region of the inguinal glands. He is a farmer by occupation, has never used alcohol in any form, and does not smoke or chew. Since two months ago he has been restless and sleeps but little.. Regarding his family history, he knows nothing of his grandparents. His mother died of general debility at the age of sixty-three years. His father is living at the age of seventy-one, and enjoys good health. He has one sister, aged thirty-seven, fairly healthy. He had whooping-cough and inflammation of the bowels two years ago, but made a good recovery.

Patient's present affection began last December, when he noticed a swelling in the right inguinal region. There is a scar in the left inguinal region, where it has been lanced, a swelling having appeared there some time previously. Whether that was the beginning of the present pathologic condition, or whether it was an abscess due to some other cause, I am unable to say. The first abscess seemed to heal promptly after evacuation and the series of abscesses on the other side developed quite independently of this one, apparently. This swelling begins in the right inguinal region and extends in a continuous line from the pubes to the anterior superior spine. The swelling, which appeared on the left side, occurred three years ago, at least two years before the one which has just been described. The openings of the present abscesses yield a fine deep-colored discharge, associated with clots. The wounds were treated by irrigating twice a day and packing with iodoform gauze. The patient has never suffered any pain whatever except since pointing became manifest. He has had a number of abscesses of the scrotum.

On examination a phlegmonous condition was present, the surface was ulcerated with undermined edges, and the discharge was thick and creamy and dirty-red in color. There was no apparent involvement of the lymph glands. The patient appears well nourished and healthy, but is very restless and sleeps but little. The man is very easily frightened and worries a great deal about himself. His pulse was 126 at the time this examination was made, tension poor, and compression easy.

The operation consisted in opening the sinuses, and curetting, irrigating, and packing them with iodoform gauze. This scar which you see here on the left is the one that was made three years ago. The appearance of the scar and its location quite independently of the others would suggest that it was an independent process. When the patient entered the hospital I was led to think, from the appearance of the wound, that this was some unusual kind of infection. The scars were much larger than they are now, showing a passive hyperemia. They do not present the appearance usually seen in tubercular sinuses, the granulations are not pale, but display a very good color. The scrotum at that time was swollen considerably, there was a mixed infection, and a greater discharge during the first few weeks than we see here now. By drain'ing thoroughly and washing frequently, this infection seemed to disappear and the wound showed signs of healing on the surfaces. You will notice that the upper part of this wound has apparently healed. You would think from close inspection of the surfaces that it is almost entirely healed, but if you were to insert a probe, you would find that

these tissues, for quite a distance, are simply granulations. The process does not seem to pass along the layers of fascia, but rather to penetrate that structure and permeate the tissues. The skin resists the infection very well, but the edges underneath are undermined much the same as in tuberculosis, although they are better nourished than tubercular granulations, the blood-vessels being more numerous. The scrotum is in much the same condition. You will find that these sinuses connect with each other and also are surrounded by this same granulation tissue, presenting the same characteristic of which I have spoken. It was this peculiar appearance of the wound which led to the belief that we were dealing with some unusual infection and prompted this investigation. Mr. Breitenbach, who recorded this history, studied the condition from a bacteriologic standpoint, but had little opportunity to thoroughly perform the task before his graduation, and since that time Mr. Carhart has been attending the patient. Some of the tissue was sent to the Pathologic Laboratory, where the nature of the infection was discovered by Doctor Warthin, who has specimens of the tissues to show you and something to say regarding the pathologic condition.

DISCUSSION.

