128 FACIO-CERVICAL ACTINOMYCOSIS mittee for severl yers, but cted s its Chirmn from Februry, I929, until the time of his deth. His uncesing work on behlf of overses post-grdutes will not be forgotten by those who were fortunte enough to come into contct with him. Dme Mry Schrlieb, Sir Andrew Blfour, Mr. Dunn, nd Dr. Soltu were ll loyl supporters of the work of the Fellowship nd hve been ssocited with it since its first dys. Conclusion. The sincere thnks of the Fellowship re due to the President nd Council of the Royl Society of Medicine for their continued generosity in plcing n office nd Committee rooms t the disposl of the Assocition. Your Honorry Secretries desire lso to thnk very hertily the members of the stffs of the vrious hospitls for their cordil co-opertion, nd especilly those who hve tken prt in the Specil Courses, without whose help it would hve been impossible to show the results recorded in this report. Lstly, the Honorry Secretries desire to thnk sincerely Miss Mry Roy nd Miss Mon Worth for their services during the pst yer. Sin HERBERT J. PATERSON, gned ARTHUR J. WHITING, Honorry Secretries. FACIO-CERVICAL ACTINOMYCOSIS. By HAMILTON BAILEY, F.R.C.S.ENG. Surgeon, Royl Northern Hospitl. ON severl occsions medicl science hs been dvnced by lte-comers from other wlks of life. One such dvnce ws mde when Bollinger [x], veterinry surgeon, embrced the medicl profession nd found in the necks of men condition similr to tht which he hd seen in the mouths of cttle. After Bollinger hd led the wy lesions due to ctinomycosis were found in humn ptients by clinicins the world over. This hs occurred within living memory, s will be pprecited when we re reminded tht the gret John B. Murphy [2] reported the first cse of ctinomycosis in the continent of Americ. Two-thirds of ll humn cses of ctinomycosis occur in the neck nd fce. At the present time this disese is often misdignosed, indeed, ctinomycosis vies with brnchil cyst [3] for the premier plce s the most frequently missed lesion in the fcio-cervicl region. This is strnge coincidence for these two conditions re the very ones bove ll others where the dignosis cn be confirmed with irrefutble precision nd scientific ccurcy there nd then by the clinicin himself. Clinicl Fetures of Fcio-cervicl A ctinoinycosis. There is incresing evidence to show tht the ry fungus gins entrnce through wound of the mucos, prticulrly from the lcerted gum fter tooth extrction. A. Christ [4] sw three consecutive cses of ctinomycosis following n ccidentl wound of the mouth. Boyksen [5] hs seen two cses develop in old wr wounds. A sinus, or sinuses, bout the upper prt of the neck or over the jw (see figs.), prticulrly indurted sinuses, should rouse suspicion immeditely. The skin bout the sinus my pper somewht mottled. On plption ech burrow feels hrd like strnd of whipcord; usully enlrged glnds re conspicuous by their bsence. There is no pin unless the disese is very dvnced nd nerves become implicted in fibrous tissue. As the disese progresses the ptient becomes nemic. The pus is thin nd wtery, which brings us to the most importnt point in the dignosis of the cse. Clinicl Confirmtory Tests. Method i.-collect drop of pus on glss slide. Press nother slide or cover slip over it so s to mke sndwich, nd hold it to the light. If the sinus hs recently
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commenced to. dischrge, or if n bscess hs been recently opened, sulphur grnules (see colour figure), which re clumps of the fungus, re often seen. Method 2.-When sinus hs been dischrging for weeks or months the grnules re more difficult to demonstrte. Express few drops of pus from sinus into test tube hlf full of wter nd plug the tube with cork. Now shke vigorously, nd the elements of pus become emulsified, but sulphur grnules re not broken up. They sink to the bottom nd cn be distinguished by holding the tube up to strong light. When secondry infection hs occurred this process my hve to be repeted t intervls of one or two dys for some time, but if the cse is one of ctinomycosis it will not be long before the ll-importnt grnules cn be demonstrted to everyone's stisfction. Modes of Spred.-The disese spreds by direct continuity. It burrows upwrds towrds the sclp or downwrds into the suprclviculr foss, when the medistinum is endngered. Spred by the lymphtic strem is prcticlly unknown, nd it is truly remrkble tht this fvourite chnnel for dissemintion of ll other infective processes should enjoy such degree of immunity in in the cse of the ry fungus. Lte in the course of the disese blood-borne metstses re not very rre, the liver nd the brin being the two regions most commonly invded in this wy. Untreted the disese runs rther chronic, but nevertheless surely ftl course. To recognize it erly is to be enbled to cure it regulrly. Tretment.-Bollinger, to whom we owe so much, pplying his veterinry knowledge, treted humn ctinomycosis with mssive doses of potssium iodide. The results, on the whole, were good, but further dvnce in tretment ws mde in I923 when H. Chitty introduced iodized milk therpy. 