usually is secondary to gastric, intestinal, biliary, or pelvic carcinoma. About two-thirds of all secondaries are due to the alimentary tract and liver and one-third to the female genital tract. The primary disease extends by continuity in a large majority of cases. In twenty-nine cases reported, only five cases were metastatic.

A CASE OF ACTINOMYCOSIS.

JOHN H. PETTIS, M. D.

Department of Surgery.

THE patient was a farmer boy of Canadian birth, single, aged nineteen. He entered the hospital June 18, 1910, as an emergency case. His family history, as well as his personal history up to the time of his present troubles, is practically negative.

His present trouble began on March 9, 1910. At this time he was taken with severe pain in the abdomen, accompanied by fever and occasional vomiting. His condition improved somewhat after a few days but for six weeks he continued to have considerable pain and was unable to do any work. May 1, he felt somewhat improved and attempted to resume his work but the pain immediately returned. He continued quite ill from this time until his entrance to the hospital.

On entrance, the patient's temperature was 101°, pulse 110. The patient complained of considerable pain in the abdomen which was much distended and very tender, especially over the right lower quadrant. A rather indefinite mass could be made out extending from the umbilicus to an inch above Poupart's ligament and from the median line to slightly beyond the outer border of the right rectus. A diagnosis of appendicitis with abscess was made and the patient prepared for operation.

The abdomen was opened by the gridiron incision. It was noted that the muscles split with great difficulty and gave the appearance of having undergone some chronic inflammatory process. On account of the numerous adhesions it was necessary to considerably enlarge the wound before the caput could be delivered. In attempting to bring up the appendix it was torn away and a small abscess broken into. Drainage was provided for this abscess cavity and no further attempt made to reach the stump of the appendix. The mass that had been felt from the external surface of the abdomen could now be easily seen and palpated. It appeared to be beneath the rectus muscle and between it and the peritoneum. In order to get at this more directly the first incision was closed and a second one made over the mass and through the rectus muscle. On opening into the mass it was found to consist of partially necrotic tissue and suppurating foci. This necrotic tissue was curetted away, and the wound packed with iodoform gauze. At the time of opening this mass the diagnosis of actinomycosis was made and this diagnosis was confirmed later by the pathologic report.

Following the operation both wounds discharged a clear pus and the wound over the appendix failed to heal, gaping widely after the removal of the sutures. On the fourth day potassium iodid in fifteen grain doses, three times a day was prescribed for the patient with directions to increase

the dose a grain each day. Three days later the patient developed rather severe symptoms of iodin poisoning. The dose was therefore decreased to ten grains three times a day. Following this reduction the symptoms became less marked but there still remained considerable gastric irritation making it necessary to discontinue the drug on the fifteenth day. Up to this time the patient had taken liquid and very soft diet. On the fifteenth day the patient vomited a great deal, the vomitus having a fecal odor, the abdomen becoming distended and the pulse rapid and weak. The stomach was washed frequently and feeding by mouth discontinued and rectal feeding begun. The following day the potassium iodid was started. by rectum, twenty grains three times a day, increasing the dose each day. Rectal feeding was continued until the twentieth day when feeding by mouth was resumed, although the potassium iodid was continued by rectum until the thirty-fifth day when the dose had reached one hundred and ten grains three times a day. The drug was now given by mouth Deginning with twenty-five grains with instructions to increase the dose each day. After the symptoms of the initial poisoning subsided there were no more toxic symptoms although the patient was taking at the time of his discharge on the forty-seventh day thirty-seven grains three times a day. The patient improved very rapidly during the time he was able to take large doses of potassium iodid and at the time of his discharge he was in very good condition and the wounds were practically healed. The patient was given a prescription of potassium iodid and was told to take it in increasing doses under the direction of his home physician.

