When the railway surgeon approaches spinal injuries, his responsibility to himself, to his profession and to the railway company increases an hundred fold. I know of no class of injury, in all the realm of accidents to the human body, which will tax the surgeon's keenness of diagnostic and prognostic ability more than do injuries to the spine.

To positively differentiate between a true cord lesion. and a malingerer may be well-nigh impossible.

It is well known that there can be no appreciable injury to the spinal cord, without more or less paralysis. And yet the surgeon will not always be able to distinguish between psychic and motor paralysis. To even make an attempt to relate all the diagnostic points, in considering these cases, would carry me beyond the scope of these remarks. The most noted neurologists are often compelled to acknowledge their inability to say how much of the symptoms presented depend on pathologic conditions, or how much of the psychic, neurasthenic or neurotic may be present.

Still, a surgeon who approaches a person with a supposed injury to the spine will, if he brings a keen intellect, ripe experience, special study, and a disposition to be fair, be able usually to make a true diagnosis. However, the difficult and obscure cases occur frequently enough, as before stated, to cause him more worry than any other class of injury.

To more than mention traumatic neurasthenia is about all I will be able to do. The severe shake-up that occurs in a railway accident must necessarily make a profound and sometimes lasting impression upon the neurotic and hysterically inclined person. Such cases will require a careful examination and the exhibition of much tact, to do exact justice between patient and railway company.

Medico-legal questions are constantly arising in the performance of the railway surgeon's duties. No greater responsibility can be thrust upon the railway surgeon than to take upon himself the burden of caring for an injured person, where the railway company is clearly responsible in law for the accident. He is acting in a dual capacity. He has a duty to discharge in the interest of his patient; also in the interest of the company. When the patient is simulating, is neurotic, psychic, neurasthenic or hysterically inclined, then does the surgeon's responsibility multiply many fold. To sift out the false symptoms from the real, and present what is really of a pathologic nature in the form of a report to the railway company, and perhaps to defend later his position in a trial court, is no easy task. The surgeon who can pass between Scylla and Charybdis without shock or collision is indeed fortunate.

And so railway surgery, in relation to medical jurisprudence, is a department of our many-sided duties of the greatest importance, by reason of its constant application to the results of the injuries frequently occurring.

In conclusion, permit me to venture the opinion, that if the railway surgeon is fired with enthusiasm for the higher ideals of his noble profession, he may surmount most of the difficulties which beset his way.

The Santa Fe is having plans made for a hospital at Los Angeles to cost $40,000.

THE IDEAL RAILWAY SURGEON.*

BY A. I. BOUFFLEUR, M. D., OF CHICAGO,

Dr. Gardner requested me to make a few remarks to this association and gave me a subject, which was very kind of him, because I would have had difficulty in selecting one, knowing from previous attendance upon these meetings that the general field of railway subjects has been appropriately covered, not only once, but sev

eral times.

The subject that Dr. Gardner suggested was "The Ideal Railway Surgeon." I do not know why he sug gested that, perhaps because in our selection of railway surgeons he thought it but natural that we had formulated some general scale by which we could estimate a man's qualification for such a position. You are aware at the present time they are putting everything down to a standard. This applies to all phases of construction and operation. I do not expect we have found the "ideal" railway surgeon, yet he thought we must have an ideal in mind, in order to make selections. The time is within the memory of a number in this room when there were no such employes as railway surgeons, like we have to-day. They were appointed not from a humanitarian, or from a charitable standpoint, but purely as a matter of business necessity; and that is, I take it, the principal object of railway companies having surgeons to-day. If it was not that it showed a distinct saving to them, I do not believe that they would care to be encumbered with us. However, that does not prove that we are not very essential.

