I bid you welcome to everything that is here. I assure you that we are willing to camp at suffrance on the stoop. You must feel at home. (Applause.)

RESPONSE TO THE ADDRESS OF WELCOME.

BY DR. GEORGE ROSS, RICHMOND, VA.

His

I have heard that snap judgments have been taken on men very often, and Dr. Bouffleur has the aptness, the boldness and the daring that does not for a moment brook defeat. purposes are preconceived, and he always effects a satisfactory solution of all his schemes. even of iniquity. What man but would feel some hesitation to follow a gentleman so admirably adapted to extend a whole-souled welcome as is Dr. Evans? Someone told me that he was born in Mississippi. I recollect that one. of the great speakers of our southern country was born in Mississippi, and, evidently, the same atmosphere has yielded its influence and contributed to make the doctor gifted in the same direction. I wish that some of the powers of speech possessed by the great Patrick Henry had fallen on me that I might have been a fit person to reply to the courteous remarks of Dr. Evans and the welcome extended by him on behalf of the local profession.

Chicago, to me, is a wonder. Only a few years ago I picked up a paper and saw that a woman of Chicago, by some accident, upset a kerosene lamp in her cow-house. The flames spread and Chicago was leveled to the ground. And look at it today! It is a perfect wonder. Look at these enormous and lofty buildings. I do not know where these people are going to stop, either in their aspirations or the performance of wonders. It is a perfect marvel to me to see it. When we come to these medical meetings and meet with the doctors from Chicago and see their progressiveness, we are astonished. Think of Murphy, of Senn, and many other men of that ilk no less brilliant, but up to this time not having had quite so large a field in which to display their tremendous luminosity. But the time is coming when the older men in the profession will drop out, and the younger men will follow in their footsteps.

It is a source of great delight to me to be in Chicago. I always learn something when I come here, and, after all, that is what we come here for-to learn, and to get a little polish, each from the other. I am sure that in this meeting the spirit of brotherly love will prevail; that there will be a coalition of two organizations whose purposes are in common. I am very glad to see that this will be done, as I have done my best, individually, to bring this about, and when a man has done his best he can not be charged with dereliction. When I was president of this organization (and I was elected to that office in this city), my first official act was to address letters to the members of this and the sister organization; urging the coming together of the two dissenting bodies. That work has gone on steadily since that time, and today we will, in all probability, have the extreme pleasure of seeing this work, which has been carried on ably by Dr. Bouffleur and Dr. Lacey, and others, culminate in the union of these two organizations. We are going to demonstrate the fact that there is nothing like union, for in union there is strength.

connection.

Some man was speaking of water in this What is water? H.O. What is a drop of it? The same, but it does not quench the thirst of either man or beast or plant. It does no one any good. That drop of water may be taken as the very basis of disunion, the symbol of the weakness of the individual. But take that drop, and put it into cohesive union with other drops of water, and what have you? The great ocean, the bearer of the navies and the merchant fleet of every nation on the globe. It is the type of the strength that there is in union. There is nothing like it. Disturbing elements may bring their influence to bear on the mass, but does it lessen the strength of the bond of union or of the union? at all. The essential element of strength is in combination, in coalition, in co-operation, in working together for the common good, in fighting the battles of the mass, and this association is in a fair way of being the nucleus of an international association, numbering among its members the surgeons of neighboring countries and cities, making of us one brotherhood working for the common good.

Not

We are factors of immense value to the corporations we represent, but do these corporations recognize and appreciate our value? I think that may be asserted to be doubtful. If they did appreciate our services, greater consideration would be shown us. Perhaps time will accomplish all we hope it will. Our association once numbered 1,500 members, but it is steadily drifting down and down, and the last few meetings have been a source of great distress to those who knew the association when it was at its zenith. Let us hope that we will inspire new life into the organization; that the men who are most deeply concerned in it will lend their energies toward the development of the work they have laid out for themselves. It is bound to redound to their credit, to be a living monument to their labors, instructive. and ennobling to all who may become a part of it. Let each man contribute his own quota, whether it be little or great. It will all help in the work we are carrying on.

