iodide independently though he has since become aware that Mendell so employed iodide. In Klemperer's report in 1915, he stated that the intravenous use of sodium iodide was well tolerated by different patients with only very slight by-effects. He used it especially in cases of general paralysis.

DeMatta (43) reported in 1916 that he began to use sodium iodide intravenously in 1914. In his report he stated that the results have been marvellous.

Farnell (44) has treated one case of oidiomycosis and one case with cutaneous and bone lesion closely resembling oidiomycosis by intravenous injections of hypertonic sodium iodide. He reports very rapid recoveries. We have been unable to find any report in the medical literature regarding the use of sodium iodide intravenously in treating actinomycosis.

We have used sodium iodide intravenously (Waterman) for approximately five years in various conditions and in no case has there been an unpleasant reaction. It is needless to say that careful technique is essential as in any intravenous therapy.

We have never employed it intravenously except in those cases where it was found impossible to give the iodide by the oral route, but it has been a pleasant surprise on many occasions to witness the beneficial result of sodium iodide, when indicated, with none of the unpleasant gastric symptoms. Kommer and Lucke (45) administered to rabbits by stomach tube large doses of potassium and sodium iodide repeatedly. The doses average as much as 15 grams, for 60 kgm. of body weight and they

repeatedly gave intravenous injections in amounts of approximately equivalent 1 gram per 60 kgm., as well as single intravenous injections in amounts equivalent to approximately from 10 to 30 grams per sixty kilograms, all of which did not cause tissue changes in the brain, heart or suprarenals. The kidneys, liver, lungs and spleen showed slight tissue reactions which may be interpreted as the result of a mild irritation due to the very large doses. They add that the dosage, compound, and route of administration did not produce any essential difference in the histologic changes and observed that their findings are in marked contrast to the well defined degenerative lesions produced by arsenic, mercury and bismuth.

We have watched the kidneys carefully while using the sodium iodide intravenously but have not observed any signs of kidney irritation.

The points of particular interest in this case are:

1. The absence of any etiological factors that might account for actinomycotic infection. The patient his lived in the city all her life and has never as far as known, been in contact with infected cattle or with exposed persons. There were no carious teeth or abrasions of the mucous membrane. The only thing that might be incriminating was the fact that the patient chewed grass in childhood.

2. That each time the patient became pregnant, actinomycotic symptoms appeared or were intensified.

3. Recurrence after apparent cure lasting sixteen months. This appears to be unique.

4. That roentgen-ray treatments

continued over a long period of time controlled the condition, but were not successful in eradicating it, relapses occurring when the treatments were stopped.

5. That intravenous massive injections of sodium iodide were efficacious in controlling the symptoms of the

disease and were well tolerated while slight doses were not.

6. That there was no idiosyncrasy towards iodism when the sodium iodide was injected into the blood stream in large doses, although the small amount caused severe reaction.

(1) BOLLINGER AND HARZ: Jahresber. d. k. Centr. Thierarzt. Schule, Muenchen, 1877-1878, p. 125.

(2) ISRAEL AND WOLFF: Virchows Arch. f. path. Anat., 1891, cxxvi, ii.

(3) PONFICK: Die Aktinomykose des Menschen, Berlin, 1882.

(4) BOESTROEM: Beitr. z. path. Anat., 1891, 1.

(5) WRIGHT: Jour. Med. Res., 1904, v, 13. (6) COLEBROOK: Brit. Jour. Exper. Path., 1915-16, iii, 55.

(7) LORD: Jour. Amer. Med. Assoc., 1910, lv, 1261.

(8) VON BARACZ: Ann. Surg., 1903, xxxvii, 336.

(9) McKENTY: Amer. Jour. Med. Sci., cxlv, 835.

(10) HARBITZ AND GRONDAHL: Beit. Z. path. Anat. u. allg. Path., 1911, 193. (11) SAWYERS: Jour. Amer. Med. Assoc., 1901, xxxvi, 1314.

(12) NEW AND FIGI: Surg. Gynec. and Obst., 1923, xxxvii, 617.

(13) MERIAR: Dermatol. Wchnschr., 1912. (14) LESER: Arch. f. klin. Chir., 1889, xxxix, 722.

(15) MONESTIé: Internat. Clinics, 1921, iii, 73.

(16) BASKIN: Jour. Amer. Med. Assoc., 1922, lxxviii, 1367.

