STKEPTOTHKICOSIS. 483 



lungs and pleurae are most frequently involved in this disease. It occur- 

 red 65 times in 257 cases reported by Duvan and 29 times in Ackland's 

 109 cases. The clinical symptoms in the lungs and the physical signs 

 may resemble a chronic tuberculosis or severe bronchitis and the pleural 

 involvement may consist of chronic, adhesive pleuritis or more often of 

 empyasnia. Unless there is perforation of the chest wall or metastases, 

 the clinical manifestations in these types show nothing characteristic of 

 the disease and the true nature of the infection can only be determined 

 by laboratory methods. Strep tothricosis of the heart and mediastinum 

 have been reported, and Ackland notes nine cases involving the oesoph- 

 agus. 



Abdominal streptothricosis, including all the organs of the abdominal 

 and pelvic cavities, have been reported by various observers. The liver 

 and gall bladder suffer most often. Involvement of these viscera, occurred 

 forty times in Duvan's series and thirty-three in Ackland's. The ap- 

 pendix is quite frequently involved and in some instances is the primary 

 seat of the lesions. 



Other lesions are found in the mesentery, intestine, rectum, spleen, 

 bladder, prostate, testicle, kidneys, and abdominal wall. In none of 

 these types are there any characteristic clinical manifestations which 

 differentiate this infection from other chronic inflammatory conditions of 

 tuberculous or other etiology in the same locations. 



Cerebral streptothricosis includes involvement of the brain, cord, men- 

 inges, and nerves, as well as the other tissues in these organs. The 

 central nervous system was involved 19 times in Duvan's 257 and 5 in 

 Ackland's 109 cases. Several different species of the organisms have 

 been found in these lesions, that of Eppinger being the principal one. 

 This species, as has been shown in Part I of this report, is identical with 

 8. freeri which caused the mycetoma in our case. The reported cases 

 show no characteristic symptoms in these types of infection. 



External streptothricosis may involve any of the external or contiguous 

 tissues, including the mouth and jaw, neck, skin, and subcutaneous 

 tissues, conjunctiva, nose, and extremities. "Lumpy-jaw" or "big-jaw" 

 is one of the most frequent of these various types; mycetoma, Madura 

 foot or streptothricosis pedis is a very common tropical type and others 

 involving many anatomical locations are frequently encountered. Prac- 

 tically all described species of the genus of the organism have been found 

 at one time or another in external streptothricosis, and there does not 

 appear to be much variation in the clinical picture because of any special 

 species or variety. The clinical manifestations of external streptothri- 

 cosis are rather characteristic. The peculiar, crater-like skin lesions of 

 a chronic character leading through ramifying channels, through which 

 is discharged the peculiar, oily, pus-like substance containing granules, 

 makes a rather constant and characteristic picture. As we have already 

 stated, mycetoma or Madura foot is best classified here as the clinical 