'We will proceed to describe the present methods of procedure. An X-ry of the jw is tken, but in none of the cses which I hve seen hs there been ny bone disese FACIO-CERVICAL ACTINOMYCOSIS 129 present. In ech of the cses illustrted the rdiogrms, sometimes repeted, were negtive. The dentl surgeon ttends to crious teeth, erring on the side of extrction rther thn repir. Forty-eight hours lter the surgeon lys open the sinuses long their course nd pcks with nrrow strips of guze soked in iodine. These re removed in forty-eight hours nd guze dressing is substituted. As soon s the dignosis hs been confirmed intensive iodine therpy is commenced. Three times dy the ptient drinks hlf pint of iodized milk prepred in the following mnner: Five drops of fresh 2 per cent. tincture of iodine re stirred into the cupful of milk, to which, if possible, tespoonful of crem hs been dded. The iodine forms colourless orgnic compound with the crem, chemiclly sid to be n iodized ft. The dose of iodine is grdully incresed until Io minims re tken three times dy in milk. There is no necessity to push the dose of iodine beyond io minims, nor is there ny method of dministering the iodine hlf s effective s tht described by For instnce, intrvenous colloidl Chitty. iodine, which theoreticlly might be supposed to be superior, is comprtively useless. The ptient cn, if necessry, continue his iodine in milk for months. He should be wtched for signs of iodism which re chrcterized by hevy pin over the frontl sinuses, running from the nose, slivtion nd erythemtous blotches of the skin. Usully the drug is well tolerted, nd in ddition it cts s generl tonic. As improvement sets in course of locl nd generl rtificil sunlight is beneficil. Under this regime the sinuses soon hel nd cure cn be hopefully nticipted except in the most dvnced cses. In the first nd second of the cses illustrted the method proved effective. Within six weeks the lesion hd completely nd permnently heled. In the third cse, which ws very dvnced, progress hs been slow, but sure. He is still under tretment.
13 " HAMMER-TOE" Even with this tretment there re few rebellious cses. Implnttion of rdon seeds or rdium itself my be tried, nd to judge by the few reported cses rdium is highly beneficil. REFERENCES. [1] HARGER, J. R. Surg. Gynec. nd Obstet., 192, xxxi, 35 (OCHSNER, A. J., in Discussion.) [2] SANFORD, A. H. Journ. Amer. Med. Assoc., 1923, xxxi, 655. L3] BAILEY, HAMILTON. (Brnchil Cysts," London, 1929. [4] CHRIST, A. Schweiz. med. Woch., 1925, Iv, 643. f5] BOYKSEN, A. Zentrlbl. f. Chirur., 1928, Iv, 1542. [6] NEW, G. B., nd FIGI, F. A. Surg. Gynec. id Obstet., 1923, xxxvii, 617. [7] CHITTY, H. Brit. Med. Journi., 1926, i, 418. [8] Idem. Ibid., 1929, i, 347. [9] HALE-WHITE, Sir W. "Mteri Medic,' 14th Edition, 1915, p. 253, London. "HAMMER-TOE." By S. L. HIGGS, F.R.C.S. Surgeon, Royl Ntionl Orthopcedic Hospitl; Assistnt Surgeon, Orthopdic Deprtment, St. Brtholomew's Hospitl, &c. THE term " hmmer-toe" should be confined to tht type of flexion deformity which cnnot be overcome by simple stretching. It therefore excludes ll types of "clwtoes" which re commonly ssocited with the wering of short stockings nd shoes, or with othe^ foot deformities, such s pes cvus or loss of the trnsverse rches. The true " hmmer-toe" cnnot be strightened by trction becuse this is prevented by ctul contrcture of the skin nd soft tissues beneth the flexed joint. CAUSE. The condition is rrely found in infnts. It is n cquired deformity nd the chief fctor in its development is n over-long toe. If short socks or shoes re worn the, projecting toe is pressed bck into line with the others nd hs to ssume the flexed position. As growth proceeds this deformity becomes fixed nd lter on pressure symptoms develop. TYPES. The typicl "hmmer-toe" shows flexion deformity of the proximl interphlngel joint whilst the mettrsophlngel nd distl interphlngel joints re hyper-extended. The only fixed deformity in this type is the flexed middle joint. This is by fr the commonest vriety 1J.5..3 Occsionlly the terminl joint is flexed nd the esiest to tret. insted of extended, producing double flexion deformity. A third type shows flexion joint only. of the terminl SYMPTOMS. Pin occurs in three situtions. Firstly, in the common type, over the prominent joint from pressure of the shoe. A corn nd underlying burs develop, nd ttcks of cute inflmmtion re not uncommon. Secondly, pin mybe complined of beneth the bll of the foot. The hyper-extended first phlnx presses downwrds the hed of the corresponding mettrsl, leding to loss of the trnsverse rch nd consequent mettrslgi. Lstly, if the end joint is flexed pinful corn my develop round the nil t the tip of the toe where pressure occurs. TREATMENT. The development of "hmmer-toe " cn be prevented in children by the wering of full-length socks or stockings. Mothers