THE INDIAN MEDICAL GAZETTE.
2?2 iv
[November 1,
1873.
i
NOTES ON SOME POINTS CONNECTED WITH FUNGUS FOOT DISEASE.
By Surgeon-Major
W. J. Moore, L.R.C.P.
Among other questions not satisfactorily answered regarding this malady is the query, whether or not there are two distinct forms of the disease?one in which the black material is found, another in which this so frequently characteristic appearance Carter describes three varieties of the affection, in one of which the black particles appear, in the second of which
is absent.
granules only are found, the third presenting a surface, appearing, when cut, as if powdered with red pepper. The connection, however, of the two latter appearances with the black variety has jiot yet been distinctly demonstrated. If the above are different forms of the same malady, it follows that the black material, presenting only in one variety, cannot be the cause ot the affection, and must therefore be an accidental complication. I certainly have seen cases of disease of the foot, involving both soft tissues ar.d bones, and presenting all the destruction of tissue noted in fungus disease, but without either black material, red specks, or white granules. In the absence of such distinctive marks, the cases have been noted as " Scrofulous." Another question therefore arises?is this so-called fungus disease simply a scrofulous affection, to which, from externally, some fungus element has been added ? The appearance of the early stage of the malady might be expected to throw some light on the matter; but, practically, this is not the case;* for, although in some instances, as I have elsewhere noted, the first condition before white
any wound of the skin occurs is a blackish or bluish mottled discolouration beneath the integument, as if gunpowder or Indian ink had been pricked into the skin, in other instances
the malady is stated
to commence
as
a
small
pimple
or
pustule,
pus, at a later period the peculiar black material. It would therefore appear certain that the latter is not present during all the stages of the disease, but withat first
discharging ordinary
out its presence the malady cannot be certainly diagnosed as foot. These are points deserving more attention than has yet been paid to them.
fungus
A second
query is.?are the deep or superficial parts first affected ? I believe that when the black fungus is present, the superficial parts are first implicated, and for the following reasons :?In three cases of incipient disease, I have incised the integument, and cut or scraped away all the diseased tissue. One of these cases on the dorsum of the foot, and involving a metatarsal bone, is reported in the November number of the
interesting
Gazette for 18G7.
Another
case
was
on
the sole of the foot, and
institutions of
Kajpootana 815
for the year 1870
:
"
In the Bhurt-
in-door
patients were received, while 71 major and 191 minor operations were performed. Some of the major operations were of great importance, and professionally interesting and instructive. I refer more particularly to one only, viz., the removal of part of the foot for mycetoma, or the fungus disease of India. In relation to this case, Dr. Ilarvev observes ?' I believe, that when taken early this disease might almost always be cured without amputation being needful, although most authorities maintain the contrary.' And in this remark of Dr. Harvey's I agree, having myself cured two cases, by simply scraping or cutting out the diseased parts. Dr. Harvey noticed the black affected portion to be enclosed in a cyst; and curiously I have very recently received a communication from Dr. Newman of Jodhpore, mentioning a similar This is interesting appearance in one of his dispensary cases. and practically useful surgically, as tending to show the localization of the malady." With the exception of the above, all I think who have written on the subject mention amputation as the only method of cure. Most authors, indeed, as Aitken, Fox, Ballingall, Btisk in Holmes' system of surgery, Byzuinjee, Colbrooke, &c., only pore
Hospital
mention treatment of the advanced stages of ihe disease. it is clear that future text-books must now notice the
But
possibility
of cure
by surgical means in the early periods of the affection. There appears to be a somewhat general impression, that fungus foot disease is confined to, or, at least, is more prevalent on, dark colored moist soils, and more especially on cotton soil, an
idea
probably originating
in the fact of the
malady having presenting such surface. But the affection is not uncommon in sandy countries, where little or positively no cotton- is grown. It is frequently met with in Marwar, in Bickanneer, and throughout the whole of the semiThe fact of its occurring desert districts of Western llajpootana. been lirst noted in localities
on
these sand tracts, where the rainfall seldom averages more or eight inches annually, and where water is two and
than seven
three hundred feet from the surface, is important, as if there be any fungus connected with the disease, it must be a fungus
capable
of
flourishing,
not
only
in moist
localities,
as
cotton
soil, but also in dry and sandy places.
