First Aid and Emergency.

(Conducted by CHARLES R. DICKSON, M. D., Toronto, Can.)

FIRST AID ON THE RAILWAYS.

Buffalo, Rochester & Pittsburg Railway Company. Rochester, N. Y.

Replying to your letter, we have never issued any "First Aid to the Injured" literature to our employes. Our instructions to employes are to hurry injured persons to the nearest point on the line where surgeons are located. We have a number of surgeons on our line, and have never felt that instructions such as "First Aid to the Injured" would be of much avail in the hands of train

men.

GEO. E. MERCHANT, Gen. Supt. Toronto, Hamilton & Buffalo Railway Company. Hamilton, Ont. I am in receipt of your letter with inclosures, for which I thank you. The emergency boxes in use on this line are the same as those used on the M. C. R. R., which are fully described on page 171 of The Railway Surgeon, inclosed with your letter. Mr. W. J. Orr, superintendent M. C. R. R. Hospital Association, is also the superintendent of this company's hospital association. Our employes are instructed in "First Aid to the Injured" and "How to Use the Emergency Box" by Dr. Geo. S. Rennie of Hamilton, surgeon-in-chief of this company. E. FISHER, Gen. Supt.

W. L. ESTES. This slip is pasted on the inside of lid of every emergency box.

List of articles in the case and their uses:

I. Two Rubber Bands. For stopping hemorrhage. Apply on sound flesh above the wound. Draw tightly each time, and encircle the limb until the whole bandage is used. Fasten securely.

2. Six Assorted Muslin Bandages. For holding dressings in place, assist in stopping hemorrhage and hold splints upon fractured limbs. Wind around the injured part from below upward.

3. Five Yards Sublimate Gauze.-—A prepared dressing for open wounds. Always used to cover large wounds, applying wet directly to the wound.

4. One Dozen Pieces of Absorbent Lint.-To be used instead of a sponge in bathing wounds. Always throw away a piece after using once.

5. One Ounce Styptic Cotton.-This cotton is

per

meated with a substance which stops small hemorrhages. Apply directly to small wounds, and hold in place with muslin bandage.

6. One-Quarter Pound Absorbent Cotton.-This is for making compresses and to assist in covering a large wound. Do not apply directly to the wound.

7. One Bottle Sublimate Tablets.-These small tablets are to be dissolved in clean warm water, in the proportion of one tablet to a pint of water, in order to disinfect a wound and keep it free from infection. They are poisonous if swallowed, or the solution be drank.

8. Two Ounces Bicarbonate of Soda. For burns and scalds. One tablespoonful to a quart of water; saturate a piece of gauze, and apply over a burn or scald.

9. Four Surgical Needles.-To be used in closing small cuts or jagged wounds after thoroughly cleansing with the sublimate solution.

10. Pair of Scissors.-Used in cutting dressings, bandages, clothing, etc.

II. Pair of Forceps.-Used for removing bits of gravel and to sieze a bleeding artery while it is being tied.

12. One Bottle Carbolized Silk (three sizes).-To be used in tying a vessel when it is seen free and bleeding, in a wound; also for closing small wounds. Never replace back into the bottle any piece that has been used.

13. Two Ounces Green Soap.-This is perfectly bland soap, which should be used in cleansing an injured part around a wound. Apply and wash off with the pieces of absorbent lint.

14. One Roll Rubber Adhesive Plaster.-For closing small torn or cut wounds, after they are cleansed with the sublimate solution. It needs no heat; apply directly to the skin, which must be perfectly dry, however. 15. One Pyramid Pins.

16. Six Safety Pins.

Rules for treatment of the injured immediately after an accident:

1. Shock. This condition usually follows every severe injury. The chief point is to restore heat to the body, as soon as the injured person is put in a comfortable position. Do this by covering with heavy coats, previously warmed-if practicable. Cut off the shoes or boots, and envelop the feet in a warmed coat or blanket. Give only small dose of whiskey in hot water.

2. Hemorrhage.-This follows shock, and is rarely severe until reaction takes place. Too much stimulation increases hemorrhage and for this reason it is best to give only a little stimulant, well warmed, and repeat the dose if reaction is delayed.

