54 THF,THE CANADIAN MFDicALMii.rnc.i AssocIATIONAsSocIATION JOURNAL [July 1934

CONCLUSIONS culosis. In this class of case the choice of the There still seems to be an antipathy to re- anesthetic is often the deciding factor in the gional ansesthesia. To paraphrase an aeronautic success of the surgery to be performed. term, the laity and a large percentage of the The absence of vomiting and straining, plus medical profession are "general-anesthesia- the cooperation of the patient, are valuable aids minded", and it is only by personal experience in avoiding the complication of post-operative that either the patient or the doctor can be hemorrhage. persuaded that "the old order changeth for the Then in this field of surgery, where electrical new The only adverse criticism that we have equipment is so much used, there is no danger to offer is thwt the procedure is somewhat time- of sparks causing an explosion, and the,value consuming, but we feel that this is more than of the removal of this fear in a staff educated in compensated by its advantages. the dangers of gas ansesthesia is not to be under- The use of pre-operative barbital medication estimated. is important, to prevent unpleasant sequele My thanks are due Dr. Boardman, Chief of Urology and, by the same token, morphine is to be of St. Boniface Hospital, for his kindness in submitting suitable material for this series, and to Dr. Inkster, avoided. Professor of Anatomy, Faculty of Medicine, Manitoba We have here a common drug that by this University, for his help in a special dissection and method of administration and in this particular reviewing the anatomy of this region. field of surgery fills the requirements of a good REFERENCES 1. BUTO, T.: Uber einige Formverhiiltnisse bei den Sakralisa- antosthetic - (a) safety, (b) efficiency, (c) tionavorgangen im Japaner-Kreuzbein, Folia Anatomica Japonica, 1932, 10: 100. economy, (d) no unpleasant after-effects or 2. MAwEiN, E. G.: Local anesthetic agents, J. Am. M. A88., 1928, 91: 555. complications. 3. MsEZKR, W. R. AND PRAzzE, E. B.: Transacral nerve block ansethetics, Sug., Gyn. & Obst., 1922, 35: 801. Its safety is a particular feature of value in 4. Dowss, A. W. AND EDDY, N. B.: Influence of barbital upon cocaine poisoning in the rat, J. Pharmacol. d Exp. the aged and in associated disease, such as tuber- Therap., 1932, 48: 383.

OBSERVATIONS ON ACTINOMYCOSIS BY STUART GORDON, M.B., M.S., Toronto

ACTINOMYCOSIS is a chronic infective dis- bacillus, B. actinontycetum comitans, is found in ease which would appear to be on the in- over 80 per cent of cases at some stage.2 crease. From 1920 to 1926, the records of the Actinomyces bovis has never been found out- Toronto General Hospital note the admission of side of man or animals. This would seem to one case. From 1926 to 1931, inclusive, 27 cases absolve grasses as a carrier, a possibility that has are recorded. During the past year there has been accepted for years. Unless an as yet un- been an average of one case a month in the identified stage in the life history of the organism wards. While part of this increase may be is spent on grasses this absolution must be apparent, due to greater clinical interest, there acknowledged. Transmission from cattle to man would seem to be a real increase in the number and from man to man must occur. There is a of cases. Twenty-nine are reported in this paper. fair amount of evidence in support of this state- Bacteriology.-The majority of cases are due ment.- It cannot be ignored that 50 per cent or to infection with Actinomyces bovis. This is an over of the cases occur in individuals associated anaerobic, non-acid-fast streptothrix. Early in with farming. Next, there is a case on record of the history of the disease it was attributed to an actinomycotic abscess in the lung of an infant one or other of the Nocardia. With the recogni- 4 weeks old, dead of marasmus.3 Falge4 reports tion of Actinomyces bovis the investigation an instance of what would appear to be direct seemed finished. However, an associated bacillus transmission from man to man. Whether the has been identified, whether in a genetic or step is a direct one, or whether an intermediate symbiotic relationship is not yet known. This stage occurs is not known. .. ACTINOMYCOSIS 55 JulyJUlY 1934] GORDON:GoRDoN ACTINOMYCOSIS

