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FILE NAME: Railroads (RR) DATE: 1941 May DOC#: RR007 DOCUMENT DESCRIPTION: Proceedings of the 21st Annual Meeting of the Medical and Surgical Section - American Railway Association )Oj z jy n J b u y rn O Cj& y u d S /^ m Jl j/]/\ji^ut) 6nA^ P R O C E E D IN G S OF THE TWENTY-FIRST ANNUAL MEETING OF THE Ai;ssociation of American Railroads M ED ICA L A N D SU RG ICA L SECTION HELD AT MOUNT ROYAL HOTEL MONTREAL, QUEBEC, CANADA MAY 27-28, 1941 E astern P bintsno Corporation New York, N. Y. /) \P \ g ' INDEX Association of American Railroads Board of Directors..................................................................................................................... Officers...................... Operations and Maintenance D epartm ent................................- ..................................... Operating-Transportation Division; officers.--.- ............................................................... Page 5 5 6 6 Bartle, H.: expressing appreciation of section to retiring chairman.,................................ discussion of report of committee on developments resulting from physical examinations--........................ 132 99-101 Brandabur, J. J.: remarks on "Alcoholism"........ ...................................................................... presenting report of committee on developments resulting from physical examinations..................................................................... -- 51-56 98, 99 Brown, A. J.: remarks on internal fixation with plates.--..................................................... 80, 81 Callender. J. W.; remarks re: handling disability cases-- .............................................84, 106, 108 Collins, J. D .: remarks on "Prevention of tetanus; the use of toxoid"--.......................... 46-50 presenting report of committee on fractures.................................................. 71 discussion of report of committee on developments resulting from physical examinations................................. ................................................ 101, 102 Committee of direction--, ................................................................................................................ 6. 7 Committee on developments resulting from physical examinations-- ............................. Report of.................... ................................................................................................................. Discussion.................................................................................................................................... 7. 8 92-97 99-108 Committee on disability and rehabilitation....................--...... - .............................................. Report of...................... ........................................ - .............................................- .................... D iscu ssion ............ ........................................................... -........................................................... 7 23-39 40-65 Committee on fractures............... Report of................ Discussion.................................................................................................................................... 7 66-70 71-83 Committee on medical aspects of air conditioning of cars...-............................................... 8 Report o f - ............................................................... -.................................................................. 109-122 Committee on nominations; report of.............................................................................. 65 Crowder, T. R.: report as chairman, committee on medical aspects of air conditioning of cars................................................................................................................................. 109-122 Dowd, K. E.: remarks on splints......................... 82 discussion of report of committee on developments resulting from physical examinations................................................................................... 106, 107 Election of members of committee of direction....................... ................................................ 65, 83 Garner, J. R.: report as chairman, committee on disability and rehabilitation......................................................................40, 43-46, 50, 56, 59, 64 remarks on application of splints...................................................................... 81, S2 Hall, G. E,: address on "Medical examinations for fitness for specific duties"...............123-131 Hansen, T. L.: remarks on first-aid and transportation splint........... ........................ ..... 79, 80 Hibbitts, William: discussion of report of committee on developments resulting from physical examinations...............................- ................................................................... 102, 103 Lancaster, Wr. J.: remarks as chairman, opening meeting--...........................................-- 17 remarks as retiring chairman................................................................ ...... 131 Mackay, F. H.: addrese on "Epilepsy and epileptic equivalents"................................... 60-64 Martin, C. F.: address.--........................................................................................................ ........ 17-22 McCombe, John: introducing Dr. Mackay............................ ................................................. . 59 Medical and Surgical Section: Officers............... .............................................. - .............................- ................................ ......... Personnel of committees..--............................................................................................. -- . Representatives attending annual m eeting-.....-.............. - ......... ................................-- Rules of order.................................................- .............-- ....... ..................................... .......... 6 6-8 13-15 9-12 Metz, Av R:; introducing Dr. Tees....--............................. .......... - .................................... -- 71 . . . remarks on. compound fractures--.......................- ............................ - ......... -- 77 ,7 8 remarks as incoming chairman.-.........._................................................... ........ 131,132 . .. V 'Viy . y '- INDEX--Continued Meyers, G. P.: discussion of report of committee on developments resulting from physical examinations.- --......................................................................................... Page 101 Neupauer, A.: discussion of report of committee on developments resulting from physical examinations-- --......................................................................................... 103-100 Nilsson, J. H.: remarks on compound fractures........................................................................ discussion of report of committee on developments resulting from. physical examinations.................................................................................. 76, 77 103 Segall, H. N.i'remarks on "Cardio-vascular-renal disease".................................... - ............ 57-59 Sessions of annual meeting: Tuesdaymorning, M ay 27.......... Tuesday afternoon, M ay 2 7 - .......... - ................................................................................... Wednesday morning. M ay 28--......................................................-- ................................. Stieglitz, E. J,: address on "Problems of aging personnel" ................................................... 17-65 65-83 83-132 84-91 Tees, F. J.: address on "Present day treatment of compound fractures"........................ 71-76 Walker, C. A.: remarks on "Changing concepts in chemotherapy"................................... 40-43 Wooisey, R . A.: remarks on "Foci of infection"...................................................................... discussion of report of committee on developments resulting from physical examinations............................................................................... Zienert, O. B : remarks on first-aid and transportation splints...._................................... 44, 45 102 79 ASSOCIATION OF J, J. Pelley, President R. V. Fleteher, Vice-President a C. H. Buford, Vice-President (( A. F. Cleveland, Vice-President E. H. Bunnell, Vice-President ( tion Department) H. J. Forster, Seeretary-Treasu Boa J. J. Pelley, Chairman (ex-offiei L. W. Baldwin, Chief Executive Gr. D. Brooke, President, Chesai M. W. Clement, President, Pern Geo. B. Elliott, President, Atlai E. J. Engel, President and CL Topeka & Santa Fe Raihva E. S. French, President and 1 Maine Railroad and Maine F. J. Gavin, President, Great N J. B. Hill, President, Louisville W. M. Jeffers, President, ITnior A. D. McDonald, President, Sov Ernest E. Norris, President, So L. B. Powell, Jr., Receiver, Sea E. W. Scheer, President, Readu M. S. Sloan, President, Missoui Daniel Willard, President, Balti B. L. Williams, Chief Executive F. E, Williamson, President, N intinued ie on developments resulting from on developments resulting from 5 on developments resulting from disease''...................................... ............ Page 101 103-106 76, 77 103 67-59 ASSOCIATION OF AMERICAN RAILRO ADS sonne!"............ compound fractures" chemotheraDv" : on developments resulting from tion splints__ 17-115 65-83 83-132 84-!)! 71-76 40-43 44, 45 02 79 Officers J. J. Pelley, President E. V. Fletcher, Vice-President and General Counsel (Law Department) C. H. Buford, Vice-President (Operations and Maintenance Department) A. F. Cleveland, Vice-President (Traffic Department) E. H. Bunnell, Vice-President (Finance, Accounting, Taxation and Valua tion Department) II. J. Forster, Secrets ry-Treasurer Board of Directors J. J. Pelley, Chairman (ex-officio). L. AV. Baldwin, Chief Executive Officer, Missouri Pacific Lines. G. D. Brooke, President, Chesapeake & Ohio Eailway. M. AV. Clement, President, Pennsylvania Eailroad Company. Geo. B. Elliott, President, Atlantic Coast Line Eailroad Company. E. J. Engel, President and Chairman of Executive Committee, Atchison, r Topeka & Santa Fe Eailway. E. S. French, President and Chairman, Executive Committee, Boston & Maine Eailroad and Maine Central Eailroad Company. F. J. Gavin, President, Great Northern Eailway. J. B. Hill, President, Louisville & Nashville Eailroad. AY. M. Jeffers, President, Union Pacific Eailroad. A. D. McDonald, President, Southern Pacific Company. Ernest E. Norris, President, Southern Eailway System. L. E. Powell, Jr., Beceiver, Seaboard Air Line Eailway. E. W. Scheer, President, Beading Company. M. S. Sloan, President, Missouri-Kansas-Texas Eailroad. Daniel Willard, President, Baltimore & Ohio Eailroad Company. E. L. Williams, Chief Executive Officer, Chicago & North Western Eailway. F. E. Williamson, President, New York Central System. Association of American Railroads OPERATIONS AND MAINTENANCE DEPARTMENT C. H. Buford, Vice-President DIVISION I--OPERATING-TRANSPORTATION Officers W. K. Etter, Chairman R. W. Brown, Vice-Chairman G. C. Randall, Chairman, General Committee L. R. Knott, Secretary MEDICAL AND SURGICAL SECTION Officers Dr. A. R. Metz, Chairman Dr. J. Frank Dinnen, Vice-Chairman J. C. Caviston, Secretary MEMBERS OF COMMITTEES Committee of Direction Dr. A. R. Metz, Chairman Dr. J. Frank Dinnen, Vice-Chairman (Term expires in 1042) Dr. T. L. Hansen, Chief Surgeon, Chicago, Rock Island & Pacific Railway, Chicago, 111. Dr. G. I. Jones, Chief Surgeon, Southern Railway System, Washington, D. C. Dr. John McCombe, Chief Medical Officer, Canadian National Railways, Montreal, Canada. Dr. G. P. Myers, Medical Director, New York Central System, Detroit, Mich. (Term expir es in 1943) Dr. Harvey Bartle, Chief Medical Officer, Pennsylvania Railroad, Phila delphia, Pa. Dr. J. Frank Dinnen, Chief Surgeon, Erie Railroad, Cleveland, Ohio. Dr. Donald Guthrie, Chief Surgeon, Lehigh Valley Railroad, Sayre, Pa. Dr. E. V. Milholland, Medical and Surgical Director, Baltimore & Ohio Railroad, Baltimore, Md. Proceedings of Mec, (Term e Dr. W. J. Lancaster, Superintende ment, Atlantic Coast Line Rail Dr. A. R. Metz, Chief Surgeon, < Railroad, Chicago, 111. Dr. John R. Nilsson, Chief Surgeo Dr. C. A. Walker, Chief Surgeon, i Calif. Honor! Dr. A. J. Chesley, Secretary-Treas Health Authorities of North Ai Dr. Thomas Parran, Jr., Surgeon Service, Washington, D. C. Committee on Dis; Dr. J. R. Garner (Chairman), Chief R. R., Atlanta, Ga. Dr. J. D. Collins, Chief Surgeon, Se Dr. W. W. Leake, Chief Surgeon, I Dr. R. A. Woolsey, Chief Surgeon, S Representative froi Dr. G. I. Jones, Chief Surgeon, Sou' Committ Dr. R. C. Webb (Chairman), Chic apolis, Minn. Dr. K. E. Dowd, Assistant Chief Montreal, Que., Canada. Dr. Duncan Eve., Chief Surgeon, Nashville, Tenn. Dr. O. B. Zeinert, Chief Surgeon, Representative froi Dr. J. R. Nilsson, Chief Surgeon, I Committee on Developments I Dr. O. H. Horrall (Chairman), Chic R. R., Chicago, 111. Dr. M. L. Bishoff, Chief Surgeon, A Kansas. Dr. J. J. Brandabur, Assistant Supc Huntington, W. Va. Dr. D. E. Eemsberg, Assistant Sup Pension Department, Norfolk - Proceedings of Medical and Surgical Section 7 (Term expires in 1944) Dr. W. J. Lancaster, Superintendent and Medical Director, Relief Depart ment, Atlantic Coast Line Railroad, Wilmington, N. C. Dr. A. R. Metz, Chief Surgeon, Chicago, Milwaukee, St. Paul & Pacific Railroad, Chicago, 111. Dr. John R. Nilsson, Chief Surgeon, Union Pacific Railroad, Omaha, Nebr. Dr. C. A. Walker, Chief Surgeon, Southern Pacific Company, San Franciso, Calif. Honorary Members Dr. A. J. Chesley, Secretary-Treasurer, Conference of State and Provincial Health Authorities of North America, St. Paul, Minn. Dr. Thomas Parran, Jr., Surgeon General, Bureau of the Public Health Service, Washington, D. C. Committee on Disability and Rehabilitation Dr. J. II. Garner (Chairman), Chief Surgeon, Western Ry. of Alabama-Georgia R. R., Atlanta, Ga. Dr. J. D. Collins, Chief Surgeon, Seaboard Air Line Ry., Norfolk, Va. Dr. W. W. Leake, Chief Surgeon, Illinois Central System, Chicago, 111. Dr. R. A. Woolsey, Chief Surgeon, St. Louis-San Francisco Ry., St. Louis, Mo. Representative from Committee of Direction Dr. G. I. Jones, Chief Surgeon, Southern Railway System, Washington, D. C. Committee on Fractures Dr. R. C. Webb (Chairman), Chief Surgeon, Great Northern P,y., Minne apolis, Minn. Dr. K. E. Dowd, Assistant Chief Medical Officer, Canadian National Rys., Montreal, Que., Canada. Dr. Duncan Eve., Chief Surgeon, Nashville, Chattanooga & St. Louis Ry., Nashville, Tenn. Dr. 0. B. Zeinert, Chief Surgeon, Missouri Pacific R. R., St. Louis, Mo. Representative from Committee of Direction Dr. J. R. Nilsson, Chief Surgeon, Union Pacific R. R., Omaha, Nebr. Committee on Developments Resulting from Physical Examinations Dr. O. H. Horrall (Chairman), Chief Surgeon, Chicago, Burlington & Quincy R. R., Chicago, 111. Dr. M. L. Bishoff, Chief Surgeon, Atchison, Topeka & Santa Fe Ry., Topeka, Kansas. Dr. J. J. Brandabur, Assistant Supervising Surgeon, Chesapeake & Ohio Ry., Huntington, W. Va. Dr. D. E. Remsberg, Assistant Superintendent & Medical Director, Relief & Pension Department, Norfolk & Western Ry., Roanoke, Va. 8 Association o f American Railroad Proceedings of M Representative from Committee of Direction Dr. Geo. P. Myers, Medical Director, New York Central System, Detroit, Mich. ASSOCIATION OF Committee on Medical Aspects of Air Conditioning of Cars Dr. T. R. Crowder (Chairman), Director Department Sanitation and Surgery, Pullman Company, Chicago, 111. Dr. I. S. Cutter, Chief Surgeon, Chicago & North Western Ry., Chicago, 111. Dr. R. S. Yancey, Medical Director, Missouri-Kansas-Texas R. R., Dallas, Texas. Representative from Committee of Direction Dr. E. V. Milholland, Medical and Surgical Director, Baltimore & Ohio R. R., Baltimore, Md. DIVISION I--OPER MEDICAL AN! RULE 1. REPRESENTATION: As ; representation of member roads h Chief Surgeons or other persons e Express Agency, Inc., and the Pul in this Section. 2. AFFILIATED MEMBERS: collaborating or cooperating with her thereof upon the approval of hi; An affiliated member shall have t road representative, except voting Officers 3. The officers of the Section s. and Secretary. (a) As provided in the PI VICE-CHAIRMAN shall be s< its membership. Their terms not succeed himself. i (b) The SECRETARY will the Division. His salary sha the approval of the Vice-Pr partment. (c) The COMMITTEE O bers, territorially reprsentai New England and Canada; f< four from the West--elected a serve for three years. The terms of office of all Direction shall expire at the c in the committee membership mittee until the next election. In addition to the above, Bureau of Public Health Serv him, and a representative to b Provincial HealthAuthoritiesc of the Committee of Directior I. lean Railroads unittee of Direction tew York Central System, Detroit, Proceedings of Medical and Surgical Section 9 ASSOCIATION OF AMERICAN RAILROADS >f Air Conditioning of Cars Department Sanitation and Surgery, & North Western Ry., Chicago, 111. ssouri-Kansas-Texas R. R., Dallas, mittee of Direction il Director, Baltimore & Ohio R. R., : ; 1 j 3 :1 1 | j | I j DIVISION I--OPERATING-TRANSPORTATION MEDICAL AND SURGICAL SECTION RULES OF ORDER 1. REPRESENTATION: As provided in the Plan of Organization, the representation of member roads in the Medical and Surgical Section shall be Chief Surgeons or other persons engaged in a similar capacity. The Railway Express Agency, Inc., and the Pullman Company are eligible for membership in this Section. 