between the date of have originated simultaneous with one or other of the causes above described, and the first appearance of the disease externally; and, finally, both, in their mode of growth and development, e.g., their painlessness, their globular shape, the presence of sinuses in abundance, the thin sacro-sanious discharge from them accompanied by the extrusion of particles peculiar to each variety, and the absence of any constitutional disturbance, display so remarkably close an analogy to each other, that, were it not for a few important clinical facts and observations, presently to be noted, it would be difficult to say anything against the opinion held forth by Dr. Carter, that the one is merely the other in a defaced condition. This condition, to begin with, is, curiously enough so complete in each and every portion of the diseased part, that it, in itself, suggests the possibility of the two being distinct forms of fungal growths; and, as a matter of fact, I have in many instances made sections and crosssections of such parts, but have never yet been able to detect a tunnel or cyst, or, for the matter of that, the barest indication of black particles, which so clearly characterize the one form, admixed with the other, and vice versa. And, further, in the course of dissection of infiltrated tissues, in following up the track of the disease along tendons, or fasciae, or in the subcutaneous areolar tissue, where, of course, it may be admitted, the disease is to be found in' its earliest state of development, there is invariably discovered pale particles in the pale kind, and black particles in the black kind, and so far as the naked eye appearance goes, no indication of transitional stages of growth from one to the other. With reference to the facts above-mentioned, the clinical history of cases manifests, in support, a point which seems to me of some importance. In all cases, without exception, patients have distinctly stated that in both forms of the disease the very earliest indication of the advancement of the growth has been by the appearance of one or more tuberculous elevations upon the surface, which, on bursting, gave exit from the very date of eruption throughout the rest of the course of the disease, no matter the length of period so occupied, either to black or to pale particles, and never to both kinds at the same time, or, to one kind first, and, at a later date, to another. Then, again, admitting for a moment, the idea of defacement of the fungus in the case of the pale variety, with due deference to the author's opinion, it would be difficult to conceive how such defaced elements could set up active morbid changes in the tissues and give rise to the enormous growth ; yet clinical history brings to lio-ht been observed to
lapse
primary infection, assuming it to
DIFNOTES ON MYCETOMA FERENTIATING the pale from the black variety.
CLINICAL
By
J. E. Bocarro, l.m.s.,. Bo., Teacher, Medical School, Hyderabad, Sindh.
Assistant-Surgeon
The object of the present paper is to place before the profession such clinical points observed by me as might help to elucidate the vexed question in the history of this curious disease; whether of the two varieties, the one is only a defaced form of the other; as Dr. Vandyke Carter has indicated in his investigations; or, whether they are perfectly independent forms of funo-al growths. Dr. Carter, as is well known, was the first to discover the fungoid character of either variety, and, more recently, other investigators in this field have clearly proved this to demonstration ; but in the absence of sufficient clinical evidence in support, they are not prepared to uphold Dr. Carter in his views that the pale is simply a defaced form of the black variety. Indeed, Drs. Boyce and Surveyor, in a paper read before the Pathological Society of London in April 1893, have been able to show clear differences in the microscopical appearance of the two forms, and are disposed to regard them as perfectly of each other in their
morphological
independent
nature.
.
. .
.
Following from a clinical standpoint this line of thought, I have put together the accompany in ?? notes of observations of a large number of cases which have come before me in the Civil Hospital practice, and would beg leave to offer them for consideration with reference to the point in question. Looking at the general history of the two forms of The disease as known in Sindh, it may be inferred that whatsoever cause applies to the black variety, as being the fons et origo males, applies also to the pale variety of the disease, since so far as historical data are concerned, no material differences exist in the one as compared with the other. Both varieties are found to affect the same class of people, namely, the cultivators, or those who have, at some time or other of their lives, exposed themselves to influences such as commonly surround people of the agricultural class; both are attributed to the same set of causes, viz., wounds, sores, prick of thorns, &c.; in both the same period of time has ,
452
INDIAN MEDICAL GAZETTE.
