that absolute confidence and absolute community of interest; if you touch one department with your finger, the whole system feels it. You cannot divorce them. You cannot separate them. Dr. Outten is just as much interested in my department as I am in the claim department, and the claim department is as much interested in him as I am in the general manager's office. We stand together as a great family. We are bound together by ties, not only of friendship, but by the strongest community of interets on a business basis. Our hospital department is one of the largest departments of our railway system. It is looked upon as a most necessary department. And the one thought, gentlemen, that I want to send you home with is this: If this condition does not prevail between your legal department and the other departments of your railroads with which you are associated and connected, I beg you to use that strong influence, which I know you possess, to bring about this condition of affairs. Understand me, I criticise no other road. I do not know to what extent there is this community of interest in other railroads. I am speaking of our own railway system, and I do know, so far as all of our departments are concerned, they act like one great greased machine, each part and parcel operating in order to make the whole thing a success, each rendering its part in the common success of all. (Applause.)

THE NEUROPATH AND RAILWAY NEUROSES.*

BY DAVID S. BOOTH, M. D., OF ST. LOUIS, MO. Neurologist to Missouri Pacific Railway Hospital Department, Local Surgeon St. Louis Southwestern Railway Co., Etc., Etc.

Since there is no evidence of a near approaching millennium to preclude the possibility of an otherwise honest. and upright citizen developing a latent moral obliquity after a railway disaster, real or fancied, it is necessary to study the Neuropath, his natural tendencies, susceptibilities and weaknesses, as well as his neurosis, if we are to distinguish real from feigned diseases, or differentiate diseases which existed prior to, from those which follow or result from, an accident or injury, and ourselves avoid that mental obliquity which causes one to view all claimants as malingerers.

We know that all persons do not begin the journey of life, much less a trip by rail, with the proverbial “sound mind in a sound body," hence we are not to assume that all conditions existing after an accident are consequent to it, though it requires a searching investigation of the claimant's personal and family history to establish a neuropathic constitution.

In this electric age, with its mad rush for fame and fortune, the neuropath is omnipresent, and hence frequently becomes a perplexing problem for the honest and conscientious physician. We must not forget that the tourist and the railway employe are built upon the same general plan of the genus homo, hence subject to the development of the same variety of nervous diseases, whether of idiopathic or traumatic origin, although it is certain that alleged neuroses following railroad accidents are less frequent with employes than with passengers; while idiopathic neuroses are equally as frequent with them as with other occupations, in the least susceptible

*Read at fifteenth annual meeting, St. Louis, Mo., April 30-May 2, 1802.

of which they are common enough to find them accompaniments of honest claimants as well as of designing adventurers.

Nervous diseases are often slow and insidious in their development, so that it is not impossible that the afflicted first learns of a firmly rooted neurosis or psychosis after passing through some unpleasant railroad experience. Neurotics are fertile soil for the development of delusions and fixed ideas—in fact, are often possessed of them, and after a jar in a railway coach, may become "possessed of the devil." You possibly have heard that "crossing a Texas heifer with a railroad train produces a Jersey," and we know of a case wherein the shaking up of a Texas clergyman in a derailed car caused in him. the idea (?) that it produced an inguinal hernia, which preyed on his mind until it dominated his personality and finally developed into litigious insanity (?), the result of which was the establishment of the fact that he had worn trusses for some twenty years.

To the physician who has himself had an experience of a railroad wreck, it is possible to conceive how a neuropath, with his susceptibility to suggestion and liability to exaggeration, and who, like the paranoiac, is ever ready to fix upon a cause for his trouble, may become morbid and bedridden, if such a fear is expressed by his attending physician and encouraged by the ubiquitous shyster who is better versed in the traditions of Erichsen than in Blackstone or moral law, and who is ever ready to sacrifice (?) time and money to aid suffering humanity, and incidentally gain notoriety, if not wealth, at the expense of a "soulless corporation."

While it appears to be the prevailing popular opinion that railroads resort to "ways that are dark and tricks that are vain" to defeat honest claimants, and that the railroad surgeon, by virtue of his position, is made a "party to the crime," we know of not a single instance wherein there was the slightest hint to influence his candid opinion-a compliment to our integrity or an insult to professional secrecy. This indicates, if anything, that we are to present facts, and leave technicalities to more able jugglers, "our friends in adversity and colaborers in prosperity," the lawyers.

