by Robert S. Gillespie, MD, MPH
June 5, 1870
A brakeman at a remote western mine siding is attempting to guide a link-and-pin coupler into its slot when he slips on an oily crosstie. His hand is crushed between the couplers. The fireman, not knowing what to do, wraps an oily rag around the stump. He lifts the brakeman into the caboose as the partly severed hand dangles in the wind. The nearest hospital is hundreds of miles away, but the conductor hopes to find a doctor in a large settlement down the line. In the meantime he can offer his comrade no comfort other than a few sips of water. The brakeman’s cries of pain grow softer and the pool of blood beside him grows larger during two-hour journey. He is unconscious when the train arrives at the settlement two hours later, and the crew carries him to a room in the station hotel. A local doctor amputates the hand, but gangrene develops in the wound. The brakeman begins to have fever and chills, and dies a few days later.
July 17, 1897
A rookie flagman walking between cars at the same remote siding fails to notice the train starting to move. The car strikes him and throws him to the ground, but his pants leg catches in the running gear. The conductor sees the flagman on the ground and halts the train. He finds his coworker with a broken leg, the jagged bone protruding from a bleeding wound. The conductor opens the emergency kit from the caboose and wraps the wound with sterile gauze to reduce the bleeding, then stabilizes the leg with a wooden splint. He gives the injured man medicines for pain and shock, while the fireman runs into town to summon the local surgeon on call for the railroad. The superintendent at a division point 100 miles away receives an urgent telegraph message and immediately calls a train crew. Scheduled trains are held in sidings as Extra 107 rushes to the scene with the railway’s own surgeon, a recognized expert in trauma care, on board. The locomotive pulls a single specially built car with a fully equipped operating room. Using a stretcher they transfer the patient to the hospital car, where the surgeon places the man under general anesthesia. The doctor dons a clean gown and sterilizes his hands with carbolic acid before setting the fractured bone and suturing the wound. When the flagman wakes up, the train is en route to the railroad’s own hospital, the only one in the region, where he will remain for several weeks of wound care and rehabilitation. At discharge his leg is well healed and he will soon return to work. He is not charged for any of the care he has received.
Railway surgeons, nearly forgotten today, once formed the nucleus of a vast and innovative health care network. These two fictional vignettes illustrate some of the remarkable improvements in medical care the railway surgeons developed. This relatively small but dedicated group of doctors made substantial advances in treatment, prevention, safety and hygiene, creating an intricate system that served as a model for many modern medical plans.
As the nineteenth century unfolded, few employers offered any kind of employee benefit packages. Workers had to secure medical care privately and at their own expense. Businesses only paid physicians to perform pre-employment physical exams or to assist them with matters of work site hygiene. Railroads developed into an exception to this rule, in part due to the inordinate number of injuries sustained by employees, passengers and bystanders. The Interstate Commerce Commission reported in 1900 that 1 of every 28 railroad employees was injured on the job, and 1 in 399 was killed. Railroads initially relied on contracts with private doctors along their lines, but the huge number of visits soon made hiring dedicated railroad physicians a practical option. In addition, the opening of the transcontinental rail line and the subsequent westward migration brought large numbers of people to remote undeveloped areas devoid of doctors or hospitals. The western railroads had no choice but to bring in physicians and establish health care facilities. By the early twentieth century, every major railroad listed full-time doctors on its payroll.
Railroads divided the cost of these services, with employees paying a fixed amount by mandatory payroll deduction and the company funding the rest. A few lines kept participation voluntary, but employees who did not elect to pay the monthly fee could not take advantage of the free services offered. Some companies charged a flat rate to all employees, while others used a graduated fee based on the worker’s salary(Table 1). The plans initially drew vocal objections from the railway employees upset with the involuntary cut in pay. At a time when many people passed their entire lives without seeing a doctor, and most women delivered their children at home, the need for medical coverage must have appeared less than compelling. Surgical historian Ira Rutkow, M.D. noted that the railway medical plans formed an important cause of labor strife in their early years. George Chaffee, M.D., a surgeon for the Long Island Railroad, spoke of the benefits of the system:
When an employe falls sick or is injured--where this system is in operation--he is promptly, and with care, removed to the company’s hospital, an institution in which he is himself a stockholder and part owner, and in which, by his monthly assessments, his bills are paid in advance, an item of no small account. Employes are not all able to be treated in luxurious homes, but their cuts, fractures and injuries are just as sore and painful as thought they were able to afford the best of everything. The simple adoption of this system on the part of the company, and the consent of the employe to the light monthly assessment, will place him in a position to receive and enjoy the very best treatment in the land, and when cured he will be discharged from the hospital and returned to his position at the earliest possible moment--free from debt.
Dr. Chaffee proceeded to read glowing testimonials from satisfied patients, but one has no way of knowing if those opinions represented the majority of workers. Over time, more workers began to accept the plans. R. Harvey Reed, M.D., a key player in the development of railway surgery, commented that “When I first heard of the hospital system I was opposed to it, but after seeing how it was conducted and inquiring of the men along the line of these roads I found there was not a single expression of disapproval from them, and if put to a vote to-day I believe that at least ninety-five out of every hundred employes would vote for its maintenance.” Indeed, statistics on the Plant system, a Florida railroad network, in 1896 showed 98 percent of workers joined the voluntary program, receiving not only free medical care but also a daily cash benefit for illness, and a death benefit. The employee contributions, along with the cash benefits, followed a graduated scale based on salary, but all participants received the same medical benefits.
A New Specialty Comes of Age
The railroad presented unique hazards and created new types of injuries to which most doctors were not accustomed. Railway surgery quickly developed into a de facto medical specialty, as the number of railroad-employed doctors swelled in the late 1880s. No single physician holds the title of founder of the specialty. One railway surgeon in 1894 suggested this honor belonged to an unnamed individual, known as “the railroad doctor,” who worked for the Erie Railroad in 1849. Most railway surgeons were actually general practitioners who also performed surgery. Railway surgery had no special training program or certification board; its practitioners learned their trade on the job, and later from the journals and conferences they produced.
