geons shook their heads after examining him, saying that the man has not one chance in a thousand to get well. During those days patients died from gunshot wounds of the abdomen. There was no hope for them; and yet to-day your medical journals and text books are full of the most wonderful resutls obtained by that wonderful discovery of what you call antiseptic surgery. In this connection it gives me great satisfaction and gratification to say that no greater honor is due any man, in the treatment of intestinal wounds and of intestinal obstruction, than to your distinguished president, Dr. Murphy. (Applause.)

I must not suffer myself to wander into these general fields of thought, because I do not want to occupy your attention for any great length of time. I want to make my remarks comparatively brief, and consequently I shall talk to you for a few minutes about the question of railway surgery and the connection between the departments. You are railroad surgeons, and we have upon the stage to-night a gentleman whom it has been an honor for me to know and to be associated with, who is at the head of the surgical and hospital department of the great system of roads with which I have the honor to be connected. What a blessing it has been to the great mass of employes engaged in the dangerous duty of railroading, to establish surgical departments on the various roads. Just think for a moment of what the condition of these poor boys would be if you withdrew this blessing from them. A train is running along through the country; there is a derailment, a collision, an accident of some kind. A poor fellow is thrown from the car, is crushed and bleeding. What are we to do with him? Who are we to communicate with? Probably the doctor at the nearest point, and very likely he is an insignificant doctor in railway surgery, because it is the exception, as we all know, to find a man who has devoted the attention, care and thought to surgery which are necessary for him to make a first-class surgeon. The country doctor may be a very estimable man, but unacquainted with such matters as these. The injured man may be taken to the nearest country hotel, or perhaps to the house of some good Samaritan, who takes him in, and then the country doctor with his medicines and appliances will try to treat the case. He

is almost as helpless in following the treatment of the case as is the poor miserable wretch, who lies crushed and mangled before him. That used to be the case in years gone by. I know it was the case when I was a boy. But now that has all been changed. From the rank and file of surgeons and physicians you select men of peculiar ability. You select them because of their brains, their courage and intelligence, and who have been associated and connected with this vast network of roads which extend from the Atlantic to the Pacific. What is the result? A man is injured. What shall we do with him? We will send him to Dr. So-and-so, our surgeon. The mere fact of saying that Dr. So-and-so is our surgeon is a sufficient guarantee of the competency of the man. The matter is attended to quickly. A car and engine are hastily run, a surgeon is summoned, who instantly understands the character of the wounds. He knows what is necessary to be done in order to alleviate the suffering and save the life, and the Missouri Pacific Company and some other companies have done what I yet hope to see every railroad in the United States do, and which I believe every railroad in the United States will yet do, namely, establish in connection with their surgical department a splendid hospital service. (Applause.) We have a place for our injured; we do not need to take our patients to country hotels; we do not need to take them into the room of some good Samaritan who throws his house open; we do not need to take them to a partially furnished hospital, or one where the patient is not able to receive the careful attention which the seriousness of his case demands. I understand that when one of the employes of our road is injured, he is at once conveyed either to our great hospital here in St. Louis, or, if it is nearer, to our hospital in Kansas City. And when he gets there, what does he find? A perfectly fitted up establishment, presided over by brains; by men who have consecrated and devoted their lives to taking care of men who have been injured in the railway service. We have a chief surgeon with all the accumulated judgment of years, competent assistants in the hospital, and every appliance for proper treatment and every medicine that is needed-in short, we have a perfect and complete establishment, surrounded by trees, greensward and flowers,

and the sufferer may glance out of the window and lift his eyes to the azure blue above him. There he is kept and the United States can give him no better attention than is given him in this hospital. Every need is supplied and in his agony he has the most competent nurses to minister to his wants and to relieve him. He is kept there until he is well. This splendid hospital system is maintained by the slight contribution of the many men who are employed in the service, extending from the highest officers down to the men who receive the lowest salaries-just a small, trifling annual contribution maintains our hospital sysGentlemen, I speak of it because I know of it, and I express again, for the purpose of emphasis, the hope that the day is not far distant when every great system of railroad in the United States will have adopted this policy.

tem.

I am pleased to say to you in this connection and Dr. Outten will pardon me for making a remark in reference to the matter, which was the result of correspondence entirely with himself—that within the past year or two many inquiries have been made of Dr. Outten as to our system from some of the strongest roads in the East. I believe this system will yet prevail throughout this country. (Applause.)

I will touch on another thought. There was a time when the railroad surgeon was supposed to be a man paid to give testimony for the company that employed him. That was the general idea. We have got our lawyer and he must fight our case, and we have got our doctor and he must fight it, too, no matter what he thinks. He has no right to think. That was the general idea that prevailed in years gone by. How glad I am to know that this idea has disappeared. It no longer remains, and to-day the men who occupy positions as surgeons of these roads are men of the highest intelligence and highest character, and I want to say this, that there ought to be the closest interest and friendship existing between the legal and surgical departments of all these systems. No railroad is complete without its surgical department. Some say: "Can you not do without it?" Can you do without your hand? Can you do without your leg? Of course, you can get a wooden leg, but you are far from being a per