2. AFFILIATED MEMBERS: A representative of an organization collaborating or cooperating with the Section may become an affiliated mem ber thereof upon the approval of his application by the Committee of Direction. An affiliated member shall have the rights and privileges accorded a member road representative, except voting or the holding of office. Officers and Committees 3. The officers of the Section shall consist of a Chairman, Vice-Chairman and Secretary. (a) As provided in the Plan of Organization, the CHAIRMAN and VICE-CHAIRMAN shall be selected by the Committee of Direction from its membership. Their terms of office shall be one year. A Chairman will not succeed himself. (b) The SECRETARY will be appointed by the General Committee of the Division. His salary shall be named by that Committee, subject to the approval of the Vice-President, Operations and Maintenance De partment. (c) The COMMITTEE OF DIRECTION will consist of twelve members, territorially representative as far as practicable--one each from New England and Canada; four from the East; two from the South and four from the West--elected as hereinafter prescribed, each of whom shall serve for three years. The terms of office of all elective members of the Committee of Direction shall expire at the conclusion of the annual meeting. Vacancies in the committee membership shall be filled by appointment of the Committee until the next election. In addition to the above, the Surgeon-General of the United States Bureau of Public Health Service or a representative to be designated by him, and a representative to be designated by the Conference of State and Provincial Health Authoritiesof North America shall be honorary members of the Committee of Direction. ... 10 Association o f American Railroads . The Committee of Direction will select from its elective membership a Chairman and Vice-Chairman of the Section, whose terms of office shall be one year. A Chairman will not succeed himself. (d) The Standing Committees of the Section will be as follows: Committee on Disability and Rehabilitation Committee on Fractures Committee on Developments Resulting from Physical Examina tions Committee on Medical Aspects of Air Conditioning of Cars The representation of member roads on these committees will be, sp far as is practicable, territorially selected, in approximately the same pro portions as that of the Committee of Direction, personnel to be named each year by the Committee of Direction immediately following adjourn ment of the annual meeting. Duties of Officers 4. The CHAIRMAN shall have general supervision over the affairs of the Section and shall preside at meetings of the Section and at meetings of the Committee of Direction. 5. The VICE-CHAIRMAN, in the absence of the Chairman, shall perform the duties of the Chairman and such other duties as may be assigned. 6. (a) The SECRETARY shall perform the usual duties of that office and such other duties as may be assigned to him by the Chairman. (b) He shall receive six weeks in advance of the annual meeting each year the report of the Committee on Nominations, as elsewhere provided for, and will submit to the membership at the annual meeting the nomina tions contained in that report, to fill the vacancies in the membership of the Committee of Direction. He shall announce the result of the election promptly to the members. Duties of Committees 7. The COMMITTEE OF DIRECTION shall: (a) Exercise general supervision over the interests and affairs of the Section. (b) Be empowered to act on behalf of the Section in the interim between meetings and shall submit at each meeting a report covering its actions. (c) Examine and decide what portion of communications, papers and reports shall be submitted at the meetings. It shall determine which, if any, of the subjects presented by the various committees, shall be referred to the General Committee of the Division. (d) Appoint two months in advance of the annual meeting each year a Committee on Nominations, consisting of representatives of five member roads, who shall not be members of the Committee of Direction. (e) Appoint additional committees as required. (f) Submit to the Chairman, General Committee, detail of con templated financial requirements for conducting the work of tire Section as required or as called for by that official. (g) Call annual meetings of the Section, subject to. the approval of the General Committee of the Division, if in its judgment conditions warrant. Proceedings of Me (h) Call meetings of the Sec to each member. It must cal request, in writing, of a majori 8. The COMMITTEE ON NOM shall report to the Secretary at leas ing of each year, at least two nom: place the four members of the Com year, and to fill any vacancy. The duties of the Standing Com 9. COMMITTEE NO. 1--The REHABILITATION shall study ar tions, on such subjects that have ciency of railroad employes. It s rehabilitation of injured or incapai tion of function. 10. COMMITTEE NO. 2--Th study and report on th treatment ing (a) Diagnosta of fraetures, (I (c) Fracture report forms, (d) X-t similar subjects. II. COMMITTEE NO. 3--Tl: RESULTING FROM PHYSICAL report, with recommends tions or periodic examinations, etc. It s warrant, the recommended standi as the forms used in connection th 12. COMMITTEE NO. 4--T1 OF AIR CONDITIONING OF CA its relation to the health and com partments handling matters reiatii 13. VOTING AT MEETINGS viva voce, by rising, by roll call entitled to one vote. The vote o ft shall be required to decide any que ordered, (b) Voting for Candida Direction shall be by ballot, (c) t officer will be recognized as the vo 14. LETTER BALLOTS may Committee of Direction and mus1 property. The voting power of th ownership of miles of track. n Railroads Proceedings o f Medical and Surgical Sedim i 11 I ect from its elective membership lection, whose terms of office shall eed himself. Section will be as follows: Rehabilitation lesulting from Physical Examina- 3 of Air Conditioning of Cars >n these committees will be, so far in approximately the same proDirection, personnel to be named ri immediately following adjourn- :ers i upervision over the affairs of the e Section and at meetings of the e of the Chairman, shall perform luties as may be assigned, he usual duties of that office and ; him by the Chairman, ance of the annual meeting each j jminations, as elsewhere provided j t the annual meeting the nomina- e vacancies in the membership of i nnounce the result of the election '{ littees shall: : the interests and affairs of the the Section in the interim between ting a report covering its actions, n of communications, papers and ngs. It shall determine which, if ious committees, shall be referred on. f the annual meeting each year a of representatives of five member Committee of Direction, required. sral Committee, detail of con nducting the work of the Section ;ial. on, subject to the approval of the its judgment conditions warrant. (h) Call meetings of the Section, upon not less than thirty days' notice to each member. It must call special meetings of the Section upon the request, in writing, of a majority of the member roads. 8. The COMMITTEE ON NOMINATIONS, appointed as above prescribed, shall report to the Secretary at least six weeks in advance of the annual meet ing of each year, at least two nominations for each impending vacancy to re place the four members of the Committee of Direction whose terms expire that year, and to fill any vacancy. The duties of the Standing Committees shall be as follows: 9. COMMITTEE NO. 1--The COMMITTEE ON DISABILITY AND REHABILITATION shall study and report, with suggestions or recommenda tions, on such subjects that have to do with the physical efficiency or ineffi ciency of railroad employes. It shall also consider ways and means for the rehabilitation of injured or incapacitated employes and the complete restora tion of function. 10. COMMITTEE NO. 2--The COMMITTEE ON FRACTURES shall study and report on the treatment and transportation of fracture cases includ ing (a) Diagnosis of fractures, (b) First aid and transportation splints, (c) Fracture report forms, (d) X-ray work in connection with fractures, and similar subjects. 11. COMMITTEE NO. 3--The COMMITTEE ON DEVELOPMENTS RESULTING FROM PHYSICAL EXAMINATIONS shall analyze and make report, with recommendations or suggestions, on data made available by periodic examinations, etc. It shall study and revise as conditions may warrant, the recommended standards covering physical.examinations as well as the forms used in connection therewith. 12. COMMITTEE NO. 4--The COMMITTEE ON MEDICAL ASPECTS OF AIR CONDITIONING OF CARS shall study and report on this subject in its relation to the health and comfort of travelers, cooperating with other de partments handling matters relating to air conditioning of equipment. 13. VOTING AT MEETINGS OF SECTION: (a) Vote may be taken viva voce, by rising, by roll call or by ballot. Each member road shall be entitled to one vote. The vote of the majority of the member roads represented shall be required to decide any question, motion or resolution, unless otherwise ordered, (b) Voting for candidates for membership on the Committee of Direction shall be by ballot, (c) Unless otherwise designated by it, the ranking officer will be recognized as the voting representative of a road at any meeting. 14. LETTER BALLOTS may be taken upon any subject by order of the Committee of Direction and must be taken on all questions affecting physical property. The voting power of the member roads shell be proportionate to the ownership of miles of track. f. 12 Association of American Railroads 15. ORDER OF BUSINESS: The order of business a t meetings of the Section shall, unless otherwise directed by a majority of the members present, be as follows: Approval of minutes of last meeting Reports of Standing Committees Reports of Special Committee Reports of Tellers Unfinished Business New Business 16. Robert's Rules of order shall govern the proceedings of this Section, including amendment to these Rules of Order. Proceedings MEDICAL Mount Royal Hotel, I The following representativ Members Atlanta & West Point R. R... Atlantic Coast Line R. R.... . Baltimore & Ohio R. R......... Baltimore & Ohio Chicago R. R.................................... Bamberger R. R................... Bessemer & Lake Erie R. R... Canadian National Rys.......... Canadian Pacific Ry.... Chesapeake & Ohio Ry. Chicago & North Western Ry. Chicago, Milwaukee, St. Paul <! Chicago, Rock Island & Pacifit Cincinnati, New Orleans & Pacific Ry............................. Denver & Rio Grand Western Detroit & Toledo Shore Line R. * Associate Member. i* Railroads >f business at meetings of the | jority of tlie members present, | ing 1 e proceedings of this Section. 1 s Proceedings o f Medical and Surgical Section 13 MEDICAL AND SURGICAL SECTION Mount Royal Hotel, Montreal, Que., Canada, May 27-28, 1941 The following representatives were present: Members Representatives Atlanta & West Point It. R.................J. R. Garner, Chief Surgeon. Atlantic Coast Line R. R.... ............... W. J. Lancaster, Superintendent and Medical Director, Relief Departs meut. Baltimore & Ohio R. R........................E. V. Milholland, Medical and Surgical Director. Baltimore & Ohio Chicago Terminal R. R...._............ ..................................E. V. Milholland, Medical and Surgical Director. `Bamberger R. R,,................................Spencer Wright, District Surgeon. Bessemer & Lake Erie R. R.................R. W. Brown, Chief Surgeon. Canadian National Rys........................John McCombe, Chief Medical Officer. Aime Chartier, Consultant. Win. H. Delaney. K. E. Dowd, Assistant Chief Medical Officer. Emmet Duryer A. J. Gilchrist, Medical Officer in Charge of Treatment and Exami nations. Keith Hutchison. J. A. Nureault, Harold N. Segall, Consultant. Archibald L, Wilkie. Canadian Pacific Ry.......... ..................H. A. Beatty, Chief Surgeon and Medical Officer. Chesapeake & Ohio Ry........................ J. Frank Dinnen, Supervising Surgeon. J. J. Brandabur, Assistant Supervising Surgeon. Wm. E. Mishler, Assistant to Assistant Supervising Surgeon. Chicago & North Western Ry............. Alfred J. Brown, Division Surgeon. Chicago, Milwaukee, St. Paul & Pacific R. R.._............................................... A. R. Metz, Chief Surgeon. Alfred J. Brown, Company Surgeon. Chicago, Rock Island & Pacific Ry..... T. L. Hansen, Chief Surgeon, Cincinnati, New Orleans & Texas Pacific Ry..........................................Ralph G. Carothers, Chief Surgeon. Denver & Rio Grand Western It. R....Geo. H. Curfman, Chief Surgeon. R. S. Allison, Assistant Chief Surgeon. John J. Galiigan, Surgeon. Detroit & Toledo Shore Line R. R........B. W. Stockwell, Chief Surgeon. * Associate Member. 14 Assod.ation of American Railroads Proceedings of J Erie R. R--.......................... ................. J. Frank Dinnen, Chief Surgeon. Wm. E. Mishler, Assistant to Chief Surgeon. Georgia R. R.........................................J. R. Garner, Chief Surgeon. Grand Trunk Western R. R................B. W. StockweU, Chief Surgeon. Gulf, Mobile & Ohio R. R...................C. H. Ramsay, Acting Chief Surgeon. Louisville & Nashville R. R........... ..... L. W. Edwards, Associate Chief Surgeon. Missouri Pacific R. R.... ..................... Oliver B. Zeinert, Chief Surgeon. Alfred J. Brown, Consulting Surgeon. Montour R. R................... ...................Grover C. Weil, Surgeon. Nashville, Chattanooga & St. Louis Ry................................................. L. W. Edwards, Associate Chief Surgeon. `Newburgh & South Shore Ry.............James N. Wyehael, Surgeon. New York Central System................... Geo. P. Myers, Medical Director. New York, Chicago & St. Louis Ry....J. Frank Dinnen, Assistant Chief Surgeon. Wm. E. Mishler, Assistant to Assistant Chief Surgeon. Norfolk & Western Ry.........................Daniel E. Itemsberg, Medical Director. W. R. Whitman, Chief Surgeon. Ralph G. Carothers. R. P. Elder, Medical Examiner. H. G. Mumma, Medical Examiner. B. E. Topham, Medical Examiner. Pennsylvania R. R................................Harvey Bartle, Chief Medical Officer. Ralph G. Carothers. Pere Marquette Ry.............................. R. A. Kirkpatrick, General Claim Agent. Pullman Company..... .......................... T. R. Crowder, Director Department Sanitation and Surgery. Reading Company..... ......................... F. S. Ferris, Chief Medical Officer. A. Neupauer, Superintendent Phila delphia and Reading Relief Asso ciation. St. Louis-San Francisco Ry................. R. A. Woolsey, Chief Surgeon. St. Louis Southwestern Ry.................. William Hibbit3, Chief Surgeon. "Salt Lake & Utah R. R...................... Spencer Wright, District Surgeon. Seaboard Air Line Ry..........................Joseph D. Collins, Chief Surgeon. Southern Pacific Co.-Pacific Lines....... Calvin A. Walker, Chief Surgeon. Staten Island Rapid Transit Ry..........E. V. Milholland, Medical and Surgical Director. Union Pacific R. R............................... John R. Nilsson, Chief Surgeon. Ralph M. Dodson, District Surgeon. J. D. Shingle, Surgeon. Spencer Wright, District Surgeon. Western Ry. of Alabama...--................ J. R. Garner, Chief Surgeon, also American Association for Surgery of Trauma.............. ............................... B. Fraser Gurd, M. D., President. Association of American Railroac McGill University....................... Railroad Retirement Board......... Royal Canadian Air Force........... United States Public Health Serv Utah Ry.._......................... ; I1 `Associate Member. : I lailroads Dinnen, Chief Surgeon. Mishler, Assistant to Chief >n. rner, Chief Surgeon, ockwell, Chief Surgeon, unsay, Acting Chief Surgeon. Edwards, Associate Chief n. Zeinert, Chief Surgeon. Brown, Consulting Surgeon. '. Weil, Surgeon. Edwards, Associate Chief n. Wychaei, Surgeon, lyers, Medical Director. Dinnen, Assistant Chief ]. lishler, Assistant to Assistant urgeon. Remsberg, Medical Director, litman, Chief Surgeon. Carothers. 3r, Medical Examiner, rama, Medical Examiner, ham, Medical Examiner, artle, Chief Medical Officer. Carothers. irkpatriek, General Claim wder, Director Department on and Surgery. is, Chief Medical Officer. uer, Superintendent Philaand Reading Relief Asso- lsey, Chief Surgeon. ibbits, Chief Surgeon. right, District Surgeon. Collins, Chief Surgeon. Walker, Chief Surgeon. jlland, Medical and Surgical Isson, Chief Surgeon. Dodson, District Surgeon. le, Surgeon. ight, District Surgeon. sr, Chief Surgeon. Proceedings o Medical and Surgical Section Association of American Railroads. j. C. Caviston, Secretary, Medical and Surgical Section. McGill University. C. F. Martin, B. A., M. D., C. M,, LL.D., Emeritus Dean of theFaculty. F. H. Mackay, M. D., C. M,, F. R. C. P., Clinical Professor of Neurology. F. J. Tees, M. C., B. A., M. D,, C. M,, F. R. C. S., F. A. C. S., Lecturer in Surgery. Railroad Retirement Board M. E. Lynch, Director, Retirement. Claims. J. Vi1. Callender, Chief Adjudicator. Royal Canadian Air Force. m. G. Edward Hall, M. D., Wing Commander. United States Public Health Service....E. J. Stieglitz, Research Associate-- National Institute of Health. Utah Ry................................ ...............Martin C. Lindem, Chief Surgeon, j ; j i ; 1 j } \ 1 i i ] urd, M. D., President. 9  f American Railroads s will be bo enjoyable in Montreal that you ant to come here again to give us all the Proceedings of Medical and Surgical Section 23 (Circular M. & S. 280) ASSOCIATION OF AM ERICAN RAILROADS ppreciative of the fine talk th at Dr. Martin ? over the hair-singed men's heads in this dy agree with him as to the fallacy of the ring hair by singeing the ends. {Laughter.) 't having you with us and we hope you will Meeting. iort of the Committee on Disability and Chairman, Chief Surgeon of the Western MEDICAI* AND SURGICAL SECTION REPORT OF COMMITTEE ON DISABILITY AND REHABILITATION Dr. J. R. Garner, (Chairman) Chief Surgeon, Atlanta and West Point Rail Road. The W estern Railway of Alabama, Georgia Railroad. I)*-. R. A. W ooleey, Chief Surgeon, St. Dr. C. A. Walker, Chief Surgeon, South ern Pacific Company. Dr. J. J. Brand&bur, Assistant Super vising Surgeon, Chesapeake & Ohio Railway. Lmiis-San Francisco Railway. Dr. J. D. Collins, Chief Surgeon, Sea board Air Line Railway. Dr. E. C. Holmblad, Regional Surgeon, Railway Express Agency. Representative of Committee of Direction Dr. Glenn I. Jones, Chief Surgeon, Southern Railway System N e w Yoke, Nt. Y., April 28, 1941. To t h e M e d ic a l a n d S u r g ic a l S e c t io n : The activities of your Committee on Disability and Rehabilitation hav ing continued during the fiscal year, a report covering same is herewith submitted. Committee meetings have been held as follows: October 11, 1940, at Washington, D. C., February 7, 1941, at Chicago, 111., and April 14, 1941, at New York, N. Y. Much of the data contained in this Report has been compiled by in dividual members of the Committee to whom specific subjects have been assigned, later being reviewed, emended and approved by the Committee as a whole. Every year the Committee receives suggestions that it consider certain topics. Often it is found that the subject has already been fully covered in previous reports. When this is the case, the member suggesting such subject is so advised with reference to the transactions of the Section in which this may be found. Where additional information is available the Committee reconsiders the subject and again reports thereon. Many subjects are of such vast and continuing importance to the maintenance of the Railway man-poivei that your Committee feels justified iu annually reporting upon such topics. In this Report attention of the Medical and Surgical Section is invited to the following: ALCOHOLISM Every Railroad occasionally encounters the problem of an employe who has reported for work while under the influence of alcohol. t-'>.'rii, .-Ji-y. encan Railroads Proceedings of Medical and Surgical Section 25 en value of the alcoholic content of ly determined as long as 12 hours S 4. In all, there was decided relief from symptoms during their period of polleu exposure and in several the manifestations were reduced from ssitive finding eliminates all doubt U r severe to negligible. after injestion of alcohol. 5. Potassium chloride properly exhibited is beneficial to sufferers from hay fever and allergic asthma, m R, ASTHMA, ETC. employes often become most dislead to at least a temporary dis se of potassium salts in such cases our Committee feels it appropriate ct. petervt observers and investigators salts (potassium chloride) in the romes, conspicuously in hay fever CARDIO-VASCUI>AR-RENAl.-I>ISEASE The subject of eardio-vascular-renal-disease is so important that it receives consideration at every meeting of your Committee and is annu ally included in its Report. Unilateral kidney disease having been found to be exceedingly pro ductive of a persistent hypertension, it is recommended that in cases where other causes for hypertension are unassignable, each kidney should be studied separately. Dr. Drew L>uten, of St. Louis, Mo., recently read a paper on the subject '`The Railroad Employe With Heart Disease." This paper contains so i to ihe value of potassium therapy many valuable suggestions that same is presented herewith tor your con jllowing conclusions quoted from sideration. i "In the cases of most patients, the question of the degree of func tional activity best for disordered organs, is one of very great im I 'ucson, Arizona.) portance. In many diseases, activity must be conspicuously reduced, ;d from the use of potassium salts while in many others, at least in certain stages, it is appropriately s. These salts are also used in increased. In either instance, the proper level of work becomes an chronic allergic sinusitis, important consideration for correct therapy. I t is with the problem m chloride is apparently inefEec- of the correct level of physical activity in railroad employes with I however, in combination with a heart disease, that this paper is concerned. 1 t curative. "According to the appropriate degree of physical activity, the i on of potassium salts is simple; Nomenclature and Criteria for Diagnosis of Diseases of the Heart, re noted. adopted by the American H eart Association, puts a cardiac patient .s predominantly a disturbance of into one of five classes. "In Class A, are those patients whose physical activity needs no with some endoerine (possibly restriction. "In Class B, are those who need no restriction of ordinary physical I collaborators) activity, but who should be advised against unusually severe effort. "Class C, is composed of those who need some restriction even of iractical therapeutic value in our r and seasonal asthma. ordinary activity. "Class D, comprises patients whose ordinary physical activity ther allergic conditions is highly must be greatly reduced. "In Class E, are those who should be at complete rest. in hay fever should be received r marks of evaluation by * * * "Before deciding into which of these classes a patient belongs, i.e. before reaching a proper `Therapeutic Classification' so far as ac tivity is concerned, various data must be taken into account. A 1 very important consideration is the degree of physical activity that T can be tolerated without discomfort, i.e. the `Functional Capacity', potassium chloride in eighteen la. 1 rable. m financially unable to accommoreatment with pollen and other as the Criteria calls it. Four classes of patients divided on the basis of functional capacity are given; In Class I are those who experience no discomfort on ordinary physical activity. They have neither pain nor dyspnoea. In Class II are those patients who experience dis comfort of some sort even on odinary physical activity. This may take the form of dyspnoea, undue fatigue, or pain. In other words there may be cardiac insufficiency of angina. Class I I I is comprised F i i 1! I1 I ;i Association of American Railroads Your attention is called to the proven value of the alcoholie content of the urine. This may be quantitatively determined as long as 12 hours after alcohol has been imbibed. A positive finding eliminates all doubt in any case if made within hours after injestion of alcohol. ALLERGY:--HAY FEVER, ASTHMA, ETC. The symptoms manifest by allergic employes often become most dis tressing in character and frequently lead to at least a temporary dis ability. The results obtained by the use of potassium salts in such cases has been so favorably reported that your Committee feels it appropriate to submit a brief review of the subject. Beginning in 1933, a number of competent observers and investigators reported on the value of potassium salts (potassium chloride) in the control and.treatm ent of allergic syndromes, conspicuously in hay fever and asthma. The attitude of the pros and cons as to the value of potassium therapy in allergy is clearly stated in the following conclusions quoted from monographs on the subject: Pro (BENSON BLOOM of Tucson, Arizona.) "1. Striking benefit was obtained from the use of potassium salts in twenty-nine cases of hay fever. These salts are also used in urticaria, eczema, nasal j'olyposis, chronic allergic sinusitis. 2. In chronic asthma potassium ehloride is apparently ineffec tive; the use of potassium iodide, however, in combination with a salt-poor diet, seems helpful but not curative. 3. The method of administration of potassium salts is simple; no complication or 'side effects' were noted. 1. It is suggested that allergy is predominantly a disturbance of electrolyte metabolism associated with some endocrine (possibly adrenal) dysfunction." Con (SIMON S. R tTBIN and collaborators) "1. Potassium salts were of no practical therapeutic value in our series of 153 patients with hny fever and seasonal asthma. 2. The effect of such salts in other allergic conditions is highly questionable. 3. Reports of therapeutic results in hay fever should be received with skepticism unless they bear ear marks of evaluation by * * * pollinosis checks and surveys." COMMENT 1. One carrier surgeon has exhibited potassium chloride in eighteen cases of hay fever and allergic asthma. 2. The results have been uniformly favorable. 3. The cases treated and observed were financially unable to accommo date themselves to allergy tests and treatment with pollen and other extracts. - ; Proceedings of . L in all, there was deeided rt pollen exposure and in sev< severe to negligible. 5. Potassium chloride properl; hay fever and allergic nsth CARDIO-VASi The subject of cardio-vasei receives consideration at every ally included in its Report. Unilateral kidney disease h; ductive of a persistent hyper where other causes for hypertei be studied separately. Dr. Drew Luten, of St. Louis, "The Railroad Employe With many valuable suggestions that sidration. "In the cases of most pa tional activity best for dii portance. In many disease; while in many others, at ! increased. In either instan important consideration fo of the correct level of ph.heart disease, that this pai "According to the appn Nomenclature and Criteria adopted by the American i into one of five classes. "In Class A, are those p restriction. "In Class B, are those wh activity, but who should bt "Class C, is composed of ordinary activity. "Class D, comprises pat must be greatly reduced. "In Class E, are those wh "Before deciding into wh before reaching a proper " tivity is concerned, variou very important eonsideratio can be tolerated without d as the Criteria calls it. Foi of functional capacity are g no discomfort on ordinary I nor dyspnoea. In Class II comfort of some sort even take the form of dyspnoea, there may be cardiac inauffi 26 Association of American Railroads of patients who are comfortable at rest, but experience discomfort on less than ordinary activity. Class IY comprises patients who' are uncomfortable even at rest. "I t is obvious that this `functional' classification must depend almost entirely upon the history. I t is the extent of the symptoms that determines functional classification, not the presence or absence of physical signs. A patient whose capacity for physical activity is conspicuously limited because of discomfort th at arises on less than ordinary activity is put in Functional Capacity Class III, whether he exhibits abnormal physical signs or not. "It must be kept in mind furthermore that a determination of functional capacity is not the only requisite for correct therapeutic classification. Other considerations, such as the anatomical and the etiological diagnoses, may be very important. A patient convalescing from a recent infectious disease, for example, might experience no symptoms on ordinary activity, and consequently be put in functional capacity class I; but, for a time at least, as a protective measure, his doctor, keeping in mind the etiological diagnosis, might put him in therapeutic class C or D. A man with an aneurysm might be without symptoms of any sort, but this fact would not place him in thera peutic class A. Begard for the anatomical diagnosis would give him a lower classification. "In the cases of railroad employes, proper advice with respect to activity must take into account also still another faetor not con sidered in the Heart Association's Criteria for Diagnosis. I t is not enough for the doctor to know the quantity of work involved in the patients occupation; he must know the quality of it. His advice must consider not only the question of harm to the patient but also the question of injury to others. "The obligation of the physician in private practice always is primarily to the patient, the doctor-patient relationship being con fidential. It is true that the private physician must nut offer advice contrary to law, and his advice to the patient must not conflict with the public interest; but such considerations are secondary. His re sponsibility is to the patient. His advice is for tho patient's welfare. "The public health physician, on the other hand, is concerned with the welfare of the community. Public Welfare comes first, eveu though it involve some inconvenience to the individual. The physi cian cannot, make or enforce regulations that work undue hardship on the individual, but his regard for the individual is secondary, his primary obligation being to prevent injury to the publie. "In the complexities of modem industry both viewpoints are essential. The industry must not hurt the individual, the individual must not hurt the industry or the public. The advice of the physician to the railroad employe with heart disease regarding his activity must consider the patient's welfare. He must not be allowed to injure himself. This advice, this therapeutic classification of the patient, must keep in mind also the obligation not to allow injury to others. Iu most instances these viewpoints in no wise conflict. "In this connection it should be noted that correct therapeutic classification may be influenced by the history of certain clinical Proceedings of Af. syndromes, with or without out accompanying evidence history of Adams-Stokes at himself. If his work is su injury to others, he must I fact also in. mind. The same dizziness or fainting attack sinus. "The more common synd congestive heart failure), ( associated with sudden attai cases of cardiac insufflciei primarily to the patient hi and dyspnoea of cardiac ins classification because of his such cases there may be re the heart. During a period i be a matter of great diffici tional capacity that soon w physical work. Here again the all important item. Fo: heart failure might find his to be relieved of duty. Aft very few evidences of the impossible for him to conti most cases, would make it therapeutic classification w incapable of maintaining. "Many patients with nngi cal, roentgenological, or c artory disorder responsible in the cases of patients u capacitated, it is my feelin; of the patient is served bes occupation, and by helping self to it, so that, in many effectively as before the 01 physical aspects of disease the psychic and the physici good therapy. Sudden deal sidration emphasized since however, should be emphasi: of continuing at work inde free. "In the cases of many p dromes that presuppose the seiousnegg, the risk of inju: people is but little increase! his usual occupation. If h of the factors which precip may well be encouraged to - ;- trican Railroads at rest, but experience discomfort^ ass IV comprises patients who' are| -1> tional' classification must depend; It is the extent of the symptoms '* cation, not the presence or absence jse capacity for physical activity of discomfort that arises on less ; 1 Functional Capacity Class III, sical signs or not. ihermore that a determination of y requisite for correct therapeutic s, such as the anatomical and the important. A patient convalescing for example, might, experience no 1consequently be put in functional least, as a protective measure, his gical diagnosis, might put him in ith au aneurysm might be without et would not place him in theratomical diagnosis would give him es, proper advice with respect to Iso still another factor not conCriteria for Diagnosis. I t is not 1 quantity of work involved in the n the quality of it. His advice i of harm to the patient but also n in private practice always is r-patient relationship being con5 physician must not offer advice he patient must not conflict with lerations are secondary. His reIvice is for the patient's welfare, .he other hand, is concerned with ublic Welfare eomes first, even ee to the individual. The physi.tions that work undue hardship for the individual is secondary, ent injury to the public. industry both viewpoints are rt the individual, the individual flic. The adviee of the physician ; disease regarding his activity 1 He must not he allowed to injure uc classification of the patient, in not to allow injury to others, u no wise conflict, noted that correct therapeutic the history of certain clinical Proceedings oj Medical and Surgical Section 27 syndromes, with or without associated discomfort, and with or with out accompanying evidences of heart disease. A patient with a history of Adams-Stokes attacks must be protected from injury to himself. I f his work is such th at a fainting attack might cause injury to others, he must be given a work classification with that fact also in mind. The same considerations apply to an employe with dizziness or fainting attacks due to hyperirritability of the carotid sin"uTs.he more common syndrome of cardiac insufficiency (BO-called congestive heart failure), on the other hand, is