ACTINOMYCOSIS. 427 



mouth could not be opened without difficulty ; the tonsil was much 

 enlarged, and pus was set free on incision. She still suffered with 

 toothache, and a small swelling now occurred on the left side of the 

 neck below the jaw. She had several carious teeth. The swelling, 

 which was about the size of a walnut, was punctured, and a drainage 

 tube inserted ; a creamy -looking discharge containing yellow granules 

 continued to escape, but the swelling and induration increased. A 

 further operation was decided upon. The carious tooth was removed, 

 and a probe passed into the alveolus showed a communication with 

 the external wound ; the angle of the jaw was chiselled away, and 

 the alveolus scraped out. lodoformed gauze was applied, and the 

 case recovered. 



The second case was a man aged eighteen, who had also siiffered 

 with severe toothache and swelling at the angle of the jaw. On 

 examination a carious tooth was noticed. The swelling was well 

 marked, and there was fluctuation ; it was as large as a pigeon's 

 egg, and situated below the jaw. When punctured, thick creamy 

 pus escaped containing the fungi ; the sinus was scraped out, and in 

 ten days the wound was healed. Another swelling appeared, and 

 this was treated as before, and the case recovered. 



The peculiar feature of these growths is their apparent migra- 

 tion. Israel states that in one case a tumour occurred on the alveolar 

 process, close to carious teeth, and later was close to the edge of 

 the jaw in the sub-maxillary region. Prom thence it disappeared, 

 and a large swelling formed below the hyoid bone, and after this had 

 been incised and had healed, an abscess formed above the clavicle. 



Actinomycotic tumours in this region would sometimes appear to 

 correspond very closely with wens or clyers in cattle ; they may dis- 

 charge through the skin, and the opening close, or a fistula result ; 

 but they differ, from their tendency to form burrowing abscesses 

 instead of recognisable tumours. In this respect they recall chronic 

 inflammation rather than the sarcoma-like growths in cattle. 



Cases in which the upper jaw is attacked are not so frequent as 

 those in the lower jaw. The progress is usually described as slow, 

 and there is a tendency for the deep-seated soft parts to be involved, 

 while in the lower jaw there is a tendency for the tumour to come 

 to the surface. There may be burrowing suppuration, or small 

 tumours, which, after a time, fluctuate and form distinct abscesses. 

 These may involve the skin, discharge their contents, and leave 

 fistulous openings. 



In other cases the disease has been described as extending from 

 the alveolar process to the temporal bone, or the base of the skull. 