Bleeding is of two kinds. First-Arterial, when the blood comes out bright and red and in spurts; second, venous, when the blood is dark and flows in an even stream.

A. To stop hemorrhage, when the wound is large and the blood comes out in spurts. Apply the rubber band tightly just above the wound, previously raising the wounded part, especially if it be a limb. Be careful to put the band on uninjured flesh if the limb be badly crushed, and about three inches above the crushed tissues, else it will slip down and increase the hemorrhage. Be very careful to see that the band be firmly hooked and fixed before leaving it. Small wounds, even though the

hemorrhage be arterial, require only a firm compress of the sublimated gauze placed immediately over the wound, and bandaged tightly in place with one of the muslin bandages. It is best after this to bandage firmly from the extremity (hand or foot) upward to beyond the wound with the muslin bandages.

B. Venous Bleeding, which occurs when the wound is shallow (does not go deeper than the skin), as a rule, requires firm pressure over the wound, and especially below it. If the wound be quite small, put a wad of styptic cotton into and over it and bandage tightly in place and then apply a bandage from below upward over and beyond the wound. If the wound be extensive, fill it full of sublimated gauze, and then put a thick wad of absorbent cotton over it and bandage tightly from below upward.

C. Bleeding from the head, if only the scalp is involved, may also be controlled by drawing the rubber band around the head, encircling it just above the eyebrows. This is very painful, however, and, unless the bleeding be very severe, it may be controlled by bringing the wounded or torn surfaces together, and applying along the wound a thick layer of styptic cotton, and over this another layer of absorbent cotton and a tight bandage. It is well to pass the bandage under the chin if the wound. be on the top of the head, as this holds it firmer and tighter.

3.

Remove the clothing from a wounded part by cutting it away. Do not attempt to tear or draw clothing off, as this may further injure the wounded part. Always see the wound, and know by your eye just what the nature of it is.

4. After Hemorrhage Has Been Stopped.-The next point is to prevent the wound from being infected and thus prevent blood poisoning. To accomplish this the wound should be cleaned if badly soiled. If soiled by oil and soot or dirt, bathe it gently with a small quantity of green soap and warm water. After it is apparently clean, wash it out carefully with a pint of warm water in which one of the corrosive sublimate tablets has been dissolved, using the bits of lint to do this. Then wet several layers of the sublimated gauze in a fresh solution of the same strength used in washing the wound, and lay them over the wound and bandage in place with a muslin bandage. Always cover an open wound with a piece of gauze wet in the solution of corrosive sublimate (three tablets to a pint of water) before transporting the wounded man. Never allow an open wound to remain unprotected longer than the time employed in stopping hemorrhage. Remember a soiled covering is worse than none at all, however.

5. Fracture. If a bone be broken in any of the limbs the member should be firmly fixed before the injured individual be moved. If this be not done, great injury may result by the movements of the sharp fragments of the broken bone while the individual is being transported. Any flat piece of smooth board or slat, broken or cut into strips long enough to reach beyond the two nearest joints, will do. A bundle of twigs or stout straw may also serve when nothing else is to be had. Always put one of the improvised splints on either side of the limb, then tie a bandage over the splints at either extremity and in the middle. If there be a

wound treat it according to the foregoing rules and then apply the splints, using some clean "waste" as padding or some strips torn from clothing. If there be no wound apply the splints over the trousers or sleeve. If nothing of any kind can be obtained to make a splint, tie the fractured leg or thigh to the sound one, or the fractured arm firmly to the side of the body, by a muslin bandage.

6. Compound fractures are fractures accompanied by a wound of the soft tissues at the point of fracture, so that the bone is exposed to the air. In these cases treat hemorrhage and the wound according to the foregoing rules, and then apply splints. If the bones project beyond the skin remember to bring them back into place by pulling the extremity in the direction of the displacement, never in the direction the bone normally should be, until the ends of the fragments are quite free from any overriding. Be very careful always to cover these wounds with the wet sublimate gauze and bandage it on. 7. Burns.-Carefully remove the clothing by cutting it off, if the part be clothed, and apply immediately three or four thicknesses of the sublimate gauze wet in warm water, in which one tablespoonful of the bicarbonate of soda to the quart has been dissolved. As a rule never attempt to clean burns immediately after they occur. Cover the wounded part immediately as directed above and leave the cleansing to the surgeon afterwards.

