NEGLIGENCE,* BY DR. A. F. JONAS, OMAHA, NEB.

Negligence signifies: “(1) Not to treat with due attention; to forbear one's duty to; to suffer to pass unimproved, unheeded, undone or the like; to omit; to disregard; to slight, as to neglect one's, duty or business; to neglect to pay one's debts; to neglect interest or policy; (2) hence, not to notice; to forbear to treat with attention or respect; to slight; (3) to cause to be omitted; to postpone."

Who of us cannot look back and recall an endless number of opportunities that have presented themselves and have been permitted to pass on account of neglectfulness? Who of us is not reminded of chances passed unheeded, chances that might have changed the course of our careers? Neglected duties which brought failure instead of success? The mile posts of our lives are dotted with a continual succession of omitted duties, great and small inattentions that have retarded our advancement, and which have ended sometimes in the injury of others as well as ourselves. With what avidity we take note of the neglect in others and how blindly we pass over our own omissions and shortcomings? Yet, if we are true to ourselves, we must all plead guilty to the same offense. Being convinced that we are no better than our neighbors, we ought to strive to advance, to do our duty, to be better, to find the cause or causes of our neglect. To do this we are grappling with a problem, if we wish to understand it in only some of its phases, that will take us far beyond the scope of this paper.

Before we proceed to discuss such a great theme as it applies to the ordinary vocations of life, we should, for a moment, consider it as it affects our profession, as it affects us personally as surgeons. We cannot deny that a lack of knowledge of the subject in hand is responsible for neglected opportunities in the proper management of many cases. This defective knowledge is in the character of inefficient training or of defective memory, and, consequently, impaired judgment must follow. Occasionally, the attendant is afflicted with temporary or permanent physical disability which disturbs and inhibits normal mental activity. Neither can we deny that there are among us some, who, from an innate indolence, physical among us some, who, from an innate indolence, physical and mental, seldom see an opportunity. Then there are, unfortunately, a few whose moral responsibility is so blunted that they trust most matters to chance and luck. We have not met to-day to discuss the character of the medical profession. We are here to consider ways and means to better the railway service, so far as it affects the physical and moral status of those whose busi

*Read before the ninth annual meeting of the American Academy of Railway Surgeons, held at Kansas City, October 2-3, 1902

ness it is to safely conduct the transportation of passengers and goods.

The men in the train service are not unlike those in all other walks in life, no better and no worse. They respond to the same influences and the same environments as others. Surgeons are human, and so are trainmen. In both callings we have the highest types of men. Men who are conscientious, painstaking and loyal, as well as those whose chief characteristic is moral obtuseness, and whose chief aim appears to be a shirking of duty.

Negligence as applied to trainmen, as well as others, may be discussed under the following heads:

(1) Those who are morally irresponsible, morally insane, if you please, who shirk every duty when possible, who consider it a great achievement to give the least pos sible service for the greatest amount of pay, whose chief attributes are dishonesty and deceit, who glory in creating discord, and whose greatest joy consists in annoying their co-workers and superiors.

(2) Those of intemperate habits, whose judgments have been impaired by vicious practices.

(3) Those who by inheritance or early training are morally irresponsible, who suffer no twinges of conscience from neglected duty so long as the omission is not discovered by their superiors.

(4) Those who from an innate mental incapacity are unable to master the details of their duties.

(5) Those who, on account of chronic indolence, will not master the rules governing their duties.

(6) Those of superficial habits, who learn their duties by halves, who, in their conceit, can be told nothing.

(7) Those who are illiterate. Willing enough they are, but they have escaped the rudiments of an education.

(8) Those who suffer from permanent or temporary disabilities.

(9) Those who suffer from defective eye-sight and hearing.

The foregoing classification might be extended and amplified, but it is sufficient for our purpose at this time. As railway surgeons it behooves us to point out the defects in the man and indicate the remedy. We, to a certain extent, must see to it that only qualified men enter the service and yet, when we scan the array of moral and mental defects, not to speak of the physical infirmities that may be responsible for negligence, we must confess that some of the most glaring deficiencies, viz., moral and mental, are often past the surgeon's finding out, and certainly beyond his control. So the duty of correcting and purging the service of the morally irresponsible, the intemperate, the mentally incapable, the

chronic indolence, the dishonest ones, the superficial and the illiterate, falls on the shoulders of those under whose immediate supervision these men labor. Superintendents and foremen quickly detect this class of men, and quickly discharge them, knowing only too well that the transportation of human beings involves responsibilities too great to be entrusted to men whose integrity and loyalty is questioned.

