perhaps entitled to the reasonable remuneration of say, five hundred or a thousand dollars, but that it is nonsense to pay him fifteen or twenty thousand dollars; that I have consulted the surgical department and find that the man was not seriously injured. We go to trial and appear before a jury. This man produces surgeon after surgeon of the highest character and reputation and proves conclusively to the jury that he has sustained the permanent injury of which he complains. How can we stand up against a case like that? The verdict of a common ordinary jury is much larger than the reasonable amount by which you can compromise a case. On the other hand if the injury is not a serious one and is simulated, look at the vast value which acarues to the legal department in having a competent surgeon point out what is the actual condition which really exists. These points of evidence must be given to the lawyers. When a surgeon says that a man was not very much injured and is not entitled to a large amount of money and is prepared to demonstrate the man's condition to the jury, it means a good deal. So what we want is truth. If a man is badly hurt through the negligence of the corporation, and if there is any legal defense of his claim, of course he is entitled to recover a reasonable sum to cover his injuries, and I do not know of any railroad in the United States that wants to deny him the reasonable sum to which he is entitled. I am afraid, however, that there is not that close interest or close sympathy, which is a better word, existing between the legal and the surgical departments of the railroads that there ought to be. It may perhaps be our fault. I have no doubt it is partially the

fault of lawyers who are generally very busy

men and very much burdened with care and responsibility. On the other hand, it may be somewhat the fault of the chief surgeons of the road themselves and their assistants in not seeking to cultivate the closest and most friendly relations between the two depart

tem and one that makes money when other systems go into bankruptcy.

Gentlemen, this is an interesting subject to me, because I have been at the head of the legal department for years and have had the benefit and privilege of the consultation and friendship of my friend, Dr. Outten. I know of what immense value it has been to me in the past, and I may say to you now, that there is nothing that could be offered to me as the head of my department which would tempt me for one moment to do away with the advantages which accrue to my department because of the surgical department. (Applause.) Lastly, I want to repeat to you that it is a pleasure to have met each one of you, and it will be a greater pleasure to me still if you will remember me and when in St. Louis will come to see me and take me by the hand. I know you collectively now, and I want to know you individually. (Loud applause.)

PRESIDENT'S ADDRESS.*

BY J. B. MURPHY, M. D., OF CHICAGO.

Mr. Chairman, members of the National Association of Railway Surgeons:-It is with much pleasure that I avail myself of this opportunity to express my high appreciation and sincere thanks for the great honor you have conferred upon me in selecting me to preside over this grand assembly of distinguished surgeons. It is my pleasant duty to express to the committee of arrangements, to the medical profession and to the citizens of this beautiful city, our grateful acknowledgment for the cordial reception extended us and to thank Dr. Starkloff for his warm words of welcome (I cannot say that they were entirely unexpected, for that hospitality and chivalry of the South). would betray an ignorance of the proverbial

It is not surprising that I enter upon the delicate duty of presiding over your deliberations with much diffidence; but, when I recall the past and remember the willing assistance you have always given your presiding officer, I take heart and venture to assume the responsibility, not altogether without the hope of discharging it in such a manner as to justify the confidence you have reposed in me. I am still further encouraged in this upon reflecting on

*Delivered at the Ninth Annual Meeting of the National Association of Railway Surgeons at St. Louis, April 30, 1896.

must not infer from the foregoing that it is my belief that operations cannot be performed aseptically in other places than the hospital. On the contrary, I am confident that the surgeon who has had the proper training in asepsis can go into the poorest hovel and perform any emergency operation in a thoroughly aseptic manner, if he can but procure there heat and water. The marble-top table, the porcelain-lined operating room, the white gowns, will not assure asepsis, if the operator strokes his whiskers, wipes off the perspiration from his forehead, holds the scalpel or forceps between his teeth while not in active service, or invites the distinguished bystander to insert his infected digits into the wound for the purpose of examining the parts. How many of you, gentlemen, have seen an operator after having devoted twenty minutes or more to the preparation of his hands prior to an operation, take hold of a patient to retain him. on the table in his struggles under the influence of the anesthetic, and without any further preparation, proceed with the operation. You may smile and say, "Who would be guilty of such gross carelessness?" I will answer you by saying, "Who is not guilty of many smaller acts, wherein his hands are as liable, if not more so, to be contaminated, than in the manner above described, at some stage of an operation?"

