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able, each branch of the service to have its own special degree. The aural surgeons of the different roads would certainly co-operate with the proper officers of the Medical and Operating Departments of their respective Roads, toward this end. They might be accorded such data, and opportunities for further investigation, as may be deemed necessary to enable them to determine these points the more accurately and the more economically and satisfactorily to all parties concerned. A comparison of their individual findings and opinions, through personal correspondence or through the press-and I feel confident that the genial and obliging Editor of The Railway Age would at any time cheerfully aid in this investigation by ceding a portion of his valuable columns to the reports of the aural department of Railway Hospital service-a comparison of individual findings and opinions, I repeat, would enable us to promptly obtain the desideratum. And, as I believe this to be the only method of perfecting the good work already so well begun by you, and of rescuing from contempt and ridicule what is otherwise indispensable to safe and economical management of our railroads, I trust it may commend itself to your better judgment and active influence, notwithstanding the manner of its presentation here to-day. And I thank you for your kind attention. 3211 Lucas avenue.

DISCUSSION OF DR. BARCLAY'S PAPER. Dr. D. Emmett Welsh: The paper covers the ground very thoroughly with reference to examining the hearing among railway employes. This is a subject to which, until recently, very little attention was given. I have nothing to do with the examination of the hearing of telegraph operators; therefore, I can give you no information relative to the examinations made by the attendant of that department. In the examination of a new employe the ears are always carefully examined, not by the watch test, but by the speaking voice, one ear being plugged tightly with The speaking voice is regulated at the ordinary pitch and the applicant is placed six feet away from the examiner. If at that distance he hears conversation in the ordinary voice, that is the end of the examination of that ear. The other ear is then plugged tightly


with cotton and examined in precisely the same manner. Among the older men employed on the road the ordinary speaking voice is simply used, and even though the applicant may be partially deaf very little attention is paid to the same on account of his long employment. We often know that an applicant may be extremely deaf on account of the sounds which are produced during his work, and while these sounds are painful to the normal ear, in his work as an engineer or conductor he is able to hear sounds that to us are not recognizable, and hence not very much attention is given to ear trouble except in new employes in the manner in which I have stated.




I am glad to avail myself of this opportunity to bring to the notice of the association my device for the control of hemorrhage. I realize that it is in the sphere of accidental surgery that the aluminum clamp artery compressor has its greatest field of usefulness. In emergency practice we have but little time to prepare or obtain aseptic ligatures, and still less time to use them. Often the railway surgeon is called upon to operate without assistants, save, perchance, some well-meaning, but ignorant fellows, who are more hindrance than help. Furthermore, rapidity in the completion of an operation and the loss of a minimum amount of blood are points of cardinal importance in the prevention of that shock too often present in this class of cases. Here, then, this device, which saves much time and does away with that necessity for the aid of an assistant, which is required where the ligature is used, shows most strikingly its advantages.

The following extract from an article published by me in the American Medico-Surgical Bulletin, explains fully what my aluminum clamp is: "This clamp consists of a small piece of curved aluminum wire, each extremity of which is thickened and rounded, to render it unirritating, by being bent back upon itself, so that it presents much the appearance of a miniature horse shoe with heel-corks. This *Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896.

curved wire clamp is placed between the jaws of a specially constructed pressure-forceps with a spring on the handles, slipping being prevented because the wire fits into a groove on the inner aspect of each blade. The upper or 'heel-cork' extremity of the wire-clamp presents at the beak of the blades, the turned-over ends of the wire "heel-cork" overlapping sufficiently to prevent the wire from sliding back within the blades when pressed into the tissues about a vessel. The accompanying illustrations will best explain both the shape of the clamps and the construction of the forceps.

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Half a dozen or more such forceps, kept 'threaded' by an assistant and laid within easy reach of the operator, would facilitate rapidity of application. The method is easily comprehended. Grasping the end of the vessel with a tenaculum or hæmostatic forceps in the usual manner, only with the left instead of the right hand (should I be operating without an assistant), I make slight traction upon it, as when about to ligate in the usual way. Then, holding in my right hand the clamp retaining forceps, I slide the clamp over (or rather around) the vessel. Having the clamp in position, I compress it firmly about the vessel by simply

closing the jaws of the forceps. All this is but the work of an instant, yet the vessel is thus tightly and permanently compressed, for the aluminum clamp is unyielding, and will retain its hold independently when applied to the largest vessel. Like the ligature, the clamp cuts the inner coat of the vessel, as well as closing the severed extremity, but, unlike the ligature, it can be removed in a moment without further injury to the tissues by grasping the closed end in a dressing forceps and making traction in the line of its application. Thus, at the completion of an operation, should a vessel be deemed so small as not to require permanent ligation, it having become closed, the clamp can be slipped off as easily as one would remove a hæmostatic forceps."

