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Some clinical observations on mycetoma
89 TRANSACTIONSOF THE ROYAL SOCIETYOF TROPICAL MEDICINE AND HYCIENE. Vo1. XXV. No. 1. June, 1931.
SOME CLINICAL OBSERVATIONS ON MYCETOMA.* BY
C. GRANTHAM-HILL, F.R.C.S. (EDIN.). Senior Surgeon, Khartoum Hospital.
T h e following study of a series of 184 consecutive cases of mycetoma, operated upon in the K h a r t o u m Hospital f r o m 1928 to 1930, is concerned mainly with the clinical aspects of this disease, and particularly with the comparison and contrasting of the two types commonly met with, namely the black-grain maduromycosis and the yellow-grain actinomycotic mycetoma.
GENERAL CONSIDERATIONS. T h e disease is widespread in the northern Anglo-Egyptian Sudan, being well known to the natives u n d e r the Arabic name of el-nebt (the growth). Tables A and B shew that m e n during the active years of life are the worst sufferers from the disease. This is in accordance with the observance of most writers. Native treatment usually takes the form of incisions and cauterisation with hot irons, t h o u g h amputations were carried out b y t h e m before the British occupation, as in the following case : - E 551. Fatma Mohammed, aged 70 years, was admitted to hospital on the 15th May, 1930, suffering from a painful epethelial horn rising from a scar of an amputation in the lower third of the right leg, carried out by a native Fikki during the time of the Mahdi. The stump had been treated with hot oil, and had never completely healed. The reason for the amputation was given as el-nebt, following a thorn-prick. TYPES OF MYCETOMA. T w o main types appear in this series, namely the black-grain and the yellow-grain. Of 32 cases examined microscopically and cultured on various media b y Dr. D. RIDINQ at the Wellcome Tropical Research Laboratory, 13 cases were *The writer wishes to express his indebtedness to Major R. G. ARCHIBALD,C.M.G., D.S.O., Director, and to Dr. D. RIDINa, Pathologist, of the Wellcome Tropical Research Laboratories, for much assistance and advice in the preparation of the MS ; to F. S. MAYNE, F.R.C.S.E., for the use of notes of some cases operated on by him, and to O. F. H. ATKEY,F.R.C.S., Director, Sudan Medical Service, for permission to publish this paper.
40
SOME CLINICAL OBSERVATIONS ON MYCETOMA.
of the black-grain type, and were all classified as the maduromycosis Glenospora khartoumensis (CHALMERS and ARCHIBALD,1906). The remaining 19 cases were of the yellow-grain type, and 17 of them were actinomycotic mycetomata of various varieties, while two were maduromycoses, probably of the Madurella variety. The proportion of black to yellow type in this series was 118 of the former to 66 of the latter. The difference in the clinical and radiographic manifestations found in cases infected with each of these two types, which will be referred to in detail hereafter, support the assumption that the varieties are morphologically distinct, as the laboratory tests suggest. TABLE A. T y p e of Mycetoma. Black Yellow
TABLE B.
Age by decades.
Sex i
1-10 10-20 20-30 30-40 40-5C 50-60 Total 5
[
I 21
16
35
37
22
17
20
18
6[3
3
Men.
118
99
[
19
66
57
[
9
TABLE C.
TABLE D.
T y p e of Length of history in years. Mycetoma. 1 and less. 2 3 4 5 10 Im o r e t h a n 10 Black
51
27 13 10 8
7 !
2
Yellow
22
17 9
3i
4
6
5
N u m b e r of relapses.
Percentage.
8
6
12
18
TABLE E. T y p e of Mycetoma.
TABLE F.
Distribution in body. Foot.
Hand. Leg.
[ Women.
Arm. Trunkl Head.
Black
83
12
11
5
6
Yellow
49
8
6
2
1
1 I
-
N u m b e r of amputations.
Percentage.
23
19
22
33
N o t e . - - O f the six cases in the trunk, four were m the buttocks or perineum.
-]ETIOLOGY. Native opinion is strongly in favour of thorn-prick as a causative factor in mycetoma, and there is considerable support of this theory in actual findings at operation and in the laboratory. Thus, in over 30 per cent. of this series of small yellow and black mycetomata, of less than six months' duration, thorns were actually found embedded in the growth after removal at operation. The
C. GRANTHAM-HILL.
41
fact that it is rare to find a thorn in large maduras, may be explained by the probability that the thorn in such cases becomes broken up and liquidified in the same way as do body tissues under the action of mycetoma. A specimen is in the possession of MAJOR R. G. ARCnmALD,shewing a mycelial filament in close apposition to a thorn removed from a small nodule of liquified tissue which had not developed macroscopic evidence of mycetoma. In this connection it is interesting to note that no case in this series occurred amongst the educated class of native normally wearing shoes, or amongst town-dwellers or Europeans. Table E shews the distribution of the tumour in the body, and it will be noticed that the vast majority occur on exposed parts. Of seven cases occurring on the trunk, three were situated on the buttocks and perineum, which are most exposed to thorn-prick when sitting. In view of the universal habit of the native of using a home-made tooth brush cut from a twig of bush or tree, it is surprising that mycetoma has not been seen affecting the mouth. This fact points to the thorn-prick as being the sole mode of entry of the fungus. It has not been possible definitely to identify the tree or bush producing thorns actually found in mycetomata, but there is reason for suspecting the Acacia family of being the chief offenders. Pricks from thorns of this variety often give rise to considerable local inflammation which may possibly influence local susceptibility to the growth of fungus. INCUBATION PERIOD.
No reliable information is forthcoming as to the incubation period in this series. Attempts at innoculation, both of portions of growth and of cultures, into white rats, monkeys, rabbits and pigeons failed at each of various attempts, even after a local injection of histamine. Table C, however, shews that 40 per cent. of all the cases had a history of less than one year, and, in all probability, a much shorter period than this may be sufficient to produce a palpable tumour, as the following case shews. E 143. Mukhtar Mohammed, aged 22 years, three months before admission had fallen off his camel into a thorn bush ; he could fix the approximate date from the fact that the particular journey occurred in Ramadan. Many thorns penetrated the sole and toes of the right foot, most of which he pulled out. No suppuration occurred at the time, but one month before admission he noticed several painless lumps on the sole and at the root of the second toe. At operation, four separate black mycetoma were removed from the subcutaneous fat beneath the ball of the foot and the root of the second toe. These varied in size from a pea to a hazel nut, and three of the four contained visible pieces of black thorn. RATE OF GROWTH.
