572 Postgrad Med J: first published as 10.1136/pgmj.28.325.572 on 1 November 1952. Downloaded from SOME COMMON ERRORS ABOUT THE * ACTINOMYCES AND ACTINOMYCOSIS By V. ZACHARY COPE, M.S., F.R.C.S. Till comparatively recently the common view A mistake which was current for many years was that actinomyces was a rare organism, whereas was that the variety which attacks human beings in fact it is very common. If cultures be made was of the aerobic type, whereas in nine cases out from soil it will be found that more than half will of ten it is the micro-aerophilic or anaerobic type. belong to the family Actinomycetaceae. Of course How this error came into currency is worth re- few, if any, of these would prove pathogenic to cording, for it shows how the doctrine which is human beings or animals, but the remarkable fact first in the field may hold its own in spite of re- needs to be remembered that from some of these peated proof to the contraty. The first to make a lowly organisms have been produced some of our culture of actinomyces was Bostroem, who in most beneficent antibiotics, e.g. streptomycin and I889 obtained some cultures aerobically, but he aureomycin. only succeeded in getting i i positive growths out There has been considerable confusion con- of several hundred planted, so that the chance ofProtected by copyright. cerning the name. The first man who clearly contamination was by no means ruled out and, differentiated the organism was Bollinger, and the as we know now, was likely. The following year name actinomyces was given to it by his friend Wolff grew the organism anaerobically from an Harz. But other observers coined other names, active lesion but his observation passed almost un- some of which are, unfortunately, used even today. noticed and Bostroem's view that the organism Discomyces, coniomycetes, oospora, nocardia, which affected human beings was an aerobic streptothrix and cohnistreptothrix are some of fungus became current. In I907 Homer Wright these names. In 1913 Foulerton commented on confirmed Wolff's observation and since that time the strange fact that while the Continental path- Colebrook, Naeslund and many others have con- ologists used the term actinomyces, in England clusively proved that the common actinomyces and in America the name streptothrix was which affects humans is anaerobic. The aerobic preferred. His words should be remem- variety which grows on grains or grasses and the bered: like is rarely pathogenic to animals. Yet to this 'Writers on general medicine have not always day at least one very well known textbook makes http://pmj.bmj.com/ appreciated that these two terms are absolutely the statement that the actinomyces which affects synonymous; so that one sometimes finds even in animals is transmitted by straw or grass. The fact recent books reference made to the strepto- is that the common pathogenic actinomyces has trichoses as if they were in a class of disease in never been found outside an animal body. It is some sort different from the actinomycoses.' true that in a few actinomycotic lesions there has Since Foulerton wrote the above senterfce the been found a particle of straw or of wood, and the terms actinomyces and actinomycosis have been writer has observed such a case in his own ex- adoptqd by nearly all pathologists and the word perience. The part which the straw plays, how- on September 28, 2021 by guest. streptothrix has almost gone out of use. But in ever, is likely to be the causing of an abrasion of reading older books one must remember the the mucosa through which the actinomyces can unfortunate confusion.' gain access to the deeper tissues in which it can The actinomyces has -been defined as 'an grow; it may also aid bacterial growth by the organism growing in the form of a much branched irritation it causes. mycelium which may break up into segments that So far as I am aware up to the present time no function as conidia. Sometimes parasitic with textbook has explained how the actinomyces gets clubbed en4s ,of radiating threads conspicuous in from one human being to another. We know from lesions in an.iaial-body. Some species are micro- the work of Lord and Naeslund that actinomyces aerophilic or anaerobic. Non-motile. Type bovis is often to be found resident in the crevices of species actinomyces bovis.' carious teeth, ready to cause trouble if given the November 1952 COPE: &ome Common Errors about the Actinomyces and Actinomycosis 573 Postgrad Med J: first published as 10.1136/pgmj.28.325.572 on 1 November 1952. Downloaded from chance. Similarly the organism resident in the occur in the cervico-facial region. In one case in mouth must