As surgeons we must occupy ourselves with matters that tend to eliminate conditions that may lead to negligence, viz., the last five propositions in our table, defective visions and hearing, physical defects, overwork, mental worry and amnesia.

It

There is, perhaps, no public or private service wherein we hear so much about negligence as in the train service of a great railroad. In no service are so many precautions taken against negligence as in the operation of a great trunk line. No expense has been spared. Every device and method that can add to the safety of the running of trains has been eagerly adopted. But, in spite of these, innumerable accidents occur. Improved graImproved gradients, the elimination of curves, improved roadbeds, double track, block system, automatic brakes and couplers have reduced accidents in a very gratifying measure. would seem that methods of transportation had reached a state where accidents are impossible, and they would be, could the movements and actions of employes be regulated with the same mathematical accuracy, if men's minds could be regulated and controlled in like manner. Men will go about their duties without due attention; they will be unheedful; they will omit an important detail; they will disregard an order; they will slight their work, or do it imperfectly; they will postpone an important duty until, all too often, a disaster cannot be averted.

The managements have spared no cost or pains to make railway travel as safe as possible, and still it is not safe. With our fast moving trains and the liability of a breakage in the mechanism of engine and cars, railway travel can never become absolutely safe. On a critical investigation, we note with what care every appliance, every machine, stations, roadbed and bridges, fuel, water and lubricants are inspected and tested by every means known to modern science. Every defect is remedied at once. If an appliance can be replaced by a more improved or a better one, it is done.

But what of the most wonderful and most important factor in the train service, the man? Is he selected with the same care, is he put to the same critical tests that the mechanical appliances are? It is true that nearly all our great trunk lines are exacting a high standard in reference to eyesight and hearing. But what of the physical condition? Under the eighth head in our etiologic list for negligence, we must admit that temporary and permanent physical disabilities play a great part in the question of negligence. A man in order to perform any task well, in whatever walk of life he may be, must have a body free from pain and defects. It was the writer's privilege to be "called on the carpet" before a committee of the Brotherhood of Locomotive Engineers and Firemen of the Union Pacific Railway shortly after the inauguration of the present plan of physical examination, to explain why many physical defects, unimportant to the layman, should disqualify an otherwise good man. The reasons given why any painful defect, or any defect that might at any moment become painful, should disqualify, were, that no man can concentrate his mind on the work in hand when he is suffering pain or physical discomfort in any form. He cannot keep his wits about him. He overlooks and omits important details of his work. He mis

understands the reading of a message, or forgets it entirely. If his physical suffering is great he fails to comprehend the significence of danger signals. If he has defective joints, they may interfere with prompt action at a critical moment, and he is then charged with negligence.

That acuity of vision, color sense and hearing should be normal in all new applicants has been conceded and is insisted upon by the majority of railways in this and other countries. Most rigid examinations for eyesight and hearing are made. The same degree of care should be exercised in reference to physical defects. A man entering the train service cannot be too perfect in physique. The exactions and requirements of trainmen become more severe as the train equipment conforms more to the most recent standards. He must start in his career with the greatest amount of vigor and endurance. He must have no physical defects that can handicap him. If it is true that to be healthy in body means to be healthy in mind, we must search for the requisite mental qualities in the physically perfect man. If this be true-and no doubt it is-we have found the man suited to the purpose, a man in whom the chances for inattention, omissions and negligences have been reduced to a minimum. The traveling public demands a safe transport. To accomplish this, means not only a perfect roadbed and perfect equipment, but the best equipped men. A rigid physical examination for all new men must be enforced. Re-examination at stated intervals must be insisted upon in order to note defects that have been acquired since entering the service. A thorough surveillance by the officers and surgeons will not only make it possible to know a man's deficiencies and his capabilities, but it will be possible to prevent intemperance and excesses, consequently to promote self-preservation and sobriety, and thereby lessen the chances for negligence.