Asepsis is secured only by the most diligent watchfulness and circumspection in regard to the hands, what they come in contact with and how they are disinfected before they again come in contact with the wound. Can this ideal asepsis be attained by the railway surgeon at the cross-roads? Yes, most assuredly it can, and it is a criminal negligence and an unpardonable indifference in his sense of obligation to his patient when he does not succeed in obtaining asepsis in every place and under every circumstance, in wounds produced by himself. The apology I have to offer for being, so emphatic on these points, is, that my observations in post-graduate teaching have convinced me that a great majority of practitioners are lamentably deficient in these particulars. In my college examinations I have made it a point to give the student who could accurately describe the proper treatment and dressing for a scalp-wound more credit than the one who could give in detail a description of an extirpa

tion of a kidney. There has been a growing tendency to sneer at the practice of antiseptics, but I hope, gentlemen, that you will not allow these comments to influence your actions in your practical work, and that you will bear in mind, that while in other fields of activity, cleanliness is next to godliness, in surgery, cleanliness is godliness itself.

I am pleased on looking over the programme to note that there is a number of papers devoted to the injuries of joints, but regret that there are none that treat of the management and care of joints in close proximity to fractures. Why this practical field has been overlooked I do not know; it certainly is not because it is of minor importance, either to the surgeon or to the patient. Is there a surgeon present who has not seen patients permanently crippled, incapacitated or compelled to undergo months of torture, to remedy the evil results to joints, situated either immediately above or below a fracture? We should ascertain the cause and remedy the evil, if possible. If you will recall to your mind the cases of acquired talipes, and remember the difficulties in treatment, the forcible flexion and extension, the tenotomy and the protracted massage which had to be carried on for months in order to obtain even a moderately useful limb, you must be forced to the conclusion that the treatment of the joint is of more importance than the treatment of the fracture. The causes of traumatic arthrosis are mainly two-fold, (1) the injury sustained in the joint by the force producing the fracture, (2) the prolonged immobilization following the primary traumatic synovitis. The latter has a tendency to lead to a plastic adhesive synovitis, peri-arthritis and peri-tendenitis. If the position of the joint be faulty while these pathologic processes are taking place, the resulting adhesions will retain the limb in its abnormal position. This may all be avoided, if even a little attention be paid to the joint during the process of repair, i. e., if the joint be subjected to passive exercise daily, after the sixth day, the limit of such exercise to be governed by the pain. It should never be carried to a degree to cause real pain, as this means additional traumatism, additional exudate, and additional danger of anchylosis, or very limited motion. The same result is obtained by the ambulatory treatment of fractures, so ardently advocated

by some surgeons at the present time, as for example Dr. A. C. Wiener of Chicago. It should be borne in mind that a limited degree of motion at the seat of fracture, rather hastens than retards the union, and lessens the liability to non-union. The old law which was so forcibly impressed upon our minds, as students, that the joint above and below the fracture should be constantly immobilized during the process of repair, must be effaced from our code, and a new one inserted, viz., that all joints in the neighborhood of a fracture must be passively exercised after the fifth or sixth day.

Another subject that I hope will receive attention at this meeting is, the importance of repose, prolonged, unconditional repose, to the patient sustaining cerebral and spinal concussions. The conspicuous place which spinal concussions have occupied for the last five years in medico-legal practice is in some degree, at least, due to the surgical management of the case immediately after the injury. True, it may not be the fault of the surgeon, for many of these patients do not consult a surgeon, and if they do, they are reluctant, and very often, even refuse to obey his order, to remain in bed. for from four to six weeks. The pathology of the process of repair of physical derangements of the tissues of the brain and spinal cord teaches us that repair and regeneration in these are slower than in that of almost any other tissue in the body, and not only are they slower, but unless the process be complete, they are liable to produce recurrence of symptoms and initiate new changes. It is, therefore, our duty to insist that they be given ample opportunity for repair, and, as we are conscious that medicine contributes comparatively nothing to these changes, the resources of nature must be depended on exclusively, and the conditions must be rendered as favorable as possible.

The teachings of modern pathology and the glorious achievements in the new fields of surgery have carried us away from the daily routine of our labors. We are prone to overlook the little things that contribute to the relief of the sufferer, and the comfort of our patient. The same spirit prevails with the clinical; when he has made his diagnosis he considers that there his labor ends, forgetting that the primary and most essential aim of the diagnosis is to suggest means for the relief of

the patient. For this reason, gentlemen, at this meeting, I trust we will descend from our revellings with the gasserian ganglion, from our ideas of direct inspection of the floor of the fourth ventricle, to the more matter-of-fact every-day topics, remembering that there are a hundred, yes, even a thousand of the commonplace cases that are indifferently, if not imperfectly treated, to the one requiring these wonderful acrobatic surgical feats.

Gentlemen, the time for this meeting is very limited, the programme very long, the number of papers which appear on it embrace a wide range of subjects. In order that we may have time for the consideration of every topic, I trust you will all be punctual in your attendance, present at every session and take a truly scientific interest in the discussions, always bearing in mind that this is not a mutual admiration society, and that our sole object is to arrive at the truth.

