claim agent, in performing his function, can be enabled to lessen disease-producing circumstances. It is a well-established fact, particularly in a certain class of cases which are the most troublesome and the most expensive for the railway, and known by the name of railway shock to the spine; but happily now, owing to honest work, they have been relagated to other causes as well. Permit me here to cite from Herbert W. Page regarding the baneful influences of litigation and causes of chronic invalidism. It is a well established fact that among the sociological problems attendant upon modern civilization, the general bestowal of damages in this class of cases is a portentous and ominous threat as regards existing social conditions. It is recognized by all competent authority that the chance of money redress is now greater than ever before; hence we have an invariable tendency inherent in human nature when anyone is injured upon a railway to exaggerate every symptom and by a more or less voluntary auto-suggestion construct a case which never would have existed had not the railway inflicted it. In fact, it is a pure litigation trouble engendered by social conditions, particularly the prospective gain, created by the competency to pay, of the inflicting agent. Let us now quote Page: "And out of this very exaggeration arises another cause of prolongation of the illness. The exaggerated estimate of the symptoms themselves leads to an erroneous estimate of the present incapacity and to an increasing belief in the impossibility of future recovery and usefulness; hence it is only natural that differences of opinions arise between those who are entitled to receive compensation for the injuries and for the perspective consequences, and those who have provided and who take a wholly unsentimental view of the value of the patient's health and life. Months, perhaps, are thus wasted in disputing about the claim, or, worse than this, the man is drawn unwittingly into litigation and is subjected to the anxieties and worries which a lawsuit involves. What surer means than this for aggravating the symptoms. Is recovery possible under such an influence? Is there not, indeed, every likelihood that the symptoms will get worse and worse, or at best, undergo no change, and is it not more appropriate now to call them litigation symptoms' than those of general nervous shock? *** Make all the allowance that may honestly be made for the

special circumstances of terror attendant upon a railway collision (and I would not for a moment seek to lessen their real influence) and compare the state of one waiting for compensation, whom for the nonce, we will call a railway patient, with the state as nearly similar as may be of a hospital patient, who has no compensation to look forward to, and who has been compelled to resume his work as soon as he was able, and then see how different is their lot, and how infinitely less wretched is the one man than the other. The hospital patient has long ago been well, while the railway patient has been waiting for months, it may be, unt!! compensation has been paid him, believing that he could not return to work and to a natural and more healthful mode of life. Settle your claim and get to work, is the best advice which can be given a man in these circumstances. Get to work and you will soon find you have the strength for it and will forget the gloomy prognostications of those who say that you can never tell what may happen after a railway accident, and that you ought to wait and see how things turn out."

We have often thought that if Erichsen, in his graphic and classical work on "Railway and Other Injuries of the Nervous System," had confined himself to clinical description, his work would have stood in the light which its merits deserve. But when he gave the details of the monetary consideration received in each case, he aroused the cupidity of the world, and he detracted from the pure, scientific character of his exposition. The damages awarded were enormous and before undreamed of. We read "the question of damages resolved itself, to a great extent, into one of loss of income and expense incurred." "The jury awarded £5,775, or the plaintiff recovered £6,000." In this country, owing to the example quoted, damages have been awarded in this class of cases as high as $49,000. From that time railway spine and railway brain became speculative troubles. Not a physician who was not impressed, dishonest ones not only supplied the legal side of the question with its medical data, but invariably pointed to the financial side. No medical book ever written has been more ex tensively read by the laity, and none, certainly, has ever been more closely studied. It has been the means, by its plain, graphic description, of educating more malingerers than any single book eminating from a professional mind.

It has been the foundation of compensation. If the baneful effects of compensation lead to the production of marked psychic anomalies, the story of rewards of damages, first detailed by Erichsen, plainly emphasized this factor and made it a disease-producing agent. In describing a new trouble Erichsen made operative a new influence, which, in its turn, is oftentimes more serious in its effects upon the psychic condition of the injured person, than traumatism itself.

We will not bore you by any more reference regarding either litigation or the creation of medical troubles through this means, but we desire to say that the great lacking element in the compromising of claims is the fact of a lack of closer harmony between the surgeon and the claim agent. This is particularly so in railways which have no organized medical service, or depend upon different medical examiners. We do not know of any more perfect arrangement in the compromising of claims than that at present existing in the hospital department, as at present established upon some railways of this country. They are the means of giving a continued experience, a close contact, a perfect understanding of claim agent and surgeon, and if there be any virtue in experience and familiarity with the multi-faced conditions surrounding the railway surgeon and claim agent, these are certainly engendered by hospital departments. With this assertion, we will then proceed to detail the benefits of a railway hospital department in the shape of compromise and the perfect settlement of claims.

The hospital departments possess the following advantages: First, they are the means of concentrating all the injured employes in the hospital of the department, and surrounding them with elements which are conducive not only to their physical, but to their mental welfare as well. Humanity and truth should constitute the basis of treatment in any hospital department, and it can be proven that they have been the means of mollifying and changing prejudices into calm, considerate and sensible action more than any other means which can be suggested. We do not believe that the concentration of all the injured employes into one place, as in a hospital, debars them from receiving injudicious and bad advice, or that it is a potent cause of preventing litigation, for sufficient liberty is always allowed for them to consult whom they desire. When frankness, hon

esty and truthfulness mark the treatment of the hospital physician to their patients, there is created a mutual confidence, which almost always leads to well-considered action. There is never any endeavor to deceive, but a plain discussion of conditions as they exist. The possibilities and probabilities of future capacity to work are all plainly considered and indicated. The employe truly knows that the claim agent of the railway company will endeavor to settle with him at the most favorable terms he possibly can, for he has been taught this by the experience of others; hence he expects nothing from this source, but a regular combat, all hinging upon the liability of the company in the infliction of his injury.

It is admitted that many consider that any person, in order to serve a railway company, must necessarily indulge in trickery and loss of individuality; yet from many years' experience we know that the reverse of this is true. None appreciates the integrity of any man more than the intelligent and competent railway manager. It has been our duty and pleasure to take injured railway employes to the claim agent and insist upon the employes listening to every statement made to the claim agent; nothing being left hidden or unstated, but a plain and truthful statement being made of facts indicating the extent of injury, the likelihood of permanent disability and any condition likely to arise in the future; even giving advice to the patient in the presence of the claim agent, that he had better not settle if at all uncertain as regards the future. When this has been done for years, there will be naturally engendered confidence upon the part of the employe from the fact that the previous experience of others indicated the honesty and truth of both claim and hospital department. Again, the union of the hospital department with the claim department of the railway enables the accumulation of a truthful history of any personal injury to employes, passengers and others. With the employe, this history extends from the inception of the injury along with a daily history until recovery, debarring dishonest persons from falsification or the substitution of origin in doubtful injuries.

Secondly, it relieves the railway company from paying doctors', board, drug, funeral and other bills in the treatment of the injured employes, as the hospital fund is always competent to pay these. That is, these hospital de

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 association 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 anaesthetics 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 acciIdent 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