Negligence is often ascribed to overwork and loss of sleep. Men may become fatigued when overburdened and fall asleep at their posts of duty. All railway officers recognize this. They know full well the dangers that stand before the man who has worked over hours, consequently, every man, except in emergencies, is given his full time for rest.

The man suffering from mental worry and trouble should not occupy a post where quick, decisive and prompt action are required. His mental suffering may, for many moments, blot his duties out of his mind and all too often he realizes his omissions when too late.

This brings us to a class of unaccountable cases where the man is apparently normal in mind and body. He never has been charged with a breach of duty; his conduct has at all times been exemplary; he has seen many years of honorable service; yet, he will on an occasion drive his engine past a danger signal, looking straight at it; but he does not see it, he does not heed it, he does not realize its significance until a collision rouses him to a realization of his whereabouts. In one of these cases where an engineer pulled his train past a red light and realized his situation only when a head-end collision was inevitable, in reply to a question why he did such a thing, said, "My mind must have stopped working." He had

the solution of his case. He had lost no sleep, he had had no worry, he, in common parlance, was absent-minded. In the language of the neurologist, he was affected with temporary amnesia. This is a condition present more often than commonly known, for, notwithstanding good luck attends many men, good fortune seeming to have willed it that no harm befall them, others are less fortunate. Amnesia is often associated with physical defects. We know that amnesia, or morbid forgetfulness, may be associated with every painful condition. It is a result of all excesses. All mental disturbances, all emotional excitement may and does, at times, carry with it amnesia optica (psychic blindness), amnesia acoustica (psychic deafness), verbal amnesia (impairment of memory of spoken or written words).

Amnesic manifestations may be the forerunners of grave neuropathic affections, hence the necessity of occasional examinations and re-examinations of old employes.

The re-examination at stated intervals, of old employes, while it does not find favor with them, is of such great importance that its gradual adoption is certain and imperative. The trainman naturally believes that his own personal interest is paramount, and anything that places his means of livelihood at stake is an unwarranted interference with his personal liberty. An obstacle is here encountered that can be overcome, in the first place, when he can be made to see that his own safety is placed in jeopardy, as well as the safety of those entrusted to his care. In the next place, some means must be provided for his maintenance, when, from incapacity, disability, or age, he can no more be entrusted with the great responsibility devolving upon him. Such a provision has been made by several of the great railway lines in the form of a pension for disabled and superannuated men. The man, knowing that he will be provided for, does not so seriously object to medical supervision. The tempta tion to conceal physical and other defects is not so great. He should also be encouraged to make provision for himself. A fund should be created by his own contributions, from which he can receive benefits when sick or disabled. With these provisions, the temptation to remain at his post when unfit, is lessened. Knowing that he will not be in absolute want as soon as he "lays off," that he will still have an income, he will the more readily refrain from work when he is incapable by reason of a temporary illness.

We may say that negligence in the train service may be reduced to a minimum by selecting:

(1) Only physically sound men.
(2) Men of good moral character.
(3) Men of temperate habits.

(4) Only those who have a good common school edu

cation.

(5) Those who, after serving a period of probation, have demonstrated that they possess sufficient mental capacity to master the details of their duties.

(6) They should be methodically instructed, theoretically as well as practically, and, when possible, in classes and schools established for the purpose. A good beginning has been made by several trunk lines in fitting out instruction cars under the supervision of competent

As we have seen, we as railway surgeons, can do much in lessening negligence. We can contribute no small factor in the direction of safety. Railway managers eagerly grasp at everything that will make travel less hazardous. We have not performed our duty unless we have contributed our share to the great traffic organizations in its endeavor to avoid accidents. We must concern ourselves with the machine that is actuated and controlled by intelligence, the human machine. We must, to a certain extent, at least, differentiate between the responsible and the irresponsible men. In doing so, we contribute our part in the prevention of negligence.

CHICAGO, MILWAUKEE & ST. PAUL RAILWAY SURGICAL ASSOCIATION.

MINUTES OF THE TENTH ANNUAL MEETING, HELD AT THE
GREAT NORTHERN HOTEL, CHICAGO, DECEM-
BER 18 AND 19, 1902.

FIRST DAY-MORNING SESSION.

There were, approximately, 140 members in attendance. Dr. H. H. Clark of McGregor, Ia., was elected chairman. for the meeting.

