ber of distinguished foreigners. The men invited from Europe were:

Professor Samuel Pozzi, of Paris.
Professor Hofmeier, of Wuerzburg, Germany.
Dr. Herbert Spencer, of London.

All three of the invited guests took part actively in the discussion. This was particularly true of Dr. Spencer, who by his frankness and discernment won the hearts of all the members. One of the main topics of discussion was "Anesthesia." Seven or eight short papers were read treating upon one or the other phase of this subject, but all bearing witness to the demoralized condition of affairs which permitted this important work to be placed in the hands of recent graduates and nurses. At the opening of the discussion of these papers, Dr. Spencer rose to express his astonishment at such a deplorable state of affairs. "It is amazing," he said, "that in this country where anesthesia was discovered and first tried there should not exist more men devoting their entire attention to the study and practice to this important branch of medicine. If I understand rightly there do not exist at the present time more than two or three men in New York who are really devoting themselves wholly to this work. In England we have a very considerable number of such gentlemen and their income is quite a respectable one since the surgeon does not include the fee of the anesthetist in his but permits these gentlemen to render their bill separately. It is quite ordinary for a well trained anesthetist to get anywhere from five to twenty guineas (twenty-five to one hundred dollars) for a single administration of ether."

The general consensus of opinion seemed to be that operators should encourage the separation of bills for anesthesia from those of the operator and that the fees for that work ought if possible to be raised, so as to give opportunity for some of our good men to take up this work. There was no decided opinion as to the advisability of having a graduate nurse trained to give the anesthesia. Dr. Baldy, of Philadel phia, had tried this system with great satisfaction during the past year.

The MacDowell banquet held in the Solarium of the Waldorf Astoria Hotel, proved a great success. There were present about one hun

dred members and guests. The first speaker of the evening was Dr. L. S. McMurtry, of Louisville, who told of the life of MacDowell in the little city of Danville, Kentucky, where he did his first operation and where in succeding years he gained note as a fearless and successful surgeon. The gavel used by the president, Dr. Goffe, on the occasion of this session was made from the door knob of MacDowell's home at Danville. A number of lantern slides illustrative of MacDowell's life and work were shown by Dr. E. C. Dudley, of Chicago. Each person who was present at the banquet was presented with a bronze medal commemorative of the meeting. Of the St. Louis members of the Society, papers were read by Dr. George Gellhorn and Dr. Fred Taussig. The paper of the former was on "Peritoneal Adhesions;" that of the latter on "What to Teach the Practitioner Concerning the Treatment of Abortion and Miscarriage."

There were a number of articles dealing with more technical work of the profession. They would hardly justify any abstract in this paper. One paper, however, that may open up a whole vista of new work in the treatment of that most frequent of all affections, namely, backache, was read by Drs. Reynolds and Lovett. It dealt with the association of gynecological diseases and symptoms to an improper equilibrium of the body. There was apparently a two-fold influence. On the one hand, a pelvic tumor or inflammatory process might from the associated pain and pressure necessitate an abnormal disposition of the center of equilibrium of the body. In this way such women were under a constant effort to maintain their new center of gravity and the result of such efforts was only too frequently manifested by backache and general lassitude. On the other hand an incorrect unstable, posture might bring on secondarily a gynecological condition owing to the strain and irritation thereby put upon the tis sues tributary to the sacro-iliac synchondrosis. The tissues primarily affected are the sacro-iliac ligaments and the infiltration thereby resulting is termed parametritis posterior. Such an infiltration with its associated backache will frequently be entirely relieved, when the equilibrium of the body is restored by a means of a proper fitting corset. The work of Reynolds

and Lovett is based on careful anatomical and physiological studies made with the special instrument devised by the authors. Dr. Lovett, the distinguished orthopedic surgeon who took up this work more along the line of his own specialty, paid particular attention to the question of high heeled shoes. His conclusion was that they were not as harmful as they had been generally supposed. Of greatest consequence was the problem of a well fitting corset. And Dr. Reynolds found that in most cases it was necessary to have such a corset made to order in order to get the proper effect.

Seven new members were elected. Among the number being Dr. Crossen of this city. The next meeting will be held in conjunction with the Congress of Medicine and Surgery at Washington in May, 1910. The president for the ensuing year is Dr. E. P. Davis, of Philadelphia.

LINE FOR TREATMENT BASED UPON THE CAUSE OF DEATH.