Some work has been done in an attempt to Table II shows the number of cases in each of prove that Actinornyces bovis is an inhabitant of the three main anatomical groups. The average the gastro-intestinal tract. Lord5 claims to have age is also shown. done this years ago, using teeth and tonsils. He The latter half of the third decade would ap- came to the conclusion that the organism was pear to be the favourite age for the development normally present in these structures. This does of this disease. The cervico-facial cases included not appear to have been verified, but on clinical infections of the tonsils, floor of the mouth, grounds it would appear that Actinomyces bovis tongue, and both sides of the neck. The two does inhabit the body. thoracic cases both occurred in the left chest. Incidence and location.- There was 1 upper abdominal infection;' 1 abscess in the left lower quadrant. Thirteen cases were associated with the ceecum and ap- TABLE I. pendix, and 1 had its primary lesion in the rectum. Author Male Female Total Etiology.-Etiological factors are somewhat

Sanford & Voelker9 ...... 536 134 670 difficult to evaluate. Nine of the cervico-facial Sanford & Magath8...... 84 12 96 cases had no apparent inciting factor. One Sanford & Magath (from literature) 79 40 119 patient had had a tooth extracted four months previously to reporting for treatment for an actinomycotic abscess. Eight of the abdominal TABLE II cases followed acute inflammation in the ap- pendix; this might suggest that the acute inflam- Cervico-facial Thoracic Abdominal Male Female Male Female Male Female mation might be a factor in lighting up an actinomycotic infection. On the other hand one Cases.... 7 4 1 1 13 3 patient developed an actinomycotic abscess in the Aver. age 40.7 40.7 48 16 38.1 38.5 scar of a McBurney incision made 13 years previously for the removal of an acute, ruptured appendix. Two abdominal cases followed injury. TABLE III. In one case the injury had resulted in a retro- MALE peritoneal rupture of the duodenum, from which point the infection had spread. No apparent Occupations Cervico-facial Abdominal Thoracic factor could be discovered in 5 of the abdominal cases. In 2 cases the finding of actinomycosis Farmer...... 5 2 0 was incidental in Student, city ..... 0 1 0 the treatment of an acute Student, farm 0 2 0 appendicitis. It is interesting to note that 24 of Gardener.....:. 0 0 1 Clerk ...... L.... 0 2 0 -the 29 cases occurred in or adjacent to regions Boat-builder ...... 0 1 0 normally possessing a high Traveller ...... 0 1 0 bacterial count, vtz., Press-feeder ...... 0 1 0 the mouth and caecum. Salesman, car ..... 0 1 0 One of the thoracic cases followed pneumonia, Smelter man ...... 0 1 0 Retired 2 years.... 0 1 0 the other pleurisy. The latter may have been Agent...... 1 0 0 actinomycotic from the beginning. Garage man ..... 1 0 0 Spread of the disease.-The disease appears to Totals...... 7 13 1 spread, in the abdomen at least, as does any acute infection. From appendix to right sub- FEMALE phrenic space and thence to the right pleura is a story common to both. It is believed that the Occupations Cervico-facial Abdominal Thoracic infection does not spread by the lymphatics. This Farmer's wife ... 1 1 0 observation has been made by many Wife, city...... 1 1 0 authorities. The neighbouring lymphatic nodes Student, city. 1 0 1 from are not enlarged in an actinomycotic infection. Stenographer ...... 0 1 0 farm The absence of multiple isolated foci leads Nurse...... 1 0 one to 0 believe that the disease is not disseminated by Totals...... 4 3 1 the blood stream. Direct extension is the com- 1934 56 THE CANADIAN MEDicALMEDIcAL ASSOCIATIONAssociATION JOURNAL [July 1934 monest, and may well be the only, method of the abdominal cases after diagnosis was 4 spread. months. Clinical syndrome.-Swelling and soreness are The following case histories are included in the two main early indications of the disease. In this report since each one has a definite point of the cervico-facial group swelling was the first interest: in 8 of 9 cases in which records sign noticed were CASE 1 case available; the other had soreness first. As R.F., Toronto, aged 16, a waitress, was admitted the disease progresses the swelling extends and on July 26, 1928. For one year this patient had swell- ing of gums and right cheek in the region of the first becomes more tender, although usually not molar tooth. In March, 1928, she had had four teeth markedly so. Trismus is an early development of extracted. Following this, swelling and pain increased cases in the of the The and a sinus developed on the cheek. The discharge region jaw. involved contained Actinomyces bovis. Treatment consisted in area is very firm (woody) and is usually of a aspiration, incision, packing of the sinus, 40 grains of dull brownish-red colour. The induration fades iodides per day, and high voltage x-ray therapy. The white blood cells were 18,000. When seen on April out into the surrounding tissue. Eventually a 19, 1933, the patient was well. soft area in the