less likely to be associated with sudden attacks or unconsciousness. In uncomplicated cases of cardiac insufficiency, consideration properly is directed primarily to the patient himself. An employe with the congestion and dyspnoea of cardiac insufficiency must receive a low therapeutic classification because of his very inability to do hard work. In some such cases there may be relatively few signs referable directly to the heart. During a period of improvement from inactivity, it might be a. m atter of great difficulty to determine the low level of func tional capacity that soon would become apparent under the test of physical work. Here again the history of previous failure may be the all important item. For example, a man wflth early congestive heart failure might find his work too hard for him, and'might have to be relieved of duty. After an interval of rest he might present very few evidences of the cardiac insufficiency that had made it impossible for him to continue his work. The history, however, in most eases, would make it very unwise to assign him again to a therapeutic classification w'hich experience already had shown him incapable of maintaining. "Many patients with angina pectoris present few evidences, physi cal, roentgenological, or electrocardiographical, of the coronary artery disorder responsible for their symptoms. As a general rule in the cases of patients with angina who are not altogether in capacitated, it is my feeling that, all things considered, the welfare of the patient is served best by encouraging him to continue in his occupation, and by helping him to modify his work and adjust him self to it, so that, in many instances, he is enabled to carry on as effectively as before the onset of symptoms. The psychic and the physical aspects of disease cannot be sharply separated, nor can the psychic and the physical details of therapy. Encouragement is good therapy. Sudden death in angina is always possible, a con sideration emphasized since the time of Heberden. To the patient, however, should be emphasized the other possibility,--the possibility of continuing at work indefinitely and even of becoming symptom free. "In the eases of many patients with angina, or with other syn dromes that presuppose the possibility of sudden death or uncon sciousness, the risk of injury to any considerable number of other people is but little increased by allowing the patient to continue a t his usual occupation. I f his work involves no particular increase of the factors which precipitate his attacks, therefore, the patient may well be encouraged to continue at it. But in the case, for ex- 28 Association of American Railroads ample, of a trainman, a dispatcher, or a switchman on the main line, primary obligation, to the patient obviously cannot supersede obliga tion to the public welfare." CHEMOTHERAPY There have been many advances in the subject of Chemotherapy since the last annual meeting of this Section. We are particularly interested in the treatment of traumatic conditions by these new drugs. Dr. Robert W. Johnson, of Baltimore, Md., writing in the American Journal of Surgery, July, 1940, says--"We have used sulfanilamide in a total of 36 very severe, contaminated, compound fractures and have found it a safe and effective drug for the prevention of streptococcus and gas bacillus infections. The use of chemotherapy complements but does not replace necessary surgical procedures." The method of treat ment recommended by Dr. Johnson is as follows: (1) "No omission or modification of thorough surgical toilet of the wound and debridement of necrotic tissue is to be countenanced." (2) "Early and adequate reduction and splinting of the fracture are as important as ever." (3) "Antitetanus serum with or without supplemental sera is to be given." (4) "A large initial dose of sulfanilamide--60 to 80 gr.--with equal quantity of sodium bicarbonate is to be given as soon as possible. Oral administration is to be preferred, otherwise hypodermoclysis or stomach tube in anesthetized patient after lavage, is used." (5) "Subsequent doses are of 10-20 gr. every 4 hours, given with sodium bicarbonate, for 3 to 10 days." (6) "A daily check is made by the Marshall colorimetric test of blood sulfanilamide level to assure maintenance of effective level at the lowest dosage. A level of 5 t,o 8 mg. per 100 cc. is sufficient for prophylactic effect." (7) "Quicker absorption is obtained in initial dose from crushed rather than whole commercial tablets. The tablets can be chewed or given powdered in capsules." CHANGING CONCEPTS IN CHEMOTHERAPY Since sulfanilamide was discovered, it has undergone many changes and modifications. These modifications have been brought about through chemi cal manipulations of the molecule, resulting in entirely different synthetic compounds which vvers given various names. The object in producing these changes in structure was to develop a product more toxic to infect ing organisms and less toxic to the host. These new compounds varied in their toxicity, solubility and range of therapeutic effectiveness. These changes direct and limit our use of the new drugs as they appear. DENTAL DISEASES Under date of October 31, 1940, your Committee sent out to the Chief Surgeons of member Lines a questionnaire asking for-- (1) The incidence of dental diseases (carles and periodontal infection) among Railroad employes. Proceedings o f Met (2) Your experience as to the Forty-seven replies to this que; of the answers to the first que3l 19.4% had some form of dental t The answers to question No. ! disabilities, attributed directly t would be impossible to tabulate s have noted the detrimental effee general health of the employes. It is recommended that closer employes' teeth, and that prope where disease or defects are note DI With reference the subject of d occupations, Dr, W. H. Olmsted treatise on this subject which is herewith: "There is an incidence of tween the ages of 45 to 54 o) ages of 55 to 64 the incide group of workers, particular there will be many who ari frequently found. It is fail treating diabetes that SO to insulin for their proper trea "I should first like to spea) efficiency of workers in haza. carbohydrate metabolism doe the disease is severe and it are able to carry on and woi involved. It is not so ruucl that interfere with the eflicit diabetics die of some form o 65 years. These complieatii apoplexy, coronary sclerosis r diabetes occurs usually lute i of life in this disease is at lea diabetes at 50 ought to live t man should probably live to we see arteriosclerosis develi diabetic population. "Because arteriosclerosis is cause a man with arterioscler capped in. other ways which i in hazardous occupations, I those engaged in train serv particularly along the followi amined, the blood pressure ta gram made. 2. The urine sho of American Railroads Proceedings of Medical and Surgical Section 29 patcher, or a switchman on the main atient obviously cannot supersede oblige KOTHERAPY ses in the subject of Chemotherapy sine,. Section. We are particularly intereste| onditions by these new drugs, altimore, Md., writing in the America^ says--"We have used sulfanilamide in minated, compound fractures and have rug for the prevention of streptococcus! : use of chemotherapy complements b u t| leal procedures." The method of treat-1 ion is as follows: tion of thorough surgical toilet of theil f necrotic tissue is to be countenanced"! ction and splinting of the fracture are:|J % or without supplemental sera is to bet ulfanilamide--60 to 80 gr.--with equal!, tnate is to be given as soon as possible.!* je preferred, otherwise hypodermoclysls|g| etized patient after lavage, is used." i 10-20 gr. every 4 hours, given w ith| ;o 10 days." | the Marshall colorimetric test of blood - re maintenance of effective level at the _ 5 to 8 mg. per 100 cc. is sufficient for ined in initial dose from crushed rather blets. The tablets can be chewed or *TS IN CHEMOTHERAPY red, it has undergone many changes and have been brought about through ebemiresulting in entirely different synthetic ious names. The object in producing develop a product more toxic to infecti host. These new compounds varied in ;e of therapeutic effectiveness. ' These f the new drugs as they appear. . DISEASES your Committee sent out to the Chief ionnaire asking for-- ises (caries and periodontal infection) m (2) Your experience as to the effect resulting from these conditions. Forty-seven replies to this questionnaire were received. A compilation of the answers to the first question showed that of all cases reported, J!>.4% had some form of dental disease. The an sw e rs to q u e stio n No. 2 were so varied and covered so many d isa b ilitie s, attributed directly or indireetly to dental disease, that it would be impossible to tabulate same in this report. Ali Lines reporting have noted the detrimental effect produced by dental diseases upon the general health of the employes. It is recommended that closer attention be paid to the conditions of employes' teeth, and that proper dental care be urged in every case where disease or defects are noted. DIABETES \ With reference the subject of diabetes in workers engaged in hazardous orcupatious, Dr. W. H. Olmsted of St. Louis, Mo., recently presented a treatise on this subject which is so forceful that same is incorporated herewith: "There is an incidence of diabetes in those of the population be tween the ages of 45 to 54 of 6.6 per thousand in those between the ages of 55 to 64 the incidence is 14 per thousand. Thus in any group of workers, particularly in those where priority is the rule, thero will be many who are in the age groups where diabetes is frequently found. I t is fairly well agreed among those who are treating diabetes that 80 to 90 per cent of the cases will require insulin for their proper treatment. "I should first like to speak on the effect of diabetes itself on the efficiency of workers in hazardous occupations. The derangement of carbohydrate metabolism does not in itself handicap workers unless the disease is. severe and it is a common experience that diabetics are able to carry on and work even in fields where manual labor is involved. I t is not. so much diabetes itself but its complications that interfere with the efficiency of workers. Sixty per cent of the diabetics die of some form of arteriosclerosis at the average age of 65 years. These complications are gangrene of the lower limbs, apoplexy, coronary sclerosis artel arteriosclerotic nephritis. However, diabetes occurs usually late in middle age and today the expectancy of life in this disease is at least 12 years. Thus the man who acquires diabetes a t 50 ought to live to a t least 62 years, whereas the normal man should probably live to 70. I t is in the younger diabetics that we see arteriosclerosis develop at an earlier age than in the nondiabetic population. "Because arteriosclerosis is so apt to complicate diabetes and be cause a man with arteriosclerosis is apt to die suddenly or be handi capped in other ways which interfere with his efficiency particularly in hazardous occupations, I believe that every diabetic, especially those engaged in train service, should have yearly examinations particularly along the following lines: 1. The heart should be ex amined, the blood pressure taken and a chest film and electrocardio gram made. 2. The urine should be examined for albumin and casts 30 Association of American Railroads and the blood examined for non-protein nitrogen. 3. Ophthalmoscopic examination of the eyes should be done to detect the early appear ance of diabetic retinitis. THE USE OF INSULIN BY DIABETICS IN HAZARDOUS OCCUPATIONS "Dr. Marble in Joslin's book says, `Insulin reactions constitute one of the major problems in the treatment of diabetes.' There is no doubt of the truth of this statement. Insulin reactions are mani fested largely by neurological symptoms but the pattern of reactions is not constant in different individuals nor in the same individual having reactions at different times. Some of the symptoms commonly seen are: hunger, nervous instability, sweating, numbness and tin gling of the tongue or lips, double vision, headaehe, faintness, tremor, unsteady gait, somnolence, unconsciousness, convulsions. In dis cussing the question of the use of insulin by workers in hazardous occupations, I shall ask a series of questions and then try to answer them. "Why is the nervous system so susceptible to hypoglycemia? The brain and presumably other nervous tissue depend wholly for their energy needs on sugar. Nervous cells cannot burn protein or fat. In addition to this fact, there is no storage of sugar or glycogen in nervous tissue. Therefore, the brain is dependent on a continuous supply of sugar. This means that when the level of the blood sugar is reduced, the metabolism of nervous tissue almost immediately suffers. "Is there any correlation between a level of hypoglycemia and the degree or the kind of nervous symptoms? Usually symptoms occur only when the blood sugar falls below 70 mgs. per cent of true sugar. But there is no exact relation between the severity of symptoms and the severity of hypoglycemia. One frequently finds blood sugar levels of from 30 to 50 mgs. per cent without any symptoms at all. But on the other hand, one never observes symp toms without the finding of a low blood sugar. At one time a patient may show severe symptoms with the blood sugar at a level of 50 mgs. per cent while at another time he may show no symptoms with the level a t 30 mgs. per cent. "Is the nature of hypoglycemic symptoms such that the individual is not responsible for his actions? I believe the answer to this ques tion is yes for these reasons: 1. The individual after insulin re actions often has no memory for what he has done or said during the attack. 2. During the attack, he says and docs things entirely foreign to his normal state of mind. 3. During a reaction, he lacks control of his muscles and i t ' is a common observation that the diabetic may have in his pocket sugar wafers but he fails to use them because either he forgets to do so or he cannot control his hand sufficiently to take the surgar from his pocket and put it in his mouth. "Can the diabetic tell when an insulin reaction is approaching? Not always. Perhaps in 4 out of 5 instances, he is aware of the approach of a reaction but the 5th time catches him so unaware Proceedings of Medical that he is in the reaction without to find that even the most inteili detect the approach of an insuii come on gradually with nervouau can easily recognize but again t with amazing suddenness. "Can insulin reactions be tota always carries a high blood sug or takes sueh a small dose that : diabetics are given the best pos insulin and even if the latter be he will, nevertheless, have oeeasii who is taking insulin and provi blood sugar at a level where s occasional reactions cannot be to may cause even the well treat' unusual exercise or forgetting tc what he eats. Human nature bei predispose to a low blood sugar "Has the use of protamine zin iietions and the severity of the both questions. However, altho insulin fewer reactions occur, v be prolonged and there is rea patient out of the reaction th; modified iorm of insulin does m severe reactiou. CONC. "When an employe of a rail judgment, his senses, and his ne> in ail respeets and at all times, mellitus. If employes are allow viding they do not take insulin result in suth diabetics being b: he has diabetes, he will postpom often to his own detriment. If tained that once the diagnosis ol is transferred irom a hazardon there is no reason why his diab if such is needed. There is no < non-kazardous jobs can be depen to do work with customary effiei EPILEPSY AND EPIL3 11111110 epilepsy has long been stu mented upon, in many past reports, i been limited to eases of grand-mal. be of more importance in connectio r'" ;. `'AV'-V: ' ' menean Railroads protein nitrogen. 3. Ophthalmoscopic? be done to detect the early appear-? Y DIABETICS IN HAZARDOUS NATIONS s says, `Insulin reactions constitute! die treatment of diabetes.' There is | atement. Insulin reactions are mani-| ,'mptoms but the pattern of reactions j ividuals nor in the same individual,! ies. Some of the symptoms commonly ibility, sweating, numbness and tin- s :c vision, headache, faintness, trem or,! consciousness, convulsions. In dis- ' of insulin by workers in hazardous . of questions and then try to answer o susceptible to hypoglycemia? The vous tissue depend wholly for their > s cells cannot burn protein or fat. no storage of sugar or glycogen in main is dependent on a continuous t when the level of the blood sugar nervous tissue almost immediately sen a level of hypoglycemia and the ymptoms? Usually symptoms occur s below 70 mgs. per cent of true relation between the severity of ypoglyeemia. One frequently finds to 50 mgs. per cent without any er hand, one never observes sympblood sugar. At one time a patient . the blood sugar at a level of 50 time he may show no symptoms symptoms such that the individual I believe the answer to this ques. The individual after insulin rewhat he has done or said during , he says and does things entirely ud. 3. During a reaction, he lacks a common observation that the sugar wafers but be fails to use o do so or he cannot control his ar from his pocket and put it in insulin reaction is approaching? 