All successful railroad management calls for the application of energy in one of two directions; first in the securing of business, and second, in the minimizing of expenses. Now, as one of the means of minimizing expense they employ surgeons. I do not doubt but what there are more gentlemen in this room who originally came to be employed as surgeons accidentally than otherwise. I know my first employment as such was purely a matter of accident and not because they were looking for a certain individual to fill a certain place. A purely incidental affair happened to bring the matter about, and I suppose the relationship has resulted in profit to the company. I certainly hope so, as I would not like to feel that I have been drawing salary for several years without giving just compensation. On the Milwaukee road, as well as the Pennsylvania lines with which I am connected, we have a little different system of selecting surgeons than prevails on most roads. The real selection is made by a non-professional man, which plan has some advantages. If we were to look over the file of surgeons which we have, and to look over the men individually, and if we were to take out those who have been the most successful from the company standpoint, we would find some general characteristics present in all of them. Of course you would find different special characteristics present in various ones. Our general ideal, therefore, could probably be shaped up in a comparatively few at

tributes.

The first essential in a railway surgeon is that he

*Extemporaneous remarks at the annual meeting Iowa State Association of Railway Surgeons Des Moines, October 17, 18, 1903.

you do not want to do it in your regular report, make a special one, and if you do not want to sign that report for some legal reason, it is a small task to write it out on a piece of paper, or have some one else write it out and pin it on your report. They will understand. You can leave it to the cleverness of their attorney to bring it out on the witness stand. It certainly would be wrong on the part of an attorney, and equally so with a surgeon, to withhold facts which would enable the company to defeat fraud and preserve justice.

In this same connection there comes the question of whether or not it is within the province of the surgeon to advise claimants not to go into litigation. I believe it is, and I believe also that in doing so we are following out the principles of our profession, because we are avoiding more serious trouble for them, a great amount of trouble in the majority of cases; we are securing for them much more money than they will eventually get out of the amount recovered. My own way of handling the situation is simply to advise all patients to "Go and see the claim agent of the company before you get into any entanglements. The company wants to do what is fair and square with all employes or persons who are injured. If the company gives what you want, or somewhere near it, that, of course, is the best way for you to settle, as you avoid trouble and delay and maintain the officers' respect; but if not, I would advise you to consult the best attorney you are acquainted with. Don't consult anyone that has sent out a runner for your business. If he is a good man he does not need any run

ners.

You certainly would not call a surgeon running up and down the street presenting his card and asking for the privilege of treating you, and neither should you employ an attorney who would resort to the same means." So far as I know, a plain, frank talk of that sort has never been completely disregarded, and in only a comparatively few instances has it failed of a settlement.

The third obligation I should mention is the duty of a surgeon to himself. While he is treating his patient and looking after the interest of the company from a professional standpoint, the doctor should remember that he has a reputation to preserve and that he should do that zealously, just as zealously as he would look after the injury of the one and the purse of the other. It is not very complimentary to a doctor to have anybody state that "he is a good surgeon, but you would not trust him as a man." I would not like to have that reputation among my friends and the employes that I treat, and I am sure that none of you would. If we can so handle our professional relationship to employes that they will believe that we are not only capable of taking care for them so far as their injuries are concerned, but also that we are fair-minded and honorable, we will find we can do a great deal for them both professionally and also morally. And if you and I conduct our business so as to keep the confidence of our patients we will do a great deal for our company, and our practice will redound to our own lasting credit.

DISCUSSION.

Dr. Clark: I do not rise for the purpose of discussing the subject in question, but, on the other hand, for the possible purpose of receiving information in regard to a troublesome case of my own. If my memory is

correct, it was during the month of May that an accident occurred on the C., M. & St. P. railroad. A mail car was derailed and hurled into the ditch, and one of the postal clerks was injured, but made what seemed a miraculous escape. He suffered a scalp wound, and also contusion of the arms, shoulders, hips and back. He was first attended by another surgeon, and subsequently came into my hands. The scalp wound healed kindly, and the other injuries apparently disappeared, but he then developed what seemed to me a condition depending upon an injury to the peripheral nerves supplying the parts. I treated him with static electricity and he said the treatment relieved him in a wonderful manner. This had a tendency to corroborate my opinion of what I believed to be the actual condition. In July (I think it was) he concluded he would resume work and accordingly made a trip, but it used him completely up, and he returned in a condition in which he was with some difficulty able to get about, and doubtless suffering considerable pain. He at once reported to me, and I resumed treatment with electricity and he again improved. About a month later he made another trip with similar results; since that time he has been calling almost daily for treatment, and his condition remains about the same.

