TREATMENT OF ACTINOMYCOSIS
Authors: H. Chitty
Journal: BMJ (1929)

GRADENIGO'S SYNDROMEr I MTDIcALJOUTa 347 cotton-wool and a pin, biat it was not marked.There was no facial weakness,, and no paresis of the ninth, tenth, eleventh, or twelftlh left cranial nierve.There was no retropharyngeal swelling.Cerebration was apparently normal.There was no stiff- ness of cervical muscles, and abdominal reflexes, knee-jerks, plantar reflexes, etc., were, all normnal.The fundi were examined .byMr. William Wyllys and reported normnal.The further progress of the case was as follows, December 25th: There was pain during the night, but the patient is easier this morning.December 26th : Pain was very severe duiring the latter part of yesterday and all the niglht in spite of the narcotics.She is now in great pain.Begs for something to be done.Bulging of Shrapnell's membranie has iniereased anid is now br ight red.Inflammation is spreading down the posterior seament.Deafness on the left side has increased, and t!he whispered voice can now only be hcard at 3 inclhes.Meatal tenderness is very marked.There is definiite periosteal thickening over the mastoid and slight tenderness.Ctlher signs as before.The temperature is 99.20 F. and above normal for the first tim-1e since admission.OpCr7tio71.-Paracentesis was filrst performed.-Schwartze'sopera- tion revealed a small granulation in the antrum, but no ptus was seen.The tegmen antri was then removed.The dura was not under tension, and the surface was finely granular.Thie cavity was packed with bipped gauze.December 27th: Patient has had a very good night without.any narcotic.She states that aural pain and neuralgia have com- pletely disappeared, but there is slight paiin round the left eye.Diplopia as before.. December 28th: The paini rouind the left eye is rather worse; no return of othet pain.December 29th First dressing, iun-der nitrous oxide anaesthesia.The gauze wick which lhad been placed in the meatus waas soiled with a little pus.Packing from the wound was fairly clean.She has had two good nights.Decenmber 30tll: Patient says she has been easier since the dressing was done yesterday, but still has some pain round the left eye.December 31st: No pain in the ear or temporo-pairietal region, but she lhas had more pain in the left eye, supraorbital region, and left cheek.Diplopia *is still present, but there seems to be slight movemient in the left external rectis.January 3rd : She has had a few shooting pains in the left ear and temporo-parietal region.January 8th: The pain round the eye has been improving gradually.She now has very little except on waking in the nmorning.There have been nio more temporo-parietal pains.She sleeps well at night and often by day.The cavity is granulating slowly.January 16th : There hlas been no pain round eye for several days, bhut slhe still wears an eye-shade in the evening as artificial light worries the eye.Januar y 26th: The mastoid cavity is now filling satisfactorily with hiealthy granulations.The patient is leaving the ward to-day and will attend daily for dressings.Eye movements are as before.Marchl lst: Comp ete healing of the wound has been very slow, but she ceased attending daily three weeks, ago, since when she hias beeni attending Dr. Blake, who states that he first noticed return of movement in the external rectus on Februiiary 22nd.There is Ino diplopia now, and all movements of the left eye are as good as those of the right.In tlle treatment of this case two points are especially open to criticism.