DOCTOR WARTHIN: The microscopic examination of the tissue that was sent to the Pathologic Laboratory showed that it consisted of granulation tissue, containing giant cells and purulent areas. In some parts of the sections there was also scar tissue. At first nothing specific was found. On further search we discovered throughout the granulation tissue small masses resembling the "Druse" of actinomyces. The specimens were stained with hematoxylin and eosin and these "Druse" appear as dark blue areas, which under the low power are finely granular and have a radial arrangement, radiating toward the periphery. In so far as the low power examination is concerned, one can say with perfect certainty, that we have to deal with an actinomyces. That does not necessarily mean an actinomyces bovis; that is, it does not mean that it is exactly the same species that produces actinomycosis in cattle. Under the high power, the resemblance to the actinomycetic "Druse" is carried out still more decidedly in that one can see the club-shaped rods. One can see that many of these rods project out between the neighboring cells. By using this hand microscope, one can see with the low power the darker periphery and the radical arrangement of the "Druse." I have placed under this microscope one of these "Druse" under the high power, showing the peripheral clubs. The lower power view is, however, much more satisfactory than the higher power. We are justified here in making the pathologic diagnosis of actinomyces. We cannot say that this is the same species found in cattle. Twentynine species or varieties of actinomyces have been described. Inasmuch as we are not sure of the botanical position of the fungus, whether it is to be classed with the streptothrix, polymorphous bacteria, or the hypomycestes, we cannot definitely assign a name to the species. It is probable that actinomycosis is not a disease entity, but only a diseased con

dition produced by a number of closely-related fungi. This has been very well shown by Howard, in the Journal of Medical Research. So, although we cannot at the present time assign this organism to a definite species, we can give the diagnosis of actinomycosis, and make that without any reserve. The patient, therefore, has actinomycosis of the skin, which is a relatively rare condition. Similar cases of actinomycosis of the skin of the abdomen have been reported. The disease usually occurs in man in the respiratory tract, infection taking place. through the mouth. I have seen two cases in Vienna in which the infection was through the vagina, with metastatic growths in the uterus and in the liver. In these cases there was the peculiar greenish pus noticed by some observers. The number of cases altogether in the human being is not very large, so this case is very important.

The infection is supposed to be carried by some bit of vegetable material or wood. In a number of cases in the human being, it has been found to be chaff of wheat or splinter of wood. The habitat outside of the body is supposed to be wood, grain, lower plants, et cetra, so that a chaff of wheat or bran or hay or straw containing the parasite might be worked into the skin through some superficial abrasion caused by friction of the clothing. The scars seen over the abdomen of the patient are undoubtedly scars resulting from older actinomycotic lesions. The progressive advancement of the disease followed by healing and cicatrization is common to the infection and is very well shown here. Selfhealing of actinomycotic lesions may occur, and the prognosis in this case would be relatively favorable if the genitals were not involved, inasmuch as this involvement favors metastasis and extension to the peri

tonem.

AN INTRALIGAMENTOUS OVARIAN CYST: UTERUS SUBSEPTUS.

DOCTOR REUBEN PETERSON: This cast represents the first case I wish to speak of, a woman of thirty-one, whose previous history presents nothing of special interest. She noticed this swelling about eight months before she came to the hospital. At first it was about the size of an orange, starting on the left side of the abdomen. The tumor has given her pain at intervals, a rather uncommon condition in ovarian cysts, and led me, with other things, to think the growth was intraligamentous. You will notice the cast shows the characteristic appearance of intraligamentous cysts. It arises abruptly from the pubes and falls abruptly into the epigastrium, because it is bound down by the broad ligament. An interesting point in connection with this tumor is that the opposite tube contains pus, that is, we had pyosalpinx associated with an intraligamentous cyst. The tumor contained about one thousand cubic centimeters of a blackish fluid. This was withdrawn and the cyst enucleated in the ordinary way, cutting through the layers of the broad ligament and then peeling it out. There was considerable bleeding surface left. so I determined to remove the uterus and drain through the vigina. I am very glad that I decided to take out the uterus, because when the

specimen was taken to the laboratory, it was found to be a uterus subseptus. There was a septum in the center dividing the cavity into two, beginning a short distance below the internal os, then extending a short distance upward. Then there was the ordinary cavity at the fundus. I have seen a number of these divided uteri, but never a case where there was a partial septum like this. The after history of the case is uneventful, and the patient will leave the hospital tomorrow.

MALIGNANT OVARIAN TERATOMA, WITH TWISTED PEDICLE AND ASCITES.

