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partments are self-sustaining and the railway company need only supply transportation to and from hospital, and a proper auditing of hospital accounts. The treatment of passengers and outsiders is paid for by the company, but these departments, being well supplied with physicians, a complete history is always obtained as regards injuries, and by these histories compromises are accomplished with the aid of the hospital department which could not be made with the same celerity and economy in any other manner. By anyone taking time to investigate, it will be found that by the perfect training of both hospital corps and claim. agent's corps, passenger wrecks are settled with greater celerity than can be done in any other way. Thirdly, by having a trained medical corps and a trained claim agent's corps, a complete history is supplied to the claim agent, and not infrequently the claim agent possesses this history months before settlement is effected, and by comparing reports made by the transportation department and the hospital department, it will be found that the reports from the hospital department give such a truthful history, taken immediately upon the inception of the injury, that it debars the possibility of the patient changing his statement and making a new case under the scheming advice of shysters and others. It comes very near being true that all injured men tell the truth to the doctor at the time of their injury. These reports being signed by the employes, it prevents the possibility of re-arranging their assertion by falsification. This complete surveillance enables the railway company to affect a compromise by the completeness of its knowledge. Upon a majority of roads having hospital departments, it will be found that in the settlement of personal injury cases, including employes, passengers and others, together with death losses, the liability of the company will rarely average more than $30 or $35 per capita. Not more than one employe in 200 sues, while with the passengers it averages one in 18, and still with this low rate of settlement, with the assistance of various orders, to which he belongs, the employe is generally able to get his average daily rate of wage in the event of sickness and injury. Economically, then, the hospital department is of great value to a railway. We do not believe that any relief sociation can show as low rate of settlement in personal injury claims in all classes in any way
approaching the rate accomplished by a claim department, assisted by a well organized hospital department.
Finally, we honestly believe that compromise and the claim agent will be the most concentrating factor in the settlement of personal injuries, as inflicted upon the railway, and we are morally convinced of this fact; that in the perfect union of claim department and hospital department, litigation will constantly lessen, and this will not only redound to the benefit of the injured person, but plainly to the benefit of all concerned. The general trend in the direction of compromise, particularly in serious cases (those which are of so-called railway spine), will in the future be more readily brought in the realm of compromise than that of litigation, for we are honestly of the opinion that the physician will find it in a positive line of his duty into whose hands the case first comes to study the subtlety of the problem with which they are called upon to deal, and that they will be as strenuous advocates of compromise as the claim agent himself. For even now the highly educated, prominent and efficient neurologists and surgeons of this country are honest advocates of compromise, knowing that prospective gain engenders diseased conditions and that a well-acted part in exaggeration of these injuries sometimes leaves them in a hopeless condition; hence, a true interpretation of their honest duty points to compromise and not to disease producing litigation.
THE MANAGEMENT OF RAILWAY INJURIES, WITH ILLUSTRATIVE CASES.*
BY DR. N. A. DRAKE, KANSAS CITY, Mo., Surgeon C. R. I. & P. Ry. and C. M. & St. P. Ry.
After a successful operation has been done and the patient has rallied from the shock of the injury, operation and anæsthetic, it would seem to those not conversant with such formidable things that the worst was past. In many of the cases this is true, while in many other cases the fight has but just begun. Before the days of anæsthetics surgeons were of necessity much more rapid operators than now. I am certain that many patients lose
* Read by title at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896.
their lives now who would have lived under the old regime. Added to the shock of the injury we now have the shock of the anæsthetic, which is the greater in some cases; then, too, the disposition is not to hurry, hence the time of the operation is often unnecessarily extended. The nausea caused by the long continued anæsthetic becomes more profound, thus increasing the danger many times. I am decidedly in favor of rapid operating. We should have everything ready; know as nearly as possible what we expect to do; give as little anæsthetic as circumstances will allow; work as rapidly as we can and still not endanger the patient. By this course part of the dangers can at least be lessened.
In the following cases the treatment is simple and appliances few:
Case I: E. D., brakeman, 26 years old. On a dark, wet night, while making a coupling, his arm was caught between the bumpers, crushing it from the fingers nearly to the shoulder. In less than an hour after the accident it was dressed by a surgeon. Several hours after I was called, as the surgeon who dressed it could not be found. The arm was bandaged from the fingers to the shoulder with an external splint. The patient complained only of the tight bandage. On removing the dressing I found the arm covered with blisters, much of the skin coming off with it. It was swollen greatly and the arm looked like one gangrenous mass. I irritated the arm with water as hot as could be borne, then applied a bandage loosely, after which I immersed the hand, forearm and arm in hot water, using a tin trough made for that purpose. I directed the nurse to keep the arm in the water three-fourths of the time, if possible, and was gratified to note the relief the patient expressed after the first few hours of immersion. Hot water was added in the top of the trough while the cool water was drawn off through a faucet at the lowest point, without removing the arm.
