128 FACIO-CERVICAL ACTINOMYCOSIS

mittee for several years, but acted as itsChairman from February, I929, until the timeof his death. His unceasing work on behalfof overseas post-graduates will not be forgottenby those who were fortunate enough to comeinto contact with him. Dame Mary Scharlieb,Sir Andrew Balfour, Mr. Dunn, and Dr. Soltauwere all loyal supporters of the work of theFellowship and have been associated with itsince its first days.Conclusion.The sincere thanks of the Fellowship are due

to the President and Council of the RoyalSociety of Medicine for their continuedgenerosity in placing an office and Committeerooms at the disposal of the Association. YourHonorary Secretaries desire also to thank veryheartily the members of the staffs of the varioushospitals for their cordial co-operation, andespecially those who have taken part in theSpecial Courses, without whose help it wouldhave been impossible to show the resultsrecorded in this report.

Lastly, the Honorary Secretaries desire tothank sincerely Miss Mary Roy and Miss MonaWorth for their services during the past year.

Sin HERBERT J. PATERSON,gned ARTHUR J. WHITING,Honorary Secretaries.

FACIO-CERVICALACTINOMYCOSIS.By HAMILTON BAILEY,

F.R.C.S.ENG.

Surgeon, Royal Northern Hospital.

ON several occasions medical science hasbeen advanced by late-comers from otherwalks of life. One such advance was madewhen Bollinger [x], a veterinary surgeon,embraced the medical profession and foundin the necks of men a condition similar tothat which he had seen in the mouths ofcattle. After Bollinger had led the waylesions due to actinomycosis were found inhuman patients by clinicians the world over.This has occurred within living memory, as

will be appreciated when we are remindedthat the great John B. Murphy [2] reportedthe first case of actinomycosis in thecontinent of America.

Two-thirds of all human cases of actino-mycosis occur in the neck and face. Atthe present time this disease is often mis-diagnosed, indeed, actinomycosis vies withbranchial cyst [3] for the premier place asthe most frequently missed lesion in thefacio-cervical region. This is a strange co-incidence for these two conditions are thevery ones above all others where the dia-gnosis can be confirmed with irrefutableprecision and scientific accuracy there andthen by the clinician himself.

Clinical Features of Facio-cervicalA ctinoinycosis.

There is increasing evidence to show thatthe ray fungus gains entrance through awound of the mucosa, particularly from thelacerated gum after tooth extraction. A.Christ [4] saw three consecutive cases ofactinomycosis following an accidentalwound of the mouth. Boyksen [5] has seentwo cases develop in old war wounds.A sinus, or sinuses, about the upper part

of the neck or over the jaw (see figs.),particularly indurated sinuses, should arousesuspicion immediately.The skin about the sinus may appear

somewhat mottled. On palpation eachburrow feels hard like a strand of whipcord;usually enlarged glands are conspicuous bytheir absence. There is no pain unless thedisease is very advanced and nerves becomeimplicated in fibrous tissue. As the diseaseprogresses the patient becomes anaemic.The pus is thin and watery, which brings usto the most important point in the diagnosisof the case.

Clinical Confirmatory Tests.Method i.-Collect a drop of pus on a

glass slide. Press another slide or a cover

slip over it so as to make a sandwich, andhold it to the light. If the sinus has recently

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FACIO-CERVICAL ACTINOMYCOSIS 129

commenced to. discharge, or if an abscesshas been recently opened, sulphur granules(see colour figure), which are clumps of thefungus, are often seen.Method 2.-When a sinus has been dis-

charging for weeks or months the granulesare more difficult to demonstrate. Expressa few drops of pus from a sinus into a testtube half full of water and plug the tubewith a cork. Now shake vigorously, andthe elements of pus become emulsified, butsulphur granules are not broken up. Theysink to the bottom and can be distinguishedby holding the tube up to a strong light.When secondary infection has occurred thisprocess may have to be repeated at intervalsof one or two days for some time, but if thecase is one of actinomycosis it will not belong before the all-important granules canbe demonstrated to everyone's satisfaction.

Modes of Spread.-The disease spreadsby direct continuity. It burrows upwardstowards the scalp or downwards into thesupraclavicular fossa, when the mediastinumis endangered. Spread by the lymphaticstream is practically unknown, and it is trulyremarkable that this favourite channel fordissemination of all other infective processesshould enjoy such a degree of immunity inin the case of the ray fungus. Late in thecourse of the disease blood-borne metastasesare not very rare, the liver and the brainbeing the two regions most commonly in-vaded in this way. Untreated the diseaseruns a rather chronic, but neverthelesssurely fatal course. To recognize it earlyis to be enabled to cure it regularly.

