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A

LTHOUGH the literature con

cerning human actinomycosis is extensive, both regarding the etiology and the treatment of the disease, yet we believe that certain features of a case of cutaneous actinomycosis, which we recently observed and treated, are of sufficient novelty and interest to warrant publication.

The occurrence of actinomycosis is probably much more common in the United States than is believed, and it is desirable that as much as possible should be known about the course of the disease and its treatment.

In

Actinomycosis is a fungoid infectious disease due to the anaerobic trichomycete the occurrence of which in cattle has been known for a long time. Bollinger and Hartz (1) discovered the specific organism in 1877 and gave it the name actinomycosis bovis. In 1878 Israel and Wolff (2) isolated the same organism from a human subject. Ponfick (3) showed that the organisms found in cattle and man were identical. Boestroem (4), Wright (5) and others have described many different biological types, and in many cases the fungus isolated differed considerably from that which is usually considered as pathognomonic (Boestroem's) fungus. Colebrook (6) isolated more than twenty different strains of actinomyces from human subjects.

There is some difference of opinion as to pathogenesis of the disease in man. Some believe that actinomyces are normal inhabitants of the human digestive tract; that carious teeth, tonsillar crypts and the intestine can harbor the organisms; others believe that the organisms enter the system through the medium of ingested grasses or vegetables. Others still think that the disease is transmitted from animal to man. In the great majority of cases reported in the literature the patient gave a history of either being directly addicted to chewing straw or some other vegetable production or of having been in contact with infected cattle. Colebrook (6) rather doubts the vegetable origin theory of human actinomycosis. He found that the common organism occurring in plants is an aerobic fungus whereas the organisms found in animal bodies are mostly anaerobic.

As support for the view that actinomyces may be normal inhabitants of the human mouth, Lord (7) injected five animals with material obtained from the teeth and tonsils of human subjects not clinically showing actinomycosis. In 3 out of 5 inoculated animals he succeeded in producing a disease histologically identical with actinomycosis.

Actinomycosis may occur in any

part of the body, but the head and neck (especially lower jaw) abdomen and lungs are the most usual regions. Cutaneous actinomycosis, unassociated with a lesion elsewhere, is comparatively rare. The following statistical accounts relative to sites of election are of interest. Von Baracz (8) collected 60 cases of which 86 per cent were in the head and neck. Of 37 cases collected by McKenty (9), 51 per cent were in the head and neck. Harbitz and Grondahl (10) collected 87 cases of human actinomycosis in Norway. Of these 39 were in the head and neck, 20 in the lungs, 26 in the abdomen and 2 were cutaneous. Sawyers (11) says that about one-half the cases occur in the head and neck and one-fifth in the thorax and lungs.

According to New and Figi (12) 157 cases of actinomycosis were examined at the Mayo Clinic from 1913 to 1922. In 107 the disease involved the head and neck (68 per cent). Ninety-eight of the 107 patients were males and nearly 70 per cent of these were between the ages of twenty-one and fifty years. Eighty-seven were farmers or laborers. Of the 107 patients, 56 per cent had not, as far as was known, been in contact with the disease in animals. Of the 107 cases 37 or 34.6 per cent were in the parotid region and outside of the cheek, this being the largest percentage of regional location in head and neck.

Primary actinomycosis of the skin is comparatively rare. The skin of the face or hands may become infected through abrasions, or an infection in the mouth through an abrasion of the mucous membrane may reach the skin of the cheek. Merian (13) in 1912

found only 25 cases of primary skin actinomycosis recorded up to then in the literature. Generally in the head and neck actinomycosis of the skin is secondary. Leser (14) who was one of the first to study actinomycosis of the skin states there are two types: (a) an ulcerating type in which there is a partially necrotic and a partly hard, firm granular area; and (b) a discreet nodular skin infiltration with central cicatrizations and peripheral extensions as in lupus.

Both these types may occur together and the evolution may be acute, sub-acute or chronic.

Monestié (15) says that cutaneous lesions are wine colored with dark slatey or bluish-red spots scattered over the lesions. These spots reach about the size of a lentil, are irregularly round, semi-transparent and give the impression that there is a gelatinous substance beneath the epidermis, and he says that a very important sign of cutaneous actinomycosis is a collection of these dark spots standing out against the rest of the lesion varying from the size of a lentil to that of a pinhead with a whitish point seen at the center. There is a zone of infiltration, almost woody to the feel, about a central superficial zone. He saw enlarged lymph nodes in all his cases although others think the lymphatics are not involved.

According to Baskin (16) the first sign is a small firm subcutaneous nodule which is fairly movable. The skin over this gradually discolors and bursts discharging a yellowish droplet. Others appear and discharge in the same way. From the discharge the organism may be easily cultured. Propagation is by extension. As the