Etiology and Morbid Anatomy.—The actinomyces, which has never been met with outside the body, gives rise in oxen, horses, and other animals to tumour-like masses composed of granulation tissue; and in man to chronic suppurative processes which may result in a condition resembling chronic pyæmia. The actinomyces is more complex in structure than other pathogenic organisms, and occurs in the tissues in the form of small, round, semi-translucent bodies, about the size of a pin-head or less, and consisting of colonies of the fungus. On account of their yellow tint they are spoken of as “sulphur grains.” Each colony is made up of a series of thin, interlacing, and branching filaments, some of which are broken up so as to form masses or chains of cocci; and around the periphery of the colony are elongated, pear-shaped, hyaline, club-like bodies ([Fig. 30]).
Infection is believed to be conveyed by the husks of cereals, especially barley; and the organism has been found adhering to particles of grain embedded in the tissues of animals suffering from the disease. In the human subject there is often a history of exposure to infection from such sources, and the disease is said to be most common during the harvesting months.
Around each colony of actinomyces is a zone of granulation tissue in which suppuration usually occurs, so that the fungus comes to lie in a bath of greenish-yellow pus. As the process spreads these purulent foci become confluent and form abscess cavities. When metastasis takes place, as it occasionally does, the fungus is transmitted by the blood vessels, as in pyæmia.
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 vertebræ may become involved by infection taking place through the pharynx or œsophagus, 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.