There is no tender spot anywhere, nor does he complain of pain. I would be glad to know my duty in the case. I recently received a letter from the special agent, in which he wanted to know the reason for the prolonged treatment, and I informed him that my patient had developed traumatic neurasthenia. I am in doubt whether treatment is necessary or really beneficial in the end. He comes in and says his back is lame, and walks in a manner that indicates that he has some trouble. It is with difficulty sometimes that he gets upon the platform of the electric machine. I use the static breeze and electrodes, and he gets off the platform feeling well. It has occurred to me that this patient's trouble is more imaginary than real, and that the condition may be almost wholly psychic.

The question is, Shall I continue treatment as he demands or inform him that in my opinion it is not necessary and permit him to fall into some other hands. I mention this for Dr. Bouffleur's consideration.

the

Dr. Bouffleur (answering Dr. Clark): I hardly believe it is good policy to discuss unsettled cases, yet the question in this one is exceptional, because it is simply a business proposition. If the doctor expects the company to pay him for his services (which I have no doubt he does) he should explain the matter fully to the party who wrote him and tell him why he continues the treatment, allowing that party who is expected to pay bills to decide whether or not he should continue to treat him on account of the company. If that party is not decided, he will refer it to some medical man to de termine the best course. So far as the surgeon's status in the case is concerned, it is for Dr. Clark to post the company in the matter, and let its officers decide whether the treatment is to be continued at the expense of the party who is to pay the bill.

Dr. Clark (in reply to Dr. Bouffleur): On several occasions I have said to the patient I am not sure that the company will be willing to pay me for the treatment

SPRAINS OF THE ANKLE.*

BY J. R. HOLLOWBUSH, M. D., OF ROCK ISLAND, ILL.

there are certain conditions or walks of life, as in workingmen, where patients are obliged to go about on their feet earlier. In such cases I think the application of a tight elastic band from the toes to the knee enables them to go to work much earlier. There is great support to the vessels, and this bandage gives less pain in walking. Let me recapitulate: Application of heat, elevation of the leg for the first few days, the application of cold, if there is no synovitis or inflammation of the joint, and after this the use of passive motion.

DISCUSSION.

Dr. Jacob A. Kimmell of Findlay, Ohio: I do not know whether the gentleman conveyed the clear meaning to me or not as to his treatment of sprains of the ankle. I do not know whether he intended to apply hot or cold applications before putting on the elastic bandage or not. After my experience with these cases, I am pretty well satisfied that we should treat them with hot

ments. Given a force which is expended upon the joint, it will produce a sprain always at the point of least resistance. The internal lateral or deltoid ligament of the ankle joint is strong and thick. It is so strong that even when it is exposed it is rarely torn. A sprain is, therefore, a rupturing or tearing of a greater or less portion of this ligament. When any violence is transmitted to the ankle joint, we have a tearing of the ligaments, usually the external lateral.

Sprains may be of a slight nature. They may consist of a slight stretching or a slight rupture of the smaller blood vessels, or the ligaments be torn from the bones to which they are attached, or even a small portion of the bony substance itself. The most severe sprain we have of the ankle is that connected with Pott's fracture, where the internal lateral ligament is torn loose from the tibia, with a fracture of the fibula. It is the most severe form of sprain we have connected with a fracture, and does not really come into the consideration of this subject.