the fact that the tumour, whilst preserving al] its morbid characters, not only gradually increases immensely in size with time, but that it also exhibits a periodicity in the course of its development, which, as far as I have been able to ascertain from these ignorant patients, is referred in the case of the pale variety to the cold months of the year, namely, about November, December, and January, and, in the case of the black variety, to the rainy months, namely, June, July, August, and September. Further, on section of a tumour of large size and of long duration, the general appearance of the cut surface in a case of the pale variety conveys to one's mind the idea of fulness and solidity rather than of contraction and vacuity; whereas, if the defacement were to be regarded simply as a stage of temporary inactivity, in course of time the growth must naturally advance to the stage of fructification, resulting in the formation of well-marked tunnels and cavities as occur in the black variety. This is not found to be the case. But additional clinical facts may be adduced to show the independent nature of the pale from the black, and of these facts two, which are closely related to each other, and mutually strengthen the distinction, are of paramount importance : first, the fact of the tendency to relapse exhibited by either variety when surgical interference has not been thoroughly successful; and, secondly, the fact, which is of still greater import, that when such relapse occurs, the black reproduces the black, and the pale the pale form of the disease. To add to the interest, as it were, there have occurred in m}' experience not only secondary, but even tertiary, relapses, where the new growth was seen to present the same morbid changes in the subsequent growths as characterized the original growth. To summarize : 1. The general historical data for either variety are the same, with this important difference, that, in all cases,without exception,patients have, with reference to both forms of the disease, distinctly stated that from the very earliest indication of the existence of the growth, when one or more mamillated excrescences appeared upon the surface and burst, the sinuses so formed gave exit, throughout the rest of the course of the disease, either to pale or to black particles, but never to both kinds at the same time, or to one kind first, and at a later date, to another. 2. Anent the idea of the defacement of the fungus, while one would naturally expect a period of stasis in the growth of the tumour, there was, on the contrar}7, following the periodical extrusion of particles, observed a more or less gradual increase in its size, and in no instance was there noted, at any time, limitation or retrogression of growth. 3. Sections and cross-sections have not, at least in my experience, shown any admixture of
[Dec.
1894.
the two kinds of fungoid particles in one and the same specimen ; on the other hand, there was a curious completeness manifest in the anatomical characters of each individual variety. 4. In the dissection of infiltrated parts on following up the advancing course of the disease along tendons, fasciae, and areolar tissue to its termination, where it must be admitted the disease is to be found in its earliest stage of development, there is invariably discovered pale particles in the pale kind, and black particles in the black kind, and so far as the naked eye appearance goes, no transitional stages of growth from one to the other. 5. Careful excision of these terminal sites of the disease effectually cuts off all chances of recurrence, if not the disease tends to relapse ; in which case the pale is followed b}7 the pale, and the black by the black form of growth. Five secondary, and in one case, a tertiary, relapse of this kind have been observed by me in the Civil Hospital, Hyderabad Sindh.
lapse
primary infection, assuming it to
DIFNOTES ON MYCETOMA FERENTIATING the pale from the black variety.
CLINICAL
By
J. E. Bocarro, l.m.s.,. Bo., Teacher, Medical School, Hyderabad, Sindh.
Assistant-Surgeon
The object of the present paper is to place before the profession such clinical points observed by me as might help to elucidate the vexed question in the history of this curious disease; whether of the two varieties, the one is only a defaced form of the other; as Dr. Vandyke Carter has indicated in his investigations; or, whether they are perfectly independent forms of funo-al growths. Dr. Carter, as is well known, was the first to discover the fungoid character of either variety, and, more recently, other investigators in this field have clearly proved this to demonstration ; but in the absence of sufficient clinical evidence in support, they are not prepared to uphold Dr. Carter in his views that the pale is simply a defaced form of the black variety. Indeed, Drs. Boyce and Surveyor, in a paper read before the Pathological Society of London in April 1893, have been able to show clear differences in the microscopical appearance of the two forms, and are disposed to regard them as perfectly of each other in their
morphological
independent
nature.
