PROCEEDINGS -OF THE FIRST THREE MEETINtjS~ OF- THE+SURGEONS -OF THE— EASTERN DIVISION, W„ ST, L, &' P, R’Y, -HELD RESPECTIVELY AT- DECATUR, ILLINOIS, JAN. 25, 1882. FORT WAYNE, INDIANA, JUNE 4, 1883. SPRINGFIELD, ILLINOIS, APRIL 30, 1884. FORT WAYNE, IND.: GAZETTE BOOK AND JOB PRINT. 1884. To the Members of the Surgical Association of the Wabash, St. Louis db Pacific Railway : Gentlemen—I liave the honor to present to you this volume of the transactions, together with the papers read at the three very inter- esting meetings, held, respectively, at Decatur, Ills.; Fort Wayne, Ind., and Springfield, Ills. You will find many imperfections in the book, hut I can assure you I have given a great deal of time to the publication of the transactions, and think it a very valuable work. Unavoidable circumstances delayed the publication some time. Thanking the members for their courtesy and kindness in the past, and asking their pardon for the delay, I am Yours Ilespectfully, C. B. STEMEN. PROCEEDINGS • -OF- THE FIRST THREE MEETINGS -OF- THE * SURGEONS OF THE- EASTERN DIVISION, W„ ST,Yr#$r%% -HELD RESPECTIVELY AT- DECATUR, ILLINOIS, JAN. 25, 1882, FORT WAYNE, INDIANA, JUNE 4, 1883, SPRINGFIELD, ILLINOIS, APRIL 30, 1884. . FORT WAYNE, IND.: GAZETTE BOOK AND JOB PRINT. 1884. PROCEEDINGS OF THE FIRST MELTING OF THE SURGEONS OE THE EASTERN DIVISION OF THE W., ST. L. & P. HY. The Surgeons in the employ of the Eastern Division of the W., St. L. & P. R’y Co., met at Decatur, Ills., on the 25th of January, 1882, in accordance with the request of the Chief Surgeon, Dr. J. T. Woods, of Toledo, O., and convened in the City Council chamber at 9 o’clock a. m. Dr. Woods qalled the meeting to order and read a very inter- esting salutatory paper on the “Organization of Railway Surgery.” After the reading of the paper the meeting adjourned to meet in the afternoon at 2 o’clock. The surgeons met according to adjournment, apd were again favored by hearing a very able paper from Dr. Woods on the “ Transportation of the Injured.” After the reading of the paper, a permanent organh zation was effected on motion of Dr. A. II. Shaffer, of Huntington, who also moved that Dr. Woods be made permanent President of the organization, which was unanimously adopted. On motion, Dr. 1ft. J. Cheneworth, of Decatur, 111., was elected ftJce-President, and Dr. C. B. Stemen, of Fort ftftffyne. Ind., Secre- tary. After the organization and the election of officers, a general discussion followed on the papers read by Dr. Woods, which was participated in by quite a number of the surgeons present; and some very practical suggestions were made by Drs. Beasley, of Lafayette, Ind.; Beard, of ftHncennes, Ind.; Cheneworth, of Decatur, 111.; McMahan, of Quincy, 111.; Shaffer, of Huntington, Ind., and others. The members present at the meeting who furnished the secretary with their name and address, are as follows ; Dr. J. T. Woods, Toledo, O., Chief Surgeon; Dr. J. S. Gregg, Fort Wayne, Ind.; Dr. C. B. Stemen, Fort Wayne, Ind.; Dr. W. II. Bell, Logansport, Ind.; Dr. J. C. Ilearne, Hannibal, Mo.; Dr. A. L. Elder, Fisher, 111.; Dr. C. Y. Rockwell, Taylorville, 111.; Dr. Jno. C. ftValker, Indian- apolis, Ind.; Dr. R. W. McMahan, Quincy, 111.; Dr. A. D. Coe, Mexico, Ind.; Dr. P. II. Barton, Danville, 111.; Dr. F. W. Beard, Vincennes, Ind.; Dr. A. H. Shaffer, Huntington, Ind.; Dr. Geo. F. 4 Beasley, Lafayette, Ind.; Dr. W. B. Graham, Noblesville, Ind.; Dr. T. B. Campbell, West Lebanon, Ind.; Dr. Alex. J. Mullen, Jr., Michigan City, Ind.; Dr. W. ,1. Cheneworth and Dr. Cass Cheneworth, Decatur, 111.; Dr. D. J. Swarts, Butler, Ind.; Dr. Wm. Scott, Koko- mo, Ind.; Dr. G. W. Parker, Cairo, 111.; Dr. A. U. Williams, Sullivan, 111.; Dr. A. T. Darrali, Tolono, 111., and Dr. N. N. Yance, Bement, 111. On motion it was ordered that the organization shall be known as the Surgical Society of the W., St. L. & P. By., east of the Mississippi River. It was ordered that the papers read by Dr. Woods, together with the proceedings, be published in the Fort Wayne Journal of Medical Sciences. A vote ot thanks was tendered to Dr. Woods for his able and in- structive papers. It was ordered by the members that the President shall call a meet- ing of this Society whenever lie may deem it expedient. On motion, the Society adjourned to meet at the call of the Presi- dent. In the evening the surgeons met again in the City Council chamber with the City Council and other citizens of Decatur, and spent the evening very pleasantly in social conversation until about 9 o’clock, when, in response to an invitation from Dr. W. J. and C. Cheneworth —who are entitled to much credit for the manner in which they enter’ tained the surgeons present at this meeting—the crowd repaired to Wood Bros.’ Restaurant, and partook of an excellent and refreshing repast. After a vote of thanks to Surgeons Cheneworth, the medical gentle- men went their various ways, all delighted with their first professional association. C. B. Stemen, M. D., J. T. Woods, M. D., Secretary. President. 5 SALUTATOEY. ORGANIZATION OF RAILWAY SURGERY. Chief Surgeon J. T. Woods. Prior to any organization, if such a step should be deemed best, I desire to call your attention to the fact that as a formal meeting of railroad surgeons, this is the first that has ever occurred. Whatever the result, we are, so far as I know in that matter pioneers ; and it seems to me fitting that I should at this time make some general ob- servations chiefly in the form of a brief sketch of the organization we represent. I do not wish to be understood as stating that this is the first at- tempt at surgical railway service, for many companies have at various times undertaken the difficult problem with more or less success ; but of their methods I have never been able to obtain any definite knowl- edge. I speak of it as a difficult problem advisedly; for there are many varied interests that must be reconciled in order to secure a sat- isfactory working system. These complications are embraced in the relations existing between the company who employs, employe, and the medical gentlemen who may be called upon to render service to those who are unfortunately injured. It may be dangerous ground, but I cannot forbear to make some observations on these relations, and would premise them with the remark that I have found that men generally, either singly or in com- bined capacity, keep a sharp look out for “ number one. ” This idea 6 concentrated means “business. ” The use of available means to make money is “business,’ and it is to that end that individuals strive, and for that purpose companies are formed. The type of a company is found in every sphere of life. Tne man who singly works out his life problem, is his own company, president, secretary and treasurer. He keeps careful note of gains and how to secure them, and strives to show a margin in his favor at the end of the year. The farmer is not indifferent to shades of value in the articles he has to sell.' It is his business to get all he possibly can, and right carefully does he attend to that point. The merchant who would avoid bankruptcy is equally cautious and careful in buying and selling, the philosophy of both being to obtain as cheaply as possible and sell for the highest prices attain- able. The laborer, citizen and professional man all seem to be actuated by the same idea. Get into a legal entanglement and you will be pretty sure to find an attorney who will fully calculate the degree of your embarrassment, the weight of your purse, and govern himself accord- ingly. Even Doctors have sometimes been presumed to be a trifle calculating and grasping. A company is, so far as I can see, actuated by much the same idea and show similar results. Organized for a special purpose, they invest their money assuming risk of loss, and strive to secure gains. Like the single individual they look out for expense and take advantage of .circumstances that enable them to obtain profits, hoping—often fruitlessly—to find at the end of the