induration forms, opens, and CASE 2 discharges a thick, greyish pus in which the W.B., Summerville, Ont., a farmer, aged 28, was characteristic granules may be found on careful admitted in November, 1931. The patient had had search. These granules are not always yellowish; "blind boil" on the left side of the neck at the level of the thyroid cartilage for 3 months. During the two abdominal cases in this group showed week previous to admission the swelling had doubled in granules that were greyish-white in colour. size; it was cold, fluctuant and not painful. The abscess was excised widely, the operative field washed Occasionally the pus is somewhat viscid. Con- with acriflavine and closed without drainage. Bac- stitutional effects are remarkably constant. Loss teriological examination showed Actinomyces bovis. This patient has never had a return of his lesion. of weight practically always occurs. It varied from 10 to 31 pounds in this group, the average CASE 3 being 19. The temperature is characteristically C.H., Fort William, a farmer, aged 44. This patient was injured in October, 1925. He fell while swinging, down in the morning and up in the carrying a heavy piece of wood on his right shoulder. late afternoon. Ninety-nine to 1020 is the usual Pain developed in the abdormen and back. After the acute symptoms subsided the right thigh slowly be- range. In the cervico-facial group the average came flexed. On January 13, 1926, more than a quart white blood count was 10,000; in the abdominal of pus was obtained from a swelling just above Poupart's ligament on the right side. On February 1, group 14,250. Appetite is variable, but as a 1926, another abscesg ruptured below Poupart's liga- rule is not much impaired. The pulse is ment. Two weeks later another abscess formed, and still later another over the back of the right ilium. moderately elevated. At post-mortem it was found that the patient had The abdominal cases run a fairly characteristic ruptured his duodenum retroperitoneally, which rup- ture had healed. 'It was felt that infection had spread course. After a variable time following an from this point through the retroperitoneal tissues. operation for ruptured appendicitis an abscess Bacteriological examination showed Actitnomyces bovis as the causative organism. points in the operative scar. The finding of a faecolith in such an abscess, or in a persistent CASE 4 sinus, should not be allowed to put one off the J. McL., Charlton, Ont., aged 47, a farmer, was admitted on July 15, 1929. In 1916 this patient had a track, as in 2 such cases a fcecolith was found, ruptured appendix removed. For six days previous to only to have the abscess recur. A subphrenic this admission had had a red, painful swelling in the right lower quadrant. He had lost thirteen pounds in abscess is usually the next development recog- the last few months. At operation a considerable nized; then abscesses in the abdominal wall, amount of greyish-white pus, containing a great many greyish particles varying in size from the head of a chest, liver; and finally the patient dies with pin to that of a small pea was evacuated. The cavity several chronic sinuses discharging on his loin, was the size of a grapefruit with hard fibrous walls and lined with pulpy granulation tissue. The pus was back, and anterior abdominal wall. The course positive for actinomycosis. Treatment was high is usually a steadily downward one, but re- voltage x-ray, potassium iodide internally, and irriga- tion of the sinuses with copper sulphate. The white gressions are not uncommon. these are Whether blood cells were 6,200. He left hospital in November because of, or in spite of, treatment is not known. with a mass in the right lower quadrant still present. The average duration of symptoms until the A month later wag readmitted for treatment. Patho- logical examination of material removed at this time correct diagnosis was made was 7 months in the was reported as chronic suppuration. The patient cervico-facial group, 81/2 months in the ab- reported from Gowganda on February 16, 1932, as "keeping pretty well". He could not be located in dominal group. The average duration of life in April, 1933. GORDON: ACTINOMYCOSIS 57 JulyJuly~~1934]194GODN CINMCSS5 ~~ ~ CASE 5 most the consistency of cartilage, and, to be M.R., Toronto, aged 32, a boat builder. On April closed, -must be excised. 