Most writers agree as to the variability of the rate of growth, though nearly all remark upon the absence of any true localising reaction on the part of the body. It is difficult to reconcile these two statements unless there is a variability in the pathogenicity of the fungus. This series throws no light on the
42
SOME CLINICAL OBSERVATIONSON MYCETOMA.
latter point, as 43 cases of advanced growth coming to amputation, shewed variation in length of history, b o t h for the black and yellow types, of from six m o n t h s to thirty years. T h e r e is, however, a good deal of evidence in favour of b o t h local and systemic resistance on the part of the body. T h e two following cases exemplify extremes of this, and further examples in the case of bone will be discussed later. E 585. Musa Mohammed, aged 40 years (Plate I, Fig. 1), gave a seven years' hlstory of swelling of left foot which gave little trouble. There were no sinuses. Four months before admission he began to have fever, and at the same time the left thigh began to swell. On admission, there was gross swelling of the left foot, the left lower leg was wasted, and the thigh distended with a uniform elastic swelling. The inguinal and femoral glands were swollen and slightly tender. The general condition of the patient was wasted and cachectic, the spleen enlarged, and benign tertian rings were present in the peripheral blood. After an intensive course of quinine, and a blood transfusion, the inguinal glands were dissected out, the external iliac artery tied, and the leg amputated just below the great trochanter. The patient made an uninterrupted recovery, and is reported to be still well, six months later. Examination of the leg after amputation shewed that actinomycotic mycetoma had apread up along the connective tissue planes deep to the deep fascia, had ramified widely in the soft tissues of the thigh, but had not reached the inguinal group of glands, and had not penetrated the bone. The inguinal glands shewed inflammatory changes but no trace of fungus. E 595. AhmedHamad, aged 45 years, had a yellow actinomycotic mycetoma removed from the left gluteal region seven years previously. Suppuration of the wound had resulted in an extensive puckered scar. There was no further trouble until six months before admission, when he noticed that a hard lump had formed in the scar, and had grown slightly since. At operation a yellow actinomycotic mycetoma, the size of a walnut, was found deeply embedded in dense fibrous tissue in the scar of the old operation. T h e s e two cases, and others of a less extreme character, support the view that intercurrent debilitating disease and local resistance of b o d y tissues may play a larger part in the rate of growth of m y c e t o m a than has hitherto been recognised. DISSEMINATION. Dissemination appears to be b y direct spread t h r o u g h the tissues only. T h e r e is no evidence in this series that the fungus has any predeliction for the lymphatics. CASTELLANIand CHALMERS(1919) quote BALFOURas saying in 1904 that in maduromycosis in the Sudan the inguinal glands are often involved. I n none of our cases, howcvcr, was thcre clinical enlargement of thc glands, with the sole exception of the case described above (Musa Mohammed). It would appear probable that glandular enlargement, when it does occur is due to chronic inflammatory changes rather than to metastasis f r o m the growth. Most writers mention cachcxy, even leading to death, as a feature of advanced mycetoma. BRUMPT(1927), attributes this to the actinomycotic variety b u t not to the maduromycoses. In this series there were no cases of cachexy, rise of t e m p e r a t u r c or malaise attributable to m y c e t o m a with the sole exception
FIG. 1.
Musa Mohammed, age 40.
Generalised actinomycotic mycetoma of left leg of 7 years' duration. No sinuses (scars on thighs those of native cauterisation). P L A T E I.
To face page 42.
FIG. 2. E 416. Fatma Mohammed Farag. Extensive subcutaneous actinomycotic my. cetoma. See p. 45 for description.
Fro. 1. (5 months' duration). Swelling over tibial tuberosity, with a small sinuses discharging sero-purulent material. Radiograph strongly suggested a Brodie's abscess. At operation (16th October, 1930), the cavity was found tightly packed with the black grains of maduromycosis, (Glenospora Khartoumensis).
Nur Mustafa, age 20.
P L A T E II.
FIG. 2.
Khadiga Idris, age 18. X-rays shew considerable periostitis. Growth adherent to periosteum and removed together with anterior wall of tibia and skin covering it. Yellow Madura
(Actinomycosis convolutus).
k
FIG. 1. Hias Nail, age 50. 5 y e a r s ' h i s t o r y o f painless tumour of wrist, with dilated veins over fuslform tumour ; no sinuses. D i a g n o s e d as s a r c o m a , b u t e,f t e r a m p u t a t i o n f o u n d to be a y e l l o w actinomycotic myeetoma.
F r o . 3.
A l i F a d l e l S i d , a g e 3(I. (3 y e a r s ' d u r a tion). Swelling of head of tibia witho u t s i n u s e s . D i a g n o s e d as o s t e o sarcoma. After amputation through l o w e r t h i r d o f f e m u r f o u n d to be y e l l o w m a d u r a (Actinomycosis convohttus).
FIG. 2. Mousa Idrls, age 42.
Black madura involving p o s t e r i o r h a l f o f os c a l c i s a n d r e n d o a e h i l l i s . S i n u s e s p r e s e n t , a t o p e r a t i o n , p o s t . 3 / 4 o f os e a l e i s c u t a w a y w i t h 3 eros. o f t e n d o a e h i l l l s j o i n t o b l i t e r a t e d . D e n s e sclerosis o f r e m a i n d e r c a r t i l a g e s o f a n k l e o f os calcis.
FIG. 4. E 615. Hias [brakim, a g e 30. (2 y e a r s ' d u r a t i o n ) . A n e l a s t i c t u m o u r t h e size o f a c r i c k e t b a l l p r o j e c t i n g from left heel. No sinuses. Radiograph shews cons i d e r a b l e n e w b o n e f o r m a t i o n a n d at o p e r a t i o n t h e g r o w t h w a s f o u n d to be a b l a c k r n a d u r a (Glenospora), w h i c h h a d i n v a d e d t h e p o s t e r i o r h a l f o f t h e os calms. PLATE IlI.
FIG. 1. Yellow Madura. N o t e . - - T h e patches of leucodermia were probably the result of scarring from native cauterisation.
FIG. 3. Yellow grain actinomycotic mycetoma of 10 years' duration.
oveF
P L A T E IV.
FIG. 2.
Yellow grain actinomycotic mycetoma involving bones round elbow of 5 years' duration. The elbow joint and hand were freely moveable. No sinuses, scars are those of native cauterisation
FIG. 4. Yellow grain actinomycotic mycetoma of over 10 years' duration. The fingers and hand were freely moveable. There was gross rarifying osteitis of bones of the forearm
C. GRANTHAM-HILL.
48
of the case described above (Musa Mohammed), who was suffering from concurrent malaria. RELATIVE PATHOGENICITY OF TYPES.
Tables F and D shew that the yellow actinomycotic variety is the more dangerous of the two, having a much higher amputation and relapse rate. Several factors would appear to contribute to this higher pathogenicity. (1) The actinomycotic type is more insidious in growth in that it infiltrates gradually, whereas the black madura forms a localised, usually subcutaneous, tumour. (2) The actinomycotic type only forms sinuses relatively late, usually after the deep tissues, and even bone have been invaded. (3) The spores thrown out by these sinuses are scanty and much less distinctive than those of the black variety. (4) Complete local removal is much more difficult in the white than in the black variety, on account of the similarity of the former to normal tissues, especially fibrous tissue and fat such as are found in the sole of the foot. (5) The rapidity with which the yellow type is disseminated in bone once it h a s penetrated the periosteum. CLINICAL COURSE.