Similarly, there is an impression that the foot only becomes affected. This idea is erroneous. An instance of what is believed to be the disease in the calf of the leg has already been mentioned, and as I have noted elsewhere, (Indian Annals, Vol. XX. J it sometimes presents on the hand or shoulder.
the disease did not
penetrate the deep fascia. The third case was on the dorsal surface of the foot, but not involving the bone. It was ascertained more than eight months afterwards that the two last patients remained well, and as nothing was heard of the first case after the man left, his permanent recovery may be inferred, as the patient departed with a singularly satisfactory cicatrix. At the present time there is a person visiting the Aboo Dispensary, with what I believe to be the disease in the calf of the leg, who was treated in similar manner, but not so successfully, the malady having returned. In addition to the above instances of cure, by excising the diseased structures, Dr. Eddowes (Indian Mcdical Gazette, September 18G7) has reported three successful instances of similar treatment, aided by the after applications of polassa fusa. Dr. Spencer of Bhurtpore recently kindly forwarded to me the notes of a case where the dorsum of the foot was affected, but not the The diseased parts were removed, and the patient left Spencer's report of the case is attached as- an addendum to this article.
bones. cured.
Dr.
In addition to the above evidence on the and therefore of the external
possibility of cure by origin of the malady, I
excision,
quote the following paragraph from my report *
on
Medical G.izett?>, November 1867. Indian Annals, Medical Science Vol. XX, Indian
the medical
Spencer's Case of "Mycetoma Tarsi," mentioned above. Jamna, Brahminee, aged 30, married, was admitted into Anah Hospital on 10th Hay 1S73, suffering from Mycetoma Tarsi of the right foot. Has had children, and is a vigorous healthy young Doctor
woman.
State on admission,?There were four small openings in the skin, through which, on introducing a probe, the diagnostic black gritty pulp exuded. The amount of skin implicated was about one and a half inch square, one sjde of the square being at the outer side of the metatarsal bone of the great toe, the disease extending outwards across the metatarsal bones. The skin lor thi3 extent was of a bluish tint, thickened, undermined, and
subjacent tissues. There was great pain, but swelling ; the natural shape of the foot was scarcely oi altered, and there was no swelling nor thickening of the sole
adherent to the little
or no
the foot. Previous history.?No history of hereditary disease. One other person in her village reported as suffering from the malady, who is also a yc;ung Bralnnince patient; says that 8 months before coming to hospital, she became aware of some "slight as the difference" in her loot, she could not bend it so freely was it as only 'l to attach this, any importance other; she did not little stiff, and did not in any way ^interfere with the perform-
Noyemheti 1,
NOTES OX FUNGUS FOOT DISEASE.?BY W. J. MOORE.
1878.]
anco of her household duties. The pain gradually increased; six months before coming to hospital it was very annoying; five months before coming she could only walk on the heel of the diseased foot; four months before coming she could not stand upright, but propelled herself about the house with her hands, keeping the aching foot clear of the ground. From first to last,
the pain was deep-seated, of a burning character, and worst at night. Says that about four days after the feeling of something "
different" in the foot noted above, the skin over the metatarsal bones became very itchy, and that a week afterwards the surface began to grow discoloured. About a fortnight after this the part swelled, a week subsequently a small boil appeared, which in three or four days burst and discharged pus and the characteristic black substance. Three boils, similar in their and progress
contents to the first, came out at intervals of a fortnight after this. For five months before coming to hospital no more boils appeared. The four sinuous openings left by the bursting of the boils did Pus and the charcoal-like substance continued to be not heal.
discharged through them. Operation.?Incisions were made, extending affected tissues, and the skin reflected and
well cut
beyond
away.