5 instances, he is aware of the ith time catches him so unaware Proceedings of Medical and Surgical Sedimi that he is in the reaction without being aware of it. I t is interesting to find th a t even the most intelligent men and women cannot always detect the approach of an insulin reaction. Insulin reactions often come on gradually with nervousness or jitteryness which the patient can easily recognize but again the patient goes abruptly into coma with amazing suddenness. "Can insulin reactions be totally prevented? Tea, if the diabetic always carries a high blood sugar and if he neither takes insulin or takes such a small dose that a reaction is not likely. However, if diabetics are given the best possible treatment with both diet and insulin and even if the latter be administered with the utmost care, he will, nevertheless, have occasional insulin reactions. In the patient who is taking insulin and providing an effort is made to keep the blood sugar at a level where sugar will not appear in the urine, occasional reactions cannot be totally excluded. The situations which may cause even the well treated diabetic to have reactions are; unusual exercise or forgetting to eat all of his meal or to measure what he eats. Human nature being what it: is, these situations which predispose to a low blood sugar are bound to oceur. "Has the use of protamine zinc insulin reduced the number of re actions and the severity of the reactions? The answer is yes to both questions. However, although with the use of this modified insulin fewer reactions occur, when they do they aie more apt to be prolonged and there, is really more difficulty in getting the patient out of the reaction than with regular insulin. The new modified form of insulin does not guarantee the diabetic against a severe reaction. CONCLUSIONS "When an employe of a railroad occupies a position where his judgment, his senses, and his neuro-muscular control must be normal in all respects and at all times, he should not suffer from diabetes niellitus. I f employes are allowed to hold hazardous positions pro viding they do not take insulin, such a policy in my opinion will result in such diabetics being badly treated. I f the1employe knows he has diabetes, he will postpone taking insulin as long as possible, often to his own detriment. If on the other hand, a rule is main tained th a t once the diagnosis of diabetes is established, an employe is transferred from a hazardous job to some other position, then there is no reason why his diabetes cannot be treated with insulin if such is needed. Theie is no doubt in my mind that diabetics in noii-hazardous jobs can.be depended upon, even if they take insulin, to do work with customary efficiency." EPILEPSY AND EPILEPTIC EQUIVALENTS While epilepsy has long been studied by your Committee, and com mented upon in many past reports, attention has, heretofore, practically been limited to eases of grand-mal. I t is felt that minor epilepsy may be of more importance in connection with Railway employes than are r 32 Association of American Railroads the major seizures. The latter being almost always detected and re ported, whereas there are many instances in which an employe momen tarily loses consciouness and yet manifests no evidence of a typical epileptic seizure. These momentary inhibitions are probably manifesta tions of a mild epilepsy and may be classed as "epileptic equivalents." Such conditions create an intense hazard in Railway service. The following data upon epilepsy and epileptic equivalents are worthy of consideration. Bates Block in an exhaustive study on epilepsy as reported in "Tices Practice of Medicine" list from work of Leftwich. eighty diseases in which convulsions occur. So-called idiopathic epilepsy; i.e., the convulsive syndrome which we identify by the irregular recurrence of attacks of loss of consciousness of varying duration accompanied by the classical general muscle spasm, the mouth frothing, and tongue biting can be no problem in identifica tion and disposition except that documentary evidence is almost always a necessary and therefore invaluable item in the medico-industrial history. Definitely established grand mal in a railroad employe engaged with operation so convincingly demonstrates intolerance of his continuance on the basis of hazard and insecurity that the one difficulty that harasses a medical supervisor is accurate history of the occurrence of the epilepticconvulsive seizure and his indisputable identification of it as epilepsy. The transiency of petit mal seizures and the fact th at epileptic stig mata are not so commonly encountered among its sufferers as in grand mal makes the establishment of a diagnosis considerably more difficult and hence disposition of the employe more embarrassing and complex. The epileptic equivalents either as substitutive manifestations for the classical grand or petit mal attacks or as a part of the epileptic con stitution are troublesome medical problems particularly when manifested as narcolepsy or as emotional outbursts. The most common and important sequel of epilepsy is mental deteriora tion. The degree and progress of deterioration is in almost direct pro portion to the frequency of attacks. Mental enfeeblement is more often associated with petit than with grand mal. In the Lumeleian Lectures for 1928, Collier makes the following ob servation: "So far as the so-called `idiopathic' epilepsy which thus effects man and the animals is concerned, no pathological changes have been found upon which any hypothesis as to the nature of epilepsy can be built up. The findings have been for the most frankly negative, or such changes as have been found in severe and long-standing cases as may be reasonably attributed to long-lasting disorder of function." Attention has, therefore, turned to the possibility of finding an explana tion of epilepsy in some perversion of the chemistry of life. Some metabolie dyserasia which may lead to the presence of substances within the system which act upon the nervous system as do convulsant poisons and which may further, by depriving the nervous system of its customary activations, cause, in some cases, a progressive impairment of the higher functions of the nervous system. Proceedings of Medic Epileptiform or epileptoid seizure way with epilepsy as a major or n of diseased conditions, and confusi serious and important symptom of epilepsy must be avoided. The diseases in which epileptifor mon and alarming episode are: a. Para lues. b. Anoxemia--physiologic or pa e. Diabetes. d. Insulin shock. e. Uraemia. f. Neurologic hyperinsulinism. g. Cerebro-arteriosclerosis. None of these represents a particul surgery with the possible exception Birmingham, Alabama, has studied monographs. He reports, in introdi case reports: "I desire it distinctly underst insulinism is the cause of epilep etiological factor in any ease of a patient with the epileptic, prs ing from hyperinsulinism may b convulsive seizures." Harris aud others have conclusive insulinism in the production of a epileptiform convulsive seizures ate studied a number of cases of convu found iu all very low blood sugar le\ Leon J. Robinson comments on < follows: "The finding of a hypoglyeei `epilepsy' is not sufficient evide glyeemic epilepsy. "Diagnosis must, be based on t tory findings. Outstanding is tt the ingestion of food, for the cor. the fasting states; at night or been depleted by exercise. Often seizures by ingesting food at fre tory symptoms of hunger, faintn FOCI OF II The snbjeet of focal infection is s< road medical supervision that, even I vious reports, a review of the subje foci of infection should be considt former, colon, teeth, tonsils and nass tant in the order named. Of the latte of American Railroads Proceedings of Medical and Surgical Section 33 r being almost always detected and re- ' y instances in which an employe momen- i yet manifests no evidence of a typical j itary inhibitions are probably manifesta- i ay be classed as "epileptic equivalents." se hazard in Railway service. ;psy and epileptic equivalents are worthy study on epilepsy as reported in "Tices I a work of Leftwieh eighty diseases. in | i.e., the convulsive syndrome which we enee of attacks of loss of consciousness by the classical general muscle spasm, biting can be no problem in identificudocumentary evidence is almost always ible item in the medico-industrial history. .1 in a railroad employe engaged with ustrates intolerance of his continuance l'ity that the one difficulty that harasses listory of the occurrence of the epileptic utabie identification of it as epilepsy, izares and the fact that epileptic stigmtered among its sufferers as in grand a diagnosis considerably more difficult ploye more embarrassing and complex. as substitutive manifestations for the cks or as a part of the epileptic conproblems particularly when manifested M bursts. t sequel of epilepsy is mental deteriora1deterioration is in almost direct pro s. Mental enfeeblement is more often and mal. 1928, Collier makes the following ob- pathie' epilepsy which thus effects man I , no pathological changes have been (osis as to the nature of epilepsy can e been for the most frankly negative, n found in severe and long-standing 1 ittributed to long-lasting disorder of Epileptiform or epileptoid seizures not identified or associated in any way with epilepsy as a major or minor syndrome may happen in scores of diseased conditions, and confusion of these convulsive seizures as a serious and important symptom of the disease with so-called idiopathic epilepsy must be avoided. The diseases in which epileptiform convulsive seizures may be a com mon and alarming episode are: a. Para lues. b. Anoxemia--physiologic or pathologic, e. Diabetes. d. Insulin shock. e. Uraemia. f. Neurologic hyperinsulin ism. g. Cerebro-arteriosclerosis. None of these represents a particular problem in industrial medicine and surgery with the possible exception of h.vperinsulinism. Seale Harris of liirmingham, Alabama, has studied this condition and reported several monographs. He reports, in introducing a presentation of patients and rase reports: "I desire it distinctly understood that 1 do not believe that hyper- insulinism is the cause of epilepsy. Nor do I think that it is the sole etiological factor in any case of epilepsy. I believe, however, that in a patient with the epileptic, predisposition, the hypoglycemia result ing from hyperinsulinism may be a precipitating factor in producing convulsive seizures." Harris and others have conclusively established the influence of hyper insulinism in the production of a characteristic syndrome in which epileptiform convulsive seizures are a prominent symptom. Harris has studied a number of eases of convulsive seizures in byperinsulinism and found in all very low blood sugar levels. Leon J. Robinson comments on epilepsy of hypoglycemic genesis as follows: "The finding of a hypoglycemic blood sugar level in a case of `epilepsy' is not sufficient evidence to justify a diagnosis of hypo glycemic epilepsy. "Diagnosis must be based on the whole clinical picture plus labora tory findings. Outstanding is the time relationship of symptoms to the ingestion of food, for the convulsions occur predominantly during the fasting states; at night or when the carbohydrate stores have been depleted by exercise. Often the patient learns that he can abort seizures by ingesting food at frequent intervals or when the premoni tory symptoms of hunger, faintness or sweating appear." 0 the possibility of finding an explauaion of the chemistry of life. Some 1 to the presence of substances within vous system as do convulsant poisons m g the nervous system of its customary progressive impairment of the higher FOCI OF INFECTION The subject of focal infection is so important in connection with rail road medical supervision that, even though included in a number of pre vious reports, a review of the subject is deemed essential at this time. Foci of infection should be considered primary and secondary. Of the former, colon, teeth, tonsils and nasal accessory sinuses are most impor tan t in the order named. Of the latter, which just as surely produce sirni- 34 Association o f American Railroads Proceedings of M lar changes are the genito urinary tract, biliary tract, etc. These are in the back in which there are usually of hematogenetic origin and are secondary to the primary infec we find due to lack of drainag tions. While the genito-urinary system may be a primary focus in spe relieved by proper treatment. cific infections, it is secondary in 65% of the cases and directly traceable to the colon. Nearly all cases of acute art standing exceptions are those o. We believe the colon to be one of the most common yet least suspected the joint symptoms are seeming. foci of infection that exists in the human body and think it worthwhile The subject is broad. Conditi, to discuss briefly the various conditions found to exist therein. We must an example, are many and var assume that the most important function of a sound organ is its ability infection in many cases of hypei to properly eliminate and that a great percentage of human ailments tion. The incidence of such an is due directly or indirectly to a cessation or impairment of this function. stances of pernicious anemia. . Physiologically speaking the colon has two distinct functions and it may are proven results of focal infer, be said that it is divided into two distant segments for the purpose of produces total disability of the ei these functions, Prom the cecum to the splenie flexure or highest portion, Conclusions: the function of the colon is highly absorptive. While from the splenic 1. Remediable foci of infect E flexure to the rectum its function is principally eliminatory. The first 2. Programs of education ai segment, may be termed the absorptive colon; the second segment may aid in the improvement of gen be termed the motor colon. When liquefied food matter leaves the small efficiency, and reduce the incidi intestine and enters the cecum, the colon immediately commences to 3. Practically all railroad oc absorb the greater portion of the liquid so that when the feces arrive at nervous capacity to perceive qi the motor colon it is semi-solid in character. In this human sewer there and conclude, in action, effectu; are countless millions of bacteria and an immense amount of toxins the expenditure of nervous ener bathing large areas. The cecum is the site of the greatest bacteriological autonomic nervous system and s activity that takes place in the intestinal canal and nearly all of the display. Foci of infection may bacteria are found viable. Absorption of these toxins and bacteria are changes in the heart and blood greater when normal elimination is interfered with, in such instances as system accentuate and hasten e: cecal or colonic stasis or when the normal defensive power is lessened as in enteritis. Focus of infection may truly be present but not the cause of the disease of which the patient complains. It may be the cause of the disease and yet be removed too late to affect an already firmly seated disease, Attention directed toward th d'.ieive to the end that October may be happy and contented tl uuced by focal infection. and the misplaced zeal on the part of the profession might cause the theory of focal infection as the cause of disease to become discredited. The fact that one finds bad teeth or tonsils in looking for foci of infec The subject of hernia lias ag tion does not mean that they are responsible for certain arthritic changes Nothing novel has developed bi since their removal may not influence the arthritis. These focal infec that, hernia is an incident to--a tions, however, if possible should be eradicated when and if the patient's lions. condition permits regardless of the question of the cause and effect. Given two patients with chronic arthritis of equal intensity a better clinical result is to be expected from removal of the virulent focus in an individual with good resistance than for the removal of mild infection in the individual of low resistance. From the standpoint of prevention the favorable time for removal is before the appearance of its results. Structural changes may be prevented but may not be returned to normal by elimination of the focus. Iladen has proven that thousands of teeth that are symptom free and that are roentgenographieally negative are found in the laboratories to be infected. He also has proven that the teeth and their surrounding tissues play a much greater part in the adult life than do the tonsils. Head has shown that nerve fibres ending in the prostate and seminal vesicles arise from the 10th dorsal to the 3rd sacral segments, hence pain MAN-FAILURE IN CO In the 1910 Report, a study w by the l.C.O. within a period o. of these accidents were found t while the remaining 16 were a and resulted in 15 deaths and li Since that Report, a total o Reports of investigated aceiden able causes, and 61 were direct The 9 accidents due to unavo. injuries; whereas, the 61 aceic deaths and 836 personal injuries wmrnmrnrnmmmmmmmmmmm. i o f American Railroads Proceedings of Medical and Surgical Section 35 inary tract, biliary traet, etc. These a rl in and are secondary to the primary infeed ry system may be a primary foeus in spejl in 65% of the cases and directly traceabl me of the most common yet least suspected a the human body and think it worthwhile conditions found to exist therein. We must! nt function of a sound organ is its ability! at a great percentage of human ailmentsj a cessation or impairment of this function.! iolon has two distinct functions and it may.J o two distant segments for the purpose of | um to the splenie flexure or highest portion,! highly absorptive. While from the splenic! ction is principally eliminatory. The first! absorptive colon; the second segment may, v'hen liquefied food m atter leaves the small! um, the eolon immediately commences to 1 the liquid so that when the feces arrive a t f d in character. In this human sewer there cteria and an immense amount of toxins) m is the site of the greatest bacteriological| the intestinal canal and nearly all of the ! bsorption of these toxins and bacteria are ! ion is interfered with, in such instances as , en the normal defensive power is lessened uly be present but not the cause of the omplains. I t may be the cause of the disease to affect an already firmly seated disease, ~j re part of the profession might cause the "Mf :he cause of disease to become discredited, eetli or tonsils in looking for foci of infecare responsible for certain arthritic changes influence the arthritis. These focal infeculd be eradicated when and if the patient's of the question of the cause and effect, onic arthritis of equal intensity a better ted from removal of the virulent focus in :ance than for the removal of mild infection stance. From the standpoint of prevention ,-al is before the appearance of its results, evented but may not be returned to normal usands of teeth that are symptom free and t negative are found in the laboratories to oven that the teeth and their surrounding part in the adult life than do the tonsils, e fibres ending in the prostate and seminal orsal to the 3rd sacral segments, hence pain in the back in which there are roentgonologically no arthritic changes, we find due to lack of drainage of these glands. The referred pain is relieved by proper treatment. Nearly all eases of acute arthritis are due to micro-organisms. Out standing exceptions are those of serum disease and acute gout in which the joint symptoms are seemingly entirely chemical in origin. The subject is broad. Conditions other than arthritis, which is used as an example, arc many and varied. For instance the incident of focal in fe< t <>11 in many eases of hyperthyroidism has been proven beyond ques tion. The incidence of such an infection is easily proven in many in stances of pernicious anemia. Innumerable general systemic conditions are proven results of focal infection and it either lessens the efficiency or produces total disability of the employe. 