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By Robert S. Gillespie, MD, MPH
Railroad surgeons formed a unique medical specialty, operating a vast and innovative network of railroad hospitals and clinics. Nearly forgotten today, this relatively small but dedicated group of doctors made many advances in medical science and embraced an innovative payment system now used by many health insurance plans.
As the nineteenth century unfolded, few employers offered employee benefit packages. Most workers had to secure medical care at their own expense. Some large industrial companies, particularly in the mining, lumber and steel industries, began to provide health care to employees during the mid-nineteenth century. The large number of injuries and the remote location of many work sites in the railroad industry led railroads to adopt similar plans. One surgeon reported that in 1897, 1693 railroad workers were killed and 27,667 injured. The opening of the transcontinental rail line and subsequent westward migration brought large numbers of people to remote areas devoid of doctors or hospitals, creating a crisis for those in need of medical attention. The earliest recorded railway surgeon may have been an individual known as “the railroad doctor,” whose name is now lost, working for the Erie Railroad in 1849. By the early twentieth century, every major railroad listed full-time doctors on its payroll.
Railroads divided the cost of these services, charging employees a fixed amount by payroll deduction, while the company funded the rest. Some charged a flat rate to all employees, while others scaled the cost based on salary. Most lines mandated participation, and many employees objected to the imposition. At a time when many people rarely, if ever, saw a doctor, the need for medical coverage must have appeared less than compelling. Surgical historian Ira Rutkow, M.D. noted that the early railway medical plans formed an important cause of labor strife. Over time, however, more workers accepted the plans, sometimes even requesting them. Statistics on the Plant system in 1896 showed that 98% of workers participated in the voluntary program.
The railroad presented unique hazards and created new types of injuries unfamiliar to most doctors. Railway surgery quickly developed into a de facto medical specialty as the number of railroad-employed doctors swelled in the 1880s. Most railway “surgeons” were actually general practitioners who also performed surgery. Unlike older specialties, railway surgery had no hospital training programs; its practitioners learned their trade on the job, and later from the publications and conferences they produced.
As the fledgling specialty grew, railway surgeons began to organize in groups defined by railroads or geography. They formed professional societies and held meetings to propagate their specialized knowledge. 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 an 1887 meeting of the surgeons of the Pennsylvania Railroad, Dr. A. W. Ridenour proposed a national organization, representing surgeons from all railroads. As a result, a group met in Chicago in 1888 to establish the National Association of Railway Surgeons (NARS), which would become a prime mover in railway medicine. Within seven years NARS grew to over 1500 members out of some 6000 railway surgeons in practice. Its annual meeting resembled that of any major medical society, with hundreds of doctors attending to hear expert talks and learn of the latest research, while pharmaceutical and medical-supply representatives eagerly promoted their wares.
The railroads contributed free travel and other benefits to support the annual meetings. At the 1893 NARS convention in Omaha, the Union Pacific entertained the visitors and their spouses with a free excursion to Denver and Hot Springs, S.D. NARS officials in 1897 reported that 53 railroads offered free passes to any railway surgeon traveling over their lines.
United States President Benjamin Harrison invited official delegates from throughout the western hemisphere to the first Pan-American Medical Congress, to be held in Washington, D.C. in 1893. The event’s organizers asked NARS to assemble a section on railway surgery for the convention. Such official recognition demonstrated the increasing acceptance of railway surgery as a distinct and legitimate medical specialty.