the It was
found that at three or four points the structures in the metatarsal interspaces were infiltrated and thickened. On cutting these out, bit by bit, the parts affected by the disease were found tough and thickened. I think the lower portions of the diseased condensed and thickened than the upper. implicated. After removing all the diseased tissues, the wound was freely burnt with strong nitric acid. It had completely healed by the 29th of June, structures were
more
The metatarsal bones were not
when the
left the
patient
hospital.
in the foot and could walk about 20 miles from and her
as
well
Bhurtpore; will be
She had a3 ever
she
can
no
pain whatever
she could.
therefore be
She lives seen
occa-
watch. A second case, also kindly forwarded to me by Dr. Spencer, may be advantageously placed in contrast to the above, as showing the advanced stage of the malady :
sionally,
case
an
interesting
one
to
?
Alcbar Jilt, zemindar, aged 36, was admitted into Anah Hospital on 19th July 1873, with Mycetoma Tarsi of right foot. Puevious History.?Says he first felt pain, and noticed '?
the black
swelling,
discharge about five years ago. Since then the pain, and small boils, have gradually increased. During the the pain has much increased in severity. No other
last year people in his
similarly affected, nor is there any being hereditary. State on admission.?Patient healthy, and does not appear pulled down by the disease. Is unable to put the whole foot on the ground, but walks on the heel with pain and difficulty. Although the patient complains much of pain, I do not think the pain is so acute as is usual in these .cases. Foot much swollen, and skin discoloured (blackened) to a line corresponding with the astrngalo-scaphoid articulation. More skin involved history
village
were
of the disease
the outer side of foot than on the inner side. The heel free disease. The usual sinuous openings on the dorsum of the foot had all healed excepting one, and from this no black but there could be no doubt whatever as matter was on
from
issuing;
to
the nature of the disease, from the appeaiance of the foot and
the
previous history.
Operation.?It was considered that amputation at the anklejoint would give the man the best chance, and PirigofPs operaThe skin being sound tion was. performed in the usual way. about the inner ankle, allowed the posterior tibial artery to be
avoided.
examining stump, foirr or five centres of disease were discovered and cut out. These I certainly did not expect to find. These black centres, if I may call them so, were found alike in muscle fat and skin. The tissue about each spot was destroyed, These black bodies were and rendered tough and fibrous. On
the
loose, as it were, in the muscular structures, sonietfmes enclosed in a membrane; but more frequently they were found in funnel-shaped cavities of dense parchment*like
sometimes found
*
283
The structure of the tissue in which the black bodies
tissue.
deposited appararently go to form these parchment-liko shafts, the original tissue becoming completely disorganized. On turning back the skin of the upper flap, I was much astonished as chagrined to find the end of the tibialis anticus, projecting from the wound like an opening convolvulus. The skin was reflected back and the muscle pulled out, and about one are
and a half inches cut off, well clear of the affected part. The funnel contained black matter. The muscular tissue, though changed, thickened, and whitened, had not yet assumed the
toughness previously alluded to. This invasion by the disease was probably of recent date. Strong nitric acid was" applied freely, the bones brought into apposition, sutures applied, and limb tightly bandaged. Remarks.?My diagnosis was imperfect, but I think I had every reason for coming to the conclusion I did, and none for The colour, touch, and coming to an opposite conclusion. appearance of the foot all supported the opinion, that by amputation through the ankle joint, flaps, free from disease, would The skin around the internal malleolus being be secured. healthy, enabled me to make sure of avoiding the posterior tibial, and of cutting the plantar arteries long, and so of getting a well-nourished heel flap. Chopart's operation, I thought, would be too near the disease ; but it was not doubted that Syine's or Pirigoff's would pass easily and completely beyond it. On the discovery of disease in the flaps, the question I did arose as to the advisability of at once amputating the leg. not contemplate doing so in this case, because I promised the poor fellow I would leave his heel, and would not remove the leg; and as every particle of diseased structure that could be found cut out, and the parts freely cauterised, the man has was chance of an useful limb. Should the disease re-appear, of the leg can be afterwards performed." The diseased portion removed was forwarded to me by Dr. Spencer, and was minutely examined by Dr. Ilendley and myself. The following is Doctor Hendley's account of the a
amputation
appearance:?