As inflammation subsided I applied soothing liniments, rubbing and kneading for a half hour at a time, then bandaged the whole arm evenly and smoothly, as tightly as the patient could bear it. For the first few days the arm was kept immersed three-fourths of the time. I rapidly reduced his system with salines, following them with quinine, which interrupted
the fever he had from the time I first saw him. On the eighth day I completed my diagnosis. The carpal bone of the middle finger was fractured and doubtless there was injury to other bones, but none broken. The cellular tissue, posteriorly-nearly to the shoulder-was full of extravasated blood. The skin from the whole arm came off. On January 1, after properly adjusting the fracture, I allowed him to go home. This case I think shows the efficacy of hot water in such injuries.
Case II: E. C. V., aged 35, engineer. While making up his train in the yard he jumped from the cab to couple on a car. In doing this his arm was caught in the coupling, tearing the sleeves of his clothing nearly off and splitting the skin and cellular tissue to the muscles, almost as clean as if cut with a knife, from the wrist to the elbow, nine inches. In the middle of the arm the skin and cellular tissue were completely severed. I could pass my hand through. Dirt, grease and iron dust were ground into the wound. There was but little hemorrhage, also but slight inflammation. I found it difficult to thoroughly clean it, the grease and dirt were so ground into the flesh. I irrigated with hot carbolized water, rubbed and scraped dirt out where I could reach it, then smoothed the skin and put it into place; sewed the cut up with catgut, dusted it with bismuth sub-iodide; then applied several layers of gauze, over this a thick covering of cotton, finishing with a smooth and evenly applied bandage. At the end of the first week, there being a rise in temperature, I removed the dressing. The inflammation was considerable. Apparently the skin and cellular tissue were united, but the edges of the skin, in places, were not, and looked unhealthy. It was very sore and he complained of a dull throbbing pain. I again irrigated with hot water and dressed as before. The next day the temperature was 100 degrees. I prescribed some calomel in broken doses during the day and in the evening a large dose of magnesium sulphate, followed with quinine. After this the temperature remained under 100 degrees. At the end of the second week all looked well except several points in the wound where the skin had not united; there was very little pus, however, and otherwise the arm was in good condition.
The separated skin and cellular skin had become adherent. I was very particular to dress it antiseptically in every way. A few of the points became unhealthy, but after touching them with a caustic several times they healed permanently.
This patient has every use of his arm; there are no adhesions anywhere. The long scar looks as though it had been made with a knife and was only skin deep.
Case III: J. B., aged 26, switchman. In trying to board a moving train in the yard he fell to the ground, striking the flexed knee on the movable end of the switch rail. His knee, as he struck, received the full force of his whole weight. The patella was split vertically, severing all tissue to the end of the femur and tibia. The cut was seven inches in length, laying the joint completely open when the knee was flexed. Believing a stiff knee at a slight angle superior to an artificial leg, and taking everything into consideration, it was determined to save the leg if possible. The wound was thoroughly irrigated with hot carbolized water, a drainage tube inserted, and the leg put up in plaster, with the knee at a slight angle. The leg was put in an easy position and everything done to make the patient comfortable. The temperature for the first week touched normal only twice-the mornings of the fourth and fifth days-the highest being 102 degrees. There was but little swelling and he made but little complaint. At the end of the third week he had several chills and the temperature stayed a few points on each side of 101 degrees. There was some discharge from the tube, and it being evident there was suppuration, the permanent dressing was removed. This was done the twenty-third day after injury. On the inner and lower aspect of the joint, near the end of the drainage tube, was a large abscess. I laid it open freely and there was at least a pint of pus discharged. The cavity was irrigated with a solution of per-oxide of hydrogen, I to 3, and I also flushed the entire wound with the same; dusted it with iodoform; packed it with iodoform gauze, wrapped the leg with absorbent cotton and over this applied a bandage from the toes to the hip. The leg was then laid over a double inclined plane, keeping it at the angle heretofore made. The splint was elevated about 45 degrees.