The meeting reassembled at 2 p. m. and was called to order by President Ford.

Dr. W. H. Condit, of Minneapolis. Minn., read a paper entitled, "Muscle Injuries." which was discussed by Drs. Stemen, Thorn, Letcher, and the discussion closed by the essa vist.

Dr. Adolph Gehrmann, of Chicago, followed with a paper on "Methods of Testing, the Efficiency of Car Disinfection." Discussed by Discussed by Drs. Thorn, Jonas, Mitchell, Plummer, Corwin, and the discussion closed by the essayist. Dr. W. H. German, of Morgan Park, Ill..

read a paper on "The Effect of Traumatism on the Kidney." Discussed by Drs. Plummer, Fairchild, Ford, and, in closing, by the essayist.

Dr. W. C. Gates, of Rockland, Mich., read a paper on "Weak Foot Prophylaxis."

Dr. R. W. Corwin, of Pueblo, Colo., read a paper on "Injuries to the Vertebræ and the Spinal Cord, and Their Treatment," which was discussed by Drs. Hoy, Stemen, Newcomb, Bouffleur, Thorn, Jonas, Williams, Getz, and the discussion closed by the essayist.

At this juncture the meeting went into special session.

The President stated that the first order was the reading of the annual report of the Secretary, which was read by Dr. Louis J. Mitchell. SECRETARY'S REPORT.

In addition to the routine business of the past year, the principal work of the Secretary has been in securing quarters for the meeting.

The recent Iroquois Theater disaster and the stringent regulations of the new fire ordinance consequent thereon have placed an embargo on the majority of available halls. It is hoped that the present meeting place will prove suitable.

Dr. James A. Duncan, of Toledo, Ohio, presented his report as Treasurer of the Association.

The President called for a report from the Executive Board. Dr. D. S. Fairchild, Chairman, stated that the Executive Board had no report to make at this time, except in relation to the question of reorganization. He said the board had had the matter of reorganization under consideration. The Executive Boards of both Associations had held meetings during the year to perfect a method of carrying out the idea of reorganization. He then spoke of amalgamating the two societies, and presented a plan by which such reorganization could be effected.

The whole subject of reorganization and amalgamation was discussed by Drs. Thorn, Brock. Stemen, Getz, Hoy, Williams, after which Dr. A. I. Bouffleur offered the following

resolution:

Resolved, That at the close of the present session the International Association of Railway Surgeons dissolve its present organization for the purpose of organizing the American Association of Railway Surgeons, provided that a union be made with the American Academy of Railway Surgeons at the meeting set for that purpose.

Resolved further, That the Executive Board of this Association be authorized to join with the Executive Board of the American Academy of Railway Surgeons and organize the American Association of Railway Surgeons.

The resolution was seconded by several, and after some discussion, which was participated in by Drs. Bouffleur, Stemen and Barr, the resolution was adopted.

On motion adjourned to 10 a. m. Thursday. JUNE 2, 1904, SECOND DAY-MORNING SESSION. The meeting was called to order at 10:10 a. m. by Dr. Ford, who introduced Dr. Plummer, President of the American Academy of Railway Surgeons, and said he would preside during the remainder of the meeting.

Dr. Plummer delivered the President's address. He selected for his subject, "Following and Assisting Nature."

PRESIDENT'S ADDRESS.

That nature has the power of protecting the living organism against harmful agents and of overcoming the effects of injuries and of pathologic processes is a truth long known, as the phrase vis medicatrix naturæ witnesses. However, we can not always keep this in mind, and entirely rid ourselves of the notion that reme

dial measures of themselves overcome disease and cure the patient. We sometimes forget that we merely assist nature in cringing about a recovery.

Accepting as a fact the tendency of nature. to heal, it is our duty to study nature's methods and learn the limitations of her power. One difficulty in determining the latter has been our lack of boldness in leaving the management of cases entirely to nature.

Prece

dent had prescribed that in a given case a certain line of treatment was to be followed, and he must indeed have been a bold man who would throw aside the prescribed practice in order to watch nature's processes.