The secretary, Dr. Bouffleur, called the roll, after which the reading of papers was proceeded with.

Dr. E. O. Plumbe of Rock Valley, Ia., read a paper on "Foreign Bodies in the Eye, From the Standpoint of the General Practitioner," which was discussed by Drs. Wescott, Hemenway, Larson, Bouffleur, Skinner, Gardner and Macrea, and the discussion closed by the essayist. The next subject for consideration was "How Can a Proper Sanitary Condition of Railway Depots and Other Buildings Be Secured and Maintained?"

No formal papers were presented on this subject. The discussion was opened by Dr. D. S. Fairchild, and continued by Drs. T. C. Clark, D. A. Stewart, A. B. Poore, Samuel Bell, Rice, Brubaker, McDonald, Rothwell and Barnett.

On motion, the association adjourned until 2 p. m.

FIRST DAY-AFTERNOON SESSION.

The association reassembled at 2 p. m., and was called to order by the chairman.

Dr. E. H. King of Muscatine, Ia., read a paper on "Abuse of Stimulants in First Aid to the Injured." Discussed by Drs. Garlock, Philler, Rome, Egloff, Stealey, Plumbe, Crawford, Allen, Haskell, Sarles, Poore, Hemenway and Nuzum, and the discussion closed by the essayist.

Dr. J. H. Rothwell of Cedar Rapids, Ia., followed with a paper on "Fractures and Dislocations of the Clavicle." This paper was discussed by Drs. Trout, Williams, Merchant, Macrea and Van Werden, after which a motion was made by Dr. Sarles that other papers on fractures be read and then discussed pointly.

Accordingly, the following papers were presented: Dr. C. F. Larson of Crystal Falls, Mich., read a paper entitled "A Modification of Existing Dressings for Fracture of the Patella."

Dr. E. C. McMeel of Delmar, Ia., read a paper on "Pott's Fracture."

Dr. J. H. Stealey of Freeport, Ill., followed with a paper on "Ununited Fractures."

Dr. W. Van Werden of Des Moines, Ia., presented a paper on "The Advisability of Wiring Simple Fractures When the Environments Are Favorable."

Dr. J. O. Cavanaugh of St. Paul, Minn., reported "A Few Cases of Delayed and Non-Union of Fractures." Dr. J. W. Kester of Mazomania, Wis., reported "A Case of Fracture of the Inferior Maxilla."

These papers were discussed by Drs. Ballard, King, McDonald, Larson, Crawford, Garlock, Macrea, Fairchild, Sarles, Binnie, Staples, Cavanaugh, Jenkins, Nuzum, Crawford, Van Werden and Stealey.

On motion, the association then adjourned until 9:30 a. m., Friday.

SECOND DAY-MORNING SESSION.

The association met at 9:40 a. m., and was called to order by the chairman.

Dr. Hugo Philler of Waukesha, Wis., read a paper entitled "Injuries of the Spine." Discussed by Drs. Kelsey, Garlock, Spilman and Williams, and the discussion closed by Dr. Philler.

Dr. F. Tice of Chicago read a paper on "Old Fractures of the Spine, with Recovery after Late Operation." Discussed by Dr. Ritchie.

The next topic, "The Management of Emergency Cases in Unhygienic Environments," was discussed by Drs. Gardner, Allen, Robinson, Adair, Macrea, Robinson, Clark and Fairchild.

The next topic for discussion was "Ways in Which the Surgical Service of the Company Can Be Improved." The discussion was opened by Dr. Sarles, and continued. by Drs. Crowell, Spilman, Fairchild and Binnie.

On motion, the association adjourned until 2 p. m.

SECOND DAY-AFTERNOON SESSION.

The association reassembled at 2 p. m., and was called to order by the chairman.

Dr. J. R. Hollowbush of Rock Island, Ill., read a paper entitled "True Conservatism in Amputations," which was discussed by Drs. Hemenway, Gardner, Stockton, Garlock, Brubaker, Graham, Staples, and the discussion closed by the essayist.

Dr. A. J. Coey of Chicago presented a paper on "The Value of Blood Examinations as an Aid in Diagnosis in Surgery." Discussed by Drs. Hemenway, Brubaker, Staples, Poore, and the discussion closed by by the

essayist.