jExamination of
a Fungus Foot, forwarded by Z>r. Spencer of Bhurtpore to Dr. Moore, Superintendent'General of Dispensaries, Sfc., ?fc., Rajpootana. Tixe foot had been carefully put up in a tin case filled witli spirit, which, when it escaped, was thickened and darkened by substances exceeding from the diseased structures. The dorsum of the foot was the part most affected. Upon section numerous bluish black granules were seen to be scattered irregularly over all the various structures, muscle bone, cartilage, &c.; theso
bodies
were
not found in the interior of muscle bone or did not communicate with each other, neither
ligament; they
perforating the tissue. metatarsal bone there was a small pocket lined with membrane and filled with black bodies; there were also small from the outer surface of the foot to the cellular sinuses were
In
there channels one
leading
tissue between the bones. The ends of several metatarsal, and the articular surface of one tarsal bone, were denuded of their and necrosed. The small bodies referred to above were usually multiple, generally from four to eight were loosely connected by a bluish, removed from white, thin membrane, which could be
coverings
easily
them. The muscles were neither softened nor altered in color. The disease had followed the course of the articulations, and surface of had only in a few places penetrated to the
plantar
the foot. examination roe-like bodies
of the black structures?the of Carter, $c. Different specimens were treated with potash, ether, dilule Others were boiled in nitric acid, acetic acid, and glycerine. dilute nitro hydrochloric acid, and potash. The best results were given by those dissolved in ether, and those treated bv boiling. After treatment with ether, numerous cells, filled
Microscopical
with
granules
The
masses
joined by apparently
and
colouring matter,
were
distinctly
a
proceeding from
the
body
with
which
it
was
All the structures delineated at page 22 of Dr. Fox's scheme for obtaining a better knowledge of skin diseases were
noted.
These were,
however,
not
seen
in
a
single speci-
spores, sporidia, and filaments, were observed. Large spore cases filled with sporidia were also observed, scattered irregularly through the field ; these resembled the structures marked C 4 on page 23 of Dr. Fox's report.
Bursting
Before the application of ether,
numerous
globules
of fat filled
the field ; there was not a trace of a single crystal. The spore cases in some instances were attached to the dark masses by
long filaments
;
in every case truces of such
a
Remarks.?The above observations entirely
observed.
of the dark-coloured substance were seen to be tubp, one end of which contained dark matter,
united.
men.
November 1873.
THE INDIAN MEDICAL GAZETTE.
284
connection
were
to
agree
assign
a
fungus (chiouyphe carteri)
with those
prominent place in the disease; they would also appear to render it probable that it. is the primary cause. The deeper structures were only partially affected, the bones not until denuded (in the case of the small sinuses the adjacent bor.e wn9 uninjured). The fungus would seem to enter from without and find its way by the cellular tissue, all over the foot, coming to the surface when its course is impeded or when which
a
The nutrition of the foot may be altered a sweat duct. pressure upon the small vessels; that this is possible, may be inferred from the great length of time a man may suffer from the disorder without much constitutional dis-
near
by
turbance.
I have
ten years without
seen
injury
a
to
case
in which the disease had lasted
the health of the sufferer.
discernible.
a.
b. c.
(1. e.
f.
Sporidia. Spore cases full. ?
,,
empty.
Two bodies joined by a tube. With a higher power shows dark fluid in the tube. A dark mass with a low power, shows filaments springing out from it.
a.
Spore. Spore.
Small spore, &. Small spore. off filaments. filaments, broken off with broken b. Spores elongated with Spores elongated case. b'. An An almost almost empty spore ease. empty spore A A bursting c. spore. bursting spore. d. Two Two filaments, magnified. filaments, highly highly magnified. hb attached filament to to the the edge of aa dark e. attached by dark body. by aa filament edge of body.