As the fledgling specialty grew, railway surgeons began to organize in groups defined by geographic areas or railroads. They formed professional societies and held conferences to propagate their specialized knowledge and address issues pertinent to the group. The first such association, founded in 1882, carried the lengthy name of the Surgical Society of the Wabash, St. Louis and Pacific Railway East of the Mississippi River. At the 1887 meeting of the surgeons of the Pennsylvania Railroad, Dr. A. W. Ridenour presented a resolution calling for the formation of a nationwide organization, representing surgeons from all railroads. The resolution passed, and in 1888 a group met in Chicago for the first meeting of the National Association of Railway Surgeons (NARS), which would become a prime mover in railway medicine. Within seven years it grew to over 1500 members out of some 6000 railway surgeons in practice. Its annual meeting, held in major cities (Table 2), resembled that of any major medical society, with hundreds of doctors in attendance to hear expert talks and learn of the latest research, while pharmaceutical and manufacturing representatives eagerly promoted their wares in adjacent exhibition halls. The 1897 convention in Chicago drew 38 exhibitors (Table 3), and a daily journal chronicled the lectures.
The railroads supported the annual meetings by contributing free travel and other benefits. NARS officials in 1897 requested travel passes from 54 railroads; all but one agreed to provide such, not only to their own surgeons, but also to any railway surgeon traveling over their lines.(a) . Both major sleeping-car operators, the Pullman Palace Car Company and the Wagner Palace Car Company, offered railway surgeons a free return trip with an outbound sleeping accommodation purchase. At the 1893 NARS convention in Omaha, the Union Pacific entertained the visitors and their spouses with a free Pullman-car excursion to Denver and Hot Springs, S.D. The meeting’s minutes note that the assembly gave U.P. and Pullman three cheers in gratitude.
The United States Congress passed a resolution in 1892 authorizing President Benjamin Harrison to invite government officials throughout the western hemisphere to send official delegates to the first Pan-American Medical Congress, to be held in Washington, D.C. the following year. The event’s organizers asked the NARS to assemble a section on railway surgery for the convention. Such official recognition showed increasing public acceptance of railway surgery as a distinct and legitimate medical specialty. Speaking at that conference, Eugene Lewis, M.D. noted that the unique forms and conditions of injuries on railways required special experience in their care and attention, adding that “I concede that history has not yet recorded railway surgery as a permanent branch of the art and science of surgery, but time only is needed for such record. . .and the leaders of this great congress will have said to the world, ‘We recognize railway surgery. . .’”
Christian B. Stemen, M.D.(b), chief surgeon for the Pennsylvania Railroad’s Ohio division, wrote the first textbook of railway surgery in 1890. At the same time, the railroad trade journal The Railway Age and Northwestern Railroader devoted a regular column to railway surgery, written by NARS members. This column quickly grew into the association’s own biweekly professional journal, The Railway Surgeon, beginning in 1894 and published by the same company. Over 100 original scientific articles appeared in its pages each year. Detailed transcripts of the annual meetings provided an early form of distance learning for those who could not attend. Clinton Herrick, M.D., a surgeon for the Delaware and Hudson and the Fitchburg Railway, published another railway surgery textbook in 1899. These measures helped lend additional legitimacy to the fledgling specialty.
A large contingent of the medical establishment still refused to recognize railway surgeons. Railroads frequently selected railway surgeons using the well-accepted business practice of competitive bidding, awarding the contract to the lowest bidder. Medical associations, not accustomed to competition, viewed this as a threat to all doctors’ incomes and attacked it vehemently. Many medical societies denied membership to all railway surgeons, and pressed for resolutions declaring contract medicine unethical. Mainstream medical publications seldom mentioned railway surgery topics, even though the care provided by railway surgeons comprised a substantial portion of the total medical practice in the United States. Dr. Rutkow noted that the major surgery textbooks of the 1890s made no mention of railway surgery, and the specialty did not appear in Index Medicus, the major index of medical literature, until 1903. In addition to this social isolation, railway surgeons stationed in remote areas also faced geographic isolation, living a rugged and austere lifestyle compared to their counterparts in the more cosmopolitan cities.
A war of words between The Railway Surgeon and the Journal of the American Medical Association illustrates some of the tension between the railway surgeons and mainstream medicine. In 1895, the Journal published an unauthorized abstract of the proceedings of the eighth annual NARS convention, noting that “. . .The Journal takes pleasure in rescuing from oblivion the very excellent papers that otherwise would have been buried in the pages of an exclusive periodical.” An unnamed Railway Surgeon editor blasted the abstract as incomplete and inaccurate. “This piece of discourtesy on the part of the Journal is extremely unkind and entirely uncalled for. . . ,” he complained. “[Journal Editor] Dr. Hamilton has our sincere sympathy whenever he is obliged to be away and leave the devil to get out the Journal.” This incident suggests that despite the social tension, mainstream doctors respected the scientific work of the railway surgeons.
NARS also faced conflict from within. Although many details have been lost to time, several news items in The Railway Surgeon suggest that its own editor, Dr. Reed, led an attempt to establish a rival society called the American Academy of Railway Surgeons. Reportedly the organizers stated that NARS had become too “promiscuous,” and they desired a more selective body of less than 200 members, “confined to only the more eminent surgeons in railway service.” NARS promptly expelled Dr. Reed from the editor’s desk, replacing him with Missouri Pacific chief surgeon Warren B. Outten, M. D. Dr. Outten was no stranger to NARS; he had been elected to the Executive Committee at the first meeting, and would later serve as president. Local and regional railway surgery associations sent letters expressing their support for NARS and condemning the rival society. In a typical letter, the Southwestern Association of Railway Surgeons wrote, “We . . . pledge our hearty and loyal support to the National Association, and regret that a few disgruntled and defeated candidates for office should seek to injure the association.” Several months later, The Railway Surgeon commented: “A year ago the future of the NARS seemed to some to be not a little uncertain. Personal differences had arisen in the membership which many were interested in magnifying as much as possible. The great mass of members of the association, however, never swerved from the course which has been marked out. The association was too big and strong--its work too large and its mission too good--for it to be checked by any purely personal influences. . .Within the year all semblance of opposition which is worth considering--all possibility of doubt as to the future of the association --has died away.” NARS continued to grow. In 1898 it expanded to include Mexico and Canada, becoming the International Association of Railway Surgeons. However, the rival American Academy of Railway Surgeons had not vanished. The two organizations put aside their differences in 1904 and merged to become the American Association of Railway Surgeons(c).
