THE MADUROMYCOSES 



2129 



Some new indurations and nodosities appear in various parts of 

 the foot, and new openings are formed, while the whole foot begins 

 to swell in a very characteristic manner. First the arch of the 

 foot fills up and disappears, the whole sole becoming so swollen and 

 convex that the toes are no longer able to touch the ground, and 

 may be pushed apart, but are usually not affected by the disease. 

 At the same time the dorsum of the foot becomes studded with 

 nodules and openings. The colour of the integument may be 

 normal, but is usually darker than in the healthy skin. It is rarely 

 oedematous. The openings, when examined by a probe, are found 

 to lead into sinuses, which penetrate deeply into the tissues, and at 

 times even into the bones of the foot. The quantity of the dis- 

 charge varies from time to time, being increased by motion. On 

 palpating the affected area, it is found to be elastic, and the sensi- 

 bility to be normal. The inguinal glands are often enlarged and hard. 



As the disease progresses, pain, which at first was slight, becomes 

 more marked, especially in cold weather. The patient ceases to 

 be able to place the foot to the ground, and is compelled either to 

 walk on the heel or to use a support. The leg begins to waste, 

 and after a long time the patient becomes weak and anaemic from 

 the constant drain on the system by the discharge, and possibly 

 also by toxins produced by the fungi. General constitutional dis- 

 turbance of a febrile nature is rare. 



The disease is very chronic, and has no tendency to heal, and if 

 not treated, will eventually cause the death of the victim, from 

 exhaustion or diarrhoea, after lasting some ten or twelve years. 



Diagnosis. — The peculiar swelling of the foot, with a filling-up of 

 the arch, and the formation of sinuses from which a discharge 

 containing the typical grains is escaping, enables the disease 

 to be diagnosed with certainty from elephantiasis or tubercular 

 disease of the foot. 



The variety of the fungus may be determined by examining the 

 grains or the scrapings of the sinuses microscopically, culturally, 

 and by inoculations in animals. 



It is to be noted that the typical grains may for a time be absent 

 from the purulent liquid exuding from the sinuses. In such cases 

 squeezing of the nodules may make the grains appear, or a nodule 

 which has not yet opened may be incised and the contents examined. 



Prognosis. — If the growth is observed when young, small, and 

 lying subcutaneously, so that it can be completely removed, the 

 prognosis is good, as the wound heals readily and the growth does 

 not recur. 



If, however, the growth has lasted some time, and has involved 

 the bones, the prognosis is not good, and is worse if the lymphatic 

 glands are also implicated. 



Treatment. — Remove the growths at an early stage and as com- 

 pletely as possible. In later stages amputations well above the 

 seat of any lesion, together with the removal of any enlarged 

 lymphatic glands, is the only possible treatment. 



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