307 307 How the Railway Surgeon Should Aid the Family Physician--By EVAN O'NEIL KANE, M. D.. 301 and Gynecologists.... Meeting of Wabash Surgeons.. NOTES, NEWS AND PERSONALS.. EXTRACTS AND ABSTRACTS: Epithelial Sowing; a New Method of SkinGrafting.... Nerve Suture and Regeneration...... Old Dislocation, with Fracture of the Neck of the Humerus. 310 308 309 309 Suture in Veins and Arteries...... No. 13. RELATION BETWEEN THE CLAIM DE- GATION.* By W. B. OUTTEN, M. D., ST. LOUIS, Mo. We believe with Thoreau, "Duty is one and invariable, requires no impossibilities, nor can it ever be disregarded with impunity." The true line of duty of the railway surgeon is essentially the same as that of any other honorable man. He should be employed for his true capacity and ability as a surgeon, for this is the cause and the criterion of his merit. The truer the railway surgeon fulfills his vocation as a physician and surgeon, the better, broader and more efficient becomes his service. In the perfection of his knowledge of medicine lies this merit. It can be safely maintained that if his knowledge of medicine is requisite to meet all demands, it can only tend in the direction of science and truth. He should never under any circumstance attempt to occupy a dual position, but preserve unceasingly an honorable, upright individuality as a surgeon and as a man, nothing more. When he essays the function of claim agent or attorney, he ceases to be a surgeon and assumes a function which the nature of his business and training do not fit him for. He can at all times best serve the corporation by which he is employed in the most effective and comprehensive manner by maintaining the just, the true, the honorable. Any service which demands the loss of individuality, the use of falsehood, or dishonest method, will in time engulf and destroy anyone employed in that service. Our actions are not only the formative element of the aggregate of our character, but most frequently the deter *Read at the annual meeting of the Association of Railway Claim Agents at Pittsburg, June, 1896. mining factor of our success and happiness. Actions make results and are often not only indelibly pressed upon an individuality, but upon a community or nation as well. The full force of trust and respect only lie in honesty and truth, but there seems to be no limit to the distrust and loss of respect when the reverse is the case. The railway surgeon should never permit his prejudice to thwart his judgment. Partisanship in his position soon leads, not only to loss of respect upon the part of his employer, but of all with whom he may be brought in contact. He should avoid falsehood, prejudice and partisanship; avoid falsehood, because it is the subterfuge of cowards, fools and villains. Prejudice is a fungus-growth causing mental deception and always thrives best in partisanship the jaundiced realni of reason. He should be faithful, sincere, honest and earnest. Faithful, because of the belief in right; sincere, because sincerity is the very soul of conscientiousness; honest, because it is the only true, straight, easily defensible line of action; earnest, as earnestness combines patience and endurance and strength. A truthful, competent, honest railway surgeon is ever a prime, economical factor in railway management. The reverse, a misleading extravagance. The full force of insinuative, plausible. and combative circumstances continuously surround the position of the railway surgeon. It requires judgment, honesty and assertiveness to maintain an upright individuality. It has been very truly said that, "A good character is in all cases the fruit of personal exertion. It is not inherited from parents, it is not created by external advantages, it is no necessary appendage of birth, wealth or station, but is the result of our own endeavors." The railway surgeon's duty is at times fourfold. His duty to himself, to his patient, to his employer and to the community. If he is true to the first two duties, the two last will never suffer. The railway surgeon's duty then is one and invariable; hence it can never lean in the direction of crime, neglect or falsehood, but only in that direction which honest function demands and carries in its very core the golden rule of action. Nothing in the shape of an organization needs and appreciates truth more than a railway corporation. The most effective and successful executive in any management has made more of a success by the use of his knowledge of a true and honest man than he has by too deep a study of the rascality and duplicity of the dishonest. This may sound like balderdash, but investigation will verify this assertion; a knowledge of whom to trust is pre-eminently the basis of all executive work and management which bears the stamp of success. "Rem acu tetigesti" truth, when it is said that all competent and discerning men prefer honesty, with its efficiency and certainty of action, to dishonesty, with its doubtfulness and equivocality. From the standpoint of expediency, if no higher motive is suggested, truth and honesty give more complete and perfect comfort to existence than the reverse. It may be true that nothing is impossible, but we maintain that the successful hiding of a lie in the guise of truth has been an impossible task to the most brilliant intellect ever created. Honesty is almost