year a satisfactory margin. It is true an organization may be severely exacting, even tyrannical, but a parallel in a smaler way may be found in every neighborhood. Then, it seems to me, that in justice, one is entitled to the same principle of treatment as the other. If this position be correct, or even approximately so, then the relation of employer to employe is much t\ie same everywhere, and a company is entitled to the right to consider its interests in whom it employs, .what their wages shall be, and, in case of injury, what it will do. As in case of a private individual, self-interest must be allowed certain scope. Railroading, like farming, merchandising or professional work, is not prosecuted for amusement, but to make money. I see little difference between an employe on a Railroad or one with a Merchant, Doctor, Lawyer or Farmer. In each case the duties and dangers are understood, the pay agreed upon and the chances accepted. In either position an injured employe cannot justly demand care, and on the part of the employer it becomes a question of humanity and what he can offer or is willing to appropriate for the purpose. The medical man becomes at once involved, but without the alter- native of choosing. Humanity demands his services, and they are freely rendered. But who is to pay him? Does the Merchant, Doctor, Lawyer, or Farmer employer, in such a case, hold himself responsble? Not by any means, and why is not the rule general? Unfortunately for the medical man those most liable to be injured in railroad service are without means, and often so mutulated that thereafter they can only expect to make a bare living; and, financially, the Doctor is “left out in the cold.” We all understand well the chilly atmosphere to which I refer. Very little experience will convince any one ot its effects. In short, recompence, as a rule, is a total failure. Now, taking this as a rough outline of the logic of the case, I am sure Railroad Companies as a whole have not shown themselves to be so excessively hard harted as they are popularly supposed. On numerous lines they have striven to do something toward caring tor those injured in their service. More or less system has been attempted, but the work was so desultory and unsatisfactory, and finally so expensive, that it usually has either gradually dropped to pieces or been suddenly abandoned, as is the case on the whole system controlled by Mr. Vanderbilt, in which the company now take no care of any one, and the medical man who serves the injured must look to the patient for pay, the maimed men who have not the means, however well disposed. But, notwithstanding the fairness aucl conlusiveness of the argument, there still remains the question as to whether it is always best to be too severely logical. Large masses of men engaged in the same service acquire views that seem to grow out of their especial occupation. These views on certain occasions become the basis ot action, and often make serious complications. The combined opinion of a large mass of men is temporarily more powerful than logic itself— opinions become impulses and excited impulses are unreasoning as a whirlwind. Railroading is a civil service, but it smacks strongly of the military, and all concerned seem to acquire its spirit and expect what pertains to it. Employes to a great extent are homeless men, and if injured are like the soldier, without a shelter or the means that will purchase it. In this strait they naturally turn to their employers as their friends, or at least those most entitled to befriend them. It often occurs that there are no others who are under the least shadow of obligation. To comply is to secure the regard of all, to refuse engenders a feeling that one day may present itself in a disagreeable form. Between logic and this feeling growing out of the special occupation, the man- agement is left to choose. Some prefer to sow the wind and take the chances as to the possible whirlwind, while others select to bend hard equity in the direction of humanity, and I think the latter act wisely. The whole is a business problem with such strong leaning to the immediate money view, that when in 1875, I sug- gested the question of Surgical Service on the Wabash to Gov. J. D. Cox, then its President, the outlook was rather dark. He at once presented me with the foregoing ideas as to the relation of employer and employe, and further that the Company was legally responsible for but few of the injuries received, and neither legally nor logically under obligation to render aid; and that if such a measure be attempted it would lead to expectations equivalent to a demand to care for all, and at such vast expense that the Company could not afford and would not undertake to meet it. There was in him no want of the feelings of humanity, but that of real duty, real obligation, and can we afford to do it. The whole question was brought down to the common standard of business. I expressed my belief that it was possible to arrange a system that would secure the best service to those they desired to care for, that would not grow into an imposition, and could be carried out at such limited expense that on the whole nothing would be lost to the organ- ization and possibly a gain made by securing the higher regard of the employes, as they would feel that an interest was taken in their wel- fare that would prompt them to greater care and efforts in matters of welfare to their employers. With misgivings on his part, and not without some doubt on my 9 own, he consented and I undertood the experiment. It was an experiment, and that only. I had not a glimmer of light ; no kind of model was known to me. I started with timidity, but resolutely de- termined to succeed in finding, in each of certain localities, a good and reliable surgeon who would serve the company on such conditions that, as a whole, advantage would accrue to the employers, the employe and and the medical man themselves. Although I was everywhere met with the utmost cordiality and kind- ness, I found the task neither uncomplicated nor particularly agree- able. At some points I found a disposition to introduce local profes- sional animosities, and the men themselves were timid and often pre- ferred to choose their own surgeon in lieu of the one selected. I also found that to secure the desired statements in reports of cases I had to arrange a blank form, and bdls were presented in the most incongruous shape until I prepared a blank for that purpose also. By dint of perseverence and using the knowledge acquired as I pro- gressed, a system gradually developed that has so far given such satis- faction to the management of the company through its various changes, that it has been maintained to this day. It has not, so far as I am aware, grown into the feared imposition, nor has there oc- curred onerous expense to the company, and has secured to the un- fortunate employed the very best surgical service, at the same time af- fording the surgeons, as a whole, more remuneration for their work than they would have obtained had they done the same in the ordinary way. The natural and pardonable timidity of employes in regard to the chosen surgeons lias gradually melted away, as they have not been slow to note that men who are expecting and hold themselves prepared for this special duty are none the less careful, and are, because of their assumed responsibility, more ready with appliances in greater prefec- tion, than those who are otherwise wholly engaged. They have also learned that each in his locality stands among the very first in his calling, a guarantee to them that they will be treated with that prompt- ness, care and humanity which is the highest merit of the surgeon. In the same direction and of vital importance alike to the employer, the patient and surgeon lies the fact that familiarity with this species of work leads to fewer unsatisfactory results than could be otherwise exr pected. Those who have had much experience in railway surgery are aware