gas, oxygen and ether, when the gases are used until the incision is made and after the suturing is begun, and the ether provides complete relaxation and freedom from cyanosis during the operation proper. The contraindications are chronic alcoholism and well-marked arteriosclerosis or cardiac lesions.

Original Research Regarding Human Perspiration.— J. H. Hoelscher describes his method of procuring normal sweat without loss by evaporation and as free as possible from skin impurities, and then describes the peculiarities of the sweat following the exhibition of various remedies. From his experiments, he draws the following general conclusions: First, the hot-air bath causes an aseptic fever despite the antipyretic action of acetanilid, sodium salicylate and quinine, given with the bath; second, the hot-air bath given in uræmic states shows a sweat with increased urea and nitrogen; third, in articular rheumatism, in conjunction with the salicylates, the hot-air bath gives more rapid results and lessens cinchonism; fourth, certain types of myocarditis are benefited by the hot-air bath; fifth, pilocarpine should never be used without the aid of hot applications to the body. So combined, there is no sialagogue and less toxic drug effect, and far more sweating than otherwise; sixth, three cases of catarrhal jaundice were sweated; all the modern tests failed to disclose the presence of bile pigments in the sweat; only the epithelial débris containing bile deposits; seventh, modern sugar tests failed to reveal the presence of sugar in sweat obtained from diabetics; eighth, a case of chronic constipation and indicanuria did not diclose the presence of indol or skatol in the Sweat: ninth, regarding the function of eliminating normal and abnormal substances, the skin is not to be compared with the kidneys; tenth, free sweating seems to affect favorably the course of psoriasis. This statement, however, needs to be sustained by more research. Equally so, the effect on other skin diseases. Lastly, 1,000 c.c. of sweat contain about eleven and one-half grams of solids (nearly three drachms), one-half norganic and one-half organic; about six decigrams nine grains) of urea; and about .47 centigram (eight grains) of nitrogen.

American Medicine, February 13, 1904. Facial Paralysis.-Norton L. Wilson enumerates various etiological factors possible in relation to facial paralysis. The diagnosis or location of the lesion is important, as the Prognosis depends upon its location. As to treatment, electricity should not be applied until the end of the third eek, except to ascertain the excitability of the muscles. Then electricity and massage should be used regularly and systematically. If the muscles respond to faradism, that current should be used. If they do not respond to the induced current, galvanism should be used, but only with the galvanometer. Flannel wrung out of hot water or the ht-water bag does something by relieving the stiffness and dilating the vessels for the first few days. The ear and eye should receive the proper attention. Internal medication is of little or no value.

Myxoneurosis Intestinalis Membranacea.-C. A. Ewald states that there are a great many reasons why myxoeurosis is of a nervous nature. The cases are most frerent in women, and are often accompanied by some genital disturbance, coming especially during the climacteric and disappearing when this period is passed. Diet plays 4 very important part in the treatment. Specially efficacias when simple constipation accompanies the myxoreurosis are the coarse breads; fats, as butter, cream, salads with oil; fatty sauces, gravies; coarse vegetables of the cabbage family; curded milk with plenty of sugar; frut juices, figs, syrup, jams, prunes, stewed fruits, and fresh vegetables of all kinds. In the cases not complicated by constipation the results of diabetic treatment are not marked. Through better nourishment, however, the hysteria and neurasthenia are directly benefited.

The Prevention and Treatment of Puerperal Infection. -Richard C. Norris declares that autoinfection is a term ady to be employed, and usually should be reserved for the one who wishes a cloak for his ignorance. The prevention of puerperal infection guided by the most recent results of bacteriology requires a study of three important details of technique: (1) The antepartum toilet of the patent; (2) hand sterilization and the dangers of vaginal examination; (3) the immediate repair of injuries to the arth canal. The writer says that antiseptic vaginal douches are unnecessary, and may be detrimental in nor

mal cases.

