of the upper and lower extremities htougnt in by ambulance in Mew York City, > you see it is a fair sited problem that e ate attempting to cover. In Philadelphia. Dr. Ov*>n, the Chief Surgeon of the Department of Public Safety, has adopted the method of traction for teaching in the police and ire *U*partcncats. and I uaderstaad it is getting under way as far as the ambulances arc concerned. The Baltimore Fire Ovnartmcac has been using it as routine for ovrf r "ce years. The Amehcsn Red Croai is adopting this in the revision of the manual which will probabiy come out in rhe next few months. They are adopting it as a detinue i.rvumanc which they t'.vi ..hoiii-l be used ftftd in which their people will in ritnod. The highway patrols in some state* arc becoming interested in this metcod. That is particularly true of Arirona and .Minnesota at the present time. Your A&.sm'tacion has s record of having br^n m the forefront m movements f<tr improvement iq the tare <>f i'smcn. M>. who .ire purttcuiariy mterested m the fracture problem, ask your serious consideration ni emergency traction treatment. We rely oa your being again in the forefront ia this movement which tve hsve every reason to expect wdi msidt witltin a few vesrs in this treatment bccomiag a ^eaerai routine for injuries ot the extremities. (Ap plause.) t'-T , .MTx4*' t 36 .toirnro liit.i rr.>i \ Tnn Chairman: 1 am sure we Appreciate the time and trouble which the doctor has taken to prrcnt to os this most important paper. 'hieh at t he same time ia ro concise and simple not onlv in it* anfdtmtion hr the medical fra ternity hut hv the layman who ran l*e (audit. as he has demonstrated this monune. lire simnitettv of it. On l**tal! of the and Surcteal Section. Doctor, we wish to extend our thanks to you. The dorter lias referred to wha' this A-wren'i-io lu*i< <ione for the advance- roeot of the impmvemett* ,i p;e injured and vr railroad wtn t:i coiiortif. < *f course ( don't n-e<t to c<* l*r.r tor itie Inst tw-h' r thirteen y*yr\ anti roview what lias lteen done i*y the varvt-committee* tn ilte way ot phyjural rt-e.xanmi- ation of employer*, the adoption ot th- Standard Sanitary Coles, etc. I am sure the railroads from east to west amt from urth to x>ttth aro aware of what is bemc done. I know !p*m exrrie**ci.. ntr '''i!- rroMvmn*'- wii i* *:: '..-i ionc. an<; is |ietn~ tir.rrc. We proud <; it. l f I tt t Tue next on the program i* the re*w*rt ;. U.uis tvart: The Ci*mmt::ec on Aommuiiofis na.-. wnvteti me i.miumc a> dates for me positions itKticaKxt: Chairman* tVwc for onei John MeOimne. Chief MedtrU Officer. Caua-uuti Nutmitai idm.uv: J. C. Laatienticrscr. Chief .'"urceuo, un*jm ro.vrt Iaic iUiurouu FltUT VlCE'CltAlUMAN tVote i*f W. L. Hartman. Meuicai Dtrcrtor. Nc* Yr Cetitnu l-iuea J. D. CylUns, Qiivf aurueon. ceutHmru Ar i..;.- ikur.t jy Second V ice-Ckajum.vx Vote forfnw J. IL Nilsson. Chief Sursson. Cnion t'actne KMiruau 0. B. Zcincrr. Chief iunreon. Missouri Pacific idiroau Committee or Direction (Vote tor Thrccj Bareev Banie. Chief Medical Examiner, Pennsylvania Railroad G- W.. Cale. Jr.. Chief Surgeon. at. L**aif .-roytiiwestcra Railway A. W. Eitinc. Chief Surreon. Delaware d: Hudson Railroad Corp. A. R. Kiieore, Chief Surgeon. Western 1'acihr Railroad R. B. Slocum. Sunt. re Med. Director. Relief Dept.. Atlantic Cuast Line Railroad F. E. Smith, Chic: Surgeon, Wuimsh Railway Committee on Nominations tor me Enscinc. Vi.au (Vote ior Five) H. A. Beatty, Chief Surccon, Canadian Pacific Railway W. X. Blount. Chief Surgeon. Gulf, Colorado d: Santa Fc Railwav Dunenn Eve. Jr., Chief Surgeon, Nashville, Cliattanoosa c: St. Louis Uaihray C. C. Green, Chief Surceon. Texas A* New Orleans Railroad A. M. Hume. Chief Suntevn. Ann Ariior Railruad A. W . I vie. Cliicf Surccon. Nun hern Pacific Railway D. B. Muss. Chief Medical dr Surgical OSccr, Clucaito, Burlineton it Quincy Railroad i : \ ; ; ; j \ ] ! > j \ . . : 'oOn/{on PrtKcetlintis of Mfliad nnd duntatl .iiction 27 .i:e the time ami trouble which the Tqwrtam paper. which at the fame :'s application hr the medii-al fra;ht. as he mis demonstrated this . - he Mvdi`~al ami .'?urt;icai ^ectioa, ;i. -i.nim mis done tor the advance' i i-tr rr.iirnad work in central. Of ......... . * n . -urs ana review '* ,n wav -it pny.-irai rr*\amia'.miard .-uata.-y C-Mos. err. ( am *r. north to .-ou;:t arc aware of what .* otEciais appreciate what luu i*.-cn : the Committee on Nominations. man. td.huro a: St. f.uuia RaUjJ ;j;e iitit; as canui- -..ind-in .Vaiooai ILuiwncs . ;:i r*itrt i.isu? iLuifoad i ork Contra! Lines :r Lice ILulwav . :te Railroad *'ilic ILiiir.r.n ( .w-.vir t ;t.( "I:<' ^.....- Atlantic C-:ist Line * * * * : *r r r.f :.*** i: ...a u* ...... * ` IV Railway 1 '.u-.-'n x 1 *r:' m< i.'-uir-.ad V:..'.- id " K.udi'av I'ld.-aeo, J'.nriixr^r<ti .v S. C. Plummer. Chief Surceon. Chicaco. Rock Island <fc Pacific Railway J. F. Roe. Chief hurscon. Denver *fc Rio Grande Western Railroad S. B. Taylor, Chief nurccon. New Vorfc Central Railroad The Cu.usman: You have heard the report of Dr. Easmincer. Chairman of the Committee on Nominations. We will appoint as tellers Dr. F. C. Warrine. oi rhe Western Maryland Railway Company, and Dr. John G. Frost, of the Chicaco <k Eastern Illinois F-uiway. The ballots wiii iv>* distributed :a t::c usual v-.v. Thee wiii isc ouoctcd at :hc '`Miin tomocrow nmrninc. s We will now proceed wita inner items on tne :>rocratn uuuor 'non Discus sion.'' One in panicuiar is the matter >^?vye mjuncs. i ^dicc-s'iic .'veretarv. has a report which was prepared by a sulicommutce in Chicaito >asi aua I wiii ask him to read same. The nECRETAnr: Gentlemen: This came about due to a report maoc uy a renresentative of the Cnitcd States Bureau of Public iicalth .service as me rv-uit of an invcsticaiionof eye accidents on the Mia^uiri-iCun.-as- icxas i.uiea <iue to >aau used in cicamaciluesot oil burninc locomotives ceicrnc :a me < yvs f i-mpiovc?. msuitinc m serious injuries. Mr. Aishcona.iked that this ttsatter iie considered. or rather, uatmc spcciuc .^'mmenuauons in the rcjiort which came to iiim throuen Lc interstate (.'tnmercc Commission. h* <nmeutai <*n hy rhe d.uVy .--vtson. ;rm r;.c c'Portirss a;aiiu;iiut we wiii .-aw ami bv hc Mroicai anu .';:rc:eai S-ctam. 'p>m the medical .-'.andpoint. Sa the snoeiric recommenuauotis in the r-.-t'-irt wiii be reauaad ;heu thccomnieois which have i.-.-en jir-paretl for rransn:ij*.*n to Mr. Aishton. 1 :aisnt also say that it i-> expected a conference wiii ;>e tteiu l*etween a renrocmattve of the Interstate Commerce Commission, ms Pfofhemood Raiirad Trainmen, and representatives of the Mcuicai and 'urmcal hectioQ ami the .ructy .seetum. Dr. Moss has been appointed to rt,trs*ent the Mctlhail and curriral >-*'ion at iimt meetinc. and Mr. ttill. of be w York Central, to rejire^rnc the rcifesv .Sxtion. r'nJersranu t!io. n-<~<frmrnda':-ns made in 'his report were prepared by A.-.-t. .-'urceon C. F.. Pi.-e **f the L'nif'-i Suites Fubitc Health .Srrvice. and in turn pis'-d down *::r*msh *!:e tutor--m:** C*<*ir.n:cr*e ConifnisMoo. . . . rise Secretary r*al the rci'ommcnuatioiis and ttic comments. . The Cn ukman: Gentlemen, von havo heani the report and the comments uatso be tit'' mb-'"ommitT<w> --i!!^<l hurri^iiv | >st we*sc. Hu. lio.cn ii.;.: Mr. Ch.unn.vi. tis or.-- :uZ'.-**ioii l -'uM i.kc to oiTrr d:.it |;:i.s .-cbf*:vv tii ih-* o' (: :nvn as to rh**ir eouip- ment. In <n ntirniiifUM then? an.- tin* words. " Ho devoirs oniv a small jxirttoi* i fits tiom to ruiroad w..rk.'' 1 think if would I** advi.-.ibie pern.tHS to !:mmat*` diat ; art of the ani'-m* ::i nti! ti.i .uu^riX'is on :*' fan that the ulisf. tlocs .iovotc iit-riiajw a -aiall part of ius time i this worK. buf leave r.'ie readme of the s>mments that it would be inappropriate to attempt to tdl aa oculist wnat etpupment to have without recard to the question whether he does or dues Qot devote a small part oi his time to the work. With that succcstion l move the elimination of fhe clause referred to. rrry'-~~'T - - .f* iV f"-. i V. / *. ` 1 r\ l 3S .lr*menfi fXtiiuwj i p > * fann-* *u,`,c mi^on-fn:e the remark and the f^rm. .`-'dinr :aat jhev had *>1 * '* mdroad os-. I thir.k you ail will acn*. wtth Dr. D'-adaH chnt Xhr queucn *nu!<! hr removed from-the r^^rt oa*r->- I:.. u-.i --onrio! : |r. H:***. :-i;t *i. .. votr nd I);. A-* I'ai: -Mr. Cuairman. I move ii.e approval hv the ^eetuui et the reviMV ti> Mr. Air.t>n. tiU'f.oti w:.-. In- 3l'.;.*or:.o' iV. - mw- iinii..- . ,. e v.ftMO-rr.:i<-n. ;ii- :;r--. I'r-stnnrv o,n*t < "in n^i show ; . aJ: .\-r.-sv. a.vi i: v.ii t a rr.-rurc nan it enow.* nonurur. vm: rno' to Oi*p..- . , uit-rr i5 normal m tr.c `vi-. *: ::-.?* mv oe omer~`.~~ is. ii mnv ! * nit >-ri*u.* i:an ; <io*ns m :ne i-n.se Of a st.tv :.; ury. ano i ur.ucmtanu tins no* rrr-rc::re oniv to >ana ir.;uru\i. t think r. r - iivt i.e west to consider *.Mt. tv-. 'MMi.r.1 .`It. k.:. .:rr::::s. m*-* .*r~o:is`ii.Ti j mnt ir.e i.* mm:if ec mu .v.:e ;r.ai. i turn*it is no overrent umxoat rematneti ta tacre. 7,;f i, : '* tuixiai o; that u w--k. D:i. ;\'" t'ALL: / sufeest taat tne .'Cretan-- rpan mat portion nn retercnee :< \ --v' c.\:inun:iuuni i<r our imoruutiwn. T:rr. .'Avm.tasv: iiccotnmtnaation o re-au: "1`rovtamj eye onviuci&as coin? wt :urraurohur with me nest of instrument* for examimnc tne interior semner.i `-i ttn* eye. Thi ttorotuiiity of particle o*vme eatereo toe interior of the nr ormar.ds. in any cane *t oil cusptcfous. ua X*ray examtaation.'' . Thr A-iuuicfits ns eorrectcu a'ouid reaa: **ft is tae eeaerai practice ot the ratirrin.i' o.vaiisaie i* eostpany ocuitsu oaiy the best obuunabie mea in their i:r>- i; M-euid be officious for the railroad to attempt to instruct the ocuti.d the kind of equipment he should have tn his office. The equipment o: the <vu '- *tu:acrcl in the ceocmi worn of his specialty will fuliv satisfy any demine.-ori; with railroad employes." It w.i* tiiuiorstandinc that this letter was to be brief and roneiie, and that i: M*Mit he einbomted on when the conference was held, at which Dr. Mom. >' tiioTouabW familiar wnh it. would represent this section, and Mr. Hill, of thr New York Central, would represent the Safety Section. That is wbv thi? .v' ivnttco up this way. Dr. P V'- Mws (Chicago, Burlington and Quincy Railroid): I don t thiok i*t put in nny objection to the X-ray. If the oculist wants one I don't Hunk we rhoutd say tuiytbinc alrom it. Du. </. vi;<vu-. !-r may be about that, but as that article reads it savg an X-rav <.-Mnination should be made in all cases where there baa been an injury. I :!nk probably whnt was intended was that ao opthalmoscopic examination lw* rnmic in all ea<es. That mtcht be far better. But when vou say an X-:ewuiuusUioii must be made %ve are going to have faulty exstmna- ,.n tea. Anyone not strictly ne term. fceijn? that they :ree with Dr. Dowdall that report. .me. put to a vote and jval oy the Section of the ii: iiefnre you put the :n there noout X-rays riimary >tnd would not show* nothin?, you have :iv he *ometninc tn. it r a diagnosis in the case only to sand injuries. I :.s that rhe Committee hat rersiuacd m there. ; rhat portion with refer- 'rivaling eve phyuriaas ''f examiaia? the interior .vine entered ihe interior examination." general practice of the r best obtainable men io atresmt *< instruct the is office. The equipment sltv w:ji fully siitofv anv hr:rf -.ivt -rvi.-e. .v.*il a .i r.fhJ. at which Or. nt 'a:.s and Mr. *-te'v ,n, Tn.it is .1.ii': I .-.a t r.'- <s.'uv;>t wants one it r-:uh it .siy* ter- fhere hits i<cn an "at an r.nihalmneooi<T ' <'ftcr. tint when you have iaully cxamina- Proceedings of Medical and Surgical Section ,39 tioa sad leave something is the man's eye because the X-ray doesn't show it. I think it is a serious problem. Dr. Hcue: I think the thine has been properly disposed of -by the pro posed comment by saying thst the physicians employed are specialists, and are employed for this purpose and it is presumed that they are abie to take care of the proposition. That is all there u to it and we have already approved that. Da. J. R. X rissox (Union Pacific Railroad): This report reeommeods that theae men wear cotrglea. We have ail oil burnias engines on the Union Pacific and we have never had an eye accident. Men are required to wear ?o??ies when cleaning the flues. We aiso blow the flues twice a montn ia tne eticine house jnu theempioyees coins tms work wear coiaxiea. L p to uatc. ;a tne last five years we have had no eye accidents of that _ Tub CiiAUUiAk: I don't beiieve we outfit to <o into too muen detail on this. As far u the X-ray is concerned, personally, 1 feel that a iroou ocuust, even though he does not and smfi by X-ray. wouid know that mere was somethin? pathologically wrong with the eye wntca has ts be investigated. He wouldn't depend entirely on the X-ray. i think it ought to be made dear with reference to the *nter.or segment of the eve. We do know that some of it will become buried in the conjunctiva,.and to the laymen woo will confer with Dr. Moss it shouid be made plain whic is meant iiy tnc anterior segment. '.Ve should. I think, define that. But I don't believe we shouid gu into too much detail on this but should leave it entirely to D.\ Moss who ius been designated to meet with the committee or the commission in Washington at the proiier time, i would like to know if that is tne feeung of the hectiou as a whole Are there any questions.' Dr. Dowsaix: Question! Tire ChaiRU.v.v: There is a motion ovfore :he noose to approve tne com ments, as revised. Are you ready for the question.' . . . The motion was put to a vote anu carried. (The letter to President Aishton dated June 13, iv32. together with the ramnieiits referred to, follow:) V--.v York City, June 13, 1932. Memo to Mr. ii. If. Adr.ton: Referring to my iotter of May it> in rep.y to yours of May 23, concerning eve injuries sustained by employees due to -and used in cleaning flues io id durum? locomotives getting m emo:*>v***9 eye*. My i.itcf .{ May lo hricflv Mii;:;;y.l ne -'nmivnts of !*c 'afety -ince tbit :m:c a .->in*'i>mnii::re nf the Committee of Direction, Mi-d:cal and rurgscal cevtum, has carefully reviewed this matter and its voggvstiunj were m turn approval at the annual meet in? of the Medical ami Mirutrai .'--.non. .lime U. 19.J2. ."? c-iv.-nn-nve. I have comnined the comments of tne cfaiety Section and the Moroni and surgical .section in the attached memorandum. Mr. C. . Hill (First Viee-Cliairmaa. Safety Section), General Safety Agent. Sew York Central Lines, has iwo designated ny the Safety 1M L-\V.\ V < t; ' rtf: rt 40 .1 firrtritn . I "<<1/11 >nn Nvunn ami IX- !). H. M.*s Chi.-; un! Surgical Officer. Chica* Huriin^'r. v i^uncy ILiiir<<a<l. ha- --n noien.-wed hy the Medtcsi a >tirrscai .Nfi >11. to r*-t*n-M-ttt t t"ir n-*r-<-tive Sort tons at the eor.t'crrr. referrvd t.. in i},*- la.*: paragraph y.ur h-tier to me <t M.-vv 27. U> will umi.ii your further insintcrtoti*. Votir.< truiv. .! (\ (AVl.-TON' -N ary. f. !, Mr. li. ff. Pre-ib'-nt. American Railway A--h-mU'-ii. I7tliai'*tv-*'t*. X. W.. Wa.amuN.f:. 11 < MEMORANDUM Comments ot iatetv Section, and Meoical and Surriul Section on recosr=*r.C4iions contained 10 tc- **. ot renreseotame of the Unitee states B-j.-e: 0: Public iieitta Service, concemtat eve miunes sustained by tram seme ema;oyes. owe to saaa useo ra cicsntnc ttues 01 oil bursme locomotives. The reeommrnaations as Known in me nmve referred to report are Quote ijviow. and thr r**Ttiins comments nie*w: R-commenoation JVo. 1 'V.-nnnc ni .ipwtaetc* witn i-t.**-^ ut ttuny ianre diameter. These ienso notti.i to thick and nmuauiy t <k- >eim'<t 'uriti'ir-phttc' glass should le useo :'<r tim rvoumwr a correct n* in tm- rvtrycriou they should be `pls.no. TLi.* would apiny u hniKcmcn auu switchmen. hinemoers should use goggles.' C\'ms<k.vt*: This is impractical due to mumiity to enforce any such regu lation. Ttorailroads cxporieucea great deal ot dixiiculty In entorangthe wear ing of soectaeiea oy this class of employees where taeir detective vision require: same, la audition. considerable expense would be Involved. Recommendation No. 2 ``Providing engineers and conductors with prophylactic tubes of ointment which should contain a smad smotuit 0/ butyn or holocaine. This squecrcd into the injured ry? wiii allay the pain. This should be followed by White s ointment bichloride 01 mercury m var)iiic 1. 30u0). which will help to keep the conjunctival sac sterile. Possibly liotb ot these drugs might be combined in one tube.'* Coum&xts: This would lend the railroads influence to employee self-treat ment. and. it is toiieved. would lie oppo.sed by all competent oculists ss totnc a dangerous practice to establish as a routine measure. Experience shows mat whenever a man uses an ointntetu of this nature which relieves the pain, he is likely to delay the necessary visit to the doctor and thereby allow more time for the ares surrounding the foreign tody to liecome infected. Considerable P.