consequently associated. with good sense and judgment. Dishonesty is in a great many instances the result of defective mentality. There is nothing, as a general thing, impossible in the performance of duty; but a duty neglected may partake of fraud, dishonesty and criminality. The true line of duty of the railway surgeon, then, must consist in honest, effective knowledge of his function, along with the true, exact and strict performance of the same. Experience and result have taught millions before us and will teach millions yet to come-that duty, honesty and truth are forces which most broadly and constantly rule the intellect of man, and that the highest success and happiness in life comes through their effects and practice. The relationship which should exist between the railway surgeon and the railway claim agent is pertinently expressed in this assertion: That truth should be the object of their understanding and there need never be any abrogation of truth. The position of a claim agent upon a railway is by every element constituted an honorable position, and as such, can be constantly maintained. An effective claim agent must of necessity be an intelligent man of rectitude and deep conviction. He can at all times honorably maintain his function and is never called on to assume unmanly function, nor assume the role of detective or brow-beater. The surgeon's line of work is entirely in the domain of the humane; in plying the true nature of his vocation, he is of constant assistance to the claim agent, as he truthfully gives a clear and honest statement of the physical condition of the claimant. In so doing he prepares the claim agent for every contingent in the evolution of the case, and thus never misleads. The claim agent is pre-eminently an agent of compromise; adverse conditions constantly make compromise a virtue. Compromise stands in relation to personal injuries upon the railway and litigation as prevention and cure. A case compromised saves a thousand elements of attendant worry upon the part of the claimant and a large expense upon the part of the railway. It is the best and most economical element for all concerned in personal injury cases, just as prevention in disease saves time, pain and ulterior consequences; while litigation involves every element of expense and is productive of mental disease and at time death. Honorable, just compromise should be encouraged whenever possible, with a desire to do strict justice. The field of compromise is one where honorable professional men rarely disagree, where dignity is maintained and a truthful, manly standard. Compromise will oftentimes permit a much nearer approach to strict justice than a court which necessarily permits the conflict of truth and falsehood, frequently to the exclusion of justice. Compromise offers to all concerned, the purest and best forms of economy; for the plaintiff, it takes away the sting of delay and irritating circumstance; for the corporation, it saves money and reputation. It is a well established fact that medical expert testimony, as used in litigation before the courts, has reached such a state as to be almost inaffective; it is certain that it is constantly unjust, not only to the plaintiff, but to the defendant as well. Certain it is that the respect accorded to the profession of medicine is not commensurate with its intelligence. The loss of individuality and the subserviency on the part of the medical expert is due in many cases to his relations to the party employing him and the adaptation of medical opinion to a theory built in law; be it true or not, it often prevents the procurement of unbiased opinion. This is pre-eminently true in cases of personal injuries occurring upon railways where an almost inherited prejudice enables the most ignorant quacks to give expert testimony. Possessing scarcely the elements. of truc medical education, these impostors are accorded credence equal to that given the most skillful of experts. So prevalent has this practice become that we have heard reputable lawyers say, that the railway, to be opposed in a legal trial, the ignorant medical witness will exert more influence over the average court and jury than the well-posted and honestly-inclined medical expert. It is not ignorance that has brought this deplorable condition about, of medical expert testimony, but duplicity, dishonesty and the ready adaptation of the medical expert to the views of the counsel. The lawyer, himself, rarely competent in his knowledge of medicine to make plain the learning, competency and proficiency of the genuine expert, is as equally certain to fail to detect the ignorance and utter incompetency of the ignorant expert. The value of the medical expert testimony should mainly depend upon the expert proficiency and learning in his profession; but this is very far from being the case in practice. Winthrop says: "Reform in the methods of using medical men as experts is a plant of slow growth. Suggestions and recommendations are offered in sufficient number and there the matter ends. English and American courts continue to follow traditional usages and show no willingness to find a better way. Each of the parties in a suit in litigation secures the services of medical witnesses favorable to him and leaves the witnesses to justify their testimony as well as they can. This being in