The use of sterilized rubber gloves is most aluable. The antiseptic solutions should always be ade with boiled water. All instruments should be biled before they are used. Careful inspection should bemade of the vaginal mucous membrane from cervix to Fulva. It must be remembered that the upper part of the parturient canal is more susceptible to infection. After

an early diagnosis of infection has been made, the infected area, usually within the uterus, should be inspected by the finger to determine if possible whether we have to deal with putrid absorption from decomposing débris or the smooth endometrium of septic infection. The appropriate cases for curettage are those in which the uterus contains débris. The writer believes the best results to follow the use of a sharp curette. When the endometrium is smooth, there is no need for scraping. Following curettage, the question of the douche is under discussion at the present time. For putrid endometritus a disinfecting douche is indicated, according to the writer. Strong antiseptics are not only useless but dangerous. Salpingitis that progresses to abscess formation requires evacuation and drainage. Injured or infected ovarian or uterine tumors should be removed after labor. Hysterectomy for puerperal infection is by no means a settled question. Ligation or excision of the uterine or spermatic veins when they are the seat of thrombosis with pyæmic symptoms is the latest attempt to reach by surgery a very dangerous type of puerperal infection. The gravest forms of puerperal infection can very often be prevented by the early recognition of beginning infection and the prompt

resort to the well-tried methods of treatment.

He

British Medical Journal, January 30, 1904. Infection in Acute Rheumatism.-W. P. Le Feuvre recalls several cases which suggest infection in acute rheumatism. One patient was a railway guard. He used the same room and bed alternately with a fellow-guard. had scarcely recovered from an attack of acute rheumatism before his room-mate was for the first time in his life similarly attacked. In the latter case there was no trace in personal or family history of any rheumatic taint. There was nothing in the position or neighborhood of the guards' quarters to suggest a cause for the attack. Another case is mentioned of a mother who came to nurse her daughter during an attack, and suffered similarly after about a week's interval. The writer says he has noted two or three similar cases.

Vasectomy for Enlarged Prostate.-Thos. Alph. Buck reports the history of an interesting case. The patient was of fat and flabby physique, aged fifty-eight and married. He was very regular in all his habits. He exhibited symptoms of enlarged prostate. Micturition was frequent both day and night. At times there was almost absolute retention, urine being voided only by drops and with extreme pain and violent strain. The prostate was uniformly enlarged like a medium-sized apple. The condition of the patient was one of chronic invalidism. No catheter could ever be passed, even under chloroform, though there was no stricture of the urethra, or spasm or pain on attempting to do so. The patient insisted upon operation. About one inch was excised from the right vas deferens. The patient experienced no discomfort and was up and about in six days. From this time he has had no difficulty in micturition or occasion to seek medical aid.

Notes on Myiasis.-P. S. Lelean in speaking of flies says that, of more recent years, perhaps the most curious biological contribution is that of Dr. Folker of Guatemala on the gusano worm. He describes the ovulation of this mosquito-like fly. After piercing its proboscis into the skin, it passes the "tail" along it as along a director, and deposits a full charge of ova into the cavity. A boil ensues in three days. From a pathological standpoint, Bruce's recent demonstration of the role of Glossinapalpalis in sleeping sickness stands alone in importance. As to treatment, the natives occlude the orifice of the cavity in which the larva is contained by a piece of stamp paper; the airbreathing parasite, being thus asphyxiated, can be expressed. The aperture is covered with a tobacco-leaf, the nicotine poisoning the grub. Folker uses a hypodermic of chloroform, which so paralyzes the larvæ that he has by this means expressed as many as fourteen in less than two minutes, a velocity which commands respect. The Dermatobia noxialis (screw worm) is killed in the frontal sinus by carbolic injections of a two-per-cent. solution. In the auditory meatus the larvæ often cause so much tenderness as to make mechanical extraction impossible. A little calomel blown into the meatus is said to cause their death and spontaneous extension. In India it has been found that maggots ingested in mangoes are most difficult to dislodge, a fact not to be wondered at when they survived five minutes' immersion in pure carbolic acid. One patient passed from 50 to 110 larvæ daily for twelve months, and greatly feared their eating through the intestine. One case was cured by enemata terebinthina; another was on buteafrondosa, and in a thirdparasiticides having no effect-scybala were produced by opium, and the embedded maggots came away by subsequent use of purgatives and enemata. Finally, in huts infected by diptera, if cones of dried pyrethrum powder

be burnt, the flies fall stupefied to the floor, whence they can be collected and burnt.

Berliner klinische Wochenschrift, January 25, 1904. Syphilis and Tabes.-Erb reviews the pros and cons of the syphilogenic theory of tabes, and reasserts his former views on the subject. The only conclusion that can be drawn from the accumulated statistics is, he thinks, that tabes stands in close relationship to syphilis, and, in most cases, originates solely in consequence of a preliminary syphilitic infection. The question, however, of whether this is its exclusive etiology, and whether every single case of the disease has its origin in a former syphilis, cannot yet be answered in the affirmative, though this is probably the

case.

