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FILE NAME: Railroads (RR) DATE: 1966 Feb DOC#: RR015 DOCUMENT DESCRIPTION: Conference Proceedings - Medical and Surgical Officers 46th Membership Meeting - Association of American Railroads rSUREAU V. -F ^ A r? V PROCEEDINGS ' MEDICAL AND SURGICAL OFFICERS FORTY-SIXTH MEMBERSHIP MEETING FEBRUARY 23, 24 AND 25, 1966 SHERATON-PALACE HOTEL SAN FRANCISCO, CALIFORNIA ASSOCIATION OF ' MERICAN RAILROADS 4 TABLE OF CONTENTS t i Page O f f ic e r s ........................... 5 C om m ittee P e r s o n n e l............................................................................. 5 C all to O r d e r ............................................................................................. 9 C hairm an's M e ssa g e - E. C. O lso n , M. D ..................................... 9 * A ddress - W illiam J a e k l e ..................................................................... 11 1. A ddress - Rodney R. B e a r d , M. D . ................................................. 16 Panel Sym posium - C a rd io p u lm on a ry P r o b l e m s ..................... 27 J-anei Sym posium - N e u r o p sy c h ia tr ie P r o b l e m s ..................... 57 j; A ddress - Grant M orrow , M. D ............................................................. 81 Report of C o m m ittee on M e d ic a l S t a n d a r d s ................................. 85 Summary of Interim M eetings: C a rd io v a scu la r S u rg ery - M in n e a p o lis, M inn.................... 91 H earin g - D e n v e r , C o lo ra d o ......................................................... 100 V isio n - C h ica g o , I l l i n o i s ............................................................. 102 Panel S ym p osiu m - N o i s e ......................................................................... 105 ii i A d d ress - J . A. R is e n d a l......................................................................... 131 t1 Report of M edical* L e g a l C o m m i t t e e ................................................. 140 f: R eport o f C o m m ittee on N o m in a t io n s ................................................. 163 Panel Sym posium - Return to W ork of E m p loyees With or F o l- f ' low in g M ajor D i s a b i l i t i e s ................................................................. 165 3 l jwgijpiwuyajifgiipi"). i, . n ya .,.n p n i!,|J-ijl-'M I>l -W" '"r" OFFICERS AND COMMITTEES 1965-1966 E rn est C. O lson , M. D. , Chairm an John R. W inston, M. D. , V ice-C hairm an W. E. Todd, Staff Secretary MEDICAL AND SURGICAL ADVISORY COMMITTEE (T erm s exp ire 1966) Stanley J. Cyran, M. D. , M edical D irecto r, Pennsylvania R ailroad, 474 T hirtieth S treet Station Bldg. , Philadelphia, Pennsylvania 19104 R. M. G raham , M. D. , D ir e c to r , D epartm ent of M edicine and Sani tation, The Pullm an Company, 165 North Canal Street, Chicago, Illinois 60606 Southgate L eig h , Jr. , M. D . , C h ie f S u rg eo n , S eab oard A ir L ine R a il road, P. O. Box 1620, R ichm ond, V irginia 23213 H arvey N e ls o n , M. D. , M ed ica l A d v iso r , Soo L ine R a ilro a d , 805 M edical A rts Bldg. , M inneapolis, M innesota 55402 V. M. Strange, M. D. , C hief Surgeon, Southern P a c ific Company, H ospital D epartm ent, 1400 F e ll S treet, San F ra n cisco , C alifor nia 94117 (T erm s exp ire 1967) M. B. C la y to n , M. D . , C h ie f S u rg eo n , S outhern R a ilw a y S y ste m , 15th & K S treets, N .W . , W ashington, D. C. , 20013 V. W. H ollo, M. D. , C hief Surgeon, St. L ou is-S an F ra n cisco R a il way, 4960 L aclede A venue, St. L ouis, M issou ri 63108 J. W. Houk, M. D. , M ed ica l D ir e c to r , N o rfo lk & W e ste r n R ailw ay, Roanoke, V irginia 24011 W. E. M ish ler, M. D. , C hief Surgeon, E rie-L ackaw anna R ailroad, 608 Republic Bldg. , C leveland, Ohio 44115 P e te r V aughan, M. D. , C h ie f M e d ic a l O ffic e r , C anadian N ational R ailw ays, P. O. Box 810 0, M ontreal, Q uebec, Canada (T erm s exp ire 1968) Isadore Kaplan, M. D. , M edical and Surgical D irecto r, M edical D e p a r tm e n t, B a ltim o r e & O hio R a ilro a d and B a ltim o r e &. Ohio C hicago T erm in al Company, B a ltim o re, M aryland 21201 E. C. O lson, M. D. , C hief Surgeon, Illin ois Central R ailroad, 5800 Stony Island A venue, C hicago, Illin ois 60637 B. W. S tockw ell, M. D. , C hief Surgeon, D etroit & T oledo Shore Line R ailroad & Grand Trunk W estern R ailroad, 1229-39 David W hit ney B ld g ., 1553 Woodward A venue, D etroit, M ichigan 48226 5 La G. E a rle W ight, M. D. , C hief of M edical S e r v ic e s, Canadian P acific R ailw ay, W indsor Station, M ontreal, Q uebec, Canada. John R. W in ston , M. D . , S y ste m M ed ica l D ir e c to r , A tc h iso n , Topeka & Santa F e R ailw ay, 80 E a st J a c k so n B lvd. , C h ic a g o , Illin o is 60604 MEDICAL-LEGAL COMMITTEE Isad ore Kaplan, M. D. (CHAIRMAN), M ed ical and S u rg ica l D irecto r, M edical D epartm ent, B altim ore & Ohio R ailroad, B altim ore, M aryland 21201 M ilton B . C layton , M. D. , C h ie f S u rg eo n , S outhern R a ilw a y S y stem , P. O. Box 1808, W ashington, D. C. 20013 G e o r g e E. D im ond, M. D. , N ew Y ork C en tra l R a ilr o a d , 861 M onroe B lv d ., D earborn, M ichigan 48184 E . A . H am ilto n , M. D. , C h ief S u rg eo n , New Y ork C e n tr a l S y ste m , LaSalle Street Station, C hicago, Illinois 60605 V . W . H o llo , M. D. , C h ief S u r g e o n , St. L o u is-S a n F r a n c is c o R a il way, 4960 Laclede A venue, St. L ouis, M issouri 63108 Southgate L eigh , Jr. , M. D. , C h ief Surgeon, Seaboard A ir Line R ail road, P. O. Box 1620, R ichm ond, V irginia 23213 F rank W. M ahoney, M. D. , M ed ical D ir e c to r , C en tral R ailroad Com pany of New Jersey , Foot o f Johnston Avenue, J er se y C ity, New Jersey 07302 W. E. M ish ler, M. D . , C hief Surgeon, E rie-L ack aw an n a R ailroad, 608 Republic Bldg. , C leveland, Ohio 44115 J. S. N ile s , J r ., M. D ., C h ief Surgeon, L ehigh V a lley R ailroad, Sayre, Pennsylvania 18840 B . W. Stockw ell, M. D . , C hief Surgeon, D etro it & T oled o Shore Line R ailroad , Grand Trunk W estern R ailroad , 1229-39 D avid Whitney B ld g ., 1553 Woodward A venue, D etroit, M ichigan 48226 V . M. S tra n g e, M. D. , C h ie f S u rg eo n , S ou th ern P a c if ic C om pany, 1400 F e ll Street, San F ra n cisco , C alifornia 94117 J. R. W inston, M. D. , S ystem M ed ical D ir e c to r , A tch iso n , Topeka & Santa F e R a ilw a y , 80 E a s t J a c k so n B lv d . , C h ic a g o , Illin o is 60604 COMMITTEE ON TRAUMA Southgate L eigh, Jr. , M. D. (CHAIRMAN), C hief Surgeon, Seaboard A ir Line R ailroad, P . O. Box 1620, Richm ond, V irginia 23213 C. M. B en age, M. D ., R egion al M ed ical D ir e c to r , N orfolk & W estern Railway - W estern R egion, Railway Exchange Bldg. , St. L ouis, M issouri 63101 C. E. Boyd, M. D. , C hief Surgeon, L ou isian a & A rk an sas R ailw ay, 6815 Southern Avenue, Shreveport, L ouisiana 71101 W. J. L on gew ay, M. D . , C h ie f S u rg eo n , C o lorad o & S ou th ern R ailw ay, 520 M etropolitan Bldg. , D en ver, C olorado 80202 6 n. w. R. IS: A. H. R. P Chest* K Stanle Munte 1 H. W. 6 f. John S P W. J. Stan ' R. J H. \ J. V J. I Is at Rol Ha: Oh:i'f of M edical S e r v ic e s , Canadian P a c ific j*;,,;i, M ontreal, Q uebec, Canada. Sv>U-m M edical D irecto r, A tch ison , Topeka oil E ast Jack son B lvd. , C h icago, Illin o is CAL-LEGAL COMMITTEE HAIHMANA, M ed ical and S u rg ica l D ir e c to r , B altim ore & Ohio R ailroad, B altim ore, , C hief Surgeon, Southern Railway System , diington, D. C. 20013 , New York C entral R ailroad , 861 -Monroe chigan 4 8184 :hief Surgeon, New York C entral System , , C hicago, Illinois 60605 f Surgeon, St. L ouis-San F ra n cisco R aile-nue, St. L o u is, M isso u r i 63108 ). , C hief Surgeon, Seaboard A ir Line R ail, Richmond, V irginia 23213 , M edical D irector, C entral R ailroad Com'oot o f Johnston A venue, J e r s e y C ity , New ief Surgeon, Erie-Lackaw anna R ailroad, ieveland, Ohio 44115 hief Surgeon, Lehigh V alley R ailroad, 3840 hief Surgeon, D etroit & T oledo Shore Line : W estern R ailroad, 1229-39 David Whitney Avenue, D etroit, M ichigan 48226 ef Surgeon, Southern P acific Company, 'r a n c is c o , C a lifo rn ia 94117 em M edical D irecto r, A tchison, Topeka East Jackson Blvd. , Chicago, Illinois UTTEE ON TRAUMA (CHAIRMAN), C hief Surgeon, Seaboard J. Box 1620, R ichm ond, V irginia 23213 anal M edical D irector, Norfolk & W estern on. R ailw ay Exchange Bldg. , St. L o u is, irgeon, Louisiana & Arkansas Railway, Ihreveport, Louisiana 71101 iff Surgeon, Colorado & Southern Railway, D enver, C olorado 80202 6 fi. IV. S t o c k w e l l , M. D . , C h ie f S u rgeon , D e tr o it & T o le d o Sh ore Line R a il r o a d , Grand Trunk W estern R ailroad , 1229-39 D avid Whitnev B ld g ., 1553 Woodward A venue, D etro it, M ichigan 18226 A. H. Win te r s , M. D. , C h ief S u rgeon , P ittsb u r g h & W est V irg in ia R ailw ay, M ansfield A ven u e, P. O. Box 4 440, P ittsb u rg h , Pennsylvania 15205 C h ester R. A e is s , M .D . , C hief Surgeon, E lg in , J o lie t & E astern Railway, 208 South L aSalle S treet, C hicago, Illin o is 60604 COM M ITTEE ON FIRST AID Stanley J. Cyran, M .D . (CHAIRMAN), M edical D ir e c to r , P en n sy l vania R ailroad, 474 T hirtieth Street Station Bldg. , Philadelphia, Pennsylvania 19104 Hunter A. C a u se y , M. D. , C h ief S u rgeon , St. L o u is-S o u th w e ste r n Railway, c /o S t . Louis Southwestern H ospital, Texarkana, Arkansas 75501 H. W. H am m att, M. D. , C h ief M ed ica l O f f ic e r , C h ic a g o , B u rlin gton &. Q uincy R a ilro a d , 547 W est J a ck so n B lv d . , C h ic a g o , Illin o is 60606 John S. N ile s , M .D . , C h ief Surgeon, L ehigh V a lley R a ilro a d , S ayre, Pennsylvania 18840 COMMITTEE ON MEDICAL STANDARDS W. J. L on gew ay, M .D . (CHAIRM AN), C h ie f S u rg eo n , C olorad o & Southern R ailw ay, 520 M etropolitan Bldg. , D en v er, C olorado 80202 Stanley J. Cyran, M .D . , M edical D irecto r, P en n sylvan ia R ailroad, 474 30th Street Station, Philadelphia, P ennsylvania 19104 R. M. G raham , M. D. , D ir e c to r , D ep a rtm en t of M ed icin e and S an i tation , The P ullm an C om pany, 165 North C anal S tr e e t, C hicago, Illinois 60606 H. W. H am m att, M. D. , C h ief M edical O ffic e r , C h icago, B urlington ti Quincy R ailroad, 547 W est Jackson Blvd. , C hicago, Illinois 60606 J. W. Houk, M .D . , M edical D ir e c to r , N orfolk & W estern R ailw ay, Roanoke, Virginia 24011 J. M. L. Jen sen , M . D . , C h ief Surgeon, C h icago, R ock Island & P acific R ailroad, LaSalle Street Station, C hicago, Illin ois 60605 isa d o re Kaplan, M. D. , M edical and S u rgical D ir e c to r , B a ltim o re & O iio R ailroad , B altim ore & Ohio C hicago T erm in a l R ailroad, M edical D epartm ent, B altim ore, M aryland 21201 R olan d s. K ieffer, M. D. , M edical D irector, M issou ri-K an sas-T exas R ailroad, 420 Gim blin Road, St. L ouis, M issou ri 63147 Harvey N elson , M .D . , M edical A d visor, Soo L ine R a ilro a d , 805 M edical A rts Bldg. , M inneapolis, M innesota 55402 7 A bbott S k in n e r , M. D. , C h ie f M e d ic a l O f f i c e r , G r e a t N o r th e r n R a il way, 1350 Dowry M edical A rts Bldg. , St. P a u l, M innesota 55102 J a m e s K. StacK, U . D. , C h i e f S u r g e o n , C h i c a g o &. N o r t h W e s t e r n Railway, 127 North Clinton S tre e t, C h icag o , Illinois 50505 P e t e r V a u g h a n , .M. D. , C h ie f .Medical O f f i c e r , C a n a d i a n N a tio n a l R a ilw a y s, P. O. Box 3100, -Montreal 3, Q u e b e c , C anada J. R. W inston, M . D . , System Medical D ire c to r, A tchison, Topeka & S a n ta F e R a il w a y , SO E a s t J a c k s o n Blvd. , C h i c a g o , I llin o is 60S 04 t 8 | r tim e, environm ent, contact with com m unicable diseasd eg cn era tiv e and c h r o n ic d is e a s e s ten d s io r e d u c e the it follow s that the m ed ica l departm ent is often regarc Iir y , b eca u se it m ay su g g e s t r e m o v a l o f th e s e in d ivid u al e for the good of a ll concerned. tn our s o c ia l a ttitu d e s and c u sto m s e x e r t a d ecid ed p r a c tic e o f m e d ic in e and p a r tic u la r ly in it s lia b ility ar.c 1 a s p e c ts . M e d ic a l o p in io n s and a ctio n s p er ta in in g to subject to a c lo s e r scru tin y and contention; the respon; -aiiroads for the health o f its em p loyees has a lso underable change. A ggravation o f p re-ex istin g functional Brnditions is c o m p e n s ib le w ithout p a r tic u la r r e g a r d to th; the origin al condition. D eath o ccu rrin g on the job is ion tiie com pany w ithout m uch r e g a r d for the n a tu ral i g or the p ro g ress o f d egen erative d ise a se s. T he repr; pleads to have an em p lo y ee w ith a given d isa b ility ark w ill freq u en tly b la m e th e com pany fo r a c c e d in g to any untoward resu lt en su es. The courts take the ocial cu stom s dem and a v erd ict in favor o f the employ; :rise and p articu larly r a ilr o a d s a r e held in creasin gly r the em ployee and h is health and w elfare. Iis the r o le o f the m e d ic a l d ep artm en t o f th e ra ilro a d ? the p rosp ective em p loyee insofar as h is p h ysical atbuild, stren gth , sta m in a and endurance m ust be a sedical exam iner. H is psychological m ake-up, lity, m aturity and su itab ility for the position sought which he m ay reasonably be expected to advance, fully weighed. Since one m ust assum e that once ablished, the individual m ay very likely make r a ilarious p hases h is life work, it follow s that any in- a r e lik e ly to h an d icap h im in th e fu tu re and w h ich can :h so m e d e g r e e o f c e r ta in ty , sh ou ld b e a s ig n a l to cien cies against the sp ecia l capabilities of the in needs of the company. seen that the m ed ica l group is in a p ositio n to r c ise great influence in the se le c tio n o f the p e r oad and act as an effective b a rrier to the unqualile. ms another im portant function; nam ely that o f ealth o f the em p loyee, the safety and w elfare o f nd the public, and fu lfillin g its obligation to the efficien t and sa fe p erform an ce. It can ad vise antinued em ploym ent m ight endanger a ll concerned. 