Medica1 Officers of the Army of India.
73
to make their appearance in their immediate neighbourhood. Accumulations of
granulomatous tissue, frequently containing bodies similar to those which occur
so abundantly in the morbid tissue in Rhinoscleroma (Plate I, Fig. 8), are gradu-
ally formed at points along their course, in some cases forming more or less
continuous sheaths and in others localised aggregates, which tend specially to
make their appearance at points of bifurcation (Plate II, Figs 8-11). As time
goes on these accumulations steadily increase in bulk, and as they do so, and as
the normal formed elements of the adjoining tissues undergo progressive solu-
tion, large areas come to be occupied by morbid vessels embedded in granuloma-
tous tissue laid down in an intricate system of masses and intercommunicating
bands. From the nature of the changes affecting the vessels, it is clear that the
nutritional requirements of the morbid tissue must be very imperfectly met,
and that the latter must consequently be specially liable to degeneration and
necrosis. Such processes must almost necessarily be attended by reactive in-
flammatory processes of like distribution, and ultimately leading to the develop-
ment of a ramified system of spaces and channels bounded by more or less de-
fined walls of fibrous connective tissue and occupied by degenerate and necros-
ed products in various stages of alteration. The precise nature of the changes
ultimately taking place in such products will naturally, not necessarily, be iden-
tical in all instances. In certain cases processes of solution into oily or mucoid
matter may occur followed by absorption or caseation, or by external dis-
charge where a communication with the surface is established. Where the
morbid products are discharged, little, save persistent elastic elements, may re-
main behind (Plate I, Fig. 7), but where caseation takes place its ultimate pro-
ducts may remain for long in a passive condition. Whatever course the pro-
ducts pursue, however, they must necessarily represent accumulations of dead
matter affording a passive nidus for the development of saprophytic fungi or
other organisms capable of deriving nutrition from materials of animal origin,
so that, if by any means the elements of these attain access to them, the normal
course of the disease must be liable to be disturbed and its products come to
contain fungal or other organised elements of extrinsic origin which do not repre-
sent causes but consequences of the primary morbid processes. In the case of
the black variety of Mycetoma which was recorded in 1888 by Bassini* as
having originated in Italy, the patient had sustained a wound in the foot in which
the black fungiferous concretions subsequently were present, and in India the
frequency with which the disease is associated with fungal elements, and the
fact that fungoid concretions occur so much more frequently in the feet than
in the hands, is probably connected with the facts that the natives of the country
in conducting agricultural operations ordinarily go bare-foot, and that at particu-
* Un caso di micetoma ul piede o piede di Madura, Archivio per le scienze mediche, Vol. XII,
p. 309.