The injury victim in the early years of the Industrial Revolution faced a dismal outlook. To make matters worse, observed James Hunt, M.D., of Utica, New York, “[m]any of these accidents happen at night, and at some out-of-the-way place, distant from medical assistance, and frequently in the most disagreeable weather”. Dr. Herrick described the plight of an accident victim in an era lacking scientific knowledge of emergency care:
Take the usual instance of a man severely injured, as, for example, having one or both arms or legs crushed. He was usually tied up with rope, old rags, soiled handkerchiefs, or anything else lying about, lifted into the first train, possibly some time after being hurt, with his crushed members dangling behind him unsupported; then sent along the road many miles in a cold
damp car, each start and jar of which would almost close the scene, only soon after to be hustled into an ambulance and hurried to the hospital. . .[There] he presents a pallid, grimy appearance, is pulseless, cold, stupefied; the crushed arm or leg so mixed up with clothing, gravel, sticks, etc., that the whole mass looks like nothing but bloody rubbish. . He has been jostled and bled to death, and so he dies.
When doctors could treat a patient at the scene of the injury, they frequently worked in poor conditions. One railway surgeon complained that “every injured man. . . has a right to expect proper treatment, and these operations out in the woods or on the back porch of some filthy house are sometimes criminal.” Railway surgeons tried using hotel rooms for emergency care, but the rooms were not suitably equipped, and the railroads accumulated large bills for room charges as well as replacement of bloodstained furnishings. To meet the challenge of providing better care to people injured far from medical facilities, railway surgeons developed emergency packs, containing medicines and sterile dressings, to be carried on all trains. These packs, the forerunners of the ubiquitous first aid kit, allowed railroad workers to treat patients with appropriate, clean supplies even if the railway surgeon could not immediately reach the scene. Dr. Hunt and others also trained railway workers in the equivalent of first aid techniques, using a mannequin, skeleton and charts. Many doctors of the time objected, believing laypersons could not administer aid correctly, or fearing that the physician’s importance might be diminished.
The railway surgeons also promoted the development and use of hospital cars, which could be taken to the site of a serious injury. Military experience during the Civil War had shown that railroad transportation could provide effective medical evacuation. Both the Union and Confederate armies had made extensive use of freight cars or hastily improvised bunk cars to transport injured soldiers to regional hospitals. The railway surgeons introduced the concept to civilian medicine and developed highly sophisticated cars. The first such cars entered service around 1894 on the Central Railway of New Jersey and on the Baltimore & Ohio Southwestern Railroad, and other railroads quickly followed. A typical car contained a holding area for three to four patients and a fully stocked operating room. These cars provided an appropriate and clean environment in which the railway surgeon could stabilize a patient before sending him or her on a long journey to a regular hospital. Such treatment ranged from controlling bleeding and cleaning wounds to performing major, emergency surgical procedures. Anesthesiology had not yet developed as an independent specialty in the late 1800s. The surgeons provided anesthesia during their operations, using ether or chloroform. Studies and expert reviews of anesthesia techniques frequently appeared in the pages of The Railway Surgeon and on convention programs(d). Patients treated in the sanitary and well-equipped cars enjoyed much better survival rates than those treated in filthy, makeshift conditions. Herrick noted “[The patient] has more chances of recovery, and he himself, as well as the surgeons and officials of the road, rests content with the knowledge that every effort has been made for the best possible results.”
The emphasis on cleanliness and sterilization in the hospital cars and emergency packs reflected a growing trend in medical thought, one which railway surgeons embraced before such ideas enjoyed universal acceptance. C. M. Woodward, M.D., told the assembled NARS in 1893, “Surgeons (so called) who do not believe in antiseptic surgery and the use of antiseptics still exist, although we trust there are few or none who bear the name of ‘railway surgeon’ who are afflicted with this mental aberration.” Dr. Herrick devoted an entire chapter of his railway surgery textbook to sterilization techniques, describing how to build a lightweight, portable sterilizer for travel use. (If all else fails, he suggested obtaining boiling water from the locomotive boiler for sterilization.)
Railway surgeons also displayed some progressive social practices, such as the promotion of women. The Railway Surgeon reported in 1894 that Dr. Carrie Lieberg of Hope, Idaho had been appointed division surgeon on the Northern Pacific. “This is the only instance of such distinction of a lady that we know of in the United States,” the journal observed. A division official of the St. Louis, Brownsville and Mexican Railway in Texas shocked observers in 1907 when he hired a woman, Sofie Herzog, M.D., as the railroad’s chief surgeon. Sadly, this progressive approach did not extend to racial differences: the Santa Fe Hospital in Temple, Texas contained separate dining rooms for white, black and Mexican patients.
Railway surgeons did not limit their activities to treating railroad-related injuries; they provided a full spectrum of medical and surgical care. They treated all manner of illnesses, gave routine checkups, performed elective surgery, delivered babies, and advised railroad officials on workplace health, safety and sanitation issues.
Color vision testing became a prominent feature of railway surgery near the end of the nineteenth century. George Wilson, a professor at the University o f Edinburgh, had tested over one thousand individuals in various occupations in 1854, and found 5.6 percent to be colorblind, challenging the widespread belief that colorblindness was an exceedingly rare condition. He warned of the dangers this posed to rail and sea transportation, but his concerns went unheeded as officials smugly assumed that a colorblind engineer or signalman would perform poorly and soon be discovered or fired. Such complacency halted in 1875, when a serious railway accident in Sweden, attributed to a colorblind employee misreading a signal, drew widespread public attention. Swedish professor Dr. Frithiof Holmgren developed a method to test color vision and applied to the entire staff of the railway line. Dr. Holmgren surprised officials by finding 4.8 percent to be colorblind—including many successful senior employees. Swedish officials promptly enacted laws requiring railway employees to pass tests for color vision prior to employment. In the U.S., only a few states passed laws on vision testing, but many railway officials took action. Ophthalmologist Dr. John Weeks reported in 1894 that some two-thirds of the railroads serving New York City had voluntarily adopted such programs.
