noticed a small tumor in region of umbilicus, for which, February 22nd, he came to the Albany Hospital, under my care.

Physical examination: There was a distinct tumor mass, size of a fist, in right iliac region, and small tumor, inflammatory in character and evidently containing pus, at umbilicus. Smaller masses could be felt through and in the abdominal wall giving one an impression of sarcoma of the mesentery. Heart and lungs normal; liver dullness extends downward about one finger's breadth below costal margin; spleen and stomach normal. For past five days the skin over tumor has been red with yellow spot in centre. Urine amber, 1030, acid, no albumin, no sugar, sediment slight and a very large number of calcium oxalate crystals present. Blood examination revealed leucocytes 18,500, red corpuscles 4,710,000. Operation February 28, 1901.

Abdominal incision in median line six c. m. long. Upon opening the peritoneal cavity the perital peritoneum was found in various places adherent to coils of small intestine, and a flattened tumor, about the size of half of one's hand, springing from the right iliac crest, other adhesions extending up to the umbilicus. The case was thought to be a multiple sarcoma of the mesentery, yet presented a very different appearance from any similar case I have ever seen. It was now observed that there was a distinct hardening over the portion of the peritoneum, extending to the umbilicus, along the course of the urachus, and round ligament of the liver, with an abscess evidently presenting just under the skin. The latter was not opened for fear of infecting the peritoneum. Incision in peritoneum closed with fine silk, continuous suture; wound then closed with interrupted silkworm gut sutures and iodoform gauze introduced in lower end of incision, standard dressing. Iodoform gauze removed on fourth day and drainage encouraged thereafter, the abscesses of the umbilicus having opened and discharged a creamy, flaky-like substance. Specimens of discharge and tumor were saved, but lost later, not reaching the laboratory for examination. The patient was put upon syrup of hydriotic acid, strychnia and elixir of calisaya, and as good nourishment as possible.

Not feeling at all certain as to my diagnosis, and as to the possibility of actinomycosis, about April 1st, I asked Dr. Elting to look the case carefully over, and to make a thorough examination of the discharge.

His report is as follows:

Patient a large framed, much emaciated man. Skin and mucous membranes pale. Tongue clean. Conjunctivæ clear. Pulse 80 to the minute and regular in rate and rhythm. Wall of artery palpable. Heart normal on percussion and auscultation; lungs normal on percussion and auscultation. Abdomen somewhat distended, fairly uniformly. Costal and iliac grooves obliterated. Respiratory movements present above level of umbilicus. In median line of

adbomen midway between umbilicus and symphysis pubis, is a discharging wound five c. m. in length, which appears to be confined to the abdominal wall. Over an area which surrounds the umbilicus, and extends from a point five c. m. to the right of the median line to the left lateral abdominal margin, and on the left from a point four c. m. below the left costal margin to the level of the line joining the anterior superior iliac spine, the abdomen presents a marked board-like hardness over a considerable extent of which the skin is much reddened. This condition appears to be due to an extensive infiltration of the abdominal wall. In the right iliac fossa there is a distinct mass to be felt which extends from a point two c. m. above the line joining the anterior superior iliac crests to the right Poupart's ligament. This mass is very hard but not tender and appears to be connected with the abdominal wall. On deep palpation a projection from the mass appears to extend upward and inward toward the umbilicus. On percussion the note over the mass in the right iliac fossa is decidedly dull, while over the indurated area of the left abdominal wall the note is tympanitic. The liver dullness begins

at the sixth rib in mammillary line and extends to the costal margin. Edge is not palpable.

Spleen is not enlarged.

Patella tendon reflexes normal.

Patient has had an irregular septic type of fever since admission to the hospital, varying from 98° to 104° F.

On incision of the abscess in the region of the umbilicus about two ounces of purulent material escaped which contained numerous yellowish-white fine granules, examination of which showed typical actinomyces. In the tissue lining the abscess cavity similar granules were visible. Cover slip stained by Gram's method showed the characteristic fungi. Cultures from several of the abscesses showed so vigorous a growth of the bacillus coli communis that the growth of the actinomyces was obscured.

Patient was administered iodide of potassium in increasing doses, i. e., a saturated solution commencing with three drops before each meal, in a wineglassful of water, increasing three drops each day until sixty drops was reached, and this dose continued.

May 1st. Condition has improved somewhat, although it has been necessary on two occasions to open abscesses in the abdominal wall. The pus evacuated was of a yellowish creamy character and contained less numerous actinomycotic granules than before the administration of the iodide of potassium was begun. There is still a large tumor mass in the lower right quadrant of the abdomen, associated with extensive induration and infiltration of the abdominal wall, which presents four fistulous openings.

June 15th. Patient's general condition is not quite as satisfactory as on previous note. There is still an extensive induration and infiltration of the abdominal wall, which occupies practically the entire

anterior wall below the level of the umbilicus, and extends on the left side as far as the costal margin. The tumor in the right iliac fossa is practically unchanged, irregular in outline and of firm consistence. There are three discharging sinuses in the abdominal wall, one at the umbilicus, one in the median line, midway between the umbilicus and the symphysis and one to the left of the median line. The discharge from these sinuses is of a sero-purulent character and contains a moderate number of actinomycotic granules. Appetite good; no gastro-intestinal symptoms. At patient's request he was discharged from the hospital and advised to continue with large doses of iodide of potassium.

June 29th. Patient re-admitted to the hospital for further observation. General condition is somewhat improved, although the abdominal condition does not appear to have changed materially, except that there are more discharging sinuses than at time of last note. The condition at this time is indicated by the accompanying photographs. (Plates I and 2.)