As there are marked differences in the clinical manifestations of the two types, these will be separately described.
Black Maduromycosis. The earliest cases shew a small subcutaneous tumour, often near the scar of a small wound or thorn prick. The swelling is soft and elastic with a definite lobulated edge, closely simulating a subcutaneous lipoma. There appears to be, at first, a resistance on the part of the skin and deep fascia, especially in the case Of the plantar fascia and fascia lata., so that the growth tends to spread laterally for a varying distance in the subcutaneous planes before penetrating the skin or to the deep tissues. This is well illustrated in the following case. E 616. Haroun Rashid Abel Rahman, aged 9 years, gave a three years' history of soft swelling on the plantar aspect of the left foot, where an elastic swelling was found covering nearly the whole of the concavity of the arch, There were no sinuses, and no visible scar. An incision was carried down to and through the plantar fascia wide of the growth. On dissecting up the fascia, the growth could be seen nearly, but not quite, penetrating to its deep aspect in several places, where the black granules were visible through their thin pseudo-capsule. At this stage, parts of the tumour may become semi-cystic owing to pus formation, and sinuses may appear. In other cases penetration to the deep tissues occurs long before sinuses are formed, and an apparently localised
44
SOME CLINICAL OBSERVATIONSON MYCETOMA.
superficial tumour may be found at operation to penetrate deeply and ramify amongst the bones. E 624. Gadallah Abdel Dagem, aged 22 years, presented a semi-cystic tumour, external to the ball of the right foot, which had been present for eighteen months. On dissection, a black madura was found penetrating down to the first metatarsal, just proximal to its head, where it split to enclose the bone, almost meeting again on the dorsum. A piece of black thorn was enclosed in the growth.
Occasionally a black madura may assume very large proportions without penetrating the deep tissues, or forming a sinus, and such cases may lead to a mistaken diagnosis. E 423. Mohammed Mohammed Ahmed, aged 25 years, gave an eighteen months' history of a slowly growing painless tumour over the fight elbow. A cystic swelling the size of an orange, was found attached to the olecranon process. It closely resembled a chronic bursitis, and was diagnosed as such. On dissection a thin-walled sac was found, filled with typical mycotic pus and black granules.
lnvasion of Bone by Maduromycosis. Most writers describe the invasion of bone by madura, but do not differentiate between the types, and characterise the nature of the lesion as rarefying osteitis. BRUMPT (1927), however, says of the maduromycosis, ". . contrairement h ce qui s'observe dans les mycttomes actinomycosiques, les os sont respectts." In the black maduromycosis of this series, two distinct types of bone lesion are seen. (1) Rarefying osteitis, in cases in which there is gross involvement of the soft tissues surrounding the bones. In most cases of this type, the fungus does not appear to have entered the bone, and the rarefaction is seen in the bones of the toes distal to, but not included in, the area invaded. Such osteitis does not appear until there is advanced liquifaction of the tissues. It is suggested that this type of rarefaction is due not to invasion by the fungus, but to interference with the blood supply to the bones as the result of the destruction of the soft tissues. (2) A localised invasion of bone by the fungus causing necrosis, with a limiting zone of sclerosis, giving a radiographic appearance closely simulating that of chronic osteomyelitis of bacterial origin. Cases of this type are shewn in the radiographs Plate III, Figs. 2 and 4 and a similar case is described below. E 631. Nur Mustapha, aged 20 years. (See Plate II, Fig. 1), had a hard swelling with no sinus on the outer side of the right tibial tuberosity growing slowly for five months. There was no history of injury. Radiography shews a cavity in the head of the tibia strongly suggesting a Brodie's abscess the size of a pigeon's egg. On chiselling open the head of the bone the cavity was found tightly packed with black graules enclosed in a fine capsule~ which was removed intact. T h e cavity was treated as a chronic osteomyelitis, and healed iia one month. There has been no recurrence to date (nine months).
C. GRANTHAM-HILL.
45
An almost identical case occurring at the lower end of the tibia was not radiographed as involvement of the bone was not suspected until operation revealed it. Both these eases shewed maduromycosis of the G. khartoumensis type.
Yellow .4ctinomycotic Mycetoma. The early stages resemble those of the black variety except that the swelling is much less definitely outlined, and is harder, and fades into the surrounding tissues, suggesting on palpation an induration rather than a tumour. This is explained by the macroscopic appearance of the growth on section, when it resembles a dense fibrous network intersperse'd with ramifying processes of the yellow fungus, but with no suggestion of an investing membrane, and no clear demarcation from the normal tissues. (Plate IV, Figs. 2, 3 and 4). Here, as in the black variety, there is a definite resistance on the part of the deep fascia, with a tendency towards lateral spread in the subcutaneous planes. ]~ 418. Fatma Farag, aged 48 years (Plate I, Fig. 2), gave a two years' history of a gradually spreading thickening over of the outer side of the left knee. On admission, an area of intradermal and subcutaneous induration 9 by 4 inches in size was found extending from the outer side of the thigh over the external aspect of the knee, and on to the outer surface of the calf. There were no sinuses. The tissues down to the deep fascia were excised in one piece after a preliminary incision for identification. The skin and subcutaneous tissues were found to be infiltrated by actinomycotic mycetoma over the whole area without any penetration of the deep fascia. There has been no recurrence after two years.
A few cases of the yellow type shew early sinus formation with copious discharge of grains. One such case proved on culture to be probably of the Madurella variety of maduromycosis, and it is thought probable that all cases which behave similarly are of this or similar varieties, and not of the commoner actinomycotic type, though enough cases have not yet been investigated to prove this.
Invasion of Bone by Actinomycotic Mycetoma. Invasion of bone is much more frequent and extensive than in the black variety, and it is found in practice that once the periosteum has been penetrated by the fungus, the latter cannot be extirpated without removal of a fairly wide area of apparently healthy bone. Where there is macroscopic destruction of bone, nothing short of amputation is likely to be of use. There appear to be definite stages in the invasion of bone as shewn by radiographs, as follows :-(1) The stage of periostitis. Here the growth penetrates the periosteum and spreads laterally under it, causing a certain amount of reactionary periostitis, resembling that seen in syphilis. (Plate II, Fig. 2). (2) The stage of penetration with necrosis, in radiographs, resembles gummatous osteomyelitis. D
46
SOME CLINICAL OBSERVATIONSON MYCETOMA.