Dr. Holmgren’s test required subjects to match colors among 150 objects such as squares of colored paper or skeins of yarn. Other physicians developed many elaborate testing methods, often using colored lights or flags to simulate railroad working conditions. Some doctors even built full-size mockups of caboose ends in their offices, testing workers with colored lanterns hanging on the false car. However, a railroad planning to test its entire workforce needed a method that was inexpensive, portable and fast, and did not require a physician to examine every single employee. When the Pennsylvania Railroad initiated system-wide color vision testing in 1880, officials commisioned Dr. William Thomson to develop such a solution. Dr. Thomson simplified Dr. Holmgren’s test into a set of 40 standardized, numbered skeins of colored yarn attached to ruler-like board, which became known as Thomson’s Stick. To perform the test, the examiner handed the subject a sample of yarn and asked him to choose from the stick other yarns similar in color. The examiner recorded the numbers of the colors the subject chose. Railroad supervisors could administer the test after minimal training, and each test required only two to three minutes. Only the odd-numbered skeins represented correct choices, and the railroad allowed the examiner to pass anyone who chose only these. However, the examiner could not fail those who selected even-numbered colors; instead, he referred them to the railway surgeon for further evaluation. This allowed the railway doctors to focus on the small number of employees with questionable results, without having to spend time examining the vast majority who had normal color vision. The railway surgeon could tell which colors the employee had chosen by reviewing the numbers on the test record, often making a preliminary diagnosis even before seeing the employee. Initial tests on the Pennsylvania showed 4.2 percent of employees to have color vision defects, similar to findings in Eurpoean studies.
The Pennsylvania, as with other railroads, also tested visual acuity (sharpness), using the familiar Snellen chart with a large “E” at the top followed by rows of progressively smaller letters. The railroad tested hearing using a pocket watch. Employees who could hear the watch ticking from five feet passed the test. These primitive tests had many shortcomings, but they formed one of the earliest attempts to use medical screening as means to enhance workplace safety, and one of the first applications of large-scale health screening using a standardized test administered by trained, non-medical personnel. Such techniques find widespread application today, as in the hearing tests given in elementary schools, or visual acuity and color vision tests administered in drivers’ licensing offices--the direct descendent of railroad vision testing. (For more information, see Testing Vision and Hearing.)
Railway surgeons examined injured persons filing claims or lawsuits against the railroads. The surgeon’s assessment of the degree of disability, or the validity of the injuries claimed, could have a significant impact on the amount of money awarded--or not awarded. This arrangement created an awkward conflict of interest, and whether the doctors worked for the best interests of the patient or the company became a topic of heated debate.
The surgeons themselves struggled with this issue, as shown by the dozens of articles in The Railway Surgeon addressing the management of these delicate situations. Dr. Herrick’s textbook devoted a full chapter to medical jurisprudence. Dr. E. R. Lewis, a nineteenth-century expert on injury cases, offered this advice at the NARS annual meeting: “We stand midway between the necessary extremes of this case; we have a double duty to perform; the path is straight--an honest representation of facts, regardless of results, must characterize our words and actions, and when we establish such reputations, we must and will acquire the confidence of both extremes, and the mammoth exaggerations often indulged in on both sides will fade from sight, right not might will triumph and equity will decide rather than the sympathy of a jury or the ambrosial curls of the lawyer.”
The physicians vigorously defended their integrity, citing the objective nature of scientific inquiry in which they were trained. They denied receiving any encouragement from the railways to favor the company in their reports. Dr. Lewis told the 1893 Pan-American Medical Congress that “. . .no railroad company with which I am at all familiar desires anything but the truth, and only fears deceit and falsehood, and of all other employees they fear deceit and falsehood most in the medical and legal departments, and feeling that they have in their employ a doctor whose character can be impeached, cannot soon enough discontinue his services.” With even more flourish, C.A. Smith, M.D., president of the Southwestern Association of Railway Surgeons, quoted a colleague, Dr. D.R. Wallace:
“I do not believe that there is a railway management from Atlantic sands to Pacific slopes, from lake to gulf, but is perfectly willing to do fullest justice to anyone, however low or obscure, having a just claim against their road. I do not believe there is a railway surgeon in all this big land of ours who would do an act or utter a word to defraud an honest claimant out of one cent due from the railroad. I challenge all comers to show an instance in which a railroad management, from the time an engine first awakened echoes amidst the solitudes of this great continent, up to this good hour, has refused or showed the least disposition to refuse the payment of any claim shown by the evidence to be just and right. I challenge all comers to name the railway surgeon who has attempted in his evidence before the courts to deprive an honest claimant of a dollar. . .”
In some twelve years’ experience of railway surgery and personal injury litigation of railways, I have never known an instance where a railway official has tried to influence the testimony of medical witnesses and I regard all intimation and charges to that effect as calumnies, both to the managers of our railroads and as honorable a body of medical men as can be found in the country.
Decades later, retired Florida East Coast Railway chief surgeon Vernon Lockwood, M.D., reflecting on the countless days he spent testifying in court cases, said simply that “[t]he railway never asked me to favor it in testimony.” Despite such assurances, the issue haunted the specialty until changes in laws allowed injury victims to choose their own physicians for medical care and as expert witnesses.
The western railroads traversed rural areas and fresh new settlements devoid of any substantial health care infrastructure. Dr. Outten noted that a person traveling between St. Louis and El Paso would go over 1300 miles without passing a single hospital. The Central Pacific Railroad, under the direction of vice-president A. M. Towne, responded by opening its own hospital in Sacramento in 1869. This institution, which most historians recognize as the first exclusive railroad hospital, served as a driving force for other railroads to develop their own facilities, and many more hospitals quickly appeared along the western rail lines. The Sacramento hospital remained in operation until 1899, when Central Pacific successor Southern Pacific relocated it to the company’s headquarters city of San Francisco.