The Active Immunization of Man against the Typhoid Bacillus. Shiga made observations on the agglutinating and bactericidal powers of his own blood serum and that of a colleague after immunization with free receptors. This was done by injecting the product obtained by mixing a one-day agar culture with 5 c.c. of sterile physiological salt solution, heating for one hour at 60°, keeping at 37° for two days, and filtering through a Reichel bougie. The filtrate was tested to determine the absence of germs. Small amounts (0.05 to 0.5 c.c.) were injected and produced practically no local or general effects. Eight days afer the last injection, agglutination was produced by the author's serum in a dilution of 1 to 640 and in that of the other subject in a dilution of 1 to 80. The difference is referred to the fact that the author had suffered an attack of typhoid fever twelve years previously; preliminary control tests had, however, been negative. The bactericidal

value of the sera was also tested and found to be well marked.

The Etiology and Pathology of Tabes, Especially Its Relation to Syphilis.-Lesser seeks to reconcile the various objections that have been brought against the theory of the syphilitic origin of tabes, and the views of the adherents of this doctrine, by considering tabes as belonging to a third class of syphilitic lesions. The group ordinarily considered as secondary lesions comprises the papular manifestations which are found almost exclusively in the skin and mucous membranes, occur in the first few years of the disease, are susceptible to treatment by mercury, and are infiltrations. The tertiary or gummatous lesions are found in all regions, are chronic, and found mostly in the later years of the disease, and are susceptible to treatment with iodides. Under the heading of quaternary lesions, the author would establish a class in which interstitial inflammations of a proliferative nature occur and attack the inner organs many years after the initial infection. These are resistant both to mercury and the iodides, and comprise such lesions as tabes, syphilitic contracture of the liver, smooth atrophy of the tongue, etc. By adopting this class of quaternary lesions, the author is able to take up in detail and refute all the objections of the opponents of the syphilogenic theory, and the conclusion he reaches is that most cases are due to the specific infection. Aneurysm occupies much the same relation to syphilis as tabes, and is also comprised in this class of quaternary lesions. Münchener medizinische Wochenschrift, January 19, 1904. Eosinophile Cells in Sputum. - Hildebrandt marizes the conclusions of various writers on the occurrence and significance of eosinophile cells in the sputum. These are very contradictory, but agree in assigning more or less importance to the presence of these cells. The author made observations on a variety of cases, in- cluding asthma, acute and chronic pulmonary tuberculosis, acute bronchitis, lobar pneumonia, etc., and found that the cells were present in each in sufficient numbers to render futile all attempts at establishing diagnostic rules. In particular, the presence of eosinophile cells in the sputum is not characteristic of bronchial asthma, nor is it evidence against the existence of pulmonary tuberculosis, as some authorities claim.

sum

Observations on the Diazo-reaction, Koplik's Spots, and the Temperature in Measles.-Müller observed these features in an epidemic of measles in Marburg, in which two hundred and fifteen cases were treated in the polyclinic. The diazo-reaction was found present in nearly all cases at the acme of the disease, but usually it appears only with the eruption, and is therefore not an early symptom. Koplik's spots are a valuable early symptom since they frequently appear on the first day and are found in at least 80 per cent. of the cases. They are not pathognomonic of measles, however, since they were repeatedly observed in röteln also. In most uncomplicated cases the temperature follows the classical course, exhibiting a short, sharp rise in the catarrhal stage followed by an intermission of one to two days and then remaining high for about four days, finally falling by crisis. Types described by Jürgensen were also seen,

viz., a gradual remittent rise or a sudden sharp rise re maining continuously high.

Serious Consequences of Deep Cervical Incisions in Labor.-Hofmeier describes two cases in which thi method of facilitating delivery, first advocated by Dührssen, had very serious results. In the first case the incisions were made by another obstetrician thre years previously. When the patient came under the author's treatment it was found that the cervical cana from its middle upward was the seat of a firm cica tricial stenosis. As no advance in dilatation was mad after the patient had been having severe pains all night a careful instrumental dilatation of the cervix was done and the child perforated and extracted. In the othe case the author himself, in 1897, incised the cervix, owing to its unyielding nature. The incision was very slight but furious bleeding was set up which could be checked only after a rapid instrumental delivery had made the parts accessible. Two subsequent deliveries were une ventful, but the fourth was protracted, and owing to the rigid scar tissue the cervix and lower uterine zone wer ruptured by the advancing head, and the resulting hemorrhage cost the patient her life. If incisions mus be made the author recommends that they shall b antero-posterior and not placed laterally.

