THE LOCAL SURGEON, HIS DUTY TO THE INJURED AND HIS DUTY TO THE RAILWAY COMPANY.*

BY G. A. SPAULDING, OF AVOCA, IOWA.

It is not my purpose to consider extensively the duties of the local surgeon to the injured nor his duties to the railway company, but rather attempt a brief consideration of his relations to both, in the dual relationship he

bears and the duties that he owes.

name over some

The title "railway surgeon" has always had something in it that was to me distasteful. Not but that it is an honor to be an appointee of a corporation and to have the opportunity of attending and relieving the suffering and injured, but rather because of the fact the name implies that we possess some special quality of surgical skill which entitles us to this other of our professional brethren. The name is, however, a proper one, perhaps. We are appointed and employed by the railway company. Our compensation for services rendered usually comes from its treasury. While we are employes of the company, we are nevertheless physicians and surgeons. Because of the name we bear and the type of character we should exemplify, we must scrupulously guard against the violation of any professional or personal trust imposed on us by either interest. In our relations to both interests whom we are trying to serve, let us remember above all else that we are doing our duty to others only when we are doing our

*Read at second annual meeting Rock Island System Surgical Association, Chicago, December 7 and 8, 1904.

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full duty to ourselves, in building up and maintaining a personal and professional reputation, recommending us alike to both interests. And further let us fully appreciate the honor and the dignity of the characters we bear. It is indeed an honor to be the appointee of a great corporation, bearing to a certain extent its endorsement and recommendation for surgical competency, but greater still is it a golden opportunity that we have for doing good, for assuaging pain, for saving life and limb, when the bleeding and pain-racked patient is brought to us. If we are to him a true surgeon in his need we are to him a friend indeed.

* * **

In the estimation of our duty to the injured let us not form a conception of it that renders us hyperconscientious, or blind to our other relationships and duties. As was well stated in the paper prepared by Claims Attorney McCaughan, for our meeting of last year: "Let your first care be the welfare of our patient," and also "Do not let the fear that you will be unduly committed to the interest of your employer cause you to stand so straight as to lean the other way." In remembering our devotion to our patients, let us not forget the fealty we owe to our employer as well. While we are employed as physicians and surgeons, with our well known convictions as to the sacredness of our professional relations to our patients, yet it is also recognized by our employers that we are practical men, possessed of a degree of surgical skill combined with other qualities, personal and professional, among these being aptness and civility, enabling us in a proper, yet practical way, to be of service in the care of and in dealing with the

injured. Fortunately for us, the seeming confliction in this duality of duty, at first glance apparently irreconcilable, calls in the main for services which are but a service for both. There is little chance of violation of either trust as compared with the greater danger of violation of both through incompetency, or in some way failing to meet the full measure of our opportunity.

With a full and high conception of the dignity of the character we bear, what is the duty we owe to the injured when he is brought to us, and what duty do we owe to the railway company? We should first give him a complete and systematic examination, noting not only open and evident conditions, but looking for evidence of old injuries as well. Anticipating a possibly delayed recovery, let us look in a general way for conditions which may have a bearing on the case. Let us interrogate the liver, the skin, the nervous and cardio-vascular systems for evidences of alcoholism. The users of alcohol are as numerous as are the leaves of autumn, and is it not reasonable and prudent for us to be on the lookout for its baneful influence in our railroad cases? Let us examine the skin, glandular, nervous and cardio-vascular systems for evidences of specific infection. Neither alcoholism nor syphilis would be apt to become known to us unless we seek them by a general objective examination. The patient, even if aware of their presence, would not be apt to tell us. It is important to both interests that they be recognized and given due consideration in diagnosis, treatment and prognosis. Let us examine the joints, the tendons and muscles about them, the endocardium and the cardio-vascular system, for evidences of rheumatic infection. Let us obtain all the diagnostic light on the case possible, and even then it is too often dark and unsatisfactory. Both the injured and the company have a great and evident interest in the existence or non-existence of these and other possible conditions in many cases of injury. In making a complete examination we are also doing much to win the confidence of the patient which will be no small factor in determining our final measure of success in directing the treatment and determining the ultimate result in the case.

