Chapter V

), and is mentioned here rather because of its specific

character. It is characterized by rapidity of spread and the specific nature of the exudate, as well as by the speedy destruction of the tissue involved, and by more or less gas formation. It is not the same as the gaseous phlegmons described by some German surgeons, yet partakes of their general character. _Gas phlegmons_ have been rarely noted, their peculiarity being formation not only of pus, but of more or less offensive gases, which escape when the phlegmon is incised. The gases are mainly due to the presence of _bacillus aërogenes capsulatus_, and gas phlegmons, as such, are to be regarded as instances of mixed or rarely pure infection.

Malignant edema is known by the brownish discoloration of the overlying skin, which is streaked with blue where the overfilled veins show through it, while the underlying tissues are sodden with fluid and more or less inflated by the gaseous products of decomposition, so that the finger detects a firm crepitus, as is common in subcutaneous emphysema. From the wound, if there is one, flows a thin, foul-smelling secretion, which may also be expressed from the deeper layers. That the neighboring lymph spaces and nodes are actively involved is evident from the enormous swelling of the latter, as well as from the general condition of the patient. The rapid elevation of temperature with but trifling remissions remains constant until shortly before death. The tongue early becomes dry and cleaves to the palate, its surface being covered with a thick, foul fur. Patients early become apathetic, complaining only of pain and burning thirst. Delirium and coma usually precede death, which may occur in fifteen to thirty hours. After death the cadaver bloats quickly and putrefaction goes on with amazing rapidity.

=Postmortem Appearances.=--At the seat of the lesion even muscles and tendons will be found macerated, bone denuded and surrounded by a putrid fluid, the entire region presenting a notable swelling and infiltration of soft parts with reddish fluids and stinking gases. The overlying skin will be stretched, and superficial blisters may deepen the intensity of the process. The veins are clogged with decomposed blood and broken-down thrombi, and in the heart and large vessels will be found putrid liquid as well as gas, to whose presence early and sudden death is probably due.

=Prognosis.=--This is unsatisfactory, especially when the bacillus of malignant edema is alone at fault. Patients may escape with their lives, but always at the expense of more or less tissue destruction.

=Treatment.=--This should consist of extensive incision to permit escape of fluids and gases and relieve tension; of such antiseptic applications as can be made available; of immersion of the affected

## part in a hot antiseptic bath; and of such vigorous stimulation by the

most powerful measures--strychnine, alcohol, etc.--in order to support the patient through the period of profound depression characteristic of the disease.

[Illustration: PLATE V

## Actinomycosis. Ray Fungus in Man. (Gaylord.)]

## ACTINOMYCOSIS.

This also is a _subacute_ but always _destructive infection by a specific microörganism, though not a bacterium_. Known always as _actinomycosis_ in man, the disease, which is most common in cattle, is called _lumpy jaw_ or _swelled head_, and years ago was usually regarded as cancer or as a malignant affection.

Many museum specimens labelled as cancer of the tongue, jaw, etc., have been shown to be instances of actinomycosis of these parts. It is occasionally met with in man, so that there are at least four hundred cases on record in this country and in Europe. The organism was recognized a half-century ago by Langenbeck and Lebert, but was not scientifically described until many years later. The names of Bollinger, Israel, and Ponfick will always be connected with these researches.

The organism belongs among the _ray fungi_, is known as the _actinomycis_, and occupies an uncertain place in classification. It is large enough, when entire, to be perceived by the naked eye, has ordinarily a yellowish tint, a tallowy consistence, and may be seen under the microscope to consist of a cluster of branching prolongations, club-shaped at the end, radiating from a common centre. They give it a sunflower appearance. It is stained with difficulty, the best stain being a combination of picrocarmine and an aniline dye. In tissue sections the Gram stain is the best. It is cultivated with difficulty, but can be grown upon solid media and may be inoculated. (See Plate V.)

As met with in tissue or in pus these fungi constitute small granulations, giving usually a gritty sensation to the finger, which is due to the presence of calcium salts. The recognition of this calcareous material is of importance, since it may enable a diagnosis to be made offhand, in a case which otherwise might puzzle one.

The disease is very common among cattle in certain regions, and causes the condemnation of many animals in every large stockyard establishment where inspection is careful and scientific. It occurs oftener in young than in old animals, and most frequently in those which come from valley regions and marshes. In animals infection occurs almost invariably through the mouth, which is easily explained by the fact that, in grazing, the lips, tongue, and gums are likely to be irritated and infected at any time from soil containing these fungi along with growing grain. The path of infection is usually by the mouth, while accident seems to determine whether the infection shall manifest itself mainly in the intestinal canal or the respiratory tract. In animals there is less tendency to suppuration than in man, the infection in man being usually a mixed one. The name _lumpy jaw_, so generally given to the affection, is indicative of the most conspicuous lesion in cattle, for the organism, having once invaded the gum, for instance, passes quickly to the bone, or, having involved the tongue, is not slow to infect the lymphatics of that region. In consequence we have tumors, often of inordinate size, which may involve the bones or the soft parts and cause great disfigurement, along with necrosis, leading eventually to the death of the animal. These tumors are essentially _granulation tumors_ due to the presence of a specific irritant--the _actinomycis_--which acts here as do the tubercle bacillus, the lepra bacillus, etc., in other infectious granulomata.

