dition had any connection in any way with the operation, which simply served the purpose of removing the pressure symptoms, and I mention it so that it may be remembered, and possibly there may be a better explanation than I, at this moment, feel prepared to offer.

DR. EWING. As I was interested in this case you speak of, I will say that at the last examination of urine we discovered albumen, and she lay perfectly unconscious all this time, having a spasm about every ten or fifteen minutes. ten or fifteen minutes. We thought, perhaps, we might relieve the patient by producing abortion, which we did. There was no hemorrhage to amount to anything, and she grew a great deal better. The convulsions ceased and she partially regained consciousness, but never fully, and as the doctor states, she died forty-eight hours later.

DR. FAIRCHILD. I am very much gratified at the discussion which has followed this paper. I was induced to present it on account of the feeling I have that many cases of this kind are not allowed to go along in a physiological way. I have nothing else to offer, as the paper expressed my views on the subject as well as I was able to present them, and therefore, I will not occupy more of your time.

REMARKS ON THE PANCREAS.

By BYRON ROBINSON.

Chicago, Illinois.

Extensive work is being done experimentally, pathologically and chemically in the field of pancreatic diseases. To one famil iar with the anatomy of the pancreas, and performing frequently post mortems, many of the current journal articles are superficial and misleading, because the writers are deficient in knowledge. The eyes of the medical world are now directed toward the pancreas. The pancreas began to be of some use to physician and patient when Moritz Hofman, of Altdorf, Germany demonstrated to John George Wirsung, of Padua, Italy, in 1642 that a rooster's pancreas had an exit duct. In 1643 John George Wirsung demonstrated that the pancreas of animals and man possessed an exit

duct, and he drew a picture of it, sending it to the Paris Academy through John Riolan. his old anatomic teacher.

For 260 years the pancreas has had a varied history in medicine. Fifty years ago Claude Bernard, of Paris, wrote the most notable monograph on the pancreas. Since that time the notable contributors to the literature of the pancreas have been from Nichalos Senn, Fitz, Balser, Minkowski, von Mehring, Robson, Opie and others. Recently the most significant contributors, to our knowledge of the pancreas, were von Mehring and Minkowski, whose experiments demonstrated that the extirpation of a dog's pancreas was followed by sugar in the urine-diabetes mellitus. Lately many contributions are being made to the literature of the pancreas, notably that of Opie, Lazarus and Koerter. By inspecting the pancreas in autopsy one is at once convinced of the difficulty, not only of diagnosing any disease which may attack it, but also of the almost insurmountable anatomic factors in surgical intervention. Physiologically its own secretion may induce digestion of its own tissue-fat necrosis. When one considers what are the common diseases of the pancreas it becomes more evident that the diagnosis is frequently impossible medically or surgically.

The pancreas experiences; (a), hæmorrhagic pancreatitis; (b), suppurative pancreatitis: (c), necrotic pancreatitis; (d), pancreolithiasis; (e), pancreatitis cystica. It is difficult in ordinary subjects with pancreatic diseases to make a diagnosis of the exact pathologic condition with the pancreas in the hand and before the eyes. I have inspected in autopsy over 500 pancreases and can say from this experience that gross, palpable pancreatic lesions, with the exception of pancreatitis chronica-a common occurrence in the caput-are, like duodenal ulcers, rare. Half a dozen years ago Korter and Olser mentioned the frequent relation of hepatic calculus to pancreatic disease. I present two typical subjects with this article. The diseases of the pancreas met in the intra-abdominal exploration as fat necrosis, hæmorrhagic pancreatitis are difficult of disposition. The surgeon can simply institute drainage. To illustrate the difficulty of diagnosing pancreatic disease within 1904, I listened to four surgeons narrate their experiences. Two cases were diagnosed as disease of the pancreas. On exploratory incision the surgeon could not diagnose the condition with eyes and fingers on the pancreas-he said one case had tubercle in the region of the pancreas, the other case was reported as simply a

dark colored pancreas. The third case was diagnosed as grave pancreatic disease, an on abdominal incision no disease of any kind could be observed in the pancreas. The fourth case was gravely ill for four to five days and died. Post mortem showed hæmorrhagic and suppurative pancreatitis, which was not diagnosed by a surgeon of more than local fame. Much more study is required

III

FIGURE 1

to make a diagnosis of pancreatic disease and to make surgery of value in the field of the pancreas. We must be able to recognize some of the diseases of the pancreas after the abdomen is opened.

Figure 1. (Byron Robinson) An X-ray of part of the ductus bilis and ductus pancreaticus of a girl eleven years old. I to II,

ductus choledochus communis. II to III ductus hepaticus. II, to IV, ductus cysticus. c, cholecyst. It is very easy to observe the segments of the pancreas, viz:-caput, collum, corpus, cauda. In fact, this beautiful accurate illustration establishes the final anatomy. Sa, ductus Santorini functionated as the celloidin projected

from its exit duct during the injecting of it. Hofman-Wirsung duct. The liver of this patient was advanced in sarcomatous disease, but the pancreas appeared healthy. P, ductus pancreaticus. The liver and pancreatic ducts were injected with red lead, mixed with starch before the X-ray was taken. The intra-pancreatic portion of the choledochus in its natural position.

FIGURE 3.