PRACTICE OF MEDICINE-Chairman, Charles L. Greene, St. Paul; Vice-Chairman, John R. Elliott, Jr., New Orleans; Secretary, Roger S. Morris, 535 Clara Ave., St. Louis.

SURGERY-Chairman, Charles H. Frazier, Philadelphia; ViceChairman, J. E. Thompson, Galveston, Tex.; Secretary, E. S. Judd, Rochester, Minn.

OBSTETRICS, GYNECOLOGY AND ABDOMINAL SURGERYChairman, E. Gustav Zinke, Cincinnati: Vice-Chairman, A. E. Benjamin, Minneapolis; Secretary, Brooke M. Anspach, 119 S. 20th St., Philadelphia.

OPHTHALMOLOGY-Chairman, Frank C. Todd, Minneapolis; Vice-Chairman. William Zentmayer, Philadelphia; Secretary, George S. Derby, 7 Hereford St., Boston.

LARYNGOLOGY, OTOLOGY AND RHINOLOGY-Chairman, Burt R. Shurly, Detroit: Vice-Chairman, L. W. Dean, Iowa City, Ia.; Secretary, F. P. Emerson, 484 Beacon St., Boston.

DISEASES OF CHILDREN-Chairman. F. S. Churchill, Chicago; Vice-Chairman, L. R. DeBuys, New Orleans; Secretary, F. P. Gegenbach, 1430 Glenarm St., Denver.

PHARMACOLOGY AND THERAPEUTICS-Chairman, J. F. Anderson, Washington, D. C.; Vice-Chairman, R. A. Hatcher, New York: Secretary, M. I. Wilbert, 25th and E Sts., N. W., Washington, D. C.

PATHOLOGY AND PHYSIOLOGY-Chairman, William Ophüls. San Francisco; Vice-Chairman, L. B. Wilson, Rochester, Minn.; Secretary, A. J. Carlson, 5228 Greenwood Ave., Chicago.

STOMATOLOGY-Chairman, William C. Fisher, New Yo Vice-Chairman, F. B. Moorehead, Chicago; Secretary, Eugene Talbot, 31 N. State St., Chicago.

NERVOUS AND MENTAL DISEASES-Chairman, W. W. Gray St. Louis: Vice-Chairman, C. D. Camp, Ann Arbor, Mich.; Sec tary, G. A. Moleen, Mack Bldg., Denver,

DERMATOLOGY-Chairman, Richard L. Sutton. Kansas C Mo.; Vice-Chairman, J. B. Kessler, Iowa City, Ja.; Secreta Howard Fox, 616 Madison Ave., New York.

PREVENTIVE MEDICINE AND PUBLIC HEALTH-Chairm M. P. Ravenel, Madison, Wis.; Vice-Chairman, W. C. Rucker, Wa ington, D. C.; Secretary, C. Hampson Jones, 2529 St. Paul Baltimore.

GENITO-URINARY DISEASES-Chairman, Arthur L. Ch Boston: Vice-Chairman, Granville MacGowan, Los Angeles; Sc tary, Louis E. Schmidt, 5 S. Wabash Ave., Chicago.

HOSPITALS-Chairman. L. B. Baldwin. Minneapolis; Secreta John A. Hornsby, 1124 Monroe Bldg., Chicago.

ORTHOPEDIC SURGERY-Chairman, Leonard W. Ely, Deny Vice-Chairman, Nathaniel Allison, St. Louis; Secretary, Emil Geist, 2904 Riverside Drive, Minneapolis.

GASTROENTEROLOGY AND PROCTOLOGY—Chairman, Jos M. Mathews, Louisville, Ky.; Vice-Chairman, J. A. MacMillan, troit; Secretary, A. J. Zobel, 352 Lake St., San Francisco.