occasionally be swallowed and live for five the lesion is in the abdomen, and the thorax is a time in other parts of the alimentary canal, for the site of disease once in every seven cases. we know that actinomycotic lesions may follow the Though actinomycosis is not very common it may perforation of a peptic ulcer or an inflamed occur in almost any part of the body, so that it is appendix. The puzzle is to account for the pre- essential that the doctor should keep it in mind as a sence of the organism in the mouth. The actino- possible cause of any internal disease of doubtful myces bovis is difficult to culture, is delicate and origin. It is because the condition is not thought soon dies if exposed outside the body, and cannot of that it is so often missed. survive in dried dust. Among all the records Apart from the well-known right iliac actino- over 75 years there are only one or two instances of mycotic lesion which sometimes follows the per- the possibility of infection by direct contact be- foration of an inflamed or gangrenous appendix, tween one person and another. There is only one actinomycosis is not often considered as a possible likely and feasible alternative left and that is the diagnosis in diseases of the thorax and abdomen, transmission of infection through such an inter- at least not in the early stage. Even when the mediary as a cUp or other drinking vessel; if the abdomen is explored it is easy to make a mistakeen cup be not care.fully cleaned between the use of it diagnosis, for the indurated tissue resulting from by one person and another it would be possible for the reaction to the actinomyces is often very hard the organism to be transmitted from one to the and may closely resemble malignant disease of the other if the first person happened to have the scirrhoid type. Most recorded cases of actino- pathogenic organism resident and latent in the mycosis of the colon have been diagnosed as mouth. This method of infection is theoretical malignant disease and either excised under that but it is difficult to think of any other possible diagnosis or left as inoperable. way. In the thorax actinomycosis is usually diagnosed Actinomyces bovis, as its name implies, often as tuberculosis or as malignant disease of the lungProtected by copyright. attacks the cow and the part chiefly affected is the until an empyema forms or a superficial abscess lower jaw, commonly called ' lumpy jaw.' In develops and is opened. Examination of the pus many books it is stated that the ' wooden tongue shows the characteristic granules containing the of the cow is due to the same organism. This fungus. latter statement is incorrect for ' wooden tongue ' Not long ago a student told me that he had been is caused by a bacillus and the condition is known taught that actinomycosis did not attack bone. So as ' actino-bacillosis.' This may seem to have far as the bones of the limbs are concerned he was little practical significance but the failure to dis- taught (almost) correctly, but it is quite wrong to tinguish between the two conditions led in some say that the disease does not attack any bone, for it cases to mistakes in treatment. In I885 Thomassen very commonly attacks the mandible and there are made known the fact that potassium iodide acted many cases on record in which the vertebral as a specific cure for the ' wooden tongue ' of column has been riddled with the disease. The cattle; although he did not know the different lower jaw may show merely a periostitis or it may aetiology of ' wooden tongue ' and ' lumpy jaw' be thickened considerably and be traversed by http://pmj.bmj.com/ he noted that the cattle with diseased jaws did not sinuses. The condition in the latter instance is respond in the same manner to potassium iodide. that of an extensive osteomyelitis somewhat re- Nevertheless, surgeons, probably basing their sembling that which is found in the jaw of the action upon the known effect of the drug upon the cow. Such a lesicn may cause great enlargement of tongue of cattle, continued to regard potassium the jaw. iodide almost as a specific cure for actinomycosis The vertebral column is affected by extensiorn and for years it was customary to administer it in from an abdominal or a thoracic focus. Usually large doses, sometimes amounting to 500 or more several vertebral bodies are involved and the patho- on September 28, 2021 by guest. grains per diem to patients suffering from the logical process does not so frequently nor so readily disease. It is true that compounds of iodine, in- attack the inter-vertebral discs. Collapse of a cluding potassium iodide, have some beneficial vertebra is not common.