Since my article just quoted was published I have devised, and by the skillful aid of Tiemann & Co., of New York, have perfected a combination instrument combining a tenaculum and clamp compressing forceps in one, whereby, through a simple maneuver (that of compressing the blades over the vessel), this latter is transfixed by the tenaculm and drawn up within the clamp, which, at the same instant, is firmly compressed about it. I would suggest that until the surgeon has thoroughly familiarized himself with the use of the clamp through clinical experience, he had better be contented with the less expensive instrument first described, which, while if often requires, as already explained, the aid of the operator's left hand in order to draw the vessel out from the tissues, yet it requires no practice in order to make use of it. I have found my newer device, however, invaluble as a saving of time, besides being indispensable in the compression of vessels in situations where they are So deeply imbedded and ill lighted as to be inaccessible to more than one instrument at a time. Where one or more intelligent assistants are present I find the rapidity with which an operation is completed greatly facilitated by having, as already stated, several pairs of forceps at hand kept constantly "threaded," so to speak, with clamps, so that all I have to do is to take them, when handed to me, and compress them upon each vessel as it is severed, just as I formerly did my hæmostatic forceps.

Aluminum clamps become embedded, more properly speaking than encysted, within the tissues, their unirritating nature, for they are

non-corrosive and of the same specific gravity as the blood, taking from them the usual objections to a foreign body. As will be seen from a few selected cases which I have appended, the clamps have been made us of in almost every form of surgical procedure, even having been left within the pelvic and abdominal cavities without producing any untoward


To recapitulate briefly the chief points of superiority possessed by the clamp over the ligature, are as follows:

(1) Their great rapidity of application enables the surgeon to apply them almost as quickly as he formerly did his hæmostatics, while no subsequent steps are required, as would be the case should its application have to be followed by ligature.

(2) It never slips from the end of the vessel, either during or after its application.

(3) Once applied it will remain in position indefinitely, its inherent non-corrosive property, smoothness and lightness reducing its power of irritating the tissues to a minimum, while it cannot become a nidus for germs.

(4) The operator does not require the aid of an assistant to make traction upon the vessel as he would if ligating.

(5) The clamp can be applied to vessels in the deepest recesses of a narrow wound, where there is no room to introduce, tie and make traction upon a thread.

(6) It is aseptic and were it not so it is easily sterilized by heat in a few minutes.

(7) And last but not least, by its means we do away with the necessity of a multitude of hæmostatic forceps hanging in our way while operating.

The following cases are taken as exemplifying the situations in which it can with propriety be used:

Case I: Chas. T., aged 50, operated upon December 13, 1895. He was brought to my hospital with a limb which had been crushed severely between two logs more than twentyfour hours before. I amputated three inches above the knee, mortification having commenced below the knee. An aluminum clamp was placed on the femoral artery, as soon as it was severed. Before closing the flaps it was observed that the tissues about the vessel were seriously pulpified, the clamp was therefore removed (and I should state that these clamps can be removed instantly, without laceration of the tissues, by grasping them at the closed extremity with a pair of dressing forceps and making traction in the line of application), and a new clamp was applied higher up, where the tissues were firmer. Three or four smaller vessels also required clamping. The flaps

were then coaptated and sutured in the usual manner. Primary union occurred despite the tumified condition of the tissues. No setbacks were encountered and within two weeks the patient was about on crutches. I saw him ten days ago and he informed me that he had been going about on an improvised peg-leg. The stump was an excellent one and no signs could be detected of the clamps having produced irritation. The time of the operation was shortened by at least one-third through the superior applicability of the clamp over the usual ligature.

