gly 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.

Success has attended the use of a vaccine prepared from cultures of the
organism; and the X-rays and radium, combined with the administration of
iodides in large doses, or with intra-muscular injections of a 10 per
cent. solution of cacodylate of soda, have proved of benefit.

MYCETOMA, OR MADURA FOOT.--Mycetoma is a chronic disease due to
an organism resembling that of actinomycosis, but not identical with it.
It is endemic in certain tropical countries, and is most frequently met
with in India. Infection takes place through an abrasion of the skin,
and the disease usually occurs on the feet of adult males who work
barefooted in the fields.

_Clinical Features._--The disease begins on the foot as an indurated
patch, which becomes discoloured and permeated by black or yellow
nodules containing the organism. These nodules break down by
suppuration, and numerous minute abscesses lined by granulation tissues
are thus formed. In the pus are found yellow particles likened to
fish-roe, or blac