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ilium and took x-ray pictures. This examination revealed a subdiaphragmatic abscess the size of an orange between the diaphragm and the upper surface of the posterior part of the liver. On account of the location of this abscess it was necessary to perform some type of a transthoracic, trauspleural, transphrenic operation in order to expose it. On December 12, 1937, he was re-admitted to the hospital, and on the following day we accomplished the first stage of our procedure m reaching the absces by resecting the Oth, 10th and 11th ribs on the right side and suturing the parietal pleura lining the thoracic wall to the diaphragmatic pleura with plain catgut, enclosing a circle the size of a silver dollar. Iodoform gauze was then packed in the wound to stimulate adhesions between these pleural membranes, and the skin was closed with silkworm gut. Six days later we completed the operation. Methylene blue, 1 per cent aqueous solution, was injected in the sinus in the lower part of the back to completely fill the subphrenic abscess cavity. The skin sutures were removed, the iodoform gauze packing removed and with a long needle on a syringe we explored through the diaphragm' from above down until we were able to aspirate methylene blue and thus know that we had located the abscess cavity. We then incised down along the course of the needle until we reached the abscess cavity, and unroofed it by clipping away as much 'of its upper and lateral wall as possible. The skin flaps were split and turned down in the wound to form a 'funnel lined with skin down to as near the cavity as possible. The following day he was given a blood'transfusion, and on January 9, 1938 he was discharged from the hospital. On March 1, 1938, the abscess cavity and sinus were completely healed and they have remained so since that date. On October 11, 1938, we operated on his right radius again as it was still discharging. The wound was laid wide open down to the bone and packed with sterile vaseline gauze. A plaster of Paris cast was applied and left on for one month without removing. By Novemb,er 26, 1938, we were fortunate enoug-h to have the radius completely healed and it has remained so since, and now after three and a half years ' disability he is able to return to work. This man's weight at the time of his injury was 165 lbs. It went down to 98 lbs. and is now up to 145 lbs.

THREE CASES OF ACTINOMYCOSIS TREATED WITH SULPHANILAMIDE

BY M. R. MACCHARLES

AND

J. W. KEPPN

Winnipeg
CASE 1 Mr. M.A. This patient, aged 39, was admitted January 5, 1939, complaminig of a swelling of the left side of the neck. It had begun below the angle of the left mandible three months previously. During this time it had spread downwards and medially and was situated at the level of the lower border of the larynx. His teeth were found to be dirty, but not carious. The mass in the left side of the neck was 5 cm. 'in diameter. It was hard but not tender. It displaced the larynx to the right and definitely involved the sterno-mastoid muscle (actually the patient had been sent with a diagnosis of a carcinoma of the thyroid). The skin overlying the mass was normal and freely movable. A few small lymphatic glands were palpable in both supra-clavicular fossm. The Wassermann test was negative. Blood count: red blood cells 5,280,000; white blood cells 9,000, normal differential; hgb. 105 per cent. Urinalysis, negative. Clisscal cour8e.-January 7th, 0.1 c.c. of 1/1,000 tubereulin was injected into the skin of the flexor surface of the left forearm. In 36 hours a violent local reaction had occurred accompanied by a rise in temperature to 1010, and a shrinkage and softening of the mass in the neck. On Janiuary 10th, this was incised and a small amount of pus escaped. Filaments of the ray fungus were demonstrated in the pus. Biopsy of the abscess wall showed non-specific subacute inflammation. On January 12th, sulphanilamide treatment was started, 80 gr. daily for 3 days, then 60 gr. By January 17th the lesion had practically disappeared. Another tuberculin test was done on the opposite forearm and again a violent local reaction occurred. On January 18th an x-ray of the chest revealed two discrete calcified areas in the left chest which were considered healed primary tuberculosis.
cured. He was advised to continue on sulphanilamide 45 gr. a day for another two weeks.

January 20th, patient was discharged apparently

The osteomyelitis is mentioned in this report because it had a direct bearing on the course of this case. The man, at the time of his injury no doubt suffered from a laceration in the upper posterior part of his liver in the region of the bare area between the anterior and posterior layers of the coronary ligament, and a hiematoma was formed at this site. 'The heematoma later became encysted in the same manner that a subdural cyst develops from a subdural haematoma following a serious injury to the skull. Later on this cyst became infected by means of a blood stream infection, the osteomyelitis in his right radius acting as the source of infection. Some might contend that this was strictly speaking, a liver abscess rather than a subdiaphragmatic abscess, but it was in direct proximity to the inferior surface of the diaphragm and when it left the confines of the liver and began tracking down along the subfascial layers of the diaphragm and quadratus lumborum it became a true subdiaphragmatic abscess.

