222 ACTING MYCOSIS HO MINIS. 



The prognosis is always more serious when the disease aftects the 

 upper than the lower jaw, as the tendency here to invade the deep 

 structures is much greater. 



Two cases of actiuomycosis in man have come under my obser- 

 vation, and as both of them originated in the mouth and represent 

 from a prognostic point two distinct classes, I will describe them 

 briefly. 



CASE I. This patient was a man, thirty years of age, German by 

 birth, and a soda-water manufacturer by occupation. His business 

 required him to make frequent trips into the country by team. He 

 had no recollection of having come in contact with cattle suffering 

 from "swelled head" or lumpy jaw. During the winter of 1886 he 

 suffered from what he supposed was an ordinary cold : the right side 

 of the lower jaw was swollen and painful. As one of the molar teeth 

 showed evidences of decay and had become loose it was extracted, 

 The pain and swelling, however, did not improve, and the attending 

 physician extracted all of the molar teeth of the lower jaw. At this 

 time a fungous mass commenced to appear over the surface of the 

 edentulous bone. The cheek on the affected side was also greatly 

 swollen. The patient was admitted into the Milwaukee Hospital 

 about six months after the first symptoms had showed themselves. At 

 this time the lower jaw, in the mouth, presented a fungous mass 

 extending from the angle of the bone to the first bicuspid ; the swell- 

 ing extended as far as the tonsils. The cheek was enormously swol- 

 len from the angle of the mouth to the lower margin of the 

 parotid gland. The skin over the swollen part presented a glossy 

 appearance, and the superficial veins were considerably dilated. 

 Around the margin of the swelling no distinct border-line could be felt, 

 the infiltrated parts fading gradually into the healthy surrounding 

 tissues. Free suppuration from the surface of the fungous granu- 

 lations, and a number of small abscesses had discharged themselves 

 into the cavity of the mouth. As some doubt existed as to the char- 

 acter of the inflammation, careful and repeated examinations were 

 made of the pus removed from the small abscess cavities, and on seve- 

 ral occasions fragments of actiuomyces were found. The discovery of 

 the specific cause of the inflammation cleared up the diagnosis and 

 furnished a strong indication for operative treatment. An incision was 

 made along the lower border of the jaw, from just below the articula- 

 tion to near the symphysis, and after arresting all hemorrhage it was 

 carried into the cavity of the mouth. The alveolar processes of the 

 jaw were affected and were removed ; wherever the periosteum showed 

 signs of infiltration it was carefully scraped away, and finally the whole 

 exposed bone surface was thoroughly cauterized. The infiltrated soft 

 tissues were dissected out with knife and scissors, the deepest portions 

 extending as far as the tonsil. The deep portion of the wound was 

 dusted over with iodoform and filled with iodoform gauze, while the 

 external wound was sutured. The entire external wound healed by 