Treatment.-Bollinger, to whom we oweso much, applying his veterinary knowledge,treated human actinomycosis with massivedoses of potassium iodide. The results, onthe whole, were good, but a further advancein treatment was made in I923 whenH. Chitty introduced iodized milk therapy.'We will proceed to describe the presentmethods of procedure. An X-ray of thejaw is taken, but in none of the cases whichI have seen has there been any bone disease

present. In each of the cases illustrated theradiograms, sometimes repeated, were nega-tive. The dental surgeon attends to cariousteeth, erring on the side of extraction ratherthan repair. Forty-eight hours later thesurgeon lays open the sinuses along theircourse and packs with narrow strips ofgauze soaked in iodine. These are removedin forty-eight hours and a gauze dressing issubstituted. As soon as the diagnosis hasbeen confirmed intensive iodine therapy iscommenced. Three times a day the patientdrinks half a pint of iodized milk preparedin the following manner: Five drops offresh 2 per cent. tincture of iodine are stirredinto the cupful of milk, to which, if possible,a teaspoonful of cream has been added. Theiodine forms a colourless organic compoundwith the cream, chemically said to be aniodized fat. The dose of iodine is graduallyincreased until Io minims are taken threetimes a day in milk. There is no necessityto push the dose of iodine beyond io minims,nor is there any method of administering theiodine half as effective as that described byChitty. For instance, intravenous colloidaliodine, which theoretically might be sup-posed to be superior, is comparatively use-less. The patient can, if necessary, continuehis iodine in milk for months. He shouldbe watched for signs of iodism which arecharacterized by a heavy pain over the frontalsinuses, running from the nose, salivationand erythematous blotches of the skin.Usually the drug is well tolerated, and inaddition it acts as a general tonic. As im-provement sets in a course of local andgeneral artificial sunlight is beneficial.Under this regime the sinuses soon healand a cure can be hopefully anticipatedexcept in the most advanced cases.

In the first and second of the cases illus-trated the method proved effective. Withinsix weeks the lesion had completely andpermanently healed. In the third case,which was very advanced, progress hasbeen slow, but sure. He is still undertreatment.

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130 " HAMMER-TOE"

Even with this treatment there are a fewrebellious cases. Implantation of radonseeds or radium itself may be tried, and tojudge by the few reported cases radium ishighly beneficial.

REFERENCES.[1] HARGER, J. R. Surg. Gynec. and Obstet.,

1920, xxxi, 305 (OCHSNER, A. J., inDiscussion.)

[2] SANFORD, A. H. Journ. Amer. Med. Assoc.,1923, xxxi, 655.

L3] BAILEY, HAMILTON. (Branchial Cysts,"London, 1929.

[4] CHRIST, A. Schweiz. med. Woch., 1925, Iv, 643.f5] BOYKSEN, A. Zentralbl. f. Chirur., 1928, Iv,

1542.[6] NEW, G. B., and FIGI, F. A. Surg. Gynec. aid

Obstet., 1923, xxxvii, 617.[7] CHITTY, H. Brit. Med. Journi., 1926, i, 418.[8] Idem. Ibid., 1929, i, 347.[9] HALE-WHITE, Sir W. "Materia Medica,'

14th Edition, 1915, p. 253, London.

"HAMMER-TOE."By S. L. HIGGS,

F.R.C.S.

Surgeon, Royal National Orthopcedic Hospital;Assistant Surgeon, Orthopadic Department, St.Bartholomew's Hospital, &c.

THE term " hammer-toe" should be con-fined to that type of flexion deformity whichcannot be overcome by simple stretching.It therefore excludes all types of "claw-toes" which are commonly associated withthe wearing of short stockings and shoes, orwith othe^ foot deformities, such as pescavus or loss of the transverse arches.The true " hammer-toe" cannot be

straightened by traction because this is pre-vented by actual contracture of the skin andsoft tissues beneath the flexed joint.

CAUSE.The condition is rarely found in infants.

It is an acquired deformity and the chieffactor in its development is an over-long

toe. If short socks or shoes are worn the,projecting toe is pressed back into line withthe others and has to assume the flexedposition. As growth proceeds this deformitybecomes fixed and later on pressuresymptoms develop.

TYPES.The typical "hammer-toe" shows a

flexion deformity of the proximal inter-phalangeal joint whilst the metatarso-phalangeal and distal interphalangeal jointsare hyper-extended. The only fixed de-formity in this type is the flexed middlejoint. This is by far the commonest varietyand the easiest to treat.

1J.5. .3Occasionally the terminal joint is flexed

instead of extended, producing a doubleflexion deformity.A third type shows flexion of the terminal

joint only.

SYMPTOMS.Pain occurs in three situations. Firstly,

in the common type, over the prominentjoint from pressure of the shoe. A corn andunderlying bursa develop, and attacks ofacute inflammation are not uncommon.Secondly, pain maybe complained of beneaththe ball of the foot. The hyper-extendedfirst phalanx presses downwards the head ofthe corresponding metatarsal, leading to lossof the transverse arch and consequent meta-tarsalgia. Lastly, if the end joint is flexed apainful corn may develop around the nail atthe tip of the toe where pressure occurs.

TREATMENT.The development of a "hammer-toe " can

be prevented in children by the wearing offull-length socks or stockings. Mothers

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