-oceedirvrJ of Mnhcat anA Snrqtcnl Xeeiion 41 -tiical and .'rurgieal Officer, Chicago. ~q d-ignated by the Medical and rvenvc Sectloos at the conference sir letter to me of .May 27. . lion*. Vour* tfulv, C. CaVIpTON*. Secretary. additional experue would also he involved as the proposed tubes of ointment would be lost or disappear lamativ instances, aad therefore would not be avail able when required. Recommendation No. 3 ``lostruetiag employees to seek medical attention as soon as possible after an eye injury even if the accident seems of trivial nature." Comments: This is already thepracticefoUowedunpracticaUy&U railroads. ::L'M :ai aad Surgical Section oa feeotnitav.re cl tie United States Bureau .njuries sustained by train service lass oi oU buram? locomotives. ^ve referred to report are quoted -i No. I .:?iv urge diameter. These lenses .rmor-plate' via.** should be used, -rtction they should lie 'piano.' !. Ksctnwr* -hmud use goggles." ..audit,y t* enu.rre any sueo resju. difficulty in enioreingthc wearacre their defective vuuyQ requires .,uld be involved. V, prophylactic tubes of ointment vn *c k->l.*'-aine. This squared .> -honi-l l--' followed by \\ hire's ruxwt). wiiich will hHp to kivp f h-- if.iits might !* <`iuruin:*l - mln.-iu** '> >-;noioyc-c soli-trent- ..1 *-} -f.-nr ...i-ism s living a ir-\ 1. ............... . itat r.-iin. he n ' .:. i . r-i'V allow more timr dim* moved. Cuu.-ivfal*ic Recommendation No. i "Some system adopted, if practicable, of giving a warning iignai when 'sanding1 of a locomotive is to take place." Comments: A signal such as promised would only apply tn a mmonrativeiy few railroads ftho<e having oil burning iucomotivini. anti it .-hnuidmn i* made a port of the Standard Code recummeruit**i bv the American iiadwnv a.nmxmTtion. !; is preferably & matter fur individual railroads directly concerned, to handle. RecomaendauoQ No. 6 "Providing eye physicians doing work for railroads with the histof instru ments for examining the interior-segment of the eye. The possibility of a panicle having entered the interior of toe ere demands, in any case at all suspicious, an JC-rav examination. * Comme-vts: It is the general practice of the railroads to designate as com pany oculists oniy tnc best obiacuaolomea in tneir line, it would iw odiuous for the raiimad (o attempt to instruct an oculist as to the kind of wjuipmeot he should have tn his office. The equipment f the oculist engaged m the general work of his specialty will fully .satisfy any dvmanu of ius work with raiimad cmuiovcvs. Recommendation No. "Warning railroad employees agaicst allowing a fellow workman to try to remove a foreign body from the eye." . Comments: Tills practice is already i:i rtlcct on the railroads as a whole. Of course, it is remised that it is difficult for an cmnldyce to abide by such warning under ail cirrumstaiirivi. Recommendation No. 7 "cniicsting rtic lanTCtaie Cuoim-n c Couuai.--ion to require rite imnii-dtaie refuting of all y* aifidcniA .ml uilly > fi-quire a i"ol!owup rctsirc himing the rinal rcauits of each eve awident, to <* reimrital in full iu their vi-sriv ar i`ifitr bulletin. AI.-hi that the disa>irous result.-* of eye acci- '.tv- '; cr.I ai-e<*rihng r. Railroad Svsienia as >. mauv blind eyes :wr i.ik| iraintwn I'liiiMored." i'--'i'.i\st: w.iuid i:ei>"` -laitU'- iiard.-hio* an>l a great deal of un- iivreseary reqiense imou the r-iiirnuiij. 1 he uumi*r <>t injuries reported V." L. _v . ' -,1" . f:V: ` i -_ 42 A tnfnfnn f?uffirnv .4 under the I. C. C. rules constitutes a wry small part of fhc total number of eye injuries. the vast majoruv os' s**me K'ifiz of a wry ;r:val nature, and it z criCn< would be unjustified to require the reponmc of t:u rlstv* <f injuries on any ? aiderHants other (Wn the basin rvemired for other iyje ot` iti)uri*- ntistainM. Toe 1 colom follow-up reports suqgrsioil would duniicaic t tie v>rk ran! pvrvrw- which would % IVn 1>0 involved, if the immediate rofmmtic of all eve ;.rrulem.< were required. as C.1I1 1*C suggested. It might be practical to arrange f.r a yubceuuem repun of eye r itrv-b injuries resulting is the total l*of sielu of one or U/fh >* hut this would he ' ddTvrvt establishing a precedent which should 5e .avoid--1. if 7 Wv General i Panieubr mention is rafM t< the following quoil from the report: "The interval that elapsed from the time of the accident until wort ins to a phy A*; sician varied from 24 hours to one w-el;. In w-r?.! i In-re w .a hi.orv of ^ simr fellow workman aii*-*rr>Tmc t-i * - f.-r.-sn i->.iy.. Om- man said ~ hi* e**U*.-tfin* U--i the r-sim of a l-d ?- The fio-.-unirty of in.Wfioti from iO'iine*this nature, if rc.-di-al attention - i.-' tiot ree-ivwl until 24 hour*- has elnre-ti. is for crnfer that* the tnjurv had '? Irttfl property rrcared within siv. eichr or ten hours aft-r it had l*een received. T -w ` dk hv.*c:v [; ! WU no' r.tlnwlvi Chairniattempt Section y On th As developed in the -urvrv marl** hv the M-nr*l and humcal Section io *; rrcard.= 1927-US, there seems to have been no particular increase in the number or 5 Dn. N seventy of eye injuries, such as referred to. ^ hM been ^ Hehaart The Chairman: cussion.' Is there nnvthinc further to come up under onen dis * 5 wiattr. a occurs ta You probably ail have heard of this matter of the six-hour law* that has i more tb.v been proposed. There has been quite a tittle data brought out oa that tad I i I have think oat or two of us have something on it which is of vatue ano voitu it tnav '* of them s be weil to discuss at this umc. I think we should co oa reeora as a section $ my. "Cer as to our views in the matter. This cl Has anyone any comments to make on the subject/ % have bees Do. Dowdau.: Mr. Chairman. I have a request from the ilimoia Central It seem Railroad to arrears for a ctuoy and report from the decuon with reference to goggle an* refuting some of the testimony that has been introduced regarding the six- Tht Cs hour day which is before the commission. I would cutseat that this be left it the suapic over uotil tomorrow under New Business and that we nandle it at that time. * without f< I hare some papers that I would like to submit to the Becuoa but I do not right of w have them with me. motive, ac The Chairman: I believe, without putting it to a motioo, it will be agree able to earn' a over until tomorrow under new* business. to suspect glasses off I think The Chairman: There is another matter that has come up that we might together w discuss at this time. As you probably know, there was a very serious train up a resolu accidcat in the Northwest last winter, where a tram ran into another tram and Personal caused a great deal of damage. The investigation brought out that the color make bare if you A mtrtean Railway Aaaocialion ^ constitutes a very small pin. of the total number of; .uijomy of same being of & very trivial nature, sod it - require the reporting of this class of injuries oq *oy ,-u required for other types of injuries sustained. The ,um would duplicate the work and expense which would :-.<viiatc reporting of all eye accidents were required, as ,> practical to arrange tor a subsequent report of eye :ai I--* of sight of one or both eyes hut this would be whi.-'n should be avoided, it posable. General - called to the following quoted from the report: "The -m the ettae of the accident until reporting to a ohyurt to one week. la several there was a history of *::aiptins to remove the foreign body. One man said me ui a lead pencil." lion from injun^s of this nature, if medical attention . iutj has eiansed. is tar greater titan if the injury had Kin six. eight or ten hours after it had been received. irvey made by the Meiiical and rjiirgfcai erection in nave Wen no particular increase in tnc nuaoer or ;ch as referred to- here anythin? funner to come up under open di* .loJieafd of this matter of the six-hour i*w that has ^jadwrn quite little data brought out on that and I -siewsonsethiog on it which is of value and which it stay crime. I think we should go on record as a section :tter. its t make on the snlij.-vt'' liiirtmn. I hav.* a i-.ft fr.-.ni 'lie Illinois Or.trul tiuiv and :vi*ort from the S-vtioa with reference to ravny that has l.<i-*i introduced retarding the six- *:.# ormnis.'unn. C would .suggest that this be left ' K--.V Hi:u,-ss .md That ac habilie t* fh it iron?. kkT t-> viicn:: to 'ix 'v-'ion i'll I du not a if bent put tin? it to a motion, it wiil be agreenarrow under new bu^inexs. . i an-'hT matter that hits come tip that tve might at i>r"*h:il)(y know, the.ee w.%4 a verv -enous tram .t * ifi'.-r. u here a tram ran into acotnor tram arid snaite. The inv>'ti?atiua brought out that the Pneuriinn* of S(edicoi and Surmcnl Section 43 engingtnan had a pair of colored cockles down in his pocket. It caused con siderable comment sad an order came mighty near joins out to remove all colored goggles from use by engmeen. Personally, I think that is wrong for the reason that there are goggles that can be used that will not chance the color or the signals. On making a test ourselves we had that there is one particular eoggie that makes very little difference and can he had at very- little exoense. this subject. Are them any remarks/ Die Dowpam.: I think that is a very taoortaot subject which we should give careful consideration to. it would be auvusoie. m my opmioo. to select the one type of goegie with toe oroper coiortog that wiii take white light and will not interfere with toe colon. I would suggest that an opportunity be afforded the various members of the Section to stucy these gonpes which the Chairman haa brought to (he meeting and test out the colors, and that we attempt, under new business tomorrow, to prepare a resolution that the ejection might see at to approve. On the Ctuon. Pacthe. I believe, they have done a good de:vl of work in this regard, and 1 think Dr. Nilsson might add to the ou'cuasiuo. DR- Niueo.v: Mr. Chairman: One of our icaritng oculists. Dr. Wherry, has been doing research work for the past three years in testing colored lenses. He ivu ridden several thousand miies under ad kinds of coomcioas. summerand winter, at all times during the day, and he has found that the greatest fatigue occurs in the afternoon when the engineer ii driving against the sun--va more than at night. After ail these tests he has selected boft Light N'o. 2. I have consulted quite a few oculists in regard to toe colored lenses and most of rhera are ooosed :o it, but they haven't any grounds for it. They simply r. "G-ream ones destroy the colors of the signals." Tins man has il.nnu tins work for four years and I am sure ha findings haw f-H-n correct. He advises Amber Colonel Soft Light N'o. 2. It --ms m :'.: -i -.hey .ire going ;> wear goezics they should wear a standard :n<l not different :ypej. Thk Cjt.uRMAx: I agree with vou. Dr. XiUson. I might say that [ think ?kn -o.-nvion 'hat the lenses 1 referred n caused the accident was entirely f.:"a r -he reason that iS:j this locomotive w.-ut t,:? *h ''gut "i a iv mu ft.m.ed uti us *uie the vngiarer was thrown clear of the Icco .ind l L<-;\ ; bvia-ve taut aav engineer would nave the presence of suad t susuect the i-as was at fault and under the stress of the moment take the v;i.ws ml *.nd ftnt them m his nccket hoiore thev found him. I 'uiait it would iic a good idea ior ad the members to-inspect the lenses together won the colors tliat 1 have here. and then tomorrow we might draw up a resolution on the matter. IVreoiudiy, 1 have not lx.-ea able to rind ia my studies that the light amber color makes any difference in reading the mooing signals. The lenses are here if you want to sec them. t: [ l' -52%^-- " r 44 .i/nmrflr IJtxiJ'.rnu .l.'*w''n Dk. D'-tvoALL: Mr. Chairman. I move that a roramitt.v* be appointed to ftudv this subject. Dk. I don't know anything :n*:it Iht* nb?vt. >m: have v?: vrry rOfntv'tvrti I U-m-vo. .v.d I rin't like > h:rv.- :ttivt}:t:ic *:' ;l ;- kind adopted mitt! at wi- ran iiarr } opimriitnH v<f rinding out v. hat i ir skilled men have to sav :bmf it. I: **ems to m* that we had in-fier v.:;u <*ui what our oculists Think al*nnt this matter i^corr we take net am tyre. I don t cbim to know anything ?d>out it ami I don't ii-iievc anv of tin- rest >t you know any more than I <io. Chairman: Tiii* r.iny to nty :.tt.-r.*:on veurrdav .ittr-n.w.t* t.-i<<*r kv.vir.g to* New York ami I dvi not have i'p|' ? s*-e more that! h-- <*t:v <j. acd he ua> m favor of the very tight tinted atnt<rr ions. Dft. Wooi.sev: It has been our exnenenre tiiat nine out of ten. or ninetynine out of a hundred of the oeiit throughout in** country know ie< nt*out coi'r pereeptton than the onnnarv divisional surg*on tvno maxes trtc vxamination of men for employment and the reexamination. The ordinary oculist knows practically notnine of this, unless he lias made a study ot color pereeptmn. The man who iias i*ecn making examinations oi men entering em ployment and reexaminations oi tne meu iu toe service Knows more aoout color perception i;^.a tv,.- ycuust docs univ.v. he has made a *r>ccua stu.iv of :t. Dtt. Hfitc: The Doctor says mocty-oinc raeo out of a hunared. The Ann Ariwtr F-aiironii has iluit huoureatn nun who has maae a study of those tnu;a>. and i would ucpeoo upon rus juagment in tne matter. Tits Chairman; I think Dr. Nilsson s remarks anout Dr. Wherry* ehouid have weight. Taking the examiners as a whom, personally. I do fool the examiner who is constantly examining ana reexamining men has a great deal more experience and can tell much more quickly and definitely than the average oculist. Of course them are some outstanding men who have made, a study of this and their opinions snouid have weight, together with the opimou of the hish-chss examiner of the railroad company who is oot an out and out oculist. .... Dr. D<>w|;tU'j> motion. ;o the e:!>ct that a committee be appointed to make a study of the matter aad report at a later date, was seconded by Dr. Hume, put to a vote and earned. The Chairman: Is there any further business for discussion this morning? If not. a motion to adjourn is in order. .... Upon motion regularly made and seconded the meeting adjourned. TUESDAY MORNING SESSION June 14. 193'2 The meeting convened at ten o'clock. Dr. Hopkins presiding. The Chairman: The first nurnucr on the program is ao address lv Dr. Frederic tt\ Bancroft, of New York. His subject is "Causes of Failure in Healing in Clean Wounds." 'Applause/. Diu Fredet alxionnnal. or or lack of limb the liberty oi deal with thr nevtrtlii-l.T.*. I elementary pr For the* aixv which tuuv set prf---nt it a* i li.r time s:at; involved. For vvm surgical tocuu sician* and iu the repair io'* one to tcu ui\ live diatuman under a rvlai e*ntirtnrt out calarmtMV or The folio*: ducioc toj'euu '2. Trauma, o Mb and nccro tt local -ypcmiA l. Introduce wound free ir Dr. lvingatey teriology of w skin incisioa negative in T bacillus grou 10 oi the atr type, and mi Similar stu was made in cultures w*er senes there cent showed vaneties of eases, varie* in 22 eases. Of TO ciea the cultures general n*' o( the pent .pjxjmtcd to - have <nme thins of this cit what our tier timi wit:.vrc. I don't r-ii vot one oculist o. or mnety-iw less about the xnmin::nurv ociihst . of color ntermg cm* more a:>iut d yttniv >ti it. i. The Ann : these things. V.'hcrry should t do feel the great deal purely than the -.-..ho have made it h the opinion n our and nt i e ctuvbntrd ' *:iMv*l lv . his morning.' ' ..-i;<< irn<M. . :dr<-<a by Or. ' "i Failure ui j; ir i t P.-scL'edtnqs of Mttlieal end Surtjiail Section f ] Dr. Frsberic W. Bxscroit: Every one of tu, whether be be a traumatic, abdominal, or neurological surgeon. id concerned with the questioo of healing i or lack of healing in wounds that are presumably clean: Therefore 1 am taking i. the lilierty of presenting this subject to you. iuch a subject must perforce deal with the nidiaeots of surgery and cover material that all of us know: nevertheless. I feel that it is essential every so often to review and discuss the elementary procedures upon which surgery U based. For the above ressoos I shall not apologue for the presentation of a subject which may seem eiementarv and trite to must ot you. I have attemoted to present it as briefly a* tx'ssibie in onier that there might be ounortumtv. m tr.c time /.slutted to me. tor a general discussion by aii of you ot the tiroulottis involved. For several years 1 had the good fortune to be pathologist m a course oi surgical technique given in the surgical Department of the College of phy sicians anu aurgeoas. Columbia L'uivcmty. In this course, in oruer to stuuv the repair following laparotomy, were autopsieu at various umn from one to ten days postoperative. I was ttnorvased by the amount ot (wstopera- tive disturbances in the suocutaneous fat, fascia and muscle tunc is iiuibea tinder a relatively aormai-uopoaricg skin. These otMervattons nave owu confirmed during postoperative autopsies ou human beings toilowuig surgical calamities or after ueatn from imercurrynt diseases. The following factors may be suggested arbitrarily as tending towaru pro ducing ir.iectton in clean Laparotomy wounds: l- Introduction of bacteria. Trauma. -1. The in.-:ruoo of foreign bodies m the wounds- 4. Devttaiucd it'ils and necrotic tissue, i. Dead spaces, d. Tension oa the wound, pruuucuig a local anemia. 