The past decade or so has taught us that nervous diseases resulting from traumatism are in no wise different. from those arising idiopathically, in which they have their counterpart, as the following brief reports of cases will serve to illustrate:

Case I. Was summoned to render emergency services to a woman above middle age, who had been in a rearend street-car collision. Found her in the car seat, faint and limp, though not unconscious, and the only one of some twenty or more passengers to experience any inconvenience as a result of the jar. She was carried to a house a few feet distant, and placed on a couch. She complained of severe pain in the cervical region of spine and extreme weakness. and extreme weakness. The only discoverable objective symptom was a rapid and not overly strong pulse. Patient admitted that she was under professional medical care for nervous prostration; that the "neckache" was an almost constant symptom, in greater or less degree, and that she was then out in company with her daughter for recreation. I learned some months later that she appeared to lose all memory of having been ill previous to

the accident, and consulted a lawyer. She developed delusions (?) of wealth which resulted in claim for damages, the outcome of which I have never heard.

Case II. In October, 1897, I examined a case in a distant city in the interest of a railroad, on whose train the patient alleged she had sustained an injury. The patient, Miss A. B., aged 27, of slight build, was confined to bed in a private hospital, where she was examined with the consent and co-operation of her two attending physicians. Patient stated that she was a school teacher in a southern state, and was on her way East, where she had been summoned on account of the serious illness of her mother with heart disease. She was only able to purchase a ticket to this point, where she was to receive a remittance with which to continue her journey, but at the date of this examination, eight days after her arrival, had not done so.

She stated that a short distance from the city as she was standing up preparing to leave the car when it should arrive at the station, the car gave a sudden lurch, when her right leg gave way under her and she fell to the floor, striking her left arm against the arm of a seat. She felt a tingling in her right leg, followed by numbness, and found she was unable to use it.

Patient admitted having suffered from "nervous prostration," due to overwork, the past summer, but had fully recovered; and from information obtained, we concluded that her mother's "heart disease" was of nervous origin. Patient complained of pain in both shoulders and along dorsal region of spine, insomnia, spitting of small quantities of blood and rigidity of right knee.

Examination showed normal temperature; pulse, 84; tongue lightly coated; no evidences of contusions; right leg felt cool to touch; anesthesia and analgesia of right thigh, leg and foot, though an unexpected pin-thrust of sole of foot caused leg to be jerked up sharply.

Sitting patient on edge of bed to examine throat, knees bent naturally and knee-jerk was found normal and equal in both legs; slight ankle clonus on affected side. Throat slightly congested. Responses to faradic electricity, normal and equal in both legs. The diagnosis of inhibitory, or hysterical, paralysis was made, which I understood, was justified by further developments, though patient made a claim for damages.

In this case, the fall itself was doubtless due solely to a giving-way of the legs, amyosthenia, which generally precedes hysterical paralysis.

Case III. Was called to a patient who was then under treatment for neurasthenia, and found her sitting in at chair unable to walk. Patient stated, in the presence of her husband, that she was sitting in the chair in which I found her, when her husband came home intoxicated, which so shocked her that her legs began to tingle and then became numb and powerless. Pin-thrusts made no impression and caused no blood to appear in wound. Limbs felt cool to touch; knee jerks normal; pulse rapid. Suffered with pain at back of neck and felt weak. sured her that her condition was not serious and would pass off in a short time, and since there was no hope for a damage suit, she fully recovered from the paralysis in a few days.

Case IV. In 1890, I reported the case of a locomotive engineer who was unable to walk unaided, with what

had been repeatedly and invariably diagnosticated asiocomotor ataxia, and, upon the report of two prominent neurologists, had been paid a benefit for total disability, to which he was thereby entitled. His disease developed shortly after an accident two years previous, in which he had jumped from a moving locomotive and struck on the left side of his head and left shoulder, and it was a year after coming under my care before he fully recovered and returned to work. This was, without doubt, a case of so-called "pseudo-tabes," from plumbism, as he had worked in lead mines for three years prior to his employment on the railroad, and had suffered three acute attacks of lead-poisoning, the last of which incapacitated him for work for six months.