that the cases, as a class, are peculiar, and, to attain the best results, especial attention, coupled with practice among them, is of in- estimable value. These, among many others, are the advantages brought to the service of injured imployes, as well as to the company by their medical officers, and, as I believe, in greater degree as they are more perfectly organized and work in systematic harmony. It is especially gratifying to me to be able to state that ever since the organization of this corps we have received the most cordial sup- port from the management of the road. This embraces Governor Cox and Colonel Hopkins, of the original Wabash, and finally Colonel Andrews, who was, until recent changes have placed him in a higher position, the general manager of the east- ern division of the Wabash system, embracing far more than the orig- inal road. Their desire has been to deal with the utmost kindness and generosity toward the injured within the limit of business possi- bilities, and I think that they are deserving of the highest regard of those over whom they have exercised managing control. Our efforts have been and are appreciated, and nothing so far as I am aware, has ever been suggested by them that was not only fair, but just and hon. orable. They have only demanded that the case be deserving, our work well done, and the expense kept within the limits of business en- durance. .There have been recently added to us a number of new professional gentlemen, of whom I know comparatively little, but with whom I am well pleased. Of those who have served from the beginning, I can only speak in terms of praise. They have shown themselves highly competent, as well as willing and painstaking. I do not believe that, as a whole, better professional men ever served an organization. Gentlemen, having th\j£ given you brief but formal greeting, I have only to refer to that which is well known to many of you. . This meeting was called after many requests, and was long delayed for reasons that need not be stated. It is not designed to be made heavy bv formalities and hard work, but rather a social occasion, affording all an opportunity to become ac- quainted, and to consult together on such themes as seem to you best. Plans for the future may be prepared if thought expedient, but I would advise that the matter be well considered, and that nothing be done in haste. There remains tor me only to thank you heartily for the duties done, the courtesies extended to me in the past, and the attention with which you have attended to these observations. I trust that you will introduce each other when necessary, and let no means of personal enjoyment pass without improvement. TRANSPORTATION OT THE INJURED. J. T. Woods, M. D. Iii its strictest sense the duty of the medical man is humanitarian. His highest function is to preserve life and next to that, to save from suffering. This is especially true of the surgeon whose path of duty leads directly to the sufferer, and whatever high examples may pre- sent, I maintain that in him, rudeness, indifference to humanity and the omission of any possible means of alleviating it is wholly inexcus- able. In actual practice both causes and consequences are ever pres- ent, the means of alleviation not always apparent or of easy attain- ment, but still worthy of the most earnest inquiry and careful effort toward removal. Neither is it always in great and showy ways that we are to do the most actual good to those who fall under our care; but little things, the veriest trifles professionally considered, are often of mammoth proportions to the sufferer. The party he is to consider is the suf- ferer only. Our duty to a patient begins on the first moment of our arrival, and everything thereafter should be directed with scrupulous care, for every twinge of pain is a blow at life. For this reason both patients and surgeons are thankful for anaesthetics, and the former is rela- tively as grateful for avoidance of the dread agony in every step pre- paratory to the operative work proper. These reflections have prompted me to present some rather crude suggestions in relatton to the handling and transporting of those who are injured, both before and after operation. The ideas are to some extent applicable wherever bodily suffering exists combined with the necessity of removal, but I desire at this time to call attention to phys- ical injuries, and more especially such as are incident to surgical rail- way service. I am not unaware that few rules or specific directions can be laid down, as conditions in every way vary, yet reflection and suggestions may prepare us to more readily and effectually do the duty of a special occasion. Whether the accident involve few or many, the surgeon usually, arrives after the lapse of some time, during which interval much has been done as seems best to those present, but on.the arrival of a med- ical man he becomes the director of every movement, and with discretion can conduct future proceedings much as is in his judgment seems best. The railway surgeon is supposed to, and always should have, his instruments and appliances ready at hand, so as to be able to move with brief notice. These instruments and appliances should not be numerous, and all parties will find that whatever the surgeon may bring nothing will be more valuable where there are badly-injured per- sons than a pair of stretchers. For the reasonably proper handling of the kind of patients that usually are found by us, they are absolutely necessary. There should be a pair certainly at every point where there is a surgeon, and they should accompany him in his response to a call. Some months since I stated this fact to the Superintendent, Colonel R. Andrews, and he directed the immediate making of a lim- ited number, but the shops have been so crowded with work that could not be deferred, that they are not as yet completed. I do not hope to get enough made so that I can do more than place one at the points where the greater number of accidents occur, and venture to suggest that in lieu of a better, an appliance that will serve a good purpose may be easily and cheaply made by even a rude workman. If two pieces of scantling 7\ feet in length and 2 by 2J inches in width, rounded at the ends so as to form convenient handles, and a light piece placed across at the distance of eight or ten inches from either end, and effi-cient frame will be formed. From outside to out- side of this frame should measure but 21 inches, which is wide enough to carry a stout man, and will pass through the guard rail posts and door of a passenger car. By nailing over this a piece of canvas, or if that is not available any stout material, as two thicknesses of ticking, you have a simple and cheap stretcher. The cloth should not be stretched very firmly, except at the ends, as a little bagging will afford much easier rest for the body. Of course it is very crude and insufficient, but so much better than none, that it seems to me that its cheapness is worth our consideration. A really good stretcher is so valuable that I have devoted some thought to the subject, and those that are being made for our use, will fold together tor convenience of carrying, the folding cross bars so constructed that they will not cut the canvas, and the legs automatic- ally held in place whether down or up, all staples and hooks, that are always in the way, being dispensed with. In my judgment it is be- yond improvement, having other valuable features. The canvas is as short as will answer the purpose and the handles not more than eight inches beyond it. The length is usually greater than is necessary. Its width is such that it will just passthrough the door of an ordinary passenger coach, a feature the value of which will be shown in our ex- planation of it in use. Having then a case of fracture, lying on the ground, the first thing that would present would be the application of support on the outside of the clothing for the purpose of preventing the sharp fragments