(3) The stage of breakdown of resistance, producing a rarefying osteitis, with patches of necrosis resembling tuberculous osteitis. (Plate III, Fig. 1). (4) Occasionally new periosteal bone formation occurs concurrently with necrosis, giving a radiographic appearance indistinguishable from sarcoma. (Plate III, Fig. 3). The following case illustrates the danger of incomplete extirpation. E 436. Osman Mohammed, aged 38 years, had a yellow mycetoma removed from the anterior border of the left tibia in 1925, the growth being then adherent to the periosteum, but the bone beneath being apparently normal. I n 1928, a recurrence of the growth had appeared, and a radiograph shewed considerable periostitis, but no necrosis. At operation the entire growth, including skin and the whole compact layer of the bone to which it was adherent, was removed in one piece. T h e cavity, treated as a chronic osteomyelitis, healed normally, and there has been no recurrence to date. DIAGNOSIS.
It will be realised from the foregoing account that diagnosis, in the absence of sinuses discharging typical granules, may be difficult from physical signs alone. Radiographs also may be confusing, and may resemble the appearances given by tuberculous, syphilitic, pyogenic, and sarcomatous disease of the bone. The safest procedure in a country in which mycetoma is common is to treat every doubtful tumour as a possible mycetoma, and to make a biopsy, being prepared to proceed immediately to a radical removal if the suspicion of madura is confirmed by naked-eye appearances. The following case is cited as an example of the mistakes which may result from the neglect of this rule. Khalid Ahmed KhogaH, aged 25 years, gave a two years' b/story of a painless swelling in the perineum just anterior to the anal orifice. Diagnosed as a sebaceous cyst, operation was started under local anaesthetic, but tumour which was found to be a black grain mycetoma, extended high up into the right ischio-rectal fossa, where it ramified extensively Chloroform had to be given to complete the dissection. TREATMENT.
Chemotherapy. Most writers doubt the value of medicinal treatment in the black variety of mycetoma. A few cases of apparent cure have, however, been reported as the result of treatment by various drugs, including neoarsphenamin, mercurocrome, (AUDRAIN, 1924), lugo1 (VoIzARD and LEROY, 1928), bismuth sodium tartrate and copper citrate, (PALMER, 1926). We have had no success with the first two preparations, cases so treated shewing no signs of healing after from two to five months, and being subsequently amputated. The third method has not yet been tried. In the ease of the antinomycotic variety, iodides and other iodine compounds have been generally recommended, though their effect is admittedly slow. Thus CHRISTOPHERSON (1928) reports a case cured after two and half years of treat-
C. ORANTHAM-HILL.
47
ment. Our experience of these drugs has not been encouraging, little if any retrogression having been observed during treatment up to six months. In view of the great difficulty of retaining under treatment natives, nearly all of whom come from a distance and are easily discouraged by the absence of rapid and obvious improvement, we have hesitated to press chemotherapy in any but inoperable cases, and even in these we find it almost impossible to pursue an unbroken course of treatment for more than a few weeks.
Surgical. It is, therefore, considered that the best routine treatment at present available in the Sudan is surgical, and that the key to success lies in early recognition and complete removal. The following procedure is recommended wherever possible : Radiographs are taken of all but superficial growths, to determine the presence and extent of invasion of bone. After a general or spinal anaesthetic, an Esmark's bandage is applied to the limb from the extremity up to the middle of the thigh or upper arm, and a tourniquet applied. In the case of the upper arm a sphygmomanometer bag is used in the place of the usual anchor tourniquet to avoid injury to the nerves. In this way a completely bloodless operation can be performed, thereby greatly increasing the ease with which the limits of the growth can be defined. In the absence of sinuses, an incision is then made into the tumour to identify its nature. If mycetoma is recognised, fresh instruments are taken, and a circumscribing incision made at a distance of about 1 cm. from the apparent margin of the growth, keeping a sharp look out for lateral extension of the growth in the skin. In the case of the black maduromycosis the pseudo capsule can readily be identified by its bluish colour, and the dissection can follow its outer surface closely, only sacrificing such tissues as are penetrated by it. Frequently a zone of a peculiar vitreous or oily degeneration is found, particularly in muscle, near the growth which is often of assistance in warning the operator that he is approaching the latter. As long as the bones are radiographicaUy and macroscopically unaffected, the growth can be peeled off them provided the pseudo capsule remains intact. Where there is visible invasion of the bone, the latter should be chiselled away and removed in one piece with the growth adhering to it. In the case of the small bones of the foot and hand, it is often simpler to remove the whole bone. Should the pseudo capsule be accidentally opened, the operation should be continued with fresh instruments further from the growth, and the wound should be subsequently carefully cleaned out with saline, and rubbed over with B.I.P. These precautions are in any case advisable on completion of the operation, with a view to removing or killing any stray grains of fungus. In the case of the yellow actinomycotic mycetoma the operation is rendered
48
SOME CLINICAL OBSERVATIONS ON MYCETOMA.
more difficult by the absence of any well defined pseudo capsule. It is wise, therefore, in this case to start well away from the growth, and to carry out the dissection as far as possible in the muscular planes, as muscle is much less difficult to distinguish from the fungus than fat or fibrous tissue. Where the periosteum has been penetrated, even though the bone appears normal, the compact layer should be removed with the growth. In the case of visible penetration and necrosis of the bone, removal of the whole bone is advisable, as it is impossible to define the limit of penetration. In cases shewing in radiographs an apparent limitation of the necrosis by sclerosis, wide dissemination of the fungus in the cancellous tissue is always found on examination after amputation. CONCLUSION.
It is hoped that these observations may be of some assistance to others in estimating the possibility of, and in carrying out the local removal of these tumours. Among natives, the fear of amputation is a strong deterrent from attendance at hospital, and any means by which the number of local removals in the later cases can be increased tend to decrease this fear, and so make for a larger percentage of early cases. SUMMARY. (1) A series of 184 cases of mycetoma are summarised, of which 118 were of the black, and 66 of the yellow grain types. (2) It is probable that the black grain type are all of the maduromycosis variety, while the majority of the yellow grain are thought to be actinomycotic mycetomata. (3) Treatment was by local removal in 141 cases, while 43 suffered amputation. (4) The relative virulence of the two types is discussed, and the differences in their clinical manifestations contrasted. (5) The operative treatment, with special reference to local removal, is described. REFERENCES. AUDRAIN. (1924). Jl. Amer. Med. Assoc., llth October, 1165. BRUMPT. (1927). PrgcisdeParasltologie. 1165-1175. Paris: Masson& Cie. BYAMand ARCHIBALD. (1923). Practice of Medicine in the Tropics. 2353-2362. London : Henry Frowde and Hodder & Stoughton. CASTELLANI and CHALMERS. (1919). Handbook of Tropical Medicine. 2110-2148. London : Bailli~re, Tindall & Cox. CHRISTOPHERSON,J. B. (1928). Proc. Roy. Soc. Med., January. 471-474. ONORATO. (1926). Mycetoma in Tripolitania. Arch. Ital. Sci. Med. Colon., Jan.-Aug. PALMER, F. J. (1928). Ind. Med. Gag., September. 530-531. SARTORY,MARCELand MAYER. (1929). C.R. Acad. SCI., March. 745-747. VOIZARDand LEROY. (1928). Bull. Soc. Path. Exot., July. 511-515.