(17) PONCET AND BÉRARD: Bulletin Academy de. med., Paris, 1911, lxv, 130. (18) THOMASSEN: L'Echo Vet., Liège, 1885, XV, 409.

(19) NOCARD: Rec. de. méd. veterinaire, Par., 1892, ix, 167 (Bulletin). (20) VAN ITERSON: Nederl. Tijdssch. v. Geneesk., 1889, xxv, 329. (21) U. S. Gov. Com. Report, Chicago, 1893. (22) BLOODGOOD AND MCGLANNAN: In Musser and Kelly's Practical treatment, 1911, ii, 617.

(23) BERARD: Internat. Clinics, 1921, iii, 107.

(24) KNOX: Lancet, 1906, ii, 1213. (25) ALLWORTHY: Brit. Med. Jour., 1909, ii, 453.

(26) MATTSON: Surg. Gynec. and Obst., 1922, xxxiv, 482.

(27) RYDGIER: Wien. Klin. Wchnschr., 1895, viii, 649.

(28) BITTNER AND TOMAN: Prag. med. Wchnschr., 1913, xxxviii, 383.

(29) BIGLAND AND SERGEANT: Brit. Med. Jour., 1923, ii, 61.

(30) DARIER AND GAUTIER: Ann. de Dermat., Paris., 1891, ii, 449.

(31) WILD: Brit. Med. Jour., 1910, ii, 851. (32) PINOY: Ann. de dermatol, 1913, iv, 545. (33) BEVAN: Jour. Amer. Med. Assoc., 1905, xlv, 1492.

(34) WHITE: Jour. Iowa St. Med. Soc., 1923, xvii, 105.

(35) PONCET: Lyon, Med., 1906, cvi, 226. (36) WAKELY: Arch. Radiol., 1923, xxviii,

129.

(37) HEYERDAHL: Jour. Amer. Med. Assoc., 1919, lxxiii, 1928.

(38) ISAACSON: New York Med. Jour., September 5, 1923, cxviii, 322. (39) DEWAR: Brit. Med. Jour., 1903, ii, 1328.

(40) BAIN: Glasgow Med. Jour., 1909, v, 345.

(41) MENDELL: Therap. d. Gegenwart, 1908, xlviii, 298.

(42) KLEMPERER: Therap. d. Gegenwart, 1915, lvi, 85.

(43) DAMATTA: Brazil Med. Jour., 1916, Xxx, 321.

(44) FARNELL: Arch. Neurol and Psychiat., 1922, vii, 729.

(45) KOLMER AND LUCKE: Arch. Der. and Syphil., 1924, ix, 242.

TH

HE great majority of cases of intra-abdominal neoplasms come first into the hands of the internist, receive from him their first clinical examination, and as the result of his differential interpretations are separated into purely medical cases or cases to be referred to the surgeon for further diagnostic consideration or for operation. With both of these classes of cases the roentgenologist occupies a middle ground of diagnostic recourse and aid. Of all the varied forms of abdominal tumors that may present themselves to the clinician, the most difficult and baffling group consists of those retroperitoneal neoplasms that may be unassociated with urinary disturbances. To this group belong the retroperitoneal lymphosarcomas, lipomas, and fibromas, and various tumor-like disturbances of development connected with adrenal or kidney, and the different types of retroperitoneal cysts. These may all offer great difficulties in diagnosis to clinician, roentgenologist and surgeon, and the problem is often solved only at operation, or in not a few cases, the operation failing to reveal the true nature of the condition, at autopsy only. Fortunately in individual practice these cases present themselves rarely as a rule, but in large general hospitals where difficult

cases are concentrated they are more frequently seen. Whenever appear

ing, however, they constitute difficult clinical problems, and our diagnostic difficulties may be lessened if they are accorded especial study. It is for these reasons that we consider it of practical value to place on record the report of a case of a rare form of retroperitoneal tumor presenting the difficulties of differential diagnosis mentioned above.

CASE REPORT

Our patient, Mrs. C., aged sixty, and housewife by occupation, entered our clinic first in December of 1923. At that time she had been operated on twice for a mass in the left upper quadrant without obtaining any relief.

Chief complaint. She complained of pain in the region of the left kidney and the presence of what she called a "tumor in the left side."

Family history. Essentially negative. Menstrual history. Reached puberty at the age of fourteen. Catamenia regular twenty-eight days, with some dysmenorrhea which lasted until the early part of her twenties. She does not recall when her menopause began but claims that she has had no bleeding for a period of several

years.

