180 An Introduction to Medical Mycology 



tissue, where nodules develop. These nodules increase in size, suppuration 

 takes place, and pus is discharged to the surface of the skin. Sinus tracts 

 then develop. The infection may slowly progress subcutaneously, with the 

 same, sequence of events, until considerable areas of skin are involved. A 

 variable degree of edema may be noted. The tissues in the affected re- 

 gions are usually bound down and often have a boardlike consistency. 

 Pus usually may be expressed from the sinus openings. In the pus, 

 the organism may be found in the form of granules (yellowish or 

 white flakes). Sometimes these granules are not grossly noticeable unless 

 the pus is spread out on a slide. The mandible and other bones, the parot- 

 id gland, the nose, the eye and the tongue have all been found capable 

 of being infected. 



(2) Abdominal organs.— The disease usually begins in the appendix or 

 cecum; in women, the fallopian tubes may be primarily involved. The 

 disease may also attack the gallbladder and the liver, producing abscesses. 

 The symptoms of involvement in the abdomen usually result in operations, 

 when the disease may or may not be suspected. The operation wound re- 

 fuses to heal, and sinuses discharging pus remain. Spontaneous sinus forma- 

 tion before operation is unusual. An instance of primary actinomycosis of 

 the stomach with metastasis to the liver was reported by Blain. 



(3) Thoracic organs— The involvement may be primary, or it may be 

 secondary to buccal actinomycosis. Tuberculosis with cavitation may be 

 markedly simulated; chronic bronchitis and pneumonia, more rarely. Car- 

 cinoma is occasionally difficult to differentiate. There is discharge of pus in 

 the sputum. Pain because of pleuritis is a common symptom. The lower 

 lobes of the lungs are usually involved. The infection almost always spreads 

 to the chest wall, with the production of sinuses to the exterior. If un- 

 treated, the patient develops a septic temperature, loses weight, and 

 secondary infection often supervenes. 



(4) Other organs.— Primary cutaneous involvement is rare; when it 

 does occur, ulcerations form, and the infection gradually becomes deeper. 

 According to Jacobson, only 13 cases of primary actinomycosis of the 

 kidney have been reported, involvement of the urinary tract being more 

 often secondary to infection of other parts. Cerebrospinal involvement 

 has been reported; it is probably always secondary. The symptoms are 

 either those of an acute infection or those of a neoplasm. Besides the 

 bones of the face, previously mentioned, the vertebral column is occasional!}' 

 involved secondarily to an intestinal or pulmonary infection. 



(d) Histology.— The morbid picture is essentially the same no matter 

 what tissue or organ is affected. At an early stage colonies of fungi are 

 noted in the center of the lesion, together with polymorphonuclear leuko- 