SOME CLINICAL OBSERVATIONS ON MYCETOMA.* BY
C. GRANTHAM-HILL, F.R.C.S. (EDIN.). Senior Surgeon, Khartoum Hospital.
T h e following study of a series of 184 consecutive cases of mycetoma, operated upon in the K h a r t o u m Hospital f r o m 1928 to 1930, is concerned mainly with the clinical aspects of this disease, and particularly with the comparison and contrasting of the two types commonly met with, namely the black-grain maduromycosis and the yellow-grain actinomycotic mycetoma.
GENERAL CONSIDERATIONS. T h e disease is widespread in the northern Anglo-Egyptian Sudan, being well known to the natives u n d e r the Arabic name of el-nebt (the growth). Tables A and B shew that m e n during the active years of life are the worst sufferers from the disease. This is in accordance with the observance of most writers. Native treatment usually takes the form of incisions and cauterisation with hot irons, t h o u g h amputations were carried out b y t h e m before the British occupation, as in the following case : - E 551. Fatma Mohammed, aged 70 years, was admitted to hospital on the 15th May, 1930, suffering from a painful epethelial horn rising from a scar of an amputation in the lower third of the right leg, carried out by a native Fikki during the time of the Mahdi. The stump had been treated with hot oil, and had never completely healed. The reason for the amputation was given as el-nebt, following a thorn-prick. TYPES OF MYCETOMA. T w o main types appear in this series, namely the black-grain and the yellow-grain. Of 32 cases examined microscopically and cultured on various media b y Dr. D. RIDINQ at the Wellcome Tropical Research Laboratory, 13 cases were *The writer wishes to express his indebtedness to Major R. G. ARCHIBALD,C.M.G., D.S.O., Director, and to Dr. D. RIDINa, Pathologist, of the Wellcome Tropical Research Laboratories, for much assistance and advice in the preparation of the MS ; to F. S. MAYNE, F.R.C.S.E., for the use of notes of some cases operated on by him, and to O. F. H. ATKEY,F.R.C.S., Director, Sudan Medical Service, for permission to publish this paper.
40
SOME CLINICAL OBSERVATIONS ON MYCETOMA.
of the black-grain type, and were all classified as the maduromycosis Glenospora khartoumensis (CHALMERS and ARCHIBALD,1906). The remaining 19 cases were of the yellow-grain type, and 17 of them were actinomycotic mycetomata of various varieties, while two were maduromycoses, probably of the Madurella variety. The proportion of black to yellow type in this series was 118 of the former to 66 of the latter. The difference in the clinical and radiographic manifestations found in cases infected with each of these two types, which will be referred to in detail hereafter, support the assumption that the varieties are morphologically distinct, as the laboratory tests suggest. TABLE A. T y p e of Mycetoma. Black Yellow
TABLE B.
Age by decades.
Sex i
1-10 10-20 20-30 30-40 40-5C 50-60 Total 5
[
I 21
16
35
37
22
17
20
18
6[3
3
Men.
118
99
[
19
66
57
[
9
TABLE C.
TABLE D.
T y p e of Length of history in years. Mycetoma. 1 and less. 2 3 4 5 10 Im o r e t h a n 10 Black
51
27 13 10 8
7 !
2
Yellow
22
17 9
3i
4
6
5
N u m b e r of relapses.
Percentage.
8
6
12
18
TABLE E. T y p e of Mycetoma.
TABLE F.
Distribution in body. Foot.
Hand. Leg.
[ Women.
Arm. Trunkl Head.
Black
83
12
11
5
6
Yellow
49
8
6
2
1
1 I
-
N u m b e r of amputations.
Percentage.
23
19
22
33
N o t e . - - O f the six cases in the trunk, four were m the buttocks or perineum.
-]ETIOLOGY. Native opinion is strongly in favour of thorn-prick as a causative factor in mycetoma, and there is considerable support of this theory in actual findings at operation and in the laboratory. Thus, in over 30 per cent. of this series of small yellow and black mycetomata, of less than six months' duration, thorns were actually found embedded in the growth after removal at operation. The
C. GRANTHAM-HILL.
41
fact that it is rare to find a thorn in large maduras, may be explained by the probability that the thorn in such cases becomes broken up and liquidified in the same way as do body tissues under the action of mycetoma. A specimen is in the possession of MAJOR R. G. ARCnmALD,shewing a mycelial filament in close apposition to a thorn removed from a small nodule of liquified tissue which had not developed macroscopic evidence of mycetoma. In this connection it is interesting to note that no case in this series occurred amongst the educated class of native normally wearing shoes, or amongst town-dwellers or Europeans. Table E shews the distribution of the tumour in the body, and it will be noticed that the vast majority occur on exposed parts. Of seven cases occurring on the trunk, three were situated on the buttocks and perineum, which are most exposed to thorn-prick when sitting. In view of the universal habit of the native of using a home-made tooth brush cut from a twig of bush or tree, it is surprising that mycetoma has not been seen affecting the mouth. This fact points to the thorn-prick as being the sole mode of entry of the fungus. It has not been possible definitely to identify the tree or bush producing thorns actually found in mycetomata, but there is reason for suspecting the Acacia family of being the chief offenders. Pricks from thorns of this variety often give rise to considerable local inflammation which may possibly influence local susceptibility to the growth of fungus. INCUBATION PERIOD.
No reliable information is forthcoming as to the incubation period in this series. Attempts at innoculation, both of portions of growth and of cultures, into white rats, monkeys, rabbits and pigeons failed at each of various attempts, even after a local injection of histamine. Table C, however, shews that 40 per cent. of all the cases had a history of less than one year, and, in all probability, a much shorter period than this may be sufficient to produce a palpable tumour, as the following case shews. E 143. Mukhtar Mohammed, aged 22 years, three months before admission had fallen off his camel into a thorn bush ; he could fix the approximate date from the fact that the particular journey occurred in Ramadan. Many thorns penetrated the sole and toes of the right foot, most of which he pulled out. No suppuration occurred at the time, but one month before admission he noticed several painless lumps on the sole and at the root of the second toe. At operation, four separate black mycetoma were removed from the subcutaneous fat beneath the ball of the foot and the root of the second toe. These varied in size from a pea to a hazel nut, and three of the four contained visible pieces of black thorn. RATE OF GROWTH.
