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PRESIDENT'S ADDRESS.*

FRED A. BARTLETT, M. D., AURORA, ILL.

In looking over the fields of medicine and surgery and its allied branches, in an effort to select a suitable topic to form the basis of an address, it occurred to me that the field itself presented perhaps as suitable a soil as any I could find for the growth of a few remarks that would not partake of too much of the technicality of the medical paper. Most of us have practiced medicine long enough, or at any rate have lived long enough, to see this field grow and expand to an astonishing degree, to an overwhelming degree when we stop and carefully consider the responsibilities of, and the usefulness of the medical man of today. Modern investigation and discovery has broadened our field to an extent that we are forced to ask ourselves if there will ever be a limit to it, if there will ever be an end to productive research and endeavor. A learned physiologist of fifteen years ago would look with paralyzing astonishment at a test book of physiology of today. If Rip Van Winkle were a doctor, falling asleep twenty years ago and awakening today, he could not understandingly read a page of a modern treatise on Theory and Practice.

Chemistry and biology have been the principal fertilizers whereby the wonderful growth of diagnosis and therapeutics has been made possible. Observers and experimenters in these lines have accomplished wonderful things and while much that is offered us is of small account, and has been and is daily being proven to be of limited practical service to us, it is all along the line of advancement and leads to a definite goal.

Sepsis, asepsis and antisepsis, while being discovered long before, have become generally recognized within our period of observation and constituted bacteriology's first feeble murmur of the now lusty cry to dominate the whole therapeutic sphere. We have seen new elements discovered and new uses for the old ones, we have seen a new element brought forth an infinitesimally small part of which is capable of producing an effect on the human body; we have seen new combinations of old and new elements made and discovered; we have seen the rays of the sun utilized, bent, sent through prisms, and variously modified, to aid us in the alleviation of pain and suffering. We have seen electricity creep from its primitive state as a curiosity and an atmospheric novelty, through the field of commerce and into our therapeutic midst. * Riverview Homeopathic Medical Association, Oct., 1912.

Valuable medical preparations have been made from the organs of lower animals, and we have found out what some of our own organs are good for where we previously knew nothing of their functions. Chemistry and biology have been the means of determining much that is known of internal secretions and animal therapy. Problems of preventive medicine, of sanitation, of hygiene, and even of dietetics were in their infancy a decade ago; and the medical profession is ever willing to lend its aid to the betterment of public welfare.

No less marvellous are the advances made in diagnosis. Here again chemistry and biology, aided by the opportunities for observation and study furnished by surgery and the much decried vivisection, have been of the utmost importance. Urinalysis has developed from a simple test for acidity and albumen and a mere observation of the readily apparent characteristics, to a veritable science in itself. A complete urinalysis is a necessity in the proper treatment of all cases, so comprehensive and far reaching is the knowledge gained hereby. Analyses of stomach contents and faecal matter were unthought of procedures. Widal's, the Wasserman, and a host of other specific tests have furnished the means for comparative if not positive diagnosis. In addition to its use therepeutically, we have seen the x-ray do work in diagnosis that had seemed to be beyond human power. For many years the value of the microscope has been appreciated but the ability to know and understand much of what it revealed has been one of the recent acquirements. Without the aid of the microscope urinalysis would be incomplete, blood analysis would amount to nothing, and histology and bacteriology would never have been heard of. Through its use blood count and analysis have been made possible, examination of diseased tissues and pathological growths, bacterial staining and examination and analysis of discharges, secretions, and excretions. However much or little we may believe in the germ theory of disease, it cannot be denied that many diseased conditions have been positively proven to be of bacterial origin, others are under observation and are awaiting the final verdict, and what the future may have we can hardly even conjecture. The physician of today must be well versed in climatology, dietetics, eugenics and social conditions, must understand the effects, limitations, and advisability of the various forms of scientific bathing as well as of massage and osteopathic treatments.

In fact, looking over this field of medicine thus roughly sketched, I am prompted to ask the question, "What are the requirements of the physician of today, and what is a reasonable limit to his knowledge?" It goes without saying that no one can know ali. The modern tendency

is toward specializing. Whether or not the up-to-date specialist knows all about his subject I am not prepared to say. It sometimes seems to me that he does. However, his field is a circumscribed one, his observation, attention, reading, and study are directed to the one subject, and while many other conditions may have a bearing on his specified. work, his efforts are in the main concentrated.

After all, is it not the general practitioner of medicine to whom falls the necessity of keeping conversant and familiar with all that is progressing in each and every branch of the medical and surgical art? Is it not to the general practitioner that the afflicted first come for relief and advice? Is not specializing the outgrowth of his ill-success in handling, or lack of ability or proper equipment to successfully manage a case? And is not the fact that a man can become more proficient by directing his energy along one line, its reason for existing?