I thank you for your attention.

SURGERY OF THE SPINAL CORD AND COLUMN.

BY T. H. BRIGGS, M. D., BATTLE CREEK, MICHIGAN.

The surgery of the spinal cord and column is brought prominently to the attention of the surgical world by a number of distinguished operators and authors of to-day, and the fact that this is an association of surgeons who are often brought in contact with injuries of the cord and column, either traumatic or otherwise, is my excuse for trespassing on your time to-day. Practically a more definite field is being opened in the primary and secondary treatment of spinal injuries. The surgical procedures in this field that were, in the near past, considered perilous in the extreme are to-day adopted as worthy of careful consideration and analysis. It has long been a tradition that following injury of the spinal cord atrophy was one of its necessary sequela, even though the cord was without maintained compression, and that pathological change supervened that could not be remedied by our art. Some of our eminent pathologists now question this position and claim that the paralyses following injuries of the cord are due to an inflammatory exudate producing and maintain

ing compression of the cord in its bony canal, and that on the removal of this product the cord will resume its normal functions.

In 1887 Drs. Horsley and Gowers reported the removal of a number of spinal tumors, and as some may not have even the report, I will give a brief synopsis of the same. The first is the case of a man 42 years of age who had been suffering from a growth in the spinal canal for three years, and for the four months preceding its removal had been completely paralyzed in the lower extremities, and at the time of its removal paralysis extended to the base of the sixth dorsal nerve with spasms in the legs and feet, cystitis and retention of urine. The tumor was removed from the dorsal region. On removal of the arches and tumor the cord was found to have been compressed by the growth and an exudate. The wound healed. by first intention, and there was complete recovery, the patient being enabled to walk and dance with ease. This was followed by the remarkable paper of McEwen reporting six cases of the removal of the arches of the vertebræ for various pathological reasons, consisting of tumors, injuries and caries of the column, causing compression of the cord and producing paralysis. All of the patients were relieved by operation, except the sixth, which was a case of traumatism treated by opening the spinal canal and elevating the arches, and if my understanding of it is right, not draining the canal, as should have been done. A majority of these patients recovered and returned to their various occupations.

Since 1887 some thirty cases have been reported of surgical treatment of the spinal cord and column, the large majority of them having been relieved by operation. Mr. Horsley has analyzed the reports of fifty-seven fatal cases of tumor of the cord, and has shown that eighty per cent. of them would have recovered had the proper surgical treatment been rendered. This is a sad reproach to the surgery of this age. The spinal cord is a segmental organ with a fixed series of nerve centers protected by a bony canal. Therefore, whatever produces compression, be it from injury or growth, the results are the same, and are to be remedied only by operative procedure. A partially separated cord should be aseptically sutured through its enveloping membranes and the sutures passed beyond the point of separation

through its covering and the raw surfaces placed in perfect contact.

In looking over the surgical history of the late war I find that all cases of this class of injuries were fatal and the treatment in the great majority was nil, presumably largely from the fact that the proper agencies were not at the command of the surgeons for their treatment at that time. Since that day a systematized care and procedure in this class of cases has been established. I wish to call your attention to one case of a number that have come under my care.

W. J. M., Canadian by birth, aged 27 years, a man of strong muscular development, on July 21, 1894, was injured near Hunt's Mills., Minn., by having a team, drawing a binder, run away with him, the binder passing. over him, injurng the spinal cord and column. He was taken to St. Luke's Hospital at Grand Forks, Dakota, on the following day and there remained until the 27th day of November, 1894. I have been unable to get any report as to his condition when he entered the hospital at Grand Forks, but from his statement and condition when he entered the Memorial Hospital at Battle Creek, Mich., on the 28th day of December, 1894, I found that the spinous processes had been removed at the time of the accident from the third and fourth lumbar vertebræ. lumbar vertebræ. The wound had healed,

but he was still suffering from incontinence of urine and fæces, was unable to move his legs or the lower part of his body, and this inability had gradually grown upon him since the time of his injury. In the region of the fourth, fifth and sixth dorsal vertebræ there existed an inflammatory and fixed condition of the column, with swelling and tenderness. I removed the arches of the three vertebræ mentioned and found the vertebral canal filled with inflammatory product about one inch each side of a small round stone about the size of large grain of wheat which was resting against the cord, compressing the same, having been driven therein at the time of his injury. I removed the arches and the exudate, drained the canal, dressed with gauze and maintained drainage for two months, when the wound healed by granulation, not one drop of pus having been developed. On closure of the wound the patient was allowed to move on crutches with a proper spinal support. The