By J. W. DRAPER MAURY, M. D., Abstracted by W. E. Leighton, M. D., St. Louis. There are two general forms of deaths which may befall the somatic cell, the physiological and the pathological. The pathological form of death may be induced by mechanical, physical, chemical or bacterial agents. With these in this paper, which deals with the cause of death in duodenojejunal obstruction alone, I hope to demonstrate that we are not concerned. Physiological death, on the other hand, that form of dissolution of somatic entity which has been studied so thoroughly, so exhaustively, in the pioneer work from the Johns Hopkins laboratories, the death following parathyroidectomy and that associated with adrenal and pituitary destruction or removal, this physiological form of death is that which immediately concerns us. I understand physiological death to comprise not only the dissolu

tion which follows the removal of certain substances by destruction of their secreting cells, such as the parthyroid, but also that dissolution of somatic life which is brought about by the mechanical interference with detoxications of the normal secretions of the body. Putting it concretely, I may say that a barrier which may prevent the normal distribution of enterokinase, or the normal reaction of antienzyme upon enzyme, is the cause of death which is physiological and somewhat of the same type as is the death brought about by removal of grandular secretions, so-called internal in character. It is not to be denied, of course, that these thoughts suggest ascribing to the duodenum a function, I believe, hitherto and as yet unknown, that, of internal secretion.

In whatever manner this may rightly be considered, I ask you to allow me to start with the hypothesis that the intestinal barrier which closes the lumen works no ill to the organism save through an interference which the physiological exchange or balance of the duodenojejunal secretions, and that the resulting death is physiological in type.

NERVOUS EFFECT OF INTESTINAL TRAUMA.

Operations which will be described later and in the course of which this highly sensitive mechanism was entirely removed or seriously injured, and furthermore operation in the remotely aboral portions of the small intestines which technically were associated with precisely the same amount of traumatism as those in the doudenum and jejunum, afford, under study, point blank evidence that the nervous shock or reaction has nothing whatsoever to do with the cause of death in the form of intestinal obstruction under consideration. Indeed, I have been led to the conviction that the infliction of even unusual mechanical traumas incident to various operative procedures upon the alimentary canal, not excepting the thoracic espohagus, is incapable of producing more than a transient and unimportant nervous reaction.

INFECTION OF BACTERIAL ORIGIN.

No one could pretend to read the literature of intestinal obstruction and not be acquainted with the contributions which have been made from the Johns Hopkins laboratory on the subject of bacterial emigration oral to the ob

struction. These studies have

contributed widely to our knowledge of the pathological type of death which unquestionably occurs from obstructions in the aboral portions of the ileum and from occlusions of the great gut.

The

It is, however, the physiological form of death alone with which I am concerned; with the fulminating prairie-fire-like toxemias which unheralded and often in a few hours, destroy the victim of douodenal obstruction. pathological form of death which results from obstruction at or near the ileo-cecal valve and which may well be of bacterial or stercoraceous origin, has not been the special object of our study. And of it therefore, I am not qualified to speak. With these premises then I ask you for the academic purposes of argument to assume that in obstruction of the intestines two entirely and distinct forms of death are to be differentiated the one doudenal and purely physiological due to an unknown disturbance of the duodenal secretion or balance, the other ileo-colic and purely pathological; the one a true auto-intoxication, the other a true exointoxication.

DUODENAL AUTO-INTOXICATION.

The following impressions have resulted from the study of over 400 cases of duodenal or oro-jejunal obstruction produced experimentally during the past five years at the Surgical Research Laboratory at the Columbia University. A chronicle of the steps which have led to the above outline position on intestinal obstruction is as follows: About five years ago while modifying the McGraw elastic ligature so as to substitute common every-day twine for the perishable elastic, and also with a view to remove sizeable apposed portions of gut and stomach wall. Dr. Weir at the time considering this a necessary part of the technique, we were suddenly confronted by the perplexing coincidence that all our animals died. There was no peritonitis; there was no gross lesion discoverable within or without the abdomen. We noted an early rigor mortis and that before death the heart-beat was accellerated, the gait was peculiar owing to the spastivcity of the hind legs and there was well defined muscular twitchings. The technic had embraced the closure of the duodenum. seems reasonable and indeed is easily suscepti

It

ble of proof, that the twine will cut out and give drainage in healthy stomachs of normal dogs at about a constant time, seventy-two hours. It is coincidence of import that the physiological death which we have been studying usually takes place in about the same time as is necessary for stoma drainage to begin.

DETERMINATION OF ABORAL LETHAL LINE FOR PHYSIOLOGICAL DEATH.

Another lengthy series of experiments determined, I believe with reasonable accuracy, that death would not occur in a medium sized dog until after the free drainage of the stomach, that is, several weeks, in any case when the obstruction lay more than 35 cm. aboral to the pylorus.

DETERMINATION OF THE ORAL LETHAL LINE FOR PHYSIOLOGICAL DEATH.