Extensive burns are attended by great shock, as a rule, and require free stimulation. As burns are very rarely followed by hemorrhage, stimulants may be and should be given in considerable quantities.

8. Prostration from Excessive Heat.-In these cases (not sunstroke) the face is pale, lips colorless or blue, breathing slow and quiet, pulse slow and very weak. Place the patient on his back, with his head level with his body, and loosen clothing. Apply heat to the surface of the body and extremities. Bathe the face with warm water, into which a little alcohol or whiskey has been poured, and if he can swallow, give the patient an ounce of whiskey in as much warm water.

B. Prostration from Drinking Too Much Ice Water When Overheated.-The face is red or even purple, breathing heavy and irregular, pulse irregular. Loosen clothing, place on back, with head slightly elevated. Give hot drinks, apply heat to the spine and the extremities. 9. Position in Which a Patient Should Be Placed After Injury.-Injuries to the head require that the head be raised higher than the level of the body. In all cases, if practical, lay the patient on his back, with the limbs stretched out in their natural positions; loosen the collar and waistbands, and, unless the head be injured, remember to have the head on the same level as the bodydo not bolster it up with anything.

TEACH FIRST AID TO FIREMEN

Questions pertaining to the care of persons injured, burned or overcome by smoke at fires will be inserted in civil service examinations as one of the requirements for a position as fireman on the Chicago fire department if Chief Musham has his way. Following a plan inaugurated by the fire department of Evanston, Chief Musham

says he will endeavor to teach his men the science of medicine in so far as it pertains to relieving the pain of burns or resuscitating persons overcome by smoke.

In addition to this, he may petition the city council to supply cabinets containing instruments, lint and bandages to be fastened to fire wagons, one at each engine house. Chief Musham-just back from New York-was enthusiastic in expressing his favor for the medicinal attachment to the fire department.

"There is no doubt that many lives could be saved by such a plan," he said to-day. "It is something that seems absolutely necessary. There are many instances. at fires where firemen and occupants of buildings are overcome by smoke. In many instances there are no physicians handy and the victims suffer for hours before. they receive medical attention. This often results in fatalities."

The Evanston firemen are to be treated to a series of lectures on "First Aid to the Injured." Each one will be required to carry a small medicine chest.

THE FIRST DRESSING ON THE BATTLEFIELD. In a paper read at the XXXI Congress of German Surgeons, Berlin, Paul von Bruns recommends, especially for the treatment of bullet wounds, a salve of xeroform kept in zinc tubes, in which it will not decompose. This salve is to be of the following composition:

Xeroform, 21⁄2 drachms.

Bol. alb., 13 drachms.

Mucil. gumm. arab., 5 drachms.
Glycerine, 5 drams.

F. pasta mollis. In zinc tube.

Prof. v. Bruns condemns impermeable dressings which prevent desiccation of the wound, and recommends xeroform because of the disadvantages of iodoform and salicylic powders.

Herman Kuttner, who took part in the Boer war, in a paper on "Shot Wounds of the Extremities," says: ""The first dressing decides the fate of the wounded;' this old maxim of Volkmann will never lose its significance. How First Aid on the battlefield is to be applied is not the subject of this paper. I will rather confine I will rather confine myself to a few salient points in the treatment of bullet wounds of the extremities. For this purpose I recommend the Bruns paste. Especially useful is the xeroform salve (according to the investigations of Honsell, xeroform has a greater antiseptic power than airol), for it does not decompose in zinc tubes. This container has the advantage that every ambulance surgeon can carry it in his pocket and have it ready to express the salve upon the wound. If the ointment is then covered with gauze or cotton, a pervious and antiseptic dressing which answers every requirement has been prepared."

The value of xeroform in army surgery is also attested to by Dr. Emilio Neguera, who used it during the Spanish-American war, and states:

"I had the satisfaction to find all the wounds entirely aseptic when the xeroform dressings were removed. This is practical proof of the fact that this simple xeroform dry dressing can be employed on the battlefield itself to keep wounds aseptic for from two to three days; a length of time more than sufficient for the removal of patients to the hospital."