Case II: John B., operated December 10, 1895. Large abscess cavity in the gluteal region, due, probably, to tubercular disease. While curetting the cavity, which was deep and narrow, extending to sacrum, I ruptured a vessel at its base. Here I made use of two of my clamps, one for each severed extremity. They were applied with the greatest ease, while, had I attempted to use the ligature, it would have been next to impossible, at so great a depth, without enlarging the external wound.

Case III: Ernest A., operated November 4, 1895, for radical cure of hernia (modified Barker's operation). Here all vessels encountered, large and small, were clamped as soon as cut. There were, if I remember, seven. All the clamps became encysted without causing the slightest apparent irritation. I have seen the case recently and while several of the clamps which were directly under the skin can be felt like little rice kernels, pressure upon them does not cause any pain.

Case IV: Charles F., operated March 27, 1896. Here I removed the left testicle for carcinoma. I clamped the vessels of the cord with three aluminum clamps. The wound healed. rapidly without suppuration. No pain or discomfort has been occasioned by the clamps, which are, of course, out of reach within the canal.

Case V: Mrs. Gust L., oörphorcetomy, operated upon March 23, 1896. In this case I used clamps for controlling the hemorrhage from the ovarian artery on both sides, where they proved entirely satisfactory. Finding, however, considerable oozing from the minute vessels supplying the tubes and a few smaller ovarian branches, and as time pressed, there being many adhesion to break up, I was forced afterward to include all within a silk ligature. I was not obliged, however, to use the customary tension, which necessarily tends to devitalization of the stump, the minuter vessels only requiring the pressure by ligature, the ovarian artery, as already stated, being firmly compressed by means of the clamps. I returned the stumps into the cavity of the abdomen without removing the clamps. Recovery was excellent and rapid without raise of temperature. I have thus far seen no reason to regret having left the clamps in position.



Editor St. Louis Clinique, and Professor Anatomy and Histology, College of Physicians and Surgeons, St. Louis.

Occupation means the environment of organic metabolism-that upon which all structural development depends. We must all admit that we become under development just what environing influences determine. Even the strictest of the orthodox agree that character itself is under the influence of conditions. A fortiori, how greatly must the physical organism, the great medium of mental expression, the photograph of the ego, to speak in modern parlance, receive impress from its surroundings, and in its development express the result of its environment.

Bernardino Ramazzini, of the University of Padua, in the first year of the eighteenth century, wrote a work in Latin, entitled De Morbis Artificum Diatriba, and it is somewhat singular that in referring to this work Dr. James Henrie Lloyd of Philadelphia has expressed exactly the ideas of the author of this paper, so far as to criticise the work as desultory, digressive and pedantic-painfully pedantic-as Dr. Lloyd well reniarks. But, as has been well said, he is to be "commemorated as the first physician who saw this great subject as a whole, and attempted to treat it in a systematic way." We shall not take up the time of this body in historical references, however; we are after facts; not who made or developed the facts.

In entering upon the discussion, therefore, of diseases which arise from occupations, we are met by the necessity, as indeed in all practical issues, of defining the subject. What do you mean by a "disease of occupation?"

It would be absurd to ascribe under this nomenclature every disease that might affect an individual devoted to any special pursuit. The ordinary diseases of humanity may affect all artisans or professional men alike, and yet. there are conditions which determine pathological relations and focalize those influences upon the organism in action, which disturb its balance and even superinduce permanent disease. Aside from the daily occupations

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.

which make up the ongoings of humanity, we are called upon also to differentiate between the pathological effects of latitude, surroundings, etc., and yet we are bound to admit that there are diseases which, however possible in all conditions of race, clime or other environment, nevertheless, are precipitated, if not indeed originated, by the character of occupation in which the individual may be engaged. For instance, it is well known that mining favors rheumatism; silk weaving, tuberculosis; file making tends to produce lead poisoning; gilding brings on mercurial poisoning when the ventilation of the workroom is deficient; constant writing, paralysis; wool sorting, anthrax; and a most signal example of the effect of the steady pursuit of a special occupation was shown right here in St. Louis at the time the caissons were sunk for the building of our great bridge, which stands to-day as a model of modern engineering unsurpassed in all the land. When we are daily brought in contact with men who occupy those positions which expose them to pathological effects or conditions which are entirely due to their occupation, it behooves us to condone many of those incivilities which are the outcome of a morbid strain upon the organism, since a sana mens, as all must admit, cannot exist except in sano corpore. It would be impossible in the limits of this paper to even enumerate the causes incident to special conditions, yet as a recent writer upon a subject germane to this has remarked, there is a temptation to carry out this plan by many authors, the obvious facts that locality, race, age, customs, habits and country affect artisans quite as much, even more, than do their occupations, are too readily ignored, e. g., the butchers of one town or race may be more healthy than those of another, although fol