fect man when you are maimed and crippled in that way. This is the case with a railroad without its surgical department. If you want to make it perfect you have got to have a surgical department, just as much so as a claim department or a law department. I take it, that we are all brothers in this matter, all working together for a common cause, for the good of the system with which we are connected and associated. There not only ought to be confidence and great friendship existing between the legal and surgical departments, but our entire relations ought to be founded upon one simple little word which we hear so often-truth. The utmost truth should prevail at all times. For instance, here is a man who is hurt; he brings a suit against the railway company for twenty-five thousand dollars. When I have such a case, my first impulse is to send for Dr. Outten, and I say to him: "This man is in your hospital. You have had him from the beginning and have treated him?" "Yes, sir," "You have examined his case and taken note of his symptoms from the beginning?" "Yes." He claims to be suffering from permanent injury; that he has railway spine or something of that, kind, which condition is not visible, but which he says has paralyzed him. He says he cannot move, cannot eat, or do anything, and he thinks $25,000 would be a small sum. I ask Dr. Outten what he thinks of this case. I want to know what value Dr. Outten would be to me or his company if he turned to me at once and said there was nothing the matter with that fellow, if there was really something the matter with him? If he is paralyzed, or permanently injured, I want to know it. I want simply to know the truth, because I cannot act intelligently unless I do know it.

When a patient comes to you, you ask him a great many questions, how he is affected, whether his head aches or not, whether he has difficulty in breathing, etc.? If the man lies to you, you cannot diagnose his case, and you are apt to give him the wrong remedy. You want to know what is the matter. If Dr. Outten informs me that there is nothing the matter with the fellow, I advise my company, basing my opinion on the expert testimony given by Dr. Outten. I say to my company, that this claim is outrageous; that the man was injured to some degree and is

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

ments. You can just mark this as the truth, that whenever you find a railway system where every department is operating in sympathy with every other department, when they are all striving for the common good of the system, you will find it to be a prosperous sys

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 would betray an ignorance of the proverbial hospitality and chivalry of the South).

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.

the truly scientific and tolerant spirit which has characterized your former meetings, the moderation and courtesy invariably observed, the entire absence of innuendo or sarcasm and the all-pervading harmony and good will-all of which I feel confident will be equally characteristic of the present one. I appeal to every member to participate in the discussion; to express his views honestly, unreservedly and as concisely as possible, that every subject may receive a free and impartial consideration.

To-day, gentlemen, we are assembled to inaugurate the ninth annual meeting of the National Association of Railway Surgeons, and does not the heart of every member of this association throb with pride when he observes the magnificent proportions which this organization has attained? From the small nucleus in Chicago, in 1887, there has developed one of the largest surgical bodies in the world-a society with a membership of twelve hundred. This, gentlemen, is not the result of accident nor of a fortuitous combination of circumstances, but is due to the yeoman service of the founders and builders of the organization, whose loyalty and fidelity of purpose have frequently been tried; but the wise counsel of my predecessors and their lieutenants has brought us safely to our present flourishing condition. There was a time when the scientific surgeons of the country looked askance at this organization, but, gentlemen, we challenge comparison in quality as well as the quantity of work accomplished at our meetings. Our efforts have revolutionized the medico-legal aspect of traumatic surgery, and systematized the treatment and care of the necessarily large number annually injured on our railways.

In the surgical literature of the day we have also taken an enviable position. The Railway Surgeon, under its present management, has attracted widespread attention. Its articles and editorials are perused with pleasure and profit by every member of the association. It is not the pedantic advertising sheet, so common in our time, but the erudite production of a master mind. In order to sustain the editor in his

position and maintain the elevated standard which this journal has taken, we must furnish him with the results of our individual investigation, original research, careful analysis and reports of the cases coming under our observation. It is not requisite that each member

should write a book-that he should become a dreamer-no; the most valuable contributions to surgical literature are concise, painstaking, detailed reports of cases treated, without the addition of a page or two of literary references.

Clinical medicine and clinical surgery, which form the practical part of our science and art, have always been, and must always be based on the clinical course of cases influenced for better or worse by the medical treatment, the surgical operation or the masterly inactivity with which the case is managed. Theories come and go, but clinical facts, accurately recorded, as wel as the results obtained, must constitute the history of medicine of that period. You, gentlemen, are in duty bound, to contribute to the formation of this history, and your recorded cases will be perused, just as the records of this association's meeting will be handed down to medical posterity, to be examined, scrutinized and analyzed, and the essence of good therein utilized a century hence.

How different is the position of the railway surgeon to-day compared with that of ten or twenty years ago. At that time, his operating room was the roundhouse, the flag station, and not infrequently he had the canopy of heaven for a roof, and a pile of ties for a table. His dressings consisted of some waste and fragments of the wearing apparel of the victim. He did not have even the advantages afforded by water, unless it were from the polluted wayside pool. Observe him to-day; in almost every caboose, every station and at every junction he has a complete outfit-all that is necessary to perform aseptically or antiseptically any emergency operation. He secures his sterilized water from the boiler of the engine, and even though he were called upon to perform an operation on the prairie, with nothing but his pocket case, he has with him now his ever-present aseptic consciousness, which enables him to convert almost any material into an aseptic dressing appropriate for a wound.

He is fortunately not frequently called upon to tax his resources in this particular, as many of the railways have their own well-equipped hospitals at short intervals, or have affiliated themselves with hospitals in which their injured are cared for. This, gentlemen, is the result of your work, and your task is not complete until every railway in the land has its own hospital with its efficient hospital corps. You

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