French and Italian Journals.

Suture of the Heart.-Georges Renon thinks that all wounds of the pectoral region with considerable hemor rhage, either external or internal, should make one think of an injury to the heart and require immediate surgical intervention. This should be carried out aseptically and as rapidly as possible, suturing the wound round the finger. Drainage is not called for. Venous injections or large subcutaneous injections are to be avoided. The case reported was in a man of twenty-three years with a stab wound in the chest made by a large pocket-knife. Before the operation of closing the wound he was considerably exsanguinated by the profuse hemorrhage. The wound was exposed by a transverse cut and many clots were found and removed. A violent hemorrhage followed which was only partially controlled by inserting the finger into the wound in the heart. The muscle was quickly sutured and drawn together, completely stopping the leakage, and the pericardium was emptied and sewn up leaving a small drain. By this time the patient was nearly collapsed, and transfusion was done. The condition of the wound continued good all except a great flow of serum from the pericardium. The patient died the next night At the autopsy it was seen that the suture had held perfectly and there had been no leakage into the peri cardium. The wound, which at the time of operation was thought to be at the base, was found at the apex of the lef ventricle.-La Tribune Médicale, January 16, 1904.

The Treatment of Uncomplicated Goiter with Intra glandular Injection of Iodized Oil.-Dubar thinks loca treatment as practised by rhinologists and ophthalmolo gists for combating infection is suggestive of possible good results if applied to other parts of the body. The cases o goiter he cites sustain his expectations. He thinks tha if there is a local need of a certain substance it may b useless or even dangerous to place it in some other part The oil used contained 40 per cent. iodine and the dos averaged 5 c.c. per day for ten days. In one of the author cases after injecting one c.c. in weekly injections for nin times, the goiter had shrunk from 34 to 32 cm. In th second case after six similar injections the goiter shran from 38 to 35.5 cm. Four injections more reduced it t He noted an absence of reaction after the in 34.5 cm. jection, which made him think that in the oil the iodin formed a true chemical compound. The author admi that he had noticed nodes after the injections of iodize oil, but says that these nodes were always reabsorbed.Le Progrès Médical, January 23, 1904.

Grocco's Paravertebral Triangle.-C. Baduel and I Siciliano state that under normal conditions percussio of the vertebral column shows good resonance as far dow as the base of the lungs. This resonance is impaire by the presence of fluid in either pleural cavity. Th triangle of Grocco is the triangular area of dulne in the neighborhood of an effusion. This triangle is very important symptom in the differential diagnos between pleuritic effusion and pulmonic consolidatio and to a lesser degree between pleuritis with effusio and without. The triangular dulness begins at abo the same height as the upper edge of the fluid, whi in the other two affections there is a margin_of_th affected area which does not give this sign. But th peculiar feature is that in the pleuritic effusion th triangular dulness is found on the opposite side of th vertebræ to that of the fluid.-Rivista Critica di Clini Medica, January 16, 1904.

Society Reports.

NEW YORK ACADEMY OF MEDICINE. Stated Meeting, Held February 4, 1904. ANDREW H. SMITH, M.D., President. Action on Proposed Amendments to Constitution and By-Laws. It was moved and carried that the number of Fellows elected as such shall not exceed one thousand, and at least three-fourths of this number shall be residents of the City of New York. It was also moved and carried that the library should be open to the public from 9.30 A.M. to I P.M. and to members of the Academy from 9.30 A.M. to 10.30 P.M. Books can now be taken out by members only when for their personal use.