1. Remediable foci of infection are common among railroad workers. I'rogiams of education and jieriodic jihysical examinations would aid in tin: improvement of general health, increase work capacity and efiicieiii'.v, and reduce the incidence of crippling cardio-vascular disease. 3. Practically all railroad occupations require a cultivated mental and nervous c a p a c ity to perceive quickly and accurately, to reason logically and conclude, in action, effectually and without expense to the body by the expenditure of nervous energy through unwarranted excitation of the autonomic nervous system and stress and strain effects of hypcremotional display. Foci of infection may be responsible for organic degenerative changes in the heart and blood vessels and by their effect on the nervous system accentuate and hasten crippling disabilities. Attention directed toward the above enumerated factors may be con ducive to the end that October's period in the life of railroad workers may be happy and contented through freedom from the disabilities pro duced by focal infection. HERNIA The subject of hernia has again been considered by your Committee. Nothing novel has developed but stress should be placed upon the point that hernia is an incident to--and not an accident in--industrial occupa tions. MAN-FAILURE IN CONNECTION WITH ACCIDENTS In the 31)40 Report, a study was made of 20 train accidents investigated by the I.C.C. within a period of 60 days immediately preceding. Only 4 f these accidents were found to have been due to unpreventable causes, while the remaining 16 were attributable to some form of man-failure and resulted in 15 deaths and 150 personal injuries. Since th at Report, a total of 70 train accidents studied from I.C.C. Reports of investigated accidents, show that only 9 were due to unavoid able causes, and 61 were directly traceable to some form of man-failure. The 9 accidents due to unavoidable causes resulted in 4 deaths and 160 injuries; whereas, the 61 accidents due to man-failure resulted in 211 deaths and 836 personal injuries. W t ' ! - I Association of American Railroads Your attention is again directed to the recommendation which has been approved by the Association of American Railroads as a recommended Standard Practice: "Whenever investigation of any train or train service accident indicates man-failure as a causative factor--such as disregard of signal indication; disregard of or misinterpretation of train orderB or rules--and suggests an impaired physical condition as a contribut ing cause of the failure, a medical examination directed by the Com pany of the employe or employes so involved is recommended." Your Committee cannot too strongly urge adoption of this recommenda tion by all member Lines, feeling confident that such adoption will un doubtedly lead to a great reduction in the number of accidents, the elimination of much pain and suffering, as well as preserving many lives. DISQUALIFYING OCULAR DEFECTS Disqualifying ocular defects among employes in train and engine service, particularly the latter, has been given much consideration. Such defects may arise as to render the employe absolutely unfit for the class of work in which he has been engaged, and the inability of the railroads to transfer these men from one craft to another operates against the possibility of placing them at work which they could do. OVERWEIGHT Obesity is a problem that is exceedingly complex, and takes into con sideration a wide variety of factors. The physician's first concern, natur ally, is the ruling out of fundamental physiological disturbances. With this in mind, it is necessary that a variety of fundamental disturbances must always be considered and excluded. Congenital factors may be concerned so that the family history needs evaluation. Abnormal regulative hypothalamic centers may be disturbed. Disturbances in appetite and demand for excessive food and drink, dis like of physical exercise, or abnormal fatigability, may be present with or without the many endocrine disturbances, which may be active. Among the endocrine possibilities, one must always rule out lower basal metabolism, or other specific dynamic action of foods. All these, however, are relatively rare conditions, and the majority of obese patients do not show such manifestations. Most cases are due to the fact that more food is consumed than is necessary for energy requirements. In a survey carried out by this Committee through a circular on obesity, it was found that only fifteen out of fifty-one railroads kept records. There were no statistics or information available regarding any of the fundamental disturbances as outlined above. There was no consistency in the reports of those roads maintaining records. For example, one railroad had 43.22% cases of obesity which appears to be a rather high incidence, while the lowest report or incidence was 0.1% which again is an extreme in the other direction. The average of all roads maintaining records was 13%. The type of occupation was not listed, therefore, we have no informa tion in this regard. Those of us who are most familiar with railroad Proceedings of Al employes, however, have probi among our section laborers whe but on the other hand, we do occupation is more or less seden The crucial importance of th calories expended determines th is accomplished by any tempora thyroid or other drugs, without patient habitually consumes, it weight he has lost as soon as tl and permanent treatment for ob is the substitution of a new am overeating. Our analyses show that all of keep statistics or not, realize tl matter, since all of these cases proper handling, and managemei regulations. PNEU Upon the subject of pneumom dred conditions) your Committee of presentation. eeha: The technical structural inhifc measures and policies in Railroai tion. It is felt that this subject \ The snbjeet is presented, at this cussion and suggestions from the S While no additional data has bimportance of the disease is by m to the advances in the treatment Chief Surgeon should acquaint hi; these is the oral administration of TE Tetanus Toxoid has been develo iioved that the use of this Toxoii a dual purpose;--First, the Toxoid toxin formerly used; and second, immunization. Another feature in is the economic one, the Toxoid co. toxin. It is understood that the U doning use of Antitoxin and relyin against tetanus is required. ation of American Railroads Proceedings of Medical and Surgical Section iirected to the recommendation which has bee) ion of American Railroads as a recommend ation of any train or train service accident as a causative factor--such as disregard o | egard of or misinterpretation of train order an impaired physical condition as a contribute e, a medical examination directed by the Com-| r employes so involved is recommended." oo strongly urge adoption of this recommendac feeling confident that such adoption will un-f reduction in the number of accidents, th e l nd suffering, as well as preserving many lives,-Jj TYING OCULAR DEFECTS fects among employes in train and engineM ter, has been given much consideration. Suchl der the employe absolutely unfit for the class' on engaged, and the inability of the railroads? n one craft to another operates against theif at work which they could do. OVERWEIGHT employes, however, have probably noted that obesity is rarely found among our section laborers who burn up their calories in their activity, but on the other hand, we do find obesity predominant in those whose occupation is more or less sedentary. The crucial importance of the balance between calories taken in and calorics exponded determines the answer to obesity. If weight reduction is accomplished by' any temporary expedient; for example, by the use of thyroid or'other drugs, without effecting the amount of food which the mllent habitually consumes, it, is obvious that he will gain back all the weight he has lost as soon as the treatment is suspended. The only real and permanent treatment for obesity when a patient is otherwise normal, is the substitution of a new and better food habit for the old habit of overeating. Our analyses show that all of the railroads regardless of whether they keep statistics or not, realize the importance of medical advice in this matter, since all of these eases are referred back to the physician for proper handling, and management, rather than setting up any dogmatic regulations. PNEUMONOCONOSIS Ujion the subject of pneumonoconosis, (silicosis, anthracosis and kin dred conditions) yrour Committee has had practically no new data worthy of presentation. : is exceedingly complex, and takes into con-Jj ' factors. The physician's first concern, natur-|g indamental physiological disturbances. With?! ' that a variety of fundamental disturbances^ md excluded. 4 e concerned so that the family history needs"! ative hypothalamic centers may be disturbed. d demand for excessive food and drink, dis-:l abnormal fatigability, may be present w ith'9 ocrine disturbances, which may be active.if ilities, one must always rule out lower basal dynamic action of foods. All these, however, j ,s, and the majority' of obese patients do not Most cases are due to the fact that more: cessary for energy requirements, by this Committee through a circular o n ; only fifteen out of fifty-one railroads kept ;| sties or information available regarding any nces as outlined above. in the reports of those roads maintaining JJI ailroad had 43.22% eases of obesity' which ucidence, while the lowest report or incidence extreme in the other direction. The average J irds was 13%. is not listed, therefore, we have no informa- j of us who are moat familiar with railroad REHABILITATION The technical structural inhibitions of applicants for rehabilitation measures and policies in Railroad occupations has been given considera tion. I t is felt that this subject will require much detailed investigation. Tlie subject is presented, at this time in hopes that it will stimulate dis cussion and suggestions from the Chief Surgeons of member Lines. SYPHILIS While no additional data has been compiled on the subject of syphilis, importance of the disease is by no means lessened. Attention is directed to the advances in the treatment of syphilis with which every member Chief Surgeon should acquaint himself. Probably the most important of these is the oral administration of bismuth preparations. TETANUS Tetanus Toxoid has been developed as an immunizing agent. I t is be lieved that the use of this Toxoid instead of Antitoxin will accomplish a dual purpose:--First, the Toxoid will be just as preventive as the Anti toxin formerly used; and second, the Toxoid will give a more lasting immunization. Another feature in favor of Toxoid as against Antitoxin is the economic one, the Toxoid costing only about half as much as Anti toxin. I t is understood that the United States Army is practically aban doning use of Antitoxin and rely'ing upon Toxoid wherever immunization against tetanus is required. 38 Association of American Railroads A member of the Committee has compiled a short monograph entitled-- "Immunization vs. Tetanus," which contains so much constructive data that same is quoted herewith in full: "This is an old subject. Its inclusion is justified for statistical reflection and because of the work which has recently been accomplished in the active immunization of individuals by the use of toxoid. "Reports of cases of tetanus are unreliable. However, reports of deaths are quite reliable in that they are consolidated from State mortality records by the United States Census and United States Public Health Service. Deaths from tetanus were as follows: Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 Deaths 1,503 1,377 1,437 1,489 1,360 1,287 1,116 1,119 1,253 1,226 1,057 1,088 930 930 Assumed cases based ou average mortality rate 2,500 2,300 2,400 2,400 2,300 2,280 1,860 1,860 2,270 2,265 1,765 1,770 1,550 1,550 "Tetanus is one of the most serious complications of trauma and traumatic surgery. It is an event which must be considered as a possibility in any perforating or penetrating wound. "The high mortality rate (over 50%) that, unfortunately, experi ence has shown to accompany tetanus statistics has developed, as a routine practice in civil as well as in military work, the administra tion of prophylactic doses of tetanus antitoxin. "Immunization against tetanus by the use of tetanus toxoid is in vogue in several European armies. In the .French Army it is compul sory. French medical journals reported some months ago that 1,500,000 individuals had been given the immunization with entirely satisfactory results. "While the prophylactic administration of tetanus antitoxin has been generally effective, it has disadvantages. Anaphylactic reac tions of varying degrees of manifestation from mild urticaria and asthma to severe shock are among the conspicuous disadvantages. With the increasing use of immune sera (antitoxin) in this country in the active treatment of pneumonia, diphtheria, scarlet fever, erysipe las, gas gangrene and other infections, and in the prophylaxis against tetanus, any group of adults will include a considerable proportion of individuals who have, in the past, received for one condition or an other antitoxin prepared from horse serum. The subsequent admini- Proceedings of Med stration of antitoxin to those tion to constitutionally allergic "The protection produced b; toxin is very transient. Labo bodies transmitted in the an blood in four to not more than some patients with badly maci cially if they have not been cl tetanus, notwithstanding the been administered promptly af " Recent studies and actual injection of small amounts of of tetanus cultures previously the individual an active prot antitoxin in his own blood. T1 is greatly increased by one or "It has been demonstrated: 1. That under favorable immi of the blood is much liighei of 1,500 units of tetanus ai 2. Its formation is sufficient! dividual against tetanus if exhibited within the first i 3. That after a second or su toxin titer of the blood r several months or years, r the ease after prophylactic "The Army plans to limit t! .1. To patients presenting evil 2. To individuals who incur u sitate their protection aga ously completed the initial CONCLUSION "For application to raiirc tetanus by use of two or moi in the present state of mind ever, it would unquestionabl where exposure to condition: contamination may contact m "Toxoid immunization has or more--susceptibility to thi to tetanus toxin by the exhil In conclusion, your Committee valuable assistance rendered by t! the Medical Profession, and othe of this support and cooperation : as a Progress Report from a C endless. Respectfu CoMiin J. R. of American Railroads has compiled a short monograph entitle! cinch contains so much constructive : full: Its inclusion is justified for statistul he work which, has recently been aeeol mnization of individuals by the use $ inus are unreliable. However, reports u that they are consolidated from Stall United States Census and "United State! ths from tetanus were as follows: Deaths 1,503 1,377 1,437 1,489 1,360 1,287 1,116 1,119 1,253 1,226 1,057 1,088 930 930 Assumed eases baaed on average mortality rate 2,500 2,300 2,400 2,400 2,300 2,280 1,860 1,860 2,270 2,265 1,765 1,770 1,550 1,550 st serious complications of trauma a n || event which must be considered as r or penetrating wound, over 50%) that, unfortunately, expert!! tetanus statistics has developed, as aS ell as in military work, the administra-S tetanus antitoxin. '% nus by the use of tetanus toxoid is ini nies. In the French Army it is compul-J als reported some months ago that! given the immunization with entirely! ministration of tetanus antitoxin has as disadvantages. Anaphylactic reac-JR lanifestation from mild urticaria a n d * miong the conspicuous disadvantages. lune sera (antitoxin) in this country in mia, diphtheria, scarlet fever, erysipe- eetions, and in the prophylaxis against 11 include a considerable proportion of ast, received for one condition or an - horse serum. The subsequent adm ini- Proceedings of Medical and Surgical Section stration of antitoxin to those individuals and its initial administra tion to constitutionally allergic persons are attended with danger. "The protection produced by a prophylactic dose of tetanus anti toxin is very transient. Laboratory tests show the protective anti bodies transmitted in the antitoxin disappear from the patient's blood in four to not more than ten days. Because of this transiency, some patients with badly macerated and contaminated wounds, espe cially if they have not been cleared of foreign material, still develop tetanus, notwithstanding the fact that prophylactic antitoxin has been administered promptly after the injury. *.