"Is It Advisable to Establish a Central Depot for the Furnishing of Surgical Supplies to Railway Surgeons?" This topic was discussed informally by Drs. Egloff, Townsend, Stockton, Hemenway and Macrea.

Dr. G. A. Staples of Dubuque, Ia., read a paper entitled "Two Cases of Alleged Orchitis." Discussed by Dr. Poore.

A paper by Dr. R. C. Kelsey of White Rock, S. D.,

was read by title, and referred for publication in the proceedings.

Dr. M. J. Kennefick of Algona, Ia., read a paper entitled "A Case of Tetanus Successfully Treated by Carbolic Acid Used Hypodermically." Discussed by Drs. Mitchell, Gardner, Binnie, Macrea, Egloff and Bouffleur, and the discussion closed by the essayist.

"In What Respects Can the Surgical Report Blanks Be Modified to Facilitate the More Accurate and Comprehensive Report of Cases by the Local Surgeon?” This subject was briefly discussed by Dr. H. H. Clark of McGregor, Ia.

Dr. T. C. Clark moved that a vote of thanks be extended to the chairman for the amiable and impartial manner in which he had presided over the deliberations of the meeting; also to Dr. Bouffleur, the proprietors of the Great Northern Hotel for the use of the room in which to hold the meetings, and for privileges enjoyed. Unanimously carried. Adjourned.

THE ABUSE OF STIMULANTS IN FIRST AID TO THE INJURED.*

BY E. H. KING, M. D., OF MUSCATINE, IA.

It is apparent that in conditions of shock, or of depression, stimulation is indicated. By stimulation, I mean the use of those remedies and means whereby the disturbed and agitated nervous system may be calmed, a weak and flagging circulation strengthened, and body heat restored. In short, a prompt bringing up of the depressed physical system to, or nearly to, its normal condition.

The intelligent surgeon has various remedies at his disposal whereby he may obtain these results, but in rendering First Aid to the injured previous to the surgeon's arrival, the help given is often administered by those having an imperfect knowledge of the proper treatment. The recipient of an accident generally receives the active sympathy of all who may be present, and vigorous and well meant, though often ill advised means are adopted to succor and relieve the unfortunate victim. To the great mass of the laity, stimulation means the administration of alcohol, generally in the form of whisky, and a majority seems governed by the idea that if a little is good, more will be better, and it is given accordingly.

To illustrate, in a railway accident a few years ago, the engineer had his leg severely crushed; he was rescued from the wreck and taken on a stretcher into the vestibule of a Pullman. During the interval pending the arrival of a surgeon, his groans excited the sympathies of the passengers, and every one felt a desire to do something towards his relief, and when I arrived upon the scene, a dozen or more flasks of whisky and brandy had been contributed, and it had been forced upon him until tion. I am confident that fully a pint of raw whisky had his stomach had rebelled at its too generous administrabeen given him, and that this overdosing was an important factor, coupled with the traumatic shock, that contributed towards a fatal result.

In instruction to employes, I would put especial empha

*Read at the tenth annual meeting C, M. & St. P. Ry. Surgical Association, Chicago, December 18, 19, 1902.

sis upon this point, "Do not allow the injured to be filled with whisky or other alcoholic stimulants." Hot coffee, or even hot water, is preferable, and not liable to cause depression by overdosing, and add to the already existing shock. The time was, and that not very long ago, when alcohol was considered by the profession as indispensable in shock, but I think that very few surgeons depend upon it now, and if used at all, it is in very limited quantities.

DISCUSSION.

Dr. F. R. Garlock, Racine, Wis.: I have made quite free use of stimulants in First Aid to the injured. I had a case this morning in which it was necessary to amputate both legs, between the hours of three and four, and if I had not given the man a stimulant in some form I should have lost him. I have found an agent which is superior to alcoholic stimulants, and that is the Armour extracts of meat, something which is slightly nourishing and stimulating. I like their use, and I have found them. much superior to alcoholic stimulants. Even hot milk is better than alcoholic stimulants, and does patients more good.

Dr. Hugo Philler, Waukesha, Wis.: As a substitute. for alcohol, I use strong coffee. I find it acts better than whisky or any other agent.