The second case that I would like to speak of also presents some interesting features. This was a woman twenty-six years of age, who came to the hospital June 5 for swelling and pain of the abdomen. She first noticed this abdominal swelling after the birth of her child three months ago. She did not notice it before her pregnancy, but thought she was considerably larger than she had been with her previous children, although she was not sure that there was any abnormality in the abdomen. She was pregnant about seven months before she had any pain. Then she noticed the abdominal pain shortly after eating. The abdomen has been increasing in size ever since the child was born. On entrance to the hospital she presented some interesting symptoms. The abdomen was enlarged symmetrically from the pubes up to the umbilicus and I could feel what appeared to be two tumors, one situated to the right and the other above and to the left. It was quite difficult, on account of the considerable ascitic accumulation, to distinguish the connections of these growths. As nearly as I could discern, they were free from the uterus. A few days after she entered the hospital the ascitic accumulation became so much greater and she suffered so much from dyspnea that it was necessary to tap her. Considerable fluid was removed and we had a better opportunity to examine the growth. Then I concluded that, instead of there being two tumors, there was one, and that this tumor was not connected with the uterus. Then came the question of diagnosis. We considered the possibility of ovarian fibroid on account of the ascitic accumulation and because uterine fibroid could be excluded. This tumor seemed hard and firm and quite movable. It was suggested by Doctor Manwaring that there might be a twisted pedicle. I told him that I thought not because of the lack of symptoms. In twist of the pedicle, the symptoms are usually acute and there is much more tenderness than existed in this case. Upon opening the abdomen, however, it was found that Doctor Manwaring was right and that there were two twists of the pedicle, not sufficient to shut off the blood supply, but enough, however, to cause local peritonitis about the growth, and the intestine and omentum were adherent to the top of it. It was removed with ease and the woman has done remarkably well since.

According to Doctor Warthin, the tumor presents many of the characteristics of a malignant teratoma.

A CASE OF CHRONIC GASTRIC ULCER, WITH PERFORATION INTO THE DUODENUM.

DOCTOR PRENTISS B. CLEAVES: The case I wish to present is that of a woman fifty years of age, an American by birth, married, and a housekeeper by occupation. She was admitted to the hospital on May 5, 1903, complaining of great weakness, loss of weight, belching, vomiting, and insomnia. The family history was entirely negative-no carcinoma, tuberculosis, nor any other disease of importance. Personal and menstrual history were negative. She had had two children, no sepsis, and no abortions. She passed the menopause at the age of forty.

Twenty-two years ago, the patient was ill, with vomiting of sour material after every meal, and belching of gas. This condition improved very much, but eleven years ago at the time of menopause, the affliction. recurred, with frequent vomiting, which occurred without reference to meal time. On various occasions she would wake in the middle of the night and vomit two or three times. The vomitus had a bitter and sour taste, a disagreeable smell, and contained a great deal of mucus; also at times, some blood, which, her physician said, was due to the excessive straining. Such attacks of vomiting, lasting two or three weeks, recurred at intervals for about two years, but during the seven years until six months ago, the patient had been fairly free from vomiting, though troubled with belching and sour stomach.

About six months ago the patient was seized with pain in the left side of the abdomen, high up, of neuralgic character. This pain was relieved by pressure on a spot about two inches below the ensiform, a little to the left of the median line, where there was a great tenderness, however. She lost her appetite and vomited material similar to that described above, but containing no blood. There was no evidence of retention of food. She also had severe jaundice. Vomiting occurred cne-half to three hours after eating. The pain was uninfluenced by eating. Constipation was severe, and finally when the bowels did move, large black masses were passed. Until about six weeks ago the patient was fed by means of a tube passed through the nose. The abdominal pain ceased about five months ago. Vomiting continued until three weeks ago.

Many years ago, the patient weighed one hundred and seventy-six pounds. Her usual weight is one hundred and twenty-five pounds, but on May 6, she weighed sixty-eight and one-half pounds. Her habits. were very good. Her bowels were usually constipated, but recently there has been diarrhea. Appetite was good until ten years ago, since which time she has taken no potatoes, and little meat; no coffee nor tea. She formerly ate a great deal of hot bread.

At present she complains principally of sleeplessness; great weakness, so that she has been in bed for the past six months, and unable to raise herself for three months; twitching of the muscles; belching of gas, sour stomach and diminished appetite, which is entirely absent at the sight of food.