Case V. In October, 1893, J. S., a painter by trade, afflicted with a malady which had been previously diagnosticated by several physicians as locomotor ataxia, was placed under treatment for pseudo-tabes from lead poisoning, and, notwithstanding the prognostications of his former attendants, who tried to discourage him while under treatment, he made a complete recovery in a few months, when he changed his employment and has never had a return of any of the symptoms. This was an idiopathic disease and was almost a counterpart of the preceding case which was supposed to have resulted from traumatism.

"To err is human," but the truth of this maxim is nowhere better demonstrated than in neuroses following railway accidents, in which our patient is probably antagonistic, if not openly rebellious, to our efforts to determine the diagnosis and etiology of his malady; so that after exhausting every avenue of investigation and applying every fact and principle of scientific and empiric medicine, we are then occasionally defeated by this Pandora-box of railway ills.

DISCUSSION.

Dr. Bowles of Kansas: I desire to call attention to one or two points in connection with this paper. After listening to the able address last evening by the Hon. Mr. Cochran, I was struck with the fact that the railroad companies are beginning to realize that the local surgeon, or surgeons, who first comes in contact with these cases can do much more than anyone else to prevent litigation, and bring about an carly settlement, and very often a cheap settlement, of the cases as compared with what it will be after the cases have been placed in the hands of blackleg lawyers. We have this class of lawyers on every hand ready to take any claim that comes along for a contingent fee. My experience has been that if I can have a conference with the patient and get the claim agent present for a short time before the patient falls into the hands of any of these lawyers, fewer neuroses develop, and that we do not have so many of these neuropathic disturbances and conditions develop thereafter.

I remember quite a number of years ago, while I was a local surgeon on the Missouri Pacific Railroad, the case of an old man who had been shipping cattle. When he was about to leave the car, by means of a rapid jerk of the train he was thrown across a seat. He came to me to be examined, but did not let me know the condition of affairs and how the accident had occurred. I was unable

to ascertain how he had sustained on injury until after having quite a talk with him; then I found he was injured on the railroad. It was one of my first cases. Suit was brought and a claim for two or three thousand dollars was allowed.

Recently I had the case of a clergyman's wife, who was injured in a similar manner, but in her case there were evidences of contusion along the back. The woman was very fleshy and had evidently been injured. Her husband came to me and said: "What are your duties as surgeon to the railroad?" And my reply was: "My duties are to tell the truth and do the best I can for patients and all concerned." After examining her and making a report of the case, I stated to my authorities that I thought the case could be settled without any suit for damages. The claim agent presented himself, and the case was settled for one hundred dollars. I have found that in most cases the application of greenbacks does more than anything else to relieve these patients.

The point is this: Early settlement can be brought about by the local surgeon in conjunction with the claim agent, if the railroad authorities are willing that an early conference takes place between them.

Dr. W. S. Hoy of Wellston, O.: There is one point I desire to make in addition to what the previous speaker has said. This association, you will remember, at one of its earlier meetings, just a few years ago, discussed a similar subject to the one presented by the essayist, and Dr. Outten, who has always taken a deep interest in the association, brought out prominently the point that the railroad surgeon in his capacity as such ought to act as surgeon to the individual, and that if there is to be any adjustment or adjudication of a claim of the individual against the railroad company, let him settle that matter with the claim agent himself. As railway surgeons, while an individual is working as an employe of the company, our duty is not only to look after the interests of the company, but our first duty is to the individual who is injured. It does not matter what the nature of the injury may be. On the railroad with which I am connected we have to make a full report of the occurrence of an accident or an injury to an individual. In making out my report of the injured, I state in it the exact condition of the patient, and I do not color the report one iota. I make it as bad as the case may be, so that the claim agent has then an opportunity to know what he has to deal with. In injuries of a neurotic character we frequently find patients who are injured in railway accidents where the lesion has not been sufficiently observed to warrant the condition of the patient in which we find him afterwards.

It is a difficult matter to determine the exact nature or seriousness of an injury, and I appreciate the trouble Erichsen had in arriving at what he called "railway spine That matter has been sifted, discussed and ably handled by this association in times past, and it is to be congratulated on having exploded the theory, to a great extent, of "Erichsen's spine" and "railway spine." The railway surgeons deserve a great deal of credit for having done that. On the other hand, we, as railway surgeons, are trying to get facts beneficial to the railroad companies, and they should remember that they have in their employ ment who are not hired on the basis of adjudicating claims of

injury. I see a number of chief surgeons present to-day, although the majority of our members are local surgeons.. The local surgeons in making out their reports to be submitted to the chief surgeons and the railroad companies should be impressed with one idea, namely, that their first duty is to the patient himself. After a person has been injured, carefully examine the patient and report the exact condition as you find it. If there should be litigation you may be called as an expert witness to tell what you found at the time you examined the patient and his present condition. Having done this, you have done your whole duty to the railroad company.