10 >r,;tu of con ten tio n s to the c o n tr a r y , it can and d o e s furnish ,, : m . im p a rtia l o p in io n s r e g a r d in g the d e g r e e o f d is a b ility as a resu lt of injury and the ability and sa fety of the em ... uj return to h is job. [ ...n su re that the p r o fe ssio n is keenly aw are of it s p o sitio n in . ._:al and eco n om ic sch em e and its o b lig a tio n s to the em p lo y ee, u .h c and the c o m p a n y . It d oes, not want on ly o r c a p r ic io u s ly K, deprive anyone o f an opportunity to earn a liv in g . iorious thought and d e lib e r a tio n a r e g iv e n to any situ a tio n w here a question is involved. O u r efforts to prom ote our rela tio n s with m an agem en t, to con. c u r aim s and d e sir e s to be of the g rea test p o ssib le a ssista n c e , ' . r.iinually a p p r a ise our p o sitio n , to keep a b r e a s t o f the ch an ges , pr o g r e ss in our p r o fe s s io n , and to apply th em ju d ic io u sly in the ...(jet of our w ork , have b een our e a r n e s t a m b itio n . Our lin e s of niv.unication may not alw ays have b een as open a s they should have _n, but we have b een try in g to expand our sp h e r e o f a c tiv ity in the ' irro o f m ore freq u en t m e e tin g s and d is c u s s io n s on s u b je c ts o f c u r rent in terest and im portance in ra ilro a d m ed icin e to the end that r.vose whom we s e r v e w ill p r o fit by it. We are p resenting at th is our 1966 Annual M eeting a program of varied subjects such as panel sy m p o sia , rep o rts o f a c tiv itie s and suggestions of the standing c o m m ittees, a d isc o u r se o r two and an ddress by the A ssista n t V ice P resid en t o f the Southern P a c ific Company, Mr. W illiam Jaekle. I want to acknow ledge our debt and gratitude to D r. Vance Strange, Chief Surgeon of the Southern P a cific Com pany, for the tune and effort he h as expended in secu rin g m ost o f the p articipants in our p an els to g e th e r w ith our sp e a k e r s . It is now m y p le a s u r e to in tro d u ce to you M r. W illia m J a e k le , A ssistant Vice P resident of O perations, Southern P a cific Company, who has g r a c io u sly c o n se n te d to a d d r e ss u s on a t im e ly su b ject. Mr. Jaekle. (A pplause.) ADDRESS; W illiam J a ek le, A ssista n t V ice P r e sid e n t O p erations, Southern P a cific Company Thank you. D r. O lson. M edical and Surgical O ffice rs of the A ssociation o f A m erican R ailroads: When D r. O lson opened the 11 . -t -- m eetin g , it rem inded m e o f the new church w hich w as r e cen tly built in Orinda. You rem em b er D r. O lson sa id , "Won't you p le a se m ove up n? If W ell, we have th is new congregational church that was built supposedly with a capacity of about fiv e hundred. When the con grega tion w alked in the fir s t Sunday to s e e it, w e ll, lo and beh old , th e r e 's only pew s for about fifteen or twenty right at the v ery back. The people scra m b led in those fifteen pew s and sa t th e r e , and suddenly the pew s m oved ahead. Som e cam e up out of the flo o r , and ju st kept m oving right on up. So, of cou rse, everybody that w as in the back fin ally ended up in the front. Our m in ister stood th ere, and he was alw ays given thirty minutes to make a serm o n . He w as a little bit long that Sunday, so at the end of th irty-on e m in u tes, the little y e llo w light cam e on, and pretty soon a red light cam e on, and he disappeared. So I hope, D r. O lson, if I overrun my fifteen m inutes that you haven't got m e w ired for the escape hatch. (L aughter.) You w ill note by your program that Mr. L am precht, Southern P a cific's V ice P resid en t of O perations, was scheduled to speak here. Y esterday m orning, Mr. R u ssell, our C hairm an, Mr. Biaggini, our P resid en t, decided they w ere going to m ake a tour o f the Rock Island p ro p erties. T h is has been scheduled for two days subsequently, but they decided to se t it up 48 hours, so Mr, L am precht turned arounc and said , " B ill, h ere are my notes. " So that is why I am substituting, and it's r e a lly a p lea su re to be here. I have Mr. L am p rech t's notes and I have done my b e st to work them over. M r. L a m p rech t w r o te b r ie f ly , "I a p p r e c ia te th e op p ortu n ity o f w elcom ing you to San F ra n cisco , Southern P a c ific 's headquarters city . I know you have very serio u s m atters on your agenda, and I am confident your stay here w ill be fruitful from that standpoint. H opefully you and your lad ies w ill a lso have at le a st som e o p portunity to s e e and enjoy so m e of the attraction s o f our city and som e o f the many points of in terest that surround it. I understand it's been tw elve y ea rs sin ce you last cam e here for your m eeting. P lea se make the m ost of this v isit. " I am su re you w ill. We intend to change the w eather a little bit for you tom orrow . It's going to be clea r and shiny both Thursday and Friday. I got that on the b a sis of our w eather man that fo re- 12 today's clear w eather. (L aughter.) "On the b a s is of m y own e x p e r ie n c e , both as an o ff ic e r of jibern P acific and of the O perating-T ransportation D ivision of the V\R, 1 look upon you r a ilr o a d p h y sicia n s and su rgeon s a s one of hardest w orking, m o st dedicated groups in our industry. "The m edical p ro fessio n and the railroad industry share alm ost a century of the c lo s e st cooperation. Even before the first tran s continental r a il lin e w as co m p leted , and w hile the p ion eer b u ild ers >i the C en tra l P a c if ic , S o u th ern P a c if ic 's p r e d e c e s s o r , w ere s t ill ngaged in the m o n u m en ta l ta sk o f b u ild in g the lin e o v e r the S ie r r a Nevada M ountains, they had organized a m ed ical departm ent, the ::rst of any railroad . And in 1858 they estab lish ed their own h o s pital, probably the fir s t in d u stria l h o sp ita l anyw here in the w orld. Shortly th ereafter estab lish m en t of m ed ical departm ents becam e general throughout the railroad industry. "In th o s e e a r ly d a y s when th e r e w e r e no o th er p u b lic health organizations, th e se railroad m ed ica l people took on a m ajor p io n eer ing resp o n sib ility in the w hole field of public health se r v ic e . Out of their c lo se relation sh ip with the railroad s cam e many significant benefits extending to the whole of humanity. "For exam ple, resea rch of our own m edical staff w as directly responsible for the erad ication o f typhus and typhoid fever. T here has been a steady flow o f new knowledge and new techniques from the continuing r e se a r c h a c tiv itie s in railroad h ospitals throughout the country. "T here h a s a lso been a tradition from the sta rt, and it has been general throughout the railroad industry, of choosing the outstanding physicians and surgeons for their m edical sta ffs. T hese m en, b e cause o f th eir high c a lib e r , have been the nucleus around which m edical s o c ie tie s have com e into being, including the A m erican C ollege of Surgeons founded in 1913. "As your p rofession and our industry have matured together, there has been a continuing m utual high regard and c lo se collab ora tion tow ard the m ajor o b jective o f providing the best p ossib le health protection for railroad w orkers. "Much has b een done by both p arties to make our railroad s a safer, healthier place to work. "On your p a rt, you have developed for us sta n d a rd s of em p lo y ment which have done m uch to elim inate at the sou rce many of those w hose p h y sica l d e fic ie n c ie s would be hazardous both to th em selv es 13 . j u f a t e M&&*'**'' w . ^ ^ i i a A V t ------ and to their fellow w orkers. The req u irem en t of including back X -r a y s has had ex ten siv e p r a c tic a l b en efits in excluding many of th o s e not q u a lified to m eet the p h y s ic a l d em a n d s of o u r s e r v ic e and a s a p r o te c tio n to us a g a in st fa ls e p e r s o n a l in ju ry c la im s . "A lm ost im m ediately, when a person b ecom es an em p loyee, we sta r t build in g up a su b stan tial in v estm en t in h is train in g and the v a rio u s frin ge b en efits to which he b e c o m e s en titled . So, in addition to a ll hum anitarian co n sid era tio n s, it is im portant that we keep him h ea lth y and a b le to p e r fo r m h is d u tie s e ff ic ie n tly , so that our g ro w ing investm ent need not be w asted. F or th is, of co u rse, we look constantly to you. " S ta tistics show th ere has been g reat p r o g r e s s in cutting down the average hospital stay. T his is due partly to the le s s e r severityof injuries. " I can speak from rather personal exp erience, too. Dr. Strange, one o f the C hief Surgeons, Operated on me a few w eeks ago for a h ern ia and V ance and D r. N ew berg ca m e in a fter about six ty hours and sa id , "It's tim e for you to go hom e. " So th ey bundled m e up and se n t m e h o m e . So at th e Southern P a cific H ospital they have done quite a job in cutting down the average hospital stay. "But, m o stly , it is due to the advan ces in m ed ica l sc ie n c e and the treatm en t and handling o f patients that you have brought into p la y . "On our part, beyond our n ever-en d in g p rogram to train our people to work sa fely , we continue to striv e to im prove that part of our technology which w ill prom ote the health and safety of our people on the j ob. s "The m odern coupler has long sin c e rep laced the old link and pin which was so great a hazard to the hands and arm s o f sw itchm en o f the old d ays. The firem an no lo n g er p erch es p reca rio u sly on top o f the ten d er to take on fuel and w a te r, thanks to the advent of the d ie s e l, so that we have far few er of the extrem ely disabling type of fallin g accident involving h eel and spinal fractu res. By the sam e token, the d ie s e ls with th eir dynam ic braking have elim inated the need for brakem en to decorate the tops of m oving freight ca rs to se t up reta in ers. The d iesels have also cut down on the hazards of slack action in long freight train s. 1 "The tech n ical revolution which has transform ed alm ost every 4 d eta il o f railroad in g in the p ast 15 y e a r s h a s, in fact, had a tr e m endous e ffe c t in im proving the sa fety o f ra ilr o a d w orking condi- 14 j .ns. Radio com m unication betw een engine and ca b o o se and betw een urlri and way s ta tio n s , c e n tr a liz e d tr a ffic c o n tr o l w hich cuts down ,,... need for brakem en to throw sw itch es by hand, hot box indica..,r < which give the crew and the d isp atch er an indication of o v er-t-ated jo u rn a ls and le t s th em g iv e prom pt a tten tio n to avoid d e r a il m ents, the in tricate m achines which take m ost of the sw eat and ih vsical strain out of m aintenance of way, autom atic classification v a rd s--a ll th ese and alm ost every other m odern developm ent we ra ve made have contributed in so m e way to cutting down the chances for accid en ts and in ju ries. "On Sou th ern P a c ific our r e p o r ta b le in ju r ie s dropped 20%, fro m 8.66 per m illio n m an hours in 1961 to 6. 93 in 1964, and 1965 w ill show a further im provem ent w hen the final fig u res a re in. On th is b a sis, together with the few er m an-hours it now tak es to run a r a il ro a d , one m ight reasonably expect our b ill for injury cla im s to follow the sa m e d eclin in g pattern. "Unfortunately, this has not been the ca se. The trend of juries continues to be toward making fan tastically high aw ards, som etim es where even the b asic m erits o f the claim seem highly doubtful. "So, instead of declining, our cost of settlin g cla im s has con tinued on a high plateau. C laim s se ttle m e n ts for C la ss I railroad s continue to run around $100 m illio n a y ea r. F or Southern P acific alone th ese cla im s run around $7. 