2?2 iv
[November 1,
1873.
i
NOTES ON SOME POINTS CONNECTED WITH FUNGUS FOOT DISEASE.
By Surgeon-Major
W. J. Moore, L.R.C.P.
Among other questions not satisfactorily answered regarding this malady is the query, whether or not there are two distinct forms of the disease?one in which the black material is found, another in which this so frequently characteristic appearance Carter describes three varieties of the affection, in one of which the black particles appear, in the second of which
is absent.
granules only are found, the third presenting a surface, appearing, when cut, as if powdered with red pepper. The connection, however, of the two latter appearances with the black variety has jiot yet been distinctly demonstrated. If the above are different forms of the same malady, it follows that the black material, presenting only in one variety, cannot be the cause ot the affection, and must therefore be an accidental complication. I certainly have seen cases of disease of the foot, involving both soft tissues ar.d bones, and presenting all the destruction of tissue noted in fungus disease, but without either black material, red specks, or white granules. In the absence of such distinctive marks, the cases have been noted as " Scrofulous." Another question therefore arises?is this so-called fungus disease simply a scrofulous affection, to which, from externally, some fungus element has been added ? The appearance of the early stage of the malady might be expected to throw some light on the matter; but, practically, this is not the case;* for, although in some instances, as I have elsewhere noted, the first condition before white
any wound of the skin occurs is a blackish or bluish mottled discolouration beneath the integument, as if gunpowder or Indian ink had been pricked into the skin, in other instances
the malady is stated
to commence
as
a
small
pimple
or
pustule,
pus, at a later period the peculiar black material. It would therefore appear certain that the latter is not present during all the stages of the disease, but withat first
discharging ordinary
out its presence the malady cannot be certainly diagnosed as foot. These are points deserving more attention than has yet been paid to them.
fungus
A second
query is.?are the deep or superficial parts first affected ? I believe that when the black fungus is present, the superficial parts are first implicated, and for the following reasons :?In three cases of incipient disease, I have incised the integument, and cut or scraped away all the diseased tissue. One of these cases on the dorsum of the foot, and involving a metatarsal bone, is reported in the November number of the
interesting
Gazette for 18G7.
Another
case
was
on
the sole of the foot, and
institutions of
Kajpootana 815
for the year 1870
:
"
In the Bhurt-
in-door
patients were received, while 71 major and 191 minor operations were performed. Some of the major operations were of great importance, and professionally interesting and instructive. I refer more particularly to one only, viz., the removal of part of the foot for mycetoma, or the fungus disease of India. In relation to this case, Dr. Ilarvev observes ?' I believe, that when taken early this disease might almost always be cured without amputation being needful, although most authorities maintain the contrary.' And in this remark of Dr. Harvey's I agree, having myself cured two cases, by simply scraping or cutting out the diseased parts. Dr. Harvey noticed the black affected portion to be enclosed in a cyst; and curiously I have very recently received a communication from Dr. Newman of Jodhpore, mentioning a similar This is interesting appearance in one of his dispensary cases. and practically useful surgically, as tending to show the localization of the malady." With the exception of the above, all I think who have written on the subject mention amputation as the only method of cure. Most authors, indeed, as Aitken, Fox, Ballingall, Btisk in Holmes' system of surgery, Byzuinjee, Colbrooke, &c., only pore
Hospital
mention treatment of the advanced stages of ihe disease. it is clear that future text-books must now notice the
But
possibility
of cure
by surgical means in the early periods of the affection. There appears to be a somewhat general impression, that fungus foot disease is confined to, or, at least, is more prevalent on, dark colored moist soils, and more especially on cotton soil, an
idea
probably originating
in the fact of the
malady having presenting such surface. But the affection is not uncommon in sandy countries, where little or positively no cotton- is grown. It is frequently met with in Marwar, in Bickanneer, and throughout the whole of the semiThe fact of its occurring desert districts of Western llajpootana. been lirst noted in localities
on
these sand tracts, where the rainfall seldom averages more or eight inches annually, and where water is two and
than seven
three hundred feet from the surface, is important, as if there be any fungus connected with the disease, it must be a fungus
capable
of
flourishing,
not
only
in moist
localities,
as
cotton
soil, but also in dry and sandy places.
