136 KEVIKW — TKOnCAL MKDICINE, ETC. 



Mycetoma by the detachment of small shoots which grow on their own account. The grains are found 

 — cojiUiiiicd in cavities surrounded by inHammatoiy tissue infiltrated with leucocytes and sometimes 

 giant cells. This is one of the forms which, I believe, exists in the Sudan. 



3. NiooUe's White Mycetoma caused by Aspergillus nidulans. The grains are more or 

 less spherical, and present a smooth surface. This fungus destroys bone, and only one case 

 is yet on record. It occurred in Tunis, and showed spore formation. 



4. Bouffard's Black Mycetoma caused by Asperyillus honffanli. The grains are black, 

 and vary in size from that of a pin's head to that of No. 1 shot. They have a mulberry 

 surface, which is smooth and glossy. They are elastic, but break when pressed. The 

 grain consists of a coilod-up mass, which unfolds when macerated in water, displaying a 

 densely felted mycelium. The grains occur in the cellular tissue always singly and within 

 small cavities. Large giant cells form a feature of the growth. Curettage may cure this 

 form, which may, however, extend by way of the lymphatics. 



5. Classic Black Mycetoma caused by Madurella mi/cetomi. The grains are dark 

 brown or black. Each measures 1 to 2 mm. in diameter, and is hard and brittle. The 

 surface is irregular and more or less " spiked." The grain is composed of white threads 

 and cement substance, and, after a period of active growth characterised by the formation 

 of chlamydospores, passes into a resting stage and becomes a sclerotium, in which form 

 it is eliminated. This tyjje is very destructive, forming large and sometimes fungating 

 tumours, and is by far the counnonest form in the Sudan. 1 have seen it affecting the 

 exterior of the knee-joint and the hand, and noted that it may spread by way of the 

 lymphatics. 



6. Brumpt's White Mycetoma caused by Indiella mansoni, an Indian form. The grains 

 are hard, white, small and resistant. 



7. Reynier's White Mycetoma caused by Indiella rei/nieii, and described from a case 

 of madura foot in a man who had never been out of France. The grains, which are soft 

 and white, were found rolled up like the excrement of earth-worms. 



8. Bouffard's White Mycetoma, caused by Indiella somaliensis. Single grains are 

 small and smooth, and consist of a mycelium which at its earliest stage is always found 

 in a giant cell. The grains vary in colour from white to reddish-yellow, and are found 

 clustered together like fish-roe in the sinuses. This fungus is most destructive, attacking 

 bone and producing sclerosis. I am inclined to think that I have seen one case of this 

 form (pink mycetoma), a specimen of which is in the laboratories' museum. 



Brumpt's paper is very well illustrated, and amongst his conclusions we note that — 



(1) it would seem that for the production of mycetoma there must be, both on the part of the host and 

 parasite, conditions not easily obtainable in Nature, otherwise the number of cases would be enormous, owing 

 to the apparent facilities for spread amongst the bare-footed natives of those countries chiefly affected ; (2) on 

 account of the feeble resistance of the conidial spores in the tissues and the slight success which has attended 

 the experimental subcutaneous injection of spores, it would seem that the fungus must be inoculated into the 

 tissues in a form better adapted to resist destruction than filaments given off by the eonidia ; (3) the giant 

 and epitheliod cells appear to play a part in the nourishment of the young parasite, and, what is remarkable, 

 the macrophages, which should defend the threatened organism, actually act as disseminators of the fungus and 

 so aid its spread ; (4) the diagnosis is to be made from the grain which is characteristic. This is not the 

 case as regards the tumour masses, the appearance of which varies according to the age of the lesion ; (5) no 

 doubt other forms will be found to exist. 



Musgrave and Clegg,' in a paper on the etiology of mycetoma, whilst acknowledging that 

 Brumpt's work is very exhaustive, conclude that he has made his classification on insufficient 

 data. This may be so, but it is likely to be helpful, and marks a step in advance. Musgrave 

 and Clegg describe the disease in the Philippines and claim to have isolated a new parasite, 

 StreptothrLr freeri, from a single case. They are of opinion that all types of mycetoma are 

 due to Streptothrix infections, albeit it is not ja^t settled whether moi-e than one species 

 plays a part in the disease. Their paper is chiefly of value because of the review of the 

 literature which it contains and the extensive bibliography appended to it. 



Vincent-* applies the name Madura to the variety with white grains due to Discmiu/ces 

 viadnnv., and the name Mycetoma to the variety with black grains caused by a fungus with a 

 septate mycelium (Madurella niycetomi). Resistance to staining is regarded as an indication 

 of degeneration, or loss of vitality in the fungus, due to long duration of a case. 



' Musgrave, W. E., and Clegg, M. T. (December, 1907), "The Etiology of Mycetoma." Philippine Journal 

 of Scicncr,, Vol. II., B. Med. Sciences. 



« Vincent (July SSth, 1906). C. R. Hoc. Biol., t. LXI. 



• Article not consulted in the original. 