from doing harm in handling. These may be made of any available mate- rial, pasteboard, a shingle or strip of board, and held in place by bandage, cords, in short, anything that will answer the purpose. I have thus temporarily dressed a fractured leg with a few corn stalks, or lashed one leg securely to the other with a couple of handkerchiefs. In case of a crushed limb the parts should be so managed as to drag as little as possible. The next step is to put the patient on the stretcher. The best method I have found is to place one or more men on the right side of the patient, their duty being to lift the body. Two take position on the opposite side to raise his legs, head and shoulders, standing as near as practicable to the upper and lower part of the body respectively. Show them where to take hold and what to do “all together” when you command. At the word the men will lift the patient directly upward just far enough to permit the surgeon to slip the stretcher with its legs folded up under the patient’s hips from his left side and sliding it quickly as near under and parallel to the body as possible. The pa- tient has thus far only been raised upward a few inches, and with a very slight lateral movement almost without moving their feet, those that hold can lay him gently down on the canvas. To avoid contact with the ground the man who handles the stretchers should keep the end on which the body is to be placed a little elevated. At once the other end is raised and the sufferer has been made ready tor removal with very little annoyance. If the body be very heavy or the assist- ants few. those who lilt may take the patient by the shoulders and raise the body and hips off of the ground. The stretchers being then slipped under, one man may take the legs and by simply turning the body on the nates as a pivot effect the desired result. In neither case has the body been jolted and dragged by raising far from the ground, and especially has the jolt, jar and dragging of carry ing in arms by inexperienced men been avoided. From this the sufferer should not be moved until he is to be placed on the operating table or in bed. The method suggested for accomplishing the latter is to fold up the legs of the stretcher and carry it somewhat diagonally across the table and near to the surface, the patient’s right hand being toward the pil- low. In this position the patient on the stretcher is allowed to rest on the table. Those who are to lift the body are placed at the patient's left side, those who handle the legs at his right %ide. Taking hold at the word of command and lifting together, the body is raised so as to clear the stretcher which is then easily withdrawn, and by a slight move- ment of those holding the body, it is placed in the desired position. Removal from the table is effected in nearly the same way that the body w$s first placed on the stretcher; and he may be laid in bed with as little discomfort as occurred in placing him there. To do this most satisfactorily, you will carry the stretcher beside the bed, the patient’s right hand being next the pillow. Carry the foot of the stretcher diagonally across the bed. Two men on his left side now raise the body, one handles the legs, while the surgeon slides the stretcher from under him,—which is usually easiest done from the foot,—when by a slight movement the assistants lay the body in its place. It not unfrequently occurs that we are required to place patients in the cars either before operation and perfect dressing, or very soon thereafter, and how to do it most readily and comfortably has been to me not a little puzzling. The baggage car is most convenient of access, as a cot can be passed through the side doors. It is, however, a rough place for a vigorous man to ride, and does not answer well for the injured, even with the aid of a cot, except for short distances. I have also suspended a stretcher from the roof by means of ropes which answered passably. This method is greatly improved by the use of long India rubber bands slipped over the end of the stretcher handles, the ropes being attached to them and the timbers above, their elacticity partially break- ing the jar of the car. These bands being usually unattainable and also liable h, break, render the plan practically useless, and so far as the baggage car is concerned we have left only rope suspension and the cot. In emergencies such as we are contemplating, the sleeping car is usually oecupied anti its use impractical, for the further reason that it is nearly impossible to get an injured man through the various passages leading into the seat or berth apartment, There is, then, nothing remaining but the passenger coach, and the problem is to take what is at hand and make out of it a bed in which a patient with crushed legs, arms or ribs, or suffering from concussion, can be placed easily, and on which he can ride without detriment. It can be done in this way : Take the back off* of one seat. This is done by the removal of a few screws, and a screw-driver will always be found in the possession of the engineer. Turn right and left the seats next before and behind, so as to leave the space of three seats open. Then take the cushion off of the seat from which the back has been removed, and turn it upside down on that at one end of the pro- posed bed, place another in the same way on the cushion at the other end. We then have an open space of sufficient length and a double set of springs on which to place our support. If we now have our patient on a stretcher that is narrow enough to go through the car door, he is hot to be removed from it, but the whole passed between the iron posts and through the door into the car, the carriers taking hold of the cross bars in lieu of the handles, in passing through the door. Of course the cars must be separated to secure the necessary space between. The stretcher with its contents is now to be laid down, the ends on our double cushion springs. If the handles are too long to lie between the open seats, one back may be raised and they be allowed to project beneath it. This, it seems to me, is not only a com- fortable, but a thoroughly practical means, provided we have the stretchers, and those that are made sufficiently narrow. By it the sufferer will not have to undergo the lifting and handling, that is often nothing but torture, from the time he is picked up until he is laid in bed or on the operating table, an avoidance of suffering that is not ap- preciable to those who have not experienced it. But, we are very likely not to have the stretcher and the patient is placed on a board. In that case I would try to arrange the board and patient exactly as I have described, believing that the double springs referred to would make it a more comfortable arrangement than can be constructed in a baggage car. Without removal of the back ot a seat, which might by some mishap be impossible, the backs of two may be raised horizontally, one seat intervening. By fastening them in this position a stretcher may be laid on them, but the whole jarring of the car will be communicated to the patient and add greatly to his discomforts. In lieu of this another method suggests itself, but it involves the lifting and handling of the patient, the very thing to be avoided. It is this : take the cushions out of the three seats, the backs of which are arranged as first described. Lay a piece of board, small pole or anything that will reach across them at either end for a sup- port. Place the three cushions side by side on these supports, and with one cushion in addition the whole surface will be covered On this bed two persons can lie quite comfortably for even a long distance. Of course varying circumstances will suggest modifications of the methods proposed, but it seems to me a valuable tiling to know that in a dense forest a common railroad car may in a few minutes be made a comfortable means of conveyance for one whose life is well nigh crushed out of him, especially when we remember that the sufferer