When inhaled, the organisms enter the deeper portions of the lung and cause a suppurative broncho-pneumonia with adhesive inflammation of the contiguous pleura. After the formation of the pleuritic adhesions the disease may

penetrate the newly formed tissue, extend to the chestwall, and ultimately form external sinuses; or, it may penetrate the diaphragm and invade the abdominal organs, causing interesting and characteristic lesions in the liver and other large viscera.

Lesions. The degree of chemotactic influence exerted by the organism seems to depend upon the tissue affected, upon the peculiarity of the animal, and upon the virulence of the organism. When an animal is but slightly susceptible, and especially when the tongue is affected, the disease is characterized by the formation of cicatricial tissue"wooden tongue." If, on the other hand, the animal be highly susceptible and the jaw-bone affected, suppuration, with the formation of abscesses, osteoporotic cavities, and sinuses, are apt to be noticed. This form of the disease is called "lumpy jaw" in cattle.

Before the nature of the affection was understood it was confounded with diseases of the bones, especially osteo

sarcoma.

From the tissues primarily affected the disease spreads to the lymphatic glands, and eventually to the lungs. Israel has pointed out that certain cases of human actinomycosis begin in the peribronchial tissues, probably from inhalation of the fungi.

But few cases recover, the disease terminating in death from exhaustion or from complicating pneumonia or other organic lesions.

CHAPTER XXXIV.

MYCETOMA, OR MADURA-FOOT.

ACTINOMYCES MADURE (VINCENT).

General Characteristics.-A non-motile, non-flagellate, sporogenous (?), non-liquefying, non-aërogenic, chromogenic, aerobic and optionally anaerobic, branched, parasitic organism belonging to the higher bacteria, staining by ordinary methods and by Gram's method, and pathogenic for man.

A curious disease of not infrequent occurrence in the Indian province of Scinde and of rare occurrence in other countries is known as mycetoma, Madura-foot, or pied de Madura. Although described as peculiar to Scinde, the dis

ease is not limited to that province, but has been met with in Madura, Hissar, Bicanir, Delhi, Bombay, Baratpur, Morocco, Algeria, and in Italy. In America less than a dozen cases of the disease have been placed on record. In India it almost invariably affects natives of the agricultural class, and in nearly all cases is referred by the patient to the prick of a thorn. It usually affects the foot, more rarely the hand, and in one instance was seen by Boyce to affect the shoulder and hip. It is more common in men than in women, individuals between (Musgrave twenty and forty years of age suffering most frequently, though persons of any age may suffer from the disease. It is insidious in onset, no symptoms being observed in what might be called the incubation stage of a couple of weeks' duration, except the formation of a nodular growth which gradually attains the size of a marble. Its deep attachments are indistinct and diffuse. The skin over it becomes purplish, thickened, indurated, and adherent. The

Fig. 269.-Madura-foot

-mycetoma and Clegg).

ball of the great toe and the pads of the fingers and toes are the points most frequently invaded. The lesions progress very slowly, and in the course of a few months form distinct inflammatory nodes. After a year or two the nodes begin to soften, break down, discharge necrotic and purulent material, occasioning the formation of ulcers and sinuses. The matter discharged from the lesions at this stage of the disease is a thin seropus, and contains occasional fine round pink or black bodies, similar to actinomyces "grains," described, when pink, as resembling fish-roe; when black, as resembling gunpowder. It is upon the de

tection of these particles that the diagnosis rests. According to the color of the bodies found, cases are divided into the pale or ochroid, and melanoid varieties.

The progress of the disease causes an enormous enlargement of the affected part.

Pale Variety. Kanthack was the first to prove the identity of the fungus with the well-known actinomyces, but there seems to be considerable doubt about the identity of the species.

Morphology. Under the microscope the organism is found by Vincent* to be

branched and belong to the higher bacteria.

*"Ann. de l'Inst. Pasteur," 94, 3.

It consists of

long, branched bacillary threads forming a tangled mass. In many of the threads spores could be made out. He was unable to communicate the disease to animals by inoculation.

Cultivation.-Vincent succeeded in isolating the specific micro-organism by puncturing one of the nodes with a sterile pipet, and cultivated it upon artificial media, acid vegetable infusions seeming best adapted to its growth. It develops scantily at the room temperature, better at 37° C.-in from four to five days. In twenty to thirty days a colony attains the size of a little pea.

Bouillon. In bouillon and other liquid media the organisms form little clumps resembling those of actinomyces. They cling to the glass, thus remain near the surface of the medium, and develop a rose- or bright-red color. Those which sink to the bottom form spheric balls devoid of the color.

Gelatin. The growth in gelatin is not very abundant, and forms dense, slightly reddish, rounded clumps. Sometimes there is no color. There is no liquefaction.

Agar-agar. Upon the surface of agar-agar beautiful rounded, glazed colonies are formed. They are at first colorless, but later become rose-colored or bright red. The majority of the clusters remain isolated, some of them attaining the size of a small pea. They are usually umbilicated like a variola pustule, and present a curious appearance when the central part is pale and the periphery red. As the colony ages the red color is lost and the colony becomes dull white or downy from the formation of aerial hyphæ. The colonies are very adherent to the surface of the medium, and are almost of cartilaginous consistence.

Milk. The organism grows in milk without causing coagulation.

Potato. Upon potato the growth of the organism is meager and slow, with very little chromogenesis. The color-production is more marked if the potato be acid in reaction. Some of the colonies upon agar-agar and potato have a powdery surface, either from the formation of spores or of aerial hyphæ.

Lesions. Microscopic study of the diseased tissues in mycetoma is not without interest. The healthy tissue is sharply separated from the diseased areas, which appear like large degenerated tubercles, except that they are ex