Logically, the first step after determining by a long series of experiments that death followed the closure of the duodenum before drainage became established through the triangular stoma, was to ascertain the effect of practicing a similar technic, but modified by placing the obstruction in the jejunum. Another lengthy series of experiments determined, I believe, with reasonable accuracy, that death would not occur in a medium-sized dog until after the free drainage of the stomach, that is, several weeks, in any case when the obstruction lay more than aboral to the pyl

orus.

DETERMINATION OF ORAL LETHAL LINE FOR PHYSIOLOGICAL DEATH.

The next step naturally was to determine the oral limits of the point of obstruction beyond which one might go and encounter physiological death within the time limit of triangular control. Roger states that simple ligation of the pylorus leads to this physiological death in from seventy-two hours to five days.

It is true, however, that we have observed this fact: Given free drainage of the duode num through the normal channel, the stomach may be constructed at or near the pylorus more frequently without lethal results until the cutting through of the triangular stoma than if the obstruction were in the duct-bearing por tion of the duodenum. In the light of our present knowledge, and measuring the degree of toxicity by our own drainage unit, rather

than attempting to measure it, as Roger has done, in terms of toxic units, we were led to assume that the source of the toxemia was not in the stomach but in the duodenum. This enabled us, for the purposes of study, at any rate, to place the oral limit of the lethal line between the pylorus and the papilla of Vater, because until now the question of the influence of the bile had not yet been worked out.

The duct-bearing portion of the duodenum has long been recognized as area having unknown and profoundly complex physiological property and it is in part the object of this paper to demonstate that the most accurate interpretation and knowledge of the physiological process going on in this short tube must form the ground work of future therapeutic progress, be it surgical or medical; not alone on the alimentary canal, but as one should logically expect, as well upon its great glands, the liver and the pancreas.

Elimination of the bile by duet ligation; Cholecystenterostomy and Transplantation of the Point of Discharge Into the Ilium.A long series of experiments, painful to the operator in point of technical detail, was created by which the bile was intended to drain into the ileum by the use of the ordinary suture opening between the gall bladded and the gut. For some reason, however, although the technical part was accurately executed, there was in every case the failure of the bile to drain.

RELATION OF THE PANCREATIC SECRETION TO INTESTINAL OBSTRUCTIVE PHYSILOGICAL DEATH.

By using Sullivan's tubes, we were able to move the point of entry of the bile as many centimeters aboral to the papilla Vater as was convenient. After ligating the lesser duct in its point of entrance beside the papilla and cutting it, we could make certain of having sufficient room to sever and investigate the

duodenum in such a manner that all the pancreatic secretion might enter into the oral or aboral loop. Opie has commented on the fact that drainage if the greater duct would usually suffice to prevent any undue hardening of the pancreatic gland because of retained secre tion, and we have been glad to make use of his observation by tying and cutting the les ser duct. The result of these cuttings was conclusive in one regard: irrespective of the

whereabouts of the discharged bile, the dogs lived during stoma control when the pancreatic secretions drained aborally, and they died during stoma control when it was confined in the oral loop.

It is a point of perhaps more than academic interest that Weinland has found an anti-tryptic ferment to exist in the oral portion of the small intestine. Is one justified in supposing that, as the pancreatic juice, grossly at least, appears to be the lethal agent, the danger from intestinal obstruction grows less and less the farther one places it from the pylorus, and therefore more and more in the antitryptic bearing portions of the canal, and this because of zymotic action. It may indeed be that there is some form of internal secretion produced by the duedenum, possibly not directly associated with the processes of digestion, which is the fundamental factor in causing this physiological form of obstructive death. This should be capable of demonstration by experimental methods. Some such hypothesis is at present necessary in order to explain the singular phenomenon of the protective power of the first 35 cm. of the intestine, the presence of which in the oral loop sufficing to prevent death before the opening of the triangular control.

THERAPEUTICS.

It

So far the suggestions as to treatment for these dogs have been based upon the belief that we had shown region of maximum toxicity to be the duodenum rather than the stomach. seemed, therefore, logical to irrigate the entire region rather than the stomach alone, and this by a sort of retrograde flushing. This in a dog is easy to accomplish, the pyloric sphincter offering no obstruction either to alkaline or to acid irrigation. It is conceivable that some modification of this method might possibly be employed upon the human being, for constant irrigation of the duct-bearing portion of the duodenum would seem on experimental grounds to be the one logical method of preventing the absorption of the physiological poisons referred to.

INUNCTION METHOD OF ADMINISTERING DRUGS TO CHILDREN. Abstracted by J. R. Clemens, M. D.

B. K. Rachford, in the course of an interesting paper on the value of the inunction method