1. Introduction of bactena. One must assume that rarely is an operative wound free from tnc presence of bactena. In a recent study conducted by Dr. Kingsley Roberts of my stati, at the Fifth Avenue Hospital, oa the bac teriology ui wounds, ths cultures taken from the knife blade which made the kui incision showed, in 105 cases, positive cultures in 72.4 per cent, and negative in 27.0 ;<*r cent. Of the bactona found there were 10 of the colon tnct.his group. 37 of the diphtheroid group, io of the staphylococcus group, id of the ->tn-pioctK'Ous group, i of the auacrobic sjHjrc-iiearing gas oaciilus *ypi*. ;ud 'nistfijanttMts 14. ` *it:::iar .-nniirnof the I'vruuncurn in clean eases were made. A small .uening was made in the '.vrntoncuin. Into this was inserted a cotton applicator, and :uitutvs w**re mad* Iwfore the introduction of any instruments. In this wer* 70 I'sy.i: 03 p*r o*nt- showed uositive cultures, and 7 per /fit .diu'.v*~i ne gative uiMjrvs. There were diphtheroids present in 42 erv-w*. v;;.*i' ,i*s 'no .;,ijHiv;.*-.'t ciis m 10 ca.v*s. variedcs oi the colon bacilli in 10 ''mu. varieties of strcplo.:occus iu H gas bacilli in V, and miscellaneous i in 22 vasci- t)i 73 . Jr-an case* where imtii knife blade and peritoneal cultures were made. :hc cultures of the knife blade and <*f tli |><-ru>i::i;tiiii correstxmued in their- general makeup m 2 ca.*o*. while in 17 cases tiie culture of the knife blade end of the peritoneal cavity were entirely dna-mit. A plate culture taken after } 4 'I : 3 1 i * J *5 v 1. 4fi American Raii^cj Atsvetnuon i exposure of 45 minutes during the periormanrr <.f a <-!<*nn operation showed the ji following bacteria: G varieties of saphropii::ir 5tannvk-ccus. 4 varieties of t I- diphtheroids, one of the colon haeiilus group. sac - of the anaerobic rod 1.' shaped eroup. L!_ The following theories are oflerrd for the piwnre of bactena in a clean wound: a. They are air-liome. la a eerie? of severe streptococcic infections c at the Presbyterian Hospital. Dr. Mdeney atm his co-workers traced the onctn of the infection to one aasimam who tw a y:rciiMe<*ceie-i>earrr. in a aeries of very seven: pneumococrin 3 wound iniwions at the (jitroln Hospital we traced the source to an ttitenu- v. im harbored a vsniivnt pneumiK-oceus 3 in hi.* throat. This series was not as aciemincatiy pn>\vn as the Presbyterian Hospi tal scries. Both epidemics of infections were sronicu in- compelling all persons entering the operating mom t* wear tua?*.s. Tii> included visitors as weii as the Burs;-*, orderlies, and doctor?. b. .jstn and sweat uianus. .No kin e^mtwtant nas liven discovered which trili penetrate the sweat and sctKieetuis euros. wmrh nmnaiiiv haroor iiactcna. After a carctui study of the various aion anuscstto in vogue. wc auuoteu. at the Fifth Avenue Hospitai, the use of 5 per cent ccauao vmiet and a per cent, methyiene blue in 50 per cent aicouoi. This comnmauoo snowed less growths (rum so-called cleats skIu. anti from sun on watch nacicna had txren ameared than, aov other akin antiseptic. Nevertheless, it docs not penetrate ueetny. Therefore it behooves every surgeon to coAimer the nun as dirty. Toweis or pads alone the edges of ttic sain, appued unrneauticiv alter making tne in cision. may reduce me numovr of oactcna from i:>u source. e. The presence of hacterta either ta iymnnatics or <ieeo structure* before the incision has been saue. Bacteria have oe-en grown trotu tissue cultures that have been made in the depths oi wounos: However, it seems impossible to rule out their introuucuon irutn the ssia or air. For uic improvement of our operative resuits it would seem best to exclude this source from our con* aidemtioa, for should infection occur it becomes an alibi that has no construc tive use. In many operating rooms it is the custom to steniue knives either in a-* Ivsol or ninety-five per cunt alcohol. Neither of these solutions wiii kill the spore-bearing organisms, and it has been shown that 45 per cent alcohol is leas jsa- e efficient than 70 per cent alcohol. Moreover, it Is necessary to have the knives *6* in that 70 per cent alcohol at least a half hour to kill the ordinary pathogenic bacteria. 2. Trauma. The prevention of trauma in an operative approach is almost impossible, dome surgeons decrease this to the minimum, while the rough ones increase it. In general it may be stated that a Urge incision is spt to create iess trauma than a small one. Where exposure is difficult, the constant moving of metal retractors on unprotected fat sod fascia is a constant menace. Many surgeons apply Kocher clamps to retract fascia. These clamps, if left on for any leneth of time, will destroy thi? relatively avascular tissue. In attempting to obtain exposure of an organ in tbc abdominal cavity, the intestines may be severely handled and pulled upon. Coarse string pads are placed to keep the intestines away, and frequently the superficial layer of peritoneum is stripped ou when they are withdrawn. Postoperative trauma n n showed (he i vineries of :.eroatc rod- in a cleo -iie infections .tni the origin a a senes of Hospital we ms 3 sn his -run Hospi- - * Ail JoTSOtld rs as wed u '>v*rrd which .-Torhacten*. - adopted. At A o per eeat. . leas growths --n smeared rate donly. Towels or :.ing the is* -Hires before -ue cultures i impossible rovement of 7t>m our con* rho construe* -'^es either ia -.Till kill the ..ohol id less - ;hc knives ; tthiigcnie T. Id almost 'he rough i * ait TO - .(.. ,i it -'ue. [ o the : ;>i'H tfe .1 I.n-*r of r trauma JI- V r F t f'roeccduvrs / .Medical nnH Suryr&U ''rttan m*y be as crest a cause of infection of clean wounds ns the trauma that occurs during operrutoo. Postoperative vomitint and retehinc stay pull sutures loose nod create dead spaces. The use of a Kevin tube inserted through the nose is a great aid o prevent immediate post-operative vomiting. When drains have been iaserted to control oozing. tbetr trmovni too rariv may traumatize tissue before it is protected hy leukocytes and onen uo new snares for in/ecttOQ. Ocr, ia his treatment of osteomyelitic*. has shown that infected wounds or open wounds do better if they are sealed wtrh a nan-imf.-uinr dressinc such as vnsehne and not dressed freouenrir. r 3. Foreign bodies. If one studies through the mirrrwrnoe the renair of it* postoperative wounds ooe is surprised to tind the .-tmotint of rmr'ana atwit any foreicn body- Where silk sutures are inserted foreign oody giant ceils and <i leukocytes may be found in their neighborhood a considerable oenod of time after their insertion. With catgut the same defense acuon otav oe seen. ? Walton Martin has said. "Every foreign body impiaoted then adds m varying ) degrees, depending on its irritative quality, to the miury of the tissues: uses j up. as it were, a certain amount of the defense reaction, and irom a theoretical i .standpoint should make it more duRcuit ior the nodv ceils to uestrov or shut in growing bacteria.'' Where heavy suture material is used to uraw unites together under tension. as m some hernias with large uciects. toe foreign my suture material, often apuiied with three knots, is too greu. an ouatacte ior iatisfacrory repair. Where tension is so necessary that Urge sutures nave to he >i5ca to maintain apposition it is reasonaide to assume coat trus suture t material wul cut through the museics through which it has been inserted, In such cases it would seem rational to make releasing incisions iu tnc ia-scia overivmg adjacent muscles which would reouee tension and a*u>w the use oi ! finer suture material. 4. Devitalized cells and aecrotic tissues. The long exposure of ceils to drying, aj occurs in iarparotomics where moist pads are not used ior protec tion. will cause death of these ceils. The insertion of mass ligatures on tissues, such as might occur m intestinal and gastnc resections, assures a death of <cils beyond the ligatures. Dc:ul tissue in a healing wound, with the presence >f only :t few bacteria which may in genend lie >u|>hrophttie. must certainly i.-rMi/ipo'e toward infection. The <urgcift i*ccn.<w>naily makes an anatomic diso'cnon of the ajHineurnsis of a muscle. not realizing this aponeurosis receives us blood supply from the areolar tt.vuie oo its surface. In fat indi viduals one is often surprised, on sfionging the wound, to observe the amount oi /.it 'hat comes away -vi'h 'he 'pong*. Thi< must be devitalised Kit which it left in tlic wound mav lin-nnc a nidus Kvp iwn-ria. U.-fore *1 *mg wounds in fa ;^--.pi` -,r would .com advi.siiile io irrigate the wounds with eiher, ia order I to remove all 5oo.se particles. .1. Dead spaces. Is" one could in.-neet with a mognityttig glass a clean Im'tir inn.dun one would tind many small depressions which arc imcnttal dead ( spaces. i'h<-* become macroscopic wh*r* large incisions have made and violent traction has been exerted with trauma to fat and mujeioa. Wherever a dead space occurs, it is usually filled with either lymph or blood, btagnant I I i i ' -`J I ;> J I '- -At i 4 ;1 ** 4S riftft /'mluni/ ,l.`r-'ilutH blond fiimt-hr* an cxeeii'-ni rulttire-inebmm for bacteria. D.-im th*- influence f colWin. of ..'-<! on *iaphyt<KKi.i* inv.-vni.ii. ilv ;#njn*i ttia: I hr <iL{irtic4jK<n i mtcrtuin was inerta-scd .iIkiui Iiv h:etrt.n.ma. JxirtrfTi cam aerOx. to tUoso (irwilv. w!<<(i*t nth-d with Ivmpb <i axui multiply mil <*f reach oi active. liviiig ln:ioryi-*.. ;m.l a When :h* v tr.a i? crrated unfavorable to the local defense rcuc-te.n ;{ the dv. :nv:a.n / tension suture* wt*i lure'- rutiiiie ii.-* plan >i .* i;urr*- *: v may irar bb<**l vcs-.*b ami Jiacrnanuw.iA. ! v -n!i **- *: I ii I h** skin i*uM l*e lucked with a Miarp niuui.i am- jh -- ?ui u;.-. ut.-- iP-u wh iKMi-ruftmc needles. ft. Tension of tissues. One frequently *v*< on iirrwm: w.nd aUm ibe fifth clay postoperative that tier icum.'ii tinfr have rut :i,ih t!:> -k::. If on* XttlM visualize tier rat ire !;*. of t *; :v: .:... -- - the**- suture?. had e-u through * ami tm.vie 11--.; tm-rc u.: r. relatively anemic area within their -en-tmi:cr>-iii-c. I i,- ..eima ' m-i.n;r and Ciay prcdiMWSO towam infectimi. To*. voip amloniieal dro*.r.- are!-'''! at the time of M,*>cmx:oii. with a resultant diMeiM*.ti *u the inn-nme? tienvntl:. may create local wound anemia. it is a genera) sunrifal impression that inguinal henna* furnish the hichest firrrmtace of infection in dean wounds. In our scrii-s ar the i-irth Avenue Hospital the incidence of infections in hernia war 1.5 titne< ihm omimnc fcllowinc a dean laparotomy through a Mellurncv incision. Tin* incidence : h'.emaiomar occurring m hermul wounur wun that irrutrinc m MrBumeys. ^t is common pntrtire m ticriorminc hc*niKcl **i-nitini!' u-- ur.'umcal pnorifilrs*. whirii ntichr readily arrmmt for tins inrmutcu incuR-nrc of liacrtuuoma and intmton. It '.vouid reem advicinlc to mentmn tiie important: in attemjmne an c.vrxi.urc ot the rxtemat oidmuc aiwncurysi-s the areniar tivue is sometimes owseeted free irom its externa: suriaee. Ti.m after income the aponemosis the arcour tissue is wineti un the inivrnai suitaec . downward as far us Pounarrs licament auu nicsuutv i<> tne n-ctai nuto-ie. The aponeurosis of any tissue receives the creator part of its vnscuair supply from the areolar tissues on iu surface, in this operation, then, in order to preserve tbe vascularity of the external ohlique aponeurosis the arrouir tuwiue should not be disturbed on its extcmui surface. The sac is often dissected free roucbly from the cord, producing a creat deal of tissue trauma. Tlic licntion of the neck of the sac with double heavy iiimturer* wiih .1 coo<l deal of ti.-v.ue lieyond the iisaturc bite leaves an area where there must i>c cim.-uirnil'lc cvllu- lar death. The conjoined tendon or the rectus mu.v-lc. an-.inimc to tl- tyjicoi herntuioperatiuQ used, is usually united tu Puupart s licament with interrupted sutures, frequently of considerable size. These suture; may be tied with more tension than is needed to approximate the fascial surfaces. Moreover, the operator, in order to prevent recurrence, is apt to use three knots--iairociucim: a larjre foreicn body in an nvasnilaritcd area. After the aponeurosis has been rinsed with or without the transplantation of the cord, the sktu is frequently dosed without suturing Scarpa's fasem. In this reeion Scarpa's fascia 15 one of considerable moment, as it has suhicient tensile strength to tic a factor in extravasation of urine. If It is observed just before ciosure of the skin, there v ui I.e f.itmd the >kin k- < The adorn *..uarl rrdiic l -a.miM hi .;,ntt' the am- .. t'.orttial .-S, Ol cm rer:r.m faetr I;.- mcih < ;;W :V Oil irOI I thu Here vnu no here. (Slide) within two ' here even iStuiej 'Tiravr.sat! here. (Slide) normal on is the skin is sewed u . the inversi. subcutaneous center of a distance extravasated operative (Slide) infceiioo. the fat: can sec. leukocitcs (Slide) This show of the skit postoperatt* that you "h.rst studied the ilc found that matoma. When a ,,r Mood, they . ami a condition -. The insentoo -' rafute of vision 'M r::re .-ursttcal -uurvs m.-crtcd utuis about the :i into the skin. i;M probably see hat there waa a a <:viay*i iivaiins .ines applied vttnes beneath. irnish the highest r'itth Avenue i that ov'-urrmu "he incidence of it uwirraj 10 .wraftons to use reused incidence mention tlie most *3?aque njxtnctirosia surface. Then internal .-urface r*^rii.< tni.4-'ic. - ..-.ilar .-uppiy :*!!. ;n r"*iar i. I'::'' iirarioit -i d*- d uv : ';........i - 'I -M'ii more lf. ;~c . jn-:nt: .. uro-is has iH-'-n :(t h t><vtcntiv lawia i.ome >,( a factor in *hr> .-kin, there Prcccolirur* of Medical anti S'tnrieol Section 40 will he found a hiatus of two or three centimeters beneath the edaes. .Should t.4 the #kin le rinsed without this suture there remains a triansuiar dead snace. The adoption of a careful, non-traumatuine surstcai technique wiU do much toward reductnc infection in clean abdominal wounds. I would like to show three seta of lantern siides of laparotomy wnumls to show toe amount of tissue trauma that rakes place beneath what appears to he a normal skin. '.Slide) Tim lirst *<ne is taken an hour md a half after a lamroromv -*0 ,:ou. XJi course a uotr is not kent as quiet as a twtent. nut ncvcrtn-l*ss we certain factors. This over here is the *k*s. This is the line of :rtstnn. this the fascia of the aponeurosis of the rectus muscle. The peritoneum ts here and here. There is already, within an hour anu a half, a bur. dense otacc wmrn is a haematoma. The blood is extravasannz down this way, and we tinu here away on from our parent wound of infection, quite a larse extravasation of blood, i think *-ve have all seen that three or four tncncs from a tuoaruiomv. Ilcre you notice, we snow the hemormaue ta between mo muscle. way ov*r here. ,Slide) This is a hich-powrtrd view of the reaction around a Mik'lnauutc within two hours of the tunc of ojwauon. You can ail see the cellular reaction here cwn some ubtance trom tns forcixa uouy inserted uuo me uounu. f.Slide) This is the nice of the u|*iaeurosis. ahowinc m itcre the .-anoutit .of extravasation ui the tissue aiuu-^ the ec-c of the wound. Here is our (lap over here. (slide) This is a two-duv laparotomy wound which appeared perfectly normal on the outside. Of course 'he sutures have not hv*n remove*!. This is the skin surface on this side. I think you ran see the epithelium here. This i is sewed up iicre wqh an over and over Lrmhert stitch. I think you can ,*e 'he inversion the two -kin irfaccs iicre. Here is a haomarmna and 'ho .i:':it:uii'ou.'i a.-foiar of fat with lympn ami td<kl iu the venter--a M.-aWii'id rv*r of oiiVrri:n. H*-e [ *hmk voq .an .-< f i-.e extravasation of Mood quite i .ii-'-kiHa* from the fine of mm-ion. ( i.hsuk you can .-e how the.fat has ltw>n t vtnvasatod with bUd ami enun to a considcraiilc distance away from the operative field. Th ' .s la^ii*i<*i-.vcred va-w : d.:s .-'..i, a hcaitnm! nidu- for r.:-'""'o(i. |(l ..r-.j.-r i -how vu more .fi'iilv ihe auiourif .! r.ruoion m rh.e : ;l aiui :nia"i,. f*>itcr in the n. :-_'iiiioriir*od the c|o. Y.oi an cxi'vpr for -..M.'d bacienal (icuu-rri'-H *.f :he -rum. little i hana; of the .K." i"'i aila. k t'.-.e Uai-iona vd'iun 1 iu* blo.~l lot. Tiii-i is a naif-lav laoaroimnv wound, cauirfftioiw on the *urfa<a*. Tins -iu*ws the of tlie -v-ralUti I.cnio*rt stiN'h, with the invmrmacion of tile .-kin 'tip-i. It looks (wrfrctly normal at ihe riitnal start. As die ;x>sfOf*vnitivn oiema vnes the edge* arc fona**i in. ami it is from this area here that you oft'-n vet ttie start of infection. I fere n the aoirnar ap,neurosts of i i l 50 American Railwat A***dntian the rectus muscle. Here is our line of ineriion and here our peritoneum on this *ic. Here you we blood cxtravasnml aionc the anterior aioncumi* of the rectus muscic to a considerable distanceamv fmm theaperitive ttcl<L (.Slide) Here is the reaction at nine days about a suture ut an apparently Hren wound. showioe the amount f eeilubr renemn that errors with the introduction of every foreign Itoby no matier hotr non-tmtntmg we consoler it to l*e. In conclusion. I apologise tor perhats having brought before yeti eietnentary subjects, hut I fed convinced that if we are to improve our results we have to go ever constantly the problem of tissue trauma, tired sjiarc. and fomett !