lowing identical occupations; or, as Altridge

states, the cotton spinners of one mill may have a great advantage over those of another because they happen to work upon a special fabric for which there is a greater demand in the market, hence receiving steadier wages and leading healthier and more secure lives. While statistics are worthy of most careful and respectful consideration, nevertheless, they fail to establish a principle of scientific accuracy in conditions so variable as these which form the subject of discussion in this paper. We shall, therefore, pass them by, and

reach at once the salient or rather the practical issues involved.

Among all the various occupations which are necessary to the conditions of civilized life there is none which makes such a draft upon the vital energy of the organism as railway service. This arises from four causes incident to this line of life.

1. Rapid and constant transit.

2. "Rattle of the Rail."

3. Irregularity of diet and the ordinary life habitudes.

4. The worry incident to the calling.

I. Rapid and Constant Transit. This acts in two general ways to bring about pathological conditions:

a. The constant and sudden change of climate made necessary by the very rapid movements of our modern railway trains could not but produce a vibratory effect upon organisms subjected daily to it. It is no uncommon sight to see a train covered with snow roll into lands of perennial bloom where snowflake never fell, and on the other hand to see a car decorated with palms and tropic flowers fresh in their beauty sweep through the icy forests of the North and lay their recent tributes at the foot of winter's throne. And yet this is not good hygiene-such changes shock the system. They must disturb the balance of the organism.

b. The change of nerve influences: A debt of eternal gratitude is due to Dr. Beard for his origination of the term Neurasthenia. No term ever introduced into medical nomenclature so completely fulfills all of the pathological expressions which are covered by its use. But we are preceding our limit of discussion and shall have to refer to this remark in our summing up of results.

II. "The Rattle of the Rail."-While the St. Louis Republic lays claim to this formulated alliteration we hardly believe that they fully appreciate from a practical, physiological and pathological standpoint the intense significance involved therein. There is always a continual quiver of the auditory filamentous spread. Of course you may say, “Well, a man becomes used to that!" Has the man who offers such reply ever considered the almost infinite changes-the necessary molecular adaptations to conform the organism which is perfectly interactional to the physiological plane? I cannot believe it if he has thoroughly cov

ered the field of investigation involved. We remember once how seriously the roar of Niagara's cataract affected the nerve systems of tourists, especially bridal tourists. Now it may be the fact that such constant vibratory motion may affect the organism constitutionally, nevertheless we must admit that there are incidental influences which largely determine the character and ultimate expression of the disease. Aside from railway employes themselves who are subjected to all of these patho-neurotic conditions, there are also those who are compelled to be constantly upon the rail in commercial transit. Now it is very evident that this constant change of nutritive gauge-if we can speak thus ex medica cathedra-must necessitate an alteration in the normal functional expression of the organism.

Nothing is more sensitive to experimental test than the ultimate filaments of the optic and olfactory nerves, and a quiver in audation makes a disturbance in nutrition. So is it with all physical influences.

We could carry out this subject to an almost indefinite extent, but the limits of this paper before you forbids my discursive tendency.

III. Now comes the irregularity of diet and the ordinary life habitudes dependent upon railway environment.

It is hardly necessary to show to any modern traveler that the change of diet to which he is subjected in transitu, to say nothing of the character of substance incident to the change, must perforce produce profound and permanent impression. And it is always and ever the nerve centers that receive the impress. Under this influence the inhibitory nerves of the pneumo-gastric are the great formers and distributers of function. This we suggest as the key to unlock the pathological issues of such molecular disturbance.

IV. The Worry Incident to the Calling.— It is not a very strange fact that apart from specific diseases fatal in their character there are extraneous conditions, produced by irritable relations such as cannot be controlled by physical causes alone. We firmly believe that we state an axiomatic fact when we say that "worry kills more men than work." Work-Steady outdoor work under the clear open sky by the bright waters, under the conditions laid down for us by nature, is just as

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