Dr. S. S. Thorn of Toledo, O.: Perhaps this is a good time and place to place on record a case. I was on the witness-stand this week on behalf of the company to resist an effort on the part of the plaintiff (a woman), who had six times before defrauded companies successfully, and this was the seventh time. I advised the attorney to put the case on record, so that it might be in the hands of every claim agent in the United States. In the first place, it was said that in 1891 she was injured on the Ann Arbor Railroad. She was examined by Dr. Herdman two or three times, who presented his report to the effect that there was a neurotic condition, but no injury of the spine was found. Case No. 2-She was after an insurance company. Case No. 3-She was after another insurance company. Case No. 4-She was after the Michigan Central Railroad. Case No. 5-She was after another company, the Pennsylvania Railroad. I made an examination of the case and reported it as nil. Case No. 6 or 7-She was after the Pere Marquette Railroad. She presented claims to all of these companies for spinal injury.

I believe cases such as this should be carefully reported and the facts given to the various claim departments, and should constitute a part of the knowledge of the different railroad surgeons. Of course, we cannot settle these claims, and I do not think we ought to do so. I think the position taken by Dr. Hoy is the correct one, namely, to keep our hands off. The officials of our railroads ask for nothing except a full and accurate presentation of the existing facts and conditions, and they are prepared to settle on that basis.

Dr. L. Worsham of Evansville, Ind.: I would like to say a word or two in connection with the excellent paper that has been read. Neuropathic conditions are serious matters for the railway surgeons to deal with. We have to deal with a hidden system, as it were; that is to say, most generally there is no evidence of contusion at the time. The effects develop afterwards. In this connection I wish to relate an interesting case which occurred in my town. It was that of a nervous woman, over fifty years of age. She was entering her seat, when the engine backed up against the car, and, as she claimed, threw her against the arm of the seat. She made a visit to St. Louis and returned home. After her return home she called her family physician. It is said that there was considerable hemorrhage from the womb. He immediately applied gauze to control the hemorrhage. There grew out of these two coincidences a damage suit for $10,000. Notwithstanding the fact that several physicians, who examined her, told the attorneys that she had a cancer of the uterus, the suit was proceeded with.

She had pains in her legs, inability to walk, gradual emaciation, continuous uterine hemorrhage and other symptoms indicative of cancer. Notwithstanding the testimony of such men as Eastman and several others from Indianapolis, a jury was found, four of which found in favor of the plaintiff. Another suit has been filed, and notwithstanding the fact that the plaintiff is dead. the suit, in all probability, like Tennyson's little brook, will "go on forever."

Dr. W. B. Outten of St. Louis, Mo.: I want to say that for many years this question to me has been a serious one, and probably my views in connection with it, largely backed up by an extensive experience, may not be sanctioned by the neurologists, but they are certainly based on pure common-sense experience. I want to make this assertion open and above board that in the so-called traumatic neuroses, be it hypochondriasis, neurasthenia or hysteria, they are self-made cases, according to the surroundings by which they are made. I do not mean by this to impute to the neurologist that he is dishonest, for I know he is honest, nor has the neurologist any right to impute to me any element of dishonesty. I can say this in an experience embracing over twenty years in this business, that I have yet to come in contact with any wellformed case of traumatic neurasthenia when this case has been properly treated. Now, gentlemen, it is simply this, the basis, if you want to call it, in traumatic neurosis is simply the surroundings. You may say, perhaps, I am a little mystical when I say this, that when, for instance, a man has received an injury upon a railroad, who is in that condition in which he is pre-eminently a being susceptible to a suggestion, when you feed him by suggestion, be it on the side of the railroad surgeon or neurologist, you will find your case made in proportion. Conceive of it, gentlemen. Take any wreck, and how often can you suggest to a man, and this suggestion is fixed? Carry your suggestion out in sequence day by day and hour after hour, what is the consequence? You have nothing more nor less than a case made by the deep suggestion of the neurologist or physician. If we have an employe suffering from what is sometimes called traumatic lumbago or traumatic hysteria, in the event he shows any tendency to go in the line of suggestion, to magnify his pains, to increase them, he is surrounded by men who pooh-pooh the idea that he has these pains, and he is reminded that he is not badly hurt, that he will soon get well, and employes under these circumstances and surroundings do get well. I think it was Charcot who said that a person with hysteria was absolutely susceptible to suggestion, and that any suggestion you give to such an individual acts like a sledge-hammer. Why can't you, therefore, make what you please, according to the line of story you give him?