Most writers agree as to the variability of the rate of growth, though nearly all remark upon the absence of any true localising reaction on the part of the body. It is difficult to reconcile these two statements unless there is a variability in the pathogenicity of the fungus. This series throws no light on the
42
SOME CLINICAL OBSERVATIONSON MYCETOMA.
latter point, as 43 cases of advanced growth coming to amputation, shewed variation in length of history, b o t h for the black and yellow types, of from six m o n t h s to thirty years. T h e r e is, however, a good deal of evidence in favour of b o t h local and systemic resistance on the part of the body. T h e two following cases exemplify extremes of this, and further examples in the case of bone will be discussed later. E 585. Musa Mohammed, aged 40 years (Plate I, Fig. 1), gave a seven years' hlstory of swelling of left foot which gave little trouble. There were no sinuses. Four months before admission he began to have fever, and at the same time the left thigh began to swell. On admission, there was gross swelling of the left foot, the left lower leg was wasted, and the thigh distended with a uniform elastic swelling. The inguinal and femoral glands were swollen and slightly tender. The general condition of the patient was wasted and cachectic, the spleen enlarged, and benign tertian rings were present in the peripheral blood. After an intensive course of quinine, and a blood transfusion, the inguinal glands were dissected out, the external iliac artery tied, and the leg amputated just below the great trochanter. The patient made an uninterrupted recovery, and is reported to be still well, six months later. Examination of the leg after amputation shewed that actinomycotic mycetoma had apread up along the connective tissue planes deep to the deep fascia, had ramified widely in the soft tissues of the thigh, but had not reached the inguinal group of glands, and had not penetrated the bone. The inguinal glands shewed inflammatory changes but no trace of fungus. E 595. AhmedHamad, aged 45 years, had a yellow actinomycotic mycetoma removed from the left gluteal region seven years previously. Suppuration of the wound had resulted in an extensive puckered scar. There was no further trouble until six months before admission, when he noticed that a hard lump had formed in the scar, and had grown slightly since. At operation a yellow actinomycotic mycetoma, the size of a walnut, was found deeply embedded in dense fibrous tissue in the scar of the old operation. T h e s e two cases, and others of a less extreme character, support the view that intercurrent debilitating disease and local resistance of b o d y tissues may play a larger part in the rate of growth of m y c e t o m a than has hitherto been recognised. DISSEMINATION. Dissemination appears to be b y direct spread t h r o u g h the tissues only. T h e r e is no evidence in this series that the fungus has any predeliction for the lymphatics. CASTELLANIand CHALMERS(1919) quote BALFOURas saying in 1904 that in maduromycosis in the Sudan the inguinal glands are often involved. I n none of our cases, howcvcr, was thcre clinical enlargement of thc glands, with the sole exception of the case described above (Musa Mohammed). It would appear probable that glandular enlargement, when it does occur is due to chronic inflammatory changes rather than to metastasis f r o m the growth. Most writers mention cachcxy, even leading to death, as a feature of advanced mycetoma. BRUMPT(1927), attributes this to the actinomycotic variety b u t not to the maduromycoses. In this series there were no cases of cachexy, rise of t e m p e r a t u r c or malaise attributable to m y c e t o m a with the sole exception
FIG. 1.
Musa Mohammed, age 40.
Generalised actinomycotic mycetoma of left leg of 7 years' duration. No sinuses (scars on thighs those of native cauterisation). P L A T E I.
To face page 42.
FIG. 2. E 416. Fatma Mohammed Farag. Extensive subcutaneous actinomycotic my. cetoma. See p. 45 for description.
Fro. 1. (5 months' duration). Swelling over tibial tuberosity, with a small sinuses discharging sero-purulent material. Radiograph strongly suggested a Brodie's abscess. At operation (16th October, 1930), the cavity was found tightly packed with the black grains of maduromycosis, (Glenospora Khartoumensis).
Nur Mustafa, age 20.
P L A T E II.
FIG. 2.
Khadiga Idris, age 18. X-rays shew considerable periostitis. Growth adherent to periosteum and removed together with anterior wall of tibia and skin covering it. Yellow Madura
(Actinomycosis convolutus).
k
FIG. 1. Hias Nail, age 50. 5 y e a r s ' h i s t o r y o f painless tumour of wrist, with dilated veins over fuslform tumour ; no sinuses. D i a g n o s e d as s a r c o m a , b u t e,f t e r a m p u t a t i o n f o u n d to be a y e l l o w actinomycotic myeetoma.
F r o . 3.
A l i F a d l e l S i d , a g e 3(I. (3 y e a r s ' d u r a tion). Swelling of head of tibia witho u t s i n u s e s . D i a g n o s e d as o s t e o sarcoma. After amputation through l o w e r t h i r d o f f e m u r f o u n d to be y e l l o w m a d u r a (Actinomycosis convohttus).
FIG. 2. Mousa Idrls, age 42.
Black madura involving p o s t e r i o r h a l f o f os c a l c i s a n d r e n d o a e h i l l i s . S i n u s e s p r e s e n t , a t o p e r a t i o n , p o s t . 3 / 4 o f os e a l e i s c u t a w a y w i t h 3 eros. o f t e n d o a e h i l l l s j o i n t o b l i t e r a t e d . D e n s e sclerosis o f r e m a i n d e r c a r t i l a g e s o f a n k l e o f os calcis.
FIG. 4. E 615. Hias [brakim, a g e 30. (2 y e a r s ' d u r a t i o n ) . A n e l a s t i c t u m o u r t h e size o f a c r i c k e t b a l l p r o j e c t i n g from left heel. No sinuses. Radiograph shews cons i d e r a b l e n e w b o n e f o r m a t i o n a n d at o p e r a t i o n t h e g r o w t h w a s f o u n d to be a b l a c k r n a d u r a (Glenospora), w h i c h h a d i n v a d e d t h e p o s t e r i o r h a l f o f t h e os calms. PLATE IlI.
FIG. 1. Yellow Madura. N o t e . - - T h e patches of leucodermia were probably the result of scarring from native cauterisation.
FIG. 3. Yellow grain actinomycotic mycetoma of 10 years' duration.
oveF
P L A T E IV.
FIG. 2.
Yellow grain actinomycotic mycetoma involving bones round elbow of 5 years' duration. The elbow joint and hand were freely moveable. No sinuses, scars are those of native cauterisation
FIG. 4. Yellow grain actinomycotic mycetoma of over 10 years' duration. The fingers and hand were freely moveable. There was gross rarifying osteitis of bones of the forearm
C. GRANTHAM-HILL.
48
of the case described above (Musa Mohammed), who was suffering from concurrent malaria. RELATIVE PATHOGENICITY OF TYPES.
Tables F and D shew that the yellow actinomycotic variety is the more dangerous of the two, having a much higher amputation and relapse rate. Several factors would appear to contribute to this higher pathogenicity. (1) The actinomycotic type is more insidious in growth in that it infiltrates gradually, whereas the black madura forms a localised, usually subcutaneous, tumour. (2) The actinomycotic type only forms sinuses relatively late, usually after the deep tissues, and even bone have been invaded. (3) The spores thrown out by these sinuses are scanty and much less distinctive than those of the black variety. (4) Complete local removal is much more difficult in the white than in the black variety, on account of the similarity of the former to normal tissues, especially fibrous tissue and fat such as are found in the sole of the foot. (5) The rapidity with which the yellow type is disseminated in bone once it h a s penetrated the periosteum. CLINICAL COURSE.