1, 1932, he was operated upon for acute appendicitis. The appendix was reported as showing acute, sub-acute, Iodine is the drug. that has been favoured and chronic appendicitis. His wound healed in five weeks. In July, 1932, his wound opened -up again. A for many years in the treatment of actinomy- fwucolith was removed, but the sinus did not heal. In cosis. It has been used locally, by mouth, and August, 1932, an abscess developed far back in the right flank. Pus from this showed typical yellow ;intravenously. At first regarded as a specific, granules. White blood count, 9,600. Temperature its importance has been questioned since the from 98 to 101.60. consisted swinging Treatment in years incision and drainage, high voltage x-ray, and colloidal closing of the last century. In the cases iodine. This patient became steadily worse and died personally observed in this series no definite in February, 1932. effect that could be directly attributed to iodine CASE 6 was noted. It is administered in many forms by W.S., Toronto, aged 40, a shoe traveller. In May, 1929, the patient was operated on for acute appendi- mouth. Potassium iodide in large doses, tinc- citis, perforative. Following this he developed sub- ture of iodine sine iodo, and a mixture of cream, phrenic abscess, and later a right-sided, acute suppura- tive pleurisy. He was discharged in October, 1929. milk, and 21/2 per cent iodine, advocated by Three months later was admitted for the treatment of Chitty,; were all tried. Diarsenol was given a cystitis. In June, 1931, he was admitted for the treatment of a fistula of five weeks' duration in his intravenously in one case with no apparent appendiceal scar. He was weak and had no appetite. effect. The sinus was explored and a facolith about the size of a marble removed. The wound was cloged without Radiation therapy was carried out by means drainage. White blood count, 15,500. Temperature of radium .packs, the introduction of radium swinging from 98 to 100.50. In November, 1931, admitted because of cystitis. In March, 1932, he was into sinuses, radium needles implanted in the -again admitted with a large painful swelling in the tissue, and the high voltage x-ray. right loin. The abscess was incised and drained, no foreign body or bare bone being found. The wound healed before the patient left hospital. Six months TABLE IV. later he was again admitted with another abscess in the right lower quadrant. Pus from this was positive for Treat- Cervico- Actinomyces bovis. Treatment consisted of large doses ment facial Result Thoracic Result Abdominal Result of potassium iodide and high voltage x-ray therapy. January 4, 1933, another abscess in the loin was 1 C 1 C opened. Healing was rapid. All treatment was re- Excision 1 C peated. Since then this patient has been in hospital twice for drainage of abscesses. Examination of this Excision 1 C man 's appendix in December, 1933, revealed the Radium presence of actinomycosis which had not been previous- Excision 1 C ly identified. Iodine CASE 7 Incision 1 D F.H., Hamilton, a gardener, aged 41. This patient 1 D had pneumonia in November, 1930. In February, 1931, he had a rib resection for empyema. The temperature Incision 1 D remained elevated and his cough became worse. The Iodine 1 D incision was reopened and large quantities of pus were 1 D obtained. Again the wound healed. The temperature kept swinging from 99 to 1010. Still later a sinus Incision 1 D developed in the chest wall, and in December, 1931, X-Ray 1 D actinomycosis was proved on examination of pus from this sinus. Treatment consisted in potassium iodide Incision 1,1 g D internally, and irrigation of the sinus with boracic acid Iodine 1 Dying 1, 1 X solution followed by the installation of iodine. He X-Ray 1 C 1,1 D died on January 29, 1932. At post-mortem he was found to have been suffering from actinomycosis of Incision 1 C left lung and pleura, right and left domes of the Iodine 1 C diaphragm, liver, spine and retroperitoneal tissue.- Radium 1 C Treatment.-Surgery, medicine, and radiology Radium 1 C all play a part in the treatment of actinomycosis. Radium Surgical procedures include incision of abscesses, X-Ray 1 C curetting of sinuses, and total excision of the Radium lesion. Abscesses must be opened and packed Iodine 1 C loosely. Actinomycosis seems to prefer muscle. Incision 1 D 1 D and forms numerous small abscesses which may Iodine 1 D Radium be entirely separate from each other. Such X-Ray abscesses must be carefully looked for. Chronic C = Cured; D = Dead; X = Still under treatment; actinomycotic sinuses have walls possessing al- Q = Not traced. 58 THE CANADIAN iVIEDICAL ASSOCIATION JOURNAL [July 1934

