in the intestines generally. A search failed to show diverticulitis or other cause for the pain and leucocytosis, except a slight, diffuse thickening of the sigmoid. The appendix was removed, and his recovery was prompt and complete. In this case I would account for the considerable amount of free fluid in the peritoneal cavity through the hyperemia of the intestines due to the influenza enteritis, but this does not account for his leucocytosis, and the appendix did not appear to be acutely inflamed. The slight thickening of the wall of the sigmoid leads me to think that he had an inflammatory infiltration of the wall at this point, secondary to the influenza inflammation, and that this sigmoiditis caused his leucocytosis.

Dr. L. W. Dean, head of the eye, ear, nose, and throat department, reports that during the epidemic his department had under observation 37 patients with acute otitis media, of whom 5 developed mastoiditis, requiring operation. In 4 of these mastoid cases the streptococcus was found, and in 1 the identification of the organism is not complete. There were 14 cases of acute paranasal sinus disease, and 12 cases of acute laryngitis. In all these complications leucocytosis was present, except in one patient, who died from pneumonia without having had leucocytosis at any time. Dr. Dean reports that he noted two rather unusual conditions.

1. "The marked tendency to orbital cellulitis in cases with infection of the anterior ethmoids; 3 cases among the 14 with paranasal sinus disease having orbital cellulitis.

2. "The laryngitis cases presented superficial ulcerations with infiltrated bases. In certain camps the same condition has been reported as caused by the pneumococcus independent of influenza."

CONCLUSION

In no case was the influenza bacillus found; therefore it cannot be regarded as the cause of this epidemic. Complications are few, and are probably due to a secondary infection. This is indicated by the fact that leucopenia is present in the uncomplicated cases, but leucocytosis develops almost invariably with the onset of complications.

Whatever the primary cause of the influenza may be, the bacteria mostly concerned in the complications are pneumococci and streptococci.

DISCUSSION

[Dr. Rowan answered some questions as below.]

DR. ROWAN: In regard to the causes of abdominal pains in influenza: I well recognize that many of these pains do exist, and are caused by a condition above the diaphragm; but apart from them we do have a good deal of abdominal pain, and it is not safe to feel that every case of abdominal pain comes from above the diaphragm. We have seen a good many cases of the gastro-intestinal form of influenza where there were vomiting and severe diarrhea with pain well localized, in some cases, to the right side, where there was no evidence of pneumonia, no empyema, and the patient recovered. We should be on the lookout and not make light of abdominal pains, because if we do, once in a while we will make a mistake.

As to operating on pleurisy: I do not think we operated on any pleurisy. The only cases requiring operation were empyema referred from the internal medicine department, where the diagnosis had been made by very conservative men. The question comes, When does a pleurisy cease to be a pleurisy, and become an empyema? I was willing to take the internist's word; although the gross appearance of the fluid in many cases indicated pus, we could not find the organism on smears, and where there seemed to be empyema with thick pus we waited until the organism appeared on smears.

CARCINOMA OF THE SMALL INTESTINE

E. S. JUDD, M.D., F.A.C.S.

ROCHESTER, MINNESOTA

According to the necropsy reports from a number of clinics in which the examinations have included many thousands of cases, carcinoma of the small intestine comprises about 3 per cent of all the carcinomas of the entire intestinal tract. It is generally noted that carcinoma occurs in the duodenum more often than in the other parts of the small intestines; however, our own records, made up almost altogether from those of patients coming for treatment, show that carcinoma has occurred 24 times in the small intestine as compared with 1,822 times in the large bowel and rectum and 1,689 times in the stomach. This very great difference is certainly striking, and indicates, for some unknown reason, an almost complete minority of carcinomas in this region.

In our series of cases carcinoma occurred 5 times in the duodenum, 11 times in the jejunum and 6 times in the ileum; and in two cases the lesions were multiple and occurred in different parts of the small bowel. In a few instances the neoplasm was close to the juncture of the duodenum and jejunum and it was difficult to establish its exact point of origin; it may have been primary in the third portion of the duodenum or in the first part of the jejunum. It should also be stated that carcinoma in the small intestine varied from the typical carcinoma found elsewhere in the gastro-intestinal tract in that in a number of cases carcinomas developed on polypi or papillomas. In a

few instances only did we observe the true colloid carcinoma, similar to the ordinary intestinal carcinoma occurring in the part of the intestine between the pylorus and the cecum.

CARCINOMA OF THE DUODENUM

A review of the reported cases shows primary carcinoma of the duodenum to be more commonly encountered than carcinoma of the jejunum or the ileum. In our own series of cases, however, this incidence is not borne out, as we have seen but five cases of carcinoma of the duodenum as compared with 11 of the jejunum and six of the ileum. It should be stated, with reference to these cases of carcinoma of the small intestine, that, in some instances, the growth was quite extensive, and it was impossible to be certain of its origin, though in each instance the person making the examination felt sure that the tumor was primarily a tumor of the small intestine. It is not always possible to differentiate a primary carcinoma of the duodenal mucosa and one originating in the bile ducts, ampulla, or the head of the pancreas, especially after the growth has become extensive. These tumors occur strictly in one of three parts of the duodenum: the supraampullary, the ampullary, and the infra-ampullary. About 70 per cent of all carcinomas of the duodenum are located at the ampulla, though probably the most interesting cases for consideration are those in which the lesion is in the first part of the duodenum above the ampulla. It is this portion which is so commonly the seat of an ulcer, and it is of considerable interest to compare the tendency of these ulcers to undergo malignant change with the tendency of the gastric ulcer to change in the same way. So far as I know, no one has ever witnessed the change of a benign gastric ulcer into a malignant ulcer, although, from the clinical, surgical, and pathologic evidence