Extracts and Abstracts.

LEGAL RAILWAY SURGERY.*

BY H. C. FAIRBROTHER, M. D., EAST ST. LOUIS, ILL., Professor of Railway and Military Surgery, Marion-Sims-Beaumont College of Medicine, St. Louis.

The phrase "Legal Railway Surgery" is used, for the want of a better one, to include the various forms of service which may be rendered by the railroad surgeon outside of pure surgery. This service may appear in the following forms:

In the making of prompt and accurate injury reports. In aid to the legal and claim departments.

In using all proper means to prevent litigation and claims.

In the general and economical management of the injured, whether employes, passengers, tramps or others. In keeping the company in close touch and friendly relation with the injured.

In attending court in company's behalf, either as witness or as expert.

In the physical examination of employes and applicants for employment.

In giving instruction in First Aid to employes. In the making of economical arrangements with hospitals and undertakers for their service when needed. In the emergency management of the injured in large numbers, such as occur in wrecks.

Aid in sanitary work, as in the fumigation of infected cars and warehouses, and in the heating, ventilation and water supply of coaches.

Assisting in the management of contagious diseases and quarantine.

In the management of the disinfection and proper packing of dead bodies for shipment.

All these subjects come within the province of railway surgery, though they are not yet fully understood or appreciated either by the companies or the surgeon. We are not yet educated. Railway surgery is in its infancy. The idea of its broader development and higher mission is not yet fully grasped. To many surgeons and. railway officials it has little higher meaning than the amputation of a finger or an occasional pass. The surgical department is still in its trial stage, and if it takes its place in comparative value and importance with other departments it must be through a better understanding and. performance by the surgeon of these collateral branches of service. The limits of one paper being entirely too brief to even touch upon all the above topics, this paper will be confined to the first two only.

THE INJURY REPORT.

The importance of this report can hardly be overestimated. Any injury, no matter how trifling, is liable to swell into the dimensions of a big law suit, and without a complete and accurate report, detailing the character of the injury and the circumstances under which it happened, the company is placed at a great disadvantage. I recently heard it stated by a superintendent that he considered the injury report alone worth the cost of the

*Read at meeting of Association of Railway Surgeons of Southern Railway, Washington, D. C., June 6, 1902.

surgical treatment. These reports should be made upon the day of the injury, or as soon thereafter as the diagnosis can be properly made. They should be made with copying ink or pencil, because it frequently happens that copies are required for other departments. It would seem a comparatively easy matter to make out one of these reports, where the forms are all printed and only the answer of questions required. But to be convinced to the contrary one has only to look over the files as they appear in the office of any superintendent or chief-surgeon. A large number of these reports he will find utterly unintelligible in many important points. In some the penmanship is such that it cannot be deciphered, and even the spelling is faulty; in others the description of the injury is so brief and vague as to give no definite information of the pathological condition, while in some, many important questions are left unanswered. Too much care cannot be given to the making of these reports. They should be full and clear in every particular and written in a legible hand.

The description of the injury is a matter deserving of greatest attention. While this should be concise it must be sufficiently clear and complete, and contain a description of each particular injury in cases where more than one exist. In the majority of blanks supplied the space allowed for this head is entirely too limited. The reply to this question is not always an easy matter. In many cases the diagnosis is difficult and in some it is impossible. In cases of internal injury, injuries to the head and fractures about the joints it is often difficult to name the exact point and extent of the lesion. But in such cases it is the wiser course to give preference to the milder form of diagnosis. If legal questions arise an exaggerated diagnosis prejudices the case. In injuries to the bone, if there is not positive evidence of fracture, such as distinct crepitus or plainly visible deformity, the word "fracture" should not be used. The phrases "fractured rib" and "fractured ankle" are used, it is to be feared, with too much frequency, and sometimes disregard for true pathological conditions. "Fractured ankle" is a misnomer. The ankle is a joint and has no bones to fracture. Also the word "dislocation" is to be avoided unless there is positive evidence of its existence. So likewise in injuries to the internal viscera. We may suspect dislocated kidney or rupture of the liver, but a less formidable diagnosis is the better policy. These remarks are especially applicable to injuries which occur to passengers. They grasp at every straw of serious diagnosis and make the most of it.