As to the treatment of sprains, it has been my custom (and I believe it is the correct one), if called early to see a sprain, to apply hot rather than cold applications, the reason being to get capillary dilatation, and by securing it you get absorption of a great deal of the fluid thrown out by the blood vessels and capillaries. Later on, when we have synovitis, or rupture of the capsular ligament, with synovitis, I think the application of cold is indicated. The treatment of sprains of the ankle joint is the same as for sprains of any other portion of the body, namely: Absolute rest, elevation of the leg to a degree that is comfortable to the patient, and support of the weakened vessels that are torn or ruptured. In a case of sprain it has been my custom to use a rubber elastic bandage, first applying the bandage from above the ankle over the foot to the toes, and applying heat over the elastic bandage. Strapping by strips of adhesive plaster is nice, but they slip and become soiled. By using a narrow strip of elastic bandage, you can apply it tighter and tighter as the swelling decreases, and have a snug support in this way to the joint. The difference in treatment in all sprains is indicated by rest and support. But

*Discussion at the sixteenth annual meeting I. A. R. S., Indianapolis, June 17, 18 and 19, 1903.

perhaps an hour or more, then wrapping the parts in absorbent cotton, applying tightly a cotton bandage, and over this putting an elastic bandage. I imagine that if an elastic bandage is applied next to the skin, it will prove somewhat of an irritant, and even a cotton bandage, if applied next to the skin, is an irritant, and you cannot put it on so smoothly but what it will leave little wrinkles in the skin. I believe the roller bandage skilfully applied in this way is far superior to a fixed bandage of plaster-of-paris. While it fixes the joint to a certain extent, it does not fix it to the degree that plaster does. Motion is allowed, and the comfort afforded to these patients is ample evidence that the treatment is in the right direction.

Dr. George Ross of Richmond, Va.: I do not intend to refer to the pathology of these sprains; but I had a personal experience many years ago. I fell down a step, caught my toe and heel, and sprained my ankle. If I may magnify the intense pain I suffered, I should say it was "horrible." I was taken to my house, and very soon after my arrival there an eminent physician, who took much interest in this subject, came to see me. He examined my foot and said, "My boy, you have got an ugly ankle." I did not deny the proposition. He said, "I suppose you want to get it well quickly" (I was a hard working boy in those days, and have been a hard worker ever since). I said to him I wanted to get well as quickly as possible. "Very well," he says, "I will give you a domestic remedy which an old woman gave me years ago." He told me to send out and get half a dozen eggs; take the white of these eggs, spread it thickly on cotton. It was not as thick as wadding. He told me to put on three or four thicknesses of cotton, and spread the white of an egg thickly over it, first soaking the foot in water for an hour, and then applying this bandage of egg and cotton, elevating the foot, and see how quickly it would get well. I did this, repeated it the next day, and the next, and I do not believe I was away from my work for more than a week.

I agree with the doctor who advocated hot applications as a primary dressing rather than cold applications. I do so upon the ground that there is no more certain astringent than heat in hemorrhage. I applied the white

of an egg because as it dries it becomes a powerful astringent, and contraction was the immediate consequence. In my case, after two days the intense soreness had disappeared. I used a crutch for a week or possibly ten days. Hearing this discussion made me think of my own case.

In all cases of sprains of the ankle, it is important to ascertain whether you have ligamentous laceration or not, and it of course means greater delay in repair. But whether there is laceration or not, whether there is ecchymosis or not, hot water should be constantly applied, so as to be comfortable to the patient. It is most direct in its curative effects.

The position of the limb is very important in the treatment of these cases. Dr. Senn gave us an illustration of the possibilities of position, showing how rapidly the blood vessels would empty and what the possibilities were by position. He demonstrated to us that if we put the patient's leg high enough we can keep the vessels empty and thereby reparation will go on much more rapidly.

Dr. J. H. William Meyer of La Porte, Ind.: I wish to call attention to the fact that, I believe, the same benefit can be accomplished by cold as by hot applications, only a different means is used. Cold, when properly and continuously applied, will cause contraction the same as hot applications. Take a washerwoman, who washes with hot water, and her hands are white. Put your Put your hands into warm water and you will have swelling.