The wide publicity given nowadays by the daily press and numerous magazines to all medical discoveries and innovations, makes it necessary for the physician to keep alive to everything that is current, to know what has been done and what is being done, to sift the good from the bad, and to measure the possibilities and to weigh the probabilities. For his opinion will soon be asked and it will be supposed to be authoritative. Every one of us present has seen many a loudly heralded, well authenticated discovery rise with the brilliancy of a rocket and fall with a sickening splash. Persistent reading of the latest articles. treating of the work and results of others, and association with others. who read, study, and think, are the only means by which this can be accomplished. Practicing medicine and doing the investigating are incompatible. The physician who practices medicine as a means of livelihood (and there are many of us who are doing that very thing) finds a serious impediment to his use of many of the newer methods in the expense of the treatment and the considerable outlay for equipment. So much of his work is at the best unremunerative that he must hesitate at the expenditure of actual money without a reasonable assurance of a return. A patient, too, dislikes to pay the necessary charges for a variety of treatment which is still in the experimental stage and for which the physician cannot give a fairly definite promise of benefit. For this reason his personal observation is necessarily limited and he must gain his knowledge largely through the experience of others. This applies particularly to the various forms of serum treatment based on the germ theory of disease where the evolution has been so rapid that the text books and journals cannot begin to keep pace with the investigators. All of these treatments involve a certain amount of

technique and demand skillful administration whether they be given subcutaneously, intramuscularly, or intravenously.

For the physician to successfully cope with the various emergencies that may arise without any warning, the age has brought forth many alleviative curative measures that require not only an intimate knowledge of anatomy but a considerable degree of skill and experience for their proper execution. Intubation and tracheotomy seldom give the doctor time to send for a man who knows how or who has had experience. If he has the knowledge and skill he is of so much greater service to his patient. But how many general practitioners do you believe are capable of performing these operations at a moment's notice? Normal salt transfusion and blood transfusion demand not only the technical skill in operating but a knowledge of the proper amount to admit into the circulation, when to discontinue, what symptoms or reactions to expect, and when to repeat. Ability to perform emergency operations and to handle obstetrical complications should be possessed by the general practitioner particularly in those districts where counsel and help from more skilful brethren cannot be readily obtained. Means of treating poison cases, asphyxiation and this class of emergencies have improved wonderfully in a comparatively few years and their successful management depends on a quick and proper diagnosis, if it is not at once apparent, and an immediate knowledge of what to do and how to do it. X-ray treatments, electricity, vibratory massage, radio-therapy, various adaptations of heat and light are recent achievements and are of value as adjuvants to the general line of treatment. However, the busy man cannot take the time to give these various treatments and watch and observe their results; he may not have adequate accommodations for the different apparatus; or the expense of installation and maintenance and the necessary assistance may not be commensurate with the income therefrom; and such matters have to be considered.

These are some of the things that are required of the physician of today. And, considering everything, I don't believe we are to be criticised if we are lacking in our ability to do, or our facilities to use, some of them. The active man, in his efforts to keep abreast of the times, finds much in the current literature that he does not understand. Nor do I believe he is to be criticised for that. Evolution is so rapid that he cannot pay much attention to anything till its field of activity is made definite and its reliability proven. The intermediate steps must be made by those who are not actually engaged in bedside practice, and who have the time and facilities for research and experimental work.

I read an article a short time ago in which one paragraph of ten lines contained twenty-seven words handed out to us by the biologists that I did not know. To understand the article it was necessary to know those words, and to know those words meant an endless amount of searching and reading. Therein lies the chief difficulty of keeping pace with medicine of today. But as the work goes on and on, first one thing and then another is anchored, becomes a fixture, and we who treat the sick and afflicted will be the ones to make the final tests and pass the final judgment. But bearing in mind the present state of research and investigation, I am inclined to the belief that the physician. today who is partly up-to-date is entirely up-to-date.

SURGICAL DISEASES OF THE PANCREAS.*

CHARLES E. KAHLKE, M. D., CHICAGO.

The pancreas as we all know is one of those glands of combined internal and external secretion, and is deeply situated behind and below the stomach and in the angle of the duodenum. In the fetal state, it is intraperitoneal, but by evolution becomes extraperitoneal.

Originally it consisted of two lobes, each having its separate duct opening into the duodenum. The upper duct, i. e., the duct of Santorini, becomes obliterated in 50% of adults. In 10% of cases, the duct of Santorini is larger than Wirsung's duct. The duct of Wirsung is joined by the common bile duct before entering the duodenum through the ampulla of Vater. In two-thirds of the cases the common bile duct passes through the head of the pancreas, in the other third behind it.

Of the surgical diseases of the pancreas, the topic assigned to me by our Chairman, there are three chief disorders; viz., inflammation, cancer and cysts.

Until the last twelve years, more attention has been given to tumors. of this gland than to inflammation. Cancer is of interest more from the standpoint of etiology and diagnosis than treatment for evident reasons. Cysts are comparatively infrequent, but can be cured surgically. Inflammations are the most important of all the diseases of this gland, not only because they can usually be relieved when recognized, but because they occur more frequently than we have heretofore believed.

Not many years ago we used to hear and read a great deal about gas* Read before the Illinois Homeopathic Medical Ass'n, May, 1912.

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