A thorough examination made, an intelligent diagnosis arrived at, we are now ready to give necessary treatment. Here is our great opportunity. It is our plain duty to both interests alike to use every possible effort, both surgical and non-surgical, for his complete recovery in the shortest possible time, with the least possible pain and suffering and with the least possible deformity and decreased earning power. Meeting the plain indications for treatment dictated by a judgment cautious but reliant, safe but not too conservative, progressive but not faddish, and we shall have performed our most important service for either interest.

We now come to the making of the report. We are appointed by and employes of the company. The injured comes to us because we are the surgeons of the company. He knows that the value of the facts contained in our report is one of the reasons why we are employed by the company, and why they pay us for the service rendered. He comes to us, knowing and realizing it is both to his interests and those of the company that the precise nature of his injury, the etiologic factors, the prognosis and the treatment given his case be known in full to the company.

You are all familiar with the form of our report and realize our duties connected therewith. Its value to both interests will depend upon its completeness in detail and the unvarnished manner of stating the information. and opinions contained therein. It should not be our endeavor to report an injury of less seriousness than the facts would warrant, and thus lull the claim department into a sense of security. It is not for us to try to make out that injuries are not serious, or that the company is not liable for them. Neither should we be alarmists. Let us endeavor to give the plain, unvarnished information called for in our re

port, which can harm no one. Both parties have a right to demand this, and it is, for evident reasons, for the benefit of both to learn the truth as nearly as it is possible for us to obtain it and give it.

In answering the questions asking for information not relating to their physical selves nor connected with the matter of etiology proper, such as whom he blames, winesses to the accident, could greater caution ha pre

vented the accident, I have always filled these out with some misgivings. We are appointed and employed as surgeons. The injured come to us as such, not as claim agents nor as representatives of the legal department. We are to deal with him as affecting his physical needs and conditions, and it seems to me there is a serious question of our professional right to take advantage (if advantage it is) of a situation where trust and confidence is imposed in us professionally to learn from him facts having no surgical bearing upon his case. I realize this feature is one about which much, both pro and con, can be said. Personally I have often wished the company had some other way of obtaining this information than through the Surgeon's Report.

In our contact with the injured we have a great opportunity for doing good, both to the injured and the company. On the contrary, we can often do great harm. Let us watch our cases carefully, expressing frank opinions to our patients and keeping the company well informed of all developments. When our examination or observation does not show any serious organic disease or lesion as the result of injury, let us express ourselves accordingly. Let us remember our great duty to both parties is to assist the patient to as early a recovery as possible. Let us always go into his presence with an air of hopefulness. Let us try to convince him that he is to get well. Let us point out the favorable symptoms and try to build up a feeling of encouragement which may become no inconsiderable factor in the course and final result. If, on the contrary, our bearing is one of seriousness, we can very easily give rise to convictions difficult to change and, in a psychic way, retard or prevent recovery. We all know that the influence of the mind over the body is very potent in determining the course and recovery from sickness or injury.

It has often seemed to me we are apt to err by obtaining the impression that we are more or less important factors in determining matters of liability growing out of our

Again, let us not forget that we are surgeons and, by learning, training and environment, have little opportunity to acquire legal knowledge. In the railroad organization there is an excellent example of the division of labor and

this part of the work is allotted to other and more competent hands. Let us keep our eyes fixed on the star of our own professional duty.

In closing, I wish to repeat and emphasize the fact (for a fact I believe it is), that in the main when we are competently and faithfully serving one interest we are also serving well the other.

DISCUSSION.