PANCREATIC LYMPHANGITIS AND CHRONIC PANCREATITIS

JOHN B. DEAVER, M.D., SCD., LL.D

Be the

PHILADELPHIA

Te most important subject which is occupying the on of abdominal surgeons to-day has to do with idation of the pathogenesis, the recognition of toms and the discovery of adequate means of -nt of the diseases of the pancreas. It is but a short pancreas was but little considered by the an er by the pathologist. Tumors, chiefly carci1, by their size or effect, occasionally thrust theminto notice, and a few cases of marked pancreatitis, ae, were recognized clinically and, if chronic, were in the archives of the pathologist. The majority terations in the pancreas were missed even by the dogist, either because of lack of interest and care, reason of the rapid digestive process which takes in the organ immediately after death, obscuring ar and the less-marked architectural changes of ge origin. In the midst of the general apathy ject came the observations of surgeons that nereas was to be found in various states of enlargeinduration, distortion or contraction in many upper abdominal disease.

Parly was it observed in disease of the gallcommon duct that the pancreas was apt to 1. Thus, in ninety-nine cases of cholelithiasis I operated during 1911, the pancreas was found d and nodular in thirty instances; in nine it eritely enlarged, in three it was unusually soft Le the lesion was more acute and accompanied is. In 45 per cent, of these cases, therefore, ed that some alteration of the pancreas had

is true that the pancreas is a firm and somearly formed organ, still, making all due for the personal equation in palpation, it must test that the pancreas participates to a very gree in the inflammatory lesions of the biliary ...ad previously been cognizant of the frequent t of gallstones with acute pancreatitis through ter studies of Fitz, and by the observation of were made aware of the fact that the lodgment tone in the papilla of Vater in such a way as retrojection of bile into the pancreatic duct was ate hemorrhagic pancreatitis. It seemed nence that the pancreatic alterations assogal-bladder disease resulted from infection Pas secondary to biliary infection and that e took place by way of the ducts, oppor**ch was provided by the usual junction of ta to form the sinus of Vater.

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JANUARY 4, 1913

There are certain objections to this easy explanation. In the first place, pancreatitis is more common in males, while, as is well known, gall-bladder disease is more common in females. This lack of parallelism arouses suspicion that pancreatitis must be due to other factors than the simple infection by continuity along the bileducts to the pancreatic duct, otherwise it would be difficult to explain why this should not take place as readily and as frequently in males as in females, the mechanism and anatomy of the parts being practically identical.

Again, the pancreas is often diseased without demonstrable disease of the biliary tract. In a series of cases which I analyzed with reference to this point, about one-third (36 per cent.) of all instances of chronic pancreatitis and 25 per cent. of the cases of acute pancreatitis were not accompanied by disease of the biliary apparatus. Desjardins attempts to explain ascending infection of the duct by assuming that the same infection gaining entrance into the ducts of the biliary or the pancreatic system may cause at one time cholangeitis and at another inflammation of the duct of Wirsung. This at present remains only an assumption.

There are three other possible avenues by which infeetion may reach the pancreas: (1) through the general circulation; (2) by direct contiguity from adjacent structures, and (3) by way of the lymphatics.

1. There is little or no evidence in favor of frequent infection by way of the systemic circulation. The rarity of pancreatic involvement in systemic and pyemic processes which are relatively so frequent speaks against this as a common mode of infection. Again, the conditions in which the pancreas is found involved are not characterized by bacteriemia, though it may occasionally

occur.

2. Infections by direct contiguity occur most often in slowly perforating ulcers of the stomach and duodenum. These are seldom in evidence in pancreatic disease, and when they do occur the portion of pancreas affected is that in immediate contact with the adherent viscus. while the remainder of the organ, as a rule, escapes material injury.

3. The lymphatics, however, in my opinion play a conspicuous role in conveying infection to the pancreas. Dr. Pfeiffer and I have pointed out that the pancreas by reason of its retroperitoneal situation bears a close relation to the thoracic duct and to many trunks which empty into it from the visceral lymphatics. Bartel had previously described and named a number of groups of lymph-nodes as the regional glands of the pancreas. Once he demonstrated by the injection method a direct communication between a pancreatic lymphatic and the lumbar trunk. Hoggan had previously shown a direct communication with the thoracic duct.

1. Pfeiffer and Deaver: Pancreatic Lymphangitis, Am. Jour. Med. Sc., 1912, cxliii, 473.