Circumstances arise at times which preclude the application of the usual means of treatment. Out of the calamity of war come some valuable lessons. The late Boer war taught Sir Frederick Treves that it was better to let alone the average gunshot wound caused by modern weapons. The surgeons learned that even gunshot wounds of the abdomen did better, as a rule, when not operated upon than when operated upon under the imperfect conditions obtainable; so that, while in civil practice prompt laparotomy gives the best results, in military practice expectant treatment was better.

Such lessons as these teach us that some of the procedures which we have regarded as essential are superfluous. To interfere unnecessarily is often to do harm. That great surgeon, the late Christian Fenger, used to say, "Our first duty is not to do any harm."

On the contrary, experience has taught us that in some cases the possibility of dangerous consequences is so great that the surgeon is not justified in leaving the case to nature, but intervenes energetically, as soon as facilities for aseptic treatment can be had. Such cases are punctured wounds of the feet and the Fourth of July blank-cartridge wounds of the

hands. In these cases, owing to the possibility of infection from both pus microbes and the tetanus bacillus, the wounds should be opened up sufficiently for thorough cleansing to the deepest part of the wound, and for drainage.

In making a diagnosis one can not, as a rule. be too thorough, but, even in this field, too energetic manipulations, while they may add to our knowledge of the conditions present, may do great harm to the patient. Especially is this true in impacted fractures. In fracture of the neck of the femur, for instance, a favorable result depends so much on the presence of impaction that Hoffa advises against the use of an anesthetic in the examination of these cases, on the ground that the freedom from pain on the part of the patient may tempt the surgeon to manipulate the limb so freely as to break up the impaction. We must not forget that a good prognosis is better than a good diagnosis.

To secure ideal healing of a wound four things are requisite: Asepsis, hemostasis, coaptation and physiologic rest.

ASEPSIS.

That, in the majority of cases, nature can overcome septic infection, we all know, and the method of her defense is better understood of late, but in the struggle the organism suffers; so that, if, in a case of solution of continuity, we can prevent infection, we have rendered a valuable service; the wound heals more quickly, with less discomfort, less danger, and less loss of time to the patient, and with better ultimate result. Thus does nature reward us for our valuable assistance.

If, then, it is one of our plain duties to prevent infection, it is a surgical sin to introduce infection by any procedure or manipulation instituted for the purpose of diagnosis or treatment. He who, without efficient aseptic preparation, would introduce his finger into a wound to determine the extent of an injury. the presence or absence of fracture, or of other lesion, would be a sinner indeed. In the preantiseptic days how many deaths were due to the use of that aid to diagnosis, the probe? So impressed was Gussenbauer with the possibilities for harm in the use of this instrument that he forbade its presence in the surgical outfits of those working under him during a military

campaign. Far better is it to apply a temporary aseptic dressing, and defer more complete examination until favorable conditions can be secured, for he who infects a wound makes nature's task harder, instead of acting as her helper.

I can think of only two conditions under which one might justifiably disregard asepsis; namely, in hemorrhage so severe as to threaten life and not controllable by pressure at a distance from the wound, and obstruction of the larynx or trachea.

As to the means of producing asepsis, it has been shown that the strong chemical solutions when applied to fresh wound surfaces are not innocuous, but kill off the superficial layers of cells, thus handicapping nature by making it necessary for her to remove this dead tissue, which, while it remains in the wound, furnishes an unresisting breeding-ground for germs. Irrigation is no longer a routine feature of the first treatment of wounds, and when it is resorted to sterilized water or normal salt solution is used in preference to chemical solutions.

In case sepsis has occurred, we may learn a lesson from nature's method of overcoming it. Sometimes the phagocytic power of the cells overcomes the invading germs without abscess formation. If an abscess has formed, it has a tendency to increase its size until an opening on to the nearest surface or into the nearest cavity is produced by sloughing of the intervening tissue. intervening tissue. This opening removes the most potent cause of the spread of aseptic intoxication, pressure against the abscess wall from within.