accordance with the theoretical right of every person to call on behalf of his defense such witnesses as he sees fit." The medical expert is supposed to have special knowledge, skill and experience in medicine. First it is not necessary according to the existing tenets of the law that the medical expert should have practiced his profession, neither does the law take cognizance of what particular school of medicine the expert belongs to. Secondly, "The extent of the previous study and investigation and the amount of skill and information which must be shown will depend upon the facts of each particular case. But some special and peculiar knowledge or skill must be established, the amount of it to be determined by the trial judge in his discretion. The possession of such knowledge and skill is presumed in medicolegal cases if the witness is a licensed practitioner."-Tracy C. Becker, Medical Jurisprudence, Forensic Medicine and Toxicology. It is not relevant to the subject-matter of this paper to discuss the justice of the expert receiving other than the ordinary fee, but it is held in some states that the expert does not stand upon the same footing as an ordinary witness. That he is in the position of impart ing something of value, that his knowledge, skill and experience "is his property as much as any other thing movable or immovable of which he is possessed."-Becker. Under the practice of the courts of this country the expert is selected by the litigants. The amount of special and peculiar knowledge or skill of the expert is to be determined by the trial judge, and he is oftentimes a very good lawyer, but a very poorly informed person in a medico-legal way. The proof demanded does not generally bear the stamp of much profundity of thought, the statement of the qualification of the expert is usually made by the expert himself. He may qualify himself by proof of his legal right to practice the profession in which he is engaged, or by showing that he is conducting a business, a wide knowledge of which he should, but may not have. To testify as an expert there is usually no proof either offered or required as to fitness; generally the fact is accepted that the expert has been or is engaged in a business or profession which should give him the required knowledge and experience to qualify him. The question of his actual knowledge is left to be ascertained from his own answers on cross-examination. And as before stated, the possession of such knowledge and skill-in the medical expert-is presumed in medico-legal cases if the witness is a licensed practitioner. A legalized or licensed practitioner in our country, particularly in some western states, means merely a self-imposed or authorized prefix to a name to constitute a full-fledged physician. I was once informed by a medical student who had failed to pass the final examination at a medical college that he was now a legal practitioner, that he had passed a satisfactory examination before a local board of examiners in a neighboring state. Upon inquiry I elicited the fact that the local or county board in the county in which he was practicing consisted of a blacksmith, a barkeeper and a justice of the peace and as our informant expressed it, that there was "not much medicine in the crowd, but a good deal of muscle and whisky." When you take into consideration the ineffectiveness of medical expert testimony, the injustice of litigation and the improbability of accomplishing normal and just results, certain it is that compromise possesses exalted virtues in comparison to litigation, and the claim agent is but an agent of compromise. I cannot refrain from mentioning, at this juncture, the contributing elements of modern civilized life in generating mental conditions, and which, when brought in contact with the railway by an injury inflicted by it, the railway receives the entire brunt of condemnation, when the contributing elements are plainly and manifestly the cause of their existing form of life. We will not endeavor to enter extensively into consideration of the elements supposed, which lead to a generation of diseased condition and the production of what is pre-eminently a condition of modern civilization. Nor will we at this juncture refer to the influence of the excessive use of narcotics and stimulants, such as alcoholic drinks, tobacco, opium, nor the absorption of tainted foods and organic poisons and to other conditions tending in this direction. But in order to make our meaning more plain, we will quote from Nordau, as regards the peculiar influences of modern life in the production of hysteria: "The enormous increase of hysteria in our day is partly due to the same causes as degeneracy, besides which there is one cause, much more general still than the growth of large towns, a cause which perhaps of itself would not be sufficient to bring about degeneracy, but which is unquestionably quite enough to produce hysteria and neurasthenia. This cause is the fatigue of the present generation. That hysteria is in reality a consequence of fatigue, Fere has conclusively demonstrated by convincing experiments. In a communication to the Biological Society of Paris, this distinguished investigator says: 'I have recently observed a certain number of facts, which have made apparent the analogy existing between fatigue and the chronic condition of