**!:> in order to have larger f*erecntare *f clean wound*. i Atmlau-- > Tnr. Chairman: I am sure t have aii benefited bv the <t<vt*ir - most excellent presentation of the paper, i know you wm join uu me m ttianxmg Dr. Bancroft for his time and trouble. On i^ehaii o; the Associattos i want to thank you for being with us this momme. Mr. C. E. De.vnet. the President of rhe Eric Railroad Company and Chair man of the Operating Division. American Kailwav Association, is wuh us this morning and we wiil be glad to bear from hist at this time. Mr. C. E. Denney: Gentlemen: it is an unusual sensation to iai* to n greyn of doctors. Vou can took me over at a distance, draw your own cunelusions as to my hrelth.. out not matte me take your meaicuic. .My presence here this morning is. however, due to following the Doctor's orders- Dr. Dinnen tastructeu me to attend the meeting. As President of the Erie Railroad I never make & speech and fortunately assuming the Chairmanship of the Operating Division of the Amencan Rail way Association does not require speech-making ability: if so there would have been another Chairman. As I have said a good many times, my pre decessor oq the Erie never made & speech over five minutes long and he left his position to become president of several railroad companies. He and I both piav goif. He piays left handed. He played In Youngstown one day, in a foursome, and drove first. He didn't like his drive and he talked to everybody about it. and he talked to God about it. Then the other three drove and they all hit worse drives than he had. One of them said, "You remind me of an Irishman who lost his friend. Casey. He couldn't find him anywhere. He looked in all the saloons and every place he could think of but he couldn't find him. Finally be-went to the morgue, and he said to the morgue keeper, 'liave you got my friend Casey in here?" "The man answered. `I don't know. I will show you what 1 have.' "5o they went into the room where the bodies were kept and pointing to one he said. `Is that him?' "The irishman said (couching). 'That ain't Casey.' "The morgue keeper took him over to another one and he said. `Is that him?' "The* Irishman said (couching). 'That ain't Casey.' "The same morcuc keep* "The Irish glad to have : Tlc worx helpful to the managements undcrsiatuim 1 am a iirn The meetings which u.-uaii' ;> rt<'iii:ir i:n <niilart f*ii'r:u:.iiv A ri-mi..iic r:uiro:ui m a*, read*. It is union the numt.cr c Divisions of t indicates tin* papers at this three uiiy* ui ana product!' Your alien to have oeea at the next A individually < Thank you Tat Caaii Nett we w and Rehabili Dr. Moss before. ... I .-.am oo 13 of :<i. rently a the nsuder -r.tnry vo to . .reign > most .rising r.at to -...-.airthis *.o & ; fon<cnce . Dr. .mely v preleft .'cc'i .-nd. md ;i:e in* .:at Proceedin']* of Medical and Surgical Section 31 "The same thine happened wheo.he looked at each of them, and finally the morgue keeper said. "That is a had cough you have/ "The Irishman said, 'A bad cough? Yea. it is. but any of them would be glad to have it/ '' (Laughter) The work of (he Medical and Surgical Section has beeo constructive and helpful to the railroad companies sad the employee*. It is anpreciatM bv the managements and hy the employees and their reo-escntauves who have an understanding of the objects and areomplwhmcr.:* of your Section. I .'.m a firm believer in organization* of people in :he same ime of Httine*.*. The meetings of committees and of the entire organization result in ennrlusv*** which usually represent the best judgment of the weTJ--ytoitoed people in tne particular line of work. Great benefit accrues to the individual tram the contact with others in bis line of husmess and association work rives an f opportunity for such contact between men who art, by location, widely separated. A requisite, in my opinion, to the successful managing of a denartment of a railroad is association with those in tne same branen of service oo other rail roads. It is unfortunate that present conditions have made it necessary to curtail (he number of mceunei and the funds available to the various Sections and Divisions of the American Railway Association. The program of your meeting indicates that you are considering a iarge number of imoortaat reports and papers at this two-day meeting. It may be that the experience named during these days of limit business and small expenaiturcs mil result in more intensive and productive association work toon m the past. Your attendance and interest in this program are commendable. I am glad i to have been here, and I will be happy to endorse the report of your section i at the next Annual Meeting of the Association, and nape to see you ail again i individually or at another meeting. * I Thank you. (Applause) Tue Chairman: Thank you Mr. Denney. N-xt we wiil have the report of the CVm-rmctee on Occupational Di-eascs and lloiiaiuiit.uiijn, by Dr. Moss. Da. M.--s: This report is largely a rehash of what has gone oo in the years before. . . . Dr. Moss rend his printed .-i-onrt :\a (..jj.v.vi: i ! I tI ) I J j i Rcshritu A!'nC>nti-n J (Gtcuift* So. M. 4; 5. I3r-) American Railway Association MEDICAL AND SURGICAL SECTION REPORT OF COMMITTEE ON OCCUPATIONAL DISEASES AND REHABILITATION L' V. Iv f\ 'V C. ilifi-.:..;; H'.J V;.....rv iUu-r-j'l. ; Du O ;*. Cui*f Siirwwn. Mmnnn !(>>''. i Kite * Hetr**t*u:tTr ' bt'tf!* J. it. C^a-i .'urw-'i*. n.e iiivir oi .iuMni oU iUniMii. - New Vork. X, V.. Anri! 30. 1922. To the MsDtCAt. aso rckgical mxtiox: Ih-trisnitur wtut thu vear. the. oc^igsatiou ui this Committee was cuanttcu irem that of "OrrnnatKinal Dwoiiea anti Hazards" tn that of "Oveunammai f l Di.wa.*1** aim Ht-iiuhmcauuO.' i Ar> injormui meet me of the Committee was ncid at Toronto oa .v-pteaitiur 22. / 1031. anti tentative plans tor the year watte were aiat>>eci out. Dr. W. II. Cohart t.< appointed Cliairman. Following this meeting. as* you no doubt know. Dr. lloiiart became til, ana because of iit iiIncas. meetings oi i the Committee were delayed to that actually there has been but one formal Committee mediae--that of April 12. 1032. in Chicago, though there was an informal meeting ot the Commute* tn Chicago uo January* 14, 1032, to & 8 make plana for the year. Because of this situation, the Committee has not had the time or the opportunely to give more than a limited consideration to subjects embraced under tin' new lit It- oi the Committee, and for that r<ftMn ir is thought tiut it might lx* helpful t utTvr a recapitulation of the more important matters already considered by the Committee and reported upoo. I<- Syphilis A very live topic of the Committee has been that of syphilis among railway employes. In looking over the Proceedings of the Section, we find that when this Committee was appointed in 1921 with Dr. Ensmmger as Chairman, this question ot syphilis was of first tmforunee. and during the intervening years has been the must important topic considered by the Committee and I discussed bv viue to the presented fore published hy calling attenuo examined at farmers. 3.S p(.*: tin-** vph Mt uervous syr vaseuiar syphti abnormalities. <'ui.".r rafales*" **nc i* r-mr:. wmen ito mas ."vtuitv ana ttoco ftatac 1. In maku lotiowuag tor sue. eausuty knee rcticxes. 2. When an a primary lust or at least sni cvtoence uiat ably be thoug for exaauflAUoa 3. An appn syphilis shoal A. Op perio lesion should proper treats considered sa 5. Those to such a stc proper treat 6. Those general pares responsible oi be able to do 7. Those should be re la 192S. iation DISEASES jurxeeo. at- U>uu* ? aurvroa. tV*baa 30. 1CC2. was changed : ui ``Occupational 2gr/>oa Septcmlier 32, t'i out. Dr. W. !. ting, us you no !nr. ntf":rsii of :i but i-nc formal though li.-Te was .;.rv 11. I'.'.I'J, to ' iitimttoe !:.is tint I f.M.icr.tuon to i :( "..it reason *.i* more mi r-riifi ! mw.n. nnuPi; rtuway * a nett -t-r o.< Chairman. ":g the intervening ' ' Committee uod I f Proceedings of Medical and Surgical Section 53 discussed by the Section, and without doubt the diacua*ioe has been of a value to the railroads which cannot be overestimated. This matter was preseated forcefully to the attention of the Chief Surgeons through a paper published by Stokes and Brehmcr. of the Mayo Clinic, about ten yean ago, calling attention to their record that IL7 per cent of railroad employe* examined at the Clinic had syphilis, contrasted with 1.5 per cent among farmers. 3S per cent among business men and d.1 per cent among laborers. Of these syphilitic railroad employes mentioned. 79 per cent had evidence of nervous system mvnivemeat. whue Id per ceat had evidence of cardio vascular synhuls. The evidence of nervous system involvement was puotiiary i abnormalities, fundus changes. disturbed reflexes, mco-oruirmiOQ anu mus cular paralysis. * Sixty-four per cent of those presenting cumcai or laboratory diagnostic evidence of syphilis had positive spinal fluids. This exhaustive report, which was corroborated by otner investigators, miiuenceu your Com I mittee to make very dedntte recommendations, which were uiscussed by toe Section and favorably received. -Recommendations: 1. In making examinations, either pre-emoiuyment or service, note the following for eye changes reaction of pupils to light and accommodation, site, equality, irregularity, iuncus changes, muscular paralysis. Note gait, knee reflexes. Romberg, extenticu arms for tremors, general adenitis. * 3. iVcen an applicant for employment on beteg examined is iounu to have i a primary lesion or other evidence of recent infection, be should be rejected. >r at least approval postponed until :uca time as he --iuil be ubie to vxAib.t evidence tnat he has received sumciea: and proper treatment and may reason i ably be thought cured; if iie then be accepted, he should be required to report i for examination and observation at least annually. i j 3. An applicant for employment who exhibits any of the signs of late syphilis should be rejected. 4. On periodical service examination, an employe found to liave a primary lesion should be temporarily removed from service and required to undergo proper treatment, not in-tag permitted to resume service until he van be ! -onsidered safe. 5. Those employes manifesting late syphilis but not having progressed to such a stage as to threaten a calamity may he omiaued in service under >ror;-r -rvatmi-nt and observation. <j. Those already having progressed to a .-rate r iuit locomotor ataxia or general paresis is inevitable, should removed :rom tram service >*r other resoonsibie or hazardous occupations and aliened to such work its they may he able to do and where they wiil be free from danger to themselves or other*. 7. Those already hopelessly involved and a mriiace to themseives or othen should be retired. la i`j3S. the Committee recommended that all applicants for employment \ in train or allied service should be required, in addition to the regular exammai i i? 54 American Rniltrau '3i<iftUnn tioa prescribed. to have a blood test made, and a positive reaction should be considered a cause for rejection. Yur 0mrmttee holds to the ooimoo that this is a recommendation which deserves to he emphasised, snd urees that it be made a routine by all road* eximtcunc applicants lor employment, particularly in cnemc. tram and switching service. Cardiovascular-Renal Disease C^rdiovusciiiar-remu diM-ase received its lirsi consideration when the Com mittee in l'J25 addressed a rtue-iMtuiairr to a number m writ-known internists, trliose replies may tie epitomized into the foUowtue: Xo definite ruirs can be set out whereby a deadline can be drawn; emnlwyea must l>e considered individual:v. Hut tn ceneraL when there is complaint 01 .s:rtn<vs oi breath on e\<r:.*iU. when :t;rfc is mart.cn accvirroun:: : i heart rate after exercise, m.icn uoes not return to us rvsime rote alter !> or Three minutes oi rest, or i? necststetutv r.ttovc a rate wt vt* at rest, iviivn t:.e blood pressure ones not elevate in a normal w*v alter exercise ana wutttn a five minute period returns to a point dolow tne nreviousiv restiue oomt. wnen there areatcythtmaaoi various sorts mtensinea iv exercise, wuea me examiner observes siens oi inaueouate neart lynction. such as uurriru uresttuuc. couea oo exertion, cyanosis. siisiit cticroa oi oi*wiucnt jiarts. aii sicns potnttas to & pendinc dccompensatiou. serious consuicratioo ahouiu be civen to auen an individual's hints.* to remain m enemc. tram or xtvuenmc service. Giver, an employe presenting such symptoms aaaoctatvu witn a itypvrtcnaioii. a kidney impairment evidenced hv an atouminuria. vasts, ana reamvo 1*;:' teas than 35 per cent to 4U tier cent m two uoura. un oraamc nvart iviuju. particularly a mural stenosis, or evidence oi an aortic lesion. esneeuulr wueu associated with syphiiis, warrants a rvconimeiiuauuu tuat ucn employe ahouid be removed irvxn tapnt. tram or nwttchmc service, and aiioutu not be returnee to duty until there oas been a marked improvement. An employe with a ubriiiuung aunue, a bundle branch niwck or a heart block u uaut for this class oi service. Dr. Frederick A. M'iUiua, oi the Mayo Clinic, presents some statistics on the electrocardiographic study oi various heart lesious, which are illuminating and important to the Ciiiei Surgeon in his attempt to decide whether an employe can with safety be continued in service. In a series of 200 eases of surictiiar fibrillation. Dr. iViilius repons a mortality oi 41.3 per cent io Jour years, while in a similar number oi cases of heart lesions oi Tarinus types without fibrillation. there is s cardiac mortality oJ 13.0 per cent. Auricular fibrillation with aboormal QR.S complexes in all derivations of the electro cardiogram has a mortality oi 63.4 per cent, while a control series with abnormal QRS complexes in all derivations without auricular fibrillation has a mortality of 54.2 per cent. In another series of auricular fibrillation with abnormal QttS complexes in all Loads and ventneuiar premature contractions there is a cardiac mortality o: $7.5 per coat. A control series of abnormal QRS complexes in all derivations with ventricular premature- contractions has the same mortality, $7.5 percent. From a prognostic standpoint, abnormal *.ioo should be .< opinion that .::t the liter two whea the .tui within s ; point, when ;e examiner ::;ng, rough siintipg to ; to such an a. t liven .-tension, :i - meed WP . art lesion. . rally when i employe ^hould not ;'ia employe ek ia unrit iAtir.4 on .minatisg -`(her an .'..`0 l\U*S t rent n - .rs.-:!:.r . fn.' -<*n has ,n '.vi> h -.renal .rtMina '.orm.al y l * Proceedings of Medical and Snrgictd .Section 55 rr. QRS complexes ia ill derivations of the electrocardiogram is one of the most r? serious conditions with which we have to deal. Auricuiar fibrillation ixso* ciated with mitral regurgitation ha** cardiac mortality oi 51.0 per cent, while uncomplicated mitral regurgitation baa a mortaiity of 27.S per cent. Auricular fibrillation aseociited with mitral srennsu has a cardiac mortality of 47.1 per cent, while uncomplicated mitral stenosis has a mortality of 02.2 ner e*i. i He further reports that of 117 patients having a T *!cv;vv >n Deriva tion [. 7S, or nd.l per c^nr. have d. .v pmod or f.mr and a haif y*t; 23 patients still alive. 10 reporting *5:eir ""ndition av.r**. 15 inoroved, A unchanged. Of 52 patients having a T wave n^cami**.* m fVrivn'tnn.* { and 11. 35,-or 67.3 per cent, have died wr h:n .a period of four and a half vests. In another $rouo with a T wave e*eat:vi'y :n all thr*'* *:*nvarinns there V has been a mortality of 30 per cent in the same tour and .a h.aif y*ar nonod. i i The Committee has reported these s'amtien to brine to vour attention 1 i the assistance which may be derived from resorting to the eieetmearaioerann in selected eases. / s.rperteasioa Hypertension, whether it be of tbe tvpe of cssentiai hvTwrteoston or -.a hypertension on so arteriosclerotic basis. of outstanding injonninti iy Chief .Surgeons, who ace responsible tor emcrencv son ansetv oi tne unman ciement in the operation >f i>ur railroads. The timenown rr*rx e*nMog in hypertension are the abbity oi the neart musete to carry on anu *ne mar. actor of the cerebral vessels. Could mtne way be uevtseu to measure tnese factors, hypertension wouid cease to oe tne prooiem wmch u . because sudden disablement under coamtiocis of risk coma men oe iTouied. Statistics tail u3 that about 14.3 per cent of those havine a Hypertension die of cerebral accidents and 7,3 per cent of Minna peetons. cither of which may ueveioo and terminate with tragic suddenness, A diminution in rtaai function, as i may be determined by laboratory tests, *u>u to the gravity of the ewe.and i i Hires dofinite prognostic evidence. cuaaus changes .two iurai.-ih evidence which should not be ignored. i Ueexuse of the unknown factors in the proo;e*:on nnd progress oi artermi hypertension, the Committee has heretofore rc<*rimm*ft<icd *hat employes engaged in train .^rvice who have a iiersistenc hyncrtenswit above 175 systolic 1 and below 200 systolic, with & diastolic above IdO .mu h#i*>w 120, should he kept under observation. Those hiving a ..vuolic above .`'0 a >ii.i.