Clinical features.—­In man the disease may be met with in the skin, the organisms gaining access through an abrasion, and spreading by the formation of new nodules in the same way as tuberculosis.

The region of the mouth and jaws is one of the commonest sites of surgical actinomycosis.  Infection takes place, as a rule, along the side of a carious tooth, and spreads to the lower jaw.  A swelling is slowly and insidiously developed, but when the loose connective tissue of the neck becomes infiltrated, the spread is more rapid.  The whole region becomes infiltrated and swollen, and the skin ultimately gives way and free suppuration occurs, resulting in the formation of sinuses.  The characteristic greenish-grey or yellow granules are seen in the pus, and when examined microscopically reveal the colonies of actinomyces.

Less frequently the maxilla becomes affected, and the disease may spread to the base of the skull and brain.  The vertebrae may become involved by infection taking place through the pharynx or oesophagus, and leading to a condition simulating tuberculous disease of the spine.  When it implicates the intestinal canal and its accessory glands, the lungs, pleura, and bronchial tubes, or the brain, the disease is not amenable to surgical treatment.

Differential Diagnosis.—­The conditions likely to be mistaken for surgical actinomycosis are sarcoma, tubercle, and syphilis.  In the early stages the differential diagnosis is exceedingly difficult.  In many cases it is only possible when suppuration has occurred and the fungus can be demonstrated.

The slow destruction of the affected tissue by suppuration, the absence of pain, tenderness, and redness, simulate tuberculosis, but the absence of glandular involvement helps to distinguish it.

Syphilitic lesions are liable to be mistaken for actinomycosis, all the more that in both diseases improvement follows the administration of iodides.  When it affects the lower jaw, in its early stages, actinomycosis may closely simulate a periosteal sarcoma.

[Illustration:  FIG. 31.—­Actinomycosis of Maxilla.  The disease spread to opposite side; finally implicated base of skull, and proved fatal.  Treated by radium.

(Mr. D. P. D. Wilkie’s case.)]

The recognition of the fungus is the crucial point in diagnosis.

Prognosis.—­Spontaneous cure rarely occurs.  When the disease implicates internal organs, it is almost always fatal.  On external parts the destructive process gradually spreads, and the patient eventually succumbs to superadded septic infection.  When, from its situation, the primary focus admits of removal, the prognosis is more favourable.

Treatment.—­The surgical treatment is early and free removal of the affected tissues, after which the wound is cauterised by the actual cautery, and sponged over with pure carbolic acid.  The cavity is packed with iodoform gauze, no attempt being made to close the wound.