Railway surgery was a branch of medical practice that flourished in the 19th and early 20th centuries. It concerned itself with the medical requirements of railway companies. Depending on country, it included some or all of: general practice for railway staff, trauma surgery as a result of accidents on the railways, occupational health and safety, medico-legal activities regarding compensation claims against the company, and occupational testing.
Railway surgery was especially well developed in the US, with formal professional organisations and scholarly journals. One of the reasons for this was that US railways were particularly dangerous, with a high number of casualties from crashes and an even higher number of workers hurt in industrial accidents. Another reason was that many US routes passed through areas with little or no existing medical infrastructure. In Europe the railways were safer and infrastructure was generally already in place. The duties of railway surgeons in Europe mostly involved investigations into accidents and the resulting claims arising from passengers. In India the railways also faced a lack of existing medical infrastructure and, like the US, had to build it from scratch. Indian Railways still maintains a network of hospitals.
By the middle of the 20th century, railway surgery had lost its separate identity. The growth of other industries and improving rail safety meant that the railways no longer stood out as a leading cause of injuries. Likewise, industrial medicine and health and safety became a concern for all industries. There was no longer a need for an industry-specific branch of medicine.
Function
The primary purpose of railway surgeons was to attend to the many injuries of staff and passengers on the railways. Railway surgeons were also responsible for assessing medical claims against their companies and providing routine medical examinations of employees and applicants.Aldrich (2001), pp. 255–256, 270, 273 Railway surgeons were keen to establish their profession as a separate discipline with unique problems. For instance, the textbook Railway Surgery, published in 1899, spends a whole chapter on the claim that crushing injuries from the heavy moving equipment on railways are of a kind not found in other industries.Herrick, pp. 18–22
Railway surgeons were generally not well paid. While a chief surgeon or consultant surgeon might attract a good salary, the ordinary doctors working out on the lines were not well rewarded.
Traumatic injuries
Rail crashes were common in the 19th century with many deaths and broken bones.Aldrich (2001), p. 255 In Europe, the majority of injuries were due to collisions, hence passengers rather than employees formed the bulk of the injured. For instance, in Britain, accidents on the line such as crushing between wagons and being struck by trains (accidents suffered mostly by railway staff) were far fewer than passenger injuries through collisions in 1887.Bond, p. 294 In the US, the railways were significantly more dangerous.Aldrich (2006), p. 2 Counterintuitively, this led to staff injuries being by far the greatest proportion. In 1892, US railroads reported 28,000 injuries to workers compared to 3,200 for passengers. The most dangerous role was brakeman, whose job included coupling and uncoupling wagons. The most frequent injury was the brakeman being crushed between wagons while carrying out this task.Herrick, pp. 5–6 One third of all railway injuries to staff were crushed hands or fingers.Herrick, p. 154
The number of deaths and injuries grew rapidly as the century progressed. In the US, the first death occurred in 1831. There were 234 deaths in 1853, the year in which there were eleven major crashes.Aldrich (2006), p. 2 In 1890, there were 6,335 deaths and 35,362 injuries,Friedman, p. 353 and by 1907 it had reached its peak at nearly 12,000 deaths.Aldrich (2006), pp. 2–3 In England, an early railway death was William Huskisson, Member of Parliament for Liverpool, killed during the opening of the Liverpool and Manchester Railway in 1830.Fletcher, pp. 6–7 In the UK as a whole, deaths and injuries grew much less dramatically than the US. There were 338 passenger deaths and injuries in 1855 and 435 in 1863, but at the same time passenger numbers were increasing. From about the middle of this period the rate of injury started to go down with improving safety—2.85 per million passengers in 1855 to 2.12 in 1863.Fletcher, p. 63 A similar picture of low rates pertained in other European countries such as France, Prussia, Belgium and Germany.Fletcher, pp. 49–50
Many injuries required amputation. For instance, in 1880 the Baltimore and Ohio Railroad reported 184 crushed limbs, including 85 fractures and fifteen amputations.Aldrich (2001), pp. 276–277 The need to perform amputations and other surgery may be why railway surgeons were named surgeon rather than doctor or physician. While traumatic injuries were not the most frequent ailment they had to deal with (that was infectious diseases) it did distinguish them from typical general practitioners. Other influences may have been the comparison to ship's surgeons in the age of sail, and the greater status and pay of surgeons.Aldrich (2001), pp. 257, 277
First aid kits and training were introduced at the instigation of Charles Dickson of the Canadian St. John Ambulance Association and backed by many railway surgeons. One railway surgeon reported that his fatality rate following amputation more than halved after first aid was introduced. There was some opposition to first aid through fear that it eroded the professional status of doctors and that local contract railway surgeons would lose the fees they would otherwise have accrued for the work.Aldrich (2001), pp. 285–287 However, by World War I first aid kits on trains had become widespread.Aldrich (2001), pp. 285–287