.
. .
.
Following from a clinical standpoint this line of thought, I have put together the accompany in ?? notes of observations of a large number of cases which have come before me in the Civil Hospital practice, and would beg leave to offer them for consideration with reference to the point in question. Looking at the general history of the two forms of The disease as known in Sindh, it may be inferred that whatsoever cause applies to the black variety, as being the fons et origo males, applies also to the pale variety of the disease, since so far as historical data are concerned, no material differences exist in the one as compared with the other. Both varieties are found to affect the same class of people, namely, the cultivators, or those who have, at some time or other of their lives, exposed themselves to influences such as commonly surround people of the agricultural class; both are attributed to the same set of causes, viz., wounds, sores, prick of thorns, &c.; in both the same period of time has ,
452
INDIAN MEDICAL GAZETTE.
the fact that the tumour, whilst preserving al] its morbid characters, not only gradually increases immensely in size with time, but that it also exhibits a periodicity in the course of its development, which, as far as I have been able to ascertain from these ignorant patients, is referred in the case of the pale variety to the cold months of the year, namely, about November, December, and January, and, in the case of the black variety, to the rainy months, namely, June, July, August, and September. Further, on section of a tumour of large size and of long duration, the general appearance of the cut surface in a case of the pale variety conveys to one's mind the idea of fulness and solidity rather than of contraction and vacuity; whereas, if the defacement were to be regarded simply as a stage of temporary inactivity, in course of time the growth must naturally advance to the stage of fructification, resulting in the formation of well-marked tunnels and cavities as occur in the black variety. This is not found to be the case. But additional clinical facts may be adduced to show the independent nature of the pale from the black, and of these facts two, which are closely related to each other, and mutually strengthen the distinction, are of paramount importance : first, the fact of the tendency to relapse exhibited by either variety when surgical interference has not been thoroughly successful; and, secondly, the fact, which is of still greater import, that when such relapse occurs, the black reproduces the black, and the pale the pale form of the disease. To add to the interest, as it were, there have occurred in m}' experience not only secondary, but even tertiary, relapses, where the new growth was seen to present the same morbid changes in the subsequent growths as characterized the original growth. To summarize : 1. The general historical data for either variety are the same, with this important difference, that, in all cases,without exception,patients have, with reference to both forms of the disease, distinctly stated that from the very earliest indication of the existence of the growth, when one or more mamillated excrescences appeared upon the surface and burst, the sinuses so formed gave exit, throughout the rest of the course of the disease, either to pale or to black particles, but never to both kinds at the same time, or to one kind first, and at a later date, to another. 2. Anent the idea of the defacement of the fungus, while one would naturally expect a period of stasis in the growth of the tumour, there was, on the contrar}7, following the periodical extrusion of particles, observed a more or less gradual increase in its size, and in no instance was there noted, at any time, limitation or retrogression of growth. 3. Sections and cross-sections have not, at least in my experience, shown any admixture of
[Dec.
1894.
the two kinds of fungoid particles in one and the same specimen ; on the other hand, there was a curious completeness manifest in the anatomical characters of each individual variety. 4. In the dissection of infiltrated parts on following up the advancing course of the disease along tendons, fasciae, and areolar tissue to its termination, where it must be admitted the disease is to be found in its earliest stage of development, there is invariably discovered pale particles in the pale kind, and black particles in the black kind, and so far as the naked eye appearance goes, no transitional stages of growth from one to the other. 5. Careful excision of these terminal sites of the disease effectually cuts off all chances of recurrence, if not the disease tends to relapse ; in which case the pale is followed b}7 the pale, and the black by the black form of growth. Five secondary, and in one case, a tertiary, relapse of this kind have been observed by me in the Civil Hospital, Hyderabad Sindh.
