﻿ETIOLOGY OF MYCETOMA. 479 



if a considerable prominence of the superficial veins about the chest is excepted, 

 appear to be normal. The blood is free from parasites. Haemoglobin, 85 per 

 cent; red cells, 4,200,000; leucocytes, 7,000.- The leucocytes by differential de- 

 termination show 4 per cent eosinophils as the only departure from normal. 

 Her appetite is good and no disturbance of the bowel function is apparent, although 

 the caecum on palpation appears to be thickened and tender. There is no cough, 

 and a physical examination of the chest is negative. There are no symptoms 

 attributable to disturbance of the urinary system and the urine is normal. The 

 uterus is retroflexed and bound down by adhesions and there is tenderness in 

 the region of the right ovary. The cutaneous system appears to be normal, except- 

 ing over the right foot. The superficial lymphatics, particularly in the right 

 groin, are moderately enlarged and quite firm. Pain of a dull character and 

 not severe is present in the right foot, more pronounced when the patient is in 

 the upright position. The reflexes and sensation in general are normal. 



The right foot (shown in PI. I, fig. 1) is much enlarged and has the appearance 

 described in mycetoma. The toes are spread apart and appear to be turned 

 upward, because of the swelling of the ball of the foot. There are numerous 

 punehed-out, craterlike openings which communicate by sinuses throughout the 

 foot. These are so extensive that a probe may be passed in almost any direction 

 through the member. Pressure shows a moderately firm, but spongy consist- 

 ency and if applied on one point will cause a discharge from several openings 

 at the same time. There is some general tenderness and but slight alteration 

 in sensation. The process apparently stops short at the ankle. Other, earlier 

 lesions are present in addition to those already mentioned. These appear some- 

 what to differ from the usually described, early lesions of mycetoma. They 

 consist of soft, dark-colored, nodular masses of various sizes which, when opened, 

 bleed most profusely, exuding a dark venous-like blood. 



The lesions, when examined microscopically, in addition to blood, contain 

 other degenerating cells. The Streptothrioo about to be described may also be 

 observed. Cultures and smears were made from the lesions. The Rtreptothrix 

 was seen in the smears, but all cultures made at this time remained sterile. 



The patient was transferred to the surgical service of Drs. McDill and Dudley, 

 and acting upon the recommendations made in the literature, Dr. F. W. Dudley 

 performed an amputation of the leg at the lower third. 



The patient made a satisfactory recovery from the operation, and after five 

 months there has been no recurrence of the disease. 



STUDY OF THE AMPUTATED FOOT. 



Gross pathology. — The foot was sent to the authors at the Bureau of 

 Science immediately after the operation. An examination of sawed 

 sections of the tibia and fibula shows that the mycetomatous lesion 

 extends to about 5 centimeters above the ankle joint, the parasitic growth 

 being demonstrated in the bone marrow and the medullary canal of the 

 tibia. The appearance of the foot in general corresponds with the usual 

 descriptions given for a well-advanced mycetoma of the ochroid variety. 

 There is general enlargement to at least twice the normal size. This en- 

 largement is perhaps more marked on the ball of the foot, giving to the 

 toes the appearance of being turned upward and spread apart. The 

 external lesions are of two kinds, the first being craterlike, nodular and 

 more or less whitish in color, usually containing an opening in the 