In the after treatment, Dr. Ford spoke of warm applications, not extremely hot applications, to stimulate the arterioles, and he accomplishes what is necessary in the second stage under different conditions. If you want to use cold applications, you can do so. Use whatever you have at hand, and do so intelligently. You must frequently use what you have, and get as good results as you can in that way.

Dr. Milton Jay of Chicago: I want to say a few words about the knee joint. In a case of synovitis, we all know in old chronic cases of rheumatic knee joints we have an effusion into the synovial membrane of the knee joint which will cause the joint to puff up and to assume large size. Years ago I had a case of that kind. What did I do? I took an aspirator, inserted it, and withdrew a pint of fluid from the synovial membrane. I sealed up the puncture with collodion, put a weight on the foot, and the knee did not get sore. When I have now an injury of the knee joint accompanied with synovitis, the synovial membrane filled up, I do not wait for absorption of the fluid, but I take an aspirator, run it into the knee joint, pull the knee joint apart to get all of the synovial fluid out, seal up the puncture with collodion, and put a weight on the foot as I did in the case I have related. With this method I believe we can accomplish more in a shorter time than by any other plan of treatment.

Dr. C. Z. Aud of Cecilian, Ky.: Speaking of the ankle, we sometimes have complications. Other joints than the ankle may be injured. For instance, we have the metatarsal and tarsal joints. It seems to me, a safe treatment is to take a towel, wet it with warm water, neither hot nor cold, and wrap the joint up in it. Instead of changing the towel, have the water poured on often. I have myself sustained an injury of the ankle joint, and

I know that treatment will relieve pain; it will bring about absorption of the fluid, and there is no danger of either extreme.

Dr. George Ross: Referring to the remarks of Dr. Jay, I had a case which gave me great concern because of the bad result. One of the difficulties which we not infrequently have is in ascertaining absolutely and certainly the pathologic condition of a joint after an injury. A young man, in riding a pony, struck his knee against a sapling. There was apparently no dislocation, so far as the attending physician could determine, and I saw the case a few weeks afterwards. There was no dislocation; there was no fracture to be detected. But the ultimate result was gangrene of the foot, with amputation above. the knee as a necessity. In examining the severed limb it was found that the crucial ligament was torn, and also a small fragment of the head of the tibia on the inside. This case illustrates the difficulty of locating the exact character of an injury.

Dr. Emory Lanphear of St. Louis, Mo.: The question of immediate treatment has been well covered, and we all practically agree as to what is best done for the first few hours, namely, either hot or cold applications, elevation of the limb, and compression. The question as to what should be done, as soon as pain and swelling have subsided, is far more important, and upon the treatment adopted will depend the future of the individual. The X-ray has shown us that a far larger proportion of socalled sprains of the ankle joint are accompanied by fracture of the external malleolus than we have previously believed, in fact, almost one-third of these severe sprains will be shown by X-ray examination to be accompanied by separation of a part of the bone. The importance, therefore, of making an X-ray examination is evident. If we find upon such examination that there is a separation of part of the bone, the treatment must of necessity differ very materially from that which would accompany just an ordinary, common, everyday sprain. In such cases the best thing, in my judgment, is to put the patient in a plaster-of-paris cast from the toes to the knee. If there is nothing but a severe sprain present, the treatment may be either complete rest or the opposite, putting the patient upon his feet immediately, within a day or two, and allowing him to go about his work, the idea being the same as that which is in the mind of the surgeon who orders massage, namely, that motion with the use of the limb will promote absorption of the extravasated blood and more rapid healing than would be accompanied by the rest treatment. I am in doubt as to the advisability of this. It has been my fortune to open a number of joints for tuberculosis subsequent to sprains that have been treated by the ambulatory method. On the other hand, in a number of instances I have seen very useful results from strapping the joints and putting the patient immediately at work. In one instance I recall there was a fracture; in the other there was not, and this again emphasizes the necessity, wherever possible, of using the X-ray in the completion of our examination.

The question as to how long a joint should be immobilized is one of importance. If the patient is a man who is going to sue a company to get damages, he will insist upon wearing a cast from six to eight weeks, and under