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BY J. a. ADAMl, M.A., M.D„ ProfesHor of PutholoKy, |Mc(Jill University ; PatholoKish to the Royal Victoria Hospital. AND ROBT. C. KIRKPATRICK, B.A., M.D., Demonstrator of Surgery, McGill University ; Surgeon to tlie Montreal General Hospital. Mm v.. {Reprinted from the Montreal Medical Journal, January, 1890.) '* ■ ■ ■'■■••«'*? "'^m 'M ■ -jf y'*;fc» I-''^,'** *f ^' .J "■"-.'*. \4i:^^0^mP^^-^'^^^'^-^''-'^'^' "'"' ^'' •■ \ T ,x .J FURTHER OBSERVATIONS UPON MADURA FOOT DISEASE IN AMERICA.' By J, G. AiJAMi, M.A., M.i . ProfesHor of Pathology, McGill University; Patholo)^ist in Uie Royal Victoria Hospital. and By Rout, C. Kikki-atkick, r A., M.D. Demon trator of Surgery, McGill University; Stirgeon *" ■'•\o Montreal General Hospital. At tlie meeting of tlie Medico-Chinirijficai Society on June 15, 1894 we exhibited a specimen of the aniputateil limb from a case of madura foot disease, or mycetoma pedis, and with tliat sliowed specimens of the granules oljtained from the sinuses, and sections exhibiting tlie specific fungus in situ. At that time we had not tiie opportunity t ) study fully the literature of the occurrence of this disease in America, but we pointed out that, to the best of our belief, ours was the first case of the kind reported in any English -.speaking country. Since then we have been al)le to make fuller studies upon the subject, and at the meetinsT of the Association of Amej"ican Phv.sicians at Wash- ington in June, 1895, we went a little more fully into the description of our case and of the microscopic examination of the same. When we brought our specimen before the Society Dr. Gordon Campbell recalled that there was the report of a previous case of the disease mentioned in Crocker's Ilimdhook of Skin Diseases. We have been able to obtain the original paper upon the .subject by Kemper and Jameson in the American Practitioner of September, 1876, there referred to. To this we shall refer later, suffice it here to say that Kemper's description of his case pi'csents so many departures from 1 Read before the Montreal Medico-Chirurgical Society, November 21), 1895. ■^' ■u i5a»fefe'iiSi«i-.»ii I the usual liistory and appcavauces that it would scfiii iniprobabU' that he was dcalini,' with a case of thu diseasi' proper. Thus, while we do not attach uuu-h inipoi'tance totpiestior- of priority, wo think we may say at least that ours is Hie first iiidul)italile case of niyeetonia recorded as occuiTiug upon the American continent in one who had never travelled outside that continent. We stated at Washington that if one casi> has occu'-red upon this continent, it is fairly certain that othei's have, anil indeed Dr. Siicpherd a.ssures us that some years ah the soft parts, and with these a condition of rarifyin-; osteitis. The history of these two eases is very similar. l)r Hyde's was that (,f a native of the I'nited Stat.>s, who had r.ever been out of the coun- try, born of IJohemian parents, and aj^'od 20, in whom tlu' condition had lieen ilevelopiiij;' for thirteen yi'ars : a hard no.luie was first noticed in the skin of the sole, and the condition <>TaduaIly involved the anterior third of the foot. Buttons of iiesli develope;!, solium of them bein^^ present in lar^e eoalesein.i;- patches, others bein<>' i.solated. These but- tons formeil the mouths of sinuses, passing in all directions internally. From a ilniwiiiK of a specimen of Fiingiin Foot in tlno Mii'lras Museum, in Ih-uitt's Suycoii's Viidr MiTKiii. Kleventh Kdilion. liondon. 1S7S. Our own case, it may lie remembered, was in a French Canadian, ai;vd 21, and the condition Viegan ten years previously as a bluish spot upon the inner side of the ri<.--ht foot, devtdoping only some months later into an open sore ;, while yet later there appeared on tlie sole, between the Hi'st and second metatarsals, one of the characteristic iiuttoiis of th'sh. In both there was characteristic swelling and deformity of the aH'ected part, with notable absence of pain. In both also from the sinuses and in sections of the affected ri'o-ion tlu're were obtainable the granules of the fungus, which on miero.scopic examina- tion resemble actinomyces in the broad details of their structure. Both, then, present the classical features of the ochroid variety of Madura foot thouo-h we observe from the short account of Dr. Hyde's case, given in the November number of the Mcdica' Joiu-ii '/, that although the rai i::^-:' t'lingns itself was not pigmented, there were pigment granules present in the secretion. In our paper at Washington we pointorl out that in one preparation we found jointed liyplue present, and we expressed a doubt as to their meaning, ami lielieve we are right in stating that Carter's material was in the main obtained like this one specimen of ours, from already openiM I sinuses, and after further search through our material and a study of that j)resented to us hy Dr. Hyde we can arrive at no other conclusion than that these hj^phre are an intrusion. The I'ay fungus is the specific organism in the disease, the branched mycelium and branched liypha; occurring parasitically and forming a contaminating ^jrowth in the dischar<>'e within the sinuses. In place of the very characteristic gj-anules, Kemper and Jameson described a white, tlufiy, nundd-like substance, with yellowish, highly refractile bodies fornnng muHierry-likc groups. In place of a slowly developing condition tln'jr ca.se was only of six months' duration, and instead of the very remarkable ab.sence of pain, a.ssocia''A'd with this very extensive diseased state, they describe a pain so intense that the patient gained very little sleep. It may be well here to .say a few words describing the specific fungus of the disease. Curiously enough Vandyke Carter, to whom we owe the fir.st fall description of the condition of Madura foot, gave it the alternative name of " fungus foot disease." This, as has been already hinted, was due to mistaken idea as to the parasite causing the di.sease. Nevertheless, what wt' know to be the specific organism is more of the nature of a fungus than are the schizomycetes of ordinary infectious diseases, and the alternative name still holds. The organism is apparently closely' allied to the moulds and pre- sents a central dense mycelium of interlacing filaments, which at the periphery pass into radiating club-like bodies. This presence of these clubs gives an appearance singularly like that of actinomyces ; we are evidently dealing with one of the ray fungi. Yet in several details, and notably in the size of he clubs, in their tendency to bifurcate, and in the character of the nvrcelium, there are well-marked ditt'er- ences separating this fungus of Madura foot disease from the ordinary actinomyces as affects man and cattle. Of late both Vincent in Algeria and Surveyor in India (with Boyce in London) have been able to gain pure cultures of this micro-organism, and the descriptions given by these observers makes it still more evident that the organism is distinct from actinomyces. It is interesting to note that Boyce in his de^priptiojj jcentions the presence and the development of small .f0f*yhr-^ P 27 1900 reddish granules in the culture media, apart from the growing fungi, which may possibly be comparable with the small pigment granules seen by Dr. Hyde in the discharge from the sinuses in his case. Unfortunately neither Dr. Hyde nor we ourselves recognized the con- dition in time to make cultures. In view of tlie importance of study- ing further this interesting condition of mycetoma as it occurs on this continent, we would strongly urge anyone in whose practice there occurs a case resembling the descriptions given of this disease to com- municati', if not with us, at least with the bacteriologist of the nearest large town, and to ensure that either before or immediately after amputation of the limb opportunity is given for an attempt to gain cultures of the fungus. The lesion is very characteristic ; the swelling of the foot an•,■ m