Lesions Peculiar to the Pancreas and Their Clinical Aspect.-Dr. EUGENE L. OPIE of Baltimore read this paper. He said that to the clinician the characteristic feature of pancreatic disease was doubtless the obscurity of its symptoms. Sometimes extensive destructive changes were unaccompanied by recognizable symptoms. Recognition of pancreatic disease was further complicated by the fact that lesions of that gland were seldom primary but were dependent upon changes in other organs, notably in the duodenum, liver, or bile passages. He said that an understanding of the peculiar pathology of the panereas and of its relation to that of other organs was therefore essential to the diagnosis of pancreatic disease. He divided diseases of the pancreas into the following two groups: first, those that effect the secreting apparatus of of the gland and, second, those which had their seat in the islands of Langerhans and interfered with the influence which those structures exerted on carbohydrate metabolism. He then mentioned some recently demonstrated facts which concerned the physiology of the pancreatic juice, the so-called external secretion of the organ, although their bearing upon clinical medicine and upon pathology might not as yet be evident, they serve to show the complexity of the pancreatic functions. The activity of the pancreatic juice was in considerable part dependent upon the secretions with which it came into contact after it had entered the intestine. He next considered the effects of pancreatic juice when it was diverted from its proper channels into the tissues about the organ, causing the characteristic lesion, but since it was usually confined to the adipose tissue of the abdominal cavity its diagnostic importance was only made manifest when the surgeon opened the abdomen. He referred to fat necrosis, which occurred only in association with disease of the pancreas. Circumscribed opaque white foci of necrosis were conspicuous upon the translucent yellow fat of the omentum, of the mesentery, and below the parietal peritoneum, and were recognized as soon as the peritoneal cavity was opened. He said acute hemorrhagic pancreatitis was most frequently associated with fat necrosis, and suppurative pancreatitis was less commonly found accompanying it. Fat necrosis might also accompany chronic interstitial pancreatitis or obstruction of the pancreatic duct caused by biliary or pancreatic calculi or by carcinoma compressing the duct. In order to explain the relation of fat necrosis to these various lesions it made it necessary for him to describe briefly its pathogenesis. The relationship between cholelithiasis and acute hemorrhagic pancreatitis was entered into. A review of forty-one reported cases in which gallstones had been found in association with acute pancreatitis had shown that a calculus in seven instances was lodged at the duodenal orifice of the common duct, and mechanical conditions favored the penetration of bile into the pancreas. The clinical aspect of certain facts described was the following: (1) The presence of jaundice or the history of previous attack of gallstone colic might give confirmation to the diagnosis of acute hemorrhagic pancreatitis when somewhat indefinite symptoms suggest the presence of this condition. (2) When at operation undertaken for the relief of obscure abdominal symptoms, disseminated fat necrosis indicated the pres

ence of acute hemorrhagic pancreatitis, examination of the gall-bladder and bile passages would in a considerable proportion of cases reveal the presence of gallstones. Another lesion which had its origin in the secreting apparatus of the pancreas was the chronic inflammation which followed obstruction or ascending infection of the pancreatic ducts. He considered another group of lesions that inhibited primarily that influence which the organ exerted on metabolism through the medium of the circulation, i.e. the so-called internal function. Clinical observation had as

early as 1788 shown that diabetes mellitus was frequently associated with grave disease of the pancreas, but the relationship of the pancreas to carbohydrate metabolism had not been clearly recognized until von Mering and Minkowski succeeded in completely extirpating the organ in dogs, and showed that in a few hours sugar appeared in the urine. The pancreas was essential to normal carbohydrate metabolism. It was evident that diabetes mellitus, or at least glycosuria, might be regarded as a symptom of pancreatic disease. The most commonly associated condition was undoubtedly chronic inflammation, causing an increase of the interstitial tissue of the gland. It must be born in mind that diabetes mellitus might occur without demonstrable changes in the pancreas; in at least onethird of the cases the organ was found by gross and microscopical examination to be normal. From facts cited, he made the following conclusion, that when diabetes mellitus was found in an individual suffering from cirrhosis of the liver, the former disease was dependent upon the co-existence of chronic interacinar pancreatitis, doubtless produced by the same etiological factor, in some cases alcoholic excess, which was responsible for the hepatic disease. There was another group of cases in which diabetes mellitus was found to be associated with advanced arterial sclerosis. Since the pancreas furnished to the blood a so-called internal secretion, perhaps a ferment, necessary to normal carbohydrate metabolism, and since diabetes mellitus resulted when the pancreas was no longer capable of supplying this need, he said the possibility of artificially replacing the defect had suggested itself. A number of observers soon found that the administration of pancreas or extracts derived from it and administered to dogs deprived of their pancreas failed to prevent glycosuria or diminish its severity when estab lished. There was, however, clinical and experimental evidence to show that when diabetes was the result of a destructive lesion which inhibited the digestive function of the pancreas, some benefit might be obtained by supplying the intestine pancreatic ferments.