may be you or me. To recapitulate, we have found our supposed patient on the ground, have lifted him directly upward a few inches, slipped the stretcher un- der him, carried him to the baggage car, and supporting the stretcher either by its leg, or by placing its ends on boxes, or by suspending it with ropes, or better still, we may have carried him through the door of a passenger coach and placed the whole on the double cushions as described, then on arrival at his -destination lie has been carried to the operating table without having once been raised up, and one slight movement places him on the table and another in bed, every step being so conducted as to avoid to the last degree the injury that pain produces, and this branch of my subject is exhausted. But this problem occasionally presents itself in another and really embarrassing form. It may be necessary to move a patient whose legs have been broken, long before recovery is sufficient to permit its use in walking. We will suppose he gets about readily with crutches, but is unable to go up or down a stairway, cannot safely at- tempt even the steps at the tront door. In that case select two men, one of whom is rather tall and the other of less height. Place your patient at the top of the steps, the injured side turned a little forward so that the broken leg will swing clear in the future movements. The tall man taking his place at the side of the injury, the patient puts his arm around his neck, and the shorter man takes his place in like manner on the opposite side, both placing their arms around his waist. The tall man steps down one step when all is ready. The in- jured leg swings clear, and the two men, slightly aided by a springing effort of the patient, easily lift him sideways and plant him on his sound leg one step downward, and thus slowly and steadily, step by step, to the bottom. The same maneuver will take him up stairs, save that in going up the short man takes the advance. This method is en- tirely practical, but a strong-armed, low-back chair may be used satisfac- torily. The patient being seated in it, one man steps in front and takes firm hold of one of the rungs; another seizes the back, and by moving together walk up or down stairs with great ease and safety in either direction, one of the carriers moving backward. The chair lias this further advantage : When it is necessary to place the cripple in a wagon, a light, open-bodied spring being the best, he may be lifted into and out ot it without leaving his seat until his arrival at the station, and in fact by no other means can be so readily got into or oh' the car platform, as by carrying him up and down the steep, long steps by the same method. Either of the methods just described will answer, but the latter is no doubt most generally applicable, and when the dreaded adventure is over an astonished patient will thank you. On Sponge Grafting, by F. L. Matthews, M. D., Springfield 111. Read at the annual meeting of the surgeons of the Wabash, St, Louis and Pacific Railway, Fort Wayne, June 4tli, 1883. I feel assm*ed that, upon the present occasion, it will not be amiss to rehearse some of the many ideas that crowded upon me after read- ing the communication from our acknowledged head, our worthy pre- siding officer, announcing a called meeting of his corps, coupled with an invitation to prepare for the same a paper upon some topic pertain- ing to railroad surgery. In casting about for a subject that might prove of general interest, I finally selected that of the sponge grafting, including some new applications of the method to our common theme— railway surgery. It is interesting to note the mutual dependence of the sciences—how developements in one suggests a new field of research in others. Till miscrocopical investigation revealed the existence of enemies to all open wounds everywhere pervading the atmosphere, we heard nothing ol antiseptic surgery. This thought, traced through the history of the past, reveals the fact that every effort at surgical advancement that neither transgresses or fails to harmonize with natural laws, proves abortive. How shall we account for the absence of pus in the healing of wounds by first intention? Is it not because the material furnished by nature’s process for cementing opposing parts are all conserved, and hence de- bris? This is an instance of nature’s power of recuperation, under favorable circumstances. The province of the surgeon is to intelli- gently interpose in behalf of crippled nature, to supply all deficiencies, as far as may be, and remove all hindrances to her perfect work. To secure a full reward, the gardner is driven to the necessity of constructing trellises to support and protect from destructive influences the tender plant under cultivation. This is one of the important offices filled by the sponge, forming a trellis or scaffold for the support and protection of numberless vascular loops (which investigation proves to be nature’s first restorative effort), these loops making a vivified net-work—every interstice to be filled, every loop surrounded with living plasma, endowed with all the necessary elements of tissue organization. Wherever the skin is lost, the circulation, unrestrained by its binding force, and impelled by the heart’s vis-a-tergo, tends to estab- lish this process, but, unaided, the surface is soon coated with pus, which means destruction of the elements necessary to success. To what extent nature can, or will battle against such difficulties, depends much upon the vigor and constitution of the subject. In excavated wounds, with great loss of tissue, completely surrounded with healthy edges, the filling up process, though lingering, will be accomplished, but with markedly different results than if aided as above mentioned. In such favorable cases the filling up would be expedited, and the character of cicaztritial tissue. Be it remembered, that the subject of the sponge grafting includes not only the application of the antiseptic sponge—the wound being properly prepared,—but such dressings as exclude every noxious influence inimical to the reparative work, insuring the perpetuity of nature’s entire armament, ‘until that forma- tive material has reached the point of organization which secures its safety. This process promises success in recent wounds of fingers, where the bone, having escaped severe injury, is laid bare. Two instances have lately come under my notice, left to the usual careless mode of dressing, in which the bird’s claw appearance, the extreme tenderness and consequent uselessness, make them a source of lasting regret that at the outset they had not been sacrificed. I am sure that, in these cases, had all the material which nature supplied been conserved, those denuded bones might have been so recushioned as to have presented a sightly appearance and proved useful members. While in railway surgery the majority of accidents to hands and fingers are so destructive and crushing as to necessitate the removal of injured parts, the kinds of casualties above cited are not infrequent, and in many instances, where the anticipated danger of septic poison- ing not only warrants but would seem to necessitate removal, such dangers might be avoided through the antiseptic precautions observed as part of this plan, and many members restored and made useful that under the ordinary plans, must have been sacrificed. The sponge, whether applied to. a comparatively recent wound or to an ulcerated surface, disappears by absorption, and the facility with which it is so removed lias led to its adoption. Time has demonstrated,, not only the feasibility, but the success ot skin grafting, but the object of skin grafting, strictly speaking, is to expedite cicatrization upon ex- tensive granulating surfaces ready for that process. Sponge grafting favors the work of proliferation; in other words, encourages granula- tion, and is adapted to excavated ulcers, or to the rapid reproduction of soft parts, where, unaided, nature