In practice we attempt by mild, wet antiseptic dressings, to decrease the activity of the germs sufficiently to allow the cells of the organism to overcome them, or, if abscess has occurred, we do with one cut of the knife what nature would accomplish only at a relatively great expenditure of time. To prevent a subsequent increase of pressure we introduce drainage material. With this assistance nature can, as a rule, bring about recovery; a wall of granulation tissue, each cell of which has phagocytic power, soon overcomes the sepsis and healing proceeds in a normal manner.

When antisepsis was first introduced we had

exaggerated ideas of its efficiency and underestimated nature's abilities in the overcoming of sepsis. In our zeal we overdid. Irrigation was practiced as a routine after opening abscess cavities, but it was soon learned that antiseptics could not be used of sufficient strength to overcome the sepsis, and that by killing off the granulations they handicapped nature's efforts. In empyema, irrigation has been found to be particularly dangerous, sudden death having followed its use.

When, however, in the later stages of healing, the wound surface is made up of granulation tissue whose resisting power has been overcome by the invading germs and their toxins, the stronger antiseptics are efficient, as they do not reach the healthy cells deeper down, but simply kill off the useless superficial cells.

HEMOSTASIS.

Nature checks hemorrhage either by the formation of a blood clot in proximity to the lacerated inner coats of the vessels, or in case the wound is not widely open, by causing such an accumulation of blood within the wound as to raise the pressure above that in the arteries, thus checking the hemorrhage by pressure. The former method is often only imperfectly carried out in incised wounds, so that the surgeon must assist in bringing the inner coats of the arteries together by clamping, twisting or ligating them. The second method is ineffective in cases where a ready exit for the blood is present, or the accumulating pressure may of itself do harm. Especially is the latter the case in intracranial hemorrhage, where the surgeon may be called upon to relieve the brain from the harmful effect of the pressure. In cases of open wound we assist nature in making pressure by the use of sponges temporarily applied, or by the aseptic tampon.

In applying the tourniquet or Esmarch's constrictor to temporarily control hemorrhage, care must be taken not to let it remain on too long, or it may cause gangrene.

COAPTATION.

Nature's efforts at immediate coaptation are not, as a rule, effective, although the parts may be held in the most advantageous position for healing in impacted fractures, or in wounds of muscles, when the wound runs in the direction

of the fibers. At times, on the contrary, muscular contraction causes actual gaping of the wound.

In case of aseptic healing, nature's task is diminished proportionately to the accuracy of the coaptation; less new tissue is required to unite a closely coapted wound than is necessary where the wound surfaces are left wider apart. Desirable, then, as is the most accurate coaptation which the conditions allow, it must never be carried out at the sacrifice of asepsis. In case of doubt as to the aseptic condition of a wound, it is better to tampon the whole wound with sterile gauze with the application of secondary sutures, coaptation being brought about after the removal of the gauze.

PHYSIOLOGIC REST.

Experience has demonstrated that, other things being equal, wounds heal better when the parts are kept at rest than otherwise. Nature attempts to keep the parts at rest by muscular contractions. These contractions, while assisting the healing by keeping the parts quiet, often cause displacement of parts which should be coapted. Hence, it is the surgeon's duty to see that the parts are placed in the most advantageous position before the necessary immobilizing apparatus is applied. The parts should then be placed in such a posture that no undue tension is present.

A patient with a wounded hand soon learns that the hand will become painful when allowed to hang down, and that it will be relieved if held in a string. We profit by this hint and place the limb in a position to prevent passive hyperemia.

Nature rids herself of toxic products in the circulation by means of elimination through the lungs, the skin, the bowels and the kidneys. We can render assistance especially through the latter two channels, hence the logic of a laxative within forty-eight hours after the operation, and the use of normal salt solution either per rectum, subcutaneously or intravenously, according to the urgency of the case. The salt solution fills the blood vessels, increases arterial tension, and greatly assists elimination by way of the kidneys.

He who intervenes in a case where nature, unassisted, can bring about a favorable result, is guilty of meddlesome surgery.