The Relation of Surgery to the Recent Advances in the Knowledge of the Pancreas.-Dr. GEORGE WOOLSEY read this paper. He said that on account of its physiological importance this organ could not be removed with impunity, for von Mering and Minkowski had shown that complete extirpation of the pancreas in dogs was followed invariably by symptoms of a fatal diabetes. These experimenters had also found that if a small portion of the gland remained, whether connected with the duct or not, there would be no glycosuria until that portion atrophied. Hence, with few exceptions, tumors of the pancreas could be removed without immediate danger of diabetes. Lack of pancreatic secretion in the intestines could be supplied by administering pancreatin, but the internal secretion could not be supplemented. He said that even incision into the pancreas had its dangers, not only from hemorrhage, but also from the fact that leakage may cause (1) A lack of peritoneal adhesions, leading to peritonitis, (2) a fat necrosis of the subperitoneal fat, and (3) a chronic fistula with irritation of the surrounding skin. The diagnosis, and treatment as well, of pancreatic disease was very much hindered because of the pancreas being so deeply situated in the upper part of the abdomen. Several points in the anatomy of the pancreas had been studied and emphasized in recent years,

and these Dr. Woolsey referred to. The relationship of the pancreatic duct to the diverticulum of Vater was noted; a stone impacted in this diverticulum might completely fill it and occlude both the biliary and pancreatic ducts. The association of pancreatitis with cholelithiasis was noted; as a prophylactic measure more general operative treatment for cholelithiasis was advocated. The severity and often rapidly fatal nature of the lesion was an important impediment to successful operative treatment. He favored the course to operate early in acute pancreatitis and not wait for recovery from the initial collapse, but to treat the latter by infusion, etc. On account of the rarity of acute or subacute pancreatitis few if any surgeons had had a large personal experience.

Diagnosis of Acute Pancreatitis.-He said it was the difficulty of diagnosis which more than anything else prevented a more rapid development of the surgery of pancreatitis. As a matter of fact, a diagnosis was seldom made until the operation or autopsy revealed it. In diagnosing acute and subacute pancreatitis, the subjective and objective symptoms and the disturbances of function were the means at the surgeon's disposal, and of the first two little or nothing could be said. The disturbed pancreatic function was almost invariably connected with chronic lesions productive of extensive destruction of the pancreatic tissue, or with interference with the passage of its secretion into the intestine. When this occurred, with or without diabetes, the patient was, as a rule, beyond the help of operative measures. But little or any light had been thrown on our knowledge of acute pancreatitis by recent advances. He believed that the severe acute form presented quite a charcteristic picture for the purpose of diagnosis and made a probable diagnosis lie within the realm of possibility. Its onset was sudden with intense, colicky epigastric pain, becoming general later, severe vomiting and eructations, and distension, rigidity and tenderness, especially of the upper abdomen. There was marked collapse and the face and extremities were cold, often cyanotic and covered with a cold sweat. The pulse was small and rapid and the temperature was not high, often subnormal. Motor disturbance of the stomach and bowels, i.e. vomiting and obstipation, were so commonly associated that a diagnosis of intestinal obstruction was most often made. If this symptom-complex occurred in connection with corpulence, alcoholism, gallstones, gastroduodenal catarrh, traumatism or arteriosclerosis, the diagnosis was made still more probable. Acute pancreatitis was often mistaken for and often could not be differentiated from acute perforative peritonitis or acute obstruction of the bowels, high up. The best means of diagnosis and treatment was an early laparotomy. The diagnosis he said would be established if the exploratory incision revealed a fat necrosis.

Treatment of Acute Pancreatitis.-He said that heretofore the expectant plan had been commonly advised until the symptoms of collapse had passed away, but the best judgment was now in favor of early operation. The severe cases die wthin the first four or five days, those that survive longer develop general peritonitis, local abscess or necrosis of the pancreas. In a few cases the progress was arrested. The question of early operative treatment was associated with that of the significance of the exudate. The pancreatic secretion from an injured pancreas mixed with blood had a very toxic effect and, in the peritoneal cavity, might so effect the peritoneum as to cause death. In acute pancreatitis he said we had a bacterial infection as well; even this may be, and often was, the cause of the pancreatitis. He said that some cases of so-called pancreatic apoplexy might run an aseptic course or the patient might die before the bacterial infection had had time to effect the peritoneal exudate. The peritoneal exudate in acute pancreatitis commonly contained bacteria, and the toxic

and infectious nature of this exudate made its evacua tion most necessary. This was borne out by the results obtained in early operation where merely evacuation, irrigation, and drainage were employed. Personally he believed this was all that could be done in these severe cases, and it could be done under cocaine.

