A Fifth Case of “Fungous Foot” in 
America. 
THE AMERICAN JOURNAL THE MEDICAL SCIENCES, 
October, 1899. Extracted from The American Journal of the Medical Sciences, October, 1899. 
A FIFTH CASE OF “ FUNGOUS FOOT” IN AMERICA. 
By 
TrrF history by Hk-Mr wtfftF Ts briof, -but the best that could be 
obtainodr - 
\Pedro B.; was born in Southwestern Texas ; of Mexican parentage ; 
aged forty-five years; married; six children. Family history good; 
no history of syphilis. He lived on a ranch thirty or from 
Fort Ringgold; had never lived elsewhere. The about 
the year 1887 with severe pain in the left foot, lasting iftyrty-six hours. 
After this a red spot appeared on the foot. The man had chills and 
fever ; no cause for the condition was known. Throughout almost the 
whole course of the disease the pain continued most severe at 
night, and was worse in summer than in toward the last it sub- 
sided. The only treatment was the use of a Jew simple household reme- 
dies. The local physicians diagnosticate^elephantiasis, and advised 
amputation. V Jr 
He came to Hr. Arwifie on March 6), 1889, complaining of the 
leg being too heavy to carry-; there Was then no pain. On the 16th Hr. 
Arwine amputated; there was but little shock; about eight arteries 
in addition to the tibials, all ©f Which were much enlarged, were tied. 
Recovery was complete and win\out event; the more gratifying because 
the man's surroundings at the timb of the operation were quite unsanitary. 
The amputated part was sent to the Army Medical Museum, but was 
not in good preservation when received. It is numbered 11,699 in the 
pathological series, and consists of the left foot and lower half of the 
leg. The foot and/ankle are much enlarged, and show the character- 
istic buttons of fungous foot (mycetoma, Madura foot, fungous foot of 
India); the buttons vary in size, and are most numerous and closely set 
on the dorsum of the foot (Fig. 1). The subcutaneous tissue shows 
numerous sinuses and fistulse filled with oily and white, pasty matter, 
mixed with innumerable rounded, brownish bodies measuring 0.5 to 2 
mm. in diameter. The bodies were sometimes in masses, the diameter 
of a centimetre, and were most numerous near to and beside the bones. 
All the bones were honeycombed with cavities and fistula, in which were 
similar masses; the bones of the foot were so friable that they could 
scarcely be handled. The tibia and fibula (Fig. 2) showed hyperostosis, 
especially in the upper part of the amputated portion; and as this who 
the part most recently affected by the disease, It "Seems probable that, soV 2 
far a»4he bone is is the first effect of the irri- 
tation of the fungus. In some places,- particularly around the ankle, 
was-ftCdense mass of connective tissue (in ong place nearly an inch 
thick), th 7 result of the tnflammatofy process. the bones are mounted 
as 11 j / 20, 
Fig. 1. 
From photographs taken by Dr. W. M. Gray, Army He lical Museum. 
Dr. James Carroll, of the Army Bacteriological Laboratory, makes 
the following statement in regard to the microscopical characters of the 
tissues and fungi; 
The specimen gave off a very disagreeable odor, showing that it was 
not in a good state of preservation. A portion of the skin and under- 
lying tissue was removed from the posterior surface of the leg for 
embedding. 
Small hempseed-like bodies were found in considerable numbers free 
in the connective-tissue spaces and sinuses. They were of a yellowish- 
brown color, some darker and some lighter, generally rounded or lobu- 
lated in outline, and their surfaces slightly roughened. In size they 
varied from about 1 to 3 millimetres. 
These seed-like bodies were easily crushed upon a slide, and appeared 
to consist of a dense, brittle, cortical layer, enclosing a central grayish, 
pulpy mass of pultaceous consistency. All attempts to identify the 
structural elements of these bodies resulted in failure. They were 3 
macerated in water, caustic potash solution, etc., and were crushed and 
examined in the fluids, or were dried upon the slide and stained by 
various methods, but no positive evidences of a mycelium or other defi- 
nite structure could be determined. The central pulpy material appeared 
Fig. 2. 
Outer side of tibia and inner side of fibula; shows hyperostosis, osteitis, and fungous masses 
in the cavities. (From a photograph taken by Dr. Gray.) 
to have undergone complete disintegration, and in consistency was 
almost caseous. The cortical layer broke up into vitreous, yellowish, 
brownish, or colorless granular masses which showed no distinct stria- 
tion or other definite arrangement. 
Among the stains tried were thionin and Weigert’s modification of 
Gram’s method. With tissue sections complete failure was the result in 
all attempts to stain the cell nuclei. Nothing better could be obtained 
than a diffusely colored structure, the minute details of which could 
only be recognized by differences in the form and arrangement of its 
components. Large numbers of mastzellen were found uniformly scat- 
tered throughout the subcutaneous connective tissue. These were not 
more numerous in the vicinity of the fungous masses than elsewhere, 
and they were easily recognized under the immersion lens by their form, 4 
their very numerous hsematoxylin-tinged granules of uniform size, and 
by their nuclei, which could often be seen as clear, unstained bodies, 
somewhat like the nucleus of a malarial parasite. 
A conspicuous feature of the section was the presence in many of the 
lymph-spaces adjacent to the fungi of abundant amorphous granular 
material of a yellowish-brown color, which was very refractive. This 
was probably hsemosiderin. In other lymph-spaces, and, indeed, in 
some of those containing the above-described pigment, there were aggre- 
gations of finely and coarsely granular material, which stained a little 
more darkly with hsematoxylin than any other element in the tissue. 