As there are marked differences in the clinical manifestations of the two types, these will be separately described.
Black Maduromycosis. The earliest cases shew a small subcutaneous tumour, often near the scar of a small wound or thorn prick. The swelling is soft and elastic with a definite lobulated edge, closely simulating a subcutaneous lipoma. There appears to be, at first, a resistance on the part of the skin and deep fascia, especially in the case Of the plantar fascia and fascia lata., so that the growth tends to spread laterally for a varying distance in the subcutaneous planes before penetrating the skin or to the deep tissues. This is well illustrated in the following case. E 616. Haroun Rashid Abel Rahman, aged 9 years, gave a three years' history of soft swelling on the plantar aspect of the left foot, where an elastic swelling was found covering nearly the whole of the concavity of the arch, There were no sinuses, and no visible scar. An incision was carried down to and through the plantar fascia wide of the growth. On dissecting up the fascia, the growth could be seen nearly, but not quite, penetrating to its deep aspect in several places, where the black granules were visible through their thin pseudo-capsule. At this stage, parts of the tumour may become semi-cystic owing to pus formation, and sinuses may appear. In other cases penetration to the deep tissues occurs long before sinuses are formed, and an apparently localised
44
SOME CLINICAL OBSERVATIONSON MYCETOMA.
superficial tumour may be found at operation to penetrate deeply and ramify amongst the bones. E 624. Gadallah Abdel Dagem, aged 22 years, presented a semi-cystic tumour, external to the ball of the right foot, which had been present for eighteen months. On dissection, a black madura was found penetrating down to the first metatarsal, just proximal to its head, where it split to enclose the bone, almost meeting again on the dorsum. A piece of black thorn was enclosed in the growth.
Occasionally a black madura may assume very large proportions without penetrating the deep tissues, or forming a sinus, and such cases may lead to a mistaken diagnosis. E 423. Mohammed Mohammed Ahmed, aged 25 years, gave an eighteen months' history of a slowly growing painless tumour over the fight elbow. A cystic swelling the size of an orange, was found attached to the olecranon process. It closely resembled a chronic bursitis, and was diagnosed as such. On dissection a thin-walled sac was found, filled with typical mycotic pus and black granules.
lnvasion of Bone by Maduromycosis. Most writers describe the invasion of bone by madura, but do not differentiate between the types, and characterise the nature of the lesion as rarefying osteitis. BRUMPT (1927), however, says of the maduromycosis, ". . contrairement h ce qui s'observe dans les mycttomes actinomycosiques, les os sont respectts." In the black maduromycosis of this series, two distinct types of bone lesion are seen. (1) Rarefying osteitis, in cases in which there is gross involvement of the soft tissues surrounding the bones. In most cases of this type, the fungus does not appear to have entered the bone, and the rarefaction is seen in the bones of the toes distal to, but not included in, the area invaded. Such osteitis does not appear until there is advanced liquifaction of the tissues. It is suggested that this type of rarefaction is due not to invasion by the fungus, but to interference with the blood supply to the bones as the result of the destruction of the soft tissues. (2) A localised invasion of bone by the fungus causing necrosis, with a limiting zone of sclerosis, giving a radiographic appearance closely simulating that of chronic osteomyelitis of bacterial origin. Cases of this type are shewn in the radiographs Plate III, Figs. 2 and 4 and a similar case is described below. E 631. Nur Mustapha, aged 20 years. (See Plate II, Fig. 1), had a hard swelling with no sinus on the outer side of the right tibial tuberosity growing slowly for five months. There was no history of injury. Radiography shews a cavity in the head of the tibia strongly suggesting a Brodie's abscess the size of a pigeon's egg. On chiselling open the head of the bone the cavity was found tightly packed with black graules enclosed in a fine capsule~ which was removed intact. T h e cavity was treated as a chronic osteomyelitis, and healed iia one month. There has been no recurrence to date (nine months).
C. GRANTHAM-HILL.
45
An almost identical case occurring at the lower end of the tibia was not radiographed as involvement of the bone was not suspected until operation revealed it. Both these eases shewed maduromycosis of the G. khartoumensis type.
Yellow .4ctinomycotic Mycetoma. The early stages resemble those of the black variety except that the swelling is much less definitely outlined, and is harder, and fades into the surrounding tissues, suggesting on palpation an induration rather than a tumour. This is explained by the macroscopic appearance of the growth on section, when it resembles a dense fibrous network intersperse'd with ramifying processes of the yellow fungus, but with no suggestion of an investing membrane, and no clear demarcation from the normal tissues. (Plate IV, Figs. 2, 3 and 4). Here, as in the black variety, there is a definite resistance on the part of the deep fascia, with a tendency towards lateral spread in the subcutaneous planes. ]~ 418. Fatma Farag, aged 48 years (Plate I, Fig. 2), gave a two years' history of a gradually spreading thickening over of the outer side of the left knee. On admission, an area of intradermal and subcutaneous induration 9 by 4 inches in size was found extending from the outer side of the thigh over the external aspect of the knee, and on to the outer surface of the calf. There were no sinuses. The tissues down to the deep fascia were excised in one piece after a preliminary incision for identification. The skin and subcutaneous tissues were found to be infiltrated by actinomycotic mycetoma over the whole area without any penetration of the deep fascia. There has been no recurrence after two years.
A few cases of the yellow type shew early sinus formation with copious discharge of grains. One such case proved on culture to be probably of the Madurella variety of maduromycosis, and it is thought probable that all cases which behave similarly are of this or similar varieties, and not of the commoner actinomycotic type, though enough cases have not yet been investigated to prove this.
Invasion of Bone by Actinomycotic Mycetoma. Invasion of bone is much more frequent and extensive than in the black variety, and it is found in practice that once the periosteum has been penetrated by the fungus, the latter cannot be extirpated without removal of a fairly wide area of apparently healthy bone. Where there is macroscopic destruction of bone, nothing short of amputation is likely to be of use. There appear to be definite stages in the invasion of bone as shewn by radiographs, as follows :-(1) The stage of periostitis. Here the growth penetrates the periosteum and spreads laterally under it, causing a certain amount of reactionary periostitis, resembling that seen in syphilis. (Plate II, Fig. 2). (2) The stage of penetration with necrosis, in radiographs, resembles gummatous osteomyelitis. D
46
SOME CLINICAL OBSERVATIONSON MYCETOMA.
(3) The stage of breakdown of resistance, producing a rarefying osteitis, with patches of necrosis resembling tuberculous osteitis. (Plate III, Fig. 1). (4) Occasionally new periosteal bone formation occurs concurrently with necrosis, giving a radiographic appearance indistinguishable from sarcoma. (Plate III, Fig. 3). The following case illustrates the danger of incomplete extirpation. E 436. Osman Mohammed, aged 38 years, had a yellow mycetoma removed from the anterior border of the left tibia in 1925, the growth being then adherent to the periosteum, but the bone beneath being apparently normal. I n 1928, a recurrence of the growth had appeared, and a radiograph shewed considerable periostitis, but no necrosis. At operation the entire growth, including skin and the whole compact layer of the bone to which it was adherent, was removed in one piece. T h e cavity, treated as a chronic osteomyelitis, healed normally, and there has been no recurrence to date. DIAGNOSIS.