5 m illio n , a fact with which I am intim ately fam iliar, sin ce the charge is against operating ex pense. "Thus, w hile between u s, I feel great p rogress has been made in the m a tter o f red u cin g the in sta n c e s and e ffe c ts o f p erso n a l in juries, we s till face a very seriou s problem from a claim s cost standpoint. In th is situ ation , m y own con cern extends beyond the fundamental m atter of keeping our people healthy to a consideration of keeping our railroad healthy, also . "You have b een m ost helpful in giving exp ert testim ony and, o f cou rse, in the very im portant m atter o f getting the em ployee back into s e r v ic e a s quickly as p o ssib le . You have m ade independent studies and you have worked very c lo sely with general claim s depart m ents of the railroad to se e how our exp erience in this field com pares with the experience o f oth er ind u stries. ''B eyond t h i s , y o u a r e lo o k in g ah ead to th e o v e r c o m in g o f new hazards that m ay a rise to rep lace som e of the old ones we have overcom e, as our technology continues to change. The effects of exposure to d etergen ts, ga ses and fu m es, acid s and so lv en ts, ir ra d ia tio n , and s o forth , a r e p o s s ib ilit ie s vve h ave to c o n sid e r and 15 } % -i p repare for. I note that one of the discussions you have scheduled for your m eeting is a panel on noise, indicating the ever-expanding scope of subjects to which you a re d irectin g y o u r attention. "lit closing, I w ish to ex p ress my p e rso n a l ap p reciatio n for all you have done and confess I cannot suggest what m o re you can do to help us solve our continuing problem s of high claim s costs. Never th e le ss, because you a re in a position to o b se rv e this problem so closely from o u r own vantage point, I do want to ask that you con tinue to be aw a re of it and to include it in y o u r thinking as individuals and in your deliberations as a group. I can ask no m o re than that, " Mr. Lamprecht wrote. P erso n ally , I have enjoyed substituting for M r. L am precht, and I want to extend my very best wishes for a m ost successful meeting. D r. Olson, and my best w ishes to you all h e re . (A pplause.) CHAIRMAN OLSON: We a re delighted to h e a r what M r. Jaekle has ju st said. We a re glad to know that ra ilro a d s a re so w ell acquainted with our problem s, and I am sure that attitudes of this so rt will be highly productive in our efforts. We do thank y ou , M r. J a ek le, v e r y m uch. We now have an ad d ress by D r. Rodney R. B eard . You w ill note in your program s that he was d esignated in a certa in m anner, and th is is in e r r o r . I w ish to c o r r e c t it by sa y in g to you that he is the P ro fesso r of Preventive M edicine of the Stanford U niversity School of M edicine, and he is going to talk to u s th is m orning on the r o le o f in d u stria l h ygiene in the railroad in d u stry. We are glad to w elcom e him . D r. B eard. (A p p lau se.) ADDRESS: R odney R. B e a r d , M. D. , P r o f e s s o r o f P r e v e n tiv e M edi cin e, Stanford U niversity School of M edicine Thank you, D r. Olson. I am v ery much honored to be speaking to you gen tlem en th is m orning. It isn 't often that I have the opportunity to talk to a group o f p eop le who have such a w ealth of ex p erien ce and background and know ledge on which to build a d iscu ssion . Xam the son of a railroad man, a train man for aw hile. He had se n s e enough to get out of that fairly soon and b ecom e a station agent and a railroad telegrapher, and he serv ed a long tim e w ith the Southern P acific Company, having recurrent gallbladder p rob lem s, h e w as a patient o f Dr. C offey's and had s e v e r a l e x p e r ie n c e s with the Southern P a c ific H ospital. They didn't get the p a tien ts out in I tvo and a h a lf d ays back in th e 1 9 2 0 's , h o w ev er. ti- Dad warned m e that he would disow n m e if I e v e r went to work for a ra ilro a d , s o , with that kind of en couragem ent I got into m ed icine. But not very long after I com pleted my m ed ical school train ing and so m e grad u ate w ork in the fie ld of public h e a lth , I found m yself back in the tran sp ortation b u sin e ss, b ecau se Pan A m erican Airways had a little p rob lem o f d iarrh eal d is e a se out on Wake Island, and they w anted so m e o n e to go and m ake a sa n ita r y s u r v e y and find out what the p r o b le m w a s. It w a s v e r y s im p le . T h ey w e r e drinking t their sew age and the people in the station knew it p erfectly well. They had told the people in the hom e office what w as the m atter but, you know, it tak es a v isitin g expert to make the lo ca l boys look good and get th e ir m e s s a g e a c r o s s . I w as su ch a s u c c e s s w ith th is that I soon becam e a p a rt-tim e perm anent em ployee o f the airlin e, and for the next ten y e a r s I had so m e of the p lea su res that are fam iliar to you gentlem en w ith prim a donna crew m em b ers, and w ith outlying station s w here th ere are few d octors and no h o sp ita ls , and with prob lem s of finding d ecen t food and clean w ater for the c r e w s and for the E | people who r id e th e lin e . V D espite this introduction to aviation, I s till have rem ained a l railroad buff, and tra v el by train when sch ed u les p erm it, p refer ably in a ca b o o se. But it would b e fa ls e for m e to c la im firsthand knowledge o f sp e c ia l health problem s o f the railroad operation s. To b e fa ir , th ere ought to be a co-au th or liste d on the p ro g ra m , and this would be M r. A. C. A rcham bault o f the Southern P a cific C om pany, who has given m e p reviou sly and recen tly a good d eal of in form ation about railroad operations. Industrial h ygiene is a field w ith considerable breadth o f activity. One can define it v e r y gen erally as the detection and co n tro l of in dustrial health hazards. F o r p u rp oses o f d etectin g h ealth h a za rd s, in m y ea r ly days in this field , I spent at le a st 10 per cent of my tim e ob servin g men at work in the sh o p s, in the o ffic e s and on the lin e. D irect p erson al observation o f th is kind ju st can't be bettered for givin g a doctor an understanding o f w orking con d ition s, the p h ysical req u irem en ts, and the dan gers which a re m e t by h is patients. The inquiring eye and nose w ill find out a ll so rts of strange things. Going through a shop you notice a stran ge but fa m ilia r odor and r e a lize that it's carbon tetrach lorid e, and knowing the hazards of this m a teria l, you trace it down and find that it's being used for cleaning spark pLugs, and h ere is a man soak in g spark plugs in an open pan o f carbon tet right under h is n ose. You are lucky if he isn 't an alcoh olic and if he can su rvive th is kind o f an exp osu re. x Th en, in another place, going about with your eyes open, you see bags of chemicals labeled potassium nitrate, and stored close by a re som e glass containers of co n cen trated acid. T his you might find in the neighborhood of a plating shop; it is co nvenient to have these things there. They are going to be used close by and where else would you store them ? T his would be all right, except for the fact that you know what happens if you put co ncentrated acid on s a ltp e te r. It w ill blow up. This is another of the things that just an open eye can detect. I recall thethorny-handed brake repairm an whose hands just looked m iserable. His explanation of this was that the brakes had sh a rp edges and his hands got cut. "W ell, couldn't he w ear gloves?" "No, he couldn't w ear gloves because he had to rely on a sense of touch in o rd e r to c a rry out his o p eratio n p ro p erly . " Of co u rse he couldn't feel anything with the heavy' calluses that he had on his hands anyway, and he might have done much b etter to put on gloves, but it was not easy to convince him of that. We find th ese bad things as we go around our work p la ces. We talk w ith the people who are concerned, talk with the people on the s job, and frequently w e can find an accep tab le way by which they can avoid injury and d isea se. This is o b servation , it's the detection of h azard s. A fter this com es the invention o f a solution which w ill be accep tab le and which w ill provide p rotection . T h is is industrial h ygiene. Any thoughtful, observant, w ell-tra in e d p hysician can p ra ctice it. T here are a few sp e c ia l points to be learn ed , p articu larly about the treatm ent of the prob lem s which one d isco v ers. T h e fir s t p rin cip le is to ask if the dan gerou s m a te r ia l cannot be r e p la c e d o r the u n sa fe p r a c tic e d isc o n tin u e d . It m a y not be e a s y to find s o m e th in g w hich w ill take the p la c e o f th e m a t e r ia l w hich is in u se and which w ill do the job a s w ell or n early as w ell, but I'm a lso .r-J encouraged when I start doing th is, b eca u se I rem em b er the exam p les o f s u c c e s s . We have su cceed ed in d isp la cin g carbon tetra ch lo rid e a s a so lv en t in industry, and in d isp la cin g that e x trem ely u sefu l and extrem ely dangerous solvent benzol. T h ese agents have alm ost com p letely vanished from A m erican industry and w here they are u s e d , th ey a r e u se d w ith v e r y c a r e fu l c o n tr o ls . It c a u se d so m e in con ven ien ce to do th is, and m aybe it r a ise d the op eratin g c o sts a little , but the in creased co st was m ore than outw eighed by the sa v in g in w orkm en's com pensation e x p e n se s and p a rticu la rly by the saving of liv es. 18 '! 1 i r. u < to r. The second p rin cip le is , if you can 't get rid of the b ea st, put it i Many hazardous op eration s like the m achining o f b e r y ll- ... b '-ryilium a llo y s can be m ade sa fe by to ta lly e n c lo s in g and . _,ni/.r .g tin; p r o c e d u r e . If you can 't do that, a s a third lin e o f .fCt.'jn, you can d ilu te and d is p la c e the d a n g ero u s m a te r ia l by ,.. ,,; ttt!on, p r e fe r a b ly c a r r y in g m a te r ia l out by a c lo s e d duct to a , ;c puint o f d is c h a r g e . F inally, if no other way is fea sib le, one can r eso rt to personal . r,iu-ctive d ev ices, such as gloves or resp ira to rs or ear plugs. Ih.ese usually are the ch eap est and th ere is a great tem ptation to .,,e them , bu t, w hen yo u do, th e r e is a g rea t r is k in v o lv e d , b e c a u se v ,j put too m uch r e lia n c e upon the human factor, that is , the e le ment of the w illin g n ess of the w orker to u se the p rotective d ev ice, jrsd on the m e c h a n ic a l b a r r ie r s w hich a r e too o ften fa llib le . I am sure you have a ll seen in stan ces w here rubber gloves extended to provide p rotection again st som e co r r o siv e m aterial got h oles in iem and soon sim p ly b ecam e containers which kept the irritant m aterial in contact w ith the skin. V ery few of us are w illin g to bear the burden o f w ea rin g a r e sp ir a to r for hours on end; th is is un pleasant, and the im p ed im en t to breathing is not a ccep tab le. I don't think it's e v e r rea so n a b le to pick up a re sp ir a to r as the answ er to a toxic gas prob lem o r a noxious dust; it's only tem porary. Any o f u s can p r a c tic e in d u stria l h ygien e, but we have to learn the lim its o f ou r a b ilit ie s . It w ill q uickly b eco m e evident that we need m easu rem en ts o f noxious vap ors, m ists, and dusts in the area, and an a n a ly s is o f m ix tu res o f ch em ica ls w hich are encountered, As ph ysician s, we m ay lead the way to acceptable solutions o f r e l atively sim p le p ro b lem s, but in terest and ingenuity are not enough to so lv e the m o re se v e r e p rob lem s. T hey are not enough to a ssu re the design o f an e ffectiv e, efficien t ventilating sy stem for a large shop, nor fo r the con trol of noxious m ists from a plating tank. H ere the p r o fe ssio n a l in d u strial h y g ien ist step s in. An in d u stria l h ygien ist is sk illed in the collection of sa m p les, he is fa m ilia r w ith the num erous instrum ents which are available to m e a su r e to x ic m a te r ia ls in the work p la c e , and he knows how to interpret the r e su lts. He knows when to take a sam ple to the lab o ratory fo r a n a ly s is by the e m issio n sp ectrograp h , for exam p le, and he knows when to take another sam ple to the laboratory for analysis by a long path in frared sp ectrom eter. He is fam iliar with all o f these availab le r e so u r c e s; he a lso has the sk ill to design suitable guards, en clo su res and ventilating sy stem s. The industrial hygienist may com e from any of a number of backgrounds; ch em istry and biology are fairly com m on exam ples, but m ost com m only he w ill have taken a college engineering course. 