*Recent studies and actual experience have shown that parenteral injection of small amounts of tetanus toxoid; i.e., the broth filtrate of tetanus cultures previously detoxified with formalin, produce in tin' individual an active protective response by the production of antitoxin in his own blood. The antitoxin concentration of the blood is greatly increased by one or more subsequent injections of toxoid. ".It has been demonstrated: 1. That under favorable immunUogieal conditions the antitoxic titer of the blood is much higher than the customary prophylactic dose of 3,5t'0 units of tetanus antitoxin. 2. Its formation is sufficiently prompt to protect the wounded in dividual against tetanus if the readministration of the toxoid is exhibited within the first twenty-four hours. 3. That after a second or subsequent injection of toxoid the anti toxin titer of the blood remains relatively high for a period of several months or years, rather than for only a few days as is the case after prophylactic injection of antitoxin. "The Army plans to limit the use of tetanus antitoxin as follows: 1. To patients presenting evidence of clinical tetanus. 2. To individuals who incur wounds or other conditions which neces sitate their protection against tetanus, but who have not previ ously completed the initial vaccination with tetanus toxoid. CONCLUSION "For application to railroad employees, immunization against tetanus by use of two or more injections of toxoid is impracticable in the present state of mind toward preventative procedures. How ever, it would unquestionably be of value in special occupations where exposure to conditions where filth containing animal fecal contamination may contact minor or major wounds. "Toxoid immunization has the advantage of prolonged--one year or more--susceptibility to the immediate reactivation of antibodies to tetanus toxin by the exhibition of antibody stimulating toxoid." In conclusion, your Committee expresses its sincere appreciation of valuable assistance rendered by the member Lines, their Chief Surgeons, the Medical Profession, and others. TVe earnestly solicit a continuance of this support and cooperation and request that this be accepted only as a Progress R eport from a Com m ittee whose duties a re obviously endless. Respectfully submitted, Committee on D isability and R ehabilitation, J . R. Garner, M.D., Chairman. T 40 Association of American Railroads Proceedings of l J. R. G arner, M. D.: Mr. Chairman, Members of the Section, Guests: The Committee on Disability and Rehabilitation has continued its activities. This is one of the oldest committees in this Section, having been appointed, I think, at the '-st meeting and it has continued to function since then. Our report has been printed, and each of you has a copy. We are not going to read this report. It would be rather tiresome to you, probably, and we feel that just a brief synopsis of the report is all that is essential here, with some remarks from members of the committee and others on certain subjects embraced in it. The committee has had three meetings since the last session of the Section. A great deal of our work has been carried on through correspondence both with and by members of the committee and other members of the Section who have very graciously given us their support and aided in our efforts. The arrangement of the program is somewhat different from the arrangement of the report of the committee, so in carrying it out I am going to try to follow the program as nearly as I can, skipping about in this report. We have given a great deal of consideration to alcoholism in connection with employees of the railways in train and engine service. We are all familiar with a recent ruling and what it means, and some method of proving the presence of alcohol has been sought. We have asked Dr. Brandabur, a member of our committee nd Assistant Supervising Surgeon of the Chesapeake & Ohio Railway to present this part of our program. I believe Dr. Brandabur is not here at the moment; if he comes in later we will ask him to speak. If not, I will make mention of the fact that an examination of the urine shows the presence of alcohol as late as twelve hours after it has been imbibed. Of course, the closer the test to the taking of the alcohol, the larger your per centage of alcohol. We will pass this part of the report and come back to it later when Dr. Brandabur will present the subject. Chemotherapy is a subject that has been very much before us of late. The new drugs that have come out have been discussed by all of us and used by many of us, and we are very deeply interested in them. On page 6 of the report, where we have presented chemotherapy, is a little resume of Dr. Robert W. Johnson's statement in the Journal of Surgery in July, 1940. We merely call your attention to this. We think it is well worth knowing. There have been many changing concepts in the problem of chemo therapy, and on this subject we have asked Dr. C. A. Walker, of San Francisco, Chief Surgeon and Manager of the Hospital Department of the Southern Pacific Company and a member of our committee, to present this to you. Dr. Walker! CHANGING CONCEPTS IN CHEMOTHERAPY Dr. C. A. Walkeb (Southern Pacific Co.): Since sulfanilamide was dis covered, it has undergone many changes and modifications. These modifica tions have been brought about through chemical manipulation of the molecule, resulting in entirely different synthetic compounds which were given various names. The object in producing these changes in structure was to develop a product more toxic to infecting organisms and less toxic to the host. These new compounds varied in their effectiveness. These changes dir appear. Ending with the year 1940, tl parts of the world: Sulfaniiamid* mide), Sulfapyridine, Disulfanil: thiazole, Promine, Uleron, and o Disulfanilamides are used wic their effectiveness. They have i Sulfones have been too toxic for extensively at the Mayo Clinic a Wlsde it was effective for staphy too narrow for general rise. Pr disagreeable side reactions, parti from use, but it has been revived in England in 1938 and 1939 but Sulfanilamide and neoprontos. widely used but no new drugs har as these four. There are several new sulfona therapeutic agents. One of these have been along the line of determ drugs, as well as combining them bailee, their therapeutic effect. Sulfanilamide has been used w Given by mouth, it has been four It has been found effective in a ft ' .(`.urioruiily in meningococcus inti Bang's bacillus infections, urinary effect in typhoid iever. Sezary re in chancroid infections and certa results of local and systemic use > vmcingly told by H. R. Bohlinan, Many workers sprinkle the powe fragments of compound fractures a and wounds. If lightly used, it is f lu-aling, Cohen and Sehuienberg i shot wounds were treated at Dunki iy, combined with the Orr-Truetta of wounds there were no deaths, amputation. One of the reasons w locally is that is has a low toxicity believed that in certain concentra bacteriostatic. Sulfapyridine. The use of this dr past eight months, with a wider use part of the United States and in Cai and has been-used longer than here, of sulfapyridine. Many reports rev and the meningitides are more pro %;*<tz*><Mr .4 v i-j/viV u-'- w o f American Railroads Proceedings of Medical and Surgical Section 41 Chairman, Members of the Section, Gue tnd Rehabilitation has continued its activiti| ttees in this Section, having been appointed! it has continued to function since then, and each of you has a copy. We are not gojJF new com pounds varied in their toxicity, solubility and range of therapeutic effectiveness. These changes direct and limit our use of the new drugs as they appear. Ending with the year 1940, the following drugs have been used in various parts of the world: Sulfanilamide, Neosulfanilamide or neoprontosil (azosulfa- 3rather tiresome to you, probably, and we fe i report is all that is essential here, with son 3 committee and others on certain subjec mide), Sulfapyridine, Disulfanilamide, Sulfones, Sulfamethylthiazole, Sulfathiazole, Promine, Uleron, and others less known. Disulfanilamides are used widely in Germany but we have no reports on i heir effectiveness. They have never been used much in this country. The : meetings since the last session of the Sectioj| Sulfones have been too toxic for general use. Sulfamethylthiazole was used n carried on through correspondence both wit! extensively at the Mayo Clinic and other places when it was first introduced. ee and other members of the Section who 1 While it was effective for staphylococcal infections, its margin of safety was ipport and aided in our efforts, '.no narrow for general use. Promine was found (1939) to produce many im is somewhat different from the arrangemen| disagienable side reactions, particularly peripheral neuritis. It was dropped ;o in carrying it out I am going to try to follow rum use, but it has been revived lately for use again. Uleron was used widely skipping about in this report, u! England in 1938 and 1939 but was proved to be too toxic for general use. consideration to alcoholism in connection wit] in and engine service. We are all familiar wife is, and some method of proving the presence < Sulfanilamide and neoprontosil, sulfapyridine and sulfathiazolo are still widely used but no new drugs have been added recently to gain as wide favor ns these four. There are several new sulfonamides looming on the horizon as effective ir, a member of our committee nd Assistant apeake & Ohio Railway to present this part idabur is not here at the moment; if he coni' Iherapeutic agents. One of these is sulfaguanidine. The newer developments have been along the line of determining various methods of application of these drugs, as well as combining them with certain other drugs and agents to en hance their therapeutic effect. .he fact that an examination of the urine show) Sulfanilamide has been used widely for many different forms of infection. s twelve hours after it has been imbibed. __ Given by mouth, it has been found most effective in streptococcal infections, e taking of the alcohol, the larger your p e r 11 has been found effective in a few types of pneumococcus, gonococcus, and occasionally in meningococcus infections. It has been found effective against report and come back to it later when D r| BCt. it has been very much before us of late. The| lave been discussed by all of us and used byi ply interested in them, s we have presented chemotherapy, is a little on's statement in the Journal of Surgery in'; r attention to this. We think it is well worth f changing concepts in the problem of ehemo--? ave asked Dr. C. A. Walker, of San Francisco, the Hospital Department of the Southern* r of our committee, to present this to you.,; Hang's bacillus infections, urinary infections, and some workers claim beneficial effects in typhoid fever. Sezary reports that powdered sulfanilamide is specific in chancroid infections and certain tropical pyoderms and trachoma. The results of local and systemic use of the drug in gas gangrene infections is con vincingly told by H. R. Bohlman, of Johns Hopkins Hospital. Many workers sprinkle the powder into infected wounds or between the bone fragments of compound fractures and between the muscle layers of infected cuts and wounds. If lightly used, it is found to be non-irritating and does not delay healing. Cohen and Schulenberg reported in the British Lancet that 266 gun shot wounds were treated at Dunkirk by sulfanilamide, externally and internal ly, combined with the Orr-Truetta closed plaster method. Out of this number of wounds there were no deaths, no tetanus, no gas gangrene and only one amputation. One of the reasons why the drug is so effective when employed locally is that is has a low toxicity and a differential killing power. It is now IEPTS IN CHEMOTHERAPY believed that in certain concentrations it is actually bactericidal as well as bacteriostatic. Pacific Co.): Since sulfanilamide was disehanges and modifications. These modificarough chemical manipulation of the molecule, ithetic compounds which were given variousJ these changes in structure was to develop a ; lrganisms and less toxic to the host. These ] Sulfapyridine. The use of this drug on the West Coast has waned during the past eight months, with a wider use of sulfathiazole. However, in the Eastern part of the United States and in Canada and England where the drug originated and has been used longer than here, there has been a backward trend to the use of sulfapyridine. Many reports revealed that the responses in the pneumonias a n d the mehingitides are more prompt and lasting than with sulfathiazole. W % r*,_-w w <.w * * . ^ w .. , ' ^ a .;l -. , fc- -. /: -,.; ,,.. 42 Association of American Railroads Proceedings of Medical a Sulfathiazole is the most popular of the sulfonamide drugs. Its therapeutic effectiveness is said to include streptococci, staphylococci, pneumococci, gonococci and meningococci. It is more soluble than sulfapyridine and so a blood concentration is more rapidly obtained. It has gained great favor with the urologists in the treatment of gonococcal infections. Compared with sulfamethylthiazole it cured less cases of gonorrhea but was favored in the long run for its lesser toxicity. (Mahoney-Van Slyke. Am. J. of Syphilis and Gon. 24:613, 1940) . A new drug to come to our attention lately is sulfaguanidine. This drug is not vet reported on extensively but is said to be effective in partial sterilization of the colon. It is said by workers at Stanford University Hospital to reduce the intestinal bacterial counts to ten per cent of the normal count. Its greatest drawback is its great insolubility and, such being the case, enormous doses must be given to be effective. Combinations of certain drugs with physiological substances to enhance their action has been accomplished by Osgood, of the University of Oregon. The reports have not yet appeared in the literature extensively but the method has been to put a solution of sulfapyridine into a quantity of the patient's own blood. This mixture is then used in a prolonged lavage of the antra of Highmore. Results are said to be surprisingly good even in chronic cases. Osgood has also combined sulfonamide drugs with arsenicals in the same patient. The sulfonamide drug is given by mouth in full dosage and, when a blood concen tration has been reached, the patient is given neoarsphenamine intravenously. The combined effect of this therapy is said to be effective against the staphylococcus in furunculosis and other affections. (Osgood, Surg. Gyn. and Obs. 71:445-450, 1940). (Osgood, J. Pediat. 