would fail. The success is due— first, to the mechanical support given to the vascular loops permeating its substance until nature provides the material for perfecting tissue organization; and, secondly, to the protection, both of the antiseptic dressing employed, by which degeneration, and consequent loss of na- ture’s material, is prevented, thus economizing resources and obtaining good results where naught but economy could prevent a failure. For this purpose, the finest surgical sponge is selected and. thor- oughly cleansed—first, by beating out the loose sand, and then washing in pure cold water; then soaking in officinal dilute nitro-hydrochloric acid for two days, which clears it of all sillicious and calcareous salts. The acid is then neutralized, by soaking in a weak solution of liquor potass, and, after washing thoroughly in several relays of pure cold water, is then put into a jar containing a five per cent solution of carbolic acid, and tightly corked. It may be thus kept, and is ready for use after one week. The conditon of the ulcei will determine some- what; the manner of application. Where proliferation, or increase of tissue, is demanded, the amount of sponge necessary will be greater than where cicatrization is the sole object. In the first ease, in evenly distributed support is demanded; in the latter, where granulation is perfected, comparatively little is required. Those who have enjoyed a more extended experience in both skin and sponge grafting, report that when cicatrization is the object a very scattering application is al[ that is required, each producing a center, from which soon springs a perceptible band, that meets a similar one from its neighbor, dividing the surface into' areas, dependent in shape upon their mutual relation. All observers assert that their use is immediately followed by an in- creased activity in the limiting edge. In all cases the surface must be very carefully prepared, the cleansing work so skillfully done as to avoid even wounding the deli- cate capillaries, since blood in the sponge will act as foreign matter and abort the whole process. A two and a half per cent, solution of carbolic acid should be used in this cleansing work—the hands of the operator, the instruments used, and everything likely to come in con- tact with the parts, should be made clean by the same means. The pieces snipped off with scissors from the prepared sponge, to be used in any given case, should be allowed to fall into a two and a half per cent, solution of carbolic acid, and then transferred, with forceps, to their proper position. The pieces to be applied to a granulating sur- face should be small, varying from one-eighth to one-third inch in length. Such sizes I have found best adapted to fill the interspaces evenly. In cases of comparatively recent date, excavated wounds, or loss of soft parts of finger ends, etc., where the reproduction of material is the object, large pieces may be applied, thicker somewhat than the lost tissue. When the bits of sponge have been arranged and covered with a piece of protective, the full Lister antiseptic dressing is then applied and left untouched for several days. On the fourth or fifth day the dressings may be removed for examination, and any grafts that may have failed be replaced and strict antiseptic measures continued. At the first dressing the drafts generally will be found adherent, and the naked eye will discern a faint, white zone, surrounding each, which a one-half or one-fourtli inch glass will resolve into bands of lymph, con- taining minute blood vessels, permeating the meshes of the sponge. The removal of a piece at this stage will be followed by an appreciable hemorrhage. At a later date, if examined microscopically, with a one-fifth or one-eighth inch objective, the interstices of the sponge will be found literally filled by a network of .capillaries, acting as a guide for the necessary material surrounding them on every hand for tissue organization. Still later examination reveals commencing disintegra- tion of the sponge, which, at about the beginning of the fifth week, has entirely disappeared. Compound Lracture of the Lower Lxtremeties, by Willliam Scott, M. D., Professor of the Throat and Respiratory Organs, in the Fort Wayne College of Medicine. Read before the meeting of the Surgeons of the Wabash, St. Louis & Pacific Railway. A compound fracture is an injury that always creates more or less anxiety in the mind of the surgeon. But when the injury has been produced by a railway accident, and the parts are lacerated by having come in contact with heavy timbers, cars, wheels, or any heavy moving body it is certainly to be regarded more serious than an injury produced by an individual falling, and the parts coming in contact with some fixed solid substance, the force no greater than the weight of the body. The difference is as great as that which exists between the latter injury and a simple fracture, or between a subcutaneous, and an open wound. On the former injury we have the shock, as well as the parts lacerated to such an extent that sloughing with all of its accompaning evils is liable to follow. In compound fractures it is the external influences that come in contact with the wound that is one of the elements of danger. In preparing this paper, I have been obliged to notice the doctrines taught by some eminent writers. I have tried to quote their opinions fairly. The great danger of wounds of the character we are discuss- ing has been noticed by the oldest practitioners of surgery. Although the fact has been so long known and admitted by all writers on the subject, until recently no satisfactory explanation of the cause of the danger has been given. An occurrence so frequent and so interesting, as the complications that are liable to arise in com- pound fractures could not fail to attract the attention of pathologists of the highest order, and men whose scientific attainments entitle them to credit. But you find in their productions on violent inflammations of lacerated wounds, Erysipelas, Pyeina, Gangrene, or Septicemia, every surgeon has embraced that which accident prejudice or reflec- tion has inclined him to adopt as his theory. However different the opinions of pathologists and surgeoias have been as to the treatment of lacerated wounds, all the old surgeons agreed that air had an injurious effect when it came in contact with wounds, Sir Charles Bell, Hunter, Albernethy, all of their age, recognized the deleterious effect of air. The generally received opinion then was, that it was the temperature of the atmosphere that excited inflammation, and some one said in support of shat theory, in cases of emphysemia when the air is brought to the temperature of the body before it enters the cavity, we have no such an effect as inflammation, as the temperature of the body is always cansiderably above that of the surrounding at- mosphere. Whenever a direct communication is made between a wound and the external air, a reduction of the temperature must be the consequence, and sudden changes of temperature, they claimed, was a predisposing cause of inflammation. As the old writers maintained in their day that it was the external influences that produced the compli- cations that arise in lacerated wounds, we, their followers, admit. But what are these exciting causes? Late experiments seem to prove that it is not air, as decomposition does not take place in pure air; but it is the organic matter that floats in the air that is giving us the trouble. If the surgeon had the means of magnifying and analyzing the parti- cles of matter that are continuously passing into the wounds that he dresses, he would not be amazed at his cases of septisemia, erysipelas, and pyemia, that follow his practice. The wound not only suffers from mechanical irritation produced by these atoms of dust, but it is the opinion of a large per cent, of the profession that these particles of organic matter carry with them the germ theory of disease as taught