19 U M U H IJ T )_> l II, I m < | H II T o th is he adds a y e a r o r two of g raduate school w ork in one of the dozen schools which give advanced train in g in this field. His g raduate studies include toxicology, an introduction to occupational d isease, pathology and symptomatology, bio statistics, epidemiolog. and ad m in istratio n . However, his main concentration is on getting the special skills for the detection, evaluation and control of en v iro n m en tal h azard s to health. If he h a s unusual talent and en ergy, he m ay go on to e a rn a d o cto rate in science. T h e re a re great opportunities for c a re e r s in r e s e a rc h and teaching in this rapidly expanding field of industrial hygiene. The railro ad industry has long recognized its multitude of prob le m s r e la te d to health. It is an in teg rated in d u s try in the s e n s e that it c a r r i e s out all p h a se s of the a c tiv itie s which go into t r a n s p o r t a ti o n , w h ic h is its f i n a l p r o d u c t . It b u ild s th e r o a d s , c o n s t r u c t s the c a r s , paints the stations, even c a te rs food for its p a sse n g e rs. Although engine building and c ar building of new equipm ent a re done by independent co m p an ies and new ro ad b ed s a re c o n s tru c te d by independent contractors, the maintenance of the railro ad and its equipm ent involve the o perating com panies in nearly every task known to the basic m an u factu rers; thus, the ra ilro a d em ployee is exposed to nearly every kind of occupational hazard known to man. A quick scanning of the m ed ical jo u rn a ls in the p a s t five y e a r s re v e a ls v ery few publications in the United States re la tin g to the health of railroad employees or the industrial hygiene problem s encountered in railroading. By co n trast, incidentally, th e re a re about a dozen titles for each y e a r in the R ussian lite r a tu r e . Ap p a re n tly they a r e getting around 10 building som e r a i lr o a d s and operating them , perhaps on the scale that was c h aracteristic of o u r own c o u n t r y 50 y e a r s ago. I think the r e a s o n we d o n 't h a v e m o r e publications in the United States about ra ilro a d occupational disease is b ecau se of the m aturity of the p rofession in this field and the fact that th ese things a re not unique to ra ilro a d s but co v er the whole breadth of industry. One valuable report recently published is by one o f your c o l le a g u e s , liste d in tom orrow 's p rogram , D r. Isadore Kaplan of B altim ore. He has a paper of a couple of y ea rs ago in the A rchives of D erm atology which rep orts an excellen t ep id em iological study o f occupational skin d isea se. As you m ust be aw are, the derm atoses co n stitu tes m ore than half the number of c a se s of occupational d is e a s e , and th ey also contribute v ery h ea v ily to the d isa b ility caused by occupations. Kaplan o b serv ed that the m ajority of th ese c a s e s o ccu rred in the o p e r a tin g d e p a rtm en t, m a in ly in the m a in ten a n ce sh o p s . C ontact 20 , :n so lv e n ts , o ils and g r e a s e s w e r e fo r e m o s t c a u s e s , w ith c h r o , e exp osu res due to a n tico rro siv e com pounds in engine coolin g ter next. 1 know you a re going to have a much m ore d etailed sc u ssio n o f o c c u p a tio n a l d e r m a t o s e s , so I w ill d w e ll no m o r e on h*l but go on to s o m e o f th e o th er th in g s lik e ly to b e en co u n tered . Many o f you w ill have in your shops vapor d e g r e a se r s w hich ,st. ch lorin ated s o lv e n ts , w h ich p r o p e r ly u se d a re s a f e , but im p r o perly used can cau se liv e r and kidney dam age. Im proper u se m eans mat the d e g r e a se r s get too hot, and, in p a rticu la r, that the cooling coils around the top of them are not operated cold enough, and so the vapor g e ts aw ay fr o m the d e g r e a s e r and sp r e a d s around the hop. Nand vr sary tmetal pco;;^ hhops and -';. infretp Sr. la rr/f becau exper and a citns sma'.: this if 'A'i ing v tion.s soh-i Whine . the US ! Nowadays every shop m ust have a good bit of w elding going on, and w elding fu m e s w ill c o n stitu te a r is k . 1 don't su p p o se it 's n e c e s sary to m ention to anyone h ere the problem o f w elding fum e fev er, metal fume fev er, which we have encountered so frequently when people use w elding to rch es o r a r c s on galvanized m etal. Railroad shops often have foundries a sso cia ted with them w here h eat, fum es and s i li c a d u st a r e e n c o u n te r e d . P la tin g o p e r a tio n s a r e a ls o not infrequent. S m all plating shops a r e , in m y v iew , m ore dangerous than large on es. A big plating shop alm ost has to be operated sa fely because the people who are involved in the work are su fficien tly expert, the su ppliers of m aterials ca ll attention to the hazards, and a large operation w ill com e to the attention o f the State agen c ie s which endorse safety regulations. D angers are m ore likely to a rise from the operation o f a sm all plating plant w here som e forem an has thought, "You know, this would be a good id ea, we could sa v e a lot of tim e and trouble if we would just plate th ese bolts and nuts o u r se lv e s instead o f send ing them o u t," or som ething o f th is so rt. T h ese am ateur opera tions a re, of co u rse, the ones m ost likely to cause trouble. You s t ill have a good b it of lead in railw ay sh op s, used in the so ld erin g o f r a d ia to r s, and in the rep a ir o f sto ra g e b a tte r ie s. W herever lead c e ll storage b atteries are handled, a lead hazard is inevitable. I understand that typesetting is now pretty w ell out of the railroad industry, though th is m ay s t ill p e r sist in a few p laces as a source of lead poisoning. N oise has been m entioned already this m orning, and you w ill have m ore attention to th is later today, so I w ill skip over that. 21 We have two relatively new and relatively se rio u s p ro b lem s; one of th ese is the use of epoxy r e s m s . I think in the h e a v ie r in d u s t r i e s , and I think of r a i l r o a d i n g a s am o n g th e s e , the use o? epoxy r e s i n s h as not b ecom e so w id esp read as it has in the a i r craft and the m issile building industries, but I think you are bound to com e to it, b ecau se the epoxy re sin s a re so highly sa tisfa c to ry m aterials for so many things. When reinforced with glass fibers or other m aterials, they make strong light stru ctu res. Epoxy resin s are quite rem ark ab le adhesives for sticking together pieces of metal o r even causing glass pieces to adhere to each other. You will find in c re asin g use of this extrem ely valuable m aterial. T h ese a re substances for which I am afraid we will be a long w hile in finding a su itab le su b s titu te , m uch as we would like to have one. The reaso n for wanting to substitute som ething else for the epoxies is that they are notoriously troublesom e as sen sitizers. Alm ost all of the troubles are skin troubles, though other possibili t i e s h a v e t o b e c o n s i d e r e d . 1 h a v e not e n c o u n t e r e d a c a s e ex a s y s tem ic sen sitizatio n re la te d to the handling of the epoxy re s in s o r the c a ta ly sts, which a re used with them , but I think this is a th e o re tic a l possib ility which has to be kept in mind always. The skin trouble a lo n e is s u f f ic ie n t to k e e p you q uite b u s y , h o w e v e r , a n o t h e r new' m ate ria l which is not quite so hazardous but which we nave to watch with ca re is polyurethane foams. These are m aterials which are extruded through a nozzle, the resin s and the am ine ac c e le ra to rs being m ixed together in this way and the resultant foam being de posited as an insulator against heat and shock. The stuff is used at a te m p e r a t u r e of about 80 d e g re e s F a h re n h e it, and p ro b le m s of h e a t m ay be encountered. A lso, the te m p e ra tu re is such as to vaporize som e of the m aterials in these polyurethane foam s and pulmonary irritation may result from this. The safe way of handling this is by supplied-air re s p ira to rs , or a very effective dilution system of ventilation. T hese foam s are being used as insulators for refrig erato r ca rs, and for a variety of o th e r situations in which heat insulation and also so m e padding against mechanical shock is desirable. Finally we m ust look at our old friend, the painting problem . W hile lead paints a re no longer in use, the synthetic re s in s which have re p la c e d them may in som e instances be se n sitiz in g agents. The biggest problem a rise s from the solvents which a re used for these m odern paints. Most of the solvents are not severely poison ous. They a re , for the m ost part, anesthetic agents and local i r rita n ts. O ne h a s to keep clo se w atch on what is b ein g used. One of the difficulties is that the advances in the paint industry a re very 22 ;.c ; a 11A! abit ' miiii': thcv f bein'. Wilk ;ntt' See, of th. mo vi whic: rr.tr- task A SO to th firs' slip': it's ity t Now engi rapid and new m a te r ia ls a re com ing along a ll the tim e. Y ou have be on your to e s to keep up w ith what the la te st one is. I have a lso in part o f m y c a r e e r worked a s a con su ltan t in the paint industry and I can te ll you that you m ust not put too much r e liance upon the w arning la b e ls w hich th eir products c a r r y . A s in a good many other situ a tio n s, ihe attitude of the paint industry is , "Let's play it sa fe , " so they lab el everything as if it w ere very hazardous. T he fact that you know in a good m any in s ta n c e s that you have breathed th ese vap ors and they haven't caused any trouble causes one to lo se faith in the w hole warning la b el sy ste m . I want to sa y a w ord about the future in the to x ico lo g y field and the ro le of the in d u stria l h y g ie n ist in connection w ith th is. 1 think that within the next ten y e a r s or s o , we are going to look in different ways for the e ffects o f to x ic agen ts. T his is the field of ou r own r e search at Stanford, so I suppose I am som ething of an enthusiast. We a r e look in g fo r w a y s to m e a s u r e the b e h a v io r a l m a n ife sta tio n s which r e su lt from ex p o su re to toxic agents. We have u sed as our typical toxic agent carbon m onoxide. T his is one with w hich c er tainly a ll of you are fa m ilia r, but m ainly as it produces sym ptom s of headache, lethergy and nausea. At our laboratory we have been able to d em on strate e ffe c ts on behavior with a hundred p a rts per m illion within a p erio d of 30 m in u tes. T h ese e ffe c ts a re subtle and they cau se no sym ptom s. We do th is in ra ts by train in g them to p erform on a standard behavior pattern, using techniques of modern beh avioral psychology. With th e s e tech n iq u es w e can o b se r v e m inor ch a n g es in th e behavior p attern . In a n im a ls e x p o se d to o n e hundred p a r ts p e r m illio n , we s e e , within half an hour, d istin ct d eterioration o f p erform an ce. One o f the in t e r e s tin g th in g s `i s th at w ith in a h a lf an h ou r th e y a r e r e moved from the exp osu re, they are back up to norm al perform ance, which su g g ests that carbon m onoxide is acting d irectly and not m erely as an asphyxiant. In g e n e r a l, w hat w e h a v e done i s s im p le . F o r m e n , w e h ave a task which in v o lv es the discrim in ation of duration o f different sounds. A 5 0-cycle ton e, w hich is a low pitched buzzing sound, is delivered to the su b ject through earp h on es. He h ears two p resen tation s; the first is one second in duration and the next is sligh tly longer, or 6lightly sh o rter, o r it m ay be the sam e. He has to d ecide whether it's the sam e, longer or sh orter. Within an hour at a hundred p a rts a m illio n o f CO a m an's ab il ity to d iscrim in ate betw een the durations is percep tib ly dim inished. Now, I don't know how se r io u s th is is . D oes th is m ean that the engineer who is gettin g so m e CO in the cab begins to lo s e som e of 23 ,1 i - * ;1 4 'i his ju d g m e n t? Is he not so sh a rp at d e te c tin g s i g n a l s ? j J On the face of it, one would suspect that he is le s s capable of p e rfo rm in g his exacting job, but we have a g re a t deal m o re to do before we can say how much of a h azard this c a u s e s , how much weight we should put on th is, and p lease don't think th at I a m about to recom m end that we change the threshold lim it value to som e still low er value. We a re going to have a lot m o re in fo rm atio n before we do anything so bold as that. I think th is kind of study is going to go on w ith r e s p e c t to a lot of toxic a g en ts and in many different fields of a c tiv ity , so that you will have the inform ation available to yon to say how long a man can be exposed to a certain concentration of a toxic agent in the a ir , and what so rt of p erfo rm an ce decrem ent you may expect as a re s u lt of v arious d e g re e s of exposure. We a re also going to le a rn m o re about how th ese things act. This is the basis of in d u stria l hygiene, know ledge about how things act, what the toxic effects a r e , and in the use of skilled p e rs o n n e l, sp e c ia lists who know how to m e a s u r e and how to control the toxic agent. I think you will find yourselves using these sk illed people m ore as tim e goes by, because they constitute an im portant part of the - occupational health team. The industrial hygienist does not work by him self, he w orks with the doctor, with the n u rs e , with the safety d irecto r, with the personnel m anager. T hose a re the people th a t I s e e as th e key e le m e n ts in m aintaining o c c u p a tio n a l health. Each of them has an im portant role to play and they have to work to g eth er as a team if they a re going to get good re s u lts . T hey call upon o th er sp e c ia lists from tim e to tim e, p sy ch o lo g ists, sp e c ia lists in speech and hearing problem s, noise sp ecialists, people who are sp e c ia lists in radiation hazard s. But the fundam ental te a m is the physician, the nurse, the industrial hygienist, the safety director i and the p e rs o n n e l d ir e c to r , to see that things a r e done with due re g a rd for protection of human life, but not only that, for pro tection of human efficiency. Thank you very much. (Applause.) CHAIRMAN OLSON: Thank you very much. Dr. B eard . I am su re q that we have found this presentation to be intensely interesting. I 1.f see that we have about ten minutes, and it occurs to m e that som e of you might want to ask Dr. Beard som e questions about his work. DR. MILTON B. CLAYTON (Southern Railway System , Washington, D. C . ): D r. B e a rd , w ill the inhalation e ith e r of a s h o r t o r o v e r a lo n g e r p e rio d of tim e of p o lyurethane