-<t/itc nixie# 120 -houid ho moved .n --rvi#* ponding investigation, and .nouid he returned * <erv:r\* -Sowing dt'daic# .mt*mvmi*nt. Vour present Committee w^rK-i to .ufirm and emphaure the importance oi i this recommendation. Di.ihers Dinliete^ ij another condition which hs.i been exhaustively :di:dicd bv vur Committee in reeent year*. Letter* of inquiry* were addressed to leading ( internets, from -.vhn.e replies it was deduced that diabetee per se was not considered a haunt in railway service. The replies were all to the <uf*ct that . A S j I t I .1 / :i*: X*o 5G American Raikmy Arrnrintian the diaixitc would probably break down ohysieally or hare developed some dijeaso which would incapacitate t>eiore hr would liecomc a hemrd Iweause of his diabetes. However, the predominant opinion of these same men was to the efTeet that a diabetic taking insulin should not be employed in a hazurd'ujs occupation. lor the reason that n bviwnnstilmaemia a real rncnaee. Your Commute* r*enmmendeil that a dsal<ctt* taking ins;:l;n stintthl n>t 1** continued in a hazardous *wipatMn wlMveby he nuent l*e injur***! <*r pjuie injury to others throueli becoming mcapacitated suddenly. This rreommemlation has not met with the unanimous approval of the Srtifln. but you? nresent Committee desires to athrm the wisdom c*f that recommendation. It : conservative, and uieetci toward me prompt : :. Non-Shatterabie Spectacles or Goggles Or. February lo. 193*.!. the Committee inrwartieu Circular M. t e. 13.' :<> venty..even ciass one railroads having Chief Surcroos to ascertain envir practice in connection with the wearing of cocctea. the oui>ti*n k.n^cu <t< this circular letter as weii an a summary >> tne repitvs reretvt-u. arc Mi*n beiow; Question No. i a Is the wearing of spectacles or goggica of aon*i.ria*uu.c it.as* uuinua;..ry in e-rtmn occupations; .vNum.*>cr answering ..xV- s- .............. ........................................................ ^ v umoer answering ....N. o..... ......... _.................. ........... ................. ...........,. (( esas llf.c Question No. 1 o ._ If so, in what occuoauooa required? T qur usu t^e Practically si! of the GO railroads answering the questionnaire indicated *1 in their replies that the practice as to requiring the use of goggles in certain .: em! oecupauons was quite uniform. Some roads stated they were required by Shopmen:" others by "Mechanical Dcficrtmcot;" others by v.M. of \V. men v*r rutting rail;'' others "In ali eye-hasardous work;'* others "when Chipping, Grtncing. Welding. Babbitting. Cutting Rivets, etc." ha: Quesuoa No. 2 Is an emoioye who has lost one eye continued in service? Number answering "Yes in some capacities" - _________ _2S Number answering `Yes*'_____________ ___ _______ , __22 Number answering "Not in Train or Engine Service"___ _____n Number answering "Not as a Rule'*____ 7 Number answering "Vo"_____________ ___ ______________________ 4 Number answering "Have had no such ease"____ 1 - developed wait hstard because < ime men w*s nvod in a hazari & real menace. ;n should cot be injured at cause This recom.'"'ct.'on. but j'jmrr.cfld.if.oc. ry. M. & S. 135 to i .ascertain their hors asked in tvcd. are ?hown ;.a*s mandatory ______ 02 ______ 11 .mure indicated .giCS Ifl ri'ftAlO rr<.tured M. </ W. men -.`ft CluopiPtr. L PrfKndirtas of Moli&d a*vl S'liyte/ii .**(1-inn .57 Question Jfg. 3 Is it required that the employe who throush accident nr disease has Inst one eye, or who has had the vinos in one eye much impaired and not correctible with ordinary lens, shad wear classes or goggles. the lens, which protects the good eye to be of nod-breakable class, mound to a correction when that is necessary? Number answering "Yes"........... ..........................._....... .................. 32 Number answering "No** _ ....................................................................... 37 j Number answering "Yes in tome instance* \ ....................................... 3 f Number answenne "Have had no t*tcn er.**"......................... ......... 3 i Number answering "Each ease handled on nrnrs *............... ............ '3 Number answering "Same rule sneties as to man who has not 4 lost an eye..----____ __________ ------------------------------------------- 1 Number answering "if injured in semce, but taken out of service r if condition is discovered and found due to injury for which we i are not responsible, especially :a ream service '_______________ 1 Numberaoswennc"Donotorovtdeorrepuireprescnotxon lens**'.. 1 Number answenos "Not yet practice but believe gooa idea '_____ l Fractured Qs Cilcis Following pare shows in detail a .-errs *>f ten < lu) cases of fractures of Os caicu treated on one radroad during I'-'oQ and 11131. As is usual in this class of accidents, the injuries are sustained uy tailing or jumping from unusual heights to the ground. In two patients both heeia were fractured. The period of disability w uniformly long, however, the end results were quite satisfactory and the majority of employes were enatiled to resume their usual occupations. Those who were permanently incapacitated to perform the dunes of their former employment, urescntrii defects due to fractures >i the femur ur uina and tibuut as factors. The latter eioiw of employe* will iie furnished light wont. All escaped .-erimis injury to the spine except one. who received fracture `.'nipre<ert) .u lumbar wrabra: hut will <)..ubtli-v< r-^utne. his wore. These rases were given artrnrwn hy >>:rgc*n* particularly qualified to handle special fractures and diMnoanoru. 5S Unrrimn f?lifir*iv ii 1c, T- if '1 ! 2i-, I mi Mi - 's i{ !1i ciia 5 ^ - .i a i? 7; I? : :r;'i 5- ii i;.t i]i:i UN |i =s" ri *i Ii JiJ il 4:ifi H J1 ii Is it H ii, rn ]4]i nU i-!-- 1 "a ' U-5- `j '= =? 'I 1 sr ? I_ s'; i}] 4 ' I i! i lH r! 4 it; ii i ii : ?i ii = 3 - '=? in ;tz i2-:n :|r = -- ; : c-- 1 :i - :V -1 i S" f !i? .|?i 7V U S :|1 , 15; i! i : vis.'; _:-i :?ii;? it ! -i li = Ijv It :{ ;jf { Iii; s* jil 5? s '! f' jii i i. IJtii !j " ,!H i* ;*5:t iT ; * =? = j iM" ii t;! ;j \1 i.i ; r* IS . -<+ This of Com Cion j add <"\f cold*, i Clothes Uiatlt in ; :h* * i t l.e twines O' IWK f i !::iii,ovr ui icsiua :i av-uab Muusuai !l sho This <losrnr with tc should it may or is a A ca. condition which severe hospital meiu of is permi occupat Sacro tion of the lua Pr^ceedintn of Mtdical and Surgical Section. S9 Lusibafo This subject under the caption "Painful backs" is included in the report of Committee in its report of Apnl US. 1931, at which time further considera tion was siren to this subject under "'Foci of infection." There is little to add except to mention general infections as causative factors as for example. Colds, influenza, sore throat, gonorrhea, etc. Exno*ure in wet or damn clothes raiv also be ioiiuwrd by lumbago. Traumatic lumuaco itself deoenos upon more or less extensive lesion to the ligaments r muscles or to some otner of^he structures which are in relation with the vertebrae, cram the anatomy of the spinal column it is obvious that these^njunes may result ir.*.i suuuen twists or wrenches of the some or ttuv occur tnrooeh biows or fans on tne back or through lifting heavy* weients. The symptoms appear soon after the injury, though it is several days before they reach their maximum intensity. The chief characteristic of the condition and indeed the one which is the oasis for most of the others, is pain in the hack. The Uumttoa of traumatic tumougo is variable; but if the condition u not accompaoieii by complications such as Hypertrophic nrtnruts or outer chronic a(dictions, the intensity of the piu on movement ramuiy i;ecrra.-te and the period of <Liability usuaily <i.es Rot exceed tiiree to four e<ri. ' Employes who because of their occupations are suoiccteu to irepuent attaras of lumoago resulting in temporan.- Luauuitv should be given employment if available, repuiriug no ufting of ueavv vwiubts or oecupaikuia nvcc>Miat.i.g unusuai muocuisr exertion. It should be emphasized that when X-ray examinations i.f the -nine are made, that aatero-posterior and lateral views be tascii. Spondylolisthesis This condition as demonstrated by X-ray csammaiions is an anier:r ami downward displacement of the body of the tilth lumbar vertebra in relation with the sacrum, ft is the ciicuotttioii of ::::my observer.. ;t;a? tin* n>utia mould be regarded as a congenital driver; i;*w.*ver. ::i aii-ged injury' cn-ovr :t may be uuhcult to exciud*: traumatism _ a direct cause *i tile i;t:..n r in aggravating the prc-c*\u:g defect. A ease of spondylolisthesis has rvc*'n:iy been r'-r.tirt*tl by .r.<* road. Tne Condition was caused by a tail, the patient -'.nkiat nu>;i the buttocks. and which tv is i:nm*'<i;at',iy w,n| i.y ; ,i.r. ;a .............. vg-al r"g:*ei. very *v?re :n haraetcr. movements of hu-k r-./*:.-'!<I wii.-ii ;o hospital. i Jv made an uneventful fro wry a .:Ji t -.. ?':. .n <; us.Miiacif mrnt of vi'rtcftra. ft was decided that o-.vmg to the latter niutimi vhn.u is. jH-rmanent. he should not be n-mmted to perform \\r< m hazardous nccutjatwtis. Sacroiliac Disease farrobiac sprain or disease may hi* considered unuvr *m general ei.e-.-iiicatum of "Low buck Pain" since its symptomatology in the main i* rerVrrwl to the luniim.iacml region. Hie Committee dvatres to tMih;i.i*e ftie fact that r.v.**. i i i i ) .1 .1 3 i GO American Railway Association it is only through a careful history of the case in connection with a critical examination assisted by even-- laboratory means that the etiology may be worked out and a correct diagnosis finally arrived at. The bucaooo of industry today is the sacroiliac sprain, brat described by Gotdlhwau: :t is fast aa'iuntae the same importance in claims and litigation as the `railway some" of s generation ago. Da Costa. in `Modem aursery," states that a fall, hftinc a hesw weight. a blow, a twist, or lone continued standing, bending, lying or sitting may cause a sacnnuac sprain. We wish to emphasise particularly "lying'' as a cau>e. Whenever so many ridimious reasons arc given as a cause for a compiamt which is wholly subjective, well may we pause to con sider whether there is in iuct any basis for assuming a sacroiliac sprain as a distinct entity. The Commuter doe* not deny the existence Kirroiiiae pain in ocrasiuual patient*, but we hold that it is not of frequent occurrence, ami tl*<- toci of infection wtucii give rise to it may frequently l*e determined ii diligentiv sought for. We uciieve that a diagnosis of sauruiiiac spnuu is too frequently made and on insufficient foundation. "CoHsiuer. if you wili. T^.e anatomy of ::.c sacroiiiac union. It is a true .mint, because the contiguous auriacea of the sacrum and diutn are covered wit:: cartiiauc. yet so uuimaiciy bounu togetner through eartuagiuous union tarodcuout the joint surface as weii as the stroug ligaments externally as to constitute almost one bone--the atrouguae joint ::: the body--*nd ordinarily the only chance which takes place m this joint throughout itfc ism the pregnant woman,aiucii is a piiys>uigicai ;>r< Tns.vnixxT: besides searching out and eradicating foci of ir.feeimn. the commonly accepted treatment in these conditions ui {amfui nacus is r. sJmirustratton of antirheumatic remedies, diathermy, ma&aagc; and up|iuri. cither by.properly applied adhesive strap or belt correctly adjustea. wperauw proccuum tsav be considered in obsunatc cases. The Committee urges as a routine practice, early and satisfactory X-ray dims, both anwrujKutenor and lateral, in even* case of compiamt of back paio following an injury; and a searching quiz for history of previous com plaints of pain in the back, as being the ooiy way in which the interests of our companies may be properly safeguarded. It will be & surprise also how frequently lateral X-ray films of the spme will reveal evidence of a fractured vertebra when least suspected, and where an anteroposterior reveaU no evidence of an injury. Dust As An Industrial Hazard Dusts rosy be industrial hazards m three wavs; first. some produce injuries by igniting, burning and exploding, as coal dust and dust of grain elevators and gram mills: second, some produce systematic poisoning by inhalation, ingesuon and absorption, as the salts of mercury, lead and arsenic; third. some, though non-noaonous. produce lung pathology when inhaled, and tnese constitute tne most usual health hazard. All lung pathology caused by inhalation ot dust is known ns Pneumo coniosis. and this ts the hazard l wish to emphasize. The terms siheosts. ntfx % critical logy may be ''o or industry *fast *S3tmtag v wne" of sail, biting a Iving or Qzrx'.-n'uely l.*J%VQ jj a I'ausc to coo--ft *nram as a :n occ&oooai >'i the foci oi i if dijicewiy <> f<'%tjucruJy auatomy of MUr'il-fr3 of 'lately bound re as n-rJJ a* !fie strongest ; ui*ee m this . gicni pftifMn nfcctioo, the . ^ rett. Operative factory X-ray -3int of baric . rrvtc>ua rom, ::u*T*->ta i |.,.w { i :rxvtMWi - ""*!., no :<|<'C injuries '.'.TV li'vunn ;<Ti:r; third, ir.alod. intf - >s i'r.cumo".:s Miicii.ite, (: Pr^ceaiincs of Mtdicai ami Soreioai Sf&im 61 f anthracosis, siderosis, etc., are used to designate the pathology caused by dusts from specific materials as silica, coal and iron. Many dusts may cause lung pathology but so far silica (Hi'>2) has been iouod to be the most harmful. Oust nathology may occur in aav pectination where dust is produced and inhaled in sufficient quantity over a too3 enough penoa of time. Crider certain conditions it occurs m from one to two years or at anv tune thereafter. \ Ii The pathology of pneumoconiosis is that of fibrosis. Wherever me oust lodges in the sruail atveolt of the lur.es ti sets un an imtsttun and the orocess <ii fibrosis begins and blocking of the lymphatics m that area occurs. Clocking i : of these lymph spaces in one area increases the burden of snowier and with j continued dust inhalation and bloclose or'spaces. the nbrotie process increases t until even an entire lobe may oe consolidated. This condition is bilateral i and symmetrical. For the purpose of description pneumoconiosis ts divided into First, ^Second and Third Stages. In the first stage the symptoms are few. usually the general i health is good except for a tendency for frequent cncat colas, there is a aught ii -shortness of breath on exertion, practically no cough or expectoration, and an occasional pleurisy pain. The capacity for worn u not decreased, physical i examination ia negative except for aught roughening of the breatA soueos. J X*ry shows a definite increase in tee lung soadows due to the increased fibrous 'issue. i In the second stage the fibrests has increased and the lung tissue oecome* I nodular, more oi the lymphatic spaces have been blocked and trie interstitial r frame work oi the lungs u thickened. The symptoms are more pronounced and exertion causes definite shortness of nrcatn. there ts an irritative cough with little expectoration, branchial colds and pleurisy pains occur more fre quently and capacity for work is decreased. On piiyu-ai examination cnese expansion is decreased. On percussion there 13 a dullness due to thickened pleura and consolidation, breath soumis are decreased in voiurae and both inspiration and expiration are sharper than normal. Xo moist rales are heard but dry cracking rales may be heard in the. Uinzs and throat. X-ray shows :nerr*a<cd fibrosis throughout 'he iwzz, the fibrosis and increased density being caused by filling up of the small lung spaces ivuh Ivmnhatic tissue deposit. Distribution of this fibrosis is equal through noth lungs and the pleura is more thickened chan :n the first stage. la the third stage *he patient presents himself wuh an advanced difiuse fibrosis ami urge r.'uiuur areas fhmuencut the lung fields. The symptoms .vrc a very marked shortness oi breath, persistent cough with a small amount of expectoration (it expectoration :s profuse it usually is due to imerturrenc infection), persistent pleurisy paias. loss of weight and inability to work. Physical examination revenis a rigid cnest wall *ith omcttrally no expansion*, breathing being almost entirely diaphragmatic, shortness of breath bring per sistent. and cyanosis present at tunes, l.'nlcss there hs.s been intcrenrrent infection no moist rales are heard m this stage. Clio X-ray shows a marked increase in the fibrous tissue and large nodular areas, giving the lung fidd the appearance of a snow storm which is characteristic of this stage. f,2 .lmrn'rnc .\s''<i'Kion 1 In the first stage the heart is normal in appearance hut as the fibrous ti.ue increases it is pulled toward the ncht 6idc un:i) in the third state it often occupies & vertical position in the thorax. i>u.*t inhalation renders the lunes .<ierptiMe to intercurrent infection and tuberculosis is often suj*enmpoxl. particularly in the second anti third states. The distinguishing features between pneumoconiosis and fuliereulosis i are: pneumoconiosis shows no elevation of temperature. impn*dne;ive much, no ( -ss of weight until the late stage. sputum negative. X-rxy hiLitrmi and M-nunetriral involvement, all JoUr- i7n*tei. .'ink-' >imi.-:1Iv r-.-r with no lunc eaviiie*. Tuberculosis sitows an elevation of temperature. productive couch. loss of weight, sputum often positive for tuliercuiar bacilli. X*my shows more often unilateral or nnn-symmetneai involvement, apin' or tipper |t.e* arc usually first and cavitation m:*v U,;st path'ilMirv of the lung-! ran he prwnt'-'t :ti tv.. way*, t-rst. hv the ad'm;atr ami proper use of water to wet >i*wn the dust at h- t,,v:u Y.f r- or:c:n: .