Eastern railroads passed through older, well-developed cities, and these railroads initially contracted with the existing hospitals rather than spending large sums of capital building their own institutions. Twenty-five years after the Central Pacific Hospital opened, the Illinois Central and the Pennsylvania Railroad still did not have their own medical facilities. Nonetheless, the railroad-owned hospitals afforded convenience, control and the economies of scale and consolidation--benefits the eastern lines ultimately could not ignore. NARS president Dr. C.W.P. Brock of Virginia said in his address to the annual meeting:
The railway hospital plan is another admirable western product; and we of the east are glad to sit at the feet of these western Gamaliels and learn of them how to do these great things. [Author’s note: Gamaliel was a member of the Sanhedrin and a highly respected teacher of the law, who taught St. Paul (Acts 5:34-39; Acts 22:3).]
Mr. Greeley’s advice to the young man to “go west” may be followed with great benefit by railway surgeons from the older sections of our country; and when they have seen the superb hospitals and the practical workings of the system they will say, as the Queen of Sheba said after seeing the splendors of King Solomon, “that the half had not been told.”
Sounding a more pragmatic note, the Long Island surgeon Dr. Chaffee (e) estimated that that the daily cost per patient at a railway hospital ran from 40 to 60 cents, compared to $1.00 to $1.50 at a city or contract hospital. “The relief and hospital department is a straight business proposition or transaction, founded upon business principles,” he declared. Railroad companies also hoped that providing generous benefits at company hospitals would foster goodwill, helping decrease injury-related lawsuits. “Comparing the suits for damages reported by the claim agents of the various companies at their meetings, the difference between the companies having the hospital system, and those not having such a system is simply astounding, and is all in favor of the highest class of surgical service,” Dr. Reed observed. Historian Mark Aldrich noted that workers also benefited from a system that avoided lawsuits: employees who sued risked losing their jobs, and most won only small judgements after long delays. By 1896, 13 railroads operated 25 hospitals, treating over 165,000 patients annually. Even a pragmatist such as Dr. Chaffee could not hide his enthusiasm with this growth. “The sun of railway surgery and of the hospital system rose in the West, but its brilliant light is rapidly breaking over the East,” he told a NARS assembly.
Railroads retained private physicians under contract in cities along their lines. Known as “local surgeons,” they were on call at all times to provide initial care at any railroad-related emergency. The railroad paid for this treatment regardless of whether the injured was an employee, passenger, bystander or hobo. If the patient required further care, the local surgeon arranged transfer to another doctor or hospital, referring non-employees to a local hospital, at the patient’s expense, or to a charity hospital, if available. Railroad employees received complimentary rail transport to the nearest company hospital, with ambulance transfers to and from the stations, if needed. Only if the patient’s condition rendered transport unsafe would the railway pay for an employee’s care at an outside hospital; even then, the company expected the patient to transfer to the nearest railroad hospital as soon as his or her medical condition allowed it (f).
Railroad hospitals ranged from small facilities resembling private homes to large medical centers such as the 300-bed Illinois Central Hospital in Chicago or the 450-bed Southern Pacific Hospital in San Francisco. The industry reached a peak of 35 railroad hospitals throughout the country, providing a total of 3700 beds (see appendix). The larger ones offered a full range of services, including consultants from various medical specialties, and facilities and equipment that compared favorably with the top private and government hospitals of their day. The Santa Fe Hospital in Topeka, which opened in 1896, boasted such innovative features as forced air ventilation with a full air exchange every 10 to 12 minutes, and independent heat control in each ward or room. The Southern Pacific’s San Francisco hospital became the second hospital in the nation to open an intensive care unit. Many of these hospitals operated nursing schools, internships, and residency training programs. Some even manufactured pharmaceuticals or raised their own farm products (g)
. The railroads also maintained many more “emergency hospitals,” usually located on the grounds of major yards or service facilities. These were not true hospitals, but rather minor emergency clinics, typically housed in a one-room building and staffed by a single doctor and nurse.
Descriptions of railway hospitals frequently mentioned efforts to create a relaxing environment for patients. Dr. Outten suggested that the camaraderie at a railroad hospital offered therapeutic value in itself. “Railway men are naturally clannish,” he said, “and they take pride in direct contact and in discussing the diverse experiences of their vocation; and it is in the nature of a curative measure for railway men to have their surroundings thoroughly railroadish, and. . . the homelike element is the one which satisfies the railroad man”. The Missouri Pacific Railroad Hospital at St. Louis, which opened in 1884, provided musical instruments and a patient library with over 2800 volumes. “Every effort is made to serve the mind as well as the body,” noted a reporter.
Railroad hospitals initially accepted only railroad employees. However, the lack of alternative facilities led hospitals in some areas to open their doors to the public. The Alaska Railroad Hospital in Anchorage, for example, maintained by far the best facilities and equipment in the area when it opened in 1916. The hospital accepted non-railroad patients until Providence Hospital opened in 1939. The U.S. Army also used the Alaska Railroad Hospital at the beginning of World War II during the construction of the Army’s own facilities. Eventually, many railroad hospitals accepted private patients to help fill unused capacity and generate revenue to reduce employee charges. Private patients paid higher fees, as the company did not subsidize their care.
The Florida East Coast Railway Hospital in St. Augustine provides an example of a large, busy railroad hospital. Operating from 1906 to 1963, at its peak it maintained 112 beds and provided all types of medical and surgical care, as well as a nurse-training program. Most patients stayed in large wards with 10-15 beds, following the standard practice of the time. In 1930 a hospital ward bed cost railroad employees $3 a day, which included all medications, tests and x-rays. Major operations cost $75-150 and infant deliveries cost $35-50. The hospital accumulated a budget deficit each year, which the railway absorbed.