fum es c a u s e a s e n s itiv ity in an individual to the extent that he cannot go into an a tm o sp h e re w here -1 24 < r exam ple, there is sm ok in g or inhalation o f other kinds of fu m es? Jm l , w ill the in h a la tio n o f p o ly u reth a n e fu m es c a u se lung dam age . hr extent that y ou w ill h a v e im p a ir m e n t o r d is a b ility o r p erm a n en t ability ? t. We have an id e n tic a l c a s e o f that kind now who is th rea ten in g ! i sue us. That is the rea so n I am asking the question. t l BEARD: On the b a sis of p revious experience with sim ila r m aterials, I would exp ect that polyurethane foam s, esp ecia lly the accelerators w hich a r e u sed w ith th em , could be s e n s it iz e r s , in some proportion o f the population. A s y et, I don't know whether ;i,t v are frequently going to s e n s itiz e people lik e so m e o f the epoxy m aterials or whether they w ill only be occasion al se n sitiz e r s. But f 1 should say that th is is on e in stan ce w here I would be in clin ed to acc e p t the ad hoc ergo p rop ter hoc doctrine. If a m an had such an exposure and subsequently show ed sen sitization to the m aterial, I would say t h i s is a r e a s o n a b le e x p e c ta tio n . I d on 't know about the permanently d isab lin g e ffe c ts. Save that question for Corwin Hin- -haw. I know he i s h e r e . CHAIRMAN OLSON: A n yon e e l s e ? y The question that you proposed about noise has not been d is cussed in our group u n til la s t y e a r . I b eliev e th ere h as been som e reluctance on the part o f m anagem ent to get into this field , prin cipally b ecau se they fea red that they would have the sa m e kind of experience as they did in the d erm atology field , which lea d s m e to this question: D o es th e p r e se n c e o f the in d u strial h y g ien ist in the % plant provoke c la im s o n th e p a rt o f the e m p lo y e e s b e c a u s e of w hat he is investigating? r k DR. BEARD: T h a t's a v e r y d iffic u lt q u estio n . On th e b a s is o f e x perience, my answ er would be no. I cannot r e c a ll in stan ces of claim s sp ecifica lly being provoked a s a resu lt o f investigations by industrial h ygien ists which I have seen carried out. I have to put a little reservation on that, in that I am currently rem otely involved with a c la im w hich o r ig in a te d b e c a u s e a m an c a m e into a h o sp ita l which is sta ffe d by S tan ford U n iv e r sity ; h e w as found to h ave a jf* peculiar pulm onary d is e a se which resem b led F a r m e r 's lung. The man gave a h is to r y o f h a v in g w ork ed in the Redwood lu m b e r in g in dustry for som e tim e and it happened that th ere w as a young man doing som e b a sic s c ie n c e w ork th ere at the h o sp ita l, who w as able to provide a red w o o d a n tig e n by w hich th is m an cou ld b e te s te d fo r Sensitivity. It tu rn ed ou t th is fe llo w had a lo t o f a n tib o d ie s a g a in st tins redwood antigen and nobody e ls e in 200 p atients from whom Moods w ere taken show ed sim ila r antigens. At this point I got in terested in se e in g what it w as lik e out in the field , and a group o f us 25 smm w ent up to E ureka and got so m e b lo o d s fro m p eo p le in the industry. W ell, nobody e lse had quite as strong a pattern of antibodies as this p a tien t had, but so m e o f the p eo p le who had b een em p lo y ed in the redwood industry for som e tim e showed reaction s. Inform ation con cern in g this got back to the patient, who did file a w orkm en's com p e n sa tio n c la im , which is now b ein g c o n te s te d . So I su p p o se w e did s e t som ething off, but I think that actually it w as as much the h o s p ital a s it was the field industrial h ygien ist. A re we going to have a w hole slew of c la im s com in g on after th is o n e? It's too soon to know. I think that that in d u stry, the ra ilro a d industry, or any other industry w ill be b e st serv ed with resp ect to workm en's com pensation claim s by having the m ost p re c is e inform ation they can get, and though you m ay h ave a few claim s which appear to originate becau se of an in vestigation which is c a r ried out, you w ill, in the long run, save m oney by having this p re c is e knowledge. CHAIRMAN OLSON: I think it's gen erally r eco g n iz ed that railroad s a s w ell as other industrial concerns are concerned about the w el fa r e o f th e ir e m p lo y e e s , and I would a s s u m e fro m w'hat you sa y that the p reven tive effort would produce in the long run a b etter overall r e su lt. DR. HARVEY NELSON (Soo Line R ailroad, M inneapolis, M inn.): D octor, may I ask a question? W hen you go into a shop, supposing you w ent into the Southern P a c ific sh o p s, how open a re you with the u se o f you r in stru m en ts? How do you answ er q u estion s as "What you a re doing?" DR. BEARD: This w ill depend on the exp erience o f the particular in d u stry and of the p a rticu la r shop w hich is in volved . If you have not p reviou sly had such ob serv a tio n s m ade, if the w o rk ers are not accustom ed to seein g a doctor w andering around the p lace asking q u estion s, watching them w ork, if they are not accustom ed to s e e ing a man going around w ith so m e kind o f an a ir sa m p lin g d ev ice, you had b etter give them so m e education ahead o f tim e . If I w ere to go into the Southern P a cific shop, th is would be no p rob lem , they a re used to it. If I go into another shop w h ere they haven't had th is so r t of se r v ic e , the fir st thing I would do would be to find out from the personnel m anager who are the people who a re topm ost in the em p loyee pow er stru ctu re in th is plant, who a re the le a d e r s am on g the em p lo y e e s. It m ay be that they a r e the union o ff ic e r s , it m ay be that they are not the union o ffic e r s at a ll. T h ere m ay be so m e em ployee so c ia l club which is m ore im portant. I would look for th ese people and would explain to them what we w ere about to do and why. Depending upon the extent o f the program , 26 i yl -SiMt , ; i o u 'il is s u e m o r e o r l e s s e la b o r a te w ritten in fo r m a tio n to th e e m ..ivt-es. In s h o r t, I w ould tr y to h elp th em to u n d ersta n d the p u r; J5t behind th is, w hich is , in the long run, for th eir own p rotection. PR. NELSON: Thank you. ' CHAIRMAN OLSON: Judging by the show of hands, it w as quite l obvious that in d u strial h y g ien ists are not in great u se in the railroad industry. I'm su re that after your d isco u rse th is m orning that that t might change things con sid erab ly. I want you to know that we all appreciate very much your com ing h ere and talk in g to us th is m orning. DR. BEARD: Thank you. CHAIRMAN OLSON: We a r e now in lin e for a sh o rt in te r m issio n , ! during which tim e I think th ere w ill be a cup of co ffee or two served (' to you. We w ill convene again p ro m p tly at 10:30, p le a s e . ; (Short r e c e s s .) !'.. CHAIRMAN OLSON: G entlem en, we have a v ery distin gu ish ed group ' 1 of p ro fesso rs who are going to d iscu ss the question o f cardiopulm on ary p rob lem s. I would lik e to ask each of you at the conclusion of their d iscu ssio n , if you have any questions, to p lea se state your i name clea rly so that it may be recorded. \ D r. Stanley J. C yran, M edical D irector, Pennsylvania Railroad, P h ilad elp h ia, P en n sy lv a n ia , w ill act a s the M oderator o f the program j and I w ill ask him to introduce his panel. < I PANEL SYMPOSIUM - CARDIOPULMONARY PROBLEMS i j MODERATOR STANLEY J. CYRAN; Thank you, D r. Olson. 1 } W e ll, th is is the cardiopulm onary panel, and I, to o , would like ! to thank D r. Strange to r a rran gin g such a d istinguished group. I > am honored to m oderate this. I w ill introduce our m em bers first. We have on the end D r. Frank Gerbode, who is Chairman of l the D epartm ent of C ardiac Surgery. P resbyterian M edical C enter, ? at San F ran cisco H ospital. Next to him is D r. H. Corwin Hinshaw, the C lin ical P rofessor ! of M edicine at the U niversity of C alifornia, San F ra n cisco , C alifor n ia, and 1 b e lie v e the attending physician of the Southc. n P acific R a ilro a d , and also a c o - e d ito r of the volum e " D is e a s e s of the Cht-si. 3 We have next to h im D r. John Sampson, C linical P ro fesso r' of M edicine at the U n iv e rs ity of C a lifo rn ia . He is the C hief of the C ard ia c Clinic of the U niversity of California M edical C e n te r and a A past P resident of the A m erican Heart Association. P e te r Vaughan is one of o u r own, who is the M edical D ire c to r of the Canadian National Railways, M ontreal, Q uebec, Canada and he will probably be d iscu ssin g som e of the views he may have on som e of the problem s that will be discussed here. i T h is p anel today is actu a lly in keeping w ith m any of the p an els } we have had acro ss the country over the past year. T hese are in fo rm ativ e p a n e ls , they tend to be a r eview of so m e of the things we know, we should know, and som e of the things we would like to know. T h ere a re fo rm al p re se n ta tio n s at first, followed by questions and answ ers after the speakers have presented their topics. I don't know w h eth er we can re a lly expect them to solve all o u r p ro b le m s that we have on the ra ilro a d s , but we can expect them to give us som e ideas, to give us the information which will make us m ore knowledgeable in evaluating and assessin g the p ro b lem s that we have on the various ra ilro a d s. T h o se o f yo u who w e r e p r e se n t at the la st m e e tin g in A p r il in - C hicago w ill rem em b er that w e did have a panei on pulm onary d ise a se then. Our P an el dealt w ith pulm onary d is e a se s rath er g en era lly and their relation sh ip to th e railroad industry. 1 r e c a ll som e oi the questions dealt with d isa b ility , estim ation of functional cap acity, ; but tim e did not p erm it m ore than gen era liza tio n s. i\ P art of this m orning's se s sio n --th e pulm onary h a lf--w a s prom pted som ew hat by so m e o f the recen t ads and headlines appear ing in jo u r n a ls and n e w s p a p e r s , m a g a z in e s, and e s p e c ia lly th e m e d ic a l jou rn als. "One m illio n are d isab led ." "70,000 w ill die in th is y e a r . " "D eaths from ch ro n ic b ron ch itis and em p h ysem a have in c r e a s e d fr o m 2300 in 1945 to 1 9 ,4 4 3 in 1963, the la t e s t y e a r fo r which Public Health S erv ice figures are available. " "The S ocial Security A dm inistration pays m ore than $60 m illion a y ea r to men disabled by em physem a. " >-1j I wonder how expensive this is to the railroad industry. Maybe D r. R osen would be able to te ll us that. ` In ten sh o r t y e a r s , c h r o n ic lung d is e a s e h a s b e c o m e the f a s t e s t grow ing ca u se o f death in th is country. Only ca rd io v a scu la r d is e a s e , the n a tio n 's No. 1 k ille r , e c lip s e s chronic lung d is e a s e as a d is - * a b le r o f m en . It w ould a p p ea r p e r tin e n t, th e r e fo r e , to d is c u s s s o m e 28 iniliUPW^My if pro--'- oppo: of tK oftc.'i to h i OL-joi ' Ji'! -'tpatunow . d.:o a if. fun. ly; o:-: P".. t.\ pu. li V in ecIS of th e se p r o b le m s, even though our tim e is n e c e s s a r ily rriited and the sc o p e of the su b je c ts o v e r w h e lm in g . One of the m ore strik in g ad v ertisem en ts for th eir product, but ,;so concerning chronic lung d ise a se , is being sponsored by a w elli rown p h a rm a ceu tica l com pany. I think many of yo u have se e n the m ultiple-page a d v ertisem en t concerning lung d is e a se in the variou s lournals. They show a dram atic picture of four h orsem en likened to the r id e r s o f the A p o c a ly p se , to w hom pow er w a s g iv e n to k ill. The ad g o es fu r th e r to s a y that th r e e o f th e s e h o r se m e n k ill with suffocation; nam ely, asth m as, chronic bronchitis and em physem a. The fourth h orsem an is called D esp air, for he attends the mounting toll of death and d isa b ility . C hronic resp ira to ry d is e a s e s are not in evitably d isa b lin g . New m eans and m ethods of treatm ent may r e verse th ese chronic resp ira to ry d ise a se s and prolong life. N otable ad van ces have b een m ade in the d ia g n o sis and treatm en t of card io p u lm o n a ry d is o r d e r s . In one d e c a d e , th is h a s m o v ed from the pure r e s e a r c h lab oratory to the cardiopulm onary lab oratory, the c lin ic , and now into th e p h y sic ia n 's o ff ic e . H igh ly te c h n ic a l procedures that have been developed are now able to definitely establish sp ecific d iso rd ers. Thus estab lish ed , th ere has been the opportunity to prove the correlation of sim p ler testin g proced u res. O ffice d iagn ostic p roced u res now can provide perm anent record s of the status o f the patient at the fir st exam ination. T hey not only often d is c lo se u n suspected pulm onary d iso rd ers in p atien ts thought to have h ea rt d is o r d e r s ,b u t m ay d etect d is e a s e s e a r ly enough to perm it e ffectiv e prevention o f its p ro g ressio n and a lso se r v e as an objective guide for d ifferen tial diagnosis and therapy. C onsequently, just as the EKG and the ch est film s are providing the ch a ra cteristic patterns o f altered function, graphic patterns of pulm onary function now fu lfill an im portant p o sitio n in the a llia n ce to d iagn ose and combat cardiopulm onary and resp iratory d isord ers. The u se of pulm onary function studies has led to m ore p recise knowledge o f the pathophysiology and the natural co u r se o f pulm onary d isea se, and has provided a better understanding of norm al pulm on ary physiology in healthy m en and wom en of all a g es. Fulm onary function te s ts m ay be u sefu l in ruling out lung d is e a s e in non-organic types o f dyspnea such as co n v ersio n and other p sych on eu rotic d is o rd ers. T hey m ay aid in d ifferen tia tin g prim ary from secondary p olycyth em ia. T hey have b een u sefu l in p reo p era tiv e and p o sto p era tive a sse ssm e n t of the patient with known or su sp ected cardiac or pulm onary d isfu n c tio n . In a d d itio n , and m o st im p o rta n tly for our in dustry, as w ell as a ll industry, th ese te sts may be helpful in ach iev ing an o b jectiv e evalu ation o f d isab ility c la im s. T hey m ay be useful in p re-em p lo y m en t ex a m in a tio n s, e sp e c ia lly in o ccu p ation s known to be poten tially hazardous to the resp ira to ry tract. 