Similarly, there is an impression that the foot only becomes affected. This idea is erroneous. An instance of what is believed to be the disease in the calf of the leg has already been mentioned, and as I have noted elsewhere, (Indian Annals, Vol. XX. J it sometimes presents on the hand or shoulder.
the disease did not
penetrate the deep fascia. The third case was on the dorsal surface of the foot, but not involving the bone. It was ascertained more than eight months afterwards that the two last patients remained well, and as nothing was heard of the first case after the man left, his permanent recovery may be inferred, as the patient departed with a singularly satisfactory cicatrix. At the present time there is a person visiting the Aboo Dispensary, with what I believe to be the disease in the calf of the leg, who was treated in similar manner, but not so successfully, the malady having returned. In addition to the above instances of cure, by excising the diseased structures, Dr. Eddowes (Indian Mcdical Gazette, September 18G7) has reported three successful instances of similar treatment, aided by the after applications of polassa fusa. Dr. Spencer of Bhurtpore recently kindly forwarded to me the notes of a case where the dorsum of the foot was affected, but not the The diseased parts were removed, and the patient left Spencer's report of the case is attached as- an addendum to this article.
bones. cured.
Dr.
In addition to the above evidence on the and therefore of the external
possibility of cure by origin of the malady, I
excision,
quote the following paragraph from my report *
on
Medical G.izett?>, November 1867. Indian Annals, Medical Science Vol. XX, Indian
the medical
Spencer's Case of "Mycetoma Tarsi," mentioned above. Jamna, Brahminee, aged 30, married, was admitted into Anah Hospital on 10th Hay 1S73, suffering from Mycetoma Tarsi of the right foot. Has had children, and is a vigorous healthy young Doctor
woman.
State on admission,?There were four small openings in the skin, through which, on introducing a probe, the diagnostic black gritty pulp exuded. The amount of skin implicated was about one and a half inch square, one sjde of the square being at the outer side of the metatarsal bone of the great toe, the disease extending outwards across the metatarsal bones. The skin lor thi3 extent was of a bluish tint, thickened, undermined, and
subjacent tissues. There was great pain, but swelling ; the natural shape of the foot was scarcely oi altered, and there was no swelling nor thickening of the sole
adherent to the little
or no
the foot. Previous history.?No history of hereditary disease. One other person in her village reported as suffering from the malady, who is also a yc;ung Bralnnince patient; says that 8 months before coming to hospital, she became aware of some "slight as the difference" in her loot, she could not bend it so freely was it as only 'l to attach this, any importance other; she did not little stiff, and did not in any way ^interfere with the perform-
Noyemheti 1,
NOTES OX FUNGUS FOOT DISEASE.?BY W. J. MOORE.
1878.]
anco of her household duties. The pain gradually increased; six months before coming to hospital it was very annoying; five months before coming she could only walk on the heel of the diseased foot; four months before coming she could not stand upright, but propelled herself about the house with her hands, keeping the aching foot clear of the ground. From first to last,
the pain was deep-seated, of a burning character, and worst at night. Says that about four days after the feeling of something "
different" in the foot noted above, the skin over the metatarsal bones became very itchy, and that a week afterwards the surface began to grow discoloured. About a fortnight after this the part swelled, a week subsequently a small boil appeared, which in three or four days burst and discharged pus and the characteristic black substance. Three boils, similar in their and progress
contents to the first, came out at intervals of a fortnight after this. For five months before coming to hospital no more boils appeared. The four sinuous openings left by the bursting of the boils did Pus and the charcoal-like substance continued to be not heal.
discharged through them. Operation.?Incisions were made, extending affected tissues, and the skin reflected and
well cut
beyond
away.