The next morning and for several mornings thereafter the temperature was normal, but very soon there was an evening rise. On the thirty-second day, the ninth morning after cast was removed, a hard chill supervened, followed by an evening temperature of 103 degrees. I removed the dressing and found three more abscesses, all above the knee. These were all laid open, irrigated as before, and packed after dusting with iodoform. The angle of the knee was maintained. The patient complained greatly of pain in the leg, so much so that we were obliged to give him morphine hypodermically.
The whole leg was swollen and the foot oedematous. After the second dressing at the end of the fourth week abscesses formed rapidly and we were obliged to dress the leg more often. All abscesses were opened and irrigated. We had kept his strength up by systematic feeding and he had been given tonics and digestives. As a result he had retained his appetite. On the sixth week he was attacked with diarrhea, nausea, profuse perspiration, in fact all the symptoms of iodoform poisoning. Iodoform was discontinued and sub-iodide bismuth substituted; also carbolized gauze for iodoform gauze. In a week's time the diarrhea was gone. About this time, fearing periostitis and necrosis, he was anæsthetized and the whole field of the disease thoroughly explored. The bone was not involved. All the abscesses were freely opened and irrigated. Anchylosis of the knee had already commenced. The morning temperature was about 100 degrees, the evening 102 degrees to 103 degrees. The patient had become greatly emaciated, yet his appetite was good. Apparently the seventh week was the crisis. The temperature had a downward tendency; abscesses were not as virulent and were less numerous; the inflammation gradually subsided and the mottled skin was clearing.
My attention was called to what might have been a bad bed sore, in the fifth or sixth week. It was in its favorite place, just over the sacrum, and the skin was broken in one place. I directed the nurse to bathe it thoroughly and then apply a large sheet of adhesive plaster, and from this time on there was no more trouble from it. It was necessary to dress the leg as often as every other day, when it was discharging so freely. This was very pain
ful to him, but if neglected the temperature would shoot up a degree or two.
During convalescence we used a strong solution of carbolic acid instead of peroxide hydrogen, as it appeared to be more stimulating. The exhaustive night sweats were controlled with atropine and acid sulphuric. With two. exceptions his appetite was always good. One has been mentioned, viz., when he was posioned by iodoform, the other, strange to say, was from accidental poisoning with atropine. A two-ounce solution of atropine for the eye was on the table in the medicine room, together with a solution of quinine and sulphuric acid, which latter he was taking, but by mistake he was given a teaspoonful of the former, which contained about one-half grain of atropine. He was delirious for a few days, but by the free use of morphia hypodermically came out all right.
He was given whisky as medicine when needed. Morphine was also prescribed when necessary, and, as is usual in such long, painful cases, the habit was formed and took considerable firmness to discontinue it when no longer necessary. There are no deformities in the leg except the stiff knee. The anchylosis is complete at a slight angle, so that in walking he does not have to swing the foot out to step forward. When he is walking from you the lameness will not be noticed.
There are many lessons taught in this case. The first abscess was at the end of the tube; there was no rise in temperature to amount to much until pus formed. Had we amputated, as advised time and again, even before and after the formation of pus, he would have recovered without suppuration, getting well in three or four weeks without a leg and suffering very little comparatively; instead getting well with a leg and a stiff knee, in fifteen or sixteen weeks, with a great deal of suffering. Now he is able to do nearly the same kind of work he did before the injury. Had I amputated and he had recovered he could not. have done his work with an artificial leg as easily as he now does with his own leg with the stiff knee.
Had I consulted my feelings-I won't say interest-I would probably have amputated. I must confess that I am human; so when one of these cases falls to my lot, where I can see several weeks of hard, aggravating work, I
often ask myself: "Why not take the shortest road and amputate?" Up to date I have never given way.
Case IV: W. R. C., aged 45; freight conductor. In doing the switching at a way station the caboose was struck by a wild car running at a high rate of speed, knocking it from the track, catching the conductor between its rear platform and the platform of the station. His right femur was fractured through the neck, and there was an impacted fracture just below the trochanter. The left femur was fractured just above the knee very obliquely. Three ribs were broken on the right side. There were several scalp wounds and the right hand was badly lacerated. Both ankles were sprained, the right the worst. There were many other contusions and sore places that were trifling compared with what is described.
This accident occurred in midwinter, 250 miles from home. By his own request he was brought home. After a little delay the fracture bed of the railway company was obtained and in a very short time the fractures were adjusted and he was lying with several pounds pulling each foot, the foot of the bed elevated six inches, the body being the counter extending force.