Locally many drugs were used; the main would seem to bear out the conclusion that the ones were copper sulphate, iodine, and hygeol. disease spreads by direct extension. In the After-care.-After discharge from hospital a cervico-facial cases radium appeared to be of careful follow-up of the case should be carried definite value, unless, of course, the case pro- out. The patient should be seen at least every gressed to a cure in spite of treatment. three months. Soreness in or near the area of the wound should be reported at once. This CONCLUSIONS symptom would appear to be the most valuable 1. Actinomycosis would appear to be on the in warning of more trouble. It may occur a increase. month before swelling develops. A careful 2. It is a relatively benign lesion in the record should be kept of the patient's weight. cervico-facial region, but is highly malignant in The methods of treating each case, together the thorax and abdomen. with the result obtained, are shown in Table IV. 3. It appears to spread by direct extension Results.-Nine of the cervico-facial cases were only. cured, a percentage of 81.89; one is improving 4. Excision is the ideal treatment and should and one is dying. Both of the thoracic patients be carried out whenever possible. are dead. In the abdominal cases there were two 5. Radium appears to be of value in the cures (12.5 per cent). One patient is still under treatment of cervico-facial cases. treatment 4 years after the diagnosis was made. 6. Iodine is not a specific. There were 11 known deaths in this group, a 7. Actinomycosis is caused by Actinomyces percentage mortality of 68.75. Two patients bovis associated with B. actinomycetum comitans. could not be traced. One of these is known to REFERENCES have been alive and well one year after leaving 1. BATEs, R.: Actinomycosis, The L,ancet, 1933, 1: 571. 2. COLEBROOK, L.: Mycelial and other micro-organisms asso- the hospital. Table V shows the mortality figures ciated with human actinomycosis, Brit. J. Exp. Pathol., for the 29 cases. 1920, 1: 197. 3. EDWARDS, A. C.: Actinomycosis in children, Am. J. Du. A study of Table IV reveals that any case Child., 1931, 41: 1419. 4. FALGE, L.: Pathology and clinical history of 3 cases of that lent itself to total excision was cured. This actinomycosis with apparently direct contagion, Wiuconsin M. J., 1909, 7: 710. (Quoted by Edwards). TABLE V. 5. LoDn, F. T.: Etiology of actinomycosis, etc., J. Am. M. A8s., 1910, 55: 1261. 6. MACFa,, W. F.: Actinomycosis of head and neck with Result Number Percentage intracranial and pulmonary metastases, Surg. Olin. N. Am., 1932, 12: 427. Dead ...... 13 44.72 7. NEw, G. B.: Actinomycosis of head and neck, Trans. Am. Acad. Ophth. & Oto-laryn., 1923, 28: 392. Cured ...... 11 37.80 8. SANFORD, A. H. AND MAGATH, T. B.: Etiology and labora- Not traced ...... 2 6.88 tory diagnosis of actinomycosis, Coll. Papers of Mayo Dying ...... 1 3.44 Clinic, 1921, 13: 1057. Improving ...... 1 3.44 9. SANFORD, A. H. AND VOELKER, M.: Actinomycosis in the Under treatment ...... 1 3.44 United States, Arch. Surg., 1925, 12: 809. 10. SMITH, F. L.: Post-operative treatment of abdominal actinomycosis, Surg. Olin. N. Am., 1930, 10: 171.

TREATMENT OF OCCIPITO-POSTERIOR PRESENTATION.- The head is then placed with the sagittal suture in the Analyzing 976 cases of occipito-posterior presentations, transverse diameter and the posterior ear lying in G. Melhado argues that subnormal formation of the the operator 's palm. Along this is passed the lower pelvis does not account for all cases. Anterior position blade of the forceps, shorter curve facing the occiput, of the placenta, uneven development of the two Miillerian and fitted over the posterior ear. The upper blade is tracts, relaxed pelvic floor, inability of the trunk and passed over the anterior ear and the pair locked. By shoulders to move forward, as well as inadequate flexion gentle rotation the occiput is brought forward and the of the head, are all causes of persistent occipito-postex'ior head into the oblique diameter. These manoeuvres are presentations. The shoulders are commonly fixed by an safe, because the head is free above the brim. When internal contration ring. To eliminate this and improve it is drawn into the brim again it descends with flexion the writer advises interference directly, follow- surprising ease, and is delivered. Criticism of the ing full dilatation, the head ceases to advance. His method is met by stating that neither prolapse of the method is manual dilatation of the vagina and careful hand or cord occurred in the series, and that operation palpation of the head to make sure of the diagnosis, above the brim, on a head that has previously descended followed, by dislodging the head upwards into the pelvic into it, is quite a different matter to the application brim. If a contraction ring is forming it is ironed out. of high forceps to a head that had never entered it.- The anterior shoulder is found and pushed well forward. Am. J. Obstet. 4- Gyn., November, 1933, p. 696.