The abdominal wall presents a board-like induration which extends on the left side from Poupart's ligament to the left costal margin and as far as the left lateral abdominal margin. The right lower quadrant of the abdomen presents the same board-like induration and the tumor in the right iliac fossa is practically unchanged. The skin over the indurated area is of a bluish-red color and scattered over this area are no less than ten fistulous openings, the discharge from which is of a sero-purulent character and contains a moderate number of actinomycotic granules. Spleen, liver and kidneys are normal. Potassium iodide continued in drachm doses three times a day.

August 20th. Patient returned to-day feeling much better than when seen about three weeks ago. The condition of the abdomen is distinctly improved. Some of the sinuses have closed and the discharge from those remaining is decidedly less than when seen last. The infiltration of the abdominal wall is less extensive and the mass in the right iliac fossa is gradually disappearing. Patient has gained gradually in weight, which to-day is 130 pounds, as compared with 90 pounds, his weight in the early spring. The abdomen is not tender and the discharge of a sero-purulent character and containing but comparatively few granules, which still show the typical actinomyces. The liver is normal, as are the other abdominal viscera, the intestinal tract excepted. Heart and lungs normal. No enlargement of the lymphatic glands. Patient says that about two weeks ago a small pimple or blackhead developed on the right side of the nose, near the inner angle of the right eye. This was squeezed by his wife, who has attended to the abdominal wounds. About forty-eight hours after the pimple was squeezed the patient noticed some pain and swelling about the same. This gradually increased until a tumor the size of a small hen's egg developed, which almost entirely closed the right eye. There was considerable pain and much redness of

the skin. Hot applications were employed and about one week after the onset the tumor broke and discharged considerable pus. To-day, situated on the right side of the nose and near the inner angle of the right eye is a tumor the size of a large pigeon's egg, the skin near and around which presents a livid appearance. The centre of the tumor presents a granulating surface, the granulations being oedematous and containing a few yellowish-white granules. The discharge is of a sero-purulent character and contains a few typical actinomycotic granules. Potassium iodide continued in drachm doses three times a day.

September 20th. Patient returns to-day feeling much improved. The actinomycotic abscess at the inner corner of the right eye is entirely healed. The abdominal condition is much improved. It is still possible to demonstrate a few actinomycotic granules in the discharge from the sinuses in the abdominal wall.

October 12th. Patient returns to-day showing still further improvement. He has no pain or discomfort in the abdomen. Bowels are regular; urination normal. Weighs 146 pounds, a gain of 56 pounds since the administration of potassium iodide was begun. Appetite good; sleeps well. Has been doing light work for several weeks past. Color good and general appearance excellent. Heart and lungs are normal. The abdominal wall still presents four or five discharging sinuses situated, for the most part, on the left side. The skin over the lower abdomen is of a bluish-red color and somewhat pigmented. When the patient stands there is some protrusion of the abdomen, as though the muscles of the abdominal wall were weakened, probably as a result of degeneration. The induration of the abdominal wall is much less extensive and is represented by an area to the left of the umbilicus measuring approximately 8 x 10 c. m. The remainder of the abdominal wall is soft and it is no longer possible to detect any tumor mass in the abdominal cavity, nor is there any tenderness on deep palpation. The percussion note over the entire abdomen is tympanitic. From the sinuses there is a small amount of sero-purulent discharge containing an occasional actinomycotic granule, most of those seen being in the early stages of development. Liver dullness not increased, edge not palpable. Spleen not enlarged. No enlargement of lymphatic glands. Rectal examination negative. Condition of patient's abdomen as seen to-day indicated in Plates Nos. 3 and 4.

If this case is studied carefully it is very striking to observe the characteristic conditions that have been described by many authors: the tumors to be felt in the peritoneal cavity, and in the abdominal walls, the peculiar reddish-blue appearance of the surface of the abdomen, the multiple abscesses containing yellowish-like pus and granules ;

all these conditions are indicative of actinomycosis, also the patient's improvement for a time after operative intervention and still further improvement when getting under the full effect of the iodide of potassium. The infection of the nose and rapid recovery also aid in confirming the previous diagnosis.

The photographs illustrate very nicely the appearance of the patient when improvement had commenced and still later on when in a condition of convalescence.

TROPICAL DISEASES AS OBSERVED IN THE
PHILIPPINES.*

By R. W. ANDREWS, M. D.,

Late First Lieutenant and Assistant Surgeon, 46th Infantry Volunteers.

The prevailing diseases met with were the malarial affections, enteric disorders and certain parasitic diseases.

DENGUE

This is a common epidemic disease in the tropics, and is characterized by paroxysms of fever, and by severe pain in the muscles and joints, and in our cases especially in the back. They could not lie comfortably in any position. From this severe pain in the muscles and joints it takes the name of "break-bone fever," and sometimes, because of the peculiar walk of the patient, due to the pain in his back, it is also called "dandy fever." It is not a fatal disease, but in camps where so many men are affected, it becomes serious, because it weakens the garrison. The patients all told the same story, and to this effect: headache and chilly feelings beginning suddenly, sometimes a distinct chill, and sometimes a chill on the following day in the hospital would lead us to think that we had cases of intermittent malarial fever of the quotidian type, and some of the cases were so diagnosed. Some aching pain, especially in the knees and lumbar region. Fever rose rapidly in some cases and gradually in others,

*Read at a meeting of the Dutchess County Medical Society, Vassar Brothers' Hospital, Poughkeepsie, N. Y., April 10, 1901.