Christian B. Stemen, M.D., chief surgeon for the Pennsylvania Railroad’s Ohio division and a founding member of NARS, wrote the first textbook of railway surgery in 1890. At the same time, The Railway Age and Northwestern Railroader devoted a regular column to railway surgery. This column quickly grew into a separate biweekly professional journal, The Railway Surgeon, beginning in 1894. 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 non-railway medical establishment still refused to recognize railway surgeons. Railroads frequently hired surgeons by soliciting bids for contracts. 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 their contracts unethical. Rutkow noted that the major surgery textbooks of the 1890s made no mention of railway surgery, and the specialty did not appear in the primary index of medical literature until 1903. However, mainstream medical journals such as the Journal of the American Medical Association occasionally reprinted articles from The Railway Surgeon, demonstrating respect for the scientific work of the railroad doctors. In addition to social isolation, railway surgeons stationed in remote areas also faced geographic isolation, living an austere lifestyle compared to their counterparts in the more cosmopolitan cities.
NARS also faced conflict from within. The association expelled Reed, editor of The Railway Surgeon, after he led an effort to create a competing society. Yet NARS continued to grow. In 1898 the association expanded to include Canada and Mexico, becoming the International Association of Railway Surgeons. This group and Reed’s rival organization, the American Academy of Railway Surgeons, put aside their differences in 1904, merging to become the American Association of Railway Surgeons.
The injury victim in the early years of the Industrial Revolution faced a dismal prognosis, as doctors knew little about emergency care. Railroad workers fared especially poorly as they often sustained injuries at remote locations, far from medical assistance. Herrick described the typical plight of such a victim:
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. . .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.
Even when doctors could get to the scene, they often had to work outdoors or under poor conditions. “These operations out in the woods or on the back porch of some filthy house are sometimes criminal,” complained Dr. H. C. Fairbrother in 1894. Surgeons tried using hotel rooms, but the rooms lacked medical equipment, while the railroads accrued large bills to replace blood-stained furnishings. To provide better care to people injured far from proper facilities, railway surgeons of the late nineteenth century developed “emergency packs.” Carried on all trains, the packs contained medicines and sterile dressings. These emergency packs, predecessors of the ubiquitous first aid kit, allowed train crews to help victims immediately, using appropriate, clean supplies. Many doctors of the time objected, believing laypersons could not administer aid correctly, or fearing such activity might diminish the physician’s importance.
Drawing on military experience in the Civil War,  the railway surgeons introduced railroad medical transport to civilian medicine. They developed sophisticated, specialized vehicles to dispatch to the site of an injury. The Baltimore & Ohio Southwestern Railroad and the Central Railway of New Jersey introduced the first such “hospital cars” around 1894, and other railroads quickly followed. One common design provided a holding area for three to four patients and a fully stocked operating room. These cars provided a hospital-quality environment in which the surgeon could stabilize a patient before sending him or her on a long journey to a regular hospital. Such treatment ranged from simple wound cleansing to major surgical procedures. The specialty of anesthesiology had not yet developed in the late 1800s. The surgeons themselves provided anesthesia during their operations, using ether and chloroform. Railway surgeons presented many studies and expert reviews of anesthesia techniques in the pages of The Railway Surgeon and at conventions. Patients treated in hospital cars enjoyed better survival rates than those treated in dirty, makeshift conditions.
The emphasis on cleanliness and sterilization in the hospital cars reflected a growing trend in medical thought, one which railway surgeons embraced before such ideas enjoyed universal acceptance. Herrick devoted one chapter of his railway surgery textbook to sterilization techniques. He taught that under emergency conditions, surgeons could obtain hot water for sterilization from the locomotive boiler.
Railway surgeons also displayed a progressive attitude toward the promotion of women. The Railway Surgeon reported in 1894 that the Northern Pacific had appointed Dr. Carrie Lieberg of Hope, Idaho, to division surgeon. “This is the only instance of such distinction of a lady that we know of,” the journal said. An official of the St. Louis, Brownsville and Mexican Railway in Texas shocked observers in 1907 when he passed over several male applicants and hired a woman, Dr. Sofie Herzog, 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 railroad-related injuries; they provided a full spectrum of care. They treated all manner of illnesses, gave routine checkups, tested vision and hearing (see related page: Testing Vision and Hearing), performed elective surgery, delivered babies, and advised railroad officials on workplace safety and sanitation issues.