On August 15, ten days after his discharge, the patient was again admitted to the hospital. He came this time because of a small mass the size of a hickory-nut situated a little to the right of the umbilicus. The patient was at once prepared for operation and the mass opened and its contents curetted away and the wound packed with iodoform gauze. At this time a considerable amount of necrotic tissue also was curetted from the wound over the appendix. Following this the patient was given. potassium iodid in increasing doses beginning with thirty-five grains three times a day. The wounds were irrigated daily with weak lugol solution and packed with iodoform gauze. The potassium iodid was continued until September 15, when it had to be discontinued on account of gastric irritation and marked loss of appetite. Up to this time the patient seemed to gain steadily and the wound healed in a very satisfactory manner. Early in October, however, several other indurated areas began to appear in the abdominal wall, and on October 19 these, as well as the one previously described, were opened and curetted. These indurated masses had a very characteristic appearance and feel. In the early stage of the process the skin over the indurated area became slightly reddened, but a little later became a peculiar, reddish blue. The skin over the area became somewhat edematous but the tumor itself did not project to any great extent above the level of the surrounding surface. To the touch, these masses were brawny, not sharply defined, and seemed to include all the layers of the abdomen. When opened they were found to contain necrotic tissue and foci of pus. This necrosis did not seem to involve the

skin or muscles very extensively but was rather confined to the fascia and subcutaneous tissue. Its extension in every case was along the fascia, and there was no tendency for the process to extend through the muscle into the peritoneum. These areas were not painful but were exceedingly tender to the touch.

From November 5 to December 5 the patient again received potassium iodid per rectum in sixty grain doses three times a day. Its administration during this time was far from satisfactory, as the patient complained of considerable tenesmus, diarrhea, and gastric irritability, and on account of these the drug had to be discontinued. From this time on the history of the case is that of a gradual but progressive advance of the disease and a slow but certain yielding of the patient to the infection. From time to time potassum iodid was given by rectum or by mouth. When given by mouth patient lost his appetite and could not eat. When given by rectum the latter became so irritable that nothing could be retained. On December 1, 1910, the patient was again operated upon and numerous new areas and several unhealed old ones were curetted and swabbed with iodin.

Early in January, 1911, the patient developed an aphasia, which was thought at the time to indicate cerebral involvement, but the condition proved to be only temporary, for on the following morning a neurologic examination showed his mental condition normal.

On January 24, a fluctuating mass was discovered in the left lumbar region posteriorly near the spine. By pressure on this mass large quantities of a rather thin grayish pus could be forced out of a previous incision which had been made over one of the indurated areas in the lower left inguinal region, just above Poupart's ligament. On January 26, an incision was made over this mass and a large amount of pus and necrotic tissue removed.

On February 4, the patient developed marked edema of the right foot and leg, but no local condition could be found to account for it. From this time on the patient failed very rapidly and died on the evening of February 7. No postmortem was allowed.

ORIGINAL ABSTRACTS.

MEDICINE.

ALBION WALTER HEWLETT, B. S., M. D.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

DAVID MURRAY COWIE, M. D.

CLINICAL PROFESSOR OF PEDIATRICS IN THE UNIVERSITY OF MICHIGAN.

CONTROL OF TYPHOID IN THE ARMY BY VACCINATION.

IN the Wesley M. Carpenter Lecture of the New York Academy of Medicine Major F. F. Russell, M. D., of the United States Army, gives (New York State Journal of Medicine, December, 1910, page 535) a very comprehensive review of the whole subject of typhoid vaccination

and reports the statistics of the United States Army for the years of 1909 and 1910.

The disappointment following the results of the British experiments during the Boer war, have been found to be due to a great extent to imperfections in the preparation and dosage of the vaccine. As a result of the work of Sir W. B. Leishman the procedure was reintroduced in the British army in 1904 on an extensive scale, and into the United States army in 1909.

The vaccine employed in the United States army has been prepared at Washington from a single strain of bacillus which has a relatively low virulence since it has been under cultivation for a number of years. Apparently the virulence of the strain has little to do with the immunity developed, although the reaction to the vaccination varies directly with the virulence. The bacilli are grown for eighteen hours on agar, collected in large flasks and sterilized for one hour at 55° centigrade in the water bath. Temperatures exceeding 55° centigrade lead to deterioration. in the emulsion and are needless. The emulsion is now tested for living germs by culture and animal experiment, the number per cubic centimeter is estimated by direct counts and sterile normal salt solution added until a given volume contains the standard number of bacilli and onefourth per cent of tricresol. The vaccine is then put in ampoules and aged for three weeks, as it is found to give rise to less reaction after such ageing.