by Madagan is that many diseases are due to the presence and propagation in the system of minute organisms having no share in its normal econemy, and the air is the agent by which they originally reach the system. If we can rely on what they teach, we have to admit that certain forms of Micrococi and Bacteri exist in all infectious diseases; and they are certain!) to be found in every case, Maclagan claims, that the Micrococi have different atoms in different diseases; but their physical characters and grouping as well as their local action classifies them sufficiently to constitute them a distinct species, each having a specific action, are producting a special form of disease, whether it be erysip- elas, pyemia, septisema or gangrene. What is there in a compound fracture that makes it more serious than a simple fracture? but the decomposition of the soft parts that are destroyed, and the absorption of the products of the decomposed tissue, which is facilitated by the presence of an open Medullary Canal, be one of the above named complications,—we know that septicimia or pyemia are liable to occur, and we cannot assocate such symptoms with external influences only as the result of the organisms that have been allowed to come in contact with the wounds, producing fermentation, followed by putrifaction, with the absorption into the blood of the septic matter. In erysipelas, we have a disease that is contagious, and results from the reception into the system of a poison from without. In traumatic erysipelas the poison has to be introduced into the wound or blood before it is possible for the complication to arise. The morbid anatomy of the local lesion of erysipelas has been carefully studied by Orth, Lukomsky, and YonKecklinliouser. The result of their obser- uations is to show that the erysipelatious process is invariably asso- ciated with the presence of Micrococi. In the inflamed tissue, and the blood, Orth found that the infiltrated liquid of the swollen parts con- tained an enormous number of bacteria. In hospital gangrene it is hard to conceive how any one that has watched its spread from ward to ward could claim anything else for the disease than that it was organisms carried from wound to wound by the atmosphere; and to arrest the disease we must destroy the germs that are thus conveyed. Every surgeon has drawn off pus from abcesses that was free from putrification was apparantly* healthy, without odor. But at the second dressing the fluid discharged as a rule is not healthy, and we will find active putrifaction going on in the cavity. I am convinced that this decay is caused by minute organisms or particles of matter that were conveyed to the cavity from without. It is a well-known assumption in surgery that a wound made in a healthy person will heal if placed in a favorable position for repair, and not interferred with. When repair does not go on kindly, it is to be presumed that there is something in the nature of the w'onnd, or in the surroundings that is retarding the process of healing. The first step in a compound fracture is to ascertain the extent of the injury. If large vessels and nerves are injured the question. at once arises as to the propriety of trying to save the limb. In fractures involving the knee joint, before antiseptic surgery was introduced and understood by all surgeons, it was considered the safest to amputate. I see one surgeon in the Russian army reports eighteen cases of gun shot wounds of the knee joint treated antiseptically with only three deaths. It is only recently in fractures involving the ankle joint, where there was a direct opening into the joint, that the authors on surgery would sustain us in a conservative course of treatment, but now we are expected save the limb. If we have to amputate, I would operate without delay, avoiding one shock, if possible. If we decide to save the limb, the next step is to cleanse the wound, and there is nothing, in my opinion, equal to hot water. I have been using hot water in all my lacerated wounds since it was introdnced as a dressing, and I am well pleased with it. I cause a continuous stream of water as hot as I can bear my hand in, to be thrown into the wound contin- uing to irigate the parts until all hemorrhage and oosing of blood has ceased, at the same time using a continuous spray of a 2£ per cent, solution of carbolic acid on and about the parts. I think the 20 per cent, solution is good to use if it does not come in direct contact with the wound. Some claim that nothing less will destroy the germs of disease. I think it acts as an iritant, and excites unnecesary suppura- tion of the parts. While the assistant is applying the hot water and using the spray, I would reduce the fracture, and remove all foreign bodies from the wound, shaving and cleansing the surface of the limb; then the wound should be adjusted, bringing the deep parts together, removing all tissue with the scissors that is destroyed to an extent that sloughing is inevitable. Then the wound in the lower extremities should be antiseptically sealed, using the antiseptic lint or cotton to the oiled silk over this dressing, fastening the edges of the surface of the limb with colodion, no drainage nor provision for it necessary at this dressing. As far back as Sir Charles Bell’s writing, he recommended this method of dressing wouuds, not assigning the same reason that we do for the treatment, but he called it a smothering mode of treating wounds, stating in support of his method that he had noticed that wounds healed more kindly under a scab. When nature fails or has not time to furnish the covering, it is now expected of the surgeon. After a compound fracture has been dressed it becomes a question with some as to when it should be redressed, and some of the authori- ties fix a definite time for redressing. Whenever a fractured limb is painful, or the patient complains of the dressing, or that the limb is not resting, or if there is any evidence of hemorrhage or a discharge of any kind, it should be dressed without delay. If I succeed in getting my first dressing well applied, and there is no swelling or evidence of suppuration, I would not disturb until there was some demand for it. At each subsequent dressing, follow up the plan of treatment adapted, applying to the wound stimu- lants, if necessary. I have been well pleased with the rapid repair of tissue under this mode of dressing, and surprised at the small amount of suppuration and sloughing; and the fractures have, with rare excep- tions, united as readily as simple fractures. Immobility so essential to the success of a fracture is best obtained, in my opinion, with a fracture box, hinges to the sides, bran placed for the limb to rest on, and sand bags for compresses, using cotton, wool, or whatever suits best that is soft and warm to keep the foot and limb in proper position. The patient will rest better and be better satisfied if the limb is placed in a swinging position, when it can be done, but we have to treat every case on its own merits, as has been said by some one, generalizing our treatment and individualizing our cases. I have long used the Plaster of Paris splint in the treatment of fractures, and now that Stimpson has adopted a plan by which we can apply the anterior or posterior splint, to suit the wound, and remove and apply at each dressing. I intend going prepared to apply if desirable, carrying the shellac and paraffine as he uses it to protect the splint, and prevent the discharges from saturating it. I have long been con- vinced of the efficacy of quinine in arresting fermentation. In all my cases, before complication aaises, I nave been in the habit of giving quinine in from 3 to -I grain doses, alternated with muriated tincture of iron, in doses suited to the stomach of the patient. A great many will not bear large doses of quinine or iron following and injury. I could report several cases of compound frac- tures successfully treated in this way, in some of which the question was