Railway surgeons evaluated persons filing injury claims against the railroads. These examinations sought to determine the extent of injury as well as detect fraudulent claims. They also created an awkward conflict of interest, and lively debate as to whether the doctors worked for the best interests of the patient or the company. Dozens of articles in The Railway Surgeon and textbooks discussed management of these delicate situations. The physicians vigorously defended their integrity. “The railway never asked me to favor it in testimony,” said retired Florida East Coast Railway chief surgeon Vernon Lockwood, M.D., in 1963. Despite such assurances, the issue haunted the specialty until changes in procedures allowed injury victims to choose their own physicians.
The western railroads traversed rural areas and new settlements devoid of any substantial health care systems. Missouri Pacific chief surgeon Dr. Warren 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 faced a similar problem in California. Under the direction of vice-president A. M. Towne, the railroad opened its own hospital in Sacramento in 1869. That institution, which most historians recognize as the first exclusive railroad hospital, stimulated other railroads to develop similar facilities, and many more hospitals quickly appeared along the western rail lines.
Eastern railroads passed through older, well-developed cities, and these companies initially contracted with existing hospitals rather than invest in building separate hospitals. Twenty-five years after the Central Pacific Hospital opened, the Illinois Central and the Pennsylvania Railroad still lacked their own medical facilities. However, the railroad-owned hospitals afforded more control and the economies of scale and consolidation--benefits the eastern lines ultimately could not ignore. By 1896, 13 railroads operated 25 hospitals, treating over 165,000 patients annually.
Railroads also retained private physicians under contract in cities along their lines. These doctors were on call at all times to provide initial care at any railroad-related emergency, even if the injured was not an employee. The local doctors referred non-employee patients requiring further care to nearby hospitals, while the railroad transferred its own employees to the nearest company hospital. Only if an employee’s condition prevented safe transport would the railway pay for an outside hospital; even then, the company expected the patient to transfer to the nearest railroad hospital as soon as medical conditions permitted.
Railroad hospitals varied 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 3700 beds at 35 railroad hospitals around the country. The larger ones offered a range of services and facilities comparable to other leading hospitals of the time. The Santa Fe Hospital in Topeka, established in 1896, boasted innovative features such as forced air ventilation with a full air exchange every 10 minutes and independent heat control in each room. The Southern Pacific’s San Francisco facility 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 manufactured pharmaceuticals or produced their own farm and dairy products. The railroads also maintained many more “emergency hospitals,” usually on the grounds of major yards or service facilities. Not true hospitals, these functioned as minor emergency clinics, typically housed in a one-room building and staffed by one 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. “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. . .” The Missouri Pacific Railroad Hospital at St. Louis, opened in 1884, provided musical instruments and a patient library with over 2800 volumes.
Early railroad hospitals accepted only railroad employees. However, some areas lacked alternative facilities, leading the hospitals to open their doors to the public. The Alaska Railroad Hospital in Anchorage accepted non-railroad patients from its opening in 1916 until a private hospital opened in 1939. The U.S. Army used the Alaska hospital at the beginning of World War II, during construction of the Army’s own facilities. In later years, many railroad hospitals accepted private patients to fill unused capacity and generate revenue to reduce employee charges.
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 care, as well as a nurses’ training program. Most patients stayed in large wards with 10-15 beds, a common practice at the time. The railroad subsidized the hospital, keeping expenses to patients low. In 1930 a ward bed cost employees $3 a day, including all medications, tests and x-rays.
Some railroads even operated long-term care facilities. Southern Pacific maintained a tuberculosis sanitarium in a converted freight station in Tucson. The Santa Fe Hospital in Los Angeles accepted tuberculosis patients, housing them in heated and lighted tents on the hospital grounds.
