Delhi, various places in the Punjab, Kashmir, and Rajputana. In recent years we have accounts of its occurrence with some degree of frequency in Senegambia, Somaliland, Algeria, Egypt, the Soudan, Cochin China, Italy, the United States, and South America. It is probable that in time mycetoma will be found to be endemic in many warm countries in which it has hitherto escaped recognition.
Symptoms.— Mycetoma begins usually, though by no means invariably, on the sole of the foot. The first indication of disease is the slow formation of a small, firm, rounded, somewhat hemispherical, slightly discoloured, painless swelling, perhaps about ½ in. in diameter (Fig. 205). After a month or more this swelling may soften and rupture, discharging a peculiar viscid, syrupy, oily, slightly purulent, sometimes blood-streaked fluid containing in suspension certain minute, rounded, greyish or yellowish particles, often compared to grains of fishroe. In other examples of the disease the particles in the discharge are black, having the size and appearance of grains of coarse gunpowder. Sometimes these particles are aggregated into larger masses up to the size of a pea. In time additional swellings, some of which break down and form similar sinuses, appear in the neighbourhood of the first or elsewhere about the foot. For the most part the sinuses are permanent, healing up in a very few instances only. Gradually the bulk of the foot increases to perhaps two or three times the normal volume (Fig. 206). There is comparatively little lengthening of the foot; but there is a general increase in thickness, so that in time the mass comes to assume an ovoid form, the sole of the member becoming convex, the sides rounded, and the anatomical points obliterated. The toes may be forced apart, bent upwards at the tarso-phalangeal joints, or otherwise misdirected; so that on the foot being placed on the ground the toes do not touch it. The surface of the skin is roughened by a number of larger or smaller, firmer or softer hemispherical elevations, in some of which the orifices of the numerous sinuses open. Most of these orifices are easily