29 J'WWMIJ . Mi WHWWW*' S t 1 I-< l T h e y c a n , and p r o b a b l y s h o u ld , be u s e d a s s c r e e n i n g p r o c e d u r e s > our periodic evaluation of the em ployee's health, just as ae use 1 E K G 's, chest X -ra y s and u rinalyses. Of co u rse , the pulm onary function studies cannot supplant a good history and physical exam ination nor offer a pathologic or etiologic diagnosis. i L im ita tio n s a r e p re s e n t in all te s ts used in m e d ic in e , and p u l m onary function testing has not escaped these lim itations. They m u s t b e a p p r e c i a te d in the light of the co n d itio n o f th e p a tie n t. In our capacity as m edical d irectors and chief surgeons of the various ra ilro a d s, with the increasing im portance of chronic lung problem s, we a re faced with making decisions concerning the employability - of such workmen. -5 Does the chronic cough mean anything? Is this just a cigarette cough o r does it actually indicate som e incipient se rio u s lung d is o r d e r ? Should this man be w'orking in a potentially ir r it a tin g e n '1 v iro n m en t? Will the diesel exhaust be m ore disturbing to this em 4 ployee than the av erag e, norm al em ployee? Is this m a n 's dyspnea j o r ap p aren t slowing down at work due to h e a rt d is e a se , o r, perhaps, a potentially reversible lung problem or both? How should he be evaluated ? A fter he has been evaluated, how to in terp ret the v a rio u s rep orts o f pulm onary function. What d o es FEV m ean, M EFR, M W , and what do th e s e m ean in relation to h is functional capacity? >. i Should he or should he not work ? l W ill h is p reexistin g pulm onary d ise a se be aggravated ? t T his is the purpose of the pulm onary part of the panel this m orning. I have asked D r. Hinshaw to d isc u ss how the pulm onary sp e c ia l is t approaches the lung problem . I expect he w ill s t r e s s so m e im portant p oints in h isto r y , so m e im portant p h y sica l sig n s that p e r haps Will g ive c lu e s to expected r e su lts o f the function stu d ies and, then, give a description o f the various p ra ctica l lung stu d ies that can be done without need for much com plicated m ach in ery. Can th e se be u sed to differentiate the variou s d ise a se s ta te s ? What can they t e ll us about the m an's functional ab ility? I am honored at this tim e to present Dr. Hinshaw, who w ill sta rt the discussion. 30 i '-ires : is e ary xam- ,. 3 pul- ` in rions *y "' lenis, ette s- mlea airv-' -aps lb! the . - >0rts r in exp rs: Wdi: I cou' the: e-St : of : k f re: to oi di; -j- lu LU U v JUNSHAW: T hank y o u , D r . C yran. p r _ Cyran has pointed out the im portance o f the recently aug--cnted in fo rm a tio n a l cam p aign about c h r o n ic lung d is e a s e s . T h is , [1(j has lon g b e e n n e g le c te d a s far a s the g e n e r a l public is con - rned. Very few people knew the word em physem a until recent ... ars when the N a tio n a l T u b e r c u lo sis A s s o c ia tio n m ade th is a m ajor Vr |,j 0 f a c tiv ity in th e e x p ecta tio n that tu b e r c u lo s is p r e v a le n c e would continue to d eclin e. Much of the apparent in c r e a se in em p h y sem a and other r e s p ir a tory d iso rd ers is only apparent. P u b lic health educators have used all news m edia to arou se in te r e st in this su b ject. The recognition of em physem a, the recognition of obstructive airway d is e a se , the appreciation o f the im portance of chronic bron chitis, a ll th ese a re rela tiv ely new to p h y sicia n s, as w ell as to the public. We m ust a lso r e a liz e that th is is to som e degree a problem of the aging lung, and much of what we c a ll pulm onary disability is really the natural p r o c e ss o f w ear and tea r on the lung. D r. Cyran h as m entioned the Social Security A dm inistration exp en d itu res in th is fie ld . In th e State o f C a lifo r n ia em p h y sem a is responsible for m ore d isab ility paym ents, than any other condition, with the ex cep tio n o f a r te r io s c le r o tic h e a r t d is e a s e , and th is su rely could not h ave b een sa id many y e a r s ago, b e c a u se doctors did not then r e c o g n iz e th e im portance o f em p h ysem a. We shouldn't under estim ate this sim ply because it is a m ore recently recognized field of im portance. In th e e s t im a t io n o f e m p lo y a b ility , w e d on 't know the b rea th in g requirem ents o f different jobs in industry. I am constantly su rp rised to se e how little breathing capacity is n e c e ss a r y fo r the perform ance of many jobs in m odern industry. Any num ber of men who have been disabled or at le a st taken off the job and given disability benefits undertake oth er w ork or even recrea tio n a l a c tiv itie s which require much m o re b reath in g capacity than th eir o rig in a l job required. But lungs do w ear out. T h ere's no doubt about that. They do fail. Just a s h e a r ts fa il, just a s liv e r s fa il, ju st a s brain s fa il, so do lu n gs. Som e a sp e c ts o f lung fa ilu re a r e e a s ie r to m easu re than in the c a se o f h ea rt fa ilu re. T oo often the patient has not sought m ed ic a l a d v ice d u rin g the y e a r s o f a tr o u b le so m e cough and the a sso c ia te d chronic b ro n ch itis, which eventually has led to pulm onary emphy sem a. Too often he has given little consideration to the fact his exertion to lera n ce has been dwindling and he doesn 't do the things he used to do. 31 Shortness of breath should be an ominous sign of impending d is ability if s h o rtn e ss of b re a th is a p r o g r e s s iv e sym ptom . Very few people re g a r d it as such; not until it in t e r f e r e s with the p le a s u r e s of life does the average man pay m uch attention to his breathing ability. He will often a ss u m e that it's due to advancing a g e --a n d perhaps it is. He will assu m e that it's due to lack of physical fit n ess, which it often is in p a rt, and will not seek m edical advice n e a rly as quickly as he would if th e r e w ere a pain s o m e w h e re , o r if he had known that this was in tru th an ominous sym ptom . B reathing ability is not likely to be regained in any very larg e m easu re: the loss is perm anent. I am not saying that th e re 's no help for a man with em physem a. I am saying that the d estructive aspect of the d ise a se is p e rm a n e n t and th e re is no such thing as lung regeneration. But had the patient sought help e a rlie r , I believe his physician might have given him som e advice, might have given him som e com fort, might have been able to p re s e rv e his working e f ficiency, and possibly could have extended his life span. Most of the changes tend to be p rogressive as well as p e rm a nent. The aggravating factors can to som e extent be controlled and can to som e extent be prevented. We are called upon o cca sio n a lly to evaluate the pulm onary r e serv e of a patient who com plains of sh ortn ess of breath, or one who is considered to be a m arginal risk for som e major su rgical p ro cedure. D r. Cyran has indicated that sim p le exam inations are often su fficien t. When we sen d the patient for the m ore so p h istica ted te s ts to a la r g e r m ed ica l c e n te r , su ch as w e have up at the U n iv ersity of C alifornia, we are ra rely confronted with any su r p r ise s. It's nearly alw ays p o ssib le , on the b a sis o f p h y sica l exam ination, and som e sim p le m easurem ents of breathing cap acity, to evaluate the individual's ventilation function. It's tru e, of co u rse, that the fine equipm ent and the sk illed clin ica l p h y sio lo g ists of a m ed ical cen ter can provide us with quantative fig u res and very often th ese figu res are im portant. They a re m o re a ccu ra te than we can obtain w ith the sim p le d ev ices v/e have in our o ffic e s . But the fin al evaluation of anyone's pulm onary r e s e r v e and our estim a tio n of his ab ility to withstand the str e s s e s of su rgery or the s tr e s s e s of daily work are not very often altered by the sop h isticated tests of a m edical center pulm onary function physiology laboratory. It's interesting but very ra rely is it very im portant for us to know such factors as lung co m p lia n ce, diffusion data, p r e c ise blood gas stu d ies, pulm onary artery p r e s s u r e s , and even such fundam ental factors as resid u al capacity can usually be anticipated at lea st by sim ple office procedures which are adequate for m ost purposes. 32 In other w ord s, the r e s e a r c h c a p a b ilitie s o f the p u lm on ary function laboratory are not e s s e n tia l to the solu tion of m ost of our clinical problem s. U nfortunately m ost of our m ea su rem en ts in the o ffice, and quite a few o f the m e a s u r e m e n ts in a p u lm on ary p h y siology laboratory are m ea su res o f voluntary effort, and the m aling erer or the stupid person m ay not p erform very w ell, but there u s ually is no difficulty in r e co g n iz in g him and u su ally he can be p e r suaded into revealin g so m e o f h is tru e ab ility. I don't b eliev e that a clever m alingerer could often delude an experienced exam iner. S J. a ' Norm al standards have been estab lish ed , but th ese are often m isused. For exam p le, the range o f n orm al is e x trem ely w ide in m ost m easures of pulm onary function, and often w e in correctly ns. u se the w ord " ab n orm al," w hen a p a tien t fa ils to atta in p r e d ic te d perform ance. Predicted values are not n ecessarily synonym ous with norm al values. P' W i F or ex a m p le , 70% o r m o r e o f a p r e d ic te d fo r c e d e x p ir a to r y volum e is norm al. Som e of the stan d ard s w hich a re quoted do not take into account the m an's age. Often tabulations and graphs which do take into account age can be d isto rted in such a way a s to m ake it appear that a man o f 60 y e a r s who has on ly 60% of p r e d ic te d b rea th ing cap acity is d isa b le d . In a c tu a lity h is job m ay not r e q u ir e even that much exertion to lera n ce and it may be a serio u s in ju stice not to perm it him to work to the u su al retirem en t age. th,- F requently, we ask the question: "How much can a man breathe?" We are asked to m ea su re h is a ir ca p a city . How m uch can a man breathe is a good deal lik e asking how fa st can a man run. What is W-- the n o rm a l ra te o f ru n n in g? And yo u w ould find a w id e ra n g e of br variation within people who have norm al le g s. The m an who wants to run fast w ill run b etter. T he man who is trained and experienced as a runner w ill undoubtedly run fa ster. The young man w ill run fa ste r than an old man, and the fig u re w e com e up w ith, ex p ressed in m iles per hour, really doesn't te ll us whether or not h is im paired sp eed is due to lack o f effo r t, w h ether it 's due to a r th r itis , whether it's polio, whether he has an am putated leg , or whether he has just had a recent bout with the flu. Any one of th ose things m ight reduce > the m an's running capacity and the sa m e things m ight w ell reduce his breathing capacity tem porarily or perm anently. When it com es to the m easu rem en t o f breathing cap acity, we are m ostly concerned with the com m on d iso rd ers and the m ost com mon disorder is generally spoken of as "obstructive airw ay d isease. T his is alm ost synonym ous with em physem a, but not quite. Ob stru ctiv e airw ay d is e a se r e fe r s o f c o u r se to o b stru ction in the flow o f a ir in and out o f the lu n gs. F o rtu n a tely , h ere th e sim p le s t m easurem ents are also the m ost m eaningful and m ost of th ese are 33 m e a su re s of a ir flow ra te s; how much a ir can a man exhale in a space of tim e. Most im p o rta n t is how much can he exhale in one second and hence FEV, the forced expiratory volume in one second, is probably the m o st useful sin g le m e a s u r e that we have in e s t i m a t ing o b s t r u c t i v e a i r w a y d i s e a s e . We d o n 't c a r e so m u c h a b o u t how much he can exhale in five o r six seconds, simply because no one can take five o r six seconds for a single respiration. "Vital c ap a c ity ," or "tim ed to vital capacity" is exactly the sam e thing. Machines are available which make this m easure very sim ple. T hose m achines which produce a graph to show the ra te of a ir flow during exhalation