Dr. John D. Seba, of Bland, Mo.: If I understood the essayist rightly, he criticized the question in our report as to "Who do you blame for the injury personally ?" I think it is a very important question. It has been to me, at least. Four or five times that question has been asked at the proper time, and at the moment the accident happened, the patient generally telling the truth and just how it occurred. Very often these patients are to blame themselves, and if that question was left out the probability is that there would be a damage suit. I could not hear very well when the Doctor was reading his paper, and if I am not right in what I have said I want to be corrected.

car.

In one case a man was on a hand-car, he stepped off in front of the car, it ran over him, and he was only to blame himself. had a couple of ribs fractured. He could easily have said somebody pushed him off the In these cases I want to do justice both to the patient and to the company. But there is great opportunity for malingerers in these cases. They go to work and make up a pitiful tale, where as if, on the spur of the moment, you ask them that important question, or where the injury happened, no matter whether it is a railroad case or any other kind, it will help you very materially. I always ask, “How did you happen to get that injury?" "Who was to blame?"

Dr. J. A. Overstreet, of Kingfisher, O. T.: I do not consider all of these cases are to blame. There is nothing so important as making an early statement of an injury or accident, and, as has been said, very often these people change their minds. I recall the case of a man who said in his early statement that he caught his foot in a switch-car, but when the case came to trial he stated it was a broken beam.

Dr. Silverthorn, of McFarland: As I under

stand it, our report is not complete unless we ask the patient, "Who do you blame?" In our final reports, we say who is to blame. The ancient Romans regarded justice as the first principle of their code, and they never allowed that which was expedient to take that which was just. We should let justice go forward, but do our duty toward the company. There are many cases we know are malingerers, and we should not be too hasty in making a diagnosis; again, there are times when we should not ask any more questions than we have to. We should draw our own conclusions and ask as few questions as possible. In that way we protect ourselves, and we have the assistance of the company in giving testimony. I think it is always proper to ask an injured man whom he blames, and I do not consider our report complete unless we do this.

Mr. George E. McCaughan: I have been very much interested in this paper, particularly with reference to the patient's statement as to cause of accident and who he blames. Is not a full, frank or truthful answer to such a question of value to the railroad surgeon in ascertaining the mental condition of his patient? Suppose he blames some one or cites facts which indicate enmity and an excited condition. of the mind, is not that something that is useful to you in your examination and treatment of the case? Does not his mental attitude in the matter constitute some benefit to you? As has been well said on the floor, the first statement of a patient is likely to be true. Of course, there are some people who, as soon as they see an approaching train, will begin to figure on a damage suit before the collision has occurred. (Laughter.) Others put off the bringing of damage suits until after the injury. The earliest statement we can get from a patient as to the facts of an accident and who he blames is of exceeding value in the adjustment of the case, and to my mind it is not unprofessional or going outside of his duty, for a railway surgeon to seek this information. He can do it at a time when we can not. We would be justly censured if we sent a man from the Claim Department before the surgeon had dressed his wound, or if we obtruded upon him in a case in the hospital, or while at home sick. The surgeon visiting him daily can get

this information without causing any harm or producing any excitement. If I should go to an injured patient in a hospital and interrogate him I would create a condition of excitement in his mind. I might cause elevation of his temperature, and I do not think such a man ought to be burdened with interrogations from a lawyer or a claim agent at such a time. But we must have this information in some way. An investigation has to be made, and the patient's statement is the very basis of the investigation. If he says, "I blame the engineer," then we can go to the engineer. We can ascertain what the engineer has done. After a patient has made that statement, and the case has been investigated along that line, it is not easy for him to take a different position later. We do not want to do any injustice to these people. You will save them money and save the company money as well. The man who gets $4,000 at the end of a law suit is far worse off than if he had accepted $1,500 in settlement. If you will say to these patients in a friendly way that their best policy is to deal first with the company, and it is time enough to hire a lawyer when they have failed in their settlement with the Claim Department, you will do a great deal for us. We of the surgical and legal departments must be true to ourselves, true to our professional obligations, seeking only truth and honesty in all things. Above all,

"To thine own self be true,

And it doth follow, as the night the day, Thou canst not then be false to any man." (Applause.)

