Provision should be made for the election of delegates to the American Medical Association-an evident oversight.

I understand that within the past few days the committee has gotten together and modified to some extent the more objectionable features of the original draft. However, there are still retained the evils of non-representation, the house of delegates, the referendum and an unwieldly system of caring for the finances as well as inserting the paternalism so obnoxious to democracy, which would charter local societies and provide them with constitutions. The local men are the best judges of their needs and to them should be left the framing of their constitutions.

I would counsel you, therefore, to keep close to the lines laid down by our old constitution. Our present requirements are safe and are for the best interests of our Society. Remember that in simplicity there is beauty, there is strength, there is safety as well as dignity.

And now when you come to consider what I have said, believeme that there has been no desire to impugn the motives or sincerity of any one, but what has been said has been with a spirit single to the welfare of our beloved association.

I leave this matter to you without fear, knowing full well that right will prevail and what you do will be for the best interests of our Society, for looking forward I can see a grand future for this organization. There is to be no turning back, there can be none. Progress is our watchword and from the very nature of things we must follow it. Coming down from the illimitable past are immeasurable energies from whose action we cannot escape. We are acted upon by the resultant of all the forces of all time compelling us on to our destiny of progress, if we but will. In so far as we place ourselves in unison with this force, Divinity, if you will, do we achieve our destiny, but woe to him who pits his puny strength against the power which is

carrying us ever onward! He will be crushed as grain between the upper and nether millstones. But of such are not we. By our work, by our enthusiasm, by our broad spirit of philanthropy we are acting in unison with the energies about us, and the result shall be increase in growth, increase in power, increase in beneficence, a blending in harmony with the divine plan, the fulfillment of our destiny.

THE ANNUAL ADDRESS IN MEDICINE.

BY SIMON FLEXNER, M. D., OF PHILADELPHIA,

PROFESSOR OF PATHOLOGY, UNIVERSITY OF PENNSYLVANIA.

It is superfluous for me to say that I regard your invitation to deliver on this occasion the Annual Address in Medicine, as a great honor, and I have accepted the invitation, although as a matter of fact I am really engaged in the study and teaching of one of the collateral branches of medicine. The field which I am supposed to occupy is that of pathology; and if it is permissible for a pathologist who does not practice to deliver an address in medicine, I will make the effort this morning.

The subject which I have chosen to speak to you upon is the pathology of the pancreas, with especial reference to pancre atitis and diabetes.

It seemed to me that that might be a subject which would insure the interest of medical men and of surgeons, for the reason that our knowledge of the pancreas, especially with reference to its function and surgical procedures has increased by leaps and bounds in the last few years; and while I shall not deal at all with the treatment of diseases of the pancreas, I thought that it might not be unprofitable to occupy the next threequarters of an hour in the consideration of what the advances have meant to us in respect to our understanding of the functions. and the diseases of that important gland.

The pancreas in some of its relations had been well understood. We have known its digestive secretion and funetion, and of certain pathological changes to which it is subject. We have learned, indeed, chiefly through the labors of a distinguished American, Dr. Fitz, very much concerning the acute

inflammations of the pancreas, and in the last few years, and especially since the experiments of Mering and Minkowski, to which I shall refer, we have paid attention to the chronic inflammations of the pancreas, under the belief that they have to do with certain forms of diabetes. But while we have in a manner, so far as description would permit, recognized the acute and the chronic inflammations of the pancreas, we have been, up to a recent time, woefully ignorant of the disturbances which lead to those pathological changes on the one hand, and ' the changes, characteristic of certain diseases which these pathological conditions provoke on the other, and the enlightenment on the subject has not come from observation of clinical cases alone. Indeed, I think it may be said with justice that the greater part of our enlightenment has come from the use of experimental methods in the study of the pancreas. These experimental methods actually go back a long time. Claude Bernard, in his classical work on the pancreas, made experiments on that organ; but those experiments had reference to the ordinary or so-called digestive secretion of the pancreas. He found, for example, that in animals this secretion is not essential, that if the ducts of the pancreas were closed, the animal survived the operation, notwithstanding the fact that the pancreas underwent a form of atrophy. Therefore the conclusion seemed justifiable that whereas the pancreatic secretion is an advantage to an animal, it is not indispensable to the life of that animal.

Since these experiments were made nothing of pathological note was done up to a comparatively recent time, when experiments were again resorted to in order to resolve what we now understand as a mere incident of diseases of the pancreas.

About the year 1882 Balser, a German, described in the peritoneal cavity certain lesions to which he gave the name of fatnecrosis and which at that time were not understood. Afterwards these lesions came to be conceived as having something

to do with the pancreas. A number of experimenters attempted to produce the lesions, but none of them were really successful until another German by the name of Langerhans comminuted a portion of the pancreas of the rabbit and injected it into the perirenal adipose tissues of another rabbit and thus set up a condition of inflammation which upon microscopic examination and also to the naked eye, showed certain resemblances to fat-necrosis. His conclusion, which was perhaps not quite justifiable at that time, but has since been supported by conclusive evidence, was that fat-necrosis depended upon the perversion of the pancreatic secretion, and that the particular constituent that brings about the lesion is the fat-splitting ferment, which having gained access into the adipose tissue of the peritoneal cavity, sets up there a condition of necrosis corresponding chemically with the changes taking place in the fat when this ferment acts upon it, as in the case of digestion in the intestinal canal. This observation of Langerhans gave great impetus to the study of experimental fat-necrosis; there is no country, in which experimental medicine is prosecuted, which has failed to supply some data of importance with reference to the experimental production of this lesion; from Germany, France and the United States have come contributions which eventually have so completely cleared up this condition and so completely demonstrated its relation to the pancreas, that we now consider it as one of the well established facts in pathology.

The next advance which was made has reference to experimental diabetes, but that point I shall defer for a moment in order that I may talk to you of a subject that comes in more properly at this part of my discourse, namely, that of experimental pancreatitis.

As we know, especially from Dr. Fitz's writings, this disease appears in human subjects under three or four different forms. The commonest form is perhaps the hemorrhagic. In addition