In man the disease is generally accompanied by abscess formation, the pus containing the distinctive yellow gritty particles which are found in no other disease. The strong resemblance between the lymphoid cells of this form of granuloma and the embryonal cells of sarcoma has permitted the perpetuation of confusion between these two neoplasms.

[Illustration: FIG. 19

## Actinomycosis in man. (Lexer.)]

Large abscesses form as the result of the coalescence of small ones, and by the time the disease is recognized extensive destruction and loss of substance may have taken place. In man it is not alone about the mouth that the disease is noted, although primary lesion here is by no means infrequent. It leads to affections similar to that already spoken of in cattle, with a progressive infiltration and breaking down, including actual necrosis of bone, etc. The pus will escape at various points, and may give to the surface an appearance as of many craters with a central cause. When the disease has involved the lung, either directly or indirectly, the fungi and the calcareous particles may be found in the sputum. Should there be suspicion of this involvement, the sputum should always be examined. Even in the heart substance tumors of this same character have been found. The first case noted in man had undergone extensive vertebral caries. Intestinal infection is possible, in which case multiple lesions will form in the intestinal walls, which may contract adhesions to the abdominal parietes and discharge externally through them. The appendix has been found involved in such lesions. Infection of the skin has also been described, though this occurs more rarely.

=Diagnosis.=--Actinomycotic lesions have been _mistaken for cancer_, _sarcoma_, _tuberculosis_, _syphilis_, etc. In man it will always be characterized by more or less suppuration, and in the purulent discharge from the infected focus the yellow calcareous particles should enable recognition of this disease at once.

=Prognosis.=--As long as the focus is accessible it is a purely local matter, and prognosis is as favorable as in local tuberculosis; but, inasmuch as in many cases infection has proceeded to a point where the surgeon cannot safely follow it, prognosis must be guarded.

## Actinomycosis is free from acute manifestations, for the main part free

from pain, pursues a chronic course, and is characterized, as are the other slow infections, by progressive emaciation, prostration, etc. As it is essentially a chronic condition, time is afforded for careful study in doubtful cases, for microscopic examination, etc.

=Treatment.=--This must consist of extirpation of all infected tissues and areas. If this can be done thoroughly there is a prospect of positive cure. Free incision, wide dissection, the use of the actual cautery, etc., are always called for in these cases. If it involves the tongue alone, there is an excellent prospect; if but a portion of the jaw is involved, a complete excision of one-half or more may be followed by excellent results. If, however, the lung, liver, vertebrae, or other vital and inaccessible parts are involved, surgical measures may afford amelioration, but can hardly be expected to cure.

Iodine, alone or in combination, has been found efficacious in the therapy of actinomycosis. In diluted solutions used locally, or as potassium iodide given internally or injected into tumors, it doubtless has a beneficial effect during the period of its administration. Recent reports and experiences show that great value attaches to the use, as suggested by Bevan, of copper sulphate in the treatment of

## actinomycosis, its use having been suggested by the fact that copper

is used to destroy rusts (fungi) on grain. One-half grain (3 Cg.) may be given internally three times a day, while the sinuses are irrigated with a 1 per cent. solution. I have seen apparently complete cure of an aggravated case follow its use. Incidentally it may be stated that Bevan advises its use also in cases of blastomycosis.

MADURA FOOT.

While _madura foot_ is not a disease from which domestic animals suffer, its general characteristics make it a proper subject for brief consideration. It is essentially a disease of the tropics and subtropics, and is often seen in some of our new possessions.

It commences as a painless swelling upon either aspect of the foot, in which hard nodules form, which later soften, ulcerate, and discharge puruloid material containing granules in which the microscope reveals mycelia of the peculiar fungus that produces the disease. In some cases these particles are black, in others colorless. The disease is of slow progress, and the lower limbs become weak, atrophied, and finally useless Death results from exhaustion or some terminal infection.

The principal lesion is the slowly growing gumma or granuloma, whose presence is unmistakable. This is due to the presence of a fungus, called by Vincent the _streptothrix maduræ_. Thus in its pathology the disease much resembles actinomycosis. The habitually bare feet of most of the inhabitants of the tropics and the habitat of the fungus explain the site of the primary lesion.

=Treatment.=--The only _treatment_ is extirpation of the growth--_i. e._, amputation.

[Illustration: PLATE VI

Tuberculosis of Testicle.

Miliary Tubercle with Caseation and Giant Cells. (Gaylord and Aschoff.)

_a_, seminal tubules; _b_, giant cells; _c_, caseated tubercles.]

##