Great aid is given to the clearness of this description by marking with red ink the line of injury upon the diagram. In a recent case against the Mobile & Ohio, the plaintiff alleged that the man who had been fatally injured was struck by a projecting car door and his skull crushed. There were no witnesses to the accident, and the only evidence to disprove the car door theory was the surgeon's report which showed that the cause of death was the passing of a car wheel over the side of the head, shoulder, and side of chest, the line of which was clearly marked upon the diagram.

The statement of the injured party with regard to the circumstances under which the injury occurred is

often a matter of great future consequence. To obtain this in every detail sometimes requires great tact on the part of the surgeon. If asked in a formal (etc.), manner, it will often be refused entirely or given in such a guarded manner as to destroy its value. In most cases it will be given voluntarily or require but little help by way of suggestion or indirect inquiry.

It is important in this statement to include whether or not there is any blame attached, and, if so, to whom and just in what particular way. Some companies require the signature of the injured party to this statement, and one company asks that the signatures of two witnesses to this statement be obtained. This is a well meant effort on the part of the legal department to increase the value of these statements. But the wisdom of it is questionable. The man will make a much freer and better statement without formality than with it, and I have never yet known a man to go back on the statement he made to the surgeon. And, further, the man that is seriously injured, although he may be able to relate how it occurred, is not in a condition for writing his name; neither do his friends look upon it kindly when he is asked to do so. Also, in procuring these signatures the surgeon places himself too much in the attitude of a claim agent to be consistent with the best professional confidence.

The various other questions in these report forms, such as "Disposition of the Patient," "Prognosis," "Probable Time of Disability," etc., are all of great importance, but the limits of this paper will not permit entering upon them.

AID TO CLAIM DEPARTMENT.

By the surgeon aiding the claim department, I mean only in a helpful way, and not in an officious or independent manner. When a claim is made the subject should be labeled, "Glass, handle with care." None but an artist should touch it. Only the right word at the right time should be spoken. An awkward speech may give it deeper root and cause it to grow like the green bay tree. A kindly conversation may cause it to melt away like the clouds after an April shower. The companies employ men for this work. They are experts. They make a study of human nature along these lines. They get hold of the heart strings and control the action to a favorable issue. But the surgeon stands near the patient and his friends. He is behind the curtains. He feels the moral pulse. He hears the first rumblings of the damage suit storm and is often in a position to throw oil upon the troubled waters. He may often cause the claim to be abandoned, or, for a few dollars, compromise a claim which, if it went to suit, might cost many thousands. A few years ago a case in East St. Louis against the B. & O. S. W. could have been settled for seventy-five dollars, which afterward cost the company seven thousand five hundred dollars.

But the place where the surgeon may be of greatest help to the claim department is in giving an exact diagnosis and prognosis as to the physical condition. This is often a matter of the greatest difficulty and sometimes an impossibility. The greatest of all problems in all these cases and hardest to solve is the matter of feigning. Malingering is inlaid in all nature. The lowest orders

of animal life practice it for a purpose, then why should not man. Errare est humanum. It is true that in some cases where claims are presented for personal injuries the injuries are not exaggerated, but these are so few as to be hardly worth mentioning. The great majority exaggerate their injuries, and in many cases the feigning is entire, there being no injury whatever. There is probably no passenger train but carries some dangerous freight. Men and women who long for a wreck, a jostle, a fall, something on which to base a claim. In the lottery of wreck they hope to win the prize of injury.