Dr. Frank D. Thomson, of Fort Worth, Tex.: I have a couple of cases to report on this line. About four years ago a boiler-maker repaired to the office with a history that while chipping the head of a screw a piece of iron flew off and struck him in the eye. The wound was located at the junction of the cornea with the sclera on the outer side, 3-16 inch long. The anterior chamber was so filled with blood it was absolutely impossible to see inside of the eyeball, though from the history we were satisfied beyond any question that the piece of iron was in the eyeball. We made an effort to remove it. The original wound was slightly enlarged, and by the aid of a magnet a piece

of iron extracted from the eyeball. The eye was dressed and the patient sent home. It was dressed antiseptically and every precaution taken to prevent any suppuration, which did not occur, and the next day the patient, when seen, was feeling comfortable, had no pain, and was feeling much encouraged as to the condition of the eye. There was a great deal of inflammation on the second day following the injury, after the eye had been dressed. The patient said to me, "Doctor, I have had some visitors today." I said, "Is that so?" "Yes," he replied, "a couple of lawyers came to see me this morning and were anxious to take my case. They say it is a fine case and want to handle it for me. What do you think about it?"

I said to him, "I am not a lawyer; I don't know much about law, but so far as my observation goes, the Rock Island Road always does the right thing by its employes, and if I were in your place I would leave the question of settlement out of consideration until you see what condition your eye is going to be in." I did not ask the names of the lawyers. The next day, at my second visit, I learned the patient had had four visitors, four lawyers, and one firm went so far as to say they would advance him $500 upon which to live while he was fighting the suit. I told him I would have nothing more to say; that I would leave this matter to take care of itself, as it would be more satisfactory to him in the end. He was a fair-minded man and said he had not committed himself one way or the other. He remarked, “I am not going to sign a contract with a lawyer; I am going to wait."

We treated him for sixty days, and while at the end of that time vision was somewhat impaired, he had fair vision in the eye. At the end of that time a proposition was made to the Claim Agent, and he also made an application for work to his foreman, and was told: "We can not take you until you make a settlement with the company." The foreman sent him to the Claim Agent. The Claim Agent said, "What do you want?" The man stated his sum. I was asked to state the condition of the man's eye, after which the man stated the sum he thought he ought to have, and wanted his position. The Claim Agent said, "We will

pay chat sum." A settlement was made and the man is now working, holding his position, and seems to be satisfied.

I felt, without any conscientious scruples on my part, I could not advise that man to take those steps. I thought he would get more out of an action in that way, or a much greater sum than he would if some firm of lawyers had taken hold of his case. I advised him, without feeling that I was doing anything wrong, to wait until he had learned definitely something about the outcome of the injury to his eye. I felt that was a duty I had to discharge toward the company, and in so doing I do not think I did the man any harm. We did not neglect treatment in this case; we gave the eye every attention.

Let me cite another case, which occurred just ten days ago, one in which a suit has been filed and is coming to trial. The patient was an old woman; I do not remember her age. Her daughter came into our office and said that she wanted to have some treatment for her eyes. She lived out of the city. We had known the family for several years and had treated her mother. When she came in I was rather surprised to see her and inquired about her mother. She said, "My mother is ill; she was injured, and now we have a suit against the Rock Island Railroad Company." I asked her how she was injured, and she replied, "She was hurt while stepping off of a platform. She injured her hip. An x-ray picture was taken and it was said that she would never be able to walk except with the aid of crutches. The date of the trial is going to be set very soon." I told her that I was very sorry to hear of her mother's misfortune. I made an application to her eyes, and an appointment with her to come back the next day. After she had left the office I called up the Adjuster, with whom I was personally acquainted, and asked him something about the case. I told him what the young lady had said to me, and stated that I was personally acquainted with her mother-in fact, knew all the members of the family, and that if the company was inclined to effect a compromise, I was in a position to render some service. The agent came to see me. I told him what the daughter had said to me about her mother's case, and said, "If you