from the bifurcation of the the

toes to the ankle joint and extending to outer edge of the sole of the foot. *




Staff Surgeon, Having had


the 011 cient interest





form of



this I hope these will be of suffi-




their publication. 1. Natha," Hindoo male, wtat 50 years, was admitted into the Staff Hospital on April 12th, suffering from mycetoma of his left foot. The disease affects principally the dorsal aspect of the foot extending backwards to the ankleto warrant



Pi ?evious History.?States that he has suffered for about 20 years from this affection. It originated in a small abscess, caused by some slight injury, which burst leaving a small open sore with a darkish induration around, and this gradually spread to its present size. From its commencement, there has been no period in At present he is which the disease got better. not able to walk or put his foot to the ground. Present Condition.?The diseased mass is darker than the surrounding skin, elevated, and on its surface are numerous fistulous channels from which serum and pus exude, and after the application of a poultice, a number of small hard, black, particles,?the shape and size of an ordinary grain of rice,? are always to be seen on the poultice after its removal. The introduction of a probe reveal, that no communication whatever exists between The lymphatics on the affected the sinuses. side are enlarged, indurated, and painful. To relieve the pain in his foot, the patient has been an inveterate opium-eater for the last 15 years. He is married and has six children, all healthy. Treatment.?Amputation above the ankle, and he was discharged well from the hospital. 2. "Juttoo," a Hindu woman, cetat (about) 35 years, was admitted on 2nd May, suffering from mycetoma of her left foot. The disease, as in the former case, is situated on the dorsal



and present Condition.?She states that about five years ago, whilst walking in the' fields, a thorn penetrated into the outer edge of her left foot, which was extracted the same day by a native by means of a pair of forceps and a needle. Two days subsequently inflammation and ultimately suppuration set in, and for three months she was confined to her bed, and since then the disease has steadily progressed and assumed its present chronic condition. Numerous small foramina (from which a bloody purulent discharge exudes) are seen on the surface of the diseased mass, and the patient states that occasionally the small black particles, as noticed in the previous case, are mixed with the discharge from the sinuses. No communication exists between these sinuses. The are affected, and her conlymphatics general dition is greatly impaired. Treatment.?Amputation above ankle joint. She was discharged in good health with the stump completely healed on the 21st May.



Punjoo Jamal," a Hindu, cetat 20 years, admitted with mycetoma of his left foot on 29th May last. Previous History.?States that about two years ago, whilst engaged in the fields, he stepped upon a sharp edged stone which caused an incised wound in the sole of his left foot. Some particles of stone were imbedded in the wound which came away after the application of poultices of nim-leaves, but, the swelling around the wound continued to increase, and numerous openings appeared on its surface from which escaped minute black particles mixed with blood and pus. Present Condition.?When admitted, the left foot was greatly swollen; the swelling beiug caused by a mass of diseased tissues of a blacker colour than the surrounding skin. Numerous short fistulous canals open on the surface, but do not communicate with each The patient is greatly emaciated ; he other. has no disease of his internal viscera, but the lymphatics on the affected side are enlarged. Treatment.?Amputation through the lower third of the leg, and he was discharged in much better health on 23rd June. " 4. Heeralal Dulla," cetat 10 years, a boy of good constitution, was admitted on 9th of lie was suffering June last for treatment. The diseased mass which ia from mycetoma. only the size of a large lien's egg, is situated about the Centre of the inner* side of the sole of his right foot. About a year Previous History. ago, thefather states, that the lad first began to scratch: the spot above describedj which gradually became hard, but at first it did not cause much 3.





further than the constant irritation which caused the boy to scratch the spot. No history of a traumatic origin is obtainable. The boy complains of Present Condition. pain when the diseased mass is pressed, and it seems to be moveable under the skin, implicating only the subdermal tissues. The mass is elevated above the surface, but owing to its recent origin, its size is limited in extent, and no minute black particles have been noticed, as in the other cases; but otherwise the disease possesses all the characteristic of mycetoma. He cannot bear the pressure of his body on the affected side of his foot, which causes him to walk as if he were suffering from talipes varus. The father states the mass is getting larger. The general constitution does not seem to be affected and so far he' has no lymphatic enlargements. Treatment.?Chloroform having been administered, the mycetomatous mass was excised on 14th June. The diseased mass was found to be superficial, engaging only the cellular tissue, and not affecting the adjacent tendons, arteries, &c. After the operation, the surface of the wound was thoroughly washed over with a strong solution of cupri sulphas. The patient was discharged on the 25th June, the wound having completely healed, and he was able to walk away with comfort. Remarks.?From my observation of the above and many other similar cases, I am of opinion, that this disease is decidedly peculiar to natives (who may suffer from it at any age) ; it does not attack Europeans, and is prevalent only in certain districts in India. Etiology.?In most cases a traumatic origin is given by most patients as to the causation of this disease, the injury usually being an abrasion or some trivial wound of the skin, from which the disease extends to the cellular and ultimately to the bony tissues. Decidedly this disease never primarily originates in the deeper tissues. Treatment.? Being convinced of this fact, I consider that if the disease is recognised early, excision of the diseased mass is the proper procedure, and the treatment laid down in most suro-ical works, viz. "that amputation is the only remedy for this disease," is not in such cases to be followed ; but if the disease has progressed so far that this operation (excision) is not feasible, then, I thinkthatamputation is the only remedy.



Local and constitutional symptoms are always present, especially if the disease has assumed a chronic form. Of the local symptoms, acute In the cases under is the most pain


my observation, this symptom varied according to the situation of the disease, which has convinced me that it is caused indirectly by pressure on the adjacent nerves, and when acutely severe, it has been the cause of patients resorting to the habitual use of opium. The constitutional symptoms are the same as those iu most other



chronic forms of disease, which tend to undermine the general system, and amongst other causes this disease may be, as in the last case, the indirect cause of other complications, such as talipes, &c. Deesa





Clinical Notes on Mycetoma.

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