are m ore valuable than the ones which give you a single figure. When that graph, repeated again, and again, shows a s e r ie s of identical c u rv es, you can be confident that the subject is not a m alingerer, that he is exerting his maximum effort. I think you find if you play with the machine using y o u rs e lf as a subject that it alm ost is im p o ssib le to reproduce the sa m e graph intentionally over several trie s , unless you are using your absolute ut most of breathing capacity. These machines are relatively sim ple. T here are about a half a dozen different types. The Jones M etabolism people m ake a bellow s m achine "F uim onor" which is quite reliable, reasonably accurate for all our ordinary purposes. The McKesson people make a little machine they call the Vitalor. T h ese cost in the vicinity of one hundred fifty to two hundred fifty dollars apiece. They should be in every hospital, and the house s t a f f s h o u l d know how to o p e r a t e t h e d e v ic e and how- to i n t e r p r e t th e findings. Most m achines provide a graph of the forced expiration, and this graph is spoken of as a "spirogram . " F rom the shape of the cu rv e you can e stim ate the a ir flow ra te in lite rs p e r minute the graph provides estim ation of the one second forced expiratory volum e, the two seconds and the th ree seconds forced expiratory volume. T he a ir flow ra te s w ill v a ry for different m achines. F o r ex am ple, with the McKesson m achine a norm al person will only be able to blow out about 200 to 300 lite r s p e r minute. T hat is b e cau se this m achine o ffers relativ ely high re s ista n c e to a ir flow. Some of the m ore fancy electronic actuated sp iro m e te rs will give you an air flow ra te much g re a te r than that. The m ost sim ple m e a s u re of a ir flow is to light a c a rd b o a rd m a tc h , hold it a foot in front of the m outh, and with the mouth wide open, try to blow it out. It re q u ire s an a ir flow ra te of a few hundred lite r s p e r m inute to blow out such a m atch at the approxim ate distance of one foot. Don't let the subject purse his lips, or you will get a false reading. We used to speak a good deal of m axim al breathing capacity, but the m ax im al b reath in g capacity designation is not so frequently 34 a 4ly ` ii-.n v. ,LU` r< i.'XTiini: ary ciu- T: exam;Mire f by ! *<inierf* so-cal lions 1 order:- m ode: w ill fct* topics . ask Dr. In ' ; once bcetera. probD :f practi: one o: Samp.-, heart proccr availa the t;a I; . DR. :: j disc;. J insor, r lerns ' seas. ? b rie: i t l r *i i j th ese d ays b e c a u s e it is n 't fe a s ib le to get the a v e r a g e p e rso n -naintain forced breathing long enough to get a good m easu re of maximal breathing capacity. I had intended to d isc u ss som e other a sp ects of ob stru ctive a ir iaV d isea se. I m ay have inferred that em physem a is the only condi. i0n we are con cern ed with. Of co u rse it's not. O b stru ctive airw ay d isease can a lso be cau sed by asthm a, which of c o u rse is a r e v e r s ible condition. T h is, again , can usually be d etected by p h y sica l examination and sim p le o ffice laboratory p roced u res. Such pulm on ary d is a b ilitie s a s m a y be due to p ulm onary f i b r o s is , w ill b e shown on sim p le m ach in es o f th is so r t. There are other conditions le s s com m only encountered. For exam ple, a care of a sb e sto sis might give a reasonably norm al m ea sure o f breathing cap acity, and yet the man m ight be incapacitated by reason o f a p ecu lia r type o f pulm onary fib r o sis w hich le a d s to an in terferen ce b etw een exch an ge o f oxygen in the a ir and hem oglobin, so -ca lled --" a lv eo la r cap illary block." T his is found also in condi tions like sa r c o id o sis and in a few other pulm onary fibrotic d is orders. MODERATOR CYRAN: Thank you v ery much. Dr. Hinshaw. There w ill be tim e for questions after the panelists have p resen ted their top ics. I know th ere a re m any other things that probably w e can ask D r. H inshaw , and I'm su re he w ill be happy to answ er those. In p r e p a r in g th is p a n e l, o f c o u r s e , th is n e c e s s ita t e d c o r r e sp o n d ence betw een P h ilad elp h ia and San F ra n cisco and D r. S trange, et cetera. We had planned on going into heart d ise a se and pulm onary problem s. H ow ever, we rea lized that perhaps it would be m ore practical to talk again about coronary heart d isea se, sin ce this is one o f our m ajor p ro b lem s today in the railroad in d u stry , so Dr. Sampson w ill d iscu ss som e o f the practical aspects of coronary heart d isea se. How do w e approach th is. What a re the diagnostic procedures available ? What are som e of the new er procedures available that can be u sed to again give us m ore know ledge to a s s e s s the functional ability o f the railroad em ployee ? Dr. Sampson. DR. SAMPSON: D r. C yran indicated in h is introduction that I would d iscu ss so m e o f the p ra ctica l asp ects of coronary heart d ise a se , but, insofar as it w as h is d e sir e that heart d isea se and pulm onary prob lem s would furnish the co re o f the presentations o f th is m orning's se s sio n , 1 am taking the lib erty of opening my rem ark s w ith certain b rief com m ents on cardio-pulm onary disease. 35 C or P ulm onale is one of the m ost subtle form s of h e a rt d isease, and its ex isten ce is often suspected by the accompanying pulm onary parenchym al o r vascular abnorm alities without obvious cardiac m anifestations. The comm onest forms of the parenchymatous d is ease, pulm onary em physem a, is comm only associated with som e degree of pulm onary arterial or arterio lar obstruction, which, through in c re a se d re s ista n c e to the pulm onary blood flow, im p re sse s an elevated load of work on the right ven tricle. Under th ese c irc u m stances, the electrocardiogram may suggest right ventricular hyp er trophy p r io r to the in c r e a s e in the s iz e of the c a r d io - silhouette by ro en tg en o g ram s o r by any evidence of right v e n tric u la r card iac in capacity. The physical signs may be relatively inconsequential with the exception of an accentuated pulmonic second sound. P rim ary pulmonary arterial hypertension is a relatively un 3 usual entity, w hich m o st often o c c u rs in childhood. S im ila r to the 3 pulm onary hyp erten sio n which exists in c ertain congenital and a c 4 quired heart disease, such as interatrial septal defect, interventri cular sep tal defect, m itra l stenosis and m itra l insufficiency, it is the result of the thickening of the pulmonary a rte ria l o r a rte rio la r walls, and the narro w in g of these v a sc u la r channels, w'hich may be e ith e r tr a n s ie n t o r p e rm a n e n t. It is im p o rta n t, by the r ig h t sided cardiac c a th e te r stu d ies, to determ ine the existence of such p ul m onary h y p erten sio n , and by dynamic studies on both sid es of the h e a rt to d ete rm in e the so u rce of it. Very often it is possible to r e 1 lieve the defect and to cause important reduction of the pulm onary arte ria l resistan ce and the accompanying pulm onary hypertension, .* and thus prevent the crippling or fatal right ventricular strain and failure. C ertain of the defects, such as patent ductus arteriosus and in te rv e n tric u la r septal defect, a re likely to be accom panied by pulm onary a r t e r i a l hypertension in early life, but in te r-a tria l septal defect, and m itr a l valve d isease, resu ltin g in pulm onary a r te ria l narrow ing, ap p ear relatively late and a re m o re likely to be r e v e r s ible. i In th e c o n g e n ita l d e fe c ts , a flow o f a t l e a s t 1. 5 t i m e s in th e pulmonary v ascu lar bed, as com pared to the system ic flow, seem s 3 to be n e c e s s a ry to lead to these pulm onary a r te r ia l changes. How ever, th e re is considerable difference from patient to patient in the j tendency to develop in creased pulmonary a rte ria l re s ista n c e , the reaso n for which is not as yet known. Undoubtedly, D r. Hinshaw j and Dr. G erbode will present the pulmonary diseases, other than em physem a m entioned above, which could cause these v ascu lar changes, and also of the surgical procedures with the proportion of su ccess now exhibited in e rasin g the dam age done by the c a rd iac lesions m entioned. Although the risk is quite high in attem pting to close the right to left h eart shunt when cyanosis is m arked and when the pulm onary a rte ria l changes apparently have reached a high de gree of developm ent, som e su ccess in relatively late c a s e s , e s- 36 i p ecia lly in m itr a l v a lv e d is e a s e and in in te r a tr ia l s e p ta l d e f e c t s , are occasion ally reported. T h ese r e v e r sa ls of the pulm onary a r teria l r e s ista n c e m ay, h o w ev er, o ccu r slo w ly , and at tim e s s ix to twelve m onths is n ec e ssa r y to p ass before seeing favorable resu lts in c o r r e c tin g th e c a r d ia c d e fe c t. T h e r e v e r s a ls a r e m o r e lik e ly to o ccu r a fter acq u ired h ea rt d is e a s e , such as m itra l s te n o s is , than after a longstanding con gen ital shunting lesio n . One of the m ost tra g ic exam p les of the m istake that has o cca sio n ally been made is from the diagnosis of prim ary pulm onary hypet-- tension, assu m ed ly ir r e v e r sib le , by only partial right sided cardiac cath eterization which has rev ea led a high pulm onary a rteria l p r e s su re, w hen, in r e a lity , a m itra l ste n o sis without c h a ra cteristic auditory sig n s is the b a sic le sio n . O bviously, this lesion is su r gically correctab le and could have led to correction if the dim inu tion in blood flow through the r e str ic te d pulm onary v ascu lar bed had not led to the lo s s o f the c h a r a c te r istic m itral d ia sto lic m urm ur, or if a rigid m itral valve had failed to exhibit the ch aracteristic opening snap. R ecu rren t pulm onary em b o lism m ay, and often d o e s, lea d to d ecreased card ia c output and acu te, subacute or chronic right heart failure and death. Since prevention and control of this condition is p ossib le by venous ligation or by anticoagulant drug therapy, and since the r e su lts are v ery often fa ta lities frequently undiagnosed, it is of v ita l im portance that it be recognized. R ecurrent pulm onary em bolism is one of the m ost subtle and difficult en tities to diagnose sin ce frequently the roentgenogram s o f the lungs, the electro ca rd io graphic changes by righ t ven tricu lar strain , and the p h ysical sign s and sym ptom s often p resen t no ch a ra cteristic diagnostic picture. T here a r e tw o tech n ica l m ethods for a ss istin g in d ia g n o sis, and it is recom m ended that they be used: The first is the scanning of the lung and angiography by rad ioactive m aterial in scanning and rad io opaque m a teria l in angiography. An additional m ethod, which is of le s s s p e c ific v a lu e , is the m ea su re o f CO2 in the alv eo la r a ir or ex pired a ir , w hich would be lo w er than expected w here a r e a s o f the lung w ere b lock ed , as by throm bi. F requently, w rong diagn oses of recurrent pneum onia, em physem a and chronic bronchitis, and con g estiv e h ea rt fa ilu re a re m ade and retained e sp e c ia lly in the p r e sen ce of a low grade, prolonged or rem ittent fever. Such u se le ss therapy a s a n tib io tics, d ig ita lis, d iu retics, fa il to term in ate the advance o f the p r o c e ss, which eventually becom es ir r e v e r sib le and cyanosis and failu re of cardiac outflow from poor intake, eventually term inates life . As a p ractical m atter, the use of adequate anti coagulant therapy, g en era lly H eparin and the Coumadin drugs, should be initiated on su sp icion of the existen ce of pulm onary recu r rent e m b o lism , e sp e c ia lly in individuals who are recogn ized ca n didates for th is condition, such a s eld erly individuals who have been bedridden with longstanding heart failure or im m obilized by broken 37 late already. T o h e r r ig h t is D r. John M oody, C lin ic a l In str u c to r in P s y c h ia tr y at th e U n iv e r sity of C a lifo rn ia and to h is r ig h t D r. P h ilip R. Calanchini o f the Teaching and R esearch Staff of P resb yterian Med ic a l C enter in San F ran cisco. D r. C alanchini and D r. M cAuliffe a re c lo s e ly a sso c ia te d with th e S outhern P a c ific M em o ria l H o sp ita l, w h ere th ey a r e in an en viable position among their colleagues a c ro ss the country, I am sure, i b ecau se they have a sep arate inpatient se r v ic e of neurology. I am su re that th is m akes for good feelin g of the sta ff and b etter care of -j the patients. J D r. M orrissey has not yet arrived. As D r. N elson indicated, to the b est o f my knowledge last year was the fir st tim e this organi zation had ev e r tackled n eu rop sych iatric p ro b lem s in a panel form and, in fact, in p ractically any form . We r e a liz e d at that tim e that w e w e r e ju st op en in g a door in th is c o m p lex su b je c t. It h as m any r a m ific a tio n s and I am su r e it is going to ta k e u s m any s e s s io n s to get very far along the road. M eanw hile, w ith our group today we w ill b ecom e much better orien ted . I rem em b er Dr. W inston pointing out la st y ea r that r a il roads w ill get bids and spend w eeks, days or m onths investigating equipm ent that co sts fifty, a hundred, $ 1 5 0 ,0 0 0 , but when you con sid e r the c o st, no m atter how you count it, o f a valuable em p loyee, I a r e we spending enough tim e in evalu atin g our ap p lican ts ? W ithout further from your m oderator, I w ill ask D r. Stockw ell r to open the program and give us a little of the ra ilro a d d o cto rs1 ap i proach to the com plex subject. D r. Stockw ell. 14 DR. STOCKWELL: Thank you. Dr. Skinner. i '1 G entlem en, I hate to w aste the tim e of this valuable panel speak in g , o f c o u r se , as a general surgeon, but I have been asked to p r e sen t the railroad physicians' point o f view . It is in te r e stin g and ch allen gin g to s it on a pan el with such d is tinguished com pany to d iscu ss a subject that I know so very little about. When asked by our Chairm an, D r. E rnest O lson , to par ticip ate in this d iscu ssio n , he told me that my function w as to p re se n t, if p o ss ib le , the p ractical view point o f the ra ilro a d ch ief m ed ic a l o ffic e r in the handling of th ese perplexing situ ation s. 58 ATTENDANCE ATCHISON, TOPEKA & SANTA FE RAILWAY H. F. G r u n d e m a n , C h i e f C l e r k - M e d i c a l D i v i s i o n System, Chicago, Illinois C. D. H o o v e r , C l a i m Ag e n t , San F r a n c i s c o , C a l i f o r n i a L. A. Ketr i n g , G e n e r a l C l a i m Agent, L os Angeles, California J. R. W i n s t o n , M.D., M e d i c a l D i r e c t o r , C h i c a g o , Illinois BALTIMORE & OHIO RAILROAD I. K a p l a n , M . D . , M e d i c a l & S u r g i c a l D i r e c t o r , Baltimore, Maryland CANADIAN NATIONAL Peter Vaughan, Canada RAILWAYS M.D., Chief Medical Officer, Montreal, CENTRAL OF GEORGIA J. G. S h a r p l e y , Georgia - SAVANNAH & ATLANTA M . D . , Chief Surgeon, RAILWAY Savannah, CHESAPEAKE & OHIO RAILWAY - BALTIMORE & OHIO RAILROAD R. A. Straub, General Tri a l Attorney, Detroit, Michigan CHICAGO & NORTH WESTERN RAILROAD J. V. Stack, M.D., C h i e f Surgeon, Chicago, Illi n o i s CHICAGO, BURLINGTON & QUINCY RAILROAD H. W. Hammatt, M.D., Chief Medical Illinois Officer, Chicago, CHICAGO SOUTH SHORE & SOUTH BEND RAILROAD P. J. P i l e c k i , M . D . , M e d i c a l D i r e c t o r , Indiana Michigan City, CINCINNATI, NEW ORLEANS & TEXAS PACIFIC RAILROAD R. G. C a r o t h e r s , M . D . , C h i e f Surgeon, C i n c i n n a t i , Ohio COLORADO & SOUTHERN RAILWAY W. J. Longeway, M.D., Chief Surgeon, Denver, Colorado ERIE-LACKAWANNA RAILROAD W. E. M i s h l e r , M.D., C h i e f Surgeon, C l e v e l a n d , O h i o 188 ' -r-1 ! G ;<A ` GR. ILL: JAPA JERS: F . KALSA, G. LAKE M. MISS: NAT 3. A; L< NEW ' I'.. [n p resen tin g th e in d u s tr ia l p h y sic ia n 's v iew p o in t, I w ould lik e , .com m end for all of you the textbook entitled "Occupational D is- and In d u strial M ed icin e" w hich w as p ublished in 1960 by *he p Saunders Company and w ritten by Dr. Rutherford T. John ,n C onsultant, In d u str ia l M ed icin e C lin ic , P r o fe s s o r of P r e v e n . . . vc M edicine and F u b lic H ea lth , and C lin ica l P r o fe s s o r at th e . -versity of C a lifo rn ia , L o s A n geles; and D r. Sew ard E. M iller, rector o f the In stitu te o f In d u stria l H ealth , P r o fe s s o r o f M ed icin e, Medical S ch ool, P r o f e s s o r o f In d u stria l H ealth , S ch o o l o f P u b lic leai'.h, at th e U n iv e r sity o f M ich ig a n , Ann A rb or, M ichigan. S p e c irally. Chapter 5 in th is tex t, en titled "Man's Adaptation to Indusr..:l L ife," is p ertin en t to o u r p ro b lem . It is pointed out that in our rapid evolution from a str ic tly agrarian life to our p resen t highly mechanized life it has placed trem endous s tr e ss upon a ll individuals. Thus "An in c r e a s in g n u m b er o f p eo p le need help in a ch ie v in g a s a t i s factory adjustm ent. " It is su g g e ste d that e m o tio n a l d istu rb a n ces a r e r e s p o n s ib le for about o n e -th ir d o f a ll adult s ic k n e s s and ab sen ce fro m w ork with a tremendous lo ss o f productivity. The im m ature individual p resen ts a rea l problem for the railw ay industry. It is su g g e s te d that the fir s t job m ay be the fir s t contact with r e a lity fo r m any young a d u lts. T h e se peop le who m ay be c la s s e d as im mature and inadequately adjusted individuals, appear norm al on the str e e t o r in a crow d , and frequently in the exam ination room . Their identification is not e a sy and handling after identification is even m ore difficult. T hese people lack se lf-d isc ip lin e and are definitely accident prone, with high a b se n te e ism ra tes. It is sta te d , "T hey a r e th e ten p er cen t that ta k e 90 p e r c e n t o f the su p e r v iso r 's tim e . " They are con stitu tion ally inadequate and not only a re they unable to p erfo rm th e ir d u tie s p r o p e r ly , but they a r e v e r y q u ick to b la m e their em p lo y er fo r th is d e fic ie n c y . It is apparent that th is type of individual would be v e r y pron e to se e k the advice of an attorney under the p rovision s of the F ed era l E m ployers L iability A ct. It h a s b een s u g g e s te d th a t m o st m an agem en t g ro u p s should a c cept the resp on sib ility of em ploying som e of these inadequate individ uals and training them to be productive w orkers. I su g g est that the railway industry is in a little different situation b ecau se of its r e sponsibility to the public. The next question is how can they be elim inated from the railw ay industry ? It is m y o p in io n th a t th e e x p e r ie n c e d e x a m in e r who r e - 59 M. N. Ray, G e n e r a l C l a i m s Attorney, N e w York, N ew York NORFOLK & WESTERN RAILWAY C. M. B e n a g e , M . D . , R e g i o n a l M e d i c a l D i r e c t o r , St. Louis, Missouri R. W. Edmo n d s , M.D., Regi o n a l M e d i c a l Director, Cleveland, Ohio Ball Lawrence, M.D., Regional Medical Director, Roanoke, Virginia NORTHERN PACIFIC RAILWAY K. W. Johnson, G e n e r a l Minnesota A. McEwan, M . D . , Chief Claim Agent, Surgeon. St. St. Paul, Paul, Minnesota PENNSYLVANIA RAILROAD S. J. Cyran, M.D., Pennsylvania Medical Director, Philadelphia, PITTSBURGH & LAKE ERIE RAILROAD A. H. Winters, M.D., Chief Surgeon, Pennsylvania Pittsburgh, PULLMAN COMPANY R. M. Graham, M.D., Director of M e d i c i n e & Sanitation, Chicago, Illinois ST. LOUIS-- SAN FRANCISCO RAILWAY V. W. H ollo, M . D . , Chief Surgeon, St. Louis, Missouri ST. LOUIS SOUTHWESTERN H. A. Causey, M.D., Arkansas RAILWAY Chief Surgeon, Texarkana, SEABOARD AIR LINE RAILROAD Southgate Leigh, Jr., M.D., Virginia Chief Surgeon, Norfolk, SOO LINE RAILROAD Harvey Nelson, Minnesota M.D., Medical Advisor, Minneapolis, SOUTHERN RAILWAY M. B. C l ayton, M.D., Chief Surgeon, W a s h i n g t o n , D.C. 190 sor VB . DE.` V. A. N SPOr 3 UNIC. ! uun l FERROCARRIL DEL PACIFICO Edvardo Contreras Reyna, Guadalajara, Jalisco, M.D., Chief Mexico Surgeon, GRAND TRUNK WESTERN B._ W . S t o c k w e l l , Michigan RAILROAD M.D., Chief Surgeon, Detroit, GREAT NORTHERN RAILWAY A. Skinner, M.D., Chief Medical Officer, St- Paul, Minnesota ILLINOIS CENTRAL RAILROAD E. C. Olson, M.D., C h i e f Surgeon, Chicago, I l l i n o i s JAPANESE NATIONAL RAILWAYS Katsumi Kaneko, M.D., Chief of the 3rd Clinic of Internal Medicine, Tokyo, Japan JERSEY CENTRAL RAILROAD F. W. Mahoney, M . D . , Medical New Jersey Director, Jersey City, KANSAS. CITY TERMINAL RAILWAY G. Owens, M.D., Chief Surgeon, Kansas City, Missouri }s L A K E S U P E R I O R & I S H P E M I N G R A I L R O A D M. C. B e n n e t t , M.D., C h i e f Surgeon, M a r g u e t t e , I Michigan 1 M I S S O U R I --KANSAS--TEXAS RAILROAD R. S- Kieffer, M.D., M e d i c a l Director, St. Louis, ? Missouri : NATIONAL RAILWAYS OF MEXICO j Antonio Regnoso cordoba. Chief of Mexican Medical I Service, Mexico i L o u i s G. Ibarra, M.D., H e a d of t h e R e h a b i l i t a t i o n f Service, Villalongin, Mexico NEW YORK CENTRAL SYSTEM i G e o r g e E. Dimond, M.D., consultant, D e t r o i t Michigan ii E. A - H a m i l t o n , M . D . , C h i e f S u r g e o n , C h i c a g o I l l i n o i s A. W. Nickels, M . D . , Ch i e f Surgeon, D e t r o i t , M i c h i g a n ? 3 189 laims Attorney, New York, New I LWAY ,, Regional M e d i c a l D i r e c t o r , euri Regional Medical Director, ) ., R e g i o n a l M e d i c a l D i r e c t o r , ;ia WAY oral Claim Agent, St. Paul, hief Surgeon, St. Paul, Minnesota Medical Director, Philadelphia, : R A I L R O A D Chief Surgeon, Pittsburgh, Director of Medicine & Sanitation 0 RAILWAY Chief Surgeon, St. Louis, Missouri RAILWAY Chief Surgeon, Texarkana, ROAD -, M.D., c h i e f S u r g e o n , N o r f o l k , , Medical Advisor, Minneapolis, Chief Surgeon, Washington, D.C. 190 SOUTHERN PACIFIC COMPANY E. R. A n d e r s o n , D i s t r i c t C l a i m s A g e n t , S a n F r a n c i s c o , California R. C. A r c h a m b e a u l t , I n d u s t r i a l H y g i e n i s t , San Francisco, California S. B. B u r t o n , A s s i s t a n t G e n e r a l M a n a g e r , S a n Francisco, California N. 0. Butler, P h o t o g r a p h e r , S a n Francisco, C a l i f o r n i a S. L. C h a p i n , A s s i s t a n t S u p e r i n t e n d e n t o f S a f e t y , San Francisco, California E. A. Chow, M .D., R e s i d e n t in M e d i c i n e , S a n F r a n c i s c o , California P. J. D e a k s o n , M . D . , R e s i d e n t - I n t e r n a l M e d i c i n e , San Francisco, California J. R. Gand y , M . D . , C h i e f S u r g e o n , H o u s t o n , T e x a s H. B. Hoyt, A s s i s t a n t G e n e r a l C l a i m Agent, San Francisco, California W. M. Jaekle, A s s i s t a n t Vice President Optns., San Francisco, California B. Kaufman, M.D., Medical Superintendent, San Francisco, California J. Lourgets, M . D . , Intern, San Francisco, C a l i f o r n i a D. K. M i l l e r , S u p e r i n t e n d e n t of S a f e t y , S a n F r a n c i s c o , California E. L. Smit h , M .D., A d m i n i s t r a t i o n A s s i s t a n t to Chief Surgeon, San Francisco, California V. M. S t r a n g e , M . D . , C h i e f S u r g e o n , S a n F r a n c i s c o , California A. C. Thom s o n , A s s i s t a n t G e n e r a l Cl a i m s Agent, Sacramento, California N. F.. W i l l i a m s o n , S p e c i a l A s s i s t a n t , S a n F r a n c i s c o , California SPOKANE, PORTLAND & SEATTLE RAILWAY M. L. M a r g a s o n , M .D., M e d i c a l D i r e c t o r , Oregon Portland, UNION H. PACIFIC RAILROAD B. Lamb, M.D., M e d i c a l Utah Consultant, Salt Lake City, UNITED STATES RAILROAD RETIREMENT BOARD B. B. R o s e n , M.D., C h i e f M e d i c a l O f f i c e r , C h i c ago, Illinois J. E. S c h w a r t z , C h i e f , D i v i s i o n D i s a b i l i t y B e n e f i t s , Chicago, Illinois 101 .Ju,.. STANK, R. \ WESTERN PACIFIC RAILROAD M. E. C h i l d r e s s , M . D . , Cali forni a Chief Surgeon, San Francisco, ASSOCIATION OF AMERICAN RAILROADS B. B. H i n k l e , R e g i o n a l M a n a g e r , Los A n g e l e s , California J. A. R i s e n d a l , D i r e c t o r - C l a i m s R e s e a r c h Bureau, Chicago, Illinois J. A. Sherman, A s s i s t a n t Director, C l a i m s R e s e a r c h Bureau, Chicago, Illinois W. A. Smith, C l a i m s Divisi o n s , San Francisco, California W. E. T o d d , S t a f f S e c r e t a r y , C h i c a g o , I l l i n o i s AMERICAN PRESIDENT LINES W. H. Rustad, M . D . , C h i e f California Surgeon, San Francisco, GREYHOUND S. D. O s s m a n , California Director Safety, San Francisco, INDUSTRIAL ACCIDENT COMMISSION E. P. W e l c h , C h i e f , Prernanent D i s a b i l i t y Bureau, San Francisco, California Rating INDUSTRIAL ACOUSTICS COMPANY, INC. D. B. C a l l a w a y , V i c e P r e s i d e n t , California Santa Monica, PACIFIC COAST ASSOCIATION OF PULP AND PAPER MANUFACTURERS Dan Adair, Safety Coordinator, Portland, Oregon PRESBYTERIAN MEDICAL CENTER P. K. C a l a n c h i n i , M.D., M e m b e r of T e a c h i n g and Research Staff, San Francisco, California F. Gerbode, M.D., Chairman, D e p a r t m e n t C a r d i a c Surgery, San Francisco, California SOUTHWESTERN MEDICAL SCHOOL OF UNIVERSITY OF TEXAS A. Glorig, M.D., Director, Callier Hea r i n g and Speech Center, Professor Otalaryngology, Dallas, Texas UNIVHP H. M. J. G. J. / ^D a., C h i e f S u r g e o n , S a n F r a n c i s c o , g RAILROADS al Manager, Los Angeles, sctor - Claims Research Bureau, s stant Director, Claims Research Illinois Divisions, San Francisco, cretary, Chicago, Illinois -3 Chief Surgeon, San Francisco, or Safety, San Francisco, STANFORD UNIVERSITY i R. R. Beard, M.D., P r o f e s s o r o f P r e v e n t i v e M e d i c i n e , Stanford, California j i' UNIVERSITY OF CALIFORNIA H. C. H i n s n a w , M.D., C l i n i c a l P r o f e s s o r M e d i c i n e , ! San Francisco, California [ M. McAuliffe, M . D . , A s sistant Professor of Neurology, | San Francisco, California j J. L. M o o d y , M.D., C l i n i c a l I n s t r u c t o r in P s y c h i a t r y , j San Francisco, California j G. Morrow, M.D. , Assi s t a n t Clinical Professor of j. Dermatology, San Francisco, California j J. J. Sampson, M.D., C l i n i c a l P r o f e s s o r Medicine, | San Francisco, California ji ! I. f( f MISSION Premanent Disability isco, California Rating .iPANY, INC. President, Santa Monica, ON OF PULP AND PAPER MANUFACTURERS ordinator, Portland, Oregon TER D., M e m b e r of T e a c h i n g a nd an Francisco, C a l ifornia airman, Department Cardiac cisco, California BOOL OF UNIVERSITY OF TEXAS eetor, Callier Hearing and ofessor Otalaryngology, Dallas, is s I 192 t ? 1