-'mnd. t.y mreed ventilation to ouud.ty reftmvf tnv uuYi parit-'jb" nnn rettUa-eThfs with ciear air V Afr'-r definite involvement of the lungs has taken puut curative measure' are htmicd. In tiie first stace if the patient is removco fmm the dusty atir.o- pherc. sortie dust excretion occurs, and a limned unprnvemetit takes piare ami the fibrosis becomes arrested, and eatiaeitv for work is not wasted. In r the second stace after removal from the dustv air the oatnningv nemmc' i stationarv. ih ceneral health improves. but shortness <>: breath imu limitctl capacity for work remain. lo me thira stacc niter removal imrn dustv air vrr.' i::t!c imprnvemetit occurs as tnc- patnolocy is too extensive ami usuauv sveonuary mteema has taken place. Capacity for wor*c is extretneiv Umiteu or absent, and treatment is symptomatic only. ^iu conclusion we wish to emphasise tor fans that undfr certain eondtuons inhalation of dusts causes a fibrosis of the lungs noown as pneumoconiosis and that this ts an industrial health hatard. that it can be prevented bv oroeer use 01 water and veotiiauoc, that after fibrosis uevciopa seconuarv loicctioo is orooe to occur and tuberculosa is often engrafted on the norosis. and the radiographic examination a the easiest and most reliable means 01 diagnosis. Respeetiully submitted. Committee os OeccrATto.vAt. Diseases a so Rehabilitation'. P. B. Moss. M. D.. Acttnc Chairman. Dr. Pu-mmer: Mr. Chairman: You will notice the repon is made by the Acting Chairman. It states in the beginning of the report that the Chairman of this committee. Dr. Bohan, became ilL The latest report we have of Dr. Bohan is that he is no better, and the prospect of his ever being with us again is poor. . I would like to make a motion that the Chairman and the Secretary formu late a message, to l>e transmitted to him. lettinc him know wc are thinking of him while he is tumble lo be with us t the meeting. D:-.. D-*wj> 4 i' OKU lot l ir. W 1 \. !:. . -.1 I I I |-.i- ;>r. .-. 15. M. .V 1-5" mita tissue :ce ic ofteo .Vetion sod *ad third nbereulosis live couch, vs bilateral rtcer with r.roducttvc ilit. X-ray or upper .r.-c. !>y the -ot of its particles measures ..ay airoosakc# place mited. la cy becomes ;nd limited .1 dusty sir -ml usually :--iy limited conditions :rioconio3ts - by proper -iX%*. infection ^Is. sad the -Sicidiacaosis. -f r:uy. T urman. uie by the Chairman . ........f Dr. ' a ..t.uti ry .rnitj. ..::iA:r2 of fcit: Proceedings / Mtdiad and Surgical Sixtmn *3 rt U Da. DrtwoAtt: l second the motion .and 4<rc~cs( it l*e .a tidccram. The motion was put to a vote and carried. (The Secretary accordingly wired Dr. Buhart as follows:) Xcw York. June W, t'Jai. Dr. W. H. Bohart, Vero Beach. Fla. I Medical atul iur^ieai Sectton in Convention assembled sends srcctmn iI and best wishes. We all miss you. V ;;d.) J. C. Caviston. u .Secretary." Da. DownALt: l more the renorr ; the Commit<>n wreMtmioua* Dwaics ami Uciiahuiiation tie aeivnmt ai :i ;rc.in*x4 r-:*>rt. . . . . The motion was seconded by Dr. Taylor, put to a vote raw catruii. T:ts Cuairma.v: As the nour is crowinr'short I Ixdieve von w..T a:rr**v with me that it would be better to proceed to ta next nutuueron tuc program. -vtucu t } is the report of the .Special Committee oa Developments itcsuttinx irom Periodic Physical Examinations. Dr. a. B. Taylor, Chairmaa. (Dr. a. B. Taylor here presented the report of his committee, per Circular M. S. WO as follows:) ] l (A American Rnihmu Aitnctrttton CIRCULAR No. M.&S.-140 American Railway Association ______________ MEDICAL AND SURGICAL SECTION REPORT OF COMMITTEE ON DEVELOPMENTS RESULTING FROM PERIODIC PHYSICAL EXAMINATIONS Dr. ?. iCkaifm***!. CI.iA Vor Central hA>iro*4 toiov Central Lu.w . Dr. tv' N'. Plvjti. ChiW >roQ. Ciul/. ilobil* A- Sonatra r^Auramu. iDr.J. r, Ciiirf ?**.r**-*v. L**w 4 Kto * Cr>M< "rnKB iUore^., Dr. ft. 11 rv<. Awmiui w .VfeoieM *mi r`4ft>eai Innnw, u<uitwn * uub n*y Dr. J. C. liswnbtrKf*. Clue/ Sufccon* Urmo aoort Lise iuuuaaa. Rtr+ftt*iaitrt from Cammiutt of Lhrntto* Dr. ilirrr) Uartlc. Cut! Mciical buauv, r'cuaavivam* iuuirwui. New York, X. Y.. May li ly32. To THE MeOJCAL A.VO SCKOIC.U. SCCTtOSt At the first meeting the Committee formulated the Questionnaire (Circular M. .i.-134) with which you are all familiar, and at the second meeting the consolidated answers to the questionnaire were assumed to members of the Committee for study and such conclusions as they could draw therefrom. We want to compliment the Representatives in the Section on giving our Questionnaire more consideration in answering the questions than they have shown heretofore. This added interest bespeaks wcil for the advancement of Periodic Examinations. After contacting with Medical Officers who have had charge of Periodic Examinations on various railroads in tin* country, we are now able to report a decrease in focal infections and their sequela. We are further able to re port that there has been a much earlier discovery of disqualify!tic defects accountable to syphilis, with the result of early treatment, intensive treat ment. which will no doubt lessen the number of paretics, tabetics, etc. There is no question but what the Periodic Examination has come to stay. Even if the railroads felt themselves too poor to stand the expense, l believe the men wouid insist upon taking tt on their own shoulders as they are now relying on this examination to keep them hcathfui and fit. There has been a noted increase in efficiency in departments that have been under the close observation of the Medical Directors and Chief Surgeoos through the Periodic E.xa bac mer. Q to p on 1 nca t.f r< Cum: rnns that is a gatu oot habi railr shot prop its : pole imp be ( or c jori abc exa: way d ion .TI.'tG -CrW 4 Rio ' -.-cal r.d I'd, lu32. ^sjpfCircuiar Meeting the .fs ui the r.vir.g cur hive a<--m~nc . Veriudic r-.-;>rt "ll-V* RlW >iiW - rVriouic t' t i. fc Pmcuturup of Medical and Surgical Section da f Examination. Personally, the Chairman feels that ret hare no*' jutHdent backing (a Large majority of tbe men so expressing themselves) to disqualify men who hATe bees confined in state or private hospitals tor the care of the iosane. from being again employed in fast or hazardous sendee. Question number one was assigned to Dr. J. C. Landeooerw, who reports as follows: i "The question reads: 'Do you soecifirally instruct you.'' Local Examiners i la pny particular attention to the reflexes. eartwviUriy those oi the..-ye:' i 5 Fifty-one roads answered affirmatively. i Ten roads said `.Vo.' t r Two make it a routine instead of special requirement. One does out have a complete physical re-eiamiaauoa. One does aot so instruct, but `expects' this to be uooe. Four rather limit this to suspicious esses. Tea rosus gave so answer. "Heoiies to the question indicate that possibly it was not aiways conquereu on the proper oasis. Our Committee is known as 'Committee on Devciopmenu Resulting irotn Periodic Physical Examinations.' from wmea tt ihuulu be .-occluded tnat the question iXu. i) deals wun 'permute pnyaicai exammacions of men in ser-viee, rather than physical uxaminaiious of new men up ;or entrance to service. "In the entrance to service examinations, it is true that we may not and n consistent to devote a lot of time and attention to reflex ucuoo. particularly chat oi the eye. which is quite technical, because the person being examined is a `stranger' to our organization, to whom we owe as yet no particular obli gation, with whom we seek largely to prevent entrance to service if he does not meet the required standards, aud finally toward whom we have no ret haliilitory obligations. "in the periodic examinations we are dealing with members of our own railroad family. men who have certain rights in the family, men upon whose .houldcrs rests the weii-iieing of our passenger patrons ax well ox the physical property of the railroad company, and toward whom the company expects i <rs physical examiners to make every effort to detect all possible svmptoms pointing toward hazard and physical failure. This. then, must include xuch imp.jrt.utt ictaii* as reflex ntervaiin. and i-srivciusly the vve. whereby may i.<t ii.'<yivr*d he t'trst dangerous symptoms of the major i-auacs for sudden >r dangerous physical failures. "P.eohes to question otic show that xrSrmruive answers are far in the raaj'-riry. -which implies the predominating opinion that particular Attention .ii.joid he paid to the reflexes, particularly those of the eye. in periodic physical examiQaiions. "Adoption of such a recommendation by (he Section would wpea up the wav for general application of this practice in periodic physical examinations." i .} 'd :.i -:3 '1 'i * ":.1 'I 3 4 5. t i i i T-o American Ra-.imy Aisoaciicm Dr. W. X. Blount was assigned quwtion number two. with its sui-dmsion: 'The question rcaL-*. '(a) Du von instruct your Examiner* to pay particular attention to foeal tmetti'm'.' i *(!/ h` focal infections are dixim-rc-i. what diipnsuian Uo you m*kc of the cases?' fa) ritjvx'irtit memlier tines arirsv-tod--ye*. Eight |ii-ti:l*or lino s--: > Four cave n*> sjteHt. itt-:::* Examiners r-cardtic focal infection. Tliree state that they have m> periodic examinations. One had no )<x-al examiner, ah examinations iiotii made hv s '.raVi-tiinc examiner. Ot>: gives sittfuil attenti-.n :< i--;r: sn.i tr.o-i>. One states that sie nmi>n arm t:.r-u: mri-Mt-ii m exanunation. ; Two cave no answer. ii>) Ttventy-sj-vcn raemier tines s^ate that in>* are n-ierrto i<> specialists. Too refer their eases to the Ciucf .-urevoa for aim to utsponc of as he sees tit. ' .Seventeen advise as to the necessity for tmmemate attention, re- qucsftnc them to consult ihetr tamnv pnystetan nr tne nnvsnian I - of tueir choice. Fourteen state that these case* are rt-onireii to i*e r*r reeled or they are uismuacu irorn eiupajvmcM uniu currecteu. 1 Eleven said that the foci of infection are corrected hv Avouimr tne ! vmpioye to the Company iiw?pi:a. iw in.iuan.ui. ( Three state that they uo nov ruve periodic examination*. I Three cave no answer. "From this report, we readily **-e that u.c iarcer percentage oi the tnemoer j lines coosider that attention to focal udecuoa at the umeoi examination and repeated check-ups in regard to correction, ciiminauoa and so forth, u very important, not oniy to the railroad hut the employe as veil. "Certainly all of us know that focal infection stays an enormous part in impending disability, that the detection and arrest of foci is a big step in pre- semac men. Whether it i>e teeth, tombs, pyelitis, chronic appeudicitis. gall madder or what not, so long as the (<-i g-jes uncorrerted, just so long is that man headed lor an early disaster. "By tin- proper detection of Kai infection, which can only be done by giving special attention to this duriug our ttenouic examinations, the arrest [ and correction of these infections, by sending the employe to his physician , (preferably a specialist), we prevent some of the major disabilities (hyper; tentioa, cardiac and renal disorders, etc.). Then these men can be held for j a number of years of useful service. Not only this, but we may detect and prevent diseases the employe might never know the existence of, which, in the course of time, micht directly or indirectly cause the loss of many lives; destruction of valuable property, lioth of the raiiruad and general public. "Al* <ihc er assurct fcilow < Dr. servi<-e subeequ T.. xusoiu; oi nre: isuusti purc;v -The blanket in mst-tt "This pressive and sen: subject "It is is toe response toxic has b formity state individ is an ueefuh dwiivisioix: icrs to pay you make . ri-gar.img mode Us* a rsmmatioa. referred to > >1130096 of *.*ntion. rephysiriaa : to be cor?r*et<i. sending the s_the member ;iinatioQ sod rth, is very us part in -p m ;, :Huttis. gall just to '...fit* i,v - 'hr arrt physician ``c* ihyper c held for :<*iect ami -. ahich. m '::anv lives; i imohc. r f Prrxeenuujs of Mtdienl and SurTieal Section R7 * "Also, tbe detection of focal injection may mean that the `bread Tinner' * (the employe) continues to report for duty in an A-1 condition aod that he is assured that his family -will not be forced to' seek aid and aasutaoce from his fellow employes and friends." Dr. Harvey Bartle reports after study of question number three: "Question three reads. `What is your otactic* as to restoring to rt-monsmie i- service an employe wtjo has been sent to a state hospital for tr.c tr.saac ana -.4 suoseouentiy discharged by the state as cured." "This question is ratner innocent on hrst glance: as a matter of fact. how. ever, its import is very tar rescuing auu serious in us reai imputation. An absolute cure in mental disease is a ueimeuiy mooccu pouit *nu tae uuestion } is quite pertinent whether the individuals charged wita tne reseousumitv of pronouncing such, a person cured iuily appreciate toe involved najaru in i industry, especially the up-to-date railroad service as we enow it. it u not purely a scientific poiat at issue, but one of decidedly industrial nature. "The answers to the question received suggest strougiy tue waiving oi *uy blanket authority in returnine persons to work who iiave been uyspuiuueu in institutions handling mental cases, and rightly so. "This croup of cases would include paresis, dementia praecox. maiuc de pressive c.-ycnosis. paranoid group, constitution psycaopatns. toxic psycr.osi* and seoiie dementia, any of which wouUi come within the purview ot ;;-.is subject and consequent care in state insane institutions. "It is very apparent that there is a decided variance in the disease* lociuued in the group aoove mentioned, as to gravity, intermissions, recurrences and i response to treatment; for instance, an obvious contrast is paresis and a toxic psychosis, the latter often yielding satisfactorily when the toxic factor has been removed. Four answers express a hesitancy in returning any such eases to duty. Twelve answers state they have had no experience, but express a {car n returning such individuals to duty should the case arise. i T;::r:y*i;ve answers would not permit such persons to resume duty in ! ".*.ia service or its associated broaches of rvue. i nvveotcen answers state it depends upon the conditions, which we must admit is somewhat vague. Five answers would re-tore to the previous work. Three answers c:ve no. reaction, stating they have no definite rule cover- :.tg iU'.h 'C.-CS. "Impression.--Or.e would -dean from this studs* that there is a i.iek of uni* infinity m evaluating mental htness alter so--ailed successful treatment in a -rate insane husnital. About .'0 i***r rent, are in accord in restricting these individuals to non-mixaruous vtnnluymcnt. "Conclusions.--("udoubtediy the character of the mental rases and dieensd is an important iactor in arriving at a decision as to the person's further usefulness. i i i i -V -1 &S Afnerienrt Rmhmv A&**mntiori "Persons encaged in engine service. who have been thus sobered. should be thoroughly studied before permission is granted them to resume duty under any circumstance. Case? coming under'the above mentioned ciaasi- ncaiions oi mental disease? rwt le permitted to resume work excepting perhaps in one or two ot the sun-grout* and then only in limited fields ot endeavor. The same thine p.-ol*ahlv holds true ia operators, train dispatcher*, etc. There art t--naiti positions in the tram service that prrhans may l>e regarded less hazardous *nd lavoralUy considered in placement. "There sr-ems to be n question as to the dtsf*vu<i<in of cases oi paresis and senile dementia, they being jrrrmxnemiy unfitted tor any responsive work whatsoever.'' Question number iour witft its subdivisions was assigned to Dr. J. T. Roc: "Question 4: `(a) What is vmtr practice as to keening in service and under observation an emotovc m whom a physical or mental detect ua? nc*n oetected. that at the tune is not dmolinc? *(!>) 4Vhat interval cianses between examinations? `(c) What determines the interval?' "Seventy-four repiies to question 4 (a) were received trom meaner rail roads. 71 reniics to question 4 (iij. anu 02 replies to question 4 m i. Mu.tiy members cave the same answer to c as to b, and reuiiy botn uepena almost entirety on answers pvea to 4 t). "Aoother obstacle which apparently the members found to b* difficult, judging from their answers, is tiic impo&sioiiity of replying to question 4 is) as u stands. No doubt many feci that it would have been muen easier to answer more definitely if the question hod been sub-divided into physical defect? (a) and toentai defects (b). Physical delects are comparatively easy to classify as to etiology, diagnosis, prognosis and treatment, "Circular IM-oO (Physical Standards), under date of February 25, 1926, has no doubt been of extreme value to the members of the Association. "Summing up the results of M. & S. Circular No. 134, as evidenced by the answers received. I feel the Committee should be gratified in the interest shown and amniy repaid for the great amount of work expended on this sub ject. Drawing attention to the subject considered by questions 0 a. b. c. and d. has revealed a hitherto practically unacknowledged dangerous con dition which is itself cenaioiy should justify and amply repay the Com mittee for its hard work." Dr. R. D. Sykes, to whom question five with its subdivisions was assigned for study, comments as follows: "Some of the repiies on the brown print are rather indefinite and it is . should .