the It was
found that at three or four points the structures in the metatarsal interspaces were infiltrated and thickened. On cutting these out, bit by bit, the parts affected by the disease were found tough and thickened. I think the lower portions of the diseased condensed and thickened than the upper. implicated. After removing all the diseased tissues, the wound was freely burnt with strong nitric acid. It had completely healed by the 29th of June, structures were
more
The metatarsal bones were not
when the
left the
patient
hospital.
in the foot and could walk about 20 miles from and her
as
well
Bhurtpore; will be
She had a3 ever
she
can
no
pain whatever
she could.
therefore be
She lives seen
occa-
watch. A second case, also kindly forwarded to me by Dr. Spencer, may be advantageously placed in contrast to the above, as showing the advanced stage of the malady :
sionally,
case
an
interesting
one
to
?
Alcbar Jilt, zemindar, aged 36, was admitted into Anah Hospital on 19th July 1873, with Mycetoma Tarsi of right foot. Puevious History.?Says he first felt pain, and noticed '?
the black
swelling,
discharge about five years ago. Since then the pain, and small boils, have gradually increased. During the the pain has much increased in severity. No other
last year people in his
similarly affected, nor is there any being hereditary. State on admission.?Patient healthy, and does not appear pulled down by the disease. Is unable to put the whole foot on the ground, but walks on the heel with pain and difficulty. Although the patient complains much of pain, I do not think the pain is so acute as is usual in these .cases. Foot much swollen, and skin discoloured (blackened) to a line corresponding with the astrngalo-scaphoid articulation. More skin involved history
village
were
of the disease
the outer side of foot than on the inner side. The heel free disease. The usual sinuous openings on the dorsum of the foot had all healed excepting one, and from this no black but there could be no doubt whatever as matter was on
from
issuing;
to
the nature of the disease, from the appeaiance of the foot and
the
previous history.
Operation.?It was considered that amputation at the anklejoint would give the man the best chance, and PirigofPs operaThe skin being sound tion was. performed in the usual way. about the inner ankle, allowed the posterior tibial artery to be
avoided.
examining stump, foirr or five centres of disease were discovered and cut out. These I certainly did not expect to find. These black centres, if I may call them so, were found alike in muscle fat and skin. The tissue about each spot was destroyed, These black bodies were and rendered tough and fibrous. On
the
loose, as it were, in the muscular structures, sonietfmes enclosed in a membrane; but more frequently they were found in funnel-shaped cavities of dense parchment*like
sometimes found
*
283
The structure of the tissue in which the black bodies
tissue.
deposited appararently go to form these parchment-liko shafts, the original tissue becoming completely disorganized. On turning back the skin of the upper flap, I was much astonished as chagrined to find the end of the tibialis anticus, projecting from the wound like an opening convolvulus. The skin was reflected back and the muscle pulled out, and about one are
and a half inches cut off, well clear of the affected part. The funnel contained black matter. The muscular tissue, though changed, thickened, and whitened, had not yet assumed the
toughness previously alluded to. This invasion by the disease was probably of recent date. Strong nitric acid was" applied freely, the bones brought into apposition, sutures applied, and limb tightly bandaged. Remarks.?My diagnosis was imperfect, but I think I had every reason for coming to the conclusion I did, and none for The colour, touch, and coming to an opposite conclusion. appearance of the foot all supported the opinion, that by amputation through the ankle joint, flaps, free from disease, would The skin around the internal malleolus being be secured. healthy, enabled me to make sure of avoiding the posterior tibial, and of cutting the plantar arteries long, and so of getting a well-nourished heel flap. Chopart's operation, I thought, would be too near the disease ; but it was not doubted that Syine's or Pirigoff's would pass easily and completely beyond it. On the discovery of disease in the flaps, the question I did arose as to the advisability of at once amputating the leg. not contemplate doing so in this case, because I promised the poor fellow I would leave his heel, and would not remove the leg; and as every particle of diseased structure that could be found cut out, and the parts freely cauterised, the man has was chance of an useful limb. Should the disease re-appear, of the leg can be afterwards performed." The diseased portion removed was forwarded to me by Dr. Spencer, and was minutely examined by Dr. Ilendley and myself. The following is Doctor Hendley's account of the a
amputation
appearance:?