I have been connected with railroads since 1875 as a medical officer, and during all that time I can say this with absolute honesty, that I have never lost my individ uality in court for the benefit of the railroad company, nor have I ever assisted anyone in the adjustment of claims. My function is a simple one, and is nothing more or less than that of a surgeon, a physician or neurologist, if you want to call me so. I have gone out in the country among my professional brethren, met them and consulted with them rather than that they should be placed in a position

of humiliation and be brow-beaten by lawyers. What is the consequence? Some of my professional brethren present know the result. I have consulted with them in cases, and I have said: "Doctor, if there is any truth in this, you and I should know it. If there is not, we should likewise know it."

We

About eight months ago I went to MacPherson, Kan., to see a case. There was great difficulty in getting testimony. The court appointed a commission. We met in a doctor's office. We examined the case, and one of the first assertions made was this: We will each examine the case as though there was no other physician present, and each form his own conclusions regarding it. began to examine the case, when lawyers entered the room, and we simply said to them: "In the event you are consulted on a legal point, you would certainly object to any of us coming in and interfering with your consultation, so permit us to say that your presence is not needed. The doctors will examine this case carefully and make an honest report."

I maintain that many of these cases that are made by suggestion can be treated by suggestion; and I want to say this, that, in my dealings with doctors (and I have had ample and rare opportunities in this regard), it is a rare thing for me to meet a dishonest doctor. Courteous treatment has been manifested toward one another, and we have sat down as students to find out the truth in connection with the case. I believe, and a great many of tthe railroad surgeons here of experience are of the same belief, that many cases of traumatic hysteria, traumatic hypochondriasis, or traumatic neurasthenia, are made by the attendant of the injured man, aided by his suggestion. This was demonstrated by Charcot many years ago, who said that when a man receives a trauma, without a period in which he can receive any suggestion you want to give him, if you place him under proper conditions and environment, there is no doubt but what you can cure him. But if you keep on adding to the suggestion, the effect of the trauma will so prey upon the patient's mind that the prospects of effecting a cure are not so bright.

Dr. George Ross of Richmond, Va.: I want to endorse what Dr. Outten has said as to the suggestive power of the doctors or the friends of the doctors. I believe with him, with all my soul, that many cases of spinal injury are imaginary, and I am quite firm in the conviction that the great majority of cases would never be heard from if the doctor, into whose hands the patient primarily goes, impressed the patient with the fact that he will get well in time. I would like to mention a case or two in illustration, because we derive more benefit from the citation of cases than from what might be called didactic talk.

I have had within the last six or eight months two cases that were particularly notable to me. One was a man who was thrown from the top of a moving train, and in falling was struck by a loaded freight car just above the junction of the cervical and dorsal vertebræ. He was found absolutely helpless. When I reached him there was a tumor as large as a derby hat at the point of impact. He could not move either leg. I supposed the man was paralyzed. I had him placed on a cot on his face, examined him as critically as I am competent to do and watched him carefully. I declared to him that he was

going to get well within a reasonable time, but that he must not be in a hurry as to the time of his recovery. Hot applications were applied incessantly. Of course I looked out for his emunctories, and in five months this man was at his work again as brakeman on a railroad train. There was no bones broken. I don't believe he had any hemorrhage into or on the spine. But here was a case out of which a suit for damages could have been easily provoked. So I say, here was simply a case where rest, quietude, assurance and a declaration positively made that he was going to get well were effective. As medicine the man received nothing but salines.

