MYŒTOMA¹

Synonyms.—Fungus foot of India; Madura foot; Tubercular disease of the foot;
Podelcoma; Ulcus grave; Morbus pedis entophyticus; Fr., Mycétome; Pied de Madura;
Ger., Madurafuss; Mycetoma.

Definition.—An endemic disease, chiefly of India, commonly
involving the foot, and characterized by swelling and the formation
of tubercular or nodular lesions which tend to break down and form
sinuses leading into the subcutaneous structures, and finally resulting
in disintegration of the affected part.

Symptoms.—With some exceptions the foot is the site of the dis­
ease, only rarely, in fact, the hand, knee, or other region being attacked.
It is observed chiefly in those who go barefooted, generally following
a slight injury. It begins, as a rule, as a small papule or nodule, and either
upon apparently normal skin or is preceded by slight edematous swelling.
The nodule increases slowly in size, new lesions appearing from time to
time near by. When at all established, the involved area or part is
somewhat reddened, variably swollen, and the seat of scanty or numerous
nodular formations, which are usually most conspicuous toward the
periphery. The nodules are elevated, some quite firm or hard, others
softer or even sluggishly furuncular, and others perforated centrally by
an opening which is the external end of a sinus leading down to muscle
or bone; from these sinuses is discharged a puriform liquid containing
small round, black, gunpowder-like bodies or “grains,'’ or a fish-roe-like
substance; in other instances the discharge is of a whitish color, and ex­
ceptionally of a reddish hue.

Occasionally, in addition to or in place of the papular or nodular
lesions, pustules may be seen, and also vesicles, blebs, and abscesses

Principal literature: Vandyke Carter, On Mycetoma or Fungus Foot of India,
London, 1874; Fox and Farquhar’s Endemic Skin and Other Diseases of India; Manson,
Tropical Diseases, 1898, p. 568; Hyde, Senn and Bishop, “A Contribution to the Study
of Mycetoma in America,” Jour. Cutan. Dis., 1896 (with colored plate case illustra­
tion, review, and bibliography; and abstract of case in Canada reported by Adami and
Kirkpatrick). In addition to these 2 American cases, 3 others have since been reported:
Pope and Lamb, New York Med. Jour., 1896, vol. lxiv, p. 386 (with case and fungus
illustrations); Wright, Trans. Assoc. Amer. Phys., 1898, vol. xiii, p. 471; and Arwine
and Lamb, Amer. Jour. Med. Sci., 1899, vol. cxviii, p. 393. Libouroux, “Contribution
a l’étude de la maladie dite pied de Madura consideré comme une tropho-névrose,”
Paris, 1886; Kanthack, “Madura Disease (Mycetoma) and Actinomycosis,” Jour.
Pathol. and Bacteriol., Edinburgh, 1892-93, vol. i, p. 140 (with illustration); Unna and
Delbanco, “Beiträge zur Anatomie des indischen Madurafuss,” Monatshefte, 1900, vol.
xxxi, p. 545 (with review, 10 colored histologic cuts, and complete bibliography); Unna,
“Aktinomycosis und Madurafuss,” Deutsche Medicinalzeitung, 1897, p. 49; Oppenheim,
Archiv, 1904, vol. lxxi, p. 209; Hooton, “Some Clinical Aspects of Mycetoma; an Un­
usual form of Callosity Complicating it,” Philippine Jour, of Sci., July, 1910, p. 215
(based upon an observation of 26 cases; in several the mycetoma was complicated by a
thickening of the sole by multiple callosities; as a rule, surgical extirpation of the fungus
gave satisfactory results; illustrations).

MYCETOMA                                          116l

have rarely been noted. The progress of the malady is slow, usually
several years or more elapsing before material damage has been done.
The sinuses finally encroach upon the bony structures, the latter being
eroded and disintegrated by the presence and action of the causative
fungus. The local conditions in the advanced disease are also often
partly due to secondary infective processes, as from pus cocci, etc

Etiology and Pathology.—The malady is most frequent in
India, and relatively rare elsewhere. Five unquestioned cases have
been recorded in our own country. For obvious reasons males are more
prone to it, as they are more in the habit of going barefooted. A slight
traumatism or break in the continuity of the skin apparently gives
access to the pathogenic fungus. The organism is the actinomyces
Maduræ, consisting of mycelium of branching threads and hyphæ and
ovoid spores. Two varieties of the malady have been noted, based upon
the color of the discharged bodies or “granules”: the black or melanoid,
and the pale, ochroid, or yellow, the former being of greater frequency.
The black granules bear resemblance to poppy-seeds or gunpowder, the
pale or pale yellowish to fish-roe. These granules microscopically are
seen to present a central network of mycelia with radiating mycelial
threads, which may terminate in bulbous swellings. In fact, the close
resemblance to the fungus of actinomycosis and the gross clinical simi­
larity have led some to believe the maladies identical, but the majority
of observers (Hyde, Paltauf, Unna, and others) are satisfied that the
etiologic fungi are not the same; that of actinomycosis is highly colored
by acid fuchsin, while that of mycetoma is not materially affected.

Section of the tissues of the involved part shows small and large
cavities or spaces connected by the sinuses; these spaces contain a fatty
or gelatinous substance, which in the black variety is dark colored and
hard, and in the pale or pale-yellowish variety soft and ochre colored.
According to Kanthack and others, there are the usual evidences of reac­
tionary inflammation surrounding the fungus collections, and the pres­
ence of granulation tissue with epithelioid cells and many vessels, and a
scattered formation of pigment; in the later stages the granulation tissue
undergoes change into fibrous tissue and the formation of abscesses and
fistulæ.

Diagnosis.—The region involved, the character of the discharge,
and the absence of any tendency to visceral involvement are usually
sufficient to distinguish the malady from actinomycosis. This latter,
moreover, is commonly seen in those who have to do with cattle or grain.
Microscopic examination of the discharge will show the fungus, which,
though presenting some resemblance to that of actinomycosis, stains
differently with acid fuchsin.

Prognosis and Treatment.—The disease pursues a chronic
course—ten to twenty years—resulting in total disorganization of the
affected structures. Instances of spontaneous cure are unknown.
Treatment consists in thorough removal of the diseased part by the
curet or knife, together with the administration of potassium iodid in
full dosage. When of long standing and a large area is involved, am­
putation is indicated, care being exercised to include all infected points.

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