the hysterical. One knows that among the hysterical involuntary symmetry of movements frequently shows itself in a very characteristic manner. characteristic manner. I have proved that in normal subjects this same symmetry of movements is met with under the influence of fatigue. A phenomenon, which shows itself in a very marked way; in serious hysteria there is that peculiar excitability which demonstrates that the energy of the voluntary movements through peripheral stimulation or mental pre sentations suffers rapid and transitory modifications co-existing with parallel modifications of sensibility and of the functions of nutrition. This excitability can be equally manifested during fatigue. Fatigue constitutes a true temporary experimental hysteria. It establishes a transition between the states which we call normal and the various states which we designate hysteria. One can change a normal into an hysterical individual by tiring him. All these causes, which produce hysteria can, as far as the pathogenic part they play is concerned, be traced to one simple physiological process, viz., fatigue and depression of vitality.' Now to this cause, fatigue, which, according to Fere, changes health into hysteria, the whole of civilized humanity has been exposed for half a century. All its conditions of life have in this period of time experienced a revolution unexampled in the history of the world. Among the hysterical, and it must not be thought that these are met with exclusively, or even proponderently among females, for they are quite as often, perhaps oftener, found among males." *** The leading characteristic of the hysterical, says Colin, "is the disproportion of impressionability of their psychic centers. They are above all things impressionable. From this primary peculiarity proceeds a second quite as remarkable and important, the exceeding ease with which they can be made to yield to suggestion. The early observers always mention the boundless mendacity of the hysterical, growing, indeed, quite indignant at it, and making it the most prominent mark of such patients. They were mistaken, the hysterical subject does not consciously lie, he believes in the truth of his craziest inventions. The morbid mobility of his mind, the excess of excitability of his imagination conveys to his consciousness all sorts of queer and senseless ideas. He suggests to himself that these ideas are founded on true perceptions and believes in the truth of his foolish invention, until a new suggestion. Added to this emotionalism and susceptibility to suggestion is a love of self, never met with in the same person, or anything like the same degree. The hysterical person owns that 'I' towers up before his inner vision and so completely fills his mental horizon that it conceals the whole of the remaining universe. He cannot endure that others should ignore him. He desires to be as important to his fellowmen as he is to him self; an incessant need pursues and governs the hysterical to busy those about them with themselves. The means of satisfying this need is the fabrication of stories, by which they become interested. Hence, comes the adventuresome occurrences, which often occupy the police and the reports of the daily press. In the busiest thoroughfare the hysterical person is set upon, robbed, maltreated and wounded, dragged to a different place and left to die; he picks himself up painfully and informs the police. He can show the wounds on his body. He gives all the details. And there is not a single word of truth in the whole story; it is all dreamt and imagined. He has himself inflicted his wounds in order for a short time to become the center of public attention, and if in a railway accident his tales are never probable, but always miraculously colored." Now, then, hysteria is characterized by hyper-susceptibility to suggestion. He believes in everything suggested to him with sufficient impressiveness. The excited and the hysterical are never to be trusted; still their stories, when taken into account in personal injuries, are not only believed by the laity, but by the physician as well. It is, indeed, a marvel to what extent suggestion may go, particularly under excitable conditions. Nordau says: "Mede Goncourt relates that in 1870, during the Franco-Prussian war, a multitude of men, numbering tens of thousands in and before the Bourse in Paris, were convinced that they themselves had seen, and really part of them had read, a telegram announcing French victories fastened to a pillar inside the Exchange, and at which people were pointing their finger, but, as a matter of fact, it never existed. This is essentially the condition of a hysteric. They see, fell, hear and taste in suggestion." These remarks are interpolated in this paper essentially for the reason that while it is absolutely necessary for the physician to understand this modern enigma of civilization, still we believe that it is pre-eminently necessary that you, as claim agents, should be at least informed of the fact of its peculiar action upon the mental condition of modern man engendered by the peculiarities of his growth, progress and civilization. Before passing on, it may not be out of place to indicate the full force and effect of litigation upon the plaintiff in a law suit, as it will serve to give a strong and forcible reason why the |