One traditional view is that this was gout. Although rarely fatal, gout (hyperuricaemia) can lead to chronic renal disease and hypertension. Peripheral vascular disease can cause discolouration of the feet and legs. Circulatory dysfunction of the extremities can predispose to gangrene and this, with systemic complications, can lead to death. The risk factors for peripheral arterial disease are smoking, hypertension, diabetes, hypercholesterolaemia, obesity, physical inactivity, stress and a family history of the complaint. If Asa had non-insulin dependent diabetes, this could predispose him to chronic ulcers and a peripheral neuropathy that would in turn make him more prone to injuries to the feet.

However, Luke favours a tropical aetiology; a chronic infection leading to a noticeable disfiguration and then acute superinfection leading to systemic sepsis and death. Fungal infections can lead to gross distortion of the normal anatomy of the feet and would certainly merit a mention in historical records. Madura foot (or mycetoma) is a chronic infection involving subcutaneous tissue, bone and skin, in which colonies of infecting fungi or actinomycetes are found. There are several possible organisms causing this condition of which Streptomyces somaliensis is the most common in the Middle East [1]. This may respond to sulphones or sulphonamides, but often radical surgery is needed. So Asa should have gone to the Lord for healing, as physicians would have been of little help in this case.

1. Weatherall DJ et al (Eds). Oxford Textbook of Medicine. Oxford Medical Publications, 1996:801-2