17:740-746). In discussing the use of physically induced pyrexia and chemotherapy, Bierman and Baebr in conclusion state, "Our experience would indicate that physically induced pyrexia enhances the value of chemotherapy in the treat ment of subacute bacterial endocarditis." (Bierman and Baehr, J. A. M. A., 116:292, 1941). . In discussing sulfanilamide in the therapy of actinomycosis, Dobson, Holman and Cutting in conclusion state, "Three eases of actinomycosis, one of the jaw, one of the lungs and rib cage, and one of the abdomen, have been apparently completely cured. Therapy included the use of sulfanilamide, iodides and roentgen rays. In view of the serious nature of this infection and the apparent value of sulfanilamide, this or a related drug should be included in the treat ment of actinomycosis." (Dobson, Holman and Cutting, J. A. M. A., 116:272, 1941) . In an article on the treatment of septicemia, results before and since the advent of sulfamido compounds, Herrell and Brown call attention to adequate versus inadequate treatment. "We believe at present that the most significant feature in recovery is the adequacy of treatment. We mean by adequate treatment that a patient has received one or several of the sulfamido drugs in dosages which would produce concentrations in the blood stream which we feel are indicated for treatment of septicemia and that the treatment has been con tinued over a period sufficient to account for the clinical response." (Herrell and Brown, J. A. M. A., 116:179, 1941). It follows that adequate treatment is indicated in all cases where sulfonamide drugs are used, for it may be that unless the drug is administered adequately at the outset, the bacteria may become "fast" and may become resistant to even an increased amount of the drug given later on. In discussing sulfonamide inhibitors Stanford University, says, "It is currently feller Institute for Medical Research, th contain active or potential chemical f therapeutic effects of sulfonamide drugs, blood serum and sterile human pleural p usually free from sulfonamide inhibitor, arthritic fluids thus far tested have shov patently, in normal tissues the inhibitoi jugated form from which it is freed by a This chemically bound inhibitor is, appai nipidly freed in active form in autolysing tissue degeneration. It was only after ci extract and bacteriophage had proved dis or cellular inhibitors were suspected a therefore, may tend to prevent unwarri commercial claims for the new sulfonai California and Western Medicine, 54:105 REFEREE 1. Jensen, Nelson Surgery, 6:1, July 19c 2. Sezary. (1939) Presse Med. 47:1408, 3. Key and Lembeek. Industr. Med. 9: 4. Brieker and Graham. (1939) J. Am5. Herrell and Brown. (1940) Proc. Stafl 6. Spind and Paine. (1940) Minn. Med 7. MacKenna. (1940) Brit. Med. J. 2:9 8. Cosgrove. (1940) Arner. J. of Oph. 2 9. Rein and Tibbets (1939) J.A.M.A. 1 10. Mahoney and Wolcott and Van Sly Ven. Disease, 24:613, 1940. 11. MacLeod, Colin M.; J. Exp. Med. Dr. Gabaer: Our next subject is one so forth- ns treated with potassium salts our investigation on page 2, giving the p: ltubm on the subject, and then our coma road: " 1. One carrier surgeon has exhib oases of hay fever and allergic asthm: "2. The results have been uniform "3. The cases treated and observe modate. themselves to allergy tests a extracts. "4. In all, there was decided relief of pollen exposure and in several tht severe to negligible. "5. Potassium chloride properly ex hay fever and allergic asthma." 1his is the subject that was called to tl we have tried to develop something for yc .'L/.-trt' y&w&s&x;.. xt+mw* 44 Association of American Railroads Proceedings of Medical The next subject that we take up is shown on page 28, Dental Diseases. Under the date of October 31, 1940, our Committee sent out to Chief Surgeons of member lines, a questionnaire asking the incidence of dental disease, caries and periodontal infections among railway employes, seeking experience as to the effect resulting from these conditions. Forty-seven replies to the questionnaire were received. A compilation of the answers to the first question showed that of all cases reported, 19.4 per cent had some form of dental disease. The answers to question No. 2 were so varied and covered so many disabili ties attributed directly or indirectly to dental disease, that it would be im possible to tabulate same in this report. All railroads reporting have noted the detrimental effect produced by dental diseases upon the general health of the employes. It is recommended that closerattention bepaid to the condition of employes' teeth, and that proper dental care be urged in every case where disease or defects are noted. Our next subject is that of Diabetes. We call attention to an article which we have published, beginning on page 29, which was an address delivered by Dr. W. H. Olmsted, of St. Louis. It is quite interesting and has a great deal of instructive data. We ask you to read that. We are not going to read it now. Then, the use of insulin in diabetes, on page 30, is also something that we want to call to your attention, and we suggest your careful study of it without presentation at this time. Our conclusions are on page 31: "When an employe of a railroad occupies a position where his judgment, his senses, and his neuro-muscular control must be normal in all respects and at all times, he should not suffer from diabetes mellitus. If employes are allowed to hold hazardous positions providing they do not take insulin, such a policy in my opinion will result in such diabetics being badly treated. "If the employe knows he lias diabetes, he will postpone taking insulin as long as possible, often to his own detriment. If on the other hand, a rule is maintained that once the diagnosis of diabetes is established, an employe is transferred from a hazardous job to some other position, then there is no reason why his diabetes cannot be treated with insulin if such is needed. "There is no doubt in my mind that diabetics in non-hazardous jobs can be depended upon, even if they take insulin, to do work with customary efficiency." That is not the opinion or, rather, the conclusion of the Committee, but of Dr. Marble in Joslin's book. We think that it is very well worded, and good information is contained therein. Our next subject, Foci of Infection, is a very important one in connection with the work of railroads, and we have Dr. R. A. Woolsey, Chief Surgeon of the St. Louis-San Francisco Railway, also a member of this Committee, to present the subject to you. Dr. Woolsey 1 Dr. R. A. W oolses (St. Louis-San Francisco Railway): Mr. Chairman, Gentlemen: This subject is written up in this report, and I do not know that there is very much additional to be said. We have always figured that in the child, the tonsils were the real focus of infection of ear troubles. In grown people, the teeth, and when the doctor figured that 19.4 per cent of focal infections in the teeth were found in railway employes, I think that is about half as high a percentage as it should be. There are many employes whose teetl: look at all of them, you would find, I beli listed for infected teeth. If the thing is studied carefully, in th satisfactory you will frequently find, if i there are infections even though they are Hayden worked this up some years age where nothing was shown by examinatio In a careful study of the foci of infect more arthritic changes, and so forth, in t place in the body, and of course this has Some of the sulfathiazole preparations tirnt may be of benefit. In fact, there may be of benefit. We found quite a m conditions were different in Bulgaria th: was found that this was because of the cattle in Bulgaria. So that Bulgarian b Acidophilus is a little better, and in usi better result if you put some sugar of mill I do not think there is anything more hut I want to make it clear that the colon in the adult. D r. G arner: Thank you, Dr. Wools Dr. Woolsey called a very important colon; it is very frequently overlooked. Our next subject is hernia. The Com hernia, but we feel that we want to stre to - and not an accident in--industrial important subject to bear in mind and L tins condition. As long as we have railn plaining of hernia. Mart-Failure in Connection with Accii 19-10 report, a study was made of twente l.C.C, within a period of sixty days in those accidents were found to have been d remaining sixteen were attributable to sc m fifteen deaths and one hundred and fifi .Since that report, a total of seventy reports of investigated accidents show thi causes, and sixty-oue were directly trac The nine accidents due to unavoidable one hundred and sixty injuries, whereas si resulted in two hundred and eleven deat lcrsonal injuries;, Your attention is again directed to the r by the Association of American Railroad quite some years ago: i! II merican Railroads Proceedings o/ Medical and Surgical Section 45 is shown on page 28, Dental Dise r Committee sent out to Chief Surge g the incidence of dental disease, carl my employes, seeking experience a s| ns. ' ire were received. A compilation of t rat of all cases reported, 19.4 per ;o varied and covered so many disabil|| >dental disease, that it would be ii All railroads reporting have noted tt liseases upon the general health of tl n be paid to the condition of employes'! urged in every ease where disease o| We call attention to an article whicl 19, which was an address delivered by| uite interesting and has a great deal of! rat. We are not going to read it nowJj m page 30, is also something that we re suggest your careful study of it; There are many employes whose teeth you never look at, but if you were to look at all of them, you would find, I believe, a percentage twice as high as that listed for infected teeth. If the thing is studied carefully, in the average mouth where the teeth look satiaiuetory you will frequently find, if the teeth are examined carefully, that there are infections even though they are not shown by X-ray. Hayden worked this up some years ago and found infections among the teeth where nothing was shown by examination, X-ray or otherwise. In a careful study of the foci of infection, it is found that they really cause more urthriiie changes, and so forth, in the adult, in the colon, than any other place in (.he body, and of course this has to be treated accordingly. Mmie of the sulfathiazole preparations may be of benefit, and there are diets (hut may be of benefit. In fact, there are a good many different things that nie v be of benefit. We found quite a number of years ago that the intestinal eonditions were different in Bulgaria than any place else in the world, and it Hun found that this was because of the bacillus that was in the milk of the enitle in Bulgarin. So that Bulgarian buttermilk is quite frequently given. Acidophilus is a little b etter, an d in using them you will get four or five tim es beU cr result if you put. som e su g ar of m ilk in th e b u tterm ilk . It is more active. i do not think there is anything more to be said about the foci of infection, but 1 want to make it clear that the colon is really "tops" in the foci of infection ien an employe of a railroad occupied , and his neuro-muscular control mustf ss, he should not suffer from diabetes! d hazardous positions providing they* opinion will result in such diabetics| 4 is, he will postpone taking insulin ass ient. If on the other hand, a rule is | iabetes is established, an employe isJj other position, then there is no reason | nsulin if such is needed, abeties in non-hazardous jobs can be ; uliu, to do work with customary! conclusion of the Committee, but of I hat it is very well worded, and good ; a very important one in connection j )r. R. A. Woolsey, Chief Surgeon of j|j o a member of this Committee, to ; ancisco Railway): Mr. Chairman,; this report, and I do not know t h a t : in th e adult. Dn. G ar.v e h : Thank you, Dr. Woolsey! Dr. Woolsey called a very important topic to your attention--that is, the colon; it is very frequently overlooked. Our next subject is hernia. The Committee has developed nothing new in hernia, but we feel that we want to stress the point that hernia is incidental to--and not an accident in--industrial occupations. We feel that is a very important subject to bear in mind and to consider at all times in dealing with this condition. As long as we have railroads, we are going to have men com plaining of hernia. Man-Failure in Connection with Accidents we have again studied. In the 19-10 report, a study was made of twenty train accidents investigated by the i.C.C. within a period of sixty days immediately preceding. Only four of these accidents were found to have been due to unpreventable causes, while the remaining sixteen were attributable to some form of man-failure and resulted in fifteen deaths and one hundred and fifty personal injuries. Since that report, a total of seventy train accidents studied from I.C.C. reports of investigated accidents show that only nine were due to unavoidable causes, and sixty-one were directly traceable to some form of man-failure. The nine accidents due to unavoidable causes resulted in four deaths and one hundred and sixty injuries, whereas sixty-one accidents due to man-failure resulted in two hundred and eleven deaths and eight hundred and thirty-six d, the tonsils were the real focus of le, the teeth, and when the doctor: s in the teeth were found in railway h a percentage as it should be. personal injuries. Your attention is again directed to the recommendation wluch was approved by the Association of American Railroads as recommended standard practice quite some years ago: 46 Association of American Railroads "Whenever investigation of any train or train service accident indicates man-failure as a causative factor--such as disregard of signal indication; disregard of or misinterpretation of train orders or rules--and suggests an impaired physical condition as a contributing cause of the failure, a medical examination directed by the company of the employe or employes so involved is recommended." Your Committee cannot too strongly urge adoption of this recommendation by all member Lines, feeling confident that such adoption will undoubtedly lead to a great reduction in the number of accidents, the elimination of much pain and suffering, as well as preserving many lives. You Committee was also asked to consider Disqualifying Ocular Defects. Disqualifying ocular defects among employes in train and engine service, particularly the latter, has been given much consideration. Such defects may arise as to render the employe absolutely unfit for the class of work in which he has been engaged, and the inability of the railroads to transfer such men from one craft to another operates against the possibility of placing them at work which they could do. The subject of overweight was discussed by your Committee, and we have given you a brief r6sum6 of our work this year. We call your attention to it on page 36. The subject of Pneumonoconosis is also referred to. We have nothing new to present on this subject. Your Chairman attended a meeting of the Air Hygiene Foundation of America where this subject was discussed at length but found nothing of particular interest to railroads at this time. Rehabilitation is discussed on page 37. The technical structural inhibitions of applicants for rehabilitation measures and policies in railroad occupations has been given consideration. It is felt that this subject will require much detailed investigation. The subject is presented at this time in hopes that it will stimulate discussion and suggestions from the Chief Surgeons of member Lines. The old subject of Syphilis has been with us and will be through time im memorial. It is very important. We have nothing particular to present at this time; there is nothing new that has been developed. We feel that prob ably the most important thing that we could present is the oral administration of the bismuth preparations, which now seems to be growing in favor with the profession. Then we come to the subject of Tetanus, and this is one that we have asked Dr. J. D. Collins, Chief Surgeon of Seaboard Air Line Railway, Norfolk, Virginia, also a member of our Committee, to handle for us. Dr. Collins! THE PREVENTION OF TETANUS; THE USE OF TOXOID Db. J. D. Collins (Seaboard Air Line Railway): We are often confronted with a problem in trying to decide whether or not it is necessary to use tetanus antitoxin following certain wounds. Especially has this been so in minor or so-called trivial injuries. This hesitation is the result of the fear of possible anaphylactic reaction, shock or serum sickness. In past years when unrefined horse serum was used there was obviously real grounds for this fear, but, with our purified products today, greatly reduced volume, tests for sensitivity and the use of epinephrine, this fear is much decreased. On the other hand we should not administer serum without testing for sensitivity. Although one should be cautious, he should not do so to the extent of neglecting entirely the Proceedingi administration of serum bee will not develop. If not adr until the period of incubatk mediate reaction there is a serum is obviously warram destruction. We frequently see wounds toxin and yet they may cause and electrical burns, effects o. and even pin pricks or slight more than 70 per cent of the in an additional G per cent injuries may and do occur of: a problem in tetanus prevent with increasing sensitivity an these wounds may not be rej tetanus may develop. Certain individuals becau: tetanus infection. Frequent! of a physician because of the cattlemen, poultrymen, teat frequent occurrence of the di contaminated with tetanus s body and arc extremely resit pathogenic bacteria. There received have a known high i: service; also those engaged i make repeated injections of railroad and industrial wor problem because they are pr< Most tetanus, as it is see; anses from wounds which a often the mother are not cot reported by Dietrich* there infection might be blamed, wounds, and blisters were all concluded that !,000 unitsap t,f>00 units of tetanus antito: compound fracture, as he foui was a compound fracture at seen, all developed tetanus a Another problem we are ft too late to administer serum rum is delayed. It may be antitoxin efficacy occurs whe blood serum. This takes pla oils administration of tetam 0,1 to 0.25 unit per cc. of blot it gradually declines to a ievi accepted that the period of in days, and the severity is dire