delayed." Yet we all know, at least I know, that cases operated on as early as possible after diagnosis is made, and by experts claiming, and justly so, high skill and success in such work, do die. On the other hand, we all know, at least I know, that not more than one-third of all the cases of appendicitis occurring in this country are operated on. This is true even now after we have worked surgical enthusiasm to the highest pitch, such results having been obtained. And yet, the mortality from unoperated appendicitis cases is not high. It must be understood that my remarks apply to the whole field. In not one-half of the children attacked is there a recurrence. In many cases the diagnosis is colic. But this is not general. In country practice, especially with children, the patient is put to bed, hot or cold, as case may be, applied over the seat of pain, or tumefaction, all food withheld, full doses of tincture of veratrum administered and continued. If the pain is intolerable, opiates by rectum or by the mouth, or hypodermically, are given. In many of these cases the disease is cut short; in others typhilitis or perityphilitis supervenes. In such cases the external tumefaction continues often for many days, but recovery without, and sometimes with, suppuration follows. Now the reliable statistic facts are not at hand to warrant wholesale condemnation of the country practician who has, in many instances, so treated these cases. Even should an occasional unoperated case of this class die, as will occur, the death cannot be charged to the family physician until the time comes, for it is not yet true that every such case operated on by skilled hands recovers. Unquestionably a certain proportion of the cases operated on that die would have recovered under the plans of medical treatment indicated without operation. Per contra, some cases not operated on that die could be saved by operation. Let us not be so boastfully dogmatic. As to the question of operating in desperate cases, I have no sympathy with the remark made tonight that the surgeon should decline to operate, when to do so jeopardizes his reputation. No man has a right to shirk duty. The highest interests of the patient are paramount to all other obligations.

Dr Geo. W. Crile, Cleveland, closing: I do not wonder that Dr Reamy did not understand under what conditions I would operate on children because I omitted a page in my paper which probably explains my views on this subject.

I think that Dr Reamy's experience is a little bit different from that of many others because his experience has largely been with children. Appendicitis occurs much more frequently in adults and young adults than in children. The point however to be considered is operation at the beginning of the attack while the inflammation is limited to the appendix itself. This I consider to be a conservative measure. If I myself had an attack of appendicitis I would prefer to be operated upon within an hour or two after the beginning of the attack, removing the appendix as a conservative measure. I have seen some very bad attacks of appendicitis in children, and I think if you can remove the appendix in these cases before the acute symptoms develop, as a conservative measure, the operation ought to be done. It is a question as to how you can best save the greatest number of lives.

From the general trend of the discussion I think perhaps that I have been a little bit misunderstood. I would not operate upon every case in which a diagnosis of appendicitis had been made. I do not mean to say however that I would hesitate to take the responsibility of an operation where the case was very bad. There are many things to be considered in connection with an operation for appendicitis, a patient's surroundings, whether he can be moved, whether he can afford a nurse, etc. Take a patient in an acute attack, say 36 hours to 48 hours after the onset, with the abdomen distended, etc., I think it better to treat such cases through the attack, but as to taking the responsibility of an operation when necessary I think we ought always to be willing to take that.

Dr Sager has spoken of patients recovering by medical treatment even after many weeks of illness. These cases do not argue against an operation, but rather for it. I myself would much prefer to perform an operation immediately, at the beginning of an attack, and let the patient out with the slight degree of danger than to wait and finally have a perforation through the bowel and a convalescence extending over many weeks or months.

Diagnosis and Treatment of Injuries to the Spine BY W. J. MEANS, A. M., M. D., COLUMBUS

Professor of Principles and Practice of Surgery, Ohio Medical University; Chief Surgeon, Protestant Hospital; Chief

Surgeon C. S. & H. R. R.; Member A. M. A.

The spinal column and cord are exposed to many kinds of injuries that may be immediate or remote in their effects. Through the massive bodies of the vertebra the spinal column forms a pillar or axis for the support of the rest of the body. Its flexibility and strength are maintained by the peculiar conformation of the vertebra, and the attachment of numerous powerful ligaments and muscles. Another important function is the protection of the spinal cord and safe exits for the spinal nerves. These considerations, however, are matters of anatomy, so well established and known that any detailed description would be superfluous in this paper.

