THE PARAMYCETOMAS 



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appear upon the scene, and the fibrocellular coat begins to circum- 

 scribe the cells and the fungus, while the damaged remains of the 

 giant cell are seen retiring towards the periphery. 



Later, the mononuclear cells mentioned above appear, and these 

 various cells, together with detritus from the destruction of similar 

 cells situate in a granular network, form the cellular sheath of the 

 grain, as shown in our specimens. This description, although 

 varying in detail, does not differ materially from a composite 

 picture such as can be derived by a study of the writings of Carter, 

 Acland, Kanthack, Boyce and Surveyor, Unna, Schlegel, Foulerton, 

 Brumpt, and other authors who have studied the reaction of the 

 body against different species of the genus Nocardia. 



In more advanced cases the morbid anatomy is like that described 

 in maduromycosis, with, of course, the difference in the grain. 



Symptomatology, Diagnosis. — These are the same as for maduro- 

 mycosis. 



Treatment. — Vaccines have not given good results in our hands. 

 The correct treatment is removal whenever possible, but, failing this, 

 iodide of potash in large doses may be administered. 



Prophylaxis. — This is the same as for maduromycosis. 



THE PARAMYCETOMAS. 



Definition. — paramycetoma is a disease which includes all 

 growths and granulations producing enlargement, deformity, or 

 destruction in any part of the tissues of man which are caused by 

 fungi of any nature whatsoever, but in which grains are either absent 

 or so few and so small as to escape observation without prolonged 

 search. 



History. — In 1917, Chalmers and Archibald first proposed this 

 differentiation, and followed it up in 1918 by a further communi- 

 cation. 



Clinical Remarks. — The Paramycetomas, as already stated, 

 cannot be recognized without microscopical assistance, because 

 they present a varied group of clinical forms comprising chronic 

 ulcers which may seem to be non-mahgnant, doubtfully malignant, 

 or malignant, of growths which appear to be innocent or which are 

 capable of diagnosis as doubtful carcinomata, epithehomata, or 

 sarcomata, or with reference to which no doubt is entertained in 

 the mind of the surgeon attending them. 



If removed in the more innocent forms or in the early stages 

 they probably do not recur, but in the later stages of the malignant 

 forms they do recur, but probably then as true mahgnant 

 growths. 



As a diagnosis cannot be made clinically, it behoves us to inquire 

 upon what it is to be based. 



Diagnosis. — The recognition of a paramycetoma is based entirely 

 upon microscopical examination, and consists in finding one or 

 more of the following features: — 



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