The injection of one-half cubic centimeter (five hundred million bacilli) is given near the insertion of the left deltoid at about 4 P. M. After ten days twice this dose is again injected and this dose (one billion) is repeated after another interval of ten days.

The reaction follows in a few hours and is "local" and "general." This local reaction is usually rather trivial and causes little inconvenience. The general reaction is marked by some rise in temperature, headache, nausea, and malaise, and varies widely with the individual. Very severe reactions with temperatures of 103° Fahrenheit or over may occur. Indeed such temperatures were recorded in nine-tenths per cent of the injections of the first dose given during 1909, but by a readjustment of the dose in 1910 the percentage fell to seven-tenths per cent. On the other hand, about sixty per cent of the first injections were followed by no elevation of temperature or headache.

The degree of immunity attained was controlled by estimating agglutination and opsonins. The two methods give directly comparable results. High degrees of agglutination were attained. Only rarely did. agglutination fail with a dilution of one in five hundred and in one case a typical reaction was obtained in the dilution of one in twenty thousand. In the fifteen thousand eight hundred and sixty-three injections there have been no complications at the site of injection. In one instance a remarkably prompt and severe reaction set in marked by chili, diarrhea, extensive herpes, and the loss of seven pounds in eighteen hours. It is assumed that a portion of the vaccine was accidentally introduced into one of the venous radicles.

Statistics covering only two years of peace with the army in barracks give no convincing evidence of the value of vaccination. However, the incidence among the vaccinated troops was about one-tenth that of the remaining unvaccinated. Several significant incidents have also been observed. The following quotation will ilulstrate:

On June 14, 1910, ninety-two men of Company A, First Battalion of Engineers were vaccinated. On June 24 the company left Washington, District of Columbia, en route to Gettysburg, Pennsylvania. The total strength of the company was one hundred and eighteen men. Ninety-two of these had received at least one inoculation, two others gave a history of having had typhoid and may be considered immune, thus leaving twentyfour men unprotected by either a previous attack of the disease or by vaccination. On August 11, five days after returning from maneuvers, two cases of typhoid fever occurred among the unvaccinated and four secondary cases occurred between the 20th and 23d, also among the unvaccinated. No cases occurred among the vaccinated, while twenty-five per cent of the nonimmune living under exactly the same conditions succumbed to infection. As great a difference as this is certainly significant and justifies us in believing that we have at last a measure which will save untold lives in time of war.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

V. Z.

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

BENJAMIN ROBINSON SCHENCK, A. B., M. D.

CONSULTING OBSTETRICIAN TO THE WOMAN'S HOSPITAL OF DETROIT.

THE TREATMENT OF ACUTE GENERAL PERITONITIS. BEVAN (The Journal of the American Medical Association, Volume LVI, page 1184) briefly considers the development of the modern treatment of acute general peritonitis, contrasting the thirty-five cases from 1885 to 1893 collected by Mikulicz and showing a mortality of ninetyseven per cent with recent work like that of Murphy, who treated twentynine cases with but one death.

At present the different methods advocated for the treatment of acute peritonitis may be summarized as follows:

(1) The saline cathartic treatment as recommended by Tait.

(2) The rest in bed and starvation treatment proposed by Ochsner. (3) Blake's plan of radical operation including irrigation of the peritoneal cavity.

(4) Murphy's treatment by operation with rapid removal of cause and drainage without irrigation and with continuous slow rectal saline and extreme Fowler position after operation.

Detailed consideration is given to each of these methods and it is shown that all of them are valuable to a certain extent. Thus, the course of saline cathartics is most useful in combating paralytic ileus, which is one of the common results of peritonitis, but no one would