Some railroads even operated long-term care facilities. The Southern Pacific maintained a tuberculosis sanitarium in a converted freight station in Tucson, allowing patients with “consumption” to enjoy the only known treatment for the dreaded disease: a mild climate, rest and fresh air. The Santa Fe Coast Lines Hospital in Los Angeles also accepted tuberculosis patients, housing them in tents on the hospital grounds. A contemporary account notes that the tents were “heated, lighted, and furnished for [their] comfort.” The belief that certain climates afforded therapeutic benefits led some doctors of the time to call for a patient-exchange system between regional railroads, such as that proposed by Dr. Chaffee:
Patients recovering from pneumonia, la grippe, rheumatism and other diseases of this class would be taken from the North to the sunny South. Typhoid, malarial and swamp fever cases would be sent North or to non-malarial sections of the country. The unfortunate consumptive would seek the West and Southwest, where he might not only find relief, but in time, employment. . .[I]t will be found to repay a thousand fold for any effort it may cost. Only the best is good enough for our faithful railway men. [Author’s note: “La grippe” is influenza.]
If such a program were ever instituted, it was not recorded.
The property, buildings and furnishings of a railroad hospital counted as fully taxable assets of the company. Many railroads opted to relieve themselves of a significant tax burden by creating independent foundations to own and operate the hospitals and health plans. These foundations, known as employee hospital associations (EHAs), also benefited the employees by allowing them more representation in hospital management. The board of directors of an EHA hospital consisted of railway employees from a variety of occupations, typically one from each of the many unions representing them (Table 4). This stood in contrast to the company-owned hospitals, which were managed primarily by corporate officers. Many EHAs chose a non-profit organizational structure, conferring tax benefits and the ability to solicit donations and grants. Funding for the hospitals and health plans managed by EHAs remained essentially unchanged: payroll deductions, patient fees, and corporate subsidies.
The EHAs published books of regulations, which bear a striking resemblance in principle to late twentieth-century managed-care handbooks. Members could use only designated hospitals and physicians; certain types of care, as well as outside consultations, required advance approval from the chief surgeon. Many benefits carried specific limits on the cost or quantity of goods and services provided. One handbook states that diabetic patients taking insulin would receive not more than one syringe and two needles; another provides for the loan of crutches, with the patient to be billed if they were not returned. The strict limits on utilization and the centralized approval process, although very familiar to the modern managed-care consumer, represented radical concepts at the time of their introduction. They challenged the traditional view of the independent private physician as an unquestionable authority. Yet the techniques proved highly effective in keeping costs under control, setting an example that would resurface decades after the EHAs disappeared.
The EHA regulations also reflected the social and moral sentiments of their times, often appearing harsh and judgmental by modern standards. A booklet of Union Pacific Railroad EHA regulations, for example, notes that no benefits were provided for pregnancy, venereal diseases, injuries received in a fight, ailments resulting from “vicious habits”, attempted suicide, or “any sickness or injury directly due to or contributed to in any way by alcoholic intoxication.” The booklet even notes that blood transfusions were covered, but recipients would be expected to provide donors to replace the blood they used.
Railway surgery fell into decline early in the twentieth century. By 1920, The Railway Surgeon (renamed The Railway Surgical Journal), only published 44 manuscripts; within a year, the word ‘railway’ vanished as the journal changed its name to The Surgical Journal Devoted to Traumatic and Industrial Surgery. NARS had become inactive and ceased its grand annual meetings. Several factors contributed to the demise of the system. Many patients did not like being required to see designated physicians, and wanted to see doctors of their choice in their communities, especially if one lived far from a railroad hospital. Private insurance policies, prior to the 1980s, offered a wide range of choices with few restrictions. Railroad employees, through their unions, pressed for contracts with these policies in place of the restrictive railroad doctor-hospital system. Injury victims frequently asked for doctors not affiliated with the railroad. Changes in government regulations, the creation of Medicaid and Medicare (h), and booming medical advances in the 1950s and 1960s also made the management of health care facilities progressively more complicated and expensive. Finally, the railroads sought to divest money-losing auxiliary enterprises. As the last railroad hospitals were sold or closed in the early 1970s, the remaining railway surgeons dispersed, setting up private offices or joining other practices, although many continued to see their previous patients in the new settings.
Some of the railroad hospitals continued to operate as independent hospitals, such as the Santa Fe Hospital in Temple, Texas, which grew into the Scott and White regional healthcare network—still offering a prepaid health plan similar to the railroad plans. The Illinois Central Hospital became a private institution, Doctors Hospital of Hyde Park, and remained open until a Medicare fraud scandal sent it into bankruptcy in 2000. Some communities found new uses for the railway hospitals. A San Francisco group converted the Southern Pacific Hospital to housing, while the Houston location, the “Sunset Hospital,” ultimately became a county clinic. Many hospitals were demolished. (See list of railway hospitals for status of facilities, if known.)
Railway surgeons left a lasting impact on the science of medicine. Through their research, associations and publications, they created the first modern and systematic study of trauma and its treatment. Dr. Rutkow observed:
Modern trauma surgeons owe gratitude to railway surgeons because they provided the first known instances of organized traumatology. Through their textbooks and journal writings, it is apparent that the concept of trauma surgery as a form of specialized surgery was an important part of the railway surgeon’s crusade for better health care in our society.
They helped shape the modern medical world with their pioneering contributions in prehospital care, emergency medical transport, wound care, mass health screening and first aid kits. The surgeons called attention to public safety and sanitation issues, and set the stage for the modern specialty of occupational medicine. Their journal, The Railway Surgeon, underwent several mergers and name changes, but its descendent remains in print today, under the name Occupational Health and Safety.
The railway surgeons also became a powerful force in shaping the social aspects of medicine. Through the railroad hospitals and hospital associations, they sought to provide comprehensive health care to large numbers of people in an economical and efficient manner--a lofty and difficult goal even today. They met the challenge by creating revolutionary managerial and financing models, pioneering the prepaid health plan and the vertically integrated healthcare network—leaving a lasting contribution for future generations.