* duty ! daaainoting '. Ida of uchers. tjxy be is and - work . Hoc : md**r -q de- r rail'Inny .ncuit. 1 t (a) <cT to :>vstc*l 1036. the *fcj; t .>tb c. .on* .r.erl t ie r* rt \ 1 r k i i j \ Proceedings 0/ Medical and Surrrieal Section 00 somewhat difficult to bring them under claasifiestioa. I hare, however, consolidated them under the various headings appearing below. "Of the 73 railroads replying to the questionnaire, the report is as follower 5-A. What is your practice in general examination relative to the thyroid gland? Routinely evamined -------No i-nw#v. .. . ----------- --------------- None made.................-_____ --.............. ............................................. So *oecial attention paid...... ................................... ....... ............... in reexaminations not considered unless toxic symptoms are. present.,,__ -------- ---- ------- ------ ---------------------------------I; symptoms pointing to disturbed action or the gland are --tOBf -- -- _________________--______________________, Examination ooiy made where maricealy noticeable 43 7 IS l o-B. Do you in every case examine size? Answered affirmatively -- ---------------------- ---------- .Answered negatively.................... ............................................... ... .tsswerea oniy in special <**** >?0 rvpiv------------ ----------------------- ----_______ __ ____--__ _ 49 IS 13 3-C. Do you consider existing nervousness and disturbed heart function in connection with thyroid giaad? Answered ia affirmative____________________ _____ .....______ ~'2 So r*miy received....-...... ..... ........... ...................................... 3 dratement was made in at least 50 per cent, of *"w_______ i This matter was coasutered oy 1 In some eases.............. .......... ........ ....... ....................... .......... .......... 3 5-D. Do you advocate metabolic tests in questionable cava? Answered in affirmative.______________ t>4 tf questionable. reject _____ ________ _____________ 1 Answered in negative.--_____________ ______ ____ _______ _____ l Replied yes. if indicated by circumstance*................ ................ S Replied not as yet-..................... \ Replied occasionally................. I Replied yes ior rc-examtnation. not for entrance to service- 1 Replied of doubtful reliability--.--..................... ........ .......... --. 1 "The Committee would recommend that where hyperthyroidism or hypo* :hro:ui.<m is discovered ia examinations. ' hat a mcrabolum test he made. `*Mre ami more attention, '.ve not*. :s :;i-ing pxid o the eye,* for color per* cenrton. visual acuity and eye grounds. We men who are encaged in periodic examination work are now placing a great deal of reliance on what we find in the ey#j. You will note the greater majority yf the inomiw lines answer in the affirmative in question one and we hope in time to include ail of the railroads." 70 American Railwtiu Aff^eiaium Is closinc. the Committee recommends that this report he accented as a progress report. Respectfully suumuted. Committo: on* Developments RcsrfcTj.vo from Pwuootc Ptitstc.u. Examinations. Da. Steiilino li. Tatlor. Chairman. Tee Chairman: Arc there any comments or discussion? Dn. Dcncax Eve ('Naahvilic. Chauanocn A* 5t. I^ouia Railway*-. I move i: ic adopted ns a proems.* report. . . . The motion was M-condrd iy Dr. I\wtUU. put to a vote ami carried. Tns Chaicmax: The next report ts that ot the Committee on Fractures, by Dr. S. C. Piummer, Chairman. ~pted u a .airman. i stove :ii carried. Fractures, . proetediruji of Medical and Suryitnl Section 71 i (Ci/cutir 1!. 4 S. US) American Railway Association MEDICAL AND SURGICAL SECTION < > REPORT OF COMMITTEE ON FRACTURES Dr. 2. C Ptuamrr (Cbtirsaai. Chief iurC;kmo. <Mc'c i>iaa jc r`eiae kau- Dr. Deeean Eee. Jr.. Chief Stw, S*bvhI*. L'wmmm A si. Lava iiaiiwr. i i j *y. Dr. C. C. Cr<n. C1M sumac, i'um .'ia* Dr. H A. 3e*v. Chief SMmOft. Cfcnxaim. imeio* lunreaa. i'u-idc jiau*v. Dr. A. S, Mett. Chief riutseen. Cbicaeo. Mii*use. it. i'-ial n aa ?.=r*texT\rrre rnox Cauurrtc r Uicsctto* Dr. '->><)lid G-itnoe. Ciuet s<<r*oa. Lwaisa *ur iluir^aii. V./rs. Mav ix UIXI. ? To ms Mzoical ano scac:c.v(. ascrios*. Your ^mmitfw met :n Chicago on A pro 12.lOd'J.ana auoams tne totlow. ; .ng report: i | The Committee, in its report, wishes to confine iis-ai to recommendations j on three suojeets. viz.: dm aid, co-operation with the AmericanC*Uce ot ( frureeoaa ana distribution ot its pnmer, "ThelYmcmio* and Outline oiFrc- | tnre Treatment,*' and the handling ot X-ray reports according to the system | .meiaated by Or. It. C. Chief .Surgeon. Great Norracrn fLuIway, ami: i r.*w in use on that railroad. First .tad j tVe wish to continue and also extend the matter of drat aid instruction to the employees -it ratlwav coinnantes. At the present time this is difficult i'.-r t-vo onruur.nl r-n.wns: mi- is. rh u > nuuiv employ.* ar- ;.id <*t[ and the mniovment of :h*e -1111 in :!: --rvuv arc un.vr'.um, and the iini rca^m js. the vrv wtitc m-v-v-uy `-r ivnii' iconev in everv wav ; possible even the slight evpcnse ot i arrytric on this instruction may ! n..i be justinrd. vw however, to ........... ti.o uianuer *i urst aid instruction as suggested by Ur. Duncan live. Jr.. of th- Gommitt.e, viz.: *\\t the various regional safety meetings which occur on Jitforrnt railroads, the Chief Atrgooa i i i T-i . .4 meneon Railiray Association or one 01 his repre*entattvcs will give a talk and ermonsiratmn t> the emplovers snti local suiteons present, in rezarri 10 the sdminsirnnc 01 first aid to fractures." Co-operation with the Americas College of Surgeons We apprmaic th** co-otic-ration of the American GUnrv of Surerons in the matter <i uniiruvinc the treatment of fractures u mdttMRcs. In rvyard to the primer. "The I'riacuiU-s anu tmusic f Frurturc Treat ment." as at present printed, we feel there is merit in the reference to this made in the region of our Committee last year to the ettcet that this bulletin is too complicated. An examination of this bulletin by our Committee leaus to the opinion Unit the rc-admc matter :< ai-u; simii," ai.d a> rouid he maue. hut that some ot the cuts are <-<iii]ii.-mc. aim "r leci tnat ii simpler cuts of k?? complicated apparatus cornu i- substituted tor -nne now contained in the Bulletin ami a suent revision made m me text, the buiitftm wouiu then be in such form that we tvmmi rvcommenu it to tue vanous Chief Surreons to distribute amone tne memoemo: tneir stalls. The financial situation at the present time. nowevet, is suen that wen tiic smaiicst expenses are scrutinized. ana u not urceutiy neeueu at tats unie arc discouraged: so that we cannot stive any assurance at the present umc urn the distribution of this Bulletin can be adopted by too various rauroaua. We. however, wish to look forward to the tuuc wnvn tms can ou uone. X-Rav Reports Or. R. C. Webb has put in practice ou tue Great Northern ilaiiuoy a method of handling X-raya. As a preliminary measure, each surceou u furnished with a pnnted Fee Schedule anti Geuerai Directions for Guidance in X-Ray Work. This circular, except for its incorporating a fee scueuuic and follow-up instructions. is identical with the "General Directions for Guidance of X-Ray Work in Fractures*' included in the American College of Surgeons primer. "The Principles and Outline of Fracture Treatment,*' Dr. Webb's method of handling the X-ray proposition is u follows: "When a fracture case is reported on the surgeon's first report blank, our system is to immediately start our fracture machinery toward getting complete records. "The surgeon is sent a special letter enclosing two fracture report blanks, which he is requested to till out at once as far as possible and to send the two blanks in to the Chief Surgeon's office with the before and after X-raya. "The X-rays are then gone over and a report ia made in triplicate. One copy goes back to the surgeon with the X-rays, one copy of the X-ray report is fastened to oae of the fracture report blanks aod for warded to the Claim Department, and the third copy of the X-ray re port is kept on ale iu the Chief Surgeon's office with the fracture report blank. i We er.abh X-ray ana ii many oaiioc auequ Dr. up the nectio the ox the cd We time i cotmes Her able g Dr. "At the Cl etratio tenng Proeeetiituja of McdicaL and Surgical Section 73 - the effl: am aid r [ `'The fracture report blank is simply the College of Surgeons' fracture sheet spread out over a railroad form of the same size sad shape as our other surgeons' report blanks. Some of the information called for can not. of course, be furnished when the first report is sent in because the case has not reached a stage when aueb information is available. This un* io the part, however, wdl be filled in when the final fracture report blank is forwarded. .re Treat- "A Company roentgenologist reads the films and makes out reports -- to this in triplicate. The local surgeon is furnished a eooy of this reoon. -- IMlctin "Th jMirwon treating a fracture aubconaciooriv improves ms X-rnv miniUi.t 'lurk ami his fracture work if ins X-ravs sre to oe systematically reoortcu : uisin as upon- through the Chief rurgeons ofiice. and when he comes to mi out -l that ti the fracture report blank he is very apt W welcome some suen tutue as i for some the American .Medical Association Primer or the Coiiree of .lunaoni text, the Outline, and it is cot ditacult to iater rvcommenu me ceuerai use oi : it to the some such book." .xifs. evco the W< recommend this practice to the members of this fiectiun because it .i time are enables the Chief surgeon to tcara at an early date whetner or not a proper time that X-ray. which will really show the condition present, iias or has not t>e*:i ia.n. - railroads, .one. t ami if such X-ray has not been taken, steps can Cc taken to ooiaut it. many cases. the only means of bringing aiwut tins mil would iie to nave tnc patient transferred to one of the central hospitals, where tiie equipment .a i adequate not ouiv for X-ray nurj**.-o but for fracture treatment. * ilauw&y a f surgeon la Kespcetiuily .submitted. -fi|-Cuidtnce ^^aehedule oyyctions tor \tn Ctlc?e I * COMMITTEE OS' I'lUCTL'rtES. Dr. if. C. 1'i.CMutR. Chairman. itroem." .jwj: Da. PiCMStsa: Mr. Chairman. Members of the Section: I cm not taking up the whole matter of fracture* but am concentrating on three points in con :-rt blank. rd a-lTuur nection with fractures on the railroad: First is the matter of iirstaid; second, the matter of miwnutuu with the American College of runtcons; ami third, the nutter of handling X-rty reports. :rc r-pnrt (.* :m>l to rt* and i Wo -re going to continue and extend the matter of first aid. At the present time it is very diificult to do (ins for reasons 1 don't need to state to anybody 'matcicd w;*h railroads. > trsoiicaw. ;*y nt the \i and iof; \'Civ relure report t i i Here :s -unettung that co.-is practically nothing hut whieii will do rnnsiderable good and which wc want reiromir.ead. This is a suggestion made by Dr. Eve. one of tho members of the committee, and l quote turn: "At the various rational safety im-eiiuga wlucii occur on ii:Tercnt railroads, the Chief ."surgeon or one of ins representatives will give a talk and detooo.trauou to thu employees aod local surgeon* present, m regard to the adainisronag of lint aid to fractures.' 1 I It seems to me that is very wort it while and can I'C carried on :rni-r the prf"*nt conditions. Tin- rti-u is thr cooj.'mtMiii with tlw American Goliec.j oi h re-^ej. V\e c on to state :i- trotutl'-* and si*-ok ultt `"The Principles and tlmlinc^ of Fracture Treatment." which was ;tUli-iicd hr the American ('!!...< of Surccoos. This v.a.- rnmmil on nr thi- .'`rtnxi U-f.re. and the rmititott or :V iirnttute was that it t. tis cofn:ilic-:tl<-*i. < iar nimmiltir. after siudvnu; i refM>i t. found the luiiCUace plain etiOueu atwi thought tl well worth whx- The conipheau-d [art of the retain camt! from the illustrations. Whets they h..J illustration* of tiwthnds of handling they line! tin* niottr ennsriiiea'--; one which rm:M lr ih-vw-j. Pi rhatis tlteV i- .(: l~x one*. i-V.t 4-. eurTitilienird :.`.,.r iiiu' tax trained in : i>o])S not cuimet.. i.i r. \\ < '.aougiit ilia: ii in tlaee 01 rl:ie- illustration*, <mirl>T ch."--:e v liaVe Ih-i-'i liisi`it-1ictl esreuiieie eotiji] !* Mll.Mltuled tliat ttL* tirttie r. as U.-v call it. `"The PrinrinJe* and I'ntaiiAmt Krwtttrc Treattner/." winihi i e... while n-cotnnwtuiiog to tiu- chief surgeon tnetnorrs oi tins >oetiyfi t.-r m. etisston with mtmsiers or the star:. , It is now utKiut vseat years smee tee hd recommend the mstrmut w- r.i something ot tius sort, and a uuoiiier oi railroads. i know itnv own among others', did distribute these to tdl their local surreocs. But to kern up mirr>i in a matter oi this sort vou have to keep at it. and 1 believe that when nau,>i\;.i conditions allow It w* uouiu on weii to consoler a revustno ot tliisixiii tu* wt: :< a view <t liistrumUtL^ e. i<> our ioval surevon-. I was at tne meeting oi tue Fracture Cotumitiee oi the American College oi Surgeons. our last meeting, ana tiiev agreeti to sucu vuwAgvs tu mu bulletin as we suggested. . In recard to tne matter of X-ray reports. Dr. Webb has formuiau-ti. and also pm into practice, a method of liundiioc X-ray ro(*ofts winch i thm* is very valuable and also inexpensive, aad the detaua oi it are wnUt-u in tnc re{X>rt. This was gotten up by Dr. Webb, was adopted by the American College of Surgeons, and is contained in the same publication with their bulletin on fractures, under the title "General Directions tor Guidance of X-ray Work in Fractures. I think it will be more interesting ior you to hear from Dr. Webb in regard to this tlian it will be ior me to read it to you. This is the report oi tr.c committee in regard to the matter: "Wo recommend tins practice to the members of this .Section because it enables the Chief -Surgeon to learn at an early date whether or not a proper X-rav, which will really snow the condition present, baa or boa not been taken, and if such X-ray has not been taken, steps can be taken to obtain it. lo many cases, the only means of bringing aliout this end would be to have the patient transferred to one oi the central hospitals, where the eyuipiacnt is adequate not only for X-ray purposes but for fracture treatment." The CkaxiuSa.v: Dr. Webb, have you anything to add'.' Dr. R. C. Webb iGrcnt Xorthcrn Railway;: The fracture program on the Great Xorthcrn Railway wutch Dr. Plummer and the members of his com- a . t?e earned on under the - ran GilWe of Surgeons. Principles and Outlines American College at \ and the opinion of the .mice, after studying the * well worth while. The ..ions. When they had v**t eimPir:ti,'d '-nos t <>n>-3. hut rh.-v w.vtM comprehend it. iwiier dioizram* which at this primer, as they rv-nt," would he worth ; this Section for <it$- -id the distribution of r.ow fray own amr>n? i hit to keep up interest ve that when national .n of this bulletin with - Amcn/vm Gdlcee of :ch v-hin^cs in uus has formulated, anti da which l think is .*. are written in the "'/rt hy the American ddication with choir us for Guidance of V. in r-enrd -r: iiocnn.se it ,-r <ir n,,t n nruOCf >j* ii'U `...... i '*.!>. \III'. . ;i '< I'tlt M yr^zr im on iho .'rs *>i Inj rom* Proceedings of Helical and .Nurptml S'Cti.-m ?5 roittee on fractures base so kindly hrourht to your attention has been rather the result of a process ai evolution which has had the splendid cooperation of the management and in particular of the claim department and safety depart ment as well as our sunncal staff. The le^ai department is frequently shown by doctors employed by personal injury lawyers the catastrophes of treatment and the reoucs* was made that a means of preventing these catastrophes ss far .. *o4.<tvi, p* .i^v< <+.\. \ r. ot these cases as w*!l as a ^"idv of a f-v of mail injuries arrancaii and 'h-.oiie.) .i;;;~n*4i-a snows 'hat rh**-5* casra arc chiefly *h"SO mvolvirp tram;?**. In order to institute the** nrraSjntive w* *.***!'{ a nl.iee 'o `w--m and our prst move was to `:*mrd our an'i'**t t;-*H vre schedule and wav* a rrw one. This new tec schedule which was our m *:'** in was im*rvv.oMr paces Ion* and hart stiff Iwiard covers wh*-h insured is b*inc'kcr*t avaiiah)*. i The Ust twelve paces consisted of "The Outline of Treatment of Fractures" ) adopted at the Boston Conference <n l?fS2 and recommended hv hc Fnerur* Committee of the Ammon Raila-av A*ee:arinn under Dr. Hookinss chairi manship. at the meeting in Richmond in ITJ7. i General inntetinns concerning fme*uree which also included a ice schedule fur the various type* of fractures covered three i An X-ray ice schedule which cave eenerat direction* tor enulancn in X-rav work .uvi provided reasonable and s*nnd.nr<i covered. mre* and or.c-hnif pages. ft'- fdt chat standard ;e*s for X-rnv work were ;*in? cnarzed anv wav fi i asn th.it by statinsthese feesm the 'chraule we would Ivina hocrc.r oosition *o request ol^sem-ance of the instructions. X-rays which were imoropeny or incompletely mane with msutricient number ot news and often incorrectlv interpreted not only permuted catastreohes of treatment tmt often prevented the Wal departments from knowing of the wnousnes* of the injuries until other ccstnitcations had occurred. This set of X-ray instructions vas utilized hy the Fracture Committee of the American Coile-e of .'iurgeona and etcept for he ritmmaiion of the fires to h* vimrtrcii * nutMiMini wuii slight -ifuin^ca in 'he M.irrh i'j.il toiucm of the American G>Hecc of rairpcons. hen the sunjeon * rirst report comes in v'iwvirjc 'he liiacnosis ot a fracture >ur?"