jExamination of
a Fungus Foot, forwarded by Z>r. Spencer of Bhurtpore to Dr. Moore, Superintendent'General of Dispensaries, Sfc., ?fc., Rajpootana. Tixe foot had been carefully put up in a tin case filled witli spirit, which, when it escaped, was thickened and darkened by substances exceeding from the diseased structures. The dorsum of the foot was the part most affected. Upon section numerous bluish black granules were seen to be scattered irregularly over all the various structures, muscle bone, cartilage, &c.; theso
bodies
were
not found in the interior of muscle bone or did not communicate with each other, neither
ligament; they
perforating the tissue. metatarsal bone there was a small pocket lined with membrane and filled with black bodies; there were also small from the outer surface of the foot to the cellular sinuses were
In
there channels one
leading
tissue between the bones. The ends of several metatarsal, and the articular surface of one tarsal bone, were denuded of their and necrosed. The small bodies referred to above were usually multiple, generally from four to eight were loosely connected by a bluish, removed from white, thin membrane, which could be
coverings
easily
them. The muscles were neither softened nor altered in color. The disease had followed the course of the articulations, and surface of had only in a few places penetrated to the
plantar
the foot. examination roe-like bodies
of the black structures?the of Carter, $c. Different specimens were treated with potash, ether, dilule Others were boiled in nitric acid, acetic acid, and glycerine. dilute nitro hydrochloric acid, and potash. The best results were given by those dissolved in ether, and those treated bv boiling. After treatment with ether, numerous cells, filled
Microscopical
with
granules
The
masses
joined by apparently
and
colouring matter,
were
distinctly
a
proceeding from
the
body
with
which
it
was
All the structures delineated at page 22 of Dr. Fox's scheme for obtaining a better knowledge of skin diseases were
noted.
These were,
however,
not
seen
in
a
single speci-
spores, sporidia, and filaments, were observed. Large spore cases filled with sporidia were also observed, scattered irregularly through the field ; these resembled the structures marked C 4 on page 23 of Dr. Fox's report.
Bursting
Before the application of ether,
numerous
globules
of fat filled
the field ; there was not a trace of a single crystal. The spore cases in some instances were attached to the dark masses by
long filaments
;
in every case truces of such
a
Remarks.?The above observations entirely
observed.
of the dark-coloured substance were seen to be tubp, one end of which contained dark matter,
united.
men.
November 1873.
THE INDIAN MEDICAL GAZETTE.
284
connection
were
to
agree
assign
a
fungus (chiouyphe carteri)
with those
prominent place in the disease; they would also appear to render it probable that it. is the primary cause. The deeper structures were only partially affected, the bones not until denuded (in the case of the small sinuses the adjacent bor.e wn9 uninjured). The fungus would seem to enter from without and find its way by the cellular tissue, all over the foot, coming to the surface when its course is impeded or when which
a
The nutrition of the foot may be altered a sweat duct. pressure upon the small vessels; that this is possible, may be inferred from the great length of time a man may suffer from the disorder without much constitutional dis-
near
by
turbance.
I have
ten years without
seen
injury
a
to
case
in which the disease had lasted
the health of the sufferer.
discernible.
a.
b. c.
(1. e.
f.
Sporidia. Spore cases full. ?
,,
empty.
Two bodies joined by a tube. With a higher power shows dark fluid in the tube. A dark mass with a low power, shows filaments springing out from it.
a.
Spore. Spore.
Small spore, &. Small spore. off filaments. filaments, broken off with broken b. Spores elongated with Spores elongated case. b'. An An almost almost empty spore ease. empty spore A A bursting c. spore. bursting spore. d. Two Two filaments, magnified. filaments, highly highly magnified. hb attached filament to to the the edge of aa dark e. attached by dark body. by aa filament edge of body.