Dr. Robinson: When people talk about stimulants, or even physicians talk about them, they generally mean alcoholic stimulants, and the people do not understand, it seems, that there are any other stimulants. I wish to say that I recommend as a stimulant nitrate of strychnia in combination with morphia, and hot water, or hot coffee, hot tea, hot beef extract, or anything of that sort, is perfectly right and proper. But I think that with nitrate of strychnia, given as a preliminary dose, a patient will go through any operation better than he will with a small or large amount of some alcoholic stimulant.

Dr. Rome, Iowa: I concur in what Dr. Robinson has said in regard to giving nitrate of strychnia in the place of an alcoholic stimulant. It is much better than an alcoholic stimulant. The great trouble is that these patients are generally overdosed with alcohol, and while they may be able to stand an operation, they do not stand the anesthetic very well. It has a bad effect on them. Strychnia will give a more permanent effect.

Dr. W. J. Egloff, Mason City, Ia.: I agree with Dr. Robinson in regard to nitrate of strychnia, but I have usually combined it with small amounts of atropin, to overcome the congestion, together with hot beef tea or hot prepared concentrated food. These are my main reliance.

Dr. J. H. Stealy, Freeport, Ill. In addition to the use of strychnia, I am very fond of giving camphor hypodermatically. I think neutral camphor, given hypodermatically, is one of the most powerful stimulants we have, in addition to hot drinks of beef tea, etc.

Dr. E. O. Plumbe, Rock Valley, Ia.: I can remember the time, particularly during the Civil War, when the first thing surgeons did was to give the injured a drink of whisky, but we have gotten over that. At the same time, I do not think, where we have a patient in profound shock and want to stimulate him quickly and thoroughly, that there is anything so good as a little alcohol. When

Ι say a little, I don't mean half a pint or one-quarter of a pint, but a little alcohol, and you find that you get the effect of it in a few minutes, so that you can go on and give something else. You can give hypodermatics of strychnia, nitroglycerin, or whatever you please. But for the time being, an alcoholic stimulant is good, I know that from experience. Some patients are injured more by the doses of alcoholic stimulants that they receive immediately after the accident by the injudiciousness of those around them, than benefited, and for that reason I do not think stimulants should be administered by parties around the injured man, particularly in railway accidents. Railway employes should keep these agents away from patients until they are seen by the surgeon.

Dr. J. P. Crawford, Davenport, Ia.: I do not understand that the writer of the paper takes the position that stimulants are not of use in the proper quantities and under the proper conditions. under the proper conditions. He protests against the abuse of alcoholic stimulation, which I think those of us who are honest believe is abused under these as well as under most other circumstances in life, but that the moderate use of stimulants, together with strychnia, and also the introduction of warm salt water into the alimentary canal, which is most always available, will enable us to overcome shock in a better way than to overcrowd stimulation. Shock is due usually to two causes, either to a loss in the volume of circulation by hemorrhage, or else to profound disturbance of the nervous system, due to the irritation of the sympathetic, whereby the great volume of blood is forced out of the peripheral vessels, and the heart is in great need of a general supply. But I think with these other conditions, moderate stimulation, and especially the introduction of large quantites of absorbable fluid into the intestinal canal and hypodermoclysis where it is possible, we are able to meet the dangerous conditions of shock in a better way than by overstimulation.

Dr. M. L. Allen, Tama, Ia.: I have never had much success in introducing fluids into the stomach during profound shock. The stomach will simply rebel, and it will counteract the very effort you are trying to sustain. As the last speaker stated, I think the judicious use of alcoholic stimulants, after the period of profound shock has passed, is to be commended, and in connection with hot alimentary enemata and hot-water bottles, hot milk, and possibly hot stimulating food, such as beef tea, are to be highly commended. But I think our greatest source of convenience in these cases is the external appliances we use in the form of heat, etc.

Dr. Marcus W. Haskell, Richland Center, Wis.: I believe considerable benefit is derived from the use of alcoholic stimulants in the class of cases under discussion. I will try to illustrate this by the citation of a case. A year ago, the 4th of December, I came to Chicago, and I happened to be on a train that was wrecked at Shermerville. The engineer had both legs broken; his side was badly burned; the fireman had a fracture of the collar bone and of the arm, and having no medicines with me. except a few strychnia tablets, and being the only physician excepting one who had care of patients just brought from the hospital, I injected 1-30 of a grain of strychnia into each one of their arms, and I found I had no more