It will be realised from the foregoing account that diagnosis, in the absence of sinuses discharging typical granules, may be difficult from physical signs alone. Radiographs also may be confusing, and may resemble the appearances given by tuberculous, syphilitic, pyogenic, and sarcomatous disease of the bone. The safest procedure in a country in which mycetoma is common is to treat every doubtful tumour as a possible mycetoma, and to make a biopsy, being prepared to proceed immediately to a radical removal if the suspicion of madura is confirmed by naked-eye appearances. The following case is cited as an example of the mistakes which may result from the neglect of this rule. Khalid Ahmed KhogaH, aged 25 years, gave a two years' b/story of a painless swelling in the perineum just anterior to the anal orifice. Diagnosed as a sebaceous cyst, operation was started under local anaesthetic, but tumour which was found to be a black grain mycetoma, extended high up into the right ischio-rectal fossa, where it ramified extensively Chloroform had to be given to complete the dissection. TREATMENT.
Chemotherapy. Most writers doubt the value of medicinal treatment in the black variety of mycetoma. A few cases of apparent cure have, however, been reported as the result of treatment by various drugs, including neoarsphenamin, mercurocrome, (AUDRAIN, 1924), lugo1 (VoIzARD and LEROY, 1928), bismuth sodium tartrate and copper citrate, (PALMER, 1926). We have had no success with the first two preparations, cases so treated shewing no signs of healing after from two to five months, and being subsequently amputated. The third method has not yet been tried. In the ease of the antinomycotic variety, iodides and other iodine compounds have been generally recommended, though their effect is admittedly slow. Thus CHRISTOPHERSON (1928) reports a case cured after two and half years of treat-
C. ORANTHAM-HILL.
47
ment. Our experience of these drugs has not been encouraging, little if any retrogression having been observed during treatment up to six months. In view of the great difficulty of retaining under treatment natives, nearly all of whom come from a distance and are easily discouraged by the absence of rapid and obvious improvement, we have hesitated to press chemotherapy in any but inoperable cases, and even in these we find it almost impossible to pursue an unbroken course of treatment for more than a few weeks.
Surgical. It is, therefore, considered that the best routine treatment at present available in the Sudan is surgical, and that the key to success lies in early recognition and complete removal. The following procedure is recommended wherever possible : Radiographs are taken of all but superficial growths, to determine the presence and extent of invasion of bone. After a general or spinal anaesthetic, an Esmark's bandage is applied to the limb from the extremity up to the middle of the thigh or upper arm, and a tourniquet applied. In the case of the upper arm a sphygmomanometer bag is used in the place of the usual anchor tourniquet to avoid injury to the nerves. In this way a completely bloodless operation can be performed, thereby greatly increasing the ease with which the limits of the growth can be defined. In the absence of sinuses, an incision is then made into the tumour to identify its nature. If mycetoma is recognised, fresh instruments are taken, and a circumscribing incision made at a distance of about 1 cm. from the apparent margin of the growth, keeping a sharp look out for lateral extension of the growth in the skin. In the case of the black maduromycosis the pseudo capsule can readily be identified by its bluish colour, and the dissection can follow its outer surface closely, only sacrificing such tissues as are penetrated by it. Frequently a zone of a peculiar vitreous or oily degeneration is found, particularly in muscle, near the growth which is often of assistance in warning the operator that he is approaching the latter. As long as the bones are radiographicaUy and macroscopically unaffected, the growth can be peeled off them provided the pseudo capsule remains intact. Where there is visible invasion of the bone, the latter should be chiselled away and removed in one piece with the growth adhering to it. In the case of the small bones of the foot and hand, it is often simpler to remove the whole bone. Should the pseudo capsule be accidentally opened, the operation should be continued with fresh instruments further from the growth, and the wound should be subsequently carefully cleaned out with saline, and rubbed over with B.I.P. These precautions are in any case advisable on completion of the operation, with a view to removing or killing any stray grains of fungus. In the case of the yellow actinomycotic mycetoma the operation is rendered
48
SOME CLINICAL OBSERVATIONS ON MYCETOMA.
more difficult by the absence of any well defined pseudo capsule. It is wise, therefore, in this case to start well away from the growth, and to carry out the dissection as far as possible in the muscular planes, as muscle is much less difficult to distinguish from the fungus than fat or fibrous tissue. Where the periosteum has been penetrated, even though the bone appears normal, the compact layer should be removed with the growth. In the case of visible penetration and necrosis of the bone, removal of the whole bone is advisable, as it is impossible to define the limit of penetration. In cases shewing in radiographs an apparent limitation of the necrosis by sclerosis, wide dissemination of the fungus in the cancellous tissue is always found on examination after amputation. CONCLUSION.
It is hoped that these observations may be of some assistance to others in estimating the possibility of, and in carrying out the local removal of these tumours. Among natives, the fear of amputation is a strong deterrent from attendance at hospital, and any means by which the number of local removals in the later cases can be increased tend to decrease this fear, and so make for a larger percentage of early cases. SUMMARY. (1) A series of 184 cases of mycetoma are summarised, of which 118 were of the black, and 66 of the yellow grain types. (2) It is probable that the black grain type are all of the maduromycosis variety, while the majority of the yellow grain are thought to be actinomycotic mycetomata. (3) Treatment was by local removal in 141 cases, while 43 suffered amputation. (4) The relative virulence of the two types is discussed, and the differences in their clinical manifestations contrasted. (5) The operative treatment, with special reference to local removal, is described. REFERENCES. AUDRAIN. (1924). Jl. Amer. Med. Assoc., llth October, 1165. BRUMPT. (1927). PrgcisdeParasltologie. 1165-1175. Paris: Masson& Cie. BYAMand ARCHIBALD. (1923). Practice of Medicine in the Tropics. 2353-2362. London : Henry Frowde and Hodder & Stoughton. CASTELLANI and CHALMERS. (1919). Handbook of Tropical Medicine. 2110-2148. London : Bailli~re, Tindall & Cox. CHRISTOPHERSON,J. B. (1928). Proc. Roy. Soc. Med., January. 471-474. ONORATO. (1926). Mycetoma in Tripolitania. Arch. Ital. Sci. Med. Colon., Jan.-Aug. PALMER, F. J. (1928). Ind. Med. Gag., September. 530-531. SARTORY,MARCELand MAYER. (1929). C.R. Acad. SCI., March. 745-747. VOIZARDand LEROY. (1928). Bull. Soc. Path. Exot., July. 511-515.