He was accompanied home by Dr. Billingsly, the company surgeon at Belleville, Kan., who aided me in putting him together. That night he had a hard chill and I found him the next morning with temperature of 101 degrees. I called in Dr. Thompson, who lived a few doors away, and requested him to look after his lungs. The second morning the temperature was 102 degrees plus, and he was expectorating blood quite freely. However, only one lung, the right, was involved. From this he recovered quite rapidly, everything considered. I endeavored to use as little retaining apparatus as possible to keep the legs in place. On either side of them I placed long, slim sandbags, and as the muscles relaxed I lightened the weights, endeavoring to keep the balance as near as possible. The cough irritated and caused a great amount of pain in the region of the broken ribs, but with careful bandaging the ribs were held in place and the muscles of respiration paralyzed. Mr. C. is of a nervous temperament, and as the pneumonia dis
appeared his wants and suggestions were very numerous. I had let up on the weights during the pneumonia, till the left, the oblique fracture, had slipped. It had eight pounds then but it required twelve to hold it. Eight held the right.
Toward the last of the third week, as he was convalescing from the pneumonia, his extremities became quite cedematous and there was quite an amount of albumen in his urine. Under a course of salines healthy conditions were soon established. The dressings of the legs had become somewhat deranged, making it necessary to renew them. In doing this we used all caution possible and took advantage of the circumstance to stimulate circulation by massage; then carefully and evenly. bandaged the foot and ankle before applying the adhesive plaster for extension. At this time also that old curse of such cases, the bed sore, began to show up. With stimulating lotions for a few days, followed by a large square of adhesive plaster, it was entirely interrupted. He was also given a course of iron and digitalis, with a good, generous diet, It was very difficult to keep him still. He would get the bandages loosened in spite of me, and but for the well arranged fracture bed I do not know how I should have come out.
The eighth week I ventured to move the joints passively when I was re-dressing. The right knee was very stiff; the left one I dared hardly stir, the fracture being so near the joint. Apparently union was advancing in all the fractures. It was more noticeable at the trochanters. The provisional callus was easily felt. I had let up on the weights, the right six pounds, the left eight. I was greatly troubled with the oedema. In spite of heart tonics and saline diuretics the urine carried albumen more or less. Finally I bandaged each leg from the toes to the body and let the foot of bed down two inches, and used massage vigorously whenever the dressing was removed, as well as putting the joints through their normal motions. This carries us to the twelfth week.
Buck's method of treating fractures cannot be too highly commended. The principle of making the body the counter extending force, thus doing away with the old perineal band, was a great relief, for it was almost impossible to prevent perineal abscesses.
The sandbags for side supports were another great improvement over the long Desault splint, saying nothing about the comfort to the patient. We learned long ago by actual experience that the simpler an apparatus was and fill all the indications, the better it was. With a good fracture bed and Buck's position, a patient has more liberty without disturbing the dressings than any other I know of.
The twelfth week I let the bed down and removed all dressings. There was bony union in all the fractures. The callus at the impacted fracture was the largest. The joints were all quite stiff. The right knee I could bend but a few degrees without causing great pain; the left, to nearly a right angle. In the right femur-the neck-I was mur-the neck-I was never sure whether
the fracture was in or outside the capsular ligament. From all appearances there was bony union, hence this leads me to infer that it was outside. The provisional callus at the trochanters was very large. The oblique fracture of the left slipped a little in spite of me and bowed out somewhat. The ankles were quite stiff. I sat him up with his feet in a vessel of hot brine and with a large, soft sponge gave his legs a good rubbing, following with a thorough kneading, then re-applying the straps for extension, bandaged as before, putting on extension every night for several days. Every morning he was let down and every joint put through its normal motion as far as possible. All joints yielded readily except the right knee. The cedema disappeared slowly. I molded a felt splint to the left leg and on the fifteenth week discontinued extension. He could sit up an hour at a time without much distress and began to put some weight on his feet, but it was slow work for him. The sixteenth week the fracture bed was deserted. The right knee was gotten to a right angle; oedema was also going, but we were obliged to continue the bandages. With care he could bear some weight on his feet. By the last of July he was going all around on his crutches. Everything was going our way except the right knee that stuck at right angles. He would not consent to forcible
The first of August he was going down from the elevated depot to Union avenue, when he stumbled and went down promiscuously. He was gathered up and sent home, where I met