CASE 2 Miss I.P. This little girl, aged 9 years, was admitted January 24, 1939. She complained of a swelling in the right cheek which had been present for two months and was accompanied by slight pain on movement of her jaw. She had been referred to the hospital with a diagnosis of sarcoma of the jaw. Examination revealed a large swelling over the front of the right antrum, obliterating the right naso-labial fold and raising the lower eyelid so as almost to close the eye. The swelling was of indiarubber consistency and slightly tender, with well defined borders. There was no sign of any lesion in the mouth and the lymph glands in the neck were normal. The Wassermann test was negative. White blood cells 14,200; sedimentation rate 26 mm. in 1 hour; sedimentation index 56; urinalysis negative. An x-ray of the skull was negative. On January 27th, a tuberculin test gave a negative reaction. Cli*noW outrse.-On February 4th, no change having occurred, the swelling was opened by an incision in the buccal mucosa beside the alveolar border of the upper jaw. It turned out to be an abseess with a very thick wall. About 2 dr. of pus escaped into the mouth. A -drainage tube was inserted into the cavity. There was a moderate reaction in the tissues of the cheek following drainage, and on February 9th softening occurred in the upper margin of the swelling, in the region of the lower eyelid. This softened area was drained and some fairly thick pus was evacuated. Examination of this pus revealed many Gram-positive cocci, fusiform

Nv-,W. 1939]

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bacilli, and some long filamentous rods. On February 15th, typical sulphur granules were observed in the discharge. On microscopic examination the ray fungus was identified. On February 19th, sulphanilamide, gr. 10 t.i.d., was given, and on February 23rd, the dose was increased to gr. 15 t.i.d. The blood sulphanilamide this day was 5.9 mg. On February 25th there was a marked reduction in the size of the mass and the redness had disappeared, but there was a small area of softening just below the previous incision in the eyelid. This second area was incised on February 27th, and pus containing more sulphur granules was found. At this time the dose of sulphanilamide was reduced- to gr. 10 t.i.d. and was continued at this level for two weeks after. The lesion

rapidly disappeared and on March 20th, the patient was discharged from the hospital with the incision completely healed, and the lesion had entirely disappeared.

CAsE 3 Mr. D.S., aged 54 years. The patient was admitted on December 5, 1938, under Dr. E. J. Washington, complaining of pain in the right cheek and throat, stiffness of the jaw, and general malaise for three weeks. Three days before admission his teeth had been extracted and this aggravated the condition. Examination revealed a grossly infected mouth and evidence of an early quinsy on the right side. There were marked trismus and pain and tenderness in the right temporo-mandibular joint; temperature 99.4. Clini,cal coxrse.-The patient was treated conservatively for two weeks, but the inflammation extended into the neck, and on December 19th it was found necessary to open an abscess at the right mandible. Microscopical examination of the pus and culture at this time showed only staphylococci. A sinus continued to discharge, although the swelling had subsided considerably. Repeated examination of the pus revealed only mixed organisms. No actinomyces filaments were found. The patient was discharged December 27th as improved.

The sinus was still discharging and there was considerable induration of the surrounding skin. The man was readmitted January 5, 1939, and the area previously incised was swollen, tender and fluctuant. His temperature was 99. The abscess was reopened and considerable pus found. Drainage was unsatisfactory, and on January 12th, under general anesthesia the abscess was opened widely. Microscopical examination of the pus at this time revealed the ray fungus. The patient was immediately given sulphanilamide, gr. 20 q.i.d., for two days and then gr. 15 q.i.d. for three days. On January 17th the blood sulphanilamide was 3.7 mg. and the dosage was increased to gr. 25 q.i.d. for the following eight days. On January 23rd blood sulphanilamide was 7.9 mg. The lesion melted away, and on February 5th he was discharged with all wounds completely healed and only slight induration in the scarred area at the angle of the jaw, and with no swelling present. There was no pain on opening the mouth and no limitation of movement.

Although it is impossible to draw definite conclusions from three cases the results obtained by the use of sulphanilamide, supplementing surgical drainage, have been so striking that the drug would appear to have definite value in the treatment of actinomycosis. These cases are reported in the hope that other cases of this rather uncommon disease might be treated in a similar manner and the results recorded. The diagnosis in the first two cases was only made after a diligent and prolonged search for the organism by one of us (W.K.).
The authors would like to thank Dr. E. J. Washington for his permission to include his case (No. 3) in this report.

2:jtraptutics
BY G. F. STRONG Vancouver

anb

3iarmatogoap

ACUTE CONGESTIVE HEART FAILURE

Acute congestive heart failure, acute decompensation, or broken compensation, is the commonest of the acute cardiac emergencies. The clinical picture presented by these patients is too familiar to require repetition. They are acutely miserable and require immediate relief. While the onset of congestive failure is almost always gradual, the doctor is often or usually not called until the plight of the patient is desperate. These patients have usually suffered from lack of rest and sleep, and probably *the most important first step is to insure a good rest which can only be done with morphine, by hypodermic. It is surprising that doctors will still try to relieve these patients with bromides or barbiturates, or will give an opiate by mouth

when only morphine by injection is adequate at this stage. Digitalis is, of course, the sheet anchor of the treatment of acute heart failure. In spite of all that is written and said about it this drug is still misused. The remarkable response to adequate digitalization is one of the bright spots in the treatment of heart disease. Inadequate dosage may delay recovery, and indeed the patient may get worse on too little digitalis. Mathematical formule are not necessary in reaching a decision as to how to' give digitalis. While we know approximately how much of the drug is necessary for complete digitalization, in actual practice it is only necessary to give enough to accomplish our main purpose, which is to slow the heart. In the ordinary case of acute congestive heart failure 3 grains every 4 hours, until the apex rate (note, not the pulse rate) comes down to 80 or thereabouts, will be a suitable means of achieving the desired result. Occasionally in