I was unable to satisfy myself as to whether these were small por- 
tions of the fungus or cell detritus. As between the two I would incline 
rather to the former than the latter explanation, for the reason that 
in the immediate vicinity of the fungi, where numerous pus-cells were 
present, no such picture was obtained. 
Other than these the section showed no traces of the minuter elements 
of the fungus apart from the small, club-shaped peripheral rays attached 
to the hempseed bodies now to be described. 
The section was made to pass vertically through one of the elevations 
upon the skin, which, apparently, marked the outlet of a discharging 
sinus. Within the sinus, which in the stained section was 3to 5 mm. 
in diameter, six small, seed-like bodies could be counted upon the slide 
with the naked eye. 
Ftr, 3. 
Several of these projected above the level of the skin into the pouch- 
like sac upon the surface. The walls of the sinus were formed of dis- 
tinct lines of connective tissue. Just within the wall and around and 
between the fungous bodies large numbers of pus-cells could be seen 
with the microscope. These were easily recognized, because in places a 5 
number of them showed characteristic nuclei in the sections stained 
with hematoxylin and eosin. 
Under the low-power the hempseed bodies were found to be made up 
of aggregations of smaller masses, some of which were rounded, others 
fan-shaped, reniform, or lobulated. One or two showed a fernleaf-like 
branching arrangement. Many of these smaller units exhibited a dis- 
tinct radial striation, which could be followed from the periphery to 
the centre, or, in the fan-shaped bodies, to the base or pedicle. The 
majority showed at the periphery a marginal zone of very small, club- 
shaped rays, which were remarkably symmetrical in form and arrange- 
ment. The central radial striations of the larger bodies were seen to 
be continuous with the lines of contact of these delicate rays about the 
periphery. In many of them a rather indistinct concentric striation 
could also be distinguished. 
Fig. 4. 
The above description applies to the section stained with hsematoxylin 
and eosin. Gram’s method proved of no service with these specimens. 
Saffranin yielded a very good picture of the gross masses with their 
peripheral rays and general striation. With thionin exquisite prepara- 
tions were obtained, which began to fade, however, in a few days. 
The accompanying pen-and-ink drawings were made from thionin 
and saffranin stained sections by Dr. J. C. McConnell, of the Army 
Medical Musuera. 
Fig. 3 (saffranin) shows the arrangement of the smaller units into 
the larger masses, the whole picture probably representing one of the 
isolated hempseed bodies. In the section from which the drawing was 
made the centres of the bodies were somewhat denser than shown in 
the drawing; they presented more of a homogeneous, finely granular 6 
appearance, with a less distinct striation, except as to the periphery, 
where it is plainly marked. Apart from the lines where the druses 
are in contact with neighboring contiguous ones, the margins should be 
undulating, as they appear in Fig. 4. 
Fig. 4 (thionin) shows in a beautiful manner the larger half of a hemi- 
spherical mass, consisting of imbricated processes arising as branches 
from a central stalk or base. The minute club-shaped elements were 
almost as distinct in the specimen as they appear in the drawing, and 
the interspaces between the processes were occupied by emigrated poly- 
morphonuclear leucocytes, by which also the fungous mass was to a 
large extent surrounded. This body was situated in the sac-like expan- 
sion formed at the opening of the sinus upon the skin. 
Fig. 5. 
In Fig. sis shown a small body that was completely isolated. In my 
opinion it should be interpreted as a cross-section through the extremity 
of a process similar to those shown in Fig. 4. 
After a study of these sections I have no hesitancy in pronouncing 
the fungus a variety of actinomyces. It is much to be regretted that 
the imperfect preservation of the tissue precluded any histological 
investigation of the lesions resulting from its presence. 
James Carroll, 
Acting Assistant Surgeon U. S. Army. 
The photographs of the leg and foot and bones of the leg were 
made by Dr. W. M. Gray, of the Army Medical Museum. One shows 
well the characteristic buttons; the other, the fungous masses on and 
in the bone. 
The cases thus far reported from America are as follows; Adami and 
Kirkpatrick (Transactions of the Association of American Physicians, 1895, 
vol. x. p. 92): Male, aged twenty-one years ; Canada ; ten years’ chron- 
icity, right side of the body. Hyde and Seun (Journal of Cutaneous and 
Genito-urinary Diseases, New York, 1896, vol. xiv. p. 1): Male, aged 
twenty years ; United States ; thirteen years’ chronicity, left side of the 
body. Pope and Lamb (New York Medical Journal, 1896, vol. Ixiv. p 
386): Male, aged twenty-seven years; Texas; eight years’ chronicity, 
right side of the body. Wright (Transactions of the Association of Amer- 
ican Physicians, 1898, vol. xiii. p. 471): Female, aged twenty-six years; 7 
Italy and United States; six months’ chronicity, left side of the body. 
Arwine and Lamb : Male ; aged forty-five years; Texas ; twelve years’ 
chronicity, left side of the body. 
It is probable, as suggested by Prof. Adami, of Montreal, that a care- 
ful examination of museums would disclose additional specimens; it is 
probable, also, that many cases of this disease have been erroneously 
diagnosticated as elephantiasis. Inasmuch as the two American cases 
in possession of the Army Medical Museum came from Texas, it would 
seem likely that that section of country would be an inviting field for 
research. Since, also, in India at least, the disease is found almost ex- 
clusively among the peasantry who go barefoot on the soft-ploughed 
ground, tropical and semi-tropical America ought, theoretically, to fur- 
nish many more cases than the few which have been reported. 
The subject has been written up so fully by previous reporters that it 
seems unnecessary to do more than refer to their papers. The Medical News. 
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