Chronic Pancreatitis.-The occurrence of the chronic form was more common than the acute, and its etiology was usually a chronic catarrh of the pancreatic duct extending from a similar condition in the duodenum or common bile duct. If in addition to the pain and tender spot an inch above the umbilicus prolonged jaundice appeared, with or without a distended gallbladder, probably a diagnosis could be made. Under anæsthesia an enlargement of the head of the pancreas could be made out. A diagnosis from cancer of the head of the pancreas was not easy even after exploratory in cision. He said that Opie, Robson, and others had called attention to the close relationship existing be tween chronic pancreatitis and cholelithiasis. In the former jaundice was more unvarying, the gall-bladder more apt to be dilated, and there might be disturbances of function evidenced in the urine and stools. Explora tory operation was the proper course for diagnosis. Robson had shown that the condition could not only be relieved but completely cured by indirect drainage through the gall-bladder, by a cholecystostomy or chole cystenterostomy, thereby relieving the tension, congestion, and inflammation of the head of the pancreas.

Cysts of the Pancreas.-The most common lesion, so far as the number of operations were concerned, had for a common cause chronic pancreatitis; the occurrence of this retention cyst added another reason for early diag nosis and operation for chronic pancreatitis and its common cause or associate, cholelithiasis. He said that pseudo- or peri-pancreatic cysts had been shown to constitute a large proportion of so-called pancreatic cysts. The commonest and safest operation he believed to be incision and drainage after fastening the cyst to the anterior abdominal wall, i.e. so-called marsupialization. Tumors of the pancreas gave a less favorable outlook. Unfortunately these cases are left too long and not referred to the surgeon early enough.

Conclusions. He urged the more general use of Hahn's method of operating for acute pancreatitis in the early stages, by evacuation, irrigation, and drainage; he emphasized the fact that as several serious lesions of the pancreas may be due directly or indirectly to cholelithiasis, we were provided with another indication for more frequently operating upon the latter; he suggested that as an exploratory operation was the only way of making a diagnosis in many cases of pancreatic disorder, and as these as well as the conditions they resembled also demanded operative treatment, they should not hesitate to advise early resort to it in case of any doubt. The diagnosis of an indication for exploratory incision was all that was absolutely necessary.

Dr. R. F. WEIR said that surgeons were indebted in pancreatic diseases as well as in appendicitis to the wisdom and astuteness of a physician, Dr. Fitz of Boston who was the first to call attention to certain points of importance in pathological changes in both organs In his past experience he recalled two cases of pancreatitis which were discovered only after opening the abdomen for some obscure surgical condition. In each instance he had found fat necrosis. Not being able then to interpret the case, he went on with the treatment of cleansing and draining, with indifferent results. He said that, after all, these troubles presented themselves to the surgeon in two ways, the acute and chronic stage the former being extremely difficult of diagnosis. There is a series of symptoms which point to trouble in the upper part of the abdomen, and, in efforts at diagnosis one should carry in mind the pathological conditions

which might occur there and attempt to arrive at a diagnosis by exclusion. In the acute form of pancreatitis, whether hemorrhagic or suppurative, he called attention to the statement made by Murphy of Chicago, that an examination of the blood would assist us; the white cells were not increased in hemorrhagic pancreatitis. He referred to the relation of a case by Dr. Eliot a short time ago, in which, on opening the abdomen, much fat was noticed in the mesentery and a bloody serum in the abdominal cavity; this latter point he believed to be an important sign because of the few conditions which might give rise to it outside of trauma, intense strangulation, or thrombosus. This was also to be found in hemorrhagic pancreatitis. In Eliot's case the fluid was found in the right flank high up and came through the foramen of Winslow. The treatment of acute pancreatitis was very unsatisfactory. He referred to the remarks of Mikulicz before the American Association of Surgeons held in Washington last year; he stated that out of fortysix cases operated upon only nine recovered. In four of these recovery was due to the sponging out of the bloody secretion; this secretion was an irritating and poisonous one. Drainage was accomplished either anteriorly or posteriorly with but little disturbance. During the past two years he had seen three cases which pointed to the passage of gallstones, but none were found; there was, however, an enlargement of the head of the pancreas. In four cases the condition was associated with the presence of gallstones; after extraction of these and the institution of drainage, the patients were relieved.

Dr. MORRIS MANGES again referred to the first case of acute pancreatitis operated upon in this city. One and a half years after the operation and discharge from the hospital, the patient developed diabetes. At the time of operation no sugar could be determined. This patient complained chiefly of constant pain, worse after eating. He said that Dr. Lilienthal had a case of supposed intestinal obstruction which proved to be one of pancreatitis. This patient gave a picture of intense pain, excessive vomiting, and collapse. He recalled a case of pancreatic fistula in which operation was declined, and the patient grew very much emaciated from loss of the pancreatic juice. Dr. Lilienthal was asked to see the case and advised the administration of pancreatin in large doses, and much surprise was expressed at the rapid recovery which followed.