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At a recent trial in East St. Louis against the Chicago & Alton, a witness testified that plaintiff had stated to her that "an easy way to make some money was to get on a train and fall, or pretend to get hurt in the car, and sue the company for damages." And such is the frequency of these damage suits that their trial becomes the chief occupation of many of our courts of justice. Railroads that were benefactors to the country through which they passed, causing villages to spring up and the land to bloom like a rose, have been utterly strangled to death by the poison-vine of innumerable damage suits. Such is the ease with which judgments are obtained against these panies that unscrupulous people make a business of bringing these suits. They ride on trains with that object in view. Upon the slightest collision or unusual jostling of the car they fall forward or backward against the seat, or, perchance, out into the aisle, carefully bump their heads upon the floor, and then, in due time, turn up with some nervous disorder, or, may be, insanity. It is these cases that try the skill and patience of the surgeon and the claim and legal department. A judgment of thousands of dollars may be threatened and yet they know that the entire case is a trumped-up affair. In such cases the surgeon, if notified in time, may be of great assistance in discovering the malingering and thwarting its purpose. In a recent case against the Southern Railway, in Belleville, Ill., the plaintiff alleged "nervous spells" and "trembling fits" for the past ten months, following an injury. caused by falling down in the aisle of the car upon a slight collision, though it developed in the testimony that he consulted his watch and noted the time immediately after the falling, got out of the coach and inspected the damages to the pilot of the engine, and then spent the remainder of the day going about the town in his usual avocation, which absolutely excluded the theory of any serious injury to the brain. And yet this man got a judgment of seventeen hundred and fifty dollars. In this case the company's surgeons were not notified until the day of trial. In 1882 a claim for $20,000 was brought against the Cairo & St. Louis Railway, now owned by the Southern Railway Company, for injuries said to have been received by a Mrs. W. in a collision. There was no evidence or report of injury at the time further than a slight jostling and shaking of the coach. Nothing was heard of the case until some months afterward, when the company was notified of the suit brought on account of injuries received, resulting in insanity. The certificates of two eminent medical men of St. Louis, and the testimony of numerous witnesses were offered in proof of the insanity. After some months' delay and consid

eration, a proposition for compromise upon the basis of five thousand dollars was taken under advisement. At this juncture the writer was asked by the superintendent to investigate the case and report to him. Permission being granted by the plaintiff's attorney to visit the lady as often as desirable, the task of investigation began, which proved not to be a difficult one at all, as I was convinced, upon my first visit, that the symptoms were largely, if not altogether, feigned, and my investigation consisted in making bi-weekly visits, sitting down beside the bed and listening to a tirade of affected insanity. After some weeks of these friendly visitations the rooms were found vacant, the patient and her husband having flown to other quarters. In a short time, however, they were found again and the visits renewed. At length, becoming weary of these regular and persistent attentions, the good couple again disappeared. During this time there had been no improvement in the symptoms. At every visit she was wildly, sometimes violently, insane; clutching the bedclothes, staring at the ceiling, and using abusive language. The husband frequently came forward and begged of me not to be disturbed or thrown off my balance by the bitterness of the speech, because in former times his wife was the very queen of peace and tranquility.

Now they had again departed and great difficulty, requiring fully six weeks' time, was experienced in their location, which was finally accomplished through the unwilling aid of their attorney. On arriving at the house, number of which had been given me a few days before, and located in one of the most distant and obscure parts of St. Louis, I found the couple had again departed, leaving only a few hours before my arrival. But here a revelation was in store. In going into the house and entering into conversation with the family I learned that Mrs. W. had showed no symptoms whatever of unsound mind since her stay there for a period of six weeks. That she had done light housekeeping, bought her groceries from the store, her vegetables from the hucksters, read the evening paper to the family and in every other way deported herself as a sensible woman should. The names of all this family, and also of some neighbor acquaintances, were carefully taken and the matter laid before the superintendent. This evidence was presented to the plaintiff's attorney and the suit was prosecuted no further.-International Journal of Surgery.

A NEW PROTECTIVE DRESSING.

The

Karl Springer describes a new protective dressing, which is intended especially for use in plastic operations, skin grafting, etc., where it is important to keep the dressing from adhering to the surface of the wound. various materials, such as rubber tissue, oiled silk, oiled gauze, etc., which are in general use for this purpose, are open to the objection that they stand sterilization by heat but once, after which they must be preserved in some antiseptic solution, which often impairs their strength or pliability, and always requires washing off in sterile water to remove before use.

The substance which the author employs as a substitute is paraffin of a melting point of 113 to 116 degrees F.