?n is imm'-'iiao'iv recpu'ited i.i m o the chief suntcon s office che X-rays ta<en before and niter reduction. The .utnteon is aLso requested to rill out and send in a fracture report hi mk. This hbok which is (he Odbce cf .^urceonj' blank for th:3 piirpo^o nur -pri-ad out >>; a railroad form .-inular re :hc surr-on j ..it r-'vsv. t.lank injures a idy of 'he fracture and also urrv-rtes much *:--tl :a:'".-m-it:on <.-.>n.-*vmn;r 'he handling of the fracture for h-* <ir5.-on revietvins tne blank. The pra<uic.it applwati**ii ihcv* m.<tmrtn.4 ir<l cho usefulness / rhe hl.ink.1 has l**ren dciinit' lv proven. Thu lns**s fomt the iraorurc cases make up . verv hi"h {*rrvnrac>; of : l*.- total costs of p.-rw'n ii injuries on railroads and th** railway manaecmenti arc not only mccrcstcd from flm humanitanan iran.lpoint in the fracture injuries but they are also interested in the lowered vts which result when the economic losses are reduced. o Amends a A*W!'ih'rt Dunne the (our year* in which our plan has boon m encct there lvs been a notable decrease in the unfortunate results from fractures. The* chum and iecal departments have noticed the chance and their cradunllv tnercasmc interest-has reached a stage or enthusiastic cvor>cration. The local inirceon s interest in the assistance and guidance is obviously present and we think that some ni the credit for the reduction uf the mst pitin of personal inmnes r***ilt from this prweram. There is no o;:< y.ion in my mind, however, mat then- i* etili room for considerably more improvemmr. Titr Chairman*: Are there any further comments or discussion nf this report? Dr_ n.ut.srn: I p.ori' the report U* r.feeutm aad ::>?--i i;: t . The motion was seconded by Dr. D.-wdaii. put t>> r. v..*e ami The Chairman: Next is the report 01 the S-jrvCoramtttee on intcihscncc Test*, by Dr. Dinnen. of the Erie Railroad Comnanv. . . . L'pon request Dr. Dinnen s rcaarvs were not renortco. . . . The Chairman: The next number on the program is tbe report ot the tellers as to the resuit ot the ejection. D?.. Frost: Mr. Chairman: The foliowin- oitircrs m the Medical and Yurc:cai Section ot the American Rahway Association nave iwu civcauu: Chairman*.* Dr. Jobs McCombe, Chief Railways. Medical Officer, Canadian National First Vice-Chairman: Dr. W. L. Hartman, Medical Director, New York Central Line*. Secosp Vice-Chairman: Dr. J. R. Nilsson. Chief Surgeon, union Pacific Railroad. Committee of Direction*: Dr. Harvey Barrie. Chief M*-diml Examiner. Pennsylvania Raiiroad. Dr. C. W. Calc. Jr., Chief Surgeon, St. Louis Southwestern Railway. Dr. F. E. Smith, Chiei Surgeon. WVnash Railway. Committee on* Nominations for the Exscixg Year: Chairman. Dr. D. B. Moss. Chief Surgeon, Chicago, Burlington <fc Quincy Railroad. Dr. Duncan Eve, Jr., Chief Surgeon, Nashville. Chattanooga St. Louis Ry. Dr. A. W. tde. Chief Sun:con. Nonhem Pacific Railway. Dr. 5. C. Tlummcr. Chief Surgeon. Chicago. Rock Island & Pacific Ry. Dr. S. B. Taylor. Chief Surccoo. New York Central Railroad Cum vi tiic r few retn Chau I thin*. driven t express nieusriy very wei You i v. t tUv CsitT aortor o: this Sect furtmry i mem. a all Xitu c Speaki CLutrma said that know ho Direction we have my Erst c services c Dn. D. The rot ' ClUIRk C&a1R> Dr. Boh*, have lost Section, checkiag this Assoc Chair* we decide We have informatic on it. Dr. Do Section's t this quest I *n a -. and osing ,.'08 8 s that .-taiuit -.re is .-nee the rid -.nal Proceedings of .Ifedicai and Surgical Section * Cum&uax Hopkins: Gentlemen. you hare heard the report as to the result of the election. I am oow going to call upoa the incoming Chairman for a few reaaarita. Dr. McCombe. Chairuax Elect McCoube: Dt. Hopkins, Mr. Secretary, Gentlemen: f think you all know that I am cot a public speaker. But anybody would be driven to apeak on receiving this honor, and I hope no matter bow badly I express it that you will believe my sincerity when f aav I nooreriatc it im mensely. My thoughts may I** ail neat but l can t always 'cprrs* them very well. Vou have been very kind to me since I entered this held four years ago wheo I met you at Quebec. I have served on vsnOhs committees memoir* the Committee of Direction, later the Vice-Chairman, and now. crowning honor of all. I am to be Chairman of the Section. And when you do tnat it u j' honoring the Canadian National thulwavs, 1 think, as well as to myseu. With this Section representing the best brains of industrial medicine ana industrial surgery in America, believe me when i say 1 do aooreeiate greatly theaooomcmenc. A ad also piease believe me woen i say I will try to echo the cnougat of ' all the members and carry on the uiustnous history of the put Chairman. "'peaking again of Qucoec, the Chairman at that time was Dr. Bohart. The Chairman now is Dr. Hopkins. Dr. Hopkins, in his opening address yesterday, said that List year when we had our meeting be was "laid out rout." Wi ail know how til was, and while attending the meetings of the Committee of Direction he was a very sick man. He cos given us one of tue neat meetings t we have ever .weened, with good papers aou good liiscuasums. and I ima* my tirst duty os the incoming Chairman is to thank Dr. Kopxioa for oii of ms .services during the lost year. I would suggest tnat someone ao move. Do. Dowpall: I make such a motion. The motion was seconded, put to a vote and.carried. CuAinuatt Horsiest Thank you. gentlemen. Ch.mkuax Elect McCombe: The hrst one I met in the o.-gauuatu/n was Dr. Quhiut, and l think we all miss him. I know that I pT*inaiiy :V-u that I have Wat a v**ty great fri-nd. '-Vr ail hvl he *.v;ts a tr.-nu-fl'ious a.-.-rft M this rh-xtioo. He was like old Father O'Flyaa in Ireland, "!ie!pto< the auv ones, checking the crazy ones, atul helping the lazy ones up with a stick" as far as this Association is concerned. C'lt.uiiMa.v Hoi-kins: t\\* come now 'n acw iiii-mc.-s. C y- .'.'rtl.vy vc dvciiivd to put nlf until today the new Imsifwa ctiai ;vr at that tune. We have this .ox-hour nrrqxjsituin. un which Or. Dowd-all has go>jl .leal of information, ami he ha.< been delegated by his management to make a report ..u it. Dr. DownAW.: Mr. Chairman: l would like to take just a moment of the SxuoqA tune to prv-ent to the rhief surgeons the situation with reference to tUu question **i the six-hour day for railroad employees. l Vrvt-<! 1 : '.J ,-1 "4 - -AI M -* -:.`rA -at 7$ .-i/j.mcca Rziiicau As you know, a joint resolution of the Congrca* dttvc'i-d the Interstate C**m- merre Commission to conduct an investigation for the pnn*>sc of determining as /sir as pottilih* what would 5-- the eiicet on tit*- vrvier. of applying the principle of the >.v-hour dr.v in *h<* employment of :di rla.vs tuui in each particular r;is<- of railroad emtdoyo** iimu.v of such application. Public hearings have )*ocn held and additional Clearing.-- will Ik; in-id :n the futtir.-. TL- Attt*r.nui Train Di-i-atchers As.<'**i.n*?>. on May 'Ji".. called as a witness Dr. Harr-' I*. Mm-Com. r.o purito*-- of i*.low t--<tt:tionv via> to .-novo that the cpiscstioiis undvr w'r.a-h ;r-u dufiuti-iwo- work put an unetuiurubl.* task on the dispatchers and jfoparuized pniiiir safety. Di. MacCofd tc?ti<icd that he based his opinion on studies that ho liad made, and said that V3 per cent, of tile eases studi<-d '"rr abnormal memallv or physutiliv, and that fi (.f them wen '* r.timn* tii-.r rt-<-i:ra!if-n as r. rr-'itt *!:* V.oli.. Ci.r.i-*tji:* r.siy, tub S-rtvjW h:.s i.'-t; jMuv*u-n t i.ioi its io.mw*>:io!j v.ttn reference particularly to analyzing tt t*.-timniiv mat has iwvti tresetuu to the interstate Commerce Commission vitn rou-n-tK-e to um ettevt oi Uu wru- patinn on train dispatchers. i should hice to suggest that a tutrcenmiuvt oi the Committee of D.nvuon L*e selected to haudle this matter because it is very extensive snu it must in* pone into very thorougniy ta order to refute the testimony tuat has been presented to the commission. Dr. MacCofd is Professor of Preventive Medicine, of the Cucvcrsity oi Cincinnati. Coiicu*; of Mcbicmc. auu from >mi' the reprints and tram*cnnt oi his evidence, it u going to ik? nnwan' i. iiave this matter analyzed very careiuiiy anu thorougniy m order to ptvj-eiii u-*u- tnony which may in* used before the commission to answer the testimony ot Dr. MacCofd and the others representing vue organizations. CitAisat.ot Hopkins: A committee of three from tne Committee oi Direction-- Dp.. DowdaU.: Mr. Chairman, may I suggest that this appear in the form of & motion, that it be a committee of five to represent the peeuon as a sub* committee of the Committee of Direction. .... The motion was seconded by Dr. Hume, put to a vote and earned. Chairman riopstxs: This question of the wearing of gnei. ami the dirTrrent tvjvs of goggles. which has arisen out of this accident that to<k place some time ago in the Northwest. couid le handled by tiie Same committee at the same time. If you are in favor of tiuit and make a motion-- Dr. Dowdau.: Mr. Chairman, I think you are confusing the issue when you have a committee which is aiouiiog such an important questioo as this also handle this question of goggles. I suggest that the two be separated. Du. Gavcer: I think the Committee on Occupational Diseases would be the committee to handle the question of goecics. I so move. .... The motion was seconded by Dr. Taylor, put to a vote and carried. Proeeerlimjs of Medical and Surgical Section 70 mate Coro ietcrmiaiag .nplytng the :ji<1 in each Caatmtax Horctss: Is there anything else to come before this meeting? Dr. .\*sxtxcett: A change in the by-laws. Csaiaacce Horcors: WtU you outline that. Dr. Enamingcr? - held in the Dr. Ensmincer: When the Committee on Nominations met tive weeits failed as a t ago in Chicago, the question came up as to the eligibility of representatives of - as to show associate rectabets to hold office. Wc felt that it use nK* fair rn tnv* them -r-.vcduraLk* an opportunity to srnre as officers of the section. Tiwrrfore. tve have nn .-J testified up he tuilowins resolution: :iiit 03 per "The regulations of the Medical and duretcal section provide that the \ and that officers, reembers of committees, and so forth, shall be rorrsmtativm of -suit of the tnemaers. Members, in accordance with the Amencan Rjulwav Association articles of organization. are earners operating sc least one honored roues of ntioQ with r-eented to : the occu- i 1 1 road. As it may some tune be desirable to have a representative of some oi the smaller railroads, members of the American Hallway Aanmuon. serve as officers of the Medical and Surgical Section. or memoer* of Us committees. - o::cr the following resolution to take care of the necewary eaaogua ia the Direction roust be * has been Preventive Medical and Surcical Section's Regulations as now* women: "UtiOtvta. That the present regulations of the MedicalaadaureicalSection be amended by inserting the wools 'or associate mcmoeis lau&etuatety after the words ' representatives oi memoers.' in Sections 1. -i. o. 0.10.11. lUanu ly." .rora suroe .cy to have -eat tosti* Chairman' Ilurfoxs: You have heard the reeommvnuauou nuuu* uy toe Committee on Nominations. Does anyone want to make a mouua.' 'tiraony of Dr. Dowp.ux: E move us adoption by the Section. The motion was seconded by Dr. Taylor, put to a vote and earned. ^niittee of Chairman Hockixs: Ia there any further new business'.' \ rhe forts .. 1 & aub- i earned. . and (he >k puce At tenon - as (ins 'old be arrival. Da. SoiTitr.ATE LcitGR : Virginian Railway;: Mr. Chairman: I wish to make a motion to the etiert that a Special Committee l>c appointed on "Surgi cal Ctv-niiness," his Cummittee to make a survey .f the situation, reporting irs obcerratinn-t ami recommendations at :i future meeting, cither ot the t Sv-riun <r of the Commit:<-c *f Direction. i' In ."peaking to this motion l would .siy that t 'ali U a very important and vital matter. In the early Java following l..j?cr's revolutionary suggestions, great effort r'-uutred ?o rirndwo '"-'li'a m N-irtrcy. but -vtth extreme '--Arc -.md tt'or*r:<n :o -vrry de'ail. :iic rouiit.i were brilliant. :n rc'-'m y-urs flic uroi->M.,n has grown dangcreu.-iv i-tivIrM. vsjwtally in N-avittg ',rer'fiant details to mirvi, m [ir nitrating room control, mixing >.\n -A-.;n >i:rty cases. and m many other vital w-iva, with the result that lui'c-t-u.-.smly too frequent and at turn's, must >'rniua. It ;a high tune that steps be taken to investigate auU correct. Chairman* IfovKtys: Vou have heard the motion by Dr. Southgate Leigh. Are there any remarks/ i V t-'C 1 . so /irnmean Rciiwav A*&<i(Uinn Dr. Ensvingcr: I would suecest that this motion of Dr. latch's l>e taken under consideration or advisement by the Committee of Direction and that they report lck to the next toeetinc. The motion was seconded by Dr. Gamer, put to a vote and carried. Chairman* Hopkins: Is there anythinc further? Da- J. R. Ntts*ox `Colon Pacific Railroad;: I umtid like to submit for statistical juirjMW only the result of our recent physical mrmnmiMi. which is biennial on the Cnion Pacific. It is interesting to me for !t shows the physical condition of the men is touch better than two years aco. Two years neo we removed 2.4 per thousand, and in our n*evni examination we removed ju f. l. If you care to have me do .-> I will submit this fer print::.;, for statistical purposes. De- Tayuh: I move it be accepted and incorporated in ine Pmeccdincs. The motioo was seconded by Dr. Dowdall. pm t> a voi>.- aim carried. The Foikwine is the report submitted by Dr. Nilsson: SEVENTH BIENNIAL REPORT OF PERIODICAL RE-EXAMINATION OF EMPLOYES IN THE TRAIN. ENGINE. YARD. TRACE AND STATION SERVICE OF TEE ONION PACIFIC RAILROAD (INCOMPLETE* Occupation Out o: Number Treated L'nacr jcrviee or Examined Discmwsea Treatment Retired n$r. Firemen, switch, Yard- 2,04!) . X| 4 Conductors. Brakemen, Train 1.441 6 39 3 SijmaL Sec. 4-men, Tr. men, BAB men. RAadmaat^re 777 0 37 0 X-ia? Watchmen, Towenacs, Switehtanacw-------------- -- . _ _ 172 5 29 0 Act. Opr. Disp. Station Dae- caccmen. Truckers nod Ck. 42 0 19 o Hostlers_______ 473 19 S4 1 nV o 1 Yd. Clerks, Mes. Callers- 155 1 t 0 Min11awwMt ------- 956 *> - 0 * ---- -- -- ______ TOTAL. 6.952 34 241 s /j* Aasifsis aken : that i-l dt for -hich :o we t LI. itical lines. ::o:f no* :d of ..>i or -ir-d o i i i Proceedings of Medical and Surgical Section Analysis of the 241 Men who are Still Under Treatment 111 High Blood Pressure, No Apparent Cause. 21 High Blood Pressure. Defective Teeth. 1 High Blood Pressure, Arteriosclerosis. 7 Hitch Blood Pressure, Diabetes. 19 High Blood Pressure. Albuminuria. 9 High Blood Pressure. Bad Heart. 1 High Blood Pressure, Tonsils. 3 High Blood Pressure. Goitre. 20 High Blood Pressure. Obu>*. 192 of the 24 L men had High Blood Pressure. 2 Low Blood Pressure. 3 Bad Heart. 14 Diabetes. 15 Albuminuria. 1 Goitre. 10 Def. Hearing. 2 Positive Wassermaon. 241 81 Analysis of the 34 lien Who Have Been Discharged From Treatment 5 High Blood Pressure, No Apparent Cause. 14 High Blood Pressure. Defective Teeth. I High Blood Pressure. Diabetes. 1 High Blood Pressure, Albuminuria. 7 High Blood Pressure, Bad Heart. 1 High Blood Pressure, Defective Tonsils. 1 High Blood Pressure. Goitre. I High Blood Pressure. Obesity. 29 of the 34 Men Had High Blood Pressure. 3 Diabetes. I Albuminuria. I Positive ii'assermsno. K'f. i:. *'."rl5S -.:j S"' A ftatiimv Ats'Kintinr. Analysis of the 8 Men Tskea Out of Service 4 Pensioned Account 2 Heannc. 1 Vision. 1 High Blond Pressure and Dtal*ct<*R. 1 Applied for Croup Insurance Account Hath Blood Pressure and Bari Heart. 2 Died Af-munt ilich Bin'll Pressure and Bad Heart. 1 Under Treatment tor Hich BIwd Pressure, over 200. Chairman Hockis'.v. i really think we sre all of the come opinion nod that we hove all noticed a marker] improvement not only in the personnel and the employee, hut in the emunir down of a t*mcadous lose of property and damner which took place throuso man failure. Is there anything further * If not. ?. motion to adjourn is in order. Upon motion rectilariy made and seconded, it was voted to adjourn, aod the meeting adjourned at twelve forty-five o'clock. DR. C. HOPKINS, Chairman. J. C. CAVISTON. Secretary. - Wood Pressure <l Heart. *ver -J00. -.moa and that lonci and the property aod : order. . adjourn. and .'.bTON, wretary. 'Ssfe { | r , j : ( t ` j> f j \ ) i i I ...--I -T-v Vi5 i^^&ssas5* ^ _ o* j* ^ i>m - - " ' '? -i* *' C<\1 *T .-Vr - . - ;. 1* 2 * *i s -~ iV* _ .***"