As the twentieth century progressed, rail safety improved dramatically. So much so that by 1956 the president of the Association of Surgeons of the Chesapeake and Ohio Railway, when asked if he saw a lot of accident cases at the company hospital, could reply "yes, I see a lot of accidents from the highway" and "[t]he primary purpose of our group has all but passed out of the picture."Gilmer, pp. 423–424 The discipline of railway surgery had been folded into the more general discipline of trauma surgery.Rutkow (1988), p. 106
Railway spine
An important function of railway surgeons was to control the costs of claims against their companies, leading to conflicts of interest regarding treatment of their patients. For instance, the chief surgeon of the Missouri Pacific Railroad proudly boasted that he kept claims in the region of 14–35 dollars whereas claims against another railroad were nearly 600 dollars on average. Company medical staff were also expected to help achieve political aims with expert evidence. In some cases chief surgeons were appointed purely on the basis of their relationship to important politicians.Aldrich (2001), pp. 266–270
Fraudulent claims were a big concern for railway companies. Sometimes, these were entirely contrived "accidents" by confidence tricksters; more commonly, however, they were exaggerations of the results of a genuine accident. In 1906, railway surgeon Willis King claimed that 96% of claimants were actually malingering.Dembe, p. 229 One common claim that was hotly debated by railway surgeons was the condition known as railway spine. Over a hundred papers were published on the subject in the medical literature for the period 1866–1890.Dembe, p. 230 In this condition, the patient reports cerebral symptoms such as headache or loss of memory, but there is no visible damage to the spine. It was first described by Danish-British surgeon John Eric Erichsen. Erichsen believed the condition was physiological, due to inflammation of the spinal cord. He compared it to meningitis which had similar symptoms and a similar cause. Others, such as Herbert W. Page (surgeon to the London and North Western Railway), argued that it was psychological, or else, like Arthur Dean Bevan (1918 president of the American Medical Association), outright faked. Railway surgeons were generally skeptical of the condition and disliked the implication that there was an injury peculiar to railways. British surgeon Edwin Morris described the term as "most reprehensible".Morris, p. 48 Bevan claimed to have cured one patient in ten minutes by standing him up and speaking to him forcefully.
In Britain, a number of major train crashes led to parliament passing an act which compelled rail companies to pay compensation to victims of accidents. A large proportion of the thousands of resulting claims were for railway spine. In a five-year period in the 1870s English railway companies paid £2.2 million ($11 million) in claims for railway spine.Brown, p. 424 Following a similar law in Germany, 78% of claims in the period 1871–1879 were for back injury. Claims for railway spine had subsided by 1900. From 1890 there were more claims for psychosomatic conditions such as hysteria and the neurasthenia of George Miller Beard rather than physiological conditions such as railway spine. Even Erichsen himself agreed that his original cases were actually traumatic neurasthenia. However, medical concern remained over these emotional damage claims regarding malingering and false claims.
Health and safety Railway companies pioneered the disciplines of industrial medicine and occupational safety and health. They were the first organisations to give physical examinations to prospective employees. The motivation was partly to prevent fraudulent claims for pre-existing conditions, but also to improve rail safety. The Baltimore and Ohio Railroad in 1884 was the first to do this and had a particularly thorough examination. They rejected 7% of applicants. Colour blindness tests were introduced for all employees in most US railway companies in the 1880s because of the need for correct signal recognition. Hearing tests were also implemented.Aldrich (2001), pp. 273–274
Colour blindness tests were a result of the 1875 Lagerlunda rail accident in Sweden. The accident was investigated by Frithiof Holmgren who concluded that the crash was a result of colour blindness of the driver.Vingrys & Cole, pp. 369–375 Holmgren created a test for use in the transportation industry based on matching coloured skeins of yarn. However, Holmgren's test was disliked by employees and there were many complaints of unfairness. Many companies preferred to test with lamps and flags, but this led to conflict with the railway surgeons who were concerned that non-professionals were administering medical tests.Aldrich (2001), pp. 273–275 Holmgren's identification of colour blindness as the cause of the Swedish crash has also been disputed.Mollon et al., pp. 178–194
Railway companies increasingly improved the health of their employees with preventative measures against disease. Vaccination schemes were introduced. Sanitation aboard trains became an issue, as did the quality of water supplies. In the 1920s the Cotton Belt Railroad succeeded in cutting hospitalization due to malaria of its workers from 21.5% to 0.2%. They did this with a program that included suppressing mosquito populations, preventative quinine treatment, education, and blood tests.Aldrich (2001), pp. 279–286
World view