raised as to the propriety of trying to save the limb. One espec- iaily, a railway accident; the subject a man sixty-eight years of age; a compound comminuted fracture of the ankle joint. lie now walks without a cane. But it is unnecessary to report cases to a body of surgeons that have met to discuss principles in surgery. I am not one of those that believe that every case that makes a good recovery enti- tles the surgeon to credit, nor does it establish the merits of a mode of dressing. We have some remarkable cases with very unfavorable treatment, some bad results with the best of treatment. Every sur- geon must have confidence in some particular treatment, and believe in his plan of dressing, then enforce it. While one class claims that air is deleterious, we have such men as Teal, Humphreys, J. Y. Simpson, recommending the air dressing. While James K. Wood was a believer in the micsrocopic organism floating in the air he also believed that their deleterious effect could be sufficiently overcome bv frequent washing with carbolized water. While the different systems are so unlike, and the advocates of each method refer to their clinical experience to prove their success,"it leads to this conclusion, that mod- ern scientists have it it to settle, and the germ theory of disease will finally decide the best method of arresting the complications that arise in lacerated wounds if it succeeds in doing what its advocates claim for it. Lacerated Woands of the Extremities Requiring Amputation, by ¥m. T. Beadles, M. D., of Bushnell, 111. Read before tlie meet- ing of the Wabash, St. Louis & Pacific Railroad Surgeons, at Fort Wayne, June 4th, 1883. Mr. President and Gentlemen of this Society:—I was requested sometime since to select a subject on railroad injuries, to be presented to you on this occasion, in as tangible a form as my experienee and time would permit. The subject selected is one of vital importance to the victims, those who are so unfortunate as to meet with such an accident, and to make it more unfortunate they are usually the result of their own careless- ness, and as well as of great interest to the surgeon in their manage- ment—it is that of lacerated wounds of the extremities requiring ampu- tation. The rapid progress of civilization and development of this vast area of country, through the construction of the immense system of rail- roads during the past twenty-five years, brought with it a degree of carelessness and recklessness, that has been the means of many being crippled, as well as great loss of life. A class of injuries unknown to surgeons of thirty to forty years ago are now so common as to furnish those of the present day with many examples of compoun commin- uted fractures of the most grave and serious character. These injuries, as well as those resulting from other machinery, as mills, threshing machines, cotton gins, or crushers of tile factoriers, are the result of the direct application of force to the limb in such a manner as to pro- duce extensive contusions, lacerations and extravasations of the neigh- boring parts, as well as lacerations or crushing of the parts at the seat of injury; therefore, it is not uncommon in the amputation of such injuries to have more or less sloughing of the stump, unless amputation is delayed until reaction has taken place sufficiently to establish a line of demarcation between the healthy and unhealthy structures, but to delay the opeartion beyond the time, when reaction has finally taken place, is questionable. While it may be the opinion of some surgeons to delay amputating until positively known wherebest to perform the operation to secure sound flaps, it appears in my judgment to be of doubtful propriety, so much so that it has been customary with me to amputate as soon as the condition of the patient will permit, and suffi- ciently far from the seat of the injury as will secure a healthy circula- tion in the flaps, when it is possible to do so, as it is often the lacera- tion is so extensive that the amputation has to be performed at or near the proximal end of the extremity, and then not able to procure sound flaps, as when the arm is lacearted or crushed above the elbow, the deltoid and pectoral muscles are drawn, and causing them to slough, and the same resulting from lacerations of the lower extremities above the knee. They often become exceedingly troublesome, requiring very close and long-cOntinued attention before they slough out and heal up. To anyone not familiar and experienced in such cases they become extremely irksome, especially in those cases where the system has been poisoned from the effects of dissipation, more especially in- toxicants. While it is much more agreeable to the surgeon to treat cases of amputation where the flaps are sound in healthy patients, but the ordeal comes in those who have contaminated blood and contused flaps. Patients are not made to suit the surgeon, nor can he have a choice in the constitutions they may occur in, but has to take them and do the best he can as they are presented to him. The constitution, as well as general physical condition of the patient, has much to do as to the result or prognosis in these injuries. While the most favorable results are found in healthy or unimpaired constitutions, the reverse is the case in the impaired or contaminated constitutions; hence, the sur- geon should be guarded in his prognosis. The shock produced in many of these accidents results in extreme prostration, especially when complicated with internal injuries, as con- tusing organs of the chest, or bowels, or concussion of the spinal cord or brain, that are usually more dangerous to life than’the mutilated limb, therefore the amputation should be delayed until reaction is com- pletely established. These precautions are obvious, that death may not occur in the midst of an operation or amputation, when no prospect of reaction ever coming on, rendering the amputation unnec- essary, as well as placing the surgeon in an unpleasant situation when uncalled for. Reaction seldom takes place rapidly, if at all, when one or more limbs are badly crushed very high up, especially if compli- cated with an internal injury. Occasionally a man receives an injury who has great tenacity of life, a nervous system that tolerates serious injuries, and most any operation, and then repeatedly, as it was dur- ing the late war, when now and then a man recovered from amputation of both legs above the knee at one time. A rather interesting patient was brought to me for an amputation above the knee, August 20th, 1882, by the name of William Russell, who met with a serious acci- dent while endeavoring to get into a box car, as the train was moving, throwing his right leg under the wheel of the car, crushing it to the knee, requiring it to be amputated. He had a mania for stealing his transportation on the cars from his boyhood days; therefore he had met with several serious accidents previously, which resulted in the loss of his left arm at the shoulder, when about fourteen years old, and the left leg above the knee at the age of seventeen, and the last accident when twenty-two years of age, and the last time I heard of him, which was only a few months ago, he had performed an opera- tion on himself, just below the chin and both ears, the result of which I have not heard, but presume he got well as he did in all former op- erations. As to the different kinds of amputations, the operator may select the circular, or oval, or Hap, or posterior flap, and anterior circular or oval, or the reverse, as in Teal’s method, as in his judgment appears to be the most suitable. As to preference, it is apparent the location has much to do with it. Above the ankle or wrist, or above the elbow, except at the shoulder, the circular or oval, and below the'knee or mid- die of the leg, a posterior flap and anterior circular or oval, or the re- verse anterior flap and posterior circular or oval, and above the knee and at the shoulder the flap or oval method. Yet