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Monthly gross earnings Monthly hospital fund assessment
$30 or less $0.25
More than $30 and less than $60 0.35
$60 and less than $100 0.50
$100 or over 1.00
Source: Rules and regulations of the A.T.&S.F. Hospital Association. The Railway Surgeon 1894; 1(3): 70.
St. Louis, Mo.
Kansas City, Mo.
Old Point Comfort, Va.
St. Louis, Mo.
Source: A bit of history. The Daily Railway Surgeon 1897;3(25):8.
Johnson & Johnson
Eli Lilly & Co.
McKessin & Robbins
Parke, Davis & Co.
Pasteur Vaccine Company
Searle & Hereth
Source: The Exhibits. The Daily Railway Surgeon 1897;3(25):13-14.
One trustee is selected from each of the following organizations:
Brakemen, switchmen and other trainmen
Station agents, telegraphers, levermen and linemen
Metal crafts and car department workers
Bridge, building, construction and trackmen
Clerks, general office, store and station employes
Source: Missouri-Kansas-Texas Railroad Employes’ Hospital Association Charter, By-Laws and Rules and Regulations, 1950.
(a) Inexplicably, the railroads did not offer free travel to the second Pan American Medical Congress, held in Mexico City in 1896. The doctors chartered a train from Chicago for the five-day journey over eight railroads. “A splendid train of palace sleeping and dining cars is being specially prepared,” proclaimed one announcement. A round trip fare of $190.10 covered “every necessary expense of the trip of twenty-one days,” including the option of using the parked train as one’s lodging during the convention. (Report on transportation for the second Pan American Medical Congress. The Railway Surgeon 1896; 3(12): 281.)
(b) Dr. Stemen was also a member of the committee which initially organized the NARS and was elected the first secretary of the organization.
(c)The “new” name actually returned the organization to its roots, as the “American Association of Railway Surgeons” was precisely the name Dr. Ridenour had specified in his 1887 resolution which led to the formation of NARS (A bit of history. The Daily Railway Surgeon 1897; 3(25):7-8.)
(d) For one thorough period review of anesthesia techniques, see: McGannon, E.A. Anaesthesia, local and general [paper read before the seventh annual meeting of the National Association of Railway Surgeons, Galveston, Tex., May 8-11, 1894.] The Railway Surgeon 1894; 1(9): 206-215.
(e) Dr. Chaffee also founded the New York State Association of Railway Surgeons.
(f) A typical policy is described in the Frisco Employes’ Hospital Association by-laws and rules and regulations, 1962, p. 18-21.
(g) A period observer of the Santa Fe Coast Lines Hospital noted that “the hospital has its own Jersey cows, a nice flock of chickens and well cultivated gardens, so that patients may be assured of the freshest milk, butter, eggs, poultry and vegetables.” (The Santa Fe Coast Lines Hospital Association. In: Meade’s Manual. http://www.atsfry.com/EasternArchive/ eades/coasthos.htm. Accessed November 27, 2001.)
(h) Railroad hospitals tallied another “first” when the first Medicare check to a hospital was sent to the Southern Pacific Hospital in San Francisco (Short, Henry J. Railroad doctors, hospitals and associations: pioneers in comprehensive low cost medical care. Lakeport, Cal.: Shearer/Graphic Arts, 1986).
 Rutkow, Ira. Railway surgery: traumatology and managed health care in 19th-century United States. Arch Surg 1993;128(4):458-63.
 Rules and Regulations of the A. T. & S. F. Hospital Association. The Railway Surgeon 1894;1(3):70.
 Chaffee, George. The railway employes’ hospital association [paper read at ninth annual meeting of National Association of Railway Surgeons, St. Louis, May 1986.] The Railway Surgeon 1896;3(9):193-7.
Reed, R. Harvey. Quoted in discussion following Caldwell, Frank H. The railway hospital--its necessity and benefits [paper read before the third annual meeting of the New York State Association of Railway Surgeons, New York City]. The Railway Surgeon 1894;1(1): 2-7.
 Chaffee, George. A review of the relief and hospital department [paper read before the Annual Meeting of the Section on Railway Surgery, of the Medico-Legal Society of New York City, Dec. 16, 1896]. The Railway Surgeon 1897;3(18): 422-4.
Lewis, Eugene R. The evolution of railway surgery. The Railway Surgeon 1894;1(10):227-231.
 Stemen, Christian B. Railway Surgery: A Practical Work on the Special Department of Railway Surgery, for Railway Surgeons and Practitioners in the General Practice of Surgery. St. Louis, Mo.: J.H. Chambers & Co., 1890: v; also noted in Rutkow.
 A bit of history. The Daily Railway Surgeon 1897;3(25):7-8.
 Reed, R. Harvey. Treasurer’s annual report. In Reed R. Harvey, ed. The National Association of Railway Surgeons official report of the sixth annual meeting held at Omaha, Nebraska May 31, June 1 and 2, 1893. Chicago: The Railway Age and Northwestern Railroader, 1893: 25.
 Caldwell, Frank H. The railway hospital--its necessity and benefits [paper read before the third annual meeting of the New York State Association of Railway Surgeons, New York City]. The Railway Surgeon 1894;1(1):2-7.
 The Exhibits. The Daily Railway Surgeon 1897;3(25):13-14.
 About Transportation. The Railway Surgeon 1897;3(23): 546-548.
 The Annual Meeting. The Railway Surgeon 1895;4(9):55.
 Second day--morning session. In Reed R. Harvey, ed. The National Association of Railway Surgeons official report of the sixth annual meeting held at Omaha, Nebraska May 31, June 1 and 2, 1893. Chicago: The Railway Age and Northwestern Railroader, 1893: 22.
 Brock, C.W.P. President’s Address. In Reed RH, ed. The National Association of Railway Surgeons official report of the sixth annual meeting held at Omaha, Nebraska May 31, June 1 and 2, 1893. Chicago: The Railway Age and Northwestern Railroader, 1893: 10-16.