Marital history. The patient has been a widow for sixteen years. During her marital life she was pregnant once and gave birth to a normal child who is living and well today at the age of twenty-four.

Past history. Denies the usual diseases

of childhood and claims that her past general health has been excellent with the exception of an occasional cold.

Present illness. The patient dates her present illness to four years ago when she began to have pain in her left side which was not continuous but markedly influenced by exertion. This pain was dull in character but occasionally became sharp and stitchlike. There was no mass in her abdomen at that time, nor did she notice anything peculiar until about a year from the onset of the pain, when she thinks she passed "red urine" occasionally. The pain became more marked, continuous and almost unbearable with absolutely no temporary relief and she began to lose strength and flesh.

In the summer of 1922 she visited a physician who advised an operation on an abdominal mass. She was therefore sent to Harper Hospital, Detroit, Michigan, for an x-ray study.

On August 30 of that year a fluoroscopic and film study was made and the following report issued:

"There is a lesion involving the lesser curvature of the stomach, middle third. The appearance is that not usually associated with an infiltrating carcinoma of the gastric walls. The findings, however, suggest somewhat an extra gastric tumor or a new growth which is in the gastric wall and not arising in the mucosa."

She was admitted to the hospital the following day with a diagnosis of "Obstruction in the upper gastro-intestinal tract, possible carcinoma, stomach carcinoma probably inoperable."

She was advised, however, that, if she so desired, an operation would be performed for the purpose of seeing the extent of the tumor, and on September 5, 1922, she left the hospital to consider whether she should be operated or not.

She returned to the hospital September 9 and added to her complaints constipation and bloody stools. She decided on an operation.

The laboratory reports showed: A mild secondary anemia; red blood cells 3,950,000; polynuclear cells 73 per cent; lymphocytes 25 per cent; hemoglobin 75 per cent.

She was not a poor operative risk so that on September 12, under gas and ether anesthesia, the patient was operated upon.

The surgeon reported: "Usual incision made, high right rectus for exploration only, for what we believe to be an inoperable carcinoma probably involving the liver and pancreas. Examination showed that the carcinoma was very extensive and apparently involving the entire pancreas. There was no involvement, as far as could be determined, of the liver.

"Diagnosis made of carcinoma of the pancreas by family physician.”

"No fluid in abdominal cavity. Pancreas six times normal size and stony hard. Prognosis absolutely hopeless as had been determined before operation."

On September 29 she was referred for deep x-ray therapy-"Area over the abdomen, right lateral, 200 KV. 1.3 mm. Cu. 1. mm. Al, 45 C.M. S. T. D., 5 M. A. two and one-quarter hours. (675 M. A. Min.)"

On June 20, 1923, the patient was admitted to the University Hospital at Ann Arbor because of constant pain.

Her history remained unchanged. Physical examination showed a poorly developed and undernourished old woman, apparently older than stated age.

Chest negative.

Abdomen showed a firm mass in the left upper quadrant, partially covered by the rib margin and extending down to the level of the umbilicus and as far over as the mid line. It was firmly fixed. There was no costo-vertebral tenderness and the tumor could not be felt in the flanks as is commonly the case with tumors of the kidney.

On July 2 a cystoscopy was done and showed a normal bladder and ureteral orifice. The left ureter was easily catheterized, but only a small amount of urine was obtained. This urine showed a considerable amount of albumin and pus, the low power cell count averaging about 200 cells per field.

An x-ray study was requested and the following report issued: "Stereoscopic plates made of the kidney followed by the introduction of a catheter into the left ureter and kidney followed by injection. Striking feature of the examination is the presence of shadows on the right side along the border of the liver which apparently are caused by six or more gall stones. There is an elongated and distorted pelvis. There is an apparent constriction at what appears

right. Phthalein appeared equally on both sides in three minutes, but the left showed 11.2 per cent in ten minutes while the right registered but 8 per cent.

A tentative diagnosis of tumor of the kidney was made and an exploratory operation advised. (Before the operation films of the chest were made to determine the presence of any metastasis. These were negative.)

On July 11 an exploratory operation was performed by Dr. Hugh Cabot. A trans

some exploration it appeared to me to be quite impossible for removal and I, therefore, abandoned the attempt and closed up the wound. I am still ignorant of the source of this tumor. It was very hard and did not particularly resemble the retroperitoneal sarcomas which are, perhaps, the common type of tumor in this neighborhood. suggested tumor of the retroperitoneal glands secondary to some type of carcinoma, but I was unable to demonstrate any source."

I