The land, buildings and furnishings of a railroad hospital counted as taxable company assets. Many railroads opted to relieve themselves of the tax burden by creating independent foundations to own and operate the hospitals and health plans. These foundations, known as employee hospital associations (EHAs), also gave employees 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 (see table below). In contrast, corporate executives managed the company-owned hospitals. Many EHAs obtained non-profit status, conferring more tax benefits and the ability to solicit donations, although the hospitals still relied on payroll deductions, patient payments, and company subsidies.
The EHAs published books of regulations which bear a striking resemblance, in principle, to modern managed-care handbooks. Members could use only designated hospitals and physicians; certain types of care and consultations required advance approval from the chief surgeon. Many benefits carried specific, sometimes draconian, limits. A Union Pacific handbook stated that diabetic patients taking insulin would receive only one syringe and two needles; the Frisco provided crutches, but would charge the patient if they were not returned. The Union Pacific, like many railroads, would not pay to treat sexually transmitted diseases or attempted suicide. UP would cover blood transfusions, but expected the recipient to supply donors to replace the blood! The strict limits and centralized approval process, very familiar to today’s managed-care consumer, represented radical concepts at the time. They challenged traditional views of the physician as an independent, unquestionable authority. Yet the techniques proved highly effective in controlling costs, setting an example that would dominate health care decades after the EHAs disappeared.
Railway surgery fell into decline early in the twentieth century. By 1921 The Railway Surgeon had changed its name to The Surgical Journal Devoted to Traumatic and Industrial Surgery. Activity in the surgeons’ professional associations dwindled. Several factors contributed to the demise of the system. Many patients disliked the requirement to see designated physicians or travel long distances to railway hospitals. They preferred to choose their own doctors in their home communities. Private insurance policies, prior to the 1980s, offered many choices with few restrictions. Railroad employees and unions pressed for these policies in place of the railroad doctor/hospital system. Injury victims requested doctors not affiliated with the railroad. Changes in government regulations, the creation of Medicaid and Medicare, and booming medical advances made the management of healthcare facilities progressively more complicated and expensive. Finally, railroad managers sought to divest unprofitable auxiliary enterprises such as hospitals. The remaining railway surgeons dispersed as the last railroad hospitals were sold or closed by the early 1970s. Many opened or joined other practices and continued to see their previous patients.
Several EHAs continue to operate into the present day, providing insurance benefits to railroad retirees. One of the oldest is the Wabash Memorial Hospital Association, founded in 1884.
Some railroad hospitals continued to operate as community hospitals, such as the Santa Fe Hospital in Temple, Texas, which grew into the Scott and White healthcare system, which to this day offers a prepaid medical plan similar to the railroad plans. Other railroad hospitals found new uses, such as the Southern Pacific Hospital in San Francisco, converted to housing, or the Houston facility, which serves as a county clinic. Many have been demolished. (See list page for updated status of some hospitals.)
Railway surgeons left a lasting impact on the science of medicine. Their research and publications created the first modern study of trauma care. They helped shape the modern medical world with groundbreaking contributions in pre-hospital care, emergency medical transport, wound care, mass health screening and first aid. The surgeons called attention to public safety and sanitation issues, setting the stage for the modern specialty of occupational medicine. The descendant of The Railway Surgeon remains in print, now called Occupational Health and Safety.
The railway surgeons also helped shape the social aspects of medicine. They sought to deliver comprehensive health care to large numbers of people efficiently and economically--a challenging goal even today. Their innovative approaches to this problem, such as the prepaid health plan and the vertically integrated regional healthcare network, left a lasting contribution for future generations.
One trustee is selected from each of the following organizations:
2. Brakemen, switchmen and other trainmen
5. Station agents, telegraphers, levermen and linemen
6. Metal crafts and car department workers
7. Bridge, building, construction and trackmen
8. Clerks, general office, store and station employes
9. Signal men
10. Supervisory officers
Source: Missouri-Kansas-Texas Railroad Employes’ Hospital Association Charter, By-Laws and Rules and Regulations, 1950.
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