Another case: A man was caught underneath a loaded car while in the act of doing some repairs, his head and neck being bent upon his knees, so that the spinal vertebræ were separated. One was broken. Three other physicians examined this man and said his case was one which probably demanded laminectomy; that his condiition was doubtful. He had a temperatture of 1011⁄2 degrees, pulse correspondingly accelerated. He had premonitory nervous manifestations. I placed him in the same position, treated him in a similar way, gave him a positive declaration that he would get well, and he is to-day working in his position as car repairer. I kept a lawyer from seeing this case, and the day his friends came to see him I informed them that they must be cheerful and not despondent.

He must do his duty to both, but under no circumstances should he allow his friendship to the railroad company to be so manifested as to couple with it a suspicion of his honesty. The surgeon should make a report of the condition of the injured man as accurately as possible, whether in the interests of the corporation he represents or not. Secondly, he should make his report utterly regardless of what anybody says. The surgeon is not the property of the railroad company at any time, or under any circumstances. He is an individual man, with a plain professional duty to discharge toward himself, the patient and the company he represents, without fear of the consequences. His duty is as an adviser, primarily, to the department he represents; secondarily, to the legal department, and there ought to be perfect accord between each one of the departments. The advice of the surgeon is invaluable to the claim agent and legal department. But I maintain, and have always insisted in my official relations to the railroad company I represent, that the railroad surgeon ought not to be placed on the witness-stand in any case except to testify as to the facts. His presence in court should not be construed in the light of an expert. When expert testimony is demanded, it should be summoned from the outside. Then, no aspersions will be cast upon the railroad surgeon as being a prejudiced witness, nor will he be subjected to mortification when placed on the witness-stand, because we know there are some

I recall the case of a blind man, which was one of more than usual interest. He was not blind from birth, but from childhood. He was sitting in a car, when a freight train backed up and threw him against the seat. He walked out of the car, leaning on the arm of a surgeon. Within three days thereafter he began to have all the symptoms of paralysis of the legs. As far as the doctor and lawyer could see, the man was absolutely paralyzed, particularly paralysis of all the organs pertaining to the pelvic region. A suit grew out of this accident. The blind man was brought before a jury in a pitiable condition. He was said to have paralysis of the spine; he was poor and depressed, and naturally his case elicited the deepest sympathy. He was awarded liberal damages. Three months before the case came off in court I said to his physician that when the case was tried he would get damages, and that soon after he had received the damages he would get well. The doctor said to me: "Doctor, it is impossible." I said to him: "Doctor, all things are possible to him who believes. I believe he will get well. My judgment is he will get well, because his whole condition has been one of nervous apprehension, of neurasthenia, or an hysterical condition." In the course of six months after the payment of the assessed damages I saw this man walking out of St. Paul's Church, leaning on a stick.

Suggestion is a tremendous factor, and I believe the doctor into whose hands the patient first goes can materially influence the patient in any manner he pleases.

There is one point I would like to comment on particularly, and which was touched upon by Dr. Hoy, when he said that the first duty of the physician is to his patient. His second duty is to his corporation, but there need not be such a distinct division between the two.

erous enough, and even cruel enough, to try to convey to the jury the impression that the testimony of this or that doctor is not true, because it has been bought by the money of the railroad company. So, I say, the railroad surgeon should never be put on the witness-stand except to give evidence as to the facts which cannot be furnished by any other man.

Dr. J. H. Ford of Indianapolis, Ind: I want to say a word in connection with this paper. I think it would be a good idea for all railroad surgeons, particularly in cases of suits for damages brought against railroads, or not, to keep track of the cases afterwards, to follow them up for one or more years, and they will learn things which they did not know by previous observation. I remember one case of a woman who really was not injured, but her neurosis was purely by suggestion. She brought suit against the railroad company and obtained a verdict of seven or eight thousand dollars against us. She went around on crutches for six years. Suddenly a Christian Scientist came along and cured her in fifteen minutes. She threw the crutches away and praised the Lord, and is now doing her duty as a housewife the same as she did before the accident. It is a good idea to make it a business to follow up such cases that have gotten money out of the railroad companies and keep track of them for years, and put them to a test. I have convinced the legal department and officials of the railroad I represent that there is such a thing as suggestion. I can recount a number of cases of this kind, but this is the most prolonged case of suggestive neurosis I have any knowledge of, namely, six years on crutches, then all at once cured by suggestion in fifteen minutes.

My friends, Drs. Ross and Outten, have enunciated two principles, and I would like to add another. The first duty of the railroad surgeon is toward the patient;