SECTION ON PEDIATRICS.

Stated Meeting, Held January 14, 1904.
DAVID BOVAIRD, JR., M.D., CHAIRMAN.

A Case of Diabetes Insipidus in a Child.-Dr. E. H. M. SILL reported this case. The patient was a boy of nine and a half years, born in New York City of Austrian parents. The family history was negative. He was healthy up to eighteen months ago, when it was noticed that he was passing large quantities of pale urine, and that he was suffering from excessive thirst. This developed after a severe fright. He was nervous, irritable, and easily fatigued. He complained of pains in the lumbar region. Recently he had been passing from five to twelve quarts of urine in the twenty-four hours. There was very little sweating; the mouth was always dry. The urine was feebly acid, had a specific gravity of 1005, and contained neither albumin nor sugar. The quantity of urea varied between 18 and 30 grams in the twenty-four hours. He had been taking fifteen drops of the fluid extract of ergot, three times a day, and had had warm baths. The speaker said that this affection was very rare in children. A case had bene

reported by Dickinson, occurring in a new-born infant and it was by no means unknown in children of five years Of thirty-five cases collected by one author twenty-one occurred under ten years of age, and nine under five years of age. The disease was noted chiefly after fright, sunstroke, lesions of the solar plexus and injury to some portion of the cerebrospinal axis. As a rule, the urine of these patients did not contain any abnormal ingredient. The disease was essentially chronic and of indefinite duration. Out of seventy-seven cases reported by Roberts, there were sixteen complete recoveries and fourteen fatalities, while in forty-seven there was an amelioration of the symptoms. Ergot, valerian, and electricity had been recommended in the treatment of this disease.

Dr. SARA WELT-KAKELS said she had seen two cases of this disease in children. One of them was a girl of nine and a half years, splendidly developed mentally, but of poor physique. The skin was dry and the appetite bad. The disease had existed for about three years before coming under her observation. The quantity of fluid taken had been restricted previously, but she was at once allowed to drink all the water she pleased, and this quickly improved the general condition. The child took between four and five quarts of fluid. The specific gravity of the urine varied between 1000 and 1003, and the quantity of urea was 0.1 per cent. The child remained under treatment about ten months, and gained about eight pounds during that time. Suddenly a paresis of the branches of the oculomotor nerve developed. The child was then lost sight of for a time, but it was learned that she became ill and died after a few days. She had tried various remedies, and obtained the best results from the administration of antipyrin.

The second case was that of a boy of six years, very well developed. He was passing from ten to twelve quarts of urine in the twenty-four hours, or about two-thirds of his weight. With the exception of the excessive thirst and the polyuria there were no symptoms. The quantity of urine was reduced to 8,640 c.c. under the influence of antipyrin. The reaction of the urine was faintly acid and the urine was almost colorless. No sugar was detected in the urine even by a number of tests. The quantity of urea excreted was about seven or eight grams above the normal. With regard to the differential diagnosis the speaker said that it was essential to exclude contracted kidney in making the diagnosis of diabetes insipidus.

Dr. JAMES J. WALSH reported a still younger case, that of a girl of sixteen months who fell out of bed. The mother told him that the child was urinating excessively, and although unable to speak, made noises indicating thirst. The child passed from four to six quarts of urine daily having a specific gravity of 1003. No treatment was given, and the child recovered. The disease had been present about three years ago.

Dr. C. HERRMAN said he had tried suprarenal extract in a case of diabetes insipidus, and it had had a marked effect on the quantity of urine secreted. Since then he had used this remedy in one or two cases with some success.

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The Symptomatology, Differential Diagnosis, and Course Bronchopneumonia in Children. Dr. MATTHIAS NICOLL, Jr., read this paper. Bronchopneumonia was essentially a disease of the poor and unfortunate. This paper was based upon an analysis of 167 cases of so-called primary bronchopneumonia occurring during the past three years in the New York Foundling Hospital. It was exceptional at this institution to find at autopsy lungs free from pneumonic lesions.

Bronchopneumonia was essentially a secondary or complicating disease. Unlike lobar pneumonia, bronchopneumonia occurred at all seasons of the year; about two-thirds of the cases referred to occurred between December and May. Of one hundred and fortyseven cases in which the age was stated, 70 per cent. were in children under two years of age. The direct causes were exposure to cold, extension of the inflamma