 Lewis, Eugene R. Railway surgery as a branch of the science and art of surgery [paper read before the Railway Section of the First Pan-American Medical Congress, Washington, D.C., Sept. 7, 1893]. The Railway Surgeon 1894;1(1):18-21.
 Herrick, Clinton B. Railway Surgery: A Handbook on the Management of Injuries. New York: William Wood and Co., 1899.
 Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.
 Hemenway, Henry B. The ethical relations of the railway surgeon [paper read at fourth annual meeting of the Chicago, Milwaukee & St. Paul Railway Surgeons’ Association, Chicago, Nov. 12-13 1896.) The Railway Surgeon 1897;3(21):481-486.
 Journal of the American Medical Association, May 11, 1895. Cited in: At the end of a year. The Railway Surgeon 1895;1(26); 626.
 Our sad promiscuosity. The Railway Surgeon 1894; 1(13):315.
 Some expressions of loyalty. The Railway Surgeon 1894; 1(11):266.
 Some more expressions of loyalty. The Railway Surgeon 1894;1(12):289.
 At the end of a year. The Railway Surgeon 1895: 1(26): 626.
 Kepner, Raymond B. A brief history. Industrial Medicine and Surgery 1963;32(9):349-50.
 Hunt, James G. Railway surgery [lecture delivered before the railway branch of the Y.M.C.A. at Utica, New York, February 1897]. The Railway Surgeon 1897;3(24):553-9.
 Fairbrother, H.C. The surgical emergency bag [letter]. The Railway Surgeon 1894;1(13):310.
 Haller, J.S. Intolerable, excruciating and troublesome: military ambulance technology, 1793-1880. Caduceus 1971;7(2):2-30.
Lewis, The evolution of railway surgery.
 Reed, R. Harvey. Quoted in discussion following Caldwell.
 Woodward, CM. The responsibility of the surgeon in suits for damages against railway companies. In Reed R. Harvey, ed. The National Association of Railway Surgeons official report of the sixth annual meeting held at Omaha, Nebraska May 31, June 1 and 2, 1893. Chicago: The Railway Age and Northwestern Railroader, 1893: 231-237.
 Notes, news and personals. The Railway Surgeon. 1894; 1(13):316.
 Cox, Mike. Dr. Sofie: frontier surgeon blazed a trail for other women to follow. Texas Medicine 1999; 95(9):41-3.
 Jennings, J. Ellis. Color-vision and color-blindness. A practical manual for railroad surgeons. Philadelphia, Pa.: The F. A. Davis Co., 1897.
 Weeks, J.E. Ophthalmology in railway surgery. The Railway Surgeon 1894 ;1(3):59.
 Welsh, D. Emmett. Color blindness. The Railway Surgeon. 1894;1(1):8-10.
 Lewis, E.R. The National Association of Railway Surgeons--not a trade union, but a philanthropic and scientific organization. In Reed R. Harvey, ed. The National Association of Railway Surgeons official report of the sixth annual meeting held at Omaha, Nebraska May 31, June 1 and 2, 1893. Chicago: The Railway Age and Northwestern Railroader, 1893: 221-4.
 Lewis, Railway surgery as a branch of the science and art of surgery.
 Wallace, D.R. Title unknown. Texas Sanitarian 1894 Sept. In Smith CA. Address of the president of the Southwestern Association of Railway Surgeons [delivered at Memphis, Tenn., Nov. 1, 1894.] The Railway Surgeon 1894;1(15):348-9.
 Smith, C.A. Address of the president of the Southwestern Association of Railway Surgeons [delivered at Memphis, Tenn., Nov. 1, 1894.] The Railway Surgeon 1894;1(15):348-9.
 Lockwood, Vernon A. The Florida East Coast Railway Hospital: A study of early corporate medicine, 1906-1963. J Florida M A 1987;74(7):499-503.
 Lewis, The evolution of railway surgery.
 Chaffee, George. A review of the relief and hospital department [paper read before the annual meeting of the Section on Railway Surgery of the Medico-Legal Society of New York City, Dec. 16, 1896]. The Railway Surgeon 1897;3(18):422-4.
 Short, Henry J. Railroad doctors, hospitals and associations: pioneers in comprehensive low cost medical care. Lakeport, Cal.: Shearer/Graphic Arts, 1986.
 Lewis, The evolution of railway surgery.
 Chaffee, A review of the relief and hospital department.
 Reed, R. Harvey. Quoted in discussion following Caldwell.
 Aldrich, Mark. Train wrecks to typhoid fever: the development of railroad medicine organizations, 1850 to World War I. Bulletin of the History of Medicine 2001;75:254-289.
 Notes, news and personals. The Railway Surgeon 1896; 3(2): 46.
 Chaffee, The railway employes’ hospital association.
 The new Santa Fe Hospital at Topeka. The Railway Surgeon 1896;3(0):212-13.
 The Santa Fe Coast Lines Hospital Association. In: Meade’s Manual. http://www.atsfry.com/ EasternArchive/ Meades/ coasthos.htm. Accessed November 27, 2001.
 Outten, W.B., quoted in Chaffee G, The railway employes’ hospital association.
 Dinsmore, Frank S. The Missouri Pacific Hospital at St. Louis. The Railway Surgeon 1897;3(22):513-5.
 The Missouri Pacific Hospital at Kansas City. The Railway Surgeon 1897;3(23):541.
 Wilson, Gwynneth Gminder. The Alaska Railroad Hospital and its last superintendent, Fred Braun. Alaska Medicine 1990;32(2):81-3.
 The Santa Fe Coast Lines Hospital Association. In: Meade’s Manual. http://www.atsfry.com/ EasternArchive/ Meades/ coasthos.htm. Accessed November 27, 2001.
 Chaffee, George. The railway employes’ hospital association.
 Union Pacific Railroad Employes’ Hospital Association Regulations, 1967.
 Frisco Employes’ Hospital Association by-laws and rules and regulations, 1954.
 Union Pacific Railroad Employes’ Hospital Association Regulations, 1967.
 Bellandi, Deanna. Chicago hospital files Chap. 11, closes doors. Modern Healthcare 2000;30(17):12-13.
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