Owing to anatomic conditions, certain portions of the spine are more subject to injury than others. The dorsilumbar and the cervicodorsal arches are more subject to sprains as they are less flexible than other portions. Owing to the close proximity of the head, the cervical region is a frequent point of injury. The upper part of the dorsal curve is relatively weak and exposed, and is, therefore, one of the commoner regions for fractures.

Injuries may be divided for clinical purposes into two classes, one in which the lesion is confined to the spinal column involving only the bony and soft tissues, and the other in which the spinal cord is involved as well. In making a diagnosis of an injury great care must be exercised in determining the location, character, and extent of the lesion. It happens sometimes that apparently trivial injuries at the start prove to be serious ones later.

I have selected a number of cases that have come under my care in the last four years, that illustrate the various forms of injury with resulting complications.

Case I: The patient, a female, aged 25, housewife by occupation, in moderate circumstances, was hurt in a railroad wreck June 10, 1898. At the time of the accident she did not complain of being hurt, but after the excitement had worn off she found that her neck was stiff, and that any movement of the head was quite painful. An examination 48 hours after the accident found the patient vomiting, and complaining of pain in her neck, head, and arms. She was nervous and unable to sleep. The objective signs were slight swelling and tenderness over the sixth and seventh cervical and eighth dorsal vertebra. There was considerable rigidity of the muscles of the back, neck, and shoulders, there was no discoloration or deformity. She complained of tingling in her hands and arms. There was partial paralysis of sensation and motion in both arms; there were no paraplegic symptoms. The patient continued to grow more hysterical, and the local symptoms became more pronounced. In the course of four weeks there was a subsidence of the gastric disturbances, but the insomnia continued. Motion and sensation in the arms gradually improved. She continued to improve slowly for several weeks, when a damage suit was started against the railroad company. She then lapsed into a nervous state with both neurasthenic and hysteric manifestations. On February 17, about eight months after the accident, the patient was troubled with insomnia, neuralgic pains over the left side of the neck and face, and the left shoulder, arm, and side. There was marked paralysis of the left arm, both in motion and sensation. The arm was considerably atrophied. There were no trophic changes, however, in the hand and fingers, the atrophy being due to lack of use. She had occasional attacks of dysphagia. An examination of the vertebra was negative so far as any lesion could be discovered. The patient complained of tender places in different portions of the back. I advised the railroad company to make a settlement with her, which was done. After the settlement she began to improve, and is now fully restored to her former health.

Diagnosis: Primarily, a sprain of the spine in the lower cervical and upper dorsal region; secondarily, traumatic hysteria.

The treatment of this case in the acute stage, was the usual one for sprains of the spine; cold applications in the beginning over the injured parts, and cupping were em

ployed, and later applications of hot water, stimulating liniments, ichthiol, and lanolin ointments were used.

Case II: The patient, a female, aged 32, married, mother of three children, in moderate circumstances, was hurt July 4, 1900, while on a street-car, in a rear-end collision. The jar threw her backward, causing over-extension of the spine at the dorsilumbar region. She was unable to go to her home without aid. A physician saw her two days later. She was then suffering from inability to move her legs, or to turn in bed. There was tingling and numbness over the anterior portion of the thighs and in the feet, and retention of urine; her temperature was 101°, and a frequent pulse; there was some swelling over the dorsilumbar vertebra, and considerable tenderness. I saw her in consultation 10 days later. There was considerable numbness over the lower portion of the body, and over the extremities, muscular weakness, inability to turn in bed, constipation, and retention of urine. With considerable exertion she was able to flex her legs; no deformity could be found along the spine. The patella reflexes were increased. The case was diagnosed as a sprain in the dorsilumbar region. This patient was bedfast for some weeks, when she regained her health sufficiently to get about the house. A suit was instituted against the railroad company, during the pending of which the patient continued to suffer more or less inconvenience. I examined her at repeated intervals during the next four or five months. There was diminished sensation over the hips and around the body in a line with the crest of the ilium. There were patches of anesthesia, and some points where the sensation increased. She was unable to assume an upright position. She complained of an irritable bladder, and constipation of the bowels, and was unable to make the least exertion toward her household duties. She became a marked neurasthenic with more or less hysteria. After the damage suit was settled she began to improve and at the present time suffers no inconvenience from the injury.

Diagnosis: Primarily, a sprain of the spine in dorsilumbar region; secondarily, traumatic neurasthenia and hysteria. The treatment consisted primarily of applications to the spine, rest, and massage.

Case III: The patient, a male, aged 70, a mail clerk, in good circumstances, and social environments above the aver